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: Psychiatric intensive care facilities have previously been poorly defined, with uncertainty existing about the appropriateness of admissions.

Aim: To offer the first large-scale systematic survey describing the clinical characteristics of patients admitted to Psychiatric Intensive Care Units.

Method: A questionnaire was sent to ward managers of every Psychiatric Intensive Care Unit in London for completion on a chosen census day. Individual demographic and clinical patient characteristics were collected, along with admission and discharge pathways.

Results: Of 186 patients on 17 NHS PICUs in London, we obtained data for 172. 80% of patients were male, with a mean age of 33; 50% were Black and all but 2 were involuntarily detained. 66% had a diagnosis of schizophrenia and 55% of admissions were due to physical aggression. 73% of the sample had at least one ‘complex need’, which was most commonly substance misuse. Black patients were younger, more likely to be male and to have a forensic history (54% vs. 31%) than white patients. A slightly lower percentage (70% vs. 79%) of Black patients were described as having complex needs. White patients were more likely to have a personality disorder or a second diagnosis.

Conclusions: Patients admitted to psychiatric intensive care units were most likely to have major psychosis, complex needs and to use illicit substances. Ethnic variations warrant further study.

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

Background: In acute psychiatry, seclusion has traditionally been used to manage people at risk of harming themselves or others. However, being secluded can be traumatising and cause harm to service users and staff. In North America, sensory modulation strategies and a focus on early identification of aggression warning signs and tailored responses have significantly improved care and reduced seclusion use.

Methods: A six-month pilot of the use of sensory modulation strategies and a brief sensory and risk assessment tool (Safety Tool) was implemented on a 30-bed acute psychiatric unit. Indicators of the impact on seclusion use were audited from service users’ files with feedback collected from clinical staff.

Results: Safety Tools for 43 psychiatric intensive care service users were audited. They required significantly longer hospitalisation (mean=39.4 days) than was the average for the unit (mean=19.0 days). Whereas 65% had been previously secluded, only 26% were secluded after completing a Safety Tool. Most staff had completed or read a Safety Tool with 76% saying it should become part of standard care.

Conclusion: Findings support the significant role that sensory assessment and engagement can play in improving service user care in acute psychiatry.

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.

The need to map women’s secure hospital services in terms of patient population and service needs over time is acknowledged given: the increase in forensic and medium secure beds nationally; and limited gender specific analysis in previous studies. Data is presented relating to 65 consecutive admissions (over a 6-year period) to a women’s medium secure unit at three (14-month) time periods. Trends noted in population statistics include a decline in special hospital referrals and an increased proportion of prison referrals with an index offence of arson in the past two years in association with a lower level of cognitive functioning, and a higher level of assaultative behaviour. In accord with the responsivity principle (Ogloff & Davis, 2004) the implications for treatment and service planning for this changing population are discussed.

Clozapine is used in combination with psychotropic medication and a wide variety of non-psychotropic medications. This article reviews the literature on clozapine drug interactions and the effect these have on serum level changes in clozapine. A total of 54 articles with a total of 109 individual case reports were obtained by manual and computerised literature search from January 1970 to May 2013. Psychotropic medications most likely to increase clozapine levels include: fluvoxamine, lamotrigine, aripiprazole and the discontinuation of levomepromazine and carbamazepine. Non-psychotropic medications associated with increase in clozapine levels include: erythromycin, ciprofloxacin, omeprazole, cimetidine, OCP containing ethinylestradiol, amiodarone, aluminum hydroxide and isoniazid. Rifampin and St John's wort resulted in low clozapine levels. Smoking cessation also increased clozapine levels. The role of routine clozapine monitoring in clinical practice requires further clarification. In the absence of recommendations for routine clozapine level monitoring, clinical judgment should always be used in addition to diagnostic testing. Clinicians must maintain increased clinical vigilance for adverse side effects when clozapine is combined with other medications.

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.

Introduction: Psychiatric intensive care units (PICU) are small wards, designed for the most difficult-to-manage patients. They have higher levels of nursing and other staff, are often locked, and sometimes have facilities for seclusion. Although PICU staff are often confronted with aggressive behavior, resulting in higher usage of coercive measures, there is need to increase understanding of the necessary infrastructure and treatment policy for successfully reducing seclusion and restraint.

Aim: To investigate whether patients transferred to a newly developed PICU, focused on the effective and non-coercive management of disruptive behavior, are secluded and restrained less than during earlier stays in a psychiatric unit.

Method: The effect of the newly developed PICU on reducing seclusion was evaluated in eight patients, six of whom had been diagnosed with a severe form of borderline personality disorder. The number of days in seclusion during the period before admission to the PICU was compared to the number of days in seclusion after admission to the PICU.

Results: After patients’ admission to PICU, the use of seclusion was almost completely eliminated, falling from 40% of admission days spent in seclusion before transfer to the PICU to 0.1% during their stay at the PICU.

Conclusion: When a special non-coercive infrastructure and treatment policy is applied at a PICU, seriously disturbed patients can be treated without coercive measures.

Background: Rapid tranquillisation is used when control of agitation, aggression or excitement is required. Throughout the UK there is no consensus over the choice of drugs to be used as first line treatment. The NICE guideline on the management of violent behaviour involving psychiatric inpatients conducted a systematic examination of the literature relating to the effectiveness and safety of rapid tranquillisation (NICE, 2005). This paper presents the key findings from that review and key guideline recommendations generated, and discusses the implications for practice of more recent research and information.

Aims: To examine the evidence on the efficacy and safety of medications used for rapid tranquillisation in inpatient psychiatric settings.

Method: Systematic review of current guidelines and phase III randomised, controlled trials of medication used for rapid tranquillisation. Formal consensus methods were used to generate clinically relevant recommendations to support safe and effective prescribing of rapid tranquillisation in the development of a NICE guideline.

Findings: There is a lack of high quality clinical trial evidence in the UK and therefore a ‘gold standard’ medication regime for rapid tranquillisation has not been established.

Rapid tranquillisation and clinical practice: The NICE guideline produced 35 recommendations on rapid tranquillisation practice for the UK, with the primary aim of calming the service user to enable the use of psychosocial techniques.

Conclusions and implications for clinical practice: Further UK specific research is urgently needed that provides the clinician with a hierarchy of options for the clinical practice of rapid tranquillisation.

Background: Psychiatric intensive care units (PICUs) have become a standard part of UK mental health services. They treat patients who may be very unwell and who are usually compulsorily detained. There is little published data about the clinical activity of such units to provide an evidence base for clinical governance.

Aim: To describe the socio-demographic characteristics, mental state and outcome of treatment for 332 patients admitted consecutively to seven English PICUs.

Method: Prospective, multi-centre case note analysis.

Results: PICU patients were predominantly Caucasian males, in their mid thirties, with complex needs and chronic psychotic illness often complicated by substance misuse. Most were admitted because of perceived risk of violence to others. Whilst most admissions appeared to be broadly in line with Department of Health guidelines some patients experienced an excessive length of PICU stay. Patients from particular BME groups were over-represented.

Conclusions: PICUs appear to deliver effective treatment but are not always the least restrictive environment as envisaged by the Department of Health. Further work is needed to evaluate treatment interventions and develop valid measures of quality of care.

Assessing a patient's risk of violent behaviour, predicting dangerousness and the development of a subsequent management plan have become integral and important aspects of contemporary mental health practices. What is less clear, and much discussed within the literature, is how we should best implement risk assessment and risk management practices within mental health care. The aim of this paper is to critically discuss risk assessment practices in order to propose a systematic approach to the effective assessment and management of aggression and violence in mental health settings. A critical review of the risk literature in mental health was undertaken. The literature search highlighted different generations or approaches to risk assessment methodology, which were critically reviewed. From this critical review a proposed model entitled ‘risk analysis’ is argued from the appraisal and critique of the literature as a more encompassing and collaborative approach to the assessment and management of risk.

Background: The psychological, social, and physical aspects of the ward milieu affect treatment outcomes and patient satisfaction. The primary aim of the present study was to describe and explore patients’ perceptions of their stay at a Norwegian seclusion area. The patients’ experience of having received help and support from the staff, sense of respectful treatment, information received regarding effects and side effects from medication, and feelings of security in the seclusion areas were of interest.

Method: In a given period, all patients acutely admitted to a seclusion area were evaluated on a number of rating scales. Immediately after discharge they were invited to evaluate their treatment satisfaction on an eight-item VAS-scale.

Results: The main finding is that the patients generally experienced the stay as positive. The three single items of support from the staff, a sense of respectful treatment, and feelings of security were assessed as positive, while the patients’ experience of having received help and information regarding medication was evaluated as neither positive nor negative.

Conclusion: In general, patients experienced their stay as positive. The patients that were admitted voluntarily reported significantly better experiences with regard to the help received, support from the staff, and respectful treatment.

Background: Psychiatric Intensive Care Units (PICUs) and Low Secure Units (LSUs) provide care for the most disturbed inpatients in adult mental health services. Little is known about levels of provision or how these units operate within local services. In 2002 the Department of Health (DoH) published National Minimum Standards of Care for Psychiatric Intensive Care and Low Secure Environments, but there remains a paucity of service level data to inform the specialism.

Aim: To offer the first large-scale systematic survey describing service structure and functioning of PICU and LSU.

Method: A questionnaire was sent to ward managers of every PICU and LSU in London. Information was gathered on provision, physical structure, staffing and aspects of unit functioning.

Results: 17 National Health Service (NHS) PICUs containing 193 beds, and 16 NHS LSUs containing 199 beds were identified in London. An additional one third of PICU provision was privately (non NHS) funded and managed. Bed occupancy was high (90%, PICUs; 95%, LSUs in the 8 weeks prior to census day) and waiting lists for LSU beds long (64 patients on waiting lists for LSU beds on the census day, mean waiting time for LSU bed, 93 days). The use of agency nursing staff was high (33% of staff per shift on PICUs, 28% of staff per shift on LSUs).

Conclusions: All but two units failed to meet the National Minimum Standards for PICU and LSU Environments. Improvements need to be made in provision and staffing levels for permanent nursing staff, psychology and other therapies. Idiosyncrasies exist in admission criteria, particularly with regard to informal patients in LSUs and Personality Disordered patients across the board.

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

Specific concerns have been raised about seclusion use within mental health services. However, it has been reported that one of the potential consequences of reduced seclusion use is an increase in assaults on either clinical staff or patients. In a high secure hospital a number of measures were implemented as part of a clinical governance programme. These measures will be described. Data on all episodes of seclusion and adverse incidents over a five year period was analysed. The results demonstrate a progressive and sustained reduction in seclusion use with over a sixty percent reduction in the number of seclusion episodes. We found no increase in adverse incidents in conjunction with the reduction in seclusion use. The results of this analysis demonstrate that reductions in seclusion use are achievable, without an increase in assaults on clinical staff or patients, when it is identified as both a managerial and clinical priority, supplemented by robust performance monitoring and effective clinical governance arrangements.

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.

Reducing the use of seclusion to deal with challenging behaviour is a priority in secure services for women. This study describes the concurrent introduction of a series of initiatives based on recovery principles and the full involvement of patients in their risk management plans.

Following change implementation, the first 19 patients who had completed one year of treatment were matched with 19 patients who had completed their first year of treatment before change.

A significant decline in both the number of seclusions and risk behaviour post-change was complemented by improved staff ratings of institutional behaviour, increased treatment engagement and a reduction in time spent in medium security. Staff and patients differed in terms of their ratings of the most effective strategies introduced. Patients favoured the Relational Security item of increased individual engagement and timetabled Behaviour Chain Analysis sessions. Staff viewed on ward training and use of de-escalation techniques as most effective.

Findings confirm results from mixed gender forensic mental health samples that seclusion can be successfully reduced without an increase in patient violence or alternative coercive strategies. Limitations of the study are discussed along with the need for future evaluations to address issues of fidelity and utilise vigorously designed case studies.