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Hopkins TM, Deardorff OG, Liu Y, Trout MG, Sommi RW, Beck NC. A Pilot Study to Explore the Effect of Long Acting Injectable Antipsychotics on Aggression. PSYCHOPHARMACOLOGY BULLETIN 2024; 54:18-24. [PMID: 38449470 PMCID: PMC10913868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Objectives To explore the effect of switching from an oral antipsychotic to a long-acting injectable (LAI) antipsychotic on aggression, in terms of the changes of verbal and physical aggression, interventions required, self-injurious behavior, use of seclusion or restraint, antipsychotic medication refusal, and use of antipsychotics as needed (PRN). Methods This was a retrospective chart review at a long-term state forensic psychiatric facility. Patients treated with an oral antipsychotic for at least 6 months and then switched to a LAI antipsychotic for an additional 6 months during an 80-month period were included. Results Out of 70 patients evaluated, 18 were the study subjects. The median age of the cohort was 38 years with a majority being male. Of the seven patients who had an incident of aggression, two had an increase in aggressive incidents following the switch, three had a decrease, and two had no change. Thirty-six interventions occurred while patients were on an oral antipsychotic, which decreased by 30.6% to 25 interventions after the switch. Three patients had an incident of self-injurious behavior, and 6 patients required restraints/seclusions. Of the eight patients who had retrievable medication refusal and antipsychotic PRN use information, five had a decrease in antipsychotic medication refusals and five had an increase in PRN antipsychotic use after the switch. Conclusion The switch from an oral antipsychotic to a LAI antipsychotic did not appear to significantly increase or decrease incidents of aggression or self-injurious behavior, but seemed to decrease the number of restraints/seclusions required.
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Affiliation(s)
- Tiffany M Hopkins
- Hopkins, PharmD, BCPP, Clinical Pharmacy Specialist, South Texas Veterans Health Care System, San Antonio, TX
| | - O Greg Deardorff
- Deardorff, PharmD, BCPP, Clinical Pharmacy Manager, Department of Pharmacy, Fulton State Hospital, Fulton, MO
| | - Yifei Liu
- Liu, BS Pharm, PhD, Associate Professor, Division of Pharmacy Practice and Administration, University of Missouri-Kansas City School of Pharmacy, Kansas City, MO
| | - Megan G Trout
- Trout, PharmD, Clinical Pharmacist, Department of Pharmacy, Fulton State Hospital, Fulton, MO
| | - Roger W Sommi
- Sommi, PharmD, BCPP, FCCP, Professor Emeritus, Division of Pharmacy Practice and Administration, University of Missouri-Kansas City School of Pharmacy, Kansas City, MO
| | - Niels C Beck
- Beck, PhD, Professor Emeritus, Department of Psychiatry, University of Missouri Health Care, Columbia, MO
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Gartenberg A, Levine K, Petrie A. Emergency department management of acute agitation in the reproductive age female and pregnancy. World J Emerg Med 2024; 15:83-90. [PMID: 38476529 PMCID: PMC10925524 DOI: 10.5847/wjem.j.1920-8642.2024.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/22/2023] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Agitation is a common presentation within emergent departments (EDs). Agitation during pregnancy should be treated as an obstetric emergency, as the distress may jeopardize both the patient and fetus. The safety of psychotropic medications in the reproductive age female has not been well established. This review aimed to explore a summary of general agitation recommendations with an emphasis on ED management of agitation during pregnancy. METHODS A literature review was conducted to explore the pathophysiology of acute agitation and devise a preferred treatment plan for ED management of acute agitation in the reproductive age or pregnant female. RESULTS While nonpharmacological management is preferred, ED visits for agitation often require medical management. Medication should be selected based on the etiology of agitation and the clinical setting to avoid major adverse effects. Adverse effects are common in pregnant females. For mild to moderate agitation in pregnancy, diphenhydramine is an effective sedating agent with minimal adverse effects. In moderate to severe agitation, high-potency typical psychotropics are preferred due to their neutral effects on hemodynamics. Haloperidol has become the most frequently utilized psychotropic for agitation during pregnancy. Second generation psychotropics are often utilized as second-line therapy, including risperidone. Benzodiazepines and ketamine have demonstrated adverse fetal outcomes. CONCLUSION While randomized control studies cannot be ethically conducted on pregnant patients requiring sedation, animal models and epidemiologic studies have demonstrated the effects of psychotropic medication exposure in utero. As the fetal risk associated with multiple doses of psychotropic medications remains unknown, weighing the risks and benefits of each agent, while utilizing the lowest effective dose remains critical in the treatment of acute agitation within the EDs.
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Affiliation(s)
- Ariella Gartenberg
- Department of Emergency Medicine, Jacobi Medical Center and Montefiore Medical Center, NY 10461, USA
| | - Kayla Levine
- Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine and Montefiore Medical Center, NY 10461, USA
| | - Alexander Petrie
- Department of Emergency Medicine, Jacobi Medical Center and North Central Bronx Hospital, NY 10461, USA
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Johnson BO, Odenigbo N, Tcedilin D, Fouron P, Chowduary M. Extensive Soft Tissue Swelling in the Larynx and Hypopharynx of a Young Female Patient After Haloperidol Use: A Case Report on Angioneurotic Edema. Cureus 2023; 15:e41684. [PMID: 37575825 PMCID: PMC10413308 DOI: 10.7759/cureus.41684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 08/15/2023] Open
Abstract
Angioneurotic edema is a potentially life-threatening condition characterized by the rapid swelling of subcutaneous and submucosal tissues of the upper respiratory and gastrointestinal tracts. It may result in laryngeal edema, thus obstructing the airway, with a potentially fatal outcome if not diagnosed early. An allergic reaction typically causes it, but certain drugs can induce or contribute to the development of angioneurotic edema in rare cases. Haloperidol is one of the most commonly used antipsychotics to treat psychiatric disorders such as schizophrenia and, in the emergency room, acute delirium and acute psychosis. While it is generally well tolerated, in rare cases, individuals may experience a severe reaction in response to haloperidol administration. Here, we present the case of angioneurotic edema associated with intramuscular haloperidol use in a 29-year-old female patient with a history of bipolar disorder and no previous history of allergy. This case report aims to raise awareness among clinicians about this rare adverse reaction associated with haloperidol use.
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Affiliation(s)
- Bamidele O Johnson
- Psychiatry and Behavioral Sciences, Interfaith Medical Center, New York City, USA
| | | | - Denis Tcedilin
- Internal Medicine, Interfaith Medical Center, New York City, USA
| | - Patrice Fouron
- Psychiatry, Interfaith Medical Center, New York City, USA
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Valencia Carlo YE, Saracco-Alvarez RA, Valencia Carlo VA, Vázquez Vega D, Natera Rey G, Escamilla Orozco RI. Adverse effects of antipsychotics on sleep in patients with schizophrenia. Systematic review and meta-analysis. Front Psychiatry 2023; 14:1189768. [PMID: 37441144 PMCID: PMC10333591 DOI: 10.3389/fpsyt.2023.1189768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/31/2023] [Indexed: 07/15/2023] Open
Abstract
Introduction Our objective was to conduct a systematic review and meta-analysis of adverse effects on sleep in patients with schizophrenia receiving antipsychotic treatment. Methods A systematic search was performed in PubMed, Cochrane Central, Embase, Toxline, Ebsco, Virtual Health Library, Web of Science, SpringerLink, and in Database of abstracts of Reviews of Effects of Randomized Clinical Trials to identify eligible studies published from January 1990 to October 2021. The methodological quality of the studies was evaluated using the CONSORT list, and the Cochrane bias tool. Network meta-analysis was performed using the Bayesian random-effects model, with multivariate meta-regression to assess the association of interest. Results 87 randomized clinical trials were identified that met the inclusion criteria, and 70 articles were included in the network meta-analysis. Regarding the methodological quality of the studies, 47 had a low or moderate bias risk. The most common adverse effects on sleep reported in the studies were insomnia, somnolence, and sedation. The results of the network meta-analysis showed that ziprasidone was associated with an increased risk of insomnia (OR, 1.56; 95% credible interval CrI, 1.18-2.06). Several of the included antipsychotics were associated with a significantly increased risk of somnolence; haloperidol (OR, 1.90; 95% CrI, 1.12-3.22), lurasidone (OR, 2.25; 95% CrI, 1.28-3.97) and ziprasidone (OR, 1.79; 95% CrI, 1.06-3.02) had the narrowest confidence intervals. In addition, perphenazine (OR, 5.33; 95% CrI, 1.92-14.83), haloperidol (OR, 2.61; 95% CrI, 1.14-5.99), and risperidone (OR, 2.41; 95% CrI, 1.21-4.80) were associated with an increased risk of sedation compared with placebo, and other antipsychotics did not differ. According to the SUCRAs for insomnia, chlorpromazine was ranked as the lowest risk of insomnia (57%), followed by clozapine (20%), while flupentixol (26 %) and perospirone (22.5%) were associated with a lower risk of somnolence. On the other hand, amisulpride (89.9%) was the safest option to reduce the risk of sedation. Discussion Insomnia, sedation, and somnolence were the most frequent adverse effects on sleep among the different antipsychotics administered. The evidence shows that chlorpromazine, clozapine, flupentixol, perospirone, and amisulpride had favorable safety profiles. In contrast, ziprasidone, perphenazine, haloperidol, and risperidone were the least safe for sleep. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42017078052, identifier: PROSPERO 2017 CRD42017078052.
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Affiliation(s)
| | | | | | - Daniela Vázquez Vega
- Health Sciences Program, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Guillermina Natera Rey
- Department of Epidemiological and Psychosocial Research, National Institute of Psychiatry Ramon de la Fuente Muñiz, Mexico City, Mexico
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Casol M, Tong A, Ng JCY, McGloin R. Characterization of Psychotropic PRN Medications in a Canadian Psychiatric Intensive Care Unit. J Am Psychiatr Nurses Assoc 2023; 29:103-111. [PMID: 34109871 DOI: 10.1177/1078390321994668] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pro re nata (PRN) antipsychotics and benzodiazepines are routinely used for the rapid stabilization of acutely agitated patients. Despite the popular use of PRN medications in mental health units, primary literature supporting efficacy and safety is poor, and there is no single universally accepted practice guideline. PRN psychotropic medications have the potential to cause adverse effects when used inappropriately. AIMS Our objective was to characterize the prescribing, administration, and documentation practices of PRN psychotropic medications in a psychiatric intensive care unit. METHODS We conducted a retrospective chart review of patients admitted to a 12-bed psychiatric intensive care unit between June and September 2018. All PRN antipsychotic and benzodiazepine orders, administrations, documentation practices, and attempted nonpharmacological strategies were assessed for each order and patient. Descriptive statistics were used to analyze data. RESULTS Thirty-two patients with a total of 123 physicians' orders and 1,179 PRN administrations of antipsychotics and benzodiazepines were reviewed. Of the total administrations, 720 (61%) were combinations with at least two psychotropic agents. Forty-one (33%) physicians' orders had a prescribed indication, and 559 (47%) administrations had an attempted nonpharmacological method prior to PRN administration. Eight patients (25%) had antipsychotic PRN orders, which exceeded the total daily maximum dose. Three adverse drug effects were attributed to PRN administration. CONCLUSIONS Areas of improvement that we identified included documentation practices of effectiveness of administered PRNs, prescriptions to include clear indications and dosage within the 24-hour maximum limits, and documentation of nonpharmacological methods utilized.
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Affiliation(s)
- Marina Casol
- Marina Casol, BSc (Pharm), ACPR, Surrey Memorial Hospital, Surrey, British Columbia, Canada
| | - Angela Tong
- Angela Tong, BSc (Pharm), ACPR, Surrey Memorial Hospital, Surrey, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada
| | - Joan C Y Ng
- Joan C. Y. Ng, BSc (Pharm), ACPR, PharmD, University of British Columbia, Vancouver, British Columbia, Canada; St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Rumi McGloin
- Rumi McGloin, BSc (Pharm), ACPR, PharmD, Surrey Memorial Hospital, Surrey, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada
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Nuss P, Corruble E, Baloche E, Garay R, Llorca PM. Fifty years of experience with loxapine for the rapid non-coercive tranquilization of acute behavioral disturbances in schizophrenia patients, and beyond. Expert Rev Neurother 2022; 22:639-653. [PMID: 35913401 DOI: 10.1080/14737175.2022.2108706] [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: 11/04/2022]
Abstract
INTRODUCTION Acute behavioral disturbances in psychosis, including agitation, comprise a heterogeneous group of manifestations varying in intensity and duration they last for. They require rapid, non-coercive treatments ranging from verbal de-escalation to the calming effect of pharmacological agents. The treatment goals are reduction of patient suffering and prevention of disease deterioration. Stabilizing rather than sedating is preferred to ensure improved compliance and a stronger therapeutic alliance. Furthermore, animal pharmacology and clinical studies on agitation reveal the robust calming and anxiolytic properties of loxapine. AREAS COVERED This review covers the pharmacological and clinical history of loxapine along with research developments. It emphasizes the advantages of its multiple formulations ranging from injectable forms and tablets to orally inhaled forms to attain rapid and fine-tuned tranquilization. EXPERT OPINION Rapid tranquillization is achieved within 2-6 hours using liquid orally-consumed loxapine, and within an hour or less with its IM or orally inhaled forms. Loxapine has been adopted in the management of a wide range of acute disturbances, such as agitation in psychosis. In the context of personalized medicine, key cellular and molecular elements of the schizophrenia phenotype were recently shown to be improved with loxapine.
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Affiliation(s)
- Philippe Nuss
- Department of Adult Psychiatry and Medical Psychology, Sorbonne University, Saint-Antoine Hospital, Paris, France & Inserm UMR-S938, Saint-Antoine Research Centre, Sorbonne University, Paris, France
| | - Emmanuelle Corruble
- INSERM CESP-Team 'Moods', Paris-Saclay University & Department of Psychiatry, Bicetre Hospital & School of Medicine Paris-Saclay, Le Kremlin Bicetre, France
| | | | - Ricardo Garay
- Department of Pharmacology and Therapeutics, Craven, France; CNRS, National Centre of Scientific Research, Paris, France
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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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Kverno K, Mangano E. Psychiatric Emergencies and the Potential Role of Psychiatric-Mental Health Nurse Practitioners. J Psychosoc Nurs Ment Health Serv 2021; 59:7-12. [PMID: 33647157 DOI: 10.3928/02793695-20210212-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Emergency departments (EDs) are experiencing a worsening crisis of overcrowding, especially during the coronavirus pandemic. Persons experiencing psychiatric emergencies must be evaluated medically and screened for risks of harm to self or others before they can be cleared for transfer to inpatient units or discharged. Severe shortages of inpatient psychiatric beds can lead to hours or even days of costly boarding in the ED. The purpose of this article is to examine the potential role of psychiatric-mental health nurse practitioners in psychiatric ED care, from initial intake and medical clearance, screening for suicide risk, de-escalation, stabilization, and discharge. [Journal of Psychosocial Nursing and Mental Health Services, 59(3), 7-12.].
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Searles Quick VB, Herbst ED, Kalapatapu RK. Which Emergent Medication Should I Give Next? Repeated Use of Emergent Medications to Treat Acute Agitation. Front Psychiatry 2021; 12:750686. [PMID: 34950067 PMCID: PMC8688542 DOI: 10.3389/fpsyt.2021.750686] [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: 07/31/2021] [Accepted: 11/10/2021] [Indexed: 11/28/2022] Open
Abstract
Agitation is a common symptom encountered among patients treated in psychiatric emergency settings. While there are many guidelines available for initial management of the acutely agitated patient, there is a notable dearth of guidelines that delineate recommended approaches to the acutely agitated patient in whom an initial medication intervention has failed. This manuscript aims to fill this gap by examining evidence available in the literature and providing clinical algorithms suggested by the authors for sequential medication administration in patients with persistent acute agitation in psychiatric emergency settings. We discuss risk factors for medication-related adverse events and provide options for patients who are able to take oral medications and for patients who require parenteral intervention. We conclude with a discussion of the current need for well-designed studies that examine sequential medication options in patients with persistent acute agitation.
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Affiliation(s)
- Veronica B Searles Quick
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Ellen D Herbst
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Raj K Kalapatapu
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
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