title: Non-pharmacological interventions for reducing aggression and violence in serious mental illness: A systematic review and narrative synthesis.
abstract: BACKGROUND
  For people with mental illness that are violent, a range of interventions have been adopted with the aim of reducing violence outcomes. Many of these interventions have been borrowed from other (offender) populations and their evidence base in a Serious Mental Illness (SMI) population is uncertain.
  
  
  OBJECTIVE
  To aggregate the evidence base for non-pharmacological interventions in reducing violence amongst adults with SMI and PD (Personality Disorder), and to assess the efficacy of these interventions. We chose to focus on distinct interventions rather than on holistic service models where any element responsible for therapeutic change would be difficult to isolate.
  
  
  METHODS
  We performed a systematic review and narrative synthesis of non-pharmacological interventions intended to reduce violence in a SMI population and in patients with a primary diagnosis of PD. Five online databases were searched alongside a manual search of seven relevant journals, and expert opinion was sourced. Eligibility of all returned articles was independently assessed by two authors, and quality of studies was appraised via the Cochrane Collaboration Tool for Assessing Risk of Bias.
  
  
  RESULTS
  We included 23 studies of diverse psychological and practical interventions, with a range of experimental and quasi-experimental study designs that included 7 Randomised Controlled Trials (RCTs). The majority were studies of Mentally Disordered Offenders. The stronger evidence existed for patients with a SMI diagnosis receiving Cognitive Behavioural Therapy or modified Reasoning & Rehabilitation (R&R). For patients with a primary diagnosis of PD, a modified version of R&R appeared tolerable and Enhanced Thinking Skills showed some promise in improving attitudes over the short-term, but studies of Dialectical Behaviour Therapy in this population were compromised by high risk of experimental bias. Little evidence could be found for non-pharmacological, non-psychological interventions.
  
  
  CONCLUSIONS
  The evidence for non-pharmacological interventions for reducing violence in this population is not conclusive. Long-term outcomes are lacking and good quality RCTs are required to develop a stronger evidence base.
authors.affiliation: Birmingham and Solihull Mental Health NHS Foundation Trust, c/o Reaside Clinic, Birmingham, UK. Electronic address: jeremy.rampling@nhs.net.
authors.forename: J
authors.initials: J
authors.lastname: Rampling
authors.affiliation: Birmingham and Solihull Mental Health NHS Foundation Trust, c/o Reaside Clinic, Birmingham, UK; Department of Mental Health and Wellbeing, Warwick Medical School, University of Warwick CV4 7AL, UK.
authors.forename: V
authors.initials: V
authors.lastname: Furtado
authors.affiliation: Department of Mental Health and Wellbeing, Warwick Medical School, University of Warwick CV4 7AL, UK.
authors.forename: C
authors.initials: C
authors.lastname: Winsper
authors.affiliation: Department of Mental Health and Wellbeing, Warwick Medical School, University of Warwick CV4 7AL, UK.
authors.forename: S
authors.initials: S
authors.lastname: Marwaha
authors.affiliation: University of Milano-Bicocca, Piazza dell'Ateneo Nuovo, 1, 20126 Milano, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Lucca
authors.affiliation: Department of Mental Health and Wellbeing, Warwick Medical School, University of Warwick CV4 7AL, UK.
authors.forename: M
authors.initials: M
authors.lastname: Livanou
authors.affiliation: Department of Mental Health and Wellbeing, Warwick Medical School, University of Warwick CV4 7AL, UK.
authors.forename: S P
authors.initials: SP
authors.lastname: Singh
mesh_terms: D000328:Adult; D000374:Aggression; D015928:Cognitive Behavioral Therapy / Q000706:statistics & numerical data*; D057237:Criminals / Q000523:psychology*; D006801:Humans; D001523:Mental Disorders / Q000628:therapy*; D011613:Psychotherapy / Q000379:methods*; D011615:Psychotherapy, Group / Q000379:methods; D016032:Randomized Controlled Trials as Topic
keywords: Forensic psychiatry; Personality disorder; Psychotherapy; Schizophrenia and psychosis; Violence