bluuebunny/crossref_metadata_2025_split huggingface dataset:
Successful Clozapine Rechallenge With Add on Filgrastim in a Case of Treatment Resistant Schizophrenia With Clozapine Associated Neutropenia: A Case Report
Authors: Shankar Nikhil Gauri , Sambhi Rajvinder Singh , Alnassar Ibrahim 
Published: July 2023

AimsClozapine is the treatment of choice in treatment resistant schizophrenia (TRS). Neutropenia is a potential life threating adverse effect associated with Clozapine treatment and one of the common reasons leading to discontinuation of Clozapine treatment. Clozapine associated neutropenia can be managed with Lithium or Granulocyte Colony Stimulating factor (G-CSF).Clozapine rechallenge in patients may often seem necessary and should follow a careful and balanced risk-benefit analysis. We present a case of a patient with TRS on Clozapine who developed neutropenia which responded to Filgrastim add on therapy and was successfully continued with Clozapine treatment.MethodsA 29 year old female with a diagnosis of Schizophrenia since age 22 years had poor response to 4 different antipsychotics and 2 episodes of Neutropenia on separate occasions with Clozapine treatment. An inpatient Clozapine rechallenge was trialled due to poor response to the ongoing antipsychotic treatment which resulted in a decrease in the absolute neutrophil count to 1.7 *109/Litre.An MDT decision was taken to continue Clozapine treatment with add on Filgrastim due to the severe psychopathology and poor quality of life. As per the advice from the haematologist Filgrastim injections at a dose of 30 million International Units were commenced on pro re nata (prn) basis whenever ANC dropped below 2.0*109/Litre. This strategy was successful and the patient did not develop agranulocytosis. Her psychotic symptoms also improved significantly and the patient was discharged to the community rehabilitation team.ResultsClozapine is often the last resort in treating refractory psychotic symptoms and this option may get limited due to adverse effects like Neutropenia and agranulocytosis. Add on therapy with G-CSF has been used in Clozapine rechallenge with various success rate and most of the supporting data are derived from case reports and case series. It is worth noting that regular and prophylactic G-CSF in absence of low neutrophil count is avoided which could mask a developing Clozapine induced Neutropenia and result in a steep drop in neutrophils.ConclusionAdd on therapy with Filgrastim is a viable option when considering Clozapine rechallenge with previous history of Clozapine induced Neutropenia. It is important that a haematologist is consulted and the patient is monitored closely throughout the treatment.
Change of Focus: Interventions of Occupational Therapy From a Psychodynamic Perspective
Authors: Gutnisky David , Ortega Licenciate Maria Soledad 
Published: July 2023

AimsStrictly speaking, occupational therapy interventions in mental health help clients through different activities to improve and develop skills that allow them to become increasingly independent and self-sufficient. Occupational therapy evaluation includes areas such as activities of daily life, play/leisure, productivity, study, work, and social participation. Occupational therapy also considers the impact of the context on the areas mentioned, but usually does not include the psychodynamic aspects of the client.MethodsMale patient in his early thirties who was suffering an acute psychotic episode. He was experiencing a mystical delusion, with grandiose ideas of personal significance and delusions of reference. His mood was elevated, in consonance with the content of his thoughts. He was disorganised and needed help to maintain his daily routine. He said that he was experiencing a Maslow's Peak-Experience not a psychotic episode although he acceded to take medication. In an attempt to avoid involuntary admission to a mental health clinic (he refused to be admitted, as did his family), we tailored a home approach, with the inclusion of an occupational therapist on the team. Our first approach was unfruitful. Our attempts to help him to organize himself and his daily routine did not work. He was so fixated with his delusional project that any other idea or plan was rapidly discarded. So, we decided to change our approach and took his delusional project as the activity to organise and plan about. We agreed with him that we were going to help him with his project, but that there were no guarantees of success. Occupational therapy interventions helped him organise his project step by step and accept the frustration that his plan was impossible to achieve. Eventually, the episode ended with no need of admission.ResultsChanging the focus of the occupational therapy interventions, paused the interventions that were aimed at activities of the daily life, and taking the delusional project as the main and the most important activity of the client at this point allowed us to build a stronger therapeutic alliance and helped the client deal with the psychotic process and tolerate the constraints of reality.ConclusionThe introduction of a psychodynamic point of view in the planning of occupational therapy interventions enriches the realm of occupational therapy and allowed, in this case, a flexible and creative approach that opened the path to a home treatment plan avoiding involuntary admission.
The Use of Genetic Testing in the Management of Depression
Authors: O'Neill-Kerr Alex , Nwabunike Nneamaka 
Published: July 2023

AimsWe report on a case of depression where genetic testing was used to determine potential treatment modalities.MethodsThe patient is a 78-year-old man who had suffered from depression for 55 years. He had a serious episode in 2002. He developed a further depressive episode in 2018 which did not respond to paroxetine. He was offered TMS and was initially treated in the NHS and subsequently in the private sector. He went into remission with TMS and continues to remit with TMS however his depression became unstable and it was clear that the paroxetine was having no effect. He agreed to have a genetic test, a buccal mouth swab was taken and posted to gensense in the United States. An 18 page document and a half hour session with gensense are included in the cost of the test. The results of his genetic test and suggestions regarding treatment are detailed below.SLC6A4 L(G)/S serotonin transporter indicating a less favourable response to SSRI medication (20% response versus 40% response). SNRI medication may be useful.BDNF Val/Met Met carriers may have poor response to SSRIs and an improved response to SNRI's and TCA's. Met carriers have a 3 times better response to exercise than Val/ValMTHFR A/A variant, this results in a 70% reduction) in the ability to convert folate to methyl folate (required for the manufacture of serotonin). Taking L-methylfolate supplementation (7.5mg) may improve serotonin production and provide a 2 times increase in response rate to antidepressants.COMT Val/Val variant indicates improved response with brain stimulation therapy such as ECT and TMSCACNA1C A/A variant which increases the anteromedial and amygdala activity and increased neuronal activity as a result of increased calcium channel receptors. This variant is associated with more depression, OCD and anxiety. Using lithium, sodium valproate and lamotrigine could be potentially useful in this group.ResultsThe patient's antidepressant was switched from Paroxetine to Venlafaxine XL 150 mg, he started taking L methyl folate supplements (7.5mg daily) and was put onto sodium valproate 250 mg 3 times a day. His HAM-D went from 39 in December 2022 to sub-baseline by the end of January 2023. He also started regular mild exercise and daily use of tDCS (Sooma and Flow).ConclusionWe conclude that genetic testing can be a useful clinical tool and can be helpful in deciding which treatments may benefit.
Sertraline-Induced Urinary Incontinence in Adolescent: A Case Report
Authors: Phiphopthatsanee Nacharin 
Published: July 2023

AimsSerotonin reuptake inhibitors (SSRIs) are commonly used to treat obsessive-compulsive disorder (OCD). In the UK, sertraline and fluvoxamine are the only SSRIs licensed for use in young patients with OCD. There is currently limited evidence suggesting an increased risk of urinary incontinence with SSRI use. Literature in children and adolescents is even more scarce, with only a few published case reports of SSRI-induced urinary symptoms. This case report adds to the pre-existing evidence in support of the previous suggestion on sertraline-induced urinary incontinence.MethodsA 14-year-old girl with a diagnosis of OCD was treated with a combination of cognitive behavioural therapy (CBT) and sertraline, which was gradually titrated in steps of 25 mg fortnightly. There was a noticeable improvement in her OCD symptoms soon after the medication was initiated. However, a few days after sertraline was increased to 100 mg, she started to report urinary incontinence, urgency, and frequency, both daytime and nighttime, which significantly impacted her quality of life. She denied other urinary symptoms or change in fluid intake. Investigations for diabetes mellitus and urinary tract infection were negative. It was therefore concluded that her urinary incontinence was related to an increase in sertraline dosage, and she was advised to take an alternating dose of 75 mg and 100 mg daily. The symptoms resolved shortly afterwards, and sertraline was subsequently titrated up to 150 mg daily without any issues.ResultsDue to its rare encounter, the association between the use of sertraline and urinary incontinence has only been quantified in a single retrospective study with an adjusted risk ratio of 2.76 (95% CI 1.47–5.21). A clear temporal relationship of symptoms, its occurrence after the dosage increase, and rapid resolution after dose reduction confirmed the role of sertraline in the development of urinary incontinence in this case. Consistent with a previous case report, the dose-dependent effect was also implied. This phenomenon might be explained pharmacologically by sertraline's serotonergic activation, which can potentiate neuromuscular cholinergic transmission in the detrusor muscle, and dopaminergic activation, which can stimulate urine micturition. However, the exact mechanism remains unclear.ConclusionAlthough sertraline-induced urinary side effects occur relatively infrequently, clinicians should be aware of and actively look for these side effects, especially in patients who are prescribed SSRIs at higher doses. It is also important to exclude other causes that may contribute to urinary incontinence.
A Case Study to Explore Safe Psychotropic Medication(s) for a Patient Suffering From Priapism
Authors: Uddin Mohammad Saif 
Published: July 2023

AimsA 53-year-old male was admitted with non-resolving Priapism for 36 hours and was reviewed for advice regarding his psychotropic medications. He previously took Viagra about 2 days ago, and had an erection which resolved spontaneously. He underwent penile aspiration in the hospital which provided relief. Following that, he developed signs of infection which was treated with IV antibiotics. He was then waiting for further surgical correction.MethodsHe has a background history of psychotic illness and been treated with Quetiapine, Mirtazapine, Sertraline and Zopiclone, which were kept on hold during his admission. He reported that he currently suffers from depression and signs of psychosis, which take the form of auditory hallucinations and paranoid delusions.He has been taking Viagra occasionally for years, but has not experienced side-effects like this before. He is a social drinker and previously smoked cannabis.ResultsFrom the above scenario, there appears to be two clinical questions:
1.Are the current medications responsible for his priapism?2.What medication(s) would be a suitable alternative if his priapism was indeed caused by his current drug regimen?The major causes of Priapism are: direct trauma; haematological diseases; neurological diseases; cerebrovascular diseases; Medications; TPN and Neoplasm. Apart from medication side-effects, these other causes were ruled out.The Summary of Product Characteristics for mirtazapine, sertraline, quetiapine and zopiclone were studied for their relative risk of causing priapism, and this is summarised below:
•Mirtazapine: unknown•Sertraline: rare•Quetiapine: rare•Zopiclone: not listedHowever, a paper by Salonia et al found that all the above medications except Zopiclone can increase the risk of priapism. Internationally published case reports also list priapism-associated medications as: risperidone; quetiapine; sildenafil; mirtazapine; citalopram; chlorpromazine and olanzapine.Anti-psychotics cause priapism by Alpha-1 blockade and anticholinergic actions. Most of the antipsychotics have anticholinergic action. The medication which demonstrates the least alpha-1 blockade is Amisulpride which acts by blocking dopaminergic receptors in the brain.ConclusionThus, it is clear from the above discussion that Amisulpride has the least possibility to cause Priapism. The patient was advised to take low dose Amisulpride and afterwards, no other complications were noted.
Outcome Measures at Discharge From a Local Early Intervention in Psychosis Team
Authors: Lathif Nismen , Ahmed Zara 
Published: July 2023

AimsReview of the outcomes from a local EIP service, in terms of symptom control employment status at referral and discharge, admissions whilst under the care of the service physical health status at discharge, discharge was back to primary care or secondary careMethodsSample of service users discharged from EIP services over the past 2 years between March 2020 and March 2022 was collatedResultsRecoveryGood proportion -84% had good symptomatic recovery at time of discharge based on discharge letterDischarge to primary careLow proportion -Only 26% were discharged onwards to secondary mental health services such as recovery teams or community mental health teams and rehabilitation services.74% discharged to primary careReview of notes indicate that patient is still within primary care 6-12 months post dischargeEmploymentA jump of 16% in employment. At start of EIT input only 40% had employment and at pint of discharge 56% of sample had employmentInpatient admissionAdmissions whilst under the service were seen in 54% patients in total; out of this number just over half (55%; )were admitted to inpatient unit only onceSmoking and Substance misuseOnly 24% were known smokers at discharge; 6%) were misusing multiple substances including smoking, alcohol, cannabis and cocaine at the time of dischargePhysical health and metabolic syndromeOnly 2% had diagnosed hyperlipidaemia at dischargeConclusionEarly Intervention in Psychosis input lead to good symptom control and resolution of psychosis leading to higher rates of discharge to primary care alongside improved physical health substance misuse employment outcomes.
A Service Evaluation of Referrals to Sheffield Community Child and Adolescent Mental Health Services (CAMHS) by Ethnicity and Areas of Deprivation
Authors: Arogundade Temitope , Shibib Shatha , Melton William , Younis Ayman 
Published: July 2023

AimsTo investigate disparities in the number and outcome of referrals to Sheffield Community Child and Adolescent Mental Health Services from different ethnic groups and areas of deprivationMethodsThe authors reviewed the the 2021 census data for Sheffield and grouped Sheffield into 3 areas of deprivation (low, medium, and high) based on Index of Multiple Deprivation (IMD 2019 Rank).Reasons and outcome of referrals to Sheffield Community CAMHS for the months of March and April 2022 were analysed by ethnicity and deprivation,ResultsOur study shows that, compared to their white counterpart, Black and Asian children and young people (CYP) were markedly under-represented in CAMHS referrals, whilst CYP of mixed ethnicities were over-represented. Of this group, Asian and mixed ethnicity CYP were less likely to have referrals accepted. Similarly, CYP from areas of high deprivation were also less likely to be accepted into the community CAMHS service. While anxiety was the most common reason for referral, CYP from areas of high deprivation were 3 times more likely to be referred for behavioural difficulties than CYP from areas of low deprivation.ConclusionOur study highlighted that black ethnicities are disproportionately underrepresented in CAMHS referrals. Furthermore, children and young people from an Asian background are not only underrepresented in the number of referrals but also in the proportion of referrals accepted. Similarly, it is reported that CYP from deprived backgrounds are more likely to experience barriers to accessibility to mental health services, and this was also evident from our evaluation.Black and Asian CYP continue to be under-represented in CAMHS services as are CYP from deprived communities. However, these ethnic groups present the highest reported mental health difficulties at adulthood. More research is therefore needed in this area, to identify the specific barriers to accessing mental health care in Sheffield Community CAMHS, so as to allow the provision of culturally appropriate mental health services for the ethnic and high derivation groups.
Service Evaluation of Treatment Response in Adult ADHD Patients With Psychiatric Comorbidities
Authors: Ashraf Afiz , George Sini , Ramaswamy Venkat , Manaswini Namilakonda , Kishore Kondapalakala Kiran 
Published: July 2023

AimsTo assess whether psychiatric comorbidities affect response to medications in adulthood ADHD.MethodsThis study included 236 subjects diagnosed with ADHD in adulthood between the ages of 18 and 65 years and receiving pharmacological treatment for the same across community treatment teams in Durham and Darlington.Patients were identified by going through electronic case notes.Review of SWMWEBS scores and clinic letters were carried out both prior to and following commencing medication for ADHD to assess response to treatment.Comorbidities were recorded by reviewing clinic letters.Results56% of the study subjects had no psychiatric comorbidity while 44% had at least one comorbid psychiatric diagnosis.Both groups had a higher prevalence of males in the ratio of 1.9:1(with comorbidities) and 3:1 (without comorbidities).Depression(56%) was noted to be the most common comorbidity followed by Autism(22%), Emotionally Unstable Personality Disorder(11%) and Bipolar Affective Disorder(10%).94% patients without comorbidities responded favourably to treatment whereas only 56% of patients with comorbidities improved with treatment.ConclusionHaving a comorbid psychiatric illness is likely to negatively impact both treatment response and recovery in adults with ADHD.Both groups(with and without comorbidities) had a male predominance (2.5:1).Higher number of patients amongst the nil comorbidities group responded favourably to treatment.Most common psychiatric comorbidity was Depression.Least favourable response to treatment was found among the groups of Emotionally Unstable Personality Disorder and Bipolar Affective Disorder.No gender bias in response to treatment across both the groups.
A Descriptive Analysis of the Clinical and Demographic Features of High Intensity Users of Charing Cross Hospital Emergency Department; Utilisation of These Data to Develop Local Services
Authors: Cho Yena , Kydd-Coutts Thomas , Newman Anastasia , Patel Sachin , Schofield Emma 
Published: July 2023

AimsOver recent years, there has been increasing national focus on High Intensity Users (HIU's) of Emergency Department's (ED's) and services designed to case manage and address the unmet needs of these individuals. The descriptive research literature focuses on measurable, demographic identifiers of this group, attendance trends and the presenting complaints driving attendance. There is more variable literature on the clinical profiles of these individuals, with findings describing a highly heterogeneous group. Our inner city service is well-established and staffed by a multidisciplinary team. We provide assessments and interventions to meet the needs of HIU's identified through a referral system which includes electronic flagging of cases. We aim to describe in detail the clinical and demographic features of a cohort of HIU's attending our department and demonstrate the utility of these data.MethodsAll individuals managed by the HIU service in 2022 were identified from our referral database. No individual was excluded. We undertook systematic notes reviews on each case, using medical, psychiatric and primary care records as well as interventional care plans produced by the service. Data were recorded against set domains covering socio-economic factors, demographics and clinical coding.ResultsThe analysis included 98 individuals. The majority were male (59%) with 85% in receipt of government benefits and 16% of no fixed abode. A variety of psychiatric diagnoses were present with 12% diagnosed with a psychotic illness, 40% with a mood disorder, 7% with a somatoform condition and 19% with a personality disorder. 83% were diagnosed with a medical long term condition (LTC), with 32% of these being diagnosed with >3 LTC's. 81% suffered from at least 1 LTC and 1 mental disorder in combination. 40% harmfully used or were dependent on alcohol and 21% misused recreational drugs. Known or likely cognitive impairment was seen in 28% of the group and 13% were diagnosed with learning disability.ConclusionOur findings demonstrate the complexity of the clinical profiles of HIU's of the ED and supports service models centred on individual case management. There is a high degree of mental and physical morbidity in this group, indicating that specialist assessment and management is required. The range of unmet need covers a breadth of health and social care requiring a multi-disciplinary approach. Homelessness, cognitive impairment and learning disability are particular areas which may benefit from expertise. Our project is limited to one localised system however we recommend ED's undertake similar analyses to better design HIU services.