A community treatment team, offering rapid assessment and intensive home treatment as an alternative to admission is described. The relationship between diagnosis and outcome was examined, in terms of initial ‘take on’ rates, admissions to in-patient areas at both initial assessment and subsequently.

There was a significant relationship between diagnosis and outcome, with marked variation between diagnostic categories.

Home treatment teams prevent admissions with the majority of people from all diagnostic groups, but less successfully with people with personality disorder.

We examined the local impact of introducing a home treatment team on the use of in-patient psychiatric resources and rates of detention under the Mental Health (Care and Treatment) (Scotland) Act 2003.

Rates of admission to hospital and duration of hospital stay were unchanged. However, there was an increase in episodes of detention in the year following the team's introduction.

Offering home treatment as an alternative to in-patient care may be associated with an increase in compulsory treatment. If true, this is incompatible with the ‘least restrictive alternative’ principle of the recently revised mental health legislation.

To develop and introduce a drug treatment protocol for schizophrenia and to evaluate its effect on prescribing. Prescribing of antipsychotics was audited in January 1998. A prescribing protocol was then developed by a collaborative process involving all medical staff, and introduced in September1998. A second prescribing audit was conducted in February 1999.

The proportion of patients prescribed atypical drugs increased from 16.6% to 25.5%. Co-prescription of atypical and typical drugs was relatively uncommon compared with findings of other prescribing surveys. The use of anticholinergic medication was significantly more likely in patients receiving regular typical drugs alongside atypical agents than in those receiving atypicals alone.

Widely agreed prescribing protocols may promote improved prescribing practices. Co-prescription of atypical and typical drugs should be discouraged.

We describe two patients, both diagnosed with psychotic illnesses, who developed stuttering while being treated with clozapine.

In both patients the stuttering was severe and significantly impaired progress towards recovery. Deviant speech dimensions and voice quality were consistent with dysarthria and dystonia.

Patients who develop abnormal electroencephalogram activity and those who have a family or personal history of stuttering might be at increased risk of developing speech problems with clozapine. Speech dysfluency might be a consequence of clozapine's action in lowering the seizure threshold. Potential management strategies include the use of sodium valproate and changing the type of antipsychotic.

An ‘assertive approach’ to clozapine, where nasogastric administration is approved, is assessed through a case-load analysis to provide the first systematic description of its use and outcomes worldwide.

Five of the most extremely ill patients with treatment-resistant schizophrenia were established and/or maintained on clozapine, resulting in improvements to their mental state; incidents were reduced, segregation was terminated and progression to less restrictive environments was achieved.

Despite being underutilised and rarely enforced, in extreme circumstances, an assertive approach to clozapine can be justified. Nasogastric clozapine can be safely delivered and the approach itself, rather than actual nasogastric administration, may be enough to help establish and maintain patients with treatment-resistant schizophrenia on the most effective treatment.

E.S. has received speaker fees from Jansen Pharmaceuticals and Novartis.

This paper describes the prevalence of substance misuse in a population with chronic psychosis and compares the results with staff estimates. Keyworkers were interviewed using validated questionnaires.

The prevalence rate of substance misuse was higher than in the general population but significantly lower than staff estimates. Staff had little specific training or experience in treating substance misuse.

Substance misuse is a significant problem among patients with chronic psychosis. Service providers should ensure than staff working with these patients are adequately trained in the management of this problem.

In view of plans to reform Mental Health Act legislation to allow compulsory treatment in the community, we examined the views of service users about this form of care, and the most acceptable setting for its delivery. A cross-sectional survey of patients discharged from two in-patient units in West London over a 5-month period was carried out.

Half of the 109 respondents stated that compulsory treatment was justified under some circumstances; 103 people told us where they would prefer to receive compulsory treatment – 49 in their home, 41 in hospital and 13 in a community treatment centre. The most commonly stated reason for favouring home treatment was dislike of in-patient care.

Compulsory treatment in the community may provide a means of improving patient experiences of non-consensual care. However, a significant minority of service users would rather this form of treatment was restricted to in-patient units. Continuing efforts are required to improve patient experiences of in-patient care.

To understand general practitioner (GP) reticence to refer older patients to a local Improving Access to Psychological Therapies (IAPT) service providing mostly cognitive–behavioural therapy (CBT)-based interventions. Semi-structured, hour-long interviews were conducted with eight GPs and then analysed by modified grounded theory and thematic analysis.

GP views regarding the treatability of older adults with CBT influenced their willingness to refer to a CBT-based IAPT service. Perceptions of local IAPT assessment processes being distressing and onerous to older patients also motivated referral inaction. GPs expressed a preference to treat depressed older patients themselves (with medication and psychological approaches such as watchful waiting).

Any strategy to increase referral rates of older adults to CBT-based IAPT services should address local GP concerns regarding assessment processes and the effectiveness of offered treatments.

None.

To describe the clinical and demographic characteristics of all in-patients experiencing delayed discharge over 3 months in an English urban mental health National Health Service trust. We carried out a cross-sectional case record study with care coordinator questionnaire.

Overall, 67 in-patients with delayed discharge occupied 18.6% of acute beds. Older in-patients were White, diagnosed with dementia and experienced relatively short admissions. Younger in-patients were often of Black and minority ethnic background with a psychotic diagnosis and long service contact, and sometimes experienced very long admissions. They were similar to a long-stay comparison group. The whole cohort was socially isolated and marginalised, and frequently misused alcohol.

People with complex mental health problems can experience long stays in acute care settings. This particularly affects people with psychosis who are isolated in the community. Alcohol misuse is the most common complicating factor. There are insufficient community-oriented rehabilitation services to meet these patients' diverse needs.

To gather opinion from trainees across England about their current experiences and future career plans. This was done via an internet-based survey.

Out of the 359 responses we received, 65.8% of trainees planned to stay in psychiatry until retirement. Trainees felt several issues were problematic, including the attitude of other specialties towards psychiatry, perceived substandard treatment of psychiatric patients by other specialties and implications of New Ways of Working.

Despite there being many areas of training respondents were happy with, if attrition is to be minimised, issues such as how psychiatric trainees integrate with the other medical specialties and how the role of doctors in the specialty is perceived need to be addressed.