Management of Acute psychosis emergency to stabilisaton
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Presented at IPSOCON 2016, Annual Conference of Indian Psychiatric Society- South Zone held at Chennai on 14, 15 and 16 October 2016
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Management of Acute psychosis emergency to stabilisaton
- 1. MANAGING ACUTE PSYCHOTIC EPISODE Dr. Jayaprakashan K P Associate Professor of Psychiatry, Govt. Medical College, Thiruvananthapuram FROM EMERGENCY TO STABILISATION
- 2. Acute behavioural disturbance ■ psychiatric illness -only one cause ■ physical illness – acute confusional state – intoxication, – head injury, – epilepsy, infection, – metabolic disturbance – hypoglycaemia ■ substance abuse ■ Personality disorder
- 3. PSYCHOSIS Common reason for presentation to ED Serious disturbance behaviour Loss of reality orientation Delusions /hallucinations/ disorganised speech or behaviour/catatonia Diagnosis may vary …
- 4. Treatment goals PE Zeller SL Primary Psychiatry. Vol 17. No 6.2010. Exclude medical etiologies for symptoms •Rapid stabilization of acute crisis Avoid coercion •Treat in the least restrictive setting Form a therapeutic alliance •Appropriate disposition and aftercare plan
- 5. Indicators for medical problem ■ Somatic complaints ■ Vital sign abnormalities ■ Physical signs ■ Signs of intoxication, ■ Disorientation, ■ Rapid onset of psychotic symptoms, or ■ A waxing and waning mental status (Allen MH (ed): Emergency Psychiatry (Review of Psychiatry Series; Oldham JM and Riba MB, series eds). Washington, DC, American Psychiatric Publishing, 2002
- 6. Investigations ■ Complete blood count ■ Metabolic profile ■ Drug and alcohol levels ■ TSH etc.. ■ First episode – more detailed investigations
- 7. Thorough workup ■ First episode psychosis ■ Elderly patients, and ■ Patients with a history of trauma, falls ■ Patients with medical comorbidities Whenever possible should be done before giving psychotropics
- 8. Referral from a general hospital ED ■ Delirium and other organic conditions may be missed ■ In patients with psychiatric diagnosis – Delirium is missed – Medical conditions are missed.
- 9. Initial assessment At first sight Capacity for consent Potential harm to self and others RISK ASSESSMENT Whether immediate intervention is needed RAPID TRANQUILISATION vs DETAILED EVALUATION
- 10. How they came ■ Came on their own ■ Brought by a relative ■ Referred from a family doctor or physician ■ Brought by police
- 11. Brought involuntarily ■ Adequate staff should be available ■ Assess with support staff in the room ■ Safe environment ■ Brought restrained – physical examination – assess the need to continue – Use less stigmatising methods
- 12. Immediate assessment THOSE WHO ARE ■ frightened or paranoid, ■ verbally responding to internal stimuli, ■ verbally aggressive or threatening, ■ psychomotor agitation (e.g., pacing or shadowboxing), ■ attempting to leave the area without being evaluated.
- 13. Risk assessment ■ Predictors of aggression – Past history – Intoxication – Recent threatening behavior ■ Assessment tools – Eg. HCR -20 Monahan J, Steadman HJ, Silver E, et al: Rethinking Risk Assessment: The MacArthur Study of Mental Disorders and Violence. New York, Oxford University Press, 2001
- 14. RAPID TRANQUILISATION ■ Calming the patient without much sedation – NON-PHARMACOLOGICAL – PHARMACOLOGICAL ■ NICE Guidelines RT “All medication given in the short-term management of disturbed/violent behaviour should be considered as part of rapid tranquillisation”
- 15. Rapid Tranquillisation (RT) ■ No strong evidence base- based on – Partly on research data – Theoretical considerations – Clinical experience
- 16. STEP 1-Nonpharmacological ■ Offering food/ drink or cloth ■ Directing to quiet/secure area ■ Distraction ■ Negotiation ■ De- escalation The management of violence in general Psychiatry Sophie E. DavisonAdvances in Psychiatric Treatment (2005), vol. 11. http://apt.rcpsych.org/
- 17. De-escalation/talking down ■ Assessment of the immediate situation; ■ Verbal and non-verbal communication designed to facilitate cooperation; ■ Problem-solving tactics Dix, R. (2001) De-escalation techniques. In Psychiatric Intensive Care (eds D. Beer, S. Pereira & C. Paton)
- 18. Time out ■ Patient is voluntarily moved to a less stimulating area ■ Different from seclusion
- 19. STEP 2- Oral ■ Roughly 30mins, may be longer ■ Affected by food ■ Can use MD/SL /liquids ■ Repeat doses after minimum 30mins ■ Standard oral doses of antipsychotics or benzodiazepines or both Rapid Tranquillisation (RT) PolicyApproval date September 2013, Executive Director – Quality & Medical Leadership, Hertfordshire Partnership, University NHS Foundation Trust
- 20. STEP 3 - Parenteral ■ Parenteral (IM): – Quicker onset of action – approx 15-30mins – Affected by blood perfusion – IV Generally avoided ■ Repeat after 30mins if necessary Rapid Tranquillisation (RT) PolicyApproval date September 2013, Executive Director – Quality & Medical Leadership, Hertfordshire Partnership, University NHS Foundation Trust
- 21. Benzodiazepines ■ Diazepam ■ Lorazepam ■ Midazolam
- 22. Antipsychotics ■ Haloperidol ■ Olanzapine ■ Ziprasidone ■ Aripiprazole ■ Loxapine
- 23. Ideal parenteral antipsychotic ■ Rapid onset of therapeutic effect ■ Calming without profound sedation ■ Low risk of acute movement disorders ■ Low risk of hypotension ■ No dysphoria ■ Effective and well-tolerated ■ Transition from intramuscular to oral/depot available Zimbroff DL. CNS Spectr. Vol 8, No 11 (Suppl 2). 2003
- 24. Use of atypical antipsychotic ■ Several RCT s supporting oral atypical APDs ■ Larger, placebo-controlled RCTs support the efficacy of IM olanzapine, ziprasidone, and aripiprazole ■ Studies are in moderately disturbed Pts ■ Efficacy and safety of combination APD not known ■ Aripiprazole less effective but Benzodiazepines can be co- administered. Villari V et alCitrome L. Comparison of intramuscular ziprasidone, olanzapine, or aripiprazole for agitation: a quantitative review of efficacy and safety. J Clin Psychiatry 2007; 68:1876–1885. Oral risperidone, olanzapine and quetiapine versus haloperidol in psychotic agitation. Prog Neuropsychopharmacol Biol Psychiatry 2008; 32:405–413.
- 25. Haloperidol ■ Cochrane – Effective alone but poorly tolerated – Co-administration of PM ■ NICE – Evidence of promethazine is inconclusive ■ Rapid Tranquilisation Clinical Trial (TREC )
- 26. TREC studies 1. Brazil, 2003 (BMJ). n=301. IM Midazolam vs. IM HPL+PM Tranquil/sedated at 20mins. 2. India, 2004 (BJPsych). n=200. IM lorazepam vs. IM HPL+PM Tranquil/calm or asleep by 4hrs 3. Brazil, 2007 (BMJ). n=316. IM Haloperidol vs. IM HPL+PM Tranquil/asleep at 20mins. 4. India, 2007 (BMJ). n=300. IM olanzapine vs. IM HPL+PM Tranquil/asleep at 15mins
- 27. Case against HPL ■ EPS and acute dystonia(5%) ■ QT Prolongation (15 ms) ■ Pre- treatment ECG ■ Seizures (rare) ■ Combination not recommended ■ PM inhibit metabolism The Maudsley Prescribing Guidelines in Psychiatry, 12th Edition, David Taylor, Carol Paton, Shitij Kapur, April 2015, Wiley-Blackwell
- 28. Haloperidol NHS /NICE Guideline ■ 10mg po = 6mg IM - no longer licensed for IV use ■ Baseline ECG is recommended prior to treatment in all patients, ■ ECG monitoring in the elderly and patients with a positive h/o cardiac problems ■ Discontinue if the QTc exceeds 500ms. ■ BNF maximums now 20mg/d po, 12mg/d IM
- 29. DOSE ■ High dose (more than 10mg HPL or equivalent) – Not more effective – More adverse effects ■ Low dose HPL - equally effective
- 30. Olanzapine IM ■ Action IM: 15-30mins (po: ~ 2 hours) ■ t½: 30 hours, duration of effect: ~24 hours Dose: 10mg. Po = IM - Inj must be at least 2 hrs apart, ■ Max 3 inj or 20mg/24hrs all routes ■ Cardiorespiratory depression, Simultaneous injection of benzodiazepine is not recommended.
- 31. Ziprasidone Injection ■ 10 mg–20 mg IM ■ maximum dose of 40 mg per day. ■ 10 mg -every 2 hours ■ 20 mg every 4 hours Not available
- 32. Aripiprazole Injection ■ Onset of action IM: 30- 45mins (slower) ■ Dose: (5.25mg) 9.75mg = 1.3mls, (15mg ) ■ Inj must be at least 2 hrs apart ■ max. 3 inj or 30mg/24hrs all routes ■ With concurrent benzodiazepines ■ Less effective than haloperidol Not available
- 33. Benzodiazepines ■ Diazepam – Not well absorbed as IM ■ Lorazepam – Short acting, rapid onset – No active metabolite- low risk of accumulation – t½ : 12-16 hours , duration effect: 6-8 hours – 2mg IM repeated 6hrly ■ Inj Midazolam 7.5 to 10mg IM ■ Risk of respiratory depression. Inj. Flumazenil should be available.
- 34. Inhalation : Loxapine Not available
- 35. Role of Clopixol Acuphase ■ Zuclopenthixol Acetate ■ Not for Rapid Tranquillisation ■ Onset of action at 2-8 hours ■ Maximum serum concentrations reached at 24-36 hours ■ Medium term plan – allow less restraint
- 36. Alternative RT Options ECT ■ Depressive disorder/ Mania/ Acute Schizophrenia Loading dose of Valproate ■ Mania, short term response to aggression in schizophrenia Midazolam – buccal & sublingual ■ Sublingual: high bioavailability (~75%) reliable plasma concs2 ■ Sedative effects at 15 minutes peaking at 30 minutes, and lasted at least 1 hour
- 37. RT NEED TO BE JUDICIOUSLY COMBINED WITH SECLUSION AND RESTRAINT
- 38. Restraint ■ Usually 4 point restraint – Manual – Mechanical – Usually with strong cotton gauze – One upper limb down – Legs to opposite side
- 39. Correct method
- 40. Manual restraint ■ 5 persons ■ One person holding each limb ■ Therapeutic hold in children
- 41. Gravitational restraint ■ Reclining chair like positioning ■ For medically ill and agitated ■ Lighter restraint of limbs O'Brien EM1, Rosenquist PB, Kimball JN, Minor LN, Arias LM. A novel positioning technique for the agitated patient after electroconvulsive therapy: gravitational restraint J ECT. 2010 Sep;26(3):158
- 42. Complications death injures Should be rigorously monitored – implemented for the shortest period Currier GW, Allen MH. Emergency psychiatry: physical and chemical restraint in the psychiatric emergency service. Psychiatr Serv. 2000;51:717-719
- 43. Seclusion Seclusion refers to the temporary, involuntary confinement of a patient in a room or area from which the person is physically prevented from leaving
- 44. Monitoring ■ 1 hour rule ■ should be monitored by „within eyesight‟ observation by a suitably trained individual ■ Record keeping
- 45. Training Behavioural management, handling patient, debriefing
- 46. Risks ■ Suicide ■ Injury ■ Poor rapport ■ Controversial ■ Traumatising ■ Chance of litigation
- 47. The aims of RT are threefold : 1. To reduce suffering for the patient: psychological or physical (through self-harm or accidents) 2. To reduce risk of harm to others by maintaining a safe environment 3. To do no harm (by prescribing safe regimes and monitoring physical health).
- 48. Detailed evaluation ■ Diagnosis and specific treatment at the point when reached specific diagnosis – Schizophrenia – Other Psychotic disorders – Psychotic depression – Mood Disorder
- 49. SETTING AND FACILITIES Lack of modern or even basic facilities General hospital ED Psychiatric hospital
- 50. An eye opener August 16, 2015 Nimhans Bangalore. A UT prisoner patient was shot dead.
- 51. Psychiatric hospital ■ Open ward ■ Closed ward ■ Seclusion/Cell room ■ BICU
- 52. WHAT WE NEED TO FOCUS ?
- 53. Pharmacological Management ■ Safety first – Oral if possible/ atypical – lower dose of Haloperidol/ atypical where affordable ■ Reduce complications – ECG/ blood level monitoring/ frequent evaluation ■ Reduce direct or indirect harm – Judicious combination with seclusion and restraint
- 54. Immediate need ■ Setting up ED with a design focussed on patient staff safety ■ A written seclusion and restraint policy ■ Developing staff training and team work in ED
- 55. Psychiatric Emergency Rooms Modern psychiatric emergency room in general hospital ED Collapsible wall converting the room into a ligature proof safe room Emory-ED-Behavioral-Health-Exam-Room-2-tamper-proof
- 57. Set up safe facility Safe environment Cell rooms to modern seclusion rooms Trained staff in adequate number Mental Health Care and Human Rights, 2008 Edited by D Nagaraja and Pratima Murthy Joint copyright: National Human Rights Commission, New Delhi and National Institute of Mental Health and Neuro Sciences, Bangalore
- 58. POSITIVE & PROACTIVE CARE ■ Respect human rights – Only few others can curtail basic rights of a citizen ■ There should be a continuous efforts at – reducing seclusion and restraint – at improving safety of hospital setting – Improving basic facilities comfort for the client – Improving staff skills and quality of care
- 59. Reducing use of seclusion and restraint
- 60. “Psychiatric emergency care should be safe and humane”
- 61. THANK YOU For patient listening!