APPROACH TO EMERGENCIES IN SCHIZOPHRENIA

 
Psychiatria Danubina, 2018; Vol. 30, Suppl. 4, pp S203-207                                                               Conference paper
© Medicinska naklada - Zagreb, Croatia

               APPROACH TO EMERGENCIES IN SCHIZOPHRENIA
                    IN UNIVERSITY HOSPITAL "VRAPýE"
                      Ante Siliü, Aleksandar Saviü, Ilaria ýulo, Suzana Kos, Jakša Vukojeviü,
                                        Daška Brumen & Draženka Ostojiü
                                       University Psychiatric Hospital Vrapþe, Zagreb, Croatia

SUMMARY
    Background: An emergency in psychiatric setting is any disorder in thought process, feelings and/or behavior of the patient that
requires urgent therapeutic intervention. In general, we can observe an increase in numbers of psychiatric emergencies throughout
the world and in Croatia as well. Agitation and aggression are one of the most common causes of emergency in psychiatry. Agitation
is common and frequent in patients suffering from schizophrenia. Patient can be agitated in various levels such as: mild, moderate or
severe and can alternate between these levels in the same presentation. Agitated patients often require hospitalization that includes
pharmacotherapy and sometimes physical restraining, in order to treat the cause of agitation and prevent auto and/or
heterodestructive behavior.
    Subjects and methods: In this paper we focus on patients suffering from schizophrenia that were admitted in University Hospital
"Vrapþe" in 2017, and assess the numbers through the criteria of voluntary vs. involuntary admissions and physical restraint usage.
    Results: Out of total observations, 130 (35.6%) were patients admitted for the first time and 179 (49%) were patients later
diagnosed with schizophrenia spectrum and other psychotic disorders. Court ordered involuntary hospitalization was ordered for 35
(2.8%) patients out of total admitted patients, and 68.6% (N24) of them were diagnosed with schizophrenia spectrum and other
psychotic disorders. Physical restraint was used for 122 patients out of total admissions and 28.7% (N35) of restrained patients were
diagnosed with schizophrenia spectrum and other psychotic disorders.
    Conclusions: Emergencies in patient suffering from schizophrenia are extremely delicate and demanding situations in every-day
clinical practice of psychiatrist. There is an increased risk involved for the patient but for the staff as well. All interventions should
be individualized and patient should carefully monitored throughout the entire process. All professionals involved in care for a
patient should be up to date with medical and legal issues.

Key words: schizophrenia - psychotic disorders - psychomotor agitation - violence

                                                             * * * * *

INTRODUCTION                                                             these visits (Sankaranarayanan & Puumala 2000, Marco
                                                                         & Vaughan 2005). 52% of presented patients in the
    An emergency in psychiatric setting is any disorder                  Psychiatric ER were agitated and 45% of them were
in thought process, feelings and/or behavior of the                      hospitalized and received specific psychopharmaco-
patient that requires urgent therapeutic intervention. In                therapy in order to reduce agitation (Boudreaux 2009).
general, we can observe an increase in numbers of                             Schizophrenia spectrum and other psychotic disorders
psychiatric emergencies throughout the world and in                      are grouped together in recent classifications - DSM 5
Croatia as well (Ostojiü & ýulo 2018, Siliü 2018). Agi-                  (American Psychiatric Association 2013). Psychiatry
tation and aggression are one of the most common cau-                    redefined the term “psychosis” in numerous occasions
ses of emergency in psychiatry. Agitation is common                      so far and it is safe to say that we did not achieve
and frequent in patients suffering from schizophrenia.                   generally accepted definition (Sadock et al. 2015). In
Patient can be agitated in various levels such as: mild,                 context of emergencies in psychiatry we can define psy-
moderate or severe and can alternate between these                       chosis as a disturbance of the perception of reality which
levels in the same presentation. Agitated patients often                 may or may not include hallucinations and delusions.
require hospitalization that includes pharmacotherapy                    We can define delusions as false, fixated beliefs and
and sometimes physical restraining, in order to treat the                hallucinations as sensory perceptions (in all sensory
cause of agitation and prevent auto and/or hetero-                       modalities) in the absence of real external stimuli.
destructive behavior (Allen 2000, Allen & Currier 2004).                 Neither hallucinations nor delusions should be consi-
Agitation is always related to the underlying disease and                dered as diagnosis rather as a symptom (Goldberg &
when patient presents with agitation we always have to                   Murray 2006, Gelder et al. 2007, Black & Andreasen
consider the possible cause such as schizophrenia, bi-                   2014). Every psychotic patient should be approached to
polar disorder, substance abuse disorders, iatrogenic etc                as having a potential for psychiatric emergency whether
(Buckley 2006, Leventhal & Zimmerman 2010, Fioren-                       it is patient’s first or repeated contact with psychiatric
tini et al. 2011). Data from the United States (US),                     services. Differential diagnostic procedures should be
suggests close to two million emergency department                       started as soon as possible in order to clarify the patho-
visits per year that involve agitated patients, with                     physiology and etiology underlying presented symp-
schizophrenia being an underlying cause for 21% of                       toms. All psychotic patients must be monitored closely

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             SCHIZOPHRENIA IN UNIVERSITY HOSPITAL "VRAPýE"                   Psychiatria Danubina, 2018; Vol. 30, Suppl. 4, pp 203-207

during their evaluation. Not all psychotic patients will                   Out of total observations, 130 (35.6%) were patients
become agitated and can be treated without difficulties,               admitted for the first time and 179 (49%) were patients
but we should anticipate and when possible prevent                     later diagnosed with schizophrenia spectrum and other
agitated and violent outbursts routinely in a manage-                  psychotic disorders.
ment of psychotic patient. Agitation is very often                         Court ordered involuntary hospitalization was orde-
preceded by verbal or behavioral hints but may also                    red for 35 (2.8%) patients out of total admitted patients,
emerge without warning (Sadock et al. 2015).                           and 68.6% (N24) of them were diagnosed with schizo-
    Diagnostic and therapeutic decisions should be made                phrenia spectrum and other psychotic disorders.
in good clinical practice manner by a team of educated                     Physical restraint was used for 122 patients out of
professionals. All involved professionals (psychiatrists,              total admissions and 28.7% (N35) of restrained patients
nurses…) should be up to date with medical and legal                   were diagnosed with schizophrenia spectrum and other
aspects of care for management of psychiatric emergen-                 psychotic disorders. Every physically restrained patient
cies (Allen et al. 2005). In medicine in general there are             diagnosed with schizophrenia spectrum and other psy-
few clinical situations that can be as complicated as are              chotic disorders was administered with parenteral the-
those emerging with management of psychotic patients.                  rapy in the acute setting (within 48 hours upon admis-
During the process of management of each individual                    sion). We used haloperidol, olanzapine, promazine and
psychotic patient we must achieve delicate balance bet-                ziprasidone i.m and/or diazepam i.m. (Table 1).
ween care (intervention) and safety of the patient and
staff while respecting patient’s human rights. Recog-                  DISCUSSION
nizing and preventing violent behavior is one of the
most important priorities in psychiatric emergencies                       According to our data, diagnosis of schizophrenia
(Chanmugam et al. 2013).                                               spectrum and other psychotic disorders was strong
                                                                       predictor of need for involuntary treatment if patient did
SUBJECTS AND METHODS                                                   not give valid informed consent upon admission and not
                                                                       a strong predictor for usage of physical restraint.
    In this paper we focus on patients suffering from                      Here we state some clinical facts and recommenda-
schizophrenia that were admitted in University Hospital                tions based on our experience and available guidelines.
„Vrapþe“ in 2017, and assess the numbers through the
criteria of voluntary vs. involuntary admissions and                   Clinical facts crucial to recognition and avoidance
physical restraint usage. We analyzed data on file in                  of violent behavior (Savic 2018)
retrospective manner.                                                   ƒ It is difficult to predict violent behavior but it is most
                                                                           often related to:
RESULTS                                                                     x Intoxication with alcohol or other psychoactive
                                                                               substances (Alkhouri et al. 2010);
    In 2017, total number of admissions in University                       x Neuro cognitive disorders such as dementia,
hospital “Vrapþe” was 7.167. Out of total admissions,                          delirium or brain injuries;
2.244 (31.3%) were diagnosed with schizophrenia spec-                       x Schizophrenia spectrum and other psychotic
trum and other psychotic disorders. Number of admis-                           disorders;
sions in Department for urgent psychiatry was 1.235.                        x Personality disorders.
Number of patients that were admitted for the first time
was 579 (46.9%) and number of patient that were admit-                   ƒ Patient must be approached in a calm manner:
ted (and discharged) prior to 2017 was 656 (53.1%).                         x Involved professional must not present in intimi-
439 (35.5%) admitted patients were discharged with                            dating, authoritative or provoking manner;
diagnosis of schizophrenia spectrum and related psycho-                     x Clinician must address patient quietly from a
sis. Out of total admissions 870 (70.4%) valid informed                       “passive position” while respecting personal space
consents were obtained during admission process and                           of the patient which can be wider than usual in a
365 (29.6%) patients were admitted for the observation                        psychotic patient – usually two arm lengths;
(up to 48 hours), according to Croatian law for psychia-                    x Neither clinician nor patient must not feel “cor-
tric patients – ZZODS (Kos 2018).                                             nered”.

Table 1. Analysis of total number of admissions in Department for Urgent psychiatry in 2017
Total no of admissions     First admission Repeated admission Sch* - admission       Observation                   Observation-first
     1235 (7167)                  579              656                439                365                            130
                                46.9%             53.1%              35.5%              29.6%                          35.6%
Sch-observation                Court**         Court - sch          Restraint      Restraint - sch                 Perenteral – sch
     179                          35                24                122                 35                             35
     49%                         2.8%             68.6%               9%                28.7%                          100%
   *schizophrenia spectrum and other psychotic disorders; **court ordered involuntary hospitalization

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             SCHIZOPHRENIA IN UNIVERSITY HOSPITAL "VRAPýE"                   Psychiatria Danubina, 2018; Vol. 30, Suppl. 4, pp 203-207

Table 2. Advantages and disadvantages of different routes of administration (adopted from Zeller et al. 2016)
Administration                                                                                  Time to peak plasma
                      Advantages                     Disadvantages                Examples
route                                                                                           concentration
Intramuscular     Rapid systemic entry;          Invasive; can damage           Haloperidol         ~20 minutes
                  patient cooperation not        patient - physician            Olanzapine          15–45 minutes
                  necessary                      relationship                   Aripiprazole*       1–3 hours
                                                                                Ziprasidone         60 minutes
Inhaled           Less invasive than             Requires patient cooperation Loxapine*             2 minutes
                  intramuscular route and can Bronchospasm/ respiratory
                  improve patient experience. distress
                  Enters alveoli for rapid entry
                  into arterial circulation
Oral
  Standard        Less invasive than             Require patient cooperation; Haloperidol           2–6 hours
  tablets/        intramuscular route and can slow onset of action; enter       Olanzapine          5–8 hours
  capsules/       improve patient experience systemic circulation via           Risperidone         ~1 hour
  solution                                       portal system resulting in     Aripiprazole        3–5 hours
                                                 potential for erratic          Ziprasidone         6–8 hours
                                                 absorption; can be diverted
                                                 (“cheeking”)
  Orally          Less invasive than intra-      Slow onset of action; enter Olanzapine             ~6 hours
  disintegrating  muscular route and can         systemic circulation via       Risperidone         1–2 hours
  tablets         improve patient experience. portal system resulting in        Aripiprazole        3–5 hours
                  Less potential for diversion potential for erratic
                  (“cheeking”) vs standard       absorption
                  tablets/capsules; suitable for
                  patients with dysphagia
  Buccal/         Less invasive than intra-      Requires patient coopera-      Sublingual          0.5–1.5 hours
  sublingual      muscular route and can         tion; needs to be taken        asenapine*
                  improve patient experience; correctly so that it is not
                  rapid absorption;              swallowed, mitigated in part
                  avoids first-pass metabolism by the friability of the tablet
  Intranasal      Less invasive than intra-      Requires patient               Intranasal          10 minutes
                  muscular route and can         cooperation.                   midazolam*
                  improve patient experience;
                  rapid absorption;
                  avoids first-pass metabolism
   * Currently not available in Croatia

Table 3. Other psychopharmacs that can be used in                        ƒ Clinician should calmly ask the patient “What seems
emergencies in patient suffering from schizophrenia                        to be wrong?” or “What is going on?” or state “You
spectrum and other psychotic disorders (Stahl 2014)                        seem to be angry, can I know why?....”
Group                               Target symptoms                      ƒ Violent patients need to be hospitalized because in
Antiepileptic / mood stabilizer     Positive symptoms                      that way we can ensure their safety and safety of
Na-valproate                        Agitation                              people surrounding them.
Carbamazepine                       Aggression                           ƒ If and when needed violent or agitated patient should
Lamotrigine                         Negative symptoms                      be restrained according to good clinical practice and
Topiramate                          Affective symptoms                     law (ZZODS).
Gabapentine                                                              ƒ Underlying cause of psychotic symptoms should be
Lithium                                                                    intensively treated.
Benzodiazepines                     Agitation                            ƒ Outpatients should be reassessed for violent behavior
Diazepam                            Anxiety                                on every visit.
Clonazepam                          Insomnia                               Therapeutic interventions in management of agita-
Lorazepam                                                              tion in patient suffering from schizophrenia can be sum-
Alprazolam                                                             marized in two groups: behavioral (non-pharmacolo-
Bromazepam                                                             gical) and pharmacological (Zeller & Citrome 2016).
Oxazepam
Flurazepam                                                             Behavioral intervention
Midazolam                                                                  Verbal de-escalation – should be attempted with all
Nitrazepam                                                             patients.

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             SCHIZOPHRENIA IN UNIVERSITY HOSPITAL "VRAPýE"                   Psychiatria Danubina, 2018; Vol. 30, Suppl. 4, pp 203-207

    Quiet unlocked room - patients in whom de-escala-                       First line therapy in acute setting can be inhaled Lo-
tion alone was insufficient to reduce dangerousness enough             xapine. Loxapine is a first-generation antipsychotic struc-
to allow to remain in general care areas, and/or may need              turally similar to clozapine. Recommended dosage via
more time to regain control away from other patients                   inhalation (approved by FDA for agitation in schizo-
    Locked seclusion - if patients are considered an immi-             phrenia and manic phase of bipolar disorder) is 10 mg
nent danger to others but not themselves, and cannot                   and should not be exceeded through 24 hours. It can be
tolerate or remain in a quiet unlocked room.                           administered only for in patients (Keating 2013, Popovic
    Restraint - if patients are considered an imminent                 et al. 2015). At this moment Loxapine is not available
danger to themselves, and cannot remain in a locked                    in-patient.
seclusion room without actively trying to injure them-                      In psychiatric emergencies with agitated or violent
selves.                                                                behavior in addition to antipsychotic we can administer
                                                                       parenterally benzodiazepines such as lorazepam (cur-
Non pharmacological interventions should be prefer-                    rently not available in-patient in parenteral formulation)
red but there are some advantages and disadvantages                    or diazepam (Beckman & Haas 1980, Citrome 2013).
of such interventions for agitation (Saviü 2018)
                                                                            Recommendations on dosages and combinations of
    Advantages: facilitates better short- and long-term                drugs are not generally accepted but there are some gene-
patient–physician relationships, reduces staff and patient             ral rules (Gugger 2011, Citrome 2013, Huang et al. 2015):
injuries associated with restraint and sedation and can                  ƒ All drug to drug interactions should be considered as
reduce resource (clinical and staff) use.                                   well as possible interactions with psychoactive sub-
    Disadvantages: may not be effective in all patients                     stances on individual basis;
and most importantly it requires at least some co-opera-                 ƒ We must not exceed maximal recommended daily
tion from the patient.                                                      dose;
Pharmacological intervention                                             ƒ Simultaneous administration of parenteral formula-
                                                                            tion of olanzapine and any benzodiazepine is not
    First line of treatment in psychiatric emergencies is
                                                                            allowed;
psychopharmacotherapy. Mechanism of action is pri-
                                                                         ƒ If i.m. therapy does not achieve desired effect, ex-
marily blockage of dopamine D2 receptors in meso-
                                                                            ception can be made and it is possible to administer
limbic projections of dopaminergic neurons. That effect
                                                                            slow intravenous application of haloperidol or dia-
in cascade reaction leads to psychomotor calming of the
                                                                            zepam with rigorous monitoring of vital functions.
patient in the acute phase of treatment but is also
important in the long run. (Zeller & Citrome 2016,                          Given the heterogeneity of presentation in psychia-
Saviü 2018).                                                           tric emergencies in schizophrenia patients, we can be
                                                                       faced with necessity of administering other group of
    Antipsychotic drugs represent highly heterogeneous
                                                                       psychopharmacs (Ostojiü et al. 2017, Siliü 2017).
group of drugs interacting with various types of recep-
tors other than dopaminergic (serotoninergic, cholinergic,
noradrenergic, histaminergic…) (Fruyt & Demyttenaere                   CONCLUSIONS
2004, Zeller & Rhoades 2010).
                                                                           Emergencies in patients suffering from schizophrenia
    Which drug will be drug of choice in psychiatric
                                                                       spectrum and related psychoses are extremely delicate
emergencies depends on various factors:
                                                                       and demanding situations in every-day clinical psychia-
  ƒ Leading symptom(s): auto or heterodestructive beha-
                                                                       tric practice. There is an increased risk involved for the
    vior, hallucinations, delusions, anxiety, agitation,
                                                                       patient but for the staff as well. All interventions should
    insomnia…
                                                                       be individualized, carefully timed and patient should
  ƒ Potential side effects: EPS, sedation, hypotension,                carefully monitored throughout the entire process. All
    QT effect…                                                         professionals involved in care for a patient should be up
  ƒ Earlier response to therapy;                                       to date with medical as well as with legal issues involved.
  ƒ Earlier developed side effects;
  ƒ Psychiatric and non psychiatric co morbidities;
  ƒ What patient prefers (when possible, respecting                      Contribution of individual authors:
    patient’s wishes regarding formulation, brand-name
    and type of therapy can lead to better long-term                     Ante Siliü: conception and design of the paper, ana-
                                                                            lysis and interpretation of data;
    outcomes).
                                                                         Aleksandar Saviü: conception and design, participa-
    Whenever it is possible we should administer mono-                      ted in drafting and revising article;
therapy. Combining two or more drugs is often neces-                     Ilaria ýulo & Suzana Kos: analysis and interpretation
sary but should be avoided if possible. There are diffe-                    of data, critical revision;
rent formulations of psychopharmacotherapy available                     Jakša Vukojeviü: analysis and interpretation of data,
for the management of emergencies in schizophrenia.                         data search
We should always prefer peroral route of administration                  Daška Brumen: acquisition of data;
if possible thus avoiding intrusive ways of admini-                      Draženka Ostojiü: conception and design, participated
stering a drug (Ostinelli et al. 2017).                                     in drafting and revising article.

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Ante Siliü, Aleksandar Saviü, Ilaria ýulo, Suzana Kos, Jakša Vukojeviü, Daška Brumen & Draženka Ostojiü: APPROACH TO EMERGENCIES IN
             SCHIZOPHRENIA IN UNIVERSITY HOSPITAL "VRAPýE"                   Psychiatria Danubina, 2018; Vol. 30, Suppl. 4, pp 203-207

                                                                           randomized controlled trial. J Formos Med Assoc 2015;
 Acknowledgements: None.                                                   114:438-45
                                                                       18. Keating GM: Loxapine inhalation powder: a review of its
 Conflict of interest: None to declare.                                    use in the acute treatment of agitation in patients with bi-
                                                                           polar disorder or schizophrenia. CNS Drugs 2013; 27:479-89
                                                                       19. Kos S: Zakonski okviri zbrinjavanja hitnih stanja u
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Correspondence:
Ante Siliþ, MD, PhD
University Psychiatric Hospital VrapĀe
BolniĀka cesta 32, 10 000 Zagreb, Croatia
E-mail: ante.silic@gmail.com

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