Factors associated with aggressive behavior in patients with schizophrenia: a systematic review and meta-analysis

Aggression in schizophrenia poses a severe global public health challenge, adversely impacting patients, families, and society. A comprehensive understanding of its associated factors is important for developing effective interventions. This study aimed to systematically review and meta-analyze the factors associated with aggressive behavior in patients with schizophrenia. Following PRISMA guidelines, systematic literature searches were conducted in 10 databases from 2014 to October 2024. Study quality was assessed using the Newcastle-Ottawa Scale (NOS). A meta-analysis was performed using Python 3.11.7 5.4 to calculate pooled odds ratios (ORs) or standardized mean differences (SMDs) with 95% confidence intervals (CIs). Subgroup and sensitivity analyses were used to evaluate heterogeneity. Twenty-four studies involving 5,096 patients with schizophrenia (1,766 aggressive, 3,330 non-aggressive) were included. The meta-analysis identified several risk factors for aggression: male gender (OR = 1.18), junior high school education or lower (OR = 1.98), a history of violence (OR = 3.33), abnormal levels of serum inflammatory markers (e.g., FT3, FT4, C-reactive protein), frontal lobe abnormalities, and the presence of psychotic symptoms (e.g., high PANSS scores) (all P < 0.05). Conversely, being married was a protective factor in male-only subgroups (OR = 0.61). Higher serum TT3 levels and higher BPRS scores were also found to be protective (P < 0.05). Our findings clarify the role of various factors in aggression among patients with schizophrenia, providing an evidence base for clinical intervention and treatment. In clinical practice, our findings could effectively reduce aggression risk and promote comprehensive patient assessment and management. PROSPERO CRD420251147415.