FLORENCE, Italy — Among physicians, psychiatrists are the most likely to be killed by their patients or a family member. The most common victims of homicide among mental health workers are young, female case workers, a systematic review of US murders among healthcare workers reveals.
Michael Knable, MD, executive director of the Sylvan C. Herman Foundation, Washington, DC, reviewed all homicides of mental health workers or physicians since the early 1980s and found that overall, it was an uncommon event.
Nevertheless, he identified a profile of perpetrators, which most often consisted of young men with a diagnosis of schizophrenia and/or a history of involuntary hospitalization.
The most common method of homicide was by gunshot.
Knable writes that "homicides of mental health workers, and of physicians generally, are rare events that emerge from a background of common aggression and violence in healthcare settings."
He adds that "many of these homicides may have been preventable."
The findings were presented here at the Schizophrenia International Research Society (SIRS) 2018 Biennial Meeting.
Knable explained that he started the research because two of his friends, Wayne Fenton, MD, and Mark Lawrence, MD, were killed by their patients. "I asked myself the question: Is it common or is it rare, and is there anything we can do to know when it's going to happen?"
He conducted systematic searches of news outlets, Internet sources, and the medical literature for accounts of homicides of US mental health workers between 1981 and 2014 and among US physicians between 1981 and 2017.
He included homicides committed by patients, the family members of patients, and coworkers, and excluded homicides that occurred in correctional settings or in agencies not focused on healthcare, as well as those unrelated to the physician's professional role.
Knable identified 33 homicides among mental health workers. He found that 39.8% of the victims were case workers, 30.3% were psychiatrists, 15.1% were social workers, 6.1% were psychologists, 6.1% were nurses, and 3.0% were physicians.
Of the victims, 54.6% were women. The average age of female victims was 35.4 years, compared with 49.1 years among men. Gunshot was the most common method, occurring in 42.4% of cases, followed by stabbing (30.3%) and beating (12.1%).
The homicides were carried out in residential facilities in 36.3% of cases; in public clinics and private hospitals in 18.2% of cases each; in private offices in 15.2%; and in public hospitals in 12.1%.
The perpetrators were mostly male (81.8% of cases); the average age was 33.0 years, vs 44.3 years among women. The most common diagnosis among perpetrators was schizophrenia, in 54.5%.
Just fewer than half (48.5%) of the perpetrators had previously been charged with a criminal offense; 51.5% had a prior history of violence; 39.4% were nonadherent to treatment; and 51.5% had prior involuntary hospitalization.
Knable notes that homicides among mental health workers were rare. The most common victim was "a young female case worker trying to resolve a problem in a residential facility without accompaniment."
He identified 31 cases of homicides of physicians. Of those, 39% of victims were psychiatrists; 22% were in other specialties; 16% were in primary care; and 13% were in obstetrics and gynecology.
The victims were mostly male (87%); their mean age was 53.3 years. The cases occurred in 18 US states: 17% in Florida, 10% in California, 10% in Massachusetts, and 63% in the remaining 15 states.
The homicide was by gunshot in 78% of cases, followed by beating in 16% and stabbing in 6%.
In 87% of cases of physician homicide, the perpetrators were male; the mean age was 44.9 years.
The majority (68%) of perpetrators had undergone psychiatric treatment; 16% had schizophrenia; 19% were in treatment but with an unknown diagnosis; 10% had bipolar disorder; and 23% had other disorders.
Knable noted that 23% of the perpetrators had a history of involuntary hospitalization.
Just more than half (55%) of perpetrators were a current or former patient; 6% were a family member; 6% were a coworker or colleague; and 13% were an abortion activist.
The homicides were performed in the physician's office in 35% of cases; 29% took place in a hospital; 16% in a clinic; 10% in the physician's home; and 10% elsewhere, including an abortion clinic.
Noting that psychiatrists were more likely to be murdered than other specialists, Knable said perpetrators "are most likely to be male, a current or former of patient, and to have a history of psychiatric treatment.
"A lot of the advocacy groups want to give the message that the mentally ill are no more violent than the general population, but a more nuanced view is that's true if they have agreed to engage in treatment," Knable told Medscape Medical News.
"If they're not engaged in treatment and if you're practicing in a hospital or an emergency room, violence is a daily occurrence," he said.
"We know very solidly that if you're male, if you have delusions and hallucinations that are giving you commands to hurt people, if you're not compliant with medications, if you're using drugs, and if you have a prior history of offence or voluntary commitment, then you're much more likely to be violent."
Knable said that low IQ was another factor. "If you have cognitive impairments, you're much more likely to act on your impulse and be violent."
A high number of homicides he identified were committed using guns. He said that in the current debate over gun control, "politicians want to make it a polarized issue between gun control vs locking up the mentally ill, but it's really much more nuanced than that.
"First of all, guns should be very difficult to get in the United States.... I personally think, and this is the law in many of the states, that if you're involuntarily committed or if you're found not guilty by reason of insanity or if you're found not competent to stand trial, that should be in the background check database, and you shouldn't be allowed to have a gun.
"In some states, that's true; in other states, it's not; and in others, it has to be litigated separately from the crime. And in some states, it's linked into the database very effectively, and in others it's not."
Still a Rare Event
Commenting on the findings for Medscape Medical News, Paul S. Appelbaum, MD, Dollard Professor of Psychiatry, Medicine and Law, Columbia University and past president of the American Psychiatric Association, told Medscape Medical News that he agreed that homicide "is a rare event in medical settings."
However, he noted that "psychiatrists often evaluate and treat people with a number of recognized risk factors for violence, including substance abuse, anger problems, personality disorders, such as antisocial personality, and psychotic symptoms, such as command hallucinations.
"It makes sense that they would be at greatest risk among their medical colleagues. With regard to other mental health workers, it does not seem surprising that home visits create the greatest risk, especially for those workers least able to protect themselves."
Appelbaum noted that the weight of the research suggests "individuals with mental disorders are at elevated risk for violence, albeit of a lesser magnitude than many people assume. Many risk factors are associated with violence, of which failure to adhere to treatment is only one."
He also noted that more should be done in the United States to restrict access to guns by individuals who pose the greatest degree of risk.
"Using that metric, you would put many other groups ahead of people with mental disorders, including people with alcohol use disorders, people who have committed violent misdemeanors, and people who abuse their spouses," he said.
No sources of funding for the study have been disclosed. The researchers and Dr Appelbaum have disclosed no relevant financial relationships.
Schizophrenia International Research Society (SIRS) 2018 Biennial Meeting. Poster F140, presented April 6, 2018.