Rapid tranquillisation for agitated patients in emergency psychiatric rooms: a randomised trial of midazolam versus haloperidol plus promethazine

We thank Dr Bradley for the very generous comments.

We did choose to use only the clinical impression of
agitation/aggression as recorded by the doctors and nurses. We ensured
that the time of tranquillisation was accurate by use of independent
observation for a proportion of participants. We had thought of using the
Overt Aggression Scale to validate the clinical impression but this would
have complicated the design and the study would have been less practical.
We are therefore left with the reliably timed clinical impression of staff
very experienced in managing aggression. We did not measure how this
differed between centres. In the survey of rates of aggression preceding
TREC the authors did not have the impression that severity of aggression
differed between centres across Rio de Janeiro(1).

Doctors working in the psychiatric emergency rooms of Rio rated most
people as 'markedly' agitated. As the survey shows these clinicians work
in situations where aggression is remarkably prevalent1 and accommodation
to such levels of agitation would be understandable.

TREC-India, using similar design and comparing haloperidol plus
promethazine with lorazepam for 200 people whose aggression was thought to
be due to psychosis(2) may shed further light on whether experienced
clinical impressions concur with measures of aggression. This study did
incorporate reliable use of simple validated rating of clinical global
impression.

Reference List

1. Huf G, Coutinho ESF, Fagundes HM Jr, Oliveira ES, Lopez JR,
Gewandszajder M, da Luz Carvalho A, Keusen A, Adams CE. Current practices
in managing acutely disturbed patients at three hospitals in Rio de
Janeiro-Brazil: a prevalence study.BMC Psychiatry 2002;2(1):4.

2. Alexander J, Tharyan P, Adams CE, John T, Mol C, Philip J. TREC-
INDIA: Rapid tranquilisation of violent or agitated patients in a
psychiatric emergency setting: a pragmatic randomized trial of
intramuscular lorazepam versus haloperidol plus promethazine. BJPsych 2003
submitted

Competing interests:
Collaborators on the TREC study