Treating Agitation in Bipolar Disorder: Challenges and Clinical Pearls

Agitation and irritability can be common manifestations in many psychiatric disorders, including bipolar disorder and schizophrenia, and can be a common occurrence in psychiatric settings. In his 2022 Psych Congress session "Treating Agitation: Can We Avoid Injections? Should We?" Leslie Citrome, MD, MPH, clinical professor at New York Medical College, Valhalla, New York, reviewed the available options for managing agitation in patients from verbal de-escalation techniques to non-invasive medication treatment options when appropriate. Following his session, Psych Congress Network caught up with Dr Citrome on treatment challenges, how episode frequency affects care, and his clinical pearls for clinicians.

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Leslie Citrome, MD, MPH, is clinical professor of psychiatry and behavioral sciences at New York Medical College in Valhalla, New York, and has a private practice in Pomona, New York. He is editor in chief of Current Medical Research and Opinion, published by Taylor & Francis. He is the current president of the American Society of Clinical Psychopharmacology. Dr Citrome was the founding director of the Clinical Research and Evaluation Facility at the Nathan S. Kline Institute for Psychiatric Research in Orangeburg, New York, and after nearly 2 decades of government service as a researcher in the psychopharmacological treatment of severe mental disorders, Dr Citrome is now engaged as a consultant in clinical trial design and interpretation.

Main areas of interest include schizophrenia, bipolar disorder, and major depressive disorder. He is a frequent lecturer on the quantitative assessment of clinical trial results using the evidence-based medicine metrics of numbers needed to treat and numbers needed to harm. 

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.

Meagan Thistle, Digital Managing Editor, Psych Congress Network: What would you say are the main challenges for clinicians treating agitation in patients with bipolar disorder and schizophrenia?

Citrome: The principal 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.

Thistle, PCN: Does agitation treatment differ in patients experiencing a first episode of bipolar disorder or schizophrenia versus a patient who has relapsed or had multiple episodes? 

Citrome: It's often challenging when managing someone in their first episode, because they often have no experience at all with the medicines that we have available. So, some of the medicines that I would talk about would be unfamiliar to them. Someone with more lived experience with the disorder has some experience and can express some likes and dislikes about how they've been treated. That can be very, very helpful in terms of offering a medicine that would be helpful to them.

Thistle, PCN: Any last clinical pearls for clinicians? 

Citrome: So, a key takeaway from my presentation, which I hope you'll be able to listen to on the web, is that we have agents much better than haloperidol to manage agitation in our patients with schizophrenia or bipolar disorder. And I think haloperidol is antiquated. We have many other options, including other intramuscular options that are better tolerated and now some oral options that work quickly as well.