Treatments for aggression and agitation

How is aggression and agitation relevant to schizophrenia?

Agitation and/or aggression are sometimes observed during a psychiatric emergency such as in onset of acute psychosis. Agitation typically includes irritability and restlessness, motor or verbal hyperactivity, uncooperativeness, and occasionally aggressive gestures or behaviour. This can pose a risk both to the individual, as well as the attending health care professionals, and so is important to manage this behaviour and prevent potential harm. A number of pharmacological therapies have been tested for quickly alleviating agitated or aggressive behaviour in people with schizophrenia.

What is the evidence for treatments for aggression and agitation?

Moderate to high quality evidence suggests both antipsychotics haloperidol and aripiprazole are effective for reducing agitation in the immediate to short-term, although aripiprazole has less side effects (e.g. movement disorder) than haloperidol. Moderate quality evidence suggests some benefit of other antipsychotics chlorpromazine, olanzapine, ziprasidone and risperidone, and benzodiazepine lorazepam. Moderate to low quality evidence suggests clozapine may be more effective than other agents for reducing aggression in acutely unwell patients. Moderate to low quality evidence suggests a medium effect of 5 to 10mg of aerosol loxapine for reducing agitation.
Also see the Course and Outcome topic on criminal offending.
August 2016

Physical restraint

What is physical restraint? 

The management of acutely disturbed patients poses a challenge for mental health services. Some patients may be suicidal while others may pose a danger to staff or other patients. The challenge is to maintain the safety of all patients and staff, while providing a therapeutic environment. Management techniques for dealing with patients who become excessively agitated, aggressive, or violent may include the use of physical restraint, seclusion or containment.

What is the evidence for physical restraint ?

Moderate to low quality evidence suggests prevalence rates of restraint vary across countries, from 3.8% of patient admissions in Finland to 20% in Japan. Slovenia had a prevalence rate of 5%, Switzerland 6.6%, Germany 7% to 10.4%, United States 8% to 13.6%, Australia 9.4% to 12.5%, and Norway, Israel and Poland all had rates between 14.1% and 15.7%. Factors associated with the use of restraint are male sex, young adult age, foreign ethnicity, schizophrenia diagnosis, involuntary admission, aggression or trying to abscond, and the presence of male staff. Review authors conclude that staff require training on the use of alternatives to physical restraint in order to reduce any risks associated with restraint.

 

April 2016

Crisis intervention

What are crisis interventions? 

People with severe mental illnesses such as schizophrenia may be in need of
emergency care at some stage in their illness, particularly in the early stages. Crisis
intervention is a treatment model designed to offer intensive crisis-focused treatment
to people living in the community, and is usually provided in the context of home-based care. Crisis intervention programs comprise teams of specialist staff who often provide 24-hour availability of support. This may be a mobile treatment, a dedicated unit based in a hospital or day centre, or a residential.

What is the evidence for crisis interventions?

Moderate to low quality evidence suggests improved overall symptoms and social
adjustment by 20 months, reduced unsociable behaviour, agitation, and disorientation
by 4-6 months, reduced family burden and disruption by 3 months but not 6 months,
and greater patient and relative satisfaction with home-based crisis intervention over
hospitalisation. Moderate to high quality evidence also suggests a small effect of home-based
crisis intervention over hospitalisation for retaining people in the study in the
medium term (6-12 months), but not the short term (< 3 months) or the long term (20
months).

 

May 2016