IJLP-01153; No of Pages 7

International Journal of Law and Psychiatry xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

International Journal of Law and Psychiatry

Violence and mental disorders. A retrospective study of people in charge of a

community mental health center
Federica Pinna a, Massimo Tusconi a, Claudio Dessì a, Giuseppe Pittaluga a,
Andrea Fiorillo b, Bernardo Carpiniello a,⁎
a
Department of Public Health, Clinical and Molecular Medicine, Unit of Psychiatry, University of Cagliari, Italy
b
Department of Psychiatry, Second University of Naples (SUN), Italy

a r t i c l e i n f o a b s t r a c t

Available online xxxx Background: Numerous studies conducted in inpatient settings have highlighted how mental disorders are asso-
ciated with an increased risk of violence, particularly during acute phases. However, to date a more limited num-
Keywords: ber of studies have been performed to assess the risk of violence in outpatients, particularly in Italy. The present
Physical violence study aims to evaluate the prevalence of violent events in a sample of patients in charge of a community mental
Mental disorders health center in Italy.
Community treatment
Methods: Based on data obtained from standardized clinical records, a retrospective study was undertaken to in-
Predictors
vestigate acts of violence (physical aggression only) in a total of 678 patients (Males = 308, 45.4%) in charge of a
university mental health center; patients were mainly affected by anxiety disorders (30.7%), depressive disorder
(17.2%), bipolar disorder (18.3%) and schizophrenia or other psychotic disorders (25.0%).
Results: 27.6% of the sample had committed at least one act of violence during their lifetime, 10.5% over the
previous year. 56.7% of those who committed violence acts had acted violently twice or more during their life-
time. A significant association of lifetime violence was found with gender (male), younger age, low education,
unemployment, living with parents. With regard to diagnosis, a significant association was found with schizo-
phrenia and other psychotic disorders, personality disorders, mental retardation, and comorbidity between
two or more psychiatric disorders. Violence was moreover associated with early age at onset and at first psychi-
atric treatment, longer duration of the disorder, previous hospital admissions, previous violent events.
Conclusion: Violent behavior is relatively common among outpatients.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction
Although controversial, the association between increased risk of
violent behavior and mental disorders has been documented by numer-
ous epidemiological studies (Arsenault, et al., 2000; Brennan et al.,
2000; Elbogen & Johnson, 2009; Hodgins, 1992; Rasanen et al., 1998;
Swanson, 1990; Tiihonen et al., 1997). With regard to clinical samples,
the risk of violence seems to be higher among inpatients and those
with more severe disorders (Fazel & Grann, 2006; Swanson et al.,
2002). Indeed, violent behavior is more frequently reported among in-
dividuals hospitalized for an acute condition (Edlinger et al., 2014). Out-
patient studies have focused largely on cases of severe and/or chronic
mental disorders, such as schizophrenia (Asnis et al., 1994; Bobes et
al., 2009; Swanson et al., 2006a, Swartz, et al., 2006), or on outpatient-
committed persons (Swanson et al., 1998, 2006b), generally reporting
⁎ Corresponding author at: Dept. of Public Health, Clinical and Molecular Medicine, Unit
of Psychiatry, University of Cagliari, Via Liguria 13, 09127 Cagliari, Italy.
E-mail address: bcarpini@iol.it (B. Carpiniello).
lower rates of violent behavior compared to those found among inpa-
tients. A certain number of studies on acute inpatients admitted to pub-
lic psychiatric wards in general hospitals, have been published in Italy
(Cornaggia et al., 2011), while only one study refers respectively to res-
idential facilities (Candini et al., 2015) and community mental health
centers (CMHCs) (Catanesi et al., 2007). The paucity of data relating to
violence among patients in charge of CMHCs in Italy is of the utmost
importance, particularly when taking into account how outpatient
community services form the backbone of the public psychiatric sys-
tem in Italy (de Girolamo et al., 2007; Ferrannini et al., 2014). Further-
more, a recently approved law providing for the closure of forensic
hospitals (Barbui & Saraceno, 2015; Peloso et al., 2014), is expected to
result in an increase in the number of people affected by mental disor-
ders with legal issues being committed to CMHCs. Starting from these
premises, and in the wake of a previous study of patients subjected to vi-
olence (Pirarba et al., 2010), the present study reports preliminary data
from a retrospective cohort study of violent behavior observed among
patients referred to a university CMHC in Italy, as a part of an ongoing
study program on violence and mental disorders. The main goal of the
study was to assess lifetime and one-year prevalence of violent acts,

http://dx.doi.org/10.1016/j.ijlp.2016.02.015
0160-2527/© 2016 Elsevier Ltd. All rights reserved.

Please cite this article as: Pinna, F., et al., Violence and mental disorders. A retrospective study of people in charge of a community mental health
center, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.02.015
2 F. Pinna et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx

and determine the main sociodemographic and clinical risk factors for males were more frequently single, unemployed or receiving a dis-
violence. ability pension. Sociodemographic characteristics of the sample are re-
ported in Table 1.
2. Materials and methods
3.2. Clinical characteristics of the sample
2.1. Methods
The distribution of the sample on the basis of the main diagnosis
Sample selection was based on a two-stage process. In the first stage, according to DSMIVTR reads as follows: 30.7% anxiety disorders
all patients aged 18 and above attending a university community men- (N = 205), 17.2% depressive disorder (N = 115), 18.3% bipolar disor-
tal health center with a catchment area of approx. 80,000 inhabitants der (N = 122), 25.0% schizophrenia and other psychotic disorders
over a four-month period (1 August–30 November 2014) were identi- (N = 167), 3.0% personality disorders (N = 20), 2.7% mental retarda-
fied from the center register. In the second stage, patients were random- tion (N = 18), 3.1% other diagnoses (N = 20); in 0.1% of cases (N = 1)
ly selected (one out of three); to enhance the retrospective evaluation the main diagnosis could not be identified. Mean age at onset of the
of cases, clinical records were examined to ascertain suitability to pro- disorders and at first treatment was lower among males; the latter
vide reliable retrospective data. In the case of largely incomplete or had been more frequently admitted into psychiatric wards or forensic
missing records, the selected case was discarded and substituted by psychiatric hospitals (Table 2).
the following one. The Ethics Committee of the Local Health Authority
approved the study. Selected patients gave their informed consent 3.3. Prevalence of violent behaviors
prior to inclusion in the study. All included subjects were receiving
standard treatment generally adopted in community mental health 27.6% of patients (N = 187) had committed at least one act of vio-
centers throughout Italy (psychopharmacological treatment, clinical lence at some point in their life. Of these, 116 (17.1%) had perpetrated
monitoring at least on a monthly basis, home care when required, psy- a violent event in the twelve months prior to the survey; the remaining
chosocial and rehabilitation interventions tailored to patients' needs). In 71 (10.5%) had been violent during the preceding year. 21.7% of the
line with procedures applied in previous studies (Carpiniello et al., total sample (n = 40) had acted violently only once in their life, 20.7%
2002; Primavera et al., 2012), data were collected retrospectively from (n = 38) twice; 57.6% (n = 106) more than twice. 14.1% (n = 26) pa-
standardized clinical records routinely used in the community mental tients had acted violently toward objects or animals; 48.6% (n = 90) to-
health center, as described by the Italian version of procedures sug- ward persons; 18.4% (n = 34) toward both things/animals and persons;
gested by the Association for Methodology and Documentation in Psy- in 18.9% of cases (n = 35) data were uncertain. A relevant correlation
chiatry (AMDP) (Conti et al., 1988). In particular, sociodemographic between lifetime and last-year violence was detected (phi = 0.52,
(gender, age, education, marital status, working status) and clinical p b 0.001).
data, namely age at onset of the disorder (based on first clear-cut psy-
chopathological symptoms), age at first treatment (pharmacological 3.4. Violent behaviors according to socio-demographic variables
and/or psychosocial), number of inpatient admissions, number of
attempted suicides and violent acts were taken into account. Physical With regard to sociodemographic and clinical variables, data analy-
aggression toward persons and/or objects were the only violent behav- sis was specifically based on lifetime violence. Lifetime violent behavior
iors considered: thus we excluded verbal aggression and any other form was mainly associated with male gender, younger age, single status,
of psychological violence. As regards suicidal attempts, only acts lower education and unemployment (Table 3). An association between
resulting in physical harm and/or a significant risk for physical health younger age and violence (OR = 1.73, 95% CI 1.23–2.44) was confirmed
or life resulting in admission to an emergency department were taken by dividing the sample into two age classes according to median age
into account. Patients' lifetime history of legal actions or trials, admis- (subjects aged below 45 years and 45 years and over): a prevalence
sions to forensic psychiatric hospitals or judicial restrictive measures of 47.0% violent subjects (n = 88) in individuals aged $_amp_$lt;45-
were also recorded. All clinical details were collected directly from pa- years, and 33.19% (n = 318) among subjects aged ≥45 years (chi square
tient interviews and, whenever possible, from other informants. test = 9.96, df = 1, p = 0.011) was identified. No association was found
Where necessary, to clarify the type of registered violent events, physi- between residential status and lifetime violence (OR = 0.98, 95% CI
cians and other members of staff (psychologists, nurses, social workers) 0.58–1.66), with a 27.8% (N = 22) frequency of violent individuals de-
in charge of patients were interviewed. All data were collected on a tected among subjects who lived alone, and 28.2% (N = 155) in subjects
datasheet specially created for this study. Data were entered in a dataset living with other people (chi square test = 0.00, df = 1, p = 1.00). How-
and evaluated using the SPSS-22 statistical package. Student's t-test for ever, on closer inspection of the violent events classified according to
unpaired data was used to evaluate differences between continuous residential status (living alone, living with acquired family, living with
variables. Pearson chi square test or Fisher exact test was used for cate- family of origin, living with all other people), a relevant connection
gorical variables. Bivariate correlations were evaluated by means of
Pearson's “r” in the case of continuous variables, or Cramer's phi in the
case of categorical variables. Strength for non-independence between Table 1
two binary data values was evaluated in terms of odds ratios and 95% Socio-demographic characteristics of the sample according to gender.
confidence limits. All tests were two-tailed; the level of statistical signif- Males Females Total Statisticsa
icance was set at a p value equal to or lower than 0.05.
N (%) 308 (45.4) 370 (54.6) 678 (100)
Mean age years (±s.d.) 47.1 (14.2) 51.6 (15.8) 49.6 (15.3) p b 0.0001
3. Results Marital status (N, %)
Singles 246 (79.9) 226 (61.1) 472 (69.6) p b 0.0001
3.1. Sample Married 62 (20.1) 144 (38.9) 206 (30.4)
Mean years of education 9.58 (3.9) 11.5 (3.5) 10.0 (3.8) n.s.b
(±s.d.)
The sample consisted of a total of 678 patients (54.6% females); Employment (N, %)
subjects were middle-aged (mean age 49.6 ± 15.3 years, range Employed 68 (22) 105 (28.4) 173 (26.1) p = 0.05
18–93 years) mostly single (69.9%), unemployed (73.9%) and with an Unemployed 240 (78) 265 (71.6) 505 (73.9)
average level of education (10.0 ± 3.82 years); 25% were receiving a a
Level of significance of differences between genders.
disability pension. A higher average age was observed among females; b
No significant difference.

Please cite this article as: Pinna, F., et al., Violence and mental disorders. A retrospective study of people in charge of a community mental health
center, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.02.015
 F. Pinna et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx 3

Table 2 Table 4
Clinical characteristics of the sample. Clinical variables associated with lifetime violence.

Diagnosis N (%) Factor Evidences Statistics

Anxiety disorders 205 (30.2) Age at onset Violent pts. = 24.3 ± 15.5 t = −5.47, p = 0.0001
Depr. disorders 115 (17.0) (years, mean ± s.d.) Not violent = 33.3 ± 16.7
Bipolar disorders 122 (18.0) Age at first treatment Violent pts. = 28.6 ± 14.5 t = −6.08, p = 0.0001
Schizophreniaa 167 (24.6) (years, mean ± s.d.) Not violent = 37.0 ± 16.0
Person disorders 20 (2.9) Duration of illness Violent pts. = 21.9 ± 12.6 t = −3.76, p = 0.0001
Mental retardation 18 (2.6) (years, mean ± s.d.) Not violent = 17.5 ± 13.8
Other 20 (2.9) Hospital admissions, Violent = 83 (61.9) OR = 2.89, Cl 95% 1.92–4.33,
Missing 11 (1.6) N (%) Not violent = 137 (36.1) p b 0.0001
Mean age (years) at onset (±s.d.) 30.8 (16.8) Forensic hospital Violent = 14 (100) OR = ∞, p = 0.0001
Mean age (years) at first treatment (±s.d.) 34.7 (10.1) admissions, N (%) Not violent = 0 (0.0)
Mean duration (years) of illness (±s.d.) 18.7 (13.6) Attempted suicides, Violent = 48 (34.5) OR = 2.91, Cl 95% 1.86–4.55,
Pts. with hospital admissions (N, %) N (%) Not violent = 59 (15.3) p = 0.001
One 77 (11.4)
Two or more 188 (27.7)
Pts. with forensic hospital admissions (N, %) 18 (2.7)
a
Other psychoses included. (5.9% vs other diagnoses, OR = 3.208, 95% CI 1.148–7.983, p = 0.019)
along with personality disorders (15.0% vs 2.3% of other conditions,
OR = 7.388, 95% CI 1.954–27.933, p = 0.001). In contrast, anxiety dis-
emerged between violent behaviors and living with family of origin orders and depression were linked to a lower frequency of violent be-
(OR = 2.08, 95% CI 1.46–2.96). Indeed, our data revealed 37.2% (N = havior than other diagnoses. As shown in Table 5 the presence of a
93) violent individuals living with their family of origin compared to psychiatric comorbidity (presence of at least two comorbid psychiatric
27.8% (n = 22) living alone, 18.6% (n = 48) living with acquired family, conditions, mostly an axis I plus an axis II disorder, or an axis I disorder
and 33.3% (N = 14) living with others (i.e. sheltered housing, foster plus substance abuse/dependence) is associated with a higher propor-
homes, assisted accommodation) (chi square test = 22.312, df = 1, tion of cases of violence. Finally, the rate of lifetime suicide attempts
p $_amp_$lt; 0.001). was 18.9% (N = 128), of which 1.9% had occurred over the last year
(N = 13). Furthermore, the proportion of patients with a lifetime
history of suicide attempts was 31.7% (n = 59) in subjects with a life-
3.5. Violent behavior based on clinical variables
time history of violent acts, and 14.1% (N = 69) in those without a his-
tory of violence. Accordingly, a marked interrelationship of lifetime
Violent behavior was associated with lower age at onset, lower age
violence and lifetime suicide attempts (phi = 0.55, p b 0.001) was
at first treatment and longer duration of illness; violent patients had
revealed.
been more frequently admitted to psychiatric wards and forensic psy-
chiatric hospitals (Table 4).
With regard to diagnosis (Table 5), a higher frequency of violent be-
3.6. Recurrent violence
haviors was associated with schizophrenia and other psychotic condi-
tions, mental retardation and personality disorders. Bipolar disorders
To investigate variables related to recurrence of violent acts, we
were associated with a non-statistically significant higher risk of vio-
compared two groups of patients: those who had committed only one
lence. However, the only conditions associated with a considerably
act of violence during their life (not recurrent cases) and those who
higher risk of being subjected to legal actions or trials are bipolar disor-
had been violent twice or more (recurrent cases). Significant variables
ders (10% of bipolar patients versus 3.3% of other patients, OR = 3.253,
associated with recurrence are shown in Table 6. Recurrent cases were
95% CI 1.5222–6.950, p b 0.001) and personality disorders (15% vs 4.2%
significantly associated with younger age and single status; on the con-
of other conditions, OR = 4.039, 95% CI 1.115–14.621, p = 0.022).
trary, having children and being affected by bipolar disorder did not ap-
Similarly, bipolar disorder is the only diagnosis associated with a sig-
pear to be associated with risk of recurrence.
nificantly higher risk of admission to a forensic psychiatric hospital

Table 3
Sociodemographic factors associated with lifetime violence. Table 5
Lifetime violence according to principal diagnosis.
Factor Evidences Statistics
Diagnosis OR 95% CI p value
Gender, N (%) Males 123 (39.9%) OR = 3.18, Cl 95% 2.22–5.52,
N, %
Females 64 (17.3%) p b 0.0001
Age (years, mean ± s.d.) Violent pts. = 46.1 ± 14.6 t = −2.71, p = 0.007 Mental retardation Any other disorder 7.22 2.23–23.45 0.0005
Not violent = 50.1 ± 15.7 10 (71.4) 129 (25.7)
Education Violent pts. = 9.5 ± 4.0 t = −2.33, p = 0.002 Personality disorders Any other disorder 3.698 0.82–16.72 0.088
(years, mean ± s.d.) Not violent = 13.8 ± 10.4 4 (57.1) 135 (26.5)
Marital status, N (%) Married 37 (18) OR = 0.42, Cl 95% 0.21–0.60, Comorbid disorders No comorbid disorders 2.75 1.85–4.10 b 0.001
Singlesa 146 (31.9) p b 0.001 76 (39.6) 64 (19.2)
Parenthood, N (%) With children 80 (33.1) OR = 0.47, Cl 95% 0.33–0.67, Schizophrenia and other Any other disorder 2.58 1.68–3.96 b 0.0001
Without children 121 p b 0.001 psychoses 87 (22.1)
(66.9) 52 (42.3)
Employment, N (%) Employed 37 (21.4) OR = 0.60, Cl 95% 0.40–0.90, Other disorders Any other disorder 1.53 0.50–4.63 0.540
Unemployed 146 (29.7) p = 0.035 5 (35.7) 134 (26.7)
Living status, N (%) Living alone 22 (27.8) OR = 0.98, Cl 95% 0.58–1.66, Bipolar disorders Any other disorder 1.43 0.89–2.31 0.136
Living with any other p = 1.0 31 (33.0) 107 (25.5)
155 (28.2) OR = 2.10, Cl 95% 1.46–2.96, Depressive disorders Any other disorder 0.48 0.26–0.88 0.017
Living alone 22 (27.8) p b 0.05 14 (16.5) 125 (37.7)
Living with family 93 (37.2) Anxiety disorders Any other disorder 0.27 1.17–0.43 b 0.0001
a 22 (12.7) 117 (34.4)
Including separated, divorced, widowed.

Please cite this article as: Pinna, F., et al., Violence and mental disorders. A retrospective study of people in charge of a community mental health
center, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.02.015
4 F. Pinna et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx

Table 6 outpatients. According to our study, 26.7% of patients in charge of the

Recurrent violence: significant associations. CMHC had displayed violent behavior at least once in their lifetime,
Variable Recurrent Not recurrent Statistics p value and approximately 69% of these had perpetrated violence twice or
violence violence more. These figures are significant, bearing in mind that we included
Age only overt acts of violence and excluded forms of violence such as verbal
b 45 years 52.1% 30% OR = 2.54 0.013 aggressiveness and psychological violence. It should be taken into ac-
N 45 years 47.9% 70% 95% CI count that this apparently high percentage relates to a very long period
1.17–5.37
of time, with the average duration of illness in our sample being more
Civil status
Single 83% 35.9% OR = 2.73 0.01 than fifteen years; on the other hand, the one-year prevalence of violent
Married 17% 64.1% 95% CI cases is approximately 10%, a relevant proportion given the relatively
.24–6.00 short span of time considered. As mentioned above, two crucial aspects
Children emerged from this study: approximately two thirds of violent patients
Yes 28.6% 46.2% OR = 0.47 0.038
No 71.4% 53.8% 95% CI
had repeatedly committed violent acts during their lifetime, and all pa-
0.22–0.97 tients who had committed violence over the preceding year had been
Bipolar disorder violent previously. Moreover, approximately 70% of the violent acts
Yes 18.8% 35.9% OR = 0.41 0.023 registered were committed against persons, although acts investigated
No 81.2% 64.1% 95% CI
in our survey did not generally jeopardize victims' health. Indeed, no
0.19–0.89
cases of extremely severe acts such as attempted homicides or homi-
cides were reported, with only 18% of violent patients being involved
in legal proceedings, and an even lower percentage (10%) being submit-
4. Discussion ted to restrictive measures following a trial (admission to a forensic hos-
pital or other forms of legal leverage, such as compulsory admission to a
The issue of violence perpetrated by people with mental disorders therapeutic community). However, these relatively low figures should
continues to be widely investigated, due to both its importance from a be interpreted with caution, as patients' families and staff of the
public health perspective, and to the common perception of the danger- CMHC, frequently the target of violence, may have been reluctant to re-
ousness of mental disorders, reflected and amplified by media reports port violence by a mentally ill patient. Furthermore, some patients may
(Carpiniello et al., 2007). The issue of violence perpetrated by the men- have denied their violent behavior (Krakowski & Czobor, 2012). The
tally ill is of outstanding importance, particularly in countries such as previously cited US review (Choe et al., 2008) reports that a percentage
Italy where the majority of people with mental disorders, even the of between 2% and 13% outpatients had perpetrated violence during a
most severely affected, live in the community. Indeed, psychiatric hos- time period between six months and three years prior to the study;
pitals in Italy were closed more than thirty years ago, and the public however, these studies were only based on patients affected by severe
mental health system is largely based on a widespread network of mental illness. In particular, in a study of severely ill outpatients, intake
community mental health centers (CMHCs) (de Girolamo et al., 2007; evaluation revealed how 4% of subjects had committed an attempted
Ferrannini et al., 2014). Moreover, a recently approved law relating to homicide in the past (Asnis et al., 1994). Moreover, a study of 802 out-
the closure of forensic hospitals (Barbui & Saraceno, 2015; Peloso patients affected by psychotic or major affective disorders followed in
et al., 2014) is expected to result in an increase of the number of people public outpatient services of four US states found an annual prevalence
affected by mental disorders with legal issues being committed to of serious assaultive behaviors of 13% (Swanson et al., 2002). A prospec-
CMHCs. tive two-year study conducted in North Carolina to evaluate the effec-
Numerous studies have investigated violent behavior among inpa- tiveness of atypical versus typical antipsychotics in reducing violent
tients of Italian psychiatric wards (Amore et al., 2008; Biancosino acts in schizophrenic patients, found at baseline evaluation that 15.3%
et al., 2009; Colasanti et al., 2008; Cornaggia et al., 2011; Troisi et al., of subjects had committed violent acts against others in the six months
2003; Vanni et al., 2004). prior to enrolment (Swanson et al., 2004). In this study the one-year
To judge from the data available in literature, the frequency of prevalence of violence was 21.8% and only 9% of the sample had official
violent behavior among Italian inpatients seems to be quite low. In records of arrest for violent offenses during the previous year; approxi-
particular, the results obtained in a multicenter study of 1324 patients mately 41% of the violent subjects had committed serious acts of vio-
admitted to a series of acute care facilities in Italy (Biancosino et al., lence involving use of weapons or resulting in injury (Swanson et al.,
2009) have demonstrated that only 10% of inpatients display hostile be- 2004). A subsequent national study of violent behavior in persons
havior (without physical aggression), and an even smaller percentage with schizophrenia was conducted on 1410 outpatients in charge of
(3%) are physically violent. However, single studies focusing on smaller 56 clinical sites in 24 states throughout the USA in the context of the
samples have reported significantly higher percentages, with 45% of CATIE study (Swanson et al., 2006a). This important study reported a
patients displaying verbal aggressiveness and 33% physical assaults 19.1% six-month prevalence of violence, mainly minor violence
(Colasanti et al., 2008). A large USA review has reported that rates of (15.5%), with only 3.6% of cases of serious violence. Another study of
violence committed by inpatients are significantly higher than those 1011 outpatients affected by any serious mental disorder in charge of
reported for other samples, ranging from 10 to 50% (Choe et al., 2008), public community services in five different American cities, mostly
while a further study investigating violence perpetrated during a first under social and/or legal leverage (Swanson et al., 2006b) reported
or subsequent admission over the next two years reported rates of that the six-month percentage of subjects who had committed violent
75% among men and 53% among women (Steinert et al., 1999). acts ranged between 18% and 21%, with 3–9% of individuals involved
In contrast with the large amount of data reported for inpatients in in serious acts of violence (using weapons, causing physical injury or
Italy, outpatient studies are lacking, with only one study published to committing sexual abuse). In Europe, a Spanish study (Bobes et al.,
date describing patients in charge of a few CMHCs (Catanesi et al., 2009) of 895 outpatients affected by schizophrenia reported a 5.1%
2007). This is not surprising however, particularly due to the similar rate of recent aggressive behavior (in the week prior to the study).
presence of a relatively scarce number of outpatient studies in the inter- About half of these cases (47%, amounting to less than 2.5% of the total
national literature. As an example, Choe et al. (2008) in their review of sample) reached the threshold for definition as violent behavior; the
violent acts perpetrated by severely mentally ill patients in the USA, majority of episodes involved verbal violence (44%), violence toward
cited eighteen studies on inpatients, six studies on mixed samples objects (29%), toward others (19%) or self-directed violence (19%);
(both in and outpatients) and only four studies specifically focused on however, the relatively low rate of violence reported in this study

Please cite this article as: Pinna, F., et al., Violence and mental disorders. A retrospective study of people in charge of a community mental health
center, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.02.015
 F. Pinna et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx
should be interpreted in light of the singular composition of the study
sample, made up of patients displaying good treatment compliance.
The only other Italian study on community-treated patients (Catanesi
et al., 2007) included all subjects (n = 1582) undergoing regular treat-
ment in four community mental health centers located in two southern
Italian regions (Puglia and Basilicata). This study reported that approx-
imately 36% of subjects had committed acts of violence over a four-year
period (1995–1999), a rate of approximately 9% per year; however, the
rate of violent acts dropped to 26.5% (less than 7% per year) when ex-
cluding verbal aggression or threats. A direct comparison of our data
with those from other studies may be misleading, due to the very differ-
ent settings (in and/or outpatient services) considered, methods
employed to collect data (interviews, chart reviews, mixed methods)
and study designs (retrospective or prospective studies), sampling (se-
lected patients with single diagnoses or pertaining to selected diagnos-
tic classes; patients selected according to severity of illness; unselected
samples of patients), time frame evaluated (six months, one or more
years, lifetime), and social and cultural background of populations con-
sidered. Overall, data emerging both from our study and the other Ital-
ian outpatient study (Catanesi et al., 2007) show, as in other Western
countries, that rates of violence among these patients are lower than
those found in inpatients, a largely expected finding when considering
the overall lower clinical severity of subjects followed by outpatient
services. However, due to the heterogeneity of patients followed in
Italian CHMCs, which routinely deal with all types of mental disorder,
the frequency of violent acts detected among outpatients appears to
be quite relevant, although very severe forms of violence are infre-
quent. In addition to evaluation of quantitative data relating to the fre-
quency of violence, the second aim of this study was to investigate the
association of violence with socio-economic and clinical variables. Un-
fortunately, the lack of reliable retrospective data made it impossible
to analyze several important factors generally associated with violence,
such as belonging to a violent family, and having been subjected to vio-
lence in childhood (Elbogen & Johnson, 2009; Monahan et al., 2001;
Mulvey et al., 1998; Swanson et al., 2002). With regard to demographic
variables, our findings reveal a greater probability of violent behavior in
males, thus reflecting the results of recently conducted inpatient studies
(Amore et al., 2008; Biancosino et al., 2009; Dack et al., 2013; Di
Giacomo & Clerici, 2010; Steinert et al., 1999) and community studies
(Swanson, Van Dorn, et al., 2006), also in Italy (Catanesi et al., 2007).
Moreover, the relatively young age of patients committing acts of vio-
lence recorded in our study is fully in keeping with the findings from
literature on both inpatients (Biancosino et al., 2009; Dack et al.,
2013) and community samples (Catanesi et al., 2007; Swanson et al.,
2006). It should be underlined that, unlike cases of isolated violence,
younger age and single status were the only sociodemographic vari-
ables significantly related to cases of recurrent violence. In our study
the status of “violent” patient is associated with a lower level of educa-
tion, a finding which is at odds with the higher rate of violent behavior
found in a sample of highly educated hospitalized patients in Italy
(Biancosino et al., 2009), and the lack of association between education
and violence found in the study carried out by Catanesi et al. (2007). To-
gether with a low level of education, the increased violent behavior ob-
served in unmarried and unemployed patients, or those who were
retired and/or receiving a disability pension, depicts a condition of
greater social marginalization of violence-prone subjects, a finding in
line with data emerging from community studies showing an increased
frequency of violence among low-income and unemployed patients
(Elbogen & Johnson, 2009). The frequency of aggressive behaviors in
subjects living with their family observed in this survey is highly signif-
icant, as it reveals how violence, frequently directed toward family
members, is apparently triggered by typical conflicting relationships
(Catanesi et al., 2007). Interestingly, the results obtained in a study of
North American outpatients treated in community services (Swanson
et al., 1998) have demonstrated that badly deteriorated subjects, who
were also characterized by poor social functioning, are more likely to
Please cite this article as: Pinna, F., et al., Violence and mental disorders. A retrospective study of people in charge of a community mental health
center, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.02.015
5
be violent when regularly in contact with household and friends. Con-
versely, the lower risk of violence observed in patients with better social
skills, tends, on the contrary, to increase when the patient engages in
frequent social relationships outside the family. These findings suggest
that, at least in severely ill patients, exposure to more frequent contacts,
such as subjects living with family members, may lead to increased
stress and conflict and, consequently, to a higher risk of violent behav-
ior. This interpretation is confirmed by the aforementioned Italian out-
patient study (Catanesi et al., 2007), in which parents and other
family members were the main victims of violence, and negative family
attitudes were markedly associated with an increased risk of violence
by the mentally ill family member.
One of the main clinical findings emerging from our study is the as-
sociation between increased frequency of violent behavior and longer
duration of the disease, a finding in line with evidence provided by
the above-cited Italian study (Catanesi et al., 2007). Moreover, we
found an increased risk of violence associated with younger age at
onset and at first psychiatric care, two aspects generally linked with a
worse outcome, particularly in patients affected by psychotic or mood
disorders. The higher frequency of violent behavior among subjects
suffering from schizophrenia and other psychotic disorders further
confirms the findings of previous studies conducted on both inpatients
(Biancosino et al., 2009; Dack et al., 2013) and outpatients (Bobes et al.,
2009; Catanesi et al., 2007; Swanson et al., 2006a), underlining the asso-
ciation between increased risk of violence and disorders of higher sever-
ity (Arango et al., 1999). Although in our study bipolar disorder was
found to be associated with a non-statistically significant higher risk
of violence, it is noteworthy that the disorder was linked to a signifi-
cantly higher risk of legal charges and a higher rate of previous admis-
sions to a forensic psychiatric hospital, thus confirming the higher risk
of violence related to this condition. As expected from literature, a di-
agnosis of personality disorder is linked with a higher risk of violence
(Asnis et al., 1997; Flannery et al., 2014). Our study shows a significantly
higher risk of violence among patients with intellectual disability, as
shown by previous studies (Hodgins, 1992; Lindsay, 2011) and among
subjects with intellectual disability in comorbidity with other disorders
(Joyal et al., 2008). This finding is worthy of consideration, bearing in
mind that people with an intellectual disability are probably one of
the most neglected subpopulations in charge of community mental
health services in Italy. In line with the study by Catanesi et al. (2007),
we found that an increased risk of violence is associated with frequency
of previous hospital admissions, a finding supporting the hypothesis
that patients with an increasingly unstable course of illness, at least
those affected by major disorders, are more prone to acts of violence.
Moreover, our findings confirmed a higher presence of violent behavior
in patients with a psychiatric comorbidity, generally personality disor-
ders and substance use disorders (Asnis et al., 1997; Edlinger et al.,
2014; Elbogen & Johnson, 2009; Swanson et al., 1997; Volavka, 2014).
Indeed, while major psychiatric disorders such as schizophrenia and bi-
polar disorder are more frequently related to violence, it is evident that
the risk of violence in patients affected by these disorders may be largely
due to the concomitant use of alcohol or substances (Arsenault et al.,
2000; Elbogen & Johnson, 2009; Hafner & Boker, 1973; Swanson,
1990; Rasanen et al., 1998; Tiihonen et al., 1997). The increased fre-
quency of violence over the last year in subjects who had previously
manifested aggressive behaviors confirms the univocal data from litera-
ture demonstrating that previous violence is one of the most relevant
predictors of recurrent violence (Arango et al., 1999; Dack et al., 2013;
Di Giacomo & Clerici, 2010; Elbogen & Johnson, 2009). In our study,
self-inflicted acts of violence such as suicide attempts, were associated
with violent behavior toward others, in agreement with the results of
a recent study of schizophrenic patients (Witt et al., 2014), thus
supporting the existence of a sort of common matrix between the two
forms of violence.
Before drawing any conclusions, several limitations of the present
study should be underlined. First, the relatively small sample size
6 F. Pinna et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx
should be taken into account, as this may have limited the statistical
power of the study. Secondly, it should be emphasized that the study
focuses on a clinical sample of patients treated in a single university
mental health center in southern Italy. Hence, the data obtained cannot
be referred to the entire Italian outpatient population. Third, the sample
examined comprises treated subjects who have been in contact with the
community mental health center, with the exception of patients who
have moved away, refused to continue treatment, no longer needed reg-
ular care, or died. This may have introduced a possible selection bias in
favor of subjects with a lower likelihood of violent behavior. Fourth, the
fact that the sample studied comprised a mix of patients with major and
minor disorders and that patients with major disorders (approx. 50%
of the sample) were generally in a stable clinical condition, being char-
acterized by mild or moderate symptoms and only slight–moderate im-
pairment of functioning (Pinna et al., 2013a; Pinna et al., 2013b; Pinna et
al., 2014; Pinna et al., 2015) should be taken into due account, together
with the fact that the vast majority of patients are undergoing treatment
programs with both psychopharmacological and/or psychosocial inter-
ventions, in the context of a continuity of care typical of community
treatment delivered in Italy. Finally, the retrospective nature of data,
or at least of clinical histories prior to being taken in charge by our
CMHC, may have affected the reliability of this study due to recall bias.
Notwithstanding these limitations, the findings obtained may be of a
certain importance for those involved in community treatment.
The first evidence provided by our study is the confirmation of the
significant proportion of violent acts perpetrated by patients in charge
of a community mental health center, a finding of particular relevance
for countries, such as Italy, in which the mental health system is largely
based on community treatment. At present, some of these patients
are assigned to public services by the legal authorities, in compliance
with the laws of each country, and are under some type of legal lever-
age. The number of these patients is expected to increase following ap-
proval of a recent law on the closure of forensic hospitals (Barbui &
Saraceno, 2015; Peloso et al., 2014). Furthermore, the results of our
study highlighted the inevitability, and at times difficulty, in predicting,
and where possible preventing violence, even for clinicians working in
community services. As Swanson (2008) maintained, “clinicians actual-
ly can predict and prevent violence if they consider their patients as a
group from the perspective of public-health epidemiology”, i.e. to iden-
tify the subset of patients in their services who are at greater risk of vi-
olence, and subsequently to assess any possibly unsatisfied needs. Our
study confirms the existence of and need to identify a subgroup of pa-
tients at major risk for repeated violence in charge of public community
services. This group is made up of poorly educated, socially disadvan-
taged young male adults, mainly affected by major mental disorders
such as schizophrenia and bipolar disorders, particularly when comor-
bid with personality and/or substance use disorder or with intellectual
disability. As shown in the literature, potentially violent patients with
mental disorders “frequently live in relative poverty, experience an as-
sociated lack of education opportunities, problems with employment
and a paucity of pro-social attachments”, so that “the social drift and re-
cruitment of adversities also contribute to the association of violence,
victimization and adverse social environments” (Scott, 2008). In coun-
tries such as Italy, where the majority of these patients live with their
family, particular attention should be paid to subjects displaying highly
conflicting family relationships, a context which seemingly fosters vio-
lence. An assertive approach, based upon the “risk-need-responsively
principle” (Scott, 2008) seems to be the most appropriate means
of managing this subset of complex cases, particularly as violence
has proved to be inversely related to treatment compliance, perceived
treatment needs (often largely unsatisfied) and perceived treatment
effectiveness (Martinez-Martin et al., 2011).
Competing interest
The authors declare that they have no competing interest.
Please cite this article as: Pinna, F., et al., Violence and mental disorders. A retrospective study of people in charge of a community mental health
center, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.02.015
Authors' contributions
Drs. FP and AF contributed to study conception and design, statistical
analysis and interpretation of data and drafting the manuscript; Drs. ED,
GP and MT provided a substantial contribution to data acquisition, data-
base management and data analysis; Prof. BC contributed to study con-
ception and design, analysis and interpretation of data and to checking
versions of the paper. All authors have approved the final version of
the text for publication.
Acknowledgments
The authors thank Ms. Anne Farmer for having revised the English
version of the paper.
References
Amore, M., Menchetti, M., Tonti, C., Scarlatti, F., Lundgren, E., Esposito, W., & Berardi, D.
(2008). Predictors of violent behaviour among acute psychiatric patients: Clinical
study. Psychiatry and Clinical Neurosciences, 62, 247–255.
Arango, C., Calcedo Barba, A., Gonzales, S., & Calcedo Ordonez, A. (1999). Violence in inpa-
tients with schizophrenia: A prospective study. Schizophrenia Bulletin, 25, 493–503.
Arsenault, L., Moffit, T. E., Caspi, A., Taylor, P. J., & Silva, P. A. (2000). Mental disorders and
violence in a total birth cohort: Results from the Dunedin Study. Archives of General
Psychiatry, 57, 979–986.
Asnis, G. M., Kaplan, M. L., Hundorfean, G., & Saeed, W. (1997). Violence and homicidal be-
haviors in psychiatric disorders. The Psychiatric Clinics of North America, 20, 405–420.
Asnis, G. M., Kaplan, M. L., van Praag, H. M., & Sanderson, W. C. (1994). Homicidal be-
haviors among psychiatric outpatients. Hospital $_amp_$amp; Community Psychiatry,
45, 127–132.
Barbui, C., & Saraceno, B. (2015). Closing forensic psychiatric hospitals in Italy: A new rev-
olution begins? British Journal of Psychiatry, 206, 445–446.
Biancosino, B., Delmonte, S., Grassi, L., Santone, G., Preti, A., Miglio, R., ... PROGRESS-Acute
Group (2009). Violent behavior in acute psychiatric inpatient facilities: A national
survey in Italy. The Journal of Nervous and Mental Disease, 197 (772–37).
Bobes, J., Fillat, O., & Arango, C. (2009). Violence among schizophrenia outpatients compli-
ant with medication: Prevalence and associated factors. Acta Psychiatrica Scandinavica,
119, 218–225.
Brennan, P. A., Mednick, S. A., & Hodgins, S. (2000). Major mental disorders and criminal
violence in a Danish birth cohort. Archives of General Psychiatry, 57, 494–500.
Candini, V., Buizza, C., Ferrari, C., Boero, M. E., Giobbio, G. M., Goldschmidt, N., et al.
(2015). Violent behavior of patients living in psychiatric residential facilities: A com-
parison of male patients with different violence histories. International Journal of Law
and Psychiatry, 39, 46–51.
Carpiniello, B., Baita, A., Carta, M. G., Sitzia, R., Macciardi, A. M., Murgia, S., & Altamura, A. C.
(2002). Clinical and psychosocial outcome of patients affected by panic disorder with
or without agoraphobia: Result of a naturalistic follow-up study. European Psychiatry,
17, 394–398.
Carpiniello, B., Girau, R., & Orrù, M. G. (2007). Mass-media, violence and mental illness,
evidence from some Italian newspapers. Epidemiologia e Psichiatria Sociale, 16,
251–255.
Catanesi, R., Carabellese, F., & Guarino, D. (2007). Analisi del comportamento violento in
una popolazione di pazienti psichiatrici in Puglia e Basilicata. Italian Journal of
Criminology, 1, 64–79.
Choe, J. Y., Teplin, L. A., & Abran, K. M. (2008). Perpetration of violence, violent victimiza-
tion, and severe mental illness: Balancing public health concerns. Psychiatric Services,
59, 153–164.
Colasanti, A., Natoli, A., Moliterno, D., Rosattini, M., De Gaspari, I. F., & Mauri, M. C. (2008).
Psychiatric diagnosis and aggression before acute hospitalization. European Psychiatry,
23, 441–448.
Conti, L., Dell'Osso, L., & Cassano, G. B. (1988). Il sistema AMDP. Manuale per la valutazione
e la Documentazione della Psicopatologia. Versione Italiana. Milano: Mazzucchelli.
Cornaggia, C. M., Bechi, M., Pavone, F., & Barale, F. (2011). Aggression in psychiatric wards:
A systematic review. Psychiatry Research, 189, 10–20.
Dack, C., Ross, J., Papadopoulos, C., Stewart, D., & Bowers, L. (2013). A review and meta-
analysis of the patient factors associated with in-patient aggression. Acta Psychiatrica
Scandinavica, 127, 255–268.
de Girolamo, G., Bassi, M., Neri, G., Ruggeri, M., Santone, G., & Picardi, A. (2007). The cur-
rent state of mental health care in Italy: Problems, perspectives and lessons to learn.
European Archives of Psychiatry and Clinical Neuroscience, 257, 83–91.
Di Giacomo, E., & Clerici, M. (2010). Violence in psychiatric inpatients. Rivista di Psichiatria,
45, 361–364.
Edlinger, M., Tauch, A. S., Kemmler, G., Yalcin-Siedentopf, N., Fleischhacker, W. W., &
Hofer, A. (2014). Risk of violence of inpatients with severe mental illness: Do patients
with schizophrenia pose harm to others? Psychiatry Research, 219, 450–456.
Elbogen, E. B., & Johnson, S. C. (2009). The intricate link between violence and mental
disorder: Results from the National Epidemiologic Survey on Alcohol and Related
Conditions. Archives of General Psychiatry, 66, 152–161.
Fazel, S., & Grann, M. (2006). The population impact of severe mental illness on violent
crime. The American Journal of Psychiatry, 163, 1397–1403.
 F. Pinna et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx
Ferrannini, L., Ghio, L., Gibertoni, D., Lora, A., Tibaldi, G., Neri, G., ... Italian Mental Health
Data Group (2014). Thirty-five years of community psychiatry in Italy. The Journal
of Nervous and Mental Disease, 201, 432–439.
Flannery, R. B., Jr., Wyshack, G., Tecce, J. J., & Flannery, G. J. (2014). Characteristics of inter-
national assaultive psychiatric patients: Review of published findings, 2000–2012.
The Psychiatric Quarterly, 85, 303–317.
Hafner, H., & Boker, W. (1973). Mentally disordered violent offenders. Social Psychiatry, 8,
220–229.
Hodgins, S. (1992). Mental disorders, intellectual deficiency, and crime: Evidence from a
birth cohort. Archives of General Psychiatry, 49, 476–483.
Joyal, C. C., Gendron, C., & Cotè, G. (2008). Nature and frequency of aggressive behaviours
among long-term in patients with schizophrenia: A 6-month report using the modi-
fied overt aggression scale. Canadian Journal of Psychiatry, 53, 478–481.
Krakowski, M. I., & Czobor, P. (2012). The denial of aggression in violent patients with
schizophrenia. Schizophrenia Research, 141, 228–233.
Lindsay, W. E. (2011). People with intellectual disability who offend or are involved with
the criminal justice system. Current Opinion in Psychiatry, 24, 377–381.
Martinez-Martin, N., Fraquas, D., Garcia-Portila, M. P., Bascaran, M. T., Arango, C., & Bobes,
J. (2011). Self-perceived needs are related to violent behaviour among schizophrenia
outpatients. The Journal of Nervous and Mental Disease, 199, 666–671.
Monahan, J., Steadman, H., Silver, E., Appelbaum, P., Robbins, P., Mulvey, E., et al. (2001).
Rethinking risk assessment: The MacArthur Study of Mental Disorder and Violence.
New York: Oxford University Press.
Mulvey, H., Monahan, E., Robbins, J., Appelbaum, P., Grisso, T., Roth, L., & Silver, E. (1998).
Violence by people discharged from acute psychiatric inpatient facilities and by
others in the same neighborhoods. Archives of General Psychiatry, 55, 393–401.
Peloso, P. F., D'Alema, M., & Fioritti, A. (2014). Mental health care in prisons and
the issue of forensic hospitals in Italy. Journal of Nervous and Mental Disorders, 202,
473–478.
Pinna, F., Deriu, L., Lepori, T., Maccioni, R., Milia, P., Sarritzu, E., et al. (2013a). Is it true re-
mission? A study of remitted patients affected by schizophrenia and schizoaffective
disorders. Psychiatry Research, 210, 739–744.
Pinna, F., Tusconi, M., Bosia, M., Cavallaro, R., Carpiniello, B., & Cagliari Recovery Group
Study (2013b). Criteria for symptom remission revisited: A study of patients affected
by schizophrenia and schizoaffective disorders. BMC Psychiatry, 13, 235.
Pinna, F., Bosia, M., Cavallaro, R., Carpiniello, B., & for the Cagliari Recovery Group Study
(2014). Consensus five factor PANSS for evaluation of clinical remission: Effects
on functioning and cognitive performances. Schizophrenia Research: Cognition, 1,
187–192.
Pinna, F., Deriu, L., Diana, E., Perra, V., Randaccio, R. P., Sanna, L., et al. (2015). Clinical
Global Impression severity score as a reliable measure for routine evaluation of re-
mission in schizophrenia and schizoaffective disorders. Annals of General Psychiatry,
14, 6. http://dx.doi.org/10.1186/s12991-015-0042-6.
Pirarba, S., Aru, D., Lai, L., Pinna, F., & Carpiniello, B. (2010). Vittimizzazione e disturbi
mentali: risultati di uno studio caso-controllo. Rivista di Psichiatria, 45, 382–392.
Primavera, D., Bandecchi, C., Sanna, L., Nicotra, E., & Carpiniello, B. (2012). Does duration
of untreated psychosis predict very long term outcome of schizophrenic disorders?
Please cite this article as: Pinna, F., et al., Violence and mental disorders. A retrospective study of people in charge of a community mental health
center, International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.02.015
7
Results of a retrospective study. Annals of General Psychiatry, 11(1), 21. http://dx.
doi.org/10.1186/1744-859X-11-2145.
Rasanen, P., Tiihonen, M., Isohanni, M., Rantakalio, P., Lehtonen, J., & Moring, J. (1998).
Schizophrenia, alcohol abuse, and violent behavior. Schizophrenia Bulletin, 24, 437–441.
Scott, R. (2008). Interventions to address violence associated with mental illness.
Australasian Psychiatry, 16, 405–411.
Steinert, T., Wiebe, C., & Gebhart, R. P. (1999). Aggressive behaviour against self and others
among first-admission patients with schizophrenia. Psychiatric Services, 50, 85–90.
Swanson, J. W. (1990). Violence and psychiatric disorders in the community: Evidence
from the Epidemiological Catchment Area Surveys. Hospital $_amp_$amp;
Community Psychiatry, 41, 761–777.
Swanson, J. W. (2008). Preventing the unpredicted: Managing violence risk in mental
health care. Psychiatric Services, 59, 191193.
Swanson, J. W., Swartz, M., Van Dorn, R. A., Elboen, E. B., Wagner, R., Rosenheck, R. A., et al.
(2006a). A national study of violent behaviour in persons with schizophrenia.
Archives of General Psychiatry, 63, 490–499.
Swanson, J. W., Van Dorn, R. A., Monahan, J., & Swartz, M. (2006b). Violence and leveraged
community treatment for persons with mental disorders. The American Journal of
Psychiatry, 163, 1404–1411.
Swanson, J. W., Estroff, S., Swartz, M., Borum, R., Lachicotte, W., Zimmer, C., & Wagner, R.
(1997). Violence and severe mental disorders in clinical and community populations:
The effect of psychotic symptoms, comorbidity and lack of treatment. Psychiatry, 60,
1–22.
Swanson, J. W., Estroff, S., Swartz, M., Borum, R., Wagner, R., & Hiday, V. (1998). Psychiat-
ric impairment, social contact, and violent behaviour. Evidence from a study of
outpatient-committed persons with severe mental disorders. Social Psychiatry and
Psychiatric Epidemiology, 33(supp 1), S86–S94.
Swanson, J. W., Swartz, M. S., & Elbogen, E. B. (2004). Effectiveness of atypical antipsy-
chotic medications in reducing violent behavior among persons with schizophrenia
in community-based treatment. Schizophrenia Bulletin, 30, 3–20.
Swanson, J. W., Swartz, M. S., Essock, S. M., Osher, F. C., Wagner, H. R., Goodman, L. A., &
Meador, K. G. (2002). The social-environmental context of violent behavior in persons
treated for severe mental illness. American Journal of Public Health, 92, 1523–1531.
Tiihonen, J., Jsohanni, M., Rasanen, P., Koiranen, M., & Moring, J. (1997). Specific major
mental disorders and criminality: 26-year prospective study of the 1996 Northern
Finland Birth Cohort. American Journal of Psychiatry, 154, 840–845.
Troisi, A., Kustermann, S., Di Genio, M., & Siracusano, A. (2003). Hostility during admission
interview as a short-term predictor of aggression in acute psychiatric male inpatients.
The Journal of Clinical Psychiatry, 64, 1460–1464.
Vanni, A., Biancosino, B., Marmai, L., Zucconi, M., Peron, L., Cavrini, L., et al. (2004).
Correlati psicobiologici dei comportamenti aggressive in pazienti psichiatrici: uno
studio controllato. Rivista di Psichiatria, 39, 40–44.
Volavka, J. (2014). Comorbid personality disorders and violent behavior in psychotic
patients. The Psychiatric Quarterly, 85, 65–78.
Witt, K., Hawton, K., & Fazel, S. (2014). The relationship between suicide and violence in
schizophrenia: Analysis of the Clinical Antipsychotic Trials of Intervention Effective-
ness (CATIE) dataset. Schizophrenia Research, 154, 61–67.