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The Treatment of Acute Agitation in Schizophrenia

Published online by Cambridge University Press:  07 November 2014

Joseph Battaglia ,
Delbert G. Robinson  and
Leslie Citrome
Joseph Battaglia
Affiliation:
Joseph Battaglia, MD, is assistant professor of psychiatry at Albert Einstein College of Medicine and clinical director of the Bronx Psychiatric Center in Bronx, New York. Dr. Battaglia reports no financial, academic, or other interest in any organization that may pose a conflict of interest.
Delbert G. Robinson
Affiliation:
Delbert G. Robinson, MD, is an associate investigator at the Feinstein Institute for Medical Research of the North Shore Long Island Jewish Health System in Manhasset, New York, and associate professor of psychiatry and behavioral sciences at Albert Einstein College of Medicine in Bronx, New York. Dr. Robinson receives research support from Bristol-Myers Squibb and Janssen.
Leslie Citrome
Affiliation:
Leslie Citrome, MD, MPH, is professor of psychiatry at the New York University School of Medicine and director of the Clinical Research and Evaluation Facility at the Nathan S. Kline Institute for Psychiatric Research in Orangeburg, New York. Dr. Citrome is a consultant and/or advisor to, receives honoraria and/or research support from, and owns stock in Bristol-Myers Squibb, Eli Lilly, and Pfizer.
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Abstract

Acute agitation is a nonspecific term applied to an array of syndromes and behaviors. It is frequently defined as an increase in psychomotor activity, aggression, disinhibition/impulsivity, and irritable or labile mood. Etiologies of acute agitation include medical disorders, delirium, substance intoxication or withdrawal, psychiatric disorders, and medication side effects. Treatment of acute agitation requires both environmental and pharmacologic intervention. Patients should be calmed with sedating agents early in the course of treatment, allowing for diagnostic tests to take place. Failure to correctly diagnose causes of agitation may lead to delayed treatment for serious conditions, and can even exacerbate agitation.The most common cause of agitation in patients with schizophrenia is psychotic relapse due to medication nonadherence. Pharmacologic treatment options for these patients include lorazepam and antipsychotic agents. Lorazepam causes nonspecific sedation and treats some substance withdrawal, but has little effect on psychosis. First-generation antipsychotics treat psychosis and, at high enough doses, cause sedation, but may induce extrapyramidal side effects (EPS). Some second-generation antipsychotics have been approved for the treatment of agitation in schizophrenia. These agents treat psychosis with a favorable EPS profile, but are comparatively expensive and cause risks such as hypotension. However, avoiding EPS may reduce patients' resistance to antipsychotic treatment.

In this expert roundtable supplement, Joseph Battaglia, MD, provides an overview of the definition of acute agitation. Next, Delbert, G. Robinson, MD, outlines evaluation methods for actue agitation. Finally, Leslie Citrome, MD, MPH, reviews interventions for acute and ongoing management of agitation.

Type
Research Article
Information
CNS Spectrums , Volume 12 , Issue S11 , 2007 , pp. 1 - 16
Copyright
Copyright © Cambridge University Press 2007

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References

1.Diagnostic and Statistical Manual of Mental Disorders. 4th ed text rev. Washington, DC: American Psychiatric Association; 2000.Google Scholar
2.RH, Swift, Harrigan, EP, Cappelleri, JC, Kramer, D, LP, Chandler. Validation of the Behavioral Activity Rating Scale (BARS): a novel measure of activity in agitated patients. J Psychiatr Res. 2002;36(2):87–95.Google Scholar
3.Yudofsky, SC, Kopecky, HJ, Kunik, M, Silver, JM, Endicott, J. The Overt Agitation Scale for the objective rating of agitation. J Neuropsychiatry Clin Neurosci. 1997;9(4):541–548.Google ScholarPubMed
4.Wolthaus, JE, Dingemans, PM, Schene, AH, et al.Component structure of the positive and negative syndrome scale (PANSS) in patients with recent-onset schizophrenia and spectrum disorders. Psychopharmacology (Berl). 2000;150(4):399–403.CrossRefGoogle ScholarPubMed
5.Kay, SR, Sevy, S. Pyramidical model of schizophrenia. Schizophr Bull. 1990;16(3):537–545.CrossRefGoogle ScholarPubMed
6.Wright, P, Birkett, M, David, SR, et al.Double-blind, placebo-controlled comparison of intramuscular olanzapine and intramuscular haloperidol in the treatment of acute agitation in schizophrenia. Am J Psychiatry. 2001;158(7):1149–1151.CrossRefGoogle ScholarPubMed
7.Best, M, Williams, MJ, Coccaro, EF. Evidence for a dysfunctional prefrontal circuit in patients with an impulsive aggressive disorder. Proc Natl Acad Sci U S A. 2002; 99(12):8448–8453.CrossRefGoogle ScholarPubMed
8.Quanbeck, CD, McDermott, BE, Lam, J, et al.Categorization of aggressive acts committed by chronically assaultive state hospital patients. Psychiatr Serv. 2007;58(4):521–528.CrossRefGoogle ScholarPubMed
9.Schatzberg, AF, DeBattista, C. Phenomenology and treatment of agitation. J Clin Psychiatry. 1999;60(suppl 15):17–20.Google ScholarPubMed
10.Hamilton, M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56–62.CrossRefGoogle ScholarPubMed
11.Montgomery, SA, Åsberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134:382–389.CrossRefGoogle ScholarPubMed
12.Young, RC, Biggs, JT, Ziegler, VE, Meyer, DA. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry. 1978;133:429–435.CrossRefGoogle ScholarPubMed
13.Center for Medicaid and Medicare Services. Definition of Chemical Restraint: January 2007. Regulation 483.Google Scholar
1.Hazlett, SB, McCarthy, ML, Lindner, MS, Onyike, CU. Epidemiology of adult psychiatric visits to US emergency departments. Acad Emerg Med. 2004;11:193–195.CrossRefGoogle ScholarPubMed
2.Owen, C, Tarantello, C, Jones, M, Tennant, C. Repetitively violent patients in psychiatric units. Psychiatr Serv. 1998;49:1458–1461.CrossRefGoogle ScholarPubMed
3.McNiel, DE, Binder, RL, Greenfield, TK. Predictors of violence in civilly committed acute psychiatric patients. Am J Psychiatry. 1988;145:965–970.Google ScholarPubMed
1.Citrome, L, Volavka, J. Treatment of Violent Behavior. In: Tasman, A, Lieberman, J, Kay, J, eds. Psychiatry. 2nd ed. John Wiley & Sons, Ltd; 2003:2136–2146.Google Scholar
2.Citrome, L, Nolan, KA, Volavka, J. Science-based treatment of aggression and agitation. In Fishbein, D, ed. The Science, Treatment, and Prevention of Antisocial Behaviors, Volume 2. Kingston, New Jersey: Civic Research Institute, Inc; 2004.Google Scholar
3.Citrome, L, Volavka, J. Clinical management of persistent aggressive behavior in schizophrenia: Part I Definitions, epidemiology, assessment, and acute treatment. Essent Psychopharmacol. 2002;5:1–16.Google Scholar
4.Citrome, L. Atypical antipsychotics for acute agitation. New intramuscular options offer advantages. Postgrad Med. 2002;112(6):85–8, 94–96.CrossRefGoogle ScholarPubMed
5.Citrome, L. Intramuscular ziprasidone, olanzapine, or aripiprazole for agitation: equipoise or not?J Clin Psychiatry. In press.Google Scholar
6.Daniel, DG, Potkin, SG, Reeves, KR, et al.Intramuscular (IM) ziprasidone 20 mg is effective in reducing acute agitation associated with psychosis: A double-blind, randomized trial. Psychopharmacology (Berl). 2001;155:128–134.CrossRefGoogle ScholarPubMed
7.Lesem, MD, Zajecka, JM, Swift, RH, et al.Intramuscular ziprasidone, 2 mg versus 10 mg, in the short-term management of agitated psychotic patients. J Clin Psychiatry. 2001;62:12–18.CrossRefGoogle ScholarPubMed
8.Tran-Johnson, TK, Sack, DA, Marcus, RN, et al: Efficacy and safety of intramuscular aripiprazole in patients with acute agitation: a randomized, double- /blind, placebo-controlled trial. J Clin Psychiatry. 2007;68:111–119.CrossRefGoogle ScholarPubMed
9.Wright, P, Birkett, M, David, SR, et al.Double-blind, placebo-controlled comparison of intramuscular olanzapine and intramuscular haloperidol in the treatment of acute agitation in schizophrenia. Am J Psychiatry. 2001;158(7):1149–1151.CrossRefGoogle ScholarPubMed
10.Breier, A, Meehan, K, Birkett, M, et al.A double-blind, placebo-controlled dose-response comparison of intramuscular olanzapine and haloperidol in the treatment of acute agitation in schizophrenia. Arch Gen Psychiatry. 2002;59(5):441–448.CrossRefGoogle ScholarPubMed
11.Meehan, K, Zhang, F, David, S, et al.A double-blind, randomized comparison of the efficacy and safety of intramuscular injections of olanzapine, lorazepam, or placebo in treating acutely agitated patients diagnosed with bipolar mania. J Clin Psychopharmacol. 2001;21:389–397.CrossRefGoogle ScholarPubMed
12.Andrezina, R, Josiassen, RC, Marcus, RN, et al.Intramuscular aripiprazole for the treatment of acute agitation in patients with schizophrenia or schizoaffective disorder: a double-blind, placebo-controlled comparison with intramuscular haloperidol. Psychopharmacology (Berl). 2006;188:281–292.CrossRefGoogle ScholarPubMed
13.Zimbroff, DL, Marcus, RN, Manos, G, et al.Management of acute agitation in patients with bipolar disorder. Efficacy and safety of intramuscular aripiprazole. J Clin Psychopharmacol. 2007;27:171–176.CrossRefGoogle ScholarPubMed
14. Geodon (ziprasidone HCl) capsules, Geodon (ziprasidone mesylate) for injection for IM use only. New York, NY: Pfizer; 2007.Google Scholar
15. Zyprexa (olanzapine) tablets, Zyprexa Zydis (olanzapine) orally disintegrating tablets, Zyprexa IntraMuscular (olanzapine) for injection. Indianapolis, IN: Eli Lilly; 2006.Google Scholar
16. Abilify (aripiprazole) tablets, Abilify (aripiprazole) DiscMelt orally disintegrating tablets, Abilify (aripiprazole) oral solution, Abilify (aripiprazole) injection. Jacksonville, FL: Bristol-Myers Squibb; 2006.Google Scholar
1.Battaglia, J, Moss, S, Rush, J, et al.Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-blind, emergency department study. Am J Emerg Med. 1997;15:335–340.CrossRefGoogle ScholarPubMed
2.Meehan, KM, Wang, H, David, SR, et al.Comparison of rapidly acting intramuscular olanzapine, lorazepam, and placebo: A double-blind, randomized study in acutely agitated patients with dementia. Neuropsychopharmacology. 2002;26:494–504.CrossRefGoogle ScholarPubMed
3.Nolan, KA, Citrome, LL, Saito, K, Xu, J. Reducing Inpatient Aggression: Paying Attention Pays Off. Poster Presented at: The 25th Congress of the Collegium International Neuropsychopharmacologicum; July 2006; Chicago, IL. Abstract in Int J Neuropsychopharmacol. 2006;9(Suppl 1):S150.Google Scholar