Treatment, management, and control: improving outcomes through more treatment and less control

Alternatives to use of restraint: A path toward humanistic care

Restraint and seclusion are measures to restrict the movement of a person. The predominant reason cited for the use of restraint in mental health settings is the safety of the staff and the patient in times of aggression and to control problem behaviors. However, there have been significant issues in terms of ethics, rights of the patient, and the harmful effects of restraint. Recently, there has been a move in Western countries to decrease its use by incorporating alternative methods and approaches. In India, the Mental Healthcare Act of 2017 advocates the use of least restrictive measures and alternatives to restraint in providing care and treatment for person with mental illness. In this context, approach to restraints is all the more relevant. This article looks to overview the types of restraints, complications of restraints, and the alternatives to restraint in diverse settings.

Staff and patient accounts of PRN medication administration and non-pharmacological interventions for anxiety

Most psychiatric inpatients will receive psychotropic PRN medication during their hospital stay for agitation, anxiety, and/or insomnia. While helpful in some cases, caution is warranted with regard to PRN use due to inherent risks of additional medication; therefore, experts advise that non-pharmacological interventions should be attempted first where indicated. However, research to date highlights that, in practice, non-pharmaceutical approaches are attempted in a minority of cases. While some information is known about the practice of PRN administration and the use of and barriers to implementing non-pharmacological interventions for treating acute psychiatric symptoms, full understanding of this practice is hampered by poor or altogether missing documentation of the process. This study used interviews with patients and staff from two psychiatric hospitals to collect first-person accounts of administering PRN medication for anxiety, thereby addressing the limitations of relying on documented notation found in previous research. Our results indicate that nurses are engaging in non-pharmacological interventions more often than had previously been captured in research. However, the types of strategies suggested are not typically evidence based and further, only happening approximately half the time. The barriers to providing such care are centred on two main beliefs about client choice and efficacy of these non-medical strategies. Implications for research and practice are discussed.

Pharmacological interventions for people with borderline personality disorder

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the beneficial and harmful effects of pharmacological treatment for adolescents and adults with borderline personality disorder (BPD).

Analysis of non-pharmacological interventions attempted prior to pro re nata medication use

The aim of the present study was to elucidate what non-pharmacological interventions are applied by nursing staff prior to the administration of psychotropic pro re nata (PRN) medication. Best practices would instruct clinical staff to provide non-pharmacological strategies, such as de-escalation and skills coaching, as the first response to patient distress, anxiety, or agitation. Non-pharmacological strategies might be safer for patients, promote more collaborative relationships, and facilitate greater skills development for managing symptoms. The literature has highlighted that poor documentation of pre-PRN administration interventions has limited our understanding of this practice, but evidence suggests that when this information is available, non-pharmaceutical approaches are not being attempted in the majority of cases. This is troubling given that, while clinically appropriate in some instances, PRN have been subject to criticism and lack critical evidence to support their use. The current study is a continuation of our previous work, which examined the reason, frequency, documentation, and outcome (e.g. effectiveness, side-effects) of PRN medication use at our facility. A chart review was conducted to understand what happens prior to the administration of PRN medication at our facility across all inpatient units over the course of 3 months. Results support previous findings that non-pharmacological interventions are poorly documented by front-line staff and are seemingly used infrequently. The use of these interventions differs by patient presentation (e.g. agitation, insomnia), and most often include supportive measures. The findings suggest that both documentation and intervention practices of nursing staff require further investigation and adjustment to align with best practices.

Descriptive analysis of pro re nata medication use at a Canadian psychiatric hospital

Pro re nata (PRN), a Latin phrase meaning 'as needed', is used to describe medications that might be used in specific situations, in addition to regularly-scheduled medications, such as when a patient is particularly anxious, experiencing insomnia, or suffering pain. While helpful in some circumstances, PRN are associated with an increased risk of morbidity, overuse, dependence, and polypharmacy. There is also a dearth of medical literature describing current practices and trends of PRN administration in mental health facilities, especially in Canada, and the literature that does exist is limited by poor documentation practices. Therefore, the primary objective of the current study was to understand the reason (purpose), frequency, use, documentation practices, and outcome (i.e. effectiveness, side-effects) of PRN medication use on inpatient units. Data were pulled to capture a snapshot of PRN administrations over a 3-month period, and included information related to the administration of the PRN medication, such as time of administration, type and dose of PRN medication, and prescribed indication, as well as patient-specific information. Results indicated that approximately 8200 psychotropic PRN medications were administered during the designated 3-month time period, and over 90% of patients received at least one PRN. Most of these were benzodiazepines, followed by antipsychotics. Further analyses were conducted to determine other characteristics of PRN use patterns and to provide a baseline of understanding that will inform future research to investigate the practice of PRN administration to psychiatric inpatients.

Pro re nata (as needed) psychotropic medication use in patients with borderline personality disorder and subjects with other personality disorders over 14 years of prospective follow-up

The use of pro re nata (PRN; as needed) psychotropic medication in patients with borderline personality disorder (BPD) has not been well characterized. This study had 3 purposes, which are as follows: (1) to describe the prevalence of PRN psychotropic medication use among patients with BPD and comparison subjects with other personality disorders (OPD) over 14 years of prospective follow-up, (2) to examine the rates reported by patients with BPD who ever recovered and never recovered, and (3) to examine the reasons for taking PRN medication reported by these patients. Overall, the prevalence of PRN psychotropic medication use was initially approximately 3 times higher among patients with BPD than comparison subjects with OPD, with a significant one-third decline in the use of PRN medication reported by patients with BPD over time. In analyses restricted to patients with BPD, patients with BPD who never recovered were approximately twice as likely to use PRN medication than patients with BPD who ever recovered over time. In reasons for use, the rates of PRN medication use to decrease agitation for both diagnostic groups declined significantly over time, whereas they remained significantly higher among patients with BPD. Likewise, patients with BPD who never recovered reported higher use of PRN medication to decrease agitation than patients with BPD who ever recovered over time. The results of this study indicate that PRN psychotropic medication is widely used for the treatment of patients with BPD, particularly those who have not achieved a recovery in both the symptomatic and psychosocial realms. They also suggest that patients with BPD use proportionally more PRN medication to decrease agitation than comparison subjects with OPD, with lower proportional use to reduce agitation found among recovered patients with BPD.

Pro re nata medication for psychiatric inpatients: time to act

Pro re nata (PRN; 'as needed') medication is an archetypal mainstay for managing acute psychiatric inpatient symptoms and behaviours. Psychiatric and mental health nursing practices have circumnavigated the development of a uniform medical-ethical standard for the administration of PRN psychotropic medication. This paper examines the evidence for administration of PRN psychotropic medications and, in the context of evidence-based best practice, current mental health policy and professional ethics, proposes a standardized Australian PRN administration protocol. The procedures and circumstances leading to a nurse administering psychotropic PRN medication are divided into five simple steps, namely (i) medical prescription; (ii) nurse evaluation of patient indications for an intervention; (iii) nurse consideration of therapeutic options; (iv) obtaining patient informed consent; and (v) documentation of outcomes of PRN administration. The literature associated with each step is reviewed, along with national and international professional ethics, guidelines and patient rights documents pertaining to the care of mental health patients. Recommendations for best-practise care are discussed for each step. There is a lacuna of published evidence supporting the use of PRN medications in psychiatric inpatients. Yet there is published evidence that PRN medications are associated with increased risks of morbidity, inappropriate use, may result in above-recommended dosages or polypharmacy, and complicate the assessment of efficacy of regular scheduled medicines. Alternative non-pharmacological treatment options to PRN medication are effective and associated with fewer side-effects. There are no national explicit standards, operational criteria or quality assurance for the use of PRN medication in inpatient psychiatric units. Contemporary PRN practices are largely unregulated and driven by essentially anecdotal evidence, leaving the clinicians and the service open to claims of poor accountability and misuse (intentional and unintentional) of psychotropic medications. Development of best practice guidelines for the use of PRN administration is essential.

Impact of a clinical-administrative review procedure on reducing reliance on psychotropic PRN medication

The author reviews and evaluates the impact of a clinical/administrative review procedure, previously demonstrated as useful for reducing seclusion/restraint reliance, on psychotropic PRN reliance within a public psychiatric hospital (average census=310; 215 with a stay of greater than 30 days). After 20 weeks of baseline, the impact of the review procedure on PRN reliance was evaluated over an additional 52 weeks. This review procedure reduced the number of individuals who exceeded a review threshold from 20.8 per week prior to initiation to 12.4 per week after initiation, a reduction of 40%. The results underscore the importance of clinical/administrative behavior for encouraging alternatives to psychotropic PRN reliance in behavior management.

Traitement multimodal de l’agressivité et de la violence chez des personnes souffrant de psychose

Dans cet article, les auteurs décrivent les traitements non pharmacologiques qui ont fait preuve d’efficacité pour réduire l’agressivité et la violence chez les personnes souffrant de psychose. Ils présentent ensuite une approche de formulation/planification du traitement qui aborde les influences étiologiques complexes, et les facteurs multiples qui jouent sur le maintien du comportement agressif chez ces patients. Finalement, ils présentent en exemple un cas où l’on se sert de cette approche.

Fipronil: environmental fate, ecotoxicology, and human health concerns

Fipronil is a highly effective, broad-spectrum insecticide with potential value for the control of a wide range of crop, public hygiene, amenity, and veterinary pests. It can generally be applied at low to very low dose rates to achieve effective pest control. Application rates vary between 0.6 and 200 g a.i./ha, depending on the target pest and formulation. It belongs to the phenyl pyrazole or fiprole group of chemicals and is a potent disrupter of the insect central nervous system via interference with the gamma-aminobutyric acid (GABA-) regulated chloride channel. Fipronil degrades slowly on vegetation and relatively slowly in soil and in water, with a half-life ranging between 36 hr and 7.3 mon depending on substrate and conditions. It is relatively immobile in soil and has low potential to leach into groundwater. One of its main degradation products, fipronil desulfinyl, is generally more toxic than the parent compound and is very persistent. There is evidence that fipronil and some of its degradates may bioaccumulate, particularly in fish. Further investigation on bioaccumulation is warranted, especially for the desulfinyl degradate. The suitability of fipronil for use in IPM must be evaluated on a case-by-case basis. In certain situations, fipronil may disrupt natural enemy populations, depending on the groups and species involved and the timing of application. The indications are that fipronil may be incompatible with locust IPM; hence, this possibility requires further urgent investigation. It is very highly toxic to termites and has severe and long-lasting negative impacts on termite populations. It thus presents a long-term risk to nutrient cycling and soil fertility where termites are "beneficial" key species in these ecological processes. Its toxicity to termites also increases the risk to the ecology of habitats in which termites are a dominant group, due to their importance as a food source to many higher animals. This risk has been demonstrated in Madagascar, where two endemic species of lizard and an endemic mammal decline in abundance because of their food chain link to termites. Fipronil is highly toxic to bees (LD50 = 0.004 microgram/bee), lizards [LD50 for Acanthodactylus dumerili (Lacertidae) is 30 micrograms a.i./g bw], and gallinaceous birds (LD50 = 11.3 mg/kg for Northern bobwhite quail), but shows low toxicity to waterfowl (LD50 > 2150 mg/kg for mallard duck). It is moderately toxic to laboratory mammals by oral exposure (LD50 = 97 mg/kg for rats; LD50 = 91 mg/kg for mice). Technical fipronil is in toxicity categories II and III, depending on route of administration, and is classed as a nonsensitizer. There are indications of carcinogenic action in rats at 300 ppm, but it is not carcinogenic to female mice at doses of 30 ppm. The acute toxicity of fipronil varies widely even in animals within the same taxonomic groups. Thus, toxicological findings from results on standard test animals are not necessarily applicable to animals in the wild. Testing on local species seems particularly important in determining the suitability of fipronil-based products for registration in different countries or habitats and the potential associated risk to nontarget wildlife. Risk assessment predictions have shown that some fipronil formulations present a risk to endangered bird, fish, and aquatic and marine invertebrates. Great care should thus be taken in using these formulations where they may impact any of these endangered wildlife groups. Work in Madagascar has highlighted field evidence of this risk. The dose levels at which fipronil produces thyroid cancer in rats are very high and are unlikely to occur under normal conditions of use. There is also dispute as to whether this is relevant to human health risk. However, as fipronil is a relatively new insecticide that has not been in use for long enough to evaluate the risk it may pose to human health, from data on human exposure to the product, a precautionary approach may be warranted. The use of some fipronil-based products on domestic animals is not recommended where handlers spend significant amounts of time grooming or handling treated animals. In general, it would appear unwise to use fipronil-based insecticides without accompanying environmental and human health monitoring, in situations, regions, or countries where it has not been used before, and where its use may lead to its introduction into the wider environment or bring it into contact with people. Further work is needed on the impacts of fipronil on nontarget vertebrate fauna (amphibians, reptiles, birds, and mammals) in the field before the risk to wildlife from this insecticide can be adequately validated. Further field study of the effects of fipronil on the nutrient cycling and soil water-infiltration activities of beneficial termites is required to assess the ecological impacts of the known toxicity of fipronil to these insects.