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EDITORIALS: Tilman Steinert Reducing violence in severe mental illness BMJ 2001; 323: 1080-1081 [Full text]

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Violence in Psychiatric Wards

Andrew Sandor   (13 November 2001)

Violence in Psychiatric Wards 13 November 2001
Andrew Sandor, Lecturer in social and community psychiatry Department of Psychiatry and Behavioural Science, RF& UC Medical School, London N19 5NF Send response to journal: Re: Violence in Psychiatric Wards	Violence in Psychiatric Wards Steinert1 is correct that violence is strongly associated with the severity of psychotic symptoms. His assertion however that substance abuse, non-compliance with medication, association with criminal peers, and living in poor conditions are minimised under the regimen of psychiatric wards seriously misrepresents the true conditions on psychiatric wards. The suggestion that medication and drug abstinence can be enforced is way off the mark, even in locked wards. Steinert tells us that conditions in the community are quite different [from conditions in the community]. He is right, but not as he intends: conditions on the wards are far worse. Indeed it is likely that the concentration of the worst problems in the community in in-patient units is the very reason for the high levels of assaults and violence that occur on in-patient wards, every day. Poor living conditions are rife on in-patient psychiatric wards as the UK National Director for Mental Health has recently acknowledged: "some of our wards are bleak and shabby, unsuitable for the care of distressed and disturbed patients"2. He has also acknowledged the problems with substance misuse on the wards and has indicated that the issuing of guidance on tackling drug misuse on wards is a priority for the modernisation of in-patient wards. Drug misuse is undeniably a very significant factor in violence among the mentally ill, yet there are major constraints to dealing with it. Even establishing that drug misuse is occurring is far from straightforward. Observation alone may raise suspicions, but even the Mental Health Act, 1983 contains no provision that allows for the searching of detained patients, and the participation by staff in such activity without consent constitutes trespass. The 1999 Code of Practice to the Mental Health Act (paragraph 25.3) indicates that routine and random searching without cause should only applied in exceptional circumstances3. More widespread drug testing may be one way forward. Hospital treatment, as described by Steinert, may reduce violence temporarily4, but it does nothing to address one of the causes of violence in a small subset of the mentally ill when they are discharged from hospital, that is, on-going substance misuse. Research into the relationship between substance misuse, mental illness and violence must be a major priority for both safeties on wards and in the community. 1 Steinert T. Reducing violence in severe mental illness BMJ 2001; 323, 1080-1081,). 2 Appleby L. Psychiatric Bulletin, 2001; 25, 391 A brighter future for in-patient wards. 3 Williams R, Cohen J. Substance misuse in psychiatric wards Psychiatric Bulletin, 2000; 24: 43-46 4 Steinert T. Sippach T, Gebbhardt RP. How common is violence despite neuroleptic treatment? Pharmacopsychiatry 2000; 33: 98-102 Andrew Sandor