Major mental illness can be associated with violent or aggressive behaviour. Electroconvulsive therapy (ECT) plays a role in managing violence in clinical practice, but there is limited evidence in the literature demonstrating its efficacy. This systematic literature review therefore sought to highlight the available data on ECT and violence in patients with major mental illness.
Method
A search of MEDLINE, Embase, and PsycInfo identified 10 relevant papers. The studies were predominantly retrospective and analysed small study populations of participants with psychotic disorders, as well as one study looking at affective disorders, who had received ECT.
Results
All studies found a reduction in violence following ECT, although there was substantial variation in methodology and outcome measures. Of the five papers using clear quantitative measures, four noted a statistically significant improvement in violence and the fifth demonstrated a non-statistically significant improvement. The remaining papers respectively demonstrated an improvement in general psychopathology, an overall reduction in assaultive behaviour, and a reduction in the use of restraint.
Conclusion
Although it is difficult for this review to draw definitive conclusions due to the low quality and heterogeneity of studies included, ECT may play a role in reducing violence in patients with severe mental illness.
MulveyEP. Assessing the evidence of a link between mental illness and violence. Psychiatr Serv1994; 45: 663–668.
2.
ElbogenEBJohnsonSC. The intricate link between violence and mental disorder: results from the national epidemiologic survey on alcohol and related conditions. Arch Gen Psychiatry2009; 66: 152–161.
3.
ChoeJYTeplinLAAbramKM. Perpetration of violence, violent victimization, and severe mental illness: balancing public health concerns. Psychiatr Serv2008; 59: 153–164.
4.
FrogleyCTaylorDDickensG, et al.A systematic review of the evidence of clozapine’s anti-aggressive effects. Int J Neuropsychopharmcol2012; 15: 1351–1371.
5.
CitromeLVolavkaJ. Specific anti-hostility effects of atypical antipsychotics in persons with schizophrenia: from clozapine to cariprazine. Harv Rev Psychiatr2021; 29: 20–34.
6.
RueveMEWeltonRS. Violence and mental illness. Psychiatry (Edgmont)2008; 5: 34–48.
7.
LindenmayerJPKotsaftisA. Use of sodium valproate in violent and aggressive behaviors: a critical review. J Clin Psychiatry2000; 61: 123–128.
8.
AliSAMathurNMalhotraAK, et al.Electroconvulsive therapy and schizophrenia: a systematic review. Complex Psychiatry2019; 5: 75–83.
9.
PerugiGMeddaPToniC, et al.The role of electroconvulsive therapy (ECT) in bipolar disorder: effectiveness in 522 patients with bipolar depression, mixed-state, mania and catatonic features. Curr Neuropharmacol2017; 15: 359–371.
10.
TrifuSSevcencoAStănescuM, et al.Efficacy of electroconvulsive therapy as a potential first-choice treatment in treatment-resistant depression (Review). Exp Ther Med2021; 22: 1281.
11.
KuhlwilmLSchönfeldt-LecuonaCGahrM, et al.The neuroleptic malignant syndrome—a systematic case series analysis focusing on therapy regimes and outcome. Acta Psychiatr Scand2020; 142: 233–241.
12.
BoonLCMichaelAMalikO. Catatonia in patients with autism spectrum disorder (asd): comorbidity, risk factors, and treatment. Dev Med Child Neurol2017; 59(4): 105.
13.
ForesterBRahmanAAshE, et al.Evidence for electroconvulsive therapy (ect) in the treatment of intractable behavioral symptoms of dementia (BPSD): a systematic review. Am J Geriatr Psychiatr2020; 28(4): S122-S123.
14.
van den BergJFKruithofHCKokRM, et al.Electroconvulsive therapy for agitation and aggression in dementia: a systematic review. Am J Geriatr Psychiatr2018; 26: 419-434.
15.
GlassOMForesterBPHermidaAP. Electroconvulsive therapy (ECT) for treating agitation in dementia (major neurocognitive disorder) – a promising option. Int Psychogeriatr2017; 29: 717-726.
16.
ConsoliACohenJBodeauN, et al.Electroconvulsive therapy in adolescents with intellectual disability and severe self-injurious behavior and aggression: a retrospective study. Eur Child Adolesc Psychiatr2013; 22: 55-62.
17.
HaqAUGhaziuddinN. Maintenance electroconvulsive therapy for aggression and self-injurious behavior in two adolescents with autism and catatonia. J Neuropsychiatry Clin Neurosci2014; 26: 64-72.
18.
SajithSGLiewSFTorPC. Response to electroconvulsive therapy in patients with autism spectrum disorder and intractable challenging behaviors associated with symptoms of catatonia. J ECT2017; 33: 63-67.
19.
CorrellCUYuXXiangY, et al.Biological treatment of acute agitation or aggression with schizophrenia or bipolar disorder in the inpatient setting. Ann Clin Psychiatr2017; 29: 92–107.
20.
QuinnJKollaNJ. From clozapine to cognitive remediation: a review of biological and psychosocial treatments for violence in schizophrenia. Can J Psychiatr2017; 62: 94–101.
21.
PageMMcKenzieJBossuytP, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
22.
IancuIPickNSeener-LorshO, et al.Patients with schizophrenia or schizoaffective disorder who receive multiple electroconvulsive therapy sessions: characteristics, indications, and results. Neuropsychiatric Dis Treat11; 853–862, 2015.
23.
KrepelaJHosakLPachlovaB, et al.Maintenance electroconvulsive therapy in schizophrenia. Psychiatr Times2019; 31: 62-68.
24.
KristensenDBauerJHagemanI, et al.Electroconvulsive therapy for treating schizophrenia: a chart review of patients from two catchment areas. Eur Arch Psychiatr Clin Neurosci2011; 261: 425-432.
25.
SuzukiKAwataSMatsuokaH. Short-term effect of ECT in middle-aged and elderly patients with intractable catatonic schizophrenia. J ECT2003; 19(2): 73–80.
26.
MohammadbeigiHAlizadeganSBarekatainM. Electroconvulsive therapy in single manic episodes: a case series. Afr J Psychiatr2011; 14: 56-59.
27.
KristensenDBrandt-ChristensenMOckelmannHH, et al.The use of electroconvulsive therapy in a cohort of forensic psychiatric patients with schizophrenia. Case Reports2012; 22: 148-156.
28.
ChanpattanaWChakrabhandML. Combined ECT and neuroleptic therapy in treatment-refractory schizophrenia: prediction of outcome. Psychiatry Res2001; 105: 107–115.
29.
HiroseSAshbyCRMillsMJ. Effectiveness of ECT combined with risperidone against aggression in schizophrenia. J ECT2001; 17(1): 22–26.
30.
ParkerVRemingtonG. Electroconvulsive therapy in cases of treatment-resistant psychosis. Can J Psychiatr2001; 46(8): 762-763.
31.
ChanpattanaWSackeimHA. Electroconvulsive therapy in treatment-resistant schizophrenia: prediction of response and the nature of symptomatic improvement. J ECT2010; 26(4): 289–298.
32.
OverallJEGorhamDR. The brief psychiatric rating scale. Psychological Reports1962.
33.
GuyW. ECDEU assessment manual for psychopharmacology. U.S. Department of health, education, and welfare, public health service, alcohol, drug abuse, and mental health administration, national institute of mental health, psychopharmacology research branch, division of extramural research programs, 1976.
34.
PhutaneVHThirthalliJKesavanM, et al.Why do we prescribe ECT to schizophrenia patients?Indian J Psychiatry2011; 53(2): 149–151.
35.
WangSYangCJiaJ, et al.Use of electroconvulsive therapy in adolescents with schizophrenia in China. Child Adolesc Psychiatr Ment Health2018; 12: 49.
36.
HajjiKChebbiWMarragI, et al.The role of electroconvulsive therapy in the treatment of schizophrenia. Eur Neuropsychopharmacol2015; 2: S482-S483.
37.
DouglasKSHartSDWebsterCD, et al.HCR-20 V3: assessing risk of violence – user guide. Burnaby, Canada: Mental Health, Law, and Policy Institute, Simon Fraser University, 2013.
38.
OgloffJRDaffernM. The dynamic appraisal of situational aggression: an instrument to assess risk for imminent aggression in psychiatric inpatients. Behav Sci Law2006; 24: 799–813. DOI: 10.1002/bsl.741.
39.
LauberCNordtCFalcatoL, et al.Can a seizure help? The public’s attitude toward electroconvulsive therapy. Psychiatry Res2005; 134: 205–209.
40.
WhitingDLichtensteinPFazelS. Violence and mental disorders: a structured review of associations by individual diagnoses, risk factors, and risk assessment. Lancet Psychiatry2021; 8: 150–161.
41.
WeissAHussainSNgB, et al.Royal Australian and New Zealand College of Psychiatrists professional practice guidelines for the administration of electroconvulsive therapy. Aust N Z J Psychiatr2019; 53: 609–623.
42.
Rubio-ValeraMLucianoJVOrtizJM, et al.Health service use and costs associated with aggressiveness or agitation and containment in adult psychiatric care: a systematic review of the evidence. BMC Psychiatry2015; 15: 35.
43.
Serrano-BlancoARubio-ValeraMAznar-LouI, et al.In-patient costs of agitation and containment in a mental health catchment area. BMC Psychiatry2017; 17: 212.
44.
CrabbeJAlexanderDKleinS, et al.Dealing with violent and aggressive patients: at what cost to nurses?Ir J Psychol Med2002; 19: 121–124.
