Violence toward healthcare professionals represents a critical challenge to clinical safety and the therapeutic alliance [1]. Although most individuals with schizophrenia are not violent, a small subgroup may commit severe acts when untreated psychosis and treatment non-adherence converge [2]. We report five forensic cases involving male patients with schizophrenia who perpetrated homicide (n=2) or attempted homicide (n=3) against their treating physicians. These cases were reviewed as part of routinely collected clinical and legal records within the National Forensic Hospital; the Institutional Review Board approved this analysis and waived the requirement for written consent due to the retrospective design and the use of anonymized information (Approval No. 1-219577-AB-N-01-202503-BR-002-01).
Across all cases, several shared clinical patterns were observed. The patients were single, unemployed, and had experienced long illness durations with repeated relapses. The most striking commonality was the presence of active persecutory delusions explicitly directed toward the physician or the treatment process. These delusions produced a total rupture of trust, transforming the physician—typically the core therapeutic figure—into a perceived persecutor.
A second shared pattern was severe treatment non-adherence. Four of the five patients had discontinued medication or were receiving irregular treatment immediately before the offense. Despite the psychotic motivation, all cases showed elements of planning: acquiring a knife or blunt object in advance, choosing the timing of the attack, or waiting for a moment of reduced staff presence. This “psychotic yet planned” pattern distinguishes these incidents from impulsive aggression commonly seen in acute inpatient units [3].
These findings emphasize that violence against physicians in schizophrenia is not random but emerges at the intersection of two factors: untreated psychosis with persecutory content specifically targeting the clinician, and prolonged medication non-adherence. Clinical interactions involving conflict—such as disability evaluations, involuntary admission discussions, or medication side-effect concerns—were frequently involved in delusion formation.
From a preventive standpoint, these cases highlight two key clinical implications. First, proactive strategies to prevent non-adherence are essential. Long-acting injectable antipsychotics (LAIs) remain underutilized despite clear evidence of their superiority for preventing relapse [4]. For individuals repeatedly hospitalized for psychosis or showing ambivalence about medication, early transition to LAIs should be considered.
Second, clinicians should routinely screen for “treatment-targeted delusions.” When such beliefs are present, enhanced safety planning is recommended. Environmental measures, such as ensuring that consultations occur in rooms with clear exit routes or maintaining adequate staff presence, may reduce risk during periods of heightened psychosis.
These cases, though representing a severe subset of schizophrenia, provide important insights into mechanisms of extreme violence within therapeutic relationships. Maintaining adherence, rebuilding alliance, and identifying early warning signs remain central to prevention.
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