Acute interventions for aggression and agitation in psychosis: study protocol for a systematic review and network meta-analysis

Abstract

IntroductionIndividuals with psychosis may access emergency services due to aggression and agitation. When the de-escalation technique fails to achieve tranquillisation, several pharmacological options are available. However, evidence on which intervention to prefer in terms of efficacy and tolerability to achieve resolution of the acute episode (ie, rapid tranquillisation) of aggression and agitation is currently fragmentary.Methods and analysisWe will include all randomised controlled trials comparing drugs or drug combinations or placebo for aggression or agitation episodes in adult individuals with psychosis. We will include individuals with psychosis (eg, schizophrenia and related disorders, bipolar disorder with psychotic symptoms, psychotic depression) but not substance or medication-induced psychosis or psychosis due to another medical condition. Our primary outcomes are the change in aggression or agitation scores within few hours since the administration of the intervention (efficacy outcome) and the proportion of participants who dropped out due to adverse effects (tolerability outcome). We will retrieve relevant studies from the register of studies of the Cochrane Schizophrenia Group. Also, we will run additional searches on CENTRAL, Embase and PubMed to retrieve potentially eligible studies focusing on other psychiatric diagnoses than those in the schizophrenia spectrum. We will conduct a random-effects network meta-analysis (NMA) for primary and secondary outcomes. In case of rare events of dichotomous outcomes, a common-effect Mantel-Haenszel NMA will be used instead. We will use the surface under the cumulative ranking curve and the mean ranks to rank all available treatments. Local and global methods of evaluation of inconsistency will be employed. Quality of evidence contributing to network estimates of the main outcomes will also be assessed with Confidence in Network Meta-Analysis.Ethics and disseminationThis study does not require ethical approval. We will disseminate our findings by publishing results in a peer-reviewed journal.PROSPERO registration numberCRD42019137945.

Psychometric Characteristics and Sociodemographic Adaptation of the Corrigan Agitated Behavior Scale in Patients With Severe Mental Disorders

“…The prevalence of psychomotor agitation is high, up to 10% of patients seen in general emergency services ( Pacciardi et al, 2013 ) and between 20 and 50% if we specifically consider psychiatric emergencies ( Allen and Currier, 2004 ; Marco and Vaughan, 2005 ). Different studies relate psychomotor agitation with the suffering of a severe mental disorder ( Bogner et al, 1999 ; Huber et al, 2016 ; Ostinelli et al, 2019 ), diverse psychiatric conditions, as well as some medical disorders ( Galián Muñoz et al, 2011 ). Agitation of psychiatric origin is seen more frequently in patients with psychotic disorders, such as schizophrenia, schizoaffective disorder and the manic phase of bipolar disorder, as well as in some personality disorders ( Feldman et al, 2001 ; Buckley et al, 2003 ; Battaglia, 2005 ; Serretti and Olgiati, 2005 ; Wittchen et al, 2011 ).…”

“…Psychomotor agitation corresponds to one of the most important hospital emergencies in the care of severe mental disorder since it requires immediate professional assistance, and the safety of the patient is seriously compromised ( Bogner et al, 2001 ; Buckley et al, 2003 ; Nott et al, 2006 ; Galián Muñoz et al, 2011 ; Ostinelli et al, 2019 ).…”

Case of reversible Mobitz type II atrioventricular block after the use of injectable antipsychotics

“…As the patient was extremely agitated, the haloperidol and levomepromazine doses were increased. However, since the elderly are at particular risk of adverse effects associated with antipsychotics, including mortality, dosage recommendations in are significantly more conservative than those for younger patients, and the medication should be titrated to the minimum effective dose 13 . If antipsychotics cannot solely control agitation in the elderly, a combination of benzodiazepines, such as diazepam and midazolam, is preferred 14…”

Management of Psychosis in the Setting of Binge Eating, Mania, and Extrapyramidal Side Effects

“…The aggression and agitation our patient exhibited upon presentation are features found in both psychotic and manic episodes. While psychosis may present with various signs, in approximately 20% of clinical manifestations, we can find agitation/aggression [ 7 , 8 ]: a state of acute anxiety and heightened emotional arousal with increased motor activity [ 9 ]. Of note, psychotic features in the setting of mania are associated with greater symptom severity and higher morbidity in the long term [ 10 ].…”