This chapter discusses the process of bringing a new PICU service into being. Commissioning a new complex service can be a daunting task fraught with risks. This chapter offers a systematic guide to the thinking of service managers and others invested in service development for people with acute mental health problems. It describes the issues involved with assessing the need for a new service, understanding the population who may benefit from the PICU and bringing together the relevant stakeholders. It also examines the key components of developing a high-quality PICU service, including project management, operational policy, team development, building a unit, standard setting and service evaluation. This chapter sets out the core facets representing essential considerations for developing a new service.

When psychiatric intensive care units (PICUs) were first created in the United Kingdom, they were mixed-sex wards. As time progressed, evidence grew stronger for the need to create separate PICUs for men and women. Female-only PICUs have been around for about a decade, making them a relatively novel phenomenon within the existing mental health services in the United Kingdom. Nevertheless, they play a crucial role within the wide net of mental health services. This chapter summarises the history and development of female-only PICUs and describes some female-specific characteristics of such wards. It then focuses on describing women-specific perinatal mental health presentations and services, including existing provisions for women with mental illness to access family support and contact with their children. Lastly, it discusses the clinical considerations for patients with EUPD and ASPD to access PICU settings.

Psychiatric intensive care units (PICUs) treat patients with an acute episode of a major mental illness who present with additional risk of harm to themselves or others that cannot be managed on an acute psychiatric ward. This chapter outlines standards of care that are expected upon such units, what they are and how the standards were developed with clinical rationale. It also gives examples of other guidelines and standards that impact practice within a PICU setting. It also describes the process of quality improvement in such units and how this relates to continual positive progress within a PICU setting. It alludes to how the principles of psychiatric intensive care can be incorporated within other settings and the need for clear definition of subspecialities within psychiatry.

Working within psychiatric intensive or low secure care requires effective multidisciplinary teamwork. This chapter outlines factors that contribute to the essential makeup as well as cohesion of such a team. This is especially pertinent within what can be a demanding and emotionally fraught environment. Management of challenging behaviour displayed by patients can prove difficult for both individual team members and the whole team. Resilience is needed, and this chapter highlights valuable aspects to positively improve team functioning within difficult clinical situations.

Patients with borderline personality disorder often pose challenges in various inpatient settings. It is becoming more common for the patients that exhibit severe disturbed or high-risk behaviour within the context of this diagnosis to be transferred to psychiatric intensive care units (PICUs). The role of the PICU is widely regarded as one which can provide focused, short-term interventions for high-risk patients with mental illness; therefore, the very nature of borderline personality disorder contradicts such admission criteria. This chapter provides an overview of the common presentation and complexities of this patient demographic in a PICU and provides suggestions for management strategies. The chapter also advocates an emphasis on professionals being mindful of the patient pathway from PICU to discharge, with the aim to avoid a counterproductive admission which results in containment and overly restrictive practices.

Whether or not seclusion has a place within the treatment of the mentally disordered is one of the longest running debates in the history of mental health care, and it is likely to continue. Controversial deaths in mental health facilities and their subsequent inquiries will further fuel speculation as to how best to manage challenging behaviour. This chapter provides an overview of the history of seclusion, its value or otherwise, its alternatives and the necessary supporting policies for its use. It also offers a practical framework within which seclusion may be considered in the context of psychiatric intensive care units (PICUs).

Absconding from mental health inpatient facilities is a long-standing and significant issue. Absconding is a core admission criterion for transfer to the psychiatric intensive care unit (PICU).

Psychiatric intensive care for young people is a developing specialism with a developing evidence base.

The care of young people is provided separately to the care of adults, and within such services there are particular considerations regarding such matters as presenting condition and legal frameworks.

The skills and knowledge required are highly specialist: pharmacology, psychological interventions and educational provision all require detailed procedures and expert practitioners.

The development of national standards has enabled the specialism to be better defined, it is expected that the emerging evidence base will grow in order that practice can be further improved.

Psychiatric intensive care units (PICUs) are an important provision but are significantly under-provided internationally. Law, funding and stigma all have significant influence on mental health service provision and the consequent lack of access to appropriate treatment. Whilst this varies from country to country, there are themes throughout which can be applied everywhere. Improving legal frameworks, providing more resources, educating the population and working more closely with patients will be key to creating a truly global approach to severe mental illness. PICUs are a key element in providing safe, effective care for the most unwell people. Practices such as shackling need to end and mental health care in all countries around the world must be brought front and centre in the twenty-first century, having spent so long in the shadows.

This chapter outlines the scale of the problem of substance misuse in the context of psychiatric intensive care units (PICUs) and related services. Further, it discusses relevant health inequalities and how these impact on the issue. It also reviews the characteristics of dually diagnosed patients and illustrates how substance use commonly presents in clinical practice in PICUs, low secure units (LSUs) and locked rehabilitation units (LRUs).

Management of the mental health emergency in the community is an emerging specialism in the United Kingdom. It works at the complex interface between the police and ambulance services and mental health system. This chapter provides an account of specialist psychiatric intensive care unit (PICU) experience with the associated skills and knowledge from the inpatient setting for intervening as early as possible in mental health emergencies. By offering solutions which ensure the right help is available as soon as possible, it has been found that the need for more restrictive interventions can be avoided; mental health care being consistent with other branches of clinical services in upholding the maxim that ‘prevention is better than cure’.

The phrase ‘complex needs patient’ is often used by clinicians to describe a patient who presents with challenges and needs that require management approaches that are resource intensive and multi-focused. These individuals are often passed from service to service, with high costs to services across the board. In this chapter, we seek to define ‘complex needs patients’, recognising that for many clinicians the phrase refers to those individuals who present with severe mental illnesses together with other comorbid challenges including, but not limited to, serious physical illness, substance misuse or addiction, social problems including a lack of support, homelessness as well as problematic, absent or abusive relationships and the presence of another comorbid mental illness. This chapter explores the possible aetiological factors of complexity as well as its background and characteristics and discusses useful treatment modalities. Lastly, it considers the impact that the Covid-19 pandemic has had both in terms of disease presentation and the impact it has had on services.