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: Psychiatric intensive care units (PICU) are a potentially expensive component of inpatient services, and exists to care for those patients who cannot be easily contained on ordinary acute wards. However, to date there is little evidence on their efficacy.

Methods: Using data from a previous study of 136 acute psychiatric wards in England (City-128) we examined whether ordinary acute wards having access to a PICU had lower rates of adverse incidents, and modelled behaviours associated with PICU transfer rates.

Results: Controlling for other factors, wards with greater ease of PICU access did not have lower rates of adverse incidents. PICU provision is related in complex ways to the use of seclusion. PICU transfers were associated with seclusion, manual restraint and other severe containment measures, and were triggered by aggression, drug use and absconding.

Conclusions: Transferring patients to a PICU may not be an effective means of reducing adverse incidents on acute wards and may not have appreciable cost benefits. However, PICUs may still produce a range of valued outcomes such as injury reduction, more effective and efficient treatment, greater feelings of security on acute wards, and care for patients within the criminal justice system. Larger and more detailed evaluations using longitudinal data are required.

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.

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.

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.

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.

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.

Recent changes in the practice of inpatient psychiatry have minimized the emphasis on psychodynamic principles in the treatment of hospitalized patients. The concepts of transference and countertransference have taken a secondary role to rapid diagnosis, treatment and discharge. This paper explores the impact of countertransference on physician decision-making and clinical care through two case histories illustrating how countertransference can impact the assessment, treatment and management of the psychiatric inpatient. The authors discuss the concept of countertransference, its effect on physicians and hospital staff and strategies for recognizing and minimizing the impact of countertransference.

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.

Background: Staff working on psychiatric intensive care units (PICUs) are routinely exposed to aggression or threats of aggression from the patients they care for. This phenomenon is identified as an ongoing factor that influences both work performance as well as staff sickness, and as such requires understanding and management.

Aims & method: This study utilized questionnaires assessing the extent to which PICU staff thought violence was a problem and how safe and supported they felt. Semi-structured interviews were conducted with five nurses to gather in-depth information on the factors involved in perceptions of safety and support.

Results: The analysis indicated that as a whole, staff feel safe and supported by their immediate team. Interview analysis produced two main domains and ten sub-domains of experiences that contribute to managing threats, these being grouped in either personal or systemic factors. It particularly highlighted that although patient aggression is a concern, the perception of threat most directly relates to beliefs about a lack of support from other teams and senior management, not the patients themselves.

Conclusions: More research and attention is needed on systemic factors in the management of threatening patients.

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.

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: A proposal to introduce metal cutlery onto a PICU in order to create a more homely environment prompted staff concerns about safety.

Aims: Based on the premise that past behaviour is a strong predictor of future behaviour, we undertook a pilot audit of history of weapon use as a measure to guide decision making on weapons security on our PICU.

Methods: Retrospective case note audit of 30 PICU patients to determine historical rates of weapon use. Secondary measures included level and type of weapon use, and mental disorder. 30 ‘non PICU pathway’ general ward patients were sampled as a ‘control’.

Results: 19/30 patients on the PICU had a history of weapon use, compared to 7/30 on the general ward. There were 23 recorded incidents in the PICU sample and 7 on the general ward.

Conclusions: The majority of the PICU sample had a history of weapon use, often recent, including improvised and bladed weapons, at times of acute disturbance and non-compliance with medications. Comparison with the non-PICU group indicates that the measure had good construct validity as rates in this group were significantly lower. Therefore history of weapon use could be a useful measure in guiding decision making about security protocols on PICU, however, further research is required.