Topiramate for anger control: A systematic review

BACKGROUND: Uncontrolled anger while being most commonly associated with personality disorders could also be part of many other conditions such as chronic low back ache and post-traumatic stress disorder. The intensity of anger as an emotional state at a particular time is known as “State Anger,” whereas how often angry feelings are experienced over time is known as “Trait Anger.” Anger could also manifest as expression of anger toward other persons or objects in the environment (Anger-Out), holding in or suppressing angry feelings (Anger-In) and controlling angry feelings by preventing the expression of anger toward other persons or objects in the environment or controlling suppressed angry feelings by calming down or cooling off (Anger Control). OBJECTIVE: To prove the effectiveness of topiramate in the control of anger as compared to placebo and to disprove that its use leads to psychiatric adverse events by systematically reviewing the available randomized controlled trials. MATERIALS AND METHODS: The basic search was performed in MEDLINE (1966 through November 2008) combined with the optimal search strategy for randomized controlled trials described in the Cochrane Reviewers’ Handbook. To update this search, we regularly screened citations from PubMed till November 2008 for eligible studies or reviews that might include eligible studies. The Cochrane Central Register of Controlled Trials (CENTRAL) was searched using the terms “topiramate” and “anger or aggression.” In addition, we screened bibliographies of reviews and identified articles. Randomized clinical trials wherein study participants were aggressive adults were included. RESULTS: We could arrive at a weighted mean difference of −3.16 (−3.64 to −2.68) in State Anger. The reduction in the score was highest in borderline personality disorder (BPD) patients as compared to those with low back ache. Trait Anger dropped by −2.93 (−3.49 to −2.37), especially in female BPD patients. Anger In reduced more or less uniformly across the studies by −1.43 (−1.84 to −1.03). Anger Out decreased by −2.8 (−3.19 to −2.42). This effect was minimal among the male BPD patients. Anger Control uniformly increased across the four studies by 2.32 (2.00−2.64). There is sufficient evidence to suggest that topiramate is significantly effective in stabilizing the “trait anger” while reducing the “state anger.” “Anger Out” and “hostility” were significantly reduced. “Anger In” was the feature that was the least affected, although this was significant. This suggests that topiramate is effective in controlling anger. There was no suggestion of topiramate precipitating psychomorbidity. CONCLUSIONS: Topiramate appears to be a safe and effective drug in the management of anger/aggression. Additional research is needed to determine whether these results can be reproduced and how long lasting are the benefits of long-term treatment with topiramate.