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Crapanzano C, Redaelli N, Politano A, Casolaro I, Amendola C. Prescription Patterns of Intramuscular Medication for Psychomotor Agitation: A Survey of Italian Psychiatrists. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE : THE OFFICIAL SCIENTIFIC JOURNAL OF THE KOREAN COLLEGE OF NEUROPSYCHOPHARMACOLOGY 2024; 22:376-382. [PMID: 38627085 PMCID: PMC11024696 DOI: 10.9758/cpn.23.1141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/13/2023] [Accepted: 12/19/2023] [Indexed: 04/20/2024]
Abstract
Objective : Intramuscular medications are widely used to treat psychomotor agitation (PMA) in uncooperative patients. We evaluated knowledge and attitude towards guidelines and the prescribing patterns in a sample of Italian psychiatrists. Methods : A structured 28-item questionnaire was submitted to psychiatrists of Italian Departments of Mental Health. We considered 8 clinical scenarios of PMA. For comparing two qualitative variables Chi-square tests were performed. Results : One hundred thirty-four psychiatrists completed the survey. The use of a monotherapy is significatively higher (p < 0.05) over a dual therapy in all clinical scenarios except PMA due to Mood Disorder and Psychotic Disorders, whereas the use of a polytherapy is significatively higher (p < 0.05) in PMA due to Mood Disorders and Psychotic Disorders. The use of second-generation antipsychotic (SGAs) as monotherapy over first-generation antipsychotics (FGAs) is significantly higher (p < 0.05) in PMA due to Central Nervous System (CNS) stimulants. The use of SGAs over FGAs in polytherapy is significantly higher (p < 0.05) in PMA due to CNS stimulants. Knowledge of guidelines results 67.1% and significatively higher (p < 0.05) among those who prefer SGAs as monotherapy rather than FGAs in PMA due to Intellectual Disability, CNS depressants and Delirium. Knowledge of guidelines results significatively higher (p < 0.05) among those who prefer SGAs rather than FGAs in polytherapy in PMA due to Mood disorders. Conclusion : This survey reports variation in prescribing patterns for medication used to treat PMA. While SGAs are often prescribed as first choice following the more recent guidelines, FGAs and multi-drug solutions seem to be still a popular solution.
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Affiliation(s)
| | - Noemi Redaelli
- University of Pavia, Faculty of Medicine and Surgery, Pavia, Italy
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Wang HJ, Kusumo RW, Kiss A, Tennen G, Marotta G, Viaje S, Lanctôt KL. Characterizing PRN Use of Psychotropic Medications for Acute Agitation in Canadian Long-Term Care Residents with Dementia Before and During COVID-19. J Alzheimers Dis Rep 2023; 7:575-587. [PMID: 37313488 PMCID: PMC10259051 DOI: 10.3233/adr-230009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/15/2023] [Indexed: 06/15/2023] Open
Abstract
Background Agitation is a disabling neuropsychiatric symptom of dementia. Pro re nata (PRN) injections of psychotropics can be administered for severe acute agitation, but little is known about the frequency of their actual use. Objective Characterize actual use of injectable PRN psychotropics for severe acute agitation in Canadian long-term care (LTC) residents with dementia and compare use before and during the COVID-19 pandemic. Methods Residents from two Canadian LTC facilities with orders for PRN haloperidol, olanzapine, or lorazepam between January 1, 2018- May 1, 2019 (i.e., pre-COVID-19) and January 1, 2020- May 1, 2021 (i.e., COVID-19) were identified. Electronic medical records were reviewed to document PRN injections of psychotropic medications and collect data on reason and demographic characteristics. Descriptive statistics were used to characterize frequency, dose, and indications of use, and multivariate regression models were used to compare use between time periods. Results Of the 250 residents, 45 of 103 (44%) people in the pre-COVID-19 period and 85 of 147 (58%) people in the COVID-19 period with standing orders for PRN psychotropics received ≥1 injections. Haloperidol was the most frequently used agent in both time periods (74% (155/209 injections) pre-COVID-19; 81% (323/398 injections) during COVID-19). Residents in the COVID-19 period were almost two times more likely to receive injections compared with those in the pre-COVID-19 period (odds ratio = 1.96; 95% CI = 1.15-3.34; p = 0.01). Conclusion Our results suggest that use of PRN injections increased in LTC during the pandemic and contribute to the mounting evidence that agitation worsened during that time.
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Affiliation(s)
- Hui Jue Wang
- Neuropsychopharmacology Research Group, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Raphael W. Kusumo
- Neuropsychopharmacology Research Group, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Alex Kiss
- Department of Research Design and Biostatistics, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Gayla Tennen
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON Canada
| | - Giovanni Marotta
- Neuropsychopharmacology Research Group, Sunnybrook Research Institute, Toronto, ON, Canada
- Division of Geriatrics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Villa Colombo Homes for the Aged Inc, North York, ON, Canada
| | - Shirley Viaje
- Villa Colombo Homes for the Aged Inc, North York, ON, Canada
| | - Krista L. Lanctôt
- Neuropsychopharmacology Research Group, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON Canada
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Singh AP, Murali Mohan NT. Second-Generation Parenteral Antipsychotic (Olanzapine) as a First-Line Treatment for Acute Undifferentiated Agitation in the Emergency Department in Comparison With Haloperidol. Cureus 2023; 15:e40226. [PMID: 37435257 PMCID: PMC10332641 DOI: 10.7759/cureus.40226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2023] [Indexed: 07/13/2023] Open
Abstract
Background Acutely agitated patients are common in the emergency department (ED). Given the myriad aetiologies of the clinical conditions that can produce agitation, such a high prevalence is unsurprising. Agitation is a symptomatic presentation, not a diagnosis, secondary to a psychiatric, medical, traumatic, or toxicological condition. Most literature on the emergency management of agitated patients is from psychiatric populations, not generalised to EDs. Benzodiazepines, antipsychotics, and ketamine have been used to treat acute agitation. However, a clear consensus is lacking. Objectives The objectives are to study the effectiveness of intramuscular (IM) olanzapine as a first-line treatment for rapid tranquillisation in undifferentiated acute agitation in the ED and compare the effectiveness of sedatives to control agitation in etiologically divided groups per the following preassigned protocols: Group A: Alcohol/drug intoxication (olanzapine vs haloperidol), Group B: Traumatic brain injury (TBI) with or without alcohol intoxication (olanzapine vs haloperidol), Group C: Psychiatric conditions (olanzapine vs haloperidol and lorazepam), and Group D: Agitated delirium, organic causes (olanzapine vs haloperidol). Methods This 18-month prospective study included acutely agitated ED patients between 18 and 65. Results A total of 87 patients between 19 and 65 were included, all with a Richmond Agitation Sedation Scale (RASS) score between +2 and +4 at presentation. Nineteen of the 87 patients were managed as acute undifferentiated agitation, and 68 were assigned to one of the four groups. In acute undifferentiated agitation, IM olanzapine 10 mg effectively sedated 15 (78.9%) patients within 20 minutes, whereas the remaining four (21.1%) were sedated with a repeat IM olanzapine 10 mg over the next 25 minutes. In 13 patients with agitation due to alcohol intoxication, zero out of three with olanzapine and four out of 10 (40%) with IM haloperidol 5 mg were sedated within 20 minutes. In patients with TBI, two out of eight (25%) receiving olanzapine and four out of nine (44.4%) receiving haloperidol were sedated within 20 minutes. In acute agitation secondary to psychiatric disease, olanzapine sedated nine out of 10 (90%), and haloperidol with lorazepam sedated 16 out of 17 (94.1%) within 20 minutes. In patients with agitation secondary to organic medical conditions, olanzapine rapidly sedated 19 out of 24 (79.1%), whereas haloperidol sedated one out of four (25%). Interpretation and conclusion IM olanzapine 10 mg is effective for rapid sedation in acute undifferentiated agitation. Olanzapine is superior to haloperidol in agitation secondary to organic medical conditions and is as efficacious as haloperidol with lorazepam in agitation due to psychiatric diseases. However, in agitation due to alcohol intoxication and TBI, haloperidol 5 mg is slightly better, although not statistically significant. Olanzapine and haloperidol were well tolerated by Indian patients in the current study, with minimal side effects.
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Affiliation(s)
- Adheera P Singh
- Emergency Medicine, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, IND
| | - N T Murali Mohan
- Emergency Medicine, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, IND
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Krenz JR, Medeiros K, Lupez K. Retrospective evaluation of ketamine versus droperidol on time to restraint removal in agitated emergency department patients. Am J Emerg Med 2023; 69:23-27. [PMID: 37031618 DOI: 10.1016/j.ajem.2023.03.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
PURPOSE Acute agitation and violent behavior in the emergency department (ED) can lead to significant patient morbidity and contribute to the growing problem of workplace violence against health care providers. To our knowledge, there is no available literature directly comparing intramuscular ketamine to intramuscular droperidol in ED patients presenting with undifferentiated agitation. The purpose of this investigation was to compare the effectiveness and safety of these agents for acute agitation in the ED. METHODS This was a retrospective observational study conducted at an urban, academic ED. The primary endpoint was time from the first dose of study medication to restraint removal. Safety endpoints included incidence of bradycardia (heart rate < 60 bpm), hypotension (systolic blood pressure < 90 mmHg), hypoxia (oxygen saturation < 90% or need for respiratory support), and incidence of intubation for ongoing agitation or respiratory failure. RESULTS An initial 189 patients were screened, of which, 92 met inclusion criteria. The median time from initial drug administration to restraint removal was 49 min (IQR 30, 168) in the ketamine group and 43 min (IQR 30, 80) in the droperidol group (Median difference 6 min; 95% CI [-7, 26]). There was no significant difference in rates of bradycardia (3% vs 3%, 95% CI [-7%, 8%]), hypotension (0% vs 2%, 95% CI [-5%, 2%]), or hypoxia (7% vs 10%, 95% CI [-15%, 9%]) in the ketamine versus droperidol groups respectively. One patient in the ketamine group was intubated for ongoing agitation, and one patient in the droperidol group was intubated for respiratory failure. CONCLUSIONS Intramuscular droperidol and intramuscular ketamine were associated with similar times from drug administration to restraint removal in patients presenting to the ED with undifferentiated agitation. Prospective studies are warranted to evaluate IM droperidol and IM ketamine head-to-head as first line agents for acute agitation in the ED.
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Behavioral Health Emergencies. PHYSICIAN ASSISTANT CLINICS 2023. [DOI: 10.1016/j.cpha.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Jeffers T, Darling B, Edwards C, Vadiei N. Efficacy of Combination Haloperidol, Lorazepam, and Diphenhydramine vs. Combination Haloperidol and Lorazepam in the Treatment of Acute Agitation: A Multicenter Retrospective Cohort Study. J Emerg Med 2022; 62:516-523. [PMID: 35287982 DOI: 10.1016/j.jemermed.2022.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/20/2021] [Accepted: 01/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antipsychotic and sedative combinations are commonly used for treating agitation in the emergency department despite limited evidence regarding their comparative safety and efficacy. OBJECTIVES To compare the efficacy and safety of combination haloperidol, lorazepam, and diphenhydramine (B52) to combination haloperidol and lorazepam (52) in treating acute agitation. METHODS This multicenter, retrospective cohort study included adult patients ≥ 18 years of age who received either B52 or 52 at a Banner Health facility between August 2017 and September 2020. Patients were excluded if they had a pre-existing movement disorder or were withdrawing from alcohol. The primary outcome was administration of additional agitation medication(s) within 2 h of B52 or 52. Secondary outcomes included incidence of extrapyramidal symptoms, length of stay, and additional safety measures. RESULTS There was no difference in administration frequency of additional agitation medication(s) (B52: n = 28 [14%] vs. 52: n = 40 [20%]; p = 0.11). Patients who received 52 were more likely to require an antimuscarinic medication within 2 days (15 vs. 6 patients, p = 0.04). Of the patients who received an antimuscarinic medication, none had documented extrapyramidal symptoms. The 52 group had shorter length of stay (13.8 vs. 17 h; p = 0.03), lower incidence of hypotension (7 vs. 32 patients; p < 0.001), and oxygen desaturation (0 vs. 6 patients; p = 0.01), and fewer physical restraints (53 vs. 86 patients; p = 0.001) compared with the B52 group. CONCLUSIONS Both the B52 and 52 combinations infrequently required repeat agitation medication; however, the B52 combination resulted in more oxygen desaturation, hypotension, physical restraint use, and longer length of stay.
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Affiliation(s)
- Trevor Jeffers
- Department of Pharmacy, Banner - University Medical Center South, Tucson, Arizona
| | - Brenna Darling
- Department of Pharmacy, Banner - University Medical Center Tucson, Tucson, Arizona
| | - Christopher Edwards
- Department of Pharmacy, Banner - University Medical Center Tucson, Tucson, Arizona; Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona; Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Nina Vadiei
- Department of Pharmacy, Banner - University Medical Center South, Tucson, Arizona; Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona; Department of Psychiatry, University of Arizona College of Medicine, Tucson, AZ
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Bhoopatiraju S, Grossberg G. Emerging Perspectives in the Management of Agitation in Alzheimer's Disease and Patients with Dementia. Neurology 2022. [DOI: 10.17925/usn.2022.18.1.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
While Alzheimer's disease, the most common cause of dementia, is perhaps best characterized by cognitive decline, more than 90% of patients exhibit behavioural and psychological symptoms of dementia. Agitation in patients with dementia is often difficult to manage, and is associated with increased morbidity and mortality in patients and a heightened caregiver burden. Thus, effective management of dementia-related agitation (DRA) is vital. Care should first be taken to consider and address causes of agitation and aggression, after which non-pharmacological interventions should be employed. If non-pharmacological measures are unsuccessful in reducing DRA then medications should be considered, although none are approved by the Food and Drug Administration for this indication. Electroconvulsive therapy may be a promising option for patients with treatment-refractory DRA, although more studies are needed. While there are several drugs in the pipeline for DRA treatment, results from robust randomized clinical trials are necessary before they can be administered to patients. Thus, clinicians should employ current strategies to manage DRA to ensure holistic care for patients with Alzheimer's disease.
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Muir-Cochrane E, Oster C, Grimmer K. Interrogating systematic review recommendations for effective chemical restraint. J Eval Clin Pract 2020; 26:1768-1779. [PMID: 32059065 DOI: 10.1111/jep.13363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 01/12/2020] [Accepted: 01/16/2020] [Indexed: 02/01/2023]
Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Candice Oster
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Karen Grimmer
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
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Mokhtari A, Yip O, Alain J, Berthelot S. Prophylactic Administration of Diphenhydramine to Reduce Neuroleptic Side Effects in the Acute Care Setting: A Systematic Review and Meta-Analysis. J Emerg Med 2020; 60:165-174. [PMID: 33131965 DOI: 10.1016/j.jemermed.2020.09.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/12/2020] [Accepted: 09/12/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Neuroleptics are commonly prescribed drugs to treat acute conditions (e.g., migraines) in the emergency department, but can cause serious adverse effects. Using diphenhydramine to prevent these adverse effects is very common but remains controversial. OBJECTIVE We performed a systematic review to determine whether prophylactic administration of diphenhydramine reduces the incidence of neuroleptic adverse effects in patients with acute conditions. METHODS Medline, Embase, Cochrane, PsycInfo, and Web of Science were searched for randomized controlled trials evaluating any neuroleptic with diphenhydramine vs. the same neuroleptic with any inactive agent. Primary outcome was incidence of any extrapyramidal adverse effect. Secondary outcomes were akathisia, rescue medication, subjective restlessness, neuroleptic malignant syndrome, and sedation. Independent reviewers scanned identified citations, extracted data, and assessed risk of bias. Meta-analysis was performed using random effect models. RESULTS Of 1566 identified citations, nine studies (n = 1648 patients) met eligibility criteria. Four studies were specifically designed to compare the incidence of neuroleptic adverse effects with and without co-administration of diphenhydramine. Four studies were at high risk of bias. In primary analysis, diphenhydramine had no effect on the incidence of extrapyramidal symptoms (7 studies, n = 1393, risk ratio [RR] 0.75; 95% confidence interval [CI] 0.44-1.31) or akathisia (5 studies, n = 1094; RR 0.78; 95% CI 0.33-1.82) or any of the secondary outcomes. In subgroup analysis, diphenhydramine was associated with a significant decrease in extrapyramidal adverse effects compared with placebo (4 studies, n = 705; RR 0.61; 95% CI 0.41-0.90). Dosage analysis yielded no further information. CONCLUSIONS When compared with placebo, diphenhydramine was associated with a significant reduction of extrapyramidal adverse effects. Overall quality of evidence is low. Further studies are warranted.
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Affiliation(s)
- Akram Mokhtari
- Centre Hospitalier Universitaire de Québec-Université Laval, Médecine d'urgencem, Québec, Québec, Canada
| | - Olivia Yip
- Centre Hospitalier Universitaire de Québec-Université Laval, Médecine d'urgencem, Québec, Québec, Canada
| | - Judith Alain
- Centre Hospitalier Universitaire de Québec-Université Laval, Médecine d'urgencem, Québec, Québec, Canada
| | - Simon Berthelot
- Centre Hospitalier Universitaire de Québec-Université Laval, Médecine d'urgencem, Québec, Québec, Canada
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Muir-Cochrane E, Grimmer K, Gerace A, Bastiampillai T, Oster C. Safety and effectiveness of olanzapine and droperidol for chemical restraint for non-consenting adults: a systematic review and meta-analysis. Australas Emerg Care 2020; 24:96-111. [PMID: 33046432 DOI: 10.1016/j.auec.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/24/2020] [Accepted: 08/27/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chemical restraint (CR) is emergency drug management for acute behavioural disturbances in people with mental illness, provided with the aim of rapid calming and de-escalating potentially dangerous situations. AIMS To describe a systematic review of Randomised Controlled Trials (RCTs) reporting on short-term safety and effectiveness of drugs used for CR, administered to non-consenting adults with mental health conditions, who require emergency management of acute behavioural disturbances. A meta-analysis was conducted of those RCTs with comparable interventions, outcome measures and measurement timeframes. METHOD Academic databases were searched for RCTs published between 1 January 1996 and 20th April 2020. Relevant RCTs were critically appraised using the 13-item JBI checklist. All RCTs were described, and step-wise filters were applied to identify studies suitable for meta-analysis. For these, forest and funnel plots were constructed, and Q and I2 statistics guided interpretation of pooled findings, tested using MedCalc Version 19.1. RESULTS Of 23 relevant RCTs, 18 (78.2% total) had excellent methodological quality scores (at least 90%). Eight RCTs were potentially relevant for meta-analysis (six of excellent quality), reporting 20 drug arms in total. Adverse events for 6-36% patients were reported in all 20 drug arms. Four drug arms from two homogenous studies of N = 697 people were meta-analysed. These RCTs tested two antipsychotic drugs (droperidol, olanzapine) delivered intravenously in either 5 mgs or 10 mg doses, with outcomes of time to calm, percentage calm within five or 10 min, and adverse events. There were no significant differences between drug arms for either measure of calm. However, 5 mg olanzapine incurred significantly lower risk of adverse events than 10 mg olanzapine (OR 0.4 (95%CI 0.2-0.8)), although no dose differences were found for droperidol. CONCLUSION 5 mg intravenous olanzapine is recommended for quick, safe emergency management of people with acute behavioural disturbances associated with mental illness.
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Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia.
| | - Karen Grimmer
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia
| | - Adam Gerace
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia; School of Health, Medical and Applied Sciences, Central Queensland University, 44 Greenhill Rd, Wayville, South Australia, Australia
| | - Tarun Bastiampillai
- College of Medicine & Public Health, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia
| | - Candice Oster
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia; College of Medicine & Public Health, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia
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Muir-Cochrane E, Oster C, Grimmer K. International research into 22 years of use of chemical restraint: An evidence overview. J Eval Clin Pract 2020; 26:927-956. [PMID: 31318109 DOI: 10.1111/jep.13232] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice. AIMS To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995. METHODS This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures. RESULTS This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%). DISCUSSION A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.
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Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia, 5042
| | - Candice Oster
- On-Line Education and Development, Flinders Human Behaviour and Health Research Unit (FHBHRU), College of Medicine and Public Health, Flinders University, South Australia, Australia, 5042
| | - Karen Grimmer
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia, 5042.,Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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De Deyn PP, Buitelaar J. Risperidone in the management of agitation and aggression associated with psychiatric disorders. Eur Psychiatry 2020; 21:21-8. [PMID: 16414250 DOI: 10.1016/j.eurpsy.2005.11.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
AbstractObjectiveThis review provides an overview of the prevalence and treatment of agitation and aggression, and focuses on the use of risperidone to treat these symptoms in patients from different age groups.MethodsMEDLINE® and EMBASE® databases were used to identify controlled studies of risperidone in the treatment of disruptive behavior disorders and pervasive developmental disorders in pediatric patients, acute agitation or aggression in adults, and psychological and behavioral symptoms of dementia in the elderly. Additionally, key open-label, long-term trials assessing the efficacy and safety of risperidone were considered.ResultsThe results of the 19 double-blind studies identified showed that risperidone is effective in treating agitation and aggression in the different populations, regardless of age. The safety and tolerability of risperidone appear to be good overall but certain safety issues, such as a higher risk of cerebrovascular adverse events in the elderly with dementia, were highlighted.ConclusionsRisperidone is useful for treating aggression and agitation associated with various psychiatric disorders in patients from different age groups.
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Affiliation(s)
- Peter Paul De Deyn
- Department of Neurology, Middelheim Hospital and Laboratory of Neurochemistry and Behavior, Department of Biomedical Sciences, Born Bunge Foundation, University of Antwerp (UA), Universiteitsplein 1, 2610 Antwerp (Wilrijk), Belgium.
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San L, Arranz B, Querejeta I, Barrio S, De la Gándara J, Pérez V. A naturalistic multicenter study of intramuscular olanzapine in the treatment of acutely agitated manic or schizophrenic patients. Eur Psychiatry 2020; 21:539-43. [PMID: 16697151 DOI: 10.1016/j.eurpsy.2006.03.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2005] [Revised: 03/07/2006] [Accepted: 03/16/2006] [Indexed: 11/22/2022] Open
Abstract
AbstractBackgroundWe conducted a naturalistic, multicenter, 24-hour, nonrandomized, observational study describing for the first time the effectiveness and safety of intramuscular (IM) olanzapine to control agitation and aggression in “real world” patients with psychosis. The data thus obtained was compared with that reported from randomized double-blind clinical trials.Method92 patients attending psychiatric emergency settings were enrolled. The study subjects were 44 male and 48 female patients with a mean age of 36.5 ± 12 years and DSM-IV-TR diagnoses of schizophrenia (48.9%), psychotic disorder not specified (23.9%) or bipolar disorder (27.2%). 10 mg IM olanzapine was administered to all patients. An optional second injection was permitted ≥ 2 hours later in line with hospital policy. Evaluations (PANSS-EC and CGI-S) were performed at baseline and 2 and 24 hours following the IM injection.ResultsTwo hours after IM olanzapine was administered, a mean decrease of –9.6 in the PANSS-EC from a baseline score of 26.5 was recorded. At the 24-hour endpoint a statistically and clinically significant reduction in the PANSS-EC scores (11.6 ± 5.3) was observed as compared with values at study entry (26.5 ± 5.9) and at 2 hours endpoint (16.9 ± 9.3), which represent a mean decrease of –14.9 and –5.3, respectively.ConclusionThe present naturalistic study provides naturalistic data on the effectiveness of IM olanzapine in the treatment of acute agitation in patients with schizophrenia or bipolar mania that is in line the data obtained in randomized double-blind clinical trials.
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Affiliation(s)
- L San
- Hospital San Rafael, Passeig Vall d'Hebrón, 107-117, 08035 Barcelona, Spain.
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Dib JE, Adams CE, Ikdais WH, Atallah E, Yaacoub HE, Merheb TJ, Kazour F, Tahan F, Haddad G, Zoghbi M, Azar J, Haddad C, Hallit S. Study protocol for a randomised controlled trial of haloperidol plus promethazine plus chlorpromazine versus haloperidol plus promethazine for rapid tranquilisation for agitated psychiatric patients in the emergency setting (TREC-Lebanon). F1000Res 2019; 8:1442. [PMID: 32528650 PMCID: PMC7262571 DOI: 10.12688/f1000research.19933.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2019] [Indexed: 01/10/2023] Open
Abstract
Background: Agitated and aggressive behaviours are common in the psychiatric setting and rapid tranquilisation is sometimes unavoidable. A survey of Lebanese practice has shown that an intramuscular haloperidol, promethazine and chlorpromazine combination is a preferred form of treatment but there are no randomised trials of this triple therapy. Methods: This is a pragmatic randomised trial. Setting - the psychiatric wards of the Psychiatric Hospital of the Cross, Jal Eddib, Lebanon. Participants - any adult patient in the hospital who displays an aggressive episode for whom rapid tranquilisation is unavoidable, who has not been randomised before, for whom there are no known contraindications. Randomisation - stratified (by ward) randomisation and concealed in closed opaque envelope by independent parties. Procedure - if the clinical situation arises requiring rapid tranquilisation, medical residents overseeing the patient will open a TREC-Lebanon envelope in which will be notification of which group of treatments should be preferred [Haloperidol + Promethazine + Chlorpromazine (HPC) or Haloperidol + Promethazine (HP)], along with forms for primary, secondary and serious adverse effects. Treatment is not given blindly. Outcome - primary outcome is calm or tranquil at 20 minutes post intervention. Secondary outcomes are calm/tranquil at 40, 60 and 120 minutes post intervention, asleep, adverse effects, use of straitjacket and leaving the ward. Follow-up will be up to two weeks post randomisation. Discussion: Findings from this study will compare the HPC versus HP combination used in Lebanon's psychiatry emergency routine practice. Trial registration: ClinicalTrials.gov NCT03639558. Registration date, August 21, 2018.
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Affiliation(s)
- Joseph E. Dib
- Institute of Mental Health, University of Nottingham, Nottingham, Nottinghamshire, NG1 1NU, UK
| | - Clive E. Adams
- Institution of Mental Health, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Werner Henry Ikdais
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Beirut, Lebanon
| | - Elie Atallah
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- Faculty of Sciences, Lebanese University of Beirut, Beirut, Lebanon
| | - Hiba Edward Yaacoub
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Tony Jean Merheb
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Francois Kazour
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- Faculty of Sciences, Lebanese University of Beirut, Beirut, Lebanon
- Department of Psychology, Holy Spirit University of Kaslik, Beirut, Lebanon
- Faculty of Medicine, St Joseph's University, Beirut, Lebanon
- INSERM U930, équipe 4 “Troubles affectifs”, Université François-Rabelais de Tours, Tours, France
| | - Fouad Tahan
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
| | - Georges Haddad
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Marouan Zoghbi
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- Faculty of Medicine, St Joseph's University, Beirut, Lebanon
| | - Jocelyn Azar
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
- Faculty of Sciences, Lebanese University of Beirut, Beirut, Lebanon
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Chadia Haddad
- Psychiatric Hospital of the Cross, Deir Salib, Jal l Dib, Lebanon
| | - Souheil Hallit
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik, Beirut, Lebanon
- INSPECT-LB: Institut National de Sante Publique, Epidemiologie Clinique et Toxicologie, Beirut, Lebanon
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Peltzer-Jones J, Nordstrom K, Currier G, Berlin JS, Singh C, Schneider S. A Research Agenda for Assessment and Management of Psychosis in Emergency Department Patients. West J Emerg Med 2019; 20:403-408. [PMID: 30881564 PMCID: PMC6404717 DOI: 10.5811/westjem.2019.1.39263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 01/29/2019] [Accepted: 01/29/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Emergency departments (ED) manage a wide variety of critical medical presentations. Traumatic, neurologic, and cardiac crises are among the most prevalent types of emergencies treated in an ED setting. The high volume of presentations has led to collaborative partnerships in research and process development between experts in emergency medicine (EM) and other disciplines. While psychosis is a medical emergency frequently treated in the ED, there remains a paucity of evidence-based literature highlighting best practices for management of psychotic presentations in the ED. In the absence of collaborative research, development of best practice guidelines cannot begin. A working group convened to develop a set of high-priority research questions to address the knowledge gaps in the care of psychotic patients in the ED. This article is the product of a subgroup considering “Special Populations: Psychotic Spectrum Disorders,” from the 2016 Coalition on Psychiatric Emergencies first Research Consensus Conference on Acute Mental Illness. Methods Participants were identified with expertise in psychosis from EM, emergency psychiatry, emergency psychology, clinical research, governmental agencies, and patient advocacy groups. Background literature reviews were performed prior to the in-person meeting. A nominal group technique was employed to develop group consensus on the highest priority research gaps. Following the nominal group technique, input was solicited from all participants during the meeting, questions were iteratively focused and revised, voted on, and then ranked by importance. Results The group developed 28 separate questions. After clarification and voting, the group identified six high-priority research areas. These questions signify the perceived gaps in psychosis research in emergency settings. Questions were further grouped into two topic areas: screening and identification; and intervention and management strategies. Conclusion While psychosis has become a more common presentation in the ED, standardized screening, intervention, and outcome measurement for psychosis has not moved beyond attention to agitation management. As improved outpatient-intervention protocols are developed for treatment of psychosis, it is imperative that parallel protocols are developed for delivery in the ED setting.
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Affiliation(s)
| | - Kimberly Nordstrom
- University of Colorado School of Medicine, Department of Psychiatry, Denver, Colorado
| | - Glenn Currier
- University of South Florida, Morsani College of Medicine, Department of Psychiatry, Tampa, Florida
| | - Jon S Berlin
- Medical College of Wisconsin, Department of Psychiatry and Behavioral Medicine, Department of Emergency Medicine, Milwaukee, Wisconsin
| | - Cynthia Singh
- American College of Emergency Physicians, Irving, Texas
| | - Sandra Schneider
- American College of Emergency Physicians, Irving, Texas.,John Peter Smith Hospital, Department of Emergency Medicine, Fort Worth, Texas.,Hofstra Northwell School of Medicine, Hempstead, New York
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Shenvi C, Wilson MP, Aldai A, Pepper D, Gerardi M. A Research Agenda for the Assessment and Management of Acute Behavioral Changes in Elderly Emergency Department Patients. West J Emerg Med 2019; 20:393-402. [PMID: 30881563 PMCID: PMC6404700 DOI: 10.5811/westjem.2019.1.39262] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 01/25/2019] [Accepted: 01/29/2019] [Indexed: 11/11/2022] Open
Abstract
Introduction Agitation, mental illness, and delirium are common reasons for older adults to seek care in the emergency department (ED). There are significant knowledge gaps in understanding how to best screen older adults for these conditions and how to manage them. In addition, in areas where research has been performed, implementation has been slow. A working group convened to develop a set of high-priority research questions that would advance the understanding of optimal management of older adults with acute behavioral changes in the ED. This manuscript is the product of a breakout session on "Special Populations: Agitation in the Elderly" from the 2016 Coalition on Psychiatric Emergencies' first Research Consensus Conference on Acute Mental Illness. Methods Participants were identified with expertise in emergency medicine (EM), geriatric EM, and psychiatry. Background literature reviews were performed prior to the in-person meeting in four key areas: delirium; dementia; substance abuse or withdrawal; and mental illness in older adults. Input was solicited from all participants during the meeting, and questions were iteratively focused and revised, voted on, and ranked by importance. Results Fourteen questions were identified by the group with high consensus for their importance related to the care of older adults with agitation in the ED. The questions were grouped into three topic areas: screening and identification; management strategies; and the approach to delirium. Conclusion It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes, have the tools to screen older adults for those causes, and employ methods to treat the underlying causes and ameliorate their symptoms. Answers to the identified research questions have great potential to improve the care of older adults presenting with behavioral changes.
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Affiliation(s)
- Christina Shenvi
- University of North Carolina, Department of Emergency Medicine, Chapel Hill, North Carolina
| | - Michael P Wilson
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Little Rock, Arkansas
| | - Alessandra Aldai
- University of California, San Diego Medical Center, Department of Emergency Medicine San Diego, California
| | - David Pepper
- Hartford Hospital/Institute of Living, Department of Psychiatry, Hartford, Connecticut
| | - Michael Gerardi
- Morristown Medical Center, Department of Emergency Medicine, Morristown, New Jersey
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Klein LR, Driver BE, Horton G, Scharber S, Martel ML, Cole JB. Rescue Sedation When Treating Acute Agitation in the Emergency Department With Intramuscular Antipsychotics. J Emerg Med 2019; 56:484-490. [PMID: 30745194 DOI: 10.1016/j.jemermed.2018.12.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 12/21/2018] [Accepted: 12/24/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Rapid treatment of agitation in the emergency department (ED) is critical to avoid injury to patients and providers. Treatment with intramuscular antipsychotics is often utilized, but there is a paucity of comparative effectiveness evidence available. OBJECTIVE The purpose of this investigation was to compare the effectiveness of droperidol, olanzapine, and haloperidol for treating agitation in the ED. METHODS This was a retrospective observational study of adult patients who received intramuscular medication to treat agitation. Patients were classified based on the initial antipsychotic they received. The primary effectiveness outcome was the rate of additional sedation administered (rescue medication) within 1 h. Secondary outcomes included rescue sedation for the entire encounter and adverse events. RESULTS There were 15,918 patients included (median age 37 years, 75% male). Rescue rates at 1 h were: 547/4947 for droperidol (11%, 95% confidence interval [CI] 10-12%), 988/8825 olanzapine (11%, 95% CI 10-12%), and 390/2146 for haloperidol (18%, 95% CI 17-20%). Rescue rates for the entire ED encounter were: 832/4947 for droperidol (17%, 95% CI 16-18%), 1665/8825 for olanzapine (19%, 95% CI 18-20%), and 560/2146 for haloperidol (26%, 95% CI 24-28%). Adverse events were uncommon: intubation (49, 0.3%), akathisia (7, 0.04%), dystonia (5, 0.03%), respiratory arrest (1, 0.006%), and torsades de pointes (0), with no significant differences between drugs. CONCLUSIONS Olanzapine and droperidol lead to lower rates of rescue sedation at 1 h and overall, compared with haloperidol. There were no significant differences in major adverse events.
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Affiliation(s)
- Lauren R Klein
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Gabriella Horton
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Sarah Scharber
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Marc L Martel
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Jon B Cole
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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Klein LR, Cole JB, Driver BE, Miner JR, Laes JR, Fagerstrom E, L Martel M. An open-label randomized trial of intramuscular olanzapine versus oral clonidine for symptomatic treatment of opioid withdrawal in the emergency department. Clin Toxicol (Phila) 2019; 57:697-702. [PMID: 30712404 DOI: 10.1080/15563650.2018.1547828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Patients with opioid withdrawal often present to the Emergency Department (ED), but many EDs do not have the infrastructure in place to initiate treatment with opioid agonists (methadone or buprenorphine). Therefore, ED management often entails symptomatic control. The purpose of this study was to compare olanzapine to clonidine for the treatment of opioid withdrawal symptoms. Methods: This was a prospective, randomized clinical trial comparing 10 mg of IM olanzapine to 0.3 mg of oral clonidine for symptoms of opioid withdrawal. Adult (18 years and older) ED patients reporting a history of opioid use and symptoms consistent with withdrawal were eligible. Patients were excluded if they had already received treatment during the ED encounter, were pregnant, incarcerated, or unable to provide consent. Patients were randomized 1:1 to receive olanzapine or clonidine for their initial treatment. A baseline Clinical Opiate Withdrawal Scale (COWS) score was calculated. After 30 min, the patient could receive any additional treatment at the ED physician's discretion. The primary outcome was need for additional medication (rescue) within 1 h of study medication administration. Secondary outcomes included change in COWS score and adverse reactions. Results: We enrolled 63 patients (33 olanzapine, 30 clonidine). Demographic characteristics were similar for both groups (median age 45, range 21-67, 54% male) as well as baseline COWS score (median score 11). The median time since last opiate use was 48 h for both groups (range 4-116). Rescue was given within 1 h for olanzapine for 9 (27%) patients and for clonidine in 19 (63%) patients (difference 36%, 95% CI 13-59%). Decrease in COWS score at 1 h was 8.3 for olanzapine and 5.1 for clonidine (difference 3.2, 95% CI 0.3-6). Adverse events were uncommon: akathisia (1, olanzapine), hypotension (2, clonidine), respiratory depression (0). Conclusions: Treatment of opioid withdrawal symptoms with 10 mg of IM olanzapine results in a lower incidence of rescue medication administration and improved symptoms (COWS score) compared to 0.3 mg of oral clonidine.
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Affiliation(s)
- Lauren R Klein
- a Department of Emergency Medicine , Hennepin County Medical Center , Minneapolis , MN , USA
| | - Jon B Cole
- a Department of Emergency Medicine , Hennepin County Medical Center , Minneapolis , MN , USA.,b Minnesota Poison Control System , Minneapolis , MN , USA
| | - Brian E Driver
- a Department of Emergency Medicine , Hennepin County Medical Center , Minneapolis , MN , USA
| | - James R Miner
- a Department of Emergency Medicine , Hennepin County Medical Center , Minneapolis , MN , USA
| | - JoAn R Laes
- b Minnesota Poison Control System , Minneapolis , MN , USA.,c Department of Internal Medicine, Division of Addiction Medicine , Hennepin County Medical Center , Minneapolis , MN , USA
| | - Erik Fagerstrom
- a Department of Emergency Medicine , Hennepin County Medical Center , Minneapolis , MN , USA
| | - Marc L Martel
- a Department of Emergency Medicine , Hennepin County Medical Center , Minneapolis , MN , USA
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RETRACTED ARTICLE: Vergleich von sublingualer und intravenöser Gabe
von Lorazepam bei psychiatrischen Notfällen im Notarztdienst. Anaesthesist 2018; 68:83-89. [DOI: 10.1007/s00101-018-0513-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 11/06/2018] [Accepted: 11/10/2018] [Indexed: 10/27/2022]
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Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med 2018; 72:374-385. [DOI: 10.1016/j.annemergmed.2018.04.027] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/17/2018] [Accepted: 04/24/2018] [Indexed: 11/17/2022]
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Characteristics of Involuntarily Admitted Patients and Treatment Patterns Over a 21-Year Observation Period. J Clin Psychopharmacol 2018; 38:376-379. [PMID: 29851706 DOI: 10.1097/jcp.0000000000000889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients suffering from psychiatric disorders are often treated in locked psychiatric units owing to psychomotor agitation, hostility and aggressive behavior, or suicidality. Because of legal conditions, investigations of these acutely ill patients are difficult, and many studies do not represent real-life psychiatry. In Austria, admission to a locked psychiatric unit is regulated by a national law for involuntary admission, which came into effect in 1991. The current retrospective study investigated the management of patients who were admitted involuntarily to an academic treatment center after the inauguration of this law. METHODS Data collection comprised all admissions to a locked unit at the Department of Psychiatry, Psychotherapy and Psychosomatics of the Medical University Innsbruck in the years 1992, 1997, 2002, 2007, and 2012. Demographics, admission diagnosis, current danger posed to self or others, and the initial psychopharmacological intervention were assessed. RESULTS The rate of admissions to a locked unit increased significantly throughout the course of the study, and the length of stay decreased from 8.57 days in 1997 to 6.43 days in 2012. Most patients received medication orally. Dosage of antipsychotics and benzodiazepines decreased throughout the investigation period. Self-endangering patients were treated with somewhat (nonsignificantly) higher benzodiazepine and significantly lower antipsychotic mean doses than patients posing danger to others. CONCLUSIONS Although dosage of medication was reduced, the duration of stay in a locked unit decreased significantly over the investigated years. These findings suggest that a carefully considered pharmacological treatment may be at least as effective as a more aggressive approach.
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Choke A, Perumal MV, Howlett M. Lorazepam prescription and monitoring in acute adult psychiatric wards. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.bp.106.012328] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodThis study examines prescription and monitoring of lorazepam on three acute adult psychiatric wards at a university teaching hospital. Retrospective data from 102 consecutive in-patients were analysed.ResultsThere were 83 patients (81.4%) who were prescribed lorazepam, however 45 of these (46%) were never administered it. Indication for lorazepam prescription was documented by the doctor in 35 patients (42.2%). Administration by nursing staff was documented in the medical notes on 86 occasions (60.0%) and on 32 of these (37.0%) the indication was unclear. On 21 occasions (14.7%) more than 2 mg was given; 13.7% of prescriptions were not reviewed and 64% of those reviewed after more than 4 weeks.Clinical ImplicationsLorazepam was overprescribed and inadequately monitored, which may increase the risk of dependence.
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Garriga M, Pacchiarotti I, Kasper S, Zeller SL, Allen MH, Vázquez G, Baldaçara L, San L, McAllister-Williams RH, Fountoulakis KN, Courtet P, Naber D, Chan EW, Fagiolini A, Möller HJ, Grunze H, Llorca PM, Jaffe RL, Yatham LN, Hidalgo-Mazzei D, Passamar M, Messer T, Bernardo M, Vieta E. Assessment and management of agitation in psychiatry: Expert consensus. World J Biol Psychiatry 2016; 17:86-128. [PMID: 26912127 DOI: 10.3109/15622975.2015.1132007] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Psychomotor agitation is associated with different psychiatric conditions and represents an important issue in psychiatry. Current recommendations on agitation in psychiatry are not univocal. Actually, an improper assessment and management may result in unnecessary coercive or sedative treatments. A thorough and balanced review plus an expert consensus can guide assessment and treatment decisions. METHODS An expert task force iteratively developed consensus using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new, re-worded or re-rated items. RESULTS Out of 2175 papers assessing psychomotor agitation, 124 were included in the review. Each component was assigned a level of evidence. Integrating the evidence and the experience of the task force members, a consensus was reached on 22 statements on this topic. CONCLUSIONS Recommendations on the assessment of agitation emphasise the importance of identifying any possible medical cause. For its management, experts agreed in considering verbal de-escalation and environmental modification techniques as first choice, considering physical restraint as a last resort strategy. Regarding pharmacological treatment, the "ideal" medication should calm without over-sedate. Generally, oral or inhaled formulations should be preferred over i.m. routes in mildly agitated patients. Intravenous treatments should be avoided.
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Affiliation(s)
- Marina Garriga
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
- b Barcelona Clinic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Clinic of Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Isabella Pacchiarotti
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Siegfried Kasper
- c Department of Psychiatry and Psychotherapy , Medical University of Vienna , Vienna , Austria
| | | | - Michael H Allen
- e University of Colorado Depression Center , Denver , CO 80045 , USA
| | - Gustavo Vázquez
- f Research Center for Neuroscience and Neuropsychology, Department of Neuroscience , University of Palermo , Buenos Aires , Argentina
| | | | - Luis San
- h CIBERSAM, Parc Sanitari Sant Joan De Déu , Barcelona , Catalonia , Spain
| | - R Hamish McAllister-Williams
- i Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK; Northumberland Tyne and Wear NHS Foundation Trust , Newcastle upon Tyne , UK
| | - Konstantinos N Fountoulakis
- j 3rd Department of Psychiatry, School of Medicine , Aristotle University of Thessaloniki , Thessaloniki , Greece
| | - Philippe Courtet
- k Department of Emergency Psychiatry and Post Acute Care , Hôpital Lapeyronie , CHU Montpellier , France
| | - Dieter Naber
- l Department for Psychiatry and Psychotherapy , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Esther W Chan
- m Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine , the University of Hong Kong , Hong Kong , China
| | - Andrea Fagiolini
- n School of Medicine, Department of Molecular Medicine , University of Siena , Siena , Italy
| | - Hans Jürgen Möller
- o Department of Psychiatry and Psychotherapy , Ludwig Maximilian University , Munich , Germany
| | - Heinz Grunze
- p Paracelsus Medical University , Salzburg , Austria
| | - Pierre Michel Llorca
- q Service De Psychiatrie B , CHU De Clermont-Ferrand , Clermont-Ferrand , France
| | | | - Lakshmi N Yatham
- s Mood Disorders Centre, Department of Psychiatry , University of British Columbia , Vancouver , British Columbia , Canada
| | - Diego Hidalgo-Mazzei
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Marc Passamar
- t Centre Hospitalier Pierre-Jamet, SAUS , Albi , France
| | - Thomas Messer
- u Danuvius Klinik GmbH, Pfaffenhofen an Der Ilm , Germany
| | - Miquel Bernardo
- b Barcelona Clinic Schizophrenia Unit (BCSU), Institute of Neuroscience, Hospital Clinic of Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
| | - Eduard Vieta
- a Bipolar Disorders Unit, Institute of Neuroscience, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, University of Barcelona , Barcelona , Catalonia , Spain
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Spyker DA, Riesenberg RA, Cassella JV. Multiple dose pharmacokinetics of inhaled loxapine in subjects on chronic, stable antipsychotic regimens. J Clin Pharmacol 2015; 55:985-94. [PMID: 25808074 PMCID: PMC5029575 DOI: 10.1002/jcph.502] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This randomized, double‐blind, placebo‐controlled, parallel‐group study was to determine the pharmacokinetic characteristics, safety, and tolerability of multiple doses of inhaled loxapine aerosol in subjects on a stable, oral, chronic antipsychotic regimen. Loxapine was delivered by means of a unique thermally generated aerosol comprising drug particles of a size designed for deep lung delivery and absorption. Thirty‐two subjects were randomized 1:1:1:1 to receive inhaled loxapine (total doses of 15, 20, or 30 mg) or inhaled placebo administered in 3 divided doses, given 4 hours apart. Following inhalation, the median Tmax was 2 minutes, and concentrations declined to about half Cmax approximately 5 minutes later across the 3 dose levels. The dose proportionality across data from this study combined with data from the single‐dose study showed a slope (90%CI) of log AUCinf versus log dose of 0.818 (0.762–0.875) across the 8 doses (n = 60 subjects) studied, indicating reasonable dose proportionality. The most common adverse events were cough (3 of 32, 9%), sedation (3 of 32, 9%), and dysgeusia (2 of 32, 6%). The inhalation of multiple doses of inhaled loxapine were well tolerated in study subjects and provided a safe, well‐tolerated means for rapidly and reliably achieving therapeutic plasma concentrations of loxapine. ClinicalTrials.gov identifier: NCT00555412
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Huang CLC, Hwang TJ, Chen YH, Huang GH, Hsieh MH, Chen HH, Hwu HG. Intramuscular olanzapine versus intramuscular haloperidol plus lorazepam for the treatment of acute schizophrenia with agitation: An open-label, randomized controlled trial. J Formos Med Assoc 2015; 114:438-45. [DOI: 10.1016/j.jfma.2015.01.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 01/24/2015] [Accepted: 01/29/2015] [Indexed: 10/23/2022] Open
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Efficacy and safety of valproic acid versus haloperidol in patients with acute agitation: results of a randomized, double-blind, parallel-group trial. Int Clin Psychopharmacol 2015; 30:142-50. [PMID: 25500684 DOI: 10.1097/yic.0000000000000064] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The objective of this study was to compare the efficacy of valproate versus haloperidol in decreasing the agitation level in affected patients in the emergency department. We assigned 80 acutely agitated patients to receive either intravenous sodium valproate (20 mg/kg) or intramuscular haloperidol (5 mg/1 ml). Agitation was measured at baseline and 30 min after the first injection using the Agitation-Calmness Evaluation Scale (ACES), the Positive and Negative Syndrome Scale-Excited Component subscale, and the Agitated Behavior Scale. For 80 patients treated with sodium valproate, the mean ± SD dosage was 1541.5 ± 286 mg (range 940-2400). The mean postintervention ACES scores from baseline to 30 min after drug injection were 4.73 (SD = 1.93) for the valproate group and 5.45 (SD = 2.09) for the haloperidol group (P = 0.028). No significant differences were observed in terms of the mean changes 30 min after the intervention for two additional agitation scales. A larger proportion of patients in the haloperidol group experienced intense sedation (36.2%, P < 0.001) and extrapyramidal symptoms (8.7%, P = 0.007) compared with the valproate group (2.5% for intense sedation, no patient for extrapyramidal symptoms). The findings suggest that in the clinical practice setting of emergency psychiatry, intravenous valproate is as effective as haloperidol in reducing agitation, with a better safety profile.
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Wheeler AJ, Sheridan J, Robinson G, Branford D, Holmes NJ. Developing Clinical Practice Guidelines for the Medication Management of Acute Behavioural Disturbance. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2007.tb00655.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Amanda J Wheeler
- Clinical Research and Resource Centre; Waitemata District Health Board
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Chan EW, Knott JC, Taylor DM, Kong DCM. Intravenous Olanzapine for Acute Agitation in the Emergency Department. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2011.tb00681.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Esther W Chan
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences; Monash University, and Department of Emergency Medicine, Austin Health
| | | | | | - David CM Kong
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences; Monash University; Parkville Victoria
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Ranney ML, Locci N, Adams EJ, Betz M, Burmeister DB, Corbin T, Dalawari P, Jacoby JL, Linden J, Purtle J, North C, Houry DE. Gender-specific research on mental illness in the emergency department: current knowledge and future directions. Acad Emerg Med 2014; 21:1395-402. [PMID: 25413369 PMCID: PMC4271843 DOI: 10.1111/acem.12524] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 07/14/2014] [Accepted: 07/29/2014] [Indexed: 12/31/2022]
Abstract
Mental illness is a growing, and largely unaddressed, problem for the population and for emergency department (ED) patients in particular. Extensive literature outlines sex and gender differences in mental illness' epidemiology and risk and protective factors. Few studies, however, examined sex and gender differences in screening, diagnosis, and management of mental illness in the ED setting. Our consensus group used the nominal group technique to outline major gaps in knowledge and research priorities for these areas, including the influence of violence and other risk factors on the course of mental illness for ED patients. Our consensus group urges the pursuit of this research in general and conscious use of a gender lens when conducting, analyzing, and authoring future ED-based investigations of mental illness.
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Affiliation(s)
- Megan L Ranney
- Injury Prevention Center, Department of Emergency Medicine, Brown University, Providence, RI; Alpert Medical School, Brown University, Providence, RI
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Soomaroo L, Mills JA, Ross MA. Air medical retrieval of acute psychiatric patients. Air Med J 2014; 33:304-8. [PMID: 25441527 DOI: 10.1016/j.amj.2014.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 04/22/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND The aim of this study is to review the characteristics of acute psychiatric patients requiring air medical retrieval across the Northern Territory (NT) of Australia, to assess the sedation requirements and incidence of in-flight complications when retrieving such patients, and to review the optimal flight crew composition required for safe retrieval. METHODS Retrospective data were collected for all psychiatric patients retrieved by an air medical retrieval service of the NT of Australia over a 12-month period between February 1, 2012, and January 31, 2013. RESULTS Two hundred sixty-two patients were retrieved using fixed wing transport; 90% were indigenous. Eighty-one percent of retrievals occurred during the day, averaging approximately 4.5 hours. A flight doctor was tasked with a nurse to retrieve 79% of patients. Eighty-nine percent of patients received sedation in the health care center before flight, whereas 39% of total patients required further in-flight sedation. Only 8 patients required intubation before transport. The only in-flight complication was hypotension occurring in 6% of patients; these cases predominantly involved the use of propofol, and the hypotension was rapidly corrected without further incident. CONCLUSIONS This review highlights the characteristics of psychiatric patients retrieved by an air medical retrieval service in the NT of Australia. The majority of patients retrieved had a background psychiatric history and also a history of violence. Given the nature of the retrieval and the risk to crew and aircraft, a flight doctor was tasked on a high number of cases. The complication rate was negligible. Further analysis of patient history and characteristics of violence could lead to a risk assessment tool for the retrieval of such patients.
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Abstract
Agitation is a chief complaint that causes many children and adolescents to present to emergency medical attention. There are many reasons for acute agitation, including toxicologic, neurologic, infectious, metabolic, and functional disorders. At times it may be necessary to pharmacologically treat the agitation to prevent harm to the patient, caregivers, or hospital staff. However, one should always be mindful that the differential diagnosis is broad, and a complete although timely assessment with targeted testing must be done before concluding that the agitation is rooted solely in nonorganic causes. There are various pharmacologic choices for the treatment of agitation, and they will be reviewed here. While treatment of agitation may be necessary to keep the patient as well as staff safe, as well as to facilitate medical evaluation in some cases, care must be taken to treat the patient with compassion, never using pharmacologic treatment for reasons of punishment or staff convenience. The focus is on the pharmacologic management of acute agitation of patients in the pediatric age group, in the context of a full evaluation for possible nonfunctional causes of agitation. Goals, risks, and benefits of medication use will be reviewed.
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Are low doses of antipsychotics effective in the management of psychomotor agitation? A randomized, rated-blind trial of 4 intramuscular interventions. J Clin Psychopharmacol 2013; 33:306-12. [PMID: 23609398 DOI: 10.1097/jcp.0b013e3182900fd6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Psychomotor agitation can be associated with a wide range of medical conditions. Although clinical practice advocates the use of several drugs for the management of psychomotor agitation, there are still very few controlled studies comparing the profiles of action and the adverse effects of different drugs that induce tranquilization. OBJECTIVES The purpose of this study was to compare the efficacy and safety of 4 low-dose pharmacological interventions used to control psychomotor agitation guided by the clinical response. METHODS Using a randomized, rated-blind design, 100 agitated patients were assigned to receive 1 of 4 treatments: haloperidol (2.5 mg) + promethazine (25 mg) (HLP + PMZ), haloperidol (2.5 mg) + midazolam (7.5 mg) (HLP + MID), ziprasidone (10 mg) (ZIP), or olanzapine (10 mg) (OLP). Patients were evaluated just before the intervention and after 30, 60, and 90 minutes, using the Agitation-Calmness Evaluating Scale. Adverse effects were assessed within 24 hours after the intervention, using selected items from the UKU Scale (Ugvalg Klinisk Undersgelser Side Effect Scale). According to the clinical indication, medication could be repeated twice after the first injection. Data were analyzed using general linear model with repeated measures and logistic regression. RESULTS All treatment options promoted a reduction in agitation, without causing excessive sedation, although a lower reduction in agitation was observed with HLP + PMZ and ZIP compared with HLP + MID and OLZ. The need for an additional dose of medication was observed in 22 patients, and only 8 remained agitated during the entire 90-minute period. A higher risk for the development of extrapyramidal symptoms within the following 24 hours was observed with HLP + PMZ. DISCUSSION Low doses of haloperidol combined with midazolam can be as effective as olanzapine in reducing psychomotor agitation without increasing the risk of extrapyramidal effects. Because of the higher risk for the occurrence of extrapyramidal symptoms, the combination of haloperidol with promethazine should be considered a second-line treatment option.
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Restraint Use in the Elderly Emergency Department Patient. J Emerg Med 2013; 44:869-74. [DOI: 10.1016/j.jemermed.2012.02.080] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 11/21/2011] [Accepted: 02/26/2012] [Indexed: 11/18/2022]
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Benoit M, Bellivier F, Llorca PM, Millet B, Passamar M, Schwan R, Marty L, Cailhol L, Giordana B, Naudet F, Samalin L, Tadri M, Yon L, Hacques E, Moreau-Mallet V. L’initiation thérapeutique dans les épisodes psychotiques et maniaques : recueil des attitudes françaises par Focus Group. Encephale 2012; 38:266-73. [DOI: 10.1016/j.encep.2012.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 03/14/2012] [Indexed: 10/28/2022]
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Kwentus J, Riesenberg RA, Marandi M, Manning RA, Allen MH, Fishman RS, Spyker DA, Kehne JH, Cassella JV. Rapid acute treatment of agitation in patients with bipolar I disorder: a multicenter, randomized, placebo-controlled clinical trial with inhaled loxapine. Bipolar Disord 2012; 14:31-40. [PMID: 22329470 DOI: 10.1111/j.1399-5618.2011.00975.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The present study evaluated inhaled loxapine for the acute treatment of agitation in patients with bipolar I disorder. METHODS A Phase 3, randomized, double blind, placebo-controlled, parallel group inpatient study was performed at 17 psychiatric research facilities. Agitated patients (N=314) with bipolar I disorder (manic or mixed episodes) were randomized (1:1:1) to inhaled loxapine 5 mg or 10 mg, or inhaled placebo using the Staccato® system. Following baseline assessments, patients received Dose 1 and were evaluated for 24 hours. If required, up to two additional doses of study drug and/or lorazepam rescue medication were given. The primary efficacy endpoint was change from baseline in the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) score two hours after Dose 1. The key secondary endpoint was the Clinical Global Impression-Improvement score at two hours after Dose 1. Additional endpoints included the changes from baseline in the PANSS-EC from 10 min through 24 hours after Dose 1. Safety was assessed by adverse events, vital signs, physical examinations, and laboratory tests. RESULTS For the primary and key secondary endpoints, both doses of inhaled loxapine significantly reduced agitation compared with placebo. Reduced agitation, as reflected in PANSS-EC score, was evident 10 min after Dose 1 with both doses. Inhaled loxapine was well tolerated, and the most common adverse events were known effects of loxapine or minor oral effects common with inhaled medications (dysgeusia was reported in 17% of patients receiving active drug versus 6% receiving placebo). CONCLUSIONS Inhaled loxapine provided a rapid, non-injection, well-tolerated acute treatment for agitation in patients with bipolar I disorder.
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Goodwin GM, Abbar M, Schlaepfer TE, Grunze H, Licht RW, Bellivier F, Fountoulakis KN, Altamura AC, Pitchot W, Ågren H, Holsboer-Trachsler E, Vieta E. Aripiprazole in patients with bipolar mania and beyond: an update of practical guidance. Curr Med Res Opin 2011; 27:2285-99. [PMID: 22014287 DOI: 10.1185/03007995.2011.628380] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Aripiprazole is an atypical antipsychotic with a pharmacological and clinical profile distinct from other atypical antipsychotics. SCOPE A European multidisciplinary advisory panel of university-based experts in bipolar disorders convened in April 2010 to review new clinical guidelines for the management of mania and the role of aripiprazole in its treatment. This report describes the consensus reached on how best to use aripiprazole in the treatment of mania. FINDINGS Current guidelines recommending aripiprazole for first-line treatment of mania have not generally translated to clinical practice. The panel agreed that clinicians may not feel sufficiently knowledgeable on how to use aripiprazole effectively in mania, and that the perception that aripiprazole is less sedating than other antipschotics may hamper its use. There was consensus about the importance of ensuring that clinicians understood the distinction between antimanic efficacy and sedation. Most acutely manic patients may require night-time sedation, but continuous daytime sedation is not necessarily indicated and may interfere with long-term compliance. If sedation is necessary, guidelines recommend the use of adjunctive benzodiazepines only for a short-time. CONCLUSIONS Clinical practice guidelines widely recommend aripiprazole as a first-line treatment for mania. Although clinical trials may not represent all patient subpopulations, they show that aripiprazole is well tolerated and has a long-term stabilizing potential. The successful use of aripiprazole rests on using the appropriate initial dose, titrating and adjusting the dose as needed and using appropriate concomitant medication to minimize any short-term adverse events. Low incidence of sedation makes aripiprazole a reasonable long-term treatment choice. If short-term sedation is required an adjunctive sedative agent can be added and removed when no longer needed. Clinical considerations should influence treatment choice, and a better distinction between sedation and antimanic effects should be an educational target aimed to overcome potential barriers for using non-sedative antimanic agents such as aripiprazole.
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[Psychomotor agitation, pharmaceutical sedation and psychiatric emergency in psychotic patients]. Encephale 2011; 37:448-56. [PMID: 22137217 DOI: 10.1016/j.encep.2011.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 09/28/2011] [Indexed: 11/20/2022]
Abstract
Psychomotor agitation, very common among psychiatric emergencies, raises the question of pharmaceutical sedation, its indications, and its issues, notably with regard to the observance in postemergency. A new approach to sedation places it within its therapeutic aim and also takes into account the sometimes harmful impact on the course of the patient's care. A pretherapeutical, analysis both clinical and environmental is crucial. The time spent on the initial meeting and assessment is essential. The evolution of professional practices in mental health allows us to distinguish three kinds of sedation (vigilance, behaviour and psychical) that guide the choice and the mode of psychotropic drug use. The harmful effects of an ever-increasing use of sedation is debated. The use of atypical antipsychotics and injectable forms is argued. Early psychical sedation is preferable to the obsolete practice of vigilance sedation and to behavioural sedation with its limited indications. The use of excessive or prolonged sedation might have a detrimental effect on the care offered after psychiatric emergency treatment.
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Comparison of Short-Acting Intramuscular Antipsychotic Medication: Impact on Length of Stay and Cost. Am J Ther 2011; 18:300-4. [DOI: 10.1097/mjt.0b013e3181d48320] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Schep LJ, Slaughter RJ, Vale JA, Beasley DMG, Gee P. The clinical toxicology of the designer "party pills" benzylpiperazine and trifluoromethylphenylpiperazine. Clin Toxicol (Phila) 2011; 49:131-41. [PMID: 21495881 DOI: 10.3109/15563650.2011.572076] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Benzylpiperazine (BZP) and trifluoromethylphenylpiperazine (TFMPP) are synthetic phenylpiperazine analogues. BZP was investigated as a potential antidepressant in the early 1970s but was found unsuitable for this purpose. More recently, BZP and TFMPP have been used as substitutes for amfetamine-derived designer drugs. They were legally available in a number of countries, particularly in New Zealand, and were marketed as party pills, but are now more heavily regulated. This article will review the mechanisms of toxicity, toxicokinetics, clinical features, diagnosis, and management of poisoning due to BZP and TFMPP. METHODS OVID MEDLINE and ISI Web of Science were searched systematically for studies on BZP and TFMPP and the bibliographies of identified articles were screened for additional relevant studies including nonindexed reports. Nonpeer-reviewed sources were also accessed. In all, 179 papers excluding duplicates were identified and 74 were considered relevant. MECHANISMS OF ACTION BZP and TFMPP have stimulant and amfetamine-like properties. They enhance the release of catecholamines, particularly of dopamine, from sympathetic nerve terminals, increasing intra-synaptic concentrations. The resulting elevated intra-synaptic monoamine concentrations cause increased activation of both central and peripheral α- and β-adrenergic postsynaptic receptors. BZP has primarily dopaminergic and noradrenergic action while TFMPP has a more direct serotonin agonist activity. TOXICOKINETICS There is limited information on the kinetics of these drugs. Following ingestion, peak plasma concentrations are reached after 60 to 90 min. Both drugs would be expected to cross the blood brain barrier and they are metabolized mainly by hydroxylation and N-dealkylation catalyzed by cytochrome P450 and catechol-o-methyl transferase enzymes. In humans, only small amounts of both BZP and TFMPP are excreted in the urine, suggesting a low bioavailability. The serum half-lives of BZP and TFMPP are relatively short with elimination being essentially complete in 44 h for BZP and 24 h for TFMPP. CLINICAL FEATURES These compounds can cause harmful effects when taken recreationally. Commonly reported features include palpitations, agitation, anxiety, confusion, dizziness, headache, tremor, mydriasis, insomnia, urine retention, and vomiting. Seizures are induced in some patients even at low doses. Severe multiorgan toxicity has been reported, though fatalities have not been recorded conclusively. MANAGEMENT Supportive care including the termination of seizures is paramount, with relief of symptoms usually being provided by benzodiazepines alone. CONCLUSIONS BZP and TFMP can cause sympathomimetic effects in the intoxicated patient. Appropriate, symptom-directed supportive care should ensure a good recovery.
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Affiliation(s)
- Leo J Schep
- Department of Preventive and Social Medicine, National Poisons Centre, University of Otago, Dunedin, New Zealand.
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Shepherd AR. The benefits of an active control arm. Br J Psychiatry 2011; 198:327. [PMID: 21972288 PMCID: PMC3548596 DOI: 10.1192/bjp.198.4.327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Lesem MD, Tran-Johnson TK, Riesenberg RA, Feifel D, Allen MH, Fishman R, Spyker DA, Kehne JH, Cassella JV. Rapid acute treatment of agitation in individuals with schizophrenia: multicentre, randomised, placebo-controlled study of inhaled loxapine. Br J Psychiatry 2011; 198:51-8. [PMID: 21200077 DOI: 10.1192/bjp.bp.110.081513] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is a need for a rapid-acting, non-injection, acute treatment for agitation. AIMS To evaluate inhaled loxapine for acute treatment of agitation in schizophrenia. METHOD This phase III, randomised, double-blind, placebo-controlled, parallel-group study (ClinicalTrials.gov number NCT00628589) enrolled 344 individuals who received one, two or three doses of inhaled loxapine (5 or 10 mg) or a placebo. Lorazepam rescue was permitted after dose two. The primary efficacy end-point was change from baseline in Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) 2 h after dose one. The key secondary end-point was Clinical Global Impression-Improvement scale (CGI-I) score 2 h after dose one. RESULTS Inhaled loxapine (5 and 10 mg) significantly reduced agitation compared with placebo as assessed by primary and key secondary end-points. Reduced PANSS-EC score was evident 10 min after dose one with both 5 and 10 mg doses. Inhaled loxapine was well tolerated, and the most common adverse events were known effects of loxapine or minor oral effects common with inhaled medications. CONCLUSIONS Inhaled loxapine provided a rapid, well-tolerated acute treatment for agitation in people with schizophrenia.
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Affiliation(s)
- Michael D Lesem
- Claghorn-Lesem Research Clinic Ltd, 1010 Waverly Street, Houston, Texas 77008, USA.
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Effects of legal and illegal use of benzodiazepines at acute admission to a psychiatric acute department. BMC Res Notes 2010; 3:263. [PMID: 20958975 PMCID: PMC2974733 DOI: 10.1186/1756-0500-3-263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 10/19/2010] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND In the psychiatric acute and emergency services patients present in severe crisis often complicated by behavioral problems, substance use, and multiple axis 1 diagnoses. In these clinical settings both legal and illegal use of benzodiazepines are difficult to evaluate since benzodiazepines could in some patients be regarded as first line treatment and in other patients as the cause of the acute psychiatric condition. The aims of this study were to evaluate the frequency and clinical effects of both legal and illegal use of benzodiazepines at admittance to a psychiatric acute department. METHODS All patients acutely admitted to a Norwegian acute psychiatric university department serving a catchment area were asked about use of benzodiazepines, other medications and substances before admission. Patients were asked to give urine samples for analyses of benzodiazepines and substances. RESULTS In 227 consecutive admissions there was legal use of benzodiazepines before admission in 39%, illegal use in 13% and no use in 48%. Patients with legal use of benzodiazepines were older, used more often antidepressants and a higher number of prescribed psychotropic medications. Illegal users of benzodiazepines more often used other illegal substances, were evaluated as clinically affected by a substance at admittance and were diagnosed with a substance use disorder. Patients with psychoses or major affective disorders treated with adequate medication (antidepressants, antipsychotics or mood-stabilizers) before admission more often received benzodiazepines than patients without adequate medication. CONCLUSIONS The patients using benzodiazepines at admittance to psychiatric acute departments could be divided in illegal and legal users. The illegal users were young, used illegal substances and were more often regarded clinically affected by substances at admittance. The legal users were older, did not use other substances and were not regarded as clinically affected by substances at admittance. Benzodiazepines were used as adjuvant therapy to specific pharmacological treatment with antidepressants, antipsychotics or mood stabilizers for major psychiatric disorders. TRIAL REGISTRATION NCT 00184119/NCT 00184132.
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Abstract
INTRODUCTION Metamfetamine is a highly addictive amfetamine analog that acts primarily as a central nervous system (CNS) stimulant. The escalating abuse of this drug in recent years has lead to an increasing burden upon health care providers. An understanding of the drug's toxic effects and their medical treatment is therefore essential for the successful management of patients suffering this form of intoxication. AIM The aim of this review is to summarize all main aspects of metamfetamine poisoning including epidemiology, mechanisms of toxicity, toxicokinetics, clinical features, diagnosis, and management. METHODS A summary of the literature on metamfetamine was compiled by systematically searching OVID MEDLINE and ISI Web of Science. Further information was obtained from book chapters, relevant news reports, and web material. Epidemiology. Following its use in the Second World War, metamfetamine gained popularity as an illicit drug in Japan and later the United States. Its manufacture and use has now spread to include East and South-East Asia, North America, Mexico, and Australasia, and its world-wide usage, when combined with amfetamine, exceeds that of all other drugs of abuse except cannabis. Mechanisms of toxicity. Metamfetamine acts principally by stimulating the enhanced release of catecholamines from sympathetic nerve terminals, particularly of dopamine in the mesolimbic, mesocortical, and nigrostriatal pathways. The consequent elevation of intra-synaptic monoamines results in an increased activation of central and peripheral α±- and β-adrenergic postsynaptic receptors. This can cause detrimental neuropsychological, cardiovascular, and other systemic effects, and, following long-term abuse, neuronal apoptosis and nerve terminal degeneration. Toxicokinetics. Metamfetamine is rapidly absorbed and well distributed throughout the body, with extensive distribution across high lipid content tissues such as the blood-brain barrier. In humans the major metabolic pathways are aromatic hydroxylation producing 4-hydroxymetamfetamine and N-demethylation to form amfetamine. Metamfetamine is excreted predominantly in the urine and to a lesser extent by sweating and fecal excretion, with reported terminal half-lives ranging from ∼5 to 30 h. Clinical features. The clinical effects of metamfetamine poisoning can vary widely, depending on dose, route, duration, and frequency of use. They are predominantly characteristic of an acute sympathomimetic toxidrome. Common features reported include tachycardia, hypertension, chest pain, various cardiac dysrhythmias, vasculitis, headache, cerebral hemorrhage, hyperthermia, tachypnea, and violent and aggressive behaviour. Management. Emergency stabilization of vital functions and supportive care is essential. Benzodiazepines alone may adequately relieve agitation, hypertension, tachycardia, psychosis, and seizure, though other specific therapies can also be required for sympathomimetic effects and their associated complications. CONCLUSION Metamfetamine may cause severe sympathomimetic effects in the intoxicated patient. However, with appropriate, symptom-directed supportive care, patients can be expected to make a full recovery.
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Affiliation(s)
- Leo J Schep
- National Poisons Centre, Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand.
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Airoldi G. Efficacia e tossicità della terapia farmacologica per il controllo del paziente acutamente agitato (II parte). ITALIAN JOURNAL OF MEDICINE 2010. [DOI: 10.1016/j.itjm.2010.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Spyker DA, Munzar P, Cassella JV. Pharmacokinetics of loxapine following inhalation of a thermally generated aerosol in healthy volunteers. J Clin Pharmacol 2009; 50:169-79. [PMID: 19915181 DOI: 10.1177/0091270009347866] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this randomized, double-blind, placebo-controlled, dose escalation study was to determine the pharmacokinetic characteristics, safety, and tolerability of single doses of inhaled loxapine aerosol in healthy volunteers. Loxapine was delivered by means of a unique thermally generated aerosol comprising drug particles of a size designed for deep lung delivery and absorption. Fifty participants were randomized to receive 0.625, 1.25, 2.5, 5.0, or 10 mg of loxapine aerosol or placebo. Following inhalation, the t(max) median (25%, 75%) was 2 (1, 3) minutes. The loxapine AUC(infinity) was dose proportional across all doses with slope (90% confidence interval) of log AUC(infinity) versus log dose = 0.909 (0.832, 0.987). No clinically meaningful changes were noted in hematology results, blood chemistry, vital signs, or respiratory function. The most common adverse events were dizziness, somnolence, and bad taste. The inhalation of Staccato loxapine represents a safe, well-tolerated means for rapidly achieving therapeutic plasma concentrations of loxapine.
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Freeman DJ, DiPaula BA, Love RC. Intramuscular Haloperidol versus Intramuscular Olanzapine for Treatment of Acute Agitation: A Cost-Minimization Study. Pharmacotherapy 2009; 29:930-6. [DOI: 10.1592/phco.29.8.930] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Paliperidone suppresses the development of the aggressive phenotype in a developmentally sensitive animal model of escalated aggression. Psychopharmacology (Berl) 2009; 203:653-63. [PMID: 19066856 DOI: 10.1007/s00213-008-1412-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Accepted: 11/03/2008] [Indexed: 12/23/2022]
Abstract
RATIONALE Atypical antipsychotics are commonly prescribed to clinically referred youngsters for treatment of heightened aggressive behavior associated with various psychiatric disorders. Previously, we demonstrated risperidone's anti-aggressive effects using a well-validated animal model of offensive aggression. Paliperidone, the main active metabolite of risperidone, is a potent serotonin-2A and dopamine-2 receptor antagonist with slightly different pharmacodynamic properties compared to risperidone. Given that much of risperidone's therapeutic efficacy is due to its active metabolite, paliperidone may effectively suppress aggression with fewer adverse side effects. OBJECTIVES Investigate whether paliperidone administration would reduce heightened aggressive behavior induced by low-dose cocaine exposure in a developmentally sensitive model of offensive aggression. MATERIALS AND METHODS Male Syrian hamsters (n = 12/group) were administered an acute dose of paliperidone (0.05, 0.1, 0.2, and 0.3 mg/kg) and then tested for aggressive behavior using the resident-intruder paradigm. To investigate the effects of chronic paliperidone administration, a separate set of animals (n = 12/group) was exposed to repeated paliperidone administration (0.1 mg kg(-1) day(-1)) during different developmental periods and varying lengths of time (1-4 weeks). RESULTS Experiment 1 results revealed a dose-dependent decrease in bite and attack behaviors with an effective dose observed at 0.1 mg/kg. In Experiment 2, the maximal reduction in aggressive behavior in response to chronic paliperidone treatment was observed in animals treated during the third week of adolescence, and this reduction occurred without concomitant alterations in non-aggressive behaviors. CONCLUSIONS These results support the specific aggression-suppressing properties of paliperidone and the potential use of this compound in the treatment of maladaptive aggression in clinical settings.
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Abstract
Oppositional defiant disorder (ODD) consists of an enduring pattern of uncooperative, defiant and hostile behaviour toward authority figures that does not involve major antisocial violations and is not accounted for by the developmental stage of the child. The rate of ODD in children and adolescents in the general population has been reported to be between 2% and 16%. The International Classification of Diseases 10th Revision (ICD-10) classifies ODD as a mild form of conduct disorder (CD), and it has been estimated that up to 60% of patients with ODD will develop CD. Therefore, ODD should be identified and treated as early and effectively as possible.In more than one-half of patients with attention-deficit hyperactivity disorder (ADHD), ODD is also part of the clinical picture. There is strong evidence in the literature to suggest that ODD and ADHD overlap; many medications that are used to treat ADHD may also be efficacious in the treatment of ODD. A few studies have reported the positive effects of psychostimulants or atomoxetine in the treatment of ODD associated with ADHD. Patients with ODD and CD with severe aggression may respond well to risperidone, with or without psychostimulants. Mood regulators, alpha(2)-agonists and antidepressants may also have a role as second-line agents in the treatment of ODD and its co-morbidities.
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Affiliation(s)
- Atilla Turgay
- Toronto ADHD Clinic, University of Toronto, Toronto, Ontario, Canada.
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