Treatment of agitation in the acute psychiatric setting. An observational study of the effectiveness of intramuscular psychotropic medication.

BACKGROUND: Agitation is frequent in the acute psychiatric setting. The observation and treatment of agitation is important to avoid harm to patients or staff, to reduce distress of the patient, and to reduce the risk of coercion, especially physical restraint. AIM: To evaluate the effect of intramuscular treatment with psychotropics on agitation in a non-selected acute psychiatric population. METHODS: The Positive and Negative Syndrome Scale Excitement Component (PANSS-EC) was implemented in the acute psychiatric ward at Psychiatric Center Copenhagen to improve assessment and treatment of agitation. During a period of almost ~2 years the staff was requested to assess agitation before and after administration of intramuscular injections. RESULTS: PANSS-EC was obtained at baseline and within 2 hours after injection for 135 injections with antipsychotics or benzodiazepines administered to 101 acute, non-selected psychiatric patients with high occurrence of co-morbid substance abuse. Mean PANSS-EC at baseline was 26.53 ± 4.87, and mean reduction in PANSS-EC was 14.99 ± 8.48 (p < 0.001). For 73% of injections PANSS-EC decreased with ≥40% (generally accepted definition of response). In 49% of cases patients were subjected to physical restraint. Patients subjected to restraint had a significantly higher PANSS-EC score. Patients who received a subsequent injection had a significantly lower decline in PANSS-EC score. Besides two cases of acute dystonia following haloperidol injections, no serious side-effects were observed. CONCLUSIONS: Treatment of agitation with intramuscular injections of psychotropics was in general effective in this non-selected, highly agitated psychiatric population, and injections were well tolerated.

[Work-related stress and the hypothalamic-pituitary-adrenal axis].

This is a review on the topic of work-related stress (WRS), and how difficulities with differential diagnostics often arise because of overlapping symptoms between WRS and depression. Investigation into the hypothalamic-pituitary-adrenal (HPA) axis deviations seems to reveal the HPA axis as a promising biomarker, since studies have shown, that patients with melancholic type depression exhibit hyper-cortisolism, while patients with WRS exhibit hypocortisolism. More studies of better quality are needed, before anything conclusive can be said. Consensus regarding definition and a development of diagnostic criteria for WRS, e.g. the Swedish "exhaustion disorder", could enable a better differentiation and contribute to more accurate treatment and research.