Violence and mental health: how can we be part of the solution?

EDITORIAL

Violence and mental health: how can we be part of the solution?

For the general population and for the lay media in particular, the association between violence and mental health usually conjures up the idea, albeit a fallacious one, of some terrible act perpetrated by a "crazy person". Admittedly, there are examples of violent acts which are unwarrantedly explored by the media that have indeed been perpetrated by someone with a mental illness. Such cases are, however, the exception rather than the rule. Contrary to what is believed, many more crimes are committed by persons without any mental disease. Persons with mental disorders are actually more likely to fall victim to the different types of violence than people without a recognizable form of mental illness.¹

In fact, the whole concept of violence is a complex one. At first, the concept of violence was limited to its legal connotation, according to which violence meant the forceful violation of someone's right or integrity by a person or a group. Gradually, the concept evolved and became associated with another complex behavioural and ethological concept, namely that of aggression. If, on one hand, in its original meaning, violence is clearly a deviant phenomenon that has led societies to conceive strategies to curb this singular act, on the other hand, ethologists have demonstrated that aggression is a phenomenon inherent to the entire animal world since it constitutes an essential tool for the survival of both the individual and the group.²

A more precise definition of violence was provided by the 49^th Health Assembly in 1996, when, after declaring it a leading public health problem, the following definition of violence was formulated:

The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation.³

In 2005, the World Health Organization issued a follow-up report entitled the World Report on Health and Violence.⁴ This document, which represented a watershed, proposed the typology of violence, which varies according to the characteristics of those committing the violent act and can be divided into: 1) self-directed violence, 2) interpersonal violence and 3) collective violence. It also classified the nature of violent acts as physical, sexual, psychological and involving deprivation or neglect.

The six papers of this Supplement address all three types of violence and contemplate certain aspects of the nature of the act itself. Three articles reviewed factors that can lead to later aggressive behaviour in general (Mendes et al.'s⁵), to the prevalence of mental disorders in low and middle income countries (Ribeiro et al.'s⁶) and the impact of child maltreatment in adult psychopathology as reflected in cortisol dysfunction (Mello et al.'s⁷). One paper considered post-traumatic stress disorder as a proxy of exposure to aggression/violence and explored its comorbid association with mood and anxiety disorders (Quarantini et al.'s⁸). Santos et al. analyzed a specific case of self-directed violence i.e., a suicide attempt in an emergency hospital in Rio de Janeiro, whereas Prado-Lima took the practical stance of presenting the basis for a rational pharmacological approach to treat impulsivity and aggressive behaviour.^9,10

If, on one hand, these papers reveal the bad news that victims of violence suffer not only the immediate effects of violence soon after exposure but also its persisting and possibly life-long negative effects, on the other hand, the good news is that by learning about the mechanisms through which violence affects human beings, a door can be opened for the development of preventive interventions in association with evidence-based pharmacological interventions to control brain structure and mechanisms that result in aggressive/impulsive behaviour.

Global violence in general and in Brazil in particular have reached such unprecedented levels that, according to a poll conducted in three of Brazil´s largest cities, citizens have ranked security as their top priority. (http://www.comunidadesegura.org/files/pesquisavitimizacao2002.pdf). Likewise, according to another national coverage poll conducted by the Brazilian Senate, 86% of those interviewed said that violence has not only increased in recent years bit also that they expect it will continue to grow in the coming years (http://www.senado.gv.br/sf/senado/centralderelacionamento/sepop/pesquisa). This is particularly relevant in view of the fact that preventing either all or most forms of violence is a task that is currently beyond our reach.

This supplement is a testimony to the noteworthy interest that psychiatrists and other health professionals presently have in both understanding and contributing to reducing the impact of violence at its different levels, studying not only as an academic subject but also as a social issue that has to be addressed and settled. In other words, a well concerted effort in an attempt at being part of the solution rather than being part of the problem. However, in spite of the extensive ground covered by the present papers, much more remains to be further explored and fully comprehended.

It is our hope that the papers herein included will elicit the interest of other professionals so that they too can contribute to finding a solution to what is obviously a social problem requiring the adoption of various different approaches. The solution for this problem, however, will only be found in the distant future. In any event, the sooner we address this issue, the higher the likelihood that we will understand and be better prepared to manage it. That is definitely a task for many.

José Manoel Bertolote

Department of Neurology, Psychology and Psychiatry, Botucatu

Medical School, Universidade Estadual de São Paulo (UNESP),

Botucatu (SP), Brazil

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References

• 1. Large M, Smith G, Swinson N, Shaw J, Nielssen O. Homicide due to mental disorder in England and Wales over 50 years. Br J Psychiatry. 2008;193(2):130-3.
• 2. Lorenz K. On Aggression San Diego: Harcourt Brace; 1966.
• ³
  3. World Health Organization. Global Consultation on Violence and Health. Violence: a public health priority Geneva: World Health Organization; 1996. (document WHO/EHA/SPI.POA.2)
• 4. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. World report on violence and health Geneva: World Health Organization; 2005.
• 5. Mello MF, Faria AA, Mello AF, Carpenter LL, Tyrka AR, Price LH. Childhood maltreatment and adult psychopathology: pathways to HPA axis dysfunction. Rev Bras Psiquiatr. 2009;31(Supl II):S41-8.
• 6. Ribeiro WS, Andreoli SB, Ferri CP, Prince M, Mari JJ. Exposure to violence and mental health problems in low and middle-income countries: a literature review. Rev Bras Psiquiatr. 2009;31 (Supl II):S49-57.
• 7. Prado-Lima PA. Pharmacological treatment of impulsivity and aggressive behavior. Rev Bras Psiquiatr. 2009;31(Supl II):S58-65.
• 8. Quarantini LC, Netto LR, Andrade-Nascimento M, Galvão-de Almeida A, Sampaio AS, Miranda-Scippa A, Bressan RA, Koenen KC. Comorbid mood and anxiety disorders in victims of violence with posttraumatic stress disorder. Rev Bras Psiquiatr. 2009;31(Supl II):S66-76.
• 9. Mendes DD, Mari JJ, Singer M, Barros GM, Mello AF. Estudo de revisão dos fatores biológicos, sociais e ambientais associados com o comportamento agressivo. Rev Bras Psiquiatr. 2009;31 (Supl II):S77-85.
• 10. Lovisi GM, Santos SA, Legay L, Abelha L, Valencia E. Epidemiological analysis of suicide in Brazil from 1980 to 2006. Rev Bras Psiquiatr. 2009;31(Supl II):S86-93.

Publication Dates

• Publication in this collection
  24 Nov 2009
• Date of issue
  Oct 2009