More insight into the link between violence & schizophrenia

The more we understand about the link between violence and schizophrenia, the better chance there is to prevent violent episodes from happening. A recent report from the CATIE studies informs us that:

there may be two pathways in which adults with schizophrenia may become violent — one in which pre-existing conditions like that of antisocial conduct in childhood, regardless of the presence of psychotic symptoms, may link to violence, and one in which psychotic symptoms of schizophrenia themselves may link to violence.

A classic case of shooting the messenger

Thanks to United States Psychiatric Rehabilitation Association (USPRA) for demonstrating so aptly why they shouldn’t be taken seriously. USPRA’s response to the Va Tech tragedies “urges all media networks to avoid over generalizations about the link between mental illness and violence.” That’s right! God forbid the media educate the public about the risks of untreated mental illness so that tragedies can be prevented. Instead follow USPRA’s lead and deceive the public:

USPRA: “Violence is no more prevalent among individuals with mental illness than the general public”
Fact: The CATIE violence study found that patients with schizophrenia were 10 times more likely to engage in violent behavior than the general public (19.1% vs. 2% in the general population).

USPRA: “Public perceptions that violence is strongly associated with mental illness are fueled by graphic media reports of violent crimes.”
Fact: The media does not commit the violent acts. Public perceptions are formed by violent crimes spawned from the dangerous untreated symptoms of mental illness and USPRA should stop trying to intimidate the media into silence.

USPRA: “it is incredibly rare for someone with a mental illness to commit gross acts of violence, especially on such a scale as the Virginia Tech shootings”
Fact: Yes, the scale of the scale of the Va Tech shooting is rare because sadly, this was a record. But, half of all “rampage shootings” such as the one in Blacksburg are committed by mentally ill shooters.

USPRA should be ashamed!

Atypicals vs. typicals

The aim of a recent study of acute response to antipsychotic treatment in first episode non-affective psychosis was to help “clinicians to identify those patients with a decrease likelihood of responding to routine pharmacological approaches is meant as a first step to optimize therapeutic effort to benefit individuals in this vulnerable group.” The researchers found that “patients with an early age of onset of schizophrenia, a poor premorbid adolescent functioning, and with a lower severity of psychopathology at intake seem to have a decrease likelihood of responding to antipsychotic treatment.”

With respect to type of medication as a predictor of response, the researchers hypothesized that “likelihood of response would be different among the groups of antipsychotic treatment.” Similar to the CATIE study, the researchers did not find a significant difference between typical (haldol) and atypical (risperidone or olanzapine) antipsychotic treatment and clinical improvement, at least in the early weeks of treatment.

The evidence is mounting that the knee-jerk assumption that atypicals should be the first line medication for treatment of psychoses is diminishing. Thanks to the Pharma funded medication algorithms, the switch has largely been made to atypicals in the public mental health system.

But, it has been very costly. For example, the Medicaid expenditures for antipsychotics increased 160% between 1995 and 1998 when the total number of prescriptions only increased 20%. That is because the proportion of atypical prescriptions grew from 17.5% in 1995 to 51% 3 years later in 1998. The cost grew as well, from $487 million in 1995 to $1.3 billion in 1998. Imagine how much more of the pie the pharmaceutical companies are getting now, 8 years and many marketing dollars later. Also imagine if that money were available for services, such as medication education and close monitoring for efficacy and side-effects. Decisions about medication should be based on efficacy and side-effects, not classification alone. And Clozapine shouldn’t be abandoned just because it is off-patent and isn’t being marketed by the Big Pharma reps. If money were freed up for better medication management services, clinicians would be in a better position to evaluate efficacy and side-effects and make more informed prescribing decisions.

Being objective about violence

A recent study of mental illness and crime in Sweden seems to be causing some confusion. The study results are being cited by what appear to be opposing views in the debate about the link between mental illness and violence. It is nonetheless a very informative study that can help all of us better understand this issue if we look at the data objectively.

One the one hand, the researchers point out that many studies have focused on the relative risk of violence in mental illness – the risk of violence for a person with mental illness as compared to the risk of violence for a non-mentally ill person. They note that focusing on relative risk “gives an incomplete picture” because it does not reflect the “proportion of violent crimes that can be attributed” to the mentally ill. In other words, because the mentally ill comprise such a small percentage of the population (1.4% in Sweden during the study period), their contribution to overall violent crime is relatively small. The researchers calculated a “population-attributable risk fraction” of 5.2% meaning that the mentally ill were responsible for only 1 in 20 violent crimes in Sweden. A simpler way of looking at it, which results in a slightly higher number, is that there were 21,119 crimes committed by mentally ill out of a total of 324,383 violent crimes in Sweden during the study period, meaning 6.5% of crimes were committed by people with mental illnesses. Thus, it is correct to try to defuse the stigmatization of people with severe mental illnesses by saying that they are responsible for a small fraction of violent crime. It is also true that only a small percentage of the mentally ill are violent. The study found that only 6.6% of the mentally ill (6,510 out of 98,082) were convicted of a violent crime.

On the other hand, the researchers found that patients with severe mental illnesses were nearly 4 times more likely to have committed at least one violent crime as compared to the general public (6.6% of mentally ill patients had a violence conviction compared with 1.8% of the general population). The study confirms findings in the U.S. that the relative risk of violence is higher for severely mentally ill patients (specifically those with diagnoses involving psychoses) than for the general public. The CATIE violence study found that patients with schizophrenia were 10 times more likely to engage in violent behavior than the general public (19.1% vs. 2% in the general population). In other words, it is more likely that a person with mental illness will be violent than a person in the general public. It is also interesting to note that patients with schizophrenia were nearly twice as likely to be violent (the number of violent crimes committed was 328 per 1,000 patients with schizophrenia and 173 per 1,000 patients with other psychoses).

Because there is a greater risk that people with mental illness may be violent, it is important for families and caregivers to recognize and have a better understanding of what factors contribute to this risk. For example, a recent CATIE study (see Figure pg. 496) reported that schizophrenia patients experiencing certain positive symptoms (hallucinations, paranoid delusions, and grandiosity) were 9 times more likely to have an episode of serious violent behavior than patients who had negative symptoms (apathy, social withdrawal, poverty of thoughts, blunting of emotions, slowness of movement, and lack of drive). This information is also important in terms of public policy because it supports the need for more timely and effective emergency psychiatric interventions when the most severely mentally ill become symptomatic.

Additional data from the study illustrates why it is important to understand the link between violence and mental illness. In a separate analysis by type of offense, researchers found that patients with severe mental illnesses, who accounted for only 1.4% of the general population, were responsible for 18% of homicides and attempted homicides in Sweden. That is not a statistic that can be ignored.

Schizophrenia and violence

A comprehensive new study confirms violence is not an anomaly for some patients with schizophrenia. Researchers, using data from the National Institute of Mental Health Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) project, found that 19.1% of participants had a violent incident in a six-month period.

“This study joins a large body of scientific research confirming what we can too easily see each day in the newspaper,” said Treatment Advocacy Center President Dr. E. Fuller Torrey. “Although most individuals with mental illnesses are not violent, violence by a subgroup of individuals with schizophrenia is far from rare. And the violent behavior is almost always associated with the person not having received treatment for their illness. The only solution is treatment.”

The study also found that the symptoms most predictive of violent behavior are positive symptoms, like hallucinations, paranoid delusions, and grandiosity. “Positive symptoms of schizophrenia are not only the ones most predictive of violence, but also the ones most responsive to medication,” noted Dr. Torrey.

CATIE - Phase 2

The National Institute of Mental Health has released further findings from its large-scale examination of treatments for schizophrenia in its Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE).

The initial results were presented last September, and were chiefly a comparison of various anti-psychotics when used as initial or first-line treatments for the symptoms of schizophrenia. The outcomes from the first stage of this large-scale study were widely reported in the national media, principally because an older and far cheaper antipsychotic of the previous generation had results analogous to "atypical" antipsychotic medications that are many times more expensive.

Results from CATIE’s second phase are reported in the April issue of the American Journal of Psychiatry and evaluate how various antipsychotics perform as second-line medications, i.e., ones that are tried after another is discontinued. The clear winner for performance in CATIE’s second round is clozapine, which was not tested in the first phase. 44% of patients who took clozapine (brand name: Clozaril) after trying another anti-psychotic stayed on it for the rest of the 18-month study, versus only 18% who switched to the other medications tested.

We caution, however, that determining what medication should and can be used for a particular person entails far more considerations than the results of a single study (no matter how large or well-constructed). Different things work for different people.

Dr. Torrey talks about CATIE study

TAC President Dr. E. Fuller Torrey will be on the Diane Rehm Show (88.5 FM) Thursday, Sept 22, from 10-11, discussing the results of the CATIE trials comparing antipsychotic medications. NIMH director Thomas Insel will also be interviewed.