Those requiring inpatient psychiatric care should be managed in the lowest level of security necessary in a ward close to their home area. The presence of informal (voluntary) patients on secure wards appears incompatible with this principle. Can such situations be justified?

An Environment Assessment Inventory was developed to conduct a Nationwide survey on the physical environment of Psychiatric Intensive Care Units (PICUs) and Low Secure Units (LSUs). The Nationwide survey was conducted in England to see if the physical environment of PICUs and LSUs were adequate to meet the therapeutic and safety needs of the patients.

In this work, a detailed account has been given about the survey tool: the “Environment Assessment Inventory”, its development, uses and limitations. This tool may be used in the future for national planning and development of the PICUs and LSUs, not only by UK but also by other countries of the world.

Background: The physical environment of a Psychiatric Intensive Care Unit (PICU) or Low Secure Unit (LSU) is one of its defining aspects. The National Minimum Standards for General Adult Services in PICUs and Low Secure Environments published by the Department of Health (2002) outlines the standards to be followed regarding design of PICUs and LSUs. Till date, no comprehensive national data exists about the standard of physical environment of these units.

Aim: To determine whether current physical environment of PICUs and LSUs are adequate to meet the therapeutic needs of patients in England.

Method: An inventory was sent to all NHS PICUs and LSUs (in England).

Results: A total of 231 units were identified as either PICUs or LSUs. Out of these, 164 valid returns were received. Sixty PICU units (62.5%) and 43 LSU units (63.5%) were good or acceptable. Thirty six PICU units (37.5%) and 25 LSU units (36.5%) failed on several issues. Analysis of the data showed that to bring the PICU/LSU Estate to a good standard is anticipated to cost approximately £140million.

Conclusion: The Department of Health has allocated funding of £30 million to be distributed amongst all the 28 Strategic Health Authorities. A further funding of £130 million has also been released to address places of safety and for upgrading PICUs and LSUs to meet the National Minimum Standards.

Declaration of Interest: The project was funded by the Department of Health.

Aims: To determine the prevalence of physical illness in patients admitted to a challenging behaviour unit and to assess whether they were physically examined and investigated.

Method: Retrospective case note analysis of patients admitted to the challenging behaviour unit during the period of July 1997 to July 2003.

Results: All patients were suffering from serious and enduring mental illness and challenged the ordinary mental health services by behaviour such as assault, fire setting, aggression, self harm, multiple substance misuse and non-compliance at least for six months.

On admission 76% of patients had examination of the cardiovascular, respiratory and gastro intestinal system and 69% of the central nervous system. During the hospital stay, all the patients had cardio vascular, respiratory and gastrointestinal system examination and 83% had central nervous system examination. All patients had base line investigations including full blood count, ESR, liver function test, urea and electrolytes, random glucose, thyroid function test and follow up investigations.

51(73%) patients were found to be suffering from some physical illness during their hospital stay. The physical illness spanned all the systems. There were newly detected cases of systemic lupus erythematosus, diabetes mellitus, glaucoma, hypertension, seizure disorder, male urinary tract infection, severe incontinence and haematological problems.

Conclusion: There is a high prevalence of physical health problems among patients admitted to a challenging behaviour unit. Some problems were associated with the mental illness, some as a complication of the mental health problem and others secondary to psychotropic medication. This study highlights the importance of a proper medical history, physical examination, base line investigations and regular monitoring of the physical health of mentally ill patients.

Rapid Tranquillisation (RT), defined as “the use of psychotropic medication to control agitated, threatening or destructive psychotic behaviour”, is a last resort pharmacological intervention. The withdrawal of the widely used droperidol in 2001 due to concerns over QTc prolongation may have increased the variability in RT practice across the UK. This paper reports on a UK wide survey of the practice of RT by psychiatrists. The survey pre-dated publication of NICE guidance on management of distributed behaviour. 257 questionnaires were received (response rate 22%). In comparison with previous surveys of this type, the overall quality of prescribing and monitoring has improved, although some apparently idiosyncratic practice remains. The majority of psychiatrists expressed concerns about prescribing and monitoring RT and would welcome an easy to use algorithm and associated training package. Findings are discussed in terms of training implications and BNF recommendations for high dose prescribing.

This article describes in detail the service delivered by the Multidisciplinary Team at the Montpellier Low Secure Unit in Gloucester. The development of the service, the physical environment and the admission criteria are described. The article focuses on the stages of treatment experienced by the patient namely: assessment, ongoing care and treatment and pre discharge planning.

The Psychiatric Intensive Care (PIC) Governance Network is a practical measure supporting the National Minimum Standards. It delivers a dynamic framework to provide users, clinicians, managers and commissioners with a structure to deliver high quality services. The Network concentrates upon four specific themes: responding to emergencies, multidisciplinary working, user/carer involvement and diversity. The inaugural year (2004–2005) was funded through the National Institute of Mental Health, England (NIMHE) and individual participating organisations and was a collaboration between NIMHE, North East London Mental Health NHS Trust (NELMHT) and the National Association of Psychiatric Intensive Care Units (NAPICU). This document outlines progress of the Network; it's developmental history, process, content and conclusions.

Most participating units were able to show benefits not only from success of a specific project (many chose a project with a user focus) but also within other areas. The most successful unit teams not only showed commitment but also adhered to their project plan, meeting regularly outside of learning set days in order to progress work.

Background: Borderline personality disorder (BPD) is a distressing disorder that is associated with significant morbidity and mortality. Patients with BPD are often admitted to PICUs where psychotropic drugs are usually prescribed to treat trait or state dependant symptoms.

Aims: To review the evidence base for the efficacy of psychotropic drugs in borderline personality disorder.

Method: Medline and Cochrane search covering the period 1966 to March 2003.

Results: Nineteen RCTs and a large number of case reports, case series and open studies were retrieved. Numerous different treatments have been used, each in a small number of patients. Open studies often report remarkable efficacy that is not reproduced in randomised controlled trials.

Conclusions: The initial placebo response to any drug treatment is high but symptoms invariably return leading to the addition of further psychotropic drugs. Long term gains from drug treatment are likely to be small in the majority of patients. Large pragmatic trials of drug treatments could be co-ordinated through the PICU network.

Declarations of Interest: None.

Anticonvulsant Hypersensitivity Syndrome (AHS) is a potentially fatal immune-mediated multi-system disorder linked to older aromatic anticonvulsants. It falls within the spectrum of Stevens Johnson Syndrome and hepatitis.