bluuebunny/crossref_metadata_2025 huggingface dataset:
Driving in Home Treatment Teams: Are We Talking About It Enough? An Audit Covering Kingston and Richmond Boroughs in South West London and St George's NHS Trust
Authors: Healy Soracha , Lakhani Radhika , Ahmad Zulkarnain , Francis Sasha
Published: August 2024

Aims

Legality of driving and serious mental illness is often poorly understood by service users and staff. The risk of rare but serious consequences indicate the value in including driving risk in initial assessments. The Driving and Vehicle Licensing Authority (DVLA) advises not to drive and notify them of changes in condition or concerns around an individual's ability to drive. Crisis periods can represent changes in condition for individuals with chronic mental health conditions including psychotic disorders, manic episodes, severe anxiety and depression, and personality disorders. It therefore is pertinent for home treatment team (HTT) clinicians to consider driving safety, in patients requiring crisis intervention. The aim of our audit was to identify what proportion of patients on the Kingston and Richmond HTT caseloads are asked about driving and implement changes to facilitate discussion thereby improving safety.

Methods

Retrospective data was collected from Rio clinical record software from the entire Richmond HTT and Kingston HTT caseloads at baseline, two and four months post-intervention. Clinical records were reviewed to establish if driving was being discussed. Data was inputted anonymously into Excel and simple statistical analyses conducted.

Inclusion criteria were patients on the Richmond Kingston HTT caseloads on the date of data extraction for cycles 1, 2 and 3. Patients were excluded who had not yet had their initial assessment.

Following initial data collection we joined stakeholders at Trust-Wide HTT Governance meeting covering five boroughs and presented findings. We agreed changes to implement including incorporating a driving prompt in the initial assessment proforma and providing a DVLA leaflet in the welcome pack.

Results

From baseline data of combined caseloads, 17.7% of patients had documented evidence of driving discussion. At two months, re-audit showed that 33.3% of patients were asked about driving. With consideration of delays in change implementation with large teams and shift work, a third data collection cycle was completed 4 months post intervention. This showed that 56.0% of patients were asked about driving.

Conclusion

The changes implemented have been effective in sustaining increased awareness on this important topic and facilitating discussion with patients. There is potential to increase awareness further by expanding this as a trust-wide, regional or national initiative whilst enhancing stakeholder engagement.
A Re-Audit of the Assessment of the Nutritional Status of Patients Admitted to the General Adult Inpatient Wards in Mersey Care NHS Foundation Trust
Authors: Hyland Declan , Abulais Faraaz , Baruah Ranjan
Published: August 2024

Aims

Obesity and malnutrition have increased prevalence in individuals with mental disorder. Patients with severe mental illness are at increased likelihood of developing weight-related comorbidities, particularly type II diabetes mellitus.

Admission to the psychiatric ward provides an opportunity to address, not only the patient's mental health issues, but also any physical health issues.

The aim of this re-audit was to assess whether patients were managed in compliance with the Mersey Care NHS Foundation Trust Nutritional Screening Protocol on eight general adult inpatient wards across the Trust.

Methods

Data from the first five admissions (starting from 1st April 2023) to eight general adult inpatient wards in the Trust was collected and assessed.

A total of 40 inpatient admissions were identified. The results were collated and compared to the standard – Mersey Care's Nutritional and Hydration Policy.

Results

36 patients (90%) had a Malnutrition Universal Scoring Tool (MUST) completed within 72 hours of admission. Of the four patients (10%) who didn't have a MUST score within 72 hours of admission, three were completed after 72 hours.

46% of patients had a MUST score of 0 (low risk), 31% a MUST score of 0 (high risk obesity), 10% a MUST score 1 (medium risk) and 13% a MUST score of 2 or above (high risk).

Of the five patients with a MUST score of 2 or above (high risk), three (60%) were compliant with all elements of the Nutrition Screening Tool Care Plan. Of the 12 patients with a MUST score of 0 (high risk obesity), seven (58%) were compliant with all elements. Of the four patients with a MUST score of 1 (medium risk), all were compliant with all elements.

Overall, 31 (79%) patients had every element of the Nutrition Screening Tool Care Plan completed.

Conclusion

There was significant assurance of systems and processes in place and working well to ensure compliance, with only minor issues of concern identified.

Whilst the MUST score within the first 72 hours following admission had been completed in most inpatients, referrals to the dietician had not been done consistently in line with Trust policy. This is an area that requires addressing. Some training may need to be delivered to underline the importance of adhering to Trust policies.

An action plan to circulate the audit findings to all general adult inpatient wards across the Trust and re-auditing with a larger sample size across the Trust has been recommended.
Audit of Resuscitation Equipment in a Mental Health Setting – Resulting in Trust-Wide Action
Authors: Knowles Natasha , Husain Noori
Published: August 2024

Aims

The aim of this audit was to review the availability of recommended resuscitation equipment in Prospect Park Hospital (PPH), a psychiatric hospital based in Berkshire.

The objective was to improve patient safety standards and address staff concerns by ensuring that recommended resuscitation equipment was accessible and fit for purpose.

Our hypothesis was that the current standard of resuscitation equipment at PPH was unsatisfactory.

Background

This review followed concerns by doctors who struggled to obtain the necessary equipment required for emergency situations, particularly during their out of hours shifts.

This project was significant as within the previous year there had been two incident reports and extensive anecdotal evidence of equipment failure/absence.

Whilst each ward had been tasked with completing a weekly checklist issued by the Resuscitation team, these had not been audited to ensure that standards were being met.

Methods

Data was collected from ten locations at Prospect Park Hospital from 9th May to 15th May 2023.

Information was obtained by two doctors visiting the specified wards, reviewing the resuscitation bag equipment based on the standardised checklist.

The standards used were from local trust policy and Resuscitation Council UK policy.

Results

7/10 locations did not meet the standards for resuscitation equipment, including missing or expired equipment such as adrenaline, suction devices and oxygen masks.

4/10 wards had not completed the weekly emergency drug checklist within the stipulated time frame.

70% of staff completed checklists were incorrect.

Conclusion

Our hypothesis was proven to be correct, in that the current standard of resuscitation equipment at PPH was unsatisfactory.

We worked closely with the Resuscitation lead to recommend improvements, including an updated, more detailed checklist, a standardised procedure for ward managers and regular future audits.

Due to the significance of the findings, this has since been re-audited and is in the process of being rolled out Trust-wide, including all inpatient and community settings.

As a result of this audit, the Resuscitation team have been granted additional staffing to action these changes and increased their remit to monitoring equipment in addition to training.

These findings demonstrate that it is vital that the recommended resuscitation equipment is available and suitably maintained, particularly in a community hospital setting with limited resources where it can be life-saving.
Audit of Compliance With Stopping the Overprescribing of People With Autism Spectrum Condition (ASC) and Intellectual Disability (STOMP) Within the Child and Adolescent Mental Health Services (CAMHS) in Warrington, Mersey Care NHS
Authors: Kwarkas Vullong , Hanna Mariam
Published: August 2024

Aims

To assess compliance with the standards set in the Royal College of Psychiatrists (2021) Position Statement PS05/21: Stopping the overprescribing of people with ASC and Intellectual disability (STOMP) within the Child and Adolescent Mental Health Services (CAMHS) in Warrington, and Mersey Care Consent to Examination and Treatment Policy SD06

Methods

A retrospective analysis of the electronic record of children and young persons (CYPs) having a diagnosis of either ASC, attention-deficit/hyperactivity disorder (ADHD), or both, and taking psychotropic medication while actively receiving care at Alders Warrington CAMHS between 1st May 2023 and 31st May 2023, was performed. The audit sample included 18 CYPs meeting the criteria, and we conducted the audit against 14 Compliance standards.

Results

18 CYPs were included in the audit. 10 (55%) had a comorbid diagnosis of anxiety disorder, depression, or both, while eight (45%) had OCD, OCD Traits or Tic disorder. Four CYPs (22%) had challenging behaviour, including self-injurious behaviour in one of them. Although 17 (95%) of the CYPs had a mental disorder, the clinical indication for the psychotropic medication, which was documented for all patients, was also for behavioural problems viz challenging behaviour, and self-injurious behaviour, for 3 (17%) CYPs. For one patient (6%), there was no behavioural support plan (BSP), before the commencement of psychotropic medication. Three patients were prescribed psychotropic medication for behavioural problems. Two of the three patients with challenging behaviour had already commenced psychotropic medication before referral to the locality. All eligible patients had an initial multi-disciplinary team (MDT) meeting before prescription and routine 3-monthly reviews for efficacy and side effects. In all the cases, a specialist prescriber prescribed medication, and mental capacity was assessed and documented. Where necessary, a decision was taken in the patient's best interest. The service met all other requirements for compliance with standards set in the RCPsych position statement except for three criteria.

Conclusion

Overall compliance with STOMP guidelines at the Alders Warrington CAMHS was 98%, with Significant Assurance. Dissemination of good practices and an early re-audit is strongly recommended.
The Use of the Emergency Department as a Place of Safety Following Section 136 Detention
Authors: Ogunsina Oluwadamilola , Hickmott James
Published: August 2024

Aims

Section 136 of the Mental Health Act 1983 allows for a person who appears to a constable to be suffering from a mental disorder and needing immediate care to be removed to a place of safety (POS) for their protection or the protection of others.

The legislation recommends that prior to making a decision to detain on Section 136, the constable must, if practicable, consult mental health services for information to guide decision making.

The 136 suite is the preferred POS except for patients requiring urgent medical treatment in which case the Emergency Department (ED) is preferred. If the 136 suite is unavailable, then alternatives like the ED may be used.

This audit examines the use of the Birmingham City Hospital Emergency Department as a POS following Section 136 detention, the adherence to the aforementioned legislation and the outcomes of the assessments.

Methods

The audit was approved by the clinical governance team and a list of all Birmingham City Hospital patients detained under Section 136 for a three-month period (January–March 2022) was retrospectively obtained. Clinical records were examined, and the relevant data was extracted from the clinical notes.

Information including the reason for use of the ED as a POS, police contact with mental health services prior to detaining, time taken prior to assessment, reasons for mental health act assessment (MHAA) delays, and outcomes were collected and collated using Microsoft Excel.

Results

The ED at City Hospital was used a place of safety for 80 patients in this period. In 52.5% of cases the ED was used as a place of safety due to lack of space at the POS. Contact with mental health services prior to detention was documented in only 29% of cases. The average time for a MHAA to take place in the period under review was 11.5 hours. Only 20% of these cases ended up detained under the mental health act.

Conclusion

The results show poor adherence in the use of Section 136 to the recommendations of the legislation. Improvements are needed on time taken for assessments and use of ED as a place of safety due to unavailability of beds at the s136 suite. The police should be re-educated on the importance of contacting mental health services prior to detaining patients on Section 136. The audit result was presented at a clinical governance meeting and repeat audits are planned across all the emergency departments in Birmingham.
Clinical Audit of Psychiatrist Reviews of Patients on Depot Antipsychotic Medication Under a General Adult Community Mental Health Service in North Norfolk
Authors: Olajide Oluseyi
Published: August 2024

Aims

In outpatient settings, depot administrations are done to a large extent by Community mental health nurses and other trained clinical personnel who are not psychiatrists. As a result of this, there is a possibility that patients who are having depot medications are not reviewed by a psychiatrist for a long duration of time which can be more than a year. The aim of this audit is to find out if patients currently taking depot medication under a General Adult Community Mental Health Service in North Norfolk are being reviewed by a psychiatrist according to the standard guidelines. The Maudsley prescribing guidelines states that all patients receiving long-term treatment with antipsychotics medication should be seen by their responsible psychiatrist at least once a year (ideally more frequently) to review their treatment and progress.

Methods

List of patients currently on depot medication were taken from the spreadsheet on the Unit's Shared drive. All 47 patients currently receiving depot medication on this list were reviewed. The review period was from Ist January 2023 to 31st December 2023. Psychiatrist Review included Reviews/Appointments by Consultant Psychiatrists, Specialty registrars, Trainee doctors and GPST doctors in psychiatry posting.

Results

It was recorded that 28 patients on depot medication have been reviewed within the last one year which is approximately 60% of the patients currently on depot medication. 19 patients who are currently on depot medication have not been reviewed by a psychiatrist in the last one year, which is approximately 40% of the patients on depot medication. Out of the 19 patients who have not been reviewed in the last one year by a psychiatrist, only 8 of them were offered an appointment.

Conclusion

We can conclude only 60% of patients currently on depot medication were seen by a psychiatrist for a medication review in the last one year. This fell below the expected target of having 100% of these patients meeting with the standard that states all patients receiving long-term treatment with antipsychotic medication should be seen by their responsible psychiatrist at least once a year. A significant proportion of patients might have been deprived of an adequate assessment of their progress and response to treatment and the review of the side effects of these depot medications. These findings have been discussed with the Community Team Manager who has agreed to facilitate that these patients are reviewed promptly.
Psychiatric Admission Documentation at Leverndale Hospital, Glasgow
Authors: Rafters Cecilia , Imrie Wai Lan
Published: August 2024

Aims

To ensure psychiatry admission assessments are well-documented and available via EmisWeb clinical notes system.

To assess whether replacing the clerk-in booklet with a digitalised version affects documentation of psychiatry admission assessments.

The standard was use of the current admission template with information under each heading. In addition, a Clinical Risk Assessment Framework for Teams (CRAFT) tool should be completed by the admitting doctor. Legal status, observation level and time-out status should be recorded.

Methods

A retrospective full-cycle audit of the first twenty patients admitted to Leverndale Hospital, Glasgow starting 1st Dec 2022, then 1st April 2023 for the second cycle. Patients were identified using EMISWeb admission dates and information from Medical Records. Data was taken from the EMISWeb record and analysed using Microsoft Excel – if incomplete paper notes were checked.

Use of the admission template and presence of meaningful content (excluding “n/a” and similar) under each heading was recorded. Data was collected on the documentation of legal status, observation level, time-out status, and CRAFT risk assessment by the admitting doctor. Perinatal psychiatry admissions and transfers between psychiatric units were excluded.

Results

Medicines reconciliation was absent in 55% and allergies in 70%. CRAFT risk assessment was completed by the admitting doctor in 55% of cases.

Following round 1, a digitalised admission proforma was introduced, replacing the traditional admission booklet.

There was little improvement in usage of the admission proforma with the introduction of the digitalised version (80% vs 75% previously). Notably, the rates of CRAFT risk assessments by the admitting doctor fell in this 2nd cycle – from 55% to 40%.

Recording of allergy status (55% from 30%) and medications (95% from 45%) seemed to improve. Importantly quality of content was not appraised – many medication entries consisted of “as per HEPMA (electronic prescribing system)”.

100% of admission documentation was now available on EMISWeb, preventing information loss and allowing remote access from Community Mental Health Teams.

Conclusion

The introduction of a digitalised admission template had little impact on use of the proforma. However it meant that 100% of admission information was available digitally, versus 85% previously.

In both cycles the CRAFT risk assessment was often not completed by the admitting doctor. Given risk assessment is a key reason for “clerking in” psychiatric inpatients, this could be a focus for future quality improvement work.

In the second cycle, recording of medications and allergy status had improved significantly. Given small sample sizes, this may be due to chance.
Fibroscanning Recommended by NICE in Drug and Addiction Services: An Audit
Authors: Atkinson Fiona , Robertson David , Saeger Ivan , Kelleher Michael
Published: August 2024

Aims

The prevalence and subsequent physical health burden of alcohol use disorder is on the increase in almost all age groups in the UK and nearly 1 in 5 of the population will drink at hazardous levels. Those who drink heavily often have limited or patchy engagement with physical health services and improving this should be a focus of drug and alcohol services.

Our aim was to audit the proportion of clients attending the alcohol service at Lorraine Hewitt House (LHH) who had completed a fibroscan, to audit the outcomes of those fibroscans and to audit the outcomes of the onward referrals where they had been made.

Methods

Since starting the liver clinic, more than 100 fibroscans have been completed. These are typically offered to clients in the alcohol pathway and where it can be facilitated, they are done on the day, or otherwise booked in for scheduled appointments.

We audited the results of the scans, for liver stiffness and liver steatosis. Additionally, for those who had abnormal results requiring onward referral, we audited the outcomes of these referrals.

Outcomes and overall physical health were subsequently discussed with each patient who underwent a liver scan.

Results

A total of 100 fibroscans were audited. This represents approximately one third of the clients with alcohol as their primary problem substance at LHH.

Every client had the results of their scan explained and discussed with them and were given lifestyle advice and interventions.

A total of 37 scans (37%) had all their parameters within the normal range. 16 (16%) showed an increased liver stiffness of >10kPa and 15 people (15%) gave consent and were subsequently referred to our local liver clinic. 13% had stage 1 steatosis (238–260dB/M), 18% had stage 2 steatosis (260–290dB/M) and 29% had stage 3 steatosis (>290/dB/M).

Of the 15 referrals made to liver clinic, 10 (66.7%) attended their liver clinic follow up appointments and 9 of these clients are awaiting further interventions – the remaining 1 client has been discharged back to their GP.

Of the remaining 5 referrals made to liver clinic, 2 are awaiting appointment dates and 3 are pending triage.

Conclusion

The physical health of clients attending drug and addiction services is often complicated and in need of specific and targeted interventions. Liver health is particularly relevant to the alcohol client group and integrating fibroscans into drug and addiction services facilitates better engagement and early assessment and intervention.
Do Not Attempt Resuscitation (DNAR) Orders in an Older-Age Psychiatric Hospital
Authors: Thompson Sian , Whybrow Michael
Published: August 2024

Aims

We aim to see whether DNAR discussions are being undertaken at an appropriate time for our patients, as well as seeing whether these are recorded formally and regularly reviewed, as per local protocol. We also aim to see whether the immediate medical/nursing teams are aware of the local guidelines, as well as which of their patients have a DNAR in situ, and how to find this out. As an old-aged psychiatric unit, this is very important.

Methods

We used 2 methods of data collection. One was questionnaires that we gave out to medics, nurses, and HCAs on our wards. We collected quantitative data from them on whether they knew where DNAR forms were and which of their patients had DNAR forms. We then also collected quantitative data from our online notes, looking into which patients had DNARs, whether these were recorded online and in a physical copy, whether it was discussed on clerking, and whether it was regularly reviewed and documented in MDTs. We used data from 51 inpatients over 3 wards.

Results

Over 30% of patients have a DNAR in situ across the 3 wards. The dementia-focussed wards have a higher number of DNARs in place. All patients with a DNAR had a purple form completed and kept on the ward. 75% of staff knew where these were. Only 20% of those with DNARs had these documented online as per local guidelines; only 45% of staff knew where to find this information online. Only 8% of patients had their DNAR status discussed on admission, and 10% in their first MDT. Only 60% staff knew which patients had a DNAR in situ.

Conclusion

There is evidence that purple forms are completed appropriately and stored well. The main issue is the online record-keeping; staff either don't know how to or that they can document this online. This is reiterated as many did not know where the information was online. This demonstrates a lack of knowledge and education.

DNAR conversations are not occurring in the first place; the status is not being regularly reviewed, leading to issues where these conversations are rushed during acute events. It is important to think about these things earlier to ensure everyone, patient, family and staff, understands the process and rationale.

Lack of staff knowledge on which patients have DNARs in situ could be a great issue if an acute event were to occur, and compromises patient safety.
Improving Completion Rates, Accuracy and Online Upload of DNA CPR, Adults With Incapacity (AWI) and Hospital Anticipatory Care Plan (HACP) Documentation in Two Old Age Psychiatry Wards in NHS Fife
Authors: Womersley Kate , Mansfield Olivia , Holland Emma , Abuthahir Adeeb , Shah Nasser
Published: August 2024

Aims

To evidence accurate completion and online upload of DNACPR, Adults with Incapacity (AWI) and Hospital Anticipatory Care Plan (HACP) paperwork at the point of admission across two old age psychiatry wards at Queen Margaret's Hospital, NHS Fife.

Methods

We identified which of our 36 inpatients required DNA CPR, AWI and HACP forms, compared with those who actually had this documentation in place, correctly completed, in their paper notes. When documents were present, we confirmed whether they were also uploaded to Morse (NHS Fife's psychiatry electronic notes system).

Data were collected on August 25th 2023 for cycle 1. A Multidisciplinary team meeting was held in each ward to consider strategies for improving performance, and 11 weeks were allocated for intervention design and implementation, before data collection was repeated on November 10th 2023.

Results

The primary outcome was whether DNA CPR, AWI and HACP documentation were correctly in place across both wards. Completion rates of all forms improved between the two cycles, as did compliance with online upload (secondary outcome) and correct completion of all fields (secondary outcome).

Since our interventions (improving availability of forms, peer education regarding correct completion of forms, ward round prompts to review paperwork, streamlining workflow for scanning), there was a marked improvement in performance on both wards 1 and 4. For patients who were assessed to need an AWI form, form completion increased from 93.3% and 94.4% for each ward respectively, to 100% on both wards. Required fields on the form were completed in 71.4% and 76.5% for each ward respectively in August, increasing to 88.2% and 100% in November. DNA CPR forms were present for appropriate patients in 100% and 88.9% of cases on the two wards in August 2023, with 75% and 62.5% uploaded to Morse. This improved to 100% presence and 100% upload rates in November 2023. HACP forms were present in 100% and 83.3% of cases on the two wards in August, but were available online in 0% and 20% of cases respectively. This improved to 100% completion of HACP forms on both wards, with 100% and 91% respectively available online in November.

Conclusion

A combination of peer education, MDT learning, readily available forms, ward round review and awareness-raising across medical, nursing and administrative staff improved rates of accurate completion and online upload of DNA CPR, AWI and HACP paperwork.
Assessing Clinician Compliance With DVLA Guidelines for Psychiatric Inpatients
Authors: Yale Samuel , Redko Anastasiia
Published: August 2024

Aims

Mental health conditions have wide ranging impacts on individuals, including in their ability to safely drive. Attention, impulse control, judgement, and psychomotor reaction times are some of the ways in which mental health conditions and psychotropic medications impair ability to drive. To ensure safety of patients and other road users, the Driving and Vehicle Licencing Agency (DVLA) provides guidance to clinicians and patients regarding fitness to drive. The General Medical Council (GMC) also states that doctors have a duty to inform patients that their condition and/or medication can impact driving ability.

To evaluate compliance with DVLA and GMC guidelines, an audit was conducted to assess: 1) whether patients’ driving status was established; 2) whether patients were advised to inform the DVLA; and, 3) whether they were advised to inform their insurance company. This was subsequently re-audited after introducing recommendations to improve compliance.

Methods

Each audit cycle reviewed the 30 most recent discharges from an adult general psychiatry inpatient unit before and after intervention. Online notes, multi-disciplinary team (MDT) minutes and discharge summaries were reviewed to assess whether the above criteria were met. Following the initial audit cycle, results were presented at Trust-wide teaching, and driving status was added to an MDT template as a prompt to discuss this with patients. A second cycle was completed four months afterwards.

Results

Results of the first cycle (pre-intervention) showed driving status was established in 73% (n = 22) of patients. Of the drivers, 90% (n = 9) were advised to tell the DVLA, whilst only 9% (n = 1) were advised to tell their insurance company. Post-intervention, 67% (n = 20) of patients had driving status established, whilst 100% (n = 11) of drivers were subsequently advised to inform the DVLA, and 64% (n = 7) advised to tell their insurance company.

Conclusion

Clinicians have a legal and ethical duty to discuss driving status with patients. Failure to do so could have significant consequences on both individual and wider public safety. This audit showed that in clinical practice, key legal requirements were not being fulfilled. Whilst staff education and changes to MDT templates increased the number of drivers being advised to tell the DVLA and insurers, it had little impact on establishing driving status. Therefore, further changes were made to the discharge letter template to remind staff to assess patients’ driving status, and to enable community team follow-up. A third cycle of the audit is currently ongoing to evaluate this change.
A Suspected Case of Kluver-Bucy Syndrome in an Adolescent Male Following SARS-CoV-2 Infection
Authors: Barmpagianni Christina , MacDaid Kerenza , Williams Joanne
Published: August 2024

Aims

We present a case of suspected Kluver-Bucy syndrome in an adolescent male, following a SARS-CoV-2 (Covid-19) infection. To the best of our knowledge, KBS has not been associated with Covid-19 before.

Methods

A 15-year-old male with a background of autism spectrum disorder (ASD) was reviewed in a children and adolescent mental health outpatient clinic. The young person was non-verbal, and history was taken from his next of kin. In the last four weeks, he had developed acute onset hyperphagia with weight gain (88th percentile for age), new onset physical and verbal aggression, and hyperorality, whereby the young person was exploring household objects with his mouth. A degree of hypersexuality was also noted in the form of rubbing and touching of the genital area.

There was no history of trauma or epilepsy; recent traveling or environmental change; psychosocial stressors or new medications, operations, or immunisations in the past year. The young person had a Covid-19 infection the month before the symptoms started. He was immunised against Covid-19 and this was the second time he contracted the infection, the first being 1 ½ years ago with full recovery.

The sudden onset of hyperphagia, aggression, hyperorality, and hypersexuality with the only known precipitating factor the recent Covid-19 infection, raised clinical suspicion for Kluver-Bucy syndrome. Six months later, the symptoms were milder but still present and no other cause had been identified. Due to ASD features, visual field testing, brain imaging, or routine blood tests were either not possible or required sedation and are being arranged with the support of his general practitioner.

Results

Kluver-Bucy syndrome is a rare neurological disorder characterised by a distinct constellation of behavioural and cognitive symptoms resulting from bilateral lesions or dysfunction in the temporal lobes, particularly the amygdala. Patients often exhibit alterations in their behavioural repertoire, including hyperorality, hypersexuality, disinhibited behaviour, and visual agnosia. The presentation has been associated with temporal lobe infarcts, epilepsy, and herpes simplex encephalitis. The differential diagnosis was based on the fulfilment of clinical criteria for KBS, while other differentials included metabolic causes or behavioural manifestations related to ASD. Although investigations to explore other causes of symptoms are still being arranged, clinical suspicion for KBS was based on the presence of diagnostic criteria and the recent viral infection.

Conclusion

Research is needed to identify potential associations between SARS and neuropsychiatric manifestations, while clinicians should be aware of the possibility of such complications.
A Case Report of a 16 Year Old With Catatonia With No Clear Medical or Psychiatric Cause
Authors: Breakwell Andrew , Kelly Claire
Published: August 2024

Aims

16 year old male with previous diagnoses of autism spectrum disorder and severe anxiety disorder was referred to Child and Adolescent Mental Health Services (CAMHS). His presentation included increasing anxiety, difficulty articulating his thoughts and emotions, difficulty completing tasks, school non-attendance, reduced food intake and possible auditory hallucinations. Risperidone was trialled in the community however refused after 5 days due to “brain fog”. He was seen by CAMHS community team twice weekly for 3 months prior to his emergency detained admission to adolescent psychiatric inpatient unit, due to no oral intake for 72 hours.

Family history included schizophrenia, bipolar disorder, depression and anxiety.

Methods

Upon admission, symptoms observed included reduced verbal communication, psychomotor retardation, low mood, agitation, sleep difficulties, ambitendency, echolalia and poor oral intake. He had a Bush-Francis rating score of 8 and given a working diagnosis of catatonia. He responded positively to a lorazepam challenge therefore commenced on 1mg of lorazepam twice daily. Despite increasing doses, the catatonia worsened with severe psychomotor retardation, “psychological pillow” and nil food or fluid intake with Bush Francis score of 18. ECT was arranged as an emergency treatment but put on hold while tolerating all food and fluids requirements via nasogastric tube. Lorazepam dose was titrated to 3mg three times daily but signs seen of benzodiazepine toxicity therefore dose was reduced and ECT arranged for treatment resistance. Improvement seen on reduced dose prior to receiving ECT, therefore ECT put on hold again. His lorazepam dose was titrated up at a slower rate to 4mg three times daily which he was able to tolerate. His catatonia fully resolved at 12mg. Once stable, lorazepam dose was very gradually decreased until stopped. No evidence of catatonia returned.

Results

Medical and psychiatric causes of catatonia were explored.

Two positive blood anti-NMDA receptor tests two months apart; both 1/10 titre. This was discussed with the specialist neurology team in Oxford who advised this was an incidental finding with no clinical implication (1% of healthy population are positive).

Throughout admission, possible fleeting psychotic and depressive symptoms were noted, including not trusting food, hallucinations, worries about contamination and apathetic mood. However, these all improved as the catatonia was treated.

Conclusion

There was no clear underlying psychiatric or medical illness identified as a cause of the patient’s catatonia. Catatonia has a higher prevalence in people with autism. At discharge he was well and reintegrated back to community life without requiring further medication.
From Irritability to Amnesia: Unraveling Thalamic Glioma – a Case Report
Authors: Inanc Oyku , Dave Tirth
Published: August 2024

Aims

Gliomas, encompassing astrocytomas, oligodendrogliomas, and ependymomas, constitute the majority (40–55%) of primary brain tumors. Diagnosis can be challenging due to their uncommon nature, subtle symptoms, and diverse clinical manifestations. While neurological signs are typical, psychiatric symptoms may occasionally precede them. This case report explores a 59-year-old man whose initial psychiatric symptoms, resistant to treatment, evolved into memory impairment, ultimately revealing a high-grade glioma in the thalamus.

Methods

A 59-year-old male patient presented to the psychiatric service, expressing concerns about excessive anger and aggression. His family observed his behavior as abnormal, noting uncharacteristic personality changes, particularly increased irritability. Following an outpatient psychiatric evaluation, he was diagnosed with excessive irritability. Over time, the patient's aggressive behaviors intensified, accompanied by feelings of being ignored and devalued by his family, heightened emotional sensitivity, and episodes of muteness. Despite two trials of medication (i.e., sertraline and alprazolam), there was a deterioration in adaptive functioning. Two years after the first onset, the patient experienced unfamiliarity with surroundings, forgetting place names, memories, and people's names. The patient had no family history of neurological or psychiatric illness, and there was no evidence of substance use in his past. To rule out organic causes, an MRI revealed a 17×21 mm lesion in the right thalamus and a calcified focus in the superior part of the left tentorium. Subsequent biopsy confirmed a high-grade glial tumor: anaplastic astrocytoma Grade III, with a Ki-67 index of 10%.

Results

The extended onset of memory impairment in our patient, following a 3-year history of aggressive attacks and irritation, prompts an exploration of the intricate interplay between psychiatric and neurological manifestations. Unlike typical associations of personality changes with frontal lobe tumors, our case challenges this by implicating a thalamic tumor, highlighting the complexity of symptom correlation with precise brain lesion locations. Psychiatric symptoms, though not exclusive, may indicate underlying brain tumors. New-onset psychosis, mood or memory symptoms, atypical occurrences, personality changes, and anorexia in individuals over 40 warrant a thorough diagnostic workup, including neuroimaging, to investigate potential intracranial lesions.

Conclusion

This case emphasizes the significance of identifying psychiatric symptoms as potential indicators of underlying brain tumors. The diverse manifestations, such as sudden psychosis, mood or memory changes, or unusual symptoms, should prompt further investigation, including neuroimaging. Early detection is crucial for improving overall quality of life, and understanding these psychiatric signs aids in unraveling the broader narrative of potential brain tumor involvement.
Identifying Organisational Factors Related to Increased Risk of Depression in Usher Syndrome Patients: A Case Report
Authors: Kwan Fiona
Published: August 2024

Aims

Usher syndrome (USH) is the leading genetic aetiology of congenital hearing loss and progressive vision loss. It is linked with a high prevalence of mental health issues, including depression. Previous literature attribute this to communication barriers, constraints in mobility, and general feelings of dependency and uncertainty. However, there is little literature considering poor mental health in USH patients as a consequence of gaps in service provision on a national level.

Methods

The present report is the case of a 54 year old woman, who was born with USH Type IIa, and was previously diagnosed with depression and retinitis pigmentosa. The patient was recruited via the RareBeacons charity through volunteer sampling. A semi-structured interview was conducted, with 3 main categories: the impact of diagnosis, interpersonal relationships, and challenges in day-to-day life. A common theme of self-isolation was found, largely due to inefficient communication between healthcare providers, including but not limited to years of waiting for hearing aid treatment exacerbating symptoms of social withdrawal. The patient also reported inadequacies in physician knowledge regarding USH and their general unwillingness to be educated further. Unprofessional physician attitudes and lack of sensitivity towards the patient's deafblindness over time led the patient to feel distrust towards the system, which further compromises care.

Results

Areas of improvement on a systemic scale were identified, including increasing awareness of deafblindness in both the medical community and the general public through patient advocacy, as well as streamlining dedicated support pathways. The patient found formal support to be unhelpful, conversely emphasising the impact of informal support, namely web-based support group platforms. Support groups can provide a sense of community and belonging, alongside sharing valuable resources – often overlooked yet vital in USH, a rare condition with little official support. Subsequent research may include expansion of this case report to yield quantitative data, alongside investigating further factors increasing depression in USH patients (e.g. psychosocial, genetic and biological factors).

Conclusion

This report concludes that the gaping inadequacies of the current medical system poses a significant psychological, emotional and social burden on USH patients.
Eating Disorder or Disordered Eating; an Interesting Case Study
Authors: Michael Gabriel , Patel Natasha , Stanley Charles
Published: August 2024

Aims

Eating disorders often present as a significant challenge in adolescents; especially with regards to early diagnosis and intervention. This case report explores the complex presentation of a 15-year-old female initially suspected of having an eating disorder. The complexity in this case lies in the differentiation between a formal eating disorder and disordered eating, emphasising the importance of thorough assessment and understanding of the underlying psychological factors.

Methods

This patient presented to the CAMHS eating disorders team having lost 14 kg in 6 weeks. Such an alarming weight loss had triggered the urgent referral and review. These symptoms initially suggested a classic eating disorder. However as the patient spent more time on the physical health ward a comprehensive evaluation revealed underlying issues related to body image, self-esteem, and emotional wellbeing as well as complex family dynamics leading to a diagnosis of disordered eating rather than a specific eating disorder. The multidimensional approach involved collaboration between mental health professionals, paediatricians and dieticians, to address the multifaceted nature of the condition whilst the patient was admitted to a physical health ward.

Results

The case highlights the intricate interplay between physical and psychological factors contributing to disordered eating behaviours in adolescence. Factors such as societal pressures, peer influences, personal expectations as well as dynamics within a family home may all contribute to a distorted relationship with food and body image. Recognising these complexities is crucial for tailored interventions that address the root causes rather than merely focusing on symptomatic relief. We also established in this case the difference in efficacy between utilising aripiprazole vs olanzapine in terms of treatment of anorexic cognitions.

Conclusion

This case study underscores the necessity of a thorough and holistic approach in assessment, diagnosis and management of eating-related concerns in adolescents. By differentiating between eating disorders and disordered eating, healthcare professionals may better accommodate interventions to address the specific needs of the individual. Early identification and comprehensive care, involving medical, nutritional, and psychological components, are essential for promoting healthy relationships with food and preventing the escalation of disordered eating into more severe conditions.
Feeding Two Birds With One Seed: Using Fluoxetine for Pre-Menstrual Dysphoric Disorder and Bulimia Nervosa
Authors: Poodipedi Prarthana , Bains Parveen
Published: August 2024

Aims

Background

This case study describes the use of fluoxetine for reduction of pre-menstrual dysphoric disorder (PMDD) and bulimia nervosa symptoms. The case report also describes an increase in binge purge symptoms in the pre-menstrual period, along with other mood and cognitive symptoms. This supports a hormonal basis to the exacerbation of eating disorders. Patient consent was obtained prior to the publication of this report.

Methods

Case report

A 41-year-old lady with significant binge purge behaviours and mood disturbance was referred to our eating disorder service. She met the diagnostic criteria for bulimia nervosa after a thorough assessment, along with a component of mood dysregulation. She was prescribed sertraline for depressive symptoms in primary care. The patient described a worsening of mood symptoms, along with cognitive difficulties before the start of her menstrual cycle. After a medical review, we agreed on tracking these symptoms along with the binge-purge frequency for a period of two cycles. This was done using a PMDD tracker. The tracker reflected a clear diagnosis of PMDD along with an exacerbation of bingeing and purging symptoms before the start of a menstrual cycle. Following this, sertraline was switched to fluoxetine, and titrated up to its maximum dose of 60 mg a day.

Results

Discussion

Following the commencement of fluoxetine, purging frequency dramatically reduced and subsequently stopped. Although mood symptoms still persisted, the specific mood symptoms along with cognitive symptoms in the pre-menstrual period reduced.

Conclusion

There is some evidence for the use of fluoxetine use for binge purge symptoms in bulimia nervosa. Fluoxetine has also been used either continuously or in the luteal phase for PMDD. This case report reflects the possible correlation between binge-purge symptoms and PMDD symptoms, and the potential use of fluoxetine for dual symptom reduction. PMDD still remains to be a significantly under-diagnosed condition in women. This case report also signifies the importance of exploring PMDD symptoms in eating disorders.