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).
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.