On Monday October 26, 2009, a psychiatrist at the Massachusetts General Hospital (MGH) in Boston was seriously assaulted by a patient in one of the hospital's psychiatric outpatient clinics. Are people with mental illness more violent? Incidents such as this one, while infrequent, are sensational and spread like a viral communication that raises the spectre of dangerous "mental patients" lurking and endangering us all.
In fact, people with mental illness are not more dangerous than the general population --unless they are abusing alcohol or drugs and they have untreated serious mental illness. They are far more likely to be the victims of violence than its perpetrators, at a rate 11 times higher than the general population.
When violence bursts onto the public stage and involves a person with a mental illness it seems to evoke a particular and often uninformed response calling for more restrictive treatment of people with mental illness, generally by demanding more and longer psychiatric hospitalizations or greater use of involuntary interventions like outpatient commitment and medication over objection (both court ordered means by which a person must comply with treatment). But research has given us other options.
Mental illness alone is not a major driver of violent crime. Research findings indicate that the risk of violence is increased among individuals with serious mental illness when they are not receiving adequate mental health treatment - and the risk is considerably greater in these individuals when they are actively drinking and abusing drugs. The implication is clear: by better identifying mental illness, engaging and retaining these individuals in quality treatment, and ensuring that care is coordinated and collaborative among all caregivers, for both mental and substance disorders, we will achieve the greatest impact on improving the safety of our communities as well as improving the lives of those with these illnesses, and their families.
Individuals with mental illness who are apt to be violent (or become victimized) almost always telegraph their problems for months, if not longer, with growing symptoms, appearing in emergency rooms and hospitals, and driving their families to distraction - with the families seldom having a responsive place to turn. Fragmentation, lack of coordination, and too often limited accountability of mental health services too often disappoint families and deny people with mental illness the services they need to control their illness, and reduce their risk of dangerousness.
Effective psychiatric treatments, the science of psychiatry, are often far from what actually happens in everyday practice: this is the gap between what we know and what we do. But solutions exist to improve the quality of care that will benefit people with mental illness. We can screen and detect in medical and mental health settings the presence of alcohol and drug abuse and provide effective treatments for people with co-occurring mental and substance use disorders. We can identify individuals with serious mental illness and substance abuse and reach out to them when they fail to fill their medication prescriptions or do not show for appointments or when they illness worsens and they appear in emergency rooms or crisis services. We can do a lot better making families a part of treatment since they are essential allies in care and invaluable supports to their loved ones. We can create quality standards that call for coordination among hospitals, clinics and other mental health care programs in the community, and make these standards a requirement for licensure. We can help train police dispatchers and police officers to recognize when a person is mentally ill and how best to manage a crisis moment.
Tragic moments such as the one created by the incident at MGH are also propitious for advocacy and action. There are no better moments to make the case for quality treatment responsibly delivered - for closing the gap between what we know and what we do.
The opinions expressed herein are solely my own as a psychiatrist and public health advocate. Lloyd I Sederer, MD