Senior medical reviews are essential for safe inpatient psychiatric care, supporting early risk assessment, treatment planning, and multidisciplinary team (MDT) coordination. National standards, including the Royal College of Psychiatrists’ Standards for Inpatient Mental Health Services – Fourth Edition (2022) and NHS England’s guidance on Acute Inpatient Mental Health Care for Adults and Older Adults, emphasise timely consultant involvement, structured review intervals, and high-quality documentation. This audit aimed to evaluate (1) whether senior medic reviews–conducted by consultants, specialty registrars (SRs), specialty and associate specialist (SAS) doctors, and multi-professional Approved Clinicians (ACs)–were completed within expected timeframes; (2) adherence to required review intervals; and (3) the quality and completeness of clinical documentation.

A retrospective audit of electronic clinical records was undertaken for psychiatric inpatients admitted to four acute wards at Roseberry Park Hospital during April 2025. Patients admitted for at least 24 hours were included. A structured audit tool assessed senior medic review within 24 hours of admission, completion of 72-hour formulation meetings and discharge reviews, documentation of senior presence in MDT meetings, integration of MDT recommendations, risk assessment, medication monitoring, and statutory documentation for detained patients. Percentages were rounded to the nearest whole number.

Senior medic assessment within 24 hours of admission occurred in 86%. Reviews at expected intervals were completed in 76%. Senior presence in key MDT meetings, integration of MDT recommendations, documentation of risk factors, contingency planning, and statutory requirements for detained patients all achieved full compliance. Documentation of senior medic reviews was clearly recorded in 80%. Clinical entries included diagnosis, risk assessment, treatment decisions, and progress updates in 97%. Medication adherence and side-effect monitoring were documented in 83%. Discharge planning was recorded in 97%. No criteria fell below the red compliance threshold. Areas requiring improvement included delayed initial reviews, inconsistent scheduling of review intervals, and incomplete documentation of progress reviews.

Overall compliance with national standards for senior medic reviews was high, with several domains achieving full adherence. The findings demonstrate strong MDT integration, robust risk documentation, and consistent statutory compliance. However, delays in initial senior reviews, variability in review scheduling, and gaps in documentation highlight opportunities for improvement. Strengthening administrative monitoring, introducing structured review checklists, and reinforcing documentation standards may enhance consistency, improve alignment with national expectations, and support safer inpatient care.

To review the utility of the traditional Mental State Examination (MSE) in identifying feeding or eating disorders (FEDs), and to propose a modernised approach that incorporates assessment of eating behaviours, nutrition, weight, and body image disturbance to improve detection and patient safety.

A narrative review of existing MSE frameworks was undertaken, examining their historical development and relevance to contemporary psychiatric presentations. The unique diagnostic challenges of FEDs were considered, alongside common barriers to detection such as stigma, ego-syntonic psychopathology and structural inequalities in the medical establishment. Our co-author provided lived experience accounts to provide a patient-led perspective on the limitations of the MSE in modern practice. Based on these gaps, a proposal was developed to integrate semi-structured questions on diet, weight, and compensatory behaviours into routine MSE practice.

The emphasis of the current MSE is seen to be heavily weighted towards traditional psychiatric presentations such as psychosis and affective disorders, inadequately capturing key psychopathology associated with FEDs such as eating behaviours, nutritional status, andbody image disturbance. This omission risks delayed diagnosis and compromised patient safety. Incorporating targeted, semi-structured questions into the MSE offers a feasible and systematic way to improve early recognition of FEDs across diverse populations. Additional benefits will be gained in safe psychotropic drug monitoring with early recognition of nutritional side effects.

Modernising the MSE to explicitly include assessment of eating behaviours and related psychopathology may enhance early detection of FEDs, reduce stigma through routine enquiry, and improve clinical outcomes and patient safety. Updates to medical training and everyday psychiatric practice are required in tandem to reflect the diverse presentations of modern mental health disorders.

Ultra-rapid cycling bipolar affective disorder (BPAD), defined by mood episodes occurring within weeks rather than months, is associated with significant morbidity and limited evidence-based guidance. Management becomes particularly challenging in women with pre-existing biological vulnerability factors such as hypothyroidism and pronounced sensitivity to antidepressants. This case highlights the complexity of balancing suicide risk, patient preference, and treatment-related mood destabilisation in ultra-rapid cycling BPAD.

We describe the case of a woman with a diagnosis of ultra-rapid cycling BPAD and a history of multiple prior admissions for mood instability. She had pre-existing hypothyroidism, neurodevelopmental comorbidity, and a past history of substance misuse, with no active substance use during admission. The patient experienced severe bipolar depressive episodes associated with high suicide risk, for which duloxetine was prescribed. However, even minor antidepressant dose changes were associated with mood elevation.

Lithium was optimised and maintained within the therapeutic range throughout admission, alongside initiation of clozapine for mood stabilisation. Following an inadvertent antidepressant dose escalation, the patient developed emerging manic symptoms, prompting urgent multidisciplinary medication review. Hypothyroidism management was concurrently reassessed, revealing suboptimal levothyroxine administration due to incorrect timing with food and other medications. Targeted education for the patient and staff was implemented, alongside dose escalation and regular thyroid function monitoring.

This case demonstrates pronounced antidepressant sensitivity in ultra-rapid cycling BPAD, with dose variability precipitating mood destabilisation even at low doses. Hypothyroidism represented a potentially modifiable biological vulnerability factor, with impaired medication absorption contributing to affective instability. A key clinical paradox emerged in which treatment required to mitigate suicide risk simultaneously increased the risk of manic relapse.

Shared decision making was central to management. Despite guideline based concerns regarding antidepressant use in rapid cycling BPAD, a consensus decision which was supported by wider acute consultant discussion and independent second opinion was made to continue antidepressant treatment at a reduced dose for a limited period, with close monitoring. Diagnostic clarity and coordinated multidisciplinary working were essential in maintaining therapeutic alliance and managing risk.

Ultra-rapid cycling BPAD necessitates highly individualised care. Antidepressants may destabilise mood even at low doses in biologically vulnerable patients, particularly women with comorbid hypothyroidism. Optimisation of physical health conditions, including attention to medication administration practices, can be clinically significant. This case underscores the importance of balancing guideline recommendations with patient-centred decision-making in complex, high-risk presentations.

Paediatric encephalitis is a medical emergency, and empirical treatment is used, given risk of neurological sequelae and death. Catatonia and first-episode psychosis can mimic encephalitis clinically, especially in medically complex children. This case describes an adolescent initially treated for suspected encephalitis.

A neuro-vulnerable 13-year-old refugee girl from Kenya presented to hospital with acute behavioural and mental state change with functional decline preceded by flu infection and major psychosocial stress due to deportation threat. Her medical history includes bilateral glaucoma, cataracts, basal ganglia calcifications, and left temporal arachnoid cyst. The initial working diagnosis was encephalitis and first-episode psychosis. IV methylprednisolone, cefotaxime, aciclovir, and immunoglobulin were commenced, followed by an oral prednisolone taper. Amlodipine 5mg once daily achieved good blood pressure control. Negative results from medical work-up (including neuro-inflammatory process and neuronal antibodies) led to immunotherapy being discontinued. During this time, catatonia developed (Bush-Francis Score of 14), 6kg was lost due to reduced intake, and psychotic symptoms continued. A lorazepam challenge showed substantial improvement in catatonia, engagement, and eating. Aripiprazole showed progressive reduction in psychotic symptoms. The patient was transferred to an adolescent mental health unit. Formulation: catatonia and psychosis in a highly neuro-vulnerable adolescent, triggered by acute psychosocial stress around asylum rejection and fear of return to an abusive environment. Lorazepam and aripiprazole were continued.

Since encephalitis is such a serious condition and takes several days of waiting on tests for diagnosis confirmation, treatment is initiated once encephalitis is suspected. Although it presents non-specifically, suggestive signs include fever, personality change, and reduced consciousness, which fit the case presentation. Subsequent treatment of IV steroids and anti-virals is in line with past literature although use of steroids (often initiated to control raised intracranial pressure) is under further research. Once encephalitis was ruled out, appropriate treatment for psychosis and catatonia was commenced. Due to complex medical history, a genetics test was ordered and results were suggestive of oculodentodigital syndrome (GJA1-related). Two variants of uncertain significance have been found in GJA1 and parental samples are being analysed.

Catatonia and first-episode psychosis can mimic encephalitis. Clinicians should treat suspected encephalitis urgently and maintain a low threshold to re-evaluate diagnosis, integrating psychosocial context (in this case, refugee status) and catatonic signs to guide psychiatric intervention. Constellations of symptoms can be indicative of syndrome diagnosis. Genetic testing should be initiated as required.

Emotional disorders are increasingly prevalent among medical students, significantly affecting their well-being and academic performance due to high levels of academic pressure. This study aims to assess emotional distress at Oman Medical College, addressing a gap in understanding mental health within this demographic and underscoring the need for targeted interventions.

Conducted from April to May 2025, this descriptive cross-sectional study utilized standardized surveys to evaluate emotional distress among medical students at the National University of Science and Technology in Oman. Data were collected through an online questionnaire from a convenience sample of 400 students, employing the General Health Questionnaire (GHQ-12) for mental health assessment. Statistical analysis was performed using SPSS to determine significance.

Of the 400 students invited, 336 completed the survey, yielding a response rate of 84%. The average age of participants was 21.6 years, with the majority identifying as female (89.6%) and Omani nationals (78.2%). Emotional distress was reported by 73% of respondents, with exam-related stress identified as a key contributing factor. Notably,students who received strong parental support exhibited significantly lower levels of emotional distress (p <0.05).

This study reveals a high prevalence of emotional distress among medical students in Oman, closely linked to academic stressors and mitigated by familial support. These findings highlight the urgent need for tailored mental health programmes and resilience-building interventions within medical education in Oman.

Large language models (LLMs) are increasingly proposed to support healthcare delivery, yet their ability to address the distinctive challenges of dementia care remains unclear. Dementia is characterised by progressive cognitive impairment, communication barriers, high caregiver burden, and substantial demands on memory services and old age psychiatry. We systematically reviewed and classified empirical applications of LLMs in dementia assessment and care, and critically appraised the maturity of evidence, intended users, and reporting of safety, fairness, and governance relevant to clinical implementation.

We searched EMBASE, MEDLINE, PsycINFO, PubMed, the ACL Anthology, the ACM Digital Library, arXiv, medRxiv, and bioRxiv (2017–June 2025). Eligible studies were empirical evaluations (simulation-based or experimental) of LLMs used for dementia-relevant clinical, caregiver-facing, or research tasks; non-evaluative commentaries were excluded. Titles/abstracts were screened by multiple reviewers, with full-text screeningconducted in accordance with PRISMA; disagreements were resolved by discussion. Using a standardised extraction form, we recorded study design, model attributes, input modalities, dementia-related use cases, evaluation setting (benchmark/vignette vs clinical data), outcomes, and reporting of ethics approval, bias assessment, and hallucination-related issues. Findings were synthesised narratively and grouped using a predefined taxonomy of clinical, patient-facing, and research-oriented applications.

We identified 35 dementia-focused studies, several covering multiple applications. The most frequently reported functions were screening/early detection (26/35) and diagnostic support (28/35), typically framed as classification tasks. Other common applications included research facilitation (19/35), evaluation/outcome measurement (19/35), information extraction (14/35), and prediction/risk stratification (13/35). Multimodal approaches were reported in (14/35). Intended users were most often researchers (22/35) and clinicians (20/35), with fewer studies targeting people living with dementia (10/35) or caregivers. Inputs included speech/audio (20/35) and free text (18/35); outputs most commonly included classification labels (26/35) and risk scores (11/35). Performance metrics were reported in 18/35. Reporting of safeguards was inconsistent: ethics approval (10/35, 29%), bias assessment (10/35, 29%), and explicit hallucination reporting (5/35, 14%).

LLMs show promising experimental performance for dementia-related classification and early detection tasks, suggesting potential roles in augmenting assessment workflows. However, evidence is largely preclinical, with limited real-world validation and inconsistent reporting of fairness, safety, and governance. Future research should prioritise prospective evaluation in memory services, robust bias and hallucination assessment, and co-designed implementation with people living with dementia and caregivers to support safe, equitable integration in psychiatric practice.

Use of amphetamines is linked to serious cardiovascular events such as tachyarrhythmias, QTc prolongation, myocardial ischemia, and even sudden death from cardiac arrest. The discontinuation of these substances will increase these risks, especially because of autonomic instability and the possibility of polypharmacy with psychotropic drugs. Although the American Heart Association (AHA) recommends using the ECG when withdrawing, there is no certainty that these procedures are followed in psychiatric withdrawal units. This audit was focused on assessing the adherence to the recommended ECG monitoring guidelines in amphetamine withdrawal inpatients and determining the gaps in the current practices that require quality improvement efforts.

A retrospective clinical audit was carried out at the Department of Psychiatry and Behavioral Sciences, Allied II Hospital, Faisalabad. A standardized checklist was used to examine the medical records of 70 inpatients admitted during a three-month time interval for amphetamine withdrawal, based on the AHA guidelines. The information was gathered, including demographic data, ECG performance, record of interpretation, repeat ECGs, and follow-up measures. The data were evaluated descriptively with Microsoft Excel, in which frequencies and percentages were computed to identify the adherence to each audit criterion.

The average age of the patients was 30.3 years (9.6), and the majority were males (97.1%). Even though all the patients confirmed taking amphetamine, only 7.1% of the patients were subjected to a baseline ECG at admission. Worryingly, none had recorded the results of ECG interpretations and QTc measurements. In addition, no repeat ECG checks or cardiac laboratory assessments were done, including the 37.1% of the patients who complained of cardiovascular symptoms. The compliance with AHA standards of monitoring was generally of low quality, which points to deep-seated flaws in the cardiac safety monitoring.

This audit has shown that there is a distressing absence of ECG checks and recording in the treatment of amphetamine withdrawal. In order to improve patient safety, it is important to introduce mandatory baseline ECG policies and staff education on the need to monitor and incorporate ECG prompts into admission workflows. It is highly advisable that a follow-up re-audit be done between 6 and 12 months after these corrective measures are put in place in order to determine how much compliance and patient outcomes have improved. With these efforts, it will be possible to protect the cardiovascular health of patients with amphetamine withdrawal symptoms in an effective way.

To address gaps in physical health teaching for psychiatric doctors, we hypothesised that a structured programme delivered collaboratively across trusts would improve confidence and knowledge in managing acute and chronic medical conditions. Psychiatric doctors frequently encounter physical health issues with their patients, yet ongoing training opportunities are limited. Feedback from trust resident-senior forums highlighted a need for teaching on medical emergencies and chronic disease management.

A curriculum was developed covering 12 core topics, including medical emergencies in psychiatry, cardiovascular health and integrated care. Sessions are delivered bi-monthly within the trust’s continuing professional development programme for higher trainees and consultants, with additional invitations sent to core trainees and IMTs for these talks. Teaching is led by resident doctors and consultants in adult medicine, with feedback provided by attendees for their portfolios. Teaching materials can be offered for review by a psychiatry trainee beforehand to ensure relevance to mental health settings and discuss further. Staff attendance is encouraged through induction packs and circulated schedules.

Sessions have been well attended, with on average 85 staff (range 67–110), including both resident doctors and consultants. Feedback has been overwhelmingly positive, citing sessions as “practical”, “relevant”, and “useful” for out-of-hours support. Participants valued guidance on identifying alarming signs, understanding hospital expectations from referrals and insight into likely treatment for their patients. One staff member noted they would “reach for these slides during on-calls” as an additional available resource. It was also highlighted that there could be misconceptions between hospital and psychiatric teams regarding available tools and resources. This shows the importance of shared understanding to improve patient care.

High engagement and positive feedback demonstrate the need for ongoing physical health teaching in psychiatry. This programme exemplifies how cross-trust collaboration can address learning gaps and could be replicated in other regions to enhance patient safety and clinician confidence.

Compulsive skin-picking is a recognised complication of cocaine misuse, frequently driven by formication and somatic delusional beliefs of infestation.¹² Repetitive excoriation may result in significant tissue damage, impaired wound healing, and long-term disfigurement, particularly when combined with psychiatric comorbidity, poor insight, and psychosocial adversity. This case highlights the interaction between trauma-related psychopathology, cocaine-induced perceptual disturbance, and severe self-inflicted facial injury.

LA, a 60-year-old woman from Brazil who moved to the UK over 20 years ago, presented with a history of trauma-related psychiatric symptoms and recurrent cocaine misuse. She had developed progressive self-inflicted injury to the nasal cleft and upper lip, particularly during periods of cocaine use. The formication and infestation beliefs also lead to compulsive aggressive cleaning of the philtrum and nasal region, including the use of sharp implements and a toothbrush, resulting in extensive soft-tissue damage and chronic non-healing wounds.

LA intermittently denied ongoing infestation beliefs but the picking behaviours continued, particularly during periods of medication non-adherence and substance use. Collateral history confirmed continued delusional beliefs. She was treated with Fluoxetine 60mg OM and Olanzapine 5mg ON. Dermatological assessment reported pyoderma-like ulceration, exacerbated by repeated trauma and cocaine adulterants. Despite periods of partial healing, recurrent excoriation prevented sustained recovery leading to consideration of future reconstructive surgery.

Management was complicated by inconsistent engagement, housing instability, and fluctuating insight. Escalation to depot antipsychotic therapy was considered due to ongoing self-injury and poor adherence. Psychological assessment identified significant functional impairment, compulsive behaviour, and substance misuse disorder, with reliance on family members for daily support.

Chronic intranasal cocaine use causes nasal and dermatological tissue damage through intense vasoconstriction, leading to ischaemia, ulceration, and tissue necrosis.³ Over time, this may progress to nasal septal perforation, collapse of nasal structures, and destruction of midline facial anatomy, including the philtrum and upper lip.

This pattern of injury is described as cocaine-induced midline destructive lesions (CIMDL), resulting from repeated vascular insult and progressive breakdown of nasal mucosa, cartilage, and surrounding soft tissues.4 Adulterants such as levamisole further contribute to vasculitic and necrotising skin lesions.5 Cocaine is also associated with formication, which can drive compulsive scratching and excoriation, particularly in individuals with underlying psychotic or somatic delusional beliefs.¹

Cocaine-associated skin-picking can result in severe and enduring facial injury when driven by somatic delusional beliefs and substance-induced perceptual disturbances. This case underscores the importance of coordinated psychiatric, psychological, substance misuse, and physical healthcare interventions to prevent further harm.

This service evaluation reviewed the distribution of intramuscular and intranasal naloxone between January 2025 and January 2026 within Richmond Community Drug and Alcohol Services, as part of a harm reduction approach for people with opioid use disorder. Naloxone is a well-established opioid antagonist used to reverse opioid-related respiratory depression in emergency situations. The evaluation was particularly relevant to the London Borough of Richmond upon Thames, where drug-related deaths continue to occur despite lower prevalence overall, and where polysubstance use and exposure to potent synthetic opioids increase the risk of overdose among people accessing local services.

A retrospective review of anonymised naloxone distribution records was undertaken, capturing all kits issued over the 12-month evaluation period. Data included the total number of kits provided and the formulation supplied, either intramuscular or intranasal. Naloxone was offered in line with UK national guidance to people using opioids alone or with others, individuals who inject drugs, those assessed as being at increased risk of overdose, and people likely to witness an overdose. Distribution was supported by brief, practical harm reduction advice. This focused on using low doses and increasing gradually, especially when using a substance for the first time, allowing time for effects to be felt, and recognising that drugs may act at different speeds or vary in strength despite similar appearance. Individuals were also encouraged to inform others when using substances, access buddy or telephone support if using alone, and seek emergency medical help when concerning symptoms occurred. Findings were summarised using descriptive analysis.

During the evaluation period, a total of 237 naloxone kits were distributed. Of these, 75 kits (31.6%) were intramuscular naloxone, and 162 kits (68.4 %) were intranasal naloxone. Intranasal naloxone accounted for the majority of kits provided. This reflects its ease of administration, lower risk of needlestick injury, and suitability for use by people without medical training. Distribution occurred within a population characterised by established opioid dependence, where polysubstance use and exposure to synthetic opioids were an identified risk.

This evaluation supports sustained naloxone distribution as an effective harm reduction measure, with intranasal naloxone facilitating wider access and rapid overdose response. Given its short duration of action, repeat dosing and urgent medical assessment remain essential, particularly with long-acting or synthetic opioids.

Perinatal depression is a significant public health concern with far-reaching consequences for mothers, their infants, families, and society. The economic burden is substantial; in the UK, the estimated lifetime cost of perinatal depression is £75,728 per woman with an average cost of £8,500 per birth. The Thinking Healthy Programme (THP) is a community based intervention integrating cognitive and behavioural strategies into the routine work of community health workers (CHWs). An accessible, practical, and cost effective approach for low resource settings.

This scoping review aims to analyse the effectiveness of the THP in reducing depressive symptoms, improving long-term maternal and child outcomes, and assessing its cost-benefit, cultural adaptability and scalability.

The methods followed the framework outlined by Arksey and O’Malley and were reported based off the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR).

Eligible studies included all forms of original empirical research evaluating interventions including: pilot studies; randomised control trials (RCTs); retrospective cohort studies reporting on THP in pregnant women and new mothers in low-and middle-income countries (LMICs). The Web of Science database search was limited to THP-specific studies published between 2008 and 2023 in English. Key data extracted included study design, population, setting, delivery mode, helper characteristics and training, safety, acceptability, feasibility, scalability, clinical and cost-effectiveness, and implementation barriers and facilitators.

Twelve studies evaluating THP were included, published between 2008 and 2023, conducted in six LMICs. Sample sizes ranged from 38 to 1,731 participants, with most studies conducted in rural or semi-urban settings. Eight studies (67%) were RCTs. The intervention was primarily delivered face-to-face, in ten studies. One study employed a remote/technology-assisted format, and another used a mixed delivery model combining face-to-face and digital methods.

Primary outcomes included depression severity measured using PHQ-9 (Patient Health Questionnaire-9) in nine studies, child development outcomes in two, delivery agent competency using the ENACT (Enhancing Assessment of Common Therapeutic Factors) rating in one, and cultural appropriateness in a qualitative study. Secondary outcomes measured included anxiety, disability and social support (five studies), cost-effectiveness (two studies), and child socio-emotional development (two studies).

The THP has demonstrated effectiveness in reducing perinatal depression among women in low-resource settings. Its success across diverse contexts highlights its adaptability, cost-effectiveness and scalability. However, while THP improves maternal mental health, its impact on child developmental outcomes appears limited. Ongoing refinement is essential to broaden its impact on family wellbeing.

Core Psychiatry Training is designed to provide structured clinical experience, supervision, and professional development while supporting trainee wellbeing and progression. However, the lived experience of trainees within training programmes, particularly in relation to supervision, workload, assessment burden, and support for examinations, is less frequently explored in depth. Understanding these experiences is important for maintaining training quality and supporting trainee confidence and retention.

This study explores the experiences of doctors enrolled in Core Psychiatry Training across core Psychiatry rotation, focusing on the quality of supervision, workload pressures, assessment burden, well-being support, and perceived preparedness for examinations and progression.

An anonymous cross-sectional survey was distributed to all 47 Core Psychiatry Trainees (CT1–CT3) within the South Yorkshire Rotation. The questionnaire covered key aspects of training, including induction, clinical and educational supervision, teaching access, workload and working patterns, workplace-based assessments and portfolio requirements, ARCP experience, wellbeing support, inclusion, and career development. Responses were analysed using both descriptive statistics and thematic synthesis to identify patterns and tensions across placements. This study did not meet the NIHR “What is Research” criteria and therefore did not require NHS Research Ethics Committee review.

Thirty of the 47 eligible trainees responded. Trainees’ experiences wereheterogeneous and strongly placement dependent. Supervision was generally valued when accessible, particularly for clinical decision-making and risk management; however, the frequency, consistency, and scope of supervisory support varied considerably. Educational supervision was more commonly experienced as administrative than developmentally proactive, with limited structured support for examination preparation or career planning.

Workload pressures were frequently reported, with many trainees working beyond contracted hours and experiencing difficulty taking breaks. Portfolio and assessment requirements were widely viewed as time-consuming, contributing to stress around ARCP preparation despite general perceptions of procedural fairness. Support for examination preparation was often informal or self-directed, influencing trainee confidence and increasing reliance on peers rather than supervisors.

Awareness of wellbeing support varied, and feeling supported did not always correlate with knowledge of available resources. While most trainees reported feeling respected within their teams, some lacked confidence in seeking help around exams or performance concerns.

This evaluation highlights substantial variation in the lived experiences of Core Psychiatry Trainees within core training Rotation. While trainees value supervision and support when available, inconsistencies in engagement, exam-focused guidance, workload protection, and wellbeing support impact confidence, stress, and perceived preparedness for progression. Capturing trainee experience in this way provides an important foundation for reflective review of training delivery and trainee support.

The Mental Capacity Act 2005 provides a statutory framework to empower and protect individuals who may lack the capacity to make specific decisions for themselves. Capacity assessments are essential to safeguarding the autonomy and rights of individuals, especially those with cognitive impairments, learning disabilities, or mental illness.

The rationale behind this audit is to ensure that capacity assessments are not only being completed when required, but that they are being carried out and clearly recorded in accordance with Mersey Care MC01 policy and the principles of the Mental Capacity Act (2005).

By identifying whether the assessment was done, and whether all steps were clearly recorded, this audit aims to promote compliance, improve clinical quality, and uphold patient rights across Mid Mersey Care LD services.

This is a retrospective audit.

The inclusion criteria:

1. New referral to the team.

2. Adults aged 16 years or older lacking capacity / under the care of Intellectual Disabilities Community Mental Health team – Mid Mersey Care NHS Foundation Trust.

3. Cases where a significant decision was required (consent to treatment).

The exclusion criteria:

1. Not a new referral to the team.

2. Adults aged 16 years or older having capacity / NOT under the care of Intellectual Disabilities Community Mental Health team – Mid Mersey Care NHS Foundation Trust.

3. Cases where a significant decision was NOT required (consent to treatment).

The sample identified from an In-House Assessment Database and the data will be extracted from the electronic system (RIO).

Sample of 21 patient was identified.

Of the 21 cases audited, 18 had an assessment completed and 3 did not. Compliance level of 86%.

Of the 21 cases audited, 10 had clearly documented steps, 8 did not and 3 were N/A. Compliance level of 56%.

While the Capacity Assessment was carried out and completed in the majority of cases. The clear documentation of all steps was only recorded in around half of them.

There is still a room for improvement by raising awareness during multidisciplinary team meeting and increase the completion of the existing capacity form on the electronic system and/or documentation of all capacity assessment steps during the patient review.

Self-injurious behaviour (SIB) is a substantial and challenging behavioural issue among individuals with intellectual disabilities (ID), resulting in heightened morbidity, caregiver stress, and healthcare consumption. Data from low- and middle-income nations, such as Pakistan, continue to be scarce,with intellectual disabilities admitted to a tertiary care psychiatric institution in Faisalabad, Pakistan.Aims were to as certain the prevalence, trends and correlating factors of self-injurious conduct in patients.

This cross-sectional study was performed in the Department of Psychiatry and Behavioural Sciences, Allied Hospital II, Faisalabad, over a duration of six months. A total of 96 patients, aged 8 years and older, diagnosed with intellectual disability under DSM–5 criteria, were recruited by non-probability consecutive sampling. Demographic data, severity of intellectual disability, existence and kind of self-injurious behaviour (SIB), severity, triggers, and interventions were gathered using a structured proforma. We used SPSS version 27 to do the statistical analysis. We used chi-square tests to look at associations, and a p-value of 0.05 or less was considered statistically significant.

35.4%of the subjects engaged in self-injurious conduct. All instances of self-injurious behaviour (SIB) were seen among the 8–20-year age demographic, with a notable prevalence in men (91.2%). SIB was not present in people with mild intellectual disability but had a significant correlation with moderate, severe, and profound disability (p < 0.001). The most common types of SIB were beating oneself, head-banging, and biting oneself. Sensory overload, difficulty with communicating, and behaviour that seeks attention were some of the most common triggers. Despite the clinical burden, most of the people who were impacted did not get structured behavioural or pharmaceutical help.

Self-injurious behaviour is a prevalent and clinically relevant issue among younger individuals with moderate to severe intellectual disability. To have better results for this vulnerable group, it is important to find them early, train caregivers, and make mental health treatments stronger.

There is a high prevalence of concentration and cognitive functioning problems in people with depression. Research evidence indicates that transcranial direct current stimulation (tDCS) can improve cognitive functioning, and an aspect of cognitive functioning is the ability to concentrate. Flow FL-100 is a tDCS device self-administered at home.

The aim was to investigate the impact of 1, 2, 3, 6 and 10 weeks of Flow Neuroscience AB FL-100 tDCS use on self-reported concentration problems in people with depression, using the Montgomery–Åsberg Depression Rating Scale Self (MADRS-S) concentration problem question.

A retrospective analysis of Montgomery–Åsberg Depression Rating Scale (MADRS-S) self-report data collected between 2020 and 2024.

Out of 20,197 tDCS users with self-reported depression at baseline, 10,888 had concentration problems (53.9%). Among those who adhered to the tDCS protocol, theproportion who moved from having concentration problems to not having them was 29.3% at one week, 37% at two weeks, 45.2% at three weeks, 54.7% at six weeks, and 57.4% at ten weeks. Concentration problems strongly correlate with depression.

The results show that tDCS can reduce concentration problems in those with self-reported depression. Some people experience concentration problems despite addressing lifestyle and environmental factors that can negatively affect concentration. There are negative side effects of some methods of improving concentration, for example, the use of stimulants. tDCS could be a valuable alternative approach to reducing concentration problems in people experiencing depression. Concentration problems are symptoms of other mental illness diagnosis, for example, schizophrenia and tDCS could be used. Appropriately designed and powered randomised controlled trials (RCTs) are warranted to investigate the impact of tDCS on cognitive functioning and concentration.

Patients assessed by liaison psychiatry frequently have mental health conditions or are prescribed medications that may impair fitness to drive. General Medical Council (GMC) and Driver and Vehicle Licensing Agency (DVLA) guidance require clinicians to assess driving status, provide appropriate advice, and document this clearly. Local observations suggested that this aspect of assessment was frequently omitted, posing patient safety and medico-legal risks.

Aims were to improve the identification, documentation, and communication of driving status and DVLA advice in liaison psychiatry assessments within an acute hospital setting.

A baseline audit of 20 consecutive liaison psychiatry assessments was conducted to assess documentation of driving status and DVLA advice when indicated. A series of Plan–Do–Study–Act (PDSA) cycles were implemented. Interventions included the addition of a “Driving Status and DVLA Advice” prompt to the assessment template, regular verbal and email reminders to the multidisciplinary team, sharing real-case learning points, and displaying visual prompts within the team office. Weekly re-audits were undertaken to assess change over time.

At baseline, driving status was documented in 5% of assessments, and no patients received documented DVLA advice when indicated. Following sequential PDSA cycles, documentation of driving status improved progressively to 50% by week three. Provision of DVLA advice also increased, reaching 13.6% of assessments by week three. Improvements were most marked following repeated reinforcement strategies alongside system-level prompts. Persistent gaps were identified in consistently providing DVLA advice once drivingstatus was confirmed.

Simple, low-cost system and behavioural interventions led to meaningful improvements in documenting driving status and DVLA advice in liaison psychiatry assessments. Sustained improvement required repeated reinforcement and team engagement. Embedding prompts into assessment templates and incorporating DVLA guidance into staff induction are key to long-term sustainability.

MHCAS is a new NHS service that manages patients with an acute mental health crisis, ensuring they are turned around quickly and safely, relieving pressure on hospital wards.

A prolonged patient stay in MHCAS indicates high-risk patients who cannot be discharged safely within 72 hours. Identifying factors associated with delayed discharge can help us characterise high-risk patients and inform safe and efficient patient management strategies. This information can be useful for future MHCAS services across the NHS, aiding in service development and resource allocation.

We aim to identify the key reasons for delayed patient discharge (>72 hours) in MHCAS.

A retrospective data analysis of 96 admissions lasting >72 hours between July and September 2025 was conducted. The main factors examined were discharge destination, borough of origin, diagnoses, and suicidality. The cumulative hours were analysed by discharge destinations as well as the diagnoses based on ICD-10 and averaged per case.

For discharge location, 19.79% were discharged to temporary residence, contributing 141.10h per patient; 42.71% to wards, contributing 139.53h per patient; and 35.42% to their usual place of residence, contributing 120.87h per patient in MHCAS.

For diagnoses, patients with Schizophrenia Spectrum and Psychotic Disorders contributed the longest average stay per admission (138.84h), followed by Trauma and Stress related disorders (133.33h) and Bipolar Spectrum Disorders (128.83h). Schizophrenia Spectrum and Psychotic Disorders were the most common diagnoses (23%), followed by Depressive Disorders (20%) and Anxiety and Somatoform Disorders (12%).

The majority of patients came from CNWL boroughs (88.37%), and Westminster was the biggest contributing borough (30%).

Most patients with prolonged stays were admitted via emergency pathways, primarily A&E or the Home Treatment Team (83%), indicating that these admissions largely reflect high-risk presentations.

Regarding suicidality, 39 patients reported suicidal ideation, 41 did not, and 16 cases were undocumented. Suicidal patients spent 8.52 hours more in MHCAS on average.

Prolonged stays in MHCAS are influenced by multiple factors. Ward admissions and temporary accommodation contributed significantly, showing that delays in beds availability or social services played a key role. Patients with more severe diagnoses, such as schizophrenia, are high-risk, therefore requiring more prolonged care. Information transfer from non-CNWL boroughs could also have resulted in delays in care planning.

Contrary to expectations, suicidal ideation was only associated with a modest increase in length of stay, indicating suicidality alone is not a primary driver.

Qualified doctors are required to manage complexity and uncertainty. This can arise with the co-occurrence of mental and physical health conditions in psychiatric settings. In response, this exploratory study was conducted to generate insights into how medical students respond to co-occurring mental and physical health problems in simulated psychiatric settings. It is hoped this can provide insights into how medical educators can better prepare the next generation of doctors for recognising and managing the complexity and uncertainty of encountering co-occurring mental and physical health problems in their clinical practice and increase awareness of the risk of diagnostic overshadowing, especially in the psychiatric patient population.

This study also seeks, through grounded thematic analysis, to gather and analyse the nuanced views of medical students at two diverse institutions on a simulation intervention; medical students’ nuanced views have historically been overlooked in medical educational interventions and are useful for medical educators to guide their practice.

Fourth-year Birmingham and Aston medical students undertake a psychiatric simulation session. This high-fidelity session, which students undertake in pairs with the others observing, is on a simulated inpatient psychiatric ward with an actor as the simulated patient and facilitators as a psychiatric nurse and as senior support via telephone. One of the cases contained co-occurring mental and physical health problems. The researcher conducted the debrief of this case using a supplementary topic guide. These debriefs were recorded, transcribed and anonymised. A grounded thematic analysis of the resultant transcripts was then conducted.

Twelve debriefs were conducted involving 110 students. Grounded thematic analysis of transcripts resulted in three overriding themes: Using previous simulation experience, Recognising and managing feelings, and View of Psychiatry.

The findings of this thematic analysis inform medical educators on how students respond and explain their responses to managing co-occurring physical and mental health problems in simulated psychiatric settings. The resultant discussion of these themes explores potential explanations for these responses, providing insights into how medical educators, especially within psychiatry, could better ensure that graduating medical students can manage complexity and uncertainty on qualification and increase awareness of the risk of diagnostic overshadowing, especially in the psychiatric patient population.

Catatonia is a neuropsychiatric condition that is frequently under-recognised in children and adolescents and may co-occur with a range of psychiatric and neurodevelopmental disorders, including autism spectrum disorder (ASD). Diagnosis is often challenging due to symptom overlap with neurological and psychotic conditions. In individuals with ASD, catatonia may be precipitated or exacerbated by environmental stressors and disruption to established routines. This case report aims to describe the presentation, diagnostic process, treatment, and longer-term management of catatonia in an adolescent with ASD, with particular emphasis on pharmacological treatment, electroconvulsive therapy (ECT), and psycho-ecological interventions.

We report the case of a 16-year-old female who presented with a five-month history of mutism, immobility, unsteady gait, and markedly reduced oral intake, resulting in significant weight loss, nasogastric feeding, and hospital admission. Extensive investigations, including CT and MRI brain imaging, EEG, autoimmune encephalitis screening, metabolic testing, chromosomal microarray, and whole genome sequencing, were unremarkable. A lorazepam challenge produced a marginally positive reaction, thus supporting the catatonia diagnosis. The lorazepam dosage was escalated to 12 mg per day, which yielded partial improvement, though this was limited by sedation. Due to the inadequate response, electroconvulsive therapy (ECT) was commenced.

The first six ECT sessions did not produce any improvement; however, from the seventh session onwards, a substantial and sustained recovery was noted, marked by the resumption of speech, mobility, and functional autonomy. Rehabilitation strategies incorporated structured physical activity and social engagement. Despite the initial progress, symptoms later recurred, including psychomotor retardation and confusion. Fluoxetine and quetiapine were subsequently introduced based on collateral history, resulting in partial improvement. A subsequent neurodevelopmental assessment confirmed a diagnosis of ASD, along with learning difficulties.

Following discharge, a relapse occurred several months later, which was linked to stopping lorazepam and less social interaction. When the patient was readmitted, a psycho-ecological approach was emphasised. This approach focused on organising the environment, managing sensory input, establishing predictable schedules, and helping the patient reintegrate socially. All psychotropic medications were stopped due to low efficacy, except lorazepam. Gradual improvement was seen, along with increased involvement in psychosocial activities.

This case highlights the importance of catatonia as a significant but treatable condition in adolescents with ASD. Although lorazepam and ECT were effective for quickly controlling symptoms, lasting recovery depended on psycho-ecological approach with consistent environment, structured routines, family involvement, and ongoing social interaction.

The Independent Review of the Mental Health Act (MHA) (2018) by Sir Simon Wessely and subsequent MHA White Paper (2021) recommended promoting patient choice, autonomy and least restrictive practice and suggested quality improvement (QI) programme. NHS England led National MHA QI Programme (July 2024– March 2025) across 52 trusts including Saunders ward, Cygnet Stevenage. The aim was to enhance patients’ reported sense of autonomy, strengthen patient voice, and improve relational engagement with staff by March 2025 through co-production and implementation of an individualised “My Story” booklet.

The project was supported by an NHSE QI Coach and Cygnet Executives. We used an evidence-based change approach to identify a local quality gap and targeted improvement ideas. Baseline information was gathered through equity huddle discussions, apre-QI patient questionnaire, and the Fearless Organisation survey to explore staff psychological safety. The key areas of inequity identified: underrepresentation of patient’s views, lack of support to identify strengths, and communication gaps with the staff especially non-permanent staff.

To address these, PDSA cycle was used to co-produce a patient-led, individualised “My Story” booklet. Five patients participated in the pilot, creating booklets describing their interests, personal journeys and future goals. The booklets were confidentially stored and made accessible to all staff to support personalised and relationally informed interactions. By making patients’ identities and preferences visible, the intervention was intended to enable more personalised interactions, thereby supporting relational engagement and patient autonomy.

Following implementation of “My Story” booklet, patients reported improved relational engagement with staff during routine day-to-day interactions. Post-intervention questionnaires demonstrated improvement across targeted domains, ability to express preferences and interests to staff (60%). Qualitative feedback indicated that staff, including agency staff, initiated more personalised conversations, such as enquiring about patients’ activities or future goals. Given the small pilot sample (n=5) limited statistical significance, patient testimonies reflected increased confidence in engaging with staff and a desire for continued involvement and further development of their “My Story” booklet.

This co-produced QI intervention supported aims of MHA reform by enhancing patient autonomy and relational engagement within a low secure setting. By making patients’ identities and preferences visible to all staff, the intervention facilitated more personalisedand meaningful interactions. As a small-scale pilot, the project demonstrates potential value of simple, patient-led tools in strengthening relational security and supporting less restrictive, person-centred care. Future work will focus on embedding the intervention into routine practice and exploring its applicability across other secure inpatient settings.