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Original Investigation
December 22, 2021

Association of Schizophrenia Spectrum Disorders and Violence Perpetration in Adults and Adolescents From 15 Countries: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Department of Psychiatry, University of Oxford, Oxford, England
  • 2University of Limerick School of Medicine and Health Service Executive, Limerick, Ireland
  • 3Oxford Health National Health Service Foundation Trust, Warneford Hospital, Oxford, England
JAMA Psychiatry. 2022;79(2):120-132. doi:10.1001/jamapsychiatry.2021.3721
Key Points

Question  What are the absolute and relative risks of perpetrating violence toward others in individuals with schizophrenia spectrum disorders compared with the general population?

Findings  In this systematic review of 24 studies, the absolute risk of perpetrating violence in a subgroup of register-based studies was less than 1 in 20 in women with schizophrenia spectrum disorders and less than 1 in 4 in men with schizophrenia spectrum disorders over a 35-year period. The elevated relative risk for all violence-perpetration outcomes was higher for women with schizophrenia spectrum disorders than for men with schizophrenia spectrum disorders, but with substantial heterogeneity in the findings.

Meaning  Violence perpetration outcomes may be an important target for prevention and to reduce stigma in people with schizophrenia spectrum disorders.


Importance  Violence perpetration outcomes in individuals with schizophrenia spectrum disorders contribute to morbidity and mortality at a population level, disrupt care, and lead to stigma.

Objective  To conduct a systematic review and meta-analysis of the risk of perpetrating interpersonal violence in individuals with schizophrenia spectrum disorders compared with general population control individuals.

Data Sources  Multiple databases were searched for studies in any language from January 1970 to March 2021 using the terms violen* or homicid* and psychosis or psychoses or psychotic or schizophren* or schizoaffective or delusional and terms for mental disorders. Bibliographies of included articles were hand searched.

Study Selection  The study included case-control and cohort studies that allowed risks of interpersonal violence perpetration and/or violent criminality in individuals with schizophrenia spectrum disorders to be compared with a general population group without these disorders.

Data Extraction and Synthesis  The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and the Meta-analyses of Observational Studies in Epidemiology (MOOSE) proposal. Two reviewers extracted data. Quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Data were pooled using a random-effects model.

Main Outcomes and Measures  The main outcome was violence to others obtained either through official records, self-report and/or collateral-report, or medical file review and included any physical assault, robbery, sexual offenses, illegal threats or intimidation, and arson.

Results  The meta-analysis included 24 studies of violence perpetration outcomes in 15 countries over 4 decades (N = 51 309 individuals with schizophrenia spectrum disorders; reported mean age of 21 to 54 years at follow-up; of those studies that reported outcomes separately by sex, there were 19 976 male individuals and 14 275 female individuals). There was an increase in risk of violence perpetration in men with schizophrenia and other psychoses (pooled odds ratio [OR], 4.5; 95% CI, 3.6-5.6) with substantial heterogeneity (I2 = 85%; 95% CI, 77-91). The risk was also elevated in women (pooled OR, 10.2; 95% CI, 7.1-14.6), with substantial heterogeneity (I2 = 66%; 95% CI, 31-83). Odds of perpetrating sexual offenses (OR, 5.1; 95% CI, 3.8-6.8) and homicide (OR, 17.7; 95% CI, 13.9-22.6) were also investigated. Three studies found increased relative risks of arson but data were not pooled for this analysis owing to heterogeneity of outcomes. Absolute risks of violence perpetration in register-based studies were less than 1 in 20 in women with schizophrenia spectrum disorders and less than 1 in 4 in men over a 35-year period.

Conclusions and Relevance  This systematic review and meta-analysis found that the risk of perpetrating violent outcomes was increased in individuals with schizophrenia spectrum disorders compared with community control individuals, which has been confirmed in new population-based longitudinal studies and sibling comparison designs.

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