Web audio at CurrentPsychiatry.com Dr. Brown talks about treatment options for acute psychosis How to stabilize an acutely psychotic patient In psychiatric emergencies, use a stepwise approach to provide safe, effective treatment cute psychosis is a symptom that can be caused by many psychiatric and medical conditions. Psychotic Apatients might be unable to provide a history or par- ticipate in treatment if they are agitated, hostile, or violent. An appropriate workup may reveal the etiology of the psychosis; secondary causes, such as medical illness and substance use, are prevalent in the emergency room (ER) setting. If the pa- tient has an underlying primary psychotic disorder, such as schizophrenia or mania, illness-specific intervention will help acutely and long-term. With agitated and uncooperative psy- chotic patients, clinicians often have to intervene quickly to ensure the safety of the patient and those nearby. This article focuses on the initial evaluation and treat- © DARREN KEMPER/CORBIS ment of psychotic patients in the ER, either by a psychiatric Hannah E. Brown, MD emergency service or a psychiatric consultant. This process Schizophrenia Fellow can be broken down into: Massachusetts General Hospital Harvard Medical School • triage or initial clinical assessment Boston, MA • initial psychiatric stabilization, including pharmaco- Joseph Stoklosa, MD logic interventions and agitation management Attending Psychiatrist • diagnostic workup to evaluate medical and psychiat- McLean Hospital ric conditions Belmont, MA Instructor in Psychiatry • further psychiatric evaluation Harvard Medical School • determining safe disposition.1 Boston, MA Oliver Freudenreich, MD, FAPM Department of Psychiatry Triage determines the next step Massachusetts General Hospital Initial clinical assessment and triage are necessary to select Associate Professor of Psychiatry Harvard Medical School the appropriate immediate intervention. When a patient ar- Boston, MA rives in the ER, determine if he or she requires urgent medi- cal attention. Basic initial screening should include: Current Psychiatry 10 December 2012 • vital signs • finger stick blood glucose pharmacotherapy may limit the amount of • medical history time spent in restraints. • signs or symptoms of intoxication or Medication choice depends on several withdrawal factors, including onset of action, available • signs of trauma (eg, neck ligature formulation (eg, IM, liquid, rapidly dis- marks, gunshot wounds, lacerations) solving), the patient’s previous medication • asking the patient to give a brief history response, side effect profile, allergies or ad- leading up to the current presentation. verse reactions to medications, and medical A review of medical records may reveal comorbidities.3 If a patient has a known psy- patients’ medical and psychiatric history chotic illness, it may be helpful to admin- and allergies. Collateral documentation— ister the patient’s regular antipsychotic or such as ambulance run sheets or police anxiolytic medication. Some medications, reports—may provide additional informa- such as lithium, are not effective in the acute tion. If no immediate medical intervention setting and should be avoided. Additionally, is warranted, determine if the patient can benzodiazepines other than lorazepam or wait in an open, unlocked waiting area midazolam should not be administered IM or if he or she needs to be in an unlocked because of erratic absorption. Clinical Point area with a sitter, a locked open area, or a Antipsychotics can be used for psy- Early signs of secluded room with access to restraints. chotic patients with or without agitation. In general, psychotic patients who pose Benzodiazepines may treat agitation, but are agitation include a threat of harm to themselves or oth- not specific for psychosis. Haloperidol can be restlessness, ers or cannot care for themselves because used to treat acute psychosis and has proven irritability, decreased of their psychosis need locked areas or efficacy for agitation. Benzodiazepines can attention, and observation. decrease acute agitation and have efficacy inappropriate or similar to haloperidol, but with more seda- tion.5 A combination of lorazepam and halo- hostile behaviors Initial psychiatric stabilization peridol is thought to be superior to either Agitation is diagnostically unspecific medication alone.6 Lorazepam helps main- but can occur in patients with psychosis. tain sedation and decreases potential side Psychotic patients can become unpredict- effects caused by haloperidol. Consensus ably and impulsively aggressive and as- guidelines from 2001 and 2005 recommend saultive. Rapid intervention is necessary to combined haloperidol and lorazepam for minimize risk of bodily harm to the patient first-line treatment of acute agitation.3,7 and those around the patient. Physicians High-potency antipsychotics such as halo- often must make quick interventions peridol have an increased risk for extra- based on limited clinical information. It pyramidal symptoms (EPS), particularly is important to recognize early signs and acute dystonic reactions—involuntary, sus- symptoms of agitation, including: tained muscle contractions—in susceptible • restlessness (pacing, fidgeting, hand patients (eg, antipsychotic-naïve patients); wringing, fist clenching, posturing) consider starting diphenhydramine, 25 to • irritability 50 mg, or benztropine, 0.5 to 2 mg, to pre- • decreased attention vent EPS from high-potency antipsychotics • inappropriate or hostile behaviors.2 (Algorithm 1, page 12). Second-generation antipsychotics (SGAs) Pharmacologic interventions. The initial increasingly have been used for managing goals of pharmacologic treatment are to calm acute agitation in patients with an underly- Discuss this article at the patient without oversedation, thereby al- ing psychotic disorder. Guidelines from a www.facebook.com/ CurrentPsychiatry lowing the patient to take part in his or her 2012 American Association for Emergency care and begin treatment for the primary Psychiatry workgroup recommend using psychotic illness.3,4 Offering oral medications an SGA as monotherapy or in combina- first and a choice of medications may help a tion with another medication instead of patient feel more in control of the situation. haloperidol to treat agitated patients with Current Psychiatry If a patient has to be physically restrained, a known psychotic disorder.8 Clinical pol- Vol. 11, No. 12 11 Algorithm 1 Treating acute psychosis: Choosing pharmacologic agents Acutely psychotic patient Unknown cause of psychosis, Known or suspected underlying Acute psychosis no known history psychotic illness • Initiate treatment with haloperidol (PO/IM/ • Continue treatment with previous IV): 0.5 mg to 5 mg + lorazepam (PO/IM/ antipsychotic IV): 0.25 to 2 mg OR • Consider adding benztropine (PO/IM/IV): 0.5 to 2 mg OR diphenhydramine (PO/ • Initiate treatment with a second- IM/IV): 25 to 50 mg to reduce likelihood generation antipsychotic: of acute dystonic reaction or other EPS • PO: olanzapine: 5 to 10 mg, • Can also consider PO risperidone: 0.5 to risperidone: 0.5 to 2 mg +/- Clinical Point 2 mg, risperidone + lorazepam (at doses lorazepam: 0.5 to 2 mg listed above), olanzapine (PO/IM/SL): • IM: olanzapine: 2.5 to 20 mg, IM ziprasidone and 2.5 mg to 20 mg, ziprasidone (IM):10 to ziprasidone:10 to 20 mg 20 mg OR olanzapine have * Interventions may be repeated if clinically indicated; benztropine, 1 mg, or diphenhydramine, 25 mg, usually • Haloperidol (PO/IM/IV): 0.5 to 5 mg + a relatively rapid provide sufficient EPS prophylaxis for 12 hours lorazepam (PO/IM/IV): 0.5 to 2 mg onset of action, *Interventions may be repeated if clinically indicated If acute mania is suspected: which makes them • Load with divalproex (Table)15,16 reasonable choices in the acute setting EPS: extrapyramidal symptoms; PO: by mouth; SL: sublingual icy guidelines from the American College schizoaffective disorder decreased within of Emergency Physicians recommend an- 2 hours of IM olanzapine administration.13 tipsychotic monotherapy for agitation and Both IM ziprasidone and olanzapine have initial treatment in patients with a known a relatively rapid onset of action (within 30 psychiatric illness for which antipsychotic minutes), which makes them reasonable treatment is indicated (eg, schizophrenia).9 choices in the acute setting. Olanzapine has For patients with known psychotic illness, a long half-life (21 to 50 hours); therefore, pa- expert opinion recommends oral risperi- tients’ comorbid medical conditions, such as done or olanzapine.3,8 The combination of cardiac abnormalities or hypotension, must oral risperidone plus lorazepam may be as be considered. If parenteral medication is re- effective as the IM haloperidol and IM lo- quired, IM olanzapine or IM ziprasidone is razepam combination.10 Patients who are recommended.8 IM haloperidol with a ben- too agitated to take oral doses may require zodiazepine also can be considered.3 parenteral medications. Ziprasidone, olan- Coadministration of parenteral olan- zapine, and aripiprazole are available in zapine and a benzodiazepine can lead to IM formulations. Ziprasidone, 20 mg IM, severe orthostatic hypotension and cardiac is well tolerated and has been shown to be or respiratory depression and should be effective in decreasing acute agitation symp- avoided in geriatric patients.14 Finally, it is toms in patients with psychotic disorders.11 important to rule out presentations that may Olanzapine is as effective as