Authors' reply

We are keen to encourage a wider discussion of the issues around the treatment of patients admitted to psychiatric intensive care units (PICUs) and welcome the opportunity to address points raised by Acharya & Sadiq. In writing the paper ¹ we made a series of judgements about how best to present a large volume of data in an easily assimilated form and we are sorry if some of these decisions led to a lack of clarity.

One of the main findings of the study was that most PICU patients are safely managed without recourse to forced intramuscular (IM) medication, indeed that some patients are managed without any psychotropic medication at all. The study only collected data about treatment while the patients were in a PICU (this was a pragmatic decision as many patients came from and returned to distant units where data collection was not feasible). We suspect that some of the patients who did not receive any psychotropic medication in the PICU had received medication before transfer, possibly in the form of medium- or long-acting antipsychotic injection. Others will have received medication after transfer to the acute ward. The diagnoses of those patients who did not receive any medication were: schizophrenia (1), depression (2), drug-induced psychosis (1), substance dependence (2), personality disorder (2), anxiety (1) and adjustment disorder (1).

The numbers in Table 1 do not always add up to 100% because some patients appear in several categories, for example: they were given IM rapid tranquillisation and IM zuclopenthixol acetate. All figures were rounded to the nearest 0.5%; with this caveat we are confident that the appropriate figures (from text and table) do add up to 100%.

The primary diagnoses of patients aggregated into the category ‘other’ were: learning (intellectual) disability, dementia, Asperger syndrome, obsessive-compulsive disorder, anxiety, adjustment disorder, and intoxication with drugs or alcohol.

We address the legal status of the patients and the level of behavioural disturbance more fully in a companion paper. ² With respect to the legal status of the patients, the findings were: 10 informal (3%), 7 on Section 5(2) (2%), 123 Section 2 (37%), 158 Section 3 (48%), 1 Section 4 (<1%), 9 Section 37 (3%), 19 a range of forensic sections covering different transfers from prison (6%).

With respect to measurement of behavioural disturbance and mental state, we used the Brief Psychiatric Rating Scale (BPRS) and those subscales (hostility score, three-item Factor V cluster and five-item hostility cluster) which focus on behavioural disturbance. The mean BPRS score fell from 58.2 on admission to 39.8 on transfer from PICU; the respective figures for the hostility score, Factor V and hostility clusters were: 4.2 to 1.8, 9.2 to 5.5 and 17.3 to 11.1.

We hope that these details clarify the points raised by Acharya & Sadiq.