A prospective naturalistic multicentre study of intravenous medications in behavioural emergencies: haloperidol versus flunitrazepam.

A prospective naturalistic multicentre study for deep sedation was conducted in intensive care with continuous electrocardiogram (ECG) monitoring. Clinical purpose was enough sedation, which made uncooperative and disrupted patients receive brain computed tomography (CT), magnetic resonance imaging (MRI), or fluid therapy, with minimum drug doses. A first infusion was either haloperidol (HAL group) or flunitrazepam (FNP group). If enough sedation was not achieved, a second infusion, which was the opposite drug to the first infusion, was given. The proportion requiring a second infusion was higher in the HAL group than in the FNP group (82% vs. 36%, P<0.0001). The mean reduction of the Excited Component for Positive and Negative syndrome scale at 15 min was greater for the FNP first group (FNP+HAL group) than the HAL first group (HAL+FNP group) (68% [S.D. 17] vs. 54% [S.D. 31], P=0.02). The mean dose of flunitrazepam in the HAL+FNP group was significantly lower than that in the FNP+HAL-group (1.3 mg vs. 3.5 mg, P=0.0003). Thus, in terms of monotherapy and speed of action, flunitrazepam has advantages over haloperidol as a first infusion for deep sedation. Regarding drug dosages, haloperidol has an advantage over flunitrazepam as a first infusion in safety.

Prevalence of i.v. thiopental use in psychiatric emergency settings in Japan.

AIM: Because i.v. barbiturates such as thiopental carry the risk of apnea and laryngeal spasm in asthmatic patients, reducing the use of barbiturate in emergency situations is important. The purpose of the present study was therefore to investigate the prevalence of i.v. thiopental as a choice of sedation in behavioral emergency settings, we conducted a cross-sectional multicenter study. METHODS: Psychiatric emergency departments of seven hospitals were studied during a 4-month period. Patients with a score >15 on the Excited Component of the Positive and Negative Syndrome Scale (PANSS-EC) who received i.v. medication were included in the study. Drugs were chosen according to the Japanese guidelines, in which the first injection was either haloperidol or benzodiazepine in accordance with clinical requirements. A second injection, which was the opposite drug to the first injection was administered as needed. Only when excitement obviously increased following the first injection, which was considered uncontrollable without thiopental according to expert experience, was thiopental given as a second injection. A total of 137 patients were included. The mean age was 40.4 years (SD 13.1), and the rate of male gender, drug-naïve, and F2 (schizophrenia, schizotypal and delusional disorders) on the ICD-10 were 48.9%, 29.9%, and 65.7%, respectively. RESULTS: The rate of patients treated with thiopental as a second injection was 8.0% (n = 11). All of the first injections in patients treated with thiopental were not haloperidol but benzodiazepines (P = 0.0072). CONCLUSION: Because this multicenter study has an epidemiological character, the prevalence of i.v. thiopental use in psychiatric emergency settings in Japan is considered to be 8.0%.

Olanzapine orally disintegrating tablet vs. risperidone oral solution in the treatment of acutely agitated psychotic patients.

OBJECTIVE: Efficacy and tolerability of risperidone oral solution (RIS-OS) and olanzapine orally disintegrating tablet (OLZ-ODT) were compared for the treatment of acute psychotic agitation. METHOD: During a 2-month period, patients scoring > or =15 on the Excited Component for Positive and Negative Syndrome Scale (PANSS-EC) were assigned to treatment with OLZ-ODT (n=34) or RIS-OS (n=53) on psychiatric emergency situations, and assessed every 15 min. RESULTS: Two (OLZ-ODT and RIS-OS) by five (0-, 15-, 30-, 45- and 60-min time points) repeated-measures analysis of variance revealed only a significant main effect of time course on PANSS-EC (F=82.2, P<.0001). No differences in the number of patients receiving additional injection due to worsening were found (OLZ-ODT, 11.8%; RIS-OS, 9.4%). No differences in rate of extrapyramidal symptoms and patient satisfaction with assigned treatment were found. However, patients in the OLZ-ODT group recovered significantly more from tachycardia than those in the RIS-OS group (t=2.17, P=.03). CONCLUSION: OLZ-ODT and RIS-OS treatments yielded similar improvements in acutely agitated patients who accepted oral medication. However, on one physiological parameter (i.e., tachycardia) OLZ-ODT might be superior to RIS-OS. Physiological indicators may also be useful for measuring levels of agitation.

[The review of seclusion and restraint in psychiatric practice].

In order to create the least restrictive setting in psychiatric practice, we investigated the effects of an assessment by a committee on seclusion and restraint. Using consistent procedures, the committees, which were established in 9 hospitals, reviewed seclusion and restraint maintained for periods of over 2 weeks during a 4-month period. Frequency and duration of seclusion and restraint, staff perceptions of and attitudes to the review system, and patient satisfaction were evaluated before and after the study period. As a result of this review process, the frequency of seclusion decreased slightly in 7 hospitals and 1 of the remaining 2 hospitals showed an increased frequency of seclusion days that were partially interrupted. Frequency of restraint decreased slightly in 5 hospitals, and of the remaining 3, 1 interrupted all periods of restraint, while the other 2 institutions showed an increase in interruption of restraint periods. As there were no common patients in 2 specialist psychiatric emergency hospitals between before and after the study periods, statistical analyses were performed. Only minor variables such as duration of partially interrupted periods of restraint, and duration of periods of restraint that were partially released showed a statistically significant increase. Although patient satisfaction showed a significant increase, staff attitudes to and perceptions of the review system became appreciably more negative. These findings suggest that although the review system had the potential to slightly reduce the use of seclusion and restraint, and to increase patient satisfaction, staff burnout was risked because staff effort was perceived to be disproportionately high in relation to the effect achieved. Furthermore, the possibility remains that the slight decrease of seclusion and restraint demonstrated did not necessarily reflect the appropriate use of these strategies, and were not necessarily lasting effects. However, as differences in opinion existed between the review system committee and treating clinicians regarding continuation of long term seclusion and restraint, the review system could have a role in monitoring the long term use of seclusion and restraint. Further investigation is needed into the long term effectiveness of procedures reviewing the use of seclusion and restraint in the psychiatric setting, taking into account both positive and negative outcomes.