New Treatment Options Offer Hope for Treating Agitation in Schizophrenia and Bipolar Disorder Patients

Among patients diagnosed with schizophrenia and bipolar disorder who exhibit agitation, there has been an overuse of suboptimal treatments and an underuse of interventions that have proven to be efficacious and better tolerated, Leslie Citrome, MD, MPH, Clinical Professor of Psychiatry and Behavioral Sciences, New York Medical College, told Psych Congress attendees in a session presented on Friday.

Agitation is defined by excessive motor or verbal activity, and in schizophrenia and bipolar disorder patients, it can escalate to aggression. Patients can be observed engaging in pacing, fidgeting, clenching fists and teeth, prolonged staring, potentially throwing objects, and responding to auditory or visual hallucinations. Patients may also describe experiencing feelings of explosive anger, anxiety, paranoia, and restlessness, as well as having a low tolerance for frustration and urges to become verbally abusive and aggressive.

With patients experiencing agitation, nonpharmacologic interventions, such as verbal de-escalation and reducing environmental stimulation, should be attempted first, Dr Citrome stated. When using medications to treat psychosis-driven agitation in patients with known psychiatric disorders, such as schizophrenia, schizoaffective disorder, or bipolar disorder, antipsychotics are recommended over benzodiazepines, Dr Citrome continued, because they address the patient’s underlying psychosis.

For schizophrenia patients exhibiting persistent aggressive behavior, the highest rates of efficacy been demonstrated by second-generation antipsychotics, followed by beta blockers, and then mood stabilizers and antidepressants. Benzodiazepines, meanwhile, have demonstrated negative evidence, Dr Citrome said.

Dr Citrome shared a study in which more than 82,000 patients had been prescribed antipsychotics or mood stabilizers. Compared with periods in which participants were not on medication, violent crime among those receiving antipsychotics fell by 45%, while those prescribed mood stabilizers had a reduction in violent crime of 24%. Mood stabilizers were associated with a reduced rate in violent crime only in patients with bipolar disorder, Dr Citrome clarified.

New intramuscular and oral formulations of second-generation antipsychotic medications provide several advantages over the frequently prescribed haloperidol in patients who require acute intervention or who refuse oral antipsychotic treatment, Dr Citrome said, adding that intramuscular second-generation antipsychotics are FDA approved for agitation. Furthermore, noninvasive methods of administration, such as inhalation and sublingual approaches, can be as rapidly acting and as efficacious as intramuscular injection.

Still, offering patients a choice is important for maintaining a therapeutic alliance, Dr Citrome concluded.

Reference

Citrome L. Managing agitation in schizophrenia and bipolar disorder: what’s available, what’s new, what’s next. Presented at Psych Congress; October 29-November 1; Virtual.