2908 results in BJPsych Open
The Malaysian Northern Stars (supervision, training, and reflective system) project: a multi-facet ecosystem of producing local talents
- Noor Melissa Nor Hadi, Jiann Lin Loo
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S148-S149
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The MRCPsych (Membership of the Royal College of Psychiatrists, United Kingdom) parallel training pathway has been introduced in Malaysia to produce competent psychiatrists to deliver evidence-based psychiatric care. Certain training centres faced specific challenges during the process of implementation, including the lacking of supervisors with experience in the MRCPsych examination, over-reliance on self-study and existing continuous medical education (CME), logistic difficulty in accessing specific training courses, the sustainability of local training, and loss of manpower due to frequent mobilisation of trainees. This article is aimed to illustrate the Northern STARS (Supervision, Training, and Reflective System) project, i.e. a project implemented as a solution for those challenges and an effort to develop a sustainable model of training for the local talents in Perlis, a northern state in Malaysia.
MethodThe Northern STARS initiatives included: setting up a library with more MRCPsych-related materials; introducing trainees to virtual MRCPsych support groups; organizing both physical and virtual training locally, collaborating with local and international experts for consultation and teaching, and the introduction of protected study time. Virtual platforms were used innovatively to minimise cost. Ongoing data were collected for programme evaluation and quality improvement. Trainees were actively involved in the process to facilitate the development of leadership and administrative skills.
ResultA total of seven courses covering both skill and theory training had been organised: Ultra-brief Psychological Intervention Workshop, Dialectic Behavioural Therapy workshop, Personality Disorder Workshop, Critical Appraisal Workshop, MRCPsych Lecture Series, Addiction Psychiatry Lecture, and Basic Revision Course on Electroconvulsive Therapy. An estimated amount of twenty thousand Malaysian Ringgit had been generated and channelled into the community mental health centre, accounting for the indirect cost of a subscription to ZoomTM and the intangible cost of labour effort. Overall feedback revealed a high level of satisfaction together with some specific suggestions on areas of improvement, including the timing of course and coverage of the curriculum. To date, six medical officers are pursuing this pathway with three of them passing one paper and another two pursuing the final part.
ConclusionThe Northern STARS project is an ecosystem of training solutions while generating income and producing more local talents to expand this project further. More long-term evaluation from the perspective of human resource and health economics can be considered to understand the efficiency of the current initiative.
An audit of lithium prescribing practices in an old age psychiatry service highlighting renal impairment in this cohort
- Leia Valentine, John Cannon, Siobhan Marmion, Michelle Corcoran, Marguerite Cryan, Geraldine McCarthy, Catherine Dolan
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S109-S110
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To compare Lithium prescribing practices in a Psychiatry of Old Age (POA) Service in the North-West of Ireland among adults aged 65 years and over with best practice guidelines.
MethodReview of the literature informed development of audit standards for Lithium prescribing. These included National Institute for Clinical Excellent (NICE) 2014 guidelines, The British National Formulary (2019) and Maudsley Prescribing Guidelines (2018). Data were collected retrospectively, using an audit-specific data collection tool, from clinical files of POA team caseload, aged 65 years or more and prescribed Lithium over the past one year.
ResultAt the time of the audit in February 2020, 18 patients were prescribed lithium, 67% female, average age 74.6 years. Of those prescribed Lithium; 50% (n = 9) had a depression diagnosis, 44% (n = 8) had bipolar affective disorder (BPAD) and 6% (n = 1) had schizoaffective disorder.
78% (n = 14) of patients were on track to meet, or had already met, the NICE standard of 3-monthly serum lithium level. Lithium levels were checked on average 4.5 times in past one year, average lithium level was 0.61mmol/L across the group and 39% (n = 7) had lithium level within recommended therapeutic range (0.6-0.8mmol/L).
83% (n = 15) of patients met the NICE standards of 3 monthly renal tests, thyroid function test was performed in 89% (n = 16) and at least one serum calcium level was documented in 63% (n = 15). Taking into consideration most recent blood test results, 100% (n = 18) had abnormal renal function, 78% (n = 7) had abnormal thyroid function and 60% (n = 9) had abnormal serum calcium.
Half (n = 9) were initiated on lithium by POA service and of these, 56% (n = 5) had documented renal impairment prior to initiation. Of patients on long term lithium therapy at time of referral (n = 9), almost half (n = 4) had a documented history of lithium toxicity.
ConclusionThe results of this audit highlight room for improvement in lithium monitoring of older adults attending POA service. Furthermore, all patients prescribed lithium had impaired renal function, half had abnormal calcium and two fifths had abnormal thyroid function. This is an important finding given the associations between those admitted to hospital with COVID-19 and comorbid kidney disease and increased risk of inpatient death.
Our findings highlight the need for three monthly renal function monitoring in older adults prescribed lithium given the additive adverse effects of increasing age and lithium on the kidney. Close working with specialised renal services to provide timely advice on renal management for those with renal impairment prescribed lithium is important to minimise adverse patient outcomes.
Mental wellbeing in doctors: the measure matters! development of a core outcome set for measuring wellbeing in doctors
- David Baldwin, Aimee O'Neill, Julia Sinclair, Gemma Simons
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S235-S236
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To achieve a consensus Core Outcome Set for measuring mental wellbeing in doctors.
Hypothesis: A minimum set of valid, reliable and practical wellbeing measures is needed for doctors.
BackgroundThe importance of doctors’ mental wellbeing to everyone using Health Care is highlighted by the levels of burnout reported in doctors around the world. In 2019 a number of UK policy documents made recommendations for the wellbeing of doctors, but how those wellbeing interventions are evaluated needs to be defined. Core Outcome Sets are increasingly being used in medicine to prevent waste in research, by recommending the inclusion of a minimum set of valid, reliable and practical measures. An operational definition and Core Outcome Set for wellbeing in doctors is needed to meaningfully progress the work in this field.
MethodThe Centre for Workforce Wellbeing (C4WW), a collaboration between the University of Southampton and Health Education England, was created to support research into the nature, assessment and enhancement of wellbeing in physicians. A Systematic Review of wellbeing measures used in doctors and the robustness of those measures, along with surveys of 250 UK doctors of all grades and specialities and patient and public involvement is informing what a core outcome set could be. A Delphi Study among 37 UK experts has been initiated to establish the consensus Core Outcome Set.
ResultPublication of research into doctors’ wellbeing is growing internationally. In the UK alone data are being captured by multiple national organisations including: the Care Quality Commission, General Medical Council, British Medical Association and the Royal Colleges. Health and Social Care Organisations are, therefore, keen to “do something” and are spending money on wellbeing interventions with little, or no, evidence base and a lack of appropriate, comparable evaluation. A Core Outcome Set for measuring wellbeing in doctors is ethically required to reduce waste, to replace burnout measures and to refine wellbeing interventions.
ConclusionWellbeing measures that actually measure wellbeing, and not burnout, which are validated, reliable and practical, are needed to inform local organisational, national government and international research policy. An absence of burnout does not equate to wellbeing. The focus of measurement needs to shift to capture in what contexts we thrive, not just survive. If everyone used the same Core Outcome Set to measure mental wellbeing, direct comparisons could be made, and money invested, in creating infrastructure, processes and cultures that really work.
Health Education England funded PhD.
Audit of pharmacological management of borderline personality disorder as per NICE clinical guidelines CG78
- Bethany Dudley, Shakina Bellam, Andrew Lawrie
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S319
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To audit the current practice of pharmacological management of Borderline Personality Disorder with NICE Clinical guideline [CG78]: Borderline personality disorder:
Objectives:
23 patient records were analysed in the last 18months with a diagnosis of EUPD to compare current practice against NICE clinical guidance. (2009)
Standards:
When prescribing
1) Use a single drug.
2) Use the minimum effective dose.
3) Agree with the person the target symptoms, monitoring arrangements and anticipated duration of treatment. Antipsychotic drugs should not be used for medium, long term treatment.
Indication:
4) Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated. (Repeated self-harm, marked emotional instability, risk taking behaviour and transient psychotic symptoms).
5) Short-term use of sedative medication may be considered cautiously as part of the overall treatment plan in a crisis. The duration of treatment should be no longer than 1 week.
6) When considering drug treatment, provide the person with written material about the drug. This should include evidence for the drug's effectiveness in the treatment of borderline personality disorder and for any comorbid condition, and potential harm.
Review:
7) Review the effectiveness and tolerability of previous and current treatments.
8) Discontinue ineffective treatments.
BackgroundBorderline Personality Disorder is common in psychiatric settings with a reported prevalence of 20%.
As per NICE Guidance (CG 78), no medications have been found effective for the longer term treatment of personality difficulties.
This audit was carried out to review if patients were offered psychiatric reviews to discuss the medications they are using, the effectiveness of these, and any potential side effects.
ResultGood practice compliance of 90-100% was noted where >90% compliance was seen in areas where the effectiveness and tolerability of current and previous medication was reviewed by the clinicians under Structured Clinical Management. Also was noted that antipsychotics were not used for medium to long term in patients with Borderline Personality Disorder in the cohort.
The following areas were non-compliant with the NICE recommendations where a compliance <79% has been achieved.
When prescribing, use a single drug (avoid polypharmacy), agree target symptoms, monitoring and duration, provide written information, discuss evidence for effectiveness in treatment of borderline personality disorder.
Partial compliance was achieved (80-89%) with use of sedatives for less than 1 week and discontinuation of ineffective treatment.
ConclusionDistribute key cards to clinicians.
Provide written information to patients.
Re-audit in 6 months.
Trainees4trainees: an innovative peer support project for junior doctors across specialties
- Sophie Behrman, Aisling Higham, Haido Vlachos, Gerti Stegen
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S126
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The BMA's survey results (Caring for the Mental Health of the Medical Workforce, 2019) and HEE's NHS Staff and Learners’ Mental Wellbeing Commission report (2019) highlighted declining staff wellbeing. The COVID-19 pandemic has sharpened focus on this and the effects of moral injury on healthcare professionals. Shielding, social distancing and redeployment led to many medical trainees being increasingly isolated at a time of heightened anxiety and adversity. Psychiatry trainees tend to have good access to reflective groups, but this is not customary in other training programmes.
MethodIntervention
“Trainees4trainees” was set up by trainees across specialties as a HEE-TV well-being project, led by the Deanery Trainee Improvement Fellow. Peer support groups are run on Zoom, facilitated by 2 trainees with special training in peer support. Psychiatry trainees have been involved in designing and facilitating groups and training facilitators from other specialties; facilitators have regular supervision from a consultant psychiatrist in medical psychotherapy. Trainees are supported to discuss challenging experiences and think about their emotional responses in a supportive and validating group.
ResultFeedback
We are in the process of formal data collection to assess the impact of the intervention. Informal feedback suggests the groups are a powerful support to individuals who otherwise have no avenue to think about the psychological impact of their experiences. The groups have supported trainees to feel less isolated and bolstered their resilience.
ConclusionFuture plans
We have faced challenges in the practicalities of establishing and maintaining groups. We are working with Training Programme Directors to move towards running the groups in protected time within working hours and advocate that reflective groups, such as our peer support groups, are a key part of future medical and surgical Training Programmes.
Let's get moving! Improving physical activity amongst rehabilitation patients; a quality improvement project
- Ruth Rowland, Laura Somerville, Sarah Dorman, Mark Finnerty
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S215-S216
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This Quality Improvement Project aimed to improve physical activity amongst patients in a 16-bedded, low secure unit in the Downshire Hospital, Northern Ireland. We introduced an exercise programme with the aim of increasing minutes of physical activity per week. Secondary outcome measures were weight, mood and energy levels.
This project took place in the context of COVID-19 restrictions having reduced opportunities for off-ward activity and staff noting subsequent deconditioning and weight gain amongst the patient cohort. Cohort consisted largely of patients with a severe mental illness, many of whom had physical health co-mobridities.
MethodThis project included all patients in the 16-bedded unit.
Baseline data were collected prior to programme introduction, including weekly activity levels and weights. A questionnaire explored patient confidence and attitude towards physical activity.
Focus groups were held with patients and staff in order to identify how best to introduce the programme, discuss content, and identify potential barriers.
We introduced an eight-week programme of weekly, thirty-minute, mixed ability exercise sessions. These were led collectively by the multi-disciplinary team. Patients actively participated in programme design; choosing session soundtracks and contributing to content planning.
Likert scales were used to measure self-report mood and energy levels pre- and post-session. Staff engaged in a weekly post session de-brief, where challenges were identified and solutions suggested. Weekly qualitative feedback was sought from participants. The sessions were thus developed and adapted according to patient and staff feedback over the programme's course.
Following the 8-week programme, activity levels and weight were re-measured and compared to baseline. Pre-programme questionnaires were also repeated.
ResultPatients reported increased enjoyment and confidence engaging in physical activity, as well as improved overall self- confidence and a sense of pride and ownership of the sessions.
Staff reported a more cohesive team environment, greater sense of work-place fulfilment and improved therapeutic relationships.
Comparing pre and post session ten-point-Likert scales showed a 153% mean increase in self-rated energy levels and a 98% mean increase in self-rated mood. This reflected a mean score increase of 3.8 in both.
Minutes of physical activity per week increased for all session participants, although remained below national guidance.
Weight reduction did not occur.
ConclusionExercise benefits not only physical health, but also emotional and psychological well-being. This project demonstrates how introduction of a weekly ward-based exercise class can offer this as well as improving working environment, team cohesion and therapeutic relationships. Weight reduction may be observed in the longer term.
Predictors of cognitive, behavioural and academic difficulties in NF1
- Kavitha Chinnappa Ramamurthy, Marie-Maude Geoffray, Louise Robinson, Lauren Manderson, Julieta O'Flaherty, Annukka Lehtonen, Grace Vassallo, Shruti Garg, Jonathan Green
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S243
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The aim of this study is to systematically investigate the demographic and disease predictors of cognitive and behavioural phenotype in the largest cohort of children with NF1 published to date. Based on previously published research, we examine the potential role of demographic predictors such as age, sex, SES, parental NF1 status as well as the neurological complications such as epilepsy and brain tumours in NF1 associated cognitive/ behavioural impairments.
MethodIn this cross-sectional study design, participant data were drawn from two large databases which included (i) A clinical database of all patients with NF1 seen in a clinical psychological service from 2010 to 2019 and (ii) A research dataset from two previously published studies (2,8). The complex National NF1 service based within Manchester regional genetic services is set up for individuals with complex NF1 (https://www.mangen.co.uk/healthcare-professionals/clinical-genomic-services/nf1/) in the North of the UK. Children were referred to the psychological services by NF1 clinicians if psychological assessment was warranted based on parental reports. In order to reduce clinic referral bias, the clinical sample was supplemented by including participants that were seen solely for the purposes of research studies within our centre.
ResultRelative to population norms, 90% of the NF1 sample demonstrated significantly lower scores in at least one cognitive or behavioral domain. Family history of NF1 and lower SES were independently associated with poorer cognitive, behavioral and academic outcomes. Neurological problems such as epilepsy and hydrocephalus were associated with lower IQ and academic skills.
ConclusionCognitive and behavioural phenotypes commonly emerge via a complex interplay between genes and environmental factors, and this is true also of a monogenic condition such as NF1. Early interventions and remedial education may be targeted to risk groups such those with familial NF1, families with lower SES and those with associated neurological comorbidities.
Tackling constipation in patients on high dose antipsychotics
- Sandhya Eappen
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
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- 18 June 2021, p. S134
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The aim of this audit was to look into patients on high dose antipsychotics who had developed complications of constipation in the PICU setting .
BackgroundAntipsychotics are usually used in the treatment of Schizophrenia and other psychotic illnesses. Drug such as Clozapine mainly has a higher risk profile due to gastrointestinal hypo motility. It could present as constipation, fecal impaction or a bowel obstruction and could even lead to death.
MethodDuring ward rounds enquired on bowel habits and diet.
Physical examination of patients complaining of abdominal pain.
Screened notes in past to see how many patients complained of constipation and interventions suggested and used.I65.
Result3 of the 10 patients on PICU were on high dose antipsychotics and 2 of them had reported constipation. Of which one required daily review and vigorous treatment with laxatives and dietary changes.
Recommendation
Bristol stool chart introduced as part of care plan for all patients.
Teaching presentation of constipation and its treatment management was given to the PICU team.
Involving medical team early on for assessment and prophylactic laxatives prescription.
Liaison with the pantry team to include more options of fruits and vegetables into daily meal plan for patients.
Data and material handed over to next trainee to Re-audit and complete audit cycle.
ConclusionAppropriate prevention and early management of side effects can enhance the benefits of antipsychotics. Bowel function monitoring and the use of prophylactic laxatives for patient on high dose antipsychotics such as clozapine is advisable to prevent complications related to it.
Where's the emergency? Improving emergency psychiatry experience for core trainees in Bath and North East Somerset (BaNES) and Gloucestershire Health and Care (GHC) localities
- Tom Nutting, Sally Stuart, Francesca Hill
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S150-S151
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The Royal College of Psychiatry advises that core trainees should be involved in 50 first-line emergency assessments during their core training. This includes assessment of suicidal risk following self-harm at least monthly. Trainees in Bath and Gloucester are not meeting these requirements. We set up an emergency experience rota, with the aim of increasing trainees’ experience and confidence in assessment and management of emergency psychiatry.
MethodAn emergency experience rota was implemented in Bath in September 2017. Trainees were surveyed before and after their 6 month rotations. In cycle 1, trainees spent two weeks with the Crisis team and an additional three days with the Liaison team per rotation. In cycle 2, we made some modifications to the rota so that it was more flexible. This system was then adopted in Gloucester where trainees were encountering similar difficulties. We hope to complete cycle 3 across the two localities by July 2021.
ResultFrom the initial two cycles conducted in Bath, post-change surveys showed an increase in trainees’ confidence in assessments in acute settings and completing risk assessments in cases of self-harm and suicidal ideation. All of the trainees who took part would recommend the experience to other trainees (100% (7/7)). In Gloucestershire, only pre-change data have been collected so far. A full analysis of all the results will be presented.
ConclusionThe introduction of working time regulations such as the European Working Time Directive (2003) as well as local service reconfigurations leading to nurse-led liaison services and home treatment teams, have reduced the opportunity for trainees to undertake emergency assessments. Across the Severn Deanery, there is a discrepancy in the opportunity core trainees’ have to undertake emergency assessments – depending on their rota, stage of training, and services available. This difference in trainee experience, depending on locality, has been further impacted by COVID-19 and the introduction of cohorted wards.
Trainees in Bath and Gloucester are predominantly covering the wards during on-calls and, therefore, we set out to ensure that they are regularly rostered to obtain emergency experience, helping them meet their core training competences. Initial results from two cycles of an emergency / out-of-hours experience rota suggest increased experience and confidence in first-line emergency assessments, enabling them to work towards meeting their core training requirements.
The improvement of the quality of medical reviews of patients in seclusion in Rampton Hospital
- Emma McPhail, Ian Yanson
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S333
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Aims
Improve and standardise the quality of medical seclusion reviews (MSRs).
Acknowledge existing good practise.
Highlight areas for improvement.
Improve the awareness of doctors performing MSRs of the requirements in the Mental Health Act Code of Practice (MHA CoP)
BackgroundMSRs are an essential clinical tool to ensure safe and consistent patient care. Patients detained in seclusion can be at heightened risk of poor mental and physical health, in addition to being a risk to themselves and others. There is clear guidance in the MHA CoP regarding what areas require to be covered in a MSR.
MethodA retrospective audit of all MSRs in September 2019 across all patients within all directorates within Rampton Hospital was undertaken. 281 inpatients were identified within Rampton Hospital, and 61 of these patients were found to have had seclusion in September 2019. A total of 439 MSRs were identified for these patients.
The standard applied was the MHA CoP guidance for MSRs:
1) MSRs should be conducted in person, and should include:
2) Review of physical health
3) Review of psychiatric health
4) Assessment of the adverse effects of medication
5) Review of observations required
6) Reassessment of medication prescribed
7) Assessment of the patient's risk to others
8) Assessment of the patient's risk of self-harm
9) Assessment of the need for continuing seclusion
ResultThe results show there is a large variation in compliance with the MHA CoP. The area with the highest compliance was the completion of reviews in person-(99.3%). The criterion with the average worst compliance was whether the need for physical observations was reviewed-(4.3%). Physical health was reviewed in 86.1% of cases, in contrast to psychiatric health at 38.3%. The adverse effects of medication and reassessment of medication prescribed were recorded in only 8.9%. The risk from the patient to others was recorded in 25.3%, whereas risk to self was recorded in 10.7%. The need for continuing seclusion was recorded in 72.7%.
ConclusionThe quality of MSRs at Rampton Hospital is currently inadequate. Improvement in practice is required to meet accepted standards and ensure safe, consistent patient care. Ways to improve this are being considered, including improving the knowledge of the MHA CoP and providing a MSR template.
Towards peak experience - exploring the influence of wilderness on conscious awareness
- Oli Purnell
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
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- 18 June 2021, p. S281
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This study examines what effect wilderness has on our conscious awareness, and by extension of that meta-cognition; our physical, mental and spiritual health. It reviews available scientific and artistic literature and integrates this with interviews in order to generate original grounded theory. It was found that intensity of wilderness experience varied proportionally with four mediators; Challenge, Immersion, Beauty and Time. With these maximised, experiences broadly within four themes occurred; Increased Awareness, Confidence, Perspective and Connectedness. When sufficiently intense, these four experiences amalgamated to elicit what Maslow described as 'Peak Experience'. As such, this thesis unexpectedly provides a pragmatic recipie towards peak experience, and a map of one's potential psychological journey, in the context of wilderness.
Audit on antipsychotic prescribing in children and young people with a learning disability under the care of mental health services in Surrey
- Timothy Cherian James, Asifa Zainab, Salvatore Mura, Aaron Vallance, Dola Okusi
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S71
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To check the extent to which National Institute of Clinical Excellence (NICE) guidelines were being followed in clinical practice with regards to prescribing antipsychotic medication to Child and Adolescent Mental Health Services (CAMHS) patients with a diagnosed learning disability (LD).
MethodA data collection tool (based on a similar Royal College of Psychiatrists [RCPsych] audit) was filled out with retrospective data from patients’ clinical records, then analysed using Microsoft Excel and Microsoft Powerpoint.
The agreed standards were the NICE guidelines.
There were no ethical issues as the data were retrospective and anonymised.
Sample size was 13, comprising 7 males and 6 females.
All service users were less than 18 years of age.
Result7 out of the 13 patients who were prescribed antipsychotics had a Severe/Profound LD.
Among the 5 patients who had been prescribed antipsychotic medication, 4 were on Risperidone and 2 were on Aripiprazole. The reasons for starting antipsychotic medication were clearly documented for all 5, the most common reasons being overt aggressive behaviour and general agitation/anxiety.
Only 1 patient had antipsychotic medication initiated in the previous 12 months. NICE guidelines had been generally followed for the management of this case, with good documented evidence.
For the other 4 patients, in whom antipsychotic medication was initiated more than 12 months ago, there was a lack of documentation of the subsequent assessment of side effects, extra-pyramidal side effects, body weight, blood pressure, glycaemic control and lipid profile. 1 of these patients did not have a documented review of antipsychotic medication in the previous 6 months. For the other 3 patients, their medication reviews did not consider whether to reduce the dose or stop antipsychotic medication.
1 patient had been transferred to primary care, with a clear transfer of prescribing responsibility and documented evidence that written guidance was provided to primary care which addressed all the necessary management details.
ConclusionAlthough there was clear documentation of reasons for initiating antipsychotics, there appeared to be a lack of awareness of NICE guidelines for antipsychotic medication reviews, side effect and metabolic markers assessment, and their documentation. This is an area for potential change in practice to conform better to national guidelines and improve patient care.
Prevalence and course of anxiety and depression among patients selected for bariatric surgery
- Jonathan Gibb, Chris Rogers, Eleanor Gidman, Graziella Mazza, Jane Blazeby, Paul Moran
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
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- 18 June 2021, p. S25
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To determine the prevalence of anxiety and depression amongst participants with severe or complex obesity randomised and selected for bariatric surgery in a large multi-centre trial.
To describe the change in prevalence of anxiety and depression amongst participants who had undergone bariatric surgery, within 6 months of randomisation and at 12 months post-randomisation.
MethodThe By-Band-Sleeve (BBS) study is a multi-site randomised controlled trial evaluating the surgical management of severe or complex obesity and is the largest trial of its kind. Participants completed the Hospital Anxiety and Depression Scale (HADS) on study enrolment (pre-randomisation) and at 12 months post-randomisation. In this sub-study, we describe provisional data concerning the baseline prevalence of anxiety and depression along with change in median HADS symptom score amongst those who actually underwent bariatric surgery.
Result758 participants met the criteria for study inclusion with 716 (94.46%) and 712 (93.93%) individuals fully completing questionnaires for HADS-A and HADS-D. At pre-randomisation, the prevalence of possible (HADS A/D = 8-10) and probable (HADS A/D >11) anxiety or depression was 46.19% (n 330/716) and 48.17% (n 48.17%) respectively. Paired and complete HADS-A and HADS-D questionnaires were available for 70.25% (n 503/716) and 69.94% (n 498/712) participants. There was a highly statistically significant decrease in median HADS-A and HADS-D scores at 12 months post-randomisation (Wilcoxon signed-rank test p < 0.001). This was coupled with a statistically significant reduction in the proportion of cases with possible and probable anxiety (–9.54%, p < 0.001) and also depression (–22.21%, p < 0.001) at 12 months post-randomisation.
ConclusionOur results characterise the high rate of psychological comorbidity amongst patients with severe or complex obesity selected for bariatric surgery. Whilst bariatric surgery remains the most clinically effective treatment for severe obesity, its effects on long-term post-operative mental health outcomes are less clear. These findings contribute to the growing body of evidence calling for increased pre/post-operative mental health surveillance and integrated care for this cohort of patients.
An unregistered TARDBP mutation in a case presenting with young-onset dementia
- Mahmoud Gad, Walid Nasr, Tareq Qassem
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
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- 18 June 2021, p. S116
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Objective
This poster aims to report an unregistered mutation in Transactive Response DNA Binding Protein (TARDBP) gene in a patient presenting young-onset dementia.
Hypothesis: Novel heterozygous mutation in the TARDBP gene is linked to a case of with young-onset dementia.
BackgroundPathogenic variants in TARDBP cause autosomal dominant fronto-temporal degeneration, characterized by TDP43-positive inclusions, dystonia, dyslexia, receptive dysphasia, and paraphrasic errors. In addition to the neurocognitive deficits, patients might suffer from cardiomyopathy and amyotrophic lateral sclerosis.
Case reportMolecular genetic analysis of whole-exome sequencing (WES) was carried out for a 45-year-old male patient presenting with cognitive decline and behavioural symptoms.
DiscussionWES Identified the heterozygous variant c.527A > T p.(Lys 176lle) in TARDBP gene. To the best of our knowledge the variant has not been described in the literature so far (HGMD 2019.3). No allele frequencies in the general population have been documented.
ConclusionWe believe that we have identified a novel mutation in the TARDBP gene. This mutation is likely to be linked to this patient presenting with young-onset dementia.
Improving facilitation of ECT treatment for patients in an acute medical hospital
- Vatsala Mishra, Chun Chiang Sin Fai Lam, Marilia Calcia, Isabel McMullen
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
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- 18 June 2021, p. S42
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Aims
A Quality Improvement Project aiming to streamline facilitation of electroconvulsive therapy (ECT) treatment for psychiatric patients at a general acute hospital and reduce cancellation rates via the use of a checklist.
ECT treatment is an essential aspect of psychiatric care for patients with severe depression or treatment-resistant psychosis. Facilitation of ECT treatment is an uncommon task for liaison psychiatry and the medical and nursing teams responsible for patients’ medical care. Between August-October 2019, this liaison psychiatry team had 3 patients undergoing ECT treatment a total of 13 times, with treatment being cancelled on 4 occasions. After engagement with stakeholders from the acute medical teams, the liaison team and the ECT suite team, key areas requiring intervention were identified to help reduce the rates of cancellation. Areas identified included a lack of ownership on the logistic and operational aspects of ECT amongst staff, a lack of knowledge of what the process involved and a lack of confidence in managing said patients. Difficulties in communication between teams and accurate documentation may contribute to errors and cancellation of ECT sessions, which in turn would delay treatment and impact on patient safety and clinical outcomes.
MethodThe first author, a Foundation Year 1 doctor, developed a 10-point checklist to be referred to when arranging ECT for patients, to ensure errors were not made which could lead to missed treatment and delayed recovery. The tasks and responsibilities of each key member of the team were clearly identified. This checklist was included in all ECT patients’ files and teaching was provided to staff involved. Feedback was obtained from staff involved regarding the clarity of information and their confidence in managing such cases.
ResultIn the month following initial intervention the liaison psychiatry team organised 12 ECT sessions. The checklist was pasted into notes the day before each ECT session and 0 sessions were missed for avoidable reasons. Feedback from staff showed all teams felt more confident co-ordinating ECT treatment as a result of the checklist.
ConclusionCreating a 10-point checklist for the facilitation of ECT treatment in patients at a medical hospital was beneficial in reducing avoidable errors from 16% to 0%. The liaison psychiatrists, medical doctors, and nurses involved reported greater confidence in managing patients undergoing ECT and described the checklist as enhancing the feeling of teamwork and communication within the multi-disciplinary team, and felt it had improved patient safety and clinical outcomes.
Wellbeing support for foundation doctors during COVID-19 in GHNHSFT
- Abbi Graham, Anna-Marie Dale
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S189
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Aims
The COVID-19 pandemic highlighted the importance of wellbeing amongst healthcare professionals. Medical professionals, notably junior doctors, are at increased risk of developing poor mental health and burnout. The GMC Barometer Study in 2020 showed that 32% of doctors found the first wave of the COVID-19 pandemic detrimental to their wellbeing and mental health.
The aim of this quality improvement project was to assess and improve hospital wellbeing support available to foundation doctors within Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) by learning and reflecting on the impact of COVID-19.
MethodAfter identifying a lack of resources within GHNHSFT, wellbeing information boards were displayed in communal areas and distributed by email. These encompassed trust wide support, practical information including childcare and relaxation resources concentrating on mindfulness, exercise and culture. A survey of foundation doctors was completed to assess doctors’ focus and approach to wellbeing. Questions assessed influential factors in maintaining wellbeing, access to current hospital resources and future interventions.
Result94% of respondents recognised that their focus on wellbeing increased during COVID-19. One third of foundation doctors found it challenging to maintain their wellbeing, with 40% reporting difficulty accessing hospital support and advice. The most important factors foundation doctors identified in maintaining wellbeing were exercise, cooking and baking, and social networks. Colleagues were a significant source of wellbeing support, followed by notice boards, email resources and social media.
ConclusionCOVID-19 highlighted the importance and burden on wellbeing of foundation doctors, with a significant number struggling to access support. Future recommendations include the use of a ‘buddy system’, regular and accessible exercise classes and improved communication of wellbeing support and resources to staff members.
Buddy systems have already shown success amongst teams however it is important these are accessible to all foundation doctors and universally offered within the trust. A weekly yoga class is being reintroduced to be available to all doctors.
A particular focus has been the development of a health and wellbeing section to feature in the trusts weekly communications, with the aim to regularly signpost staff to ongoing wellbeing resources and support.
Social networking and media were highlighted as important in both maintaining wellbeing and accessing resources. A future goal is to develop an official GHNHSFT Instagram or Twitter account focused on wellbeing. We hope to continue to learn from the impact of COVID-19, improving the availability of wellbeing support at GHNHSFT that will continue into the future.
Dublin's homeless crisis – is this reflected in emergency department psychiatry referrals?
- Aoibheann McLoughlin, Anna Feeney, John Cooney
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S207-S208
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Aims
This study seeks to explore the prevalence and impact of homelessness in an adult sample of psychiatry referrals over a one-month period via the Emergency Department at St. James's Hospital.
BackgroundHomelessness has now reached a crisis point in Ireland. In July 2019, there were 10,275 people documented as homeless nationwide, with the number of homeless families increasing by 178% since June 2015. The majority of individuals registered as homeless are located in Dublin. St. James's Hospital (SJH) provides psychiatric care to a population of 136,704 people across Dublin South-City within areas of significant deprivation according to the most recent social deprivation index.
MethodAll Emergency Department psychiatry referrals over a one-month period were recorded. Month of study was randomly generated. Data were collected from electronic records. Socio-demographic information was analysed. Data were anonymised and recorded using Microsoft Excel. Current homelessness statistics were accessed from the Department of Housing, Planning, and Local Government and compared to the data collected.
ResultDuring the month of the Study (March 2019), 4315 adults accessed emergency homeless accommodation in Dublin. Of the 109 psychiatry referrals received through the Emergency Department at SJH during this time, over a quarter (28%) of those referred reported themselves to be homeless or living in temporary accommodation. An additional 5% were documented as living in residential or sheltered care at time of assessment. All of the referred homeless patients were unemployed (n = 30). 50% of homeless patients were referred to psychiatry following expressed thoughts or acts of self-harm. Illicit drug abuse was associated with 73% of referrals. Alcohol abuse was associated with 47%. Of those who were referred, under a quarter (23%) were assessed as having a major mental illness, and in the majority of these cases, illicit drug and alcohol abuse were compounding factors in exacerbating symptomatology. Of those referred, 66% had previously been reviewed by psychiatry during prior ED presentations and 60% of homeless presenters reported that they had previously been, or were currently linked in with community mental health teams.
ConclusionFrequently, vulnerable patients most in need of social and psychiatric care, such as homeless people with addiction issues, are eclipsed from accessing supports. The high proportion of patients reporting to be homeless is cause for concern and suggests the need for tailored and integrated multi-disciplinary assessments and interventions at an Emergency Department level.
Clinical audit of prescribing for attention deficit hyperactivity disorder (ADHD) in children and young people services (CYPS)
- Mary Parker, Elaine Martin
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S45
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Background
The audit aimed to assess, when 3rd and 4th line medications were prescribed for ADHD, if practice was compliant with Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) prescribing guidelines and the updated NICE Guideline NG87: Attention deficit hyperactivity disorder: diagnosis and management 2018.
MethodThe audit was conducted in the four Teesside Child & Adolescent community teams during April/May 2018. Each team identified all patients prescribed 3rd and 4th line ADHD medications leading to 30 responses (n = 30).
Information was collected from electronic and paper medical records using a designated audit tool compiled from the above evidence based guidelines. The data were analysed for compliance against standards using an excel spreadsheet and reviewed by the audit lead.
ResultThere were many areas of good practice demonstrated in the audit including diagnostic recording, pre-treatment non-medical interventions where ADHD was not severe, and use of Methylphenidate as first line medication in accordance with BNF limits. In the majority of records reviewed, there was good evidence of a variety of NICE recommended non-medication interventions which were often continued post medication initiation.
There was also very good evidence of comprehensive verbal and written information and psychoeducation including benefits and potential side effects of medication (92% verbal and 58% written).
A pre-treatment assessment was completed in all but 3 cases, 1 of which had no assessment documented and 2 cases were transferred from out of area.
Issues identified by the audit, where there was deviation from guidelines, included 4 cases where Methylphenidate was not prescribed as first line, of these, 3 were prescribed Atomoxetine due to parental choice and one was due to contraindications, suggesting patient choice was an important factor in selection of 2nd line medication.
The audit demonstrates that clinical practice had moved away from the previous guidance in NICE CG72 (to prescribe atomoxetine 2nd line) towards the prescription of Lisdexamfetamine 2nd line (75%) as reflected in the new NICE guidelines: NG87, 2018 (updated 2019).
ConclusionThis audit cycle has demonstrated that use of an evidence based approach has been instrumental in improving patient care. The Audit evidenced good practice in areas such as pre-assessment, information and psychological education, initial use of Methylphenidate, use of Lisdexamfetamine 2nd line, as well as consideration of patient choice. Importantly the audit highlighted that implementation of updated NICE compliant trust guidance, followed by a planned trust-wide audit will promote continuous improvement in patient care.
War-related trauma and post-traumatic stress disorder prevalence among Syrian university students
- Fatema Mohsen, Yousef Latifa, Bisher Sawaf
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S43
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Aims
PTSD is one of the most prevalent mental disorders in war-affected regions. Syria has endured 10 years of war and yet little is known about the impact of the conflict on the well-being of Syrians who remain. This study aimed to provide an estimated prevalence of PTSD among trauma-exposed university students in Deir-ez-Zor, Syria, a war-ridden region, that was under siege by the Islamic State of Iraq and the Levant (ISIS) for over 3 years. Moreover, we aimed to study the different types of trauma to which the students were exposed and studied the association between PTSD and multiple covariates including, socio-demographic characteristics, smoking habits, academic performance, and stress levels, and identify factors that influence the development of PTSD symptoms.
MethodA descriptive cross-sectional study design was used on a sample of Al-Furat university students in Deir-ez-Zor. We collected data on socio-demographics, trauma exposure, and stress levels. PTSD Checklist for DSM-5 was used to carry out PTSD diagnosis and to determine the severity of the disorder.
ResultA total of 833 Syrian students were recruited into the study, the mean was 22.4 ± 3.2 years. Of those, (22.2%) have been displaced 3 times, while (18.8%) were displaced over 5 times. (86.4%) reported experiencing at least one traumatic event, (33.8%) of the participants were exposed to one traumatic event, and (44.7%) experienced four or more traumatic events. PTSD prevalence was (28.2%), and the highest PTSD rates were found among students who were forced into sexual acts (46.3%), followed by those who witnessed childhood trauma or violence and those who witnessed violence as adults (42.6%). Sample distribution over stress levels was as follows: normal (39.5%), mild (16.0%), moderate (17.8%), severe (17.3%), and extremely severe (9.8%). A statistically significant association was found between PTSD prevalence and stress severity (p = 0.000). A significant association was found between PTSD and internal displacement (p = 0.032), academic year (p = 0.002), and social-economic status (p = 0.000). Binary logistic regression revealed that smokers (vs non-smokers, OR = 0.259, p = .034) and third-year students (vs fifth year, OR = 0.44, p = .019) were significantly associated with PTSD.
ConclusionThe results presented in this research revealed a high prevalence of trauma exposure and PTSD among a sample of university students in Deir-ez-Zor. These findings call for immediate actions to help the affected population in restoring their mental health, so they can be prepared to face the challenges and demands of the post-conflict period.
A retrospective observational study of vitamin D levels in patients within the Tameside and Glossop early intervention in psychosis team
- Emily Kaye, Pete Parker, Thomas Fyall, Katie Arrowsmith, Holly Hark, Samei Ahmed Huda
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S263
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Aims
Growing evidence indicates that Vitamin D deficiency is associated with psychotic symptoms. Although evidence suggesting a causal relationship is limited, theories regarding neuro-inflammatory modulation are promising. Alternatively, deficiency may signify chronic illness or poor functioning. Nevertheless, Vitamin D levels below 50nmol/L increase the risk of osteoporosis, muscle weakness, falls and fractures, thus identification and treatment are important.
The association between Vitamin D levels in patients within the Tameside Early Intervention in Psychosis Team (EIT) was studied, hypothesising a strong correlation.
MethodThe records of all patients in the EIT as of 01/07/2020, over the age of 16 years old (n = 183), were studied. The first Vitamin D level taken while under the EIT and the CGI scores closest to the date of this level were recorded. Vitamin D levels of 25nmol/L and under were classified as deficient, levels of 25.1 - 50nmol/L were insufficient.
Result45.90% (n = 84) of patients did not have their levels recorded. Of the 55% (n = 99) patients who had Vitamin D levels recorded, 49.50% (n = 49) were insufficient and 22.22% (n = 22) were deficient. Therefore, only 28.28% (n = 28) had either optimal or sufficient Vitamin D levels. The majority of Vitamin D levels were taken in Autumn (36.46% n = 36).
75.76% (n = 75) of patients had both vitamin D levels and CGI scores recorded, with an average of 35.65 days between date level and score recorded. A weak negative correlation between overall CGI scores and vitamin D level was calculated, producing Spearman R Correlation Coefficient of -0.15.
ConclusionAlmost 3/4 of the studied patients being assessed for psychotic symptoms had either insufficient or deficient levels of Vitamin D. The correlation between symptom severity and Vitamin D level was weak however. While we cannot comment on the causality of the relationship, it appears that there is an association between our studied patient group and Vitamin D insufficiency.
The evidence to suggest that supplementation can reduce psychotic symptoms is limited however, supplementation can reduce the risk of osteoporosis and falls, therefore would improve patient care. Only 55% of the patients within the EIT had their Vitamin D levels tested. As a result of this study, the authors recommend that all patients in the EIT have their Vitamin D levels tested as part of their psychosis assessment.
The study is limited due to low numbers of patients studied and the fact that recorded CGI scores were often recorded at a later date to Vitamin D levels.