Successful suicides with thioridazine and mesoridazine: a result of probable cardiotoxicity.

Five cases of successful suicides from thioridazine and mesoridazine occurred. The clinical course and management are outlined. A sixth case of reversible total heart block associated with thioridazine is presented giving further evidence that the deaths from overdose probably resulted from drug cardiotoxicity.

Haloperidol for acute schizophrenic patients. An evaluation of three oral regimens.

The relative efficacy of three oral regimens of haloperidol was compared in a ten-day, double-blind study of 63 acutely ill schizophrenic patients newly admitted to the hospital. One group of patients received 20 mg of haloperidol on day 1, then increasing increments of 20 mg a day, reaching a maximum dosage of 100 mg daily on day 5. Another group received 10 mg of haloperidol on day 1, then increasing increments of 10 mg daily, reaching 100 mg daily on day 10. A third group of patients received a fixed dosage of 10 mg daily for ten days. Haloperidol was well tolerated by the patients; there were no serious adverse reactions. The data indicated that the regimens had similar therapeutic efficacy, suggesting that acutely ill schizophrenic patients respond to a wide range of doses of haloperidol but that onset of response and efficacy are not increased in most patients by providing a high initial loading dosage. Adequate, safe dosage must be determined in each case.

Psychiatric diagnosis of chronic pain patients.

Using DSM-III, the authors reviewed the psychiatric diagnoses of 43 patients evaluated over a 1-year period by a university medical center pain board and found that 98% of the patients had an axis I disorder and 37% had an axis II disorder. The findings are discussed in relationship to earlier findings and treatment implications.

Overview: efficacy and safety of the rapid neuroleptization method with injectable haloperidol.

The authors review the literature on the rapid neuroleptization (titration) method with I.M. haloperidol. Most of the approximately 650 predominantly schizophrenic and manic patients represented in the studies calmed down rapidly on medication, and some demonstrated an early reduction in core psychotic symptoms. The initial doses varied widely, ranging from 1 to 30 mg, with a maximum total daily dosage of 100 mg. The medication seemed to have been well tolerated in all cases, with no reported major complications. The authors conclude that the method shows definite merit with agitated and belligerent patients. However, they make a number of specific recommendations for further research to clearly establish the effectiveness and safety of this method of neuroleptic administration.

Prediction of response to treatment in chronic pain patients.

A seven-item rating scale reported by researchers from the Mayo Clinic to have high validity in identifying chronic pain patients who would benefit from inpatient treatment was administered to an outpatient sample. Initial results did not replicate the previous findings; inclusion of four additional variables (disruption of a close relationship, altered body image, history of childhood illness, and history of abuse in childhood) produced results comparable to the Mayo study. This expanded screening test appears to be a useful method for selecting patients in a pain-management program and warrants further investigation.

High vs standard dosage fluphenazine HCL in acute schizophrenia.

This rater blind project compared the efficacy and safety of using an oral rapid or neuroleptization method (maximum 80 mg./day) versus fixed standard dosage (20 mg./day) fluphenazine, a commonly used neuroleptic. There were 32 hospitalized, acutely decompensated schizophrenic patients in the experiment; the study period for each patient was a maximum of 7 days. The data were collected using the Benjamin Proverb Test and rating scales for psychopathology and adverse effects. Data analysis by means of the analysis of covariance demonstrated few significant differences between the 2 treatment methods: both methods produced a similar reduction in psychopathological symptoms and incidence of adverse effects. The authors conclude that the rapid neuroleptization method is not superior to the fixed standard dosage method in treating acute schizophrenia.

Family grief in the emergency department.

Emergency physicians frequently face death, yet many are unprepared to deal with the family survivors of a patient who has died unexpectedly. Without the benefit of establishing prior rapport with the family, the emergency physician must anticipate the family's grief response so that he or she can intervene to avoid an unnecessarily prolonged or morbid grief reaction. Factors predisposing to a pathologic grief response in the death of a spouse or of an infant or child must be recognized, and the physician's power to assuage survivor guilt should be used. Certain key actions in the process of notifying survivors, viewing the body, concluding the emergency department visit, and following up after the patient's death help facilitate survivor grief in the least traumatic way possible. Emergency Departments can improve their dealing with death by instituting a team approach using doctors, nurses, social workers, and clergy to better support family members in their emergency department experience and to provide a link with community service organizations helpful to the family after they leave the hospital.

Focal neuroleptization: an approach to optimal dosing for initial and continuing therapy.

Concerns about the cumulative effects of long-term neuroleptic therapy have stimulated interest in approaches to assure the lowest possible effective medication level. The examination of present strategies to assure that they are consistent with overall treatment goals is one approach that can significantly contribute to lower-dose therapy. To this end the technique of rapid neuroleptization, which originated in the 1950s, has been assessed and redefined as focal neuroleptization, a term which directs attention to the integral relationship between acute and chronic therapy. Dosing practices that have become associated with rapid neuroleptization are less likely to occur with focal neuroleptization: the use of unnecessarily high doses during acute therapy and the failure to reduce dosages to appropriate levels for maintenance. Studies comparing high dose (above 10 to 20 mg/day of haloperidol or the equivalent of other high potency neuroleptics) with low dose therapy show that there are no significant differences in the completeness or speed of symptom remission. High doses during acute therapy make low dose maintenance more difficult to achieve. In light of these findings, physicians are encouraged to re-evaluate their approach to high dose therapy for rapid neuroleptization. The objective is to achieve the lowest possible effective dose of medication during both acute and maintenance phases of therapy. The term focal neuroleptization encompasses the key elements of neuroleptic therapy: rapid reduction of target symptoms as the end point of initial therapy, focus on individualized treatment, and low dose maintenance therapy.

The violent patient: a strategy for management and diagnosis.

Violence among psychiatric patients, while uncommon, is a serious problem mental health professionals must face. The author discusses the social, psychological, developmental, cultural, psychiatric, biological, and other factors that contribute to violence and the complex ways in which they interact. Management of the violent patient, the author says, can be broken down into two types: emergency short-term management and long-term management and diagnosis. Short-term care includes psychotherapeutic, environmental-physical, and pharmacologic tactics for controlling violence. Long-term management includes medication and careful diagnostic assessment. Mental health professionals need to understand both types of management to ensure effective treatment.