Massacres and Madness

With yet another school shooting in Colorado, an important question remains unanswered: Will more spending on mental health treatment actually reduce violence?

12.14.13 10:45 AM ET

The massacre at Sandy Hook Elementary School a year ago has stoked new interest in the connection between mental health and mass violence. Treat mental health disorders and seemingly random violence will ebb too, the theory goes. As an offshoot of his program to reduce gun violence (including mass murder), President Obama mandated that insurers cover equally treatment for mental health problems and physical disease. A new report found that 37 states have increased their mental health spending since the tragic shooting.

But Obama’s mandate and the states’ augmented spending—clear reactions to the Sandy Hook massacre—raise a critical question: will more spending on mental health treatment actually reduce violence? These efforts suggest that the president and the public believe that mental disorder and violence are inextricably linked, when there is little science to support that assumption. In fact, mentally ill people may be more likely to be victims of violent crime than perpetrators of it.

No study has found a definitive link between mental disorder and violence. Because severe mental disorder and violence are both relatively uncommon events, studies of the general population require large sample sizes and are expensive, which is why they are seldom undertaken. The studies that do exist all use data collected for other purposes to estimate the prevalence of psychiatric disorders. While these data reveal much about psychiatric disorder, they say little about violence. Moreover, the few large-scale studies of general populations use simple variables, conflating relatively minor events, like slapping a spouse or “getting into trouble with the law,” with serious assault and homicide. Slapping a spouse and murdering a person are vastly different crimes, but respondents were categorized as “violent” if they said yes to either. Studies that do find a relationship between mental disorder and gun violence or homicide only do so when they add another factor—usually substance abuse.

Another reason studies that investigate the link between mental illness and violence are inconclusive is that their samples are predisposed to find one. Most studies examine patients in mental health treatment, many of whom are involuntarily hospitalized for criteria, which include in most states, “dangerous to self or others.” These samples are biased, stacking the deck in favor of a connection between mental disorder and violence. Researchers cannot determine this connection by investigating a sample that over-represents mentally ill people who are violent. Furthermore, findings pertain only to a fraction of persons with mental disorders—those whose situations required involvement of the courts.

Having worked in this area for 30 years, I have learned that the greater risk is stigmatizing people with mental disorders.  What concerns me most is that Obama’s mandate, while a step forward, will fuel stigma and negative stereotypes about persons with major mental disorders, which include schizophrenia, affective disorder, and other psychoses. The nation’s predominant concern should not be the violence perpetrated by persons with major mental disorders, but instead their victimization.

In a comprehensive review of prior scientific studies, my research group found only a slightly elevated risk of violent perpetration, largely accounted for by methodological limitations.  But in the largest empirical study ever conducted of the victimization of people with mental disorders, we found the likelihood of a mentally ill person becoming a victim of violent crime was more than 11 times higher than general population rates. Our findings, first published in 2005, contradict the president’s and the public’s perception that persons with major mental illness pose a significant risk to society.

Perhaps, rather than looking to mental illness to answer questions about violence we should look instead at demographics. Overall, the attributable risk of mental illness to violence in the U.S. is approximately 2%, according to a 2005 study published in the journal Psychiatric Research.  By comparison, two demographic variables—gender and age—are far more powerful predictors of violence.  Nearly 80% of arrests for serious violent crimes are males, and more than half of them are 24-years-old or younger, according to the U.S. Department of Justice.  Simply put, the common denominator among perpetrators of mass shootings is not mental disorder, but being a young male.

Many clinicians—especially those who work in jails, prisons or forensic hospitals—may point to the violent propensities of their patients.  These stereotypes are also rampant in American media, television, and film. A report released just last week emphasized Sandy Hook shooter, Adam Lanza’s “significant mental health issues,” yet could not conclude the cause or motive behind his crime. News coverage of the report perpetuated the stereotype that mental illness causes mass murder with one watchdog group positing, “Lanza’s mental health/medication history is key to establishing some reasonable explanation for this tragic event.” These are impressions, however, not scientific observations.  We must rely instead on systematic scientific investigations when setting forth changes in public policy, rather than stereotypes or isolated anecdotes.

There is much we can do to treat severe mental illness and to protect ill individuals from becoming victims of assault, theft and other crimes.  First, by all means, implement parity for mental health treatment—but for the right reasons:  to reduce barriers to mental health care and improve outcomes. Currently, 11.4 million Americans suffer from a major mental disorder, but nearly half do not receive care. This must change. Second, the media should stop highlighting the mental health history of perpetrators of major violent crimes. Doing so perpetuates the stigma of mental disorder, discouraging persons with mental disorders from seeking care.

We should care for those with mental disorders, rather than fear their potential for violence. Parity for mental health treatment, while long overdue, will not reduce violence very much if at all according to the science, but hopefully it will provide care and relief for those who suffer most.

Linda Teplin is Vice Chair for Research in the Department of Psychiatry at Northwestern University and a Public Voices Faculty Fellow with The OpEd Project