The Use of Rapid Tranquilization in Aggressive Behavior.

backgroundPsychomotor agitation and aggressiveness in the context of mental illnessare medical emergencies. In a survey of six German psychiatric hospitals, 1.7 to 5 aggressive attacks per patient-year were reported. If talking to the patient has no calming effect, intervention with drugs is required. In this article, we review the evidence on tranquilizing drugs and discuss clinically relevant ethical and practical questions, e.g., with respect to involuntary medication.

methodsThis review is based on pertinent articles retrieved by a selective search in MEDLINE, supplemented by a reference search.

resultsThe evidence for the treatment of psychomotor agitation with antipsychotic drugs and benzodiazepines is relatively good. Randomized, controlled trials and a number of Cochrane reviews are available. These publications, however, contain data only on patients who were able to give informed consent. Their findings are often not applicable to real-life emergencies, e.g., when the patient is intoxicated with alcohol or suffers from a pre-existing disease. Haloperidol has a relatively weak effect on aggression when given alone and can also cause side effects such as early dyskinesia and epileptic seizures. It should, therefore, no longer be used as monotherapy. On the other hand, haloperidol combined with benzodiazepines or promethazine and monotherapy with lorazepam, olanzapine, ziprasidone, or aripiprazole intramuscular are effective options for the treatment of aggressive psychomotor agitation.

conclusionAll of these drugs, if accepted by the patient, can also have an additional, beneficial placebo effect, with the patient calming down more rapidly than could be explained on pharmacological grounds alone. It is, therefore, important in emergencies (as at other times) for the patient to be involved in treatment decisions to the greatest possible extent.