Christina Moore and Judith Wolf miss out an important clinical factor with considerable impact on acute psychiatric bed use.

Patients with co-existent personality disorders are often inappropriately treated with the type of regimes in place on most acute wards. Admission can lead to the escalation of disturbed behaviour, and a disproportionate emotional burden on clinical staff.

'Personality disorder' is often a diagnosis of despair in psychiatry, and psychiatrists in training are generally taught not to make it as a primary diagnosis. However, many patients on acute wards do have a personality disorder in addition to their presenting complaint and official diagnosis: epidemiological figures for 'emotionally unstable personality disorder' give similar incidence rates in schizophrenia, and similar rates for mortality by suicide.

These people generally need specialist regimes, such as the newly commissioned Henderson Hospital and Francis Dixon Lodge in Leicester.

Economic evaluation at the latter has demonstrated that there is considerable cost-offset in such definitive treatment programmes (called 'therapeutic communities') and they can reduce subsequent admissions in the long term (continued reduction of service use has been demonstrated at three-year follow-up) as well as other savings in health service utilisation, such as treating the consequences of repeated deliberate self-harm.

The clinical picture and service need is considerably more complex than Moore and Wolf's description of a simple medical model would suggest.

Rex Haigh

Consultant psychiatrist in psychotherapy,

West Berkshire Priority Care Service trust