None.

A.M. works in a National Health Service general adult community mental health team and is an elected member of the Royal College of Psychiatrists General Adult Faculty Executive Committee.

None.

In this paper, we summarise and critique a network meta-analysis (NMA) of antidepressant efficacy and tolerability for paediatric depression and an accompanying editorial. Although we agree that many of the extant studies are flawed, this meta-analysis showed clear efficacy of fluoxetine in the NMA, and for sertraline and escitalopram in pairwise analyses. Consequently, these papers underestimate the benefits of antidepressants for paediatric depression, and provide support for current practice guideline, which recommends the use of an antidepressant if the patient does not respond to psychotherapy. In these circumstances, fluoxetine should be the first choice, with escitalopram and sertraline as alternatives.

D.A.B. receives royalties from Guilford Press, has or will receive royalties from the electronic self-rated version of the C-SSRS from eResearch Technology, Inc., is on the editorial board of UpToDate, and is a reviewer for Healthwise. R.D.G. serves as an expert witness for the US Department of Justice, Pfizer, Wyeth and GSK; and is the founder of Adaptive Testing Technologies. P.W. receives personal fees from Lundbeck and Takeda. B.D. reports a licensing agreement with Lundbeck for a psychosocial treatment manual for depression. No other disclosures were reported.

None.

Dr Poole is editor of the BJPsych Bulletin.

None.

We explored the prevalence and use of constant supportive observations (CSO) in high, medium and low secure in-patient services in a single National Health Service (NHS) mental health trust. From clinical records, we extracted data on the length of time of CSO, the reason for the initiation of CSO and associated adverse incidents for all individuals who were placed on CSO between July 2013 and June 2014.

A small number of individuals accounted for a disproportionately large proportion of CSO hours in each setting. Adverse incident rates were higher on CSO than when not on CSO. There was considerable variation between different settings in terms of CSO use and the reasons for commencing CSO.

The study describes the prevalence and nature of CSO in secure forensic mental health services and the associated organisational costs. The marked variation in CSO use between settings suggests that mental health services continue to face challenges in balancing risk management with minimising restrictive interventions.

A.B. and J.L.I. are both directly employed by the NHS trust in which the study was conducted.

None.

Following the introduction of new standards for early intervention in psychosis (EIP) in England, EIP services are accepting referrals for people aged 35–65. The Cambridgeshire and Peterborough EIP service (CAMEO) aimed to explore the immediate implications for the service, especially with regards to referral numbers and sources. Data were collected from April 2016 to June 2017.

Referrals for over-35s represented 25.7% of all new referrals. Fifty per cent of referrals for over-35s were accepted onto caseload (40.2% for under-35s). The over-35s were more likely to be referred from acute and secondary mental health services (P < 0.01) and had longer durations of untreated psychosis than the under-35s (P = 0.02).

CAMEO has received a significantly higher number of referrals as a result of age inclusivity, with an increased proportion of patients suffering from severe, acute psychotic presentations and existing mental health difficulties. This has implications for service planning.

None.

A cognitive–behavioural therapy in-patient treatment model for adults with severe anorexia nervosa was developed and evaluated, and outcomes were compared with the previous treatment model and other published outcomes from similar settings.

This study showed the Pathways to Recovery outcomes were positive in terms of improvements in body mass index and psychopathology.

Adults with anorexia nervosa can achieve good outcomes despite longer illness duration and comorbidities.

A.B., A.C. and L.H. work at The Retreat where the Pathways to Recovery were developed.

To identify temporal and demographic trends in referrals made to psychiatric liaison services. Routine clinical data from 16 105 individual referrals from three central London accident and emergency (A&E) departments to psychiatric liaison services from 2012 to 2014 were obtained and analysed using the Clinical Record Interactive Search (CRIS).

Referrals from A&E to psychiatric liaison services increased 16% over the 3-year study period. There were fewer referrals to psychiatric liaison services in winter months compared with other seasons. There were fewer referrals to psychiatric liaison services over the weekend compared with weekdays (average 15.4 daily weekday referrals v. 13.2 weekend, z = 5.1, P < 0.001), and weekend referrals were slightly less likely to result in admission to psychiatric hospital (11.3% v. 12.8%, respectively, χ2 = 6.33, P = 0.01).

Psychiatric staffing in A&E and inpatient psychiatric wards requires planning to meet temporal and regional variations in the pattern of demand.

None.

This article examines mental health disorders as individuals transition from adolescence to adulthood. Data were collected from clinical records of patients who had transitioned from child and adolescent mental health services to adult mental health services in a region in South Wales. Demographics and clinical diagnoses under both services were recorded. Patterns between adolescent and adult disorders as well as comorbidities were investigated using Pearson's χ2-test and Fisher's exact test.

Of the 98 patients that transitioned from one service to the other, 74 had changes to their diagnoses. There were 164 total changes to diagnoses, with patients no longer meeting diagnostic criteria for 64 disorders and 100 new disorders being diagnosed. Comorbidity increased in adulthood.

Diagnoses can evolve, particularly during adolescence and early adulthood. Therefore regular reassessment is paramount for successful treatment.

None.

Structured clinical judgement tools provide scope for the standardisation of forensic service gatekeeping and also allow identification of heuristics in this decision process. The DUNDRUM-1 triage tool was completed retrospectively for 121 first-time referrals to forensic services in South Wales. Fifty were admitted to medium security, 49 to low security and 22 remained in open conditions.

DUNDRUM-1 total scores differed appropriately between different levels of security. However, regression revealed heuristic anchoring on the ‘legal process’ and ‘immediacy of risk due to mental disorder’ items.

Patient placement was broadly aligned with DUNDRUM-1 recommendations. However, not all triage items informed gatekeeping decisions. It remains to be seen whether decisions anchored in this way are effective.

Dr Mark Freestone gave permission for AUC values from Freestone et al. (2015) to be presented here for comparison.

To compare rates of admission for different types of severe mental illness between ethnic groups, and to test the hypothesis that larger and more clustered ethnic groups will have lower admission rates. This was a descriptive study of routinely collected data from the National Health Service in England.

There was an eightfold difference in admission rates between ethnic groups for schizophreniform and mania admissions, and a fivefold variation in depression admissions. On average, Black and minority ethnic (BME) groups had higher rates of admission for schizophreniform and mania admissions but not for depression. This increased rate was greatest in the teenage years and early adulthood. Larger ethnic group size was associated with lower admission rates. However, greater clustering was associated with higher admission rates.

Our findings support the hypothesis that larger ethnic groups have lower rates of admission. This was a between-group comparison rather than within each group. Our findings do not support the hypothesis that more clustered groups have lower rates of admission. In fact, they suggest the opposite: groups with low clustering had lower admission rates. The BME population in the UK is increasing in size and becoming less clustered. Our results suggest that both of these factors should ameliorate the overrepresentation of BME groups among psychiatric in-patients. However, this overrepresentation continues, and our results suggest a possible explanation, namely, changes in the delivery of mental health services, particularly the marked reduction in admissions for depression.

None.

We aimed to evaluate clinical note documentation of valproate prescribing and establish the level of knowledge among women of child-bearing potential regarding valproate-associated adverse effects, including teratogenesis, in a regional Irish mental health service.

Of the 42 women prescribed sodium valproate, 21.4% (n = 9) had some documentation in relation to associated risks and 33.3% (n = 14) described an awareness of these risks from consultation with their treating mental health team. On clinical interview, 9.5% (n = 4) of individuals with clear documentation of the risks of teratogenesis described no such awareness. Augmentation with lithium was associated with greater awareness of the teratogenic risks of valproate (P = 0.011).

A clear description of the teratogenic risks of valproate and potential management strategies, including advice regarding contraception and supplementation with folic acid, should be clearly documented and provided repeatedly and in context to all women of child-bearing age who are prescribed valproate.

None.

Caring for patients with personality disorder is one of the biggest challenges in psychiatric work. We investigated whether mentalisation-based treatment skills (MBT-S) teaching improves clinicians' understanding of mentalising and attitudes towards personality disorder. Self-report questionnaires (Knowledge and Application of MBT (KAMQ) and Attitudes to Personality Disorder (APDQ)) were completed at baseline and after a 2-day MBT-S workshop.

Ninety-two healthcare professionals completed questionnaires before and after training. The mean within-participant increase in scores from baseline to end-of-programme was 11.6 points (95% CI 10.0–13.3) for the KAMQ and 4.0 points (1.8–6.2) for the APDQ.

MBT-S is a short intervention that is effective in improving clinicians' knowledge of personality disorder and mentalisation. That attitudes to personality disorder improved overall is encouraging in relation to the possibility of deeper learning in staff and, ultimately, improved care for patients with personality disorder.

None.

The increased rates of smoking in people with mental illness is well documented, and establishing smoke-free mental health environments has been emphasised over recent years. This article examines the financial costs of implementing smoke free guidance and assesses the cost associated with patients who were prescribed clozapine and who committed to stopping smoking cigarettes for the duration of the study period.

Patients (38) who were prescribed clozapine were included in the study. A moderate reduction in dose was noted with a moderate reduction in prescribing costs. The total increase in cost for the whole group, however, was £17 624, largely due to the use of nicotine replacement therapy and an increase in the number of clozapine assay tests.

Further studies on implementing this important policy change are needed. The positive effects must be balanced with increased financial pressure on Mental Health Trusts.

None.

A national survey investigated the implementation of mental health crisis resolution teams (CRTs) in England. CRTs were mapped and team managers completed an online survey.

Ninety-five per cent of mapped CRTs (n = 233) completed the survey. Few CRTs adhered fully to national policy guidelines. CRT implementation and local acute care system contexts varied substantially. Access to CRTs for working-age adults appears to have improved, compared with a similar survey in 2012, despite no evidence of higher staffing levels. Specialist CRTs for children and for older adults with dementia have been implemented in some areas but are uncommon.

A national mandate and policy guidelines have been insufficient to implement CRTs fully as planned. Programmes to support adherence to the CRT model and CRT service improvement are required. Clearer policy guidance is needed on requirements for crisis care for young people and older adults.

None.

We examined whether intensive home treatment (IHTT) was beneficial for acute schizophrenia, using the Clinical Global Impression (CGI) scale as a measure of severity and change, between 2011–2015. Demographic and clinical details were collected.

309 cases were referred to IHTT, comprising 245 separate individuals. This represented all severe acute psychotic episodes in Edinburgh during the study period. Three quarters of individuals had an improvement in CGI following IHTT and were safely managed at home. Thirty-nine per cent of all people received three or more regular medications. Comorbid drug and alcohol misuse was also frequently seen.

IHTT can be beneficial to those suffering an acute episode of psychosis and has been shown to improve overall clinical outcome based on the CGI. Medication polypharmacy, as well as drug and alcohol use, are commonly seen in this population.

M.T. worked in IHTT at the time of the study, and has received fees and/or hospitality from Janssen, Lundbeck and Otsuka in the past 3 years.