Treatment challenges in the acute hospital setting

Despite recent advances in the treatment of schizophrenia and related psychoses, management of acutely ill patients in the hospital setting remains a significant challenge for clinicians. Patients in the hospital setting, e.g., those experiencing symptomatic relapse or their first psychotic episode, or indeed an acute manic episode, are often highly agitated, uncooperative, and in some cases, display hostile and aggressive behaviour. For such patients, the focus of initial treatment is to resolve symptoms, calm agitation and minimise the risk of harm to themselves and others. In achieving these aims, we should strive to foster a collaborative and proactive relationship with our patients, preferably caring for them in the least restrictive setting possible. Environmental or behavioural strategies form a key part of patient management in the hospital setting; however, in most cases, pharmacological intervention is also required. Unfortunately, intramuscular administration of antipsychotics and other medications is still widely used as a first-choice option in clinical practice, despite a variety of expert treatment guidelines advising against this. A survey by Allen et al. (2003) revealed that many patients perceive parenteral administration as coercive and abusive, and 93% of patients chose pills or capsules as their preferred formulation. In the small number of patients who are uncooperative or dangerous, parenteral medication is required; however, it is preferable to use oral medication in cooperative patients wherever possible (Allen et al. 2001; Falkai et al. 2005). Furthermore, when possible, the use of a single agent, rather than combination therapy, is desirable. As continuity of care is crucial, selection of treatment in the hospital setting should be based not only on short-term needs but also on the longterm objectives of maintaining remission and preventing relapse. Although conventional antipsychotics are seen by many clinicians as an effective first choice in acutely ill patients, unpleasant side effects such as extrapyramidal symptoms and subjective dysphoria can lead to non-adherence and eventual relapse. The aforementioned survey by Allen et al. (2003) found that patients ranked haloperidol as their least-preferred treatment option during a behavioural emergency, expressing instead a marked preference for benzodiazepines, followed by atypical antipsychotics, quetiapine, risperidone, and olanzapine, in that order. By definition, atypical antipsychotics are associated with a much lower incidence rate of EPS than conventional agents, and although few directly comparative data are available, studies indicate that their risk of inducing EPS can be ranked in the following order: clozapineB/ quetiapineB/olanzapine /ziprasidoneB/risperidone. Atypical antipsychotics also have a broader spectrum of efficacy than conventional agents, alleviating not only positive symptoms, but also the negative, affective and cognitive symptoms of schizophrenia. For these reasons, the Expert Consensus Guidelines on the treatment of schizophrenia, which were developed by 60 leading experts, recommend that atypical antipsychotics are used first-line in acutely ill patients (Allen et al. 2001). Despite these clear advantages of atypical antipsychotics, many clinicians remain to be convinced of their effectiveness in behavioural emergencies, stating lack of efficacy and slow onset of action as reasons against their use. Recent literature tends not to support this view and there is now a growing body of evidence that, dosed appropriately, atypical antipsychotics can be just as effective as conventional agents in acutely ill patients. For example, quetiapine has been shown to be superior to haloperidol in reducing aggression and hostility in patients experiencing an acute exacerbation of schizophrenia (Chengappa et al. 2003), and in patients with aggressive psychosis, quetiapine significantly decreased Overt Aggression Scale (OAS) scores in patients after 1 day of treatment (Ganesan et al. 2005). In addition, studies have shown that oral olanzapine plus lorazepam is as effective as oral haloperidol plus lorazepam in reducing acute agitation (Kinon et al. 2004); intramuscular olanzapine and intramuscular haloperidol have equivalent efficacy (Wright et al. 2001); and risperidone plus lorazepam is as effective as intramuscular haloperidol plus lorazepam (Currier et al. 2004) or intramuscular zuclopenthixol plus lorazepam (Hovens et al. 2005). Collectively, these data present a convincing argument for first-line use of atypical antipsychotics in acutely ill patients. In general, the use of oral atypical antipsychotics in the hospital setting has been limited by initial The World Journal of Biological Psychiatry, 2005; 6(4): 210 /211