Page 36 - JSOM Fall 2024

Treatment of Psychosis and Mania Suicide risk can then be categorized into acute and chronic
The medication recommendations for the treatment of agita- risks, with three levels of severity: low, intermediate, and high
tion associated with psychosis and mania are listed in Table 1. (see Tables 2 and 3). 15
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Oral administration is preferred to intramuscular administra-
tion, if the patient is cooperative. Treatment of Suicidality
Suicidal thoughts are to be primarily managed through PIES
TABLE 1 Tactical Psychiatric Care Medications 15–17 principles. Given that most suicidal thoughts are relatively
Medication Indications brief (hours to a few days long), most patients with suicidal
Oral, IM, or IN lorazepam* Unknown causes of agitation, thoughts are expected to have their suicidal ideations subside
7
(Ativan), 2mg initial dose, can agitation from psychiatric and psychiatric conditions or stressors managed in theater.
be repeated every 2hr, max dose illnesses aside from mania and
of 12mg per 24hr. Time to peak psychosis, substance intoxication If a servicemember is in the acute high-risk category (i.e., delib-
concentration for oral is 2hr; aside from alcohol intoxication, erate planning and intention for suicide), medical evacuation to
IM is 3hr ; IN is 30min. 20 agitation associated with alcohol 14,15
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withdrawal enable psychiatric hospitalization is likely indicated. Suicidal
Oral risperidone (Risperdal), Agitation associated with behaviors are to be managed in general through medical evacu-
the initial dose is 2mg, can be psychosis and mania, agitation ation. For cases with suicidal preparatory behavior only, provid-
repeated every 2hr, max dose associated with delirium, ers can consider using PIES, but the patient should be carefully
of 6mg per 24hr. Time to peak cooperative to oral medication evaluated to determine whether a suicide attempt or prepara-
concentration is 1hr. tory act toward suicide have been verified to have occurred.
IM olanzapine (Zyprexa), 10mg Agitation associated with
initial dose, can be repeated psychosis and mania, agitation Buddy watch and weapons restrictions should be used with
20min, max dose 30mg per 24hr. associated with delirium, not
Time to peak concentration is cooperative to oral medication caution and only in emergency scenarios, such as when an
15–45min. acutely and severely suicidal patient is awaiting medical evac-
14
IM ziprasidone (Geodon), Agitation associated with uation. A mental health professional and command should
10–20mg initial dose, 10mg can psychosis and mania, agitation be consulted prior to medical evacuation for suicidal ideation.
be repeated every 2hr, 20mg can associated with delirium, not Medical evacuation for suicidal ideation should only be used
be repeated every 4 hr, for a max cooperative to oral medication when there is imminent risk in terms of a clear intention and
dose of 40mg per 24hr. Time to 14
peak concentration is 15min. plan for suicide or when PIES principles fail to resolve risk.
Oral or IM haloperidol Agitation associated with
(Haldol), 5mg, can be repeated alcohol intoxication Assessment of Malingering
after 15min, max dose of Malingering is the deliberate act of a patient feigning mental
20mg per 24hr. Time to peak or physical illness. Malingering does not preclude the presence
concentration is 30–60min. of an actual mental disorder. Frontline providers should be
IM or IN ketamine 4–5mg/kg, Severe nonpsychotic agitation aware of the common signs of malingering psychiatric con-
single dose. Time to peak
concentration is 22min for IM ditions in military settings, which include implausible clinical
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and 16min for IN. 22 presentation (e.g., reported symptoms that do not match what
Source: This table is largely copied and reformatted from Wilson et al. the clinician views in terms of stress level or functioning), lack
(2015) article and table on recommended medications for agitation. of consistency in the patient’s report of their symptoms, and
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*Contraindications for these medications are alcohol intoxication and contradiction in reported functioning by collateral sources
delirium. (e.g., reports by command).
IM = intramuscular; IN = intranasal.
Treatment of Malingering
It is not advised to directly confront a patient about a suspicion
Assessment of Suicidality of malingering. Treat suspected malingering as an indicator
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Suicidal thoughts are defined as expressed words by the patient of stress and use PIES as the principal treatment approach. Use
or confirmed reports that the patient has a desire or plan to of verbal de-escalation may be needed for cases of malingering
die by suicide. Suicidal thoughts should be distinguished from with agitation.
thoughts of wanting to be dead (more formally called morbid
ideations). Morbid ideations present as a patient lacking the Summary
desire to live anymore or not caring if they die. Suicidal ide-
ation exists on a continuum from brief, momentary thoughts A treatment and assessment algorithm was developed (out-
without a plan of wanting to kill themselves to chronic, fre- lined in Box 4) to summarize this guideline.
quent thoughts involving a plan and place where they intend
to die by suicide. More planning indicates greater risk.
Discussion
Suicidal behaviors are defined as actual acts by a patient that This guideline is a summary of emergency psychiatric proce-
are intended to cause death. Suicidal behaviors may also be dures for assessing and treating combat stress, agitated, psy-
preparatory, only meaning that the behavior may not cause chotic, suicidal, and malingering patients on the battlefield
harm (e.g., putting a gun to their temple but then abandon- based on several best practice guidelines. A potential use and
ing the plan before pulling the trigger), but this would be an benefit of this guideline is an improvement in the management
indicator of a substantially increased risk for eventual suicide. of psychiatric casualties. There would likely be clinical benefits
Suicidal behaviors also include suicide attempts, which are de- in the short- and long-term for patients: better use of verbal
fined as behavior by a patient that was previously enacted and de-escalation results in fewer cases of use of restraints and po-
intended to cause death. tential injury. Longitudinal studies of the PIES model indicate

34 | JSOM Volume 24, Edition 3 / Fall 2024