Education And Debate

Dangerous patients with mental illness: increased risks warrant new policies, adequate resources, and appropriate legislation

BMJ 1996; 312 doi: (Published 13 April 1996) Cite this as: BMJ 1996;312:965
  1. Jeremy W Coid, professor of forensic psychiatrya
  1. a St Bartholomew's and the London Hospitals Medical College, London EC1A 7BE
  • Accepted 8 November 1995

British people have become increasingly concerned about the risk of violence from patients with severe mental illness who have been discharged into the community. A few incidents have received considerable media attention and left a strong impression of the potential dangerousness of psychotic patients. Subsequent inquiries have revealed serious shortcomings both in the clinical management and supervision of these patients, with failures in liaison and cooperation between agencies being coupled with inadequate service provision, particularly of secure inpatient beds.1 2 3 The government has become increasingly vulnerable to opposition or pressure groups that will seize any opportunity to criticise its programme of care in the community. Health ministers may now be questioning whether current policies are adequate to deal with a growing crisis of public confidence and whether the proposed new mental health legislation will deal with the problem.4

No evaluation of current policy for dangerous patients can be undertaken without knowing whether the general public is genuinely at increased risk of harm from mentally ill patients. Unfortunately, the Department of Health is not helped by lack of research in this subject and the recent shift of position by academics.5 6 It is widely feared that bed closures mean predisposed patients are spending longer periods at risk of offending in the community. But earlier research suggesting that cohorts of patients discharged from public mental hospitals showed increasing rates of offending over time is now seen as inadequate.5 7 The progressive reduction in beds has itself altered the picture. Inadequate data and poor methodology still continue to confuse debate on clinical management. For example, the risks that mentally disordered people will commit homicide have been claimed to be both higher and lower than the risks for the general population but without adequate data to support either assertion. …

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