Protocol for the management of psychiatric patients with psychomotor agitation

New trends of drug abuse in custodial settings: A systematic review on the misuse of over-the-counter drugs, prescription-only-medications, and new psychoactive substances

The article presents a systematic literature review on the use and the psychiatric implications of over-the-counter drugs (OTC), prescription-only-medications (POM), and new psychoactive substances (NPS) within custodial settings. The searches wer carried out on 2 November 2022 on PubMed, Scopus, and Web of Science in line with PRISMA guidelines. A total of 538 records were identified, of which 37 met the inclusion criteria. Findings showed the most prevalent NPS and OTC and POM classes reported in prisons were synthetic cannabinoids receptor agonists (SCRAs) and opioids, respectively. NPS markets were shown to be in constant evolution following the pace of legislations aimed to reduce their spread. The use of such substances heavily impacts the conditions and rehabilitation of persons in custody, with consequent physical and mental health risks. It is important to raise awareness of the use and misuse of such substances in prisons (i) from an early warning perspective for law enforcement and policy makers (ii) to prompt doctors to cautiously prescribe substances that may be misused (iii) to improve and increase access to treatment provided (iv) to add such substances to routine toxicological screening procedures (v) to improve harm reduction programmes.

Prescription Patterns of Intramuscular Medication for Psychomotor Agitation: A Survey of Italian Psychiatrists

Objective

: Intramuscular medications are widely used to treat psychomotor agitation (PMA) in uncooperative patients. We evaluated knowledge and attitude towards guidelines and the prescribing patterns in a sample of Italian psychiatrists.

Methods

: A structured 28-item questionnaire was submitted to psychiatrists of Italian Departments of Mental Health. We considered 8 clinical scenarios of PMA. For comparing two qualitative variables Chi-square tests were performed.

Results

: One hundred thirty-four psychiatrists completed the survey. The use of a monotherapy is significatively higher (p ＜ 0.05) over a dual therapy in all clinical scenarios except PMA due to Mood Disorder and Psychotic Disorders, whereas the use of a polytherapy is significatively higher (p ＜ 0.05) in PMA due to Mood Disorders and Psychotic Disorders. The use of second-generation antipsychotic (SGAs) as monotherapy over first-generation antipsychotics (FGAs) is significantly higher (p ＜ 0.05) in PMA due to Central Nervous System (CNS) stimulants. The use of SGAs over FGAs in polytherapy is significantly higher (p ＜ 0.05) in PMA due to CNS stimulants. Knowledge of guidelines results 67.1% and significatively higher (p ＜ 0.05) among those who prefer SGAs as monotherapy rather than FGAs in PMA due to Intellectual Disability, CNS depressants and Delirium. Knowledge of guidelines results significatively higher (p ＜ 0.05) among those who prefer SGAs rather than FGAs in polytherapy in PMA due to Mood disorders.

Conclusion

: This survey reports variation in prescribing patterns for medication used to treat PMA. While SGAs are often prescribed as first choice following the more recent guidelines, FGAs and multi-drug solutions seem to be still a popular solution.

Humanization in mental health plans in Spain

INTRODUCTION

Mental health (MH) care has important challenges, especially in the field of humanization. Our objectives were to identify the humanization measures in MH plans of the Spanish autonomous communities (AC) and the priorities to be developed in this area.

MATERIAL AND METHODS

A large and multidisciplinary group of people involved in MH care participated in a consensus, according to a modified Delphi method, based on «design thinking», in three phases: (1) identification of humanization measures in MH plans of AC; (2) analysis of the implementation of these measures; and (3) identification of humanization priorities in MH.

RESULTS

Fourteen of the 17 AC have current MH plans. They contained four types of humanization measures: (1) improvement of the quality of care; (2) promotion of user participation; (3) campaigns against stigma and discrimination; (4) caring for especially vulnerable people. Implementation of measures ranged from 6.3% (i.e.: specific budget) to 100%, with an average of 64.1%. We identified priority issues, operationalized in 5 proposals: (1) information campaigns; (2) multidisciplinary meeting forums; (3) platforms of support entities; (4) strategies on MH education; (5) humanization in study plans.

CONCLUSIONS

Some MH plans include humanization among their objectives, but partially. The implementation of humanization proposals such as those identified in this study is essential to achieve a high-quality MH care.

Assaults and Microaggressions Against Psychiatric Residents: Findings from a US Survey

OBJECTIVES

Psychiatric physicians may experience higher rates of assault than those in other fields. For many reasons, residents may be especially vulnerable. This study updates rates of assaults among US psychiatry residents as well as the reporting rates and emotional effects of these incidents. Little data exists to examine rates of microaggressions against psychiatry residents.

METHODS

A cross-sectional online survey was distributed through a national residency database via a snowball-sampling approach between June and September of 2021. The questionnaire asked about experiences of verbal, physical, and sexual assaults, as well as microaggressions and their impact. Descriptive analyses of the obtained data were conducted.

RESULTS

The survey was completed by 275 psychiatry residents from 29 states (63.6% women). At least one form of assault was experienced by 78.9% of participants with 74.5% experiencing verbal, 22.2% experiencing physical, and 6.2% experiencing sexual assault. At least one type of microaggression was experienced by 86.9% of trainees. Elevations in PTSD scores were seen in residents who identified as women and non-White and those physically injured or sexually assaulted. While 92.7% of residents stated their program provided training about assault, 25% of residents indicated they had no training on recognizing and responding to microaggressions.

CONCLUSIONS

Psychiatric residents experience widespread assault and microaggressions in the clinical setting but often do not report them. Due to the ubiquitous nature of these events, programs should provide training about early recognition and de-escalation techniques for agitation, responding effectively to microaggressions, and the importance of reporting events.

Dexmedetomidine Sublingual Film: A New Treatment to Reduce Agitation in Schizophrenia and Bipolar Disorders

OBJECTIVE

The objective of this study was to review the available literature for dexmedetomidine sublingual film use in the treatment of acute agitation associated with schizophrenia and bipolar disorders.

DATA SOURCES

A literature search of PubMed (January 2017-March 2023) and EMBASE (January 2017-March 2023) was performed using the terms: Igalmi, dexmedetomidine, schizophrenia, bipolar disorder, and agitation. Additional information sources include ClinicalTrials.gov, scientific posters, and articles identified through review of references from clinical trials publications.

STUDY SELECTION AND DATA EXTRACTION

Relevant English-language articles conducted in humans were considered, with a preference for phase 3 clinical trials. Trial analyses and articles discussing pharmacology, pharmacokinetics, efficacy, and safety were also evaluated.

DATA SYNTHESIS

Dexmedetomidine sublingual film was evaluated for use in schizophrenia in the SERENITY 1 pivotal trial and for bipolar disorders in the SERENITY 2 pivotal trial. Both studies found treatment of mild to moderate agitation with dexmedetomidine sublingual film 180 and 120 μg to be superior to placebo in reducing the severity of agitation. Treatment effect was seen as early as 20 minutes. Somnolence was the most common adverse effect in both studies. Cardiovascular adverse effects were mild and transient in most cases.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Dexmedetomidine sublingual film is a new and novel treatment for agitation and gives clinicians an alternative to antipsychotic and benzodiazepine use. It has advantageous properties including its noninvasive route of administration, fast absorption, and rapid onset of effect. Cost may limit its use.

CONCLUSION

Dexmedetomidine sublingual film provides an alternative approach to treatment of acute agitation in adults with schizophrenia and bipolar disorders based on both mechanism of action and route of administration.

Reduction of aggressive behaviour following hypothalamic deep brain stimulation: Involvement of 5-HT1A and testosterone

BACKGROUND

Aggressive behaviour (AB) may occur in patients with different neuropsychiatric disorders. Although most patients respond to conventional treatments, a small percentage continue to experience AB despite optimized pharmacological management and are considered to be treatment-refractory. For these patients, hypothalamic deep brain stimulation (pHyp-DBS) has been investigated. The hypothalamus is a key structure in the neurocircuitry of AB. An imbalance between serotonin (5-HT) and steroid hormones seems to exacerbate AB.

OBJECTIVES

To test whether pHyp-DBS reduces aggressive behaviour in mice through mechanisms involving testosterone and 5-HT.

METHODS

Male mice were housed with females for two weeks. These resident animals tend to become territorial and aggressive towards intruder mice placed in their cages. Residents had electrodes implanted in the pHyp. DBS was administered for 5 h/day for 8 consecutive days prior to daily encounters with the intruder. After testing, blood and brains were recovered for measuring testosterone and 5-HT receptor density, respectively. In a second experiment, residents received WAY-100635 (5-HT_1A antagonist) or saline injections prior to pHyp-DBS. After the first 4 encounters, the injection allocation was crossed, and animals received the alternative treatment during the next 4 days.

RESULTS

DBS-treated mice showed reduced AB that was correlated with testosterone levels and an increase in 5-HT1_A receptor density in the orbitofrontal cortex and amygdala. Pre-treatment with WAY-100635 blocked the anti-aggressive effect of pHyp-DBS.

CONCLUSIONS

This study shows that pHyp-DBS reduces AB in mice via changes in testosterone and 5-HT1_A mechanisms.

Staff and ward factors associated with aggression development on an acute closed psychiatric ward: an experience sampling method study

Aggression on psychiatric wards develops under influence of patient, staff and ward factors. Assessment of naturalistic derived staff and ward factors might increase better understanding of how aggressive incidents develop on psychiatric wards.

OBJECTIVE

Studying staff and ward factors including interactions between patients and nurses prior and after development of aggression, within a naturalistic closed ward setting.

DESIGN

A prospective naturalistic experience sampling method (ESM) study.

SETTING AND PARTICIPANTS

A high intensive care unit of a mental health institution in The Netherlands where 29 nurses answered beeps generated by an app during approximately 7 consecutive days with questions regarding their subjective feelings, ward atmosphere, location, interaction they had with patients and their colleagues and whether an incident took place.

MAIN OUTCOME MEASURES

Associations were established between different staff and ward factors and the occurrence of aggressive incidents on the ward.

RESULTS

Risk for aggression was associated with the nurse being with a patient (OR=2.26, 95% CI 0.99 to 5.15, p=0.05). No significant association was found between discussing with the patient and setting a limit or physical absence of the nurse on the one hand and aggression on the other. More experienced nurses encountered more aggression (OR=3.5, 95% CI 1.32 to 8.26, p=0.01). Age and gender of the nurse were not associated with aggression development. Exceeding the maximum bed capacity was associated with a greater risk for aggression (OR=5.36, 95% CI 1.69 to 16.99, p=0.004). There was no significant association when analysing a more positive atmosphere on the ward or positive affect of the nurse, but negative affect of the nurses showed a trend for an association with less aggression.

CONCLUSION

Aggression is a problem that should be managed from a multidimensional perspective. The quality of interaction between nurses and patients is crucial. Exceeding the maximum bed capacity is likely associated with more aggression.

Network analysis of anxiety and depression in the functionally impaired elderly

Background

Evidence from previous studies has confirmed that functionally impaired elderly individuals are susceptible to comorbid anxiety and depression. Network theory holds that the comorbidity emerges from interactions between anxiety and depression symptoms. This study aimed to investigate the fine-grained relationships among anxiety and depression symptoms in the functionally impaired elderly and identify central and bridge symptoms to provide potential targets for intervention of these two comorbid disorders.

Methods

A total of 325 functionally impaired elderly individuals from five communities in Xi'an, China, were recruited for our investigation. The GAD-7 and PHQ-9 were used to measure anxiety and depression, respectively. SPSS 22.0 software was used for descriptive statistics, and R 4.1.1 software was used for network model construction, expected influence (EI) evaluation and bridge expected influence (BEI) evaluation.

Results

In the network, there were 35 edges (indicating partial correlations between symptoms) across the communities of anxiety and depression, among which the strongest edge was A1 "Nervousness or anxiety"-D2 "Depressed or sad mood." A2 "Uncontrollable worry" and D2 "Depressed or sad mood" had the highest EI values in the network, while A6 "Irritable" and D7 "Concentration difficulties" had the highest BEI values of their respective community. In the flow network, the strongest direct edge of D9 "Thoughts of death" was with D6 "Feeling of worthlessness."

Conclusion

Complex fine-grained relationships exist between anxiety and depression in functionally impaired elderly individuals. "Uncontrollable worry," "depressed or sad mood," "irritable" and "concentration difficulties" are identified as the potential targets for intervention of anxiety and depression. Our study emphasizes the necessity of suicide prevention for functionally impaired elderly individuals, and the symptom "feeling of worthlessness" can be used as an effective target.

Clinical and Sociodemographic Profile of Psychomotor Agitation in Mental Health Hospitalisation: A Multicentre Study

Psychomotor agitation is characterised by an increase in psychomotor activity, restlessness and irritability. People with psychomotor agitation respond by over-reacting to both intrinsic and extrinsic stimuli, experiencing stress and/or altered cognition. The objective of this study is to assess the clinical and sociodemographic profile of psychomotor agitation in patients with severe mental disorders. The study was carried out in Spain by means of multicentre cross-sectional convenience sampling involving 140 patients who had been admitted to psychiatric hospital units and had experienced an episode of psychomotor agitation between 2018 and 2021.Corrigan's Agitated Behaviour Scale was used to assess psychomotor agitation. The results show that the predominant characteristic in psychomotor agitation is aggressiveness, which is also the most reported factor in patients with severe mental disorder. Patients who also have anxiety develop psychomotor agitation symptoms of moderate/severe intensity. The clinical and sociodemographic profile found in our study is consistent with other studies on the prevalence of psychomotor agitation.

The Utilization of a Rapid Agitation Scale and Treatment Protocol for Patient and Staff Safety in an Inpatient Psychiatric Setting

Agitation is a common and potentially dangerous condition requiring rapid recognition and treatment in acute psychiatric units. Prompt intervention can prevent a patient with agitation from harming themselves, harming others, or needing restraints or seclusion. After the review of numerous guidelines, the Modified Agitation Severity Scale (MASS) agitation treatment protocol was developed to identify and manage agitation in an inpatient adult psychiatric setting. This protocol involved modifying an existing agitation scale and pairing scores with a treatment algorithm to indicate which behavioral and medication interventions would be most appropriate. All scoring and interventions were recorded in the electronic medical record (EMR). Three months of data were collected before and after the protocol was implemented. The new, modified scale had high reliability and correlated well with another validated agitation scale. Perceived patient safety was high during both study phases. Nurses' perceptions of safety trended upward after the protocol was implemented, though these differences were not significant, likely due to insufficient power. Although there was no decrease in seclusion events after implementation of the treatment protocol, there was a 44% decrease in restraint events and average restraint minutes per incident. Despite a potential increase in workload for nursing staff, implementation of the protocol did not increase burnout scores. Physicians continued to order the protocol for 55% of patients after the study period ended. These findings suggest that including a rapid agitation assessment and protocol within the EMR potentially improves nurses' perceptions of unit safety, helps assess treatment response, reduces time patients spend restrained, and supports decision making for nurses.

Experience of mental health nurses regarding mechanical restraint in patients with psychomotor agitation: A qualitative study

AIM

To explore mental health nurses' experiences whilst managing a patient with psychomotor agitation, and the factors that influence the decision to use mechanical restraints.

BACKGROUND

Psychomotor agitation is considered a potentially violent psychiatric emergency. The management of disruptive behaviours includes mechanical restraints as the last resort although its use has consequences for patients, professionals and the therapeutic relationship.

DESIGN

A qualitative study design with a hermeneutical approach was developed.

METHODS

A total of 31 nurses were purposively sampled from six short- and medium-stay mental health inpatient units. Data were obtained from semi-structured interviews. A thematic content analysis following the seven steps of Colaizzi's method was performed. Three researchers independently conducted an inductive analysis within a perspective of a hermeneutic paradigm. The COREQ checklist was followed in carrying out this research.

RESULTS

Four themes emerged from the analysis: 1) Nurses' perceptions of restraint methods, 2) Factors influencing decision-making, 3) Consequences for professionals of the use of mechanical restraint and 4) Alternatives to mechanical restraint.

CONCLUSIONS

Aspects such as the importance of teamwork, the issue of cognitive dissonance, ethical conflict and barriers to effecting the withdrawal of these measures affect the mental health nurse's decision-making process. The understanding of these aspects is crucial to further reducing its incidence and negative consequences and achieving the elimination of mechanical restraints.

RELEVANCE FOR CLINICAL PRACTICE

Knowing how nurses feel during the patient's episode of psychomotor agitation and which factors influence the decision on whether to apply coercive methods can guide us on the quality of care offered.

A Narrative Review of Studies Comparing Efficacy and Safety of Citalopram with Atypical Antipsychotics for Agitation in Behavioral and Psychological Symptoms of Dementia (BPSD)

Background: Psychomotor agitation as part of the behavioral and psychological symptoms of dementia (BPSD) is one of the common issues found in aged care facilities. The current inadequate management strategies lead to poor functional and medical outcomes. Psychotropic interventions are the current preferred treatment method, but should these medications be the prescribers’ first preference? This review aims to compare pharmacological interventions for psychomotor agitation, judging them according to their effectuality and justifiability profiles. This is to be achieved by retrieving information from Randomized Control Trials (RCTs) and systematic reviews. Objectives: This review evaluates evidence from RCTs, systematic reviews, and meta-analyses of BPSD patients who have taken agitation treatments. Assessing the efficacy of citalopram, other selective serotonin reuptake inhibitors (SSRIs) and antipsychotic treatments were compared to each other for the purpose of improving agitation outcomes and lowering patient side effects. Methods: This review includes RCT that compared citalopram with one or more atypical antipsychotics or with a placebo, along with systematic reviews comparing citalopram (SSRI) with antipsychotics such as quetiapine, olanzapine, and risperidone. Studies were extracted by searching and accessing databases, such as PubMed, OVID, and Cochrane with restrictions of date from 2000 to 2021 and published in the English language. Conclusion: There are still a limited number of studies including SSRIs for the treatment of agitation in BPSD. SSRIs such as citalopram were associated with a reduction in the symptoms of agitation, and lower risk of adverse effects when compared to antipsychotics. Future studies are required to assess the long-term safety and efficacy of SSRI treatments for agitation in BPSD.

Current State of Research on Coercion in Mental Health: Umbrella Review Protocol

In recent years, international organizations, professionals, and representatives of mental health service users have expressed the need to regulate, limit, and even eliminate coercive measures in psychiatric treatment. The main objective of the current review is to provide a comprehensive synthesis of existing evidence on coercion in mental health care through a protocol for an umbrella review of systematic reviews. This protocol was designed according to the Joanna Briggs Institute guide for methodological development, conduct, and reporting of umbrella reviews. To minimize bias in the process, two independent reviewers selected the studies to be included, extracted, and synthesized; analyzed the data; and assessed risk of bias of each review. The review protocol was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines. This review offers a comprehensive compilation of systematic reviews on coercion developed to date. Coercion causes adverse physical and psychological effects and is an emotional stressor for individuals with psychiatric diagnoses and health care workers. Characterization of coercion across care settings, its impact on clinical outcomes, the perception of those involved, and how coercion could be reduced will also be discussed. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

Triggers of Agitation in Psychiatric Hospitalization Ward According to Professional Experience Questionnaire

AIM

To create and analyze an instrument to assess the possible agitation triggers of hospitalized psychiatric patients.

BACKGROUND

No tools exist for identifying according to a professional's experience.

METHODS

Descriptive and cross-sectional study. The questionnaire of possible triggers of agitation behaviors of patients hospitalized in psychiatric wards according to professional experience (TAPE) was designed and analyzed.

RESULTS

The questionnaire was provided to 156 mental health workers (76.9% women, average work experience: 10.15 ± 8 years, 46.8% were nurses specialized in mental health, and 21.2% psychiatrists). A good internal consistency was obtained, with a Cronbach α value of 0.791 in the initial test, and 0.892 in the retest. The factorial analysis found four factors: factor 1 "personnel", factor 2 "routines", factor 3 "norms-infrastructure", and factor 4 "clinic". Factor 1 obtained the highest value, with a mean of 4.16 ± 0.63, highlighting the item "lack of specialized personnel" (mean 4.38 ± 0.81). The specialized professionals provided higher scores to the items from the factors associated with the training of the personnel and routines (p = 0.017; p = 0.042).

CONCLUSIONS

The TAPE questionnaire is useful for identifying the possible triggers that could lead to situations of agitation of hospitalized patients.

Effectiveness of De-Escalation in Reducing Aggression and Coercion in Acute Psychiatric Units. A Cluster Randomized Study

OBJECTIVE

Most guidelines for the management of aggressive behavior in acute psychiatric patients describe the use of de-escalation as the first-choice method, but the evidence for its effectiveness is inconsistent. The aim of the study was to assess the effect of verbal and non-verbal de-escalation on the incidence and severity of aggression and the use of physical restraints in acute psychiatric wards.

METHODS

A multi-center cluster randomized study was conducted in the acute wards of all psychiatric hospitals in Slovenia. The research was carried out in two phases, a baseline period of five consecutive months and an intervention period of the same five consecutive months in the following year. The intervention was implemented after the baseline period and included training in verbal and non-verbal de-escalation techniques for the staff teams on experimental wards.

RESULTS

In the baseline study period, there were no significant differences in the incidence of aggressive behavior and physical restraints between the experimental and control groups. The incidence rates of aggressive events, severe aggressive events, and physical restraints per 100 treatment days decreased significantly after the intervention. Compared to the control group, the incidence rate of aggressive events was 73% lower in the experimental group (IRR = 0.268, 95% CI [0.221; 0.342]), while the rate of severe events was 86% lower (IRR = 0.142, 95% CI [0.107; 0.189]). During the intervention period, the incidence rate of physical restraints due to aggression in the experimental group decreased to 30% of the rate in the control group (IRR = 0.304, 95% CI [0.238; 0.386]). No reduction in the incidence of restraint used for reasons unrelated to aggression was observed. After the intervention, a statistically significant decrease in the severity of aggressive incidents (p < 0.001) was observed, while the average duration of restraint episodes did not decrease.

CONCLUSION

De-escalation training is effective in reducing the incidence and severity of aggression and the use of physical restraints in acute psychiatric units.

CLINICAL TRIAL REGISTRATION

[www.ClinicalTrials.gov], identifier [NCT05166278].

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

Background: Severe mental disorder (SMD) is understood in a first approximation as a disorder of thought, emotion, or behavior of long duration, which entails a variable degree of disability and social dysfunction. One of the most widely used assessment scales for agitated behavior, in its English version, is the Corrigan Agitated Behavior Scale (ABS); several studies have demonstrated solid psychometric properties of the English version, with adequate internal consistency. Objective: The objective of this study was to evaluate the psychometric properties of the Spanish version of the ABS Corrigan scale, in a sample of patients with severe mental disorders. The psychometric analyses of the Spanish version of the ABS Corrigan included tests of the reliability and validity of its internal structure. Results: The structure of the factorial loads of the analyzed elements is consistent with the hypothesized three-dimensional construction referred to in the original ABS. The results suggest that the reliability and validity of the three dimensions are acceptable (First 0.8, Second 0.8, and Third 0.7). The internal consistency of the Spanish version of the complete ABS and of each of the three domains that compose it is high, with values very close to those found in the original version, with approximate figures of 0.9. Conclusion: In our study, the three domains aim to explain 64.1% of the total variance of the scale, which exceeds the 50% found in the original version.

Physical Restraint in Psychiatric Care: Soon to Fall Out of Use?

International directives all recommend that using restraints on psychiatric patients should be avoided, yet scientific literature shows that such practices are still largely in use. This article aims to lay out strategies that could be put in place in order to gradually discard the use of restraints, particularly through a "restraint-free" approach, nursing, logistic-environmental pathways, and locally centered health care provision. All such tools have proven valuable for the purpose of safeguarding the health of psychiatric patients. Hence, the failure to put in place such measures may lead to litigation and lawsuits against physicians and particularly health care facilities. Undoubtedly, the ability to effectively implement such methods largely depends on the financial resources available, which in countries such as Italy are poorer than in others. Still, the risk of being sued and held professionally liable may constitute a factor in raising awareness among operators, facilities, and public health care management, leading to the implementation of policy changes aimed at minimizing the use of restraints.

Managing acute agitation and aggression in the world of drug shortages

Acute agitation and aggression create safety risks for both patients and staff, often leading to psychiatric emergencies. Quick and appropriate treatment is necessary to achieve safe and effective outcomes. Unfortunately, there are several factors that hinder timely interventions, such as medication shortages and delay in staff preparedness. Ultimately, the goal of managing acute agitation and aggression in the clinical setting is to de-escalate the situation and prevent harm to patients and staff. This article will explore useful interventions in realizing treatment goals for the management of agitation and aggression in adults while navigating limitations faced in practice.

Efficacy and safety of intranasal haloperidol in an acute Psychiatry Unit: a pilot study on schizophrenic patients with mild-modedate agitation

To study the efficacy and safety of intranasal administration of 5 mg haloperidol on mild-moderate agitated patients with schizophrenia or schizoaffective disorder in an acute psychiatry unit setting.

Agitation in schizophrenia: origins and evidence-based treatment

PURPOSE OF REVIEW

Agitation associated with schizophrenia remains an important clinical concern and if not managed effectively, can escalate into aggressive behavior. This is a review of the recent biomedical literature on agitation in individuals with schizophrenia.

RECENT FINDINGS

Themes in the recent literature include consideration of comorbidities such as cigarette smoking and cannabis use. Surveys reveal that pharmacological approaches to manage agitation have changed little, with haloperidol remaining in common use and intramuscular administration of antipsychotics and/or benzodiazepines being frequently administered to more severely agitated/aggressive individuals. Of note, ketamine has been recently adopted for use in severe agitation in medical emergency departments, but the risk of this medication for people with schizophrenia is unclear. At present, inhaled loxapine remains the only rapidly acting noninjectable FDA-approved treatment for agitation associated with schizophrenia. In development is an intranasal formulation for olanzapine (a well characterized atypical antipsychotic already approved to treat agitation) and a sublingual film for dexmedetomidine (an α2-adrenergic agonist used as an anesthetic and now being repurposed).

SUMMARY

Comorbidities can contribute to agitation and can make an accurate differential diagnosis challenging. The ongoing development of rapidly acting novel formulations of antiagitation medications, if successful, may facilitate clinical treatment by providing additional options.

The Management of Psychomotor Agitation Associated with Schizophrenia or Bipolar Disorder: A Brief Review

The early and correct assessment of psychomotor agitation (PMA) is essential to ensure prompt intervention by healthcare professionals to improve the patient’s condition, protect healthcare staff, and facilitate future management. Proper training for recognizing and managing agitation in all care settings is desirable to improve patient outcomes. The best approach is one that is ethical, non-invasive, and respectful of the patient’s dignity. When deemed necessary, pharmacological interventions must be administered rapidly and avoid producing an excessive state of sedation, except in cases of severe and imminent danger to the patient or others. The purpose of this brief review is to raise awareness about best practices for the management of PMA in emergency care situations and consider the role of new pharmacological interventions in patients with agitation associated with bipolar disorder or schizophrenia.

Link between temperament traits, brain neurochemistry and response to SSRI: insights from animal model of social behavior

BACKGROUND

Dominant-submissive relationships depend upon functionality of the neural circuits involving monoaminergic neurotransmission. Behavioral profiles of selectively bred dominant (Dom) and submissive (Sub) mice have been proposed to mimic hyperthymic- or depressive-like temperaments observed in patients with affective disorders. These mice differentially respond to psychotropic agents and stressful stimuli, however, the mechanisms underlying these differences remain unclear. To address these mechanisms, we analyzed the brain monoamine content and responses to paroxetine (PXT) in Dom and Sub mice.

METHODS

The behavioral effects of PXT (3 mg/kg, single injection) were assessed with the Elevated Plus Maze (EPM) and Forced Swim Test (FST). Monoamine tissue content was analyzed by HPLC-ECD.

RESULTS

Compared to Dom, Sub mice had decreased levels of serotonin (5-HT) in the brainstem (BS), reduced levels of norepinephrine (NE) in the prefrontal cortex (PFC), hippocampus (HPC), and striatum (STR) and elevated levels of dopamine (DA) in PFC, HPC, STR and BS. In EPM, PXT administration increased locomotion and exploration in Dom mice, with no effect in Sub mice. In FST, PXT disrupted immobility in Dom mice only. The PXT-produced differences in regional monoamine content were strain-dependent and consistent with the behavioral alterations.

LIMITATIONS

Chronic PXT treatment, in vivo monoamine assays and sex-dependent analysis were out of the scope of this study and will be performed in the future in order to provide an in-depth evaluation of the neurochemical mechanisms underlying temperament-dependent responses to SSRIs.

CONCLUSIONS

Our findings suggest neurochemical mechanisms that underlie temperament-based response to antidepressant treatment.

Which Emergent Medication Should I Give Next? Repeated Use of Emergent Medications to Treat Acute Agitation

Agitation is a common symptom encountered among patients treated in psychiatric emergency settings. While there are many guidelines available for initial management of the acutely agitated patient, there is a notable dearth of guidelines that delineate recommended approaches to the acutely agitated patient in whom an initial medication intervention has failed. This manuscript aims to fill this gap by examining evidence available in the literature and providing clinical algorithms suggested by the authors for sequential medication administration in patients with persistent acute agitation in psychiatric emergency settings. We discuss risk factors for medication-related adverse events and provide options for patients who are able to take oral medications and for patients who require parenteral intervention. We conclude with a discussion of the current need for well-designed studies that examine sequential medication options in patients with persistent acute agitation.

An in-depth neurobehavioral characterization shows anxiety-like traits, impaired habituation behavior, and restlessness in male Cryptochrome-deficient mice

Many psychiatric disorders, for example, anxiety, are accompanied by disturbances of circadian rhythms, including disturbed sleep/wake cycles, changes in locomotor activity, and abnormal endocrine function. Conversely, alternations of circadian rhythms are a risk factor for the development of psychiatric disorders. This assumption is supported by animals with clock gene mutations which often display behaviors that resemble human psychiatric disorders. In this study, we performed an in-depth behavioral analysis with male mice lacking the central clock genes Cryptochrome 1 and 2 (Cry1/2^-/- ), which are thus unable to express endogenous circadian rhythms. With wild-type and Cry1/2^-/- mice, we performed an extensive behavioral analysis to study their cognitive abilities, social behavior, and their expression of depression-like and anxiety-like behavior. While Cry1/2^-/- mice showed only mild abnormalities at cognitive and social behavioral levels, they were consistently more anxious than wildtype mice. Anxiety-like behavior was particularly evident in reduced mobility in new environments, altered ability to habituate, compensatory behavior, and consistent restless behavior across many behavioral tests. In line with their anxiety-like behavioral phenotype, Cry1/2^-/- mice have higher c-Fos activity in the amygdala after exposure to an anxiogenic stressor than wild-type mice. In our study, we identified Cry1/2^-/- mice as animals that qualify as a translational mouse model for anxiety disorder in humans because of its consistent behavior of restlessness, increased immobility, and dysfunctional habituation in new environments.

Validation methods of nursing protocols: an integrative review

OBJECTIVE

to identify scientific production about validation methods of nursing care protocols.

METHOD

an integrative review with search at Scielo, Pubmed/MEDLINE, Virtual Health Library, Web of Science, Scopus, and EBSCOhost. The descriptors "validation studies", "validation studies as topic", "protocols", "clinical protocols", "practice guidelines as topic", "nursing" and "nursing assessment" and the uncontrolled descriptor "validation" were used.

RESULTS

thirty-two articles were selected, most of them Brazilian. Content validation by experts was the most frequent method, with no consensus on the number of participants for the process. The collection instruments were mostly created by the authors. Data analysis was performed using descriptive statistics and Content Validity Index, with a variable consensus rate in the analyzed articles.

CONCLUSION

protocols validated by experts are robust tools for use in clinical practice, with methodological rigor in development essential for its quality.

How to treat mania

OBJECTIVE

In this paper, we aimed at reviewing evidence-based treatment options for bipolar mania and proposed tentative evidence-based clinical suggestions regarding the management of a manic episode, especially regarding the choice of the proper mood stabilizer and antipsychotic medication.

METHOD

A narrative review was undertaken addressing 'treatment of bipolar mania'. Findings have been synthesized and incorporated with clinical experience into a model to support different treatment choices.

RESULTS

To date, there is solid evidence supporting the use of several medications, such as lithium, divalproex, and carbamazepine, and antipsychotics, such as chlorpromazine, haloperidol, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, inhaled loxapine, asenapine, and cariprazine in acute mania, and some evidence supporting the use of clozapine or electroconvulsive therapy in treatment-refractory cases. However, in clinical practice, when making decisions about treatment, personalized treatment is needed, according to the different clinical presentations and more complex clinical situations within the manic episode and considering a long-term view and with the objective of not only a symptomatic but also functional recovery. After remission from acute mania, psychoeducation strategies are useful to ensure adherence.

DISCUSSION

Despite the evidence forefficacy of many currently available treatments for mania, the majority of RCTs provide little direction for the clinician as to what steps might be optimal in different presentations of mania as well as in the presence of specific patient characteristics. Manic episodes should be managed on a personalized basis considering the clinical course and patient criteria and with the expectation of maintaining that treatment in the long-term.

The treatment of acute agitation associated with schizophrenia or bipolar disorder: investigational drugs in early stages of their clinical development, and their clinical context and potential place in therapy

Introduction: Acute agitation in patients with schizophrenia or bipolar disorder may require pharmacologic management. Ideal medication characteristics for this indication include rapid onset, minimal side effects, and noninvasive administration techniques.Areas Covered: This review summarizes investigational agents in early clinical development for the management of acute agitation in patients with psychosis or mania; it also assesses where these agents may fit with current therapies to provide a clinical perspective. The authors conducted a broad search of clinicaltrials.gov to identify investigational agents for agitation or aggression in patients with schizophrenia or bipolar disorder. Two medications met the search criteria: dexmedetomidine film (BXCL501) and intranasal olanzapine (INP105).Expert Opinion: Olanzapine is a well-known molecular entity in the psychiatric armamentarium but dexmedetomidine would be a new and unfamiliar agent for mental health providers. Nonetheless, although it is too early to make definitive statements about tolerability and efficacy, their unique administration mechanisms suggest that dexmedetomidine film and intranasal olanzapine may become valuable options for the rapid management of acute agitation in patients who are willing to cooperate with medication therapy.

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.

Inhaled Loxapine for the Management of Acute Agitation in Bipolar Disorder and Schizophrenia: Expert Review and Commentary in an Era of Change

Agitation is a common and costly phenomenon associated with a number of psychiatric conditions including schizophrenia and bipolar disorder. Early identification and prompt intervention to relieve the symptoms of agitation are essential to avoid symptomatic escalation and emergence of aggressive behaviour. Recent consensus guidelines emphasise the need for non-coercive management strategies to protect the therapeutic alliance between patients and their healthcare providers—an alliance that is critical for the effective management of chronic psychiatric conditions. Rapid symptom relief and de-escalation of agitation are necessary to avoid the costly and traumatic use of coercive techniques of physical restraint and seclusion, which require admission and prolonged hospitalisation. Inhaled loxapine is approved for the treatment of acute agitation in patients with schizophrenia or bipolar disorder. Clinical studies have confirmed the efficacy, rapid onset of action, and safety and tolerability of this agent in the psychiatric emergency and hospital settings. Emerging data have indicated the potential for inhaled loxapine as a self-administered agent for use in the community setting without the direct supervision of a healthcare professional. We discuss the evolving treatment paradigm and the place of inhaled medications for acutely agitated patients both within and outside the emergency and hospital setting.

How to improve clinical practice on forced medication in psychiatric practice: Suggestions from the EUNOMIA European multicentre study

BACKGROUND

The decision to adopt forced medication in psychiatric care is particularly relevant from a clinical and ethical viewpoint. The European Commission has funded the EUNOMIA study in order to develop European recommendations for good clinical practice on coercive measures, including forced medication.

METHODS

The recommendations on forced medication have been developed in 11 countries with the involvement of national clinical leaders, key-professionals and stakeholders' representatives. The national recommendations have been subsequently summarized into a European shared document.

RESULTS

Several cross-national differences exist in the use of forced medication. These differences are mainly due to legal and policy making aspects, rather than to clinical situations. In fact, countries agreed that forced medication can be allowed only if the following criteria are present: 1) a therapeutic intervention is urgently needed; 2) the voluntary intake of medications is consistently rejected; 3) the patient is not aware of his/her condition. Patients' dignity, privacy and safety shall be preserved at all times.

CONCLUSION

The results of our study show the need of developing guidelines on the use of forced medication in psychiatric practice, that should be considered as the last resort and only when other therapeutic option have failed.

1st International Experts' Meeting on Agitation: Conclusions Regarding the Current and Ideal Management Paradigm of Agitation

Agitation is a heterogeneous concept without a uniformly accepted definition, however, it is generally considered as a state of cognitive and motor hyperactivity characterized by excessive or inappropriate motor or verbal activity with marked emotional arousal. Not only the definition but also other aspects of agitated patients' care are still unsolved and need consensus and improvement. To help the discussion about agitation among experts and improve the identification, management, and treatment of agitation, the 1st International Experts' Meeting on Agitation was held in October 2016 in Madrid. It was attended by 20 experts from Europe and Latin America with broad experience in the clinical management of agitated patients. The present document summarizes the key conclusions of this meeting and highlights the need for an updated protocol of agitation management and treatment, the promotion of education and training among healthcare professionals to improve the care of these patients and the necessity to generate clinical data of agitated episodes.