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.

I take the art form opera as an example from which practicing mental health professionals can learn some important lessons. After an introduction to the representation of mental illness in opera, the focus turns to one specific opera: La Bohème. Some pivotal scenes in this opera are reviewed and reflection points for mental health practitioners are suggested. By reflecting on the words sung in the opera, I draw parallels between mental health clinical practice and the content and performance of opera. The paper concludes with some general lessons mental health practitioners can take from opera.

To determine the nature of psychotropic medication routinely prescribed in Scottish PICUs, the medical notes and prescription charts of 75 patients from 10 out of 14 units were consulted. These included 55 males (73%), the majority of whom were detained and had a diagnosis of schizophrenia. There was good conformance with mental health legislation treatment plans (T2/T3 forms) with only five instances of non-conformance identified. Antipsychotics were prescribed to 60 patients (80%) of which olanzapine and zuclopenthixol decanaote were the most common. The average number of regular psychotropic medicines prescribed per patient was two. In total, 14 drugs, encompassing 21 formulations, were prescribed for PRN use. Lorazepam and haloperidol were the most common PRN medicines. 76 PRN prescriptions (32%) had the oral and IM doses written on the same line of the prescription chart and showed no allowance for bioavailability when detailing the maximum dose that could be administered. 16 patients (21%) were prescribed more than one antipsychotic. Seven patients were prescribed high dose therapy, but this increased to 25 when PRN antipsychotics were included. This study provides information about psychotropic medication prescribing in Scottish PICUs and highlights areas where practice is sub-optimal.

Ward round is an integral platform for patients and the multidisciplinary team to communicate, assess and plan treatment. With such a key process, it is vital that the effectiveness of the ward round is maximised and that reliable follow of information is addressed. This can be achieved using lean methodology.

There is considerable variability in the ethos of the various adolescent in-patient units in Britain. Currently, there are few services within NHS settings able to manage acute behavioural disturbance in adolescents despite the prevalence of psychiatric disorder in this population group. Due to this variation, individual units around the country have developed their own bespoke services for managing disturbance. These services are given different names although may be operating with similar models. However, there is little consensus on these definitions, resulting in services with similar titles providing differing levels of service and varying capacity to manage violence or aggression. We attempt to define patient populations in need of such services and suggest a nomenclature for defining such services that could be universally adopted. We also describe the five-year review of admissions of one adolescent psychiatric intensive care unit and suggest how well its name fits with our proposed model.

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.

Loxapine has recently been licensed in the UK for the management of mild-to-moderate agitation in adults with schizophrenia or bipolar affective disorder.

Loxapine is a first generation antipsychotic, and although not previously available in the UK, it has been used orally and as an intramuscular injection in some countries for many years. It is now formulated in a single use inhalator.

This is the first newly licensed medicine in the UK for the management of agitation for over five years.

This brief article provides an overview of this new medicine in order to help readers consider its place in regular clinical practice prior to its UK launch.

The role of the internet is increasingly pertinent in the daily lives of both clinicians and patients. We present two case reports, concerning patients recently presented to our service, involving beliefs concerning the social media website, Facebook. We consider the basis of a delusional experience from both categorical and dimensional perspectives. We consider the context of the nature of social networking media and the internet, including examples of how it has been used therapeutically, as well as the potential for detrimental use. Whilst keeping the principle of a delusion in mind we also explore some of the challenges that are presented in the assessment of such beliefs and how, or indeed whether, to incorporate them into the understanding of a patient's presentation. We also briefly consider the impact that beliefs arising from and incorporating social media and the internet may have on the practice of clinicians, descriptive phenomenology research, diagnosis and management of mental disorder.

Auditory hallucinations present a significant challenge. Despite advances in treatment with novel antipsychotic agents, there are still a significant number of non-responders to standard therapy. We describe the case of a young patient with treatment resistant auditory hallucinations, with positive outcomes after being fitted with auditory sound generators commonly used for the treatment of tinnitus. As far as we are aware, this is only the third case so far described in the literature.