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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“Third, thepossiblecontribution of genetic and early environmental factors in mediating the link between schizophreniaandviolencehasnotbeen reliably studied.(10) Conceptual models of violence in schizophrenia postulate that patients with schizophrenia are violent as a consequence of the psychopathologic symptoms of the…”
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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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“Although we relied on conviction data, other work has shown that the degree of underestimation of violence is similar in psychiatric patients and controls compared with self-report measures; hence, the risk estimates were not affected.(43) A further limitation is that we did not have data on whether treatment was rece…”
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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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“69,70 Additionally, previous brain imaging research has suggested that myelination may be affected by antipsychotic medication 71 and the violent-PSY group had a significantly higher total DDD of antipsychotic medication use compared with nonviolent PSY group.”
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“Previous studies have found that people with schizophrenia are at significantly higher risk for violence than the general population ( Fazel et al., 2009b ; Fazel et al., 2009a ; Short et al., 2013 ), and these studies have had several adverse effects, including discrimination, stigma, and negative…”
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Blunted niacin skin flushing response in violent offenders with schizophrenia: A potential auxiliary diagnostic biomarker
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“This has direct clinical implications regarding treatment: The comorbidity of substance use disorders in general is known to aggravate the course of disorder of offender patients with SSD in terms of severity of symptoms and expression of antisocial behavior [36,55].”
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“Comorbidity with substance- related disorders increases the risk of violence among individuals with schizophrenia [3,4,24,25].”
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“In adult samples, factors like severe mental illness, antisocial personality disorder and substance abuse are associated with increased risk of violence (Douglas, Guy, & Hart, 2009 ; Fazel, Langstrom, Hjern, Grann, & Lichtenstein, 2009 ; Hodgins, 2007 ).”
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“A variety of studies indicate that there is an association between serious violence and Schizophrenia, and that this link could be explained simply on the basis of either comorbid substance abuse, or prior criminal offending (Bennett et al., 2011; Fazel et al., 2009).”
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Enhancing Predictive Power: Integrating a Linear Support Vector Classifier with Logistic Regression for Patient Outcome Prognosis in Virtual Reality Therapy for Treatment-Resistant Schizophrenia
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Babchishin, K. M., Seto, M. C., & Långström, N. (2025) · Journal of Criminal Justice · doi:10.1016/j.jcrimjus.2025.102355 · Cited by 6
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“, 2005) and in the study done in Iran, it was 71-98% (Fazel et al., 2009).”

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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