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Kassam AS, Karalis P, Aydinian T, Panjwani A, Martinez G, Whiteman A, Daas M, Cunningham EA. Racial disparities with PRN medication usage in inpatient psychiatric treatment. SCHIZOPHRENIA (HEIDELBERG, GERMANY) 2024; 10:46. [PMID: 38615056 PMCID: PMC11016118 DOI: 10.1038/s41537-024-00461-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 03/15/2024] [Indexed: 04/15/2024]
Abstract
Racial disparities in psychiatric diagnoses and treatment have significant public health implications, contributing to inequities in healthcare outcomes. We specifically examined racial disparities regarding pro re nata (PRN), or as needed, medications. Data from 14,616 encounters across 2019-2020 within Community Health Network's inpatient psychiatric setting in Indianapolis, Indiana were included in this study. Due to the demographic sample size, analyses were narrowed to Black and White patients. Primary outcomes included comparisons across race for all PRN administrations and PRN administrations of antipsychotics vs. non-antipsychotics. Logistic regression was used to examine associations between race and PRN administrations by medication category, including all antipsychotics vs. non-antipsychotics overall, hydroxyzine, and lorazepam, independently. Significant differences in the percentage of administrations between Black and White patients were observed. Black patients received more PRN medications overall (71.0%) compared to White patients (67.7%) (p < 0.01). Further, while 17.7% of Black patients were administered PRN antipsychotics, this was true for only 8.2% of White patients (p < 0.001). When comparing antipsychotic PRNs with non-antipsychotic, hydroxyzine, and lorazepam PRNs, independently, Black patients were 58% (OR 1.58, p < 0.001), 109% (OR 2.09, p < 0.001), and 32% (OR 1.32, p < 0.001), more likely to receive antipsychotic PRNs, respectively, than White patients, controlling for sex, age, length of stay, and psychotic disorder diagnosis. Our study identifies yet another area of medical care with significant racial disparities. In this analysis of PRN medications during psychiatric admission, we identified significant differences in medication utilization by race. This information provides a basis for further investigation of disparities in patient-centered data.
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Affiliation(s)
- Areef S Kassam
- Community Health Network, Behavioral Health Department, Indianapolis, IN, USA.
| | - Peter Karalis
- Community Health Network, Behavioral Health Department, Indianapolis, IN, USA
| | - Taline Aydinian
- Harvard Medical School, Department of Psychiatry, Boston, MA, USA
| | - Anita Panjwani
- Purdue University, Department of Nutrition Science, West Lafayette, IN, USA
- Center on Aging and the Life Course, Purdue University, West Lafayette, IN, USA
| | - Gabriel Martinez
- Community Health Network, Behavioral Health Department, Indianapolis, IN, USA
| | - Aaron Whiteman
- Community Health Network, Behavioral Health Department, Indianapolis, IN, USA
| | - Magdoline Daas
- Community Health Network, Behavioral Health Department, Indianapolis, IN, USA
| | - E Ann Cunningham
- Community Health Network, Behavioral Health Department, Indianapolis, IN, USA
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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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Burk BG, Penherski P, Snider K, Lewellyn L, Mattox L, Polancich S, Fargason R, Waggoner B, Caine E, Hand W, Eagleson RM, Birur B. Use of a Novel Standardized Administration Protocol Reduces Agitation Pro Re Nata (PRN) Medication Requirements: The Birmingham Agitation Management (BAM) Initiative. Ann Pharmacother 2023; 57:397-407. [PMID: 35950625 DOI: 10.1177/10600280221117813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Agitation management is a principal challenge on inpatient psychiatric units. Overreliance on common prescribing strategies of pro re nata (PRN) medication administration is problematic, given the tendencies to have overlapping or unclear indications. OBJECTIVE Piloted project to determine whether a standardized protocol for agitation intervention may reduce PRN medication administration. METHODS The Birmingham Agitation Management (BAM) interdisciplinary team uniquely connected the Brøset Violence Checklist (BVC) for assessment of agitation severity to a standardized PRN medication order set. Nurses on the piloted unit were trained on how to score the BVC and administer medications. Patients were assessed by the BVC every 4 hours and, based on their score, would receive no medication, low-dose benzodiazepine, high-dose benzodiazepine, or high-dose benzodiazepine plus antipsychotic. The primary end point compared the number of PRNs administered after novel protocol implementation with a retrospective cohort. Secondary measures included analysis of medication-related effects, seclusion, and physical restraint rates. RESULTS 377 patients were included in the final analyses (184 pre-BAM, 193 BAM intervention group). No significant differences were seen in patient characteristics between groups. The total number of PRNs administered decreased by 42.5%, with both the mean and median number of administrations decreasing significantly (95% confidence interval [CI] = [1.68-5.75]; P < 0.001). A trend was noted between the number of PRNs administered and seclusion rates, but did not reach statistical significance (95% CI = [-7.28 to 60.31]; P = 0.124). CONCLUSIONS In seemingly the first initiative of its kind, we found that a standardized agitation management protocol can help decrease the total number of PRN administrations for agitation without worsening of restraint rates and may possibly reduce the risk of adverse effects. These results require validation in specific, larger populations.
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Affiliation(s)
- Bradley G Burk
- Department of Pharmacy, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Peter Penherski
- Department of Psychiatry, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA.,Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Kendall Snider
- Department of Regulatory Services, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Lesli Lewellyn
- Department of Nursing, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Lisa Mattox
- Department of Nursing, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Shea Polancich
- Department of Regulatory Services, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA.,Department of Nursing, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA.,School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rachel Fargason
- Department of Psychiatry, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA.,Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Barry Waggoner
- Department of Clinical Informatics, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Elizabeth Caine
- Department of Hospital Administration, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Wren Hand
- Department of Nursing, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Reid M Eagleson
- Department of Nursing, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Badari Birur
- Department of Psychiatry, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA.,Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
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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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Garrote-Cámara ME, Gea-Caballero V, Sufrate-Sorzano T, Rubinat-Arnaldo E, Santos-Sánchez JÁ, Cobos-Rincón A, Santolalla-Arnedo I, Juárez-Vela R. Clinical and Sociodemographic Profile of Psychomotor Agitation in Mental Health Hospitalisation: A Multicentre Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15972. [PMID: 36498042 PMCID: PMC9735933 DOI: 10.3390/ijerph192315972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 06/17/2023]
Abstract
Psychomotor agitation is characterised by an increase in psychomotor activity, restlessness and irritability. People with psychomotor agitation respond by over-reacting to both intrinsic and extrinsic stimuli, experiencing stress and/or altered cognition. The objective of this study is to assess the clinical and sociodemographic profile of psychomotor agitation in patients with severe mental disorders. The study was carried out in Spain by means of multicentre cross-sectional convenience sampling involving 140 patients who had been admitted to psychiatric hospital units and had experienced an episode of psychomotor agitation between 2018 and 2021.Corrigan's Agitated Behaviour Scale was used to assess psychomotor agitation. The results show that the predominant characteristic in psychomotor agitation is aggressiveness, which is also the most reported factor in patients with severe mental disorder. Patients who also have anxiety develop psychomotor agitation symptoms of moderate/severe intensity. The clinical and sociodemographic profile found in our study is consistent with other studies on the prevalence of psychomotor agitation.
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Affiliation(s)
- María Elena Garrote-Cámara
- Care and Health Research Group, Department in Nursing, University of La Rioja, C/Duquesa de la Victoria 88, 26004 Logroño, Spain
| | - Vicente Gea-Caballero
- Research Group on Community Health and Care, Faculty of Health Science, Valencia International University, 46002 Valencia, Spain
| | - Teresa Sufrate-Sorzano
- Care and Health Research Group, Department in Nursing, University of La Rioja, C/Duquesa de la Victoria 88, 26004 Logroño, Spain
| | - Esther Rubinat-Arnaldo
- Society, Health, Education and Culture Study Group, Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida, 25003 Lleida, Spain
| | | | - Ana Cobos-Rincón
- Care and Health Research Group, Department in Nursing, University of La Rioja, C/Duquesa de la Victoria 88, 26004 Logroño, Spain
| | - Iván Santolalla-Arnedo
- Care and Health Research Group, Department in Nursing, University of La Rioja, C/Duquesa de la Victoria 88, 26004 Logroño, Spain
| | - Raúl Juárez-Vela
- Care and Health Research Group, Department in Nursing, University of La Rioja, C/Duquesa de la Victoria 88, 26004 Logroño, Spain
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Manning T, Bell SB, Dawson D, Kezbers K, Crockett M, Gleason O. The Utilization of a Rapid Agitation Scale and Treatment Protocol for Patient and Staff Safety in an Inpatient Psychiatric Setting. Psychiatr Q 2022; 93:915-933. [PMID: 36006571 PMCID: PMC9402403 DOI: 10.1007/s11126-022-10001-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 10/27/2022]
Abstract
Agitation is a common and potentially dangerous condition requiring rapid recognition and treatment in acute psychiatric units. Prompt intervention can prevent a patient with agitation from harming themselves, harming others, or needing restraints or seclusion. After the review of numerous guidelines, the Modified Agitation Severity Scale (MASS) agitation treatment protocol was developed to identify and manage agitation in an inpatient adult psychiatric setting. This protocol involved modifying an existing agitation scale and pairing scores with a treatment algorithm to indicate which behavioral and medication interventions would be most appropriate. All scoring and interventions were recorded in the electronic medical record (EMR). Three months of data were collected before and after the protocol was implemented. The new, modified scale had high reliability and correlated well with another validated agitation scale. Perceived patient safety was high during both study phases. Nurses' perceptions of safety trended upward after the protocol was implemented, though these differences were not significant, likely due to insufficient power. Although there was no decrease in seclusion events after implementation of the treatment protocol, there was a 44% decrease in restraint events and average restraint minutes per incident. Despite a potential increase in workload for nursing staff, implementation of the protocol did not increase burnout scores. Physicians continued to order the protocol for 55% of patients after the study period ended. These findings suggest that including a rapid agitation assessment and protocol within the EMR potentially improves nurses' perceptions of unit safety, helps assess treatment response, reduces time patients spend restrained, and supports decision making for nurses.
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Affiliation(s)
- Tessa Manning
- School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA.
| | - Sarah Beth Bell
- School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | - Drew Dawson
- Oklahoma City Indian Clinic, 5208 W Reno Ave, Oklahoma City, OK, USA
| | - Krista Kezbers
- School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA.,Health Promotion Research Center, The University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma City, OK, USA
| | - Micheal Crockett
- School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
| | - Ondria Gleason
- School of Community Medicine, The University of Oklahoma, Tulsa, OK, USA
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7
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Deng Y, Qin Z, Wu Q, Liu L, Yang X, Ju X, Zhang Y, Liu L. Efficacy and Safety of Remimazolam Besylate versus Dexmedetomidine for Sedation in Non-Intubated Older Patients with Agitated Delirium After Orthopedic Surgery: A Randomized Controlled Trial. Drug Des Devel Ther 2022; 16:2439-2451. [PMID: 35937566 PMCID: PMC9354763 DOI: 10.2147/dddt.s373772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/23/2022] [Indexed: 12/26/2022] Open
Abstract
Purpose The purpose of the present study was to investigate the efficacy and safety of remimazolam besylate compared with dexmedetomidine for the relief of agitated delirium in non-intubated older patients after orthopedic surgery. Patients and methods Seventy-five patients were randomly divided into two groups. Patients assigned to the remimazolam group received a loading dose of 0.075 mg/kg remimazolam besylate over 1 minute, followed by a continuous infusion of 0.1 to 0.3 mg/kg/h. Subjects randomized to the dexmedetomidine group received a loading infusion of 0.5 μg/kg dexmedetomidine over 10 minutes, followed by a maintenance dose of 0.2 to 0.7 μg/kg/h. Meanwhile, RASS score-guided dose titration was followed. To assess the efficacy of the study drugs in terms of time to resolution of agitation, time to first achievement of target sedation, percentage of time within the target sedation range, and time to delirium resolution. Safety of the sedatives was evaluated by adverse events during hospitalization. Results Time to resolution of agitation did not differ between the two groups. The time to first achievement of target sedation was 19.0 (9.5 to 31.0) minutes for remimazolam besylate vs 43.5 (15.0 to 142.5) minutes for dexmedetomidine (P < 0.001). Percentage of time within the target sedation range was 77.8% for remimazolam besylate-treated patients and 67.4% for dexmedetomidine-treated patients (P = 0.001). Patients in the remimazolam group had longer time to delirium resolution (29.5 [21.3 to 32.5] hours) than those in the dexmedetomidine group (22.8 [18.9 to 28.5] hours) (P = 0.042). Patients sedated with remimazolam besylate had more oversedation (P = 0.036) but less hypotension (P = 0.007). Conclusion Compared with dexmedetomidine, remimazolam besylate was equally effective in relieving agitation, and resulted in earlier achievement of sedation goal and more controllable sedation. Remimazolam may be an ideal agent for obtaining rapid tranquillisation.
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Affiliation(s)
- Yang Deng
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Zhijun Qin
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
- Correspondence: Zhijun Qin, Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, No. 132, West First Section, First Ring Road, Chengdu, 610041, People’s Republic of China, Tel +86-18708499493, Email
| | - Qianyun Wu
- Nursing Department, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Linsong Liu
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Xi Yang
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Xuan Ju
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Ying Zhang
- Intensive Care Unit, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
| | - Lei Liu
- Department of Infection Control, Sichuan Provincial Orthopedic Hospital, Chengdu, 610041, People’s Republic of China
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Carmassi C, Pacciardi B, Gravina D, Fantasia S, De Pascale G, Cutuli SL, Bertelloni CA, Dell’Osso L. Pharmacological Treatment of Acute Psychiatric Symptoms in COVID-19 Patients: A Systematic Review and a Case Series. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:4978. [PMID: 35564372 PMCID: PMC9099660 DOI: 10.3390/ijerph19094978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/10/2022] [Accepted: 04/12/2022] [Indexed: 02/04/2023]
Abstract
Delirium and psychomotor agitation are relevant clinical conditions that may develop during COVID-19 infection, especially in intensive care unit (ICU) settings. The psychopharmacological management of these conditions is receiving increasing interest in psychiatry, considering hyperkinetic delirium as one of the most common neuropsychiatries acute consequences in COVID-19 recovery patients. However, there are no actual internationally validated guidelines about this topic, due to the relatively newly introduced clinical condition; in addition, a standardized psychopharmacologic treatment of these cases is a complex goal to achieve due to the risk of both drug-drug interactions and the vulnerable conditions of those patients. The aim of this systematic review and case series is to evaluate and gather the scientific evidence on pharmacologic handling during delirium in COVID-19 patients to provide practical recommendations on the optimal management of psychotropic medication in these kinds of patients. The electronic databases PubMed, Embase and Web of Science were reviewed to identify studies, in accordance with the PRISMA guidelines. At the end of the selection process, a total of 21 studies (n = 2063) were included. We also collected a case series of acute psychomotor agitation in COVID-19 patients hospitalized in ICU. Our results showed how the symptom-based choice of the psychotropic medication is crucial, and even most of the psychotropic drug classes showed good safety, one must not underestimate the possible drug interactions and also the possible decrease in vital functions which need to be strictly monitored especially during treatment with some kinds of molecules. We believe that the evidence-based recommendations highlighted in the present research will enhance the current knowledge and could provide better management of these patients.
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Affiliation(s)
- Claudia Carmassi
- Psychiatric Unit, Department of Clinical and Experimental Medicine, AOUP, University of Pisa, 56126 Pisa, Italy; (C.C.); (B.P.); (S.F.); (C.A.B.); (L.D.)
| | - Bruno Pacciardi
- Psychiatric Unit, Department of Clinical and Experimental Medicine, AOUP, University of Pisa, 56126 Pisa, Italy; (C.C.); (B.P.); (S.F.); (C.A.B.); (L.D.)
| | - Davide Gravina
- Psychiatric Unit, Department of Clinical and Experimental Medicine, AOUP, University of Pisa, 56126 Pisa, Italy; (C.C.); (B.P.); (S.F.); (C.A.B.); (L.D.)
| | - Sara Fantasia
- Psychiatric Unit, Department of Clinical and Experimental Medicine, AOUP, University of Pisa, 56126 Pisa, Italy; (C.C.); (B.P.); (S.F.); (C.A.B.); (L.D.)
| | - Gennaro De Pascale
- Department of Emergency, Catholic University of the Sacred Heart, 00168 Rome, Italy; (G.D.P.); (S.L.C.)
| | - Salvatore Lucio Cutuli
- Department of Emergency, Catholic University of the Sacred Heart, 00168 Rome, Italy; (G.D.P.); (S.L.C.)
| | - Carlo Antonio Bertelloni
- Psychiatric Unit, Department of Clinical and Experimental Medicine, AOUP, University of Pisa, 56126 Pisa, Italy; (C.C.); (B.P.); (S.F.); (C.A.B.); (L.D.)
| | - Liliana Dell’Osso
- Psychiatric Unit, Department of Clinical and Experimental Medicine, AOUP, University of Pisa, 56126 Pisa, Italy; (C.C.); (B.P.); (S.F.); (C.A.B.); (L.D.)
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9
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Preskorn SH, Zeller S, Citrome L, Finman J, Goldberg JF, Fava M, Kakar R, De Vivo M, Yocca FD, Risinger R. Effect of Sublingual Dexmedetomidine vs Placebo on Acute Agitation Associated With Bipolar Disorder: A Randomized Clinical Trial. JAMA 2022; 327:727-736. [PMID: 35191924 PMCID: PMC8864508 DOI: 10.1001/jama.2022.0799] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Acute agitation is common in patients with bipolar disorder and requires urgent management to relieve distress and to prevent escalation to aggressive behavior. OBJECTIVE To evaluate the effect of orally absorbed, sublingual dexmedetomidine, a selective α2A-adrenergic receptor agonist on symptoms of acute agitation in patients with bipolar disorder. DESIGN, SETTING, AND PARTICIPANTS Phase 3, randomized, double-blind, placebo-controlled trial conducted in 15 sites in the US with enrollment between February 24, 2020, and April 27, 2020, and final follow-up on May 21, 2020. A total of 380 adults with bipolar I or II disorder were randomized and 362 completed the study. INTERVENTIONS Participants were randomized to 3 groups: sublingual dexmedetomidine 180 μg (n = 127), sublingual dexmedetomidine 120 μg (n = 127), or placebo (n = 126). MAIN OUTCOMES AND MEASURES The primary efficacy end point was the mean change from baseline at 2 hours for the Positive and Negative Syndrome Scale-Excited Component (PEC) total score. The range of possible total scores is 5 (absence of agitation) to 35 (extremely severe). The secondary end point was the earliest time of a statistically significant change in PEC total score from baseline for the drug vs placebo. On the primary efficacy end point, to account for multiplicity associated with comparing 2 sublingual dexmedetomidine doses with placebo, the 2-sided significance level for each dose vs placebo was set at .025. RESULTS Of 380 patients randomized (mean age, 45.6 years; 54.8% women; and 56.1% Black individuals), 378 (99.5%) self-administered the study medication and completed the study. Baseline agitation was mild to moderate, with an overall mean PEC total score of 18.0. Two hours after taking the medication, the mean changes from baseline in PEC total score were -10.4 for sublingual dexmedetomidine 180 μg, -9.0 for sublingual dexmedetomidine 120 μg, and -4.9 for placebo. Least-square mean differences from placebo in the sublingual dexmedetomidine groups at 2 hours were -5.4 (97.5% CI, -6.6 to -4.2) for 180 μg and -4.1 (97.5% CI, -5.3 to -2.9) for 120 μg (both doses P < .001 vs placebo). Treatment effects began 20 minutes after taking the medication among patients in the sublingual dexmedetomidine groups (least-square mean difference for 180 μg, -1.1 [97.5% CI, -2.0 to -0.2]; P = .007; for 120 μg, -1.0 [97.5% CI, -1.9 to -0.1]; P = .009). Adverse events occurred in 35.7% of patients taking 180 μg of dexmedetomidine, 34.9% taking 120 μg, and 17.5% taking placebo. The most common adverse events (≥5%) in the respective 180 μg, 120 μg, and placebo groups were somnolence (21.4% and 20.6% vs 4.8%); dry mouth (4.8% and 7.1% vs 0.8%); hypotension (6.3% and 4.8% vs 0%); and dizziness (5.6% and 5.6% vs 0.8%). CONCLUSIONS AND RELEVANCE Among patients with mild to moderate agitation associated with bipolar disorder, treatment with a sublingual film formulation of dexmedetomidine 120 μg or 180 μg, compared with placebo, resulted in significantly greater reduction in the agitation score at 2 hours. Further research is needed to understand the spectrum of patients for whom this treatment would be effective and feasible and to better understand the clinical importance of the observed effect size. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04276883.
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Affiliation(s)
| | - Scott Zeller
- Department of Psychiatry, University of California-Riverside School of Medicine, Riverside
| | - Leslie Citrome
- Department of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla
| | - Jeffrey Finman
- Jupiter Point Pharma Consulting, LLC, Groton, Connecticut
| | - Joseph F. Goldberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Maurizio Fava
- Massachusetts General Hospital and Harvard Medical School, Boston
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10
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Garrote-Cámara ME, Santolalla-Arnedo I, Ruiz de Viñaspre-Hernández R, Gea-Caballero V, Sufrate-Sorzano T, del Pozo-Herce P, Garrido-García R, Rubinat-Arnaldo E, Juárez Vela R. Psychometric Characteristics and Sociodemographic Adaptation of the Corrigan Agitated Behavior Scale in Patients With Severe Mental Disorders. Front Psychol 2021; 12:779277. [PMID: 34955998 PMCID: PMC8693627 DOI: 10.3389/fpsyg.2021.779277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Severe mental disorder (SMD) is understood in a first approximation as a disorder of thought, emotion, or behavior of long duration, which entails a variable degree of disability and social dysfunction. One of the most widely used assessment scales for agitated behavior, in its English version, is the Corrigan Agitated Behavior Scale (ABS); several studies have demonstrated solid psychometric properties of the English version, with adequate internal consistency. Objective: The objective of this study was to evaluate the psychometric properties of the Spanish version of the ABS Corrigan scale, in a sample of patients with severe mental disorders. The psychometric analyses of the Spanish version of the ABS Corrigan included tests of the reliability and validity of its internal structure. Results: The structure of the factorial loads of the analyzed elements is consistent with the hypothesized three-dimensional construction referred to in the original ABS. The results suggest that the reliability and validity of the three dimensions are acceptable (First 0.8, Second 0.8, and Third 0.7). The internal consistency of the Spanish version of the complete ABS and of each of the three domains that compose it is high, with values very close to those found in the original version, with approximate figures of 0.9. Conclusion: In our study, the three domains aim to explain 64.1% of the total variance of the scale, which exceeds the 50% found in the original version.
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Affiliation(s)
- María Elena Garrote-Cámara
- Mental Health Center of Albelda de Iregua, Riojan Health Service, Government of La Rioja, La Rioja, Spain
- Group of Research in Sustainability of the Health System, Biomedical Research Center of La Rioja (CIBIR), Logroño, Spain
| | - Iván Santolalla-Arnedo
- Group of Research in Sustainability of the Health System, Biomedical Research Center of La Rioja (CIBIR), Logroño, Spain
- Care Research Group (GRUPAC) - University of La Rioja, La Rioja, Spain
| | - Regina Ruiz de Viñaspre-Hernández
- Group of Research in Sustainability of the Health System, Biomedical Research Center of La Rioja (CIBIR), Logroño, Spain
- Care Research Group (GRUPAC) - University of La Rioja, La Rioja, Spain
| | | | - Teresa Sufrate-Sorzano
- Group of Research in Sustainability of the Health System, Biomedical Research Center of La Rioja (CIBIR), Logroño, Spain
- Care Research Group (GRUPAC) - University of La Rioja, La Rioja, Spain
| | - Pablo del Pozo-Herce
- Group of Research in Sustainability of the Health System, Biomedical Research Center of La Rioja (CIBIR), Logroño, Spain
- Care Research Group (GRUPAC) - University of La Rioja, La Rioja, Spain
- Department of Psychiatry, Fundación Jiménez Díaz University Hospital, Madrid, Spain
| | - Rebeca Garrido-García
- Group of Research in Sustainability of the Health System, Biomedical Research Center of La Rioja (CIBIR), Logroño, Spain
- Care Research Group (GRUPAC) - University of La Rioja, La Rioja, Spain
- Najera Health Center, Riojan Health Service, Government of La Rioja, La Rioja, Spain
| | - Esther Rubinat-Arnaldo
- Research Group of Health Care (GRECS) - IRBLleida, Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
- Research Group Society, Health, Education and Culture (GESEC), University of Lleida, Lleida, Spain
- Center for Biomedical Research Network on Diabetes and Associated Metabolic Diseases (CIBERDEM), Carlos III Health Institute, Barcelona, Spain
| | - Raúl Juárez Vela
- Group of Research in Sustainability of the Health System, Biomedical Research Center of La Rioja (CIBIR), Logroño, Spain
- Care Research Group (GRUPAC) - University of La Rioja, La Rioja, Spain
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11
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Barbic D, Andolfatto G, Grunau B, Scheuermeyer FX, Macewan B, Qian H, Wong H, Barbic SP, Honer WG. Rapid Agitation Control With Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial. Ann Emerg Med 2021; 78:788-795. [PMID: 34353650 DOI: 10.1016/j.annemergmed.2021.05.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/12/2021] [Accepted: 05/24/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE We hypothesized that the use of intramuscular ketamine would result in a clinically relevant shorter time to target sedation. METHODS We conducted a randomized clinical trial comparing the rapidity of onset, level of sedation, and adverse effect profile of ketamine compared to a combination of midazolam and haloperidol for behavioral control of emergency department patients with severe psychomotor agitation. We included patients with severe psychomotor agitation measured by a Richmond Agitation Score (RASS) ≥+3. Patients in the ketamine group were treated with a 5 mg/kg intramuscular injection. Patients in the midazolam and haloperidol group were treated with a single intramuscular injection of 5 mg midazolam and 5 mg haloperidol. The primary outcome was the time, in minutes, from study medication administration to adequate sedation, defined as RASS ≤-1. Secondary outcomes included the need for rescue medications and serious adverse events. RESULTS Between June 30, 2018, and March 13, 2020, we screened 308 patients and enrolled 80. The median time to sedation was 14.7 minutes for midazolam and haloperidol versus 5.8 minutes for ketamine (difference 8.8 minutes [95% confidence interval (CI) 3.0 to 14.5]). Adjusted Cox proportional model analysis favored the ketamine arm (hazard ratio 2.43, 95% CI 1.43 to 4.12). Five (12.5%) patients in the ketamine arm and 2 (5.0%) patients in the midazolam and haloperidol arm experienced serious adverse events (difference 7.5% [95% CI -4.8% to 19.8%]). CONCLUSION In ED patients with severe agitation, intramuscular ketamine provided significantly shorter time to adequate sedation than a combination of intramuscular midazolam and haloperidol.
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Affiliation(s)
- David Barbic
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada; Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada.
| | - Gary Andolfatto
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Brian Grunau
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada; Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Frank X Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada; Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Bill Macewan
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Hong Qian
- Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Hubert Wong
- Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Skye P Barbic
- Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada; Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, BC, Canada
| | - William G Honer
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
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12
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Lin J, Figuerado Y, Montgomery A, Lee J, Cannis M, Norton VC, Calvo R, Sikand H. Efficacy of ketamine for initial control of acute agitation in the emergency department: A randomized study. Am J Emerg Med 2021; 44:306-311. [DOI: 10.1016/j.ajem.2020.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/18/2020] [Accepted: 04/04/2020] [Indexed: 11/17/2022] Open
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13
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Pompili M, Ducci G, Galluzzo A, Rosso G, Palumbo C, De Berardis D. The Management of Psychomotor Agitation Associated with Schizophrenia or Bipolar Disorder: A Brief Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18084368. [PMID: 33924111 PMCID: PMC8074323 DOI: 10.3390/ijerph18084368] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 02/02/2023]
Abstract
The early and correct assessment of psychomotor agitation (PMA) is essential to ensure prompt intervention by healthcare professionals to improve the patient’s condition, protect healthcare staff, and facilitate future management. Proper training for recognizing and managing agitation in all care settings is desirable to improve patient outcomes. The best approach is one that is ethical, non-invasive, and respectful of the patient’s dignity. When deemed necessary, pharmacological interventions must be administered rapidly and avoid producing an excessive state of sedation, except in cases of severe and imminent danger to the patient or others. The purpose of this brief review is to raise awareness about best practices for the management of PMA in emergency care situations and consider the role of new pharmacological interventions in patients with agitation associated with bipolar disorder or schizophrenia.
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Affiliation(s)
- Maurizio Pompili
- Department of Neuroscience, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy
- Correspondence:
| | - Giuseppe Ducci
- Mental Health Department, ASL Roma 1, 00193 Rome, Italy;
| | - Alessandro Galluzzo
- Department of Mental Health and Addiction Services, ASST Spedali Civili, 25123 Brescia, Italy;
| | - Gianluca Rosso
- Psychiatric Unit, San Luigi Gonzaga University Hospital, 10043 Torino, Italy;
- Department of Neurosciences, University of Turin, 10126 Torino, Italy
| | - Claudia Palumbo
- Department of Psychiatry, Hospital Papa Giovanni XXIII-Bergamo, 24127 Bergamo, Italy;
| | - Domenico De Berardis
- Department of Mental Health, Psychiatric Service of Diagnosis and Treatment, Hospital “G. Mazzini”, National Health Service (NHS), ASL 4 Teramo, 64100 Teramo, Italy;
- Department of Neurosciences and Imaging, Chair of Psychiatry, University “G. D’Annunzio”, 66100 Chieti, Italy
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14
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Paris G, Bighelli I, Deste G, Siafis S, Schneider-Thoma J, Zhu Y, Davis JM, Vita A, Leucht S. Short-acting intramuscular second-generation antipsychotic drugs for acutely agitated patients with schizophrenia spectrum disorders. A systematic review and network meta-analysis. Schizophr Res 2021; 229:3-11. [PMID: 33607608 DOI: 10.1016/j.schres.2021.01.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 01/20/2021] [Accepted: 01/24/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Psychomotor agitation is a common condition in patients with psychotic disorders. One treatment possibility is intramuscular (IM) second-generation antipsychotics. Yet their efficacy in this formulation and for this aim is unclear. This network meta-analysis aims to evaluate the efficacy of short-acting IM second-generation antipsychotic drugs, haloperidol and placebo in patients with diagnosis of schizophrenia and schizophrenia-like disorders that present acute agitation. METHODS We searched the Cochrane Schizophrenia Group Controlled Trials Register, MEDLINE, EMBASE, PsycINFO, Cochrane Library, PubMed, BIOSIS, ClinicalTrials.gov and WHO ICTRP up to November 2018 and PubMed until March 2020. Study selection and outcome extraction were performed independently by two reviewers. Pairwise and network meta-analyses were conducted to compare the different IM second-generation antipsychotics among themselves and with IM haloperidol and placebo. The primary outcome was the number of responders at 2 h after the first injection. Responders at 24 h were also analysed. RESULTS 10 studies with 1964 patients were included in the meta-analysis. Ziprasidone, olanzapine, aripiprazole and haloperidol were more efficacious than placebo in calming patients at 2 h after administration. Furthermore, olanzapine was superior to aripiprazole. The results at 24 h confirmed the superiority of aripiprazole, olanzapine and haloperidol over placebo, while for ziprasidone no data were available. CONCLUSIONS All second-generation antipsychotics available as intramuscular medications were effective in reducing agitation in people with schizophrenia. Olanzapine was somewhat more efficacious than aripiprazole.
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Affiliation(s)
- Giulia Paris
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
| | - Irene Bighelli
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Giacomo Deste
- Department of Mental Health and Addiction Services, Spedali Civili Hospital, Brescia, Italy.
| | - Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Yikang Zhu
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - John M Davis
- Department of Psychiatry, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States of America.
| | - Antonio Vita
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Department of Mental Health and Addiction Services, Spedali Civili Hospital, Brescia, Italy.
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
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15
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Kim HK, Leonard JB, Corwell BN, Connors NJ. Safety and efficacy of pharmacologic agents used for rapid tranquilization of emergency department patients with acute agitation or excited delirium. Expert Opin Drug Saf 2021; 20:123-138. [PMID: 33327811 DOI: 10.1080/14740338.2021.1865911] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Management of patients with acute agitation or aggressive behavior can pose a significant challenge to health-care providers in emergency departments. Areas covered: This article provides a comprehensive review of the pharmacologic properties, efficacy, and safety profiles of select intramuscular (IM) sedative agents (i.e., antipsychotics, benzodiazepines, and ketamine) for rapid tranquilization. Expert opinion: Using antipsychotics and benzodiazepines - whether a single agent or combined - will have similar efficacy in producing sedation. But there are differences in the time to sedation depending on which agent is used. Based upon the available studies, droperidol (5-10 mg IM) and midazolam (5-10 mg IM) have the fastest onset of sedation when either is used as a single agent. When combination therapy is used, using midazolam with an antipsychotic agent, instead of lorazepam, may result in faster sedative effect. QT prolongation and torsades de pointes are uncommon adverse drug effects of antipsychotic administration. Ketamine is often reserved as a second-line agent when antipsychotics and benzodiazepines fail to produce the desired tranquilization. However, ketamine (5 mg/kg IM) is more frequently associated with airway compromise requiring endotracheal intubation. A low-dose of ketamine (2 mg/kg IM) may reduce the risk of airway compromise while providing adequate sedation.
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Affiliation(s)
- Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - James B Leonard
- Maryland Poison Center, University of Maryland School of Pharmacy , Baltimore, MD, USA
| | - Brian N Corwell
- Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - Nicholas J Connors
- Department of Emergency Medicine, HCA Healthcare Trident Medical Center , Charleston, SC, USA
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16
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Amore M, D'Andrea M, Fagiolini A. Treatment of Agitation With Lorazepam in Clinical Practice: A Systematic Review. Front Psychiatry 2021; 12:628965. [PMID: 33692709 PMCID: PMC7937895 DOI: 10.3389/fpsyt.2021.628965] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/19/2021] [Indexed: 12/04/2022] Open
Abstract
Acute agitation is a frequent occurrence in both inpatient and outpatient psychiatric settings, and the use of medication to calm a patient may be warranted to mitigate the situation. Lorazepam is a benzodiazepine that is widely used for management of acute agitation. Despite its widespread use, there is remarkably little clinical evidence for the benefits of lorazepam in acute agitation. We performed a systematic review with focus on lorazepam, including all randomized clinical trials on lorazepam in mental and behavioral disorders, excluding studies on dementia and pediatric patients and in mixed conditions. A total of 11 studies met inclusion criteria, and all were in patients with mental and behavioral disorders. Most trials generally found improvements across a variety of outcomes related to agitation, although there was some disparity if specific outcomes were considered. In the five studies with haloperidol, the combination of lorazepam and haloperidol was superior to either agent alone, but with no differences between monotherapy with the individual agents. In the study comparing lorazepam to olanzapine, olanzapine was superior to lorazepam, and both were superior to placebo. As expected, the safety of lorazepam among the different studies was consistent with its well-characterized profile with dizziness, sedation, and somnolence being the most common adverse events. Based on this structured review, lorazepam can be considered to be a clinically effective means of treating the acutely agitated patient.
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Affiliation(s)
- Mario Amore
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics and Infant-Maternal Science, University of Genoa, Genoa, Italy.,Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Andrea Fagiolini
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
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17
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Mirfazeli FS, Faiz SHR, Shariati B, Rahimzadeh P, Kalantari S. Mental health care for hospitalized COVID-19 patients; an experience from Iran. Med J Islam Repub Iran 2020; 34:162. [PMID: 33816361 PMCID: PMC8004565 DOI: 10.47176/mjiri.34.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Indexed: 11/09/2022] Open
Affiliation(s)
| | - Seyed Hamid Reza Faiz
- Rasoul Akram Hospital Clinical Research Development Center (RCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Behnam Shariati
- Mental Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Poupak Rahimzadeh
- Rasoul Akram Hospital Clinical Research Development Center (RCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Kalantari
- Antimicrobial Resistance Research Center, Iran University of Medical Sciences, Tehran, Iran
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18
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Lao KSJ, Zhao J, Blais JE, Lam L, Wong ICK, Besag FMC, Chang WC, Castle DJ, Chan EW. Antipsychotics and Risk of Neuroleptic Malignant Syndrome: A Population-Based Cohort and Case-Crossover Study. CNS Drugs 2020; 34:1165-1175. [PMID: 33010024 DOI: 10.1007/s40263-020-00767-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Neuroleptic malignant syndrome (NMS) is a rare and acute adverse drug reaction associated with antipsychotic therapy. However, few data on the risk and epidemiology of NMS are available. OBJECTIVES The aim of this study was to ascertain the incidence risk and all-cause mortality of NMS associated with antipsychotic use, and to assess the association of recent antipsychotic exposure and NMS. METHODS We did a population-based study using data from the Hong Kong Hospital Authority's Clinical Data Analysis and Reporting System database. Cases had a first diagnosis of NMS between 1 January 2004 and 30 November 2017. A case-crossover analysis was used to compare antipsychotic exposure 30 days before the diagnosis of NMS (index date) and a reference period 91-120 days before the index date. To adjust for potential time trends in antipsychotic exposure, we sampled from cases to match current cases and future cases, and further adjusted for select medications and acute medical conditions. RESULTS 297,647 patients were prescribed antipsychotics, and the incidence risk of NMS was 0.11%. Of the 336 cases included in the case-crossover analysis, 20 (6%) died within 30 days after the index date; only one case had NMS recorded as the primary cause of death. When compared with the reference period, cases were more frequently prescribed multiple antipsychotics (15.8% vs 26.8%; standardized mean difference [SMD] 0.27) and short-acting injectable antipsychotics (3.6% vs 13.7%; SMD 0.37) during the 30 days prior to the diagnosis of NMS. Odds ratios for antipsychotic exposure in the case-crossover, case-crossover adjusted for time trend, and case-crossover adjusted for time trend and potential confounders analysis were 8.00 (95% confidence interval 3.42-18.69), 5.88 (2.46-14.04), and 4.77 (1.95-11.66). CONCLUSIONS Our results suggest that recent use of antipsychotics is associated with NMS. Although a case-only design inherently controls for confounding by time-invariant factors, residual confounding by acute medical conditions with similar presentations to NMS cannot be fully excluded.
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Affiliation(s)
- Kim S J Lao
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China.,Global Medical Affairs, Merck Research Laboratories, Shanghai, China
| | - Jiaxi Zhao
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China
| | - Joseph Edgar Blais
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China
| | - Lam Lam
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China.,Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Frank M C Besag
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK.,East London NHS Foundation Trust, Bedford, Bedfordshire, UK.,Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Wing Chung Chang
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.,State Key Laboratory of Brain & Cognitive Sciences, The University of Hong Kong, Hong Kong SAR, China
| | - David J Castle
- St Vincent's Hospital, Melbourne, Vic, Australia.,Department of Psychiatry, University of Melbourne, Melbourne, Vic, Australia
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China. .,Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
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19
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Reinert JP, Colunga K, Etuk A, Richardson V, Dunn RL. Management of overdoses of salvia, kratom, and psilocybin mushrooms: a literature review. Expert Rev Clin Pharmacol 2020; 13:847-856. [DOI: 10.1080/17512433.2020.1794811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Justin P. Reinert
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Kayla Colunga
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Alexandria Etuk
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | | | - Rebecca L. Dunn
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
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20
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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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21
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Perrin E, Anand E, Dyachkova Y, Wagner T, Frediani S, Ballerini A. A prospective, observational study of the safety and effectiveness of intramuscular psychotropic treatment in acutely agitated patients with schizophrenia and bipolar mania. Eur Psychiatry 2020; 27:234-9. [DOI: 10.1016/j.eurpsy.2010.04.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Revised: 03/04/2010] [Accepted: 04/04/2010] [Indexed: 11/15/2022] Open
Abstract
AbstractThis naturalistic, observational pan-European study assessed the safety and early effectiveness of intramuscular (IM) psychotropic treatments in patients with acute agitation suffering from schizophrenia or bipolar mania. One thousand nine hundred and forty of 1945 patients completed the 24-hour observation period after initial IM treatment. Patients from 12 European countries were included (mean age 39 years; 58% male, 66% schizophrenia). IM treatment was at the physician's discretion. The primary objective was to describe the acute tolerability of IM psychotropic therapies in clinical practice, with particular emphasis on EPS. At baseline, 68% of the patients received IM monotherapy, with IM olanzapine most commonly prescribed (36%). During the first 24hours, 190 (9.8%) patients experienced EPS. The occurrence of EPS was statistically significantly lower in patients treated with IM olanzapine compared to those treated with other IM psychotropic medications (mainly typical antipsychotics and benzodiazepines): acute dystonia: 1.1%, 95% CI 0.5–2.3 and 2.9%, CI 2.0–4.0; akathisia: 2.3%, CI 1.3–3.7 and 5.5%, CI 4.3–6.9; Parkinsonism: 2.9%, CI 1.8–4.4 and 7.8%, CI 6.4–9.4, respectively. Anticholinergic treatment was given to 12% IM olanzapine versus 31% non-olanzapine treated patients. Acute agitation after 24hours was reduced by 1.68 (95% CI 1.46–1.91) points on the Clinical Global Impression of Severity (CGI-S) in IM olanzapine patients and 1.51 (95% CI 1.30–1.73) points in non-olanzapine patients. Additional psychotropic medication was required for 90% of the patients during the first 24hours of treatment. Results provide naturalistic evidence for low EPS rates and improvement of agitation with IM psychotropic medications during acute states of patients suffering from acute mania or schizophrenia.
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Muir-Cochrane E, Oster C, Gerace A, Dawson S, Damarell R, Grimmer K. The effectiveness of chemical restraint in managing acute agitation and aggression: A systematic review of randomized controlled trials. Int J Ment Health Nurs 2020; 29:110-126. [PMID: 31498960 DOI: 10.1111/inm.12654] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2019] [Indexed: 12/26/2022]
Abstract
One approach to manage people with behaviours of concern including agitated or aggressive behaviours in health care settings is through the use of fast-acting medication, called chemical restraint. Such management often needs to be delivered in crisis situations to patients who are at risk of harm to themselves or others. This paper summarizes the available evidence on the effectiveness and safety of chemical restraint from 21 randomized controlled trials (RCTs) involving 3788 patients. The RCTs were of moderate to high quality and were conducted in pre-hospital, hospital emergency department, or ward settings. Drugs used in chemical restraint included olanzapine, haloperidol, droperidol, risperidol, flunitrazepam, midazolam, promethazine, ziprasidone, sodium valproate, or lorazepam. There was limited comparability between studies in drug choice, combination, dose, method of administration (oral, intramuscular, or intravenous drip), or timing of repeat administrations. There were 31 outcome measures, which were inconsistently reported. They included subjective measures of behaviours, direct measures of treatment effect (time to calm; time to sleep), indirect measures of agitation (staff or patient injuries, duration of agitative or aggressive episodes, subsequent violent episodes), and adverse events. The most common were time to calm and adverse events. There was little clarity about the superiority of any chemical method of managing behaviours of concern exhibited by patients in Emergency Departments or acute mental health settings. Not only is more targeted research essential, but best practice recommendations for such situations requires integrating expert input into the current evidence base.
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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
| | - Adam Gerace
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia.,School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, Queensland, Australia
| | - Suzanne Dawson
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Raechel Damarell
- 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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Shirzad F, Hadi F, Mortazavi SS, Biglari M, Sari HN, Mohammadi Z, Atoofi MK, Shariat SV. First line in psychiatric emergency: pre-hospital emergency protocol for mental disorders in Iran. BMC Emerg Med 2020; 20:19. [PMID: 32178629 PMCID: PMC7074981 DOI: 10.1186/s12873-020-00313-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 02/26/2020] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION This article is a report of designing a rapid and effective guide for paramedics who take care of patients in a pre-hospital setting to answer developing demands. METHODS The relevant literature was reviewed, and the topics were extracted. Then, the extracted items were discussed in an expert panel. Finally, items were discussed in a meeting including emergency technicians and emergency technical assistants to identify implementation problems. RESULTS Important topics for managing psychiatric patients were categorized at three levels: 1) Patient safety and security issues, 2) Patient status assessment and diagnosis, and 3) Patient management (medical, behavioral management, and referral to a treatment center). DISCUSSION This protocol can be a solution to improve emergency technician training. Such summarized protocols can be used for rapid review immediately before exposing a patient with an acute psychiatric condition. Due to specific cultural and different access to medicines in Iran, some issues are different.
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Affiliation(s)
- Fatemeh Shirzad
- Spiritual Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Hadi
- Mental Health Research Center, Department of Psychiatry, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyede Salehe Mortazavi
- Spiritual Health Research Center, Iran University of Medical Sciences, Tehran, Iran
- School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Biglari
- Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hassan Noori Sari
- Deputy of Technical and Operations of the Emergency Organization, Tehran, Iran
| | | | | | - Seyed Vahid Shariat
- Mental Health Research Center, School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Tehran, Iran
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Finucane AM, Jones L, Leurent B, Sampson EL, Stone P, Tookman A, Candy B. Drug therapy for delirium in terminally ill adults. Cochrane Database Syst Rev 2020; 1:CD004770. [PMID: 31960954 PMCID: PMC6984445 DOI: 10.1002/14651858.cd004770.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Delirium is a syndrome characterised by an acute disturbance of attention and awareness which develops over a short time period and fluctuates in severity over the course of the day. It is commonly experienced during inpatient admission in the terminal phase of illness. It can cause symptoms such as agitation and hallucinations and is distressing for terminally ill people, their families and staff. Delirium may arise from any number of causes and treatment should aim to address these causes. When this is not possible, or treatment is unsuccessful, drug therapy to manage the symptoms may become necessary. This is the second update of the review first published in 2004. OBJECTIVES To evaluate the effectiveness and safety of drug therapies to manage delirium symptoms in terminally ill adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO from inception to July 2019, reference lists of retrieved papers, and online trial registries. SELECTION CRITERIA We included randomised controlled trials of drug therapies in any dose by any route, compared to another drug therapy, a non-pharmacological approach, placebo, standard care or wait-list control, for the management of delirium symptoms in terminally ill adults (18 years or older). DATA COLLECTION AND ANALYSIS We independently screened citations, extracted data and assessed risk of bias. Primary outcomes were delirium symptoms; agitation score; adverse events. Secondary outcomes were: use of rescue medication; cognitive status; survival. We applied the GRADE approach to assess the overall quality of the evidence for each outcome and we include eight 'Summary of findings' tables. MAIN RESULTS We included four studies (three new to this update), with 399 participants. Most participants had advanced cancer or advanced AIDS, and mild- to moderate-severity delirium. Meta-analysis was not possible because no two studies examined the same comparison. Each study was at high risk of bias for at least one criterion. Most evidence was low to very low quality, downgraded due to very serious study limitations, imprecision or because there were so few data. Most studies reported delirium symptoms; two reported agitation scores; three reported adverse events with data on extrapyramidal effects; and none reported serious adverse events. 1. Haloperidol versus placebo There may be little to no difference between placebo and haloperidol in delirium symptoms within 24 hours (mean difference (MD) 0.34, 95% confidence interval (CI) -0.07 to 0.75; 133 participants). Haloperidol may slightly worsen delirium symptoms compared with placebo at 48 hours (MD 0.49, 95% CI 0.10 to 0.88; 123 participants with mild- to moderate-severity delirium). Haloperidol may reduce agitation slightly compared with placebo between 24 and 48 hours (MD -0.14, 95% -0.28 to -0.00; 123 participants with mild- to moderate-severity delirium). Haloperidol probably increases extrapyramidal adverse effects compared with placebo (MD 0.79, 95% CI 0.17 to 1.41; 123 participants with mild- to moderate-severity delirium). 2. Haloperidol versus risperidone There may be little to no difference in delirium symptoms with haloperidol compared with risperidone within 24 hours (MD -0.42, 95% CI -0.90 to 0.06; 126 participants) or 48 hours (MD -0.36, 95% CI -0.92 to 0.20; 106 participants with mild- to moderate-severity delirium). Agitation scores and adverse events were not reported for this comparison. 3. Haloperidol versus olanzapine We are uncertain whether haloperidol reduces delirium symptoms compared with olanzapine within 24 hours (MD 2.36, 95% CI -0.75 to 5.47; 28 participants) or 48 hours (MD 1.90, 95% CI -1.50 to 5.30, 24 participants). Agitation scores and adverse events were not reported for this comparison. 4. Risperidone versus placebo Risperidone may slightly worsen delirium symptoms compared with placebo within 24 hours (MD 0.76, 95% CI 0.30 to 1.22; 129 participants); and at 48 hours (MD 0.85, 95% CI 0.32 to 1.38; 111 participants with mild- to moderate-severity delirium). There may be little to no difference in agitation with risperidone compared with placebo between 24 and 48 hours (MD -0.05, 95% CI -0.19 to 0.09; 111 participants with mild- to moderate-severity delirium). Risperidone may increase extrapyramidal adverse effects compared with placebo (MD 0.73 95% CI 0.09 to 1.37; 111 participants with mild- to moderate-severity delirium). 5. Lorazepam plus haloperidol versus placebo plus haloperidol We are uncertain whether lorazepam plus haloperidol compared with placebo plus haloperidol improves delirium symptoms within 24 hours (MD 2.10, 95% CI -1.00 to 5.20; 50 participants with moderate to severe delirium), reduces agitation within 24 hours (MD 1.90, 95% CI 0.90 to 2.80; 52 participants), or increases adverse events (RR 0.70, 95% CI -0.19 to 2.63; 31 participants with moderate to severe delirium). 6. Haloperidol versus chlorpromazine We are uncertain whether haloperidol reduces delirium symptoms compared with chlorpromazine at 48 hours (MD 0.37, 95% CI -4.58 to 5.32; 24 participants). Agitation scores were not reported. We are uncertain whether haloperidol increases adverse events compared with chlorpromazine (MD 0.46, 95% CI -4.22 to 5.14; 24 participants). 7. Haloperidol versus lorazepam We are uncertain whether haloperidol reduces delirium symptoms compared with lorazepam at 48 hours (MD -4.88, 95% CI -9.70 to 0.06; 17 participants). Agitation scores were not reported. We are uncertain whether haloperidol increases adverse events compared with lorazepam (MD -6.66, 95% CI -14.85 to 1.53; 17 participants). 8. Lorazepam versus chlorpromazine We are uncertain whether lorazepam reduces delirium symptoms compared with chlorpromazine at 48 hours (MD 5.25, 95% CI 0.38 to 10.12; 19 participants), or increases adverse events (MD 7.12, 95% CI 1.08 to 15.32; 18 participants). Agitation scores were not reported. SECONDARY OUTCOMES use of rescue medication, cognitive impairment, survival There were insufficient data to draw conclusions or assess GRADE. AUTHORS' CONCLUSIONS We found no high-quality evidence to support or refute the use of drug therapy for delirium symptoms in terminally ill adults. We found low-quality evidence that risperidone or haloperidol may slightly worsen delirium symptoms of mild to moderate severity for terminally ill people compared with placebo. We found moderate- to low-quality evidence that haloperidol and risperidone may slightly increase extrapyramidal adverse events for people with mild- to moderate-severity delirium. Given the small number of studies and participants on which current evidence is based, further research is essential.
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Affiliation(s)
- Anne M Finucane
- Marie Curie Hospice Edinburgh45 Frogston Road WestEdinburghUKEH10 7DR
- University of EdinburghUsher InstituteEdinburghUK
| | - Louise Jones
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | - Baptiste Leurent
- London School of Hygiene and Tropical MedicineDepartment of Medical StatisticsLondonUK
| | - Elizabeth L Sampson
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | - Patrick Stone
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
| | | | - Bridget Candy
- University College LondonMarie Curie Palliative Care Research Department, Division of PsychiatryLondonUK
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Gerdtz M, Yap CY, Daniel C, Knott JC, Kelly P, Braitberg G. Prevalence of illicit substance use among patients presenting to the emergency department with acute behavioural disturbance: Rapid point-of-care saliva screening. Emerg Med Australas 2020; 32:473-480. [PMID: 31927789 DOI: 10.1111/1742-6723.13441] [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: 07/30/2019] [Revised: 11/18/2019] [Accepted: 11/20/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the prevalence of illicit substance use among patients presenting to one ED with acute behavioural disturbance using point-of-care saliva testing. METHODS A prospective observational study was conducted. Acute behavioural disturbance was defined as any episode requiring a security response for unarmed threat (Code Grey). The setting was a single ED and tertiary referral centre located in metropolitan Australia. Participants were adults presenting to the ED requiring a Code Grey. Saliva was analysed for meth/amphetamine, cannabis, cocaine and opiates using a rapid point-of-care test. Self-reported drug use was recorded at the time of saliva testing. Data collection occurred between August 2016 and March 2017. RESULTS There were 229 valid saliva samples. Participants were, on average, 35 years (range 18-72) and male (168/229; 73%). Forty percent (95% confidence interval 34-47) of samples tested positive, with 20% positive for two or more substances. Meth/amphetamines was detected in 92% of positive samples, 17% of samples tested positive for opiates, 8% for cannabis and 7% for cocaine. Among participants, 19% self-reported current substance use and 20% reported using illicit substances within the past 24 h. CONCLUSIONS The prevalence of illicit substance use among this cohort was 40%. Self-reporting was unreliable. Point-of-care saliva testing is feasible. Early identification of harmful drug use may assist clinical decision making in selected or undifferentiated cases and provide an opportunity to implement harm minimisation strategies and make referrals.
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Affiliation(s)
- Marie Gerdtz
- Department of Nursing, Melbourne School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Celene Yl Yap
- Department of Nursing, Melbourne School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Cathy Daniel
- Department of Nursing, Melbourne School of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Jonathan C Knott
- Emergency Department, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Peter Kelly
- NorthWestern Mental Health, Melbourne Health, Melbourne, Victoria, Australia
| | - George Braitberg
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.,Strategy, Quality and Improvement, Melbourne Health, Melbourne, Victoria, Australia
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Yap CYL, Taylor DM, Kong DCM, Knott JC, Taylor SE. Risk Factors for Sedation-related Events During Acute Agitation Management in the Emergency Department. Acad Emerg Med 2019; 26:1135-1143. [PMID: 31265756 DOI: 10.1111/acem.13826] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/04/2019] [Accepted: 06/25/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective was to describe the incidence, nature, and risk factors for adverse events (AEs) among patients who received parenteral sedation for acute agitation in an emergency department (ED) setting. METHODS We undertook a prospective observational study and a clinical trial of parenteral sedation for the management of acute agitation. We included agitated adult patients who required parenteral sedation from 2014 to 2017 in 12 Australian EDs, excluding those with incomplete information or aged under 18 years. The primary outcome was the number of patients who experienced at least one AE. Multivariable logistic regression was used to determine factors associated with AEs. RESULTS A total of 904 patients were included in the analyses (62.3% male; median age = 34 years, range = 18 to 95 years). Of these, 144 (15.9%) patients experienced at least one AE. The most common AEs were oxygen desaturation (7.4%), airway obstruction (3.6%), bradycardia (1.9%), hypotension (1.7%), and prolonged QTc interval (1.3%). No deaths or serious AEs were reported. The following factors had an increased adjusted odds ratio (OR) for experiencing an AE: age 65 years and older (OR = 2.8, 95% confidence interval [CI] = 1.2 to 7.2), more than one type of parenteral sedation administered within 60 minutes (OR = 2.1, 95% CI = 1.4 to 3.1), and alcohol intoxication (OR = 1.8, 95% CI = 1.2 to 2.6). CONCLUSIONS Sedation-related AEs are common, especially respiratory events. Elderly patients, sedation with multiple sedatives within 60 minutes, and alcohol intoxication increased the risk.
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Affiliation(s)
- Celene Y. L. Yap
- Faculty of Medicine Dentistry and Health SciencesThe University of Melbourne ParkvilleVictoria
- Centre for Integrated Critical Care Department of Medicine and Radiology Melbourne Medical School The University of Melbourne Parkville Victoria
- Emergency Department The Royal Melbourne Hospital Parkville Victoria
- Centre for Medicine Use and Safety Monash University Parkville Victoria
| | - David McD. Taylor
- Faculty of Medicine Dentistry and Health SciencesThe University of Melbourne ParkvilleVictoria
- Centre for Integrated Critical Care Department of Medicine and Radiology Melbourne Medical School The University of Melbourne Parkville Victoria
- Emergency DepartmentAustin Health HeidelbergVictoria
| | - David C. M. Kong
- Faculty of Medicine Dentistry and Health SciencesThe University of Melbourne ParkvilleVictoria
- Centre for Medicine Use and Safety Monash University Parkville Victoria
- Pharmacy Department Ballarat Health Services Ballarat Victoria Australia
| | - Jonathan C. Knott
- Faculty of Medicine Dentistry and Health SciencesThe University of Melbourne ParkvilleVictoria
- Centre for Integrated Critical Care Department of Medicine and Radiology Melbourne Medical School The University of Melbourne Parkville Victoria
- Emergency Department The Royal Melbourne Hospital Parkville Victoria
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Connors NJ, Alsakha A, Larocque A, Hoffman RS, Landry T, Gosselin S. Antipsychotics for the treatment of sympathomimetic toxicity: A systematic review. Am J Emerg Med 2019; 37:1880-1890. [DOI: 10.1016/j.ajem.2019.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 12/19/2018] [Accepted: 01/02/2019] [Indexed: 11/24/2022] Open
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Yap CYL, Taylor DM, Kong DCM, Knott JC, Taylor SE, Graudins A, Keijzers G, Kulawickrama S, Thom O, Lawton L, Furyk J, Finucci D, Holdgate A, Watkins G, Jordan P. Management of behavioural emergencies: a prospective observational study in Australian emergency departments. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Celene Y. L. Yap
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Emergency Department The Royal Melbourne Hospital Melbourne Australia
- Centre for Medicine Use and Safety Monash University Melbourne Australia
| | - David McD. Taylor
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Emergency Department Austin Health Melbourne Australia
| | - David C. M. Kong
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Centre for Medicine Use and Safety Monash University Melbourne Australia
- Pharmacy Department Ballarat Health Services Ballarat Australia
| | - Jonathan C. Knott
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Emergency Department The Royal Melbourne Hospital Melbourne Australia
| | | | - Andis Graudins
- Emergency Department Monash Health Melbourne Australia
- Department of Medicine, Clinical Sciences at Monash Health Monash University Melbourne Australia
| | - Gerben Keijzers
- Emergency Department Gold Coast University Hospital Gold Coast Australia
- School of Medicine Bond University Gold Coast Australia
- School of Medicine Griffith University Gold Coast Australia
| | | | - Ogilvie Thom
- Emergency Department Nambour General Hospital Nambour Australia
| | - Luke Lawton
- Emergency Department The Townsville Hospital Townsville Australia
| | - Jeremy Furyk
- Emergency Department The Townsville Hospital Townsville Australia
| | - Daniel Finucci
- Emergency Department Liverpool Hospital Sydney Australia
| | - Anna Holdgate
- Emergency Department Liverpool Hospital Sydney Australia
| | - Gina Watkins
- Emergency Department Sutherland Hospital Sydney Australia
| | - Peter Jordan
- Emergency Department The Northern Hospital Melbourne Australia
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Clinical Outcomes in Patients Taking Inhaled Loxapine, Haloperidol, or Ziprasidone in the Emergency Department. Clin Neuropharmacol 2019; 42:23-26. [PMID: 30747748 PMCID: PMC6426345 DOI: 10.1097/wnf.0000000000000325] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Our objective was to compare outcomes of discharge disposition, need for additional medications, and restraint use for patients who received inhaled loxapine compared with patients receiving traditional antipsychotic drugs in the emergency department (ED). METHODS A retrospective chart review was conducted on all patients who presented to the ED with agitation and received antipsychotic therapy, including loxapine, ziprasidone, or haloperidol from December 1, 2014, through October 31, 2016. RESULTS The mean time from physician assignment to medical clearance was 7.9 hours for patients treated with inhaled loxapine versus 10.3 hours for controls (P < 0.01). Those who received inhaled loxapine were given significantly less benzodiazepines as additional rescue medications as compared with other antipsychotic medications (P < 0.01, 35.2% vs 65.1%). Additionally, restraints were utilized less frequently in the loxapine group (P < 0.01, 1.8% vs 19.8%). CONCLUSIONS Treating patients with agitation due to psychotic episodes in an ED setting with inhaled loxapine versus haloperidol or ziprasidone was associated with significantly improved treatment outcomes, suggesting that inhaled loxapine may be a more effective and rapid treatment option.
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Management of Violence and Aggression in Emergency Environment; a Narrative Review of 200 Related Articles. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2019; 3:e7. [PMID: 31172118 PMCID: PMC6548084 DOI: 10.22114/ajem.v0i0.117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Context: The aim of this study is to reviewing various approaches for dealing with agitated patients in emergency department (ED) including of chemical and physical restraint methods. Evidence acquisition: This review was conducted by searching “Violence,” “Aggression,” and “workplace violence” keywords in these databases: PubMed, Scopus, EmBase, ScienceDirect, Cochrane Database, and Google Scholar. In addition to using keywords for finding the papers, the related article capability was used to find more papers. From the found papers, published papers from 2005 to 2018 were chosen to enter the paper pool for further review. Results: Ultimately, 200 papers were used in this paper to conduct a comprehensive review regarding violence management in ED. The results were categorized as prevention, verbal methods, pharmacological interventions and physical restraint. Conclusion: In this study various methods of chemical and physical restraint methods were reviewed so an emergency medicine physician be aware of various available choices in different clinical situations for agitated patients.
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Treatment and Outcomes in Adult Designated Psychiatric Emergency Service Units. Crit Care Nurs Clin North Am 2019; 31:225-236. [DOI: 10.1016/j.cnc.2019.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Legrand G, Guiguet-Auclair C, Viennet H, Aumeran C, Reynaud D, Badrikian L, Debost-Legrand A. Nurses' practices in the preparation and administration of intramuscular injections in mental health: A cross-sectional study. J Clin Nurs 2019; 28:3310-3317. [PMID: 31070824 DOI: 10.1111/jocn.14909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 04/25/2019] [Accepted: 05/02/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Intramuscular injections (IMIs) remain a frequent practice in mental health. Few studies have examined the issue of nurses' practices concerning IMI in this domain, and none considered specifically hygiene. Finally, no study appears to have looked at emergency situations and their possible influence on practices. The principal objective of our study was to assess the practices associated with IMI in mental health, especially the hygiene-related practices. The secondary objectives were as follows: 1) to assess the practices for the preparation and administration of IMI in mental health for criteria other than hygiene and 2) to determine whether professional experience and emergency situations influence these practices. DESIGN Single-centre cross-sectional study in a psychiatric Hospital and adherence to the STROBE guidelines. METHODS The participating nurses all worked with inpatients, and all volunteered for the study. A self-administered questionnaire was sent to all participants. The questionnaire included questions about knowledge and practices associated with IMI, some considered in two different situations: emergencies and planned injections. The distribution of the responses was tested by the chi-squared test or Fisher's exact test, as appropriate, or by McNemar's chi-squared test or Friedman's nonparametric chi-squared test for matched data. RESULTS Response rate was 48.6%. Overall, 81% of nurses reported correct handwashing before preparation, 87.5% responded that the dorsogluteal site is currently recommended for IMI, and 74.6% that they did not know the "Z track" technique. In planned injections, 58.7% reported that the choice of needle was determined, at least in part, by the patient's body mass index. In emergency situations, adherence to guidelines was less frequent for all types of practices. CONCLUSIONS This study shows the need to improve practices for the frequently used procedure of IMI among mental health nurses. RELEVANCE TO CLINICAL PRACTICE Better professional education appears necessary to develop optimal practices, especially in emergency situations.
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Affiliation(s)
- Guillaume Legrand
- Association Hospitalière Sainte Marie, Centre Hospitalier Sainte Marie Clermont-Ferrand, Clermont-Ferrand cedex 1, France
| | - Candy Guiguet-Auclair
- CNRS, CHU de Clermont-Ferrand, SIGMA, Institut Pascal, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Hervé Viennet
- Association Hospitalière Sainte Marie, Centre Hospitalier Sainte Marie Clermont-Ferrand, Clermont-Ferrand cedex 1, France
| | - Claire Aumeran
- Service d'Hygiène Hospitalière, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Dominique Reynaud
- Association Hospitalière Sainte Marie, Centre Hospitalier Sainte Marie Clermont-Ferrand, Clermont-Ferrand cedex 1, France
| | - Laurence Badrikian
- Service d'Hygiène Hospitalière, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Anne Debost-Legrand
- CNRS-UMR 6602, Institut Pascal, Axe TGI, équipe PEPRADE, Université Clermont Auvergne, Clermont-Ferrand, France.,Pôle Femme Et Enfant, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
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Lakstygal AM, Kolesnikova TO, Khatsko SL, Zabegalov KN, Volgin AD, Demin KA, Shevyrin VA, Wappler-Guzzetta EA, Kalueff AV. DARK Classics in Chemical Neuroscience: Atropine, Scopolamine, and Other Anticholinergic Deliriant Hallucinogens. ACS Chem Neurosci 2019; 10:2144-2159. [PMID: 30566832 DOI: 10.1021/acschemneuro.8b00615] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Anticholinergic drugs based on tropane alkaloids, including atropine, scopolamine, and hyoscyamine, have been used for various medicinal and toxic purposes for millennia. These drugs are competitive antagonists of acetylcholine muscarinic (M-) receptors that potently modulate the central nervous system (CNS). Currently used clinically to treat vomiting, nausea, and bradycardia, as well as alongside other anesthetics to avoid vagal inhibition, these drugs also evoke potent psychotropic effects, including characteristic delirium-like states with hallucinations, altered mood, and cognitive deficits. Given the growing clinical importance of anti-M deliriant hallucinogens, here we discuss their use and abuse, clinical importance, and the growing value in preclinical (experimental) animal models relevant to modeling CNS functions and dysfunctions.
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Affiliation(s)
- Anton M. Lakstygal
- Graduate School of Biology, St. Petersburg State University, St. Petersburg 199034, Russia
| | | | | | | | - Andrey D. Volgin
- Institute of Experimental Medicine, Almazov National Medical Research Centre, Ministry of Healthcare of Russian Federation, St. Petersburg 197341, Russia
| | - Konstantin A. Demin
- Institute of Experimental Medicine, Almazov National Medical Research Centre, Ministry of Healthcare of Russian Federation, St. Petersburg 197341, Russia
- Institute of Translational Biomedicine (ITBM), St. Petersburg State University, St. Petersburg 199034, Russia
| | | | | | - Allan V. Kalueff
- School of Pharmacy, Southwest University, Chongqing 400700, China
- Anatomy and Physiology Laboratory, Ural Federal University, Ekaterinburg 620002, Russia
- Laboratory of Biological Psychiatry, ITBM, St Petersburg State University, St. Petersburg 199034, Russia
- Scientific Research Institute of Physiology and Basic Medicine, Novosibirsk 630117, Russia
- Granov Russian Scientific Center of Radiology and Surgical Technologies, Ministry of Healthcare of Russian Federation, St. Petersburg 197758, Russia
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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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Larsen JB, Stunes AK, Iversen VC, Vaaler AE, Reitan SK. Cytokines in Relation to Motor Activity in an Acute Psychiatric Population. Front Psychiatry 2019; 10:920. [PMID: 31920766 PMCID: PMC6930926 DOI: 10.3389/fpsyt.2019.00920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/19/2019] [Indexed: 12/03/2022] Open
Abstract
Background: Deviations in motor activity are important clinical features of several psychiatric disorders in an acute state. Immune activity is associated with several psychiatric disorders and may affect motor activity. We aimed to examine the association between immune activity measured as serum levels of cytokines and deviations in motor activity, in an acute psychiatric setting. Methods: Data on motor activity and immune markers were available on 277 patients admitted to an acute psychiatric inpatient department. The degree of increased or decreased motor activity was clinically assessed at admission. Serum concentrations of the following immune markers were measured: interleukin (IL) -1β, IL-4, IL-6, IL-10, tumor necrosis factor (TNF) -α, interferon (IFN) -γ, and transforming growth factor (TGF) -β. Results: Scores of increased motor activity were negatively correlated with IFN-γ (rho = -0.128, p = 0.033) in an acute psychiatric population. There was also a trend towards an association between motor activity and TGF-β (rho = 0.118, p = 0.050). In a multiple-linear-regression model correcting for age, gender, and body-mass index (BMI, kg/m2), the association did not remain significant. No significant correlations between motor retardation and circulating cytokines were found. Conclusions: After adjustment for potential confounders our study did not reveal any significant association between cytokines and motor activity. However, there is an indication of increased Th17 and decreased Th1 responses in relation to increased motor activity in line with the few previous reports in the field. The phenomenon however needs further exploration.
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Affiliation(s)
- Jeanette Brun Larsen
- Division of Mental Health Care, St. Olav's University Hospital, Trondheim, Norway.,Department of Mental Health, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Astrid Kamilla Stunes
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway.,Medical Clinic, St. Olav's University Hospital, Trondheim, Norway
| | - Valentina Cabral Iversen
- Division of Mental Health Care, St. Olav's University Hospital, Trondheim, Norway.,Department of Mental Health, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Arne Einar Vaaler
- Division of Mental Health Care, St. Olav's University Hospital, Trondheim, Norway.,Department of Mental Health, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Solveig Klæbo Reitan
- Division of Mental Health Care, St. Olav's University Hospital, Trondheim, Norway.,Department of Mental Health, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
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Page CB, Parker LE, Rashford SJ, Isoardi KZ, Isbister GK. A Prospective Study of the Safety and Effectiveness of Droperidol in Children for Prehospital Acute Behavioral Disturbance. PREHOSP EMERG CARE 2018; 23:519-526. [PMID: 30380965 DOI: 10.1080/10903127.2018.1542473] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Study objective: Although uncommon, children (<16 years) with acute behavioral disturbance are a significant issue for emergency medical service providers. In this study, we aimed to investigate the safety and effectiveness of droperidol in children with prehospital acute behavioral disturbance. Methods: This was a prospective observational study over 1 year investigating the use of droperidol (0.1-0.2 mg/kg) for children (< 16 years) with acute behavioral disturbance. Inclusion criteria for acute behavioral disturbance were defined by a sedation assessment tool score of ≥2 determined by the attending paramedic. The primary outcome was the proportion of adverse effects (need for airway intervention, oxygen saturation <90% and/or respiratory rate <12, systolic blood pressure <90 mmHg, sedation assessment tool score of -3 and dystonic reactions). Secondary outcomes included time to sedation (sedation assessment tool score decreased by 2 or more, or a score of zero), requirement for additional sedation, failure to sedate and proportion of sedation success defined as the number of patients successfully sedated who did not suffer any adverse events or receive additional sedation. Results: There were 96 patients (males 51 [53%], median age 14 years [range 7-15 years]) who presented on 102 occasions over the one year study period. Self-harm and/or harm to others was the commonest (74/105 [70%]) cause of acute behavioral disturbance followed by alcohol (16/105 [15%]). There were 9 adverse events in 8 patients (8/102 [8%]; 95% confidence intervals [CI]: 3-13%) Five patients had hypotension, all asymptomatic and only one required treatment; 2 dystonic reactions managed with benztropine and one patient with respiratory depression. Median time to sedation was 14 min (interquartile range (IQR): 10-20 min; range: 3-85 min). There was no requirement for prehospital additional sedation (0/102 [0%]; 95% CI: 0-4%) and additional sedation in the first hour of arrival to hospital was required by 4 patients (4/102 [4%]; 95% CI: 1-10%). Overall successful sedation was achieved in 89 (87%) patients. Conclusions: The use of droperidol in children for acute behavioral disturbance in the prehospital setting is both safe and effective.
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Barbic D, Andolfatto G, Grunau B, Scheuermeyer FX, MacEwan W, Honer WG, Wong H, Barbic SP. Rapid agitation control with ketamine in the emergency department (RACKED): a randomized controlled trial protocol. Trials 2018; 19:651. [PMID: 30477544 PMCID: PMC6258312 DOI: 10.1186/s13063-018-2992-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 10/16/2018] [Indexed: 01/26/2023] Open
Abstract
Background The rapid control of patients presenting to the emergency department (ED) with psychomotor agitation and violent behavior is paramount for the safety of patients and ED staff. The use of intramuscular (IM) ketamine in the pre-hospital and ED settings has demonstrated promising preliminary results to provide rapid and safe behavioral control. A prospective, randomized controlled trial is required to measure the potential superiority of IM ketamine compared to current standard care (IM benzodiazepines plus antipsychotics). Methods This will be a parallel, prospective, randomized, controlled trial of 5 mg/kg IM ketamine compared to a combination of 5 mg IM midazolam and 5 mg IM haloperidol. The study will enroll approximately 184 patients, randomized equally to two study arms. There will be one study visit during which study medication will be administered and assessments will be completed. A follow-up safety visit will occur on day 3. The primary objective of this study is to compare IM ketamine to a combination of IM midazolam and haloperidol with regards to the time required for adequate behavioral control, in minutes, in patients presenting to the ED with psychomotor agitation and violent behavior, as measured by the Richmond Agitation-Sedation Scale (RASS). Discussion We present a novel study to determine whether ketamine is a rapid and safe option, compared to a combination of midazolam and haloperidol for the sedation of patients presenting to the ED with psychomotor agitation and violent behavior. To our knowledge, this study is the first randomized controlled trial to compare ketamine to current standard care for this indication. We have attempted to address numerous logistical issues with the design of this study including a waiver of consent, ensuring adequate blinding of outcome assessors, patient enrolment, and data monitoring. Trial registration Clinicaltrials.gov, NCT03375671. Registered on 18 December 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2992-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David Barbic
- Department of Emergency Medicine, St Paul's Hospital, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada. .,Centre for Health Evaluation Outcome Sciences, Vancouver, BC, Canada.
| | - Gary Andolfatto
- Department of Emergency Medicine, Lion's Gate Hospital, 231 15th St E, North Vancouver, BC, Canada
| | - Brian Grunau
- Department of Emergency Medicine, St Paul's Hospital, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada.,Centre for Health Evaluation Outcome Sciences, Vancouver, BC, Canada
| | - Frank X Scheuermeyer
- Department of Emergency Medicine, St Paul's Hospital, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada.,Centre for Health Evaluation Outcome Sciences, Vancouver, BC, Canada
| | - William MacEwan
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - William G Honer
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Hubert Wong
- School of Public Health and Epidemiology, University of British Columbia, Vancouver, BC, Canada.,Centre for Health Evaluation Outcome Sciences, Vancouver, BC, Canada
| | - Skye P Barbic
- Department of Occupational Science and Occupational Therapy, Vancouver, BC, Canada.,Centre for Health Evaluation Outcome Sciences, Vancouver, BC, Canada
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Hirano Y. Risk of Extrapyramidal Syndromes Associated With Psychotropic Polypharmacy. Ther Innov Regul Sci 2018. [DOI: 10.1177/2168479018808248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Yoko Hirano
- Department of Clinical Medicine (Pharmaceutical Medicine), Graduate School of Pharmaceutical Sciences, Kitasato University, Minato-ku, Tokyo, Japan
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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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San L, Estrada G, Oudovenko N, Montañés F, Dobrovolskaya N, Bukhanovskaya O, Popov M, Vieta E. PLACID study: A randomized trial comparing the efficacy and safety of inhaled loxapine versus intramuscular aripiprazole in acutely agitated patients with schizophrenia or bipolar disorder. Eur Neuropsychopharmacol 2018; 28:710-718. [PMID: 29724638 DOI: 10.1016/j.euroneuro.2018.03.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 02/13/2018] [Accepted: 03/12/2018] [Indexed: 10/17/2022]
Abstract
The aim of the study was to investigate the efficacy and safety of inhaled loxapine compared with the intramuscular (IM) antipsychotic aripiprazole in acutely agitated patients with schizophrenia or bipolar I disorder. PLACID was an assessor-blind, parallel-group trial conducted in 23 centres in the Czech Republic, Germany, Spain, and Russia. Patients (aged 18-65 years) diagnosed with schizophrenia or bipolar I disorder experiencing acute agitation (Clinical Global Impression [CGI]-Severity score ≥ 4) while hospitalized or attending an emergency room were randomized to receive up to two doses of inhaled loxapine 9.1 mg or IM aripiprazole 9.75 mg (≥ 2 h between doses) during the 24-h study period. The primary efficacy endpoint was time to response (CGI-Improvement score 1 [very much improved] or 2 [much improved]). The primary analysis included randomized patients who provided informed consent (full analysis set [FAS]); the safety analysis included all patients who received study medication. The FAS comprised 357 patients (enrolled December 2, 2014 - October 31, 2016). The between-treatment difference in median time to CGI-Improvement response was 10 min (95% CI 0.0-30.0); p = 0.0005) in favour of inhaled loxapine (median [95% CI]: 50 min [30.0-50.0] vs 60 min [50.0-90.0] with IM aripiprazole); the difference was significant at 10 min (responders: 14% [loxapine] vs 4% [aripiprazole]; p = 0.001). There were no safety issues. Inhaled loxapine reduced agitation faster than IM aripiprazole, supporting its use as a first-line option for managing acute agitation in patients with schizophrenia or bipolar disorder.
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Affiliation(s)
- Luis San
- Parc Sanitari Sant Joan de Deu, CIBERSAM, Barcelona, Spain.
| | | | | | | | | | - Olga Bukhanovskaya
- Treatment and Rehabilitology Scientific Center "Phoenix", Rostov on Don, Russia
| | - Mikhail Popov
- City Psychiatric Hospital No. 3, Bekhterev Psychoneurological Research Institute, Sankt Peterburg, Russia
| | - Eduard Vieta
- Hospital Clínic, Institute of Neuroscience, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Spain
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Højlund M, Høgh L, Bojesen AB, Munk-Jørgensen P, Stenager E. Use of antipsychotics and benzodiazepines in connection to minimising coercion and mechanical restraint in a general psychiatric ward. Int J Soc Psychiatry 2018; 64:258-265. [PMID: 29480051 DOI: 10.1177/0020764018760650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Decrease in coercive measures can lead to increased exposure to antipsychotics and benzodiazepines. This is not desirable as these drugs are associated with harmful side effects and reduced life expectancy. AIM To quantify and compare the use of antipsychotic and anxiolytic medications in connection with the implementation of a programme to reduce coercion and restraint. METHODS Observational study in a general psychiatric ward comparing psychopharmacological treatment after implementation of non-pharmacological interventions to reduce coercion and mechanical restraint with a historical reference cohort from the same ward. RESULTS Data from 101 admissions after implementation of interventions were compared with data from 85 admissions in a historical reference cohort. Mean defined daily doses of antipsychotics, benzodiazepines or the total amount of both showed no difference before and after implementation of the programme. Standardised regression coefficients (β) from a mixed effects linear regression model, adjusted for age, gender, length of admission, involuntary admission and history of substance abuse showed that neither total dose of antipsychotics (adjusted β: .05, 95% confidence interval (CI): -0.20 to 0.31), total dose of benzodiazepines (adjusted β: -.13, 95%CI: -.42 to 0.16) nor total amount of both drugs (adjusted β: .00, 95%CI: -.26 to 0.21) increased after implementation. CONCLUSION Decrease in coercive measures from 2013 to 2016 has not lead to significant increases in the use of antipsychotic medication or benzodiazepines. The interventions are useful in establishing restraint-free wards, and careful monitoring of the psychopharmacological treatment is important for patient safety.
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Affiliation(s)
- Mikkel Højlund
- 1 Department of Psychiatry Aabenraa, Mental Health Services Region of Southern Denmark, Aabenraa, Denmark.,2 Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lene Høgh
- 1 Department of Psychiatry Aabenraa, Mental Health Services Region of Southern Denmark, Aabenraa, Denmark
| | - Anders Bo Bojesen
- 1 Department of Psychiatry Aabenraa, Mental Health Services Region of Southern Denmark, Aabenraa, Denmark
| | - Povl Munk-Jørgensen
- 3 Department of Psychiatry Odense, Mental Health Services Region of Southern Denmark, Odense, Denmark.,4 Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Elsebeth Stenager
- 1 Department of Psychiatry Aabenraa, Mental Health Services Region of Southern Denmark, Aabenraa, Denmark.,2 Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Evidence-Based Review of Pharmacotherapy for Acute Agitation. Part 1: Onset of Efficacy. J Emerg Med 2018; 54:364-374. [DOI: 10.1016/j.jemermed.2017.10.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 09/28/2017] [Accepted: 10/11/2017] [Indexed: 11/22/2022]
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Schleifer JJ. Management of acute agitation in psychosis: an evidence-based approach in the USA. ACTA ACUST UNITED AC 2018. [DOI: 10.1192/apt.bp.109.007310] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummaryAgitation in psychiatric settings, particularly in psychosis, presents a staggering challenge for clinicians, who must both manage the patient's acute symptoms and simultaneously make an accurate diagnosis. Too often, the management of the former confounds the latter. Patients are very often sedated medically, which masks their underlying condition, rendering accurate diagnosis delayed and inherently difficult. Significant data are available regarding both pharmacological and non-pharmacological interventions for agitation that maximise symptom control while minimising confounding side-effects. In this article, a review of the historical evolution of agitation management in psychotic illness is presented, followed by an evidence-based clinical guideline for managing agitation in psychosis in the USA.
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Martínez-Raga J, Amore M, Di Sciascio G, Florea RI, Garriga M, Gonzalez G, Kahl KG, Karlsson PA, Kuhn J, Margariti M, Pacciardi B, Papageorgiou K, Pompili M, Rivollier F, Royuela Á, Safont G, Scharfetter J, Skagen B, Tajima-Pozo K, Vidailhet P. 1st International Experts' Meeting on Agitation: Conclusions Regarding the Current and Ideal Management Paradigm of Agitation. Front Psychiatry 2018; 9:54. [PMID: 29535649 PMCID: PMC5835036 DOI: 10.3389/fpsyt.2018.00054] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Agitation is a heterogeneous concept without a uniformly accepted definition, however, it is generally considered as a state of cognitive and motor hyperactivity characterized by excessive or inappropriate motor or verbal activity with marked emotional arousal. Not only the definition but also other aspects of agitated patients' care are still unsolved and need consensus and improvement. To help the discussion about agitation among experts and improve the identification, management, and treatment of agitation, the 1st International Experts' Meeting on Agitation was held in October 2016 in Madrid. It was attended by 20 experts from Europe and Latin America with broad experience in the clinical management of agitated patients. The present document summarizes the key conclusions of this meeting and highlights the need for an updated protocol of agitation management and treatment, the promotion of education and training among healthcare professionals to improve the care of these patients and the necessity to generate clinical data of agitated episodes.
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Affiliation(s)
- José Martínez-Raga
- Hospital Universitario Doctor Peset, University of Valencia & CEU Cardenal Herrera University, Valencia, Spain
| | | | - Guido Di Sciascio
- Azienda Ospedaliero Universitaria "Consorziale Policlinico" di Bari, Bari, Italy
| | | | | | - Gabriel Gonzalez
- Hospital de Emergencias Psiquiátricas Torcuato de Alvear, Buenos Aires, Argentina
| | - Kai G Kahl
- Medizinische Hochschule, Hannover, Germany
| | | | - Jens Kuhn
- Johanniter Krankenhaus, Evangelisches Klinikum Niederrhein, Oberhausen, Germany
| | - Maria Margariti
- Medical School of Athens, National and Kapodistrian University of Athens, Eginition Hospital, Athens, Greece
| | | | | | | | | | - Ángel Royuela
- Complejo asistencial Universitario de Palencia, Palencia, Spain
| | - Gemma Safont
- Hospital Universitari Mútua Terrassa, Universitat de Barcelona, Barcelona, Spain
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Zaman H, Sampson SJ, Beck AL, Sharma T, Clay FJ, Spyridi S, Zhao S, Gillies D. Benzodiazepines for psychosis-induced aggression or agitation. Cochrane Database Syst Rev 2017; 12:CD003079. [PMID: 29219171 PMCID: PMC6486117 DOI: 10.1002/14651858.cd003079.pub4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Acute psychotic illness, especially when associated with agitated or violent behaviour, can require urgent pharmacological tranquillisation or sedation. In several countries, clinicians often use benzodiazepines (either alone or in combination with antipsychotics) for this outcome. OBJECTIVES To examine whether benzodiazepines, alone or in combination with other pharmacological agents, is an effective treatment for psychosis-induced aggression or agitation when compared with placebo, other pharmacological agents (alone or in combination) or non-pharmacological approaches. SEARCH METHODS We searched the Cochrane Schizophrenia Group's register (January 2012, 20 August 2015 and 3 August 2016), inspected reference lists of included and excluded studies, and contacted authors of relevant studies. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing benzodiazepines alone or in combination with any antipsychotics, versus antipsychotics alone or in combination with any other antipsychotics, benzodiazepines or antihistamines, for people who were aggressive or agitated due to psychosis. DATA COLLECTION AND ANALYSIS We reliably selected studies, quality assessed them and extracted data. For binary outcomes, we calculated standard estimates of risk ratio (RR) and their 95% confidence intervals (CI) using a fixed-effect model. For continuous outcomes, we calculated the mean difference (MD) between groups. If there was heterogeneity, this was explored using a random-effects model. We assessed risk of bias and created a 'Summary of findings' table using GRADE. MAIN RESULTS Twenty trials including 695 participants are now included in the review. The trials compared benzodiazepines or benzodiazepines plus an antipsychotic with placebo, antipsychotics, antihistamines, or a combination of these. The quality of evidence for the main outcomes was low or very low due to very small sample size of included studies and serious risk of bias (randomisation, allocation concealment and blinding were not well conducted in the included trials, 30% of trials (six out of 20) were supported by pharmaceutical institutes). There was no clear effect for most outcomes.Benzodiazepines versus placeboOne trial compared benzodiazepines with placebo. There was no difference in the number of participants sedated at 24 hours (very low quality evidence). However, for the outcome of global state, clearly more people receiving placebo showed no improvement in the medium term (one to 48 hours) (n = 102, 1 RCT, RR 0.62, 95% CI 0.40 to 0.97, very low quality evidence). Benzodiazepines versus antipsychoticsWhen compared with haloperidol, there was no observed effect for benzodiazepines for sedation by 16 hours (n = 434, 8 RCTs, RR 1.13, 95% CI 0.83 to 1.54, low quality evidence). There was no difference in the number of participants who had not improved in the medium term (n = 188, 5 RCTs, RR 0.89, 95% CI 0.71 to 1.11, low quality evidence). However, one small study found fewer participants improved when receiving benzodiazepines compared with olanzapine (n = 150, 1 RCT, RR 1.84, 95% CI 1.06 to 3.18, very low quality evidence). People receiving benzodiazepines were less likely to experience extrapyramidal effects in the medium term compared to people receiving haloperidol (n = 233, 6 RCTs, RR 0.13, 95% CI 0.04 to 0.41, low quality evidence).Benzodiazepines versus combined antipsychotics/antihistaminesWhen benzodiazepine was compared with combined antipsychotics/antihistamines (haloperidol plus promethazine), there was a higher risk of no improvement in people receiving benzodiazepines in the medium term (n = 200, 1 RCT, RR 2.17, 95% CI 1.16 to 4.05, low quality evidence). However, for sedation, the results were controversial between two groups: lorazepam may lead to lower risk of sedation than combined antipsychotics/antihistamines (n = 200, 1 RCT, RR 0.91, 95% CI 0.84 to 0.98, low quality evidence); while, midazolam may lead to higher risk of sedation than combined antipsychotics/antihistamines (n = 200, 1 RCT, RR 1.13, 95% CI 1.04 to 1.23, low quality evidence).Other combinationsData comparing benzodiazepines plus antipsychotics versus benzodiazepines alone did not yield any results with clear differences; all were very low quality evidence. When comparing combined benzodiazepines/antipsychotics (all studies compared haloperidol) with the same antipsychotics alone (haloperidol), there was no difference between groups in improvement in the medium term (n = 185, 4 RCTs, RR 1.17, 95% CI 0.93 to 1.46, low quality evidence), but sedation was more likely in people who received the combination therapy (n = 172, 3 RCTs, RR 1.75, 95% CI 1.14 to 2.67,very low quality evidence). Only one study compared combined benzodiazepine/antipsychotics with antipsychotics; however, this study did not report our primary outcomes. One small study compared combined benzodiazepines/antipsychotics with combined antihistamines/antipsychotics. Results showed a higher risk of no clinical improvement (n = 60, 1 RCT, RR 25.00, 95% CI 1.55 to 403.99, very low quality evidence) and sedation status (n = 60, 1 RCT, RR 12.00, 95% CI 1.66 to 86.59, very low quality evidence) in the combined benzodiazepines/antipsychotics group. AUTHORS' CONCLUSIONS The evidence from RCTs for the use of benzodiazepines alone is not good. There were relatively few good data. Most trials were too small to highlight differences in either positive or negative effects. Adding a benzodiazepine to other drugs does not seem to confer clear advantage and has potential for adding unnecessary adverse effects. Sole use of older antipsychotics unaccompanied by anticholinergic drugs seems difficult to justify. Much more high-quality research is still needed in this area.
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Affiliation(s)
- Hadar Zaman
- Bradford School of Pharmacy & Medical Sciences, Faculty of Life Sciences, University of Bradford, Horton Road, Bradford, UK, BD7 1DP
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Protocol for the management of psychiatric patients with psychomotor agitation. BMC Psychiatry 2017; 17:328. [PMID: 28886752 PMCID: PMC5591519 DOI: 10.1186/s12888-017-1490-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 08/31/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Psychomotor agitation (PMA) is a state of motor restlessness and mental tension that requires prompt recognition, appropriate assessment and management to minimize anxiety for the patient and reduce the risk for escalation to aggression and violence. Standardized and applicable protocols and algorithms can assist healthcare providers to identify patients at risk of PMA, achieve timely diagnosis and implement minimally invasive management strategies to ensure patient and staff safety and resolution of the episode. METHODS Spanish experts in PMA from different disciplines (psychiatrists, psychologists and nurses) convened in Barcelona for a meeting in April 2016. Based on recently issued international consensus guidelines on the standard of care for psychiatric patients with PMA, the meeting provided the opportunity to address the complexities in the assessment and management of PMA from different perspectives. The attendees worked towards producing a consensus for a unified approach to PMA according to the local standards of care and current local legislations. The draft protocol developed was reviewed and ratified by all members of the panel prior to its presentation to the Catalan Society of Psychiatry and Mental Health, the Spanish Society of Biological Psychiatry (SEPB) and the Spanish Network Centre for Research in Mental Health (CIBERSAM) for input. The final protocol and algorithms were then submitted to these organizations for endorsement. RESULTS The protocol presented here provides guidance on the appropriate selection and use of pharmacological agents (inhaled/oral/IM), seclusion, and physical restraint for psychiatric patients suspected of or presenting with PMA. The protocol is applicable within the Spanish healthcare system. Implementation of the protocol and the constituent algorithms described here should ensure the best standard of care of patients at risk of PMA. Episodes of PMA could be identified earlier in their clinical course and patients could be managed in the least invasive and coercive manner, ensuring their own safety and that of others around them. CONCLUSION Establishing specialized teams in agitation and providing them with continued training on the identification of agitation, patient management and therapeutic alternatives might reduce the burden of PMA for both the patient and the healthcare system.
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Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication. Ann Emerg Med 2017; 71:279-288. [PMID: 28844504 DOI: 10.1016/j.annemergmed.2017.07.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 07/05/2017] [Accepted: 07/13/2017] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Emergency department (ED) visits for acute alcohol intoxication are common, but this population is at risk for decompensation and occult critical illness. The purpose of this study is to describe the incidence and predictors of unsuspected critical illness among patients with acute alcohol intoxication. METHODS This was a retrospective observational study of ED patients from 2011 to 2016 with acute alcohol intoxication. The study cohort included patients presenting for alcohol intoxication, whose initial assessment was uncomplicated alcohol intoxication without any other active acute medical or traumatic complaints. The primary outcome was defined as the unanticipated subsequent use of critical care resources during the encounter or admission to an ICU. We investigated potential predictors for this outcome with generalized estimating equations. RESULTS We identified 31,364 eligible patient encounters (median age 38 years; 71% men; median breath alcohol concentration 234 mg/dL); 325 encounters (1%) used critical care resources. The most common diagnoses per 1,000 ED encounters were acute hypoxic respiratory failure (3.1), alcohol withdrawal (1.7), sepsis or infection (1.1), and intracranial hemorrhage (1.0). Three patients sustained a cardiac arrest. Presence of the following had an increased adjusted odds ratio (aOR) of developing critical illness: hypoglycemia (aOR 9.2), hypotension (aOR 3.8), tachycardia (aOR 1.8), fever (aOR 7.6), hypoxia (aOR 3.8), hypothermia (aOR 4.2), and parenteral sedation (aOR 2.4). The initial blood alcohol concentration aOR was 1.0. CONCLUSION Critical care resources were used for 1% of ED patients with alcohol intoxication who were initially assessed by physicians to have low risk. Abnormal vital signs, hypoglycemia, and chemical sedation were associated with increased odds of critical illness.
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