2917 results in BJPsych Open
Neurodiversity in the teaching of the mental state examination: a pilot study of interactive mind-mapping seminars for the new ScotGem (Scottish graduate-entry medicine) students during the COVID-19 pandemic
- Kathleen Breslin, Sara Mohsen, Praveen Kumar
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S10-S11
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Agility in educational delivery has been catalyzed in response to national restrictions mandated by the recent COVID-19 pandemic. Increased use of assistive technologies further aligns with the General Medical Council's aims that medical educators provide an 'accessible training experience'. The study examined medical students' receptiveness to different types of interactive teaching. Two undergraduate cohorts received teaching on the Mental State Examination, either socially-distanced delivered by traditional powerpoint or remotely by mind-mapping software on a tablet hand-held digital device. We required an effective program which would retain the popular interactive elements of Psychiatry teaching and promote inclusivity across students' diverse learning styles.
MethodTwo cohorts of Year 2 students from the Universities of Dundee and St Andrew's Scottish Graduate-Entry Medicine (scotGEM) course took part in an Introduction to Psychiatry seminar which involved a presentation of the Mental State Examination. One was conducted in a face-to-face setting via traditional PowerPoint. The second was conducted via remote-conferencing with mindmaps of key concepts drawn and screen-shared live to students as teaching progressed.
This was a qualitative study, with online links to questionnaires for 24 student participants across 5 domains. (1. The tutorial met my learning objectives, 2. The format was suitable for me, 3. The balance of theory and cases was suitable for me, 4. The tutorial was of appropriate length, 5. I was satisfied with the performance) Response options included: strongly disagree, disagree, neutral, agree, strongly agree. A section was also included with open-ended questions pooled for thematic analysis.
ResultResponse rate reached >60% with >80% respondents answering strongly agree across all domains. Thematic results demonstrated positive responses across both teaching sessions, with the interactive elements valued by students. Comments included: “great job was done with the delivery of the session considering it was online rather than in person”; “drawing element was fantastic”; “Good: interactivity of the session drawing and creativity element”.
ConclusionThe Mental State Examination (MSE) via live-drawn mind-maps allows salient clinical information to be conceptualised in non-linear diagramatic format. This paediological approach can offer further access points across wide range of learning styles. This pilot study demonstrated such interactive components of Psychiatry teaching continue to be well received and can be effectively delivered remotely. Such sessions also serve to promote inclusivity, linking those who are geographically distant in addition to the visual learner and the neurodiverse. We aim to incorporate these dynamic teaching sessions into our online induction programs and disseminate Intelligent Tutorials to our remote and rural learners throughout Scotland.
Rates of cervical screening amongst females admitted to the psychiatric inpatient hospital in Jersey, Channel Islands
- Jade Wright
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S228-S229
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Patients with enduring mental health conditions are known to have higher morbidity and mortality rates than the general population. It has been identified that this is due to lifestyle risk factors, medication side effects and barriers to receiving physical health care. National screening programmes; including cervical screening, save lives, however depends upon patient engagement. We hypothesised that due to the factors stated above, psychiatric inpatients are more at risk of cervical cancer and less likely to engage in cervical screening. This study aimed to assess the cervical screening history of patients discharged from the psychiatric inpatient hospital in Jersey, Channel Islands.
MethodUsing computerised laboratory records, the cervical smear history of female patients discharged from the paychiatric inpatient hospital was analysed. Inclusion criteria were: being aged between 25–64 years and having a cervix in situ. Exclusion criteria were total hysterectomy. Cervical smear history was compared to the national guidelines of having routine smears every 3 years for women aged 25–49 and every 5 years for women aged between 50–64 years.
ResultIn the period 1 December 2019–1 December 2020 there were 45 females discharged from the psychiatric inpatient hospital that fit the inclusion criteria. 26 (58%) were up to date with their cervical smears in accordance with national guidelines. 12 (27%) had previously had a smear but were not up to date. 19 smears were done at the GP, 13 at the sexual health clinic and 6 at gynaecology clinic. 7 (16%) had never had a cervical smear. Of these 7 patients it was identified that one patient was in a same sex relationship and one was a victim of sexual assault.
Conclusion58% of women discharged from the psychiatric inpatient hospital were up to date with their smears. This is down from the 72.2% coverage rate of the general population. Although this was a small study, it highlights that engagement with cervical screening amongst psychiatric inpatients is less than the general population. Admission presents a crucial contact between patients and healthcare services and this could be utilised to engage patients in physical health screening. Cervical screening history could be checked upon admission and patients not adequately screened, assisted to make an appointment on discharge.
Use of clonidine in the management of opiate withdrawal in community patients
- David Kelsey, Pierre Hoezoo, Pardeep Grewal
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S200
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Clonidine has been used to alleviate symptoms of opiate withdrawal. No validated prescribing schedules exist for the use of Clonidine in opiate detoxification in community patients. We have devised a Clonidine prescribing schedule for adult outpatients seeking opiate detoxification.
BackgroundOpiate cessation following prolonged use produces a central noradrenergic (NA) response in the locus coeruleus (LC), causing symptoms that can result in reinstatement of use. Pharmacotherapies for withdrawal are thought to work through decreased NA release in the LC by agonising pre-synaptic alpha-2 adrenoceptors. Clonidine has been used since the 1970s. However, it is off-license in the UK, and superseded by Lofexidine. Though both cause hypotension, this is less marked with Lofexidine, which may be anxiolytic and considered better tolerated. Lofexidine is no longer available in the UK. Specialists may need to resort to Clonidine for those seeking opiate detoxification.
MethodWe performed a feasibility study with the primary outcome being tolerability of an outpatient clonidine schedule. Patients (n = 7) were aged between 18 and 65 years (mean 32). Six were prescribed buprenorphine as opiate substitution (OST), and one methadone.
Exclusion criteria were in keeping with BNF contraindications.
An ECG was obtained for each patient before treatment. A urine drug screen and Clinical Opiate Withdrawal Scale were taken to confirm opiate dependence and withdrawal. Patients self-monitored withdrawal using the Subjective Opiate Withdrawal Scale and daily blood pressure measurements. Standard adjuvants for withdrawal were prescribed.
A test dose of 100mcg Clonidine was given to assess for hypotension. If tolerant they received 100mcg QDS, reducing over eight days.
Patients were contacted by their recovery worker twice during the period.
ResultFive of the seven completed the course, two dropped out due to hypotension. No other adverse effects warranting discontinuation were encountered. Patients reported fatigue and light-headedness as their most troublesome side-effects. Of 3 patients who returned SOWS scores, 2 reported decline by 21/64 and 14/64 respectively. One reported an increase of 49/64 over 8 days. 3 of the 5 subjects who completed the course were not abstinent at completion, citing opiate withdrawal symptoms as causative.
ConclusionThere is scope for the safe use of clonidine in the community for motivated individuals. Adequate monitoring of heart rate and blood pressure is required. Starting doses at 100mcg QDS appear well tolerated. Prescribers may wish to reduce this over a longer period to encourage completion and improve tolerability. Further research is needed.
Clinical audit of the inclusion of the Lester Tool details in discharge documents at Foss Park Hospital, York
- Kayleigh Jones, Shona McIlrae, Karen Ball, Rohma Tahir
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S86
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Patients with serious mental health illnesses die on average 15–20 years before the rest of the general population. Anti-psychotic medication, lifestyle and difficulty accessing healthcare services all have a detrimental effect on their life expectancy. To improve outcomes for these patients the Lester Tool; a method to assess the cardiovascular health of patients and implement change, was developed. Including the Lester Tool information in discharge letters allows transfer of information to other care providers (mainly GP's) who can implement and monitor any interventions made, improving outcomes for our patients. With this in mind, discharge documents should contain all of the information listed in the Lester Tool.
We aimed to check if 100% of data required by the Lester Tool is included in discharge documents of the inpatients at Foss Park Hospital.
Method20 patients from each of the male and female wards at Foss Park hospital, discharged in September or October 2020, were identified. A review of the discharge documents established whether the smoking status, BMI, ECG, blood pressure and blood results of each patient were recorded.
ResultOf the 40 discharges, none had 100% compliance. On average across both wards; only 23% of the Lester tool information was included in the documents. On the female ward, 40% had none of data recorded, while on the male ward, 15% had none of the data recorded. Across both wards, not a single patient had details about their cholesterol ratio recorded, only 50% of BMI's were recorded and only 27% had a smoking status included.
ConclusionOur results have shown that compliance with the Lester Tool falls short of what is expected. As a result, information about the physical health of our patients is not being communicated effectively with other care providers. This in turn can prevent patients being offered interventions needed to improve their cardiovascular health.
Identifying this shortcoming in the transfer of information will allow us to educate the staff in our organisation and ensure that all the necessary physical health details will be included in future discharge documents. The result being improved outcomes and longer life expectancy of patients with serious mental illnesses, satisfying the purpose of the Lester Tool.
Neuroimaging in an older adult inpatient psychiatric unit
- Aoife Nechowska
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
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- 18 June 2021, p. S95
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This audit aimed to analyse the use of neuroimaging and its effect on treatment in an older adult inpatient psychiatry unit over the period of one year.
BackgroundBrain imaging can be used as a diagnostic tool in psychiatry. According to NICE guidelines, structural imaging, such as magnetic resonance imaging (MRI) or computed topography (CT), can be used in the workup for dementia diagnosis in order to exclude non-dementia pathology and identify dementia subtype. This is important in the geriatric population where evidence of small vessel disease has an impact on treatment options and management of polypharmacy.
MethodA list of patients from the past year (January to December 2019) was accessed. Patient records were then analysed to see if neuroimaging had been accessed during their admission at The Meadows Hospital, Surrey and Borders Partnership. This included imaging from prior to admission. Analysis was divided into type of imaging, comments and impact on diagnosis.
ResultOverall numbers for the audit were small. A total of 74 patients were admitted onto the unit, of which 3 were readmissions. There was missing information for 8 patients, giving a total of 63 patients. CT scans were accessed for 35 patients (56% of total); 3 of these were done during the admission. MRI scans were completed for 21 patients (33%), with one requested during admission. A total of 9 patients (14%) had both CT and MRI scans. Neuroimaging results led to a change in diagnosis for 6 patients (10%). In all cases this reflected the finding of small vessel disease and a change of diagnosis to either vascular dementia or mixed dementia.
Diagnoses were also analysed. The Meadows Hospital has 2 dementia wards (male and female) and 1 functional ward (for females). A total of 36 patients (57%) were diagnosed with dementia, of which the biggest groups were: Alzheimer's dementia (13 patients, 36%) and Vascular dementia (11 patients, 31%).
ConclusionThe majority of the patients were admitted with established diagnoses and so only a small number had changes made following review of imaging. Good imaging results and reports help to differentiate types of dementia. Although neuroimaging is not gold standard in diagnosing dementia syndromes, it is now an important aspect in the diagnostic pathway. Getting the diagnosis correct will help with treating individuals appropriately and avoid unnecessary prescribing.
Reduced motivation to work for financial reward associated with harmful alcohol use in a community sample of young adults
- Jessica Henry, Karen Ersche, Tsen Vei Lim
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S255
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Neuroimaging research suggests that alcohol dependency is associated with impairments in anticipating monetary rewards, but not aversive or alcohol-related cues.
We sought to investigate if reinforcement sensitivity is altered in young adults, who regularly consume harmful levels of alcohol, using a monetary incentive reinforcement (MIR) task. In light of previous research suggesting reduced motivation to obtain reward, we hypothesized that young alcohol users would show reduced motivation for monetary gain, but unimpaired loss avoidance behaviour.
MethodWe recruited 46 volunteers from the local community in Cambridge (UK), half of whom reported consuming alcohol at harmful levels, as reflected by the Alcohol Use Disorder Test. Participants completed a number of personality questionnaires, including the Barratt Impulsivity Scale (BIS-11) and Sensation-Seeking-Scale (SSS-V) and performed the MIR task, which measures participants’ efforts in avoiding punishment and gaining rewards. Data were analysed using Statistical Package for Social Sciences (SPSS) version 25 (IBM, Chicago IL). Analysis of co-variance (ANOVA) were used to explore group differences in demographics, personality traits and task performance; age and gender were included as co-variates.
ResultThe groups were well-matched in terms of socioeconomic status and education levels. As the alcohol group was significantly younger than the control group and dominated by females, age and gender were statistically controlled for. Alcohol users reported significantly higher levels of impulsivity (F1,41 = 6.0, p = 0.019) and sensation-seeking traits (F1,42 = 36.7, p < 0.001) and demonstrated normal sensitivity to monetary value (F1,41 = 1.07,p = 0.307). However, when challenged to on the MIR task to gain reward or avoid punishment, alcohol users were as equally motivated as control volunteers to take action to avoid financial loss (F1,41 = 2.6,p = 0.112) but showed less motivation to work towards financial reward (F1,41 = 4.7,p = 0.036). Especially for small rewards, alcohol users exerted significantly less efforts, as reflected by a reduced accuracy rate (F1,41 = 6.6,p = 0.014) and a significant increase in late responses (F1,41 = 7.7,p = 0.008). The lack of motivation to work for reward was negatively associated with the severity of alcohol use, as reflected by the AUDIT score (r=−.48,p < 0-05).
ConclusionWe observed reduced motivation to obtain financial reward, but not avoid loss in a community sample of heavy drinkers. As the observed effect was directly related to alcohol use severity, it may suggest changes in reinforcement sensitivity occur at an early stage of chronic alcohol use. Future research may want to monitor reward motivation in alcohol users longitudinally to evaluate whether it would be a suitable target for early intervention.
The diagnosis and management of adult ADHD in HMP Elmley, a Category B remand prison
- Kathleen McCurdy, Nosa Igbinomwanhia
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S90
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Attention deficit hyperactivity disorder (ADHD) is a highly prevalent disorder in young adult prisoners. This audit aimed to identify how many residents are prescribed medication treatment for ADHD in HMP Elmley and whether those seen by the prison psychiatrists have been managed in line with NICE guidelines. We also audited waiting times and time to follow-up appointments. This was done with the overall aim to identify potential areas for development.
MethodWe performed a spot audit of all residents in HMP Elmley who were prescribed ADHD medication on 4th November 2019, using their electronic patient records. Appointments with the psychiatrists were then subdivided into initial assessments and follow-up appointments for the purpose of analysis. Performance was measured against NICE Guideline [NG87]: Attention deficit hyperactivity disorder: diagnosis and management. We also calculated the waiting times for initial appointment and follow-up appointment.
ResultWe found that 33 of residents were on ADHD medication at the time of the audit, approximately 3% of the prison population. 64% of those had a pre-existing diagnosis and 36% had been given a new diagnosis at HMP Elmley. Of those newly diagnosed 100% had undergone a Diagnostic Interview for Adults in ADHD (DIVA) assessment for diagnosis.
Baseline physical health checks had been performed in 68% of patients prior to starting medication and a cardiovascular examination had occurred in 9%. At follow-up 100% of patients had their physical observations and weight checked and their symptoms reviewed.
91% of patients were started on methylphenidate or lisdexamfetamine as first line treatment, with the rest started on atomoxetine and the reason for this documented.
100% patients were offered general psychological support.
There was a mean 22 day wait for an initial appointment (range 0-65) and a mean 20 day wait from starting medication to a psychiatric follow-up appointment (range 8-37)
ConclusionThe number of residents treated for ADHD in HMP Elmley is relatively low (3%) compared to the estimated prevalence in prison population.
The key areas for improvement are in baseline cardiovascular examinations and physical health evaluations. The waiting time between initial psychiatric appointment and follow-up is another area where improvement is needed and this will form the basis of a quality improvement project.
Future steps include setting up a specific ADHD clinic with an allocated nurse practitioner to support, producing a template for ADHD assessments and follow-ups, producing a local policy on ADHD and developing specific resources for ADHD psychoeducation.
Evaluation of a specialist service model for treating body dysmorphic disorder (BDD): application of National Institute for Health and Clinical Excellence Guidelines for BDD (NICE, 2006)
- Anusha Govender
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S322
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Body dysmorphic disorder (BDD) is still poorly recognised with a dearth of research into treatment. The OCD/BDD Service (South West London St. George's Mental Health NHS Trust) is a specialist service offering treatment for BDD using the National Institute for Health and Clinical Excellence (NICE) stepped care model for BDD as a basis for service provision.
This is the only known study to date to evaluate the implementation of the NICE guidelines recommended treatment for BDD in clinical practice. Furthermore, a sample of patients and clinicians were interviewed to elicit their evaluation of treatment.
MethodA total of 48 patients with a primary diagnosis of BDD who were offered treatment between 2006 and 2018 were identified. Questionnaires routinely completed at time of assessment were Yale Brown Obsessive Compulsive Scale for BDD (YBOCS-BDD); Montgomery-Asberg Depression Rating Scale (MADRS); Beck Depression Inventory (BDI) and Sheehan Disability Scale (SDS). Assessments were conducted by clinicians with expertise in BDD. Clinical data including risks and sociodemographic information were collated and analysed. Data were examined with intention to treat analysis. Thematic Analysis (TA) was used to analyse data from semi-structured interviews conducted with ten clinical staff and seven patients regarding their experiences of treatment. Qualitative data were coded and themes identified.
ResultClinical data at assessment indicated impaired functioning plus high risks and substance misuse. There was a higher percentage of females (58%); average duration of BDD was 19.23 years. Clinical outcomes indicated significant improvements in the total sample from baseline on measures of BDD, depression and functioning (p = 0.001). Patients described their progress in terms of living skills, social interactions and quality of life. The main themes identified included the significance of the therapeutic relationship expressed by both patients and clinicians; the lack of early intervention and knowledge of BDD in healthcare.
ConclusionCurrent recommendations for treating BDD were found to be beneficial overall. However, there are patients who are non-responders and including experiences of patients’ and clinicians’ perspectives provided valuable insights into other options for treatment which are lacking and could enhance current recommendations where CBT and medication have not enabled progress. The young onset age with long duration, highlights the need for developing awareness of BDD so that it is not a hidden disorder.
An evaluation of the prevalence of physical health comorbidities in patients with severe and enduring mental illness following admission to the general adult psychiatric inpatient wards in Mersey Care NHS Foundation Trust
- Declan Hyland, Millie Prime, Ellen Carter
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
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- 18 June 2021, pp. S84-S85
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This evaluation aimed to establish the prevalence of physical health comorbidities in SMI patients admitted to the general adult wards in Mersey Care NHS Foundation Trust.
BackgroundMean life expectancy in individuals with severe and enduring mental illness (SMI) is 15-20 years shorter than that of the general population. A significant proportion of excess mortality in patients with SMI is due to natural causes, e.g. cardiovascular disease and type II diabetes mellitus. Although SMI patients are at greater risk of developing chronic physical health problems, they often receive worse health care than the general population. SMI patients more likely to engage in unhealthy lifestyle behaviours, such as poor dietary choices, smoking and physical inactivity; Antipsychotic medication prescribed to these patients can cause adverse metabolic side effects.
MethodA list of all inpatients on the eight general adult wards in the Trust was obtained in September 2020, producing a sample of 135 inpatients.
An audit tool was designed, capturing demographic data – gender, age, ethnicity, and also recording whether the patient had a diagnosis of an SMI (e.g. schizophrenia, bipolar affective disorder). The presence of any physical health comorbidities and whether the inpatient was a smoker was also recorded.
ResultOf the 135 inpatients, 10 didn't have any physical health monitoring completed and were excluded from the sample, making the final sample 125 inpatients. 68 of the inpatients were male, 57 were female. 98 had a diagnosis of an SMI, 27 did not. Most inpatients were of “white British” ethnicity. Of the 98 SMI patients, 14 had type II diabetes mellitus, 11 had essential hypertension, 12 had chronic obstructive pulmonary disease and 22 were obese (i.e. a BMI > 30 kg/m2). 70 of the 98 patients with an SMI were smokers.
ConclusionAs expected, a significant proportion of patients with SMI admitted to the general adult inpatient wards are smokers. Whilst admission to hospital may not be considered an ideal time to get patients to consider quitting smoking, admission does at least provide an opportunity to educate patients on the negative effects on physical health that smoking has. This evaluation has highlighted that physical health comorbidities are common in this patient group. Admission to the psychiatric ward provides a golden opportunity to provide education to patients on the importance of making healthy lifestyle choices and also to assess any physical health comorbidities and ensure the management of any such comorbidities is optimised prior to discharge.
Improving the management of menopause in women with serious mental illness
- Maria-Elena Di Lorenzo, Thomas Reilly, Tom Walker-Tilley, Shubhra Mace
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S185
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To improve the diagnosis and management of menopause in women with a serious mental illness in psychiatric services. This will be achieved by developing a questionnaire to systematically assess symptoms related to the menopause, based on NICE guidelines. Women will be offered information and advice, according to these guidelines. Barriers to the assessment or management of the menopause will be identified by piloting the questionnaire on an inpatient female ward.
MethodWomen aged 40 years and over, admitted to an acute female in-patient ward in South London and Maudsley NHS Foundation Trust, were interviewed using a structured questionnaire.
ResultIn total, 23 eligible women were approached of whom 17 (74%) agreed to take part with mean age 53 years (range 40–67 years). Nine women reported that they had undergone the menopause and four women reported experiencing perimenopausal symptoms. Fifteen women had not previously received information about the menopause. Of the 13 women who had undergone the menopause or were experiencing irregular periods, 7 reported experiencing hot flushes, night sweats and a general change in physical and mental health and four reported a change in mood. Seven women reported that the changes noted may have been related to the menopause over the previous 12 months. Eight women requested further information either in written format or in the form of an information group about the menopause.
ConclusionWe identified women who were admitted to a psychiatric ward who had experienced symptoms related to the menopause that had impacted on their mental and physical health. It was evident that the majority of these women with severe mental illness had not had the opportunity to discuss their symptoms with a healthcare professional in the past and a significant proportion welcomed further information to help make sense of their symptoms. We intend to implement the questionnaire trust-wide with the eventual aim of developing a local guideline to inform the assessment and management of the menopause within our services.
The Safety Conversation: developing a trustwide safety conference at CNWL during a pandemic
- Emily Duncan, Simon Edwards, Alison Butler, Cornelius Kelly
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S133-S134
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The COVID pandemic has had both a massive impact on clinical service delivery and the way that training and education is provided. CNWL is a large NHS provider and has approximately 7000 staff working across 150 locations, providing mental health and community health services. In response to the need to share learning across the organisation, a trustwide “Safety Conversation Day” took place to spotlight the work being done to promote safety and to act as a platform to share ideas and learning across the trust. This was the first ever virtual conference organised by the trust.
MethodThe one-day conference included virtual posters and an all-day open access virtual conversation delivered via zoom. The day was divided into 6 safety themes: Safety tools; Safer Environments; Supporting and Involving Staff; Safer use of Medicines; See Think Act and Relational Security; and Prevention is Better than Cure. Frontline staff delivered 5-6 short presentations each hour highlighting new ways of working, quality improvement, local research etc.
Staff were also encouraged to submit posters for the event, with webinars held on how to write a poster held prior to the safety conversation to promote engagement. Prizes were awarded for best posters in the different categories.
A mentimeter survey was running throughout the day to get feedback from participants.
ResultThis was the largest event of this kind held by the trust. 430 unique viewers logged in during the day to watch the presentations.
Feedback was very positive on the mentimeter survey. 3 questions were asked on a likert scale of: Strongly Disagree – Strongly Agree (rated out of 5):
– ‘I found the posters really useful': 4.5/5
– ‘I found the presentations very useful': 4.6/5
– ‘I will share what I've learnt about safety': 4.6/5
174 posters were presented with good representation from all services and staff groups across the trust (18 on safer use of medicines, 15 on co-production, 52 on quality improvement, 50 on COVID and non-COVID safety, 16 on use of technology, 23 on supporting and involving staff). These posters have since been downloaded 4062 times.
ConclusionThe first CNWL safety conference proved an excellent opportunity to celebrate achievements in patient safety in a very difficult year. It was very well-received and well-attended by staff, promoting maximal learning across the organisation.
An evaluation of barriers to the initiation of clozapine in patients with treatment-resistant schizophrenia
- Declan Hyland, Seth Jamieson
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
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- 18 June 2021, pp. S30-S31
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This evaluation aimed to identify patient, practitioner and infrastructural barriers to initiation of clozapine treatment in patients with treatment-resistant schizophrenia (TRS). In response to recent research supporting use of clozapine as the most effective treatment for patients with TRS, concerted efforts have been made to establish why clozapine is underutilised in the NHS. Following a study conducted by South London and Maudsley NHS Foundation Trust, which identified barriers and made recommendations, this evaluation aimed to identify barriers to initiation of clozapine in patients under the care of Mersey Care NHS Foundation Trust.
This evaluation also aimed to make further recommendations to increase use of clozapine in Mersey Care's TRS patients and assess whether there have been any differences to concerns about clozapine initiation compared to previous evaluations.
MethodAn online questionnaire containing a series of Likert scales was e-mailed to all Consultant Psychiatrists in Mersey Care NHS Foundation Trust. The questionnaire asked Consultants to rate how often they felt a range of barriers interfered with successful initiation of Clozapine treatment. The barriers chosen were based on the 2019 systematic review “Barriers to using clozapine in treatment-resistant schizophrenia.”
ResultNineteen consultant psychiatrists completed the online questionnaire. All 19 indicated they either “agreed” (16%) or “strongly agreed” (84%) that they were confident in diagnosing TRS. This was a significant increase compared to the South London and Maudsley evaluation, with only 81% of participants in that study being “fairly familar” or “very familiar” with clozapine guidelines.
Furthermore, concerns about inadequate blood testing facilities appear to have been addressed, with no participants in this evaluation staing there were insufficient blood testing facilities. However, 53% of Consultants who completed this evaluation stated they “often” (37%) or “very often” (16%) have patients who refuse clozapine because of the requirement for regular blood testing. Refusal to agree to required blood testing was the commonest reason identified for failure to initiate clozapine in TRS patients. This was consistent with the results from the South London and Maudsley study.
ConclusionThose Mersey Care consultants surveyed identified that providing patients with further information about clozapine would be the most valuable intervention to increase likelihood of uptake of clozapine in the treatment of TRS. Significant progress has been made in improving the likelihood that clozapine can be successfully initiated, especially in the removal of practitioner barriers. This evaluation suggests interventions should now be aimed at reducing patient barriers to initiation of treatment.
Quality improvement project: to improve adherence to DVLA (driving and vehicle liscensing agency) guidance in the tyrone & fermanagh hospital acute inpatients ward
- Vivian Sing, Chad Ballantine, Peter Hackett
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
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- 18 June 2021, pp. S221-S222
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To reach 80% adherence to DVANI (Driving and Vehicle Agency Northern Ireland) guidance in acute inpatients ward, T&F Hospital
BackgroundThis is a scale-up of a previous successful QI project on driving and Attention Deficit Hyperactivity Disorder in Belfast Trust. According DVLA's guidance for medical practitioners on the current medical standards of fitness to drive, patients with certain mental health diagnosis are required to inform DVLA of their diagnoses and refrain from driving. Different factors are considered in order to determine patients’ fitness to drive. According to DVLA and GMC, it is medical professionals’ responsibility to advise patients to inform DVLA/DVANI of their mental health diagnosis. It is the patient's legal duty to notify DVLA/DVANI of their diagnosis. Patients can be fined up to £1000 if they failed to inform DVANI of their medical condition.
MethodOutcome: Completeness of driving advice given to consecutive patients discharged from T&F hospital from April 2019 to early August 2019 in %
Process: Document clearly in electronic and written notes on following - (1) has driving status been asked (2) has patient been advised to inform DVA if required (3) has patient been advised likely how long he/she is to refrain from driving for
Balancing: increased the time of reviews, increased numbers of consultant reports requested from DVA
Result4 cycles have been completed. Cycle 1 – baseline and review guidance; Cycle 2 – medical staff education and developed driving advice pathway and patient leaflet; Cycle 3 – admin staff was involved for putting driving advice pathway in admission pack; Cycle 4 – medical staff was educated again regarding importance of documenting electronically. Clear changes were seen after cycle 3 showing an increase of mean of 25% completeness of driving advice to over 90%.
ConclusionIt is the legal duty of patients to notify DVANI of mental health diagnosis, however it is the responsibility of medical professionals to advise patients to do so. This QI project has shown improvement in the completeness of driving advice given. Further cycles are to be completed to obtain patient feedback.
Experiences of people seen in an acute hospital setting by liaison mental health services: responses from an online survey
- Daniel Romeu, Elspeth Guthrie, Carolyn Czoski-Murray, Samuel Relton, Andrew Walker, Peter Trigwell, Jenny Hewison, Robert West, Mike Crawford, Matt Fossey, Claire Hulme, Allan House
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S346
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Recently the NHS has expanded the provision of liaison mental health services (LMHS) to ensure that every acute hospital with an emergency department in England has a liaison psychiatry service. Little work has been undertaken to explore first-hand experiences of these services. The aim of this study was to capture service users’ experiences of LMHS in both emergency departments and acute inpatient wards in the UK, with a view to adapt services to better meet the needs of its users.
MethodThis cross-sectional internet survey was initially advertised from May-July 2017 using the social media platform Facebook. Due to a paucity of male respondents, it was re-run from November 2017-February 2018, specifically targeting this demographic group. 184 people responded to the survey, of which 147 were service users and 37 were service users’ accompanying partners, friends or family members. The survey featured a structured questionnaire divided into three categories: the profile of the respondent, perceived professionalism of LMHS, and overall opinion of the service. Space was available for free-text comments in each section. Descriptive analysis of quantitative data was undertaken with R statistical software V.3.2.2. Qualitative data from free-text comments were transcribed and interpreted independently by three researchers using framework analysis; familiarisation with the data was followed by identification of a thematic framework, indexing, charting, mapping and interpretation.
ResultOpinions of the service were mixed but predominantly negative. 31% of service users and 27% of their loved ones found their overall contact with LMHS useful. Features most frequently identified as important were the provision of a 24/7 service, assessment by a variety of healthcare professionals and national standardisation of services. Respondents indicated that the least important feature was the provision of a separate service for older people. They also expressed that a desirable LMHS would include faster assessments following referral from the parent team, clearer communication about next steps and greater knowledge of local services and third sector organisations.
ConclusionOur survey identified mixed responses, however service users and their loved ones perceived LMHS more frequently as negative than positive. This may be attributed to the recent governmental drive to assess, treat and discharge 95% of all patients seen in emergency departments within four hours of initial attendance. Additionally, dissatisfied service users are more likely to volunteer their opinions. The evaluation and adaptation of LMHS should be prioritised to enhance their inherent therapeutic value and improve engagement with treatment and future psychiatric care.
Management of emotionally unstable personality disorder in an urban Irish setting
- Calvin Har Siu Yee
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S324-S325
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To determine the prevalence of emotionally unstable personality disorder (EUPD) attending a community mental health team (CMHT) in a major Irish city
To describe the current psychiatric care afforded to this cohort of service user
MethodClinical chart review of all 328 patients attending a CMHT outpatient in an urban setting was carried out. Patients diagnosed with EUPD or displayed features of EUPD were identified. Data on the various interventions offered to this cohort of service users were collected and compared against current guidelines.
ResultOut of the 328 patients actively attending the service, almost 17% (n = 55) were diagnosed with EUPD and further 6% (n = 19) were found to display features of EUPD such as emotional dysregulation, self-harming behaviour and cognitive distortions. Comorbid psychiatric disorder such as mood or anxiety spectrum disorder was diagnosed in 23% (n = 17) of this cohort. Meanwhile, 8% (n = 6) was diagnosed with addiction disorders and 5% (n = 4) was diagnosed with a comorbid personality disorder. A significant proportion of 77% (n = 57) were prescribed psychotropic medication with 51% (n = 29) being on more than one psychotropic medication. Antidepressants, antipsychotics and hypnotics were the three most common medications prescribed at the rate of 89% (n = 51), 30% (n = 17) and 28% (n = 16) respectively. A majority of 66% (n = 49) were offered intervention from a multi-disciplinary team (MDT) member with 47% (n = 23) being offered more than one type of intervention. Referrals to community mental health nurses and psychology service were the two most common interventions offered with a referral rate of 59% (n = 29) and 55% (n = 27) respectively. 28% (n = 21) of service users with EUPD or EUPD traits has had at least one hospital admission while attending the CMHT and 46% (n = 34) have been admitted to the day hospital at least once.
ConclusionThe prevalence of EUPD in our outpatient sample corresponds with findings in previous studies. Standard psychiatric care is the most common option available to the majority of general adult patients with EUPD in Ireland due to the lack of any national treatment programme and scarce availability of specialised therapeutic approaches such as dialectical behavioural therapy within community mental health teams. Our CMHT will attempt to integrate mentalization-based treatment into our outpatient management of EUPD patients taking into account current clinical guidelines for management of EUPD and resources needed for training and delivering the intervention.
Reducing aggression and improving offending outcomes in youth with conduct disorder, results of a systematic review
- Craig McEwan, Lauren Dunn, Jake Harvey
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S270
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The aim of this literature review was to determine what interventions are effective in reducing aggression and offending behaviour in under 18's with conduct disorder.
Null hypothesis: There is no difference in aggression or offending behaviour in under 18's with conduct problems in spite of interventions offered
BackgroundMental health services for children and adolescents who are aggressive or who have come into contact with the Youth Justice System are sparse and often under resourced. Conduct disorder (CD) is one of the most frequently diagnosed conditions in adolescents, particularly in young offenders (Kenny et al 2007). The most effective prevention programs for youth at risk of persistent delinquency has previously been found to be a multi model program focussing on the family context. However, this has not taken in to consideration the extent and prevalence of mental disorder, including conduct disorder, within the target population.
MethodA systematic literature search was undertaken on medline and psychoinfo between January and December 2018. Identified papers were then screened by two independent researchers against pre-agreed inclusion and exclusion criteria. Relevant papers were assessed for bias and results summarised.
ResultFrom an initial data set of 526 papers, 9 were included for review. 4 focussed on psychopharmacology (1 aripiprazole, 1 risperidone, 1 risperidone vs clozapine, 1 clozapine), 1 family centred feedback, 1 Mode Deactivation Therapy and 3 were multi modal (combinations of Mode Deactivation Therapy, Stop Now and Act Programme, CBT, Didactic sessions, 1:1 counselling). None of the multi-modal interventions were standardised or comparable to each other. End points varied from 8 weeks (aripiprazole) to 15 months (multimodal SNAP programme). Settings varied from community programmes to secure inpatient settings. Whilst one risperidone study reported it to be effective in reducing aggression, it was not significant. One SNAP (multimodal) programme failed to show significant effect. All other 7 interventions, across various methods, demonstrated significant reductions in aggression, violence or other antisocial behaviour.
ConclusionFew papers were identified that assessed interventions for youth with conduct disorder. The papers that were identified were significantly heterogeneous in their intervention, sample selection, methodology and outcome measures. Unfortunately, this leads to an inability to compare any interventions for this demographic. Despite the rise in Forensic Child and Adolescent Mental Health Services, there is a weak and poorly understood evidence base for supporting and managing young people with conduct disorder.
The links between the amount of antipsychotic medication prescribed at GP practice level, local demographic factors and medication selection
- Adrian Heald, Mike Stedman, Sanam Farman, Mark Davies, Roger Gadsby, David Taylor
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S165-S166
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To examine the factors that relate to antipsychotic prescribing in general practices across England and how these relate to cost changes in recent years.
BackgroundAntipsychotic medications are the first-line pharmacological intervention for severe mental illnesses(SMI) such as schizophrenia and other psychoses, while also being used to relieve distress and treat neuropsychiatric symptoms in dementia.
Since 2014 many antipsychotic agents have moved to generic provision. In 2017_18 supplies of certain generic agents were affected by substantial price increases.
MethodThe study examined over time the prescribing volume and prices paid for antipsychotic medication by agent in primary care and considered if price change affected agent selection by prescribers.
The NHS in England/Wales publishes each month the prescribing in general practice by BNF code. This was aggregated for the year 2018_19 using Defined Daily doses (DDD) as published by the World Health Organisation Annual Therapeutic Classification (WHO/ATC) and analysed by delivery method and dose level. Cost of each agent year-on-year was determined.
Monthly prescribing in primary care was consolidated over 5 years (2013-2018) and DDD amount from WHO/ATC for each agent was used to convert the amount to total DDD/practice.
ResultDescription
In 2018_19 there were 10,360,865 prescriptions containing 136 million DDD with costs of £110 million at an average cost of £0.81/DDD issued in primary care. We included 5,750 GP Practices with practice population >3000 and with >30 people on their SMI register.
Effect of price
In 2017_18 there was a sharp increase in overall prices and they had not reduced to expected levels by the end of the 2018_19 evaluation year. There was a gradual increase in antipsychotic prescribing over 2013-2019 which was not perturbed by the increase in drug price in 2017/18.
Regression
Demographic factors
The strongest positive relation to increased prescribing of antipsychotics came from higher social disadvantage, higher population density(urban), and comorbidities e.g. chronic obstructive pulmonary disease(COPD). Higher %younger and %older populations, northerliness and non-white (Black and Minority Ethnic (BME)) ethnicity were all independently associated with less antipsychotic prescribing.
Prescribing Factors
Higher DDD/general practice population was linked with higher %injectable, higher %liquid, higher doses/prescription and higher %zuclopenthixol. Less DDD/population was linked with general practices using higher %risperidone and higher spending/dose of antipsychotic.
ConclusionHigher levels of antipsychotic prescribing are driven by social factors/comorbidities. The link with depot medication prescriptions, alludes to the way that antipsychotics can induce receptor supersensitivity with consequent dose escalation.
Improving knowledge and confidence in the acute management of eating disorders and resulting complications
- Sarah Fynes-Clinton, Clare Price, Louisa Beckford, Maisha Shahjahan, Brendan McKeown
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S186
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This project aimed to improve the knowledge and confidence of doctors at all levels when managing patients with eating disorders while on call.
BackgroundA recent survey found just 1% of doctors have the opportunity for clinical experience on eating disorders. Anecdotally, a number of junior doctors within our trust had mentioned that they felt unsure when asked to manage patients with eating disorders during their out of hours shifts.
MethodThis project aimed to ascertain levels of confidence with managing patients with eating disorders, and to collect suggestions to improve this. This was achieved using a survey sent out to 97 doctors working in a Mental Health Trust.
We then utilised two of the suggestions to improve the identified areas of concern. The first method involved direct lectures. This was followed up with the creation of a poster highlighting the pertinent information which was displayed in key clinical areas. The second avenue was the creation of an information booklet covering key clinical information that is available to all on call doctors.
ResultThe response rate for the survey was 37.11%. The survey found that doctors lacked confidence in the management of common conditions that arise in patients admitted with eating disorders. Refeeding syndrome was identified as the greatest area of concern by responding doctors.
To assess the impact of the lectures, MCQs were given out before and after the presentation. The results were compared, and showed a clear improvement in overall knowledge, with results going from an average score of 56.6% to 80%.
ConclusionBy using multiple methods to improve doctors confidence, (lectures, written information and visual posters), this quality improvement project achieved its aims in improving doctors knowledge, and through having easy access to important information, will have long term positive effects on patient care.
Innovating in CMHT's: mental health wellbeing group visits
- Samuel Mammolotti Parkinson, Ismail Laher, Shola Johnson
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S205-S206
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‘Group consultations/visits’ are described as providing shared medical appointments delivering a range of care options and education by clinicians while providing elements of patient choice, empowerment and peer support.
This innovative and cost effective model of care delivery was first conceived in the US and has been gaining a strong foothold in the UK since 2016, mainly limited to GP settings.
The project goal was to attempt to transfer the model into a mental health setting by developing and delivering a novel intervention, to improve health and wellbeing options in a CMHT population.
MethodA four session course was developed focussing on stress, sleep and nutrition. These chosen topics covered common significant challenges to patient health in psychiatry. Sessions were delivered to proactively address these important health related issues in a group visit setting.
Baseline and post intervention feedback including telephone interviews were conducted to evaluate the effectiveness of the intervention.
ResultThe qualitative data and the positive feedback obtained from participants indicate the intervention was highly valued and deemed effective in promoting positive health and lifestyle changes. Participants valued the educational and co-production aspects as well as the social and peer support elements of the groups. They appreciated the level of access they had with the clinicians involved, to explore their health and wellbeing in more detail without being limited by the usual 30 minute clinic follow-up sessions.
The clinicians involved found the sessions rewarding and more engaging than most of routine 1:1 clinic sessions as they were able to spend quality time exploring important issues and not just educate the patients but also be educated by their questions and feedback about their lived experiences.
ConclusionThe project aim was met and we believe this intervention can be successfully incorporated into the identified service provision gap within the CMH T model. There is potential to build on and embed this innovation with roll-out to a wide range of service users in different settings.
In line with existing literature from GP settings, the consensus was that the amalgamated group visits/consultations model could be successfully modified to meet the needs of patients in the Mental Health arena who have a range of physical health and lifestyle concerns.
We planned to obtain more information about improvement in patient self-management but this was affected by the pandemic. However, we believe it is a cost effective and helpful innovation which warrants further promotion and evaluation.
Self-harm on a specialist adult eating disorder unit: a retrospective cohort study of patient characteristics and outcomes
- Leah Holm-Mercer, Douglas Kohler, Agnes Ayton
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S257
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Deliberate self-harm (DSH) is common but rarely studied among inpatients with eating disorders. We sought to investigate the frequency of DSH among inpatients in a specialist adult eating disorders unit, and the association of DSH with comorbidities and treatment outcomes. We also investigated changes in these parameters during the pandemic.
MethodWe included the records of 70 patients consecutively admitted to Cotswold House in Oxford between April 2018 and November 2020. Data were analysed using Microsoft Excel using descriptive statistics. For comparisons, student T-tests were used for continuous variables and Chi-square tests used for categorical variables.
Result99% of patients were female; their ages ranged from 17 to 67 years (mean 30.7). 81% had a primary diagnosis of anorexia nervosa, and 67% had a history of DSH prior to admission. There was a total of 100 incidences of DSH, of which 12% required transfer to a general hospital for medical treatment.
Frequency of self-harm decreased with time throughout admission (17% self-harming on admission, vs 7% at discharge, p = 0.043).
Compared to those with no history of DSH, patients who self-harmed during admission were more likely to be detained under the Mental Health Act (45% vs 17.4%, p = 0.003), and to have psychiatric comorbidities (85% vs 35%, p = 0.001). Patients whose self-harm required transfer for general hospital treatment had a lower mean discharge BMI (18.18kg/m2 vs 20.23kg/m2, p = 0.039), longer admission (105.9 days vs 78.1 days, p = 0.037), and gained weight at a slower rate (0.26kg/m2/week vs 0.43kg/m2/week, p = 0.048) than those who did not require transfer.
During the pandemic, the frequency of DSH doubled on the ward. Overall outcomes were similar, however mean length of admission was lower during the pandemic (67.83 vs 89.94 days, p = 0.046), and patients regained weight more rapidly (0.43kg/m2/week vs 0.28kg/m2/week, p = 0.003) than prior to it.
ConclusionSelf-harm during admission was seen in 29% of patients and was associated with the presence of comorbid psychiatric diagnoses. The frequency of DSH much reduced between admission and discharge, suggesting a beneficial effect of treatment. Medical transfer for DSH, considered as a proxy measure for severity, predicted poorer outcomes in weight restoration. We also noted an increase in rates of DSH during the pandemic, which may have resulted from a combination of increased psychosocial stressors and a reduction in admission capacity in eating disorder units.