Objectives: To study the frequency of use, indications and reported side-effects of antidepressants in the treatment of adult inpatients at a UK secure hospital.

Methods: Cross-sectional survey of the use of antidepressants for forensic rehabilitation patients, together with structured interviews with the treating psychiatrists.

Results: A total of 94 patients (40.7%) were prescribed antidepressants. The majority (68.9%) were prescribed SSRIs. Antidepressant usage was associated with female gender, depression and emotionally unstable personality disorder. Patients with learning disabilities and pervasive developmental disorders were less likely to be prescribed antidepressants than the rest. Only 10 patients (10.6%) had a formal diagnosis of depression, anxiety or obsessive compulsive disorder. For 67.0% of patients the plan was to continue with the antidepressant long-term. Although 83.0% of psychiatrists said they had asked about side-effects, few (14.9%) had asked about sexual side-effects and only 3.2% of patients were reported as having side-effects.

Conclusions: Long-term antidepressant usage in this population was common. The reported incidence of side-effects was very low and is likely to be much higher in reality. Psychiatrists should make regular inquiry about side-effects, including sexual side-effects when appropriate, as well as regularly reviewing the need for continuing treatment.

Aim and method: To review antipsychotic prescribing practice using selected recommendations from the 2006 Royal College of Psychiatrists’ (RCPsych) consensus statement on the use of high dose antipsychotic medication. A clinical audit of antipsychotic prescribing for patients from two periods, February to October 2005 and February to October 2006, who were discharged from Hollywell PICU at Hillcrest and had received one or more antipsychotic medications whilst an inpatient there.

Results: The proportion of patients receiving a single antipsychotic increased from 9 (31%) in 2005 to 22 (55%) in 2006 and the proportion prescribed high dosages of antipsychotics declined, 10 (33%) in 2005 vs. 3 (8%) in 2006. The number of high dose combination prescriptions also declined, 4 (13%) in 2005 vs. 1 (3%) in 2006.

Clinical implications: The audit illustrates the potential for individual variation in prescribing practice in the PICU environment. It suggests that the Royal College of Psychiatrists’ 2006 consensus statements on antipsychotic prescribing can be used to both benchmark clinical practice and promote evidence based prescribing.

Background: Rapid tranquilisation (RT) is one of the highest risk clinical procedures currently undertaken by mental health services, yet it is underpinned by a surprisingly weak evidence base. The evidence base is weaker still when applied to post RT monitoring.

Aims: To review current clinical monitoring practice contained within adult RT documents in the UK.

Method: A review of adult RT documents currently in use in NHS or HSC trusts providing adult mental health services in the UK.

Findings: A total of 44 RT documents were examined. A picture of wide ranging practice was observed that prevented us from undertaking a full analysis of the data collected. Even when analysis was confined to the intramuscular route, there were concerning differences between documents in: when monitoring was initiated; what was being monitored; and the frequency and duration of this monitoring.

Conclusions and implications for clinical practice: There is a fundamental need for consensus in this high risk practice. The College of Mental Health Pharmacists, Royal College of Nursing and Royal College of Psychiatrists should have a key role in fashioning this consensus in both practice and policy.

Physical interventions, including restraint, are a necessary but controversial component of mental health care. This paper outlines developments in one trust to prioritise this area and take an integrated, whole trust approach. The paper discusses ‘physical interventions’, describes the organisational approach to support the development and outlines the training package developed to promote safe and effective practice. In addition the approach is reviewed using team members' views within the National Patient Safety Agency's seven steps to patient safety. Data on incidences of interventions prior to and following the approach are presented and conclusions and recommendations to further guide practice are proposed.

Background: Structured assessment of risk is a standard element of the core psychiatric assessment, particularly in respect of individuals, who are perceived to be at risk of violence or suicide. Many acute mental health trusts have introduced risk assessment tools, often without evidence of validity.

Aim: To evaluate a tool designed to predict the acute risk of violence by patients detained in a PICU.

Method: A risk assessment form was completed weekly for each patient on the PICU. Multivariate logistic regression analysis was used to measure the predictive value of particular variables in respect of violent behaviour during the next two weeks.

Results: Violent behaviour during the previous two weeks was a significant predictor of subsequent violence. Drug use was a negative predictor. None of the other variables tested were predictive of violent behaviour.

Conclusions: A complicated risk assessment tool probably adds little to the process of predicting acutely violent behaviour in PICU patients. The introduction of procedures such as structured risk assessment tools should be subject to the same validation process as any other clinical initiative.

Belgium has a large capacity of psychiatric beds as compared to most other European countries and is on the verge of reducing this capacity. An accompanying augmentation of assertive community treatment strategies alongside acute crisis resolution has already begun. The latter function has been implemented in recently developed psychiatric intensive care units. Whether this development will result in improved care for psychiatric patients and in a reduction in cost for the government remains unanswered. Outcomes research in psychiatric intensive care is ongoing in the United Kingdom but this is not the case in Belgium. In this commentary we suggest that this moment of change is a perfect time for initiating research on psychiatric intensive care units in Belgium preferably in close collaboration with experienced staff in the United Kingdom.

In this case report, we describe the clinical course of a 16 yr old asylum seeker from Afghanistan who developed paranoid schizophrenia complicated by catatonia and was successfully treated with diazepam and clozapine. To our knowledge, this is the first case report of its kind in this age group.

Our patient became psychotic and presented to A&E after cutting off the tip of his nose in response to command hallucinations telling him to kill himself, his mother and his siblings. His catatonic features, which emerged after hospitalization, were those of mutism, akinesia, posturing including the psychological pillow. He did not respond to risperidone or haloperidol; showed a partial response to lorazepam and diazepam. His catatonic features and psychosis only resolved upon the introduction of clozapine.

We go on to review the literature about catatonia in children and adolescents. We discuss the nosological dilemma with classification, the evolution of treatments and the role of anti-psychotic medication in the treatment of catatonia. Specifically, we advocate the usefulness of clozapine as an adjunct and as monotherapy.

We present the case of a 25-year-old woman who initially presented after committing an assault resulting in serious injury. She exhibited recent onset psychiatric symptoms which were later followed by a rapid deterioration in her physical health. She was treated with electroconvulsive therapy on a medical intensive care unit for a presumptive diagnosis of malignant catatonia. A test for anti-NMDA receptor antibodies returned positive. She was treated with IV immunoglobulin (IVIg) and high dose steroids, then underwent a left ovarian cystectomy. She was subsequently treated on a psychiatric intensive care unit until discharge.