bluuebunny/crossref_metadata_2025_split huggingface dataset:
Acute mania with psychotic symptom in post COVID-19 patient
Authors: Shanmugam Sridevi , Kumar Praveen , Carr Blaga 
Published: June 2021

AimsCOVID-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.MethodA 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.ResultThis 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.ConclusionClinicians 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

AimsThe study aims to examine the severity of anxiety in primary and secondary doctors in the UK during first wave of COVID-19 pandemic.MethodAn 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.Result273 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.ConclusionThe 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

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

AimsAmong 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.MethodParticipants 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.ResultAmong 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.ConclusionThere 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

AimsTreatment 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.MethodWe 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.ResultTEP 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.ConclusionTEP 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

AimsSexual 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).BackgroundResearch 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.MethodOur 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.ResultOur 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.ConclusionOur 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

AimsDriving 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.MethodA 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.Result100% 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.ConclusionDiscussing 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

AimsThe 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.BackgroundRisperidone 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.MethodRetrospective 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.Result1. 28 Risperidone2. 23 of 28 never had any Prolactin measurements3. 2 of 28 patients had the appropriate level of monitoring done for the year of 2018a. One patient complained of Galacotorrheab. Another patient had baseline done while on the ward and isn't due for any further monitoring at the time of writing.ConclusionThe 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.