Suicide is a problem for society. On examination, current medical/legal concepts of suicide and responsibility rely on imprecise definitions and neglect aspects of suicide which are social rather than medical. A non-medical approach to those cases of people at risk who do not suffer a mental disorder is suggested, along with factors to be considered when the actions of mental health professionals are being evaluated.

Background: Psychiatric intensive care units (PICUs) provide care for patients who may demonstrate agitation and aggressive tendencies. Such behaviour has traditionally been managed using interventions such as seclusion and/or physical restraint. There is little published data about the use of these measures within different PICUs. This paper attempts to provide such evidence as a base for clinical governance.

Aims: To describe patterns of seclusion and restraint usage within the care of 332 patients admitted consecutively to seven English PICUs.

Method: Prospective, multi-centre patient case note analysis.

Results: Within the four units that utilised seclusion in the study period, it was used on 16% of patients who had been admitted. All seven units used control and restraint and 28% of admitted patients were formally restrained at some point during their admission. There was no significant difference in mean duration of restraint or proportion of patients who were restrained between the units that used seclusion and those that did not. Use of seclusion was significantly associated with patient violence and property damage in PICU. Restraint usage was also significantly associated with patient violence and property damage but also with higher two week BPRS scores and a younger patient age.

Conclusions: It appears that PICUs manage disturbed behaviour differently, either dependent upon facilities or local policies. In attempting to reduce the use of seclusion and restraint, a multi-faceted approach must be taken both locally and nationally. PICU clinicians and service users should be integral within this.

Background: Both the National Health Service (NHS) and the private sector provide psychiatric intensive care. To date little is known about the differences between the two sectors regarding the unit functioning and characteristics of patients who are accommodated in psychiatric intensive care units (PICUs).

Aim: To compare the unit and patient characteristics of NHS and private PICUs.

Method: A cross sectional census day postal design was employed.

Results: A total of 170 PICUs (154 NHS, 16 private) were identified. NHS PICUs accommodated 1038 patients and the private PICUs housed 200 patients. Analysis of the data showed that some differences existed between the two sectors related to unit characteristics. Private units reported having higher number of beds, more nursing staff, more unit facilities and more out of area referrals than the NHS Units. Regarding the patient characteristics, private PICUs had significantly more patients with personality disorders and forensic history than the NHS PICUs. NHS patients had a shorter length of stay compared to those in the private sector. The demographic profiles of NHS and private PICU patients were similar. The majority of the patients were white, male, unemployed and single.

Conclusion: The NHS and the private sector PICUs share many characteristics in terms of unit functioning and patient characteristics, however, some significant differences between the two sectors have also emerged.

Aims: To compare the clinical characteristics of patients who absconded and those who did not abscond; and to show the types of absconding behaviour in a low secure challenging behaviour mental health unit.

Method: A retrospective case control study was conducted. Details of the absconding incidents were collected from an electronic incident database. Clinical predictors of patients who absconded (cases) and those who did not (controls) were compared. Statistical analysis was performed to determine statistical significance of the observed differences.

Results: 80 admissions resulted from 78 patients during a period of 6½ years. 22% of the inpatients absconded from the unit. 84% of the incidents occurred while patients were utilising their unescorted leave. Only one patient escaped from the building. No serious incidents resulted from any of the abscondings. On univariate analysis, the following predictors were more likely to be statistically associated with patients who absconded from the unit: a history of absconding behaviour and a history of substance misuse or dependence. A history of non-compliance with treatment, a history of sexually inappropriate behaviour and a history of childhood conduct problems showed a trend towards statistical significance.

Conclusion: The clinical characteristics of patients who abscond from low secure units show similarities with those who abscond from other psychiatric inpatient settings.

Declaration of interests: None.

Background: Both the National Health Service (NHS) and the private sector provide low secure care. Little is known about the differences between the two sectors regarding the unit functioning and characteristics of patients admitted to low secure units (LSUs).

Aim: To compare the unit and patient characteristics of NHS and private LSUs.

Method: A cross sectional census day postal design was employed.

Results: The analysis is based on 128 LSUs (98 NHS, 30 private). NHS LSUs accommodated 1084 patients and the private LSUs accommodated 359 patients. Analysis of the data showed that some differences existed between the two sectors related to the number of beds, unit facilities, interventions and the referral-discharge route. The demographic characteristics of NHS and private patients were similar. The majority of patients were white, male, unemployed and single.

Conclusion: Although the NHS and the private sector LSUs work similarly and share many characteristics in terms of the unit functioning and the patient characteristics, a few very significant differences between the two sectors have also emerged.

This article presents the initial implementation and adaptation of a group for people who hear voices in a psychiatric intensive care unit (PICU) using a cognitive behavioural therapy (CBT) approach. It highlights the lack of evidence-based psychosocial group interventions designed specifically for the PICU environment and challenges the traditional medical-model of PICU care. It also highlights national policy and guidelines advocating the implementation of CBT approaches for severe and enduring mental illness. An overview of the group sessions is described, with particular focus on adaptations of the group content and delivery for PICU populations. The authors note that twenty three clients have attended the PICU voices groups to date, demonstrating the feasibility of voices groups in PICU environments. Further work is currently being undertaken including formal evaluations of group outcomes using standardised measures.

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.

Aims and method: To measure the numbers of staff and patients experiencing physical assault, and identify the perception of staff and patients regarding alcohol and drug related violence on Psychiatric Intensive Care wards (PICUs), acute adult wards and forensic wards. Postal questionnaires were received from 2761 individuals. They yielded quantitative and qualitative data. Further information arose from discussion groups of staff at feedback events.

Results: Nurses on PICUs (61%) were more likely to report assault than those on acute wards (45%) or forensic wards (33%). Patients on PICUs (25%) were significantly more likely to report assault than those on acute wards (14%) but not forensic wards (23%). Nurses were more likely than patients to report that drugs and alcohol had caused violence on their ward. Nurses on PICUs and forensic wards thought drug use was more likely to cause violence than alcohol. Compared with PICUs, more nurses considered that violence was due to alcohol and drugs on acute wards but not on forensic wards. Many nurses on PICUs carried out personal searches but few had received training in this.

Conclusion: Nurses on PICUs appear to be at particularly high risk of violence. Reducing the availability of illegal drugs on PICUs and improvement of staff training could be important means of reducing violence.

Persons with mental diseases are admitted to acute care psychiatric units during the day and night. The distribution of diagnoses given to these patients according to time of day has not previously been studied. All referrals during one year to a 27-bed facility were studied using the computerized medical records. 998 patients were referred during the year, of whom 480 were female. 47% arrived within office hours, 41% in the evening and 12% during the night. In order of frequency, patients with psychotic disorders comprised 26%, narrowly followed by the affective disorders (25%), substance abuse disorders (17%), then personality disorders (13%) and crises and anxiety disorders (12%). There is a tendency towards patients with lower diagnostic ICD-numbers (especially psychotic and affective diagnoses) arriving earlier than the other diagnostic groups. The diurnal variations in diagnoses were otherwise small.

Women with personality disorders were almost thrice as frequent as males, whereas males with substance abuse were almost twice as frequent as females. Patients above 60 years of age with non-abuse related organic disorders were mainly males (26 versus 7).

Patients > 60 years of age (N = 57) had the following frequencies of admission through the 24 hour period: 54.4%, 36.8% and 8.8% (office hours, evening, night), whereas patients below 60 years of age (N = 941) had 46.7%, 41.0% and 12.3%, respectively.

The assessment of judgment has a central role in court-appointed evaluation, especially when criminal responsibility is in debate. Psychiatry and the law view the concept of judgment differently. The legal system aims for clear determinations of right or wrong, guilty versus not guilty. In psychiatry, judgment is a more complex concept; it involves analytical thinking, socio-ethical behaviors and insight. In clinical practice, these are inter-related and affect each other. The two viewpoints meet in court where they sometimes clash. Judgment is considered preserved when all three components are intact, or when only one is impaired. Impairment of two components inevitably leads to compromise of the third and to judgment impairment as a whole, resulting in criminal non-responsibility.

Clinical vignettes, mainly from acute secured wards, will illustrate the dynamic inter-relation among the different components of judgment and show the influence of judgment evaluation as a whole in criminal law.

The diagnostic process after referral to an acute psychiatric treatment facility consists of more than the clinical investigation and laboratory tests. Psychometric tests in a broad range of languages may be such an augmentation of our diagnostic armamentarium, especially for immigrants for whom oral understanding of a dialogue may be restricted. The aim of this study was to discover whether such tests are in use, and how they are distributed among different patient categories. All referrals in one calendar year (N = 1168), as they are depicted in the hospital computerized medical records, were investigated. Fifty-six (6.1%) out of 926 ethnic Norwegians and six (3.0%) out of 198 non-Western immigrants were tested, whereas none of the 44 Western immigrants were. The difference between ethnic Norwegians and the immigrants was significant (Z = −3.05 and p = 0.002). Psychometric tests were thus almost not in use, and even less so in immigrants.

The mean number of resident days was higher among those tested, 11.7 (SD = 11.2), versus those not tested, 7.4 (SD = 10.4) days (t = 2.97 and p = 0.004). Among those tested, length of stay was not significantly different; 11.4 and 11.7 days respectively. The patients tested were older than those not tested. Mean age was 43.0 (SD = 14.4) versus 38.8 (SD = 12.1), with t = 2.65 and p = 0.03. Ethnic Norwegians had the longest mean stay, followed by Western immigrants and non-Western immigrants. The difference in resident days between all immigrants and ethnic Norwegians was significant with Z  =  −2.232 and p = 0.026. There was no such difference between Western and non-Western immigrants: Z = −0.057 and p = 0.95. The level of testing was higher in ethnic Norwegians, and the tested patients stayed longer, maybe indicating more time for testing. Whether this low test activity influences treatment quality is an unsettled question.

In England and Wales, the law allows a mentally disordered person who is in a public place and requires care or control to be taken to a Place of Safety (POS) for assessment. Historically the POS has usually been the police cells but recent policy development has supported the provision of alternative POSs. In this article we describe how a new POS was set up on a hospital site in Gloucestershire.

The anti-psychotic drug management of patients with schizophrenia and HIV-1 infection is problematic. Such individuals are prone to extra-pyramidal reactions on account of HIV-1 induced sub-cortical involvement and exacerbation of cognitive impairment due to underlying CNS infection. Compliance with treatment can be problematic due to a disordered mental state and bone marrow toxicity may also result from the combined effects of anti-psychotic and retroviral agents. It is generally thought that atypical anti-psychotic drugs are the treatment of choice in such cases.

We present the case of a 30-year-old man with a history of schizophrenia who was successfully treated with clozapine following an admission to a psychiatric unit with acute confusional symptoms secondary to HIV-related central nervous system (CNS) involvement.

This practice evaluation paper will present the case for the use of trampolining as a therapeutic activity within an acute care setting for people experiencing mental ill-health. A brief history of this activity within a therapeutic context will be outlined and a theoretically analysed rationale for the development of trampoline sessions explained. A case vignette will illustrate the argument that trampolining is a realistic and therapeutic option for people who need the care of a Psychiatric Intensive Care Unit (PICU) or Low Secure Unit (LSU). The paper will conclude that service users can find trampoline activity useful as part of a recovery journey from acute mental illness.