Violence and mental illness--how strong is the link?

n engl j med 355;20 www.nejm.org november 16, 2006 2064 O Sunday afternoon, September 3, 2006, Wayne Fenton, a prominent schizophrenia expert and an associate director at the National Institute of Mental Health (NIMH), was found dead in his office. He had just seen a 19-yearold patient with schizophrenia who later admitted to the police that he had beaten Fenton with his fists. This tragic incident was widely publicized and raises, once again, the controversial question about the potential danger posed by people with mental illness. The killing also left many in the mental health and medical communities concerned about their own safety in dealing with psychotic patients. After all, if an expert like Fenton, who understood the risks better than most, could not protect himself, who could? It is not an idle question. According to the National Crime Victimization Survey for 1993 to 1999, conducted by the Department of Justice, the annual rate of nonfatal, job-related, violent crime was 12.6 per 1000 workers in all occupations. Among physicians, the rate was 16.2 per 1000, and among nurses, 21.9 per 1000. But for psychiatrists and mental health professionals, the rate was 68.2 per 1000, and for mental health custodial workers, 69.0 per 1000. For Tim Exworthy, a forensic psychiatrist at Redford Lodge Hospital in London who was recently assaulted by a patient, the risk of job-related violence is no longer a dry statistic. He was beaten unconscious by a 19-year-old psychotic man whom he had been treating in the hospital for 5 months. “I was talking with him in a room and telling him why he couldn’t leave, when I was suddenly aware of a few blows to my head,” recounted Exworthy. “The next thing I knew, I was at the nursing station wiping the blood off my face. I never saw this coming and hadn’t anticipated that he would react like that.” Such attacks by psychotic patients highlight a larger question: Are people with mental illness really more likely than others to engage in violent behavior? If so, which psychiatric illnesses are associated with violence, and what is the magnitude of the increase in risk? Posing these questions is itself not without risk: being perceived as dangerous can have a devastating effect on a person’s prospects for relationships, employment, housing, and social functioning. People with mental illness already bear the burden of much social stigma, and I am loath to add to Recalibrating Medicare Payments for Inpatient Care