Psychiatric Emergencies

1. Psychopharmacotherapy of Aggression &PsychiatricEmergencies in Children & AdolescentsMental HealthServicesElham SalariChild & Adolescent Psychiatrist

2. PsychiatricEmergencies • Aggression • Delirium

3. Aggression

4. PRN Sedation–patterns • Aggressive behaviors, may be associated with a variety of psychiatric disorders and are often the reason for referral to psychiatric treatment.

5. PRN Sedation–patterns • Acute episodes of aggression or agitation are common in children and adolescents receiving inpatient psychiatric treatment.

6. PRN Sedation–patterns • Although behavioral techniques are usually first-line interventions, psychotropic medications with sedative effects are widely used on an ‘as needed’, or prn (Pro Re Nata) basis to treat acute aggressive episodes.

7. The use of p.r.n medication to control aggression in child and adolescent mental health inpatient services

8. France, 2009 • The study was carried out on the psychiatry ward of a paediatric teaching hospital in Paris, France. • P.r.n prescriptions were written, for 27% of the patients (51) but only 14% (26) received a total of 76 administrations.

9. France, 2009 • Anxiety was the reason given for 67% of the p.r.n administrations, with hydroxyzine used in 69% of these cases.

10. France, 2009 • Disruptive behaviour accounted for 22% of prn administrations, with antipsychotic drugs accounting for 88% of these administrations.

11. Australia, 2006 • A retrospective chart review examined 122 medical charts from a child and youth mental health inpatient service in South Brisbane.

12. Australia, 2006 • 71.3% of patients were prescribed prn sedation and 50.8% were administered prn sedation. • Patients received an average of 8.0 doses of prn sedation, with 9.8% receiving 10 or more doses.

13. Australia, 2006 • Chlorpromazine and • diazepam were the most commonly utilised agents.

14. Drugs prescribed and administered for prnsedation

15. Comparison with other studies • The nature of drugs utilized for prn sedation varies with other studies reporting predominance of • thioridazine, • thioridazine or lorazepam • or chlorpromazine in combination with chloral hydrate

16. Comparison with other studies • The lower rate of use of atypical antipsychotics is noteworthy as it contrasts with other reports describing escalating utilization rates of atypical antipsychotics for nonprn use in children and adolescents

17. Antihistamines

18. Antihistamines • Antihistamines, particularly first generation (older) antihistamines, are known to have effects on the central nervous system by causing rapid sedation and slowing down psychomotor performance and cognitive function.

19. Antihistamines • Despite the common use of antihistamines for aggression and agitation, there is only one published, controlled study for an antihistamine (diphenhydramine) on managing child and adolescent aggression on psychiatric inpatient units on acute basis.

20. Diphenhydramine • In this double-blind, placebo-controlled, pilot study of an antihistamine for 21 male patients (aged 5–13 years old), PRN diphenhydramine was not superior to placebo in reducing aggression, as there was a significant placebo effect.

21. Typical Antipsychotics

22. Atypical Antipsychotics

23. Atypical Antipsychotics • For acute treatment of aggression on child and adolescent inpatient units, ziprasidone is the most extensively studied atypical antipsychotic medication.

24. Ziprasidone

25. Ziprasidone • Ziprasidone was the first atypical antipsychotic available in IM form and this might be the reason that it was observed as the most extensively studied antipsychotic for managing aggression in inpatient children and adolescents.

26. Ziprasidone • A case report of youths treated with IM ziprasidone reported an immediate beneficial effect on controlling the aggressive episode on the inpatient child psychiatry unit. • Ziprasidone has been found to be beneficial in treating aggression in child and adolescent inpatients as well as adolescents in the emergency room

27. Ziprasidone vs haloperidol Ziprasidone Haloperidol with Lorazeoam

28. Ziprasidone vs haloperidol • Both treatment groups had similar outcomes in regards to restraint time and use of rescue medications. • The Behavior Activity Rating Scale(BARS) scores in subjects started decreasing immediately after the IM ziprasidone injection and had a significant decrease after one half hour and continued to decrease up to two hours.

29. Ziprasidone vs haloperidol • Although no severe side effects were found, side effects may not have been monitored or documented carefully. • Nonetheless, the authors conclude that IM ziprasidone should be considered since it leads to a similar clinical outcome while avoiding potential severe adverse events associated with typical antipsychotic medications such as haloperidol.

30. Olanzapine (Zyprexa)

31. olanzapine vs ziprasidone olanzapine ziprasidone

32. olanzapine vs ziprasidone • A retrospective study comparing the efficacy of IM ziprasidone and IM olanzapine PRN in 100 juvenile (younger than 18 years) psychiatric inpatients found that these medications were similar in terms of their ability to address inpatient Aggression.

33. olanzapine vs ziprasidone • However, patients taking IM ziprasidone received significantly more doses of IM ziprasidone, as well as other potentially calming medications, such as antihistamines or lorazepam.

34. olanzapine vs ziprasidone • Somnolence was the most common side effect noted during this study for either IM ziprasidone or IM olanzapine. • Neither medication had any documented significant effect on QTc interval, blood pressure, or heart rate.

35. Risperidone (Risperdal)

36. Risperidone • Most of the risperidone studies were conducted in outpatient settings and are targeted to treat chronic aggression rather than acute inpatient aggression. • As per our search, only one study has attempted to observe the effects of risperidone in treating the aggression in an inpatient unit.

37. Risperidone • In this study, 38 aggressive adolescent inpatients with CD and other oppositional problems were randomly assigned to risperidone or placebo treatment for six weeks in a doubleblind, placebo-controlled, randomized clinical trial. • Risperidone was superior to placebo in reducing aggression.

38. Orally Dissolvable Form

39. Risperidone Zyprexa Zydis Olanzapine Orally disintegrating tablet Risperdal m-tab Orally disintegrating tablet

40. Orally Dissolvable Form • Orally Disintegrating Tablets (ODTs) which disintegrate rapidly in saliva, usually in a matter of seconds, without the need to take it water.

41. Orally Dissolvable Form • Absorption through the cheek allows the drug to bypass the digestive tract for rapid systemic distribution. • Drug dissolution and absorption as well as onset of clinical effect and drug bioavailability may be significantly greater than those observed from conventional dosage forms.

42. Orally Dissolvable Form • The need for non-invasive delivery systems persists due to patients’ poor acceptance of, and compliance with, existing delivery regimes, limited market size for drug companies and drug uses, coupled with high cost of disease management.

43. Orally Dissolvable Form • A patient in a psychiatric institutional setting who may try to hide a conventional tablet under his or her tongue to avoid their daily dose of a psychotropic drug. • Patients who are unwilling to take solid preparation due to fear of choking. • Pediatric and geriatric patients who have difficulty in swallowing or chewing solid dosage forms.

44. Orally Dissolvable Form • Risperidone and olanzapine, both are available in an orally dissolvable form (Risperdal M-tab and Zyprexa Zydis), • Risperidone is also available as a liquid concentrate, again broadening the clinical situations in which it may be of benefit.

45. Risperidal Oral Solution Risperidone

46. Quetiepine (seroquel)

47. Quetiepine • In one short-term (eight week), open-label, outpatient study (including 6–12 year old children with CD), quetiepine was found to be helpful and well tolerated when targeting aggression.

48. Aripiprazole (Abilify)

49. Aripiprazole • Although the inpatient studies on aripiprazole for pediatric aggression are also lacking, one open-label study of 15-day duration suggests that it is effective and safe in reducing aggression in children and adolescents with CD

50. Benzodiazepines