Institute of Psychiatry, London
University of California, Davis, CA, USA
Royal Free School of Medicine, London
St Georges Hospital Medical School, London
University Department of Psychiatry, Manchester Royal Infirmary, Manchester
St Marys Hospital Medical School, London
Institute of Psychiatry, London
the UK700 GROUP
Correspondence: Dr Elizabeth Walsh, Section of Forensic Mental Health, The Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, UK. E-mail: sppmemw{at}iop.kcl.ac.uk
* This paper was accepted before the appointment of P.T. as Editor of the
Journal.
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ABSTRACT |
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Aims To establish the 1-year prevalence of violent victimisation in community-dwelling patients with psychosis and to identify the socio-demographic and clinical correlates of violent victimisation.
Method A total of 691 subjects with established psychotic disorders were interviewed. The past-year prevalence of violent victimisation was estimated and compared with general population figures. Those who reported being violently victimised were compared with those who did not on a range of social and clinical characteristics.
Results Sixteen per cent of patients reported being violently victimised. Victims of violence were significantly more likely to report severe psychopathological symptoms, homelessness, substance misuse and previous violent behaviour and were more likely to have a comorbid personality disorder.
Conclusions Those with psychosis are at considerable risk of violent victimisation in the community. Victimisation experience should be recorded in the standard psychiatric interview.
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INTRODUCTION |
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Background
Criminal victimisation of those with severe mental illness has been
associated with more severe clinical symptoms
(Brekke et al, 2001; Hiday et al, 2002),
substance misuse (Hiday et al,
1999; Brekke et al,
2001), transient living conditions (including homelessness)
(Hiday et al, 1999),
lower functioning, lack of social support and a history of previous
victimisation (Hiday et al,
2002). However, most studies examining associated factors have
failed to distinguish between being the victim of a violent or a non-violent
crime. Only one study to date has examined socio-demographic and clinical
correlates of violent victimisation separately; this study found that
one-third of patients discharged from psychiatric hospitals and living in
hostels had been the victims of crime in the preceding year. Victims of
violence were younger, more socially active, reported more psychopathology and
less satisfaction with their lives and engaged in more criminal behaviour than
both non-victims and the victims of non-violent crime
(Lehman & Linn, 1984).
The aims of the present study are two-fold: to establish the 1-year prevalence of violent victimisation in community-dwelling patients with psychosis and to compare this with the official statistics concerning prevalence in the general population; and to examine the socio-demographic and clinical correlates of violent victimisation in the largest sample of patients with psychosis to date.
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METHOD |
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In this way, we set out to collect a sample of patients with established illness typical of those receiving multi-disciplinary psychiatric care in the community.
Data collection
All subjects were interviewed between 1994 and 1996 using a battery of
instruments; these baseline assessments provided the data that were analysed
for the purposes of this study. The interviewers were either senior trainee
psychiatrists or psychology graduates, all of whom participated in an initial
2-day training course and completed five pilot interview schedules. Training
materials included lectures, joint patient interviews, case vignettes and
video interviews. Completed interview schedules were inspected regularly on
site for errors and inconsistencies (UK700
Group, 1999).
Outcome variables
The primary outcome of interest was violent victimisation in the year prior
to interview. As part of the Lancashire Quality of Life Profile (Oliver,
(Oliver, 1991), subjects were
asked the following question: In the last year have you been assaulted,
beaten, molested or otherwise the victim of violence? Respondents
answered yes or no to this question. Perceived
vulnerability to victimisation was measured by asking how satisfied subjects
were with their own personal safety and the safety of their neighbourhood.
Responses, scored on a seven-point Likert scale, were categorised into a
binary outcome of satisfied/dissatisfied.
Explanatory variables
Possible correlates of violent victimisation, chosen a priori on
the basis of previous research, were measured using the following
instruments.
Statistical analysis
The proportion of subjects reporting violent victimisation and perceived
threat of victimisation was estimated. Possible socio-demographic and clinical
correlates of violent victimisation were examined using logistic regression.
Initially, the association between violent victimisation and each explanatory
variable was examined unadjusted for other variables. All variables in the
univariate analysis significant at P=0.05 were then entered into a
multivariate model and stepwise methods were used to identify the final model
best associated with violent victimisation. All other variables then were
added to this final model to check that no significant correlates were missed.
The final model was adjusted for age and gender. All analyses were conducted
using STATA 6.0 (Stata-Corp,
1999).
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RESULTS |
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The demographic and clinical characteristics of the UK700 study profile have been described elsewhere (Burns et al, 1999). Tables 1 and 2 list these according to the victim profile. In the sample, more than half of the patients were young men with long histories of illness (median of 10 years; median of 2 months in hospital in the preceding 2 years). Most were diagnosed with schizoaffective disorder and schizophrenia. Nearly one-third of patients were AfricanCaribbean. Mean CPRS and DAS scores indicated that patients were moderately to severely ill.
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Prevalence of violent victimisation
Information on victimisation was available for 691 (98%) of the subjects at
interview; 111 (16%) reported being a victim of violence in the previous year.
With regard to perceived threat, 269/678 (40%) were dissatisfied with their
personal safety and 301/677 (44%) were dissatisfied with the safety of their
neighbourhood. Victims were significantly more likely to report feeling
personally unsafe (n=65, 58%; P<0.001) and unsafe in
their neighbourhood (n=66, 59%; P<0.001) than
non-victims. Our interviews were conducted between 1994 and 1996. For
comparison, crime figures collected at that time for the British Crime Survey
reveal an annual percentage of victimisation for contact crime of 6.7% in
London and 7.1% for all inner cities. The figure for non-inner-city areas was
4.9% (Murless-Black et al,
1996).
Characteristics of victims: univariate analysis
The socio-demographic characteristics of subjects reporting victimisation
are presented in Table 1.
Compared with non-victims, victims were significantly more likely to be male,
under 40 years and with transient living conditions, including homelessness.
Victims were less likely to have daily contact with their families and spent
less time in independent accommodation in the community compared with
non-victims. Victims were more likely to have had contact with the law, with
significantly more criminal convictions for violent and non-violent crime and
more recent self-reported violent behaviour. There was no significant
association between being a victim of violence and being a member of an ethnic
minority group, recent employment or degree of deprivation of area of
residence.
The clinical characteristics of subjects reporting victimisation are presented in Table 2. Although those with early illness onset, higher scores on general psychopathology and more unmet needs for care were more likely to be victims, the length of illness, level of negative symptoms and disability were not associated with victim status. Compared with non-victims, victims also were more likely to have a comorbid personality disorder. With regard to substance misuse, victims used significantly more illegal drugs but were not more likely to misuse alcohol. Those using one illegal drug were almost two and a half times more likely to be victimised and those using two or more such drugs were over four times more likely to be victims of violence than those denying any use.
Assessment of independent effects using multivariate analysis
Table 3 presents the final
multivariate model identifying the associations between each variable and
victim status, adjusted for age, gender and each other. Being homeless
(P=0.01), using illegal drugs (P<0.001), being the
perpetrator of an assault (P=0.01), having greater current
symptomatology (P=0.02) and a comorbid personality disorder
(P=0.006) were all independently associated with being a victim of
violence.
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DISCUSSION |
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Strengths and weaknesses of the study
This is the largest study to date to examine the prevalence and correlates
of violent victimisation in severe mental illness. The validity of our
findings is increased by the use of operational definitions of psychosis and
well-validated instruments based on interview rather than records,
comprehensive staff training and the availability of additional sources of
information, which included case notes, information from carers and clinical
staff and official criminal records. The participants were recruited from four
clinical centres and were chosen to be representative of those patients with
chronic psychosis dwelling in the community and receiving care from community
mental health teams. The choice of inner-city areas, with all their attendant
problems, no doubt will have increased the prevalence of victimisation
compared with rural samples (Hiday et
al, 1999) and our results refer to urban rather than other
areas. Owing to the cross-sectional nature of our data, we have been able to
examine only associations of violent victimisation rather than predictive
factors. We are therefore cautious about drawing inferences concerning
causation based on these data.
The UK700 study did not employ a general population or non-psychotic control sample with whom we could compare the prevalence of victimisation. We thus chose to rely on official records for comparison, which were collected in a different way and for different purposes. There is evidence to suggest that individuals with mental illnesses are more likely to be assaulted by people with whom they have a close relationship (Cascardi et al, 1996). It is therefore likely that victimisation will be underreported for various reasons, including protection of the perpetrator, shame and guilt, reluctance to discuss unpleasant memories and fear of future violence. The comparative figures for the general population derive from anonymous interviews with members of the public and are therefore less susceptible to underreporting. Despite this, the difference in the prevalence of violent victimisation is still impressive. We did not include non-violent victimisation, emotional abuse or social exploitation in our definition.
Prevalence of violent victimisation
Sixteen per cent of our subjects reported having been the victims of
violence in the previous year. Because information was missing for 17
patients, the highest possible prevalence for victimisation in the sample was
18%, assuming that all those missing had been victimised, and the lowest
prevalence was 16%, assuming that they had not. This gives a prevalence range
of 1618%, a figure more than twice that recorded in the general
population at that time, according to the British Crime Survey. This
prevalence figure is higher than that reported in the USA. Hiday et
al (2002) reported that
10% of persons with severe mental illness who had been deemed suitable for
enforced community treatment post-discharge were victimised in the first year.
The comparative national rate was 3.1%. In an earlier study of the same
patients the 4-month period prevalence of victimisation was 8.2%, suggesting
that the annual prevalence rate would be somewhat higher. Brekke et
al (2001) followed 172
patients in the community for 3 years to assess their vulnerability to risk
and reported that 34% of their sample were victims of violence over this
period, presenting an annual risk closer to ours. Silver
(2002), in a
casecontrol study, compared the prevalence of violent victimisation
among 270 recently discharged people with severe mental illness over 10 weeks
post-discharge with 477 neighbourhood controls. Using data from the Pittsburgh
site of the McArthur Risk Assessment Study, he found that significantly more
patients (15%) than neighbourhood controls (7%) reported violent
victimisation. Certain factors have been found to increase the risk of
victimisation in the general population, including male gender, younger age,
unemployment and ethnic minority status. Despite controls being derived from
the same neighbourhood, patients still possessed more of these factors.
Following statistical adjustment for these and for the individuals own
violence perpetration, patients were still nearly twice as likely to be
violently victimised than controls.
Factors associated with violent victimisation
Our finding that victims of violence display more severe clinical symptoms
is consistent with previously published literature on the subject
(Lehman & Linn, 1984;
Brekke et al, 2001;
Hiday et al, 2002).
Homelessness (Hiday et al,
1999), substance misuse (Hiday
et al, 1999; Brekke
et al, 2001) and a history of violence
(Lehman & Linn, 1984) were
also identified as significantly related to victimisation, as in previous
work. However, it is difficult to make valid comparisons with other studies
because researchers have either grouped non-violent victimisation together as
a single outcome (Hiday et al,
1999,
2002) or they have used highly
heterogeneous samples of patients.
Our results show that victims were more likely to misuse illegal substances, to have a recent history of assaulting others and to be diagnosed with a comorbid personality disorder, all of which have been shown previously to increase the risk for violent behaviour in the sample (Walsh et al, 2001; Moran et al, 2003). Victimisation also has been found independently to predict violence in the sample (Walsh et al, 2001). Childhood abuse and neglect are risk factors for adult mental illness and have been shown to have a significant impact on the likelihood of delinquency, adult criminality and violence (Maxfield & Widom, 1996; Hiday et al, 2001). Those with psychosis are more likely to be born in cities (Marcelis et al, 1998), and social drift (Goldberg & Morrison, 1963) makes them more likely to live in socially disorganised and crime-ridden neighbourhoods and be subjected to violence (Hiday et al, 2001). Our results show that those who have been victimised were significantly more likely to feel threatened and unsafe than others and consequently it is more likely that they will engage in violence themselves. It is therefore conceivable that victimisation and violence in severe mental illness share a common pathway and that the occurrence of one or both outcomes will be determined by complex interactions between these factors across the life cycle. It should be noted, however, that less than half of victims reported committing an assault in the 2 years before interview, indicating that an individuals own violence may only explain a proportion of violent victimisation in the sample. Furthermore, the link between severe mental illness and violent victimisation has been shown recently to be independent of an individuals own tendency towards violence (Silver, 2002).
Compliance with treatment was not measured in this study, but all subjects were in contact with services, suggesting that patients at particular risk of victimisation could be targeted for more assertive follow-up. One such assertive approach, called out-patient commitment, is practised in certain states in North America, where it has been shown to reduce significantly criminal victimisation in people with severe mental illnesses (Hiday et al, 2002). Within this approach, patients are ordered by law to receive treatment and supervision by a named treatment provider.
Implications of the study
It is becoming increasingly clear that there is a need to refocus the issue
of community risk away from the danger posed by mentally ill individuals to
the danger posed to them from other members of society
(Walsh & Fahy, 2002). This
has been highlighted by an American finding that patients with psychosis
living in the community are 14 times more likely to be the victims of a
violent crime than to be arrested for such a crime
(Brekke et al, 2001). Further longitudinal work is needed to clarify the predictors of
victimisation, which may be used to target vulnerable subgroups with
additional care. Enquiry about victimisation experiences does not form part of
the routine psychiatric interview. interview. In light of our findings and
other emerging evidence on the size of the victimisation problem among people
with mental illnesses, we suggest that such enquiry be incorporated as
standard.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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The UK700 Group is a collaborative study team involving four clinical and two non-clinical centres: Manchester Royal Infirmary: Tom Butler, Francis Creed, Janelle Fraser, Peter Huxley, Nicholas Tarrier, Theresa Tattan. Kings/Maudsley Hospital, London: Tom Fahy, Catherine Gilvarry, Kwame McKenzie, Robin Murray, Jim van Os, Elizabeth Walsh. St Marys Hospital/St Charles Hospital, London: John Green, Anna Higgitt, Elizabeth van Horn, Donal Leddy, Catherine Manley, Patricia Thornton, Peter Tyrer. St Georges Hospital, London:Robert Bale, Tom Burns, Matthew Fiander, Kate Harvey, Andy Kent, Chiara Samele. Centre for Health Economics, York: Sarah Byford, David Torgerson, Ken Wright. London (Statistics): Simon Thompson (Royal Postgraduate Medical School) and Ian White (London School of Hygiene and Tropical Medicine).
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Received for publication February 12, 2003. Revision received May 19, 2003. Accepted for publication May 21, 2003.
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