Psychiatry, behavioural disturbance and risk management have conceptually coexisted for hundreds of years, however, prior to the 1800 Criminal Lunatics Act, drafted exigently following an attempt on the life of the then King by the “insane” Hadfield, the only means of care was custodial, under arcane vagrancy legislation, such as the 1714 Vagrancy Act, or on the basis of the poor laws. Mentally disordered individuals were either incarcerated as criminals or paupers (Select Committee, 1807) falling under the responsibility of local parish councils. At this point, incarceration was just that, with prisons hosting most detained mentally disordered individuals, under the indefinite see of the monarch. The first vision for caring, secure, environments for mentally disordered individuals was in the development of asylums following the 1808 County Asylums Act, which recognised that detaining, “lunatics and other insane persons…in Gaols, Houses of Correction, Poor Houses and Houses of Industry, is highly dangerous and inconvenient.”

Background: Low Secure Mental Health Services provide care for highly disturbed psychiatric patients. Little is known about the characteristics of such patients in the UK.

Aims: To perform the first UK wide survey developing a national data set of low secure services.

Method: A cross-sectional census day postal survey design was employed.

Results: A total of 307 units were identified this comprised 170 Psychiatric Intensive Care Unit (PICU) housing 1,242 patients and 137 Low Secure Units (LSUs) treating 1,583 patients. The majority of patients in Low Secure care were male, white, single, unemployed and with a diagnosis of schizophrenia. Complex needs, violence and forensic histories were common. There was a clear overrepresentation of black ethnic patients.

Conclusions: Patients in Low Secure Services shared many characteristics. However, there were important differences between PICU and LSU patients. The overrepresentation of black ethnic groups is concern that requires NHS action to ensure that the specific needs of black patients are met.

Background: The principle that patients should be cared for under conditions of no greater security than is justified is well established and applies to patients cared for on psychiatric intensive care units.

Aims: This audit aimed to establish: (1) the characteristics of patients admitted to a PICU, (2) whether patients experienced delays in discharge to care in lower levels of security and (3) the characteristics of patients who experienced a delayed discharge.

Method: An audit survey of the case notes of patients discharged from an inner city PICU in 2005 to establish compliance with the standards described.

Results: Of 109 patients discharged from the PICU, 88 were included in the survey. 51.1% of patients experienced a delay in discharge from the PICU. The characteristics of the patients discharged from the PICU are described, and compared with those experiencing a delay in discharge.

Conclusions: Patients often experience a delay in discharge to clinically appropriate levels of security from a typical PICU. The source of referral of patients and diagnosis are associated with a delay in discharge. The findings warrant wider study.

Background: Low Secure Mental Health Services provide care for highly disturbed psychiatric inpatients. Little is known about the provision of such services in the UK.

Aims: To perform the first UK wide survey developing a national data set for Low Secure Services.

Method: A cross-sectional census day postal survey design was employed.

Results: A total of 307 units were identified in the UK, this was comprised of 170 Psychiatric Intensive Care Units (PICUs) housing 1,242 patients and 137 Low Secure Units (LSUs) treating 1,583 patients. The survey achieved a 98% response rate. PICUs on average had more qualified staff and were more medically oriented than LSUs. PICUs offer a time limited, medically oriented treatment strategy with a higher number of qualified nursing staff then LSUs. Whereas, LSUs placed more of an emphasis on long-term therapeutic treatment and rehabilitation.

Conclusions: Although there were a variety of names, Low Secure Services were organised into two main categories of unit: the PICU and the LSU. These names should be adopted nation-wide as standard. There is need for a national strategy relating to the way PICUs and LSUs are developed.

Background: Previous studies have shown that as well as being an effective antipsychotic, clozapine reduced aggressive and violent incidents. Most of the studies measured the length of time the patients were on clozapine, or the dose of the clozapine when the effectiveness was evaluated.

Method: A retrospective audit was designed to see the effectiveness of clozapine in reducing incidents in a low-secure challenging behaviour unit. The number of incidents was calculated pre and post the date when clozapine serum level reached the therapeutic level of 0.35μg/l. Then, the number of incidents per month (incidents/month ratio) before and after reaching the therapeutic level was calculated.

Results: The number of incidents per month was reduced by over 75%. Before serum clozapine level reached 0.35μg/l the number of incidents/month/patient was 1.22 and after reaching 0.35μg/l, it was 0.26 (p=0.004).

Conclusions: The use of clozapine reduced the number of adverse incidents by 75%. The monitoring of serum levels was found to be clinically useful.

The National Institute for Clinical Excellence (2005) published guidance on the management of disturbed behaviour in mental health settings and emergency departments. The guidance included some of the recommendations made in the Independent Inquiry into the death of David Bennett (2003). One important recommendation requires that staff implementing physical interventions (restraint) and/or parenteral rapid tranquilisation are able to effectively manage the physical health of the patient including any immediate complications that may arise.

This article provides background and a syllabus for training for staff to be able to meet the physical assessment skills and interventions required by recent UK national guidance. Also reported is the creation, role and deployment of a 24-hour Medical Emergency Response Team in an in-patient mental health setting to ensure responses to both medical and psychiatric emergencies offer improved safety and adhere to the new guidance. The article describes the provision of a person with the sole responsibility monitoring a patients physical safety during restriant, 24 hour a day, 7 days a week.

The article will be of interest to those working in in-patient mental health and learning disability services, especially those where they are not served by a resuscitation team as part of a District General Hospital and where there is no resident Duty Medical Officer.

Agitation is a common and serious problem presenting a conflict of values: the need for safety temporarily outweighing the emphasis on dignity, autonomy and privacy that should characterize usual care. Given the difficulty of experimenting with this population, a group of experts in emergency psychiatry met to discuss the management of behavioural emergencies. This was conceptualised as occurring in phases including the first 2 hours, 2–24 hours, and after 24 hours. A number of general principles were recognised, including initial efforts devoted to less coercive strategies that appear as part of a graded hierarchy of choices, awareness of potential organic causes, and an endpoint of calming and patient participation rather than sleep. Anticipation of various contingencies in standard procedures is encouraged. Nonpharmacological methods should always be emphasised. Pharmacological treatment may target symptoms non-specifically in the first phase until the syndrome responsible can be identified and definitive treatment tailored to individual needs in later phases can be started. Benzodiazepines are recommended for their non-specific effects. Second-??generation antipsychotics are preferred for their lower side-effect burden initially and advantages in the domain of hostility as well as relapse prevention. Oral treatment with an orodispersible formulation is preferred to parenteral treatment if possible. Moderate doses of antipsychotics are recommended in contrast to rapid neuroleptisation. Combinations of benzodiazepines and antipsychotics may enhance calming and reduce total antipsychotic dose required for calming but caution is warranted with some agents. Frequent monitoring and reassessment of initial interventions is critical. In later phases, the focus shifts from managing behaviour to treating acute symptoms and finally to education and recovery. The ultimate goal is the return of autonomy, formation of an alliance and development of a durable, mutually agreeable plan of care that considers both tolerability and efficacy in multiple domains. Every effort should be made to prevent undesirable outcomes in the early stages from compromising care in the much longer periods following the behavioural emergency.

Little is known about how different groups of health-care workers compare to each other and to the general public in their opinions about involuntary admission and treatment. In the present study, 1,094 people in Norway responded to a questionnaire containing three cases with patients suffering from schizophrenia. They were asked in which cases they would admit involuntarily and treat involuntarily with neuroleptics. An overwhelming majority would coerce when the patients were violent. Between a third and a half would coerce when the patients had problems coping with activities of daily life, or when the patients were in an early schizophrenic development with few symptoms. In all the cases, significantly more would accept involuntary admission than involuntary treatment with neuroleptics. The results suggest that health-care workers' attitudes to coercion in psychiatric care are in line with the attitudes of the general public. Prior experience with coercion, female sex, not having a college/university education, having a profession other than social worker, and not currently being employed in the psychiatric services, were positive predictors of willingness to coerce.

Problems in the acute sector of psychiatric care are not unique to the Netherlands and at an international level appear to be linked to problems that are significant for big cities. The search for an “acute bed” had become more difficult and patients were being placed and transported through the whole country. The three mental health care institutions in Amsterdam joined forces and opened a gateway facility in order to confront the pressure on admissions. The object??ive of this facility was to create a buffer for the relief of acute compulsory admissions and thus reduce the period that patients had to stay in police cells and decrease the number of placements outside the Amsterdam region.

In this article the goals, patient groups and achievements of this interim facility, called the Temporary Admission Unit (TOA), are described.

The TOA has proved to be able to fulfil its promise to function as a buffer towards the secure admission units in Amsterdam. For a small group of patients (13%) a short admission period on the TOA is sufficient and they can be discharged immediately. The average occupancy rate of the beds of 5 (out of 8 beds) means that the TOA can usually guarantee availability of beds for acute admissions. Between 2000 and 2002 the number of guest placements outside Amsterdam has drastically lowered, along with a gradual rise in the number of compulsory admissions. Finally, the waiting time in the police stations has been diminished considerably.

The advantages of the TOA are clear. Expensive (nocturnal) ambulance transport can be avoided. The stay in the police cell is reduced and the patient arrives in a facility where psychiatric care is available with greater speed. Contact with a regular therapist and therefore continuity of care guarantees a better situation than when the patient is admitted in a distant facility. The same holds good for family contacts.

We report on an adolescent with Asperger's syndrome who developed acute pancreatitis during treatment with risperidone and citalopram. On discontinuation of psychopharmacotherapy, he fully recovered. A rechallenge testing of citalopram did not result in a relapse of pancreatitis. Other known causes of pancreatitis were not obvious. Clinicians should be alert to this rare adverse event in patients who exhibit symptoms of an acute abdominal disorder during risperidone treatment.

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.

Aims and Methods: A retrospective cohort was identified to examine the impact of information availability on outcome of emergency psychiatric assessment.

Results: Of 144 assessments undertaken during a 2-month period, 110 (76%) involved patients already known to regional psychiatric services, with records held on-site and remote from acute services at the District General Hospital site. 18 (16%) on-site clinical records were accessed during emergency assessments, only 3 (3%) of which were accessed during out-of-hours. No off-site records were accessed. Admission rates were low, with only 22 (15%) of assessments leading to admission and 63 (44%) resulting in onward referral to other services. Outcome for in- and out-of-hours assessments did not differ.

Conclusion: Our data failed to show a significant effect of accessing clinical records on admission rate.

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.

Background: The role of psychiatric intensive care units is well established for the general adult psychiatric population, but these units are often less suitable for the elderly psychiatric population. An increase in the number of behaviourally challenging demented male patients in the elderly psychiatric admission wards of one Scottish health region created an opportunity to develop a psychiatric intensive care unit for elders with these problems (PICUe).

Method: Prospective survey of activity in the PICUe during 2005, using routinely collected data.

Results: 14 male patients, mean age 70 years, were admitted to the PICUe on 17 occasions during 2005, with 76% detained under the Mental Health (Scotland) Act, 1984. The majority (43%) of patients had a primary diagnosis of Alzheimer's dementia, 21% with vascular dementia. The main transfer reason was resistive behaviours, with persistent physical aggression being the next most common reason. The average mini-mental state score was 14/30, and the mean duration of patient stay in the PICUe was 46 days, with 71% of admissions discharged from the unit during the evaluation period. Benefits were noted for referring clinical teams and for patients.

Conclusions: The results suggest that a regionally-based psychiatric intensive care unit for older adults can serve a useful function in the management of disturbed elders who are otherwise difficult to manage within the current hospital-based elderly psychiatric care facilities.

Towards the end of 2005, a long running battle over the seclusion of mentally disordered patients in hos??pitals reached the House of Lords. Over-ruling the Court of Appeal, their Lordships decided in Munjaz vs. Ashworth Hospital Authority that the strict guidelines of the Mental Health Act Code of Practice on seclusion were not always legally binding, and could in certain circumstances be departed from. This was seen as a victory for the hospitals and practitioners, who had fought long and hard for the decisions on seclusion to be made as “close to the ground” as possible, and for there to be leeway in how the Code of Practice was applied. Many on the patients' side, who had argued for the Code to be strictly followed so that patients could always know where they stood, likewise saw the result as a defeat.

However, the authors – who were respectively junior counsel and solicitor representing the patient in the case of S vs. Airedale NHS Trust with which Munjaz vs. Ashworth Hospital Authority was paired and heard together in the Court of Appeal – argue below that Munjaz has been misunderstood and the circumstances in which the Code of Practice can be departed from are strictly defined, in such a way that important arguments on the patients' side must be seen to have succeeded.

Background: Heterotopia are believed to result from faulty neuronal migration. Formerly considered to be extremely rare, with the availability of MRI reports they have appeared more frequently.

Case details: We describe a 42 year old man with episodic disinhibition (violent and sexual) with disorganized thinking and behaviour, and a 20 year history of a diagnosis of schizophrenia. Soon after admission there were vague paranoid delusions. Initially, the cognitive state was impossible to access, but cognitive deficit was later demonstrated using the Mini Mental State Examination (MMSE). Although there was no clear evid??ence of delirium, the MMSE score subsequently improved, as did the disinhibited behaviour.

Results: CT revealed no abnormality. Brain MRI, however, revealed multiple bilateral subependymal heterotopia (SEH).

Conclusion: It is possible for SEH to be associated with a schizophrenia-like syndrome. CT is not sufficient and MRI is required to exclude SEH.

Neuroleptic malignant syndrome (NMS) is a severe and potentially lethal complication of antipsychotic medication. Differential diagnosis is extremely important because severe catatonia, which has some simi??larities to NMS, may also be lethal but requires antipsychotic treatment. We present a case report of a 62-year-old woman who was admitted to hospital for differential diagnosis of NMS and suffered from severe haloperidol intoxication, which complicated the diagnostic evaluation. Further differential diagnostic aspects are summarised and their therapeutic implications are outlined.

Aims: To measure how the opening of a new PICU affected the clinical activity of the local acute in-patient psychiatric wards.

Method: Retrospective analysis of Trust statistical reports.

Results: The opening of a PICU was associated with small and temporary reductions in disturbed behaviour and detained patient numbers on the acute wards.

Conclusions: Opening a PICU appeared to have little long term effect on the clinical activity of the other hospital wards. It is likely that any effects of the PICU were obscured by the many other factors impacting on acute ward activity.