Monday, December 24, 2012

Check My Math

The APA put out a statement in response to the NRA's recommendation to put armed guards in every school. Quoting from the statement:

“Only four to five percent of violent crimes are committed by people with mental illness,” said the APA’s president, Dilip Jeste, M.D. “About one quarter of all Americans have a mental disorder in any given year, and only a very small percentage of them will ever commit violent crimes,” he added.
 So Dinah sent me an email asking this question:

"So if 1/4 of all people have a mental illness in any given year, and 56% of people have a lifetime incidence, then why are only 4-5% of violent crimes committed by people with mental illnesses?  It might seem that we'd all want to be mentally ill so we wouldn't be violent."
 My answer to that is:

Only 4-5% of crimes are committed by mentally ill people because most violence is due to personality disorders combined with substance abuse, and once you combine that trifecta the number of people at risk of committing violence drops quite a bit.

Here are the prevalence rates:

ASPD 15% prevalence (per ECA study)
MI 25% prevalence
SA 10% prevalence (per NIDA)

The population of the US at this minute is 314,996,054 (US Census Bureau). So, at any point in time now we've got:

(per million)
MI alone 79 314,996,054 x .25
MI + ASPD + SA 5.9 314,996,054 x .25 x .15 x .1
ASPD + SA alone 4.7 314,996,054 x .15 x .1

In other words, very few mentally ill people commit violence crimes because most of them don't have the main necessary risk factors. And there are relatively few people with ASPD running around so that when you throw in the MI folks it doesn't increase the pool that much. And when it comes to violent crime, a disproportionately small number of people commit the majority of offenses. The relative risk of a small number of violent offenders outweighs the small number of mentally ill people who have the trifecta. Does that make sense?

Ugh, I just spent far too much time trying to get the table formatting right and then Blogger messed up my HTML code. I give up. And I can't believe I'm writing about this the day before Christmas.

Happy Holidays!

Oh yeah, one more thing:

The APA response dings the NRA for conflating mental illness with "evil," and criticizes the NRA for using the term "lunatic." I'm going to ding the APA for referring to my prison patients as "evil." I'm going to object to that, big time. The people I treat may have poor judgement, may have substance abuse problems, may have done awful things during desparate times, but I have met very few truly evil people even in prison. Demonizing and dehumanizing criminals is a very very bad idea. These people are part of our society, they will be coming back to our cities and neighborhoods some day, and it does nobody any good to say that my correctional patients are evil people. Please.


Liz said...

Thanks for a great post!

Anonymous said...

I totally agree with Liz about this post being great.

What is ironic about the NRA is they are doing exactly what they don't want being done to gun owners which is to demonize a group of people who are easy pickings in their minds.

And even though they keep talking about their rights in the name of the 2nd amendment, they don't seem to mind if people with an MI label lost their rights simply because they "might" commit violence.
In their minds, folks with an MI label are guilty until proven innocent.


ILuvCats said...

I always assumed that people advocating for those with mental illness were mismatching statistics on purpose - mixing numbers for serious mental problems with those who have minor problems without saying so. 4 to 5% sounds a lot like those with SERIOUS mental illness, 25% in a year sounds like it's including people with snake phobias. If people with serious mental illness committed violent acts at about the same rate as others, that would yield the numbers stated. If those with snake phobias, general anxiety problems, and mild depression etc committed violent acts at the same rate as those without mental problems, then about 25% of crimes would be committed by those with a mental illness.

I see this when groups like NAMI state that some huge percentage of people don't get treatment for mental illness and we need better coverage for it In this case referring to ALL people with mental illness of any sort), and then they talk about people with schizophrenia and bipolar, and finally they state that 25% have a mental illness, and it's very misleading all jumbled together in the same paragraph, with serious mental illnesses sandwiched in there between stats for people with mild and moderate problems.

I hope that made sense.

Joel Hassman, MD said...

What needs to be clarified, at least from my perspective, is that Antisocial personality disorder and substance abuse are not in the sole domain of psychiatry, and in my opinion should NOT be part of the DSM. Guilty by association is not whnt I want in my practice experiences. Also, I have real issue with this 25% figure being used so liberally. It only validates the agenda of DSM 5.

jesse said...

We are all saying much of the same thing, but in different ways. The NRA purposefully misuses information on mental illness because it diverts attention from the real problem, which is the vast supply of powerful weapons in our society. If you say "It's not the guns, it's those lunatics!" you can divert attention pretty well. But it's the guns, stupid!

But I do think there is such a thing as evil. We can discuss it in terms of enjoyment of cruelty, sadistic impulses out of control, or whatever, but the bottom line is that there are people who get some form of enjoyment from hurting others, and there are people to whom killing and torturing mean very little because they have little conscience.

I am not talking about most criminals and certainly not the great majority of those who are mentally ill. But how do we explain the ability of people like Hitler to carry out the most horrendous acts, or those who dehumanize other groups and so lay the groundwork for their rape and killing?

The concept of evil speaks to our ability to differentiate right from wrong and to act accordingly. It speaks to a conscience.

jesse said...

Oh oh, breaking news from the New York Times:

"The gunman was identified as William Spengler, 62, who lived at 191 Lake Road, where the fire began, and had served about 18 years in prison for killing his grandmother, the police chief said. Officials said he was imprisoned until 1998, and had remained on supervised parole until 2006.

"Mr. Spengler’s motives were unclear, though Chief Pickering said 'there were certainly mental health issues involved.'"

Zoe Brain said...

I'm wondering how big a role religion plays in either helping, or exacerbating, violent mental illness.

I find this post deeply troubling, in fact I find the whole "spiritual warfare" site deeply troubling.


First time posting.

I am a child of God. I was in the world for some time in the past and came back to Christ a couple of years ago. I need help in dealing with stubborn enemies - stuff moving around in my body (pins/snakes/scopions/birds/etc.). They seem lodged in belly/arms/feet/loins/back/breasts. I can physically feel them moving inside my body esp when I pray. I fast and pray, and I am able to get deliverance, but only for them to return later. It seems like back and forth.

I have been for deliverance and relief lasts only for a moment. The Lord has been good in showing me where the attacks come from - which seems to be everwhere (skies/waters/trees/mountains) and all sorts of people - I am able to identify some but they are never alone they are always in what seems like multitudes.

Maybe there is someone out there who may help me understand what is going on or what I am not doing right.

Many thanks for your replies.

I wish I could help. I'm not cut out to be a therapist, I couldn't retain enough detachment when I see a crie de coeur like that, and know they'll get "help" from charlatans not the neurotransmitter-balancers they need.

Clinkshrink, how do you manage it? You must see so much tragedy, for both perps and victims. "I made some bad choices" is often literally true.

jesse said...

Yes, the poster is in South Africa and would do well to seek out an experienced psychiatrist for a consultation. There are no replies to her post and it is possible she received a PM suggesting she do just that.

It is often very difficult to distinguish psychosis from strong religious conviction, but there is a difference. There are frequently in people who are not mentally ill convictions which are virtually unshakeable. Religious ideas are in a shared belief system and we differentiate those from idiosyncratic ones.

The economist Paul Krugman wrote yesterday a piece in the New York Times where he pointed out that economic ideas are thought of in such a way: Regardless of how the economy goes the "true believers" will shift their rationalizations to maintain that their beliefs are justified by events.

So now we will see emphasis by the gun lobby that mental illness is the singular problem in recent violence. Anything to divert attention away from the swamp of weapons we're sinking in.

Skizzy said...

I always supported the NRA but as a schizophrenic, I can't help but be offended by their stigmatizing choice of words. But they are just vocalizing what the rest of the world really thinks. I am an avid gun enthusiast but couldn't harm a fly. I don't like that they have a platform to protect the second amendment rights of everyone but me. I am now considered an animals because they want me in a national registry stripping me of my rights to privacy. This is what the average American thinks of us. We are less than human and should be euthanized if you read some of the horrible commentary on various news sites. Mental illness is not synonymous with violence.

roblindeman said...

First they came for the mentally ill, but I wasn't mentally ill, so I said nothing...

shruti said...

Great post!

Sunny CA said...

Great post! This belongs in the NY Times to be read by a wide audience.

ClinkShrink said...

Thank you all for your kind feedback about my post. I'm sorry I can't respond individually to each comment or commenter, so I'm just hitting a couple highlights.

Dr. Hassman objects to having ASPD and substance abuse as part of the DSM. I'm not sure why ASPD would be isolated from the other personality disorders, unless you're proposing also to eliminate schizoid, schizotypal, dependent personality disorders, etc? If the purpose of a diagnosis is, in part, to clarify the condition being treated why would these be excluded?

As for Jesse's comment about psychopathy, lack of remorse and the existance of evil: Yes, evil exists and I've met a few psychopaths. True hardcore psychopaths are few and far between even in forensic work, at least in my experience. And while there are evil and bad behaviors, I'm reluctant to attach that label to a person. I see the term used a little too liberally and there's a lot of consequence to it.

Zoe's comment is a two-parter: first, the role of religion in the course of mental illness and secondly the question: "Clink, how do you manage it? (seeing tragedy)"

I'm not a sociologist so I can't speak for the role of religion in society, but for mentally ill individuals religion can play a protective effect on mortality rates, at least as far as suicide risk is concerned. Religious affiliation is also a social support system for some people which is good. While preoccupation with religion, or religious delusions, can be a sign of mental illness it has no prognostic significance as far as predicting response to treatment or the course of the illness. It's a non-factor.

As far as how I manage, I get by with a little help from my friends :)

Anonymous said...

Since the story of the 2nd victim being pushed tragically to his death on the NY subway tracks by someone allegedly with mental illness has come out, all the "lock the mentally ill up" folks are coming out of the woodwork.

A big fat sigh!


Anonymous said...


Either you or one of your colleagues needs to talk to Dr. Paul Steinberg, who apparently hasn't gotten the word that people with mental illness are no more violent than the rest of the population. He seems to want to do away with those "pesky" civil liberties.

Yeah, that will encourage people to see help who need it.

Anonymous said...

I have recently finished a project on Violence Risk Assessment and my findings so far support your theory that there actually are very few evil among us in our society and that labeling a person with a prison history can pose serious problems for later rehabilitation processes.