Rapid-acting IM ziprasidone in a psychiatric emergency service: a naturalistic study

Prevalence of the use of chemical restraint in the management of challenging behaviours associated with adult mental health conditions: A meta-synthesis

WHAT IS KNOWN ON THE SUBJECT?: The use of chemical restraint in emergency situations is to control aggression or violence to protect consumers and staff and is to be used as a last resort when all other behavioural control alternatives have been exhausted. Chemical restraint involves the use of medication. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first paper to systematically review the prevalence of the use of chemical restraint. The use of chemical restraint is common across emergency departments and acute psychiatric inpatient units worldwide. Consumers who are restrained are also likely to receive chemical restraint. The studies reviewed demonstrate that there is a need for more standardized data collection so that clearer comparisons can be made between healthcare settings and countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Implications of practice include the need to report adverse events post-chemical restraint as these can deleteriously affect a person's physical health. Identification of and staff education about first-line management techniques before chemical restraint is administered are significant to reduce its use. ABSTRACT: Introduction Chemical restraint is used to manage uncontrolled aggression, agitation or violent behaviours of consumers with mental health disorders admitted to acute psychiatric or emergency settings. Aim This systematic review aimed to synthesize the international prevalence of chemical restraint for non-consenting adults. Method PsycINFO, CINAHL, MEDLINE/PubMed and Google Scholar databases were searched for peer-reviewed literature published between January 1996 and July 2018. This paper reports on data extracted from retrospective audits of chemical restraint practice. Results Forty-eight papers were included. The median prevalence of use of any restraint was 21.2% (25th% 8.0 to 75th% 36.3). Median prevalence of people who were chemically restrained, of all people restrained in any manner, was 43.1% (25th% 22.9% to 75th% 70.7%). Of all people admitted to facility(ies), the median prevalence of chemical restraint was 7.4% (25th% 2.7 to 75th% 17.6). There was no statistically significant difference in any prevalence measure considering healthcare setting or country. There was a significant decrease over the review period in the use of any restraint, including chemical restraint. Discussion and implications for practice This is the first known comprehensive meta-view of chemical restraint use worldwide, highlighting the need for standardized data collection to enable comparisons between healthcare settings and countries. Relevance statement There is an international imperative to reduce or eliminate the use of coercive practices, such as physical and chemical restraint, in mental health care. This study provides important information for mental health nursing by synthesizing the international prevalence of chemical restraint for non-consenting adults. This meta-view of the worldwide use of chemical restraint can inform ongoing efforts to reduce its use.

International research into 22 years of use of chemical restraint: An evidence overview

BACKGROUND

Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice.

AIMS

To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995.

METHODS

This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures.

RESULTS

This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%).

DISCUSSION

A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.

Management of Violence and Aggression in Emergency Environment; a Narrative Review of 200 Related Articles

Context:

The aim of this study is to reviewing various approaches for dealing with agitated patients in emergency department (ED) including of chemical and physical restraint methods.

Evidence acquisition:

This review was conducted by searching “Violence,” “Aggression,” and “workplace violence” keywords in these databases: PubMed, Scopus, EmBase, ScienceDirect, Cochrane Database, and Google Scholar. In addition to using keywords for finding the papers, the related article capability was used to find more papers. From the found papers, published papers from 2005 to 2018 were chosen to enter the paper pool for further review.

Results:

Ultimately, 200 papers were used in this paper to conduct a comprehensive review regarding violence management in ED. The results were categorized as prevention, verbal methods, pharmacological interventions and physical restraint.

Conclusion:

In this study various methods of chemical and physical restraint methods were reviewed so an emergency medicine physician be aware of various available choices in different clinical situations for agitated patients.

Brazilian guidelines for the management of psychomotor agitation. Part 2. Pharmacological approach

Objective:

To present the essential guidelines for pharmacological management of patients with psychomotor agitation in Brazil.

Methods:

This is a systematic review of articles retrieved from the MEDLINE (PubMed), Cochrane Database of Systematic Reviews, and SciELO databases published from 1997 to 2017. Other relevant articles in the literature were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools.

Results:

Of 5,362 articles retrieved, 1,731 abstracts were selected for further reading. The final sample included 74 articles that met all inclusion criteria. The evidence shows that pharmacologic treatment is indicated only after non-pharmacologic approaches have failed. The cause of the agitation, side effects of the medications, and contraindications must guide the medication choice. The oral route should be preferred for drug administration; IV administration must be avoided. All subjects must be monitored before and after medication administration.

Conclusion:

If non-pharmacological strategies fail, medications are needed to control agitation and violent behavior. Once medicated, the patient should be monitored until a tranquil state is possible without excessive sedation.

Systematic review registry number:

CRD42017054440.

The pharmacological management of agitated and aggressive behaviour: A systematic review and meta-analysis

Introduction:

Non-pharmacological interventions preferably precede pharmacological interventions in acute agitation. Reviews of pharmacological interventions remain descriptive or compare only one compound with several other compounds. The goal of this study is to compute a systematic review and meta-analysis of the effect on restoring calmness after a pharmacological intervention, so a more precise recommendation is possible.

Method:

A search in Pubmed and Embase was done to isolate RCT’s considering pharmacological interventions in acute agitation. The outcome is reaching calmness within maximum of 2 h, assessed by the psychometric scales of PANSS-EC, CGI or ACES. Also the percentages of adverse effects was assessed.

Results:

Fifty-three papers were included for a systematic review and meta-analysis. Most frequent studied drug is olanzapine. Changes on PANNS-EC and ACES at 2 h showed the strongest changes for haloperidol plus promethazine, risperidon, olanzapine, droperidol and aripiprazole. However, incomplete data showed that the effect of risperidon is overestimated. Adverse effects are most prominent for haloperidol and haloperidol plus lorazepam.

Conclusion:

Olanzapine, haloperidol plus promethazine or droperidol are most effective and safe for use as rapid tranquilisation. Midazolam sedates most quickly. But due to increased saturation problems, midazolam is restricted to use within an emergency department of a general hospital.

Characteristics of Involuntarily Admitted Patients and Treatment Patterns Over a 21-Year Observation Period

BACKGROUND

Patients suffering from psychiatric disorders are often treated in locked psychiatric units owing to psychomotor agitation, hostility and aggressive behavior, or suicidality. Because of legal conditions, investigations of these acutely ill patients are difficult, and many studies do not represent real-life psychiatry. In Austria, admission to a locked psychiatric unit is regulated by a national law for involuntary admission, which came into effect in 1991. The current retrospective study investigated the management of patients who were admitted involuntarily to an academic treatment center after the inauguration of this law.

METHODS

Data collection comprised all admissions to a locked unit at the Department of Psychiatry, Psychotherapy and Psychosomatics of the Medical University Innsbruck in the years 1992, 1997, 2002, 2007, and 2012. Demographics, admission diagnosis, current danger posed to self or others, and the initial psychopharmacological intervention were assessed.

RESULTS

The rate of admissions to a locked unit increased significantly throughout the course of the study, and the length of stay decreased from 8.57 days in 1997 to 6.43 days in 2012. Most patients received medication orally. Dosage of antipsychotics and benzodiazepines decreased throughout the investigation period. Self-endangering patients were treated with somewhat (nonsignificantly) higher benzodiazepine and significantly lower antipsychotic mean doses than patients posing danger to others.

CONCLUSIONS

Although dosage of medication was reduced, the duration of stay in a locked unit decreased significantly over the investigated years. These findings suggest that a carefully considered pharmacological treatment may be at least as effective as a more aggressive approach.

Management of acute agitation in psychosis: an evidence-based approach in the USA

Agitation in psychiatric settings, particularly in psychosis, presents a staggering challenge for clinicians, who must both manage the patient's acute symptoms and simultaneously make an accurate diagnosis. Too often, the management of the former confounds the latter. Patients are very often sedated medically, which masks their underlying condition, rendering accurate diagnosis delayed and inherently difficult. Significant data are available regarding both pharmacological and non-pharmacological interventions for agitation that maximise symptom control while minimising confounding side-effects. In this article, a review of the historical evolution of agitation management in psychotic illness is presented, followed by an evidence-based clinical guideline for managing agitation in psychosis in the USA.

Treatment of agitation in the acute psychiatric setting. An observational study of the effectiveness of intramuscular psychotropic medication

BACKGROUND

Agitation is frequent in the acute psychiatric setting. The observation and treatment of agitation is important to avoid harm to patients or staff, to reduce distress of the patient, and to reduce the risk of coercion, especially physical restraint.

AIM

To evaluate the effect of intramuscular treatment with psychotropics on agitation in a non-selected acute psychiatric population.

METHODS

The Positive and Negative Syndrome Scale Excitement Component (PANSS-EC) was implemented in the acute psychiatric ward at Psychiatric Center Copenhagen to improve assessment and treatment of agitation. During a period of almost ~2 years the staff was requested to assess agitation before and after administration of intramuscular injections.

RESULTS

PANSS-EC was obtained at baseline and within 2 hours after injection for 135 injections with antipsychotics or benzodiazepines administered to 101 acute, non-selected psychiatric patients with high occurrence of co-morbid substance abuse. Mean PANSS-EC at baseline was 26.53 ± 4.87, and mean reduction in PANSS-EC was 14.99 ± 8.48 (p < 0.001). For 73% of injections PANSS-EC decreased with ≥40% (generally accepted definition of response). In 49% of cases patients were subjected to physical restraint. Patients subjected to restraint had a significantly higher PANSS-EC score. Patients who received a subsequent injection had a significantly lower decline in PANSS-EC score. Besides two cases of acute dystonia following haloperidol injections, no serious side-effects were observed.

CONCLUSIONS

Treatment of agitation with intramuscular injections of psychotropics was in general effective in this non-selected, highly agitated psychiatric population, and injections were well tolerated.

Assessment and management of agitation in psychiatry: Expert consensus

BACKGROUND

Psychomotor agitation is associated with different psychiatric conditions and represents an important issue in psychiatry. Current recommendations on agitation in psychiatry are not univocal. Actually, an improper assessment and management may result in unnecessary coercive or sedative treatments. A thorough and balanced review plus an expert consensus can guide assessment and treatment decisions.

METHODS

An expert task force iteratively developed consensus using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new, re-worded or re-rated items.

RESULTS

Out of 2175 papers assessing psychomotor agitation, 124 were included in the review. Each component was assigned a level of evidence. Integrating the evidence and the experience of the task force members, a consensus was reached on 22 statements on this topic.

CONCLUSIONS

Recommendations on the assessment of agitation emphasise the importance of identifying any possible medical cause. For its management, experts agreed in considering verbal de-escalation and environmental modification techniques as first choice, considering physical restraint as a last resort strategy. Regarding pharmacological treatment, the "ideal" medication should calm without over-sedate. Generally, oral or inhaled formulations should be preferred over i.m. routes in mildly agitated patients. Intravenous treatments should be avoided.

Gender-specific research on mental illness in the emergency department: current knowledge and future directions

Mental illness is a growing, and largely unaddressed, problem for the population and for emergency department (ED) patients in particular. Extensive literature outlines sex and gender differences in mental illness' epidemiology and risk and protective factors. Few studies, however, examined sex and gender differences in screening, diagnosis, and management of mental illness in the ED setting. Our consensus group used the nominal group technique to outline major gaps in knowledge and research priorities for these areas, including the influence of violence and other risk factors on the course of mental illness for ED patients. Our consensus group urges the pursuit of this research in general and conscious use of a gender lens when conducting, analyzing, and authoring future ED-based investigations of mental illness.

QT Interval Prolongation Associated with Intramuscular Ziprasidone in Chinese Patients: A Case Report and a Comprehensive Literature Review with Meta-Analysis

Intramuscular (IM) ziprasidone has been associated with QTc interval prolongations in patients with preexisting risk factors. A 23-year-old male Chinese schizophrenia patient experienced an increase of QTc interval of 83 milliseconds (ms) after receiving 20 mg IM ziprasidone (baseline and increased QT/QTc were, respectively, 384/418 and 450/501). This was rated as a probable adverse drug reaction (ADR) by the Liverpool ADR causality assessment tool. A systematic review including all types of trials reporting the effect of IM ziprasidone on the QTc interval prolongation identified 19 trials with a total of 1428 patients. Mean QTc change from baseline to end of each study was −3.7 to 12.8 ms after IM ziprasidone. Four randomized trials (3 of 4 published in Chinese) were used to calculate a meta-analysis of QTc interval prolongation which showed no significant differences between IM ziprasidone and IM haloperidol groups (risk ratio 0.49 to 4.31, 95% confidence interval 0.09 to 19.68, P = 0.06 to 0.41). However, our review included two cases of patients who experienced symptoms probably related to QTc prolongation after IM ziprasidone. Thus, careful screening and close monitoring, including baseline ECG, should be considered in patients receiving IM ziprasidone for the first time.

QTc interval prolongation and torsade de pointes associated with second-generation antipsychotics and antidepressants: a comprehensive review

We comprehensively reviewed published literature to determine whether it supported the link between corrected QT (QTc) interval prolongation and torsade de pointes (TdP) for the 11 second-generation antipsychotics and seven second-generation antidepressants commonly implicated in these complications. Using PubMed and EMBASE, we identified four thorough QT studies (one each for iloperidone, ziprasidone, citalopram, and escitalopram), 40 studies specifically designed to assess QTc interval prolongation or TdP, 58 publications based on data from efficacy and safety trials, 18 toxicology studies, and 102 case reports. Thorough QT studies, QTc prolongation-specific studies, and studies based on efficacy and safety trials did not link drug-associated QTc interval prolongation with TdP. They only showed that the drugs reviewed caused varying degrees of QTc interval prolongation, and even that information was not clear and consistent enough to stratify individual drugs for this risk. The few toxicology studies provided valuable information but their findings are pertinent only to situations of drug overdose. Case reports were most informative about the drug-QTc interval prolongation-TdP link. At least one additional well established risk factor for QTc prolongation was present in 92.2 % of case reports. Of the 28 cases of TdP, six (21.4 %) experienced it with QTc interval <500 ms; 75 % of TdP cases occurred at therapeutic doses. There is little evidence that drug-associated QTc interval prolongation by itself is sufficient to predict TdP. Future research needs to improve its precision and broaden its scope to better understand the factors that facilitate or attenuate progression of drug-associated QTc interval prolongation to TdP.

The comparative efficacy of intramuscular antipsychotics for the management of acute agitation

OBJECTIVE

To review the current role and comparative efficacy of short-acting intramuscular (IM) antipsychotics in the management of acute agitation, in current clinical practice.

METHOD

The efficacy and tolerability of IM antipsychotics in the management of acute agitation in current clinical practice were reviewed in the Medline, PubMed, Cinahl Plus, Scopus-v.4 and PsycInfo databases.

RESULTS

The comparative efficacy of the rapidly-acting IM atypical antipsychotics (olanzapine, ziprasidone and aripiprazole) is similar to that of the typical antipsychotic, haloperidol. IM olanzapine and ziprasidone were associated with fewer extrapyramidal side-effects and had similar cardiac tolerability to IM haloperidol.

CONCLUSIONS

Further studies are required in the ongoing development of contemporary, evidence-based clinical guidelines in acute agitation, including head-to-head comparisons of currently utilized IM atypical antipsychotics, sequential treatment or combinations of medications.

Pharmacological management of acute and persistent aggression in forensic psychiatry settings

Aggressive behaviour is common in forensic psychiatric settings. The aetiology of aggressive behaviour is multifactorial and can be driven by psychosis, impulsivity, psychopathy, intoxication, cognitive impairment, or a combination of all of these. Recognition of the different factors behind the aggression can inform medication selection and the relative need for specific environmental and behavioural interventions in a forensic psychiatric setting. Acute agitation needs to be managed quickly and effectively before further escalation of the behavioural dyscontrol occurs. Benzodiazepines and/or antipsychotic medications are often used and can be given intramuscularly to achieve a rapid onset of action. Available are intramuscular preparations of second-generation antipsychotics that have similar efficacy to lorazepam and haloperidol in reducing agitation, but are well tolerated and not associated with the extrapyramidal adverse effects, including akathisia, that can plague the older first-generation antipsychotics. The longer-term management of persistent aggressive behaviour can be quite complex. A major obstacle is that the causality of aggressive events can differ from patient to patient, and also from event to event in the same patient. For patients with schizophrenia and persistent aggressive behaviour, clozapine is recommended both for its superior antipsychotic effect and its specific anti-hostility effect. Mood stabilizers such as valproate may be helpful in instances of poor impulsivity and personality disorders. Other agents that have been successfully used include β-adrenoceptor antagonists (β-blockers) and antidepressants.

Psychopharmacology of aggression in schizophrenia

The management of aggression in patients with schizophrenia is a complex and challenging clinical dilemma. It also is greatly influenced by prevailing societal and medicolegal considerations regarding the perceived associations between violence and mental illness. This article provides a succinct account of a complex area and offers evidence for available treatments to reduce the occurrence of violent behavior among patients with schizophrenia.

Ziprasidone hydrocloride: what role in the management of schizophrenia?

Background

Since schizophrenia is considered one of the top ten causes of disease-related disability in the world, the development of second-generation (atypical) antipsychotics (SGAs) has increased the hopes of psychiatrists. SGAs, however, cannot be considered a unique pharmacological class since each SGA has many complex pharmacologic actions, only some of which are shared with other SGAs. Even though manyantipsychotics have similar efficacy on average, prescribers may be able to achieve better than average results by considering differences in selecting a specific drug for a specific patient. Clinicians know that each patient is unique. In order to achieve best outcomes for the individual patient, the better therapy is the therapy tailored for the single patient.

Objectives

With this article, we provide information on a relatively new antipsychotic ziprasidone released in 2001 by Pfizer for the treatment of schizophrenia. Compared with other first line atypical antipsychotics ziprasidone has a unique profile due to potent interaction with serotonergic receptors and lesser action upon α1 adrenergic, H1 and M1 antagonist activities. This paper describes the development of ziprasidone, its unique properties and its metabolically-friendly profile including its receptor binding affinities, pharmacokinetics, CNS activity results of clinical efficacy and relevant clinical trials. Safety, efficacy and patient preference are also examined. The available literature on ziprasidone of the last five years is reviewed.

Intramuscular olanzapine versus short-acting typical intramuscular antipsychotics: comparison of real-life effectiveness in the treatment of agitation

OBJECTIVE

To compare the effectiveness of intramuscular (IM) olanzapine and typical IM antipsychotics in naturalistically treated acutely agitated patients with schizophrenia or acute mania.

METHODS

During the acute phase, 2011 inpatients (including emergency settings) were assessed at 2, 24 and 72 h, and 7 days following initial injection and on oral antipsychotic transition. Mean change in agitation was assessed via Positive and Negative Symptom Scale-Excited Component (PANSS-EC) and Clinical Global Impressions-Severity (CGI-S) scores. Response (> or = 40% reduction in baseline PANSS-EC score) was analysed using logistic regression.

RESULTS

Significantly greater decreases in PANSS-EC and CGI-S scores were observed in patients receiving IM olanzapine (n = 1294) as their first injection compared with patients receiving other IM antipsychotics (n = 717) (P<0.05; 2 h: effect size 0.1); IM haloperidol treatment (all assessments, P<0.05); and IM zuclopenthixol treatment (2 h, P<0.001). Higher response rates were observed with IM olanzapine compared with other IM antipsychotics at 24 and 72 h, and 7 days (P<0.05). IM olanzapine was associated with fewer extrapyramidal side effects compared with other assessed IM antipsychotics.

CONCLUSIONS

IM olanzapine provided somewhat more effective control of acute agitation than other assessed IM antipsychotics.

Conventional intramuscular sedatives versus ziprasidone for severe agitation in adolescents: case-control study

OBJECTIVE

The objective of this study was to compare intramuscular (IM) ziprasidone to conventional IM medications (haloperidol combined with lorazepam) for the treatment of severe agitation in adolescents (age 12-17).

METHODS

We retrospectively identified consecutive severe agitation episodes (defined as requiring physical restraint) in adolescents treated with either IM ziprasidone or conventional IM agents in a psychiatric emergency room. For ziprasidone, the dosage was 20 mg for 23 episodes and 10 mg for 5 episodes. For 24 episodes treated with combined haloperidol and lorazepam, the dosages were 4.8 +/- 0.3 SEM mg and 1.9 +/- 0.4 mg respectively. Outcomes were the duration of restraint and need for adjunctive "rescue" medications within 60 minutes. These outcomes were decided prior to reviewing any records.

RESULTS

No difference was found in restraint duration (ziprasidone, N = 28, 55 +/- 5 minutes; haloperidol with lorazepam N = 24, 65 +/- 7 minutes, P = NS). Use of "rescue" medications did not differ between the two groups. No changes in blood pressure were found, but pulse decreased 8.3 +/- 2.4 for haloperidol with lorazepam and 8.9 +/- 4.24 for ziprasidone (P = NS). No instances of excessive sedation or extra-pyramidal symptoms were documented.

CONCLUSION

In this study, IM ziprasidone appeared effective, well tolerated, and similar in clinical profile to combined conventional IM medications for treating severe agitation in adolescents. Given the reportedly favorable acute side effect profile of parenteral atypical agents, they may provide an alternative to conventional antipsychotics for treating acute agitation in both adult and adolescent populations. Future randomized, controlled studies are needed.

A meta-analysis of the risk of acute extrapyramidal symptoms with intramuscular antipsychotics for the treatment of agitation

OBJECTIVE

We examined the evidence for a decreased risk of extrapyramidal symptoms (EPS) with intramuscular second-generation antipsychotics (SGAs) versus intramuscular haloperidol alone or in combination with an anticholinergic agent.

DATA SOURCES

We searched MEDLINE (1950 to the present), and EMBASE and the Cochrane Database through January 16, 2008, for studies published in English of intramuscular SGAs and intramuscular haloperidol alone or in combination with an anticholinergic agent using the following drug names: ziprasidone, Geodon, olanzapine, Zyprexa, aripiprazole, Abilify, haloperidol, and Haldol. We then searched this pool of studies for trials with the terms intramuscular, IM, or injectable. Initially, we included only randomized controlled trials (RCTs). To obtain more data comparing SGAs to the combination of haloperidol and an anticholinergic, we conducted a second analysis including studies of any methodology.

STUDY SELECTION

Seven RCTs that compared intramuscular SGAs to intramuscular haloperidol alone were identified. However, we found only one RCT of haloperidol plus an anticholinergic. In the second analysis, we identified 18 studies, including 4 using haloperidol combined with promethazine (an antihistamine with anticholinergic properties).

DATA EXTRACTION

The primary outcome measure was acute dystonia; secondary outcome measures included akathisia, parkinsonism, or the need for additional anticholinergic medication. For RCTs, risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for each outcome. When all studies were included in the second analysis, we calculated the risk of acute dystonia.

DATA SYNTHESIS

Among RCTs (N = 2032), SGAs were associated with a significantly lower risk of acute dystonia (RR = 0.19, 95% CI = 0.10 to 0.39), akathisia (RR = 0.25, 95% CI = 0.14 to 0.44), and anticholinergic use (RR = 0.19, 95% CI = 0.09 to 0.43) compared with haloperidol alone. When all trials were considered (N = 3425), rates of acute dystonia were higher for haloperidol alone (4.7%) than for SGAs (0.6%) or for haloperidol plus promethazine (0.0%).

CONCLUSIONS

Intramuscular SGAs have a significantly lower risk of acute EPS compared to haloperidol alone. However, intramuscular haloperidol plus promethazine has a risk of acute dystonia comparable to intramuscular SGAs. The decision to use SGAs should consider other factors in addition to the reduction of EPS, which can be prevented by the use of an anticholinergic agent.

Pharmacological control of acute agitation: focus on intramuscular preparations

Acute agitation in the psychiatric emergency setting is a common presentation, which can endanger the patient, caregivers and professional staff. Rapid and effective treatment, followed by ongoing evaluation and maintenance treatment where appropriate, is key to circumvent negative outcomes. Nonpharmacological measures are the first step in treating the acutely agitated patient, and include verbal intervention and physical restraint. Pharmacological treatment is often required to ensure the safety of the patient, caregivers and the treatment team. The need for drug delivery in uncooperative patients favours the use of intramuscular preparations for the acutely agitated patient. Intramuscular treatment options include benzodiazepines, conventional antipsychotics and atypical antipsychotics. Each of these medications offers a unique pharmacological profile that must be considered when treating acutely agitated patients, who may be unwilling or unable to accurately communicate their co-morbid conditions and concomitant medications.

Ziprasidone in the treatment of mania in bipolar disorder

Ziprasidone is an atypical antipsychotic with a unique receptor-binding profile. Currently, ziprasidone is approved by the US Food and Drug Administration for the acute treatment of psychosis in schizophrenia and mania in bipolar disorder. When compared to certain other atypical antipsychotics, ziprasidone appears to have a relatively benign side effect profile, especially as regards metabolic effects eg, weight gain, serum lipid elevations and glucose dysregulation. Taken together, these data suggest that ziprasidone may be a first line treatment for patients with bipolar mania. However, ziprasidone is a relatively new medication for which adverse events after long-term use and/or in vulnerable patient populations must be studied. Unstudied areas of particular importance include the efficacy and safety of ziprasidone in the treatment of bipolar depression and relapse prevention of mania as, well as in the subpopulations of pregnant women, the elderly and pediatric patients. The emergence of mania in patients taking ziprasidone is another topic for further study.

Managing the acutely agitated and psychotic patient

Agitation can present as an emergency in the course of numerous psychiatric conditions including intoxication, schizophrenia, bipolar disorder, and delirium. This article reviews relevant literature regarding the definition, etiology, measurement, and management of episodic agitation and pays particular attention to intramuscular treatments. The impact of changes in methodology between the era of first- and second-generation antipsychotics, the implications of those changes for external validity of studies of second-generation studies, and the recent evolution of expert consensus are discussed.

An observational study of the effectiveness and safety of intramuscular olanzapine in the treatment of acute agitation in patients with bipolar mania or schizophrenia/schizoaffective disorder

OBJECTIVE

To determine the effect of intramuscular (IM) olanzapine in severely agitated patients.

METHODS

This was an open-label multicenter 1-week observational study of IM olanzapine treatment in severely agitated inpatients and psychiatric emergency services with bipolar mania (n = 22) or schizophrenia (n = 52). Mean change from baseline to 2 h post-first injection (LOCF) in agitation was assessed by PANSS-Excited Component (PANSS-EC) (score range: 5-35 points) mean change from baseline to 15, 30, 45, 60, 90, and 120 min post-first injection, and visit-wise mean changes from mixed-model repeated measures analysis of variance. Kaplan-Meier survival curve analyses estimated time to categorical response (rating of <or=3 points each PANSS-EC item).

RESULTS

Two hours post-injection of olanzapine (mean dose = 9.9 mg), patients exhibited mild calmness and agitation was significantly reduced by 19.2 +/- 1.0 points (p < 0.001) (mean baseline = 29.0). Over 90% of the patients received only one injection in the first 24 h and 50% had a categorical response within 30 min.

CONCLUSIONS

Severely agitated patients responded rapidly after a single injection of olanzapine with mild levels of sedation and without serious treatment-emergent adverse events.

Ziprasidone for schizophrenia and bipolar disorder: a review of the clinical trials

Ziprasidone is a newer "atypical" or "second-generation" antipsychotic. Oral ziprasidone (ziprasidone hydrochloride) is approved by the U.S. Food and Drug Administration (FDA) for the treatment of schizophrenia, and acute manic or mixed episodes associated with bipolar disorder (with or without psychotic features). Ziprasidone intramuscular (ziprasidone mesylate) is FDA-approved for acute agitation in patients with schizophrenia. Oral ziprasidone appears efficacious, and has been shown to have some limited clinical advantages over chlorpromazine and haloperidol in ameliorating negative symptoms of schizophrenia. In Phase 2 of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) for schizophrenia, ziprasidone did not match the clinical performance of olanzapine and risperidone, appearing closer in overall effectiveness to quetiapine. The rate of dose titration and the dose achieved may have an important bearing on ziprasidone's efficacy profile. In studies of usage for acute agitation in individuals with schizophrenia, intramuscular ziprasidone has been shown to be efficacious and relatively well tolerated. Regarding tolerability, ziprasidone, has important advantages in that it is not associated with clinically significant weight gain or adverse changes in cholesterol, triglycerides, or glycemic control, and patients may experience moderate improvement in these measures when switching to ziprasidone from a different antipsychotic agent. It also lacks significant persistent effects on prolactin levels, is not anticholinergic, and only infrequently causes extrapyramidal side effects or postural hypotension, although it can be associated with somnolence. This tolerability profile may be quite valuable in the treatment of some patients. Ziprasidone may prolong the electrocardiogram (ECG) QTc interval (QT interval corrected for heart rate by a standard algorithm), but after 5 years' clinical availability ziprasidone (by itself) does not appear to pose a substantial clinical problem in this regard. Therefore, ziprasidone may be considered a first-line drug option in the treatment of schizophrenia or manic episodes, but, in view of the differences among antipsychotic medications, drug selection should be guided by the patient's individual characteristics and situation.

Cost-effectiveness analysis of ziprasidone versus haloperidol in sequential intramuscular/oral treatment of exacerbation of schizophrenia: economic subanalysis of the ZIMO trial

OBJECTIVE

This study aimed to assess the cost effectiveness of ziprasidone versus haloperidol in sequential intramuscular (IM)/oral treatment of patients with exacerbation of schizophrenia in Spain.

METHODS

A cost-effectiveness analysis from the hospital perspective was performed. Length of stay, study medication and use of concomitant drugs were calculated using data from the ZIMO trial. The effectiveness of treatment was determined by the percentage of responders (reduction in baseline Brief Psychiatric Rating Scale [BPRS] negative symptoms subscale >or=30%). Economic assessment included estimation of mean (95% CI) total costs, cost per responder and the incremental cost-effectiveness ratio (ICER) per additional responder. The economic uncertainty level was controlled by resampling and calculation of cost-effectiveness acceptability curves.

RESULTS

A total of 325 patients (ziprasidone n = 255, haloperidol n = 70) were included in this economic subanalysis. Ziprasidone showed a significantly higher responder rate compared with haloperidol (71% vs 56%, respectively; p = 0.023). Mean total costs were euro3582 (95% CI 3226, 3937) for ziprasidone and euro2953 (95% CI 2471, 3436) for haloperidol (p = 0.039), mainly due to a higher ziprasidone acquisition cost. However, costs per responder were lower with ziprasidone (euro5045 [95% CI 4211, 6020]) than with haloperidol (euro5302 [95% CI 3666, 7791], with a cost per additional responder (ICER) for ziprasidone of euro4095 (95% CI -130, 22 231). The acceptability curve showed an ICER cut-off value of euro13 891 at the 95% cost-effectiveness probability level for >or=30% reduction in BPRS negative symptoms.

CONCLUSIONS

Compared with haloperidol, ziprasidone was significantly better at controlling psychotic negative symptoms in acute psychoses. The extra cost of ziprasidone was offset by a higher effectiveness rate, yielding a lower cost per responder. In light of the social benefit (less family burden and greater restoration of productivity), the incremental cost per additional responder with sequential IM/oral ziprasidone should be considered cost effective in patients with exacerbation of schizophrenia in Spain.

Intramuscular aripiprazole in the control of agitation

OBJECTIVE

To evaluate response to intramuscular (IM) aripiprazole injections using secondary analyses from clinical trials.

METHODS

Data from one trial in patients with bipolar I disorder and two trials in patients with schizophrenia were assembled and used for three secondary analyses. Analysis 1 looked at data from "nonsedated" patients (i.e., patients with scores < 8 [deep sleep] or 9 [unarousable] on the Agitation-Calmness Evaluation Scale [ACES]). In analysis 2, patients were subdivided into "higher" and "lower" agitation groups according to a median split on the baseline score for the Positive and Negative Syndrome Scale (PANSS) Excited Component (PEC) (median = 18). Analysis 3 looked at the patients who received a second injection within the 24-hour study period. In each analysis, the mean change from baseline in PEC scores was re-evaluated.

RESULTS

Analysis 1 found that nonsedated patients with bipolar I disorder and schizophrenia showed significant decreases in PEC scores following treatment with aripiprazole IM (p < 0.005). Analysis 2 found that aripiprazole IM significantly reduced agitation compared with placebo in patients with bipolar I disorder who had lower baseline agitation (p < 0.01), while patients with bipolar I disorder who had higher baseline agitation showed similarly large PEC decreases with aripiprazole (-9.9) and placebo (-7.9). Patients with schizophrenia showed significant reductions in PEC scores compared with placebo regardless of baseline level of agitation (p < 0.01). Analysis 3 found that a second injection of aripiprazole IM significantly reduced agitation in patients with bipolar I disorder or schizophrenia (p < 0.05); repeated injections were safe and well tolerated.

CONCLUSION

Improvements with aripiprazole IM appeared to be specific to core agitation symptoms, as opposed to nonspecific sedation, and to be independent of baseline level of agitation. Furthermore, patients benefited from a repeated aripiprazole injection when clinically warranted. These results address important clinical issues regarding use of aripiprazole IM in treating agitation.

Intramuscular olanzapine in patients with borderline personality disorder: an observational study in an emergency room

OBJECTIVE

Despite the frequency of borderline personality disorder (BPD) in patients with acute agitation in emergency departments (EDs), there are few data about the use of intramuscular (IM) psychotropics in those patients. This is the first open-label study with olanzapine in this setting.

METHOD

Measures were collected prospectively for patients with acute agitation in ED. Consent was obtained subsequently and diagnosis ascertained using the Structured Clinical Interview for DSM-IV. A group of 25 patients with severe agitation and BPD received olanzapine 10 mg IM. Efficacy and safety data are available at baseline, 2 h postinjection and at discharge.

RESULTS

Significant reductions of agitation associated with good tolerance were observed 2 h after the first IM olanzapine. Sixteen percent of patients required a second IM olanzapine.

CONCLUSIONS

Randomized, placebo-controlled studies are needed to confirm the efficacy of IM olanzapine in patients with acute agitation and BPD.

Management of acutely ill patients in the hospital setting: focus on quetiapine

We have considered published work and clinical experience focusing on the atypical antipsychotic quetiapine in order to form a consensus on the most appropriate treatment strategies for hospitalised patients with acute schizophrenia or bipolar disorder. It is important to consider the specific treatment needs of these patients and these are discussed in the context of current treatment guidelines. We will review the efficacy and tolerability of atypical antipsychotics versus conventional antipsychotics and/or benzodiazepines as a first-line treatment, and examine the suitability of oral versus intramuscular formulations in the acute setting. The potentially beneficial properties of specific atypical agents are also considered. Appropriate dosing is particularly important in acutely ill patients as it can help achieve rapid improvement. We will discuss emerging data which show that rapid initiation of quetiapine in patients with acute psychosis or mania is not only as effective as standard initiation, but is also well tolerated. This may be important for treatment in the long term as a positive initial treatment experience can determine patient compliance and treatment adherence. In conclusion, this review recommends that oral atypical antipsychotics should be a first-choice medication for acutely ill cooperative patients in the hospital setting.

A pilot, open-label safety study of quetiapine for treatment of moderate psychotic agitation in the emergency setting

OBJECTIVE

The goal of this pilot study was primarily to explore the safety and, secondarily, the efficacy of the use of "prn" quetiapine for treatment of moderate agitation accompanied by psychosis in an emergency department setting.

METHODS

This was an open-label study in which 20 patients with psychotic agitation were treated in the emergency department with 100, 150, or 200 mg of quetiapine. Physicians who were unaffiliated with the study established the diagnoses and selected the doses to be used for each patient. A rater who was blinded to the dose performed the assessments. The primary safety measure was the onset of orthostatic hypotension. The primary efficacy measure was a 40% reduction in scores on the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) over 120 minutes. The secondary efficacy measure was a reduction of 2 points or more on the Behavioral Activity Rating Scale (BARS) at 120 minutes post-dose. All subjects provided written informed consent.

RESULTS

With regard to safety outcomes, 40% of subjects exhibited orthostasis by 120 minutes, although only 25% of these patients described clinically significant symptoms. In terms of efficacy, 50% of subjects experienced at least a 40% reduction in PANSS-EC scores at 2 hours, while 68.8% showed reductions of 2 points or more in scores on the BARS over the same time period.

CONCLUSION

Quetiapine demonstrated some efficacy as a sedative agent in the emergency setting, although no clear dose-response pattern emerged over the narrow dose range tested. Orthostasis was common and did not correlate with dosing. This small study did not support the use of quetiapine to treat acute agitation in potentially volume-depleted patients.

Intramuscular ziprasidone treatment of acute psychotic agitation in elderly patients with schizophrenia

OBJECTIVE

Intramuscular (i.m.) ziprasidone treatment has been shown to be effective and well tolerated in reducing the symptoms of acute psychosis in adults. Few data are available as to safety in the elderly. The growing utilization of health services by elderly psychiatric patients warrants an evaluation in this population.

METHOD

Consecutive elderly patients (60 years of and older) admitted to a psychogeriatric ward in a large, university-affiliated tertiary psychiatric center were treated by i.m. ziprasidone for acute psychotic agitation. Patients received three days of flexible-dose i.m. ziprasidone. After an initial dose of 10-20 mg, a subsequent dose of 10-20 mg could be given after 12 hours if needed (maximum daily dose: 40 mg).

RESULTS

All treatment emergent side effects and adverse events along with the investigators' assessments of severity were systematically recorded as the primary outcome. The Brief Psychiatric Rating Scale (BPRS) and the Behavioral Activity Rating Scale (BARS) were the secondary outcomes. Twenty-one patients, six male and 15 female, mean age 71.4 +/- 1.3 years (range: 60-81 years) were enrolled. All had completed the three days i.m. ziprasidone treatment. There was one adverse event in a patient with untreated benign prostatic hypertrophy who developed urinary retention. Two side effects of mild severity that resolved spontaneously were observed: blurred vision and sedation. The BPRS decreased by 26.8 points after three days of treatment (p = 0.001). The BARS score, reflecting agitation, decreased significantly after each injection, reaching maximal decrease of 2.14 points at completion of study (p = 0.001).

CONCLUSION

Intramuscular ziprasidone in this series of elderly patients suggests acceptable safety and efficacy in the management of acute psychotic agitation among elderly patients with schizophrenia.

The expert consensus guideline series. Treatment of behavioral emergencies 2005

OBJECTIVES

Due to inherent dangers and barriers to research in emergency settings, few data are available to guide clinicians about how best to manage behavioral emergencies. Key constructs such as agitation are poorly defined. This lack of empirical data led us to undertake a survey of expert opinion, results of which were published in the 2001 Expert Consensus Guidelines on the Treatment of Behavioral Emergencies. Several second-generation (atypical) antipsychotics (SGAs) are now available in new formulations for treating behavioral emergencies (e.g., intramuscular [i.m.] olanzapine and ziprasidone; rapidly dissolving tablets of olanzapine and risperidone). Critical questions face the field. The SGAs are significantly different from the FGAs and from each other and have not been studied in unselected patients as were the FGAs. Can the SGAs can be thought of as a class, do all antipsychotics have similar anti-agitation effects in different conditions, and, if equally effective, what limits might their safety profiles impose? Should antipsychotics be used more specifically to treat psychotic conditions, while benzodiazepines (BNZs) alone are used nonspecifically? Few data are available concerning combinations of SGAs and BNZs, and findings concerning the traditional combination of haloperidol plus a BNZ may not be relevant to combinations with SGAs. The culture is also evolving with more emphasis on patient involvement in treatment decisions. An international consensus has been developing that calming rather than sedation is the appropriate endpoint of behavioral emergency interventions. We undertook a new survey of expert opinion to update recommendations from the earlier survey.

METHOD

A written survey of 61 questions (1,020 options) was mailed to 50 experts in the field, 48 (96%) of whom completed it. The survey sought to define level of agitation at which emergency interventions are appropriate, scope of assessment depending on urgency and patients' ability to cooperate, guiding principles for selecting interventions, and appropriate physical and medication strategies at different levels of diagnostic confidence for a variety of provisional diagnoses and complicating conditions. A modified version of the RAND Corporation's 9-point scale for rating appropriateness of medical decisions was used to score most options. Consensus was defined as a non-random distribution of scores by chi-square "goodness-of-fit" test. We assigned a categorical rank (first line/preferred, second line/alternate, third line/usually inappropriate) to each option based on the 95% confidence interval around the mean. Ratings were used to develop guidelines for preferred strategies in key clinical situations. This study received financial support from multiple sponsors, with the panel kept blind to sponsorship to reduce possible bias. Medication ratings were based on responses of only those respondents with direct experience with each drug. In reporting practice patterns, the panel was asked to respond based on actual data rather than estimates.

RESULTS

The expert panel reached consensus on 78% of the options rated on the 9-point scale. The responses suggest that physicians can make provisional diagnoses with some confidence and that pharmacological and nonpharmacological interventions are selected differentially based on diagnosis and other salient demographic and medical features. BNZs are recommended when no data are available, when there is no specific treatment (e.g., personality disorder), or when they may have specific benefits (e.g., intoxication). No single SGA emerges as a nonspecific replacement for haloperidol; instead, different SGAs are preferred in various circumstances consistent with current evidence. To the degree that haloperidol is recommended, it is almost always in combination with a BNZ; haloperidol alone is preferred only in the medically compromised. In contrast, the SGAs are more often recommended for use alone, and the panel would avoid combining BNZs with some SGAs. Oral risperidone alone or combined with a BNZ receives strong support in a variety of situations. Oral olanzapine was rated very similarly to risperidone, with slightly higher ratings than risperidone in situations where it has been studied (e.g., schizophrenia, mania) and slightly lower ratings where it has not been studied or safety may be a concern; there was less support for combining oral olanzapine with a BNZ. For oral treatment of agitation related to schizophrenia or mania, olanzapine alone, risperidone alone or combined with a BNZ, and haloperidol plus a BNZ are first line, with strong support also for combining divalproex with the antipsychotic for presumed mania. Oral ziprasidone and quetiapine generally received similar second-line ratings in most situations. If a parenteral agent is needed, i.m. olanzapine alone received somewhat more support than i.m. ziprasidone alone; however, there was more support for i.m. ziprasidone alone or combined with a BNZ than for i.m. olanzapine plus a BNZ, probably reflecting safety concerns. For example, for a provisional diagnosis of schizophrenia, first-line parenteral options are i.m. olanzapine or ziprasidone alone or i.m. haloperidol or ziprasidone combined with a BNZ. Neither of the new parenteral formulations received as much support as traditional agents (i.m. BNZs, i.m. haloperidol) when no data are available or the diagnosis involves medical comorbidity or intoxication. When initial intervention with risperidone, ziprasidone, or haloperidol is unsuccessful, the panel recommended adding a BZD to the antipsychotic. However, when initial treatment with olanzapine or quetiapine is unsuccessful, increasing the dosage is recommended. Perphenazine was consistently rated second line and droperidol and chlorpromazine received third-line ratings throughout.

CONCLUSIONS

Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines suggest that the SGAs are now preferred for agitation in the setting of primary psychiatric illnesses but that BNZs are preferred in other situations.

Pharmacological management of acute agitation

Acute agitation occurs in a variety of medical and psychiatric conditions, and when severe can result in behavioural dyscontrol. Rapid tranquillisation is the assertive use of medication to calm severely agitated patients quickly, decrease dangerous behaviour and allow treatment of the underlying condition. Intramuscular injections of typical antipsychotics and benzodiazepines, given alone or in combination, have been the treatment of choice over the past few decades. Haloperidol and lorazepam are the most widely used agents for acute agitation, are effective in a wide diagnostic arena and can be used in medically compromised patients. Haloperidol can cause significant extrapyramidal symptoms, and has rarely been associated with cardiac arrhythmia and sudden death. Lorazepam can cause ataxia, sedation and has additive effects with other CNS depressant drugs.Recently, two fast-acting preparations of atypical antipsychotics, intramuscular ziprasidone and intramuscular olanzapine, have been developed for treatment of acute agitation. Intramuscular ziprasidone has shown significant calming effects emerging 30 minutes after administration for acutely agitated patients with schizophrenia and other nonspecific psychotic conditions. Intramuscular ziprasidone is well tolerated and has gained widespread use in psychiatric emergency services since its introduction in 2002. In comparison with other atypical antipsychotics, ziprasidone has a relatively greater propensity to increase the corrected QT (QTc) interval and, therefore, should not be used in patients with known QTc interval-associated conditions. Intramuscular olanzapine has shown faster onset of action, greater efficacy and fewer adverse effects than haloperidol or lorazepam in the treatment of acute agitation associated with schizophrenia, schizoaffective disorder, bipolar mania and dementia. Intramuscular olanzapine has been shown to have distinct calming versus nonspecific sedative effects. The recent reports of adverse events (including eight fatalities) associated with intramuscular olanzapine underscores the need to follow strict prescribing guidelines and avoid simultaneous use with other CNS depressants. Both intramuscular ziprasidone and intramuscular olanzapine have shown ease of transition to same-agent oral therapy once the episode of acute agitation has diminished. No randomised, controlled studies have examined either agent in patients with severe agitation, drug-induced states or significant medical comorbidity. Current clinical experience and one naturalistic study with intramuscular ziprasidone suggest that it is efficacious and can be safely used in such populations. These intramuscular atypical antipsychotics may represent a historical advance in the treatment of acute agitation.

Best clinical practice with ziprasidone IM: update after 2 years of experience

Acute agitation is a common psychiatric emergency often treated with intramuscular (i.m.) medication when rapid control is necessary or the patient refuses to take an oral agent. Conventional i.m. antipsychotics are associated with side effects, particularly movement disorders, that may alarm patients and render them unreceptive to taking these medications again. Ziprasidone (Geodon) is the first second-generation, or atypical, antipsychotic to become available in an i.m. formulation. Ziprasidone IM was approved by the Food and Drug Administration in 2002 for the treatment of agitation in patients with schizophrenia. In October 2004, a roundtable panel of physicians with extensive experience in the management of acutely agitated patients met to review the first 2 years of experience with this agent. This monograph, a product of that meeting, discusses clinical experience to date with ziprasidone IM and offers recommendations on its use in various settings. In clinical trials, patients treated with ziprasidone IM demonstrated significant and rapid (within 15-30 minutes) reduction in agitation and improvement in psychotic symptoms, agitation, and hostility to an extent greater than or equal to that attained with haloperidol i.m. Tolerability of ziprasidone IM was superior to that of haloperidol IM, with a lower burden of movement disorders. Clinical trials have also shown that ziprasidone IM can be administered with benzodiazepines without adverse consequences. Transition from i.m. to oral ziprasidone has been well tolerated, with maintenance of symptom control. The most common adverse events associated with ziprasidone IM were insomnia, headache, and dizziness in fixed-dose trials and insomnia and hypertension in flexible-dose trials. No consistent pattern of escalating incidence of adverse events with escalating ziprasidone doses has been observed. Changes in QTc interval associated with ziprasidone at peak serum concentrations are modest and comparable to those seen with haloperidol IM. Results of randomized clinical trials of ziprasidone IM have been corroborated in studies in real-world treatment settings involving patients with extreme agitation or a recent history of alcohol or substance abuse. In these circumstances, clinically significant improvement was seen within 30 minutes of ziprasidone IM administration, without regard to the suspected underlying etiology of agitation. Agents with a good safety/tolerability profile, such as ziprasidone IM, may be more cost effective long term than older agents, due to reduced incidence of acute adverse effects (eg, acute dystonia) that often require extended periods of observation. Additional trials of ziprasidone IM in agitated patients in a variety of clinical setting are warranted to generate comparative risk/benefit data with conventional agents and other second-generation antipsychotics.