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Review
. 2019 Jun 28;116(26):445-452.
doi: 10.3238/arztebl.2019.0445.

The Use of Rapid Tranquilization in Aggressive Behavior

Sophie Hirsch  1 , Tilman Steinert
Affiliations
Review

The Use of Rapid Tranquilization in Aggressive Behavior

Sophie Hirsch et al. Dtsch Arztebl Int. .

Abstract

Background: Psychomotor 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.

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

Results: The 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.

Conclusion: All 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.

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Figures

Figure
Figure
Algorithm to help select the drug type and mode of administration in the treatment of psychomotor agitation and aggressive behavior
See this image and copyright information in PMC

Comment in

  • Therapeutic Drug Monitoring.
    Dolscheid-Pommerich R, Stoffel-Wagner B. Dolscheid-Pommerich R, et al. Dtsch Arztebl Int. 2019 Oct 11;116(41):691. doi: 10.3238/arztebl.2019.0691a. Dtsch Arztebl Int. 2019. PMID: 31709976 Free PMC article. No abstract available.
  • In Reply.
    Hirsch S, Steinert T. Hirsch S, et al. Dtsch Arztebl Int. 2019 Oct 11;116(41):691. doi: 10.3238/arztebl.2019.0691b. Dtsch Arztebl Int. 2019. PMID: 31709977 Free PMC article. No abstract available.

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