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Background:A second antipsychotic is commonly added to clozapine to treat refractory schizophrenia, notwithstanding the limited evidence to support such practice.Methods:The efficacy and adverse effects of this pharmacological strategy were examined in a double-blind, placebo-controlled, 12-week randomized trial of clozapine augmentation with amisulpride, involving 68 adults with treatment-resistant schizophrenia and persistent symptoms despite a predefined trial of clozapine.Results:There were no statistically significant differences between the amisulpride and placebo groups on the primary outcome measure (clinical response defined as a 20% reduction in total Positive and Negative Syndrome Scale score) or other mental state measures. However, the trial under recruited and was therefore underpowered to detect differences in the primary outcome, meaning that acceptance of the null hypothesis carries an increased risk of type II error. The findings suggested that amisulpride-treated participants were more likely to fulfil the clinical response criterion, odds ratio 1.17 (95% confidence interval 0.40–3.42) and have a greater reduction in negative symptoms, but these numerical differences were not statistically significant and only evident at 12 weeks. A significantly higher proportion of participants in the amisulpride group had at least one adverse event compared with the control group ( p = 0.014), and these were more likely to be cardiac symptoms.Conclusions:Treatment for more than 6 weeks may be required for an adequate trial of clozapine augmentation with amisulpride. The greater side-effect burden associated with this treatment strategy highlights the need for safety and tolerability monitoring, including vigilance for indicators of cardiac abnormalities, when it is used in either a clinical or research setting.

In this article we compare a recent audit of the group psychotherapy service at the Maudsley Hospital with Foulkes's description of the same Unit during his tenure there. During this time huge changes have occurred in the NHS (UK National Health Service) both in service delivery and in the way audit is carried out — the main reason why we believe that comparing the two time frames will be of interest to those working in this field. We will also present some more detailed findings from the more recent audit. To set the scene, a description is offered of how the service was organized at these two time points.

Risk management is increasingly seen as a task for health professionals. However little is known about how different professionals perceive and rate risk. The purpose of this study was to see if professional background and experience influence how an assessor rates risk. Psychiatric staff were presented with identical clinical information about one case. They were then asked to score the HCR-20. This is a structured clinical assessment and gives a score of between 0 and 40. Higher scores indicate increased risk of future violence. There was a twofold variation in the score from 15 to 30. There was no difference between medical and non-medical staff. However there was a significant difference between different grades of psychiatrists. Senior psychiatrists scored the clinical and risk items significantly lower when compared with junior psychiatrists. There was no significant difference in the scoring of historical items. The twofold variation in the score on the HCR-20 emphasises that risk assessment is a two-way process. Individual differences of assessors may be very important. Our findings suggest that senior psychiatrists score risks as lower. Possible explanations are discussed.

Sodium valproate is a commonly used anticonvulsant, particularly in the management of childhood refractory epilepsy. There is a good literature base regarding its haematological effects in this group of patients including the potential for toxic effect on the bone marrow. Valproate is increasingly being used in the treatment of psychiatric conditions, particularly bipolar affective disorder. In this article we describe a case of pancytopenia associated with a valproate level of 166mg/l. The population of psychiatric patients is different in several ways from the population of children and young adults with epilepsy from whom the existing data comes. The psychiatric patients are older, more likely to misuse substances, more likely to take overdoses and may metabolize valproate more slowly. For these reasons it would be worthwhile investigating the relationship between valproate levels, macrocytosis, platelet counts and B12 levels in this group of patients. The results of such a study would give us a clearer understanding of what the desirable therapeutic range is for valproate in bipolar affective disorder and what, if any, monitoring should be undertaken.