Functionalisation - the separation of in-patient and community consultant roles - has eroded the longitudinal clinical memory of individual patients. Unlike specialisation, which deepens expertise, functionalisation has fragmented patient care. In functional models, critical decisions regarding admission, discharge and aftercare are often made without a comprehensive knowledge of the patient's history. National inquiries highlight that risks cluster at these transition points, where information is fragmented and responsibility is unclear. Functional models fail to improve efficiency while significantly damaging continuity of care. Reform must become a proactive clinical priority rather than a reactive response to adverse events or inquiry findings.
Aims and method Services for people who are high users of emergency departments (EDs) have developed in a piecemeal fashion, including those embedded within liaison mental health services, over the past decade. We conducted a national survey of all 171 National Health Service hospitals in England with an ED to identify high user services, alongside 20 interviews from exemplar services to characterise the interventions offered. Results We had a 100% response rate. Of the 171 hospitals, 76 (44%) had a high user service in the ED without designated staff and 71 (42%) offered services with some designated staff time; 10 (6%) had community services, either separate or with hospital outreach; and 14 (8%) had no service. Interviews revealed great variability among services on most parameters, including staffing levels, entry criteria, case-load and types of intervention. Clinical implications There is a need for clarity on entry criteria, case-load and types of intervention, to improve consistency and effectiveness of these services to guide decision-making.
Aims and method To evaluate the real-world effectiveness of electroconvulsive therapy (ECT) in schizophrenia and schizoaffective disorder, and to identify clinical predictors of response. We conducted a naturalistic study using routinely collected data from the Scottish ECT Accreditation Network between 2009 and 2018. Individuals with schizophrenia or schizoaffective disorder who had complete pre- and post-treatment Clinical Global Impression ratings were included. Clinical improvement and associations with demographic and clinical variables were examined. Results A total of 153 patients were included (94 with schizophrenia, 59 with schizoaffective disorder). Overall, 86% showed clinical improvement following ECT. Marked improvement (‘much’ or ‘very much improved’) was observed in 65% of patients with schizophrenia and in 78% with schizoaffective disorder. In schizophrenia, younger age, greater baseline depressive symptoms and receipt of emergency treatment were associated with higher likelihood of improvement. Clinical implications These findings indicate robust effectiveness of ECT for schizophrenia and schizoaffective disorder in routine National Health Service practice and highlight clinically relevant predictors of response, suggesting that current guideline positions may warrant re-evaluation.
What can we learn from the principles of feminism that might improve care for our patients - of any gender? How can psychiatry address its historically difficult relationship with women, and what can we, as mental health professionals, consider doing differently in our everyday work? We discuss what psychiatrists might learn from the work of feminist theorists, and what we can do as a profession to create a feminist psychiatry. This includes acknowledging and owning our troubled history, pressing for gender-sensitive mental healthcare, promoting trauma-informed care that is focused on the importance of developing collaborative therapeutic relationships and improving our ability to listen.
Medical decision-making involves choosing from diverse - even oppositional - viewpoints to guide patient care. Critical psychiatry aims to improve psychiatric practice by providing alternative viewpoints on several topics: interrogating psychiatric concepts (for example, 'mental disorder'); flattening power differentials between professionals and patients; highlighting misuse of psychiatric authority; increased focus on social factors; scepticism about biological emphasis in psychiatry; using natural science methodologies and the 'medical model' in mental health; and critiquing the psychiatric evidence base, such as the effectiveness of medication and concern over pharmaceutical company influence. Critical psychiatry has helped identify and raise awareness about treatment-related adverse effects. Among concerns regarding current critical psychiatry are a reluctance to reconsider its positions when many of them are contradicted by the evidence, and promotion of views that can be used to justify reductions in services and welfare benefits for patients. Changes in leadership within critical psychiatry may help address these issues.
Aims and method This study aimed to explore the demand for mental health services among people experiencing homelessness in multiple settings. Participants included all persons referred to nine community mental health teams (CMHTs), three in-patient psychiatric units and one emergency department in Dublin, Ireland, over 1 year (1 July 2022 to 30 June 2023). Key aspects of service provision were examined, including population characteristics, relevant history, referral outcomes and alternative care pathways. Results There were 401 referrals to all services in the study period, the majority males. Half of those admitted acutely and one-quarter of out-patient referrals had a diagnosis of a psychotic illness. There were high rates of comorbid substance and alcohol use in presentations across all settings. Clinical implications High rates of mental illness and comorbid vulnerabilities were found. Appropriately addressing the needs of this population will require increased resourcing of CMHTs, as well as the provision of assertive outreach.
In his analysis of 'ignorance culture' in eating disorder services, Downs describes how repeated alarms raised by patients, carers and clinicians are routinely ignored, deflected or reframed as individual pathology. In this Opinion piece, I reflect on the clinical implications of that analysis, arguing that ignorance culture is enacted through everyday treatment structures that misread multi-layered presentations, invalidate advocacy and displace responsibility. Drawing on dialectical theory and biosocial frameworks, and using multidiagnostic eating disorder-dialectical behaviour therapy as an illustrative example, I suggest that addressing ignorance culture requires treatment models that operationalise responsibility rather than merely espouse it.
Aims and method Despite evidence of disparities in care received by Black communities, limited interventions exist to address them. The SEE ME training is a co-produced intervention using video testimonials to improve the care of Black individuals with psychosis within NHS early intervention in psychosis (EIP) services. This study explored mental health professionals’ experiences of the SEE ME training and its impact on addressing racial inequalities within EIP services. Semi-structured interviews were conducted with 21 mental health professionals, and the data were analysed with thematic analysis. Results Thematic analysis identified six superordinate themes and 17 subthemes, encompassing the importance of adopting clients’ perspectives, prioritising individuals’ voices, enabling reflection, fostering shared humanity and creating psychological safety. Clinical implications This is the first qualitative study exploring the impact of SEE ME training. Findings offer valuable insights for improving anti-racist practice and service development in mental healthcare.
Bowlby’s Maternal Care and Mental Health and its abridgement Child Care and the Growth of Love present two claims. The first (MCMH1) holds that children develop better mental health when they experience care from at least one familiar caregiver. The second (MCMH2) states that a child’s development and well-being depend on their mother’s constant presence and attention. Archival material suggests that the popular abridgement was written by Margery Fry rather than Bowlby, based on an interpretation of Maternal Care and Mental Health supporting MCMH2 and incorporating extracts supporting this conclusion. This may have contributed to enduring misconceptions about Bowlby’s theoretical position.
Kindness is often championed in mental healthcare but is too easily reduced to niceness or rhetoric. Drawing on my experience of research working alongside mental healthcare teams, I argue for intelligent kindness grounded in relational, courageous, boundaried and systemic practice that seeks what is ultimately good for patients and protects staff, even if it is not immediately apparent. Misapplied kindness risks burnout, moral injury and stalled recovery, whereas intelligent kindness protects staff integrity and patient dignity. Importantly, it must be structurally enabled across clinical, organisational and policy levels. Intelligent kindness is a fundamental requirement for humane mental healthcare.
Aims and method A forum theatre-based intervention was delivered to medical students undertaking their psychiatry rotation. A professionally written and acted play titled Revolving Door was adapted for undergraduate education to illuminate the lived experience of a young man with psychosis and his family. A mixed-methods evaluation, comprising a post-intervention survey and focus group, was undertaken to assess to what extent forum theatre can support medical student learning and to identify the aspects that contribute to its pedagogical value. Results Quantitative and qualitative data revealed that forum theatre is an effective pedagogical method that helps medical students to improve their intellectual understanding of a condition or clinical skill and gain insight into the lived experience of patients, empowering them to make meaningful change as future clinicians. Clinical implications The study highlights an innovative intervention that champions transformative learning, an aspect that is often overlooked in traditional medical education.
The debate on euthanasia for mental suffering in young people in The Netherlands has become highly polarised, with a novel, apparently epidemiological argument taking centre stage: that psychiatric euthanasia is necessary to prevent suicide. This article evaluates that claim. Using data from 353 young applicants (annual suicide risk 2.9%) and optimistic assumptions (80% sensitivity and specificity), the number needed to treat was 10 and the number needed to harm 9. Thus, ten youths would need to undergo assisted dying to prevent one suicide, and nine would die without a preventive purpose having been served. Empirically and ethically, the prevention argument does not appear to hold; real prevention requires other, previously well-debated factors such as relational continuity, trauma-informed care and social inclusion in response to mental suffering.
Aims and method Parental hospitalisation harms parent–child relationships and child outcomes. Thus, supporting parent–child connection is enshrined in the Mental Health Act (1983). However, there is no recent evaluation of provision or understanding of the prevalence of parents in in-patient settings. We sent a cross-sectional Freedom of Information request to all 50 English National Health Service (NHS) trusts that provide in-patient psychiatric services, aiming to capture the following: parental admissions; information on parental status; parenting-related policies/procedures/materials; and frequency of children’s visits. Results Only 5 trusts could report the prevalence of parenthood (M = 13.9% of patients); 11 could report the information they collect on parental status; 28 provided policies; 18 provided materials for parents, carers or children; and 1 held data on child visits. Clinical implications Most English NHS trusts do not hold basic information about parents in in-patient psychiatric settings. This suggests widespread failure to meet the requirements of the Mental Health Act, and probably failure to support families and ensure the safeguarding of children.
