'As required' medication regimens for seriously mentally ill people in hospital

Impact of psychotropic pro re nata prescription-monitoring programme on prescriptions for inpatients with psychiatric disorders: a retrospective observational study

BACKGROUND

Pro re nata (PRN) medication is used "as needed" for symptoms such as agitation and insomnia, in addition to regular daily pharmacotherapy of mental disorders. However, there is no high-quality evidence on the effectiveness of psychotropic PRN medications and concerns have been raised about their potential to contribute to polypharmacy. This study introduced a psychotropic PRN prescription-monitoring programme for psychiatric inpatients with the aim of examining the change before and after the implementation of the programme.

METHOD

This study included 389 patients admitted to the psychiatric department between 1 July 2021 and 30 June 2023. The psychotropic PRN prescription-monitoring programme was implemented in July 2022, and the participants were classified into monitoring and non-monitoring groups. Demographic data (age, sex, and diagnosis), regular prescriptions before admission and at discharge, psychotropic PRN prescriptions before admission and at discharge, and the total number of psychotropic PRN prescriptions during hospitalisation were compared between the two groups. Data on psychotropic prescription were collected by psychotropic category. The significance level of 5% was set at 1.67 × 10-3 using the Bonferroni correction for multiple testing.

RESULTS

The psychotropic PRN prescription ratio at discharge in the monitoring group was 9.3%, which was significantly lower than the 28.1% in the non-monitoring group. The percentage of patients with a PRN prescription during hospitalisation in the monitoring group was 29.8%, which was significantly lower than the 64.5% in the non-monitoring group. In the non-monitoring group, there was no statistically significant difference in the number of psychotropic drugs prescribed regularly before and after admission. However, in the monitoring group, the number of psychotropic drugs in the regular prescriptions at discharge was 1.87 ± 1.24, which was significantly lower than 2.47 ± 1.90 in the regular prescription before admission.

CONCLUSIONS

Our findings suggest that a psychotropic PRN prescription-monitoring programme may contribute to the elimination of polypharmacy, including regular prescriptions. Further research is required to optimise psychotropic PRN prescriptions and reduce polypharmacy.

Characterization of Psychotropic PRN Medications in a Canadian Psychiatric Intensive Care Unit

BACKGROUND

Pro re nata (PRN) antipsychotics and benzodiazepines are routinely used for the rapid stabilization of acutely agitated patients. Despite the popular use of PRN medications in mental health units, primary literature supporting efficacy and safety is poor, and there is no single universally accepted practice guideline. PRN psychotropic medications have the potential to cause adverse effects when used inappropriately.

AIMS

Our objective was to characterize the prescribing, administration, and documentation practices of PRN psychotropic medications in a psychiatric intensive care unit.

METHODS

We conducted a retrospective chart review of patients admitted to a 12-bed psychiatric intensive care unit between June and September 2018. All PRN antipsychotic and benzodiazepine orders, administrations, documentation practices, and attempted nonpharmacological strategies were assessed for each order and patient. Descriptive statistics were used to analyze data.

RESULTS

Thirty-two patients with a total of 123 physicians' orders and 1,179 PRN administrations of antipsychotics and benzodiazepines were reviewed. Of the total administrations, 720 (61%) were combinations with at least two psychotropic agents. Forty-one (33%) physicians' orders had a prescribed indication, and 559 (47%) administrations had an attempted nonpharmacological method prior to PRN administration. Eight patients (25%) had antipsychotic PRN orders, which exceeded the total daily maximum dose. Three adverse drug effects were attributed to PRN administration.

CONCLUSIONS

Areas of improvement that we identified included documentation practices of effectiveness of administered PRNs, prescriptions to include clear indications and dosage within the 24-hour maximum limits, and documentation of nonpharmacological methods utilized.

Practical Considerations of PRN Medicines Management: An Integrative Systematic Review

Background and objectives: Highly widespread use of pro re nata (PRN) medicines in various healthcare settings is a potential area for improper medication prescription and administration leading to patient harm. This study aimed to summarize and integrate the findings of all relevant individual studies regarding the practical considerations of PRN medicines management including strategies and interventions by healthcare professionals for safe prescription, dispensing, administration, monitoring, and deprescription of PRN medicines in healthcare settings. Methods: An integrative systematic review on international databases were performed. Electronic databases including Web of Knowledge, Scopus, PubMed (including MEDLINE), and Cinahl were searched to retrieve articles published until end of May 2021. Original qualitative, quantitative, and mixed methods studies written in English were included with a focus on PRN medicines management in healthcare settings. Research synthesis using the narrative method was performed to summarise the results of included studies. Results: Thirty-one studies on PRN medicines in healthcare settings by different healthcare providers were included after the screening of the databases based on eligibility criteria. They were published from 1987 to 2021. The majority of studies were from Australia, the United States, Canada, and the United Kingdom and were conducted in psychiatric settings. Given variations in their purposes, methods, and outcomes, the research synthesis was conducted narratively based on diversities and similarities in findings. Eight categories were developed by the authors as follows: "PRN indications and precautionary measures," "requirements of PRN prescription," "interventions for PRN administration," "monitoring and follow up interventions," "deprescription strategies," "healthcare professionals' role," "participation of patients and families," and "multidisciplinary collaboration." Each category consists of several items and describes what factors should be considered by healthcare professionals for PRN medicines management. Conclusion: The review findings provide insights on the practical considerations of PRN medicines management in clinical practice. The suggested list of considerations in our review can be used by healthcare professionals for optimal PRN medicines management and safeguarding patient care.

Ethical Tenets of PRN Medicines Management in Healthcare Settings: A Clinical Perspective

Prescription and administration of pro re nata (PRN) medications has remained a poorly discussed area of the international literature regarding ethical tenets influencing this type of medication practice. In this commentary, ethical tenets of PRN medicines management from the clinical perspective based on available international literature and published research have been discussed. Three categories were developed by the authors for summarising review findings as follows: 'benefiting the patient', 'making well-informed decision', and 'follow up assessment' as pre-intervention, through-intervention, and post-intervention aspects, respectively. PRN medicines management is mainly intertwined with the ethical tenets of beneficence, nonmaleficence, dignity, autonomy, justice, informed consent, and error disclosure. It is a dynamic process and needs close collaboration between healthcare professionals especially nurses and patients to prevent unethical practice.

Prescription patterns in psychiatric compulsory care: polypharmacy and high-dose antipsychotics

BACKGROUND

Antipsychotic polypharmacy and prescription of high-dose antipsychotics are often used for the treatment of psychotic symptoms, especially in compulsory psychiatric care although there is lack of evidence to support this practice and related risks for patients.

AIMS

We aimed to investigate prescription patterns in patients with psychosis under compulsory psychiatric treatment in Cyprus and to identify predictors for pharmaceutic treatment patterns.

METHOD

This was a nationwide, descriptive correlational study with cross-sectional comparisons, including 482 patients with compulsory admission to hospital. Sociodemographic and clinical data were collected. Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Prescribed medication patterns, including use of medication pro re nata (PRN, when required), were recorded.

RESULTS

Antipsychotic polypharmacy with a PRN schema was reported in 33.2% (n = 160) of the participants. Polypharmacy without a PRN schema was reported in 5.6% (n = 27) of the participants. We found that 27.2% (n = 131) of the participants were prescribed high-dose antipsychotics without PRN included; and 39.2% (n = 189) prescribed high-dose antipsychotics with PRN included. In the logistic regression analyses, predictors for prescription of high-dose antipsychotics were male gender, positive psychiatric history, receiving state benefits and a negative history of substance use. Male gender was the only predictor for polypharmacy without a PRN schema whereas male gender, negative family psychiatric history, receiving state benefits and the total score on the positive symptoms PANSS subscale were predictors for polypharmacy with a PRN schema included.

CONCLUSIONS

A high frequency of polypharmacy and use of medication PRN beyond clinical guidelines has been reported for the first time in psychiatric compulsory care in Cyprus; revision in antipsychotic prescription is needed.

PRN Medicines Management for Older People with Long-Term Mental Health Disorders in Home Care

Older people with long-term mental health conditions who receive care in their own home are vulnerable to the inappropriate use of medications and polypharmacy given their underlying health conditions and comorbidities. Inappropriate use of pro re nata (PRN) medications in these older people can enhance their suffering and have negative consequences for their quality of life and well-being, leading to readmission to healthcare settings and the increased cost of health care. This narrative review on published international literature aims at improving our understanding of medicines management in home care and how to improve PRN medication use among older people with long-term health conditions in their own home. Accordingly, the improvement of PRN medicines management for these older people requires the development of an individualised care plan considering ‘reduction of older people’s dependence on PRN medications’, ‘empowerment of family caregivers’, and ‘support by healthcare professionals.’ PRN medication use should be reduced through deprescription and discontinuation strategies. Also, older people and their family caregivers should be encouraged to prioritize the use of non-pharmacologic methods to relieve physical and psychological problems. Besides the empowerment of family caregivers through role development, education and training about PRN medications, and involvement in decision-making, they need support by the multidisciplinary network in terms of supervision, monitoring, and home visits.

Design and Implementation of an Analgesia, Sedation, and Paralysis Order Set to Enhance Compliance of pro re nata Medication Orders with Joint Commission Medication Management Standards in a Pediatric ICU

BACKGROUND

The use of pro re nata (PRN) medication orders increases nursing flexibility and efficiency of bedside patient care. However, misuse and/or ambiguity of PRN medication orders may increase the propensity for medication errors. The Joint Commission has Medication Management (MM) standards to mitigate such risks. This quality improvement study with a pre-post design aimed to increase compliance of PRN sedative and analgesic orders with use of failure mode and effects analysis (FMEA) and human factors risk assessment methodologies in a pediatric ICU (PICU).

METHODS

Staff education and a PICU analgesia, sedation, and paralysis order set, with predefined PRN orders, were implemented to enhance PRN medication compliance with Joint Commission MM standards. The primary goal was to achieve and maintain a weekly average compliance of ≥ 90%. Proportions of compliant PRN analgesic and sedative orders before and after interventions were compared.

RESULTS

Weekly average PRN orders compliance increased from 62.0% ± 9.2% to 77.7% ± 10.1% after staff education was implemented (p = 0.013). After order set implementation, weekly average compliance further increased to 93.2% ± 3.6% (p < 0.0001) and remained > 90% until the end of the study period.

CONCLUSION

Interdisciplinary synthesis using FMEA and human factors risk assessment is effective for identifying system failure modes associated with Joint Commission MM standard noncompliance. Implementation of an order set with forced functionality to include order information compliant with Joint Commission MM standards can enhance and maintain Joint Commission-compliant PRN medication orders.

Pro Re Nata Medication Use in Acute Care Adolescent Psychiatric Unit

Objective: Evidence to support the use of pro re nata (PRN) medication is limited, and the details of PRN use (indication, frequency of administration, patient characteristics) are rarely reported, particularly in youth populations. The goal of this study was to report on the pattern of PRN use over 6 years in an acute care psychiatric unit for adolescents. Methods: A retrospective chart review of patients' records from November 2012 to October 2018 was conducted. Variables extracted from electronic medical records included age, gender, race/ethnicity, clinical rating scores at admission (on a subset of patients), length of stay, psychotropic and nonpsychotropic PRN medication administration, timing of administration, discharge diagnosis, and discharge medication. Results: Records from 2961 individuals with a total 3937 admissions were analyzed. A total of 62% of admissions had at least one PRN medication administration. Severity of symptoms, as indicated by higher scores on clinical rating scales at admission, longer length of stay, and readmission were related to high PRN use. Patients with bipolar spectrum disorders received more psychotropic and nonpsychotropic PRN medications than other patients. Patients who were high psychotropic PRN users were also high nonpsychotropic PRN users. Conclusion: Despite the lack of clear evidence in support of the efficacy of PRN medications, they commonly used to control symptoms in acute care inpatient settings. Youth with severe symptoms utilized not only psychotropic PRN medication but also nonpsychotropic PRN more frequently, suggesting a possible role of systemic disorder among youth with serious mental illness. More research is necessary to examine the efficacy of PRN medications for managing targeted symptoms.

PRN Medicines Management for Psychotropic Medicines in Long-Term Care Settings: A Systematic Review

Many medications are prescribed and administered PRN (pro re nata, as needed). However, there are few integrative reviews to inform PRN psychotropic medication use in long-term care facilities and nursing or care homes. Accordingly, this integrative systematic review aimed to improve our understanding of PRN medicines management with a focus on psychotropic medications (antipsychotics, sedatives, anxiolytics, and hypnotics) in long-term care settings. Keywords relating to PRN in English, Norwegian, and Spanish were used, and articles published between 2009 and 2019 were retrieved. Based on the inclusion criteria, eight articles were used for data analysis and synthesis. This review offers a description of PRN prescription and administration of psychotropic medications in long-term care. Variations were observed in the management of PRN psychotropic medications based on residents’ underlying health conditions and needs, duration of use, and changes between medications and doses. Neither the reasons for PRN prescription and administration nor the steps taken to identify and manage any associated adverse reactions or adverse drug events were reported. Further initiatives are needed to improve PRN medicines management to explore factors that affect PRN prescription and administration and to develop appropriate PRN guidelines to prevent harm and improve the safety of people living in long-term care facilities.

Evaluating the impact of an electronic application of the Dynamic Appraisal of Situational Aggression with an embedded Aggression Prevention Protocol on aggression and restrictive interventions on a forensic mental health unit

Risk assessment is a pre-requisite for violence prevention in mental health settings. Extant research concerning risk assessment and nursing intervention is limited and has focused on the predictive validity of various risk assessment approaches and instruments, with few attempts to elucidate and test interventions that might prevent aggression, and reduce reliance on coercive interventions. The integration of risk assessment and violence prevention strategies has been neglected. The aim of this feasibility study was to test a novel Aggression Prevention Protocol designed to prioritize the instigation of less restrictive interventions on an acute forensic mental health unit for female patients. A prospective quasi-experimental study was designed to test an Aggression Prevention Protocol, linked to an electronic application of the Dynamic Appraisal of Situational Aggression (DASA). Following introduction of the DASA and Aggression Prevention Protocol, there were reductions in verbal aggression, administration of Pro Re Nata medication, the rate of seclusion, and physical and mechanical restraint. There was also an increase in documented nursing interventions. Overall, these results support further testing of the electronic application of the DASA and the Aggression Prevention Protocol.

The Administration of Pro re nata Medication by Mental Health Nurses: A Thematic Analysis

Pro re nata (PRN) medication is medication administered by nurses as required commonly in response to a patient's symptoms or behaviour including insomnia, agitation or anxiety. There is a paucity of research around the process of PRN administration in mental health settings in Ireland and international evidence suggests inconsistencies in practices. This study aimed to explore the process of PRN medication administration by mental health nurses. Using a qualitative descriptive design, semi-structured interviews were undertaken with 19 mental health nurses in three acute inpatient units in one mental health service in Ireland. Most participants reported undertaking an assessment of the patient before administering PRN medication; however, many also reported having observed incidents of poor practice. There was evidence of some interdisciplinary sensitivities around instructions regarding the use of PRN medications between doctors who prescribed them and nurses who dispensed them. A need for service improvements were also identified including the use of alternative strategies to PRN use such as de-escalation techniques and education around psychopharmacology. PRN medication is commonly used in mental health settings; however, this study suggests that there is potential for improvement in relation to how it is prescribed and administered. Overuse of PRN medication has been associated with increased morbidity. Mental health nurses are required to carefully consider whether PRN medication is warranted in the first instance and how its use might impact on patients.

The pharmacological management of acute behavioural disturbance: Data from a clinical audit conducted in UK mental health services

BACKGROUND

A quality improvement programme addressing prescribing practice for acutely disturbed behaviour was initiated by the Prescribing Observatory for Mental Health.

METHOD

This study analysed data from a baseline clinical audit conducted in inpatient mental health services in member trusts.

RESULTS

Fifty-eight mental health services submitted data on 2172 episodes of acutely disturbed behaviour. A benzodiazepine alone was administered in 60% of the 1091 episodes where oral medication only was used and in 39% of the 1081 episodes where parenteral medication (rapid tranquillisation) was used. Haloperidol was combined with lorazepam in 22% of rapid tranquillisation episodes and with promethazine in 3%. Physical violence towards others was strongly associated with receiving rapid tranquillisation in men (odds ratio 1.74, 1.25-2.44; p<0.001) as was actual or attempted self-harm in women (odds ratio 1.87, 1.19-2.94; p=0.007). Where physical violence towards others was exhibited, a benzodiazepine and antipsychotic was more likely to be prescribed than a benzodiazepine alone (odds ratio 1.39, 1.00-1.92; p=0.05). The data suggested that 25% of patients were at least 'extremely or continuously active' in the hour after rapid tranquillisation was administered.

CONCLUSION

The current management of acutely disturbed behaviour with parenteral medication may fail to achieve a calming effect in up to a quarter of episodes. The most common rapid tranquillisation combination used was lorazepam and haloperidol, for which the randomised controlled trial evidence is very limited. Rapid tranquillisation prescribing practice was not wholly consistent with the relevant National Institute for Health and Care Excellence guideline, which recommends intramuscular lorazepam on its own or intramuscular haloperidol combined with intramuscular promethazine. Clinical factors prompting the use of rapid tranquillisation rather than oral medication may differ between the genders.

Managing acutely aggressive or agitated people in a psychiatric setting: a survey in Lebanon

Background: Violent patients constitute 10% of all psychiatric admissions. Treatment options and clinical practice interventions vary across the globe and no survey of practice in a Middle Eastern setting exists. Surveying treatments in Lebanon will show treatment interventions used in this part of the world and, most importantly, provide the treatment options that could potentially be used for clinical trials pertaining to emergency psychiatry. Methods: A survey of clinicians' opinions and practice was conducted between July and August 2017 at the largest psychiatric hospital in Lebanon. Results: Five of seven experienced psychiatrists provided opinions when interviewed of their preferred intervention when dealing with an emergency psychiatric episode. Whilst this varied in detail, there was a consistent view that there should first be verbal control, then use of medications, and finally physical restrain of the patient. A total of 39 emergency episodes (28 people) occurred in the one month (64% men in their 30s). Bipolar disorder was the most frequent single diagnosis behind the aggression (n=16, 41%; 12 people 43%) but the combined schizophrenia-like illnesses underlay 18 of the 39 episodes (46%; 13/28 people 46%). In clinical life, we found evidence of high family involvement, but little attempts made at initial verbal control in the hospital. All 39 episodes involved administration of pharmacological interventions. Medications were used in 29 of cases (74%) and non-medication interventions used in the remaining 10/39 (26%). Conclusion: This survey provides some evidence that clinicians' preferences may not fully reflect clinical practice but also that experienced clinicians are using several clearly effective techniques to manage these very difficult situations. However, as for other parts of the world, treatment in Lebanon has limited or no underpinning by evidence from well-designed, conducted and reported evaluative studies.

Patient Safety and Pro Re Nata Prescription and Administration: A Systematic Review

PRN is the acronym for 'pro re nata,' written against prescriptions whose administration should be based on patients' needs, rather than at set times. The aim of this systematic review was to explore safety issues and adverse events arising from PRN prescription and administration. Electronic databases including Scopus, PubMed [including Medline], Embase, Cinahl, Web of Science and ProQuest were systematically searched to retrieve articles published from 2005 to 2017.

SELECTION CRITERIA

we included all randomized controlled trials (RCTs) and studies with comparison groups, comparing PRN prescription and administration with scheduled administration, where safety issues and adverse events were reported. The authors independently assessed titles, abstracts and full-texts of retrieved studies based on inclusion criteria and risk of bias. Results were summarised narratively. The search identified 7699 articles. Title, abstract and full-text appraisals yielded 5 articles. The included studies were RCTs with one exception, a pre-test post-test experimental design. Patient populations, interventions and outcomes varied. Studies compared patient-controlled or routine administration with PRN and one trial assessed the effect of a practice guideline on implementation of PRN administration. More analgesia was administered in the patient-controlled than the PRN arms but pain reduction was similar. However, there was little difference in administration of psychotropic medicines. No differences between patient-controlled and PRN groups were reported for adverse events. The PRN practice guideline improved PRN patient education but non-documentation of PRN administration increased. This systematic review suggests that PRN safety issues and adverse events are an under-researched area of healthcare practice. Variations in the interventions, outcomes and clinical areas make it difficult to judge the overall quality of the evidence. Well-designed RCTs are needed to identify any safety issues and adverse events associated with PRN administration.

Patient participation in pro re nata medication in psychiatric inpatient settings: An integrative review

Pro re nata (PRN) medication is widely used and studied in psychiatric care, but our knowledge about patient participation in its administration is fragmented. The aim of this integrative review was to describe and synthesize previous knowledge of patient participation in PRN in psychiatric inpatient settings. We conducted both electronic and manual searches, using the CINAHL, Scopus, PsycINFO, and PubMed databases, and eight scientific journals. Searches were limited to the English language, to the years 2006-2016, and to selected papers using inclusion, exclusion, and quality criteria. We identified 16 relevant papers, and these showed that patient participation included patient-related starting points, including the patients' willingness to participate and their knowledge of the medication. The patients' participation in PRN practices was demonstrated by the opportunity to request PRN and to refuse any PRN that was offered. Patient participation was shown to be linked to certain situations where PRN was recommended. The role that the professionals played in patient participation included interacting with patients, providing counselling and alternatives for PRN. Our results also revealed that coercion was used administering PRN. The existing literature exposed challenges that need to be addressed if patient participation in the use of PRN medication is to be effectively achieved in psychiatric inpatient settings. Equal partnerships between patients, nurses, and physicians are an essential part of this process, and further research into PRN medication is urgently needed, particularly studies that focus on patients' experiences.

Nurses' attitudes towards the use of PRN psychotropic medications in acute and forensic mental health settings

Many countries now have national mental health policies and guidelines to decrease or eliminate the use of seclusion and restraint yet the use of Pro Re Nata (PRN) medications has received less practice evaluation. This research aimed to identify mental health nurses' attitudes towards the use of PRN medications with mental health consumers. Participants were working in forensic mental health and non-forensic acute mental health settings. The "Attitudes towards PRN medication use survey" was used and data were collected online. Data were analysed using the Statistical Package Social Sciences, Version 22.0. Practice differences between forensic and other acute mental health settings were identified related to the use of PRN medications to manage symptoms from nicotine, alcohol and other drug withdrawal. Differences related to the useage of comfort rooms and conducting comprehensive assessments of consumers' psychiatric symptoms were also detected. Qualitative findings highlighted the need for increased accountability for the prescribing and administration of PRN medications along with more nursing education/training to use alternative first line interventions. Nurses administering PRN medications should be vigilant regarding the indications for this practice to ensure they are facilitating the consumer's recovery by reducing the use of all forms of potentially restrictive practices in the hospital setting. The reasons for using PRN medications and PRN administration rates must be continually monitored to avoid practices such as high dose antipsychotics use and antipsychotic polypharmacy to ensure the efficacy of the consumers' management plans on their health care outcomes.

Aripiprazole (intramuscular) for psychosis-induced aggression or agitation (rapid tranquillisation)

BACKGROUND

People experiencing psychosis may become aggressive. Antipsychotics, such as aripiprazole in intramuscular form, can be used in such situations.

OBJECTIVES

To evaluate the effects of intramuscular aripiprazole in the treatment of psychosis-induced aggression or agitation (rapid tranquillisation).

SEARCH METHODS

On 11 December 2014 and 11 April 2017, we searched the Cochrane Schizophrenia Group's Study-based Register of Trials which is based on regular searches of CINAHL, BIOSIS, AMED, Embase, PubMed, MEDLINE, PsycINFO, and registries of clinical trials.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that randomised people with psychosis-induced aggression or agitation to receive either intramuscular aripiprazole or another intramuscular intervention.

DATA COLLECTION AND ANALYSIS

We independently inspected citations and, where possible, abstracts, ordered papers and re-inspected and quality assessed these. We included studies that met our selection criteria. At least two review authors independently extracted data from the included studies. We chose a fixed-effect model. We analysed dichotomous data using risk ratio (RR) and the 95% confidence intervals (CI). We analysed continuous data using mean differences (MD) and their CIs. We assessed risk of bias for included studies and used GRADE to create 'Summary of findings' tables.

MAIN RESULTS

Searching found 63 records referring to 21 possible trials. We could only include three studies, all completed over the last decade, with 885 participants, of which 707 were included for quantitative analyses in this systematic review. Due to limited comparisons, small size of trials and a paucity of investigated and reported 'pragmatic' outcomes, evidence was mostly graded as low or very low quality. No trials reported useful data for one of our primary outcomes of tranquil or asleep by 30 minutes. Economic outcomes were also not reported in the trials.When compared with placebo, fewer people in the aripiprazole group needed additional injections compared to the placebo group (2 RCTs, n = 382, RR 0.69, 95% CI 0.56 to 0.85, very low-quality evidence). Clinically important improvement in agitation at two hours favoured the aripiprazole group (2 RCTs, n = 382, RR 1.50, 95% CI 1.17 to 1.92, very low-quality evidence). The numbers of non-responders after the first injection also favoured aripiprazole (1 RCT, n = 263, RR 0.49, 95% CI 0.34 to 0.71, low-quality evidence). Although no effect was found, more people in the aripiprazole compared to the placebo group experienced adverse effects (1 RCT, n = 117, RR 1.51, 95% CI 0.93 to 2.46, very low-quality evidence).Aripiprazole required more injections compared to haloperidol (2 RCTs, n = 477, RR 1.28, 95% CI 1.00 to 1.63, very low-quality evidence), with no significant difference in agitation (2 RCTs, n = 477, RR 0.94, 95% CI 0.80 to 1.11, very low-quality evidence), and similar non-responders after first injection (1 RCT, n = 360, RR 1.18, 95% CI 0.78 to 1.79, low-quality evidence). Aripiprazole and haloperidol did not differ when taking into account the overall number of people that experienced at least one adverse effect (1 RCT, n = 113, RR 0.91, 95% CI 0.61 to 1.35, very low-quality evidence).Compared to aripiprazole, olanzapine was better at reducing agitation (1 RCT, n = 80, RR 0.77, 95% CI 0.60 to 0.99, low-quality evidence) and had a more favourable effect on global state change scores (1 RCT, n = 80, MD 0.58, 95% CI 0.01 to 1.15, low-quality evidence), both at two hours. No differences were found in terms of experiencing at least one adverse effect during the 24 hours after treatment (1 RCT, n = 80, RR 0.75, 95% CI 0.45 to 1.24, very low-quality evidence). However, participants allocated to aripiprazole experienced less somnolence (1 RCT, n = 80, RR 0.25, 95% CI 0.08 to 0.82, low-quality evidence).

AUTHORS' CONCLUSIONS

The available evidence is of poor quality but there is some evidence aripiprazole is effective compared to placebo and haloperidol, but not when compared to olanzapine. However, considering that evidence comes from only three studies, caution is required in generalising these results to real-world practice. This review firmly highlights the need for more high-quality trials on intramuscular aripiprazole in the management of people with acute aggression or agitation.

Haloperidol for psychosis-induced aggression or agitation (rapid tranquillisation)

BACKGROUND

Haloperidol used alone is recommended to help calm situations of aggression or agitation for people with psychosis. It is widely accessible and may be the only antipsychotic medication available in limited-resource areas.

OBJECTIVES

To examine whether haloperidol alone is an effective treatment for psychosis-induced aggression or agitation, wherein clinicians are required to intervene to prevent harm to self and others.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials (26th May 2016). This register is compiled by systematic searches of major resources (including AMED, BIOSIS CINAHL, Embase, MEDLINE, PsycINFO, PubMed, and registries of clinical trials) and their monthly updates, handsearches, grey literature, and conference proceedings, with no language, date, document type, or publication status limitations for inclusion of records into the register.

SELECTION CRITERIA

Randomised controlled trials (RCTs) involving people exhibiting aggression and/or agitation thought to be due to psychosis, allocated rapid use of haloperidol alone (by any route), compared with any other treatment. Outcomes of interest included tranquillisation or asleep by 30 minutes, repeated need for rapid tranquillisation within 24 hours, specific behaviours (threat or injury to others/self), adverse effects. We included trials meeting our selection criteria and providing useable data.

DATA COLLECTION AND ANALYSIS

We independently inspected all citations from searches, identified relevant abstracts, and independently extracted data from all included studies. For binary data we calculated risk ratio (RR), for continuous data we calculated mean difference (MD), and for cognitive outcomes we derived standardised mean difference (SMD) effect sizes, all with 95% confidence intervals (CI) and using a fixed-effect model. We assessed risk of bias for the included studies and used the GRADE approach to produce 'Summary of findings' tables which included our pre-specified main outcomes of interest.

MAIN RESULTS

We found nine new RCTs from the 2016 update search, giving a total of 41 included studies and 24 comparisons. Few studies were undertaken in circumstances that reflect real-world practice, and, with notable exceptions, most were small and carried considerable risk of bias. Due to the large number of comparisons, we can only present a summary of main results.Compared with placebo, more people in the haloperidol group were asleep at two hours (2 RCTs, n=220, RR 0.88, 95%CI 0.82 to 0.95, very low-quality evidence) and experienced dystonia (2 RCTs, n=207, RR 7.49, 95%CI 0.93 to 60.21, very low-quality evidence).Compared with aripiprazole, people in the haloperidol group required fewer injections than those in the aripiprazole group (2 RCTs, n=473, RR 0.78, 95%CI 0.62 to 0.99, low-quality evidence). More people in the haloperidol group experienced dystonia (2 RCTs, n=477, RR 6.63, 95%CI 1.52 to 28.86, very low-quality evidence).Four trials (n=207) compared haloperidol with lorazepam with no significant differences with regard to number of participants asleep at one hour (1 RCT, n=60, RR 1.05, 95%CI 0.76 to 1.44, very low-quality of evidence) or those requiring additional injections (1 RCT, n=66, RR 1.14, 95%CI 0.91 to 1.43, very low-quality of evidence).Haloperidol's adverse effects were not offset by addition of lorazepam (e.g. dystonia 1 RCT, n=67, RR 8.25, 95%CI 0.46 to 147.45, very low-quality of evidence).Addition of promethazine was investigated in two trials (n=376). More people in the haloperidol group were not tranquil or asleep by 20 minutes (1 RCT, n=316, RR 1.60, 95%CI 1.18 to 2.16, moderate-quality evidence). Acute dystonia was too common in the haloperidol alone group for the trial to continue beyond the interim analysis (1 RCT, n=316, RR 19.48, 95%CI 1.14 to 331.92, low-quality evidence).

AUTHORS' CONCLUSIONS

Additional data from new studies does not alter previous conclusions of this review. If no other alternative exists, sole use of intramuscular haloperidol could be life-saving. Where additional drugs are available, sole use of haloperidol for extreme emergency could be considered unethical. Addition of the sedating promethazine has support from better-grade evidence from within randomised trials. Use of an alternative antipsychotic drug is only partially supported by fragmented and poor-grade evidence. Adding a benzodiazepine to haloperidol does not have strong evidence of benefit and carries risk of additional harm.After six decades of use for emergency rapid tranquillisation, this is still an area in need of good independent trials relevant to real-world practice.

De-escalation techniques for psychosis-induced aggression or agitation

BACKGROUND

Aggression is a disposition, a willingness to inflict harm, regardless of whether this is behaviourally or verbally expressed and regardless of whether physical harm is sustained.De-escalation is a psychosocial intervention for managing people with disturbed or aggressive behaviour. Secondary management strategies such as rapid tranquillisation, physical intervention and seclusion should only be considered once de-escalation and other strategies have failed to calm the service user.

OBJECTIVES

To investigate the effects of de-escalation techniques in the short-term management of aggression or agitation thought or likely to be due to psychosis.

SEARCH METHODS

We searched Cochrane Schizophrenia Group's Study-Based Register of Trials (latest search 7 April, 2016).

SELECTION CRITERIA

Randomised controlled trials using de-escalation techniques for the short-term management of aggressive or agitated behaviour. We planned to include trials involving adults (at least 18 years) with a potential for aggressive behaviour due to psychosis, from those in a psychiatric setting to those possibly under the influence of alcohol or drugs and/or as part of an acute setting as well. We planned to include trials meeting our inclusion criteria that provided useful data.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Two review authors inspected all abstracts of studies identified by the search process. As we were unable to include any studies, we could not perform data extraction and analysis.

MAIN RESULTS

Of the 345 citations that were identified using the search strategies, we found only one reference to be potentially suitable for further inspection. However, after viewing the full text, it was excluded as it was not a randomised controlled trial.

AUTHORS' CONCLUSIONS

Using de-escalation techniques for people with psychosis induced aggression or agitation appears to be accepted as good clinical practice but is not supported by evidence from randomised trials. It is unclear why it has remained such an under-researched area. Conducting trials in this area could be influenced by funding flow, ethical concerns - justified or not - anticipated pace of recruitment as well the difficulty in accurately quantifying the effects of de-escalation itself. With supportive funders and ethics committees, imaginative trialists, clinicians and service-user groups and wide collaboration this dearth of randomised research could be addressed.