Context Matters: Variation in Pharmacologic Management of Pediatric Agitation Across Emergency and Inpatient Psychiatric Settings

Background: Management of acute agitation in youth frequently involves intramuscular (IM) antipsychotics; however, little is known about how treatment strategies vary across care settings. Differences between emergency and inpatient psychiatric environments may influence medication selection and dosing. Methods: This retrospective secondary analysis included youth (<18 years) who received IM antipsychotics for agitation across multiple emergency departments and inpatient psychiatric units within a large urban health system (2019–2023). Comparisons between settings examined antipsychotic selection, coadministration of adjunctive medications, and dosing. To account for differences in medication selection, dosing comparisons were conducted within each antipsychotic agent. Secondary outcomes included repeat IM administration and restraint or seclusion within 24 hours. Results: The sample included 158 youth (86 emergency, 72 inpatient). Antipsychotic selection differed significantly by setting, with greater use of haloperidol in emergency settings and chlorpromazine in inpatient settings ( p < 0.001). Midazolam coadministration was more common in emergency settings (10.5% vs. 1.4%, p = 0.020). When examined within agents, chlorpromazine doses were higher in inpatient settings (36.7 mg vs. 30.4 mg, p = 0.035), while haloperidol and olanzapine dosing did not differ. Rates of additional IM administration were similar across settings ( p = 0.295), although restraint or seclusion was more common in inpatient settings ( p < 0.001). Conclusions: Pharmacologic management of pediatric agitation varies by care setting, particularly in antipsychotic selection and adjunctive medication use. Differences in dosing were limited to chlorpromazine, suggesting that variation reflects agent-specific prescribing patterns rather than overall treatment intensity. These findings highlight the influence of clinical context and provider practice patterns in shaping management strategies for pediatric agitation.