bluuebunny/crossref_metadata_2025 huggingface dataset:
The emerging role of acceptance and commitment therapy as a way to treat trauma and stressor related disorders
Authors: Simões Gisela , Silva Rita
Published: June 2021

Aims

The aim of this work is to gather and evaluate scientific evidence about the clinical effects of Acceptance and Commitment Therapy (ACT) in the treatment of patients with trauma-related Post-Traumatic Stress Disorder (PTSD).

Method

A literature search was conducted on PubMed platform, starting from the following MeSH terms: “Acceptance and Commitment Therapy”, “Trauma and Stressor Related Disorders”, “Psychological Trauma”. Studies obtained were analysed, corresponding to investigations based on an adult population with trauma and stressor related disorders.

Result

The search provided 13 results, of which 12 met the defined criteria. Different types of studies with variable samples were considered, including randomised clinical trials, longitudinal observational studies, narrative reviews and an analysis of case reports.

Globally, ACT has been showing a crescent role in the treatment of individuals with trauma histories by enhancing positive outcomes and by being associated with greater psychological flexibility. It is increasingly considered to be well-suited to the treatment of trauma by targeting avoidance, coping strategies with emotional disengagement and persistent dissociation, aspects associated with greater PTSD symptom severity and related psychopathology.

Furthermore, research suggests that acceptance-based treatments are helpful in promoting emotional, behavioural, and neural changes in psychological disorders characterised by disgust, shame and guilt that commonly co-occur with PTSD.

Among the various exposure factors, we found a growing production of recent literature in which ACT has been applied in the context of oncology life-threatening settings, demonstrating significant improvements in symptoms and quality of life, as well as reductions in emotional disturbances, physical pain and traumatic responses.

However, little is known about implementation and results of ACT in situations of trauma and psychiatric comorbidities. Data suggest that, when applied to individuals with psychosis and history of trauma, there is an improvement in overall severity and anxiety symptoms, emotion regulation strategies and a greater sense of engagement in care; nevertheless, reduction of specific trauma symptoms remains controversial. More mention is made about the growth of literature evaluating the application of ACT as a conjunctial therapeutic method for trauma and simultaneous addictive disorders.

Conclusion

Overall, despite limited published research currently available, some evidence starts to support ACT's promising role as an effective psychotherapeutic approach to trauma and stressor related disorders. Its application in situations where organic diseases represent stress factors has been growing. Future research should focus on clarifying the role of ACT in psychiatric comorbidity scenarios, allowing this psychotherapy to help individuals find a meaningful and valuable life beyond trauma.
Pharmacological interventions for improving cannabis use and psychosis in dual diagnosis: a systematic review
Authors: Bharj Arundeep Singh , Jones Katy , Sami Musa
Published: June 2021

Aims

Many patients with psychosis symptoms and schizophrenia use cannabis as a recreational drug. Patients who use cannabis respond differently to antipsychotic treatment compared to those who do not. Despite this, there is a lack of evidence, and therefore clinical guidance, pertaining to the best pharmacological treatment to improve psychosis or cannabis use in this population. This systematic review was carried out to assess the current evidence base regarding the most effective pharmacological treatment for patients with psychosis who also have a background of using cannabis. Our specific question was: ‘in patients with a dual diagnosis of psychosis and cannabis use, which pharmacological interventions have the most efficacy in improving psychosis or reducing cannabis use?’.

Method

A search of EMBASE, PsychINFO, and MEDLINE(R) databases was carried out on September 30, 2020. Bibliographies of other studies were also searched for relevant articles. After exclusion of any articles which did not meet inclusion criteria for this review, eleven full texts remained; a qualitative analysis was carried out on these, but there was no meta-analysis. Only randomised control trials (RCTs) whose interventions and controls were pharmacological therapies, and which included patients with a background of cannabis use and psychosis, and which measured clinical outcomes, were included.

Result

We found 11 articles which analysed 10 RCT studies (n = 363) investigating risperidone, olanzapine, clozapine, haloperidol, ziprasidone and imipramine. 6/11 were double blind. The studies were small in size, varied in their methodology, exact inclusion criteria, exact outcomes, and all had a high risk of bias. Few significant findings were found. There is limited evidence for clozapine having anti-craving effect however whether this is associated with reduction in use remains to be demonstrated. We found no studies of adjunctive anticonvulsant agents, which are often used in psychotic disorders.

Conclusion

This review underlines the paucity of studies on which to make evidence-based decisions. No new studies have been undertaken since the last systematic review in this area in the last 7 years. Due to the lack of high-quality evidence found by this review, there remains a considerable need for interventional, high-quality RCTs in this comorbid patient group.
Prevalence and associated factors of antenatal depression of women attending antenatal clinics in two tertiary care maternity hospitals in Sri Lanka
Authors: Suraweera Chathurie , Perera Iresha , Amila Isuru L.L. , Galhenage Janith
Published: June 2021

Aims

To determine the prevalence of depression among antenatal mothers in two tertiary care maternity hospitals in Colombo and associated factors of antenatal depression.

Method

A descriptive cross-sectional study was conducted in antenatal clinics in two tertiary care maternity hospitals in Sri Lanka. Every second woman attending the clinic was recruited using systematic sampling until the calculated sample size was obtained. A structured questionnaire and Edinburgh Postnatal Depression Scale (EPDS) were used for data collection. Data were analysed using SPSS.

Result

A total of 536 pregnant women were participated in the study. Around one third (180, 33.6%) of pregnant women had depression according to the EPDS score (Mean = 7.66, SD = 5.17). The mean age was 29.65(SD = 9.30) years and among them 387(74.3%) had at least secondary education. The majority lived with parents or in-laws (329, 61.4%) in addition to nuclear family members and 266(49.6%) were in their third trimester. Most women were in first pregnancy (149, 39.5%) and 11 (2.1%) had a history of psychiatric illness. Sixty (11.2%) women and 156(29.1%) of partners used psychoactive substances. Verbal abuse and physical abuse were reported by 5(0.9%) and 3(0.6%) respectively. Sixty one (11.4%) women have reported inadequate family support, and 226 (42.2%) had only support of the partner. Among them 346 (64.6%) reported excellent support from partner. One third (186, 34.7%) of pregnancies were unplanned, 328(61.2%) women reported a very good relationship with their partner. Complications were experienced by 123(22.9%) of women during this pregnancy and commonest was gestational diabetes. The presence of depression was significantly associated with living with extended family (p = 0.033) and in-laws(p = 0.014). Multi parity (>2 children) (p = 0.008), partner's substance use (p = 0.002), inadequate family support (p = 0.024), inadequate partner's support (p = 0.003), unsatisfactory relationship with partner (p = 0.000) and unplanned pregnancies (p = 0.001) were also associated with depression. Logistic regression analysis indicated a significant association between depression with partner's substance use, unavailability of family support and poor relationship with the partner.

Conclusion

Around one-third of mothers were having antenatal depression. Several spouse related factors and unsatisfactory family support were associated with depression among antenatal mothers.
An analytical cross-sectional study to describe and compare the mental health status of doctors and medical undergraduates in selected institutions in Colombo, Sri Lanka during COVID-19 pandemic
Authors: Suraweera Chathurie , Perera Iresha , Rupasinghe Priyanka , Galhenage Janith
Published: June 2021

Aims

The aim of this study was to describe and compare the mental health status of doctors and medical undergraduates in selected institutions during COVID-19 pandemic.

Method

A cross-sectional analytical study was conducted among doctors working in major tertiary care hospitals two of which, risk is unpredictable and high, the other where all patients are positive for COVID-19 and among medical undergraduates. The doctors were selected using disproportionate stratified sampling and medical undergraduates using stratified cluster sampling. Data were gathered using a Google form containing socio-demographic details, perception on the pandemic and the General Health Questionnaire-12(GHQ-12).

Result

There were 468 participants in the study and among them 243(51.9%) were doctors. Mean age of the doctors’ is 34.54(SD = 7.43) years and more than half (50.06%) were in post graduate training. Majority were worried about their health (65%) and their loved one's health (90.1%). Among doctors 220(90.5%) felt that they have moderate or higher risk of acquiring COVID-19 and 15.6% would not have worked due to the risk. According to GHQ-12, 182(74%) doctors were psychologically distressed (mean GHQ = 12.64, SD = 4.54) and it was significantly associated with age less than 35 years (p = 0.039) and worry about interruption of their daily routines(p = 0.010).

The mean age of 225 medical undergraduates was 25.20 (SD = 1.34) years and 176(78.2%) of the participants were psychologically distressed (mean GHQ = 14.32, SD = 6.67). Majority (59.11%) believed that they are at high risk of getting COVID-19. Their distress was significantly associated with the worry about the impact of COVID-19 related restrictions on their daily routines (p = 0.000).

Binomial logistic regression confirmed that doctors were distressed due to impact on their income whereas both doctors and medical undergraduates were distressed due to impact on daily routines.

Conclusion

Nearly three quarter of both doctors and medical undergraduates were psychologically distressed during COVID-19 pandemic. The worry was due to contracting illness, financial issues and the COVID-19 regulations.
Prevalence and associations of psychoactive substance use among male supportive staff members in a tertiary care hospital of Sri Lanka
Authors: Suraweera Chathurie , Perera Iresha , Rupasinghe Priyanka , Galhenage Janith
Published: June 2021

Aims

The study describes the prevalence and associated socio-demographic variables of psychoactive substance use among male supportive staff members at a tertiary care hospital in Sri Lanka.

Method

A cross-sectional descriptive study was carried out among male supportive staff members of a tertiary care hospital in Colombo District, Sri Lanka by using a self-administered anonymous questionnaire. Participants were recruited using stratified cluster sampling in thirteen overseer divisions of the hospital. Anonymous questionnaires were collected into a sealed box and analysed using Statistical Package for Social Sciences 20.

Result

The mean age of the 404 male staff members who participated in the study was 38.78(SD = 10.90) years and 71.5% were married. Among them 202 (49.1%) were educated up to grade 6-11 and 30 of them has had encounters with law in the past. Thirty of participants had history of psychoactive substance use in the family. Alcohol was used more than once a month by 127(30.9%) and more than once a week by 19(4.6%) individuals. Among other substances, tobacco, beetle and beedi were used by 104(25.3%), 78(19.0%) and 18(4.4%) respectively at least once a month. Further, 22(5.3%), 20(4.8%), 7(1.7%) and 7(1.7%) participants used Mava, Cannabis, Methamphetamine and Thool respectively at least less than once a month. Heroin, Tramadol and Morphine were used by two individuals at least less than once a month. Among substance using participants, 132 wished to cut down their habit. Most commonly identified (14.1%) adverse consequence was financial issues secondary to psychoactive substance use. Eleven (4.5%) staff members used the substance at hospital. Alcohol use was associated with age more than 35 years (p = 0.039) and history of forensic involvement (p = 0.038). Tobacco(p = 0.000), beetle (p = 0.056), Cannabis (p = 0.000) and mava (p = 0.015) use were significantly associated with positive forensic history. Supportive staff members’ alcohol and cannabis use was associated with tobacco (p = 0.000, p = 0.000) and beetle use (p = 0.001, p = 0.049). Mava use was associated with alcohol (p = 0.060) use in addition to tobacco (p = 0.020) and beetle use (p = 0.008).

Binomial logistic regression revealed alcohol use and beetle use were associated with the number of children in family and above associations.

Conclusion

Commonest psychoactive substance consumed by supportive staff members were alcohol, tobacco, beetle, Cannabis and Mava in descending order of frequency. Forensic history was significantly associated with substance use. True prevalence of substance use can be higher than these values.
Interview skills – psychiatry reel to reality
Authors: Tharmapoopathy Mathuri , Kumar Santosh , Thavarajah Abishan
Published: June 2021

Aims

This reel analysis identifies quotes and actions of fictional characters from TV shows, namely: Hercules Poirot, Sherlock Holmes and House who can demonstrate learning points for clinical students to use within real psychiatric practice, using scientific theories such as the Hypothetico-deductive model, Empirical falsification and Occam's razor. This analysis explores what an ideal psychiatric interview consists of and what can be learnt from these characters and implemented within medical education.

Method

Each show was watched by one researcher over the period of March to August 2020. The researcher noted insightful quotes which were relevant to one of the three philosophical theories. Quotes were included if they demonstrated deduction skills, revealed a character's ethos and supported the Calgary-Cambridge model of interviewing such as building rapport. 32 quotations were collected in total and narrowed to 6 quotations. These were then analysed, learning points were made and linked to the Calgary Cambridge model.

Result

Dr House demonstrates objectivity when taking a patient's history. He utilises empirical falsification when diagnosing to avoid missing a differential diagnosis. Detective Poirot displays how empathic listening allows disclosure of details in the history, which would have otherwise been omitted. Additionally, he illustrates the importance of collateral interviewing which allows one to identify misinterpretations and inconsistencies. Sherlock teaches us the importance of perception regarding mismatching information which can help to gather new facts. All three characters interview beginning with open questions to more closed questions, supplementing with deductive reasoning in order to solve cases. Objectivity, empirical falsification, empathetic listening and deductive reasoning are the key skills displayed by these characters, that medical students can most use in their own practices.

Conclusion

The perfect interview discovers new information through synchronised collaboration, whilst adhering to the Hypothetico-deductive model of thought. A combination of the Calgary-Cambridge model of interviewing and skillset of the TV characters should be considered for implementation in some aspects of psychiatric interviewing. Medical education can utilise these TV shows to teach students how to conduct history-taking.
Resolving the discrepancies of suicide risk in obsessive-compulsive patients: a review of incidence rates and risk factors of suicide and suicide attempts in OCD
Authors: Tyagi Himanshu , Bundies Gabriel
Published: June 2021

Aims

Obsessive-Compulsive Disorder (OCD) describes a mental health condition in which affected patients experience persistent obsessions, which may often, but not always result in compulsions, causing major distress and anxiety. Obsessions are defined as intrusive thoughts with a high emotional valence, whereas compulsion are repetitive actions, which demonstrate the attempt to eliminate obsessive thoughts.

When speaking of OCD, risk of suicide is rarely a topic of concern. There is still no consensus about whether OCD and suicide are associated. Early schools of clinical sciences propose a low risk of harm, which was taught to most mental health practitioners currently working in health services. Moreover, the World Health Organisation currently classifies OCD as the 11th leading cause of nonfatal burden, indicating that despite the potential for causing significant disabilities, OCD does not pose any serious health risks. Contemporary evidence, however, suggests that the risk for suicide may be underestimated.

This literature review aims to cumulate evidence for the risk of suicide in OCD and its associated underlying factors to clarify and resolve the discrepancies that currently exist regarding this topic.

Method

To identify eligible studies, the databases MEDLINE(R), PubMed, and PsycINFO are used. Selected studies provide data on suicide rates, attempts, and risk factors. Grey literature is included in the review to consider results from studies which may not have qualified for publishing. This literature review is conducted according to the PRISMA guidelines.

Result

After deduplication, 653 studies could be found out of which 15 studies meet the inclusion criteria. Rates of suicide attempts appear to lie between 12% and 27%. Death-to-suicide rates in OCD are shown to range from 0.7% to 1.4%. Associated risk factors for suicide in OCD include, mistrust and unacceptable thoughts, depression, and comorbid substance use disorders. The strongest predictor for death caused by suicide is having a history of previous suicide attempts. Higher education and comorbid anxiety disorders act as protective factors. Lastly, gender differences remain unclear since some studies classify female sex as a protective, and some as a risk factor.

Conclusion

This review provides a good overview of the actual risk for suicide in OCD. Current evidence suggests high suicidality in patients with OCD, leading to suicide attempts in affected patients, but not necessarily resulting in death, as the death-to-suicide rates are low. Genetic heritage and comorbidities of further mental health disorders may increase the risk for suicide in OCD.
Obsessive compulsive disorder in coroners’ reports
Authors: Tyagi Himanshu , Quigley Lisa
Published: June 2021

Aims

The frequency and burden of suicidality in obsessive-compulsive and related disorders have historically been under-reported, despite research pointing to a significant association between OCD and suicidality. Likewise, OCD is frequently undiagnosed or misdiagnosed. This study looks at coroners’ reports relating to suicides in UK, Australia and Canada in order to:

Explore characteristics of suspected or confirmed cases of OCD in coroners’ reports

Identify instances of possible undiagnosed or misdiagnosed OCD

Identify recurring themes in the reports

Method

1869 publicly available coroners’ reports were accessed from England (n = 200), Scotland (n = 128), Canada (n = 680) and Australia (n = 861). Reports were screened in order to identify individuals who had either a diagnosis of OCD (n = 16), a diagnosis of a related condition (n = 4), or indications of possible undiagnosed OCD (n = 12). Wherever possible, demographic and psychiatric characteristics were extracted for statistical analysis. Qualitative thematic analysis was carried out on selected reports.

Result

32 cases of interest were identified from analysis of coroners’ reports of suicides that took place between the years of 2000 and 2020. Breakdown by country was as follows:

United Kingdom: n = 6 (1.8% of total reports analysed from United Kingdom)

Canada n = 3 (0.4% of total reports analysed from Canada)

Australia n = 23 (2.7% of total reports analysed from Australia)

Among those with possible undiagnosed OCD, common experiences were fear of causing harm, intrusive thoughts of guilt and shame, and compulsive checking and/or reassurance seeking. Further themes included: misdiagnosis, failings in mental health care, stigma and discrimination.

Conclusion

Individuals with OCD are thought to be up to ten times more likely to die by suicide, with this risk increasing in the presence of psychiatric comorbidities. However, OCD remains underdiagnosed, and this may be reflected in the relatively low number of suicides identified for this study where OCD was diagnosed before death. The low numbers may also point to a tendency among both coroners and healthcare professionals to underestimate the association between OCD and suicidality.

Qualitative analysis of the coroners’ reports identified a theme of intolerable distress. This distress was documented most extensively in reports where OCD was strongly indicated but never diagnosed, highlighting the impact of missed, late or incorrect diagnosis.

Notably, nearly all of the reports reveal repeated attempts by the individual to seek help. Despite this, many experienced stigma, mental health service failings and missed opportunities for help in the months preceding their deaths.
Patient experiences of the pandemic; exploring the effect of COVID-19 on patients detained under the Mental Health Act
Authors: Watson Emily , Rowles Samuel
Published: June 2021

Aims

The current pandemic and the restrictions on liberty that it has necessitated has had a huge impact on society as a whole. We were interested to learn how the constraints of sequential lockdowns and social distancing measures had affected inpatients in a mental health setting, many of whom were already contending with significant restrictions on their freedom.

Method

We conducted structured interviews with 24 service users across the Low Secure and Locked Rehabilitation Division at St Andrews Healthcare Northampton. We interviewed male and female inpatients with diverse diagnoses including emotionally unstable personality disorder, anorexia nervosa, schizophrenia and offending behaviours. All participants were detained under the Mental Health Act throughout the pandemic. Service users were asked the following questions:

How has the pandemic affected your mood?

How has it affected your relationship with your family?

How has it affected your treatment?

How has the pandemic affected your leave?

How has it affected how you use your free time?

Are there any other ways the pandemic has affected you?

We performed thematic analysis to identify ways the pandemic has affected service users.

Result

Four major themes were identified:

1)

Mental health

Participants reported a decline in mood.

2)

Changing relationships

Service users reported that relationships with loved ones in the community had suffered from lack of contact and missing significant life events, however several participants felt that their relationships with peers had strengthened.

3) Delivery of care

Responses were split on the increased reliance on technology to replace face-to-face interaction between patients and team members, with some respondents reporting this as 'less intimidating', while others found this ‘isolating’. Respondents reported reduced contact with MDT members and delays to recovery and step-down placements due to decreased leave.

4) Routine

Respondents reported an increase in free time throughout the pandemic. Some used this to develop hobbies whereas others reported becoming ‘lazy’ and expressed disappointment with the lack of exercise provision.

Conclusion

The pandemic has had significant emotional and psychological effects on society as a whole, but perhaps no group has been more affected than detained patients who have had their lives restricted to a massive degree. This group has been largely marginalised by government guidelines which often fail to consider individuals living in large group settings. By learning from the experiences of these service users we can adapt our practices to alleviate these issues in any future lockdowns and ensure our practices are the least restrictive possible.
Polypharmacy and potentially inappropriate medications (PIMs) in older adults referred to a memory clinic
Authors: Akpan Anietie , Blaquiere Bruno De , Nellaya Issadevi , Termure Cornelia , Mukherjee Sujoy
Published: June 2021

Aims

The older adult is more likely to be prescribed a lot of medications (polypharmacy) on account of multi-morbidity and consequently being under the care of several specialists. Adverse drug events and reactions account for significant morbidity and mortality in this population group. Common sequelae include confusional episodes, dementia syndromes, falls, and higher rates of acute hospital admissions.

Medications are not routinely reviewed in elderly care. We sought to estimate the prevalence of polypharmacy, and potentially inappropriate medications (e.g. anticholinergics or medications with central anticholinergic effects) in those referred to the Cognitive Impairment and Dementia Service (Elm Lodge), Older Persons Mental Health, West London NHS Trust.

Method

All referrals between 01/10/2020 and 30/11/2020 were screened for medications prescribed. Polypharmacy was defined as prescription of 5 or more medications. Medications with anticholinergic properties were considered examples of Potentially Inappropriate Medications (PIMs). The Anticholinergic Effect on Cognition (AEC) Tool, ‘Medichec’, was used to identify and rate anticholinergic burden. Anticholinergic load was also compared using the Anticholinergic Burden Scale (ABS).

Result

Total number of patients referred – 193

11 patients excluded due to unavailable/incomplete medication records.

Study number: 182

Polypharmacy:

79.67% (n = 145) were prescribed 5 or more medications.

44.51% (n = 81) prescribed 5–9 medications.

23.08% (n = 42) prescribed 10–14 medications.

8.79% (n = 16) prescribed 15–19 medications.

1.67% (n = 3) prescribed more than 20 medications.

Anticholinergics prescribed (AEC Tool):

37.36% (n = 68) prescribed an anticholinergic.

6.59% (n = 12) prescribed more than 1 anticholinergic.

Anticholinergics (ABS):

29.67% (n = 54) prescribed an anticholinergic.

7.699% (n = 14) prescribed more than 1 anticholinergic.

Conclusion

Polypharmacy and potentially inappropriate prescribing (e.g. anticholinergics) remain widespread within the older adult population. Anticholinergic load was broadly similar with the Anticholinergic Effect on Cognition tool and the Anticholinergic Burden Scale. Increased anticholinergic burden further compounds risks of cognitive impairment, delirium and death.

Other categories of Potentially Inappropriate Medications, including those no longer needed, ought to be identified and reviewed. Over-the-counter medications also need to be screened for.

Elimination or reduction of anticholinergic burden may improve quality of life for patients, as well as cost burden on services.

Pharmacovigilance, collaborative working, and regular training are needed across services providing care for the older adult.
Coping with and management of COVID-19 restrictions within the secure and forensic inpatient setting - a patients' and carers’ perspective
Authors: Ali Syed , Glennon Katie
Published: June 2021

Aims

To seek patients' feedback on their wellbeing and the service adaptations during the COVID-19 pandemic

To obtain carers’ views on service adaptations during the COVID-19 pandemic.

To establish impact on patients' wellbeing and progress in the context of COVID-19

Background

The COVID-19 pandemic resulted in unprecedented challenges faced by healthcare systems worldwide. Public Health England (PHE) provided guidance to manage the spread of the virus. In response to the national lockdown, the Forensic Healthcare Service part of Sussex Partnership NHS Foundation Trust (SPFT) took measures that were considered necessary to prevent the risk of spread to patients and staff.

Restrictions necessary to contain the virus included immediate suspension of all patients leave except emergency leave, suspension of visits by family members and professionals including legal visits and restrictions on multidisciplinary (MDT) members physically present on the wards. It was necessary to adapt our existing model of care to reflect and represent the challenges faced by such restrictions.

A service evaluation project was undertaken to ascertain the patients' and carers’ perspectives of the management of restrictions.

Method

Standards

It is noteworthy that no service standards in the context of this unique global pandemic were available internationally, nationally or regionally at the time of undertaking the project.

Methodology / Data collection

An anonymous patient feedback questionnaire was developed to collect data on voluntary basis from all the inpatients within the secure and forensic CDS. Patients' feedback was broadly divided in to three sections 1) personal factors, 2) satisfaction with access to information and 3) satisfaction with services to include mental and physical well-being.

Patients' feedback was collected during a 6-week period. For observation purposes, risk comparison anonymous data were also collected. Informal Carers' feedback was collected with regard to virtual visits.

Result

During the data collection period 99 out of 105 beds were occupied. The response rate was 49% (49 responders).

Overall 73% of responders expressed that their mental health was affected. Approximately 51% of responders expressed that progress towards their discharge was very much affected. 91% of responders were not coping well with the new circumstances

Overall, carers' feedback was positive in regard to provision of virtual visits.

Conclusion

Our survey has shown that the necessary COVID-19 pandemic restrictions have in some domains resulted in a negative impact on patients’ mental wellbeing and progression. However, it also identifies positive areas of new practice, which have been maintained by the service.
A new service model in East Lothian community learning disability team: evaluation of service with and without specialist positive behaviour support team
Authors: Asif Saima , McKechanie Andrew
Published: June 2021

Aims

To evaluate the provision of services to patients with challenging behaviour in East Lothian Community Learning Disability population with and without specialist behaviour support team.

Background

Behaviour that proves to be a challenge to manage (Challenging behaviour) is not uncommon in adults with intellectual disability and has a reported prevalence of 10–15%.1,2

Positive behaviour support (PBS) is recommended as evidence-based intervention for adults with intellectual disability who have challenging behaviour. East Lothian community learning disability team (CLDT) underwent a change in service model for people with challenging behaviour. This change followed a Health and Social care partnership agreement that behaviour support and management could be provided by multidisciplinary CLDT rather than region-wide specialist team.

Method

Data collection was split into two cycles. First cycle looked retrospectively at six months prior to exit of Specialist Positive Behaviour Support Team (SPBST). Second cycle looked prospectively at 6 months after exit of SPBST.

In first cycle, data were collected doing retrospective review of cases known and referred to SPBST. This included calculating time spent on each individual case by SPBST and by CLDT. SPBST provided information in the form of hours spent on each individual case for patients identified by them. For CLDT, electronic medical records system (TRAK) was used by looking at appointment entries on TRAK. For second cycle, newly developed Complex Behaviour pathway was used to identify the patients. Data were collected by using TRAK system as in the first cycle for CLDT.

Data collected in both cycles was compared at the end of second cycle.

Result

In first cycle, 5 patients were managed jointly by SPBST and CLDT in 96.4 hours over six months and average clinical time spent on each patient was 19 hours. SPBST spent a total of 59 hours and CLDT spent 40 clinical hours. In second cycle, 12 patients were managed by CLDT alone in 130 hours over six months and average clinical time spent on each patient was nearly 11 hours.

Conclusion

Results of this evaluation suggest that SPBST had been providing significant contribution to East Lothian CLDT not only with their expertise but also with clinical time. More than 50 % of total clinical time spent on the patients with challenging behaviour in first cycle, was provided by SPBST. This is also evidenced in second cycle where there is an increase in clinical time of some professions when SPBST was withdrawn.
Pharmacological treatment of post-traumatic stress disorder- an audit of Cardiff Health access practice using a pharmacological prescribing algorithm
Authors: Baker Amy , Bisson Jonathan
Published: June 2021

Background

Post-Traumatic Stress Disorder (PTSD) is a mental health disorder characterised by symptoms of re-experiencing, avoidance and hyperarousal that may develop after exposure to a traumatising event. The prevalence of PTSD within the refugee population is ten times higher than in the general population. This audit was carried out in Cardiff Health Access Practice (CHAP) which is the main provider of primary health care for refugees and asylum seekers who are sent to Cardiff. The main objective of this audit was to evaluate current PTSD prescribing practice for patients presenting to Cardiff Health Access Practice (CHAP) against a pharmacological prescribing algorithm which has been developed for the Cardiff and Vale Traumatic Stress Service based on NICE and International Society for Traumatic Stress Studies guidelines

Method

A retrospective audit of patients with PTSD seen in the last 12 months at CHAP. Data were collected from patient notes and information on age, sex, trauma, comorbidities and medication dose was collated and analysed using SPSS statistics.

Result

130 patients with PTSD were identified and their medications assessed for the audit. The mean age of these patients was 33 years and there was a 1.5:1 male to female ratio. Of the 130 patients only 10 were initiated on a first line medication, 117 were started on a fourth line medication. No patients were prescribed either the second- or third-line medications.

Conclusion

The low rates of compliance with the All Wales Pharmacological PTSD pharmacological prescribing algorithm are disappointing although not unexpected as it has yet to be fully introduced to the service. Following discussion of the results and teaching about the algorithm with clinicians in Cardiff Health Access Practice rates of evidence-based prescribing should improve. This audit focuses on a patient group (refugee and asylum seekers) which has been identified as a priority group by the Welsh Government. Through further implementation of this algorithm there should be improved evidence-based prescribing and continuity of care for refugees
Implementing a physical healthcare clinic in a CAMHS neurodevelopmental population
Authors: Bruce Helen , Mansoor Sharika , Evans Sacha
Published: June 2021

Aims

To establish a physical health clinic in a community CAMHS to monitor patients in the NDT who are on stimulant/antipsychotic medication

To re-audit to assess adherence to physical health monitoring in accordance with guidelines

Background

Studies have indicated that people with severe mental illness have higher rates of mortality and are prone to development of physical health problems compared to the general population. Monitoring physical health is therefore important as it allows early detection and intervention where appropriate.

Method

17 out of 120 patients in the NDT were identified as taking either an antipsychotic (8 patients) or stimulant medication (9 patients). Physical health data required were determined by local policy and the Maudsley guidelines.

Parents were invited to attend the clinic with their child through telephone calls. Height, weight, blood pressure and pulse were measured in the appointment. A blood test form was provided for parents to take to local outpatient phlebotomy services. A GP letter was sent with the results of the physical health check with a request to conduct an ECG and notify us of any abnormal results. Feedback forms were collected from parents to share their experience of attending the physical health clinic.

Five patients were identified as having difficulty attending the CAMHS clinic due to refusal/challenging behaviour. For three patients, school visits were organised to conduct a physical health check.

Result

The results from the second round of the audit indicate an overall improvement in the adherence to monitoring guidelines for antipsychotic and stimulant medication. This was particularly evident for the patients on antipsychotic medication. Feedback collected from parents regarding the service provided was also positive.

Conclusion

The physical health clinic identified challenges preventing 100% compliance in all patients. This included difficulties with parents bringing their child to CAMHS due to challenging behaviour. In a few of the patients, it was possible to solve this issue by conducting a school visit.

It was also observed that there were multiple instances where challenging behaviour lead to inability to conduct certain tests including blood pressure, blood tests and ECG. Additional strategies should be considered to improve compliance.

A notable issue that also arose from the development of the physical health clinic was that it was unclear how to obtain an ECG at CAMHS.

Continuation of the clinic as well as extension to include patients within other teams at Tower Hamlets CAMHs would be recommended.
Listen to hard topics with soft ears - domestic violence and family carer; a survey of referrals to a MHIDD forensic mental health service in Ireland
Authors: Elamin Mohamed Elhassan , Kearns Anthony , Cooney Aidan
Published: June 2021

Aims

A number of studies sought to explore and define families needs, experiences and concerns associated with being a carer for a detained person and their interaction with Forensic services (McKeown et al, 1995, MacInnes et al, 2002, Tsang et al, 2002, Absalom et al, 2012 Horberg et al, 2015).

Relatives can be victims of the service user's offence (Ferriter & Huband, 2003, Tsang et al 2002), and may even blame the service user for their behaviour (Barrowclough et al., 2005). Service user becomes violent and aggressive family members are less likely to be motivated to participate, due to the service user's behaviour (MacInnes, 2000).

An initial domestic violence survey of in-patient case files found that in 66%of the patients files, there were reported incidents of domestic violence in family caring relationships prior to the index offence and subsequent admission to NFMHS (Cooney, 2018).

Method

A quantitative methodology was used. A domestic violence survey of referrals was conducted of 100 referrals to the National Forensic Mental Health Services – Mental Health and Intellectual & Development Disability Services between 2016-2019.

Result

22% of the referrals reported Domestic Violence in the family care-giving relationships.

The father was recorded as the parent to be experience most Domestic Violence; 40%. Other family members who experienced domestic violence ranged from the mother 32%, brother 12% and sister 8%. Other family members were 8%.

100% of the referrals did not report the domestic violence in the carer relationships, nor did referring agencies recorded safeguarding adults concerns.

Conclusion

The findings from this audit raises a couple of clinical, legal and safeguarding adults work in National Forensic Mental Health Services with regards to family work. Firstly, the need to (re)conceptualising family work in the context of trauma informed care. Secondly, family work should offer some families, who are victim of crime, a restorative approach. Thirdly, safeguarding adults will need to consider complex caring relationships and acknowledged this as part of care planning and support.
An audit into the physical health monitoring of patients who are prescribed antipsychotics in HMP Birmingham
Authors: Horton Olivia , Moholkar Rajesh
Published: June 2021

Aims

To assess the compliance of physical health monitoring with NICE and Maudsley prescribing guidelines for those patients prescribed antipsychotics in HMP Birmingham. To assess secondary objectives including who prescribed the antipsychotics (GP vs psychiatrist), the indication and diagnosis they are prescribed for (licensed or otherwise) and which antipsychotics were usually prescribed.

Background

Patients with psychosis or schizophrenia have a reduced life expectancy of 15-20 years when compared to the general population. The physical health effects of the medication prescribed for these conditions play a large role in this. Physical health monitoring and appropriate intervention is vital to reduce the discrepancy in life expectancy and improve the quality of life of these patients.

Method

Notes of 105 patients in total at HMP Birmingham were reviewed to assess whether the primary outcomes of weight, waist circumference, physical observations, blood tests, medical systems review and education/lifestyle advice were done at the correct times. Secondary objectives of which antipsychotics were prescribed, the profession of the prescriber and the indication for the medications (or diagnosis) were also audited.

Result

Antipsychotics were initiated by both GP's and psychiatrists. Appropriately, there were no prescriptions for clozapine. Olanzapine and quetiapine were the most common antipsychotics prescribed. Not all medications were prescribed for licensed indications and some lacked documentation of both a mental health diagnosis and indications in terms of symptoms. Average BMI of patients was overweight, with BMI ranging as high as 45. The pre-prescription, 12 weekly and annual physical health checks had poor compliance. Those that were completed in line with NICE and Maudsley guidelines were done so by coincidence at the time of diabetic reviews.

Conclusion

The physical health monitoring of patients on antipsychotics in HMP Birmingham is not currently compliant with clinical guidelines. There needs to be improved systems in place for the monitoring of physical health both before prescriptions are initiated and after at the NICE recommended intervals. Amongst other actions, improved computer reminders and training of existing and new team members will be done. The monitoring requirements will be re-audited in 6 months following immediate implementation of the recommendations outlined below.
An evaluation of the incorporation of psychological interventions into the care of patients with a diagnosis of emotionally unstable personality disorder following admission to the general adult inpatient setting
Authors: Hyland Declan , Daniels Charlie , Ionescu Iulian , Goodier Katie , Graham Simon
Published: June 2021

Aims

To assess incorporation of and access to psychological therapies for patients with a diagnosis of emotionally unstable personality (EUPD) who were discharged from the inpatient wards at Clock View Hospital, an inpatient unit in Mersey Care NHS Foundation Trust.

Method

A retrospective analysis of the electronic record of 50 patients discharged from Clock View Hospital between 1st of January 2020 and 1st of November 2020 was performed to assess whether patients were engaged with psychotherapy and whether they had an extended care plan in place.

25 patients with EUPD and no associated psychiatric comorbidities were included in the sample, as well as 25 patients with EUPD and associated psychiatric comorbidities.

Result

Those EUPD patients with no psychiatric comorbidities were more likely to be under the care of the Liverpool Personality Disorder (PD) Hub compared to those with psychiatric comorbidities (12 vs seven patients). Of the 19 patients under the PD Hub, 11 had a Case Manager, four were engaged with the PD Hub's day services / safe service and one with a PD Hub readiness group. Six of the 50 patients had a documented refusal to engage with the PD Hub.

Only 27 of the patients had either received psychological intervention, were on a waiting list, or had a referral in place. 16% of patients refused a psychotherapy referral. Of the 20 patients who received psychological treatment, eight completed a form of psychotherapy (cognitive analytic therapy, dialectical behaviour therapy, cognitive behavioural therapy, eye movement desensitisation and reprocessing) and 12 psychological intervention (either structured case management, psychoeducation or emotional coping skills).

Only 28 of 50 patients had an extended care plan and 28 had a collaborative risk management plan in place.

Conclusion

There was no obvious correlation between previous completion of psychological therapy and degree of polypharmacy. Median admission time was reduced for patients under the PD Hub (six vs 14 days). This was also reduced for patients who accessed psychotherapy or psychotherapeutic interventions (nine vs 10 days).

This audit coincided with the COVID-19 pandemic and subsequent reduced access to the PD Hub and psychotherapy service. There is a need to consider barriers to EUPD patients receiving psychotherapy.

EUPD patients may have numerous hospital admissions and frequently present in crisis. Given the iatrogenic harm from prolonged hospital admission, there is a need to consider incorporating a collaborative extended care plan and risk management plan as part of discharge planning, following admission to hospital.
Audit report of physical health examination and baseline investigations on high dependency unit (HDU) and acute ward, Nepean Mental Health Centre, Sydney, Australia
Authors: Jawad Adil , Mikes-Liu Kristof , Mah Christopher , Elmakki Amgad , Fatima Riffat
Published: June 2021

Aims

All patients on High Dependency Unit (HDU) and Acute Ward, Mental Health Centre, Nepean Hospital, were included in a cross-sectional audit on 22nd January 2020. Out of a total of 43 patients admitted on both these wards, 88.4% had baseline blood tests done, but almost half did not have baseline ECG done and 1/3rd did not have a physical examination done. The physical examination on admission on these wards is better than in 2017 & 2018 when half and more than 1/3rd respectively did not have physical examination done.