VIOLENCE BY MENTALLY ILL TIED TO SUBSTANCE ABUSE

BOSTON -- After a generation of believing that the mentally ill are no more
violent than other people, psychiatrists and advocates for the emotionally
disturbed are wrestling with studies that show that the mentally ill may
indeed be more violent in some circumstances.

Their difficulty was underscored Thursday in a report of the latest of
these studies in The Archives of General Psychiatry, a publication of the
American Medical Association. The studies found that mental patients
discharged from a hospital stay are no more violent than other members of
their community, unless they have been abusing alcohol or drugs. Substance
abuse increased the rates of violence by mental patients by up to five
times, the study concluded, while it tripled the rate of violence by other
people.

The finding about substance abuse is particularly important because the
mentally ill are almost twice as likely as other people to be alcoholics or
on drugs, the report said.

The study, paid for by the MacArthur Foundation, is part of a broad effort
by researchers to find out why recent reports have found higher levels of
violence among the mentally ill than in the general population,
contradicting previous research dating from the 1950s and 1960s.

The relationship between mental illness and violence is an extremely
sensitive subject because the public has long believed that the emotionally
disturbed are more dangerous, despite the experts' views, and this popular
perception has helped stigmatize the mentally ill.

To complicate the situation, with the closure of most state hospitals in
recent years an increasing number of the mentally ill have been sent to
jail or prison, where they receive little treatment, then are released only
to be arrested again.

"We wanted to find some factors that distinguished which patients were at
higher risk of violence, and substance abuse turned out to be a key
distinction," said John Monahan, an author of the report who is a
psychologist and a law professor at the University of Virginia. "We hope
this will lead people not to tar everybody who is discharged from the
hospital with the same brush."

The study also found that the types of violence committed by the mentally
ill were largely the same that other people committed and that more than 85
percent of the violence committed by the mentally ill was directed at
family members or friends, with only 14 percent of the attacks involved
strangers.

"These findings clearly indicate that public fears of violence on the
street by discharged patients who are strangers to them are misdirected,"
Monahan said.

The study was conducted on 1,000 patients discharged from hospitals in
Pittsburgh, Kansas City, Mo., and Worcester, Mass.

Another recent study, by Bruce Link, a professor at the Columbia University
School of Public Health, found that the mentally ill are more violent if
they are suffering from paranoia or from certain delusions and hallucinations.

Still another new study, by Jeffrey Swanson, an assistant professor of
psychiatry at Duke University Medical Center, showed an increased risk of
violence for mentally ill patients who are substance abusers and who stop
taking their antipsychotic drugs, a frequent problem.

As an indication of how sensitive the issue of mental illness and violence
is, the authors of the MacArthur Foundation study conducted focus groups
before writing their report. "Language is important, and we wanted to cast
things in the least inflammatory way," Monahan said.

As a further indication of this sensitivity, the report immediately
produced different reactions from the two major advocacy groups.

Mike Faenza, president of the National Mental Health Association, the
nation's oldest and largest mental health organization, said: "This study's
findings counter the fictional and highly stigmatizing images propagated by
Hollywood movie studios and New York ad men. It is time we kill our
cultural fantasy of deranged psychotic killers on the loose. The public's
fear is out of line with reality."

Faenza said the report also underscored the need to "bring mental health
and substance abuse treatment services together." He maintained that
because of the ingrained habits of mental health professionals and the way
government money is allocated, people now tend to be treated for either
mental illness or for substance abuse but not jointly for both. This
practice, he said, lets many patients fall through the cracks.

But Dr. E. Fuller Torrey, a psychiatrist affiliated with the National
Alliance for the Mentally Ill, an advocacy group made up of family members
of the emotionally disturbed, said the authors of the report had failed to
draw the most important conclusion from their own data. These were data
showing that mentally ill people who underwent hospitalization had a 50
percent reduction rate in violent acts in the year after their release, and
people who were both mentally ill and abused drugs or alcohol had a 54
percent reduction rate in violent behavior.

"This is the first time that anyone has shown what we have long suspected,
that if you treat mental illness you can reduce the violence," said Torrey,
who is executive director of the Stanley Foundation research programs in
Washington.

Torrey's point was echoed in an editorial in The Archives of General
Psychiatry by Link of Columbia, who said that the most important finding in
the MacArthur study is that the mentally ill tend to be violent when they
are "symptomatic" in the period before hospitalization, and that after
treatment, when their symptoms wane, "the risk for violence declines to the
point where it is no different from the base level in the community."

Torrey is an outspoken critic of the restrictive laws against involuntarily
hospitalization of the mentally ill, believing that many disturbed people
do not understand their disease and therefore resist attempts to treat
them. This can sometimes result in untreated mentally ill people harming
themselves or others.

Laurie Flynn, executive director of the National Alliance, said, "This
violence is preventable." But she added that the lack of access to
treatment "is a direct contributor to the criminalization problem," the
growing number of mentally ill people who are sent to jail or prison rather
than a clinic or hospital.

The situation is especially hard on family members who care for the
mentally ill, Ms. Flynn said, since, as the new study found, it is
relatives and friends who are most likely to be the victims of violence.

"People end up telling us it is easier to get your relative arrested than
to get them treatment," she said. "It is a kind of family secret."

Torrey said he believes the amount of violence by the mentally ill has been
increasing because of the closing of state hospitals and with financial
pressures resulting in shorter stays for those patients who are
hospitalized. Torrey estimates that the mentally ill are responsible for
about 1,000 homicides a year in the United States.

But Swanson said that in an earlier study he conducted in five cities,
he found that the mentally ill were responsible for only about 4
percent of overall violence. Mental illness, he found, is a much
smaller risk factor for violence than is being young, male, poor or
addicted to alcohol or drugs.


Checked-by: Mike Gogulski