Joint BAP NAPICU evidence-based consensus guidelines for ...

1 776738. research-article2018. of PsychopharmacologyPatel, Sethi et al. BAP NAPICU guidelines Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid Journal of Psychopharmacology tranquillisation 1 40. The Author(s) 2018. Reprints and permissions: DOI: This contribution is being co-published in the following journals: Journal of Psy- chopharmacology and Journal of Psychiatric Intensive Care. To request permission to re-use any part of this contribution, please contact SAGE Publishing: https://. Maxine X Patel1*, Faisil N Sethi2* With co-authors (in alphabetical order): Thomas RE Barnes3, Roland Dix4, Luiz Dratcu5, Bernard Fox6, Marina Garriga7, Julie C Haste8, Kai G Kahl9, Anne Lingford-Hughes10, Hamish McAllister- Williams11,12, Aileen O'Brien13, Caroline Parker14, Brodie Paterson15, Carol Paton16, Sotiris Posporelis17, David M Taylor18, Eduard Vieta7, Birgit V llm19, Charlotte Wilson-Jones20 and Laura Woods21.

2 * Joint first author (both first authors contributed equally to the article). Abstract The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this Joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder.

3 There is a focus on three key interventions: de-escalation, pharmacological interventions pre-rapid tranquillisation and rapid tranquillisation (intramuscular and intravenous). Most of the evidence reviewed relates to emergency psychiatric care or acute psychiatric adult inpatient care, although we also sought evidence relevant to other common clinical settings including the general acute hospital and forensic psychiatry. We conclude that the variety of options available for the management of acute disturbance goes beyond the standard choices of lorazepam, haloperidol and promethazine and includes 1 Department 14 Central & North West London NHS Foundation Trust, London, UK.

4 Of Psychosis Studies, Institute of Psychiatry, Psychology 15 CALM Training Ltd, Menstrie, UK. and Neuroscience, King's College, London, UK. 2 Maudsley Hospital, South London and Maudsley NHS Foundation 16 Oxleas NHS Foundation Trust, Dartford, UK. 17 South London and Maudsley NHS Foundation Trust, London, UK and Trust, London, UK. 3 The Centre for Psychiatry, Imperial College London, London, UK Institute of Psychiatry, Psychology and Neuroscience, King's College 4 Wotton Lawn Hospital, together NHS Foundation Trust, Gloucester, UK London, London, UK. 5 Maudsley Hospital, South London and Maudsley NHS Foundation 18 South London and Maudsley NHS Foundation Trust, London, UK.

5 19 Institute of Mental Health, School of Medicine, University of Trust, London, UK. 6 National Association of Psychiatric Intensive Care Units, East Nottingham, Nottingham, UK. 20 Maudsley Hospital, South London and Maudsley NHS Foundation Kilbride, Glasgow, UK. 7 Hospital Clinic, Institute of Neurosciences, University of Barcelona, Trust, London, UK. 21 The Hellingly Centre, Forensic Health Care Services, Sussex Barcelona, Catalonia, Spain 8 Mill View Hospital, Sussex Partnership NHS Foundation Trust, Hove, Partnership NHS Foundation Trust, East Sussex, UK. East Sussex, UK. 9 Department of Psychiatry, Social Psychiatry and Psychotherapy, Corresponding authors: Hannover Medical School, Hanover, Germany Maxine X Patel, Department of Psychosis Studies, Institute of 10 The Centre for Psychiatry, Imperial College London, London, UK and Psychiatry, Psychology and Neuroscience, King's College London, Box Central North West London NHS Foundation Trust, London, UK 68, 16 De Crespigny Park, London SE5 8AF, London, UK.

6 11 Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK Email: 12 Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK Faisil N Sethi, Maudsley Hospital, South London and Maudsley NHS. 13 South West London and St Georges NHS Foundation Trust, London, Foundation Trust, Denmark Hill, London SE5 8AZ, UK. UK and St George's University of London, London, UK Email: 2 Journal of Psychopharmacology 00(0). oral-inhaled loxapine, buccal midazolam, as well as a number of oral antipsychotics in addition to parenteral options of intramuscular aripiprazole, intramuscular droperidol and intramuscular olanzapine.

7 Intravenous options, for settings where resuscitation equipment and trained staff are available to manage medical emergencies, are also included. Keywords Acute disturbance, violence, aggression, rapid tranquillisation, de-escalation, antipsychotics, benzodiazepines, psychiatric illness Table of contents Levomepromazine 20. Zuclopenthixol acetate 21. Dexmedetomidine 22. Introduction 3 Barbiturates 22. Valproate 22. Acute disturbance 3 Ketamine 22. De-escalation and rapid tranquillisation 3 Electroconvulsive therapy 23. Restraint and restrictive practices 4 From evidence to practice 24. Rapid tranquillisation practice in the UK 5. National guidelines 5.

8 International perspectives 6 Modifiers, special settings and A patient's perspective 6. Guideline scope 7. circumstances 24. Pregnancy 24. Intoxication and withdrawal 25. Method 7 Rapid tranquillisation in the general hospital 26. Psychiatric intensive care unit and inpatient forensic settings 26. De-escalation 8 Seclusion 26. Physical health monitoring 26. Benzodiazepines 9. Pharmacokinetics 9. Oral 11 An algorithm for the management Oral versus intramuscular 11 of acute disturbance 27. Intramuscular monotherapy 11. Intramuscular benzodiazepines in combination Model and components 27. with other medications 12 Principles 28. Intravenous 14 Recommendations for interventions 29.

9 Adverse effects 14. From evidence to practice 15. Discussion 31. Overview 31. Common antipsychotics 15. Key uncertainties and research recommendations 31. Pharmacokinetics 15 Conclusions 32. Oral 15. Oral versus intramuscular 16. Intramuscular monotherapy 17 Acknowledgements 32. Intramuscular antipsychotics in combination with other medications 18. Intravenous 18 Declaration of conflicting interest 32. Adverse effects 19. From evidence to practice 19. Funding 32. Other interventions 19. Promethazine 19 References 32. Loxapine 20. Patel, Sethi et al. 3. Introduction whether it is verbally or behaviourally expressed, physical harm is sustained, or the intention is clear.

10 Acute disturbance This guideline covers the clinical management of acute distur- De-escalation and rapid tranquillisation bance', which we use here as a composite term to include the In this guideline, we define de-escalation' as an explicitly col- concepts of agitation', aggression' and violence' in the context laborative process involving a range of verbal and non-verbal of an acute mental state associated with an underlying mental interventions that aim to reduce agitation and distress, with the and/or physical disorder. No commonly accepted definitions purpose of averting aggression or violence. This differs slightly exist for any of these concepts.