Pharmacological treatment of violence in schizophrenia

Personality disorders and schizophrenia spectrum disorders in the Italian forensic psychiatric population: clinical features, pattern of violence and treatment

Starting in 2015, the Residencies for Execution of Security Measures (REMS) became the place of treatment and care for dangerous offenders who were acquitted due to a mental disorder in Italy. Schizophrenia spectrum disorders (SSD) and personality disorders (PD) are the most common psychiatric disorders among REMS patients. This study aimed to identify and describe potential clinical, therapeutic, and criminal-related differences in REMS patients with SSD and PD. A sample of 528 REMS patients extracted from a previous observational retrospective study underwent secondary analysis. The group of PD patients (n = 150) comprised more females (p < 0.001) and had a higher frequency of substance abuse (p < 0.001) than the SSD group (n = 378). The SSD group was more frequently admitted to the REMS due to homicide/attempted homicide (p < 0.001). Among SSD patients, we found a higher recognition of criminal irresponsibility (p < 0.001). Patients with PD were more likely to engage in violent behavior in the REMS than their SSD counterparts (p < 0.001). Patients with SSD were more likely to receive antipsychotic polypharmacy (p < 0.05) and a higher dose of antipsychotics (p < 0.001). These initial results provide empirical evidence to support the need for personalized forensic treatment paths.

Long-acting antipsychotic treatments: focus on women with schizophrenia

Effective management of schizophrenia (SZ) requires long-term treatment with antipsychotics (APs) to prevent clinical relapse, attain remission and improve patients' personal and social functioning, and quality of life. Although APs remain the cornerstone treatment for patients with SZ, despite their potential benefits, long-acting injectable APs (LAI-APs) remain underused, most notably in women with SZ. The efficacy and tolerability of APs differ significantly between men and women, and some of these differences are more noticeable depending on the patient's age and the stage of the disorder. Although sex differences may influence treatment outcomes in SZ, their pertinence has been insufficiently addressed, especially regarding the use of LAI-APs. Some biological and social experiences, such as pregnancy, lactation, contraception and menopause, are specific to women, but these remain under-researched issues. Implications of this disorder in parenting are also of special pertinence regarding women; therefore, taking sex differences into account when treating SZ patients is now recommended, and improving personalized approaches has been proposed as a priority in the management of psychosis. In this narrative, critical review, we address some aspects specific to sex and their implications for the clinical management of women with SZ, with a special focus on the potential role of LAI-AP treatments.

A systematic review of clozapine for aggression and violence in patients with schizophrenia or schizoaffective disorder

Although uncommon, the risk of aggression and violence is greater in people with schizophrenia than in the general population. Clozapine is the "gold standard" pharmacologic treatment for the management of persistent agitation and aggression in people with schizophrenia and is consistently recommended by guidelines and reviews for this purpose. Although clozapine is indicated for treatment-resistant schizophrenia based on its superior efficacy, studies have proposed that clozapine may have specific properties that ameliorate aggression and hostility that are distinct from its antipsychotic effects. A literature review was conducted on June 3, 2023, using the US National Library of Medicine's PubMed resource to identify articles focusing on clozapine for the treatment of aggression, violence, and/or hostility in patients with schizophrenia or schizoaffective disorder. The majority of evidence, including from randomized control trials, supports the utilization of clozapine as maintenance treatment for persistent aggressive behavior in patients with schizophrenia, and supports that its anti-aggressive effects may be independent from its antipsychotic properties (e.g. - treatment of hallucinations and delusions). Future randomized control studies evaluating clozapine and clozapine serum levels with aggression as the primary outcome would be of benefit.

Differences between criminal offender versus non-offender female patients with schizophrenia spectrum disorder: a retrospective cohort study

The purpose of this study was to investigate the difference between offender female patients (OFS) and non-offender female patients (NOFS) with schizophrenia spectrum disorder (SSD).The patients in this study were admitted to the university psychiatry in Zurich Switzerland between 1982 and 2016. Demography, psychopathology, comorbidity, and treatment differences were analyzed using binary statistics to compare 31 OFS and 29 matching NOFS with SSD. The Fisher's exact test was used for categorical data variables in small size samples and the Mann-Whitney-U-Test for nonparametric test variables, adjusted with the Benjamini and Hochberg method.The results indicate that the NOFS were cognitively more impaired, they were more likely to have had antipsychotic drugs prescribed (NOFS; 100%, OFS: 71%, OR 1.41, 95% CI 1.13-1.77, p=0.022) and their medication compliance was higher (NOFS: 84.6%, OFS: 4.5%, OR 0.09, 95% CI 0.00-0.08, p=0.000). In contrast, the OFS had completed compulsory school less often and the were observed to be more often homeless and socially isolated (OFS: 72.4%, NOFS: 34.6%, OR 4.96, 95% CI 1.58-15.6, p=0.026), self-disorders (OFS: 51.6%, NOFS: 11.1%, OR 8.53, 95% CI 2.12-34.32, p=0.011), delusions (OFS: 96.8%, NOFS: 63%, OR 17.65, 95% CI 2.08-149.99, p=0.014) and substance use disorder (51.6%, OR 0.27, 95% CI 0.09-0.85, p=0.039). Clinicians treating female offender patients with SSD should focus more on the treatment for substance use disorder, medication and early recognition of the illness for preventative purposes.

Real-World Evidence of Antipsychotic Monotherapy Versus Polypharmacy in the Treatment of Schizophrenia Spectrum Disorders

PURPOSE/BACKGROUND

It is still not well known whether antipsychotic monotherapy versus polypharmacy differs in terms of efficacy in the emergency department (ED) utilization, presentation with agitation/aggression, and rehospitalization in schizophrenia spectrum disorders (SSD) patients. This study aimed to determine the effectiveness of antipsychotic monotherapy and polypharmacy for these outcomes in the real world.

METHODS/PROCEDURES

The study was conducted with electronic health records of 669 SSD patients admitted to the ED. Patients were evaluated in 4 groups according to antipsychotic use at the first admission to ED: antipsychotic noncompliance for more than 90 days, antipsychotic noncompliance for 15 to 90 days, antipsychotic monotherapy, and polypharmacy. All patients followed up for at least 1 year after index admission. The primary outcomes determined an association between antipsychotic monotherapy versus polypharmacy and all-cause psychiatric hospitalization between the groups after index admission in the SSD.

FINDINGS/RESULTS

The groups, including patients with antipsychotic noncompliance, had higher ED visits, more hospitalizations, and more admissions with agitation/aggression compared with antipsychotic monotherapy or polypharmacy. However, no differences were found between monotherapy and polypharmacy groups regarding these outcomes. In addition, there was no difference in the risk of hospitalization in monotherapy antipsychotic users compared with polypharmacy users. Patients discharged with monotherapy or polypharmacy also had similar rehospitalization rates at follow-up.

IMPLICATIONS/CONCLUSIONS

There is no positive evidence that recommending polypharmacy over antipsychotic monotherapy is superior with regard to the resulting frequency of ED visits, ED admissions with agitation/aggression, hospitalization, and rehospitalization. In this context, antipsychotic monotherapy may be preferred over polypharmacy in patients who are not resistant to treatment.

Rethinking Clozapine: Lights and Shadows of a Revolutionary Drug

The current literature globally highlights the efficacy of Clozapine in several psychiatric disorders all over the world, with an FDA indication for reducing the risk of repeated suicidal behavior in patients with schizophrenia or schizoaffective disorder. A growing field of research is also stressing a possible broader beneficial effect of Clozapine in promoting neuroprotection and neurotrophism. However, this drug is linked to several life-threatening side effects, such as agranulocytosis, myocarditis and seizures, that limit its use in daily clinical practice. For this work, a search was performed on PubMed using the terms "Clozapine indications", "Clozapine adverse effects", "Clozapine regenerative effects", and "Clozapine neuroplasticity" with the aim of reviewing the scientific literature on Clozapine's treatment indications, adverse effects and potential regenerative role. The results confirmed the efficacy of clozapine in clinical practice, although limited by its adverse effects. It appears crucial to raise awareness among clinicians about the potential benefits of using Clozapine, as well educating medical personnel about its risks and the early identification of possible adverse effects and their management.

Targeted Treatment of Schizophrenia Symptoms as They Manifest, or Continuous Treatment to Reduce the Risk of Psychosis Recurrence

Current pharmacological treatment of schizophrenia employs drugs that interfere with dopamine neurotransmission, aiming to suppress acute exacerbation of psychosis and maintenance treatment to reduce the risk of psychosis recurrence. According to this treatment scheme, available psychotropic drugs intended to treat negative symptoms, cognitive impairment, or anxiety are administered as add-ons to treatment with antipsychotics. However, an alternative treatment scheme proposes a targeted or intermittent treatment approach, by which antipsychotic drugs are administered upon psychosis exacerbation and discontinued upon remission or stabilization, while negative symptoms, cognitive impairment, or anxiety are treated with specific psychotropics as monotherapy. Along these lines, antipsychotics are renewed only in the event of recurrence of psychotic symptoms. This 50-year-old debate between targeted and continuous treatment schemes arises from disagreements about interpreting scientific evidence and discordant views regarding benefit/risk assessment. Among the debate's questions are: (1) what is the percentage of individuals who can maintain stability without antipsychotic maintenance treatment, and what is the percentage of those who exacerbate despite antipsychotic treatment? (2) how to interpret results of placebo-controlled 9- to 18-month-long maintenance trials in a life-long chronic disorder, and how to interpret results of the targeted trials, some of which are open label or not randomized; (3) how to weigh the decreased risk for psychotic recurrence vs the almost certainty of adverse effects on patient's quality of life. Patients' profiles, preferences, and circumstances of the care provision should be considered as the targeted vs continuous treatment options are considered.

Violence, neurocognitive function and clinical correlates in patients with schizophrenia

BACKGROUND

Schizophrenia patients with violent behavior are a severe public health concern, but the correlates of this violent behavior are unknown. Additionally, the relationship between neurocognitive function and violent behavior in Chinese patients with schizophrenia has not yet been investigated.

METHODS

A total of 337 schizophrenia inpatients were recruited. The Positive and Negative Syndrome Scale (PANSS) was used to assess psychopathological symptoms. Neurocognitive functioning was evaluated using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS).

RESULTS

The percentage of violent behavior was 10.4% in patients with schizophrenia. Patients with violent behavior had higher PANSS-positive, excited, and total subscale scores than patients who did not show violent behavior. Patients with violent behavior also had lower RBANS language, semantic fluency, and total subscale scores. Gender (OR = 0.066∼0.819, p = 0.023), illness duration (OR = 0.876∼0.971, p = 0.002), smoking (OR = 1.127∼2.950, p = 0.014), the PANSS positive subscale (OR = 1.050∼1.197, p = 0.001), and the RBANS language subscale (OR = 0.927∼0.987, p = 0.005) significantly contributed to the development of violent behavior in schizophrenia patients.

CONCLUSION

Our findings revealed that cognitive and clinical assessments should be considered in comprehensive assessments of future risks of violence in schizophrenia patients.

Young age and the risk of violent behaviour in people with severe mental disorders: prospective, multicentre study

Background

During adolescence and young adulthood people appear to be more prone to violent behaviour. A greater tendency to violent behaviour appears to be associated with hyperactivity, impulsivity and low tolerance for frustration and provocation in social settings.

Aims

This prospective cohort study aimed to evaluate rates of violent behaviour among young people with mental disorders, compared with older age groups.

Method

A total of 340 individuals with severe mental disorders (125 living in residential facilities and 215 out-patients) were evaluated at baseline with the SCID-I and II, Brief Psychiatric Rating Scale, Specific Level of Functioning scale, Brown–Goodwin Lifetime History of Aggression scale, Buss–Durkee Hostility Inventory, Barratt Impulsiveness Scale and State–Trait Anger Expression Inventory-2. Aggressive behaviour was rated every 15 days with the Modified Overt Aggression Scale (MOAS).

Results

The sample comprised 28 individuals aged 18–29 years, 202 aged 30–49 and 110 aged 50 and over. Younger age was associated with a personality disorder diagnosis, substance use disorder, being single and employed. These results were confirmed even controlling for the gender effect. The patterns of the cumulative MOAS mean scores showed that younger (18–29 years old) individuals were significantly more aggressive than older (≥50) ones (P < 0.001).

Conclusions

This study highlights how young age in people with severe mental disorders is correlated with higher levels of impulsivity, anger and hostility, confirming previous analyses. Our results may assist clinicians in implementing early interventions to improve anger and impulsivity control to reduce the risk of future aggressive behaviours.

Domestic Mass Shooters: The Association With Unmedicated and Untreated Psychiatric Illness

BACKGROUND

Given the relative lack of psychiatric information and data on the perpetrators of US mass shootings, the aim of our study was to understand who these "mass shooters" were and whether they had a psychiatric illness. If so, were they competently diagnosed, and if so, were they treated with appropriate medication for their diagnoses before the violence?

METHODS

Because a prospective study of diagnosis and treatment could not, for obvious reasons, be carried out, we designed a retrospective, observational study of mass shooters, defined as those who killed 4 or more people with firearms between 1982 and 2012 or who killed 3 or more people with firearms between 2013 and 2019 in the United States. We used the Mother Jones database-a database of 115 persons identified as committing a mass shooting in the United States between January 1982 and September 2019. In the vast majority of the incidents identified in the database, the perpetrator died either during or shortly after the crime, leaving little reliable information about their history-especially psychiatric history. We focused on the 35 mass shooters who survived and for which legal proceedings were instituted because these cases presented the most reliable psychiatric information. For each of these 35 mass shootings, we interviewed forensic psychiatrists and forensic psychologists who examined the perpetrator after the crime and/or collected the testimony and reports by psychiatrist(s) at trial or in the postconviction proceedings contained in the court record. In addition, we reviewed available information from the court proceedings, public records, a videotaped interview of assailant by law enforcement, social media postings of the assailant, and writings of the assailant. After collecting the clinical information from multiple sources on each case to make a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosis, we also completed a Sheehan Diagnostic Scale. After this, 20 additional cases where the assailant died at the crime were randomly selected form the remaining 80, to determine whether there were differences in psychiatric diagnoses and treatment between such assailants and those who survived.

RESULTS

Twenty-eight of 35 cases in which the assailant survived had a psychiatric diagnosis-18 with schizophrenia, 3 with bipolar I disorders, 2 with delusional disorders, persecutory type, 2 with personality disorders (1 paranoid and 1 borderline), 2 with substance-related disorders without other psychiatric diagnoses, and 1 with posttraumatic stress disorder. Four had no psychiatric diagnosis, and in 3, we did not have enough information to make a diagnosis.Of 15 of 20 cases in which the assailant died, 8 had schizophrenia. None of those diagnosed with psychiatric illnesses were treated with medication.

CONCLUSIONS

A significant proportion of mass shooters experienced unmedicated and untreated psychiatric disorder.

Candidate symptomatic markers for predicting violence in schizophrenia: A cross-sectional study of 7711 patients in a Chinese population

OBJECTIVE

Violent behaviour is an alarming problem among schizophrenia patients. The effects of historical, clinical, and pathological risk factors for violence have been investigated by multiple studies, but consensus has not been achieved. As psychotic symptoms are more direct and intuitive indicators for violence, identifying robustly associated symptoms is a crucial part of the future prediction and precise management of violent patients in clinics. This study aims to identify the psychotic symptoms correlated with violence among schizophrenia patients in a Chinese population.

METHODS

In this cross-sectional study, the medical records of 7711 schizophrenia patients (4711 in the discovery set and 3000 in the validation set) were collected from 1998 to 2010. Their psychotic symptoms were extracted, and the patients were divided into violent and non-violent groups. Multivariate logistic analysis was applied to identify symptoms associated with violence in the discovery set.

RESULTS

Eight psychotic symptoms were found to be significantly correlated with violence in schizophrenia. "Destruction of property", "verbal aggression" and "insomnia" increased the risk of violence, while "flat affect", "delusion of persecution", "auditory hallucination", "vagueness of thought" and "poverty of thought" decreased the risk of violence. The regression model was evaluated by receiver operating characteristic (ROC) analysis for its discriminatory performance, achieving area under curve (AUC) values of 0.887 in the discovery sample set and 0.824 in the validation sample set.

CONCLUSIONS

The correlated symptoms identified by this study can serve as future candidate predictors for violence in schizophrenia, paving the way for precise management of schizophrenia patients in clinics.