Managing Agitation Associated with Schizophrenia and Bipolar Disorder in the Emergency Setting
Introduction: Patient agitation represents a significant challenge in the emergency department (ED), a setting in which medical staff are working under pressure dealing with a diverse range of medical emergencies. The potential for escalation into aggressive behavior, putting patients, staff, and...
| Main Authors: | , |
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| Format: | Article |
| Language: | English |
| Published: |
eScholarship Publishing, University of California
2016-03-01
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| Series: | Western Journal of Emergency Medicine |
| Subjects: | |
| Online Access: | http://escholarship.org/uc/item/74w6d6vr |
| _version_ | 1819024013565886464 |
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| author | Scott L. Zeller, MD Leslie Citrome, MD, MPH |
| author_facet | Scott L. Zeller, MD Leslie Citrome, MD, MPH |
| author_sort | Scott L. Zeller, MD |
| collection | DOAJ |
| description | Introduction: Patient agitation represents a significant challenge in the emergency department
(ED), a setting in which medical staff are working under pressure dealing with a diverse range of
medical emergencies. The potential for escalation into aggressive behavior, putting patients, staff,
and others at risk, makes it imperative to address agitated behavior rapidly and efficiently. Time
constraints and limited access to specialist psychiatric support have in the past led to the strategy
of “restrain and sedate,” which was believed to represent the optimal approach; however, it is
increasingly recognized that more patient-centered approaches result in improved outcomes. The
objective of this review is to raise awareness of best practices for the management of agitation in the
ED and to consider the role of new pharmacologic interventions in this setting.
Discussion: The Best practices in Evaluation and Treatment of Agitation (BETA) guidelines
address the complete management of agitation, including triage, diagnosis, interpersonal
calming skills, and medicine choices. Since their publication in 2012, there have been further
developments in pharmacologic approaches for dealing with agitation, including both new agents
and new modes of delivery, which increase the options available for both patients and physicians.
Newer modes of delivery that could be useful in rapidly managing agitation include inhaled, buccal/
sublingual and intranasal formulations. To date, the only formulation administered via a nonintramuscular
route with a specific indication for agitation associated with bipolar or schizophrenia
is inhaled loxapine. Non-invasive formulations, although requiring cooperation from patients, have
the potential to improve overall patient experience, thereby improving future cooperation between
patients and healthcare providers.
Conclusion: Management of agitation in the ED should encompass a patient-centered approach,
incorporating non-pharmacologic approaches if feasible. Where pharmacologic intervention is
necessary, a cooperative approach using non-invasive medications should be employed where
possible. |
| first_indexed | 2024-12-21T04:48:02Z |
| format | Article |
| id | doaj.art-097872f984364bf3bb55ee8ec4ea3038 |
| institution | Directory Open Access Journal |
| issn | 1936-900X 1936-9018 |
| language | English |
| last_indexed | 2024-12-21T04:48:02Z |
| publishDate | 2016-03-01 |
| publisher | eScholarship Publishing, University of California |
| record_format | Article |
| series | Western Journal of Emergency Medicine |
| spelling | doaj.art-097872f984364bf3bb55ee8ec4ea30382022-12-21T19:15:30ZengeScholarship Publishing, University of CaliforniaWestern Journal of Emergency Medicine1936-900X1936-90182016-03-0117216517210.5811/westjem.2015.12.28763Managing Agitation Associated with Schizophrenia and Bipolar Disorder in the Emergency SettingScott L. Zeller, MD0Leslie Citrome, MD, MPH1Alameda Health System, Department of Psychiatric Emergency Services, Oakland, California; University of California-Riverside, Department of Psychiatry, Riverside, CaliforniaNew York Medical College, Department of Psychiatry and Behavioral Sciences, Valhalla, New YorkIntroduction: Patient agitation represents a significant challenge in the emergency department (ED), a setting in which medical staff are working under pressure dealing with a diverse range of medical emergencies. The potential for escalation into aggressive behavior, putting patients, staff, and others at risk, makes it imperative to address agitated behavior rapidly and efficiently. Time constraints and limited access to specialist psychiatric support have in the past led to the strategy of “restrain and sedate,” which was believed to represent the optimal approach; however, it is increasingly recognized that more patient-centered approaches result in improved outcomes. The objective of this review is to raise awareness of best practices for the management of agitation in the ED and to consider the role of new pharmacologic interventions in this setting. Discussion: The Best practices in Evaluation and Treatment of Agitation (BETA) guidelines address the complete management of agitation, including triage, diagnosis, interpersonal calming skills, and medicine choices. Since their publication in 2012, there have been further developments in pharmacologic approaches for dealing with agitation, including both new agents and new modes of delivery, which increase the options available for both patients and physicians. Newer modes of delivery that could be useful in rapidly managing agitation include inhaled, buccal/ sublingual and intranasal formulations. To date, the only formulation administered via a nonintramuscular route with a specific indication for agitation associated with bipolar or schizophrenia is inhaled loxapine. Non-invasive formulations, although requiring cooperation from patients, have the potential to improve overall patient experience, thereby improving future cooperation between patients and healthcare providers. Conclusion: Management of agitation in the ED should encompass a patient-centered approach, incorporating non-pharmacologic approaches if feasible. Where pharmacologic intervention is necessary, a cooperative approach using non-invasive medications should be employed where possible.http://escholarship.org/uc/item/74w6d6vrAgitationSchizophreniaBipolar DisorderAntipsychoticBETA Guidelines |
| spellingShingle | Scott L. Zeller, MD Leslie Citrome, MD, MPH Managing Agitation Associated with Schizophrenia and Bipolar Disorder in the Emergency Setting Western Journal of Emergency Medicine Agitation Schizophrenia Bipolar Disorder Antipsychotic BETA Guidelines |
| title | Managing Agitation Associated with Schizophrenia and Bipolar Disorder in the Emergency Setting |
| title_full | Managing Agitation Associated with Schizophrenia and Bipolar Disorder in the Emergency Setting |
| title_fullStr | Managing Agitation Associated with Schizophrenia and Bipolar Disorder in the Emergency Setting |
| title_full_unstemmed | Managing Agitation Associated with Schizophrenia and Bipolar Disorder in the Emergency Setting |
| title_short | Managing Agitation Associated with Schizophrenia and Bipolar Disorder in the Emergency Setting |
| title_sort | managing agitation associated with schizophrenia and bipolar disorder in the emergency setting |
| topic | Agitation Schizophrenia Bipolar Disorder Antipsychotic BETA Guidelines |
| url | http://escholarship.org/uc/item/74w6d6vr |
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