Assessment and management of agitation in psychiatry: Expert consensus

Garriga, Marina; Pacchiarotti, Isabella; Kasper, Siegfried; Zeller, Scott L.; Allen, Michael; Vázquez, Gustavo; Baldaçara, Leonardo; San, Luís; McAllister-Williams, R. Hamish; Fountoulakis, Konstantinos Ν.; Courtet, Philippe; Naber, Dieter; Chan, Esther W.; Fagiolini, Andrea; Möller, Hans; Grunze, Heinz; Llorca, Pierre Michel; Jaffe, Richard L.; Yatham, Lakshmi N.; Hidalgo‐Mazzei, Diego; Passamar, Marc; Messer, Thomas; Bernardo, Miquel; Vieta, Eduard

doi:10.3109/15622975.2015.1132007

Cited by 249 publications

(404 citation statements)

References 177 publications

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“…Regarding treatment considerations, recent guidelines recommend the need for the early detection of aggressive behaviors in mood disorders (53)(54)(55). In our sample, the MDE-A group presented higher rates of psychotic symptoms and more severe mania, together with higher rates of no current pharmacological treatment.…”

Section: Discussionmentioning

confidence: 69%

Aggressiveness in depression: a neglected symptom possibly associated with bipolarity and mixed features

Verdolini

Perugi

Samalin

et al. 2017

Acta Psychiatr Scand

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Objective: To evaluate aggressiveness during a major depressive episode (MDE) and its relationship with bipolar disorder (BD) in a post-hoc analysis of the BRIDGE-II-MIX study.Method: A total of 2,811 individuals were enrolled in this multicenter cross-sectional study. MDE patients with (MDE-A, n=399) and without aggressiveness (MDE-N, n=2,412) were compared through Chi-square test or Student's t-test. A stepwise backward logistic regression model was performed.Results: MDE-A group was more frequently associated with BD (p<0.001) whilst aggressiveness was negatively correlated with unipolar depression (p<0.001). At the logistic regression aggressiveness was associated with: the age at first depressive episode (p<0.001); the severity of mania (p=0.03); the diagnosis of BD (p=0.001); comorbid borderline personality disorder (BPD) (p<0.001) but not substance abuse (p=0.63); no current psychiatric treatment (p<0.001); psychotic symptoms (p=0.007); the marked social/occupational impairment (p=0.002). The variable most significantly associated with aggressiveness was the presence of DSM-5 mixed features (p<0.001, OR=3.815). After the exclusion of BPD, the variable of lifetime suicide attempts became significant (p=0.013, OR=1.405). Conclusion:Aggressiveness seems to be significantly associated with bipolar spectrum disorders, independently from BPD and substance abuse. Aggressiveness should be considered as a diagnostic criterion for the mixed features specifier and a target of tailored treatment strategy.Keys words: aggressiveness, bipolar disorder, DSM-5 mixed features specifier, major depressive episode 3 Significant outcomesIn this post-hoc analysis of the BRIDGE-II-MIX study, the presence of aggressive behaviors was mainly related with socio-demographic and clinical characteristics associated with bipolarity.

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Section: Discussionmentioning

confidence: 69%

Aggressiveness in depression: a neglected symptom possibly associated with bipolarity and mixed features

Verdolini

Perugi

Samalin

et al. 2017

Acta Psychiatr Scand

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“…If oral preparations are ineffective or if the agitation is severe and if the patient is refusing oral medications, or when oral therapy cannot be safely or reliably administered, then IM formulations should be considered 124. Because of the strength of evidence for efficacy in alleviating agitation in this population, aripiprazole IM (level 2),125, 126 lorazepam IM (level 2),125, 127 loxapine inhaled (Level 1)128, 129 and olanzapine IM (level 2)127, 130, 131, 132, 133 are recommended as the first‐line option.…”

Section: Acute Management Of Bipolar Maniamentioning

confidence: 99%

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

et al. 2018

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The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third‐ line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment‐emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second‐ line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence‐based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first‐line treatments for acute mania. First‐line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first‐line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.

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“…Recently, a panel of 24 international experts have published a consensus on the assessment and treatment decisions for psychiatric agitation has that provides some useful recommendations for daily clinical practice based on the current knowledge of agitation [26]. However, data on the epidemiology and management of acute agitation at the psychiatric emergency services in Europe is scarce, probably due to the lack of standard studies or systematic data collection.…”

Section: Introductionmentioning

confidence: 99%

State of Acute Agitation at Psychiatric Emergencies in Europe: The STAGE Study

San¹,

Marksteiner²,

Zwanzger³

et al. 2016

CPEMH

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Background:Agitation is an array of syndromes and types of behaviors that are common in patients with psychiatric disorders. In Europe, the estimation of prevalence of agitation has been difficult due to the lack of standard studies or systematic data collection done on this syndrome.Objective:An observational, cross-sectional, multicenter study aimed to assess the prevalence of agitation episodes in psychiatric emergencies in different European countries.Method:For 1 week, all episodes of acute agitation that were attended to at the psychiatric emergency room (ER) or Acute Inpatient Unit (AIU) in the 27 participating centers were registered. The clinical characteristics and management of the agitation episode were also described. A descriptive analysis was performed.Results:A total of 334 agitation episodes out of 7295 psychiatric emergencies were recorded, giving a prevalence rate of 4.6% (95% CI: 4.12-5.08). Of them, 172 [9.4% (95% CI: 8.2-10.9)] were attended at the ER and 162 [2.8% (95% CI: 2.4-3.3)] at AIU. Only data from 165 episodes of agitation (those with a signed informed consent form) was registered and described in this report. The most common psychiatric conditions associated with agitation were schizophrenia, bipolar disorder and personality disorder. The management of agitation included from non-invasive to more coercive measures (mechanical, physical restraint or seclusion) that were unavoidable in more than half of the agitation episodes (59.5%).Conclusion:The results show that agitation is a common symptom in the clinical practice, both in emergency and inpatient psychiatric departments. Further studies are warranted to better recognize (using a standardized definition) and characterize agitation episodes.

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Assessment and management of agitation in psychiatry: Expert consensus

Cited by 249 publications

References 177 publications

Aggressiveness in depression: a neglected symptom possibly associated with bipolarity and mixed features

Aggressiveness in depression: a neglected symptom possibly associated with bipolarity and mixed features

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

State of Acute Agitation at Psychiatric Emergencies in Europe: The STAGE Study

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