Prevalence and Impact of Abuse Experienced by Persons with Severe Mental Illness: A Systematic Review

Abstract

Severe mental illness (SMI) and victimization are intersectional as one preceded the other. This study estimated the prevalence rates of different forms of abuse and the multidimensional impact of abuse among persons with SMI. Eleven electronic databases were searched for studies published during 2010–2021. A total of 38 studies in English were included if full-text articles published in peer-reviewed journals; cross-sectional, cohort, and case–control studies; measuring abuse among males and females ≥16 years with psychiatric illness but excluded studies if focusing on populations such as prisoners or homeless, or individuals with substance abuse or intellectual developmental disorder; review articles, qualitative studies, case series, and experimental studies. A total of 76,499 participants with SMI were included in 28 (73.7%) cross-sectional studies, 3 (7.9%) case–control studies, and 7 (18.4%) cohort design studies. The prevalence of physical abuse ranged from 5% to 64% among men and 6–37.7% among women; sexual abuse ranged from 3% to 22.9% among men and from 2% to 62% among women; psychological abuse was 27% among men and women ranging from 39% to 83%; domestic violence ranged from 14.8% to 95.2% among men and from 10% to 67% among women, and criminal victimization ranged from 3.5% to 70% among the mixed psychiatric sample. The systematic review showed the following significant impact: poor clinical outcomes; physical injury; higher level of depression, anxiety, somatic symptoms, and self-harm tendencies among women, and substance abuse and aggressive behavior among men; role strain; parentification; social withdrawal and interpersonal difficulties. Psychiatric populations were at higher risk of victimization by multiple perpetrators at different points in time. Physical abuse was easily identified and reported largely; but sexual and emotional abuse present subtly, depends upon clinician skills, judgment, and confidence to explore and report. Often, victimization has a negative impact on physical and mental well-being, relationships, and community life.

Introduction

Abuse is a broad term, and it may take the form of physical abuse, sexual abuse, and psychological abuse, whereas violence is one of its forms (Burge 1998). There is an increasing tendency in the literature to use both the terms interchangeably, or regard them as synonymous or make little distinction between them (Burge 1998; Chapman and Styles 2006; Whitehead 2004). However, it is important to make the distinction between the two as evidence also suggests that when using both terms for the study, it is important to differentiate between the type of behavior (e.g., violent or abusive) and type of relationship (e.g., familial or in a social context) we intend to study (Rakovec-Felser 2014; Walker 1999).

The Council of Europe defines violence as violating an individual's fundamental right to life, dignity, liberty, security, and equality, leading to discrimination, exclusion, and disintegration of physical and mental state (Meyersfeld 2012). Pence et al. (1993) describe the key elements in the definition of abuse as power that perpetrator holds over the victims and strategies used by the perpetrator to maintain control over the victims in terms of verbal insults, physical assaults, threats, intimidation, economic control, isolation, and minimization.

Psychiatric disorders and interpersonal violence are intersectional. Shah et al. (2018) reported that exposure to domestic violence, especially emotional and sexual abuse, can lead to a three- to fivefold increase in the risk of developing delusions, hallucinations, and formal thought disorder. A systematic review indicated that with the increase in severity of mental illness, the risk of domestic violence also increases as the mean prevalence of past-year domestic violence was 33% among female outpatients, 30% among female in-patients, and 32% among male in-patients and outpatients (Oram et al. 2013).

Furthermore, multiple studies suggested that men were at higher risk of violent victimization, such as physical assault and robbery, whereas females were at higher risk of sexual abuse, sexual harassment, threats, and coercive controls (Hughes et al. 2012; Oram et al. 2013). There was a significant association between treatment-resistant psychotic symptoms (e.g., delusions and hallucinations) and physical and sexual abuse, especially among those who had a severe mental illness (SMI) such as schizophrenia, as reported by observational studies with a larger sample size (Khalifeh et al. 2016; Maniglio 2009; Walsh et al. 2003). Persons with Severe Mental Illness (PwSMI) were twofold to a 100-fold higher risk of domestic violence (physical, sexual, and emotional) compared with the general population (de Vries et al. 2019a).

It is apparent that the prevalence of abuse varies widely across studies, which are due to the different methods of assessments such as single validated or nonvalidated tools, the use of interviewer-rated questionnaires to self-report by the participants, and differences in the characteristics of the samples (de Vries et al. 2019a; Khalifeh et al. 2016; Oram et al. 2013). However, the literature gives a bleak picture of the prevalence, reporting higher among PwSMI (de Vries et al. 2019a; Orchowski and Gidycz 2012).

Consequently, there is a need to explore multiple manifestations of abuse in the form of physical, sexual, and psychological abuse, as previous reviews have mainly focused on one or the other aspects of abuse. Exploring the prevalence of abuse by taking a broader definition will also help design interventions to prevent violence experienced by PwSMI, as most interventions are planned based on prevalence studies focusing on the general population (Evans et al. 2016). However, the results of these studies cannot be generalized to the SMI population as the nature and severity of abuse may differ.

Victimization can occur within a family or more extensive social system, but the potential negative consequences of victimization on individuals can be throughout their life span (Swartz and Bhattacharya 2017). Literature has consistently indicated that victimization is associated with poor quality of life and greater treatment resistance among psychiatric populations, affecting the course of illness and the outcome of the treatment (Bengtsson-Tops and Tops 2007; Brekke et al. 2001; Hiday et al. 2001; Khalifeh et al. 2016).

Moreover, the impact of trauma is more pervasive and severe as it increases with associated individual factors such as addiction or noncompliance to medication and adverse social context in the form of homelessness, poverty, or socially deprived neighborhoods (Swanson et al. 2002). It is essential to know the severity of impact from the clinical and public health perspective as victimization of PwSMI is related to higher utilization of services due to injuries and medical comorbidities, poor physical and mental health outcomes, and higher functional impairment, which act as a barrier to reintegrate the person within a community (Coker et al. 2005; Choe et al. 2008; Devries et al. 2013). Nevertheless, no reviews try to look at the multidimensional impact of abuse on treatment outcome, physical or psychological health, family, and social life, which will give a broader perspective to design a framework for the interventions and prevention of violence.

The current review aims to update and expand data on the prevalence of abuse and the multidimensional impact of abuse among men and women with SMI.

Methods

Search strategy

This systematic review was conducted following Vandenbrouckel et al. (2007), Strengthening the Reporting of Observational Studies in Epidemiology (STROBE), and Moher et al. (2009), Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA-P), guidelines. The study protocol was registered on the PROSPERO international prospective register of systematic reviews vide CRD42020163292.

Eleven databases were searched: PubMed, SCOPUS, OVID, EBSCO-Host, ProQuest, Directory of Open Access Journals (DOAJ), Web of Science, Sociological Abstract, ERIC, PLOS One, and JSTOR. The search considered papers published between 2010 and 2021 with a preference for English language articles using a combination of Medical Subject Headings (MeSH) and keywords.

The following search terms were used: “Severe Mental Illness” OR “Severe Mental Disorder” OR “Schizophrenia” OR “Schizoaffective” OR “Bipolar Affective Disorder” OR “Bipolar” OR “Major Depressive Disorder” OR “Recurrent Depressive Disorder,” AND “Violence” OR “Assault” OR “Maltreatment” OR “Neglect” OR “Victimisation,” AND “Burden” OR “Morbidity” OR “Disability” OR “Psychopathology” OR “Treatment Outcome” OR “Impact Psychological Health” OR “Impact Physical Health” OR “Impact Family Life” OR “Impact Social Life.”

A complete search strategy and database search terms can be accessed on Open Science Framework. These searches were supplemented by backward and forward citations of included studies, hand searching of studies from Google Scholar and universities' repositories, and expert recommendations.

Selection criteria

Studies were eligible for inclusion if they included full-text articles published in English in peer-reviewed journals. The type of studies was cross-sectional, cohort, and case–control. Other inclusion criteria were studies that measure abuse among males and females with psychiatric illness who are ≥16 years; studies that reported abuse patterns, prevalence, and impact. When the reviewers identified multiple eligible research papers from the same study, only the main article was included, which reported the maximum number of participants with the latest data relevant to the current review's objectives.

We excluded studies focusing on selected populations affected by abuse (e.g., prisoners or homeless, or individuals with substance abuse or intellectual developmental disorder), considering it as one of the confounding factors for the findings of current review. We also excluded qualitative studies, case series, review articles, and experimental studies (e.g., randomized control trials, parallel-group studies).

Study selection

Two reviewers, A.R. and S.G.P., screened the titles and abstracts of studies that met the inclusion criteria. Further, the same two reviewers assessed the full text of potentially eligible studies, which met the inclusion criteria (refer to Fig. 1), and discrepancies were ruled out after discussion with the third reviewer V.K.S. to reach an agreement between the reviewers.

FIG. 1.

PRISMA flow chart (Moher et al. 2009).

Data extraction

The two reviewers, A.R. and S.G.P., developed the data extraction form based on the Cochrane handbook guideline for systematic reviews and the STROBE checklist. The data extraction consisted of five subsections, which provided information on the following:

Study characteristics (e.g., study design, setting, and location).

Study participants (e.g., sample size, sampling method, and inclusion/exclusion criteria).

Exposure (e.g., type of diagnosis, sources of diagnosis, and criteria for diagnosis).

Outcome (e.g., type of abuse or violence, which was determined by taking into consideration Pence et al.'s definition and Council of Europe definition, time frame of abuse in which incident occurred, and measurement tool used).

Result (e.g., information on the prevalence of abuse—gender-wise or specific diagnosis, or with or without comorbidity, and multiple impacts of abuse).

The researchers (A.R. and S.G.P.) independently extracted data from the selected studies. The authors were contacted for further information if studies had collected data on abuse's prevalence and impact but had not reported it. In addition, a third researcher not otherwise involved in this project compared the completed extracted forms to identify discrepancies in the extraction form and identified rater agreement on >90% of items extracted from a total of 38 included studies.

Quality appraisal

Two reviewers, A.R. and V.K.S., independently appraised the quality of included studies, and the reviewers' disagreement was settled through discussion. The reporting quality of included studies was assessed using the Newcastle–Ottawa Quality Assessment Scale for case–control and cohort studies (Wells et al. 2016). A modified version for cross-sectional studies was used. Each study received up to 10 stars for methodological quality of cross-sectional studies, and up to nine stars for case–control and cohort studies. Studies that scored above the median stars were considered high-quality studies and were included in the review, though meeting other inclusion criteria. The quality appraisal checklist is uploaded online as a Supplementary Document.

Data availability statement

Data can be found on Open Science Framework (https://osf.io/h8d2n/?view_only=f951f557a9fd44ecbc45d8b39fdda5fb).

Results

This study reports prevalence for physical, sexual, or psychological abuse; otherwise, we used prevalence for domestic violence. Thirty-eight studies reported the prevalence of any or specific abuse (regardless of perpetrators) with a total of 76,499 participants with SMI. The characteristics of included studies are mentioned in Table 1, and details about the prevalence of abuse are mentioned in Table 2.

Table 1.

Summary of Characteristics of Prevalence Studies (n = 38)

Characteristics	Time frame of abuse
	Combination of the two	Recent	Lifetime
	Number of studies
Countries
The United Kingdom	2	1	3
America (e.g., the United States, Brazil)	—	5	3
Rest of Europe	1	7	3
Oceania (e.g., Australia, New Zealand)	—	1	1
Africa (e.g., Nigeria or Ethiopia)	1	2	—
Asian countries (e.g., India, China)	—	2	2
Other countries (e.g., Egypt, Turkey, Canada)	—	2	2
Study design
Cross-sectional	3	15	10
Case–control	—	1	2
Cohort	1	4	2
Sample size
<100	—	2	5
100–500	2	10	5
500–1000	—	3	—
>1000	2	5	4
Sample
Male only	—	—	—
Female only	1	3	2
Males and females	3	17	12
Diagnoses
Schizophrenia spectrum disorder	—	4	3
Bipolar disorder	—	1	1
Depressive disorder	—	—	—
Schizoaffective disorder	—	—	—
MMD	2	8	1
SMI	2	4	3
CMD	—	2	6
Any of the above	—	1	—
Assessment of mental disorders
Self-reported	—	2	—
Casefile review/database	—	1	1
ICD-10/DSM-IV criteria	1	1	4
Validated measurement tool	2	8	4
Any of the above	1	8	5
Type of abuse
Verbal abuse/psychological abuse	—	—	—
Physical abuse	—	2	—
Sexual abuse	—	—	1
Domestic violence	2	7	9
Violent and nonviolent crime	2	11	4
Time frame of abuse
Recent (10 weeks–5 years)	—	20	—
Lifetime	—	—	14
Any of the above	4	—	—
Perpetrator
Partner only	2	1	3
Family only	2	1	2
Other (acquaintance, strangers)	—	3	—
Any of the above	—	1	1
Not reported	—	14	8
Assessment of abuse
Self-reported	—	2	—
Validated measurement tool	2	6	5
Nonvalidated measurement tool	2	12	9

MMD (major mental disorder), mood disorder, schizophrenia spectrum disorder, substance abuse disorder; SMI (severe mental illness), schizophrenia, bipolar affective disorder, major depressive disorder, schizoaffective disorder; CMD (common mental disorder), mood disorder, somatoform disorder, schizophreniform disorder, anxiety spectrum disorder, personality and behavioral disorder.

Table 2.

Prevalence Rates and Impact of Abuse on Persons with Psychotic Disorders (n = 38)

S. No.	Study and Year	Study Design/setting	N	Gender	Diagnosis	Type of abuse	Prevalence with time frame	Impact of abuse	Quality score
1	Zarchev et al. (2021) The Netherlands	CS Household survey (regional)	956	Males and females	Psychosis, bipolar, major depression	VV and NVV	Past 1 year: Victimization was highest in living in sheltered housing (50.8%), followed by living alone (43%) than living with family (37%)	—	9/10
2	Wang et al. (2020) China	CS OP (local)	487	Males and females	SZ	Violent crime	Victimized (18.9%) in past 6 months	—	9/10
3	Gatov et al. (2020) Canada	Cohort IP and OP (local)	50,832	Males and females	Schizophrenia spectrum, MD, anxiety	PA, SA, EA	Lifetime prevalence: SA (72.2%), EA (62.1%), PA (61.1%)	Increased acute psychiatric care (55.5%). Inability to care for self (25.4%) Self-harm tendencies (57.1%)	6/9
4	Harris et al. (2020) The United States	Cohort OP (multicenter)	184	Males and females	Schizophrenia spectrum, SZ, major depression, bipolar	VV	Past 1 year: VV before baseline assessment (57%) VV reported in follow-up (18%)	—	8/9
5	Tasa- Vinyals et al. (2020) Spain	CS OP (local)	102	Males and females	SZ, SZA, bipolar	Any IPV, PA, SA, PsyA	Lifetime prevalence: Any IPV (24.5%), PA (20.6%), SA (3.9%), PsyA (8.8%)	—	6/10
6	El Missiry et al. (2019) Egypt	CS IP and OP (local)	300	Males and females	SZ, bipolar, major depression	EA PA MA	Past 1 year: 43.3% were victimized, whereas 56.7% were nonvictimized. All victimized subjected to EA. 64.6% were subjected to PA. 53.8% were subjected to MA.	Severe functional impairment in the victimized group (47.75 ± 15.56)	5/10
7	de Vries et al. (2019a, 2019b) The Netherlands	Cohort IP and OP (multicenter)	Patient group (353) Comparison group (9135)	Males and females	SZ, SZA, psychotic	VV and NVV	Past 1 year: Property crime (18.8% patients vs. 11.3% comparisons) Vandalism (6.6% in patients vs. 9.3% comparisons) Personal crime (9.7% patients vs. 4.5% comparisons) Other crime (4.% patients vs. 0.8% comparisons)	—	7/9
8	Bhavsar et al. (2019) London	Cohort Household survey (local)	Patient group (369) Comparison group (629)	Males and females	Psychosis, common mental disorder, PTSD, PD, psychotic	Physical abuse, witness violence	Lifetime exposure to any violence at baseline (45.8% patients vs. 54.2% comparisons) 19.2% have either physically abused or witness violence at follow-up.	—	9/9
9	Ram (2017) India	CS OP (local)	100	Only females	SUD, SZ, bipolar, anxiety	PA, EA, SCA, H	Past 1 year: Any abuse (86%), EA (83%), SCA (68%), PA (62%), H (60%)	Role strain (58%) and parentification of eldest child (24%)	6/10
10	Afe et al. (2017) Nigeria	CS OP (local)	79	Only females	SZ	IPV, VA, PA, SA	Past 1 year: Any form of IPV (73%), VA (71%), PA (51%), SA (24%)	Bruises (49%)	7/10
11	Monahan et al. (2017)	CS OP (multicenter)	951	Males and females	SZ, bipolar, depression, SUD, PD	VV	Past 1 year: any (43%)	—	6/10
12	Anderson et al. (2016) London	CS OP (multicenter)	318	Males and females	SZ, schizotypal and delusional, bipolar, MD, PD, behavioral	DV, SA	Lifetime prevalence: DV (46.86%), SA (34.59%)	—	9/10
13	Afe et al. (2016) Nigeria	CS OP (local)	77	Only females	SZ	VA, PA, SA	Past 1 year: At least one type of IPV (75%), VA only (73%); PA only (53%), SA only (25%), VA and PA (49%), VA and SA (25%); VA, PA, and SA (10%).	—	7/10
14	Bhatia et al. (2016)	CS OP (local)	406	Males and females	Bipolar, depression, anxiety, psychotic, OCD	PA, EA, SA	Lifetime prevalence: Any (72%) PA (39%) SA (21%) EA (64%)	—	5/10
15	Khalifeh et al. (2015a) England	CS OP (multicenter)	Patient group (303) Comparison group (22,606)	Males and females	Schizophrenia spectrum, bipolar, recurrent depression, PD, other disorder	DV, SA	Any DV in a lifetime (57.75% patients vs. 25.52% comparisons). Any SA in a lifetime (37.95% patients vs. 12.86% comparisons)	Physical injuries (49% patients vs. 40.4% comparisons) Psychological/social (91.8% patients vs. 64.2% comparisons) Suicidal attempts (53.1% patients vs. 3.4% comparisons)	8/10
16	Khalifeh et al. (2015b) England	CS OP (multicenter)	Patient group (361) Comparison group (3138)	Males and females	Schizophrenia spectrum, bipolar, depression, MD, PD, psychotic	VV and NVV	Past 1 year: Any assault (60.5% patients vs. 10.8% comparisons)—PA (46% patients vs. 8.8% comparisons) SA only in females (9.4% patients vs. 2.3% comparisons) DV (18.4% patients vs. 3.6% comparisons) Community violence (19.6% patients vs. 5.1% comparisons)	Injury (8.4% patients vs. 47.9% comparisons) Anxiety/depression/panic attack (50.9% patients vs. 19.5% comparisons). Low self-esteem/social withdrawal (60.4% patients vs. comparisons) Financial loss (25% patients vs. 16.1% comparisons) Physical health problems (37.3% patients vs. 28.7% comparisons)	9/10
17	Karakoc et al. (2015) Turkey	CS OP (local)	Patient group (100) Comparison group (30)	Only females	Depressive disorder	PA, SA, EA, FA (during pregnancy)	Lifetime prevalence: PA (64% patients vs. 26.7% comparisons) EA (73% patients vs. 33.3% comparisons) FA (51% patients vs. 10% comparisons) SA (48% patients vs. 20% comparisons)	Suicidal ideation (67.2% patients vs. 33.3% comparisons) Suicidal attempt (45.3% patients vs. 16.7% comparisons)	7/10
18	de Mooij et al. (2015) The Netherlands	CS IP, OP, and sheltered housing (multicenter)	216 (OP- 89, IP-51, sheltered housing-76)	Males and females	SZ, psychotic, other disorder, dual diagnosis	VV and NVV	Past 1 year: Any crime (41.6% outpatients, 27.6% sheltered housing, 58.9% in-patients, and 42.3% comparisons). Violent crime (22.5% outpatients,15.8% sheltered housing, 35.3% in-patients, and 8.5% comparisons). Property crime (15.7% outpatients, 13.2% sheltered housing, 47.1% in-patients, and 26.2% comparisons). Vandalism (11.2% outpatients, 9.2% sheltered housing, 19.6% in-patients, and 23.1% comparisons).	—	9/10
19	Silver et al. (2011) New Zealand	Birth cohort	No mental disorder (562), any mental disorder (388)	Males and females	Depression, anxiety, schizophreniform, alcohol and marijuana dependence	VV and NVV	Past 1 year Any mental disorder group: threatened PA (21.5%), attempted PA (12.6%), completed PA (33.8%), SA (38.9%). Schizophreniform group: threatened PA (44.7%), attempted PA (15.6%), completed PA (57.9%), SA (13.2%). Depression group: threatened PA (21.4%), attempted PA (11.9%), completed PA (31%), SA (10.7%). Anxiety group: threatened PA (20.7%), attempted PA (9.8%), completed PA (28.5%), SA (11.9%).	—	8/9
20	Meijwaard et al. (2015) The Netherlands	CS OP (multicenter)	Patient group (300) Comparison group (10,865)	Males and females	Depression, SUD, SMI	VV and NVV	Past 1 year: Victimized (61% patient group vs. 46.9% comparison group). VV (33% patient group vs. 9.5% comparison group) NVV (36.3% patient group vs. 29.2% comparison group).	—	7/10
21	Yildirim et al. (2014) Turkey	CS OP (local)	70	Only females	SZ	PA, EA, EN, SH, SA	Lifetime prevalence: Any SA and PA (87.1%) followed by PA only (81.40%). EA only (78.60%), EN only (55.70%), any sexual trauma (34.3%), SH only (28.60%), SA only (24.30%)	—	8/10
22	Tsigebrhan et al. (2014) Ethiopia	CS Household survey (Regional)	Patient group (201) Comparison group (200)	Males and females	SZ, bipolar	VV	Lifetime victimization: 66.7% in SMI group vs. 44.0% in comparison group.	—	8/10
23	Teasdale et al. (2014) The United States	Cohort Community	262	Males and females	Schizophrenia spectrum, manic spectrum, depression, SUD	PA	23% were victims at baseline. 64% revictimized during 1-year follow-up.	—	6/9
24	Muenzenmaier et al. (2014) The United States	Cohort OP (multicenter)	183	Males and females	Schizophrenia spectrum, bipolar, major depression, other disorder	PS, SA	Adulthood victimization (59.89%), PA (70.64%), SA (28.44%).	PTSD symptoms (79.78%) Dissociative symptoms (13.3%) Self-harm tendencies (33.15%)	6/9
25	Cases et al. (2014) Spain	CS OP (multicenter)	142	Only females	SZ, PD, bipolar, psychotic	PA, SA, PsyA	Lifetime victimization (79.6%)	Interpersonal difficulties (62.2%)	6/10
26	Fortugno et al. (2013) Europe	CS IP (multicenter)	English sample (343) European sample (543)	Males and females	Schizophrenia spectrum	PA	Past 1 year: English sample (37.8%) and European sample (28%)	—	8/10
27	Crisanti et al. (2014) The United States	CS OP (multicenter)	2209	Males and females	Schizophrenia spectrum, MD	VV and NVV	Past 6 months: any crime (25.4%), NVV (20.3%), VV (12.2%)	—	5/10
28	Short et al. (2013) Australia	CC Victorian Psychiatric Case Register & Database from state electoral role	Patient group (4168) Control group (4641)	Males and females	Schizophrenia spectrum	VV and NVV	Lifetime prevalence: any crime: 28.7% cases vs. 39.1% controls. VV: 10.1% cases vs. 6.6% controls. NVV: 25% cases vs. 36.8% controls.	—	7/9
29	Katsikidou et al. (2012) Greece	CC Cases: Ops (Regional) Controls: Relative of IPs	Patient group (150) Control group (150)	Males and females	SZ, SZA, bipolar	VV and NVV	Past 1 year: Theft (36.5% cases vs. 18.2% controls). Robbery/burglary (10.6% cases vs. 11.4% controls). Sexual offenses (16.7% cases vs. 8.5% controls). Assault/threat (28.7% cases vs. 8% controls). Discrimination (52% cases vs. 24% in control group).	—	6/9
30	Hart et al. (2012) Europe	CS Birth cohort	Patient group (6828) Comparison group (1858)	Males and females	Bipolar, depression, somatoform, psychosis, SUD	CV and NVV	Victimization at the age of 46: CV (18.2% patient vs. 14.5% comparison group). VV (3.5% patient vs. 1.9% comparison group).	—	9/10
31	Shannon et al. (2011) The United Kingdom	CS Case-notes review	60	Males and females	Bipolar	LT	61.7% of LT measured by THQ vs. 33.3% measured by case notes. 35% of trauma-related civil unrest was measured by TREQ vs. 3.3% by case notes.	—	8/10
32	Chang et al. (2011) The United States	CS IP, OP, and Emergency Dept. (multicenter)	428	Males and females	SZ, bipolar, depression, anxiety, PTSD, SUD	Any IPV, PA, SA, EA	Past 1 year: Any IPV (51%), any PA (38%), any SA (22%), any EA (35%). Only PA (10%), only SA (2%) PA, SA, and EA (10%); PA and EA (9%); PA and SA (6%)	—	5/10
33	Silver et al. (2011) The United States	CS Community	826	Males and females	Major mental disorder with SUD, Major mental disorder without SUD, Other mental disorders with SUD	VV	Ten weeks postdischarge: VV (19%)	—	8/10
34	Fekry et al. (2012) Egypt	CS IP and OP (Regional)	48 Victimized (48) Nonvictimized (52)	Males and females	Bipolar	PA, EA, MA	Past 1 year: Victimized (48%) and nonvictimized (52%) EA (100%), PA (58.3%), MA (66.6%)	—	5/10
35	de Oliveira et al. (2012) Brazil	CS OP (multicenter)	2475	Males and females	Schizophrenia spectrum, bipolar, depression, other disorder	SA	Lifetime sexual victimization (19.8%)	—	6/10
36	Sturup et al. (2011) Sweden	CC IP, Emergency Dept. & Annual Survey of living condition (multicenter)	Cases (390) Controls (1170)	Males and females	MD, psychosis, PD, SUD, other disorder	Any victimization	Any victimization (20% cases vs. 3.8% controls)	Visible injury (14.5% cases vs. 2.9% controls) Need for medical attention (10.2% cases vs. 1.3% controls)	8/9
37	Newman et al. (2010) The United States	CS IP (multicenter)	70	Males and females	Schizophrenia spectrum	TE VV	Lifetime prevalence of TE (87%) Lifetime prevalence of VV (79%)	Lifetime PTSD diagnosis (31% had lifetime diagnosis, and 12.8% met criteria for current PTSD diagnosis) and cognitive decline (90.45 ± 12.45).	5/10
38	Mowlds et al. (2010) Ireland	CS Community	52	Males and females	Anxiety, depression	LT	Adulthood LT (90.4%) General crime (86.5%) Other crime (50%) Criminal acts (36.5%) PA/SA (34.6%)	Increase in symptom severity (13.67%)	7/10

CC, case–control; CS, cross-sectional; IP, in-patient; OP, outpatient; MD, mood disorder; PD, personality disorder; PTSD, post-traumatic stress disorder; SUD, substance use disorder; SMI, severe mental illness; SZ, schizophrenia; SZA, schizoaffective disorder; CV, criminal victimization; DV, domestic violence; EA, emotional abuse; EN, emotional neglect; FA, financial abuse; IPV, intimate partner violence; LT, lifetime trauma; MV/A, miscellaneous victimization/abuse; NVV, nonviolent victimization; PA, physical abuse; PsyA, psychological abuse; SA, sexual abuse; SH, sexual harassment; VA, verbal abuse; VV, violent victimization.

Victim–perpetrator relationship

Of 38 studies, 16 have reported the relationship between the victim (a PwSMI) and perpetrator. The majority of the studies have assessed the prevalence of lifetime or past 1-year domestic violence perpetrated either by a partner or by other family members (Afe et al. 2016; Anderson et al. 2016; Bhatia et al. 2016; Cases et al. 2014; Chang et al. 2011; Karakoc et al. 2015; Khalifeh et al. 2015a, 2015b; Tasa-Vinyals et al. 2020).

In contrast, some studies reported that acquaintances, friends, colleagues, housemates, and even strangers could perpetrate physical and sexual abuse or threats and property crime within the community (de Mooijet al. 2015; de Vries et al. 2019b; El Missiry et al. 2019; Katsikidou et al. 2013; Meijwaard et al. 2015; Monahan et al. 2017; Yildirim et al. 2014).

Prevalence of abuse (by all perpetrators)

Physical abuse

Three studies assessed the prevalence of lifetime physical abuse in female outpatients, ranging from 49.5% to 64% (Gatov et al. 2020; Karakoc et al. 2015; Muenzenmaier et al. 2014), but only one study compared it with the general population, which was reported as 26.7% (Karakoc et al. 2015), and another study reported a specific count on the (lifetime) prevalence in male outpatients as 30.6% (Muenzenmaier et al. 2014).

Only one study reported the prevalence estimates of 29.7% to 38.1% among female in-patients and 26.2% to 37.7% among male in-patients in the previous year (Fortugno et al. 2013). Four studies assessed the prevalence of past-year physical abuse in female outpatients, which ranged from 23.4% to 64% (Afe et al. 2016, 2017; Khalifeh et al. 2015a, 2015b; Ram 2017; Teasdale et al. 2014) and in male outpatients ranging from 7.5% to 22.6% (Bhavsar et al. 2019; Khalifeh et al. 2015a; Teasdale et al. 2014), and only one study compared the prevalence with the general population, which was reported as 5.3% (Khalifeh et al. 2015a).

Sexual abuse

The lifetime prevalence of sexual abuse in female outpatients reported in eight studies ranged from 8.3% to 62% (Anderson et al. 2016; de Oliveira et al. 2012; Gatov et al. 2020; Karakoc et al. 2015; Khalifeh et al. 2015a; Monahan et al. 2017; Muenzenmaier et al. 2014; Tasa-Vinyals et al. 2020), and only one study compared prevalence rates from the general population and reported it as 20% (Karakoc et al. 2015). The prevalence rates for male outpatients ranged from 6.3% to 22.9% (Anderson et al. 2016; de Oliveira et al. 2012; Khalifeh et al. 2015a; Muenzenmaier et al. 2014), and only one study compared and reported a specific count on prevalence in the general population as 3.1% (Khalifeh et al. 2015a).

Khalifeh et al. (2015b) assessed the past 1-year prevalence of sexual abuse in male outpatients, reported it as 3.2%, and compared the prevalence rates with males from the general population, which was reported as 0.32%. On the contrary, the reported prevalence of sexual abuse in female outpatients in the previous year ranged from 9.4% to 55% (Afe et al. 2016, 2017; Bhatia et al. 2016), which was compared with the reported prevalence of 2% to 2.3% in females from the general population (Khalifeh et al. 2015a, 2015b). The combined past 1-year prevalence in both in-patients and outpatients was reported to be 3–32% among women and 3–4% among men (Chang et al. 2011).

Psychological abuse

In female outpatients, reported lifetime prevalence of psychological abuse (per review definition, including emotional abuse and verbal abuse) ranged from 62.1% to 83% (Gatov et al. 2020; Karakoc et al. 2015; Ram 2017), but only one study has compared the prevalence with the general population, which was reported as 33.3% (Karakoc et al. 2015). Past-year prevalence of psychological abuse in female outpatients ranged from 71% to 73% (Afe et al. 2016, 2017). The prevalence of past 1-year emotional abuse in female outpatients and in-patients was reported as 39%, and in male outpatients and in-patients as 27% (Chang et al. 2011).

Adulthood domestic violence

The prevalence of any adulthood lifetime domestic violence among male outpatients ranged from 14.8% to 95.2%, and that among female outpatients ranged from 67% to 87.1% (Anderson et al. 2016; Khalifeh et al. 2015a; Mowlds et al. 2010; Tasa-Vinyals et al. 2020). Three studies assessed past 1-year domestic violence in outpatients, with the reported prevalence among females ranging from 10% to 30.3% (Afe et al. 2016; Cases et al. 2014; Khalifeh et al. 2015b), and males reporting a specific count of 12.9% (Khalifeh et al. 2015b).

The reported prevalence in the previous year among male in-patients and outpatients ranged from 19.2% to 32%, comparatively higher than the healthy males (4.9%). Similarly in the female in-patients and outpatients, the past 1-year prevalence ranged from 27.3% to 63%, relatively higher than the healthy females, which was 2.8% (Chang et al. 2011; Sturup et al. 2011).

Criminal victimization

The reported lifetime prevalence of violent crime in the psychiatric population ranged from 10.1% to 66.7% (Crisanti et al. 2014; Short et al. 2013; Tsigebrhan et al. 2014), whereas the reported prevalence in the general population was relatively low, ranging from 6.6% to 44.0% (Harris et al. 2020; Tsigebrhan et al. 2014). The reported lifetime prevalence of nonviolent crime in the psychiatric population varied from 2.5% to 12.2%, while it was as high as 36.8% in the general population (Tsigebrhan et al. 2014).

Six studies have assessed a larger representative sample of psychiatric population receiving in-patient and outpatient services for 1–5 years (Harris et al. 2020; Hart et al. 2012; Meijwaard et al. 2015; Tsigebrhan et al. 2014; Wang et al. 2020; Zarchev et al. 2021). The prevalence estimates varied for the type of crime in different populations: property crime in the psychiatric population (18.8–36.3%) and general population (3.5–30.5%); vandalism in the psychiatric population (6.6–20.7%) and general population (0.9–9.3%); and personal crime in the psychiatric population (9.7–28.2%) and general population (4.5–5.1%).

Impact of abuse

The main impact dimensions were treatment outcome, physical health, psychological health, family, and social life (Table 2).

Impact on treatment outcomes

Four studies reported the impact of abuse on the treatment outcome. PwSMI who are abused are less likely to come for follow-up and have increased postdischarge risk of visiting the emergency department due to symptom elevation or risk of self-harm, which also increases the duration of in-patient care and leads to frequent rehospitalization (Gatov et al. 2020; Newman et al. 2010). In addition, individuals with SMI are at higher risk of discharge against medical advice (RR = 1.27, 95% CI = 1.21–1.33) due to retraumatization, which could be as a result of lack of familiarity with the in-patient unit, hierarchal structures of the institutions, and restrictive environment (Mowlds et al. 2010).

Impact on physical and psychological health

Studies have reported that the psychiatric population are more prone to experience severe bodily injury, and develop physical health problems that require medical attention through in-patient care or visits to the emergency department than the general population (Afe et al. 2017; Khalifeh et al. 2015a, 2015b; Sturup et al. 2011). Men and women with SMI who experienced abuse also reported severe impairment in their sociooccupational functionality (El Missiry et al. 2019).

The psychological impact was higher than the other impact dimensions in 16 included studies. Women with psychiatric disorders exposed to physical, sexual, or psychological abuse had a higher level of depression, anxiety, post-traumatic stress disorder (PTSD), somatic symptoms, and suicidal ideation compared with men with psychiatric disorders who had attempted suicide by taking an overdose of medicines or had self-inflicted injuries on their body and substance abuse, and men as well as women in the general population (Gatov et al. 2020; Karakoc et al. 2015; Khalifeh et al. 2015a, 2015b; Mowlds et al. 2010; Mowlds et al. 2010; Muenzenmaier et al. 2014).

Impact on family and social life

No study directly assessed the impact of abuse on family life. However, Cases et al. (2014) reported that when women with psychiatric disorders experience abuse, it leads to interpersonal difficulties. In addition, Ram (2017) opined that women with long-term mental illness experience repeated victimization, which could often result in difficulty performing their roles and responsibilities and parentification of their eldest child.

One study reported that the social life of PwSMI was severely impacted by decreased social interaction and difficulty in trusting others after being subjected to abuse (Khalifeh et al. 2015a).

Discussion

Prevalence of abuse

Present review findings suggest that the lifetime prevalence of any form of abuse was higher among persons with psychiatric disorders compared with prevalence in the general population, indicating that the psychiatric population are at higher risk (de Vries et al. 2019b; Katsikidou et al. 2013; Khalifeh et al. 2015a; Meijwaard et al. 2015; Sturup et al. 2011).

Further, the intersectional theory suggested a bidirectional relationship between psychotic symptoms and victimization as one precedes the other, and these experiences qualitatively differed among PwSMI and the general population (de Vries et al. 2019b). The focus of the analysis of this theory was how men and women with SMI are oppressed, discriminated against, marginalized, and isolated due to negative stereotypes and prejudice against them, and denied privileges and rights enjoyed by the general population (Tasa-Vinyals et al. 2020).

Intersectionality as a framework for analysis has been criticized. It focuses on macrolevel factors such as social identities, structures, and hierarchies, making it too broad in concept and lacking specific goals of interventions that are possible to prevent violence (Tomlinson 2013). It also fails to understand how mental illness intersects with other socially powerful determinants (e.g., sexuality, caste, class, etc.) to exclude, devalue, and victimize PwSMI, which often results in a perceived sense of helplessness, disempowerment, and poor help seeking (King et al. 2019; Oexle and Corrigan 2018; Turan et al. 2019).

Most of the studies in this review have reported abuse in individuals with different psychiatric disorders, hence it is difficult to say a specific disorder is related to a particular abuse type. However, a few studies have focused on specific disorders such as schizophrenia spectrum disorder (Afe et al. 2016, 2017; Fortugno et al. 2013; Newman et al. 2010; Short et al. 2013; Wang et al. 2020; Yildirim et al. 2014) and depressive disorder (Karakoc et al. 2015; Silver et al. 2011).

On the contrary, it is difficult to generalize the findings of these studies as it has assessed the prevalence of different forms of abuse (e.g., physical, emotional, or sexual abuse; violent and nonviolent crime) in a different time frame (e.g., childhood, lifetime, or 1 year) and in different psychiatric settings (in-patients, outpatients, and community setting). Most of these studies have also used a different method to assess abuse, either by doing case-note analysis retrospectively or by using a short validated or nonvalidated screening tool, either self-administered or administered by the researcher in a face-to-face interview.

More than half of the studies included in the review have not identified perpetrators of abuse. Studies that have assessed perpetrators have mostly reported that PwSMI were subjected to domestic violence by partners and family members such as parents, grandparents, or siblings. This could be due to an increased need for supervision of PwSMI's day-to-day activities, resulting in expressed emotion and emotional or financial exhaustion in family members (Howard et al. 2010; Loughland et al. 2009).

Studies have suggested that PwSMI are vulnerable to physical or sexual victimization by multiple people at different points in time because of impairment in personal judgment, reality testing, difficulty identifying high-risk situations or asserting themselves, poverty, unemployment, and poor social support, which was consistent with our findings (Chandra et al. 2003; Pettitt et al. 2013; Trani et al. 2015).

Many studies in this review have concluded that women can experience domestic violence. In contrast, men can experience domestic and community-based violence. However, reporting of cases of domestic violence, in particular, is relatively low for men with SMI because of feeling ashamed, confused, embarrassed, fear of being disbelieved or judged, and low self-esteem often make them rationalize abuse, emotional blunting leading to difficulty to understand and report abuse, financial and emotional dependence on family members, and gender stereotypes, which is consistent with the findings of the previous studies (Oram et al. 2013; Rose et al. 2011; Zarchev et al. 2022).

Impact of abuse

Gatov et al. (2020) reported that psychiatric in-patients were more likely to visit their family physician if they were traumatized rather than consulting a psychiatrist. One recent review found that interpersonal violence is linked to higher health care utilization. It can often lead to dropout from psychiatric treatment, poor clinical outcomes, and increased need for repeated hospitalization (Latalova et al. 2014).

There is also increasing evidence that trauma plays an essential role in developing psychiatric comorbidities. Mowlds et al. (2010) have explained the impact of trauma on PwSMI through the vulnerability stress model. The model states that if a PwSMI develops PTSD, they re-experience traumatic memories, increasing the illness's symptom severity and chronicity. However, traumatic experiences have a more significant effect on women with SMI because women, in general, tend to respond to stress with increased psychological stress, which is an effect of gender-based socialized response to adversity in life (Axinn et al. 2013; Canetto 2019; Chandra et al. 2003).

According to Meijwaard et al. (2015), the substance can be used to cope with negative feelings of powerlessness, humiliation, or sadness, especially when men with a psychiatric disorder experience repeated victimization. Men typically exhibit externalizing traits while under stress and have difficulty with affect regulation (Axinn et al. 2013; Umberson et al. 2012). Further, as seen in previous studies, men with SMI are less likely to disclose suicidal ideation if it occurs because of prevalent gender stereotypes about help seeking; as a result, they can have higher rates of attempted suicide (Choe et al. 2008; de Vries et al. 2019b; Latalova et al. 2014). However, we cannot generalize the findings of these studies due to heterogeneity in settings, populations, and measures used to assess the impact of abuse.

Only a few studies included the general population as a control group, and tried to assess the differential impact of abuse among the psychiatric and general populations (Karakoc et al. 2015; Khalifeh et al. 2015a, 2015b; Sturup et al. 2011). These studies suggested that PwSMI were more likely to report severe psychological and social impact of abuse than the general population. More importantly, evidence suggests that victimization of PwSMI can have severe psychosocial impacts, increasing personal, economic, and public health costs (Latalova et al. 2014; Oram et al. 2013).

In addition, victimization often worsens functionality, affects the course and outcome of treatment, and leads to poor quality of life. Thus, this vulnerable group should be prioritized in public health policies on violence prevention (Howard et al. 2010; Willie et al. 2020).

This review has provided evidence that PwSMI are more likely to disclose their feelings to their health professionals. If professionals do not explore it, it increases the feelings of helplessness, desperation, and psychological distress in PwSMI, affecting the therapeutic relationship between the two (Gatov et al. 2020; Karakoc et al. 2015; Khalifeh et al. 2015b).

Often, health care professionals have concerns about probing abuse as they feel they can offend the patient, cause anxiety by creating false memory, and lack the skills and confidence to provide interventions (Bhavsar et al. 2019; de Mooij et al. 2015; de Oliveira et al. 2012; El Missiry et al. 2019; Fortugno et al. 2013; Gatov et al. 2020; Katsikidou et al. 2013; Khalifeh et al. 2015a; Meijwaard et al. 2015; Monahan et al. 2017; Mowlds et al. 2010; Muenzenmaier et al. 2014; Ram 2017; Shannon et al. 2011; Teasdale et al. 2014; Yildirim et al. 2014). So, health institutions or organizations should provide regular training and workshops to enhance health care professionals' knowledge, skills, and expertise. They can follow models such as Community Coordinated Care (CCC) (Khalifeh et al. 2016; Nyame et al. 2013).

The CCC Model involves collaboration and coordination between various domestic violence service providers such as mental health professionals, voluntary organizations, and the criminal justice system. The service providers develop a shared understanding of violence committed against PwSMI, and try to change societal attitudes, norms, and social practices by sensitizing the community. They also try to create a support system that is available, accessible, and acceptable to the PwSMI and their family members within the community.

Strengths and Limitations

The strengths of this review involve using a comprehensive search strategy by referring to STROBE and PRISMA-P guidelines and comprehensive research updates on the prevalence of abuse based on gender, time frame, and type of abuse. New quantitative syntheses on evidence for the multidimensional impact of the abuse add more strength to the current review. The review evaluated rigorously study quality and tried to identify potential sources of heterogeneity. Those studies that were not included in previous systematic reviews and scored higher in the quality appraisal were included in this review.

We established inter-rater reliability by involving multiple researchers in screening, extracting data, and quality appraisal of included studies, which helped minimize selection and information bias. We also avoided including multiple studies using the same data set, which prevented a skewed estimate of the prevalence rate.

Heterogeneity between studies was quite significant, due to which further inference could not be made. The methodological data presented in the published articles, some of which were inadequate, hindered assessing the quality of the articles we identified and included in our review.

There were limited case–control studies and cross-sectional studies with comparison groups. Even though studies revealed that victimization prevalence was higher among PwSMI than in the general population, how much it is remains unknown. The differences in the prevalence rates of individual forms of violence between the psychiatric and general populations are also unidentified. Most studies that have reported the impact of abuse have assessed the effects on psychological health alone, rather giving importance to the fact that psychological health is also connected to the physical health and interpersonal relationship (Howard et al. 2010; Ram 2017).

Future research should consider above-mentioned factors, report the prevalence and multidimensional impact of different forms of abuse comparing it with the general population, and give information about contextual factors of abuse, which will help design primary prevention, intervention, and rehabilitative programs.

Conclusion

The review synthesizes findings from 38 studies, which reported that around one-fifth of PwSMI had experienced lifetime or recent victimization regardless of sociodemographic and clinical characteristics. The psychological impact of abuse was more severe in women than in men with SMI as they were at higher risk of developing psychiatric comorbidities such as depression, anxiety, somatoform disorder, and self-harm tendencies due to internalizing traits. There was limited evidence on the gender-based differences in the impact of abuse on family and social life. There were a few studies on the prevalence and effects of specific abuse (e.g., physical, sexual, and psychological abuse) on specific mental disorders (e.g., schizophrenia or depression) with gender-wise comparison.

Hardly any study compared the prevalence of abuse among the psychiatric population with other disabilities or medical conditions or with the general population. Future studies should address these gaps in evidence to improve the effectiveness of mental health services and provide trauma-informed care as part of the treatment plan, as evidence has suggested that trauma-focused interventions improve clinical outcomes, prevent revictimization, and empower PwSMI.

Authors' Contribution

A.R., V.K.S., and K.J.R. contributed to the study concept and design. All the authors contributed equally toward article drafting and the final article. All authors gave their approval to the final article submitted here.

Footnotes

Author Disclosure Statement

The author(s) declared no potential conflicts of interest with respect to this article's review, authorship, and/or publication.

Funding Information

No funding from any source has been received to conduct the review.

Supplementary Material

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