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C.07.01 Global overview of epidemiology of agitation
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C.07. Agitation in psychiatric emergencies
achieve relief of symptoms of manic and/or depressive episodes, as well as long-term maintenance of symptom stability across both poles. Current guidelines recommend similar treatment algorithms for all patients and do not account for the heterogeneity of bipolar disorder. Episodes of mania or depression with symptoms from the opposite pole are more difficult to treat than episodes of depression or mania alone. Indeed, mania with depressive symptoms or depression with manic symptoms represent some of the most challenging situations encountered in the management of patients with bipolar illness. Effective treatment of mixed states depends on identifying both states, starting treatment for both states early, and considering maintenance treatment and long-term outcome in addition to acute management. The treatment of mania with depressive symptoms is hindered by the fact that the efficacy of drugs used for the treatment of pure manias is largely unproven in this subset of patients; most mixed state data comes from post-hoc analyses of trials including both manic and mixed patients [1]. In clinical practice, antipsychotics and anticonvulsants are the most commonly prescribed drug class in mixed state patients [2]. Currently, no pharmacological treatment has an indication for the treatment of mania with depressive symptoms. Emerging data, applying DSM-5 methodology, supports the use of antipsychotic treatment, such as treatment with asenapine, in patients displaying depressive symptoms during their manic episodes [3].
Akathisia is frequent with the use of antipsychotics. Treatment with antidepressants like SSRIs may also aggravate agitation in sensitive individuals. Agitated conditions are associated with challenging behavior like increased risk of violence. Severe agitation is associated with behavioral dyscontrol and assaultiveness. Agitation is strongly associated to inpatient suicides [1]. Treatment of agitated conditions is thus mandatory in order to prevent harmful behavior towards the self, other patients or staff. There are few epidemiological studies assessing the prevalence or clinical impact of agitated states in different clinical settings [2]. The studies are complicated by a number of imprecise or conflicting definitions. In a recent study from psychiatric emergency services in US agitation was present in 52% of the subjects [3]. However, agitation has not been adequately addressed in clinical research. Epidemiological and controlled clinical trials are urgently needed. References [1] Busch, K.A., Fawcett, J., Jacobs, D.G., 2003. Clinical correlates of inpatient suicide. J Clin Psychiatry 64(1), 14−19. [2] Sachs, G.S., 2006. A review of agitation in mental illness: Burden of illness and underlying pathology. J Clin Psychiatry 67, 5−12. [3] Boudreaux, E.D., Allen, M.H., Claassen, C., et al., 2009. The psychiatric emergency research collaboration-01: Methods and results. Gen Hosp Psychiatry 31(6), 515–522.
References [1] Muralidharan, K, Ali, M, Silveira, L.E., et al. 2013. Efficacy of second generation antipsychotics in treating acute mixed episodes in bipolar disorder: a meta-analysis of placebo-controlled trials. J Affect Disord 150(2), 408–414. [2] Vieta, E, Langosch, J.M., Figueira, M.L., et al. 2013. Clinical management and burden of bipolar disorder: results from a multinational longitudinal study (WAVE-bd). Int J Neuropsychopharmacol 16(8), 1719–1732. [3] McIntyre, R.S., Tohen, M, Berk, M, et al. 2013. DSM-5 mixed specifier for manic episodes: evaluating the effect of depressive features on severity and treatment outcome using asenapine clinical trial data. J Affect Disord 150(2), 378–383. Disclosure statement: Professor Fagiolini has received research grants and/or has participated in symposia sponsored for by, and/or has been a speaker and/or a consultant for: Angelini, Astra Zeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Pfizer, Eli Lilly, Janssen, Lundbeck, Novartis, Otsuka, Roche. This abstract is financially supported by an educational grant from H. Lundbeck A/S.
C.07. Agitation in psychiatric emergencies C.07.01 Global overview of epidemiology of agitation A. Vaaler1 ° 1 The Norwegian University of Science and Technology, Department of Neuroscience, Trondheim, Norway Agitation is frequently observed as a cluster of unspecific symptoms in patients acutely admitted to psychiatric facilities or hospital emergency services. There is no consensus for a definition of the condition, but it may be defined as a state of motor restlessness accompanied by mental tension. Agitated mental states are frequent in a number of psychiatric disorders including schizophrenia, bipolar disorders, dementia and substance abuse. It is also a frequent symptom in a number of medical conditions like organic brain disorders. Agitation may also develop as a side effect of the pharmacological treatment of acute psychiatric conditions.
C.07.02 Agitation continuum as critical symptom in psychiatric emergencies P. Llorca1 °
1 Universit´ e
d’Auvergne, Clermont-Ferrand, France
Emergency department is commonly the first point of care for patients with acute behavioral issues from the community. Emergencies are frequently emotional and chaotic. These stressful situations are amplified by long wait times, noise of the emergency department and other various environmental aspects. All these factors can trigger or exacerbate agitation. Every day emergency providers encounter agitated patients, from the actively psychotic schizophrenic to the belligerent chronic alcoholic. Physician have to quickly limit these behaviors and identify and treat their etiology, while simultaneously protecting patients’ rights and reducing the risks of injury to other patients and medical staff [1]. More than 10 specific scales for the evaluation of agitation have been developed and validated [2]. Their use to assess the level of agitation, to determine the appropriate treatment whether to use deescalation, restraint, seclusion, medication, or a combination of these, is strongly recommended. Despite this, in clinical practice, they are not frequently used in emergency departments, and clinicians don’t use the information collected to drive their medical decision. The agitated patient may need the application of restraints or use of seclusion to ensure patient and staff safety. Few studies describe the fact that being restrained appears to be associated with decreased likelihood of attending prescribed outpatient follow-up mental health treatment [3]. Clinicians should consider alternatives to physical restraints whenever possible to minimize impact on treatment compliance after discharge from the emergency department. References [1] Zun LS. Pitfalls in the care of the psychiatric patient in the emergency Department. The Journal of Emergency Medicine, Vol. 43, No. 5, pp. 829–835, 2012.
C.07. Agitation in psychiatric emergencies
achieve relief of symptoms of manic and/or depressive episodes, as well as long-term maintenance of symptom stability across both poles. Current guidelines recommend similar treatment algorithms for all patients and do not account for the heterogeneity of bipolar disorder. Episodes of mania or depression with symptoms from the opposite pole are more difficult to treat than episodes of depression or mania alone. Indeed, mania with depressive symptoms or depression with manic symptoms represent some of the most challenging situations encountered in the management of patients with bipolar illness. Effective treatment of mixed states depends on identifying both states, starting treatment for both states early, and considering maintenance treatment and long-term outcome in addition to acute management. The treatment of mania with depressive symptoms is hindered by the fact that the efficacy of drugs used for the treatment of pure manias is largely unproven in this subset of patients; most mixed state data comes from post-hoc analyses of trials including both manic and mixed patients [1]. In clinical practice, antipsychotics and anticonvulsants are the most commonly prescribed drug class in mixed state patients [2]. Currently, no pharmacological treatment has an indication for the treatment of mania with depressive symptoms. Emerging data, applying DSM-5 methodology, supports the use of antipsychotic treatment, such as treatment with asenapine, in patients displaying depressive symptoms during their manic episodes [3].
Akathisia is frequent with the use of antipsychotics. Treatment with antidepressants like SSRIs may also aggravate agitation in sensitive individuals. Agitated conditions are associated with challenging behavior like increased risk of violence. Severe agitation is associated with behavioral dyscontrol and assaultiveness. Agitation is strongly associated to inpatient suicides [1]. Treatment of agitated conditions is thus mandatory in order to prevent harmful behavior towards the self, other patients or staff. There are few epidemiological studies assessing the prevalence or clinical impact of agitated states in different clinical settings [2]. The studies are complicated by a number of imprecise or conflicting definitions. In a recent study from psychiatric emergency services in US agitation was present in 52% of the subjects [3]. However, agitation has not been adequately addressed in clinical research. Epidemiological and controlled clinical trials are urgently needed. References [1] Busch, K.A., Fawcett, J., Jacobs, D.G., 2003. Clinical correlates of inpatient suicide. J Clin Psychiatry 64(1), 14−19. [2] Sachs, G.S., 2006. A review of agitation in mental illness: Burden of illness and underlying pathology. J Clin Psychiatry 67, 5−12. [3] Boudreaux, E.D., Allen, M.H., Claassen, C., et al., 2009. The psychiatric emergency research collaboration-01: Methods and results. Gen Hosp Psychiatry 31(6), 515–522.
References [1] Muralidharan, K, Ali, M, Silveira, L.E., et al. 2013. Efficacy of second generation antipsychotics in treating acute mixed episodes in bipolar disorder: a meta-analysis of placebo-controlled trials. J Affect Disord 150(2), 408–414. [2] Vieta, E, Langosch, J.M., Figueira, M.L., et al. 2013. Clinical management and burden of bipolar disorder: results from a multinational longitudinal study (WAVE-bd). Int J Neuropsychopharmacol 16(8), 1719–1732. [3] McIntyre, R.S., Tohen, M, Berk, M, et al. 2013. DSM-5 mixed specifier for manic episodes: evaluating the effect of depressive features on severity and treatment outcome using asenapine clinical trial data. J Affect Disord 150(2), 378–383. Disclosure statement: Professor Fagiolini has received research grants and/or has participated in symposia sponsored for by, and/or has been a speaker and/or a consultant for: Angelini, Astra Zeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Pfizer, Eli Lilly, Janssen, Lundbeck, Novartis, Otsuka, Roche. This abstract is financially supported by an educational grant from H. Lundbeck A/S.
C.07. Agitation in psychiatric emergencies C.07.01 Global overview of epidemiology of agitation A. Vaaler1 ° 1 The Norwegian University of Science and Technology, Department of Neuroscience, Trondheim, Norway Agitation is frequently observed as a cluster of unspecific symptoms in patients acutely admitted to psychiatric facilities or hospital emergency services. There is no consensus for a definition of the condition, but it may be defined as a state of motor restlessness accompanied by mental tension. Agitated mental states are frequent in a number of psychiatric disorders including schizophrenia, bipolar disorders, dementia and substance abuse. It is also a frequent symptom in a number of medical conditions like organic brain disorders. Agitation may also develop as a side effect of the pharmacological treatment of acute psychiatric conditions.
C.07.02 Agitation continuum as critical symptom in psychiatric emergencies P. Llorca1 °
1 Universit´ e
d’Auvergne, Clermont-Ferrand, France
Emergency department is commonly the first point of care for patients with acute behavioral issues from the community. Emergencies are frequently emotional and chaotic. These stressful situations are amplified by long wait times, noise of the emergency department and other various environmental aspects. All these factors can trigger or exacerbate agitation. Every day emergency providers encounter agitated patients, from the actively psychotic schizophrenic to the belligerent chronic alcoholic. Physician have to quickly limit these behaviors and identify and treat their etiology, while simultaneously protecting patients’ rights and reducing the risks of injury to other patients and medical staff [1]. More than 10 specific scales for the evaluation of agitation have been developed and validated [2]. Their use to assess the level of agitation, to determine the appropriate treatment whether to use deescalation, restraint, seclusion, medication, or a combination of these, is strongly recommended. Despite this, in clinical practice, they are not frequently used in emergency departments, and clinicians don’t use the information collected to drive their medical decision. The agitated patient may need the application of restraints or use of seclusion to ensure patient and staff safety. Few studies describe the fact that being restrained appears to be associated with decreased likelihood of attending prescribed outpatient follow-up mental health treatment [3]. Clinicians should consider alternatives to physical restraints whenever possible to minimize impact on treatment compliance after discharge from the emergency department. References [1] Zun LS. Pitfalls in the care of the psychiatric patient in the emergency Department. The Journal of Emergency Medicine, Vol. 43, No. 5, pp. 829–835, 2012.