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Guidelines for Managing Agitated Patients in the ED

Proper management of agitated patients presenting to the ED is essential to keeping staff safe and ensuring appropriate care. In many cases, agitation cases can be managed with non-pharmacologic methods, but medications are becoming increasingly important in acute agitation in EDs. In the February 2012 Western Journal of Emergency Medicine, my colleagues and I at the American Association for Emergency Psychiatry published consensus recommendations on best practices for using medication to manage agitated patients in emergency settings. Rationale & Goals When Calming Patients Non-pharmacologic approaches—verbal de-escalation, quieting the room, and dimming the lighting—should be attempted before medications are administered. When initial verbal methods fail to calm patients, medication may be necessary. Clinicians should make a provisional diagnosis on the likely cause of the agitation because this can help guide medication choices. In many cases, agitation increases over time during ED treatment. By intervening early, to preempt the potential escalation of agitation to severe and dangerous levels, it may be possible to include patients in the medication decision process and use lower doses. The goal of using medication in agitated patients is to calm them without inducing sleep. Excessive sedation may interfere with assessment and treatment of underlying conditions. To the extent possible, medications should be used that specifically target the cause of agitation based on the provisional diagnosis. “The goal of using medication in agitated patients is to calm them without inducing sleep.” No class of medication is considered “best” in all cases of agitation, but three drug classes have been studied and used most frequently, including first- and second-generation antipsychotics and benzodiazepines. Although these drugs may manage acute...

Analyzing Antipsychotic Therapy in Office-Based Care

Investigators in New York have found that adults appear to make considerably more medical visits with a prescription of antipsychotics than adolescents or children, but antipsychotic treatment has increased rapidly among young people. From 2005 to 2009, depression and bipolar disorder were the most common diagnoses in adult antipsychotic visits while disruptive behavior disorders were the most common diagnoses in children and adolescents. The authors add that antipsychotics have been prescribed in about the same proportion of youth and adult visits to psychiatrists in more recent years. Abstract: Archives of General Psychiatry, August 2012...

2012 American Psychiatric Association Annual Meeting

New research was presented at the American Psychiatric Association’s 165th Annual Meeting from May 5-9, 2012 in Philadelphia. The features below highlight just some of the studies that emerged from the conference. Treating Sleep Disorders Benefits Psychiatric Patients The Particulars: Research has shown that disturbances in quality and quantity of sleep can exacerbate underlying psychiatric illness. It has been hypothesized that treatment of sleep disorders might improve symptoms of psychiatric illness. Data Breakdown: Investigators reviewed the charts of patients with and without psychiatric disorders at a sleep disorders clinic. They recorded outcomes at 6, 12, and 24 months in those with comorbid psychiatric disorders. Compliance with sleep disorder treatment was compared between those with and without comorbid psychiatric illness. When compared with baseline, psychiatric status progressively improved significantly, with no differences in treatment compliance observed between the groups. Take Home Pearls: Treatment of comorbid sleep disorders in patients with comorbid psychiatric illness appears to significantly improve psychiatric disorder symptoms. Compliance with sleep disorder treatment does not appear to be affected by the presence of a psychiatric disorder. Improving Metabolic Monitoring of Patients on Antipsychotics The Particulars: Antipsychotic medications, particularly second generation antipsychotics (SGAs), have been linked to various metabolic changes that are associated with cardiovascular disease. Despite recommendations from the American Psychiatric Association and American Diabetes Association that patients on SGAs be monitored for metabolic changes, it is unknown how well these individuals are systematically monitored. Data Breakdown: At a primary care network, multiple departments monitored metabolic syndrome in patients placed on SGAs more closely. All members of these departments were educated on the morbidity associated with SGA use...

The American Psychiatric Association 2011 Annual Meeting

The American Psychiatric Association’s 2011 annual meeting was held May 14-18 in Honolulu. The features below highlight some of the news emerging from the meeting. » Depression Screening May Reduce Future Clinic Visits » Examining Atypical Antipsychotic Use in Children » Sulfonylureas May Have Antidepressant Effects » Type of Media Affects Sleep Patterns for Teens » Views on Depression From PCPs & Psychiatrists  Depression Screening May Reduce Future Clinic Visits The Particulars: The United States Preventive Services Task Force has recommended screening patients with certain physical diagnoses for depression on the basis of previous studies showing an increased risk. However, little evidence is available demonstrating that these screenings lead to improved outcomes. The recommendation has recently been criticized for its lack of proven cost-effectiveness. Data Breakdown: Researchers screened patients with certain physical diagnoses—including cardiovascular diseases, type 2 diabetes, COPD, and obesity—for depression. The PHQ-9 was administered to study participants. Patients whose screening results indicated at least mild depression showed no significant difference in the number of visits during the following year, compared with the year before. However, among those with negative screenings, the average number of visits declined after the screening. In the year before screening, the average number of clinic or hospital visits was 2.8 for non-depressed patients, compared with 2.7 after the screening. About 30% of positive screens led to actual contact with a nurse or psychiatrist. Among patients who had follow-up engagement, 44% had full remission and 29% had significant improvement in PHQ-9 scores. Take Home Pearls: Depression screening in patients with chronic physical diseases appears to reduce subsequent clinic visits. However, more research is needed as this finding...
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