Our objective is to overview the literature and introduce the Intentional Relationship Model (IRM) as a new framework for psychiatric intensive care. We present a case application of this model with a suicidal service user undergoing rehabilitation for a spinal cord injury. The example illustrates how IRM may be used to guide clinical reasoning when working with acutely distressed service users.

Two stays in different psychiatric hospitals left me with very differing experiences of severe mental illness. The impact of the more severe episode was much reduced due to the positive way in which staff interacted with me. Recovery was impeded during the first episode by the paucity of therapeutic relationships with staff and the absence of control over one’s medical choices. The role of being a patient was very much a negative experience and the memories of which are still with me ten years on. A positive outlook can be enormously helpful when relayed from staff to patients.

Objective: To examine the distribution of length of stay (LOS) in acute psychiatric units.

Method: Analysis of one year of LOS data from twelve acute psychiatric units in New South Wales, Australia.

Main findings: LOS had a complex distribution, with a ‘head’ of discharges within a day, a ‘body’ of discharges that approximated an exponential distribution and a ‘tail’ made up of a small group of patients discharged after very long admissions. There were substantial differences between units in the proportions of discharges classified as being in the head and the tail of the LOS distribution. With regards to the traditional measures of central tendency, the median LOS was affected by the proportion of patients discharged within a day, and the mean LOS was strongly influenced by small numbers of very long stay patients.

Conclusions: A graphic representation of logarithmically transformed LOS values might assist in understanding the LOS of individual acute psychiatric units. A modified median LOS, calculated after the removal of patients staying less than a day, was found to be a simple and reliable measure that can potentially provide a more meaningful measure of LOS than the mean or the median LOS.

The literature describes increasing acuity on inpatient psychiatric wards. This pressure is sometimes implicated in reduced effectiveness of service delivery. Policy changes have resulted in the gradual reduction in the number of inpatient beds. This has been supported by an increase in community mental health service provision with the community now being the preferred setting. This paper reviews current literature to debate the concept of acuity and its usefulness for mental health care in the UK. The findings suggest the concept of acuity can be misleading for services. The effectiveness of inpatient care is dependent on numerous factors, of which acuity is only one component. To focus on acuity as a measure of inpatient care detracts energy and resources from those factors which can impact on and improve inpatient mental health care and serves only to blame service users for being too ill for the service to cope with.

Objective: To explore, using a naturalistic design, the efficacy of typical and atypical antipsychotics in the management of behavioural disturbance in people with psychiatric disorders.

Method: Prospective naturalistic study of 15,278 incidents of behavioural disturbance perpetrated by 1,059 patients, over a two year period.

Results: Typical and atypical antipsychotics did not differ in terms of their efficacy, overall. In terms of specific agents, haloperidol and quetiapine tended to show equal efficacy, with olanzapine being somewhat less effective on two of three outcome measures.

Conclusions: Overall, atypical antipsychotics were as effective as typical agents in the management of acute behavioural disturbance in a mental health setting. Further work is required to determine the relative side effect burden of those agents.

Background: Borderline personality disorder (BPD) is a distressing disorder that is associated with significant morbidity and mortality. Patients with BPD are often admitted to PICUs where psychotropic drugs are usually prescribed to treat trait or state dependant symptoms.

Aims: To review the evidence base for the efficacy of psychotropic drugs in borderline personality disorder.

Method: Medline and Cochrane search covering the period 1966 to March 2003.

Results: Nineteen RCTs and a large number of case reports, case series and open studies were retrieved. Numerous different treatments have been used, each in a small number of patients. Open studies often report remarkable efficacy that is not reproduced in randomised controlled trials.

Conclusions: The initial placebo response to any drug treatment is high but symptoms invariably return leading to the addition of further psychotropic drugs. Long term gains from drug treatment are likely to be small in the majority of patients. Large pragmatic trials of drug treatments could be co-ordinated through the PICU network.

Declarations of Interest: None.

The role of the internet is increasingly pertinent in the daily lives of both clinicians and patients. We present two case reports, concerning patients recently presented to our service, involving beliefs concerning the social media website, Facebook. We consider the basis of a delusional experience from both categorical and dimensional perspectives. We consider the context of the nature of social networking media and the internet, including examples of how it has been used therapeutically, as well as the potential for detrimental use. Whilst keeping the principle of a delusion in mind we also explore some of the challenges that are presented in the assessment of such beliefs and how, or indeed whether, to incorporate them into the understanding of a patient's presentation. We also briefly consider the impact that beliefs arising from and incorporating social media and the internet may have on the practice of clinicians, descriptive phenomenology research, diagnosis and management of mental disorder.

Current western involuntary hospitalisation legislation is based on legal philosophy and the freedom of the individual. Legislation based on medical philosophy, which focused on the need for care has been deposed. Formerly, doctors had greater authority, but with this came the difficulty of balancing the opposing agendas from various quarters. This role has been adopted by Mental Health Tribunals. Eventually, doctors accepted the new system, which in some ways made their lives easier. They continue to be concerned that the emphasis on freedom leaves some non-dangerous disorganized patients without care.

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.

This article discusses the methodology used to engage a group of patients in a low secure unit in a research project to evaluate the effects of methods of observation.

The results are summarised, and some surprising themes from the interviews are reflected upon.

This very small scale, qualitative study suggests that patients in secure units can be meaningfully engaged in research; and this must continue, as this project has demonstrated that these patients have views which other published research has not brought to light.

New psychoactive substances (NPS) or ‘legal highs’ are defined as unregulated psychoactive substances including synthetic and/or plant derived substances (marketed as research chemicals, party pills and herbal highs) that are intended to mimic the effects of controlled drugs. Psychiatric services around the country are seeing a rise in the use of NPS complicating mental health presentations. The challenge surrounding these substances is the fact that they are not under the international drug control system and are proving to have a detrimental health effect on users. This article reviews the current literature on this subject and discusses some of the most common examples of NPS and their potential effects on mental health.

Background: The highly prevalent comorbidity of substance use disorders and psychiatric disorders represents challenges concerning diagnosis and treatment in acute psychiatric wards.

Aims: To study the feasibility of the first Norwegian version of the Psychiatric Research Interview for Substance and Mental Disorders (PRISM) in an acute psychiatric ward.

Methods: 61 consecutively admitted substance abusing patients, presenting with mood symptoms, psychotic symptoms, or both, were interviewed. Assessments included variables concerning the way the interviews were carried out.

Results: 51% of eligible patients were interviewed. The main reason for non-inclusion was short stay on the ward. Median interview time was 155 minutes and median number of interview sessions was three.

Conclusion: It was possible to use the PRISM in a busy acute psychiatric ward. Patients mainly had positive reactions to this extensive interview.

Patients can be referred at any time of day or night for acute care in an inpatient setting in a psychiatric hospital. The time of arrival at an acute psychiatric care unit has not previously been studied. We studied all referrals (1323) of 1027 individual patients to our unit in 2005 according to time of arrival at the unit.

Between 08.00 and 16.59 51.6% arrived, between 17.00 and 00.59 39.1%, and between 01.00 and 07.59 in the morning 9.3%. Mean length of stay was lowest for patients arriving at night. 637 referred patients were female and 686 male. This was not different from the representation in the catchment area population. Females had longer mean stays than men, 11.3 versus 9.4 days, but more men than women were referred during the year. 19.4% of referred patients ended their stay within the first day; two referrals lasted for more than 100 days. Patients referred between 01.00 and 07.59 ended their stay within one day in 39.0% of cases, and within seven days in 76.4% of cases.

Almost half of all patients arrived when all therapists except the doctor on duty, who is in training, had left the unit.