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.

Firesetting is traditionally a forensic problem which is nevertheless a frequent co-morbidity within mental health settings. The associations between mental health and firesetting are diverse and poorly understood, and with forensic services under increasing pressure, non-forensic settings may be increasingly expected to manage such presentations. With this in mind, and in the absence of a specific risk assessment tool, we propose a care pathway and rationale for its use in the assessment and management of individuals with firesetting behaviours as part of their presentation.

Aims: To conduct a survey investigating the provision of psychiatric intensive care within NHS medium secure units in England and Wales, gaining preliminary information about PICU size and clinical structure, and using this information to inform a discussion regarding PICU provision in medium security.

Method: A postal survey was conducted.

Results: A total of 30 MSUs were identified. The three groups of MSU differed significantly in size. Half of the MSUs surveyed either had a PICU or were developing one. There was a great variation in clinical service structure.

Discussion: There appears to be a growing trend for the provision of intensive care within medium security. Possible explanations for this movement are discussed. Reasons for PICUs not being developed are also explored. Forensic psychiatry needs to consider whether the national standards are appropriate for medium security. Further research is required to understand the reasons for the changing practice that we have identified, to develop a base of knowledge to inform service structure and to investigate the effects of different structures on clinical outcomes.

To determine the nature of psychotropic medication routinely prescribed in Scottish PICUs, the medical notes and prescription charts of 75 patients from 10 out of 14 units were consulted. These included 55 males (73%), the majority of whom were detained and had a diagnosis of schizophrenia. There was good conformance with mental health legislation treatment plans (T2/T3 forms) with only five instances of non-conformance identified. Antipsychotics were prescribed to 60 patients (80%) of which olanzapine and zuclopenthixol decanaote were the most common. The average number of regular psychotropic medicines prescribed per patient was two. In total, 14 drugs, encompassing 21 formulations, were prescribed for PRN use. Lorazepam and haloperidol were the most common PRN medicines. 76 PRN prescriptions (32%) had the oral and IM doses written on the same line of the prescription chart and showed no allowance for bioavailability when detailing the maximum dose that could be administered. 16 patients (21%) were prescribed more than one antipsychotic. Seven patients were prescribed high dose therapy, but this increased to 25 when PRN antipsychotics were included. This study provides information about psychotropic medication prescribing in Scottish PICUs and highlights areas where practice is sub-optimal.

An evaluation of the Extra Care Area (ECA) in a medium secure psychiatric facility for women is described. A retrospective case note audit over an 18 month period concluded that the ECA was used infrequently for the most disturbed service users who had previously been frequently secluded. Ongoing self harm and aggression in ECA was a feature of some cases raising the possibility that admission may be counter productive for some, particularly when it is combined with a lack of occupational stimulation. Service users valued the opportunity for reflection in a low stimulus environment and there were no repeat admissions. A number of initiatives to improve multidisciplinary care planning, documentation, therapeutic engagement and service user involvement to reduce risk have been actioned. Of particular importance is the need to begin ‘discharge planning’ at the first point of entry to avoid prolonged stays, isolation from peers and dependence on both individual staff attention and a special status living arrangement.

The exceptional use of a Taser by the police on a low secure unit, and the extent to which the clinical team had gone to in managing the man, is described. A companion article discusses clinical and ethical aspects to taser use in psychiatry.

Aims: To measure how the opening of a new PICU affected the clinical activity of the local acute in-patient psychiatric wards.

Method: Retrospective analysis of Trust statistical reports.

Results: The opening of a PICU was associated with small and temporary reductions in disturbed behaviour and detained patient numbers on the acute wards.

Conclusions: Opening a PICU appeared to have little long term effect on the clinical activity of the other hospital wards. It is likely that any effects of the PICU were obscured by the many other factors impacting on acute ward activity.

In England and Wales, the law allows a mentally disordered person who is in a public place and requires care or control to be taken to a Place of Safety (POS) for assessment. Historically the POS has usually been the police cells but recent policy development has supported the provision of alternative POSs. In this article we describe how a new POS was set up on a hospital site in Gloucestershire.

Rapid tranquillisation (RT) aims to quickly calm the severely agitated patient, in order to reduce the risk of imminent and serious violence to self or others. While it is widely used within mental health care settings, there is little published information on patterns of practice. Retrospective data collection identified a total of 2267 incidents of RT within the Central and North West London NHS Foundation Trust over a 19 month period equating to a mean frequency of approximately four incidents per day. These incidents mainly occurred in acute inpatient services and two and a half times more frequently in PICUs than on open wards. Of all the PICUS, the female PICU used most RT. Intramuscular RT was reported more often in most services. Restraint was used in 57% (n=1300) of RT incidents and minor injury resulted in only 11% of these incidents overall. There were no reports of major injury or death in the data set. Variations in RT use were seen across the Trust’s geography and ward types.

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.

Ward round is an integral platform for patients and the multidisciplinary team to communicate, assess and plan treatment. With such a key process, it is vital that the effectiveness of the ward round is maximised and that reliable follow of information is addressed. This can be achieved using lean methodology.

Background: Both the National Health Service (NHS) and the private sector provide psychiatric intensive care. To date little is known about the differences between the two sectors regarding the unit functioning and characteristics of patients who are accommodated in psychiatric intensive care units (PICUs).

Aim: To compare the unit and patient characteristics of NHS and private PICUs.

Method: A cross sectional census day postal design was employed.

Results: A total of 170 PICUs (154 NHS, 16 private) were identified. NHS PICUs accommodated 1038 patients and the private PICUs housed 200 patients. Analysis of the data showed that some differences existed between the two sectors related to unit characteristics. Private units reported having higher number of beds, more nursing staff, more unit facilities and more out of area referrals than the NHS Units. Regarding the patient characteristics, private PICUs had significantly more patients with personality disorders and forensic history than the NHS PICUs. NHS patients had a shorter length of stay compared to those in the private sector. The demographic profiles of NHS and private PICU patients were similar. The majority of the patients were white, male, unemployed and single.

Conclusion: The NHS and the private sector PICUs share many characteristics in terms of unit functioning and patient characteristics, however, some significant differences between the two sectors have also emerged.

Background: The role of psychiatric intensive care units is well established for the general adult psychiatric population, but these units are often less suitable for the elderly psychiatric population. An increase in the number of behaviourally challenging demented male patients in the elderly psychiatric admission wards of one Scottish health region created an opportunity to develop a psychiatric intensive care unit for elders with these problems (PICUe).

Method: Prospective survey of activity in the PICUe during 2005, using routinely collected data.

Results: 14 male patients, mean age 70 years, were admitted to the PICUe on 17 occasions during 2005, with 76% detained under the Mental Health (Scotland) Act, 1984. The majority (43%) of patients had a primary diagnosis of Alzheimer's dementia, 21% with vascular dementia. The main transfer reason was resistive behaviours, with persistent physical aggression being the next most common reason. The average mini-mental state score was 14/30, and the mean duration of patient stay in the PICUe was 46 days, with 71% of admissions discharged from the unit during the evaluation period. Benefits were noted for referring clinical teams and for patients.

Conclusions: The results suggest that a regionally-based psychiatric intensive care unit for older adults can serve a useful function in the management of disturbed elders who are otherwise difficult to manage within the current hospital-based elderly psychiatric care facilities.

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.

Psychiatry, behavioural disturbance and risk management have conceptually coexisted for hundreds of years, however, prior to the 1800 Criminal Lunatics Act, drafted exigently following an attempt on the life of the then King by the “insane” Hadfield, the only means of care was custodial, under arcane vagrancy legislation, such as the 1714 Vagrancy Act, or on the basis of the poor laws. Mentally disordered individuals were either incarcerated as criminals or paupers (Select Committee, 1807) falling under the responsibility of local parish councils. At this point, incarceration was just that, with prisons hosting most detained mentally disordered individuals, under the indefinite see of the monarch. The first vision for caring, secure, environments for mentally disordered individuals was in the development of asylums following the 1808 County Asylums Act, which recognised that detaining, “lunatics and other insane persons…in Gaols, Houses of Correction, Poor Houses and Houses of Industry, is highly dangerous and inconvenient.”