Management of treatment resistant schizophrenia in medium secure care

nia (TRS) is relatively common, in that between a fifth and a third of service users show a disappointing response to adequate trials of conventional antipsychotic drugs.1–3 The economic burden of this is considerable, both in direct health care costs and loss of productivity due to patients being unable to work. The Schizophrenia Commission report identified the employment rate of patients with schizophrenia as being around 8% in the UK, within a range of 5–15%, against a national UK employment rate of 71%.4 A prospective longitudinal study of TRS patients identified 47 of 59 (79.7%) patients were unemployed at baseline. However, over a 12-month period of clozapine therapy, 23 (48.9%) additional patients were able to gain paid or volunteer jobs, or attend school.5 The average total direct health care costs of treating each patient with schizophrenia amounts to £1670 per year.6 For all patients in the UK, this represents £310 million annually, of which hospital and residential care account for 74% of the total.7 It was initially thought that the target length of stay in medium security hospitals should range between 18 months and two years.8,9 However, several studies have identified that a significant proportion of the medium secure population have treatment needs that extend beyond the twoyear duration.10 Prolonged stay of these patients, many of whom have been transferred from high security psychiatric hospitals, has led to silting up of medium secure beds with inherent consequences for patient flow through the care pathway.11 An earlier study found that, among 21% (25 out of 122) of medium secure male patients who had been admitted for five years or longer, there were high levels of comorbidity and treatment resistance.12 The primary aim of our study was to determine the prevalence of TRS within the male medium secure unit (MMSU). Secondary aims were to establish what factors contributed to long stay, and to use these data towards future service redesign.