bluuebunny/crossref_metadata_2025 huggingface dataset:
Quality Improvement Project to Improve GP Referrals to a Rural Psychiatric Team
Authors: Tresilian George , Nasser Hamnah , Park Su Hyun , Asad Dehneez , Khan Raja Akbar , Moran Helen , Gopal Vishnu
Published: June 2022

Aims

With increasing awareness and reduction of stigma associated with Mental Health issues, referrals to services are increased, pushing specificity of commissioning and therefore declining patients of services when referrals are inadequate. Standards would be improved by better inclusion of information necessary for the Single Point of Access process (SPOA) in the Bolsover Community Mental Health Team (CMHT) to make prompt, effective decisions on allocating care.

A Quality Improvement project in a Mental Health Team was devised to improve standards, and acceptance rate, of appropriate referrals to the Bolsover CMHT from General Practitioners (GPs). This would encourage GPs to refer patients whose mental health difficulties do not meet CMHT thresholds to alternative services. A higher acceptance rate and lower rejection rate would indicate that the proportion of suitable referrals had increased.

Methods

Using the Plan, Do, Study, Act (PDSA) model, Driver diagrams were used to create a template with the crucial information necessary for GP referrals to psychiatry/SPOA. Data were collected to check aims of the referral, sufficient information of the presenting complaint, personal & family history, safety concerns, protective factors, comorbidities, medication and substance misuse. The outcome of each referral was recorded and categorised as either Community Psychiatric Nurse Assessment, Outpatient Appointment, Referral Rejected, Referred Elsewhere or No Patient Response.

All referrals in September and October 2021 were analysed to assess whether enough information had been included for each variable. The September and October data were compared to check if the template had been associated with improved quality of referrals.

Results

Pre-template, 17.4% of referrals were accepted, 13.0% received a SPOA assessment, 17.4% were rejected, 39.1% were re-referred elsewhere and 21.8% did not respond to the CMHT. After the template was circulated, 28.0% were accepted, 36.0% received a SPOA assessment, 4% received joint Doctor-SPOA care, 8% had a medication review and 12% were waiting for an MDT decision when data were analysed. The results for SPOA assessment and rejection were statistically significant (p < 0.05), while results for other outcomes were not.

Information on presenting complaint (82.1% to 100%, p < 0.05), personal history (39.3% to 92.3%, p < 0.05) and aims (50% to 88%, p < 0.05) increased, while other information did not change in a statistically significant manner.

Conclusion

The template led to an increased proportion of accepted referrals and a decreased proportion of rejected referrals. However, information on variables did not necessarily improve in the same manner. The template is useful to improve decision-making in SPOA.
Sustainable Prescribing in Secure Services – a Quality Improvement Initiative
Authors: Weeks Catherine , Thomas Toral
Published: June 2022

Aims

In 2021 The Department of Health published a report into the safer use of medicines in health and justice mental health services, advocating sustainable prescribing as a way of improving patient care and reducing carbon emissions. Improving prescribing behaviour could lead to a reduction of 170,000 kg CO2e per year across England, along with cost savings which contribute to higher value service provision and improved service user experience. We aim to evaluate and improve the prescribing of antipsychotic depot and ‘as required’ (PRN) medication in a male secure unit.

Methods

Baseline data were gathered from the patient population in a male secure unit (1 low and 2 medium secure wards, total 50 beds) in December 2021. This included the number of patients prescribed a depot, the type of depot prescribed and whether or not these were administered at the longest evidence-based interval. As part of a wider trust initiative “prn” medication was moved to a fortnightly review cycle to ensure medication was used for as short a duration as necessary. Over a six-week period medication rationale was analysed and discussed with the Responsible Clinician for the service user to optimise prescribing. Data collected following this intervention was compared with baseline results.

Results

The project found that 26 patients in the service were prescribed an antipsychotic depot in December 2021. In this group 17 (65%) were prescribed their medication at the longest evidence-based interval. Of the 9 (35%) that were not, 5 had clinical reasons why a change would not be appropriate at present, however it was agreed this could be considered later in their pathway. Of the remaining service users, two had their dose of medication reduced and their prescribing interval increased. “As needed” (PRN) medications of 15 patients were evaluated; 9 (60%) had medications prescribed which were not in use (4 patients had 3 or more prescribed not used within 2 weeks). Following intervention this reduced to 2 patients, both of which had only 1 PRN medication which required review.

Conclusion

Deprescribing can have a significant impact on patient care and safety and can reduce the environmental impact of a service. This project demonstrated the advantages gained from regular medication reviews and taking into consideration dose and administration interval when prescribing antipsychotic depots. Using protocols for prescribing as needed medications, a structure for reviewing prescriptions, collaboration with patients and utilising patient group directions where appropriate can all aid in improving prescribing sustainability.
Case Study on an Ethical Dilemma
Authors: Akella Anusha , Moe Kyaw
Published: June 2022

Aims

Mr AB is a 58-year-old male with diagnosis of Schizoid Personality disorder. An articulate and intelligent man, AB derived happiness and contentment from his work. Due to workplace conflicts, he was asked to resign several years ago and has not worked since. Mr AB then found a sense of purpose in life by looking after his elderly parents. His parents sadly died a few years ago and since then he has been living on his own. He has never married. AB has one brother who helps him with shopping and groceries. Prior to this admission, AB was admitted once a few years ago when he was diagnosed with Depressive Disorder.

Methods

Mr AB was admitted last year with profound self-neglect. He was detained under Section 2MHA as he wasn't eating and drinking and wasn't engaging with services. With the initial diagnosis being Recurrent Depressive Disorder, AB was commenced on treatment for the same and eventually received ECT, for which he had strongly opposed. Following 6 sessions of ECT, AB bargained with the team that he would start eating and drinking if ECT was stopped and did so as well. He then requested a transfer to a different ward and consultant, with whom he shared that he doesn't agree with our diagnosis of depression or Schizoid personality disorder. AB expressed that he doesn't find his life worth living and wants to be left alone. He strongly believed that his liberty to take decisions about his life is being unfairly taken away by the NHS and accused professionals of trying to protect themselves. No evidence of SMI found at this stage. Following several discussions, AB was discharged home. He however was readmitted within a couple of days’ time by his brother following disengagement, self-neglect and again, no evidence of SMI.

Results

A capacitous patient, in the absence of Serious Mental Illness puts forth an argument that purely because his way of living and his opinions on life and death differ from that of the society, doesn't mean that his rights over his life can be taken away from him. He, however, struggles to acknowledge that as fellow humans we are strongly inclined to intervene and try to stop anyone from taking their own life.

Conclusion

A Challenging case that raises several questions surrounding Medical Ethics. The team is now looking into guardianship to ensure welfare of the patient.
Key Learning Points from a Case of Cannabinoid Induced Catatonia
Authors: Benazaize Lydia , Mercadillo Nieves
Published: June 2022

Aims

Catatonia has an effective treatment: benzodiazepines. A first presentation of catatonia may present initially to an acute medical trust. It is important acute clinicians are familiar with its manifestations, medical differentials, and most importantly, understand the role of benzodiazepines in both the investigation and management of catatonia.

Methods

Here we describe a case of catatonia in a nineteen-year-old male, who presented acutely to the accident and emergency department with odd behaviour following inhalation of the synthetic cannabinoid ‘spice’. Initially, he was found to be rigid, mute and doubly incontinent, but able to follow vague commands. He was admitted to the acute trust for twelve days in which he was worked-up as a case of drug induced psychosis. As he was not improving, he was then transferred to psychiatric inpatient services for further investigation and management.

Results

The acute medical team did not recognise this as a presentation of catatonia and did not conduct a lorazepam challenge, as suggested by specialist services. A lorazepam challenge is helpful in both diagnosing and treating catatonia. In this case, we believe this may have been missed, due to a lack of knowledge and understanding of the condition. Medical mimics of psychosis, such as autoimmune encephalitis, may be life threatening, but have a good prognosis if treated early. Here, these were not considered, which may have led to disastrous consequences had they been present. This case shows an opportunity for education into the differentials and management of catatonia.

Conclusion

We believe this case highlights a degree of poor understanding surrounding catatonia and its clinical work-up in the acute setting. There were missed opportunities to instigate treatment earlier and consider rarer alternative causes for the presentation. We hope this case will simplify diagnosis and management for acute clinicians, and highlight important medical mimics of catatonia. This case also shows the potential significant harms of synthetic cannabinoids such as ‘spice’ and highlights a need for further research and potential review for grading above Class B in the Misuse of Drugs act 1971.
Trauma-Informed Care on CAMHS ID Unit. Case Study of a Child with Neurodevelopmental Disorder and Self-Injurious Behaviour
Authors: Eggleston Evelina , Daoud Omaima
Published: June 2022

Aims

Crystal House is a specialist CAMHS ID inpatient 5-bedded unit based in the Kingswood Centre, North West London - for children aged between 13 and 18 years with primary diagnosis of Intellectual Disabilities with or without additional concerns that warrant admission to hospital for purpose of assessment and management. Reporting this case, we wanted to highlight complexities of management of children presenting with neurodevelopmental conditions and history of trauma.

Methods

This is a case of a fourteen-year-old girl with established diagnoses of Moderate Intellectual Disability, Childhood Autism, Foetal Alcohol Syndrome and childhood trauma. She was admitted to our CAMHS ID Assessment and Treatment Unit with a nine- year history of self-injurious behaviour, suicidal ideation and voice-hearing experiences – after failed treatment in the community and in-patient treatment (including under restrictions of long-term segregation) on generic CAMHS unit. Her current treatment includes a person-centred Trauma- Informed Positive Behaviour Support Plan; individual and family therapy psychology sessions based on the principles of trauma-informed care and consultation with staff on trauma-informed care. She also undertook ADHD assessment, and we are in the process of optimising ADHD medication.

Results

Trauma-Informed Positive Behaviour Support Plan was a new concept for the team. Therefore, this was supported by training and consultations with staff. The latter was introduced to create a psychologically oriented environment using trauma-informed care principals and helping the team understand what trauma means and how it affects the individual. ADHD assessment confirmed the diagnosis of ADHD which was followed by optimising ADHD medication.

Conclusion

Systemic and a person-centred approach is used for this child with concerning presentation and history of neurodevelopmental disorder and childhood trauma.
Surviving Fifty Years With Shrapnel Within the Brain
Authors: Inam Muhammad Sayed
Published: June 2022

Aims

Traumatic brain injury during the war by shrapnel or bullet is lethal and life-threatening. The mortality rate from traumatic brain injury is more than 90%. Mrs. N (70) of Bangladesh is an exceptional and one of the luckiest women of the world. She is a war victim and has been living with shrapnel within her brain for the last 50 years.

Methods

According to the patient attendant, half a century ago, during the Liberation War of Bangladesh, one shell accidentally exploded in their backyard. Unfortunately, a few pieces of shrapnel penetrated her arm, leg and right side of the head. She lost her consciousness and immediately treated at war hospital as per level best. She forgets details of her treatment and has no treatment records. Last 50 years, she has been surviving with movement difficulties, weaknesses of the upper and lower limbs and occasional convulsions. Her sufferings have intensified day by day. Last few years she has been experiencing headaches, dizziness, vomiting and forgetfulness. Two months back, she drank some insecticide mistakenly. She also suffering insomnia and she often cried out from deep sleep. She complains about hearing unknown voices. The voices were talking about her. She also started to suspect her family members. She claims that her family members were conspiring to kill her. She has history of convulsions three times in the last 50 years, which were generalized and tonic clonic in nature. She didn't take any medication for convulsion. As her suspicion, irrelevant talk and oddity in behavior worsened, her family members took her to me for treatment. Considering her past traumatic brain injury, an X-ray skull was advised. Surprisingly, it showed a metallic foreign body (shrapnel) within her skull. Furthermore, a CT scan of the brain was done, and it showed there was an irregular bony gap at right parietal area, a shrapnel at right frontal area with extensive encephalomalacic Porencephaly communicating with lateral ventricle. Her thyroid and liver function are normal. She is non-diabetic, non-hypertensive. She was advised to take risperidone 2 mg daily at night. With this low dose antipsychotic medication her psychosis controlled.

Results

Surviving with shrapnel within the brain followed by traumatic brain injury is very much rare. Shrapnel gradually damages the brain parenchyma and creates a large porencephaly.

Conclusion

Traumatic brain injury by bullet or shrapnel is always fatal. It is very much rare in medical to survive fifty years with shrapnel within the brain after shrapnel injury.
Who Let the Dogs Out? a Case of Delirium Induced by Lyme Borreliosis in a Patient With a Severe Intellectual Development Disorder
Authors: Pinto Joana Marques , Andrade José Diogo , Andrade Joana , Martins Vera
Published: June 2022

Aims

Lyme borreliosis is caused by certain genospecies of the Borrelia burgdorferi sensu lato complex, which are transmitted by hard ticks of the genus Ixode. The most common clinical manifestation is erythema migrans, an expanding skin redness that usually develops at the site of a tick bite and eventually resolves regardless of antibiotic treatment. It may result in a range of clinical manifestations involving different organ systems, and can lead to persistent sequelae in a subset of cases.

Methods

We describe a case of a 47-year-old male, with severe intellectual development disorder (IDD), who presented with behavioural changes, aggressiveness, psychomotor agitation and confusion. 15 days prior to admission in the psychiatry ward he had recurred several times to the emergency department with similar clinical presentation, and had been discharged following adjustments to his medication. After showing no improvement and no response to treatment he was admitted. He then presented fever and laboratory study (LS) revealed increased inflammatory markers. His family also informed he came from a rural area and had contact with wild dogs. No tick bite or erythema was identified during physical examination. Nevertheless a serologic study for Borrelia burgdorferi was performed and turned out positive. An antibiotic regimen was administered and and the patient's symptoms fully remitted 48 hours after treatment was initiated.

Results

Borreliosis usually presents erythema at the site of the tick bite which could have already resolved when the patient was examined. It was first assumed that the clinical manifestations were part of his psychiatric condition. An infectious etiology was presumed after the onset of fever and increased inflammatory markers were identified. Given the patient's context, Borrelia in particular was considered a likely hypothesis. This case illustrates the difficulties of differential diagnosis inherent to patients with IDD, both because of the pathology itself, which can mask such clinical manifestations as delirium, and of the stigma associated with mental health patients, which frequently cuts the diagnostic work-up of organic causes short.

Conclusion

This case highlights the clinical challenge patients with IDD represent. Differential diagnosis can be elusive, especially in the context of infectious diseases like borrelia, as they can present with unspecific clinical manifestations in this subgroup of patients, and hence why a complete and thorough clinical evaluation is essential. This case also illustrates that mental health patients suffer from stigma: Being branded a “psychiatric patient” created a 16-day delay between onset of symptoms and appropriate treatment initiation- antibiotics.
Chronic Misuse of Paracetamol in OCD Without Hepatic Injury: A Case Report and Literature Review
Authors: Mohamed Ashma , Wacker Alexa , Schmidt Martin
Published: June 2022

Aims

Paracetamol is a commonly used antipyretic and analgesic over the counter medication. In acute or chronic overuse it is associated with dose-dependent hepatic injury. There is a narrow therapeutic margin and that consistent use of as little as 7.5 g/day may be hazardous. Unintentional overdose with paracetamol is the most common cause of acute liver failure in the United Kingdom Here we present an unusual case of a 60-year-old lady with a reported chronic history of self-medicating with an above daily recommended dose of paracetamol without evidence of hepatic injury.

Methods

A 60-year-old Caucasian lady known to psychiatric services for 20 years with Recurrent Depressive disorder, Obsessive Compulsive Disorder (OCD), Dependent Personality Disorder with Borderline personality traits. She reported consuming 32 tablets of paracetamol (16gm per day) every day for the past 11 years. She experienced obsessions of fear that if she did not take a particular number of paracetamols in a day then her friends will come to harm and her anxiety was relieved by the compulsion of consuming supratherapeutic doses of paracetamol. There was no evidence of misuse of any other medications other than paracetamol. Her blood investigations revealed liver function tests within normal limits and ultrasound of the liver was unremarkable.

Results

A literature search of “paracetamol or acetaminophen” and “no liver or hepatic” and “damage or injury” found only one case report. The case reported that studies of paracetamol metabolism were performed in a 58-year-old female with rheumatoid arthritis who had consumed 15–20 g paracetamol daily for 5 years without developing liver damage and data were compared with results in seven normal volunteers. The report concluded that a combination of slow paracetamol absorption, enhanced detoxication of paracetamol (by sulphation) and reduced metabolism to potentially cytotoxic metabolites may have reduced the risk of liver damage in this patient.

Conclusion

In OCD, misusing medications can be an uncommon presentation of compulsive acts to relieve anxiety. The diagnostic dilemma of factitious illness is probable, however supratherapeutic use of paracetamol without physical harm is rare but possible.
Beyond “Evidence-Based Medicine” in “Detained Patients"
Authors: Shaddel Farshad
Published: June 2022

Aims

Treatments without robust evidence are not recommended. However, some patients detained in secure hospitals might need novel approaches such as: off-license use of medication, use of psychological (rather than their biological) effects of drugs. In addition, some detained patients may request for unconventional treatments they believe in. In community and capacitous patients, the clinician's role is advisory and the burden is on the patient to make the final decision and access such treatments privately. However, in a detained patient (with or without capacity), it may fall on the Responsible Clinician (RC) to deny or facilitate access to such interventions. Currently, there is no guidance for such circumstances. We have presented three real cases followed by proposing a flowchart to guide RCs.

Methods

Case 1 (2019–2020): X with mild Learning Disability (LD) and mixed personality disorder detained under Section 3 with no leave to community. X asked for Hypericum which has been helpful with her headaches in the past. X had capacity to make that decision.

Case 2 (1996–97): Y with mild LD and aggressive behaviours responding instantly to any injection. Y lacked capacity so injections of distilled water was tried in his best interest, with equal positive effect. The question was about using distilled water as rapid tranquilisation with no side effects.

Case 3 (2020–21): Z with a treatment-resistant psychosis who has been unwell for months and detained in four different PICUs. Z's father requested N Acetyl Cysteine which had historical calming and sedative effects for Z.

Results

The main issue in case 1 is the conflict between the patient's Human Rights and RC's Duty of care. Here the patient could be potentially deprived of their right to make an ‘unwise decision’ should the RC bar her access to a treatment which lacks evidence but is privately available to public. This can be construed as an infringement of Article 8 of Human Rights.

The issue in case 2 and 3 is rather different. Here the conflict is between the RC's duty of care to provide evidence-based treatments and the patient's “best interest” which seems to be an intervention without robust evidence.

Conclusion

We have developed a flowchart to help RCs by navigating amongst several competing/ conflicting legal and ethical concepts such as: Patient's wish/Human rights, Patient's capacity, Bolam test, “Medical Treatment” Under Section 63, 62 or 58 of Mental Health Act 1983, Best interest, Second Opinion (SOAD) and advice from court.
The Impact of Stigma on Forensic Psychiatric Patients - a Case Report
Authors: Umakanthan Tharshni
Published: June 2022

Aims

The Royal College of Psychiatrists’ Fair Deal (RCPsych 2008) highlighted the far-reaching impact of stigma and discrimination on the lives of people with mental illness. The pervading nature of stigma has been acknowledged in recent national and international mental health policies (WHO). The World Health Organisation reiterates people affected by mental illness should not suffer social exclusion and marginalisation due to stigma.

Methods

A sixty-year-old gentleman presented to the Emergency Department following self-inflicted stabbing to the neck resulting in pharyngeal tear and surgical repair. Previous psychiatric history included inpatient admission on Section 2 following a major depressive episode. On this admission, inpatient psychiatric review elicited three months of psychotropic medication non-adherence due to difficulties the patient had encountered in acquiring repeat medications from his GP. He had relapsed into alcohol misuse as a coping mechanism culminating in a suicide attempt at home with a knife. Upon recommencing of sertraline and risperidone during admission, he was assessed as euthymic with low risk to self. The patient had been previously abstinent from alcohol and described religion as a protective factor. Prior to discharge, the patient's GP stated he must present to the surgery in person with a form of identification. This is despite CQC guidance stipulating practices should not refuse patients registration if proof of identity cannot be produced.

Results

This case illustrates the socioeconomic factors increasing likelihood of suicide including forensic history, low financial status, unstable housing and lack of social support. Substance dependence is a risk factor that can be reduced by supporting patients in accessing specialist misuse input from inpatient and community teams. The patient reported fear of stigmatisation and criminalisation which led to the avoidance of seeking treatment, deterioration in mental health and severe clinical consequences. It is imperative marginalised patients with mental illness can access quality health care and this starts with GP registration.

Conclusion

Forensic mental health patients experience multiple stigmas impacting on well-being including social, institutional and media stigmatisation and high levels of internalised stigma. The Time to Change campaign focused on changing attitudes and behaviour however evaluation illustrated difficulties in tackling this issue. Healthcare professionals should be mindful to avoid stigmatising language and actions to ensure fairness in care. There is a need for the medical profession to continue striving for a tangible shift in attitudes. Advocating for those with mental illness can enhance quality of life for vulnerable patient groups.
Ataque De Nervios: A Case Report
Authors: Ustun Sitki
Published: June 2022

Aims

Ataque de nervios is a culture-bound syndrome among individuals of Latin descent.The case study presents an ataque de nervios case triggered by unique stressors in a transgender female of Mexican origin. This case also highlights the critical features of ataque de nervios, and discusses the challenges in diagnosis, classification and management.

Methods

47-year-old transgender (male to female) woman was admitted to an acute female inpatient unit following a presentation of erratic behaviour and a collapse episode under mental health act. During her observation and assessment period, multiple ataque episodes were observed with characteristic features triggered by gender phobic comments. After ruling out the organic causes and ruling out other differentials, she was diagnosed with ataque de nervios. She completed her treatment and continues to remain on remission.

Results

The case presents a rather recognized presentation of ataque de nervios, however, the unique triggers rooted from her gender identity are more relevant to the current 21st century social context which is also an important ongoing discussion topic in psychiatry. The themes are also good presentation of the evolving psychosocial context of the specialty.

Conclusion

Further study is needed to examine the relationship between ataque de nervios and gender identity, as well as the relationship to cultural, demographic, environmental, and personality factors.
Behavioural Changes in a Patient With Schizoaffective Disorder
Authors: Varughese Anto
Published: June 2022

Background:

A 46-year-old man has a diagnosis of schizoaffective disorder complained of intermittent abdominal pain for many years. Due to this, he had been reviewed by the GP and he was prescribed medication to help with his intermittent abdominal pain.

Case Report:

Over the years the abdominal pain gradually worsened. He also has communication issues due to language barriers and was unsettled for most of his assessment.

His past medical history includes a duodenal ulcer, infected swollen legs and recurrent urinary tract infections.

He continued to have pyrexia despite being on regular paracetamol. Following his second episode of pyrexia, he was referred to the hospital for further investigation.

This was found to be acute acalculus cholecystitis, with possible cholecystocolic fistula and pneumonia. He was managed conservatively with intravenous antibiotics and is awaiting cholecystectomy.

Discussion:

Behavioural change in people with mental illness need not necessarily be linked to their mental state as it can very well be the atypical manifestation of physical illnesses- some of which could be fatal. Prompt recognition and referral to acute medical or surgical services is essential. Staff need training in bias, diagnostic overshadowing and atypical presentations in those with mental illness which will help reduce rates of avoidable morbidity and premature mortality.

In any case physical illnesses may not present typically. Acalculous cholecystitis is a rare type of gall bladder inflammation and the cause in Mr X's case is not clear. At times of COVID-19, with the anxieties around exposure to hospitals and infections, it is important to be aware of this and ensure that people with worrying physical symptoms are promptly referred whether or not it is considered to be related to COVID-19.

Conclusion

Due to the pandemic, we were cautious on the ward and community about COVID-19 and preventing catching and spreading the infection. During all this, patients change of behaviour shouldn't be alluded to deterioration of mental health and mental health professionals should also consider ruling out physical causes for the change of presentation.
“Life, Interrupted”: A Patient Experience Encompassing the Journey From Hospital to the Community, With Support From the Mental Health Intensive Support Team (MhIST)
Authors: McPherson Jen , Whyler Jonathon , Shetty Amrith , Mahon Lucy
Published: June 2022

Aims

We present outcomes of a newly developed Community Rehabilitation team (MhIST) using the context of Jen's personal story. Jen is a 31-year-old student and freelance journalist. This story encompasses her journey from inpatient rehabilitation services to the community, completed with support from MhIST.

Methods

“For nearly four years, I was sectioned under the Mental Health Act as an inpatient in hospital. As I had been denied my fundamental liberties for so long, the prospect of leaving hospital for good and enjoying total freedom was both exhilarating and terrifying. How would I fare in the community, living on my own? Would I be lonely? Would I relapse? Would I survive?”

Upon leaving hospital, I immediately received intensive support from MhIST. They were the bridge between the gulf that was hospital and the community. Since leaving hospital, I have been relishing my freedom. I enjoy meeting up with my friends after so long apart. I have volunteered at The Storyhouse, a local arts venue. The Spider Project – a non-clinical community mental health service in Chester - has also provided me with fulfilling activities from yoga to creative writing. The MHIST team have not only kept me well but, most importantly, helped me thrive. Leaving hospital has been an adventure. It has been a joy to regain my independence and freedom. To live rather than to exist. Life is amazing. Long may it continue.”

Results

MhIST provides an intensive rehabilitation and recovery service, delivering bespoke packages of care to individuals. This is achieved using key working and a shared team approach, outcome focused goal-based interventions, weekly reflective/formulation meetings, and a focus on social rehabilitation. Patients referred to MhIST will have a high level of complexity plus severe, treatment refractory symptoms, with impaired social, interpersonal and occupational function and high support needs. They may have co-occurring mental health conditions including substance misuse or neurodevelopmental disorders.

MhIST is a new service and has been active for around 6 months. The first 10 patients referred have been from acute wards (3), community mental health teams (1), and inpatient rehabilitation wards (6). 60% of patients are currently housed in independent accommodation.

Conclusion

Jen's story narrates the experience she encountered during transition from inpatient rehabilitation services to the community. This was completed with support from MhIST, a new community rehabilitation service which provides an intensive rehabilitation and recovery service.
Clozapine for Treatment Resistant Aggression in Autism
Authors: Williamson Abi , Raja Vanathy , Bailey Lesley
Published: June 2022

Aims

The National Institute for Health and Care Excellence (NICE) guidance on the management of behaviour that challenges in autism, is that medication should be considered when psychosocial or other interventions cannot be delivered because of the severity of the behaviour. In our experience of working in Secure and Specialist Learning Disability, there are also times when challenging behaviour continues despite non-pharmacological interventions being optimised. There is (limited) evidence that clozapine should be considered for the management of aggression in patients with autism not improved by first-line antipsychotic drugs.

Methods

We present two cases of female patients with autism and learning disability, both of whom had been detained for a long period under the Mental Health Act 1983. Both continued to present with significant aggression despite non-pharmacological treatment being optimised. The aggression did not respond to first-line antipsychotic drugs, nor other psychotropic medication. They were started on clozapine.

In the first case, that of a 32-year-old, aggressive incidents reduced from a mean of 15 per month to 5 per month. The use of physical restraint reduced from 10 episodes per month to 5 per month. Staff reported that aggression was less severe than previously. Due to the improvement, the patient began having access to escorted community leave.

In the second case, that of a 31-year-old, incidents of aggression requiring floor restraint reduced from a mean of 30 episodes per month to 15 per month. The average monthly duration of restraint reduced from 29.5 minutes to 18.5 minutes. Although difficult to quantify, the staff team consistently reported that her level of arousal at times of incidents was less. Her engagement levels also increased. She became more tolerant of people being in her living space and actively sought out contact with staff.

Results

Clozapine resulted in a reduction in aggression and arguably, improved quality of life, for the two patients described. We make recommendations on when clozapine could be considered for treatment resistant aggression in autism and what should be done before this. We also provide guidance on how a therapeutic trial should be conducted, in line with Stopping Over Medication of People with a Learning Disability, autism or both with psychotropic medicines (STOMP-LD).

Conclusion

It is reasonable to consider clozapine for aggression in autism when all other interventions have failed. It may result in meaningful change and improved quality of life.
Response to Perinatal Psychosis in West Essex During COVID-19 Pandemic
Authors: Abdelkhalek Hesham , Sibindi Thando , Harris Vivienne , El-Maraghy Manal
Published: June 2022

Aims

The aim of this audit is to look at the presentation of women who were pregnant or less than one-year post-partum presenting with psychotic symptoms in the A&E Department, general hospital and calls to crisis line, particularly with the fact that the pandemic impact remains on the nation. Our aim was to ensure that all referred patients were assessed within the first 24 hours, all the assessments were completed face-to-face, a biopsychosocial assessment was completed for each patient and an outcome was agreed on and clearly documented in the notes.

Methods

All referrals to West Essex access and assessment team from the A&E department, the general hospital and calls logged to crisis line were included. Data were collected prospectively over a six-month period from mid-November 2020 to mid-April 2021. For the purpose of this audit, an identification form was designed and disseminated to access and assessment and crisis teams to identify illegible patients. Our data collectors then used the main audit tool to gather the data.

Results

In total, our sample included sixteen patients who met our criteria over the six months period. There was only one patient who was out of area. Most of the patients were of white British ethnicity (ten out of sixteen) and other six patients were five white other and one of Asian origin. The mean maternal age in our sample was 27.3 years old and the majority of the referrals came from the labour ward in Princess Alexandra hospital (57%). The two main outcomes of our audit were to check the response time and the way the initial assessment was carried over. Our results show that the team responded to all referrals on the same day with no delays. All the assessments were carried out in a face-to-face fashion in the general hospital apart from one assessment that came through the crisis line and this was carried out in the patient's home.

Conclusion

From our data we can identify that the access and assessment team met the standards we set for this audit. This fulfills the recommendations of MBRRACE-report and the RCPsych. One of our recommendations was to provide educational sessions to the emergency department in the general hospital to raise awareness on psychotic presentation during perinatal period.
Attention Deficit Hyperactivity Disorder in a Male Medium Secure Unit
Authors: Swain Rachel , Azim-Naqvi Zara , Balasubramaniam Sinthujah , Dujic Maja
Published: June 2022

Aims

The worldwide prevalence of Attention Deficit and Hyperactivity Disorder (ADHD) in the adult population is estimated to be 2.5%. Prevalence studies have shown rates to be consistently around ten times higher in the prison population, but there is less known about secure psychiatric hospital populations. ADHD has relevance as a predictor for offending, for challenging behaviours when incarcerated, for lower quality of life and high costs for both the NHS and prison systems. This service evaluation aimed to establish estimated prevalence of ADHD within one male medium secure unit.

Methods

A cross sectional review of computerised medical records for all service users on the male medium secure forensic unit took place, to identify those who met inclusion criteria. Service users who were too acutely unwell or had an established or pending diagnosis of ADHD were excluded.

The Brief Barkley Adult ADHD Rating Scale (B-BAARS), a 5 minute screening questionnaire, was given to service users to complete. Anonymised responses were converted to electronic format and the compiled results analysed.

Results

There were 125 service users at the time of information gathering, with 112 eligible according to inclusion and exclusion criteria. 2 of the excluded service users already had an ADHD diagnosis. 70 service users out of those approached, agreed to take part in the screening (62.5%). 2 out of 70 (2.9%) service users met criteria for a possible diagnosis of ADHD.

Conclusion

Using the B-BAARS, 2.9% of service users on the male medium secure forensic unit reported clinically significant symptoms suggestive of a diagnosis of ADHD. This estimate is significantly lower than other studies in prison settings. When combined with the figure for service users with a pre-existing diagnosis, however, the figure is still higher than in the general population (5.5% compared to 2.5%), and illustrates that screening tools can have a useful function in forensic settings.

There may have been methodological issues with this evaluation, including the self-reported nature of symptoms, the comparatively high level of functioning required to complete the questionnaire and the low response rate amongst the service users.

This evaluation serves to increase awareness about ADHD in the forensic population in general. It also highlights the value of this simple screening tool, or one similar, to clinical teams on the forensic wards. The screening tool could be further utilised in low secure and women's services to establish if results are similar amongst these populations.
An Investigation Into the Impact of Dementia Knowledge and Attitudes on Individuals’ Confidence in Practice: A Survey of Non-Healthcare Staff Inside the Prison Estate in England and Wales
Authors: Burke Sarah , Hassoulas Athanasios , Forrester Andrew
Published: June 2022

Aims

Whilst the majority of age groups are seeing a decline in numbers in prison custody, the older male population continues to rise year on year. This unexpected trend has led researchers to investigate the needs of this particular cohort in more detail and start to question if the prison estate is able to care for the specific needs of the ageing population. This primary research specifically, looks to investigate what relationship, if any knowledge and attitudes to dementia have on how the confidence in practice levels of non-healthcare prison staff

Methods

This research, in a specific, applied context considers the relationship between attitudes toward the prison estate alongside knowledge and attitudes toward dementia in general and the potential relationship these may have on confidence levels. To do this, the research scored individuals’ responses against the dementia knowledge assessment scale, attitudes to the prison estate and general attitudes toward dementia. These three independent variables were measured both overall and individually against individual confidence in practices scores. 50 individuals participated with differing roles and length of service in the prison estate

Results

The results of the study found that the overall model was significant. Of the three independent variables, it was found that positive attitudes to dementia were the most influential predictor of confidence. Knowledge of the condition and attitudes to the prison estate, the second and third independent variable however were not significant predictors of confidence in practice levels. Overall, the results indicate that there is a relationship between knowledge, attitudes, and confidence in delivery of dementia care in the prison estate as an overall model.

Conclusion

The main objective of this study was to determine the knowledge and attitudes to dementia of non-healthcare prison staff and if that knowledge and those attitudes had an impact on confidence in practice levels. It could be argued that this research has fulfilled its primary aim, reporting that knowledge about and attitudes toward dementia scores are a significant predictor of knowledge of the condition in non-healthcare-based staff.
A 3 Year Follow-Up After Discharge From Early Intervention Service- Are Patients Less Likely to Be in Contact With Mental Health Services After Discharge From Eis and Are They Healthier?
Authors: Cesnaite Giedre , Weston Latha
Published: June 2022

Aims

To determine the utilization of mental health (MH) services, antipsychotic use and weight gain 3 years after discharge from an Early Intervention Service (EIS).

Methods

A retrospective anonymized survey was conducted of the trust electronic records of patients discharged from Barnet EIS in April to May 2018. 25 case records were identified of which 4 were excluded due to relocation out of area. Information was reviewed from the time of referral to 3 years post discharge. Data included patient demographics, number of referrals to home treatment team (HTT), inpatient admissions, medication and cardiometabolic parameters (weight and HbA1c) during this period.

Results

21 records were analysed - 13 males, 3 females, average age of 24 years. 12 patients had been discharged to primary care of which 5 were re-referred to community mental health team (CMHT) during the 3 year follow-up. 9 patients were discharged to the CMHT of which 4 were later discharged to primary care.

There was no significant difference in the number of referrals to HTT and hospital admissions in the GP and CMHT follow-up groups (50% and 33%; 56% and 44% respectively). At the time of discharge from EIS 67% were on antipsychotic medication. At 3 year follow-up 90% in CMHT group continued antipsychotics. There was an average of 15.6 kg weight gain while under EIS with further 11.7 kg gain over the next 3 years under CMHT care. According to available data for those still in contact with MH services, no patients newly met criteria for pre-diabetes or diabetes. No records were available on our system pertaining to GP discharges.

Conclusion

We discuss the impact of EIS on affecting future MH service contact. There were a similar number of future MH referrals regardless of initial discharge destination. We consider whether there may be a different quality of these contacts that need further inspection.

The majority discharged continued taking antipsychotic medication and experienced considerable weight gain. This significant ongoing weight gain in a group of young people only starting to use MH services is of great concern due to negative cardiometabolic impact. It highlights the need for urgent proactive attention to ensure the best physical and mental health for these patients.
Remote Clinical Assessments and Management During COVID-19: Views of the Patients and Clinicians About the Future Preferences
Authors: Kar Nilamadhab , Cheung Lai-Ting , Jiwanmall Stephen
Published: June 2022

Aims

During the COVID-19 pandemic most clinical services changed to remote consultation and management to minimise virus transmission by direct contact. As the social distancing and restrictions have eased with greater control of the pandemic, the nature of consultations is going to change. At this juncture we intended to understand the perception and satisfaction of patients and clinicians on remote consultations and management during COVID-19 and to determine their preference about clinical engagement in the future.

Methods

This was a trust-wide anonymous survey conducted through surveymonkey. It involved both patients and mental healthcare staff (MHS) and explored about the quality and satisfaction in remote consultations, option to patients, and use of remote consultations in future. Clinicians were sent the online link to complete, with a reminder two weeks later. The patients were explained during their appointments about the survey, those who agreed to participate and gave informed consent, their responses to the questions were recorded.

Results

The sample consisted of 78 patients and 107 MHS representing adult, old age, children and adolescent and intellectual disability subspecialties. Most (92.4%) participants had participated in remote consultations and understood the reason behind it. Around a third (32.7%) of MHS and 46.2% of patients felt strongly satisfied in remote consultations, and together with satisfaction these were 56.1% v 71.8% respectively (p < 0.05). The quality of the remote consultations were considered somewhat (11.2% v 23.1%) or a lot better (8.4% v 15.4%) by MHS and patients respectively (p < 0.05). Majority (82.7%) felt that an option should be given to patients for the type of consultation, face to face or remote. After the pandemic, the preference for psychiatric consultations were primarily face to face (30.3%), primarily remote (8.6%) and a mixture of the two (61.1%); there were no difference between patients and MHS. However while 71.4% doctors, 70.8% other clinicians (occupational therapists and psychologists) and 75.0% of clinical managers opted for mixture of face to face and remote, 26.9% of nurses opted for that. Background subspecialty, age group, ethnicity, experience of remote consultation with GP or hospital doctors, attendance or admission to general or psychiatric hospitals during pandemic, disabilities, or having COVID-19 did not influence the suggestion for the future consultation type.

Conclusion

Following the pandemic, both clinicians and patients express a preference for a mixture of face to face and remote consultations; and an option regarding that should be given to the patients.