Deinstitutionalization and The Rise of Violence

The deinstitutionalization of individuals with serious mental illness was driven by 4 factors: public revelations regarding the state of public mental hospitals, the introduction of antipsychotic medications, the introduction of federal programs to fund patients who had been discharged, and civil libertarian lawyers. 

The result is approximately 3.2 million individuals with untreated serious mental illness living in the community. Beginning in the 1970s in the United States, there began to be reported increasing incidents of violent behavior, including homicides, committed by these untreated individuals. Such incidents became more numerous in the 1980s and 1990s, and have further increased since the turn of the century. 

Existing studies suggest that individuals with untreated severe mental illness are responsible for at least 10% of all homicides and approximately half of all mass killings. 

Studies have also shown that when these individuals are treated, the incidence of violent behavior decreases significantly. Examples of treatment mechanisms that have proven effective include assisted outpatient treatment (AOT), conditional release, and mental health courts.

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By: Fuller Torrey E1.

• 1Department of Psychiatry,Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland, USA; Stanley Medical Research Institute,Chevy Chase, Maryland, USA.

Selective Serotonin Reuptake Inhibitors and Violent Crime: A Cohort Study

From Swedish national registers we extracted information on 856,493 individuals who were prescribed SSRIs, and subsequent violent crimes during 2006 through 2009. We used stratified Cox regression analyses to compare the rate of violent crime while individuals were prescribed these medications with the rate in the same individuals while not receiving medication. Adjustments were made for other psychotropic medications. Information on all medications was extracted from the Swedish Prescribed Drug Register, with complete national data on all dispensed medications. Information on violent crime convictions was extracted from the Swedish national crime register. 

• Using within-individual models, there was an overall association between SSRIs and violent crime convictions. 
• With age stratification, there was a significant association between SSRIs and violent crime convictions for individuals aged 15 to 24 y. 
• However, there were no significant associations in those aged 25–34 y, in those aged 35–44 y, or in those aged 45 y or older. 
• Associations in those aged 15 to 24 y were also found for violent crime arrests with preliminary investigations, non-violent crime convictions, non-violent crime arrests, non-fatal injuries from accidents, and emergency inpatient or outpatient treatment for alcohol intoxication or misuse. 
• With age and sex stratification, there was a significant association between SSRIs and violent crime convictions for males aged 15 to 24 y and females aged 15 to 24 y . 
• However, there were no significant associations in those aged 25 y or older. 
• One important limitation is that we were unable to fully account for time-varying factors.

The association between SSRIs and violent crime convictions and violent crime arrests varied by age group. The increased risk we found in young people needs validation in other studies.

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By: Yasmina Molero, Clara Hellner Gumpert

Center for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden

Paul Lichtenstein, Johan Zetterqvist

Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden

Seena Fazel

Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, United Kingdom