Agitation refers to a spectrum of abnormal behaviors frequently seen in patients with psychiatric illnesses, including in individuals with schizophrenia or bipolar disorder.1 It is a mental and physical state that is characterized by motor restlessness, mental tension, and excitement, and it is often marked by poorly organized, aimless psychomotor activity.1 Agitated patients may exhibit aggressive behavior, resulting in harm to themselves, other patients, and healthcare workers.2 Therefore, prompt and effective management of agitation is critically important in the care of schizophrenia or bipolar disorder, and it requires the skills and expertise of several types of professionals. Typically, both pharmacologic and nonpharmacologic strategies are necessary to achieve optimal results.
Pharmacologic and Nonpharmacologic Management of Agitation Associated with Schizophrenia or Bipolar Disorder
Antipsychotics and benzodiazepines may be used to treat agitation.3 Route of administration is an important consideration because the same drug administered orally may take at least twice as long to take effect as it does when administered intramuscularly.3 In fact, severely agitated patients are successfully managed with oral drugs alone in only 55% of cases.4
Unfortunately, medication administration requiring use of hypodermic syringes poses hazards to medical personnel when dealing with agitated patients. Therefore, a different delivery system eschewing use of these syringes is desirable. The recent development and approval of a first-generation antipsychotic drug that uses an inhalation-activated aerosol as its delivery modality is an important therapeutic advance in the management of patients with agitation associated with schizophrenia or bipolar disorder.2,5 Because of the risk for bronchospasm, patients receiving this drug need to be screened and monitored.2
The goal of managing agitation is for the patient to be calm but not asleep, so that practitioners are able to perform a more in-depth assessment to determine the next steps of treatment.6 Whenever possible, nonpharmacologic interventions should be implemented in advance of treatment with drugs,6 and patients should be involved in decisions regarding the types of drugs used and the route of administration.
A differential diagnosis is essential for the effective management of agitated behavior. For example, in hospital settings, agitation may be seen as delirium or hyperactive cognitive impairment, particularly among geriatric patients.7 Research indicates that violence among hospitalized patients is often preceded by agitation, and this should be recognized by mental health professionals so that de-escalation techniques and medications can be administered.8 For example, engaging hospitalized agitated patients in a directed activity may be an effective technique to reduce their agitation levels. In one study, patients who had a dedicated observer were less likely to become agitated when they were involved in an individualized therapeutic activity.9
The Role of Healthcare Professionals in Community-Based and Hospital Settings
Patients with agitation associated with schizophrenia or bipolar disorder may get assistance from healthcare professionals in community-based, hospital, and day-hospital settings. Community-based services help individuals with psychiatric illness integrate into society and into daily routines outside of hospitals. Such services emphasize personal goals and independence.10 Social support services and mental health services, provided by professionals, play an important role in community-based approaches. The professionals are primary facilitators of patient recovery in this setting. Specialty nurses, such as community psychiatric nurses or psychiatric–mental health nurses, often work in community settings, supplementing psychiatrists, social workers, and psychologists. Because nurses focus on patient care, these professionals are well-suited to observe and help patients manage their symptoms. Other advantages of having nurses manage outpatients are their relative accessibility, their ability to deliver support and counseling to patients, and their ability to monitor medication use (Table 1).11 All professionals who work in community-based settings must be trained to recognize and prevent relapses. In one study, training that focused specifically on recognizing patient relapses increased staff skills and confidence in implementing these new skills.12
Community-based mental health facilities often use assertive community treatment (ACT) or intensive case management (ICM).13 The latter approach is meant for small caseloads (<20 patients).14 According to a meta-analysis of 24 randomized controlled trials that compared ICM with standard outpatient care, ICM was associated with a significantly reduced length of hospitalization and significantly less risk for being lost to follow-up psychiatric care.14 ICM did not, however, reduce the length of hospital stay when caseworkers had >20 patients.14
ACT was created to be a community-based alternative to hospitalization for patients with mental health disorders such as schizophrenia or bipolar disorder.13 It is delivered by multidisciplinary teams, generally in patients’ homes or public places, and offers 24-hour coverage.13 The team usually consists of a psychiatrist, a nurse, and case managers who provide most of the services.13 The low patient-to-staff ratio plus the emphasis on treatment in a patient’s own environment reflects a model that puts a priority on activities of daily living.13 However, not all attempts to establish ACT teams are successful, nor is there a single model for a successful ACT team.13
The most consistent findings when comparing ACT with ICM programs are that both approaches reduce inpatient hospitalization time13 and hospital admissions.15 Time spent in hospital is closely linked with housing stability, and ACT and ICM were associated with improvements in this area as well.13 Controlled studies also indicate that ACT and ICM decrease symptom severity and improve quality of life for patients, which may correlate with greater housing stability and reduced hospitalization. An integrated care treatment model that included ACT showed better efficacy for patients with schizophrenia and bipolar disorder at reduced costs, compared with standard care.15 Importantly, the disengagement rate among patients was low—only 6.3% in the first year—compared with 23.2% among those in standard care.15 As one may expect, ACT and ICM programs result in higher satisfaction among patients and their relatives compared with hospital- or clinic-based treatment.13
Although few studies of long-term follow-up of community-based services such as ACT have been conducted, there is evidence to suggest that patients benefit from additional support services.16 Results from a recent, very small study indicate that patients receiving ACT had fewer hospital admissions and higher social functioning scores than those who received standard community-based care.17 A study of ACT embedded in intensive care showed that for patients with schizophrenia or bipolar disorder I, such an integrated level of care offered more efficacy than standard care in the short-term (<1 year).15 At the 2-year follow-up, there was a statistically significant decrease in the rate of involuntary hospital admissions (Table 2).15 All patients showed significant improvement in psychopathology, illness severity, level of functioning, quality of life, satisfaction with treatment, and adherence to medication.
Family and friends often act as important supports for individuals with schizophrenia or bipolar disorder. Fortunately, guidelines have been developed that discuss real-life dilemmas that lay and professional caregivers may face. They also describe methods that can be used to move patients toward self-management.18 Because caregivers interface with patients more frequently than professionals do, they may be able to deliver more flexible support to patients, as well as serve as a conduit between mental health professionals and patients, for example, by recognizing when symptoms worsen.18
Day hospitals offer another treatment option for patients with schizophrenia or bipolar disorder. With limited data available, there appears to be no difference between day-hospital and outpatient care with regard to continuation of treatment at 6 months for patients with schizophrenia.19 Whereas day hospitals may help individuals avoid inpatient care, data are lacking regarding outcomes such as quality of life and cost containment.19 However, evidence does show that day hospitals are as effective as inpatient care for patients with acute psychiatric disorders.20 Few studies regarding the benefit of community-based care have been conducted among those with bipolar disorder. One ongoing study that enrolled patients with major depressive disorder is comparing the effects of cognitive and dynamic therapies in the community setting.21 The results of this study should disclose whether short-term dynamic psychotherapy is a suitable treatment option for major depressive disorder.21
- Mohr P, Pecenak J, Svestka J, et al. Treatment of acute agitation in psychotic disorders. Neuro Endocrinol Lett. 2005;26:327-335.
- Citrome L. Addressing the need for rapid treatment of agitation in schizophrenia and bipolar disorder: focus on inhaled loxapine as an alternative to injectable agents. Ther Clin Risk Manag. 2013;9:235-245.
- Schleifer JJ. Management of acute agitation in psychosis: an evidence-based approach in the USA. Adv Psychiatr Treat. 2011;17:91-100.
- De Fruyt J, Demyttenaere K. Rapid tranquilization: new approaches in the emergency treatment of behavioral disturbances. Eur Psychiatry. 2004;19:243-249.
- Owen RT. Inhaled loxapine: a new treatment for agitation in schizophrenia or bipolar disorder. Drugs Today (Barc). 2013;49:195-201.
- Wilson MP, Pepper D, Currier GW, et al. The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project Beta Psychopharmacology Workgroup. West J Emerg Med. 2012;13:26-34.
- Sendelbach S, Guthrie PF, Schoenfelder DP. Acute confusion/delirium. J Gerontol Nurs. 2009;35:11-18.
- Hankin CS, Bronstone A, Koran LM. Agitation in the inpatient psychiatric setting: a review of clinical presentation, burden, and treatment. J Psychiatr Pract. 2011;17:170-185.
- Waszynski C, Veronneau P, Therrien K, et al. Decreasing patient agitation using individualized therapeutic activities. Am J Nurs. 2013;113:32-39.
- Chang YC, Heller T, Pickett S, Chen MD. Recovery of people with psychiatric disabilities living in the community and associated factors. Psychiatr Rehabil J. 2013;36:80-85.
- Goossens PJ, Beentjes TA, de Leeuw JA, et al. The nursing of outpatients with a bipolar disorder: what nurses actually do. Arch Psychiatr Nurs. 2008;22:3-11.
- Lobban F, Taylor L, Chandler C, et al. Training staff in enhanced relapse prevention for bipolar disorder: rates of uptake and measures of skill and confidence. Psychiatr Serv. 2009;60:702-706.
- Mueser KT, Bond GR, Drake RE, Resnick SG. Models of community care for severe mental illness: a review of research on case management. Schizophr Bull. 1998;24:37-74.
- Dieterich M, Irving CB, Park B, Marshall M. Intensive case management for severe mental illness. Cochrane Database Syst Rev. 2010:CD007906.
- Schottle D, Schimmelmann BG, Karow A, et al. Effectiveness of integrated care including therapeutic assertive community treatment in severe schizophrenia spectrum and bipolar I disorders: the 24-month follow-up ACCESS II study. J Clin Psychiatry. 2014;75:1371-1379.
- Rana T, Commander M. Long-term follow-up of individuals on assertive outreach teams. Psychiatrist. 2010;34:88-91.
- Zhao W, Law S, Luo X, et al. First adaptation of a family-based ACT model in mainland China: a pilot project. Psychiatr Serv. 2015;66:438-441.
- Berk L, Jorm AF, Kelly CM, et al. Development of guidelines for caregivers of people with bipolar disorder: a Delphi expert consensus study. Bipolar Disord. 2011;13:556-570.
- Shek E, Stein AT, Shansis FM, et al. Day hospital versus outpatient care for people with schizophrenia. Cochrane Database Syst Rev. 2009:CD003240.
- Marshall M, Crowther R, Sledge WH, et al. Day hospital versus admission for acute psychiatric disorders. Cochrane Database Syst Rev. 2011:CD004026.
- Connolly Gibbons MB, Mack R, Lee J, et al. Comparative effectiveness of cognitive and dynamic therapies for major depressive disorder in a community mental health setting: study protocol for a randomized non-inferiority trial. BMC Psychol. 2014;2:47