Increasing rates of involuntary treatment in the UK and persisting ethnic disparities in detentions have led to the reform of the Mental Health Act (MHA) in 2025. The MHA bill introduces several new measures including the offer of Advance Choice Documents (ACDs) to people who wish to make them. ACDs are written statements of a person’s wishes and preferences for treatment and care, made when a person is well and has the capacity to do so. Systematic reviews show that ACDs can reduce detention rates by up to 25%. The South London and Maudsley NHS Foundation Trust (SLaM) rolled out ACDs as part of routine care, ahead of the MHA 2025. This study describes the implementation of ACDs as part of routine care at SLaM.

SLaM recruited independent senior mental health professionals (ACD facilitators) to lead the creation, use and review of ACDs. The facilitators underwent training and utilised resources previously developed through previous research. The resources included an ACD template, an ACD manual and role description for facilitators, simulation training and Recovery College courses. A clinical lead and clinical supervisor were also employed to provide oversight for the implementation project. Data on implementation were collected through case note reviews, and interviews with service users and staff. Analyses on how ACDs were created and used when people experienced crises were conducted.

At the time of abstract submission, 77 ACDs have been created with service users at SLaM. The implementation of ACDs has been aided by service user-led initiatives such as the Patient Carer Race Equality Framework, staff training, and Recovery College courses which enabled people to create ACDs with high fidelity to the evidenced interventions. Staff and service users report that the ACD creation process is a holistic experience that is empowering and beneficial for improving therapeutic alliance between service users and mental health professionals. The main barrier cited by staff was a lack of time due to large caseloads.Service users expressed scepticism about their ACDs being accessed and honoured during times of crisis.

Implementing evidence-based interventions in healthcare settings is complex. SLaM has replicated the implementation of ACDs with high fidelity to the intervention trials that reported reductions in Mental Health Act detentions and greater autonomy for service users. Our results show that multiple strategies are needed to accelerate the reach and adoption of ACDs in other Trusts.

According to existing evidence, during menopause transition, women with psychosis may present with exacerbated psychiatric symptoms, due to age-related hormonal changes.

We aimed to (a) replicate this evidence, using age as a proxy for peri/menopausal status; (b) investigate how clinical presentation is affected by concomitant factors, including hyperprolactinaemia, dose and metabolism of prescribed antipsychotics using cross-sectional and longitudinal analyses.

Secondary analysis on 174 women aged 18–65, from the IMPaCT (Improving physical health and reducing substance use in psychosis) randomised controlled trial. We compared women aged below (N = 65) and above 40 (N = 109) for (a) mental health status with the Positive and Negative Syndrome Scale (PANSS) and Montgomery Asberg Depression Rating Scale; (b) current medications and (c) prolactin levels, at baseline and at follow-up (12/15 months later).

Women aged above 40 showed higher baseline PANSS total score (mean ± s.d. = 53.4 ± 14.1 v. 48.0 ± 13.0, p = 0.01) and general symptoms scores (28.0 ± 7.4 v. 25.7 ± 7.8, p = 0.03) than their younger counterparts. Progressive sub-analysis revealed that this age-related difference was observed only in women with non-affective psychosis (n = 93) (PANSS total score: 57.1 ± 13.6 v. 47.0 ± 14.4, p < 0.005) and in those prescribed antipsychotic monotherapy with olanzapine or clozapine (n = 25) (PANSS total score: 63 ± 16.4 v. 42.8 ± 10.9, p < 0.05).

Among all women with hyperprolactinaemia, those aged above 40 also had higher PANSS positive scores than their younger counterparts. No longitudinal differences were found between age groups.

Women aged above 40 showed worse psychotic symptoms than younger women. This difference seems diagnosis-specific and may be influenced by antipsychotics metabolism. Further longitudinal data are needed considering the menopause transition.

Advance Choice Documents (ACDs) have been recommended for inclusion in new mental health legislation for England and Wales based on evidence they reduce compulsory psychiatric admission, with particular benefit for Black people. As Black people disproportionately experience compulsory psychiatric admission in the UK, our aim was to explore potential barriers and enablers to effective ACD implementation for Black people with previous experience of compulsory admission.

Six stakeholder workshops and one consensus workshop were held with: Black service users who had previously been involuntarily admitted, carers/supporters of Black service users, and mental health staff. Thematic analysis was conducted on workshop transcripts.

Participants were service users (n = 13), carers/supporters (n = 7), service users and carers/supporters (n = 3), and staff (n = 18). Thematic analysis identified themes of ‘training’, ‘completion’, ‘access’, and ‘use’ concerning ACD implementation. Stakeholders highlighted the importance of understanding the racialised experience of Black service users for effective ACD implementation. Strong communication between and amongst stakeholders and helpful systems for access were also emphasised. Stakeholders also recommended joint training and independent facilitation of ACDs to address Black service user-staff power imbalances.

Known enablers and barriers to ACD implementation are important when considering ACDs for Black people, as is explicitly engaging with their experiences holistically, including racialised historical and individual experiences that underline some treatment preferences. Independent facilitation and shifts in service user-staff power dynamics present as key to realising the potential of ACDs to empower Black service users in relation to their care, and in turn to potentially reduce coercive care.

Acute behavioural disturbance (ABD) is a controversial descriptor for presentations of severe agitation, aggression and physiological compromise.

To characterise the use of ABD-related terms in the electronic record of a large UK provider of mental health services during 2006–2021.

The free text of all records relating to patient contacts with acute assessment mental health teams during 2006–2021 were searched for references to ABD. Identified text was coded for context of use and presence of clinical features of ABD described in the literature. Poisson regression was used to analyse differences in rates of use over time and between demographic groups.

Mentions of ABD increased by an average of 1.12 (95% confidence interval (CI), 1.08–1.17) per year, with the greatest increase from 2019 to 2021. Black people were more than twice as likely as White people to have reference to ABD included in their assessments (rate: 2.4/1000 (95% CI 1.8–3.1) in Black people compared with 1.0/1000 (95% CI 0.8–1.3) in White people). The clinical characteristics in notes describing a current presentation of ABD rarely corresponded to those included in UK medical guidelines on ABD.

The term ABD in mental health notes appears to often, but not exclusively, be a synonym for severe agitation and conveys little meaning beyond this. However, the term's connection to a literature emphasising the high risk of physical health collapse and need for urgent treatment means that its disproportionate use in Black people may contribute to existing racial inequalities in the use of coercive measures during crisis presentations.

People with psychosis experience cardiometabolic comorbidities, including metabolic syndrome, coronary heart disease and diabetes. These physical comorbidities have been linked to diet, inactivity and the effects of the illness itself, including disorganisation, impairments in global function and amotivation associated with negative symptoms of schizophrenia or co-morbid depression.

We aimed to describe the dietary intake, physical activity (PA) and sedentary behaviour patterns of a sample of patients with established psychosis participating in the Improving Physical Health and Reducing Substance Use in Severe Mental Illness (IMPaCT) randomised controlled trial, and to explore the relationship between these lifestyle factors and mental health symptomatology.

A majority of participants had poor dietary quality, low in fruit and vegetables and high in discretionary foods. Only 29.3% completed ⩾150 min of moderate and/or vigorous activity per week and 72.2% spent ⩾6 h per day sitting. Cross-sectional associations between negative symptoms, global function, and PA and sedentary behaviour were observed. Additionally, those with more negative symptoms receiving IMPaCT therapy had fewer positive changes in PA from baseline to 12-month follow-up than those with fewer negative symptoms at baseline.

These results highlight the need for the development of multidisciplinary lifestyle and exercise interventions to target eating habits, PA and sedentary behaviour, and the need for further research on how to adapt lifestyle interventions to baseline mental status. Negative symptoms in particular may reduce patient's responses to lifestyle interventions.

The steep rise in the rate of psychiatric hospital detentions in England is poorly understood.

To identify explanations for the rise in detentions in England since 1983; to test their plausibility and support from evidence; to develop an explanatory model for the rise in detentions.

Hypotheses to explain the rise in detentions were identified from previous literature and stakeholder consultation. We explored associations between national indicators for potential explanatory variables and detention rates in an ecological study. Relevant research was scoped and the plausibility of each hypothesis was rated. Finally, a logic model was developed to illustrate likely contributory factors and pathways to the increase in detentions.

Seventeen hypotheses related to social, service, legal and data-quality factors. Hypotheses supported by available evidence were: changes in legal approaches to patients without decision-making capacity but not actively objecting to admission; demographic changes; increasing psychiatric morbidity. Reductions in the availability or quality of community mental health services and changes in police practice may have contributed to the rise in detentions. Hypothesised factors not supported by evidence were: changes in community crisis care, compulsory community treatment and prescribing practice. Evidence was ambiguous or lacking for other explanations, including the impact of austerity measures and reductions in National Health Service in-patient bed numbers.

Better data are needed about the characteristics and service contexts of those detained. Our logic model highlights likely contributory factors to the rise in detentions in England, priorities for future research and potential policy targets for reducing detentions.

The first episode of psychosis is a critical period in the emergence of cardiometabolic risk.

We set out to explore the influence of individual and lifestyle factors on cardiometabolic outcomes in early psychosis.

This was a prospective cohort study of 293 UK adults presenting with first-episode psychosis investigating the influence of sociodemographics, lifestyle (physical activity, sedentary behaviour, nutrition, smoking, alcohol, substance use) and medication on cardiometabolic outcomes over the following 12 months.

Rates of obesity and glucose dysregulation rose from 17.8% and 12%, respectively, at baseline to 23.7% and 23.7% at 1 year. Little change was seen over time in the 76.8% tobacco smoking rate or the quarter who were sedentary for over 10 h daily. We found no association between lifestyle at baseline or type of antipsychotic medication prescribed with either baseline or 1-year cardiometabolic outcomes. Median haemoglobin A1c (HbA1c) rose by 3.3 mmol/mol in participants from Black and minority ethnic (BME) groups, with little change observed in their White counterparts. At 12 months, one-third of those with BME heritage exceeded the threshold for prediabetes (HbA1c >39 mmol/mol).

Unhealthy lifestyle choices are prevalent in early psychosis and cardiometabolic risk worsens over the next year, creating an important window for prevention. We found no evidence, however, that preventative strategies should be preferentially directed based on lifestyle habits. Further work is needed to determine whether clinical strategies should allow for differential patterns of emergence of cardiometabolic risk in people of different ethnicities.

Sexual dysfunction is common in psychotic disorder but it is not clear whether it is intrinsic to the development of the illness or secondary to other factors.

To compare sexual function in people at ultra-high risk (UHR) of a psychotic disorder, patients with first-episode psychosis predominantly taking antipsychotic drugs and healthy volunteers.

Sexual function was assessed in a UHR group (n = 31), a group with first-episode psychosis (n = 37) and a matched control group of healthy volunteers (n = 56) using the Sexual Function Questionnaire.

There was a significant effect of group on sexual function(P<0.001). Sexual dysfunction was evident in 50% of the UHR group, 65% of first-episode patients and 21% of controls. Within the UHR group, sexual dysfunction was more marked in those who subsequently developed psychosis than in those who did not. Across all groups the severity of sexual dysfunction was correlated with the severity of psychotic symptoms (P<0.001). Within the first-episode group there was no significant difference in sexual dysfunction between patients taking prolactin-raising v. prolactin-sparing antipsychotics.

Sexual dysfunction is present prior to onset of psychosis, suggesting it is intrinsic to the development of illness unlikely to be related to the prolactin-raising properties of antipsychotic medication.

Cardiovascular disease is more prevalent in patients with severe mental illness (SMI) than in the general population.

Seven geographically diverse centres were assigned a nurse to monitor the physical health of SMI patients in secondary care over a 2-year period in the “Well-being Support Programme” (WSP). A physical health screen was performed and patients were given individual weight and lifestyle advice including smoking cessation to reduce cardiovascular risk.

Nine hundred and sixty-six outpatients with SMI >2 years were enrolled. The completion rate at 2 years was 80%. Significant improvements were observed in levels of physical activity (p < 0.0001), smoking (p < 0.05) and diet (p < 0.0001). There were no changes in mean BMI although 42% lost weight over 2 years. Self-esteem improved significantly. Low self-esteem decreased from 43% at baseline to 15% at 2 years (p < 0.0001). At the end of the programme significant cardiovascular risk factors remained, 46% of subjects smoked, 26% had hypertension and 81% had BMI >25.

Physical health problems are common in SMI subjects. Many patients completed 2 years follow up suggesting that this format of programme is an acceptable option for SMI patients. Cardiovascular risk factors were significantly improved. interventions such as the Well-being Support Programme should be made widely available to people with SMI.

High rates of osteoporosis in schizophrenia may result from the prolactin-raising effects of some antipsychotic medication.

To examine bone mineral density in relation to relevant endocrine variables in patients with schizophrenia taking prolactin-raising antipsychotics.

Fifty-five patients who had been receiving prolactin-raising antipsychotic medication for > 10 years underwent dual-energy X-ray absorptiometry of their lumbar and hip bones. Among the endocrine variables assessed were plasma prolactin and sex hormones.

Age-related reduced bone mineral density measures were found in 17 (57%) of the male and 8 (32%) of the female patients. Higher doses of medication were associated with increased rates of both hyperprolactinaemia and bone mineral density loss. Bone loss for the whole group was correlated with medication dose, and for men was inversely correlated with testosterone values.

These results suggestthat patients with schizophrenia on long-term prolactin-raising antipsychotic medication are at high risk of developing reduced bone mineral density as a consequence of hyperprolactinaemia-induced hypogonadism.

Antipsychotic drugs are associated with sexual dysfunction but the mechanisms are poorly understood.

To ascertain the frequency of sexual dysfunction in patients taking conventional antipsychotics and to determine the possible underlying mechanisms.

Sexual dysfunction was assessed in 101 patients receiving conventional antipsychotic medication, 57 normal controls and 55 controls attending a sexual dysfunction clinic.

Sexual dysfunction occurred in 45% of patients taking antipsychotic medication, 17% of normal controls and 61% of controls attending a sexual dysfunction clinic. Sexual dysfunction was associated with autonomic side-effects in normoprolactinaemic males, but the presence of hyperprolactinaemia overrode other causes of sexual dysfunction. For women, hyperprolactinaemia was the main cause of sexual dysfunction.

Conventional antipsychotic medications cause significant levels of sexual dysfunction. Clinicians should routinely enquire about sexual symptoms prior to the prescription of antipsychotics and on follow-up.

Information given to patients about side-effects of their medication plays a key role in future adherence. It is possible that when antipsychotic medication is prescribed routinely, insufficient information is given to them. In order to investigate the amount of information doctors feel they need to give to patients when they are prescribing conventional antipsychotic medication, all the clinical doctors at a large mental health trust were surveyed by anonymous questionnaire.

Overall, doctors said they gave large amounts of information to patients about possible side-effects of anti-psychotic drugs, but some side effects we discussed far more frequently than others.

The selectivity of information given to patients appears to reflect the doctors perception of what is important. This might not correlate with what the patient may wish to be told. Discussions with patients about side-effects may need to be more comprehensive than they currently are.

Medical reports submitted to mental health review tribunals should be of a clinically acceptable standard. We examined 100 medical reports to assess whether they stated the four criteria for detention under Section 3 of the Mental Health Act 1983. We compared the standard of reports according to the seniority, qualifications and speciality of the doctor, and with the outcome from the tribunal.

The majority of the reports were written by junior doctors and did not fulfil the criteria laid down by the Mental Health Act 1983. Consultant and forensic psychiatry status were associated with completed reports.

This study was performed in one hospital only but highlights the ongoing need to review and improve the workings of the Mental Health Act before reform is considered.