Sedation is not the opposite of agitation

Abstract

The induction of sleep was originally considered to be a desirable therapeutic endpoint for the rapid control of agitation associated with psychotic disorders. However, it has become clear that sleep is not essential for a decrease in agitation or for the rapid improvement in core psychotic symptoms. Indeed, although the initial calming effects of treatment may be considered useful, excessive sedation or ‘oversedation’ is not a desirable effect, as it can interfere with both the physician's ability to interview/evaluate the patient and establish an effective therapeutic alliance with them, and with the patient's ability to participate in their treatment (e.g., answer questions, hydrate themselves). Furthermore, oversedation has the potential to mask illnesses that show central nervous system depression as a symptom, which could lead to further morbidity or mortality. Thus, although sleep may be advantageous in certain circumstances, achieving control of agitation via rapid calming rather than sedation is becoming an important therapeutic goal. Management of acute agitation has traditionally involved the use of benzodiazepines, such as lorazepam; however, problems with oversedation have led to the increased use of intramuscular antipsychotics in place of, or in combination with, benzodiazepines. Although combination treatment, for example, with intramuscular haloperidol plus intramuscular lorazepam, may provide superior efficacy to treatment with either agent alone, the sedative effects are at least as great as with the use of benzodiazepines as monotherapy. Specific calming without excessive sedation is emerging as a significant clinical advantage of intramuscular formulations of atypical antipsychotics versus conventional treatments.