Preventing Violence in Patients with Schizophrenia

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.