A study of the use of sedative PRN medication in patients at a secure hospital

We have investigated the use of ‘as required’ (PRN), sedative psychotropic medication in 242 forensic rehabilitation patients at a UK secure psychiatric hospital. In total, 176 (73%) patients were prescribed PRN medication and 90 (37%) received a total of 542 doses in the preceding two weeks. The principle indication for use was agitation. Oral benzodiazepines, particularly Lorazepam, were most commonly prescribed and administered followed by Haloperidol. Although high-dose antipsychotics and polypharmacy due to PRN prescribing were common (11 and 20%, respectively), on only 6% of the days studied did patients actually receive PRN antipsychotic medication. Using univariate analyses, PRN administration was associated with younger age, female gender, emotionally unstable personality disorder, shorter length of stay and detention in medium security. Case note documentation of PRN administration was often absent (44%) or vague. Further research, both quantitative and qualitative, is needed into the precise circumstances under which PRN is administered.     

Quality of low secure services in the UK: development and use of the Quality of Environment In Low Secure Services (QELS) checklist

Low secure services provide care for psychiatric patients whose risk cannot be safely managed in other settings. The physical environment in these units plays an important role in supporting recovery and risk management. We developed the Quality of Environment in Low secure Services (QELS) checklist to assess the quality of the physical environment of these services. Using recommendations from previously published standards we piloted a draft checklist with a weighted scoring system reflecting the views of patients and providers. The checklist showed good criterion validity and inter-rater reliability. Data collected from 33 low secure services showed considerable variation in the quality of the physical environment. The QELS checklist provides an accessible and reliable means for managers and clinicians to assess whether the quality of the physical environment of low secure units meets recommended standards and can be used to support efforts to improve the quality of care delivered by these services.     

Staff members’ evaluation of inpatients’ motivation for aggression – the roles of staff restrictions and aggression severity

Improved understanding of inpatient aggression can come from systematic assessment of motivation for aggressive incidents. This study investigates staff members’ evaluation of motivation for aggressive incidents, and how such evaluations are influenced by staff restrictions and aggression severity. Staff reports of aggressive incidents in a secure psychiatric unit were collected in clinical practice over a ten-year period (2006–2015). Motivation for aggression was assessed with the Aggressive Incident Motivation Evaluation Scale, measuring irritable, instrumental, and defensive dimensions. Information about staff restrictions was collected with the Staff Observation Aggression Scale – Revised, and severity was rated with the Visual Analog Scale. Multilevel analyses of 2649 aggressive incidents, committed by 67 inpatients, revealed greater variation in aggression motivation across incidents than between individual patients. Staff restrictions preceding the aggressive incident and rating of severity were positively related to staffs’ evaluation of motivation for aggression, but their impacts differed across motivational dimensions. Staff reports of motivation provide important additional information beyond current standard report forms. Systematically evaluating motivation is essential to risk management, and may contribute to develop more fine-tuned interventions for preventing and managing aggression in inpatient settings.     

Mentalisation-based therapy (MBT) in a high-secure hospital setting: expert by experience feedback on participation

Evidence for mentalisation-based therapy (MBT) is increasing in relation to the treatment of personality disorder. Individuals with personality disorder are over-represented in inpatient, forensic and forensic inpatient mental health services. This study explores MBT within a forensic setting as an intervention designed to moderate deficits linked to violence and to improve adaptive coping. Interpretative phenomenological analysis was conducted on interviews with four patients who completed MBT at a high-secure hospital. Findings suggest that MBT-enhanced participants’ mentalising which had a positive impact upon their capacity to manage their behaviour and emotions. MBT further enabled participants to process past experiences of violence and develop some degree of empathy for others, which led to a trend in abstinence from risk behaviours. Findings contribute a secure inpatient perspective on the experience of MBT and to MBT clinical outcomes.     

住院病人请假外出相关法律问题探讨

对住院病人请假外出的相关法律问题，目前各方的观点和做法不一。笔者从医疗机构能否阻止住院病人请假外出、医患之间签订的免责条款的效力、医疗机构在病人外出时应尽的义务及病人外出受到损害医疗机构的责任四个角度人手，试图对住院病人请假外出涉及的相关主要法律问题做出梳理和分析，以期为解决病人请假外出相关法律问题提供思路。     

Patients’ views of the quality of Danish forensic psychiatric inpatient care

The present study describes the quality of psychiatric care among forensic inpatients in Denmark who answered the Danish version of the Quality in Psychiatric Care–Forensic In-Patient (QPC–FIP) instrument. A sample of 143 patients (response rate 53%) from 25 of the 27 specialized forensic units in Denmark participated in the study. The patients’ ratings of the quality of care were generally high. The highest rating was found for the quality of the secluded environment and the lowest for patient participation in the care. The results showed that several factors influenced the patients’ ratings. Women rated the quality of care lower in comparison to men. Patients living together with someone before admission, patients with a lower level of education, and patients who were better informed regarding their diagnosis, who was the responsible physician, and where to complain rated the quality of care higher. We can recommend the use of the Danish version of the QPC–FIP instrument for measuring and improving the quality of care in forensic inpatient care.     

精神病住院患者通信自由立法保护探析

众所周知,我国目前尚无统一的精神卫生法,精神病住院患者的权益时常受到忽视,甚至遭到他人侵犯。比如在通信方面,患者在医院往往不能依自己的意愿随时会见、联系他人。而能否自由地通信,无疑关系着每一位住院患者的切身利益。对精神病住院患者通信自由进行立法保护,尽快制定精神卫生法既是依法治国的基本要求,也是我国的现实需要。     

Who’s going to leave? An examination of absconding events by forensic inpatients in a psychiatric hospital

Absconding is a potentially risky event that has wide reaching consequences both for the institution and greater community; however, few studies have examined the characteristics of clients who abscond, their motivations, and details about their absconding event, especially within a forensic context. The purpose of this research was to determine if risk factors could be identified that might predict absconding behavior. A retrospective chart review was conducted of all reported absconding events between 1 January 2012 and 31 August 2015 by clients on forensic units in a public psychiatric hospital in Ontario, Canada. In addition, these clients were matched with a comparison group. Categories of motivations for absconding including goal-directed, frustration/boredom, symptomatic/disorganized, and impulsive/opportunistic were identified. The best indicator of a client’s risk for absconding was having experienced a stressful, significant event in the two weeks prior to the absconding event. Additionally, total scores on the HCR-20 and the presence of a co-occurring substance use disorder differentiated the absconders from the comparison group. This research contributes to our knowledge base regarding absconding events by forensic psychiatric patients and highlights specific targets for clinical staff in assessing risk for absconding and managing privileges leading to more effective care planning.