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HeikkiRytsälä

Drugs Used in Psychiatric Emergencies

General principles for psychiatric medication in emergency situations

  • As a principal rule, it is inappropriate to start any psychiatric medication in an emergency situation if proper follow-up care is not arranged for. The patient's overall situation and the background causes should always be sorted out and the possible somatic factors excluded.
  • A person with mental problems is most urgently in need of treatment for the acutely developed condition, e.g. anxiety and hopelessness, regardless of the background illness or disturbance. If hospitalization is not considered necessary, the patient's anxiety should be got under control as soon as possible.
  • Risk of suicide should always be kept in mind and should always be inquired into. At the emergency department it is safest always to prescribe the smallest available package of a psychotropic drug.
  • It is always necessary to arrange for appropriate follow-up care.
  • Benzodiazepines are still the safest and most effective drugs for the treatment of acute anxiety. Dependence is, however, easily developed and the effect of the drug is often decreased within a few weeks. They are thus apt for a very short-term use only, and if their use is considered absolutely necessary the smallest possible package size should be prescribed.
  • SSRI drugs are best suitable for chronic anxiety, e.g. for generalized anxiety and panic disorder.
  • In an emergency situation it is seldom necessary to start antidepressant medication, and antipsychotic medication still more seldom. An exception is maybe a situation where the patient has had the same problem earlier and it is known what kind of medication was effective then.

Antipsychotic drugs in acute psychosis Haloperidol Plus Promethazine for Psychosis Induced Aggression

  • The management of an aggressive and/or very agitated patient may be initiated with e.g.
    • aripiprazole at a starting dose of 9.75 mg (1.3 ml) in a single deep intramuscular injection avoiding adipose tissues. The effective dosage range is 5.25-15 mg in a single injection.
      • The next injection, if needed, may be given not earlier than after 2 hours from the first. The maximum amount of injections per 24 h is three.
      • The maximum dose per 24 h is 30 mg with all the different drug forms of aripiprazole summed up.
    • haloperidolHaloperidol Dose for the Acute Phase of Schizophrenia 2.5-5 mg i.m.
      • The dose can be repeated several times per day. It can be administered once per hour i.m. until the patient calms down.
      • Extrapyramidal symptoms are the most common adverse effects.
    • olanzapine 10 mg i.m.
      • The maximum number of injections is 3 per 24 hours. The maximum dose is 20 mg daily all drug forms combined.
      • Concomintant use of parenteral benzodiazepines may be dangerous.
    • risperidoneRisperidone for Psychosisinduced Aggression or Agitation (Rapid Tranquillisation) 2 mg and lorazepam 2 mg orally
    • zuclopenthixol acetate 50-150 mg i.m.
      • If necessary, the dose may be repeated but not earlier than after 24 hours, usually 2-3 days after the initial dose (extrapyramidal symptoms are the most common adverse effects, for management see section Adverse effects), or
  • Diazepam 5-10 mg 3-4 times daily p.o., or lorazepam 1-2.5 mg p.o. or i.m. (i.m. use may require special authorization), during the first days of acute psychosis will relieve anxiety.

Mania

  • Medication is usually warranted when the patient suffers from sleep disorders, as extreme insomnia may trigger mania.
  • A sedating antipsychotic drug is the drug of choice (quetiapine, chlorprothixene, levomepromazine or olanzapine). If necessary, a hypnotic can be added for a brief period.
  • Titration of the daily dose, the highest dose administered in the evening: in out-patient care, quetiapine 100 mg on the first day, increased by 100 mg on the following days up to 400 mg, or alternatively chlorprothixene 100-400 mg in gradually increasing doses, levomepromazine 25-50 mg or olanzapine 5-15 mg.
  • Maximum daily doses in out-patient care: quetiapine 400 mg, chlorprothixene 750 mg, levomepromazine 150-250 mg and olanzapine 20 mg
  • If the patient sleeps at least 5 hours and is not too drowsy the next morning, the next evening he/she should take the entire dose of the first evening approximately 2 hours before his/her usual bed-time.

Delirium

  • The main aim is to establish the cause of delirium and, if possible, to treat it.
  • Alcoholic delirium (delirium tremens) is a life-threatening condition and the patient should be referred to emergency care in a hospital.

Agitated patient with dementia

Adverse effects

  • Neuroleptic malignant syndrome, see Neuroleptic Malignant Syndrome (Nms)
  • Dystonia and akathisia (extrapyramidal symptoms)
    • The primary treatment is to reduce the dose of the drug causing the symptoms or to change to a drug with fewer symptoms.
    • Extrapyramidal symptoms occur most frequently with flupenthixol, haloperidol, chlorprothixene, perphenazine, zuclopenthixol, asenapine, lurasidone, risperidone and ziprasidone.
    • Acute dystonia may be treated with biperiden 2 mg three times daily orally or 2.5-5 mg i.m. In akathisia the dose of the antipsychotic should be reduced. The symptoms can be alleviated temporarily with propranolol with a dose up to 40-120 mg daily.
  • Anticholinergic adverse effects
    • Constipation, urinary retention, elevated intraocular pressure.
    • Large doses of sedating antipsychotic drugs and tricyclic antidepressants co-administered with antiparkinsonian and other anticholinergic drugs may cause anticholinergic syndrome, which is characterized by confusion, irritability and delirium.
  • All antidepressants may produce akathisia during the first days of treatment.
    • Patients with panic disorder are particularly susceptible.
    • Treatment is important because akathisia can contribute to an elevated risk of suicide.
    • Benzodiazepines are a suitable treatment(remember the dangers of long-term use).
  • Decrease of seizure threshold
    • Antipsychotic drugs: clozapine is the most epileptogenic and fluphenazine the least.
    • Tricyclic antidepressants: amitriptyline, clomipramine and nortriptyline are the most epileptogenic, doxepin the least.
    • Caution should be exercised with other antidepressants when prescribing for a patient with epilepsy.
  • Agranulocytosis may result from the use of clozapine (1:100-1:1000), mianserin (1:4000-1:10 000) as well as mirtazapine.
  • Priapism may be induced by trazodone (1:1000-1:10 000). The patient should have emergency urological consultation.

Changes in blood concentration of other drugs

  • Carbamazepine induces liver enzymes and decreases the blood concentrations of many other medications.
  • Fluoxetine, fluvoxamine and paroxetine inhibit metabolizing enzyme activity, and may lead to elevated concentrations of other drugs.
  • Monoamine oxidase inhibitors (moclobemide) may in conjunction with other antidepressants cause a hypertensive crisis or the so-called serotonin syndrome (with symptoms like profuse sweating, ataxia, agitation, vertigo, hyperreflexia, myoclonus, tremor, diarrhoea, coordination disturbances, increased body temperature, confusion or hypomania). These drugs should not be used together concomitantly.
  • Serotonin syndrome may follow if the patient uses two (or more) antidepressants concomitantly or tramadol together with drugs that increase serotonin activity (like most antidepressants).

References

  • Reeves RR, Burke RS. Tramadol: basic pharmacology and emerging concepts. Drugs Today (Barc) 2008 Nov;44(11):827-36. [PubMed]

Evidence Summaries ⬆