Psychiatry & Psychotherapy Podcast - How Much Violence Is Due To Mental Illness?

Episode Date: February 8, 2020

In this short episode of The Psychiatry and Psychotherapy Podcast, I interview Dr. Cummings, a forensic psychiatrist, on the topic of the correlation of mental illness and violent crime, and what causes violent crime. I start out with reviewing some studies and then subsequently interview Dr. Cummings, a leading psychiatrist at one of the largest forensic psychiatric hospitals in the United States.  By listening to this episode, you can earn 0.5 Psychiatry CME Credits. Link to blog. Link to YouTube video.

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All right, welcome back to the podcast. Today, I'm going to have Dr. Cummings on, but before I do, I'm going to have a little bit of an introduction to this topic of violence and mental health. I think this is an important topic to discuss because so much in the media and in movies, there's this depiction of the person with mental health issues having a major psychiatric diagnosis being very violent. And so I recently posted it on TikTok and, you know, this went out and got, got something like 27,000 hearts and 143,000 views on this topic saying that, you know, only 5% of violent acts are done by someone with a major mental health issue without the comorbidity of drug or alcohol use. And that 5% people are, people got really upset about this. People are saying like, oh, there's, you know, where's your data? Where's your citations? And so I thought I would have Dr. Cummings on talk about this a little bit, but I thought I would also go through some studies talking about this, you know, because it's a major stigma-increasing idea that a lot of the

violent acts in America are caused by people with mental health issues. So there's this nice article, Stewart 2003, and for those of you who like to look at the citations, this will all be in my resource library on my website, Psychiatrypodcast.com. So there's this article, Stuart 2003, that goes through some details on this. It's called violence and mental illness and overview. And they talk about, first of all, how there's this common fear that mentally ill are violent. for example in one study they found that respondents rated the following groups as very or somewhat likely of doing something violent to others drug dependence 87 percent alcohol dependence 70 percent schizophrenia 60 percent major depression 33 percent and troubled 16 point eight percent so there's this

kind of thought that people with schizophrenia or you know, depression or maybe bipolar are at high risk of doing these violent acts. And we know that people with mental illness are more likely to be victims of violence, right? So in one study of the current victimization among impatience, for example, 63% of those with a dating partner reported physical victimization in the previous year. and a recent study of criminal victimization of people with severe mental illness showed that 8.2% were criminally victimized over a four-month period, much higher than the annual rate of violent victimization of 3.1% of the general population.

So we know that people with mental health issues are more likely to be victimized. In the MacArthur Violence Risk Assessment Study, they followed 1,136 people with good controls. They looked at their neighbors, so people with the same socioeconomic status. And they found that of those that had mental illness but did not abuse substances, the risk of violence was indistinguishable from their non-substance abusing neighbors. Substance abuse doubled the risk. That was interesting to me. Another study showed that in the general population, the attributable risk, the overall effect a factor has on the level of violence in a population for mental health issues, major mental

health illness. They found it was 4.3% of violent acts, whereas the attributable risk for substance abuse was 34%. And if they had substance abuse and a major mental illness, it was another 5%. So this study said that only 10% of the violent acts would be reduced in the U.S. if you treated those with major mental illness or if you remove those people from the population and you remove the people with major mental illness and substance abuse. So that's only 10% of all violent acts.

So in a Canadian study of 1,151,000, newly detained, criminals, so people detained, only 3% of the crimes were attributable to mental disorders, such as schizophrenia, bipolar, and depression. If we zoom in on specifically schizophrenia and violence, there was this very nice systemic review meta-analysis in 2009, Frazel. And he showed that those with substance abuse and schizophrenia had an odds ratio of violence of about nine. But if they just had pure schizophrenia without substance abuse, the odds ratio was only 2.1. And in my PDF that I'm going to make with this, I'll give you the picture of those. And it's very remarkable.

So only two times more likely than the general population of committing a violent act with schizophrenia and no comorbid substance abuse. And they also found that those with schizophrenia and substance abuse had about the same odds ratio as those with just substance abuse. But coming back, why is this important? Because the population at large, when they're surveyed, another study showed that 46% of people surveyed said that those with mental illness were far more dangerous than the general population, far more. So a lot of people believe this. In another study, Hodgkins' 1992 article, they found that those who were intellectually handicapped were five times more likely to commit a violent offense if they were male and 25 times more likely if they were female. So people with lower

IQ tend to be more violent. And we don't consider low IQ a mental health diagnosis per se. You know, when we're looking at that 5%, this is sort of outside of that. In another study of patients with bipolar disorder, bipolar patients, they found that about 8.4% of bipolar patients will commit a violent act compared to about 3.5% in the general population. So they gave it an odds ratio of 2.3. But the risk was actually mostly related to those who were bipolar with substance abuse. And the risk was actually decreased if you compare the person with their own sibling. So if you compare the person with an unaffectual. sibling, so this is kind of controlling for all the environmental factors that they were raised in,

the risk goes down to 1.1 odds ratio, so very low. In another study of risk of violent crimes and individuals with epilepsy and traumatic brain injury, they found that among those with TBI, 2011 individuals, 8.8% committed violent crimes after the diagnosis, which is compared to the general population that was around at that time, gave them an odds ratio of 3.3. But then when you compared them with their unaffected siblings, the odds ratio went down to 2. So once again, you're controlling for that environmental upbringing, so the risk went from 3.3 to 2. of increased violent events. Further substance misuse in violent crimes was a nice Swedish study,

and they found that the population attributable risk in this very large study for misuse of any substance was 23%. Alcohol was 16.2%. Interesting, they put marijuana at 1.7%, opiates at 2.5% and the amphetamines at 3.4%. I'm not surprised by that amphetamines being high. And polysubstance at 6.3%. So overall, 23% of all violent acts could be attributed to some substance use in this one study.

In another study, they looked at personality disorders, and they found that in general, people who had a diagnosis of personality disorder had it increased odds of violence of three, so three times more likely, but with antisocial personality disorder, the odds ratio was 12.8. And they said that specifically 14% of those with antisocial personality sort of were violent.

So all of this kind of coming back to this point, and now we'll listen to Dr. Cummings and ask them some questions, and we'll talk about, some of the details on not only the physical shootings and antisocial personality disorder. And I really hope that this helps clear your mind and helps you answer the question if people were to ask, you know, oh, is this mental health illness that's causing the large amounts of violence that we see? But coming back to this big point is that I think we really put a lot of,

lot of focus on the mental health issues of a lot of these violent acts that we see, both in movies and on the media. And as mental health professionals, I think we need to be more vocal that actually the data says most violent acts are not related to a major mental health diagnosis. So I hope you join me on social media and promoting these good ideas. And if you're not on TikTok, check me out at DR. dot David Puter. I'll put the link on this document if you find it. And I think those of you who don't know what TikTok is, it's a good way to reach this upcoming

generation. There's a large amount of people who are interested in mental health is what I've found. And if you want to be on social media, I think it's a good place to reach people with good knowledge. So that's what I'm trying to do. And I hope you join me. All right, so we'll get into the topic with Dr. Cummings. So, Dr. Cummings, what, when we talk about the violence rate in mental health diagnosis

as being around 5%, what are we talking about in particular there? Okay. We're talking about two separate statistics, and it's important to think about them separately. If you ask, out of all of the violent crimes, how many of those are committed by people with a mental disorder? And the answer is about 5% of violent crime is committed by people with mental illness. The other 95% are committed by people who have other motivations for committing a violent crime. On the other hand, if you say, well, do people who suffer people who suffer? from mental illness, particularly severe or serious mental illness, have an elevated individual

rate of violent behavior compared to the general population, the answer is yes, they do. In particular, those people who suffer from illness characterized by persecutory delusions, beliefs that other people are trying to harm them, understandably, from their perspective, they may act violently to defend themselves. And most studies have found that those people have violent behavior at about 10 times the rate of people who have no mental illness. But we're talking about a very tiny number of people that although they have individually an elevated rate of violence,

mentally ill people still account for a very tiny portion of violent crime in general. So when we talk about mentally ill patients, we're talking about major depressive disorder, bipolar, schizophrenia. We're not talking about substance use disorder. Substance use disorder is one of those, it almost acts like a leavening agent with respect to violence. If somebody has a serious mental illness and they also are prone to substance use, the substance use will increase their risk of becoming violent, which is no huge surprise. People without mental illness if they are intoxicated

are more likely to engage in violent acts. Many of the substances that are abused impair judgment, impair impulse control, you know, the classic historic bar room brawl, is not entirely fiction. What do you think that other 95% like what percent of those are people with psychopathy,

sociopathy? Fairly, well, a fair number of the people who commit violent crimes would meet the DSM criteria for antisocial personality disorder. Now, one of the criticisms of the DSM is that in its attempt,

to be a theoretical, they approached antisocial almost purely on behavioral terms, without much consideration of the intra-psychic characteristics of psychopathy. So that if you look at, for example, a prison population, you'll find that the number of people in prison, serving a prison term, somewhere roughly between two-thirds and three-quarters of those people would meet the criteria for antisocial personality disorder. But if you ask how many of them meet the definition of psychopathy, at least as defined by Robert Hare in his research studies, meaning a psychopathy checklist revised score of greater than 30,

it's only about a third of the antisocial people who meet that level on the PCR. are. So the psychopaths are a much smaller group than people who are antisocial. I think the other valid criticism of antisocial personality disorder is that the DSM also does not consider the environment in which the person exists. There are neighborhoods and social circumstances in which frankly if you had no capacity for antisocial behavior odds are your long-term survival would not be good okay so people are struggling with like what is that other 95 percent like what is what is happening what is causing all the violent acts that we're seeing like especially the school shooters that was a

big thing that came up people are really wondering like what is going on with this population The school shooters, like most things, have varied from Columbine onward. These are often disaffected, isolated, not uncommonly marginalized individuals who may then take on a program somewhat of self-radicalization, where they become enamored of violent themes, violent groups. There is one of the things that has evolved with the Internet are essentially violent Internet subcultures, not that everyone who goes to those sites or engages in those chat rooms goes on to create violent behavior,

but it's an excellent mechanism for sort of self-radicalization, not in this case having anything to do. do with religion or politics, but just if you're an unhappy teen who's been marginalized, perhaps bullied or mistreated, and you find a group that espouses violence and revenge as major themes, that may become attractive. And, you know, it's a way to feel powerful and in control. And in some people, that's enough to push them into planning and then executing a mass shooting.

One of the posts that someone posted was that they felt like every single mass shooter was on SSRIs. Do you have any comment on that? Well, I don't know that people have looked at the prescriptions of all mass shooters, but I seriously doubt that that's true. You know, the data that does exist

regarding serotonin is that an acute deficit in serotonin is associated with violent impulsive behavior. Certainly if you had people who had that as a history and they were exposed to treatment, it's plausible that someone would have prescribed them in SSRI. I don't think it would be a correct inference to say that SSRIs cause people to become violent. Yeah, I think I was at an APA meeting and there was a forensic psychiatrist. who was on a lot of these cases. And one of his comments was that some blogs will start a rumor that this person was on this drug or that drug. And then it will be copied.

And he's actually seen like cases where he's been involved in the actual case. And he's seen, you know, the actual court records. And this person wasn't on this medication, but in blogs and, you know, media, it will be kind of repeated over and over again. Well, one of the, well, you know, very broadly with respect to the NRA, One of the problems, of course, is that anyone can post anything, and frankly, when things that are false get repeated often enough, people sometimes assume they're true. There's also an issue of cause and effect. If someone has difficulty with anxiety, depression, impulsivity, and they do seek psychiatric care, the SSRI antidepressants may be very commonly prescribed. class of medication for such individuals, but to then turn around and blame the SSRI for the

person's subsequent violent behavior is a bit like blaming the tombstones in the cemetery as causes of death. But death is correlated with tombstones, Dr. Cummys. Yes, it is. It's correlated. There's a high correlation. There's a high correlation. But correlation and causality are two separate things.

So, okay, coming back to that, like, how much violent events are gang related or how much of them are choice or how much of them are, like, have nothing to do with PTSD or with depression or with bipolar, with... Very likely the majority. You know, there are subcultures and regions in which, you know, gangs are dominant and do engage in violent behavior. intimidation. That's a major contributor in some areas to violence. Domestic disputes, arguments within families are another area that is ripe with violent behavior. And most of these people would not be characterized as suffering from a mental illness. They may indeed be in very difficult social circumstances or they may be engaging in violent behavior. with respect to gangs and groups as a means to assert authority and gain advantage over others.

You know, coming back to your original question, it's simply not true that the vast majority of criminal behavior in general is the byproduct of mental illness. Another kickback people say is that like, aren't there probably underlying like mental health issues in these people? like how can someone, you know, do something incredibly violent like a mass shooting from just ideas or choice or, you know, if that person was bullied, wouldn't that be then they have PTSD and need psychiatric treatment, you know? They may or may not have PTSD. There are some cases that we don't understand very well. For example, I don't think we'll ever know the motivation of the mass shooter in Las Vegas who decided to, shoot up a country music festival from a hotel room. His history was he had been successful, had a girlfriend, was successful in real estate, but apparently had been collecting weapons

for years without anyone knowing about it. What his reasons were for seeking to be violent, we'll never know, because unfortunately he didn't survive to tell us why he did that. And he didn't leave any records. Other cases like the shootings last year in Virginia seem more straightforward. Disgruntled city employee decides to go on a shooting spree at work, although he wasn't being disciplined. Apparently he was unhappy about his work circumstances. Here in San Bernardino a number of years ago, we had a mass shooting by a pair who had become

a husband and wife who had become radicalized. with respect to Islam, and they were also unhappy with their work circumstances and basically killed a number of their work colleagues before they themselves were killed. I guess the point I'm getting to is simply that the motivations vary tremendously from incident to incident. I don't think there is a single sort of universal thing you can point to and say, well, this is the cause of mass violence. I think one of the unfortunate things that has happened

is that mass shootings, which are formally defined as four or more victims, have become increasingly common in the U.S., and I think that, unfortunately, the more of these occur, the more it has a normalizing effect, meaning that people may be more likely to choose that option as a way to express their distress or their displeasure. Yeah, it has increased.

It's still very rare, I mean, relatively to other causes of death. The mass shooting sort of trend in the U.S. is unique to this time. Do you have any other sort of reflections or would, like, as a forensic psychiatrist who's been looking at this, like, what are some of the big things? that you think about when you see the mass shootings? I think that in many ways this is a reflection of the fact that over time, as a society, we have become more and more polarized. And in some cases, for some groups, that means becoming more marginalized,

having less advantage. Upward mobility in the U.S. has largely stagnated. So I think there are many large-scale social issues that may be driving people toward greater unhappiness and frustration. Unfortunately, you know, when you have large numbers of people who may be frustrated and who may be to some extent becoming hopeless about their situations, turning to violent behavior is a potential outcome of that. Yeah.

All right. Let's maybe we'll bring it to a close. Any closing thoughts on this sort of question or further reading? I certainly would encourage people to read the works of Robert Hare and Adrian Raine with respect to a more in-depth understanding of psychopathy. You know, certainly the literature abounds now with issues about violence, both related to mental illness and unrelated to mental illness. I would encourage people to not get caught up in believing everything they read on the

internet, however. Yeah. And so check our details as well, you know. Check it for yourself. Read the actual studies. Okay, so once again, these notes will be in the resource library. Go to Psychiatrypodcast.com. It's pretty easy to find from there.

It's also posted in the show notes here, the link. And I really hope that this has helped you move from a place of thinking that a lot of the violent acts that occur in the U.S. are due to a mental illness. Okay. and more often they're due to other reasons, like drugs and alcohol seem to be one of the big things that increases the risk of violent acts. And if you have any questions, I would love to hear them.

I will be posting this on my social media platforms, and so you're welcome to jump on and comment or shoot me an email.