Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-cd9895bd7-fscjk Total loading time: 0 Render date: 2024-12-23T15:23:08.021Z Has data issue: false hasContentIssue false

Chapter 6 - Use of Medication and Electroconvulsive Therapy in the Management of Violence

from Section 2 - Medical and Psychological Intervention

Published online by Cambridge University Press:  09 May 2023

By
Peter Pratt ,
Caroline Parker ,
Masum Khwaja  and
Jonathan Waite
Edited by
Masum Khwaja  and
Peter Tyrer
Masum Khwaja
Affiliation:
Imperial College of Science, Technology and Medicine, London
Peter Tyrer
Affiliation:
Imperial College of Science, Technology and Medicine, London
Get access

Summary

This chapter considers the use of medication as an emergency response in the management of violent and disturbed behaviour. It addresses the complex factors surrounding the decision to use rapid tranquillisation, followed by reviewing the risks and benefits of specific medication options. This is discussed within the context and continuum of acute patient care, in keeping with good practice principles, and with consideration to the relevant patient-related and medication-related risks. The current evidence for using medication or ECT in the management of a medium- and longer-term risk of violence in the context of mental illness is briefly reviewed. The recommendations are applicable to all inpatient mental health units in the United Kingdom.

Keywords

violenceacute disturbancebehavioural disturbancemedicationprescribingpsychotropicrapid tranquillisationelectroconvulsive therapyECT
Type
Chapter
Information
The Prevention and Management of Violence
Guidance for Mental Healthcare Professionals
 , pp. 76 - 106
Publisher: Cambridge University Press
Print publication year: 2023

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

National Institute for Health and Care Excellence. Violence and aggression: Short-term Management in Mental Health, Health and Community Settings. NICE Guideline NG10 [online]. 2015. www.nice.org.uk/guidance/ng10 [Accessed 25.9.2021].Google Scholar
Patel, M. X., Sethi, F. N., Barnes, T. R. et al. Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation. Journal of Psychopharmacology 2018;32(6):601–40.Google Scholar
Royal College of Psychiatrists. Consensus statement on high-dose antipsychotic medication. College Report CR190 [online]. 2014. www.rcpsych.ac.uk/docs/default-source/members/faculties/rehabilitation-and-social-psychiatry/rehab-cr190.pdf?sfvrsn=d8397218_4 [Accessed 29.4.2022].Google Scholar
Swanson, J. W., Swartz, M. S., Van Dorn, R. A. et al. Comparison of antipsychotic medication effects on reducing violence in people with schizophrenia. British Journal of Psychiatry. 2008;193(1):37–43.Google Scholar
Appelbaum, P. S., Robbins, P. C., and Monahan, J. Violence and delusions: Data from the MacArthur Violence Risk Assessment Study. The American Journal of Psychiatry. 2000;157(4):566–72.Google Scholar
Látalová, K. Violence and duration of untreated psychosis in first-episode patients. International Journal of Clinical Practice 2014 Mar;68(3):330–5. https://doi.org/10.1111/ijcp.12327. Epub 2014 Jan 28. PMID: 24471741.Google Scholar
Witt, K., van Dorn, R., and Fazel, S. Risk factors for violence in psychosis: Systematic review and meta-regression analysis of 110 studies. PLOS One. 2013;8(2):e55942. https://doi.org/10.1371/journal.pone.0055942. Epub 2013 Feb 13. Erratum in: PLOS One. 2013;8(9). https://doi.org/10.1371/annotation/f4abfc20-5a38-4dec-aa46-7d28018bbe38. PMID: 23418482; PMCID: PMC3572179.Google Scholar
Goedhard, L. E., Stolker, J. J., Heerdink, E. R. et al. Pharmacotherapy for the treatment of aggressive behavior in general adult psychiatry: A systematic review. Journal of Clinical Psychiatry 2006;67(7):1013–24.Google Scholar
Fazel, S., Zetterqvist, J., Larsson, H., Långström, N., and Lichtenstein, P. Antipsychotics, mood stabilisers, and risk of violent crime. The Lancet 2014 Sep 27;384(9949):1206–14. https://doi.org/10.1016/S0140-6736(14)60379-2. Epub 2014 May 8. PMID: 24816046; PMCID: PMC4165625.Google Scholar
Victoroff, J., Coburn, K., Reeve, A., Sampson, S., and Shillcutt, S. Pharmacological management of persistent hostility and aggression in persons with schizophrenia spectrum disorders: a systematic review. Journal of Neuropsychiatry and Clinical Neurosciences 2014;26(4):283–312.CrossRefGoogle ScholarPubMed
Chengappa, K. N. R., Vasile, J., Levine, J. et al. Clozapine: Its impact on aggressive behavior among patients in a state psychiatric hospital. Schizophrenia Research 2002; 53(1–2):1–6.CrossRefGoogle Scholar
Volavka, J., Czobor, P., Nolan, K. et al. Overt aggression and psychotic symptoms in patients with schizophrenia treated with clozapine, olanzapine, risperidone, or haloperidol. Journal of Clinical Psychopharmacology. 2004;24(2):225–8.Google Scholar
Krakowski, M. I., Czobor, P., Citrome, L., Bark, N., and Cooper, T. B. Atypical antipsychotic agents in the treatment of violent patients with schizophrenia and schizoaffective disorder. Archives of General Psychiatry 2006;63(6):622–9.Google Scholar
Frogley, C., Taylor, D., Dickens, G., and Picchioni, M. A systematic review of the evidence of clozapine’s anti-aggressive effects. International Journal of Neuropsychopharmacology 2012;15(9):1351–71.Google Scholar
Kraus, J. E., and Sheitman, B. B. Clozapine reduces violent behavior in heterogeneous diagnostic groups. Journal of Neuropsychiatry and Clinical Neurosciences 2005;17(1):36–44.Google Scholar
Strassnig, M. T., Nascimento, V., Deckler, E. and Harvey, P. D. Pharmacological treatment of violence in schizophrenia. CNS Spectrums 2020;25(2):207–15.Google Scholar
Krakowski, M. I., Czobor, P. and Nolan, K. A. Atypical antipsychotics, neurocognitive deficits, and aggression in schizophrenic patients. Journal of Clinical Psychopharmacology 2008;28(5):485–93.Google Scholar
Krakowski, M. I. and Czobor, P. Neurocognitive impairment limits the response to treatment of aggression with antipsychotic agents. Schizophrenia Bulletin 2011;37 311–2.Google Scholar
National Institute for Health and Clinical Excellence. Borderline Personality Disorder: The NICE Guideline on Treatment and Management (Clinical Guideline CG78). London: The British Psychological Society & The Royal College of Psychiatrists, 2009.Google Scholar
National Institute for Health and Clinical Excellence. Antisocial Personality Disorder: Treatment, Management and Prevention Clinical Guideline CG77 [online]. 2009. www.nice.org.uk/guidance/cg77/resources/antisocial-personality-disorder-prevention-and-management-pdf-975633461701 [Accessed 29.4.2022].Google Scholar
National Institute of Clinical Excellence (NICE). Quality standard [QS88]. Personality disorders: borderline and antisocial. www.nice.org.uk/guidance/qs88/chapter/Quality-statement-4-Pharmacological-interventions [Accessed 24.9.2021].Google Scholar
Soloff, P. H. Algorithms for pharmacological treatment of personality dimensions: symptom-specific treatments for cognitive-perceptual, affective, and impulsive-behavioral dysregulation. Bulletin of the Menninger Clinic 1998;62(2):195–214.Google Scholar
Tyrer, P. and Bateman, A. W. Drug treatment for personality disorders. Advances in Psychiatric Treatment 2018;10(5):389–98.Google Scholar
Block, H., George, S., Milanese, S. et al. Evidence for the management of challenging behaviours in patients with acute traumatic brain injury or post-traumatic amnesia: An umbrella review. Brain Impairment, 2021;22(1):1–19. https://doi.org/10.1017/BrImp.2020.5Google Scholar
Jacobson, R. R. Commentary: Aggression and impulsivity after head injury. Advances in Psychiatric Treatment 2018;3(3):160–3.Google Scholar
Khan, O., Ferriter, M., Huband, N., at al. Pharmacological interventions for those who have sexually offended or are at risk of offending. Cochrane Database of Systematic Reviews 2015;2015(2):Cd007989.Google Scholar
Ballard, C. and Waite, J. The effectiveness of atypical antipsychotics for the treatment of aggression and psychosis in Alzheimer’s disease. Cochrane Database of Systematic Reviews 2006(1):CD003476.Google Scholar
National Institute for Health and Care Excellence. Dementia: Assessment, management and support for people living with dementia and their carers. Guideline NG97 [online]. 2018. www.nice.org.uk/guidance/ng97/resources/dementia-assessment-management-and-support-for-people-living-with-dementia-and-their-carers-pdf-1837760199109 [Accessed 29.4.2022].Google Scholar
Stahl, S. M. and Morrissette, D. A. Stahl’s Illustrated: Violence: Neural Circuits, Genetics and Treatment. Cambridge: Cambridge University Press, 2014.Google Scholar
Ferrier, I. and Waite, J. The ECT Handbook, 4th ed. Cambridge: Cambridge University Press, 2019.Google Scholar
National Institute for Health and Care Excellence. Guidance on the Use of Electroconvulsive Therapy. Technology Appraisal Guidance TA59 [online]. 2009. www.nice.org.uk/guidance/ta59 [Accessed 29.4.2022].Google Scholar
Royal College of Psychiatrists. Statement on Electroconvulsive Therapy (ECT), CERT01/17 London: R; 2017 www.rcpsych.ac.uk/docs/default-source/about-us/who-we-are/electroconvulsive-therapy–-ect-ctee-statement-feb17.pdf?sfvrsn=2f4a94f9_2 [Accessed 29.4.2022].Google Scholar
Tharyan, P. and Adams, C. E. Electroconvulsive therapy for schizophrenia. Cochrane Database of Systematic Reviews 2005(2):Cd000076.Google Scholar
Commission CQ. Guidance for SOADS: Consent for Treatment and the SOAD Role under the Revised Mental Health Act. CQC, 2008.Google Scholar
Rogers, P., Leung, C. and Nicholson, T. R. J. Pocket Prescriber Psychiatry. Florida: CRC Press.Google Scholar
Citrome, L., Landbloom, R., Chang, C. T., and Earley, W. Effects of asenapine on agitation and hostility in adults with acute manic or mixed episodes associated with bipolar I disorder. Neuropsychiatric Disease and Treatment 2017;13:2955–63.Google Scholar
Hassaballa, H. A. and Balk, R. A. Torsade de pointes associated with the administration of intravenous haloperidol. American Journal of Therapeutics 2003;10(1):58–60.Google Scholar
Hassaballa, H. A. and Balk, R. A. Torsade de pointes associated with the administration of intravenous haloperidol: a review of the literature and practical guidelines for use. Expert Opinion on Drug Safety 2003;2(6):543–7.Google Scholar
National Institute of Clinical Excellence. NICE guideline NG10 Appendix 15B: Clinical evidence – forest plots for review of rapid tranquillisation. [online] 2015. www.nice.org.uk/guidance/ng10/evidence/appendix-15b-pdf-2549889109 [Accessed 29.4.2022].Google Scholar
Huf, G., Coutinho, E. S., Adams, C. E. and TREC Collaborative Group. Rapid tranquillisation in psychiatric emergency settings in Brazil: Pragmatic randomised controlled trial of intramuscular haloperidol versus intramuscular haloperidol plus promethazine. BMJ 2007;335(7625):869.Google Scholar
Raveendran, N. S., Tharyan, P., Alexander, J., Adams, C. E. and TREC Collaborative Group. Rapid tranquillisation in psychiatric emergency settings in India: Pragmatic randomised controlled trial of intramuscular olanzapine versus intramuscular haloperidol plus promethazine. BMJ 2007;335(7625):865.Google Scholar
Paton, C., Adams, C. E., Dye, S. et al. The pharmacological management of acute behavioural disturbance: Data from a clinical audit conducted in UK mental health services. Journal of Psychopharmacology 2019;33(4):472–81.Google Scholar
Baker, J. A., Lovell, K. and Harris, N. A best-evidence synthesis review of the administration of psychotropic pro re nata (PRN) medication in in-patient mental health settings. Journal of Clinical Nursing 2008;17(9):1122–31.CrossRefGoogle ScholarPubMed
National Institute for Health and Care Excellence. Violence: The Short-Term Management of Disturbed and Violent Behaviour in Inpatient Psychiatric Settings and Emergency Departments. NICE Clinical Guideline CG 25 [online]. 2005. www.ncbi.nlm.nih.gov/books/NBK305020/ [Accessed 29.4.2022]Google Scholar
Ostinelli, E. G., Brooke-Powney, M. J., Li, X. and Adams, C. E. Haloperidol for psychosis-induced aggression or agitation (rapid tranquillisation). Cochrane Database of Systematic Reviews. 2017;7:CD009377.Google Scholar
Hsu, W. Y., Huang, S. S., Lee, B. S. and Chiu, N. Y. Comparison of intramuscular olanzapine, orally disintegrating olanzapine tablets, oral risperidone solution, and intramuscular haloperidol in the management of acute agitation in an acute care psychiatric ward in Taiwan. Journal of Clinical Psychopharmacology 2010;30(3):230–4.Google Scholar
Baldacara, L., Sanches, M., Cordeiro, D. C. and Jackoswski, A. P. Rapid tranquilization for agitated patients in emergency psychiatric rooms: A randomized trial of olanzapine, ziprasidone, haloperidol plus promethazine, haloperidol plus midazolam and haloperidol alone. Revista brasileira de psiquiatria (Sao Paulo, Brazil: 1999) 2011;33(1):30–9.Google Scholar
Belgamwar, R. B. and Fenton, M. Olanzapine IM or velotab for acutely disturbed/agitated people with suspected serious mental illnesses. Cochrane Database of Systematic Reviews 2005;2:CD003729.Google Scholar
Kishi, T., Matsunaga, S. and Iwata, N. Intramuscular olanzapine for agitated patients: A systematic review and meta-analysis of randomized controlled trials. Journal of Psychiatric Research 2015;68:198–209.CrossRefGoogle ScholarPubMed
Eli Lilly. Zyprexa powder for solution for injection 2009. www.ema.europa.eu/en/documents/product-information/zyprexa-epar-product-information_en.pdf [Accessed 29.4.2022]Google Scholar
Wright, P., Birkett, M., David, S. R. et al. Double-blind, placebo-controlled comparison of intramuscular olanzapine and intramuscular haloperidol in the treatment of acute agitation in schizophrenia. The American Journal of Psychiatry. 2001;158(7):1149–51.Google Scholar
Eli Lilly. Important safety information: Reported serious adverse events following use of Zyprexa Intramuscular (28 September) 2004. www.palliativedrugs.com/download/SafetyLetterzyprexa.pdf [Accessed 29.4.2022].Google Scholar
Ostinelli, E. G., Jajawi, S., Spyridi, S., Sayal, K., and Jayaram, M. B. Aripiprazole (intramuscular) for psychosis-induced aggression or agitation (rapid tranquillisation). Cochrane Database of Systematic Reviews 2018;1:CD008074.Google Scholar
Zimbroff, D. L., Marcus, R. N., Manos, G. et al. Management of acute agitation in patients with bipolar disorder: Efficacy and safety of intramuscular aripiprazole. Journal of Clinical Psychopharmacology 2007;27(2):171–6.Google Scholar
Broadstock, M. The effectiveness and safety of drug treatment for urgent sedation in psychiatric emergencies. A critical appraisal of the literature. NZHTA Report 2001; 4(1):2001.Google Scholar
Huf, G., Alexander, J., Gandhi, P. and Allen, M. H. Haloperidol plus promethazine for psychosis-induced aggression. Cochrane Database of Systematic Reviews 2016;11:CD005146.Google ScholarPubMed
Trec Collaborative Group. Rapid tranquillisation for agitated patients in emergency psychiatric rooms: A randomised trial of midazolam versus haloperidol plus promethazine. BMJ 2003;327(7417):708–13.Google Scholar
Alexander, J., Tharyan, P., Adams, C. et al. Rapid tranquillisation of violent or agitated patients in a psychiatric emergency setting: Pragmatic randomised trial of intramuscular lorazepam v. haloperidol plus promethazine. British Journal of Psychiatry 2004;185:63–9.Google Scholar
Allen, M. H., Feifel, D., Lesem, M. D. et al. Efficacy and safety of loxapine for inhalation in the treatment of agitation in patients with schizophrenia: A randomized, double-blind, placebo-controlled trial. Journal of Clinical Psychiatry 2011;72(10):1313–21.Google Scholar
Lesem, M. D., Tran-Johnson, T. K., Riesenberg, R. A. et al. Rapid acute treatment of agitation in individuals with schizophrenia: Multicentre, randomised, placebo-controlled study of inhaled loxapine. British Journal of Psychiatry 2011;198(1):51–8.Google Scholar
Shrewsbury, S. B., Hocevar-Trnka, J., Satterly, K. H. et al. The SNAP 101 double-blind, placebo/active-controlled, safety, pharmacokinetic, and pharmacodynamic study of INP105 (nasal olanzapine) in healthy adults. Journal of Clinical Psychiatry 2020;81(4):19m13086.Google Scholar
Ravi, A. D., Sadhna, D., Nagpaal, D. and Chawla, L. Needle free injection technology: A complete insight. International Journal of Pharmaceutical Investigation 2015;5(4):192–9.Google Scholar
GMC. Prescribing unlicensed medicines. [online] 2021. www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-practice-in-prescribing-and-managing-medicines-and-devices/prescribing-unlicensed-medicines [Accessed 29.4.2022].Google Scholar
Royal College of Psychiatrists. Use of licensed medicines for unlicensed applications in psychiatric practice. College report CR210. [online]. 2010. www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr210.pdf?sfvrsn=60c7f2d_2 [Accessed 29.4.2022].Google Scholar
Nobay, F., Simon, B. C., Levitt, M. A. and Dresden, G. M. A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine. 2004;11(7):744–9.Google Scholar
Martel, M., Sterzinger, A., Miner, J., Clinton, J. and Biros, M. Management of acute undifferentiated agitation in the emergency department: A randomized double-blind trial of droperidol, ziprasidone, and midazolam. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine. 2005;12(12):1167–72.Google Scholar
Isbister, G. K., Calver, L. A., Page, C. B. et al. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: The DORM study. Annals of Emergency Medicine 2010;56(4):392–401 e1.Google Scholar
Sweetman, S. Martindale: The Complete Drug Reference. Medicines Complete Royal Pharmaceutical Society; 2009. www.medicinescomplete.com/mc/martindale/current/ [Accessed 29.4.2022].Google Scholar
Taylor, D., Okocha, C., Paton, C., Smith, S. and Connolly, A. Buccal midazolam for agitation on psychiatric intensive care wards. International Journal of Psychiatry in Clinical Practice 2008;12:309–11.Google Scholar
Parker, C. Midazolam for rapid tranquillisation: Its place in practice. Journal of Psychiatric Intensive Care 2014;11(01):66–72.Google Scholar
Schwagmeier, R., Alincic, S. and Striebel, H. W. Midazolam pharmacokinetics following intravenous and buccal administration. British Journal of Clinical Pharmacology 1998;46(3):203–6.Google Scholar
Perkins, J., Ho, J. D., Vilke, G. M., and DeMers, G. American Academy of Emergency Medicine position statement: Safety of droperidol use in the emergency department. Journal of Emergency Medicine 2015;49(1):91–7.Google Scholar
Brook, S., Lucey, J. V., and Gunn, K. P. Intramuscular ziprasidone compared with intramuscular haloperidol in the treatment of acute psychosis. Journal of Clinical Psychiatry 2000;61(12):933–41.Google Scholar
Khan, S. S. and Mican, L. M. A naturalistic evaluation of intramuscular ziprasidone versus intramuscular olanzapine for the management of acute agitation and aggression in children and adolescents. Journal of Child and Adolescent Psychopharmacology 2006;16(6):671–7.Google Scholar
Barzman, D. H., DelBello, M. P., Forrester, J. J., Keck, P. E. and Jr., Strakowski, S. M. A retrospective chart review of intramuscular ziprasidone for agitation in children and adolescents on psychiatric units: prospective studies are needed. Journal of Child and Adolescent Psychopharmacology 2007;17(4):503–9.Google Scholar
Kohen, I., Preval, H., Southard, R. and Francis, A. Naturalistic study of intramuscular ziprasidone versus conventional agents in agitated elderly patients: retrospective findings from a psychiatric emergency service. American Journal of Geriatric Pharmacotherapy 2005 3(4):240–5.Google Scholar
Barak, Y., Mazeh, D., Plopski, I. and Baruch, Y. Intramuscular ziprasidone treatment of acute psychotic agitation in elderly patients with schizophrenia. American Journal of Geriatric Psychiatry 2006 14(7):629–33.Google Scholar
Ahmed, U., Jones, H. and Adams, C. E. Chlorpromazine for psychosis induced aggression or agitation. Cochrane Database of Systematic Reviews 2010 (4):Cd007445.Google Scholar
Royal College of Psychiatrists. Management of Imminent Violence: Clinical Practice Guidelines to Support Mental Health Services (Occasional Paper OP41). Royal College of Psychiatrists, 1998.Google Scholar
National Institute for Health and Care Excellence. Psychosis and Schizophrenia in Adults: Prevention and Management. Clinical Guideline CG178 [online]. 2014. www.nice.org.uk/guidance/cg178 [Accessed 29.4.2022].Google Scholar
National Institute for Health and Clinical Excellence. Venous Thromboembolism: Reducing the Risk Clinical Guideline CG 92 [online]. 2010. www.nice.org.uk/guidance/cg92 [Accessed 29.4.2022].Google Scholar
European Pharmacovigilance Working Party. Antipsychotics and Cerebrovascular Accident. 2005. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/368871/Pharmacovigilance_Working_Party_Public_Assessment_Report_on_antipsychotics_and_cerebrovascular_accident.pdf [Accessed 29.4.2022].Google Scholar
Sorrentino, A. Chemical restraints for the agitated, violent, or psychotic pediatric patient in the emergency department: Controversies and recommendations. Current Opinion in Pediatrics 2004;16(2):201–5.Google Scholar
Einfeld, S. L. Systematic management approach to pharmacotherapy for people with learning disabilities. Advances in Psychiatric Treatment 2018;7(1):43–9.Google Scholar
Allington-Smith, P. Mental health of children with learning disabilities. Advances in Psychiatric Treatment 2018;12(2):130–8.Google Scholar
National Institute for Health and Care Excellence. Antenatal and postnatal mental health: Clinical management and service guidance Clinical guideline CG192 [online]. 2020. www.nice.org.uk/guidance/cg192 [Accessed 29.4.2022].Google Scholar
McAllister-Williams, R. H., Baldwin, D. S., Cantwell, R. et al. British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum 2017. Journal of Psychopharmacology 2017;31(5):519–52.Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×