Jeffrey W. Swanson

Neighborhood structural characteristics and mental disorder: Faris and Dunham revisited.

We examined the relationship between neighborhood structural characteristics and mental disorder using data from the National Institute of Mental Healths Epidemiological Catchment (ECA) surveys (n = 11,686). After controlling for individual-level characteristics, we found that neighborhood disadvantage was associated with higher rates of major depression and substance abuse disorder, and that neighborhood residential mobility was associated with higher rates of schizophrenia, major depression, and substance abuse disorder. Implications for future research on the social ecology of mental disorder are discussed.

Reliability and validity of the SF-12 health survey among people with severe mental illness.

Objective.The objective of this work was to assess the reliability and validity of the Medical Outcomes Study Short-Form 12-Item Health Survey (SF-12) in a large sample of people with severe mental illness (SMI). Methods.We examined the internal factor structure of the SF-12, compared component scores for this sample with normative levels, examined test-retest reliability, and examined convergent and divergent validity by comparing SF-12 scores to other indexes of physical and mental health. Results.The SF-12 distinguished this sample of people with SMI from the general population, was stable over a 1-week interval, consisted of 2 fairly distinct factors, and was related to physical and mental health indexes in expected ways. Conclusions.The SF-12 appears to be a psychometrically sound instrument for measuring health-related quality of life for people with SMI.

Recent Victimization in Women and Men With Severe Mental Illness: Prevalence and Correlates

The problem of violence against individuals with severe mental illness (SMI) has received relatively little notice, despite several studies suggesting an exceptionally high prevalence of victimization in this population. This paper describes the results of an investigation of the prevalence and correlates of past year physical and sexual assault among a large sample of women and men with SMI drawn from inpatient and outpatient settings across 4 states. Results confirmed preliminary findings of a high prevalence of victimization in this population (with sexual abuse more prevalent for women and physical abuse more prevalent for men), and indicated the existence of a range of correlates of recent victimization, including demographic factors and living circumstances, history of childhood abuse, and psychiatric illness severity and substance abuse. The research and clinical implications of these findings are discussed.

The Social–Environmental Context of Violent Behavior in Persons Treated for Severe Mental Illness

OBJECTIVES This study examined the prevalence and correlates of violent behavior by individuals with severe mental illness. METHODS Participants (N = 802) were adults with psychotic or major mood disorders receiving inpatient or outpatient services in public mental health systems in 4 states. RESULTS The 1-year prevalence of serious assaultive behavior was 13%. Three variables-past violent victimization, violence in the surrounding environment, and substance abuse-showed a cumulative association with risk of violent behavior. CONCLUSIONS Violence among individuals with severe mental illness is related to multiple variables with compounded effects over the life span. Interventions to reduce the risk of violence need to be targeted to specific subgroups with different clusters of problems related to violent behavior.

Violence and severe mental disorder in clinical and community populations: the effects of psychotic symptoms, comorbidity, and lack of treatment

This paper examines links between violent behavior, type and severity of psychopathology, substance abuse comorbidity, and community mental health treatment, using matched data from two surveys: the National Institute of Mental Health Epidemiologic Catchment Area project and the Triangle Mental Health Survey (a North Carolina study of adults with severe and persistent mental illness). Multivariate logistic regression analysis was used to model the risk of violent acts attributable to three domains of independent variables: sociodemographic characteristics, clinical diagnoses and symptomatology, and mental health services utilization. Findings include: (1) Symptom severity was significantly greater in the clinically-selected sample than in the community survey of respondents with comparable diagnoses who self-reported using mental health services; (2) Violence risk was related to psychoticism/agitation in a curvilinear form; (3) In a multivariable model, violence was significantly associated with substance abuse comorbidity, particular psychotic symptoms (perceived threat and loss of internal cognitive controls), and absence of recent contact with a community mental health provider; (4) The relationship between lack of treatment and higher odds of violence was less pronounced among respondents with substance abuse comorbidity; (5) When clinical and services-use variables were taken into account, sociodemographic predictors were not significantly related to violence.

Comparison of antipsychotic medication effects on reducing violence in people with schizophrenia

BACKGROUND Violence is an uncommon but significant problem associated with schizophrenia. AIMS To compare antipsychotic medications in reducing violence among patients with schizophrenia over 6 months, identify prospective predictors of violence and examine the impact of medication adherence on reduced violence. METHOD Participants (n=1445) were randomly assigned to double-blinded treatment with one of five antipsychotic medications. Analyses are presented for the intention-to-treat sample and for patients completing 6 months on assigned medication. RESULTS Violence declined from 16% to 9% in the retained sample and from 19% to 14% in the intention-to-treat sample. No difference by medication group was found, except that perphenazine showed greater violence reduction than quetiapine in the retained sample. Medication adherence reduced violence, but not in patients with a history of childhood antisocial conduct. Prospective predictors of violence included childhood conduct problems, substance use, victimisation, economic deprivation and living situation. Negative psychotic symptoms predicted lower violence. CONCLUSIONS Newer antipsychotics did not reduce violence more than perphenazine. Effective antipsychotics are needed, but may not reduce violence unrelated to acute psychopathology.

Taking the wrong drugs: the role of substance abuse and medication noncompliance in violence among severely mentally ill individuals

Abstract Increasing numbers of severely mentally ill individuals are being treated in nonhospital, community-based settings and public concern about potential violence by these individuals has increased, often as a result of tragic, albeit uncommon events. The present study examines potential predictors of serious violence among persons with severe mental illness (SMI), with a specific focus on the joint effect of substance abuse and medication noncompliance. Subjects in the study are involuntarily admitted inpatients with SMI awaiting a period of court-ordered outpatient treatment, termed “involuntary outpatient commitment”. During enrollment in a longitudinal outcome study of the effectiveness of OPC, 331 subjects and, whenever feasible, family members or other informants were interviewed. In addition, complementary data were gathered by review of involuntary commitment records and hospital records. Data collection included sociodemographic characteristics, illness history, clinical status, medication adherence, substance abuse and violent behavior during the 4 months preceding hospitalization. Descriptive and multivariable logistic regression procedures were used to examine the association between serious violent acts and a number of personal, social, and clinical characteristics. The combination of medication noncompliance and substance abuse was a significant predictor of serious violent acts in the community. Individuals who had problems with both alcohol and illicit drug abuse appear to be at greatest risk for violence. These results suggest that reducing violence risk among persons with SMI requires an aggressive approach to improving medication adherence in the context of integrated mental health and substance abuse treatment.

Substance use in persons with schizophrenia: Baseline prevalence and correlates from the NIMH CATIE study

This study examined baseline correlates of substance use in the NIMH Clinical Antipsychotic Trials of Intervention Effectiveness project. Approximately 60% of the sample was found to use substances, including 37% with current evidence of substance use disorders. Users (with and without substance use disorders), compared with nonusers, were significantly more likely to be male, be African-American, have lower educational attainment, have a recent period of homelessness, report more childhood conduct problems, have a history of major depression, have lower negative symptom and higher positive symptom scores on the Positive and Negative Syndrome Scale, and have a recent illness exacerbation. Individuals with comorbid substance use disorders were significantly more likely to be male, report more childhood conduct problems, have higher positive symptom scores on the Positive and Negative Syndrome Scale, and have a recent illness exacerbation. These analyses suggest that substance use disorders in schizophrenia are especially common among men with a history of childhood conduct disorder problems and that childhood conduct disorder problems are potent risk factors for substance use disorders in schizophrenia.

Risk reconsidered: targets of violence in the social networks of people with serious psychiatric disorders

Abstract Risk Reconsidered: Targets of violence in the Social Networks of People with Serious Mental illness. This exploratory analysis addresses the questions: 1) Who among the members of the social network of a person diagnosed with a major psychiatric disorder is likely to become a target of violence?; 2) What kind of relationships do targets have with respondents in terms of the quality and quantity of interactions?, and 3) What are the risk factors that contribute to being a target of violence for people who are in the social networks of persons with serious mental disorders? The samples of 169 people with serious mental disorders were followed for 30 months. A logistic regression model of the risk for being a target of violence among the members of the cohorts social network reveals that both target and respondent characteristics are salient, and that mothers who live with adult children who have schizophrenia and co-occurring substance abuse bear a substantially elevated risk of becoming a target of violence, compared to other social network members. Other factors that elevate the risk for being a target of violence are being an immediate family members of the respondent, more time in residence with the respondent, and whether the respondent is financially dependent on the family. Respondents with the most mental health center visits had lower odds of committing an act or threat of violence against a social network member.

Patient perceptions of coercion in mental hospital admission

In civil commitment the state applies its police and parens patriae powers in order to coerce mentally ill persons into treatment. Coercion, thus, is central to civil commitment. It also has been central in the mental health law debate over the justification of civil commitment of mentally ill patients. Civil libertarians, concerned with deprivations to free choice and movement, have argued for imposition of formal legal procedures and limitation of this coercion of mentally ill persons to those who are dangerous (La Fond & Durham, 1992; Morse, 1982; Wald & Friedman, 1978). Mental health practitioners, concerned with reducing symptoms and providing psychiatric care, have argued for minimal procedural and substantive limits on their ability to hospitalize and treat mentally disordered persons (Stone, 1975; Torrey, 1988; Treffert, 1981). Despite this debate, empirical researchers neglected development of the construct of coercion in psychiatric treatment (Hiday, 1992; Monahan et al., 1995); and only recently have they begun to lay the foundation conceptually and empirically to advance our understanding of it (Lidz & Hoge, 1993). In the substantial empirical literature on civil commitment, the existence of coercion was assumed to be inherent in the process while the focus was on other components of commitment such as characteristics of actors and rates of commitment. With few exceptions, researchers equated the legal category of involuntary patient with coercive practices.