Psychopharmacology of Aggression and Violence in Mental Illness

A Review of Evidence-Based Treatments

By Jan Volavka, MD, PhD and Leslie L. Citrome, MD, MPH | April 2, 2012

Dr Volavka is Professor Emeritus in the department of psychiatry, at New York Univer-sity School of Medicine, New York. Dr Citrome is Clinical Professor of Psychiatry & Behavioral Sciences, New York Medical College in Valhalla, NY. Dr Volavka reports that Eli Lilly has paid his travel expenses to a meeting. Dr Citrome reports that he has engaged in collaborative research with, or received consulting or speaking fees from, Alexza, Alkermes, AstraZeneca, Avanir, Bristol-Myers Squibb, Janssen, Eli Lilly, Lundbeck, Merck, Novartis, Noven, Otsuka, Pfizer, Shire, Sunovion, and Valeant.

A recent meta-analysis examined the effects of valproate(Drug information on valproate), carbamazepine(Drug information on carbamazepine), and phenytoin(Drug information on phenytoin) in the treatment of aggression with associated impulsivity in various psychiatric disorders. The researchers found that the evidence is insufficient to allow any firm conclusion to be drawn about the use of antiepileptic medication in the treatment of aggression and associated impulsivity.⁴⁵

Another meta-analysis excluded patients with psychosis, organic brain disorder, and mental retardation and, thus, focused mainly on personality disorders.⁴⁶ The effects of valproate, carbamazepine, phenytoin, levetiracetam(Drug information on levetiracetam), and lithium(Drug information on lithium) on aggression were analyzed. Some evidence of antiaggressive efficacy was found for carbamazepine, phenytoin, and lithium.

Lithium has been found to reduce aggressive behavior in mood disorders, particularly in bipolar disorder.⁴⁷ There is some evidence of antiaggressive effects of mood stabilizers in personality disorders.

Although mood stabilizer treatment of aggression in schizophrenia is not supported by adequate empirical evidence and is not approved by the FDA, it is possible that it may be effective in some patients. Such use must be weighed against potential adverse effects. The effectiveness of adjunctive treatment must be closely monitored, and the treatment must be promptly discontinued if it fails to show clear benefits.³⁹

SSRIs were reported to reduce aggressive behavior in patients with personality disorders and in the intellectually disabled.^48,49 Adjunctive citalopram(Drug information on citalopram) showed antiaggressive efficacy in persistently violent schizophrenia inpatients in a study that awaits replication.⁵⁰

Summary

Several studies have been undertaken to test the efficacy of drugs in the management of aggression and hostility in patients with schizophrenia and other mood disorders. Clozapine(Drug information on clozapine) was found to be most efficacious in reducing violent behavior in agitated patients with schizophrenia. However, clozapine is not likely to be fully effective against aggression before an optimal dose (approximately 400 mg/d) is reached, and dose titration may take several weeks. During the initial escalation period, clozapine should not be prematurely discontinued for apparent lack of effectiveness; if necessary, other medications can be added to clozapine temporarily to reduce aggressive behavior. If clozapine is contraindicated, olanzapine(Drug information on olanzapine) may be the second choice. Other antipsychotics do not show any systematic differences in their antiaggressive effects.

Pages: 1 2 3 4

Also in the Special Report

Introduction: Strategies for Treatment

Psychopharmacological Treatment to Reduce Suicide Risk

Psychopharmacology of Aggression and Violence in Mental Illness

Strategies to Improve Medication Adherence in Youths

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Psychopharmacology of Aggression and Violence in Mental Illness

A Review of Evidence-Based Treatments

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