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Aggressive antipsychotic dosing

Vol. 3, No. 11 / November 2004

Reading “High-dose antipsychotics: Desperation or data-driven?” (Current Psychiatry, August 2004) brings back memories.

In 1980, I worked in a rural hospital. Our psychiatrist gave patients with acute mania a loading dosage of lithium, 900 mg tid to qid on day one, and drew a level in the morning. He reduced the dosage daily until target symptoms improved and/or serum concentration reached the high therapeutic range, or until side effects occurred.

During acute mania, the psychiatrist controlled unsafe agitation with short-acting barbiturates. Some extremely hostile, aggressive patients got IM sodium amobarbital. We observed the patient one-on-one until he or she awoke and could take fluids, food, and lithium. When manic symptoms began escalating, the patient again was medicated and the cycle continued. This cycle might continue for 1 to 3 days with decreasing frequency and sedation based on behavior.

Although I’m not advocating this regimen, it worked well from an empirical perspective. Our patients never acted out or had breathing problems.

Thomas Dowling, RN, MSN
St. Peter’s Hospital, Albany, NY

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