Violent behavior and aggression in schizophrenia: Prevalence and risk factors. A multicentric study from three Latin-America countries

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Abstract

Objective

The aim of the present study was (i) to assess the prevalence of Violent Behavior in Schizophrenia (VBS) in a sample of community-dwelling outpatients in three middle-income countries of Latin America and (ii) to determine the clinical and socio-demographical risk factors associated with VBS and aggression level.

Methods

The study included 253 stabilized outpatients with schizophrenia and their principal caregivers from 3 public ambulatory psychiatric care centers in Bolivia (N = 83), Chile (N = 85), and Peru (N = 85). VBS was defined according to the Overt Aggression Scale (OAS) score and the aggression level was measured by the aggression subscore of the Agitated Behavior Scale of Corrigan. We collected socio-demographic information and clinical data. Multiple linear and logistic regressions were performed to determine which variables were associated with VBS and aggression level.

Results

The prevalence of VBS differed statistically between the three countries (p < 0.001) with 3.5% in Chile, 14.6% in Peru and 55.4% in Bolivia. After adjustment for confounding factors, VBS was associated with a younger age, a more severe psychotic symptomatology, a lower family income and unemployment. After adjustment for confounding factors, aggression level was associated with a more severe psychotic symptomatology, a lower family income, a younger age at illness onset and higher number of hospitalizations in the last 3 years.

Conclusion

These results may guide future health policies to specifically provide social support and rehabilitation care to VBS patients in middle-income countries, including psychoeducation and a more integrated work between the treating medical team and the social workers.

Introduction

There is consensus in the literature concerning a modest but consistent association between violent behavior, aggression and schizophrenia (SZ) (Fazel et al., 2009, Large and Nielssen, 2011, Witt et al., 2013, Knezevic et al., 2015, Fleischman et al., 2014, Iozzino et al., 2015, Dack et al., 2013). Violent Behavior in Schizophrenia (VBS) evaluation is crucial for social and clinical prognosis of schizophrenia as well as for personalized care of VBS patients.

A recent meta-analysis assessed the VBS-associated socio-demographical variables (Witt et al., 2013). Overall, VBS was moderately associated with homelessness, being male, and weakly associated with non-white ethnicity and a lower socio-economic status. VBS was also strongly associated with psychotic symptomatology (including delusions, hallucinations, hostility, lack of insight and mood symptomatology). However, most of the included studies were carried out in inpatient samples. Including only inpatients is associated with a potential recruitment bias and with VBS risk factors associated with hospitalization (e.g., involuntary hospitalization) (Hodgins and Müller-Isberner, 2014).

Outpatients' studies are therefore needed to correctly evaluate VBS prevalence and associated risk factors in the real world. However, only a small number of VBS studies have been carried out in community-dwelling SZ patients. In the USA, a subgroup analysis of the CATIE study in 1410 SZ outpatients concluded that minor violence (estimated in 19.1% of the sample) was associated with co-occurring substance abuse and interpersonal and social factors (Swanson et al., 2006). Serious violence (3.6%) was associated with psychotic and depressive symptoms, childhood conduct problems, and victimization in this study. In Spain, 5% of 895 SZ outpatients were found to have shown verbal violence in the last week, and 47% were defined as VBS according to the study's criterion (Bobes et al., 2009). In this study, VBS was associated with more past episodes of violence, higher psychotic relapses and lower satisfaction with treatment. In the UK, a study conducted in 251 SZ outpatients concluded that VBS (20.1% of the sample) was significantly and positively associated with childhood conduct disorder, current use of illicit drugs, positive, threat-control-override, and depression symptoms (Hodgins and Riaz, 2011). Similar findings come from a study of 421 SZ Japanese outpatients (Imai et al., 2014). More recently, another study carried out in 331 SZ outpatients in France found that self-reported higher aggression level was associated with younger age, lower education level, and higher psychotic symptomatology independent of type of treatment (Fond et al., 2015). In this last study, no VBS prevalence was determined because there was no cut-off on the self-reported scale used to assess aggression level. Moreover most of the VBS studies to date were carried out in North America and in Europe, with none in Latin America.

The aim of the present study was (i) to assess the prevalence of VBS in sample of community-dwelling SZ outpatients in three middle-income countries of Latin America (Bolivia, Chile, and Peru) and (ii) to determine the clinical and socio-demographical risk factors associated with VBS and aggression level.

Section snippets

Study participants

Overall, 253 stabilized outpatients with schizophrenia and their primary caregivers were consecutively recruited between May 2012 and February 2013 in three public ambulatory psychiatric care centers of three areas: Arica, northern Chile (N = 85, 33.6%), Tacna, southern of Peru (N = 85, 33.6%), and La Paz, Central-Western of Bolivia (N = 83, 32.8%). The three centers shared similar characteristics in terms of size, type of treatment given to patients, professionals and free access of care.

Sample characteristics (Table 1)

Two hundred and fifty-three stable community-dwelling SZ outpatients were enrolled in the present study. The mean age of patients was 35.6 years (SD = 12.5), 164 (66.4%) were men, 213 (84.2%) had low educational level (< 12 years), 176 (69.6%) were unemployed and 117 (46.2%) were Aymara. The median monthly family income was 331.6 US dollars (interquartile range = 144.9–517.9). The mean duration of illness was 14.6 (± 11.8) years. The patients had moderately severe symptoms with a total PANSS score of

Discussion

Our main results may be summarized as follows: (i) the prevalence of VBS in our sample of 253 Latin America community-dwelling SZ patients varied strongly between countries, from 3.5% in Chile to 14.6% in Peru and 55.4% in Bolivia. (ii) After adjustment for confounding factors, VBS was associated with a younger age, a more severe psychotic symptomatology, a lower family income and unemployment. After adjustment for confounding factors, aggression level was associated with a more severe

Conclusion

Altogether, these results may guide future health policies to specifically provide social support and rehabilitation care to VBS patients. Psychoeducation has also been shown to improve family attitude towards VBS, which may be recommended to diminish the risk of VBS onset (Rahmani et al., 2015, Asmal et al., 2014) as well as the caregiver burden in schizophrenia. A more integrated work is necessary between the treating medical team and the social workers. Addressing both sides would be

Role of the funding source

This research was funded by Proyecto UTA-Mayor 3732-16 and also by the Convenio de Desempeño UTA-MINEDUC.

Contributors

Conception and design: A. Caqueo-Urízar, L. Boyer, G. Fond and D. Williams. Data collection and analysis of data: A. Caqueo-Urízar, L. Boyer, G. Fond and A. Urzúa. Interpretation of data: A. Caqueo-Urízar, L. Boyer, G. Fond and A. Urzúa. Drafting and writing the manuscript: A. Caqueo-Urízar, L. Boyer, G. Fond, A. Urzúa and D. Williams.

Conflict of interest

The authors have declared that there are no conflicts of interest in relation to the subject of this study.

Acknowledgements

This research was funded by Proyecto UTA-Mayor 3732-16 and also by the Convenio de Desempeño UTA-MINEDUC.

We thank Felipe Ponce y Jorge Escudero for their assistance in the study and also the following people and facilities: Dr. Hugo Sánchez, Dr. Ricardo Alvites, Dr. Andrés Collado, Gladys Coaquira, Vilma Liendo and specially thanks to Dr. José Revilla from Hipólito Unanue Hospital in Tacna, Perú; Dr. Marcio Soto from Arequipa, Perú; Dr. Fernando Garitano, Dr. Mauricio Peredo and Dra. Mabel

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