Violent victimization of psychiatric patients: a Swedish case-control study

Victimisation in the life of persons with severe mental illness in Uganda: a pluralistic qualitative study

INTRODUCTION

Victimisation of persons with severe mental illness is recognised as an urgent global concern, with literature pointing to higher rates of violent victimisation of persons with severe mental illness than those of the general population. Yet, for low income countries, there is a huge gap in the literature on the risk, character and victims' in-depth experiences of victimisation of persons with severe mental illness. We explore the lived experiences and meanings of victimisation of persons with severe mental illness in Uganda, and discuss their implications for care of the mentally ill.

METHODS

A pluralistic qualitative study was undertaken to explore victimisation among patients with severe mental illness. Patients who had suffered victimisation were purposively sampled from Butabika National Referral Mental Clinic and Masaka Regional Referral Hospital, following confirmation of symptom remission. In-depth interviews were held with 18 participants, comprising 13 females and 5 males from low to moderate socioeconomic status. Interpretative phenomenological analysis and thematic content analysis were conducted.

RESULTS

Victimisation was exhibited in three main forms: (a) psychological, expressed in attitudes towards mentally ill family members as valueless and dispensable, and stigmatisation, (b) physical, as manifested in beatings, indoor confinement and tethering mostly by family members and (c) sexual victimisation, particularly rape. Also observed were victim's various responses that pointed to the negative impact of victimisation, including a heightened risk of suicide, social withdrawal, a sense of hatefulness and a predisposition to more victimisation.

CONCLUSION

The family environment plays a predominant role in perpetrating victimisation of the mentally ill in some sub-Saharan African contexts such as Uganda. We propose a holistic framework for mental health interventions, incorporating biomedical but notably also social determinants of mental health, and targeted at improving familial relationships, social support and a sense of belongingness both within the family and the broader community.

Self-Reported Experience of Abuse During the Life Course Among Men Seeking General Psychiatric or Addiction Care-A Prevalence Study in a Swedish Context

A prevalence study was conducted using the NorVold Abuse Questionnaire for men (m-NorAQ) to estimate the prevalence of self-reported experience of life-course abuse and to identify the perpetrators of the abuse. This among men seeking general psychiatric and addiction care in a Swedish context. In total, 210 men completed the questionnaire, and were included in the study. The total prevalence of life-course abuse (i.e., any emotional, physical or sexual abuse during the life course) was 75% (n = 157). The results of this study indicate the importance of identifying experiences of life-course abuse among men in general psychiatric and addiction care settings.

A scoping review of measurement of violence against women and disability

INTRODUCTION

Existing evidence indicates that prevalence of violence against women with disability is elevated compared to women without disability. We conducted a scoping review with a focus on measurement to assess the forms of measurement and study design utilized to explore the intersection of violence against women with disabilities, and to identify strengths and limitations in current approaches to measuring violence against women with disabilities. This scoping review is designed to inform current debates and discussions regarding how to generate evidence concerning violence against women with disabilities.

METHODS AND RESULTS

We conducted systematic searches of the following databases: PubMed, PsycINFO, Embase, CINAHL, PILOTS, ERIC, Social Work Abstracts, International Bibliography of the Social Sciences, Social Services Abstracts, ProQuest Criminal Justice, and Dissertations & Theses Global, and conducted structured searches of national statistics and surveys and grey literature available on-line. We identified 174 manuscripts or reports for inclusion. n = 113 manuscripts or reports utilized acts-specific measurement of violence. In terms of measurement of disability, we found that amongst the included manuscripts and reports, n = 75 utilized measures of functioning limitations (n = 20 of these were Washington Group questions), n = 15 utilized a single question approach and n = 67 defined participants in the research as having a disability based on a diagnosis or self-report of a health condition or impairment.

DISCUSSION

This scoping review provides a comprehensive overview of measurement of violence against women with disabilities and measurement of violence within disability-focused research. We identified several important gaps in the evidence, including lack of sex and disability disaggregation, limited evidence concerning adaptation of data collection methods to ensure accessibility of research activities for women with disabilities, and limited evidence concerning differential relationships between types of disability and violence exposure. This scoping review provides directions for sub-analyses of the included studies and further research to address gaps in evidence.

Risk of Subjection to Violence and Perpetration of Violence in Persons With Psychiatric Disorders in Sweden

IMPORTANCE

Key outcomes for persons with psychiatric disorders include subjection to violence and perpetration of violence. The occurrence of these outcomes and their associations with psychiatric disorders need to be clarified.

OBJECTIVE

To estimate the associations of a wide range of psychiatric disorders with the risks of subjection to violence and perpetration of violence.

DESIGN, SETTING, AND PARTICIPANTS

A total of 250 419 individuals born between January 1, 1973, and December 31, 1993, were identified to have psychiatric disorders using Swedish nationwide registers. Premorbid subjection to violence was measured since birth. The patients were matched by age and sex to individuals in the general population (n = 2 504 190) and to their full biological siblings without psychiatric disorders (n = 194 788). The start date for the patients and control groups was defined as the discharge date of the first psychiatric episode. The participants were censored either when they migrated, died, experienced the outcome of interest, or reached the end of the study period on December 31, 2013. Data were analyzed from January 15 to September 14, 2019.

EXPOSURES

Patients with common psychiatric disorders (eg, schizophrenia, bipolar disorder, depression, and anxiety) were differentiated using a hierarchical approach. Patients with personality disorders and substance use disorders were also included.

MAIN OUTCOMES AND MEASURES

Subjection to violence was defined as an outpatient visit (excluding a primary care visit), inpatient episode, or death associated with any diagnosis of an injury that was purposefully inflicted by other persons. Perpetration of violence was defined as a violent crime conviction. Stratified Cox regression models were fitted to account for the time at risk, a range of sociodemographic factors, a history of violence, and unmeasured familial confounders (via sibling comparisons).

RESULTS

Among 250 419 patients (55.4% women), the median (interquartile range) age at first diagnosis ranged from 20.0 (17.4-24.0) years for alcohol use disorder to 23.7 (19.9-28.8) years for anxiety disorder. Compared with 2 504 190 matched individuals without psychiatric disorders from the general population, patients with psychiatric disorders were more likely to be subjected to violence (7.1 [95% CI, 6.9-7.2] vs 1.0 [95% CI, 0.9-1.0] per 1000 person-years) and to perpetrate violence (7.5 [95% CI, 7.4-7.6] vs 0.7 [95% CI, 0.7-0.7] per 1000 person-years). In the fully adjusted models, patients with psychiatric disorders were 3 to 4 times more likely than their siblings without psychiatric disorders to be either subjected to violence (adjusted hazard ratio [aHR], 3.4 [95% CI, 3.2-3.6]) or to perpetrate violence (aHR, 4.2 [95% CI, 3.9-4.4]). Diagnosis with any of the specific disorders was associated with higher rates of violent outcomes, with the sole exception of schizophrenia, which was not associated with the risk of subjection to violence.

CONCLUSIONS AND RELEVANCE

In this study, persons with psychiatric disorders were 3 to 4 times more likely than their siblings without psychiatric disorders to have been subjected to violence or to have perpetrated violence after the onset of their conditions. The risks of both outcomes varied by specific psychiatric diagnosis, history of violence, and familial risks. Clinical interventions may benefit from targeted approaches for the assessment and management of risk of violence in people with psychiatric disorders.

Psychiatric symptoms and risk of victimisation: a population-based study from Southeast London

AimsAlthough violence is a vital public health problem, no prospective studies have tested for subsequent vulnerability to violence, as a victim or witness, in members of the general population with a range of psychiatric symptoms, or evaluated the importance of higher symptom burden on this vulnerability.

METHODS

We used successive waves of a household survey of Southeast London, taken 2 years apart, to test if association exists between psychiatric symptoms (symptoms of psychosis, common mental disorders, post-traumatic stress disorder and personality disorder) and later victimisation, in the form of either witnessing violence or being physically victimised, in weighted logistic regression models. Statistical adjustment was made for prior violence exposure, sociodemographic confounders, substance/alcohol use and violence perpetration. Sensitivity analyses were stratified by violence perpetration, sex and history of mental health service use.

RESULTS

After adjustments, psychiatric symptoms were prospectively associated with reporting any subsequent victimisation (odds ratio (OR) 1.88, 95% confidence interval (CI) 1.25-2.83), a two times greater odds of reporting witnessed violence (OR 2.24, 95% CI 1.33-3.76) and reporting physical victimisation (OR 1.76, 95% CI 1.01-3.06). One more symptom endorsed was accompanied by 47% greater odds of subsequent victimisation (OR 1.47, 95% CI 1.16-1.86). In stratified analyses, statistical associations remained evident in non-perpetrators, and among those without a history of using mental health services, and were similar in magnitude in both men and women.

CONCLUSIONS

Psychiatric symptoms increase liability to victimisation compared with those without psychiatric symptoms, independently of a prior history of violence exposure and irrespective of whether they themselves are perpetrators of violence. Clinicians should be mindful of the impact of psychiatric symptoms on vulnerability to victimisation, including among those with common psychiatric symptoms and among those who are not considered at risk of perpetrating violence.

Violent victimization and health service utilization in a forensic psychiatric context: a comparison between offenders with mental disorders and matched controls

BACKGROUND

Offenders with mental disorders constitute a particularly exposed group in society, with high rates of morbidity, mortality, and social deprivation. Often thought of primarily as perpetrators, these individuals may also be subjected to violence. Previous research indicates that violent victimization during lifespan is a risk factor for violent perpetration among psychiatric patients, but victimization studies on the group of offenders with mental disorders are scarce. Health services are pivotal to this group, but although most individuals do utilize these services, their vulnerability seems to remain. This study aimed at exploring the rates of victimization and health service utilization, including perceptions of unmet health care needs, among offenders with mental disorders.

METHODS

Two hundred detainees undergoing a forensic psychiatric evaluation in Stockholm were asked about violent victimization and health service utilization. Each detainee was compared with three controls from the general population, matched regarding age, sex, and occupation.

RESULTS

Victimization during the past year was reported by 52.3% of the detainees and 11.1% of the controls, with a corresponding risk ratio of 8.2. Health service utilization during the past three months was reported by 47.7 and 23.7%, respectively (risk ratio 2.0); and unmet health care needs by 42.2 and 16.7%, respectively (risk ratio 3.4). There was no distinct association between victimization and health service utilization among detainees.

CONCLUSIONS

Offenders with mental disorders are at great risk of being victimized, and they experience impediments to receiving requisite health care. A possible way to reduce victimization and improve health service utilization may be to establish interdisciplinary yet specialized health centers with outreach teams but without complicated referral procedures.

Recent physical and sexual violence against adults with severe mental illness: a systematic review and meta-analysis

People with severe mental illness (SMI) have high prevalence of lifetime victimization, but little is known about the extent and risk of recent domestic/sexual violence. The objective was to synthesize evidence on prevalence, odds, and risk factors for recent violence against people with SMI, with a focus on domestic and sexual violence. Relevant studies were identified through literature searches in Medline, Psychinf, Embase (for studies published in 2010-2015), and through existing systematic reviews (for studies published in 2000-2014). The review included 30 studies (with 16 140 SMI participants), including six on domestic violence and 11 on sexual violence. Prevalence of recent domestic violence ranged from 15-22% among women and from 4-10% among men/mixed samples; with little evidence on risk compared with the general population. Median prevalence of sexual violence was 9.9% (IQR = 5.9-18.1%) in women and 3.1% (IQR = 2.5-6.7%) in men; with 6-fold higher odds of victimization compared with the general population. There was little evidence on risk factors for domestic or sexual violence. In conclusion, people with SMI have a high prevalence of recent domestic and sexual violence, but little is known about risk factors for these violence types, or extent of domestic violence victimization compared to the general population.

Disclosure of abuse among female patients within general psychiatric care - a cross sectional study

BACKGROUND

Experiences of abuse are common among women in general psychiatric care. Even so, there are to our knowledge no previous national or international studies exploring disclosure in a general psychiatric setting of female patient's experiences of abuse to staff or to formal and informal networks. This study aimed to explore women's disclosure of experiencing physical, emotional and/or sexual abuse during their most recent contact with staff at a general psychiatric clinic. The study also aimed to determine whether the women have previously disclosed abuse to anyone.

METHODS

A consecutive sampling of eligible female patients at a general psychiatric clinic in an urban area of southern Sweden answered the NorVold Abuse Questionnaire, NorAQ, a self-administrated questionnaire. NorAQ has previously been used and further developed to compare the prevalence of abuse in women present in gynecological outpatient settings in the five Nordic countries. Seventy-seven women with experiences of abuse participated in the research. Descriptive statistics were used to analyse the data.

RESULTS

Most respondents did not disclose their experiences of abuse to staff at the general psychiatric clinic. Women with experiences of physical abuse (n = 40), emotional abuse (n = 37) and sexual abuse (n = 37) chose not to disclose their experiences. Respondents disclosed abuse more often to others than to staff.

CONCLUSIONS

Our findings indicated the importance of including routine questions concerning abuse experiences as a natural part of female patients' medical history.

Victimisation in adults with severe mental illness: prevalence and risk factors

BACKGROUND

Patients with a severe mental illness (SMI) are more likely to experience victimisation than the general population.

AIMS

To examine the prevalence of victimisation in people with SMI, and the relationship between symptoms, treatment facility and indices of substance use/misuse and perpetration, in comparison with the general population.

METHOD

Victimisation was assessed among both randomly selected patients with SMI (n = 216) and the general population (n = 10 865).

RESULTS

Compared with the general population, a high prevalence of violent victimisation was found among the SMI group (22.7% v. 8.5%). Compared with out-patients and patients in a sheltered housing facility, in-patients were most often victimised (violent crimes: 35.3%; property crimes: 47.1%). Risk factors among the SMI group for violent victimisation included young age and disorganisation, and risk factors for property crimes included being an in-patient, disorganisation and cannabis use. The SMI group were most often assaulted by someone they knew.

CONCLUSIONS

Caregivers should be aware that patients with SMI are at risk of violent victimisation. Interventions need to be developed to reduce this vulnerability.

[Violence by and against people with mental illnesses]

There is robust evidence for an increased risk of violence through people with psychotic disorders. Until recently this was frequently denied to prevent stigmatization. Alcohol and drug abuse equally increases the risk, while appropriate treatment reduces it drastically. Staff in psychiatric hospitals is exposed to an elevated risk of aggressive assaults. A limited number of severely ill and socially disintegrated patients accounts for these incidents, which are often recurrent. Besides patient characteristics, factors such as ward climate, staffing levels, education and attitudes of staff, and physical environment play a major role in aggressive escalations. On the other hand, mentally ill people, particularly women, are themselves at a higher risk of becoming victims of violent and non-violent crime. This also applies after correction for variables such as social status and living environment. Additionally mentally ill people are confronted with violence in the form of coercive interventions legitimised by the state (involuntary admission, involuntary treatment, freedom-restrictive measures such as seclusion or manual/physical restraint). In contrast to other countries in Central and Western Europe, involuntary outpatient treatment has never been legalized in Germany. Efforts to reduce violence and coercion in psychiatric facilities by evidence-based interventions are widespread nowadays, treatment guidelines are available.

Violent and non-violent crime against adults with severe mental illness

BACKGROUND

Little is known about the relative extent of crime against people with severe mental illness (SMI).

AIMS

To assess the prevalence and impact of crime among people with SMI compared with the general population.

METHOD

A total of 361 psychiatric patients were interviewed using the national crime survey questionnaire, and findings compared with those from 3138 general population controls participating in the contemporaneous national crime survey.

RESULTS

Past-year crime was experienced by 40% of patients v. 14% of controls (adjusted odds ratio (OR) = 2.8, 95% CI 2.0-3.8); and violent assaults by 19% of patients v. 3% of controls (adjusted OR = 5.3, 95% CI 3.1-8.8). Women with SMI had four-, ten- and four-fold increases in the odds of experiencing domestic, community and sexual violence, respectively. Victims with SMI were more likely to report psychosocial morbidity following violence than victims from the general population.

CONCLUSIONS

People with SMI are at greatly increased risk of crime and associated morbidity. Violence prevention policies should be particularly focused on people with SMI.

Violence and violent victimization in people with severe mental illness in a rural low-income country setting: a comparative cross-sectional community study

BACKGROUND

Violence perpetrated by and against people with severe mental illness (SMI) is important but rarely investigated in low- and middle income countries.

OBJECTIVE

To compare the prevalence of perpetrated violence and violent victimization, and associated factors, in people with and without SMI in rural Ethiopia.

METHOD

A random sub-sample of people with a standardized, clinician diagnosis of SMI (n=201) was recruited from an existing population-based study and compared to a group of unaffected individuals from the same neighborhood (n=200). The lifetime and 12-month prevalence of violence and violent victimization was measured using an adapted version of the McArthur Violence Interview.

RESULT

Lifetime and 12-month prevalence of perpetrated violence in people with SMI (28.4% and 17.4%, respectively) was significantly higher than in the non-mentally ill comparison group (15.0% and 8.5%, respectively). Male gender, being literate and violent victimization were associated independently with violence in both groups. In people with SMI, violence was associated additionally with being unmarried, exposure to stressful life events and non-response to medication. The prevalence of violent victimization was also significantly higher in people with SMI than those without SMI (60.7% vs. 41.5%). In people with SMI, violent victimization was associated with unemployment, non-adherence to treatment and being a perpetrator of violence.

CONCLUSIONS

Our finding of high levels of violence and violent victimization in people with SMI underscores the need to improve access to mental health services in this setting, as well as the urgent need to raise awareness about victimization of people with SMI.

Factors associated with self-report of sexual violence against men and women with mental disorders in Brazil

OBJECTIVES

Patients with mental illness (PMI) are more vulnerable to sexual violence (SV). This study aimed at assessing factors associated with SV against PMI, stratified by gender in Brazil.

METHODS

Cross-sectional multicenter study with a national sample of 2,475 PMI randomly selected from 26 psychiatric services. Odds ratios were estimated with 95% confidence interval using logistic regression.

RESULTS

A high prevalence of lifetime SV against PMI was observed (19.8%) and it was higher among women (26.6%) than men (12.5%). Among women, episodes of SV were more often caused by intimate partners and in the domestic environment, and among men, by strangers and in the streets. Among women, the following variables were independently associated (p < 0.01) with SV: younger age, living alone, history of homelessness, previous psychiatric hospitalization, lifetime STD diagnosis, early debut of sexual intercourse, irregular condom use, receiving/offering money for sex, and psychiatric diagnosis. Among men, younger age, previous and earlier psychiatric hospitalization, lifetime illegal drug use, receiving/offering money for sex, and psychiatric diagnosis were independently associated with SV.

CONCLUSIONS

The prevalence of SV in the studied population was high, especially among women. Women have more behavior factors associated with SV and they need protection, especially those in isolation and socially deprived. However, men also suffer SV, usually more often during childhood than adulthood and special attention should be given to lifetime illegal drug use and earlier psychiatric hospitalization. Preventive actions beyond mental health are important, such as social and economic actions to improve the living conditions of PMI.

A UK population-based study of the relationship between mental disorder and victimisation

PURPOSE

To establish the prevalence of victimisation in a UK population-based sample and to investigate the association between mental disorder and victimisation in both cross-sectional and prospective manner, whilst adjusting for potential confounds.

METHODS

Data from the National Child Development Study (NCDS) were used to examine criminal victimisation, violent victimisation, and mental disorder at age 46 yerars, and also to measure history of mental disorder, when cohort members were aged 23, 33 and 42 years. Variables considered to be potential confounders or mediators of the association, including socio-economic status, family income, financial strain, education, housing ownership status, heavy drinking and gender, all measured at age 46 years, were considered in multivariate analyses.

RESULTS

The prevalence of criminal victimisation amongst cohort members in the 12 months preceding interview was 15%; 2.2% of the participants reported experiencing violent victimisation in the past year. Mental disorder at age 46 was significantly associated with criminal and violent victimisation, even after adjusting for potential confounds. A prior history of mental disorder was found to be a robust predictor of criminal and violent victimisation.

CONCLUSIONS

This study provides evidence that those with a mental disorder are at elevated risk of victimisation, including violent victimisation. That such an association might reflect an underlying causal relationship is further supported by the confirmation that the association holds true when mental disorder is measured well before the assessment of victimisation risk, and that it persists despite adjustment for a number of potential confounding factors.

Violent behaviour by general psychiatric patients in Sweden - validation of Classification of Violence Risk (COVR) software

The objectives of the study are to report the 20-week base rate of violent behaviour in the community among a general psychiatric patient population from Stockholm and to establish the validity of a violence risk assessment software program, Classification of Violence Risk (COVR), in a European setting. Three hundred and thirty one patients at two psychiatric hospitals in Stockholm were interviewed upon discharge. Telephone interviews with the patients and collaterals were conducted 10 and 20 weeks later. The violent behaviour was also measured through a national criminal register. The allocation of patients into different risk groups according to COVR software was compared with the occurrence of actual acts of violence during the follow-up. The base rate of violent behaviour was 5.7% and a ROC-analysis showed that the AUC for COVR was 0.77. Since there were few patients in the high risk groups, the 95% confidence interval for the proportion of violent patients was wide. The base rate of violent behaviour is relatively low in Sweden and prediction is therefore difficult. The predictive validity of COVR software is comparable to other risk assessment tools.