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

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Schizophrenia, Substance Abuse, and Violent Crime

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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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“It would also explain why attempts to find psychoticsymptomsassociatedwithviolence haveproducedcontradictoryresults.(11,13,14) Therefore,byusinglongitudinaldesigns, we examined the relationship of schizophrenia with violent crime in Sweden from 1973 until 2006.”
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“Because substance abuse could be on the causal pathway between schizophrenia and violent crime, it has been argued that it is not appropriate to include it as a confounder in regression modeling.(31) Another argument for not including substance abuse as a confounder is whether effect modification occurred (whether the…”

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“Finding a higher relative risk of offending among women with mental disorder compared with men replicates previous studies of schizophrenia (Fazel et al. 2009a), major mental disorders (Brennan et al. 2000) and recently discharged psychiatric patients (Robbins et al. 2003).”
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A meta-analysis of the relationship between psychosis and any type of criminal offending, in both men and women
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BackgroundResultInfluential
A Longitudinal Study of Violent Behavior in a Psychosis-Risk Cohort
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“Some environmental factors such as violence history, substance use, sex, and unemployment [1, 6, 7] could mediate the association between schizophrenia and violence; however, controlling these factors could not eliminate this association [7].”
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“threats or violence against an officer, arson, gross violation of a person’s integrity, or harassment, and sexual offenses, with attempted or aggravated offences were included wherever applicable (Fazel et al., 2009); and (2) non-violent criminal convictions, defined as any other crimes that were not violent, driving…”
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Psychiatric Assessment of Aggressive Patients: A Violent Attack on a Resident
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“When substance use is linked with schizophrenia, rates of violence have been shown to be consistently higher (Wallace et al., 2004; Foley et al., 2005; Erkiran et al., 2006; Fazel et al., 2009), although not exclusively so (Modestin and Wuermle, 2005).”
Background
A Novel Approach to Determining Violence Risk in Schizophrenia: Developing a Stepped Strategy in 13,806 Discharged Patients
Singh, J. P., Grann, M., Lichtenstein, P., Långström, N., & Fazel, S. (2012) · PLoS ONE · doi:10.1371/journal.pone.0031727 · Cited by 35
“The inclusion of noncontact offences in the operational definition of violence is consistent with previous risk assessment research [20,21], including studies that have specifically investigated the association between schizophrenia and criminal behaviour [1].”
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Targeted violence against law enforcement officers
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“(Fazel et al., 2009).”
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“, SMI + substance use disorder), we find a higher rate of violent crimes (12, 13), more hospitalization, poorer compliance to treatment (13, 14), more relapses (14), a higher rate of sexually transmitted and blood-borne infections (STBBIs, including HIV) (15), a higher rate of homelessness (16, 17), more psychiatric s…”
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Stress, Schizophrenia, and Violence: A Machine Learning Approach
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“098 Poor financial situation (large debts or no monthly income) (n1⁄4 118) 27 (23) 11 (37) 0.”
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“As in the general population, co-morbid substance misuse is a very strong predictor, especially of violent offending (Fazel et al., 2009).”
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Arrest Types and Co-occurring Disorders in Persons with Schizophrenia or Related Psychoses
McCabe, P. J., Christopher, P. P., Druhn, N., Roy-Bujnowski, K. M., Grudzinskas, A. J., & Fisher, W. H. (2012) · The Journal of Behavioral Health Services & Research · doi:10.1007/s11414-011-9269-4 · Cited by 33
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“Swedish studies estimate that between 8 and 13 % of people with psychotic illnesses had committed at least one violent crime—twice the rate in the general population [68, 69].”
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Criminal Behavior in Opioid‐Dependent Patients Before and During Maintenance Therapy: 6‐year Follow‐Up of a Nationally Representative Cohort Sample
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“In addition, substance use in general is a severe risk factor for criminality and in particular for violent crime in individuals with major mental disorders such as schizophrenia and bipolar disorder (25,26).”
Background
Mortality among male forensic and non-forensic psychiatric patients: matched cohort study of rates, predictors and causes-of-death
Sørensen, L. U., Bengtson, S., Lund, J., Ibsen, M., & Långström, N. (2020) · Nordic Journal of Psychiatry · doi:10.1080/08039488.2020.1743753 · Cited by 32
“Specifically, a substantial body of research has found (some forms of) substance abuse to be a risk factor both for being classified as a FP patient and violent reoffending among psychiatric patients [29,30].”
Background
Advancing paternal age and offspring violent offending: A sibling-comparison study
Kuja‐Halkola, R., Yudi Pawitan, Y., D'Onofrio, B. M., Långström, N., & Lichtenstein, P. (2012) · Development and Psychopathology · doi:10.1017/s095457941200034x · Cited by 33
“…increased the risk for violent offending (12.5% for bipolar disorder and 21.8% for schizophrenia) compared to the total population (4.0%), indicating relative risks consistent with previous research (see the systematic reviews in Fazel, Lichtenstein, Grann, et al., 2010; and Fazel et al., 2009).”
ResultInfluential
Zwischenmenschliche Gewalt im Kontext affektiver und psychotischer Störungen
Maier, W., Hauth, I., Berger, T., & Saß, H. (2015) · Der Nervenarzt · doi:10.1007/s00115-015-0040-6 · Cited by 31
Serious Violence by People With Mental Illness: National Clinical Survey
Flynn, S., Rodway, C., Appleby, L., & Shaw, J. (2014) · Journal of Interpersonal Violence · doi:10.1177/0886260513507133 · Cited by 31
“…literature can be limiting, with several studies reporting either a combined group of mental disorders, or specific diagnosis, particularly schizophrenia/psychosis (Elbogen, Van Dorn, Swanson, Swartz, & Monahan, 2006; Fazel et al., 2009; Kooyman et al., 2007; Silver, Felson, & Vaneseltine, 2008).”
Background
Risk factors for inpatient violence and self-harm in forensic psychiatry: the role of head injury, schizophrenia and substance misuse
Brown, S., O’Rourke, S. J., & Schwannauer, M. (2018) · Brain Injury · doi:10.1080/02699052.2018.1553064 · Cited by 30
“This finding contradicts previous meta-analytic results that suggest that the increased risk of violence associated with schizophrenia and psychosis is mediated by substance abuse comorbidities (20).”
Result
Adverse experiences, mental health, and substance use disorders as social determinants of incarceration
Henry, B. F. (2019) · Journal of Community Psychology · doi:10.1002/jcop.22289 · Cited by 31
“Social dangerousness and incurability in schizophrenia”: Results of an educational intervention for medical and psychology students
Magliano, L., Read, J., Sagliocchi, A., Oliviero, N., D’Ambrosio, A., Campitiello, F., Zaccaro, A., Guizzaro, L., & Patalano, M. (2014) · Psychiatry Research · doi:10.1016/j.psychres.2014.06.002 · Cited by 31
“…that epidemiological data demonstrate that persons with a drug addiction rather than “schizophrenics” are at increased risk for aggressive behaviours (Fazel et al., 2009) and that perceptions of dangerousness are influenced by the interpretation of the word “schizophrenia” in a given culture,…”
The Relationship Between Level of Training and Accuracy of Violence Risk Assessment
Teo, A. R., Holley, S. R., Leary, M. R., & McNiel, D. E. (2012) · Psychiatric Services · doi:10.1176/appi.ps.201200019 · Cited by 34
Brain structure differences among male schizophrenic patients with history of serious violent acts: an MRI voxel-based morphometric study
Kuroki, N., Kashiwagi, H., Ota, M., Ishikawa, M., Kunugi, H., Sato, N., Hirabayashi, N., & Ota, T. (2017) · BMC Psychiatry · doi:10.1186/s12888-017-1263-9 · Cited by 34
“A history of substance abuse can affect brain morphometry, and previously shown to be associated with violence risk [1].”
Background
Rampage Violence Requires a New Type of Research
Harris, J. M., & Harris, R. B. (2012) · American Journal of Public Health · doi:10.2105/ajph.2011.300545 · Cited by 31
Outcomes in adulthood of adoption after long-term foster care: A sibling study
Hjern, A., Vinnerljung, B., & Brännström, L. (2019) · Developmental Child Welfare · doi:10.1177/2516103218815702 · Cited by 30
Advantages of Machine Learning in Forensic Psychiatric Research—Uncovering the Complexities of Aggressive Behavior in Schizophrenia
Hofmann, L. A., Lau, S., & Kirchebner, J. (2022) · Applied Sciences · doi:10.3390/app12020819 · Cited by 32
The factor structure of the Barratt Impulsiveness Scale (BIS-11) and correlates of impulsivity among outpatients with schizophrenia and other psychotic disorders in Singapore
Lau, J. H., Jeyagurunathan, A., Shafie, S., Chang, S. S. H., Samari, E., Cetty, L., Verma, S. K., Tang, C. Y. Z., & Subramaniam, M. (2022) · BMC Psychiatry · doi:10.1186/s12888-022-03870-x · Cited by 33
“In addition, schizophrenia has also been associated with an increased risk of violent behaviors compared to other psychiatric illnesses [16, 17] and the general population [18].”
Background
Hostility in schizophrenia: An integrated analysis of the combined Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and the European First Episode Schizophrenia Trial (EUFEST) studies
Volavka, J., Dorn, R. A. V., Citrome, L., Kahn, R. S., Fleischhacker, W. W., & Czobor, P. (2015) · European Psychiatry · doi:10.1016/j.eurpsy.2015.10.003 · Cited by 30
“Criminal violence by schizophrenia patients is largely (but not completely) attributable to substance abuse comorbidity [10].”
Background
History of offending behavior in first episode psychosis patients: A marker of specific clinical needs and a call for early detection strategies among young offenders
Marion‐Veyron, R., Lambert, M., Cotton, S., SCHIMMELMANN, B. G., Gravier, B., McGorry, P. D., & Conus, P. (2014) · Schizophrenia Research · doi:10.1016/j.schres.2014.09.078 · Cited by 29
“Prevalence of offending behavior has been reported to be higher among patients with psychosis compared to the general population (Fazel et al., 2009).”
Background
Early sensory–perceptual processing deficits for affectively valenced inputs are more pronounced in schizophrenia patients with a history of violence than in their non-violent peers
Sanctis, P. D., Foxe, J. J., Czobor, P., Wylie, G. R., Kamiel, S. M., Huening, J., Nair-Collins, M., & KRAKOWSKI, M. I. (2012) · Social Cognitive and Affective Neuroscience · doi:10.1093/scan/nss052 · Cited by 29
Schizophrenia and Criminal Responsibility
Tsimploulis, G., Niveau, G., Eytan, A., Giannakopoulos, P., & Sentissi, O. (2018) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000000805 · Cited by 30
Informal Caregiving Relationships in Psychosis: Reviewing the Impact of Patient Violence on Caregivers
Onwumere, J., Zhou, Z., & Kuipers, E. (2018) · Frontiers in Psychology · doi:10.3389/fpsyg.2018.01530 · Cited by 36
“The statistical association between violence and psychosis is frequently reported as modest (Coid et al., 2006; Taylor, 2008; Douglas et al., 2009; Fazel et al., 2009), and is particularly evident during the first psychosis episode (Nielssen et al.”
Background
Childhood Trauma in Persons With Schizophrenia and a History of Interpersonal Violence
Storvestre, G. B., Jensen, A., Bjerke, E., Tesli, N., Røsæg, C., Friestad, C., Andreassen, O. A., Melle, I. S., & Haukvik, U. K. (2020) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2020.00383 · Cited by 33
“Emotional abuse 11 (9, 12) 5–18 9 (5, 11) 5–20 5 (5, 6.”
Patterns of Justice Involvement Among Adults With Schizophrenia and Bipolar Disorder: Key Risk Factors
Robertson, A. G., Swanson, J. W., Frisman, L. K., Lin, H., & Swartz, M. S. (2014) · Psychiatric Services · doi:10.1176/appi.ps.201300044 · Cited by 30
Violent behavior in autism spectrum disorders: Who's at risk?
Pozzo, J. D., Roché, M. W., & Silverstein, S. M. (2018) · Aggression and Violent Behavior · doi:10.1016/j.avb.2018.01.007 · Cited by 33
Effect of aripiprazole lauroxil on agitation and hostility in patients with schizophrenia
Citrome, L., Du, Y., Risinger, R. C., Stankovic, S., Claxton, A., Zummo, J., Bose, A., Silverman, B. L., & Ehrich, E. W. (2015) · International Clinical Psychopharmacology · doi:10.1097/yic.0000000000000106 · Cited by 28
“Studies have shown a higher incidence of violent, aggressive behavior among patients with schizophrenia compared with the general population, and the incidence increases further with comorbid substance abuse (Eronen et al., 1996; Wallace et al., 1998; Fazel et al., 2009).”
Background
The Influence of Causal Explanations and Diagnostic Labeling on Medical Studentsʼ Views of Schizophrenia
Magliano, L., Read, J., Rega, S., Oliviero, N., Sagliocchi, A., Patalano, M., & D’Ambrosio, A. (2011) · Academic Medicine · doi:10.1097/acm.0b013e318226708e · Cited by 28
Violent behaviour in early psychosis patients: Can we identify clinical risk profiles?
Moulin, V., Palix, J., Golay, P., Dumais, A., Gholam‐Rezaee, M., Azzola, A., Baumann, P., Alameda, L., & Conus, P. (2017) · Early Intervention in Psychiatry · doi:10.1111/eip.12512 · Cited by 28
“…patients with schizophrenia and first episode psychosis (FEP), the presence of isolated dynamic risk factors such as substance abuse or dependency (Fazel et al., 2009; Large, 2014; Latalova, 2014; Vacheron & Cornic, 2010), antisocial personality disorders (APDs) (Putkonen, Kotilainen, Joyal, &…”
Background
Maternal age at first birth and offspring criminality: Using the children of twins design to test causal hypotheses
Coyne, C. A., Långström, N., Rickert, M. E., Lichtenstein, P., & D'Onofrio, B. M. (2013) · Development and Psychopathology · doi:10.1017/s0954579412000879 · Cited by 33
Psychiatric and neurological disorders in late adolescence and risk of convictions for violent crime in men
Moberg, T., Stenbacka, M., Tengström, A., Jönsson, E. G., Nordström, P., & Jokinen, J. (2015) · BMC Psychiatry · doi:10.1186/s12888-015-0683-7 · Cited by 33
“offenders [1], as well as in studies on other violent crimes [2, 3] and other factors, such as substance use disorders, have been suggested to be a possible mediator of the increase in the risk of violent crime among pa-”
Background
Associations with violent and homicidal behaviour among men with schizophrenia
Karabekiroğlu, A., Pazvantoğlu, O., Karabekiroğlu, K., Böke, Ö., & Korkmaz, I. Z. (2015) · Nordic Journal of Psychiatry · doi:10.3109/08039488.2015.1109139 · Cited by 25
“reported that rates of violent crimes change between 10–15% among patients with any psychotic disorder (7).”
Background
Leading indicators of community-based violent events among adults with mental illness
Dorn, R. A. V., Grimm, K. J., Desmarais, S. L., Tueller, S., Johnson, K. L., & Swartz, M. S. (2016) · Psychological Medicine · doi:10.1017/s0033291716003160 · Cited by 27
“2013), whereas community research suggests that substance use is a key driver of violence risk (Fazel et al. 2009).”
Background
Zur Gefährlichkeit ehemaliger Patienten des Maßregelvollzugs (§ 63 StGB)
Seifert, D. (2010) · Forensische Psychiatrie Psychologie Kriminologie · doi:10.1007/s11757-009-0037-8 · Cited by 27
Violent and non-violent offending in patients with schizophrenia: Exploring influences and differences via machine learning
Sonnweber, M., Lau, S., & Kirchebner, J. (2021) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2021.152238 · Cited by 27
“This is inconsistent with previous findings that have linked substance abuse to a higher likelihood of violence in SSD patients [5,12,44,45] and requires further clarification.”
Result
Adjuvant chemotherapy for breast cancer in patients with schizophrenia
Johnson, F. (2012) · Oncology Letters · doi:10.3892/ol.2012.560 · Cited by 28
“The hazard increases markedly when other predisposing factors (particularly drug abuse) are present (36).”
Violent offending and IQ level as predictors of suicide in schizophrenia: National cohort study
Webb, R. T., Långström, N., Runeson, B., Lichtenstein, P., & Fazel, S. (2011) · Schizophrenia Research · doi:10.1016/j.schres.2011.04.031 · Cited by 27
Quantifying violence in mental health research
Harris, S. T., Oakley, Ç., & Picchioni, M. (2013) · Aggression and Violent Behavior · doi:10.1016/j.avb.2013.07.022 · Cited by 26
From Clozapine to Cognitive Remediation
Quinn, J., & Kolla, N. J. (2016) · The Canadian Journal of Psychiatry · doi:10.1177/0706743716656830 · Cited by 26
Adolescent daytime sleepiness as a risk factor for adult crime
Raine, A., & Venables, P. H. (2017) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.12693 · Cited by 26
Delusion, excitement, violence, and suicide history are risk factors for aggressive behavior in general inpatients with serious mental illnesses: A multicenter study in China
Li, Q., Zhong, S., Zhou, J., & Wang, X. (2018) · Psychiatry Research · doi:10.1016/j.psychres.2018.12.071 · Cited by 25
Psychotic Domestic Murder: Neuropsychological Differences Between Homicidal and Nonhomicidal Schizophrenic Men
Hanlon, R. E., Coda, J., Cobia, D. J., & Rubin, L. H. (2012) · Journal of Family Violence · doi:10.1007/s10896-011-9410-4 · Cited by 27
“…an increased risk for violent criminal acts among individuals with schizophrenia when compared to the general population (e.g., Brennan et al. 2000; Fazel et al. 2009a; Swanson et al. 2006; Swanson et al. 1990) and an increased risk for homicide, specifically (e.g., Erb et al. 2001; Fazel and…”
Background
Major mental disorders, gender, and criminological circumstances of homicide
Richard‐Devantoy, S., Bouyer-Richard, A.-I., Annweiler, C., Gourévitch, R., Jollant, F., Olié, J., Bourdel, M., Lhuillier, J.-P., & Beauchet, O. (2016) · Journal of Forensic and Legal Medicine · doi:10.1016/j.jflm.2016.01.014 · Cited by 26
Prevalence and phenomenology of violent ideation and behavior among 200 young people at clinical high-risk for psychosis: an emerging model of violence and psychotic illness
Brucato, G., Appelbaum, P. S., Masucci, M. D., Rolin, S. A., Wall, M. M., Levin, M., Altschuler, R., First, M. B., Lieberman, J. A., & Girgis, R. R. (2018) · Neuropsychopharmacology · doi:10.1038/s41386-018-0304-5 · Cited by 25
Criminal Justice Settings as Possible Sites for Early Detection of Psychotic Disorders and Reducing Treatment Delay
Ramsay Wan, C., Broussard, B., Haggard, P., & Compton, M. T. (2014) · Psychiatric Services · doi:10.1176/appi.ps.201300206 · Cited by 24
Prevention of homicidal behaviour in men with psychiatric disorders
Sher, L., Rice, T., & on behalf of the World Federation of Societies of Biological Psychiatry (Wfsbp) Task Force on Men's Mental Health (2015) · The World Journal of Biological Psychiatry · doi:10.3109/15622975.2015.1028998 · Cited by 24

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: 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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Schizophrenia, Substance Abuse, and Violent Crime

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