A postal questionnaire was sent to 100 Section 12 (2) approved consultant psychiatrists in the West Midlands to ascertain their perceptions of the role of general psychiatric services in the care of imprisoned patients with mental disorder previously cared for by generic services.

Of 59 respondents 90% believed they could contribute to the care of imprisoned patients with mental disorders. Ten per cent would delegate total responsibility to specialist forensic services. Lack of awareness of imprisonment of patients was a common problem.

Insufficient liaison between prison and general psychiatric services may impede the provision of psychiatric care in prison and prevent discharge planning in line with the Care Programme Approach and current Government guidelines.

A postal and telephone survey of 140 community drug teams was undertaken to determine geographical variations in waiting times and methadone prescribing policies.

The average waiting time was 7.2 weeks for assessment and 10.6 weeks from referral to receiving methadone. ‘Methadone maintenance’ was not available in 25 units, although it was commonly provided in 41 units. In-patient detoxification for illicit drug dependence was available in 108 units, of which 59 units had access to beds in dedicated drug-dependency units, while the remaining 49 units referred in-patients to general psychiatry wards.

Despite government guidelines, it was clear that methadone was readily available to opiate users in some units whereas prescribing was very limited in others. The great variation in prescribing policies and waiting lists between community drug teams will make it extremely difficult to compare their effectiveness. Waiting lists are an explicit target for the National Treatment Agency involved in commissioning substance misuse services.

To compare current prescribing practice for psychotic and behavioural symptoms in dementia with the available research. An anonymous questionnaire was sent to all members of the Faculty of Old Age Psychiatry, enquiring about preferred drug treatments.

Classical antipsychotics were chosen by 50% for psychotic symptoms over atypical antipsychotics (43%) and were preferred for aggression (48%) and sexual disinhibition (55%). Antidepressants were favoured in treating anxiety (41%) and lability (45%).

Alternatives to classical antipsychotics, especially for behavioural symptoms, have yet to be researched satisfactorily. In view of the continued widespread use of classical antipsychotics and recent concerns about their safety, we call for this to be addressed.

To evaluate patterns of antipsychotic co-prescription and to establish documented outcome, we reviewed 1441 in-patient and community prescriptions written in a large mental health trust. For patients co-prescribed regular atypical and typical antipsychotics for longer than 6 weeks, medication histories were taken and case notes examined to determine sequence of prescribing, documented outcome and reasons for co-prescription.

Fifty-three patients had been co-prescribed aytpical and typical antipsychotics for more than 6 weeks. In 62% of cases the atypical drug had been prescribed first and a typical drug added later. The most frequently documented reason for co-prescription was that symptoms persisted when prescribed a single antipsychotic. Clinical outcome was documented for 64% of patients: 45% of the total number treated showed some improvement, with seven of 53 patients noted to have shown improvements in psychotic symptoms.

Co-prescription of aytpical and typical antipsychotics often occurs as a consequence of poor outcome with single drug treatment. In this study there was minimal evidence to suggest that co-prescription improved outcome to an important extent. There remains little support for co-prescription of antipsychotics but considerable evidence to suggest that such practice worsens adverse effect burden. Co-prescription of atypical and typical antipsychotics should be avoided in all but very exceptional circumstances.

The ability of routine clinical practice to detect drug use at acute psychiatric admission was assessed by comparing the results of urinalysis with information on drug use extracted from patient records (n=112).

Urinalysis detected drug use in 23% of the sample. Cannabis was the drug most frequently found. Of the cases of drug use positively identified by urinalysis, 54% were not identified in the notes. Some information on drug use proximal to admission was found in 40% of patient records. Patients asked about proximal drug use were younger than those not asked.

All patients should be asked about drug use.

The study investigated the personal impact of patient suicides on the members of community mental health teams and the sources of support utilised for coping with adverse effects.

Forty-four questionnaires were returned. Eighty-six per cent of staff reported having had at least one patient suicide, with an average of 4.2 suicides. The majority of staff reported that patient suicides had significant adverse effects on their personal and professional lives. Some of the effects were long-lasting (greater than 1 month). Staff found that peer support, reviews, dedicated staff meetings and support from senior colleagues were of most value.

Staff require skilled and dedicated support following a patient suicide in order to minimise its detrimental effects on personal, professional and team functioning.

Atypical antipsychotics have less neurological side-effects than the older drugs but are only available as oral preparations. This may limit their use in forensic patients. We sent a postal questionnaire to all consultant psychiatrists working in forensic settings in the UK to determine their views.

The response rate was 60%. Respondents tended to overestimate the benefits and underestimate the side-effects of the atypical antipsychotics. The majority often prescribed atypical antipsychotics and depots together. Psychoeducation and serum level monitoring were used to optimise/monitor compliance by 50%.

Using atypical antipsychotics as monotherapy is problematic in forensic settings. The extent of polypharmacy means that patients may experience the side-effects of both typical and atypical antipsychotics. More could be done to facilitate and monitor compliance.

To investigate the transfer of information regarding prescribed medication between primary and secondary care sectors. Patients aged 18–65 years, ready for discharge from hospital, were invited to participate. Prescribed medication was recorded from their hospital and general practitioner records. The significance of discrepancies identified between medication lists was assessed independently by four judges.

Discrepancies occurred for 39 out of 43 patients at each stage of medication information transfer. Discrepancies at the time of admission and following discharge occurred in 69% and 43%, respectively, of drugs studied. It was judged that harm would occur to the patient, should the discrepancy be reproduced, in 24% and 18%, respectively, of cases.

IMPLICATIONS Discrepancies in the transfer of information regarding prescribed medication may result in harm to patients.

The aim of the study was to determine whether diagnostic case-mix influenced the distribution of clinical activity within the community mental health team (CMHT). Information concerning every patient involved with the CMHT and every episode of clinical activity was collected over a 2-week period.

Data were obtained concerning 417 patients and 1744 corresponding episodes of clinical activity. Diagnostic case-mix significantly differed between the professions. The duration of episodes of clinical activity varied significantly according to the type of patients involved and whether or not direct face to face contact occurred.

Diagnostic case-mix, in addition to absolute numbers, should be considered when estimating the actual work generated by the different professions' case-loads. Patients with psychosis may place an increased time burden upon CMHT members.

To assess the impact of a clinical risk assessment and management policy introduced in a tertiary rehabilitation service, in response to UK government statute. The study assessed the effect of a formal risk management approach for high-risk cases over a year, in terms of changes in risk-associated behaviour and perceived levels of risk, and in achievement of clinical risk management goals.

Initially 35 of 107 patients were rated as high risk, mostly of neglect or of harm to others, and were subjected to formal risk management. At follow-up only 16 patients were still rated as high risk, most reduction occurring in risk of neglect. Half of the 112 risk management goals established were fully achieved, 58 partially and 18 not achieved. Total Social Behaviour Schedule ratings were significantly lower at follow-up.

Risk management appeared to be successful in terms of reducing overall levels of risk, the achievement of risk management goals and the reduction of risk-associated behaviours. The lack of a control group and blindness limits the validity of these findings. However, organised risk management procedures may help to support and promote good general clinical management.

The aim of the audit was to ensure that the case-load and case mix for trainees in child and adolescent psychiatry met Child and Adolescent Psychiatry Specialist Advisory Committee guidelines and that trainees were seeing cases with an appropriate mix of age, gender and diagnoses. Data on case-load and case mix were analysed annually and problem areas were identified and reviewed when the audit cycle was repeated. The audit cycle has been repeated three times.

Specific findings from the audit included: female trainees were seeing a high percentage of girls; male trainees were seeing a high percentage of boys; some trainees were seeing a high proportion of cases of deliberate self-harm; and there was a recent increase in the number of cases of attention-deficit hyperactivity disorder. The first two issues were rectified as a result of the audit process; the last is being monitored.

Training needs should come before service needs. Auditing trainees' case-loads and case mixes helped best to utilise the time available for clinical work during training.

Patient records from the emergency clinic at the Maudsley Hospital were analysed from July 1999 to assess the standard of risk assessment for self-harm and for harm to others routinely recorded by junior doctors. The recorded risk factors for the consultation and the evidence that risk had been considered were noted. An intervention that comprised two seminars and two written reminders about the importance of risk assessment was made and the analysis of records in the emergency clinic repeated for July 2000.

Risk factors were recorded more frequently for harm to self than for harm to others. There was little recorded evidence that consideration had been given to the overall risk of harm to self, and there was no evidence of this for harm to others. Recording of risk did not change significantly between 1999 and 2000.

Assessment for risk of harm to others is not a part of the emergency consultation that is emphasised by the majority of junior psychiatrists. Changing practice will require a shift in the way that risk to others is presented in psychiatric teaching.

To evaluate psychiatric training in one deanery following a programme of site visits, interviews with trainers and trainees, reports, and recommendations. To assess the findings in the context of NHS training requirements. Information was collected by semi-structured interviews and questionnaire surveys.

Forty-three sites were visited, training is generally of a high standard and most trainees are satisfied with their posts. There are significant problems in delivering sufficient community experience to general practice trainees and deficits in availability of multi-professional training programmes.

College tutors should work to ensure that trainees have access to shared learning occasions with non-medical health professionals to meet the NHS training agenda.

To describe the work and patient characteristics of one of the first combined mental illness and drug and alcohol services (MIDAS) in the UK. We examined MIDAS as an assertive community service, for individuals receiving long-term community care. We selected the case files of the first 80 patients accepted over a 10-month period and examined variables including demographic details, diagnosis, associated substance use and length of engagement with the service.

Our findings show that there was no relationship between responders to the service and basic demographic data. Patients with bipolar affective disorder and personality disorders were more likely to use the service than patients with unipolar disorder or schizophrenia. Despite the use of an assertive service, there was difficulty engaging patients with schizophrenia and comorbid drug use. These same patients also had a high level of criminal convictions as well as a trend towards using alcohol and cannabis as their main substances of misuse. At 18 months 38% of patients had failed to remain engaged with the service.

This specialist type of service may be more useful than other services in engaging patients with comorbidity. Systematic research is required in the UK to explore the effectiveness of this type of new service. More innovative resources need to be identified to specifically deal with patients with severe mental illness and comorbid substance use.

To look at whether the opening of a day programme for the intensive care of people with severe anorexia nervosa in Leicester had the expected impact on admission rates, length of stay, cost of treatment and also simple measures of whether patients got better. Is this day programme an effective resource?

Since the opening of the day programme, in-patient bed days and overall costs of treatment for local patients have been reduced, and the early results in terms of weight gain and readmission rates are promising.

With many areas planning to set up eating disorder services for local patients, it is important to consider which are the best resources to invest in. The experience of a well-established specialist service in Leicester has shown that a day programme can be an enriching and cost-effective way to treat patients with anorexia nervosa, but that it does not replace the need for the availability of in-patient beds.

To evaluate the effectiveness of the antipsychotic medication review service (AMRS) at the Maudsley Hospital. Patient notes were analysed from the AMRS and estimates of Global Assessment Scale (GAS) scores were made from entries in the notes. Data on hospital admissions before and during attendance at the AMRS were obtained from the trust-wide computerised patient administration system.

A statistically significant improvement in GAS scores was seen for patients who stayed in contact with the AMRS. Patients who did not respond to the first atypical drug often made a good response to an alternative atypical antipsychotic. Patients attending the AMRS had fewer hospital admissions than they did before attendance, although this was not statistically significant.

Although more expensive on a dose-by-dose rate, atypical antipsychotics may be cost effective by improving compliance and reducing the number of relapses and hospital admissions. Specialised services with frequent patient contact can be effective in preventing relapse and improving global function.

A survey of 89 psychiatric trainees in a regional rotational training scheme was carried out to investigate the impact immediately after a patient's suicide and at the time of the study. Main outcome measures used were the Impact of Events Scale and a rating scale of the impact on personal and professional life.

Twenty-three trainees out of 53 who returned questionnaires reported at least one suicide. Initial reactions included shock, self-blame, guilt, grief and fear of negligence. Impact on personal and professional life was moderately severe. Over half of the trainees were ‘clinically stressed’ in the immediate aftermath, with no statistically significant reduction overtime.

The impact of a patient suicide can be profound. It can be experienced as a stressful event but can also lead to positive changes in clinical practice. Greater availability of training and support as well as further research in this area are recommended.