Comparative effectiveness research trial for antidepressant incomplete and non-responders with treatment resistant depression (ASCERTAIN-TRD) a randomized clinical trial.

Further research is needed to help improve both the standard of care and the outcome for patients with treatment-resistant depression. A particularly critical evidence gap exists with respect to whether pharmacological or non-pharmacological augmentation is superior to antidepressant switch, or vice-versa. The objective of this study was to compare the effectiveness of augmentation with aripiprazole or repetitive transcranial magnetic stimulation versus switching to the antidepressant venlafaxine XR (or duloxetine for those not eligible to receive venlafaxine) for treatment-resistant depression. In this multi-site, 8-week, randomized, open-label study, 278 subjects (196 females and 82 males, mean age 45.6 years (SD 15.3)) with treatment-resistant depression were assigned in a 1:1:1 fashion to treatment with either of these three interventions; 235 subjects completed the study. 260 randomized subjects with at least one post-baseline Montgomery-Asberg Depression Rating (MADRS) assessment were included in the analysis. Repetitive transcranial magnetic stimulation (score change (standard error (se)) = -17.39 (1.3) (p = 0.015) but not aripiprazole augmentation (score change (se) = -14.9 (1.1) (p = 0.069) was superior to switch (score change (se) = -13.22 (1.1)) on the MADRS. Aripiprazole (mean change (se) = -37.79 (2.9) (p = 0.003) but not repetitive transcranial magnetic stimulation augmentation (mean change (se) = -42.96 (3.6) (p = 0.031) was superior to switch (mean change (se) = -34.45 (3.0)) on the symptoms of depression questionnaire. Repetitive transcranial magnetic stimulation augmentation was shown to be more effective than switching antidepressants in treatment-resistant depression on the study primary measure. In light of these findings, clinicians should consider repetitive transcranial magnetic stimulation augmentation early-on for treatment-resistant depression.Trial registration: ClinicalTrials.gov, NCT02977299.

Brief Intervention and Follow-Up for Suicidal Patients With Repeat Emergency Department Visits Enhances Treatment Engagement.

We implemented an innovative, brief, easy-to-administer 2-part intervention to enhance coping and treatment engagement. The intervention consisted of safety planning and structured telephone follow-up postdischarge with 95 veterans who had 2 or more emergency department (ED) visits within 6 months for suicide-related concerns (i.e., suicide ideation or behavior). The intervention significantly increased behavioral health treatment attendance 3 months after intervention, compared with treatment attendance in the 3 months after a previous ED visit without intervention. The trend was for a decreasing hospitalization rate.

Older Adults with Mental Disorders: What Factors Distinguish Those Who Present to Emergency Departments for Mental Health Reasons from Those Who Do Not?

OBJECTIVE: To identify among older adults with mental disorders factors associated with those who present to emergency departments (EDs) for mental health reasons versus those who do not. METHODS: The authors conducted a secondary, cross-sectional analysis of the Medical Expenditure Panel Survey (MEPS), which comprises a representative sample of the U.S. civilian noninstitutionalized population. Of the MEPS participants ages 66 and older on December 31 of the survey years 2000-2005, the analysis sample (2,757) included the 177 persons with at least one mental health ED visit and the 2,580 persons with mental disorders without such a visit. The three categories of the Andersen behavioral model for healthcare services utilization-predisposing, enabling, and need factors-were used as the theoretical framework for the independent variables. RESULTS: Logistic regression analysis indicated that four need factors (adjustment disorder [OR: 3.42], psychosis [OR: 2.68], fair perceived physical health status [OR: 2.24], and anxiety disorder [OR: 1.85]) and two predisposing characteristics (widowed and living alone [OR: 1.68] and female [OR: 1.56]) were significantly associated with older adults with mental disorders who present to an ED for mental health reasons. Good perceived mental health status (OR: 0.55) was protective against presenting to an ED. CONCLUSION: EDs that serve populations with higher proportions of older persons that are women, widowed and living alone, with adjustment disorder, psychosis, anxiety disorders, or fair perceived physical health should expect to have a greater likelihood of older persons visiting the ED for mental health reasons.

Impact of the Patient Protection and Affordable Care Act on Emergency Psychiatry.

Emergency psychiatry (EP) is an integral component of comprehensive hospital-based emergency care. EP developed and grew into a medical subspecialty in response to deinstitutionalization and other large-scale forces, resulting in large numbers of psychiatric patients presenting to emergency departments. The Affordable Care Act (ACA) of 2010 contains several features and provisions that are likely to impact the practice of EP. This article reviews and examines the impact of the ACA on psychiatric emergency care to date and anticipated in the near future.

Incidence of Suicidal Ideation and Suicide Attempt Based on Time in a Deployed Environment.

INTRODUCTION: Knowing when suicidal ideation (SI) or suicide attempt (SA) is most likely to occur in a deployed environment would aid in focusing prevention efforts. This study aims to determine when evacuation for SA and SI is most likely to occur based on the absolute and relative number of months in a deployed setting. MATERIALS AND METHODS: This is a case-control study of active-duty military personnel evacuated from the U.S. Central Command area of responsibility for SI or an SA between April 1, 2020, and March 30, 2021. The arrival month and expected departure month were identified for all the included evacuees. The month of evacuation and proportion of completed deployment were compared. Secondary outcomes of mental health diagnosis or need for a waiver was also examined. RESULTS: A total of 138 personnel evacuated for SI or attempted suicide during the 12-month study period were included in the analysis. Evacuations occurring during month 3 of deployment were significantly higher (P < .0001) than those during other months. The 30% and 50% completion point of deployment had statistically higher frequencies of evacuations for SI/SA (<.0001). A secondary analysis revealed that 25.4% of the individuals had a documented preexisting behavioral health condition before deployment (P < .0001). CONCLUSION: Specific points along a deployment timeline were significant predictors for being evacuated for SI and SA.

An emergency department-based brief intervention for veterans at risk for suicide (SAFE VET).

Reducing deaths from veteran suicide is a public health priority for veterans who receive their care from the Department of Veterans Affairs (VA) and those who receive services in community settings. Emergency departments frequently function as the primary or sole point of contact with the health care system for suicidal individuals; therefore, they represent an important venue in which to identify and treat veterans who are at risk for suicide. We describe the design, implementation and initial evaluation of a brief behavioral intervention for suicidal veterans seeking care at VA emergency departments. Initial findings of the feasibility and acceptability of the intervention suggest it may be transferable to diverse VA and non-VA settings, including community emergency departments and urgent care centers.

Prevalence, correlates, and symptom profiles of depression among men with a history of military service.

PURPOSE: The purpose of this study was to examine the prevalence, correlates, and symptom profiles of depressive disorders in men with a history of military service. METHODS: Data were obtained from the 2006 Behavioral Risk Factor Surveillance System survey. Multivariable logistic regressions were used to identify correlates of lifetime and current depression. Regularly occurring symptom profiles were identified via cluster analysis. RESULTS: Prevalence of lifetime and current depression was similar in men with and without a history of military service. Younger age was positively, and black minority status, being in a relationship and self-reported good health were negatively associated with a lifetime diagnosis of depression. Other minority status (non-Hispanic, non-black) was positively, and older age, some college, being in a relationship, and self-reported good health were negatively associated with current depression. A cluster of younger men who experience significant depressive symptoms but may not report depressed mood or anhedonia was identified. CONCLUSIONS: Depression is as prevalent in men with a history of military service as it is in men without a history. Research should focus on subpopulations of men with a history of military service in which depression may be more prevalent or burdensome. Younger men with significant depressive symptoms may be missed by standard depression screens and still be at elevated risk for negative outcomes associated with depression.

Predictive Validity of the Columbia-Suicide Severity Rating Scale among a Cohort of At-risk Veterans.

OBJECTIVE: To examine the psychometric properties of the Columbia- Suicide Severity Rating Scale (C-SSRS) among a cohort of veterans identified to be at risk for suicide. METHOD: Convergent, divergent, and predictive validity of the C-SSRS were examined using secondary data from a study of veterans who presented to the psychiatric emergency room (n = 237). Data were collected 1 week, 1 month, 3 months, and 6 months following emergency room discharge. RESULTS: Results demonstrated good evidence for convergent and divergent validity. Baseline intensity subscale scores predicted actual and interrupted attempts, and any behavior for all available data and for the subsample who had 6-month follow-up data, and also predicted preparatory behavior in the full sample. Baseline severity subscale scores predicted preparatory behavior and any behavior for the full sample and for those with 6 months of follow-up, and actual attempts for the full sample. Severity of ideation cutoff scores was significantly associated with actual attempts and any behavior in both samples. Adding a prior behavior criterion demonstrated similar results. CONCLUSIONS: Findings suggest that the C-SSRS is a psychometrically sound measure that can be used to augment suicide risk assessment with veterans who are already identified to be at risk for suicide.

Do geographic regions with higher suicide rates also have higher rates of nonfatal intentional self-harm?

Fatal and nonfatal intentional self-harm events in eight U.S. states were compared using emergency department, hospital, and vital statistics data. Nonfatal event rates increased by an estimated 24.20% over 6 years. Case fatality ratios varied widely, but two northeastern states' total event rates (fatal plus nonfatal) were very high (New Hampshire 206.5/100,000 person years; Massachusetts 166.7/100,000). Geographic context did not uniformly impact the likelihood of self-harm across event types. The state-level public health burden posed by such acts cannot, therefore, be accurately estimated from either mortality or morbidity data alone.

Modeling the Cost-Effectiveness of Interventions to Reduce Suicide Risk Among Hospital Emergency Department Patients.

OBJECTIVE: This study estimated the expected cost-effectiveness and population impact of outpatient interventions to reduce suicide risk among patients presenting to general hospital emergency departments (EDs), compared with usual care. Several such interventions have been found efficacious, but none is yet widespread, and the cost-effectiveness of population-based implementation is unknown. METHODS: Modeled cost-effectiveness analysis compared three ED-initiated suicide prevention interventions previously found to be efficacious-follow-up via postcards or caring letters, follow-up via telephone outreach, and suicide-focused cognitive-behavioral therapy (CBT)-with usual care. Primary outcomes were treatment costs, suicides, and life-years saved, evaluated over the year after the index ED visit. RESULTS: Compared with usual care, adding postcards improved outcomes and reduced costs. Adding telephone outreach and suicide-focused CBT, respectively, improved outcomes at a mean incremental cost of $4,300 and $18,800 per life-year saved, respectively. Monte Carlo simulation (1,000 repetitions) revealed the chance of incremental cost-effectiveness to be a certainty for all three interventions, assuming societal willingness to pay ≥$50,000 per life-year. These main findings were robust to various sensitivity analyses, including conservative assumptions about effect size and incremental costs. Population impact was limited by low sensitivity of detecting ED patients' suicide risk, and health care delivery inefficiencies. CONCLUSIONS: The highly favorable cost-effectiveness found for each outpatient intervention provides a strong basis for widespread implementation of any or all of the interventions. The estimated population benefits of doing so would be enhanced by increasing the sensitivity of suicide risk detection among individuals presenting to general hospital EDs.

Suicidal Behavior and Non-Suicidal Self-Injury in Emergency Departments Underestimated by Administrative Claims Data.

BACKGROUND: External causes of injury codes (E-codes) are used in administrative and claims databases for billing and often employed to estimate the number of self-injury visits to emergency departments (EDs). AIMS: This study assessed the accuracy of E-codes using standardized, independently administered research assessments at the time of ED visits. METHOD: We recruited 254 patients at three psychiatric emergency departments in the United States between 2007 and 2011, who completed research assessments after presenting for suicide-related concerns and were classified as suicide attempters (50.4%, n = 128), nonsuicidal self-injurers (11.8%, n = 30), psychiatric controls (29.9%, n = 76), or interrupted suicide attempters (7.8%, n = 20). These classifications were compared with their E-code classifications. RESULTS: Of the participants, 21.7% (55/254) received an E-code. In all, 36.7% of research-classified suicide attempters and 26.7% of research-classified nonsuicidal self-injurers received self-inflicted injury E-codes. Those who did not receive an E-code but should have based on the research assessments had more severe psychopathology, more Axis I diagnoses, more suicide attempts, and greater suicidal ideation. LIMITATIONS: The sample came from three large academic medical centers and these findings may not be generalizable to all EDs. CONCLUSION: The frequency of ED visits for self-inflicted injury is much greater than current figures indicate and should be increased threefold.

Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department.

Importance: Suicidal behavior is a major public health problem in the United States. The suicide rate has steadily increased over the past 2 decades; middle-aged men and military veterans are at particularly high risk. There is a dearth of empirically supported brief intervention strategies to address this problem in health care settings generally and particularly in emergency departments (EDs), where many suicidal patients present for care. Objective: To determine whether the Safety Planning Intervention (SPI), administered in EDs with follow-up contact for suicidal patients, was associated with reduced suicidal behavior and improved outpatient treatment engagement in the 6 months following discharge, an established high-risk period. Design, Setting, and Participants: Cohort comparison design with 6-month follow-up at 9 EDs (5 intervention sites and 4 control sites) in Veterans Health Administration hospital EDs. Patients were eligible for the study if they were 18 years or older, had an ED visit for a suicide-related concern, had inpatient hospitalization not clinically indicated, and were able to read English. Data were collected between 2010 and 2015; data were analyzed between 2016 and 2018. Interventions: The intervention combines SPI and telephone follow-up. The SPI was defined as a brief clinical intervention that combined evidence-based strategies to reduce suicidal behavior through a prioritized list of coping skills and strategies. In telephone follow-up, patients were contacted at least 2 times to monitor suicide risk, review and revise the SPI, and support treatment engagement. Main Outcomes and Measures: Suicidal behavior and behavioral health outpatient services extracted from medical records for 6 months following ED discharge. Results: Of the 1640 total patients, 1186 were in the intervention group and 454 were in the comparison group. Patients in the intervention group had a mean (SD) age of 47.15 (14.89) years and 88.5% were men (n = 1050); patients in the comparison group had a mean (SD) age of 49.38 (14.47) years and 88.1% were men (n = 400). Patients in the SPI+ condition were less likely to engage in suicidal behavior (n = 36 of 1186; 3.03%) than those receiving usual care (n = 24 of 454; 5.29%) during the 6-month follow-up period. The SPI+ was associated with 45% fewer suicidal behaviors, approximately halving the odds of suicidal behavior over 6 months (odds ratio, 0.56; 95% CI, 0.33-0.95, P = .03). Intervention patients had more than double the odds of attending at least 1 outpatient mental health visit (odds ratio, 2.06; 95% CI, 1.57-2.71; P < .001). Conclusions and Relevance: This large-scale cohort comparison study found that SPI+ was associated with a reduction in suicidal behavior and increased treatment engagement among suicidal patients following ED discharge and may be a valuable clinical tool in health care settings.

Intramuscular aripiprazole in the control of agitation.

OBJECTIVE: To evaluate response to intramuscular (IM) aripiprazole injections using secondary analyses from clinical trials. METHODS: Data from one trial in patients with bipolar I disorder and two trials in patients with schizophrenia were assembled and used for three secondary analyses. Analysis 1 looked at data from "nonsedated" patients (i.e., patients with scores < 8 [deep sleep] or 9 [unarousable] on the Agitation-Calmness Evaluation Scale [ACES]). In analysis 2, patients were subdivided into "higher" and "lower" agitation groups according to a median split on the baseline score for the Positive and Negative Syndrome Scale (PANSS) Excited Component (PEC) (median = 18). Analysis 3 looked at the patients who received a second injection within the 24-hour study period. In each analysis, the mean change from baseline in PEC scores was re-evaluated. RESULTS: Analysis 1 found that nonsedated patients with bipolar I disorder and schizophrenia showed significant decreases in PEC scores following treatment with aripiprazole IM (p < 0.005). Analysis 2 found that aripiprazole IM significantly reduced agitation compared with placebo in patients with bipolar I disorder who had lower baseline agitation (p < 0.01), while patients with bipolar I disorder who had higher baseline agitation showed similarly large PEC decreases with aripiprazole (-9.9) and placebo (-7.9). Patients with schizophrenia showed significant reductions in PEC scores compared with placebo regardless of baseline level of agitation (p < 0.01). Analysis 3 found that a second injection of aripiprazole IM significantly reduced agitation in patients with bipolar I disorder or schizophrenia (p < 0.05); repeated injections were safe and well tolerated. CONCLUSION: Improvements with aripiprazole IM appeared to be specific to core agitation symptoms, as opposed to nonspecific sedation, and to be independent of baseline level of agitation. Furthermore, patients benefited from a repeated aripiprazole injection when clinically warranted. These results address important clinical issues regarding use of aripiprazole IM in treating agitation.

Efficacy and safety of oral aripiprazole compared with haloperidol in patients transitioning from acute treatment with intramuscular formulations.

OBJECTIVE: To report efficacy and safety of transitioning patients receiving intramuscular (IM) formulations of aripiprazole or haloperidol to their respective oral formulations. METHODS: 448 agitated patients with schizophrenia (73%) or schizoaffective disorder (27%) were randomized to receive aripiprazole IM 9.75 mg, haloperidol IM 6.5 mg, or placebo IM within 24 hours. Patients treated with aripiprazole IM or haloperidol IM who completed this 24-hour IM phase were transitioned to the respective blinded oral formulations for 4 days (aripiprazole 10-15 mg/day, n = 153; haloperidol 7.5-10 mg/day, n = 151). Patients treated with placebo IM were transitioned to oral aripiprazole (analysis not included). The primary efficacy measure was mean change in Positive and Negative Syndrome Scale-Excited Component (PEC) score from baseline of oral phase (last value from 24-hour IM phase) to endpoint (study day 5, last observation carried forward). RESULTS: During the oral phase, aripiprazole 15 mg and haloperidol 10 mg were both effective in maintaining responses achieved on all efficacy measures during the 24-hour IM phase. Mean improvements in PEC scores from study day 1 to 5 were -1.37 for aripiprazole and -1.40 for haloperidol (p = NS for aripiprazole versus haloperidol). Oral aripiprazole was well tolerated. Extrapyramidal symptom-related adverse events were lower for aripiprazole (1.3%) than haloperidol (8.0%). Nausea and vomiting occurred more frequently in patients receiving aripiprazole (3.9% and 2.6%, respectively) than in those receiving haloperidol (0.7% and 1.3%, respectively). CONCLUSIONS: Acutely agitated patients with schizophrenia or schizoaffective disorder treated with aripiprazole IM or haloperidol IM demonstrated similar effective and safe transition to their respective oral formulations. Initial benefits of reduced agitation and improved clinical status during the IM phase of the study were maintained throughout the oral phase of the study with good tolerability.

Innovations: Emergency psychiatry: Relative accuracy of breath and serum alcohol readings in the psychiatric emergency service.

Management of changes in physiologic and mental status due to alcohol is a core skill utilized in the psychiatric emergency service. Blood alcohol concentrations are commonly approximated by measuring breath alcohol at triage. However, the blood-breath ratio is highly variable, and breath tests have produced lower readings than blood tests. The authors assessed the accuracy of breath alcohol readings at triage in a medical emergency department compared with subsequent serum alcohol levels taken in the psychiatric emergency service. The mean breath ethanol concentration was significantly lower than the mean corrected serum ethanol concentration (.15+/-.05 grams per 210 liters and .23+/-.05 grams per 100 milliliters, respectively). The relative accuracy of breath alcohol tests decreased with increasing serum alcohol. Although its low false-positive rate makes the breath test acceptable for legal purposes, the blood alcohol level is more appropriate for clinical use in emergency settings, because breath tests can underestimate the degree of toxicity.

Orally versus intramuscularly administered antipsychotic drugs in psychiatric emergencies.

High utilization of emergency services by patients at increased risk for agitation and aggression makes the determination of effective therapy a major concern of psychiatric care. Agitated and aggressive behavior needs to be treated rapidly and effectively to minimize the risk to both patients and staff. Traditionally, short-acting intramuscular (IM) formulations of conventional antipsychotic drugs have been preferred in the emergency setting due to their rapid onset of action and the ability to administer them to uncooperative patients. IM injections, however, may not always be the preferred option. Recently, orally administered second generation (atypical) antipsychotics have been shown to be at least as effective in managing acute agitation as conventional antipsychotic drugs, with a superior tolerability profile. The current review evaluates pharmacokinetic parameters, formulation options, and clinical efficacy data for the treatment of acute agitation or aggressive behavior with antipsychotic medications. A synthesis of data from individual clinical trials, meta-analyses, review articles, and expert consensus recommendations is used to develop a working clinical algorithm for the acute management of aggression and agitation.

Consumer and family experiences in the emergency department following a suicide attempt.

OBJECTIVE: To understand the separate experiences of consumers (patients) and family members in the Emergency Department (ED) following a suicide attempt. METHODS: Separate anonymous surveys were created for two groups: 1) consumers (n = 465) who had made a suicide attempt and been to the ED, and 2) others (referred to here as family members; n = 254) who had a close friend or relative treated in an ED due to suicidal behavior. Surveys were available on the National Alliance on Mental Illness (NAMI) website (www.nami.org) for 2 months. RESULTS: Almost half of consumers were accompanied by a family member to the ED following their suicide attempt. Over half of consumers and family members felt that staff treated them with respect and addressed ethnic and cultural issues appropriately. However, fewer than 40% of consumers felt that staff listened to them, described the nature of treatments to them, or took their injury seriously. Family members were more likely than consumers to feel heard or to receive information about treatment. More than half of consumers and almost a third of family members felt directly punished or stigmatized by staff. Consumers and family members also reported negative experiences involving a perception of unprofessional staff behavior, feeling the suicide attempt was not taken seriously, and long wait times. CONCLUSIONS: Individuals who visited the NAMI website reported a range of negative experiences in EDs following visits for suicide attempts. The effects of these experiences on retention in care and subsequent self-injurious behavior are largely unexplored. A greater understanding of these effects may inform development of interventions to increase the satisfaction of consumers and their families and friends and improve outcomes that result from emergency care of suicidal patients and their families.

A pilot, open-label safety study of quetiapine for treatment of moderate psychotic agitation in the emergency setting.

OBJECTIVE: The goal of this pilot study was primarily to explore the safety and, secondarily, the efficacy of the use of "prn" quetiapine for treatment of moderate agitation accompanied by psychosis in an emergency department setting. METHODS: This was an open-label study in which 20 patients with psychotic agitation were treated in the emergency department with 100, 150, or 200 mg of quetiapine. Physicians who were unaffiliated with the study established the diagnoses and selected the doses to be used for each patient. A rater who was blinded to the dose performed the assessments. The primary safety measure was the onset of orthostatic hypotension. The primary efficacy measure was a 40% reduction in scores on the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) over 120 minutes. The secondary efficacy measure was a reduction of 2 points or more on the Behavioral Activity Rating Scale (BARS) at 120 minutes post-dose. All subjects provided written informed consent. RESULTS: With regard to safety outcomes, 40% of subjects exhibited orthostasis by 120 minutes, although only 25% of these patients described clinically significant symptoms. In terms of efficacy, 50% of subjects experienced at least a 40% reduction in PANSS-EC scores at 2 hours, while 68.8% showed reductions of 2 points or more in scores on the BARS over the same time period. CONCLUSION: Quetiapine demonstrated some efficacy as a sedative agent in the emergency setting, although no clear dose-response pattern emerged over the narrow dose range tested. Orthostasis was common and did not correlate with dosing. This small study did not support the use of quetiapine to treat acute agitation in potentially volume-depleted patients.

Risperidone versus haloperidol, in combination with lorazepam, in the treatment of acute agitation and psychosis: a pilot, randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To compare oral risperidone and intramuscular (IM) haloperidol, both in combination with IM lorazepam, in the management of acute agitation and psychosis in the medical emergency department. METHODS: In this prospective, randomized, placebo-controlled, double-blind study of 30 patients presenting to the emergency department with acute agitation and/or psychosis, three groups of 10 patients received oral and IM medications: 1) 2 mg oral risperidone and 2 mg IM lorazepam; 2) 5 mg oral haloperidol and 2 mg IM lorazepam; 3) oral placebo and 2 mg IM lorazepam. Each treatment group received both an injection and a tablet to reduce treatment group variability. Patients were evaluated using the Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS) before receiving medication and at 30 and 90 minutes after medication was administered. The intergroup mean percent reductions in rating scale scores were compared using ANOVA, chi-square, and Kruskal-Wallis tests. RESULTS: There were no statistically significant differences among the groups at any point. The two groups receiving an antipsychotic plus lorazepam showed a trend towards increased symptom reduction compared with the group receiving lorazepam alone, although this trend was not statistically significant. CONCLUSIONS: Lorazepam alone was as effective as lorazepam plus haloperidol or lorazepam plus risperidone in this small trial. While not statistically significant, a trend toward better outcomes with combined treatment warrants further study.

Behavioural manifestations of anabolic steroid use.

The use of anabolic androgenic steroids (AAS) for gains in strength and muscle mass is relatively common among certain subpopulations, including athletes, bodybuilders, adolescents and young adults. Adverse physical effects associated with steroid abuse are well documented, but more recently, increased attention has been given to the adverse psychiatric effects of these compounds. Steroids may be used in oral, 17alpha-alkylated, or intramuscular, 17beta-esterified, preparations. Commonly, steroid users employ these agents at levels 10- to 100-fold in excess of therapeutic doses and use multiple steroids simultaneously, a practice known as 'stacking'. Significant psychiatric symptoms including aggression and violence, mania, and less frequently psychosis and suicide have been associated with steroid abuse. Long-term steroid abusers may develop symptoms of dependence and withdrawal on discontinuation of AAS. Treatment of AAS abusers should address both acute physical and behavioural symptoms as well as long-term abstinence and recovery. To date, limited information is available regarding specific pharmacological treatments for individuals recovering from steroid abuse. This paper reviews the published literature concerning the recognition and treatment of behavioural manifestations of AAS abuse.