Rapid tranquillisation:are we getting it right?

. We found


The study
A questionnaire was circulated to trainees participating in three training schemes.Respon dents were questioned as to their use of RT measures in the previous six months.Data collected included the type, dosage, and route of administration of medication.

Findings
Fifty-five questionnaires were returned (response rate 79.7%).Forty-six (83.6%) respondents re ported experiencing at least one violent incident, with 108 separate incidents reported.On 98 occasions (90.7%), trainees prescribed medica tion to control behavioural disturbance.In 45 (46%) incidents one drug was used, with two drugs prescribed on 43 (44%) occasions, while three drugs were prescribed on 10 (10%) occa sions.On 88 (90%) occasions, intramuscular (i.m.) medication was administered.Zuclo penthixol acetate was prescribed in a total of 45 incidents, alone on 25 occasions, and in combi nation on 20 occasions.Benzodiazepines were prescribed on 40 occasions (41%), in combina tion in the majority of instances (34).Chlorpromazine and haloperidol were both prescribed on a total of 26 occasions (26.5%).Further informa tion is given in Table 1.
Examination of drug combinations and do sages revealed that on 38 (39%) occasions the trainee prescribed medication that could be regarded as being within a high-dose range compared with British National Formulary (BNF) (1995) recommendations.
For example, the BNF recommendations regarding the maximum single i.m. dose of chlorpromazine was exceeded on 25 occasions.Other examples of high-dose regimes include the use of a combination of haloperidol 15 mg, droperidol 10 mg and lorazepam 4 mg; and a combination of haloperidol 20 mg, loraze pam 4 mg and zuclopenthixol acetate 100 mg, all given i.m.Further information as to high-dose prescribing is given in Table 2.
Trainees prescribed more than one antipsy chotic on 24 (24%) occasions.On 18 (18%) occasions a butyrophenone/benzodiazepine combination was used, and in six incidents a phenothiazine/benzodiazepine combination.When questioned as to the existence of a policy for RT in their workplace, 53 trainees (96.3%) replied that no such policy was in place.

Comment
We found that 39% of trainees surveyed pre scribed drugs within a high-dose range.This trend is a cause for concern, especially in light of the Royal College of Psychiatrists' Consensus Statement on the use of high-dose antipsychotic medication (Thompson, 1994), which states that exceeding the recommended dose range is likely to risk higher levels of side-effects, thereby exceeding the acceptable risk-benefit ratio.Furthermore it states that a trainee psychiatrist is not considered sufficiently qualified to exceed the recommended BNF upper dose limit.In this survey it was difficult to establish whether trainees were at all times acting under specialist supervision, but as the majority of incidents occurred in an on-call or emergency situation it may be that this was not the case.Trainees prescribed more than one antipsychotic on 24 (24.4%)occasions.The BNF warns against this, as it may constitute a hazard and does not appear to minimise side-effects.It would appear that trainees do not have a full knowledge of the equivalent doses of antipsychotics, and the consequent risk of exceeding dose recommendations when combining drugs.Med ication was administered intramuscularly on 88 (90%) occasions.On 55 (56%) occasions this involved an antipsychotic other than zuclopenthixol acetate.The risks of parenteral admin istration are recognised, with higher blood levels known to be achieved via this route.Our results suggest that some trainees prescribe i.m. doses of antipsychotics as they would oral medication, without decreasing the dose accordingly.
The combination of a butyrophenone and a benzodiazepine has been recommended for RT practice (Dubin, 1989: Thompson, 1994).This combination was prescribed on 18 (18%) occa sions only.Zuclopenthixol acetate was far more frequently prescribed.The Royal College agrees that Zuclopenthixol is useful in these situations, but caution has been expressed with regard to the hazards of administering an antipsychotic with a long half-life to previously untreated patients.Zuclopenthixol acetate was used fre quently in combination with other drugs.Its use in combination with another antipsychotic may, however, produce an unacceptably high total dose of medication.Finally, we found that only two trainees knew of the existence of a policy for RT in their workplace.
This study has methodological flaws, given that it was retrospective and reliant on memory.However, it is likely that respondents documen ted their 'usual' RT regimes, revealing a wide variation in prescription habits.
Several studies in recent years have looked at RT practice, with similar results noted.Pilowsky et al (1992) found that trainees regularly ex ceeded BNF dose recommendations and that medication was most often prescribed parenterally.Cunnane (1994), using a vignette, surveyed consultant psychiatrists.The use of a vignette often leads to the description of the ideal, rather than the actual response to a situation.Notwith standing the caveat, it was notable that there was evident uncertainty among consultants as to optimal management.Chlorpromazine i.m. pre scribed in high dosage was the most frequent response, followed by haloperidol recommended at a far higher equivalent dosage.Most signifi cant, perhaps, was the finding that 15% of consultant psychiatrists did not feel competent to give an opinion, although participating in an emergency on-call rota.Simpson & Anderson (1996), in a similar vignette-based study, exam ined RT practice in a group of senior registrars and consultant psychiatrists.They found that a majority would use a single non-depot antipsychotic, although a significant minority preferred zuclopenthixol acetate.Notably nearly 50% of respondents felt that BNF guidelines regarding maximum doses were irrelevant for RT use, thus indicating that they would exceed these in practice.Major deficiencies were evident with regard to training.Only 15% had a written policy and less than 50% were confident that junior doctors were trained in RT practice.Hillam & Evans (1996) noted that the majority of patients in a psychiatric intensive therapy unit received antipsychotic doses which exceeded BNF max imum limits.It appears that the practice of RT is consistent in its inconsistency.The Royal College published a consensus report on the use of high-dose antipsychotics in 1994.Obviously there is al ways a lag time between publication of a report and adoption of its recommendations; however, recent evidence suggests that these guidelines are not yet being adhered to in RT use.High-dose prescribing is very common, as is parenteral prescribing.Polypharmacy compounds the pro blem.Why are there ongoing problems with rapid tranquillisation?We would suggest that there are several reasons for the variation observed.
From our study it would appear that trainees have inadequate knowledge of equivalent doses of antipsychotics and the consequent risks of exceeding dose recommendations when combin ing drugs.Similarly, Mullen et al (1994) in a study of perception of equivalent antipsychotic dosages, found a wide variation in perceived potencies.Others (Hillam & Evans, 1996) have commented on the disagreement regarding re lative potencies of drugs and the wide variations in published tables of drug equivalents.Difficul ties in converting depot medication (e.g.zuclo penthixol acetate) remain, leading to the propensity for unwittingly exceeding BNF guide lines.Furthermore, BNF guidelines regarding maximum dose limits appear inadequate.Max imum dose limits are provided for some drugs but not for others (e.g.droperidol).Similarly, no guidance is given as to maximum dosing for benzodiazepines in the emergency setting.Not withstanding this, it has been reported that approximately half of a group of psychiatrists surveyed thought that BNF guidelines were actually irrelevant for RT use.The frequency of high-dose prescribing in most surveys would tend to confirm this.This is an important issue, implying that psychiatrists are deliberately and necessarily exceeding dose guidelines in emer gency situations.
Finally, perhaps the most important issue to be addressed is the lack of training of junior doctors in this area.Simpson & Anderson (1996) commented that senior registrars and consul tants used sensible drug regimes for RT.How ever, this group indicated that 52% of their trainees did not receive training in RT proce dures, thus indicating that their sensible drug regimes may not be filtering down to a more junior level.
To improve the practice of rapid tranquillisa tion we would call for standardised guidelines for neuroleptic equivalence to aid rational prescrib ing.The BNF guidelines with regard to high-dose prescribing are inadequate and regarded by some psychiatrists as irrelevant in the area of RT.These guidelines should be realistically amended to take into account the necessity for emergency tranquillisation.
Finally, trainees should be made aware, through adequate train ing programmes and written policies, of what drugs to use in RT, what doses to employ, and how often these drugs can safely be repeated.