Emergency Psychiatry The Acutely Disturbed Patient A Professor David

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Emergency Psychiatry (The Acutely Disturbed Patient) A/Professor David Ash Senior Visiting Consultant Intensive Care Emergency Psychiatry (The Acutely Disturbed Patient) A/Professor David Ash Senior Visiting Consultant Intensive Care Unit Glenside Hospital

Introduction 1. A/Professor David Ash • Overview • Setting • Cedars Psychiatric Intensive Care Introduction 1. A/Professor David Ash • Overview • Setting • Cedars Psychiatric Intensive Care Unit • Violence and aggression • Pharmacotherapy – – – Agitated, psychotic patient Mania, schizomania Bipolar depression, schizodepression Unipolar depression Patient perspective • ECT • Substance abuse A/Professor David Ash 2

Overview • Emergency psychiatry is a subspecialty of psychiatry that has evolved over the Overview • Emergency psychiatry is a subspecialty of psychiatry that has evolved over the last 30 years. • Reduction in inpatient beds has resulted in the growth of psychiatric emergency services and an increase in the numbers of people seen in the community. • Principles of crisis intervention. A/Professor David Ash 3

Psychiatric Emergencies • No single condition or illness • Any situation requiring immediate assessment Psychiatric Emergencies • No single condition or illness • Any situation requiring immediate assessment and rapid intervention • Involve behavioural disturbance, threat of behavioural disturbance, physiological disturbance, high risk assessment A/Professor David Ash 4

Psychiatric Emergencies • • • Suicidal Presentations Aggression and Violence Acute psychosis Mood disorders Psychiatric Emergencies • • • Suicidal Presentations Aggression and Violence Acute psychosis Mood disorders – mania and depression Personality disorders in crisis Major disasters A/Professor David Ash 5

Psychiatric Emergencies • • • Alcohol / substance abuse or intoxication Medical conditions Delirium Psychiatric Emergencies • • • Alcohol / substance abuse or intoxication Medical conditions Delirium Neuroleptic Malignant Syndrome Serotonin syndrome Lithium toxicity A/Professor David Ash 6

Psychiatric Emergencies • • • Alcohol / substance abuse or intoxication Medical conditions Delirium Psychiatric Emergencies • • • Alcohol / substance abuse or intoxication Medical conditions Delirium Neuroleptic Malignant Syndrome Serotonin syndrome Lithium toxicity A/Professor David Ash 7

Risk Assessment • • • • Self harm Self neglect Victim of aggression, violence Risk Assessment • • • • Self harm Self neglect Victim of aggression, violence Suicide Disinhibition Impulsivity Restlessness, agitation Harassment, verbal aggression Threatened / actual aggression, violence Absconding risk Available support Insight Ability to work with treating clinicians Availability of suitable accommodation Substance use Alcohol A/Professor David Ash 8

The Setting • • • Community Crisis units / short stay units/ crisis beds The Setting • • • Community Crisis units / short stay units/ crisis beds Emergency department Inpatient unit High dependency unit (HDU) / Intensive care unit (ICU) A/Professor David Ash 9

The Community • Location – community clinic, patient’s home • Preferred by patients • The Community • Location – community clinic, patient’s home • Preferred by patients • Able to assess person’s capacity to cope in familiar home environment • Presence of family, neighbours, friends • Safety issues – Work in pairs – Risk assessment prior to visit, if necessary police in attendance – Weapons – Ensure front door not deadlocked – Decision to detain – end interview – ensure that ambulance, police in attendance A/Professor David Ash 10

I didn’t know they made house calls A/Professor David Ash 11 I didn’t know they made house calls A/Professor David Ash 11

Emergency Department • Triage • Safe environment for emergency evaluation – Weapon screening – Emergency Department • Triage • Safe environment for emergency evaluation – Weapon screening – Rooms in which the examiner cannot be easily trapped – Open vs enclosed interview area – Method to call for help – Adequate personnel to respond if help is needed including trained security personnel A/Professor David Ash 12

Crisis Units / Short Stay Units/ Crisis Beds, PECCU • Location – community, mental Crisis Units / Short Stay Units/ Crisis Beds, PECCU • Location – community, mental health centres, psychiatric hospitals (Ash, Galletly), general hospitals (Frank et al) • Short term crisis admission, triage, transfer • Early discharge, community treatment A/Professor David Ash 13

Inpatient Units • • • Higher acuity Aggression and violence Substance abuse Forensic issues Inpatient Units • • • Higher acuity Aggression and violence Substance abuse Forensic issues Homelessness (Ash, Galletly et al) A/Professor David Ash 14

Inpatient Units • • • Safe environment for patients / staff Time out, restraint, Inpatient Units • • • Safe environment for patients / staff Time out, restraint, seclusion Guidelines for risk management Staff training / staff morale Leadership / support Linkage and communication with community resources A/Professor David Ash 15

Not much of a psychiatric unit, though, is it? A/Professor David Ash 16 Not much of a psychiatric unit, though, is it? A/Professor David Ash 16

ICU / HDU Admission to the ICU / HDU is indicated for: Dangerous, aggressive ICU / HDU Admission to the ICU / HDU is indicated for: Dangerous, aggressive self harming behavior, not able to be contained in a less restrictive environment Aim for brief admission with: • Intensive treatment • High nurse / patient ratios • Calming environment • Recovery based services Potential disadvantages of ICU / HDU: • Risk of assault • Overmedication • Overstimulation • Worsening of symptoms A/Professor David Ash • PTSD 17

Options 1. Central, stand alone ICUs 2. Smaller HDU / ICUs in inpatient units Options 1. Central, stand alone ICUs 2. Smaller HDU / ICUs in inpatient units Flexibility, closed / open options 3. Intensive nursing 1: 1 in open ward Associated Issues • consumer involvement • how to reduce trauma associated with inpatient care in the HDU / ICU • safety care plans • sensory modulation • debriefing, counselling following seclusion and restraint A/Professor David Ash 18

Cedars PICU - Adelaide • Intake from: CNAHS (North, East), overflow from West Rural Cedars PICU - Adelaide • Intake from: CNAHS (North, East), overflow from West Rural and Remote (on Glenside Campus) + all indigenous people • 10 beds Cedars PICU: Psychiatrist 1. 1 FTE Psychiatric Registrars 1 – 2 FTE CSC 1 FTE CN 1 FTE Primary Nurses 4 Social Worker 1 FTE Drug and Alcohol Clinician 0. 2 FTE Carer Support Worked 0. 5 FTE • • • Daily handover meetings and clinical review Experienced nursing staff Non-pharmacological interventions include: • • One to one counselling and support Recovery-focussed care Early intervention/de-escalation techniques Psycho-education Drug and alcohol counselling Judicious use of medication, restraint, seclusion A/Professor David Ash Communication with patients, family, support networks, treating teams (clinicians) 19

Cedars PICU - Adelaide Routine monitoring of electrolytes, renal function, liver function, glucose, cholesterol, Cedars PICU - Adelaide Routine monitoring of electrolytes, renal function, liver function, glucose, cholesterol, lipid profile, ECG, BMI A/Professor David Ash 20

Treatment of Behavioural Emergencies – summary of expert consensus guidelines Preferred initial interventions for Treatment of Behavioural Emergencies – summary of expert consensus guidelines Preferred initial interventions for an imminently violent patient: • • • Verbal intervention Voluntary medication Show of force Emergency medication Offer food, beverage, other assistance Alternate Interventions: • Physical restraint • Locked or unlocked quiet room, seclusion A/Professor David Ash 21

- Treatment of Behavioural Emergencies summary of expert consensus guidelines When to use physical - Treatment of Behavioural Emergencies summary of expert consensus guidelines When to use physical restraint: Extremely or usually appropriate: • Acute danger to other patients, bystanders, staff or self Sometimes appropriate: • To prevent an involuntary patients from leaving prior to assessment or transfer to a locked facility Rarely or never appropriate: • • Lack of resources to supervise patient adequately To prevent a voluntary patient from leaving prior to assessment To maintain an orderly treatment environment History of previous self-injury or aggression A/Professor David Ash 22

A/Professor David Ash 23 A/Professor David Ash 23

Illusion - self deception in regard to the memory of a past experience A/Professor Illusion - self deception in regard to the memory of a past experience A/Professor David Ash 24

Violence and Aggression: Hostile or destructive behaviour or actions Violence: Physical force exerted for Violence and Aggression: Hostile or destructive behaviour or actions Violence: Physical force exerted for the purpose of violating, damaging, or abusing Contemporary concerns • Unprovoked, haphazard violence • Violence by people suffering from mental illness • Terrorism A/Professor David Ash 25

Models of Aggression • Don Grant dehumanization acceptance of violence rage and its control Models of Aggression • Don Grant dehumanization acceptance of violence rage and its control • Learning Theory Bandura - imitation and modeling of aggression • Megargee over vs under controlled personality • Group dynamics primitive, murderous rage A/Professor David Ash 26

Psychodynamic Concepts of Aggression • • aggression as an innate drive ambivalence of primary Psychodynamic Concepts of Aggression • • aggression as an innate drive ambivalence of primary love object deficits in superego development defence against feelings of inferiority or impotence splitting displacement projection projective identification A/Professor David Ash 27

Social and Cultural Aspects • Young men in low socioeconomic groups have an increased Social and Cultural Aspects • Young men in low socioeconomic groups have an increased risk of violence and of being a victim of violence • USA – nonwhites are more likely to be offenders and victims of violence • There are differences between countries (e. g. Europe compared to USA) • Culture: • Subcultures of violence • Regional cultures of violence • Societal values and violence • Economic inequality and criminal violence • Inequality of opportunity and criminal violence A/Professor David Ash 28

Biological • Lorenz – aggression is an inherent tension-producing drive • Amygdala, hypothalamus, prefrontal Biological • Lorenz – aggression is an inherent tension-producing drive • Amygdala, hypothalamus, prefrontal cortex, limbic system • Cortical dysfunction e. g. abnormal EEG in antisocial personality disorder • Genetic e. g. sex chromosome abnormalities • Hormonal • Neurotransmitters GABA, serotonin, noradrenalin and dopamine are associated with increased aggression • Alcohol, substance abuse A/Professor David Ash 29

Developmental Factors Associated with Adult Violence • • Abuse by parents Truancy, school failure, Developmental Factors Associated with Adult Violence • • Abuse by parents Truancy, school failure, lower IQ Delinquency as an adolescent Arrest for prior assaults Childhood hyperactivity First psychiatric hospitalization by age 18 years Fire setting and animal cruelty History of being a childhood bully A/Professor David Ash 30

Risk Factors for Aggression or Violence • • • young, male developmental factors less Risk Factors for Aggression or Violence • • • young, male developmental factors less education lack of sustained employment lower socioeconomic status history of substance abuse acute intoxication with alcohol and / or psychoactive substances past history of violence, aggression violent fantasies forensic history A/Professor David Ash 31

Risk Factors for Aggression and Violence (continued) • chronic anger towards others • recent Risk Factors for Aggression and Violence (continued) • chronic anger towards others • recent sense of being unfairly treated. • residential instability – homeless mentally ill more likely to offend • antisocial / borderline personality disorder • mania • acute psychosis – delusional beliefs involving particular individuals • command hallucinations • delirium • dementia A/Professor David Ash 32

A/Professor David Ash Paranoia – delusions of persecution 33 A/Professor David Ash Paranoia – delusions of persecution 33

Assessing the Aggressive, Violent Patient Aims: • • • To ensure your own safety Assessing the Aggressive, Violent Patient Aims: • • • To ensure your own safety To ensure the safety of staff and other patients To keep the patient safe To detect the presence of acute medical problems To detect the presence of psychiatric illness To achieve rapid stabilization and disposition of the patient A/Professor David Ash 34

Clinical Evaluation • • • Remain at a safe distance Privacy but not isolation Clinical Evaluation • • • Remain at a safe distance Privacy but not isolation Offer food, drink, universal language of hospitality Look and listen, be respectful Talk with an even, concerned tone of voice Consider the timing of questions and directions Ask simple questions Avoid being provocative Agree to disagree Maintain observational awareness – warning signs Obtain collateral history A/Professor David Ash 35

Clinical Evaluation • The environment should not be fragile • Know where the alarms Clinical Evaluation • The environment should not be fragile • Know where the alarms are located and how to activate them • Ensure availability, presence of adequately trained staff and security personnel • Ensure a means of escape A/Professor David Ash 36

Predictors of Impending Violence Include: • • • Refusal to cooperate Intense staring Motor Predictors of Impending Violence Include: • • • Refusal to cooperate Intense staring Motor restlessness Purposeless movements Labile affect Loud speech Irritability Intimidating behavior Damage to property Demeaning or hostile verbal behavior Direct threat of assault A/Professor David Ash 37 Hillard and Zatek

Management • Establish differential diagnosis • Attempt where possible to initiate treatment with medication Management • Establish differential diagnosis • Attempt where possible to initiate treatment with medication to treat underlying illness. • Assess risk to others (specific threats) – duty to warn • Weapons – firearms notification • Where to treat? • Voluntary or detained? • Use verbal strategies initially; if necessary use restraint, emergency medication, seclusion • Liaise with treating team/clinicians (if any) • If no evidence of psychiatric or medical illness – consider involving the police. A/Professor David Ash 38

Pharmacotherapy – General Principles Choice of medication is based on: • diagnostic assessment, • Pharmacotherapy – General Principles Choice of medication is based on: • diagnostic assessment, • past history, • medical comorbidities, • substance abuse and intoxication A/Professor David Ash 39

Choice of Medication Consider: • speed of onset • oral vs IM • duration Choice of Medication Consider: • speed of onset • oral vs IM • duration of action • side effects • past response • patient preference A/Professor David Ash 40

Consumer Perspective • Consumers stress the importance of staff treating them with respect, communicating, Consumer Perspective • Consumers stress the importance of staff treating them with respect, communicating, listening, involving them in treatment decisions (Allen) • Expert Consensus Guidelines (Behavioral Emergencies), (Allen): - Verbal interaction - Collaborative approach - Oral medication if possible – guided by consumer’s problems, medication experiences and preferences • IM medication – can be a symbolic assault involving – Physical trauma – emotional trauma – Risk of side effects Compromises the clinician – patient relationship May reduce future medication adherence A/Professor David Ash 41

Consumer Perspective • 1/5 of a consumer panel attributed their emergency contact to lack Consumer Perspective • 1/5 of a consumer panel attributed their emergency contact to lack of access to more routine mental health care • almost 50% of consumers said they wanted medication and benefited from medication • Many complained about forced administration and unwanted side effects A/Professor David Ash 42

Consumer Panel Stressed the Importance of: • • Alternatives to traditional emergency room services Consumer Panel Stressed the Importance of: • • Alternatives to traditional emergency room services Increased use of advance directives More comfortable physical environments Improved training of emergency unit staff to foster a humane, person-centres approach • Collaboration between practitioners and consumers • Improved discharge planning and reliable , consistent aftercare A/Professor David Ash 43

Benzodiazepines Exercise caution in the use of benzodiazepines: • • • elderly patients with Benzodiazepines Exercise caution in the use of benzodiazepines: • • • elderly patients with respiratory disease acute intoxication with alcohol severe impairment of hepatic or renal function depressed level of consciousness, patients using other sedating medications A/Professor David Ash 44

Midazolam • Midazolam 2 – 10 mg (IM/IV) is often used in the emergency Midazolam • Midazolam 2 – 10 mg (IM/IV) is often used in the emergency department for agitated, aggressive patients • Midazolam IM is also used in ICU – Brentwood • Risk of respiratory depression – requires close monitoring and ideally pulse oximetry • Onset of action 1 – 15 minutes (depending on route of administration) • Half life 1 – 2. 8 hours A/Professor David Ash 45

Clonazepam • Clonazepam (0. 5 – 2 mg) is a longer acting IM alternative Clonazepam • Clonazepam (0. 5 – 2 mg) is a longer acting IM alternative to midazolam – but risks associated with excessive sedation, ataxia • Onset of action 5 – 15 minutes • Peak plasma levels in less than 4 hours • Half life 20 – 40 hours A/Professor David Ash 46

Lorazepam • Lorazepam (0. 5 – 2. 5 mg) is often favoured over diazepam Lorazepam • Lorazepam (0. 5 – 2. 5 mg) is often favoured over diazepam because of the shorter half life • Onset of action 5 – 15 minutes • Peak plasma levels in 2 hours (oral and IM have a similar absorption profile) • Half life 10 – 20 hours • Less respiratory depression than Diazepam and Midazolam A/Professor David Ash 47

Diazepam • • Diazepam (2. 5 – 10 mg) is well absorbed orally IM Diazepam • • Diazepam (2. 5 – 10 mg) is well absorbed orally IM absorption is erratic Onset of action (oral) up to 30 minutes Half life 14 - 60 hours (has multiple active metabolites) A/Professor David Ash 48

Antipsychotic Medication First Generation Antipsychotics – Low Potency sedation postural hypotension EPS Chlorpromazine (oral) Antipsychotic Medication First Generation Antipsychotics – Low Potency sedation postural hypotension EPS Chlorpromazine (oral) • • • Onset of action up to 20 minutes with oral medication Peak plasma levels -2 -4 hours Half life 24 hours (range 8 -35 hours) Intermediate Potency e. g. perphenazine A/Professor David Ash 49

First Generation Antipsychotics – High Potency tranquilization EPS Haloperidol (oral / IM) • Time First Generation Antipsychotics – High Potency tranquilization EPS Haloperidol (oral / IM) • Time of Onset of action depends on route of administration – IV – immediate – Oral - up to 60 minutes • Half life 24 hours A/Professor David Ash 50

Zuclopenthixol • Zuclopenthixol HCl (Clopixol) 10, 25 mg tablets • Onset of action 10 Zuclopenthixol • Zuclopenthixol HCl (Clopixol) 10, 25 mg tablets • Onset of action 10 -30 minutes • Peak plasma levels in less than 4 hours • Half life 24 hours A/Professor David Ash 51

Droperidol • • Droperidol is a high potency Butyrophenone Parenteral preparation Maximum dose 30 Droperidol • • Droperidol is a high potency Butyrophenone Parenteral preparation Maximum dose 30 mg over 24 hours Onset action (IM) 1 – 20 minutes Duration of action 2 – 4 hours Half life 2. 2 hours Prolongation QT interval A/Professor David Ash 52

Acuphase (Zuclopenthixol acetate) • Acuphase (Zuclopenthixol acetate) – short acting depot used when IM Acuphase (Zuclopenthixol acetate) • Acuphase (Zuclopenthixol acetate) – short acting depot used when IM medication is required, with tranquilization lasting 24 to 72 hours • Onset of action 4 to 6 hours • Monitor for EPS • Exercise caution in treatment naive patients A/Professor David Ash 53

Second Generation Antipsychotics (SGAs) • Risperidone (tablets, quicklets, depot) • Paliperidone (tablets, depot) • Second Generation Antipsychotics (SGAs) • Risperidone (tablets, quicklets, depot) • Paliperidone (tablets, depot) • Olanzapine (tablets, wafers, short-acting IM, depot) • Amisulpride (tablets, syrup) • Aripiprazole (tablets, short-acting IM) • Quetiapine IR, XR (tablets) • Ziprasidone (tablets, short-acting IM) • Clozapine (tablets, syrup) A/Professor David Ash 54

Second Generation Antipsychotics • Until recently research suggested SGAs have superior efficacy for negative Second Generation Antipsychotics • Until recently research suggested SGAs have superior efficacy for negative symptoms, cognition and mood in schizophrenia. • First episode psychosis (low dose) • SGAs are also used – – For tranquilization and to reduce hostility in agitated patients In mania and depression As mood stabilizers In anxiety disorders including GAD and social anxiety disorder – As augmentation treatments in OCD and treatment-resistant depression – As monotherapy / augmentation in PTSD and borderline personality disorder – Behavioral disturbance in dementia and brain injury A/Professor David Ash 55

Second Generation Antipsychotics • Less likely to cause EPS, although can occur with 2 Second Generation Antipsychotics • Less likely to cause EPS, although can occur with 2 nd generation antipsychotics esp. Risperidone, Amisulpride in higher doses (Aripiprazole – restlessness) • EPS less likely with Quetiapine and Clozapine • Metabolic syndrome (predominantly Clozapine, Olanzapine) • Cardiovascular / cerebrovascular events in the elderly ? class effect • Postural hypotension (Risperidone, Quetiapine) • Hyperprolactinemia (Risperidone, Amisulpride) • QTc prolongation (e. g. Ziprasidone, Amisulpride, Quetiapine) A/Professor David Ash 56

Second Generation Antipsychotics – Controversies, Unresolved Issues • Drug development studies have focused on Second Generation Antipsychotics – Controversies, Unresolved Issues • Drug development studies have focused on reduction in symptoms severity with restrictive inclusion / exclusion criteria. • Short term, narrowly focused trials provide limited information about the effectiveness of drugs in clinical practice. • Recent studies have raised questions about the advantages of SGAs in schizophrenia: (CATIE, CAFÉ, CUt. LASS 1, EUFEST, Goldberg et al) A/Professor David Ash 57

Risperidone • • Oral, quicklets 0. 5 – 2 mg stat dose Onset action Risperidone • • Oral, quicklets 0. 5 – 2 mg stat dose Onset action 10 - 30 minutes Peak plasma levels 1 -2 hours Duration of action 6 - 10 hours Half life 19 hours Postural hypotension, EPS (high dose), hyperprolactinemia A/Professor David Ash 58

Paliperidone • Active metabolite of risperidone • Prolonged release tablet • Peak plasma concentrations Paliperidone • Active metabolite of risperidone • Prolonged release tablet • Peak plasma concentrations about 24 hours after oral dosing • Elimination half-life of about 23 hours • Similar side effects to risperidone A/Professor David Ash 59

Olanzapine • • Oral, wafers, IM 2. 5 – 10 mg stat dose Onset Olanzapine • • Oral, wafers, IM 2. 5 – 10 mg stat dose Onset of action 15 - 60 minutes Peak plasma levels 15 minutes -8 hours (depending on route of administration) • Half life 27 hours • Metabolic syndrome, sedation A/Professor David Ash 60

Amisulpride • • Oral – tablets, syrup Peak plasma level 1 – 4 hours Amisulpride • • Oral – tablets, syrup Peak plasma level 1 – 4 hours Half life 12 hours EPS, hyperprolactinemia and QTc prologation at high dose Aripiprazole • • • Oral – tablets Onset action 1 – 3 hours Peak plasma level 3 -5 hours Half life 75 hours Restlessness A/Professor David Ash 61

Quetiapine IR • • Oral - tablets 50 -150 mg stat dose Onset of Quetiapine IR • • Oral - tablets 50 -150 mg stat dose Onset of action 10 - 30 minutes Peak plasma level 1 -5 hours Duration of Action 4 - 12 hours Half life 6 -7 hours Postural hypotnesion, sedation ? QTc prologation at high dose XR form now available, longer half life. A/Professor David Ash 62

Ziprasidone • • • 80 – 160 mg / day Must be taken with Ziprasidone • • • 80 – 160 mg / day Must be taken with food Low incidence weight gain Akathisia QTc prologation A/Professor David Ash 63

Clozapine • • Oral - tablets Peak plasma levels 2 -5 hours Half life Clozapine • • Oral - tablets Peak plasma levels 2 -5 hours Half life 12 hours Agranulocytosis, myocarditis, cardiomyopathy, metabolic syndrome, lower seizure threshold – balance benefit against risk. A/Professor David Ash 64

Antipsychotics and Risk of Sudden Death Straus et al. 2004 Precise mechanism uncertain, suggestions Antipsychotics and Risk of Sudden Death Straus et al. 2004 Precise mechanism uncertain, suggestions include: • • • Peripheral vasodilatation and cardiovascular collapse Oral laryngeal / pharyngeal dystonia Acute myocarditis Cardiomyopathy QTc prolongation A/Professor David Ash 65

Antipsychotics and Risk of Sudden Death Straus et al. 2004 • Integrated Primary Care Antipsychotics and Risk of Sudden Death Straus et al. 2004 • Integrated Primary Care Information Project • 554 cases of sudden cardiac death • Current use of antipsychotics was associated with a 3 fold increase in the risk of sudden cardiac death • Risk highest with butyrophenone antipsychotics (e. g. haloperidol / droperidol) and short term use A/Professor David Ash 66

QTc Interval • Dose dependant prolongation of QTc interval may potentiate risk of serious QTc Interval • Dose dependant prolongation of QTc interval may potentiate risk of serious ventricular arrhythmias such as Torsade de Pointes (rare occurrence < 0. 01%) • Risk enhanced by existence of – bradycardia (< 55) – hypokalaemia – congenital prolongation of QTc interval – treatment with medications that produce pronounced bradycardia, slowing of intracardiac conduction or prolongation of QTc interval – should not be given with drugs that induce arrythmias such as amiodorone, quinidine, sotolol, cisapride, thioridazine and erythromycin. Ash A/Professor David 67

Medication for agitated, psychotic patients Generally involves a combination of: • Oral atypical antipsychotic Medication for agitated, psychotic patients Generally involves a combination of: • Oral atypical antipsychotic • Oral benzodiazepine in the first instance If compliance is an issue: • Olanzapine / risperidone dissolvable wafers or • Risperidone / amisulpride syrup A/Professor David Ash 68

Parenteral Medication If patient more agitated or unwilling to accept oral medication: • IM Parenteral Medication If patient more agitated or unwilling to accept oral medication: • IM olanzapine or IM haloperidol plus • IM lorazepam / clonazepam /midazolam If patient extremely agitated and presents an ongoing threat to self or others or has not responded to IM olanzapine / IM haloperidol consider use of: • zuclopenthixol acetate plus • IM lorazepam / clonazepam / midazolam Monitor level of sedation, respiration. Ideally pulse oximetry if using midazolam. A/Professor David Ash 69

Mania / Schizoaffective Disorder with Mania Medications which have efficacy include: • • • Mania / Schizoaffective Disorder with Mania Medications which have efficacy include: • • • Lithium Carbonate Sodium Valproate Carbamazepine Olanzapine ziprasidone • • Quetiapine Risperidone Aripiprazole Clozapine In practise second generation antipsychotics are often used in combination with anticonvulsants / lithium carbonate. Concurrent use of oral / parenteral benzodiazepines to sedate and reduce arousal. A/Professor David Ash 70

Sodium Valproate: • loading dose 20 -30 mg/kg. • If no response after 7 Sodium Valproate: • loading dose 20 -30 mg/kg. • If no response after 7 - 10 days consider alternative mood stabilizer • more efficacious in patients with: mixed affective states rapid cycling comorbid substance abuse A/Professor David Ash 71

Bipolar Depression / Schizoaffective Disorder with Depression • Optimize mood stabilizer • Antidepressant medication Bipolar Depression / Schizoaffective Disorder with Depression • Optimize mood stabilizer • Antidepressant medication – ? Efficacy in BP depression • Benzodiazepines to reduce arousal / agitation • SGA to reduce arousal / agitation and/or psychotic symptoms, augment treatment of depression • If compliance has not been an issue consider an alternative mood stabilizer • Lamotrigine has efficacy in prophylaxis of bipolar depression – however has limited value in the acute setting • Monitor mood / suicidal ideation – provision of treatment in safe environment A/Professor David Ash 72 • SGA monotherapy in bipolar depression

Unipolar Depression • Antidepressant medication • Second generation antipsychotic monotherapy (quetiapine) • Second generation Unipolar Depression • Antidepressant medication • Second generation antipsychotic monotherapy (quetiapine) • Second generation antipsychotic to reduce arousal / agitation and / or psychotic symptoms • Benzodiazepines to reduce arousal / agitation • Monitor mood / suicidal ideation – provision of treatment in safe environment • Consider augmentation strategies e. g. lithium, thyroxine, second generation antipsychotic etc. A/Professor David Ash 73

Schizophrenia RANZCP Clinical Practice Guidelines, Mc. Gorry et al 2005 • SGA – treatment Schizophrenia RANZCP Clinical Practice Guidelines, Mc. Gorry et al 2005 • SGA – treatment of first choice • Conventional antipsychotic in low dosage where there is remission, good tolerability, or depot medication unavoidable • Consider clozapine if there is incomplete remission with at least 2 other antipsychotic agents • Psychosocial interventions – assertive community treatment, medication adherence therapy, (cognitive remediation therapy) • Consumer involvement • Physical health – prevention and early treatment of medical illness • Shared care with GP. A/Professor David Ash 74

Treatment Resistant Schizophrenia Also: • Clozapine / amisulpride combination • Clozapine / aripiprazole combination Treatment Resistant Schizophrenia Also: • Clozapine / amisulpride combination • Clozapine / aripiprazole combination • Clozapine / ECT A/Professor David Ash 75

ECT - Indications Depression Bipolar depression Unipolar depression Psychotic features Lack of response to ECT - Indications Depression Bipolar depression Unipolar depression Psychotic features Lack of response to pharmacotherapy Severe illness with significant risk to self through suicide or self neglect Mania Severe mania unresponsive to pharmacotherapy A/Professor David Ash 76

ECT - Indications Schizophrenia Catatonia Associated depression Inadequate response to pharmacotherapy Severe illness, risk ECT - Indications Schizophrenia Catatonia Associated depression Inadequate response to pharmacotherapy Severe illness, risk to self, others Evidence for combined clozapine and ECT in treatment refractory schizophrenia A/Professor David Ash 77

Shock treatment – therapy used to alter favorably the course A/Professor David Ash 78 Shock treatment – therapy used to alter favorably the course A/Professor David Ash 78 of a mental illness

Substance Abuse • Two to three times more common among those with psychiatric illness Substance Abuse • Two to three times more common among those with psychiatric illness than in general population. • Negative attitudes towards this subset of the population hinders the provision of effective care. • Urine drug screening helpful A/Professor David Ash 79

Common Substances of Abuse • • Alcohol Cocaine Amphetamine Methamphetamine MDMA (3, 4 methylene Common Substances of Abuse • • Alcohol Cocaine Amphetamine Methamphetamine MDMA (3, 4 methylene dioxymethamphetamine), (ecstasy) Ketamine Cannabis Opiates A/Professor David Ash 80

The Drug Abusing Patient • Patient may present with intoxication or withdrawal symptom. • The Drug Abusing Patient • Patient may present with intoxication or withdrawal symptom. • Stimulant intoxication may induce paranoid symptoms, delirium. • Opiate withdrawal marked by pupillary dilatation, lacrimation, diarrhoea, cramping • Patient may present with physical symptoms and demand opiates for pain relief A/Professor David Ash 81

Amphetamine – Methamphetamine Abuse • Clinical Presentation: – – – – – Acute anxiety Amphetamine – Methamphetamine Abuse • Clinical Presentation: – – – – – Acute anxiety Paranoid ideation Loud, demanding behaviour Motor agitation, aggression Stereotypic behaviours –sniffing, teeth clenching, purposeless searching, picking of skin May be evidence of needle marks Pulse, BP, respiration rate, increased and dilated pupils Exacerbation, precipitation of mania/psychosis Persisting delusional state A/Professor David Ash 82

Treatment • • Support, verbal de-escalation Safety first – potential for aggression Benzodiazepines – Treatment • • Support, verbal de-escalation Safety first – potential for aggression Benzodiazepines – to reduce arousal Second generation antipsychotics • i. e. Olanzapine - Quetiapine • • Monitor for orthostatic hypertension with SGAs ECG – QTc General medical including hydration, malnutrition Routine screens including Biochemistry, CBP, Hep screens, HIV • Assess need for inpatient treatment • Referral to specialist drug, alcohol service where appropriate A/Professor David Ash 83

Case Presentation Mrs B. 52 year old married woman, lives in a country town Case Presentation Mrs B. 52 year old married woman, lives in a country town 200 km from Adelaide. 2 sons aged 28, 33 years. 1995: sexual assault by chiropractor, later developed severe illness with mood disturbance, auditory and ? olfactory hallucinations, passivity experiences, religious delusions, delusions of reference. Past History: postpartum depression; social anxiety disorder No family history of psychiatric illness Emotional deprivation, physical aggression and neglect by parents esp. father. History of sexual assaults in childhood, adolescence and adult life Husband emotionally abusive, controlling, similarities to father A/Professor David Ash 84

Case Presentation cont. Employed as registered nurse, managed several successful businesses prior to illness Case Presentation cont. Employed as registered nurse, managed several successful businesses prior to illness onset. Self esteem linked to work, parenting, physical appearance. Since 1995: chronic, fluctuating psychotic symptoms with episodic mood disturbance. Ongoing social anxiety and posttraumatic symptoms. Underlying Axis 2 issues although functioned well prior to illness onset. Organic screens including EEG, CT head, MRI head, ECG, echocardiogram NAD. A/Professor David Ash 85

Case Presentation cont. Intensive outpatient treatment including: Supportive psychotherapy Psychoeducation Marital counselling Theological input Case Presentation cont. Intensive outpatient treatment including: Supportive psychotherapy Psychoeducation Marital counselling Theological input CBT Cautious exploration of past traumas and underlying dynamic issues Pharmacotherapy Second and third opinions Inpatient treatment: numerous admissions including ICU due to psychotic symptoms and risk of self harm Traumatic experience in hospital A/Professor David Ash 86

Case Presentation cont. Pharmacotherapy • • FGAs – oral / depot SGAs – including Case Presentation cont. Pharmacotherapy • • FGAs – oral / depot SGAs – including clozapine Mood stabilisers Antidepressants Current medication • • • Amisulpride 1, 000 mg daily Seroquel 300 mg bd Benztropine 2 -3 mg daily Lorazepam 1. 5 mg daily Temapzepam 10 mg prn nocte Psychotic symptoms have settled, mood stable for last 6 months. Still has moderately severe social anxiety. A/Professor David Ash 87

A/Professor David Ash 88 A/Professor David Ash 88

References • • • Crisis Beds: The Interface Between the Hospital and the Community. References • • • Crisis Beds: The Interface Between the Hospital and the Community. Ash et al. International Journal of Social Psychiatry 43: 193 -198, 1997 Development of Australia’s first psychiatric emergency centre. Frank et al Australasian Psychiatry, 13: 266 - 272, 2005 A survey of violence, self harm, victimisation and homelessness in patients admitted to an acute regional inpatient unit in South Australia. Ash et al. International Journal of Social Psychiatry 49 112 -118, 2003 Self reported forensic histories amongst patients admitted to an acute psychiatric unit. Ash et al. Psychiatry, Psychology and the Law 6: 197 -202, 1999 Emergency Psychiatry ed Hillard and Zitek; Mc. Graw and Hill Psychotropic Drug Directory ed Basire 2003/2004 Acute Inpatient Psychiatric Care A Source Book –Treatment Protocol Project WHO – Andrews Safety and Tolerability of Oral Loading Divalproex Sodium in Acutely Manic Bipolar Patients Hirschfeld et al, J Clin Psychiatry 1999; 60, 815 -818 Managing the Agitated Psychotic Patient – an Update. Forster, Emergency Psychiatry 8; 2, 2002 A/Professor David Ash 89

 • • • Efficacy of Atypical Antipsychotics in Bipolar Disorder Berk and Dodd • • • Efficacy of Atypical Antipsychotics in Bipolar Disorder Berk and Dodd Drugs 2005 65 (2); 257 -269 Review and Update of the American Psychiatric Association Practice Guidelines for Bipolar Disorder James C-Y. Chou, Primary Psychiatry Sept. 2004; 11 (9), 73 -84 Treatment options for Bipolar Mania Kasper and Attarbaschi, Clinical Approaches in Bipolar Disorders 2004; 3. 24 -32 RANZCP Clinical Practice Guidelines – Summary of guidelines for the treatment of bipolar disorder P Mitchell et al, Australasian Psychiatry, Vol 11, No. 1, March 2003 A Meta-analysis of the Efficacy of Second Generation Antipsychotics John Davis, Nancy Chen, Ina Glick. Arch. Gen. Psychiatry Vol 60; June 2003, 553 -564 RANZCP Clinical Practice Guidelines Summary of Guidelines for the treatment of Schizophrenia Mc. Gorry et al; Australasian Psychiatry; Vol 11 No 2, June 2003, 135 -150 What Do Consumers Say They Want and Need During a Psychiatric Emergency Allen et al, J Psychiatr Pract. 2003 9 (1), 39 -58 Treatment of Behavioural Emergencies: a summary of the expert consensus guidelines Allen et al , J Psychiatr Pract. 2003 9 (1), 16 -38 Goldberg et al Cognitive improvement after treatment with secondgeneration antipsychotic medications in first-episode schizophrenia: is it a practice effect? Arch Gen Psychiatry 2007 64 1115 -22 A/Professor David Ash 90

 • • • Atypical antipsychotics in the treatment of schizophrenia – systematic overview • • • Atypical antipsychotics in the treatment of schizophrenia – systematic overview and metaregression analysis Geddes et al 2000, BMJ 321, 13711376 The European First Episode Schizophrenia Trial (EUFEST) Rationale and design of the trial. Fleischhacker et al 2005 Schizophrenia Research 78, 147 -156 Antipsychotics and the Risk of Sudden Cardiac Death. Straus et al, Arch Int Med 2004 164: 1293 -1297. The Usefulness and Use of Second Generation Antipsychotic Medication Sartorius et al 2002 Current Opinion in Psychiatry 15, S 1 -S 51 The Usefulness and Use of Second Generation Antipsychotic Medication Sartorius et al 2003 Current Opinion in Psychiatry 16, S 44 Guidance on New (Atypical) Antipsychotic Drugs for the Treatment of Schizophrenia – National Institute of Clinical Excellence (NICE) Barnett 2002 Effectiveness of Antipsychotic Drugs in Patients With Chronic Schizophrenia Lieberman et al New England Journal of Medicine 2005 353 12; 1209 -1223 Clinical Trials for Antipsychotic Drugs; design conventions, dilemmas and innovations. Stroup et al, Nature Reviews Drug Discovery 2006 5, 133 -146 Randomised Controlled Trial of the Effect on Quality of Life of Second –vs First-Generation Antipsychotic Drugs in Schizophrenia, CUt. LASS 1, Arch Gen Psychiatry, Vol 63, Oct 2006. A/Professor David Ash 91

 • • Treatment of a first episode of psychotic illness with quetiapine. An • • Treatment of a first episode of psychotic illness with quetiapine. An analysis of 2 year outcomes. Kopola et al. Schizophrenia Research 81 (2006) 29 -39. Higher than Physician’s Desk Reference (US) doses on atypical antipsychotics, Goodnick, Expert Opinion Drug Saf. (2005) 44): 653 -668 Clinical experience with atypical antipsychotics in an acute inpatient unit. Focus on quetiapine. Keks et al. , International Journal of Psychiatry in Clinical Practice, 2006; 10(2): 0 -00. RANZCP Clinical Practice Guidelines – Summary of guidelines for the treatment of bipolar disorder Mitchell et al, Australasian Psychiatry, Vol 11, No. 1, March 2003 Amisulpride augmentation of Clozapine – an open non-randomized study in patients with schizophrenia partially responsive to Clozapine Munro et al, Acta Psychiatrica Scand. 2004; 110, 292 -298 Co-administration of Clozapine and Amisulpride in patients with Schizophrenia. Ziegenbein et al; 58 th Annual Convention Biol. Psychiatry; May 2003 Combination of Clozapine and Amisulpride in Treatment Resistant Schizophrenia –case reports and review of the literature Zink et al, Pharmacopsychiatry 2004; 27, 20 -31 Differential effects of high-dose amisulpride versus flupenthixol on latent dimensions of depressive and negative symptomatology in acute schizophrenia: an evaluation using confirmatory factor analysis Muller et al. , Int. Clin. Psychopharmacol 2002 Sep, 17 (5) 249 -61 A/Professor David Ash 92




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