Context
Persons with schizophrenia are thought to be at increased risk of
committing violent crime 4 to 6 times the level of general population
individuals without this disorder. However, risk estimates vary
substantially across studies, and considerable uncertainty exists as to what
mediates this elevated risk. Despite this uncertainty, current guidelines
recommend that violence risk assessment should be conducted for all patients
with schizophrenia.
Objective
To determine the risk of violent crime among patients diagnosed as
having schizophrenia and the role of substance abuse in mediating this
risk.
Design, Setting, and Participants
Longitudinal designs were used to link data from nationwide Swedish
registers of hospital admissions and criminal convictions in 1973-2006. Risk
of violent crime in patients after diagnosis of schizophrenia (n = 8003) was
compared with that among general population controls (n = 80 025). Potential
confounders (age, sex, income, and marital and immigrant status) and
mediators (substance abuse comorbidity) were measured at baseline. To study
familial confounding, we also investigated risk of violence among unaffected
siblings (n = 8123) of patients with schizophrenia. Information on treatment
was not available.
Main Outcome Measure
Violent crime (any criminal conviction for homicide, assault,
robbery, arson, any sexual offense, illegal threats, or intimidation).
Results
In patients with schizophrenia, 1054 (13.2%) had at least 1 violent
offense compared with 4276 (5.3%) of general population controls (adjusted
odds ratio [OR], 2.0; 95% confidence interval [CI], 1.8-2.2). The risk was
mostly confined to patients with substance abuse comorbidity (of whom 27.6%
committed an offense), yielding an increased risk of violent crime among
such patients (adjusted OR, 4.4; 95% CI, 3.9-5.0), whereas the risk increase
was small in schizophrenia patients without substance abuse comorbidity
(8.5% of whom had at least 1 violent offense; adjusted OR, 1.2; 95% CI,
1.1-1.4; P<.001 for interaction). The risk increase
among those with substance abuse comorbidity was significantly less
pronounced when unaffected siblings were used as controls (28.3% of those
with schizophrenia had a violent offense compared with 17.9% of their
unaffected siblings; adjusted OR, 1.8; 95% CI, 1.4-2.4;
P<.001 for interaction), suggesting significant
familial (genetic or early environmental) confounding of the association
between schizophrenia and violence.
Conclusions
Schizophrenia was associated with an increased risk of violent crime
in this longitudinal study. This association was attenuated by adjustment
for substance abuse, suggesting a mediating effect. The role of risk
assessment, management, and treatment in individuals with comorbidity needs
further examination.