Agitation: a central challenge in psychiatry

Conventionally, depression is seen as the main problem in psychiatric services. Depression has been described as being responsible for the largest burden of disease (as measured in disability-adjusted life years) in developed countries (Mathers and Loncar 2006), causing a severe handicap for the individual patients and their relatives as well as a severe financial burden for modern societies. Some authors have questioned this primacy of depression and have alternatively suggested the primacy of mania (Koukopoulos and Ghaemi 2009): this seems bold, as all epidemiological studies show higher values for the prevalence of depressive disorders (or episodes) compared to manic or hypomanic episodes. But in the broader sense this idea has its attractiveness: could it be that our modern world is depressiocentric (or depressio-phobic) as it attaches particular value to energy, to lust for life and to going to the limit (all potential hypomanic symptoms)? Could it be that we therefore easily identify fatigue, anergy, diminished interest or pleasure as abnormal psychiatric symptoms, while neglecting symptoms of over-excitement and agitation? (This might be one of the reasons why depression in males is so difficult to assess (Winkler et al. 2005).) Finally: could it be that overexcitement of the nervous system and agitation are indeed “primary symptoms” as opposed to the downregulation of biological function by melancholia (see, e.g. Michael et al. (2003a, 2003b))? (This concept of “first comes the burn, then the burn-out” is in fact an old idea: according to Aretaeus of Cappadocia [around 80–138 AD] “those who are overexcited by this evil, become melancholics”.) In this context, the WFSBP consensus paper on assessment and management of agitation in psychiatry (Garriga et al. 2016) is an important achievement: it gives the right perspective to the importance in clinical practice of over-excitement, restlessness, irritability as well as heightened responsiveness to internal and external stimuli. This consensus is particularly welcome as it integrates the views and perspectives of psychiatric experts from all over the world. Indeed, the evaluation of the psychopathological phenomena of agitation is linked to cultural interpretation (e.g. Mediterranean cultures seem more tolerant towards increased motor activity – including in children – than countries in Northern Europe). Furthermore, the treatment of agitation is clearly linked to the availability of drugs (e.g. pipamperone, which is widely used in Germany, is not marketed in Austria; chlorpromazine, intramuscularly, is largely used for emergency treatment in Italy but is not available in Germany and Austria) and of psychiatric structures (the management of severe agitation will be different in Belgium, Germany or Norway, countries with many psychiatric beds, as opposed to Italy or Turkey, countries with few beds for psychiatric emergencies). Finally, the perspectives, needs and requests of the patients play an important role. It has been described that pathophysiological and treatment concepts of patients vary from country to country (Qureshi 1989). German patients tend to search for the external reason of their disease (a common cold is induced by external causes, e.g. viruses or bacteria). French patients are more often convinced that the pathology is related to the reduced function of their own immune system (in accordance with Claude Bernard’s “the germ is nothing, the terrain is everything”). Ethnic Asian patients might believe that “cold” versus “hot” foods might exacerbate or improve the symptoms of their disorder. Often, patients in Austria (being convinced that serious pathologies demand serious treatment) ask for an initial intravenous treatment and they do so both for medical treatment (e.g. therapy with antibiotics) and for psychiatric interventions. Consecutively, intravenous pharmacotherapy of agitation (e.g. with lorazepam; with trazodone in agitated depression or with