The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder. There is a focus on three key interventions: de-escalation, pharmacological interventions pre-rapid tranquillisation and rapid tranquillisation (intramuscular and intravenous). Most of the evidence reviewed relates to emergency psychiatric care or acute psychiatric adult inpatient care, although we also sought evidence relevant to other common clinical settings including the general acute hospital and forensic psychiatry. We conclude that the variety of options available for the management of acute disturbance goes beyond the standard choices of lorazepam, haloperidol and promethazine and includes oral-inhaled loxapine, buccal midazolam, as well as a number of oral antipsychotics in addition to parenteral options of intramuscular aripiprazole, intramuscular droperidol and intramuscular olanzapine. Intravenous options, for settings where resuscitation equipment and trained staff are available to manage medical emergencies, are also included.

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Objectives-To report on the extent and nature of acute MDMA (ecstasy) related problems presenting to a large London hospital's accident and emergency (A&E) department. Method-The computerised attendance records for all patients attending the A&E department over a 15 month period were retrospectively screened. Potential cases thus identified had their case notes systematically reviewed to confirm the history of MDMA use and to extract other relevant data. Results-Forty eight consecutive MDMA related cases were identified. All were in the 15-30 year age group with the majority presenting in the early hours at weekends and having consumed the drug at a night club. The mean number of tablets consumed was two and almost 40% had taken MDMA before. Polydrug use was common with half of the sample having concurrently taken another illicit substancemost commonly other stimulants (amphetamines and cocaine). A wide range of adverse clinical features was found. The most common symptoms were vague and non-specific such as feeling strange or unwell, however many patients had collapsed or lost consciousness. The most common signs elicited were related to sympathetic overactivity, agitation/ disturbed behaviour, and increased temperature. The more serious complications of delirium, seizures, and profound unconsciousness (coma) were commoner when MDMA was used in combination with other substances. Conclusions-For young adults presenting late at night at weekends and exhibiting symptoms of sympathetic overactivity, disturbed behaviour, and increased temperature ("Saturday night fever") the use of stimulant dance drugs especially MDMA should be suspected. As MDMA use does not appear to occur in isolation, the clinical picture is likely to be complicated by multiple rather than single drug ingestion. This poses increased diagnostic and management challenges for A&E staff who typically represent the front line response to dance drug related problems. (JAccid Emerg Med 1998;15:322-326)

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More than 30% of patients with psychotic disorders who are refractory to antipsychotic treatment also fail to respond to clozapine. Despite the high prevalence of smoking and caffeine use in the psychiatric population, these habits are usually overlooked as factors contributing to antipsychotic treatment failure. We describe 2 male patients with severe treatment-resistant psychosis, one with schizophrenia and the other with bipolar affective disorder-both of whom smoked heavily, and the latter also consumed enormous amounts of caffeine-whose symptoms were refractory to clozapine. Both patients experienced a major, sustained amelioration of their psychotic symptoms when clozapine treatment was recommenced under supervision in the inpatient setting and the pharmacological interactions between clozapine, smoking, and caffeine were considered. Therapeutic strategies included gradual increases in daily doses of clozapine, monitoring clozapine plasma levels, using single daily doses of clozapine at night, and augmenting clozapine treatment with low doses of amisulpride, a selective antagonist at the dopamine D2 and D3 receptors. Smoking and excessive caffeine use are associated with poor therapeutic responses to clozapine and should be considered in the pharmacological management of treatment-refractory psychosis, regardless of the primary diagnosis.

Cross-cultural investigation in psychiatry is revealing the need for standardised instruments in diagnosing and assessing depression. Recently, a new instrument was developed to evaluate depressed patients, namely the Montgomery-Asberg Depression Rating Scale (MADRS). The present study introduced the MADRS in Brazil, comparing it to the Hamilton Depression Rating Scale, the Visual Analogue Mood Scale (a self-rating scale), and with the global clinical assessment of independent Brazilian psychiatrists. The results show correlation between MADRS and the three other assessments, indicating that it is a useful and operational instrument to evaluate depressed patients. They also support the application of the MADRS in cross-cultural studies of depression in Brazil and other countries. These results are critically discussed.

Clozapine is the most effective antipsychotic for treatment resistant schizophrenia but adverse reactions to clozapine include neutropenia. The current COVID-19 pandemic may raise specific concerns for clinicians prescribing clozapine for patients who need it. We report on two actively psychotic patients with treatment resistant schizophrenia who required admission to our inner-London acute psychiatric unit during the COVID-19 pandemic and who were treated with clozapine. One was a young patient who developed COVID-19 symptoms and tested positive for the SARS-CoV-2 virus while receiving clozapine and the other was an aging man who tested negative for the SARS-CoV-2 virus but had contact with COVID-19 during initiation of clozapine treatment. Both responded to clozapine treatment and were safely discharged from hospital without any complication. These cases suggest that, in the absence of complications, exposure to COVID-19 per se and the onset of mild symptoms in those infected may not warrant withdrawal or postponement of clozapine treatment when this is indicated.

Ukraine, a nation of 48 million, became independent in 1991 following the collapse of the USSR. Ukraine still lags far behind many European countries in absolute income per capita and indices of transparency and corruption in public life, but its economy, grounded on robust industrial and agricultural resources, has grown 10% annually in the past 4 years. The extraordinary developments associated with the 2004 presidential elections and the Orange Revolution mean that democracy is now at the core of the state-building process and that Ukrainians are ready for radical changes. These changes are bound to include the principles and methods that have long prevailed in Ukrainian psychiatry.