Openmind 154, Nov/ Dec 2008
Recently a story about two patients absconding from a secure hospital received national media coverage in England, while the publication of a study showing that homicides by mental health patients have declined to the lowest levels on record was largely ignored. This highlights the difficulties experienced by people with mental health problems in overcoming the stigma of being labelled as dangerous. Some of that stigma has now been passed into law, with a new mental health act that emphases dangerousness to self and others as grounds for involuntary treatment.
The study, published in the August issue of the British Journal of Psychiatry, [1] showed that homicide due to mental disorder rose dramatically from the mid-1950s to a peak of 130 per year in the late 1970s, and has fallen steadily since then, while the overall rate of homicide has continued to climb. The decline in homicide due to mental disorder is matched by a similar decline in suicide, [2] and both findings probably result from better treatment.
We also examined homicides in New South Wales, Australia, and found that the risk of lethal violence by a person diagnosed with schizophrenia who has received adequate treatment was not much higher than among the community as a whole, and the period of greatest risk is before initial treatment. [3] The most common reason for a person with mental health problems committing an act of violence was in response to a frightening delusional belief - usually they believed that they were in immediate danger from the victim of the assault. The victims were almost always family members or close associates. The chance of a person with mental health problems attacking a complete stranger is very low.
In related studies we have demonstrated that mental health laws that require a person to be dangerous to themselves or others before they can receive treatment have the effect of delaying initial treatment for an average of 22 weeks. [4] By linking studies of treatment delay and homicide in mental disorder we were also able to show that the proportion of homicides prior to treatment is greatest in countries with the longest treatment delays. [5] In other words, earlier treatment means significantly fewer homicides.
As well as increasing the risk of serious violence, mental health laws that require patients to be dangerous before they can receive treatment are unscientific and unethical. They are unscientific because we are not able to predict either suicide [6] or homicide, [7] and they are unethical because, in addition to the treatment delay, the prediction of violence is so unreliable that as many as 20 patients would have to be detained to prevent one act of violence if dangerousness is used as the grounds for involuntary admission. [8]
The reasons for the comparatively good performance of mental health services in England and Wales are not entirely clear, but must be due, at least in part, to the way in which providing care to all patients within a given area is the responsibility of designated health trusts; the quality of primary care; the generous availability of new and better medications by the NHS; and the absence of barriers to care that exist in countries where the best mental health care is provided by the private sector. Our research suggests the presence of a mental health law allowing treatment of the acute phase of illness without a requirement to prove dangerousness may also have been an important factor.
The media has missed a gold medal winning performance by mental health services that may be saving as many as 100 lives per year in England and Wales. At the same time, giving national prominence to a local story about escapees from a secure hospital has increased the stigma of people with mental health problems.
1. Large. M., Smith, G., Swinson, N., Shaw, J. and Neilssen, O. (2008) 'Homicide due to mental disorder in England and Wales over 50 years', British Journal of Psychiatry 193: 130-33.
2. Biddle, L., Brock, A., Brookes, S.T., Gunnell, D. (2008) 'Suicide rates in young men in England and Wales in the 21st century: time trend study', BMJ 336(7643): 539-42.
3. Nielssen, O.B., Westmore, B.D., Large, M.M., Hayes, R.A. (2007) 'Homicide during psychotic illness in New South Wales between 1993 and 2002', Medical Journal of Australia 186(6): 301-4.
4. Large, M.M., Nielssen, O., Ryan, C.J., Hayes, R. (2008) 'Mental health laws that require dangerousness for involuntary admission may delay the initial treatment of schizophrenia', Social Psychiatry and Psychiatric Epidemiology 43(3): 251-6.
5. Large, M., Nielssen, O. (2008) 'Evidence for a relationship between the duration of untreated psychosis and the proportion of psychotic homicides prior to treatment', Social Psychiatry and Psychiatric Epidemiology 43(1): 37-44.
6. Pokorny, A.D. (1993) 'Suicide prediction revisited', Suicide and Life Threatening Behaviour 23 (1):1-10.
7. Munro, E., Rumgay, J. (2000) 'Role of risk assessment in reducing homicides by people with mental illness', British Journal of Psychiatry 176: 116-20.
8. Buchanan, A. (2008 ) 'Risk of violence by psychiatric patients: beyond the "actuarial versus clinical" assessment debate', Psychiatric Services 59 (2):184-90.