bluuebunny/crossref_metadata_2025 huggingface dataset:
Acute Psychotic Episode Due to Milk-Alkaline Syndrome
Authors: Adeyemo Suraju , Erfani John , Shafiq Attique , Chukwuma Collins , Worthington Mark
Published: July 2023

Aims/ Background

: Milk-alkali syndrome is a medical condition, which could present with psychiatric manifestations. It is caused by hypercalcemia resulting from the ingestion of large amounts of calcium and absorbable alkali. The core symptoms include hypercalcemia, metabolic alkalosis, and renal failure. Diagnosing this syndrome requires a high index of suspicion. The aim of this paper is to describe the case of Mrs. C who had psychotic symptoms because of Milk-Alkaline syndrome

Methods/ Case Report

Mrs. C was a 75-year-old white British female with a previous history of anorexia nervosa who has been clinically stable for more than 15 years. She was discharged by the community mental health services about 11 years ago but has been on a repeated dose of Gaviscon for about 8 years.

She presented to the accident and emergency (A and E) unit with a history of confusion, unsteadiness, paranoid beliefs, low mood, and reduced rate of speech. No history of infection or other physical health concerns. Routine blood showed increased calcium 3.41(2.2-2.60) and a reduced potassium level 2.9 (3.5-5.3). CT head scan did not show any acute changes.

She was stabilized and transferred to the ward for further management.

While on the ward, she had a diagnosis of Milk-Alkaline syndrome with psychiatric manifestation. Gaviscon was discontinued because the medics felt this was responsible for the electrolyte imbalance. She was also referred to the mental health liaison team (MHLT).

Following the mental health liaison team review, Mrs. C's psychiatric presentation was suspected to have been probably related to her medical condition. After a few weeks on the ward, her electrolyte became normalized; adjusted Ca 2.72 (2.2-2.6), serum ca 2.74(2.2-2.6). She had a follow-up review by the mental health team that showed her psychosis had also resolved. No medication was prescribed for her presentation. She was subsequently discharged from MHLT and referred to the GP for follow-up.

Results/ Discussion

previous case-report have shown a suspected link between Milk alkaline syndrome and acute psychosis, although the reasons for this have not been understood. The current case further emphasized this link. What is not evident however is if there were other physical health issues that might have also contributed to the patient's initial presentation.

Conclusion

Diagnosis of Milk-Alkaline Syndrome requires a high index of suspicion, missing this could lead to inappropriate use of medication. As a psychiatrist, this case has shown the importance of adequate investigation before making a definitive diagnosis, especially in a psychiatric liaison setting.
A Tale of Two Catatonic States
Authors: Birgi Harleen Kaur , Lawrence-Smith Geoff , Kirwin Simon
Published: July 2023

Aims

Catatonia is a psychomotor state characterised by a multitude of clinical signs such as abnormal movements, mutism and withdrawal. This condition is usually associated with medical and psychiatric aetiologies with potential of being life-threatening. It is usually managed with benzodiazepines, the commonest being lorazepam. In this piece of work, we would like to focus on the principles of care that should be considered whilst managing such presentations.

Methods

Case 1- 71, male with diagnosis of paranoid schizophrenia was brought to Emergency department (ED) via ambulance, as he was found ‘unresponsive’ in care home. On arrival, he was alert with GCS 11/15 and was observed to be mute, ‘gesturing’ and making purposeless movements. Following our assessment, he was administered 0.5mg of lorazepam whilst in resuscitation bay. Subsequently, he started making sounds and was given another dose of 0.5mg lorazepam. He then vocalised his thoughts and we established that his mental state had relapsed and he was harbouring paranoid delusions.

Case 2- 18, male with no prior psychiatric history was brought to ED by his parents following 3 day history of being mute, not ‘responding’, not eating or drinking and insomnia. On arrival, he was alert, pacing in the room, however remained mute. Following our assessment, he was given a 2 mg dose of lorazepam whilst in resuscitation bay as the initial 1mg showed minimal response. On later review, he was smiling, conversant and co-operative, thus allowing assessment of his unmasked mental state which was suggestive of first episode psychosis.

Following few hours, both patients reverted back to their original catatonic state.

Results

Lorazepam can be used as a diagnostic measure in conjunction to a therapeutic intervention. A positive Lorazepam Challenge test confirms the diagnosis of catatonia. It must be borne in mind that Lorazepam is only used as a temporary holding measure to assess patient's unmasked mental state and they would need further monitoring and interventions to treat the underlying cause.

Conclusion

Lorazepam Challenge test can be safely used as an assessment technique for patients presenting in acute catatonia. This should be conducted in closely monitored environments namely, resuscitation bay, HDU or ITU with appropriate support and ongoing liaison with psychiatry team. Treating teams should be mindful of various patient characteristics including age, past treatment with benzodiazepines, psychiatric history to inform dose adjustments as necessary.

Disclaimer: Unable to obtain patient consent due to unstable mental state but ensured minimal patient identifiable data included.
Schizotypal Disorder With Borderline Personality Traits: A Case Report
Authors: Reddy Rakesh Byra , Hullumane Surabhi
Published: July 2023

Aims

Schizotypal disorder is characterized by pervasive patterns of odd behavior, appearance, or thinking. There is also a high degree of overlap in symptoms between schizotypal and borderline personality disorders. The following case describes a case of schizotypal disorder with borderline traits.

Methods

25-year-old female presented with history of mood fluctuations with recent low mood, anxiety and an ability to read other people's thoughts. She was admitted to hospital 4 years ago and was diagnosed with emotionally unstable personality disorder (EUPD) and mixed anxiety and depression.

She reported anxiety to leave the house due to referential and persecutory ideas, odd beliefs of being able to read people's minds and predict future. She lacked friends and also had fear of abandonment. There was intermittent impulsive self-harm behavior and reportedly harmed herself indirectly through casual sex in the past and also had two failed relationships. She denied illicit drug use. Childhood was uneventful, except that schooling was difficult due to anxiety. She was treated on Quetiapine, Fluoxetine and Promethazine. Further assessments confirmed added features of unusual perceptions, smelling things, superstitious ideas regarding colours and magical thinking. Dissociative episodes of her being a devil, expressing thoughts of slitting her throat were present.

As there was minimal improvement, Aripiprazole was tried. She had poor compliance with Aripiprazole due to the belief that it was poison. She herself requested depot injection, which was started. There has since been mild improvement in her paranoia, but social anxiety is persistent. Psychoeducation about the diagnosis was challenging, after which she accepted referral for psychotherapy.

Results

The initial diagnosis of EUPD was inconsistent with other features like ideas of reference, strange beliefs, magical thinking, abnormal perceptions and social anxiety. On further assessments, a diagnostic clarification of schizotypal disorder was considered. This poses challenge in diagnosis and therapeutic approach due to the overlap of symptoms. Cognitive-perceptual distortions and affective symptoms of EUPD appear to overlap with disorganized and cognitive-perceptual symptoms of schizotypal disorder. Historically, borderline was separated from schizotypal personality disorder from an entity called borderline schizophrenia.

Conclusion

Schizotypal disorder is rarely seen as the primary reason for treatment in a clinical setting and can be misdiagnosed. The presence of co-morbid personality disorder traits can be challenging for the management decisions. It also has an impact on the individual and family for acceptance of the diagnosis and compliance to treatment.
Ventriculomegaly in Mania - a Possible Neural Correlate?
Authors: D'Souza Galina Lisa , Joe Avinash , Rao Pavithra P , Yadiyal Aruna
Published: July 2023

Aims

Bipolar disorder is one of the most common psychiatric illness, however the neurophysiologic basis remains unknown. Lateral ventriculomegaly is a well-recognized finding in bipolar disorder. Multiple-episode patients exhibited significantly greater ventricular volumes than first-episode patients. Traumatic brain injury is also an independent risk factor for the development of mania.We present to you a case where a patient with mania had the above mentioned risk factor and finding.

Methods

40 year old married lady hailing from a rural nuclear family presented with decreased sleep, increased talk, increased activity, elevated mood and overfamiliarity since 1 month. On further interviewing patient was found to have sustained mild head injury around 8 months ago .MRI study of the brain revealed mild lateral and third ventriculomegaly.A diagnosis of organic mania with a differential of mania with psychotic symptoms was made.

Results

Ventriculomegaly in bipolar disorder has been reported but not in mania alone-its occurrence at illness onset or progression remains unclear. There is no literature on the prognostic value of the finding. Ventriculomegaly in our patient was found incidentally on MRI whether the finding was present prior to the head injury or is a post head injury change is unclear. There are studies which indicate development of posttraumatic ventriculomegaly in severe head injury. Nonetheless we cannot completely rule out a possibility of neurodevelopmental / neurodegenerative link in this case which maybe be independent of the head injury

Conclusion

There is a paucity of studies that focus on neurodevelopment and neurodegeneration as etiological basis for mania and affective disorders in general need to shift our focus on research in brain imaging in psychiatry
Functional Cognitive Disorder and Mild Cognitive Impairment: A Thin Line
Authors: Jeje Jide , Odutola Akinkunmi , Qudus Lawal , Sodiya Olusegun , Ogungbayi Modupe , Prabhu Aishwarya
Published: July 2023

Aims

Functional cognitive disorders (FCDs) refer to conditions where patients present with persistent problematic subjective memory complaints that are not consistent with their observed level of cognitive functioning. The demonstrated symptoms are also not in keeping with a recognized psychiatric or neurodegenerative process. FCD is likely to be underdiagnosed in clinical practice with the place-holder label of mild cognitive impairment being used in some cases due to lack of clarity about its symptomatology. In this paper, we describe two cases whose presentations were suggestive of FCDs.

Methods

Mrs X, 53 years old female not previously known to mental health services referred for increasing difficulties with her memory over 2 years which she believed was impacting her activities of daily living. She has a history of ischaemic heart disease, fibromyalgia, Insulin-dependent diabetes mellitus, depression, and polycystic ovarian syndrome. On assessment MOCA = 15/30, and MMSE = 25/30.

Mr Y, 57 years old male not known to mental health services. Although, has been treated for anxiety and depression by GP. He presented with a 3-year history of struggling with his memory. He reported being forgetful of appointments and he has to paste sticky papers on the fridge for reminders. Similarly, he has a diagnosis of Fibromyalgia and essential hypertension. On Assessment MOCA – 19/30 and MMSE – 25/30.

Results

FCDs can be quite challenging because the clinical picture overlaps with other neurodegenerative conditions. Typically, patients report issues around memory function in the absence of relevant neuropathology and with evidence of inconsistency between symptoms reported and observations at assessment. Regarding our cases, the primary presenting issues were increasing difficulties with memory, and forgetfulness. Other noteworthy observations were a mismatch between their scores in the MOCA, MMSE, their level of functioning, and reported memory problems. Neurological examinations and neuroimaging were not suggestive of any neurodegenerative disorders. A differential diagnosis of functional cognitive disorder was considered due to the discrepancies between symptoms reported, the level of their functioning, observations at assessments as well as absence of relevant neuropathology on imaging.

Conclusion

FCD is a condition that is common in clinical practice but underdiagnosed. Hence, it is imperative that clinicians keep this diagnosis in mind when patients present with memory difficulties that do not meet the diagnostic criteria for dementia and is not due to a recognized medical or psychiatric condition. Correctly identifying and diagnosing FCD can positively impact patient outcomes.
Full Remission of Obsessive Compulsive Disorder (OCD) Symptoms in Huntington's Disease (HD) Using Fluoxetine
Authors: Devasia Mithun , Kumar Praveen , Kottelassal Abdurazak
Published: July 2023

Aims

HD is an autosomal, dominantly inherited, neurodegenerative disorder which can present with cognitive, motor and behavioural symptoms. Recent studies suggest that obsessive compulsive disorder (OCD) symptoms, although not common, may precede or coincide with symptoms in patients with HD. We present a case of an adolescent boy presenting with symptoms of OCD, for 4 months duration, in background of three years diagnosis of HD.

Methods

A 15-year-old boy from South India, presented with recurrent, intrusive thoughts of sexual content, consistent with obsessions and some instances of compulsions in the form of avoiding to do deviant sexual act like fetishism, and having excessive worries about an act he had done earlier for 3 months duration (supported by high scores on Yale-Brown Obsessive Compulsive Scale; Y-BOCS). Patient had normal birth and development and had no past history of psychiatry disorder, however there was family history of HD in multiple first and second-degree relatives. He was on treatment for movement symptoms of HD, diagnosed 3 years back and was on Tetrabenazine for 2 years. Initial psychiatric assessment found the symptoms to be consistent with OCD due to Huntington's disease, according to Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The patient was admitted to the mental health unit and was started on Fluoxetine, titrated to a dose of 20mg daily for symptoms of OCD.

Results

Subject showed an excellent response to fluoxetine with complete remission of OCD symptoms within 4 weeks of treatment. The relationship between OCD and HD has been little-investigated, despite the fact that both diseases are associated with striatal dysfunction and that the number of case reports of obsessive-compulsive symptoms either preceding the clinical onset of HD or during later stages of the disease is increasing. For example, Dewhurst et al. reported “obsessional features” in 7 of 102 patients at onset of HD.

Conclusion

Firm conclusions to explain this result cannot be drawn. However, a hypothetical involvement of the serotonergic system, suggested by the excess of OCD, seems supported by the response of said subject to fluoxetine. It may be worth further exploring the value of the psychiatric picture in selecting the appropriate treatment for at least some cases of HD. Anecdotal evidence suggest that SSRIs alone or in combination with atypical antipsychotics like olanzapine may be useful for these patients. However, these hypotheses need further testing.
Moral Injury, Trance and Possession State or a Schizophrenic Illness. a Case report
Authors: Ajayi Oluwatomiwa , Esangbedo Arit , Lawal Abisola , Olanrewaju Abimbola , Ojo Temitope , Talabi Olufemi
Published: July 2023

Aims

Moral Injury is a strong cognitive and emotional response occurring upon witnessing, participating in, or failing to prevent an act that goes against one's ethical code. This has been linked with Post Traumatic Stress Disorder, Depression, Suicidality, and Anxiety, amongst others. Data on its association with Schizophrenia are however lacking. Trance and Possession Disorders defined by the ICD-10 refers to a group of disorders involving temporary loss of both the sense of personal identity and full awareness of the surrounding with individuals acting in some cases as if taken over by another personality, spirit, deity, or force with reports of such states occurring in primary psychotic disorder. This case presentation describes a 22-year-old male whose first episode of schizophrenia was preceded by moral injury

Methods

A 22-year-old male Nigerian with a strong conservative Christian religious upbringing and a history of receiving a prophecy against having intercourse with women. He started showing symptoms of a mental illness a month after attaining coitarche with a lady. This presentation was characterized by irrelevant speech, intrusive flashbacks and unusual beliefs (excessive guilt, ill health). 7 months after, he was presented to the hospital with above symptoms and disorganized behavior characterized by beliefs of being possessed by four different people, shouting in different voice textures, throwing himself on the floor. We kept in view a diagnosis of schizophrenia and placed him on oral Olanzapine 5mg nocte following which he made significant improvement within 2 weeks with no memory of the event.

Results

Different factors can be considered in the aetiopathogenesis and presentation of symptoms in this patient. According to Williamson V. et. al; An Individual's experience of moral injury may lead to feelings of shame or guilt which was present in this patient (delusion of guilt). The pathogenic effect of culture and religion(e.g through prophecy against intercourse with women) may account for this illness. Moreso, pathoplastic and pathoreactive effects of culture could be said to have contributed significantly to the presentation of a psychotic disorder with trance and possession state as a reaction to moral injury.

Conclusion

Moral Injury, not previously considered to be associated with primary psychotic disorder may not only possibly precipitate a primary psychotic disorder but also show cultural/religious differences in phenomenology.

Further studies are therefore required to explore these associations.
Optimise – Service Evaluation of an Innovative Service to Reduce Prescription Medication Dependence
Authors: Mayet Soraya , Drozdova Zuzana , Easingwood Sarah , Nadin Kate , Morgan Merran , Blakeston Eleanor , Reade Dave
Published: July 2023

Aims

Opioids, gabapentinoids, benzodiazepines and z-drugs cause dependence, increase deaths, and have been found to be ineffective for long-term conditions. Despite the risks, these are some of the most prescribed medications. In response, we worked with commissioners to develop an innovative service ‘Optimise’ for the treatment of prescription medication dependence. Optimise aimed to support patients to reduce and stop prescribed medications that can cause dependence when the medications were not clinically recommended.

Methods

Optimise started in February 2020 in the North of United Kingdom. The service was staffed by two addiction nurses, with support from the Addictions Consultant Psychiatrist and team leaders. GP's identified suitable patients, gained consent to refer and referred to Optimise. Patients received a harm information and service letter, after which they were offered telephone triage, assessment, and ongoing psycho-social support. The nurses worked closely with GP's and advised on prescribed medication reduction plans. Due to COVID-19, most patients had telephone appointments.

Humber Teaching NHS FT service evaluation approval. All referrals were reviewed retrospectively to assess demographics and outcomes. Friends and family (FFT) test offered to patients. Data were analysed via excel.

Results

Twenty-one GPs referred 258 patients (Feb 20-Oct 22). Most were female (70%) and all white; mean age 56 (21-97) years. Patients were prescribed opioids (92%), gabapentinoids (32%), benzodiazepines (9%), and/or zopiclone (7%). The most common opioid prescribed was morphine, followed by oxycodone and fentanyl. A letter was sent to 254 patients referred, 217 patients attended telephone triage, with 148 agreed to work with Optimise. Of 145 (56% of referred patients) who attended the assessment, 86% gradually stopped (n=24; 17%) or reduced (n=100;69%) their prescribed medications.

Patient feedback:

Eighteen patients completed FFT and stated the service was good or very good.

‘The nurse was informative and has helped me reduce my medications when I thought I wouldn't be able to.’

‘Listened to my concerns and gave me time before changing my medication.’

Conclusion

Optimise is an innovative service that has helped patients of all ages to reduce and stop prescribed opioids, benzodiazepines, gabapentinoids and zopiclone, that can cause dependence, increase overdose risks, and were not clinically recommended. These patients had previously not been able to reduce or stop these medications. It is positive that with two nurses there has been such a great impact with excellent outcomes and good patient engagement. Commissioners should look at funding similar services to enhance the support for patients who are prescribed medications that can cause dependence.
Keeping the Door Open: The Function of the Supported Employment Programme During the First Year of COVID-19 Pandemic
Authors: Gutnisky David , Soledad Ortega Licenciate Maria , O'Connor Horacio Rodriguez , Taboada Licenciate Sandra Garcia
Published: July 2023

Aims

The Supported Employment Programme of the General Directorate of Mental Health of the Autonomous City of Buenos Aires has been running for the last five years. Its purpose is to help adults with severe mental illness obtain and maintain competitive work in the community and provide the support necessary throughout the entire process and follow-up after successful inclusion. The aim of this paper is to evaluate the impact of the COVID-19 pandemic has had upon the Programme and to analyse the main causes of clients’ drop-off despite the fact the modifications were put in order to keep running the service during the lockdown.

Methods

Retrospective analysis of case records of the Supported Employment Programme from 1 January 2020 to 31 December of 2020.

Different variables were analysed to identify the main causes of dropout. Between them, variables related to the digital divide, fear of COVID-19, and increased economic vulnerability.

Results

At the beginning of 2020, the programme had 51 users and received 11 referrals throughout the year, of whom 8 users were finally admitted. Therefore, 59 users entered this sample, 40.7% were women (n=24) and 59.3% were men (n=35). Mean age 40.4, ranging from 18 to 65 years of age (sd = 11.6). No significant differences were found in sex, age, or level of instruction between participants. The dropout rate after the lockdown was introduced reached 50.3% (n = 30), and there were no significant differences between those who left the programme and those who continued, with respect to sex, age, or level of instruction. Significant differences were found between these two groups in access to Technology (T= –6.158 p<0.000); Digital illiteracy (T–3.247 p<0.003); fear of getting COVID-19 (–7.616 p<0.000). However, having obtained a job through the programme was a protective factor against leaving, and only one user out of nine who got a job through the programme dropped out. This difference was at the significant level (T=2.671 p<0.05).

Conclusion

Even though, in an attempt to keep the Programme running during the strict lockdown that was imposed during the first year of the COVID-19 pandemic, moving the face-to-face interviews to remote ones through digital platforms did no guarantee the access to service. The digital divide was one of the main causes of dropout of users. It is important to point out the protective value that had to have obtained a job through the programme against leaving.
Serum Prolactin Level Monitoring in Children and Adolescents on Antipsychotic Treatment: Evaluating the Current Practice in Al Ain, United Arab Emirates
Authors: Javaid Syed Fahad , Afzal Ayesha , Ahmed Zahra Yusuf
Published: July 2023

Aims

The use of antipsychotics in children and adolescents requires close supervision in a specialist clinic. The decision to commence antipsychotics should be made jointly with the young person, their parents, carers, and healthcare professionals. It is critical to provide age-appropriate information and discuss the possible benefits and side effects, including raised serum prolactin levels, potentially leading to serious consequences such as reduced bone density and abnormal pubertal development. This audit aimed to appraise the antipsychotic prescribing practice in children and adolescents in psychiatric outpatient clinicians in Al Ain Hospital, United Arab Emirates. The authors analysed the compliance against the standards set out in The National Institute for Health and Clinical Excellence (NICE) Clinical Guidance 155 concerning monitoring prolactin levels in children on antipsychotic medications at baseline, 12 weeks, and every six months thereafter.

Methods

This Hospital-wide audit involved a retrospective review of case notes. A questionnaire was developed to capture the required information anonymously. The audit sample comprised 135 children under the age of 16 who were on antipsychotics for more than six months and were followed up in the child psychiatry clinic between January 2018 and December 2019. We chose this pre-Coronavirus Disease 2019 (COVID-19) period when services were running as usual. Data collection took place between September and December 2022.

Results

Out of 135, 28 (21%) patients were males, with 51 (38%) being Emirati citizens. The sample age ranged between 6 and 16 years, with a mean of 13.5 years. Risperidone was the most commonly used antipsychotic. The majority of patients (63%) had a diagnosis of psychosis in the context of Attention Deficit Hyperactivity Disorder (ADHD), Autistic Spectrum Disorder, and intellectual disability. None of the patients had a baseline prolactin measurement performed, while only 10 (7%) had prolactin levels checked at 12 weeks. No patient had prolactin levels checked at six-monthly intervals.

Conclusion

This audit has identified a clear need to develop local guidance on monitoring antipsychotic side effects in children and adolescents. We recommend enhanced staff training in monitoring for the relevant side effects and introducing a mechanism to electronically alert the prescribing clinician when the time of monitoring is due. We suggest educating the patients about symptoms of high prolactin levels and re-audit the practice after one year of implementing the above action plan.

No financial sponsorship has been received for this evaluative exercise.
Review of Admissions to Local Division, Mersey Care NHS Foundation Trust Between June 2017-June 2022
Authors: Leadbetter Jane , Richman Anna
Published: July 2023

Aims

The aim of the study is to investigate if a trend in admissions to wards within Local Division in Mersey Care NHS Foundation Trust has been evident over the past five years and hypothesise rationale for this.

Methods

Mersey Care NHS Foundation Trust has collated information on admissions to wards within their Local Division from June 2017 to June 2022. These data were reviewed and analysed.

We considered contributory reasons for any trends in admissions, for example, establishment of the Crisis Resolution Home Treatment Team (CRHTT) in 2017 and the impact of the Coronavirus pandemic. We also reviewed the number of assaults over this period, to see if a trend was evident.

Results

There has been a downward trend in the total number of admissions to wards within Local Division.

The average total number of monthly admissions pre establishment of the CRHTT was 186, which declines to 133 when the service was functioning. For general adult admissions, the average number of monthly admissions pre commencement of the CRHTT was 160, which reduced to 118 after implementation of the CRHTT, a 26.3% reduction. For old age admissions, the average number of monthly admissions was 25, which reduced to 19 after implementation of the CRHTT, a 24% reduction.

At the height of the Coronavirus pandemic, the average number of admissions dropped to 124, and 80% of results fell below the trendline. There was a less significant reduction in old age admissions due to the Coronavirus pandemic, perhaps reflecting less family support during lockdown periods, reduced access to carers and less input from the community mental health team in care homes; all of which could increase the need for older adults to be admitted to inpatient mental health beds.

The number of assaults across wards within Local Division increased significantly from 602 in 2017 to 1527 in 2021. This suggests there is perhaps a higher threshold to admit patients, with more significant risk profiles.

Conclusion

A downward trend in admissions to Local Division within Mersey Care NHS Foundation Trust has been evident since 2017.

There are a several factors that could have contributed to this, including commencement of the CRHTT and restrictions due to the Coronavirus pandemic. The significant increase in the number of assaults, may also suggest there is now a higher threshold to admit patients, with more significant risk profiles.
High Lithium Levels: Dead, Alive or Doing Well? a Service Evaluation Looking at Outcomes Over Subsequent 2 Years
Authors: Raphael Juliet , Heatley William , Patel Maryam , Dastidar Supriya , Ormerod Sara
Published: July 2023

Aims

Lithium is an effective mood stabiliser in the management of Bipolar affective Disorder. Timing and decision to restart lithium after an episode of toxicity can be challenging. National guidelines offer advice on management of acute toxicity but little information on restarting lithium. Abrupt withdrawal of lithium can provoke relapse. Clinical experience of the authors was that patients who had Lithium stopped following toxicity often relapsed, leading to poor mental health, frequent admissions to acute and psychiatric hospitals and sometimes death. Restarting of lithium in hospital or after discharge was often variable. The aim of the evaluation was to review the outcomes of patients admitted to the University Hospitals Birmingham NHS Foundation Trust (UHB) with a lithium level over 1.2 mmol/L.

Methods

Patients were selected if recorded lithium level was over 1.2mmol/L on admission to UHB. Case note review of electronic patient records was carried out to identify demographic factors of participants alongside medical and psychiatric outcomes over the following 2 years.

Results

84 patients were identified as having lithium levels over 1.2mmol/L. 76% Female. Mean age 61 years (range 20-95 years). 77% of patients had been prescribed lithium for more than 6 years. Mean lithium level was 1.68 mmol/L (range 1.2-3.44 mmol/L). Around 2/3 of patients admitted with lithium above therapeutic range were referred to the liaison psychiatry team. 12% of the patients died during that admission. Just over 2/3 (69%) of those discharged from hospital had been restarted on lithium. When lithium was not restarted during the acute admission, only 13% were restarted in the community within the next 2 months. Two year mortality of patients admitted with elevated lithium levels was 31%. 10% of patients were admitted to a psychiatric hospital within 1 year. The mean number of admissions to the acute hospital (UHB ) within one year was 1.6 (range 0-26).

Conclusion

Admission to hospital with high lithium levels appears to be associated with a number of negative outcomes. These data cannot attribute causality. Conditions predisposing to lithium toxicity such as frailty could contribute to negative outcomes. Given these high mortality figures for this group, discussions on restarting lithium following high levels may need to focus more on the priorities for the patient. Further studies looking at the outcomes of restarting and discontinuing lithium and comparing with those who have not experienced elevated levels would be helpful.
RCPsych MTI Scheme; Cultural Differences in Psychiatry Training Among MTI Fellows From Low and Middle-Income Countries in the UK
Authors: Razak Razrin , Kumar Praveen
Published: July 2023

Aims

The Royal College of Psychiatrists’ Medical Training Initiative is a scheme aimed at psychiatrists from lower and middle-income countries to work and train in the National Health Service (NHS) UK for up to 2 years before returning to their home countries. They came from various countries and cultural backgrounds, however, there is a lack of study being done on how these cultural differences and experiences are impacting the newly recruited MTI fellows while working in the UK at a CT3 level. In this study, we distributed a brief questionnaire to the 2022 Rcpsych MTI trainees cohort to explore the sociocultural differences between working in the NHS and their home countries and surveyed the things that could be improved within the MTI scheme.

Methods

Royal College of Psychiatrists MTI Fellows from various backgrounds and countries participated in a survey between December 2022 and January 2023. The survey consisted of open-ended and closed-ended questions about the differences in psychiatric practices from their home countries alongside cross cultural differences while working in the NHS.

Results

The response rate was 55% from five different countries; Egypt, Malaysia, Nigeria, Sudan, and Turkey. The majority of the participants have worked in the UK under the MTI scheme for more than 3 months and reported that English is not a widely spoken language in their countries of origin. 72.8% of respondents find it easy to incorporate their skills and knowledge in the UK despite the linguistic, cultural and mental health act differences while 72.7% of the fellows reported that psychiatric patients' presentations are similar between their home countries and the UK. There is also a bigger mental health stigma reported in their home countries. It appears based on experiences in their home countries, culture indeed plays a major role in mental illness and treatment. Besides that, 72.8% of respondents are satisfied with the MTI scheme while 81.9% of them would recommend this scheme to others. Some of the respondents recommended for introductory course about the mental health system in the UK and the mental health act before starting the scheme.

Conclusion

There are cultural and linguistic differences impacting the experiences of newly recruited MTI fellows in the UK. There is room for improvement to bridge the sociocultural gaps for the MTI Fellows to improve their experience and service provision.
Learning From Existing Services: Developing an Intensive Outpatient Services for Children and Adolescents With Eating Disorders
Authors: Salucci Katie , Cini Erica
Published: July 2023

Aims

Gain an insight into learnings/pitfalls that existing services have met whilst setting up/running intensive outpatient pathways/ services (IOS).

Methods

4 Focus Groups (FGs) were conducted virtually through MS Teams from December 2022- January 2023 of duration 90 minutes each for health professionals involved in a leadership role in IOS pathways across England. The FGs were recorded with participant consent, transcribed and analysed with an inductive approach for thematic analysis.

Results

4 main themes emerged including (i) patient and (ii) team considerations, (iii) approach and (iv) commissioning. A key sub-theme emphasised the importance of flexible and creative approaches in IOS to supplement existing evidence base therapies as well as the importance of a well-rounded MDT approach with good communication across the board. Key set-ups include: enhanced outpatient offers, home treatments, in-reach, and hybrid.

Conclusion

Intensive outpatient services for EDs allows an enhanced community offer that is needs led and flexible and individualised approach.
The Role of a Specialist Community Rehabilitation Team (Mental Health Intensive Support Team) in Reducing Referrals for Out-of-Area Placements
Authors: Whyler Jonathon , Chamles Darleen , Shetty Amrith
Published: July 2023

Aims

Patients may be referred for out-of-area (OOA) placements for a variety of reasons, including a lack of local service provision to meet the requirements of patients with complex or longer-term needs. OOA placements can lead to patients experiencing social isolation from family and friends, as well as disjointed access to local services. In addition, placements can be costly in comparison with locally provided services. Mental health Intensive Support Team (MhIST) is a specialist community rehabilitation service within Cheshire and Wirral Partnership NHS Foundation Trust which was established in June 2021. Although the team does not have specific diagnostic inclusion criteria, patients referred will typically have a high level of complexity in addition to severe, treatment refractory symptoms and impaired social, interpersonal and occupational functioning.

Methods

We analysed routinely collected data to explore two methods by which MhIST is reducing referrals for OOA placements including i) direct diversion of patients who would otherwise have been referred for OOA placements to the community with MhIST support, and ii) facilitating discharge from local high dependency inpatient rehabilitation services in order to improve patient flow, which in turn additionally enables repatriation from pre-existing OOA placements.

Results

We identified a cohort of 33 patients who had been supported by MhIST for ≥3 months. This cohort includes seven patients who would otherwise have been referred for an OOA placement. Further analysis for this group showed that initial referrals to MhIST were received from community mental health teams (CMHT) (n=1), acute inpatient wards (n=4) and high dependency inpatient rehabilitation services (n=2). Two patients (29%) were discharged to supported accommodation, and five (71%) were discharged to independent accommodation. Within the wider patient cohort identified (n=33), 66% of patients are living independently in the community.

In total, 13 patients have been discharged from high dependency inpatient rehabilitation services to MhIST during the review period.

Conclusion

MhIST uses a multi-disciplinary model which offers an intensive level of support and a high frequency of interventions. The team includes support workers, nurses, doctors, occupational therapists, psychologists and social workers, and in addition links with other community services involved in housing, employment and social projects. A bespoke and flexible approach allows complex needs to be addressed within local services, and here we highlight the role of MhIST in reducing referrals to OOA placements.
Aetiological Investigation of Epilepsy in Adults With a Learning Disability – a Community Audit
Authors: Carroll John , Winterhalder Robert
Published: July 2023

Aims

To demonstrate adherence to national standards for the aetiological investigation of epilepsy in Bromley Community Learning Disability Team (CLDT), Oxleas NHS Foundation Trust. The National Institute for Health and Care Excellence (NICE) and International League Against Epilepsy (ILAE) advise strenuous attempts to identify the aetiology of epilepsy as it often carries significant treatment implications. The ILAE divides aetiology into six categories selected because of their potential therapeutic consequences (structural; genetic; infectious; metabolic; immune; unknown).

Methods

Audit standards were derived from NICE and ILAE. The key standard was that 100% of patients should have sufficient aetiological investigation of their epilepsy, including a dysmorphism assessment, neuroimaging, and genomics, as appropriate. The population was defined as all patients open to the Epilepsy Service of Bromley CLDT in December 2021. Data were collected using a secure electronic database between December 2021 and January 2022.

Results

76 patients (52 male, 24 female) were audited, mean age 38 years (range 18-79 years). Learning disability severity included borderline (n=3), mild (n=28), moderate (n=24), severe (n=17) and profound (n=4). Identified aetiologies included structural (42%; n=32), genetic (13%; n=10), and infectious (5%; n=4), with one patient having both genetic and infectious aetiology. Aetiology was unknown in the remaining 41% (n=31) of patients, of which 58% (n=18) had outstanding investigations. In 72% (n=13), there was no apparent reason for investigations to be outstanding. Genomics was the commonest outstanding investigation (70%, n=14), followed by neuroimaging (20%, n=4) and dysmorphism assessment (10%, n=2). In addition, 40% (n=12) of patients were newly eligible for whole genome sequencing – a recent development within 12 months and thus excluded from outstanding investigations.

Conclusion

This audit demonstrates adherence to national standards is below 100%. Where appropriate, patients with outstanding investigations should be approached. Dissemination of findings and an action plan are required before re-audit.
Stopping Over-Medication of People With a Learning Disability, Autism or Both (STOMP) – a Community Audit
Authors: Carroll John , Davies Jill
Published: July 2023

Aims

The stopping over-medication of people with a learning disability, autism or both (STOMP) campaign was launched by NHS England in 2016 as part of the Transforming Care programme. It aims to reduce the inappropriate prescribing of psychotropic medication to manage challenging behaviour in the absence of a licenced indication. The current audit aimed to demonstrate adherence to national standards for STOMP within the community learning disability teams (CLDTs) of Oxleas NHS Foundation Trust. Additionally, a secondary aim was to compare current adherence to the previous audit undertaken in 2019.

Methods

Audit standards were derived from national guidance by the Royal College of Psychiatrists and the National Institute for Health and Care Excellence. The population was defined as all patients open to a CLDT prescriber (medical or non-medical) between April 2020 - March 2021. A multidisciplinary working group agreed inclusion and exclusion criteria before designing an electronic audit questionnaire. A random sample of 20% of patients from each of the three CLDTs (Bexley, Bromley & Greenwich) was generated. Data were collected between October and November 2021.

Results

The clinical records of 111 patients were reviewed, 86 of whom met inclusion criteria. Of these, 65 patients were taking psychotropic medication and progressed to full auditing. Key findings were: 85% of patients on established psychotropics had a medication review within the previous 6 months, of which 100% were assessed for their response to treatment and 86% were assessed for side effects; 78% of patients had their capacity to consent to treatment documented and, of those lacking capacity, 81% had a best interests decision documented. All but one of these key findings demonstrated an improvement compared to the 2019 audit.

Conclusion

Overall, this 2021 audit demonstrates a substantial improvement since the previous audit in 2019. However, adherence to national standards continues to be below 100%. Dissemination of findings and an updated action plan are indicated before re-audit in 2023.
Clozapine Serum Level Timing Audit: Medium Secure Rowan View
Authors: Daniels Charles
Published: July 2023

Aims

To assess the degree of compliance for clozapine serum level timing post clozapine dose using synnovis (previously viapath) and maudsley 14th edition guidelines in a medium secure hospital.

Methods

Electronic prescribing systems were reviewed on each ward to identify clozapine established patients. Viapaths electronic database was reviewed from 01 May 2021 (18 months) and recorded timings were compared to guidelines in Maudsley, 14th edition and synnovis. 12 hours was used as the guideline post dose in OD (once daily), BD (twice daily)/TDS (three times daily) regimes following the night time or evening dose.

Results

4 different types of clozapine prescribing regimes were identified – OD, BD am/nocte or evening, BD pm/night or evening and TDS. 45 patients in total.

OD 12 - most recent bloods 8/12 patients were >15 hours. Total samples in 18 months >12 hours 63.6% (38/55). Total samples in 18 months >15 hours 56.3% (31/55). In the OD group 26 samples are from 2 patients both of whom have samples taken later than 14 hours.

BD 26 - BD mane evening/nocte - 2/5 most recent samples were >15 hours. Total samples in 18 months >12 hours 51.6% (32/62). Total samples in 18 months >15 hours 12.9%(9/62). Need to consider – evening dose time 18:00 compared to 22:00 adding more time.

BD pm evening/night 5 - 2/5 patients > 15 hours. 4/5 patients not at 13-14 hours. Total samples in 18 months >12 hours 75% (9/12). Total samples in 18 months >15 hours 25% (3/12)

TDS 2 - 0 patient > 15 hours, 1 patient at 14 hours. Total samples at 18 months >12 hours - 41.7% (5/12). Total samples at 18 months >15 hours - 16.7% (2/12).

Conclusion

Higher than expected clozapine serum level timing inaccuracy was demonstrated, markedly in bespoke regimes - OD (56.3%) or BD pm evening/night regimes (25%) compared to traditional regimes (TDS 16.7 %, BD am nocte/evening 12.9%). Contributing factors are a knowledge gap amongst services, Maudsley guidelines don't consider bespoke timings when advising trough levels. Findings suggest bespoke regimes need greater consideration when assessing clozapine serum levels.

Action from this initial audit involves informing teams regarding recent samples which are >15 hours post dose. Service education highlighting safety concerns of potential underestimation of clozapine serum level. Guideline change with support from pharmacy. Re audit in 12 months.