Use of the ‘emerging personality disorder’ label in young people has been a controversial topic amongst CAMHS clinicians. Following discussions in a CAMHS focus group, we formally explored the views and experience of CAMHS clinicians across teams in Humber Teaching NHS Foundation Trust with the view to gain more understanding of the different stances of the clinicians, the reasons behind them and to inform future care pathways.

The service evaluation was approved by Humber NHS FT CAMHS Clinical Network and Clinical Audit Team and conducted across the Humber CAMHS service, made up of multi-disciplinary professionals including medical, psychological, therapy, nursing and social work clinicians. Data were collected prospectively, using an anonymous online survey design, with Likert scale and open-ended questions, with the option of additional comments. Consent was gained form all participants. Qualitative data collected from the open-ended survey questions were analysed using thematic analysis as described by Braun and Clarke (2006). Researchers were blind to the demographic variables of respondents, in order to promote anonymity. Authentic anonymous citations were used to illustrate the findings.

A total of 50 survey responses were received from CAMHS clinicians from 9 teams. Clinicians’ views of the helpfulness of the label of ‘emerging personality disorder’ within CAMHS (n = 49): 22.4% found it helpful (very or somewhat) to staff; 21.3% helpful to families; 65.4% found it unhelpful (somewhat or actively) to staff and 63.8% unhelpful to families. 47 responded to the optional open-ended questions eliciting experiences and views of the use of the label. Qualitative analysis revealed evidence of polarity of opinion, particularly in perceived consequences for the young people and families, and identified three major themes: a shared developmental and trauma-informed understanding; the perceived impacts associated with the label of ‘emerging personality disorder’ (9 subthemes); and clinicians’ proposed next steps. There was a shared understanding of the role of interpersonal trauma and invalidation, resulting impacts on the development of skills in emotion regulation and interpersonal relationships.

Our findings highlighted the polarity of the views, the lack of consensus in the use of this label amongst CAMHS clinicians and the importance of discussions around future pathways. There is a need to consider the view of experts by experience (young people and families who have been through this process) to consider the short and, more importantly, the long term impacts of living with a label of ‘emerging personality disorder’.

1. 1. To improve ward round efficacy and efficiency.

2. 2. To make ward rounds more patient informed and create an updated ward round patient “preparation sheet”.

3. 3. To improve collaboration and communication between the multidisciplinary team (MDT).

4. 4. To review and modify ward round/Care Programme Approach (CPA) proformas.

1. 1. Quality Improvement training was delivered to the MDT.

2. 2. An anonymous Likert scale survey was completed by the MDT (n=10), to gather views on ward round experience and documentation.

3. 3. Patients: 2 interactive, breakout sessions (n=4) were facilitated to:

   • • Explore their experience of ward rounds through discussion and Likert scale questionnaires (n=4).

   • • Review the existing patient preparation sheet and coproduce a revised version.

4. 4. MDT: 4 interactive, breakout sessions were facilitated with staff (n=10) to create a:

   • • Process map of ward rounds.

   • • Fish bone diagram of the challenges within ward rounds.

   • • Reverse fish bone diagram, to consider solutions.

   • • Revised ward round and nursing proformas.

5. 5. A driver diagram was developed to generate change ideas.

6. 6. A scoping exercise was completed, comparing ward round proformas within the rehab division, to consider areas of best practice.

7. 7. A Plan Do Study Act (PDSA) cycle was initiated.

1. 1. Patient discussion and questionnaire feedback re: ward round experience was positive. Patients felt “respected”, “supported,” “understood team roles” and “plans” within ward rounds.

2. 2. Patients mostly agreed with the current format of the patient preparation sheet, however wanted a visual prompt, for their recovery areas. A diagram, “My recovery wheel”, was designed, to include diet, hobbies, mood, exercise, substances etc.

3. 3. Staff felt “respected”, and “listened to” and “understood their roles” in the staff survey; MDT proformas and time keeping were highlighted as requiring improvement.

4. 4. The fishbone diagram identified challenges within: staffing, procedural factors, time, resources/equipment, training and education, communication, proformas and patient engagement.

5. 5. New, succinct, MDT ward round proformas were designed, with focus on rehab goals, in order to facilitate the patient journey and discharge pathway.

6. 6. A ward round prompt sheet for the chair was created.

1. 1. Both MDT and patients feel largely positive re: ward round experience.

2. 2. The improved patient preparation sheet is more patient centred, after being co-produced with patients.

3. 3. The MDT highlighted multifactorial challenges pertaining to ward rounds running in an efficacious and efficient manner.

4. 4. The next cycle of the project will focus on testing the new forms and change ideas.

Service users taking long-acting injectable antipsychotics (LIAs) may experience recurrence of symptoms as they approach trough levels within a steady-state cycle. Limited research exists around symptom variation between peak-to-trough plasma concentrations of LIA inter-dose intervals. Different LIAs have variable rates of change in dopamine receptor occupancy during this peak-to-trough variation due to differing elimination half-lifes. It is unclear what rate of change in D2 blockade is tolerated by patients at present, which this trial aims to determine through observing symptom severity differences during peak-to-trough variation.

A real-world observational longitudinal cohort study is proposed. Inclusion criteria would be working-age adults (18–65 years) who have received five consecutive and timely LIA administrations of a consistent drug and dose. The study would exclude anyone with significant hepatic or renal impairment, anyone on concurrent oral antipsychotic medication or anyone deemed not to yet be within steady-state plasma levels of their LIA medication.

Serum assays for drug level will be obtained at both peak and trough concentrations during an LIA cycle. Expected timings for peak levels will be determined by derived tmax values from existing pharmacokinetic literature for individual drugs. Trough levels will be taken within 24 hours of the next LIA administration being due. Plasma drug concentrations will then be used to calculate expected striatal D2 blockade using EC50 values and maximal occupancy for individual drugs derived from existing PET scan data.

Symptom severity will be assessed by completing Positive and Negative Symptom Scores (PANSS) questionnaires with service users at the time of both peak and trough plasma concentrations of LIA. The difference in these scores will then be plotted alongside the difference in expected D2 blockade derived from plasma drug concentrations.

We hypothesize that the rate of D2 occupancy change would correlate with symptom severity differences in an exponential manner, in that drugs with shorter elimination half-life would have greater difference in symptom severity between peak and trough. We expect that service users would be able to tolerate such change to a degree without significant emergence of symptoms; the trial aims to determine the threshold for what most service users can tolerate, which may then assist in guiding how to effectively reduce and discontinue medications.

This outlines a research protocol to monitor response to pharmacokinetic variation within inter-dose intervals of LIA medication, which may ultimately aid service users in reducing and discontinuing antipsychotics.

How frequently and to what quality are mental capacity assessments being recorded on inpatient acute ward? Capacity is the ability to consent to a particular decision and is defined in law by the Mental Capacity Act (MCA). Capacity to make decisions is an area of particular importance in mental health care, as many mental illnesses can lead to people losing the capacity to make some decisions. Capacity assessment is a two-stage process. If a patient passes Stage 1, then they have capacity. If they fail Stage 1 then the assessment progresses to Stage 2. The person being assessed must then be competent at every step of Stage 2 to then be deemed to have capacity. Documentation of capacity assessments should demonstrate this two-stage assessment.

The sample included all people who were inpatients during the data collection window of 05 to 09 Sep 2022.

For each person, their MHA status was recorded as this determined whether capacity to consent to admission was relevant. For each patient, their EPR was checked for any Mental Capacity Assessment proformas which were examined and recorded as being for admission, treatment, or something else. The cumulative case notes were then searched for any mention of ‘capacity’ and any additional capacity assessments were examined and added to the tool. All capacity assessments were reviewed against the defined standards.

Sample and demographics - 22 male inpatients. 21 patients subject to the MHA and 1 was an informal patient. The CTT rule applied to 7 patients.

Treatment - 17 of 22 had capacity assessment for treatment at admission. All of these were recorded using the proforma and all were in line with best practice guidance. 7 had the CTT rule applied to at the time of the audit. None of the records for these people included documentation of a repeated mental capacity assessment.

Something Else - 9 capacity assessments recorded for ‘something else’. Five were recorded on proforma and in line with best practice guidance. 4 capacity assessments were as case notes and didn't meet best practice criteria.

Capacity assessment for treatment is being conducted and recorded well at the time of admission, but not at the point that CTT rules apply from.

Most capacity assessments were recorded on the EPR proforma and all of these met best practice guidance. 4 capacity assessments were recorded in case notes and none of these met best practice guidance.

To investigate compliance with British Society of Haematology (BSH) guidelines and NICE clinical summarieson diagnosis and treatment of folate and cobalamin deficiencies in CAMHS Transition service, Oldham.

The standards used were based on BSH guidelines and Nice clinical summaries, with targets for all 100%:

1. 1. Haemoglobin concentration and mean corpuscular volume (MCV) checked at the same time as assay for serum cobalamin and folate.

2. 2. Cobalamin and folate assays should be assessed concurrently due to the close relationship in metabolism.

3. 3. Treatment of established cobalamin deficiency should follow the schedules in the BNF.

4. 4. All patients with anaemia, neuropathy or glossitis, and suspected of having pernicious anaemia, should be tested for anti-IFAB regardless of cobalamin levels.

5. 5. Patients found to have a low serum cobalamin level in the absence of anaemia and who do not have food malabsorption or other causes of deficiency, should be tested for IFAB to clarify whether they have an early/latent presentation of pernicious anaemia.

6. 6. Treatment of folate disorders should follow the schedule in the BNF.

7. 7. We reviewed all open cases to Transition service in Oldham. Their NHS number was checked through the pathology laboratory portal. In addition, notes on Paris electronic system and digital letters were checked to see if results were acknowledged. The initial audit period run from February 2021 to April 2021.The results were shared with the Multidisciplinary Team and an algorithm was created and shared in an attempt to improve the practice. The re-audit run from May 2022 to July 2022. A total of 80 patients were included in the audit and 25 patients in the re-audit. We entered and analysed our data using Microsoft excel.

Compliance levels for the standards for the audit were as following: standard number 1, 2 and 5 were 100%, number 3 and 6 were 0%, and number 4 was not applicable.

Compliance levels for all the standards were 100% for the re-audit.

The results of the initial audit indicate that not all standards were met. However, results of the re-audit indicate all standards were met. It appears implemented changes may have affected the outcome of results. However, as the sample of patient was small might need to repeat this audit cycle in the future to see if the results remain the same.

The physical health protocols are relevant to psychiatric practice and the algorithm can be disseminated for further use.

Mental health comorbidity is higher in those with learning disability especially those who are within forensic services than the general population and diagnostic overshadowing is a particular problem. Hence, all behavioural or mental health related presentations are often attributed to the learning disability and vice versa without an adequate investigation of the causes of learning disability. This is a case report of a young male with mild LD with longstanding mental health and behavioural problem who was described as having a personality disorder in the community. Systematic diagnostic evaluation showed the presence of 22q11.2 Duplication Syndrome. While adding to the sparse literature on the behavioural and physical phenotype of the syndrome, it also allowed his mental health presentation to be re-formulated. This changed his treatment plan and outcome.

28-year-old, single, Caucasian male with delayed developmental milestones who was referred to Children Mental Health Services for behavioural difficulties and ADHD-like features. In early adulthood, behavioural problems continued with aggression towards others and was under the care of a community mental health team although with lack of diagnostic clarity and poor compliance. Violence towards self and others led to several short hospital admissions, mainly because he tended to discharge himself against medical advice. The predominant diagnostic formulation was one of a young man with mild learning disability + psychosis related to substance misuse + personality disorder. Facing multiple charges of assault, the court, on medical advice, gave him a hospital order to a medium secure unit for people with learning disabilities where he went through a detailed and systematic diagnostic evaluation that revealed several new findings. Based on this, he went through the 10-point-treatment programme.

Clinicians need to be aware of diagnostic overshadowing leading to misattribution and consequently poor treatment. In this case, the sensory impairments associated with 22q11.2 Duplication Syndrome affected his communication. His tunnel vision led him to bump into people in pubs and other public places giving impression of deliberate antisocial behaviour. The atypical autism, learning disability and co-existing mental illness further complicated the picture. Confirmation of the underlying genetic syndrome and its physical and behavioural phenotype led to a different diagnostic and psychological formulation from the earlier one which was based on a personality disorder. It also allowed more targeted treatment strategies and the patient could be discharged back to the community from a secure hospital setting.

22q11.2 Duplication Syndrome is a rare genetic syndrome that can cause learning disability. Its physical and behavioural phenotypic features described in literature, were all present in this patient. In addition, this case report highlights three previously unreported findings: Cochlear Nerve Atresia, Tubular Vision, the Characteristic groove and skin fold on the back of the scalp and the presence of a schizoaffective mental illness.

Neuroleptic malignant syndrome (NMS) is a rare condition experienced by patients taking typical and/or atypical antipsychotic medications. There are well-established diagnostic criteria for NMS. However, differentiating it from serotonin syndrome and malignant hyperthermia—particularly in the intensive care setting--is problematic and thus remains a diagnosis of exclusion. A case report of a patient with atypical NMS in intensive care is described and the subsequent learning points gleaned from the patient are presented.

A 28 year-old female was admitted to the intensive care unit (ITU) following a self-inflicted traumatic injury. The patient was known to local mental health services and her medical history includes personality disorder, anxiety and depression. Regular psychiatric medications prior to hospitalization included flupentixol and quetiapine. Remifentanil was administered in a continuous infusion for sedation as the patient was intubated and ventilated. Valproic acid and levetiracetam were given for seizures.

Repeated spikes in temperature, rigidity and slightly elevated creatine kinase (CPK) were observed in the patient. Autonomic dysfunction was also noted; the patient experienced bradycardic episodes that increased in frequency and duration. On two occasions, this resulted in asystole and cardiopulmonary resuscitation (CPR) had to be commenced with return of spontaneous circulation following CPR. Mental status changes were unable to be assessed due to ongoing sedation of the patient. On the advice of the clinical pharmacist, remifentanil was switched to fentanyl. Quetiapine and flupentixol were also discontinued after consulting with the psychiatric team. In addition, the patient responded quickly to dantrolene administration and to active cooling.

Main diagnostic criteria for NMS include hyperthermia, rigidity, mental status changes and autonomic dysfunction. The definition of atypical NMS includes three of these four criteria. Serotonin syndrome was ruled out as the patient was not taking any selective serotonin reuptake inhibitors (SSRI) nor selective serotonin-norepinephrine reuptake inhibitors (SNRI). Malignant hyperthermia was also considered as the patient had received a volatile anaesthetic gas, isoflurane, for sedation purposes; however, symptoms persisted long after it was stopped.

Atypical NMS is a diagnosis of exclusion that must be considered in patients in an intensive care setting who experience refractory hyperthermia. A multidisciplinary team is essential in caring for critical care patients who exhibit symptoms of NMS, including psychiatry, neurology, and clinical pharmacy.

Assessment of the capacity to consent to admission is an important legal and ethical issue in daily medical practice. Mental Capacity Assessment (MCA) should be carried out thoroughly based on all the domains mentioned in the Mental Capacity Act (2005) and be recorded in the patient's notes or admission. This audit evaluated the documentation available on the electronic database (Paris) in order to ascertain what information was and wasn't documented. The standard used: “Decision–making and mental capacity”. NICE guideline NH108 (2018) recommendations 1.4 Assessment of mental capacity were used as a standard for this audit. 100% of all admitted patients should have MCA completed during the admission clerking.

The data were examined retrospectively from the MCA on admission, available on the electronic health record database (Paris). The audit tool focuses on quantitative data collection on Mental capacity documentation.

A random sample was selected of 15 patients admitted in May, June, September, and October 2022 to the Peter Bruff MH Assessment Unit (male and female). Total 60 patients.

All data were anonymised. Results were tabulated and presented in statistical form back to the clinical teams.

All patients who were admitted to the assessment unit were subjected to capacity assessment, consenting to informal admission and acceptance of treatment.

MCA was completed and patients had capacity both on clerking and during the ward review in 85% of cases, (n=61). MCA was completed and 3 % of all patients were found to lack capacity on clerking (n=2). MCA was completed, and patients had the capacity on admission, however, they had no capacity during the review in 5% of cases (n=3). MCA was not completed, or the information was unavailable, for 7% of the cohort (n=4).

Capacity to consent is specific to a decision and can vary over time; a patient is therefore competent or not with respect to a specific decision and for a given moment in time.

We found that after the clerking assessment, when patients were reviewed by the unit doctor and the consultant, whether on the day of admission or shortly after (in a matter of hours), on several occasions some patients were lacking the capacity to consent to the admission.

The missing link to be identified between the MCA capacity assessment that was carried out by the clerking doctor, compared to the MCA that was conducted by the unit doctor and consultant. This could be a restrictive environment on the unit or less attention paid to the quality of capacity assessment and further training is needed for professionals.

Mental illness has been very common lately and the mentally ill are a special population with their own particular set of needs and challenges. In general physical health of the mentally ill is poorer than that of the general population and oral health is especially neglected hence the desire to quantify this.

This study was a cross-sectional hospital based study conducted in the outpatient clinic of Taha Basher Psychiatric teaching hospital. The sample (90) was selected randomly from among the adult patient attendants who agreed to participate in the study.

The mean DMF was 4.91 +/-4.46 . It was positively correlated to age and duration of illness. It was higher in females and the greatest proportion was due to missing teeth and the smallest proportion was the filled teeth. There were no dentures used by any of the patients.

Those involved in the study reflect the poor level of oral health among the mentally ill population and this deficiency is unfortunately not receiving enough attention of care givers or mental health professionals. The dental community ought to establish a professional referral system with such facilities to facilitate patient care.

Social determinants of health (SDOH) are social factors that have a causal role in ill health and have an adverse effect on health outcomes. SDOH are part of the UK medical student curriculum but mainly discusses epidemiologically. There are few educational approaches that aim to incorporate an understanding of SDOH into the experiential and competency-based elements of undergraduate medical education. Prisoners are a population who experience high levels of stigma, social adversity and health disadvantage. Clinical attachments in prison may teach students about the impact of SDOH in a vivid and memorable way. Aims: We aim to explore changes in medical students' knowledge/attitude towards SDOH during and after psychiatry placements at HMP-Berwyn prison.

All year four medical students on psychiatry placement in North East Wales during 2021–2022 participated. In each of the six placement cohorts, one student did their psychiatry placement in prison. All the other students visited for one day. All students participated in two seminars focused on their prison experience and SDOH in psychiatry. Baseline and mid-placement bespoke questionnaires were completed, and all students participated in end-of-placement individual interviews.

29 students participated. Student assessment of the importance of SDOH did not show a significant change between baseline and mid-placement. However, student attitudes to experience in prison became more positive at end-of-placement. Comparing baseline to mid-placement questionnaires showed a 14% increase in students' rating of prison placements as educationally beneficial. 14% of students mentioned improved confidence in dealing with challenging patients, and 28% commented on the benefits of exposure to incarcerated patients. Interestingly, only 3% of students considered hospital placement more beneficial than prison placement. Prison placement was considered an exceptional experience than other settings by 17%.

There are no previous UK empirical studies on medical student placements in prison. Overseas studies identify reduced anxiety over dealing with demanding patients. Our findings so far lack statistical power but show positive satisfaction and knowledge trends amongst participants. Prison placement appears to be acceptable and educationally valuable. It offers opportunities for experiential teaching about SDOH. In addition, it may improve student understanding of a marginalised and stigmatised population.

On completion, this study may provide evidence on one method of improving attitudes toward marginalised people and understanding SDOH in the medical profession.

This research was funded by Betsi Cadwaladr University Health Board and sponsored by Bangor University.

Sierra Leone has a 98% mental health treatment gap. This has been attributed to lack of resources and attitudinal/cultural barriers. Community health workers (CHWs) are the backbone of healthcare delivery in the country, constituting 1,500 of the general health workforce. The government has trained CHWs to improve mental health care. However, evidence have shown that this training is inadequate, leading to poor mental health literacy among CHWs. Sierra Leonean CHWs' perceptions of mental health and experiences of mental healthcare delivery have not been investigated. Therefore, this study aims to assess CHWs' knowledge regarding depression and suicidality, as well as their perceptions of barriers to, and facilitators of, mental health care in Sierra Leone.

Purposive sampling and snowballing were used in this qualitative descriptive study (N = 10) to recruit CHWs in Kono and Freetown, Sierra Leone. Participants were interviewed remotely using Zoom. A short vignette on depression and suicidality was employed, together with remote semi-structured interviews exploring mental health literacy, perceptions of mental health care, and experiences in providing care during COVID-19. Thematic analysis was utilized.

Five themes and 10 subthemes were derived from the thematic analysis. More than two-thirds of the participants viewed the problem as 'depression', while none mentioned suicidal ideation. Life events were the most commonly identified causes of depression, with no mention of spiritual, supernatural or biological attribution as possible causes. The inductively coded themes include the need for change; barriers to mental health care; accessing care; and COVID-19-related mental health care challenges. All participants agree that seeking counselling or speaking with a mental health expert is preferred. Stigma, prejudice, misconceptions, religious and traditional beliefs and insufficient government support were perceived as key impediments to care. Community health workers' experiences during COVID-19 were mixed. Awareness campaigns, training, establishing mental health policies, and integrating mental health into communities were identified as facilitators of mental health care.

The findings have shown that developing and implementing a comprehensive multi-agency approach is fundamental in dealing with mental health problems in Sierra Leone. In addition, future larger-scale research should be conducted on the underlying cultural principles and traditions regarding mental illness and the status of mental health care provision in Sierra Leone.

There has been growing interest in regression among adolescents and young adults with Down Syndrome. Regression can also be referred to Acute Regression, Down Syndrome Regression Disorder (DSRD), Down Syndrome Disintegrative disorder (DSDD) or Unexplained Regression in Down Syndrome (URDS) and these terms are sometimes used interchangeably. Characterised by reduction in expressive language, decreased functional skills and reduced psychomotor activity, regression can result in a significant change in the long-term needs of these individuals. Reporting this case, we wanted to highlight challenges in diagnosing, treating and supporting young people with regression in Down Syndrome.

This is Case Study of a young adult with Down Syndrome presenting with symptoms of mood disorder, apathy, new-onset vocal tics and ritualistic behaviours and profound loss of expressive language - both verbal and sign language.

Diagnosis included ruling out physical causes for regression. The management remains largely symptomatic and aims to address as many as possible bio-psycho-social aspects of the concerning presentation.

Multitude of interventions and external events made it difficult to see what intervention was the most useful. Despite initial positive response to medication and behavioural strategies, a long term prognosis remains uncertain.

Self-harm is a common presentation in emergency services, and ambulance clinicians are often the first professionals involved. The aims of this study were to explore the experiences of Yorkshire Ambulance Service (YAS) clinicians of caring for people who self-harm, and to seek their views of the care provided to this group in the pre-hospital setting.

This preliminary cross-sectional study involved a self-completed questionnaire using an online platform (Online Surveys, www.onlinesurveys.ac.uk). The questionnaire was designed by the research team, piloted by four academic paramedics, and shared with ambulance clinicians employed by YAS via social media and email bulletins. Multiple-choice answers were analysed using descriptive statistics, and two researchers (DR, EG) independently analysed free-text responses thematically. Participants could only proceed to the questionnaire if they agreed to an online consent statement. Ethical approval was granted by the University of Leeds.

26 clinicians responded to the questionnaire (1.0% response rate), of whom 17 (65%) were female and 16 (62%) were paramedics. 17 (65%) indicated that they had not received specific mental health training in their roles. Only nine (35%) respondents felt comfortable caring for this group, and four (15%) thought that their training had adequately prepared them.

Respondents identified the following as facilitators to high-quality clinical care for people who have self-harmed: previous clinical experience, training in mental health and injury management, availability of mental health advice and services, good communication skills, relevant online resources, and support from senior colleagues. Barriers identified included patient factors, a lack of mental health pathways, services and support and a lack of training and education in mental health. Suggested improvements to emergency services for self-harm were alternatives to emergency departments, greater availability of mental health support, more staff, mental health training for ambulance clinicians, and guidance for the management of patients declining to attend hospital.

Respondents generally felt unconfident and unprepared when called to assess and manage people who have harmed themselves. Improvements in mental health training for ambulance clinicians and greater availability of mental health services are needed to improve pre-hospital care for people who self-harm. Although the study was limited by a low response rate, it has begun to address the literature gap in paramedic care for self-harm. Questionnaire responses corroborate NICE recommendations that alternative services to emergency departments, where appropriate, could improve patient satisfaction and the quality of clinical care. This should be considered by commissioners and policymakers.

Our aim was to improve service user satisfaction by increasing the interval between their depot injections where clinically feasible. By doing this, we aimed to reduce attendance at the South Kensington and Chelsea Community Mental Health Team (SK&C CMHT) depot clinic by 25% over a period of 3 months, improving the workload for nurses running the clinic.

Our first baseline measure was data gathered about service user satisfaction with their depot. Our second baseline measure was the average number of service users attending the depot clinic per week between May and November 2022. The balance measure was a medical review 3 months post-interval change to ensure there were no negative impacts from this change.

10 service users on 3-weekly anti-psychotic depots were identified. Our team devised criteria to select service users who were appropriate for our project. This included: a stable mental state, minimal side effects on the current dose, no breakthrough symptoms, good engagement with the depot clinic, and scope to increase the current dose. These service users were discussed with their care coordinator, consultant and depot clinic nurse. If the criteria were met, the dose and interval change was discussed with our pharmacist. Finally, service users were consented and their depot charts were amended.

The interval between depot injections for 2 service users was increased from 3 to 4 weeks on December 5th, 2022. The other 8 service users failed to meet the criteria set out in our methodology.

These 2 service users were asked to fill in a questionnaire on January 23rd, 2023. They reported that “it was not comfortable having an injection” and that “having it every 4 weeks was better” and “less hassle”. Their first medical review did not raise any safety concerns.

On average, 20 service users attend the SK&C CMHT depot clinic every week. There was no change in the average number of patients attending the depot clinic in the last two months as only 2 service users had their depot interval successfully altered.

Service users on depot injections can benefit from increasing the interval between their injections where clinically feasible. We would like to repeat this project for service users on 2-weekly depots and reassess if that makes an impact on satisfaction levels and attendance numbers at our depot clinic.

Serotonin in platelets has a major role in promoting vasoconstriction and platelet aggregation. Selective serotonin reuptake inhibitors (SSRIs), which are widely used clinically, inhibit the serotonin transporter responsible for serotonin uptake into platelets. This serotonin depletion reduces clot formation, thus increasing bleeding risk. This risk is particularly elevated in older adults who are also more likely to have co-morbid physical health conditions. The Maudsley Guidelines recommend that if SSRIs cannot be avoided in those assessed as high bleeding risk, then gastro-protective proton pump inhibitors (PPIs) should be prescribed. The aim of this full cycle audit was to evaluate all patients in an older adult community health team (OACMHT) to assess how many were prescribed an SSRI and whether PPI cover had been considered in those deemed to be at higher risk of a GI bleed due to either age or concomitant medication use.

All patients open to the OACMHT prescribed an SSRI were identified. Their electronic notes were checked to see if they were either prescribed medications or had comorbidities which increased bleeding risk. Electronic notes were reviewed to assess if bleeding risk had been considered at the time of prescribing SSRI, in addition to whether a PPI had been prescribed.

This was repeated 6 months later following the results being presented to prescribers within the OACMHT.

Patient age ranged from 60 – 101 years. 23% of patients were prescribed SSRI medication. There was an improvement in the proportion of patients on SSRIs prescribed PPIs in the second cycle compared to the first cycle of this audit (64.7% vs 56.5%). We also found that the majority of patients prescribed an SSRI and medications known to increase bleeding risk were prescribed a PPI in both audit cycles. We found only 1 patient in our cohort had bleeding risk explicitly documented in electronic notes.

SSRI use is common within the OACMHT. The majority of patients were prescribed a PPI alongside their SSRI. This improved in the second cycle of this audit. A significant number of those prescribed a PPI had their PPI prescription commenced prior to an SSRI being prescribed which may have artificially inflated our results.

However, a significant proportion of patients prescribed SSRIs were not prescribed PPI cover which is not in line with current Maudsley guidelines. Therefore there is still work to be done in minimising bleeding risk in patients taking an SSRI within the OACMHT.

The purpose of this QI project was to assess risk of CVD (cardiovascular disease) in adults with SMI (severe mental illness) admitted to acute psychiatric ward as risk can be reduced by relevant changes in lifestyle, optimizing treatment of relevant comorbidities, and by drug treatment, if appropriate. Nice guidelines for CVD risk assessment and management were followed for those with CVD risk of 10% or more.

This QI project focused on patients with a diagnosis of severe mental illness admitted to ward Ty Cyfannol, YYF hospital, ABUHB in South Wales from 1st April 2021 to 30th November 2021. QRISK®3-2018 risk calculator used to estimate risk of cardiovascular disease. Patients younger than 25 years old at the time of QI project were excluded as QRISK tool is only valid for patients aged 25–84 years. Patients who already had a diagnosis of Ischaemic heart disease or stroke/transient ischaemic attack were also excluded as per criteria of QRISK3. Total number of patients included in this project was 43 patients. Data were collected from patients’ medical records including their weights, heights, routine physical examinations and laboratory investigations requested during their admission. In order to maintain anonymity, patients were assigned to their hospital number. This information was saved in a password protected Excel Spreadsheet.

The mean age of patients was 43.3 ± 11.06 years ranging from 25-69 years. Most patients were males (65.1 %). Schizophrenia was the most prevalent diagnosis (32.5%) followed by emotionally unstable personality disorder (18.6%). 72% out of total 43 patients were smokers. The mean BMI was 23.6 ranging from 17 to 31. 41.9% had their BMI ≥ 25, 8 patients out of those with BMI equal to or higher than 25 scored 10 or more on QRISK3. 13 (30.2%) patients were estimated to have high CVD risk using QRISK3 assessment tool, of whom 76.7% (n=10) aged 55 years or more. 69.2% (n=9) were current smokers, 23% (n=3) were diabetic and 15.2% (n=2) had hypertension.

The findings of this project conform the consensus that people with SMI are at a higher risk of having CVD. Therefore, this should emphasize the importance to assess CVD risk in patients with SMI and to manage modifiable risk factors accordingly and to incorporate the assessment of cardiovascular risk in patients with severe mental illness in day-to-day practice in mental health inpatient units.

Recent reports and inquiries indicate that the potential, identified from the early days of the asylum era, for residents of psychiatric institutions to be subject to abuse has not been eradicated. The findings and recommendations of individual inquiries are often so specific to their unique context that it can be difficult to draw general principles that have wider operationalizability. The aims of this study are to thematically analyse available inquiry reports into health care institutions from the mid-20th century to the present using a ‘generalisable’ framework in order (i) to identify the key themes underpinning the concerns raised, and (ii) to analyse how themes change (or persist) over time.

Inquiries relating to concerns about the institutional care of patients over the past 70 years were identified. In this pilot study, a selection of available reports were subject to thematic analysis to address the first phase of the study (identifying themes underpinning concerns).

Four overarching themes were identified. The first three themes reflect the different levels of system analysis. Thus, the first theme, ‘the proximal dynamic,’ describes the nature of the interaction between staff and patients which is influenced by staff experience, attitude, and actions. The second theme, ‘the organisational dynamic’, comprises processes, policy and culture particularly, but exclusively, within the provider organisation. The third level of analysis, ‘the system dynamic’ theme, includes the influence on the concerns raised of the way the health system is configured (e.g. commissioning arrangements, and use of 'out-of-area' placements). The fourth theme, which cuts across the first three, is ‘the response to concerns’ which ranges from identifying early warning signs to responding to overt expressions of concerns (including whistleblowing).

Using thematic analysis to examine past inquiries into poor institutional care of patients, this study has identified a thematic structure which (i) emphasises that problems arise in a ‘dynamic’ that can be located at three levels of analysis (proximal, organisational and system) and (ii) includes a cross-cutting theme of the way concerns are responded to. This structure can be used as a learning framework for the current provision of inpatient services that has the potential to improve care in institutions, but this will require empirical testing.

Dengue is caused by an arbovirus and is a common vector borne disease in south east Asia. Each year upto 400million people get infected with dengue and 40,000 die from severe dengue. Psychiatric symptoms following dengue fever is relatively uncommon. Mania is the most common psychiatric disorder reported followed by anxiety, depression and catatonia. We present to you a 19 year old girl who presented with psychosis 10 days post recovery from dengue

A 19 year old bachelors in commerce student hailing from rural south India from a middle socioeconomic family presented to us with fearfulness and decreased sleep since 1-2 days which was abrupt in onset and gradually progressive. MSE revealed a conscious and alert female with normal talk ,psychomotor activity and delusion of reference which was fleeting ,ill systematized ,hearing of voices was clear however the content of which was not elaborated upon.Her affect was fearful.Past history revealed an admission for dengue fever around 2 weeks prior to symptoms, course of which was uncomplicated and unremarkable. Diagnosis of Organic delusional disorder was made according to ICD 10 and she was started on Tablet Olanzapine 2.5mg and dose was escalated to 5mg after 3 days. Her symptoms remitted completely with 5mg and is currently doing well socially and academically

Psychiatric comorbidities of dengue fever including mania, anxiety, depression, and catatonia are mentioned in literature .The exact incidence of neuropsychiatric manifestation remains unknown due to lack of studies. Literature search revealed various case reports where patients have developed psychosis during acute phase of the illness, however we did not find any case report or studies similar to ours

Most literature on neuropsychiatric manifestations in dengue are limited to case reports. There is a need to conduct prospective follow up studies and inclusion of regular psychiatric evaluation during various phases of dengue fever

To explore the phenomenon of non-suicidal self-injury (NSSI) in adolescent patients and to assess adolescent-parent attachment and childhood trauma in relation to NSSI behaviour through a case control comparison between adolescents with and without NSSI.

NSSI group included 30 adolescent patients presenting to psychiatry outpatient clinic with history of NSSI. Controls were 30 non-psychiatric adolescent patients recruited from other specialties outpatient clinics. Tools applied were: Semi-structured Psychiatric Interview, Structured Clinical Interview for Diagnostic and Statistical Manual (DSM IV-TR) Axis I and II Disorders (SCID-I and II), Brief Non-Suicidal Self-Injury Assessment tool (BNSSI-AT), Inventory of Parent and Peer Attachment (IPPA)-Parent form, Parental Bonding Instrument (PBI) and Childhood Trauma Questionnaire (CTQ). Patient-rated tools were translated into Arabic language.

Self-cutting was the primary method of NSSI in 86.7% followed by interference with wound healing in 73.3%. Of NSSI group, 60% met the criteria for diagnosis of borderline personality disorder (BPD) while 16.7% showed only traits. Moreover, 40% were diagnosed with depressive disorders. While 93.3% used NSSI to deal with anger, 80% used it to cope with uncomfortable feelings or to relieve stress and pressure. In addition, 73.3% reported self-injuring because of their self-hatred. The main motivation for initial NSSI was negative feelings such as being upset (90%), being angry at oneself (73.3%) or at someone else (53.3%). Also, 36.7% reported seeing it in media or reading about it while 40% of the motivations were found related to peer pressure. NSSI group scored significantly lower than controls in their attachment to parents (particularly to mothers). A positive correlation was found between perceived parental care and attachment to parents (mainly trust and communication). A statistically significant difference was found between both groups regarding severity of childhood trauma experiences. In NSSI group, emotional neglect was reported in 80%, emotional abuse in 63.3%, sexual abuse in 50% and physical abuse in 46.7%. Perceived emotional neglect was positively correlated with sense of alienation from fathers and negatively correlated with trust in mothers.

Females constituted 80% of the NSSI group, primarily with the diagnosis of BPD. The most common method of NSSI was “self-cutting”. A significantly high percentage of adolescents with NSSI described their attachment to parents as insecure. The majority of NSSI patients perceived their relationship to both parents as “affectionless control”. A significant correlation was found between perceived parental care and security of attachment. Results also suggest that different types of child maltreatment might predict later NSSI.

To assess whether psychiatric comorbidities affect response to medications in adulthood ADHD.

This study included 236 subjects diagnosed with ADHD in adulthood between the ages of 18 and 65 years and receiving pharmacological treatment for the same across community treatment teams in Durham and Darlington.

Patients were identified by going through electronic case notes.

Review of SWMWEBS scores and clinic letters were carried out both prior to and following commencing medication for ADHD to assess response to treatment.

Comorbidities were recorded by reviewing clinic letters.

56% of the study subjects had no psychiatric comorbidity while 44% had at least one comorbid psychiatric diagnosis.

Both groups had a higher prevalence of males in the ratio of 1.9:1(with comorbidities) and 3:1 (without comorbidities).

Depression(56%) was noted to be the most common comorbidity followed by Autism(22%), Emotionally Unstable Personality Disorder(11%) and Bipolar Affective Disorder(10%).

94% patients without comorbidities responded favourably to treatment whereas only 56% of patients with comorbidities improved with treatment.

Having a comorbid psychiatric illness is likely to negatively impact both treatment response and recovery in adults with ADHD.

Both groups(with and without comorbidities) had a male predominance (2.5:1).

Higher number of patients amongst the nil comorbidities group responded favourably to treatment.

Most common psychiatric comorbidity was Depression.

Least favourable response to treatment was found among the groups of Emotionally Unstable Personality Disorder and Bipolar Affective Disorder.

No gender bias in response to treatment across both the groups.