Carol Paton

The London Survey of Psychiatric Intensive Care Units: psychiatric intensive care; patient characteristics and pathways for admission and discharge

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.

The potential impact of antipsychotics on lipids in schizophrenia: is there enough evidence to confirm a link?

Lipid abnormalities are common in the general population and early data suggests that they may be more common in people with schizophrenia. Little data exist from treatment-naive patients making it difficult to differentiate any genetic contribution associated with a diagnosis of schizophrenia from the lifestyle risks associated with this diagnosis. Additional potential risks associated with antipsychotic drug treatment have been noted in the literature since 1971. The majority of the existing data on lipids derive from retrospective and cross-sectional analyses of datasets that have been designed for other purposes. Specifically screening bias for lipid testing and treatment selection bias are important potential confounders. Prospective clinical trials are difficult to interpret, as many are short-term, report on non-fasting data and were never designed to evaluate the differential effects of antipsychotic drugs on lipids as a primary endpoint. There is little reported data on lipid fractions such as LDL and HDL. Nevertheless there is some evidence from placebo-controlled studies that antipsychotics may be differentially associated with a small, clinically insignificant increase in cholesterol and a larger, potentially clinically significant increase in triglycerides. Further prospective randomized trials, using fasting data and controlling for established risk factors such as diet and exercise are essential to determine if there are clinically meaningful differential effects on lipids associated with individual antipsychotic drugs.

The London Survey of Psychiatric Intensive Care Units: service provision and operational characteristics of National Health Service units

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.

Treatment of acute behavioural disturbance: a UK national survey of rapid tranquillisation

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.