Inhaled Loxapine for the Management of Acute Agitation in Bipolar Disorder and Schizophrenia: Expert Review and Commentary in an Era of Change.

Agitation is a common and costly phenomenon associated with a number of psychiatric conditions including schizophrenia and bipolar disorder. Early identification and prompt intervention to relieve the symptoms of agitation are essential to avoid symptomatic escalation and emergence of aggressive behaviour. Recent consensus guidelines emphasise the need for non-coercive management strategies to protect the therapeutic alliance between patients and their healthcare providers-an alliance that is critical for the effective management of chronic psychiatric conditions. Rapid symptom relief and de-escalation of agitation are necessary to avoid the costly and traumatic use of coercive techniques of physical restraint and seclusion, which require admission and prolonged hospitalisation. Inhaled loxapine is approved for the treatment of acute agitation in patients with schizophrenia or bipolar disorder. Clinical studies have confirmed the efficacy, rapid onset of action, and safety and tolerability of this agent in the psychiatric emergency and hospital settings. Emerging data have indicated the potential for inhaled loxapine as a self-administered agent for use in the community setting without the direct supervision of a healthcare professional. We discuss the evolving treatment paradigm and the place of inhaled medications for acutely agitated patients both within and outside the emergency and hospital setting.

Perception and use of informal coercion in outpatient treatment: a focus group study with mental health professionals of Latin culture / Percepción y uso de la coerción informal en el tratamiento ambulatorio: estudio de un grupo focal con profesionales de la salud mental en países de cultura latina

Abstract Introduction. In addition to compulsion (involuntary hospitalization, seclusion, restraint, etc.), there are broader forms of coercion (persuasion, interpersonal pressure, inducement or threat), called informal or covert coercion, all of which try to improve patients adherence to treatment. Objective. To analyse the use of covert coercion in mental health outpatients and the mental health professionals´ views on this practice comparing four countries (Spain, Italy, Mexico and Chile). Methods. We conducted a qualitative research using four focus groups in each country with mental health professionals working in mental health centres and based on a thematic analysis approach. Sample. The total sample was made up of 98 professionals (31 psychiatrists, 25 clinical psychologists, 28 nurses, eight social workers and six other professionals). Results. The use of informal coercion was recognized in clinical practice, but its intensity was related to professionals´ characteristics and to factors related to diagnosis, clinical course, perceived risk, insight, therapeutic relationship and organizational issues in the delivery of services. Its use was justified by effectiveness in improving adherence and, generally, in seeking benefits for the patient, but sometimes in a paternalistic way. Discussion and conclusion. Our results match those described in the literature in terms of: 1. sociodemographic and clinical profile; 2. the reason that leads to its use (adherence); 3. ethical justification (search for patient´s benefit, trying not to impair his freedom); hence, the most intense forms (threat) were misperceived. Our professionals acknowledged the use of covert coercion in their clinical practice, justifying it on ethical and clinical grounds.

Resumen Introducción. Además de la coerción formal (hospitalización involuntaria, contención, etc.), en salud mental existen otras formas de coerción (persuasión, presión interpersonal, inducción o amenaza), denominada informal o encubierta, que pretenden mejorar la adherencia. Objetivo. Conocer el uso de la coerción informal en el tratamiento ambulatorio de enfermos mentales y la percepción que de ella tienen los profesionales de salud mental de cuatro países (España, Italia, México y Chile). Método. Utilizamos una investigación cualitativa con cuatro grupos focales por país, compuestos por profesionales que trabajaban en centros de salud mental, con un enfoque basado en el análisis temático. La muestra fue de 98 profesionales (31 psiquiatras, 25 psicólogos clínicos, 28 enfermeros, ocho trabajadores sociales y otras seis profesiones). Resultados. Se reconoció el uso de la coerción informal en la práctica clínica. Su intensidad dependió de características del profesional y factores relacionados con el diagnóstico, clínica, evolución de la enfermedad, peligrosidad del paciente, conciencia de enfermedad, relación terapéutica y aspectos organizativos asistenciales. Su uso se justificó por la eficacia y la búsqueda de beneficios para el paciente, a veces de forma paternalista. Discusión y conclusión. Nuestros resultados coincidieron en cuanto al perfil sociodemográfico y clínico con lo descrito en la bibliografía. También lo hicieron en cuanto al motivo que lleva a su uso (la adherencia) y su justificación ética (la búsqueda del beneficio del paciente menoscabando su libertad lo menos posible), de ahí que las formas más intensas (amenaza) fueron mal percibidas. Nuestros profesionales reconocieron el ejercicio de la coerción encubierta en su práctica habitual, justificándola clínica y éticamente.