ORIGINAL ARTICLE Self-Perceived Needs Are Related to Violent Behavior Among Schizophrenia Outpatients Nuria Martı́nez-Martı́n, MD, PhD,* David Fraguas, MD,Þþ Marı́a Paz Garcı́a-Portilla, MD, PhD,§|| Pilar Alejandra Sáiz, MD, PhD,§|| Marı́a Teresa Bascarán, MD, PhD,§|| Celso Arango, MD, PhD,þ¶ and Julio Bobes, MD, PhD§|| Abstract: This study assessed the relationship between self-perceived clinical and social needs and aggressive behavior in outpatients with schizophrenia. A total of 895 outpatients with schizophrenia were enrolled. The presence of aggressive episodes was assessed using the Modified Overt Aggression Scale. Self-perceived needs were assessed using the Camberwell Assessment of Need in six areas of needs (food, household skills, self-care, daytime activities, psychotic symptoms, satisfaction with treatment, and company). The most common areas of needs were ‘‘psychotic symptoms’’ (81.6%), ‘‘daytime activities’’ (60.6%), and ‘‘household skills’’ (57.5%). More needs were expressed by patients who had more severe illnesses ( p G 0.001) and more aggressive behavior ( p G 0.001). Multivariate analysis showed that, in schizophrenia outpatients, self-perceived needs were associated with aggressive behavior (adjusted odds ratio, 11.43; 95% confidence interval, 5.11 to 25.56). Appropriate compliance with antipsychotic treatment was related with lower aggressive behavior ( p G 0.001). Key Words: Aggression, needs, risk factors, ambulatory care, schizophrenia. (J Nerv Ment Dis 2011;199: 666Y671) P ersons with a major mental illness are among the most stigmatized groups in society (Cooper et al., 2003; Henderson and Thornicroft, 2009), and the perception that these persons are violent or have aggressive behavior contributes to the well-documented stigma (Fazel et al., 2009b; Henderson and Thornicroft, 2009; Link et al., 2004). The conventional view held that there is no association, or at least no demonstrated association, between mental disorders and aggressive or violent behavior. However, starting in the 1990s, this view evolved to acknowledging that the association between mental disorders and violence is statistically robust and important (Arango et al., 1999; Dean et al., 2007; Douglas et al., 2009; Fazel et al., 2009b). The relationship between schizophrenia and violence can be explained partly through sociodemographic factors, such as young age, male sex, low socioeconomic status, or unmarried status (Douglas et al., 2009; Fazel et al., 2009a; Kelly, 2005). Other factors with *Hospital Universitario 12 de Octubre, Secretarı́a de Psiquiatrı́a, Madrid; †Complejo Universitario Hospitalario de Albacete, Albacete; ‡Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid; §School of Medicine, Psychiatry Department, University of Oviedo, Oviedo; ||Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Oviedo; and ¶Adolescent Unit, Psychiatry Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain. This study was supported by Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Spanish Ministry of Science and Innovation. All authors declare that they do not have any conflict of interest in connection with the submitted article. Send reprint requests to David Fraguas, MD, Complejo Universitario Hospitalario de Albacete, Calle Seminario 4, 02006 Albacete, España. E-mail: davidfraguas@gmail.com. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0022-3018/11/19909<0666 DOI: 10.1097/NMD.0b013e318229d0d5 666 www.jonmd.com predictive value include a history of violence (Monahan et al., 2005; Serper et al., 2005), incarceration (Mcniel et al., 1988), drug or alcohol abuse ( Fazel et al., 2009c; Van Dorn et al., 2011), or being a victim of child abuse (Steel et al., 2009). These factors have been related to self-perceived unmet needs of care (Grinshpoon and Ponizovsky, 2008; Wiersma, 2006; Wiersma et al., 2009), which comprise conditions such as psychological distress, daytime activities, social contacts, and psychotic symptoms (Grinshpoon and Ponizovsky, 2008; Ochoa et al., 2003, 2005). In light of these data, we planned to evaluate whether there is a relationship between unmet needs of care and violent behavior among schizophrenia outpatients. This study was conducted within the framework of a nationwide epidemiological study in Spain, the EPISOL Study, in which outpatients with a diagnosis of schizophrenia were studied. Characteristics of the EPISOL Study have been reported elsewhere (Bobes et al., 2009). The purpose of this study was to assess self-perceived clinical and social needs among outpatients with schizophrenia and the relationship between met and unmet needs and aggressive behavior. Our hypothesis was that comprehensive needs would positively correlate with aggressive behaviors. METHODS This is a descriptive cross-sectional study in a sample of schizophrenia outpatients treated using second-generation antipsychotic drugs. The patients selected were attending a routine follow-up visit to community-based mental health service facilities at centers in Spain within the national public health system. Subjects The sample was drawn from patients 18 years or older who visited the participating centers for their routine follow-up. To be included, the patients must have had an established diagnosis of schizophrenia according to DSM-IV-TR criteria and must have been receiving stable maintenance therapy with at least one second-generation antipsychotic drug as the primary treatment for at least 3 months. The exclusion criteria were not having a clinical history at the center and refusal to participate. A sample consisting of 1060 patients was enrolled in this study. We detected 165 patients who failed to comply with one of the screening criteria: a diagnosis other than schizophrenia (n = 1), younger than 18 years (n = 9), stable antipsychotic therapy for less than 3 months (n = 142), or other exclusion criteria such as refusing to cooperate (n = 13). Therefore, 895 patients who satisfied the criteria and gave their consent to participate in the study were included in the analysis. The protocol was approved by the ethics committee of the participating centers. All participants were informed about the objective of the study. Written informed consent was obtained from the patients and their caregivers before enrollment in the study. Patients were enrolled from April to December 2005 consecutively, with the first patient enrolled at each center after April 1. The Journal of Nervous and Mental Disease & Volume 199, Number 9, September 2011 Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. The Journal of Nervous and Mental Disease & Volume 199, Number 9, September 2011 Characteristics of the sample have been reported elsewhere (Bobes et al., 2009). Measures Data on sociodemographic information, clinical information, and records about antipsychotic and concomitant treatments were collected. The clinical psychiatric diagnostic of schizophrenia was made according to DSM-IV-TR criteria. Information about psychiatric comorbidity and substance use was recorded according to World Health Organization guidelines (Kleber et al., 2006). The severity of the disorder was measured using the Clinical Global Impression of Severity Scale (CGI-S). Information on the clinical course of the disease included time since last relapse and records from the previous year regarding number of relapses, outpatient visits, and admissions for psychiatric causes. The antipsychotic treatment prescribed at the time of the visit and the degree of therapeutic compliance (in a dichotomic way: appropriate compliance [at least 80%]/partial or bad compliance [less than 80%]), according to the investigator’s opinion based on the doses missed during a standard week, were recorded. Staff observations and patient reports were used to estimate compliance during the week. The needs of the patients were assessed using the Camberwell Assessment of Need (CAN) (Phelan et al., 1995). The CAN is described as a tool for assessing the needs of people with a serious mental illness. In the CAN, the concept is that the need for care or support is present when a disability exists in terms of impairment in physical, psychological, or social functioning. It is used as a structured interview and assesses both general and special needs caused by the disabilities that have occurred during the previous month. In the present study, the Spanish translation of the research version was used (Rosales et al., 2002). The CAN scale recognizes the subjective nature of ‘‘need’’ and emphasizes the importance of gathering information from both service users and staff caregivers. To determine the type of aggressive behavior and the frequency and degree of violence involved, we used the Manifest Overt Aggression Scale (MOAS). The MOAS is a valid instrument for the study of the aggression. In accordance with investigators, the total MOAS score average is 8.4 (SD, 5.8) for aggressive cases, whereas it is .26 (SD, 1.7) for nonaggressive healthy subjects, demonstrating a large statistically significant ( p G 0.001) difference between the two groups (Margari et al., 2005). Chukwujekwu and colleagues demonstrated similar results, comparing 40 aggressive psychiatric patients and 40 nonaggressive healthy subjects. The mean global weighted scores of the aggressive and nonaggressive categories were 13.70 (SD, 7.25) and 0.65 (SD, 1.01), respectively. The difference in means is statistically significant; therefore, the MOAS has discriminant validity (Chukwujekwu and Stanley, 2008). The MOAS rates the most severe act in four categories: verbal aggression (verbal hostility, statements or invectives that seek to inflict psychological harm on another through devaluation/degradation and threats of physical attack), aggression against objects (wanton and reckless destruction of ward paraphernalia or another person’s possessions), aggression against self (physical injury toward self, selfmutilation, or suicide attempt), and aggression against other people (violent action intended to inflict pain, bodily harm, or death upon another). The total score of the MOAS is a weighted sum of the scores of the subscales. This comprises sixteen items, all referring to aggressive incidents classified according to the degree of violence involved (Song and Min, 2009). This classification reflects the duration of each incident and the intervention required for its control (Chukwujekwu and Stanley, 2008; Ratey and Gutheil, 1991; Tyrer et al., 2007). Within each type of aggressive behavior, high scores correspond to a greater degree of violence (on a scale of 1 to 5, with 1 indicating ‘‘none’’ and 5 indicating ‘‘extreme violence’’). The patients were * 2011 Lippincott Williams & Wilkins Needs and Violence in Schizophrenia asked whether they had behaved aggressively during the past week in any of these domains: verbal aggression, physical aggression toward others or himself/herself, or aggressive behavior toward objects. A violent episode was considered to be any episode scoring at least 3 on each of the 4 MOAS subscales. If that was the case, the investigator completed the MOAS with the help of the patient’s caregiver. In this study, we did not have different records from the families or the patients. Data Analyses The statistical analysis was done using SPSS for Windows, version 16.0 (SPSS Inc., Chicago, IL). To estimate the prevalence in the population of patients with schizophrenia in Spain, the prevalence figures were adjusted to the number of inhabitants in each region (latest population figures available for 2003 were provided by the Spanish National Statistics Institute; available at www.ine.es). It was assumed that the prevalence of schizophrenia is 1% (although prevalence ranging from .5% to 3.46% have been reported; Perala et al., 2007) and that this is constant in the different geographical regions into which Spain is divided. The descriptive analysis was computed in terms of mean and standard deviation with range for continuous variables and frequency with percentage for ordinal and nominal variables. Correlations between the needs and other continuous variables were studied using the Pearson product-moment correlation. Multivariate models were estimated using a mixed-effects logistic regression model and a factorial analysis of variance. Univariate and multivariate logistic regression models were used to test which factors among the variables recorded were associated with aggressive behavior on each of the four subscales (verbal aggression and physical aggression against self, against objects, or against other people). To provide knowledge of the relationships and strengths among the variables, we added a logistic regression statistical model. To accomplish this goal, backward stepwise regression was used as a method of exploratory analysis. Variables were entered into the model, and the analysis began with a saturated model. Variables were eliminated from the model in an iterative process. The fit of the model was tested after the elimination of each variable to ensure that the model still adequately fit the data. When no more variables could be eliminated from the model, the analysis was complete. The analyses were two-tailed, with p G 0.05 considered statistically significant. RESULTS Table 1 shows the psychosocial characteristics, clinical diagnoses, and reported prescribed psychoactive medication. Most of the patients were appropriately compliant with their antipsychotic treatment (77.5%). Substance use within the previous year was found in 21.9% of the cases (n = 174), most of which involved multiple substances at the same time (predominantly alcohol and cannabis); if we consider only the use of illegal substances, the percentage was 14.5% (130 cases of substances other than tobacco or alcohol). According to the CGI-S, 38.4% of the participants were moderately ill, and 23.8% ranged from very ill to seriously ill; the rest of the patients were classified at lower severity scores. For all the patients, during the previous year, the mean number of outpatient visits was 9.1 (SD, 7.2), and, in general, half of the patients experienced a relapse during the past year. The mean time since the last relapse was 8.8 months (SD, 12.3 months), with a median of 6 months. Relapses resulted in psychiatric hospitalization in the year before the study in 16.7% of the sample (n = 149). Patients with appropriate compliance to antipsychotic treatment had lower aggressive behavior, including total aggressive behaviors www.jonmd.com Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 667 The Journal of Nervous and Mental Disease Martı́nez-Martı́n et al. & Volume 199, Number 9, September 2011 TABLE 1. Baseline Demographic Characteristics of Patients (N = 895) Mean SD 38.7 6.1 11.5 11.8 Age, yrs Hospital admissions Male Marital status Single Stable partner Married Other Living situation Own family Parents/other relatives By themselves In shelter Other situations Occupational status Employed Unemployed n 589 % 66.9 669 33 115 78 74.2 3.7 12.9 9.2 144 595 79 45 32 16.1 66.5 8.8 5 3.6 165 730 18.4 81.6 Diagnosis Schizophrenia subtypes Paranoid (295.30) Catatonic (295.90) Residual (295.60) Disorganized (295.10) Undifferentiated (295.90) Age at onset, mean (SD), yrs Satisfaction with treatment Extremely satisfied Moderately satisfied Somewhat dissatisfied Compliance with treatment Misses a dose Never misses a dose Unknown Treatment Combined treatment Monotherapy (APS) n % 644 6 97 50 96 72.0 .7 10.8 5.6 10.7 25.6 (8.2) 578 212 99 64.6 23.7 12.1 175 686 10 19.8 77.5 2.7 280 615 31.3 68.7 Values are expressed as either mean (SD) or n (%). APS indicates antipsychotic treatment. (W2 = 20.42; df = 1; p G 0.001), physical aggression against objects (W2 = 29.96; df = 1; p G 0.001), verbal aggression (W2 = 15.62; df = 1; p G 0.001), and aggression against others (W2 = 12.96; df = 1; p G 0.001). However, compliance was not related with self-aggression (W2 = 0.49; df = 1; p = 0.483). (4.6%). After adjusting the prevalence for community population, the point prevalence of aggressive episodes was 5.07% (95% confidence interval [CI], 5.04% to 5.10%). No relationship was found between recent episodes and sex or age. We recorded a total of 96 aggressive behaviors in the aforementioned 41 subjects, with physical aggression against objects observed in most cases (65 of 96), followed by verbal aggression (59 of 96), and aggression against others (26 of 96). In a lower number of cases, the patients were aggressive against themselves (14 of 96). These figures sum up to more than 96 because a given patient may be involved in one or more types of violent behavior. Within this prevalence rate, the levels of severity are mainly from 2 to 3 on a 5-point scale, with a large number of behaviors (Q3) reaching the specified violent threshold (43 of 96 behaviors; 45%). More than half of the patients with recent violent episodes had been evaluated by the investigator at the highest levels of clinical severity (from very to extremely ill) on the CGI-S scale (n = 24; 58.3%). Among the patients with recent episodes, very few (n = 2) had had legal problems caused by violent behavior in the past year. Nearly a third were using or had used substances in the past 12 months (n = 12; 29.3%); the substances predominantly used were cannabis, alcohol, or a combination of both. Self-Perceived Needs in the Study Population Based on the CAN, the needs of the patients were rated as 0 (no problem), 1 (moderate problem), or 2 (severe problem). These were recoded as dichotomous, rated as 0 (no problem) or 1 (any problem). For the areas in which patients reported met or unmet needs, their level of satisfaction with the help received from either formal or informal sources was assessed. The areas of need most commonly reported by the patients were related to psychotic symptoms (81.6%) and daytime activities (60.6%), followed by household skills (57.5%), food (37.5%), and self-care (34%). Table 2 shows the perspective of the patients in relation to their felt needs and the help received from formal sources. Point Prevalence of Aggressive Episodes Of the 895 patients included in the analysis, at least one episode of aggressive behavior in the past week was recorded in 41 cases TABLE 2. Self-Perceived Needs of the Patients Camberwell Assessment of Needs Unmet Areas of Needs, n (%) Food Household skills Self-care Daytime activities Psychotic symptoms 668 www.jonmd.com Help Received From Formal Sources Met Moderate Severe None Low Moderate High 557 (62.2) 374 (41.8) 584 (65.0) 343 (38.3) 160 (17.9) 295 (33.0) 445 (49.7) 240 (27.0) 328 (36.6) 572 (63.9) 40 (4.5) 70 (7.8) 63 (7.0) 215 (24.0) 158 (17.7) 267 (29.8) 151 (16.9) 336 (37.5) 160 (17.9) 126 (14.1) 162 (18.1) 219 (24.5) 224 (25.0) 311 (34.7) 319 (35.6) 101 (11.3) 188 (21.0) 123 (14.7) 226 (25.3) 253 (28.3) 245 (27.4) 246 (21.0) 79 (8.8) 111 (12.4) 151 (16.9) * 2011 Lippincott Williams & Wilkins Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. The Journal of Nervous and Mental Disease & Volume 199, Number 9, September 2011 Correlates of Aggressive Behavior and Needs for Care A chi-square test was used to compare sociodemographic variables, clinical variables, severity of psychopathology, and social support. With respect to sociodemographic variables, male patients had more needs than did the women (W2 = 9.46; p = 0.009) even when they received more total help in care (W2 = 12.50; p = 0.002). Regarding influence of familial status, only patients belonging to nonnuclear families (single or divorced/separated) had a correlation with needs (W2 = 21.90; p = 0.003). Single and divorced patients had more needs and more total number of needs than did married patients (W2 = 21.18; p = 0.002). With regard to clinical factors, more needs were expressed by patients who had more severe illnesses (W2 = 217.09; p G 0.001) and more aggressive behavior (W2 = 30.26; p G 0.001). Similarly, compared with the nonparanoid subtype of schizophrenia, patients with the paranoid subtype had more needs (W2 = 9.02; p = 0.03). Satisfaction with the treatment and level of compliance with treatment correlated with fewer needs (W2 = 96.23; p G 0.001). Compliance with treatment correlated with all aggression subtypes except aggression against self (Table 3). Drug abuse correlated with more needs (W2 = 9.08; p = 0.03) and more aggressive behavior (W2 = 7.94; p = 0.05). No other sociodemographic and clinical variables had a significant correlation with needs. Table 3 shows the positive correlation between needs and aggressive behavior. Univariate logistic regression models, adjusting for age, sex, ethnicity, working status, clinical severity (as measured by CGI-S), substance abuse, and reported help received, were used to test which comprehensive needs were associated with aggressive behavior. In general terms, the presence of at least one comprehensive need was related to a significant increase in the risk of committing an aggressive behavior (adjusted odds ratio [OR] = 11.43; 95% CI, 5.11 to 25.56). Regarding specific needs, psychotic symptoms (adjusted OR = 4.19; 95% CI, 2.01 to 8.73), daytime activities (adjusted OR = 2.33; 95% CI, 1.14 to 4.76), and satisfaction with treatment (adjusted OR = 1.24; 95% CI, 1.03 to 1.47) were associated with aggressive behavior (any type of aggression). Sex, ethnicity, working status, clinical severity, and reported help received were not significantly associated with aggressive behavior, whereas substance abuse was related to a mild increase in risk of aggression (adjusted OR = 2.02; 95% CI, 1.11 to 3.69). The results of the logistic regression statistical model showed that psychotic symptoms (adjusted OR = 3.68; 95% CI, 1.57 to 8.63) were associated with verbal aggression. Table 4 summarizes the results of this analysis. DISCUSSION The major finding of the present study is the association between self-perceived needs and aggressive behavior in a schizophrenia outpatient population that has appropriate treatment compliance Needs and Violence in Schizophrenia and receives regular mental health care after controlling for age, sex, ethnicity, working status, clinical severity, substance abuse, and reported help received. Although there has been increasing interest in the relationship between violence and the extent of comprehensive needs for care and services in mentally ill individuals, there has been almost no research focused on schizophrenia outpatient populations receiving regular treatment. Our results confirm previous findings that relate the occurrence of violent behavior to clinical course factors, needs, and satisfaction with prescribed treatment (Amore et al., 2008; Bobes et al., 2009). Although patients with schizophrenia may commonly report a violent episode during the lifetime of the disorder (Appelbaum et al., 2000), in our study, we conclude that violent episodes are also not uncommon among clinically stable outpatients receiving regular mental health care with appropriate treatment compliance. The observed association between aggressiveness and clinical variables of the disease, such as psychotic symptoms, is consistent with other recent studies that used the same assessment method (MOAS; Dean et al., 2007). Consistent with previous studies, more than half of the patients with severe mental illness expressed a need concerning psychotic symptoms, daytime activity, or household skills (Honkonen et al., 2004; Wiersma, 2006). The highest proportion of met needs concerned self-care and food. These results are somewhat unexpected because all patients had regular contact with a psychiatrist, received formal help in this area, and reported having adequate compliance with treatment. One explanation for this finding may be that existing antipsychotic drugs do not sufficiently relieve or reduce symptoms. The high proportion of unmet needs in the area of psychotic symptoms suggests the need for a more continuous clinical assessment of need and outcome of treatment in this area. The analysis of the relationship between severity of needs and violence or aggressive behavior showed that a further 20% of the variation in aggressive behavior was accounted for by the severity of needs concerning psychotic symptoms, daytime activity, and satisfaction with treatment. Unexpectedly, at the multivariate level, ethnicity, age, and employment status were not significantly associated with aggressive behavior, despite associations in the literature on general community samples (Appelbaum et al., 2000; Ochoa et al., 2003). On the contrary and in keeping with most of the literature, substance abuse was associated with an increased risk of violent behavior (Fazel et al., 2009c). Although pessimistic implications regarding the relationships between unmet and met needs and violence may be deduced from this finding, we feel compelled to take an optimistic view because comprehensive needs are always targets of clinical and social interventions. We believe that it is important to emphasize the relevance of subjective psychotic symptoms as the most consistent predictor of any type of violent behavior, particularly in this study, TABLE 3. Correlates of Needs and Violent Behavior Food Verbal aggression 0.03 ( p = 0.58) Aggression against self 0.10 ( p = 0.06) Aggression against objects 0.13* ( p = 0.02) Aggression against others 0.09 ( p = 0.11) Any subtype of aggression 0.18** ( p = 0.001) Household Skills Self-Care 0.14* ( p = 0.01) 0.11* ( p = 0.05) 0.15** ( p = 0.006) 0.06 ( p = 0.31) 0.24** ( p G 0.001) 0.14* ( p = 0.01) 0.17** ( p = 0.002) 0.07 ( p = 0.17) 0.24** ( p G 0.001) 0.13* ( p = 0.02) Daytime Activities Psychotic Symptoms Compliance With Treatment 0.21** ( p G 0.001) 0.16** ( p = 0.004) 0.28** ( p G 0.001) 0.25** ( p G 0.001) 0.32** ( p = 0.001) 0.31** ( p G 0.001) 0.20** ( p G 0.001) 0.34** ( p G 0.001) 0.33** ( p G 0.001) 0.39** ( p G 0.001) j0.17** ( p G 0.001) j0.05 ( p = 0.38) j0.17** ( p G 0.001) j0.116* ( p = 0.027) j0.19** ( p G 0.001) The values shown in the table are Pearson moment-correlation values. *p G 0.05. **p G 0.01. * 2011 Lippincott Williams & Wilkins www.jonmd.com Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 669 The Journal of Nervous and Mental Disease Martı́nez-Martı́n et al. TABLE 4. Univariate Logistic Regressions of the Areas of Need Included in the Study and Different Types of Aggression Factor Any aggression Food Household skills Self-care Daytime activities Psychotic symptoms Satisfaction with treatment Verbal aggression Food Household skills Self-care Daytime activities Psychotic symptoms Satisfaction with treatment Self-directed aggression Food Household skills Self-care Daytime activities Psychotic symptoms Satisfaction with treatment Aggression to objects Food Household skills Self-care Daytime activities Psychotic symptoms Satisfaction with treatment Aggression to others Food Household skills Self-care Daytime activities Psychotic symptoms Satisfaction with treatment 95% CI df Chi-Square Analysis p OR Low High 1 1 1 1 1 1 0.73 3.53 3.61 5.37 14.66 5.51 0.54 0.06 0.06 0.002** 0.000** 0.01** 1.53 3.04 0.30 2.33 4.19 1.24 0.40 0.95 0.09 1.14 2.01 1.03 5.89 9.70 1.04 4.76 8.73 1.47 1 1 1 1 1 1 1.72 2.74 0.58 1.67 9.02 2.76 0.19 0.98 0.45 0.20 0.003** 0.09 0.33 2.88 0.61 1.73 3.68 1.19 0.06 1.72 0.82 10.05 0.17 2.16 0.75 3.96 1.57 8.63 0.97 1.46 1 1 1 1 1 1 0.22 0.28 0.76 0.56 4.19 1.35 0.64 0.60 0.38 0.45 0.04* 0.24 1.76 1.83 0.39 1.77 5.20 1.25 0.16 18.78 0.19 17.08 0.49 3.17 0.39 7.88 1.07 25.25 0.86 1.83 1 1 1 1 1 1 0.18 4.77 1.69 4.30 11.15 2.29 0.67 0.03* 0.19 0.03* 0.001** 0.13 0.73 3.78 0.44 2.31 3.97 1.16 0.17 3.07 1.15 12.46 0.13 1.51 1.05 5.09 1.77 8.91 0.96 1.42 1 1 1 1 1 1 0.32 3.76 3.18 2.43 11.19 3.47 0.57 0.05 0.07 0.12 0.001** 0.06 0.59 4.52 0.23 2.34 6.92 1.30 0.09 3.65 1.93 20.73 0.05 1.15 0.80 6.81 2.23 21.48 0.99 1.71 Analyses were adjusted for age, sex, ethnicity, working status, clinical severity, substance abuse, and reported help received. df indicates degrees of freedom; OR, odds ratio; CI, confidence interval. *p G 0.05. **p G 0.01. where clinically stable outpatients with routine follow-up visits were included. CONCLUSIONS This study shows that, among schizophrenia outpatients, aggressive behavior is significantly related to self-perceived needs, after controlling for age, sex, ethnicity, working status, clinical severity, substance abuse, and reported help received (adjusted OR = 11.43; 95% CI, 5.11 to 25.56). 670 www.jonmd.com & Volume 199, Number 9, September 2011 Our study also shows that, even among the members of the schizophrenia outpatient population who have appropriate treatment compliance and receive regular mental health care, violent episodes are not uncommon (point prevalence of aggressive episodes, 5.07%; 95% CI, 5.04% to 5.10%). REFERENCES Amore M, Menchetti M, Tonti C, Scarlatti F, Lundgren E, Esposito W, Berardi D (2008) Predictors of violent behavior among acute psychiatric patients: Clinical study. Psychiatry Clin Neurosci. 62:247Y255. Appelbaum PS, Robbins PC, Monahan J (2000) Violence and delusions: Data from the MacArthur Violence Risk Assessment Study. 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