Agitation is a common and serious problem presenting a conflict of values: the need for safety temporarily outweighing the emphasis on dignity, autonomy and privacy that should characterize usual care. Given the difficulty of experimenting with this population, a group of experts in emergency psychiatry met to discuss the management of behavioural emergencies. This was conceptualised as occurring in phases including the first 2 hours, 2–24 hours, and after 24 hours. A number of general principles were recognised, including initial efforts devoted to less coercive strategies that appear as part of a graded hierarchy of choices, awareness of potential organic causes, and an endpoint of calming and patient participation rather than sleep. Anticipation of various contingencies in standard procedures is encouraged. Nonpharmacological methods should always be emphasised. Pharmacological treatment may target symptoms non-specifically in the first phase until the syndrome responsible can be identified and definitive treatment tailored to individual needs in later phases can be started. Benzodiazepines are recommended for their non-specific effects. Second-??generation antipsychotics are preferred for their lower side-effect burden initially and advantages in the domain of hostility as well as relapse prevention. Oral treatment with an orodispersible formulation is preferred to parenteral treatment if possible. Moderate doses of antipsychotics are recommended in contrast to rapid neuroleptisation. Combinations of benzodiazepines and antipsychotics may enhance calming and reduce total antipsychotic dose required for calming but caution is warranted with some agents. Frequent monitoring and reassessment of initial interventions is critical. In later phases, the focus shifts from managing behaviour to treating acute symptoms and finally to education and recovery. The ultimate goal is the return of autonomy, formation of an alliance and development of a durable, mutually agreeable plan of care that considers both tolerability and efficacy in multiple domains. Every effort should be made to prevent undesirable outcomes in the early stages from compromising care in the much longer periods following the behavioural emergency.

Clinical researchers in acute emergency settings are commonly faced with the difficulty of satisfying the conventional ethical requirement of obtaining informed consent, whilst ensuring a representative group of patients is recruited into studies. We discuss our own experience in addressing institutional ethical requirements to obtain informed consent in a multi-centre trial, recruiting highly agitated patients in the emergency setting in Melbourne, Australia. We suggest that, through the application of existing ethical and legal frameworks and pre-emptive communication with the key stakeholders in ethics committees, hospital insurers and legal representatives, a balance can be struck between ethical and legal requirements on the one hand, and the integrity of the research question, on the other.

Benzodiazepines are mainstay medicines in rapid tranquillisation. Midazolam is a short acting benzodiazepine. It is not available for oral administration as this route of administration leads to poor bioavailability. It has recently become available in a new formulation specifically designed for buccal administration, and is also available as a solution for injection.

The absorption of intramuscular midazolam is erratic and it has an unpredictable propensity for causing profound oversedation. Healthcare providers who include IM midazolam in their rapid tranquillisation guidelines or policies need to ensure that clinicians using it have the necessary knowledge, skills and competencies surrounding its use including clinical sequelae and the use of the ‘antidote’ flumazenil.

This brief review describes midazolam's potential role in rapid tranquillisation via these routes, and discusses the risks and benefits of these options in order to help readers consider their places in regular clinical practice, particularly in light of the shortage of lorazepam injection.

Information concerning the administration of psychotropic PRN medication in Scottish PICUs is scarce. The medical notes and prescription charts of all patients (n = 75) admitted during the study period were consulted to determine the frequency and nature of PRN practice.

65% of patients (n = 49) were administered up to 11 drugs comprising of antipsychotics (n = 8), benzodiazepines (n = 2) and zopiclone. The most frequently administered PRN medicines were lorazepam, haloperidol and zuclopenthixol. The mean dose administered for oral and intramuscular (IM) forms of both lorazepam and haloperidol were very similar. The mean number of PRN administrations per patient per day was 0.4. 40% of psychotropic PRN administrations were initiated by the nurse with the majority of doses administered at bedtime. Ten patients received an IM injection. Four patients were restrained during these administrations. Documentation pertaining to the rationale for IM administrations and of pre and post rapid tranquillisation physical health monitoring was lacking. This study highlights variation in practice between units, inadequate monitoring and documentation, a possible lack of understanding by prescribers of the differences in bioavailability between oral and injectable forms of medication and relatively limited use of newer drugs.

Background: Heterotopia are believed to result from faulty neuronal migration. Formerly considered to be extremely rare, with the availability of MRI reports they have appeared more frequently.

Case details: We describe a 42 year old man with episodic disinhibition (violent and sexual) with disorganized thinking and behaviour, and a 20 year history of a diagnosis of schizophrenia. Soon after admission there were vague paranoid delusions. Initially, the cognitive state was impossible to access, but cognitive deficit was later demonstrated using the Mini Mental State Examination (MMSE). Although there was no clear evid??ence of delirium, the MMSE score subsequently improved, as did the disinhibited behaviour.

Results: CT revealed no abnormality. Brain MRI, however, revealed multiple bilateral subependymal heterotopia (SEH).

Conclusion: It is possible for SEH to be associated with a schizophrenia-like syndrome. CT is not sufficient and MRI is required to exclude SEH.

Aims: (1) To ascertain characteristics of patients in low secure units; (2) To examine whether standard 5 of the National Service Frameworks was being followed; (3) To investigate reasons for any delays in discharge and how these could be addressed.

Method: Audit survey of National Service Frameworks for Mental Health standard 5 patients being treated in least restrictive environment as close to their home as possible by case notes, interviews with ward manager and questionnaires.

Results: Patients in mental health units had greater numbers of admissions to hospital than those from learning disabilities units. They had more contact with the criminal justice system and had spent time in prison. The main diagnosis was schizophrenia.

Patients in learning disabilities units were more likely to be Black Caribbean or African and to have had special needs at school. They exhibited current higher risk to others and to self, by deliberate and non-deliberate self-harm. They had diagnoses of mild learning disabilities and autism. About a third of both groups of patients were assessed as being able to move to a lower level of security. The most suitable facility for these patients was an open unit in the community staffed by nurses.

Conclusion: For a third of the patients standard 5 of the National Service Frameworks was not met because they were not ‘in the least restrictive environment’. Open community facilities staffed by nurses over 24 hours was the most appropriate unit for a majority of these patients.

Aims: To describe the pattern of aggressive incidents, compare clinical characteristics of aggressive and non aggressive inpatients and determine predictors of inpatient aggressive behaviours in a low secure mental health unit population.

Method: Clinical data were extracted from inpatient records and a critical incident database for a low secure unit population. Clinical variables between those with inpatient aggressive behaviours (inpatient aggressors) and those without inpatient aggressive behaviours (inpatient non aggressors) were compared. Statistical analysis was carried out on the differences to establish predictors of inpatient aggression.

Results: 80 admissions resulted from 78 patients during a 6½ year period. 44% of patients presented with inpatient aggressive incidents. 64% of aggressive incidents resulted from 15% of patients. 54% of aggressive incidents were directed towards staff, 16% towards property and 15% towards other patients. 8% and 4% contributed to disturbed behaviour (non-directed aggression) and sexually inappropriate behaviour respectively. Most aggressive incidents are perpetrated by males and directed towards staff though a larger proportion of females (compared to males) were aggressive. On univariate analysis, clinical variables of more than one previous psychiatric admission, auditory hallucinations and delusions of control and persecution were significantly higher in patients displaying inpatient aggression. Logistic regression analysis identified the former two as predictors of inpatient aggression.

Conclusion: In a low secure inpatient population, the majority of aggressive incidents are perpetrated by a minority of patients. Clinical variables such as history of more than one previous psychiatric admission and psychopathological symptoms such as presence of auditory hallucinations and delusions of control and persecution can influence inpatient aggression.

Recent changes in the practice of inpatient psychiatry have minimized the emphasis on psychodynamic principles in the treatment of hospitalized patients. The concepts of transference and countertransference have taken a secondary role to rapid diagnosis, treatment and discharge. This paper explores the impact of countertransference on physician decision-making and clinical care through two case histories illustrating how countertransference can impact the assessment, treatment and management of the psychiatric inpatient. The authors discuss the concept of countertransference, its effect on physicians and hospital staff and strategies for recognizing and minimizing the impact of countertransference.

Background: People with severe mental illness are at increased risk of developing serious physical health problems, including metabolic syndrome, cardiac and respiratory diseases.

Aims: To audit the admission physical examinations carried out on patients admitted to a male psychiatric intensive care unit.

Method: A retrospective audit of 100 sets of case notes. After the first 45 case notes had been audited, the results were presented at a clinical meeting and an action plan formulated. A further 55 cases were then audited.

Results: Overall, 70 patients had an admission physical examination and 25 (36%) of these were abnormal. In 11 (16%) cases medical intervention was required, occasionally urgently and in 5 (7%) the abnormalities detected impacted on psychiatric diagnosis or management. In the re-audit there was no significant improvement in the proportion of patients having an admission physical but better documentation as to why one was not done and more patients had had a physical by discharge.

Conclusion: Physical examination on admission is an integral part of patient assessment and may identify underlying physical illness that may require urgent intervention and/or impact on psychiatric diagnosis or management. Clinical audit provides a means of detecting and rectifying absent admission physicals.

Evidence regarding medical practice in seclusion is limited, and far outweighed by opinion. Here, we present one approach to medical reviews of patients in seclusion rooms, aiming to drive consistent practice. We address the work of clinicians prior to their arrival in the seclusion area, information-gathering prior to entry into the seclusion room, relevant aspects of history-taking and mental state examination in the seclusion area, and the implications for clinical and risk-management. We discuss issues raised by the logistics of seclusion for the planning and undertaking of the consultation. Physical examinations of secluded patients are commonly complicated by patient-related and environment-related factors; we suggest a pragmatic approach to determining the scope of physical examination in seclusion. While risk assessments are a vital aspect of seclusion practice for psychiatrists, structured instruments for the assessment of risk within these environments do not exist. We lay out principles regarding risk assessment in this population. We comment on the role of the clinician in the debrief phase of the seclusion review, and deal with legal issues pertaining to seclusion in England. Ultimately, we are left with a number of questions relating to what constitutes best practice for psychiatrists fulfilling this role on the PICU.

An Environment Assessment Inventory was developed to conduct a Nationwide survey on the physical environment of Psychiatric Intensive Care Units (PICUs) and Low Secure Units (LSUs). The Nationwide survey was conducted in England to see if the physical environment of PICUs and LSUs were adequate to meet the therapeutic and safety needs of the patients.

In this work, a detailed account has been given about the survey tool: the “Environment Assessment Inventory”, its development, uses and limitations. This tool may be used in the future for national planning and development of the PICUs and LSUs, not only by UK but also by other countries of the world.

Background: Structured assessment of risk is a standard element of the core psychiatric assessment, particularly in respect of individuals, who are perceived to be at risk of violence or suicide. Many acute mental health trusts have introduced risk assessment tools, often without evidence of validity.

Aim: To evaluate a tool designed to predict the acute risk of violence by patients detained in a PICU.

Method: A risk assessment form was completed weekly for each patient on the PICU. Multivariate logistic regression analysis was used to measure the predictive value of particular variables in respect of violent behaviour during the next two weeks.

Results: Violent behaviour during the previous two weeks was a significant predictor of subsequent violence. Drug use was a negative predictor. None of the other variables tested were predictive of violent behaviour.

Conclusions: A complicated risk assessment tool probably adds little to the process of predicting acutely violent behaviour in PICU patients. The introduction of procedures such as structured risk assessment tools should be subject to the same validation process as any other clinical initiative.

Background: Refugees and asylum seekers may have other feelings and expectations about the future than immigrants do. The aim of this study was to explore and analyse the expectations for the future among populations of immigrants, asylum seekers and refugees admitted to Norwegian acute psychiatric departments.

Method: In a prospective study in the period 2005 to 2008, data were collected from two acute psychiatric departments.

Results: There were 48 immigrants, 24 refugees, and 21 asylum seekers. A significantly higher proportion of asylum seekers than refugees had nightmares (p = 0.04), feelings of guilt (p = 0.04) and feelings of hopelessness (p = 0.04). A significantly higher proportion of asylum seekers than immigrants had sleeping problems (p = 0.03), nightmares (p = 0.03), feelings of hopelessness (p = 0.03) and reduced appetite (p = 0.04). Significantly more asylum seekers than refugees maintained that life would change for the better over time (Z = 2.0; p = 0.04). More refugees than asylum seekers indicated problems judging life ten years from now (Z = 2.1; p = 0.04).

Conclusion: Being an asylum seeker seems to incur greater distress and higher negative expectations for the future. Preventive strategies should be created to improve refugees’ and asylum seekers’ life in exile. Priority and speed in processing of asylum cases should be given higher priority.

The HCR-20 is the most widely used structured professional judgement instrument for assessing risk of violence. Recent developments in secure settings have addressed service user involvement in risk assessment to empower service users, and encourage them to take responsibility for their pathway through hospital. This audit aimed to examine the quality of, and service-user involvement in, the HCR-20 assessments completed on two wards (a low secure and a psychiatric rehabilitation ward) within Somerset Partnership NHS Foundation Trust. Data from the current RiO (electronic patient record system) Risk Screen and Risk Information sections and the most up-to date HCR-20 report (if there was one) was reviewed across a number of domains. The in-house HCR-20 training programme appeared to be effective, with most assessors following the appropriate data collection process. The quality of the risk assessments was mixed with the historical section being more consistently completed than the clinical and risk sections. The results of the audit facilitated the development of standards for the completion of HCR-20 risk assessments on the two wards reviewed. Limitations of the audit in terms of generalisation are noted. Nonetheless, this audit serves to give an early impression on the extent of collaboration with service users on risk assessments.

Aims: To describe the methods of self harm incidents in a low secure unit population and to identify and compare the clinical characteristics of patients displaying inpatient self harming behaviours with those who do not display such behaviours.

Method: A retrospective case control study was conducted. Details about the inpatient self harming incidents were collected from an incident database. Clinical characteristics of those who displayed inpatient self harming incidents (cases) and those who did not display such behaviours (controls) were compared. Analysis was performed to establish statistical significance on the observed differences.

Results: 80 admissions resulted from 78 patients during a 6½ year period. 21% of patients presented with inpatient self harming behaviours. 57% of the incidents were caused by 13% of patients. Clinical characteristics such as white ethnic background, histories of self harm, physical or sexual abuse, childhood conduct problems and lack of educational qualifications and having a diagnosis of schizoaffective disorder were more likely to be associated with inpatients self harming in low secure settings. Sexually inappropriate behaviours and a diagnosis of schizophrenia were less likely to be associated with this group.

Conclusion: The majority of self harm incidents are caused by a minority of patients. Most of the clinical characteristics associated with the low secure inpatient self harming patients are similar to those observed in other psychiatric inpatient settings.