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Psychiatric intensive care and low secure units: where are we now?

  • M. Dominic Beer (a1)
Summary

The last decade has seen clinicians and policy makers develop psychiatric intensive care units and low secure units from the so-called ‘special care wards’ of the 1980s and 1990s. Psychiatric intensive care units are for short-term care, while low secure units are for care for up to about 2 years. Department of Health standards have been set for these units. A national survey has shown that there are two main patient groups in the low secure units: patients on forensic sections coming down from medium secure units and those on civil sections who are transferred from general psychiatric facilities. Recent clinical opinion has emphasised the important role both psychiatric intensive care units and low secure units play in providing a bridge between forensic and general mental health services.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
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Psychiatric intensive care and low secure units: where are we now?

  • M. Dominic Beer (a1)
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eLetters

Where are we now with treating offenders with mental illness in psychiatric intensive care units?

Tina E Thomas, Doctor
19 December 2008

Dear Editor,

We read this editorial with interest and would like to raise some points surrounding the challenges of treating patients transferred from prison to psychiatric intensive care units (PICUs). Beer made reference tothis group as one of the three types of patients who were originally supposed to be managed by the ‘interim units’, of the 70's and 80's. It is important to note that these units were medium secure. Beer also refers tothe Department of Health standards (Department of Health 2002) recognisingthat PICUs generally treat patients in an acute state for a limited period of time (usually less than 8 weeks).

However there is an increasing expectation that mentally ill offenders should be managed in a hospital setting, thus patients are admitted not because they are necessarily especially disturbed, but ratherbecause they are prisoners who also have mental illness (and are usually refusing treatment in prison). This creates a dual stream of patients on the ward with very different needs and care pathways. It also creates a pressure on beds as the PICU acts as a general adult ward for prisoners but without recourse to rapid discharge, restricting the capacity for admitting patients with acutely disturbed behaviour from the open wards.

A second challenge is raised by the security needs of such patients. Psychiatric intensive care units are low secure; this raises thecomplications of an abscond risk especially if transfer is needed for example to a medical hospital for physical investigations, or to Court. If these patients go directly from the prison to a general hospitalor Court they are accompanied by prison officers and are usually hand cuffed. This is not the level of security which an intensive care unit canor should provide and PICUs are left in a vulnerable position if patients abscond.

Treating mentally ill offenders is a complex area and we support the need for prisoners to receive timely and appropriate mental health care. However it seems to us that PICUs have become the option for prisoners by default, largely because of the lack of appropriate long-term minimum secure provision. Policy makers could benefit from giving consideration tothe above issues when thinking about the present state of play.
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Conflict of interest: None Declared

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PICUs for older people

Claire Hilton, Old age psychiatrist
03 December 2008

The editorial on psychiatric intensive care units (PICUs)(Beer 2008) describes the benefits of PICUs and the significant progress made in theirdevelopment in the last 10 years. However, currently these important facilities only accept patients who ‘will not normally be over the age of 65’. People are also excluded if they have ‘a primary diagnosis of dementia’ (Department of Health 2002, paras 1.3.1 and 1.4.4). Since most people with dementia are also over 65 years, these two criteria make the provision of psychiatric intensive care inequitable and ageist. Very few places have a PICU specifically for older people as an alternative to the standard older adults’ assessment ward.

The Equality Bill will make it unlawful to discriminate against someone because of their age when providing goods, facilities and services(Government Equalities Office 2008). Thus services will have to be provided on the basis of need rather than chronological age. We have yet to see how providers of mental health services will fulfil this obligation, for example, in relationship to equitable access for older people to the expertise offered by PICUs.

Beer MD (2008) Psychiatric intensive care and low secure units: whereare we now? Psychiatric Bulletin 32 441-443

Department of Health (2002) Mental Health Policy Implementation Guide: National Minimum Standards for General Adult Services in Psychiatric Intensive Care Units (PICU) and Low Secure Environments http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4010439

Government Equalities Office (2008) Framework for a Fairer Future – The Equality Bill Cm 7431, The Stationery Office http://www.equalities.gov.uk/publications/FRAMEWORK%20FAIRER%20FUTURE.pdf
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Conflict of interest: None Declared

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