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Clinical guidelines recommend the routine use of a single antipsychotic drug in a standard dose, but prescriptions for high-dose and combined antipsychotics are common in clinical practice. To evaluate the effectiveness of a quality improvement programme in reducing the prevalence of high-dose and combined antipsychotic prescribing in acute adult in-patient wards in the UK. Baseline audit was followed by feedback of benchmarked data and delivery of a range of bespoke change interventions, and then by a further audit 1 year later. Thirty-two services participated, submitting data for 3,942 patients at baseline and 3,271 patients at the 1-year audit. There was little change in the prevalence of high-dose (baseline 36%; re-audit 34%) or combined antipsychotic prescribing (baseline 43%; re-audit 39%). As required ('p.r.n.') prescriptions were the principal cause of both high-dose and combined antipsychotic prescribing on both occasions. The quality improvement programme did not have a demonstrable impact on prescribing practice in the majority of services. Future efforts to align practice with clinical guidelines need to specifically target the culture and practice of p.r.n. prescribing.

Purpose Partial or non-adherence is common in people taking antipsychotic medication. A good therapeutic alliance is thought by psychiatrists to encourage engagement with a service and improve adherence. This paper aims to examine how psychiatrists and patients communicate in outpatient consultations about partial or non-adherence to antipsychotic prescribing. Methods Ninety-two outpatient consultations involving patients prescribed antipsychotic medication and their psychiatrists were tape recorded. Parts of consultations where partial/non-adherence to antipsychotic medication was discussed were analysed using conversation analysis. Results In 22 (24 %) consultations, partial/non-adherence was disclosed. Most commonly, it was volunteered without prompting and was more likely to be presented as a deliberate choice than omission by the patient. Psychiatrists responded to all but one disclosure, and patients delivered their reports in ways that minimised the prospect of this response being disciplinary. The most common outcome was a change in prescribing: a medication omission, swap or dosage reduction. Conclusions Patients and psychiatrists work together to create a safe conversational environment in which to discuss this potentially difficult issue. Unlike previous studies of patient reports of psychotic symptoms and side effects of drowsiness being ignored, psychiatrists nearly always respond to disclosures of partial/non-adherence. Psychiatrists should apply the same listening skills to patients’ disclosures of troubling side effects and psychotic symptoms.

Mental illness is now the leading cause of both sickness absence andincapacity benefits in most high-income countries. The rising economic andsocial costs make health and work an increasing priority for policy makers.We discuss the findings from Dame Carol Black's recent review of the healthof Britain's working-age population and examine how her recommendations mayimpact and challenge mental health services.

A cross-national randomised trial of alprazolam for chronic panic disorder with agoraphobia was run. Compared with previous trials it had three new features: an exposure therapy contrast group, a six-month treatment-free follow-up, and a low rate of early placebo drop-outs (‘non-evaluables’). The dose of alprazolam was high (5 mg/day). The 154 patients had eight weeks of: alprazolam and exposure (combined treatment); or alprazolam and relaxation (a psychological placebo); or placebo and exposure; or placebo and relaxation (double placebo). Drug taper was from weeks 8 to 16. Follow-up was to week 43. Results were similar at both sites. Treatment integrity was good. All four treatment groups, including double placebo, improved well on panic throughout. On non-panic measures, by the end of treatment, both alprazolam and exposure were effective, but exposure had twice the effect size of alprazolam. During taper and follow-up, gains after alprazolam were lost, while gains after exposure were maintained. Combining alprazolam with exposure marginally enhanced gains during treatment, but impaired improvement thereafter. The new features put previous trials in a fresh light. By the end of treatment, though gains on alprazolam were largely as in previous studies, on phobias and disability they were half those with exposure. Relapse was usual after alprazolam was stopped, whereas gains persisted to six-month follow-up after exposure ceased. Panic improved as much with placebo as with alprazolam or exposure.

Mental illness is now the leading cause of both sickness absence and incapacity benefits in most high-income countries. The rising economic and social costs make health and work an increasing priority for policy makers. We discuss the findings from Dame Carol Black's recent review of the health of Britain's working-age population and examine how her recommendations may impact and challenge mental health services.

Aggregate returns give limited information about those detained under the Mental Health Act 1983. To use existing data-sets to examine detentions under Part II of the Act. Data from 26 areas, with a combined population of 9.2 million, were combined. Population census data were used to standardise rates of detention by age, gender and ethnicity. The 31 702 detentions are distributed bimodally with peaks at age 25-34 years and at over age 80 years. In the younger age group rates of detention are higher for men. The excess of women in the older group is no longer apparent when rates are standardised for age and gender. Detentions are over six times more likely to be of Black people than of White (450 v. 68 per standardised 100 000 population). The difference in rates of detention between Black and White people is greater than previously thought. The excess of older women detained under Part II of the Act is largely due to the lower life expectancy of men.

BackgroundFollowing the development of a child and adolescent version of the Health of the Nation Outcome Scales (HoNOSCA), field trials were conducted to assess their feasibility and acceptability in routine outcome measurement.AimsTo evaluate the reliability, validity and acceptability of HoNOSCA in routine outcome measurement.MethodFollowing training, 36 field sites provided ratings on 1276 cases at one time point and outcome data on 906. Acceptability was assessed by way of written feedback and at a debriefing meeting.ResultsHoNOSCA demonstrated satisfactory reliability and validity characteristics. It was sensitive to change and its ability to measure change accorded with the clinicians' independent rating. HoNOSCA was reasonably acceptable to clinicians' from a range of disciplines and services.ConclusionsProvided that training needs can be met, HoNOSCA represents a satisfactory brief outcome measure which could be used routinely in child and adolescent mental health services.

Background The EU currently lacks reliable data on the prevalence and incidence of mental disorders in older people. Despite the availability of several national and international epidemiological studies, the size and burden of mental disorders in the elderly remain unclear due to various reasons. Therefore, the aims of the MentDis_ICF65+ study are (1) to adapt existing assessment instruments, and (2) to collect data on the prevalence, the incidence, and the natural course and prognosis of mental disorders in the elderly. Method/design Using a cross-sectional and prospective longitudinal design, this multi-centre study from six European countries and associated states (Germany, Great Britain, Israel, Italy, Spain, and Switzerland) is based on age-stratified, random samples of elderly people living in the community. The study program consists of three phases: (1) a methodological phase devoted primarily to the adaptation of age- and gender-specific assessment tools for older people (e.g., the Composite International Diagnostic Interview, CIDI) as well as psychometric evaluations including translation, back translation; (2) a baseline community study in all participating countries to assess the lifetime, 12 month and 1 month prevalence and comorbidity of mental disorders, including prior course, quality of life, health care utilization and helpseeking, impairments and participation and, (3) a 12 month follow-up of all baseline participants to monitor course and outcome as well as examine predictors. Discussion The study is an essential step forward towards the further development and improvement of harmonised instruments for the assessment of mental disorders as well as the evaluation of activity impairment and participation in older adults. This study will also facilitate the comparison of cross-cultural results. These results will have bearing on mental health care in the EU and will offer a starting point for necessary structural changes to be initiated for mental health care policy at the level of mental health care politics.

Expert clinical judgement combines technical proficiency with humanistic qualities. To test the psychometric properties of questionnaires to assess the humanistic qualities of working with colleagues and relating to patients using multisource feedback. Analysis of self-ratings by 347 consultant psychiatrists and ratings by 4422 colleagues and 6657 patients. Mean effectiveness as rated by self, colleagues and patients, was 4.6, 5.0 and 5.2 respectively (where 1=very low and 6=excellent). The instruments are internally consistent (Cronbach's alpha >0.95). Principal components analysis of the colleague questionnaire yielded seven factors that explain 70.2% of the variance and accord with the domain structure. Colleague and patient ratings correlate with one another (r=0.39, P<0.001) but not with the self-rating. Ratings from 13 colleagues and 25 patients are required to achieve a generalisability coefficient (Erho(2)) of 0.75. Reliable 360-degree assessment of humane judgement is feasible for psychiatrists who work in large multiprofessional teams and who have large case-loads.

Little is known about the current state of provision of child and adolescent mental health service in-patient units in the UK.BACKGROUNDLittle is known about the current state of provision of child and adolescent mental health service in-patient units in the UK.To describe the full number, distribution and key characteristics of child and adolescent psychiatric in-patient units in England and Wales.AIMSTo describe the full number, distribution and key characteristics of child and adolescent psychiatric in-patient units in England and Wales.Following identification of units, data were collected by a postal general survey with telephone follow-up.METHODFollowing identification of units, data were collected by a postal general survey with telephone follow-up.Eighty units were identified; these provided 900 beds, of which 244 (27%) were managed by the independent sector. Units are unevenly distributed, with a concentration of beds in London and the south-east of England. The independent sector, which manages a high proportion of specialist services and eating disorder units in particular, accentuates this uneven distribution. Nearly two-thirds of units reported that they would not accept emergency admissions.RESULTSEighty units were identified; these provided 900 beds, of which 244 (27%) were managed by the independent sector. Units are unevenly distributed, with a concentration of beds in London and the south-east of England. The independent sector, which manages a high proportion of specialist services and eating disorder units in particular, accentuates this uneven distribution. Nearly two-thirds of units reported that they would not accept emergency admissions.A national approach is needed to the planning and commissioning of this specialist service.CONCLUSIONSA national approach is needed to the planning and commissioning of this specialist service.