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Victimization in people with severe mental health problems: the need to improve research quality, risk stratification and preventive measures
World Psychiatry ( IF 73.3 ) Pub Date : 2021-09-09 , DOI: 10.1002/wps.20908
Seena Fazel 1 , Amir Sariaslan 2
Affiliation  

Research over the last few decades has reported high rates of victimization in people with severe mental health problems1, and this is increasingly viewed as a key adverse outcome to prevent. Consequences can arise directly: more commonly, worsening of psychiatric conditions through the effects of trauma, but also physical health morbidities and even death. Indirect consequences may be disruptions to care, breakdowns in social support and networks, and the harmful use of drugs and alcohol to manage the physical and psychological effects of victimization.

However, despite the importance of the issue, research designs have had until now significant limitations. Many studies have used cross-sectional designs, asking people with vs. without psychiatric conditions to report on their victimization histories. This approach can be informative, but is likely to overestimate the association with psychiatric conditions, as people who are unwell are more likely to attribute their current problems to external causes. More importantly, these studies cannot deal with reverse causality – that the victimization has led to severe mental health problems rather than the reverse. This information remains useful to estimate needs, but not in terms of understanding causal links, which is necessary for prevention.

These designs are particularly problematic when rates of victimization are compared with other adverse outcomes, such as violence perpetration, as thresholds and time scales for these outcomes may be different. The commonly repeated statement that psychiatric patients are ten times more likely to be victims of crime than the general population, and that this rate is higher than the perpetration rate, is based on research with these suboptimal designs.

More informative are cohort studies, which can account for the timing of victimization and mental health conditions. Birth cohorts in the UK2 and New Zealand3 have reported that the following factors increase victimization risk: male gender, self-reported financial difficulties (but not other more objective markers of socioeconomic status), and comorbid alcohol and cannabis dependence. Confounds can be accounted for, but only those that are measured, and measured accurately. Residual confounding is, therefore, a threat to the validity of these studies.

One way of addressing such residual confounds is to use genetically informed controls, such as siblings. With biological full-sibling controls, half the co-segregating genes and much of the early environment are accounted for, which most observational studies do not capture. Siblings with and without mental health conditions can be followed up for victimization outcomes and, after adjusting for age and using same-sex sibling controls, studies can rule out several alternative hypotheses and provide stronger evidence for the associations to be consistent with a causal inference.

One such study using Swedish registers examined more than 250,000 patients diagnosed with psychiatric disorders and compared them with nearly 195,000 of their full siblings without psychiatric disorders4. Those with psychiatric diagnoses were found to be about three times as likely as their siblings to be violently victimized, and there was a four-fold increase in perpetration of violence in psychiatric patients.

Another genetically informative cohort is the E-Risk twin study, which found that measures of victimization up to age 18 were at least moderately heritable (>30%) and correlated with other heritable traits, including lower self-control and cognitive abilities, childhood conduct disorder, substance misuse, and family history of mental illness and antisocial behaviours5. These findings underline the importance of accounting for unmea­sured genetic confounding in studies of victimization risk.

In the above-mentioned Swedish study4, the risk of victimization was increased three-fold in siblings with bipolar disorder and doubled in those with depression compared to siblings without mental health problems. Unexpectedly, the risk was not increased in siblings with schizophrenia-spectrum disorders compared to their unaffected siblings, which may be explained by the fact that people with such disorders are more socially isolated, with less opportunities to be victimized than others.

Another national investigation that used a novel design, in which individuals acted as their own controls (“within individual”), found that violent victimization was the strongest trigger for violent perpetration in psychotic disorders6. Consideration, therefore, should be given to providing psychosocial support for at least one week following any victimization, to minimize the risk of a cycle of violence.

What do these findings mean for psychiatrists, other mental health professionals, and services? First, there is a considerable overlap between violence perpetration and victimization. Any improvements are likely to lead to reductions across these outcomes, and may also reduce suicide and premature mortality. Second, research design is critically important in this area, since small study effects have been magnified by poor measurement in previous work. Third, prevention will require two components: better risk stratification and effective interventions.

Risk stratification is required to determine who can benefit from additional interventions aimed at prevention, which will likely be resource intensive and complex. Criticisms of risk assessment rarely consider real world implications: psychiatric services need to stratify in order to allocate resources effectively, transparently and consistently, and cannot provide gold standard interventions to all people with mental health problems.

Most clinicians are unable to weigh up more than a few risk factors simultaneously, and very unlikely to make sense of their interactions. Once you reach more than five or so risk factors, assessment will benefit from simple algorithms to support, rather than replace, clinical decision-making. Simple scalable online tools with high negative predictive values can usefully screen out low-risk persons to preserve resources7.

But evidence-based risk assessment will only improve outcomes if linked to interventions, and effective ones. A key uncertainty is whether treating symptoms of mental illness will prevent victimization outcomes. There is some evidence suggesting that depressive symptoms may be predictive of victimization8, but this work needs replication.

Research on specific interventions aiming to reduce victimization risk in persons with mental disorders remains rare, because victimization has traditionally been viewed as a risk factor rather than a consequence of mental illness. One significant change would be to consider including victimization as an outcome in mental health treatment trials, particularly those that follow up people beyond a few weeks. Improving access to treatment for comorbid substance misuse is an important policy consideration, as research has clearly demonstrated that this comorbidity explains a large share of the elevated victimization risk in persons with mental illness4.

More contact with friends and family members may act as a protective factor against victimization risk, and supporting mea­sures to promote this can be enhanced across all mental health services. However, it is important to make sure that such interactions do not actually lead to increased exposure to criminogenic environments9. Finally, large-scale clinical and genetically informed studies, preferably linked with registry data and electronic health records, may clarify specific etiological mechanisms involved, leading to trials of interventions targeting these mechanisms.



中文翻译:

有严重心理健康问题的人受害:需要提高研究质量、风险分层和预防措施

过去几十年的研究报告称,患有严重心理健康问题的人1的受害率很高,这越来越被视为需要预防的关键不良后果。后果可能直接出现:更常见的是,由于创伤的影响,精神状况恶化,还有身体健康发病率甚至死亡。间接后果可能是护理中断、社会支持和网络崩溃,以及有害使用药物和酒精来管理受害的身体和心理影响。

然而,尽管这个问题很重要,但迄今为止,研究设计仍然存在很大的局限性。许多研究使用了横断面设计,要求有或没有精神疾病的人报告他们的受害历史。这种方法可以提供信息,但可能会高估与精神疾病的关联,因为身体不适的人更有可能将他们当前的问题归因于外部原因。更重要的是,这些研究无法处理反向因果关系——受害导致了严重的心理健康问题,而不是相反。该信息对于估计需求仍然有用,但对于了解预防所必需的因果关系而言却无济于事。

当将受害率与其他不利结果(例如暴力犯罪)进行比较时,这些设计尤其成问题,因为这些结果的阈值和时间尺度可能不同。精神病患者成为犯罪受害者的可能性是普通人群的十倍,而且这一比率高于犯罪率,这一普遍重复的说法是基于对这些次优设计的研究。

提供更多信息的是队列研究,它可以解释受害时间和心理健康状况。英国2和新西兰3的出生队列报告称,以下因素会增加受害风险:男性、自我报告的经济困难(但不是其他更客观的社会经济地位标志)以及合并酒精和大麻依赖。可以解释混淆,但只有那些被测量和准确测量的。因此,残余混杂对这些研究的有效性构成威胁。

解决这种残留混淆的一种方法是使用遗传信息控制,例如兄弟姐妹。使用生物学全兄弟控制,一半的共同分离基因和大部分早期环境都被考虑在内,大多数观察性研究都没有捕捉到。可以对有或没有精神健康状况的兄弟姐妹进行受害结果的跟踪,并且在调整年龄和使用同性兄弟姐妹对照后,研究可以排除几种替代假设,并为这些关联与因果推理一致提供更有力的证据。

一项使用瑞典登记册的此类研究检查了超过 250,000 名被诊断患有精神疾病的患者,并将他们与近 195,000 名没有精神疾病的兄弟姐妹进行了比较4。被诊断出患有精神病的人遭受暴力侵害的可能性大约是其兄弟姐妹的三倍,而精神病患者的暴力行为增加了四倍。

另一个遗传信息丰富的队列是 E-Risk 双胞胎研究,该研究发现,直到 18 岁的受害测量至少具有中等遗传性(>30%),并且与其他可遗传特征相关,包括较低的自我控制和认知能力、儿童行为精神疾病和反社会行为的障碍,药物滥用和家族史5。这些发现强调了在受害风险研究中考虑未测量的遗传混淆的重要性。

在上述瑞典研究4中,与没有精神健康问题的兄弟姐妹相比,患有双相情感障碍的兄弟姐妹受害的风险增加了三倍,而患有抑郁症的兄弟姐妹受害的风险增加了一倍。出乎意料的是,与未受影响的兄弟姐妹相比,患有精神分裂症谱系障碍的兄弟姐妹的风险并未增加,这可能是因为患有此类疾病的人在社会上更加孤立,受害的机会比其他人少。

另一项采用新颖设计的全国性调查发现,个人作为自己的控制者(“在个人内部”)发挥作用,发现暴力受害是精神障碍中暴力犯罪的最强触发因素6。因此,应考虑在任何受害后至少提供一周的社会心理支持,以尽量减少暴力循环的风险。

这些发现对精神科医生、其他心理健康专业人员和服务意味着什么?首先,暴力实施和受害之间存在相当大的重叠。任何改善都可能导致这些结果的减少,也可能减少自杀和过早死亡。其次,研究设计在该领域至关重要,因为先前工作中的测量不佳会放大小的研究效果。第三,预防需要两个组成部分:更好的风险分层和有效的干预措施。

需要进行风险分层以确定谁可以从旨在预防的额外干预中受益,这可能是资源密集型和复杂的。对风险评估的批评很少考虑现实世界的影响:精神科服务需要分层以便有效、透明和一致地分配资源,并且不能为所有有精神健康问题的人提供黄金标准干预。

大多数临床医生无法同时权衡多个风险因素,也不太可能理解它们之间的相互作用。一旦您达到超过五个左右的风险因素,评估将受益于简单的算法来支持而不是取代临床决策。具有高阴性预测值的简单可扩展在线工具可以有效地筛选出低风险人员以保护资源7

但基于证据的风险评估只有与干预措施和有效的干预措施相联系才能改善结果。一个关键的不确定性是治疗精神疾病的症状是否会防止受害结果。有一些证据表明,抑郁症状可能预示着受害8,但这项工作需要复制。

旨在降低精神障碍患者受害风险的具体干预措施的研究仍然很少,因为传统上受害被视为一种风险因素,而不是精神疾病的后果。一项重大变化是考虑将受害作为心理健康治疗试验的结果,特别是那些对人们进行几周以上随访的试验。改善对共病药物滥用的治疗是一项重要的政策考虑,因为研究清楚地表明,这种共病解释了精神疾病患者受害风险升高的很大一部分4

与朋友和家人的更多接触可以作为防止受害风险的保护因素,并且可以在所有精神卫生服务中加强促进这一点的支持措施。然而,重要的是要确保这种相互作用实际上不会导致增加接触犯罪环境9。最后,大规模临床和遗传信息研究,最好与登记数据和电子健康记录相关联,可以阐明所涉及的具体病因机制,从而针对这些机制进行干预试验。

更新日期:2021-09-10
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