A general consensus exists that severe mental illness (SMI) increases violence risk. However, a recent report claimed that SMI “alone was not statistically related to future violence in bivariate or multivariate analyses.” We reanalyze the data used to make this claim with a focus on causal relationships between SMI and violence, rather than the statistical prediction of violence.
Data are from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a two-wave study (N = 34,653: Wave 1: 2001–2003; Wave 2: 2004–2005). Indicators of mental disorder in the year prior to Wave 1 were used to examine violence between Waves 1 and 2.
Those with SMI, irrespective of substance abuse status, were significantly more likely to be violent than those with no mental or substance use disorders. This finding held in both bivariate and multivariable models. Those with comorbid mental and substance use disorders had the highest risk of violence. Historical and current conditions were also associated with violence, including childhood abuse and neglect, household antisocial behavior, binge drinking and stressful life events.
These results, in contrast to a recently published report, show that the NESARC data are consistent with the consensus view on mental disorder and violence: there is a statistically significant, yet modest relationship between SMI (within 12 months) and violence, and a stronger relationship between SMI with substance use disorder and violence. These results also highlight the importance of premorbid conditions, and other contemporaneous clinical factors, in violent behavior.
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Given the wording of the NESARC interview question for “schizophrenia”, it is more accurate to refer to this cluster of mental disorders as “psychotic disorders” . However, we will use the term “schizophrenia” in order to maintain a consistent reference point to the prior authors’ work.
Data from the MacArthur Violence Risk Assessment study showed that patients without alcohol or drug symptoms, as assessed by the MAST and DAST, were not significantly more violent than comparison group subjects without alcohol or drug symptoms (4.7 vs. 3.3%). However, it is also important to note that the MacArthur study used a patient sample (i.e., recently discharge from the hospital), which differs from the NESARC sample.
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The authors would like to thank Dr. Randy Borum for his helpful comments on an earlier draft of the manuscript.
Conflict of interest
The authors declare that they have no conflict of interest.
This paper is released to inform interested parties of research and to encourage discussion. Any views expressed on statistical, methodological, or technical issues are those of the author(s) and not necessarily those of the U.S. Census Bureau.
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Van Dorn, R., Volavka, J. & Johnson, N. Mental disorder and violence: is there a relationship beyond substance use?. Soc Psychiatry Psychiatr Epidemiol 47, 487–503 (2012). https://doi.org/10.1007/s00127-011-0356-x
- Severe mental illness
- Causality versus statistical prediction