Those requiring inpatient psychiatric care should be managed in the lowest level of security necessary in a ward close to their home area. The presence of informal (voluntary) patients on secure wards appears incompatible with this principle. Can such situations be justified?

At least twenty-five years have passed since the term ‘psychiatric intensive care unit’ (PICU) was imported into the UK and Western Europe from the United States. During that time the concept of psychiatric intensive care has continued to develop, with a number of important milestones.

An Environment Assessment Inventory was developed to conduct a Nationwide survey on the physical environment of Psychiatric Intensive Care Units (PICUs) and Low Secure Units (LSUs). The Nationwide survey was conducted in England to see if the physical environment of PICUs and LSUs were adequate to meet the therapeutic and safety needs of the patients.

In this work, a detailed account has been given about the survey tool: the “Environment Assessment Inventory”, its development, uses and limitations. This tool may be used in the future for national planning and development of the PICUs and LSUs, not only by UK but also by other countries of the world.

The National Minimum Standards (NMS) for General Adult Services in Psychiatric Intensive Care Units (PICUs) and Low Secure Environ ments were published by the Department of Health in April 2002 (DOH, 2002). As a Policy Implementation Guide, the document provides each unit with a tool for benchmarking their own service and gives any stakeholder or staff member associated with PICUs/Low Secure Services something to take from it.

Background: The physical environment of a Psychiatric Intensive Care Unit (PICU) or Low Secure Unit (LSU) is one of its defining aspects. The National Minimum Standards for General Adult Services in PICUs and Low Secure Environments published by the Department of Health (2002) outlines the standards to be followed regarding design of PICUs and LSUs. Till date, no comprehensive national data exists about the standard of physical environment of these units.

Aim: To determine whether current physical environment of PICUs and LSUs are adequate to meet the therapeutic needs of patients in England.

Method: An inventory was sent to all NHS PICUs and LSUs (in England).

Results: A total of 231 units were identified as either PICUs or LSUs. Out of these, 164 valid returns were received. Sixty PICU units (62.5%) and 43 LSU units (63.5%) were good or acceptable. Thirty six PICU units (37.5%) and 25 LSU units (36.5%) failed on several issues. Analysis of the data showed that to bring the PICU/LSU Estate to a good standard is anticipated to cost approximately £140million.

Conclusion: The Department of Health has allocated funding of £30 million to be distributed amongst all the 28 Strategic Health Authorities. A further funding of £130 million has also been released to address places of safety and for upgrading PICUs and LSUs to meet the National Minimum Standards.

Declaration of Interest: The project was funded by the Department of Health.

Background: Psychiatric Intensive Care Units (PICUs) and Low Secure Units (LSUs) provide care for the most disturbed inpatients in adult mental health services. Little is known about levels of provision or how these units operate within local services. In 2002 the Department of Health (DoH) published National Minimum Standards of Care for Psychiatric Intensive Care and Low Secure Environments, but there remains a paucity of service level data to inform the specialism.

Aim: To offer the first large-scale systematic survey describing service structure and functioning of PICU and LSU.

Method: A questionnaire was sent to ward managers of every PICU and LSU in London. Information was gathered on provision, physical structure, staffing and aspects of unit functioning.

Results: 17 National Health Service (NHS) PICUs containing 193 beds, and 16 NHS LSUs containing 199 beds were identified in London. An additional one third of PICU provision was privately (non NHS) funded and managed. Bed occupancy was high (90%, PICUs; 95%, LSUs in the 8 weeks prior to census day) and waiting lists for LSU beds long (64 patients on waiting lists for LSU beds on the census day, mean waiting time for LSU bed, 93 days). The use of agency nursing staff was high (33% of staff per shift on PICUs, 28% of staff per shift on LSUs).

Conclusions: All but two units failed to meet the National Minimum Standards for PICU and LSU Environments. Improvements need to be made in provision and staffing levels for permanent nursing staff, psychology and other therapies. Idiosyncrasies exist in admission criteria, particularly with regard to informal patients in LSUs and Personality Disordered patients across the board.

Declaration of Interest: The project was part-funded by Department of Health.

Background: Psychiatric intensive care facilities have previously been poorly defined, with uncertainty existing about the appropriateness of admissions.

Aim: To offer the first large-scale systematic survey describing the clinical characteristics of patients admitted to Psychiatric Intensive Care Units.

Method: A questionnaire was sent to ward managers of every Psychiatric Intensive Care Unit in London for completion on a chosen census day. Individual demographic and clinical patient characteristics were collected, along with admission and discharge pathways.

Results: Of 186 patients on 17 NHS PICUs in London, we obtained data for 172. 80% of patients were male, with a mean age of 33; 50% were Black and all but 2 were involuntarily detained. 66% had a diagnosis of schizophrenia and 55% of admissions were due to physical aggression. 73% of the sample had at least one ‘complex need’, which was most commonly substance misuse. Black patients were younger, more likely to be male and to have a forensic history (54% vs. 31%) than white patients. A slightly lower percentage (70% vs. 79%) of Black patients were described as having complex needs. White patients were more likely to have a personality disorder or a second diagnosis.

Conclusions: Patients admitted to psychiatric intensive care units were most likely to have major psychosis, complex needs and to use illicit substances. Ethnic variations warrant further study.

Declaration of Interest: The project was partly funded by the Department of Health.

Aims: To determine the prevalence of physical illness in patients admitted to a challenging behaviour unit and to assess whether they were physically examined and investigated.

Method: Retrospective case note analysis of patients admitted to the challenging behaviour unit during the period of July 1997 to July 2003.

Results: All patients were suffering from serious and enduring mental illness and challenged the ordinary mental health services by behaviour such as assault, fire setting, aggression, self harm, multiple substance misuse and non-compliance at least for six months.

On admission 76% of patients had examination of the cardiovascular, respiratory and gastro intestinal system and 69% of the central nervous system. During the hospital stay, all the patients had cardio vascular, respiratory and gastrointestinal system examination and 83% had central nervous system examination. All patients had base line investigations including full blood count, ESR, liver function test, urea and electrolytes, random glucose, thyroid function test and follow up investigations.

51(73%) patients were found to be suffering from some physical illness during their hospital stay. The physical illness spanned all the systems. There were newly detected cases of systemic lupus erythematosus, diabetes mellitus, glaucoma, hypertension, seizure disorder, male urinary tract infection, severe incontinence and haematological problems.

Conclusion: There is a high prevalence of physical health problems among patients admitted to a challenging behaviour unit. Some problems were associated with the mental illness, some as a complication of the mental health problem and others secondary to psychotropic medication. This study highlights the importance of a proper medical history, physical examination, base line investigations and regular monitoring of the physical health of mentally ill patients.

Rapid Tranquillisation (RT), defined as “the use of psychotropic medication to control agitated, threatening or destructive psychotic behaviour”, is a last resort pharmacological intervention. The withdrawal of the widely used droperidol in 2001 due to concerns over QTc prolongation may have increased the variability in RT practice across the UK. This paper reports on a UK wide survey of the practice of RT by psychiatrists. The survey pre-dated publication of NICE guidance on management of distributed behaviour. 257 questionnaires were received (response rate 22%). In comparison with previous surveys of this type, the overall quality of prescribing and monitoring has improved, although some apparently idiosyncratic practice remains. The majority of psychiatrists expressed concerns about prescribing and monitoring RT and would welcome an easy to use algorithm and associated training package. Findings are discussed in terms of training implications and BNF recommendations for high dose prescribing.

Aim: To survey the twenty low secure mental health and learning disabilities units in the South Thames Region.

Method: Ward Managers were interviewed and data gathered on: (1) Buildings and security; (2) Beds; (3) Staffing; (4) Therapeutic activities; (5) Policies; (6) Issues of concern.

Results: Learning disabilities units tended to be smaller, older and not purpose built with more issues of security and observation. There was an under provision of Clinical Psychology, Occupational Therapy and Social Work staff.

Conclusion: Any issues of concern raised by staff tended to reflect any structural and staffing deficiencies.

Aims: (1) To ascertain characteristics of patients in low secure units; (2) To examine whether standard 5 of the National Service Frameworks was being followed; (3) To investigate reasons for any delays in discharge and how these could be addressed.

Method: Audit survey of National Service Frameworks for Mental Health standard 5 patients being treated in least restrictive environment as close to their home as possible by case notes, interviews with ward manager and questionnaires.

Results: Patients in mental health units had greater numbers of admissions to hospital than those from learning disabilities units. They had more contact with the criminal justice system and had spent time in prison. The main diagnosis was schizophrenia.

Patients in learning disabilities units were more likely to be Black Caribbean or African and to have had special needs at school. They exhibited current higher risk to others and to self, by deliberate and non-deliberate self-harm. They had diagnoses of mild learning disabilities and autism. About a third of both groups of patients were assessed as being able to move to a lower level of security. The most suitable facility for these patients was an open unit in the community staffed by nurses.

Conclusion: For a third of the patients standard 5 of the National Service Frameworks was not met because they were not ‘in the least restrictive environment’. Open community facilities staffed by nurses over 24 hours was the most appropriate unit for a majority of these patients.

This article describes in detail the service delivered by the Multidisciplinary Team at the Montpellier Low Secure Unit in Gloucester. The development of the service, the physical environment and the admission criteria are described. The article focuses on the stages of treatment experienced by the patient namely: assessment, ongoing care and treatment and pre discharge planning.

The Psychiatric Intensive Care (PIC) Governance Network is a practical measure supporting the National Minimum Standards. It delivers a dynamic framework to provide users, clinicians, managers and commissioners with a structure to deliver high quality services. The Network concentrates upon four specific themes: responding to emergencies, multidisciplinary working, user/carer involvement and diversity. The inaugural year (2004–2005) was funded through the National Institute of Mental Health, England (NIMHE) and individual participating organisations and was a collaboration between NIMHE, North East London Mental Health NHS Trust (NELMHT) and the National Association of Psychiatric Intensive Care Units (NAPICU). This document outlines progress of the Network; it's developmental history, process, content and conclusions.

Most participating units were able to show benefits not only from success of a specific project (many chose a project with a user focus) but also within other areas. The most successful unit teams not only showed commitment but also adhered to their project plan, meeting regularly outside of learning set days in order to progress work.

A major social policy aim in the UK is to promote social inclusion in order that people with mental ill health have the same opportunities as other people to have a family, work and live. However, people with mental ill health remain amongst the most socially excluded in the UK and their social needs are largely unmet. In this article, the social policy, theoretical underpinning, and evidence base for the development of a social work model is considered with a focus on social inclusion. It is argued that in order to provide a more holistic package of care, each low secure service should have a dedicated social worker as part of its multi-disciplinary team. A social work model linking the areas of social work to an individual's progress through a low secure environment and into the community is presented and the social work process is discussed using a case vignette.

Background: Borderline personality disorder (BPD) is a distressing disorder that is associated with significant morbidity and mortality. Patients with BPD are often admitted to PICUs where psychotropic drugs are usually prescribed to treat trait or state dependant symptoms.

Aims: To review the evidence base for the efficacy of psychotropic drugs in borderline personality disorder.

Method: Medline and Cochrane search covering the period 1966 to March 2003.

Results: Nineteen RCTs and a large number of case reports, case series and open studies were retrieved. Numerous different treatments have been used, each in a small number of patients. Open studies often report remarkable efficacy that is not reproduced in randomised controlled trials.

Conclusions: The initial placebo response to any drug treatment is high but symptoms invariably return leading to the addition of further psychotropic drugs. Long term gains from drug treatment are likely to be small in the majority of patients. Large pragmatic trials of drug treatments could be co-ordinated through the PICU network.

Declarations of Interest: None.

It has become evident that Psychiatric Intensive Care Units (PICU) accept aggressive, violent patients often with criminal histories and personality disorders. This paper aims to document the effects that this patient group can have on a PICU and the significant role that psychotherapy can offer this complex patient group. The conclusions have been drawn from psychotherapeutic work on a PICU (Pathways on Tagore, NELMHT). Such patients present unique therapeutic and emotional challenges to staff. As a result staff need to recognise and address these issues. This paper identifies and discusses a number of central themes, challenges and practical skills that may be important in enabling the successful treatment of such patients within a PICU setting.

Anticonvulsant Hypersensitivity Syndrome (AHS) is a potentially fatal immune-mediated multi-system disorder linked to older aromatic anticonvulsants. It falls within the spectrum of Stevens Johnson Syndrome and hepatitis.