Speak to Dr. Watson Today

920.918.7377

Information

"Not all answers are found in a prescription pad...    

it's elementary Dr. Watson!"

Summary of Research on Mental Illness, Violence or Dangerous to Self-Other

The purpose of this document is to inform the reader of some of the vast literature supporting the fact that those individuals who suffer with mental illness are not more overall violent and dangerous than the general public.  Special considerations and factors are noted below.

Professor Mike Crawford reviewed the studies on predicting violence and stated there are no instruments that can accurately identify people at high risk for committing violent incidents, and that for every one person correctly identified, 5,000 people might be incorrectly identified (false positive) as high risk for homicide. [1]

The 1988 Department of Justice study found that only 4.3% of all homicides in a sample of the nation's 33 largest counties had been committed by assailants with a history of mental illness. This did not limit the criteria to "schizophrenia". [2]

Ten years later, a Washington State evaluation of more than 300 mentally ill offenders released from prison found that only 2% committed serious violent crimes in the first 18 months of a scheduled 5 year follow-up. [3] [4]

The mentally ill may in fact be more likely to withdraw or harm themselves than to act aggressively toward others, and if they do act aggressively, it tends to occur within 20 weeks after discharge from institutionalization[5]. Further, most incidents occur in the normal flow of daily life, family members are likely to be involved, most incidents occur in the home, and alcohol plays a large role. In only 13% of the violent incidents did the mentally ill seek out the other person with the intent of harming them. Strikingly, one-fourth of the violent incidents involved a situation where prescribed medication was not being taken.[6]

Mentally ill are more likely to commit "trivial and nonviolent offenses" than general public, often due to homelessness (e.g. trespass). [7]

The fact is, the severely mentally ill are usually prey, not predators. Published in 2005, the results of a large study conducted by researchers at Northwestern University examined rates of criminal victimization. After interviewing 936 patients in the Chicago area, the investigators found that people diagnosed with severe mental illness were 6 to 23 times more likely to be victims of violent crime than the general population [8] [9] [10].

Over ninety percent (90%) “of persons with mental illness have no history of violence….through media sensationalism (it sells papers) the cases that do occur stand out in peoples minds.”[11] 

The relationship between diagnosis and violence has long been confusing and contested.  Some research indicates those with schizophrenia have higher rates of violence than those with other Axis I diagnoses (Baxter, 1997). One recent study showed a significant association between schizophrenia and a higher rate of criminal convictions for violent offenses[12].  Other research suggests those with schizophrenia present less risk of violence than persons with other serious mental illnesses such as bipolar disorder or depression[13].  In a 2013 published study looking at violence an crime with patients diagnosed with schizophrenia, the study concluded that being diagnosed with schizophrenia was positively correlated with an increase in violence towards family members, and that the increase could not be solely attributed to a co-morbid substance abuse diagnosis; however, such disorder did significantly increase the rate of violence. Limitations to such studies often include that fact the subjects all came from a clinical population through a government community mental health center (i.e. whereby socio-economic status, poverty, high crime neighborhoods, etc… are all factors also linked to increases in violence and crime), that these patients also were not being treated in a private treatment setting (i.e. whereby treatment itself could be factored as a cause of any increase in violence and crime).[14]  Clinical depression and feelings of hopelessness as well as anger and impulsiveness is tied with half of suicides[15].  However, some researchers have found that the highest rates of violence are not among Axis I diagnoses at all, but rather among Axis II diagnoses[16].

Other researchers argue and have found that people suffering with substance abuse and neuroticism are at the highest risk for chronic criminal behavior.[17]

Those Who Are Violent, tend to have dual diagnosis, substance abuse problems, frequent moving, are young, have a history of aggression prior to being diagnosed and either start or stop taking psychotropic medications abruptly.  The GREATER risk of violence is from those who have dual diagnosis, (i.e., individuals who have a mental disorder as well as a substance abuse disorder).[18]
Swanson, 1994;  Eronen et al, 1998; Steadman et al., 1998.

Psychopathy in adulthood is more powerfully related to future illegal aggression than any other single characteristic investigated by violence-prediction researchers[19]. Approximately 80 percent of the most dangerous predatory criminals exhibit sociopathic behavior patterns, and although they comprise about 4 percent of the total male population, they are responsible for fifty percent of all serious felony offenses[20].

Researcher Monahan also noted childhood violence together with a history of mental disorder was significant in predicting violence, and the seriousness and frequency of having been physically abused as a child predicted subsequent violent behavior[21].

An injury from an adult received before a child is 15 years old has been found to be predictive of subsequent violence in schizophrenic male patients (Klassen & O’Conner, 1988). 

 Severe paternal discipline has been found to be predictive of violence among male schizophrenic patients (Yesavage, 1984). 

As with those without mental illness, there is a great falloff in rates of violence as people age (Swanson et al. 1990). 

Found people Dx Sz and Bipolar were no more violent than general population, unless problems with substance abuse or psychopathology. 

Monahan, J. and Shah, S. Dangerousness and commitment of the mentally disordered in the United States. Schizophrenia Bulletin, 15: 541-553. Reprinted in: Social and Clinical Psychiatry, 1991, 1: 56-70 [in Russian].

Cirincione, C., Steadman, H., Robbins, P. and Monahan, J. Schizophrenia as a contingent risk factor for criminal violence. International Journal of Law and Psychiatry 15: 347-358.

Elbogen, E.B. & Johnson, S.C. (2009). The intricate link between violence and mental disorder. Archives of General Psychiatry, 66, 152-161.  “mental illness suggests a lower probability of violence”

In a report which followed patients for one year after discharge from hospitalization, patients who did not have a co-occurring substance abuse disorder were no more likely to have a violent incident than others living in the same neighborhoods (Steadman et al., 1998)

Fazel in 2009 did a meta-analysis of the 20 studies between January, 1970 and February, 2009 that assessed the risk of violence of 18,423 individuals diagnosed as Schizophrenia or other psychoses, which they compared with the level of violence in the general population of 1,714,904. [22]  Eleven of the studies reported on the affect of co-morbid substance abuse. The authors found that there was no significant difference between people with Schizophrenia and those with other psychotic disorders. People with psychoses were slightly more likely to exhibit violence than the general population, and significantly more likely to commit homicides, though the homicide probability was only 0.3% for either psychosis or substance abuse. However, "the increased risk of violence in schizophrenia and the psychoses comorbid with substance abuse was not different than the risk of violence in individuals with diagnoses of substance use disorders. In other words, schizophrenia and other psychoses did not appear to add any additional risk to that conferred by the substance abuse alone [pp. 7-8]." Further, substance abuse markedly increased the risk of violence for people with co-morbid psychotic and substance abuse disorders.

The above findings are consistent with those of the MacArthur violence risk assessment research, particularly the finding that people with psychoses but without substance abuse do not have a high level of violence, while those who abuse alcohol or other drugs do have a significantly higher risk of violence.[23] [24][25]According to Martin Grann, Ph.D., one author of the 2009 study, "people with schizophrenia are not dangerous…. If a person is an alcoholic or a drug addict, he is less likely to be violent if he also has schizophrenia. So, in this context, you could say schizophrenia is actually protective" (quoted in Cassels 2009 study),[26] [27]

 
John Monahan, Professor of Law,  Psychology and Legal Medicine at the University of Virginia (2001, 1993, 1992),  concluded the rate of violent behavior among persons with mental disorders, is at least somewhat  slightly higher than of people without such disorders.  Monahan did not factor and account for psychiatric medication induced violence and worsening of symptoms or violence and such ideation due to psychotropic medication usage.[28] [29] [30]  Dr. Monahan stated with diagnosed individuals:

1. Around 25 percent of those in mental hospitals assault another person during hospitalization.  Another interpretation could be that the individual was attacked and they were defending themselves, whereby, both patients are coded as aggressive and violent.

2. Approximately 12 percent of all people with schizophrenia, major depression, or bipolar have assaulted other people, compared with 2 percent of persons without a mental disorder. Again, a limitation to that research is double accounting and coding whereby, they will often engage in physical conflict with others who also have similar disorders, whereby, one may be the aggressor, but both then get coded as violent.

3. Approximately 4% who report being violent during the past year suffer with schizophrenia, whereas only approximately 1% of population suffer from schizophrenia.

The NIMH MacArthur study found that recently discharged psychiatric patients were not statistically more dangerous than people in the communities they were discharged to, and those same patients were not more dangerous even if they had threat/control delusions. "...[T]he presumed risk of violence associated with delusions per se does not justify hospitalization of a patient...."  Monahan has stated the presence of delusions does not predict higher rates of violence among recently discharged psychiatric patients[31].  On the other hand, non-delusional suspiciousness – involving the tendency toward misperception of others’ behavior as indicating hostile intent – does appear to be linked with subsequent violence[32]. The NIMH MacArthur study was a multi-year study of over 1,000 patients found a number of violence risk factors and provided an “odds ratio” table for the first year discharge, indicating the increase in probability for a given factor (male=1.51, i.e. 51% more likely to be violent than females when other factors removed).

The assessment used was the Classification of Violence Risk (COVR), an interactive software program-interview that provides an estimate on future violence. Patients were followed for 20 weeks after discharge and measured violence towards others by official police and hospital records, patients' self-report, and by collateral contacts (e.g. family).  COVR can be found at: P.A.R., 800 331 8378: www.parinc.com.

Hare PCL:SV > 12                                                                              4.05
Chart diagnosis of Antisocial Pty. Dis.                                            3.11
Violent fantasies about escalating harm                                        2.80
Substance disorder, no major disorder                                            2.47
Father ever used illegal drugs                                                            2.40
Recent violent behavior                                                                     2.32
Frequent violent fantasies                                                                 2.23
Any arrest for a crime against a person                                          2.11
Violent fantasies while with target                                                   2.08
Serious adult arrest                                                                              2.04
Substance abuse at time of admission                                            2.01
Violence at time of admission                                                          1.97
Violent fantasies                                                                                  1.94
Violent fantasies focused on 1 person                                            1.91
Father ever intoxicated      (alcohol)                                                1.87
Any arrest besides crime against person                                         1.80
Father ever arrested                                                                            1.79
Involuntary hospitalization                                                               1.78
Any head injury w/loss of consciousness                                       1.69
Homelessness                                                                                       1.66
Frequency of adult arrests                                                                 1.60
Mother ever used illegal drugs                                                           1.54
Perceived stress                                                                                    1.54
Seriousness of physical child abuse                                                 1.51
Male gender                                                                                          1.51
Major disorder and substance abuse                                                               1.47       
Personality disorder only                                                                    1.46
Nonviolent aggression at admission                                                1.44
Command hallucinations                                                                  1.43
Any head injury w/o loss of conscious.                                           1.43
Mother ever intoxicated (alcohol)                                                    1.41
Suicide attempt                                                                                    1.31
Unable to care for self                                                                        1.29
Frequency of abuse as a child                                                          1.25
Diagnosis of “other psychosis”                                                         1.00
Diagnosis of depression                                                                      0.92
Any delusions                                                                                       0.74
Diagnosis of Mania                                                                             0.74
Diagnosis of Schizophrenia                                                               0.38

Consistent with the literature that ranks prior history of violence as the most important factor for predicting risk of future violent behavior, overall the best predictor of violence in psychiatric patients is past behavior[33] [34].  Presence of a juvenile record, the number of prior arrests, prior incarcerations and seriousness of prior offenses have been found to be predictive of adult violence among male psychiatric patients[35].  Monahan’s research indicates that the propensity for violence is the result of the accumulation of risk factors. Not one of which is either necessary or sufficient for a person to behave violently[36]. 

The proportion of societal violence attributable to schizophrenia is small.  A review of population-based studies on the epidemiology of violence and schizophrenia. Population-attributable risks for violence in schizophrenia were calculated.  Recent good evidence supports a small but independent association.  Comorbid substance abuse considerably increases this risk. The proportion of violent crime by people Diagnosed with schizophrenia falls below 10%. They concluded: Strategies aimed at reducing this small risk require further attention, in particular treatment for substance misuse.  Problems with this study are the fact they did an epidemiological “selective review” of the literature and indicated “most” studies indicate there is a correlational link between violence and schizophrenia.  This does not account for negative result non-publishing biases (i.e. negative results to not get published nearly as much as positive results), nor does it factor into account the fact that substance abuse was mixed with schizophrenia (i.e. whereby, if you only factored substance abuse, this one factor accounts for even a higher rate of violence, and as such, meeting criteria for schizophrenia actually is then protective against becoming violent).[37]

This Duke University study of 1,445 Sz randomly assigned to 1 of 5 Rx groups.  Violence declined with from 16% to 9% with the group maintained on drugs the whole time, and from 19% to 14% with the group who did not stay on the medications the whole time (e.g. intent to treat, Thus Both Groups had Violence Reduced, but just more with Rx compliance.  BUT NO Difference with people diagnosed schizophrenic with antisocial behaviors.   Confounding variable was the stopping of drug caused the aggression. No Rx free control was used as a comparison group. Prospective predictors of violence included childhood conduct problems, substance use, victimisation, economic deprivation and living situation.  Negative psychotic symptoms predicted lower violence.  Huge drug funding.[38]

Brekke et al in 2001 examined the incidence and predictors of police contact, criminal charges, and victimization for people diagnosed with schizophrenia and schizo-affective disorder.[39]  He sampled 172 patients in a urban Los Angles area between 1989-1991.  He then followed up with them every six months over a three year period. They ruled out anyone with substance abuse.  He reported that 48% had police contact because of being either a victim or perpetrator, and only a very small percentage of the contacts involved aggressive behavior against property or persons.  Being younger, more address changes at baseline, and having a history of arrest and assault were significant predictors.  Twenty two (22%) percent had charges filed against them, although not necessarily for aggression.  Poorer social functioning, more address changes, fewer days of taking medication at baseline, and a history of arrest and assault were significant predictors of criminal charges.  Thirty eight (38%) percent reported having been the victim of a crime during the three years, whereby 91% of which was violent, and having more severe symptoms and more substance abuse at baseline was a statistically significant predictor of victimization.

Arseneault at el in 2000 reported on mental disorders and violence for 94% of a total-city birth cohort in New Zealand, for April 1, 1972 through March 31, 1973.[40]  The researchers assessed 1,999 of those born in 1972-1973 and recorded if there was violence within the prior year. They took self reports and cross referenced this with official conviction records.  A limitation is that people other than those diagnosed could have reported on whether they thought someone diagnosed was violent.  They researchers accounted for: substance use before violence, adolescent excessive perceptions of threat, juvenile conduct disorder and other mental disorders, as well as violence.  The results indicated only 10% of violence risk was uniquely attributable to schizophrenia (Note: they expanded the diagnosis to a “spectrum disorder” to achieve such a rate), and by excessive perceptions of threat and a history of conduct disorder. 



There is now growing evidence that psychotropic can also be linked to violence.

A December 2012 review of the FDA's Adverse Event Reporting System that had extracted all serious adverse drug related violence from 2004 through September 2009, found 484 drugs triggered at least 200 case reports of serious adverse violent events during the 69-month period.[41]

They disproportionately identified 31 drugs, out of the 484, that were more likely to cause violence, noting they accounted for over 1,500 of the nearly 2,000 case reports of violence toward others in the FDA database for the short period.  The 31 drugs included an anti-smoking drug and 11 of the most widely used antidepressants, 6 of the hypnotic sedatives, and 3 drugs used on children for Attention Deficit Hyper-activity Disorder, ADD or ADHD. Sixty seven (67%) or 2/3 of all “adverse” reports were from psychiatric drugs, and antidepressants were responsible for nearly 600 reports of violence toward others, the ADHD drugs and sedatives EACH accounted for approximately another 100 violence episodes, and of the nearly 2,000 total case reports of violence toward others, there were almost 400 cases of homicide, about 400 physical assaults and 223 cases of other types of "violence".  All together, there were approximately 900 reports of homicidal ideation!  The authors note this is only a fraction of the actual episodes since reporting only represents a few percent of actual episodes. This study identified 31 drugs responsible for most of the FDA case reports of violence toward others, with drugs they give to depressed people all being at the top portion of the list.

There is also growing evidence that anti-psychotics may not lower aggression.  Focusing on overt acts of aggression and violence at Millhaven Maximum Security Prison, the Canadian researchers found that “violent, aggressive incidents occurred significantly more frequently [2 to 3.6 times, 250% increase] in inmates who were on psychotropic medication than when these inmates were not on psychotropic drugs”, and “were clearly tied to taking of psychotropic drugs”.[42]  They compared acts of aggression prior to administration of the drug to post administration of the drugs with 375 inmates.  82 percent had prior acts of aggression, 20% had acts of aggression in the prior.  28 of them went on psychotropic drugs and 22 showed an increase in aggression after ingestion.  With Antipsychotic drugs combined with anti-anxiety drugs, the rate of aggression increased by 280%, and over 500% with anti-anxiety drugs alone.  230% with anti-psychotics alone, and when antianxiety, sedative and hypnotic classes are combined at high doses the rate jumps over 1,000% increase in violence when compared to no medication alone.   At P<.001   3.6x with diazepam (benzo) and 2x with other drugs combined.

Patients discharged prior to 1955, neuroleptic drugs, committed crimes equal to or less than general population, but then in 1965 and 1979, post neuroleptic adminstration, patients discharged intoxicated were being arrested at rates exceeding those of general population.[43]

The trial included 86 nonpsychotic patients with an IQ of less than 75 who presented with aggressive challenging behavior at 10 centers in England and Wales and one in Australia. Although aggression decreased substantially whether patients were given a typical or an atypical antipsychotic, the greatest improvements were seen with placebo (65%, 58%, and 79% from baseline, P=0.06), reported Peter Tyrer, M.D., of Imperial College.[44]

There is also evidence that using pro re nata (PRN or as the situation arises) orders may not serve the benefit most institutions thought.  The Stanley Foundation and National Institutes of Health (NIH) study indicated, PRN’s are nurse ordered drugs to prevent or limit agitation, anxiety, and physical aggression.[45]  Arkansas State Hospital in Little Rock Nov. 1, 1999 through February, 2000 banned PRN orders for psychotropic medications, and needed to rely upon “order medications” from a doctor.  Dr. Thapa stated, “we were able to look at the frequency of unscheduled PRN doctor orders prior to the change and compare that with the frequency after the policy shift… (and)…what we found was clearly a dramatic reduction in the use of unscheduled psychotropic medications-greater than a 40 percent reduction."

"The underlying concern at the time-among the psychiatrists and the staff-was that the delay caused by having to contact one of the physicians for a 'now' order might result in patients getting a bit out of hand or too agitated," Thapa said. "The concern was that it would result in an increase in the use of seclusion and restraint for incidents of aggression."

Unexpected Results: Thapa and his colleagues were able to collect data retrospectively on medication orders, use of seclusion and restraint and any events involving aggression. "We did not see any increase in adverse events when staff lost the option of PRN orders,"  but rather saw it decrease.  Because the numbers are low in general, it was impossible to reach statistical significance.

When PRN orders were not allowed- there was a 47% percent reduction in unscheduled medication orders-the number of times seclusion was utilized to manage patient behavior decreased from 48 events to 41 events, and the use of restraints was cut by 50%. (eight to four).

"Clearly this was reassuring…but essentially then, one could argue whether the PRN orders are really necessary."   "The results of our study thus raise the uncomfortable question of whether PRN orders are for the benefit of the patient or the staff."   At Arkansas State Hospital, staff psychiatrists are in the hospital 24 hours a day, seven days a week. This makes obtaining a "now" order relatively easy and quick for the staff.  

Many hospitals across the country, he noted, have attached restrictions to PRN orders-for example, time limits that cause all PRN orders to expire in three days unless re-evaluated and reordered by the physician.
In addition, some institutions now look for appropriateness of PRN orders for specific patient conditions.
Thapa and his co-authors believe that "given the objective of regulatory bodies to minimize the use of 'chemical restraints' in this population of vulnerable patients, these findings have important policy
implications."  


[1] Crawford, M., 2000, Homicide is Impossible to Predict, Psychiatric Bulletin 24: 152.

[2] Dawson, J.M. and Langan, P.A. (1994). 1988 Department of Justice study.  Retrieved May 18, 2006 at: http://www.psychlaws.org/BriefingPapers/BP11.htm

[3] Kisely, S., Campbell, L.A., and Preston, N. (2005). Compulsory community and involuntary outpatient treatment for people with severe mental disorders [abstract]. Cochrane Database Systematic Reviews, Jul 20 (3): CD004408.

[4] Lovell, D., Gagliardi, G.J., and Phipps, P. (2005). Washington's Mentally Ill Offender Law: Was Community Safety Increased? Retrieved May 18, 2006 at: http://depts.washington.edu/washinst/One %20Page%20Summaries/Mentally%20Ill%20Offender%20Studi es.htm

[5] Hillbrand, M., Krystal, J., Sharpe, K., & Foster, H. (1994).  Clinical predictors of self-mutilation  in hospitalized patients. Journal of Nervous and Mental Disease, 182, 9-13.

[6] Monahan, J., Steadman, H., Silver, E., Appelbaum, P., Robbins, P.C., Mulvey, E.M., Roth, L.H., Grisso, T., Banks, S. (2001).
Rethinking risk assessment, the MacArthur Study of Mental Disorder and Violence. New York: Oxford University Press

[7] Dennis, D.L. and H.J. Steadman. 1991. "The Criminal Justice System and Severely Mentally III Homeless Persons: An Overview." Report Prepared for the Task Force on Homelessness and Severe Mental Illness. Delmar, NY: Policy Research Associates. Dennis and Steadman, 1991.

[8] Teplin, L.A. (1985). The criminality of the mentally ill: a dangerous misconception [abstract]. American Journal of Psychiatry, 142, 593-9.

[9] Teplin, L.A., Abram, K.M., and McClelland, G.M. (1994). Does psychiatric disorder predict violent crime among released jail detainees? A six-year longitudinal study. American Psychologist, 49, 335-342.

[10] Teplin, L.A., McClelland, G.M., Abram, K.M., and Weiner, D.A. (2005). Crime Victimization in Adults With Severe Mental Illness: Comparison With the National Crime Victimization Survey. Archives of General Psychiatry, 62, 911-921.

[11] Serper, M, Bergman, A. (2003) Psychotic Violence: Methods, Motives, Madness, Psychosocial Press of Madison, CT.

[12] Wallace, C., Mullen, P., Burgess, P. (2004). Criminal offending in schizophrenia over a 25-year period marked by deinstitutionalization and increasing prevalence of comorbid substance use disorders. Am J Psychiatry, 161, 716-727.

[13] Monahan, J., Steadman, H., Silver, E., Appelbaum, P., Robbins, P.C., Mulvey, E.M., Roth, L.H., Grisso, T., Banks, S. (2001).
Rethinking risk assessment, the MacArthur Study of Mental Disorder and Violence. New York: Oxford University Press.

[14] Center for Substance Abuse Treatment (US). Behavioral Health Services for People Who Are Homeless. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2013. (Treatment Improvement Protocol (TIP) Series, No. 55.) A Review of the Literature.Available from: http://www.ncbi.nlm.nih.gov/books/NBK138716/

[15] King, R., & Apter, A. (2003). Suicide in children and adolescents. New York: Cambridge University Press.

[16] Monahan, J., Steadman, H., Silver, E., Appelbaum, P., Robbins, P.C., Mulvey, E.M., Roth, L.H., Grisso, T., Banks, S. (2001).
Rethinking risk assessment, the MacArthur Study of Mental Disorder and Violence. New York: Oxford University Press.

[17] Berenbaum, H., &  Fujita, F. (1994). Schizophrenia and personality: exploring the boundaries and connections between vulnerability and outcome. Journal of Abnormal Psychology, 103, 148-58.

[18] Eronen, M., Angermeyer, MC, Schulze, B. (1998).  The psychiatric epidemiology of violent behavior.  Soc Psychiatry Psychiatr Epidemiol. 33: S13-S23.

[19] Monahan, J., Steadman, H., Silver, E., Appelbaum, P., Robbins, P.C., Mulvey, E.M., Roth, L.H., Grisso, T., Banks, S. (2001).
Rethinking risk assessment, the MacArthur Study of Mental Disorder and Violence. New York: Oxford University Press.

[20] Cohen, L., &  Villa, B. (1996). Self-control and social control: An exposition of the Gottfredson-Hirschi/Sampson-Laub debate. Studies on Crime and Crime Prevention 5, 31-58.

[21] Monahan, J., Steadman, H., Silver, E., Appelbaum, P., Robbins, P.C., Mulvey, E.M., Roth, L.H., Grisso, T., Banks, S. (2001).
Rethinking risk assessment, the MacArthur Study of Mental Disorder and Violence. New York: Oxford University Press.

[22] Fazel S, Gulati G, Linsell L, Geddes JR, Grann M (2009) Schizophrenia and Violence: Systematic Review and Meta-Analysis. PLoS Med 6(8): e1000120. doi:10.1371/journal.pmed.1000120

[23] Monahan, J., Steadman, H.J., Silver, E., Appelbaum, P.S., Robbins, P.C., Mulvey, E.P., Roth, L.H., Grisso, T., & Banks, S. (2001). Rethinking risk assessment: The MacArthur Study of Mental Disorder and Violence. New York: Oxford University Press. .  “mental illness suggests a lower probability of violence.”

[24] Applebaum P, Robbins P, and Monahan , Violence and Delusions: Data from the MacArthur Violence Risk Assessment Study, by J. Am J Psychiatry 2000; 157:566-572. 

[25] Monahan, J, Steadman, H., Robbins, et al. (2005). An actuarial model of violence risk assessment for persons with mental disorders. Psychiatric Services, 56, 810-815.

[26] Cassels, C. 2009, August 31; Quinsey, V. et al 2006: The elements of the Violence Risk Appraisal Guide). Substance abuse main driver of violence in Schizophrenia, psychoses. Medscape Medical News. Retrieved from www.medscape.com September 10, 2009)

[27] Quinsey, V., Harris, G., Rice, M., & Cormier, C. (2006). Violent  Offenders: Appraising and  Managing Risk (2nd Edition). Washington DC: American Psychological Association.

[28] Monahan, J., Steadman, H.J., Silver, E., Appelbaum, P.S., Robbins, P.C., Mulvey, E.P., Roth, L.H., Grisso, T., & Banks, S. (2001). Rethinking risk assessment: The MacArthur Study of Mental Disorder and Violence. New York: Oxford University Press. .  “mental illness suggests a lower probability of violence.”

[29] Monahan, J, Steadman, H., Robbins, et al. (2005). An actuarial model of violence risk assessment for persons with mental disorders. Psychiatric Services, 56, 810-815.

[30] Applebaum P, Robbins P, and Monahan , Violence and Delusions: Data from the MacArthur Violence Risk Assessment Study, by J. Am J Psychiatry 2000; 157:566-572. 

[31] Monahan, J., Steadman, H., Silver, E., Appelbaum, P., Robbins, P.C., Mulvey, E.M., Roth, L.H., Grisso, T., Banks, S. (2001). Rethinking risk assessment, the MacArthur Study of Mental Disorder and Violence. New York: Oxford University Press.

[32] Arseneault, L., Moffit, T., Caspi, A., Taylor, P., & Silva, P. (2000). Mental disorders and violence in a total birth cohort: Results from the Dunedin Study. Archives of General Psychiatry, 57, 979-986.

[33] Bartol, C. (2002). Criminal behavior, a psychosocial approach. Upper Saddle River, NJ: Prentice Hall.

[34] Monahan, J., Steadman, H., Silver, E., Appelbaum, P., Robbins, P.C., Mulvey, E.M., Roth, L.H., Grisso, T., Banks, S. (2001). Rethinking risk assessment, the MacArthur Study of Mental Disorder and Violence. New York: Oxford University Press.

[35] Steadman, H., & Cocozza, J. (1974). Careers of the criminally insane. Lexington, MA: Lexington Books.

[36] Monahan, J., Steadman, H., Silver, E., Appelbaum, P., Robbins, P.C., Mulvey, E.M., Roth, L.H., Grisso, T., Banks, S. (2001). Rethinking risk assessment, the MacArthur Study of Mental Disorder and Violence. New York: Oxford University Press.

[37] Walsh E, Buchanan A, Fahy T., Br J Psychiatry. 2002, Violence and schizophrenia: examining the evidence.  Jun;180:490-5. full text:  http://bjp.rcpsych.org/cgi/content/full/180/6/490 Section of Forensic Mental Health, Institute of Psychiatry, Denmark Hill, London.  sppmemw@iop.kcl.ac.uk

[38] Swanson, J. and Swartz, M., The British Journal of Psychiatry (2008) 193: 37-43.  Comparison of antipsychotic medication effects on reducing violence in people with schizophrenia.  jeffrey.swanson@duke.edu

[39] Brekke JS, Prindle C, Bae SW, Long JD, Risks for individuals with schizophrenia who are living in the community.  Psychiatr Serv. 2001 Oct;52(10):1358-66. http://ps.psychiatryonline.org/cgi/content/full/52/10/1358 School of Social Work, University of Southern California, Los Angeles, CA 90089-0411, USA. brekke@usc.edu

[40] Arseneault L, Moffitt TE, Caspi A, Taylor PJ, Silva PA.  Mental disorders and violence in a total birth cohort: results from the Dunedin Study.  Arch Gen Psychiatry. 2000 Oct;57(10):979-86.

Institute of Psychiatry, 111 Denmark Hill, London SE5 8AF, England.

[41] Moore, T., Glenmullen, J., & Furberg, C. (2010). Prescription drugs associated with reports of violence towards  others. PLoS ONE. 5(12):e15337.

[42] Workman, D.G., Cunningham, D.G., “Psychotropic Drugs on Aggression in a Prison Setting” In Canadian Family Physician, Nov. 1975, pp. 63-64.  Queens University, Kingston.

[43] Rabkin, J.1979, Criminal Behavior of Discharged Mental Patients, Psychological Bullentin, 86, 1-27. 

[44] Tyrer P, et al "Risperidone, haloperidol, and placebo in the treatment of aggressive challenging behavior in patients with intellectual disability: a randomized controlled trial" Lancet 2008; 371: 57-63.

[45] Rosack, J, PRN Orders May Benefit Staff More Than Patients, In Psychiatric News, vol.  XXXVIII no 19, Oct 3, 2003 p35-36. and  original article can be found here: http://psychservices.psychiatryonline.org/cgi/content/full/54/9/1282.  Psychiatr Serv 2003 54 1282