Antipsychotic Drugs and Violence: A Research Report

Questions have been circulating about whether Adam Lanza had been taking psychotropic medications. We hope that the inquiry into the mass murder will determine what psychotropic medications he may have been on. Meanwhile, Catherine Clarke and Jan Evans research paper “Neuroleptic Drugs and Violence” is archived on Madinamerica, and may shed further light on why this question arises in the context of these terrible events.

Of Further Interest:
Asperger’s Is a Red Herring to Explain the Newtown Massacre (New York Magazine)

 

11 COMMENTS

  1. I read the original Ron Fournier article that appeared in the National Journal http://www.nationaljournal.com/magazine/how-two-presidents-helped-me-deal-with-love-guilt-and-fatherhood-20121129

    Aspergers is, of course, a red herring in this tragedy, but in Fournier’s article he provides important clues, I believe, into what may have been the breaking point for Adam Lanza. Fournier admits he couldn’t accept his son for what he was, he was often embarrassed in his presence, etc. This reality was only hit home when a psychiatrist told him how depressed his son was. Lucky for Fournier he got the picture and changed his belief system and his attitudes towards his son.

    • As part of human diversity –necessary for the survival of the species – differing genotypes exist – fact.

      What we are saying is that people who have a genotype which compromises their ability to metabolise psychotropic drugs because of certain gene variations, are prone to suffer drug toxicities causing ADRs. Extra copies of genes with prodrugs will result in drug toxicities as will deletions in Intermediate and Poor Metabolisers.

      All people can be prone to toxic behavioural reactions to neuroleptics depending on dose, genotype, drug ½ life and withdrawal status.

      If 100 African or Asian people all had inefficient metabolising genes for a specific drug, all would suffer ADRs. However if all 100 African/Asian people had efficient metabolising genes, they would not suffer with ADRs. Likewise with Caucasian or any other people etc.

      We presented a reason for Psychiatric Intensive Care Units being over full of BME people in UK and suggest that the failure to recognise all peoples’ genotype, i.e. drug metabolism ability before using neurotoxic drugs is tantamount to clinical negligence.

      It is unfortunate that in today’s global arena of political correctness stating the obvious can be unpalatable.

      These “claims” are not ours – they are from solid pharmacogentics research – please see refs.

  2. I am not a scientist. I have not read this article and I have not seen these references.

    All the same, I would like to conjecture my disagreement with you, janevs.

    The total genetic variance between races of the human species is quite small (isn’t it like .2%?).

    I had a friend who went into debt to travel to the famed Mayo Clinic in Minnesota to get a genetic test to see which psychotropics would be “scientifically” most suited to her unique make-up to treat her bipolar. What was the end result? Well, debt.

    I can’t speak for intensive care in the UK but I can speak to the fact that in America Caucasians are more suspect to believing in the bio-psychiatry paradigm and that the placebo effect of any medication (in any field of medicine) must be taken into consideration. If you were to come over to this side of the pond and attend a prestigious NAMI conference and to look around in the audience you would look in vain for many Asians or African Americans.

  3. Emily

    A person does not have to be a scientist to read a collection of research data.

    Since the contents of the paper have not been read,I am unsure where your disagreement lies. Although the points you raised are interesting, I think they are irrelevant to the issue of neuroleptic drugs and violence – for some people.

    • To Jan Evans and Catherine Clarke:

      I’m sorry for my initial uninformed response. I have now downloaded and read your report which I find to be edifying.

      I didn’t originally realize that this was an MIA exclusive, so I was being cheeky about not wanting to go to another site to read the findings… It was rude of me, please accept my apologies.

      Interested in your work,
      Emily

  4. Just a quick comment. The paper was great, but the beginning has a few distorted facts and poor research cited. Mentally “ill” people may be slightly more violent than the general public when looking at multiple studies. The paper above cites one study from Sweden, with a higher rate (13% vs 5% of general public).

    Over ninety percent (90%) “of persons with mental illness have no history of violence….through media sensationalism (it sells papers) the cases that do occur stand out in peoples minds.” Serper, M, Bergman, A. (2003) Psychotic Violence: Methods, Motives, Madness, Psychosocial Press of Madison, CT.

    Monahan, J. and Shah, S. Dangerousness and commitment of the mentally disordered in the United States. Schizophrenia Bulletin, 15: 541-553. Reprinted in: Social and Clinical Psychiatry, 1991, 1: 56-70 [in Russian]. Monahan found people Diagnosed Sz and Bipolar were no more violent than general population, unless problems with substance abuse or psychopathology. Also found by:

    Cirincione, C., Steadman, H., Robbins, P. and Monahan, J. Schizophrenia as a contingent risk factor for criminal violence. International Journal of Law and Psychiatry 15: 347-358.

    Elbogen, E.B. & Johnson, S.C. (2009). The intricate link between violence and mental disorder. Archives of General Psychiatry, 66, 152-161. “mental illness suggests a lower probability of violence”

    Fazel S, Gulati G, Linsell L, Geddes JR, Grann M (2009) Schizophrenia and Violence: Systematic Review and Meta-Analysis. PLoS Med 6(8): e1000120. doi:10.1371/journal.pmed.1000120

    The paper above was correct that the GREATER risk of violence is from those who have dual diagnosis, i.e., individuals who have a mental disorder as well as a substance abuse disorder.
    Swanson, 1994; Eronen et al, 1998; Steadman et al., 1998.

    Fazel, et al (2009) did a meta-analysis of the 20 studies between January, 1970 and February, 2009 that assessed the risk of violence of 18,423 individuals diagnosed as Schizophrenia or other psychoses, which they compared with the level of violence in the general population of 1,714,904. Eleven of the studies reported on the affect of comorbid substance abuse. The authors found that there was no significant difference between people with Schizophrenia and those with other psychotic disorders. People with psychoses were slightly more likely to exhibit violence than the general population, and significantly more likely to commit homicides, though the homicide probability was only 0.3% for either psychosis or substance abuse. However, “the increased risk of violence in schizophrenia and the psychoses comorbid with substance abuse was not different than the risk of violence in individuals with diagnoses of substance use disorders. In other words, schizophrenia and other psychoses did not appear to add any additional risk to that conferred by the substance abuse alone [pp. 7-8].” Further, substance abuse markedly increased the risk of violence for people with comorbid psychotic and substance abuse disorders.

    These findings are consistent with those of the MacArthur violence risk assessment research, particularly the finding that people with psychoses but without substance abuse do not have a high level of violence, while those who abuse alcohol or other drugs do have a significantly higher risk of violence. According to Martin Grann, Ph.D., one author of the 2009 study, “people with schizophrenia are not dangerous…. If a person is an alcoholic or a drug addict, he is less likely to be violent if he also has schizophrenia. So, in this context, you could say schizophrenia is actually protective” (quoted in Cassels, C. (2009, August 31). Substance abuse main driver of violence in Schizophrenia, psychoses. Medscape Medical News. Retrieved from http://www.medscape.com September 10, 2009).

    The NIMH MacArthur study found that recently discharged psychiatric patients were not statistically more dangerous than people in the communities they were discharged to, and those same patients were not more dangerous even if they had threat/control delusions. “…[T]he presumed risk of violence associated with delusions per se does not justify hospitalization of a patient….” This multi-year study of over 1,000 patients found a number of violence risk factors and provided an “odds ratio” table for the first year discharge, indicating the increase in probability for a given factor (male=1.51, i.e. 51% more likely to be violent than females when other factors removed).

    The assessment used was the Classification of Violence Risk (COVR), an interactive software program-interview that provides an estimate on future violence. Patients were followed for 20 weeks after discharge and measured violence towards others by official police and hospital records, patients’ self-report, and by collateral contacts (e.g. family). COVR can be found at: P.A.R., 800 331 8378: http://www.parinc.com.

    Hare PCL:SV > 12 4.05
    Chart diagnosis of Antisocial Pty. Dis. 3.11
    Violent fantasies about escalating harm 2.80
    Substance disorder, no major disorder 2.47
    Father ever used illegal drugs 2.40
    Recent violent behavior 2.32
    Frequent violent fantasies 2.23
    Any arrest for a crime against a person 2.11
    Violent fantasies while with target 2.08
    Serious adult arrest 2.04
    Substance abuse at time of admission 2.01
    Violence at time of admission 1.97
    Violent fantasies 1.94
    Violent fantasies focused on 1 person 1.91
    Father ever intoxicated (alcohol) 1.87
    Any arrest besides crime against person 1.80
    Father ever arrested 1.79
    Involuntary hospitalization 1.78
    Any head injury w/loss of consciousness 1.69
    Homelessness 1.66
    Frequency of adult arrests 1.60
    Mother ever used illegal drugs 1.54
    Perceived stress 1.54
    Seriousness of physical child abuse 1.51
    Male gender 1.51
    Major disorder and substance abuse 1.47
    Personality disorder only 1.46
    Nonviolent aggression at admission 1.44
    Command hallucinations 1.43
    Any head injury w/o loss of conscious. 1.43
    Mother ever intoxicated (alcohol) 1.41
    Suicide attempt 1.31
    Unable to care for self 1.29
    Frequency of abuse as a child 1.25
    Diagnosis of “other psychosis” 1.00
    Diagnosis of depression 0.92
    Any delusions 0.74
    Diagnosis of Mania 0.74
    Diagnosis of Schizophrenia 0.38

    Applebaum P, Robbins P, and Monahan , Violence and Delusions: Data from the MacArthur Violence Risk Assessment Study, by J. Am J Psychiatry 2000; 157:566-572.

    Monahan, J., Steadman, H.J., Silver, E., Appelbaum, P.S., Robbins, P.C., Mulvey, E.P., Roth, L.H., Grisso, T., & Banks, S. (2001). Rethinking risk assessment: The MacArthur Study of Mental Disorder and Violence. New York: Oxford University Press. . “mental illness suggests a lower probability of violence.”

    Monahan, J, Steadman, H., Robbins, et al. (2005). An actuarial model of violence risk assessment for persons with mental disorders. Psychiatric Services, 56, 810-815.

    Walsh E, Buchanan A, Fahy T., Br J Psychiatry. 2002, Violence and schizophrenia: examining the evidence. Jun;180:490-5. full text: http://bjp.rcpsych.org/cgi/content/full/180/6/490 Section of Forensic Mental Health, Institute of Psychiatry, Denmark Hill, London. [email protected]
    The proportion of societal violence attributable to schizophrenia is small.
    METHOD: A review of population-based studies on the epidemiology of violence and schizophrenia. Population-attributable risks for violence in schizophrenia were calculated.
    RESULTS: Recent good evidence supports a small but independent association. Comorbid substance abuse considerably increases this risk. The proportion of violent crime by people Diagnosed with schizophrenia falls below 10%. CONCLUSIONS: Strategies aimed at reducing this small risk require further attention, in particular treatment for substance misuse.

    Kindly,
    Toby Watson, PsyD
    [email protected]
    ISEPP Past Exec. Director, http://www.psychintegrity.org

  5. I almost forgot…they also state right away:
    “Violence is reported with command hallucinations: 48% experienced harmful or dangerous actions and this increased to 63% in medium secure units and was significantly higher, 83%, in the forensic population.2”

    But, what the study had as a confounding variable was that for inclusion into the study you had to: 1) have 6 months of command hallucinations, BUT 2) a history within that time of being violent! Thus, the reported violence was not a typical group of patients, but those who were already known to be violent…within the past 6 months. Thus, they showed that past violence is a great predictor of future violence, not that Sz patients are prone to violence.

  6. The comments section for that article is hilarious and disturbing in equal measure.

    Here’s some of my favourite quotes, chosen for how representative of public opinion they are as well as/or how utterly inane they are:

    “Antipsychotics do more good than harm. Sorry it’s true.”

    I particularly like the last part, which is designed to give a semblance of scientific impartiality to what is a completely random speculation in no way susceptible to proper independent empirical corroboration. It is like when people lard their discourse with adverbs such as “certainly”, “definitely” or “truly”, in order to give substance to pure wind, in a pathetic, desperate attempt to assimilate reality to their despotism. “This is certainly one of the greatest films ever made (the kind of claim made by millions but in no way allowing of proof)”, or, “things are truly the way I say they are.” I’ll leave the reader to think of other variants of this kind of debauchment of language.

    Sadly, because of the mutally-reinforcing relationship that exists between stupidity on the one hand, and smugness, arrogance and shamelessness on the other, the person who made that paltry comment thinks that all he has to do is advance the comment “Sorry, but it’s true” in support of his argument, and that makes it so!

    Personally, and the following statement reposes not only on learning but also direct experience, I think it overreaches the limits of credibility to say such a thing and that, if we exhume the actual research findings from underneath all the propaganda, it might be fair to say that the evidence is preponderately weighted in favour of an entirely different reading. Yet such people, by erecting an impermeable wall between their minds and all the disconfirming evidence out there, evidence that is much more substantial, at least from my perspective, than the ipse dixits of psychiatrists, sit blissfully ensconsed in their own delusions. I need do nothing more than point to all the research Whitaker has gathered and presented on this site for our perusal in support of my assertion that the evidence is far more substantial for a reading that the drugs are doing more harm than good.

    I won’t quote directly anymore, but I will say that that one of the unifying themes amongst many of the comments seems to be that the drugs are good, that the PR fraud that was the pharmacological revolution attests to the progress psychiatry has made. Who shoulders the burden of this complacency and ignorance?

    One commenter, moralizing with a backwards gaze (Szasz), deplores the use of lobotomy and ECT, completely ignoring just how prevalent the usage of ECT is today, shielded against the reality by his/her ignorance of the epidemic of brain damage and disease, as well as many other medical conditions, that have resulted from the often forced administration of these drugs, rarely administered with the informed consent of the patient.

    One critic of psychiatric drugs is accused of being Tom Cruise, which is little more than a thought-terminating cliche and a rhetorical strategy adopted by people ossified in their thinking. One toilet-mouthed commenter even hurls expletives at the heretic, trying desperately it seems to extort conformity from the heretic through aggression and intimidation, a commonplace strategy amongst the protectors of the pharmacological paradigm and of the reputation of organised psychiatry.

  7. I can only speak from experience. The daughter of a friend of mine was put on clozapine during a breakdown. She had never been violent before. She attacked her mother with a knife. She didn’t blame voices for the attack but a strange compulsion. I believe she blamed her mother for getting her trapped in the psychiatric system. Once taken off the clozapine the compulsion disappeared and she has been able to talk things through with her mother. She has moved out of her mother’s house mainly because her mother believes in the label of schizophrenia.