Hello and welcome. I'm Dr. Rob Cotez, Director of the Clinical and Research Program for Psychosis at Grady Health System and an Associate Professor at Emory University School of Medicine. I'm so pleased that you're going to be joining us today for our SMI Advisor webinar, Updates on the Best Practices for the Management and Treatment of Agitation. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoting to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers that you need to care for your patients. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians, one Continuing Education Credit for Psychologists, one Nursing Continuing Professional Development Contact Hour, and one Continuing Education Credit for Social Workers. Credit for participating in today's webinar will be available until August 8th, 2023. Slides from the presentation today are available to download in the webinar chat. Select the link to view. Please feel free to submit your questions throughout the presentation by typing them into the question area found at the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. All right, now I'd like to introduce today's faculty for the webinar, Dr. Tony Thrasher. Dr. Thrasher is a board-certified psychiatrist employed as the Medical Director for the Crisis Services Branch of the Milwaukee County Behavioral Health Division. He currently serves as the President for the Wisconsin Psychiatric Association, as well as the President of the Wisconsin Association of Osteopathic Physicians and Psychiatrists. He is a Clinical Associate Professor at the Medical College of Wisconsin. Dr. Thrasher, we're so glad to have you today. Thank you so much for leading today's webinar, and I'll turn it over to you. Thank you so much for the invitation, the kind introduction, and to all the participants that are here. Thank you for taking time out of your summer Friday to learn about this very important topic that affects us, those of us that work in the field and those that we care for. So thank you for making the time today. I have no significant relationships or conflicts of interest related to this subject matter. A couple objectives, and it seems like there's only three because there's three big topics I want to cover. First of all, we're going to talk about culture, why the treatment of agitation is important in all venues, not just if I do inpatient, not just if I'm in forensics, not just if I consult to the emergency department. For all venues of care, we should be treating agitation, psychiatric or otherwise. We'll also talk about that while most of our focus as of late, appropriately so, has been on workplace violence and how to protect providers of care. I would argue the treatment of agitation is a win-win. You are not only helping yourself and other staff members with patients and their own safety, but you ease patient suffering. And that particular optics that we are doing this not to protect ourselves as much as to ease patient suffering is an important component of really reaching best practices and handling agitation. And then lastly, we'll spend some time on an evidence base so you can look and see what research studies have shown, and we'll talk about both non-pharmacological and pharmacological approaches to treating agitation. A couple acknowledgments here, a lot of the great work you're going to see today came out of the American Association of Emergency Psychiatry or AAEP, a group that I currently serve as the immediate past president for. All right, you're going to hear me say this a lot today, so I tend to put it at the very beginning of the presentation. Somebody very famous in the world of business said it, and I've never gotten a clear citation on it, but the phrase is culture eats process. And it's very important when dealing with agitation. We in medicine often initiate process changes and protocols and update our policies. And that's fine, but if your culture doesn't buy in, it doesn't matter what sort of process and procedure you do. You're really trying to go bottom up instead of top down. You need to have the right type of culture. If people believe that I shouldn't have to do this or this shouldn't be my responsibility or those types of patients belong to somebody else, it's going to be hard to completely address that in a process sense. You have to address the culture, which is why I like to spend the first 10 to 15 minutes of this topic really digging into that component. How do we change manage individual's opinions on why this is so important? So first off, agitation is an emergency. I often remind people, EMTALA considers it an emergency medical condition or EMC that you are federally required to screen and or treat if possible at the point of emergency evaluation. There are a lot of emergency department visits that are tied strictly to agitation. So right off the bat, when I'm working with emergency departments, I remind them you have a protocol for chest pain. You have a protocol for abdominal pain. You probably have a protocol for certain vaginal bleedings, depending upon the gestational status of a pregnant female. No matter what these different emergencies are that you practice protocols and procedures for, you need to have one for agitation and treat it with the same level of urgency and import. This came out several years ago, but it's a good reminder that when people look at the idea of why this has so much variation, even though the Joint Commission continues to focus on agitation via their focus on restraints, which we're going to get to at the end of the talk, there's still a lot of variation in scales, variation in protocols. And very often when people are looking to address this, they look at changing not just how they process or handle patients, but also the physical plant in which patients are seen. Now, as I mentioned, the Joint Commission does look at this as a marker of functionality. Restraints and agitation are always up there at the top, along with, you know, indwelling catheter infections, falls and things of that sort. I would take it a step further, though, and say this is more than us trying to be statutorily compliant. This is also about the fact that we care about each other and we care about the team. And unfortunately, when there is some sort of assaultive behavior that occurs, the staff often is affected in many, many ways, including less efficient, less days at work, or God forbid, deciding no longer to work in said field at all. So since most of these assaults happen during containment procedures, it's incumbent upon all of us to learn how to treat agitation at a further stage upstream. How can we keep it from getting to hands-on, if at all possible? And I also hear this a lot from different people. Well, that's somebody else's job. I'll wait for psych. They're on the way. The consultant's coming. Why are they here? We just need to get them out of here. I think a big misunderstanding here is as long as that is the culture that is being disseminated, it's hard to go into some of these next steps. So before we start talking about, well, these are the meds you should give, and this is the room we want to have you in, and this is who you consult when somebody's agitated, start thinking about some of these bigger picture items. How do we get all of our staff, not just physicians, all of our staff to understand that people that are dealing with agitation are not there to make your life difficult. They're having one of the worst days of their life. They are suffering. And we should treat it like any other suffering that we deal with day in and day out. Resolve the suffering, ease the other concerns. So a big message there. And for those of you that work in the current era of medical systems and fractionated concerns and some siloing and things like that, we hear this a lot. We aren't used to handling those types of patients. This is unethical. This is uninformed. This is liable. This is unacceptable. Culture eats processed. So as I slowly step off this soapbox, please understand why I devote time to this at the beginning of the message. If the take home from this is these are the meds that I need to give somebody, then I have failed you. That's an important part of it, and we're going to get to it. But this is a bigger picture than let's find our renowned psychopharmacologist somewhere and see what meds they use. Treating agitation is this entire culture shift. It involves a lot of things that do take training and practice, but they are so helpful, and they will often work with your pharmacological interventions to make for a much, much better experience. Better experience for the patient, better experience for those of you that treat the patient. And I would also argue for you ethicists or philosophers out there, or you sit on the ethics committee in your hospital, patients have a right not to be agitated. And very often that's a frame I have to be very clear on with people. We're not doing this because they are being bad. We're doing this because they are suffering. They are hurting. How do we resolve that suffering? Just like if you were laying on the ground, clutching your abdomen, saying that it hurts so much and I couldn't even get close to you to examine you, I have to treat the pain first to get that symptom out of the way so I can diagnose what's going on. It's no different with agitation. Something is likely driving the agitation that you need to know about. But it's going to be real hard to figure out what that etiology is until you treat the symptom in front of you, which happens to be agitation. We treat pain, we treat fever, why wouldn't agitation also be a core concept that we should handle as physicians? And just another piece of information here, this came out of UT Southwestern. I think this is a really good selection bias, if you will, because they really looked not just at your typical emergency department, but your public sector emergency departments, which often has a selection bias for higher acuity, more involuntary issues, other social determinants of health that has been proven to lead to increased restraints, unfortunately. And what they found was the most successful programs right off the bat were able to triage who is at higher risk for agitation and who is not. And then you'll see down here, and we're going to talk about this more in about 20 minutes, successful programs shortened the time to de-escalation and shortened the time to some type of intervention. I include the word chemical restraints in here because it was the verbiage used in this 2016 article. That being said, that term is relatively, I would say, out of date and passe now. That's not really what we're doing. We're treating agitation. We're not restraining somebody with medications. So this is what we are always trying to balance out. How do we take somebody from a state of very high intensity to something that is calmer? And to do that, we got to think about what causes agitation to begin with. Because I think too often people see agitation and they think psychiatric. I have run a public sector, a safety net psychiatric emergency room for over a decade. And what I can tell you is the most severe case of agitation I've seen had no prior psychiatric history. So I think it's a mistake sometimes to lump the automatic knee jerk of agitation means psych. It can mean that. It can definitely make issues more difficult or add a different flavor to the de-escalation process. But sometimes people that are very, very agitated are simply having a very bad day. So what are some things that could be causing this? We have delirium. We have your rights being taken away. We have true target symptoms of psychiatric illness like paranoia, mania, irritability, different phases of the substance abuse paradigm, intoxication, withdrawals, cravings, et cetera, any history of trauma, or my personal favorite, which is why I put it in red, feeling like things are out of control. There's a well-known forensic psychologist who first quoted, all acts of violence are in some way an attempt to take back control. And that always stuck with me. Because when people are feeling out of control, that is a very dangerous situation. And to be fair, sometimes they are out of control. If they've had their rights taken away, they're in front of you under some sort of involuntary or legal hold. How do we get them to feel like things are more in their control? Because that is not necessarily a pathological feeling, depending upon the steps that brought you to them or brought them to you. So as I mentioned, just a slide to kind of really nail it home, agitation can happen to anybody at any time. So when I'm working with people that say, we don't do agitation, we leave that to psychiatry, I call them out right off the bat. So you're telling me if somebody is coding in front of you and clutching their chest, your doc sit back and page cardiology? No, you take and treat the suffering, you treat the emergency, agitation is an emergency. And it can happen to anybody at any time, given the right circumstances. And to that, I add a quote, there is but an inch of difference between the cushion chamber and the padded cell. A little bit of a harsh comment, but I think it gets across the point. Very often, I think people view agitation as the other, or that's some other type of person, the right type of circumstances, the right type of social stressors, and anybody can feel out of control and have that incredibly difficult day. What a huge responsibility and honor it is for us to be there to try to help them during that time. That's why this topic is so important. Now, fair question is, how do I know if they're agitated? Or better yet, I probably know that they're agitated. How do I quantify it? How do I document it? There is no clear one way to do this. I'm going to give you a couple that I think are really good, but I'm sure there's others. I'm not suggesting these are the only ones out there. The BROSE set actually originated in emergency departments, but has really good applicability for psychiatric conditions. Inpatient hospitals, most of its literature can be found fairly easily. It's a six-item scale, so obviously you can rate zero to six. One nice thing about the BROSE set is it has what I call both obvious indicators and not so obvious indicators. The obvious are D through F. Usually, when people are threatening, throwing things, or attacking things, you know they're agitated. It kind of jumps out at you. A, B, and C, I think are often missed, even by seasoned professionals. Confusion ties to delirium. There's a lot of assaultive behavior from people that don't mean to do it because they're confused. Irritability, you often see with a lot of patients, maybe even without a psychiatric diagnosis, but they're irritable, and that leads to agitation, as does boisterousness. I see this a lot in teaching facilities, where mania is so fascinating that we try to get our trainees to see it and to understand it, but oftentimes there's a boisterousness that can be dangerous. You basically score the patient zero through six, and if you're anywhere from a one to two, you should be documenting, considering why you have either tried to treat agitation or weren't able to because of patient refusal, legal status, but you definitely want to try to intervene, and this actually has about a 24-hour predictive value, so if you are admitting from, say, an emergency department to a psychiatric unit, this is another nice option because you can use it in your handoff communication. Patient came in with a BDC of three. I talked with him and his family, did some de-escalation. He received zytus, 10 milligrams, and his broset went down to zero, but it's still important that they know that the broset was three. He was that agitated earlier in the day, and that's a good handoff from a safety standpoint between ambulatory-level care and inpatient-level care. Another great one is BARS. This came out of the Denver program. I cite the source there for if you want to look into it, and what they found was by training their staff in an objective way to describe agitation, they found increased feelings of staff safety and increased feelings of staff skill set, and we're going to get back to that at the back end of this talk as to why it's so important for our staff to feel like, I know what's going on. I'm a part of this. Things are not just kind of ad hoc handle them as they pop up because there isn't esprit de corps. Handling agitation is a teamwork type of thing. While the physicians should be leading that charge, it's also very true in most scenarios. The doctor is not the first person to see the agitated patient. In fact, there's many other scopes of practice that will probably interact with the patient long before an MD or a DO shows up, so have the whole team understand the process, and that's when I mentioned to you all those cultural things in the first five to ten minutes. That's not just for us. I do that exact same training with security staff, the people that answer the phones, front desks at clinics, which usually decide if a clinic is successful or not is who runs your front desk, right? All those individuals need to understand why we de-escalate, why agitation is important, so people are not accidentally worsening it before they even get to you, which does happen in many systems. And guess what? The more we feel comfortable and we feel safe, the better the patient feels too. There is a very disconcerting thing that is seen when the provider is anxious and that anxiety transfers over to the patient. I think sometimes we've called that third year medical student effect, where the patient was fairly decent until they encountered a very anxious student who, in trying their best to interview, accidentally kind of complicated things. All right, so let's assume we've got the cultural approach, right? We know why we're doing it. We're doing it for the right reasons. We want to see people feel better. We've also figured out that we know how to diagnose it. We know how to maybe put a number to it, maybe not, but now what do we do? Now that we know we have an agitated patient, what comes next in the best practices flow sheet? Well, there's four big things, and I would say these come pretty common sense to most people, but let's list them just to be certain. First off, make sure you're not missing something life threatening. I have seen some arachnoids present with significant agitation. I have seen MIs present with significant agitation. I've seen aneurysms present with significant agitation. I've seen liver failure present with severe agitation. People couldn't get close enough to see the significant color of the eyes because of the agitation. So just be sure that once we're kind of working through this, we're never forgetting that agitation can be caused by many different items. Then two and three kind of go together in my book. I think too often people mistake this as a pure staircase. You must fail nonverbal to qualify for the farm. Please get that out of your mind. They both work. Verbal works, pharmacological works, and guess what works better? The synergy of the two together. So if you can pair them kind of in how you're de-escalating people, and I'll give you some suggestions here in a bit, it works well. Now one thing you do try to leave till the end is anything that restricts civil rights, such as seclusion and restraint, which once again cannot be avoided in all cases. And if people are saying, I will avoid them in all cases, then you have a selection for who you're treating and what illnesses you're caring for. But we will talk about the end about the best way to minimize their role in this particular process. Now I mentioned to you that we're going to be referring to an evidence base. That way you don't have to say, why am I just listening to this dude in Milwaukee? The one I'm going to refer to most commonly, although you will see other citations as well, is what's called known as Project Beta. The best practices and evaluation and treatment of agitation came out in the WGEM a decade ago. It continues to be their most downloaded article in the history of that particular journal, which is a fairly significant journal. It looks like this when it came out. It is a series of six articles, each one covering a different component of the de-escalation and treatment of agitation process. It is free to download. There are no costs to this. You can use it. I've seen many people use it in a journal club or for different things. I would also say the articles were written very specifically to cover a myriad of scopes. You don't have to worry. You can use this with a myriad of different educational backgrounds, training scopes, practice locations. This is not just for people that do inpatient psych or not just for people that do psychiatric emergency departments, things like that. Here are the big six articles. There's of course an overview. There is the medical examination. Notice how that goes right up at top because if you miss the delirium, you are in for a big problem. The psychiatric evaluation, the verbal de-escalation, the psychopharm of agitation, and then lastly, the use and or avoidance of seclusion and restraint. I really like the way they worded that because both of those are important components. How do we avoid it? How do we make it the absolute least restrictive option? Then if we do, how do we use it humanely quickly and then move on to something that is less restrictive? First off, medical, you guys know this, but this is an educational webinar. Let me remind everybody because you may be working with people that don't know this. Our patients, particularly our patients with severe and persistent mental illness, have not less medical issues. They have more medical issues. In fact, there's a lot of reasons why there's issues with compliance. Sometimes it's due to the side effects of our own well-intended treatments. Some of the stuff we just don't know. We also know that with the SPMI population, there's a significant higher degree of morbidity about 10 years earlier than their peers, their non-SPMI peers. We don't always have a rationale for that, but we know it's there. we always got to remind people just because agitation is there don't stop thinking about you would anything else that's a major medical emergency rule out life threatening issues. Verbal de-escalation. The thing that I'm guessing for everybody here, no matter where you practice, I bet you at your practice that you have somebody that does this really, really well. And that's both good and bad. It's great because it gives people a model to kind of build off of. However, it can also de-incentivize you to getting better at it yourself. Because you'll say, oh, yeah, they're not doing too well. But Tony comes in for a second shift. Let's just wait and hand it off to him. That's not going to work. Everybody needs to be in on this. The patient needs to have a consistent presentation. Otherwise, you get intermittent reinforcement, which is we know from substance use literature is not good. So verbal de-escalation is something that some of you may be good at. Even if you're not good at it, you can get good at it. I would argue many of you already do this if you've ever been in a relationship. If you've ever had children, you've done verbal de-escalation. You may not have called it that, but you've done it. How do we apply it in a respectful, skillful sense to those people that we serve? So a couple of suggestions here. I'm guessing many of these will be familiar to you. But I just want to throw a couple out there. It is well known for those of you that have ever been in couples therapy or led couples therapy, that when you start with the word you, things get really funky. It doesn't matter what follows the word you. If you start with you, they're going to take it a little bit defensively. So stick with I, stick with we. Watch your posture and keep your space. I was consulted to check on a system one time, and they wondered why they had such a high degree of restraint. And their method of handling agitation was to have five very, very large men, at least all of them over 230, 240, show up and cross their arms like this. And they wondered why they were getting into physical altercations. To which I said, you are telling the cornered person who's already having the worst day of their life, who's already been triggered into somewhat of a fight or flight type of response into the fight. And so we got to be careful how we present ourselves. This is not about us trying to force people to do things our way or the right way. It's to recognize that they're suffering. I see that you're suffering. I want you to feel better. How can I help you feel better? Be aware of your position in the emergency room or anywhere else. Don't walk up behind people. I see that too. All of us have been conditioned through our autonomic nervous system to not feel good when somebody's standing behind us. You'll know it. Think of an elevator. You can just watch people slowly kind of move to the side, so somebody's not completely behind them. Now imagine that you're agitated. Now imagine that you're agitated on the worst day of your life. Now imagine that you're agitated on the worst day of your life, suffering from significant symptoms from an SPMI. It can be pretty understood why people going behind them is not going to be good. To that point, don't circle the wagon. If you can, six and seven go together. Have one voice at a time. We actually practice this. I encourage it as you get better within your system. Practice this like you would practice a cardiac respiratory code, which you do, right? And everybody has got their own thing that they do. Somebody's got the bag. Somebody's got the IV. Somebody's recording. Somebody's calling the shots. It can be very similar in a behavioral type of agitation code, if you will, and having only one speaker helps. Otherwise, what you see in some of these when you review them afterwards on video is what we've seen actually in law enforcement interactions, which is the patient is understandably confused because there are multiple voices telling them to do multiple opposing things. So somebody says, stand up. Somebody says, sit down. Somebody says, put up your hand. Somebody says, don't you let go of that. And all these contrasting issues would be confusing to anybody, let alone somebody who's agitated. So speak low and slow. For you docs that are here, I find that to be incredibly helpful in the interview format. Once you have been identified as the physician, most patients are going to want to get your attention and get across important information to you because they see you as the driver in what happens next, admission, discharge, medications, treatment, whatever it may be. They will focus in that you are the person to talk to. So I just find that the slower I talk and the more I still very exacerbate all of my syllables and speak slowly and lowly, they start to as well. They don't want to miss what you are saying and they will pay attention. Give it a shot next time. Now, this is something I always like to talk about in the treatment of agitation. And I want to warn you, it comes off a little bit sappy, a little bit after school, but here's the kicker. It works. It works really well. Once again, I have a lot of experience with some of the most affected individuals under the most difficult circumstances. This stuff works. And it's the whole phrase, seek first to understand, then to be understood. And we got to call this out because this is not how we are trained. This is not how doctors are trained at all. We are trained to walk into the room, gather some information and offer our point. That's why we're there. And that's not wrong, by the way. Now, we are subject matter experts. You do have a fund of knowledge and you want to impart that to people usually as quickly as possible because you got other people you got to part that information to. So nothing in that is wrong. It just doesn't fit with agitation. It doesn't work well. People don't want to know that you're on the scene and you know what you're doing and you're about to relay this information. They want to be heard. So even if you have been watching the case from afar, you've read the record. You're almost positive you know what's going to happen next and what you want to say and what you want to suggest. I would really suggest giving the first two to three minutes to the patient. Always give it to the patient, no matter what. Hey, I'm Dr. Thrasher. I'll be taking care of you today. I'm sorry. It sounds like you've had just a horrible time of it. And I've read some of it, but I'd really rather hear it from you. Can you fill me in on what's going on? And then be quiet. Now, I don't mean to do that for 30 minutes, but give some time. Try to understand first. Sometimes it's just good for people to catharsis. And people that are agitated and having the worst day of their life probably haven't had a good go of it leading up to you. It can't hurt to have people that are in positions of respect to listen to them. And there's a lot of times we don't know it all. There's a lot of times we can't proactively know what's going to happen. And this is really important information that will help drive your next decision, such as what's got them agitated. Sometimes it's a much easier answer than you may think. The number of times I've sat and listened for five minutes and found out, oh, they don't mind being here at all, but they're worried that nobody's going to feed their cat. Let's call their neighbor. Let's get them to talk to their neighbor and feed their cat. Little things like that can make restraints be null and void. So seek first to understand. We got to kind of change the physician approach on this. Go in there and just say, talk to me. What's going on and how can I help? That doesn't mean you're going to give them whatever they want. It doesn't mean that we're just there taking a checklist, but you can still have therapeutic limit setting and still help people get what they want. I would say in 95% of times when I say, what do you want? It's something I can give them. It's very basic. It's very Maslow's hierarchy. We're typically talking food, shelter. People are hungry. People are thirsty. People are tired. Sometimes they just need a little bit of time to decompress. And here we are in a system trying to make sure everybody kind of follows the same pattern. And we got lots of people to see. Sometimes the best de-escalation I've ever done is just say, empty out the room and give them 15 minutes to themselves. Yeah, I want to get to you right now, but you know what? You're not in the right place. So how about I give you something to drink? I'm going to go make that phone call for you. Check on another patient. I'll be back in 15 to 20. And when I come back, they're dramatically better. So you've got to think about different ways to seek first to understand. Then you share your point of view. Then once you've listened to them, share all the different awesome things that you know about this that will make their life better, that will ease their suffering. But I highly suggest not leading with it. They don't want to hear about your experience or what you can do to help them. They want to be heard. That's an important component of agitation. So a couple topics to keep in mind that I alluded to on the prior slide whenever you are being understood. Trauma-informed care. We want to avoid re-traumatizing people. It's why restraints can be so concerning. It's why coercive care can be concerning. Not to say it's not needed sometimes. It's to say we always want to make it the least restrictive. And psychological first aid is somewhat inherent in the past eight or 10 slides that I presented. Psychological first aid is the idea of being there for what people need, not what you think they need. In other words, sometimes what people need doesn't even feel very medical to you, but it's exactly what they need in the moment. It's very easy to provide to them. And maybe that's all they need to calm down. I have seen cases escalate because well-meaning staff are following their policy. And the policy says, I got to take off your shoes right now. Your shoes and your shoelaces must come out right now. Meanwhile, they're screaming, my kid's at daycare. Nobody's going to pick them up. My kid's at daycare. They're going to call cops. Sorry, ma'am. We must have your shoes. Take off your shoes. Now, what makes sense here is to say, how about we just give her a phone and let her call daycare, and then we can take off the shoes? But that's psychological first aid. Letting the patient drive things a bit. I think people get nervous because they're like, well, then you're going to do whatever they want. No, that's not the case at all. There is a nuance to this. Meet them where they are first. And what they need is often something very different than what we think they may need. We got to listen. Now, let's say something happens. Something goes down, and you've got to debrief with people. I think most people are actually using PFA or psychological first aid, not debriefing. But it's good to check on your staff. Your staff may have a history of trauma. Your staff could be affected by this. You don't have to do it right away. You don't have to stop all operations and go sit in a circle kumbaya style. But pay attention to who had the roughest go of it and go talk to them that day or talk to them the next day. I find checking in on people two to three days later is also very powerful because it reminds the staff that you care about them and reminds that you were paying attention. And that was a pretty big event that happened. We do this in cardiac respiratory codes all the time, particularly those that end in unfortunate deaths. And debrief with the patient. Don't be afraid to talk to them. I had a wise mentor once tell me, Tony, when they're agitated, they are there to use your frontal lobe. And that always stuck with me because all of us, if any one of us were agitated, the frontal temporal turns off and we go all to the amygdala, right? Amygdala hippocampus takes over. So how do we help reflect what seemed to be very basic things to us, but they aren't basic to somebody who's agitated? Check on them. See how they're doing. Is there somebody I can call for you? Did you understand why we had to go down that road? I hope we don't have to go down that road anymore. If you don't check on the patient after all this has gone down, you're somewhat accidentally reinforcing said behavior. You're reinforcing that the squeaky wheel gets the grease. Now, we're going to talk about meds. God, yes. It's time to talk about meds. I hope you understand though that that first 20, 25 minutes was not about meds because in my mind, when we're talking about agitation, there's so much more to this than meds. And if you only focus on this back half, I would argue you're not going to be very successful or at least not as successful as if you do it all together. So couple of soapbox issues. You see this a lot as psychiatrists. Most people overemphasize the risks of psych meds and they underemphasize the risks of what mental illness looks like when it's not treated. I'll take phone calls. I hear glass breaking in the back. I hear people screaming. And they're like, I'm like, well, what have you given them? Oh, well, they don't want meds. Like, well, they're destroying everything around them. So that consent has kind of passed. You have some imminent dangerousness here to medicate, but people get very nervous about this. So we have to educate that it's safe. There are many things that are safe to give during agitation. And I alluded to this, I think on slide 10 or 11. Sometimes we don't intervene early enough. One thing I teach our trainees is agitation doesn't spontaneously resolve. It's like mania. Maybe it will resolve after like two weeks, but only after significant damage has occurred. You need to get in there and do something. And it's not do it once and then sit back and wait for psych to show up. Just like if I was having chest pain, if you gave me one dose of nitro, you don't stop. Do you, if it didn't resolve? No, you continue to treat the symptom until it resolves. Agitation is similar. And I said a lot of these, but I put a slide in it all the same. Restraints may be necessary, but theoretically it's inappropriate if all you're doing is restraints. Restraints are not a treatment at all. Restraints are a method to get to a treatment. So if you've passed the burden of physically restraining somebody, you've already passed the burden for refusing medications. So the idea is to get medications into people as quickly as possible to get them out of restraints, because we don't want that to be a treatment. That also helps you with any adverse events because most adverse events involving restraints are when people are in restraints for a long period of time. All right, off the soap boxes. When you're looking at what meds to use, a lot of different things to consider. I bolded the most important one. What are you trying to treat? This is why you can't just say it's always this, or it's always 5, 2, and 50. You can't say that because it depends upon the scenario. I've consulted on many people that have given 18 to 20 milligrams of Ativan to somebody who was clearly psychotic, and they say, well, we keep knocking them out, but when they wake up, they're still agitated. I'm like, yeah, because you haven't treated their psychosis. You have to know kind of what you're treating. You won't always have the blessing of knowing that during agitation, but if you do, aim for the target symptom. The target symptom is not just all agitated people get the same meds. Try to clarify allergies. I'm a big fan of saying what has worked for you in the past. For a lot of people, this is not their first time being agitated, and most often, the answer they give you to what has worked for you in the past is awesome. It's something you can use, so you're listening to them. It's something that works for you and them, so you can provide it. You're showing that you are a competent physician, and you can be trusted. All of those components lead to de-escalation with markedly less medications as opposed to I have to keep giving this to you until you calm down. You see the difference between the two, right? One is going to need much more meds. One is not. This is a really good question, and even if they say something funny like, well, I usually like a 750 of Jack Daniels. Well, I can't do you that way, but I do have medications that work similarly in the brain. Let me get you some of this benzodiazepine and see if that can help with your agitation. Here's something else. Whenever I'm treating agitation, I'm doing my best not to sedate them. There are rare times. There are rare times where people are incredibly agitated. You already know it's going to be an admission. You have the past information, so you may be looking for sedation. I get it. Those do exist, but they should be your minority. The majority of time, I don't want them knocked out. I want to be able to talk to them because once again, I'm clearing out the symptom of agitation so I can be a better diagnostician. As long as the agitation is there, I can't diagnose. I don't know what's going on, so I don't want them knocked out for four hours. If anything else, you learn how to use these things to help facilitate an interview, and in a psychodynamic process, it also builds your trust with the person. When I say I'm going to give you this pill, you're going to feel better, so we can have a better conversation. Then I go see some of the people, and I come back. I've established that I'm trustworthy, and I guarantee you the agitation process from then on is easy street. Beta looked at a lot of things, predominantly FGAs, SGAs, and benzos. Once again, when it came to delirium, saying try to find out the cause first so we're not just covering that up. Intoxication, the first line was benzos. It seemed to work very, very well. It doesn't reinforce addiction or anything like that that is still somewhat of a stigma out there. I will say an interesting, I think it's an artifact of research. When it came to alcohol use disorders, haloperidol had a lot of the data. Just to be fair, though, at the time those studies were conducted, most of the usage of antipsychotics was haloperidol. SGAs hadn't really come into the forefront yet. Risperidone and others of that generation hadn't really come up, so I'm a little bit nervous that might be artifact of when the studies were created, but it did come up that way. For psychiatric illness, antipsychotics, first line. Most people don't recognize this. They call you for consultation. They're expecting benzos, antihistamines, and I'm like, well, have you done Risperdal, Zyprexa, Seroquel, Geodon? No? Why not? Well, those are antipsychotics. Well, they are, through many studies, first line for agitation. Very easy to use, very easy to titrate. You're not looking at any significant side effects in the one-time usage or two-time usages. Risperidone and Zyprexa had probably the most data. Benzos was second line. What about ketamine? We don't have time to talk to all 206 of you to see what your different thoughts are, but I bet you most of you have had some involvement with ketamine. Now, please understand, we're talking about ketamine. There's like seven different psychiatric conversations here. I'm going to narrow this to ketamine for the purpose of agitation. I'm not speaking to ketopine for acute SI resolution, chronic SI resolution, PTSD, MDD. There's a lot of other good educational services on that. This is just going to be about ketamine within agitation. This has become very popular, particularly the more rural you are. And you may say, Doc, why is that? Well, because EMS likes it because it tends to have a longer degree of sedation. So if you're transporting somebody two to three hours to get to the nearest hospital, I can see why rural EMS may be incentivized to consider this. Quick onset, longer degree of sedation. Here's the kicker. Since you don't always know what's causing the agitation at time equals zero, ketamine's got real good data for non-psychiatric agitation. Not so good for mental illness. Because once again, the ketamine model was helped kind of find some of the neurobiology behind schizophrenia back in the day. So somebody's psychotic and you're giving them ketamine, it's going to get funky real quick. But there will be some initial sedation. There's also markedly more concerns with ketamine on respiratory insufficiency and stability than there is with the antipsychotic realm and other items. So can it be used? Yes. I don't think it should be your first line option at all. And guess who else doesn't think that? Emergency medicine. So ASAP has really kind of been clear about this. They keep it a level C rec, which isn't very high at all. So even they have noted it's there. Could you use it safely and effectively level C? Now you can't talk about ketamine without talking about excited delirium, which once again is a whole nother topic, but I want to put a couple slides in here. There's a lot of controversies here. And I don't pretend that today's talk is going to clarify all that for you, but I'd like to at least try to put some information out there. There is a significant difference in opinion right now between the professional organization of ASAP, which is emergency medicine, and the APA, psychiatry. What we have noticed is that diagnosis has been tied to some increased deaths with law enforcement, some concerns and criticisms of coroners, that often deaths within law enforcement seems to be disproportionately assigned to this particular diagnosis. So I can tell you as someone that works a lot with advocacy groups and CIT training, we do include this in our training because cops need to hear it, because cops have kind of been given some different training on this that isn't always medically based. And they are often being put in some positions where they're being asked to direct EMS to give medications, which is a whole nother issue. I quote a really nice article here from Applebaum if you want to read more on this, but they do note that when they are agitated and uncooperative and involving police, you see more diagnosis of excited delirium. It is not a formal diagnosis. It has not been approved by anybody, formally speaking, and there's a lot of different research on that. So whether it is right on the money or whether it needs modification, what we can clearly say is it's not good enough to stand on its own. And as Applebaum pulled out in this particular article, there is some concerns that it's used kind of in an exculpatory sense, because we're seeing so much of it used only when there's been bad outcomes or forceful restraints, as opposed to not seeing like a normal case of excited delirium, where somebody had excited delirium, they took two milligrams of risperidone, and they felt great. There isn't tons of that in the literature. For whatever reason, that term is much more used in bad outcomes. So one last article from Dr. Slocum, who's currently out there on the East Coast, try to separate the medicine from the controversy. Focus on future state. You can't avoid this topic, but I'd be very cautious if you're using it as a formal diagnosis. I don't think it has the backing to back you up legally. Some other options other than ketamine that are a bit newer, Adesuv. I was really looking forward to this as a psychiatrist who trained back in the 90s, early 2000s. I love the loxapine, a good mid potency, typical antipsychotic that kind of got pulled off the market because the demand wasn't there to encourage people to make it. But it came back in a formal way as an inhaled quick onset, almost like an albuterol, like an MDI. Really nice for multiple reasons. A, you're getting the inhaled response so quick as can be. B, the patient is getting to administer it. So we're really working on that. I want to give you some control back. You're not feeling good. Let's together work on this for you to feel good. The hard part with this, as with many things, is there is a REMS. The REMS is hard to get through because there was some bronchospasms that led to the need to possibly intubate. So I don't know a lot of freestanding psychiatrists that are using this because of the intubation concern, but it's out there. If you have a chance to try it out, I think it's a really interesting new ad. Other things that we use all the time, I'm a big fan of the format more than the branded name. We've always used more risperidone and olanzapine, mainly because they have dissolvable tabs, which is great in agitation, right? You're gonna get away the stigma. It's gonna work quicker. You're gonna miss most of the first pass. It's kind of a win-win. So just think about that whenever you're, I always say, if any antipsychotic has a quick dissolve affordable option, I'd be curious to see how it plays out. Benzos are fine. Use benzos, you know, first time, one time, two times. You're not gonna send somebody out of the ER on a script for 90 with three refills, but they do not have a lot of data for one time bad outcomes that people seem to kind of have as a hidden curriculum that people are trained in that. Antihistamines are similar. Just be careful with antihistamines, particularly if you're doing a lot of IMs. It has a distinct anticholinergic load. A lot of patients are on a lot of anticholinergic meds. You don't wanna see that play out. IM antipsychotics, there's a lot of different ones you can do. You can do the depots as well. Newer addition. This is probably the newest thing on the market. This is called Igalmi. Now the medicine itself is not new. If you guys have done any internal medicine or rotated in the ICUs or consulted in the ICUs, we're all familiar with dex or dexametadine. I prefer dex because I always mess up the long word. They have now come out with a sublingual form of that known as Igalmi. It has been proven in both schizophrenia bipolar and bipolar II cases to treat agitation. The study I sit down here is specifically to the bipolar cases. There's another one by Leslie Citron, who many of you are very famous psychopharmacologist who did a recent study on the schizophrenia components as well. Seems to have an onset of average. It's pretty consistent with sublingual formulations. And this has been shown to have some pretty decent reductions as well. So depending upon what sort of hospital you're in, this is another one to keep an eye on. How about kids? We've talked predominantly about adults, but I wanna let you at least know that a lot of the same members that did the original project beta rebooted about seven years later and came out with a child version. We call it baby beta. They really don't like that, but it just rolls off the tongue. And so we keep calling it baby beta when they're not paying attention. Hopefully they're not on this right now. But it's a great, once again, free read on how to apply this to kids. If kids are more your domain, I'm gonna give you the high level overview. They found five main areas. They said treat delirium the same as adults. Treat substance intox roughly the same. IDD and autism. This is where things went really different. And it's important because the IDD autism population is overrepresented amongst kids who show up with agitation to hospitals. So they really pushed non-pharm, non-pharm, non-pharm. Then if you're stuck with pharm, go home meds. And if needing to raise the dosing, but don't. This is not the group to start trying new things they've never been on before. You tend to get a lot of odd kind of unindicated, contraindicated type of reactions that show up. And the same things for psychiatric. The only difference here is they found in the kid studies that you actually saw Benadryl and Ativan pop up a bit earlier in the game than the antipsychotics. I don't think that's clear if that's the selection bias, if that's what people's comfort level is in prescribing those to children, but it definitely came up above the antipsychotics. Now, as you're thinking about all this, restraints do come up. There are some, just like there are some cases that no matter your best efforts of CPR, AED, they're gonna need to be stented, or they're gonna need to have some sort of antiarrhythmic therapy, right? Things happen at the end of the continuum of a severe illness, agitation is no different. So if you do need to do restraints, minimize the amount of time. They are there simply to give medications and to get better, not to sit there. Nobody gets better from being tied to a bed and being told to listen. It's pretty pedantic and counterintuitive. For those of you that are looking to initiate some of these things and wonder how to sell it to your programs, restraints are costly. Restraints are not just costly financially, they're costly in terms of turnover, they're costly in terms of process, and they're really costly in terms of throughput. They slow everything down with your patient. If you wanna fix the throughput, fix your restraint issue. Now, there's also a business case here. Everything we've been talking about for the past 40 minutes, you will get better patient satisfaction, you will get better staff satisfaction, your throughput will be lower, your length of stays will be lower. There's a lot of lowered grievances. If you're trying to sell this to administration who often have to handle the grievance process, tell them this too. If you are training everybody in these principles, following these particular culture shifts, non-pharm and pharm approaches, you are gonna be having a lot better partnership with everybody. There is a business case to be made. And I also include here some great stuff, particularly Dr. Smith. Here, the top article out of Duke has been doing some great stuff with restraints and disparities, particularly with populations that are black compared to patients that are white. I'll leave the citations there for you, but the more we do this, the more we can decrease those disparities as well. So running through all that, we're coming up kind of towards our concluding time and hopefully get into some questions. Just please remember, agitation is an emergency. It's a complex emergency that cannot be reduced to, I'll just give the same med every single time and call that one psychiatrist who's on the call. It really needs to be something that is team-focused, team-taught, and here's the kicker. They will feel better when you teach them this. Empowering our staff to know that this isn't a mystery. They don't have to be scared. We don't have to see this as an us versus them, but more or less, oh, you're hurting and you're suffering and how can I assist you? That becomes less adversarial. That becomes less zero sum. And overall, everything will improve. You wanna rule out your medical, use your verbal and pharmacological options in the support your team. And then I also just remind everybody of some of those soapbox items down here. We don't want to underutilize psychiatric meds, particularly for our non-psychiatric physician peers. They seem to get very, very scared whether because they aren't familiar with it, didn't have a lot of psychiatric training or have just heard a lot of things about the meds we use to treat agitation. They can be taught how to use these meds. Believe me, as I tell emergency department docs all the time, you use many more dangerous meds. Every single, I mean, you use antithrombotics. You use all sorts of dangerous things that would honestly scare me. You can handle these meds for agitation. I just got to teach you about them so you feel comfortable because you don't want to underemphasize untreated psychiatric illness. It is severe. It is not behavioral. And agitation will continue to increase unless you address it. And I would argue you can use this in all settings, particularly the cultural approach and the non-pharmacological approach. Works great now in patient settings. We often do that all the time. And then kind of just do the pharmacological talk with the docs, but use everything else for everybody there. How do we interact with people? How do we engage with people? How do we handle it when the patient and we have a difference of opinion? How do we handle that without it being argumentative or us iatrogenically making it worse? That's all part of best practices for agitation. Please recognize it in early stage. Realize that the culture should be they're not here trying to hurt us. It's their right to feel better. Let's do it. And the most dangerous thing is to do nothing. Don't sit back and just think it's gonna get better or wait for someone else to show up and fix it. If you don't know how to do it, let's train people how to do it. This doesn't take long. Those articles are quick to read and quick to implement. And once again, you've got an evidence base. And I would leave you with this before we take questions. One of my favorite things about this entire subject matter is it involves patient interactions. And regardless of what type of interview you're doing, diagnostic, treatment, assessment, therapeutic, forensic, CL, whatever it may be, every interaction can be therapeutic. If you're using these types of protocols and these types of approaches, when people are working with you, they are going to feel better. And that's kind of what we're all about. That should be applied to agitation, just like it would for PTSD or generalized anxiety or ADHD. And there are some references for you guys. I know you have all the slides to take a peek at. And I really appreciate your time. I'll be happy to take any questions that the group has seen kind of a fit to send in. Dr. Thrasher, thank you so much. That was just really, really terrific. You're just a wealth of knowledge and you can tell you've just got a lot of really great experience, very practical, humanistic, and really normalizing approach to a tough topic of agitation. So really, really great. Before we shift into the Q&A, I just want to let everybody know that SMI Advisor is available from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts, download the app now at smiadvisor.org slash app. All right, so let's get into the questions. Got some great questions from the audience already. One of the ones I wanted to start out with was, are there, Dr. Thrasher, particular considerations for treating agitation for older adults where people may be physically frail or compromised or have comorbid medical conditions and may be taking a lot of different medications? Great question, and to be fair, one that is, I don't think, specifically called out in either of the beta projects that I mentioned. So thank you for raising it now. What most evidence has shown is you will be handling it as you would any psychopharmacological issue in the geriatric population. You're probably gonna be lowering your dosages for a myriad of both pharmacokinetic and pharmacodynamic changes that occur as people get older. I would also argue, clinically speaking, I tend to intervene with meds even quicker with that population, usually because depending upon where we are, like in an inpatient or emergency department format, I'm worried about their fragility. If it's a young 20, 30-year-old that wants to pace in the back, that doesn't bother me at all. But somebody that can not walk that well and they've probably already had their cane taken away because it's considered a safety issue, I may even intervene a little bit earlier, try to isolate, get them into a safer part of the milieu if the situation allows for it. Otherwise, lower your dosing, and as you would with anything, pay attention to their med regimen. You could also almost look at their regimen like we looked at IDD and autism with kids. Find what they're already on that they tolerate and maybe raise it or lower the dose a tad. Okay, great. I wanted to get your thoughts on droperidol. Oh, yes, good old droperidol. As many of you know, depending upon when you trained, used to be used for agitation a lot, and it will reduce the agitation. It will typically reduce the agitation via sedation. Most articles that I've read, the risk-benefit analysis to me does not weigh in favor of using it, either primary or secondarily. I'm not against that people do use it. I don't think it's contraindicated. I would hope that if you're doing that, in a very strict inpatient type of monitored area where you can follow everything, droperidol does carry some decent QT concerns. To be fair, all antipsychotics have QT concerns, but droperidol has more than most. And so kind of for the same reason that Pimazide kind of got pulled out of a lot of usages for there for a while, I would keep droperidol down on your tertiary or your quaternary type of choicing. And I'd be surprised if you couldn't find something in the higher levels that work better for you with less concern. Okay, thanks. And sort of a related question, sort of around chlorpromazine. Yeah, that's an interesting one. You know, now we're getting into the low potency, typical antipsychotics. Chlorpromazine has tons of usage in kids. And I think the reason there is one of the biggest things we see with IM chlorpromazine is orthostasis and people passing out. Kids are usually less prone to that. They've just got a better kind of cardiac support. So maybe that's how it got used more in kids. I have not seen as many adverse events from that. I think the problem with chlorpromazine is the dosing's a little bit hard to get right in agitation. I think it gets used sequentially a little bit more. It's not uncommon to see on kids' psych units, you know, 12.5 to 25 to 50 mgs Q so many hours. So it's not contraindicated. It would fit under antipsychotics for agitation, but I think you got better options that you may only have to give once as opposed to giving multiple times. Okay, great. Thank you. I wanna just shift gears for a moment and get to some of your earlier remarks, which I really appreciated about culture change. Because really, I think that in order to be successful, it has a lot to do with that, as you said. And I know that you also work as a consultant to various systems. What do you see as some of the successful elements of sort of shifting the culture, changing the culture? What works? I think you have to acknowledge that people have been hurt. I think otherwise, that's why I always try to give some of my work background. It's not really to, I guess I'm trying to establish a bone a few days and also tell people I've been there. You know, I have been the victim of an assault. I have cared for and supervised people that have been victims of assaults. And once that happens, I think the problem then becomes, it's very hard to get you into that supportive frame of mind. It's natural once anybody has been traumatized to be more concerned of future assaults. So I think you gotta acknowledge those things existed, offer to talk to those people and kind of walk them through that I'm not negating what you went through. You didn't do anything wrong. You didn't do anything wrong. I'm not so sure. Depending upon the circumstance, the patient may have either. Things just transpire. How can we now move forward? But I think you gotta acknowledge that probably in any group you're talking to, something has gone awry. Or for instance, they wouldn't be calling in a consultant. So then I say, now that we're here at time zero and we're all together, how can we really change this from, we need to protect ourselves, to I see that you're having a significant emergency, how can I help you? That optic shift is everything. And very often it's not present. Even in the literature, a lot of the workplace violence literature, and I understand it, is very much how do we protect ourselves from kind of this other thing. But a lot of times this other thing, not in all cases, but in some cases is a treatable medical emergency such as agitation. Thank you. Very, very helpful to think about it through that lens. And one of the other questions is sort of about the behavioral de-escalation strategies, sort of non-pharmacologic approaches. What sort of resources could you maybe direct us to for people who wanna kind of think more about those options? Yeah, I think you really wanna get into the idea of trauma-informed care and psychological first aid. PFA is wonderful, and there's a lot of great data on it. And the fact that it leads with the word psychological should not scare us off in the psychiatric field. It's a very well-established form of intervention that's been adopted by almost... The idea of debriefing is almost completely gone across the country, actually across the globe. PFA is... So I would start there. And then here's kind of a curve ball. Some of the best things I have found have been in the world of business. I'm not one of these doctors that's gonna come out and say we should all be MBAs. What I'm saying is there's ways to approaching individuals and engaging with individuals who have a different opinion than ours or engaging with individuals that disagree with a decision that we have made that business does very well and medicine does not. And so another real big topic I like to work with my staff on is something called service recovery, which is the idea of you, the patient, you, the consumer disagreed with something, and I feel bad that you disagreed. I feel bad that you disagreed with what I did. Doesn't mean I'm wrong. I'm not looking to apologize per se, but I wanna empathize with you that I really hoped every one of our interactions was gonna be... And it wasn't this time. How can we talk about it? I think those are great things to start talking to staff about, which is hard. You wouldn't think that healthcare would need that, but we do need that. We need to have different approaches in engaging with people. How do we... And it's not always the docs, because once again, we are often picking up the pieces of five or six other staff that have seen them first. I always start with the person at the front door. How are you engaging them? How are you working with them? If they look upset, do you say you can't come in or I've got to call the cops? Well, that's only gonna set them off more. How do we engage with people? That's where I would start, that and PFA. Yeah, it kind of made me think a little bit about... I wanted to ask you about your experience working with folks with lived experience in emergency room settings or possibly in sort of crisis settings. Can you tell us a little bit about your experience there? I've seen it work. We didn't use tons in our psychiatric ER because at the time we felt it was too much acuity and we were worried that it could actually worsen that lived experience person's progress and their recovery. I'm not against it though. I know other psychiatric ERs that have used them and use them to great success. But I do think there's a great deal to be said by somebody else meeting them and say, listen, I'm not a doc. I'm just telling you I've been there. And I think what's key for if you're ever gonna put that into your protocols is you don't make it a black and white that that must be the next step. Because for some people you're gonna find out in the first 30 seconds, they don't wanna hear from that person. So then you gotta kind of pivot. You have to call an audible and then move down a different path. But I have seen the lived experience work very well in de-escalation. And sometimes the person who was agitated is getting more from that person than they would be from me. So you just kinda gotta read the room and be like, is this the right time to let them, once again, going back to one person being the lead, it doesn't have to be the doctor. Who has the most connection? Who's got the most things, the most shared empathy going on with the patient? That's who should be leading the scenario at that moment. And one more question. I think that the project beta is really quite excellent and is the kind of gold standard in terms of the guidelines. If you were to be able to wave a magic wand and update project beta, is there anything that you feel like is sort of that we should be thinking about since the guideline was released, at least the adult guideline? Yeah, I definitely, we actually have had this conversation at the national level. So thank you for bringing it up. I think the biggest issue would be updating the cycle farm. I think most of the other principles are pretty, but not much has changed. I think we could reiterate certain things more. Like I said, maybe even bring in more of kind of a business sense, like how do we handle grievances and complaints of dissatisfaction? But the one part I would just wanna update is, the cycle farm from 2012 is different than the cycle farm now. So we do have other things, some that I alluded to here, some that I did not. There's other alpha-2 agonists, there's other things that people use. It may be worth discussing that. And even looking at things that people may be trying to use out in the real world that may actually be hurting them. Some OTC stuff, some different items. So I would say probably out of all those six sections, it'd be wanting to update the cycle farm in the future. Outstanding, thank you. Thank you so much. So that was the end of the Q&A session, Dr. Thrasher. Again, really, really outstanding. And now we'll kind of go into the outro. So, let's see if you could get the next slide for me. So if there are any topics covered in this webinar that our audience would like to discuss with colleagues in the mental health field, just post a question or comment in SMI Advisors Webinar Roundtable Topics Discussion Board. This is an easy way to network and share ideas with other clinicians who participate in the webinar. If you have questions about this webinar or any topic related to evidence-based care for SMI, you can get an answer within one business day from one of our SMI Advisors National Experts. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals with SMI. It's completely free and confidential. All right, next. An SMI Advisor offers more evidence-based guidance on psychopharmacology, such as the webinar, Ketamine, Esketamine, and the Treatment of Serious and Persistent Depression, Practical Considerations. 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And again, thank you so much for joining us. Until next time, take care, everybody. Thank you.

agitation management

serious mental illness

cultural shift

non-pharmacological approaches

medication role

early intervention

restraints in treatment

ketamine use

trauma-informed care

holistic approach