ATLANTA – About half of all mental health professionals at all levels and in all practice settings can expect to be threatened by a patient at some point in their career, with as many as 40% sustaining a patient-inflicted injury, according to a researcher.

Despite these numbers, there exist few formal protocols for mental health personnel to learn how to protect themselves against the risk of being harmed by a patient.

Why this is, and what can be done to fill this void, has become an area of deep interest for Dr. Michael Knable, the executive director of the Sylvan C. Herman Foundation in Frederick, Md., a major underwriter for Clearview Communities’ residential treatment facilities for persons with mental illness, where Dr. Knable is also the medical director.“I really only got interested in this because of these two friends of mine who were killed [by patients],” Dr. Knable said in an interview at the annual meeting of the American Psychiatric Association.

His two friends were Dr. Wayne Fenton and Dr. Mark Lawrence, two Washington-based psychiatrists killed in their private offices by patients in 2006 and 2011, respectively.

“It’s true that the seriously mentally ill are more likely to be victimized than to be the victimizers, but it’s also true that, especially in acute settings like emergency rooms and hospitals, that they can be very violent,” Dr. Knable said in the interview.

Based on his research, Dr. Knable said the risks to practitioners include being physically threatened, stalked, sued, stabbed, and even shot to death, among other injuries. According to statistics from the Department of Justice, between 2004 and 2009, mental health workers were second only to law enforcement officers in sustaining on-the-job violence: 38 victims per 1,000 mental health workers, compared with 48 per 1,000 law enforcement officers.

Dr. Knable conducted a literature review of all published surveys of mental health professionals ranging from those with 4-year degrees, to social workers, to psychiatrists. He found that the typical profile of a mental health provider murdered by a patient is a female case worker in her 30s who has been shot to death. The typical patient perpetrator is a male, also in his 30s, who has a form of schizophrenia, a history of violence, and non-adherence to medication. More than half of these individuals also have a history of involuntary hospitalization.

“Our field attracts a lot of idealistic people who want to help others,” said Dr. Knable. “But until they’ve experienced [violence], they simply don’t evaluate the risks carefully enough.”

The National Institute of Mental Health’s Clinical Antipsychotic Treatment Intervention Effectiveness (CATIE) trial found that 19.1% of 1,410 patients with schizophrenia had a violent episode in the prior six months.

A meta-analysis of 110 studies of more than 45,000 patients with schizophrenia also found that nearly 20% had a history of violence, and review of registry data from Sweden showed that in 82,647 patients with schizophrenia, 6.5% of men and 1.4% of women had been convicted of a violent crime when not taking their medication. When they were taking their prescribed medications, crime rates fell by 45% in the cohort taking antipsychotics and 24% in those taking mood stabilizers.

Given these data, when asked why there are not more mandatory personal security training programs for mental health personnel, Dr. Knable said it comes down to a mix of naiveté and politics.

“The perception is that if you worry about this, you are stigmatizing the patient, and, to a certain extent, you are. But my desire is to be factual and to know what we’re really dealing with,” Dr. Knable said. Those in his profession most likely to underestimate the seriousness are those in private practice who “aren’t on the front lines” treating persons with serious mental illnesses like schizophrenia.

The national debate over gun control in the context of persons with mental illness also clouds the issue, he said. “People are afraid it will be stigmatizing and keep people out of treatment to say it, but if you have had an involuntary hospitalization, you should not be allowed to have a gun.”

In addition to taking a danger assessment of a patient in the pre-screening interview, Dr. Knable recommended clinicians set up their office so that there is a desk between them and the patient, and more importantly, that the patient is not between the clinician and the exit. Have an established escape route and consider installing cameras in the waiting area so you can see patients before they enter your office. Be aware of solo meetings such as after hours or on weekends. Above all, he said it was best to see potentially violent patients only in tandem with a member of that person’s family, a colleague, or even a security officer.“Before my friends were killed, I was just like everybody else. I just went to work and thought, ‘Well, you just have to be careful.’ I thought I had good instincts. But now, I think there is a lot of room for study and training on this issue.”

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

This article was updated May 17, 2016.

Mental health workers urged to guard against the possibility of patient violence