When choosing an antipsychotic for first-episode schizophrenia, clinicians often prioritize side effects over efficacy. But what if the patient has a history of violence? This review suggests that taking violence history into consideration could lead to better treatment decisions.
The authors conducted a nonsystematic review of antipsychotic options for first-episode schizophrenia, stratifying patients based on violence history. This was assessed via high hostility scores on the Positive and Negative Syndrome Scale or Overt Aggression Scale, and was present in 9% of cases. Medications were evaluated for long-term efficacy, all-cause discontinuation rates, and mortality. Olanzapine, risperidone, perphenazine, and aripiprazole were considered, but cariprazine, brexpiprazole, lumateperone, lurasidone, and xanomeline-trospium were not, as they lacked long-term data.
Results
For violent patients, olanzapine was the most effective antipsychotic, except for clozapine, which remains the gold standard for treatment-resistant and highly aggressive cases.
For nonviolent patients, olanzapine still showed strong efficacy and lower discontinuation rates, but its metabolic risks made aripiprazole, risperidone, and perphenazine equally appealing.
Perphenazine stood out for its efficacy with minimal weight gain, but it was not specifically identified as superior for violent patients. The main concern with perphenazine remains the risk of tardive dyskinesia.
CARLAT TAKE Consider olanzapine and then clozapine for psychotic patients with a history of violence, where the benefit of reduced hostility better outweighs metabolic risks. As always, work for shared decision-making about side effects.
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