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, 41 (2), 153-167

Brazilian Guidelines for the Management of Psychomotor Agitation. Part 1. Non-pharmacological Approach


Brazilian Guidelines for the Management of Psychomotor Agitation. Part 1. Non-pharmacological Approach

Leonardo Baldaçara et al. Braz J Psychiatry.


Objective: To present the essential guidelines for non-pharmacological management of patients with psychomotor agitation in Brazil.

Methods: These guidelines were developed based on a systematic review of articles published from 1997 to 2017, retrieved from MEDLINE (PubMed), Cochrane Database of Systematic Review, and SciELO. Other relevant articles identified by searching the reference lists of included studies were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools.

Results: We initially selected 1,731 abstracts among 5,362 articles. The final sample included 104 articles that fulfilled all the inclusion criteria. The management of agitated patients should always start with the least coercive approach. The initial non-pharmacological measures include a verbal strategy and referral of the patient to the appropriate setting, preferably a facility designed for the care of psychiatric patients with controlled noise, lighting, and safety aspects. Verbal de-escalation techniques have been shown to decrease agitation and reduce the potential for associated violence in the emergency setting. The possibility of underlying medical etiologies must be considered first and foremost. Particular attention should be paid to the patient's appearance and behavior, physical signs, and mental state. If agitation is severe, rapid tranquilization with medications is recommended. Finally, if verbal measures fail to contain the patient, physical restraint should be performed as the ultimate measure for patient protection, and always be accompanied by rapid tranquilization. Healthcare teams must be thoroughly trained to use these techniques and overcome difficulties if the verbal approach fails. It is important that healthcare professionals be trained in non-pharmacological management of patients with psychomotor agitation as part of the requirements for a degree and graduate degree.

Conclusion: The non-pharmacological management of agitated patients should follow the hierarchy of less invasive to more invasive and coercive measures, starting with referral of the patient to an appropriate environment, management by a trained team, use of verbal techniques, performance of physical and mental assessment, use of medications, and, if unavoidable, use of the mechanical restraint.

Systematic review registry number: CRD42017054440.

Conflict of interest statement

LB has served as consultant for Apsen and participated in a meeting from Libbs. LAP has served as speaker for Janssen-Cilag, Servier, EMS, and Libbs. LAP has received support to participate in meetings from Janssen-Cilag, Lundbeck, Abbott, Servier, and Libbs. CAM has served as speaker for Lundebeck and has performed research for Janssen-Cilag. TCT has served as member of the advisory board/consultant for Aché, Abbott, Servier, Lundbeck, and Apsen; has served as speaker for Aché, Abbott, Pfizer, EMS, Medley/Sanofi, Lundbeck, Servier, Libbs, Apsen, Torrent, and Daichii-Sankyo; has performed research for Janssen-Cilag and served as consultant for clinical/scientific related promotional articles for Aché, Abbott, Pfizer, EMS, Medley/Sanofi, Lundbeck, Servier, Supera, Janssen-Cilag, Cristália, Libbs, Apsen, Torrent, and Daichii-Sankyo. QC works in the Ministry of Health and is responsible for the elaboration of public policies in mental health in Brazil. The other authors report no conflicts of interest.


Figure 1
Figure 1. Flowchart for the study selection process.
Figure 2
Figure 2. Flow diagram of the management of psychomotor agitation. * Little available evidence. Use only if all else fails.

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