Droperidol: efficacy and side effects in psychiatric emergencies

BACKGROUND

As admission criteria to inpatient units become more focused on patient safety and behavioral instability, primary treatment often requires use of medications that need to be quick, safe, and effective for control of agitation. This article reviews the evidence that droperidol may serve as the optimal medication for this task.

DATA SOURCES

A comprehensive MEDLINE search of English-language literature was conducted using the search term droperidol concerning the use of droperidol in psychiatric emergencies. Cross-referencing of those articles was conducted to include pertinent articles in the non-psychiatric and European literature regarding safety and early development of the drug.

STUDY FINDINGS

As evidenced in the animal and clinical literature, studies demonstrate the efficacy and rapidity of onset of droperidol and its relative safety compared with the most widely used antiagitation drug, haloperidol. Evidence for this use of droperidol is particularly compelling for situations in which intramuscular administration is necessary.

CONCLUSION

Droperidol, while not in widespread use, may prove to be the superior typical neuroleptic for psychiatric emergencies. Increased clinical utilization and study of droperidol for this use is warranted.

Association between use of unconventional therapies and conventional medical services

CONTEXT

The terms alternative and complementary medicine suggest 2 contradictory possibilities. Whether individuals use unconventional therapies as a substitute for or as an "add on" to conventional medical treatments is uncertain.

OBJECTIVE

To determine the association between use of unconventional therapies and conventional medical care in a national sample.

DESIGN, SETTING, AND PARTICIPANTS

The 1996 Medical Expenditure Panel Survey was distributed to a probability sample of the noninstitutionalized civilian US population. Of 24676 individuals responding (77.7% response rate), 16068 adults 18 years or older were included in the analysis.

MAIN OUTCOME MEASURES

Visits to practitioners for unconventional therapies and conventional medical services, including number of inpatient, outpatient, and emergency department visits and use of 8 types of preventive medical services (blood pressure, cholesterol level, physical examination, influenza vaccination, prostate examination, breast examination, mammography, and Papanicolaou test).

RESULTS

During 1996, an estimated 6.5% of the US population had visits for both unconventional therapies and conventional medical care; 1.8% used only unconventional services; 59.5% used only conventional care; and 32.2% used neither. Compared with those with only conventional visits, those who used both types of care had significantly more outpatient physician visits (7.9 vs 5.4; P<.001), and used more of all types of preventive services except mammography. These groups did not differ significantly in inpatient care, prescription drug use, or number of emergency department visits. Individuals in the top quartile of number of physician visits were more than twice as likely as those in the bottom quartile to have used unconventional therapies in the past year (14.5% vs 6.4%; P<.001). The association between unconventional treatments and physician visits remained after adjusting for potential confounders and across different types of unconventional treatment.

CONCLUSIONS

In this sample, use of unconventional therapies was substantially lower than has been reported in previous national surveys, but was associated with increased use of physician services. From a health services perspective, practitioner-based unconventional therapies appear to serve more as a complement than an alternative to conventional medicine.

Patient satisfaction and administrative measures as indicators of the quality of mental health care

OBJECTIVE

Although measures of consumer satisfaction are increasingly used to supplement administrative measures in assessing quality of care, little is known about the association between these two types of indicators. This study examined the association between these measures at both an individual and a hospital level.

METHODS

A satisfaction questionnaire was mailed to veterans discharged during a three-month period from 121 Veterans Administration inpatient psychiatric units; 5,542 responded, for a 37 percent response rate. These data were merged with data from administrative utilization files. Random regression analysis was used to determine the association between satisfaction and administrative measures of quality for subsequent outpatient follow-up.

RESULTS

At the patient level, satisfaction with several aspects of service delivery was associated with fewer readmissions and fewer days readmitted. Better alliance with inpatient staff was associated with higher administrative measures of rates of follow-up, promptness of follow-up, and continuity of outpatient care, as well as with longer stay for the initial hospitalization. At the hospital level, only one association between satisfaction and administrative measures was statistically significant. Hospitals where patients expressed greater satisfaction with their alliance with outpatient staff had higher scores on administrative measures of promptness and continuity of follow-up.

CONCLUSIONS

The associations between patient satisfaction and administrative measures of quality at the individual level support the idea that these measures address a common underlying construct. The attenuation of the associations at the hospital level suggests that neither type can stand alone as a measure of quality across institutions.

Depressive symptoms and health costs in older medical patients

OBJECTIVE

The authors assessed the association between depressive symptoms and health costs for a national Veterans Administration (VA) sample.

METHOD

The Rand Depression Index was administered to 1,316 medical or surgical inpatients over the age of 60 at nine VA hospitals. Scores were merged with utilization, demographic, and hospital data from national VA inpatient and outpatient files.

RESULTS

Medical costs for respondents with the highest quartile of symptoms were approximately $3,200-or 50%-greater than medical costs for those in the least symptomatic quartile. Depressive symptoms were not associated with any statistically significant mental health expenditures.

CONCLUSIONS

The study extends previous reports of the high medical costs associated with depressive disorders to an older, public sector population. The mechanisms underlying increased medical costs associated with depressive symptoms, while the subject of much speculation in the literature, still remain largely unknown.

Patterns of health care costs associated with depression and substance abuse in a national sample

OBJECTIVE

The associations between self-reported depressive and substance use disorders and estimated health care costs were examined in a representative national sample.

METHODS

Data were from the 1994 National Health Interview Survey (N=77,183). Respondents who reported depressive symptoms or major depression (depressive syndromes) or a substance abuse disorder in the past year were compared with respondents who did not report these conditions. The mean number of inpatient days and outpatient visits in both the general medical and the specialty mental health settings were determined, and costs per individual were calculated based on mean costs of such care in each respondent's geographic region. Multivariate models were constructed to calculate mean costs, controlling for demographic variables, insurance coverage, and physical health status.

RESULTS

Individuals with self-reported depressive syndromes or substance abuse had mean health care costs that were $1,766 higher than costs for individuals without these conditions. Depressive syndromes were associated with increases in both inpatient and outpatient costs. However, substance abuse was almost exclusively associated with increased inpatient expenditures rather than outpatient costs. The magnitude of increased costs associated with mental disorders was substantially larger for patients in fee-for-service plans than for those in health maintenance organizations. Only 14.3 percent of visits made by individuals reporting depressive syndromes or substance abuse were made to specialty health providers (psychiatrists, psychologists, and social workers).

CONCLUSIONS

Health care costs of people with self-reported mental illness varied significantly across diagnoses and systems of care. It is crucial that researchers estimating increased costs associated with mental illness account for both diagnostic and system factors that can influence the estimates.

Mental disorders and access to medical care in the United States

OBJECTIVE

The authors examined the barriers to receipt of medical services among people reporting mental disorders in a representative sample of U.S. adults.

METHOD

The sample was drawn from adults who responded to the 1994 National Health Interview Survey (N=77,183). The authors studied the association between report of a mental disorder and 1) access to health insurance and a primary provider, and 2) actual receipt of medical care. Multivariate techniques were used to model problems with access as a function of mental disorders, controlling for demographic, insurance, and health variables.

RESULTS

While people who reported mental disorders showed no difference from those without mental disorders in likelihood of being uninsured or of having a primary care provider, they were twice as likely to report having been denied insurance because of a preexisting condition or having stayed in their job for fear of losing their health benefits. Among respondents with insurance, those who reported mental illness were no less likely to have a primary care provider but were about two times more likely to report having delayed seeking needed medical care because of cost or having been unable to obtain needed medical care.

CONCLUSIONS

People who reported mental disorders experienced significant barriers to receipt of medical care. Efforts to measure and improve access to health care for this population may need to go beyond simply providing insurance benefits or access to general medical providers.

Physical health, depressive symptoms, and managed care enrollment

OBJECTIVE

This study used a national employee survey to test the hypothesis that symptomatic individuals in general, and individuals with depressive symptoms in particular, are disproportionately enrolled in fee-for-service health care plans as compared to health maintenance organizations (HMOs).

METHOD

The study analyzed data from the 1993 Employee Health Care Value Survey, a questionnaire distributed to employees of three large corporations. The sample comprised 20,283 employees covering six U.S. geographic regions and 46 health plans. The authors used logistic regression to model the association between HMO enrollment and presence of physical and depressive symptoms, measured by subscales derived from the Medical Outcomes Study 36-item Short-Form Health Survey, adjusting for health, demographic, and insurance variables.

RESULTS

In unadjusted models, enrollees in fee-for-service plans had higher rates of both depressive and physical symptoms than HMO enrollees. After adjustment for age alone or for age and other potential confounders, there was no difference in physical symptoms between plan types. However, individuals with high levels of depressive symptoms were 16% less likely to be enrolled in HMOs than in fee-for-service plans after adjustment for age, other demographic variables, physical health status, and insurance characteristics.

CONCLUSIONS

This study provides evidence that symptomatic individuals are more likely to be enrolled in fee-for-service plans than in HMOs. While much of the effect for physical symptoms may be explained by differences in demographic variables, particularly age, the difference in depressive symptoms appears to be independent of those variables.

Trends over a decade for a general hospital psychiatry unit

This study examines the composition and delivery of services in a general hospital inpatient psychiatry unit during a 10-year period. Multiple regression techniques were used to assess the association of clinical, insurance, and demographic data with length of stay and likelihood of readmission for all admissions from 1985-1993. Two variables became progressively associated with readmission--Medicaid and psychotic diagnosis. The results indicate that: (1) the hospital is increasingly treating a poorer, sicker group of patients with shorter lengths of stay and more readmissions, and (2) the rise in readmissions, particularly within vulnerable populations, could represent an inadequate length of initial treatment. Future research should further investigate the generalizability of these results and implications for quality of inpatient care.

Use of medical services by veterans with mental disorders

This study examined timeliness, access, and intensity of outpatient medical service use in a national sample of veterans with comorbid medical disorders discharged from Veterans Affairs (VA) psychiatric units (N = 44,533). The factors that predicted decreased use of medical services included diagnosis of schizophrenia, posttraumatic stress disorder, and substance abuse. The factors associated with increased use of medical services included proximity to a VA outpatient clinic, receipt of VA compensation payments, discharge from a facility with greater resources devoted to medical-surgical care, and prompt outpatient mental health follow-up. Better integration of medical and psychiatric services may help improve access to medical care for the severely mentally ill.

Resident and faculty evaluations of a psychiatry night-float system

This study used self-report questionnaires to examine resident and faculty perceptions of a new night-float schedule for coverage of a psychiatric emergency room compared with a traditional night-call system. The residents reported improved well-being, educational experience, and performance of clinical duties under the night-float system compared with a traditional call schedule. The faculty had a generally favorable impression of the new system. Night-float systems may provide a means of improving psychiatric residents' emergency room and outpatient experiences without compromising patient care, although further studies are needed to measure fully the cost-benefit ratio of such programs.