Despite Atlantic City attack, schizophrenia needn't lead to violence

People with schizophrenia, the mental illness that afflicted a woman who allegedly killed two Canadian tourists in Atlantic City on Monday, are generally not violent, experts say, but the risk that they will be rises when they stop taking medications and start taking illicit drugs. A history of violent behavior and exposure to violence as a child are also red flags.

It is difficult to get people with any chronic mental illness to take their medicines properly, psychiatrists pointed out, but it can be especially challenging with people whose brains are so dysfunctional that they may not realize they are sick. Such people need a lot of support, and psychiatrists are worried that planned state budget cuts may put more people at risk.

Kenneth Certa, a psychiatrist at Thomas Jefferson University and Hospital, said restrictions in Medicaid's drug formulary were already reducing medication choices. It's also harder to get subway tokens that help poverty-stricken patients go to doctors' appointments.

Treatment experts and mental-health advocates have long debated how far to go in forcing people to accept treatment. Current laws allow patients to be held and treated only when they are deemed a threat to themselves or others.

The most disabling of the psychiatric illnesses, schizophrenia, affects about 1 percent of the population, according to the National Institute of Mental Health. Its hallmark symptoms — hallucinations and delusions — often emerge in late adolescence or young adulthood.

People with schizophrenia also have disordered thinking and trouble with decision-making. Emotional symptoms, such as a lack of interest in everyday activities and withdrawing from other people, can easily be misinterpreted as depression.

Research has shown that people with schizophrenia are more likely than those without mental illness to commit crimes, although area psychiatrists noted that it's difficult to say how much more likely.

Certa said a Swedish study found that schizophrenics were 3 to 4 times more likely than the general population to commit violent crimes, but only 1.5 to 2 times more likely if substance abuse was removed from the equation. He guessed that the difference would be less in the United States because violent crime is more common here.

William R. Dubin, chair of the department of psychiatry at Temple University School of Medicine, said a University of Virginia study found that, in the absence of substance abuse, people with schizophrenia were less violent than those with depression or bipolar disorder.

Raquel Gur, a psychiatry professor at the University of Pennsylvania's Perelman School of Medicine, said only a minority of people with schizophrenia have a propensity to violence. Often, it occurs when hallucinations or delusions make them perceive others as a threat, symptoms that are much more likely to occur in patients who aren't taking their medication. Substance abuse magnifies the risk, she said. A history of being arrested for other crimes, Gur said, is a "red light.".

Most people with schizophrenia are the opposite of aggressive, Gur said. "Most of them are afraid of people," she said. "They don't like to go out."

Matthew Hurford, Philadelphia's chief medical officer for community behavioral health, said people with schizophrenia were much more likely to be the victims of assault than the perpetrators.

With treatment, the psychiatrists said, people with schizophrenia can keep their symptoms under control.

"There are people that are living with schizophrenia that are in happy relationships, that are parents, that are working, that go to our churches and our synagogues and are very active participants in our community," Hurford said. "It's important to remember that recovery from schizophrenia is possible."

The drugs have side effects: weight gain, drowsiness, tremors.

"People don't like that," Gur said.

Both Gur and Dubin said appropriate housing for people with serious mental illnesses is a problem.

"Being in a shelter is not a solution," Gur said.

Dubin said the mental health crisis service at Temple health system's Episcopal Campus sees about a thousand patients a month.  He guesses that 700 are there because they take illicit drugs on top of a mental illness. They get better in the hospital and swear they'll stop the drugs.

"As soon as they leave and go back to the unstructured sometimes chaos of their neighborhood, they don't have a chance," he said.

He would like to see communities for the mentally ill modeled after facilities for the elderly that provide varying degrees of independence.

"There is no money for that," he said.