New Treatment for Acute Agitation

The FDA has approved dexmedetomidine sublingual film for the treatment of agitation associated with schizophrenia or Bipolar I/II disorder in adults.  

When agitation and aggression are severe, swift resolution of the situation is required.


Since the advent of chlorpromazine in the 1950’s pharmacological intervention has been a mainstay in these acute situations. In many cases the combination of haloperidol, lorazepam, and diphenhydramine, the so called B-52 are administered intramuscularly when quick resolution of agitation is required for the safety of the person and staff. 

But what happens when these methods fail to provide adequate relief and person remains agitated?

There are few options available outside of the dopamine blocking medications and benzodiazepines. 

I’ve been in situations as an early career psychiatrist where I’ve had to treat severe agitation that is unresponsive to the traditional methods of treating agitation. 

After multiple medications failed to adequately treat the agitation, I called the medical floor to transfer the person for a Dexmedetomidine (precedex) drip. This is a medication I’ve seen work well in the ICU setting with agitated delirium. 

But drips are complicated to use and require careful monitoring on the medical floor. I was thinking it would be great if there was an option that did not require IV placement or transfer to the medical floor. 

Mechanism of Action:

Recent studies have looked at sublingual Dexmedetomidine as a potential new treatment for agitation. 

Dexmedetomidine is an alpha-2 noradrenergic agonist approved by the FDA for IV sedation and analgesia and limitted to 24 hours. It induces sleep by activating alpha-2 presynaptic receptors reducing norepinephrine release. Both sedation and awakening are rapid, and the medication is safe but does require monitoring of blood pressure and heart rate. 

Phase 3 Clinical Trial Results:

A phase 3 clinical trial of 120 micrograms and 180 micrograms of sublingual dexmedetomidine was compared to placebo in patients with bipolar disorder. They used the excited portion (PEC) of the PANSS to measure efficacy and found a response beginning at 20 minutes and continuing to 120 minutes at both doses. 90% of participants in the 180 microgram and 76% in the 120 microgram groups achieved a response. No significant adverse events occurred in the treatment groups.  

Hsiao JK. Sublingual Dexmedetomidine as a Potential New Treatment for Agitation. JAMA. 2022;327(8):723–725. doi:10.1001/jama.2021.21313

Help, I think I’m a Narcissist


It seems like everywhere I look there’s a video or article with titles such as “how to tell if you’re a narcissist” or “is your significant other a narcissist.” This got me thinking about narcissistic personality disorder (NPD), and why everyone thinks they or someone they know has this disorder. 

Brief Review of NPD Criteria from DSM-5 (5 out of 9 required) 

-Grandiose sense of self-importance 

-Preoccupied with fantasies of unlimited power, success, beauty etc. 

-Believes they are special and unique 

-Requires excessive admiration 

-Has a sense of entitlement (unreasonable expectations) 

– Interpersonally exploitative 

-Lacks empathy 

-Often envious of others or believes others are envious of them 

-Shows arrogant, haughty behaviors and attitudes 

Distinction Between a Disorder, and being a Jerk 

There is an important distinction between having NPD and having narcissistic traits. In diagnosing NPD there is a long list in DSM-5 of which the person must have 5 out 9 criteria to qualify for the diagnosis. These criteria will be present in all circumstances and relationships. Most importantly it must cause impairment in function and a subjective sense of distress. If the person meets these criteria, and it’s working for them in their life, they would not be diagnosed with NPD. You need to have the functional impairment, that is what makes it a disorder. Although these people may not have a disorder, it still does not make them a pleasure to be around. There can still be relationship difficulties both professionally and on a personal level.

Common Types of Narcissism 

The classic grandiose narcissist, this is the kind of person who cannot stop bragging about what they have, and what they have done. They tend to enjoy showing off symbols of status such as new cars or even attractive partners. They do things based on what will get them the most admiration and recognition from others rather than personal values. These types are encountered on a regular basis, you may know people like this in your personal life. 

There is a classic example of the highly successful professional who will stop at nothing to achieve their goals even if it’s at the expense of others. So naturally one place you may encounter these individuals is in the workplace. These types will exploit other people, cheat, work the system, whatever they can do to get ahead. They are usually successful and superficially charming. This pattern is less commonly encountered in daily life.

When Should Hospitalization be Considered for Depression?


This post is significant to me because one area I really enjoy working is the inpatient psychiatric unit. This might seem strange, but it’s a place I just gravitate towards and fell like I’m having a meaningful impact. You can think of it as the equivalent to the medical intensive care unit (ICU). It’s a place to learn about the most severe psychiatric pathologies and medication management.

In this post I will cover some of the signs and symptoms that may indicate inpatient hospitalization could help and possibly be lifesaving. 

Signs and Symptoms

Suicidal Ideation:

If your depression has become so profound that you have thoughts about “killing yourself,” then it might be time for inpatient treatment. Many clinicians, especially those not working in mental health, feel uncomfortable asking direct questions about suicide. Contrary to a common belief, asking about suicide does not increase the risk of suicide. I like to use the term “kill yourself” when doing a suicide assesment. It’s very definitive and clear to the patient what I’m talking about. The concern increases if there is a plan in place for the person to kill themselves, the plan is logical, feasible, and the person intends to carry out the plan. All of these are warnings that the person is at high risk. If these thoughts are persistent that’s another indicator that the problem is more serious. 

There is a significant difference between the above situation and the person who has “passive suicidal thoughts.” Passive suicidal thoughts are statements like “If I didn’t wake up tomorrow, I would be okay with it.” It’s not that the person is actively trying to prematurely end their life, rather they would not mind if something happened that hastened the path towards death. 


Another validated risk factor for suicide is severe, unremitting hopelessness. Hopelessness consists of feeling that nothing is getting better, nothing will ever get better, and there’s nothing I can do about it. This, independent of other risk factors, puts the person at high risk for suicide.

Loss of Interest:

Severe anhedonia (loss of interest) in previously pleasurable activities is part of the diagnostic criteria for depression, it’s also something that can increase suicide risk. If a person previously went to the gym five days a week or watched every new episode of The Bachelor and suddenly no longer cares about these things, it may be cause for concern.

Poor Response to Outpatient Treatment:

If you have been in traditional outpatient therapy and medication management for many years with minimal or no improvement, and you have never been hospitalized for psychiatric purposes before, then inpatient hospitalization may help. Sometimes the break from the daily life stressors for 3-5 days allows the mind and body to rest. If you tried everything else, then who knows? This could be the intervention that changes your life.

Seeking inpatient psychiatric care is nothing to be ashamed of, and many mental health professionals are working hard to destigmatize psychiatric care. I like to think about inpatient psychiatric care as a mental wellness camp, and not as a punishment for mental illness.

If this information is useful please like, share, and subscribe to the blog and other social media sites. Drop us a comment about what topics you are interested in, and we will try to cover them. 

If you or someone you love is at risk for suicide, the following resources are available. 

National Suicide Prevention Lifeline:

National Suicide Prevention Hotline: 1-800-273-8255


How to Tell if You Have Depression

Images that show what it feels like to suffer from mental illness. Bringing the inside to the outside.

Depression is not always easy to spot, and in a world filled with social media it always seems like everyone is living their best life. 

In the most severe states people can have suicidal thoughts and profound hopelessness. The symptoms can be mild, moderate, or severe. Depression can affect anyone. 

Depression is an illness like any other disease (diabetes, hypertension, heart disease) that affects thoughts, feelings, physical health, and behaviors. 

People with major depressive disorder have several of these symptoms every day or nearly every day for 2 weeks or more. 

Here are some signs that you may have depression 

At least one of the following, loss of interest in things you previously enjoyed or depressed mood  

At least 3 of the following 

  • Feeling slow or restless 
  • Feeling guilty or worthless
  • Increased or decreased appetite
  • Suicidal thoughts 
  • Problems concentrating, making choices, or remembering things 
  • Difficulty sleeping or sleeping too much 
  • Having low energy 

Potential physical signs of depression include 

  • Headaches
  • Muscle tension 
  • Digestive symptoms 
  • Sexual problems 
  • Feeling “keyed up”

This can be summed up in the mnemonic SIGECAPS taught to medical students everywhere. The mnemonic comes from the prescription a doctor might write for a depressed patient

 SIG:  1 energy capsules per day 

Please like, comment, and share the post if it was helpful. Let us know what else you would like to see. 

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