Soc Psychiat Epidemiol (2011) 46:29–34 may be inﬂated since it is likely that an ongoing therapeutic contact with a psychiatric hospital facilitates the full acknowledgement of having been victimised, while, in contrast, the interviews of the controls were unrelated to a therapeutic setting. There are at least four possible selection biases of this study. Firstly, the patient group was more disadvantaged than the controls in terms of income and had a somewhat higher rate of individuals born outside Sweden. Secondly, the ULF survey targets residents with an address or a tele- phone number, which reduces the proportion of homeless, incarcerated, or otherwise socially isolated control subjects. Both of these biases will tend to inﬂate the odds ratio, since socially marginalised groups are more vulnerable to vic- timisation [6]. However, a third bias, working in the opposite direction, is that the ULF survey, in contrast to the patient group, includes people without a Swedish social security number, which means that immigrants without residence permits, poor, and socially marginalised people may be overrepresented compared to the patient group. A fourth bias, in our mind the most important one, relates to the fact that patients might be in a hospital because of current vic- timisation. Having been physically attacked is likely to de- stabilise the psychiatric condition and promote the need to seek professional advice, although the patients may not always communicate that they have been victimised to the clinicians. Furthermore, the police may transport an assaul- ted person to hospital for a physical and/or psychiatric check- up. Thus, life-time rate of victimisation would be a better variable for measurement of relative risk of victimisation, since this would be independent of current psychiatric interventions. However, from a clinical point of view, it is of less importance to know the exact relationship between rate of victimisation among patients and non-patients, respec- tively. What matters is that there are many patients who ought to be identiﬁed in terms of their vulnerability to vio- lence by others. The ambiguous results concerning gender may be related to observational bias. The incitement for women to report victimisation, especially sexual violence, is related to con- temporary attitudes in society. If violence towards women is ‘‘normalised’’, there will be little understanding and support for battered women, who, consequently, will be less inclined to report victimisation. On the other hand, in societies with a low acceptance of such violence, such as in Sweden, the reported rate will be higher. However, differences in the relative rate of violent victimisation are not affected by this observational bias, as such societal factors are likely to inﬂuence cases and controls equally. In summary, the strengths of this study are that the number of cases and controls are large enough to produce rather small CI and the comparatively low proportion of refusals, who, additionally, shared the basic properties of the participants. 33 The major limitation is that the cases were recruited in a life situation which may be associated with the outcome, in contrast to the controls. However, all in all, we believe that this study presents a fair estimate of the problem of vic- timisation in a group of general psychiatric patients. Proper professional management of these patients is likely to increase treatment efﬁciency and maybe prevent further victimisation [5, 9]. Since so many patients are victimised there is a need for clinical guidelines to screen, support and intervene. There are presently no accepted guideline for the management of adult physical abuse and victimisation, but some work based on patients that have been victimised in childhood, may be applicable for adult victimisation as well [16]. Future studies should provide clinicians with empirical data on speciﬁc risk groups, enabling resources to be allocated to where they pay off best. Controlled intervention studies would provide infor- mation on the size of the problem and its clinical impor- tance including risk factors such as substance abuse and residential factors. Acknowledgments The study was funded by grants from The National Board of Health and Welfare, Sweden, and Centre for Gender Medicine at Karolinska Institutet, Sweden. We want to thank Anne Berman, Kristina Sygel and John Monahan for reviewing earlier drafts of this article. Conﬂict of interest statement None. Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which per- mits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. References 1. Brunette MF, Drake RE (1997) Gender differences in patients with schizophrenia and substance abuse. Compr Psychiatry 38(2):109–116 2. Chapple B, Chant D, Nolan P, Cardy S, Whitford H, McGrath J (2004) Correlates of victimization amongst people with psycho- sis. Soc Psychiatry Psychiatr Epidemiol 39:836–840 3. Choe JY, Teplin LA, Abram KM (2008) Perpetration of violence, violent victimization, and severe mental illness: balancing public health concerns. Psychiatr Serv 59(2):153–164 4. Coverdale JH, Turbott S (2000) Sexual and physical abuse of chronically ill psychiatric outpatients compared with a matched sample of medical outpatients. J Nerv Ment Dis 188:440–445 5. Dean K, Moran P, Fahy T, Tyrer P, Leese M, Creed F, Burns T, Murray R, Walsh E (2007) Predictors of violent victimization amongst those with psychosis. Acta Psychiatr Scand 116:345–353 6. Estrada F, Nilsson A (2003) Victimization, inequality and welfare during an economic recession: a study of self-reported victim- ization in Sweden 1988–99. Br J Criminol 43:655–672 7. Goodman LA, Salyers MP, Meuser KT et al (2001) Recent vic- timization in woman and men with severe mental illness: prev- alence and correlates. J Traum Stress 14(4):615–632 123