Violence in schizophrenia and bipolar disorder

Although most psychiatric patients are not violent, serious mental illness is associated with increased risk of violent behavior. Most of the evidence available pertains to schizophrenia and bipolar disorder.

MEDLINE data base was searched for articles published between 1966 and November 2012 using the combination of key words 'schizophrenia' or 'bipolar disorder' with 'aggression' or 'violence'. For the treatment searches, generic names were used in combination with key words 'schizophrenia' or 'bipolar disorder' and 'aggression' No language constraint was applied. Only articles dealing with adults were included. The lists of references were searched manually to find additional articles.

There were statistically significant increases of risk of violence in schizophrenia and in bipolar disorder in comparison with general population. The evidence suggests that the risk of violence is greater in bipolar disorder than in schizophrenia. Most of the violence in bipolar disorder occurs during the manic phase. The risk of violence in schizophrenia and bipolar disorder is increased by comorbid substance use disorder. Violence among adults with schizophrenia may follow at least two distinct pathways-one associated with antisocial conduct, and another associated with the acute psychopathology of schizophrenia. Clozapine is the most effective treatment of aggressive behavior in schizophrenia. Emerging evidence suggests that olanzapine may be the second line of treatment. Treatment adherence is of key importance. Non-pharmacological methods of treatment of aggression in schizophrenia and bipolar disorder are increasingly important. Cognitive behavioral approaches appear to be effective in cases where pharmacotherapy alone does not suffice.

Violent behavior of patients with schizophrenia and bipolar disorder is a public health problem. Pharmacological and non-pharmacological approaches should be used to treat not only violent behavior, but also contributing comorbidities such as substance abuse and personality disorders. Treatment adherence is very important for successful management of violent behavior.