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Am J Psychiatry 155:2, February 1998 SWARTZ, SWANSON, HIDAY, ETAL.VIOLENCEAND SEVERE MENTAL ILLNESS

Violence and Severe Mental Illness:The Effects of Substance Abuse and Nonadherence to Medication

Marvin S. Swartz, M.D., Jeffrey W. Swanson, Ph.D., Virginia A. Hiday, Ph.D.,Randy Borum, Psy.D., H. Ryan Wagner, Ph.D., and Barbara J. Burns, Ph.D.

O bjective: Violent behavior among ind ivi duals wi th severe mental il lness has become an

impor tant focus in communi ty-based care. Thi s study examines the joi nt effect of substance

abuse and medication noncompli ance on t he greater r isk of seri ous viol ence among persons

w ith severe mental ill ness. M ethod: I nvoluntari ly admitt ed i npatients wit h severe mental ill ness

who were awaiting a peri od of out patient commitment were enrol led in a longitud inal outcome

study. A t baseli ne, 331 subjects underw ent an ext ensive face-to -face int erv iew. Complemen-

tary data were gathered by a review of hospital records and a telephone int ervi ew w ith a fami ly

member or ot her informant . These data included subjects’ sociodemographi c characteristics,

il lness history, cli ni cal status, medication adherence, substance abuse, insight i nto i ll ness, and viol ent behavior dur ing t he 4 months that p receded hospitalization. Associations betw een

seri ous viol ent acts and a range of ind ivi dual characteri sti cs and probl ems were analyzed by

using mult ivari able logisti c regression. Result s: T he combi nation of medication noncompli-

ance and alcoho l or substance abuse probl ems was signi fi cant ly associated w ith seri ous vio lent

acts in the communi ty, aft er sociodemographi c and clini cal characteristi cs were cont ro ll ed.

Conclusions: A lcohol o r other dr ug abuse prob lems combined w ith poor adherence to medi-

cation may signal a higher r isk of vio lent behavior among persons wi th severe mental i ll ness.

Reduction of such risk may requir e carefully targeted communit y int erventions, including

int egrated mental health and substance abuse tr eatment .

(Am J Psychiatry 1998; 155:226–231)

V iolence committed by individuals with severe men-tal illness living in the community has become an

increasing focus of concern among clinicians, policymakers, and the general public—often as the result oftra gic, a lbeit uncommon events (1–3). In the current eraof cost conta inment, in w hich the use of hospitalizatio nis increasingly limited, there is a renewed priorit y ondeveloping strategies for managing violence risk in thecommunity. Such stra tegies may include form alized riskassessment procedures (4), closer monitoring of outpa-tient treatment, greater attention to substance abuse co-morbidity, and efforts to improve treatment retentionand compliance through intensive case management

(5). Legal interventions such as court-mandated, com-

munity-based treatment or involunta ry outpa tient com-mitment are also being cited as promising methods ofimproving treatment adherence (6–9) and thereby re-ducing violence (1, 10).

As risk management strategies per se, a number ofthese approaches are being advocated on the strengthof general clinical assumptions about what may causementally ill individuals to commit violent acts, but theylack the benefit of a solid research base that demon-strates the specific and interacting effects of major riskfactors for violent behavior as they actually operate inthe severely mentally ill population. Such effects areshaped not only by the features of major psychiatric

disord er but by the social environments in w hich peoplew ith severe mental illness oft en live. The present a rticleta kes a step tow ard providing a b etter empirical under-standing o f violent behavior in individuals w ith severemental illness by specifying the magnitude of violencerisk represented by tw o key problems—substance abuseand medication noncompliance—and show ing how theserisk factors operate together in a group of 331 recentlyhospitalized severely mentally ill individuals.

A number of studies have linked medication noncom-pliance to decompensation and hospital readmission.

Received March 11, 1997; revision received May 27, 1997; ac-cepted Aug. 29, 1997. From the Services Effectiveness ResearchProgram, Department of Psychiatry and Behavioral Sciences, DukeUniversity Medical Center, and the D epartment of Sociology a nd An-thropology, N orth Ca rolina State University, Ra leigh. Address reprintrequests to Dr. Swartz, Box 3173, Duke University Medical Center,Durham, NC 27710. Supported by NIMH grant M H-48103 and by the University ofNo rth C aro lina-Cha pel H ill/D uke Pro gram o n Services Research forPeople with Severe Mental D isorders (NIMH grant M H-51410).

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Substance abuse comorbidity has also been associatedwith generally poor clinical outcomes among severelymentally ill individuals in the community (11–19). H ay-w ood and co-wo rkers (14) found high rates of a lcohol orother drug abuse and medication noncompliance amonga subgroup of state mental hospital patients who exhib-ited a pattern of multiple readmissions. O ther studies of

severely mentally ill individuals in the community haveshown that substance abuse comorbidity is associatedw ith medication and aft ercare noncompliance (19, 20) asw ell a s w ith violent behavior (21–25).

A new analysis by Swanson and colleagues (26) suggeststhat substance abuse, psychotic symptoms, and lack ofcontact w ith specialty mental health services in the com-munity all are associated with greater risk of adult-lifetimeviolence among persons with severe mental illness. In astate fo rensic hospital population, Smith (27) found a sig-nificant relationship betw een medication noncomplianceand violent acts in the community. Similarly, Bartels andcolleagues (28) reported a relat ionship among noncom-pliance, hostility, and violence in a group of 133 outpa-

tients with schizophrenia. C onsistent w ith the findings ofBartels and colleagues, a new a nalysis from the same studypresented here show s that both violent behavior a nd thecombination of substance use with medication noncom-pliance are significant statistical predictors of police en-counters for people with severe mental illness (29).

Taken together, these findings suggest that medicationnoncompliance may exert an effect on violence by meansof a preexisting or concomitant relationship w ith alcoholor other drug abuse. Both of these variables—substanceabuse and medication nonadherence—may combine toincrease the risk of violence, o r perhaps a t hird var iable,such as poor insight into illness (30–34), may lead bothto substa nce abuse and noncompliance and thus increase

the risk of violence and institutional recidivism.Lack of awareness of illness and need for treatment—termed poor insight into illness—has been associatedwith noncompliance, illness relapse, and recidivism (33–35), b ut systematic research has no t linked poor insightw ith violence per se. For that matt er, limited empiricalevidence to date has implicated noncompliance as a di-rect risk factor for violent acts among severely mentallyill individuals or has d ocumented its potential interactionwith substance abuse while holding constant demo-graphic a nd social-contextual variab les (10, 11).

Identifying the relative and combined impact of spe-cific risk factors is a necessary f irst step in designing moreeffective wa ys to prevent the violent a nd threatening be-

havior that often attends relapse and hospital recidivismin this population. Hence, the current study seeks to ex-amine the effects of selected predictors of recent commu-nity violence in a multivariable ana lysis of 331 hospital-ized individuals with severe mental illness.

METHOD

Da ta for this article are drawn from a randomized clinical trial (8)that examined the effectiveness of involuntary outpatient commit-

ment and case management in reducing noncompliance with psychi-atric treatment and preventing relapse, rehospitalization, reducedfunctioning, and other poor outcomes among people with severemental illness. Because the present art icle will include only the base-line data of t he 331 severely mentally ill subjects from t he longitudinalstudy, the random assignment of subjects after their baseline inter-view will not be an issue here; hence, all the baseline data will beanalyzed as one study group.

Involunta rily admitt ed patients were recruited from the admissions

unit of a regional state psychiatric hospital and three other inpatientfacilities that serve the catchment area in which the participating areamental health programs are located. Because involuntary admissionis used extensively in public-sector psychiatric institutions in NorthCa rolina (accounting for a bout 90% of a dmissions to the state mentalhospitals), patients admitted to inpatient treatment under this statusare quite representative of the population of persons with severe andpersistent mental disorders—particularly the subgroup of repeatedlyadmitted (“ revolving door” ) patients in the public mental health sys-tem. Eligible patients were approached for informed consent to par-ticipate and included individuals with a primary diagnosis of a severeand persistent psychiatric disorder who were awaiting a period ofcourt-ordered outpatient commitment. Of 374 identified eligible pa-tients, about 11.5% (N= 43) refused.

An extensive face-to-face interview was conducted with each re-spondent and by telephone with a designated family member or other

informant w ho knew the respondent well. Interviews covered a w ide

variety of personal historical information, sociodemographic andclinical characteristics, and specific information about violent behav-ior and its surrounding context. In ad dition, a systematic review ofthe hospital record was conducted, including clinical assessments,

treatment progress notes, and the legal section of the chart in whichinvoluntary commitment petitions and criminal charges were noted.

In the direct interviews, subjects were asked specifically whetherthey had gotten into trouble with the law or had been arrested forphysical or sexual assault. Each respondent was also asked specifi-cally about getting into physical fights in the past 4 months in whichsomeone wa s “ hit, slapped, kicked, grabbed, shoved, bitten, hurtw ith a knife or gun, or had something thrown at t hem.” Subjects werealso asked a series of questions about engaging in threatening behav-ior, defined as “ saying or doing anything that ma kes a person afraidof being harmed by you—like saying you are going to hit them, de-manding money, raising a fist, pointing a weapon, trying to pick afight, following or chasing or stalking someone, or anything like

that.” Family members or other collateral informants were askedsimilar questions about the subject’s behavior.

For the present study, w e used combined dat a fro m subjects, familymembers, and hospital records to adopt a severity threshold for seri-ous violent events that included any assaultive act in which the re-spondent used a weapon against another person or made a threatw ith a w eapon or that resulted in an injury to another person. Thisoperat ional definition of serious violent behavior corresponds to level1 violence as measured specifically in the MacArthur Research Net-w ork on M ental Health and the Law (36). A more detailed examina-tion of the prevalence and characteristics of violent events in thisstudy group is in preparation (unpublished 1997 study of J.W. Swan-son et al.).

Medication noncompliance was measured by the subject’s self-re-port or the report of a fa mily member or collateral informant. Inform-ants were asked 1) whether there had been prescription medicationsor shots (for mental or emotional health problems) that the subject

w as supposed to t ake but did not, o r 2) whether the subject had neveror almost never taken the shots or oral medications as prescribed.Insight into illness wa s assessed w ith the Insight and Treatment Atti-tudes Questionna ire (34), a n 11-item scale that measures recognitionof menta l illness and the need fo r treatment. L ow scores on the Insightand Treatment Attitudes Questionnaire have been shown to be pre-dictive of poor treatment compliance and higher rates of hospitalreadmission (35).

Overa ll, 17.8% of the study group (N= 59) had engaged in seriousviolent acts that involved weapons or caused injury. Characteristicsof the subjects are presented in table 1. Respondents in the groupw ere predominantly ma le, yo unger, o f low er educational level, a nd

neither married nor cohabiting. The racial distribution of the cohort

SWARTZ, SWANSON, HIDAY, ET AL.

Am J Psychiatry 155:2, February 1998 227

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was about two-thirds African American and one-third white. Thisracial an d sociodemo gra phic composition is quite representativeof the severely mentally ill population in these public hospitals and

closely matches the sociodemographic composition of study sub-jects screened fo r the study. While a m ajority o f respondents w ere

city residents, a substantial proportion lived in rural areas and smalltowns.

The study group was made up predominantly of persons withpsychotic disorders (schizophrenia, schizoaffective disorder, or otherpsychotic disorders). An additiona l 26.9% (N= 89) had d ischargediagnoses of bipolar disorder, and only a small minority—5.1%(N= 17)—w ere diagnosed wit h major depression. While the currentanalysis used discharge diagnoses that incorporated chart review

data, approximately one-third of thegroup were administered the Struc-tured Clinical Interview for DSM-III-R(SCID) (37). These interviews showeda very high level of agreement withchart review diagnoses, which used allsources of available data; hence, theSCID assessments were discontinued.

The study interview elicited extensive

data on lifetime and recent use of alcoholand illicit substances, including seda-tives, cocaine, cannabis, stimulants,opioids, hallucinogens, inhalants, andother substances. It was found that33.8% of the subjects (N= 112) had usedat least one type of illicit substance,53.2% (N= 176) had used a lcohol, and58.9% (N= 195) had used either (orboth) at least once a mo nth during the 4months before hospitalization. Theserates reflect data combined from threesources: respondent’s self-report, inter-view with family members or collateralinformants, and hospital record review.In addition, 57.4% (N=112) of the users(33.8% of the total cohort) had “ prob-

lems” related to alcohol or substanceabuse according to one o r more sources(e.g., problems with family, friends, job,or police or physical health problemsdue to drinking) or had a co-occurringdiagnosis of substance use disorder atdischarge. Since research suggests thatuse of a lcohol or illicit drugs below a di-agnostic abuse threshold by personswith major psychiatric disorders canlead to trouble and complicates treat-ment (16, 38), the present study uses co-occurring alcohol or drug use problemsin the previous 4 months as the key se-verity threshold.

RESULTS

Table 1 shows selected char-acteristics of study subjects andthe percent in each categoryw ho committed serious violentacts in the 4 months before ad-mission. In all subsequent analy-ses, any serious violent act (i.e.,assault or threat with a w eaponor causing injury to anotherperson) was used as the depen-dent variable. While most of

these sample characteristics showed no significantbivariate relationship to violence, it can be seen thatserious violent acts were more likely to be committedby subjects w ho w ere male, African American, or vic-tims of crime in the previous 4 months and by thosewith co-occurring substance abuse problems. We usedFisher’s exact test, an appropriate alternative statistic,to demonstrate significance for adjusted chi-square va l-ues that were close to significance. Victimization wasused in t his and subsequent a nalyses as a prox y contex-tual measure of exposure to crime and violence in the

TABLE 1 . Characteristics of 33 1 Involuntarily Admitted I npatients With Severe Mental I llness andRelation to Prevalence of Serious Violence in the 4 Months Before Admission

CommittedViolent Actin Previous Analysisa

4 MonthsAdjusted

Characteristic N % N % χ2 df p

Age (years) 2.89 2 n.s.18–29 60 18.13 15 25.0030–44 168 50.76 29 17.26≥45 103 31.12 15 14.56

Sexb 3.81 1 <0.06Female 153 46.22 20 13.07M ale 178 53.78 39 21.91

Educationc 1.53 2 n.s.Less than high school 114 34.44 23 20.18H igh school 186 56.19 33 17.74C ollege 29 8.76 3 10.34

M arita l status 0.84 1 n.s.M arried or cohabiting 67 20.24 15 22.39Not married or cohabiting 264 79.76 44 16.67

Place of residence 0.51 1 n.s.Rural 124 37.46 25 20.16Urban 207 62.54 34 16.43

Race 3.85 1 0.05White 112 33.84 13 11.61African American 219 66.16 46 21.00

Victimization historyb 4.34 1 <0.05C rime victim in past 4 months 90 27.19 23 25.56Not a crime victim 241 72.81 36 14.94

D ischarge diagnosis 0.41 2 n.s.Schizophrenia or schizoaffec-

tive disorder 198 59.82 35 17.68O ther psychotic disorder 27 8.16 6 22.22Affective disorder 106 32.02 18 16.98

Alcohol or drug problem 8.38 1 <0.01No 219 66.16 29 13.24Yes 112 33.84 30 26.79

Score for insight into illnessd 0.88 1 n.s.Low (below median) 164 49.55 33 20.12H igh (above median) 167 50.45 26 15.57

G lobal functioning scoree 0.01 1 n.s.Low (low est q uartile) 69 20.85 12 17.39O ther (upper quartiles) 262 79.15 47 17.94

M edication noncompliance 0.68 1 n.s.No 96 29.00 14 14.58Yes 235 71.00 45 19.15

aFor two-level categorical variables, Yates’s correction is used; for three-level variables, adjustedlikelihood chi-squar e is used.

bp= 0.04, Fisher’s exa ct test.cDa ta missing for tw o subjects.dScore on the Insight and Treatment Attitudes Questionna ire (34); median= 14.00 (mean= 13.10,SD= 5.74).

eScore on the Glo bal Assessment of Functioning Scale; median= 47.00 (mean= 48.82, SD= 7.94); low -est quartile=25–45.

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surrounding social environment (unpublished 1997study of Hiday et al.), since victimized subjects arelikely to feel more threat ened and ma y engage in violentacts at least partly in self-protection. Preliminary datasuggested tha t much of the bivariat e association o f raceand violence could be explained by higher rates ofcriminal victimizatio n in t he particular communities ofthese African American subjects.

Surprisingly, urba n residence in and of itself w as no t

associated w ith serious violent acts nor w as medicationnoncompliance or low insight into illness, as measuredby the Insight and Treatment Attitudes Questionnaire.Also surprising was the lack of relationship of seriousviolent a cts w ith the clinical characteristics of d iagnosisand score on the Globa l Assessment of Functioning Scale.

Since some bivariate a ssociat ions w ith violence w ereconfounded by relationships among predictors, w e nextconducted multivariable logistic regression analysesthat used demographic characteristics, diagnosis, vic-timization, alcohol or drug problems, insight into ill-ness, a nd medication noncompliance as predictor va ri-ables. The dependent variable in these models was,again, a dichotomous measure of any serious violent

acts in the previous 4 months, a s determined fro m a nyone of three sources of informa tion.Variables were entered into the regression equations in

three stages: 1) demographic variables (age, gender, edu-cation, ma rital status, urban residence, race, and victimi-zation); 2) clinical variables (diagnosis, insight into ill-ness, G loba l Assessment o f Functioning Scale score,medication noncompliance, and alcohol or drug prob-lems); a nd 3) terms that show ed the single and combinedeffects of noncompliance and substance abuse problemson violence. R esults are show n in ta ble 2.

In stage 1, the combinat ion of being African Americanand a crime victim w as the only predictor o f violence thatemerged as statistically significant. Race and victimiza-tion were coded together in the manner shown becauserace was not of interest as a n intrinsic individual risk fac-tor but rather as a social designation that may correlatewith environmental precipitants of violence. As shownby Hiday and colleagues (unpublished 1997 study) in re-lated a nalyses of these dat a, African Americans w ere no

more likely than w hites to commit violent acts unless theyalso reported recent victimization. Similarly, the currentana lysis show s that African American crime victims wereroughly twice as likely as African American nonvictimsto ha ve committed violent acts. Ra tes of violence amongthese African American nonvictims were not significantlyhigher than those of their white counterparts. This sug-gests tha t the apparent ra ce effect is largely explained bysocial-environmental strains.

In stage 2, d iagnosis, insight into illness, and noncom-pliance were not significant as main effects, while pa-tients with substance abuse problems were tw ice as likelyto have engaged in violent behavior. In stage 3, we fol-lowed the lead of prior studies, which, taken together,

suggested a complex linkage among noncompliance, sub-stance abuse, a ssaultiveness, a nd poor clinical outcomes.Specifically, we explored the potential for a combinedeffect of substance abuse and medication noncomplianceon the risk of serious violent acts by creating a new dummy variable for subjects with both substance abuseand noncompliance to compare to subjects without oneof these two attributes. It should be noted that thesedummy va riables are subcategories of subjects w ith theseco-occurring attributes and not interaction terms as areoften used in multivariable regression analyses.

TABLE 2. Logistic Regression Analysis of Predictors of Serious Violence by 331 Involuntarily Admitted Inpatients With Severe Mental Illness

Predictor

Stage 1(demographic

variables)a

Stage 2(stage 1 plus

clinical variables)b

Stage 3(stage 2 plus

noncompliance andsubstance problems)c

OddsRatio

95%Confidence

IntervalOddsRatio

95%Confidence

IntervalOddsRatio

95%Confidence

Interval

Age 0.74 0.48–1.16 0.75 0.48–1.19 0.81 0.51–1.28M ale 1.77 0.95–3.30 1.59 0.81–3.11 1.64 0.84–3.23Education 0.89 0.67–1.17 0.87 0.66–1.15 0.86 0.66–1.14M arried or cohabiting 1.84 0.90–3.75 1.72 0.83–3.59 1.79 0.85–3.76Urban versus rural 0.71 0.39–1.31 0.62 0.33–1.17 0.62 0.33–1.19African American and not crime victim 1.69 0.76–3.76 1.55 0.67–3.56 1.58 0.69–3.65Crime victim and not African American 1.04 0.26–4.20 0.99 0.24–4.10 0.99 0.24–4.13African American and crime victim 3.92** 1.63–9.42 3.87** 1.56–9.63 3.96** 1.59–9.86Schizophrenia 0.96 0.47–1.95 0.93 0.46–1.91O ther psychotic disorder 1.36 0.44–4.21 1.28 0.41–4.01Insight into illness 1.68 0.91–3.12 1.71 0.91–3.21Low globa l functioning score 0.63 0.29–1.35 0.63 0.29–1.35Noncompliant w ith medications 1.39 0.67–2.87Alcohol or drug problems 2.00* 1.03–3.86Compliant and has substance problems 0.24 0.03–2.10Noncompliant but no substance problems 0.77 0.33–1.79

Noncompliant and has substance problems 2.29* 1.01–5.21aOb served/predicted ratio = 0.69, χ2=20.92, df=8, p=0.007. cOb served/predicted rat io= 0.75, χ2=36.43, df=15, p=0.002.bO bserved/predicted rat io= 0.74, χ2= 29.47, df= 14, p= 0.009. *p<0.05. **p<0.01.



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These results suggest that the co-occurrence of sub-stance abuse with medication noncompliance may ex-plain much of the observed relationship of comorbid itywith violence among the severely mentally ill. Specifi-cally, it can be seen that those respondents with both noncompliance and substance abuse problems weremore than twice as likely to commit violent acts, while

those individuals with either of these problems alonehad no greater risk of violence. Thus, compliant, sub-stance-abusing, or non-substance-abusing and non-compliant severely mentally ill individua ls w ere nomore likely to commit violent acts tha n other individu-als in the study.

A final model (not shown here) examined the risk ofviolence among respondents w ho, in a ddition t o medi-cation nonadherence and substance abuse, also mani-fested low insight into illness, as measured by the In-sight and Treatment Attitudes Questionnaire score.This analysis also showed a high risk of violence in thegroup w ith all three of these risk factors, but the paucityof subjects in certain comparison groups (e.g., subjects

w ith noncompliance, substance abuse, and high insight)makes this model less reliable.

DISCUSSION

In this study we examined a number of risk factorsfor violent behavior in a study group of recently hospi-talized severely mentally ill individuals. In a multivari-able model, the combination of substance abuse prob-lems and medication noncompliance was found to besignificantly associated with serious violent behaviorthat occurred in the 4-month period b efore hospitaliza-tion a fter key sociodemographic and clinical character-

istics w ere controlled. G reater risk for violence wa s alsolikely associated with the combination of substanceproblems, medication noncompliance, a nd low levels ofinsight into illness, but we have less confidence in re-sults that incorporate insight because low insight washighly correlated w ith these other va riables.

Among the sociodemographic variables examined,only the combined effect of being victimized and Afri-can American was significant, while urban residencew as not. O ne wa y to interpret this result is that the liv-ing environments in w hich many severely mentally illAfrican Americans find themselves—high-crime areasexperienced as dangerous and threatening—explainsmuch of the violence risk that might otherwise be sta-

tistically attributa ble to ra ce per se.These findings suggest generally tha t substa nce abuse

problems, medication noncompliance, and low insightinto illness operate together to increase violence risk.H ow ever, the study is limited in several w ays. In thesecross-sectional, retrospective analyses, the sequencingof pa thw ays to violence among these risk factors is notpossible. Future analyses will examine such causal rela-tionships and pathways by using longitudinal data cur-rently being collected in this study.

The findings presented here may not b e generalizable

to all persons w ith severe menta l illness. Subjects in thisstudy w ere involuntarily admitted and outpatient com-mitted patients—individuals who exhibited “ da nger-ous” or “ gravely disabled” behavior and who w ere alsojudged to be at risk for poor outcomes in communitytreatment. However, while the subjects were arguablymore severely impaired than many severely mentally ill

pat ients, there is nothing to suggest that the relationshipbetween violence and t he predictors show n here wouldbe different for less severely ill individuals. For exam-ple, controlling for level of functional impairment didnot change these relationships.

Various interpretat ions of our findings a re plausible.Noncompliance and substance abuse may be mutuallyreinforcing problems in that substance impairment ma yimpede medicat ion ad herence w hile noncompliance, inturn, ma y lead to self-medicating w ith alcohol or illicitdrugs (39). However, it is also possible that both vari-ables—noncompliance and substance abuse—result fromsome other latent factor such as general disaffili-ation from treatment or unspecified personality traits,

although w e have no evidence of these facto rs at pres-ent. We did not administer a personality inventory, whichis another limitation to this study.

In sum, these findings shed light on a particular set ofproblems experienced by persons w ith severe menta ldisorders—specifically those who may fall into a self-perpetuating cycle of resistance to treatment, illness ex-acerbation, substance abuse, violent behavior, and insti-tutiona l recidivism (1, 2, 19, 40). Adverse side effects andcomplicated dosing regimens can make it especially diffi-cult for patients to take neuroleptic medications as pre-scribed. In turn, untreated psychopathology and distressmay lead to alcohol and other drug abuse (39). Risk ofviolence may then increase as well because of substance

use, exacerbation of psychiatric symptoms, or the influ-ence of criminal environments in which illicit drugs areprocured. Finally, violent behavior may further erodesupportive social and therapeutic relationships and mayprecipitate involuntary commitment or incarceration(29). As these problems compound one another, conven-tional separate-track mental health and substance abusetreatment is unlikely to succeed (19, 20, 26).

Our d ata also suggest that effective community treat-ment for this population requires careful attention tomedication ad herence and the ava ilability of integratedsubstance abuse and mental health treatment (16, 19).Specialized outpatient services focused on people withdually diagnosed severe mental illness are in short sup-

ply in ma ny publicly funded mental health systems butmay be crucial for effective management of violencerisk in the era o f cost co ntainment.

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