Rates and profile of victimization in a sample of Egyptian patients with major mental illness

Abstract

Background:

Patients with major mental illness have an increased risk of victimization. Nevertheless, this topic was not thoroughly studied in Egyptian patients with major mental illness.

Objectives:

The objectives of this study are to investigate the rates of victimization and understand its profile, psycho-demographic and clinical correlates among a sample of Egyptian patients with major mental illness.

Participants and Methods:

A total of 300 patients (100 patients with schizophrenia, 100 with bipolar and 100 with major depression) were recruited from the inpatient wards and outpatient clinics at Ain Shams University. They were subjected to a demographic questionnaire, the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Global Assessment of Functioning (GAF), Clinical Global Impression (CGI) and a Victimization Questionnaire (VQ).

Results:

In our study population, 130 (43.3%) of patients were victimized, of them 52 (40%) were diagnosed with major depressive disorder, 48 (36.9%) with bipolar disorder and 30 (23.1%) with schizophrenia. Victimization was more in female, married, unemployed individuals and those living in rural areas. Patients exposed to domestic violence or abuse during childhood had higher rates of victimization. All victimized patients were subjected to emotional victimization, 64.6% were physically victimized and 53.8% were subjected to miscellaneous types of victimization. Patients were victimized mainly by acquaintance followed by family members. The majority of patients did not report their victimization and considered it as a personal issue or not important enough to be reported.

Conclusion:

Patients with major mental illness are susceptible to significant victimization. Clinicians should explore possible history of abuse or victimization in their patients, empower and support the victimized ones.

Keywords

Major mental illness victimization perpetrator physical abuse emotional abuse

Introduction

Victimization of patients with major mental illness dates back since Roman encyclopedist Celsus (~25 BC to AD ~50) who recommended ‘torture, starvation or flogging’ as treatments for mental illness (Stone, 2003).

Mentally ill patients represent a potentially vulnerable population and can be subjected to significant victimization in the community, compared to regular population (Benjet, Thompson, & Gotlib, 2010; Lehman, 1999; White, Chafetz, Collins-Bride, & Nickens, 2006).

According to international records, the yearly prevalence rate of victimization of mentally ill patients was estimated between 16% and 60%. The rates variability depends mainly upon the operational definition used (Choe, Teplin, & Abram, 2008; Dekker et al., 2010; van Weeghel et al., 2009).

‘Victimization’ is defined as the act of being a victim of any aggressive behavior (Hodgins, Alderton, Cree, Aboud, & Mak, 2007), which comprises violent victimization as rape, sexual assault, robbery and physical assault (Teplin, McClelland, Abram, & Weiner, 2005), and domestic victimization is defined as any incidence of threatening behavior or abuse such as psychological, emotional and financial ones (Fitzgerald et al., 2005; Oram, Trevillion, Feder, & Howard, 2013).

High rates of victimization among the mentally ill patients have been reported; in the US National Crime Victimization Survey, 936 patients with ‘chronic major mental illness’ were interviewed and it was found that one-quarter of them had been victims of violent crimes, a rate more than 11 times higher than the general population (US Department of Justice, 2001).

A myriad of factors increases the risk of victimization in patients with major mental illness such as cognitive impairment, impaired reality testing, poor planning and problem-solving skills, disorganized thought processes, poor confidence and impulsivity. These can hinder the individual’s ability to perceive risks and safeguard himself or herself (Goodman, Rosenberg, Mueser, & Drake, 1997). Furthermore, the severity of psychiatric symptoms, the presence of comorbid substance abuse (Brekke, Prindle, Bae, & Long, 2001), coexistent personality disorder (Walsh et al., 2003) and conflicted social relationships are all predictive factors for victimization (Silver, Arseneault, Langley, Caspi, & Moffitt, 2005). Moreover, other individual risk factors for victimization include sex, race, employment status, economic status, poor physical condition, criminal history and history of previous victimization (Ascher-Svanum et al., 2006; Dekker et al., 2010; Latalova, Kamaradova, & Prasko, 2014; Passos, Stumpf, & Rocha, 2013). Regrettably, a history of victimization is often undetected by mental health professionals and rarely influences treatment decisions (Menesini, Modena, & Tani, 2009).

Victimization is a serious issue. It has profound consequences such as the exacerbation of preexisting psychiatric symptoms, predisposing to chronicity and poor recovery, increasing hospitalization rates and substantially diminishing the quality of life of mentally ill patients. Consequently, this can significantly contribute to the increased utilization of services and the burden of mental illness. In addition, victimization may increase the likelihood of re-victimization and perpetration of violence in those patients (Kamperman et al., 2014; Oram et al., 2013; Passos et al., 2013). Although victimization of mentally ill patients has been frequently researched yet, unfortunately it was not thoroughly addressed in Egypt. This current study is the third of a series designed to investigate this topic (El Missiry, El Meguid, Soltan, & El Missiry, 2014; Fekry, Bassim, Maguid, Al Ghoniemy, & Zaki, 2011).

Objectives

We hypothesized (a) that the rate of victimization may be high among our patient population, (b) that some sociodemographic factors might be related to victimization and (c) that victimization may be more among patients who were severely or extremely ill and those who were poorly functioning. Thus, objectives of this study are to investigate the rates of victimization and understand its profile, psycho-demographic and clinical correlates among a sample of Egyptian patients with major mental illness. We aim at providing necessary information to help clinicians to identify and protect their patients and to policy makers to consider implementing statutory programs for prevention and early intervention to safeguard vulnerable individuals with mental illness.

Participants and methods

Operational definitions

We adopted an open definition to ‘Victimization’. This includes either covert/relational victimization or overt/physical victimization, in which an individual is either threatened with or subjected to corporeal damage (Cole, Maxwell, Dukewich, & Yosick, 2010).

We recruited patients with functional major mental illness and this includes those diagnosed with schizophrenia, bipolar disorder and major depression (Kamperman et al., 2014).

In this retrospective study, we recorded the incidence rates of victimization during the past year among a sample of Egyptian patients with the major mental illness.

Patients were recruited from the inpatient and outpatient departments of the Institute of Psychiatry, Ain Shams University, Cairo, Egypt. The institute is located in Eastern Cairo and serves a catchment area for about a third of Greater Cairo. It serves both urban and rural areas, including areas around Greater Cairo as well. It recruits patients mainly from middle and low social class.

Participants

A convenient sample included 300 male and female patients, aged 18 years or older, with a primary diagnosis of schizophrenia (100 patients), bipolar disorder (100 patients) and major depressive disorder (100 patients) according to Diagnostic and Statistical Manual of Mental Disorders (4th ed; DSM-IV).

The patients should have had a history of (mental illness) for at least more than 1 year, in the absence of organic mental disorder.

We recruited only patients who accepted to sign the consent and who continued the entire assessment.

Participants were interviewed in the assessment office on the inpatient department or the outpatient clinic. Each interview required about 90 to 120 minutes, sometimes divided into two sessions according to the cooperativeness of the patient.

We used the following tools:

An extensive questionnaire was designed to obtain demographic data and other relevant information, and to assess compliance with medications. In addition, we used the Fahmy and El Sherbini Scale (Fahmy & El Sherbini, 1988) for social class classification in Egyptian community.

The Structured Clinical Interview for DSM-IV Axis I Disorders SCID-I (Clinical Version; First, Spitzer, Gibbon, & Williams, 1997) is a semi-structured diagnostic interview based on an efficient but thorough clinical evaluation. It was administered by experienced and trained researchers. We used the Arabic Standardized Version by El Missiry (2003).

Global Assessment of Functioning (GAF; Jones, Thornicroft, Coffey, & Dunn, 1995) is a numeric scale (0–100) to subjectively rate the social, occupational and psychological functioning of adults – for example, how well or adaptively an individual is dealing with various problems in life.

Clinical Global Impression (CGI; Guy, 1976) is a 7-point scale that requires the clinician to rate the severity of the patient’s illness at the time of assessment, relative to the clinician’s past experience with patients who have the same diagnosis. Considering the total clinical experience, a patient is assessed on the basis of the severity of mental illness at the time of rating.

Victimization Questionnaire (VQ) is developed by El Missiry et al. (2011) . It includes inquiry about being the victim of one or more of the following: personal theft, robbery, burglary, vandalism, assault with or without a weapon, attempted assault, biased physical and verbal assault, kidnapping, threatening, blackmailing, verbal or physical sexual harassment, emotional abuse, financial abuse or different types of emotional victimization. We inquired about the frequency of perpetration in the last 12 months, type of perpetration, reporting and reasons for not reporting. This questionnaire is derived from the Criminal Victimization Questionnaire Package 2009 and the Juvenile Victimization (Finkelhor, Hamby, Ormrod, & Turner, 2005), but it was modified to fit the Egyptian culture.

Ethical issues

Ethical approval for the protocol of research was obtained from the Ain Shams University Ethical and Research Committee.

The research protocol is in compliance with the Helsinki Declaration denoting ethical principles for research involving human subjects.

The researchers obtained informed consent from participants after they were provided with a detailed description of the study and were assured of the confidentiality of information obtained. Patients were informed that participation in the study is voluntary and that they have the freedom to withdraw from the assessment at any time.

Statistical analysis

We used descriptive statistics, mean and standard deviation for continuous data, and frequencies for categorical data.

Data analysis was carried out using SPSS, Version 15. Student’s t test was used for comparison between the means of the different groups. The Pearson χ² test was used for comparison between qualitative variables; p < .05 was considered as statistically significant.

Results

Rate of victimization

The study included 300 patients who fulfilled the diagnostic criteria of the DSM-IV for schizophrenia, bipolar disorder and major depressive disorder. They were interviewed by experienced investigators to confirm the diagnosis. The entire sample of patients was assessed using VQ. Data obtained (Figure 1) revealed that 130 patients (43.3%) had been previously victimized and 170 patients (56.7%) had never been subjected to victimization. Patients with major depressive disorder were the most frequently victimized (40%, n = 52), second in line patients with bipolar disorder (36.9%, n = 48) then patients with schizophrenia (23.1%, n = 30) (Figure 2).

Figure 1.

Rate of victimization among patients with major mental illness.

Figure 2.

Diagnostic categories among victimized versus nonvictimized patients with major mental illness.

Demographic variables

Table 1 displays the demographic data, which pointed to a statistically significant more exposure of female patients (63.1%) and married patients (56.9%) to victimization compared to their nonvictimized counterparts. Patients who lived in their marital houses (60%) or patients belonged to rural areas (84.6%) were more statistically vulnerable to victimization than patients who live with their families or in urban areas. Patients who received university education were less likely to be victimized, while those who received technical education were more prone to be victimized. Housewives and unemployed patients were significantly more victimized compared to the nonvictimized group. Patients who belonged to lower social class were exposed to victimization more commonly than the other group.

Table 1.

Sociodemographic characteristics of victimized versus nonvictimized patients with major mental illness.

Variables	VictimizedN = 130			NonvictimizedN = 170			Test	p	95% confidence interval
	M/SD			M/SD					Lower	Upper
Age	34.29 ± 10.41			35.8 ± 11.0			t = 1.197	.232	0.971	3.987
	N	%		N	%
Gender
Male	48		36.9	96		56.5	χ² = 11.27	.001
Female	82		63.1	74		43.5	χ² = 11.27
Marital status
Single	34		26.2	80		47.1	χ² = 17.56	.001
Married	74		56.9	72		42.4
Separated	4		3.1	0		0
Divorced	12		9.2	12		7.1
Others	6		4.6	6		3.5
Current living status
Family house	46		35.4	96		56.5	χ² = 26.25	<.001
Marital house	78		60	58		34.1
With relatives	0		0	6		3.5
Alone	4		3.0	10		5.9
With friends	2		1.5	0		0
Educational level
Illiterate	12		7.1	14		10.8	χ² = 17.43	.008
Primary schools (6 years of education)	18		10.6	12		9.2
Preparatory schools (9 years of education)	8		4.7	8		6.2
Secondary schools (12 years of education)	14		8.2	12		9.2
Technical (14 years of education)	46		27.1	24		18.5
University (16 years of education)	58		34.1	60		46.2
Postgraduate (>16 years of education)	14		8.2	0		0
Social class
Low	68		52.3	60		35.3	χ² = 8.72	.013
Middle	42		32.3	74		43.5
Low–middle	20		15.4	36		21.2
Place of living
Urban	20		15.4	52		30.6	χ² = 9.33	.002
Rural	110		84.6	11.8		69.4	χ² = 9.33	.002
Occupation
No job	12		23.1	8		16.7	χ² = 22.96	<.001
Manual work	4		7.7	12		25
Skilled work	4		7.7	8		16.7
Semiskilled job	4		7.7	8		16.7
Professional job	4		7.7	8		16.7
Housewives	24		46.2	4		8.3

SD: standard deviation.

Family circumstances

Victimized patients were more likely to record more exposure to maternal domestic violence during their childhood (p <.001); they had more frequent emotional abuse than did the nonvictimized patients (Table 2).

Table 2.

Family circumstances of victimized versus nonvictimized patients with major mental illness.

Variable	VictimizedN = 130		NonvictimizedN = 170		Test	p
Variable	N	%	N	%	Test	p
Parental separation
No	88	67.7	122	71.8	χ² = 3.84	.279
Parents divorced	20	15.4	20	11.8
Death of one parent	20	15.2	20	11.8
Parent working abroad	2	10.5	8	40.7
Parental domestic violence
No	92	70.8	160	94.1	χ² = 29.94	<.001
Maternal violence	32	24.6	8	4.7
Paternal violence	6	4.6	2	1.2
Child abuse
No	86	66.2	150	88.2	χ² = 25.17	<.001
Emotional	12	21.5	10	5.9
Physical	28	21.5	10	26.3
Sexual	4	3.1	0	0
Family history of psychiatric disorder
No positive family history	86	66.2	110	64.7	χ² = 0.87	.645
First-degree relatives	24	18.5	38	22.4
Second-degree relatives	20	15.4	22	12.9
Family history of drug abuse
No	96	73.81	150	88.2	χ² = 20.89	<.001
First-degree relatives	20	15.4	20	11.8
Second-degree relatives	14	10.8	0	0

Despite that there was no statistically significant difference between the two groups as regards family history of psychiatric disorders, the victimized groups recorded more drug abuse problems among first- and second-degree relatives than their comparative nonvictimized groups.

Clinical variables

Victimized patients had a significantly earlier age of disease onset than the nonvictimized subjects (p = .001). No significant differences could be elicited between the two groups as regards duration of illness, psychiatric and substance abuse comorbidities (Table 3).

Table 3.

Clinical variables of victimized versus nonvictimized patients.

Variable	VictimizedN = 130	NonvictimizedN = 170	Test	p	95% confidence interval
Variable	M ± SD	M ± SD	Test	p	Lower	Upper
Age of onset	24.28 ± 9.45	28.35 ± 11.51	t = 3.278	.001	1.629	6.523
Duration of illness	8.95 ± 8.59	8.06 ± 6.97	t = 0.978	.329	0.97	0.934
	N (%)	N (%)
Psychiatric comorbidity
0. No	102 (78.5)	140 (82.4)	χ² = 0.715	.461
1. Yes	28 (21.5)	30 (17.6)
Substance comorbidity
0. No	112 (86.2)	138 (81.2)	χ² = 2.07	.354
1. Misuse	14 (10.8)	28 (16.5)
2. Dependence	4 (3.1)	4 (2.4)
Clinical Global Impression
Mildly ill	8 (6.2)	16 (66.7)	χ² = 8.83	.66
Moderately ill	54 (41.5)	44 (44.9)
Markedly ill	28 (21.5)	50 (64.1)
Severely ill	38 (29.2)	56 (32.9)
Extremely ill	2 (1.5)	4 (2.4)
	M ± SD	M ± SD			95% confidence interval
Global Assessment of Functioning	47.75 ± 15.56	44.93 ± 15.69	t = 1.55	.122	−6.41	0.762
Self-rated compliance	70.06 ± 27.85	71.27 ± 24.24	t = 0.401	.688	−4.71	7.13
No. of previous hospital admission	1.25 ± 1.66	1.66 ± 2.88	t = 1.458	.164	−0.44	−0.97

SD: standard deviation.

There was no statistically significant difference between victimized and nonvictimized patients as regards mean scores of CGI, GAF, mean number of previous hospital admission and self-rated compliance.

Profile of perpetration

All victimized patients (100%) were subjected to emotional victimization, which included being locked indoors, name-calling and false accusations. Around 64.6% (84 patients) were exposed to physical victimization, which included hitting, slapping and pushing, while 53.8% (70 patients) were exposed to miscellaneous victimization, which included biased verbal assault, personal theft, sexual harassment and unwanted sexual activity.

The mean frequency of perpetration last year was 7.03 ± 4.66 and the mean number of perpetrators was 3.89 ± 4.174.

Victimized patients were asked whether the perpetrators of different victimization acts were one of their family members or strangers. The results revealed that victimization was mainly inflicted by acquaintance 27.7% (n = 36), 18.4% (n = 24) were victimized by their daughters or sons, whereas in 13% (n = 17) the perpetrator was the spouse. The least reported perpetrators were the siblings 7.7% (n = 10) and parents 6% (n = 8). The remaining 27% (n = 35) were victimized by strangers (Table 4).

Table 4.

Profile of perpetration.

Variable	N	%
Types of victimization
Emotional	130	100
Physical	84	64.6
Miscellaneous	70	53.8
No. of perpetrators	3.89 ± 4.174
Frequency last year	7.03 ± 4.66
Type of perpetrators
Acquaintance	36	27.7
Others	35	27
Daughters or sons	24	18.4
Spouses	17	13
Siblings	10	7.7
Parents	8	6

Incident reporting

Victimized patients were also asked about reporting of victimization acts; unfortunately, 87.7% of the victimized patients did not report the occurrence of the victimization act, either to a family member, friend or police. Reasons for nonreporting included fear of offender, fear of publicity and feeling that the matter is not important enough to report.

Discussion

In contrast to the common perception that persons with mental illness are violent, there is evidence that those patients are more likely to have a history of victimization than their nonmentally ill counterparts (Choe et al., 2008; McFarlane, Schrader, Bookless, & Browne, 2006; Teplin et al., 2005). Thus, the level of public fear of violence from mentally ill individuals in the community is largely skewed.

Moreover, patients with mental illness may lack basic human rights and are discriminated against. The ‘Bill of Rights for Persons with Mental Illness’, published by the World Psychiatric Association, highlighted those rights. Among other points, it included ‘the right to be free from cruel, inhuman, degrading treatment, and punishment’ (Bhugra, 2016).

On the other hand, few researches in Egypt have been conducted to study this issue. Hence, this research was designed to uncover and understand this problem, and hopefully encourage clinicians to pay attention to it.

Rates of victimization

The results of different studies that examined the prevalence of victimization have been inconsistent and do not provide a definite answer. In the current study, we found 43.3% rate of victimization among our patients with major mental illness. Different prevalence rates of victimization were reported in previous studies, ranging from 19.0% in the study conducted by Teplin et al. (2005) on outpatients and residential patients with major mental illness, and 35.0% in the study conducted by Goodman et al. (2001) on combined sample of inpatients and outpatients with major mental illness. In accordance with our study, the results of the largest study of patients with major mental illness by Lam and Rosenheck (1998) found that 44.0% had been violently victimized. The variation of the findings of these studies could be explained by different sampling size, variable tools of assessment and different time frames.

Hiday, Swartz, Swanson, Borum, and Wagner (1999) reported 8.2% prevalence rate in the past 4 months preceding their study. While Goodman et al. (2001) reported 35% in the past year; they explained this variation by the differences in the recall periods.

In Taiwan and Dutch population, they found that the prevalence of victimization of mentally ill patients was higher than the general population (Goodman et al., 1999; Link, Phelan, Bresnahan, Stueve, & Pescosolido, 1999).

Patients with depression seem to be particularly vulnerable to victimization; de Mooij et al. (2015) estimated that depressed patients were 3.8 times more likely to be victimized in comparison to general population, even after recovery from depression; and former patients still show higher levels of victimization (Haden & Scarpa, 2008).

Our study proved that patients with depression presented the highest rate of victimization (40%) among patients with major mental illness. Particularly in Arab culture, depressed mood may not present as the primary complaint. Depressed patients may not readily volunteer or verbalize feeling of sadness; instead, they have increased rates of alexithymia and somatization. They tend to transfer their low mood to multiple somatic physical complaints together with the adaptation of sick role and inability to pursue work or social obligations (Amin, Hamdi, & Abousalah, 2001). These symptoms may probably increase their vulnerability to be victimized (Ragheb, Attia, Abdel Wahab, El Missiry, & Hussein, 2009).

Patients with schizophrenia are also vulnerable to victimization owing to the delusions, hallucinations, negative symptoms or the odd and bizarre behavior (Schomerus et al., 2007).

In Egypt, such behavioral symptoms are sometimes culturally attributed to acts of Jinni possessions or spirits (Khalil, 2001). Thus, families who believed in this (usually from rural areas) resort to traditional healers who hit the patient to get rid of those spirits (Ragheb et al., 2009). A higher rate of victimization in patients with schizophrenia (38%) was found by Brekke et al. (2001). Contrary to our expectations, the rates were only 23.1% in our sample.

Patients with bipolar disorder are also at a high risk to be victimized either during the manic or depressed phase. White et al. (2006) reported that 38% of patients with bipolar disorder were victimized, whereas in our study it was a slightly lower (36.9%).

In Egyptian culture, the disinhibited risky behavior and the breaching of the social norms of conduct from patients with mania were believed to be a dishonor to the family; this can attract physical and emotional abuse and victimization by the family (Fekry et al., 2012).

Type of victimization

Studying the type of victimization among patients in the current study showed that all of them were exposed to emotional victimization. This includes being locked indoors, called name and false accusations. The explanation of this high percentage is attributed to the high degree of emotional involvement of Egyptian families, besides the high emotional expression, including excessive blame and criticism (Okasha et al., 1994). Still, the patriarchal Egyptian family culture considers harsh criticism, locking and segregating their mentally ill family members, a part of care and not a type of emotional abuse. This kind of abuse can even have a greater health impact than physical violence (Jewkes, 2010).

In a study by Silver (2002), he reported that 15.2% of a sample of acute psychiatric inpatients has been hit or attacked. Another study by Kamperman et al. (2014) reported a high percentage of violent threats, physical assault, sexual assault and sexual harassment.

In the current study, 53.8% had been subjected to miscellaneous victimization such as biased verbal assaults, personal theft and sexual harassment, whereas 64.6% had been subjected to physical victimization, which included hitting, slapping and pushing.

Results are in accordance with that of Khalifeh et al. (2015) who studied about 300 psychiatric patients, in contact with community services, and compared them with general population controls. He found that mentally ill patients had two- to fourfold elevated odds of all subtypes of domestic violence (emotional, physical and sexual) compared to the general population.

Type of perpetrators

In a Swedish study, 45% of perpetrators of violence were acquaintances of the victims (friends, neighbors and members of user organizations; Bengtsson-Tops & Ehliasson, 2011).

A lower percentage was recorded in the current study; 27.7% of the victimization incidents were inflicted by an acquaintance, followed by others (27%), family members as daughters and sons (18.4%), then spouse (13%), siblings (7.7%) and parents (6%).

Our results seem to be concordant with Khalifeh et al. (2015) who reported that domestic violence was perpetrated by partners and family members, while community violence was perpetrated by strangers or acquaintances.

Reporting

Reporting victimization and abuse have received little attention. Hence, little is known about how frequent mentally ill patients report victimization incidents. Marley and Buila (1999) in their study on 234 adults – diagnosed with a major mental illness, who were victimized – found that 51% reported the crime to the police and 70% to a family member, relative or service provider.

In the current study, victimized patients were asked about reporting of victimization incidents; we found that victimized patients did not report the occurrence of the victimization act. In a study by Khalifeh and his coworkers (2015), only 43% of the victimized patients with major mental illness disclosed their experiences to health care professionals.

Only a few mental patients speak out about their experiences of victimization. There is still a common misconception that people with mental illness are unreliable informants, or that their reports are products of their psychopathology. This misconception may obscure legitimate concerns about their victimization experiences and increase their reluctance to report abuse.

Hence, it is imperative that clinicians should routinely inquire not just about physical domestic violence but also emotional and sexual abuse. Mental health services should work in collaboration with police officers to protect and safeguard mentally ill victims.

Psycho-demographic and clinical correlates

Our results showed that more females (63.1%) compared with males (36.9%) were subjected to victimization. A study by Van Weeghel et al. (2009) also shared these findings. However, the finding of Hiday et al. (1999) noted that in violent crimes, men were significantly victimized more than women, while for nonviolent crimes the opposite was seen. Sex difference in victimization rates can also vary due to cultural differences, and social and religious background (Douki, Ben Zineb, Nacef, & Halbreich, 2007) . In Egypt, corporal punishment is commonly used by families as a mean of disciplining boys as compared with girls, and some victims may not see as a form of abuse (Youssef, Attia, & Kamel, 1998).

We found a significant relation between the marital status of patients, current living status, occupational status and the likelihood of being victimized; 52.3% of the victimized mentally ill patients in our sample were unemployed versus 35.3% of the nonvictimized patients. Being unemployed may lead to more victimization by family and neighborhood due to the impact of mental illness. Furthermore, the role of the symptoms of mental illness, their severity and the nature of the psychopathology can be a risk factor for both unemployment and victimization (Teplin et al., 2005).

Hiday et al. (1999) reported that individuals with higher levels of education have more feelings of vulnerability to victimization and higher perceptions of coercion. In contrast, university graduates in our study were less likely to be victimized in contrast to those with lesser education. Perhaps, as illiteracy is common in Egypt, those with higher education appear less vulnerable.

Living in urban areas has been reported to be a major risk factor for victimization in several studies (Eisenberg, 2005). Patriarchal closed societies are typically seen in rural Egypt, as compared with urban open societies. The difference in the lifestyle and perception of mental illness between rural and urban Egypt might have contributed to our finding that 84.6% of victimized patients lived in rural areas. Moreover, religious and cultural belief systems in rural areas are more convinced by the role of supernatural powers as the devil, evil eye, Jinni possessions and so on in the genesis of mental illness, and hence the majority will ask for the help of traditional healers. These may advise practices like hitting patients or inflicting pain on them to get rid of the devil in them (El-Islam, 1982).

Clinical symptom severity measured by CGI revealed nonstatistically significant differences between victimized and nonvictimized patients in our study. This comes in contrast to several studies that previously reported that patients with more severe illness are more vulnerable to victimization (Latalova et al., 2014; McFarlane et al., 2006). Despite that Fitzgerald et al. (2005) reported in their studied sample that those who had no substantial daily activities and showed high degree of psychosocial disability were more liable to victimization, we found no statistically significant difference between those who were poorly functioning assessed by GAF and those who were not.

Conclusion and recommendations

Studies on the victimization of the mentally ill did not draw the attention of researchers and clinicians in the Arab world. This study proves that victimization is not uncommon among patients with major mental illness. Patients who were exposed to victimization were female, married and exposed to parental domestic violence; history of child abuse and family history of substance abuse were among variables associated with victimization of our patients with major mental illness.

Thus, to deal with ongoing victimization, clinicians should inquire about these incidents in patients with major mental illness. Indeed, psycho-education of the caregivers and enrolling them in the rehabilitation programs are needed.

Clinicians should endeavor to build a good therapeutic alliance with patients to facilitate disclosure of abuse or victimization. They should routinely inquire about this in clinical interviews and make sure that they are able to raise alerts, empower their patients and guide them.

Mental health professionals should work along with other statutory agents, nongovernmental organizations and policy makers to increase awareness and develop joint working safeguarding protocols to help and empower this disadvantageous group (Bhugra, 2016).

Strengths and limitations

This research finding serves as a message to policy makers and clinicians to provide procedures and policies aiming to reduce the occurrence and hopefully mitigate the consequence of victimization.

Some limitations of the current study should also be considered. These results cannot be generalized as our sample was a convenient one, and yet, they should be considered as preliminary results.

We did not identify the protective or risk factors associated with victimization and also we did not compare our sample with victimization in the general population. We also did not explore whether doctors in the inpatient department inquired about victimization or not.

Thus, future studies with a larger sample dedicated to highlighting the risk and protective factors together with the consequence of victimization would be of great importance.

Footnotes

Acknowledgements

We would like to express our gratitude to the Institute of Psychiatry, Ain Shams University, for the technical support of this research; also, we are thankful to all who helped us in collecting data. We especially acknowledge Dr Mohamed Hassan, Top Information Technology (TIT) Solutions manager, for the statistical part of this work. Finally, we would like to thank patients who voluntarily participated in this research.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Hussien Elkholy

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