Pharmacotherapy for the Treatment of Aggressive Behavior in General Adult Psychiatry: A Systematic Review
Laurette E. Goedhard, MD; Joost J. Stolker, MD, PhD; Eibert R. Heerdink, PhD; Henk L. I. Nijman, PhD; Berend Olivier, PhD; and Toine C. G. Egberts, PharmD, PhD;
J Clin Psychiatry 2006;67(7):1013-1024
© Copyright 2015 Physicians Postgraduate Press, Inc.
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Objective: To systematically review the evidence
for pharmacologic management of outwardly directed
aggressive behavior in general adult psychiatry.
Data Sources: Literature searches in
PubMed, EMBASE, PsycINFO, and Cochrane libraries
from 1966 through March 2005 were used to identify
relevant studies. The keywords aggression,
violence, anger, and
hostility combined with drug therapy,
psychotropic drugs, adrenergic
beta-antagonists, anticonvulsants,
antidepressants, antipsychotic
agents, benzodiazepines, and
lithium were searched. Furthermore, the
retrieved publications were searched for additional references.
Study Selection: All randomized controlled
trials addressing pharmacotherapy for aggression or
aggression-related symptoms were included, except
studies addressing the "emergency situation" and studies
conducted in specialized psychiatric or nonpsychiatric
settings.
Data Extraction: Evidence synthesis was
performed using the "best-evidence principle." Two authors
independently adjudicated methodological quality and
generalizability to daily clinical practice.
Data Synthesis: Thirty-five randomized
controlled trials met the inclusion criteria and were evaluated.
On the basis of a best-evidence synthesis model, weak
evidence for antiaggressive effects of antipsychotics,
antidepressants, anticonvulsants, and
beta-adrenergic-blocking drugs was found. Atypical antipsychotics appeared superior to typical antipsychotics. The use
of various outcome measures and insufficient data
reporting in the individual studies hampered the
quantitative assessment of efficacy across studies. Further
limitations of the available randomized controlled trials
included small sample sizes, short study duration,
and poor generalizability to daily clinical practice setting.
Conclusions: Whereas pharmacotherapy is
frequently applied in aggressive patients, only weak
evidence of efficacy of various drug classes was
found. Consensus about the use of aggression
measurement scales in clinical trials is necessary for future
research. Furthermore, large-scale trials with more
naturalistic designs, as opposed to classical randomized
controlled trials with strict inclusion and exclusion criteria, may
be advisable in order to obtain results that are more
generalizable to daily clinical practice.