Self-Perceived Needs Are Related to Violent Behavior Among

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: [email protected].
Copyright * 2011 by Lippincott Williams & Wilkins
ISSN: 0022-3018/11/19909<0666
DOI: 10.1097/NMD.0b013e318229d0d5
666
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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
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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
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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
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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)
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The Journal of Nervous and Mental Disease
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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.
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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).
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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%).
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