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Night-time confinement, locking patients in their bedrooms overnight, is practiced within high-secure hospitals in the UK. This article provides context, sets out the history and reviews the ethical and pragmatic issues at stake. Thought is given to the future, where we appear to be moving toward a different approach.

E.S. is a consultant forensic psychiatrist at Ashworth Hospital. All his patients are confined at night. He represents the Royal College of Psychiatrists Forensic Faculty at the National Oversight Group, which is the strategic advisory body providing assurance to NHS England regarding the commissioning and provision of high-secure services.

C.B. is editor of the BJPsych Bulletin trainees' section.

The influence of pharmaceuticals on the environment is an increasing concern among environmental toxicologists. It is known that their growing use is leading to detectable levels in wastewater, conceivably causing harm to aquatic ecosystems. Psychotropic medication is one such group of substances, particularly affecting high-income countries. While these drugs have a clear place in therapy, there is debate around the risk/benefit ratio in patients with mild mental health problems. Therefore, it is necessary to evaluate the wider implications as risks could extend beyond the individual to non-target organisms, particularly those in rivers and estuaries.

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We aimed to examine clinical and risk outcomes at follow-up, and reoffending and readmission rates, for a sample of 50 admissions to a female medium secure unit (MSU). Demographic, clinical risk assessment (HCR-20 and HoNOS-Secure) and quality of life data were collected using validated measures for all admissions to a female MSU ward in London, UK, between April 2008 and November 2014.

All clinical and risk assessment scale scores had improved at follow-up. Quality of life compared favourably to community samples and was good for physical, social and environmental factors and acceptable for psychological health. Twenty-six per cent had at least one readmission, while 17.5% reoffended in the period studied. A longer duration of admission and use of restrictions on discharge was associated with reduced reoffending, but not readmission.

Admission is associated with improvement on clinical risk assessment at follow-up. Longer hospital admissions and use of restrictions on discharge may be necessary to prevent reoffending in this group.

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We assessed venous thromboembolism (VTE) risk, barriers to prescribing VTE prophylaxis and completion of VTE risk assessment in psychiatric in-patients. This was a cross-sectional study conducted across three centres. We used the UK Department of Health VTE risk assessment tool which had been adapted for psychiatric patients.

Of the 470 patients assessed, 144 (30.6%) were at increased risk of VTE. Patients on old age wards were more likely to be at increased risk than those on general adult wards (odds ratio = 2.26, 95% CI 1.51–3.37). Of those at higher risk of VTE, auditors recorded concerns about prescribing prophylaxis in 70 patients (14.9%). Only 20 (4.3%) patients had a completed risk assessment.

Mental health in-patients are likely to be at increased risk of VTE. VTE risk assessment is not currently embedded in psychiatric in-patient care. There is a need for guidance specific to this population.

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David Gilbert is Director of InHealth Associates Ltd, a small consultancy organisation that supports patient and public engagement.

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To systematically review the literature on barriers to the use of clozapine and identify any interventions for optimizing clozapine use in treatment-resistant schizophrenia. Journal databases were searched from 1972 to March 2018. The following search terms were used: treatment-resistant schizophrenia, clozapine, barriers, use, prescription rates, implementation, clozaril and prescribing practices. Following a review of the literature, 15 papers were included in the review.

The major barriers that were identified included mandatory blood testing, fear of serious side-effects and lack of adherence by the patients, difficulty in identifying suitable patients, service fragmentation, and inadequate training in or exposure to using clozapine.

In view of consistent evidence across the studies on inadequate knowledge and skills as a significant barrier, we suggest that a certification requiring competence in initiating and managing side-effects of clozapine becomes a mandatory requirement in training programmes.

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Admissions of patients to secure forensic hospitals are often lengthy. Previous research has examined factors associated with prolonged admission, but studies analysing admission data at a single medium secure unit (MSU) over a prolonged time period are lacking. We compared admission data for all patients admitted to a MSU in England during the years 1985, 1995, 2005 and 2012.

The median length of admission increased from 167 days in 1985 to 580 days in 2012, though not in the intervening cohorts. There have been changes in the discharge destination of patients, away from independent accommodation in the community towards further care or supported accommodation.

The results suggest a change in the delivery of care. Further studies should be performed to assess whether the same trends exist at other sites. If these trends are also found elsewhere, this should trigger a specialty-wide discussion about admission length and its effects on bed availability.

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To understand the experience of companions of patients seen in the emergency department by liaison psychiatry teams. Participants were recruited via purposive sampling following a recent visit to the emergency department of an inner- or outer-London hospital. Semi-structured interviews were administered to all participants.

Two major themes were generated. The first concerned the appropriateness of the clinical space, in which ‘noise’, ‘privacy’ and the ‘waiting area’ were subthemes. The second was communication with staff, including subthemes of ‘wanting more information’ and a ‘desire to be more involved’.

Liaison psychiatry services should consider appropriateness of the clinical space, promoting improved communication between staff and patients' companions, and a review of the information provided to companions in the emergency department. This research offers a novel perspective on liaison psychiatry and will enhance current understanding and clinical practice.

The OPTIMA mood disorders service is a newly established specialist programme for people with bipolar disorder requiring frequent admissions. This audit compared data on hospital admissions and home treatment team (HTT) spells in patients before entry to and after discharge from the core programme. We included patients admitted between April 2015 and March 2017 who were subsequently discharged. Basic demographic data and numbers of admissions and HTT spells three years before and after discharge were collected and analysed.

Thirty patients who completed the programme were included in the analyses. The median monthly rate of hospital admissions after OPTIMA was significantly reduced compared with the rate prior to the programme. HTT utilisation was numerically reduced, but this difference was not statistically significant.

These results highlight the effectiveness and importance of individually tailored, specialist care for patients with bipolar disorder following discharge from hospital.

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The National Institute for Health and Care Excellence recommends involving the families of patients admitted to psychiatric hospital care, without specific guidance on how to do it. To improve family involvement in a National Health Service psychiatric intensive care unit, a relatives' and carers' clinic was set up. Fifty family members attended and completed questionnaires. Nine went on to take part in interviews, the results of which were analysed using thematic analysis.

Families felt more informed and found the increased access to information useful. They felt that the process showed respect for them and their family member, and that their contribution was valued. Running throughout the interviews was the contrast with previous experiences; families reported feeling heard and understood and attributed this in part to timing and environment.

The clinic was viewed positively by families and met the trust's commitment to including carers, as well as national guidance which suggests it should be part of routine practice.

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Schizophrenia is a psychotic disorder that is stereotypically stigmatised as untreatable and associated with violence. Several authorities have suggested that changing the name, for example to psychosis, would reduce such stigmatisation. We aimed to compare attitudes to schizophrenia and psychosis on Twitter to see if psychosis was associated with less negative attitudes. Tweets containing the terms ‘schizophrenia’, ‘schizophrenic’, ‘psychosis’ or ‘psychotic’ were collected on www.twitter.com and were captured with NCapture. On NVivo, tweets were coded into categories based on user type, tweet content, attitude and stigma type by two independent raters. We compared the content and attitudes of tweets referring to schizophrenia/schizophrenic and psychosis/psychotic.

A total of 1120 tweets referring to schizophrenia/schizophrenic and 1080 referring to psychosis/psychotic were identified over two 7-day periods; 424 original tweets for schizophrenia and 416 original tweets for psychosis were included in the analysis. Psychosis was significantly more commonly included in tweets expressing negative attitudes (n=131, 31.5%) than schizophrenia (n=41, 9.7%) (χ² = 237.03, P < 0.0001). Of the personal opinions or dyadic interactions, 125 (53.4%) in the psychosis data set were stigmatising, compared with 33 (24.6%) of those in the schizophrenia set (χ² = 44.65, P < 0.0001).

The terms psychosis/psychotic are associated with a significantly higher number of tweets with negative content than schizophrenia/schizophrenic. Together with other evidence, this suggests that changing the name of schizophrenia to psychosis will not reduce negative attitudes toward the condition.

S.L. has received personal fees from Otsuka and Sunovion, and personal and research fees from Janssen.

The concept of personal resilience is relevant to physician well-being, recruitment and retention, and to delivering compassionate patient care. This systematic review aims to explore factors affecting personal resilience among psychiatrists, in particular, those that may impair well-being and those that facilitate resilience practice. A literature search was performed of the Ovid®, Embase®, CINAHL and PsycINFO databases, using keywords to identify empirical studies involving psychiatrists that examined resilience, stress and burnout from the past 15 years.

Thirty-three international English language studies were included, showing that a combination of workplace, personal and non-workplace factors negatively and positively influenced well-being and resilience.

Given that workplace factors were the most commonly cited, it would appear that any resilience package that predominantly targets interventions at the workplace level would be particularly fruitful. Future research, however, needs to address the absence of a universal measurement of well-being and its moderators so that any potential interventions are better evaluated.