Carbamazepine in Treatment of the Violent Psychotic Patient

Abstract

Violence in th e psychiatric setting may be perpet rated by patients with a var ie ty of diagnoses including characte r d isorders, episodic dyscontrol syndromes, and drug or a lco hol intoxication . The vio lent behavio r of ag gressive psychotic patients is typicall y the most bi zarre , unpred ictable , and th e least responsive to intervention with neuroleptics or lithium carbonate. Carbamazepine , an estab lished anticonvulsant , has ac h ieved growing prominence as an adj unc t ive measure in treatment of th e vio lent psych o tic . This paper will review th e literature and summar ize th e posited p ha r maco logica l mech anisms, reported sid e effects, and clinical experience wit h carbamazepine in controll ing th e symptoms of vio lence and aggression in psychosis . An ticonvul san ts were first used in the treatment of aggressive psych o tic patients in 1943 (1). Carbamazepine , introduced in 1963 as an anticonvulsant particularly effec tive in temporal lobe epilepsy, has been reported to be useful in treating aggressio n associated wit h psych osis in patients with bipolar affective di sorder, schizoaffec tive di sorder , and sch izophrenia with and without EEG ab no r malit ies . T he first successfu l open clin ical tria ls in patients with bipolar d isorde r were co nd ucted in Japan in the early 197 0 's. Two groups o f in vestigators demonstrat ed anti-man ic and sligh t anti-depressive effects in 75% (2) and 55%, respectively, of th eir patients with bipolar affective disorder, and prophylactic effects in both manic (7 1%) and depressive (64 %) episodes (3 ,4), although some patients recei ved combinat ions of carbamazepine and lith ium and/or other drugs. A ser ies of double-blind controlled trials foll owed these stu d ies . Okuma et a l. compared chlorpromazin e and car ba mazepine and reported equivalent anti-manic effects (5) . Ballenger and Post cond uc ted double-bl ind , placebocontrolled trials of carbamazepine in nine manic patients, seven of whom had partial to marked therapeutic responses (6); a n additio nal pati ent who had been unresponsive to lithium and other anticonvulsants a lso improved on carbamazepine (7). Subsequent published case s and open stud ies reported the efficacy of ca rbamazepine combined with lithium carbonate (815), par ticul arl y in pati ents in whom lithium was less effect ive or who exper ie nced a contin uo us circular or a rapidly cycling course . Post et al. also provid ed case reports wh ich suggest th at car bamazep ine ma y have prophylacti c e ffec ts (16). Okuma et a l. conducted a