***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective Patients suffering from psychosis are more likely than the general population to commit aggressive acts , but the therapeutics of aggressive behavior are still a matter of debate . Methods This pilot r and omized , open-label study compared the efficacy of quetiapine versus olanzapine in reducing impulsive and aggressive behaviors ( primary endpoints ) and psychotic symptoms ( secondary endpoints ) from baseline to days 1 , 7 , 14 , 28 , 42 , 56 , and 70 , in 15 violent schizophrenic patients hospitalized in a maximum-security psychiatric hospital . Results Quetiapine ( 525±45 mg ) and olanzapine ( 18.5±4.8 mg ) were both efficacious in reducing Impulsivity Rating Scale from baseline to day 70 . In addition , both treatments reduced the Brief Psychiatric Rating Scale , Positive and Negative Syndrome Scale , and Clinical Global Impression Scale scores at day 70 compared to baseline , and no differences were observed between treatments . Moreover , quetiapine , but not olanzapine , yielded an improvement of depressive symptoms in the items “ depression ” in Brief Psychiatric Rating Scale and “ blunted affect ” in Positive and Negative Syndrome Scale . Modified Overt Aggression Scale scores were also decreased from baseline to the endpoint , but due to the limited number of patients , it was not possible to detect a significant difference . Conclusion In this pilot study , quetiapine and olanzapine equally decreased impulsive and psychotic symptoms after 8 weeks of treatment . Double-blind , large studies are needed to confirm the validity of these two treatments in highly aggressive and violent schizophrenic patients Forensic psychiatry in Europe is a specialty primarily concerned with individuals who have either offended or present a risk of doing so , and who also suffer from a psychiatric condition . These mentally disordered offenders ( MDOs ) are often cared for in secure psychiatric environments or prisons . In this guidance paper we first present an overview of the field of forensic psychiatry from a European perspective . We then present a review of the literature summarising the evidence on the assessment and treatment of MDOs under the following headings : The forensic psychiatrist as expert witness , risk , treatment setting s for mentally disordered offenders , and what works for MDOs . We undertook a rapid review of the literature with search terms related to : forensic psychiatry , review articles , r and omised controlled trials and best practice . We search ed the Medline , Embase , PsycINFO , and Cochrane library data bases from 2000 onwards for adult groups only . We scrutinised publications for additional relevant literature , and search ed the websites of relevant professional organisations for policies , statements or guidance of interest . We present the findings of the scientific literature as well as recommendations for best practice drawing additionally from the guidance documents identified . We found that the evidence base for forensic-psychiatric practice is weak though there is some evidence to suggest that psychiatric care produces better outcomes than criminal justice detention only . Practitioners need to follow general psychiatric guidance as well as that for offenders , adapted for the complex needs of this patient group , paying particular attention to long-term detention and ethical issues This study examines the effectiveness of risperidone compared with traditional neuroleptic medications in the areas of clinical functioning and aggressive behaviors in a sample of in patients diagnosed with chronic schizophrenia . Similar to the methodology of Menditto et al. ( Psychiatr Serv 47:46 - 51 , 1996 ) , two groups of 10 patients were selected from those being treated in a comprehensive psychosocial rehabilitation program . Group 1 subjects were placed on risperidone at various times during their treatment . Group 2 subjects , who were matched with Group 1 subjects on pre- study levels of clinical functioning as measured by the  Time- Sample Behavioral Checklist ( TSBC ) , remained on traditional neuroleptics throughout the study period . For each subject , scores on six TSBC subscales were examined at four time points ; data were analyzed with repeated- measures multivariate analyses of variance and univariate analyses of variance . Frequency counts of aggressive behaviors ( threats and assaults ) were compiled into two six-month time periods and analyzed with nonparametric techniques . The risperidone group did not differ from the traditional neuroleptic group on measures of clinical functioning and aggressiveness measured over time . Both groups evidence d improvements in bizarre motor behaviors over the study period . The risperidone group evidence d some deterioration in measures of appropriate interpersonal interaction over time . No differences in aggressive behaviors were noted for either group . The study concludes that for forensic patients with chronic schizophrenia , risperidone failed to produce therapeutic effects in overall clinical functioning and aggressive behaviors that were significantly different from traditional neuroleptics . Descriptive comparisons are made between the receptor-binding profiles and clinical effectiveness of risperidone and clozapine in an attempt to explain these findings Abstract Objective To study the association between prescribed antipsychotic drugs and outcome in schizophrenia or schizoaffective disorder in the community . Design Prospect i ve cohort study using national central registers . Setting Community care in Finl and . Participants Nationwide cohort of 2230 consecutive adults hospitalised in Finl and for the first time because of schizophrenia or schizoaffective disorder , January 1995 to December 2001 . Main outcome measures Rates of discontinuation of drugs ( all causes ) , rates of rehospitalisation , and mortality associated with monotherapy with the 10 most commonly used antipsychotic drugs . Multivariate models and propensity score methods were used to adjust estimates of effectiveness . Results Initial use of clozapine ( adjusted relative risk 0.17 , 95 % confidence interval 0.10 to 0.29 ) , perphenazine depot ( 0.24 , 0.13 to 0.47 ) , and olanzapine ( 0.35 , 0.18 to 0.71 ) were associated with the lowest rates of discontinuation for any reason when compared with oral haloperidol . During an average follow-up of 3.6 years , 4640 cases of rehospitalisation were recorded . Current use of perphenazine depot ( 0.32 , 0.22 to 0.49 ) , olanzapine ( 0.54 , 0.41 to 0.71 ) , and clozapine ( 0.64 , 0.48 to 0.85 ) were associated with the lowest risk of rehospitalisation . Use of haloperidol was associated with a poor outcome  among women .  Mortality was markedly raised in patients not taking antipsychotics ( 12.3 , 6.0 to 24.1 ) and the risk of suicide was high ( 37.4 , 5.1 to 276 ) . Conclusions The effectiveness of first and second generation antipsychotics varies greatly in the community . Patients treated with perphenazine depot , clozapine , or olanzapine have a substantially lower risk of rehospitalisation or discontinuation ( for any reason ) of their initial treatment than do patients treated with haloperidol . Excess mortality is seen mostly in patients not using antipsychotic drugs The value of lithium carbonate as an adjunctive treatment of resistant schizophrenia was tested in a 4‐week clinical trial using a single‐blind , r and omized , consent design . Treatment and control groups were drawn from a population of detained patients in an English special ( maximum security ) hospital . The 2 groups were comparable in terms of age , sex , severity of symptoms , length of hospitalization and concurrent neuroleptic dosage . The addition of lithium carbonate to the treatment regimen did not result in symptomatic improvement in patients completing the treatment protocol . The ethical and practical difficulties raised by the trial are discussed This article introduces the approach of GRADE to rating  quality of evidence .  GRADE specifies four categories-high , moderate , low , and very low-that are applied to a body of evidence , not to individual studies . In the context of a systematic review , quality reflects our confidence that the estimates of the effect are correct . In the context of recommendations , quality reflects our confidence that the effect estimates are adequate to support a particular recommendation . R and omized trials begin as high- quality evidence , observational studies as low quality . " Quality " as used in GRADE means more than risk of bias and so may also be compromised by imprecision , inconsistency , indirectness of study results , and publication bias . In addition , several factors can increase our confidence in an estimate of effect . GRADE provides a systematic approach for considering and reporting each of these factors . GRADE separates the process of assessing quality of evidence from the process of making recommendations . Judgments about the strength of a recommendation depend on more than just the quality of evidence Abstract : Topiramate is an antiepileptic drug , recently also used in the treatment of psychiatric diseases . Inasmuch as topiramate and valproate , which are currently used for aggressive behavior , share several pharmacological mechanisms ( positive modulatory effect on the GABA activity and negative modulatory effect on glutamatergic neurotransmission ) , the objective of the present study was to compare the pharmacological effects of topiramate with those of valproate and their combination in patients with psychiatric disorders showing marked aggression and agitation . A retrospective , case-controlled , mirror-image study was carried out in a sample of 45 in patients affected by schizophrenia , schizoaffective and bipolar disorder , and hospitalized in a maximum-security Canadian psychiatry hospital .  Overt Aggression Scale , Agitation-Calmness Evaluation Scale , number and intensity of psychotic episodes , number of episodes of withdrawal from group activities per week , and number of therapeutic isolation per week and of strict surveillance intervention per week were evaluated before and after the treatments . Results indicate that patients treated with topiramate show a decrease in the average score of the Overt Aggression Scale , a decrease of episodes of agitation and of strict surveillance interventions . This effect was similar to the group treated with valproate or with the combination of valproate-topiramate . However , valproate therapy , but not topiramate therapy , decreased the intensity of agitation episodes measured by the Agitation-Calmness Evaluation Scale ;  valproate and the combination topiramate-valproate decreased the number of psychotic disorganization episodes as well . These results suggest that topiramate could be a valid medicine in the control of aggression in psychosis . Double-blind , r and omized , placebo-controlled studies need to further assess this pharmacological indication BACKGROUND It is generally believed that long-term use of antipsychotics increases mortality and , especially , the risk of cardiovascular death . However , there are no solid data to substantiate this view . METHODS We identified all individuals in Sweden with schizophrenia diagnoses before year 2006 ( N = 21 492 ) , aged 17 - 65 years , and persons with first-episode schizophrenia during the follow-up 2006 - 2010 ( N = 1230 ) . Patient information was prospect ively collected through nationwide registers . Total and cause-specific mortalities were calculated as a function of cumulative antipsychotic exposure from January 2006 to December 2010 . RESULTS Compared with age- and gender-matched controls from the general population ( N = 214920 ) , the highest overall mortality was observed among patients with no antipsychotic exposure ( hazard ratio [ HR ] = 6.3 , 95 % CI : 5.5 - 7.3 ) , ie , 0.0 defined daily dose (DDD)/day , followed by high exposure ( > 1.5 DDD/day ) group ( HR = 5.7 , 5.2 - 6.2 ) , low exposure ( < 0.5 DDD/day ) group ( HR = 4.1 , 3.6 - 4.6 ) , and moderate exposure ( 0.5 - 1.5 DDD/day ) group ( HR = 4.0 , 3.7 - 4.4 ) . High exposure ( HR = 8.5 , 7.3 - 9.8 ) and no exposure ( HR = 7.6 , 5.8 - 9.9 ) were associated with higher cardiovascular mortality than either low exposure ( HR = 4.7 , 3.7 - 6.0 ) or moderate exposure ( HR = 5.6 , 4.8 - 6.6 ) . The highest excess overall mortality was observed among first-episode patients with no antipsychotic use ( HR = 9.9 , 5.9 - 16.6 ) . CONCLUSIONS Among patients with schizophrenia , the cumulative antipsychotic exposure displays a U-shaped curve for overall mortality , revealing the highest risk of death among those patients with no antipsychotic use . These results indicate that both excess overall and cardiovascular mortality in schizophrenia is attributable to other factors than antipsychotic treatment when used in adequate dosages 
    Output:
    
Psychotic symptoms after treatment were more pronounced in the clozapine group .