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Background Black, Asian and minority ethnicity groups may experience better health outcomes when living in areas of high own-group ethnic density – the so-called ‘ethnic density’ hypothesis. We tested this hypothesis for the treatment outcome of compulsory admission. Methods Data from the 2010–2011 Mental Health Minimum Dataset (N = 1 053 617) was linked to the 2011 Census and 2010 Index of Multiple Deprivation. Own-group ethnic density was calculated by dividing the number of residents per ethnic group for each lower layer super output area (LSOA) in the Census by the LSOA total population. Multilevel modelling estimated the effect of own-group ethnic density on the risk of compulsory admission by ethnic group (White British, White other, Black, Asian and mixed), accounting for patient characteristics (age and gender), area-level deprivation and population density. Results Asian and White British patients experienced a reduced risk of compulsory admission when living in the areas of high own-group ethnic density [odds ratios (OR) 0.97, 95% credible interval (CI) 0.95–0.99 and 0.94, 95% CI 0.93–0.95, respectively], whereas White minority patients were at increased risk when living in neighbourhoods of higher own-group ethnic concentration (OR 1.18, 95% CI 1.11–1.26). Higher levels of own-group ethnic density were associated with an increased risk of compulsory admission for mixed-ethnicity patients, but only when deprivation and population density were excluded from the model. Neighbourhood-level concentration of own-group ethnicity for Black patients did not influence the risk of compulsory admission. Conclusions We found only minimal support for the ethnic density hypothesis for the treatment outcome of compulsory admission to under the Mental Health Act.

BackgroundNHS Psychiatric beds comprise mental illness and intellectual disability beds. Penrose hypothesised that the number of psychiatric in-patients was inversely related to prison population size.AimsTo ascertain whether the Penrose hypothesis held true in England between 1960 and 2018–2019.MethodA time-series analysis explored the association between total prison population and NHS psychiatric beds; this was also tested for the male and female prison populations, using non-psychiatric beds as a comparator. Associations were explored with time lags of up to 20 years. Linear regression was conducted to estimate the size of the effect of bed closures.ResultsNHS psychiatric beds decreased 93% and the prison population increased 208%. A strong (r =−0.96) and highly significant negative correlation between these changes was found. Annual reduction in psychiatric bed numbers was associated with an increase in prison population, strongest at a lag of 10 years. The closure of mental illness and intellectual disability beds was associated with increases in female prisoners 10 years later. The only significant explanatory variable for the increase in male prison population was intellectual disability bed reduction.ConclusionsThe Penrose hypothesis held true between 1960 and 2018–2019 in England: psychiatric bed closures were associated with increases in prison population up to 10 years later. For every 100 psychiatric beds closed, there were 36 more prisoners 10 years later: 3 more female prisoners and 33 more male prisoners. Our results suggest that the dramatic increase in the female prison population may relate to the closure of NHS beds.

Background The steep rise in the rate of psychiatric hospital detentions in England is poorly understood. Aims To identify explanations for the rise in detentions in England since 1983; to test their plausibility and support from evidence; to develop an explanatory model for the rise in detentions. Method Hypotheses to explain the rise in detentions were identified from previous literature and stakeholder consultation. We explored associations between national indicators for potential explanatory variables and detention rates in an ecological study. Relevant research was scoped and the plausibility of each hypothesis was rated. Finally, a logic model was developed to illustrate likely contributory factors and pathways to the increase in detentions. Results Seventeen hypotheses related to social, service, legal and data-quality factors. Hypotheses supported by available evidence were: changes in legal approaches to patients without decision-making capacity but not actively objecting to admission; demographic changes; increasing psychiatric morbidity. Reductions in the availability or quality of community mental health services and changes in police practice may have contributed to the rise in detentions. Hypothesised factors not supported by evidence were: changes in community crisis care, compulsory community treatment and prescribing practice. Evidence was ambiguous or lacking for other explanations, including the impact of austerity measures and reductions in National Health Service in-patient bed numbers. Conclusions Better data are needed about the characteristics and service contexts of those detained. Our logic model highlights likely contributory factors to the rise in detentions in England, priorities for future research and potential policy targets for reducing detentions.

Compulsory community treatment for people with severe mental illness remains controversial due to conflicting research evidence. Recently, there have been challenges to the conventional view that trial‐based evidence should take precedence. This paper adds to these challenges in three ways. First, it emphasizes the need for critiques of trials to engage with conceptual and not just technical issues. Second, it develops a critique of trials centred on both how we can have knowledge and what it is we can have knowledge of. Third, it uses this critique to develop a research strategy that capitalizes on the information in large‐scale datasets.\ud \ud

There is growing interest in the health correlates of people detained in police custody, and a number of innovations have been introduced to try to meet the complex needs of detainees. The ...

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.

AimsTo assess the feasibility and utility of introducing the following changes on to in-patient units:Structural and cultural adaptation to create a sleep friendly ward environmentA “Protected Sleep Time” between midnight and 6amRoutine screening for sleep disorders, including obstructive sleep apnoea and restless leg syndromeBackgroundInsomnia and other sleep disturbances are cause, correlate and consequence of psychiatric disorders. Routine hourly night time observations, ward noise, bright lights at night time, sleep disorders, insufficient exercise, insufficient day light exposure, too much caffeine and inappropriate psychotropic use are all causes of disturbed sleep (Horne 2018).MethodSeven wards participated in a pilot (SleepWell). These consisted of one male and two female Acute Wards (General Adult), a High Dependency Unit, a Neurorehabilitation ward, an in-patient dementia service and one rehabilitation ward. These wards were supported via an existing trust management structure and the pilot was specifically supported by two trust managers (RW and RB) and by a clinical director (PK). The expectation was that each ward would identify a sleep champion from existing staff to facilitate the changes. A “product” was developed which identified core sleep management features but, in addition, wards were not confined to these. The existing policy that all inpatients should be checked each hour over night was suspended for the pilot wards and the patients had protected sleep time (PST) if the MDT agreed that it was clinically appropriate.Quantitative and qualitative techniques were used to identify facilitators of change, impact on sleep and, outcome.ResultProtected sleep was viewed positively by all staff and approximately 50% of patients on the pilot wards were able to have PST at some point in their admission. Routine sleep disorder assessments were harder to implement and 33% of patients were screened. There were no deaths or significant events on patients due to PST. Hypnotic use on the pilot wards reduced. It is anticipated that PST where it is safe will be rolled out across all adult and old age wards in the trust.ConclusionWith support, it has been feasible to change many aspects of sleep management across a breadth of inpatient units in a large NHS trust.

IntroductionSupervised community treatment (SCT) for people with serious mental disorders has become accepted practice in many countries around the world. In England, SCT was adopted in 2008 in the form of community treatment orders (CTOs). CTOs have been used more than expected, with significant variations between people and places. There is conflicting evidence about the effectiveness of SCT; studies based on randomised controlled trials (RCTs) have suggested few positive impacts, while those employing observational designs have been more favourable. Robust population-based studies are needed, because of the ethical challenges of undertaking further RCTs and because variation across previous studies may reflect the effects of sociospatial context on SCT outcomes. We aim to examine spatial and temporal variation in the use, effectiveness and cost of CTOs in England through the analysis of routine administrative data.Methods and analysisFour years of data from the Mental Health Services Dataset (MHSDS) will be analysed using multilevel models. Models based on all patients eligible for CTOs will be used to explore variation in their use. A subset of CTO-eligible patients comprising a treatment group (CTO patients) and a matched control group (non-CTO patients) will be used to examine variation in the association between CTO use and study outcomes. Primary outcome will be total time in hospital. Secondary outcomes will include time to first readmission and mortality. Outputs from these models will be used to populate predictive models of healthcare resource use.Ethics and disseminationEthical approval has been granted by the National Health Service Data Access and Advisory Group and Warwick University. To ensure patient confidentiality and to meet data governance requirements, analyses will be carried out in a secure microdata laboratory using de-identified data. Study findings will be disseminated through academic channels and shared with mental health policy-makers and other stakeholders.

BackgroundConcerns have been raised about the increase in the use of involuntary detentions under the Mental Health Act in England over a number of years, and whether this merits consideration of legislative change.AimsTo investigate changes in the rate of detentions under Part II (civil) and Part III (forensic) sections of the Mental Health Act in England between 1984 and 2016.MethodRetrospective analysis of data on involuntary detentions from the National Archives and NHS Digital. Rates per 100 000 population were calculated with percentage changes. The odds of being formally admitted to a National Health Service hospital compared with a private hospital were calculated for each year.ResultsRates of detention have at least trebled since the 1980s and doubled since the 1990s. This has been because of a rise in Part II (civil) sections. Although the overall rate of detentions under Part III (forensic) sections did not rise, transfers from prison increased and detentions by the courts reduced. The odds of being detained in a private hospital increased fivefold.ConclusionsThe move to community-based mental health services in England has paradoxically led to an increase in the number of people being detained in hospital each year, and in particular an inexorable rise in involuntary admissions. This is likely to be partly because of improved case finding with an increased focus on treatment and risk management, and partly because of changes in legislation. An increasing proportion of this government-funded care is being provided by private hospitals.Declaration of interestNone.

BackgroundCommunity treatment orders (CTOs) were introduced in England in 2008.AimsTo measure the rate of CTO use in England during the first 5 years following introduction.MethodThe number of involuntary detentions and CTOs in National Health Service (NHS) hospital trusts was collected between 2009 and 2014. Rates of CTO use and the ratio of CTOs to detentions on admission were calculated, and how these varied between trusts.ResultsThe number of new CTOs each year ranged between 3834 and 4647. The number subject to a CTO per 100 000 population increased from 6.4 in 2009/10 to 10.0 in 2013/14. There was variation between NHS trusts in the use of CTOs when compared with the number of involuntary detentionsConclusionsThe number of patients on CTOs increased year on year. Those on forensic sections were more likely to be discharged on a CTO than those on civil sections. There was considerable variation in the pattern of use between hospitals.Declaration of interestNone.

Background, The current Mental Health Act (MHA 1983) in England and Wales allows for two broad types of detentions in hospital: civil detentions under Part II; and forensic detentions under Part III. Concern has recently been expressed about the rising rate of detention. A strong association between the closure of mental illness beds and the rise in civil detentions has previously been reported. We will test whether there has been an association between the reduction of beds and the rate of forensic detentions, as well as the size of the prison population. We will explore any association between the rate of civil detentions and the rate of forensic detentions. Methods, Secondary analysis of routinely collected data with a time lagged analysis of time series of yearly rates of detention. Yearly rates of the prison population were also calculated. Forensic detentions were separated into prison transfers, court treatment orders, and court assessment orders. Findings, From 1984 until 2016 the rate of civil detention nearly tripled from 38.8 to 112.6 per 100,000 ( 191%) and the rate of prison transfers increased eightfold from 0.2 to 1.6 per 100,000 ( 710%). In contrast the rate of court treatment orders reduced by 39% from 2.3 to 1.4 per 100,000. There was an association between the reduction of psychiatric beds and the increase in prison transfers, and between the increase in civil detentions and the reduction in court orders. Interpretation, The closure of psychiatric beds, which has occurred at the same time as a substantial increase in the prison population, has been associated with a subsequent increase in the need for patients to be transferred from prison to hospital for treatment. The increase in civil detentions which has occurred over the thirty years of the study has been associated with a reduction in the rate of courts detaining people who have committed serious crimes to hospital. Funding Statement: "none" Declaration of Interests: "no conflict of interests identified for any author" Ethics Approval Statement: "not applicable as this was a secondary analysis of routinely collected data."

Aims and methodThis paper investigates the relationship between cluster (Mental Health Clustering Tool, MHCT) and diagnosis in an in-patient population. We analysed the diagnostic make-up of each cluster and the clinical utility of the diagnostic advice in the Department of Health's Mental Health Clustering Booklet. In-patients discharged from working-age adult and older people's services of a National Health Service trust over 1 year were included. Cluster on admission was compared with primary diagnosis on discharge.ResultsOrganic, schizophreniform, anxiety disorder and personality disorders aligned to one superclass cluster. Alcohol and substance misuse, and mood disorders distributed evenly across psychosis and non-psychosis superclass clusters. Two-thirds of diagnoses fell within the MHCT ‘likely’ group and a tenth into the ‘unlikely’ group.Clinical implicationsCluster and diagnosis are best viewed as complimentary systems to describe an individual's needs. Improvements are suggested to the MHCT diagnostic advice in in-patient settings. Substance misuse and affective disorders have a more complex distribution between superclass clusters than all other broad diagnostic groups.

Background: The negative symptoms of schizophrenia represent deficiencies in emotional responsiveness, motivation and socialization that tend to be persistent despite standard antipsychotic treatment. Two sub-domains of expressive deficits (affective flattening and poverty of speech) and avolition-amotivation for daily-life and social activities (apathy, amotivation and asociality) are recognized. Reviews of randomized controlled trials of adjunctive antidepressant treatment have concluded that the combination of antipsychotics and antidepressants may be effective in treating the negative symptoms of schizophrenia, but the amount and quality of the evidence available do not allow for any robust conclusion about the potential risks and benefits of such a strategy.

Background: In around a third of people with schizophrenia, the illness responds poorly to standard treatment with antipsychotic medication. Clozapine is the only antipsychotic medication with robust evidence for efficacy in strictly defined treatment-resistant schizophrenia, but even then, an adequate response is seen in only 30%–60% of patients. When a trial of clozapine proves to be insufficient, clinicians commonly add a second antipsychotic, although robust evidence to justify this practice, with regard to the potential benefits and risks, is lacking.

Background The increasing rate of compulsory admission to psychiatric inpatient beds in England is worrying. Studying variation between places and services could be key to identifying targets for interventions to reverse this trend. We modelled spatial variation in compulsory admissions in England using national patient-level data and quantified the extent to which patient, local-area, and service-setting characteristics accounted for this variation. Methods This study is a cross-sectional, multilevel analysis of the 2010–11 Mental Health Minimum Data Set (MHMDS). Data from eight provider trusts were excluded, including three independent provider trusts that lacked spatial identification codes. We excluded patients detained under sections of the Mental Health Act concerned only with conveyance to, or assessment in, a registered Place of Safety, or for short-term (≤72 h) assessment only, as these do not in themselves necessarily mean that the person will be admitted to an inpatient mental health bed. MHMDS contained reasonably complete data for a limited number of patient characteristics, namely age, sex, and ethnicity; however, several patient-level variables could not be included in our analysis because of high levels of missing data. Multilevel models were applied with MLwiN to estimate variation in compulsory admission, starting with null (unconditional) models that partitioned total variance in compulsory admission between each level in the model. The primary outcome was compulsory admission to a psychiatric inpatient bed, compared with people admitted voluntarily or receiving only community-based care. Findings Data were available for 1 238 188 patients, covering 64 National Health Service provider trusts (93%) and 31 865 census lower super output areas (LSOAs; 98%). 7·5% and 5·6% of the variance in compulsory admission occurred at LSOA level and provider trust levels, respectively, after adjusting for patient characteristics. Black patients were almost three times more likely to be admitted compulsorily than were white patients (odds ratio [OR] 2·94, 95% CI 2·90–2·98). Compulsory admission was greater in more deprived areas (OR 1·22, 1·18–1·27) and in areas with more non-white residents (OR 1·51, 1·43–1·59), after adjusting for confounders. Interpretation Rates of compulsory admission to inpatient psychiatric beds vary significantly between local areas and services, independent of patient, area, and service characteristics. Compulsory admission rates seem to reflect local factors, especially socioeconomic and ethnic population composition. Understanding how these factors condition access to, and use of, mental health care is likely to be important for developing interventions to reduce compulsion. Funding National Institute for Health Research Health Services and Delivery Research Programme.

Aims and methodTo detail changes in the use of place of safety orders in England, including the outcome of these detentions, using publicly available data.ResultsThere was a sixfold increase in the rate of the Mental Health Act Section 136 detentions to places of safety in hospitals between 1984 and 2011. The use of Section 135 and the rate of subsequent detention under Section 2 or 3 also increased, but the proportion of people detained fell as the absolute rate of detention increased. There was a wide variation between regions in the use of hospitals or police stations as places of safety. The change in the annual rate of detention under Section 136 was associated with the annual change in the population of England.Clinical implicationsThe increase in detentions to places of safety in hospitals may in part reflect their move from police cells. It may also reflect a real increase in overall rate of detention and possibly a change in the threshold for the use of Section 136 detentions.

Objectives To describe the impact of Street Triage (ST) on the number and rate of Section 136 Mental Health Act (S136) detentions in one NHS Mental Health and Disability Trust (Northumberland, Tyne and Wear (NTW)). Design Comparative descriptive study of numbers and rates of S136 detentions prior to and following the introduction of ST in NTW. More detailed data were obtained from one local authority in the NTW area. Setting NTW, a secondary care NHS Foundation Trust providing mental health and disability services in the north-east of England, in conjunction with Northumbria Police Service. Participants People being detained under S136 Mental Health Act (MHA). Routine data on S136 detentions and ST interventions were obtained from NTW, Northumbria Police, Sunderland Hospitals NHS Foundation Trust and Sunderland Local Authority. Interventions Introduction of a ST service in NTW. The main outcome measures were routinely collected data on the number and rate of ST interventions as well as patterns of the numbers and rates of S136 detentions. These were collected retrospectively. Results The annual rate of S136 detentions reduced by 56% in the first year of ST (from 59.8 per 100 000 population to 26.4 per 100 000). There was a linear relationship between the rate of ST in each locality and the reduction in rate of S136 detentions. There were 1623 ST contacts in the first 3 localities to have a ST service during its first year; there were also 403 fewer S136 detentions. Data from Sunderland indicate a 78% reduction in S136 use and a significant reduction in the number and proportion of adult admissions that originated from S136 detentions. Conclusions There is evidence to support the hypothesis that ST decreases the rate of s136 detention. When operating across the whole of NTW, ST resulted in 50 fewer S136 detentions a month, which represents a substantial reduction.

BackgroundNegative symptoms of schizophrenia represent deficiencies in emotional responsiveness, motivation, socialisation, speech and movement. When persistent, they are held to account for much of the poor functional outcomes associated with schizophrenia. There are currently no approved pharmacological treatments. While the available evidence suggests that a combination of antipsychotic and antidepressant medication may be effective in treating negative symptoms, it is too limited to allow any firm conclusions.ObjectiveTo establish the clinical effectiveness and cost-effectiveness of augmentation of antipsychotic medication with the antidepressant citalopram for the management of negative symptoms in schizophrenia.DesignA multicentre, double-blind, individually randomised, placebo-controlled trial with 12-month follow-up.SettingAdult psychiatric services, treating people with schizophrenia.ParticipantsInpatients or outpatients with schizophrenia, on continuing, stable antipsychotic medication, with persistent negative symptoms at a criterion level of severity.InterventionsEligible participants were randomised 1 : 1 to treatment with either placebo (one capsule) or 20 mg of citalopram per day for 48 weeks, with the clinical option at 4 weeks to increase the daily dosage to 40 mg of citalopram or two placebo capsules for the remainder of the study.Main outcome measuresThe primary outcomes were quality of life measured at 12 and 48 weeks assessed using the Heinrich’s Quality of Life Scale, and negative symptoms at 12 weeks measured on the negative symptom subscale of the Positive and Negative Syndrome Scale.ResultsNo therapeutic benefit in terms of improvement in quality of life or negative symptoms was detected for citalopram over 12 weeks or at 48 weeks, but secondary analysis suggested modest improvement in the negative symptom domain, avolition/amotivation, at 12 weeks (mean difference –1.3, 95% confidence interval –2.5 to –0.09). There were no statistically significant differences between the two treatment arms over 48-week follow-up in either the health economics outcomes or costs, and no differences in the frequency or severity of adverse effects, including corrected QT interval prolongation.LimitationsThe trial under-recruited, partly because cardiac safety concerns about citalopram were raised, with the 62 participants recruited falling well short of the target recruitment of 358. Although this was the largest sample randomised to citalopram in a randomised controlled trial of antidepressant augmentation for negative symptoms of schizophrenia and had the longest follow-up, the power of statistical analysis to detect significant differences between the active and placebo groups was limited.ConclusionAlthough adjunctive citalopram did not improve negative symptoms overall, there was evidence of some positive effect on avolition/amotivation, recognised as a critical barrier to psychosocial rehabilitation and achieving better social and community functional outcomes. Comprehensive assessment of side-effect burden did not identify any serious safety or tolerability issues. The addition of citalopram as a long-term prescribing strategy for the treatment of negative symptoms may merit further investigation in larger studies.Future workFurther studies of the viability of adjunctive antidepressant treatment for negative symptoms in schizophrenia should include appropriate safety monitoring and use rating scales that allow for evaluation of avolition/amotivation as a discrete negative symptom domain. Overcoming the barriers to recruiting an adequate sample size will remain a challenge.Trial registrationEuropean Union Drug Regulating Authorities Clinical Trials (EudraCT) number 2009-009235-30 and Current Controlled Trials ISRCTN42305247.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 29. See the NIHR Journals Library website for further project information.

Background It is unclear whether the substantial decline in number and duration of admissions for patients with intellectual disability (ID) have occurred uniformly over time with respect to age, gender, severity of disability, legal status and location of treatment. Method A retrospective analysis of NHS (National Health Service) admissions for ID and use of NHS ID beds in England between 1998/9 and 2007/8. Results NHS admissions for ID halved from 37 736 to 18 091, and admissions with a primary diagnosis of ID to beds reduced by 71% from 21 866 to 6420. This reduction was most marked among children with the result that the average age of those admitted increased from 26 years to 36 years. Mean length of stay shortened except for mild ID where it increased from 131 days to 244 days (the median increased from 6 days to 32 days). There was an 18% reduction in the number of patients with ID who were legally detained to NHS facilities but a 170% increase in those to private facilities (from 202 to 545). Conclusions The number of patients with ID admitted to NHS facilities, especially children, has fallen dramatically. There has been a marked shift towards legal detentions to private facilities. The most notable finding was the increased duration of admissions for those with mild ID, possibly indicating that substituting mainstream for specialist services for this group has had negative consequences.

Aims and MethodTo investigate changes to admissions, compulsory detentions, diagnosis, length of stay and suicides following introduction of crisis resolution home treatment and assertive outreach teams.ResultsThere was a 45% reduction in admissions with an increase in the median length of stay from 15.5 to 25 days. Bed occupancy fell by 22%. The number of suicides remained constant. Detentions under sections 2 and 3 of the Mental Health Act 1983 increased whereas those under sections 5(2) and 5(4) declined.Clinical ImplicationsThe introduction of crisis and assertive outreach teams was followed by a reduction in admissions, particularly short admissions. The impact differed according to gender (reduction in female bed occupancy). This and the increased length of stay need to be considered when determining the number of acute psychiatric beds needed.

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.

BackgroundIndividual variables and area-level variables have been identified as explaining much of the variance in rates of compulsory in-patient treatment.AimsTo describe rates of voluntary and compulsory psychiatric in-patient treatment in rural and urban settings in England, and to explore the associations with age, ethnicity and deprivation.MethodSecondary analysis of 2010/11 data from the Mental Health Minimum Dataset.ResultsAreas with higher levels of deprivation had increased rates of in-patient treatment. Areas with high proportions of adults aged 20–39 years had the highest rates of compulsory in-patient treatment as well as the lowest rates of voluntary in-patient treatment. Urban settings had higher rates of compulsory in-patient treatment and ethnic density was associated with compulsory treatment in these areas. After adjusting for age, deprivation and urban/rural setting, the association between ethnicity and compulsory treatment was not statistically significant.ConclusionsAge structure of the adult population and ethnic density along with higher levels of deprivation can account for the markedly higher rates of compulsory in-patient treatment in urban areas.

The use of inpatient psychiatric services has been correlated with certain demographic and clinical variables. However, there is limited information about the impact of personality disorder. To describe the impact of severe mental illness, personality disorders and demographic variables on psychiatric bed use amongst people in contact with a Community Mental Health Team (CMHT). Two-year retrospective and 2-year prospective bed use by the caseload of one Community Mental Health Team. Psychotic disorders (odds ratio 2.7), personality disorders (OR 2.2), marital status (OR 2.1) and unemployment (OR 1.9) were significantly related to psychiatric admissions from community care. Gender, accommodation, drug and alcohol problems, and ethnicity were not. Psychosis, personality disorder and unemployment appear to have independent effects on psychiatric bed use. Patients with a combination of psychotic disorders and diffuse personality disorders were very high users of inpatient services. This suggests that this group have particular needs that community mental health teams find difficult to manage.

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.

Objective To examine the rise in the rate of involuntary admissions for mental illness in England that has occurred as community alternatives to hospital admission have been introduced.\ud Design Ecological analysis.\ud Setting England, 1988-2008.\ud Data source Publicly available data on provision of beds for people with mental illness in the National Health Service from Hospital Activity Statistics and involuntary admission rates from the NHS Information Centre.\ud Main outcome measures Association between annual changes in\ud provision of mental illness beds in the NHS and involuntary admission rates, using cross correlation. Partial correlation coefficients were calculated and regression analysis carried out for the time lag (interval) over which the largest association between these variables was identified.\ud Results The rate of involuntary admissions per annum in the NHS increased by more than 60%, whereas the provision of mental illness beds decreased by more than 60% over the same period; these changes seemed to be synchronous. The strongest association between these variables was observed when a time lag of one year was introduced, with bed reductions preceding increases in involuntary admissions (cross correlation −0.60, 95% confidence interval −1.06 to −0.15). This association increased in magnitude when analyses were restricted to civil (non-forensic) involuntary admissions and non-secure mental illness beds.\ud Conclusion The annual reduction in provision of mental illness beds was associated with the rate of involuntary admissions over the short to medium term, with the closure of two mental illness beds leading to one additional involuntary admission in the subsequent year. This study\ud provides a method for predicting rates of involuntary admissions and what may happen in the future if bed closures continue.

Sodium valproate is an anticonvulsant that is also one of the common treatments used for bipolar disorder. The present study was conducted in psychiatric patients with the aim of examining the effects of valproate on hematological parameters and to explore any association with sex and age.A list of all psychiatric patients who underwent valproate level estimation in the years 2004-2008 in Newcastle upon Tyne was drawn from the biochemistry database of the local hospital. The names and date of births of these patients were used to draw corresponding hematological data, including hemoglobin, white blood cell count, mean corpuscular volume (MCV), and platelet count, conducted on the same day or within a week of the valproate level measurement.: The data from 126 patients were analyzed. The prevalence of thrombocytopenia (platelet count,150,000/microL) was found to be approximately 5%. In female subjects, a significant negative correlation was found between serum valproate level and platelet count; also, a positive correlation between valproate level and MCV was found. Neither correlation was found in male subjects. The risk of a low platelet count was found to be significantly increased at serum valproate level above 80 microg/mL in female subjects. The regression analysis in female patients showed a trend toward fall in platelet count and an increase in MCV with increasing age.In psychiatric patients on valproate therapy, close monitoring of full blood count is required in women particularly at valproate serum level above 80 microg/mL. This may be particularly important in older patients.

Objective To analyse the number of voluntary and involuntary (detentions under the Mental Health Act 1983) admissions for mental disorders between 1996 and 2006 in England. Design Retrospective analysis. Setting England. Main outcome measures Number of voluntary and involuntary admissions for mental disorders in England’s health service, number of involuntary admissions to private beds, and number of NHS beds for patients with mental disorders or learning disabilities. Results Admissions for mental disorders in the NHS in England peaked in 1998 and then started to fall. Reductions in admissions were confined to patients with depression, learning disabilities, or dementia. Admissions for schizophrenic and manic disorders did not change whereas those for drug and alcohol problems increased. The number of NHS psychiatric beds decreased by 29%. The total number of involuntary admissions per annum increased by 20%, with a threefold increase in the likelihood of admission to a private facility. Patients admitted involuntarily occupied 23% of NHS psychiatric beds in 1996 but 36% in 2006. Conclusions Psychiatric inpatient care changed considerably in the decade from 1996 to 2006, with more involuntary admissions to fewer NHS beds. The case mix has shifted further towards psychotic and substance misuse disorders, which has changed the milieu of inpatient wards. Increasing proportions of involuntary patients were admitted to private facilities.

Background There is a lack of information regarding the prevalence and co-occurrence of personality disorders, psychotic disorders and affective disorders amongst patients seen by community mental health teams. This study aims to describe the population of patients served by a community mental health team in South London in terms of demographic and clinical characteristics. Method Computerised hospital records and keyworkers' caseloads were used to identify 193 patients. The Standardised Assessment of Personality was used to assess personality disorders and the Operationalised Criteria Checklist was used to assess psychotic and affective disorders. Results Fifty-two per cent of patients met the criteria for one or more personality disorders, 67 % of patients had a psychotic illness and 23 % had a diagnosis of a depressive disorder. Community psychiatric nurses (CPNs) mainly saw patients with psychotic illnesses. The non-psychotic patients seen by CPNs had extremely high rates of personality disorder. Patients seen by psychiatrists and psychologists had significantly lower rates of personality disorder. Conclusions The prevalence of personality disorder is high amongst patients seen by community mental health teams. Possible explanations for this are presented and implications for community care are discussed.

Aims and methodSleep disturbance is common in psychiatry wards despite poor sleep worsening mental health. Contributory factors include the ward environment, frequent nightly checks on patients and sleep disorders including sleep apnoea. We evaluated the safety and feasibility of a package of measures to improve sleep across a mental health trust, including removing hourly checks when safe, sleep disorder screening and improving the ward environment.ResultsDuring the pilot there were no serious adverse events; 50% of in-patients were able to have protected overnight sleep. Hypnotic issuing decreased, and feedback from patients and staff was positive. It was possible to offer cognitive–behavioural therapy for insomnia to selected patients.Clinical implicationsMany psychiatry wards perform standardised, overnight checks, which are one cause of sleep disruption. A protected sleep period was safe and well-tolerated alongside education about sleep disturbance and mental health. Future research should evaluate personalised care rather than blanket observation policies.