Drug and talking treatments can reduce violent behaviour in mental health and criminal populations, but more research is needed


Studies show that over 1.6 million people are killed as a result of violence each year and it is thought that this estimate is considerably less than the actual number who die from assaults.

Violence in inpatient hospital settings and emergency departments is the subject of a NICE guideline that is currently being updated.

A group of researchers from the University of Liverpool have published a health technology assessment report (PDF) that seeks to summarise the evidence for pharmacological, psychosocial and organisational interventions aimed at reducing violence.

They conducted a search of a wide range of databases to find meta-analyses and randomised controlled trials (RCT) from 2002-2008 (they were updating a previous review that was published in 2002).

They found 198 studies to include, 51 of which were RCTs. They were unable to carry out a meta-analysis of the data because there was too much heterogeneity.

A cost effectiveness analysis was beyond the scope of the review, but this is clearly an essential component of future research, given the huge expenditure required to implement solutions to this widespread problem and the cost that such universal violence must have on our society.

Here’s what the reviewers found:

  • Small to moderate effects were found for three interventions:
    • Atypical antipsychotic drugs [OR 0.21, 95% CI 0.16 to 0.27, fixed effects; OR 0.24, 95% CI 0.14 to 0.43, random effects; 10 studies, I(2) = 72.2, Q = 32.4 (df = 9), p < 0.0001],
    • Psychological interventions [OR 0.63, 95% CI 0.48 to 0.83, fixed effects; OR 0.53, 95% CI 0.31 to 0.93, random effects; nine studies, I(2) = 62.1, Q = 21.1 (df = 8), p = 0.007]
    • Cognitive behavioural therapy (CBT) as a primary intervention [OR 0.61, 95% CI 0.42 to 0.88, fixed effects; OR 0.61, 95% CI 0.37 to 0.99, random effects; seven studies, I(2) = 21.6, Q = 7.65 (df = 6), p = 0.26]

The authors concluded:

Results from this review show small-to-moderate effects for cognitive behavioural therapy, for all psychological interventions combined, and larger effects for atypical antipsychotic drugs, with relatively low heterogeneity. There is also evidence that interventions targeted at mental health populations, and particularly male groups in community settings, are well supported, as they are more likely to achieve stronger effects than interventions with the other groups.

Future work should focus on improving the quality of evidence available and should address the issue of heterogeneity in the literature.


Hockenhull JC, Whittington R, Leitner M, et al. A systematic review of prevention and intervention strategies for populations at high risk of engaging in violent behaviour: update 2002-8 (PDF). Health Technol Assess 2012;16:1–152.

Violence: The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments. NICE, Feb 2005.

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Andre Tomlin

André Tomlin is an Information Scientist with 20 years experience working in evidence-based healthcare. He's worked in the NHS, for Oxford University and since 2002 as Managing Director of Minervation Ltd, a consultancy company who do clever digital stuff for charities, universities and the public sector. Most recently André has been the driving force behind the Mental Elf and the National Elf Service; an innovative digital platform that helps professionals keep up to date with simple, clear and engaging summaries of evidence-based research. André is a Trustee at the Centre for Mental Health and an Honorary Research Fellow at University College London Division of Psychiatry. He lives in Bristol, surrounded by dogs, elflings and lots of woodland!

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