Abstract
Most individuals diagnosed with a mental illness are not violent, but some mentally ill patients commit violent acts. PubMed database was searched for articles published between 1980 and November 2013 using the combination of key words “schizophrenia” or “bipolar disorder” with “aggression” or “violence.” In comparison with the general population, there is approximately a twofold increase of risk of violence in schizophrenia without substance abuse comorbidity and ninefold with such comorbidity. The risk in bipolar disorder is at least as high as in schizophrenia. Most of the violence in bipolar disorder occurs during the manic phase. Violence among adults with schizophrenia may follow two distinct pathways: one associated with antisocial conduct and another associated with the acute psychopathology, particularly anger and delusions. Clozapine is the most effective treatment of aggressive behavior in schizophrenia. Emerging evidence suggests that olanzapine may be the second most effective treatment. Treatment nonadherence greatly increases the risk of violent behavior, and poor insight as well as hostility is associated with nonadherence. Nonpharmacological 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 is not sufficient.
Highlights
Many people believe that psychiatric patients are dangerous, and fear of violence is the most important part of the stigma of mental illness
The risk increase among the patients with substance abuse comorbidity was significantly less pronounced when unaffected siblings were used as controls (28.3% of those with schizophrenia had a violent offense compared with 17.9% of their unaffected siblings; adjusted OR = 1.8; 95% CI = 1.4–2.4; P < .001 for interaction), suggesting significant familial confounding of the association between schizophrenia and violence [20]
Contrary to the results reported by Elbogen and Johnson [22], we found that individuals with severe mental illness with or without comorbid substance abuse were significantly more likely to be violent than those with no mental or substance use disorders
Summary
Many people believe that psychiatric patients are dangerous, and fear of violence is the most important part of the stigma of mental illness. This belief persists despite the fact that most psychiatric patients are not violent and that they are much more likely to be victims rather than perpetrators of aggressive behavior. The public fear of patients is overblown, there is a general consensus among experts that severe mental illness does increase the risk of violence. Caring for violent psychiatric patients challenges the clinician. It elicits fear, countertransference problems, and eventual burnout. This review will examine the epidemiology, underlying mechanisms and pathways to violence, and the management of aggression in schizophrenia and bipolar disorder
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