Rapid tranquilization of acutely psychotic patients with intramuscular haloperidol and chlorpromazine

Brazilian guidelines for the management of psychomotor agitation. Part 2. Pharmacological approach

Objective:

To present the essential guidelines for pharmacological management of patients with psychomotor agitation in Brazil.

Methods:

This is a systematic review of articles retrieved from the MEDLINE (PubMed), Cochrane Database of Systematic Reviews, and SciELO databases published from 1997 to 2017. Other relevant articles in the literature were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools.

Results:

Of 5,362 articles retrieved, 1,731 abstracts were selected for further reading. The final sample included 74 articles that met all inclusion criteria. The evidence shows that pharmacologic treatment is indicated only after non-pharmacologic approaches have failed. The cause of the agitation, side effects of the medications, and contraindications must guide the medication choice. The oral route should be preferred for drug administration; IV administration must be avoided. All subjects must be monitored before and after medication administration.

Conclusion:

If non-pharmacological strategies fail, medications are needed to control agitation and violent behavior. Once medicated, the patient should be monitored until a tranquil state is possible without excessive sedation.

Systematic review registry number:

CRD42017054440.

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.

Analytic Reviews : Rapid Tranquilization of the Agitated Intensive Care Unit Patient

Agitation in intensive care unit patients is a problem that is often ignored or undertreated. The presence of agita tion warrants a thorough investigation for underlying causes (e.g., metabolic and systemic abnormalities, drug intoxication or withdrawal, hypoxia, and pain) so that the precipitating disturbances can be identified and cor rected. When these conservative measures fail to con trol a patient's agitation, it may be necessary to resort to mechanical restraint and sedating medication. The au thors present guidelines for the pharmacological man agement of agitation and the risks and benefits associ ated with the use of specific agents.

'Rapid tranquillisation': an historical perspective on its emergence in the context of the development of antipsychotic medications

This paper examines factors involved in the theory and practice of emergency sedation for behavioural disturbance in psychiatry in the mid-twentieth century, and the emergence of the concept of 'rapid tranquillisation'. The practice received little attention until the arrival of antipsychotic drugs, which replaced older sedatives and became the agents most strongly associated with the treatment of aggression and challenging behaviour. Emergency sedation was subsequently portrayed in psychiatric literature and advertising as a therapeutic and diagnosis-driven endeavour, and the concept of rapid tranquillisation emerged in this context in the 1970s. Use of non-antipsychotic sedatives, like the benzodiazepines, is barely visible in contemporary sources, and the research suggests that antipsychotics became the mainstay of rapid tranquillisation strategies because of beliefs about their specific therapeutic properties in psychosis and schizophrenia, and not because of demonstrated superiority over other agents.

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

BACKGROUND

Haloperidol, used alone is recommended to help calm situations of aggression with people with psychosis. This drug is widely accessible and may be the only antipsychotic medication available in areas where resources are limited.

OBJECTIVES

To investigate whether haloperidol alone, administered orally, intramuscularly or intravenously, is effective treatment for psychosis-induced agitation or aggression.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (1st June 2011).

SELECTION CRITERIA

Randomised controlled  trials (RCTs) involving people exhibiting agitation or aggression (or both) thought to be due to psychosis, allocated rapid use of haloperidol alone (by any route), compared with any other treatment. Outcomes 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.

DATA COLLECTION AND ANALYSIS

We independently selected and assessed studies for methodological quality and extracted data. 'Summary of findings' tables were produced for each comparison grading the evidence and calculating, where possible and appropriate, a range of absolute effects.

MAIN RESULTS

We included 32 studies comparing haloperidol with 18 other treatments. Few studies were undertaken in circumstances that reflect real world practice, and, with notable exceptions, most were small and carried considerable risk of bias.Compared with placebo, more people in the haloperidol group were asleep at two hours (2 RCTs, n = 220, risk ratio (RR) 0.88, 95% confidence interval (CI) 0.82 to 0.95). Dystonia was common (2 RCTs, n = 207, RR 7.49, CI 0.93 to 60.21). Compared with aripiprazole, people in the haloperidol group required fewer injections than those in the aripiprazole group (2 RCTs, n = 473, RR 0.78, CI 0.62 to 0.99). More people in the haloperidol group experienced dystonia (2 RCTs, n = 477, RR 6.63, CI 1.52 to 28.86).Despite three larger trials with ziprasidone (total n = 739), data remain patchy, largely because of poor design and reporting. Compared with zuclopenthixol acetate, more people who received haloperidol required more than three injections (1 RCT, n = 70, RR 2.54, CI 1.19 to 5.46).Three trials (n = 205) compared haloperidol with lorazepam. There were no significant differences between the groups with regard to the number of participants asleep at one hour (1 RCT, n = 60, RR 1.05, CI 0.76 to 1.44). However, by three hours, significantly more people were asleep in the lorazepam group compared with the haloperidol group (1 RCT, n = 66, RR 1.93, CI 1.14 to 3.27). There were no differences in numbers requiring more than one injection (1 RCT, n = 66, RR 1.14, CI 0.91 to 1.43).Haloperidol's adverse effects were not offset by addition of lorazepam (e.g. dystonia 1 RCT, n = 67, RR 8.25, CI 0.46 to 147.45; required antiparkinson medication RR 2.74, CI 0.81 to 9.25). Addition of promethazine was investigated in one larger and better graded trial (n = 316). More people in the haloperidol group were not tranquil or asleep by 20 minutes (RR 1.60, CI 1.18 to 2.16). Significantly more people in the haloperidol alone group experienced one or more adverse effects (RR 11.28, CI 1.47 to 86.35). Acute dystonia for those allocated haloperidol alone was too common for the trial to continue beyond the interim analysis (RR 19.48, CI 1.14 to 331.92).

AUTHORS' CONCLUSIONS

If no other alternative exists, sole use of intramuscular haloperidol could be life-saving. Where additional drugs to offset the adverse effects are available, sole use of haloperidol for the extreme emergency, in situations of coercion, 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. Evidence for use of newer generation antipsychotic alternatives is no stronger than that for older drugs. Adding a benzodiazepine to haloperidol does not have strong evidence of benefit and carries a 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.

Pharmacological management of acute and persistent aggression in forensic psychiatry settings

Aggressive behaviour is common in forensic psychiatric settings. The aetiology of aggressive behaviour is multifactorial and can be driven by psychosis, impulsivity, psychopathy, intoxication, cognitive impairment, or a combination of all of these. Recognition of the different factors behind the aggression can inform medication selection and the relative need for specific environmental and behavioural interventions in a forensic psychiatric setting. Acute agitation needs to be managed quickly and effectively before further escalation of the behavioural dyscontrol occurs. Benzodiazepines and/or antipsychotic medications are often used and can be given intramuscularly to achieve a rapid onset of action. Available are intramuscular preparations of second-generation antipsychotics that have similar efficacy to lorazepam and haloperidol in reducing agitation, but are well tolerated and not associated with the extrapyramidal adverse effects, including akathisia, that can plague the older first-generation antipsychotics. The longer-term management of persistent aggressive behaviour can be quite complex. A major obstacle is that the causality of aggressive events can differ from patient to patient, and also from event to event in the same patient. For patients with schizophrenia and persistent aggressive behaviour, clozapine is recommended both for its superior antipsychotic effect and its specific anti-hostility effect. Mood stabilizers such as valproate may be helpful in instances of poor impulsivity and personality disorders. Other agents that have been successfully used include β-adrenoceptor antagonists (β-blockers) and antidepressants.

Chlorpromazine for psychosis induced aggression or agitation

BACKGROUND

Agitated or violent behaviour constitutes 10% of all emergency psychiatric treatment. Some guidelines do not recommend the use of chlorpromazine for rapid tranquillisation but it is still often used for this purpose.

OBJECTIVES

To examine the effects of oral or intramuscular chlorpromazine for psychosis induced agitation or aggression.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (up to July 2009) which is based on regular searches of CINAHL, EMBASE, MEDLINE and PsycINFO.

SELECTION CRITERIA

Randomised control trials or double blind trials (implying randomisation) comparing chlorpromazine with another drug or placebo for people who are thought to be acutely aggressive or agitated due to psychotic illness.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based on a fixed-effects model.

MAIN RESULTS

One study (total n=30) met the inclusion criteria. When compared with haloperidol (Man 1973) (1 RCT, n=30) people allocated chlorpromazine were no more likely to have one additional injection than those allocated haloperidol (RR 3.00 CI 0.13 to 68.26). This remained true for 2-4 injections (RR 0.90 CI 0.52 to 1.55) and for 5 or more injections (RR 0.75 CI 0.20 to 2.79). Two people allocated chlorpromazine had sudden, serious hypotension while no one allocated haloperidol had such an effect (RR 5.00 CI 0.26 to 96.13). No extrapyramidal symptoms were observed. One person allocated chlorpromazine developed status epilepticus (RR 3.00 CI 0.13 to 68.26).

AUTHORS' CONCLUSIONS

Overall the quality of evidence is limited, poor and dated. Where drugs that have been better evaluated are available, it may be best to avoid use of chlorpromazine. Where chlorpromazine is used for acute aggression or where choices are limited, relevant trials are possible and urgently needed.

Haloperidol versus chlorpromazine for schizophrenia

BACKGROUND

Chlorpromazine and haloperidol are benchmark antipsychotic drugs. Both are said to be equally effective when used at equivalent doses, but have different side-effect profiles.

OBJECTIVES

To compare the effects of haloperidol and chlorpromazine for people with schizophrenia and schizophrenia-like psychoses.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's register (August 2006). We searched references of all included studies for further trials. We contacted pharmaceutical companies and authors of relevant trials.

SELECTION CRITERIA

We included all randomised controlled trials that compared haloperidol with chlorpromazine for people with schizophrenia and/or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by at least two reviewers, papers ordered, re-inspected and quality assessed. We independently extracted data. For dichotomous data we calculated the relative risk (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis using a random-effects model. For continuous data, we calculated weighted mean differences (WMD).

MAIN RESULTS

We found 14 relevant studies, mostly of short duration, poorly reported and conducted in the 1970s (total n=794 participants). Nine of these compared oral formulations of both compounds, and five compared intramuscular formulations. Haloperidol was associated with significantly fewer people leaving the studies early (13 RCTs, n=476, RR 0.26 CI 0.08 to 0.82). The efficacy outcome 'no significant improvement' tended to favour haloperidol, but this difference was not statistically significant (9 RCTs, n=400, RR 0.81 CI 0.64 to 1.04). Movement disorders were more frequent in the haloperidol groups ('at least one extrapyramidal side effect': 6 RCTs, n=37, RR 2.2 CI 1.1 to 4.4, NNH 5 CI 3 to 33), while chlorpromazine was associated with more frequent hypotension (5 RCTs, n=175, RR 0.31 CI 0.11 to 0.88, NNH 7 CI 4 to 25). Similar trends were found when studies comparing intramuscular formulations and studies comparing oral formulations were analysed separately.

AUTHORS' CONCLUSIONS

Given that haloperidol and chlorpromazine are global standard antipsychotic treatments for schizophrenia, it is surprising that less than 800 people have been randomised to a comparison and that incomplete reporting still makes it difficult for anyone to draw clear conclusions on the comparative effects of these drugs. However, it seems that haloperidol causes more movement disorders than chlorpromazine, while chlorpromazine is significantly more likely to lead to hypotonia. We are surprised to have to say that we feel further, large, well designed, conducted and reported studies are required.

Haloperidol alone or in combination for acute mania

BACKGROUND

The main objectives in treating mania are to control dangerous behaviour, reduce suicide, produce appropriate acute sedation and shorten the episode of mood disturbance. Among different drugs, haloperidol has for many years been used in treating psychotic patients, but it has a troublesome side effect profile.

OBJECTIVES

To assess the effects of haloperidol for the treatment of mania in comparison with placebo or other active drugs, either as monotherapy or add-on treatment.

SEARCH STRATEGY

We searched the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (11 October 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005), MEDLINE (1966-2003), EMBASE (1980-2003), CINAHL (1982-2003), PsycINFO (1872-2003) and reference lists. We also contacted experts, triallists and pharmaceutical companies in the field.

SELECTION CRITERIA

Randomised trials comparing haloperidol with placebo or other active treatment in the treatment of acute manic or mixed episodes in patients with bipolar disorder or schizoaffective disorder.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials.

MAIN RESULTS

Fifteen trials involving 2022 people were included. Compared to placebo, haloperidol was more effective at reducing manic symptoms, both as monotherapy (Weighted Mean Difference (WMD) -5.85, 95% Confidence Interval (CI) -7.69 to -4.00) and as adjunctive treatment to lithium or valproate (WMD -5.20, 95% CI -9.26 to -1.14). There was a statistically significant difference, with haloperidol being less effective than aripiprazole (Relative Risk (RR) 1.45, 95% CI 1.22 to 1.73). No significant differences between haloperidol and risperidone, olanzapine, carbamazepine or valproate were found. Compared with placebo, a statistically significant difference in favour of haloperidol in failure to complete treatment (RR 0.74, 95% Cl 0.57 to 0.96) was reported. Haloperidol was associated with less weight gain than olanzapine (RR: 0.28, 95% CI 0.12 to 0.67), but with a higher incidence of tremor (RR: 3.01, 95% CI 1.55 to 5.84) and other movement disorders.

AUTHORS' CONCLUSIONS

There is some evidence that haloperidol is an effective treatment for acute mania. From the limited data available, there was no difference in overall efficacy of treatment between haloperidol and olanzapine or risperidone. Some evidence suggests that haloperidol could be less effective than aripiprazole. Referring to tolerability, when considering the poor evidence comparing drugs, clinicians and patients should consider different side effect profiles as an important issue to inform their choice.

Managing the aggressive and violent patient in the psychiatric emergency

Throughout history most societies have assumed a link between mental disorders and violence. Although the majority of users of mental health services are not violent, it is clear that a small yet significant minority are violent in inpatient settings and in the community. The assessment of a violent patient may be very difficult due to the lack of a full medical and psychiatric history and the non-cooperativeness of the patient. Thus a full assessment is important for the early decisions that the clinician has to take in a very quick and effective way. The primary task and the short term outcome in a behavioral emergency is to act as soon as possible to stop the violence from escalating and to find the quickest way to keep the patient's agitation and violence under control with the maximum of safety for everybody and using the less severe effective intervention. The pharmacological treatment of acute, persisting and repetitive aggression is a serious problem for other patients and staff members. Currently, there is no medication approved by the Food and Drug Administration (FDA) for the treatment of aggression. Based on rather limited evidence, a wide variety of medications for the pharmacological treatment of acute aggression has been recommended: typical and atypical antipsychotics and benzodiazepines.

Dose response and dose equivalence of antipsychotics

We review evidence from randomized, placebo-controlled studies of patients with schizophrenia or schizoaffective disorder, which compared 2 or more doses of an antipsychotic to calculate the dose-response curve for each first-generation (typical) antipsychotic (FGA) or second-generation (atypical) antipsychotic (SGA) and as a group (based on dose equivalence). We identified the near-maximal effective dose (ED; ie, the threshold dose necessary to produce all or almost all the clinical responses for each drug). In randomized, fixed-dose studies of SGAs, the near-maximal efficacy dose for olanzapine may be greater than 16 mg; for risperidone, it is 4 mg; and for ziprasidone, it is 120 mg. Risperidone at 2 mg daily is 50% less efficacious than higher doses. Olanzapine at about 6 mg is approximately 33% less effective than higher doses. Aripiprazole at 10 mg daily was fully efficacious. Doses of clozapine well above 400 mg are necessary for optimal treatment of many schizophrenia patients. We found 3.3 to 10 mg haloperidol to be the near-maximal ED range. We find no evidence that doses higher than these are more effective. We failed to find that high doses of haloperidol (or all other first-generation comparison drugs converted to equivalent doses) were less effective than medium doses (3.3 to 10 mg). While high-dose FGAs are not less effective, we feel it is important not to avoid using high dose to avoid excessive toxicity.

Pharmacological management of aggression and violence

The pharmacological management of violence and aggression is a common and substantial clinical dilemma in the emergency psychiatric situation. A literature search was conducted through PubMed and using the Cochrane Library. This was followed by a manual search of selected literature. Randomised controlled trials were sought that specifically addressed the acute situation, rather than the ongoing management of chronic conditions. There was a paucity of well-controlled data and insufficient evidence to support the use of many agents in emergency situations. Many studies had considerable limitations making comparison difficult. Efficacy data for a range of treatment options exists, including the use of classical and atypical anti-psychotic agents, benzodiazepines and combination therapies. Clinical risk, tolerability and environmental factors need to form part of a careful and considered judgement in the choice of treatment. Safety, tolerability and the potential for a positive experience are major considerations, thus paving the way for long term compliance.

Pharmacological treatment of psychotic agitation

The presentation of agitated psychotic patients to psychiatric emergency services is a common occurrence. The traditionally accepted treatment for such patients involves the use of a typical antipsychotic, generally haloperidol. More recently benzodiazepines, such as lorazepam, have been used in combination with antipsychotics due to their sedative properties and relatively benign adverse effect profiles. Standard clinical protocol at many institutions involves the intramuscular administration of 5 to 10mg of haloperidol and 1 to 2mg of lorazepam. Atypical antipsychotics have gained acceptance as first-line treatments for psychotic disorders. These drugs are seen as an improvement over traditional antipsychotics because of their increased efficacy and reduced extrapyramidal effects. The utility of atypical antipsychotics in the emergency setting has been relatively unexplored because slow titration schedules or dose-limiting adverse effects for some members of the class have made this form of treatment impractical. However, the recent availability of oral liquid and rapidly dissolving tablet preparations of some atypical agents has provided useful alternatives in some cases. Nevertheless, for many patients a parenteral drug is the only desirable or feasible treatment option. Intramuscular preparations of the atypical antipsychotics olanzapine and ziprasidone have been developed, and are close to launch in the US. The availability of a rapid-acting intramuscular preparation of an atypical antipsychotic could represent a significant advancement in the treatment of agitation associated with psychosis.

Rapid tranquilization of the violent patient

Agitated, psychotic patients with the potential for violence pose significant management problems for emergency department staff. With the advent of rapid tranquilization (RT), clinicians were offered a safe, effective method for controlling such patients, eliminating the need for restraints or seclusion rooms. While RT is regarded as a major treatment innovation in psychiatry, nonpsychiatrists are reluctant or unaware of the uses of antipsychotic medication as it pertains to RT. This article provides a brief overview of the pharmacokinetics of antipsychotic medication and reviews the following aspects of RT: route of administration, dosing, time intervals between doses, side effects, and alternative medications for RT. The authors also offer practical guidelines for RT use in the emergency department.

A "new" drug for treating agitation and psychosis in the general hospital: chlorpromazine

Psychiatric residents on a consultation-liaison service consistently avoid chlorpromazine in favor of haloperidol for the treatment of psychotic, agitated patients. The residents' fears of chlorpromazine as a dangerous medication are presented and the literature about chlorpromazine's side effects is reviewed. Evidence was not found to support the contention that chlorpromazine is too dangerous to use in the medical setting. Case material illustrating the benefits of chlorpromazine is presented. A theoretical explanation for the observed prescribing practices is suggested.

The intensive care unit syndrome: causes, treatment, and prevention

The psychological assessment and management of the critically ill patient is often overlooked as a part of the patient care plan. The intensive care unit (ICU) syndrome is a type of organic brain syndrome manifested by a variety of psychological reactions, including fear, anxiety, depression, hallucinations, and delirium. Causes, treatment modalities, and a multidisciplinary approach to preventing the ICU syndrome are presented. Causative factors that should be assessed in the psychological evaluation of ICU patients include: (1) preadmission history; (2) past ability to adapt to stress; (3) past and current medications; (4) current clinical status; and (5) environmental factors. The treatment of the ICU syndrome includes: (1) the correction or elimination of causative factors; (2) the appropriate choice, dose, and route of administration of anxiolytic and antipsychotic agents; (3) reduction or elimination of sources of environmental stress; and (4) frequent patient and family communication. Finally, the prevention of the ICU syndrome through the involvement of physicians, nurses, and pharmacists is stressed.

Neuroleptics under high risk conditions

A critical review of various high risk situations in which neuroleptics could be used and have been used in clinical practice is presented. These high risk situations include: women of child bearing age (pregnant women, lactating and/or nursing mothers), the two extremes of life (children and the elderly), patients with sexual dysfunction, patients with tardive dyskinesia, non-psychotic psychiatric patients, physically ill and suicidal patients. The extraordinary applications of these drugs, such as for rapid tranquilization and megadose regimens are examined. The author provides guidelines for the use of neuroleptics in these clinical situations.

Clinical state, plasma levels of haloperidol and prolactin: a correlation study in chronic schizophrenia

Chronic schizophrenic patients were maintained for six months on a dosage of haloperidol adjusted to give optimum clinical effect. A correlation was found between extrapyramidal symptoms and prolactin levels and also between plasma haloperidol concentration and plasma prolactin levels. Estimation of plasma prolactin would be a reliable measurement of patients' compliance with medication.

A comparison of the efficacy and acceptability of two formulations of injectable serenace in the treatment of states of excitement

Seranace was tested in its two formulations of dextrose and saline base and the results confirm no significant differences between the two preparations, either in their efficacy and acceptability or in the control of presenting symptoms.

Parenteral treatment of acute psychotic patients with agitation: a review

Representative studies which elucidate present treatment principles regarding parenteral administration of neuroleptics for acute psychoses with agitation are reviewed. "Rapid tranquillization" with drugs such as haloperidol generally appears preferable, but controlled comparisons with more conservative types of treatment are lacking. It is suggested that parenteral chlorpromazine should be avoided because of its tendency to provoke severe hypotension, whereas loxapine apparently is a valuable drug if strong sedation is required for behavioural control. Possible advantages of ultra-high-dose therapy need to be proved in controlled trials, and the occurrence of toxic side-effects requires further evaluation. From an ethical and psychological point of view, it is recommended that antiparkinsonian medication should be administered simultaneously with neuroleptics which induce a high incidence of acute dystonia. Several types of acute psychosis with agitation which do not require treatment with a neuroleptic as drug treatment of first choice are briefly mentioned.

Psychotropic drugs in the management of psychiatric emergencies

Antipsychotic drugs are the agents of choice for the management of acute functional psychoses. In most instances, hourly intramuscular injections of chlorpromazine or haloperidol will bring tranquilization within six hours or less. These drugs also are useful in amphetamine-induced psychoses. In psychosis resulting from hallucinogen, however, an antipsychotic drug should be given only as a last resort. In many organic psychoses, including psychosis due to ingestion of an atropine-like drug, use of anti-psychotic drug should be avoided. Before any drug is given to a psychotic patient, an effort should be made to identify an organic brain syndrome, characterized by clouded sensorium, disorientation, and poor recent memory.