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Cited by 726Psychopathy, Forensic Psychiatry, Sexual OffendingSchizophrenia research and treatmentCrime Patterns and Interventions

Schizophrenia, substance abuse, and violent crime

Open access
Fazel, Seena·2009·JAMA
DOI 10.1001/jama.2009.675PMC PMC4905518
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Abstract

CONTEXT: Persons with schizophrenia are thought to be at increased risk of committing violent crime 4 to 6 times the level of general population individuals without this disorder. However, risk estimates vary substantially across studies, and considerable uncertainty exists as to what mediates this elevated risk. Despite this uncertainty, current guidelines recommend that violence risk assessment should be conducted for all patients with schizophrenia. OBJECTIVE: To determine the risk of violent crime among patients diagnosed as having schizophrenia and the role of substance abuse in mediating this risk. DESIGN, SETTING, AND PARTICIPANTS: Longitudinal designs were used to link data from nationwide Swedish registers of hospital admissions and criminal convictions in 1973-2006. Risk of violent crime in patients after diagnosis of schizophrenia (n = 8003) was compared with that among general population controls (n = 80 025). Potential confounders (age, sex, income, and marital and immigrant status) and mediators (substance abuse comorbidity) were measured at baseline. To study familial confounding, we also investigated risk of violence among unaffected siblings (n = 8123) of patients with schizophrenia. Information on treatment was not available. MAIN OUTCOME MEASURE: Violent crime (any criminal conviction for homicide, assault, robbery, arson, any sexual offense, illegal threats, or intimidation). RESULTS: In patients with schizophrenia, 1054 (13.2%) had at least 1 violent offense compared with 4276 (5.3%) of general population controls (adjusted odds ratio [OR], 2.0; 95% confidence interval [CI], 1.8-2.2). The risk was mostly confined to patients with substance abuse comorbidity (of whom 27.6% committed an offense), yielding an increased risk of violent crime among such patients (adjusted OR, 4.4; 95% CI, 3.9-5.0), whereas the risk increase was small in schizophrenia patients without substance abuse comorbidity (8.5% of whom had at least 1 violent offense; adjusted OR, 1.2; 95% CI, 1.1-1.4; P<.001 for interaction). The risk increase among those with substance abuse comorbidity was significantly less pronounced when unaffected siblings were used as controls (28.3% of those with schizophrenia had a violent offense compared with 17.9% of their unaffected siblings; adjusted OR, 1.8; 95% CI, 1.4-2.4; P<.001 for interaction), suggesting significant familial (genetic or early environmental) confounding of the association between schizophrenia and violence. CONCLUSIONS: Schizophrenia was associated with an increased risk of violent crime in this longitudinal study. This association was attenuated by adjustment for substance abuse, suggesting a mediating effect. The role of risk assessment, management, and treatment in individuals with comorbidity needs further examination.

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  • Dual disorders are associated with worse clinical and social outcomes than noncomorbid severe mental illness, including more hospitalizations, poorer treatment compliance, more relapses, higher rates of sexually transmitted and blood-borne infections, higher homelessness, more psychiatric symptoms, poorer treatment outcomes, and greater suicide rate.

    “This dual disorder often starts during youth and leads to significant societal costs, including lower employability rates, more hospitalizations, and higher risk of homelessness and of suicide attempts when compared to those with a serious mental illness without substance misuse.”

    From Mobile intervention for individuals with psychosis, dual disorders, and their common comorbidities: A literature review (2019) · cites this paper as [12]

    The Results compare violent-crime rates in people with schizophrenia with and without substance-abuse comorbidity, not the clinical and social outcomes attributed to the paper. The Methods (Sociodemographic Covariates; page unavailable) explicitly state that homelessness data were unavailable. Searches for hospitalizations, employability, suicide attempts, treatment outcomes, and the other listed outcomes found no comparison supporting the claim. (LLM, conf=0.76)

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Authors
Fazel, S.
Affiliations
Warneford Hospital (GB)
Corresponding author
Fazel, Seena
ORCID
Fazel, Seena
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2009-05-20
Volume
301
Issue
19
Pages
2016
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2009.675
PMC
PMC4905518
OpenAlex
W2073141569
Cited by
726
References
45
Citations by year
2026: 36 · 2025: 22 · 2024: 37 · 2023: 24 · 2022: 45 · 2021: 25 · 2020: 38 · 2019: 46 · 2018: 48 · 2017: 73 · 2016: 32 · 2015: 49 · 2014: 49 · 2013: 50 · 2012: 55
FWCI
53.88
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
Wellcome Trust (095806)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Psychopathy, Forensic Psychiatry, Sexual Offending
  • Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
  • Social Sciences › Sociology and Political Science › Crime Patterns and Interventions
Keywords
schizophrenia, violent crime, substance use comorbidity, violence risk, criminal conviction, homicide, assault, unaffected siblings, familial confounding, risk factors for violence, Sweden, hospitalization, criminal records, mental illness and crime, risk assessment guidelines, family history of schizophrenia, income, marital status
MeSH terms
Adult, Crime, Female, Humans, Longitudinal Studies, Male, Registries, Risk, Schizophrenia, Socioeconomic Factors, Sweden, Violence, Comorbidity, Substance-Related Disorders, Young Adult

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