Experiences of violence linked to poorer outcomes for people with severe mental illness

People with severe mental illness (SMI) who have experienced violence are more likely to need emergency and inpatient mental health care in the future, according to new research from King’s College London.

A study, published in the British Journal of Psychiatry, found that people living with SMI who had violence recorded in their mental health records early in their care were at increased risk of crisis service use, hospital admission and detention under the Mental Health Act in the years that followed. The authors studied patient records on people diagnosed with schizophrenia or related disorders, or bipolar disorder or mania.

The findings highlight the importance of identifying and responding to experiences of violence as part of routine mental health care.

People living with conditions such as schizophrenia and bipolar disorder are known to be at much higher risk of being victims of violence, including physical, domestic and sexual violence. Previous studies have shown links between violence and more severe mental health symptoms. However, less was known about whether these experiences also affect longer‑term outcomes, such as whether someone is more likely to need emergency care, be admitted to hospital or experience compulsory treatment.

The researchers wanted to understand whether violence recorded early in someone’s contact with mental health services could help predict these later outcomes. The researchers analysed anonymised electronic mental health records from more than 16,000 adults who received care from South London and Maudsley NHS Foundation Trust between 2007 and 2022.

Using natural language processing (NLP), the researchers identified whether any current or previous physical, domestic or sexual violence had been recorded in the first three months after someone first came into contact with services.

They then followed people over time to see whether they later experienced emergency mental health assessments, crisis care, inpatient admissions, detention under the Mental Health Act or died.

People who had experienced violence were:

• more likely to require emergency mental health care,
• more likely to be admitted to hospital,
• more likely to be detained under the Mental Health Act, and
• more likely to have a higher number of contacts with mental health services over time.

These associations remained even after accounting for differences in diagnosis, medication use and symptom levels recorded in early care.

They found that the patterns were similar across physical, domestic and sexual violence, suggesting that it is the experience of violence itself, rather than the type, that matters.

When the researchers examined outcomes separately for men and women, they found broadly similar patterns after accounting for age and social factors. However, once early clinical factors were considered, some associations, particularly around inpatient care and detention, were stronger and more consistent for men than for women.

The researchers stated that this may reflect differences in how men and women enter care, disclose experiences of violence, or move through mental health services, and that further research is needed to understand these pathways.

Dr Vishal Bhavsar, NIHR Advanced Fellow, King’s College London and a co-author on the paper, stated:

“The high prevalence of violent experiences among people using mental health services, and the strong association of these experiences with use of crisis or emergency care, highlights that mental health services should properly identify and assess violence as part of routine clinical care. The differences we observed between men and women emphasise the need for service responses which are sensitive to gender differences in the occurrence and impact of violence, including domestic violence. Use of natural language processing techniques to look at clinical activity in relation to violence could be a useful way of developing these strategies in the future.

The findings suggest that experiences of violence are not only common among people with severe mental illness, but also important indicators of future risk.

Author Dr Ava Mason is currently a Trainee Clinical Psychologist at University of Oxford, and works at the Berkshire Traumatic Stress service and Birth in Mind in Berkshire Healthcare NHS Foundation Trust. She adds,

“The findings from this study highlight how experiences of violence are not simply part of a patient’s background history, but are closely tied to future patterns of mental health service use. Embedding routine identification of victimisation into care pathways could improve how clinicians anticipate risk and support recovery in people with severe mental illness. The differences observed between men and women also highlight the importance of trauma-informed approaches that are sensitive to how victimisation may affect clinical outcomes differently across genders.”