Acute tranquilisation in young people with first-episode psychosis: Let’s start low,go slow

To the Editor

Pharmacological management of young people experiencing their first episode of psychosis is guided by the maxim, ‘Start low, go slow’. Recommended antipsychotic dose ranges are lower because such doses have been demonstrated to lead both to response and to fewer adverse side effects in neuroleptic-naïve patients (ENSP Medical Management Writing Group, 2014).

Recent guidelines for ‘Management of patients with Acute Severe Behavioural Disturbance in Emergency Departments’ (NSW Health, August 2015) recommend that during acute tranquilisation, an antipsychotic be offered as first-line oral sedation in both adults and young people (<16 years). If oral sedation fails, intramuscular antipsychotic (droperidol) is recommended. However, the UK National Institute for Health and Care Excellence (NICE, 2015) recommends lorazepam in all patients (<16 years and 16–65 years) who are neuroleptic-naïve (NICE, 1.4.38). Furthermore, in those <16 years, no antipsychotic is recommended for parenteral use rather than lorazepam (NICE, 1.7.21). NICE summated evidence on acute tranquilisation for violence and aggression from 54 randomised controlled trials and 4 Cochrane reviews, the most recent of which concluded that there was good evidence that benzodiazepines are at least as effective as antipsychotics for psychosis-induced aggression or agitation (Gillies et al., 2013).

We examined the pharmacological management of first presentation for first-episode psychosis patients by conducting a retrospective file audit of all referrals to our youth-focused Early Psychosis Program at Bondi Junction, Sydney. Of the 79 patients (aged 15–25 years) referred over the 12-month period, 1 April 2014–31 March 2015, detailed data on initial presentation and treatment were available for 75 (Table 1). Of these, 37 (49.3%) were initially assessed in emergency department (ED), of whom 10 (27.0%) received acute tranquilisation. In 90% of the acute tranquilisation events, antipsychotic treatment was administered (Table 1). We acknowledge the small numbers in our audit but conclude that antipsychotic use is frequent in this group, while evidence does not support this use.

Table 1.

Early Psychosis Program referrals and acute tranquilisation in the emergency department.

	Totaln = 75	Malesn = 38	Femalesn = 37
Age (years)
<16	2	1	1
16–25	73	37	36
Source of referral
ED	37	21	16
Others	38	17	21
Acute tranquilisation	10	5	5
Oral	8	3	5
Benzodiazepine alone	1	0	1
Antipsychotic alone	4	1	3
Benzodiazepine and antipsychotic	3	2	1
Intravenous	2	2	0
Both benzodiazepine and antipsychotic	1	1	0
Benzodiazepine (and oral antipsychotic)	1	1	0

ED: emergency department.

We recognise that behavioural disturbance in young people presenting to ED has other causes, including intoxication. We also recognise that detection of psychotic symptoms may in some individuals only be possible after sedation is administered. Nonetheless, it is important that emergency staff consider emerging psychosis as a potential diagnosis, and it is essential that in those individuals, management aligns with NICE recommendations: antipsychotics should not be used in the neuroleptic-naïve and not in any young person (<16 years). Where antipsychotics are to be prescribed in the neuroleptic-naïve, their use should be introduced via slow and gradual titration in a supportive therapeutic environment rather than in an acute setting.