Elucidating both the non-existent and extensive violent criminal career
Authors: Matt DeLisi
Journal: The Lancet Psychiatry (2017)

Although most individuals with severe mental illness such as schizophrenia are neither antisocial nor violent, the risk of committing a homicide for people with schizophrenia is higher than that for those in the general population.1Fazel S Gulati G Linsell L Geddes JR Grann M Schizophrenia and violence: systematic review and meta-analysis.PLoS Med. 2009; 6: e1000120Crossref PubMed Scopus (755) Google Scholar Thus, a paradox typifies many psychiatric conditions for which a specific disorder is associated with increased risk of violence, despite a low prevalence of violence among those with the disorder. Seena Fazel and colleagues'2Fazel S Wolf A Larsson H Lichtenstein P Mallett S Fanshawe TR Identification of low risk of violent crime in severe mental illness with a clinical prediction tool (Oxford Mental Illness and Violence tool [OxMIV]): a derivation and validation study.Lancet Psychiatry. 2017; (published online May 4)http://dx.doi.org/10.1016/S2215-0366(17)30109-8PubMed Google Scholar new study in The Lancet Psychiatry seeks to clarify this paradox by identifying low risk of committing violent crime among a national cohort of 75 158 Swedish individuals between the ages of 15 years and 65 years with a diagnosis of schizophrenia spectrum or bipolar disorders. A 16 item derivation model was developed and tested in external validation, and similar to their previous research,3Fazel S Chang Z Fanshawe T et al.Prediction of violent reoffending on release from prison: derivation and external validation of a scalable tool.Lancet Psychiatry. 2016; 3: 535-543Summary Full Text Full Text PDF PubMed Scopus (54) Google Scholar the authors also generated a web-based risk calculator (Oxford Mental Illness and Violence tool) to facilitate practical application. The risk of committing a violent offence at 1 year after hospital discharge with use of a 5% cutoff had a sensitivity of 62% (95% CI 55–68) and specificity of 94% (93–94). The positive predictive value was 11% and the negative predictive value was 99%. This risk calculator tool cannot be used in isolation from clinical assessment in predicting violence risk, and the low positive predictive value especially means that additional thorough clinical input is essential in determining need for extra risk management in high-risk individuals. Fazel and colleagues' findings show that previous violent crime was the strongest predictor of violent offence, with an odds ratio of 5·03 (95% CI 4·23–5·98), although male sex, previous substance abuse, and previous self-harm were also associated with an elevated risk of committing violent crime. These findings are consistent with criminal career research, which has consistently shown the continuity between antisocial conduct and violence, particularly among those with previous evidence of these factors.4DeLisi M Career criminals and the antisocial life-course.Child Dev Perspect. 2016; 10: 53-58Crossref Scopus (28) Google Scholar, 5DeLisi M Piquero AR New frontiers in criminal careers research, 2000–2011: a state-of-the-art review.J Crim Just. 2011; 39: 289-301Crossref Scopus (289) Google Scholar, 6Baglivio MT Wolff KT Prospective prediction of juvenile homicide/attempted homicide among early-onset juvenile offenders.Int J Environ Res Public Health. 2017; 14: 197Crossref Scopus (13) Google Scholar Aside from not specifying psychopathy—a powerful predictor of antisociality7DeLisi M Psychopathy as unified theory of crime. Palgrave Macmillan, New York2016Crossref Google Scholar, 8Corrado RR DeLisi M Hart SD McCuish EC Can the causal mechanisms underlying chronic, serious, and violent offending trajectories be elucidated using the psychopathy construct?.J Crim Just. 2015; 43: 251-261Crossref Scopus (51) Google Scholar, 9Corrado RR McCuish EC Hart SD DeLisi M The role of psychopathic traits and developmental risk factors on offending trajectories from early adolescence to adulthood: a prospective study of incarcerated youth.J Crim Just. 2015; 43: 357-368Crossref Scopus (59) Google Scholar, 10Debowska A Boduszek D Dhingra K Sherretts N Willmott D DeLisi M Can we use Hare's psychopathy model within forensic and non-forensic populations? An empirical investigation.Deviant Behav. 2017; (published online Jan 6)https://doi.org/10.1080/01639625.2016.1266887Crossref PubMed Scopus (20) Google Scholar—in their models, the study by Fazel and colleagues is strong. They also found that more than 80% of the sample had little-to-no risk of violent crime, despite their mental illness. Unlike their violent peers, these individuals lacked previous criminal offences and additional behavioural evidence of violence. However, the real contribution of the study is the contemplation of those with non-existent criminal careers. Those who abstain from crime and violence have long been largely overlooked by clinicians and criminal justice practitioners who focus their energies on understanding those who do commit crime. Yet non-offenders serve as important exemplars, whose traits, attitudes, behaviours, and social circumstances serve to buffer them from antisocial conduct, even among those with serious mental illness. OxMIV has made an important step forward in helping to identify this group at low risk of committing violent crime. The prediction tool still needs to be combined with clinical judgement before decisions on violence risk are made, and there are ethical issues to be considered in the use of the tool, such as who should be able to access it and how much weight should be put on the findings, because measures used to contain risk might have severe implications on the lives of the patient and wider society, but this is another useful tool to be added to the individual clinical picture. Given the large-scale data sources available to Fazel and colleagues, a promising next study would be to identify behavioural assets that keep people with serious mental illness from violence and subsequent criminal justice system contact. Indeed, they account for more than 80% of the population. I declare no competing interests. Identification of low risk of violent crime in severe mental illness with a clinical prediction tool (Oxford Mental Illness and Violence tool [OxMIV]): a derivation and validation studyWe have developed a prediction score in a national cohort of patients with schizophrenia spectrum or bipolar disorder, which can be used as an adjunct to decision making in clinical practice by identifying those who are at low risk of violent offending. The low positive predictive value suggests that further clinical assessment in individuals at high risk of violent offending is required to establish who might benefit from additional risk management. Further validation in other countries is needed. Full-Text PDF Open Access