Atypical antipsychotics for acute agitation. New intramuscular options offer advantages

Violent or threatening behavior is a common reason for a visit to the emergency department. Patients with aggressive behavior must first be assessed for the possibility of comorbid medical conditions, which can complicate management. The introduction of intramuscular preparations of atypical antipsychotics provides new treatment options for acute agitation. These agents appear to be fast-acting and well tolerated and do not induce the akathisia of the older neuroleptic agents. Short-term sedation with lorazepam remains a safe and effective choice for managing acute agitation, in particular when withdrawal from alcohol may be a precipitating factor. However, lorazepam does not address the psychotic symptoms that may be at the core of much of this behavior. The intramuscular preparations of the atypical antipsychotics will probably supplant the intramuscular formulations of the older neuroleptics, much in the same way that the oral forms of these agents have become the agents of choice in treating psychosis. In addition, development of depot preparations of atypical antipsychotics is progressing rapidly. These products may further revolutionize the emergency and postemergency care of psychotic patients.