Psychotic agitation in the emergency: main drugs used in pharmacological management

Abstract

Psychomotor agitation (PMA) is a state of motor restlessness and mental tension frequently associated with psychiatric disorders such as schizophrenia and bipolar disorder, as well as being present in pediatric psychiatric emergencies and individuals with autism spectrum disorder (ASD). PMA can escalate to aggression and violence, posing a significant challenge for healthcare teams. Early recognition and appropriate therapeutic interventions are crucial to minimizing risks and avoiding unnecessary coercive measures. This systematic review investigates the main pharmacological treatments for psychotic agitation in emergency settings, analyzing their efficacy, safety, and clinical impact. The research was conducted in PubMed, LILACS, and SciELO, selecting studies published in the last 20 years on typical and atypical antipsychotics, benzodiazepines, and other therapeutic options. Findings suggest that verbal de-escalation and environmental management should be the first-line approach, while medication choice should be guided by the etiology of agitation. In psychotic episodes, inhaled loxapine, olanzapine, risperidone, aripiprazole, and haloperidol are the most frequently used options, whereas in non-psychotic cases, such as anxiety and substance withdrawal, benzodiazepines are recommended. Inhaled loxapine stands out for its rapid onset of action and lower need for physical restraint. In pediatric and ASD populations, individualized strategies are crucial to reducing excessive medication use and ensuring safer care. This review concludes that structured, evidence-based protocols are essential to optimizing the management of psychotic agitation in emergency settings, ensuring effective treatment, risk reduction, and a safer environment for patients and healthcare professionals.