To the Editor: The study by Dr Fazel and colleagues1 linked treatment for schizophrenia, conviction for violent offenses, and a history of substance misuse. The authors found that 27.6% of a sample of patients with schizophrenia and a coexisting substance use disorder committed a violent offense, compared with 8.5% of a control group of patients with schizophrenia without a substance use disorder and 5.1% of a general population control group. They concluded that schizophrenia alone has a modest association with violent offending on the basis of the small difference in the rate of conviction for violent offenses between the population control group and the non–substance-using schizophrenia group.
We are concerned that methods used in this study have 2 important limitations that might have led to a significant underestimation of the risk of violent crimes committed by people with schizophrenia. First, the population control group included people with substance use disorders. Given an association between substance use and violent crime,2 it is probable that a population control group including people with substance use disorders would have a substantially higher rate of violent offenses than a non–substance-using group. Therefore, the comparison between this group and the non–substance-using schizophrenia group would underestimate the difference in the rates of violent crime.
Second, the study excluded patients with schizophrenia who committed a violent offense during their first episode of psychotic illness and were treated for the first time in prison. In a meta-analysis, we estimated that 38.5% of homicides during psychotic illness were committed by patients who had not received prior treatment.3 It is therefore likely that this exclusion led to a significant underestimate of rates of violent crime in both substance-using and non–substance-using schizophrenia groups.
Fazel et al1 concluded that their findings should reduce stigma about the relation between schizophrenia and violence. We are concerned that a diminution of their important findings by underestimation of the true violence risk in schizophrenia might actually increase stigma by drawing attention away from the need to develop policies to prevent and treat schizophrenia, particularly combined with substance misuse.
Financial Disclosures: Dr Smith reported receiving a special training fellowship from the New South Wales Institute of Psychiatry. Dr Large reported receiving a grant in aid of research from Janssen-Cilag. Dr Nielssen reported receiving a grant in aid of research from Janssen-Cilag; participating in advisory boards for Sanofi and Hospira; and receiving speaker's fees from Janssen-Cilag, Lilly, Bristol Myers Squibb, and AstraZeneca.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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