bluuebunny/crossref_metadata_2025_split huggingface dataset:
Re-Audit of The Anticholinergic Burden on A later Life Psychiatry Inpatient Ward
Authors: Webb Cara , Kaur Japsimar 
Published: August 2024

AimsTo reassess and compare whether changes to medications are being made based on the anticholinergic effect on cognition (AEC) score. To understand the impact and implementation of recommendations from the first audit and whether these have led to change.MethodsData on AEC scores were collected from one later life ward in Greater Manchester. The audit considered patients admitted September 2022 to January 2023 and the re-audit those admitted March 2023 to September 2023. The data was collected retrospectively by the auditors by going into the electronic notes of the initial ward round, the four week ward round and the patients' electronic prescription charts, information was then inputted into and analysed in Excel.Results21 patients were included in the audit and 23 in the re-audit. Roughly 50% of patients in the initial audit scored 0 at 4 weeks, only 13% re-audit patients scored a 0. Eight more patients saw an increase in their AEC score within the re-audit than the audit. 5 patients had a lower anticholinergic burden during the audit, only 3 patients saw this decrease during the re-audit.ConclusionUnfortunately it appears the first audit's recommendations were not adequately implemented as no improvement was seen between audits. We must therefore try to increase awareness of the adverse effects of anticholinergic medications through posters, teaching sessions by pharmacists and information posters on the ward; the effectiveness of these interventions can be analysed through a future quality improvement project.The second recommendation is that the AEC score is to be calculated routinely for all patients admitted to an old age ward within the GMMH trust. This information to be included in the junior doctor induction pack and as a subcategory in the ward round documentation proforma.A final recommendation is for the electronic prescribing system to include a built-in AEC calculator and prompt at admission and 4 weeks with the AEC score.
Lithium and Bariatric Surgery: A Balancing Act
Authors: Anwar Zarina , Rajadurai Anjali , Dholakia Diya 
Published: August 2024

AimsPatients with severe mental illness (SMI) are at greater risk of poor physical health with higher prevalence of obesity, cardiovascular disease, diabetes and higher premature mortality than the general population. The reasons are complex and interventions are multifaceted. Obesity is highly prevalent in the general population and pharmacological and surgical treatments have become more widely available; however, SMI patients may face barriers accessing these. This case highlights specific factors for consideration in managing a patient on lithium therapy undergoing sleeve gastrectomy to balance the risk of lithium toxicity with risk of relapse. Currently, there is limited clinical experience of managing lithium in this context.Methods49 yr old female diagnosed with schizoaffective disorder well-maintained for several years on aripiprazole depot and 800mg lithium carbonate (Priadel) with therapeutic levels in treatment range (0.4–0.8mmol/L). Severe obesity (BMI 41kg/m2) despite dietary modifications and metformin trial, and recently diagnosed with diabetes. Family history of cardiovascular disease and diabetic related complications with early mortality were additional factors in her request for bariatric surgery. Multidisciplinary discussion including patient, psychiatrist, mental health pharmacist, specialist bariatric dietician and GP prior, to ensure sharing of relevant information pertinent to re-titration and monitoring of lithium therapy and risks of toxicity and relapse.ResultsPatient underwent sleeve gastrectomy with discontinuation of lithium 72 hours prior to surgery. Stomach pouch capacity reduced to 120ml and advised daily fluid intake 500–1000ml in first two weeks. Lithium therapy re-commenced when fluid intake adequate and renal function within normal limits. Formulation changed to liquid for 6–8 weeks to avoid disruption to the healing line, and the dose gradually re-titrated with close monitoring of serum lithium levels. Stabilised on reduced dose of 400mg Priadel at 3 months with therapeutic levels. At 6 months BMI reduced to 32kg/m2, antihypertensive and metformin discontinued and maintained remission of schizoaffective disorder.ConclusionSleeve gastrectomy is an increasingly common procedure to treat obesity, with potential long-term positive physical health outcomes and reduction in mortality which may have a role in addressing health inequalities for SMI patients. Psychiatrists need to be aware of key aspects of bariatric surgery particularly relating to safe and effective prescribing of psychotropic medication including potential change to liquid or orodispersible formulation in the post-operative period, close monitoring of serum lithium levels in the short and medium term due its narrow therapeutic index, and consideration of longer-term dose adjustments due to ongoing weight loss.
Case Report of Prescribing in Attention Deficit Hyperactivity Disorder With Glycogen Storage Disease Type 1A
Authors: ElGhandour Mahmoud , Gill Roop , Morganstein Louise 
Published: August 2024

AimsAttention Deficit Hyperactivity Disorder (ADHD), is a neurodevelopmental condition affecting both children and adults, with a global prevalence estimated to be around 5% in children and 2.5% in adults, significantly impacting daily functioning, academic performance, and interpersonal relationships.Glycogen Storage Disease Type 1A (GSD1A) is a rare metabolic disorder that occurs in approximately 1 in 100,000 births. It is characterized by accumulation of excessive glycogen and fat in the liver and kidneys that can result in growth retardation.The aim is to increase knowledge of pharmacological management of ADHD in patients with GSD1A.MethodsOur patient is a 16-year-old boy with both diagnoses of GSD1A and ADHD.GSD1A is treated with a special diet of frequent small servings of carbohydrates which must be maintained day and night throughout life, given via PEG tube.ADHD symptoms cause functional impairment and affecting his school attainment requiring treatment. However, stimulant medication, such as methylphenidate, which are first- and second-line treatments, can cause appetite suppression that would increase the risk of fatal hypoglycaemia in GSD1A.The literature review of case reviews with similar presentations, aiming to confirm the absence of contraindications for prescribing methylphenidate in patients with GSD1A, showed no identified contraindications, and relevant papers were not found.Collaboration with the metabolic disorders team at Great Ormond Street Hospital was established to verify the absence of contraindications and facilitate potential adjustments to feeds if necessary.Short-acting methylphenidate was administered to mitigate appetite suppression and enable prompt reversal of potential side effects, owing to its brief half-life. This approach also aimed to facilitate regular dietary intake.Gradual bi-weekly dosage increments of 5mg, coupled with vigilant side-effect monitoring, lead to enhanced attention and concentration, ultimately contributing to improved school attainment.ResultsTrial of short acting methylphenidate to ensure limited appetite suppression and allow opportunities for regular dietary intake. Slow dose titrations and weekly monitoring for response and side effects is vital. This young man's ADHD was successfully and safely treated.ConclusionThis case shows that with careful liaison and planning, methylphenidate can be safely prescribed to patients with GSD1A. Our experiences show that using short-acting preparations of methylphenidate initially allows slow and careful titrations.
Restorative Justice by Proxy: A Forensic Psychiatry Case Study
Authors: Farrell Suhanthini 
Published: August 2024

AimsRestorative justice (RJ) is the process of bringing together offender and victim in the aftermath of an offence. Handled correctly, there can be substantial benefits for both parties. Communication is typically direct with an RJ facilitator from the criminal justice system, but the Crown Prosecution Service makes reference to the option of “shuttle mediation”, with the RJ facilitator relaying information indirectly between parties.The use of RJ in forensic psychiatry has been limited, with reasons including concern for the patient offender's vulnerability, impact on their mental state from the stress of facing their victim, and unpredictability of response. Adaptation of the “shuttle mediation” model with use of a trusted mental health professional may help to overcome many such obstacles.MethodsPatient A committed his index offence of murder at age 22. During his mandatory life sentence, he developed schizophrenia and was transferred to a secure hospital. His illness proved treatment resistant and many years passed before he was discharged to the community on life licence following Parole Board release. Although generally stable, he was easily overwhelmed by stressful situations, in which he could struggle to articulate his thoughts.His victim’s wife and daughter enquired about the possibility of restorative justice. A's probation officer liaised with A's consultant psychiatrist. A was considered unsuitable for direct approach, but following discussion with an RJ facilitator, a proxy model was agreed upon. This was based on shuttle mediation but with the consultant psychiatrist acting as shuttle, or proxy, for A.The aims of the family were elicited in advance. Capacitous consent to information sharing was obtained from A, with boundaries of what would be shared clearly agreed. Information A wished to share with the family was established, including verbatim quotes.ResultsFollowing the RJ meeting, feedback from the victim's family and A was strongly positive. The victim's family reported a sense of peace and closure from the experience. A's longstanding anxiety, with feelings of guilt and self-blame reduced. Both parties expressed gratitude for the meeting and did not find the use of a proxy negated the benefits of the experience.ConclusionThis case report demonstrates that a proxy model of restorative justice is feasible and can be successful for patient offenders with severe and enduring mental disorder. The potential benefits to patient and victim suggest that it could be considered more widely as an option in forensic psychiatry settings.
Case Study of Traumatised Sub-Postmasters
Authors: Foster Paul 
Published: August 2024

AimsThe scandal of sub-postmasters wrongly accused by the post office of offences relating to the faulty IT Horizon system is of ongoing media prominence.Since May 2021 I have undertaken personal injury medico legal assessments at the request of a solicitor representing those falsely accused and convicted of offences by the post office. Their convictions had been quashed in the court of appeal.MethodsI interviewed fourteen individuals, age range 35 to 70 years, five women and nine men. Ten had brought claims for Malicious Prosecution. The remaining four sub-postmasters were part of the historical financial shortfalls scheme set up for those who had not been prosecuted but were applying for compensation.Of the ten convicted sub-postmasters, four spent periods in prison and the remaining six were given suspended or community sentences. Those in prison were often separated from young children by distance or withholding family members.I assessed to what extent and in what way their mental health and that of their families had been adversely affected as a result of their experiences.Assessments were undertaken remotely, including speaking with a family member.ICD 10 diagnostic criteria were used.ResultsAll of the cases revealed evidence of psychopathology at the time of the allegations or convictions and continued to varying degrees subsequently.A diagnosis of PTSD was made in five cases, Adjustment Disorder in 2 cases, Dysthymia in one case and depressive illness in eight cases. In only four cases had the disorders resolved.Four of the five cases of PTSD had evidence of a past psychiatric history prior to becoming sub-postmasters. Past history included depression, impulsive overdose, eating disorder, problems related to gambling and abuse of alcohol and cocaine.Both sub-postmasters who had been accused of taking money due to faulty software and those who had been wrongly convicted had high rates of psychopathology.These findings are consistent with the only other study of the psychological effects on sub-postmasters which found high rates of psychopathology in both accused and convicted individuals.Existing diagnostic criteria were limited in capturing the suffering of individuals who had endured such complex trauma so a narrative description including the effects on family members was also used.ConclusionThis study of the mental health of falsely accused sub-postmasters demonstrates a high degree of psychopathology which may require therapeutic intervention.
Diagnosis and Treatment of Anxiety Disorders in Autistic Patients: A Case Report
Authors: Govender Anusha 
Published: August 2024

AimsAnxiety disorders are common in Autistic Spectrum Disorder (ASD) patients. There are limited resources dedicated to ASD and mental health services are not equipped to adapt assessment and treatment protocols to address their needs. Adaptations to diagnosis and treatment are discussed in a single case study of an autistic patient with anxiety disorders. In addition, effectiveness of providing adapted versus standard treatment is evaluated.MethodsThis study describes a 45-year-old, single, employed male diagnosed as autistic at age 37. He was referred for a second course of Cognitive Behavioural Therapy (CBT) for anxiety disorders consisting of agoraphobia with panic; blood injury phobia; needle phobia; dental phobia; claustrophobia. The duration of symptoms was 35 years. The main impairments to functioning were inability to use public transport; attending healthcare appointments; going to public places; returning to office-based working.Questionnaires routinely completed at assessment and end of treatment: Montgomery–Åsberg Depression Rating Scale (MADRS); Beck's Anxiety Inventory (BAI); Beck's Depression Inventory (BDI). Adapted treatment with CBT included an extended assessment which helped differentiate anxiety symptoms from ASD. Main CBT adaptations included development of skills for the patient to identify and express emotional experiences and thoughts with the focus on physical sensations and behaviour. Graded exposure items were linked to concrete aims or interests and structured to fit around the patient's routine daily activities. Clinical data was analysed and compared outcomes from the initial standard and subsequent adapted treatment.ResultsThe patient's response to the initial course of standard CBT showed a 14% increase in anxiety and 14% increase in symptoms of depression on self-rated measures. The subsequent adapted CBT showed a 31% improvement in anxiety and a 16% improvement in symptoms of depression on self-rated measures.ConclusionThis case report supports literature describing the need to adapt standard assessment and treatment to differentiate experiences related to ASD from discrete anxiety disorders, although there may be some overlap. The promising results support using adapted CBT to ensure appropriate treatment of anxiety disorders in autistic people.
Exploring the Potential of Primary ECT Modulation: A Transformative Approach in Schizophrenia Treatment
Authors: Khan Ahmad Rehan , Inanc Oyku , Sadana Sukhmani Kaur , Fida Ania 
Published: August 2024

AimsElectroconvulsive therapy (ECT) stands as a crucial intervention for severe and treatment-resistant schizophrenia. Despite being recognized as the most effective acute treatment for severe mood and psychotic disorders, its controversial nature persists due to misconceptions and a lack of familiarity among healthcare professionals regarding modern ECT techniques. This case explores the effectiveness of maintenance ECT in preventing relapse among individuals with schizophrenia, a dimension with scarce existing data.MethodsA 28-year-old unemployed Caucasian male with treatment-resistant schizophrenia underwent multiple trials of atypical, typical, and depot antipsychotics, yielding no significant improvement in the Positive and Negative Syndrome Scale (PANSS) score. Two attempts with clozapine were hindered by neutropenia. With a baseline PANSS symptom score of 110, the patient struggled with severe auditory and visual hallucinations, preventing coherent conversations. Following 26 sessions of bilateral ECT, the PANSS scale score decreased to 65, prompting transfer to a Transitional Living Facility. After an additional 14 sessions, the patient exhibited significant symptomatic improvement, leading to discharge. The PANSS scale score, after 40 sessions, reached 50. Monthly bilateral ECT sessions and one antipsychotic medication now maintain the patient's reasonably functional lifestyle, encompassing employment, social outings, and assistance in farming with his father. ECT proved highly successful in alleviating both positive and negative symptoms, transforming the patient from severe conversational impairment to independent living and employment.ResultsEmpirical data validates clozapine's efficacy for treatment-resistant schizophrenia, yet its clinical use is limited by the substantial risks of agranulocytosis and neutropenia, relegating it to a third-line option. Neutropenia's onset in our case during clozapine trials prompted a therapeutic shift to electroconvulsive therapy (ECT). Aligned with American Psychiatric Association guidelines, our case underscored ECT's superior efficacy compared with traditional antipsychotics. Acknowledging a 40% non-response rate to clozapine across diverse studies emphasizes ECT's significance as a viable alternative. Despite challenges, contemporary ECT methods promise to overcome traditional constraints, reduce stigma, and improve treatment accessibility.ConclusionThis case underscores the potential benefits of ECT as a valuable treatment modality for individuals with treatment-resistant schizophrenia, effectively managing both positive and negative symptoms and significantly improving daily functioning. The success observed in this case suggests that monthly bilateral ECT and one antipsychotic medication can play a crucial role in enhancing the quality of life for patients with treatment-resistant schizophrenia.
Paediatric Catatonia as a First Presentation of Autism: A Case Report
Authors: Mandagere Vinay , Stephens Helen , Kwan Kitty , Singh Jatinder , Santosh Paramala 
Published: August 2024

AimsCatatonia is a rare neuropsychiatric syndrome in children. It is characterised by mutism, stupor, posturing, negativism, and rigidity. Historically, catatonia was associated only with psychosis, however catatonic symptoms are being recognised as more prevalent in people with Autism Spectrum Disorder (ASD). Our case report highlights the importance of investigating the potential underlying psychopathology and/or neurodevelopmental condition as this may guide management.MethodsWe present a case of a boy in early adolescence who was admitted to the Emergency Department for abnormal slowing of movement and stuttered speech. He described losing all interest in his hobbies, lying down for long periods of time, sometimes being unresponsive and ‘freezing’ in place. On examination, his symptoms were consistent with catatonia: mutism, grimacing, abnormal gait, and ambitendency were all present. He was investigated extensively to rule out medical and neurological causes, all of which were normal. He was assessed and managed by the Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD). After appropriate treatment, he was discharged from the hospital and was managed jointly by CIPPRD and the local Child and Adolescent Mental Health Service (CAMHS). This assessment revealed that the presentation of catatonia occurred during a depressive episode on a background of ASD and underlying Intellectual Disability. He was prescribed fluoxetine as opposed to benzodiazepines or antipsychotics, which led to the catatonic symptoms receding. The neurodevelopmental review revealed that his pattern of social communication and speech after catatonia improvement was consistent with ASD, which was then formally diagnosed.ResultsUntreated catatonia can be fatal. Early diagnosis and management are crucial to avoiding complications. Our case report highlights the challenge of treating paediatric catatonia and the diagnostic and therapeutic importance of understanding underlying psychopathology to decide treatment. Studies have shown that in this population, assessing and treating the underlying psychopathology as opposed to sole use of the lorazepam is essential.ConclusionCatatonia in paediatric and adolescent populations may be a first presentation of emotional and behavioural problems underlying autism spectrum disorder (ASD). When treating catatonia, consideration of the underlying psychopathology may warrant alternative pharmacological treatments to the traditional lorazepam challenge test and antipsychotics. The course of catatonia and associated comorbid affective and/or psychotic disorders may fluctuate with environment and therefore a biopsychosocial therapeutic model is warranted.
Capgras Delusion in Late Onset Postpartum Psychosis and Persistent Delusional Disorder
Authors: Nurlu Derya , Gupta Rina , Charlton Emily 
Published: August 2024

AimsThe Capgras syndrome is one of the four disorders defined under Delusional Misidentification. In the Capgras syndrome the patient believes that someone close to them has been replaced by an imposter pretending to be that person; the abnormality is delusional and not hallucinatory. It is a specific delusion of a person with whom the subject has close emotional ties and towards whom there is a feeling of ambivalence at the time of the onset.Methods37 year old Caucasian female presented to the local emergency department 4 months after delivery of her baby. She presented with a suicidal attempt in which she cut her neck and drank bleach. She was convinced that her parents and daughters were replaced by a network and her ex-partner was part of this network. She also believed that the network was out to harm her. She showed other psychotic symptoms along with low mood and hopelessness. Despite being offered high doses of antidepressants and antipsychotics she did not show any improvement hence she was given 12 sessions of ECT. Though this treatment was seen to bring in some benefits, her beliefs were still observed to persist. As her delusions were resistant to treatment and lasted more than 3 months, she was diagnosed to have a Persistent Delusional Disorder.ResultsA literature search showed that Capgras delusions rarely occur in postpartum psychosis. It generally poses a risk to baby's care and wellbeing since in most cases mother either refuses to care for baby or attempts to harm them. Interestingly in this case, mother met her daughter's physical needs but struggled with baby's emotional needs most of the time and was rarely observed to smile and play with her.ConclusionIn this case report, we present the occurrence of different psychopathologies during postpartum psychosis including Capgras delusion. We underline that this case is different from other cases reported in the literature due to unusual nature of the bond between the mother and baby and the onset of the symptoms.