bluuebunny/crossref_metadata_2025 huggingface dataset:
Effectiveness of rTMS on Suicidal Thoughts in Patients With Depression
Authors: Bapakunhi Dilshana Nafisa , Pillay Parvathy
Published: July 2023

Aims

rTMS (Repetitive transcranial magnetic stimulation) as a brain stimulation modality is approved to treat treatment-resistant depression. Its efficacy in depression and anxiety is well supported in several studies. However, its direct effect on suicidality is still unclear, unlike electroconvulsive therapy. This study aims to evaluate the effectiveness of rTMS on pessimistic and suicidal thoughts. We hypothesized that rTMS reduces pessimistic and suicidal thoughts, alongside other symptoms, in patients experiencing depression and anxiety as the therapy progresses over six weeks.

Methods

The study is a retrospective observational study. The study was conducted in the rTMS Clinic, Brentwood. All of the patients undergoing treatment at the rTMS Clinic were assessed with subjective and objective scales for depression. One of the scales was MADRS (Montgomery Asperger's Depression Rating Scale); this was used to study the response of therapy. I looked into the pessimistic and suicidal thoughts component in MADRS, the baseline score was recorded, and its progression on weekly monitoring for six weeks was noted.

63 patients attended the rTMS clinic from January 2019 to October 2022. 21 patients were excluded for reasons that included dropping out before completion of treatment, MADRS weekly scores not being available, and some of them still undergoing treatment. A total of 42 patients, 21 male and 21 female, who successfully finished rTMS therapy at the Neuromodulation clinic were included in the study.

Results

The study showed that rTMS was effective and well-tolerated in reducing pessimistic and suicidal thoughts in the majority of patients. Average baseline scores and their average weekly progressions for pessimistic and suicidal thoughts over six week's period were recorded. The average score of baseline pessimistic thoughts was 3.925, and baseline suicidal thoughts was 3, in the severity scale of 0–6. There was a gradual reduction in scores of pessimistic and suicidal thoughts from baseline to the end of intensive six-week treatment. Scores measured at the end of every week showed a reduction in scores from the previous week of treatment. Average scores at the end of six weeks showed 2.375 and 1.65 in the pessimistic and suicidal thought domains respectively in the MADRS scale.

Conclusion

rTMS is being used for symptoms of depression and anxiety and evidence is encouraging in treating symptoms including pessimistic and suicidal thoughts. rTMS therapy over six weeks showed a gradual reduction in the severity of pessimistic and suicidal thoughts, demonstrated by decreases in average MADRS weekly score.
Integrating Cultural Awareness to Improve Mental Health Services in the Multi-Ethnic Community: A Systematic Literature Review
Authors: Olotu Sarah
Published: July 2023

Aims

The challenges in providing mental healthcare in an ethnically diverse society exist within the limited frameworks of psychopathologies. Ethnocultural communities suggest relative syndrome of beliefs and practices so that experiences of mental illness differ and may not fit into the concept of colonial psychiatry. This review examines the necessity to recognise these trends as social determinants in the effectiveness and accessibility of healthcare and in preventing disparities.

Methods

According to the Centre for Reviews and Dissemination (CRD), this abstract adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Standards using a search strategy of major online databases. The published studies selected were based on inclusion and exclusion criteria surrounding cultural competency in clinical practice in the context of global mental health. The studies were analysed and synthesised with quality appraisal tools and reported in a narrative approach.

Results

The outcome from the pool of studies revealed the following common themes.

Culturally informed clinical practice/transcultural psychiatry: Integrating the perspectives of the client's explanatory model with the clinician lens in a shared narrative through ethnographic principles. The cultural consultation service (CCS) recommendations increased knowledge of the specific issues of the patient's background and improved empathy and communication.

The improvement of therapeutic alliance: A focus on the aspects of religiosity/spirituality on human life experiences and the implication in healing and psychotherapy for better positive clinical outcomes.

The impact of psychosocial stressors: The clinician highlights the significant contributing factor to the mental distress of the patient, which may include cultural stressors, to provide tailored care and solutions within a multidisciplinary team.

Conclusion

The research on cultural competency in the mental health setting is multifaceted. The ongoing discussion on transcultural psychiatry, integrating biomedical and traditional practices and specialised clinical formulations, can improve mental health service delivery in a global society.
Assessing Prevalence of Post- Traumatic Stress Disorder Symptoms Following the 2015 Earthquake in Langtang ,Nepal
Authors: Sharma Rajasee , Tamang Ngawang Dorje , Bhattarai Gaurav
Published: July 2023

Aims

Among the consequences of natural disasters, post-traumatic stress disorder (PTSD) has been one of the most prevalent mental health issue. Nepal has been categorized as a region prone to natural disasters including earthquakes and avalanches. However, mental health implications of such disasters have been rarely explored in Nepal especially in remote regions like Langtang.In this research, we have estimated the prevalence of post-traumatic stress disorders (PTSD) among the survivors 7 years after the mega earthquake and avalanche in 2015 in rural mountainous region of Langtang in Nepal. We also explored the association between sociodemographic parameters and PTSD scores.

Methods

A Cross sectional quantitative observational study was carried out in 2022. Study population included the residents of Langtang who are the survivors of 2015 earthquake. Simple random sampling was done and participants aged 18 years and above who consented to the study were included. Sociodemographic details were assessed using a predesigned structured questionnaire and PTSD symptoms were measured using the Nepali version of PTSD Symptom Checklist 5 (PCL 5). PCL-5 scores of >31 was used as cutoff for presence of PTSD. Data were analysed using SPSS software.

Results

A total of 124 participants were included in the study. PTSD symptoms score were above the cut off in 7.3% . Most respondents were males (60.5%), young adults aged 18–30 years (36.3%), with no formal education (53.2%), with at least loss of one family member (66.1), and majority rescued after a week(42.7%). Sociodemographic variables such as age group, education, occupation, location during the incident, rescue time and substance use were significantly associated with the PTSD scores. Middle aged respondents were observed to have significantly high PTSD scores followed by older age group(p = 0.04). Similarly, PTSD scores were significantly higher among the respondents with no formal education and who had agriculture/tourism as their main occupation(p = 0.02). Likewise, respondents who were in Langtang during the incident were found to have significantly higher scores(p < 0.001). Interestingly, PTSD scores were found higher among those respondents who were rescued within a week from the time of incident as compared to individuals who were rescued after a week(p < 0.001). Also, PTSD scores were higher among the respondents who consumed any type of substance(p = 0.002).

Conclusion

PTSD was prevalent even 7 years after the incident in the Langtang community. Certain sociodemographic parameters were identified to be associated with increased PTSD symptoms.
High Intensity User Quality Improvement Project
Authors: Allam Heba , Bradley Rhian
Published: July 2023

Aims

To ensure that patients who are high intensity users of acute mental health services (136 suite, Liaison, and inpatient admissions) have a ‘safety plan’ in place .This should contain person centred and specific recommendations to avert crisis and guide acute clinicians in managing care in a crisis situation.

Methods

Audit of electronic health care records of top 10 patients who most frequent attend each of s136 suite, LPS and inpatient wards (26 in total) in the period 05/2021 to 04/2022.

Process mapping

Driver diagram

Coproduction via patient engagement team

Focus group-across care groups and lived experience

Results

-Audit of 26 identified HIU – whilst most (>80%) had a ‘safety plan’ in place, these lacked sufficient detail to avert ‘crisis’ and guide appropriate treatment should the situation escalate. The most frequent diagnosis was EUPD (77%). Most (93%) were open to CPA pathway.

•

Process mapping – visual representation of crisis planning process within CPA process.

•

Driver Diagram – primary and secondary drivers leading to change ideas of: additional ‘HIU response plan’ template; best practice example to guide care coordinators; process of flagging up HIU to community mental health services.

•

Focus group – themes included the importance of : joint working across care groups’ transparency with patients regarding professional opinion; consistency of interventions during a ‘crisis’; and coproduction of safety plans.

•

HIU response plans are incorporated into the safety plans of 20/26 HIUs.

•

PDSA process ongoing – quality assurance and clinical effectiveness of changes to be reviewed. Further change ideas sought through QI process.

Conclusion

High intensity users who often present in ‘crisis’ to acute mental health services, have unmet needs.

This cohort require an additional framework to meet their needs.

When patients experience a mental health ‘crisis’, a consistent and clear treatment response is experienced as helpful.

Safety/crisis planning is thus an important aspect of meeting needs.

HIU response plans’ can be incorporated into a patients ‘safety plan’ to ensure that individualised and specific guidance is available.

Best practice example of ‘HIU response plans’ can empower community mental health colleagues to co-produce such plans.
Psychiatric Inpatient Admissions–- Improving Handover Standards
Authors: Barrett Megan , Fraser Sam
Published: July 2023

Aims

Within NHS Ayrshire and Arran for psychiatric inpatient admissions, the admitting clinician is to directly handover clinical details and relevant aspects of mental state, risk and management plan to the inpatient duty doctor. Over 2022, there was concerns this process was not being followed, resulting in prescription errors, difficulty in assessing risk at admission and difficulty in prioritising workload. The aim of the project was to first assess pre-intervention rates of handover for inpatient admissions. Then with these data, look for interventions. The final aim was to re-asses post-intervention, analysing if interventions improved rates of handover.

Methods

Pre-intervention quantitative data were gathered over a three week period in April 2022, with Junior Doctors noting for admissions to Woodland View Psychiatric Hospital whether handover had been received, or if the Duty Doctor had been alerted at all to the admission prior to patient's arrival on the ward.

Qualitative data were also gathered, specifically asking what factors admitting clinicians found impacted ability to handover.

Data were presented at the monthly division of psychiatry meeting, and subsequently interventions were discussed in a meeting with Hospital bed managers, Hospital co-coordinators and the clinical director for inpatient care. The outcome resulted in change to the local hospital admission protocol, with bed managers prompting the importance of handover, and transferring admitting clinician's phone calls to the duty doctor at the time admissions are accepted by bed managers.

Post-Intervention, the same criteria assessed in April 2022 was reassessed in January 2023.

Results

Pre-intervention, of 25 admissions, a handover was provided for 32% of patients. Duty doctor was alerted to 52% of admissions prior to the patient's arrival on the ward. Post-intervention, this increased to 71% and 82% respectively for 17 patients admitted in January 2023.

Qualitative themes thought to impact ability of handover were admitting clinicians feeling there was already a number of calls made when admitting, and one with duty doctor could be neglected. Secondly the clinicians thought another member of the team would alert duty doctor of admissions.

Conclusion

The project met its aims, showing pre-intervention rates of handover as low, and post-intervention rates rising after the admission process was changed, taking on the feedback from admitting clinicians. Given rates remain still significantly below 100%, there is still further work to be done. Results are due to be shared again with bed managers and at division to discuss further interventions.
Audit and Quality Improvement of Physical Health of New Admissions to an Acute Inpatient Facility
Authors: Grant Heidi
Published: July 2023

Aims

The poorer physical health of psychiatric versus non-psychiatric patients has been well-documented. Lifestyle and antipsychotic medications have an adverse effect on the cardiovascular system and are more likely to cause metabolic syndrome, obesity and diabetes. The purpose of this audit was to determine if Samphire ward is in 100% compliance with the Norfolk and Suffolk NHS Foundation Trust (NSFT) Physical Healthcare Policy (C84). The aim is to ensure minimum physical health investigations are requested within 24 hours of admission, including: 1) baseline blood tests, 2) physical examination, and 3) electrocardiogram (ECG). A re-audit was also completed, which aimed to determine if compliance improved following a quality improvement (QI) intervention.

Methods

A retrospective data collection (Lorenzo and WebICE) was compiled of all new patients admitted and transferred to Samphire ward from 01/06/21 to 03/10/21 (n=66). Data included baseline bloods, physical exam, and ECG documentation within 24 hours of admission. A QI intervention (A3 visual aid) was then placed on the ward. The policy was re-audited from 04/10/21 to 30/11/21, including all new patients admitted and transferred to Samphire ward (n=24).

Results

Initially, 34.5% of new admissions had a physical examination or a patient refusal to consent that was documented on the physical exam form (NSFT Physical Exam Form v2.0) on Lorenzo completed within 24 hours of admission; post-intervention, this increased to 47%. 53% of new admissions had an ECG or a documented refusal in the initial audit; this increased to 61%. 68% of patients had baseline blood tests taken or a documented refusal within 24 hours of admission but only 4.5% had the correct blood tests taken; this increased to 71% and 33%, respectively, following the QI intervention. All 3 components within the 24-hour time period were met 0% of the time during the baseline audit; this increased to 33% post-QI intervention.

Conclusion

Overall, there was still poor compliance noted for all 3 physical health components required upon admission and fell far below the minimum standard as set out in the NSFT Trust Physical Healthcare policy. Further analysis showed ward doctors adhered to the standard significantly more than duty doctors. Recommendations include teaching regarding the physical health standard at junior doctor induction training and encouraging accountability among junior medical staff. A re-audit is recommended that includes further elements of physical health, including venous thromboembolism (VTE), height/weight, and nursing elements.
A Quality Improvement Project to Increase Junior Doctors’ Satisfaction With Handover Process Using Microsoft Teams (MS Teams) as a Platform
Authors: Gupta Aradhana , Narula Amitav , Patel Devika , Arifin Mohamad , Wheeldon Helen , Ajayi Ayomide , Sachdeva Gagandeep , Aung Nay
Published: July 2023

Aims

To improve junior doctors’ satisfaction with handover process to >70% over a period of 10 weeks.

Methods

Baseline level of overall satisfaction with current handover practice was measured through a survey using Likert scale. Using the same scale, the team also looked at:

1.

Degree of confidence in tasks being completed

2.

Degree of confidence in handover being confidential

3.

Degree of confidence in handover being sufficient for medico-legal purposes

Part of the survey also asked junior doctors using free text comments on how handover is currently carried out between shifts. The results from the survey were analysed and suggestions were considered for improvement.

A new method of handover using MS Teams was trialled. During subsequent PDSA cycles change ideas were adopted to improve engagement with the new process and allow for safe handovers.

On a weekly basis, post-intervention level of overall satisfaction with the new handover process was measured using the same Likert scale. Other measurements measured weekly included:

1.

Percentage of handovers completed using the agreed template

2.

Percentage of handed over jobs being acknowledged to signify receipt of handover

Results

Pre-intervention, verbal handover was the most frequent way of handing over (85.7%) followed by Whatsapp/text messaging (64.3%) and paper (42.9%).

Baseline level of overall satisfaction of handover process is 21.4%. At the end of PDSA Cycle 1, this increased significantly to 78% and by week 10 (end of PDSA Cycle 2) it rose to 92%.

Pre-intervention, 35.7% of junior doctors reported feeling confident in the handed over tasks being completed. 28.5% were confident that the handover process is confidential and 14.3% that it is sufficient for medico-legal purposes.

Post-intervention, 100% of the handovers are completed using a standardised template and 100% of the tasks were being acknowledged by the appropriate team members.

Conclusion

Prior to this intervention the process of junior doctor handover was not uniform and led to near-misses. This created confusion hence opportunities for errors to occur which can compromise patients’ care. Following the introduction of MS Teams as the handover platform, overall satisfaction from junior doctors on the handover process has increased significantly. Moreover, it provides a clear record of handovers taking place which ensures accountability, safety and continuity of patients’ care.
Improving the Quality of Valproate Prescribing in Adult Mental Health Services - POMH Topic 20b - Enhanced Community Rehabilitation Service (ECRS), Bognor Regis, West Sussex
Authors: Hussain Labib , Ahmed Shuchita , West Elizabeth , Tanner Claire
Published: July 2023

Aims:/Background

The licensed indications for Sodium Valproate are narrow however the medication is commonly prescribed amongst mental health services in the UK. Such practice can be associated with ineffective and poorly tolerated treatment, especially given the limited evidence re efficacy of 'off label' use of Valproate.

Aims and auditable outcomes

•

Annual review of risk benefit balance for those on continued Valproate treatment to include asking about adverse effects, medication adherence and therapeutic benefit Any 'off label' prescription of Valproate, should be explained to the patient and documented

•

Clinician's reasons for initiating Valproate treatment should be documented in clinical records

•

Plasma level monitoring of Valproate treatment should not be used unless there is evidence of concerns about medication adherence, dose related side effects and/or ineffectiveness

•

Prior to initiating Valproate, the following should be documented in the clinical records: Full Blood Count (FBC), Liver Function Tests (LFTs) and Weight and/or BMI

•

Review within first three months of Valproate treatment should include: Screening for common side effects and assessment of the response of treatment

Methods

Only 7 of 51 patients on the ECRS caseload were eligible for the study i.e. currently prescribed Valproate, irrespective of age.

Audit forms provided by POMH team. Clinical records used to complete included all electronic/paper notes, letters, and other patient information available to clinical team.

Due to nature of information required we involved doctors and nurses from the clinical team.

Results

6/7 (86%) of patients had clinical reasoning for Valproate prescription documented in their clinical records - 5/7 (71%) were prescribed 'off-label' - mainly as adjunct for refractory Schizophrenia.

7/7 (100%) of patients had a documented review in the past year which included asking about adherence to their Valproate medication.

2/7 (29%) of patients had plasma monitoring of Valproate treatment in the past year as part of routine hospital admission blood tests. No evidence of concerns for the other patients documented otherwise.

5/7 (71%) had treatment initiated with Valproate more than 5 years ago, hence unable to see if prescription initiations were explained to patients due to lack of historical records.

Conclusion

First cycle of this internal audit which forms part of a wider national prescribing audit, demonstrates that the ECRS team are generally meeting current standards for Valproate prescription.

Despite the majority (71%) being initiated >5y ago - 86% of our patients have documented clinical reasons for ongoing prescription, with100% having a documented review in the past year.
Recognition and Management of Depression in Adults With a Chronic Physical Health Problem in the Acute Medical Setting
Authors: Lonergan Rebecca Murphy , Mainuddin Muhammed
Published: July 2023

Aims

To compare current trust practice to NICE clinical guideline 91. To identify patients with a history of depression or chronic physical illness on admission to acute medical services. To assess such patients for evidence of new or ongoing depression and establish prevalence of depressive symptoms in high risk patient groups. To establish appropriate pathways for referral to mental health services

Methods

Cycle one: Eligible adult medical patients were screened for self-reported symptoms of low mood and anhedonia over the 2 weeks prior to admission. Inclusion criteria required patients to have either a past history of a chronic physical health condition or a past history of depression.

For those who answered “YES” to depressive symptoms, clinicians were prompted to refer to mental health services.

Intervention:

Screening questions were added to the adult medical clerking proforma for routine screening of admitted patients.

Patients self-identifying as depressed were triaged as requiring either inpatient liaison psychiatry team support or were referred to Improving Access to Psychological Therapies (IAPT) team on discharge with GP follow up.

Acute Medical departmental teaching session held on CG91 and new referral pathway created with input from liaison psychiatry team.

Cycle two:

Audit cycle repeated, including audit of outcomes following identification of patients with depressive symptoms.

Results

In cycle one, of 123 patients, 90 were eligible for inclusion (PPHx depression n=39; PMHx chronic physical condition n=51).

Of those with a past history of depression, 85% reported YES to current symptoms.

Of patients with a chronic physical condition, without prior history of depression, 48% reported low mood or anhedonia in the past two weeks.

Following introduction of electronic screening questions, completion rate by clinicians was 65% (eligible patients n=102; PPHx depression n=43; PMHx chronic physical condition n=59). 44% of patients with a chronic physical health problem self-reported symptoms of depression.

After local educational meeting, 84% of identified patients had a planned referral to primary or secondary care for further mental health assessment and support.

Conclusion

Around half of patients with chronic physical health conditions self-report high levels of depressive symptoms, without a known mental health diagnosis or support in place.

Screening of patients on admission provides an opportunity for appropriate intervention.

Establishing clear referral pathways and ongoing education is needed to ensure all identified patients are referred for further assessment.
Induction Folder for New Doctors in Psychiatry in North Wales- a Quality Improvement Project to Make Life Easy for Junior Doctors
Authors: Soundararajan Sathyan , Dhandapani Asha , Baker Catherine
Published: July 2023

Aims

The purpose of induction is to welcome our new employees and also ensure that they have the information and support to carry out their roles effectively. A robust induction not only benefits the doctor but also helps employers to ensure the delivery of high-quality patient care, increases retention, reduces absenteeism, and will promote the organization as a good employer. Doctors need to be supported in the workplace to provide safe, high-quality patient care. Induction as a minimum should introduce doctors to employer procedures and rules, arrangements for clinical governance (patient safety, clinical errors, clinical risk management, complaints, and litigation), orientation, and support. We have developed a new Induction folder containing all the necessary information for a beginner in Psychiatry in North Wales

Methods

We initially arranged for a preintervention questionnaire for the Junior doctors in Psychiatry in North Wales. That included Core trainees, Foundation year doctors, Senior house officers (LAS CT- SHO, JCF- non-training post), and GP trainees.

The QIP started in 2019 August with Audits followed by PDSA cycles. Over a period of 2 years, various doctors both from the present and from the last 3 years were contacted via email and google forms. We completed 3 PDSA cycles.

During these 2 years, we included certain topics that were missed, such as medication during an emergency, contact details from the deanery, etc. We have been following up on the Induction folder with the new doctors as and when there is new recruitment.

Results

The first PDSA showed promising results. Following the first PDSA, we amended a few changes in order to improve the response which resulted in an overwhelmingly positive response from the new doctors/ old doctors in Psychiatry. Following the third PDSA, we included details from the deanery contact and updated the contact details from our own trust.

Conclusion

2 years of work on this project has yielded good results. However, the sustainability of changes is questionable. This indicates continuity in changes. We are hoping that the new trainee doctors, either junior or senior trainees can consider working on this project and continue to amend changes on yearly basis.

The amended version of the folder can be completed at least 4 weeks prior to the major induction that happens every August.

We will consider sharing the Induction folder as handbooks/ pdf versions to all the trainees and non-trainees in our trust. Apart from this, we will continue to keep the information at a high quality and standards. We will achieve this by ensuring feedback from the new doctors.
Acute Psychosis in Hashimoto's Thyroiditis
Authors: Adeyemo Suraju , Erfani John , Shafiq Attique , Chukwuma Collins , Nwokonko Charles , Worthington Mark
Published: July 2023

Aims

Hashimoto thyroiditis was discovered by Hakaru Hashimoto in 1912 but became more recognized in the 1950s. It is an autoimmune disorder with an incidence rate of about 0.8/1000/year in men and 3.5/1000/year in women. The inheritance pattern of Hashimoto thyroiditis is not fully understood and diagnosing this condition could be challenging. Among many presentations, its effects on mental health can lead to a greater burden on a patient. There has been an increased report of acute psychiatric symptoms in this condition. Literature has described a wide spectrum of psychiatric manifestations occurring prior to, during, and after this illness. The aim of this report is to describe a woman with diagnosed psychosis secondary to Hashimoto's thyroiditis.

Methods

Ms S is a 22-year-old female who was admitted in January 2021 to the emergency department of Hospital B with a history of sudden behavioural changes: agitation, responding to unseen stimuli, and bizarre behaviour.

Her previous record reveals that she had a similar presentation in November 2019, managed with antipsychotics. The diagnosis at the time was unclear however; meningoencephalitis was suspected and later for NDMA encephalitis. After 4 months of admission to Hospital A, her behavioural changes remained unresolved but she was discharged to a care home with 2:1 support. She remained in the care home until further deterioration, which warranted a further admission to Hospital B.

Following a psychiatric review in Hospital B, she was initially diagnosed with an Acute psychotic episode with query cause and managed with IM Aripiprazole.

Due to physical health concerns and the unclear nature of her diagnosis, she was transferred to the acute medical ward and further investigation was requested.

Her result showed significantly elevated Thyroid Peroxidase Antibodies of 845 IU/ml (normal up to 24 IU/ml), lumbar puncture and NMDA antibody test were both normal, TSH level was raised to 6.73. Following further discussion with the medical team, a diagnosis of Psychosis secondary to Hashimoto's thyroiditis was made.

She was co-managed by the psychiatrist, endocrinologist and others.

Ms S became settled but due to residual psychosis, she was transferred to an inpatient psychiatric ward where her psychosis resolved, and was discharged back to the community mental health services.

Results/Discussion

As a result of the late diagnosis of her condition and delayed hospital stay, Ms. S developed a lot of mistrust for the services as she believe that the 19-month delay had significantly impacted her quality of life.

Conclusion

Diagnosis of psychosis secondary to Hashimoto's thyroiditis requires a high index of suspicion, missing this could lead to inappropriate use of medication and increased mobility.
Psychosis Post Uncomplicated Dengue Fever - an Uncommon Manifestation
Authors: D'Souza Galina Lisa
Published: July 2023

Aims

Dengue is caused by an arbovirus and is a common vector borne disease in south east Asia. Each year upto 400million people get infected with dengue and 40,000 die from severe dengue. Psychiatric symptoms following dengue fever is relatively uncommon. Mania is the most common psychiatric disorder reported followed by anxiety, depression and catatonia. We present to you a 19 year old girl who presented with psychosis 10 days post recovery from dengue

Methods

A 19 year old bachelors in commerce student hailing from rural south India from a middle socioeconomic family presented to us with fearfulness and decreased sleep since 1-2 days which was abrupt in onset and gradually progressive. MSE revealed a conscious and alert female with normal talk ,psychomotor activity and delusion of reference which was fleeting ,ill systematized ,hearing of voices was clear however the content of which was not elaborated upon.Her affect was fearful.Past history revealed an admission for dengue fever around 2 weeks prior to symptoms, course of which was uncomplicated and unremarkable. Diagnosis of Organic delusional disorder was made according to ICD 10 and she was started on Tablet Olanzapine 2.5mg and dose was escalated to 5mg after 3 days. Her symptoms remitted completely with 5mg and is currently doing well socially and academically

Results

Psychiatric comorbidities of dengue fever including mania, anxiety, depression, and catatonia are mentioned in literature .The exact incidence of neuropsychiatric manifestation remains unknown due to lack of studies. Literature search revealed various case reports where patients have developed psychosis during acute phase of the illness, however we did not find any case report or studies similar to ours

Conclusion

Most literature on neuropsychiatric manifestations in dengue are limited to case reports. There is a need to conduct prospective follow up studies and inclusion of regular psychiatric evaluation during various phases of dengue fever
Successful Clozapine Rechallenge With Add on Filgrastim in a Case of Treatment Resistant Schizophrenia With Clozapine Associated Neutropenia: A Case Report
Authors: Shankar Nikhil Gauri , Sambhi Rajvinder Singh , Alnassar Ibrahim
Published: July 2023

Aims

Clozapine is the treatment of choice in treatment resistant schizophrenia (TRS). Neutropenia is a potential life threating adverse effect associated with Clozapine treatment and one of the common reasons leading to discontinuation of Clozapine treatment. Clozapine associated neutropenia can be managed with Lithium or Granulocyte Colony Stimulating factor (G-CSF).Clozapine rechallenge in patients may often seem necessary and should follow a careful and balanced risk-benefit analysis. We present a case of a patient with TRS on Clozapine who developed neutropenia which responded to Filgrastim add on therapy and was successfully continued with Clozapine treatment.

Methods

A 29 year old female with a diagnosis of Schizophrenia since age 22 years had poor response to 4 different antipsychotics and 2 episodes of Neutropenia on separate occasions with Clozapine treatment. An inpatient Clozapine rechallenge was trialled due to poor response to the ongoing antipsychotic treatment which resulted in a decrease in the absolute neutrophil count to 1.7 *109/Litre.

An MDT decision was taken to continue Clozapine treatment with add on Filgrastim due to the severe psychopathology and poor quality of life. As per the advice from the haematologist Filgrastim injections at a dose of 30 million International Units were commenced on pro re nata (prn) basis whenever ANC dropped below 2.0*109/Litre. This strategy was successful and the patient did not develop agranulocytosis. Her psychotic symptoms also improved significantly and the patient was discharged to the community rehabilitation team.

Results

Clozapine is often the last resort in treating refractory psychotic symptoms and this option may get limited due to adverse effects like Neutropenia and agranulocytosis. Add on therapy with G-CSF has been used in Clozapine rechallenge with various success rate and most of the supporting data are derived from case reports and case series. It is worth noting that regular and prophylactic G-CSF in absence of low neutrophil count is avoided which could mask a developing Clozapine induced Neutropenia and result in a steep drop in neutrophils.

Conclusion

Add on therapy with Filgrastim is a viable option when considering Clozapine rechallenge with previous history of Clozapine induced Neutropenia. It is important that a haematologist is consulted and the patient is monitored closely throughout the treatment.
Change of Focus: Interventions of Occupational Therapy From a Psychodynamic Perspective
Authors: Gutnisky David , Ortega Licenciate Maria Soledad
Published: July 2023

Aims

Strictly speaking, occupational therapy interventions in mental health help clients through different activities to improve and develop skills that allow them to become increasingly independent and self-sufficient. Occupational therapy evaluation includes areas such as activities of daily life, play/leisure, productivity, study, work, and social participation. Occupational therapy also considers the impact of the context on the areas mentioned, but usually does not include the psychodynamic aspects of the client.

Methods

Male patient in his early thirties who was suffering an acute psychotic episode. He was experiencing a mystical delusion, with grandiose ideas of personal significance and delusions of reference. His mood was elevated, in consonance with the content of his thoughts. He was disorganised and needed help to maintain his daily routine. He said that he was experiencing a Maslow's Peak-Experience not a psychotic episode although he acceded to take medication. In an attempt to avoid involuntary admission to a mental health clinic (he refused to be admitted, as did his family), we tailored a home approach, with the inclusion of an occupational therapist on the team. Our first approach was unfruitful. Our attempts to help him to organize himself and his daily routine did not work. He was so fixated with his delusional project that any other idea or plan was rapidly discarded. So, we decided to change our approach and took his delusional project as the activity to organise and plan about. We agreed with him that we were going to help him with his project, but that there were no guarantees of success. Occupational therapy interventions helped him organise his project step by step and accept the frustration that his plan was impossible to achieve. Eventually, the episode ended with no need of admission.

Results

Changing the focus of the occupational therapy interventions, paused the interventions that were aimed at activities of the daily life, and taking the delusional project as the main and the most important activity of the client at this point allowed us to build a stronger therapeutic alliance and helped the client deal with the psychotic process and tolerate the constraints of reality.

Conclusion

The introduction of a psychodynamic point of view in the planning of occupational therapy interventions enriches the realm of occupational therapy and allowed, in this case, a flexible and creative approach that opened the path to a home treatment plan avoiding involuntary admission.
The Use of Genetic Testing in the Management of Depression
Authors: O'Neill-Kerr Alex , Nwabunike Nneamaka
Published: July 2023

Aims

We report on a case of depression where genetic testing was used to determine potential treatment modalities.

Methods

The patient is a 78-year-old man who had suffered from depression for 55 years. He had a serious episode in 2002. He developed a further depressive episode in 2018 which did not respond to paroxetine. He was offered TMS and was initially treated in the NHS and subsequently in the private sector. He went into remission with TMS and continues to remit with TMS however his depression became unstable and it was clear that the paroxetine was having no effect. He agreed to have a genetic test, a buccal mouth swab was taken and posted to gensense in the United States. An 18 page document and a half hour session with gensense are included in the cost of the test. The results of his genetic test and suggestions regarding treatment are detailed below.

SLC6A4 L(G)/S serotonin transporter indicating a less favourable response to SSRI medication (20% response versus 40% response). SNRI medication may be useful.

BDNF Val/Met Met carriers may have poor response to SSRIs and an improved response to SNRI's and TCA's. Met carriers have a 3 times better response to exercise than Val/Val

MTHFR A/A variant, this results in a 70% reduction) in the ability to convert folate to methyl folate (required for the manufacture of serotonin). Taking L-methylfolate supplementation (7.5mg) may improve serotonin production and provide a 2 times increase in response rate to antidepressants.

COMT Val/Val variant indicates improved response with brain stimulation therapy such as ECT and TMS

CACNA1C A/A variant which increases the anteromedial and amygdala activity and increased neuronal activity as a result of increased calcium channel receptors. This variant is associated with more depression, OCD and anxiety. Using lithium, sodium valproate and lamotrigine could be potentially useful in this group.

Results

The patient's antidepressant was switched from Paroxetine to Venlafaxine XL 150 mg, he started taking L methyl folate supplements (7.5mg daily) and was put onto sodium valproate 250 mg 3 times a day. His HAM-D went from 39 in December 2022 to sub-baseline by the end of January 2023. He also started regular mild exercise and daily use of tDCS (Sooma and Flow).

Conclusion

We conclude that genetic testing can be a useful clinical tool and can be helpful in deciding which treatments may benefit.
Sertraline-Induced Urinary Incontinence in Adolescent: A Case Report
Authors: Phiphopthatsanee Nacharin
Published: July 2023

Aims

Serotonin reuptake inhibitors (SSRIs) are commonly used to treat obsessive-compulsive disorder (OCD). In the UK, sertraline and fluvoxamine are the only SSRIs licensed for use in young patients with OCD. There is currently limited evidence suggesting an increased risk of urinary incontinence with SSRI use. Literature in children and adolescents is even more scarce, with only a few published case reports of SSRI-induced urinary symptoms. This case report adds to the pre-existing evidence in support of the previous suggestion on sertraline-induced urinary incontinence.

Methods

A 14-year-old girl with a diagnosis of OCD was treated with a combination of cognitive behavioural therapy (CBT) and sertraline, which was gradually titrated in steps of 25 mg fortnightly. There was a noticeable improvement in her OCD symptoms soon after the medication was initiated. However, a few days after sertraline was increased to 100 mg, she started to report urinary incontinence, urgency, and frequency, both daytime and nighttime, which significantly impacted her quality of life. She denied other urinary symptoms or change in fluid intake. Investigations for diabetes mellitus and urinary tract infection were negative. It was therefore concluded that her urinary incontinence was related to an increase in sertraline dosage, and she was advised to take an alternating dose of 75 mg and 100 mg daily. The symptoms resolved shortly afterwards, and sertraline was subsequently titrated up to 150 mg daily without any issues.

Results

Due to its rare encounter, the association between the use of sertraline and urinary incontinence has only been quantified in a single retrospective study with an adjusted risk ratio of 2.76 (95% CI 1.47–5.21). A clear temporal relationship of symptoms, its occurrence after the dosage increase, and rapid resolution after dose reduction confirmed the role of sertraline in the development of urinary incontinence in this case. Consistent with a previous case report, the dose-dependent effect was also implied. This phenomenon might be explained pharmacologically by sertraline's serotonergic activation, which can potentiate neuromuscular cholinergic transmission in the detrusor muscle, and dopaminergic activation, which can stimulate urine micturition. However, the exact mechanism remains unclear.

Conclusion

Although sertraline-induced urinary side effects occur relatively infrequently, clinicians should be aware of and actively look for these side effects, especially in patients who are prescribed SSRIs at higher doses. It is also important to exclude other causes that may contribute to urinary incontinence.
A Case Study to Explore Safe Psychotropic Medication(s) for a Patient Suffering From Priapism
Authors: Uddin Mohammad Saif
Published: July 2023

Aims

A 53-year-old male was admitted with non-resolving Priapism for 36 hours and was reviewed for advice regarding his psychotropic medications. He previously took Viagra about 2 days ago, and had an erection which resolved spontaneously. He underwent penile aspiration in the hospital which provided relief. Following that, he developed signs of infection which was treated with IV antibiotics. He was then waiting for further surgical correction.

Methods

He has a background history of psychotic illness and been treated with Quetiapine, Mirtazapine, Sertraline and Zopiclone, which were kept on hold during his admission. He reported that he currently suffers from depression and signs of psychosis, which take the form of auditory hallucinations and paranoid delusions.

He has been taking Viagra occasionally for years, but has not experienced side-effects like this before. He is a social drinker and previously smoked cannabis.

Results

From the above scenario, there appears to be two clinical questions:

1.

Are the current medications responsible for his priapism?

2.

What medication(s) would be a suitable alternative if his priapism was indeed caused by his current drug regimen?

The major causes of Priapism are: direct trauma; haematological diseases; neurological diseases; cerebrovascular diseases; Medications; TPN and Neoplasm. Apart from medication side-effects, these other causes were ruled out.

The Summary of Product Characteristics for mirtazapine, sertraline, quetiapine and zopiclone were studied for their relative risk of causing priapism, and this is summarised below:

•

Mirtazapine: unknown

•

Sertraline: rare

•

Quetiapine: rare

•

Zopiclone: not listed

However, a paper by Salonia et al found that all the above medications except Zopiclone can increase the risk of priapism. Internationally published case reports also list priapism-associated medications as: risperidone; quetiapine; sildenafil; mirtazapine; citalopram; chlorpromazine and olanzapine.

Anti-psychotics cause priapism by Alpha-1 blockade and anticholinergic actions. Most of the antipsychotics have anticholinergic action. The medication which demonstrates the least alpha-1 blockade is Amisulpride which acts by blocking dopaminergic receptors in the brain.

Conclusion

Thus, it is clear from the above discussion that Amisulpride has the least possibility to cause Priapism. The patient was advised to take low dose Amisulpride and afterwards, no other complications were noted.
Outcome Measures at Discharge From a Local Early Intervention in Psychosis Team
Authors: Lathif Nismen , Ahmed Zara
Published: July 2023

Aims

Review of the outcomes from a local EIP service, in terms of symptom control employment status at referral and discharge, admissions whilst under the care of the service physical health status at discharge, discharge was back to primary care or secondary care

Methods

Sample of service users discharged from EIP services over the past 2 years between March 2020 and March 2022 was collated

Results

Recovery

Good proportion -84% had good symptomatic recovery at time of discharge based on discharge letter

Discharge to primary care

Low proportion -Only 26% were discharged onwards to secondary mental health services such as recovery teams or community mental health teams and rehabilitation services.

74% discharged to primary care

Review of notes indicate that patient is still within primary care 6-12 months post discharge

Employment

A jump of 16% in employment. At start of EIT input only 40% had employment and at pint of discharge 56% of sample had employment

Inpatient admission

Admissions whilst under the service were seen in 54% patients in total; out of this number just over half (55%; )were admitted to inpatient unit only once

Smoking and Substance misuse

Only 24% were known smokers at discharge; 6%) were misusing multiple substances including smoking, alcohol, cannabis and cocaine at the time of discharge

Physical health and metabolic syndrome

Only 2% had diagnosed hyperlipidaemia at discharge

Conclusion

Early Intervention in Psychosis input lead to good symptom control and resolution of psychosis leading to higher rates of discharge to primary care alongside improved physical health substance misuse employment outcomes.