Huntington’s disease (HD) is an autosomal dominant neurodegenerative disorder characterised by a pathologically prolonged CAG nucleotide sequence in the huntingtin gene (HTT). Neuropsychiatric symptoms such as aggression, depression, impulsivity and psychosis are non-motor signs of HD. The association between HD and criminal behaviour is debated, and evidence lacking. This is particularly relevant in forensic psychiatry, which focusses on the risk assessment of mentally disordered offenders. This manuscript examines the antecedents of offending behaviour in a male diagnosed with HD during admission to a high secure unit, and the evolution of his risk profile from childhood to post-diagnosis. Additionally, through exploration of psychopharmacological management of psychiatric symptoms in HD, this study aims to further our understanding as to how we can best support people with HD in a forensic mental health setting.

Following review of relevant literature on criminal behaviour in the context of HD, we report the case of a 41-year-old man with a background of dissocial personality traits admitted to a high security unit with symptoms of a delusional disorder; manifesting as paranoia, delusional beliefs and aggression. These were believed to be organically induced within the context of HD, a diagnosis confirmed through genetic testing six months following admission. The patient's symptoms were only partially responsive to first-line antipsychotics; however, good symptomatic control was achieved with clozapine and sodium valproate, enabling step-down to medium secure specialist services.

In HD patients, there may be a challenge of discerning whether offending behaviour relates to prodromal presentation or whether there are pre-existing antisocial attitudes or behaviour; an uncertainty which was present in this case and within the literature. The age of HD onset is inversely correlated with CAG repeat length, and a longer repeat length has been associated with criminal behaviour. This has the potential for use as a marker to determine the time point in which presenting features are attributable to HD. In this case study it was possible to determine through analysis of the CAG repeat length that the delusional disorder was likely linked to the onset of HD; however, dissocial personality traits were not.

A patient's background relating to the life-course persistence of violence, suicidality and psychiatric symptoms in patients with HD informs the process of formulating their risk profile. Changes to the risk profile also reflect the progressing stages of HD. This highlights the need for awareness of how HD may contribute or predispose to criminal behaviour and how interventions could be targeted during critical periods where they benefit most.

1. 1. To evaluate sources and demographics of referrals to the Northwest Surrey Psychotherapy Service, a secondary care service covering Runnymede, Spelthorne, and Woking in Surrey, England. To compare these data with local population data to assess equality of access and whether any groups are underrepresented.

2. 2. To evaluate what diagnoses are most frequent in those referred and the respective characteristics of those whose referrals are accepted for treatment and those who aren't.

A retrospective case note review using SystmOne of all patients referred to Psychotherapy between January 2021 and June 2021. Data were extracted by hand: demographics (age, gender, ethnicity, sexual orientation, marital status, employment status, dependents, caring responsibilities, disability, religion), diagnosis, source and outcome of referral. Reasons for referrals not progressing were correlated with current service inclusion/exclusion criteria. Demographics were compared with local population data available from ONS and Surrey County Council.

Fifty-one people were referred, 10 (19.6%) males and 41(80.4%) females.

Twenty-six (51%) referrals were accepted. Amongst those referred, depression n = 15 (29%), post-traumatic stress disorder (PTSD) n = 15 (29%) and emotionally unstable personality disorder (EUPD) n = 13 (25%) were the most reported diagnoses. Persons with depression or EUPD were most frequently accepted for assessment and treatment. The most common reason for a referral not progressing was the patient experiencing active PTSD symptoms requiring prior stabilisation work n = 9 (17%) or the patient not opting in n = 5 (10%).

Referrals came from a range of sources, mostly general practitioners (GPs) n = 18 (35%) and MindMatters (primary care talking therapies) n = 8 (16%).

Males were underrepresented in referrals to Psychotherapy and reasons may vary. It may be beneficial for referrers to be more proactive in considering and recommending referring males for psychotherapeutic input. Other groups were not significantly underrepresented compared with local population data, including ethnic minorities and those with protected characteristics.

Psychotherapy services frequently declined those suffering acute symptoms of PTSD; there may be a need to educate referrers that this is a likely exclusion criterion. Those who were declined on this basis were signposted to services offering stabilisation work, a positive finding in terms of our service facilitating access to ongoing care.

The sources of referrals suggest that GPs and MindMatters are important partners in identifying those needing psychotherapy services. Some referrals were inappropriate, and clearer referral criteria may be helpful. Some people declined assessments or treatment, which may indicate a need for more outreach or education on the potential benefits of psychotherapy services.

Patients experiencing Medically Unexplained Symptoms (MUS) are some of the costliest in both primary and secondary care. Psychotherapy is one of the most efficacious ways of treating them although the most superior modality is unclear. Cognitive Behavioural Therapy (CBT) has the greatest evidence base, but a growing number of studies have investigated the role of Psychodynamic Psychotherapy (PPT). This is the first study to compare the two modalities concerning their impact on healthcare utilisation and cost to the NHS.

Patients referred to the Oxford Community Psychological Medicine Service in 2021 and who went on to complete a course of psychotherapy for MUS were included. 78 patients were referred, 66 patients were assessed, 16 patients began treatment and 9 patients completed treatment. 4 received CBT and 5 received PPT based on a ‘best fit’ assessment. Their healthcare utilisation (GP appointments, health investigations, A&E attendances, inpatient admissions and outpatient appointments) was assessed during the 6 months prior to their initial assessment and compared with the 6 months after therapy had ended using data from ‘Health Information Exchange’.

Overall, psychotherapy reduced primary care use but our data was insufficiently powered for this to be statistically significant. There was a significant reduction in outpatient appointments after psychotherapy, mostly representing mental health consults.

Significant differences between pre-therapy and post-therapy were only observed for the number of health investigations in the PPT group which, surprisingly, increased with a large effect size (d = 1.19 95% CI 1.12–2.88, P = 0.03). The same trend towards increased utilisation were observed for every outcome measure in PPT besides outpatient appointments. Conversely, all outcome measures showed an improvement after CBT apart from the number of health investigations which marginally increased.

CBT significantly decreased GP appointments at 6 months follow-up compared with PPT with a large effect size (η2 = 0.5, p < 0.05). A similar trend was seen for total cost (η2 = 0.5, p < 0.06) with each PPT patient costing £790 more on average than their CBT counterparts during the 6 months after therapy.

Whilst CBT appears to be efficacious in the short-term, PPT caused significantly increased healthcare utilisation compared with CBT in the 6 months after therapy. This aligns with similar studies that demonstrate a ‘sleeper effect’ in which patients who receive PPT, but not CBT, deteriorate before improving over long-term follow-up.

Additional research is needed to correlate this data with symptoms and capture the long-term benefits of these psychotherapies for MUS.

Recommendations from the NHS and the Royal College of Psychiatrists advise that patients receive a copy of all correspondence that is sent on to the GP. Often, within psychiatric services, letters are not routinely sent to patients.

To improve communication with patients and their carers, the Aneurin Bevan Learning Disability team have been writing letters directly to patients and sending a copy to the GP.

There is limited use of jargon, and the complexity of the language aims to reflect the individual's reading level.

This study aimed to gain feedback from local GPs on the new letter format to ensure effective communication between teams.

We contacted Primary Care Services in the local area to gain feedback on how our clinic letters were being processed, we were informed that letters are reviewed by an admin team and only sent on to GPs if there are specific tasks to action, meaning that many of our letters remain unread.

We identified 16 GP practices in the Torfaen and Monmouthshire area and sent a survey by email to gain feedback on the new correspondence style. The survey was sent out three times within a 12-month period.

Of 16 GP practices just 6 responded, with just 1 GP stating that they had noticed a change in the letter style. 50% of GPs felt they received relevant information in the letters from the CLDT. The comments were largely positive with suggestions reflecting changes that have already been made. There is no feedback that suggests GPs feel they are not receiving adequate clinical information.

The lack of response may highlight how infrequently GPs are reviewing the letters from the CLDT confirming the importance of prioritising doctor–patient correspondence. The limited communication from GP to CLDT emphasises the need for improvement in liaison between secondary and primary care services.

The lack of negative feedback about the letters is encouraging. There is no feedback that suggests GPs feel they are not receiving adequate clinical information and clear feedback that GPs want clear and accessible information, particularly regarding specific actions for GPs.

A clear limitation of this work is the lack of response to our survey. Reviewing these letters from our team is a very small proportion of a GPs workload, more time may be needed to ensure GPs have had contact with our team and are able to provide more detailed feedback.

Emotionally unstable personality disorder (EUPD) is characterized by affective instability, unstable interpersonal relationships, poor self-image and marked impulsivity. Patients may present with a variety of symptoms including impulsivity, suicidal behavior, affective instability and intense anger. This makes the treatment very patient specific.

Treatment guidelines support the use of Dialectical Behavior Therapy (DBT) as the first line treatment of EUPD. Currently, no medications are indicated for the treatment of EUPD which leads to off label use of medicines by clinicians.

More than 90% of individuals receive a variety of pharmacologic treatment with psychotropic medications, especially second-generation antipsychotic drugs for the treatment of cognitive perceptual symptoms and impulse control behavior. Additional psychotropics are usually added leading to psychotropic polypharmacy which should be avoided.

Aim of this study is to assess the frequency of prescription of antipsychotic medications in patients with a primary diagnosis of emotionally unstable personality disorder.

Protocol was registered with the Audit and Quality Improvement project team of the NHS trust and the audit registration certificate was obtained.

Case records of 42 patients with EUPD who attended psychiatric outpatient department from June to August 2023 were collected and screened. A retrospective study was carried out.

Inclusion criteria

Patients above 18 years of age, with a primary diagnosis of emotionally unstable personality disorder.

Exclusion criteria

Patients with comorbid diseases like Attention Deficit Hyperactivity Disorder, Bipolar Affective Disorder and Psychosis where use of antipsychotics is warranted.

All other personality disorders.

After screening 42 case records, 20 cases of EUPD which fulfilled the inclusion and exclusion criteria were found and analyzed. Descriptive statistics were used.

Retrospective data of 20 patients with a primary diagnosis of EUPD were analyzed which included 18 females and 2 males. The mean age of the participants was 27.1.

70% (14) of the patients diagnosed with EUPD were treated with antipsychotics. 20% (4) patients received antidepressants. 10% (2) of the patients received only DBT.

Quetiapine was the most commonly used antipsychotic – 43% (6) followed by Olanzapine – 22% (3), Risperidone – 21% (3) and Zuclopenthixol long-acting injection – 14% (2).

Dialectical behavior therapy is the first line treatment of EUPD. National Institute for Health and Care Excellence (NICE) guidelines do not recommend the use of antipsychotics in the treatment of EUPD. Contrary to the guidelines, antipsychotics are prescribed long term for patients with EUPD who are without any comorbid conditions. This audit has found that 70% of patients with a primary diagnosis of EUPD are being prescribed antipsychotic medication. This needs to be kept in check so that polypharmacy can be avoided.

Mental illness is associated with poorer physical health and reduced life expectancy in comparison to the general population. This is influenced by many factors, one of which is medication related. Antipsychotics can have multi system effects on the body such as increasing the risk of metabolic syndrome and cardiovascular disease. Our objective was to understand current challenges when monitoring patients' physical health and thereby improve overall health outcomes.

Utilising a clinical audit template, the study group was 9 inpatients during cycle 1 and 10 inpatients during cycle 2, who were prescribed antipsychotics on an Old Age Psychiatry ward. Northumberland, Tyne and Wear (NTW) antipsychotic monitoring guidelines were used as criteria which stipulate that blood tests, ECGs, BMI, waist circumference, side effects and lifestyle effects should be recorded at defined intervals. A proforma highlighting these guidelines was created following audit cycle 1 and utilised by the MDT on the ward, the purpose of cycle 2 was to compare findings following the implementation of the proforma. The standard to meet was that 100% of patients should fulfil the guidelines. Data was collected by retrospectively reviewing paper and electronic notes.

Audit cycle 1 revealed 0 of the patients met the physical health criteria. 0 had the full set of required bloods in the correct timeframe, 0 had waist circumference checked and 2 and 1 patients had side effect and lifestyle effects documented respectively. By comparison, ECGs and BMIs were recorded well. Audit cycle 2 demonstrated significant improvement in all areas. 9 patients had bloods accurately measured. 3 and 6 had side effect and lifestyle reviews respectively. ECGs and BMIs continued to be monitored well. However, waist circumference remained poor with 1 patient recorded. Qualitative feedback when presenting these findings to the MDT highlighted an interest debate into the cost/benefit of measuring waist circumference with the main point being not wishing to cause undue anxiety to the patient.

The use of an accessible proforma clearly outlining the criteria to meet for each patient proved valuable in improving the monitoring of physical health parameters. This study highlighted a need for increased awareness of metabolic syndrome and the importance of empowering patients with knowledge regarding their healthcare to help tailor a patient-centred approach to physical health monitoring. Our presentation aims to encourage discussion among attendees around measuring waist circumference and raise awareness of metabolic syndrome.

The National Drug Treatment Centre in Dublin is the longest established treatment service for drug users in Ireland. Led by Addiction Psychiatry teams, it provides specialist multidisciplinary input for patients with complex medical and psychiatric needs secondary to substance use. Many patients attending the centre engage poorly with other healthcare services in the community. The aim of this audit was to improve physical healthcare engagement in a caseload of 60 patients, through improving GP registration rates and possession of medical cards (providing access to free public health services).

The comparison standard for the audit was the Irish Health Service Executive (HSE) Clinical Guidelines for Opiate Substitution Therapy: 2016. These stipulate that all drug users entering treatment and rehabilitation should have a care plan based on assessed need. Specific domains covered include: Drug and Alcohol use, Physical Health, Psychological Health and Social Functioning.

During the initial audit cycle, electronic care plans in a caseload of 60 patients were reviewed for information on their GP and medical card status.

Intervention: Following the initial cycle, results were presented and discussed at a multidisciplinary team meeting. A combined MDT effort was made to discuss medical card and GP status with patients during each interaction. Patients were referred to social work for support in application/renewal of medical cards and GP registration where required.

Results following re-audit:

The percentage of patients with GP registration clearly displayed on their care plan increased from 66% to 93%.

The percentage of patients with an up to date medical card increased from 12% to 45%.

The percentage of patients whose medical card status was unknown reduced from 72% to 44%.

The percentage of patients with their medical card number displayed on their care plan increased from 25% to 55%.

There was a significant improvement in the number of patients with GP and medical card information documented clearly on their electronic care plan. This has assisted National Drug Treatment Centre staff in supporting patients' physical health needs more effectively, through close liaison with primary care providers and onwards referral to other services where required. It was noted that further efforts were required to build upon these results and reach 100% compliance. Recommendations and an action plan were developed to ensure ongoing improvement in standards.

Patients with serious mental disorders like psychosis may pose a significant risk to themselves and others when they drive. The DVLA has set out guidance for driving for patients with psychiatric disorders, substance use disorders, and for those taking psychotropic medications. It's good medical practice to identify risks associated with driving, discuss, advise appropriately, and document the same in the clinical notes.

To assess the compliance of the mental health professionals at Rathbone Rehabilitation Centre (RRC) with DVLA guidelines regarding patients about driving restrictions, documenting this appropriately and to increase awareness of the DVLA guidelines.

Data of all the discharged patients from RRC over a 12-month period was collected following a standardised process and assessed for 6 parameters.

A total of 51 discharges were identified and audited against the DVLA guidelines.

51 (100%) patients had a mental health diagnosis documented on patient electronic records (Rio).

9 (18%) of patients had their driving status documented. 42 (82%) did not.

Of the 9 patients whose driving status was recorded, 6 did not drive and are thus labelled not applicable for subsequent criteria. The type of vehicle driven was not documented in any of the cases and therefore was 0%.

Of the 3 patients who drive, 2 (67%) had been informed that their condition may affect their ability to drive.

67% had documented evidence of receiving advice on driving restrictions.

67% had documented evidence that the practitioner has informed the patient that they have a legal duty to inform the DVLA about their condition.

An action plan was designed to improve compliance with DVLA guidelines for practitioners managing inpatients.

• • On admission all patients should be asked for their driving status and the result documented on Rio. This could be done on the clerking admissions proforma on Rio.

• • For all patients that do drive, the types of vehicles they drive should be documented–this can also be included in the clerking admissions proforma on Rio.

• • At their first ward review/discharge meeting and whenever relevant, patients should be informed whether their condition affects their ability to drive and if so, what the restrictions are. They should be informed of the legal requirements regarding informing the DVLA and documented.

• • To consider driving status when assessing risk.

To study the risk factors for burnout among doctors in a tertiary general hospital in Singapore. We hypothesized that burnout would be associated with singles, young age, females, foreign born staff who had recently moved to this country unaccompanied by family, and those showing less resilience. We hypothesised perceived support and satisfaction with leisure would mitigate against burnout.

An anonymised survey was carried out, with questionnaires sent to all staff via email. Survey instruments included the Oldenburg Burnout Inventory, Connor Davidson Resilience Scale, Brief Form of Perceived Social Support Questionnaire, Patient Health Questionnaire-4 items (PHQ-4), Leisure Time Satisfaction Survey and the Demand Control Support Questionnaire (DCSQ). Descriptive statistics for normally-distributed numerical variables were presented as mean (SD or standard deviation), and for categorical variables, median and n (%). One-way ANOVA was performed to determine differences in total burnout scores across categorical variables and simple linear regression was used to assess for binary and numerical outcomes in terms of resilience, PHQ, DSCQ, satisfaction with leisure time and perceived social support, with significance set as p < 0.05.

A total of 129 doctors responded to the survey. Over half were male, and nearly 70% were married. Nearly half were below age 40 and only about 5% had no immediate family living in Singapore.

Burnout was associated with young age (p < 0.004) and those with anxiety 2.39 (2.13 to 2.64) p = 0.038, and depressive symptoms 2.71 (2.44 to 2.97) p < 0.001. Psychological demand was positively associated with burnout (1.52 (1.32 to 1.71) p < 0.001; whereas decision latitude −0.69 (−0.85 to −0.52), social support at work −1.35 (−1.49 to −1.21), and high resilience −0.56 (−0.63 to −0.48), were negatively associated (all p < 0.001).

Satisfaction with leisure time was negatively correlated with burnout (p < 0.001). Contrary to hypothesis, singlehood, gender, overseas staff recently joined with no accompanying family were not associated with burnout (p > 0.05). In addition, perceived social support from outside work did not mitigate against burnout (p > 0.05).

Young age, anxiety and depression, and psychological demands were risk factors, whereas resilience, decision latitude, satisfaction with leisure, and social support at work were protective factors against burnout. Reducing workload, improving work schedules, promoting self-management, teaching physical, mental, and emotional self-care, and other stress management activities are among the effective techniques shown to reduce burnout. Interventions should be made available for all staff, but specifically focusing on those at greatest risk.

The Institute of Mental Health is the only tertiary Psychiatric Hospital in Singapore. It has two 29 bedded inpatient wards which provide acute care for the elderly with severe mental health conditions including dementia. Restraints are one of the methods employed in managing agitation in patients with dementia. The physical consequences of restraints are reduced mobility resulting in decreased muscle tone and mass, bone demineralisation, orthostatic hypotension, and atelectasis. This results in patients who are more prone to falls, aspiration pneumonia, deep vein thrombosis/pulmonary embolism and ulcers. The psychological consequences include aggravating agitation, feelings of humiliation, negative emotions like anger and despair. Hence, we embarked on a program to reduce the use of physical restraints in the management of agitation in patients with dementia.

Baseline restraint hours were collected from 7am to 9pm for all dementia patients who were restrained for agitation for a period of 5 months. Patients on Geri chair with seatbelt used primarily for fall prevention were not included. The Pittsburgh Agitation Scale was used to measure agitation.

The nursing staff were trained on the Enriched model for targeting behaviour and on the VIPS (Valuing people, Individualised care, Personal perspectives, Social environment) framework for person centred care. Restraint hours were collected post intervention as well as benzodiazepine usage data over both periods to monitor any changes in the usage.

The baseline data (preintervention) over a 5-month period determined that patients with dementia who were agitated were being restrained on an average for 3.33 hrs per day from the period of January to May 2021. Following the training of nursing staff on the enriched model of care and the use of VIPS framework for person centered care the restraint hours reduced to 1.48hr per day over 5 months from January to May 2022. Benzodiazepines usage went down from 0.34mg at baseline to 0.17mg per dementia patient per day post intervention.

Nonpharmacological interventions (enriched model and VIPS framework for person centered care) using a multidisciplinary team approach is effective in the management of agitation resulting from dementia and should be used as a first line in the management of such conditions.

In Malawi, there are three Consultant psychiatrists for a population of approximately 20 million people. We cannot rely solely on specialists to provide mental health care. We produced the Malawi Quick Guide to Mental Health (the Guide) to improve the psychiatric health-care resources available to frontline mental health workers in Malawi, thus improving service provision to patients. We aimed to evaluate its impact on the frontline non-specialists who provide most mental health care in Malawi.

In collaboration with the Malawi Ministry of Health, the University of Malawi, St John of God Malawi, and a Malawian user group, a group of psychiatrists with experience working in Malawi co-produced the Malawi Quick Guide to Mental Health. It provides practical information for assessing and managing mental disorders in Malawi. We distributed the Guide to over 400 health centres in Malawi. Next, we converted the Guide into a freely available phone app in both Android and Apple stores.

To study its impact, we baseline surveyed frontline mental health professionals regarding their access to basic psychiatry guidelines and information in clinics, as well as their confidence in delivering mental health care. We repeated this survey six months after the distribution of the printed Guide and six months after the app launch.

Baseline survey: 20 health-care professionals representing regions throughout Malawi responded. 70% of respondents were between 25–40 years old and 45% were female. All respondents either agreed or strongly agreed that they needed more support caring for mentally unwell patients. 15% had no access to any resources whatsoever to guide their care.

Printed guide survey: 95% agreed or strongly agreed that having a printed copy of the Guide increased their confidence in caring for patients. Information resource accessibility, availability and usage in mental health clinics had improved from baseline. The respondents found the Guide helped their day-to-day practice, with 95% rating it either extremely helpful or very helpful. 95% either agreed or strongly agreed that it had improved the care they provided their patients.

App survey: 66% of respondents prefer using the app over the textbook version. All agreed that the app made them more confident in caring for their patients and that their care had improved because of the app. They were all likely to recommend it to a colleague. It has now been downloaded almost 1000 times.

A free, co-produced mental health book and phone app have helped to address the issue of limited access to basic psychiatry guidelines and information in clinics in Malawi. This has improved clinicians’ confidence and their perceived patient care.

Suicide is one of the leading causes of death among young people. For adolescents, schools are considered as the best place to identify and respond to youth suicide risk but evidence on culturally sensitive, school-based suicide prevention programs is limited in low-resource settings such as Pakistan. This study aims to explore the perspectives of students, parents, teachers, and general practitioners regarding cultural adaptation, participation experiences, identified areas for improvement, and recommendations for scaling up the school-based suicide prevention program in Pakistan.

This qualitative study was nested in a pilot randomized controlled trial that aimed at exploring the feasibility, acceptability and preliminary effectiveness of three suicide prevention interventions: (1) Linking Education and Awareness of Depression and Suicide-LEADS training for students (12–17 years), (2) Question-Persuade-Refer (QPR) training for teachers and parents and (3) Professional screening of at-risk students (ProfScreen) for health practitioners. A total of 8 focus group discussion (FGDs) were conducted at pre- and post-intervention stage with each type of stakeholder (students, teachers, parents and health professionals) by trained qualitative researchers using the semi-structured topic guides. Each FGDs involved a detailed presentation on intervention, sharing videos and educational posters.

As a result of pre-intervention FGDs, adaptations were made in the content of the interventions and were further refined through consultations with Patient and Public Involvement and Engagement group. All stakeholders who participated in post-intervention FGDs marked this suicide prevention program as feasible, acceptable and helpful in both identifying the risk of and preventing self-harm and suicide among young individuals, while also enhancing treatment pathways. Stakeholders perceived the interventions as valuable in augmenting knowledge about mental health, understanding the impact of mental health challenges on functioning, reducing stigma, and providing stakeholders with the necessary skills to identify and guide at-risk individuals. Teachers and parents endorsed the importance of discussing issues with children. Improvement in clinical practice of clinicians and teaching practice of teachers as well as understanding others’ behaviors were also reported.

This study highlights potential role of culturally adapted school-based youth suicide prevention program for settings where rates of suicide are high and there are limited mental healthcare resources in addition to limited access to healthcare. School-based suicide prevention program is perceived as helpful in improving knowledge, attitudes, and help-seeking behaviours in adolescents.

To ascertain the service performance against the standards set by National Institute for Clinical Excellence (NICE) guidelines on physical health monitoring of children and adolescents prescribed antipsychotics.

Initial audit: April–June 2021.

Re-audit: January–February 2024.

Registered with the Lancashire and South Cumbria NHS Foundation Trust audit department. An audit tool was developed by the investigators. The investigators carried out a review of patient electronic records and clinical letters to gather information pertaining to initiation of antipsychotics and physical health monitoring.

Amongst other variables in this trust-wide audit, we considered age, ethnic background, reason of initiation of anti-psychotic, comorbid conditions among which most common is epilepsy, dose of antipsychotic used and distributions across various CCGs. Were they regularly reviewed by medic reviews and side effects monitored? We also looked at choice of antipsychotic used, which was largely aripiprazole and risperidone. Were antipsychotic bloods done or not and were we able to complete children's height and weight measurements whilst they were on antipsychotics? It was important that these are documented as being considered or ‘offered' even if could not be successfully completed due to e.g. challenging behaviour from the child. Detailed and comparative results can be shown in final submission along with charts.

The recommendations from initial audit were compared with the second audit, and whilst some of them were completed such as incorporating growth chart in the electronic records system, some ongoing challenges were identified. Positive and negative findings were both noted although the final conclusions lies in favour of good changes been made to service including the caseload becoming more ID specific in this age group.

Gliomas, encompassing astrocytomas, oligodendrogliomas, and ependymomas, constitute the majority (40–55%) of primary brain tumors. Diagnosis can be challenging due to their uncommon nature, subtle symptoms, and diverse clinical manifestations. While neurological signs are typical, psychiatric symptoms may occasionally precede them. This case report explores a 59-year-old man whose initial psychiatric symptoms, resistant to treatment, evolved into memory impairment, ultimately revealing a high-grade glioma in the thalamus.

A 59-year-old male patient presented to the psychiatric service, expressing concerns about excessive anger and aggression. His family observed his behavior as abnormal, noting uncharacteristic personality changes, particularly increased irritability. Following an outpatient psychiatric evaluation, he was diagnosed with excessive irritability. Over time, the patient's aggressive behaviors intensified, accompanied by feelings of being ignored and devalued by his family, heightened emotional sensitivity, and episodes of muteness. Despite two trials of medication (i.e., sertraline and alprazolam), there was a deterioration in adaptive functioning. Two years after the first onset, the patient experienced unfamiliarity with surroundings, forgetting place names, memories, and people's names. The patient had no family history of neurological or psychiatric illness, and there was no evidence of substance use in his past. To rule out organic causes, an MRI revealed a 17×21 mm lesion in the right thalamus and a calcified focus in the superior part of the left tentorium. Subsequent biopsy confirmed a high-grade glial tumor: anaplastic astrocytoma Grade III, with a Ki-67 index of 10%.

The extended onset of memory impairment in our patient, following a 3-year history of aggressive attacks and irritation, prompts an exploration of the intricate interplay between psychiatric and neurological manifestations. Unlike typical associations of personality changes with frontal lobe tumors, our case challenges this by implicating a thalamic tumor, highlighting the complexity of symptom correlation with precise brain lesion locations. Psychiatric symptoms, though not exclusive, may indicate underlying brain tumors. New-onset psychosis, mood or memory symptoms, atypical occurrences, personality changes, and anorexia in individuals over 40 warrant a thorough diagnostic workup, including neuroimaging, to investigate potential intracranial lesions.

This case emphasizes the significance of identifying psychiatric symptoms as potential indicators of underlying brain tumors. The diverse manifestations, such as sudden psychosis, mood or memory changes, or unusual symptoms, should prompt further investigation, including neuroimaging. Early detection is crucial for improving overall quality of life, and understanding these psychiatric signs aids in unraveling the broader narrative of potential brain tumor involvement.

The aim of this study is to investigate incident and total benzodiazepine prescribing in the Netherlands during the COVID-19 pandemic, including the impact of lockdown periods.

A national Dutch pharmacological registry was used, investigating extramural psychiatric drug prescriptions, between March 2020 and March 2022. Data included incident and total prescriptions as well as daily defined doses (DDDs) of benzodiazepines. The data covered 96% out of a total Dutch population of 17.5 million people. This was compared with the previous calendar year as a reference expressed as a monthly risk ratio (RR) and was corrected for population growth. Changes over time will be discussed if the RR was above 1.1 or below 0.9.

A total of 13.4 million prescriptions over a period of three years were included of which 5.8% were incident prescriptions. Three lockdown periods were identified during pandemic.

When analysing the total benzodiazepine prescription group, prescriptions and DDDs remained mostly stable throughout the pandemic. A brief relative increase in prescription DDD amounts was found during the second lockdown (RR: 1.11). When viewing the incident benzodiazepine prescriptions, there was a short period between the first and second lockdown when both prescription numbers and DDDs decreased (RR: 0.86 and RR: 0.83 respectively). The DDDs of incident prescriptions increased sharply during the second and third lockdown period and remained elevated between both, with an average RR of 1.13.

Total monthly benzodiazepine prescriptions and DDDs remained mostly stable during the COVID-19 pandemic in the Netherlands. COVID-19 related lockdowns seem to have mainly influenced incident benzodiazepine DDDs dispensed during the second and third lockdown. Increased incident DDDs, but not prescription numbers, imply that new patients on average received larger benzodiazepine prescriptions. The increase in incident prescription DDDs could be indicative of decreased accessibility to (psychiatric) healthcare. It could also have been driven by an increase of the incidence and/or severity of sleep and anxiety symptoms during the second and third lockdown. A better understanding of exact causes and mechanisms behind these changes is relevant in order to limit the psychiatric repercussions of future (inter)national emergencies.

There is a well-established association between sleep disturbance and cognitive decline. Poor sleep can have a significant effect on patient and carer wellbeing and is a potentially modifiable risk factor for dementia. Sleep medications are problematic in cognitive impairment due to the increased risk of adverse events such as falls and confusion. There is good evidence for Cognitive Behavioural Therapy for Insomnia (CBTI) in older adults but its effectiveness in cognitive impairment is unclear. In 2021, only one RCT on CBTI in cognitive impairment was identified (Cassidy-Eagle et al. 2018). This review seeks to establish if there is any new evidence.

Ovid Medline (1946 to present) and clinicaltrials.gov were searched for all interventional trials testing CBTI including RCTs, single-arm studies and protocols, written in English. Inclusion criteria:

1. 1. Adults with a diagnosis of MCI or Alzheimer's dementia;

2. 2. Sleep as a primary outcome, using a validated outcome measure.

172 citations were screened by the first author and 26 underwent full text review. Eight papers were eligible for inclusion. Four of these studied MCI, three looked at people living with dementia (PLWD) and caregivers as a dyad and one combined MCI and Alzheimer's (protocol only).

The search found two pilot RCTs and two protocols for MCI. Cassidy-Eagle et al. (2018) found a highly significant positive effect on four of five sleep outcome measures with large effect sizes. The Insomnia Severity Index (ISI) decreased from 15.29 to 3.25 (p < 0.001; Cohen's d −4.22). Mattos et al. (2021) also found significant improvements on all sleep outcome measures; ISI decreased from 13.5 to 8.3 (p < 0.01).

Three papers study joint CBTI for PLWD and their care partners (one pilot RCT and two protocols). Song et al. (2024) reported improvements in sleep parameters for both participants in the dyad but were not statistically significant. They are recruiting for a larger trial.

This review identified 7 new RCTs in progress. In MCI, new data continue to show a significant association between CBTI and improved sleep. Published data for people with dementia have not found a significant relationship, although the data set remains very limited. It is not yet possible to synthesise the results and future systematic reviews are needed. If effective, CBTI could offer a lower risk alternative to medications in managing sleep disturbance in people with cognitive impairment.

Clinical Global Impression Scale (CGI) is a recognised scoring system used to assess patients across a variety of medical specialties. In this study we aim to evaluate the use of the severity scale (CGI-S) in a female adult mental health unit. We aim to explore how frequently it is used to assess patients on admission and discharge and investigate its utility in predicting a variety of patient outcomes. We hypothesise that gaining a greater understanding of the significance of CGI-S scoring can enhance in-patient care by offering insights into factors such as probable length of stay and potential benefits of in-patient admission.

Patient data was collected retrospectively for the last 60 patients discharged. The resulting population data from an inpatient female ward which was then analysed using Microsoft Excel and Jamovi.

59 patients were included in the final data set. Population age at time of admission ranged from 18–68 years with a mean age of 38. The mean length of stay was found to be 40.2 days. 80% of patients had an admission CGI-S recorded with a mean score of 2.77. 71% had a discharge CGI-S recorded with a mean score of 1.79. 58% of patients had both admission and discharge CGI-S score recorded. The key findings of the study were a mean reduction of 1.09 in CGI-S scores, indicating an overall improvement in patient presentation by the point of discharge. Length of admission was increased by 14 days per 1 integer increase in admission CGI-S score. The data also suggests that the correlation between admission CGI-S and length of stay is statistically significant (p value of 0.016). It was also noted that patients with a discharge diagnosis of ‘Emotionally Unstable Personality Disorder’ had a smaller reduction in CGI-S score at point of discharge and required shorter hospital stays, compared with other diagnoses.

The results of this study imply that use of CGI-S scoring in adult inpatient units is beneficial. However, its value can be better seen with improved adherence to regular completion of scores during patient reviews and is an important step to prioritise. Increase in utilisation of this tool will also likely provide clinicians with guidance in predicting which patients are likely to benefit from lengthier admissions and those that might fare better with community support.