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Ask the Mental Health Expert Archives 2001-2004

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Psychopharmacology for Aggression

Q. I am a mental health care provider and would like to know if you have any current information on new psychopharmacology for managing aggressive behaviors in the mental retardation population. What treatments exist in addition to Depakote?

A. The approach to aggressive or self-injurious behavior in mentally retarded patients should begin with a diagnostic formulation: is the aggression of recent onset? Are there medical, neurological, or psychosocial factors that may have precipitated it? Is it secondary to an underlying Axis I psychiatric disorder, such as attention deficit hyperactivity disorder, schizophrenia, bipolar disorder, or depression? (Mental retardation does not, of course, innoculate people from other psychiatric disorders).

The most successful medication treatment of aggression in this population probably occurs when we can identify a primary disorder that is known to be medication-responsive; e.g., lithium for bipolar disorder in an MR patient. There is much less unanimity on the preferred medication for aggression of non-specific origin in this population.

Selective serotonin reuptake-inhibiting antidepressants [SSRIs], buspirone, lithium, anticonvulsants, opiate blocking agents[naltrexone], propranolol, nadolol, and clonidine, are all potential candidates, but controlled studies are few and far between. Some recent encouraging reports suggest that the SSRIs are helpful; e.g., see Hellings et al, Journal of Clinical Psychiatry Auguest 1996 for a report of sertraline [Zoloft] in treating aggression in MR/autistic patients.

Paroxetine and trazodone have also been used with anecdotal reports of success. (There is a suggestion of only temporary benefit with paroxetine; see Davanzo et al, Am J Ment Retard March 1998). Antipsychotics, historically, have probably been over-used in MR populations, with resulting increased motor side effects in many cases. However, some recent reports suggest that newer, atypical agents, such as risperidone, may be useful, albeit with sedation and restlessness as side effects (see Cohen et al, : J Autism Dev Disord 1998 Jun;28(3):229-33).

Finally, in my view, behavioral modification and other psychosocial strategies should always be considered, and ideally, integrated with any use of medications for aggression. The book, Self-Injurious Behavior, by Gardner & Sovner (VIDA Publishing) may also be of use to you.

January, 2001

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