Violence and mental disorders. A retrospective study of people in charge of a community mental health center

IJLP-01153; No of Pages 7 International Journal of Law and Psychiatry xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

International Journal of Law and Psychiatry

Violence and mental disorders. A retrospective study of people in charge of a community mental health center Federica Pinna a, Massimo Tusconi a, Claudio Dessì a, Giuseppe Pittaluga a, Andrea Fiorillo b, Bernardo Carpiniello a,⁎ a b

Department of Public Health, Clinical and Molecular Medicine, Unit of Psychiatry, University of Cagliari, Italy Department of Psychiatry, Second University of Naples (SUN), Italy

a r t i c l e

i n f o

Available online xxxx Keywords: Physical violence Mental disorders Community treatment Predictors

a b s t r a c t Background: Numerous studies conducted in inpatient settings have highlighted how mental disorders are associated with an increased risk of violence, particularly during acute phases. However, to date a more limited number of studies have been performed to assess the risk of violence in outpatients, particularly in Italy. The present study aims to evaluate the prevalence of violent events in a sample of patients in charge of a community mental health center in Italy. Methods: Based on data obtained from standardized clinical records, a retrospective study was undertaken to investigate acts of violence (physical aggression only) in a total of 678 patients (Males = 308, 45.4%) in charge of a university mental health center; patients were mainly affected by anxiety disorders (30.7%), depressive disorder (17.2%), bipolar disorder (18.3%) and schizophrenia or other psychotic disorders (25.0%). Results: 27.6% of the sample had committed at least one act of violence during their lifetime, 10.5% over the previous year. 56.7% of those who committed violence acts had acted violently twice or more during their lifetime. A significant association of lifetime violence was found with gender (male), younger age, low education, unemployment, living with parents. With regard to diagnosis, a significant association was found with schizophrenia and other psychotic disorders, personality disorders, mental retardation, and comorbidity between two or more psychiatric disorders. Violence was moreover associated with early age at onset and at first psychiatric treatment, longer duration of the disorder, previous hospital admissions, previous violent events. Conclusion: Violent behavior is relatively common among outpatients. © 2016 Elsevier Ltd. All rights reserved.

1. Introduction Although controversial, the association between increased risk of violent behavior and mental disorders has been documented by numerous epidemiological studies (Arsenault, et al., 2000; Brennan et al., 2000; Elbogen & Johnson, 2009; Hodgins, 1992; Rasanen et al., 1998; Swanson, 1990; Tiihonen et al., 1997). With regard to clinical samples, the risk of violence seems to be higher among inpatients and those with more severe disorders (Fazel & Grann, 2006; Swanson et al., 2002). Indeed, violent behavior is more frequently reported among individuals hospitalized for an acute condition (Edlinger et al., 2014). Outpatient studies have focused largely on cases of severe and/or chronic mental disorders, such as schizophrenia (Asnis et al., 1994; Bobes et al., 2009; Swanson et al., 2006a, Swartz, et al., 2006), or on outpatientcommitted persons (Swanson et al., 1998, 2006b), generally reporting

⁎ Corresponding author at: Dept. of Public Health, Clinical and Molecular Medicine, Unit of Psychiatry, University of Cagliari, Via Liguria 13, 09127 Cagliari, Italy. E-mail address: [email protected] (B. Carpiniello).

lower rates of violent behavior compared to those found among inpatients. A certain number of studies on acute inpatients admitted to public psychiatric wards in general hospitals, have been published in Italy (Cornaggia et al., 2011), while only one study refers respectively to residential facilities (Candini et al., 2015) and community mental health centers (CMHCs) (Catanesi et al., 2007). The paucity of data relating to violence among patients in charge of CMHCs in Italy is of the utmost importance, particularly when taking into account how outpatient community services form the backbone of the public psychiatric system in Italy (de Girolamo et al., 2007; Ferrannini et al., 2014). Furthermore, a recently approved law providing for the closure of forensic hospitals (Barbui & Saraceno, 2015; Peloso et al., 2014), is expected to result in an increase in the number of people affected by mental disorders with legal issues being committed to CMHCs. Starting from these premises, and in the wake of a previous study of patients subjected to violence (Pirarba et al., 2010), the present study reports preliminary data from a retrospective cohort study of violent behavior observed among patients referred to a university CMHC in Italy, as a part of an ongoing study program on violence and mental disorders. The main goal of the study was to assess lifetime and one-year prevalence of violent acts,

http://dx.doi.org/10.1016/j.ijlp.2016.02.015 0160-2527/© 2016 Elsevier Ltd. All rights reserved.

Please cite this article as: Pinna, F., et al., Violence and mental disorders. A retrospective study of people in charge of a community mental health center, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.02.015

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F. Pinna et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx

and determine the main sociodemographic and clinical risk factors for violence.

males were more frequently single, unemployed or receiving a disability pension. Sociodemographic characteristics of the sample are reported in Table 1.

2. Materials and methods 3.2. Clinical characteristics of the sample 2.1. Methods Sample selection was based on a two-stage process. In the first stage, all patients aged 18 and above attending a university community mental health center with a catchment area of approx. 80,000 inhabitants over a four-month period (1 August–30 November 2014) were identified from the center register. In the second stage, patients were randomly selected (one out of three); to enhance the retrospective evaluation of cases, clinical records were examined to ascertain suitability to provide reliable retrospective data. In the case of largely incomplete or missing records, the selected case was discarded and substituted by the following one. The Ethics Committee of the Local Health Authority approved the study. Selected patients gave their informed consent prior to inclusion in the study. All included subjects were receiving standard treatment generally adopted in community mental health centers throughout Italy (psychopharmacological treatment, clinical monitoring at least on a monthly basis, home care when required, psychosocial and rehabilitation interventions tailored to patients' needs). In line with procedures applied in previous studies (Carpiniello et al., 2002; Primavera et al., 2012), data were collected retrospectively from standardized clinical records routinely used in the community mental health center, as described by the Italian version of procedures suggested by the Association for Methodology and Documentation in Psychiatry (AMDP) (Conti et al., 1988). In particular, sociodemographic (gender, age, education, marital status, working status) and clinical data, namely age at onset of the disorder (based on first clear-cut psychopathological symptoms), age at first treatment (pharmacological and/or psychosocial), number of inpatient admissions, number of attempted suicides and violent acts were taken into account. Physical aggression toward persons and/or objects were the only violent behaviors considered: thus we excluded verbal aggression and any other form of psychological violence. As regards suicidal attempts, only acts resulting in physical harm and/or a significant risk for physical health or life resulting in admission to an emergency department were taken into account. Patients' lifetime history of legal actions or trials, admissions to forensic psychiatric hospitals or judicial restrictive measures were also recorded. All clinical details were collected directly from patient interviews and, whenever possible, from other informants. Where necessary, to clarify the type of registered violent events, physicians and other members of staff (psychologists, nurses, social workers) in charge of patients were interviewed. All data were collected on a datasheet specially created for this study. Data were entered in a dataset and evaluated using the SPSS-22 statistical package. Student's t-test for unpaired data was used to evaluate differences between continuous variables. Pearson chi square test or Fisher exact test was used for categorical variables. Bivariate correlations were evaluated by means of Pearson's “r” in the case of continuous variables, or Cramer's phi in the case of categorical variables. Strength for non-independence between two binary data values was evaluated in terms of odds ratios and 95% confidence limits. All tests were two-tailed; the level of statistical significance was set at a p value equal to or lower than 0.05. 3. Results 3.1. Sample The sample consisted of a total of 678 patients (54.6% females); subjects were middle-aged (mean age 49.6 ± 15.3 years, range 18–93 years) mostly single (69.9%), unemployed (73.9%) and with an average level of education (10.0 ± 3.82 years); 25% were receiving a disability pension. A higher average age was observed among females;

The distribution of the sample on the basis of the main diagnosis according to DSMIVTR reads as follows: 30.7% anxiety disorders (N = 205), 17.2% depressive disorder (N = 115), 18.3% bipolar disorder (N = 122), 25.0% schizophrenia and other psychotic disorders (N = 167), 3.0% personality disorders (N = 20), 2.7% mental retardation (N = 18), 3.1% other diagnoses (N = 20); in 0.1% of cases (N = 1) the main diagnosis could not be identified. Mean age at onset of the disorders and at first treatment was lower among males; the latter had been more frequently admitted into psychiatric wards or forensic psychiatric hospitals (Table 2). 3.3. Prevalence of violent behaviors 27.6% of patients (N = 187) had committed at least one act of violence at some point in their life. Of these, 116 (17.1%) had perpetrated a violent event in the twelve months prior to the survey; the remaining 71 (10.5%) had been violent during the preceding year. 21.7% of the total sample (n = 40) had acted violently only once in their life, 20.7% (n = 38) twice; 57.6% (n = 106) more than twice. 14.1% (n = 26) patients had acted violently toward objects or animals; 48.6% (n = 90) toward persons; 18.4% (n = 34) toward both things/animals and persons; in 18.9% of cases (n = 35) data were uncertain. A relevant correlation between lifetime and last-year violence was detected (phi = 0.52, p b 0.001). 3.4. Violent behaviors according to socio-demographic variables With regard to sociodemographic and clinical variables, data analysis was specifically based on lifetime violence. Lifetime violent behavior was mainly associated with male gender, younger age, single status, lower education and unemployment (Table 3). An association between younger age and violence (OR = 1.73, 95% CI 1.23–2.44) was confirmed by dividing the sample into two age classes according to median age (subjects aged below 45 years and 45 years and over): a prevalence of 47.0% violent subjects (n = 88) in individuals aged $_amp_$lt;45years, and 33.19% (n = 318) among subjects aged ≥45 years (chi square test = 9.96, df = 1, p = 0.011) was identified. No association was found between residential status and lifetime violence (OR = 0.98, 95% CI 0.58–1.66), with a 27.8% (N = 22) frequency of violent individuals detected among subjects who lived alone, and 28.2% (N = 155) in subjects living with other people (chi square test = 0.00, df = 1, p = 1.00). However, on closer inspection of the violent events classified according to residential status (living alone, living with acquired family, living with family of origin, living with all other people), a relevant connection

Table 1 Socio-demographic characteristics of the sample according to gender.

N (%) Mean age years (±s.d.) Marital status (N, %) Singles Married Mean years of education (±s.d.) Employment (N, %) Employed Unemployed a b

Males

Females

Total

Statisticsa

308 (45.4) 47.1 (14.2)

370 (54.6) 51.6 (15.8)

678 (100) 49.6 (15.3)

p b 0.0001

246 (79.9) 62 (20.1) 9.58 (3.9)

226 (61.1) 144 (38.9) 11.5 (3.5)

472 (69.6) 206 (30.4) 10.0 (3.8)

68 (22) 240 (78)

105 (28.4) 265 (71.6)

173 (26.1) 505 (73.9)

p b 0.0001 n.s.b

p = 0.05

Level of significance of differences between genders. No significant difference.

Please cite this article as: Pinna, F., et al., Violence and mental disorders. A retrospective study of people in charge of a community mental health center, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.02.015

F. Pinna et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx Table 2 Clinical characteristics of the sample.

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Table 4 Clinical variables associated with lifetime violence.

Diagnosis

N (%)

Factor

Evidences

Statistics

Anxiety disorders Depr. disorders Bipolar disorders Schizophreniaa Person disorders Mental retardation Other Missing Mean age (years) at onset (±s.d.) Mean age (years) at first treatment (±s.d.) Mean duration (years) of illness (±s.d.) Pts. with hospital admissions (N, %) One Two or more Pts. with forensic hospital admissions (N, %)

205 (30.2) 115 (17.0) 122 (18.0) 167 (24.6) 20 (2.9) 18 (2.6) 20 (2.9) 11 (1.6) 30.8 (16.8) 34.7 (10.1) 18.7 (13.6)

Age at onset (years, mean ± s.d.) Age at first treatment (years, mean ± s.d.) Duration of illness (years, mean ± s.d.) Hospital admissions, N (%) Forensic hospital admissions, N (%) Attempted suicides, N (%)

Violent pts. = 24.3 ± 15.5 Not violent = 33.3 ± 16.7 Violent pts. = 28.6 ± 14.5 Not violent = 37.0 ± 16.0 Violent pts. = 21.9 ± 12.6 Not violent = 17.5 ± 13.8 Violent = 83 (61.9) Not violent = 137 (36.1) Violent = 14 (100) Not violent = 0 (0.0) Violent = 48 (34.5) Not violent = 59 (15.3)

t = −5.47, p = 0.0001

a

emerged between violent behaviors and living with family of origin (OR = 2.08, 95% CI 1.46–2.96). Indeed, our data revealed 37.2% (N = 93) violent individuals living with their family of origin compared to 27.8% (n = 22) living alone, 18.6% (n = 48) living with acquired family, and 33.3% (N = 14) living with others (i.e. sheltered housing, foster homes, assisted accommodation) (chi square test = 22.312, df = 1, p $_amp_$lt; 0.001). 3.5. Violent behavior based on clinical variables Violent behavior was associated with lower age at onset, lower age at first treatment and longer duration of illness; violent patients had been more frequently admitted to psychiatric wards and forensic psychiatric hospitals (Table 4). With regard to diagnosis (Table 5), a higher frequency of violent behaviors was associated with schizophrenia and other psychotic conditions, mental retardation and personality disorders. Bipolar disorders were associated with a non-statistically significant higher risk of violence. However, the only conditions associated with a considerably higher risk of being subjected to legal actions or trials are bipolar disorders (10% of bipolar patients versus 3.3% of other patients, OR = 3.253, 95% CI 1.5222–6.950, p b 0.001) and personality disorders (15% vs 4.2% of other conditions, OR = 4.039, 95% CI 1.115–14.621, p = 0.022). Similarly, bipolar disorder is the only diagnosis associated with a significantly higher risk of admission to a forensic psychiatric hospital

Table 3 Sociodemographic factors associated with lifetime violence. Evidences

Gender, N (%)

Males 123 (39.9%) Females 64 (17.3%) Age (years, mean ± s.d.) Violent pts. = 46.1 ± 14.6 Not violent = 50.1 ± 15.7 Education Violent pts. = 9.5 ± 4.0 (years, mean ± s.d.) Not violent = 13.8 ± 10.4 Marital status, N (%) Married 37 (18) Singlesa 146 (31.9) Parenthood, N (%) With children 80 (33.1) Without children 121 (66.9) Employment, N (%) Employed 37 (21.4) Unemployed 146 (29.7) Living status, N (%) Living alone 22 (27.8) Living with any other 155 (28.2) Living alone 22 (27.8) Living with family 93 (37.2) a

Including separated, divorced, widowed.

t = −3.76, p = 0.0001 OR = 2.89, Cl 95% 1.92–4.33, p b 0.0001 OR = ∞, p = 0.0001 OR = 2.91, Cl 95% 1.86–4.55, p = 0.001

77 (11.4) 188 (27.7) 18 (2.7)

Other psychoses included.

Factor

t = −6.08, p = 0.0001

Statistics OR = 3.18, Cl 95% 2.22–5.52, p b 0.0001 t = −2.71, p = 0.007 t = −2.33, p = 0.002 OR = 0.42, Cl 95% 0.21–0.60, p b 0.001 OR = 0.47, Cl 95% 0.33–0.67, p b 0.001 OR = 0.60, Cl 95% 0.40–0.90, p = 0.035 OR = 0.98, Cl 95% 0.58–1.66, p = 1.0 OR = 2.10, Cl 95% 1.46–2.96, p b 0.05

(5.9% vs other diagnoses, OR = 3.208, 95% CI 1.148–7.983, p = 0.019) along with personality disorders (15.0% vs 2.3% of other conditions, OR = 7.388, 95% CI 1.954–27.933, p = 0.001). In contrast, anxiety disorders and depression were linked to a lower frequency of violent behavior than other diagnoses. As shown in Table 5 the presence of a psychiatric comorbidity (presence of at least two comorbid psychiatric conditions, mostly an axis I plus an axis II disorder, or an axis I disorder plus substance abuse/dependence) is associated with a higher proportion of cases of violence. Finally, the rate of lifetime suicide attempts was 18.9% (N = 128), of which 1.9% had occurred over the last year (N = 13). Furthermore, the proportion of patients with a lifetime history of suicide attempts was 31.7% (n = 59) in subjects with a lifetime history of violent acts, and 14.1% (N = 69) in those without a history of violence. Accordingly, a marked interrelationship of lifetime violence and lifetime suicide attempts (phi = 0.55, p b 0.001) was revealed.

3.6. Recurrent violence To investigate variables related to recurrence of violent acts, we compared two groups of patients: those who had committed only one act of violence during their life (not recurrent cases) and those who had been violent twice or more (recurrent cases). Significant variables associated with recurrence are shown in Table 6. Recurrent cases were significantly associated with younger age and single status; on the contrary, having children and being affected by bipolar disorder did not appear to be associated with risk of recurrence.

Table 5 Lifetime violence according to principal diagnosis. Diagnosis N, % Mental retardation 10 (71.4) Personality disorders 4 (57.1) Comorbid disorders 76 (39.6) Schizophrenia and other psychoses 52 (42.3) Other disorders 5 (35.7) Bipolar disorders 31 (33.0) Depressive disorders 14 (16.5) Anxiety disorders 22 (12.7)

Any other disorder 129 (25.7) Any other disorder 135 (26.5) No comorbid disorders 64 (19.2) Any other disorder 87 (22.1) Any other disorder 134 (26.7) Any other disorder 107 (25.5) Any other disorder 125 (37.7) Any other disorder 117 (34.4)

OR

95% CI

p value

7.22

2.23–23.45

0.0005

3.698

0.82–16.72

0.088

2.75

1.85–4.10

b 0.001

2.58

1.68–3.96

b 0.0001

1.53

0.50–4.63

0.540

1.43

0.89–2.31

0.136

0.48

0.26–0.88

0.017

0.27

1.17–0.43

b 0.0001

Please cite this article as: Pinna, F., et al., Violence and mental disorders. A retrospective study of people in charge of a community mental health center, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.02.015

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F. Pinna et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx

Table 6 Recurrent violence: significant associations. Variable

Recurrent violence

Not recurrent violence

Statistics

p value

Age b 45 years N 45 years

52.1% 47.9%

30% 70%

OR = 2.54 95% CI 1.17–5.37

0.013

Civil status Single Married

83% 17%

35.9% 64.1%

OR = 2.73 95% CI .24–6.00

0.01

Children Yes No

28.6% 71.4%

46.2% 53.8%

OR = 0.47 95% CI 0.22–0.97

0.038

Bipolar disorder Yes No

18.8% 81.2%

35.9% 64.1%

OR = 0.41 95% CI 0.19–0.89

0.023

4. Discussion The issue of violence perpetrated by people with mental disorders continues to be widely investigated, due to both its importance from a public health perspective, and to the common perception of the dangerousness of mental disorders, reflected and amplified by media reports (Carpiniello et al., 2007). The issue of violence perpetrated by the mentally ill is of outstanding importance, particularly in countries such as Italy where the majority of people with mental disorders, even the most severely affected, live in the community. Indeed, psychiatric hospitals in Italy were closed more than thirty years ago, and the public mental health system is largely based on a widespread network of community mental health centers (CMHCs) (de Girolamo et al., 2007; Ferrannini et al., 2014). Moreover, a recently approved law relating to the closure of forensic hospitals (Barbui & Saraceno, 2015; Peloso et al., 2014) is expected to result in an increase of the number of people affected by mental disorders with legal issues being committed to CMHCs. Numerous studies have investigated violent behavior among inpatients of Italian psychiatric wards (Amore et al., 2008; Biancosino et al., 2009; Colasanti et al., 2008; Cornaggia et al., 2011; Troisi et al., 2003; Vanni et al., 2004). To judge from the data available in literature, the frequency of violent behavior among Italian inpatients seems to be quite low. In particular, the results obtained in a multicenter study of 1324 patients admitted to a series of acute care facilities in Italy (Biancosino et al., 2009) have demonstrated that only 10% of inpatients display hostile behavior (without physical aggression), and an even smaller percentage (3%) are physically violent. However, single studies focusing on smaller samples have reported significantly higher percentages, with 45% of patients displaying verbal aggressiveness and 33% physical assaults (Colasanti et al., 2008). A large USA review has reported that rates of violence committed by inpatients are significantly higher than those reported for other samples, ranging from 10 to 50% (Choe et al., 2008), while a further study investigating violence perpetrated during a first or subsequent admission over the next two years reported rates of 75% among men and 53% among women (Steinert et al., 1999). In contrast with the large amount of data reported for inpatients in Italy, outpatient studies are lacking, with only one study published to date describing patients in charge of a few CMHCs (Catanesi et al., 2007). This is not surprising however, particularly due to the similar presence of a relatively scarce number of outpatient studies in the international literature. As an example, Choe et al. (2008) in their review of violent acts perpetrated by severely mentally ill patients in the USA, cited eighteen studies on inpatients, six studies on mixed samples (both in and outpatients) and only four studies specifically focused on

outpatients. According to our study, 26.7% of patients in charge of the CMHC had displayed violent behavior at least once in their lifetime, and approximately 69% of these had perpetrated violence twice or more. These figures are significant, bearing in mind that we included only overt acts of violence and excluded forms of violence such as verbal aggressiveness and psychological violence. It should be taken into account that this apparently high percentage relates to a very long period of time, with the average duration of illness in our sample being more than fifteen years; on the other hand, the one-year prevalence of violent cases is approximately 10%, a relevant proportion given the relatively short span of time considered. As mentioned above, two crucial aspects emerged from this study: approximately two thirds of violent patients had repeatedly committed violent acts during their lifetime, and all patients who had committed violence over the preceding year had been violent previously. Moreover, approximately 70% of the violent acts registered were committed against persons, although acts investigated in our survey did not generally jeopardize victims' health. Indeed, no cases of extremely severe acts such as attempted homicides or homicides were reported, with only 18% of violent patients being involved in legal proceedings, and an even lower percentage (10%) being submitted to restrictive measures following a trial (admission to a forensic hospital or other forms of legal leverage, such as compulsory admission to a therapeutic community). However, these relatively low figures should be interpreted with caution, as patients' families and staff of the CMHC, frequently the target of violence, may have been reluctant to report violence by a mentally ill patient. Furthermore, some patients may have denied their violent behavior (Krakowski & Czobor, 2012). The previously cited US review (Choe et al., 2008) reports that a percentage of between 2% and 13% outpatients had perpetrated violence during a time period between six months and three years prior to the study; however, these studies were only based on patients affected by severe mental illness. In particular, in a study of severely ill outpatients, intake evaluation revealed how 4% of subjects had committed an attempted homicide in the past (Asnis et al., 1994). Moreover, a study of 802 outpatients affected by psychotic or major affective disorders followed in public outpatient services of four US states found an annual prevalence of serious assaultive behaviors of 13% (Swanson et al., 2002). A prospective two-year study conducted in North Carolina to evaluate the effectiveness of atypical versus typical antipsychotics in reducing violent acts in schizophrenic patients, found at baseline evaluation that 15.3% of subjects had committed violent acts against others in the six months prior to enrolment (Swanson et al., 2004). In this study the one-year prevalence of violence was 21.8% and only 9% of the sample had official records of arrest for violent offenses during the previous year; approximately 41% of the violent subjects had committed serious acts of violence involving use of weapons or resulting in injury (Swanson et al., 2004). A subsequent national study of violent behavior in persons with schizophrenia was conducted on 1410 outpatients in charge of 56 clinical sites in 24 states throughout the USA in the context of the CATIE study (Swanson et al., 2006a). This important study reported a 19.1% six-month prevalence of violence, mainly minor violence (15.5%), with only 3.6% of cases of serious violence. Another study of 1011 outpatients affected by any serious mental disorder in charge of public community services in five different American cities, mostly under social and/or legal leverage (Swanson et al., 2006b) reported that the six-month percentage of subjects who had committed violent acts ranged between 18% and 21%, with 3–9% of individuals involved in serious acts of violence (using weapons, causing physical injury or committing sexual abuse). In Europe, a Spanish study (Bobes et al., 2009) of 895 outpatients affected by schizophrenia reported a 5.1% rate of recent aggressive behavior (in the week prior to the study). About half of these cases (47%, amounting to less than 2.5% of the total sample) reached the threshold for definition as violent behavior; the majority of episodes involved verbal violence (44%), violence toward objects (29%), toward others (19%) or self-directed violence (19%); however, the relatively low rate of violence reported in this study

Please cite this article as: Pinna, F., et al., Violence and mental disorders. A retrospective study of people in charge of a community mental health center, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.02.015

F. Pinna et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx

should be interpreted in light of the singular composition of the study sample, made up of patients displaying good treatment compliance. The only other Italian study on community-treated patients (Catanesi et al., 2007) included all subjects (n = 1582) undergoing regular treatment in four community mental health centers located in two southern Italian regions (Puglia and Basilicata). This study reported that approximately 36% of subjects had committed acts of violence over a four-year period (1995–1999), a rate of approximately 9% per year; however, the rate of violent acts dropped to 26.5% (less than 7% per year) when excluding verbal aggression or threats. A direct comparison of our data with those from other studies may be misleading, due to the very different settings (in and/or outpatient services) considered, methods employed to collect data (interviews, chart reviews, mixed methods) and study designs (retrospective or prospective studies), sampling (selected patients with single diagnoses or pertaining to selected diagnostic classes; patients selected according to severity of illness; unselected samples of patients), time frame evaluated (six months, one or more years, lifetime), and social and cultural background of populations considered. Overall, data emerging both from our study and the other Italian outpatient study (Catanesi et al., 2007) show, as in other Western countries, that rates of violence among these patients are lower than those found in inpatients, a largely expected finding when considering the overall lower clinical severity of subjects followed by outpatient services. However, due to the heterogeneity of patients followed in Italian CHMCs, which routinely deal with all types of mental disorder, the frequency of violent acts detected among outpatients appears to be quite relevant, although very severe forms of violence are infrequent. In addition to evaluation of quantitative data relating to the frequency of violence, the second aim of this study was to investigate the association of violence with socio-economic and clinical variables. Unfortunately, the lack of reliable retrospective data made it impossible to analyze several important factors generally associated with violence, such as belonging to a violent family, and having been subjected to violence in childhood (Elbogen & Johnson, 2009; Monahan et al., 2001; Mulvey et al., 1998; Swanson et al., 2002). With regard to demographic variables, our findings reveal a greater probability of violent behavior in males, thus reflecting the results of recently conducted inpatient studies (Amore et al., 2008; Biancosino et al., 2009; Dack et al., 2013; Di Giacomo & Clerici, 2010; Steinert et al., 1999) and community studies (Swanson, Van Dorn, et al., 2006), also in Italy (Catanesi et al., 2007). Moreover, the relatively young age of patients committing acts of violence recorded in our study is fully in keeping with the findings from literature on both inpatients (Biancosino et al., 2009; Dack et al., 2013) and community samples (Catanesi et al., 2007; Swanson et al., 2006). It should be underlined that, unlike cases of isolated violence, younger age and single status were the only sociodemographic variables significantly related to cases of recurrent violence. In our study the status of “violent” patient is associated with a lower level of education, a finding which is at odds with the higher rate of violent behavior found in a sample of highly educated hospitalized patients in Italy (Biancosino et al., 2009), and the lack of association between education and violence found in the study carried out by Catanesi et al. (2007). Together with a low level of education, the increased violent behavior observed in unmarried and unemployed patients, or those who were retired and/or receiving a disability pension, depicts a condition of greater social marginalization of violence-prone subjects, a finding in line with data emerging from community studies showing an increased frequency of violence among low-income and unemployed patients (Elbogen & Johnson, 2009). The frequency of aggressive behaviors in subjects living with their family observed in this survey is highly significant, as it reveals how violence, frequently directed toward family members, is apparently triggered by typical conflicting relationships (Catanesi et al., 2007). Interestingly, the results obtained in a study of North American outpatients treated in community services (Swanson et al., 1998) have demonstrated that badly deteriorated subjects, who were also characterized by poor social functioning, are more likely to

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be violent when regularly in contact with household and friends. Conversely, the lower risk of violence observed in patients with better social skills, tends, on the contrary, to increase when the patient engages in frequent social relationships outside the family. These findings suggest that, at least in severely ill patients, exposure to more frequent contacts, such as subjects living with family members, may lead to increased stress and conflict and, consequently, to a higher risk of violent behavior. This interpretation is confirmed by the aforementioned Italian outpatient study (Catanesi et al., 2007), in which parents and other family members were the main victims of violence, and negative family attitudes were markedly associated with an increased risk of violence by the mentally ill family member. One of the main clinical findings emerging from our study is the association between increased frequency of violent behavior and longer duration of the disease, a finding in line with evidence provided by the above-cited Italian study (Catanesi et al., 2007). Moreover, we found an increased risk of violence associated with younger age at onset and at first psychiatric care, two aspects generally linked with a worse outcome, particularly in patients affected by psychotic or mood disorders. The higher frequency of violent behavior among subjects suffering from schizophrenia and other psychotic disorders further confirms the findings of previous studies conducted on both inpatients (Biancosino et al., 2009; Dack et al., 2013) and outpatients (Bobes et al., 2009; Catanesi et al., 2007; Swanson et al., 2006a), underlining the association between increased risk of violence and disorders of higher severity (Arango et al., 1999). Although in our study bipolar disorder was found to be associated with a non-statistically significant higher risk of violence, it is noteworthy that the disorder was linked to a significantly higher risk of legal charges and a higher rate of previous admissions to a forensic psychiatric hospital, thus confirming the higher risk of violence related to this condition. As expected from literature, a diagnosis of personality disorder is linked with a higher risk of violence (Asnis et al., 1997; Flannery et al., 2014). Our study shows a significantly higher risk of violence among patients with intellectual disability, as shown by previous studies (Hodgins, 1992; Lindsay, 2011) and among subjects with intellectual disability in comorbidity with other disorders (Joyal et al., 2008). This finding is worthy of consideration, bearing in mind that people with an intellectual disability are probably one of the most neglected subpopulations in charge of community mental health services in Italy. In line with the study by Catanesi et al. (2007), we found that an increased risk of violence is associated with frequency of previous hospital admissions, a finding supporting the hypothesis that patients with an increasingly unstable course of illness, at least those affected by major disorders, are more prone to acts of violence. Moreover, our findings confirmed a higher presence of violent behavior in patients with a psychiatric comorbidity, generally personality disorders and substance use disorders (Asnis et al., 1997; Edlinger et al., 2014; Elbogen & Johnson, 2009; Swanson et al., 1997; Volavka, 2014). Indeed, while major psychiatric disorders such as schizophrenia and bipolar disorder are more frequently related to violence, it is evident that the risk of violence in patients affected by these disorders may be largely due to the concomitant use of alcohol or substances (Arsenault et al., 2000; Elbogen & Johnson, 2009; Hafner & Boker, 1973; Swanson, 1990; Rasanen et al., 1998; Tiihonen et al., 1997). The increased frequency of violence over the last year in subjects who had previously manifested aggressive behaviors confirms the univocal data from literature demonstrating that previous violence is one of the most relevant predictors of recurrent violence (Arango et al., 1999; Dack et al., 2013; Di Giacomo & Clerici, 2010; Elbogen & Johnson, 2009). In our study, self-inflicted acts of violence such as suicide attempts, were associated with violent behavior toward others, in agreement with the results of a recent study of schizophrenic patients (Witt et al., 2014), thus supporting the existence of a sort of common matrix between the two forms of violence. Before drawing any conclusions, several limitations of the present study should be underlined. First, the relatively small sample size

Please cite this article as: Pinna, F., et al., Violence and mental disorders. A retrospective study of people in charge of a community mental health center, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.02.015

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should be taken into account, as this may have limited the statistical power of the study. Secondly, it should be emphasized that the study focuses on a clinical sample of patients treated in a single university mental health center in southern Italy. Hence, the data obtained cannot be referred to the entire Italian outpatient population. Third, the sample examined comprises treated subjects who have been in contact with the community mental health center, with the exception of patients who have moved away, refused to continue treatment, no longer needed regular care, or died. This may have introduced a possible selection bias in favor of subjects with a lower likelihood of violent behavior. Fourth, the fact that the sample studied comprised a mix of patients with major and minor disorders and that patients with major disorders (approx. 50% of the sample) were generally in a stable clinical condition, being characterized by mild or moderate symptoms and only slight–moderate impairment of functioning (Pinna et al., 2013a; Pinna et al., 2013b; Pinna et al., 2014; Pinna et al., 2015) should be taken into due account, together with the fact that the vast majority of patients are undergoing treatment programs with both psychopharmacological and/or psychosocial interventions, in the context of a continuity of care typical of community treatment delivered in Italy. Finally, the retrospective nature of data, or at least of clinical histories prior to being taken in charge by our CMHC, may have affected the reliability of this study due to recall bias. Notwithstanding these limitations, the findings obtained may be of a certain importance for those involved in community treatment. The first evidence provided by our study is the confirmation of the significant proportion of violent acts perpetrated by patients in charge of a community mental health center, a finding of particular relevance for countries, such as Italy, in which the mental health system is largely based on community treatment. At present, some of these patients are assigned to public services by the legal authorities, in compliance with the laws of each country, and are under some type of legal leverage. The number of these patients is expected to increase following approval of a recent law on the closure of forensic hospitals (Barbui & Saraceno, 2015; Peloso et al., 2014). Furthermore, the results of our study highlighted the inevitability, and at times difficulty, in predicting, and where possible preventing violence, even for clinicians working in community services. As Swanson (2008) maintained, “clinicians actually can predict and prevent violence if they consider their patients as a group from the perspective of public-health epidemiology”, i.e. to identify the subset of patients in their services who are at greater risk of violence, and subsequently to assess any possibly unsatisfied needs. Our study confirms the existence of and need to identify a subgroup of patients at major risk for repeated violence in charge of public community services. This group is made up of poorly educated, socially disadvantaged young male adults, mainly affected by major mental disorders such as schizophrenia and bipolar disorders, particularly when comorbid with personality and/or substance use disorder or with intellectual disability. As shown in the literature, potentially violent patients with mental disorders “frequently live in relative poverty, experience an associated lack of education opportunities, problems with employment and a paucity of pro-social attachments”, so that “the social drift and recruitment of adversities also contribute to the association of violence, victimization and adverse social environments” (Scott, 2008). In countries such as Italy, where the majority of these patients live with their family, particular attention should be paid to subjects displaying highly conflicting family relationships, a context which seemingly fosters violence. An assertive approach, based upon the “risk-need-responsively principle” (Scott, 2008) seems to be the most appropriate means of managing this subset of complex cases, particularly as violence has proved to be inversely related to treatment compliance, perceived treatment needs (often largely unsatisfied) and perceived treatment effectiveness (Martinez-Martin et al., 2011). Competing interest The authors declare that they have no competing interest.

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Please cite this article as: Pinna, F., et al., Violence and mental disorders. A retrospective study of people in charge of a community mental health center, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.02.015