The expert consensus guideline series. Treatment of behavioral emergencies 2005. European Psychiatric Association (EPA) guidance on forensic psychiatry: Evidence based assessment and treatment of mentally disordered offenders. The expert consensus guideline series. Treatment of dementia and its behavioral disturbances. Introduction: methods, commentary, and summary. Treatment of Behavioral Emergencies: A Summary of the Expert Consensus Guidelines Oral risperidone with lorazepam versus oral zuclopenthixol with lorazepam in the treatment of acute psychosis in emergency psychiatry: a prospective, comparative, open-label study Are Low Doses of Antipsychotics Effective in the Management of Psychomotor Agitation? A Randomized, Rated-Blind Trial of 4 Intramuscular Interventions Medication development for agitation and aggression in Alzheimer disease: review and discussion of recent randomized clinical trial design. The case for practical clinical trials in psychiatry. Intramuscular Ziprasidone Versus Haloperidol for Managing Agitation in Chinese Patients With Schizophrenia Risk assessment and shared care planning in out-patient forensic psychiatry: cluster randomised controlled trial. Efficacy of Topiramate, Valproate, and Their Combination on Aggression/Agitation Behavior in Patients With Psychosis An investigation of long-term effects of group music therapy on agitation levels of people with Alzheimer's Disease Does psychomotor agitation in major depressive episodes indicate bipolarity? Consensus Recommendations for the Clinical Application of Repetitive Transcranial Magnetic Stimulation (rTMS) in the Treatment of Depression. Reducing seclusion through involuntary medication: A randomized clinical trial TREC-Rio trial: a randomised controlled trial for rapid tranquillisation for agitated patients in emergency psychiatric rooms [ISRCTN44153243] Clinical practice with anti-dementia drugs: a revised (second) consensus statement from the British Association for Psychopharmacology Psychometric Testing of the Agitation Severity Scale for Acute Presentation Behavioral Management Patients in the Emergency Department Stage-tailored tobacco cessation treatment in inpatient psychiatry. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition Partial Gland Ablation for Prostate Cancer: Report of a Food and Drug Administration, American Urological Association, and Society of Urologic Oncology Public Workshop. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition) Involving patients in decisions during psychiatric consultations.
OBJECTIVES Due to inherent dangers and barriers to research in emergency setting s , 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 up date recommendations from the earlier survey . METHOD A written survey of 61 questions ( 1,020 options ) was mailed to 50 experts in the field , 48 ( 96 % ) of whom completed it . The survey sought to define level of agitation at which emergency interventions are appropriate , scope of assessment depending on urgency and patients ' ability to cooperate , guiding principles for selecting interventions , and appropriate physical and medication strategies at different levels of diagnostic confidence for a variety of provisional diagnoses and complicating conditions . A modified version of the R AND Corporation 's 9-point scale for rating appropriateness of medical decisions was used to score most options . Consensus was defined as a non-r and om distribution of scores by chi-square " goodness-of-fit " test . We assigned a categorical rank ( first line/preferred , second line/alternate , third line/usually inappropriate ) to each option based on the 95 % confidence interval around the mean . Ratings were used to develop guidelines for preferred strategies in key clinical situations . This study received financial support from multiple sponsors , with the panel kept blind to sponsorship to reduce possible bias . Medication ratings were based on responses of only those respondents with direct experience with each drug . In reporting practice patterns , the panel was asked to respond based on actual data rather than estimates . RESULTS The expert panel reached consensus on 78 % of the options rated on the 9-point scale . The responses suggest that physicians can make provisional diagnoses with some confidence and that pharmacological and nonpharmacological interventions are selected differentially based on diagnosis and other salient demographic and medical features . BNZs are recommended when no data are available , when there is no specific treatment ( e.g. , personality disorder ) , or when they may have specific benefits ( e.g. , intoxication ) . No single SGA emerges as a nonspecific replacement for haloperidol ; instead , different SGAs are preferred in various circumstances consistent with current evidence . To the degree that haloperidol is recommended , it is almost always in combination with a BNZ ; haloperidol alone is preferred only in the medically compromised . In contrast , the SGAs are more often recommended for use alone , and the panel would avoid combining BNZs with some SGAs . Oral risperidone alone or combined with a BNZ receives strong support in a variety of situations . Oral olanzapine was rated very similarly to risperidone , with slightly higher ratings than risperidone in situations where it has been studied ( e.g. , schizophrenia , mania ) and slightly lower ratings where it has not been studied or safety may be a concern ; there was less support for combining oral olanzapine with a BNZ . For oral treatment of agitation related to schizophrenia or mania , olanzapine alone , risperidone alone or combined with a BNZ , and haloperidol plus a BNZ are first line , with strong support also for combining divalproex with the antipsychotic for presumed mania . Oral ziprasidone and quetiapine generally received similar second-line ratings in most situations . If a parenteral agent is needed , i.m . olanzapine alone received somewhat more support than i.m . ziprasidone alone ; however , there was more support for i.m . ziprasidone alone or combined with a BNZ than for i.m . olanzapine plus a BNZ , probably reflecting safety concerns . For example , for a provisional diagnosis of schizophrenia , first-line parenteral options are i.m . olanzapine or ziprasidone alone or i.m . haloperidol or ziprasidone combined with a BNZ . Neither of the new parenteral formulations received as much support as traditional agents ( i.m . BNZs , i.m . haloperidol ) when no data are available or the diagnosis involves medical comorbidity or intoxication . When initial intervention with risperidone , ziprasidone , or haloperidol is unsuccessful , the panel recommended adding a BZD to the antipsychotic . However , when initial treatment with olanzapine or quetiapine is unsuccessful , increasing the dosage is recommended . Perphenazine was consistently rated second line and droperidol and chlorpromazine received third-line ratings throughout . CONCLUSIONS 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 Forensic psychiatry in Europe is a specialty primarily concerned with individuals who have either offended or present a risk of doing so , and who also suffer from a psychiatric condition . These mentally disordered offenders ( MDOs ) are often cared for in secure psychiatric environments or prisons . In this guidance paper we first present an overview of the field of forensic psychiatry from a European perspective . We then present a review of the literature summarising the evidence on the assessment and treatment of MDOs under the following headings : The forensic psychiatrist as expert witness , risk , treatment setting s for mentally disordered offenders , and what works for MDOs . We undertook a rapid review of the literature with search terms related to : forensic psychiatry , review articles , r and omised controlled trials and best practice . We search ed the Medline , Embase , PsycINFO , and Cochrane library data bases from 2000 onwards for adult groups only . We scrutinised publications for additional relevant literature , and search ed the websites of relevant professional organisations for policies , statements or guidance of interest . We present the findings of the scientific literature as well as recommendations for best practice drawing additionally from the guidance documents identified . We found that the evidence base for forensic-psychiatric practice is weak though there is some evidence to suggest that psychiatric care produces better outcomes than criminal justice detention only . Practitioners need to follow general psychiatric guidance as well as that for offenders , adapted for the complex needs of this patient group , paying particular attention to long-term detention and ethical issues OBJECTIVES New treatment options for dementia and its behavioral disturbances have become available since publication of The Expert Consensus Guidelines on the Treatment of Agitation in Older Persons with Dementia in 1998 . While only 2 cholinesterase inhibitors , donepezil and tacrine , were available in 1998 , 3 new cognitive-enhancing agents have been introduced since that time as well as several new atypical antipsychotics and antidepressants . However , there are still limited data from controlled studies to guide clinicians in choosing among these agents and sequencing and combining treatments . We therefore conducted a new survey study of expert opinion on the treatment of cognitive impairment and behavioral disturbances associated with dementia . METHODS Based on a literature review , a 61- question survey was developed with 1,225 options . Most options were scored using a modified version of the R AND 9-point scale for rating appropriateness of medical decisions . For other options , the experts were asked to write in answers . The survey was sent to 50 North American experts on dementia , 100 % of whom completed it . In analyzing responses to items rated on the 9-point scale , consensus was defined as a nonr and om distribution of scores by chi-square " goodness-of-fit " test . Based on the 95 % confidence interval around the mean , we assigned a categorical rank ( first line/preferred , second line/alternate , third line/usually inappropriate ) to each option . Guidelines indicating preferred treatment strategies were then developed for selected clinical situations . RESULTS For patients at risk for dementia , the experts recommended control of hypertension and diabetes . They also recommended aspirin and would consider a lipid-lowering agent in patients at risk for vascular dementia . Cholinesterase inhibitors were an option for patients with mild cognitive impairment ( i.e. , at risk for Alzheimer 's dementia [ AD ] ) . To slow cognitive impairment in mild/moderate AD , the experts recommended a cholinesterase inhibitor alone or combined with vitamin E. Donepezil and  galantamine  were the preferred cholinesterase inhibitors . The experts recommended combining a cholinesterase inhibitor with a N-methyl-D-aspartate ( NMDA ) antagonist ( e.g. , memantine ) if a patient with mild/moderate dementia has an inadequate response to monotherapy . Control of hypertension and diabetes was the treatment of choice , in patients with mild/moderate vascular or mixed AD/vascular dementia , with aspirin another first-line option . Cholinesterase inhibitors were also a first-line option for mild/moderate mixed AD/vascular dementia . Among nonpharmacological interventions for mild/moderate dementia , the experts recommended caregiver education , supportive therapy for caregivers , referral to day treatment , exercise programs , and respite care . For moderate/severe AD or mixed AD/vascular dementia , the experts recommended combining an NMDA antagonist with a cholinesterase inhibitor . For moderate/severe vascular or mixed AD/vascular dementia , they recommended control of hypertension and diabetes . The experts ' ratings underscore the importance of nonpharmacological strategies aim ed at reducing caregiver burden in more severe dementia . Management of agitation and other behavioral disturbances was another focus of this study . The experts recommended using an atypical antipsychotic for agitation associated with delirium , psychosis , aggression , or anger . They would also consider divalproex to manage anger with a risk of physical aggression . Selective serotonin reuptake inhibitors were recommended for the treatment of depression or anxiety in patients with dementia . Benzodiazepines or atypical antipsychotics were viewed as short-term options for acute anxiety .  Trazodone was recommended for insomnia . The experts also gave recommendations concerning dosage levels , duration of treatment , and choice of medications for patients with different complicating conditions . CONCLUSIONS The experts reached high levels of consensus on key steps in treating dementia and associated behavioral disturbances . Within the limits of expert opinion and with the expectation that new research data will take precedence , these guidelines may provide direction for clinicians offering care to patients with dementia Objectives . Behavioral emergencies are a common and serious problem for consumers , their communities , and the healthcare setting s on which they rely , but there is little research to guide provider responses to this challenge . Key constructs such as agitation have not been adequately operationalized so that the criteria defining a behavioral emergency are vague . A significant number of deaths of patients in restraint has focused government and regulators on these issues , but a consensus about key elements in the management of behavioral emergencies has not yet been articulated by the provider community . The authors assembled a panel of 50 experts to define the following elements : the threshold for emergency interventions , the scope of assessment for varying levels of urgency and cooperation , guiding principles in selecting interventions , and appropriate physical and medication strategies at different levels of diagnostic confidence and for a variety of etiologies and complicating conditions . Method . A written  survey with 808 decision points was completed by 50 experts . A modified version of the R AND Corporation 9-point scale for rating appropriateness of medical decisions was used to score options . Consensus on each option was defined as a non-r and om distribution of scores by chi-square “ goodness-of-fit ” test . We assigned a categorical rank ( first line/preferred choice , second line/ alternate choice , third line/usually inappropriate ) to each option based on the 95 % confidence interval around the mean rating . Guideline tables were constructed describing the preferred strategies in key clinical situations . Results . The expert panel reached consensus on 83 % of the options . The relative appropriateness of emergency interventions was ascertained for a continuum of behaviors . When asked about the frequency with which emergency interventions  ( parenteral medication , restraint , seclusion ) were required in their services , 47 % of the experts reported that such interventions were necessary for 1%–5 % of patients seen in their services and 32 % for 6%–20 % . In general , the consensus of this panel lends support to many elements of recent regulations from the Health Care Financing Administration ( now the Centers for Medicare and Medicaid Services ) , including the timing of clinician assessment and re assessment and the intensity of nursing care . However , the panel did not endorse the concept of “ chemical restraint , ” instead favoring the idea that medications are treatments for target behaviors in behavioral emergencies even when the causes of these behaviors are not well understood . Control of aggressive behavior emerged as the highest priority during the emergency ; however , preserving the physician-patient relationship was rated a close second and became the top priority in the long term . Oral medications , particularly concentrates , were clearly preferred if it is possible to use them . Benzodiazepines alone were top rated in 6 of 12 situations . High-potency conventional antipsychotics used alone never received higher ratings than benzodiazepines used alone . A combination of a benzodiazepine and an antipsychotic was preferred for patients with suspected schizophrenia , mania , or psychotic depression . There was equal support for high-potency conventional or atypical antipsychotics  ( particularly liquids ) in oral combinations with benzodiazepines .  Droperidol emerged in fourth place in some situations requiring an injection . Conclusions . To evaluate many of the treatment options in this survey , the experts had to extrapolate beyond controlled data . Within the limits of expert opinion and with the expectation that future research data will take precedence , these guidelines provide some direction for addressing common clinical dilemmas in the management of psychiatric emergencies and can be used to inform clinicians in acute care setting s regarding the relative merits of various strategies Acutely psychotic patients presenting as psychiatric emergencies with aggression or agitation are often administered conventional antipsychotics intramuscularly . However , patients view intramuscular administration as coercive , and conventional antipsychotics are often associated with adverse events . In this open study , consecutive adult patients presenting with an acute exacerbation of schizophrenia or other psychotic disorder were assigned to oral risperidone 2 - 6 mg/day ( n = 48 ) or oral zuclopenthixol 20 - 50 mg/day ( n = 27 ) for 7 - 14 days . Lorazepam ( either oral or intramuscular ) was administered to both groups as needed . Patients were assessed regularly until day 14 or discharge . Mean Positive And Negative Syndrome Scale ( PANSS ) aggression scores ( sum of item scores on excitement , poor impulse control , hostility and uncooperativeness ) decreased steadily and similarly in both groups ; the mean changes from baseline were statistically significant at days 10 and 14 and at study end-point . The mean decrease at study end-point in the PANSS component score for hostility was statistically significant in the risperidone group , but not in the zuclopenthixol group . Social Dysfunction and Aggression Scale aggression scores and Clinical Global Impression scores decreased significantly and similarly in both groups . Overall , 18.7 % of patients showed minor extrapyramidal symptoms during the study , but only 16.7 % of risperidone-treated patients , compared to 59.3 % of zuclopenthixol-treated patients , received anti-parkinsonian medication ( p < 0.001 ) . Lorazepam was administered to all of the patients assigned to risperidone and to 89 % of those assigned to zuclopenthixol . Oral risperidone plus lorazepam is a convenient , effective and well-tolerated alternative to conventional antipsychotics for the treatment of acute psychosis in emergency psychiatry Background Psychomotor agitation can be associated with a wide range of medical conditions . Although clinical practice advocates the use of several drugs for the management of psychomotor agitation , there are still very few controlled studies comparing the profiles of action and the adverse effects of different drugs that induce tranquilization . Objectives The purpose of this study was to compare the efficacy and safety of 4 low-dose pharmacological interventions used to control psychomotor agitation guided by the clinical response . Methods Using a r and omized , rated-blind design , 100 agitated patients were assigned to receive 1 of 4 treatments : haloperidol ( 2.5 mg ) + promethazine ( 25 mg ) ( HLP + PMZ ) , haloperidol ( 2.5 mg ) + midazolam ( 7.5 mg ) ( HLP + MID ) , ziprasidone ( 10 mg ) ( ZIP ) , or olanzapine ( 10 mg ) ( OLP ) . Patients were evaluated just before the intervention and after 30 , 60 , and 90 minutes , using the Agitation-Calmness Evaluating Scale . Adverse effects were assessed within 24 hours after the intervention , using selected items from the UKU Scale ( Ugvalg Klinisk Undersgelser Side Effect Scale ) . According to the clinical indication , medication could be repeated twice after the first injection . Data were analyzed using general linear model with repeated measures and logistic regression . Results All treatment options promoted a reduction in agitation , without causing excessive sedation , although a lower reduction in agitation was observed with HLP + PMZ and ZIP compared with HLP + MID and OLZ . The need for an additional dose of medication was observed in 22 patients , and only 8 remained agitated during the entire 90-minute period . A higher risk for the development of extrapyramidal symptoms within the following 24 hours was observed with HLP + PMZ . Discussion Low doses of haloperidol combined with midazolam can be as effective as olanzapine in reducing psychomotor agitation without increasing the risk of extrapyramidal effects . Because of the higher risk for the occurrence of extrapyramidal symptoms , the combination of haloperidol with promethazine should be considered a second-line treatment option ABSTRACT Background : The management of disruptive neuropsychiatric symptom ( NPS ) such as agitation and aggression ( A/A ) is a major priority in caring for people with Alzheimer 's disease ( AD ) . Few effective pharmacological or non-pharmacological options are available . Results of r and omized clinical trials ( RCTs ) of drugs for A/A have been disappointing . This may result from the absence of biological efficacy for medications tested in treating A/A. It may also be related to method ological issues such as the choice of outcomes . The aim of this review was to highlight key method ological issues pertaining to RCTs of current and emerging medications for the treatment of A/A in AD . Methods : We search ed PubMed / Medline , Cochrane Central Register of Controlled Trials , and Clinical Trials.gov for RCTs comparing medications with either placebo or other drugs in the treatment of A/A in AD , between January 2008 and December 2013 . Results : We identified a total of 18 RCTs ; of these , 11 were completed and 7 ongoing . Of the ongoing RCTs , only one is in Phase III . Seven of 10 completed RCTs with reported results did not report greater benefit from drug than placebo . Each of the completed RCTs used a different definition of " clinical ly significant A/A. " There was considerable heterogeneity in study design . The primary endpoints were largely proxy-based but a variety of scales were used . The definition of caregiver and scales used to assess caregiver outcomes were similarly heterogeneous . Placebo response was notable in all trials . Conclusions : This review highlights a great heterogeneity in RCTs design of drugs for A/A in AD and some key method ological issues such as definition of A/A , choice of outcome measures and caregiver participation that could be addressed by an expert consensus to optimize future trials design OBJECTIVE Clinical trials in psychiatry frequently fail to maximize clinical utility for practicing clinicians , or , stated differently , available evidence is not perceived by clinicians ( and other decision makers ) as sufficiently relevant to clinical practice , thereby diluting its impact . To attain maximum clinical relevance and acceptability , research ers must conduct clinical trials design ed to meet the needs of clinicians and others who are making decisions about patients ' care . The authors present the case for psychiatry 's adoption of the practical clinical trials model , which is widely used in research in other areas of medicine . METHOD The authors outline the characteristics and scope of practical clinical trials , give examples of practical clinical trials , and discuss the challenges of using the practical clinical trials model in psychiatry , including issues of funding . RESULTS Practical clinical trials , which are intended to provide generalizable answers to important clinical questions without bias , are characterized by eight key features : a straightforward clinical ly relevant question , a representative sample of patients and practice setting s , sufficient power to identify modest clinical ly relevant effects , r and omization to protect against bias , clinical uncertainty regarding the outcome of treatment at the patient level , assessment and treatment protocol s that enact best clinical practice s , simple and clinical ly relevant outcomes , and limited subject and investigator burden . CONCLUSIONS To implement the practical clinical trials model in psychiatry will require stable funding for network construction and maintenance plus method ological innovation in governance and trial selection , assessment , treatment , data management , site management , and data analytic procedures Abstract Intramuscular ( IM ) antipsychotics are preferred for efficient control of agitation symptoms . Previous studies have demonstrated that IM ziprasidone is efficacious and safe for treatment of agitation in schizophrenia . However , clinicians now recognize that racial differences may contribute to altered therapeutic response and tolerability . This study compared the efficacy and tolerability of IM ziprasidone versus IM haloperidol for the management of agitation in Chinese subjects with schizophrenia . Subjects with acute schizophrenia were r and omized to either ziprasidone ( n = 189 , 10 to 20 mg as required up to a maximum of 40 mg/d ) or haloperidol ( n = 187 , 5 mg every 4 to 8 hours to a maximum of 20 mg/d ) for 3 days . Psychiatric assessment s and adverse events were assessed at baseline , 2 , 4 , 24 , 48 , and 72 hours . In the ziprasidone group , 2.1 % of subjects discontinued versus 3.7 % in the haloperidol group . The least squares mean change ( SE ) from baseline to 72 hours in Brief Psychiatry Rating Scale total score was −17.32 ( 0.7 ) for ziprasidone ( n = 167 ) and −18.44 ( 0.7 ) for haloperidol ( n = 152 ) , with a 95 % confidence interval treatment difference of −0.7 to 2.9 . Fewer subjects experienced adverse events after ziprasidone ( n = 54 , 28.6 % ) than haloperidol ( n = 116 , 62.0 % ) , with a notably higher incidence of extrapyramidal symptoms in the haloperidol group ( n = 69 , 36.9 % ) compared to the ziprasidone group ( n = 4 , 2.1 % ) . For controlling agitation in schizophrenia in this Chinese study , ziprasidone had a favorable tolerability profile and comparable efficacy and safety compared to haloperidol BACKGROUND Forensic psychiatry aims to reduce recidivism and makes use of risk assessment tools to achieve this goal . Various studies have reported on the predictive qualities of these instruments , but it remains unclear whether their use is associated with actual prevention of recidivism in clinical care . AIMS To test whether an intervention combining risk assessment and shared care planning is associated with a reduction in violent and criminal behaviour . METHOD A cluster r and omised controlled trial ( Netherl and s Trial Register number NTR1042 ) was conducted in three out-patient forensic psychiatric clinics . The intervention comprised risk assessment with the Short Term Assessment of Risk and Treatability ( START ) and a shared care planning protocol formulated according to shared decision-making principles . The control group received usual care . The outcome consisted of the proportion of clients with violent or criminal incidents at follow-up . RESULTS In total 58 case managers and 632 of their clients were included . In the intervention group ( n = 310 ) , 65 % received the intervention at least once . Findings showed a general treatment effect ( 22 % of clients with an incident at baseline v. 15 % at follow-up , P<0.01 ) but no significant difference between the two treatment conditions ( odds ratio ( OR ) = 1.46 , 95 % CI 0.89 - 2.44 , P = 0.15 ) . CONCLUSIONS Although risk assessment is common practice in forensic psychiatry , our results indicate that the primary goal of preventing recidivism was not reached through risk assessment embedded in shared decision-making Abstract : Topiramate is an antiepileptic drug , recently also used in the treatment of psychiatric diseases . Inasmuch as topiramate and valproate , which are currently used for aggressive behavior , share several pharmacological mechanisms ( positive modulatory effect on the GABA activity and negative modulatory effect on glutamatergic neurotransmission ) , the objective of the present study was to compare the pharmacological effects of topiramate with those of valproate and their combination in patients with psychiatric disorders showing marked aggression and agitation . A retrospective , case-controlled , mirror-image study was carried out in a sample of 45 in patients affected by schizophrenia , schizoaffective and bipolar disorder , and hospitalized in a maximum-security Canadian psychiatry hospital .  Overt Aggression Scale , Agitation-Calmness Evaluation Scale , number and intensity of psychotic episodes , number of episodes of withdrawal from group activities per week , and number of therapeutic isolation per week and of strict surveillance intervention per week were evaluated before and after the treatments . Results indicate that patients treated with topiramate show a decrease in the average score of the Overt Aggression Scale , a decrease of episodes of agitation and of strict surveillance interventions . This effect was similar to the group treated with valproate or with the combination of valproate-topiramate . However , valproate therapy , but not topiramate therapy , decreased the intensity of agitation episodes measured by the Agitation-Calmness Evaluation Scale ;  valproate and the combination topiramate-valproate decreased the number of psychotic disorganization episodes as well . These results suggest that topiramate could be a valid medicine in the control of aggression in psychosis . Double-blind , r and omized , placebo-controlled studies need to further assess this pharmacological indication This study aim ed to investigate the long-term effects of group music therapy on  agitation manifested by nursing home residents with Alzheimer 's disease . A non-r and omised experimental design was employed with one group receiving weekly music therapy ( n = 26 ) and another group receiving st and ard nursing home care ( n = 19 ) .  Agitation levels were measured five times over one year using the Cohen-Mansfield Agitation Inventory ( Cohen-Mansfield , J. ( 1989 ) . Agitation in the elderly . In N. Billig & P. V. Rabins ( Eds . ) , Issues in geriatric psychiatry ( pp . 101–113 ) . Basel , Switzerl and : Karger ) . Although music therapy participants showed short-term reductions in agitation , there were no significant differences between the groups in the range , frequency , and severity of agitated behaviours manifested over time . Multiple measures of treatment efficacy are necessary to better underst and the long-term effects music therapy programs have on this population Abstract Background Kraepelin ’s partial interpretation of agitated depression  as a mixed state of “ manic-depressive insanity ” ( including the current concept of bipolar disorder ) has recently been the focus of much research . This paper tested whether , how , and to what extent both psychomotor symptoms , agitation and retardation in depression are related to bipolarity and anxiety . Method The prospect i ve Zurich Study assessed psychiatric and somatic syndromes in a community sample of young adults ( N = 591 ) ( aged 20 at first interview ) by six interviews over 20 years ( 1979–1999 ) .  Psychomotor symptoms of agitation and retardation were assessed by professional interviewers from age 22 to 40 ( five interviews ) on the basis of the observed and reported behaviour within the interview section on depression . Psychiatric diagnoses were strictly operationalised and , in the case of bipolar-II disorder , were broader than proposed by DSM-IV-TR and ICD-10 . As indicators of bipolarity , the association with bipolar disorder , a family history of mania/hypomania/cyclothymia , together with hypomanic and cyclothymic temperament as assessed by the general  behavior inventory  ( GBI ) [ 15 ] , and mood lability ( an element of cyclothymic temperament ) were used . Results Agitated and retarded depressive states were equally associated with the indicators of bipolarity and with anxiety . Longitudinally , agitation and retardation were significantly associated with each other ( OR = 1.8 , 95 % CI = 1.0–3.2 ) , and this combined group of major depressives showed stronger associations with bipolarity , with both hypomanic/cyclothymic and depressive temperamental traits , and with anxiety . Among agitated , non-retarded depressives , unipolar mood disorder was even twice as common as bipolar mood disorder . Conclusion Combined agitated and retarded major depressive states are more often bipolar than unipolar , but , in general , agitated depression ( with or without retardation ) is not more frequently bipolar than retarded depression ( with or without agitation ) , and pure agitated depression is even much less frequently bipolar than unipolar . The findings do not support the hypothesis that agitated depressive syndromes are mixed states . Limitations The results are limited to a population up to the age of 40 ; bipolar-I disorders could not be analysed ( small N ) OBJECTIVE To provide expert recommendations for the safe and effective application of repetitive transcranial magnetic stimulation ( rTMS ) in the treatment of major depressive disorder ( MDD ) . PARTICIPANTS Participants included a group of 17 expert clinicians and research ers with expertise in the clinical application of rTMS , representing both the National Network of Depression Centers ( NNDC ) rTMS Task Group and the American Psychiatric Association Council on Research ( APA CoR ) Task Force on Novel Biomarkers and Treatments . EVIDENCE The consensus statement is based on a review of extensive literature from 2 data bases ( OvidSP MEDLINE and PsycINFO ) search ed from 1990 through 2016 . The search terms included variants of major depressive disorder and transcranial magnetic stimulation . The results were limited to articles written in English that focused on adult population s. Of the approximately 1,500 retrieved studies , a total of 118 publications were included in the consensus statement and were supplemented with expert opinion to achieve consensus recommendations on key issues surrounding the administration of rTMS for MDD in clinical practice setting s. CONSENSUS PROCESS In cases in which the research evidence was equivocal or unclear , a consensus decision on how rTMS should be administered was reached by the authors of this article and is denoted in the article as " expert opinion . " CONCLUSIONS Multiple r and omized controlled trials and published literature have supported the safety and efficacy of rTMS antidepressant therapy . These consensus recommendations , developed by the NNDC rTMS Task Group and APA CoR Task Force on Novel Biomarkers and Treatments , provide comprehensive information for the safe and effective clinical application of rTMS in the treatment of MDD PURPOSE The study evaluated whether seclusion and coercive incidents would be reduced in extent and number if involuntary medication was the first choice of intervention . Patients admitted to an acute psychiatric ward were r and omly allocated to two groups . In Group 1 , involuntary medication was the intervention of first choice for dealing with agitation and risk of violence . In Group 2 , seclusion was the intervention of first choice . Patients ' characteristics between the groups were compared by Pearson χ(2 ) and two- sample t-tests ; the incidence rates and risk ratios ( RRs ) were calculated to examine differences in number and duration of coercive incidents . In Group 1 , the relative risk of being secluded was lower than in Group 2 , whereas the risk of receiving involuntary medication was higher . However , the mean duration of the seclusion incidents did not differ significantly between the two groups ; neither did the total number of coercive incidents . Although the use of involuntary medication could successfully replace and reduce the number of seclusions , alternative interventions are needed to reduce the overall number and duration of coercive incidents . A new policy for managing acute aggression - such as involuntary medication - can be implemented effectively only if certain conditions are met Background Agitated or violent patients constitute 10 % of all emergency psychiatric treatment . Management guidelines , the preferred treatment of clinicians and clinical practice all differ . Systematic review s show that all relevant studies are small and none are likely to have adequate power to show true differences between treatments . Worldwide , current treatment is not based on evidence from r and omised trials . In Brazil , the combination haloperidol-promethazine is frequently used , but no studies involving this mix exist . Methods TREC-Rio ( Tranquilização Rápida-Ensaio Clínico [ Translation : Rapid Tranquillisation- Clinical Trial ] ) will compare midazolam with haloperidol-promethazine mix for treatment of agitated patients in emergency psychiatric rooms of Rio de Janeiro , Brazil . TREC-Rio is a r and omised , controlled , pragmatic and open study . Primary measure of outcome is tranquillisation at 20 minutes but effects on other measures of morbidity will also be assessed . TREC-Rio will involve the collaboration of as many health care professionals based in four psychiatric emergency rooms of Rio as possible . Because the design of this trial does not substantially complicate clinical management , and in several aspects simplifies it , the study can be large , and treatments used in everyday practice can be evaluated The British Association for Psychopharmacology ( BAP ) coordinated a meeting of experts to review and revise its first ( 2006 ) Guidelines for clinical practice with  anti-dementia drugs .  As before , levels of evidence were rated using accepted st and ards which were then translated into grade s of recommendation A to D , with A having the strongest evidence base ( from r and omized controlled trials ) and D the weakest ( case studies or expert opinion ) . Current clinical diagnostic criteria for dementia have sufficient accuracy to be applied in clinical practice ( B ) and brain imaging can improve diagnostic accuracy ( B ) . Cholinesterase inhibitors ( donepezil , rivastigmine , and galantamine ) are effective for mild to moderate Alzheimer ’s disease ( A ) and memantine for moderate to severe Alzheimer ’s disease ( A ) . Until further evidence is available other drugs , including statins , anti-inflammatory drugs , vitamin E and Ginkgo biloba , can not be recommended either for the treatment or prevention of Alzheimer ’s disease ( A ) . Neither cholinesterase inhibitors nor memantine are effective in those with mild cognitive impairment ( A ) . Cholinesterase inhibitors are not effective in frontotemporal dementia and may cause agitation ( A ) , though selective serotonin reuptake inhibitors may help behavioural ( but not cognitive ) features ( B ) . Cholinesterase inhibitors should be used for the treatment of people with Lewy body dementias ( Parkinson ’s disease dementia and dementia with Lewy bodies ( DLB ) ) , especially for neuropsychiatric symptoms ( A ) . Cholinesterase inhibitors and memantine can produce cognitive improvements in DLB ( A ) . There is no clear evidence that any intervention can prevent or delay the onset of dementia . Although the consensus statement focuses on medication , psychological interventions can be effective in addition to pharmacotherapy , both for cognitive and non-cognitive symptoms . Many novel pharmacological approaches involving strategies to reduce amyloid and /or tau deposition are in progress . Although results of pivotal studies are awaited , results to date have been equivocal and no disease-modifying agents are either licensed or can be currently recommended for clinical use Agitation is a vexing problem frequently observed in emergency department acute psychiatric patients , yet no instruments to measure agitation in this setting and population were found upon review of the literature . Previously developed agitation rating scales are limited by the length of observation they require , their need for participation by the patient , complexity in scoring , and a lack of validity in this setting and population . The purpose of this study was to psychometrically evaluate and refine an observation-based agitation scale for use with emergency department acute psychiatric patients . Using a method ological design , the 21-item Agitation Severity Scale was utilized to assess 270 adult psychiatric patients in the emergency setting in a prospect i ve , observational fashion . Reliability analysis , item analysis , exploratory factor analysis , and validity assessment s were completed . The relationship between Agitation Severity Scale scores and scores on the previously established Overt Agitation Severity Scale was evaluated . The instrument was reduced to 17 items representing four factors ( Aggressive Behaviors , Interpersonal Behaviors , Involuntary Motor Behaviors , and Physical Stance ) that accounted for nearly 70 % of observed variance , Cronbach 's & agr ; = 0.91 . Evidence of internal consistency reliability , equivalence reliability , construct validity , and convergent validity was established . Through this study , the 17-item Agitation Severity Scale demonstrated acceptable levels of reliability and validity when used with acute psychiatric patients in the emergency setting . This instrument holds promise as a method of enhancing clinical communication about agitation , evaluating the efficacy of interventions aim ed at decreasing agitation , and as a research tool Individuals with mental illness and co-occurring addictive disorders account for 44 % of the cigarettes sold in the United States ( JAMA 284:2606–2610 , 2000 ) . Smokers with mental illness face serious tobacco-related consequences , including increased morbidity and mortality , isolation , stigma , and financial hardship . Tobacco use also increases the metabolism of some antipsychotic and antidepressant medications , with the potential for subtherapeutic treatment and higher rates of rehospitalization . Nearly half of U.S. state psychiatric hospitals now ban tobacco use on their premises . The American Psychiatric Association identifies psychiatric hospitalizations as an ideal opportunity to treat tobacco dependence . Yet little research has examined tobacco cessation treatments in inpatient psychiatry . If tobacco dependence is left unaddressed , most psychiatric patients return to smoking immediately after discharge ( American Journal of Addictions 15:15–22 , 2006 ) . Multi-component interventions are needed that address the motivational , behavioral , and physiological aspects of nicotine dependence for smokers with co-occurring psychiatric disorders . We briefly describe an innovative tobacco treatment intervention initiated during psychiatric hospitalization . The intervention combines a computer-delivered expert system intervention and manual based on the transtheoretical model , an individual counseling session , and nicotine replacement therapy ( NRT ) . The model identifies five stages of change : precontemplation ( no immediate intention to stop smoking ) , contemplation ( intending to quit in the next six months ) , preparation ( considering quitting in the next month with a quit attempt in the past year ) , action ( quit smoking for less than six months ) , and maintenance ( smoke-free for at least six months ) . The 20-minute computer intervention generates individualized feedback at a sixth- grade reading level to guide participants through the stages of quitting smoking and to direct them to relevant sections of the manual . In a 30-minute session with the participant , study counselors review the printed feedback and manual , identify and support goals concerning tobacco use , and discuss proper use of NRT .  Nine hospitalized psychiatric patients representing a range of psychiatric , demographic , and tobacco-use characteristics intensively evaluated the intervention components . Despite having fairly limited computer experience , all agreed or strongly agreed that the program was easy to underst and and gave sound advice , and all recommended the computer program to others . Most participants required assistance with program navigation , suggesting the need for more user-friendly capabilities , such as a touch screen and audio . All participants read part of the manual , and most read beyond their stage-of-change chapter . Participants rated the manual highly for its organization and helpful strategies , describing it as “ realistic ” and “ easy to underst and … good for any person to read . ” Participants also rated the counseling session highly , citing the openness of the dialogue , the focus on their needs and interests , and the lack of pressure to quit : “ She did n’t push any points … she just presented the material . She was open , nonjudgmental . … She let me come to my own conclusions that I want to quit . ” Most participants used NRT , identified several benefits , and expressed interest in continuing NRT after hospitalization . Side effects also were noted . Of concern , most participants stated that clinical staff did not instruct them in proper use of NRT . This small and intensive evaluation suggests that the intervention provides a viable and acceptable strategy for initiating tobacco treatment in the inpatient psychiatric setting . In a r and omized clinical trial , we are evaluating efficacy of the intervention relative to usual care . With a 79 % recruitment rate , we enrolled 224 participants . After the brief hospital stay , intervention participants received ten weeks of NRT and two additional computer contacts , and their outpatient providers were informed of their cessation goals . Follow-up continues for 18 months . Psychiatric hospitals are making important strides in banning tobacco use . Bans , however , are only part of a much larger strategy needed to overcome the high rates of tobacco use in population s with mental illness . If cessation services are not offered , patients may misperceive smoking bans as punitive and themselves as unworthy of receiving intervention on this deadly addiction . When smoking was allowed on psychiatric units , an average of 15 minutes was spent per nursing shift managing patients ’ cigarette use . Ideally , a portion of the time saved with a no-smoking policy could be shifted to delivery of cessation services . The findings present an innovative , acceptable , multicomponent intervention for initiating tobacco treatment in inpatient psychiatry Background Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial . A number of initiatives have aim ed to provide guidance on the management of trauma patients . This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution . Methods The pan-European , multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies . The group used a structured , evidence -based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale . Expert opinion and current clinical practice were also considered , particularly in areas in which r and omised clinical trials have not or can not be performed . Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice ; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated . This guideline represents the fourth edition of a document first published in 2007 and up date d in 2010 and 2013 . Results The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation . Best- practice use of blood products during further resuscitation continues to evolve and should be guided by a goal -directed strategy . The identification and management of patients pre-treated with anticoagulant agents  continues to pose a real challenge , despite accumulating experience and awareness . The present guideline should be viewed as an educational aid to improve and st and ardise the care of the bleeding trauma patients across Europe and beyond . This document may also serve as a basis for local implementation . Furthermore , local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome . Conclusions A multidisciplinary approach and adherence to evidence -based guidance are key to improving patient outcomes . The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome OBJECTIVE To summarize the discussion that took place at a public workshop , co-sponsored by the U.S. Food and Drug Administration , the American Urological Association , and Society of Urologic Oncology review ing the current state of the art for partial gl and ablation ( PGA ) for the management of patients with prostate cancer . The purpose of this workshop was to discuss potential indications , current available evidence , and design s for future trials to provide the evidence needed by patients and providers to decide how and when to use PGA . METHODS A workshop evaluating  PGA for prostate cancer was held in New Orleans , Louisiana , in May 2015 . Invited experts representing all stakeholders and attendees discussed the regulatory development of medical products , technology available , potential indications , and design s of trials to evaluate this modality of therapy . RESULTS The panel presented the current information on the technologies available to perform PGA , the potential indications , and results of prior consensus conferences . Use of magnetic resonance imaging for patient selection , guide therapy , and follow-up was discussed . Design s of trials to assess PGA outcomes were discussed . CONCLUSION The general consensus was that currently available technologies are capable of selective ablation with reasonable accuracy , but that criteria for patient selection remain debatable , and long-term cancer control remains to be established in properly design ed and well-performed prospect i ve clinical trials . Concerns include the potential for excessive , unnecessary use in patients with low-risk cancer and , conversely , that current diagnostic techniques may underestimate the extent and aggressiveness of some cancers , leading to inadequate treatment The actual incidence of neurologic dysfunction result ing from hemorrhagic complications associated with neuraxial blockade is unknown . Although the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics , recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient population s. Overall , the risk of clinical ly significant bleeding increase with age , associated abnormalities of the spinal cord or vertebral column , the presence of an underlying coagulopathy , difficulty during needle placement , and an indwelling neuraxial catheter during sustained anticoagulation ( particularly with st and ard heparin or low-molecular weight heparin ) . The need for prompt diagnosis and intervention to optimize is also consistently reported . In response to these patient safety issues , the American Society of Regional Anesthesia and Pain Medicine ( ASRA ) convened its Third Consensus Conference on Regional Anesthesia and Anticoagulation . Practice guidelines or recommendations summarize evidence -based review s. However , the rarity of spinal hematoma defies a prospect i ve r and omized study , and there is no current laboratory model . As a result , the ASRA consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation . These are based on case reports , clinical series , pharmacology , hematology , and risk factors for surgical bleeding . An underst and ing of the complexity of this issue is essential to patient management BACKGROUND Patient involvement in the decision-making process is a key element for good clinical practice . Few data are available on patient involvement in psychiatry . AIMS To assess in a psychiatric out-patient context how psychiatrists involve patients in therapeutic decisions and to determine the extent to which patient and psychiatrist characteristics contribute to patient involvement . METHOD Eighty transcripts from audiotaped first out-patient consultations , conducted by 16 psychiatrists , were rated with the OPTION ( observing patient involvement ) scale . Interrater reliability indices were obtained for 30 r and omly selected interviews . Associations between OPTION scores and some clinical and socio-demographic variables were tested using t-test , ANOVA and Pearson 's correlation coefficient where appropriate . The distribution of scores for each psychiatrist was assessed by intracluster correlation coefficients . RESULTS Interrater reliability and internal consistency of the OPTION scale in the psychiatric setting were satisfactory . The total score and the ratings for the single OPTION items showed a skewed distribution , with a prevalence of scores in the low range of abilities , corresponding to minimal attempts to involve patients or a minimal skill level . CONCLUSIONS The OPTION scale proves to be a reliable instrument to assess patient involvement in a psychiatric setting . Psychiatrists showed poor patient involvement abilities parallel to previous findings in psychiatry and primary care . They need to be encouraged to share treatment decisions with their patients and to apply patient involvement skills . Further research is needed to establish which patient variables and clinical setting s in psychiatry are more amenable to shared decisions , and how participation of psychiatric patients in treatment decisions will affect the outcome
For its management , experts agreed in considering  verbal de-escalation  and  environmental modification techniques  as first choice , considering physical restraint as a last resort strategy .
BACKGROUND Psychomotor agitation is associated with different psychiatric conditions and represents an important issue in psychiatry .
Current recommendations on agitation in psychiatry are not univocal .
Actually , an improper assessment and management may result in unnecessary coercive or sedative treatments .
A thorough and balanced review plus an expert consensus can guide assessment and treatment decisions .