Offenders with mental disorders constitute a particularly exposed group in society. They often have multiple psychiatric diagnoses [1], somatic comorbidity [2], and addiction [3]; mortality rates are high [4–6] and social deprivation is widespread [7]. Often thought of primarily as perpetrators, these individuals may also be subjected to violence to a large extent, as some of the aforementioned problems also are associated with violent victimization [8]. Furthermore, recent violent victimization may be a risk factor for violent perpetration among persons with severe mental illness comprising schizophrenia, bipolar disorder, and major depression [9]. The health care services are pivotal to this group, but although most individuals utilize both somatic health services [2] and mental health services [10], much of their vulnerability seems to remain. Based on these findings, we wanted to conduct a study on victimization and health service utilization, including perception of unmet health care needs, among offenders with mental disorders.

Violent victimization

Violent victimization is ubiquitous, and violence has been described as a global health problem by the World Health Organization [11]. According to the 2004–5 International Crime Victims Survey, the annual victimization rate was 0.6% for sexual assault and 3.1% for other assaults and threats, but much of the problem is hidden, as only around a third of the assaults are reported to the police [12]. Consequently, interview surveys demonstrate higher rates; 6.2% of adults in Sweden reported that they were subjected to violence or threats in a twelve-month period [13].

Although universal, violent victimization is not evenly distributed in the population. Well-known demographic risk factors are young age, male sex, unemployment, unmarried state, and poverty [14]; other important risk factors are homelessness [15, 16] and substance abuse [17]. Based on these and other factors, theoretical frameworks have been formed. Three of the most prominent theories are the lifestyle theory, the routine activities theory [18], and the victim precipitation theory. According to the lifestyle theory, an individual’s demographics, such as age and sex, interact with role expectations and social constructs, which in turn determines the lifestyle and in that way also the exposure and risk of victimization [19]. The routine activities theory suggests that victimization depends on the presence of a potential offender and suitable victim, and on the absence of capable guardians; this is influenced by daily routine activities such as employment, leisure activities, and socializing [20]. Finally, the victim precipitation theory posits that victims contribute or sometimes even instigate to the violent acts being committed [21].

These theories may explain why violent victimization is even more widespread in certain groups. One risk group consists of persons with severe mental illness, where a recent review states an annual prevalence of 6.4–56% [8], and a lifetime prevalence of over 90% for traumatic events has been reported [22, 23]; victimization is also associated with greater current symptomatology [24]. Indeed, research indicates that persons with severe mental illness are more likely to be victims than perpetrators of violence [25]. However, offending is a risk factor for victimization [26], which applies also to persons with mental disorders [27], in whom the presence of offending is associated with an 11-fold increase in victimization [28]. Victimization may in turn be a risk factor for offending: a Swedish registry-based study showed that persons diagnosed with schizophrenia spectrum disorders or bipolar disorder were significantly more likely to commit violent crimes if they had been subjected to violence in the previous week compared with earlier periods for the same individuals, with adjusted odds ratios ranging from 7.6 to 12.7 [29]. There appears to be a paucity of studies of violent victimization using study samples consisting of offenders with mental disorders, but higher rates are reported for inmates with dual disorders [30] or any mental disorder [31] than for other inmates during incarceration.

Health service utilization

In general, the state of public health in the Western world is satisfactory, and to a certain degree, this may be due to the highly accessible health care services in the region. For example, 61.0% of American adults reported excellent to very good health, and 80.3% undertook at least one visit to a health care professional in a twelve-month period [32]; whereas 80.2% of Swedish adults report good health, and 35.3% undertook at least one visit to a doctor in a three-month period [13]. However, in some western countries more than 10.0% of adults report unmet health care needs [33].

Unfortunately, the general state of health among individuals with mental disorders is poorer. For example, when persons with schizophrenia are compared with the general population, diabetes and cardiovascular diseases are at least twice as common [34], the all-cause standardized mortality ratio is 3.6 [35], and the expected lifetime is reduced by 15–20 years [36]. The general state of health is poor also among offenders [37]: the psychosis prevalence is 3.6% and the major depression prevalence is 10.2% among prisoners [38], equivalent to a two-fold to four-fold excess in comparison with the general population [39]; and around 40% of American prisoners suffer from chronic physical medical conditions [40]. The findings from these two populations indicate that the general health state is especially poor among offenders with mental disorders, even though they utilize a considerable amount of health care services [2, 10]. This imbalance suggests the occurrence of unmet health care needs, but studies in the field are scarce. There may be an association between violent victimization and health care utilization, in so far as the former is reduced by the latter to some extent [41].

Aims and hypotheses

This study aimed at describing the extent of violent victimization and health service utilization in a Swedish forensic psychiatric sample, and at comparing it with controls from the general population. We hypothesized that offenders with mental disorders would have higher rates of (1) violent victimization, (2) health service utilization, and (3) unmet health care needs than the general population. Furthermore, we hypothesized that these three rates would be higher for offenders with severe mental disorders than for offenders with non-severe mental disorders (4, 5, 6). Finally, we wanted to explore the association between violent victimization and health service utilization among offenders with mental disorders.