bluuebunny/crossref_metadata_2025 huggingface dataset:
An audit to review the extent to which appropriate preconception advice is given to women being discharged from mental health wards on psychotropic medication, in line with NICE guidelines
Authors: Muskett Helen , Bradley Kirsty , Stott Lauren , Moreton William , Jones Sarah
Published: June 2021

Aims

The release of the Cumberlege Report in 2020 served as a reminder of the importance of informed consent for women when they are started on treatment that may affect their fertility or future pregnancies.

Our aim was to evaluate current performance with regards to advice given to women of childbearing age around contraception, impacts of psychotropic medication on fertility and future pregnancies, and availability of preconception counselling.

Method

Standard identified as NICE Guideline 192 (Antenatal and Postnatal Mental Health), sections 1.2 and 1.4.

60 female inpatients were selected by looking at the most recent discharges prior to 03/11/2020 from 3 local acute adult wards. All females aged between 18 and 48 years were included.

Electronic notes were reviewed for each patient. The discharge summary and last four ward round entries were reviewed, then key-word search of the patients’ records was performed using the terms “pregnan*”, “conception”, “contraception”, and “fertility”.

The following information for each patient was documented in a spreadsheet:

Discharge medication

Is there any discussion or advice around contraception?

Have women taking antipsychotic medication been given advice regarding the possible impact on fertility?

Has the potential impact of psychotropic medication on a future pregnancy been discussed?

Has advice been given about the availability of preconception counselling should they plan a pregnancy in future?

Result

On discharge, a total of 33 women were taking one or more antipsychotics and 14 were prescribed a benzodiazepine. 24 women were discharged with antidepressants and 10 women were using a mood stabilising agent. 8 women were discharged without any psychotropic medication.

Overall, 4 women received advice about contraception, and a further 8 women were already using contraception. The impact of taking an antipsychotic on fertility was not discussed with any patient. No women were advised about pre-conception counselling. The impact of taking psychotropic medication on a future pregnancy was discussed with one woman.

Conclusion

Current practice falls well below the standard set by NICE. Opportunities to inform women are being missed, and this has implications for the wellbeing of the patient and, potentially, future children.

Action plan;

Present findings at teaching.

Deliver local teaching covering preconception counselling and the role of adult mental health teams when managing women of childbearing age.

Produce a poster for inpatients wards and an information leaflet for women of childbearing age to aid with discussions.

Create a poster for doctors’ offices to remind about NICE standards and documentation.

Re-audit in 6 months.
GASS-tly side effects: antipsychotic monitoring for inpatients across NHS Lanarkshire
Authors: Paton Cristina , Hammond Siggi , Hills James , Jones Leah , Wong Eugene
Published: June 2021

Aims

Best practice in the prescribing of antipsychotic therapy includes monitoring for medication side effects. National guideline SIGN 131 advises the use of a validated side effect scale, for example the Glasgow Antipsychotic Side-effect Scale (GASS). Local recommendation in NHS Lanarkshire advises that patients prescribed antipsychotic therapy should be offered GASS at each contact and after initiation or titration. We aimed to improve compliance with antipsychotic side effect monitoring for inpatients in general adult psychiatry across two hospital sites in NHS Lanarkshire.

Method

We conducted a full-cycle audit. In October 2020, we took a cross-sectional sample of inpatients in general adult psychiatry in University Hospital Hairmyres and University Hospital Wishaw who were prescribed antipsychotic therapy for a functional psychotic disorder. For these inpatients, if applicable, we identified whether GASS had been completed on admission (OA), whether GASS had been completed after initiation or titration of antipsychotic therapy (I/T), and whether GASS had been acknowledged and discussed at consultant-led multi-disciplinary team meeting (MDT). Thereafter, we implemented several targeted interventions in order to improve compliance. In January 2021, we completed the cycle by taking a new cross-sectional sample of inpatients fulfilling identical parameters.

Result

First cycle in October 2020 (n = 27) showed compliance OA of 4.2%, I/T of 9.5%, and MDT of 3.7%. Our interventions included a presentation at trust-wide clinical governance meeting; a presentation at one of the weekly departmental teaching sessions in psychiatry; an email summarising the audit to consultants in general adult psychiatry; meetings with senior charge nurses for each ward; and inclusion of GASS as part of routine admission paperwork. Re-audit in January 2021 (n = 23) showed compliance OA of 11.1%, I/T of 40.0%, and MDT of 21.7%.

Conclusion

Our full-cycle audit led to modest improvement in documented monitoring for antipsychotic side effects. There was relatively greater improvement in prescriber-led outcomes I/T and MDT, suggesting increased prescriber awareness. However, rather than reliance on individual prescribers to ensure compliance, consideration of GASS alongside monitoring of other physical health parameters would likely result in greater and more sustained improvement. In NHS Lanarkshire there is ongoing work to this end, ultimately with the intention to set up a defined antipsychotic physical health monitoring schedule, integrated across inpatient and community care.
Investigation and management of vitamin D insufficiency and deficiency in acute adult psychiatric admissions: a clinical audit
Authors: Sood Rhiya , Hughes Richard , Romeu Daniel , Mahmood Tariq , Cardno Alastair
Published: June 2021

Aims

Growing evidence suggests vitamin D as a contributing factor in psychiatric illness, particularly depression. Leeds and York Partnership NHS Foundation Trust (LYPFT) has a policy recommending that vitamin D levels are checked in all inpatients. The principal aims of this audit were to establish whether vitamin D levels were checked in inpatients and whether oral supplementation was commenced where appropriate, with a pre-determined target of 90% for both. The secondary aims were to assess whether rates of checking and replacing vitamin D, and mean vitamin D levels, differed between Caucasian and non-Caucasian populations.

Method

We investigated adults aged 18–65 years newly admitted to the Becklin Centre, an acute psychiatric inpatient unit of four wards, between 1st December 2019 and 29th February 2020. 140 patients met eligibility criteria and were included in this study, of which 86 (61.4%) were Caucasian. Data were collected between 25th and 28th February 2021 by retrospectively reviewing two electronic patient record systems, Care Director and PPM, and the electronic prescribing platform EPMA. Results were compiled on a pre-determined data collection tool and analysed using Microsoft Excel. We defined insufficiency as serum 25-hydroxyvitamin D levels below 75nmol/l and deficiency as below 30nmol/l.

Result

Vitamin D levels were checked in 79 (56.4%) inpatients, and the proportion checked differed significantly according to ethnicity (Caucasian = 64.0%, non-Caucasian = 44.4%; χ2 = 4.59, p = 0.032). Of these, 1 (1.3%) had an insufficient sample, 5 (6.3%) had normal levels, 41 (51.9%) had insufficient levels and 32 (40.5%) were deficient. Colecalciferol was commenced for 61 (83.6%) of those with insufficient or deficient vitamin D levels. Rates of colecalciferol prescribing did not differ between ethnic groups (Caucasian = 82.0%, non-Caucasian = 85.0%; χ2 = 0.091, p = 0.76). Mean vitamin D levels did not significantly differ (p = 0.77) between Caucasians (38.3nmol/l) and non-Caucasians (36.2nmol/l).

Conclusion

LYPFT did not meet the target for testing for and treating vitamin D insufficiency and deficiency in psychiatric inpatients. Other blood results were often available when vitamin D levels were not, suggesting a lack of awareness of the guidance. Ethnicity influenced rates of vitamin D analysis but not replacement or mean serum levels. We aim to present our findings to the Trust's medical workforce to raise awareness of the relevant guidance. Given the paucity of psychiatric inpatients with normal vitamin D levels, further research into the role of vitamin D in psychopathology is warranted.
Audit on the documentation of ethnicity within CAMHS
Authors: Scott Charlotte , Lakin Roger
Published: June 2021

Aims

Evidence suggests children from minority ethnic groups have lower rates of referrals from primary care to CAMHS, are more likely to be referred via involuntary or compulsory routes and less likely to have access to therapies than children from white backgrounds. In order to understand how ethnicity influences individuals and ensure service innovation meet these needs data collected have to be accurate. The Mental Health Services Data Set outlines all children and families receiving NHS care should have ethnicity included as a mandatory data submission and services are performance managed on this.

The aim of this audit to review the documentation of ethnicity for service users in CAMHS. We agreed that 100% of patients within York and North Yorkshire (Y&NY) CAMHS should have their ethnicity documented.

Method

Integrated Information Centre (IIC) was used to collect data on the documentation of ethnicity for patients under Y&NY CAMHS on 27th August 2020.

Result

The total caseload was 4109 patients.

823 (20%) had their ethnicity documented as ‘unknown’ (the clinician had entered ‘unknown’ or the patient has ‘declined to disclose’).

49 (1.2%) patients had no entry regarding ethnicity (missing).

Conclusion

We recommend further exploration to consider why 1 in 5 patients have ‘unknown ethnicity’ documented. We recommend: conducting a refined search considering the percentage of ‘declined to disclose’ and ‘not stated’ within the ‘unknown ethnicity’ section emailing care coordinators for patients with ‘unknown ethnicity’ or ‘missing ethnicity’ conducting a questionnaire to gather the opinions and experiences of clinicians, patients and families when talking about ethnicity

reviewing the process for documenting ethnicity to improve accuracy developing staff training, to promote a culture of confidence and curiosity when discussing ethnicity Following this intervention we will aim to re-audit and consider if this has improved the rates of documentation of ethnicity.
High dose antipsychotic therapy (HDAT) prescibing practice within the south trafford community mental health team
Authors: Sparasci Oli , Rojo Luis
Published: June 2021

Aims

High Dose Antipsychotic Therapy (HDAT) is defined by the Royal College of Psychiatrists as either: “A total daily dose of a single antipsychotic which exceeds the upper limit stated in the BNF” or “A total daily dose of two or more antipsychotics which exceeds the BNF maximum as calculated by percentage.”

The use of HDAT is associated with significant risks to physical health and as such requires regular monitoring of various physiological parameters such as ECG, bloods and an assessment of cardiometabolic risk.

Following previous audits of HDAT prescribing practice in the inpatient setting within Greater Manchester Mental Health (GMMH) NHS FT, an audit of HDAT prescription in a general adult CMHT was conducted in Summer 2020, with the following aims:

To identify patients in the South Trafford CMHT who are prescribed HDAT.

To assess the prescription of HDAT against local guidance on the use of unlicensed medications.

To highlight good practice and areas for improvement in the prescription of HDAT.

Method

All patients under the South Trafford CMHT in Summer 2020 were identified. Current prescriptions for antipsychotic medication were ascertained through review of electronic patient records. Those noted to be on HDAT were assessed against audit criteria derived from the GMMH Unlicensed Medicines Policy, previous audits of HDAT use and the RCPsych consensus report on HDAT prescription.

Result

11 of 252 patients (4%) were identified as being on HDAT, of which eight were due to polypharmacy and three to high dose of a single antipsychotic. For 1/11 patients target symptoms and a risk/benefit rationale were documented. The mean length of time on HDAT was 6 years. 7/11 patients had either tried or considered clozapine in the past. 8/11 patients had not had an ECG within the last year, 4/11 had not had yearly U&E. 8/11 had regular mental health reviews.

Conclusion

Compliance with the audit standards was found to be highly variable. This may reflect many factors, including the length of time since commencing HDAT and the complex shared care arrangements currently in place in Trafford. Thus, the following recommendations have been made:

To start a register of all patients prescribed HDAT.

To review local guidelines and documentation to ensure they are up to date and can be effectively implemented in routine clinical practice.

To ensure that the responsibility for conducting yearly physical health checks for patients prescribed HDAT is communicated to the relevant parties.
Improving risk assessments for CAMHS admissions at Great Ormond Street Hospital
Authors: Stock Lisanne , Evans Sacha
Published: June 2021

Aims

During the COVID-19 pandemic, admissions to the Mildred Creek Unit (MCU), an Inpatient CAMHS Ward at Great Ormond Street Hospital (GOSH) changed.

The MCU is a 7–10 bed unit for children aged 7–15 years based on therapeutic milieu principles. The ward accepts patients via a planned national referral pathway, however, during the COVID-19 pandemic, patients were admitted as emergencies and consequently risk assessments were missed. Risk assessment is important in all admissions and as the MCU is not a locked unit, early risk assessment is particularly important.

We aimed to review whether risk assessment occurred within one working day of admission, as suggested by the ward risk assessment policy, and if this was not the case, our aim was to ensure that all risk assessments took place within this period via our audit interventions.

Method

We collated data looking at the time between admission to GOSH and the date at which first risk assessments took place. We then put in place three interventions.

1)

Posters prompting doctors who were providing on-call liaison input to perform a risk assessment within one working day of admission.

2)

New junior doctors were provided with written and verbal information to emphasise the importance of early risk assessment.

3)

Guidelines also highlight that assessment of risk may need to be on-going. We therefore added a prompt section in the weekly ward round proforma with the aim of reducing the interval between risk assessments during admission.

The first audit cycle was conducted on the 3/8/2020 and the second on the 28/11/21 to allow for a comparative number of inpatients between the first and second audit cycle.

Result

We found these interventions significantly reduced delays in risk assessments. Prior to the audit's first cycle the average delay between admission to GOSH/MCU and a risk assessment was 2 weeks. After the interventions there were no patients whose risk assessment was delayed outside the next working day parameters.

Conclusion

This full cycle audit demonstrates the impact that prompts to clinical practice can make on patient care. It is important to recognise the need for flexible risk assessment with regular review, especially at times of clinical change. We hope that this continued trend for early risk assessment leads to improved clinical care and timely discussion of risk for all new CAMHS inpatients at GOSH.
Service evaluation of weight gain in patients prescribed antipsychotics within the early intervention service
Authors: Ward Louisa , Marriott Charlotte , Tong Godwin
Published: June 2021

Aims

To assess physical health in patients under the Early Intervention Service, whom are prescribed antipsychotics.

To consider whether further intervention needs to be provided or promoted to improve physical health in this group.

Method

Assessment of carenotes database for all 63 patients on EIS caseload prescribed antipsychotics.

Result

Out of 47 patients studied, 20 were non-smokers at baseline. 25% of them ended up becoming smokers by the end of the study time.

Out of 47 patients studied 28 were non-drinkers at baseline. 32% of them ended up engaging in alcohol by the end of the study time.

Out of 47 patients studied, 38 patients had data available to record weight changes per year. Out of the 38 patients, 27 of them had positive weight change; average weight change was + 6.38 kg per year. The highest weight gain was 38.4 kg, the highest weight lost was 47.3 kg.

Out of 47 patients studied, 35 patients had data available to record BMI changes. Out of the 35 patients, 27 of them had positive BMI increases, average BMI change was + 2.68. The highest BMI increase was 12.84. The highest BMI decrease was 8.24.

Out of 47 patients studied, 11 patients had data available to record random glucose level changes. Out of the 11 patients, 7 of them had increased glucose levels, average glucose change were + 0.5mmol/l. The highest increase in glucose was 3.9mmol/l and the highest drop in glucose was 2.6mmol/l.

Out of 47 patients studied, 19 patients had data available to record HbA1c levels. Out of the 19 patients, 10 of them had increased HbA1c levels, with the average change being + 0.31 mmol/mol. The highest increase in HbA1c levels was 5 mmol/mol and the highest drop in HbA1c levels was 3 mmol/mol.

Out of 47 patients studied, 30 patients had data available to record cholesterol changes. Out of the 30 patients, 21 of them had increased cholesterol levels, with the average change being + 0.09mmol/l. The highest increase in cholesterol was 1.7mmol/l and the highest drop in cholesterol levels was 2.6.

Taken together, we show that anti-psychotic use has a negative effect on physical health parameters such as weight gain, BMI increase, HbA1c levels and cholesterol levels. This increases the patient's risk of developing diabetes/metabolic syndrome in the future.

Conclusion

Re-audit.
An audit of waiting times in the outpatient clinic in Inverness Sector A NHS Highland during the COVID-19 pandemic
Authors: Zinchenko Oksana , Hyland Jennifer
Published: June 2021

Aims

This audit was to assess and improve the organizational efficiency of referrals to Inverness Sector A Outpatient Service. The referrals were audited to measure the average waiting time from referral to first offered outpatient appointment and to assess the proportion of patients waiting longer than 12 weeks.

Method

The audit included routine referrals to the CMHT Inverness Sector A, NHS Highland from GP practices: Kingsmills, Burnfield, Riverside, Fairfield, Foyers and Drumnadrochit Medical Practices. The number of referrals and the number and proportion of clients given appointments for assessments were calculated. Referrals were received directly from primary care and the Mental Health Liaison Team or following Out of Hours contacts at the Mental Health Assessment Team.

Data were collected retrospectively: referrals from 1 Jan 2020–31 Aug 2020. Sample size came to 160 patients aged 16–65 years. Data were collected via review of recorded documentation on the NHSH electronic patient record systems (SCIstore), from 5th–25th January 2021.

Result

160 patients (male 82, female 78) were referred from 1 Jan to 1 Sept 2020. Of these, 140 (87.5%) were given an appointment for an assessment. The mean waiting time was 12 weeks for 103 patients (64%), with 57 patients (36%) waiting longer than 13 weeks. The bimodal distribution of waiting times prompted an analysis of those with longer waiting times. In some instances, appointments were delayed because patients either did not attend (DNA) or cancelled their appointments. Reasons for delays included: postponement until further information was available; cancellation of meetings or patients DNA. In 20 cases (12.5%), the referrals deemed inadequate, prompting further liaison with the referrer for clarification about the nature of the problem and previous psychological interventions.

Conclusion

The number of transactions (any amendment to a patient record) was higher than the number of patients affected, as several transactions can relate to one patients’ record.

Most referrals are vetted in advance via the daily Inverness triage huddle. Ways of improving the quality of information provided by referrers would be explored.

On receipt of each referral, the date of the 12 week deadline would be calculated and highlighted in a database.

The cross-sector (Highland wide) standardisation will add clarity about medical capacity, that does not involve use of excessive clinician time.
Facilitated early discharge in Wandsworth
Authors: Firdosi Mudasir , Hubbeling Allerdiena , Kapoor Twaisha
Published: June 2021

Objective

There is limited research surrounding facilitated early discharge (FD) and Home Treatment Teams (HTTs). This study aimed to compare patients who received FD with patients who were discharged without FD to identify whether there were significant differences in terms of social demographics, illness characteristics, health outcome and treatment duration. Using this data we furthermore aimed to provide proposals to help advance the effectiveness of FD, as well as suggesting concepts of where future research should lie.

Case report

A randomised sample of patients who received FD and patients who were discharged without FD was obtained from a South London Hospital. This was manually narrowed down to patients specifically treated by the Wandsworth Home Treatment Team (WHTT). Socio-demographic and clinical data were then attained from the patients’ electronic records to compare and statistically analyse between the two groups.

Discussion

Patients who received FD from the WHTT were found to have significantly less previous psychiatric admissions compared to those who were discharged without FD (p = 0.032). All other variables were found to have no association with FD.

Conclusion

Having a high number of previous psychiatric admissions seems to be an aspect that decreases the chance of being allocated FD. This variable can be seen as an indicator of severity of illness and a challenging social environment; it could therefore be valuable to take this variable into consideration when allocating FD. Furthermore, total treatment duration was found to not be significantly different for FD and non-FD patients, thus supporting the use of CRHTTs as an equivalent alternative for inpatient admission, however, national scale research should be conducted to strengthen and expand on these findings.
Prolong psychosis preceding cognitive and motor symptoms; an unusual presentation in Huntington's disease
Authors: Khan Nida , Mansoor Marium
Published: June 2021

Objective

To describe an unusual clinical presentation of Huntington's disease.

Case report

A 39-years-old married female, a homemaker, presented to the psychiatry clinic with her husband, with over a nine-year history of decreased sleep, suspiciousness, self-talking, agitation, anger outbursts, aggression, and social isolation. The patient was diagnosed with schizophrenia. Previously, she received various antipsychotics and Electroconvulsive therapy (ECT). The patient showed a partial response to treatment. Over the last 2-3 years, the patient had a progressive decline and later required supervision in her Activities of Daily Living (ADLs). She developed slurred speech limited to 1-2 worded answers, gait disturbance, falls, involuntary movements of the trunk and distal extremities, bowel and bladder incontinence, and severe weight loss. The patient's mother and older brother had a history of death in their early 40s due to an unknown cause.

At presentation, the patient was restless, irritable, self-talking incoherently, neither made nor maintained eye contact and tried hitting and biting upon approaching closely. She did not respond to any queries or followed commands. The patient showed poor personal hygiene. On examination, the patient was hemodynamically stable, had a loss of muscle bulk, broad-based gait, and choreiform movements of the trunk and distal extremities. We admitted the patient to the psychiatry ward and also consulted the neurology team. Her blood investigations showed ASMA antibodies positive, MRI brain was suggestive of Huntington's disease (HD), and her genetic test for Huntington gene confirmed the diagnosis of HD. We started the patient on Fluoxetine, Clonazepam, and Olanzapine. The patient showed a decrease in agitation, and her self-talking stopped.

Discussion

HD is a rare genetic disease that has well-characterized symptoms. However, as seen in our patient, these symptoms can evolve and progress unusually in the early and middle stages. Psychosis in HD patients is rare but known. Psychosis is rare in HD and usually presents after a clear clinical picture of HD is apparent. Our case discussed psychotic symptoms in the pre-choreic stage of HD which adds to the existing evidence on challenging presentations and management of HD. Further research can help increase confidence in these outcomes and treatment guidelines.

Conclusion

Our case highlights an unusual clinical presentation of HD, which can be challenging and lead to diagnostic delays. We recommend a thorough approach to history and revision of diagnosis in case of atypical presentations.
A rare case of a patient with resistant schizophrenia who hears a voice reading the texts instead of being read in her mind
Authors: Nanayakkara Thilini , Wijesiri Vipula
Published: June 2021

Objective

This case is presented to describe a rare psychopathology in which the patient hears her own voice speaking out loud all the texts that she sees in books or papers and she cannot read them inside her mind. This psychopathological phenomena has some features of reflex hallucinations, thought echo as well as of inner reading voices yet it cannot be categorized into either one.

Case report

This is a 26-year-old female with Schizophrenia for 3 years. While on medication 8 months before presentation she started hearing her own voice reading any text that she sees. When she sees a text she cannot read it in her mind and understand, but she hears it in her own voice to her ears. With this she also hears other voices talking about her and to her. She also believes that her father is the one who controls all her actions and the things that happen to her. In her mental state examination her mood was euthymic and she had delusions of control, thought broadcasting and in her perceptions she had visual perceptual abnormality where she saw the same object she would look at in another direction but they are under her control. She also had second and third person auditory hallucinations. She was admitted to start on clozapine because her voices did not respond to any medication.

Discussion

Auditory hallucinations are the most commonly encountered type in schizophrenia with a prevalance of 70–80%. This patient hears the words that she sees which has some features of reflex hallucinations, however in the latter the hallucination is not a transformation of the perception. This also has some qualities of thought echo, where just as the patient thinks she can hear them. However in this patient she cannot read the texts in her mind. Inner reading voices are where a person talks to oneself while reading, however in the subjective mind. In our patient this phenomenon also proved to be the most difficult to treat as all her other auditory hallucinations responded to Clozapine, while still this phenomenon remained.

Conclusion

This case is presented to describe the rare psychopathology in this patient in the form of auditory hallucinations
Treatment with the direct oral anticoagulants (DOACs) Apixaban and Rivaroxaban associated with significant worsening of behavioural and psychological symptoms of dementia (BPSD)
Authors: Porter Kim , Souza Stephen De , Hargreaves Iain , Goddard Rebecca
Published: June 2021

Objective

To demonstrate the increasing evidence for an aetiological role of cerebral mitochondrial dysfunction in neuropsychiatric disorders.

To raise awareness of the importance of frontline staff partaking in post marketing surveillance of medications.

Case report

We report the cases of two patients who developed worsening BPSD, coinciding with starting the factor Xa inhibitor DOAC medications Apixaban and Rivaroxaban respectively. Both patients required detaining under the Mental Health Act (MHA). Their symptoms improved significantly, within two weeks, on switching to alternative anticoagulant therapies and they were both discharged from the acute psychiatric ward.

Discussion

Frontline healthcare staff in acute settings and the community manage a heavy workload. It is all too easy to overlook potential neuropsychiatric drug side effects, especially if they are not clearly listed. They may be easily missed amongst older patients and wrongly attributed to dementia.

Rivaroxaban is structurally related to the antibiotic Linezolid which has been reported to cause mitochondrial toxicity. Pre marketing In vitro studies concluded the risk of mitochondrial toxicity associated with this anticoagulant to be low. However a more recent in vitro study, using rat kidney mitochondria, reported evidence of mitochondrial swelling and a collapse of the membrane potential following exposure to low doses of Rivaroxaban. The effect of Apixaban, which is structurally related to Rivaroxaban, has yet to be investigated on mitochondrial function.

Recent research supports not only an association between reduced cerebral mitochondrial function and neuropsychiatric symptoms and disorders, but also the aetiological role it may play.

There is a need for a far greater awareness and understanding of the potential cerebral mitochondrial toxicity of drugs commonly prescribed to our older populations.

Conclusion

Cerebral mitochondrial toxicity can have a significant impact on the health and well-being of patients.

Older patients are particularly prone to experiencing neuropsychiatric side effects that may not have been apparent during preclinical trials.

Development of a rating scale of drugs that are potentially less toxic to cerebral mitochondria could inform national prescribing guidelines and enable safer treatments to be offered to older people, reducing the likelihood of them experiencing apparent behavioural and psychological symptoms of dementia.
The impact of the COVID-19 pandemic on obsessive compulsive disorder: a single case study
Authors: Sibanda-Mbanga Josephine , Govender Anusha
Published: June 2021

Objective

A growing body of research evidence shows that individuals with Obsessive Compulsive Disorder (OCD) have been negatively affected by the COVID-19 pandemic including deterioration of OCD symptoms plus relapse from previously well-controlled OCD. The impact of the COVID-19 pandemic is discussed in a single case study of a patient with OCD consisting of contamination concerns. In addition, the effectiveness of providing Exposure and Response Prevention (ERP) virtually is evaluated with regards to the treatment outcome in COVID-19 related OCD.

Case report

This study describes a 41-year-old, single, employed female with OCD consisting of concerns of contamination and infecting others thereby causing harm. The total duration of the disorder is 32 years with the most recent presentation being of three years duration. Relapse during the pandemic resulted in OCD symptoms being solely concerned with COVID-related contamination. The questionnaires routinely completed at the time of assessment and treatment were the Obsessive Compulsive Inventory (OCI); Yale Brown Obsessive Compulsive Scale (YBOCS); Beck Depression Inventory (BDI). Clinical data were collated and analysed prior to and during the pandemic. Treatment consisted of ERP and was adapted for provision via a virtual platform. ERP involved exposure to a graded hierarchy of COVID-specific anxiety-provoking situations modified to take government guidelines into consideration.

Discussion

Prior to the COVID-19 pandemic the patient's response to treatment with cognitive behavioural therapy (CBT) including ERP indicated a 79% improvement in OCD symptoms on self -rated measures. The impact of the pandemic led to a significant 65% deterioration in OCD symptoms, regarding COVID-19 contamination concerns. Intervention with ERP resulted in 73% improvement over a three-month period. Measures of depression symptoms indicated an 80% improvement pre-COVID, with a 78% deterioration at relapse. Following treatment, the patient also showed a 65% improvement in depression symptoms. Improvements have been maintained at one month follow-up.

Conclusion

The case study supports literature indicating the exacerbation of OCD symptoms due to the COVID-19 pandemic for patients with contamination fears and washing compulsions. The promising results support the use of ERP as an effective treatment for COVID-related OCD symptoms. It also validates the provision of CBT interventions virtually to ensure accessibility of treatment to OCD sufferers.
The catatonia syndrome: forgotten but not gone – a case report
Authors: Cenko Blerta , Milic Spiro
Published: June 2021

Aims

To highlight the presentation and treatment of catatonia in a patient with Schizophrenia.

Background

Catatonia is a syndrome of altered motor behaviour accompanying many general and neurological disorders. It frequently goes unrecognized, leading to the erroneous conclusion that it is rare. Signs and symptoms of catatonia are commonly relieved by the intravenous (IV) administration of a barbiturate or benzodiazepine. If the patient does not fully respond to the sedative drug, ECT becomes the default.

Result

A 61-year Caucasian male with a diagnosis of Paranoid Schizophrenia had been stable for 17 years on Clozapine. He was monitored by his GP. He resided in supported accommodation for 19 years and he was rehoused in a new borough. He was unable to obtain new prescription for Clozapine from his new GP and suffered a psychotic relapse following a period with no Clozapine and admitted under section 2 of the MHA. Clozapine was not restarted due to concerns of prolonged QTc and ectopics. Aripiprazol 15 mg and promethazine were prescribed. He was transferred to a medical ward three weeks later presenting as rigid with abnormal posturing on his bed, febrile, tachycardic and mute. He was confused, withdrawn and not responding to questions. In the medical ward he was bedbound, had high spiking temperatures, raised CK, ongoing fever.He was agitated , restless and confused with dystonic movements of arms and legs and echolalia. He developed an oral thrush, fecal impaction and was catheterised, had mittens put on due to pulling his iv cannulas. Clonazepam 2 mg QDS was prescribed, antipsychotic stopped and rehydrated. After two weeks in hospital clozapine was reintroduced and titrated accordingly. After 8 weeks Lorazepam was introduced as 1 mg QDS and he discharged to psychiatry unit on Lorazepam 1.5 mg QDS after 82 days in medical ward. He continued to be rigid and psychotic. Treatment continued with lorazepam increased up to 16 mg daily and 8 session of ECT were prescribed. Following ECT his mental state improved significantly and there was no rigidity or abnormal movements.

Conclusion

Catatonia is better regarded as a movement and behavioral syndrome with particular attributes and diverse antecedents. First line of treatment is high dose of Lorazepam and second line ECT. Catatonia is a diagnosable and treatable entity.More education is needed to reinforce this message for physicians, especially in emergency departments and psychiatric facilities.
A literature review for the introduction of psychiatric simulation to University of Liverpool Medical School
Authors: Challinor Alexander , Hyland Declan
Published: June 2021

Aims

The aim of this review is to systematically investigate simulation in psychiatry to enable the evidence based introduction of psychiatry simulation into the undergraduate curriculum at the University of Liverpool.

Background

Transformations in the structure of psychiatric delivery and reductions in funding to mental health care have limited the availability of direct patient clinical experiences for medical students. Experiential learning through simulation can be utilised as a powerful pedagogical tool and provide exposure to a broad range of psychopathology.

Although psychiatric skills and knowledge are gained from the current University of Liverpool undergraduate curriculum, there is no specific well-designed psychiatry simulation.

Method

The author searched MEDLINE, EMBASE and PsycINFO databases for studies that met the inclusion criteria. Search terms included ‘simulation (psychiatry or ‘mental health’). Studies were also searched using snowballing via citation tracking within the databases.

Inclusion criteria comprised studies of an educational intervention that involved simulation. The intervention had to be utilised within the field of psychiatric teaching.

Result

The literature review illustrated the dearth of studies analysing role-playing (RP) and/or simulated patients (SP) in psychiatry with it typically encountered as part of the more general communication skills curriculum. Studies analysing SP and RPs demonstrate how they build on the social context of learning alongside drawing on a range of educational theories, including experiential learning. However, studies show that well-designed simulation training should encompass more facets of learning to be transformative, specifically reflecting upon ones experiences alongside understanding and interpreting this new knowledge, allowing it to guide future actions and change practice.

Studies analysing virtual-reality in psychiatry are limited but demonstrate significant improvements in students’ acquisition of key psychiatric skills and exposure to psychopathology. More studies are needed to evaluate the efficiency and cost-effectiveness of virtual-reality over more traditional methods.

Despite the increase in simulation teaching within psychiatry, and the expansion of innovative simulation approaches in other specialties, there was limited use of novel approaches found within the studies analysing psychiatric simulation. There were studies evaluating novel approaches to psychiatry simulation outside of the undergraduate curriculum.

Conclusion

Whilst there are barriers to overcome in simulation training, these are primarily logistical and are clearly outweighed by the educational gain demonstrated throughout this review. Simulation training in psychiatry has often remained limited to traditional communication-oriented scenarios using RP or SP. A greater emphasis on furthering the advancement and integration of more innovative approaches into psychiatric undergraduate teaching is needed.
Exploring student thoughts and perception of videos as a learning resource
Authors: Pasqua Gianluca Di , Mahajan Pranav
Published: June 2021

Aims

As medical education becomes increasingly digital, there is a plethora of readily available video resources available to medical students, aimed at teaching a wide range of topics. Despite this abundance, students report a myriad of issues. These range from videos containing outdated material, being of a poor production quality, and not being entirely relevant to their learning objectives. The aim of this study is to explore student thoughts and perceptions of videos as a teaching and learning resource. As the Mental State Examination is a component of the Psychiatry curriculum that students often find difficult, we have written, filmed and produced a video series explaining and demonstrating it.

Method

Following the production of the Mental State Examination videos at the University of Sheffield – which contained multiple doctor-patient consultations, interspersed with narration outlining the key learning points – three focus groups were undertaken. These were aimed at understanding student thoughts and perception on the new videos, and the use of videos in medical education in general. Taking a qualitative approach, thematic analysis was performed on the content of the focus groups.

Result

There was universal positive feedback about the structure and content of the videos we had produced; students enjoyed observing the various doctor-patient consultations and felt the separate elements of the Mental State Examination was explained logically and concisely. Furthermore, students appreciated that the videos were produced at their own University, believing this added to their validity. With regards to videos as a teaching resource in general, focus groups revealed that students appreciated specific, relevant and novel video material. Most students felt that videos can play an important role in medical education. There was a unanimous belief however that videos used in medical education should be produced well and be factually correct.

Conclusion

Understanding how students feel about videos as a teaching and learning resource is crucial in the development of more in the future. This study suggests more video resources for many areas, both within Psychiatry, and within the greater sphere of medical education, would be welcomed. This ought to be accompanied with student evaluation.
Whistle while you work: improving psychiatry training in a London NHS Trust and what we learned along the way
Authors: Duncan Emily , Bailey Alex , Edwards Simon , Butler Alison , Humsi Layth
Published: June 2021

Aims

The aim of this project is to improve the training experience of Psychiatry trainees across CNWL. In QI terms, we want to achieve a satisfaction rating of above 7/10 for all themes identified by August 2021.

Method

Collected baseline data on satisfaction and priority ratings on 7 training themes Held discussion groups with trainees for specific themes to generate issues and solutions Developed and provided Quality Improvement training for trainees and trainers, 1:1 support and QI clinics – empowering trainees to develop their own local project and to make changes to issues on the ground Enacted central changes in communication, responsiveness, recognising success.

Reassessed and fedback to the trainees throughout.

Result

Our baseline satisfaction survey was completed in June 2020. Trainees their satisfaction for each theme out of 10 and to rank their priorities for change. Results showed satisfaction was lowest in morale and in safety and highest in education and supervision. Their highest priorities for change were safety, then morale, with induction as the lowest priority.

We repeated the survey in October 2020. This showed improvements in most themes (apart from induction, perhaps due to induction having to be delivered virtually). Satisfaction in key priority areas of morale and safety increased from 4.53 to 6.37, and 5.12 to 6.70 respectively. We also asked what ‘one thing’ would they improve about their training. Key phrases included teaching, on-call, communication and induction.

From this data, and softer feedback from trainees, it is encouraging that we are moving in a positive direction, but we are continuing to make changes.

Conclusion

•

Trainees must be central to the work in improving their training

•

Using QI methodology helps – developing a structure and breaking down a bigger task helps make a plan

•

Feedback is key – but people are busy and receive a lot of emails and requests to fill surveys – catching people ‘in person’ (virtually) was the best way to ensure a lot of responses

•

Trainees have loads of great ideas, but they need support, time and resources to be able to develop their projects and changes

•

Flexibility is crucial: some topics work better locally, driven by trainees and some require a more coordinated, central role

We hope that developing a structured approach to a large task like improving training will help make changes sustainable, and enables us to share our learning with others.
Foundation doctor preparedness for treating mental health conditions: results from a national survey
Authors: Gillett George , Davis Owen , Gill Amarit , van Hamel Clare
Published: June 2021

Aims

Previous research suggests the prevalence of mental health conditions among medical inpatients may be as high as 38%. Anecdotally, junior doctors report lacking the confidence, knowledge and skills to assess and treat patients with psychiatric conditions. Identifying this unmet need offers potential to improve standards of care and achieve parity of esteem between psychiatric and medical conditions within the general hospital. Aims:

To assess self-reported preparedness of newly-qualified Foundation Doctors to care for patients with acute or chronic psychiatric symptoms in comparison to physical health conditions.

Method

In September of each year (2017, 2018, 2019), a survey was cascaded to all incoming Foundation Year 1 Doctors. For each respective year there were 1673, 961 & 1301 respondents. Respondents were asked to rate their agreement with statements on a Likert scale. Statements pertaining to mental health included “a) I am competent in acute mental health care provision, b) I am competent in chronic mental health care provision” and “I feel confident in prescribing the following drugs; c) drugs for mental health problems”. Comparison statements assessed confidence caring for medically unwell patients, performing practical procedures and prescribing drugs for physical health conditions.

Result

Preparedness for acute and chronic mental health were lower than both physical health comparison items; preparedness to care for patients with critical illness (acute: r = 0.794, p < 0.001, chronic: r = 0.556, p < 0.001) and preparedness to perform practical procedures (acute: r = 0.724, p < 0.001, chronic: r = 0.433, p < 0.001).

Confidence prescribing mental health drugs was lower than all other comparison items (simple analgesia: r = 0.854, bronchodilators: r = 0.789, antimicrobials: r = 0.772, inhaled steroids: r = 0.720, intravenous fluids: r = 0.702, oral anti-diabetics: r = 0.611, anticoagulants: r = 0.515, narcotics: r = 0.514, insulin: r = 0.206; p < 0.001)

Conclusion

These results identify a disparity in foundation doctors’ self-reported preparedness to treat acute and chronic mental health conditions and prescribe psychotropic medications, compared to a variety of physical health domains. To our knowledge this is the first large-scale study to empirically test a potential discrepancy between newly-qualified doctors’ preparedness to treat patients’ mental and physical health needs. Medical school education and foundation training may therefore present a fruitful opportunity to improve care for patients with psychiatric conditions within general hospital settings.