Steven H. Littrell

Current understanding of violence and aggression: assessment and treatment.

Links between violence, aggression, and mental illness are well documented. Despite this association, our current understanding of the causation and optimal treatment of aggression remains limited. This lack of knowledge is alarming because nurses treating patients with mentally illness are frequent targets of patient aggression. Consequently, the aim of this article is to provide contemporary information regarding the concept of patient aggression, assessment of violent behavior, and implementation of treatment interventions. A review of pharmacological and psychosocial strategies are presented as well. These findings provide psychiatric nurses with a conceptual model as well as practical interventions for patient aggression.

Schizophrenia and Comorbid Substance Abuse

Abstract Research suggests that nearly half of all patients with schizophrenia concurrently abuse substances. However, despite the prevalence of substance abuse among persons with schizophrenia, the effective treatment of these comorbid conditions has eluded mental health professionals for decades. Apart from the obvious problems associated with schizophrenia and alcohol or drug abuse, schizophrenic persons who abuse substances also experience increased rates of depression, suicide, homelessness, unemployment, and illegal activity. These diverse problems necessitate interventions that address the special needs of this population. Research indicates that the use of atypical antipsychotic agents with persons who have a dual diagnosis may prove to be efficacious with treatment, overall. This article reviews the current literature pertaining to the potential expanded therapeutic benefits of enhanced efficacy of atypical antipsychotic medication in association with decreased substance use and craving.

Managing Aggression in Schizophrenia

Abstract Agitation and aggression are frequent behavioral manifestations of persons diagnosed with a psychiatric illness. Data from the Epidemiological Catchment Area study indicate that persons with schizophrenia have a four-fold increase for the risk of violent behavior in a 1-year period. Additional research indicates that acute psychosis is a consistent risk factor for the occurrence of violence; approximately 10% of patients diagnosed with schizophrenia display assaultive behavior within 2 weeks before hospital admission. In addition, 20% to 30% of patients who display psychotic symptoms engage in threats, verbal aggression, and property damage within the same period. Once hospitalized, 10% to 15% of these patients become physically assaultive, and 30% to 35% engage in fear-inducing behaviors. Clearly, the management of aggression in patients with schizophrenia is an important consideration for nurses working with this population.

Choosing an antipsychotic in the treatment of schizophrenia: Conversions to olanzapine

Abstract The recent introduction of olanzapine (Zyprexa) has provided another first-line antipsychotic treatment option in the pharmacologic treatment of psychiatric patients. Unlike clozapine which is restricted to use with refractory schizophrenia, olanzapine is labeled for the management of manifestations of psychotic disorders . This implies a much larger potential treatment population besides schizophrenia, and nurses should consider its use beyond patients with treatment-resistant schizophrenia. Matters of therapeutic dosing, titration, and maintenance dosing are remarkably simple with this compound. With the current availability of olanzapine, nurses will need to be familiar with the issues surrounding conversion from other antipsychotic agents to this new agent.

Therapeutic efficacy of olanzapine

Abstract The evaluation of efficacy of antipsychotic medications is a complex process. For more than 40 years conventional antipsychotic agents have formed the cornerstone of treatment for patients with schizophrenia. During this period the marker for therapeutic effectiveness has focused almost exclusively on the control of psychotic symptoms. Now with the introduction of atypical antipsychotic agents it seems possible to achieve control of symptoms in multiple domains. Clinical trials of the new antipsychotic, olanzapine (Zyprexa), demonstrated control of both positive and negative symptoms of schizophrenia and comorbid depressive symptoms. Olanzapine appeared to be significantly better than haloperidol in maintaining symptom remission and preventing relapse. Recently approved by the Food and Drug Administration as a first-line agent for the treatment of psychosis, olanzapine has demonstrated enhanced efficacy for use in both acute and maintenance treatment modalities. This article reports results from a 6-week open label trial of the drug. Significant improvements were found. Findings are limited by small sample size. However, the early positive results encourage both further testing and challenge nurses to expand their skills in assisting patients and their families with the recovery process.

Emerging applications of newer antipsychotic agents in specific patient populations

Abstract Conventional neuroleptics have been the mainstay of treatment for patients with schizophrenia for many years. The mechanism of action of these drugs has long been accepted and their side effects well documented. With the recent introduction of newer antipsychotics such as clozapine, risperidone, and olanzapine, a new generation of medications has become available whose pharmacologic properties are just beginning to be realized. These newer antipsychotics appear to be superior to conventional neuroleptics in treating patients with schizophrenia. Because of their reduced neurotoxicity, the newer antipsychotics may be particularly beneficial in treating psychosis in specific patient populations. This review presents preliminary findings on the use of the newer antipsychotics for treating psychosis in five patient populations: children and adolescents with schizophrenia and other psychotic disorders; first-episode schizophrenia; dual diagnosis; bipolar disorder; and elderly patients. Because of the expanded utilities of the newer antipsychotics, psychiatric nurses should be familiar with all available treatment options.

Recent advances in the understanding of negative symptoms in schizophrenia

Abstract The aim of this article is to provide a comprehensive and concise review of existing literature and findings about negative symptoms associated with the diagnosis of schizophrenia. Significant progress has been made regarding the awareness of negative symptoms associated with schizophrenia. Given this progress, psychiatric nurses should find it useful to have information about how to provide state-of-the-art care and clinical interventions for treatment of negative symptoms. Acquiring this information requires some understanding of etiologic factors, assessment, and use of contemporary medications to attend to the disabling effects of negative symptoms.