Victimization of persons with severe mental illness: a pressing global health problem
Authors: Marvin S. Swartz, Sayanti Bhattacharya
Journal: World Psychiatry (2017)

A colleague likes to say that an alien visiting the US from outer space, after watching a few hours of television, would surely conclude that persons with severe mental illness (SMI) perpetually perch on the cusp of violence and mass mayhem. Media accounts in the US portray such persons as if their greatest risk of violence is towards others, and the risk of violent victimization of trivial concern. It is hard for the general public and even many clinicians to acknowledge that this simply is not so. Research to date has amply documented that acts of violence perpetrated by people with SMI are rare and committed by a small minority of individuals1. Indeed, if mental illness in the US was cured tomorrow, violence would only be reduced by roughly 4%, and 96% of violence would continue unabated2. In contrast, violent victimization is all too prevalent among persons with SMI3. What puts these persons at great risk of violent or criminal victimization? Such victims tend to be younger, socially active, and more symptomatic than those not victimized4. However, their impoverished social environments, risky interpersonal behaviors and often predatory peer networks likely put them at greater risk than their psychiatric symptoms. A longitudinal community study in four inner cities in England followed patients with recent psychosis for a year and observed that, compared to the general population, they were twice as likely to be victims of violence (16%), more likely to be homeless, abuse substances, have comorbid personality disorders and be more violent themselves5. These data suggests that victimization and risk of perpetrating violence may share a common social-environmental pathway. A birth cohort in New Zealand, followed for 21 years, revealed that – compared to individuals with no mental illness and when controlling for socio-demographic characteristics, risk of violence and comorbid psychiatric conditions – those with anxiety disorders suffered more sexual assaults, those with psychotic illnesses experienced more threatened and completed assaults, those with alcohol abuse experienced more completed physical assaults, and those using marijuana encountered more attempted assaults6. A systematic review of nine studies reporting on criminal victimization of persons with mental illness found a large variation in risk of victimization, ranging from 2.3 to 140 times higher than reported in the general population. The wide range of risk is likely due to differences in measures of victimization, study populations and geographic region7. Association of victimization with substance use, homelessness, severe psychopathology and involvement in criminal activity was a common finding in most studies. Other factors that increased risk of victimization included poor social and occupational functioning, female gender, lack of daily activity, and childhood sexual and physical abuse. Another systematic review, including 34 studies, similarly found that younger age, comorbid substance use, and being violent and homelessness are risk factors for victimization. Violent victimization also has long-term adverse consequences for the course of mental illness, and further erodes the quality of lives of patients with SMI and their families8. Studies focusing on victimization in women find a particularly adverse psychosocial impact on vulnerable homeless women with psychiatric illnesses9. Similarly, a UK based study observed that women with SMI were more likely to report psychological and social problems following violent victimization than the general population. These women experienced a four-fold increase in the odds of experiencing domestic and sexual violence, and a ten-fold increase in community violence10. Violence against persons with SMI is a pressing global health concern thwarting recovery and community integration. The preoccupation of the popular media with the violence risk of such vulnerable and disenfranchised individuals only serves to further exacerbate their community exclusion and, worse, to perpetuate cycles of victimization. The prevention and management of victimization optimally starts with assertive engagement in mental health care, integrated with substance use prevention and treatment. But the social environment matters a great deal. In addition to a durable connection to mental health and substance use services, social and housing supports are vital to offer, as far as possible, non-criminogenic and non-substance abusing peer networks, meaningful engagement in vocational and leisure activities and safe living environments. All this may sound aspirational, but treatment itself will only get us part of the way toward reducing victimization in this population. Marvin S. Swartz, Sayanti Bhattacharya Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA