Clozapine vs. Haloperidol in Aggression Prevention (original) (raw)
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Clozapine in Reducing Aggression and Violence in Forensic Populations
Psychiatric Quarterly, 2017
Popular media often portray people with a mental illness as being aggressive, violent, and incarcerated as a result of their behavior. Despite exaggeration in the media, risks for some aggressive behaviors are in fact higher in individuals with schizophrenia. This is often the case with influence of comorbid substance use disorders. It is essential that mental health professionals are aware of treatments that may help with attenuating and treating behaviors that contribute to violence, aggression and incarceration. This paper reviews violence and incarceration in individuals with schizophrenia as well as recommendations, guidelines and benefits for the use of clozapine in this population. Clozapine remains one of the most underutilized evidence-based medications available in the psychiatric arena in the United States. It is a viable and recommended option in the forensic population and it may be helpful on the path to recovery as well as bring substantial savings to the criminal justice system.
CNS Spectrums, 2021
Background The purpose was to systematically investigate which pharmacological strategies are effective to reduce the risk of violence among patients with Schizophrenia Spectrum Disorders (SSD) in forensic settings. Methods For this systematic review six electronic data bases were searched. Two researchers independently screened the 6,003 abstracts resulting in 143 potential papers. These were then analyzed in detail by two independent researchers. Of these, 133 were excluded for various reasons leaving 10 articles in the present review. Results Of the 10 articles included, five were merely observational, and three were pre-post studies without controls. One study applied a matched case-control design and one was a non-randomized controlled trial. Clozapine was investigated most frequently, followed by olanzapine and risperidone. Often, outcome measures were specific to the study and sample sizes were small. Frequently, relevant methodological information was missing. Due to heterog...
ABSTRACT Schizophrenia, violence and homicidal act: assessing the risks, preventive measures and place of clozapine in the treatment Objective: This review is designed to analyze the potential risk factors and preventive measures involved in homicidal behaviors in schizophrenic individuals and investigate the efficacy of clozapine in preventing these violence behaviors and evaluate the results. Method: For this purpose, the psychiatry literature was comprehensively reviewed. A screening of the articles in the international and national databases, covering the period between 1979 and 2010 was performed. Trials that have contributed to this field were also utilized. Results: Although the risk of homicidal behaviors is higher in the schizophrenic individuals compared to the overall population, little is known about the relevant conditions triggering this act of violence among criminals. The available results suggest that certain factors, including some socio-demographic characteristics, male gender, young age, alcoholism, substance abuse, incompliance with the treatment, fulfillment of the criteria for antisocial personality disorder and paranoid subtype, history of suicidal ideation and attempts, and history of frequent hospitalization increase the probability for occurrence of violent episodes. Conclusion: In the clinical practice, the patients with a risk of committing homicide should be detected and monitored closely. The available data show clozapine to be the most rational therapeutic choice in preventing the acts of violence in schizophrenics. Key words: Schizophrenia, violence, homicide, risk factors, preventive measures, clozapine
Preventing Violence in Patients with Schizophrenia
Current Treatment Options in Psychiatry, 2015
Violence in patients with schizophrenia has garnered substantial public attention in the lay press. Although schizophrenia is associated with a modestly elevated risk for violent behavior, which is further increased by comorbid substance use disorders, most patients with schizophrenia are not violent and most violent individuals do not have schizophrenia. At present, primary prevention efforts are of theoretical interest and include attention being placed on childhood maltreatment. Research into secondary prevention, defined as the prevention of occurrence of violent behavior in persons already diagnosed with schizophrenia, has identified several risk factors including substance use and nonadherence to medication treatment. A specific antiaggressive effect of clozapine has been identified and should be considered as a treatment option for persons with schizophrenia and persistent aggressive behavior. A potential alternative to clozapine is olanzapine, based on a randomized controlled trial where although olanzapine was less efficacious than clozapine in aggression outcomes, olanzapine was more efficacious than haloperidol, and the choice of olanzapine is further supported by evidence from two large effectiveness studies, the Clinical Antipsychotic Trials of Intervention Effectiveness and the European First-Episode Schizophrenia study. Tertiary prevention, defined as the acute management of agitated and aggressive behavior, is accomplished with the use of psychological and behavioral interventions such as verbal de-escalation techniques, in combination with pharmacological agents. For persons with schizophrenia, antipsychotics are preferred. Although rapidly acting intramuscular formulations have been the mainstay for this type of treatment, oral agents such as inhaled loxapine and sublingual asenapine can be considered.
Effect of clozapine on physical and verbal aggression
Schizophrenia Research, 1996
Objective: The hypothesis that clozapine reduces serious physically and verbally aggressive behavior of persons with schizophrenia whose symptoms did not respond to typical neuroleptic treatment was tested. Method: Incident reports of aggression and restraint of 75 such inpatients were reviewed for 3 months before clozapine treatment and for 6 months of clozapine treatment. BPRS scores were also examined. Twenty-eight patients with no incidents were removed from study. Results: There were significantly fewer incidents of physical aggression per month per patient on clozapine than before clozapine (mean ___ S.D. = 0.13 + 0.25 vs. 0.54_ 0.93; t = 3.4, df= 46, p < 0.002) and a similar decline in verbal aggression (0.21+0.31 vs. 0.73+0.83; t=4.3, df=46, p<0.000). On clozapine, 49% (n=23) of patients had fewer incidents of physical aggression, 36% (n = 17) showed no change and 15% (n = 7) showed more. Seventy percent (n = 33) of patients had fewer incidents of verbal aggression, 4% (n =2) showed no change and 25% (n= 12) had more. During the 3 months before clozapine, 14 patients (30%) were restrained a total of 40 times. During the first 6 months of clozapine treatment, three patients (6%) were restrained a total of six times. There were significant decreases in BPRS hostility, positive, negative and psychosis scores. Conclusion: Clozapine appears to reduce serious aggression among some patients.
CNS Spectrums, 2014
ObjectiveA number of studies have demonstrated the anti-aggressive properties of clozapine in schizophrenia and its positive effect in borderline personality disorder. There is no published literature on the treatment of antisocial personality disorder (ASPD) with clozapine. We present a case series of 7 patients with primary ASPD and high psychopathic traits treated with clozapine, having a significant history of serious violence and currently detained in a UK based high-security hospital.MethodsA retrospective review of case notes was carried out to formulate Clinical Global Impression (CGI) scores and record incidents of violence and aggression. Effect on specific symptom domains (cognitive-perceptual, impulsive-behavioural dyscontrol, affective dysregulation) was also noted. Metabolic parameters and serum clozapine levels were also sampled.ResultsAll 7 patients showed significant improvement on clozapine. It was shown to benefit all symptom domains, especially impulsive behavior...
Treatment of the psychotic patient who is violent
Psychiatric Clinics of North America, 2003
Aggression among patients with serious mental illness occurs relatively infrequently, but it is a significant concern for patients, relatives, mental health professionals, and the public. Recognition of this risk and providing access and continuity of appropriate psychiatric care should be major clinical and administrative objectives in the management of violence in psychotic patients. To date, pharmacologic approaches have been unclear and inconsistent. At present, typical antipsychotics continue to have a primary role in acute management and in long-term management, in which noncompliance necessitates the use of long-acting depot neuroleptic preparations. Atypical antipsychotics in acute and long-acting intramuscular forms doubtless will influence and expand the choice for acute management of hostile psychotic patients and the long-term management of poorly compliant patients who are at risk to become violent on relapse. Persistent aggression should be managed by atypical antipsychotics with a preferential indication for clozapine, for which the most data on efficacy are available. The role of adjunctive medications is presently unclear. A major focus of care should be to refine legal processes and to conduct intervention studies aimed at enhancing treatment compliance. Violence risk reduction is not only crucial from a societal perspective, but also it is a humanitarian necessity to alleviate the burden and stigma for patients with serious mental illness.
Comparison of antipsychotic medication effects on reducing violence in people with schizophrenia
The British Journal of Psychiatry, 2008
Background Violence is an uncommon but significant problem associated with schizophrenia Aims To compare antipsychotic medications in reducing violence among patients with schizophrenia over 6 months, identify prospective predictors of violence and examine the impact of medication adherence on reduced violence Method Participants (n=1445) were randomly assigned to double-blinded treatment with one of five antipsychotic medications. Analyses are presented for the intention-to-treat sample and for patients completing 6 months on assigned medication Results Violence declined from 16% to 9% in the retained sample and from 19% to 14% in the intention-to-treat sample. No difference by medication group was found, except that perphenazine showed greater violence reduction than quetiapine in the retained sample. Medication adherence reduced violence, but not in patients with a history of childhood antisocial conduct. Prospective predictors of violence included childhood conduct problems, sub...
The pharmacological management of violence in schizophrenia: a structured review
Expert Review of Neurotherapeutics, 2011
Although the increased risk of violent behavior in individuals with schizophrenia is now wellestablished, there is considerable uncertainty in pharmacological strategies to reduce this risk. In this review, we performed a systematic search of three electronic databases from January 2000 to March 2010 of treatment research on the management of violence in schizophrenia. We identified eight randomized controlled trials. The main findings included the association of nonadherence to antipsychotic medication to violent outcomes, a specific anti-aggressive effect of clozapine and short-term benefits of adjunctive b-blockers. There was little evidence on the efficacy of adjunctive mood stabilizers, depot medication or electroconvulsive therapy. Future research should use validated outcomes, longer follow-up periods and investigate patients with comorbid substance misuse.
Introduction: The aim of this study was to compare the therapeutic and adverse effects of haloperidol to the combination of haloperidol and promethazine (antipsychotic + antihistamine) for controlling patients with aggressive or violent behavior referred to psychiatric emergency rooms. Methods: Using a double-blind randomized controlled trial, 100 eligible psychiatric patients admitted to emergency room of Taleghani hospital, Tehran, Iran, randomly received intramuscular haloperidol or haloperidol plus promethazine. The patients were observed at 20, 40, 60, 120 minute intervals and then at 6, 12 and 24 hourly intervals to determine if they were tranquil or asleep, need for further injection, serious adverse effects, acute dystonia, akathisia, need for other medications, and need for admission to hospital based on clinical judgment. Results: The mean age of patients was 36.25 years and 69% were male. Patients receiving promethazine plus haloperidol were more tranquil after 2, 6 and 12 hours and sustained sleep after hours 2 and 6. Adding promethazine to haloperidol decreased the need for repeated involvement of the psychiatrist on duty, using additional medications and hospital admission. Patients taking the combination of haloperidol and promethazine did not experience more adverse effects than those taking only haloperidol. Conclusion: The combination of haloperidol plus promethazine can be safely used in emergency rooms for controlling patient with agitation and aggressive behavior resulting in a sustained tranquilization or asleep and lower need for further intervention.