Violence is pervasive in our culture. Some, but not all, people with mental illness have problems with violence. About 50% of patients with schizophrenia exhibit violent behavior. These patients are 5 to 6 times more likely to have a problem with violent behavior than people without any diagnosed mental disorder. Comorbid substance abuse increases the probability of violent behavior further. Patients that exhibit violent or threatening behavior are often admitted to a psychiatric inpatient facility. Upon admission, these patients should be assessed for the possibility of comorbid conditions.

Treatment approaches depend on the underlying clinical problem. Short-term sedation with lorazepam is a safe and effective choice for acute agitation. However, sedation is not an acceptable method of treatment. Preferred treatments for acute agitation are intramuscular preparations of the atypical antipsychotics such as clozapine, olanzapine and quetiapine. Longer-term solutions include strategies that treat impulsivity. Mood stabilizers, such as valproate, carbamazepine and lithium may be used. Valproate is often used with neuroleptics to decrease the intensity and frequency of agitation and poor impulse control. Beta-blockers such as propranolol and nadolol may be used as an adjunctive agent to antipsychotics for aggression and schizophrenia. The anti-aggressive effect of beta-blockers may be delayed by 4 to 6 weeks. Benzodiazepines such as clonazepam are not effective in this population and may worsen aggressive behavior. Recent research has shown the serotinergic neurotransmitter system may be involved in aggressive behavior. For this reason, adjunctive serotonin-specific reuptake inhibitors (SSRIs) may be used to treat this population. These drugs include fluoxetine and citalopram.

Dr. Citrome showed data from a double-blind study that treated 157 patients with either haloperidol, clozapine, risperidone or olanzepine for 14 weeks. The experimental design is shown below:

The primary outcome measure was the PANSS hostility item. On this scale, the number 1 represents no hostility while the number 7 indicates extreme hostility. The data indicate clozapine significantly reduced hostility in these patients. In contrast, risperidone and haloperidol did not affect hostility.

From these results, Dr. Citrome concluded that clozapine was more effective than typical antipsychotics in decreasing aggressivity in schizophrenia and superior to risperidone and haloperidol in reducing aggressivity in patients with schizophrenia or schizoaffective disorder.

(abstract Symposia No. 6C)