M. Dominic Beer

Physical health problems in schizophrenia and other serious mental illnesses

Background : Physical illnesses are more prevalent among patients with serious and enduring mental illnesses. This is mainly due to the association between mental and physical illnesses, complications of the mental illness itself and as a side effect of medication. Medical problems can be overlooked by psychiatrists due to several reasons. More research and audit of the existing services are necessary to establish the physical needs of patients with complex mental health problems. Aim : To give an account of the causes of excessive mortality and physical morbidity among patients with serious mental health problems. Method : Review of the worldwide literature. Results : Physical problems are more common and the standardised mortality rate (SMR) is higher in psychiatric patients compared to the general population. The main causes are association between mental and physical illnesses, lifestyle including lack of physical activity, smoking and poor dietary habits, metabolic syndrome, diabetes mellitus and other cardiac risk factors. There is a close association between treatment with antipsychotic medication and weight gain, diabetes mellitus, sudden death, cardiac and endocrine complications such as QT prolongation and also hyperprolactinemia. Conclusion : The paper highlights the importance of monitoring physical problems in patients with serious and enduring mental illnesses. Good practice points include help with smoking cessation, psycho-education about healthy lifestyle, close liaison between carers and professionals, the importance of taking baseline investigations before commencing antipsychotics, a shared care approach with primary care, early identification of the risk factors for physical illnesses and regular monitoring of physical health. Also important are social interventions such as appropriate accommodation and structured day, leisure and sporting activities.

Predicting outcome in low secure environments: A case series from one low secure unit

Aims : To measure the effectiveness of treatment in a low secure challenging behaviour unit and to identify predictors of change. Method : Routine clinical data and outcome scores were collected on a case series of 86 patients admitted to and discharged from one low secure unit. Results : Significant improvements were found on Health of the Nation Outcome Scale (HoNOS), Staff Observed Aggression Scale (SOAS) and the Global Assessment Scale (GAS). Improvements in GAS and HoNOS were associated with moves to a lower level of security. Patients with a history of conviction for property damage, cannabis use, who were admitted on a forensic section or with a diagnosis of personality disorder were more likely to move to a higher level of security. Increased length of stay was related to the presence of physical assault, physical health problems and anxiety symptoms. Conclusions : Clinical outcomes and behaviour improve during admission to one low secure unit and characteristics of the type of patients who respond to this form of treatment are proposed.

Outcome study of patients exhibiting challenging behaviours four years after discharge from a low secure mental health unit

Aim : To follow up a series of patients admitted to a low secure mental health unit for challenging behaviour. Method : Clinical outcome measures (Health of the Nation Outcome Scale (HoNOS), Global Assessment Scale (GAS) and Staff Observed Aggression Scale (SOAS)) and keyworker interviews were used to follow up the progress of patients at least one year after discharge. Results : 33 patients had a mean time since discharge of 43 months. The typical patient was a man with a history of violent offences, admitted from an open ward because of aggression. The observed improvement on HoNOS and GAS during admission had been maintained at follow up. There had been no re-convictions. All patients were compliant with medication. Five patients had been re-admitted to hospital during the follow up period. The current placement showed that more of the patients were in the community compared with at discharge. Conclusion : Patients admitted to a low secure unit improved during their stay and this improvement was maintained at follow up.

Aggression patterns and clinical predictors of inpatient aggression in a mental health low secure unit population

Aims : To describe the pattern of aggressive incidents, compare clinical characteristics of aggressive and non aggressive inpatients and determine predictors of inpatient aggressive behaviours in a low secure mental health unit population. Method : Clinical data were extracted from inpatient records and a critical incident database for a low secure unit population. Clinical variables between those with inpatient aggressive behaviours (inpatient aggressors) and those without inpatient aggressive behaviours (inpatient non aggressors) were compared. Statistical analysis was carried out on the differences to establish predictors of inpatient aggression. Results : 80 admissions resulted from 78 patients during a 6½ year period. 44% of patients presented with inpatient aggressive incidents. 64% of aggressive incidents resulted from 15% of patients. 54% of aggressive incidents were directed towards staff, 16% towards property and 15% towards other patients. 8% and 4% contributed to disturbed behaviour (non-directed aggression) and sexually inappropriate behaviour respectively. Most aggressive incidents are perpetrated by males and directed towards staff though a larger proportion of females (compared to males) were aggressive. On univariate analysis, clinical variables of more than one previous psychiatric admission, auditory hallucinations and delusions of control and persecution were significantly higher in patients displaying inpatient aggression. Logistic regression analysis identified the former two as predictors of inpatient aggression. Conclusion : In a low secure inpatient population, the majority of aggressive incidents are perpetrated by a minority of patients. Clinical variables such as history of more than one previous psychiatric admission and psychopathological symptoms such as presence of auditory hallucinations and delusions of control and persecution can influence inpatient aggression.

Clinical characteristics of patients with self harming behaviour in a low secure mental health unit

Aims : To describe the methods of self harm incidents in a low secure unit population and to identify and compare the clinical characteristics of patients displaying inpatient self harming behaviours with those who do not display such behaviours. Method : A retrospective case control study was conducted. Details about the inpatient self harming incidents were collected from an incident database. Clinical characteristics of those who displayed inpatient self harming incidents (cases) and those who did not display such behaviours (controls) were compared. Analysis was performed to establish statistical significance on the observed differences. Results : 80 admissions resulted from 78 patients during a 6½ year period. 21% of patients presented with inpatient self harming behaviours. 57% of the incidents were caused by 13% of patients. Clinical characteristics such as white ethnic background, histories of self harm, physical or sexual abuse, childhood conduct problems and lack of educational qualifications and having a diagnosis of schizoaffective disorder were more likely to be associated with inpatients self harming in low secure settings. Sexually inappropriate behaviours and a diagnosis of schizophrenia were less likely to be associated with this group. Conclusion : The majority of self harm incidents are caused by a minority of patients. Most of the clinical characteristics associated with the low secure inpatient self harming patients are similar to those observed in other psychiatric inpatient settings.

Clinical predictors and patterns of absconding in a low secure challenging behaviour mental health unit

Aims : To compare the clinical characteristics of patients who absconded and those who did not abscond; and to show the types of absconding behaviour in a low secure challenging behaviour mental health unit. Method : A retrospective case control study was conducted. Details of the absconding incidents were collected from an electronic incident database. Clinical predictors of patients who absconded (cases) and those who did not (controls) were compared. Statistical analysis was performed to determine statistical significance of the observed differences. Results : 80 admissions resulted from 78 patients during a period of 6½ years. 22% of the inpatients absconded from the unit. 84% of the incidents occurred while patients were utilising their unescorted leave. Only one patient escaped from the building. No serious incidents resulted from any of the abscondings. On univariate analysis, the following predictors were more likely to be statistically associated with patients who absconded from the unit: a history of absconding behaviour and a history of substance misuse or dependence. A history of non-compliance with treatment, a history of sexually inappropriate behaviour and a history of childhood conduct problems showed a trend towards statistical significance. Conclusion : The clinical characteristics of patients who abscond from low secure units show similarities with those who abscond from other psychiatric inpatient settings. Declaration of interests : None.

Cannabis and mental health

This article provides review evidence that cannabis use potentially leads to psychosis in vulnerable people, especially if started in adolescence. Possible modes of action and biochemical mechanisms are suggested. The dangers of cannabis, especially for PICU/LSU patients, are discussed and ways forward in PICU/LSU care are suggested.

User empowerment: A user-led survey of user-staff ward meetings in a challenging behaviour unit

Aims : Evaluation of users’ perspectives on ward meetings on a low secure challenging behaviour unit with high levels of morbidity as a means towards increasing their sense of empowerment. Method : Semi-structured questionnaire designed and administered by a user to all users on the unit over the period of June–Aug 2004 and review of ward meeting minutes over the same period. Results : 60% response rate. Issues were analysed and issues of importance highlighted and changes made. Conclusion : On challenging behaviour wards with very high morbidity and long stays, involving the users actively in ward meetings and addressing concerns with feedback is empowering and can be therapeutic. This study highlights this need.

Ethnic group and other characteristics of patients referred to a low secure mental health service

This longitudinal audit aimed to determine the ethnic groups and other characteristics of patients referred to a Low Secure Unit in South East London over a period of 9 years between 1997 and 2005. The data provide a picture of the characteristics of those most likely to be referred to a Low Secure Unit, and highlights an over-representation of Black Caribbean and Black African people. Discussion is provided for this latter finding.