British Journal of Psychiatry. Supplement

A new approach to understanding severe mental illnesses such as schizophrenia and affective disorders is to adopt a clinical staging model. Such a model defines the extent of the illness such that earlier and milder phenomena are distinguished from later, more impairing features. Part of the appeal of such a model is that it should have cross-diagnostic applications, but to date there has been no attempt to examine imaging or neurocognitive evidence for staging in this way. We review these two domains of study with particular focus on major depression and bipolar affective disorder...

It is now known that the onset of severe and recurring mental health problems begins for the most part before the age of 25: this provides a clear focus for preventive strategies and public mental health that are a feature of many health policy frameworks. The present distinction between child and adolescent mental health services and adult services at 16 or 18 does not fit easily with these data and the now well-documented problems of transition suggest that a fundamental review of services for young people is overdue...

BACKGROUND: Key questions regarding residential alternatives to standard acute psychiatric care, such as crisis houses and short-stay in-patient units, concern the role that they fulfil within local acute care systems, and whether they manage people with needs and illnesses of comparable severity to those admitted to standard acute wards. AIMS: To study the extent to which people admitted to residential alternatives and to standard acute services are similar, and the role within local acute care systems of admission to an alternative service...

The quest for alternatives to traditional psychiatric wards has a long history but methodological difficulties have limited research into their benefits. Two UK studies suggest that community-based residential alternatives are valued by service users and may be cost-effective. Establishing and/or maintaining such services, where they function as an integrated component of local acute care pathways, is a justifiable decision. However, our findings do not provide compelling evidence that they should be seen as essential in every catchment area...

BACKGROUND: Differences in the content of care provided by acute in-patient mental health wards and residential crisis services such as crisis houses have not been researched. AIMS: To compare planned and actual care provided at alternative and standard acute wards and to investigate the relationship between care received and patient satisfaction. METHOD: Perspectives of stakeholders, including local service managers, clinicians and commissioners, were obtained from 23 qualitative interviews...

BACKGROUND: Alternatives to traditional in-patient services may be associated with a better experience of admission. AIMS: To compare patient satisfaction, ward atmosphere and perceived coercion in the two types of service, using validated measures. METHOD: The experience of 314 patients in four residential alternatives and four standard services were compared using the Client Satisfaction Questionnaire (CSQ), the Service Satisfaction Scale - Residential form (SSS-Res), the Ward Atmosphere Scale (WAS) and the Admission Experience Scale (AES)...

British hospital alternatives inherit some of their most valuable features, such as the use of small, domestic environments and the avoidance of coercion and confinement, from the early 19th-century moral management movement. The North American experience illustrates that these advantages can be lost if clinical benefits are overridden by cost and other practical concerns.

BACKGROUND: Women's crisis houses have been developed in the UK as a less stigmatising and less institutional alternative to traditional psychiatric wards. AIMS: To examine the effectiveness and cost-effectiveness of women's crisis houses by first examining the feasibility of a pilot patient-preference randomised controlled trial (PP-RCT) design (ISRCTN20804014). METHOD: We used a PP-RCT study design to investigate women presenting in crisis needing informal admission...

BACKGROUND: Little is known about the preferences and experiences of people with mental illness in relation to residential alternatives to hospital. AIMS: To explore patients' subjective experiences of traditional hospital services and residential alternatives to hospital. METHOD: In-depth interviews were conducted with 40 purposively selected patients in residential alternative services who had previously experienced hospital in-patient stays...

BACKGROUND: Residential alternatives to standard psychiatric admissions are associated with shorter lengths of stay, but little is known about the impact on readmissions. AIMS: To explore readmissions, use of community mental health services and costs after discharge from alternative and standard services. METHOD: Data on use of hospital and community mental health services were collected from clinical records for participants in six alternative and six standard services for 12 months from the date of index admission...

BACKGROUND: Outcomes following admission to residential alternatives to standard in-patient mental health services are underresearched. AIMS: To explore short-term outcomes and costs of admission to alternative and standard services. METHOD: Health of the Nation Outcome Scales (HoNOS), Threshold Assessment Grid (TAG), Global Assessment of Functioning (GAF) and admission cost data were collected for six alternative services and six standard services...

Many service users and professionals are not satisfied with current hospital care: they call for a safer and more friendly environment, with greater freedom and less social distance between staff and patients. Phase 2 of the Alternatives Study was designed to improve the evidence base for such residential alternatives. Findings suggest that offering a more acceptable environment increases satisfaction with treatment, although it does not improve the clinical outcome. This set of coordinated studies also suggest that we should listen (and talk) more to our patients, and make our style of working in hospital and community facilities less paternalistic...

BACKGROUND: Clinical experience has shown considerable potential benefits from long-term continuous medication for chronic or relapsing forms of schizophrenia. These benefits have not always been realised. AIMS: To review the research literature in order to understand the problems of long-term medication and use of antipsychotic oral medication and long-acting injections (LAIs), and to place these in an historical context. METHOD: Review of literature...

BACKGROUND: Long-acting injections (LAIs) of antipsychotic drugs were developed over 40 years ago in an attempt to improve the long-term treatment of schizophrenia. AIMS: To review existing guidelines concerning antipsychotic use generally, and LAIs in particular, and how patients might be identified as potential candidates for LAI treatment. METHOD: Literature review. RESULTS: Currently several first-generation and one second-generation antipsychotic LAIs are available, with others under development...

BACKGROUND: The community treatment order (CTO) is the legal framework by which people in the community are compelled to accept treatment. Both antipsychotic long-acting injections (LAIs) and CTOs are used to address treatment non-adherence. AIMS: To investigate the relationship between CTOs and LAI use in patients with schizophrenia. METHOD: Prescribing, demographic and CTO data were collected for patients from four community mental health clinics in Melbourne, Australia, in 1998 and 2002...

BACKGROUND: A patient-centred approach to care, focusing on recovery, demands a reconsideration of how choices are made about treatment, how this affects medication adherence, and the role of long-acting antipsychotics (LAIs) in this process. AIMS: To explore the role of the mental health professional (particularly nurses) in helping patients manage their medication, with a specific focus of the use and administration of LAIs. METHOD: A pragmatic review of the literature...

Antipsychotics in depot (or ;long-acting injection', LAI) form are shown in this supplement to be a significant component of clinical practice. They are comparatively underresearched, which may reflect their frequent use witih poorly adherent patients. This supplement clearly demonstrates the need for that research, highlighting the variations in dosing and the absence of established, specific guidelines in their use. Traditional evidence-based approaches to systematic reviews are of limited utility in this area so this supplement's blending of experimental trials with observational research is particularly appropriate and effective...

BACKGROUND: The attitudes of staff and patients have been demonstrated to influence the acceptance of long-acting injections (LAIs) or depot antipsychotics. AIMS: To examine the attitudes of patients and staff to LAIs. METHOD: A systematic review was carried out. Studies included contained quantitative data for attitudes of patients or staff to LAIs. RESULTS: Twelve studies published subsequent to the systematic review reported in 2001 were identified...

BACKGROUND: Data from the USA, Australia and Europe suggest that the proportion of patients with schizophrenia prescribed an antipsychotic long-acting injection (LAI) varies from around a quarter to a third. Use of LAIs has been associated with male gender and younger age. AIMS: To characterise the use of LAIs in people with schizophrenia in three clinical settings in the UK. METHOD: The study used audit data from quality improvement programmes conducted by the Prescribing Observatory for Mental Health...

BACKGROUND: Second-generation antipsychotics (SGAs) represent an advance in the long-term management of schizophrenia. AIMS: To review the available evidence concerning SGA long-acting injections (LAIs). METHOD: A systematic review of the literature was conducted using PubMed. RESULTS: Risperidone long-acting injection was the first licensed SGA-LAI compound and is effective in the long-term management of schizophrenia, with a safety profile similar to that of oral risperidone...