Anxiety disorders are common in Autistic Spectrum Disorder (ASD) patients. There are limited resources dedicated to ASD and mental health services are not equipped to adapt assessment and treatment protocols to address their needs. Adaptations to diagnosis and treatment are discussed in a single case study of an autistic patient with anxiety disorders. In addition, effectiveness of providing adapted versus standard treatment is evaluated.

This study describes a 45-year-old, single, employed male diagnosed as autistic at age 37. He was referred for a second course of Cognitive Behavioural Therapy (CBT) for anxiety disorders consisting of agoraphobia with panic; blood injury phobia; needle phobia; dental phobia; claustrophobia. The duration of symptoms was 35 years. The main impairments to functioning were inability to use public transport; attending healthcare appointments; going to public places; returning to office-based working.

Questionnaires routinely completed at assessment and end of treatment: Montgomery–Åsberg Depression Rating Scale (MADRS); Beck's Anxiety Inventory (BAI); Beck's Depression Inventory (BDI). Adapted treatment with CBT included an extended assessment which helped differentiate anxiety symptoms from ASD. Main CBT adaptations included development of skills for the patient to identify and express emotional experiences and thoughts with the focus on physical sensations and behaviour. Graded exposure items were linked to concrete aims or interests and structured to fit around the patient's routine daily activities. Clinical data was analysed and compared outcomes from the initial standard and subsequent adapted treatment.

The patient's response to the initial course of standard CBT showed a 14% increase in anxiety and 14% increase in symptoms of depression on self-rated measures. The subsequent adapted CBT showed a 31% improvement in anxiety and a 16% improvement in symptoms of depression on self-rated measures.

This case report supports literature describing the need to adapt standard assessment and treatment to differentiate experiences related to ASD from discrete anxiety disorders, although there may be some overlap. The promising results support using adapted CBT to ensure appropriate treatment of anxiety disorders in autistic people.

To establish the proportion of CMHT Preston service users with schizophrenia who met the NICE standard (CG 178) of being offered clozapine after inadequate response to treatment with at least two antipsychotic drugs.

Inclusions – Service users on the CMHT Preston caseload with schizophrenia who attended outpatient clinic between January and June 2023.

Exclusions – Organic psychosis and non-schizophrenic/unspecified psychosis.

Sample size – 50.

Sampling – First 50 service users with established diagnosis of schizophrenia.

Data collection – Retrospective case-note audit from electronic patient records.

Data analysis – Quantitative.

45 service users (90%) met the clozapine eligibility criteria of not responding adequately to or tolerating at least 2 other antipsychotic medications while 5 service users (10%), did not meet the criteria. The proportion of eligible service users who were offered clozapine, and therefore met the standard, was approximately 64%, representing 29 out of the 45 eligible service users. Approximately 36%, representing 16 eligible service users, were not offered clozapine. In one isolated case, a service user who had only 1 previous antipsychotic trial and therefore did not meet the eligibility criteria, was offered clozapine. No reason was given in 13 out of the 16 service users who were not offered clozapine despite meeting the eligibility criteria. In the remaining 3 service users in this group, 2 were not offered clozapine because of cardiac problems and 1 was not offered because of significant history of poor compliance with antipsychotic medications. Furthermore, 25 eligible service users (86%) of those who were offered clozapine went on to initiate it with only 4 service users (14%) in this group not going ahead to initiate clozapine. In all 4 service users who did not initiate clozapine after being offered, the reason given was that the service users declined it.

The findings from this audit indicate that a considerable proportion (64%) of CMHT Preston service users with schizophrenia are being offered clozapine in line with the NICE standard, and 86% of those offered went on to initiate clozapine. However, there is room for improvement in terms of offering and ultimately initiating clozapine in a timely manner as evident from the findings which highlighted an average of three antipsychotic trials before eligible service users were offered clozapine. The existing established local clozapine community initiation pathway can potentially be optimised to improve clozapine access and ultimately enhance clinical outcomes for this subset of service users.

To explore the views of healthcare practitioners from diverse clinical settings on management practices when supporting older adults with self-harm behaviour.

Semi-structured interviews were conducted with healthcare practitioners with previous experience supporting older adults who self-harm, including consultant psychiatrists, general practitioners, clinical psychologists, psychotherapists, clinical nurse specialists and social workers. Purposive sampling was used to recruit participants in the Republic of Ireland to ensure a varied representation of location and clinical area. Healthcare practitioners were recruited by advertising the study via professional and clinical research networks, social media and snowballing methods. Interviews were audio-recorded and transcribed verbatim. Transcripts were uploaded to QSR NVivo Software Version 12 to facilitate analysis. Themes were identified in the data using the steps of thematic analysis which involve data familiarization, coding, theme development and revision.

Interviews were conducted with 20 healthcare practitioners from April to July 2023. Healthcare practitioners offered diverse perspectives across general practice, community mental health services, liaison psychiatry, emergency department settings and inpatient mental health units. Three main themes were generated:

1. 1. Supporting older adults after self-harm: complex and challenging.

2. 2. Multiple barriers to the management of self-harm: i) strained resources and unclear referral pathways, ii) limited awareness/health promotion, iii) unsuitable environments, iv) stigma and shame, and v) complexity of self-harm.

3. 3. Risk assessment in older adults: increased risk and the importance of safety planning.

Healthcare practitioners viewed self-harm in older adults as complex, challenging and associated with high suicide risk. Increased mental health promotion and awareness of mental health and suicidal behaviour in this age group would help address current stigma and shame. Primary care was identified as a sector that older adults often access and where prevention, identification and support can be offered, with more complex cases being promptly referred to more specialist services. Several supports and therapies that could help older adults were identified; however, due to the limited availability of services, supports were often restricted due to cut-off age criteria or disparity of care at a national level. Provision of care needs to be improved upon, with standardised supports still needing to be implemented across the country. Future research can address the perspectives of older adults on how they would prefer to be supported for their self-harm.

According to the World Health Organization (WHO), there has been a 13% increase in mental health and substance abuse disorders within the last decade. Typical and atypical antipsychotics are the most common treatment mechanisms for mental health-related disorders such as schizophrenia, depression with psychotic symptoms and bipolar disorders. However, antipsychotic usage is associated with more than a 50% increase in CVD such as ischaemic heart disease, resulting in cardiovascular-related mortality.

This review aims to investigate the most common type of cardiovascular event causing mortality due to antipsychotic use.

A systematic search within PubMed and Medline was conducted on 3 October 2023. Selection criteria were limited to English, full-text studies excluding case reports. The time frame selected was up to 3 October 2023. All studies included adults only. Interventions of focus include typical and atypical antipsychotics licensed in the UK. Outcome measures include cardiovascular mortality/events post-antipsychotic prescription.

13 studies were included out of 1088 records. Studies originated from 4 nations with the most studies coming from the USA (n = 7), UK (n = 2), Taiwan (n = 2) and Canada (n = 2).

The most common antipsychotic reported in the records was risperidone (n = 11), followed by haloperidol (n = 9), olanzapine (n = 8) and quetiapine (n = 8).

From data extraction, the most common cardiovascular events leading to death were sudden cardiac death/arrest (n = 6), ventricular arrhythmias (n = 6), myocardial infarction (n = 4), and heart failure (n = 2).

Due to data heterogeneity, discrete outcome measures were extracted from each record. This included outcomes measuring: relative risk between various groups (n = 9), rate of cardiovascular event per 100 patient year (n = 3), and mortality post cardiovascular event (n = 1).

From this study, ventricular arrhythmias and sudden cardiac deaths were the most common cardiovascular events secondary to antipsychotic use leading to mortality. Owing to patient safety and benefits, patients with psychotic illness are unable to go untreated. They are consequently very vulnerable to the cardiovascular side effects of prescribed high-dose antipsychotic drugs. Despite current monitoring guidelines worldwide, cardiovascular-associated mortality in patients on antipsychotics is still elevated. This may indicate the potential inadequacy of current measures for these patients while demonstrating the need for more aggressive cardioprotective interventions and monitoring.

The pursuit of a career in medicine, while potentially rewarding, is undeniably accompanied by demanding challenges. These challenges encompass not only rigorous academic demands and long work hours but also contend with a competitive academic environment, conflicts in maintaining a study-life balance, and a multitude of other stressors unique to the medical profession. Amidst this backdrop, concerns are growing worldwide about the mental health challenges that medical students face as they start their careers in medicine. Coping can play a pivotal role in overcoming these challenges. This study explores how coping is associated with wellbeing aspects, i.e., anxiety and depression, as well as personality, and looks into the coping strategies adopted by medical students, specifically focusing on whether they predominantly employ problem-focused or emotion-focused coping. Additionally, it aims to explore contextual factors influencing students' coping strategies, which is crucial for informing wellbeing interventions and support services.

This study used a mixed-methods approach, employing quantitative data on coping, personality, stress, anxiety and depression and qualitative data from semi-structured interviews with preclinical and clinical year medical students at the University of Nottingham.

Regression findings revealed that medical students primarily used emotion-focused over problem-focused coping. Interestingly, thematic analysis showed that medical students employ problem-focused coping strategies in rigorous, academically challenging and controllable situations such as upcoming exams; they prioritise structured study schedules, seek additional academic resources, and actively engage with faculty to enhance their understanding of complex topics; conversely, emotion-focused coping emerged prominently in the face of personal or interpersonal stressors, particularly in situations perceived as uncontrollable. In such instances, like unexpected setbacks or health concerns, students may acknowledge and express their emotions and engage in activities for emotional relief, including seeking wellbeing support.

The study reveals a dynamic interplay between problem-focused and emotion-focused coping strategies in medical students. Recognising that medical students tend to adopt different coping strategies in different situations, medical education systems should aim to develop or tailor existing resources to provide appropriate academic and wellbeing support.

The COVID-19 pandemic placed increased pressure on service provision and healthcare worker [HCW] wellness. As the pandemic recedes, staff need an appropriate response to facilitate individual and organisational recovery, to minimise long-term healthcare worker burnout and to be better equipped for future crisis in healthcare. The aim was to explore and reflect on the experiences of staff working during the COVID-19 pandemic in an acute paediatric hospital to determine an appropriate response in the post-crisis work environment.

A Qualitative research design using responses from open ended questions from one hundred and thirty-three clinical and non-clinical staff (89% clinical) from an Irish paediatric teaching hospital. Reponses were thematically analysed.

HCWs experienced frustration, uncertainty, anxiety and stress, during the pandemic crisis. This included communication inconsistencies, inadequate support and staffing and other resource shortages, leaving staff at high risk for long-term burnout as the pandemic recedes. Three themes were developed detailing this; 1) Support, 2) Communication and 3) Trust.

This research supports the long-standing need to increase mental health service investment and to implement an appropriate response to regain and maintain a healthy workforce, post COVID-19. This response should address the biopsychosocial needs of the individual and healthcare organisations should work dynamically, creatively and collaboratively to ensure the psychological safety of its workforce moving forward.

Functional outcome can be even more important than syndromic outcomes, as the ability to meet role expectations at work, home, or school and the quality of interpersonal relationships are often cited as the most important outcomes for people with bipolar disorder (BD) and their families. We investigated the factors correlated with functioning by using the Functioning Assessment Short Test (FAST).

A total of 197 bipolar disorder out-patients were involved in this study, 166 (84.3%) were bipolar I disorder (BD-I) patients and 31 (15.7%) were bipolar II (BD-II) patients. We used the FAST for functioning of the patients and the severity of depressive and manic/hypomanic symptoms were measured by bipolar depression rating scale (BDRS) and Young Mania Rating Scale (YMRS). We also examined the disturbances in biological rhythm by the Biological Rhythm Interview of Assessment in Neuropsychiatry (BRIAN).

There were significant positive correlations between FAST and numbers of depressive episode, YMRS, BDRS and BRIAN and showed negative correlation between FAST and age at onset of mood disorder. FAST was associated with YMRS (β=0.3768, p < 0.001), BDRS (β=0.293, p < 0.001), BRIAN (β=0.167, p = 0.011), with 47.1% of the variance explained (R2=0.471, Durbin-Watson test = 1.51, p < 0.001) in multiple linear regression. In other words, residual mood symptoms and biological rhythm imbalance have a negative impact on the functioning of BD patients.

Although the other factors must be present to predict the functioning of bipolar disorder patients, manic symptoms, depressive symptoms and biological rhythm imbalance have negative impacts on functioning of BD patients in this study.

Introduction: During involuntary hospital commitment, patients are detained and receive treatment involuntarily without prior judicial authorisation. Instead, detentions are scrutinised after-the-fact through mental health review tribunals (MHRTs), where psychiatrists must satisfy the panel that hospital detention is the least restrictive option. Such settings are different from what doctors are typically trained to do – namely provide care to willing patients. Yet, presenting evidence at MHRTs is part of regular psychiatric practice. Thus, doctors training in psychiatry would need to learn this skill.

Objective: Review the available literature on learning methods that are effective at developing junior doctors’ capability to present evidence at MHRTs.

Methodology: Seven electronic databases (Medline, Embase, PsycINFO, Web of Science, Education Source, ERIC, Westlaw UK) were searched for studies evaluating the teaching/training of junior doctors to deliver evidence at MHRTs and related settings (inquests, criminal courts), published within the last 25 years. Due to the heterogeneity in methodology, the studies were reviewed narratively.

2,206 articles were found, of which six met criteria (four quasi-experimental studies, two qualitative studies). All quasi-experimental studies were from the UK whilst both qualitative studies were of non-UK origin. Sample sizes were uniformly small (3–16 participants) or unclear/undocumented (2 studies). One study revolved around interprofessional learning in criminal court setting. The remainder were about MHRTs, using a mix of modalities (simulation = 2, workshop = 1, lecture with demonstration = 1, instructional document = 1). Simulation, lecture with demonstration, and workshop were effective at developing skills in oral presentation and being cross-examined. All methods were effective at developing report writing skills. However, articles mainly assessed efficacy through pre/post self-assessment of confidence without control/comparator.

Discussion: MHRT guidelines indicate hands-on learning as mainstay of how doctors develop their capabilities in MHRT. However, this is not reflected in or supported by the published evidence. Likewise, evidenced methods (e.g. simulation, workshops) are resource-intensive and may be difficult to replicate at scale. Additionally, identified articles lacked clear articulation of the pedagogy or theory underpinning the learning, though they appeared constructivist in nature.

The literature around training junior doctors to deliver evidence at MHRT is underdeveloped. Current standard methods are not supported by evidence whilst evidence-backed methods may be difficult to implement cohort-wide. What evidence that exists is weak and based on subjective self-assessment. Further research on the topic is needed, both around standard training/learning methods and more objective methods of assessing efficacy.

Lithium is the recommended first-line pharmacological treatment for bipolar disorder and as an augmentation of the treatment for depression. Both NICE and local guidelines stipulate the need for patient counselling regarding side effects, interactions and toxicity, alongside strict monitoring requirements for initiation and maintenance.

We aimed to assess compliance with these guidelines for patients prescribed lithium on a functional older adult inpatient ward in Hertfordshire Partnership NHS Foundation Trust (HPFT). Additionally, following feedback from the local crisis and community colleagues, concerns were emphasised around inconsistent communication on discharge. We therefore also aimed to evaluate the introduction of a small-scale intervention to the method of discharge communication.

A retrospective analysis of electronic patient records was undertaken for the 43 patients within HPFT prescribed lithium during their inpatient stay on a functional older adult ward over a five-year period (2019–2023).

Lithium monitoring on drug initiation was assessed for compliance with the standards set by NICE guidelines for the management of bipolar disorder. For all patients prescribed lithium, we also noted demographics, diagnosis, rate of side effects and toxicity, discontinuation, and documentation of discharge communication to the community. A standardised template for communication with community and crisis colleagues was introduced, and its impact was assessed.

58% (n = 25) of patients were initiated on lithium, with 80% (n = 20) of them having documentation of counselling. Baseline blood tests were consistently recorded for all newly prescribed lithium patients (n = 25), and regular serum monitoring was present in all patients. Common side effects included tremors (26%; n = 11) and polyuria (7%; n = 3), while in 63% of patients (n = 27), no side effects were noted. Toxicity occurred in four cases, leading to discontinuation in 50% of them.

Prior to concerns being highlighted around handovers to community colleagues, there was specific documentation of a handover in 19% (n = 6) of cases. Following consultation with stakeholders and consensus regarding the trial of a template for communication to the patient's community consultant, documentation improved to 75% (n = 6).

All patients in this study who were initiated or maintained on lithium received serum monitoring as inpatients in accordance with NICE guidelines. The introduction of small-scale improvements with a standardised template has been effective, significantly improving discharge communication with community colleagues for patients on lithium. Further research is necessary to elucidate the impact of these changes on patient care in the community by gathering feedback from a diverse group of community colleagues.

This audit aimed to review prescribing in First Episode Psychosis (FEP) in Gloucestershire Health and Care NHS Trust, against NICE guidelines (CG 178) we hoped to develop prescribing guidelines for the Trust and to compare our results with Avon and Wiltshire Partnership (AWP) Trust's results of similar audit (AWP-235 Audit of Prescribing in FEP).

The sample was the Trust Early intervention (EI) caseload of patients with diagnosis FEP. We developed the audit tool based on AWP's audit methodology.

We gathered information about

• • The role of initial prescribers.

• • The prescribing of up to three antipsychotics.

• • Choices of antipsychotic medication, whether the patient was given choice and information about the antipsychotic.

• • Recorded reviews of side effects.

• • Duration of treatment.

• • Reasons for switching antipsychotic.

• • Whether clozapine was offered to patients where indicated.

• • Whether a recommended antipsychotic free period allowing for investigations and assessments was adhered to.

• • Other medications prescribed alongside the antipsychotics.

77 patients were identified.

• • Adherence to the NICE guideline criterion of initial prescriber being in secondary care was good.

• • Olanzapine was the preferred first antipsychotic choice for 50% of patients, aripiprazole was the most common choice as 2nd and 3rd antipsychotic (around 30% patients).

• • Recording of Information about antipsychotic treatment was lower than expected, about 30% of the sample at first choice, this increased to 50% for second choice and 40% at the third choice of antipsychotic.

• • Around 90% of the sample had recorded review of medication and its side effects.

• • 17% of the sample had duration of treatment less than 6 weeks at first antipsychotic, this dropped to 9% and 6% at second and third respectively.

• • Reasons for switching were mostly due to side effects and lack of efficacy. Refusal to take the antipsychotic was a common reason for switching to the third antipsychotic.

• • Only about 20% of patients who were eligible were offered clozapine.

• • An antipsychotic free period up to 7 days was adhered to in almost 70%.

As a result of the audit findings we have developed Trust prescribing guidelines for adults presenting with FEP, which include recommendation for 7-day antipsychotic free assessment period, need to involve patients and family/carers when making decisions about choice of medication and recorded discussion about clozapine for eligible patients.

Apathy is a complex clinical, neurobehavioural and neurobiological construct that occurs across a range of neuropsychiatric disorders. Apathy is defined as persistent, diminished motivation with impairments in goal-directed behaviour, thought, cognitive activity and emotions. Apathy negatively impacts on participation/engagement in rehabilitation and community reintegration, quality of life, and increased occupational and economic burden on families and traumatic brain injury (TBI) patients. Apathy is among the most common sequelae of TBI, with prevalence estimated to be in excess of 10%, and up to 60% in comorbid depression and apathy.

There is no standard treatment for apathy, although anecdotal evidence suggests that Modafinil may be effective. Current pharmacological management strategies focus on addressing the comorbidities associated with it: e.g. acetylcholinesterase inhibitors to treat both Alzheimer's disease and apathy; dopaminergic agonists for Parkinson's disease and apathy; and antidepressants for depression and apathy.

This literature review will assess the clinical evidence of Modafinil, and recommended use for treating post-TBI apathy.

An extensive search was conducted in the major databases, PsychInfo, Cochrane, Europe PMC, PubMed, EMBASE and MEDLINE, to evaluate Modafinil treatment for apathy in TBI patients. Additionally, the literature review included extra sources found in the citations. Out of 70 citations, only one was accepted for further analysis. The remaining citations were rejected due to their ineligible abstracts, absence of pharmacological interventions, inclusion of non-TBI apathy and being non-English language articles.

The accepted paper did not meet Level III evidence or better following analysis.

The review however identified case reports suggesting the potential effectiveness of Modafinil in treating post-TBI apathy.

Although the exact mechanism of action of Modafinil remains unclear, it is associated with improvement in working memory, attention and prefrontal-dependent cognitive function. This improvement is linked to elevated levels of extracellular dopamine, norepinephrine, serotonin, glutamate and histamine, as well as decreased GABA levels. Modafinil activates the anterior cingulate cortex, and shows positive correlation with cognitive improvement. Neuroanatomically, there is a strong association between apathy and disruption of the cortico-basal ganglia loop, involving the dorsal anterior cingulate cortex, ventral striatum and connected brain regions. Modafinil possibly has unexplored benefits in improving apathy through activation of the anterior cingulate cortex.

There is limited empirical evidence for effective treatments for post-TBI apathy. This review emphasizes the urgent need for further research that aligns with underlying neuroanatomical pathology in order to determine the most effective psychopharmacological interventions for managing post-TBI apathy.

Belfast Trust Addictions Service was among the first addictions teams in the UK to get their own Fibroscan® machine, in March 2021. In the two preceding years (2019–2020), only 32% of patients referred by addictions to hepatology for hepatitis C virus (HCV) attended their appointments.

Patients under the addictions service are known to access healthcare services poorly while being at increased risk, with a clear need to improve their access to appropriate care.

We aimed to review how the Fibroscan® machine has been used in the addictions service, and if there has been an impact on how the patient cohort access healthcare.

We reviewed our case records of all patients offered a Fibroscan®, and whether they attended the appointment, and reviewed indications of each scan in the three following categories. Firstly, for those with alcohol misuse. Secondly, for HCV cases in which Fibroscan® results help decide treatment choice. Thirdly, ‘other’ – for example, consultant discretion due to LFT results.

308 patients were offered Fibroscans® between March 2021 and February 2023.

238 patients attended their appointments, of which 194 were for alcohol misuse, 43 for HCV and 1 ‘other’.

70 patients did not attend their appointments, of which 67 were for alcohol misuse and 3 ‘other’.

Scans for HCV were completed ad hoc (i.e. without an arranged appointment) so are not included in attendance rates. The attendance rate for scheduled Fibroscan® appointments (for alcohol misuse and ‘other’) was 74%.

Of the 194 patients scanned for alcohol misuse, 40 were then referred to hepatology with likely cirrhosis.

238 patients underwent a Fibroscan®, leading to 40 hepatology referrals for likely cirrhosis, and 43 patients being offered appropriate HCV treatment.

Crude DNA rates appear greatly improved – 74% attendance at our Fibroscan® appointments vs 32% attendance at hepatology referral appointments.

Many antipsychotics are known to adversely affect prolactin levels causing hyperprolactinemia. National Institute for Health and Care Excellence (NICE) guidelines have suggested monitoring of prolactin levels. It specifies that prolactin should be checked 6 months after starting treatment, then every 12 months; and to ask about symptoms of raised prolactin which include low libido, sexual dysfunction, menstrual abnormalities, gynaecomastia, and galactorrhoea. This also mentions that it is not required for aripiprazole, clozapine, quetiapine, or olanzapine (less than 20 mg daily). We intended to audit the monitoring of prolactin in a sample of inpatients who are on antipsychotic drugs and to check whether action was taken in the event of a high prolactin level.

All the adult inpatients of a general psychiatric hospital on a specific date (34, 16 (47.1%) female and 18 (52.9%) male patients), who were on antipsychotics were considered for the audit. We checked the antipsychotic drugs, prolactin assessment within one year and level, action taken if there was hyperprolactinemia. The data was collected from electronic patient records and medication charts.

The mean age of the sample was 39.1 ± 14.2 years (range 18–63). Most inpatients (91.2%, 31/34) were on antipsychotics and 25.8% (8/31) were on two antipsychotic drugs. Prolactin was measured in 80.6% (25/31) patients in the last year, with 48% (12/25) having hyperprolactinemia; and amongst these action was taken in 5 (41.7%). Hyperprolactinemia was present in 58.3% of female and 38.5% of male patients. Specifically, out of 31 patients, 14 (45.2%) were on antipsychotic drugs that need monitoring, and 9 (74.3%) of them had taken it for at least one year. Out of these 9 patients, prolactin was measured in 8 (88.9%) patients in the last year, it was elevated in 5 (55.6%), action was taken in 3 (60%) and action was not clear in 2 (40%) patients.

Almost half of the patients on antipsychotic drugs had hyperprolactinemia, highlighting the need to monitor prolactin levels. Along with this, symptoms of hyperprolactinemia should be consistently checked in routine clinical evaluations. Clinician and patient education regarding hyperprolactinemia and its symptoms might improve its monitoring.

1. 1. To provide Scotland-wide data on Core Trainees’ motivations, their future plans and the barriers to applying for Higher Training.

2. 2. To raise awareness of any collective issues.

3. 3. To provide recommendations to the Royal College of Psychiatrists, NHS Education for Scotland (NES) and the Scottish Government based on the results.

A Microsoft Forms survey was emailed to all 176 Core Trainees in Scotland through regional PTC representatives in East, West, South East and through the Core Training Programme Director in the North. Speciality doctors who were post Core Training, and waiting to apply for Higher Training, were identified by snowball sampling and were also emailed a link to the survey. Data was collected between 26/10/23 and 21/11/23.

• – All regions in Scotland and all levels of training were well represented by trainee response rates. Trainee participation was high with 90 doctors responding from across all areas in Scotland and all levels of training.

• – 83.3% of trainees feel that the current availability of Higher Training posts is affecting morale and motivation in psychiatry.

• – 96% of trainees plan to enter Higher Psychiatry Training and the majority of trainees (63%) want to enter Higher Training directly from Core Training. The availability of their chosen Higher Training post was the number one reason for not wanting to enter Higher Training directly.

• – Less than full time working is increasing and likely to increase further (nearly 29% of participants are currently LTFT. 30% definitely plan to do some of their Higher Training LTFT and a further 34% are considering it).

• – The majority of trainees (70%) wish to continue training in their current region. Trainees may be lost from Scotland if they are unable to secure a training post in their chosen region (27% of those considering another region would consider leaving Scotland). Those who would consider leaving Scotland came from all regions – of the 27%: 22% were East, 26% North, 26% South East and 26% West. Second choice regions for consideration remain those that have the most filled posts in Scotland (27% would consider South East Scotland, 22% West, 15% East and 9% North).

• – Participants included lengthy and detailed responses to a free text box at the end of the survey titled “Do you have any additional comments” with several recurring themes. These included less than full time not being accounted for in the overall Higher Training numbers, difficulties in moving region, feeling stressed and demoralised by the application process, feeling undervalued and considerations around leaving Scotland.

1. 1. The primary obstacle preventing core trainees from progressing to Higher Training, as identified by them consistently across regions, is the scarcity of available Higher Training posts across regions, relative to the number of Core Trainees finishing their Core Training.

2. 2. The ongoing increase in less than full time working, with two-thirds of trainees considering pursuing some of their Higher Training on a less than full time basis, will further delay the release of training numbers and therefore growth of consultant numbers without full time equivalent numbers.

3. 3. Trainees may be lost from Scotland. The majority of trainees settle in their Core Training region and there are several reasons that moving may be difficult. Of those who would contemplate relocation, 27% would consider leaving Scotland and the main regions in Scotland that would be considered as alternatives already have the highest fill rates.

Referrals to secondary mental health services in the United Kingdom are at record levels. In the wake of the coronavirus pandemic and cost of living crisis, many experienced a deterioration in their social and financial circumstances. It is widely accepted that social determinants impact mental health and wellbeing. This analysis aimed to investigate socioeconomic and psychosocial stressors contributing to referrals to the Community Mental Health Recovery Service (CMHRS) for the general adult population in Epsom, Surrey.

This retrospective case note analysis focused on Single Point of Access (SPA) referrals made to CMHRS Epsom between 1st September 2022 and 1st September 2023. A random number generator was used to select a cross-section of 30 cases from 141 referrals. Following exclusion criteria, 29 cases were examined using an ICD–10 social determinants of health (Z55-Z65) lens. Finally, thematic analysis was used to identify key socioeconomic and psychosocial factors impacting referred patients.

Patients were most commonly referred to CMHRS for presentations of suicidal ideation and self-harm (n = 13). Referrals were also related to symptoms of depression, anxiety and psychosis, the need for diagnostic clarity and for review of medication. All but one referral (n = 28) cited psychosocial stressors contributing to the patient’s presentation. Five key themes were identified. These were: current unemployment (n = 18), current housing and financial concerns (n = 18), ongoing social isolation (n = 19), relationship conflict and breakdown (n = 10) and a background of child sexual and physical abuse (n = 10). Protective factors, for those able to identify them, were exclusively linked to the patient’s social network (n = 22). Patients cited family members, friends, neighbours, the church and their pets as reasons to stay alive and accept support.

This analysis concluded that referrals to secondary mental health services in Epsom are significantly associated with a person's current and historical social circumstances. Policies and services which provide early intervention support with housing, employment and finances are vital in reducing the mental distress of at-risk individuals while also reducing pressure on mental health services. Reinforcing community and social support systems may be key in helping patients buffer psychosocial stress. Further study on this issue, involving a larger cohort, would be beneficial.

STOMP (stopping the over-medication of people with a learning disability, autism, or both) is a national project launched by NHS England in 2016. The objective is to curb the excessive use of psychotropic medication in individuals with a learning disability, autism, or both to manage behaviour that challenges. This means ensuring that medications are prescribed at the lowest effective dose for the shortest duration of time, and aiming to discontinue if appropriate.

We aim to broaden the implementation of the STOMP initiative to a relatively new residential nursing home in Northern Ireland that is home to individuals with learning disabilities and complex care needs. The residents are discussed at monthly MDT meetings attended by psychiatry, positive behaviour support (PBS) practitioners, activities coordinators, and nursing home managers.

The inclusion criteria for STOMP are 1. Diagnosis of learning disability, autism, or both, 2. Currently taking psychotropic medication primarily for behaviour that challenges and 3. No diagnosis of severe and enduring mental illness. Five patients were eligible for STOMP.

Outpatient letters and medication prescriptions from the time of admission were compared with the most recent outpatient letters and medication prescriptions.

The five residents were on a range of psychotropic medications including antipsychotics, antidepressants, benzodiazepines, and antihistamines. Following STOMP implementation there was a reduction in psychotropic medication for 80% of the residents.

Patient 1: Reduction in antipsychotic from 75% BNF max daily dose to 40%.

Patient 2: Previously on two antipsychotics with combined use of 75% BNF max daily dose – both medications now discontinued.

Patient 3: Reduction in antipsychotic from 69% max daily BNF dose to 50%, PRN antihistamine discontinued.

Patient 4: PRN antipsychotic discontinued from 15% max daily BNF dose, benzodiazepine use reduced by 5%.

Patient 5: Antipsychotic use increased from 25% max daily BNF dose to 33%.

There was a reduction in psychotropic medication in 80% of the residents. This is an encouraging finding and shows that the STOMP initiative can be expanded to include residential nursing homes. Despite relatively limited resources for STOMP implementation in our local service, we have shown that by keeping the STOMP ethos at the centre of our thinking during monthly MDT meetings involving nursing home management, PBS practitioners, psychiatry, and activities coordinators, we can make sustained reductions in psychotropic prescribing.

To carry out systematic literature search on an international medical database to find what the emerging categories in which the word hatred is used in medical literature are, and to gather information regarding the generation of the emotion of hatred in human beings by thematically analysing the relevant collected data.

To identify the information on hatred relevant for mental health professionals, we performed a systematic review using a systematic approach and criteria.

Six themes regarding generation of hatred identified.

Theme one: Targets of hatred.

Theme two: Self-hatred.

Theme three: Self-perceived hatred.

Theme four: Hatred towards inanimate objects.

Theme five: Reasons for hating other humans.

Theme six: Internal reasons for development of hatred.

The word ‘hatred’ is used in medical literature in a multiplicity of meanings that range from using it in its literal sense to describe a subtle attitude such as a phobia-philia relationship, or to describe a unique outcome that is generated as an interplay of several different kind of factors. These may include cognitions, behaviours, social interactions, attitudes, sentiments, developmental backgrounds, psychodynamic interactions with others in real and virtual worlds etc. Hatred is more like a mind-set that people can develop towards themselves, towards others and towards inanimate objects or situations too. Fear, anger and disgust are primary emotions (that we are born with); human psyche is naturally prone to several inevitable cognitive errors; human thought is subjected to unavoidable logical fallacies; and human ego cannot avoid utilising unhealthy ego-defence mechanisms. Every child is born in a family and culture that has its own unique background and history. We humans are prone to the generation of the hateful mindset as an unavoidable outcome in a variety of scenarios. Keeping these generational patterns in view, it would be reasonable to say that an early detection and addressing the early warning signs towards development of the hateful mind-set would be helpful for ourselves and for others. As the word is used in several different meanings, the background information, context, and overall scenario of the discussion needs to be kept in mind whilst attempting to draw any meanings about the use of hate/hatred in a verbal or written expression. In each case where the word ‘hatred’ is used, needs to be approached with epistemic curiosity and in some instances, it may need detailed epistemic inquiry to fully comprehend the meaning of this word in any given expression.