La Pertenencia a Pandillas, Violencia y Morbilidad Psiquiatrica

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Article Gang Membership, Violence, and Psychiatric Morbidity Jeremy W. Coid, M.D. Simone Ullrich, Ph.D. Robert Keers, Ph.D. Paul Bebbington, M.D. Bianca L. DeStavola, Ph.D. Constantinos Kallis, Ph.D. Min Yang, M.D. David Reiss, M.D. Rachel Jenkins, M.D. Peter Donnelly, M.D. Objective: Gang members engage in many high-risk activities associated with psychiatric morbidity, particularly violencerelated ones. The authors investigated associations between gang membership, violent behavior, psychiatr
  Article Gang Membership, Violence, andPsychiatric Morbidity  Jeremy W. Coid, M.D.Simone Ullrich, Ph.D.Robert Keers, Ph.D.Paul Bebbington, M.D.Bianca L. DeStavola, Ph.D.Constantinos Kallis, Ph.D.Min Yang, M.D.David Reiss, M.D.Rachel Jenkins, M.D.Peter Donnelly, M.D. Objective: Gang members engage inmany high-risk activities associated withpsychiatricmorbidity,particularlyviolence-related ones. The authors investigatedassociations between gang membership,violentbehavior,psychiatricmorbidity,anduse of mental health services. Method: The authors conducted a cross-sectional survey of 4,664 men 18  –  34 yearsof age in Great Britain using randomlocationsampling.Thesurveyoversampledmenfromareaswithhighlevelsofviolenceand gang activities. Participants completedquestionnairescoveringgangmembership,violence,useofmentalhealthservices,andpsychiatric diagnoses measured using stan-dardized screening instruments. Results: Violent men and gang membershad higher prevalences of mental disor-ders and use of psychiatric services thannonviolentmen,butalowerprevalenceof depression. Violent ruminative thinking,violent victimization, and fear of furthervictimization accounted for the high levelsof psychosis and anxiety disorders in gang members, and with service use in gang members and other violent men. Associa-tions with antisocial personality disorder,substance misuse, and suicide attemptswere explained by factors other thanviolence. Conclusions: Gang members show inor-dinately high levels of psychiatric morbid-ity, placing a heavy burden on mentalhealthservices.Traumatizationandfearof further violence, exceptionally prevalentin gang members, are associated withservice use. Gang membership should beroutinely assessed in individuals present-ing to health care services in areas withhigh levels of violence and gang activity.Health care professionals may have animportant role in promoting desistencefrom gang activity. (Am J Psychiatry 2013; 170:985  – 993)  V  iolence is a de fi ning characteristic of gang member-ship (1, 2), together with extensive criminality and sub-stance misuse (3). Street gangs are increasingly evident inU.K. cities (1, 4), with similarities to gangs in the UnitedStates, where fl uctuations in gang activity correspond tochanges in homicide rates (5), youth violence, and vic-timization (6, 7). Gun control has resulted in low ratesof homicides involving  fi rearms in the United Kingdom,but gang members are estimated to carry out half of allshootings and 22% of serious violent crimes in London (1).The spread of gang-related violence is held to resemble anepidemiological “ core infection ” model (8) through a pro-cess of social contagion (9) in which gangs evaluate andrespondtothehighlyvisibleviolentactionsofothergangs,retaliate, and attempt to achieve dominance throughviolent retribution (10). Violence is necessary for building and maintaining personal status and enforcing groupcohesion, is instrumental in obtaining sexual access andmoney through robbery and intimidation, and may bea source of excitement. It is essential to the regulation of localdrugsmarketsbyorganizedgangs(11).Gangviolencerepresents a major public health problem. Gang membersengage not only with criminal justice agencies (1) but also with the health care system, by multiple entry points,particularly trauma services (2). To our knowledge, noprevious research has investigated whether gang violenceis related to psychiatric morbidity (other than substancemisuse) or places burdens on mental health services.Epidemiological studies have shown that psychiatricmorbidity is associated with violent behavior (12 – 15),although the mechanisms involved are complex and arenot fully understood. In addition to violence towardothers, gang violence can result in high levels of traumaticvictimization and fear of violence (16).Through their violence, gang members are potentially exposed to multiple risk factors for psychiatric morbidity.Our aim in this study was to investigate associationsbetween gang membership, violent behavior, and psy-chiatric morbidity in a nationally representative sampleof young men and to identify explanatory factors. Weexamined associations between violent behaviors, atti-tudes toward and experiences of violence, a range of mental disorders, and use of mental health services. Toidentify the speci fi c effects of gang membership, wecompared gang members with young men who wereviolent but not in gangs. This article is featured in this month ’ s AJP Audio and is discussed in an Editorial by Dr. Monahan (p. 942)  Am J Psychiatry 170:9, September  985  Method Data Collection  We carried out the survey in 2011. It was based on randomlocation sampling, an advanced form of quota sampling shownto reduce the biases introduced when interviewers choosea location to sample from. Individual sampling units (censusareas of 150 households each) were randomly selected withinBritish regions, in proportion to their population. The basicsurvey derived a representative sample of young men (18 – 34 years of age) from England, Scotland, and Wales. In addition,there were four boost surveys. First, young black and minority ethnic men were selected from output areas with a minimum of 5% black and minority ethnic inhabitants. Second, young menfrom the lower social grades (grades D and E, as de fi ned by theMarket Research Society, based on head of household: semi-skilled, unskilled, and occasional manual workers; and pen-sioners and welfare recipients) were selected from output areasin which there were a minimum of 30 men 18 – 64 years of age inthese social grades. The fi nal boost surveys were based on outputareas in two locations characterized by high gang membership,the London borough of Hackney and Glasgow East, Scotland.The same sampling principles applied to each survey type. A self-administered questionnaire piloted in a previous survey  was adapted for this one. Informed consent was obtained from allsurvey respondents. Respondents completed the pencil-and-paperquestionnaire in privacy and were paid £5 for their participation. Survey Measures The Psychosis Screening Questionnaire (17) was used toscreen participants for psychosis; a positive screening was one in which three or more criteria were met. Questions from theStructured Clinical Interview for DSM-IV Personality DisordersScreening Questionnaire (18) identi fi ed antisocial personality disorder.The Hospital Anxiety and Depression Scale (19) was used to de fi neanxiety and depression, based on a score $ 11 in the past week.Scores $ 20 on the Alcohol Use Disorders Identi fi cation Test (20) andscores $ 25 on the the Drug Use Disorders Identi fi cation Test (21) were used to identify alcohol or drug dependence, respectively.Participants were asked if they had ever deliberately attemptedto kill themselves. They were also asked whether they werecurrently taking any prescribed psychotropic medications, hadconsulted a medical practitioner over the past 12 months formental health problems, had ever seen a psychiatrist or psychol-ogist, or had ever been admitted to a psychiatric hospital. Gang Membership and Violence   All participants were questioned about violent behavior,including whether they had been “ in a physical fi ght, assaultedor deliberately hit anyone in the past 5 years, ” as used in previoussurveys of violence (13, 15). Information was sought about thenumber of violent incidents they had been involved in and theirattitudes toward and experiences of violence. They were ad-ditionally asked, “  Are you currently a member of a gang? ” Forinclusion in the study, gang members had to endorse gang membership and one or more of the following: serious criminalactivities or convictions, involvement with friends in criminalactivities, or involvement in gang  fi ghts during the past 5 years.Participants were divided into three mutually exclusive groupsaccording to participation in violence and gang membership: 1)nonviolent men — participants reporting no violent behavior overthe past 5 years and no gang membership; 2) violent men — participants reporting violence over the past 5 years but nogang membership or involvement in gang  fi ghts; and 3) gang members. Statistical Analysis Initially, we compared the demographic characteristics of non-violent men, violent men, and gang members using logistic re-gressions to identify potential confounders. Three analyses wereperformed, comparing nonviolent men and violent men, nonviolentmen and gang members, and violent men and gang members.Differences between the nonviolent men, the violent men, andthe gang members with respect to psychopathology and serviceuse were established by performing logistic regression analysesin the three comparison groups. Linear trends were establishedby entering group membership as an ordinal variable. As above,three analyses were conducted, comparing nonviolent men andviolent men, nonviolent men and gang members, and violentmen and gang members.Finally, we investigated whether associations between 1) gang membership, 2) violence, and 3) psychopathology or serviceuse were explained by attitudes toward violence, victimiza-tion experiences, and characteristics of violent behaviors. Po-tential explanatory variables were fi rst identi fi ed by testing their association with 1) gang membership or violence and 2)psychopathology or service use. Only if both associations weresigni fi cant at an alpha level of 0.05 were variables selected andthen entered in an adjusted model, with group membership asthe independent variable and psychopathology or service use asthe dependent variable. We examined the percentage reductionin the baseline odds of each mental disorder and type of serviceuse after adding each of the potentially explanatory variables intothe following equation: ( b unadjusted 2 b adjusted ) / b unadjusted 3 100. In a  fi nal model, all explanatory variables were enteredsimultaneously. Comparisons between baseline-adjusted andfully adjusted coef  fi cients were used to estimate the extent to which the association between group membership and psycho-pathology or service use was accounted for by the explanatory variable.To control for differences between samples, survey type wasincluded as a covariate in all analyses. We also used robuststandard errors to account for correlations within survey areasbecause of clustering within postal codes. An alpha level of 0.05 was adopted throughout. All analyses were performed in Stata,version 12 (StataCorp, College Station, Tex.). Results Demography and Sampling  The weighted sample included 4,664 men 18 – 34 years of age: 1,822 (39.1%) from the main survey; 969 (20.8%) fromthe ethnic minority sample; 555 (11.9%) from the sampleofmenfromlowersocialclasses;624(13.4%)fromHackney;and 694 (14.9%) from Glasgow East. Of the total sample,3,285 (70.4%) reported no violence over the past 5 years,1,272 (27.3%) reported assaulting another person or in-volvement in a  fi ght, and 108 (2.1%) reported current gang membership. Violent men were younger on average than nonviolentmen, more were U.K. born and unemployed, and fewer were black or from the Indian subcontinent. Gang members were also younger than nonviolent men, lesslikely to be single and non-U.K. born, and more likely tobe unemployed, black, and from the Indian subcontinent.Compared with violent nonmembers, fewer gang mem-bers were single and non-U.K. born, while more were of minority ethnic srcin (Table 1). 986 Am J Psychiatry 170:9, September 2013 GANG MEMBERSHIP, VIOLENCE, AND PSYCHIATRIC MORBIDITY   Psychiatric Morbidity and Service Use  Table 2 summarizes the psychiatric morbidity andservice use of nonviolent men, violent men, and gang members. The data show a marked gradient: psychiatricmorbidity and service use were infrequent among non-violent men but increased progressively from violentnonmembers to gang members. This gradient was con- fi rmed for all outcomes (p , 0.001) except depression.The three pairwise sets of analyses were used to explorethe relationships in more detail (Table 2). Violent mendiffered signi fi cantly from nonviolent men on all mea-sures of psychopathology except drug dependence, andon all service use variables. The differences betweengang members and nonviolent men in relation to psy-chopathology and service use were considerably greater(Figure 1). After adjustment, depression was signi fi -cantly less prevalent among gang members and violentmen. Gang members were signi fi cantly less likely thanviolent men to be depressed but demonstrated higherlevels of other mental disorders, except psychosis andanxiety disorders. They were also signi fi cantly morelikely than violent men to report use of all forms of service(Table 2).  Attitudes Toward Violence and Victimization and Characteristics of Violent Behavior   As shown in Table 2, violent men differed from thenonviolent reference group in their attitudes towardviolence and violent victimization. However, greater dif-ferences were observed between gang members andnonviolent men. Gang members were signi fi cantly morelikely than nonviolent men to have been victims of vi-olence and to fear further violent victimization. They  were also more likely to experience violent ruminationsand more prepared to act violently if disrespected. Theseattitudes and experiences were also signi fi cantly higher ingang members than in violent men. The characteristics of violence among gang members also differed considerably from those in violent men who were not gang members.Gang members reported signi fi cantly more violent inci-dents and were more likely to have previous convictionsfor violence, to report using instrumental violence, and tobe excited by violence (Table 2). Explaining Links Between Psychopathology, Service Use, and Violence/Gang Membership  Violent men and gang members were signi fi cantly morelikely to acknowledge positive attitudes toward violence,increased violent victimization, and more severe charac-teristicsofviolence(Table2).Manyofthesesamevariables were signi fi cantly associated with psychopathology andservice use (see Table S1 in the data supplement thataccompaniestheonlineeditionofthisarticle).Wethereforeinvestigated whether violence variables explained theelevated rates of psychopathology and service use among violent men and gang members. TABLE 1. Demographic Characteristics of Nonviolent and Violent Men and Gang Members Violent Men ComparedWith Nonviolent MenGang MembersCompared WithNonviolent MenGang MembersCompared With ViolentMenCharacteristicNonviolentMenViolentMenGangMembersAdjustedOdds Ratio 95% CIAdjustedOdds Ratio 95% CIAdjustedOdds Ratio 95% CIN % N % N %Non-U.K. born 520 16.1 102 8.1 5 4.6 0.76* 0.58, 0.99 0.15*** 0.06, 0.38 0.19** 0.07, 0.51Single 1,944 59.9 862 68.1 70 57.7 1.16 0.97, 1.39 0.45** 0.27, 0.74 0.38*** 0.23, 0.65Unemployed 1,128 35.1 542 43.8 51 50.4 1.23* 1.04, 1.45 1.96** 1.21, 3.16 1.59 0.97, 2.61EthnicityWhite(reference)1,961 59.8 980 77.1 37 34.1Black 473 14.4 135 10.6 53 49.3 0.62** 0.45, 0.85 9.81*** 5.50, 17.48 15.9*** 8.57, 29.50Indiansubcontinent788 24.0 143 11.2 16 15.3 0.41*** 0.29, 0.57 2.36* 1.15, 4.87 5.78*** 2.71, 12.30Other 57 1.7 13 1.0 1 1.2 0.62 0.30, 1.28 2.3 0.52, 10.29 3.74 0.75, 18.75Survey typeMain(reference)1,228 37.4 575 45.2 19 17.8Ethnicminorities786 23.9 175 13.8 8 7.9 0.85 0.58, 1.24 0.27* 0.10, 0.74 0.32* 0.11, 0.89Lower socialclasses350 10.7 190 14.9 16 14.6 1.06 0.84, 1.33 2.41* 1.09, 5.33 2.28* 1.04, 5.01London,Hackney459 14.0 111 8.7 54 49.9 0.66* 0.48, 0.90 4.04** 1.83, 8.92 6.16*** 2.86, 13.26Glasgow East 462 14.1 221 17.4 11 9.8 0.83 0.63, 1.08 2.39 0.84, 6.82 2.89* 1.01, 8.25Mean SD Mean SD Mean SDAge (years) 26.6 4.9 25.4 5.0 25.1 5.3 0.96*** 0.94, 0.97 0.93** 0.88, 0.98 0.97 0.92, 1.02*p , 0.05. **p , 0.01. ***p , 0.001.  Am J Psychiatry 170:9, September  987 COID, ULLRICH, KEERS, ET AL.  Table 3 presents the change in odds of psychopathol-ogy and service use among violent men after accounting for their attitudes toward violence and their violentvictimization experiences (percentage of change in oddsexplained by these variables). Once violent ruminations,fear of victimization, and violent victimization were takenintoaccount,someofthepreviouslyobservedassociationsbetween violent men and psychosis were considerably reduced in size and no longer signi fi cant. These samevariables also explained the elevated likelihood in this TABLE 2. Independent Associations of Violence and Gang Membership With Psychiatric Morbidity and Service Use a NonviolentMenViolentMenGangMembersViolent Men ComparedWith Nonviolent MenGang Members ComparedWith Nonviolent MenGang MembersCompared WithViolent MenMeasure N % N % N %AdjustedOdds Ratio 95% CIAdjustedOdds Ratio 95% CIAdjustedOdds Ratio 95% CI Psychiatricmorbidity Psychosis b 25 0.8 61 4.9 26 25.1 2.94** 1.49, 5.78 4.16** 1.50, 11.59 1.42 0.54, 3.68Anxiety b 343 10.6 242 19.2 63 58.9 1.83*** 1.39, 2.42 2.25* 1.09, 4.65 1.23 0.61, 2.45Depression b 303 9.4 107 8.5 21 19.7 0.65* 0.44, 0.97 0.18** 0.05, 0.63 0.27* 0.08, 0.89Alcoholdependence b 191 6.0 174 14.2 68 66.6 1.63** 1.14, 2.34 6.49*** 3.04, 13.87 3.97*** 1.90, 8.30Drug dependence b 26 0.8 61 5.0 59 57.4 1.40 0.59, 3.33 12.71*** 3.64, 44.37 9.06*** 3.60, 22.83Antisocialpersonalitydisorder b 117 3.6 359 29.2 86 85.8 8.84*** 6.75, 11.58 57.39*** 23.94, 137.62 6.49*** 2.73, 15.43Suicide attempt c 94 2.9 121 9.7 35 34.2 3.32*** 2.40, 4.60 13.09*** 7.74, 22.16 3.94*** 2.34, 6.63 Psychiatricservice use c Consulted medicalpractitioner213 6.6 144 11.4 28 27.1 1.91*** 1.48, 2.48 4.31*** 2.33, 7.96 2.25** 1.21, 4.18Consultedpsychiatrist orpsychologist40 1.2 45 3.6 13 12.1 2.71*** 1.65, 4.47 7.75*** 3.51, 17.10 2.86** 1.29, 6.32Psychiatricadmission76 2.4 63 5.0 21 20.7 2.21*** 1.48, 3.29 7.80*** 3.66, 16.62 3.53*** 1.67, 7.46Psychotropicmedication95 3.0 77 6.3 16 15.9 2.04*** 1.44, 2.89 5.00*** 2.23, 11.22 2.45* 1.11, 5.41 Attitudes towardviolence c Violent if disrespected272 9.3 513 46.7 87 87.3 8.84*** 7.18, 10.89 68.27*** 29.81, 156.34 8.10*** 3.65, 17.97Violent ruminations 98 3.1 202 17.0 68 70.1 5.49*** 4.10, 7.36 61.76*** 34.71, 109.88 12.63*** 7.33, 21.75 Violentvictimization c Fear violentvictimization510 16.3 236 19.5 67 65.4 1.32** 1.08, 1.62 8.84*** 5.00, 15.62 6.69*** 3.78, 11.86Violent victimization 281 8.6 410 32.2 41 38.6 4.96*** 4.03, 6.10 10.37*** 6.17, 17.45 2.09** 1.25, 3.50 Characteristics of violence c Number of violentincidents0 0 0 10 10.0 4.70*** 2.21, 20.001 238 23.1 1 0.92 336 32.6 10 9.9 $ 3 456 44.3 80 79.1Previous convictionfor violence208 16.4 37 34.6 7.54*** 3.99, 14.23Excited by violence 203 16.4 58 62.8 7.87*** 4.39, 14.13Instrumentalviolence122 9.7 77 72.7 21.80*** 12.20, 38.96 a All 95% con fi dence intervals are computed using robust standard errors to account for correlations within survey areas due to clusteringwithin postal codes. b Adjusted for all other psychiatric morbidity outcomes, non-U.K. birth, being single, unemployment, ethnicity, age, Index of MultipleDeprivation (a relative measure of deprivation at small-area level across the United Kingdom), and survey type. c Adjusted for non-U.K. birth, being single, unemployment, ethnicity, age, Index of Multiple Deprivation, and survey type.*p , 0.05. **p , 0.01. ***p , 0.001. 988 Am J Psychiatry 170:9, September 2013 GANG MEMBERSHIP, VIOLENCE, AND PSYCHIATRIC MORBIDITY 
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