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This qualitative study investigates how the decision is taken to grant leave to patients in a forensic psychiatric in-patient medium secure unit. This study aims to understand better the process of decision making at multidisciplinary ward rounds. The study is based in a single medium secure unit. Data were collected by a researcher from ward rounds over a period of 15 months using non-participant observation. These data were subjected to content analysis. Two main thematic dialectics emerged: risk and humanity and power and responsibility. Leave decisions were made in 96 instances and risk, per se, was seldom explicitly discussed. This study raises key questions about the balance between explicit information and implicit clinical knowledge that underpins routine clinical decisions. This study is important because it has implications for the reliance on written records in the review of clinical practice, specifically in relation to serious acts of violence committed by psychiatric patients.

Aims and MethodWe describe two patients, both diagnosed with psychotic illnesses, who developed stuttering while being treated with clozapine.ResultsIn both patients the stuttering was severe and significantly impaired progress towards recovery. Deviant speech dimensions and voice quality were consistent with dysarthria and dystonia.Clinical ImplicationsPatients who develop abnormal electroencephalogram activity and those who have a family or personal history of stuttering might be at increased risk of developing speech problems with clozapine. Speech dysfluency might be a consequence of clozapine's action in lowering the seizure threshold. Potential management strategies include the use of sodium valproate and changing the type of antipsychotic.

Sexual side-effects are common among those using antipsychotic medication and may result in poor compliance and reduced quality of life. Retrograde ejaculation (RE) has been described occurring with a number of antipsychotic medications (thioridazine, risperidone, iloperidone and clozapine) but there are no guidelines regarding management of antipsychotic-associated RE. Imipramine has been suggested as a treatment for antipsychotic-associated RE in one small study of patients prescribed thioridazine and a case series of patients prescribed iloperidone. Quetiapine is a commonly used antipsychotic and is thought to be associated with less sexual side-effects relative to other antipsychotic medications. This case report describes a 25-year-old man with first episode psychosis who developed RE during treatment with quetiapine which improved with low-dose imipramine. This is the first description of RE occurring with quetiapine and successful treatment of quetiapine-associated RE with imipramine.

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