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Comparison of Lurasidone and Quetiapine in Critically Ill Patients

I would like to thank Fox et al for their efforts to systematically study the effects of lurasidone in critically ill patients with delirium, an area with a dearth of reported investigations. I believe, however, that the conclusions presented in the abstract, which are often relied on by clinicians, have been overstated. Fox et al conclude that there is no difference between quetiapine and lurasidone in the time to delirium resolution without reporting in the abstract that the study was underpowered to find a difference. Similarly, the lack of power and uneven baseline characteristics of groups should qualify the conclusion in the abstract that the incidence of QTc prolongation is not different between agents. Finally, it is not clear from the article how consent was obtained from participants or their surrogate decision makers. The paper states that an “opt-out waiver of informed consent was provided to each study participant or their legal representative.” It would be helpful if the authors clarified how an opt-out waiver of informed consent was implemented while still obtaining clinical informed consent. I concur with the investigators that large, randomized, controlled trials are needed to determine the effects of antipsychotics, including lurasidone, in the treatment of delirium. In the interim, it is important for the limitations of currently available evidence to be accurately reported.