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.

Substance abuse is a frequent comorbidity in patients referred for severe acute psychiatric disorders, but is not always documented in medical record diagnoses. We estimated the presence of substance abuse problems in 74 acute patients in a psychiatric intensive care unit. Instruments used were the AUDIT (Alcohol Use Disorders Identification Test), and DUDIT (Drug Use Disorders Identification Test). Medical record diagnoses were divided into four groups: psychotic disorders (N=18), affective disorders (N=34), substance abuse disorders (N=9) and other diagnosis (N=13).

The AUDIT questionnaire indicated scores above cut-off for seven (38.9%) patients with a psychotic disorder, 18 (52.9%) with an affective disorder, six (66.7%) with a substance abuse diagnosis and three (23.1%) with other diagnoses. The DUDIT questionnaire indicated scores above cut-off for six (33.3%) patients with a psychotic disorder, four (11.8%) with an affective disorder, seven (77.8%) with a substance abuse diagnosis and none of the patients with other diagnoses. The sensitivity and specificity of the AUDIT test in this sample were calculated as 0.67 and 0.57 respectively and of the DUDIT test as 0.78 and 0.13 respectively.

Substance abuse in patients in an acute ward is under-communicated in medical record file diagnoses. Using tests could enhance diagnostic accuracy and help clinicians in choosing correct treatment.

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.

Background: PICUs traditionally manage patients who can display disturbed behaviour. Recent guidance has advocated patient engagement in outlining preferences regarding management strategies should they display such behaviour.

Aim: To audit the use, within one PICU, of a mechanism that formally records individual patient preference in management of episodes of acute disturbed behaviour.

Method: Two sets of fifteen retrospective case note analyses in an audit cycle.

Results: Initial findings revealed that advance statements were completed by eight of the fifteen patients admitted (53%). Patients’ wishes were followed for two thirds of patients following incidents needing interventions. Following changes to practice, although only minimal improvement occurred in patients completing advance statements, they were completed sooner after admission and, despite more incidents needing interventions, patients’ wishes following episodes of disturbed behaviour were followed in two thirds of those who completed an advance statement.

Conclusion: Use of advance statements regarding management of disturbed behaviour can be introduced in PICUs and this should be advocated.

Background: Some psychiatric illnesses tend to predispose patients to metabolic syndrome. Some psychiatric medications have been linked with an elevated risk of metabolic syndrome. Metabolic syndrome has an increased risk of cardiovascular disease and type 2 diabetes.

Method: The following data were obtained from the last 6 months’ medical notes of inpatients in two rehabilitation units: waist circumference; BP; fasting blood tests: triglycerides, HDL cholesterol and glucose; psychiatric and medical diagnoses and medication.

Results: 58% of the patients met the criteria for metabolic syndrome. However, due to lack of appropriate physical monitoring in some cases, only 19% had previously been diagnosed. Therefore not all the patients with metabolic syndrome were being appropriately treated or monitored.

Conclusion: A systematic approach to assessment and management of physical health needs in people with severe mental illness is necessary. Suggestions for improvement include: healthy lifestyle encouragement; refer patients with metabolic syndrome to GP for treatment; optimization of current psychiatric treatment; monitor waist circumference, fasting lipids and glucose 4 times a year if patient has ≥ 3 criteria, or twice yearly if patient has 0–2 criteria; monitor BP monthly for all patients.

Evidence suggests violence and aggression are key reasons for admission to Psychiatric Intensive Care Units (PICUs). Research and national guidelines highlight the potential benefits of anger management interventions in this setting, however such interventions are often only offered in a minimal number of units. This paper describes the implementation of a two session cognitive behaviour therapy informed anger management intervention within a PICU setting. Twelve service users completed the sessions. There was a statistically significant reduction in the frequency of violent and aggressive incidents instigated by these patients in the two week period post intervention compared to the two weeks prior. It is possible that participation in anger management sessions contributed to the reduction in violence and aggression; however, large scale, longer term research is necessary controlling for other contributing variables, in order to establish the true effectiveness of this approach.

Aims and method: NICE guidelines provide a framework for decision making with regard to the management of disturbed or violent behaviour in inpatient mental health settings, although also point to the fact that there is a limited evidence base for the use of more high risk interventions such as rapid tranquillisation, restraint, and seclusion. The current study sought to elicit the views of a team of PICU staff regarding their preference for management strategies for such behaviour.

Results: Forty-three staff assigned ranks to five intervention options: restraint to administer medication, restraint without medication, seclusion, individual counselling, and offering PRN medication. The results revealed a clear preference for individual counselling as the first choice of intervention, and offering PRN medication as a second choice. The three remaining options could not be statistically separated.

Clinical implications: The results indicate that respondents viewed the choice of intervention beyond counselling and the offer of PRN medication as an issue of clinical judgement, dependent on a range of factors relevant to the presenting clinical situation. As such they offer support for the current NICE guidelines. The results are discussed with reference to the NICE guidelines, and areas for further study are highlighted.

Giving medicines to quickly calm the severely agitated patient, in order to reduce the risk of imminent and serious violence to self or others, is referred to as rapid tranquillisation (RT).

Despite national guidelines on the management of violence, several Royal College of Psychiatrists guidelines, consensus statements, best practice guidelines, and numerous reviews of the evidence, there is no current consensus as to the first line pharmacological agent in RT.

Over the last few years there have been a number of new medicines for RT, new formulations, and new evidence. The discontinuation of droperidol injection led to more widespread use of haloperidol. The maximum dose of haloperidol has decreased, baseline ECGs are now recommended, and it is no longer licensed for IV administration. These developments have led to changes in RT practice.

In order to safely use the new medicines and new formulations it is imperative that all staff involved in prescribing and administration should be familiar with the practical use of these medicines. This includes methods of preparation and administration, specific side effects and monitoring requirements, as well as their own responsibilities in regard to these medicines.

Our objective is to overview the literature and introduce the Intentional Relationship Model (IRM) as a new framework for psychiatric intensive care. We present a case application of this model with a suicidal service user undergoing rehabilitation for a spinal cord injury. The example illustrates how IRM may be used to guide clinical reasoning when working with acutely distressed service users.

Two stays in different psychiatric hospitals left me with very differing experiences of severe mental illness. The impact of the more severe episode was much reduced due to the positive way in which staff interacted with me. Recovery was impeded during the first episode by the paucity of therapeutic relationships with staff and the absence of control over one’s medical choices. The role of being a patient was very much a negative experience and the memories of which are still with me ten years on. A positive outlook can be enormously helpful when relayed from staff to patients.

This article describes the development of a low secure service in Gloucester, England. It uses the structure of the service user journey to analyse practice and innovations which have been implemented within the service. The article refers to evidence and discusses the implications of the changing market place within which low secure services are positioned.

Rapid tranquilization (RT) is a procedure used in an inpatient setting to deal with acute behavioural disturbance not manageable by other means. The 2gether NHS Foundation Trust has an RT policy which incorporates the National Institute of Clinical Excellence (NICE) guidance on best practice which breaks down into eight domains.

The aim of this audit was to scrutinize practice in relation to this policy.

The audit team sampled 50 Prevention and Management of Violence and Aggression (PMVA) incidents that occurred over a four month period at Wotton Lawn Hospital and the Montpellier Low Secure Unit in Gloucester. PMVA is a method of organized restraint involving a team of three staff used to administer parenteral RT as well as managing disturbance. Data was collected using an audit proforma.

This audit demonstrated adherence to the majority of standards in the RT policy in most incidents. However, there was a significant non-compliance in two areas: appropriate physical observations being carried out after an RT incident and administration of RT in a private area. It may be that standards were in fact met but that there was no evidence for this in the documents examined.

The authors believe that clinical practice can be improved by effective training of staff that emphasizes the need to meet standards and the importance of contemporaneous documentation following an RT incident. They have disseminated the results of this audit to appropriate clinical leads and trainers.

The audit will be repeated in 12 months’ time.

Clinical researchers in acute emergency settings are commonly faced with the difficulty of satisfying the conventional ethical requirement of obtaining informed consent, whilst ensuring a representative group of patients is recruited into studies. We discuss our own experience in addressing institutional ethical requirements to obtain informed consent in a multi-centre trial, recruiting highly agitated patients in the emergency setting in Melbourne, Australia. We suggest that, through the application of existing ethical and legal frameworks and pre-emptive communication with the key stakeholders in ethics committees, hospital insurers and legal representatives, a balance can be struck between ethical and legal requirements on the one hand, and the integrity of the research question, on the other.

Adverse cutaneous reactions are known to occur in approximately 5% of individuals prescribed antipsychotics. A case report of a 27 year old male who developed an allergic rash after six weeks of treatment with olanzapine, which reoccurred with more aggression following a single dose of risperidone, is described. To my knowledge, this is the first case to be reported in the literature.