Agitation — MSF Clinical guidelines — Médecins Sans Frontières 2026

MSFClinical guideline (chapter)Current edition

From Clinical guidelines — Diagnosis and treatment manual › Chapter 11: Mental disorders in adults · Médecins Sans Frontières, Current online edition (updated November 2021)

Management of psychomotor agitation in adults, including pharmacological sedation and alcohol withdrawal treatment.

In one sentenceManage agitation with diazepam 10 mg orally or intramuscularly (repeat after 30–60 minutes), but use haloperidol instead in alcohol intoxication or delirium; treat alcohol withdrawal with diazepam taper, hydration, and thiamine.

Issuer: Médecins Sans Frontières
Edition: Current online edition (updated November 2021)
Audience: Clinicians working in resource-limited settings
Evidence: Expert consensus based on MSF field experience
Reviewed: 22 Oct 2026 · GMJ

Read the original on MSF Whole guideline (PDF)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 22 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This MSF clinical guideline addresses the management of psychomotor agitation in adults, which commonly occurs following violent events or in patients with anxiety, depression, psychotic disorders, delirium, acute intoxication, or withdrawal syndromes. Certain medications including SSRIs, levodopa, mefloquine, and efavirenz may also cause agitation.

The guideline emphasises that clinical evaluation should be conducted in pairs in a calm setting, with priority given to identifying and treating any underlying delirium. Pharmacological management centres on diazepam 10 mg orally for moderate agitation or 10 mg intramuscularly for violent or dangerous patients, with repetition after 30 to 60 minutes if needed. However, diazepam is contraindicated in acute alcohol intoxication or delirium due to respiratory depression risk; haloperidol should be used instead.

Special attention is given to alcohol withdrawal syndrome, which can develop 6 to 24 hours after cessation of drinking. The guideline provides specific treatment protocols including diazepam taper over 7 days, oral hydration of 3 litres daily, and thiamine 100 mg three times daily for at least 3 days to prevent complications in hospitalised patients forced to stop drinking abruptly.

Key points

For clinicians — doses and thresholds as stated in the guideline

Administer diazepam 10 mg orally to reduce agitation and enable clinical examination without over-sedation
For violent or dangerous patients requiring urgent sedation: diazepam 10 mg intramuscularly, repeat after 30 to 60 minutes if necessary
Avoid diazepam in acute alcohol intoxication or delirium due to respiratory depression risk; use haloperidol instead
Alcohol withdrawal symptoms appear 6 to 24 hours after cessation; treat with diazepam 10 mg every 6 hours for 1 to 3 days, then taper over 7 days
Alcohol withdrawal management includes oral hydration 3 litres daily plus thiamine 100 mg intramuscularly or slow intravenous three times daily for at least 3 days
Always check for signs of delirium first; if present, identify and treat the underlying cause as priority
Conduct clinical evaluation in pairs, in a calm setting, with or without family/friends depending on situation
Physical restraint should only be used in certain circumstances, strictly following established procedures

Management of Alcohol Withdrawal Syndrome

Table extracted from the guideline

Component	Dosage/Schedule	Duration
Diazepam	10 mg orally every 6 hours	1–3 days, then reduce and stop over 7 days
Oral hydration	3 litres of water daily	Throughout withdrawal
Thiamine	100 mg IM or very slow IV, 3 times daily	At least 3 days

Source: Médecins Sans Frontières, Agitation — MSF Clinical guidelines. Reproduced in summary form.

From the guideline

Verbatim

“It is essential to check for signs of delirium. If present, the priority is to identify the cause and treat it.”

— Médecins Sans Frontières, Agitation — MSF Clinical guidelines, Management section (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute of Georgia, I recognise that agitation management is a critical gap in Georgian primary care and emergency services, where mental health integration remains incomplete despite our Universal Health Care reforms since 2013. The MSF protocol for alcohol withdrawal is particularly relevant given the high prevalence of hazardous alcohol use in Georgia and the South Caucasus; our clinicians must ensure thiamine availability and understand the 6 to 24-hour window for withdrawal onset in hospitalised patients. I would stress to Georgian colleagues the absolute contraindication of diazepam in acute alcohol intoxication and delirium due to respiratory depression risk—a potentially fatal error in busy emergency departments. The realistic implementation challenge is ensuring that parenteral thiamine and haloperidol are consistently stocked at district hospitals and that clear physical restraint protocols are established within our medico-legal framework to protect both patients and healthcare workers.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 22 Oct 2026

Applicability

Georgia and the South Caucasus

This guideline is highly relevant for Georgia and the South Caucasus, where mental health and substance use services are often limited, particularly in primary care settings. Georgia’s ongoing healthcare reforms under the Universal Health Care programme need to ensure that essential medications like diazepam, haloperidol, and parenteral thiamine are available at district-level facilities where agitated patients commonly present. National programmes should consider training primary care physicians and emergency department staff in the systematic assessment of agitation, safe use of sedation protocols, and recognition of alcohol withdrawal syndrome, which may be under-diagnosed in the region. Physical restraint protocols require clear national guidelines adapted to Georgian medico-legal frameworks to protect both patient rights and staff safety.

Questions this guideline answers

Quick answers

When should I avoid using diazepam for agitation?

Avoid diazepam if agitation is related to acute alcohol intoxication or if the patient has delirium, due to the risk of respiratory depression. In these cases, use haloperidol instead.

How quickly can alcohol withdrawal symptoms develop?

Alcohol withdrawal symptoms can begin within 6 to 24 hours after a patient stops drinking. This is particularly important for hospitalised patients who are forced to stop drinking abruptly.

What is the dose of diazepam for a violent, dangerous patient?

For urgent sedation in violent or dangerous patients, give diazepam 10 mg intramuscularly, which can be repeated after 30 to 60 minutes if necessary.

Why is thiamine important in alcohol withdrawal treatment?

Thiamine (100 mg intramuscularly or very slow intravenous, three times daily for at least 3 days) is essential in alcohol withdrawal to prevent Wernicke encephalopathy and other neurological complications in patients with chronic alcohol use.

Related on GMJ

Interconnected resources

Dictionary of Public Health

Drugs A–Z

Conditions A–Z

Generalized Anxiety Disorder

GMJ News coverage

Quality & accreditation

Same guideline

Insomnia — MSF Clinical guidelinesChapter 11: Mental disorders in adults
Anxiety — MSF Clinical guidelinesChapter 11: Mental disorders in adults
Venomous bites and stings — Clinical guidelines — MSF Clinical guidelinesChapter 10: Medical and minor surgical procedures
Dental infections — MSF Clinical guidelinesChapter 10: Medical and minor surgical procedures
Necrotising infections of the skin and soft tissues — MSF Clinical guidelinesChapter 10: Medical and minor surgical procedures
Leg ulcers — MSF Clinical guidelinesChapter 10: Medical and minor surgical procedures

Agitation — MSF Clinical guidelines

What this guideline says

Key points

Management of Alcohol Withdrawal Syndrome

From the guideline