There are significant challenges to providing psychiatric care to people on the migratory route in Central America, including the low probability of face-to-face follow-up. However, there is a clear need for psychiatric care, for both pre-existing psychiatric conditions, and new onset conditions, some related to stressors experienced on the migratory route.

There is no literature providing clear guidance as to how to provide psychiatric care to people on the move. Therefore, this quality improvement project had the following aims:

1. To provide clinicians with greater clarity as to whether to offer psychiatric medication to people on the move

2. To improve continuity of care for people on the move taking psychiatric medication

Through a consultation process, four Médecins Sans Frontières (MSF) psychiatrists created five flowcharts to aid clinicians in assessing the benefits and risks of providing psychiatric treatment to a person on the move, in collaboration with the person. The flowcharts were piloted by clinicians, evaluated, and improved in a second cycle of change.

In consultation with mental health teams and patients from MSF’s projects across the region, a migrant health package was created, including psychoeducation leaflets, detailed medication labels, a regional map of clinics (MSF and non-MSF) providing psychiatric care on the migratory route, and a referral form. The package was implemented across four of MSF’s project sites.

A survey revealed that the flowcharts improved clinician confidence in deciding whether it was appropriate to prescribe psychiatric medication to people on the move.

In 2023, 78 patients were provided with the migrant health package. There were challenges in assessing whether the intervention increased continuity of care, as in many cases contact with the person was lost, and currently there is no regional patient database across MSF projects. However, of the 78 patients, 21% (16) were confirmed to successfully receive follow up at a clinic further along their route.

The project provided clarity for clinicians as to when it is appropriate to offer psychiatric medication to a person on the move. Further work is needed to evaluate whether the migrant health package improves continuity of care for people on the move receiving psychiatric care from MSF in Mexico and Central America. However, at least 21% of patients provided with the package were able to access face-to-face follow up following initial contact.

Antipsychotic medications are widely prescribed in child and adolescent mental health services (CAHMS) and carry recognised metabolic and cardiovascular risks. National Institute for Health and Care Excellence (NICE) guidance outlines minimum standards for physical health monitoring before and during antipsychotic treatment. This audit aimed to assess compliance with NICE-recommended physical health monitoring for children and young people prescribed antipsychotic medication within a CAHMS Head-to-Head (H2H) community service.

A retrospective audit of electronic patient records (Rio) was conducted. All patients under the CAHMS H2H team prescribed antipsychotic medication were identified. Physical health monitoring was assessed at baseline, six weeks, twelve weeks, and at six-monthly intervals thereafter. Six-monthly monitoring was analysed per eligible monitoring window, recognising that patients commenced treatment at different times. Patients admitted to inpatient wards when monitoring was due were excluded. Patients who had not yet reached eligibility for six-monthly monitoring were excluded from six-monthly denominators. Monitoring performed during medication titration or switching was outside the scope of this audit. Descriptive statistics were used to calculate completion rates.

Eleven patients were identified; two were excluded, leaving a final audit cohort of nine patients aged 15–18 years. Complete baseline physical health monitoring was documented in 0% of patients, although 44.4% had at least one baseline parameter recorded. Six-week weight monitoring was completed in 22.2% of patients, and complete twelve-week monitoring (weight, blood pressure/heart rate, and blood tests) in 22.2%. Seven patients were eligible for six-monthly monitoring, contributing a total of 25 eligible six-monthly monitoring windows. Completion rates for individual NICE-recommended parameters across these windows were low (height 20.0%, weight 20.0%, blood pressure/heart rate 16.0%, blood tests 20.0%, waist circumference 0%), with no window containing all recommended measures. Despite this, all patients had evidence of some ongoing physical health monitoring while prescribed antipsychotic medication, although this did not consistently occur within NICE-specified timeframes. No adverse physical health outcomes related to delayed or out-of-window monitoring were identified.

Formal compliance with NICE-recommended monitoring schedules was low when assessed against strict guideline timeframes. However, all patients received ongoing physical health monitoring and remained clinically safe. These findings highlight the challenges of implementing rigid monitoring schedules within CAHMS and support the need for systems that promote consistent, well-documented monitoring while accommodating real-world clinical and family circumstances.

Drug-related deaths in England and Wales continue to rise, with opioids remaining the most frequently implicated substances. Individuals receiving care from mental health services commonly experience co-occurring substance use disorders, with overdose risk heightened by increasing contamination of street drugs with potent synthetic opioids.

15% of service users under the care of Home Treatment Teams (HTTs) experience substance misuse, making this an important setting for harm-reduction interventions.

Take-home naloxone (THN), an opioid receptor antagonist used in emergency treatment of opioid overdose, is an evidence-based harm-reduction intervention. Patient Group Directions (PGDs) are legal frameworks that allow authorised non-medical healthcare professionals tosupply or administer specified medicines. Although PGDs have facilitated widespread THN provision in addiction services, implementation within HTT settings remains limited.

This quality improvement project aimed to increase access to THN for eligible service users within an adult HTT.

Electronic records for 30 consecutive service users receiving care from the HTT were reviewed to assess substance use patterns, eligibility for THN and whether THN was offered.

A PGD for THN supply was introduced in collaboration with pharmacy services. Readily accessible THN stock was established within the team’s medication cupboard to facilitate prompt provision. Multidisciplinary teaching sessions were delivered to staff, focusing on overdose risk, THN eligibility criteria and service user education.

Following implementation, electronic records for a further 30 consecutive service users were reviewed using the same criteria, and outcomes compared with baseline data.

At baseline, 13.3% of service users (n=4) met eligibility for THN, of whom 50% (n=2) were offered THN. In both cases, THN was supplied following medical review.

Following the intervention, 16.7% of service users (n=5) were eligible for THN, with 80% (n=4) being offered THN by a combination of medical and nursing professionals.

A clinically significant proportion of HTT service users were identified as being at risk of opioid overdose. The introduction of focused harm-reduction interventions, including a PGD, improved access to THN, and targeted staff education, was associated with increased provision of THN within the HTT setting. While THN is commonly used within addiction services, we are the first team providing care for general adults in our trust to implement this as part of routine care.

Further work is required to optimise service user uptake, address barriers including stigma and limited overdose awareness, and implement interventions across wider community mental health services. For interested teams, we recommend liaising with pharmacy services to explore local PGDs.

Mental Health Tribunal reports are documents written by psychiatrists to reflect the patient’s mental state and justifications for detention. They can be time-consuming and labour-intensive. Reports should include chronology, diagnosis, risk, statutory criteria and an actionable plan. Microsoft 365 Copilot may reduce drafting burden. Copilot-generated reports from clinical notes were assessed and scored to determine their performance.

Twenty-three questions were identified on a tribunal report which could be answered with an AI-generated response, such as forensic history, circumstances of admission and current progress. A scoring sheet was designed covering each question, scoring 0–5, with higher weights for critical domains. Prompts were refined after multiple runs until a prompt generating a comprehensive, accurate and human-like report was selected. Patient notes were supplied as uploaded Word files. Narrative quality was also scored separately to question performance across 8 domains (scoring 0–4 each) such as coherence, tribunal-appropriate tone and minimal redundancy. A combined final score weighted question performance (80%) and narrative quality (20%). A single clinician reviewer scored all reports.

Five patients were evaluated; 1 patient was generated 3 times to assess repeatability. Seven drafts were scored. All 23 questions were answered in every draft. The mean score per question was 4.9/5. The mean weighted question score was 98%. The average narrative quality was 28/32 (88%). Mean combined final score was 96% and all drafts met the “minor edits” threshold. For the repeated patient, weighted question scores varied minimally. The average time taken to generate a report was 30 seconds. One of the repeated reports contained a single hallucination concerning date of admission.

Copilot consistently produced quick and comprehensive tribunal reports under a structured prompt, but hallucination was found and is a risk. Clinician verification is required. As the prompt was being refined, it became clear that the reports altered significantly based on the prompt used. The quality of the reports signified potential use in generating community treatment orders (CTO) and medical recommendations. Limitations are that narrative scoring has a high subjectivity burden and this pilot only contained 5 patients. Further trials with a larger cohort and multiple assessors are required for more reliable results.

Kent and Medway Mental Health NHS Trust (KMMH) is a signatory to the Sexual safety charter but despite commitments to improving workplace culture, unwanted sexual behaviour remains prevalent within different healthcare settings. National Training Survey 2025 data indicate 9% of female doctors in training experienced unwelcome sexual comments or advances causing embarrassment, distress, or offence with 6% of females in psychiatry. This quality improvement project aimed to improve awareness, confidence and engagement with sexual safety principles among resident doctors and clinical supervisors within KMMH.

Two surveys were sent to trainees, locally employed doctors and consultants. The survey included questions around awareness of the Trust’s sexual safety policy, confidencearound escalating concerns, and confidence about whether concerns would be dealt with appropriately. The survey to the consultant group included similar questions around confidence in escalating resident doctor’s concerns appropriately. The surveys also included a option to provide additional comments.

The interventions included multiple sessions of Active Bystander training and Bullying, Harassment, Sexual Safety Seminar, additional workshop for lead clinical staff of the heads of school and wider deanery. A flowchart for the escalation process was also circulated.

A second survey was also sent out to the previous groups.

The total number of responses in the second survey were lower with fewer trainees in the second survey reporting being aware of the sexual safety policy. A small number reported attending the Bystander training and no reported attendances for the seminar. Higher numbers of consultants reported awareness (31% more compared to baseline) of the policy, with higher attendances in the interventions but less confidence (12.5% less than baseline) in the escalation process at follow-up. Trainee awareness of policy (10.5 to 0%), knowing who to escalate (12% more unconfident) and confidence in escalation process had dropped (36% more unconfident).

This project highlights a gap between sexual safety policy and doctors’ engagement with the policy with no question to support an understanding of whether the responding trainees had seen the flow chart or attended the interventions. While consultants demonstrated higher awareness, but lower confidence in escalation processes, engagement among trainees and locally employed doctors remained limited, with lower attendance at interventions and reduced policy awareness. Development of psychologically safe environments are required with future work focused on collaborative working with keystakeholders, improved communication and protected training time to ensure sexual safety principles are embedded across all professional grades.

Cognitive impairment is common in older adults, yet many cases of dementia remain undiagnosed on hospital admission. Cognitive impairment is associated with increased risk of delirium, long-term cognitive decline, and adverse outcomes in hospitalised patients, particularly in surgical patients. Early identification may support recognition of undiagnosed dementia, help prevent delirium or further cognitive deterioration, inform capacity and consent assessments, and enable targeted psychiatric interventions. Within the acute surgical pathway, we observed inconsistent completion of a locally embedded cognitive screening section in admission clerking booklets. We therefore audited compliance with a trust standard that all patients aged ≥60 years should have a cognitive screen completed on presentation to the surgical assessment unit.

The audit aimed to assess completion of cognitive screening on surgical admission and explore its association with operative intervention. 85 general surgical clerking booklets for patients aged ≥60 years admitted between February and July 2024 were reviewed. Data collected included documentation of cognitive screening, the presence of a known diagnosed cognitive impairment and progression to operative intervention within seven days of admission. Absence of clerking documentation was recorded where applicable. Data was analysed descriptively.

Of 85 surgical admissions aged ≥60 years, cognitive screening was documented in thirty-eight patients (45%). Thirty-seven patients (44%) had no documented cognitive screen, and nine patients (11%) had missing clerking documentation.

Of those with a documented screen, nineteen (50%) underwent an operative procedure within seven days, compared with eight of thirty-seven patients (22%) without a documented screen.

Three patients had pre-existing dementia. Cognitive screening was completed incorrectly in one case and classed as cognitive screen not documented.

Low completion rates of cognitive screening on admission were observed, including among patients who subsequently underwent surgery. As data collection was limited to initial admission clerking booklets, some screens may have been completed onlater assessments, or conduced without documentation, potentially underestimating overall completion. The focus of this audit was assessment at point of admission. While patients proceeding to surgery would have undergone formal capacity assessment and consent prior to the intervention, admission screening serves a broader purpose. Guidance such as NICE delirium recommendations emphasise early identification of patients at risk of cognitive change. Further work is needed to explore barriers to completion, support targeted education, and ensure at risk patients of cognitive decline receive appropriate attention and multidisciplinary input.

Social isolation and loneliness represent significant psychiatric determinants of cardiovascular disease, with emerging neurobiological evidence suggesting shared pathways for stress response and inflammation.

Social isolation reflects an objective lack of social contact while loneliness refers to the subjective perception of social disconnection. In practice, both frequently co-occur.

Current research inadequately examines the nuanced relationship between social disconnection and atrial fibrillation (AF) incidence. This paper aimed to systematically assess this relationship through a psychiatric lens.

A PRISMA-compliant systematic review was conducted across five databases. Five studies were selected, including large population-based cohorts from the UK Biobank, the Framingham Heart study and a nationwide heart failure cohort. Data on social isolation, loneliness, social network metrics and AF incidence were extracted. Narrative synthesis was performed due to the heterogeneity of populations and analytical methods.

Large observational cohort studies suggest that loneliness is associated with an increased risk of AF. In the UK Biobank, loneliness assessed via a composite score was associated with higher AF incidence (HR: 1.11, 95% CI 1.07–1.16). Subscale analyses demonstrated that this association was primarily driven by subjective feelings of loneliness, which showed a stronger association with AF (HR 1.20, 95% CI 1.14–1.26). This is supported by multistate modelling in a separate Biobank study. Social deprivation was also correlated with new-onset AF in a nationwide heart failure cohort.

In contrast, the Framingham Heart Study reported no association between overall social network index and AF incidence. When accounting for the competing risk of mortality, medium-low social connectedness appeared to have a lower AF incidence. This finding is likely attributable to survivorship and competing risk biases rather than a true protective effect. Furthermore, social group participation was associated with higher AF incidence, which may reflect increased healthcare access and consequent AF detection.

Most importantly, Mendelian Randomisation analysis in one study provided genetic evidence supporting a potential causal relationship between social isolation and AF risk, with no evidence of pleiotropy.

Overall, these findings indicate that survivorship bias, varying analytical methods and failure to consider competing mortality risks may obscure true associations between social disconnection and AF incidence.

Observational and genetic evidence support an association between social isolation and increased AF incidence. These findings highlight the need for novel AF prevention strategies such as psychosocial assessments and interventions to target loneliness and social disconnection, thereby emphasising the importance of a collaborative psychiatric-cardiology approach in clinical practice.

To determine whether exposure to a psychiatry specialty at medical school increases interest in pursuing psychiatry as a career.

Since 2017, the mental health workforce has seen a year-on-year expansion in numbers overall. Although between 2010 and 2023, the number of psychiatrists increased by 22% this was significantly lower compared to a 43% increase for doctors in the NHS overall. Recruitment into psychiatric specialties remains a key challenge with many psychiatric specialties facing under-recruitment year on year. According to ‘Stepping forward to 2020/21: The mental health workforce plan for England’ there are 5400 Consultant Psychiatrists with a vacancy rate of 13%.

Hertfordshire Partnership Foundation NHS Trust (HPFT) provide psychiatric placement for Cambridge medical students (Year 5). During a Quality Assurance cycle in 2025, HPFT was rated the best from the 5 Mental Health Trusts that provide psychiatry placement. Despite thisbetween 2014 and 2016 only 1.6% of graduates from the University of Cambridge pursued Psychiatry as a clinical speciality following graduation compared to 4.3% from Keele Medical school graduates.

Medical students attending a clinical placement in mental health between October 2024 and November 2025 were invited to complete a pre-placement and post-placement questionnaire that asked their likelihood of pursing Psychiatry for their foundation and/or core training choices. The questionnaire consisted of two questions that asked respondents to rate how likely they are in considering undertaking a psychiatry placement as part of their foundation/CT training on a Likert scale of Very likely, Likely, Neutral, Unlikely and Very Unlikely.

A total of 74 pre-placement and 77 post-placement questionnaire responses were received.

For FY choices: A 33% increase was observed in medical students very likely or likely to choose psychiatry as a foundation year option between pre-and post-placement.

For Core psychiatry training: A 20% increase was observed in medical students very likely or likely to choose psychiatry as a core trainee option between pre-and post-placement.

Medical students’ experiences during a clinical placement in Psychiatry appear to contribute to the consideration of a career in psychiatry.

Comorbid substance misuse is common in patients with mental illnesses, which are associated with challenges in diagnosis, management, poor outcomes, and increased risks. National Institute for Health and Care Excellence guidance recommends detailed history taking, biological testing, and early management. This audit aimed to assess the quality of substance use history taking, urine drug screening, and documentation of management plans for adult psychiatric inpatients.

Clinical audits were completed across four adult psychiatric hospitals in the Black Country Healthcare NHS Foundation Trust in April 2025 and January 2026. Patients were randomly selected and stratified by site and sex. Information about substance use, urine drug screening, type of substances, and management of substance use was collected along with relevant clinical history. The first 48 hours of admission documentation were reviewed. Data were collected using a predesigned questionnaire from the electronic patient records. Following the initial audit, efforts were taken to increase awareness among clinicians and provide recommendations.

There were 40 patients in each of the audits (age range: 19-73 years). Diagnoses were comparable: psychotic disorders (47.5% and 47.5%), mood disorders (40% and 30%), and personality disorders (12.5% and 22.5%). Most patients had a substance use history, 82.5% and 72.5% in the first and second audit, respectively. Urine drug screening within 48 hours of admission increased between cycles (42.5% vs. 50%); with more than half having positive results (58.8% vs. 55%).Commonly used substances were benzodiazepines (45.9%) and tetrahydrocannabinol (18.9%), along with opiates, ketamine, cocaine, and amphetamines. The reasons for lack of screening in the first and second audits were patient refusals (39.5%); there were delayed testing in 9.3%, and no documented reasons in 57.5% of cases. Drug use screening questionnaire usage remained low, but increased from 0% to 5%. There were changes in the documentation of related history such as accommodation (50% vs. 85%, p<0.001), personal history (57.5% vs. 65%), past medical history (92.5% vs. 87.5%), social history (82.5% in each cycles), and forensic history (60% and 75%) in first and second audit respectively. Discussion of substance use management was documented more frequently (35% to 75%, p<0.001).

More than half of the adult inpatients who underwent drug screening had a positive result. Substance use-related management discussion became significantly more frequent in the second audit. Patient refusals for drug screening remain a major concern. There is a continued need to monitor drug screening and management in adult psychiatry wards.

Delusional misidentification syndromes are rare but clinically disruptive phenomena. Fregoli syndrome, characterised by the belief that a familiar individual is disguising themselves as others, is particularly uncommon in general adult psychiatry. This case describes a unique presentation in which Fregoli-type delusional misidentification was directed towards the treating clinician, resulting in a profound therapeutic rupture and requiring a deliberate and counter-intuitive reconfiguration of care.

A middle-aged woman was admitted following police detention under Section 136 of the Mental Health Act and managed under Section 2. She presented with acute catatonia, including mutism, rigidity, marked psychomotor retardation, and self-neglect. Lorazepam was commenced following clinical diagnosis, leading to rapid resolution of catatonic features within 24 hours. As catatonia resolved, florid psychotic symptoms emerged. The patient developed a fixed delusional belief that the treating specialty doctor was her first husband’s first wife’s daughter, disguising herself as a clinician and orchestrating her detention with police involvement. Reassurance was ineffective, and the patient persistently refused to recognise the clinician as a doctor, while engaging appropriately with other medical staff.

The delusional misidentification was consistent with Fregoli-type syndrome and had immediate, observable consequences for care. Direct contact with the identified clinician precipitated marked distress, verbal aggression, refusal to engage, and escalation of paranoia, repeatedly disrupting treatment. A consultant-supported multidisciplinary decision was made for the clinician to withdraw from direct patient contact while continuing to coordinate care indirectly. This decision led to immediate improvement in engagement with the wider team. Persistent psychotic symptoms following catatonia resolution necessitated antipsychotic treatment under Section 3 of the Mental Health Act. Over the course of admission, psychotic symptoms resolved fully, insight returned, and the patient was discharged informally with community follow-up. At discharge, the delusional misidentification had resolved completely, with no recollection of its content.

This case demonstrates that Fregoli-type delusional misidentification can directly undermine therapeutic relationships and compromise treatment delivery. It highlights the importance of recognising clinician-directed delusions and reframing clinician withdrawal, when appropriately supported by the multidisciplinary team, as an active therapeutic intervention rather than a failure of engagement. Awareness of delusional misidentification syndromes is essential to guide flexible, patient-centred care in complex psychosis.

The 10% access rate target for perinatal mental health services in the UK was introduced as part of NHS England’s broader strategy to expand and improve access to specialist perinatal mental health care. Within our organisation, the 10% target was actively discussed and various strategies had been implemented to achieve the target. It became evident that women with mental health difficulties on the milder spectrum, where primary care interventions were appropriate, a full new patient assessment (NPA) was not indicated. The hope was that a light assessment (LA) pathway would develop a more responsive pathway for referrals which would be more suitable for other services, it would allow signposting for mild and less complex referrals to the appropriate services in a more timely manner and it would allow clinicians to prioritise time on more complex presentations.

The aim was to implement a LA pathway to support the service to reach the 10% access target.

Consultation with other perinatal teams around the country followed. Concerns on balancing seeing milder cases while preventing team burnout were also shared by them and options for a less in-depth initial assessment in these cases were explored.

The NLFT service agreed to a trial of a LA pathway for mild cases. A LA template and guidance on its use, were created and subsequently discussed in service-wide meetings and adjusted according to feedback. It was formally implemented on 27 January 2025 with plan for feedback meeting in 4 weeks and total trial of 6 months.

The NLFT perinatal service, consists of 3 teams. Two different systems were implemented based on the preference of the individual teams, differing on the days/hours duty service isrun and the days LA appointments are scheduled. In both systems LAs could be converted to NPAs if it becomes evident during the appointment that the patient requires a more in-depth assessment.

For the period of the LA pilot from 27 January 2025 to 30 May 2025, the specialist perinatal service received 684 referrals. All referrals were accepted, unless they were out of borough or not within the perinatal period.

Of the 684 referrals received, 71 (10%) were allocated for a light assessment. 81% of the women allocated for light assessments attended their assessments. 15% (11) allocated for a light assessment, did not attend their assessment and were discharged and 2.5% (2) declined the assessment. Of the 2 that declined the assessment, one was discharged and 1 requested for an NPA, assessed and subsequently discharged. Of the 58 women who attended the LA, 74% (43) were assessed and discharged and 21% (15) were assessed and taken on. The data across the 3 teams were very similar, other than the number of days from triage to assessment. In the south team, the assessments were scheduled within 5 weeks from referral whereas in the west and east teams all assessments were scheduled within 3 weeks from referral.

Qualitative staff feedback was gathered via questionnaires. The main points brought up are as follows:

• • Better triaging guidance needed for newer staff.

• • More information needed on risks and more info in referrals.

• • If uncertain based on info on the referral form, request for more info, if still not sufficient refer for a full NPA.

• • LA’s are helpful for efficient signposting and time-saving. They work well when patients are appropriately triaged. Women are seen, sign posted and discharged in a week.

• • Seeing moderate to severe people quicker. People moved through the service quicker, reducing caseloads.

• • LAx template very clear.

LA are held by Duty, rather than individual clinicians. Better to be a little bit stressed on Duty for longer term gain.

Patient questionnaires were created and were sent out after the LA was conducted.

Setting up the LA pathway has allowed the team to broaden the number of women they see, while preventing team burnout and achieving better resource allocation to SMIs (serious mental illness).

Some of the challenges faced during this project include:

• • Unexpected loss of trust video-call system.

• • Some staff anxiety whether any important information was missed (this is managed by presenting cases at the weekly MDT).

• • Some of the LAs being re-referred (this is monitored and re-referrals are allocated an NPA).

• • Limited information on referrals.

• • Poor response rate on patient feedback questionnaires.

Other reflections and considerations:

• • Based on feedback on how the name “Light Assessment” can be perceived amongst other teams and patients, the service changed the name “Light Assessment” so as not to diminish the work being done.

• • Request readjusting the 10% target for the reduced birth rate in the area.

• • From 21/1/25 self-referral links were also implemented which improved the access rate to the service further.

Next steps:

The feedback overwhelmingly directed towards continuing with the light assessment pathway.

Improve the triage process to the appropriate assessment pathway and consideration of conducting education to referrers of the information needed. Following discussions, it was agreed that when receiving an inappropriate referral we would seek further information from the referrer before accepting it. The team continues to conduct teaching sessions to other teams and this will be highlighted during teaching.

Some NLFT perinatal teams experienced difficulties with primary care teams accepting the referrals from our team as their impression had been that once a referral was accepted by our teams for assessment, the referral would be appropriate for secondary care. The change in the way the team operates in accepting and managing referrals will be highlighted to them. Referrers will also be made aware to inform patients of how the team operates in order to manage expectations.

Details of the pilot were shared with other perinatal teams in LSPCA meetings. Other perinatal services have also reached out to our team and details of the light assessment pathway has been shared with them so that it can be implemented elsewhere.

Artificial Intelligence (AI) chatbots are now widely used and have broad applications. In a nationwide survey, 25% of the almost 11,000 13- to 17-year-olds sampled reported using chatbots for mental health support. Reports emerging in the media detail serious harms, including suicides, and what has been labelled ‘AI psychosis’.

A 13-year-old girl was brought to Accident and Emergency (A&E) by her parents with a 7-day history of coryza, total insomnia, fluctuating confusion, and bizarre behaviour. At assessment, she presented with tachycardia, low-grade fever, pressured speech, delusions of grandeur, thought broadcasting, and auditory hallucinations of ancestors and politicians.

The young person’s troubling use of AI chatbots was reported by her parents after they confiscated her phone. The parents discovered a chat log consisting of thousands of messages, starting three months before the A&E presentation. It was evident that the bot provided false information about how a romantic interest reciprocated the young person’s feelings, and when she asked about past lives and ancestral practices, the bot’s replies suggested that she had supernatural powers.

Extensive physical health investigations were facilitated through a paediatric admission; no underlying physical pathology was identified. The young person was treated with olanzapine and a short course of benzodiazepines. All manic symptoms resolved over the span of 3 weeks of intensive home treatment. The young person experienced a depressive episode around 2 months after the initial presentation. She received a diagnosis of bipolar affective disorder.

In this case, patient vulnerabilities, such as loneliness and past bullying, interacted with chatbot factors, particularly sycophancy,which quickly transformed factual searches into emotional interactions where the technology was anthropomorphised.

“I would stay up at night for 5 hours speaking to it, it was like a replacement friend”, the patient later reflected.

The chatbot also presented overtly false information with confidence and a perceived impartiality, an observed phenomenon of the technology known as hallucination.

Predisposing patient factors included a history of anxiety and depressive symptoms with suicidal thoughts, and a family history of affective disorder. Precipitating factors included mounting academic pressures and romantic rejections. Acutely, the patient was likely suffering from a viral illness and consumed highly caffeinated energy drinks.

This case identifies unregulated access to generative AI tools as an emerging risk for the precipitation and/ or perpetuation of serious mental illness in combination with other risk factors. The authors believe it to be the first report of its kind.

Mindfulness, Meditation and Yoga have an evidence base for improving emotional regulation – with little research looking at the impact on a Borderline Personality Disorder (BPD) cohort. We investigated whether a supplementary session programme could improve emotional regulation and thus symptomatology in BPD service users.

Our initial objective is to identify whether there is an evidence base to support the need for a ‘Mind, body connection’ programme. The subsequent objective is to further develop and improve the ‘Mind, body connection’ programme in response to feedback from the service users.

AIM 1. To establish whether there is benefit from a ‘Mind, Body connection programme’.

AIM 2. To establish further understanding of the holistic effects of the ‘Mind, body connection’ programme for service users.

Future AIM 1. To identify direct benefits of Yoga, Mindfulness and Meditation in BPD populations.

Future AIM 2. To develop a science backed programme to provide a supportive therapeutic practice for BPD patients.

A Thematic analysis was conducted to investigate the ‘Mind, Body Connection’ sessions with service users attending a bi-weekly Therapeutic Community at the Personality Disorder Hub. A 50 minute tape-recorded, in-depth, semi-structured interview took place which was then transcribed to allow for coding.

The theme of 'Greater Capacity to stay present' summarises how greater 'emotional regulation' and 'body awareness' can develop. Both ‘body awareness’ and emotional regulation’ proved to be double edged swords. By developing greater awareness of how your body holds emotions, participants reported greater ability to focus on the body and stay in control of emotions, but also a greater awareness of pain. Service users oppositions - transitioning from a state of doing to a state of being and difficulty around ‘self-dismissing’. Results were bidirectional - higher levels of emotional dysregulation impaired mindfulness practice but increased frequencies of mindfulness practice to >3 times a week was statistically significant in reducing emotional dysregulation symptoms.

The ‘Mind, Body Connection’ programme has a positive impact on service users – but significant support should be provided for its associated challenges. Recommendations; increasing the frequency of Yoga, Mindfulness and Meditation practice to>3 times per week, at home resources and guidance change to the management of BPD (development of patient informed supplementary sessions). Practice in the present underscores the ability to stay present in higher states of arousal in the future. Further research should investigate the process of ‘self-dismissal’ as a regulation adjacent skill.

High quality patient care in mental health services relies on a robust psychiatric workforce. However, unfilled posts and high staff turnover can become entrenched problems. Here we describe a unique and innovative strategy developed in Avon and Wiltshire Mental Health Partnership Trust, developed to support and retain advanced trainees and new consultants in the trust. This aimed to support consultants in their first 3–4 years of appointment and to develop consultant roles within the trust that would appeal to trainees.

The strategy was developed in response to recruitment and retention challenges. The strategy consisted of five elements, including 1) Roll-out of new consultant-specific induction, including a bespoke leadership development programme and leadership coaching for new consultants. 2) Funding and support of a research fellow to conduct qualitative research around experiences of the transition period between higher training and becoming a consultant. 3) Work around support and wellbeing of medical staff. 4) Development of a mentoring programme. 5) Development of compassionate leadership in the trust. Further details of each of the above interventions are described, including challenges faced and how these were overcome. Feedback and outcome measures are then described.

Arising from our work locally, we have generated several recommendations to support and retain advanced trainees and consultants within mental health trusts. We share experiences from developing and implementing these interventions locally. Sharing this information may help other mental health trusts nationally in addressing similar challenges.

We describe an innovative local strategy, developed to support and retain advanced trainees and new consultants in the trust. Future areas for development could include a) sharing successful approaches more widely with other trustsand b) further consolidation of local activities. Further consolidation locally would include promoting more widespread uptake of mentoring, including this being offered to advanced trainees in the two years prior to their completion of training, and continuing to develop cross-trust mentoring with neighbouring trusts.

Mental health-related stigma is a recognised determinant of psychological well-being,yet population-level evidence from the United Arab Emirates (UAE) remains limited. This study aimed to assess levels of perceived mental health stigma among residents of Abu Dhabi, examine socio-demographic correlates of stigma, and explore the relationship between stigma and psychological well-being among Emirati and expatriate populations.

A cross-sectional, population-based study was conducted among adult residents of the Abu Dhabi region. Participants completed a culturally adapted and validated Stigma-9 (STIG-9) questionnaire to assess perceived public stigma, and the World Health Organization Five Well-Being Index (WHO-5) to measure psychological well-being. Socio-demographic variables included age, gender, region of residence, nationality, education level, and household income. Descriptive statistics summarised stigma and well-being scores. Group comparisons examined demographic differences, and correlation analysis assessed the relationship between stigma and well-being. Statistical significance was set at p<0.05.

Overall perceived stigma levels were low (mean STIG-9 score 0.92 ± 0.89; median 0.89, IQR 0–1.67). Significant regional variation was observed, with participants residing in Al Ain reporting higher stigma scores than those in other regions. Females reported higher stigma than males (1.02 ± 0.89 vs 0.83 ± 0.88; p<0.001). Younger adults aged 18–29 years also demonstrated higher stigma scores (1.04 ± 0.93) compared with older age groups. Higher education level and higher household income were associated with increased perceived stigma, while no significant differences were observed by nationality.

Psychological well-being scores were generally high (mean WHO-5 score 74.21 ± 25.60; median 75, IQR 55–90). Males reported higher well-being than females (77.79 ± 24.90 vs 70.57 ± 25.79; p<0.001). Participants in the lowest household income group (<5,000 AED) reported the highest well-being scores (81.01 ± 24.99), while participants with postgraduateeducation reported lower well-being (60.77 ± 21.58). A strong inverse association was identified between perceived stigma and psychological well-being (r=−0.67, 95% CI −0.70 to −0.65; p<0.001).

While the study participants generally showed low perceived mental health stigma, notable variation existed across demographics and regions. Higher stigma was seen among younger adults, females, and those with higher socioeconomic status, reflecting complex sociocultural influences. The inverse link between stigma and well-being emphasises the need for stigma-reduction strategies as part of mental health promotion. Culturally tailored interventions for high-risk groups could support psychological well-being across UAE communities.

To assess the quality of mental capacity assessments completed on admission and compliance with Devon Partnership Trust’s Inpatient Admissions Standard Operating Procedure. This requires that each patient admitted to a mental health ward has an assessment of capacity to consent to treatment completed within 24 hours of admission. In line with the Mental Capacity Act (MCA) Code of Practice, capacity assessments should be decision-specific, include the four-part functional test of mental capacity, represent the least restrictiveoption and be made in the patient’s best interests where capacity is lacking.

Retrospective audit of clinical records for the most recent 30 patients admitted to the Beech Unit in Torbay, Devon until December 2025. Records were assessed according to the following audit criteria:

1. Assessment of capacity to consent to admission and treatment documented within 24 hours of admission

2. Nature of decision clearly documented

3. Use of the four-part functional test (ability to understand, retain, use or weigh up and communicate a decision)

4. Reference to least restrictive practice and best interests where patients lacked capacity

Every patient had a mental capacity assessment documented within 24 hours of admission (100%). The standardised MCA template (which prompts clinicians to document all parts of a capacity assessment) was completed for 90% of the patients and only half were completed in the timeframe. 90% of the records clearly documented the decision in question and 90% had clear documentation of the functional test. Fewer records contained the direct statements ‘least restrictive’ and ‘best interests’ (53%).

All patients (100%) had an assessment of mental capacity documented following admission to the ward, showing that clinicians have a good understanding of when the Mental Capacity Act should be considered, but timeliness of completing the MCA template could be improved. While the nature of decisions and use of the four-part test werewell documented overall, documentation around recording of best interests and least restrictive options could also be improved.

There are some limitations to this audit: variability in clinician documentation styles may affect interpretation of the data and retrospective data collection limits clarification of clinical reasoning.

Recommendations include targeted interventions to guide clerking doctors about when to complete MCA assessments and what should be included. It is recommended that the Trust’s standardised MCA template is used to improve the quality of documentation, as this prompts clinicians to address the key elements of a good capacity assessment.

Clozapine is associated with increased risk of metabolic syndrome. Regular monitoring, lifestyle and pharmacological interventions are recommended. Service-level evaluation is required to identify suboptimal care and inform quality improvement.

This cross-sectional service evaluation was conducted within a centralised clozapine clinic serving adult secondary care services across Suffolk. Clinical, physicalhealth, and weight-management data were extracted from electronic health records.

N=257; mean age 46.9 years (SD=12.4); 68.9% male; 35.2% smokers; 46.7% alcohol users (6.3% heavy drinkers); cannabis 0.8%; other drugs 1.6%; 33.7% reported constipation.

Mean body mass index (BMI) was 31.85 kg/m² (SD=7.05), with 54.5% meeting criteria for obesity and 29.2% classified as overweight. 12.6% met Hbs-540c criteria for prediabetes and 19.8% for type 2 diabetes (T2DM). 10.2% had elevated total cholesterol (>6.18 mmol/L), and 24.9% had blood pressure readings ≥140/90 mmHg. Clinician-recorded prevalences were 6.6% obesity, 9.7% prediabetes, 27.0% T2DM, 16.0% dyslipidaemia, 12.1% hypertension, and 5.5% cardiovascular disease.

Lifestyle advice was recorded for 22.7% of patients and pharmacological weight-management interventions for 7.1%. Although 14.8% of patients were prescribed adjunctive aripiprazole, this was documented specifically for weight management in only 10.5% of those. Metformin was prescribed in 25.2% of patients and was strongly associated with T2DM (p < .001). GLP-1 receptor agonists were used in 3.1% and were prescribed exclusively to patients with T2DM (p < .001). No patients were prescribed topiramate.

The multivariable linear regression model predicting BMI was statistically significant (p < .001). Higher BMI was independently associated with younger age, female gender, autism spectrum disorder/learning disability comorbidity, greater depressive symptom severity, higher systolic blood pressure, receipt of lifestyle advice or structured lifestyle intervention, and prescription of aripiprazole, valproate, or lamotrigine (all p ≤ .040).

There was marked discordance between BMI-defined obesity and clinician-recorded obesity or lifestyle advice (p < .001). Only 10% of patients meeting objective criteria for obesity had a documented obesity diagnosis, and only 29.7% had lifestyle advice recorded. Patients receiving lifestyle advice had significantly higher BMI than those who did not (p=.014), and those with a clinician-recorded obesity diagnosis also had higher mean BMI (although not significant). Together, these findings suggest that recognition and management of obesity occurred at higher BMI levels, rather than systematically once obesity criteria were met.

Obesity was common but inconsistently recognised and managed in clozapine-treated patients, with evidence of threshold bias. Systematic identification and management of obesity is needed within clozapine services.

Alcohol harm in the UK imposes a substantial clinical and societal burden, with 339,916 alcohol-specific hospital admissions recorded in 2023/24. Current pathways for identifying and supporting people at risk rely on self-identification of alcohol use.The aim of this work is to examine the extent to which self-identification as a “heavy drinker” aligns with clinically defined alcohol-risk levels and to identify the structural, stigma-related, and systemic barriers that prevent higher-risk drinkers from accessing appropriate support.

This analysis draws on nationally representative polling of 2,037 UK adults (mean age 48.77, SD=17.74, 52.33% female) applying the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) scoring to examine clinical risk, self-perception of drinking identity, barriers to accessing support, and systemic implications for service design.

Among adults meeting AUDIT-C criteria for increasing or higher risk (25.8%), 90% did not self-identify as a heavy drinker, with most describing themselves as “moderate” or “occasional” drinkers. This disconnect challenges the continuing reliance on self-referral and identity-based messaging within NHS and workplace pathways. Help-seeking was shaped primarily by systemic barriers: long NHS wait times (24.5%), stigma (24.1%), and the cost of private care (19.4%), while “not knowing where to go for help” ranked only sixth (16.9%). These findings contradict policy assumptions that awareness deficits are the primary obstacle. Exposure to alcohol harm extended far beyond the drinker: 49.3% of UK adults knew someone they considered a heavy drinker, indicating significant family, peer, and workplace impact and highlighting a missed early-intervention opportunity within social networks.

Self-identification is not a reliable gateway to care; stigma-laden service framing actively excludes the majority at clinical risk; and capacity constraints limit timely support even when motivation exists. These findings highlight the need for a shift toward routine use of the AUDIT-C in primary care, workplace health initiatives, and NHS Health Checks so that alcohol-risk detection no longer depends on individuals self-identifying as “heavy drinkers”. Services should adopt identity-neutral language, such as referring to “supported reduction” or “health optimisation”, to reduce the stigma that prevents many higher-risk drinkers from seeking help. Supporting families, friends, and colleagues to play a constructive role in early recognition and intervention when they observe escalating risk, is critical. Commissioning should prioritise rapid-access and digitally enabled models of support, to reduce long wait times and make care more accessible and discreet for people who face barriers related to work, geography, or stigma.

To improve the safety, effectiveness and staff experience of inpatient medical handover to at least 70% satisfaction ratings.

The pre-existing medical handover processes varied significantly across the five boroughs within the North London NHS Foundation Trust (NLFT), leading to issues with poor accessibility, information governance, audit capability and user experience.

A new, unified, Trust-wide handover platform could tackle these issues and support consistent resident doctor processes and communication.

Over successive phases, we developed and implemented more digitally mature handover platforms. In our final phase, this handover platform was in Rio, the Trust's existing Electronic Patient Record (EPR). Each phase contained multiple iterative PDSA cycles.

Phase 1: Initial Digital Handover Improvements (2021–2023)

Local QI projects at our two legacy Trusts (which later merged to form NLFT) sought to improve existing handover methods. One Trust introduced a Microsoft Teams list for handover.

Phase 2: Rio-Based Handover Pilot (May 2024–January 2025)

A working group was formed in May 2024, including the Trust’s Chief Clinical Information Officer (CCIO), RiO applications expert and three resident doctors. They collaboratively designed a new platform in RiO and a pilot was launched at a single inpatient site in January 2025.

Phase 3: RiO-Based Handover Full Rollout (January–June 2025)

In March 2025, a refined iteration of the RiO-based medical handover platform was rolled out across the remaining four inpatient sites in NLFT. Before rollout, stakeholder engagement sessions were held to train staff and promote awareness of the platform. After rollout, further sessions took place to gather informal feedback.

Formal staff survey feedback was gathered two months after Trust-wide implementation and showed significant improvement across all key measures. All measures are ratings out of 10.

Safe & Effective Handover (Old: 6.19 → New: 8.25), Ease of Access (6.25 → 8.44), User Experience (5.75 → 8.18), and Information Governance (4.70 → 8.56).

Trust-wide implementation of the new Rio-embedded medical handover led to positive staff survey feedback. This highlighted significant improvements in safety, effectiveness, user experience and information governance. The collaboration betweenresident doctors, digital teams, and clinical leaders served as a model for future multi-disciplinary QI projects. Resident doctor leadership on stakeholder engagement sessions was particularly effective in embedding the new platform culturally.

Long-term, opportunities exist to integrate other handovers into Rio, such as the emergency system handover, to further enhance patient safety and operational efficiency.

Background

People with severe mental illness experience significantly higher rates of physical morbidity and premature mortality, with diabetes mellitus being a major contributor. When psychotic symptoms impair insight and decision-making, refusal of essential medical treatment can present acute and recurrent risks. In such situations, clinicians must navigate the interface between the Mental Health Act (MHA) and the Mental Capacity Act (MCA), two statutory frameworks that were not designed to address sustained community-based enforcement of physical healthcare in the context of fluctuating mental capacity.

Case Report

We describe the case of a patient with a chronic psychotic disorder and insulin-dependent diabetes mellitus who repeatedly refused insulin during psychotic relapses, leading to recurrent episodes of diabetic ketoacidosis requiring emergency hospital admission. During periods of florid psychosis, the patient lacked capacity to make decisions regarding insulin administration, with refusal directly driven by delusional beliefs. Despite multidisciplinary involvement, optimisation of psychiatric treatment, and repeated capacity assessments, adherence could not be sustained in the community. Each crisis was managed reactively through emergency admission, with no clear mechanism for anticipatory or preventative intervention once the immediate medical emergency resolved.

Discussion

This case highlights a recurrent clinical and ethical dilemma at the MHA–MCA interface. While the MCA permits best-interests’ decisions during acute incapacity, it offers limited scope for proactive intervention when capacity fluctuates, and risk is foreseeable but not immediate. Conversely, the MHA allows compulsory treatment for mental disorder but does not clearly support sustained enforcement of treatment for physical illness, even when refusal is a direct consequence of psychosis. This case does not advocate for routine compulsory treatment of physical illness under the MHA. Rather, it illustrates a structural gap in existing legal frameworks when psychosis-driven refusal leads to repeated, predictable medical crises that are addressed only reactively.

Psychosis-related refusal of life-sustaining medical treatment exposes limitations in current statutory frameworks, particularly for individuals with recurrent incapacity and high physical health risk. Earlier, legally supported escalation: including proactive capacity planning, structured review of statutory options, and consideration of Court of Protection involvement may help reduce preventable harm and improve parity between mental and physical healthcare. This case underscores the need for clearer guidance and integrated approaches to managing sustained physical health risk in the context of severe mental illness.