We reviewed the literature regarding acute therapy of manic patients and compared these recommendations with actual practice by reviewing 399 therapies in 100 patients each from two psychiatric care centres between 1975 und 1991. Higher age, more serious disease and a higher percentage of compulsory commitments are typical of patients treated in institutions with a mandatory admission policy as compared to university clinics, which are not compelled to admit patients. The treatment methods practised in both centres deviated greatly from recommendations in the literature. In spite of widespread therapeutic recommendations, lithium and carbamazepin are seldom employed for acute treatment; neuroleptic agents were preferred for all grades of severity. Combinations of more potent antipsychotics with more sedative neuroleptics were preferred. In contrast, the chosen substances, the preferred combinations and the application form varied considerably. The state mental hospital preferred haloperidol and levomepromazin; in the university clinic clozapin and perphenazineoenanthate were important adjuncts. Both clinics remained in the low therapeutic range of dose recommendations. There were no statistically meaningful differences with regard to either the total amount of chlorpromazine equivalents applied or the duration of inpatient care. In the first one-tenth of the total treatment period, 85% of the maximal dose reached in the second tenth is already given. A continual reduction begins thereafter, until app. 40% of the peak dose in reached. Active treatment of side effects as well as more common use of depot neuroleptics in order to minimize custodial treatment, may explain the lower number of compulsory admissions in the university hospital. Extreme interindividual differences in both dosage and length of stay help in elucidating the apparently contradictory results of comparative investigations with small patient groups. Previous treatments have little or no predictive value due to large intraindividual variations.

AimsAims included to explore how, within a London trust, staff at the interface between patients, relatives and access to services view their understanding of confidentiality, and to determine ways to improve knowledge if needed.BackgroundConfidentiality is essential to the trust and development of clinician-patient relationships. National policies set guidance on how confidential information should be recorded, secured and shared. However, confidentiality breaches are reportedly common within health professions. Working with adolescent patient groups brings additional issues regarding confidentiality. Care-givers who contact services, often desiring containment, may experience a sense of uncertainty when confidentiality policy prevents details being shared about a young person's clinical experience.MethodStakeholders were identified from the multidisciplinary team, with a collaborative rather than ‘top-down’ approach. Administrators in patient-facing roles were surveyed to ascertain current understanding and frequency of involvement in confidentiality issues. Based on feedback, a flowchart prompt was designed, ensuring it reflected best practice. Qualitative and quantitive data were collected before and after a two month implementation period.ResultAll respondents (n = 10) dealt with confidentiality issues at work, with 50% experiencing issues daily. 33% respondents did not feel confident dealing with confidentiality queries at work. The majority (60%) had received confidentiality training, but all respondents thought extra information would be useful. Of possible interventions, 70% supported a flowchart. Following an implementation period, 100% respondents re-surveyed agreed they felt confident dealing with issues related to confidentiality at work. The majority of respondents had used the flowchart and found it useful (83%). Qualitative data gathered suggested rolling-out the project elsewhere.ConclusionA lack of confidence surrounding issues with confidentiality, including information sharing, was identified. This can negatively impact patient engagement and delivery of care. The introduction of the confidentiality flowchart demonstrated improved understanding of, and confidence in, patient confidentiality issues. The small sample size means there are limitations in extrapolating findings to wider contexts. However, it is likely that more confidentiality training and practical information for NHS staff at the interface between patients, clinicians and services would reduce the risk of confidentiality breaches and reinforce positive relationships with services.

AimsSleep is essential for optimal physiological functioning, but often interrupted in hospital settings. Disturbed sleep is associated with relapse of mood disorders and multiple comorbidities including impaired immunological function and increased cardiovascular risk. There are unique environmental challenges on psychiatry wards, such as overnight monitoring. Recent studies highlight the importance of evaluating and managing inpatient sleep disturbance. Aims include exploring the extent to which patients’ sleep is impacted by inpatient admission, elucidating causes of sleep disturbance and determining ways to improve sleep during admission.MethodPatients aged 18–65 years, who consented and were expected to be inpatients for a week, were approached after 72 hours of admission (n = 35). Quantitative and qualitative data, including on pre-hospital and hospital sleep quantity and quality, were gathered, as part of a cohort characterisation. Questionnaires using Pittsburgh Sleep Quality Index elements were used to gather data. Offering earplugs as a sleep-aid intervention was implemented, with sleep quantity and quality reassessed 72 hours post-intervention. In response to feedback, sound monitoring at regular intervals overnight was undertaken using a decibel-metre to determine noise baseline and variation.ResultAll patients approached agreed to participate. Pre-hospital average sleep quantity was 5.2 hours, with restedness score of 4.3, and 71% patients rating their sleep as ‘bad’. After 72 hours post-admission, average sleep length was 6.5 hours and restedness 5.3. Of patients who accepted earplugs (59%), there were improvements to mean sleep quality and quantity (7.6 hours), with 86% patients rating earplugs helpful. All patients surveyed thought that earplugs should be offered routinely on admission. 70% of patients were prescribed benzodiazepines or z-drugs as required. Self-reported factors affecting sleep included noise, psychiatric symptoms and medication side effects, with 13 patients mentioning the former. Sound monitoring recorded an average decibel level with a range of 35–75 dB, with peaks reaching 95 dB.ConclusionPoor sleep in hospital is widespread. There is a need to understand and address modifiable environmental and ward factors implicated in sleep disturbance within inpatient settings. Pharmacological options for sedation are common, but it is important to focus on alternative options of low-cost, non-pharmacological interventions which promote sleep optimisation and enhance inpatient care.

AimsThe aim of this study was to identify pre-discharge risk factors associated with early inpatient readmission in general adult service users, with a particular focus on modifiable factors. We hypothesised that stability prior to discharge would reduce readmission to inpatient services within 90 days.BackgroundEarly readmission to inpatient psychiatric services is a poor outcome for service users, staff and the healthcare system. A variety of clinical, demographic and system factors, mostly non-modifiable, have been investigated previously. The identification of pre-discharge and particularly modifiable factors associated with readmission would give an opportunity for intervention and changes in policy.Method272 medical records of all admissions within an 8 month period to a NHS inner city psychiatric inpatient service were reviewed to identify factors associated with readmission within 90 days of discharge. The data were analysed by simple comparison, calculation of odds ratios and logistic regression.Result26% of service users were readmitted to the mental health trust within 90 days of discharge. Incidents (OR = 3.86; 95% CI 1.39–10.75) and psychotropic medication change in the week before discharge (OR = 2.94; 95% CI 1.43–6.03) were significantly associated with readmission, as were the number of previous admissions, and comorbid substance misuse. Successful overnight leave was found to be significantly protective against readmission (OR = 0.29; 95% CI 0.11–0.72).ConclusionThe ability to predict those at high risk for readmission means they can be targeted for interventions and it can also help develop best practice around inpatient care and the discharge process. The novel findings in this study of pre-discharge modifiable risk factors such as stability and successful overnight leave could have significant implications in discharge planning policy.

AimsVoting is an intrinsic part of being a member of society and promotes social inclusion. The vast majority of mental health service users have the same right to vote as the general population but are a disenfranchised group and inpatients are half as likely to vote. Service users experience many barriers to voting including knowledge of their eligibility and the accessibility of the registration and voting process. Mental health staff need to understand service users’ voting rights so they can offer appropriate support. This project aimed to explore staff knowledge of service users’ voting rights.Methods77 multidisciplinary team members from inpatient and community settings in Haringey were surveyed about voting rights.Questions focussed on staff knowledge of service users’ right to vote (whether or not subject to various civil or forensic sections), if capacity to vote was required and if those with certain diagnoses were legally disenfranchised.27 Care Coordinators were asked if they discussed voting with service users and whether support around voting and registration was in care plans.ResultsThe response rate was 96%. No respondents answered completely correctly. Staff knowledge was similar across all groups and settings.The majority of staff believed community service users (89%) and informal inpatients (93%) were able to vote.63% of respondents knew inpatients on civil sections could vote. 81% knew those on a Community Treatment Order could vote. 40% of responses regarding the forensic sections were correct.56% believed service users needed to have capacity in order to vote.Certain diagnoses were believed to legally prevent service users from voting, including dementia (19%) and schizophrenia (13%).44% of Care Coordinators discussed voting with service users and 26% included voting in care plans.ConclusionDespite a national campaign, the level of staff knowledge is disappointingly low throughout all groups and settings, risking service users being given wrong information. This further disenfranchises a group that already experiences significant barriers to vote.It is of particular concern that a significant minority of staff believed certain diagnoses legally prevent voting.It was poorly understood that capacity is not relevant to the right to vote.Voting rights and available support is not widely discussed by care coordinators with service users.Clearly, education and training on voting rights is necessary for mental health professionals. We are planning staff education sessions and service user workshops as a quality improvement project.