To validate care cluster allocation for payment by results (PbR) in mental health and to evaluate clustering and auditing methodologies. We applied exclusion criteria to the patient population of a mental health trust. An automated validation compared cluster with expected ICD-10 codes or scores on the Health of the Nation Outcome Scales (HoNOS) and Mental Health Clustering Tool (MHCT). Six hundred ‘mismatched’ cases were reviewed in depth to better understand the reasons why these cases appeared misclustered.

There was a significant mismatch between ICD-10 codes, HoNOS and MHCT scores and allocated care cluster, with differences between services and localities. Some clusters appeared to be more accurately allocated. The ‘deep dive’ analysis indicated that most mismatches occurred because psychosis was allocated to a non-psychotic cluster and vice versa, but also as a result of inherent weaknesses of the MHCT.

High levels of inappropriate care cluster allocation highlight the need to improve practice. Weaknesses in the MHCT and ICD-10 coding mean that the final arbiter should be clinical judgement. Auditing will, by necessity, have a significant margin of error.

We examined readmission to psychiatric hospital of 550 patients discharged from one medium secure unit over 20 years. Multiple sources were used to obtain readmission data.

Readmission was common, particularly to non-secure psychiatric hospitals. At least 339 patients (61.6%) were readmitted to any psychiatric hospital (mean follow-up 9.5 years), with over a third (37.6%) subsequently being readmitted to medium- or high-security or both. Of those discharged directly to the community, having previous in-patient treatment and a Mental Health Act classification of mental illness were associated with shorter time to first readmission.

The long-standing nature of disorders is evident in the high rates of readmission overall and the need for readmission to medium and high secure services, suggesting that these patients require long-term follow-up and support from mental health services.

A cross-sectional study to ascertain levels of personal and perceived public mental illness stigma in a university student population and the association between the respective levels of stigma and help-seeking intention. An adaptation of the Discrimination-Devaluation scale was used.

A total of 735 students participated in the study (response rate 77%). There were higher mean perceived public stigma levels than personal stigma levels. Perceived public stigma was not significantly associated with future non-help-seeking intention (odds ratio (OR) = 0.871, P = 0.428). Personal stigma was significantly associated with a decreased likelihood of future help-seeking intention (OR = 1.44, P = 0.043). Being younger than 25, having no history of or treatment for mental illness and having no personal contact with someone with a history of mental illness were all associated with higher personal stigma levels.

This study indicates that personal stigma as distinct from perceived public stigma is a significant barrier to mental health utilisation for a student population and future stigma reduction campaigns could strategically focus on this.

To detail changes in the use of place of safety orders in England, including the outcome of these detentions, using publicly available data.

There was a sixfold increase in the rate of the Mental Health Act Section 136 detentions to places of safety in hospitals between 1984 and 2011. The use of Section 135 and the rate of subsequent detention under Section 2 or 3 also increased, but the proportion of people detained fell as the absolute rate of detention increased. There was a wide variation between regions in the use of hospitals or police stations as places of safety. The change in the annual rate of detention under Section 136 was associated with the annual change in the population of England.

The increase in detentions to places of safety in hospitals may in part reflect their move from police cells. It may also reflect a real increase in overall rate of detention and possibly a change in the threshold for the use of Section 136 detentions.

We audited prescribing within our area to ascertain how widespread the practice of antipsychotic polypharmacy using clozapine was, and whether it was being carried out within existing standards, including those of high-dose monitoring when required.

Data on 169 patients were reviewed in year one, rising to 193 in year three. Around 30% of patients on clozapine received additional antipsychotic medication. A disturbingly low proportion of patients on clozapine whose antipsychotic polypharmacy brought them into the high-dose range were being monitored appropriately after three audit cycles (the proportion rose from 10% in cycle 1 to 28% in cycle 3). A wide range of additional antipsychotic medications was used.

Clozapine antipsychotic polypharmacy was prevalent at just below a third of all patients in this review. Prescribers should be alert to the fact that clozapine antipsychotic polypharmacy can push patients into the high-dose range and ensure appropriate monitoring.

To evaluate outcomes for service users during their first year of treatment in three English assertive outreach teams. Changes in health and social functioning, engagement with services, service use and need (rated by staff and service users) were evaluated.

In 49 service users we found a significant increase in mean staff-rated met needs up to 6 months of treatment. There were no significant changes in ratings of engagement or Health of the Nation Outcome Scales (HoNOS) scores at 6 and 12 months. Unmet needs rated by service users and staff showed a non-significant trend for improvement across a range of individual health and social domains. Duration of hospital admission reduced significantly between the 12 months before the evaluation and the 12 months of the evaluation. Formal and informal admission and levels of contact with crisis teams reduced over the study period.

Although these results offer some support to the assertive outreach approach, further research in larger samples is needed to identify which changes in health and social functioning are associated with transfer to assertive outreach teams.

This is a longitudinal, observational prospective study carried out in a 50-bedded dementia care unit. Fifty patients who had been assessed in 2009 as part of an earlier study were reassessed 2 years later.

All patients had a diagnosis of dementia, with Alzheimer's dementia being the most common. By 2011, 23 (46%) patients reviewed in 2009 were deceased. We found that there was a reduction in psychotic symptoms in patients 2 years later despite none of them being on antipsychotics. The most common problems on follow-up were apathy, agitation and aggression, irritability and anxiety.

Our findings support the view of the need to regularly review patients with dementia who have psychotic symptoms that require antipsychotics, as long-term treatment may not be required or beneficial in light of known adverse side-effects.

A baseline audit of trainees' ability to recognise Wernicke's encephalopathy and initiate appropriate thiamine regimes in an in-patient alcohol detoxification unit was carried out. Based on the findings, gaps were addressed using targeted education and training, and their impact on improving standards of managing Wernicke's encephalopathy was re-audited.

The initial audit revealed that trainees' ability to recognise Wernicke's encephalopathy and initiate thiamine was inadequate. Significant improvement in appropriate use of treatment regime (P < 0.05) of thiamine and the monitoring of clinical response was observed after addressing the initial gaps through education.

Treatment of Wernicke's encephalopathy can be inadequate, given a lack of awareness of clinical presentation and appropriate management. This can be addressed through education and training.

To inform the development of a new, recovery-oriented rehabilitation service, identify local needs and create a pathway for appropriate referrals, accelerating the build up of case-load. We surveyed 1353 secondary service users using a purpose-made needs assessment and case identification questionnaire, completed by nominated care coordinators.

Significant unmet need for rehabilitation and recovery-oriented interventions was found. The results were used to invite referrals, create a case-load of 150 and allocate the appropriate resources for the new team.

The results highlight the untapped recovery potential among users of mainstream secondary mental health services and support investment in rehabilitation at a time of resource restriction. This work also supports a similar, evidence-based approach to targeting appropriate referrals during the development and the early stages of rehabilitation services.

Voice recognition software is promoted to improve clinician efficiency and decrease overall costs. Our aim was to compare its efficiency against the traditional method of dictation and typing in an older people's community mental health team. We compared the time taken to dictate, edit and type letters, and the total number of days required to send them out after seeing the patient, using the two methods. We also correlated the time taken by one doctor to dictate and edit clinic letters with the actual days on which they were dictated.

The voice recognition system reduced the time taken to turn around clinic letters but at the cost of increased doctor's time being spent on dictating and editing the letters. We found no increase in efficiency with experience.

The benefits of faster letter production may be outweighed by the effect of the extra time spent by clinicians to the detriment of their other commitments. The narrative form of psychiatry letters may make them less suited to computer transcription than those in other specialties.

To assess the views of trainees and trainers of the impact of the European Working Time Directive (EWTD). The study was conducted in two stages. First, a qualitative survey of trainees and trainers in the Oxford Deanery was carried out on the positive and negative aspects of the EWTD to identify key areas. Second, a self-completed questionnaire was developed separately for trainees and trainers and the results collated. Twenty trainers and nineteen trainees took part in the study.

About 70% of trainees and trainers were aware of the EWTD objectives. Ninety per cent of trainers and 30% of trainees believed that the introduction of the EWTD was a negative development. Compared with 42% of trainees, 80% of trainers believed that the EWTD had not improved the quality of care and instead had a negative effect on doctor–patient alliance and continuity of care. Although 53% of trainees believed that the quality of training was not compromised by the introduction of the EWTD, 84% of trainers thought otherwise. Less hands-on experience and some doctors' roles being given to other professionals were the most stated negative impacts of the EWTD on the quality of doctors' training. Positive effects of the EWTD from both trainees' and trainers' points of view were a better work-life balance and less burnout for junior doctors.

The EWTD may not have been successful in achieving all of its intended objectives. Further studies on different sample groups would help clarify the wider impact of the EWTD.

To evaluate the effect of liothyronine administration on the cognitive side-effects of electroconvulsive therapy (ECT), 30 participants with major depressive disorder that were suitable candidates for ECT were randomly allocated to either a liothyronine or a placebo group. Participants in the liothyronine group received a daily 50 μg dose for the whole period of receiving ECT starting the day before ECT, whereas the other group received a placebo. The Hamilton Rating Scale for Depression (HRSD) and the Wechsler Memory Scale – revised (WMS-R) were used for evaluating mood and memory before the first ECT session and after the sixth session (the HRSD was also used after the third session).

The results indicated that after the sixth ECT session, participants that received liothyronine achieved significantly better scores on the HRSD and WMS-R.

Further studies with a larger number of participants, through multicentre research projects, are indicated to obtain adequate data for meta-analysis and systematic review.

A completed audit cycle, consisting of email surveys of all psychiatrists and a review of acute trust information technology registers was undertaken in Derbyshire Healthcare NHS Foundation Trust, to assess whether psychiatrists could access electronic laboratory results from the neighbouring acute trust laboratory. This was replicated in Nottinghamshire Healthcare NHS Trust, with an initial audit; plans were then implemented to increase access.

In Derbyshire, 14% of psychiatrists could access electronic results initially, with limited ward access. By re-audit, all wards had access, and 28% used those systems. The later initial audit in Nottinghamshire Healthcare Trust revealed 6% access.

Benefits of electronic results include clinical (faster decisions, safer monitoring, prompt detection of acute problems); efficiency savings (less wasted time telephoning); and other (improved relationships with general practitioners and laboratories, reduced marginalisation of patients with mental illness and professionals). There may be considerable clinical and efficiency savings for trusts.

Electroconvulsive therapy (ECT) prescription rates in Scotland are decreasing. This study aims to look for possible causes, in particular psychiatrists' attitudes. Ninety-one Scottish psychiatrists completed a survey in 2009 relating to demographics, training, current practice, National Institute for Health and Care Excellence (NICE) guidelines and attitudes.

The mean number of times the psychiatrists had prescribed ECT in the past 2 years was twice. About 43% felt that their prescribing rates had decreased. Reasons for this included more effective medication, public and patient perception, and NICE guidelines. There was a significant correlation between doctors' gender and estimated prescription rates (P = 0.004), however, not with other prescription data. Almost all surveyed psychiatrists (97%) agreed that ECT has a place in current psychiatric practice.

Despite generally positive attitudes to ECT shown by psychiatrists in this study, prescription rates were low and decreasing. With more effective medication the role of ECT in therapy appears to be changing.

In April 2007, the National Specialist Commissioning Team of the Department of Health commissioned a group of services to provide treatment to patients with the most severe and profound obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD). We decided to examine the usage of these services across England 4–5 years after the start of the new funding arrangements. This survey used data about patients treated in the financial year 2011–2012.

Despite the services offering intensive home-based as well as residential and in-patient services, there was a greater proportion of referrals from London, the South East of England and counties closer to London.

It is important that all patients, regardless of where they live, have access to highly specialist services for OCD and BDD. We discuss potential ways of improving this access but we hope this paper will act as a discussion forum whereby we can receive feedback from others.

To review the evidence for the use of paliperidone palmitate for people with schizophrenia and schizophrenia-like illnesses. We searched the Cochrane Schizophrenia Group Specialised Register and contacted the manufacturer of paliperidone palmitate, the US Food and Drug Administration, and the authors of papers that reported study results.

Based on the evidence from five short-term, placebo-controlled studies, paliperidone palmitate is efficacious as an antipsychotic. Its adverse effects are similar to those of the closely related compounds paliperidone and risperidone. Extrapyramidal side-effects, weight gain and tachycardia are more common with paliperidone palmitate than placebo. Paliperidone palmitate was associated with substantial increases in serum prolactin but not with increased sexual side-effects in these studies. In two studies paliperidone palmitate was similar to depot risperidone.

Paliperidone palmitate is an effective antipsychotic whose optimal dose appears to be between 39 and 234 mg every 4 weeks. We have no data assessing its long-term effectiveness or comparing it with any long-acting injected antipsychotic other than depot risperidone.

Community treatment orders (CTOs) have been used more than anticipated. We report data from the North Wales audit about their current use and explain how a SMART framework can be used to potentially improve their effectiveness.

Findings from this audit confirm those from other studies, with the reasons for use of CTOs extending beyond that of medication adherence to risk management. The combined recall and voluntary admission rate was 40%, which raises questions about the effectiveness of CTOs.

More research is needed as it remains to be seen whether CTOs are able to achieve their intended aims. The SMART framework can be used to aid clinicians in ensuring that conditions placed on patients have a specific purpose and are clinically meaningful.

Crisis resolution and home treatment teams (variously abbreviated to CRTs, CRHTTs, HTTs) were introduced to reduce the number and duration of in-patient admissions and better manage individuals in crisis. Despite their ubiquity, their evidence base is challengeable. This systematic review explored whether CRTs: (a) affected voluntary and compulsory admissions; (b) treat particular patient groups; (c) are cost-effective; and (d) provide care patients value.

Crisis resolution teams appear effective in reducing admissions, although data are mixed and other factors have also influenced this. Compulsory admissions may have increased, but evidence that CRTs are causally related is inconclusive. There are few clinical differences between ‘gate-kept’ patients admitted and those not. Crisis resolution teams are cheaper than in-patient care and, overall, patients are satisfied with CRT care.

High-quality evidence for CRTs is scarce, although they appear to contribute to reducing admissions. Patient-relevant psychosocial and longitudinal outcomes are under-explored.