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Objective This post hoc analysis evaluated the effect of lurasidone on agitation in acutely ill patients with schizophrenia. Method Patient-level data were pooled from five 6-week, randomized, double-blind, placebo-controlled studies of fixed-dose, once-daily, oral lurasidone (40, 80, 120, or 160 mg/d). Agitation was assessed with the Positive and Negative Syndrome Scale–Excited Component (PANSS-EC) score, utilizing a mixed model for repeated measurement analysis. Results In patients with higher levels of agitation at baseline (PANSS-EC score ≥ 14; n = 773), lurasidone was associated with significantly greater improvement in least-squares (LS) mean PANSS-EC scores versus placebo at Day 3/4 (− 1.6 vs − 1.0; p < 0.05), Day 7 (− 2.3 vs − 1.6; p < 0.05), and at Week 6 endpoint (− 5.5 vs − 3.8; p < 0.001; effect size = 0.43). In patients with lower agitation at baseline (PANSS-EC score < 14; n = 754), LS mean PANSS-EC score change was significantly greater for lurasidone compared with placebo at Day 7 (− 0.8 vs − 0.1; p < 0. 01) through Week 6 endpoint (− 1.9 vs − 0.9; p < 0.001; effect size = 0.31). Higher doses of lurasidone were notably more effective than lower doses in patients with more severe agitation at study baseline. Conclusion In this pooled analysis of 5 short-term studies, lurasidone provided early and sustained reduction in agitation, assessed using the PANSS-EC score, in patients with an acute exacerbation of schizophrenia. Higher doses of lurasidone were particularly effective in patients with more severe agitation at study baseline. Overall, these results suggest that lurasidone may be a useful treatment option for patients exhibiting agitation associated with acute psychotic symptoms of schizophrenia. ClinicalTrials.gov Identifiers: NCT00088634 (Study D1050196); NCT00549718 (Study D1050229), NCT00615433 (Study D1050231); NCT00790192 (Study D1050233). Study D1050006 was completed prior to the requirement to register trials. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To describe the Psychiatric Emergency Research Collaboration (PERC), the methods used to create a structured chart review tool and the results of our multicenter study. Method: Members of the PERC Steering Committee created a structured chart review tool designed to provide a comprehensive picture of the assessment and management of psychiatric emergency patients. Ten primary indicators were chosen based on the Steering Committee''s professional experience, the published literature and existing consensus panel guidelines. Eight emergency departments completed data abstraction of 50 randomly selected emergency psychiatric patients, with seven providing data from two independent raters. Inter-rater reliability (Kappas) and descriptive statistics were computed. Results: Four hundred patient charts were abstracted. Initial concordance between raters was variable, with some sites achieving high agreement and others not. Reconciliation of discordant ratings through re-review of the original source documentation was necessary for four of the sites. Two hundred eighty-five (71%) subjects had some form of laboratory test performed, including 212 (53%) who had urine toxicology screening and 163 (41%) who had blood alcohol levels drawn. Agitation was present in 220 (52%), with 98 (25%) receiving a medication to reduce agitation and 22 (6%) being physically restrained. Self-harm ideation was present in 226 (55%), while other-harm ideation was present in 82 (20%). One hundred seventy-nine (45%) were admitted to an inpatient or observation unit. Conclusion: Creating a common standard for documenting, abstracting and reporting on the nature and management of psychiatric emergencies is feasible across a wide range of health care institutions. [Copyright &y& Elsevier]

Psychiatric emergency services (PES) are an increasingly important component of mental health services. To assess the type and scope of services delivered in the PES setting, the American Association for Emergency Psychiatry sponsored an Expert Consensus Panel Survey of these services in 1999. The questionnaire was mailed to medical directors of PES facilities with 91% (n = 51) responding. More than 90% of the respondents were teaching sites. Restraints were reportedly used in a mean of 8.5% of presentations for a mean of 3.3 h per episode. Restraint utilization correlated with the percentage of psychotic patients treated, but not with a wide variety of other patient and service variables. Involuntary medications were used in 16% of cases, though in oral form in 29% of those cases. A large majority (94%) endorsed mild sedation permitting further assessment as the appropriate endpoint and rejected sleep or heavy sedation as an endpoint (82%). Benzodiazepines received the strongest endorsements and 82% indicated it would be appropriate to administer a benzodiazepine alone for agitation first and initiate antipsychotic treatment subsequently if appropriate. When there is no history of prior antipsychotic exposure, 60% favored a benzodiazepine alone. However, given a history of previous antipsychotic treatment, only 8% endorsed this strategy. Most respondents (78%) preferred to use oral medication for treating behavioral emergencies, whenever possible but 70.3% reported regular use of an IM combination of a benzodiazepine and high-potency typical neuroleptic when necessary. In addition to managing emergencies, 82% of services initiated standing medications for patients being admitted to hospital settings and 70% initiated regular medication treatments for patients being released to the community. Of patients started on oral antipsychotics, 42% received an atypical antipsychotic. Reflecting medication characteristics of particular importance in emergency settings, most respondents (92%) cited selective serotonin reuptake inhibitors as the preferred type of antidepressant, and divalproex or related compounds (90%) for treatment of bipolar disorder in the PES. [Copyright &y& Elsevier]

Psychiatric emergency services (PES) are evolving as freestanding, parallel components of emergency departments at many tertiary care medical centers in the U.S. While PES facilities provide an increasing percentage of first-line care for patients with psychiatric crises, the services they provide and their interactions with medical emergency services have not been systematically assessed. The purpose of this study was to examine PES structure, care processes, patient characteristics and relationship with medical emergency services by surveying PES directors with a 70-item questionnaire about PES facilities in 1998. This report presents information about staffing adequacy, medical evaluation and other procedures, length of stay, and aftercare. The response rate was 91% (n=51), and most sites (>90%) were academic training sites. A large percentage (92%) of PES sites were open 24 h a day, 7 days a week, and 94% had an attending psychiatrist present at least 8 h daily. PES psychiatrists performed initial medical evaluation at 55% of sites and were often responsible for medical clearance. Pharmacologic therapy was routinely initiated for patients being admitted in 92% of facilities and for patients being released in 70% of facilities. Mean (SD) length of stay in the PES was 9.0 (11.3) hours. The PES facilities were effective at referring patients to aftercare, and 51% of PES sites provided follow-up care. However, 69% of respondents reported inadequate referral options for patients with substance abuse. The mean recidivism rate was 18%, primarily attributed to substance abuse and medication noncompliance. The results of this survey show that PES facilities are organizationally complex units in which staff routinely perform medical clearance, initiate treatment, and coordinate aftercare. Our findings highlight the importance of adequate medical training for PES psychiatrists, the need for improved aftercare programming, and better access to substance abuse treatment for discharged patients. [Copyright &y& Elsevier]

Abstract: Objective: In spite of much effort to create guidelines on the management of violent behavior (VB) in emergency departments, little is known about the impact of such guidelines on a real-life emergency environment. The aim of this study is to investigate the impact of a staff educational crisis intervention (SECI) on the reduction of VB in patients admitted to emergency departments following drug suicidal attempt. Method: The impact of a SECI on VB of patient consulting the ER following a drug suicide attempt was assessed by comparing the occurrence of VB before (5 months) and after (5 months) the introduction of a SECI. Results: A significant reduction in VB (from 17.32% to 7.14%) was found with the comparison of two 5-month periods: before (254 patients) and after (224 patients) the introduction of a SECI program (χ 2=11.238; P=.0008). Conclusion: These preliminary data suggest the need for further prospective randomized studies aiming to prevent VB in emergency departments by developing specific SECI programs. [Copyright &y& Elsevier]

Many patients treated in the emergency department (ED) for non-psychiatric complaints have elevated suicide risk. Universal screening can detect occult suicide risk, but gold standard risk measurement tools, such as the Beck Scale for Suicidal Ideation (BSS), are too long and cumbersome for ED use. To test the performance of seven novel 0- to 10-point suicide risk "rulers" against the BSS. 399 patients from three EDs completed seven novel risk rulers, traditional binary screening items, and the BSS. Using BSS criterion references, we tested the diagnostic performance of each risk ruler and examined correlations between the rulers and BSS scores. By varying thresholds on the risk rulers, high levels of sensitivity and specificity were obtained. A threshold of 3 on the "sadness" ruler gave 89% sensitivity for the BSS criterion reference, and a threshold of 1 on the "wish to be dead" ruler provided 94–97% specificity. Our novel risk rulers may be an efficient way to detect risk and triage potentially suicidal patients, showing good concurrent validity with the BSS. Clinicians can obtain high sensitivity and high specificity using just two rulers. Further research should examine the rulers' ability to predict independent clinician risk ratings and prospective suicidal behavior. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To examine factors associated with physical restraint in psychiatric emergency rooms. Method: We extracted variables likely to predict use of physical restraints from a large randomised trial undertaken in three psychiatric emergency rooms in Rio de Janeiro. We fitted a Bayesian binary multivariate model using only variables clearly preceding the restraints. Results: Of 301 agitated, aggressive people admitted to emergency rooms, 73 (24%) were restrained during the first 2 h of admission. In Rio, younger people (OR=1.03 for each year younger), exhibiting intense (OR=2.53) or extreme agitation (OR=7.71), thought to result from substance misuse (OR=1.75) or diagnoses other than psychosis (OR=1.88), arriving in the morning (OR=1.64) were at greater risk of physical restraints than older, less severely aggressive or agitated people, arriving at the hospital during the afternoon or night. Hospital, gender, first admission to hospital and medication were not associated with risk of being restrained. Conclusion: Restraint practices in Rio are predictable and based on a limited clinical assessment. Predictive factors for physical restraint may vary worldwide, but should be monitored and studied to assist training, and to establish programs to evaluate and refine this controversial practice. [Copyright &y& Elsevier]

Abstract: Objective: Only a few small descriptive studies have examined the prevalence and correlates of tobacco use among bipolar patients. We predicted that poorly controlled manic, depressed and mixed states, and the presence of psychotic symptoms, would be associated with a greater prevalence of smoking among patients with bipolar disorder. Method: We examined the prevalence of smoking in a cross-sectional sample of 1904 patients with bipolar disorder enrolled in the National Institute of Mental Health''s Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) database. We also examined the relationship between smoking and other factors including: bipolar subtype, current clinical status, illness severity (e.g., number of prior mood episodes), age of bipolar onset, gender, education, socioeconomic status, and concurrent substance use. Results: At STEP-BD program entry, 31.2% of patients reported that they were smokers. Patients who were male, less educated, and/or had lower income were more likely to be smokers (P&#60;.01). Additionally, patients with rapid cycling, comorbid psychiatric disorders, and/or substance abuse, and those experiencing a current episode of illness were more likely to be smokers (P&#60;.0001). More lifetime depressive and manic episodes as well as greater severity of depressive and manic symptoms were associated with smoking (P&#60;.001). Use of atypical antipsychotic medications was more prevalent among smokers (P=.04). Conclusions: Clinical and demographic variables are associated with smoking in this sample of bipolar patients. Longitudinal analyses are needed to determine how mood and bipolar symptoms interact with smoking over the episodic course of bipolar disorder. Additional studies should focus on whether controlling bipolar symptoms is associated with cessation of smoking. [Copyright &y& Elsevier]

Abstract: Objective: The objective was to describe continuity of care approaches for psychiatric emergencies in the emergency department. Methods: A national survey of all 138 academic emergency departments in the United States was conducted. Results: Most emergency physicians (81%) had no systematic method for identifying psychiatric emergency patients with high recidivism. In order to promote outpatient care, sites commonly reported using intensive interventions, including scheduling outpatient appointments prior to discharge (72%) and in-house case management (64%). Conclusion: While systematic identification of repeat psychiatric emergency patients was uncommon, emergency departments reported using a variety of fairly intensive strategies to promote continuity of care with outpatient mental health services. [Copyright &y& Elsevier]

Abstract: Objective: Despite the frequency of borderline personality disorder (BPD) in patients with acute agitation in emergency departments (EDs), there are few data about the use of intramuscular (IM) psychotropics in those patients. This is the first open-label study with olanzapine in this setting. Method: Measures were collected prospectively for patients with acute agitation in ED. Consent was obtained subsequently and diagnosis ascertained using the Structured Clinical Interview for DSM-IV. A group of 25 patients with severe agitation and BPD received olanzapine 10 mg IM. Efficacy and safety data are available at baseline, 2 h postinjection and at discharge. Results: Significant reductions of agitation associated with good tolerance were observed 2 h after the first IM olanzapine. Sixteen percent of patients required a second IM olanzapine. Conclusions: Randomized, placebo-controlled studies are needed to confirm the efficacy of IM olanzapine in patients with acute agitation and BPD. [Copyright &y& Elsevier]

Abstract: Introduction: Chemical restraint is controversial. Appropriate use is ill-defined and chemical restraint may be overutilized. During the period of an unrelated observational study for patients with acute psychomotor agitation in a psychiatric emergency service, we noticed a significant reduction in the number of involuntary intramuscular injections administered. Results: We observed a 27% decrease (P=.015) in the number of involuntary intramuscular injections in the 3-month observational study period, compared to 3-month periods before and after the study. Conclusion: We suggest that the observation process itself may have been beneficial and may have reduced the incidence of unnecessary intramuscular injections. [Copyright &y& Elsevier]