bluuebunny/crossref_metadata_2025_split huggingface dataset:
Quality Improvement Project to Improve the Implementation of Mental Health Act Code of Practice Guiding Principles and Patient Knowledge About MHA in In-Patient Psychiatric Unit
Authors: Tahseen Hina , Parry Nicola 
Published: July 2023

AimsTo improve the efficiency of MHA documentation, patient education on MHA and implementation of guidelines of Code of Practice in in-patient unit. We also aimed to involve patients at some stages of the QI project to ensure they remain updated about the legal framework and associated documents and their voice remains central.MethodsThe QI Project was started after an initial audit was conducted which included MHA documentation on admission and during the length of stay, patients’ legal rights, section-17 leaves, capacity and treatment forms, tribunal reports, section-117 meetings and arrangement of independent managers hearings prior to Section Renewals. Using 5-Why QI methodology, the medical team and the MHA administrator reviewed the gaps in the initial audit. Using the QI “theory of change” model, three primary drivers of “Responsible Clinician and MHA Administration Liaison”, “Patient Education on MHA” and “Policies and Guidelines Implementation” were established. Secondary drivers for “RC and MHA Administration Liaison” required inputs from doctors, secretaries, nurses and MHA Admin. Change ideas of introducing weekly email template for required MHA actions, section paper scrutiny template made for approval by MHA Admin/ RC prior to patient's admission, Introduction of MHA relevant actions section in the morning handover and patient's review record form.Secondary drivers and change ideas for “Patient Education on MHA” included discussions with MDT, easy- language information leaflets, discussion slots with pharmacists about medications before consenting for treatment forms, discussion slots with the key nurse and RC about MHA related decisions and going through statutory reports together to understand the nature and degree of illness, and risks necessitating the renewal of admission.Secondary drivers and change ideas for “Policies and Guidelines Implementation” included teaching sessions for nurses on report writing, giving evidence at tribunals, and how to inform patients about legal rights, and liaison with medical management QI committee to ensure capacity and treatment certificates are up to date and filed in the medical folders. The initial audit tool was repeated on quarterly basis in addition to the PDSAs to measure results.ResultsResults showed 100% score in capacity assessments, treatment certificates and timely reports. There was still improvement needed in organising managers hearing prior to section renewal, likely section renewals left till late. A pre-and-post intervention score on patients’ knowledge of rights and MHA showed an improvement of 68%.ConclusionThe QI-project helped in implementing MHA code of practice guiding principles and patients’ knowledge about MHA and their rights.
Reducing Restrictive Practice on a Medium Secure High Dependency Forensic Inpatient Unit
Authors: Wong Brandon , Khan Mohsin 
Published: July 2023

AimsRestrictive practice can include physical and chemical restraint and should be utilised as a last resort. It has been found to negatively impact patients causing psychological distress, re-traumatisation, and a sense of helplessness. Restrictive practice also negatively impacts staff, causing emotional distress, moral conflict and the risk of physical harm. Since 2018, there has been a drive to reduce restrictive practice in inpatient mental health wards across England by the National Collaborating Centre for Mental Health, which has been further developed by NHS England in 2021 within the Mental Health Safety Improvement Programme (MH-SIP). This study aims to reduce restrictive practice on a 10-bedded Medium Secure High Dependency Male Forensic Mental Health Unit over a 6-month period, incorporating staff and patient feedback and utilise QI methodology.MethodsNumber of total seclusion hours, seclusion episodes and secluded patients per day were measured at baseline utilising the Rio clinical system and continuously tracked during the study period. Interventions were discussed by a multi-disciplinary team including nurses, pharmacists, health care assistants, occupational therapists, psychologists, and doctors. Patients were invited to give feedback on restrictive practice during ward rounds. Potential interventions were then implemented utilising PDSA methodology with iterative changes tested and analysed. Staff and patients were also invited to complete surveys and semi-structured interviews to give further comments during the study.ResultsBaseline data of monthly activity showed 3,758 total seclusion hours, 10 seclusion episodes and 5.3 seclusions per day. Iterative interventions included; (i) MDT discussions to support positive risk taking (ii) Improved collaborative care planning with patients (iii) Incident calendars for patients (iv) excel spreadsheet indicating progress towards leave / referral to stepdown ward and (v) improving transparency on impact of incidents on progress. Month 6 activity showed 174 total seclusion hours (95% reduction), 1 seclusion episode (90% reduction), and 1 average seclusion per day (82% reduction). A survey completed at the end of the study period showed all patients either strongly agreed or agreed that they understood the process for termination of seclusion, with 100% either responding between “neutral" to "strongly agree” that this had improved.ConclusionIt was hypothesised that a more collaborative approach with positive risk taking could lead to the reduction of restrictive practice. The interventions enacted have significantly reduced the use of restrictive practice. Further study is recommended into these interventions to review if similar results can be replicated in other inpatient wards.
Acute Psychotic Episode Due to Milk-Alkaline Syndrome
Authors: Adeyemo Suraju , Erfani John , Shafiq Attique , Chukwuma Collins , Worthington Mark 
Published: July 2023

Aims/ Background: Milk-alkali syndrome is a medical condition, which could present with psychiatric manifestations. It is caused by hypercalcemia resulting from the ingestion of large amounts of calcium and absorbable alkali. The core symptoms include hypercalcemia, metabolic alkalosis, and renal failure. Diagnosing this syndrome requires a high index of suspicion. The aim of this paper is to describe the case of Mrs. C who had psychotic symptoms because of Milk-Alkaline syndromeMethods/ Case ReportMrs. C was a 75-year-old white British female with a previous history of anorexia nervosa who has been clinically stable for more than 15 years. She was discharged by the community mental health services about 11 years ago but has been on a repeated dose of Gaviscon for about 8 years.She presented to the accident and emergency (A and E) unit with a history of confusion, unsteadiness, paranoid beliefs, low mood, and reduced rate of speech. No history of infection or other physical health concerns. Routine blood showed increased calcium 3.41(2.2-2.60) and a reduced potassium level 2.9 (3.5-5.3). CT head scan did not show any acute changes.She was stabilized and transferred to the ward for further management.While on the ward, she had a diagnosis of Milk-Alkaline syndrome with psychiatric manifestation. Gaviscon was discontinued because the medics felt this was responsible for the electrolyte imbalance. She was also referred to the mental health liaison team (MHLT).Following the mental health liaison team review, Mrs. C's psychiatric presentation was suspected to have been probably related to her medical condition. After a few weeks on the ward, her electrolyte became normalized; adjusted Ca 2.72 (2.2-2.6), serum ca 2.74(2.2-2.6). She had a follow-up review by the mental health team that showed her psychosis had also resolved. No medication was prescribed for her presentation. She was subsequently discharged from MHLT and referred to the GP for follow-up.Results/ Discussionprevious case-report have shown a suspected link between Milk alkaline syndrome and acute psychosis, although the reasons for this have not been understood. The current case further emphasized this link. What is not evident however is if there were other physical health issues that might have also contributed to the patient's initial presentation.ConclusionDiagnosis of Milk-Alkaline Syndrome requires a high index of suspicion, missing this could lead to inappropriate use of medication. As a psychiatrist, this case has shown the importance of adequate investigation before making a definitive diagnosis, especially in a psychiatric liaison setting.
A Tale of Two Catatonic States
Authors: Birgi Harleen Kaur , Lawrence-Smith Geoff , Kirwin Simon 
Published: July 2023

AimsCatatonia is a psychomotor state characterised by a multitude of clinical signs such as abnormal movements, mutism and withdrawal. This condition is usually associated with medical and psychiatric aetiologies with potential of being life-threatening. It is usually managed with benzodiazepines, the commonest being lorazepam. In this piece of work, we would like to focus on the principles of care that should be considered whilst managing such presentations.MethodsCase 1- 71, male with diagnosis of paranoid schizophrenia was brought to Emergency department (ED) via ambulance, as he was found ‘unresponsive’ in care home. On arrival, he was alert with GCS 11/15 and was observed to be mute, ‘gesturing’ and making purposeless movements. Following our assessment, he was administered 0.5mg of lorazepam whilst in resuscitation bay. Subsequently, he started making sounds and was given another dose of 0.5mg lorazepam. He then vocalised his thoughts and we established that his mental state had relapsed and he was harbouring paranoid delusions.Case 2- 18, male with no prior psychiatric history was brought to ED by his parents following 3 day history of being mute, not ‘responding’, not eating or drinking and insomnia. On arrival, he was alert, pacing in the room, however remained mute. Following our assessment, he was given a 2 mg dose of lorazepam whilst in resuscitation bay as the initial 1mg showed minimal response. On later review, he was smiling, conversant and co-operative, thus allowing assessment of his unmasked mental state which was suggestive of first episode psychosis.Following few hours, both patients reverted back to their original catatonic state.ResultsLorazepam can be used as a diagnostic measure in conjunction to a therapeutic intervention. A positive Lorazepam Challenge test confirms the diagnosis of catatonia. It must be borne in mind that Lorazepam is only used as a temporary holding measure to assess patient's unmasked mental state and they would need further monitoring and interventions to treat the underlying cause.ConclusionLorazepam Challenge test can be safely used as an assessment technique for patients presenting in acute catatonia. This should be conducted in closely monitored environments namely, resuscitation bay, HDU or ITU with appropriate support and ongoing liaison with psychiatry team. Treating teams should be mindful of various patient characteristics including age, past treatment with benzodiazepines, psychiatric history to inform dose adjustments as necessary.Disclaimer: Unable to obtain patient consent due to unstable mental state but ensured minimal patient identifiable data included.
Schizotypal Disorder With Borderline Personality Traits: A Case Report
Authors: Reddy Rakesh Byra , Hullumane Surabhi 
Published: July 2023

AimsSchizotypal disorder is characterized by pervasive patterns of odd behavior, appearance, or thinking. There is also a high degree of overlap in symptoms between schizotypal and borderline personality disorders. The following case describes a case of schizotypal disorder with borderline traits.Methods25-year-old female presented with history of mood fluctuations with recent low mood, anxiety and an ability to read other people's thoughts. She was admitted to hospital 4 years ago and was diagnosed with emotionally unstable personality disorder (EUPD) and mixed anxiety and depression.She reported anxiety to leave the house due to referential and persecutory ideas, odd beliefs of being able to read people's minds and predict future. She lacked friends and also had fear of abandonment. There was intermittent impulsive self-harm behavior and reportedly harmed herself indirectly through casual sex in the past and also had two failed relationships. She denied illicit drug use. Childhood was uneventful, except that schooling was difficult due to anxiety. She was treated on Quetiapine, Fluoxetine and Promethazine. Further assessments confirmed added features of unusual perceptions, smelling things, superstitious ideas regarding colours and magical thinking. Dissociative episodes of her being a devil, expressing thoughts of slitting her throat were present.As there was minimal improvement, Aripiprazole was tried. She had poor compliance with Aripiprazole due to the belief that it was poison. She herself requested depot injection, which was started. There has since been mild improvement in her paranoia, but social anxiety is persistent. Psychoeducation about the diagnosis was challenging, after which she accepted referral for psychotherapy.ResultsThe initial diagnosis of EUPD was inconsistent with other features like ideas of reference, strange beliefs, magical thinking, abnormal perceptions and social anxiety. On further assessments, a diagnostic clarification of schizotypal disorder was considered. This poses challenge in diagnosis and therapeutic approach due to the overlap of symptoms. Cognitive-perceptual distortions and affective symptoms of EUPD appear to overlap with disorganized and cognitive-perceptual symptoms of schizotypal disorder. Historically, borderline was separated from schizotypal personality disorder from an entity called borderline schizophrenia.ConclusionSchizotypal disorder is rarely seen as the primary reason for treatment in a clinical setting and can be misdiagnosed. The presence of co-morbid personality disorder traits can be challenging for the management decisions. It also has an impact on the individual and family for acceptance of the diagnosis and compliance to treatment.
Ventriculomegaly in Mania - a Possible Neural Correlate?
Authors: D'Souza Galina Lisa , Joe Avinash , Rao Pavithra P , Yadiyal Aruna 
Published: July 2023

AimsBipolar disorder is one of the most common psychiatric illness, however the neurophysiologic basis remains unknown. Lateral ventriculomegaly is a well-recognized finding in bipolar disorder. Multiple-episode patients exhibited significantly greater ventricular volumes than first-episode patients. Traumatic brain injury is also an independent risk factor for the development of mania.We present to you a case where a patient with mania had the above mentioned risk factor and finding.Methods40 year old married lady hailing from a rural nuclear family presented with decreased sleep, increased talk, increased activity, elevated mood and overfamiliarity since 1 month. On further interviewing patient was found to have sustained mild head injury around 8 months ago .MRI study of the brain revealed mild lateral and third ventriculomegaly.A diagnosis of organic mania with a differential of mania with psychotic symptoms was made.ResultsVentriculomegaly in bipolar disorder has been reported but not in mania alone-its occurrence at illness onset or progression remains unclear. There is no literature on the prognostic value of the finding. Ventriculomegaly in our patient was found incidentally on MRI whether the finding was present prior to the head injury or is a post head injury change is unclear. There are studies which indicate development of posttraumatic ventriculomegaly in severe head injury. Nonetheless we cannot completely rule out a possibility of neurodevelopmental / neurodegenerative link in this case which maybe be independent of the head injuryConclusionThere is a paucity of studies that focus on neurodevelopment and neurodegeneration as etiological basis for mania and affective disorders in general need to shift our focus on research in brain imaging in psychiatry
Functional Cognitive Disorder and Mild Cognitive Impairment: A Thin Line
Authors: Jeje Jide , Odutola Akinkunmi , Qudus Lawal , Sodiya Olusegun , Ogungbayi Modupe , Prabhu Aishwarya 
Published: July 2023

AimsFunctional cognitive disorders (FCDs) refer to conditions where patients present with persistent problematic subjective memory complaints that are not consistent with their observed level of cognitive functioning. The demonstrated symptoms are also not in keeping with a recognized psychiatric or neurodegenerative process. FCD is likely to be underdiagnosed in clinical practice with the place-holder label of mild cognitive impairment being used in some cases due to lack of clarity about its symptomatology. In this paper, we describe two cases whose presentations were suggestive of FCDs.MethodsMrs X, 53 years old female not previously known to mental health services referred for increasing difficulties with her memory over 2 years which she believed was impacting her activities of daily living. She has a history of ischaemic heart disease, fibromyalgia, Insulin-dependent diabetes mellitus, depression, and polycystic ovarian syndrome. On assessment MOCA = 15/30, and MMSE = 25/30.Mr Y, 57 years old male not known to mental health services. Although, has been treated for anxiety and depression by GP. He presented with a 3-year history of struggling with his memory. He reported being forgetful of appointments and he has to paste sticky papers on the fridge for reminders. Similarly, he has a diagnosis of Fibromyalgia and essential hypertension. On Assessment MOCA – 19/30 and MMSE – 25/30.ResultsFCDs can be quite challenging because the clinical picture overlaps with other neurodegenerative conditions. Typically, patients report issues around memory function in the absence of relevant neuropathology and with evidence of inconsistency between symptoms reported and observations at assessment. Regarding our cases, the primary presenting issues were increasing difficulties with memory, and forgetfulness. Other noteworthy observations were a mismatch between their scores in the MOCA, MMSE, their level of functioning, and reported memory problems. Neurological examinations and neuroimaging were not suggestive of any neurodegenerative disorders. A differential diagnosis of functional cognitive disorder was considered due to the discrepancies between symptoms reported, the level of their functioning, observations at assessments as well as absence of relevant neuropathology on imaging.ConclusionFCD is a condition that is common in clinical practice but underdiagnosed. Hence, it is imperative that clinicians keep this diagnosis in mind when patients present with memory difficulties that do not meet the diagnostic criteria for dementia and is not due to a recognized medical or psychiatric condition. Correctly identifying and diagnosing FCD can positively impact patient outcomes.
Full Remission of Obsessive Compulsive Disorder (OCD) Symptoms in Huntington's Disease (HD) Using Fluoxetine
Authors: Devasia Mithun , Kumar Praveen , Kottelassal Abdurazak 
Published: July 2023

AimsHD is an autosomal, dominantly inherited, neurodegenerative disorder which can present with cognitive, motor and behavioural symptoms. Recent studies suggest that obsessive compulsive disorder (OCD) symptoms, although not common, may precede or coincide with symptoms in patients with HD. We present a case of an adolescent boy presenting with symptoms of OCD, for 4 months duration, in background of three years diagnosis of HD.MethodsA 15-year-old boy from South India, presented with recurrent, intrusive thoughts of sexual content, consistent with obsessions and some instances of compulsions in the form of avoiding to do deviant sexual act like fetishism, and having excessive worries about an act he had done earlier for 3 months duration (supported by high scores on Yale-Brown Obsessive Compulsive Scale; Y-BOCS). Patient had normal birth and development and had no past history of psychiatry disorder, however there was family history of HD in multiple first and second-degree relatives. He was on treatment for movement symptoms of HD, diagnosed 3 years back and was on Tetrabenazine for 2 years. Initial psychiatric assessment found the symptoms to be consistent with OCD due to Huntington's disease, according to Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The patient was admitted to the mental health unit and was started on Fluoxetine, titrated to a dose of 20mg daily for symptoms of OCD.ResultsSubject showed an excellent response to fluoxetine with complete remission of OCD symptoms within 4 weeks of treatment. The relationship between OCD and HD has been little-investigated, despite the fact that both diseases are associated with striatal dysfunction and that the number of case reports of obsessive-compulsive symptoms either preceding the clinical onset of HD or during later stages of the disease is increasing. For example, Dewhurst et al. reported “obsessional features” in 7 of 102 patients at onset of HD.ConclusionFirm conclusions to explain this result cannot be drawn. However, a hypothetical involvement of the serotonergic system, suggested by the excess of OCD, seems supported by the response of said subject to fluoxetine. It may be worth further exploring the value of the psychiatric picture in selecting the appropriate treatment for at least some cases of HD. Anecdotal evidence suggest that SSRIs alone or in combination with atypical antipsychotics like olanzapine may be useful for these patients. However, these hypotheses need further testing.