HomicidesofMentalHealthWorkersbyPatientsMichaelB.Knable,DOAssistantClinicalProfessorofPsychiatryandBehavioralSciencesGeorgeWashingtonUniversitySchoolofMedicine617WestPatrickStreetFrederick,MD21701240-439-4900mknable@clearviewcommunities.orgAbstract

Usingelectronicsearchmethodologies,weidentified33casesinwhich

mentalhealthworkershadbeenmurderedbypatientsintheUnitedStatessince

1981.Althoughanapparentlyrareevent,withafrequencyofapproximately1

homicideperyear,ourdataindicatemanyofthesehomicidesmayhavebeen

preventable.Thegroupmostlikelytohavebeenvictimsofhomicidalattackswas

youngwomencaseworkers,mostofwhowerekilledduringunaccompaniedvisitsto

residentialtreatmentfacilities.Thegroupmostlikelytohavebeenperpetratorsof

violencewasmaleswhocarriedadiagnosisofschizophrenia.Themostlikely

methodofhomicidewasbygunshot(42.4%)but57.6%ofhomicideswere

committedbyothermeans,whichmayhavebeenpreventedbycareful

implementationofsafetyprotocols.Perpetratorswerelikelytohavehadaprior

historyofviolence,criminalcharges,involuntarypsychiatrichospitalizationornon-

adherencetomedications.Despiteconvincingevidenceforchronicmentalillnessin

theperpetrators,theyweremorelikelytobeimprisonedthanhospitalizedafter

trial.Safetyandpublicpolicyrecommendationsareofferedinconclusion.

Introduction

Withinthelastdecade,twopsychiatristsintheWashington,DCareathat

wereknowntotheauthors,werekilledbytheirpatients.Inthisreportwe

attemptedtodeterminehowfrequentlyhomicidesofpsychiatristsandothermental

healthcouldbeexpectedtooccur.Whilethegeneralliteratureonviolencetowards

mentalhealthworkersremainsrelativelysparse,reportsusingavarietyof

methodologiesindicatethatactsofviolenceamongthosewithuntreatedpersistent

mentalillnessmaybequitecommon.Forexample,studiesusingsurveytechniques

reportthat50-60%ofmentalhealthworkerscanexpecttobethreatened,30-40%

canexpecttobeassaulted,40%canexpecttoreceivesometypeofphysicalinjury,

andupto5%canexpecttowithstandseriousphysicalharm1-3.

Retrospectivestudiesusingpopulationbasedstrategiesorregistriesalso

suggestthatviolenceperpetratedbythepersistentlymentallyillisquitecommon.

UsingdatafromtheEpidemiologicCatchmentArea(ECA)Study,Swansonetal4,

estimatedthelifetimeprevalenceofviolencetobe16.1%inpatientswithserious

mentalillness(schizophrenia,majordepression,orbipolardisorder),35%in

patientswithsubstanceabuseordependence,43.6%inpatientswithbothserious

mentalillnessandsubstanceabuse,and7.3%insubjectswithnomajormental

disorder.InthemostrecentdataavailablefromtheU.S.DepartmentofJustice’s

NationalCrimeVictimizationSurvey5,therateofworkplaceviolencebetween2005

and2009wasreportedtobe5.1/1000personsoverall,10.1/1000forphysicians

and8.1/1000fornurses.Formentalhealthworkerstherateswere20.5/1000

overall,17.0/1000forprofessionalworkersand37.6/1000forcustodialworkers.

Therateofviolencetowardsmentalhealthworkerswassecondonlytotheratefor

lawenforcementworkers(47.7/1000).IntheClinicalAntipsychoticTrialsof

InterventionEffectiveness(CATIE),19.1%of1,410patientswithschizophreniahad

exhibitedsometypeofviolenceoverthepriorsixmonths,while3.6%hadexhibited

“seriousviolence”6.Furthermore,violencedeclinedfrom16%to9%inCATIEtrial

participantsretainedinthestudywhoreceivedoneoffiveantipsychotic

medications7.Factorsassociatedwithahistoryofviolenceincludedchildhood

antisocialbehavior,substanceuse,victimization,andeconomicdeprivation.

Negativesymptomswerenegativelycorrelatedwithariskforviolence.Inameta-

analysisof110studiesreportingon45,533individualswithpsychiatricdisordersit

wasfoundthat18.5%hadahistoryofviolence8.Violentpatientsweremostlikelyto

havehadadiagnosisofschizophrenia,recentsubstancemisuse,andnon-adherence

withpsychologicaltherapiesormedications.UsingaSwedishregistryof82,647

patientswhowereprescribedantipsychoticsormoodstabilizers,Fazeletal9

reportedthat6.5%ofmenand1.4%ofwomenwereconvictedofviolentcrimes.

Comparedwithperiodswhenparticipantswerenotonmedication,violentcrime

fellby45%inpatientsreceivingantipsychoticsandby24%inthosereceivingmood

stabilizers.

Prospectivestudieshavealsofoundelevatedratesofviolenceamongthose

withchronicmentalillness.Newhilletal10followed1136patientswhohadbeen

admittedtooneof3psychiatrichospitalsfor1year.Whiletheauthorsfoundthat

theratesofviolentoraggressiveactswerequitecommon,patientswithborderline

personalitydisorderweresignificantlymorelikelytocommitviolentactseven

whenintentionalself-harmwasexcluded.Langeveldetal11followed178patients

withafirstepisodeofpsychosisinNorwayfor10years.Twentypercentwere

reportedlyapprehendedorincarceratedvs.1.6%ofthegeneralpopulation.Fifteen

percentreportedlyperpetratedorengagedinthreateningorphysicallyviolent

behavior.Apprehensionorincarcerationdecreasedovertimetothelevelfoundin

generalpopulationexceptinthosewithillicitdruguse.

Methods

Forthisreportwesearchedthemedicalliterature(PubMed)andtheinternet

atlargetofindcasesinwhichmentalhealthworkersintheUnitedStateshadbeen

killedbypatients.Weexcludedcasesthatoccurredincorrectionalsettingsthat

werenotpartofapsychiatrichospitalorhealthcaresystem,casesrelatedtocourt

orderedchildcustodyevaluations,casesoccurringinchildprotectiveservice

agencies,andcasesoccurringinstatesocialserviceagenciesthatwerenot

specificallygearedtowardspsychiatrictreatment.Alldatawerecollectedfrom

publicsourcesincludingpublicationsinjournals,newspaperaccountsandcourt

records(whenavailable).Dataregardingdiagnosisandtreatmenthistorywerenot

verifiedindependently.

Weattemptedtocapture:theage,sexandoccupationalroleforthemental

healthworkers;theage,sexandprobablediagnosisoftheperpetrators;themethod

ofhomicide;thesettingofthehomicide;ahistoryofpriorinvoluntary

hospitalizationfortheperpetrators;ahistoryofpriorviolencefortheperpetrators;

andahistoryofpriorcriminalconvictionsfortheperpetrators.Wealsoattempted

tosummarizethedispositionoftheperpetratorsfollowingthehomicides,i.e.to

determineiftheywerekilledatthesiteofthecrime,committedsuicide,werefound

guiltyandsentencedtoprison,orwerecommittedtopsychiatrichospitals.

Results

Table1containsdemographicdataonvictimsandperpetratorsandTable2

summarizesinformationregardingthesettingandmethodofhomicide,andprior

historiesofinvoluntarytreatment,medicationnon-adherence,violence,orcriminal

charges.

ThecaseofStephanieMoultonillustratesmanyofthefeaturesthatwe

describeinthisreport.Ms.Moultonwas25yearsold,5feetand1inchtall,and

weighed110poundswhenshewaskilledbyDesahwnJamesChappellin2011.Ms.

Moultonwasthefirstinherfamilytograduatefromcollege.Shehadanassociate’s

degreeinmentalhealthandabachelor’sdegreeinsocialwork.Shewasdrawnto

thementalhealthfieldpartlybecauseshehadanunclewithschizophrenia.After

graduationfromcollegeshebeganworkwiththeNorthSuffolkMentalHealth

Association,anon-profitorganizationthatprovidescommunity-basedcontract

services,includingresidentialcare,totheMassachusettsDepartmentofMental

Health,forapproximately600patients.Thistypeofcontractualarrangementis

increasinglycommonwiththeclosureofstatementalhospitalbedsandoutpatient

programs.TheNorthSuffolkMentalHealthAssociationhadpreviouslybeenfined

bytheOccupationalSafetyandHealthAdministrationforfailingtoprovide

adequatesafeguardsagainstworkplaceviolence.

ThefamilyofDeshawnJamesChappellhadnoticedhisincreasinglybizarre

behaviorsince2003.Duringthatyearhewasarrestedfortheassaultandrobberyof

ahomelessman,duringwhichheslashedtheforeheadofhisvictim,andproduced

aneyeinjurythatrequiredsurgery.AfterthisincidentMr.Chappell’spsychosis

appearedtoworsenandhebeganusingalcoholandmarijuanaonaregularbasis.

HewaslaterhospitalizedatMassachusettsGeneralHospitalandwasgivena

diagnosisofschizophrenia.Hisconditionseemedtoimprovewithantipsychotic

medications,buthefrequentlyfailedtotakeprescribedmedicationsafterdischarge

fromhospital.Hehadatleast4additionalhospitalizationsandseveralarrestsfor

assaults.In2006,heattackedhisstepfather,fracturingthebonesofhisorbit.

ChappellwascommittedtotheBridgewaterStateHospitalfor3monthsandwas

released.ThetermsofChappell’sreleasearenotknown,butitisinterestingtonote

thatMassachusettsisoneofonly5oftheUnitedStatesthatdoesnothavean

assistedoutpatienttreatment(AOT)law,alsoknownasciviloutpatient

commitment.In2010Chappellhadanaltercationwithagrouphomeresidentand

hewastransferredtoseveralothergrouphomesbeforecomingtoresideatthe

homeinRevere,MassachusettsmanagedbytheNorthSuffolkMentalHealth

Association.InNovember2010Chappellbegancallinghismothercomplainingof

paranoidthoughtsandofintenseauditoryhallucinations.Hismotherbelievedthat

hehadagainstoppedtakinghismedications.InJanuary2011,StephanieMoulton

calledChappell’smotherandconfirmedthathehadnotbeenreceiving

antipsychoticsandsaidshewouldtrytogetthemstartedagain.OnJanuary20,

2011ChappellandMoultonwerealoneinsidethegrouphomewhenhebeather,

stabberher,slitherneckandthendumpedherbodyinachurchparkinglot.Itisnot

knownwhattranspiredbetweenthetwoofthempriortothemurder.Themurder

occurredtwodaysbeforeGovernorDevalPatrickreleasehisannualstatebudget,

whichproposedfundingcutsformentalhealthservicesforthethirdyearinarow.

Chappellwasfoundguiltyoffirst-degreemurderonOctober28,2013intheSuffolk

SuperiorCourtandwassentencedtolifeinprison.StephanieMoulton’sfamilyfiled

suitagainsttheNorthSuffolkMentalHealthAssociationforfailingtoprotect

Stephanie’ssafetyandlaterhelpedtoestablishtheStephanieMoultonSafety

Symposium,whichisnowhostedonanannualbasisbytheMassachusetts

DepartmentofMentalHealth.

Ofthe33victims,20(60.6%)werelicensedprofessionals(psychiatrist,

physician,psychologist,nurse,socialworker)and13(39.4%)weretechnicalorcase

workers.Asaclass“caseworkers”werethemostlikelygrouptohavebeenexposed

toattack.Fifteen(45.4%)ofthevictimsweremenand18werewomen.Themean

ageofthevictimsoverallwas41.6yearsbutforfemalevictimsthemeanagewas

35.4yearsandformalevictimswas49.1years.Therefore,themostcommon

subgrouptohavebeenthevictimofahomicidewascomposedofyoungwomen

caseworkerswithrelativelylittleexperienceinthefield.Victimcharacteristicsare

summarizedinTable3.

Twenty-sevenperpetratorsweremale(81.8%),4werefemale(12.1%)and

for2thegendercouldnotbedetermined(6.1%).Themeanageoftheperpetrators

was34.5years,withatendencyforfemaleperpetratorstobeolder(44.3years)

thanmaleperpetrators(33.0years).Seventeenperpetratorswerethoughttohave

hadadiagnosisofschizophreniaand1wasgivenadiagnosisofthecloselyrelated

schizotypalpersonalitydisorder(54.5%takentogether).Fourperpetratorswere

thoughttohaveadiagnosisofbipolardisorder(12.1%)and1(3.0%)wasgivena

diagnosisofmajordepression.Publicrecordsdidnotyieldadiagnosisfor10

(30.4%)perpetrators.Thelackofdiagnosisinpublicaccountswasfrequentlydueto

concernsoverconfidentiality,especiallyincaseswheretheperpetratordidnothave

acriminalrecord,orinwhichtheperpetratorwaskilledduringtheincidentor

committedsuicide.Themostcommonsubgrouptohavebeenaperpetratorof

homicidewascomposedofyoungmalesdiagnosedwithschizophrenia.

Elevenhomicides(33.3%)occurredduringvisitstoresidentialfacilities,6

occurredinpublicclinics(18.2%),5occurredinprivateoffices(15.2%),6occurred

inprivatehospitals(18.2%),4occurredinpublichospitals(12.1%)and1occurred

whileintransitwithapatient(3.0%).Therefore,themostcommonsettingfor

homicidesofmentalhealthcareworkerswasduringvisitstopatientsinresidential

facilities.Therewasrelativelylittledifferenceinthefrequencyofhomicidesthat

couldbeexplainedbypublicversusprivatehospitalsettings,orpublicversus

privateclinicsettings.

Themostcommonmethodforhomicidewasbygunshot(42.4%).Four

victims(12.1%)werekilledbybeating,3(9.1%)byacombinationofbeatingand

stabbing,and1(3.0%)byacombinationofbeatingandstrangling.Tenvictims

(30.3%)werekilledbystabbingorlacerationwithasharpobject.Onevictimwas

killedbystrangling(3.0%).Onecouldarguethatitisverydifficultforanindividual

mentalhealthcareworkertodefendthemselvesagainstgunshotswithout

comprehensiveinstitutionalproceduresforweaponsscreeningormorerestrictive

legislationregardinggunpossession.However,non-gunshotmethodsforhomicide

constitutedthemajoritywhengroupedtogether(57.6%)anditmaybearguedthat

thesearequitepreventableifappropriatesafetyprecautionsandeducational

requirementsformentalhealthworkersweretobeenforced.

Sixteenoftheperpetrators(48.5%)hadapriorhistoryofcriminalcharges,6

(18.2%)didnothavesuchahistory,andinadequateinformationwasavailablefor

11(33.3%).Seventeenoftheperpetrators(51.5%)hadapriorhistoryofviolence,3

(9.1%)didnothavesuchahistory,andinadequateinformationwasavailablefor13

(39.4%).Thirteenoftheperpetrators(39.4%)hadapriorhistoryofnon-adherence

tomedications,whileinadequateinformationwasavailablefortheremaining20

(60.6%).Seventeenoftheperpetrators(51.5%)hadapriorhistoryofinvoluntary

hospitalization,2(6.1%)didnothavesuchahistory,andinadequateinformation

wasavailablefor14(42.4%).Thus,apriorhistoryofcriminalcharges,violence,

non-adherencetomedications,andinvoluntaryhospitalizationwerequitecommon

amongperpetratorsandshouldbeseenaswarningsignsforpotentialviolence.

Followingthehomicides,15perpetrators(45.5%)werefoundguiltyofcriminal

chargesandwereimprisoned,8(24.2%)werecommittedtopsychiatrichospitals,4

(12.1%)committedsuicide,2(6.1%)werekilledatthecrimescene,and1(3.0%)

wasawaitingtrialatthetimeofthiswriting.Legalstatuscouldnotbedetermined

for3(9.1%)perpetrators.Perpetratorcharacteristicsandcrimedetailsare

summarizedinTable4.

Discussion

Wewereabletoidentify33casessince1981inwhichmentalhealthworkers

weremurderedbypatientsintheUnitedStates.Therefore,onemightexpectthat

sucheventscanbeexpectedapproximatelyonceperyear.Wecannotconcludethat

ourlistofcasesiscomplete,especiallysincemanydocumentsandnewsreports

relatedtohomicidesofmentalhealthworkerspriortothewidespreaduseofthe

internetinthe1990’smayhavebeendifficulttolocate.Wealsoexcludedcasesof

homicideoutsideofpsychiatricsettingsprovidingdirectcaretotheperpetrators;

webelievemanyhomicidescommittedinothersocialserviceagenciesmayalso

involveperpetratorswithmentalillnesses.

Homicidesseemtohavebeencommittedagainstawiderangeof

professionalroleswithinthementalhealthsystem.Indeed,theprolongedtraining

necessarytobecomeapsychiatristorpsychologist,andlongexperienceasa

practitioner,didnotseemtoprotectparticularvictimsfromthesetragicevents.

Nevertheless,thelargestsinglegrouptohavebeenvictimizedappearedtobeyoung

womencaseworkerswhohadbeensent,usuallyunaccompanied,toperformtasks

withinresidentialtreatmentsettings.Thiswouldappeartobeapracticethatcould

beremediedquiteeasilywithappropriatesafetymeasuresfollowedinthese

settings.Whileresidentialfacilitieswereacommonsiteforthehomicideswefound,

itisimportanttonotethatnoparticularclinicalsettingseemedtobeimmunefrom

theriskforattack.Itmaybemisguidedforpractitionersinprivateofficestofeelsafe

withoutputtingintoplacespecificsafeguards.

Withregardstotheperpetrators,oursummaryseemstobeconsistentwith

otherreportsconcerningtheriskofviolenceamongthementallyill,inthatmost

perpetratorsweremales,hadadiagnosisofschizophrenia,andfrequentlyhadprior

historiesofviolence,arrest,involuntaryhospitalizationornon-adherenceto

treatmentrecommendations.

Basedonthedatawehavegatheredweofferthefollowingsafety

recommendationsforpractitioners:

1. Developthecapacitytoassessthedangerousnesslevelofpatientsina

prescreeninginterviewbeforethefirstappointment.

2. Takespecialcarewitheveningorweekendappointmentsorinother

situationsinwhichadditionalofficepersonnelarenotpresent.

3. Forpatientsthathaveahistoryofviolentactsorpoorimpulsecontrol,see

thepatientalongwithfamilymembersorwithothercolleagues.

4. Haveasecuritybarrierbetweenthewaitingroomandtheconsultingroom

sothatpatientscannoteasily“bargein”.Thismightincludeelectroniclocks

orvideosurveillanceofthewaitingroom,whichwouldallowpractitionersto

seewhoiswaitingpriortoadmittingthemtotheoffice.

5. Sitbehindadeskratherthaninamoretraditional“psychotherapeutic”

environment.Thisbarrierwouldallowsomedefenseagainstassaultsthatdo

notinvolvefirearms.

6. Haveanescaperoute:don’tsitbetweenthepatientandtheonlyavailable

exitfromtheoffice.

7. Iffeasible,haveanemergencyalertsystem.However,theseareonlyeffective

whentheconsultingroomisinaninstitutionalsettingwithenough

personnelpresentwhoareequippedtorespondtothealert.

8. Homevisitstopatientswithahistoryofviolenceorinvoluntarytreatment

shouldbemadebyteamswithadequatetrainingandnotbyindividuals.

9. Forpatientswhobecomethreatening,obtainconsultationsoonerratherthan

later.Inisolatedoutpatientsettings,consultationwithothercolleaguesmay

betheonlywaytogetfurtherguidanceandsupport.Ininstitutionalsettings

threatsshouldbereportedtoappropriateadministratorsimmediately.These

reportsdonotusuallyconstituteaviolationofprivacylaws.

10. Fordirectthreatsofviolence,orthreatsthatoccuroutsideofofficeor

institutionalsetting,lawenforcementagentsshouldbeinformed.Onemust

evaluatetheneedforrestrainingordersunderstandingthattheysometime

provokeincreasedthreatsorviolence.Onemustalsodetermineifthereisa

sufficientlevelofdangerousnesstomeritcriminalchargesorinvoluntary

psychiatricdetention.

Basedonthedatawehavegatheredwealsoraisethefollowingpolicy

considerationsforadministratorsandgovernmentofficials:

1. Mentalhealthworkersshouldreceivetraininginviolenceriskassessmentas

acorecompetenceandthistrainingshouldbereviewedperiodically.

2. IntheUnitedStatestherearecurrently5statesthatdonothavelegislation

allowingassistedoutpatienttreatment(AOT),oroutpatientcommitment.In

thisreport,wewerenotabletodeterminewhich,ifany,oftheperpetrators

hadsuchanorderpertainingtothem.However,thereissubstantialevidence

thatAOTreducesviolenceinthecommunityperpetratedbyindividualswith

persistentmentalillness45.

3. EveninstateswithadequateAOTlaws,thereisfrequentlynotanefficient

methodtoimplementthelawortoenforcethecourtordersremandingthe

patienttotreatment.Webelievethisisanurgentproblemthatstate

governmentsmustworktoresolve.

4. Patientswithpriorhistoryofcriminalconvictions,arrest,violence,and

involuntaryhospitalizationshouldhavethesefactorsclearlynotedinthe

medicalrecordandthesefactorsshouldbegivenadequateweightwhen

planningtreatment.

5. Considerationshouldbegiventotheideaofhavinginvoluntarypsychiatric

treatmentbecomeamatterofpublicrecord,sothatmoreadequatescreening

forgunpossessionanddeterminationoftheappropriatesitefordetention

(psychiatrichospitalversusprison)canbemoreeasilymade.

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42. BalingitM:ShootingvictimMichaelSchaabwasengagedtobemarried.

PittsburghPost-Gazette.March10,2012.http://www.post-

gazette.com/local/city/2012/03/10/Shooting-victim-Michael-Schaab-

was-engaged-to-be-married/stories/201203100150

43. KennedyK:Floridacaseworkerstabbedtodeathduringhomevisit.

WashingtonTimes.December13,2012.

http://www.washingtontimes.com/news/2012/dec/13/florida-

caseworker-stabbed-death-during-home-visit/?page=all

44. LandauJ:SuspectchargedwithmurderinshootingatPennsylvania

hospital.NewYorkDailyNews.July27,2014.

http://www.nydailynews.com/news/crime/suspect-charged-murder-

shooting-pennsylvania-hospital-article-1.1881920

45. TreatmentAdvocacyCenter:DoesAssistedOutpatientTreatment(AOT)

DecreaseViolence?2014,

http://www.treatmentadvocacycenter.org/storage/documents/does%2

0assisted%20outpatient%20treatment%20decrease%20violence%20fin

al.pdf

Table1.DemographicDataonVictimsandPerpetrators.

Case Worker Occupation Year State Age Sex Perpetrator Age Sex Diagnosis1 ErnestPullman12 Psychiatrist 1981 CA 55 M n/a n/a n/a n/a2 AlanShields12 Psychiatrist 1981 MA 32 M JamesPalmer 27 M Schizophrenia

3 DeanneCoombs13 Psychologist 1981 MA 32 F JamesPalmer 27 M Schizophrenia

4 JuanOcana14 Psychiatrist 1981 FL 48 M JohnMcGoff 35 M n/a5 BrianBuss15 Psychiatrist 1985 OR 37 M KedronEllis 39 M Bipolardisorder6 MichaelMcCulloch16 Psychiatrist 1985 OR 41 M JohnEaton 39 M Schizophrenia7 Dr.O17 Psychiatrist 1986 FL 38 M Mr.F 32 M Schizophrenia8 NormanFournier18 Socialworker 1987 WA 51 M n/a n/a n/a n/a9 LindaRosen19 Socialworker 1988 PA 27 F Edith

Anderson32 F n/a

10 RobbynPanitch20 Socialworker 1989 CA 36 F DavidSmith 27 M Schizophrenia11 RebeccaBinkowski21 Caseworker 1993 MI 25 F David

Stappenbeck26 M Schizophrenia

12 SharonEdwards22 Nurse 1995 MD 26 F BenjaminGarris

16 M n/a

13 DonnaMillette-Fridge23

Socialworker 1998 CT 36 F AdrianIsom 28 M Depressionandsubstanceabuse

14 ReuvenBar-Levav24 Psychiatrist 1999 MI 72 M JosephBrooks

27 M Schizophrenia

15 JudyScanlon25 Nurse 1999 NY 44 F DianeWylie 46 F Schizophrenia16 LauraWilcox26 Caseworker 2001 CA 19 F ScottThorpe 41 M Schizophrenia17 NicoleCastro27 Caseworker 2002 MD 23 F JohnLutz 64 M Schizophrenia18 ErlindaUrsua28 Physician 2003 CA 60 F RenePavon 37 F Bipolardisorder19 TeriZenner29 Caseworker 2004 KS 26 F Andrew

Ellmaker17 M Schizotypalpersonality

20 WayneFenton30 Psychiatrist 2006 MD 53 M VitaliDavydov

19 M Schizophrenia

21 MartySmith31 Caseworker 2006 WA 42 M LarryClark 33 M Schizophrenia22 GenineHolznagel-

Leary32Caseworker 2007 AK 32 F Brian

Galbraith53 M Schizophrenia

23 LouisMartin33 Psychiatrist 2007 NE 78 M EricLewis 35 M Schizophrenia24 DiruhiMattian34 Socialworker 2008 MA 53 F Thomas

Belanger18 M Bipolardisorder

25 KathrynFaughey35 Psychologist 2008 NY 56 F DavidTarloff 39 M Schizophrenia26 ScottFleming36 Caseworker 2010 AR 40 M SamuelLands 24 M Bipolardisorder27 DonnaGross37 Technician 2010 CA 54 F JesseMassey 37 M n/a28 StephanieMoulton38 Caseworker 2011 MA 25 F Deshawn

Chappell27 M Schizophrenia

29 MarkLawrence39 Psychiatrist 2011 VA 71 M BarbaraNewman

62 F n/a

30 JenniferWarren40 Caseworker 2012 OR 38 F BrentRedd 30 M Schizophrenia31 StephanieRoss41 Caseworker 2012 FL 25 F Lucious

Smith53 M n/a

32 MichaelSchaab42 Caseworker 2012 PA 25 M JohnShick 30 M n/a33 TheresaHunt43 Caseworker 2014 PA 53 M Richard

Plotts49 M n/a

Table2.SettingandMethodofHomicide,HistoricalPredictorsofViolence,andStatusofPerpetrator

Case Perpetrator Setting Method InvoluntaryHospitalizations

Non-adherence

Violence CriminalCharges

StatusofPerpetrator

1 n/a Hospital Gunshot n/a n/a n/a n/a n/a2 James

PalmerOfficeinclinic

Gunshot n/a n/a n/a n/a Suicide

3 JamesPalmer

Officeinclinic

Gunshot n/a n/a n/a n/a Suicide

4 JohnMcGoff Officeinclinic

Gunshot Yes n/a n/a Yes Guiltyoffirstdegreemurderandimprisoned

5 KedronEllis Privatehospital

Beatingwithobject

Yes Yes No No Guiltyandinsaneandhospitalized

6 JohnEaton Privateoffice Gunshot Yes Yes Yes No Hospitalizedwithcivilcommitmentwithouttrial

7 Mr.F Publichospital

Gunshot Yes Yes Yes No Notguiltybyreasonofinsanityandhospitalized

8 n/a Homevisit Gunshot n/a n/a n/a n/a n/a9 Edith

AndersonPrivatehospital

Gunshot n/a Yes n/a n/a Guiltyofthirddegreemurderandimprisoned

10 DavidSmith Officeinclinic

Stabbing Yes Yes Yes Yes Guiltyoffirstdegreemurderandimprisoned

11 DavidStappenbeck

Transportingpatient

Stabbing Yes n/a Yes Yes Guiltyoffirstdegreemurderandimprisoned

12 BenjaminGarris

Privatehospital

Stabbing n/a n/a n/a n/a Guiltyoffirstdegreemurderandimprisoned

13 AdrianIsom Officeinclinic

Stabbing n/a n/a n/a n/a Killedatscene

14 JosephBrooks

Privateoffice Gunshot n/a Yes n/a n/a Suicide

15 DianeWylie Homevisit Beatingwithobject

Yes n/a Yes Yes Guiltyoffirstdegreemurderandimprisoned

16 ScottThorpe Clinic Shooting n/a Yes n/a Yes Incompetenttostandtrialandhospitalized

17 JohnLutz Homevisit Beatingandstabbing

Yes n/a n/a n/a Incompetenttostandtrialandhospitalized

18 RenePavon Publichospital

Beatingandstrangling

Yes Yes Yes No n/a

19 AndrewEllmaker

Homevisit Stabbing Yes n/a n/a n/a Guiltyoffirstdegreemurderand

imprisoned20 Vitali

DavydovPrivateoffice Beating No Yes No No Guiltybutnot

criminallyresponsibleandhospitalized

21 LarryClark Homevisit Beatingandstabbing

n/a n/a Yes Yes Guiltyoffirstdegreemurderandimprisoned

22 BrianGalbraith

Residentialfacility

Stabbing n/a n/a Yes Yes Guiltyoffirstdegreemurderandimprisoned

23 EricLewis Publichospital

Beating Yes Yes Yes Yes Guiltyofseconddegreemurderandimprisoned

24 ThomasBelanger

Homevisit Stabbing n/a n/a n/a Yes Guiltyofmanslaughterandimprisoned

25 DavidTarloff

Privateoffice Meatcleaver

Yes Yes Yes Yes Guiltyoffirstdegreemurderandimprisoned

26 SamuelLands

Residentialfacility

Gunshot Yes Yes Yes Yes Guiltyoffirstdegreemurderandimprisoned

27 JessMassey Publichospital

Strangling Yes n/a Yes Yes Guiltyoffirstdegreemurderandimprisoned

28 DeshawnChappell

Residentialfacility

Beatingandstabbing

Yes Yes Yes Yes Guiltyoffirstdegreemurderandimprisoned

29 BarbaraNewman

Privateoffice Gunshot No n/a No No Suicide

30 BrentRedd Residentialfacility

Stabbing Yes n/a Yes Yes Guiltyandinsaneandhospitalized

31 LuciousSmith

Homevisit Stabbing n/a n/a Yes Yes Incompetenttostandtrialandhospitalized

32 JohnShick Privatehospital

Gunshot n/a n/a Yes Yes Killedatscene

33 RichardPlotts

Privatehospital

Gunshot Yes n/a Yes Yes Awaitingtrial

Table3.SummaryofVictimCharacteristicsProfessionalStatus

PsychiatristPhysician

PsychologistNurse

SocialWorkerTechnicalorCaseWorker

10(30.3%)1(3.0%)2(6.1%)2(6.1%)5(15.1%)13(39.4%)

FemaleGender 18(54.6%)MeanAge

AllvictimsFemalevictimsMalevictims

41.6years35.4years49.1years

Table4.SummaryofPerpetratorandCrimeCharacteristicsMaleGender 27(81.8%)MeanAge

AllperpetratorsMaleperpetrators

Femaleperpetrators

34.5years33.0years44.3years

DiagnosisSchizophrenia

SchizotypalpersonalityBipolardisorderMajordepression

Unknown

17(51.5%)1(3.0%)4(12.1%)1(3.0%)10(30.4%)

LocationResidentialFacility

PublicClinicPrivateClinic

PublicHospitalPrivateHospital

InTransit

11(33.3%)6(18.2%)5(15.2%)4(12.1%)6(18.2%)1(3.0%)

MethodGunshotBeating

BeatingandstabbingBeatingandstrangling

StabbingStrangling

14(42.4%)4(12.1%)3(9.1%)1(3.0%)10(30.3%)1(3.0%)

PriorHistoryCriminalcharge

ViolenceNon-adherence

Involuntaryhospitalization

16(48.5%)17(51.5%)13(39.4%)17(51.5%)

StatusImprisoned

CommittedtohospitalSuicideKilled

AwaitingtrialUnknown

15(45.5%)8(24.2%)4(12.1%)2(6.1%)1(3.0%)3(9.1%)