The Psychiatrist

Contingency management is a highly effective treatment for substance use and related disorders. However, few psychiatrists are familiar with this intervention or its application to a range of patient behaviours. This paper describes contingency management and evidence of its efficacy for reducing drug use. It then details areas in which contingency management interventions can be applied in the context of psychiatric treatments more generally, including increasing abstinence in individuals with dual diagnoses, encouraging attendance in mental health treatment settings, enhancing adherence to psychiatric medications, reducing weight, and improving exercise. Greater awareness and use of contingency management in practice may improve outcomes across a range of mental health and related conditions.

AIMS AND METHOD The study aimed to identify the predictors of drop-out from clozapine treatment by examining the demographic and clinical characteristics of patients registered on clozapine within a 6-month period in one NHS Trust. RESULTS During the study period, 54 patients were registered and began clozapine treatment and 31% had discontinued within 6 months. Two people died and the remainder discontinued because of non-compliance or side-effects, including neutropenia. Two factors were predictive: the age of the patient (older patients were more likely to discontinue) and the hospital where the initial registration was made. CLINICAL IMPLICATIONS Neither ethnicity, previous registration nor the individual prescriber are a bar to successful persistence with clozapine. However, one set of hospitals with a history of evidence-based practice and high clozapine prescribing was more successful in retaining patients on maintenance treatment. Although specific dataare needed to identify more subtle contributing factors to continuation, it is clear that there is scope for improving the rate of persistence with clozapine treatment. Yes Yes

Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons RCPsych Publications, 2011, £20.00, pb, 256 pp. ISBN: 9781908020017 In the foreword, Professsor Robert Howard writes: ‘A psychiatrist who cannot show that he or she has been involved in audit is going to be in

Liz Tate[1][1] rightfully mentioned that there are junior trainees attending to the Section 136 assessments, despite clear guidance in the Mental Health Act Code of Practice that it should be done by Section 12(2)-approved doctors. Further to that, the Code states that a reason should be documented

Opportunities for emergency assessments by junior trainees are certainly being reduced, largely as a result of rota merges to comply with the European Working Time Directive for doctors[1][1] and New Deal.[2][2] However, rather paradoxically, in areas where Section 136 suites have been created as an

The article by Patrick Keown[1][1] was a timely contribution to discussions currently taking place about the use of Section 136 between the Royal College of Psychiatrists, Home Office, Department of Health, Police, Health and Social Care Information Centre, and Care Quality Commission. A major and

Stanley Smith’s grand-daughter often teased him for having more letters after his name than he had in it, but to Stanley, qualifications really mattered. He was a consultant psychiatrist in Lancaster, Chairman of Lancaster Area Health Authority, a member of the Butler Committee on Mentally

Aims and method To audit the quality of medical recommendations for detention under the Mental Health Act 1983, Section 2 and 3. The recommendations were tested against a gold standard based on the statutory criteria. Two cycles were completed, the first containing 214 recommendations, the second 202. Relevant education took place after the first cycle. Results The percentage of medical recommendations containing clear statements of why each of the statutory criteria was met increased in the second cycle. It reached 87% for mental disorder; 87% for nature and/or degree; 75% for why community treatment was not possible; 64% for why detention was in the interests of health; 60% for safety; 55% for protection of others; and 70% why informal admission was not possible. Clinical implications Doctors, scrutineers and approved mental health practitioners welcomed clear guidance about what is expected in a medical recommendation for detention and endorsed the gold standard described. Armed with a better understanding of what is expected and a template to follow, there was an improvement in the reasons given for detention.

Aims and method To assess the extent to which psychiatric history, with specific regard to compulsory psychiatric admission, is questioned in visa, insurance and permit applications. Application forms for the top UK destinations for immigration, work and travel visas, six types of insurance, and driving, sporting and vocational permits were analysed. Results Psychiatric history is questioned in some applications across all visa types. Hospital admission, but not compulsory psychiatric admission, is questioned in some immigration visas. Psychiatric history is not questioned in mortgage protection, car or pet insurance but it is questioned in some travel, life and health insurance applications, as is hospital admission. The majority of permit applications questioned psychiatric history and one vocational permit considered compulsory psychiatric admission. Clinical implications The majority of visa, insurance and permit application forms enquire about past medical and psychiatric history. Information concerning detention under the Mental Health Act is very rarely questioned, indicating that a direct link between detention and access restriction is not evident.

Aims and method We assess and compare: (a) the attitudes of final-year medical students in 2010 to their 1994 counterparts; (b) the attitudes of third-year medical students with those of their final-year colleagues; (c) the impact of two different teaching modules on students' attitudes. All students completing the year 3 psychiatry preclinical module and the final-year clinical clerkship were asked to anonymously complete three well-validated attitudinal questionnaires on the first and final day of their module in psychiatry. Results These data indicate that Irish medical students have a positive attitude to psychiatry even prior to the start of their clinical training in psychiatry. This attitude is significantly more positive now than it was in 1994. A positive attitudinal change was brought about only by the final-year psychiatric clerkship. Students who have completed a degree prior to medicine are less likely to express an interest in a career in psychiatry. Clinical implications If we are to address the recruitment difficulties in psychiatry we need to look at innovative and specific ways of translating these positive attitudes into careers in psychiatry.

Aims and method On 1 November 2006, Ireland's Mental Health Act 2001 was implemented, replacing the country's Mental Treatment Act 1945. We aimed to assess the impact of this change in legislation on the number and duration of involuntary admissions. We undertook a retrospective review of all admissions to a psychiatric admissions unit from January to October 2006 (pre-implementation) and January to October 2007 (post-implementation). Results There were 46 involuntary admissions in the 10-month period under study in 2006, or 33.8 per 100 000 population. There were 53 in 2007, or 39.3 per 100 000 population. This increase was not significant ( z = – 0.7, P = 0.46), however involuntary admissions formed a larger proportion of all admissions under the Mental Health Act 2001 than under the Mental Treatment Act 1945 (χ ² = 4.2, P =0.04). There was no difference in the duration of involuntary admissions but under the 2001 Act, involuntary patients had longer periods of voluntary status as part of their admissions than under the 1945 Act. Clinical implications The introduction of more rigorous procedures for involuntary admission did not significantly change the rate or duration of involuntary admissions in our centre. The finding that involuntary admissions included longer periods of voluntary status suggests that more care is being taken to revoke involuntary admission orders under the Mental Health Act 2001 than under the Mental Treatment Act 1945.

The Sexual Offences Act 2003 repealed and revamped almost all of the existing statute law in relation to sexual offences. The purpose of this was to strengthen and modernise the law in this area. Incorporated within the Act were new and specific offences providing for 'Offences against persons with a mental disorder impeding choice' and offences involving 'Inducement, threat or deception to procure sexual activity with a person with a mental disorder'. Psychiatrists may be involved in such cases to provide assessment and opinion as to whether the alleged victim had a mental disorder and because of this lacked the capacity to consent to sexual activity. Knowledge of the intricacies and implementation of these offences against people with mental disorder can aid clinicians who may be asked to provide expert written and oral evidence and opinion for court cases.

Aims and method Following recommendations made by our 2004–2005 audit, we carried out a re-audit of the local Section 297 protocol in 2007–2008. Our aim was to establish the quality of documented information provided by the police; adherence to the protocol; completion rates of documentation; and rates of notification to the Mental Welfare Commission for Scotland, in keeping with the standards set in the Code of Practice of the Mental Health (Care and Treatment) (Scotland) Act 2003. Results We reliably traced 84 POS1 forms completed in accordance with the protocol. The audit identified a rate of 74–89% notification to the Mental Welfare Commission for Scotland. By comparison, there is a surprisingly wide variation in notification rates across Scotland. Good-quality information was given by the police, despite receiving no additional training. Clinical implications This audit highlights a serious lack of information about place-of-safety legislation in Scotland. For patients in the catchment area, the joint protocol and use of standard documentation has significantly standardised patient care. Other health boards and police forces should consider this as they implement legislation.

Aims and method The effectiveness of official support provided following a disaster has not been fully evaluated. This study aimed to ascertain whether there was an association between perceived support shortly after the 2004 Indian Ocean tsunami and later mental health symptoms in those affected, and to explore the factors associated with this. A survey, semi-structured interviews and focus group were used to explore the experiences and perceptions of 116 individuals severely affected by the tsunami. Results Agency or official support was perceived as poor overall. Perceived ineffectiveness of support available within a few days after the tsunami was associated with increased symptoms of post-traumatic stress disorder 15–19 months later. The strongest themes that emerged from our study were that support provided in a humane manner was perceived as effective and that uncoordinated support, poor communication and limited accessibility to support and information were perceived as ineffective. Clinical implications Improved planning of coordinated, flexible, multi-agency responses to traumatic events before they occur is required.

The Mental Capacity Act 2005 is a critical statute law for psychiatrists in England and Wales. Its best interests provision is fundamental to substitute decisionmaking for incapacitated adults. It prescribes a process of and gives structure to substitute decision-making. The participation of the incapacitated adult must be encouraged where practicable. In addition to this, 'the best interests checklist' must be applied in every case before a practitioner can arrive at a reasonable belief that the action or decision taken on behalf of an incapacitated adult is in his best interests. Most commentators have shown goodwill towards the workings of the Act and want it to succeed.

Aims and method The assessment of capacity is integral to all areas of medical practice; however, research has shown that doctors in many specialties have inadequate knowledge about both the Mental Capacity Act and the Mental Health Act. In this study, 39 trainee doctors and 49 fourth-year medical students completed an e-learning package, which included a pre- and post-evaluation of knowledge of the Mental Capacity Act and confidence in the use of this act. Results In comparison to pre-intervention scores, trainee doctors and students displayed a statistically significant improvement in knowledge and subjective confidence. Clinical implications The e-learning package is an effective educational tool for improving knowledge about the Mental Capacity Act for trainee doctors and could be included as part of induction training for all foundation doctors as well as being considered for use in the induction programme of other trainee doctors. It is an effective tool for educating clinical medical students about the Mental Capacity Act.

Aims and method This study explores knowledge and uptake of the voting rights of adult in-patients in the 2010 UK general election. A clinician-completed survey was used. Results Eligible to vote psychiatric adult in-patients were half as likely to register as the general population and half as likely to vote if registered. Nine out of ten of those unregistered cited a lack of knowledge of their eligibility to vote or of the registration process. Long-stay patients were particularly disenfranchised. Clinical implications Many patients and staff remain unaware of the new rules which have given a greater proportion of in-patients the right to vote and have simplified the registration and voting processes. This information barrier may be addressed in future elections by providing timely written information to both patients and staff. Once registered, patients may need further support to overcome practical and psychological barriers, and cast their vote.

The host country's legacy after the Olympic Games is multifaceted. Alongside such diverse elements as tourism, commerce and transport sit the health benefits of increased participation in sports and provision of the highest quality medical support for the nation's elite sporting performers. Mental health, however, merits no specific mention. This could be a missed opportunity to create a legacy that promotes the mental health benefits of exercise as well as ensuring that the mental health needs of elite sportsmen and women are recognised and met in the same manner as their physical health needs.

The Health and Social Care Act 2012 brings in profound changes to the organisation of healthcare in England. These changes are briefly described and their implications for mental health services are explored. They occur as the National Health Service (NHS) and social care are experiencing significant financial cuts, the payment by results regime is being introduced for mental health and the NHS is pursuing the personalisation agenda. Psychiatrists have an opportunity to influence the commissioning of mental health services if they understand the organisational changes and work within the new commissioning structures.