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A series of editorials in this Journal have argued that psychiatry is in the midst of a crisis. The various solutions proposed would all involve a strengthening of psychiatry's identity as essentially ‘applied neuroscience’. Although not discounting the importance of the brain sciences and psychopharmacology, we argue that psychiatry needs to move beyond the dominance of the current, technological paradigm. This would be more in keeping with the evidence about how positive outcomes are achieved and could also serve to foster more meaningful collaboration with the growing service user movement.

Bill Fulford has argued convincingly that the widely held view that bodily illness is ‘relatively transparent in meaning’ and less ‘value-laden’ than mental illness does not stand up to scrutiny. 1 For him, it is simply that the values inherent in our concepts of bodily disorder are just not as obvious as those involved in our discourse of mental illness. When the presenting problem is pain from an arthritic joint or from a myocardial infarction, there is usually agreement between the doctor, the patient and the carer about what the priorities are and what would count as recovery. In the world of mental health, disagreements about values, priorities and frameworks have always been part of day-to-day work and thus value judgements more obvious.

Background: Psychiatric intensive care units (PICUs) provide care for patients who may demonstrate agitation and aggressive tendencies. Such behaviour has traditionally been managed using interventions such as seclusion and/or physical restraint. There is little published data about the use of these measures within different PICUs. This paper attempts to provide such evidence as a base for clinical governance. Aims: To describe patterns of seclusion and restraint usage within the care of 332 patients admitted consecutively to seven English PICUs. Method: Prospective, multi-centre patient case note analysis. Results: Within the four units that utilised seclusion in the study period, it was used on 16% of patients who had been admitted. All seven units used control and restraint and 28% of admitted patients were formally restrained at some point during their admission. There was no significant difference in mean duration of restraint or proportion of patients who were restrained between the units that used seclusion and those that did not. Use of seclusion was significantly associated with patient violence and property damage in PICU. Restraint usage was also significantly associated with patient violence and property damage but also with higher two week BPRS scores and a younger patient age. Conclusions: It appears that PICUs manage disturbed behaviour differently, either dependent upon facilities or local policies. In attempting to reduce the use of seclusion and restraint, a multi-faceted approach must be taken both locally and nationally. PICU clinicians and service users should be integral within this.

Moving ‘beyond the current paradigm’ is not about a search for another singular framework, but a realisation that the complex world of mental health demands openness to multiple paradigms. Many psychiatrists strive to work in this way already and there is evidence that an increasing number are keen to move towards recovery-oriented service models. 1 We do not claim to have all the answers and value the work of Professor Holmes, for example in relation to the role of narrative in mental health practice. 2 However, we would caution against any attempts to explain the insights of psychodynamics through the discourse of neuroscience. Crucially, it involves a rethinking of the nature of mental health expertise and, with this, a commitment to rethinking the power structures of our field. 1 Baker E, Fee J, Bovingdon L, Campbell T, Hewis E, Lewis D, et al From taking to using medication: recovery-focused prescribing and medicines management.

Background: Psychiatric intensive care units (PICUs) initially developed in a haphazard fashion. In the UK, in an attempt to standardise quality of services, guidance for PICUs was published in 2002. Subsequently there has been a paucity of information outlining compliance with standards within different units. Aims: To describe adherence to a subset of national standards in the care of 332 patients admitted consecutively to seven English PICUs. Methods: Prospective, multi-centre patient case note analysis and staff questionnaire for each patient admitted. Results: There was significant variation in different PICUs’ compliance with standards. Seventeen percent of patients were deemed not to meet basic criteria for admission to PICU. Pre-admission assessment and identification of treatment aims were poorly adhered to. Inappropriate mix of gender within patients occurred following 33% of admissions. Conclusions: Implementation of national standards varies between different PICUs according to local policy and interface between acute wards and PICUs. This highlights the importance of, and challenge for, a national accreditation scheme.

Background: Psychiatric intensive care units (PICUs) have become a standard part of UK mental health services. They treat patients who may be very unwell and who are usually compulsorily detained. There is little published data about the clinical activity of such units to provide an evidence base for clinical governance. Aim: To describe the socio-demographic characteristics, mental state and outcome of treatment for 332 patients admitted consecutively to seven English PICUs. Method: Prospective, multi-centre case note analysis. Results: PICU patients were predominantly Caucasian males, in their mid thirties, with complex needs and chronic psychotic illness often complicated by substance misuse. Most were admitted because of perceived risk of violence to others. Whilst most admissions appeared to be broadly in line with Department of Health guidelines some patients experienced an excessive length of PICU stay. Patients from particular BME groups were over-represented. Conclusions: PICUs appear to deliver effective treatment but are not always the least restrictive environment as envisaged by the Department of Health. Further work is needed to evaluate treatment interventions and develop valid measures of quality of care.