(Dec. 5, 2017) The following is the first of a series of guest commentaries from members of the Psychiatric Advisory Board. Each will present data and results from their own research and experience in the field of psychiatry.
Dr. Michael Knable, DO, DFAPA, is the executive director of the Sylvan C. Herman Foundation and medical director of Clearview Communities. He was recently elected as a Distinguished Fellow of the American Psychiatric Association (DFAPA) and as a member of the American College of Psychiatrists
Many publications have asserted that the overall rate of violent acts committed by people with serious mental illnesses is no different than the rate of violent acts committed by the general population. However, I believe it is often overlooked that the rate of violent acts committed by people with serious mental illnesses, who are not accepting treatment, is more than twice that of the general population. And, when substance abuse and serious mental illnesses are combined, the rate is about six times greater than in the general population.
Mental health workers stationed on the front lines in emergency departments and in psychiatric hospitals know that the threat of violence is a daily concern. Past literature suggests that about 50% of mental health workers will be threatened during their careers, 40% can expect to sustain a physical injury, and 5% of workers will sustain a serious physical injury1. In 2009, the Department of Justice reported that the rate of workplace violence for mental health workers was 20.5 per 1,000 workers, a rate that was second only to that for law enforcement officers (47.7 per 1000)2. In a Joint Commission report on violence in health care facilities between 2010 and 2014, 210 violent "sentinel events" in accredited organizations were noted, and half of these events occurred in behavioral health settings3.
Earlier this year, I reported on 33 cases of homicides of mental health workers1. I found that homicides were rare at about 1 per year, but many of these deaths could have been prevented if adequate attention had been paid to prior risk factors for violent acts such as prior history of violence, criminal charges, involuntary hospitalizations and non-adherence to medications. Taken together, these data suggest that people with poorly or incompletely treated severe mental illnesses pose a real risk of violence towards others, including their caregivers in healthcare settings.
Recently, I reviewed cases of homicides of physicians in which the doctors were killed by patients or by other personnel related to their practices. I was able to locate 31 cases that occurred between 1981 and 2017. The following is a snapshot of the findings:
- 39% of these homicides involved psychiatrists, compared to lower rates for other specialties (primary care 16%, obstetrics 13%, urology 10%, and a miscellaneous collections of other specialties 22%)
- 87% of the perpetrators were males
- 68% of the perpetrators had a history of psychiatric treatment (16% had schizophrenia, 19% were in treatment but the diagnosis was not known, 10% had bipolar disorder, and 23% had a collection of miscellaneous other diagnoses)
- 23% of the perpetrators had a known history of involuntary hospitalization
- 55% of the perpetrators were current or former patients of the physicians
- 35% of the homicides occurred in private physician offices, 29% occurred in hospitals, 16% in medical clinics, 10% in physician homes, and 10% in other locations such as abortion clinics
- 78% of homicides were committed by gunshot
In summary, mental health workers and physicians should familiarize themselves with violence risk assessment and take steps to insure that their work environments are equipped with adequate safety procedures. A variety of data also suggest that expanded access to assisted outpatient treatment (AOT) helps to reduce violent acts, in addition to reducing hospitalizations and incarcerations. Furthermore, I have come to believe that a lack of careful attention to the risks for workplace violence is one of the reasons that the supply of mental health workers is inadequate in many parts of our country. I believe workplace violence is one of the main reasons that mental health workers begin to suffer from "burn-out" and "compassion fatigue", and seek to leave institutions caring for the severely ill.
Mike Knable, DO, DFAPA
Chair of Psychiatric Advisory Board
Board Member of Treatment Advocacy Center
Executive Director, Sylvan C. Herman Foundation
References:
- Knable, M. B. (2017). Homicides of Mental Health Workers by Patients: Review of Cases and Safety Recommendations. Psychiatric Annals.
- Harrell,E. (2009). Workplace Violence, 1993-2009.
- The Joint Commission.(August 2014). Quick Safety-Issue Five.