Studying Patients with Severe Mental Disorders Who Act Violently: Italian and European Projects
Background: The management of mentally ill offenders in the community is one of the great challenges imposed on community psychiatry.
Aim: The aim of this study is to analyze the association between sociodemographic, clinical, and psychosocial factors and violent behavior in a sample of patients (both residential and outpatients) with severe mental disorders.
Method: This was a prospective cohort study with a baseline cross-sectional design used to provide a detailed analysis of patients’ profiles, followed by a longitudinal design to measure aggressive and violent behavior during a 1-year follow-up. Patients with severe mental disorders, with a history of violence (“cases”) or with no such history (controls), were enrolled in 22 residential facilities and in 4 Italian departments of mental health and underwent a comprehensive multidimensional assessment at baseline, and were then monitored with the Modified Overt Aggression Scale (MOAS) every 2 weeks for 1 year.
Results: The sample included 139 residential patients and 247 outpatients, for a total of 208 cases and 178 controls. Compared to controls, all patients with a history of violence had a higher number of compulsory admissions and a higher score at the Brown-Goodwin Lifetime History of Aggression (BGLHA); among residential patients many cases had been in a forensic mental hospital or in prison, while outpatient cases displayed a greater frequency of lifetime domestic violence and a greater lifetime propensity to misuse substances. The fortnightly monitoring during the 1-year follow-up did show statistically significant differences in aggressive and violent behavior rates between outpatient cases and all the rest of the sample, including residential cases. This shows that being in a residential setting, where treatment compliance is granted and substance-use disorders are prevented or controlled, is associated with a lower risk of aggressive and violent behavior. There was a continuum in aggression, with verbal aggression significantly associated with aggression against objects and the latter associated with physical aggression.
Conclusions: Outpatients with a history of violence had specific characteristics and showed a greater occurrence of additional community violence during a 1-year observation period. Our results may assist clinicians in implementing standardized methods of patient assessment and violence monitoring in outpatient mental health services and may prompt improved collaboration between different community services.
KeywordsViolence Risk factors Substance use Self-harm
The VIORMED-2 (Violence Risk and Mental Disorder 2) project was funded by the Health Authority of Regione Lombardia, Italy, grant CUP E42I14000280002 for “Disturbi mentali gravi e rischio di violenza: uno studio prospettico in Lombardia” with Decreto D.G. Salute N.6848, date16.7.2014.
The VIORMED-2 Group also includes Valentina Candini, PhD.; Cesare Cavalera, PhD.; Giovanni Conte, M.D.; Giulia Gamba, M.D.; Laura Iozzino, PhD.; Assunta Martinazzoli, M.D.; Giuliana Mina, M.D.; Alessandra Ornaghi, M.D.; Alberto Stefana, PhD.; and Bruno Travasso, M.D. The authors wish to thank the many clinicians, mental health staff, and family relatives who provided invaluable help for the realization of the project; the authors wish to particularly thank the patients who gave their time and their collaboration to the realization of the project.
Declaration of interest: All authors have no competing interests to disclose.
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