Violence against adults with severe mental illness compared with the UK general population

Lead Research Organisation: University College London
Department Name: Division of Psychiatry

Abstract

Past research on violence and mental illness focussed on crimes committed by psychiatric patients. However, recent evidence suggests that, compared with the general population, people with severe mental illness (such as schizophrenia or bipolar disorder) are significantly more likely to be victims of violence than to carry out violent acts. This can lead to physical ill health, a worsening of their pre-existing mental illness, and poorer quality of life. In order to protect them, we need to understand why they are vulnerable to abuse, and what helps them avoid repeated violence.

There are no detailed UK studies on violence against people with mental illness, so it difficult to develop effective interventions. I plan to study the extent, nature and causes of being a victim of violence in this group. I will interview patients under the care of mental health services in North London using the Home Office British Crime Survey questionnaire, and compare my findings to the general population. I will also carry out in-depth interviews with some patients who experienced repeated violence to explore their coping strategies. This will increase our scientific understanding of violence against people with mental illness, with the aim of helping them to avoid abuse.

Technical Summary

Aims To investigate the extent, correlates and impact of violence against adults with severe mental illness (SMI), and to compare findings with the UK general population

Objectives
To determine the prevalence of interpersonal violence against adults with SMI
To test the hypothesis that victimisation prevalence is higher in SMI patients compared with the general population, after controlling for gender, age and residential area
To identify demographic, socio-economic and behavioural factors associated with victimisation, and to test the hypothesis that SMI modifies the effect of significant correlates including substance misuse and social deprivation
To test the hypothesis that service contact and associated cost are greater in victimised SMI patients compared with non-victimised SMI patients
To qualitatively explore the strategies used by SMI patients to cope with repeated violence

Design
A cross-sectional survey of violence against SMI patients using the British Crime Survey (BCS) questionnaire (the same instrument used by the Home Office in its annual survey of violence against the general population of England and Wales).
A qualitative study of the experiences of SMI patients in coping with repeated victimisation.

Methodology
Setting and participants
The patient study population will be a random sample of adults with schizophrenia or bipolar disorder who are under the care of mental health services in one of five North London boroughs. The general population comparison sample will be drawn from the Home Office BCS database.

Measurements
The BCS questionnaire will be used to measure the following dimensions of self-reported experiences of victimisation: frequency, nature, correlates, physical and psychological impact, and contacts with health services or police. Additional measures (instrument) used among SMI patients will include diagnosis (OPCRIT), symptoms severity (BPRS), disability (DASII), social support (MOS-SSS), childhood abuse (CTQ) and service contacts (CSRI).

Qualitative study
I will conduct semi-structured interviews with a purposive sample of patients who experienced repeated violence, and compare the coping strategies of patients where the abuse was on-going with those where the abuse had stopped, using thematic analysis to extract relevant themes.


Scientific and medical opportunities
A recent government initiative to tackle the impact of violence is currently being piloted in the health sector, but has limitations among people with SMI because the extent, correlates and impact of abuse in this population are not known. The proposed study will directly address these unknowns and provide essential, timely information for prevention policy in this vulnerable group.

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Publications

10 25 50

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Khalifeh H (2015) Recent intimate partner violence among people with chronic mental illness: findings from a national cross-sectional survey. in The British journal of psychiatry : the journal of mental science

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Khalifeh H (2015) Violent and non-violent crime against adults with severe mental illness. in The British journal of psychiatry : the journal of mental science

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Khalifeh H (2009) Violence against people with severe mental illness in Europe. in Acta psychiatrica Scandinavica

 
Description Advisory Group (including legal and Ministry of Justice reps)
Geographic Reach National 
Policy Influence Type Participation in advisory committee
 
Description Change in barrister training for vulnerable witnesses
Geographic Reach National 
Policy Influence Type Influenced training of practitioners or researchers
 
Description Co-author of CMO report chapter on violence and mental health
Geographic Reach National 
Policy Influence Type Citation in other policy documents
URL https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/351629/Annual_report_2013_...
 
Description Local mental health trust policy on sexual and domestic violence
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Influenced training of practitioners or researchers
 
Description Victim Support training workshop (for health professionals / voluntary sector practitioners)
Geographic Reach National 
Policy Influence Type Influenced training of practitioners or researchers
 
Description MRC-Academy of Medical Sciences Policy Internship
Amount £10,021 (GBP)
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 04/2013 
End 06/2013
 
Title Crime against people with SMI 
Description Data on past-year violent and non-violent crime against patients with SMI (N=361 patients) 
Type Of Material Database/Collection of data 
Year Produced 2014 
Provided To Others? Yes  
Impact Data from this survey were used in the outputs / activities reported under the relevant sections. The data has been shared with MSc and other students at the IOP, who are preparing manuscripts for publication. 
 
Description Collaboration with MIND 
Organisation MIND (Mental Health Charity)
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution We worked collaboratively with MIND to develop the study methods (on crime against people with severe mental illness) and disseminate research findings.
Collaborator Contribution MIND were on the Study Advisory Group. They helped to recruit patients for the qualitative study, advised on the use of study findings for guiding health and criminal justice policy, and contributed to disseminating the findings.
Impact As per entry under Victim Support and IOP collaboration
Start Year 2010
 
Description Collaboration with the IOP and Victim Support 
Organisation Victim Support
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution In a research collaboration between Victim Support, the Institute of Psychiatry (IOP) and UCL, we conducted the first UK study on victimisation among people with severe mental illness (SMI) compared with the general population. This comprised a survey (conducted by UCL and the IOP) and a qualitative study (conducted by Victim Support). I developed a joint study protocol with IOP colleagues. I was principal investigator at the North London site, where I led patient recruitment. I led data management, data analysis and preparation of manuscripts for publication.
Collaborator Contribution The IOP Team led overall project management and patient recruitment at the South London site; and contributed to preparation of manuscripts for publication. Victim Support carried out the qualitative study. They were instrumental in disseminating research findings and developing policy recommendations and training materials on the basis of these findings.
Impact (1) Publications: Journal articles (Khalifeh H et al in press, Khalifeh et al 2014, Khalifeh et al 2013); policy reports (Howard et al 2014); Victim Support report (Pettit et al 2013) (2) Presentations: BMA House, APPG on Victims and witnesses, national and international academic conferences (3) Training: courses and video (4) Public engagement / Other: national and international media, radio interviews, magazine articles, non-academic conferences (e.g. Feminism in London)
Start Year 2011
 
Description All Party Parliamentary Group for Victims and Witnesses of Crime 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Around 50 people attended this APGG session chaired by the Chief Executive of Victim Support, Director of Public Prosecution (Keir Stramer) and Deputy Director of Ministry of Justice (Isable Sutcliffe)- where the key findings of our research project were presented. Attendees included MPs, policy makers, health and voluntary sector workers and crime victims.

The APPG discussion contributed to the implementation of specialist barrister training on vulnerable witnesses.
Year(s) Of Engagement Activity 2013
 
Description Lancet Psychiatry/Mental Elf public debate on 'Preventable Harm' 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact I was invited to be an expert pannelit on a Lancet Psychiatry/Mental Elf public debate on 'Preventable Harm', which sought to explore the question: 'Can mental health services use new research into risks of self-harm, harm to others and violence from others to make better decisions? This event was attended by around 150 mental health service users, carers, students and professionals. It reached a wider audience via a live weblink, and sparked ongoing online debate and interest.
Year(s) Of Engagement Activity 2016
URL http://events.ucl.ac.uk/event/event:bf-iqi2vpg3-575ru7
 
Description Podcast on Women's Mental Health for the Lancet Psychiatry 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact I was interviewed by the Lancet Psychiatry editor for a podcast on 'Women's Mental Health' linked to our review article 'Violence against women and mental health' and related articles in a series on 'Women's Mental Health' in the Lancet Psychiatry Nov/16 issue. The podcast was promoted on the Journal's website and via social media
Year(s) Of Engagement Activity 2016
URL http://www.thelancet.com/series/women-mental-health
 
Description Presentation at 'Feminism in London' conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact I was part of a panel discussing 'Mothers and lovers: How societal expectations influence women's risk for mental health' at the Feminism in London Conference. The talk led to questions and debate.

The seminar and its implications for women's rights / activism was discussed in social media (e.g. Tomorrow's Girls)
Year(s) Of Engagement Activity 2014
URL http://static.feminisminlondon.co.uk/index.php/fil-2014/workshops-and-panels-2014/index.html
 
Description Presentations: RCPsych GA Faculty (London); ENMESH (Italy) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Talks led to questions and discussion, and further invitations to present at international conferences (e.g. EUPHA meeting in Glasgow)

As the RCPsych GA Faculty talk won the 'oral presentation prize for trainees and new consultants' a summary will be included in the Faculty's newsletter, which will reach psychiatrists nationally.
Year(s) Of Engagement Activity 2014
URL http://www.rcpsych.ac.uk/workinpsychiatry/faculties/generaladultpsychiatry/aboutthefaculty/prizesand...
 
Description Press release; radio and magazine interviews; media intereset; planned shadow minister meeting 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact The press release on the article by Khalifeh et al (2014, Psychological Medicine) on domestic and sexual violence against people with severe mental illness was published on the websites of UCL, KCL and the MRC. It drew international media coverage.

The 'Altmetrics' provided by Psychological Medicine indicated that the article was picked up by 11 news outlets and tweets from 66 accounts (with an upper bound of 166,400 combined followers). Following publication I gave live radio interviews (on LBC and BBC Radio London) and interviews for magazine articles (e.g. Reuters Health, Police Professional). Professor Howard and I have been invited to meet the Shadow Minister for the Prevention of Violence Against Women and Girls, Seema Malhotra, to discuss implications of study findings for government policy.
Year(s) Of Engagement Activity 2014
URL http://www.altmetric.com/details.php?domain=journals.cambridge.org&citation_id=2650353
 
Description Study findings launched at BMA House; media interest 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact The meeting led to debate and coverage in national media.

We were invited to present findings at an All Party Parliamentary Group
Year(s) Of Engagement Activity 2013
 
Description Victim Support training (for health, criminal justice and voluntary sectors) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? Yes
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Victim support ran separate training workshops for their own staff, mental health professionals, police officers and Crown Prosecution Service practitioners.

Participants expressed limited prior training and improved knowledge and skills following the workshops.
Year(s) Of Engagement Activity 2012