Our guidance will focus on the use of medication as an emergency response – i.e. rapid tranquillisation – but we will also briefly discuss the use of medication in the management of the risk of violence in the medium to longer term. We suggest that our guidance is read in conjunction with the 2005 NICE guidelines.

General principles for prescribing medication to prevent or control violence

The use of medication in the control of violence is only one part of a comprehensive treatment plan to manage the risk of violence that includes an assessment of environmental factors and the use of other therapies.

Medication should not be used to manage aggression caused by identifiable environmental factors (such as understaffing or lack of staff skills) that can be dealt with by other means.

Good practice principles in prescribing medication to prevent or control violence include the list below.

1. • Medication should only be used when the risk of not using medication is judged to be greater than that arising from its use.

2. • The indication for which any pro re nata (p.r.n.) medication is prescribed should be clearly stated.

3. • The lowest dose compatible with effective treatment should be used.

4. • The dose prescribed should be individually tailored for each patient; for example, older patients generally require lower doses of antipsychotic medication, and comorbid physical disorders and concomitant medication may influence the dose (and type) of medication prescribed.

5. • The choice of medication used should also be individually tailored to the patient and informed by a knowledge of their psychiatric and medical history, mental and physical state, treatment history, any existing advanced directive, and after an attempt has been made to establish a provisional diagnosis.

6. • As few medicines as possible should be used.

7. • The use of combinations from the same class of medicine is often unnecessary and should be avoided if possible.

8. • Patients should be regularly monitored for side-effects of medication, and both regular and as required (p.r.n.) medication should be reviewed on a regular basis.

9. • If there is evidence that the medicines prescribed are unnecessary or ineffective then they should be reduced and discontinued.

10. • The use of medicines outside their licence, or above maximum recommended dosage (either alone or in combination), is the responsibility of the individual practitioner who should undertake the recommended safeguards in relation to documentation of indications and consent.