Addressing Agitation Through a Collaborative Conversation

Among the clinical challenges that come with treating patients living with bipolar disorder and/or schizophrenia is how to address agitated states in a way that is safe, effective, and reinforces the integrity of the patient-doctor relationship.

On Monday, September 19, at the 35th Annual Psych Congress in New Orleans, Psych Congress Network Section Editor Leslie Citrome, MD, MPH, presented his session titled “Treating Agitation: Can We Avoid Injections? Should We?” before an audience of mental healthcare professionals, including doctors, nurse practitioners, care advocates, and non-profit representatives.

Dr Citrome sat down with Psych Congress Network on-site at the meeting to discuss his clinical approach to handling patient agitation, including presenting patients with a range of medication administration options from oral to intramuscular injection.

Be sure to reserve your spot now for Psych Congress 2023 and join us in Nashville, Tennessee, next September! For more insights direct from the 2022 session rooms, check out the Psych Congress newsroom here.

Read the Transcript:

Leslie Citrome, MD, MPH: Hi, I'm Dr. Leslie Citrome, Clinical Professor of Psychiatry and Behavioral Sciences at New York Medical College in Valhalla, New York.

I've been interested in the problem of agitation in psychiatric patients since the beginning of my career some years ago. My first job was at a psychiatric intensive care unit in a VA hospital. I also spent quite a bit of time working in different emergency departments in my county and the county right over. And I often had to deal with agitation and I was very interested in ways of handling that emergency safely and effectively.

The principle challenge in managing agitation in people with schizophrenia or bipolar disorder is its early identification and effective intervention before it escalates into aggressive behavior or possibly violence. So the idea here is to offer something early and also engage in a conversation with the person when they're able to do so and you could nip it in the bud so to speak.

In my presentation I talk about the use of oral interventions to manage agitation rather than focusing on intramuscular injections of agents that would be used to treat agitation. By the time that intramuscular injection is required it's often too late to have a good experience. Sometimes though patients will ask for an injection knowing that in the past it has worked for them rather quickly, and they may have identified an agent that they were able to tolerate. But far more often I've seen patients receive injections after things got out of control, and it's a bad experience for everyone. Moreover, staff are placed in danger by having to give an injection over a patient's objection. It takes five people, one to hold each limb and one to do the injection. Someone invariably gets hurt.

Oral medications are often preferred by everyone, it's just simply easier. There's no needle involved. Patients are used to taking a medicine to feel differently. When offered a medicine to help them relax they're often accepting of it if they've had some experience with it, and they realize that this is an attempt to decrease their level of discomfort. We have to remember that agitation is ego dystonic, people don't like feeling agitated, they want relief. On the other hand they may be somewhat paranoid or suspicious. They may be thinking that you want to medicate them or sedate them. So the idea here is to present a choice for patients. You seem like you're not comfortable and you seem what we call agitated. Is there something that we can do to help you with that? So tell me about that. So it starts a dialogue. I also offer something like water, or if I have a sandwich, we call it sandwich therapy, and it is offering something to the person to show that you care for their wellbeing.

At the same time when given a choice about what kind of medicine to receive they're able to express a preference. You can also even say we have injectable medicines that work really quickly and we have oral medicines that work a little bit more slowly, which one would you rather have? Oh, I don't want to take anything sometimes what we hear. Well what if you had to take something, which one would you prefer? And we have something new that you put in your mouth that is absorbed in the mouth that works just as fast as an injection. I think it's worthwhile to give it a try.

Leslie Citrome, MD, MPH, is clinical professor of psychiatry and behavioral sciences at New York Medical College in Valhalla, New York, and adjunct clinical professor of psychiatry, Icahn School of Medicine at Mount Sinai in New York City, New York. In addition to his academic positions, he has a private practice in psychiatry in Pomona, New York, and is a volunteer consultant to the Assertive Community Treatment team/Mental Health Association of Rockland County. He is a Distinguished Life Fellow of the American Psychiatric Association and a Fellow of the American Society of Clinical Psychopharmacology where he currently serves as President. Dr Citrome is editor emeritus, International Journal of Clinical Practice, where he was editor-in-chief 2013-2019; psychiatry topic editor for Clinical Therapeutics; editor for the American Society of Clinical Psychopharmacology Corner in the Journal of Clinical Psychiatry; section editor for psychopharmacology for Current Psychiatry; and also serves as an editorial board member for several other medical journals.