Comparison of antipsychotic medication effects on reducing violence in people with schizophrenia

Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, 905 West Main Street, Durham, NC 27710, USA.
The British Journal of Psychiatry (Impact Factor: 7.99). 08/2008; 193(1):37-43. DOI: 10.1192/bjp.bp.107.042630
Source: PubMed


Violence is an uncommon but significant problem associated with schizophrenia.
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.
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.
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, substance use, victimisation, economic deprivation and living situation. Negative psychotic symptoms predicted lower violence.
Newer antipsychotics did not reduce violence more than perphenazine. Effective antipsychotics are needed, but may not reduce violence unrelated to acute psychopathology.

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    • "There is also promising evidence from rich case studies and open trials suggesting that metacognitive therapy can improve overall functioning in patients with schizophrenia (Van Donkersgoed et al., 2014). The consideration of such interventions are especially important in light of research showing that pharmacotherapeutic interventions appear to have little effect on reducing the propensity of these patients for violence (Nolan et al., 1999; Swanson et al., 2008). Methodologically, our analytical approach clearly demonstrates that standard linear regression analyses can yield underspecified explanatory models, and thus we highlight the importance of examining nonlinear relationships within the context of complex disorders such as schizophrenia. "
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    ABSTRACT: Psychopathy and metacognitive difficulties have been associated with the occurrence of violence in schizophrenia. However, evidence suggests that nonschizophrenic psychopaths match or even outperform healthy controls on tests of metacognition. We hypothesize that the metacognitive difficulties associated with schizophrenia may be ameliorated by comorbid psychopathy. To this end, metacognition (using the Metacognition Assessment Scale-Abbreviated [MAS-A]) and psychopathy (using the Hare Psychopathy Checklist-Revised [PCL-R]) are assessed in 79 patients with schizophrenia with a history of criminal offending. Piecewise regression reveals that the association between metacognition and psychopathy changes from a negative to a positive association at a breakpoint corresponding to a score of 24 on the PCL-R. This score is within the range of the cut-off point used for the diagnosis of psychopathy in Europe, which corresponds to a score of 26 on the PCL-R. The patients scoring above 24 on the PCL-R demonstrated better overall metacognitive abilities, suggesting that these patients constitute a specific group in which schizophrenia has an attenuated impairing effect on metacognition. However, this effect was absent for the Mastery subscale of the MAS-A, which refers to the ability to use one’s own mental states to solve social and psychological dilemmas. Our results suggest that the relative preservation of metacognitive abilities in schizophrenic patients with extreme levels of psychopathy may contribute to their offending behavior as it may enable them to understand how to manipulate and extort their victims. However, enhancing the Mastery domain of metacognition in these patients may attenuate this offending behavior.
    Journal of Abnormal Psychology 09/2015; DOI:10.1037/abn0000096 · 4.86 Impact Factor
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    • "Although findings from prior studies vary, TCO symptoms (Link and Stueve, 1994), auditory hallucinations (McNiel, 1994), systematization of delusions (Yoshikawa, 1995), gross excitement (Fullam and Dolan, 2008), living with others (Swanson et al, 2008) and prior violence (Walsh et al., 2004) were found to be significant predictors of violence. "
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    ABSTRACT: Numerous studies have examined a wide range of risk factors associated with violence among patients with schizophrenia. However, risk factors linked to different socio-cultural backgrounds remain unclear.Objective The objectives were to investigate factors associated with violence among Japanese patients with schizophrenia prior to emergency hospitalizations and to compare them with factors found in studies on other populations.Methods We recruited 420 Japanese patients with schizophrenia who had committed violent acts immediately prior to emergency admission to a psychiatric hospital in Tokyo, during the period 1986 to 2005. Cases were compared with controls (non violent hospitalized patients with schizophrenia) matched for gender, age and admission year. All medical records were reviewed retrospectively. Inter-rater reliability tests of assessment were performed. Conditional logistic regression analysis was used to identify factors associated with violence.ResultsThe symptoms of gross excitement, prior violence, auditory hallucinations, systematization of delusions, incoherence of speech, delusions of reference, TCO symptoms, living with others and long duration of illness were found to be associated with violence. In contrast, antisocial traits such as substance abuse and antisocial episodes were not recognized as significant violence-associated factors.Conclusion Violence among Japanese patients with schizophrenia was strongly associated with elements of schizophrenia itself, rather than antisocial traits. This study highlighted associated factors for violence among Japanese patients with schizophrenia which differ distinctly from associated factors in other countries. This result demonstrates that future studies assessing the risk of violence among patients with schizophrenia need to consider cultural and racial differences in cohorts.
    Schizophrenia Research 11/2014; 160(1-3). DOI:10.1016/j.schres.2014.10.016 · 3.92 Impact Factor
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    • "The ECA, MVRAS, and five-state findings tended to support that view, in part. At the same time, there is evidence that psychiatric symptomsdand particular combinations of symptoms such as delusions, suspiciousness, and extreme angerdcan increase violence risk under certain conditions in certain individuals, and that treatment such as antipsychotic medication to reduce these symptoms can, in turn, reduce violence risk [33] [34]. A recent large meta-analysis identified a range of risk factors for violence in persons with psychotic symptoms, which notably included concurrent substance abuse (especially polysubstance abuse) along with antisocial or criminal history, but also identified treatment nonadherence as a significant risk factor in these individuals [35]. "
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    ABSTRACT: Purpose This article describes epidemiological evidence concerning risk of gun violence and suicide linked to psychiatric disorders, in contrast to media-fueled public perceptions of the dangerousness of mentally ill individuals, and evaluates effectiveness of policies and laws designed to prevent firearms injury and mortality associated with serious mental illnesses and substance use disorders. Methods Research concerning public attitudes towards persons with mental illness is reviewed and juxtaposed with evidence from benchmark epidemiological and clinical studies of violence and mental illness and of the accuracy of psychiatrists’ risk assessments. Selected policies and laws designed to reduce gun violence in relation to mental illness are critically evaluated; evidence-based policy recommendations are presented. Results Media accounts of mass shootings by disturbed individuals galvanize public attention and reinforce popular belief that mental illness often results in violence. Epidemiological studies show that the large majority of people with serious mental illnesses are never violent. However, mental illness is strongly associated with increased risk of suicide, which accounts for over half of US firearms-related fatalities. Conclusion Policymaking at the interface of gun violence prevention and mental illness should be based on epidemiological data concerning risk, to improve the effectiveness, feasibility, and fairness of policy initiatives.
    Annals of Epidemiology 04/2014; 25(5). DOI:10.1016/j.annepidem.2014.03.004 · 2.00 Impact Factor
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