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Pharmacological Management of Acute Agitation

Abstract

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.

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References

  1. Mendelowitz AJ. Assessment and treatment of acute psychotic agitation in an emergency room setting. Essent Psychopharmacol 2002; 5(1): 31–43

    Google Scholar 

  2. Citrome L, Volavka J. Violent patients in the emergency setting. Psychiatr Clin North Am 1999 Dec; 22(4): 789–801

    PubMed  CAS  Article  Google Scholar 

  3. Elbogen EB, Tomkins AJ, Pothuloori AP, et al. Documentation of violence risk information in psychiatric hospital patient charts: an empirical examination. J Am Acad Psychiatry Law 2003; 31(1): 58–64

    PubMed  Google Scholar 

  4. Soliman AE, Reza H. Risk factors and correlates of violence among acutely ill adult psychiatric inpatients. Psychiatr Serv 2001 Jan; 52(1): 75–80

    PubMed  CAS  Article  Google Scholar 

  5. Lindenmayer JP. The pathophysiology of agitation. J Clin Psychiatry 2000; 61 Suppl. 14: 5–10

    PubMed  CAS  Google Scholar 

  6. Citrome L, Nolan KA, Volavka J. Science-based treatment of aggression and agitation. In: Fishbein DH, editor. The science, treatment and prevention of antisocial behaviors: evidence-based practice. Kingston (NJ): Civic Research Institute, Inc., 2004

    Google Scholar 

  7. Van Kamman DP. Gamma-aminobutyric acid and the dopamine hypothesis of schizophrenia. Am J Psychiatry 1977 Feb; 134: 138–43

    Google Scholar 

  8. Steiniger B, Kretschmer BD. Glutamate and GABA modulate dopamine in the pedunculopontine tegmental nucleus. Exp Brain Res 2003 Apr; 149: 422–30

    PubMed  CAS  Google Scholar 

  9. Mason AS, Granacher RP. Clinical handbook of antipsychotic drug therapy. New York: Brunner/Mazel, 1980

    Google Scholar 

  10. Nilsen JA. Immediate treatment expedites hospital release. Hosp Community Psychiatry 1969 Jan; 20: 36–8

    Google Scholar 

  11. Oldham AJ, Bott M. The management of excitement in a general hospital psychiatric ward by high dosage haloperidol. Acta Psychiatr Scand 1971; 47: 369–76

    PubMed  CAS  Article  Google Scholar 

  12. Battaglia J, Lindborg SR, Alaka K, et al. Calming versus sedative effects of intramuscular olanzapine in agitated patients. Am J Emerg Med 2003; 21: 192–8

    PubMed  Article  Google Scholar 

  13. Huf G, Coutinho ES, Adams CE, et al. Rapid tranquillisation for agitated patients in emergency psychiatric rooms: a randomized trial of midazolam versus haloperidol plus promethazine. TREC Collaborative Group. BMJ 2003 Sep 27; 327: 1–6

    Google Scholar 

  14. Agid O, Kapur S, Arenovich T, et al. Delayed-onset hypothesis of antipsychotic action: a hypothesis tested and rejected. Arch Gen Psychiatry 2003 Dec; 60(12): 1228–35

    PubMed  CAS  Article  Google Scholar 

  15. Leonard BE. Fundamentals of psychopharmacology. Chichester: Wiley & Sons, 1992

    Google Scholar 

  16. Mountain HE. Crash tranquilization in a milieu therapy setting. J Fort Logan Mental Health Center 1963; 11: 42–4

    Google Scholar 

  17. Menuck M, Voineskos G. Rapid parenteral treatment of acute psychosis. Compr Psychiatry 1981 Jul/Aug; 22: 351–61

    PubMed  CAS  Article  Google Scholar 

  18. Dubin WR, Waxman HM, Weiss KJ, et al. Rapid tranquilization: the efficacy of oral concentrate. J Clin Psychiatry 1985 Nov; 46: 475–8

    PubMed  CAS  Google Scholar 

  19. Coffman JA, Nasrallah HA, Lyskowski J, et al. Clinical effectiveness of oral and parenteral rapid neuroleptization. J Clin Psychiatry 1987; 48: 20–4

    PubMed  CAS  Google Scholar 

  20. American Hospital Formulary Service drug information. 28:16.08 —antipsychotics. Bethesda (MD): American Society of Health System Pharmacists, 2004

    Google Scholar 

  21. Baldessarini RJ, Cohen BM, Teicher MH, et al. Significance of neuroleptic dose and plasma level in the pharmacological treatment of psychoses. Arch Gen Psychiatry 1988 Jan; 45: 79–91

    PubMed  CAS  Article  Google Scholar 

  22. Neborsky R, Janowsky D, Munson E, et al. Rapid treatment of acute psychotic symptoms with high- and low-dose haloperidol. Arch Gen Psychiatry 1981 Feb; 38: 195–9

    PubMed  CAS  Article  Google Scholar 

  23. Ulrich S, Neuhof S, Braun V, et al. Therapeutic window of serum haloperidol concentration in acute schizophrenia and schizoaffective disorder. Pharmacopsychiatry 1998; 31: 163–9

    PubMed  CAS  Article  Google Scholar 

  24. Bartels M, Heide K, Mann K, et al. Treatment of akathisia with lorazepam: an open clinical trial. Pharmacopsychiatry 1987; 20: 51–3

    PubMed  CAS  Article  Google Scholar 

  25. Baldessarini RJ. Chemotherapy in psychiatry: priniciples and practice. Rev ed. Cambridge (MA): Harvard University Press, 1985

    Google Scholar 

  26. Lawrence KR, Nasraway SA. Conduction disturbances associated with administration of butyrophenone antipsychotics in the critically ill: a review of the literature. Pharmacotherapy 1997 May–Jun; 17: 531–37

    PubMed  CAS  Google Scholar 

  27. Glassman AH, Bigger JT. Antipsychotic drugs: prolonged QTc interval, Torsade de pointes, and sudden death. Am J Psychiatry 2001; 158: 1774–82

    PubMed  CAS  Article  Google Scholar 

  28. Lazarus A, Dubin WR, Jaffe RL. Rapid tranquilization with neuroleptic drugs: neurologic concerns. Clin Neuropharmacol 1989; 12: 303–11

    PubMed  CAS  Article  Google Scholar 

  29. Caroff SN, Mann SC. Neuroleptic malignant syndrome. Med Clin North Am 1993 Jan; 77(1): 185–202

    PubMed  CAS  Google Scholar 

  30. Ananth J, Parameswaran S, Gunatilake S, et al. Neuroleptic malignant syndrome and atypical antipsychotic drugs. J Clin Psychiatry 2004 Apr; 65(4): 464–70

    PubMed  CAS  Article  Google Scholar 

  31. American Hospital Formulary Service drug information. 28:24.92 — miscellaneous anxiolytics, sedatives, hypnotics. Bethesda (MD): American Society of Health System Pharmacists, 2004

    Google Scholar 

  32. Chambers RA, Druss BG. Droperidol: efficacy and side effects in psychiatric emergencies. J Clin Psychiatry 1999; 60: 664–7

    PubMed  CAS  Article  Google Scholar 

  33. Leeuwen AM, Molders J, Sterkmans P, et al. Droperidol in acutely agitated patients. J Nerv Ment Dis 1977; 164: 280–3

    PubMed  Article  Google Scholar 

  34. Resnick M, Burton BT. Droperidol vs. haloperidol in the initial management of acutely agitated patients. J Clin Psychiatry 1984; 45: 298–9

    PubMed  CAS  Google Scholar 

  35. Szuba MP, Bergman KS, Baxter LR, et al. Safety and efficacy of high dose droperidol in agitated patients [letter]. J Clin Psychopharm 1992 April; 12: 144–6

    CAS  Article  Google Scholar 

  36. Stanislav SW, Childs A. Evaluating the usage of droperidol in acutely agitated persons with brain injury. Brain Inj 2000; 14: 261–5

    PubMed  CAS  Article  Google Scholar 

  37. Thomas H, Schwartz E, Petrilli R. Droperidol versus haloperidol for chemical restraint of agitated and combative patients. Ann Emerg Med 1992 April; 21: 407–13

    PubMed  Article  Google Scholar 

  38. Lischke V, Behne M, Doelken P, et al. Droperidol causes a dose-dependent prolongation of the QT interval. Anesth Analg 1994 Nov; 79(5): 983–6

    PubMed  CAS  Article  Google Scholar 

  39. Chase PB, Biros MH. A retrospective review of the use and safety of droperidol in a large, high-risk, inner-city emergency department patient population. Acad Emerg Med 2002; 9: 1402–10

    PubMed  Article  Google Scholar 

  40. Shale JH, Shale CM, Mastin WD. A review of the safety and efficacy of droperidol for the rapid sedation of severely agitated and violent patients. J Clin Psychiatry 2003 May; 64: 500–5

    PubMed  CAS  Article  Google Scholar 

  41. Lundbeck. Schizophrenia [online]. Available from URL: http://www.lundbeck.com/ourbusiness/ourfocus/schizophrenia [Accessed 2004 Aug 10]

  42. Chakravarti SK, Muthu A, Muthu PK, et al. Zuclopenthixol acetate: single dose treatment for acutely disturbed psychotic patients. Curr Med Res Opin 1990; 12: 58–65

    PubMed  CAS  Article  Google Scholar 

  43. Taymeeyapradit U, Kuasirikul S. Comparative study of the effectiveness of zuclopenthixol acetate and haloperidol in acutely disturbed psychotic patients. J Med Assoc Thai 2002 Dec; 85: 1301–8

    PubMed  Google Scholar 

  44. Fitzgerald P. Long-acting antipsychotic medication, restraint and treatment in the management of acute psychosis. Aust N Z J Psychiatry 1999; 33: 660–6

    PubMed  CAS  Article  Google Scholar 

  45. Allen MH. Managing the agitated psychotic patient: a reappraisal of the evidence. J Clin Psychiatry 2000; 61 Suppl. 14: 11–20

    PubMed  CAS  Google Scholar 

  46. Singhal RL, Rastogi RB, Lapierre YD. Diazepam potentiates the effect of neuroleptics on behavioral activity as well as dopamine and norepinephrine turnover: do benzodiazepines have antipsychotic potency? J Neural Transmission 1983; 56: 127–38

    CAS  Article  Google Scholar 

  47. Wassef AA, Dott SG, Harris A, et al. Critical review of GABA-ergic drugs in the treatment of schizophrenia. J Clin Psychopharmacol 1999 Jun; 19: 222–32

    PubMed  CAS  Article  Google Scholar 

  48. Wolkowitz OM, Pickar D. Benzodiazepines in the treatment of schizophrenia: a review and reappraisal. Am J Psychiatry 1991; 148: 714–26

    PubMed  CAS  Google Scholar 

  49. Gaudreault P, Guay J, Thivierge RL, et al. Benzodiazepine poisoning: Clinical and pharmacological considerations and treatment. Drug Saf 1991 Jul–Aug; 6(4): 247–65

    PubMed  CAS  Article  Google Scholar 

  50. Shorr RI, Robin DW. Rational use of benzodiazepines in the elderly. Drugs Aging 1994 Jan; 4(1): 9–20

    PubMed  CAS  Article  Google Scholar 

  51. Dietch JT, Jennings RK. Aggressive dyscontrol in patients treated with benzodiazepines. J Clin Psychiatry 1988 May; 49: 184–8

    PubMed  CAS  Google Scholar 

  52. Greenblatt DJ, Shader RI, Franke K, et al. Pharmacokinetics and bioavailability of intravenous, intramuscular, and oral lorazepam in humans. J Pharm Sci 1979 Jan; 68: 57–63

    PubMed  CAS  Article  Google Scholar 

  53. Greenblatt DJ, Divoll M, Harmatz JS, et al. Pharmacokinetic comparison of sublingual lorazepam with intravenous, intramuscular, and oral lorazepam. J Pharm Sci 1982 Feb; 71: 248–52

    PubMed  CAS  Article  Google Scholar 

  54. Cohen S, Khan A, Johnson S. Pharmacological management of manic psychosis in an unlocked setting. J Clin Psychopharmacol 1987; 7: 261–4

    PubMed  CAS  Google Scholar 

  55. Foster S, Kessel J, Berman ME, et al. Efficacy of lorazepam and haloperidol for rapid tranquilization in a psychiatric emergency room setting. Int Clin Psychopharmacol 1997; 12: 175–9

    PubMed  CAS  Article  Google Scholar 

  56. Lenox RH, Newhouse PA, Creelman WL, et al. Adjunctive treatment of manic agitation with lorazepam versus haloperidol: a double-blind study. J Clin Psychiatry 1992; 53: 47–52

    PubMed  CAS  Google Scholar 

  57. Salzman C, Solomon D, Miyawaki E, et al. Parenteral lorazepam versus parenteral haloperidol for the control of psychotic disruptive behavior. J Clin Psychiatry 1991; 52: 177–80

    PubMed  CAS  Google Scholar 

  58. Modell JG. Further experience and observations with lorazepam in the management of behavioral agitation [letter]. J Clin Psychopharmacol 1986 Dec; 6: 385–7

    PubMed  CAS  Google Scholar 

  59. Bird RD, Makela EH. Alcohol withdrawal: what is the benzodiazepine of choice? Ann Pharmacother 1994 Jan; 28(1): 67–71

    PubMed  CAS  Google Scholar 

  60. Miller Jr WC, McCurdy L. A double-blind comparison of the efficacy and safety of lorazepam and diazepam in the treatment of the acute alcohol withdrawal syndrome. Clin Ther. 1984; 6(3): 364–71

    PubMed  Google Scholar 

  61. Greenblatt DJ, Miller LG, Shader RI. Clonazepam pharmacokinetics, brain uptake, and receptor interactions. J Clin Psychiatry 1987; 48 Suppl. 10: 4–9

    PubMed  CAS  Google Scholar 

  62. Crevoisier C, Delisle MC, Joseph I, et al. Comparative single-dose pharmacokinetics of clonazepam following intravenous, intramuscular, and oral administration to healthy volunteers. Eur Neurol 2003; 49: 173–7

    PubMed  CAS  Article  Google Scholar 

  63. Chouinard G, Annable L, Turnier L, et al. A double-blind randomized clinical trial of rapid tranquilization with IM clonazepam and IM haloperidol in agitated psychotic patients with manic symptoms. Can J Psychiatry 1993 Nov; 38 Suppl. 4: 114–20

    Google Scholar 

  64. Benazzi F, Mazzoli M, Rossi E. Benzodiazepines and acute psychotic agitation [letter]. Can J Psychiatry 1992 Dec; 37: 732–3

    PubMed  CAS  Google Scholar 

  65. Bradwejn J, Shriqui C, Koszycki D, et al. Double-blind comparison of the effects of clonazepam and lorazepam in acute mania. J Clin Psychopharmacol 1990; 10: 403–8

    PubMed  CAS  Article  Google Scholar 

  66. Binder RL. Three case reports of behavioral disinhibition with clonazepam. Gen Hosp Psychiatry 1987; 9: 151–3

    PubMed  CAS  Article  Google Scholar 

  67. Karson CN, Weinberger DR, Bigelow L, et al. Clonazepam treatment of chronic schizophrenia: negative results in a double-blind, placebo-controlled trial. Am J Psychiatry. 1982 Dec; 139(12): 1627–8

    PubMed  CAS  Google Scholar 

  68. Greenblatt DJ, Raskin A. Benzodiazepines: new indications. Psychopharmacol Bull 1986; 22: 77–87

    PubMed  Google Scholar 

  69. Lerner Y, Lwow E, Levitin A, et al. Acute high-dose parenteral haloperidol treatment of psychosis. Am J Psychiatry 1979 Aug; 136: 1061–4

    PubMed  CAS  Google Scholar 

  70. Salzman C. Use of benzodiazepines to control disruptive behavior in inpatients. J Clin Psychiatry 1988 Dec; 49 Suppl. 12: 13–5

    PubMed  Google Scholar 

  71. Wyant M, Diamond BI, O’Neal E, et al. The use of midazolam in acutely agitated psychiatric patients. Psychopharmacol Bull 1990; 26: 126–9

    PubMed  CAS  Google Scholar 

  72. Medoza R, Djenderedjian AH, Adams J, et al. Midazolam in acute psychotic patients with hyperarousal. J Clin Psychiatry 1987; 48: 291–2

    Google Scholar 

  73. Dorevitch A, Katz N, Zemishiany Z, et al. Intramuscular flunitrazepam versus instramuscular haloperidol in the emergency treatment of aggressive psychotic behavior. Am J Psychiatry 1999; 156: 142–4

    PubMed  CAS  Google Scholar 

  74. Garza-Trevino ES, Hollister LE, Overall JE, et al. Efficacy of combinations of intramuscular antipsychotics and sedative-hypnotics for control of psychotic agitation. Am J Psychiatry 1989; 146: 1598–601

    PubMed  CAS  Google Scholar 

  75. Thornton WE, Thornton BP. Crisis psychopharmacology techniques. Dis Nerv Syst 1974; 35: 32–4

    PubMed  CAS  Google Scholar 

  76. Barbee JG, Mancuso DM, Freed CR, et al. Alprazolam as a neuroleptic adjunct in the emergency treatment of schizophrenia. Am J Psychiatry 1992; 149: 506–10

    PubMed  CAS  Google Scholar 

  77. Busch FN, Miller FT, Weiden PJ. A comparison of two adjunctive treatment strategies in acute mania. J Clin Psychiatry 1989; 50: 453–5

    PubMed  CAS  Google Scholar 

  78. Menza MA, Murray GB, Holmes VF, et al. Controlled study of extrapyramidal reactions in the management of delirious, medically ill patients: intravenous haloperidol versus intravenous haloperidol plus benzodiazepines. Heart Lung 1988 May; 17: 238–41

    PubMed  CAS  Google Scholar 

  79. Salzman C, Green AI, Rodriguez-Villa F, et al. Benzodiazepines combined with neuroleptics for management of severe disruptive behavior. Psychosomatics 1986 Jan; 27 Suppl. 1: 17–21

    PubMed  CAS  Article  Google Scholar 

  80. Battaglia J, Moss S, Rush J, et al. Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-blind, emergency department study. Am J Emerg Med 1997; 15: 335–40

    PubMed  CAS  Article  Google Scholar 

  81. Bieniek SA, Ownby RL, Penalver A, et al. A double-blind study of lorazepam versus the combination of haloperidol and lorazepam in managing agitation. Pharmacotherapy 1998; 18: 57–62

    PubMed  CAS  Google Scholar 

  82. Bodkin JA. Emerging uses for high-potency benzodiazepines in psychotic disorders. J Clin Psychiatry 1990 May; 51 Suppl. 5: 41–6

    PubMed  Google Scholar 

  83. Adams F, Fernandez F, Andersson BS. Emergency pharmacotherapy of delirium in the critically ill cancer patient. Psychosomatics 1986 Jan; 27 Suppl. 1: 33–7

    PubMed  CAS  Article  Google Scholar 

  84. Battaglia J, Thornton L, Young C. Loxapine-lorazepam induced hypotension and stupor [letter]. J Clin Psychopharmacol 1989; 9: 227–8

    PubMed  CAS  Article  Google Scholar 

  85. Cohen S, Khan A. Respiratory distress with use of lorazepam in mania [letter]. J Clin Psychopharmacol 1987; 7: 199–200

    PubMed  CAS  Article  Google Scholar 

  86. Citrome L. Atypical antipsychotitcs for acute agitation. Postgrad Med 2002 Dec; 112: 85–96

    PubMed  Article  Google Scholar 

  87. Awad AG, Voruganti LN. Impact of atypical antipsychotics on quality of life in patients with schizophrenia. CNS Drugs 2004; 18(13): 877–93

    PubMed  CAS  Article  Google Scholar 

  88. Jann MW, Bunt RM. Switching antipsychotic drugs: a pharmacokinetic, pharmacodynamic, and practical perspective. Psychopharmacol Bull 2002; 36: 22–41

    PubMed  Google Scholar 

  89. Gerlach J. Improving outcome in schizophrenia: the potential importance of EPS and neuroleptic dysphoria. Ann Clin Psychiatry 2002 Mar; 14(1): 47–57

    PubMed  Google Scholar 

  90. McGorry PD, Chanen A, McCarthy E, et al. Posttraumatic stress disorder following recent-onset psychosis: an unrecognized postpsychotic syndrome. J Nerv Ment Dis 1991 May; 179: 253–8

    PubMed  CAS  Article  Google Scholar 

  91. Currier GW, Simpson GM. Risperidone liquid concentrate and oral lorazepam versus intramuscular haloperidol and intramuscular lorazepam for treatment of psychotic agitation. J Clin Psychiatry 2001; 62: 153–7

    PubMed  CAS  Article  Google Scholar 

  92. Currier GW, Chou JC, Feifel D, et al. Acute treatment of psychotic agitation: a randomized comparison of oral treatment with risperidone and lorazepam versus intramuscular treatment with haloperidol and lorazepam. J Clin Psychiatry 2004; 65: 386–94

    PubMed  CAS  Article  Google Scholar 

  93. Brook S. Intramuscular ziprasidone: moving beyond the conventional in treatment of acute agitation in schizophrenia. J Clin Psychiatry 2003; 64 Suppl. 19: 13–8

    PubMed  CAS  Google Scholar 

  94. Daniel DG, Potkin SG, Reeves KR, et al. Intramuscular ziprasidone 20mg is effective in reducing acute agitation associated with psychosis: a double-blind, randomized trial. Psychopharmacology 2001; 155: 128–34

    PubMed  CAS  Article  Google Scholar 

  95. Lesem MD, Zajecka JM, Swift RH, et al. Intramuscular ziprasidone, 2mg versus 10 mg, in the short term management of agitated psychotic patients. J Clin Psychiatry 2001; 62: 12–8

    PubMed  CAS  Article  Google Scholar 

  96. Brook S, Lucey JV, Gunn KP, et al. Intramuscular ziprasidone compared with intramuscular haloperidol in the treatment of acute psychosis. J Clin Psychiatry 2000; 61: 933–41

    PubMed  CAS  Article  Google Scholar 

  97. Daniel DG, Zimbroff DL, Swift RH, et al. The tolerability of intramuscular ziprasidone and haloperidol treatment and the transition to oral therapy. Int Clin Psychopharmacol 2004; 19: 9–15

    PubMed  Article  Google Scholar 

  98. Preval H, Klotz SG, Southard R, et al. Rapid-acting IM ziprasidone in the psychiatric emergency service: a naturalistic study. Gen Hosp Psychiatry 2005; 27: 140–4

    PubMed  Article  Google Scholar 

  99. Battaglia J. Intramuscular olanzapine: treating acute agitation in psychosis and bipolar mania. Curr Psychiatry 2004 May; 3: 76–8

    Google Scholar 

  100. Wright P, Birkett M, David SR, et al. Double-blind, placebo-controlled comparison of intramuscular olanzapine and intramuscular haloperidol in the treatment of acute agitation in schizophrenia. Am J Psychiatry 2001; 158: 1149–51

    PubMed  CAS  Article  Google Scholar 

  101. Breier A, Meehan K, Birkett M, et al. A double-blind, placebo-controlled dose-response comparison of intramuscular olanzapine and haloperidol in the treatment of acute agitation in schizophrenia. Arch Gen Psychiatry 2002; 59: 441–8

    PubMed  CAS  Article  Google Scholar 

  102. Meehan K, Zhang F, David S, et al. A double-blind, randomized comparison of the efficacy and safety of intramuscular injections of olanzapine, lorazepam, or placebo in treating acutely agitated patients diagnosed with bipolar mania. J Clin Psychopharmacology 2001; 21: 389–97

    CAS  Article  Google Scholar 

  103. Meehan KM, Wang H, David SR, et al. Comparison of rapidly acting intramuscular olanzapine, lorazepam, and placebo: a double-blind, randomized study in acutely agitated patients with dementia. Neuropsychopharmacology 2002; 26: 494–504

    PubMed  CAS  Article  Google Scholar 

  104. Lindborg SR, Beasley CM, Alaka K, et al. Effects of intramuscular olanzapine vs. haloperidol and placebo QTc intervals in acutely agitated patients. Psychiatry Res. 2001 Jul; 119(1–2): 113–23

    Google Scholar 

  105. Eli Lilly and Company Limited. Letter to healthcare professionals. Basingstoke, Hampshire, UK: Eli Lilly and Company Limited, 2004 Sep

    Google Scholar 

  106. Wright P, Meehan K, Birkett M, et al. A comparison of the efficacy and safety of olanzapine versus haloperidol during transition from intramuscular to oral therapy. Clin Ther 2003; 25: 1420–8

    PubMed  CAS  Article  Google Scholar 

  107. Bergstrom RF, Mitchell M, Witcher J, et al. Rapid onset of absorption with olanzapine orally disintegrating tablets [poster]. American Psychiatric Association Annual Meeting; 2004 May 1–6; New York

  108. Aijluni V, Amirsadri A, Haddad L, et al. The use of orally disintegrating olanzapine for the control of acute agitation in an urban emergency psychiatric center [poster]. American Psychiatric Association Institute on Psychiatric Services; 2003 Oct 29–Nov 2; Boston

  109. Battaglia J. Is this patient dangerous? 5 steps to assess risk for violence. Current Psychiatry 2004 Feb; 3: 14–21

    Google Scholar 

  110. Alexopoulos GS, Streim J, Carpenter D, et al. Using antipsychotic agents in older patients. J Clin Psychiatry 2004; 65 Suppl. 2: 5–99

    PubMed  Google Scholar 

  111. Levy WO, Robichaux-Keene NR, Nunez C. No significant QTc interval changes with high-dose ziprasidone: a case series. J Psychiatr Pract 2004; 10: 227–32

    PubMed  Article  Google Scholar 

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Acknowledgements

No sources of funding were used to assist in preparation of this manuscript. The author has served as a consultant and speaker for Eli Lilly & Co. and Pfizer Inc. Pharmaceuticals. The author would like to thank Dr Arthur Walaszek for his review of this manuscript.

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Battaglia, J. Pharmacological Management of Acute Agitation. Drugs 65, 1207–1222 (2005). https://doi.org/10.2165/00003495-200565090-00003

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Keywords

  • Haloperidol
  • Risperidone
  • Olanzapine
  • Ziprasidone
  • Droperidol