Behavioral Activity Rating Scale (BARS)

Why use it

Provides a standardized, reproducible measure of agitation severity that can be applied rapidly in emergency settings without extensive training. Particularly useful for monitoring response to pharmacological treatment of acute agitation (antipsychotics, benzodiazepines). Also identifies over-sedation (scores 1–3) which is a common adverse effect of agitation treatment and requires clinical response.

About

The Behavioral Activity Rating Scale (BARS) is a validated 7-point single-item observational scale used to assess the severity of agitation in patients presenting to emergency departments, psychiatric units, and other acute clinical settings. The scale ranges from 1 (difficult or unable to rouse — sedated) to 7 (dangerously agitated and uncooperative — requiring restraints). A score of 4 represents the target state of "quiet and awake," which is the goal of treatment for both over-sedation and agitation. BARS is widely used in emergency department agitation trials and has been validated in multiple studies of pharmacological treatment of acute agitation.

When to use

• Acute agitation in emergency departments or psychiatric units
• Monitoring response to pharmacological treatment of agitation (sedation endpoint)
• Identifying over-sedation following treatment of acute behavioral disturbance
• Behavioral assessment in ICU and post-anesthesia care settings
• Research and clinical trials involving agitation management

Formula

Pearls & pitfalls

• BARS score of 4 (quiet and awake) is both the treatment endpoint for agitation and the clinical threshold for safe discharge or transfer.
• BARS was validated in a randomized controlled trial of intramuscular droperidol vs. haloperidol for acute agitation (Knott et al. 2006).
• A score of 1 or 2 (unable to rouse or asleep) after treatment of agitation indicates over-sedation — the clinician should not administer additional medication.
• Scores are based on observation of CURRENT behavior — reassess within 15–20 minutes after pharmacological intervention.
• BARS correlates well with other validated agitation scales including PANSS-EC, ACES, and SAS.
• The BARS was designed for emergency and general medical use — it does not require specific psychiatric training to administer.
• Verbal de-escalation should be attempted before pharmacological treatment in BARS 5 patients when safety allows.
• For BARS ≥ 6–7, concurrent safety planning (removal of dangerous objects, staff positioning, restraints if necessary) should occur simultaneously with pharmacotherapy.

Next steps

BARS 1–2: Over-sedated — monitor airway, breathing, circulation; reduce or hold sedating medications; frequent reassessment. BARS 3: Approaching target — monitor for further sedation; no additional sedation needed. BARS 4: Target state (quiet and awake) — maintain current management; reassess periodically. BARS 5: Mild agitation — verbal de-escalation first; if persistent, low-dose pharmacotherapy may be appropriate. BARS 6: Moderate agitation — pharmacological treatment indicated; maintain verbal engagement; safety measures. BARS 7: Severe agitation — immediate safety measures required; pharmacological treatment; physical restraints only as last resort with close monitoring.

Evidence

Swift RH et al. (Psychopharmacol Bull 2002) validated BARS in 71 acutely agitated patients using intramuscular antipsychotics. Demonstrated good inter-rater reliability (ICC > 0.80) and responsiveness to pharmacological treatment. Knott JC et al. (Emerg Med Australas 2006) used BARS as primary outcome in a randomized trial of droperidol vs. haloperidol for acute agitation in the ED.

References

1. Swift RH et al. The Behavioral Activity Rating Scale (BARS): a novel measure of activity in agitated patients. J Psychiatr Res. 2002;36(2):87-95. — link
2. Knott JC et al. Randomized clinical trial comparing intravenous midazolam and droperidol for sedation of the acutely agitated patient in the emergency department. Emerg Med Australas. 2006;18(3):230-238. — link