One in three homicides fuelled by psychosis, as doctors fear growing crisis

A fourfold increase in the number of homicides committed by people with psychotic disorders in Victoria is the result of catastrophic failings in the mental health system that are exposing the community to dangerous levels of risk, experts have warned.

Frustrated psychiatrists say the alarming uptick in killings by people with psychosis is a triple tragedy for perpetrators, victims and the wider public because many of the recent deaths could have been prevented had the offenders received proper treatment.

Some are also concerned the homicides are just the tip of an iceberg — the most extreme, most visible symptom of a deepening crisis that the mental health royal commission should have addressed but hasn't, and on some fronts may have exacerbated.

Data compiled by consultant forensic psychiatrist Dr Rajan Darjee suggests 43 out of an estimated 126 homicides in Victoria in 2024 and 2025 — about one in three — were committed by people with psychosis, a significant increase from a decade ago, when one in 10 homicides per year were perpetrated by people with psychotic disorders.

Half of all stranger homicides in Victoria in the same period were committed by people with psychosis, Dr Darjee's research shows, as were two in three intimate partner and family homicides, raising questions about the adequacy of domestic violence prevention policies which emphasise addressing gender inequality and "disrespectful" attitudes.

"I remember looking at the raw number" — 43 homicides in two years, with 45 victims — "going, this is astounding," said Dr Darjee, clinical director of psychiatry at Forensic Behavioural Assessment and Consultation Services and adjunct professor at Swinburne University's Centre for Behavioural Science.

But perhaps the most important finding, he said, is that almost 84 per cent of homicide offenders in the sample had previously received treatment by mental health services, while half were connected with a service at the time of the incident.

'The public should not feel safe'

Psychosis is a set of psychological symptoms that impair a person's sense of reality. A central feature of schizophrenia spectrum disorders, it usually occurs in episodes that last days, months or even years and can include hallucinations, delusions, disordered thinking and disordered behaviour.

Though most people with psychotic disorders are never violent, there is a clear association between psychosis and violence. Australian and international studies also show people with psychotic illness are more likely to perpetrate homicide than people in the general population — a major reason why experts have long stressed the importance of effectively treating psychosis to reduce and prevent violence.

"If you treat people with psychosis early and effectively, you prevent poor outcomes later, including chronic mental ill-health, disengagement from family, not being able to work, homelessness … but also violence and aggression," Dr Darjee said.

Dr Darjee and his colleagues designed the study — which is yet to be published in a peer-reviewed journal — to understand whether their anecdotal observations were reflected in formal data.

He surveyed nine forensic psychiatrists who write defence reports for courts in Victoria about how many people they assessed in 2024 or 2025 who were charged with murder or manslaughter and diagnosed with psychosis, and whether they were connected with mental health services, among other details.

"It's terrible that 45 people have died, especially when you think the majority of those were probably preventable deaths," Dr Darjee said. "But the homicides are the tip of the iceberg. The bigger [part of the] iceberg underneath means that people with mental illness and their families are living lives that are much worse than they need to be."

Professor Patrick McGorry, a psychiatrist who chaired the expert advisory committee for the Royal Commission into Victoria's Mental Health System, said the homicide data was the result of a "public policy failure" to build a modern system of care to replace the state's old psychiatric hospitals, which were decommissioned in the 1990s.

"What it shows is that people have had ineffective contact with mental health services," Professor McGorry said. "They've either tried to get access but have failed, or they've gained access but haven't been able to get effective treatment, which is what people with serious mental illness need. They get episodes of care rather than sustained, safety net-type treatment."

The royal commission, which ran from 2018 to 2021, was "largely a successful blueprint" to fix the system, he said, but the government "has not really invested properly in implementing its recommendations — every single one has been delayed or poorly implemented".

"I thought for sure the royal commission … would have led to a once-in-a-generation transformational reform — I was wrong," Professor McGorry said. "So I think the only thing … that will actually galvanise the public into demanding something is done is if they themselves don't feel safe. And the public should not feel safe in the context of the current mental health system."

Crucially, he added, most people with psychosis pose no harm when they are well. "It's the acute illness that has made them dangerous and so that's a tragedy — not just for their victims but for them personally — that they've been allowed to harm other people. And it's not a character problem, it's a health problem."

Compulsory treatment can be 'life-saving'

Several experts told ABC News they were particularly concerned about an anecdotal increase in the number of short-term admissions to mental health units when longer stays are generally required to stabilise patients with psychosis.

Many are also worried a royal commission recommendation to reduce the use and duration of compulsory treatment orders has contributed to a system-wide reluctance to use them, including in cases where they ought to be.

"With the best of intentions we've instigated these least restrictive care policies but they've become negligent," Dr Darjee said. "I don't like compelling people [into treatment], I always do it reluctantly, but sometimes it's life saving."

Forensicare chief executive and Swinburne University Adjunct Professor Colmán O'Driscoll agreed people should ideally be compelled to take psychiatric treatment only as a last resort. But he said the mental health system was at risk of "swinging the pendulum too far the other way" if people with psychosis aren't being put on compulsory treatment orders when they need to be.

"We always think about these orders as a compulsion on the individual to receive care. In my view, a significant part of their benefit is that they compel the system to provide the care you deserve as a member of our community," Professor O'Driscoll said.

And given psychosis can affect people's ability to make "good decisions", he said, maintaining their engagement with treatment is crucial, and leads to better outcomes. 

Australian studies have found people with psychosis are much more likely to be convicted of a violent criminal offence than the general population, but that early and frequent contact with mental health services reduces their risk of reoffending — and those on community treatment orders are less likely to reoffend than those who receive punitive sanctions.

"The starting point is finding a way to conceptualise violence among people with psychosis as a complication of their illness and therefore we should have a health system that sees the prevention of it as core to its work, not separate from it," Professor O'Driscoll said.

He said Victoria should be invest more in programs that divert people with psychosis away from the criminal justice system into treatment programs, focus on improving patient engagement with such programs, and upskill the mental health workforce in violence risk assessment and management.

Some doctors also believe there is a trend in Victoria, particularly since the introduction of the Mental Health and Wellbeing Act in 2022, to view a wide spectrum of mental health and "wellbeing" issues as equally important, but that severe mental illness must be prioritised.

"I genuinely think that, even though the royal commission and what came after it hasn't been fully implemented, we need a wholesale review and almost a reversal of some of its recommendations," Dr Darjee said. "And I think in mental health policy and care there needs to be more emphasis on people with severe mental illness."

So long as nothing changes, he added, "we're just going to carry on having lots of people dying unnecessarily".

"I just don't think it's right for a relatively well-off jurisdiction like Victoria to be neglecting people with mental illness as much as we're neglecting them."

Minister for Mental Health Ingrid Stitt did not respond to specific questions but a government spokesperson told ABC News that Victoria's mental health system was focused on ensuring people with serious mental illness can access safe, compassionate treatment.

"Every homicide is a tragedy and while these incidents are rare, it's vital they're not used to stigmatise people living with mental ill-health," they said.

"The Mental Health and Wellbeing Act provides for compulsory assessment and treatment where the legal criteria are met, while recognising that compulsory treatment should only be used as a last resort."