The chapter describes the history, mechanisms and phases of drug treatment of antipsychotics including at-risk mental states (ARMS), first-episode psychosis (FEP), maintenance, treatment-resistant schizophrenia (TRS) and ultra-resistant psychosis. Specific treatments of schizoaffective disorder, catatonia and affective comorbidities of psychosis target negative symptoms and cognition. Rapid tranquilisation is described: general principles, de-escalation, routes of administration and medication selection. Management of organic psychotic disorders is discussed: general principles and specific conditions, epilepsy, Huntington’s, stroke, drug-induced, autoimmune encephalitis, inflammatory, CNS infections, thyroid disorders and traumatic brain injury. Side effects are elaborated: somnolence and sedation; hyperprolactinaemia and sexual dysfunction; motor, cardiac, metabolic and anticholinergic side effects; and also diabetes and impaired glucose tolerance and clozapine-specific side effects. Finally, potential drug interactions are explored.

Whether or not seclusion has a place within the treatment of the mentally disordered is one of the longest running debates in the history of mental health care, and it is likely to continue. Controversial deaths in mental health facilities and their subsequent inquiries will further fuel speculation as to how best to manage challenging behaviour. This chapter provides an overview of the history of seclusion, its value or otherwise, its alternatives and the necessary supporting policies for its use. It also offers a practical framework within which seclusion may be considered in the context of psychiatric intensive care units (PICUs).

Patients presenting with acute behavioural disturbance pose a significant challenge in terms of management of risk to the patient (particularly when there is potentially life-threatening illness and/or injury) and to others. The consultation-liaison (CL) team offers acute advice and expertise across the general hospital setting and has a key role in policy development in collaboration with medical colleagues to ensure timely and effective intervention for patients presenting with acute behavioural disturbance. This chapter explores aetiological factors contributing to presentations of acute behavioural disturbance and approach to assessment. Behavioural and pharmacological interventions are outlined along with guides for optimising assessment and management of patients with acute behavioural disturbance in the emergency department (ED).

Violence in the acute hospital sector is a common occurrence; however, it is often poorly understood and managed when compared to violence in other healthcare or institutional settings. Aetiological factors, the victim profile and perpetrator profiles vary when compared to other settings. There are particular challenges when considering risk assessment and how violence is managed in these settings. We explore these challenges in the context of staffing, training, environmental factors and the medical model of care. The milieu of an emergency department with high-turnover acute healthcare delivery and the impact this has on violence and its management are also explored. We aim to describe the extent of the problem and provide recommendations specific to the challenges faced in the acute hospital setting, with learning being applied from outside sectors. The topical subject of acute behavioural disturbance/excited delirium is also discussed.