Avoiding Medication Coercion While Treating Agitation in Bipolar Disorder

In his Psych Congress 2022 session "Treating Agitation: Can We Avoid Injections? Should We?" Leslie Citrome, MD, MPH, clinical professor at New York Medical College, Valhalla, New York, reviewed his professional history with agitation management and indicated that medication coercion should be a last result when working with patients with bipolar disorder or schizophrenia. Psych Congress Network sat down with Dr Citrome following his session to understand why he began investigating agitation management in the first place, how treatment strategies should differ between disorders, and how to ensure that injections are good experiences for patients.

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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.

Psych Congress Network (PCN): What led you to investigate managing and treating agitation?

Dr Citrome: 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.

PCN: You recently discussed some strategies for discussing medication with patients and listed coercion as a last resort and great danger. What is the danger of coercing and why should it only ever be a last resort in these discussions with patients?

Dr Citrome: 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 5 people, 1 to hold each limb and 1 to do the injection. Someone invariably gets hurt.

PCN: How do treatment strategies differ in patients with disorders other than bipolar disorder or schizophrenia?

Dr Citrome: Patients with schizophrenia or bipolar disorder are treated in a similar way when they are agitated. You offer either a non-specific anti-agitation agent like a benzodiazepine or an antipsychotic. Commonly, it's going to be intramuscular haloperidol, even though it comes with a lot of baggage. And my own preference, if I were to use an intramuscular injection, it would be either intramuscular is ziprasidone or olanzapine. But as it may, what do we do when someone who doesn't have schizophrenia or bipolar disorder is agitated? Pretty much the same thing. If someone is suffering through a withdrawal from alcohol, though, I'm not going to give an antipsychotic. I'm going to give a benzodiazepine, which will help in terms of the alcohol withdrawal.