No abstract

The psychiatric intensive care unit (PICK) is now at the cutting edge of acute psychiatric care. Very little guidance has been produced to ensure that the PICK structure and design is able to meet the complex demands put upon it. The creation, development and relocation of a PICU has taken place within the Severn NHS Trust. We describe the experience gained from a recently commissioned unit together with a review of the relevant literature. Recommendations are offered for core features and design.

Ninety-six successive acute psychiatric admissions were assessed with regard to dress, level of hygiene, the presence of tattoos, bodily piercing/decoration and surface marks of self-harm. These features were also examined in relation to ICD-10 category diagnosis. One-third were described as 'dishevelled', 21% 'unclean', 7% had multiple pierced ears and 3% other pierced body parts. Sixteen per cent had tattoos, rising to 34% in the F10-19 (substance misuse) category, and 15% had scars of self-harm. People with schizophrenia and related disorders were more likely to present in an unclean state. Those with personality disorders were no more likely to bear the scars of self-harm, tattoos or body piercing.

The lifetime prevalence of bipolar affective disorder is approximately 1% in both men and women (Reiger et al, 1998). In women the illness is most prevalent in the child-bearing years (Robins et al, 1984). While lithium for the treatment of bipolar disorder is a cornerstone of modern psychopharmacology (Llewellyn et al, 1998), there are inherent problems in treating this sizeable subgroup of patients, as lithium presents small, but significant, risks to a potential foetus. It is also becoming increasingly obvious that serious mental illness poses a risk to the unborn child. This paper reviews those risks, presents a protocol in algorithmic form for dealing with the prescription of lithium in pregnancy and discusses practical issues pertaining to dosage and lithium monitoring.

Lithium carbonate is an effective, commonly used treatment for manic-depressive illness. The drug is known to produce a number of renal side effects, including impaired urinary acidification, polyuria, and impaired renal concentrating ability, which have been summarized elsewhere (1, 2). Lithium is a rare cause of nephrotic syndrome, a complication that reduces renal lithium excretion and precipitates lithium toxicity (1). We describe here a case in which the clinical features of lithium toxicity appeared after nephrotic syndrome, due to focal segmental glomerulosclerosis, developed in a patient treated with lithium. We report the case of a 59year-old woman with bipolar affective disorder.For 3 weeks Ms. A had been experiencing progressive lethargy and diarrhea. She was finally admitted to the hospital because of anemia and leukopenia of unknown origin. She had bipolar disorder, which had been well controlled for 3 years with a regimen of 2.5 mg/day of haloperidol, 50 mg/day of doxepin, 2 mg/day of biperiden, and 800 mg/day of lithium carbonate. There had been no recent change in her medication regimen. Three days after admission Ms. A developed cerebellar ataxia, dysarthria, and bilateral pleural effusions.The following laboratory values were noted: 6.9 g/dl of hemoglobin, 2.4 × 10 9 /liter of leukocytes, 52 mg/dl of urea, and 268 mg/dl of cholesterol. Both her electrolyte levels and creatinine values were normal. Ms. A's serum lithium level was markedly elevated at 1.9 mmol/liter (therapeutic range=0.6-1.2 mmol/liter). Her serum albumin level was 18 g/liter (normal range=36-47 g/liter). Her renal function had been normal during the previous 3 years of treatment. Her 24-hour urine protein excretion was 12.23 g (normal range: <0.15 g). Serum electrophoresis showed an increase in α 2 globulin, with no paraprotein detected. Antinuclear antibodies were absent. A renal biopsy analysis revealed focal segmental glomerulosclerosis. Ms. A's lithium therapy was discontinued, and her serum lithium level fell to 1.1 mmol/liter after only 2 days. Six weeks later her edema and effusions had completely disappeared, her serum albumin level had risen to 29 g/liter, and her 24-hour urine protein excretion had fallen to 3.19 g. After 3 months both her red and white blood cell counts had returned to normal, and her renal function had improved markedly, with only mild proteinuria (0.3 g/ 24 hours). The reason for her anemia and leukopenia remained unclear, despite a bone marrow biopsy.