By Matthew Owens
Schizophrenia is associated with violent crime, premature death and suicide and the trend is rising, according to new research out today in The Lancet Psychiatry.
The findings from the study, led by Oxford University, come from a long-term investigation in Sweden that tracked the lives of nearly 25,000 people with schizophrenia from 1972 to 2009.
“In recent years, there has been a lot of focus on primary prevention of schizophrenia – preventing people from getting ill. While primary prevention is clearly essential and may be some decades away, our study highlights the crucial importance of secondary prevention – treating and managing the risks of adverse outcomes…” said lead author of the report Dr Seena Fazel.
“Risks of these adverse outcomes relative to others in society appear to be increasing in recent decades, suggesting that there is still much work to be done in developing new treatments and mitigating risks of adverse outcomes in people with schizophrenia.”
For the study, adverse outcomes were defined as conviction of a violent crime, premature death (before the age of 56) and death by suicide. Overall, the results showed that within five years of diagnosis people with schizophrenia were 20 times more likely than the general population to die from suicide, 8 times more likely to die prematurely from other causes and 7 times more likely to be convicted of a violent offence.
This pattern of results demonstrates how people with schizophrenia are more likely to direct violence towards themselves rather than others, a fact that is often overlooked.
Paul Farmer, chief executive of Mind, the mental health charity, said: “It’s important to remember that all studies into schizophrenia and violence, including this one, agree that the vast majority of people who have been diagnosed with schizophrenia will never be violent. Around 1 in 100 people will experience schizophrenia at some point in their life, while only a very small number are linked to violent behaviour.”
This is despite the fact that media portrayals of mental health have sometimes been skewed towards sensational claims focussing on violence. The Sun’s now infamous 2013 front page headline, for example, “1,200 killed by mental patients”, was unlikely to have been anything other than a backwards step for mental health awareness campaigners.
“Because we only ever seem to talk about schizophrenia in the context of violence, it has created an exaggerated risk in the public imagination. This fuels stigma and is extremely distressing for the vast majority of people affected, who are quietly getting on with their lives and pose no threat to anyone.” Said Mark Winstanley, CEO of Rethink Mental Illness.” Indeed the current study shows the overwhelming majority of people living with schizophrenia (around 98% of women and 90% of men) had not committed violent offences 5 years after diagnosis.
It is also important to point out that offences recorded in the study varied in their nature. Homicides, assault, robbery and arson were included alongside sexual offences (including indecent exposure) and threats or intimidation. Furthermore, conviction data included cases where the person was fined or let off with a caution. That’s not to imply that such offences are not serious, just that we are already talking about small proportions of individuals in this category and so cases of the ilk of, let’s say for the sake of argument, indecent exposure dismissed with a warning, may well account for a chunk of the statistics.
The report also notes annual rate rises, albeit modest, for adverse outcomes in schizophrenia over the study period (2.6% suicide, 1.6% premature death and 1.3% violence). However, most of these increases were similar to those for siblings without schizophrenia (violence being a barely ‘significant’ difference at 1.1%), raising important questions over underlying causes of adverse outcomes.
Three main risk factors for future adverse outcomes, present before diagnosis, were identified; Substance use disorders, criminality and self-harm. Interestingly, this triad was also found both in the unaffected siblings and in the general population. This has two implications. First, targeting these factors should help reduce adverse outcomes in schizophrenia (as it should for everyone) and second, it underscores similarities between the rest of the population and so may help to reduce stigma for those affected and their families. As noted in a linked commentary by Dr Eric Elbogen and Sally Johnson from the University of North Carolina: “In this way [targeting common risk factors], we might not only reduce actual risk in people with schizophrenia, but appropriately place this in the context of violence reduction for society as a whole.”
Additionally, the study also found a correlation between patient care and adverse events. That is, at the same time that adverse events were creeping up, patient care was on the decline, raising the possibility that a lack of treatment should be the focus of concern for society as opposed to schizophrenia, per se. A finding that Farmer said: “underlines how important it is that people get the help they need, when they need it, and that treatment and support is tailored to the person with the diagnosis.” Winstanley added, “When people don’t get access to decent treatment they are more likely to self-medicate. This primarily accounts for the small increased risk of violence, not the illness itself.”
Arguably the most important messages to take from this study centres around the high levels of premature death, a much neglected issue in mental health, and schizophrenia in particular. “As our report Lethal Discrimination highlighted last year” the Rethink chief reminds us, “people with schizophrenia die on average, 20 years earlier than the rest of the population. People with severe mental illness are being badly let down when it comes to their physical health and we need health professionals to take urgent action to address this.”
Similarly, the high rate of suicide in schizophrenia (more than 20 times that of the general population) should be a major concern for us all. However, the rate may not be exclusively attributable to schizophrenia. For example, the authors told Chileno that data on depression were not good enough to be included in the study and so it remains possible that depression, or indeed other illnesses, are partly driving some of the associations with adversity (particularly suicide but violence and poor physical health too). Moreover, ‘schizophrenia’ may be acting as a signpost for other underlying problems not measured in the study such as a lack of support or employment.
The study was carried out in Sweden and so how the conclusions translate to other developed and developing countries remains to be seen. As Elbogen and Johnson point out there are some potential differences between Nordic countries and other parts of the world, not least of them being treatment rates, where unmet needs can be lower than 10% in the former and around 40% in the latter.
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