Marina Garriga1,2, Isabella Pacchiarotti1, Siegfried Kasper3, Scott L Zeller4, Michael H Allen5, Gustavo Vázquez6, Leonardo Baldaçara7, Luis San8, R Hamish McAllister-Williams9, Konstantinos N Fountoulakis10, Philippe Courtet11, Dieter Naber12, Esther W Chan13, Andrea Fagiolini14, Hans Jürgen Möller15, Heinz Grunze16, Pierre Michel Llorca17, Richard L Jaffe18, Lakshmi N Yatham19, Diego Hidalgo-Mazzei1, Marc Passamar20, Thomas Messer21, Miquel Bernardo2, Eduard Vieta1. 1. a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain ; 2. b Barcelona Clinic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Clinic of Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain ; 3. c Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria ; 4. d Alameda Health System , Oakland , CA 94602 , USA ; 5. e University of Colorado Depression Center , Denver , CO 80045 , USA ; 6. f Research Center for Neuroscience and Neuropsychology, Department of Neuroscience , University of Palermo , Buenos Aires , Argentina ; 7. g Federal University of Tocantins , Palmas , Tocantis , Brazil ; 8. h CIBERSAM, Parc Sanitari Sant Joan De Déu , Barcelona , Catalonia , Spain ; 9. i Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK; Northumberland Tyne and Wear NHS Foundation Trust , Newcastle upon Tyne , UK ; 10. j 3rd Department of Psychiatry, School of Medicine , Aristotle University of Thessaloniki , Thessaloniki , Greece ; 11. k Department of Emergency Psychiatry and Post Acute Care , Hôpital Lapeyronie , CHU Montpellier , France ; 12. l Department for Psychiatry and Psychotherapy , University Medical Center Hamburg-Eppendorf , Hamburg , Germany ; 13. m Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine , the University of Hong Kong , Hong Kong , China ; 14. n School of Medicine, Department of Molecular Medicine , University of Siena , Siena , Italy ; 15. o Department of Psychiatry and Psychotherapy , Ludwig Maximilian University , Munich , Germany ; 16. p Paracelsus Medical University , Salzburg , Austria ; 17. q Service De Psychiatrie B , CHU De Clermont-Ferrand , Clermont-Ferrand , France ; 18. r Belmont Behavioral Hospital , Philadelphia , PA , USA ; 19. s Mood Disorders Centre, Department of Psychiatry , University of British Columbia , Vancouver , British Columbia , Canada ; 20. t Centre Hospitalier Pierre-Jamet, SAUS , Albi , France ; 21. u Danuvius Klinik GmbH, Pfaffenhofen an Der Ilm , Germany.
Abstract
BACKGROUND: Psychomotor agitation is associated with different psychiatric conditions and represents an important issue in psychiatry. Current recommendations on agitation in psychiatry are not univocal. Actually, an improper assessment and management may result in unnecessary coercive or sedative treatments. A thorough and balanced review plus an expert consensus can guide assessment and treatment decisions. METHODS: An expert task force iteratively developed consensus using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new, re-worded or re-rated items. RESULTS: Out of 2175 papers assessing psychomotor agitation, 124 were included in the review. Each component was assigned a level of evidence. Integrating the evidence and the experience of the task force members, a consensus was reached on 22 statements on this topic. CONCLUSIONS: Recommendations on the assessment of agitation emphasise the importance of identifying any possible medical cause. For its management, experts agreed in considering verbal de-escalation and environmental modification techniques as first choice, considering physical restraint as a last resort strategy. Regarding pharmacological treatment, the "ideal" medication should calm without over-sedate. Generally, oral or inhaled formulations should be preferred over i.m. routes in mildly agitated patients. Intravenous treatments should be avoided.
BACKGROUND:Psychomotor agitation is associated with different psychiatric conditions and represents an important issue in psychiatry. Current recommendations on agitation in psychiatry are not univocal. Actually, an improper assessment and management may result in unnecessary coercive or sedative treatments. A thorough and balanced review plus an expert consensus can guide assessment and treatment decisions. METHODS: An expert task force iteratively developed consensus using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new, re-worded or re-rated items. RESULTS: Out of 2175 papers assessing psychomotor agitation, 124 were included in the review. Each component was assigned a level of evidence. Integrating the evidence and the experience of the task force members, a consensus was reached on 22 statements on this topic. CONCLUSIONS: Recommendations on the assessment of agitation emphasise the importance of identifying any possible medical cause. For its management, experts agreed in considering verbal de-escalation and environmental modification techniques as first choice, considering physical restraint as a last resort strategy. Regarding pharmacological treatment, the "ideal" medication should calm without over-sedate. Generally, oral or inhaled formulations should be preferred over i.m. routes in mildly agitated patients. Intravenous treatments should be avoided.
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