Background: People with severe mental illness are at an increased risk of physical health problems including diabetes.

Aims: To identify the proportion of patients with diabetes in specialist secure psychiatric care, establish current practice in diabetes care and management, and clarify the role of the psychiatric medical team versus the on-site general practitioner.

Method: Hospital-wide data collection from electronic and paper case notes of all identified diabetic patients. Audit standards were based on current National Institute for Clinical Excellence guidelines.

Results: 64 out of 548 patients (11.7%) were identified with a diagnosis of diabetes. 18 (28%) of these patients had an individual care plan to address their diabetic management and risk. The majority of patients had regular blood glucose and HbA1c monitoring.

Clinical implications: Patients should receive regular structured education sessions, regular feedback about their own management, and individual care plans that include the management of common and potentially life threatening complications. These are essential components of providing good quality diabetes care. Clinical audit may provide a means of identifying and rectifying problems in relation to diabetes care in long-stay psychiatric inpatients.

Background: Some psychiatric illnesses tend to predispose patients to metabolic syndrome. Some psychiatric medications have been linked with an elevated risk of metabolic syndrome. Metabolic syndrome has an increased risk of cardiovascular disease and type 2 diabetes.

Method: The following data were obtained from the last 6 months’ medical notes of inpatients in two rehabilitation units: waist circumference; BP; fasting blood tests: triglycerides, HDL cholesterol and glucose; psychiatric and medical diagnoses and medication.

Results: 58% of the patients met the criteria for metabolic syndrome. However, due to lack of appropriate physical monitoring in some cases, only 19% had previously been diagnosed. Therefore not all the patients with metabolic syndrome were being appropriately treated or monitored.

Conclusion: A systematic approach to assessment and management of physical health needs in people with severe mental illness is necessary. Suggestions for improvement include: healthy lifestyle encouragement; refer patients with metabolic syndrome to GP for treatment; optimization of current psychiatric treatment; monitor waist circumference, fasting lipids and glucose 4 times a year if patient has ≥ 3 criteria, or twice yearly if patient has 0–2 criteria; monitor BP monthly for all patients.

This article provides review evidence that cannabis use potentially leads to psychosis in vulnerable people, especially if started in adolescence. Possible modes of action and biochemical mechanisms are suggested. The dangers of cannabis, especially for PICU/LSU patients, are discussed and ways forward in PICU/LSU care are suggested.

Tasers are tools of law enforcement. With their increasing use, Tasers may also be deployed on those occasions where the person is both threatening and mentally ill. This article considers various ethical propositions and describes the ability of psychiatry to minimise the use of physical interventions.

This commentary outlines the need for a PICU accreditation system, its development and initial use. The development of a framework that includes clinical outcomes in conjunction with accreditation to measure quality of care is discussed.

Background: Both the National Health Service (NHS) and the private sector provide low secure care. Little is known about the differences between the two sectors regarding the unit functioning and characteristics of patients admitted to low secure units (LSUs).

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

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

Results: The analysis is based on 128 LSUs (98 NHS, 30 private). NHS LSUs accommodated 1084 patients and the private LSUs accommodated 359 patients. Analysis of the data showed that some differences existed between the two sectors related to the number of beds, unit facilities, interventions and the referral-discharge route. The demographic characteristics of NHS and private patients were similar. The majority of patients were white, male, unemployed and single.

Conclusion: Although the NHS and the private sector LSUs work similarly and share many characteristics in terms of the unit functioning and the patient characteristics, a few very significant differences between the two sectors have also emerged.

Aims: To find out what other acute ward in-patient staff think about the role and activity of the Psychiatric Intensive Care Unit (PICU).

Method: A semi-structured questionnaire administered to a selected group of in-patient staff.

Results: Respondents were generally pleased with the PICU. Their views about its role were similar to those of the Department of Health. Many staff were significantly anxious about the possibility of having to work or attend an incident on the PICU.

Conclusions: Acute ward staff have realistic views on the role of a PICU. Many staff view the PICU as different to the rest of the in-patient unit and want to have as little to do with it as possible. This could cause serious problems for the safe running of the PICU and needs to be addressed both by the hospital managers and the PICU staff.

While eating disorder symptomatology may be part of a broader picture of challenging behaviour for women admitted to secure care, little is known of the nature and incidence of such conditions. A survey of 131 women admitted to a secure psychiatric facility found 25 to have a recognized eating disorder, most with a diagnosis of eating disorders not otherwise specified (EDNOS) or binge eating disorder. However, few staff had experience of working with such patients and most expressed a need for training and support with such cases. The clinical and training implications of these findings are discussed.

This practice evaluation paper will present the case for the use of trampolining as a therapeutic activity within an acute care setting for people experiencing mental ill-health. A brief history of this activity within a therapeutic context will be outlined and a theoretically analysed rationale for the development of trampoline sessions explained. A case vignette will illustrate the argument that trampolining is a realistic and therapeutic option for people who need the care of a Psychiatric Intensive Care Unit (PICU) or Low Secure Unit (LSU). The paper will conclude that service users can find trampoline activity useful as part of a recovery journey from acute mental illness.

Problems in the acute sector of psychiatric care are not unique to the Netherlands and at an international level appear to be linked to problems that are significant for big cities. The search for an “acute bed” had become more difficult and patients were being placed and transported through the whole country. The three mental health care institutions in Amsterdam joined forces and opened a gateway facility in order to confront the pressure on admissions. The object??ive of this facility was to create a buffer for the relief of acute compulsory admissions and thus reduce the period that patients had to stay in police cells and decrease the number of placements outside the Amsterdam region.

In this article the goals, patient groups and achievements of this interim facility, called the Temporary Admission Unit (TOA), are described.

The TOA has proved to be able to fulfil its promise to function as a buffer towards the secure admission units in Amsterdam. For a small group of patients (13%) a short admission period on the TOA is sufficient and they can be discharged immediately. The average occupancy rate of the beds of 5 (out of 8 beds) means that the TOA can usually guarantee availability of beds for acute admissions. Between 2000 and 2002 the number of guest placements outside Amsterdam has drastically lowered, along with a gradual rise in the number of compulsory admissions. Finally, the waiting time in the police stations has been diminished considerably.

The advantages of the TOA are clear. Expensive (nocturnal) ambulance transport can be avoided. The stay in the police cell is reduced and the patient arrives in a facility where psychiatric care is available with greater speed. Contact with a regular therapist and therefore continuity of care guarantees a better situation than when the patient is admitted in a distant facility. The same holds good for family contacts.

This article describes in detail the service delivered by the Multidisciplinary Team at the Montpellier Low Secure Unit in Gloucester. The development of the service, the physical environment and the admission criteria are described. The article focuses on the stages of treatment experienced by the patient namely: assessment, ongoing care and treatment and pre discharge planning.

Little is known about the types of patients admitted to medium secure psychiatric intensive care units, which cater for some of the most mentally disordered and dangerous patients. Only one retrospective study has profiled this subgroup (Dolan & Lawson, 2001).

Using a pre-coded proforma, the study prospectively profiled patient characteristics over a year, for those who were admitted or transferred to the unit. It was predicted that patients detained under Section 3 of the Mental Health Act, 1983 (Civil section) would be overrepresented and present with more management problems.

Information on 24 patients was gathered. Patients detained under Section 3 featured heavily in the cohort and were more difficult to manage, though this did not reach statistical significance. All patients had a criminal history, particularly of violence. Serious adverse incidents on the ward were relatively infrequent. A small number of patients were responsible for the majority of adverse incidents.

The cohort demonstrated serious risk signatures and forensic histories. Management problems may not necessarily reflect underlying mental disorder. There was a trend towards violent offending and co morbid substance misuse. The unit was an effective environment. The study was limited due to low numbers of patients and a lack of comparable populations.

Background: The principle that patients should be cared for under conditions of no greater security than is justified is well established and applies to patients cared for on psychiatric intensive care units.

Aims: This audit aimed to establish: (1) the characteristics of patients admitted to a PICU, (2) whether patients experienced delays in discharge to care in lower levels of security and (3) the characteristics of patients who experienced a delayed discharge.

Method: An audit survey of the case notes of patients discharged from an inner city PICU in 2005 to establish compliance with the standards described.

Results: Of 109 patients discharged from the PICU, 88 were included in the survey. 51.1% of patients experienced a delay in discharge from the PICU. The characteristics of the patients discharged from the PICU are described, and compared with those experiencing a delay in discharge.

Conclusions: Patients often experience a delay in discharge to clinically appropriate levels of security from a typical PICU. The source of referral of patients and diagnosis are associated with a delay in discharge. The findings warrant wider study.

The anti-psychotic drug management of patients with schizophrenia and HIV-1 infection is problematic. Such individuals are prone to extra-pyramidal reactions on account of HIV-1 induced sub-cortical involvement and exacerbation of cognitive impairment due to underlying CNS infection. Compliance with treatment can be problematic due to a disordered mental state and bone marrow toxicity may also result from the combined effects of anti-psychotic and retroviral agents. It is generally thought that atypical anti-psychotic drugs are the treatment of choice in such cases.

We present the case of a 30-year-old man with a history of schizophrenia who was successfully treated with clozapine following an admission to a psychiatric unit with acute confusional symptoms secondary to HIV-related central nervous system (CNS) involvement.