Patients with psychotic illnesses may exhibit agitated, threatening, or destructive behaviour that could be dangerous to themselves or others. Researchers have found that as many as 1 in 5 individuals admitted to acute psychiatric units may commit an act of violence while in hospital. Additional research suggests that patients with psychosis who have a history of violence or substance abuse may be at an increased risk of committing violence. To ensure a safe environment, clinical practice guidelines suggest that health care providers first use verbal de-escalation techniques to engage agitated patients. In some cases, however, verbal de-escalation may be ineffective, thereby necessitating the use of alternative management approaches. One such strategy is rapid tranquilization, the aim for which is to use psychotropic medications “to calm/lightly sedate the service user, reduce the risk to self and/or others and achieve an optimal reduction in agitation and aggression.” Ideally, medications for rapid tranquilization should have a rapid onset of action, result in few adverse effects, and have a short duration of action. Empirical evidence suggests that clinicians often prefer to use two major drug classes – benzodiazepines and antipsychotics, either alone or in combination – to manage agitated patients. Intramuscular (IM) injections of these drugs appear attractive as they may offer superior pharmacokinetic properties and more favourable clinical profiles versus their respective oral formulations.
In 2010, a previous Rapid Response Report found six systematic reviews (SRs), one meta-analysis (MAs), three randomized controlled trials (RCTs), one major clinical practice guideline (CPG), and five supplementary guideline sources. Based on the available literature, antipsychotics and benzodiazepines appeared to be effective in mediating the symptoms of agitation or aggression. Further, guidelines appeared to vary on the choice of drugs for rapid tranquilization, but they recommended using a combination of an IM antipsychotic (haloperidol) and an IM benzodiazepine (lorazepam) to effectively cope with agitated patients.
The purpose of this Rapid Response report is to update the previous review to assess the extent to which there have been advances in the evidence informing the clinical efficacy of antipsychotics and benzodiazepines for rapid tranquilization of in-patients of mental facilities and emergency departments.
Disclaimer: The Rapid Response Service is an information service for those involved in planning and providing health care in Canada. Rapid responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list of sources of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time allowed. Rapid responses should be considered along with other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report.
