For many patients, the continuum of psychiatric care begins in an emergency room, where they present with violent behavior that may pose risks to themselves and others. A study by The American Association for Emergency Psychiatry reported that 56.5% of emergency room staff reported at least one injury serious enough to require time off from work..

Studies conducted with clozapine, olanzapine, ziprasidone, risperidone, and quetiapine indicate that atypical antipsychotic medications are effective for aggression. Use of medication avoids possible trauma from physical restraints. When medication is administered orally, trauma from intamuscular injection is avoided.

Dr. Currier discussed a pilot study that compared orally administered risperidone with intramuscularly administered haloperidol for acute control of psychotic agitation. Patients seen in the emergency room chose treatment arm (either oral or intramuscular, in addition to lorazepam), and research raters were blind to treatment choice. The study was conducted with 39 men and 21 women ranging in age from 19-58 years (mean age= 37.5 years). Of the 60 patients, 30 were treated with risperidone and 30 with haloperidol. Urine toxicology screens were performed in 17 patients, of whom two tested positive for cocaine. Admitting diagnosis was psychosis not otherwise specified for the majority of patients (56 of 60).

Both treatment groups had similar agitation ratings at baseline. The combination of oral risperidone and lorazepam was as effective as the combination of intramuscular haloperidol and lorazepam. Onset of therapeutic effects was similar in both treatment groups. One patient who initially received risperidone required haloperidol for response. There was one adverse drug reaction (dystonia in a patient treated with haloperidol).

Aware of the limitations of their small, non-randomized pilot study, Dr. Currier and colleagues are participating in a large, multicenter trial studying the use of risperidone in emergency settings.

Dr. Currier closed by noting that careful management of acute aggression and violence in schizophrenic patients may help reduce risk of aggression over the longer term. Additional issues for study include alternative routes of administration, use of other atypical agents, use of droperidol, and investigation of impact of acute treatment choices on long-term treatment retention.