The COVID-19 pandemic has put the UK's National Health Service under extreme pressure, and acute psychiatric services have had to rapidly adapt to a new way of working. This editorial describes the experience of a London psychiatric intensive care unit (PICU) where all nine in-patients ultimately tested COVID-19 positive.

Little is known about the types of patients admitted to medium secure psychiatric intensive care units, which cater for some of the most mentally disordered and dangerous patients. Only one retrospective study has profiled this subgroup (Dolan & Lawson, 2001).

Using a pre-coded proforma, the study prospectively profiled patient characteristics over a year, for those who were admitted or transferred to the unit. It was predicted that patients detained under Section 3 of the Mental Health Act, 1983 (Civil section) would be overrepresented and present with more management problems.

Information on 24 patients was gathered. Patients detained under Section 3 featured heavily in the cohort and were more difficult to manage, though this did not reach statistical significance. All patients had a criminal history, particularly of violence. Serious adverse incidents on the ward were relatively infrequent. A small number of patients were responsible for the majority of adverse incidents.

The cohort demonstrated serious risk signatures and forensic histories. Management problems may not necessarily reflect underlying mental disorder. There was a trend towards violent offending and co morbid substance misuse. The unit was an effective environment. The study was limited due to low numbers of patients and a lack of comparable populations.

Introduction: Psychiatric intensive care units (PICU) are small wards, designed for the most difficult-to-manage patients. They have higher levels of nursing and other staff, are often locked, and sometimes have facilities for seclusion. Although PICU staff are often confronted with aggressive behavior, resulting in higher usage of coercive measures, there is need to increase understanding of the necessary infrastructure and treatment policy for successfully reducing seclusion and restraint.

Aim: To investigate whether patients transferred to a newly developed PICU, focused on the effective and non-coercive management of disruptive behavior, are secluded and restrained less than during earlier stays in a psychiatric unit.

Method: The effect of the newly developed PICU on reducing seclusion was evaluated in eight patients, six of whom had been diagnosed with a severe form of borderline personality disorder. The number of days in seclusion during the period before admission to the PICU was compared to the number of days in seclusion after admission to the PICU.

Results: After patients’ admission to PICU, the use of seclusion was almost completely eliminated, falling from 40% of admission days spent in seclusion before transfer to the PICU to 0.1% during their stay at the PICU.

Conclusion: When a special non-coercive infrastructure and treatment policy is applied at a PICU, seriously disturbed patients can be treated without coercive measures.

This commentary aims to explore the benefits of having a designated, specialised clinical lead on the psychiatric intensive care unit (PICU). It discusses the problems, disadvantages and risks of not having such leadership, especially where a multiple consultant psychiatrist model is employed. The impact of clinical leadership on specific aspects of work on the PICU is examined including multidisciplinary team working, patients’ clinical time and safety, decision making, resource expertise, delayed discharges, and staff stress levels. Reference is made to standards in the literature which show that departure from designated leadership on the PICU is unsatisfactory.

Background: People with severe mental illness are at increased risk of developing serious physical health problems, including metabolic syndrome, cardiac and respiratory diseases.

Aims: To audit the admission physical examinations carried out on patients admitted to a male psychiatric intensive care unit.

Method: A retrospective audit of 100 sets of case notes. After the first 45 case notes had been audited, the results were presented at a clinical meeting and an action plan formulated. A further 55 cases were then audited.

Results: Overall, 70 patients had an admission physical examination and 25 (36%) of these were abnormal. In 11 (16%) cases medical intervention was required, occasionally urgently and in 5 (7%) the abnormalities detected impacted on psychiatric diagnosis or management. In the re-audit there was no significant improvement in the proportion of patients having an admission physical but better documentation as to why one was not done and more patients had had a physical by discharge.

Conclusion: Physical examination on admission is an integral part of patient assessment and may identify underlying physical illness that may require urgent intervention and/or impact on psychiatric diagnosis or management. Clinical audit provides a means of detecting and rectifying absent admission physicals.

Objective: A paucity of research exists on the types of patients admitted to psychiatric intensive care units (PICUs), which is important in terms of identifying patient needs, training and service provision. Questions have also been raised as to whether or not ethnic minorities are overrepresented in these units.

Method: A literature review using MeSH headings from a wealth of databases was performed to identify such studies. In addition studies on ethnic minority overrepresentation in psychiatric care were also identified.

Results: Under a dozen studies were identified, mainly from the UK and Australia. Study designs tended to be basic and heterogeneous, but this was reflected in the nature of the study and the data gained. A typical PICU patient emerged, namely a young schizophrenic detained male, belonging to an ethnic minority (if in an inner city), known to mental health services with previous informal, detained and PICU admissions, admitted due to violence and often possessing a forensic history. If a complex need existed, it was usually substance misuse. The inpatient stay tended to be for less than two months and discharge was usually to an acute ward. Ethnic minorities were overrepresented in PICU care.

Conclusions: The literature review highlighted a paucity of good-quality studies in this field. The establishment of a national association of intensive care units as well as national guidelines can only improve services. The reason for ethnic minority over-representation on these units is still far from clear.