Our mental health placement has a longitudinal design and students spend one day per week in psychiatry throughout their academic year, attending clinical placement and academic days on alternate weeks. Academic days include a small group tutorial, Balint group and self-directed learning, during which students are expected to complete a ‘virtual patient’ (VP) e-learning module. VPs align with the topic of their small group tutorial and are intended to facilitate their learning. Despite this, only a minority of students complete them. Our aim is to investigate and iteratively design interventions to improve uptake of learning.

Using an iterative process, we explored potential reasons for low student uptake by reviewing routine feedback from faculty and students; most tutors and students were unaware of the e-learning. We hypothesised that increased faculty awareness and promotion of VP could lead to an increase in student access numbers. The intervention was therefore of improved communication amongst faculty by fortnightly newsletter emails which include the topic of the academic day, explanation around what is expected of students with the website link to the VP, and other useful resources tutors may wish to use. Emails are sent by medical education administrators in the week before the academic day to all tutors. Access logs for the previous (2022–2023) and current (2023–2024) academic year were obtained so comparison could be made pre- and post-intervention.

Results are available for 4 modules; thus far we are yet to see significant differences in engagement. There was a technical glitch for one module and for the other modules the difference in student access has been minimal (<5%). We also have qualitative feedback from 5/28 tutors. One was confused and thought they were being asked to do additional work, one requested for information about the VP without realising it was included in the newsletter email, and three said they found it helpful.

Fortnightly email newsletters is a simple and cost-effective way to possibly improve communication within faculty. It is likely difficult to promote student engagement with activities that their tutor is unaware of or perceives as invaluable. However there remain real challenges of using email as a communication tool for busy clinicians and is unlikely to make a difference as a stand-alone intervention. For future development we plan to include medical students and clinical supervisors as recipients in the mailing-list and spend time on a faculty development day to further explore this issue.

Rapid tranquillisation – the parenteral administration of a sedating psychotropic – is frequently utilised to manage acute behavioural disturbances. Each mental health trust in England utilises independent guidelines for rapid tranquillisation, which vary geographically in both recommendations for therapeutic agents, as well as the format in which this information presented. Audits have identified that there is currently poor adherence to rapid tranquillisation protocol guidelines; this may be due to a lack of guideline clarity allowing for personal interpretation. This service evaluation aims to determine the clarity and uniformity of protocols outlined in mental health trust guidelines, in addition to analysing the outcomes of guideline testing to identify if there is consistency between policies, or whether outcomes varied depending on the trust guidelines used.

Five reviewers (of differing positions throughout clinical training) utilised 52 guidelines from each mental health trust in England, as well as Maudsley and NICE. These were assessed using the same fictional scenario, which simulated a common presentation in which the use of rapid tranquillisation is required. Reviewers deduced the most appropriate therapeutic agent according to the guideline, rated the clarity of each guideline and were invited to leave comments highlighting the guideline's useability.

Seven different management plans were generated by the majority of respondents from the 52 guidelines. Lorazepam was the most frequently selected therapeutic agent. Guidelines with better subjective ratings of clarity had more agreement between reviewers, but full agreement between reviewers was only present for 10 out of 52 guidelines. For 11 guidelines, consensual agreement between reviewers was not reached. Qualitative analysis of comments identified the inclusion of past medical history, drug history and flow charts as positive sub-themes. Redundant language, contradictions and the suggestion to seek senior intervention before trialling a second agent were viewed negatively. Many guidelines did not sufficiently emphasise the need for performing an ECG before administering therapeutic agents, such as haloperidol, which may lead to potentially fatal arrhythmias.

There is no national consensus on the most appropriate rapid tranquillisation agents, with the available evidence being interpreted variously by different trusts and organisations. Poor guideline comprehensibility impacts clinician adherence and allows for personal preference to influence choice of drug. Clear guidelines utilising flow charts to succinctly outline relevant doses and absolute contraindications were viewed favourably by reviewers. The findings of this project highlights to relevant stakeholders the attributes that should be implemented when improving guidelines for the future.

To understand the prescribing habits and trends of clinicians in a large ADHD clinic and the medication journey of patients from point of diagnosis to the point of agreeing a shared care plan with primary care services.

This was a non-interventional retrospective study collecting information from anonymised electronic patient and prescription records. Following approval by the Clinical Governance body of the practice, in June 2023, all patients with a SCP between the years 2019 and 2021 were identified. Data collected included patient demographics, date that medication was started, discontinued, or switched along with associated reasons. Additionally, to better understand the time taken to gain publication of a SCP, the amount of clinician-patient facing time was recorded, including the number of brief follow-up appointments, number of repeat prescriptions and number of clinician to patient emails. Patient data was fully anonymised and any identifiable data removed.

All but one patient was started on a stimulant medication immediately following diagnosis, in line with national prescribing guidance. Atomoxetine was the medication of choice for a patient with a previous history of stimulant intolerance. 74% (n = 95) of patients were started on lisdexamfetamine, 20% (n = 25) were started on methylphenidate long-acting formulations and five patients on short-acting methylphenidate agent.

Of the 95 patients initiated on lisdexamfetamine, 78 (82.1%) were continued on lisdexamfetamine until the point of publication of their Shared Care Policy (SCP), nine (9.5%) patients switched medication, 10 patients initiated additional fast-acting dexamfetamine tablets and two had a second agent added to their therapy (atomoxetine n = 1, methylphenidate n = 1).

Of 25 patients initiated on methylphenidate long acting, 18 (72%) continued this medication at the point of publication of SCP. Of 25 patients initiated on methylphenidate long acting, seven (28%) patients switched medication and two patients were initiated on an additional fast acting methylphenidate.

To successfully stabilise and publish 134 patients on a SCP, 404 brief follow up appointments of 15-minute duration were utilised, which totals 6060 minutes of patient facing time. Of 134 patients, most n = 41 (30.6%) had 2 brief follow-up appointments; 32 (23.9%) had 3 brief follow up appointments and 22 (16.4%) had 4 appointments. Two patients did not attend a follow up appointment, and one patient had 11 brief follow up appointments.

Stimulant medications were typically used as first line treatment however, of these 74% were started on lisdexamfetamine while only 20% were initiated on long acting methylphenidate. Those started on lisdexamfetamine were more likely to continue on this medication to the point shared care agreement than those started on methylphenidate, 28% of whom switched to an alternative, for a variety of reasons. Mean time to reading a shared care agreement was longer for those initiated on methylphenidate long acting compared to lisdexamfetamine.

The data show that for most patients the journey from initiation of a stimulant medication to a shared care agreement was a straightforward one, with the majority having either two or three follow up appointments.

More research is needed to better understand the apparent differences in pathway for those commenced on lisdexamfetamine and long acting methylphenidate.

This clinical audit aimed to assess if the recording of patients seen for their diagnostic appointments in memory clinic measures up to the minimum standards required in the delivery of dementia services. This standard mandated primarily that a minimum body of key information must be promptly recorded by clinicians, in patient electronic records within 24 hours, as stipulated by Trust and NICE guidelines.

The first cycle was conducted from 16 October 2022 to 10 February 2023. In this cycle random sampling was used to select 25 patients on the caseloads of the mental health services for older people. Before the start of the second phase all diagnosing clinicians within the team were informed about the project and the expected improvements against which compliance would be audited. The second phase was conducted between 10 February 2023 to 31 March 2023 and another 25 patients on the caseloads were obtained via random sampling for the second cycle. Inclusion criteria for both phases were patients who had received a diagnostic assessment in these periods.

In the first set of records, the minimum body of information was recorded in 90–100% of cases according to the team's recommended standards namely diagnostic information, prognostic information, treatment plans, post-diagnostic contact plans and documentations being made within 24hrs of consultation. In the Set 2 the minimum body of information was recorded in 95–100% records studied. That is, diagnosis, treatment, medication treatment plans (prescription plans), and post-diagnostic contact plans were covered in the diagnostic sessions. In particular, case note documentations were made within 24 hours in all but one of the records applicable.

Given that a diagnosis of dementia can be life-changing, not discussing prognostic information would not prepare patients and carers adequately with information on how to live well with dementia following their diagnosis. This could potentially lead to poor adjustment to the condition and anxiety for some. At a trust-wide level, this means there is still room for improvement for the trust as regards dementia care ideals recommended by NICE.

Adapting to academic and social demands may be challenging for university students. Healthcare students are thought to be at high risk of burnout and Major Depressive Disorder (MDD) due to the demands of their training and emotional toll of caring for patients. This risk extends well into physician years, suggesting the persistence of an abnormal psychological state developed during training years. We aimed to investigate the prevalence and severity of depressive symptoms, burnout, and resilience in healthcare students, examine their correlation with salivary cortisol levels, and assess how these factors change during examination periods.

This longitudinal study investigated the mental health and salivary cortisol levels of medical, dental, or health science students in the UAE at two distinct periods, at the start of the academic semester, and within one week of the examination period. A total of 147 students (51% females) were included, and their demographics and education variables, including cumulative GPA (cGPA), were assessed. Depression, resilience, and burnout scores were measured using the Patient Health Questionnaire-9, Nicholson-McBride Resilience questionnaire, and Maslach Burnout Inventory-Student-Survey, respectively. Participants who met the criteria for MDD were identified. Time-dependent cortisol levels were modelled using functional data analysis and standardised cortisol levels were calculated. Data analysis was done using mixed effect models in R 4.1.2.

Among participants, 12.2% screened positive for MDD at the beginning of the semester, increasing to 16.6% during the examination period. Depression scores were higher during the examination period (p = 0.011). Female gender was significantly associated with higher levels of depression (median difference = 3.00; p < 0.001) and burnout but lower levels of resilience (mean difference = 3.27; p < 0.001). cGPA below 75% (p = 0.009) and history of mental illness (p = 0.015) were associated with increased levels of depression. High cortisol responders (z-value > 1) developed higher depression scores (p = 0.033) compared with low cortisol responders (z-value < −1). Participants with higher resilience were less likely to develop depression and burnout (p < 0.003).

This study shows relatively high levels of depression among healthcare students in the UAE, particularly in females, students with history of mental illness, students with low cGPA, and students with high cortisol levels. Efforts to promote culturally appropriate resilience skills need to be developed to reduce distress and depression in this population.

Menopausal symptoms often go unrecognised in individuals with intellectual disability (ID). There is growing societal awareness of the impact of menopause on mental health, yet this has not been replicated in the ID population. In light of this, we wanted to establish the current levels of knowledge, confidence and skills of staff working in a specialist community intellectual disability service (CIDS). The findings from the survey may help identify ways of improving awareness of menopausal symptoms with individuals with ID.

We performed a cross sectional survey of staff views and practice in relation to considering and discussing menopausal symptoms with individuals with ID. The survey was anonymous, and conducted on Microsoft Forms. A mixture of quantitative and qualitative data was captured. A QR code linking to the survey was disseminated to the whole team (60 staff) via email and in-person staff meetings.

There was 50% (30/60) responses to the staff survey. The majority of respondents worked in either health (16/30) or social care (12/30). Two thirds of respondents either agreed or strongly agreed (20/30) that discussing menopausal symptoms was part of their role. 57% of respondents (17/30) felt confident discussing menopausal symptoms with service users, while 20% (6/30) felt neutral and 23% did not feel confident. 90% (27/30) of respondents either agreed or strongly agreed that they would benefit from teaching and training in the effects of menopause in our service users. Thematic analysis of the free text responses revealed that staff wanted to understand treatments available for menopause as well as improved easy read material explaining menopausal symptoms to individuals with ID.

Our survey revealed a spectrum of confidence levels in discussing menopausal symptoms with service users, and a large appetite for further training and resources to aid these conversations. In light of the results from this survey, a Quality Improvement (QI) project has been initiated. Once QI change ideas have been tested, a repeat survey will be completed to compare staff views and confidence in this area and in this way measure the effectiveness of those changes.

Obesity and malnutrition have increased prevalence in individuals with mental disorder. Patients with severe mental illness are at increased likelihood of developing weight-related comorbidities, particularly type II diabetes mellitus.

Admission to the psychiatric ward provides an opportunity to address, not only the patient's mental health issues, but also any physical health issues.

The aim of this re-audit was to assess whether patients were managed in compliance with the Mersey Care NHS Foundation Trust Nutritional Screening Protocol on eight general adult inpatient wards across the Trust.

Data from the first five admissions (starting from 1st April 2023) to eight general adult inpatient wards in the Trust was collected and assessed.

A total of 40 inpatient admissions were identified. The results were collated and compared to the standard – Mersey Care's Nutritional and Hydration Policy.

36 patients (90%) had a Malnutrition Universal Scoring Tool (MUST) completed within 72 hours of admission. Of the four patients (10%) who didn't have a MUST score within 72 hours of admission, three were completed after 72 hours.

46% of patients had a MUST score of 0 (low risk), 31% a MUST score of 0 (high risk obesity), 10% a MUST score 1 (medium risk) and 13% a MUST score of 2 or above (high risk).

Of the five patients with a MUST score of 2 or above (high risk), three (60%) were compliant with all elements of the Nutrition Screening Tool Care Plan. Of the 12 patients with a MUST score of 0 (high risk obesity), seven (58%) were compliant with all elements. Of the four patients with a MUST score of 1 (medium risk), all were compliant with all elements.

Overall, 31 (79%) patients had every element of the Nutrition Screening Tool Care Plan completed.

There was significant assurance of systems and processes in place and working well to ensure compliance, with only minor issues of concern identified.

Whilst the MUST score within the first 72 hours following admission had been completed in most inpatients, referrals to the dietician had not been done consistently in line with Trust policy. This is an area that requires addressing. Some training may need to be delivered to underline the importance of adhering to Trust policies.

An action plan to circulate the audit findings to all general adult inpatient wards across the Trust and re-auditing with a larger sample size across the Trust has been recommended.

Rosewood Mother and Baby Unit (MBU) aims to provide inpatient psychiatric care to women with severe mental illness in Kent, Surrey & Sussex (KSS) in UK. Data from admissions during 2022 demonstrated discernible inequalities in admissions. A quality improvement project was undertaken to improve equity of access for admission of women with severe mental illness to Rosewood MBU, specifically, those under 18 years old, black and minority ethnicities, and across counties in KSS. The aim was to improve quality of care and patient experience for vulnerable groups across all ethnicities, not limited to their location or age.

Baseline data of MBU admissions in 2022 was collated, including demographics, age, origin of referrals, diagnosis, ethnicity, length of stay, parity, previous MBU admissions, safeguarding concerns.

The project group, inclusive of an expert by lived experience, presented the data at various network meetings and stakeholder events that helped to share information and gather experiences on barriers to referrals to Rosewood MBU, barriers for women of black and ethnic minority background accessing MBU, differences in service provisions for under-18-year-old women with perinatal mental illness in various counties.

Data for women discharged from Rosewood MBU in 2023 was collated and compared against the findings from the previous year.

In the first half of 2022, there were 20% more women admitted from Kent than Surrey and Sussex combined. This improved following interventions with a better spread of patients across counties in July–December 2023 and a 11% rise in admissions of women from Surrey and Sussex compared with Kent.

There was a greater number of ethnicities and a greater number of women from different ethnicities admitted to Rosewood MBU when comparing 2022 with 2023, and specifically across each of the 6-monthly periods. In January–June 2022, 3 women of non-White British ethnicity were admitted, compared with a 400% increase in July–December 2023 with 12 women. Overall there was 260% increase in admissions of women of Black, Asian, Mixed, White-Other ethnicity in 2023 compared with 2022. Also, in 2023, there were 2 referrals and 1 admission of a women under the age of 18, compared with no referrals in 2022.

Overall, the project demonstrates the positive impact of streamlining referral pathway, fostering collaborative working and integrating expertise from diverse professionals including experts by experience that can reduce service inequalities and improve patient outcomes.

Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) has 28 Promises as part of its Strategy.

Promise 16 is to: Focus on collating, assessing and comparing the outcomes that our services deliver, which matter to local people, and investing in improving those outcomes year on year.

This audit in November 2023 looked at the practice of using outcome measures for CAMHS patients in order to highlight areas of development for the service to work toward achieving the promise.

We wanted to understand if young people were having outcome measures completed and if so, when, what and how often. We achieved this by using a dip sample of five patients each across the three different localities (Rotherham, Doncaster and Scunthorpe).

A report was generated to include all patients discharged from CAMHS in the preceding three months to September 2023. Young people who had been with the service less than six months were excluded from the audit. Five patients were chosen randomly from each locality and their electronic patient record on System One was studied.

Information in the patient records was compared against the audit standards and recorded in Excel so the data could be analysed.

The results showed that 11 of 15 young people had an outcome measure completed at some point during their episode of care. All five young people in Scunthorpe had an outcome measure recorded in their clinical records however this tended to only happen at the very start, meaning there was no basis for comparison. Four out of five patients in Doncaster had outcome measures in the clinical record and these were undertaken throughout the episodes of care. In Rotherham, two of five young people had outcome measures recorded in the clinical records.

The most frequently used outcome measure was the RCADS but the SDQ was also used.

There is work to be done to ensure the use of outcome measures becomes routine, and also to standardise both the type and frequency of use. The Trust is aiming to increase their use by utilising SystmOne's capabilities to interface with service user mobile devices to send out outcome measures to patients. There is also a plan to inform staff within the service about the expected use of outcome measures. This audit will be repeated in 2024 to see if the Trust are moving closer to delivering their promise.

Dementia is a debilitating disease with multiple potential causes, no cure and rising incidence. New studies suggest that gut bacteria not only aid in the digestion of bowel products but also other bodily functions such as immune systems and relaying messages to the brain. This review aims to examine the potential link between gut microbiota and dementia by performing a systematic review to assess whether gut bacteria play a role in the development of dementia.

The systematic review was designed and conducted according to PRISMA guidelines. A modified PICO model was used to perform a literature search in Medline, CINAHL PLUS and APA PsychInfo databases. The search identified 401 articles, 49 of which met the predefined inclusion criteria. Twenty-one final studies were included in the results; 14 cross-sectional, two cohort, three case-control, one randomised control study and one case report. The reviewer extracted and analysed data from these studies for quality using the AXIS and CASP tools. A narrative synthesis of the results was performed due to the heterogeneity of the data.

Individuals with dementia have lower microbial diversity than healthy controls, including changes in specific bacterial taxa, pro-inflammatory and anti-inflammatory balance. The results of the review were subdivided into four identified themes which helped further identify that microbial metabolites, diet and gastrointestinal disease can also influence the composition of gut microbiomes and, therefore, the development of cognitive impairment and dementia.

This systematic review found a link between gut bacteria, bacterial metabolites, gastrointestinal health, diet, and dementia. Although the studies were mostly observational, they suggest that gut microbiota can affect brain function through dysbiosis, which can lead to neuroinflammation and dementia. More research is needed to confirm a causal relationship, but targeting the gut microbiota could be a potential therapy for MCI and AD. Innovative strategies may help combat the growing challenge of dementia.

Current guidelines provide for short-term relief of symptoms using benzodiazepines, but patients, including those with complex emotional disorders often seek these medicines for longer. The current audit aims to review clinical practice in respect of benzodiazepine prescribing against national and local guidelines.

Retrospective analysis of all benzodiazepines prescriptions during the study period (March–December 2021 and January–December 2023). Data was assessed against National Institute for Health and Care Excellence, British National Formulary and local Trust guidelines using a proforma and spreadsheet. The study authors separately reviewed prescribing for separate years of the study.

In the 2021 subsample, (9/15) 60% of patients received a benzodiazepine for less than one month. All of these patients had a psychotic disorder diagnosis. 6/15 (40%) received a benzodiazepine for more than 4 weeks, with an average duration of 5 months. Of these, only one patient had a diagnosis of a Personality Disorder. 7 patients in total (46%) were offered psychological interventions. Patients receiving benzodiazepines for more than 4 weeks were offered a tailored management plan to address their use.

In the 2023 re-audit, 10/51 (20%) patients received a benzodiazepine for greater than one month. The common indications were agitation, anxiety and crisis management. The commonest diagnoses were Personality Disorder, Post-Traumatic Stress Disorder and Schizoaffective Disorder. 4/10 (40%) patients with a Personality Disorder were prescribed a benzodiazepine for more than 4 weeks. The average duration of benzodiazepine prescribing was 11 weeks.

Although benzodiazepines continued to be commonly used for a range of conditions, the proportion of patients not compliant with the one month, recommended duration for prescribing was reduced by half. There was a general reduction in the overall duration of prescribing but patients with a Personality Disorder continued to receive benzodiazepines for longer than recommended.

Heat exposure can negatively impact mental health. Evidence for the effect of temperature on mood disorders is inconsistent. Current studies exploring the link between temperature and mood disorders are limited by poor temporal and geographical resolution. We aimed to use ecological momentary assessment (EMA) to investigate the effect of real-time temperature on depressive and manic symptoms. We hypothesised higher temperatures would be associated with increased depressive and manic symptoms.

We used EMA data from the digital platform and smartphone app juli to investigate the effect of real-time mean and maximum ambient temperature on depressive and manic symptoms in adults with depression and bipolar disorder. Depressive and manic symptoms were assessed using the Patient Health Questionnaire-8 and the Altman Self Rating Mania score, respectively. Time- and location-specific temperature data were collected from participants’ smartphone geolocation on a 5-by-5 km resolution grid. We analysed data using negative binomial mixed-effects regression models, controlled for demographic and weather variables, and stratified by season.

We analysed data from 4,000 participants with depressive symptoms and 2,132 with manic symptoms, between July 2021 and March 2023. We found that each 1°C increase in mean daily temperature in the preceding two weeks was associated with a 0.2% reduction in depressive symptom scores (IRR 0.998, 95%CI 0.997–0.999). This association was most pronounced in the spring (IRR 0.995, 95%CI 0.992–0.999). For manic symptoms, we found that each 1°C increase in mean temperature in the preceding two weeks was associated with a 0.4% increase in manic symptom scores (IRR 1.004, 95%CI 1.001–1.007), with the strongest association observed in the autumn (IRR 1.011, 95%CI 1.002–1.020). Associations between maximum temperature and depressive and manic symptoms followed a similar pattern.

We found evidence that higher temperatures were associated with decreased depressive symptoms and increased manic symptoms, indicating a complex relationship between temperature and mood disorder symptoms. With globally rising temperatures due to climate change, there is a need to understand the impact of heat on mental health symptoms to provide targeted support. This study demonstrates the potential for using novel data sources and EMA methods to inform our understanding of the link between climate and mental health, although there is a need for improved data collection to realise the potential of these methods. Clinically, our findings highlight opportunities for risk stratification and targeted interventions based on local temperature patterns.

To evaluate the adherence to shared care guidelines for ADHD patients by assessing if their Blood Pressure, Pulse Rate, and Weight have been monitored at least twice within the last year by their GP, as recommended by NICE guidelines.

Following initiation and stabilization on an ADHD medication, shared care with the GP is initiated whereby the GP is responsible for prescribing the medication, and monitoring physical observations every 6 months.

Data Collection:

1. a. Collate the list of patients that were due for annual structured review in August and September 2023 from the team's shared drive.

2. b. Randomly select 50 patients from this list.

Inclusion criteria:

1. 1. Patient must have been on ADHD medication in the past 12 months.

Data Assessment:

1. a. Access the GP records (Patient Practice Management system) for the selected 50 patients.

2. b. Review the patient records for each of these 50 patients to identify when Blood Pressure, Pulse Rate, and Weight measurements were recorded within the last 12 months.

3. c. Record the date and results of the Blood Pressure, Pulse Rate, and Weight measurements for each patient.

4. d. Determine if each patient had these measurements done at least twice within the last year as per NICE guidelines.

5. e. Calculate the percentage of patients who met this guideline.

Sample size: 22 patients patients met the inclusion criteria.

• • Blood pressure checked within the last 6 months – 22/22 (100%)

  Blood pressure checked within the last 1 year – 19/22 (86%)

• • Pulse rate checked within the last 6 months – 20/22 (90%)

  Pulse rate checked within the last 1 year – 18/22 (81%)

• • Weight checked within the last 6 months – 21/22 (95%)

  Weight checked within the last 1 year – 20/22 (90%)

8 out of 22 had a “significant” change in their BP reading.

This significance is in keeping with NICE Guidelines that is, an increase of 2–4 mmHg for patients on ADHD medication, but this is generally not significant in terms of risk.

How was the project outcome disseminated?

A letter was sent out to GP practices commending the positive outcome of the audit. Recommendations for further improvement were suggested flagging up a review if there is a reduction of 10% or more in body weight within 12 months of treatment.

The positive outcome of the audit shows the effectiveness of current practices. However, it's important to maintain a commitment to ongoing improvement. Regular evaluations and audits remain essential to adapt to evolving guidelines, address emerging challenges, and sustain a culture of excellence in healthcare delivery.

Patients with severe mental illness (SMI) are at greater risk of poor physical health with higher prevalence of obesity, cardiovascular disease, diabetes and higher premature mortality than the general population. The reasons are complex and interventions are multifaceted. Obesity is highly prevalent in the general population and pharmacological and surgical treatments have become more widely available; however, SMI patients may face barriers accessing these. This case highlights specific factors for consideration in managing a patient on lithium therapy undergoing sleeve gastrectomy to balance the risk of lithium toxicity with risk of relapse. Currently, there is limited clinical experience of managing lithium in this context.

49 yr old female diagnosed with schizoaffective disorder well-maintained for several years on aripiprazole depot and 800mg lithium carbonate (Priadel) with therapeutic levels in treatment range (0.4–0.8mmol/L). Severe obesity (BMI 41kg/m2) despite dietary modifications and metformin trial, and recently diagnosed with diabetes. Family history of cardiovascular disease and diabetic related complications with early mortality were additional factors in her request for bariatric surgery. Multidisciplinary discussion including patient, psychiatrist, mental health pharmacist, specialist bariatric dietician and GP prior, to ensure sharing of relevant information pertinent to re-titration and monitoring of lithium therapy and risks of toxicity and relapse.

Patient underwent sleeve gastrectomy with discontinuation of lithium 72 hours prior to surgery. Stomach pouch capacity reduced to 120ml and advised daily fluid intake 500–1000ml in first two weeks. Lithium therapy re-commenced when fluid intake adequate and renal function within normal limits. Formulation changed to liquid for 6–8 weeks to avoid disruption to the healing line, and the dose gradually re-titrated with close monitoring of serum lithium levels. Stabilised on reduced dose of 400mg Priadel at 3 months with therapeutic levels. At 6 months BMI reduced to 32kg/m2, antihypertensive and metformin discontinued and maintained remission of schizoaffective disorder.

Sleeve gastrectomy is an increasingly common procedure to treat obesity, with potential long-term positive physical health outcomes and reduction in mortality which may have a role in addressing health inequalities for SMI patients. Psychiatrists need to be aware of key aspects of bariatric surgery particularly relating to safe and effective prescribing of psychotropic medication including potential change to liquid or orodispersible formulation in the post-operative period, close monitoring of serum lithium levels in the short and medium term due its narrow therapeutic index, and consideration of longer-term dose adjustments due to ongoing weight loss.

This interdisciplinary research explored how responsibility is attributed to patients with personality disorders (PDs). The attribution of responsibility to this group has been extensively discussed by philosophers, and appears to be associated with negative attitudes towards the diagnosis amongst clinicians. This research aimed to both examine the philosophical literature available on this topic, and to explore how future clinicians make judgements of these patients’ responsibility.

A qualitative study was conducted to answer the following four research questions:

1. 1. What do medical students think responsibility means in the context of healthcare?

2. 2. What factors influence when medical students consider patients with mental health disorders, in particular PDs, responsible for their behaviours?

3. 3. How responsible do medical students consider patients with PDs for their behaviours in comparison to patients with other mental health conditions?

4. 4. Do medical students think that responsibility attributions could affect the stigmatisation of the condition and patient care?

Seven in-depth semi-structured interviews were conducted, involving the discussion of a case report. Interviews had a mean length of 53 minutes. They were then transcribed, coded, and thematic analysis of the data was undertaken. Four main themes were identified: understanding of responsibility, the factors affecting responsibility attribution, stigma and responsibility attribution, and the role of the clinician and the healthcare service.

It was found that medical students considered similar conditions and factors in attributing responsibility to those identified in the philosophical literature. However, several important practical concerns about responsibility attribution in practice were raised, including the possible impact on the therapeutic relationship, difficulties in separating responsibility and blame, and the impact comorbidities and misdiagnoses can have on attributions. Participants believed that stigma towards the diagnosis remains prevalent amongst healthcare professionals, due to stereotypes of these patients being manipulative, and insufficient education about the condition. Additionally, participants highlighted that patient responsibility may be reduced when clinicians and the healthcare service fail to meet their own responsibilities to these patients.

Future research into how other groups of healthcare professionals attribute responsibility is recommended, alongside research into how improved education could reduce stigma and inform responsibility attribution. It is suggested that further education is provided to healthcare professionals about the condition, and more support is offered to those working with patients with PDs to reduce stigma and make the attribution of responsibility fairer to these patients.

Clozapine, a second-generation antipsychotic licensed for treatment-resistant schizophrenia, has a well-documented side effect profile, the most common of which is decreased gastrointestinal motility. Clozapine-induced constipation occurs more frequently than blood dyscrasias and can lead to severe complications such as paralytic ileus and intestinal blockage; in extreme cases, it can be fatal, with a fatality rate of 20–30%. The risk of gastrointestinal hypomotility is most pronounced during the initial four months of treatment; hence, weekly assessments are imperative during this period. According to Lanarkshire's local guidelines, bowel habits should be assessed at baseline, during routine blood sampling, and ideally at every clinical interaction. Our audit aims to determine the frequency of bowel habit monitoring in inpatient settings and to ascertain the prevalence of laxative prescriptions among these patients.

Data were collected retrospectively from psychiatric inpatient wards in Lanarkshire for patients on Clozapine therapy. The review focused on electronic medical records to evaluate the regularity of bowel habit screening. Additionally, we examined the Hospital Electronic Prescribing and Medicines Administration (HEPMA) system to gather information on laxative prescriptions.

The audit revealed that bowel habit monitoring, which should be a standard practice at each clinical encounter, was found to be inconsistent. Regular assessments were documented for only 40% of patients. Monitoring was most thorough in rehabilitation wards, where patients on Clozapine had their gastrointestinal function assessed routinely through screening questionnaires. Furthermore, 80% of the surveyed patient population was documented as having been prescribed laxatives.

The documentation of bowel movements for inpatients on Clozapine was suboptimal, leading to the potential oversight of critical side effects. The audit highlights a discrepancy in adherence to national and Lanarkshire's local guidelines for the monitoring of inpatients treated with Clozapine. To rectify this, we recommend the implementation of a standardized screening protocol to assess constipation risk systematically. Proactive monitoring should be incorporated into regular clinical evaluations for patients on Clozapine, ensuring that this assessment occurs at every clinical interaction. This approach is crucial not only for patient safety but also for enhancing treatment efficacy and patient quality of life. Moreover, these measures will likely lead to improved documentation and compliance with established guidelines, thereby reducing the incidence of preventable complications associated with Clozapine-induced constipation.