I understand the need to administer psychotropic medications to patients when it is court ordered or when a patient is not mentally ill, but needs treatment for physical injury. However, with respect to those who are mentally ill/acutely disturbed, those who would reject PO drugs, and for whom an IM/SQ formulation of the needed drug does not exist or would work too slowly or far too erraticly (diazepam) if given IM, do you establish patent IV access to administer the drug? Even those who are being held with every orderly and nurse in the ward can make miniscule movements that would seem to render a proper IV line placement difficult.

Taking this further, how do you do this over and over, to a patient who is refusing something like valproate (the therapeutic portion being the valproate anion of compounds containing it valproic acid, sodium valproate, etc.) or another agent that can only be given PO or IV, due to tissue damage for instance? This would seem to be a very tedious task that would take up an enormous amount of staff resources if a medication had to be administered even just daily, but if this was a B.I.D. or T.I.D. dosing, and you had a refractory patient (refusing more out of spite than out of illness), this could go on ad infinitum. I'm adding the caveat that the medication does work when administered, which is a mitigating factor in ECT use. However, there again, even with ECT, most physicians would make an allowance for a short acting anesthetic (Brevital(R), Diprivan(R), etc.) and a paralytic (Anectine(R), Pavulon(R), Norcuron(R), etc.) which are optimally given through an IV line (propofol can only be given that way). So with consistently refractory and recalcitrant patients, is a dose of remifentanil given IM and the anesthetic effect awaited? With ECT, can it just be administered unmodified? It can't be that painful, it will induce immediate unconsciousness anyway and it is the patient's fault, perhaps unmodified ECT can induce a change.

I'm just curious to know from those who work in ER's, psych. wards/hospitals, etc.