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.

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.

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.