Chronic pain is common and debilitating, and recommended treatments are only moderately effective for pain relief. Focus has shifted to refining targets for change within psychological therapy to improve pain management. Evidence has shown the role of intrusive images in many psychological disorders. However, only a few studies have advanced our knowledge of the presence and impact of mental imagery in chronic pain. This exploratory study aimed to increase our understanding of how people with chronic pain perceive intrusive visual images to influence their daily life. The study employed a qualitative design, using semi-structured interviews to explore the content, emotional valence, cognitive and behavioural impact of pain-related visual images of ten participants with self-reported diagnosis of chronic pain. Data analysis was conducted by performing an inductive thematic analysis. Three key themes were identified: (1) ‘I start to create images in my head’: pain-related mental images, which revolves around descriptions of participants’ most significant visual image; (2) metaphors for pain, related to the imagery as a means to conceptualise and give meaning to the pain; and (3) “With the pain comes the image”: a companion to pain, which focuses on the role of intrusive images in the experience of pain. Results show that pain-related mental imagery appeared to be an intrusive, uncontrollable, and vivid cognitive accompaniment for many pain sufferers. The findings suggest that mental images may serve as an additional target in cognitive behavioural therapy to enhance individuals’ cognitive, behavioural and emotional change.

1. (1) To understand the role of mental imagery in the daily life of individuals with chronic pain.

2. (2) To examine the impact of intrusive images on the emotions, cognitions, and behaviours of people with chronic pain.

3. (3) To consider clinical implications for CBT interventions targeting pain-related mental images to manage chronic pain.

The National Institute For Health And Care Excellence (NICE) is widely acknowledged as a seminal health technology assessment (HTA) body, known for its transparent and accountable approach to decision-making. This research aimed to investigate the impact of NICE methodology and decisions on international HTA bodies. We sought to identify direct and indirect factors that may influence an international HTA body’s methods or outcomes. To the best of our knowledge, this is the first research to use a qualitative approach to understand the influence of NICE on other HTA bodies.

We conducted 13 semi-structured qualitative interviews with HTA and market access experts from industry and academia from nine countries (Brazil, Israel, Italy, Japan, Poland, Saudi Arabia, South Korea, Sweden, and the United Arab Emirates). The interview script was organized into three main sections: comparing NICE methods and processes with other HTA bodies; the impact of specific NICE decisions; and Likert scale questions (to allow for comparability of opinions).

Most interviewees believed their local HTA body would consider NICE’s decision when evaluating a medicine. However, the way and extent to which NICE influences HTA varied across countries. The most common means of considering a NICE decision was as background information or context for an HTA evaluation. Generally, interviewees suggested that negative NICE decisions had more impact on local decision-making than positive decisions. Nine of the 13 interviewees agreed or strongly agreed that their country’s HTA body considers the decisions of other HTA bodies in their decision-making process. Eleven of the 13 interviewees agreed or strongly agreed that the development of their country’s HTA body methods and processes was influenced by NICE.

NICE is perceived to be a seminal HTA body, with continued influence on HTA agencies in other countries. However, the mechanisms and extent of this influence varies considerably between countries. We suggest that implicit factors are likely to contribute more to NICE’s influence than individual decisions. Nevertheless, further research is needed to reveal these factors and increase efficiency in international HTA decision-making processes.

The report examined reciprocal within-person associations among maternal depressive symptoms and offspring depressive, anxiety and irritability symptoms from early childhood to adolescence using a random intercept cross-lagged panel model (RI-CLPM).

Participants were 609 mother–child dyads participating in the Stony Brook Temperament Study. Child and maternal internalizing symptoms were assessed every 3 years from ages 3 to 15 using maternal report on the Child Behavior Checklist (CBCL) and Diagnostic Inventory for Depression, respectively.

At the between-person level, maternal depressive symptoms, and child depressive, anxiety, and irritability symptoms were all positively associated with one another. At the within-person level, greater within-person child anxiety symptoms at age 3 predicted both greater child anxiety and depressive symptoms at age 15 via greater child anxiety from ages 6 to 12, and greater within-person child irritability at age 3 predicted greater maternal depressive symptoms at age 15 via greater child irritability from ages 6 to 12.

Findings reveal novel within-person developmental pathways from early childhood internalizing problems to later internalizing problems in both the child and mother. Intervention and prevention efforts should thus focus on early identification and prevention of childhood internalizing symptoms to reduce negative effects on both child and parent symptoms.

To improve the confidence and preparedness of junior doctors in managing medical or psychiatric emergencies when on call at an inpatient psychiatric unit.

Facilities for emergency care differ between acute medical and psychiatric units. Protocols for managing acutely deteriorating patients and those requiring immediate resuscitation differ across these organisations.

Managing medical emergencies can be stressful for all involved. Junior doctors rotate between services where the level of support varies depending on specialty and setting. For doctors who have worked in a setting where the minimum emergency response includes a Resuscitation team, moving to an environment with less support available is a challenge.

In our unit, the protocol following an urgent call is for the on-call doctor (who has access to basic resuscitation equipment) to attend and assess the need for paramedics and transfer to local hospital. Stress can be worsened by change of environment, change of expectation and concern about best management in new settings.

A cohort of junior doctors were recruited. Baseline assessment included rating their confidence level (scale 1- 10), listing common medical and psychiatric scenarios they had experienced and those they felt least confident managing. Over a period of 10 weeks, follow-up data was obtained. Interventions to improve confidence were assessed during this period, including a handbook and a teaching session on emergency medications. At the end of the project a wordcloud was created in response to the request to “choose 5 words to describe your feelings when called to an emergency”. Identified themes have been fed back to relevant senior staff and will form the basis of future projects.

The initial average confidence score improved from 4.9 to 9.2 and was sustained out to 14 weeks. According the word cloud the most commonly used words were “morale” and “education”.

Prior to the study, confidence levels amongst the Junior Doctors was low. Introduction of the handbook and teaching session led to an improvement which was sustained. Key themes identified using a word cloud were “morale” and “education”.

For junior doctors moving from between services, different expectations and protocol for management of emergencies can influence confidence levels. Psychiatric units should be cognisant of these concerns and implement evidence-based intervention to support junior doctor confidence and improve quality of working experience.

The aim of this project is to improve the training experience of Psychiatry trainees across CNWL. In QI terms, we want to achieve a satisfaction rating of above 7/10 for all themes identified by August 2021.

Collected baseline data on satisfaction and priority ratings on 7 training themes Held discussion groups with trainees for specific themes to generate issues and solutions Developed and provided Quality Improvement training for trainees and trainers, 1:1 support and QI clinics – empowering trainees to develop their own local project and to make changes to issues on the ground Enacted central changes in communication, responsiveness, recognising success.

Reassessed and fedback to the trainees throughout.

Our baseline satisfaction survey was completed in June 2020. Trainees their satisfaction for each theme out of 10 and to rank their priorities for change. Results showed satisfaction was lowest in morale and in safety and highest in education and supervision. Their highest priorities for change were safety, then morale, with induction as the lowest priority.

We repeated the survey in October 2020. This showed improvements in most themes (apart from induction, perhaps due to induction having to be delivered virtually). Satisfaction in key priority areas of morale and safety increased from 4.53 to 6.37, and 5.12 to 6.70 respectively. We also asked what ‘one thing’ would they improve about their training. Key phrases included teaching, on-call, communication and induction.

From this data, and softer feedback from trainees, it is encouraging that we are moving in a positive direction, but we are continuing to make changes.

• • Trainees must be central to the work in improving their training

• • Using QI methodology helps – developing a structure and breaking down a bigger task helps make a plan

• • Feedback is key – but people are busy and receive a lot of emails and requests to fill surveys – catching people ‘in person’ (virtually) was the best way to ensure a lot of responses

• • Trainees have loads of great ideas, but they need support, time and resources to be able to develop their projects and changes

• • Flexibility is crucial: some topics work better locally, driven by trainees and some require a more coordinated, central role

The COVID pandemic has had both a massive impact on clinical service delivery and the way that training and education is provided. CNWL is a large NHS provider and has approximately 7000 staff working across 150 locations, providing mental health and community health services. In response to the need to share learning across the organisation, a trustwide “Safety Conversation Day” took place to spotlight the work being done to promote safety and to act as a platform to share ideas and learning across the trust. This was the first ever virtual conference organised by the trust.

The one-day conference included virtual posters and an all-day open access virtual conversation delivered via zoom. The day was divided into 6 safety themes: Safety tools; Safer Environments; Supporting and Involving Staff; Safer use of Medicines; See Think Act and Relational Security; and Prevention is Better than Cure. Frontline staff delivered 5-6 short presentations each hour highlighting new ways of working, quality improvement, local research etc.

Staff were also encouraged to submit posters for the event, with webinars held on how to write a poster held prior to the safety conversation to promote engagement. Prizes were awarded for best posters in the different categories.

A mentimeter survey was running throughout the day to get feedback from participants.

This was the largest event of this kind held by the trust. 430 unique viewers logged in during the day to watch the presentations.

Feedback was very positive on the mentimeter survey. 3 questions were asked on a likert scale of: Strongly Disagree – Strongly Agree (rated out of 5):

• – ‘I found the posters really useful': 4.5/5

• – ‘I found the presentations very useful': 4.6/5

• – ‘I will share what I've learnt about safety': 4.6/5

174 posters were presented with good representation from all services and staff groups across the trust (18 on safer use of medicines, 15 on co-production, 52 on quality improvement, 50 on COVID and non-COVID safety, 16 on use of technology, 23 on supporting and involving staff). These posters have since been downloaded 4062 times.

The first CNWL safety conference proved an excellent opportunity to celebrate achievements in patient safety in a very difficult year. It was very well-received and well-attended by staff, promoting maximal learning across the organisation.

This study aimed to investigate general factors associated with prognosis regardless of the type of treatment received, for adults with depression in primary care.

We searched Medline, Embase, PsycINFO and Cochrane Central (inception to 12/01/2020) for RCTs that included the most commonly used comprehensive measure of depressive and anxiety disorder symptoms and diagnoses, in primary care depression RCTs (the Revised Clinical Interview Schedule: CIS-R). Two-stage random-effects meta-analyses were conducted.

Twelve (n = 6024) of thirteen eligible studies (n = 6175) provided individual patient data. There was a 31% (95%CI: 25 to 37) difference in depressive symptoms at 3–4 months per standard deviation increase in baseline depressive symptoms. Four additional factors: the duration of anxiety; duration of depression; comorbid panic disorder; and a history of antidepressant treatment were also independently associated with poorer prognosis. There was evidence that the difference in prognosis when these factors were combined could be of clinical importance. Adding these variables improved the amount of variance explained in 3–4 month depressive symptoms from 16% using depressive symptom severity alone to 27%. Risk of bias (assessed with QUIPS) was low in all studies and quality (assessed with GRADE) was high. Sensitivity analyses did not alter our conclusions.

When adults seek treatment for depression clinicians should routinely assess for the duration of anxiety, duration of depression, comorbid panic disorder, and a history of antidepressant treatment alongside depressive symptom severity. This could provide clinicians and patients with useful and desired information to elucidate prognosis and aid the clinical management of depression.