Agitation and Psychiatric Disease

Essex Ballrooms Center and South The Westin Copley Place, Boston Boston, Massachusetts

This activity is jointly provided by Global Education Group and Integritas Communications.

This activity is supported by an educational grant from Teva Pharmaceutical Industries Ltd. This symposium is not part of the official ACEP15 educational program as planned by the ACEP Educational Meetings Committee.

CME/MEDICAL COMMUNICATIONS INQUIRIES info@integritasgrp.com integritasgrp.com

FACULTY FACULTY

MICHAEL H. Allen, MD

Professor, Department of Psychiatry University of Colorado School of Medicine Director of Psychiatry University of Colorado Hospital Anschutz Medical Campus Aurora, Colorado

LESLIE

Citrome, MD, MPH

Clinical Professor of Psychiatry & Behavioral Sciences New York Medical College Valhalla, New York

KIMBERLY

Nordstrom, MD, JD Assistant Professor Department of Psychiatry Medical Director Psychiatric Emergency Services Denver Health Medical Center University of Colorado Denver Denver, Colorado

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FACULTY

STATEMENT OF NEED/PROGRAM OVERVIEW Broadly defined as a state of extreme arousal characterized by excessive, poorly organized motor and/or verbal activity, agitation is a frequent cause of emergency psychiatric interventions and hospitalizations for patients with schizophrenia or bipolar disorder.1 In fact, studies suggest that as many as half of psychiatric emergency visits involve agitated patients.2,3 Differential diagnosis of the underlying cause can be challenging, particularly because patients often are uncooperative or otherwise unable to provide relevant details from their histories.4 In some cases, agitation can escalate to aggression and violent behavior, which can place the patient and members of the health care team at risk for injury.5,6 Thus, emergency care clinicians often are faced with the difficult tasks of quickly determining the etiology of agitation symptoms, implementing initial de-escalation efforts to decrease the likelihood of violent outbursts, and helping patients participate in assessment queries and treatment decisions.7 During this Interactive Exchange™ program, presenting faculty will discuss practical strategies for uncovering the likely cause of agitation, stratifying agitated patients with mental illnesses based on risks of aggressive behaviors, and implementing interpersonal and medical interventions that can ameliorate symptoms and reduce the utilization of seclusion and restraint.8-10

REFERENCES 1. Sachs GS. A review of agitation in mental illness: burden of illness and underlying pathology.

J Clin Psychiatry. 2006;67(suppl 10):5-12.

2. Harvey PD, Loewenstein DA, Czaja SJ. Hospitalization and psychosis: influences on the course of cognition and everyday functioning in people with schizophrenia. Neurobiol Dis. 2013;53:18-25.

3. Andreasen NC. Standardized remission criteria in schizophrenia. Acta Psychiatr Scand. 2006;113(2):81.

4. Stowell KR, Florence P, Harman HJ, Glick RL. Psychiatric evaluation of the agitated patient: consensus statement of the American association for emergency psychiatry project Beta psychiatric evaluation workgroup. West J Emerg Med. 2012;13(1):11-16.

5. Citrome L, Volavka J. Violent patients in the emergency setting. Psychiatr Clin North Am. 1999;22(4):789-801.

6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed.

Arlington, VA: American Psychiatric Publishing; 2013.

7. Doshi A, Boudreaux ED, Wang N, Pelletier AJ, Camargo CA, Jr. National study of US emergency department visits for attempted suicide and self-inflicted injury, 1997-2001. Ann Emerg Med. 2005;46(4):369-375.

8. Knox DK, Holloman GH, Jr. Use and avoidance of seclusion and restraint: consensus statement of the American Association for Emergency Psychiatry Project Beta seclusion and restraint workgroup.

West J Emerg Med. 2012;13(1):35-40.

9. Lesem MD, Tran-Johnson TK, Riesenberg RA, et al. Rapid acute treatment of agitation in individuals with schizophrenia: multicentre, randomised, placebo-controlled study of inhaled loxapine.

Br J Psychiatry. 2011;198(1):51-58.

10. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25.

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TARGET AUDIENCE This educational activity is targeted to an audience of emergency physicians and other health care providers involved in emergency psychiatry care.

EDUCATIONAL OBJECTIVES Upon completion of this activity, participants will be better prepared to: • Discuss the pathophysiology and potential presentations of schizophrenia and bipolar disorder with a focus on agitation

PREAMBLE

• Evaluate agitated patients presenting for emergency care to determine likely etiology, stratify risks of aggression, and guide the course of care • Engage agitated patients with schizophrenia or bipolar disorder using de-escalation strategies • Tailor pharmacotherapy for agitated patients with schizophrenia or bipolar disorder based on presentation, medical history, patient preferences, and potential benefits and risks of available agents

PROGRAM AGENDA 6:00 am – 6:30 am Registration, Meal, Pre-Activity Assessment 6:30 am – 6:50 am Disease Management Primer 6:50 am – 7:30 am Case Series in Agitation and Psychiatric Disease 7:30 am – 7:50 am Choose-a-Case Collaboration 7:50 am – 8:00 am Post-Activity Assessment, Question-and-Answer Session

PHYSICIAN ACCREDITATION STATEMENT This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Global Education Group (Global) and Integritas Communications. Global is accredited by the ACCME to provide continuing medical education for physicians.

This CME/CE activity complies with all requirements of the federal Physician Payment Sunshine Act. If a reportable event is associated with this activity, the accredited provider managing the program will provide the appropriate physician data to the Open Payments database.

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PHYSICIAN CREDIT DESIGNATION Global Education Group designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

GLOBAL CONTACT INFORMATION

PREAMBLE

For information about the accreditation of this program, please contact Global at (303) 395-1782 or inquire@globaleducationgroup.com.

INSTRUCTIONS TO RECEIVE CREDIT In order to receive credit for this activity, the participant must complete the program evaluation.

FEE INFORMATION& REFUND/ CANCELLATION POLICY There is no fee for this educational activity.

DISCLOSURE OF CONFLICTS OF INTEREST Global Education Group (Global) requires instructors, planners, managers, and other individuals and their spouses/life partners who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are vetted thoroughly by Global for fair balance, scientific objectivity of studies mentioned in the materials or used as the basis for content, and appropriateness of patient care recommendations.

The faculty have reported the following financial relationships or relationships to products or devices they or their spouses/life partners have with commercial interests related to the content of this CME activity.

Michael H. Allen, MD

Consultant – Ferrer Internacional, S.A.

Leslie Citrome, MD, MPH Consultant – Actavis plc, Alexza Pharmaceuticals Inc., Alkermes plc, Allergan plc, Bristol-Myers Squibb, Eli Lilly and Company, Forest Laboratories, Inc., Forum Pharmaceuticals Inc., Genentech, H. Lundbeck A/S, Janssen Pharmaceuticals, Inc., Jazz Pharmaceuticals plc, Medivation, Inc., Merck & Co., Inc., Mylan N.V., Novartis, Noven Pharmaceuticals, Inc., Otsuka America Pharmaceutical, Inc., Pfizer Inc., Reckitt Benckiser Pharmaceuticals Inc., Reviva Pharmaceuticals, Inc., Shire plc, Sunovion Pharmaceuticals Inc., Takeda Pharmaceutical Company Limited,

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Teva Pharmaceutical Industries Ltd., Valeant Pharmaceuticals International, Inc. Speaker’s Bureaus – Actavis plc, Allergan plc, AstraZeneca, Forest Laboratories, Inc., H. Lundbeck A/S, Janssen Pharmaceuticals, Inc., Jazz Pharmaceuticals plc, Merck & Co., Inc., Novartis, Otsuka America Pharmaceutical, Inc., Pfizer Inc., Shire plc, Sunovion Pharmaceuticals Inc., Takeda Pharmaceutical Company Limited, Teva Pharmaceutical Industries Ltd. Shareholder – Bristol-Myers Squibb, Eli Lilly and Company, Johnson & Johnson, Merck & Co., Inc., Pfizer Inc. Kimberly Nordstrom, MD, JD Honorarium – Teva Pharmaceutical Industries Ltd.

Amanda Glazar, PhD

PREAMBLE

The planners and managers have reported the following financial relationships or relationships to products or devices they or their spouses/life partners have with commercial interests related to the content of this CME activity.

Nothing to disclose

Andrea Funk

Nothing to disclose

Jim Kappler, PhD

Nothing to disclose

Rose O’Connor, PhD

Nothing to disclose

DISCLOSURE OF UNLABELED USE This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. Global and Integritas Communications do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of any organization associated with this activity. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

DISCLAIMER Participants have an implied responsibility to use newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management.

Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions, possible contraindications, dangers of use, review of applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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CLINICAL ASSESSMENT TOOLS »» Behavioral Activity Rating Scale (BARS) The BARS allows for a quick assessment of agitation via a numerical rating score of 1 to 7. www.intljourtranur.com/article/S0099-1767(10)00014-0/fulltext?mobileUi=0

»» Overt Agitation Severity Scale (OASS) Designed to assess agitation, this comprehensive evaluation scale relies on the observation of specific agitation-related behaviors and the frequencies at which they manifest. neuro.psychiatryonline.org/doi/pdf/10.1176/jnp.9.4.541

»» Positive and Negative Syndrome Scale, Excited Component (PANSS-EC) This subscale of the Positive and Negative Syndrome Scale specifically evaluates excited states by assessing patients for 5 items: poor impulse control, tension, hostility, uncooperativeness, and excitement. www.schres-journal.com/article/S0920-9964(03)00087-2/abstract

»» American Association for Emergency Psychiatry Project BETA Guidelines: Use and avoidance of seclusion and restraint: consensus statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup.

Knox DK, Holloman GH, Jr. West J Emerg Med. 2012;13(1)35-40. www.ncbi.nlm.nih.gov/pmc/articles/PMC3298214/pdf/wjem-13-01-35.pdf

RESOURCE CENTER

»» Medical evaluation and triage of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup.

Nordstrom K, et al. West J Emerg Med. 2012;13(1):3-10. www.ncbi.nlm.nih.gov/pmc/articles/PMC3298208/pdf/wjem-13-01-3.pdf

»» Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup.

Richmond JS, et al. West J Emerg Med. 2012;13(1):17-25. www.ncbi.nlm.nih.gov/pmc/articles/PMC3298202/pdf/wjem-13-01-17.pdf

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»» Psychiatric evaluation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA Psychiatric Evaluation Workgroup.

Stowell KR, et al. West J Emerg Med. 2012;13(1):11-16. www.ncbi.nlm.nih.gov/pmc/articles/PMC3298217/pdf/wjem-13-01-11.pdf

»» The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup.

Wilson MP, et al. West J Emerg Med. 2012;13(1):26-34. www.ncbi.nlm.nih.gov/pmc/articles/PMC3298219/pdf/wjem-13-01-26.pdf

SUGGESTED READING »» Delirium: a neurologist’s view—the neurology of agitation and overactivity.

Caplan LR. Rev Neurol Dis. 2010;7:111-118. www.ncbi.nlm.nih.gov/pubmed/21206426

»» Heisenberg in the ER: observation appears to reduce involuntary intramuscular injections in a psychiatric emergency service.

Damsa C, et al. Gen Hosp Psychiatry. 2006;28(5):431-433. www.ncbi.nlm.nih.gov/pubmed/16950380

»» Alternative delivery systems for agents to treat acute agitation: progress to date.

Nordstrom K, Allen MH. Drugs. 2013;73:1783-1792.

RESOURCE CENTER

www.ncbi.nlm.nih.gov/pubmed/24151084

»» The neurobiology of the switch process in bipolar disorder: a review.

Salvadore G, et al. J Clin Psychiatry. 2010;71(11):1488-1501. www.ncbi.nlm.nih.gov/pmc/articles/PMC3000635/pdf/nihms256274.pdf

»» Schizophrenia: a systematic review of the disease state, current therapeutics and their molecular mechanisms of action.

Shin JK, et al. Curr Med Chem. 2011;18(9):1380-1404. www.ncbi.nlm.nih.gov/pubmed/21366526

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Best Practices for EMERGENCY CARE »» A national study of violent behavior in persons with schizophrenia.

Swanson JW, et al. Arch Gen Psych. 2006;63(5):490-499. archpsyc.jamanetwork.com/article.aspx?articleid=209569

»» The assessment and management of the violent patient in critical hospital settings.

Tischler CL, et al. Gen Hosp Psychiatry. 2013;35(2):181-185. www.ncbi.nlm.nih.gov/pubmed/23260370

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Please visit the CLINICAL RESOURCE CENTER for additional information and resources

www.ExchangeCME.com/AGITATION

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