For many of us in the mental health field, the January 8 shooting in Tucson, Arizona was like a darker version of the movie, “Groundhog Day.” Surely we had seen this all before: the “senseless, horrific attack” on innocent persons; the “mentally disturbed young man” charged with murder; the ever-recurring polemical arguments between supporters and opponents of gun control.
While the facts are still unfolding, and the accused shooter’s motivations — Jared Lee Loughner — still unclear, the murders in Arizona have once again raised a number of troubling questions: what if any link is there between violence and mental illness? Which problems in our health care system may contribute to untreated or inadequately treated mental illness? How should we balance civil liberties — including legitimate second amendment rights — against society’s very real safety concerns, when deciding whether guns should be sold to those with a history of severe mental illness? And would the answers to these questions have made any substantial difference in the case of the Arizona shootings?
In dealing with these complex questions, I don’t claim to “represent” psychiatrists, physicians, or any particular interest group. I am writing as a concerned citizen who happens to be a psychiatrist and bioethicist. I do not propose to offer any armchair “diagnoses” of the person now charged with murder in the Arizona shooting. Nor do I want to pre-empt a determination of the shooter’s degree of responsibility and culpability — those will be determined, one hopes, through due process of law and appropriate expert testimony. (Mental illness, so-called, is sometimes a partial explanation of someone’s behavior — is not an “excuse” for carrying out evil acts, nor does it rule out personal or political motives for a given action). Finally, by way of personal disclosure, I am a supporter of both single-payer, national health insurance; as well as more stringent controls over the sale and possession of lethal firearms.
Let’s start with the supposed link between mental illness and violence. Though the data are complicated, the overall conclusion from recent research is that violence is not closely linked to the major psychiatric disorders (major depression, bipolar disorder, and schizophrenia) per se. For example, the 1998 MacArthur Violence Risk Assessment Study, led by John Monahan and Henry Steadman, evaluated psychiatric patients recently discharged from the hospital. Unlike some studies that relied solely on self‐reports of violence, the MacArthur study used a combination of self‐reports, collateral informants, and police and hospital records.
The study found that the prevalence of violence among discharged psychiatric patients without a substance abuse disorder was similar to that among community‐dwellers who did not abuse substances. Furthermore, violence by these discharged patients rarely involved vicious attacks on strangers or clinicians. Usually, it resembled violence committed by other community‐dwellers, such as hitting a family member inside the home. The study revealed 6 homicides committed by 3 of the 951 discharged patients — thus, approximately 0.3% (3 in 951) of the released population were homicidal or committed acts of lethal violence. This rate is indeed higher than that in the general population, and is certainly not to be dismissed lightly. Still, in my view, the findings suggest that lethal violence among discharged psychiatric patients is quite rare.
To be sure, the MacArthur study has been criticized on various methodological grounds (see Torrey et al, 2008). Furthermore, mental disorders do increase susceptibility to substance abuse, and thus, indirectly increase risk of violence.
Nevertheless, a recent study by Eric Elbogen and colleagues at the University of North Carolina Chapel Hill School of Medicine tends to confirm the MacArthur findings. Based on face-to-face surveys conducted by the National Institute on Alcohol Abuse and Alcoholism, and involving nearly 35,000 subjects, Elbogen and his team found that when psychiatric diagnosis was examined, severe mental illness alone was not associated with increased risk of violence — but severe mental illness plus substance abuse/dependence was significantly associated. Indeed, severe mental illness per se did not independently predict future violent behavior; rather, other factors — such as a history of physical abuse, environmental stressors, or parental arrest record — predicted violent acts.
The image of the violent mentally ill person must also be tempered by research from Linda A. Teplin and colleagues, of Northwestern University. Teplin et al have found that those with mental illness are much more likely to be victims than perpetrators of a violent crime. They discovered in their work that among psychiatric outpatients, about 8 percent reported committing a violent act, whereas about 27 percent reported being the victim of a violent crime.