The Tower Hamlets Crisis House (voluntary sector), in partnership with the local home treatment team, offers a brief residential alternative to psychiatric hospital admission. Here, we review clinician-reported (Health of the Nation Outcome Scales; HoNOS) and patient-reported (DIALOG) outcome scores collected from successive admissions between June 2015 and December 2016, to assess the effectiveness of the service model. We identified 153 successive admissions, and of these, 85 (55.6%) and 91 (59.5%) patients completed both admission and discharge DIALOG and HoNOS questionnaires, respectively. We analysed ten out of twelve HoNOS domains and eight patient-reported outcome measure DIALOG domains.

We found a statistically significant improvement in nine out of ten domains of HoNOS and three out of eight domains of DIALOG.

A partnership between a home treatment team and crisis house can result in positive outcomes for patients, as determined by both clinicians and patients.

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Recent funding from Welsh Government for mental health has helped to develop liaison psychiatry services in Wales. Systematic data collection was undertaken to map the liaison psychiatry services in Wales in collaboration with the Royal College of Psychiatrists in Wales and Public Health Wales 1000 Lives Improvement. A questionnaire was designed and circulated to all the health boards in Wales to gather information to map liaison psychiatry services in Wales. Up-to-date information was confirmed in January 2018, via email.

Over the past 2 years, liaison psychiatry services have been set up in six out of seven health boards in Wales. Staffing levels have increased and the remit of services has broadened.

Mapping has highlighted that liaison psychiatry services in Wales continue to evolve. It will be important to continue to monitor these developments and their effects. Comparison with services in England will provide a useful comparison of service provision. A particular challenge will be to establish and monitor liaison psychiatry standards in Wales.

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Workforce shortages in psychiatry are common worldwide. The international literature provides insights into factors influencing decisions to train in psychiatry but is predominately survey based. This national cohort study aimed to identify the characteristics of doctors who were most likely to apply to psychiatry training programmes. The sample comprised doctors who entered UK medical schools in 2007/8 and who made first-time specialty training applications in 2015. The association between application to psychiatry and doctors' sociodemographic and educational characteristics was examined using multivariable logistic regression.

Those most likely to apply were White, privately educated older doctors with below average performance at medical school.

To reduce workforce shortages, psychiatry must make itself more attractive to all doctors, especially those from underrepresented groups such as state-educated Black and minority ethnic individuals. Otherwise, national policies to widen participation in the study of medicine by such groups may exacerbate the current recruitment crisis.

The aim of the study is to improve patient safety by identifying factors influencing gatekeeping decisions by crisis resolution and home treatment teams. A theoretical sampling method was used to recruit clinicians. Semi-structured interviews to elicit various aspects of clinical decision-making were carried out. The transcripts were thematically analysed using a grounded theory approach.

Patient needs (safety and treatment) was the primary driver behind decisions. The research also revealed that information gathered was processed using heuristics. We identified five key themes (anxiety, weighting, agenda, resource and experience), which were constructed into an acronym ‘AWARE’.

AWARE provides a framework to make explicit drivers for decision-making that are often implicit. Incorporating these drivers into reflective practice will help staff be more mindful of undue influences and result in improved clinical decisions.

None.

The authors have no conflict of interest to declare regarding this manuscript.

An ‘assertive approach’ to clozapine, where nasogastric administration is approved, is assessed through a case-load analysis to provide the first systematic description of its use and outcomes worldwide.

Five of the most extremely ill patients with treatment-resistant schizophrenia were established and/or maintained on clozapine, resulting in improvements to their mental state; incidents were reduced, segregation was terminated and progression to less restrictive environments was achieved.

Despite being underutilised and rarely enforced, in extreme circumstances, an assertive approach to clozapine can be justified. Nasogastric clozapine can be safely delivered and the approach itself, rather than actual nasogastric administration, may be enough to help establish and maintain patients with treatment-resistant schizophrenia on the most effective treatment.

E.S. has received speaker fees from Jansen Pharmaceuticals and Novartis.

The aims of this review were to explore the effectiveness and patient and provider acceptability of telepsychiatry consultations in intellectual disability, contrasting this with direct face-to-face consultations and proposing avenues for further research and innovation. Computerised searches of databases including AMED and EMBASE were conducted.

Four USA studies of intellectual disability telepsychiatry services have been reported. The majority (75%) focused on children with intellectual disability. Sample sizes ranged from 38 to 900 participants, with follow-up from 1 to 6 years. Outcome measures varied considerably and included cost savings to patients and healthcare providers, patient and carer satisfaction and new diagnoses.

The innovations summarised suggest a requirement to further explore telepsychiatry models. Despite some promising outcomes, there is a relative dearth in the existing literature. Further studies in other healthcare systems are required before concluding that telepsychiatry in intellectual disability is the best approach for providing psychiatric services to this population.

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Memory services have expanded significantly in the UK, but limited performance data have been published. The aim of this programme was to determine variation in London memory services and address this through service improvement projects. In 2016 London memory services were invited to participate in an audit consisting of case note reviews of at least 50 consecutively seen patients.

Ten services participated in the audit, totalling 590 patients. Variation was noted in neuroimaging practice, neuropsychology referrals, diagnosis subtype, non-dementia diagnoses, waiting times and post-diagnostic support. Findings from the audit were used to initiate four service improvement projects.

Memory services should consider streamlining pathways to reduce waiting times, implementing pathways for patients who do not have dementia, monitoring appropriateness of neuroimaging, and working with commissioners and primary care to ensure that access to post-diagnostic interventions is consistent with the updated National Institute for Health and Care Excellence (NICE) dementia guideline.

To investigate the percentage of patients who commenced smoking after transferring out of a non-smoking forensic psychiatric unit, the corresponding clozapine dose adjustments, the effects on plasma clozapine/norclozapine concentrations and observed changes in mental state. We reviewed the notes and plasma clozapine/norclozapine concentrations of 46 patients transferred to medium secure units between July 2008 and December 2013.

Thirty-five patients commenced smoking. Their median clozapine dose was increased by 50 mg/d. In the non-smokers, the median clozapine dose remained unchanged. Plasma clozapine/norclozapine concentrations were significantly reduced in smokers despite dosage adjustment. Eighteen patients experienced deterioration in mental state after transfer; almost all these patients were smokers.

Approximately three-quarters of patients who were non-smokers by virtue of being in a secure non-smoking environment commenced smoking after transfer. Monitoring of clozapine serum levels and assessment of mental state in the immediate period after a change in smoking status is indicated.

To describe the functions of the Aneurin Bevan University Health Board Risk Reference Panel and characterise the typical referrals presented and outcomes from the panel. A structured thematic analysis was performed on verbatim transcripts of 48 panel sessions.

The 79 codes identified were grouped into 16 subthemes. Four principal themes were identified: two characterising cases brought to the panel (childhood risk factors and current presenting difficulties) and two describing advice given (risk management and wider organisational issues). Quotations are given to illustrate cases presented and advice given by the panel.

The panel provides a valuable source of special expertise in the management of complex and exceptional cases where risk of harm is significant and clinical teams have ongoing concerns. This paper describes a model of peer-working to support staff and may further reduce the risk of harm associated with mental illness.

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The Norfolk Youth Service was created in 2012 in response to calls to redesign mental health services to better meet the needs of young people. The new service model transcends traditional boundaries by creating a single, ‘youth friendly’ service for young people aged 14–25 years. The aim of this study was to investigate the effect of the transition to this new model on patterns of referral, acceptance and service use. We analysed routinely collected data on young people aged 14–25 years referred for secondary mental healthcare in Norfolk before and after implementation of the youth mental health service. The number of referrals, their age and gender, proportion of referrals accepted and average number of service contacts per referral by age pre- and post-implementation were compared.

Referrals increased by 68% following implementation of the new service model, but the proportion of referrals accepted fell by 27 percentage points. Before implementation of the youth service, there was a clear discrepancy between the peak age of referral and the age of those seen by services. Following implementation, service contacts were more equitable across ages, with no marked discontinuity at age 18 years.

Our findings suggest that the transformation of services may have succeeded in reducing the ‘cliff edge’ in access to mental health services at the transition to adulthood. However, the sharp rise in referrals and reduction in the proportion of referrals accepted highlights the importance of considering possible unintended consequences of new service models.

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Despite substantial evidence to show that unaccompanied refugee children suffer a high prevalence of mental illness, their access to services remains poor. One may hypothesise that this is associated with their negative perceptions of mental illness. However, there has been little research exploring this important subject. We aimed to explore unaccompanied refugee children's experiences, perceptions and beliefs of mental illness, focusing on stigma. Fifteen unaccompanied refugee children and 15 carers were interviewed by a semi-structured interview. Thematic analysis was used to analyse data.

Three main themes were identified, focusing mainly on issues of stigma related to mental health, mental illness and their treatment, and they were interpreted in detail.

Our findings will contribute to current understanding of stigma and discrimination, and their effect on service engagement, and will hopefully stimulate interest to further explore this area and develop potential solutions.

Few studies have looked at subjective memory impairment from electroconvulsive therapy (ECT) after treatment completion. We aimed to systematically review all available evidence for subjective post-treatment effects.

We included 16 studies in this review. There was considerable between-study heterogeneity in clinical population, ECT modality and assessment scales used. The most common assessment scale (eight studies) was the Squire Subjective Memory Questionnaire. The majority of studies reported an improvement in subjective memory after ECT, which correlated with improved depression scores. Subjective complaints were fewer in studies that used ultra-brief pulse ECT. Longer pulse widths were associated with more subjective complaints, as was female gender and younger age of treatment in the largest study.

There is considerable heterogeneity between studies, limiting meaningful conclusions. Ultra-brief pulse ECT appears to result in fewer subjective complaints.

None.

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The Frequent Attenders Programme is a joint initiative between Hertfordshire Rapid Assessment, Interface and Discharge service and the Emergency Department of the West Hertfordshire NHS Trust, which aims to divert frequent attenders from the emergency department by addressing their unmet needs. This paper describes the range of interventions put in place from the time that the service was set up in 2014 until the introduction of the new national Commissioning for Quality and Innovation 2017–2019, which tasked National Health Service trusts to improve services for people with mental health needs who present to Accident and Emergency. The terms emergency department and Accident and Emergency are used interchangeably, reflecting the practice in policy documents. A subsequent article will report on the impact of the Commissioning for Quality and Innovation in Hertfordshire.

Analysis of the interventions indicated a highly significant (P < 0.0001) mean reduction in attendances. Lower gains were made in patients whose primary presentations were alcohol-related. A failure to effect change in two patients led to a significant revision of their respective care plans, resulting in a subsequent reduction in their attendances.

An integrated approach to patients with complex presentations was associated with high levels of both patient and referrer satisfaction. It is hypothesised that dismantling the barriers between physical and mental health may lead to similar successes in frequent attenders in other in-patient and community medical and psychiatric services.

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We evaluated routine use, acceptability and response rates for the Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder Scale (GAD-7) and Short Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS) within adult community mental health teams. Measures were repeated 3 months later. Professionals recorded the setting, refusal rates and cluster diagnosis.

A total of 245 patients completed 674 measures, demonstrating good initial return rates (81%), excellent scale completion (98–99%) and infrequent refusal/unsuitability (11%). Only 32 (13%) returned follow-up measures. Significant improvements occurred in functioning (P = 0.01), PHQ-9 (P = 0.02) and GAD-7 (P = 0.003) scores (Cohen's d = 0.52–0.77) but not in SWEMWBS (P = 0.91) scores. Supercluster A had higher initial PHQ-9 and GAD-7 scores (P < 0.001) and lower SWEMWBS scores (P = 0.003) than supercluster B. Supercluster C showed the greatest functional impairment (P = 0.003).

PHQ-9 and GAD-7 appear acceptable as patient-reported outcome measures in community mental health team. SWEMWBS seems insensitive to change. National outcome programmes should ensure good follow-up rates.

Night-time confinement is the practice of routinely locking patients in their rooms at night unless there is a contrary clinical indication. It is used in high-secure psychiatric hospitals. This article argues in favour of this practice on the basis of realistic medicine, an individual human rights based approach, the principles of mental health legislation in Scotland and England and cost effectiveness. This is not an academic debate. There is a real danger that those advocating against night-time confinement, if successful, will at best make little difference to the lives of our patients as they sleep, and at worst may hugely impoverish their lives because of reduced daytime activities.

L.T. is Medical Director at The State Hospital. Night-time confinement is used within this setting.

We conducted a secondary analysis of data from the National Audit of Psychosis to identify factors associated with use of community treatment orders (CTOs) and assess the quality of care that people on CTOs receive.

Between 1.1 and 20.2% of patients in each trust were being treated on a CTO. Male gender, younger age, greater use of in-patient services, coexisting substance misuse and problems with cognition predicted use of CTOs. Patients on CTOs were more likely to be screened for physical health, have a current care plan, be given contact details for crisis support, and be offered cognitive–behavioural therapy.

CTOs appear to be used as a framework for delivering higher-quality care to people with more complex needs. High levels of variation in the use of CTOs indicate a need for better evidence about the effects of this approach to patient care.

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Psychotic phenomena include a far wider range of experiences than is captured by the brief descriptions offered in contemporary diagnostic guides. Given the richness of historical clinical phenomenology, what can account for the recent ascendancy of relatively impoverished descriptions of psychosis? One possible explanation is provided by Hacking's notion of dynamic nominalism, where human categories change over time in tandem with those who they classify. But although dynamic nominalism makes sense of changes in behaviour, it fails to account for change at the level of subjective experience. In this paper, psychotic symptoms are addressed in the light of the indeterminacy of subjective mental content. A naïve-introspectionist approach to mental symptoms assumes that, notwithstanding practical difficulties, such symptoms are reliably describable in principle. Contemporary philosophy of mind challenges this assumption. Lighting upon a verbal description for ineffable phenomena changes their nature, resolving them into new forms.

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