Perpetrating Violent Outcomes Risk Increased for Schizophrenia Patients


There was an elevated risk of violence perpetration in both men and women with schizophrenia spectrum disorder.

Daniel Whiting, BM, BCh

Daniel Whiting, BM, BCh

Violence perpetration has been a major issue for patients with schizophrenia spectrum disorder, dating back at least 4 decades.

A team, led by Daniel Whiting, BM, BCh, Department of Psychiatry, University of Oxford, reviewed the risk of perpetrating interpersonal violence in patients with schizophrenia spectrum disorders compared to the general population.

For individuals with schizophrenia spectrum disorders, violence can increase the rates of morbidity and mortality at a population level, while disrupting care and leading to stigma.

50 Years of Data

In the meta-analysis, the investigators examined multiple databases for studies between January 1970 and March 2021, including case-control and cohort studies that allowed risks of interpersonal violence perpetration and/or violent criminality in individuals with schizophrenia spectrum disorders.

Overall, they identified 24 studies of violence perpetration outcomes in 15 countries involving 51,309 individuals with schizophrenia spectrum disorders.

The investigators sought main outcomes of violence to others, which was obtained either through official records, self-reports and/or collateral-reports, or medical file review. The analysis included any physical assault, robbery, sexual offenses, illegal threats or intimidation, and arson.


The investigators found an increase in the risk of violence perpetration in men with schizophrenia and other psychoses (pooled OR, 4.5; 95% CI, 3.6-5.6) with substantial heterogeneity (I2 = 66%; 95% CI, 31-83).

However, violence was not only found in the male subpopulation.

There was also an elevated risk of violence perpetration in women (pooled OR, 10.2; 95% CI, 7.1-14.6), with substantial heterogeneity (I2 = 66%; 95% CI, 31-83).

The odds of perpetrating sexual offenses (OR, 5.1; 95% CI, 3.8-6.8) and homicide (OR, 17.7; 95% CI, 13.9-22.6) were also looked at.

A trio of trials also identified the increasing relative risks of arson. However, this data was not pooled for the current analysis owing to the heterogeneity of outcomes.

Finally, the absolute risks of violence perpetration in register-based studies were less than 1 in 20 for women with schizophrenia spectrum disorder, compared to less than 1 in 4 in men over a 35-year period.

“This systematic review and meta-analysis found that the risk of perpetrating violent outcomes was increased in individuals with schizophrenia spectrum disorders compared with community control individuals, which has been confirmed in new population-based longitudinal studies and sibling comparison designs,” the authors wrote.

Schizophrenia Treatment

While schizophrenia treatment has evolved from symptom reduction and relapse prevention to functional recovery in recent years, the recovery rates remain low.

However, identifying variables linked to the real-life functioning domains could help yield more effective personalized and integrated treatment programs.

The researchers found 5 baseline variables directly associated with real-life functioning at follow-up—neurocognition with everyday life (β, 0.274; 95% CI, 0.207-0.341; P < .001) and work (β, 0.101; 95% CI, 0.005-0.196; P = .04) skills; avolition with interpersonal relationships (β, −0.126; 95% CI, −0.190 to −0.062; P < .001); positive symptoms with work skills (β, −0.059; 95% CI, −0.112 to −0.006; P = .03); and social cognition with work skills (β, 0.185; 95% CI, 0.088-0.283; P < .001) and interpersonal functioning (β, 0.194; 95% CI, 0.121-0.268; P < .001).

The study, “Association of Schizophrenia Spectrum Disorders and Violence Perpetration in Adults and Adolescents From 15 Countries,” was published online in JAMA Psychiatry.

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