Letters

Mental health emergencies

BMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7112.884 (Published 04 October 1997) Cite this as: BMJ 1997;315:884

Details of studies of zuclopenthixol acetate are needed

  1. Evandro Coutinho, Lecturer in epidemiologya,
  2. Mark Fenton, Research nurseb,
  3. Colin Campbell, Consultant psychiatristb,
  4. Anthony David, Professorc
  1. a FIOCRUZ/UERJ, Rio de Janeiro, Brazil,
  2. b South Warwickshire Mental Health Services Trust, Warwick CV35 7EE,
  3. c Institute of Psychiatry, London SE5 8AZ
  4. d Dewsbury, Yorkshire
  5. e St James's University Hospital, Leeds LS9 7TF
  6. f Psychiatric Intensive Treatment Unit, Lambeth Healthcare NHS Trust, London SW9 9NT,
  7. g United Medical and Dental Schools, St Thomas's Hospital, London SE1 7EH
  8. h Maudsley Hospital, London SE5 8AZ

    Editor—The issue of mental health emergencies is rarely addressed. As we are currently working with the Cochrane Schizophrenia Group to produce a systematic review on the use of zuclopenthixol acetate for acutely disturbed people, we were interested to see that Zerrin Atakan and Teifion Davies recommend its use in certain circumstances.1 Despite our best efforts at searching electronic databases such as Biological Abstracts, the Cochrane Library, Embase, LILIACS, Medline, PsycLIT, and PSYNDEX and many conference proceedings, and contacting Lundbeck, we have found only three fully published controlled clinical trials from which data can be extracted.2 3 4 The paucity of studies may be due to the great difficulty in carrying out trials of emergency treatment in psychiatry, but the fact that all three identified studies give equivocal results suggests that the recommendation of zuclopenthixol acetate in preference to other treatments may be premature. We would welcome any information that the authors or others may have on any controlled clinical trials, published or unpublished, relating to this issue.

    References

    1. 1.
    2. 2.
    3. 3.
    4. 4.

    Patients need to be monitored when given rapid tranquillisation

    1. Ed Walker (ed_walker{at}limeland.demon.co.uk), Staff grade practitioner in accident and emergencyd
    1. a FIOCRUZ/UERJ, Rio de Janeiro, Brazil,
    2. b South Warwickshire Mental Health Services Trust, Warwick CV35 7EE,
    3. c Institute of Psychiatry, London SE5 8AZ
    4. d Dewsbury, Yorkshire
    5. e St James's University Hospital, Leeds LS9 7TF
    6. f Psychiatric Intensive Treatment Unit, Lambeth Healthcare NHS Trust, London SW9 9NT,
    7. g United Medical and Dental Schools, St Thomas's Hospital, London SE1 7EH
    8. h Maudsley Hospital, London SE5 8AZ

      Editor—Zerrin Atakan and Teifion Davies have a box listing precautions with rapid tranquillisation in their article in the ABC of mental health.1 With the use of the doses suggested, some patients will be nearly anaesthetised, and certainly heavily sedated. There are now stringent guidelines on using intravenous sedation for diagnostic and therapeutic procedures (for example, endoscopy), which include continuous monitoring of oxygen saturation and ideally the presence at all times of a trained anaesthetist. I would suggest that the degree of respiratory depression and obtundation of the airway is greater in some sedated acutely disturbed patients than it is in those having an endoscopy under sedation.

      Should we not be applying the same rigid criteria in both instances? Most anaesthetic departments have a good working relationship with their psychiatric colleagues due to the running of lists for electroconvulsive therapy, so should not perhaps the services of the anaesthetists be called on if intense sedation is required? It is not enough merely to state that resuscitation equipment is available if no one knows how to use it properly.

      Finally, the authors suggest using a butterfly cannula in a large vein to give the sedatives. These cannulas may be easier to insert than flexible Teflon cannulas, but they also have a well known propensity for “cutting out” of the vein at crucial moments—for example, when life saving drugs are being given.

      References

      1. 1.

      Zuclopenthixol acetate is given by intramuscular injection, not intravenously

      1. Robert Orange-Bromehead, Senior registrar in general psychiatrye
      1. a FIOCRUZ/UERJ, Rio de Janeiro, Brazil,
      2. b South Warwickshire Mental Health Services Trust, Warwick CV35 7EE,
      3. c Institute of Psychiatry, London SE5 8AZ
      4. d Dewsbury, Yorkshire
      5. e St James's University Hospital, Leeds LS9 7TF
      6. f Psychiatric Intensive Treatment Unit, Lambeth Healthcare NHS Trust, London SW9 9NT,
      7. g United Medical and Dental Schools, St Thomas's Hospital, London SE1 7EH
      8. h Maudsley Hospital, London SE5 8AZ

        Editor—The article on mental health emergencies contains a flow chart for rapid tranquillisation of acutely disturbed patients.1 I was extremely concerned, however, to see the recommendation to give zuclopenthixol acetate 100–150 mg intravenously. This preparation of zuclopenthixol has been designed for, and indeed is only licensed for, deep intramuscular injection.2 Were it given intravenously at this dose it would be extremely dangerous to the patient, with a high risk of cardiac arrhythmia, profound hypotension, severe dystonic reaction, and many other adverse effects.

        References

        1. 1.
        2. 2.

        Authors' reply

        1. Zerrin Atakan, Consultant psychiatristf,
        2. Teifion Davies, Senior lecturer in community psychiatryg
        1. a FIOCRUZ/UERJ, Rio de Janeiro, Brazil,
        2. b South Warwickshire Mental Health Services Trust, Warwick CV35 7EE,
        3. c Institute of Psychiatry, London SE5 8AZ
        4. d Dewsbury, Yorkshire
        5. e St James's University Hospital, Leeds LS9 7TF
        6. f Psychiatric Intensive Treatment Unit, Lambeth Healthcare NHS Trust, London SW9 9NT,
        7. g United Medical and Dental Schools, St Thomas's Hospital, London SE1 7EH
        8. h Maudsley Hospital, London SE5 8AZ

          Editor—Our article on mental health emergencies was necessarily brief, and its advice, particularly on treatment, was simplified for clarity. The correspondents raise several broader issues. We agree with Evandro Coutinho and colleagues that there are few studies of zuclopenthixol acetate in emergency situations and that it may be difficult to pinpoint a rapid tranquillisation regimen that is clearly superior to all others. Thus we restricted our advice to drug regimens that we find effective as first line treatment in emergencies.

          Ed Walker points to the potential dangers of rapid tranquillisation. It must be remembered that, as we pointed out, this is an emergency treatment “to control potentially destructive behaviour”; it is to be used only when other treatments are unlikely to be effective and when the anticipated benefits outweigh the expected risks. All psychiatric units should operate guidelines stating in what circumstances rapid tranquillisation may be used and by whom, and the precautions to be taken. The involvement of anaesthetists in these procedures would be welcomed by many psychiatrists but could present huge logistic difficulties since acute psychiatric units are often situated some distance from the nearest general hospital.

          We thank Robert Orange-Bromehead for drawing attention to the error introduced into the flow chart on rapid tranquillisation when the artwork was being prepared by the BMJ. As Orange-Bromehead notes, zuclopenthixol acetate is intended for deep intramuscular injection, and intravenous administration is potentially dangerous.

          Caution is needed with rapid tranquillisation protocol

          1. Ian B Ker, Senior registrarh,
          2. David Taylor, Chief pharmacisth
          1. a FIOCRUZ/UERJ, Rio de Janeiro, Brazil,
          2. b South Warwickshire Mental Health Services Trust, Warwick CV35 7EE,
          3. c Institute of Psychiatry, London SE5 8AZ
          4. d Dewsbury, Yorkshire
          5. e St James's University Hospital, Leeds LS9 7TF
          6. f Psychiatric Intensive Treatment Unit, Lambeth Healthcare NHS Trust, London SW9 9NT,
          7. g United Medical and Dental Schools, St Thomas's Hospital, London SE1 7EH
          8. h Maudsley Hospital, London SE5 8AZ

            Editor—We would add a note of caution to Zerrin Atakan and Teifion Davies's article on mental health emergencies.1 They discuss the use of pharmacotherapy for rapid tranquillisation for disturbed and violent behaviour and give an algorithm for this, which is a simplified version of one developed in our trust. We have recently reviewed the treatment of acute disturbed and violent behaviour, including its causes, the context in which it occurs, and use of this algorithm.2 We found that there are few controlled studies of treatment, pharmacological or otherwise, in this situation. We warn that the algorithm represents simply an attempt to synthesise local clinical practice and experience (which is known to be generally idiosyncratic3), a review of pharmacological and pharmacokinetic data, and careful consideration of issues relating to patients' safety. Thus its use constitutes an attempt at good clinical practice given limited background information, rather than evidence based practice as such.

            In considering contextual issues, we also emphasise that rapid tranquillisation should be used only during an attempt at considered assessment (and treatment if possible) of underlying causes, after a trial (if possible) of non-pharmacological methods and, preferably, with a protocol to avoid inappropriate or counterproductive interventions. Such interventions may also occur when responses are due to pressure on junior staff to act, essentially as a result of “institutional anxiety,” which may in some cases be extreme.4 The importance of a protocol therefore partly lies in relieving stress on junior staff, both medical and nursing, in what is often already a highly stressful situation.

            Finally, we note that a further, valid, reason for rapid tranquillisation, in addition to treatment of disturbed or violent behaviour, is relief of distressing symptoms for the patient.

            References

            1. 1.
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            View Abstract

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