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Schizophrenia, Substance Abuse, and Violent Crime
Open accessAbstract
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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“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]
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“Consistent with other work, violent crime was defined as homicide, assault, robbery, arson, any sexual offense (rape, sexual coercion, child molestation, indecent exposure, and sexual harassment), illegal threats, and intimidation recorded up to 2009 in the National Crime Register (Fazel et al. 2009).”
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“Also in agreement with our finding of a higher suicide risk in patients convicted for a violent crime, previous studies have found not only a higher risk of suicide in the general population with a history of juvenile delinquency but also that a major proportion of the risk increase was due to concomitant mental illne…”
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ResultA Meta-Analysis of the Val158Met COMT Polymorphism and Violent Behavior in Schizophrenia
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“Substance abuse elevates the risk of violence in schizophrenia [51], and it is possible that this effect is partially moderated by the COMT polymorphism.”
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Marital Status and Mental Health
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Impulsivity-related brain volume deficits in schizophrenia-addiction comorbidity
Schiffer, B., Müller, B. W., Scherbaum, N., Forsting, M., Wiltfang, J., Leygraf, N., & Gizewski, E. R. (2010) · Brain · doi:10.1093/brain/awq153 · Cited by 68
“This includes an overall reduced quality of life, more frequent and longer periods of hospitalization, higher relapse rates, less treatment compliance and higher incidence of violent behaviour (Fazel et al., 2009).”
BackgroundInfluentialNew Clinically Relevant Findings about Violence by People with Schizophrenia
Hodgins, S., & Klein, S. (2016) · The Canadian Journal of Psychiatry · doi:10.1177/0706743716648300 · Cited by 71
“Persons with schizophrenia are more likely than those without this disorder to misuse substances, and substance misuse is a potent risk factor for AGB.(4) The misuse of alcohol observed in previous generations is being replaced by cannabis use.”
BackgroundNederlof, A. F., Muris, P., & Hovens, J. E. J. M. (2012) · Aggression and Violent Behavior · doi:10.1016/j.avb.2012.11.018 · Cited by 70
Lundholm, L., Haggård, U., Möller, J., Hallqvist, J., & Thiblin, I. (2012) · Drug and Alcohol Dependence · doi:10.1016/j.drugalcdep.2012.09.019 · Cited by 68
“In accordance with previous studies, violent crime was defined as homicide, manslaughter, assault, unlawful threat, robbery, arson, illegal threat, illegal coercion, intimidation, violation of a person’s or a woman’s integrity, and sexual offences (Fazel et al., 2009; Frisell et al., 2010).”
BackgroundTsigebrhan, R., Shibre, T., Medhin, G., Fekadu, A., & Hanlon, C. (2013) · Schizophrenia Research · doi:10.1016/j.schres.2013.10.032 · Cited by 65
Imaging Violence in Schizophrenia: A Systematic Review and Critical Discussion of the MRI Literature
Fjellvang, M., Gröning, L., & Haukvik, U. K. (2018) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2018.00333 · Cited by 65
“(2) To critically discuss the promises and”
BackgroundMethodInfluentialLundholm, L., Frisell, T., Lichtenstein, P., & Långström, N. (2014) · Addiction · doi:10.1111/add.12715 · Cited by 64
Public Safety, Mental Disorders, and Guns
Appelbaum, P. S. (2013) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2013.315 · Cited by 65
“Substance abuse, for example, accounts for a large proportion of the incremental risk.(5) Indeed, the effect of substance abuse on violence is significantly greater than the effect of mental disorder.”
Zhu, W., Zhou, X., & Xia, L. (2019) · Scientific Reports · doi:10.1038/s41598-019-44115-4 · Cited by 69
Biological Aspects of Aggression and Violence in Schizophrenia
Cho, W., Shin, W., An, I., Bang, M., Cho, D., & Lee, S.-H. (2019) · Clinical Psychopharmacology and Neuroscience · doi:10.9758/cpn.2019.17.4.475 · Cited by 70
“Several studies have shown minimal increase in hostile behavior in schizophrenia when comorbidity for substance abuse was considered as a confounding factor [14,15].”
BackgroundSchizophrenia and violence: realities and recommendations
Silverstein, S. M., Pozzo, J. D., Roché, M. W., Boyle, D., & Miskimen, T. (2015) · Crime Psychology Review · doi:10.1080/23744006.2015.1033154 · Cited by 66
“However, even when these factors are taken into account, the rate of schizophrenia-associated violence is higher than in the general population (Fazel et al., 2009a, 2009b; Hodgins et al., 2007a; Steadman et al., 1998; Swanson et al., 1990; Volavka, 2013; see above).”
BackgroundWell-Being across the Life Course
Mirowsky, J., & Ross, C. E. (2009) · Cambridge University Press eBooks · doi:10.1017/cbo9780511984945.023 · Cited by 60
Fazel, S., Wolf, A., Fimińska, Z., & Larsson, H. (2016) · PLoS ONE · doi:10.1371/journal.pone.0155906 · Cited by 68
“Data on the most recent offence (also known as the index offence) was gathered from the Crime Register, and we used a standard system to classify crimes into six main categories.[37, 41] From the Patient Register, the following psychiatric diagnoses on discharge were investigated: schizophrenia and related disorders (…”
BackgroundMethodResultSchizophrenia disorders, substance abuse and prior offending in a sequential series of 435 homicides
Bennett, D. J., Ogloff, J. R. P., Mullen, P. E., Thomas, S. D. M., Wallace, C., & Short, T. (2011) · Acta Psychiatrica Scandinavica · doi:10.1111/j.1600-0447.2011.01731.x · Cited by 59
“Studies have often either excluded cases with comorbid substance abuse when calculating the true relationship between having a schizophrenia disorder and violence or compared rates with comorbid substance abuse to cases without known substance abuse (1, 2, 23).”
BackgroundPredicting Psychiatric Hospital Admission Among Adults With Schizophrenia
Olfson, M., Ascher‐Svanum, H., Faries, D. E., & Marcus, S. C. (2011) · Psychiatric Services · doi:10.1176/ps.62.10.pss6210_1138 · Cited by 58
Severe Mental Illness and Aggressive Behavior: On the Importance of Considering Subgroups
Joyal, C. C., Côté, G., Meloche, J., & Hodgins, S. (2011) · International Journal of Forensic Mental Health · doi:10.1080/14999013.2011.577136 · Cited by 59
“These results are consistent with previous studies suggesting that the classical risk factors for violence among the general population, including alcohol use (e.g., Soyka, 2000; Fazel et al., 2009), illegal drug use (e.”
BackgroundResultLund, C., Hofvander, B., Forsman, A., Anckarsäter, H. S., & Nilsson, T. (2013) · International Journal of Law and Psychiatry · doi:10.1016/j.ijlp.2013.04.015 · Cited by 57
Sariaslan, A., Larsson, H., & Fazel, S. (2015) · Molecular Psychiatry · doi:10.1038/mp.2015.184 · Cited by 57
“Validation studies examining single-episode hospital admissions for schizophrenia in the NPR have reported satisfactory validity (3, 18, 19) but this strict definition is commonly used in the literature to minimize the risk of identifying false-Sariaslan positive cases (11).”
Involuntary detention and treatment: are we edging toward a “paradigm shift”?
Szmukler, G. (2020) · Schizophrenia Bulletin · doi:10.1093/schbul/sbz115 · Cited by 55
Correlates of Substance Use Severity Among Homeless Youth
Nyamathi, A., Hudson, A. L., Greengold, B., Slagle, A., Marfisee, M., Khalilifard, F., & LEAKE, B. D. (2010) · Journal of Child and Adolescent Psychiatric Nursing · doi:10.1111/j.1744-6171.2010.00247.x · Cited by 55
Witt, K., Hawton, K. E., & Fazel, S. (2014) · Schizophrenia Research · doi:10.1016/j.schres.2014.02.001 · Cited by 56
“Schizophrenia is associated with significantly elevated rates of both suicide (Harris and Barraclough, 1997; Palmer et al., 2005; Saha et al., 2007) and violence (Fazel et al., 2009a,b) compared to general population rates.”
BackgroundMethodNeuroimaging correlates of aggression in schizophrenia: an update
Hoptman, M. J., & Antonius, D. (2010) · Current Opinion in Psychiatry · doi:10.1097/yco.0b013e328342c8e0 · Cited by 56
Darmedru, C., Demily, C., & Nicolas Franck, B. (2017) · Psychiatry Research · doi:10.1016/j.psychres.2016.12.062 · Cited by 55
“Substance abuse comorbidity and poor treatment observance (Fazel et al., 2009(b); Witt et al., 2013), which is often caused by a lack of clinical insight, are considered to be significant predictors of violence in SCZ (Ekinci et al., 2013).”
Hofvander, B., Ståhlberg, O., Nydén, A., Wentz, E., Degl’Innocenti, A., Billstedt, E., Forsman, A., Gillberg, C., Nilsson, T., Råstam, M., et al. (2010) · Psychiatry Research · doi:10.1016/j.psychres.2010.05.008 · Cited by 56
“The major mental disorders, such as schizophrenia and bipolar disorder, have been shown to carry an increased risk for violent offending (Hodgins et al., 1996; Fazel et al., 2009), but this association is mainly caused by a subgroup of disordered persons who have had an early onset of norm-breaking, aggressive behavio…”
BackgroundSelective Serotonin Reuptake Inhibitors and Violent Crime: A Cohort Study
Molero, Y., Lichtenstein, P., Zetterqvist, J., Gumpert, C. H., & Fazel, S. (2015) · PLoS Medicine · doi:10.1371/journal.pmed.1001875 · Cited by 57
“Violent crimes were defined as crimes against persons as per previous work [30], and included attempted, completed, and aggravated forms of homicide, manslaughter, unlawful threats, harassment, robbery, arson, assault, assault on an official, kidnapping, stalking, coercion, and all sexual offences (see S1 Methods for…”
BackgroundDepression and Violence in Adolescence and Young Adults: Findings From Three Longitudinal Cohorts
Yu, R., Aaltonen, M., Branje, S., Ristikari, T., Meeus, W., Salmela‐Aro, K., Goodwin, G. M., & Fazel, S. (2017) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2017.05.016 · Cited by 62
“Compared with severe mental illnesses, such as schizophrenia and bipolar disorder, which are associated with violent behaviors, 35,36 adolescent and young adult depression is a more prevalent mental health condition.”
BackgroundViolence in psychosis: Conceptualizing its causal relationship with risk factors
Lamsma, J., & Harte, J. M. (2015) · Aggression and Violent Behavior · doi:10.1016/j.avb.2015.05.003 · Cited by 58
Metadata
- 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
- 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
- green
- www.ncbi.nlm.nih.gov
- 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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