BACKGROUND PAPER
June 2016
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SUMMARY
Multiple studies have shown that individuals with serious mental illness are especially vulnerable to being victimized. This frequently involves acts such as theft of clothing or money but also includes violent victimization such as physical and sexual assault, emotional abuse and being killed. Women who have severe psychiatric disease are especially vulnerable. Some studies suggest that individuals who are victimized are less likely to have been adherent to medication prescriptions. This role of treatment adherence is strongly supported by the 2002 North Carolina study by Hiday and colleagues that found individuals with severe mental illness participating in court-ordered outpatient treatment – and thereby taking medication as prescribed – were victimized half as often as those who were not on assisted outpatient treatment.
OVERVIEW
- A 2009 review of victimization studies reported: “Rates of victimization among severely mentally ill persons were 2.3–140.4 times higher than in the general population.” Victimization occurred more frequently among individuals who were also abusing drugs and/or alcohol and among individuals who had the most severe symptoms.
- In 13 rural counties in Vermont, all individuals with serious mental illness who were victimized in a one-year period (July 2005 through June 2006) who came to the attention of the police were studied. Among 2,610 individuals with serious mental illness, 7.1% were the victim of a crime. Among those who were 18 to 34 years of age, the percentage victimized was 13.2%, compared to those who were 50 or older, for whom the percentage was 4.5%.
- A National Crime Victimization Survey interviewed 936 patients with “chronic and severe mental illnesses.” Among them, “more than one quarter . . . had been victims of a violent crime in the past year, a rate more than 11 times higher than the general population.” The authors suggested that the study “may underestimate victimization.”
- In a study in Connecticut, 207 patients with severe psychiatric disorders who were living in the community were followed for one year. Individuals who also were substance abusers had significantly more episodes of violent victimization then did the patients without substance abuse. Much of the victimization was said to be associated with “social isolation related to disorders such as schizophrenia [which] may lead persons with co-occurring disorders to make poor judgments about whom to trust.”
- In Pittsburgh, 270 individuals with severe psychiatric disorders who had been recently discharged from psychiatric hospitals were followed for 10 weeks and compared with 477 neighborhood controls. During this 10-week period, 15% of the psychiatrically ill individuals were violently victimized compared to 7% of the neighborhood controls.
- In New York, New York Times reporter Clifford Levy, in a 2002 Pulitzer Prize-winning exposé, illustrated how egregiously people with serious mental illness can be victimized. Residents of a board-and-care home in Queens were subjected to prostate surgery and eye surgery (mostly cataract surgery), most of which was completely unnecessary but done simply to generate Medicaid fees for the physicians involved. At least 24 male residents were subjected to prostate surgery, and more than 30 residents underwent eye surgery; at least 8 residents had both.
- In Los Angeles, 172 individuals with schizophrenia who were living in the community in stable housing were followed for three years. During that time, 34% of them were victims of robbery, assault or rape. Although medication compliance was not assessed in this study, individuals who were victimized were more likely to have more severe symptoms, suggesting non-treatment. The authors concluded, “This finding suggests that the most ill and vulnerable persons with schizophrenia are the most likely to be victimized.”
- Seven hundred eighty-two (782) individuals with serious mental illnesses living in New Hampshire, Connecticut, Maryland, and North Carolina were asked whether they had been victimized. Within the previous year, 20% of women and 8% of men had been sexually assaulted, and 33% of women and 37% of men had been physically assaulted.
VICTIMIZATION OF WOMEN
Individuals with serious mental illness are 11 times more likely to be victims of a violent crime than the general public, AND Women with serious mental illness are more at risk than men.
- A 2014 systematic review examined the literature of violent victimization and severe mental illness, including correlations to victimization. The authors concluded there is clear evidence that women with severe mental illness are more likely to be sexually victimized than males with the same conditions or than either gender in the general population. Additionally, the risk of nonsexual violent victimization was higher in females serious mental illness than in males.
- A 2014 longitudinal study of 300 homeless women conducted in San Francisco examined the relationship of recent violent victimization, psychiatric conditions and risk of HIV infection. In the study population, 77% of women reported violent victimization at any time point in the four-year follow-up period, regardless of mental health status. Psychiatric disorders were associated with increased risk for emotional and physical violence and psychiatric hospitalization.
- In San Francisco, 103 individuals with schizophrenia spectrum disorders and 36 with bipolar disorder were asked whether they had been victimized (by robbery, rape, mugging, or assault) within the past six months. At the time of the interview, all were living in residential homes. One-third of those with bipolar disorder and one-fifth of those with schizophrenia spectrum disorders had been victimized. Females were almost twice as likely to have been victimized compared to males.
- In Baltimore, data on physical and sexual abuse was collected for one year on three groups of women who were also substance abusers: schizophrenia, nonpsychotic affective disorders (e.g., depression), and not mentally ill. The results demonstrated “high rates of past year violent sexual and physical abuse,” with significantly higher risks among the women with schizophrenia.
- In Seattle, between 1997 and 1999, 819 women who had been sexually assaulted were asked about their history of psychiatric disorders. Eighty of the women (10%) had been diagnosed with schizophrenia or schizoaffective disorder; an additional 55 (6%) had been diagnosed with bipolar disorder or severe depression. Because of the way the study was carried out, the authors said they believed that “most likely we underreported the prevalence of major psychiatric diagnosis in this population.” Women with a severe psychiatric disorder, compared to those without such disorders, were significantly more likely to have been sexually assaulted by a stranger, assaulted by multiple assailants, and injured during the assaults. They were also more likely to have been homeless or to have spent time in jail. The authors concluded that “sexual assaults in women with a major psychiatric diagnosis are common” and “more violent” than in women without such diagnoses.
VICTIMIZATION AND OUTPATIENT COMMITMENT (AOT)
- In North Carolina, detailed information on victimization was obtained on 184 individuals with schizophrenia, schizoaffective disorder and affective disorders (e.g., bipolar disorder, depression), who were followed for one year. Eighty-five of the individuals were participants in assisted outpatient treatment (AOT, called “outpatient commitment” in North Carolina) for part or all of the year; 99 were not. Victimization was classified as either a violent crime (e.g., assault, rape or mugging) or a nonviolent crime (e.g., burglary, theft of money, being cheated) against the psychiatrically ill person.
Among the 85 individuals receiving AOT, 24% were victimized; among the 99 not under outpatient commitment orders, 42% were victimized. The authors noted “risk of victimization decreased with increased duration of outpatient commitment.” Individuals in the AOT group were victimized significantly less often despite the fact that individuals in both groups received standard outpatient care and case management services. The authors suggest that “outpatient commitment reduces criminal victimization through improving treatment adherence, decreasing substance abuse, and diminishing violent incidents” that may evoke retaliation. - In North Carolina, 331 individuals with severe psychiatric disorders (schizophrenia, schizoaffective disorder, affective disorders with psychotic features) were questioned about victimization in the four-month period immediately preceding their psychiatric hospitalization.
All 331 individuals had been referred for outpatient commitment, strongly suggesting they were noncompliant with their medications. Of the 331 individuals, 27 (8.2%) had been the victim of a violent crime (assault, rape or mugging) within the previous four months, a rate 2.7 times higher than the annual rate of violent criminal victimization in the United States. The authors point to factors that “probably caused underreporting of some victimization” and also note that the rate of violent victimization in North Carolina is lower than the rate for the United States as a whole. These facts, plus the fact that the study compared victimization for four months in the study population to one year in the control population, all suggest that the difference between the patients and controls was substantially greater. Using a multivariate analysis, the two variables that most strongly predicted criminal victimization among these individuals with severe psychiatric disorders were occasional drug or alcohol use and homelessness during the four-month period.