The pharmacological management of agitated and aggressive behaviour: A systematic review and meta-analysis

Maarten Bak; Irene Weltens; Chris Bervoets; Jurgen De Fruyt; Jerzy Samochowiec; Andrea Fiorillo; Gaia Sampogna; Przemyslaw Bienkowski; W. Ulrich Preuss; Blazej Misiak; Dorota Frydecka; Agnieszka Samochowiec; Emma Bak; Marjan Drukker; Geert Dom

doi:10.1016/j.eurpsy.2019.01.014

The pharmacological management of agitated and aggressive behaviour: A systematic review and meta-analysis

Maarten Bak^*, Irene Weltens, Chris Bervoets, Jurgen De Fruyt, Jerzy Samochowiec, Andrea Fiorillo, Gaia Sampogna, Przemyslaw Bienkowski, W. Ulrich Preuss, Blazej Misiak, Dorota Frydecka, Agnieszka Samochowiec, Emma Bak, Marjan Drukker, Geert Dom

^*Corresponding author for this work

Research output: Contribution to journal › Review article › peer-review

20 Citations (Web of Science)

Abstract

Introduction: Non-pharmacological interventions preferably precede pharmacological interventions in acute agitation. Reviews of pharmacological interventions remain descriptive or compare only one compound with several other compounds. The goal of this study is to compute a systematic review and meta-analysis of the effect on restoring calmness after a pharmacological intervention, so a more precise recommendation is possible.

Method: A search in Pubmed and Embase was done to isolate RCT's considering pharmacological interventions in acute agitation. The outcome is reaching calmness within maximum of 2 h, assessed by the psychometric scales of PANSS-EC, CGI or ACES. Also the percentages of adverse effects was assessed.

Results: Fifty-three papers were included for a systematic review and meta-analysis. Most frequent studied drug is olanzapine. Changes on PANNS-EC and ACES at 2 h showed the strongest changes for haloperidol plus promethazine, risperidon, olanzapine, droperidol and aripiprazole. However, incomplete data showed that the effect of risperidon is overestimated. Adverse effects are most prominent for haloperidol and haloperidol plus lorazepam.

Conclusion: Olanzapine, haloperidol plus promethazine or droperidol are most effective and safe for use as rapid tranquilisation. Midazolam sedates most quickly. But due to increased saturation problems, midazolam is restricted to use within an emergency department of a general hospital. (c) 2019 Elsevier Masson SAS. All rights reserved.

Original language	English
Pages (from-to)	78-100
Number of pages	23
Journal	European Psychiatry
Volume	57
DOIs	https://doi.org/10.1016/j.eurpsy.2019.01.014
Publication status	Published - Apr 2019

Keywords

Agitation
Agression
Olanzapine
Halperidol
Rapid tranquillisation
PANNS-EC
RANDOMIZED CONTROLLED-TRIAL
EMERGENCY PSYCHIATRIC ROOMS
RISPERIDONE ORAL SOLUTION
RAPID ACUTE TREATMENT
INTRAMUSCULAR OLANZAPINE
DOUBLE-BLIND
PSYCHOTIC AGITATION
IM ZIPRASIDONE
V. HALOPERIDOL
PLACEBO

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10.1016/j.eurpsy.2019.01.014

Cite this

Bak, M., Weltens, I., Bervoets, C., De Fruyt, J., Samochowiec, J., Fiorillo, A., Sampogna, G., Bienkowski, P., Preuss, W. U., Misiak, B., Frydecka, D., Samochowiec, A., Bak, E., Drukker, M., & Dom, G. (2019). The pharmacological management of agitated and aggressive behaviour: A systematic review and meta-analysis. European Psychiatry, 57, 78-100. https://doi.org/10.1016/j.eurpsy.2019.01.014

@article{524a73ab69ef42a9a9491f7b681a9b21,

title = "The pharmacological management of agitated and aggressive behaviour: A systematic review and meta-analysis",

abstract = "Introduction: Non-pharmacological interventions preferably precede pharmacological interventions in acute agitation. Reviews of pharmacological interventions remain descriptive or compare only one compound with several other compounds. The goal of this study is to compute a systematic review and meta-analysis of the effect on restoring calmness after a pharmacological intervention, so a more precise recommendation is possible.Method: A search in Pubmed and Embase was done to isolate RCT's considering pharmacological interventions in acute agitation. The outcome is reaching calmness within maximum of 2 h, assessed by the psychometric scales of PANSS-EC, CGI or ACES. Also the percentages of adverse effects was assessed.Results: Fifty-three papers were included for a systematic review and meta-analysis. Most frequent studied drug is olanzapine. Changes on PANNS-EC and ACES at 2 h showed the strongest changes for haloperidol plus promethazine, risperidon, olanzapine, droperidol and aripiprazole. However, incomplete data showed that the effect of risperidon is overestimated. Adverse effects are most prominent for haloperidol and haloperidol plus lorazepam.Conclusion: Olanzapine, haloperidol plus promethazine or droperidol are most effective and safe for use as rapid tranquilisation. Midazolam sedates most quickly. But due to increased saturation problems, midazolam is restricted to use within an emergency department of a general hospital. (c) 2019 Elsevier Masson SAS. All rights reserved.",

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author = "Maarten Bak and Irene Weltens and Chris Bervoets and {De Fruyt}, Jurgen and Jerzy Samochowiec and Andrea Fiorillo and Gaia Sampogna and Przemyslaw Bienkowski and Preuss, {W. Ulrich} and Blazej Misiak and Dorota Frydecka and Agnieszka Samochowiec and Emma Bak and Marjan Drukker and Geert Dom",

year = "2019",

month = apr,

doi = "10.1016/j.eurpsy.2019.01.014",

language = "English",

volume = "57",

pages = "78--100",

journal = "European Psychiatry",

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publisher = "Elsevier France-{\'E}ditions Scientifiques et Medicales Elsevier",

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Bak, M , Weltens, I, Bervoets, C, De Fruyt, J, Samochowiec, J, Fiorillo, A, Sampogna, G, Bienkowski, P, Preuss, WU, Misiak, B, Frydecka, D, Samochowiec, A, Bak, E, Drukker, M & Dom, G 2019, 'The pharmacological management of agitated and aggressive behaviour: A systematic review and meta-analysis', European Psychiatry, vol. 57, pp. 78-100. https://doi.org/10.1016/j.eurpsy.2019.01.014

TY - JOUR

T1 - The pharmacological management of agitated and aggressive behaviour

T2 - A systematic review and meta-analysis

AU - Bak, Maarten

AU - Weltens, Irene

AU - Bervoets, Chris

AU - De Fruyt, Jurgen

AU - Samochowiec, Jerzy

AU - Fiorillo, Andrea

AU - Sampogna, Gaia

AU - Bienkowski, Przemyslaw

AU - Preuss, W. Ulrich

AU - Misiak, Blazej

AU - Frydecka, Dorota

AU - Samochowiec, Agnieszka

AU - Bak, Emma

AU - Drukker, Marjan

AU - Dom, Geert

PY - 2019/4

Y1 - 2019/4

N2 - Introduction: Non-pharmacological interventions preferably precede pharmacological interventions in acute agitation. Reviews of pharmacological interventions remain descriptive or compare only one compound with several other compounds. The goal of this study is to compute a systematic review and meta-analysis of the effect on restoring calmness after a pharmacological intervention, so a more precise recommendation is possible.Method: A search in Pubmed and Embase was done to isolate RCT's considering pharmacological interventions in acute agitation. The outcome is reaching calmness within maximum of 2 h, assessed by the psychometric scales of PANSS-EC, CGI or ACES. Also the percentages of adverse effects was assessed.Results: Fifty-three papers were included for a systematic review and meta-analysis. Most frequent studied drug is olanzapine. Changes on PANNS-EC and ACES at 2 h showed the strongest changes for haloperidol plus promethazine, risperidon, olanzapine, droperidol and aripiprazole. However, incomplete data showed that the effect of risperidon is overestimated. Adverse effects are most prominent for haloperidol and haloperidol plus lorazepam.Conclusion: Olanzapine, haloperidol plus promethazine or droperidol are most effective and safe for use as rapid tranquilisation. Midazolam sedates most quickly. But due to increased saturation problems, midazolam is restricted to use within an emergency department of a general hospital. (c) 2019 Elsevier Masson SAS. All rights reserved.

AB - Introduction: Non-pharmacological interventions preferably precede pharmacological interventions in acute agitation. Reviews of pharmacological interventions remain descriptive or compare only one compound with several other compounds. The goal of this study is to compute a systematic review and meta-analysis of the effect on restoring calmness after a pharmacological intervention, so a more precise recommendation is possible.Method: A search in Pubmed and Embase was done to isolate RCT's considering pharmacological interventions in acute agitation. The outcome is reaching calmness within maximum of 2 h, assessed by the psychometric scales of PANSS-EC, CGI or ACES. Also the percentages of adverse effects was assessed.Results: Fifty-three papers were included for a systematic review and meta-analysis. Most frequent studied drug is olanzapine. Changes on PANNS-EC and ACES at 2 h showed the strongest changes for haloperidol plus promethazine, risperidon, olanzapine, droperidol and aripiprazole. However, incomplete data showed that the effect of risperidon is overestimated. Adverse effects are most prominent for haloperidol and haloperidol plus lorazepam.Conclusion: Olanzapine, haloperidol plus promethazine or droperidol are most effective and safe for use as rapid tranquilisation. Midazolam sedates most quickly. But due to increased saturation problems, midazolam is restricted to use within an emergency department of a general hospital. (c) 2019 Elsevier Masson SAS. All rights reserved.

KW - Agitation

KW - Agression

KW - Olanzapine

KW - Halperidol

KW - Rapid tranquillisation

KW - PANNS-EC

KW - RANDOMIZED CONTROLLED-TRIAL

KW - EMERGENCY PSYCHIATRIC ROOMS

KW - RISPERIDONE ORAL SOLUTION

KW - RAPID ACUTE TREATMENT

KW - INTRAMUSCULAR OLANZAPINE

KW - DOUBLE-BLIND

KW - PSYCHOTIC AGITATION

KW - IM ZIPRASIDONE

KW - V. HALOPERIDOL

KW - PLACEBO

U2 - 10.1016/j.eurpsy.2019.01.014

DO - 10.1016/j.eurpsy.2019.01.014

M3 - Review article

C2 - 30721802

VL - 57

SP - 78

EP - 100

JO - European Psychiatry

JF - European Psychiatry

SN - 0924-9338

ER -