The tragic deaths of all 150 people on board the Germanwings flight that the 27 year old co-pilot apparently flew into the Alps last Tuesday (17.03.2015) has brought the relationship between mental illness and violence to the fore again. The association has long exercised the public imagination, intermittently reinforced by prominent reporting on TV news programmes and in the newspapers and other media.
This time it is depression and violence that is in the news. Thus far at least the reporting of Mr Lubitz’s case has been fairly sober. At this point however it is important to note that we do not know whether Mr Lubitz was depressed, only that he had been treated for depression in the past. Indeed, the Dusseldorf clinic where he was last seen in February and March this year has apparently issued a statement to the effect that he was not being treated for depression in recent months.[1]
Mr. Lubitz At Golden Gate Bridge
Statistically speaking it is highly unlikely that depression is the culprit here. Depression is typically associated with violence against the self rather than others. Just this month, Seena Fazel and colleagues reported the results of a relevant and important study in Lancet Psychiatry.[2] They identified 47 158 individuals (17 249 men and 29 909 women) given outpatient diagnoses of depression between 2001 and 2009 in Sweden using high quality routinely collected data. They excluded inpatients because they might have been admitted because of a risk of violence to others, being suicidal, having psychosis, or comorbid substance abuse – all of which are risk factors for violence. During a follow-up period of about 3 years after diagnosis, 641 (3·7%) of the depressed men and 152 (0·5%) of the depressed women committed a violent offence. The risk of violent crime was increased about three-fold compared to the general population – but a violent act was still only committed by less than 1% of depressed people each year.
It has to be acknowledged that there is an increased rate of violent crime amongst people with severe mental illness – they account for around 10-15% of it. But this association is largely attributable to other factors such as substance misuse, a lack of treatment, family background and current environment.[3,4] Sufferers of severe mental illness are often rendered poor by their condition, through for example unemployment due to disability or discrimination, and may thereby end up living in deprived areas with endemic violence. This may explain why those with mental illness are at an even higher risk of being the victims of violence. Indeed, they are much more likely to be at the receiving end of violence than commit such acts. Each year, world-wide, about 25% of patients with schizophrenia or depression will be subject to violent crime.[5] In short, the mentally ill are much more likely to be the sufferers rather than the perpetrators of violence.
The mentally ill commit less than 10% of all homicides
The mentally ill commit less than 10% of all homicides in the western world and are much more likely to kill themselves than other people.[3,4,5] In fact, people are more likely to win the lottery than be murdered by a ‘mental patient’ or ‘axe wielding madman’. On average, every week someone in the UK wins the jackpot on the National Lottery, while rather less than one person a week loses their life to a person with mental illness.[6,7] (It is this very rarity of criminal acts in the mentally ill that makes them difficult to predict and impossible to entirely prevent). Moreover, most murder is committed by a close contact; indeed, one in seven of all homicides is committed by a former or current intimate partner. [6,7,8] In essence, we are much more likely to be killed by our family or friends than strangers. We humans have a tendency to equate heinous otherwise apparently inexplicable or incomprehensible crimes with being ‘mad’, and perhaps this brings us some comfort in an unpredictable and sometimes scary world, but when it comes to violence people with severe mental illnesses are both victimised and scapegoated.
Statistically speaking therefore, before we have any other information, the most likely scenario is that Mr Lubitz was not mentally ill. He may have been developing a psychotic illness such as schizophrenia, but other factors would need to be invoked to explain his apparent decision to fly into a mountain. We will probably never know how opportunistic or premeditated was this action. Perhaps he shared some or all of the features highlighted in the cases of suicide bombers – people rendered desperate by mixtures of anger, humiliation, alienation, frustrated ambition and a desire for recognition.[9] All we can say for sure is that most violence is committed by people who are not mentally ill. If it turns out Mr Lubbitz was ill then the real lesson of this tragic case may be that people with mental illness need to feel able to reach out for help without fear of stigmatisation, prejudice and discrimination.
REFERENCES
[1] http://www.bbc.co.uk/news/world-europe-32098578
[2] Fazel, S., et al. Lancet Psychiatry 2015; 2: 224–32
[3] Fazel, S., et al. JAMA 301, 2016-23 (2009).
[4] Fazel, S., et al. Arch Gen Psychiatry 67, 931-8 (2010).
[5] Hughes, K. et al. The Lancet 379, 1621-1629 (2012).
[6] National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Annual Report 2014 (http://www.bbmh.manchester.ac.uk/cmhr/research/)
[7] Taylor, P.J. & Gunn, J. Br J Psychiatr 174, 9-14 (1999).
[8] Stöckl H, et al. Lancet 382, 859-65 (2013).
[9] Gordon, H. Psychiatric Bulletin, 26, 285=7 (2002)