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Updated 20 January 2011
Printable version

Forum Discussion: Schizophrenia and Violence, Case Not Closed

In response to the recent discourse in the general media about the mental health status of Jared Loughner, the man accused of killing six and injuring 12 in Arizona on 8 January 2011, the SRF editors have decided to open up a special forum discussion focusing on violence and the mentally ill. We have asked Paul Appelbaum of Columbia University to begin the discussion by posing some questions that can promote a deeper, more complex rendering of the issues that emerge whenever events likes these occur in our society. We welcome your thoughts, interpretations, suggestions, and citations where appropriate. The editors at SRF are grateful to Paul Appelbaum of Columbia University for his timely and succinct introduction.

For additional commentary and discussion, check out National Alliance on Mental Illness (NAMI) Medical Director Ken Duckworth's blog. Duckworth, along with Pete Earley, a NAMI member and author of Crazy: A Father's Search Through America's Mental Health Madness; Lisa Dixon, M.D., University of Maryland and NAMI scientific advisory council member, and E. Fuller Torrey, M.D., of the Treatment Advocacy Center and the Stanley Medical Research Institute, were featured on the Diane Rehm Show (NPR).

Also, here's a New York Times piece focusing on the challenges of seeking psychiatric help.

Lastly, a few CNN videos to reflect on:
Living With Schizophrenia
Examining Mental Illness in America
Federal Government Approach to Mental Health

View Comments By:
Jan Volavka — Posted 26 January 2011
Matthew Large — Posted 28 January 2011
Fuller Torrey — Posted 28 January 2011
Seena Fazel — Posted 31 January 2011
Paulo Negro — Posted 2 February 2011
Jan Golembiewski — Posted 3 February 2011
Anne Grasbeck — Posted 14 February 2011
David Shern, Steven Vetzner — Posted 14 February 2011
Sandeep Saluja — Posted 17 February 2011
Anne Grasbeck — Posted 17 February 2011
Jan Golembiewski — Posted 22 February 2011
Lennart Borgman — Posted 25 March 2011

Background Text
Paul S. Appelbaum, Elizabeth K. Dollard Professor of Psychiatry, Medicine and Law
Director, Division of Law, Ethics & Psychiatry, Department of Psychiatry, Columbia University College of Physicians and Surgeons/New York State Psychiatric Institute

The tragic shootings in Tucson have once again made the link between schizophrenia and violence a matter of considerable public concern. No one at this point can say with assurance whether Jared Loughner, the troubled young man behind the Glock semi-automatic pistol, has a mental disorder and, if so, what his diagnosis is. However, ignorance of his actual mental condition has not stopped confident assertions by a variety of commentators that he suffers from a mental illness, with schizophrenia by far the most popular choice.

Rapid acceptance by the public of these virtual diagnoses in part reflects deep-rooted preconceptions about the relationship between schizophrenia and violence. Although the weight of the literature suggests that schizophrenia and other psychotic disorders increase the risk of violent behavior, a substantial part of that link—in some studies, the entire differential risk—is accounted for by higher rates of substance abuse among people with psychotic illnesses (Elbogen and Johnson, 2009; Fazel et al., 2009). Data from the CATIE study indicated that positive symptoms increased violence risk, while negative symptoms had a protective effect (Swanson et al., 2006). Even accepting some increased risk associated with schizophrenia, though, it is clear that only a small percentage of violence in our society is due to serious mental illness, with the most frequently cited figure for attributable risk in the range of 3-5 percent (Swanson, 1994).

Nonetheless, the discussion has highlighted several issues regarding young people who may be experiencing early symptoms of a major mental disorder that are worth considering. How adequate are our mechanisms for detecting the onset of schizophrenia and intervening early in its course, and if they are lacking, what might improve our practices? Given that many young people resist accepting the diagnosis of a disorder, and even those who initiate treatment frequently abandon it, when should involuntary evaluation and treatment take place, and what are the longer-term consequences of these approaches? Should restrictions on access to weapons by people with mental illnesses be strengthened, or by focusing on this already stigmatized group, are we colluding in the denial of a broader problem of too-easy availability of guns in our country? And lastly, how can we better educate the public about the nature of schizophrenia and encourage adoption of reasonable policies to help people with the disorder?

Elbogen EB, Johnson SC. The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry . 2009 Feb 1 ; 66(2):152-61. Abstract

Fazel S, Gulati G, Linsell L, Geddes JR, Grann M. Schizophrenia and violence: systematic review and meta-analysis. PLoS Med . 2009 Aug 1 ; 6(8):e1000120. Abstract

Swanson, 1994, In Monahan J and Steadman H (Eds.), Violence and Mental Disorder. Chicago: University of Chicago Press, 101-136.

Comments on Online Discussion
Comment by:  Jan Volavka
Submitted 24 January 2011 Posted 26 January 2011

A substantial part of the link between schizophrenia and...  Read more

View all comments by Jan Volavka

Comment by:  Matthew Large
Submitted 28 January 2011 Posted 28 January 2011

Professor Appelbaum makes a number of indisputable points...  Read more

View all comments by Matthew Large

Comment by:  Fuller Torrey
Submitted 28 January 2011 Posted 28 January 2011

The issue of the involuntary treatment of individuals with...  Read more

View all comments by Fuller Torrey

Comment by:  Seena Fazel
Submitted 31 January 2011 Posted 31 January 2011

Professor Applebaum makes important observations about the...  Read more

View all comments by Seena Fazel

Comment by:  Paulo Negro
Submitted 2 February 2011 Posted 2 February 2011

It's my understanding that the literature of risk...  Read more

View all comments by Paulo Negro

Comment by:  Jan Golembiewski
Submitted 2 February 2011 Posted 3 February 2011

The discussion of violence in mental illness inevitably...  Read more

View all comments by Jan Golembiewski

Comment by:  Anne Grasbeck
Submitted 14 February 2011 Posted 14 February 2011

Psychiatric symptoms including disinhibition with...  Read more

View all comments by Anne Grasbeck

Comment by:  David Shern (Disclosure)Steven Vetzner
Submitted 14 February 2011 Posted 14 February 2011

The discussion surrounding the tragic shootings in Arizona...  Read more

View all comments by David Shern
View all comments by Steven Vetzner

Comment by:  Sandeep Saluja
Submitted 17 February 2011 Posted 17 February 2011

May I please ask what specific drug therapies target...  Read more

View all comments by Sandeep Saluja

Comment by:  Anne Grasbeck
Submitted 17 February 2011 Posted 17 February 2011

In geriatric psychiatry, interviews with relatives are...  Read more

View all comments by Anne Grasbeck

Comment by:  Jan Golembiewski
Submitted 22 February 2011 Posted 22 February 2011

Anne Gräsbeck’s comment on 17 February seems to suggest...  Read more

View all comments by Jan Golembiewski

Comment by:  Lennart Borgman
Submitted 25 March 2011 Posted 25 March 2011

It is interesting to note that clozapine, the substance...  Read more

View all comments by Lennart Borgman
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