Physician Focus: Violence and Mental Illness
By John Bradley, M.D. and Michael Tang, D.O., M.P.H.
The names bring unwanted reminders: Newtown, Aurora, Virginia Tech, Fort Hood, Columbine, Washington Navy Yard. These are places associated with some of the most recent and deadliest mass shootings in United States history. Violent incidents such as these never fail to shock the nation and shake our national conscience.
These horrible events also raise deep concerns about the connection between violence and mental illness. Indeed, such events have created strong public perceptions that mental illness and violence are linked and that the one can lead to the other. ?A recent Gallup poll, for example, found that nearly half of Americans – 48 percent – blame the mental health system “a great deal” for mass shootings and, specifically, for failing to identify individuals who may be a danger to others.
Certainly, violence is pervasive in our daily lives. We view and read about real-life incidents in the news. We watch fictional accounts on television and in the movies. Video games invite our participation.? We even see violence in some sporting events.
The notion, however, that violence occurs because of mental illness is more of a myth than reality. What is known is that people with mental illness are much more likely to be victims of violence rather than perpetrators, and that the vast majority of violence occurs outside the context of any mental illness.
The idea that violence and mental illness are linked arises, in part, from the intense media coverage of sensational incidents such as the mass shootings. This has led to public perceptions that the perpetrator usually has a mental illness and that people with mental illness are prone to violence. But the link between mental illness and violence is unclear; some perpetrators do have a mental illness, but many do not. Research has shown that the people with mental illness who are prone to violence tend to be those who are not receiving treatment that would be effective.
The single greatest predictor for violent behavior is a past history of violent behavior. Other risk factors include being raised in an environment of violence, being abused as a child, and abusing drugs and alcohol.
Research has also shown that more than half of violent acts, including homicides, occur within a family or household setting where people are known to one another. Perhaps one in six or seven occur between strangers. Violence also occurs more often in lower socio-economic areas, and people who have been abused as a child are more likely to engage in violent behavior.
While the public's tendency to blame the mental health system for violent incidents and its failure to identify people who may be dangerous is understandable, the fact is that it is difficult to predict who is prone to violence and who is not.
To be sure, there are shortcomings in the mental health system. Currently, the stigma of the disease remains, and only one-third of people with a mental illness actually receive care. Greater understanding of mental illness and more treatment for those affected are in order, and adherence to the Mental Health Parity and Addiction Act of 2008, buttressed by the Affordable Care Act -which puts insurance coverage of mental health on an equal level with physical health – should offer help for those affected.
The issue of access to firearms also needs more scrutiny. It is indisputable that the most profound episodes of mass violence involve firearms and that access to firearms is a risk factor for violence – both for suicide and for homicide. Having a firearm in the home, for example, is twice as likely to result in death by suicide as it is by homicide.
Mental illness is common; in any year, more than one-fourth of adults are diagnosed with one or more disorders, with more than 22 percent of those rated as severe, according to the National Institute of Mental Health. And more than 21 percent of 13-18-year-olds, currently or at some point in their lives, have a seriously debilitating mental disorder.
It is important to recognize that mental illnesses are brain diseases, similar to diabetes or hypertension or a physical illness. Mental illnesses just happen to have emotional, behavioral, or functional impairments with them. The diseases are treatable, and the treatments are effective.
John Bradley, M.D. is Chief of Psychiatry and Deputy Director of Mental Health for the Veterans Administration Boston Healthcare System, and Michael Tang, M.D., M.P.H. is a psychiatry resident at Harvard Medical School's South Shore Psychiatry program. Physician Focus is a public service of the Massachusetts Medical Society. Readers should use their own judgment when seeking medical care and consult with their physician for treatment. Send comments to PhysicianFocus@mms.org?
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