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The psychopharmacology of violence: making sensible decisions

  • Leslie Citrome (a1) and Jan Volavka (a2)
Abstract

Violent behavior associated with mental disorders is a common reason for admission to a psychiatric inpatient unit. Once hospitalized, patients may continue to be intermittently agitated and have persistent aggressive behaviors, preventing their discharge back into the community. Managing agitation quickly with effective pharmacological agents can avoid further escalation to aggression and violence. In the acute setting, this usually involves the parenteral use of antipsychotics, with or without benzodiazepines. Within the past decade, short-acting intramuscular formulations of second-generation antipsychotics have become available and provide a means to induce calm with a substantially lower risk of acute dystonia or akathisia compared with haloperidol. New alternative formulations that avoid injections include inhalation and sublingual administration. Longer-term management of persistent aggressive behavior by reducing the frequency and intensity of future episodes of agitation is more complex. In contrast to agitation associated with schizophrenia or bipolar mania, no agents have yet been approved by regulatory agencies for the treatment of persistent aggressive behavior. The strongest evidence supports the use of clozapine as an antihostility agent, followed by olanzapine. Adjunctive strategies with anticonvulsants and beta-adrenergic agents may also be worthwhile to consider.

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Corresponding author
*Address for correspondence: Leslie Citrome, MD, MPH, 11 Medical Park Drive, Suite 106, Pomona, NY 10970, USA. (Email: citrome@cnsconsultant.com)
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1. RH Swift , EP Harrigan , JC Cappelleri , D Kramer , LP Chandler . Validation of the behavioural activity rating scale (BARS): a novel measure of activity in agitated patients. J Psychiatr Res. 2002; 36(2): 8795.

2. JP Lindenmayer , E Brown , RW Baker , etal. An excitement subscale of the Positive and Negative Syndrome Scale. Schizophr Res. 2004; 68(2–3): 331337.

8. DA Regier , ME Farmer , DS Rae , etal. Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiologic Catchment Area (ECA) Study. JAMA. 1990; 264(19): 25112518.

9. J Battaglia , S Moss , J Rush , etal. Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-blind, emergency department study. Am J Emerg Med. 1997; 15(4): 335340.

10. S Brook , JV Lucey , KP Gunn . Intramuscular ziprasidone compared with intramuscular haloperidol in the treatment of acute psychosis: Ziprasidone I.M. Study Group. J Clin Psychiatry. 2000; 61(12): 933941.

12. S Brook , J Walden , I Benattia , CO Siu , SJ Romano . Ziprasidone and haloperidol in the treatment of acute exacerbation of schizophrenia and schizoaffective disorder: comparison of intramuscular and oral formulations in a 6-week, randomized, blinded-assessment study. Psychopharmacology (Berl). 2005; 178(4): 514523.

14. R Andrezina , RN Marcus , DA Oren , etal. Intramuscular aripiprazole or haloperidol and transition to oral therapy in patients with agitation associated with schizophrenia: sub-analysis of a double-blind study. Curr Med Res Opin. 2006; 22(11): 22092219.

15. MD Lesem , JM Zajecka , RH Swift , KR Reeves , EP Harrigan . Intramuscular ziprasidone, 2 mg versus 10 mg, in the short-term management of agitated psychotic patients. J Clin Psychiatry. 2001; 62(1): 1218.

16. DG Daniel , SG Potkin , KR Reeves , RH Swift , EP Harrigan . Intramuscular (IM) ziprasidone 20 mg is effective in reducing acute agitation associated with psychosis: a double-blind, randomized trial. Psychopharmacology (Berl). 2001; 155(2): 128134.

19. P Wright , M Birkett , SR David , etal. Double-blind, placebo-controlled comparison of intramuscular olanzapine and intramuscular haloperidol in the treatment of acute agitation in schizophrenia. Am J Psychiatry. 2001; 158(7): 11491151.

23. R Andrezina , RC Josiassen , RN Marcus , etal. Intramuscular aripiprazole for the treatment of acute agitation in patients with schizophrenia or schizoaffective disorder: a double-blind, placebo-controlled comparison with intramuscular haloperidol. Psychopharmacology (Berl). 2006; 188(3): 281292.

24. TK Tran-Johnson , DA Sack , RN Marcus , etal. Efficacy and safety of intramuscular aripiprazole in patients with acute agitation: a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry. 2007; 68(1): 111119.

28. MD Lesem , TK Tran-Johnson , RA Riesenberg , etal. Rapid acute treatment of agitation in individuals with schizophrenia: multicentre, randomised, placebo-controlled study of inhaled loxapine. Br J Psychiatry. 2011; 198(1): 5158.

29. J Kwentus , RA Riesenberg , M Marandi , etal. Rapid acute treatment of agitation in patients with bipolar I disorder: a multicenter, randomized, placebo-controlled clinical trial with inhaled loxapine. Bipolar Disord. 2012; 14(1): 3140.

33. L Citrome . Asenapine for schizophrenia and bipolar disorder: a review of the efficacy and safety profile for this newly approved sublingually absorbed second-generation antipsychotic. Int J Clin Pract. 2009; 63(12): 17621784.

35. MP Wilson , D Pepper , GW Currier , GH Holloman Jr, D Feifel . The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project Beta Psychopharmacology Workgroup. West J Emerg Med. 2012; 13(1): 2634.

36. J Volavka , L Citrome . Heterogeneity of violence in schizophrenia and implications for long-term treatment. Int J Clin Pract. 2008; 62(8): 12371245.

37. KA Nolan , J Volavka , P Czobor , etal. Aggression and psychopathology in treatment-resistant inpatients with schizophrenia and schizoaffective disorder. J Psychiatr Res. 2005; 39(1): 109115.

38. KA Nolan , J Volavka , P Mohr , P Czobor . Psychopathy and violent behavior among patients with schizophrenia or schizoaffective disorder. Psychiatr Serv. 1999; 50(6): 787792.

39. DJ Cooke , C Michie . Refining the construct of psychopathy: towards a hierarchical model. Psychol Assess. 2001; 13(2): 171188.

40. KA Nolan , P Czobor , BB Roy , etal. Characteristics of assaultive behavior among psychiatric inpatients. Psychiatr Serv. 2003; 54(7): 10121016.

42. J Volavka , JM Zito , J Vitrai , P Czobor . Clozapine effects on hostility and aggression in schizophrenia. J Clin Psychopharmacol. 1993; 13(4): 287289.

44. J Volavka , P Czobor , K Nolan , etal. Overt aggression and psychotic symptoms in patients with schizophrenia treated with clozapine, olanzapine, risperidone, or haloperidol. J Clin Psychopharmacol. 2004; 24(2): 225228.

45. MI Krakowski , P Czobor , L Citrome , N Bark , TB Cooper . Atypical antipsychotic agents in the treatment of violent patients with schizophrenia and schizoaffective disorder. Arch Gen Psychiatry. 2006; 63(6): 622629.

47. J Volavka , P Czobor , EM Derks , etal; EUFEST Study Group.Efficacy of antipsychotic drugs against hostility in the European First-Episode Schizophrenia Trial (EUFEST). J Clin Psychiatry. 2011; 72(7): 955961.

50. L Citrome , J Volavka . Pharmacological management of acute and persistent aggression in forensic psychiatry settings. CNS Drugs. 2011; 25(12): 10091021.

52. L Citrome , J Levine , B Allingham . Changes in use of valproate and other mood stabilizers for patients with schizophrenia from 1994 to 1998. Psychiatr Serv. 2000; 51(5): 634638.

57. N Caspi , I Modai , P Barak , etal. Pindolol augmentation in aggressive schizophrenic patients: a double-blind crossover randomized study. Int Clin Psychopharmacol. 2001; 16(2): 111115.

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CNS Spectrums
  • ISSN: 1092-8529
  • EISSN: 2165-6509
  • URL: /core/journals/cns-spectrums
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