Agitation in the Inpatient Psychiatric Setting

Abstract

Agitation among psychiatric inpatients (particularly those diagnosed with schizophrenia or bipolar disorder) is common and, unless recognized early and managed effectively, can rapidly escalate to potentially dangerous behaviors, including physical violence. Inpatient aggression and violence have substantial adverse psychological and physical consequences for both patients and providers, and they are costly to the healthcare system. In contrast to the commonly held view that inpatient violence occurs without warning or can be predicted by "static" risk factors, such as patient demographics or clinical characteristics, research indicates that violence is usually preceded by observable behaviors, especially non-violent agitation. When agitation is recognized, staff should employ nonpharmacological de-escalation strategies and, if the behavior continues, offer pharmacological treatment to calm patients rapidly. Given the poor therapeutic efficacy and potential for adverse events associated with physical restraint and seclusion, and the potential adverse sequelae of involuntary drug treatment, these interventions should be considered last resorts. Pharmacological agents used to treat agitation include benzodiazepines and first- and second-generation antipsychotic drugs. Although no currently available agent is ideal, recommendations for selecting among them are provided. There remains an unmet need for a non-invasive and rapidly acting agent that effectively calms without excessively sedating patients, addresses the patient's underlying psychiatric symptoms, and is reasonably safe and tolerable. A treatment with these characteristics could substantially reduce the clinical and economic burden of agitation in the inpatient psychiatric setting.

The Role of Inhaled Loxapine in the Treatment of Acute Agitation in Patients with Psychiatric Disorders: A Clinical Review

“…Inhaled loxapine should only be used in the case of agitated, but somewhat or partial collaborative patients, and in such cases, this drug may be as useful as IM SGAs, to obtain a more rapid tranquillisation than the oral administration [59]. Moreover, it frequently occurs that, in everyday clinical practice, the agitated patients may initially and apparently accept the oral medications (often to avoid involuntary admissions), but they may spit out the oral medications, or need a relatively long time to achieve tranquilisation after oral administration [1,2,3]. The use of inhaled loxapine may overcome these shortcomings, as the administration and the rapid onset of the anti-agitation effect are warranted [52,53,54,55].…”

“…Being faced with an agitated or violent patient is a challenge for every psychiatrist and associated health care professional, working in the everyday “real world” clinical practice [1]. Even if agitation or violence are not common symptoms of all psychiatric disorders, and the majority of persons with such disorders are not violent [2], it is undoubtable that these manifestations may more often occur in some psychiatric disorders (e.g., schizophrenia or bipolar disorders) [3,4], when there are comorbid conditions (e.g., substance and alcohol abuse or dependence, some personality disorders) [5], or lack of medication compliance [6].…”

Rationale and design of the PLACID study: a randomised trial comparing the efficacy and safety of inhaled loxapine versus IM aripiprazole in acutely agitated patients with schizophrenia or bipolar disorder

“…Acute agitation in patients with psychiatric disorders including schizophrenia and bipolar disorder is a serious complication with the potential to escalate rapidly to aggression and physical violence [3, 5, 6]. Early recognition of the onset of acute agitation and intervention to rapidly calm the agitated patient without over-sedation are the main goals of the pharmacological management of such patients [3].…”

“…However, such coercive management measures may damage the therapeutic relationship between patients and their carer’s and evoke feelings of panic, fear, powerlessness, anger, frustration, and injustice [2]. The consequence of this negative association of feelings may destroy trust and lead to patient reluctance to seek psychiatric care [3]. Early intervention for acute agitation with a medication delivered via a non-traumatic route has the potential to avoid the negative feelings evoked by a traumatic therapeutic encounter and reinforce the partnership between patient and their carer [2, 3].…”

Correlates of nicotine withdrawal severity in smokers during a smoke-free psychiatric hospitalization

“…Further, anger, agitation, and restlessness, which can be heightened during NW, are associated with behaviors that may disrupt psychiatric treatment. In locked psychiatric units, agitation has been found to increase the likelihood of assaultive behavior (Hankin et al, 2011) and the need for physical restraint (Bowers et al, 2003). Untreated NW also has been associated with hospital discharges against medical advice (AMA), ostensibly due to patients wanting to leave to smoke; notably, the AMA rate among smokers offered NRT was no different from nonsmokers (Prochaska et al, 2004).…”