bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessing Improvement in Prescription Writing Quality in Adult Male and Female Wards of Psychiatry Department, Lahore, Pakistan: Three Cycles of Clinical Audit
Authors: Khan Aazeen , Arif Umaira , Shahzad Aamir , Tahir Sania Mumtaz , Khan Roop Kiran
Published: August 2024

Aims

1. To measure the extent to which medication orders in inpatient prescription charts conform to the section in BNF (British National Formulary) on prescription writing.

2. To implement changes with the intention of improving prescriptions and administration records.

Methods

Prescription charts of patients admitted in adult male and female psychiatry ward were analysed in three cycles, (1 September to 20 October 2022, then 1st December to 31st 2022 and then: 1st January 2023 to 28th February 2023) which added up to a total of 431, 170 and 490 prescriptions in respective cycles.

Each drug prescription was examined to see if it met the standards outlined in BNF.

Percentage of prescriptions meeting each standard was calculated in each cycle.

First Cycle was followed by presentation of BNF guidelines of prescription writing on 7th December 2022 and copies of those BNF guidelines were placed at both male and female nursing counters. After 1 month, a short re-audit was done to assess the improvement which was satisfactory but this audit's results were not presented. Lastly, after one year of presentation of BNF guidelines in the department, two months of prescription charts were re-audited in cycle 3.

Results

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Cycle 1: Initial evaluation revealed significant discrepancies in prescription accuracy and adherence to administration protocols. Key areas for improvement were identified and discussed with the postgraduate residents.

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Cycle 2: Following the implementation of targeted interventions, a re-evaluation showed measurable improvements in prescription accuracy and compliance with administration protocols. However, areas for further improvement were still identified, particularly in the documentation of prescription changes.

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Cycle 3: The final cycle demonstrated further improvements in prescription practices, with a significant reduction in discrepancies and errors.

•

Legibility remained high across all cycles, with a slight improvement in Cycle 3.

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The use of generic drug names saw a remarkable increase from 40.6% in Cycle 1 to 84.69% in Cycle 3, indicating a strong adherence to best practices.

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Block letters usage improved significantly from 17% in Cycle 1 to 71.42% in Cycle 3, enhancing the clarity of prescriptions.

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The practice of providing a start date saw near-perfect compliance by Cycle 3, increasing from 82.8% in Cycle 1 to 99.18%.

Other findings were similar as well.

Conclusion

The audit successfully demonstrated the effectiveness of clinical audits in improving prescription quality in male and female adult wards. It highlighted the effectiveness of the interventions and the importance of continuous monitoring and feedback.
Forensic Psychiatry at a Tertiary Care Hospital in Faisalabad, Pakistan: An Audit From 2015 to 2018
Authors: Siddique Irum
Published: August 2024

Aims

In Pakistan forensic psychiatry lacks behind as far as formal training and separate departments are concerned. In spite the cases are ever increasing. To find out the magnitude of the burden of forensic cases, current study was conceptualized. This audit would highlight the burden and endorse the demand of specific training in this area. A retrospective study was designed to determine the frequency of various psychiatric disorders, reasons and sources of referrals of the cases coming for forensic opinion to a tertiary care unit.

Methods

All 174 cases admitted to inpatient psychiatry department, Faisalabad for opining about psychiatric condition were included in the study through consecutive sampling techniques, only repeated cases were excluded. As the study was retrospective, data files were retrieved and desired variables were enlisted in SPSS to calculate the frequency and percentage of different variables.

Results

Majority cases were male. One third were referred in year 2018. 47 (27%) criminal cases were being referred while 25 (14.3%) civil cases were received; most of the cases 102 (58.6%) were departmental (cases of the employees of different public departments). As per source of referral 72 (41.3 96%) cases were referred from courts directly, 21 (12.2 96%) cases were directly referred from various departments while most the cases 81 (46.5%) were referred from other public hospitals, As per diagnoses schizophrenia, depression and intellectual disability (ID) were the most prevalent diagnosis with 47 (27%), 41 (23.5%) and 33 (18.9%) cases respectively while 26 (14.9%) cases had no psychiatric diagnosis. 40 (22.9%) cases were advised treatment and follow up, most of these cases 26 (14.9%) were diagnosed as having depression; 30 (17.2%) cases were granted guardianship, 20 (11.4%) out of these were intellectually disabled; 18 (10.2%) cases were referred to other departments for long term psychiatric care institutions, these cases were diagnosed as having schizophrenia, BAD and epilepsy; 9 (5.1%) cases were advised adjustments in jobs, these were diagnosed as depression, schizophrenia and BAD; only 6 (3.4%) cases were suggested to board out on the basis of illness.

Conclusion

Department of psychiatry and behavioral sciences, FUM, Faisalabad, Pakistan is burdened with forensic cases that may be managed at other appropriate places. Society and policy makers need to be sanitized in order to make a framework for patients having mental disorder to avoid them ending as criminals or being involved in other forensic issues.
Full Cycle Audit on Health Appointment Attendance: Comparative Analysis of Initial Audit and Reaudit Findings in a Psychiatric Care Setting
Authors: Teama Ramy , Reid Keith , Lawal Qudus
Published: August 2024

Aims

The full cycle audit aimed to evaluate and enhance attendance rates at health appointments in a psychiatric care setting. The initial audit (Phase 1) identified baseline attendance rates and underlying factors contributing to missed appointments. The reaudit (Phase 2) was conducted to assess the effectiveness of implemented interventions from Phase 1 and to identify areas for continued improvement.

Methods

Both phases employed a retrospective evaluation methodology. Phase 1 reviewed records of 23 patients over two years, totaling 89 appointments. Phase 2, conducted as a follow-up, involved 19 patients with 39 appointments over a six-month period. Data collected included the number of attended and missed appointments, and reasons for non-attendance. Interventions after Phase 1 focused on addressing identified issues such as patient transfers, leave protocols, and transportation challenges.

Results

Phase 1 recorded an attendance rate of 68.5%, with the missed appointment rate at 25.8%. Common reasons for non-attendance included patient decline and unclear reasons. Phase 2 showed a slight improvement in attendance rates (71.8%) but also an increased missed appointment rate (28.2%). Notable reasons for missed appointments in Phase 2 included patients on leave, ward cancellations, and transportation issues. The comparison revealed an improvement in attendance rates post-interventions, though challenges persisted, particularly in patient leaves and transportation.

The chi-square statistic is 2.2893 and the p-value is 0.3183. This indicates that there is no statistically significant difference between the attendance rates in Phase 1 and Phase 2. This suggests that the changes implemented between the two phases did not result in a statistically significant difference in attendance rates.

Conclusion

The full cycle audit demonstrated marginal improvements in appointment attendance rates following targeted interventions. While Phase 2 showed a higher attendance rate, it also highlighted ongoing challenges, particularly in managing patient leaves and transportation. These findings underscore the need for continuous monitoring and adaptable strategies to further enhance attendance rates. Recommendations include improved communication during patient transfers, proactive leave management, addressing transportation issues, and ongoing evaluation to sustain improvements in health appointment attendance in psychiatric settings.
First Time Presentation of Graves' Hyperthyroidism With Psychotic Symptoms: A Case Report
Authors: Ajewole Oluwatobi , Doku Victor
Published: August 2024

Aims

Graves’ disease, an autoimmune illness, is one of the most common causes of thyrotoxicosis and often presents with classic symptoms of hyperthyroidism. However, patients can rarely present for the first time with psychiatric symptoms, including psychotic and mood symptoms or a combination of both, and there is limited data on the most effective treatment.

Methods

Here, we report the case of a 24-year-old black British female who had no previous psychiatric or medical history, presenting for the first time with one week history of poor sleep, disordered thought, and bizarre and violent behaviour towards family. Collateral history describes her premorbid personality as “anxious and perfectionist”, with the only recent stressors identified being preparations for her best friend's wedding. Her mental state on presentation was remarkable for tangential and circumstantial speech, incongruent affect, and lack of insight into illness. She was admitted to an acute adult ward under Section 2 of the Mental Health Act (MHA) after being “medically cleared” but before the results of her thyroid function tests were available.

She was transferred back to the acute medical ward a day into psychiatric admission, where she was treated medically for thyrotoxicosis and discharged with the support of the Home Treatment Team after an almost complete recovery in her mental state. Initial symptoms recurred two weeks after discharge, culminating in another admission cycle initially to a psychiatric unit under the MHA, where she was treated with oral risperidone and a medical ward for further medical investigations. Her mental state improved significantly again, and she was discharged home to the concerted care of both a community mental health team and follow-up with the endocrinology team. On outpatient psychiatric review a year following discharge, the patient remains stable in her mental state and has achieved a euthyroid state with plans to taper off and withdraw risperidone gradually.

Results

This case shows the importance of a thorough physical health assessment and investigation before making psychiatric management decisions. It also points out the drawback of the divide between physical and mental health services, the impact this has on patient care and experience within the National Health Service, and the mixed success of medical management in controlling psychiatric symptoms.

Conclusion

This case describes the rare presentation and successful management of psychosis induced by thyrotoxicosis in a female patient with Graves’ disease. It highlights the need for prompt, interdisciplinary care to diagnose and safely manage such patients correctly.
Case Study: Pseudobulbar Affect During Recovery From Locked in Syndrome
Authors: Ankolekar Sunil J. , Parke Sheryl
Published: August 2024

Aims

We would like to report a case of pseudo bulbar affect during recovery from locked in syndrome due to brainstem stroke.

Methods

We present a lady in her early 60s who developed pseudobulbar affect during recovery from locked in syndrome. MRI brain confirmed brain stem infarct. No personal or family history of mental illnesses was noted. Neurological examination on our rehabilitation unit confirmed dense weakness in all four limbs. She would cry even when family gave her good news or made jokes with her. This appeared to be the only method of expressing her emotions she had; however, it was unclear if this was aligned to her internal emotional experience.

Results

Through clinical observation and using the Testing Emotionalism After Recent Stroke-Questionnaire (TEARS-Q) measure of emotionalism we identified that pseudobulbar affect was present, and intervention should be considered. The patient also stated that her crying was not always aligned with her emotional experience, but laughter was. The Clinical Outcome Routine Evaluation (CORE-10) was also used to screen out other potential psychological difficulties including depression. The assessment indicated she was experiencing low levels of psychological distress.

We initiated fluoxetine and clonazepam was given to help with spasticity and sleep. Our non-pharmacological measures included sitting with the emotional expression and not asking her to stop, encouraging her to take deep breaths and modelling this and when she presented as calmer supporting her to identify if her emotional expression was in line with her internal emotional experience and using different communication strategies to explore this and support her to have her needs met. If the crying persisted mid communication, staff supporting her would reorientate her to what she had been attempting to communicate and encourage her to continue, which she would be able to do. All staff were asked to do this during their interactions with the patient to support identification of emotional alignment. Significant reduction in emotional misalignment was noted following the implementation and increased use of external communication aids. Within a few months her distressing crying episodes reduced and neurologically she improved.

Conclusion

Pseudo bulbar affect is a distressing condition that can occur during recovery from locked in syndrome. Diagnosis can be confirmed by ruling out other common conditions like anxiety or depression. Treatment includes both non-pharmacological and pharmacological measures best provided by a specialist multidisciplinary team.
Huntington's Disease and Criminal Behaviour: An Exploration of Psychiatric Risk and Management in a High Secure Forensic Unit
Authors: Gupta-Jessop Thomas , Caldwell-Dunn Ellice
Published: August 2024

Aims

Huntington’s disease (HD) is an autosomal dominant neurodegenerative disorder characterised by a pathologically prolonged CAG nucleotide sequence in the huntingtin gene (HTT). Neuropsychiatric symptoms such as aggression, depression, impulsivity and psychosis are non-motor signs of HD. The association between HD and criminal behaviour is debated, and evidence lacking. This is particularly relevant in forensic psychiatry, which focusses on the risk assessment of mentally disordered offenders. This manuscript examines the antecedents of offending behaviour in a male diagnosed with HD during admission to a high secure unit, and the evolution of his risk profile from childhood to post-diagnosis. Additionally, through exploration of psychopharmacological management of psychiatric symptoms in HD, this study aims to further our understanding as to how we can best support people with HD in a forensic mental health setting.

Methods

Following review of relevant literature on criminal behaviour in the context of HD, we report the case of a 41-year-old man with a background of dissocial personality traits admitted to a high security unit with symptoms of a delusional disorder; manifesting as paranoia, delusional beliefs and aggression. These were believed to be organically induced within the context of HD, a diagnosis confirmed through genetic testing six months following admission. The patient's symptoms were only partially responsive to first-line antipsychotics; however, good symptomatic control was achieved with clozapine and sodium valproate, enabling step-down to medium secure specialist services.

Results

In HD patients, there may be a challenge of discerning whether offending behaviour relates to prodromal presentation or whether there are pre-existing antisocial attitudes or behaviour; an uncertainty which was present in this case and within the literature. The age of HD onset is inversely correlated with CAG repeat length, and a longer repeat length has been associated with criminal behaviour. This has the potential for use as a marker to determine the time point in which presenting features are attributable to HD. In this case study it was possible to determine through analysis of the CAG repeat length that the delusional disorder was likely linked to the onset of HD; however, dissocial personality traits were not.

Conclusion

A patient's background relating to the life-course persistence of violence, suicidality and psychiatric symptoms in patients with HD informs the process of formulating their risk profile. Changes to the risk profile also reflect the progressing stages of HD. This highlights the need for awareness of how HD may contribute or predispose to criminal behaviour and how interventions could be targeted during critical periods where they benefit most.
Nabilone as Part of the Holistic Treatment in Early Onset Alzheimer's Dementia: A Case Study
Authors: Saraswat Charvi , Lei Jiedi , Zacharia Tharun , Bonnici Mallia Anne M.
Published: August 2024

Aims

Optimal management of Behavioural and Psychological symptoms of Dementia (BPSD) remains challenging. This report describes using nabilone, a synthetic cannabinoid, in a 61-year-old woman with Alzheimer's dementia (AD) experiencing progressive BPSDs.

Methods

AM was diagnosed with AD in February 2019 and prescribed donepezil and mirtazapine. In August 2021, her behaviour deteriorated, becoming paranoid, repeatedly pacing and developing expressive aphasia. Behaviours further declined leading to an admission to our dementia ward under the Mental Health Act 2007 in January 2022. AM showed limited response to medications including risperidone and mirtazapine which were switched to olanzapine and citalopram. “Controlled falls” were observed, during which AM placed herself suddenly onto the floor. In February 2022, she was witnessed having a self-terminating generalised tonic clonic seizure (GTCS) lasting 3 minutes and later witnessed having three more seizures. Computed tomography excluded acute intracranial pathology. She had no previous history of seizures. An electroencephalogram displayed focal slowing over the frontal region greater on the right and presence of sharp, transient, sharpened slow wave, triphasic waves and reported that epileptiform discharges can be seen in AD in the absence of epilepsy.

Behavioural charts, Cohen Mansfield Agitation Inventory (CMAI) and Neuropsychiatric inventory (NPI) questionnaires were used to monitor response. Decision was made to trial Nabilone in April 2022 due to minimal improvement. Nabilone was started at 0.25 mg daily and up-titrated by 0.25 mg fortnightly based on the response. Over the subsequent month there was a measurable improvement. This was temporarily halted due to issues with nabilone supply, together with cessation of lorazepam, showing worsening in behaviours. Nabilone was eventually restarted and increased to 1 mg once daily with promising effect.

Results

There was a notable qualitative improvement in AM's engagement and communication with family and staff. Prior to treatment the frequency of aggressive incidents ranged from 25–35, reducing to five to ten incidents per day. Controlled falls largely ceased. The NPI Caregiver distress score dropped from 21 to 8 over three months; Frequency and severity scores dropped from 73 to 40 during the same period. CMAI scores dropped from 86 to 64 over two months.

Conclusion

We describe a measurable improvement in BPSDs and quality of life in a patient with severe AD. Reduction in irritability, agitation and improvements in sleep were observed after initiating nabilone. The mechanism of nabilone via CB1 agonism has shown to be neuroprotective and anti-inflammatory. This indicates a promising treatment for BPSDs.
Navigating the Balance: Treatment-Resistant Schizophrenia Relapse Risks Versus Clozapine-Related Cardiovascular Complications - a Case Report
Authors: Singh Hardeep , Blackman Alexandra
Published: August 2024

Aims

Clozapine, known for its efficacy in treating treatment-resistant schizophrenia, offers significant benefits. However, its use also carries potential cardiovascular side effects, such as myocarditis early in treatment and cardiomyopathy with prolonged use. This case highlights the challenge of balancing the risks of treatment-resistant schizophrenia relapse against the potential cardiovascular complications associated with clozapine therapy.

Methods

An adult male with treatment-resistant schizophrenia was initially prescribed clozapine but switched to paliperidone depot due to compliance issues. However, he relapsed shortly after and had to be restarted on clozapine, albeit at a lower dose due to associated tachycardia, supplemented with risperidone. After two years on clozapine, he was diagnosed with cardiomyopathy, prompting a cardiology review. Clozapine was withheld, and risperidone dosage was increased, but he experienced a severe relapse. Despite the risks, multiple multidisciplinary meetings and approval from the medication optimization committee led to his re-commencement on clozapine due to the treatment-resistant nature of his illness and associated risks.

Results

Clozapine, a benzisoxazole derivative, is used for treatment-resistant schizophrenia and aggressive behaviours. Its pharmacological action involves D2 and 5HT2A receptor antagonism, affecting serotonergic, dopaminergic, adrenergic, cholinergic, and histaminergic receptors. However, severe side effects like agranulocytosis, seizures, myocarditis, tachycardia, and cardiomyopathy can occur. Cardiomyopathy incidence is rare (0.02–0.1%) with a mortality rate of 17.9%. Proposed mechanisms include undetected myocarditis and persistent tachycardia-induced changes leading to ventricular dysfunction. Common findings in investigations include raised CRP, leucocytosis, eosinophilia, increased lactate, elevated troponin, non-specific ECG changes, and ventricular dysfunction on echocardiography.

Conclusion

Clozapine poses rare but potentially fatal cardiac risks, including myocarditis and cardiomyopathy. Essential baseline investigations and close monitoring during the initial weeks are crucial. Persistent tachycardia may signal trouble. If suspected, serial monitoring of FBC, troponin, and CRP levels is recommended, with prompt management if confirmed with discontinuation of clozapine, as the cardiomyopathy is often reversible. A multidisciplinary approach involving cardiology is vital for optimal management. This is particularly crucial when weighing the risks of relapse in schizophrenia against the potential cardiovascular complications of clozapine therapy.
A Rare Case of rTMS Induced Schizophrenia Symptom Switch
Authors: Sobhani Aayushi , Pursnani Sachin , Chandi Anureet kaur , Bhardwaj Akansha , Kumar Nand
Published: August 2024

Aims

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This case study investigates a rare occurrence of symptom transition in a chronic schizophrenia patient following high-frequency repetitive transcranial magnetic stimulation (rTMS), aiming to understand the unexpected shift from predominantly negative to positive symptoms.

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rTMS, known for inducing changes in neuronal activity based on Faraday's law, is believed to enhance cortical excitability through high-frequency stimulation.

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Schizophrenia, a severe and chronic mental disorder, presents with both positive (e.g., delusions, hallucinations) and negative symptoms (e.g., apathy). Current treatments, predominantly antipsychotic drugs, often show limited efficacy, especially for negative symptoms. Non-invasive neuromodulation techniques like rTMS are emerging as potential interventions.

Methods

This case involves a 27-year-old banking executive with a 30 months illness duration primarily marked by negative symptoms over the past 3 months. Despite various antipsychotics, there was no improvement, leading to the initiation of high-frequency rTMS on the left dorsolateral prefrontal cortex (DLPFC) as an adjunct strategy for persistent negative symptoms. Surprisingly, after the 5th rTMS session, positive symptoms like delusions and hallucinations emerged. Serial assessments demonstrated a decrease in negative symptom domain scores on PANSS but an increase in positive symptom domain scores on PANSS.

Results

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Results suggest that 5 Hz rTMS over the left DLPFC may have contributed to the transition to positive symptoms. The discussion explores limited literature on rTMS-induced positive symptoms, with case reports dating back to 2004 indicating the possibility of such induction. Studies propose a link between higher pulse frequency, motor threshold intensity, left prefrontal cortex stimulation, and longer trial durations with the exacerbation of positive symptoms, possibly linked to dopamine changes in specific brain tracts.

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Recent trials indicate potential improvement in positive symptoms, such as excitement, with low frequency rTMS of the temporo parietal area. However, the efficacy of rTMS varies with the stimulation site, with left prefrontal rTMS showing promise for negative symptoms and left temporo-parietal junction stimulation possibly reducing auditory hallucinations.

Conclusion

This case report suggests that a subset of schizophrenia patients may experience a transient exacerbation of positive symptoms following rTMS. This underscores the need for increased awareness of potential side effects, serving as an exploratory study that calls for future research to refine these findings for a clearer understanding of rTMS-induced symptom switches in schizophrenia.
Effect of Escitalopram on Glycemic Control and C-Reactive Protein in Patients With Depression and Co Morbid Type 2 Diabetes Mellitus – a Study on Indian Population
Authors: Tiwary Shubhankar , G. Vishnuvardhan , Tripathi Richa , M. Manojprithviraj
Published: August 2024

Aims

There is a bidirectional link between Depression and type 2 Diabetes mellitus (T2DM). Treatment of depression with selective serotonin reuptake inhibitors (SSRIs) may improve glycaemic control and may be beneficial for patients with comorbid depression and diabetes mellitus. The aim of the present study was to assess the effect of escitalopram on C-reactive protein (CRP) and glycaemic control in patients with comorbid T2DM and depression.

Methods

A prospective interventional follow up study was conducted in a tertiary health care institute in urban India. Adult males and females who were diagnosed with Type 2 DM, having depression as per ICD-10 and treatment naïve for both the disorders were included for the study. Participants with other psychiatric disorders, on thyroid medication or on any medication that can have effect on CRP levels, having history of any infection/allergic or inflammatory conditions were excluded from the study. Sociodemographic details were collected. The severity of depression was assessed using Hamilton Depression Rating Scale (HDRS) at baseline. Escitalopram was started and titrated upto required doses for each patient. Levels of fasting blood glucose, post prandial blood glucose, HbA1c (Glycated Hemoglobin) and CRP were also measured at baseline. At the end of 3 months, severity of depression scores and blood levels of above mentioned parameters were measured and compared with their baseline values.

Results

A total of 125 patients (females-n = 70, males-n = 55) were included for the study. The mean age of the sample was 63.2 years (SD 10.6). Most of the participants were educated and employed. The mean HRDS score of the participants at baseline and at three months was 20.3 (SD 3.7) and 18.0 (SD 3.9) respectively. The mean HbA1C of the participants at baseline and at three months was 8.4 (SD 1.2) and 7.8 (SD 1.2) respectively. The mean CRP of the participants at baseline and at three months was 4.0 (SD 5.6) and 2.8 (SD 4.3) respectively. There was significant reduction in depressive symptoms (Z score= -6.894, P value <0.05), levels of HbA1C (Z score= -7.936, P value <0.05) and CRP levels (Z score= -6.158, P value <0.05) at follow up after treatment with escitalopram. No significant correlation was observed in these parameters across gender.

Conclusion

Treatment with escitalopram reduces the severity of depression and the ongoing inflammatory process amongst these patients.
Fahr's Disease (Primary Basal Ganglia Calcification) and Violence: Case Report and Literature Review
Authors: Yorston Graeme , Mumonyedi Sidney , Rehman Muhammad Abdur , Baig Ifrah Ali
Published: August 2024

Aims

Background: Fahr's disease is a rare and complex neuropsychiatric disorder resulting from abnormal calcium deposition in the basal ganglia and cerebral cortex. It can have a profound impact on an individual's social functioning as well as causing a wide variety of neurological symptoms, cognitive deficits and motor impairment. A number of specific mutations have recently been identified in phosphate transporter and other genes, but around half of all cases have unidentified mutations. Impulsivity, aggression and violence may pre-date the other manifestations of the illness.

Methods

Case Report: Patient X is a 58 year old man currently detained in an independent hospital locked rehabilitation unit following the breakdown of a care home placement. His first admission to hospital was at the age of 18 when he was diagnosed with mania. He had multiple further hospital admissions as well criminal convictions for acquisitive and violent offences. In 2005 he threatened to stab a stranger if he did not give him a cigarette and he was arrested and admitted to a medium secure unit under Section 37 with diagnoses of bipolar affective disorder and emotionally unstable personality disorder. He remained in secure hospital care until 2018 when concerns about Parkinsonian symptoms led to him being referred to a neurologist and a diagnosis of Fahr's disease being made on the basis of his CT findings. He was transferred to a locked rehabilitation service in 2019 but continued to exhibit challenging behaviour on a daily basis. After a reduction in the frequency and severity of his behaviour he was discharged to a care home, but this broke down after a few months as his assaultive and sexually inappropriate behaviour re-emerged.

Results

Discussion: Fahr's disease is traditionally thought of as a late life neurological condition, but as with Huntington's disease neuropsychiatric symptoms of irritability, sexually disinhibited behaviour, impulsivity and aggression can occur early and may pre-date any neurological manifestations. Treatment is often difficult because of sensitivity to antipsychotic medication.

Conclusion

It is important to consider neuropsychiatric conditions in the assessment of adults presenting with antisocial behaviours, especially when these are associated with a change in overall functioning and an absence of adolescent conduct disorder. There is as yet no specific treatment for Fahr's disease, but early identification allows appropriate risk management strategies to be adopted.
Late-Onset Tay-Sachs Disease With a Predominantly Neuropsychiatric Presentation: Case Report and Literature Review
Authors: Yortston Graeme , Ain Awan Noor Ul , Aref Mahmoud , Thirumalai Srinivasa
Published: August 2024

Aims

Background: Late-onset Tay-Sachs disease (LOTS) is an autosomal recessive lysosomal storage disease due to a variety of mutations in the hexosaminidase-A gene which leads to accumulation of GM2 ganglioside in the brain. It typically presents in late adolescence with a slowly progressive spectrum of neurologic symptoms including lower-extremity weakness with muscle atrophy, dysarthria, incoordination, tremor and mild spasticity and/or dystonia. Psychiatric symptoms including mood disorder, psychosis and neurocognitive symptoms occur in around 50% of cases but are rarely the presenting feature.

Methods

Case Report: Patient X is a 35 year old man of Irish descent currently detained in an independent hospital locked rehabilitation unit following the breakdown of a care home placement. He first presented to mental health services at the age of 17 with psychomotor agitation, rapidly changeable moods, manic-like symptoms and sexual disinhibition. He was diagnosed with schizoaffective disorder, attention deficit hyperactivity disorder and Asperger's syndrome and he had several compulsory hospital admissions over the next five years before a prolonged period of rehabilitation and discharge to a residential home for people with autistic spectrum disorders. However, he continued to exhibit disruptive behaviour, often triggered by periods of insomnia and had further hospital admissions. When he was 31 his brother was diagnosed with LOTS and this led to him being tested and found to have the same mutation.

Results

Discussion: There had been no suspicion of a neuropsychiatric disorder prior to the diagnosis of the patient's brother with LOTS and he was treated with conventional psychotropic medication with limited success. However, when the case records were obtained from his first hospital admission there was evidence of dysarthria although the significance of this was not appreciated. With hindsight many of his other symptoms can be seen as indicative of a neuropsychiatric disorder.

Conclusion

It is important to take a family history and consider a neuropsychiatric condition in families with multiple affected individuals. There are as yet no specific treatments for LOTS, and management is aimed at symptom reduction and enhancing quality of life, but a number of disease modifying strategies are being investigated including enzyme replacement therapy, pharmaceutical chaperone therapy, substrate reduction therapy, gene therapy, and hematopoietic stem cell replacement therapy, making it even more important the condition is recognized early.
Choices Today, Behaviours Tomorrow: Longitudinal Associations Between Childhood Risky Decision-making and Adolescent Conduct Disorder Behaviours – a Nationally Representative Prospective Cohort Study in the United Kingdom
Authors: Cheung Christy , Lewis Gemma , Lewis Glyn , Srinivasan Ramya
Published: August 2024

Aims

Conduct disorder carries significant individual and societal repercussions. Despite heightened risk-taking and challenges in adapting to changing probabilities of choice outcomes being linked to maladaptive behaviours such as conduct disorder, no study to date has examined the association behind childhood decision-making and adolescent conduct disorder. This study seeks to address this gap by exploring the longitudinal association between these two variables. Understanding the mechanisms underlying conduct disorder could help with developing new preventive interventions.

Methods

We used data from the Millennium Cohort Study, a nationally representative UK cohort; participants included those with complete data on exposure, outcome and confounding variables (n = 7,237). The exposure, childhood decision-making at 11 years was measured using the Cambridge Gambling Task risk-taking and risk-adjustment measures. The outcome, a binary measure of adolescent conduct disorder was created using items from the risky and antisocial behaviour interview sections at age 17. We used logistic regression to examine the association between childhood decision-making and adolescent conduct disorder and adjusted for relevant confounders.

Results

The univariable model showed that at age 11, each 20-point increase in risk-taking score increased the odds of conduct disorder behaviour at age 17 by 32% (OR = 1.32, 95% CI 1.18–1.44, p < 0.0001). In the multivariable model, there was strong evidence that a 20-point increase in risk-taking at 11 years was associated with 18% higher odds of conduct disorder behaviour at 17 years (OR = 1.18, 95% CI 1.05–1.33, p = 0.005). There was no evidence that this association differed by sex. Risk adjustment at 11 years showed no association with conduct disorder behaviours at age 17 both in the univariable model (OR = 0.96, 95% CI 0.88–1.06, p = 0.440) and the multivariable model (OR = 0.96, 95% CI 0.88–1.06, p = 0.433).

Conclusion

We found that risk-taking at 11 years was associated with conduct disorder behaviour at 17 years. If causal, our findings suggest that risk-taking might be a potential mechanism underlying adolescent conduct disorder behaviours. This may be useful in informing the design of preventive strategies, such as encouraging positive risk-taking in children and discouraging negative risk-taking behaviours.
A Systematic Review of the Financial Impact of Living as an Autistic Person in the UK
Authors: Bowley Mary , Jordan Mary
Published: August 2024

Aims

Being an autistic person in the United Kingdom (UK) is associated with a range of costs. This study reviews published literature which estimates the cost of living as an autistic person in the UK.

Methods

A systematic review of published peer-reviewed studies was undertaken. Search criteria included papers which were published after 2008, looked exclusively at costs of living as an autistic person in the UK and discussed quantitative data. Papers recovered during the literature search were screened by title and abstract independently by two reviewers. Papers included in the final review were critically appraised using the Critical Appraisal Skills Program (CASP) checklist. Four papers were selected for inclusion in this study. Following data extraction, results were compared in a narrative synthesis across six key domains defined in previous literature: Caregiver costs, Loss of productivity, Healthcare costs, Education costs, Accommodation costs, Therapeutic costs. During the data extraction process, analysis of cost inclusion criteria, data collection methods and cohort characteristics was conducted.

Results

Across the literature the following findings emerged: Costs for autistic people with co-occurring intellectual disability (ID) are higher per year than for those without a co-occurring ID. Costs of care vary with age, with different cost categories peaking at different points in a person's life. Loss of productivity is one of the greatest costs, with education and accommodation costs also proving significant. Data looking at a wide range of expenses however do not determine whether expenses are paid by the individual or by the Government. There is a lack of data regarding financial income, whether sourced from employment or government support, such as Personal Independent Payments or Universal Credit. A lack of consistency regarding cost inclusion criteria and differences in data collection methods severely limit direct comparison of outcomes across the literature.

Conclusion

Lack of consistency in the measurement of cost components and defined cohort characteristics makes comparison across the literature challenging, comparison cannot inform any meaningful economic evaluation. Despite this, the overarching theme across all studies in this review is that current service expenditure is higher for autistic people than non-autistic people. This is particularly clear when discussing accommodation, healthcare and costs due to loss of productivity. Both age and co-occurring conditions have an impact on overall cost. These findings form a strong basis for future research in this area to standardise cost calculations across specified age ranges and evaluate current government-centered financial support available to autistic people.
Investigating History of Suicidal Ideation Among Patients Attending Early Intervention for Psychosis Services: A Retrospective Analysis Using Clinical Records
Authors: Mongan David , Quattrone Diego , Kelleher Ian , Cannon Mary , Cotter David
Published: August 2024

Aims

Previous population-based studies have identified suicidal ideation (SI) as a potential risk marker for psychosis. We aimed to investigate the prevalence of previous SI in a large sample of patients with first episode of psychosis accepted to early intervention services (EIS) in South London and Maudsley (SLaM) NHS Foundation Trust using clinical records. We further aimed to investigate differences in patients with and without recorded SI according to age at diagnosis, gender, ethnicity and neighbourhood deprivation.

Methods

We designed a retrospective cohort using the Clinical Record Interactive System. Included were patients who were accepted by SLaM EIS from 2015–2018 and received a psychotic disorder diagnosis (n = 1658). We used a natural language processing algorithm that searches deidentified textual clinical records, returning a binary variable indicating presence or absence of SI recorded at any time prior to acceptance to EIS. The algorithm has high precision (97%) and inter-rater reliability (Cohen's k 92%). The t-test was used to compare mean age at first diagnosis in patients with and without recorded SI, while chi-squared tests evaluated differences according to gender, ethnicity and tertiles of index of multiple deprivation (based on 2015 postcode). The significance threshold was p = 0.05.

Results

The cohort included 1658 patients, of whom 656 (39.6%) were female. The natural language processing algorithm identified 600 patients (36.2%) who had SI recorded in their clinical records at any time prior to acceptance by EIS. On average, patients with recorded SI were younger at first diagnosis of psychotic disorder (mean 27.7 years, standard deviation 10.5) compared with patients without recorded SI (mean 30.1 years, standard deviation 11.2; p < 0.001). There was little evidence for differences on gender (p = 0.950), ethnicity (p = 0.059) or deprivation index (p = 0.597).

Conclusion

Approximately 1 in 3 patients attending SLaM EIS had evidence of SI recorded prior to acceptance by EIS. Consistent with previous studies, the current findings emphasise the high prevalence of SI in this clinical population. Compared with those without SI, patients with recorded SI were on average 2–3 years younger at diagnosis. This may reflect general population age differences in prevalence of suicidal ideation; increased severity of illness with earlier age of onset; or patterns of contact with services which facilitated earlier diagnosis. There was little evidence that patients with and without recorded SI differed significantly on gender, ethnicity or neighbourhood deprivation. Prospective studies would be helpful to assess whether SI is a risk marker for first episode of psychosis.
Development of an Integrated Electronic Platform for ADHD Medication Initiation in Child and Adolescent Mental Health Services
Authors: Stanton Noah , Iqbal Hamzah , Bailey Sandra , Morganstein Louise , Jakhra Salim
Published: August 2024

Aims

Children and young people (CYP) with attention deficit hyperactive disorder (ADHD) under Brent Child and Adolescent Mental Health Services (CAMHS) experience long waiting times before treatment with medication is initiated: on average 3 months. Therefore, the aims were firstly, to create an electronic platform (e-platform) to educate parents about ADHD medication and facilitate its initiation in Brent CAMHS. The e-platform replaced the previous method of medication initiation which was typically delivered to a group over Zoom. Secondly, to reduce time-to-treatment initiation (TTI) by January 2024. Thirdly, to increase the proportion of patients with ADHD who were initiated on medication (when appropriate) by the same date.

Methods

The content from neurodevelopmental clinicians counselling parents about ADHD medication was transcribed. Individual transcripts were collated into a master transcript to standardise the information delivered to parents. Medication initiation psychoeducation videos were created using the master transcript and a videographer and editor, in collaboration with the Trust's Director of Communications and Web Development Team. The videos were integrated electronically with a question-and-answer section, a useful websites section and a medication decision section to construct an e-platform, which was embedded in the Brent CAMHS website.

Following the QI model-of-improvement, objective clinical measures included TTI, the proportion of CYP initiated on medication, and total clinical and administrative time saved. User-reported outcomes were measured using a pre- and post-intervention questionnaire combining Likert scale and free-response items.

Results

TTI reduced by 37% from 92 days (Zoom) to 58 days (e-platform). The proportion of CYP initiated on medication increased from 64% (Zoom) to 72% (e-platform). Over a 2-month period, 9 hours of clinician time was saved. Based on 20 respondents, overall user satisfaction increased from 4.13/5 (Zoom) to 4.71/5 (e-platform). Qualitative feedback revealed that users found the e-platform ‘easy to understand’, ‘easy to access, quick and useful’ and ‘provided clear explanations’.

Conclusion

The results indicate the positive impact of the e-platform initiative which can be derived from both clinical and user-reported outcomes. By integrating standardized educational content, user-friendly features and streamlined processes, the e-platform empowers parents with knowledge, enhances communication between families and the neurodevelopmental team, and ultimately expedites ADHD medication initiation and saves clinical time. Regional spread has commenced, and the authors are engaged in discussions with other CAMHS to facilitate this further.
Introducing Step-Down Summaries to the Intensive Psychiatric Care Unit
Authors: Mahony Ewan , Johnston Zoe
Published: August 2024

Aims

The intensive psychiatric care unit (IPCU) is a 10-bedded unit which houses some of the most unwell psychiatric inpatients, generally those with psychosis and mania who require enhanced care and restriction. Admissions can be long and involve high levels of clinical complexity. This project identified the need for clear communication at the point of discharge with regards to rationale for decision making, mental health act status, risk and outstanding issues. The aim was to develop and test a tool for communicating this: the step-down summary.

Methods

Three plan, do, study, act cycles were run. The first involved creating a draft proforma and testing this with 3 complex patients, gathering qualitative feedback from receiving clinicians. The proforma was then improved and a full-scale trial including all patients with stays of 2 weeks or more was conducted, a total of 18 patients. Data were collated on the timing of summary completion and further improvements to the proforma were made based on consultant feedback. Finally, a third cycle was run to establish whether the new process was sustainable between rotating trainees.

Results

Initial feedback was positive with clinicians highlighting that the summaries saved time reading extensive notes, clearly identified outstanding tasks, and helped with final discharge document writing. It became clear that there was a need to agree a cut-off time of how long a patient should be in IPCU to merit a stepdown summary. Of the 18 patients who met this cut-off in the 2nd cycle all had a stepdown summary at the point of transfer with 89% of these fully complete before their next clinical review. During the 3rd cycle, there were 19 relevant patients only one of whom did not have a summary, due to their transfer coinciding with trainee leave. Feedback remained positive, highlighting that the summaries avoided duplication of work.

Conclusion

Overall, the use of stepdown summaries proved useful to receiving clinicians in both communicating important information and in saving further time when later creating final discharge documents. It was sustainable between trainees, however there remained an issue with these not being produced during trainee leave. It may be useful to consider alternate clinicians who can support with the production of summaries to minimise this as well as measuring more clear clinical outcomes, such as the repetition of investigations. This would support an expansion to other UK IPCUs.