‘Rapid tranquillisation’ refers to the use of medication to calm highly agitated individuals experiencing mental disorder who have not responded to non-pharmacological approaches. Commonly it is the initial stage in the treatment of severe and enduring illness. Using medication in this way requires particularly robust evidence of efficacy and the management of side-effects. This article attempts to integrate current understanding of the neurochemical mechanisms of underlying illness and drug actions with therapeutic interventions. It distinguishes arousal from agitation, and effects on sedation from tranquillisation. It reviews critically the practice of rapid tranquillisation in the light of new evidence, changes in the NICE guidelines and British National Formulary recommendations and a national audit (POMH-UK). Broader aspects of management, known as ‘restrictive practices’ (such as control and restraint and seclusion), psychological support of team members, incident reporting, risk assessment, monitoring and medico-legal aspects are not covered.

‘Deprescribing’ here comprises arguments against treating patients who have been psychotic beyond first episode. Nevertheless, four out of five patients relapse, compared with only two of five still taking medication. However, much first-episode psychosis is not schizophrenia, but persistent substance-induced psychotic disorder. Virtually nothing is known about factors which facilitate this in the minority who develop it, nor how to decide if the patient will relapse off medication. Patients who are well, stable and tolerating minimal doses of medication should be the first to suggest that they try to do without it, not us.