Hostname: page-component-8448b6f56d-gtxcr Total loading time: 0 Render date: 2024-04-23T17:10:30.622Z Has data issue: false hasContentIssue false
  • English
  • Français

Management of Acute Psychosis: From Emergency to Stabilization

Published online by Cambridge University Press:  07 November 2014

Dan L. Zimbroff
Get access Rights & Permissions [Opens in a new window]

Abstract

In treating and managing acute psychosis in patients with schizophrenia, early intervention may be valuable. The need to quickly control severe symptoms, however, must be balanced with a treatment algorithm that is both safe and effective. The present management of acute psychotic agitation varies among clinicians. Key treatment goals have been to calm the agitated, assaultive, violent, or disruptive patient, minimize the danger to self and others, and achieve a smooth transition from intramuscular to oral maintenance. For many years, intramuscular treatment with benzodiazepines and/or conventional antipsychotics, such as haloperidol, has been the mainstay of treatment for acute psychosis. Unfortunately, the poor tolerability of conventional antipsychotics compromises their usefulness for both short- and long-term treatment. Although new antipsychotics have a more favorable side-effect profile, the transition from an intramuscular formulation has been problematic. Fortunately, the development of intramuscular formulations of olanzapine and ziprasidone offer new treatment options for patients experiencing acute psychotic episodes. This article will review the use of intramuscular agents, standard antipsychotics, and new antipsychotics in the emergency room setting. The strengths and limitations of each will be discussed.

Type
Academic Supplement
Information
CNS Spectrums , Volume 8 , supplement S2: Optimizing Treatment for Patients With Schizophrenia: Targeting Positive Outcomes , November 2003 , pp. 10 - 15
Copyright
Copyright © Cambridge University Press 2003

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1.Allen, MH, Currier, GW. Medical assessment in the psychiatric emergency service. New Dir Ment Health Serv. 1999;82:21–28.CrossRefGoogle Scholar
2.Currier, GW, Allen, MH. Emergency psychiatry: physical and chemical restraint in the psychiatric emergency service. Psychiatr Serv. 2000;51:717–719.CrossRefGoogle ScholarPubMed
3.Battaglia, J, Moss, S, Rush, J, et al.Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-Mind, emergency department study. Am J Emerg Med. 1997;15:335–340.CrossRefGoogle ScholarPubMed
4.Brook, S, Lucey, JV, Gunn, KP. Intramuscular ziprasidone compared with intramuscular haloperidol in the treatment of acute psychosis. Ziprasidone IM Study Group. J Clin Psychiatry. 2000;61:933–941.CrossRefGoogle ScholarPubMed
5.Spohn, HE, Strauss, ME. Relation of neuroleptic and anticholinergic medication to cognitive functions in schizophrenia. J Abnorm Psychol. 1989;98:367–380CrossRefGoogle ScholarPubMed
6.van Leeuwen, AM, Molders, J, Sterkmans, P, et al.Droperidol in acutely agitated patients. A double-blind placebo-controlled study. J Nerv Ment Dis. 1977;164:280–283.CrossRefGoogle ScholarPubMed
7.Chambers, RA, Druss, BG. Droperidol: efficacy and side effects in psychiatric emergencies. J Clin Psychiatry. 1999;60:664–667.CrossRefGoogle ScholarPubMed
8.Allen, MH, Currier, GW, Hughes, DH, Reyes-Harde, M, Docherty, JP, Expert Consensus Panel for Behavioral Emergencies. The Expert Consensus Guideline Series. Treatment of behavioral emergencies. Postgrad Med. 2001;(Spec No):1–88.Google Scholar
9. FDA strengthens warnings for droperidol. Available at: http://www.fda.gov/bbs/topics/ANSWERS/2001/ANS01123.html. Accessed June 10, 2003.Google Scholar
10.Young, D. Black-box warning for droperidol surprises pharmacists: shortage of inexpensive alternatives will increase budgets. Am J Health Syst Pharm. 2002;59:494–504.CrossRefGoogle Scholar
11.Greenblatt, DJ, Joyce, TH, Comer, WH, et al.Clinical pharmacokinetics of lorazepam. II. Intramuscular injection. Clin Pharmacol Ther. 1977;21:222–230.CrossRefGoogle ScholarPubMed
12.Malcolm, R, Myrick, H, Roberts, J, Wang, W, Anton, RF, Ballenger, JC. The effects of carbamazepine and lorazepam on single versus multiple previous alcohol withdrawals in an out-patient randomized trial. J Gen Intern Med. 2002;17:349–355.CrossRefGoogle Scholar
13.Goldney, RD. Paradoxical reaction to a new minor tranquilizer. Med J Aust. 1977;1:139–140.CrossRefGoogle ScholarPubMed
14.Cobb, CD, Anderson, CB, Seidel, DR. Possible interaction between clozapine and lorazepam. Am J Psychiatry. 1991;148:1606–1607.Google ScholarPubMed
15.Klimke, A, Klieser, E. Sudden death after intravenous application of lorazepam in a patient treated with clozapine. Am J Psychiatry. 1994;151:780.Google Scholar
16. Risperdal [package insert]. Titusville, NJ: Janssen Pharmaceutica Products, L.P.; 2003.Google Scholar
17. Zyprexa, Zyprexa Zydis [package insert]. Indianapolis, Ind: Eli Lilly and Company; 2003.Google Scholar
18.Kinon, BJ. Presented at: US Psych Congress; November 16-29, 2000; San Diego, Calif.Google Scholar
19.Currier, GW, Simpson, GM. Risperidone liquid concentrate and oral lorazepam versus intramuscular haloperidol and intramuscular lorazepam for treatment of psychotic agitation. J Clin Psychiatry. 2001;62:153–157.CrossRefGoogle ScholarPubMed
20.US Department of Health and Human Services. Psychopharmacological Drugs Advisory Committee Meeting on NDA 21-253: Zyprexa. February 14, 2001. Available at: http://www.fda.gov/ohrms/dockets/ac/01/slides/3685s1.htm. Accessed July 10, 2003.Google Scholar
21.Wright, P, Birkett, M, David, SR, et al.Double-blind, placebo-controlled comparison of intramuscular olanzapine and intramuscular haloperidol in the treatment of acute agitation in schizophrenia. Am J Psychiatry. 2001;158:1149–1151.CrossRefGoogle ScholarPubMed
22.Breier, A, Meehan, K, Birkett, M, et al.A double-blind, placebo-controlled dose-response comparison of intramuscular olanzapine and haloperidol in the treatment of acute agitation in schizophrenia. Arch Gen Psychiatry. 2002;59:441–448.CrossRefGoogle ScholarPubMed
23.Meehan, KM, Zhang, F, David, S. A double-blind, randomized comparison of the efficacy and safety of intramuscular injections of olanzapine, lorazepam, or placebo in treating acutely agitated patients diagnosed with bipolar mania. J Clin Psychopharmacol. 2001;21:389–397.CrossRefGoogle ScholarPubMed
24.Meehan, KM, Wang, H, David, SR. Comparison of rapidly acting intramuscular olanzapine, lorazepam, and placebo. A double-blind, randomized study in acutely agitated patients with dementia. Neuropsychopharmacology. 2002;26:494–504.CrossRefGoogle ScholarPubMed
25. Geodon [package insert]. New York, NY: Pfizer Inc.; 2002.Google Scholar
26.Daniel, DG, Potkin, SG, Reeves, KR, Swift, RH, Harrigan, EP. Intramuscular (IM) ziprasidone 20 mg is effective in reducing acute agitation associated with psychosis: a double-blind, randomized trial. Psychopharmacology (Berl). 2001;155:128–134.CrossRefGoogle ScholarPubMed
27.Lesem, MD, Zajecka, JM, Swift, RH, Reeves, KR, Harrigan, EP. Intramuscular ziprasidone, 2 mg versus 10 mg, in the short-term management of agitated psychotic patients. J Clin Psychiatry. 2001;62:12–18.CrossRefGoogle ScholarPubMed
28.Swift, RH, Harrigan, EP, Cappelleri, JC, Kramer, D, Chandler, LP. Validation of the behavioral activity rating scale (BARS): a novel measure of activity in agitated patients. J Psychiatr Res. 2002;36:87–95.CrossRefGoogle Scholar
29.Reeves, KR. Presented at: 38th Annual New Clinical Drug Evaluation Unit (NCDEU) Meeting; June 10-13, 1998; Boca Raton, Fla.Google Scholar
30.Brook, S. Presented at: 53rd Institute on Psychiatric Services; October 10-14, 2001; Orlando, Fla.Google Scholar