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We review key recent research and guidance for staff working with acutely disturbed psychiatric patients. Assessment of aggressive patients and their situation should enable full risk assessment, which may ideally involve the use of advance directives. We discuss appropriate use of the Mental Health Act 1983 and consider benefits and adverse effects of rapid tranquillisation. We present a simple protocol for oral or intramuscular rapid tranquillisation. Staff using physical restraint should be properly trained and consider sensitively issues of the patient's diginity, gender and the most appropriate location for restraint to occur. Simple precautions can improve safety when working with potentially disturbed patients. Staff need support during and after the management of an aggressive incident.

The treatment of acutely disturbed patients is a stressful area of psychiatric practice. Castleet al(1994) found that MRCPsych Part II trainees expressed a general dissatisfaction with training in the management of violence, and in our experience junior trainees are even less confident in the treatment of the disturbed patient. A survey by Cunnane (1994) found that no consensus exists among consultant psychiatrists on which drug treatment is most appropriate for the management of the aggressive, acutely disturbed psychotic patient. There was uncertainty as to optimal management, low expectation of quick results, unwillingness to express an opinion and the use of drug cocktails of dubious rationale.

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.