There is strong evidence that people diagnosed with schizophrenia benefit from psychosocial treatments in addition to pharmacological treatment. Multiple randomized controlled studies, as well as national guidelines, have demonstrated cognitive behavioral therapy and family therapy to be effective for the treatment of schizophrenia.44-51 Particular focuses of therapy include communication skills, problem solving, psychoeducation, and assisting with family conflict,18,19 which are feasible in an emergency setting.52
Recent studies have shown promise using a “crisis intervention” approach as an alternative option to the hospital or emergency medical services systems. Treatment usually involves a combination of medication as well as counseling (practical help with living skills and support for close family members). After the crisis has been stabilized, sufferers are carefully introduced to other models of care more suited for the chronic phases of psychiatric illnesses.53 This is particularly important as psychosocial instability, such as changes in the psychosocial environment (ie, a primary caretaker going on vacation, or a patient being distanced from their family or support environment) have been associated with relapse.19
Acute Agitation
The vast majority of patients suffering from mental illness, including schizophrenia, are not violent and only a small proportion of the violence in our society can be attributed to persons who are mentally ill.54 Furthermore, people with psychiatric disabilities are far more likely to be victims than perpetrators of violent crime.55 However, schizophrenia and related disorders are associated with substantially increased rates of violence and violent offences compared to those who did not, independent of substance use.56,57 Furthermore, the majority of acute hospital assaults occur in the ED.58
Two emergency medicine evidence-based guidelines state a benzodiazepine (lorazepam or midazolam) or a conventional antipsychotic (droperidol or haloperidol) should be used as monotherapy for the treatment of acute undifferentiated agitation in the ED.12,59 However, in cases of patients with a diagnosis or suspicion of schizophrenia, an antipsychotic should be used in order to start a “disease modifying agent” earlier in the course of treatment.20,59,60Where possible, the same antipsychotic should be used as monotherapy for treatment of both acute agitation and standing antipsychotic medication.13The choice of medication for the treatment of acute agitation should be based on patient preference, past experience of antipsychotic treatment, the adverse effect profile, and concurrent medical history.19,58 This is supported by a case controlled study, which showed patients’ subjective experiences in the acute phase of treatment affected their long-term adherence to medication.61
Haloperidol is the most commonly used medication for agitation in patients with schizophrenia.59,62 When haloperidol is used to treat acute violence, it is almost always used in combination with a benzodiazepine unless medically compromised.62,63 Intramuscular olanzapine has been shown to be effective in managing acute aggression or agitation in patients with schizophrenia, especially where it is necessary to avoid some of the older treatments. Olanzapine causes fewer movement disorders than halopridol.64 Chlorpromazine is available in both per os and intramuscular formulations. However, chlorpromazine is associated with more side effects than other antipsychotics, including a higher incidence of prolonged QT and Torsades.65 However, where choices are limited, chlorpromazine may be the only treatment available for acute agitation. If used, the close monitoring of blood pressure is indicated.65 Inhaled loxapine received US Food and Drug Administration approval for treatment of acute agitation in 2012.66 This is a useful option for an agitated patient who is calm enough to receive an inhaler, but is unable to take medication per os.
Restrictive intervention (restraints or seclusion) should only be used if de-escalation and other preventive strategies, including medication as needed, have failed and there is potential for harm to the patient or other people if no action is taken.58
