Skip to main content Accessibility help

Pharmacological treatment of violence in schizophrenia

  • Martin T. Strassnig (a1), Vanessa Nascimento (a2), Elizabeth Deckler (a2) and Philip D. Harvey (a1) (a3)


Chronic aggression and violence in schizophrenia are rare, but receive disproportionate negative media coverage. This contributes to the stigma of mental illness and reduces accessibility to mental health services. Substance Use Disorders (SUD), antisocial behavior, non-adherence and recidivism are known risk factors for violence. Treatment with antipsychotic medication can reduce violence. Aside from clozapine, long-acting injectable antipsychotics (LAI) appear to be superior to oral antipsychotics for preventing violence, addressing adherence and recidivism. LAI also facilitate the implementation of functional skills training. For the high-risk recidivist target population with schizophrenia, better life skills have the potential to also reduce the risk for contact with the legal system, including an improved ability to live independently in supported environments and interact appropriately with others. High-risk patients who are resistant to treatment with other antipsychotics should receive treatment with clozapine due to its direct positive effects on impulsive violence, along with a reduction in comorbid risk factors such as SUDs.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Pharmacological treatment of violence in schizophrenia
      Available formats

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Pharmacological treatment of violence in schizophrenia
      Available formats

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Pharmacological treatment of violence in schizophrenia
      Available formats


Corresponding author

*Address correspondence to: Philip D. Harvey, Department of Psychiatry, University of Miami, Miami, FL 33136, USA. (Email:


Hide All
1. Citrome, L, Volavka, J. The psychopharmacology of violence: making sensible decisions. CNS Spectr. 2014; 19(5): 411418.
2. Meyer, JM, Cummings, MA, Proctor, G, et al. Psychopharmacology of persistent violence and aggression. Psychiatr Clin North Am. 2016; 39(4): 541556.
3. Fazel, S, Gulati, G, Linsell, L, et al. Schizophrenia and violence: systematic review and meta-analysis. PLoS Med. 2009; 6(8): e1000120.
4. Witt, K, van Dorn, R, Fazel, S. Risk factors for violence in psychosis: systematic review and meta-regression analysis of 110 studies. PLoS One. 2013; 8(2): e55942.
5. Sariaslan, A, Lichtenstein, P, Larsson, H, et al. Triggers for violent criminality in patients with psychotic disorders. JAMA Psychiatry. 2016; 73(8): 796803.
6. Torrey, EF. Stigma and violence: isn’t it time to connect the dots? Schizophr Bull. 2011; 37(5): 892896.
7. Bhavsar, V, Bhugra, D. Violence towards people with mental illness: assessment, risk factors, and management. Psychiatry Clin Neurosci. 2018; 72(11): 811820.
8. Walsh, E, Buchanan, A, Fahy, T. Violence and schizophrenia: examining the evidence. Br J Psychiatry. 2002; 180: 490495.
9. Nolan, KA, Volavka, J, Czobor, P, et al. Aggression and psychopathology in treatment-resistant in patients with schizophrenia and schizoaffective disorder. J Psychiatr Res. 2005; 39(1): 109115.
10. Quanbeck, CD, McDermott, BE, Lam, J, et al. Categorization of aggressive acts committed by chronically assaultive state hospital patients. Psychiatr Serv. 2007; 58(4): 521528.
11. Sirotich, F. The criminal justice outcomes of jail diversion programs for persons with mental illness: a review of the evidence. J Am Acad Psychiatry Law 2009; 37(4): 461472.
12. Volavka, J, Van Dorn, RA, Citrome, L, et al. Hostility in schizophrenia: an integrated analysis of the combined Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and the European First Episode Schizophrenia Trial (EUFEST) studies. Eur Psychiatry. 2016; 31: 1319.
13. Morrissette, DA, Stahl, SM. Treating the violent patient with psychosis or impulsivity utilizing antipsychotic polypharmacy and high-dose monotherapy. CNS Spectr. 2014; 19: 439448.
14. Patchan, K, Vyas, G, Hackman, AL, et al. Clozapine in reducing aggression and violence in forensic populations. Psychiatr Q. 2018; 89(1): 157168.
15. Ratey, JJ, Leveroni, C, Kilmer, D, et al. The effects of clozapine on severely aggressive psychiatric inpatients in a state hospital. J Clin Psychiatry. 1993; 54(6): 219223.
16. Rabinowitz, J, Avnon, M, Rosenberg, V. Effect of clozapine on physical and verbal aggression. Schizophr Res. 1996; 22(3): 249255.
17. Chiles, JA, Davidson, P, McBride, D. Effects of clozapine on use of seclusion and restraint at a state hospital. Hosp Community Psychiatry. 1994; 45(3): 269271.
18. Sinyor, M, Remington, G. Is psychiatry ignoring suicide? The case for clozapine. J Clin Psychopharmacol. 2012; 32(3): 307308.
19. Brunette, MF, Drake, RE, Xie, H, et al. Clozapine use and relapses of substance use disorder among patients with co-occurring schizophrenia and substance use disorders. Schizophr Bull. 2006; 32(4): 637643.
20. Misawa, F, Kishimoto, T, Hagi, K, et al. Safety and tolerability of long-acting injectable versus oral antipsychotics: a meta-analysis of randomized controlled studies comparing the same antipsychotics. Schizophr Res. 2016; 176(2–3): 220220.
21. Khan, AY, Salaria, S, Ovais, M, et al. Depot antipsychotics: where do we stand? Ann Clin Psychiatry. 2016; 28(4): 289298.
22. Arango, C, Bombin, I, Gonzalez-Salvador, T, et al. Randomised clinical trial comparing oral versus depot formulations of zuclopenthixol in patients with schizophrenia and previous violence. Eur Psychiatry. 2006; 21(1): 3440.
23. Correll, CU, Citrome, L, Haddad, PM, et al. The use of long-acting injectable antipsychotics in schizophrenia: evaluating the evidence. J Clin Psychiatry. 2016; 77(Suppl.3): 124.
24. Rezansoff, SN, Moniruzzaman, A, Fazel, S, et al. Adherence to antipsychotic medication and criminal recidivism in a Canadian provincial offender population. Schizophr Bull. 2017; 43(5): 10021010.
25. Lynn Starr, H, Bermak, J, Mao, L, et al. Comparison of long-acting and oral antipsychotic treatment effects in patients with schizophrenia, comorbid substance abuse, and a history of recent incarceration: an exploratory analysis of the PRIDE study. Schizophr Res. 2018; 194: 3946.
26. Iozzino, L, Ferrari, C, Large, M, et al. Prevalence and risk factors of violence by psychiatric acute inpatients: a systematic review and meta-analysis. PLoS One. 2015; 10(6): e0128536.
27. Trudeau, KJ, Burtner, J, Villapiano, AJ, et al. Burden of schizophrenia or psychosis-related symptoms in adults undergoing substance abuse evaluation. J Nerv Ment Dis. 2018; 206(7): 528536.
28. Alphs, L, Benson, C, Cheshire-Kinney, K, et al. Real-world outcomes of paliperidone palmitate compared to daily oral antipsychotic therapy in schizophrenia: a randomized, open-label, review board-blinded 15-month study. J Clin Psychiatry. 2015; 76(5): 554561.
29. Strassnig, M, Bowie, C, Pinkham, AE, et al. Which levels of cognitive impairments and negative symptoms are related to functional deficits in schizophrenia? J Psychiatr Res. 2018; 104: 124129.
30. Fu, DJ, Turkoz, I, Walling, D, et al. Paliperidone palmitate once-monthly maintains improvement in functioning domains of the personal and social performance scale compared with placebo in subjects with schizoaffective disorder. Schizophr Res. 2018; 192: 185193.
31. Montemagni, C, Frieri, T, Rocca, P. Second-generation long-acting injectable antipsychotics in schizophrenia: patient functioning and quality of life. Neuropsychiatr Dis Treat. 2016; 12: 917929.
32. Sajatovic, M, Ramirez, LF, Fuentes-Casiano, E, et al. A 6-month prospective trial of a personalized behavioral intervention + long-acting injectable antipsychotic in individuals with schizophrenia at risk of treatment nonadherence and homelessness. J Clin Psychopharmacol. 2017; 37(6): 702707.
33. Medrano, S, Abdel-Baki, A, Stip, E, et al. Three-year naturalistic study on early use of long-acting injectable antipsychotics in first episode psychosis. Psychopharmacol Bull. 2018; 48(4): 2561.
34. Krakowski, MI, Czobor, P. Depression and impulsivity as pathways to violence: implications for antiaggressive treatment. Schizophr Bull. 2014; 40(4): 886894.
35. Krakowski, MI, Czobor, P, Citrome, L, et al. Atypical antipsychotic agents in the treatment of violent patients with schizophrenia and schizoaffective disorder. Arch Gen Psychiatry. 2006; 63(6): 622-629.
36. Krakowski, M, Czobor, P, Citrome, L. Weight gain, metabolic parameters, and the impact of race in aggressive inpatients randomized to double-blind clozapine, olanzapine or haloperidol. Schizophr Rese. 2009; 110(1–3): 95102.
37. Citrome, L, Volavka, J, Czobor, P, et al. Effects of clozapine, olanzapine, risperidone, and haloperidol on hostility among patients with schizophrenia. Psychiatr Serv. 2001; 52(11): 15101514.
38. Swanson, JW, Swartz, MS, Van Dorn, RA, et al. Comparison of antipsychotic medication effects on reducing violence in people with schizophrenia. Br J Psychiatry. 2008; 193(1): 3743.
39. Hodgins, S, Riaz, M. Violence and phases of illness: differential risk and predictors. Eur Psychiatry. 2011; 26(8): 518524.
40. Swanson, JW, Swartz, MS, Elbogen, EB. Effectiveness of atypical antipsychotic medications in reducing violent behavior among persons with schizophrenia in community-based treatment. Schizophr Bull. 2004; 30(1): 320.
41. Chengappa, KN, Vasile, J, Levine, J, et al. Clozapine: its impact on aggressive behavior among patients in a state psychiatric hospital. Schizophr Res. 2002; 53(1–2): 16.
42. Fond, G, Boyer, L, Boucekine, M, et al. Illness and drug modifiable factors associated with violent behavior in homeless people with severe mental illness: results from the French Housing First (FHF) program. Prog Neuro-Psychopharmacol & Biol Psychiatry. 2019; 90: 9296.
43. Kranzler, H, Roofeh, D,Gerbino-Rosen, G, et al. Clozapine: its impact on aggressive behavior among children and adolescents with schizophrenia. J Am Acad Child Adolesc Psychiatry. 2005; 44(1): 5563.
44. Chalasani, L, Kant, R, Chengappa, KN. Clozapine impact on clinical outcomes and aggression in severely ill adolescents with childhood-onset schizophrenia. Can J Psychiatr. 2001; 46(10): 965968.
45. Cohen, SA, Underwood, MT. The use of clozapine in a mentally retarded and aggressive population. J Clin Psychiatr. 1994; 55(10): 440444.
46. Hotham, JE, Simpson, PJ, Brooman-White, RS, et al. Augmentation of clozapine with amisulpride: an effective therapeutic strategy for violenttreatment-resistant schizophrenia patients in a UK high-security hospital. CNS Spectr. 2014; 19(5): 403410.
47. Ifteni, P, Szalontay, AS, Teodorescu, A. Reducing restraint with clozapine in involuntarily admitted patients with schizophrenia. Am J Ther. 2017; 24(22): 222226.
48. Volavka, J. The effects of clozapine on aggression and substance abuse in schizophrenic patients. J ClinPsychiatry. 1999; 60: 4346.
49. Balbuena, L, Mela, M, Wong, S, et al. Does clozapine promote employability and reduce offending among mentally disordered offenders? Can J Psychiatry. 2010; 55(1): 5056.
50. Kraus, JE, Sheitman, BB. Clozapine reduces violent behavior in heterogeneous diagnostic groups. J Neuropsychiatr Clin Neurosci. 2005; 17(1): 3644.
51. Kelly, DL, Conley, RR, Feldman, S, et al. Adjunct divalproex or lithium to clozapine in treatment-resistant schizophrenia. Psychiatr Q. 2006; 77(1): 8195.
52. Kisely, SR, Campbell, LA. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Schizophr Bull. 2015; 41(3): 542543.
53. Swartz, MS, Bhattacharya, S, Robertson, AG, et al. Involuntary outpatient commitment and the elusive pursuit of violence prevention. Can J Psychiatr. 2017; 62(2): 102108.
54. Barnett, P, Matthews, H, Lloyd-Evans, B, et al. Compulsory community treatment to reduce readmission to hospital and increase engagement with community care in people with mental illness: a systematic review and meta-analysis. Lancet Psychiatr. 2018; 5(12): 10131022.
55. Swartz, MS, Wilder, CM, Swanson, JW, et al. Assessing outcomes for consumers in New York’s assisted outpatient treatment program. Psychiatr Serv. 2010; 61(10): 976–81.
56. Segal, SP, Rimes, L, Hayes, SL. The utility of outpatient commitment: reduced-risks of victimization and crime perpetration. Eur Psychiatry. 2019; 56: 97104.


Pharmacological treatment of violence in schizophrenia

  • Martin T. Strassnig (a1), Vanessa Nascimento (a2), Elizabeth Deckler (a2) and Philip D. Harvey (a1) (a3)


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed