bluuebunny/crossref_metadata_2025 huggingface dataset:
It's a risky business: use of the QCovid risk calculator in a psychiatric rehabilitation population to enhance prevention
Authors: Patel Jinal , Scott Fraser , Mohan Rajesh
Published: June 2021

Aims

Serious mental illness (SMI) is now accepted as a significant risk factor for contracting COVID-19, increasing the rates of adverse outcomes, including hospitalisation and mortality. Risk assessments are the cornerstone of protecting vulnerable groups of individuals. The QCovid risk calculator is a newly developed tool to predict the risk of death or hospitalisation from COVID-19. It has not been applied in SMI populations. We aimed to use the QCovid risk calculator in an inpatient rehabilitation setting to identify and mitigate risk for people with SMI with personalised COVID-19 prevention plans.

Method

Clinical and sociodemographic characteristics were obtained for 22 inpatients. Firstly, the QCovid risk calculator was used to ascertain the absolute and relative risks to patients (Odds Ratios (OR) of mortality and/or hospitalisation) from COVID-19. Patients were stratified as high (OR > 10), moderate (OR 5-10) and low (OR < 5) risk. Secondly, personalised COVID-19 prevention plans were coproduced by patients and clinicians addressing 1) risk factors contributing to increased QCovid risk, 2) patient's personal goals, concerns, and preferences 3) maximizing patient engagement in COVID-19 infection prevention strategies. Finally, uptake of personalised COVID-19 prevention plans was evaluated after four weeks using a customised patient feedback questionnaire.

Result

Of the 22 inpatients (68% male), 14 patients (64%) had schizophrenia and 3 patients (14%) had schizoaffective disorder as primary diagnosis. 13 (59%) patients were prescribed clozapine. QCovid risk stratification showed 10% of patients as high risk, 29% as moderate risk, and 61% as low risk. Apart from SMI in all 22 inpatients, the most common QCovid risk factors were increased body mass index (64%, n = 14; 23% overweight and 41% obese), diabetes mellitus type 1 or 2 (27%, n = 6) and epilepsy (n = 4, 18%). 19 of the 22 patients provided feedback on their personalised COVID-19 prevention plans. Most patients (79%) felt they had “contributed significantly” to their COVID-19 prevention plans, and their individual goals and concerns were valued. 79% were “satisfied” with their COVID-19 prevention plans. Subjective perception of safety from COVID-19 was high, with 95% of patients feeling “safe and well-protected from COVID-19”.

Conclusion

Comprehensive assessment of COVID-19 risks in vulnerable groups enables personalised risk mitigation, both at an individual and service level. Our findings show the importance of applying current knowledge to protect vulnerable patients with SMI through personalised prevention plans. This approach can be scaled up to understand risks for services and teams, while allowing clinicians to adapt their use for individualised COVID-19 prevention.
Sexual and reproductive health needs assessment & interventions in a female psychiatric intensive care unit
Authors: Rose Elizabeth , Covshoff Elana , Blake Lucy , Bolade Adenike , Rathouse Robert , Wilson Aleshia , Cotterell Arthur , Pittrof Rudiger , Sethi Faisil
Published: June 2021

Aims

To assess the sexual and reproductive health (SRH) needs of women admitted to a psychiatric intensive care unit (PICU), and acceptability of delivering specialist SRH assessments/interventions in this setting. Secondary aims were to explore the barriers to access and the feasibility of providing SRH assessments and interventions in the PICU.

Method

A retrospective analysis of fifteen months’ activity data found that only 25 SRH referrals had been made across 205 PICU admissions. This low referral rate of 12% likely reflected pathway barriers and was unlikely to represent the actual clinical need in female PICU patients. A bi-monthly SRH in-reach clinic and a nurse led SRH referral pathway were implemented on the PICU over a seven-month period. Within a quality improvement framework, a staff training needs assessment was performed, training delivered, a protocol developed, staff attitudes explored, and patient and carer engagement sought.

Result

A quality improvement approach streamlined SRH assessments on the PICU and resulted in 42% of women being assessed and a 3.5-fold increase in uptake. At least 30% of the women in the PICU had unmet SRH needs identified and proceeded to a specialist appointment. This amounts to a minimum 2.5-fold increase in SRH unmet need detection.

The most common SRH needs were complex gynaecological issues (such as period problems, pelvic pain, vaginal discharge), STI advice/testing and contraception advice/options. 21% of women initiated SRH interventions, and 14% completed all the interventions required for their needs. The most common interventions were in the areas of contraception advice/family planning and STI advice/testing.

Staff confidence on assessing SRH topics was identified as a barrier to access with a positive shift noted after bespoke SRH training was implemented and a protocol introduced: on a scale of 0-10 (with 10 being high), 81.3% of staff rated their confidence 8 or above in relation to discussing contraception/sexually transmitted infections (pre-training: 25.0%), and 93.8% in relation to discussing risky behaviours (pre-training: 18.8%). All 11 patient and carer participants felt it was important to have a forum to talk about SRH and 8 (72.7%) agreed it was important in the PICU.

Conclusion

Results identify that SRH needs for PICU admissions are greater than previously realised. Staff highlighted the acceptability and importance of SRH care, if interventions are appropriately timed and the patient's individual risk profile considered. Providing a nurse led referral pathway for an SRH in-reach clinic is acceptable, feasible and beneficial for PICU patients.
Sleep and the risk of cognitive impairment and dementia: further insights from the Caerphilly Prospective Study
Authors: Selwood James , Coulthard Elizabeth , Bayer Antony , Fish Mark , Gallacher John , Ben-Shlomo Yoav
Published: June 2021

Aims

Sleep disorders are highly prevalent with growing evidence that sleep problems may predict cognitive decline and dementia. A previous analysis of the Caerphilly Prospective Study (CaPS), a cohort of middle-aged men, found that daytime sleepiness predicted vascular dementia and cognitive impairment. We have re-examined this hypothesis with additional events based on further follow-up. The study aimed to examine the role of different sleep problems in predicting cognitive impairment not dementia (CIND) and dementia. Our hypothesis was that sleep problems in mid-life would predict CIND and dementia in later life.

Method

CaPS is a population cohort of men born between 1920 and 1935 and resident in Caerphilly in South Wales, first seen between 1979–1983. Cognitive tests and a sleep questionnaire were introduced at Phase III (men aged 55–69 years). The questionnaire asked about daytime dysfunction, hypnotic use, insomnia, napping, nocturnal limb movements, sleep apnoea, sleep duration, sleep latency and snoring.

At Phase V (men aged 68–82 years), poor performance on the Cambridge Cognition Exam (CAMCOG) was used to select men for detailed clinical assessment. Subjects were classified as having normal cognition, CIND or dementia. Cognitive disorders were sub-classified as vascular or non-vascular. At Phase VII (men aged 78–92 years), new cases were identified and survivors with existing diagnoses were reassessed.

We initially conducted separate logistic regressions for vascular and non-vascular cognitive outcomes with the individual sleep measures, but where there was no evidence of heterogeneity, we combined these outcomes to enhance power. We also ran ordered logistic regression models to test for association of our sleep measures with CIND and dementia from any cause, with no cognitive problems as the reference group. All models were adjusted for potential confounders such as age and lifestyle variables.

Result

There were 256 cases of CIND, 155 dementia and 118 vascular cognitive disorders. 889 had normal cognition. Nocturnal limb movements strongly predicted vascular cognitive disorders (OR 2.59, 95% CI 1.34–4.98, p = 0.004). Poor sleep duration, defined as less than 6 or more than 8 hours, predicted all-cause CIND and all-cause dementia (OR 1.62, 95% CI 1.01–2.61, p = 0.045). The other sleep measures showed weak associations consistent with chance.

Conclusion

We have provided further evidence that sleep problems predict cognitive decline, justifying the growing interest in sleep as a potentially modifiable risk factor for dementia. Future evidence is required from intervention studies that attempt to improve sleep parameters.
Mechanisms of transcranial magnetic stimulation in the treatment of anorexia nervosa
Authors: Shackshaft Lydia
Published: June 2021

Aims

Severe and Enduring Anorexia Nervosa (SE-AN) is a challenging condition to treat, with limited therapeutic options, high morbidity, and the highest mortality rates of any psychiatric illness. Repetitive Transcranial Magnetic Stimulation (rTMS) is an emerging treatment option, as evidence demonstrates promising efficacy in improving mood and reducing core Anorexia Nervosa symptoms, as well as safety and tolerability to patients. We aimed to investigate the neurophysiological mechanisms of rTMS use in SE-AN patients by assessing changes in resting state functional connectivity, in the first functional neuroimaging analysis investigating rTMS effects in Anorexia Nervosa patients.

Method

26 females with a current diagnosis of SE-AN received 20 sessions of sham or real high frequency rTMS (10 hertz) to the left dorsolateral prefrontal cortex in a randomised double-blind trial. Resting-state functional magnetic resonance imaging was performed before and after rTMS. Neural correlates of rTMS treatment were identified using a seed-based functional connectivity analysis with the left dorsolateral prefrontal cortex and bilateral amygdalae as regions of interest. Functional connectivity differences were analysed using t-contrasts in a mixed ANOVA (flexible factorial analysis) to assess interactions between treatment group (real rTMS vs sham) and time-point (pre or post TMS).

Result

No statistically significant changes in resting-state functional connectivity were observed post-rTMS compared to baseline in participants receiving active rTMS compared to sham. Increased functional connectivity between the left amygdala and left pre-supplementary motor area was observed to reach cluster-wise significance (PFWE < 0.05). However, after Bonferroni correction for multiple comparisons (3 seed regions), this did not reach the significance threshold PFWE <0.017.

Conclusion

This study highlights the need for further investigation of neurophysiological mechanisms, including resting-state functional connectivity modulation, resulting from rTMS to the dorsolateral prefrontal cortex in SE-AN patients. This requires higher powered studies to account for heterogeneity in treatment response. We have provided some indication that high frequency rTMS may have therapeutic benefit in SE-AN by modification of functional connectivity between prefrontal and limbic brain regions, resulting in improved top-down cognitive control over emotional processing and ability to enact goal-directed behaviours, enabling secondary reductions in eating disorder behaviours.
Acute mania with psychotic symptom in post COVID-19 patient
Authors: Shanmugam Sridevi , Kumar Praveen , Carr Blaga
Published: June 2021

Aims

COVID-19 is an on-going pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Recent evidence suggests that SARS-CoV-2 may be associated with various neuropsychiatric symptoms, including mania. We present a case of a middle aged man presenting with acute mania with psychotic symptoms 20 days post COVID infection in the absence of prior psychiatric illness. This report highlights the need for rigorous neuropsychiatric assessment in patient with symptoms of SARS-CoV-2 infection.

Method

A 52-year-old man of West African origin with past history of hypertension and no previous history of mental health illness presented with acute manic symptoms on background of two weeks of high fever, diarrhoea, mild headache, dry cough and anosmia. He was tested positive for SARS-CoV-2 infection on COVID PCR test. He was under self-isolation along with his family members who exhibited mild symptoms of SARS-CoV-2, none of them required hospital admission. He was initially fearful to seek medical attention but was brought in by family after exhibiting behaviour changes, obsession with toilet cleaning, reckless spending and getting aggressive approximately two weeks after the onset of acute upper respiratory symptoms. He presented elated in mood with pressure of speech and grandiose ideas. Investigations like neuroimaging and bloods were unremarkable. Initial psychiatric assessment found symptoms consistent with acute mania and he was detained under the Mental Health Act. During admission, he was sexually disinhibited and agitated on the ward requiring IM antipsychotics. He was treated with high dose of Olanzapine and Sodium valproate and his symptoms subsided within two weeks.

Result

This case emphasises the manifestation of neuropsychiatric illness post COVID-19 without a background of psychiatric illness, hypoxemia and cerebral infarction.

Based on the CORONERVE Programme and latest retrospective Lancet cohort studies, the period between 14 and 90 days after diagnosis, 5.8% COVID-19 survivors had their first recorded diagnosis of psychiatric illness.

It is also important to consider other organic disease given the simultaneous diagnosis of COVID-19. Although it is not yet possible to confirm here due to the lack of a validated CSF-PCR assay, previous reports have implicated SARS-CoV-2 in the development of viral encephalitis, and this remains an important differential.

Conclusion

Clinicians should be alert to the possibility of patients with COVID-19 developing neuropsychiatric complications post SARS-CoV-2 infection, mandating the need for vigilant initial neuropsychiatric assessment and possibly follow-up care in 3 months.
Anxiety levels during COVID 19 pandemic in primary and secondary doctors in UK
Authors: Mittal Dr Shweta , Abouebeid Abdalla
Published: June 2021

Aims

The study aims to examine the severity of anxiety in primary and secondary doctors in the UK during first wave of COVID-19 pandemic.

Method

An online General Anxiety Disorder-7 (GAD7) survey was distributed during the first wave of COVID-19 pandemic (April-May 2020) to doctors in primary and secondary care in the UK. Seven closed-ended questions were included in the questionnaire. Respondents were to indicate how frequently they experienced specific issues in the previous fortnight: Feeling nervous, anxious, or on edge; being unable to stop or control worrying; worrying too much generally; trouble relaxing; being so restless that it's hard to sit still; becoming easily annoyed or irritable, feeling afraid of something awful happening. Participants were required to tick one of four choices for each of the seven parameters - not at all (0), several days (1), more than half the days (2) and nearly every day (3). A person with minimal or no anxiety will score less than 5. The survey was anonymous and circulated in professional online doctors' forums. Participation was voluntary and no incentives were given.

Result

273 completed surveys were received; 120 doctors were in primary care and 153 were in secondary care. Average GAD7 score was 6.4 in primary care and 7.9 in secondary care. 57% of primary care doctors and 66% of secondary care doctors reported score of 5 or more, representing at least mild anxiety symptoms. 22% doctors in primary care and 31% doctors in secondary care reported GAD7 score of 10 or more, indicating moderate to severe anxiety. One in ten doctors in both primary and secondary care reported severe anxiety due to the ongoing COVID-19 pandemic.

Conclusion

The finding of more anxiety in secondary care doctors might be because general practitioners could resort early in the pandemic to remote consultations along with inadequacy of resources, greater exposure to suffering/deaths of patients and colleagues in hospital and perceived risk of catching COVID-19 infection.

Results are limited due to relatively low numbers and it would be useful to replicate this study on a larger scale. Doctors are less likely to acknowledge their mental health difficulties due to stigma associated with mental health.

Many employers have psychological support systems in place for their staff, but it is questionable if affected individuals are willing to receive this support. This paper; therefore, calls for creating open anonymous platforms for professionals to get access to appropriate support to address their anxiety.
A case of olanzapine-associated rhabdomyolysis
Authors: Skryabin Valentin , Zastrozhin Michael , Sychev Dmitry , Bryun Evgeny
Published: June 2021

Aims

To describe the case of olanzapine-associated rhabdomyolysis in a 20-year-old patient with a suspected diagnosis of paranoid schizophrenia.

Method

A 20-year-old male Caucasian patient was admitted to the Psychiatric Department with a one-month history of irrational behavior, talking to himself, persecutory delusions, and poor sleep. He was prescribed oral olanzapine at a dose of 10 mg per day. After two days of olanzapine monotherapy, the patient experienced muscle jerks in the legs. Four days after the initiation of olanzapine treatment, he complained about fatigue and weakness in the lower extremities along with myalgia. Physical examination revealed decreased muscle power with no extrapyramidal symptoms. Blood chemistry showed serum creatine kinase (CK) and serum lactate dehydrogenase (LDH) of 9,725 U/L and 843 U/L, respectively, on day four of the therapy. The Naranjo algorithm score of 6 suggested that olanzapine was the probable cause of rhabdomyolysis. A diagnosis of drug-induced rhabdomyolysis was established from the background of blood tests (increased serum CK and LDH levels), clinical presentation (fatigue and weakness in the lower extremities, muscle jerks, and myalgia), and Naranjo algorithm score of 6 for olanzapine. On suspicion of its contribution to rhabdomyolysis, olanzapine was immediately withdrawn. The patient was referred to the intensive care unit. To prevent acute renal failure, high-volume alkaline diuresis was initiated. After consulting a clinical pharmacologist, the patient's primary physician decided to perform a pharmacogenetic test to develop an individualized treatment regimen. Pharmacogenetic test results were interpreted using the PGX2 software (Meditsina LLC, Moscow, Russia). The test revealed that the patient was a homozygous mutant for CYP2D6*4, which corresponds to CYP2D6 PM phenotype. With this in mind, trifluoperazine was prescribed at a daily dose of 10 mg instead of olanzapine as recent data indicate that trifluoperazine is metabolized by CYP1A2 and UGT1A4 instead of CYP2D6. Subsequently, the patient recovered well and was discharged without any nephrological sequelae.

Result

Recent research demonstrates that CYP2D6 is one of the most important isoenzymes implicated in drug metabolism because the CYP2D6 gene is highly polymorphic. Few reports on the association between olanzapine use and rhabdomyolysis have been published to date, and the present case report draws attention to pharmacogenetic testing which allowed the psychiatrist to prescribe another antipsychotic with no risk of rhabdomyolysis.

Conclusion

The presented case demonstrates that pharmacogenetic-guided personalization of treatment may allow selecting the best medication and determining the right dosage, resulting in the reduced risk of adverse drug reactions and pharmacoresistance.
Suicidality in patients with bipolar depression: findings from a lower middle-income country
Authors: Xue Siqi , Hodsoll John , Khoso Ameer Bukhsh , Husain Muhammad Omair , Chaudhry Imran B , Young Allan H , Zaheer Juveria , Husain Nusrat , Mulsant Benoit
Published: June 2021

Aims

Among low- and middle-income countries (LMICs), bipolar disorder is recognized as one of the leading causes of disease burden for adults and is associated with marked suicide risk. There are limited data on suicidal ideation in bipolar disorder from LMICs. This study presents cross-sectional data on the prevalence of suicidality and associated patient characteristics among patients with bipolar depression in Pakistan, a lower-middle income country and the fifth most populous country in the world.

Method

Participants were recruited through outpatient psychiatric clinics in between 2016–2019 in Karachi, Lahore, Hyderabad and Rawalpindi between 2016–2019. Participants were aged 18 to 65 years with a known diagnosis of bipolar disorder and currently in a depressive episode. Suicidality was assessed using the suicide item of the 17-item Hamilton Depression Rating Scale (HAM-D) and levels of severity were categorized as absent, mild/moderate, or severe. Biometric data and biomarkers were obtained. Descriptive statistics were used to describe prevalence and proportional odds regression models were applied to establish correlates to suicidal ideation.

Result

Among the 266 participants, 67% indicated suicidality of any level and 16% endorsed severe suicidality. Lower body mass index (BMI) (OR = 0.93, 95% CI = 0.88–0.98), higher HAM-D score (OR = 1.29, 95% CI = 1.16–1.43), lower C-reactive protein (CRP) level (OR = 0.53, 95% CI = 0.40–0.70), and increased number of inpatient hospitalizations (OR = 1.16, 95% CI = 1.03–1.31) were identified as significant predictors of suicidality in the fully adjusted regression model. No patient demographic data, including age, gender, marital status, socioeconomic status, and years of education were associated with severity of suicidality.

Conclusion

There exists a high prevalence of suicidal ideation among patients with bipolar depression in Pakistan. Our findings add to the limited literature on suicidality in bipolar disorder in the LMIC context and suggest roles of biological variables such as BMI and CRP level in predicting suicidal ideation and potentially suicidal behaviours in bipolar depression. More studies are needed to see whether such findings can be replicated in other similar LMIC settings, and to explore potential physiological pathways linking BMI, inflammatory biomarkers and suicidality in bipolar disorder.
Implementation of treatment escalation plans in a community psychiatric hospital
Authors: Chua Anne Yan Ting , Ghanchi Adnaan , Grayston Jessica , Yasmeen Nida , Insigne Sean , Woolford Stephen , Wijayaweera Sahan , Patel Harnish P , Amin Jay , Makh Sangeeta
Published: June 2021

Aims

Treatment Escalation Plans (TEP) detail appropriate ceilings of care and guide treatment of patients based on shared decision making. Whilst established in many acute trusts, TEP are not frequently used in community mental health hospitals. This is particularly concerning in organic mental health wards, where patients with severe dementia may be transferred to acute hospitals for treatment without consideration about whether this is appropriate. Our aim for this quality improvement project was to develop and implement TEP within a community mental health hospital to support the management of our older patients with severe mental illness.

Method

We designed a TEP form based on a prototype used in a partner acute trust and evaluated its use on our wards, comprising 20 patients between August-September 2020. This included clear options of the different ceilings of care and what they comprised of for our patients. We obtained quantitative data on the use of TEP, including the length of time from admission to completion, as well as qualitative data from healthcare staff regarding their experience of using TEP.

Result

TEP implementation was feasible and well received among members of staff. All 20 patients had a TEP in place within 2 weeks of admission. The mean number of days taken to complete a TEP form in August-September was 7.1. A snapshot done 2 months later showed new admissions had a mean number of days to complete TEP reduced to 3.2. There was an improvement in understanding the purpose, comprehensiveness and location of TEP forms during their implementation. The key theme that arose from qualitative analysis of healthcare staff comments was that TEP forms provided clear guidance on the appropriateness of escalation of care.

Conclusion

TEP forms offer clear guidance to treating clinicians about the ceilings of care for patients. This also allows for open conversations with patients or their next of kins regarding ceiling of care. This is especially important in mental health inpatients with dementia, when escalation of treatment is not always appropriate. TEP were successfully implemented in our community mental health hospital and we plan further post-implementation evaluation. We intend to roll out the TEP form across our mental health trust and share findings globally to promote best practice.
Audit to assess discussion of sexual dysfunction for new patients entering a community mental health recovery service
Authors: Abbasi Yasmin , Robertson Dina , Anosike Amarachi , Pearson Margaret , Pankhurst Kevin , Perera Jane
Published: June 2021

Aims

Sexual dysfunction should be enquired about as a symptom of mental health disorders and as side effects of commonly used psychotropic drugs. We audited against NICE guidelines the record of sexual dysfunction discussion at initial assessment and follow-up by the community mental health recovery service (CMHRS).

Background

Research reports that sexual dysfunction occurs more often in individuals with serious mental illnesses including depression and schizophrenia. Sexual dysfunction is also a reported side effect of antidepressant and antipsychotic medications. NICE guidelines recommend assessment of biological symptoms of mental health disorders and discussion of potential side effects of treatments being considered prior to initiation and at follow-up.

Method

Our sample consisted of 71 patients, all new patient assessments from referrals made to CMHRS between January 1st and March 31st 2019.

We reviewed all initial assessment and follow-up electronic notes and any correspondence generated from these meetings.

Result

Our results showed that no record was made of sexual dysfunction as present or absent by health care professionals (HCPs) completing initial assessment or follow-up.

We surveyed the HCPs from the team and observed a high level of confidence in discussing sexual dysfunction and high self report of this discussion being conducted.

Conclusion

Our audit results show no records of the discussion of sexual dysfunction, we held to the principal that in absence of record the discussion did not take place. Our survey results suggested that HCPs were confident they do assess for sexual dysfunction. We wondered, therefore, if HCPs would be less likely to make record in the event that symptoms are denied, recognizing that the list of potential symptoms and side effects is extensive and documentation of all negative results would be time consuming.

Our audit results may show then, that sexual dysfunction is not present in any of the sample; however this would contrast to research findings of higher than average rates of sexual dysfunction in groups with serious mental illness and those using antidepressants or antipsychotics.

We propose further assessment is needed for the disparity between our and recognised rates of sexual dysfunction.

We propose the standard that recording ‘absence of biological symptoms’ of mental health disorders or recorded supply of medicine information leaflets are adequate record. We also made suggestions for training and recording to assist HCPs initial assessment.
Compliance with Driver and Vehicle Licensing Agency guidance in a psychiatric inpatient setting
Authors: Babu-Mathew Nishanth , Chard Sasha , Winfield Sarah
Published: June 2021

Aims

Driving is complex, requiring adequate: attention and concentration, memory, insight and understanding, judgement, planning and the ability to self-monitor1. Psychiatric illness, and associated medications, may affect patients’ ability to drive safely. The DVLA is responsible for determining individuals’ safety to drive and produces guidance specific to psychiatric disorders. Patients must comply with relevant guidance and clinicians must determine patients’ driving status and offer appropriate advice about medications and any need to inform the DVLA. This audit aimed to determine the compliance with DVLA guidance on a single inpatient psychiatric ward within Merseycare NHS Foundation Trust, UK.

Method

A retrospective review of electronic patient records was completed. Clerical staff identified all patients admitted to Windsor House from 1/8/20–30/11/20 (n = 42). Data relating to driving status and driving advice were collected onto individual patient audit proformas, and uploaded to the online Audit Management and Tracking (AMaT) system.

Result

100% of patients had diagnoses that would require the DVLA to be informed and 100% were prescribed medication with potential side effects that could impair ones’ ability to drive safely such as dizziness, drowsiness or impaired concentration2. Driving status was only documented for 12 patients (29%) and type of vehicle driven for only 6 patients (1 of whom had an HGV licence).

Discussion of DVLA guidance within the last 3/12 by the mental health team was documented in 17% patients. Of these patients, appropriate driving advice was given to 86%. All patients advised to cease driving were willing to. No patients were advised about side effects of medications on driving. No notes evidenced if the DVLA had been informed of patients’ admission, diagnosis or medication regimes.

Conclusion

Discussing diving status and DVLA advice with psychiatric patients is important but may not always happen in inpatient settings, despite most patients having a relevant diagnosis. Failure to determine driving status may mean some patients are not being given appropriate guidance as required. Counselling on medication side effects in relation to driving should be encouraged as the majority of patients are taking prescribed medication that can potentially impair driving. Recommendations to improve compliance include: adding “driving status” to admission clerking and ward review proformas, educating staff to actively discuss driving with inpatients and create discharge checklists which prompt discussing driving status, medications and driving advice, and to re-audit in 6 months time.
Audit on prolactin monitoring for patients on oral risperidone, intramuscular risperidone, and intramuscular paliperidone
Authors: Bader Mohamed
Published: June 2021

Aims

The aim of this audit was to investigate whether sufficient Prolactin monitoring was completed in a patient sample in the Torfaen area of Aneurin Bevan University Health Board. This audit targetted patients an oral or intra-muscular formulation of Risperidone in the year 2018 with the hypothesis that Prolactin monitoring is done less frequently than recommended.

Background

Risperidone is the anti-psychotic drug most frequently associated with hyperprolactinemia which is often asymptomatic but can present with symptoms of oligomenorrhea, amenorrhea, galactorrhea, decreased libido, infertility, and decreased bone mass in women. Men with hyperprolactinemia may present with erectile dysfunction, decreased libido, infertility, gynecomastia, decreased bone mass, and rarely galactorrhea. The BNF advises monitoring of Prolactin at baseline, after 6 months, and then annually.

Method

Retrospective review of 150 patients’ clinical letters to identify if they are on the above medications, using the local digital records system EPEX. Emails were also sent to community psychiatric nurses asking them if they could highlight any patients they were caseholding on the above medication. Depot clinic lists were also examined. Patients identified as being on the above medication had their blood tests reviewed on the online system Clinical Workstation (CWS) to determine whether they had their Prolactin level tested. A single spot sample of all patients on Talygarn ward in January 2019 was also included.

Result

1. 28 Risperidone

2. 23 of 28 never had any Prolactin measurements

3. 2 of 28 patients had the appropriate level of monitoring done for the year of 2018

a. One patient complained of Galacotorrhea

b. Another patient had baseline done while on the ward and isn't due for any further monitoring at the time of writing.

Conclusion

The above results identify that Prolactin monitoring is not being routinely completed for patients on the studied medication at an acceptable compliance level. Limitations around utitlity of prolactin monitoring may be the contributing factors; eg. Prolactin levels or medication dose may not be positively associated with adverse effects.. Further efforts were made to highlight the importance of baseline prolactin monitoring, as well as including a baseline Prolactin as an admission blood test for patients presenting with psychotic symptoms or on an anti-psychotic. A complete audit of metabolic monitoring and Prolactin levels for all patients on anti-psychotics would be an appropriate next step.
Audit of ADHD medication prescription and monitoring in intellectual disability services, Greater Glasgow & Clyde
Authors: Bansal Neha , Hayat Muzammil
Published: June 2021

Aims

Studies have shown that people with intellectual disability (ID) show a greater severity of attention deficit hyperactivity disorder (ADHD) symptoms and atypical presentation, as well as having a greater risk of developing comorbidities, such as challenging behaviour, anxiety, tic disorders and sleep problems. It is estimated that 1.5% of patients with ID will have a clinical diagnosis of ADHD.

The aim of this audit was to find whether individuals with ID and ADHD, who are prescribed medication for ADHD are adequately monitored and reviewed in accordance with the ADHD medication prescription guidance by NICE and the Royal College of Psychiatrists (RCPsych).

Method

This audit looked at ADHD medication prescription for the ID population within Greater Glasgow & Clyde NHS. This is the 6th audit cycle where electronic records (EMIS) were analysed between 28/9/19 to 09/10/20. (The 5th cycle data collection period ended on 28/9/19). We collected data on all patients aged over 18 years.

An audit tool was developed to find whether the following were documented; patient demographics, physical health monitoring, symptom severity, medication dosage, side effects, need for ongoing treatment and frequency of review. 100% of patients should have all components on the ADHD audit tool documented, as per NICE/ RCPsych prescription guidance.

Result

32 patients were identified as being diagnosed with ADHD prescribed medication. One patient was impacted by the COVID-19 pandemic which meant that the required monitoring was not fully carried out. The age ranged from 18 to 56 years. 75% had mild intellectual disability, 19% had moderate and 6% had severe, with no cases of profound intellectual disability. Blood Pressure/pulse was recorded in 84% of patients. Height/weight/ BMI was recorded in 81% of patients. 97% of patients had ADHD symptom severity, medication dosage, side effects, need for ongoing treatment and frequency of review recorded.

Conclusion

There is further scope for improvement in the monitoring and documentation of physical health observations, however there was a significant improvement compared to the previous cycle of the audit. Other aspects of monitoring and documentation appear to be recorded in almost 100% of patients. This finding emphasises the challenges of physical health monitoring and compliance in psychiatry as a whole. We need to continue to encourage awareness and education around the physical health risks to our patients, not only due to their comorbidities but also as a result of the psychotropic medications we prescribe them.
Annual physical health checks within a forensic inpatient service
Authors: Cooper Michael , Gangopadhyay Partha
Published: June 2021

Aims

Patients prescribed antipsychotics are at risk of ill effects to their physical health. Our aims were to assess whether inpatients within a forensic service, on antipsychotic medications, were receiving annual physical health monitoring in accordance with current NICE and SIGN Guidelines. Based on these Guidelines the following objectives were identified:

1: Physical examination, BMI and blood pressure recorded within the past year

2: FBC recorded within the past year

3: U&Es recorded within past year

4: LFTs recorded within the past year

5: HbA1C / random glucose / fasting glucose recorded within the past year

6: Random lipids / fasting lipids recorded within the past year

Method

Inclusion Criteria: Patients admitted for longer than a year currently prescribed an antipsychotic.

Data were collected cross-sectionally on 24/7/20 for all inpatients meeting the inclusion criteria. Medical notes and the blood results system were reviewed for results of any annual physical examinations and blood monitoring over the past year.

Anonymized data were analysed using Excel.

Result

13 out of 17 inpatients fulfilled the inclusion criteria. Of these 13 inpatients, 9 (69.2%) were prescribed clozapine, 1 (7.7%) zuclopenthixol, 1 (7.7%) paliperidone and 1 (7.7%) amisulpride.

All patients had BMI and blood pressures recorded within the preceding month. Only 1 patient (7.7%) had an annual physical health examination within the past year.

Findings for bloods taken within the past year were as follows:

12 patients (92.3%) had an FBC recorded

9 patients (69.2%) had U + Es recorded

9 patients (69.2%) had LFTs recorded

11 patients (84.6%) had HBA1c recorded

7 patients (53.8%) had lipids recorded

Conclusion

There is scope for improvement with both annual physical examinations and blood monitoring.

All patients had regular BMIs and blood pressure recorded which is largely attributable to nursing staff protocols. Low compliance with full annual physical examination could be explained by there being no local system in place for annual physical health checks and also frequent changes in junior doctor ward cover.

Blood monitoring showed variable compliance with established standards. FBC monitoring had the best compliance, likely because the vast majority of our patients are prescribed clozapine, which necessitates minimal monthly FBC monitoring.

This audit was presented to the Forensic Team and thereafter it was agreed for a local system to be put in place for annual physical health checks in the summer each year. This will improve oportunities to optimise our patients health. We plan to re-audit at this time.
Audit of the quality and content of discharge summaries from mental health inpatient units across Betsi Cadwaladr University Health Board
Authors: Dhandapani Asha , Soundararajan Sathyan , Williams Laura , Aghahowa Ediriverere Endurance , Clifford John
Published: June 2021

Aims

Our aim was to carry out an audit of summaries sent from inpatient psychiatric units across North Wales (namely Heddfan in Wrexham, Ablett in Rhyl, and Hergest in Bangor), against recommendations from ‘Standards for Inpatient Mental Health Services’ (RCPsych 2014) and PRSB Mental Health Discharge guidelines (2018).

Method

Ablett summaries are typed onto and electronically sent through the Welsh Clinical Portal (WCP) directly to the GP. Hergest and Heddfan both have their own templates which are then sent to the GP and filed in the case notes. Data were collected from both sources. The first audit cycle used 25 discharges selected at random from the male and female open wards in each site (n = 75 summaries). Data were collected over 3 months time using the audit proforma.

Result

All mandatory headings are automatically inputted into the WCP summary used in Ablett therefore documentation was 100% for information such as patient name, DOB, and GP Details. Documentation of allergies was poor across 3 sites, particularly in Hergest, in which there was no mention of allergy status in 96% of summaries. Only 13% of Ablett summaries and 0% of Hergest summaries reach the GP on the day of discharge, however, 100% of summaries from Heddfan do, possibly due to their method of ‘discharge notification’. The date and location of discharge were documented in 84% of Heddfan summaries, 100% of Hergest summaries, and 100% of Ablett summaries. This implies that this heading is already incorporated into the templates for the 2 sites which scored 100%. In the Ablett, medication was documented in 88%, but we found that in 49% of discharge summaries, the medication was the only field filled in! In these cases, the GP may not even know why the patient had been admitted. This is clearly unacceptable. Risk history is poorly documented across the sites, with 0% in Hergest and Heddfan, and 12% in Ablett. 0% of summaries across the Health Board mentioned crisis contacts. 0% of summaries in Heddfan and Ablett contained details of the patient's care coordinator.

Conclusion

Our audit has identified a lack of psychiatry-relevant headings in the discharge summaries, particularly for those working in Ablett.
An audit of ECG monitoring in patients admitted to the general adult wards at clock view hospital
Authors: Hyland Declan , Thandi Unmol , Mahamithawa Udani , Elagamy Yasmine , Uddin Mohammed
Published: June 2021

Aims

To identify whether patients admitted to the general adult inpatient wards at Clock View Hospital, an inpatient unit in Mersey Care NHS Foundation Trust, have an ECG performed following admission and whether, if this done, the ECG report is properly documented in the patient's electronic record, and whether those patients with an abnormal ECG have any further investigations requested.

Background

An important risk factor for development of cardiac disease is use of psychotropic medications. Antipsychotics can increase the QTc interval.

NICE guidelines recommend that, before starting antipsychotic medication, an ECG should be offered if physical examination identifies cardiovascular risk factors, there is personal history of cardiac disease or if the individual is being admitted to hospital. The Royal College of Physicians states all patients should be assessed for cardiovascular disease, including having a routine ECG. Mersey Care's physical health policy recommends all new admissions to inpatient wards have an ECG performed within 24 hours of admission as part of their admission physical examination and investigation.

Method

A sample of 60 patients discharged from the general adult wards at Clock View Hospital between 16th of July 2019 and 30th of September 2019 was obtained. An audit tool was designed and each patient's electronic record scrutinised to determine whether an ECG was performed within 24 hours of admission; in those patients who didn't, whether the reason why was recorded; and whether those patients who had an abnormal ECG were referred for further investigation. The quality of documentation of ECG reports was also analysed.

Result

Age range of patients was 19–66 years. Only 31 patients had an ECG performed within 24 hours of admission. Of the remaining 29, there was documentation of why an ECG was not performed in only 16 cases. Thirteen patients had an abnormal ECG, but only three were referred for further investigation. Of the ECG reports that were analysed, only a minority met the required standard for “good”, with there being no documentation of the ECG report in one third of cases.

Conclusion

There is significant room for improvement in performance of ECG monitoring and documentation of the ECG report. The importance of the ECG as part of the admission process needs to be highlighted in the induction of junior doctors. Training nursing staff on the wards to perform ECGs would reduce the likelihood of unnecessary delay to a patient having an ECG done following admission.
An evaluation of the prevalence of weight-related comorbidities in patients following admission to the general adult inpatient wards in Mersey Care NHS Foundation Trust
Authors: Hyland Declan , Prime Millie , Khaliq Rabia
Published: June 2021

Aims

This audit aims to evaluate the prevalence of any weight-related comorbidities in patients following their admission to the general adult inpatient wards in Mersey Care NHS Foundation Trust.

Background

Obesity has an increased prevalence in those with mental disorder. There are many factors that influence this, e.g. sedentary lifestyle and poor dietary intake. Medication prescribed to treat mental disorders may increase risk of weight gain, particularly most of the second generation antipsychotics. Patients with severe mental illness are at increased likelihood of developing weight-related comorbidities - essential hypertension, ischaemic heart disease, hyperlipidaemia and type II diabetes mellitus.

Many patients with severe and enduring mental illness do not readily or regularly access primary care services. Admission to the psychiatric ward therefore provides an ideal opportunity to address, not only the patient's mental health issues, but also any physical health issues.

Method

A list of all inpatients on the eight general adult wards was obtained on 3rd of December 2020. Inpatients on the Psychiatric Intensive Care Unit were also incorporated, providing a final sample of 148 inpatients.

An audit tool was designed, to collect demographic data for each inpatient – gender, age, ethnicity, psychiatric diagnosis, as well as the presence of any cardiovascular comorbidities and, if so, what were they and how many were present.

Result

Of the 148 inpatients, 91 were male, 57 female. Patient age ranged from 19 to 71 years. The majority were of “white British” ethnicity. The most common mental disorder diagnosis was schizophrenia (35 inpatients), followed by schizoaffective disorder (22 inpatients). Twenty-one of the 148 patients had at least one weight-related comorbidity recorded. Only 2 of the 21 inpatients with a diagnosis of one or more weight-related comorbidity had a recorded BMI in the “healthy” range. The gender split for the presence of weight-related comorbidities was almost equal. The most common comorbidity recorded was type II diabetes mellitus. Most patients with a weight-related comorbidity had only one recorded, but three patients had two comorbidities recorded, and one patient had three recorded.

Conclusion

A significant proportion of patients admitted to the general adult inpatient wards in the trust have a weight-related comorbidity. Admission to hospital provides an ideal opportunity to review the management of any such comorbidity and optimise this as required. There is a need to ensure there is a strong focus on, not only the patient's mental health issues, but also his / her physical health status.