Research
Mental disorders and vulnerability to homicidal death: Swedish nationwide cohort study
Cite this as:
BMJ
2013;346:f557
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11 March 2013
Crump et al.1 (BMJ 2013; 346: f557) show that, in 2001-2008, the major part of the vulnerability of Sweden’s mentally disordered patients to homicidal death is accounted for by patients who had a recorded substance use disorder, of whom 8.5 had died by homicide per 100,000 person-years (pys) of follow-up. By comparison, homicidal deaths claimed the life of only one mentally disordered patient with no substance misuse disorder per 100,000 pys.
The evidence-table below summarises the corresponding results, published a year ago by Merrall et al.2, on 118 homicidal deaths among 69,456 clients who attended Scotland’s drug services in 1996-2006, and contributed 350,315 pys of follow-up. Merrall et al. 2 demonstrated that, whereas clients’ drugs-related death-rate per 100,000 pys and their non-drugs-related suicide rate had both decreased significantly between the eras of 1996/97 to 2000/01 and 2001/02 to 2005/06, clients’ non-drugs-related homicide-rate had not reduced across the decade.
Scottish Drug Misuse Database (SDMD) clients had a homicidal death-rate per 100,000 pys which was four times that of their Swedish counterparts (34 vs 8.5). Male SDMD clients had three times the homicide-rate of their female counterparts. Notice that, consistent with UK’s harmonized definition of drugs-related deaths, Merrall et al. counted deaths coded as X85 or E962.0 as drug-related deaths and so excluded them from their count of homicides: to avoid double-counting.
International comparisons should focus at least as much attention on substance users’ homicidal death-rate (column 2 in evidence-table) as on standardized homicide ratios (column 3). As Crump et al. reported for the Swedish general population, there were, across all ages, twice as many male homicide victims (410) as female (205). Relative to their age-appropriate female counterparts in the Scottish general population (see column 3), female SDMD clients experienced 15 times the expected number of homicides (1.0) but male SDMD clients only 7.5 times their age-appropriate expectation of 13.7 (or 5.7 homicides expected per 100,000 pys). It is, however, rather more insightful to observe that female SDMD clients’ homicidal death-rate of 14 per 100,000 pys (column 2) was a third that of their male counterparts: see also adjusted hazard ratios in final column of evidence-table.
We end on a more positive note: the risk of homicidal death decreased by two-thirds if a Scottish client’s most recent SDMD registration had been at least 5 years previously. Thus, recovery from drug-dependency may have the potential to reduce substantially a former client’s vulnerability to homicidal death.
Sheila M. Birda, Sharon J. Hutchinsonc, Elizabeth LC Merralle.
References
1. Crump C, Sundquist K, Winkleby MA, Sundquist J. Mental disorders and vulnerability to homicidal death: Swedish nationwide cohort study. BMJ 2013; 346: f557.
2. Merrall ELC, Bird SM, Hutchinson SJ. Mortality of those who attended drug services in Scotland 1996-2006: record-linkage study. International Journal of Drug Policy 2012; 23(1): 24-32.
Competing interests: None declared
MRC Biostatistics Unit, Robinson Way, Cambridge CB2 0SR
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11 March 2013
This interesting paper seems, in the discussion section, to suggest a direction of causation from suffering mental disorder to being a victim of homicide. Whilst, that is a reasonable explanation, it is likely not the whole story. The study design does not capture baseline data regarding exposure to violence, particularly within the family or from a partner, which is a risk factor for both future homicide and development of mental disorder; in other words, people suffer violence and abuse, and develop mental disorder, rather than, necessarily, the other way round.
The paper rightly reminds clinicians to be aware of the patient's risk of violence from others. In my experience, this is relatively easy to do with the patients who wish to escape violent relationships, but much harder in the group who seemingly wish to tolerate abuse; a wish that is either directly related to their psychopathology, or because they have become so disenfranchised that they consider a violent relationship with family or partner is better than no relationship at all; it is all too common that a partner leaves a violent spouse only to return weeks later.
So whilst a reduction in stigma and perception of psychiatric patents as violent would be beneficial, more important, in my experience, are caring, accepting persons and communities which seek to cherish and nurture those who have escaped violent relationships.
Competing interests: None declared
2gether NHSFT, 110 Eastgate Street, Gloucester
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8 March 2013
A study of victims of criminal homicide in Sweden was published in 2000: Allgulander C, Nilsson B. Victims of criminal homicide in Sweden: A matched case control study of health and social risk factors among all 1,739 cases during 1978-1994. Am J Psychiatry 2000;157:244-47.
Competing interests: None declared
Karolinska Institutet, M67, KUS-Huddinge, 141 86 Huddinge, Sweden
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6 March 2013
A nationwide cohort study in Sweden showed that those with any mental disorder had a 5-fold increased risk of dying by homicide compared with their counterparts without mental illness.
You do not say who was studied, nor how they were identified, without that information the broad conclusion above fails the test of research, defining terms.
As a demographic we earn to the millions, hold every university degree and every professional, white, and blue collar job. Our risks of being murdered are similar to yours.
They also note that national mental health strategies "should reflect the broad nature of safety concerns in mental healthcare, while anti-stigma campaigns among the public should aim to counter fear of mentally ill people with sympathy for the risks they face."
Anti-stigma campaigns are pro-stigma campaigns, placing that association in people’s minds. Associating fear in this article is equally irresponsible, unethical. We are not a generic” they”, the allegation is as offensive as reducing any group to a generic and positing conclusions therefrom. I recall in my lifetime this was done with Jews and African Americans.
Too many people in the mental health professions are not careful with their language. It is time that changed.
Harold A. Maio, retired Mental Health Editor
8955 Forest St
Ft Myers FL 33907
239-275-5798
khmaio@earthlink.net
Competing interests: None declared
none, 8955 Forest St Ft Myerss Fl
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6 March 2013
This article couldn't have been published at a more apt time, given the very recent news of a homicide perpetrated by the paranoid schizophrenic patient, Nicola Edgington. This case and the nature in which it has been broadcasted serves to remind us all how difficult it is to reinforce in the public's perception how rare homicidal acts are perpetrated by the mentally ill. I read several newspaper articles regarding this case, and only on a couple of occasions can I recall reading how rare such incidents are. Most of the articles only served to perpetuate the misconceived notion that all psychotic patients are violent and potentially murderous psychopaths, through what can only be described as grossly irresponsible and misleading journalism. It seems as though one isolated incident has the potential to undo all the hard work of anti-stigma campaigns in attempting to educate the public in relation to the low risk of violence being perpetrated by the mentally ill.
It is therefore refreshing to read of a study which attempts to ascertain how at risk the mentally ill are from being victims of homicide. It is a sad reflection of our myopic view of risk assessment that such risk has been hitherto neglected. After all, we are meant to assess our patients' vulnerability when assessing risk, which should include their risk of harassment, exploitation, psychological and physical abuse, and potential violence from others. Unfortunately, in everyday clinical practice, many mental health practitioners tend to focus their assessment of risk purely on self-harm, suicide and harm to others. If only we took a broader picture of our patients and the potential risks they may face, we may have a greater awareness of the fact that they are more likely, much more likely to be victims of violence and homicide, as opposed to perpetrators.
Competing interests: None declared
Mersey Deanery, Summers Road, Brunswick Business Park, Liverpool, L3 4BL
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