Therapeutic engagement involves healthcare professionals spending quality time with patients and aims to empower the patient to actively participate in their care. This project was commissioned by the National Institute for Mental Health in England (NIMHE) Acute Care Programme in order to gain a greater understanding of how this process is successfully achieved and maintained on psychiatric wards. The NIMHE acute care lead in each regional development centre was asked to nominate wards that they thought were accomplishing a high level of therapeutic engagement. From this selection, a steering group identified seven ’positive practice units’ that were suitable for inclusion in the study.

Representatives of the multidisciplinary teams (MDT) who worked on the positive practice units took part in focus groups, which discussed the practices employed on the units to engage patients. Thematic analysis was used to code the data and raise themes. The themes that emerged from this analysis were: Respecting and empowering patients; Staff being ’available’; Engagement-focused observation; Good MDT working; Therapeutic work; Services for discharged patients; Embracing change. The study concluded that the positive practice on the units was the result of having a dynamic ward culture which was grounded in having empathy for patients and supporting staff.

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.

Aim: To follow up a series of patients admitted to a low secure mental health unit for challenging behaviour. Method: Clinical outcome measures (Health of the Nation Outcome Scale (HoNOS), Global Assessment Scale (GAS) and Staff Observed Aggression Scale (SOAS)) and keyworker interviews were used to follow up the progress of patients at least one year after discharge. Results: 33 patients had a mean time since discharge of 43 months. The typical patient was a man with a history of violent offences, admitted from an open ward because of aggression. The observed improvement on HoNOS and GAS during admission had been maintained at follow up. There had been no re-convictions. All patients were compliant with medication. Five patients had been re-admitted to hospital during the follow up period. The current placement showed that more of the patients were in the community compared with at discharge. Conclusion: Patients admitted to a low secure unit improved during their stay and this improvement was maintained at follow up.

Psychological trauma and post-traumatic stress disorder (PTSD) are prevalent among adults with severe mental illness, but their impact on the psychosocial and physical health-related impairment of women with major mental illnesses is not known. A sample of 35 low-income urban women receiving community mental health services for severe and chronic mental illness was assessed with psychometrically validated structured interview instruments for psychiatric diagnosis, lifetime history of exposure to traumatic stressors, PTSD, substance use, health-related impairment, and complex psychosocial problems. Exposure to multiple types of traumatic stressors was reported by 98% of respondents, and more than half met criteria for lifetime PTSD (44% for current PTSD). Current PTSD prevalence was highest (>56%) when traumatic loss, sexual abuse, physical abuse, traumatic assault, or community violence were reported. A history of childhood sexual abuse or PTSD or both were associated with use of multiple substances and complex psychosocial problems. Assessment and treatment of complex PTSD appears warranted in psychiatric intensive care and community aftercare for women with severe mental illness.

Aims: To measure the effectiveness of treatment in a low secure challenging behaviour unit and to identify predictors of change.

Method: Routine clinical data and outcome scores were collected on a case series of 86 patients admitted to and discharged from one low secure unit.

Results: Significant improvements were found on Health of the Nation Outcome Scale (HoNOS), Staff Observed Aggression Scale (SOAS) and the Global Assessment Scale (GAS). Improvements in GAS and HoNOS were associated with moves to a lower level of security. Patients with a history of conviction for property damage, cannabis use, who were admitted on a forensic section or with a diagnosis of personality disorder were more likely to move to a higher level of security. Increased length of stay was related to the presence of physical assault, physical health problems and anxiety symptoms.

Conclusions: Clinical outcomes and behaviour improve during admission to one low secure unit and characteristics of the type of patients who respond to this form of treatment are proposed.

Background: There are few studies that describe differences in measures of burden and participation in care relating to whether the relatives live with or apart from the person with a mental illness. Aim: To investigate different aspects of family burden, need for support and participation in care situations specifically considering whether the relative and the patient are living together or apart. Method: 162 relatives (73 relatives of committed patients and 89 relatives of voluntarily admitted patients) answered a semi-structured questionnaire concerning their situation as a relative of a severely mentally ill person. Results: There was increased experienced family burden in several aspects due to the relative and patient living together. However, relatives who lived with the patient were less likely to believe that the patient would be better off dead, experienced more participation in the patient’s treatment and more often viewed the psychiatric services as being of good quality than those relatives who did not live with the patient. Conclusion: Persons with a severe mental illness who are admitted to inpatient units are in need of different aspects of intensive psychiatric care. Some of these needs are supplied by relatives in everyday life, often without any support. In providing for the needs of relatives, in relieving their burden, the psychiatric services needs to implement different methods according to whether the relatives live with or apart from the patient.

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.

Seclusion of psychiatric inpatients is used as a last resort in managing disturbed behaviour. Research on factors contributing to its use is limited. The aim of this study was to examine the effect of a change in unit size and other variables, such as time of day and nursing workload, on the rates of use of seclusion in an intensive care inpatient psychiatric unit. Rates of seclusion were examined in randomly selected nursing shifts across three time periods; one before and two after a change in the size of the unit. Effects on seclusion rates of size, shift and four nursing workforce variables were explored using multivariate analysis. Unit size, shift and nurse hours together explained 23% of the variance in seclusion use. Of particular significance was the change from a 20 bed unit to two separate 10 bed units. The findings have implications for the organisation of inpatient psychiatric units. Smaller units may allow better management of disturbed behaviour.

Background: Physical illnesses are more prevalent among patients with serious and enduring mental illnesses. This is mainly due to the association between mental and physical illnesses, complications of the mental illness itself and as a side effect of medication. Medical problems can be overlooked by psychiatrists due to several reasons. More research and audit of the existing services are necessary to establish the physical needs of patients with complex mental health problems.

Aim: To give an account of the causes of excessive mortality and physical morbidity among patients with serious mental health problems.

Method: Review of the worldwide literature.

Results: Physical problems are more common and the standardised mortality rate (SMR) is higher in psychiatric patients compared to the general population. The main causes are association between mental and physical illnesses, lifestyle including lack of physical activity, smoking and poor dietary habits, metabolic syndrome, diabetes mellitus and other cardiac risk factors. There is a close association between treatment with antipsychotic medication and weight gain, diabetes mellitus, sudden death, cardiac and endocrine complications such as QT prolongation and also hyperprolactinemia.

Conclusion: The paper highlights the importance of monitoring physical problems in patients with serious and enduring mental illnesses. Good practice points include help with smoking cessation, psycho-education about healthy lifestyle, close liaison between carers and professionals, the importance of taking baseline investigations before commencing antipsychotics, a shared care approach with primary care, early identification of the risk factors for physical illnesses and regular monitoring of physical health. Also important are social interventions such as appropriate accommodation and structured day, leisure and sporting activities.

Background and case description: Virchow-Robin spaces are fluid filled perivascular spaces in the brain which are rarely found in asymptomatic children. Their frequency increases with age and they are associated with cognitive decline in otherwise healthy elderly. They are common in high altitude mountain climbers, mild traumatic brain injury and in certain hereditary vascular diseases. In children they are associated with mental retardation, developmental delay and headache. They have been identified in children with autistic disorder.

We describe a 28 year old female with severe catatonia, auditory hallucinations and delusions, and prominent Virchow-Robin spaces, who responded to ECT and olanzapine. Conclusion: MRI was valuable in the management of this case. While prominent Virchow-Robin spaces may have been a coincidental finding (not aetiologically significant) there was loss of brain parenchyma and we believe this contributed to the severity of the presentation and suggests a less favourable prognosis.

Clozapine has been found to be of superior efficacy in treatment-resistant schizophrenia. However, haematological complications of clozapine are much better known than the equally serious cardiac complications. The potential risk of cardiovascular complications persists throughout the duration of clozapine use, as compared to a higher incidence of agranulocytosis being more pronounced during the first year of treatment. We describe a case of a young male with a diagnosis of treatment-resistant schizophrenia who developed clozapine related cardiomyopathy after being maintained on the medication for about eighteen months. The only initial cardiovascular findings were sinus tachycardia on both physical and electrocardiographic examinations. Subsequent echocardiography showed evidence of impaired ventricular systolic function. A repeat echocardiogram, three months post clozapine termination, showed improved ventricular functions. Sinus tachycardia also resolved both on physical and electrocardiographic examination. A high level of clinical suspicion and clozapine withdrawal after an early cardiology liaison proved beneficial in appropriately managing this case. The case report ends with suggestions of good practice points in managing clozapine related cardiomyopathy.

Aims and method: We audited the caseload of an Assertive Community Treatment (ACT) team against National Institute of Clinical Excellence (NICE) guidelines in the treatment of schizophrenia. Care coordinators rated the work carried out by the team on an audit tool. Results were compared to a case note audit completed 2 years earlier.

Results: 61 patients had a primary diagnosis of schizophrenia. Rates of compliance with NICE guidelines varied from 0% (provision of advance directive) to 85% (written information given, no antipsychotic polypharmacy). Compliance was greater than in the earlier audit.

Discussion: When refusal, lack of capacity or indication were taken account of, guidelines were generally adhered to. Although a useful benchmarking process and an opportunity to identify skill deficits in the team, our findings raised concerns about simplistic notions of guideline implementation, as a means to improve practice. Patient choice is an important consideration.

People with SMI have high levels of physical illness and significantly raised natural mortality compared to the general population. This is largely explicable by altered exposure to ordinary environmental risk factors and to poorer quality of medical treatment; partly because SMI can interfere with the individual's ability to organise their healthcare and partly because it can affect the quality of treatment delivered by professionals.

People with SMI can suffer the same range of physical illnesses as anyone else in the population but are at significantly greater risk of developing particular illnesses. Admission to a PICU presents an excellent opportunity for assessment and management of their physical health needs. PICU staff have a responsibility to develop effective mechanisms for identifying and treating acute physical illness, they also need to think about how best to address the detection and management of chronic physical illness and about their responsibilities in respect of health promotion.