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By Dr. Ronald Pies February 25, 2008

The man had his hands around my neck so quickly I didn't have time to react. I was a second-year resident in psychiatry. He was an impulsive loner with a history of alcoholism who, unbeknownst to the staff, had returned to the inpatient unit intoxicated.

Fortunately, before the man could do serious harm, three patients had pulled him off me. In 25 years of psychiatric practice, this was the first and last time any patient laid a hand on me in violence.

And yet, in recent weeks, the news has been full of horrendous stories involving killers with known or suspected mental illness. As I write this, the nation is still reeling from the shootings at Northern Illinois University. Press reports now indicate that the shooter had a long history of mental illness and had recently stopped taking antidepressant medication.

To make matters worse, three psychotherapists have been assaulted or murdered in the past month. The most brutal attack involved a Manhattan psychologist murdered by a man who also gravely injured a psychiatrist. The New York Times reported that the accused man blamed the psychiatrist for having him institutionalized 17 years ago; apparently, the psychologist was not the intended victim. And only a few weeks ago, a social worker in Andover was killed, allegedly by her 19- year-old patient, during a visit to the man's home.

What do these attacks say about mental illness? Surely they create the impression that individuals with mental illness are a dangerous and violent lot. And as professor John Monahan and colleagues at the University of Virginia School of Law wrote recently, "the more a member of the general public believes that mental disorder and violence are associated, the less he or she wants to have an individual with a mental disorder as a neighbor, friend, colleague, or family member."

Yet the impression that we are awash in a sea of psychotic violence is clearly unfounded. Writing in the Nov. 16, 2006, New England Journal of Medicine, Dr. Richard A. Friedman of the Weill Cornell Medical College notes that only about 3 to 5 percent of violence in the general population is attributable to those with "serious mental illness," conventionally defined as schizophrenia, major depression, or bipolar disorder. The combined lifetime prevalence of these conditions in the US general population is estimated at 19 percent - far larger than their contribution to violence.

Furthermore, it is wrong to tar all emotionally disturbed individuals with the same stereotype-tainted brush.

True: A 1980s study from the National Institute of Mental Health found, using community surveys, that individuals with schizophrenia, major depression, or bipolar disorder were two to three times as likely as those without these illnesses to commit acts of violence. However, to put this in perspective, substance abusers had more than twice the rate of violence as those with these serious mental illnesses.

Moreover, the study found that the vast majority of individuals with serious mental illness were not violent: The lifetime prevalence of violence among people with schizophrenia, major depression, or bipolar disorder was 16 percent, versus 7 percent among people without a mental illness. Those with anxiety disorders had no increased risk of violence.

Even more reassuring is the 1998 MacArthur Violence Risk Assessment Study, led by John Monahan and Henry Steadman, now of Policy Research Associates, which advocates for better mental health services. Unlike the NIMH study, which surveyed people randomly in the community, the MacArthur study evaluated psychiatric patients recently discharged from the hospital. And unlike the NIMH study, which relied solely on self-reports of violence, the MacArthur study used a combination of self-reports, collateral informants, and police and hospital records.

The MacArthur study found that the prevalence of violence among discharged psychiatric patients without a substance abuse disorder was similar to that among community-dwellers who didn't abuse substances. Furthermore, violence by these discharged patients rarely involved vicious attacks on strangers or clinicians. Usually, it resembled violence committed by other community-dwellers, such as hitting a family member inside the home. Lethal violence among the discharged patients was very rare.

In the February 2008 issue of Psychiatric Services, Monahan and Steadman conclude: ". . . for people [with mental illness] who do not abuse alcohol and drugs, there is no reason to anticipate that they present greater risk than their neighbors."

That said, mental disorders do increase susceptibility to substance abuse, and thus indirectly increase risk of violence. Moreover, as Eric Elbogen of University of North Carolina Chapel Hill School of Medicine wrote me in an e-mail, ". . . a subgroup of people with mental illness likely uses alcohol and drugs to 'self-medicate' psychiatric symptoms." In my experience, this behavior may reflect the inadequate, fragmented care often provided to those with mental illness who also abuse drugs or alcohol so-called "dual diagnosis" patients.

The image of the violent mentally ill person must also be tempered by research from Linda A. Teplin, of Northwestern University. Teplin finds that those with mental illness are much more likely to be victims than perpetrators of a violent crime. Among psychiatric outpatients, about 8 percent reported committing a violent act, whereas about 27 percent reported being the victim of a violent crime.

What can be done for the relatively few mentally ill individuals who do become violent? The good news is that adherence to treatment is associated with reduced risk of violence. Research from Elbogen and colleagues finds that as self-reported adherence to outpatient psychiatric treatment increases, violence decreases. Though treatment varied significantly from site to site, Dr. Elbogen tells me that "typically [patients] had a combination of case management, pharmacotherapy, [and] psychotherapy or group therapy."

An understanding and supportive family may also reduce the risk of violence in their emotionally disturbed loved ones. Finally, all of us can support increased funding for comprehensive, compassionate treatment of those with mental illness, substance abuse, or both.

Recent events have shown us that anyone may become the victim of a violent person with severe mental illness. And yet, we must put the violence-mental illness link into perspective. The patient who assaulted me more than 25 years ago was 1 in 1,000. Nearly all those I have treated since have been nonviolent. Most have coped heroically with unspeakable sorrow and pain. In truth, I would trust many of them with my life.

Dr. Ronald Pies is a clinical professor of psychiatry at Tufts University and a professor of psychiatry at SUNY Upstate Medical University in Syracuse, N.Y.

© Copyright 2008 Globe Newspaper Company.

Audit throws spotlight on violence in mental health units and highlights areas for action

More than half of nurses on mental health wards report being physically assaulted at work.

Published: 13 February 2008

More than half of nurses on mental health wards report being physically assaulted at work. The figure rises to almost three-quarters for mental health nurses working on wards for patients with disorders such as dementia.

The findings were published today (Wednesday) in the second national audit of violence in mental health services conducted on behalf of the Healthcare Commission by the Royal College of Psychiatrists.

There are about 30,000 in-patients in mental health units in NHS and independent organisations in England and Wales. The audit involved 211 units at 69 of those organisations and for the first time looked separately at services for working-age adults and wards for people over 65.

The Commission and the Royal College joined forces to highlight the high levels of violence on mental health wards, saying the impact on staff and patient can be “constant and intolerable”.

They said that improvements had been made to the way violence is managed on wards for people of working age, particularly in providing effective alarm systems, reporting incidents and having an appropriate mix of skills among the staff team.

But the Commission and the Royal College said more improvements were needed, particularly on wards for older people, where physical environments, activities for patients, training and staffing levels were particularly poor.

Sixty-four per cent of nurses in wards for older people said they had been physically assaulted, compared to 46% of nurses on wards for adults of working age. Some described serious injury such as fractures, dislocations and black eyes.

When looking specifically at wards for older people with organic disorders such as dementia, the number of nurses reporting physical assaults rose to 73%. But patients on wards for older people were less likely to be physically assaulted.

Six per cent of patients on wards for older people reported being physically assaulted, 14% said they had been threatened or made to feel unsafe and 29% had been made to feel upset or distressed. On wards for working-age adults, these figures were 18%, 34% and 45% respectively.

Dr Paul Lelliott from the Royal College of Psychiatrists commented: “Those working on psychiatric wards, and in particular the nurses, are the unsung heroes of mental healthcare. Their every working day is a challenge and this audit once again highlights the danger to their personal safety. Despite this, ward staff continue to provide care to the most severely ill people in a professional and compassionate manner.

“The re-audit involving wards for adults of working age shows that improvements can be made. We have learnt from working with hundreds of wards involved in the audit over the past five years that good leadership is the single most important ingredient for quality and safety. Mental health services must give ward managers the authority to manage their wards effectively and must ensure that they have the resources they need to create as safe an environment as possible.

“The Royal College of Psychiatrists is committed to continuing its work with inpatient units throughout the United Kingdom through its accreditation system for psychiatric wards. This publicly recognises excellence in this most challenging of environment and encourages all wards to constantly work to improve the quality of care they provide and their safety.”

Anna Walker, chief executive of the Healthcare Commission, said: “This audit reveals worrying levels of violence against nursing staff in mental health units, particularly on wards for people with disorders such as dementia. It is a testament to the commitment and compassion of nurses that such a high number of patients in their wards say they are treated with dignity and respect.

“The report highlights areas where if acted on, we know can make a difference in reducing levels of violence. Services need to concentrate on giving people meaningful activities in an environment that is designed to ensure that patients, staff and visitors are as safe as possible. They should ensure that staff have the proper training and skills and that patients get good continuity of care, without the overuse of bank and agency staff. Finally, they should have proper systems to report and manage incidents when they do happen.

“We urge all organisations to look at these areas. We will be checking on performance through our assessments, including the annual health check ratings. We will also carry out this year a national study of mental health services for older people.

“Leaders of mental health providers must check that they are not allowing a culture to develop that accepts daily violence as part of the norm. I doubt any patient in an acute hospital bed would put up with physical violence and there’s no reason why patients or staff in mental health services should either.”

National audit of violence in mental health services (opens new window)

For more information contact:

Megan Tudehope at the Healthcare Commission on 0207 449 0868 or 07795 548 529 out of hours, or Deborah Hart at the Royal College of Psychiatrists on 0207 235 2351 ext.127


The standards for the audit were largely drawn from the 2005 NICE Guideline (The short-term management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departments. Clinical Guideline, NICE, London.)

A previous Healthcare Commission-funded phase of the audit was carried out between 2003-5. The standards for this audit were drawn from the Royal College of Psychiatrists’ Guideline on the subject (Wing, JK, Marriott, S Palmer C and Thomas V (1998) The Management of Imminent Violence: Clinical Practice Guidelines to Support Mental Health Services. Occasional Paper OP41. London: Royal College of Psychiatrists).

However, due to the intervening implementation of new NICE guidance in 2005, comparisons between the findings from the two phases of the audits is not always possible. Where comparisons have been made, appropriate samples have been used. This could mean that some figures may vary, depending on whether they have been made in comparison, or are the overall figures for 2007.

Functional disorder: These are mental disorders that cannot be attributed to an identified physical process in the brain and are sometimes caused by psychological distress. Function disorders include major depression, schizophrenia and mania.

Organic disorder: These are caused by a detectable physiological or structural change in the brain and mostly affect older people. Dementia is the most common organic disorder and can cause patients to act aggressively when at an advanced stage.

Wards types: The audit looked separately at services for working-age adults and wards for people over 65. Patients on both types of wards can be suffering from functional disorders such as schizophrenia or depression.

There are three types of wards for older people: wards for patients with functional disorders; wards for patients with organic disorders; and wards with a mix of patients.

Physical assault: Nurses in wards for older people were significantly more likely to experience physical assaults (64%) than those on wards for adults of working age (46%). Some described serious injury such as fractures, dislocations and black eyes.

When looking specifically at wards for older people with organic disorders, the number of nurses reporting physical assaults rose to 73%.

Looking at patients’ experience of violence, the relationship was reversed. Patients on wards for adults of working age were more likely to be made to feel upset or distressed (45%), threatened or made to feel unsafe (34%) or physically assaulted (18%), compared to patients on wards for older people (29%, 14% and 6% respectively).

Increase in violence: On wards for people of working age, qualitative responses from staff 

suggest that the number violent incidents and severity of violence has increased. One possible explanation is the move towards caring for people with mental illnesses within the community. The shift has seen only the most severe and complex cases referred to in-patient mental health facilities.

Alarm systems: Despite higher risk of physical assault, only 57% of nurses on wards for older people had access to a personal alarm, compared to 86% on working-age wards. However, this represented significant improvement on working-age wards.

However, when looking at comparable sample groups, the number of nurses on acute wards who said they are satisfied with the alarm system rose from 57% in 2004 to 80% in 2007.

Boredom on wards: Forty-eight per cent of working-age patients said there were not enough activities during the day and two-thirds said there weren’t enough on weekends.

Twenty-one per cent of patients on adult wards and 24% of patients on wards for older people said they did not have opportunities to leave the ward.

Ward design: On wards for older people, many had long corridors and a lack of signage. This is known to increase confusion and anxiety for people with dementia. Only 31% of wards guidelines from the Royal College of Psychiatrists that lines of sight are unimpeded so staff can see patients in all areas of the ward. Fifty-five percent of nurses and 27% of patients said wards were too noisy during the day. At night, 18% of nurses and 21% of patients thought the wards were too noisy.

Looking at comparable samples of acute working-age wards from 2004 and 2007, more wards have now been designed with no “blind spots” so staff could observe patients in all areas of the ward and more wards have a separate area for patients arriving with police escorts.

Training, staffing and skill mix: Despite the higher risk of physical assault, nurses on wards for older people were less likely to receive training, with 66% reporting they had been trained to manage incidents, compared to 75% of nurses on working-age wards.

Thirty-nine per cent of nurses in services for older people and 36% in services for adults of working age did not feel that the ratio of staff on the wards was appropriate to the needs of their patients.

In relation to the mix of skills staff have, 24% of nursing staff in older people’s services and 26% in working-age services did not feel that the skills mix on the wards was appropriate to the needs of their patients. However, the comparable data for skills mix indicated an improvement in acute wards between 2004 and 2007, with a rise from 53% of nurses in 2004 to 70% saying the skill-mix of staff was appropriate to the needs of patients.

Mix of patients: But the audit highlighted a potential concern that on almost a third of wards for older people included in the survey, older people with functional orders shared wards with older people suffering organic disorders.

This can put patients with dementia, who are often frail, at risk from stronger patients with functional disorders. For patients with functional disorders such as depression, sharing a ward with someone suffering from advanced dementia can adversely affect their treatment.

Treating patients with dignity: Despite the issues faced on wards for older people, 92% said they were cared for in a dignified manner. On working-age wards 83% of patients said this.

Alcohol and drugs: more nurses in acute mental health services said there were problems resulting from patients using alcohol and illegal drugs. In 2007, 85% of nurses felt alcohol was a problem and 88% felt illegal drugs were a problem, compared 76% and 84% respectively in 2004.

Interestingly, the number of patients who cited drugs and alcohol as a problem fell. In 2007, 18% of patients on working-age wards considered alcohol to be a problem and 20% felt illegal drugs were an issue, compared to 27% and 31% respectively in 2004.

Reporting: Looking at comparable samples, the reporting of incidents improved significantly on wards for patients of working age. Ninety per cent of nurses in 2007 said that all incidents of threatening behaviour and violence were reported, compared to 75% in 2004.


The Commission and the Royal College made recommendations to mental health units of either type.

Wards for patients of adult working age should:

• Examine the way they involve patients in decision-making about their own care.

• Address any lack of activities.

• Work towards staffing strategies that minimise dependence on bank and agency staff.

• Review the provision of training relating to managing violence.

• Address any concerns raised about the environment, for example alarm systems and provision of de-escalation areas.

• Ensure that intelligence about safe environmental design is considered during any builds.

• Ensure that patient privacy, dignity and choice were not being compromised by limited access to outside areas, doors that cannot be locked, or the absence of a separate area to receive people with a police escort.

• Examine any potential barriers to reporting incidents.

• Improve support to patients and visitor who might experience violent or threatening behaviour.

• Do more to make staff aware of available support from their Local Security Management Specialist.

Wards for older patients should:

• Address the problem of patients with functional disorders sharing wards with patients who have organic disorders.

• Do more to reduce avoidable noise.

• Review their provision of therapies and activities, particularly during evenings and weekends.

• Assess whether measures can be taken to reduce confusion and anxiety caused by the layout of the ward, for example by using pictures, colour coding or signage.

• Examine whether they adequately share information with patients.

• Review the training and support they provide relating to preventing and managing violent behaviour.

• Develop staffing strategies that minimise dependence on bank and agency staff.

• Improve alarm systems.

• Review whether incident reporting systems are adequate.

Information on the Healthcare Commission

The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services.

Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales (HIW). The Healthcare Commission has certain statutory functions in Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.

The Healthcare Commission does not cover Scotland as it has its own body, NHS Quality Improvement Scotland. The Regulation and Quality Improvement Authority (RQIA) undertakes regular reviews of the quality of services in Northern Ireland.