Journal of psychiatric practice
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Randomized Controlled Trial
Risperidone versus haloperidol, in combination with lorazepam, in the treatment of acute agitation and psychosis: a pilot, randomized, double-blind, placebo-controlled trial.
To compare oral risperidone and intramuscular (IM) haloperidol, both in combination with IM lorazepam, in the management of acute agitation and psychosis in the medical emergency department. ⋯ Lorazepam alone was as effective as lorazepam plus haloperidol or lorazepam plus risperidone in this small trial. While not statistically significant, a trend toward better outcomes with combined treatment warrants further study.
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Due to inherent dangers and barriers to research in emergency settings, few data are available to guide clinicians about how best to manage behavioral emergencies. Key constructs such as agitation are poorly defined. This lack of empirical data led us to undertake a survey of expert opinion, results of which were published in the 2001 Expert Consensus Guidelines on the Treatment of Behavioral Emergencies. Several second-generation (atypical) antipsychotics (SGAs) are now available in new formulations for treating behavioral emergencies (e.g., intramuscular [i.m.] olanzapine and ziprasidone; rapidly dissolving tablets of olanzapine and risperidone). Critical questions face the field. The SGAs are significantly different from the FGAs and from each other and have not been studied in unselected patients as were the FGAs. Can the SGAs can be thought of as a class, do all antipsychotics have similar anti-agitation effects in different conditions, and, if equally effective, what limits might their safety profiles impose? Should antipsychotics be used more specifically to treat psychotic conditions, while benzodiazepines (BNZs) alone are used nonspecifically? Few data are available concerning combinations of SGAs and BNZs, and findings concerning the traditional combination of haloperidol plus a BNZ may not be relevant to combinations with SGAs. The culture is also evolving with more emphasis on patient involvement in treatment decisions. An international consensus has been developing that calming rather than sedation is the appropriate endpoint of behavioral emergency interventions. We undertook a new survey of expert opinion to update recommendations from the earlier survey. ⋯ Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines suggest that the SGAs are now preferred for agitation in the setting of primary psychiatric illnesses but that BNZs are preferred in other situations.
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Sleep and wakefulness are fundamental behavioral and neurobiological states that characterize all higher animals, including human beings. This article presents an overview of the current state of our knowledge concerning the function of sleep and sleep-wake rhythms, the neurobiology of circadian rhythms, how wakefulness and sleep are studied, and the clinical assessment and diagnosis of sleep and circadian rhythm disorders. Major theories of the function of sleep and sleep-wake rhythms are reviewed, including ecological or environmental advantage, physical restoration, optimizing waking function, learning and integration of experience, and survival. ⋯ How sleep is studied using polysomnography (PSG) is explained, and the PSG characteristics of the three major neurobehavioral states, wakefulness, rapid eye movement (REM) sleep, and non-rapid eye movement (NREM) sleep, are described. Systems of classifying sleep disorders are reviewed, including those of the DSM-IV-TR, the International Classification of Sleep Disorders, and the ICD-10. Methods of assessing sleep complaints are then described, including taking an accurate history from the patient and bed partner, use of sleep history questionnaires and sleep-wake diaries, use of actigraphy, and use of PSG.