Dangerousness and mental health: the facts

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Introduction
What is dangerousness?
Key facts about violence
Historical background
Violent behaviour and mental disorder
Homicide
Suicide
Relationship with victims
Mental health and the media
Further reading
References

Introduction

This factsheet explores the nature of dangerousness and the differing perceptions of dangerousness, how literature and the media influence these perceptions, and how these perceptions can impact different groups of people, particularly those with mental health problems. The factsheet also provides statistics relating to dangerousness and its links with mental health problems, propensity to violence and predictors of dangerousness.

This factsheet has been written for students and professionals, and anyone else who is interested in dangerousness and mental health.

Note on language

The terminology of psychiatric diagnosis used in this factsheet reflects the language of the sources referred to. The use of such language in no way implies Mind's unqualified acceptance of it.

What is dangerousness?

Although “dangerousness” is an emotive term that is widely used in the mental health field and the media, there is no consensus on its meaning. [1] Dangerousness has been described as: "an unpredictable and untreatable tendency to inflict or risk serious, irreversible injury or destruction, or to induce others to do so" [2] and "a propensity to cause serious physical injury or lasting physical harm". [3]

In his article ‘Defining the terms’ in Dangerousness, psychiatric assessment and management, Gunn states that the term dangerousness is made up of three elements – destructiveness, prediction and fear. “The latter, fear, makes it at least partially subjective, therefore it can never be entirely objective." [4] Prediction is also highly subjective.

Perceptions of dangerousness vary, and literature and the media influence these perceptions. The most common perception of dangerousness is in the form of one person presenting a danger to others. More often than not, however, dangerousness presents in the form of people being a danger to themselves, through suicide or deliberate self-harm.

Public perceptions of dangerousness can impact on different groups of people, particularly people with mental health problems and people from minority ethnic groups. The effects of such stigmatisation can be extremely negative, and in some cases has even led people from these groups to become victims of violent crime.

These issues are discussed in more detail below.

Key facts about violence

Out of 1,564 people convicted for homicide in England and Wales between April 1996 and April 1999, 164 (10 per cent) were found to have had symptoms of mental health problems at the time of the offence. [5] A later study looking at homicides committed between January 1997 and December 2005 found that the same proportion, 10 per cent (510 of 5,189), were by individuals known to have had mental health problems at the time of the offence. [6]
In 2009, the total population in England and Wales aged 16 or over was just over 43 million. It has been estimated that about one in six of the adult population will have a significant mental health problem at any one time, [7], [8] which amounts to more than 7 million people. Given this number and the 50–70 cases of homicide a year involving people known to have a mental health problem at the time of the murder, [9] clearly the statistics data do not support the sensationalised media coverage about the danger that people with mental health problems present to the community.
The majority of violent crimes and homicides are committed by people who do not have mental health problems. In fact, 95 per cent of homicides are committed by people who have not been diagnosed with a mental health problem.[10]
Contrary to popular belief, the incidence of homicide committed by people diagnosed with mental health problems has stayed at a fairly constant level since the 1990s. [11]
The fear of random unprovoked attacks on strangers by people with mental health problems is unjustified. This has been highlightedby a US finding that patients with psychosis who are livingin the community are 14 times more likely to be the victimsof a violent crime than to be arrested for such a crime. [12]
According to the British Crime Survey, almost half (47 per cent) of the victims of violent crimes believed that their offender was under the influence of alcohol and about 17 per cent believed that the offender was under the influence of drugs. [13] Another survey suggested that about 30 per cent of victims believed that the offender attacked them because they were under the influence of drugs or alcohol. In contrast, only one per cent of victims believed that the violent incident happened because the offender had a mental illness. [14]
People with mental health problems are more dangerous to themselves than they are to others: 90 per cent of people who die through suicide in the UK are experiencing mental distress. [15]
People with serious mental illness are more likely to be the victim of a violent crime than the perpetrator. One study found that more than one in four people with a severe mental illness had been a victim of crime in one year. [16]
It is also worth keeping in mind that many cases of violence in the community get reported three times – the event, the court case, and the inquiry report – thus greatly exaggerating the number of cases in the public’s mind.

Historical background

In recent history, people with mental health problems were housed in large institutions, isolated from the rest of the community. However, psychiatric hospitals have been closing down since the early 1950s. The 1980s saw large-scale closures , forming part of the government's policy of care in the community, and large numbers of former psychiatric patients were discharged into the community.

The main intention of de-institutionalisation was to increase the freedom of people with mental health problems by promoting the principle of ‘least restrictive alternative’. The ’’least restrictive’‘ philosophy underpins the principles of care outlined in the Reed Report, [17] which states that care arrangements for people with mental health problems should “have proper regard to the quality of care and the needs of individuals; as far as possible, in the community, rather than in institutional settings; under conditions of no greater security than is justified by the degree of danger; so as to maximise rehabilitation and the chances of sustaining an independent life; as close as possible to their own homes and families.”

The main recommendation of the Reed report was that “ …mentally disordered offenders should, wherever possible, receive care and treatment from health or social services rather than in the criminal justice system” and that “…we see community services as providing wherever possible for the majority of mentally disordered offenders”.

Until 1981, inquiries had addressed scandals in hospitals on behalf of an angry public, almost invariably showing patients as helpless victims and staff as abusers. A shocking event in July 1984 had major repercussions for mental health care, and eventually, public attitudes. Sharon Campbell, a former inpatient, killed Isabel Schwartz, her former social worker, at Bexley Hospital. From then on, community care became associated with danger. [18]

In 1992, there were a cluster of tragic cases involving people with mental health problems. Michael Buchanan, Christopher Clunis and Erhi Inweh were all experiencing serious mental health illness when they attacked and killed strangers. [19] The publicity around these events created a sense that random irrational acts of violence were increasing. However, this is far from the case.

There is a common perception that people with mental health problems are likely to behave in a violent way – a view that is supported repeatedly by films, novels and the media. The facts demonstrate how exaggerated and unfair this view is. Figures from 2007–08 show that about 1.2 million people were treated by secondary mental health services in England and Wales in one year. [20], [21], [22] More than 110,000 people were admitted to hospital for a mental health problem, [23], [24], [25] and close to 34,000 people spent some time as formally detained inpatients. [26], [27], [28] In this same period, there were 662 homicides in England and Wales, [29] of which little more than 10 per cent would have involved people known to have a mental illness.

Violent behaviour and mental disorder

Press coverage focusing on crimes of violence committed by people with a diagnosis of schizophrenia has led some commentators to seek a link between psychosis and violence. Although there is research suggesting a modest link between psychosis and violence, it emphasises that the majority of such crimes are associated with drug and alcohol abuse. [30]

The public perception is that community care policy has failed and that there are now more people with mental health problems on the streets. Many believe that this has increased the risk of being harmed by someone diagnosed with a mental health problem. However, research shows otherwise. Rates of homicide committed by people with a mental illness peaked in the 70s and have since reached historically low rates. [31]

The MacArthur Foundation’s Community Violence Risk Study was set up to compare the rates of violence by former mental patients and other members of the community. [32] The study reported the following findings.

People with a diagnosis of a major mental disorder but without a diagnosis of substance abuse are involved in significantly less community violence than people with both diagnoses.
The prevalence of violence among people who have been discharged from a psychiatric hospital but who do not have symptoms of substance abuse is about the same as that among people living in their communities who have not spent time in psychiatric hospitals and who do not have symptoms of substance abuse.
The prevalence of violence is higher among people who have symptoms of substance abuse (discharged psychiatric patients and non-patients). People who have been discharged from a psychiatric hospital are more likely than other people living in their communities to have symptoms of substance abuse.
The prevalence of violence for the first few months after discharge from a psychiatric hospital among patients who have symptoms of substance abuse is significantly higher than among other people living in their communities who have symptoms of substance abuse.
Violence committed by people discharged from a psychiatric hospital is very similar to violence committed by other people living in their communities in terms of type (hitting), target (family members), and location (at home).

Homicide

In their annual report, published in 2009, The National Confidential Inquiry into Homicides and Suicides by People with Mental Illness received statistics and information from the Home Office about 5,189 homicide offences committed between January 1997 and December 2005. [33] The report focuses on the number of homicides committed by people with mental health problems – or with a previous history of mental illness.

Of the total number of homicides committed in the nine- year period covered by the study, a total of 510 (10 per cent of the total) were identified as patient homicide. This means that the person charged with the offence had been in contact with mental health services in the 12 months before committing the homicide.
A total of 550 individuals were found to have had symptoms of mental illness at the time of the offence. Symptoms included hypomania, depression, delusions, hallucinations and other psychotic symptoms.
Among the people found to have a mental illness, 289 were diagnosed as psychotic. Of these, 226 were diagnosed with schizophrenia.

The National Confidential Inquiry suggests that there has been an increase in recent years in the number of murders committed by people who were later found to have had symptoms of mental illness at the time of the offence. [34] Because these individuals were not in contact with mental health services when the crime was committed, and were only interviewed after the homicide, it is possible that the increase is due to assessors using assessment tools that allow them to identify more symptoms of mental illness than were able to be identified in previous years. It is important to note that some mental disorders, for example antisocial personality disorder, are associated with crime and violence. This means that when someone is known to have been violent and to have committed homicide they are also likely to meet the criteria for a mental disorder such as antisocial personality disorder.

Another study looked into homicide due to mental disorder in England and Wales over a 50- year period, from 1946 to 2004. [35] The researchers found that the total rate of homicide in the general population and the rate of homicide by people with mental illness rose until the mid-1970s. Since then the rate of homicide in the general population has continued to rise, while the number of homicides committed by people with mental illness has fallen to historically low levels. Although the rates may vary from one year to another, the pattern has been that the risk of being killed by someone with a mental illness has declined and remained very low.

The researchers suggest that the decrease in the number of killings by people with mental illness is due to better treatment, including use of antipsychotic medication and increased awareness of the treatment of psychosis in primary care.

Suicide

In most Western countries, close to 90 per cent of those who die by suicide have a mental disorder. This proportion is much smaller in some Asian countries, but there is still a strong link between mental illness and suicidal behaviour. [36] More than 60 per cent of those who die by suicide are thought to have been experiencing a depressive illness at the time. Bipolar disorder, alcohol and substance abuse and schizophrenia are also linked to an increased risk of suicide.

It is important to be aware that the majority of people with a mental disorder will never attempt suicide. [37]

A UK study found that about 10 per cent of people with no mental disorder have had suicidal thoughts at some time in their life, [38] and about 2 per cent have attempted suicide. The study showed that rates were much higher among people with mental disorders. As expected, the researchers found that people who had experienced a depressive episode had high rates of suicidal thoughts. About 52 per cent of those with depression had a lifetime prevalence of suicidal thoughts, and 25 per cent had attempted suicide at some stage in their life. People with obsessive-compulsive disorder had the highest rate of suicidal thoughts, with a 64 per cent lifetime prevalence.

The most common methods of suicide in men are hanging, strangulation and suffocation (44 per cent), drug-related poisoning (20 per cent) and ‘other poisoning’, including motor vehicle exhaust gas (10 per cent). The most common methods of suicide in women are drug-related poisoning (46 per cent), hanging, strangulation and suffocation (27 per cent) and drowning (7 per cent). [39]

Relationship with victims

There is a common misconception that homicides by people with mental health problems tend to be random unprovoked attacks on complete strangers. Although this type of attack does happen occasionally, figures from the National Confidential Inquiry into Suicide and Homicide by People with a Mental Illness show that the majority of victims are family members or otherwise acquainted with the aggressor. [40]

Mental health and the media

The media frequently draws links between mental illness and crime, particularly violent crime such as homicide. [41] In one survey, homicide and crime were the most common stories covered in relation to mental health. [42] The sources most frequently used in reporting on mental health were the police and the courts. One journalist said that ”there is no sexiness in mental health unless someone has committed a terrible crime.” [43]

People who have personal experience of mental illness are rarely quoted in the media: one survey showed that they were quoted in only six per cent of articles covering topics relating to mental health. [44]

References

[1] Jones, D 1995, ‘Prediction of dangerousness’, in B Kidd and C Stark (eds), Management of Violence and Aggression in Health Care, Gaskell.
[2] Scott PD 1977, ‘Assessing dangerousness in criminals’, British Journal of Psychiatry, vol. 131, pp. 127–142.
[3] Butler Report. 1975, ‘Report of the Committee on Mentally Abnormal Offenders’, London, The Stationery Office.
[4] Gunn J 1982, ‘Defining the terms’, in JR Hamilton and H Freeman (eds), Dangerousness: Psychiatric Assessment and Management, Gaskell.
[5] Department of Health 2001, Safety First, Report of the National Confidential Inquiry (NCI) Into Suicide and Homicide by People with Mental Illness – Annual report: England and Wales. Department of Health.
[6] Large M, et al., 2008, ‘Homicide due to mental disorder in England in Wales over 50 years’, British Journal of Psychiatry, vol. 193, pp. 130–133.
[7] The Health & Social Care Information Centre, 2009, Adult Psychiatric Morbidity in England, 2007, Result of a household survey
[8] Data provided for Mind by Health Solutions Wales, Information and Statistics, 2009
[9] National Confidential Inquiry into Suicide and Homicide by People with Mental Illness – Annual report: England and Wales, 2009
[10] Kings College London, Institute of Psychiatry, 2006, Risk of violence to other people,
[11] National Confidential Inquiry into Suicide and Homicide by People with Mental Illness – Annual report: England and Wales 2009
[12]Walsh E et al. 2003, ‘Prevalence of violent victimisation in severe mental illness’, British Journal of Psychiatry, vol. 183, pp. 233–238.
[13] Home Office, 2009, Crime in England and Wales 2008/09, Vol. 1, Findings from the British Crime Survey and police recorded crime, Statistical Bulletin, 11/09, vol. 1.
[14]Coleman K, Hird C, Povey D. 2006, ‘Violent Crime Overview, Homicide and Gun Crime 2004/2005’, Home Office Statistical Bulletin,
[15] Hall D et al. 1998, ‘Thirteen-year follow-up of deliberate self-harm, using linked data’, British Journal of Psychiatry, vol. 172: pp. 239–242.
[16] Teplin L, McClelland M, Abram K, Weiner D, 2005, ‘Crime victimization in adults with severe mental illness’, Archives of General Psychiatry, vol. 62, pp. 911–921.
[17] Reed DJ. 1992, Review of Health and Social Services for Mentally Disordered Offenders and Others Requiring similar Services, Final Summary Report, Home Office.
[18] Muijen M. 1995, ‘Scare in the community: Britain in moral panic’, in Heller T, et al (eds), Mental Health Matters, MacMillan Press.
[19] Searl, Liz, 1995, Living in fear of a man who could strike again, The Independent, 25/08/95.
[20] The Health and Social Care Information Centre, 2009, Mental Health Bulletin, Second report on experimental statistics for Mental Health Minimum Dataset (MHMDS) annual returns, 2003–2008.
[21] STATSWALES, 2009, Consultant lead out-patient clinics, summary date, by speciality group.
[22] Data provided for Mind by Health Solutions Wales, Information and Statistics, 2009.
[23] The Health and Social Care Information Centre, 2009, Mental Health Bulletin, Second report on experimental statistics for Mental Health Minimum Dataset (MHMDS) annual returns, 2003–2008.
[24] Health Statistics Wales, 2009, Chapter 10, Hospital Statistics for people with a mental illness.
[25] Data provided for Mind by Health Solutions Wales, Information and Statistics, 2009.
[26] The Health and Social Care Information Centre, 2009, Mental Health Bulletin, Second report on experimental statistics for Mental Health Minimum Dataset (MHMDS) annual returns, 2003–2008.
[27] STATSWALES, 2009, Admission of patients to NHS Mental Health Facilities by status.
[28] Data provided for Mind by Health Solutions Wales, Information and Statistics, 2009.
[29] British Crime Survey, 2009, table 2.04, Recorded crime by offence, 1997 to 2008/09 and percentage change between 2007/08 and 2008/09, revised figures.
[30] Fazel S, Långström N, Hjern A, Grann M, and Lichtenstein P, 2009, Schizophrenia, substance abuse and violent crime, JAMA 2009;301(19):2016-23.
[31] Large M, Smith G, Swinson N, Shaw J. and Nielssen O, 2008, Homicide due to mental disorder in England and Wales over 50 years, The British Journal or Psychiatry (2008) 193, 130-133. doi: 10.1192/bjp.bp.107.046581
[32] MacArthur Violence Risk Assessment Study, Executive Summary September 2005, available at: www.macarthur.virginia.edu/risk.html#_ftnref1 Accessed 12/01/10.
[33] National Confidential Inquiry into Suicide and Homicide by People with Mental Illness – Annual report: England and Wales 2009
[34] National Confidential Inquiry into Suicide and Homicide by People with Mental Illness – Annual report: England and Wales 2009
[35] Large M, Smith G, Swinson N, Shaw J. and Nielssen O, 2008, Homicide due to mental disorder in England and Wales over 50 years, The British Journal or Psychiatry (2008) 193, 130-133. doi: 10.1192/bjp.bp.107.046581
[36] International Association for Suicide Prevention (IASP) 2006, Co-sponsored by the World Health Organization (WHO), World Suicide Prevention Day.
[37] International Association for Suicide Prevention (IASP) 2006, Co-sponsored by the World Health Organization (WHO), World Suicide Prevention Day.
[38] Meltzer H, et al. 2002, Non-fatal suicidal behaviour among adults aged 16 to 74 in Great Britain, Office of National Statistics.
[39] Brock A., Griffiths C., 2003, ‘Trends in suicide by method in England and Wales, 1979 to 2001’, Health Statistics Quarterly, vol. 20, Office of National Statistics.
[40] National Confidential Inquiry into Suicide and Homicide by People with Mental Illness – Annual report: England and Wales 2009.
[41] CSIP/Shift, 2006, Mind over matter, Improving media reporting of mental health.
[42] CSIP/Shift, 2006, Mind over matter, Improving media reporting of mental health.
[43] CSIP/Shift, 2006, Mind over matter, Improving media reporting of mental health.
[44] CSIP/Shift, 2006, Mind over matter, Improving media reporting of mental health.

Updated by Inger Hatloy, January 2010.

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