Year : 2019  |  Volume : 61  |  Issue : 2  |  Page : 218--219

Letter to editor regarding “comparison of efficacy of haloperidol and olanzapine in the treatment of delirium”


Pawan Kumar, Hitesh Khurana, Ankit Kumar, Sujata Sethi 
 Department of Psychiatry, PGIMS, Rohtak, Haryana, India

Correspondence Address:
Dr. Pawan Kumar
Department of Psychiatry, PGIMS, Rohtak, Haryana
India




How to cite this article:
Kumar P, Khurana H, Kumar A, Sethi S. Letter to editor regarding “comparison of efficacy of haloperidol and olanzapine in the treatment of delirium”.Indian J Psychiatry 2019;61:218-219


How to cite this URL:
Kumar P, Khurana H, Kumar A, Sethi S. Letter to editor regarding “comparison of efficacy of haloperidol and olanzapine in the treatment of delirium”. Indian J Psychiatry [serial online] 2019 [cited 2020 Nov 29 ];61:218-219
Available from: https://www.indianjpsychiatry.org/text.asp?2019/61/2/218/253839


Full Text



Sir,

We found the study by Jain et al.[1] quite interesting. The sample having been allocated to treatment arms randomly and inclusion of flowchart make this study particularly attractive. However, we feel that the study needs replication with following points in consideration.

The authors have mistakenly classified the study by Hu et al. referred to on page 452 as a nonrandomized one.[2]

The authors have used randomization to prevent bias in the results; however, the unbiasedness is apparently lost due to heavy (24%) dropout. The authors could have taken up analysis of dropouts, survival analysis or intent to treat design for unbiased interpretation of the results. This was an open-label study by design; however, the authors while discussing mentioned this being a single-blind study. Both these statements are contradictory.

The control of concomitant treatments appears difficult as the patients have been selected from different specialties. Thus, the primary diagnosis as well as treatment is likely to be heterogeneous make it improper to call the study as an efficacy study. Moreover, the inclusion of a placebo arm makes it easy to interpret the results of an efficacy study.[3]

The authors appear having overstepped the recommendation proposed by Lacasse et al. In fact, they have clearly stated that evidence till now is falling short of recommending any antipsychotic as first-line choice in managing delirium. They have in fact recommended treatment of the underlying cause and supportive treatment for delirious patients.[4] The National Institute for Health and Care Excellence guidelines also recommend to be cautious in the use of antipsychotics in delirium and at the best avoid it.[5]

To the best of our efforts, we could not find any recommendation about antipsychotic doses with severity of delirium. It would be interesting if the authors could throw some light on use of different doses for different severity of delirium as shown the [Table 1] of the study.[1]{Table 1}

The authors also seemed unclear about the method of reporting drug doses. While mentioning mean doses, the authors have mentioned range too; however, it appears that it is actually the minimum and maximum doses rather than the range. Moreover, it is always a good practice to mention standard deviations along with the mean values as both statistics are applicable on continuous variables and take all values in consideration whereas the range is based only on two extreme values does not give any robust idea about distribution pattern of the values in the sample.

To us the results of the study appear having little external validity as the sociodemographic, and the clinical profile of the patients is not mentioned anywhere in the study. In subsequent studies, care needs to be taken for heterogeneity in the sample, inclusion of placebo arm and managing attrition rate either by robust experimental design or by statistical methods.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Jain R, Arun P, Sidana A, Sachdev A. Comparison of efficacy of haloperidol and olanzapine in the treatment of delirium. Indian J Psychiatry 2017;59:451-6.
2Hu H, Deng W, Yang H, Liu Y. Olanzapine and haloperidol for senile delirium: A randomized controlled observation. Chin J Clin Rehabil 2006;83:88-190.
3Singal AG, Higgins PD, Waljee AK. A primer on effectiveness and efficacy trials. Clin Transl Gastroenterol 2014;5:e45.
4Lacasse H, Perreault MM, Williamson DR. Systematic review of antipsychotics for the treatment of hospital-associated delirium in medically or surgically ill patients. Ann Pharmacother 2006;40:1966-73.
5Young J, Murthy L, Westby M, Akunne A, O'Mahony R, Guideline Development Group, et al. Diagnosis, prevention, and management of delirium: Summary of NICE guidance. BMJ 2010;341:c3704.