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Part III - Queer Families
- Marie-Amélie George, Wake Forest University School of Law
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- Family Matters
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- 27 May 2024
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- 01 August 2024, pp 227-266
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Adultish
- The Body Image Book for Life
- Charlotte Markey
- Coming soon
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- August 2024
- Print publication:
- 01 August 2024
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Discover the ultimate guide to taking on adulthood with body confidence. In a world where body satisfaction plummets during adolescence, and a global pandemic and social media frenzy have created extra pressure, Adultish is a survival kit for young adults. This all-inclusive book provides evidence-based information on everything from social media and sex to mental health and nutrition. Packed with valuable features like Q&As, myth-busting, real-life stories, and expert advice, it is a go-to source for discovering the importance of self-acceptance and embarking on a journey towards loving the skin you're in.
Scotland's Core Trainees & Specialty Doctors: A Collective Report on Opinions and Attitudes Towards the Current Limits on Higher Training in Psychiatry
- Ailsa Bruce, Ewan Mahony, Arwa Elawad, Siobhan Connelly, Rachel Ball
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S98
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1. To provide Scotland-wide data on Core Trainees’ motivations, their future plans and the barriers to applying for Higher Training.
2. To raise awareness of any collective issues.
3. To provide recommendations to the Royal College of Psychiatrists, NHS Education for Scotland (NES) and the Scottish Government based on the results.
MethodsA 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.
Results– 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.
Conclusion1. 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. 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. 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.
Socioeconomic and Psychosocial Stressors Contributing to General Adult Community Mental Health Recovery Service Referrals in Epsom, Surrey, a Retrospective Case Note Analysis
- Christine Fullerton, Afaf Qazi
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S34
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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.
MethodsThis 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.
ResultsPatients 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.
ConclusionThis 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.
Dedication
- Marie-Amélie George, Wake Forest University School of Law
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- Family Matters
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- 27 May 2024
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- 01 August 2024, pp v-vi
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Extending the Reach of the STOMP Initiative to a Residential Nursing Home in Northern Ireland
- Emily Stirling, Michael Doris
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
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- 01 August 2024, pp. S170-S171
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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.
MethodsThe 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.
ResultsThe 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%.
ConclusionThere 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.
Hatred Is a Mindset Triggered by Stressful External Events, Negative Personal or Group Interpretations and Unhealthy Social Environments
- Salman Shafiq
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S80
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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.
MethodsTo identify the information on hatred relevant for mental health professionals, we performed a systematic review using a systematic approach and criteria.
ResultsSix 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.
ConclusionThe 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.
If at First You Don't Succeed, Try, Try Again? Antipsychotic Trials and Clozapine Provision in Glasgow's Esteem (Early Intervention in Psychosis) Service
- Matthew Beattie, Josie Nott, Rajeev Krishnadas
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S220
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To support evidence gathering for Esteem's RCPsych Early Intervention in Psychosis (EIP) network accreditation efforts, an audit was conducted to investigate compliance with EIPN's quality standards (QS) no. 33 and no. 36.
EIPN QS 33 = patients with first episode psychosis (FEP) are offered antipsychotic medication.
EIPN QS 36 = If the patient's illness does not respond to an adequate trial of two different antipsychotic medicines given sequentially, they are offered clozapine.
EIPN QS 36 is also specifically included in RCPsych's National Clinical Audit of Psychosis (NCAP) (listed as standard 4), but a more pragmatic definition is used, to factor in the issue of antipsychotic intolerance.
NCAP Standard 4 = People with FEP who have not responded adequately to or tolerated treatment with at least two antipsychotic drugs should be offered clozapine (NICE QS80).
This broader standard definition was used for this audit, to allow for results comparison with national data.
MethodsFor EIPN QS 33, all patients on North East Esteem caseload (any primary diagnoses) for at least 6 months on 01/04/2023 were included.
For EIPN QS 36/NCAP Standard 4, the same inclusion criteria were used but refined to FEP cases only.
The electronic clinical records (EMIS) of such cases were reviewed manually by an ST5 and CT3 psychiatrist. Data on prescription history was collected then analysed in Microsoft Excel.
ResultsEIPN QS 33: 58 patients with any primary diagnosis were initially identified as being on NE Esteem caseload > 6 months as of 01/04/23. 58 (100%) patients were offered antipsychotic medication ⋅ 1 (2%) patient was prescribed an antipsychotic but never took it ⋅ 21 (36%) patients were only ever prescribed one antipsychotic ⋅ 17 (29%) patients were prescribed two antipsychotics sequentially trialled ⋅ 11 (19%) patients were prescribed three antipsychotics sequentially trialled ⋅ The remainder, 8 (14%) patients, had four or more antipsychotics sequentially prescribed (with the maximum number of trials being eight).
EIPN QS 36 / NCAP Standard 4: 55 patients with FEP diagnosis were initially identified as being on NE Esteem caseload > 6 months as of 01/04/23. 16 (29%) of these patients had at least three or more trials of antipsychotic medication, i.e. patients eligible for clozapine. However, only 5 (31%) of these 16 patients had either been prescribed clozapine (3 patients, 19%) or offered/trialled clozapine (2 patients, 13%). This 31% figure compares with 85% in Wales, 52% in England, and 50% in Ireland (NCAP 2021–22).
ConclusionEIPN QS 33: The standard that patients with first episode psychosis are offered antipsychotic medication was fully met. About a third of patients required only one antipsychotic trial. Less than a third required two antipsychotic trials. One in five required three antipsychotic trials, and approximately one in seven patients required more than three antipsychotic trials.
EIPN QS 36/NCAP Standard 4: The number of eligible patients being offered or prescribed clozapine for first episode psychosis under care of NE Esteem falls well below NCAP averages for Wales, England and Ireland.
Role of Parental Supervision on Digital Screen Use and Its Effects on Children's Mental Health and Wellbeing in Bangladesh: A Cross Sectional Study
- Hafiz Shahria Kakon, Rashid Tanjir Soron, Mohammad Shorif Hossain, Rashidul Haque, Fahmida Tofail
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S50
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The younger generation of today is highly dependent on digital technologies worldwide. Studies on young children's cognitive and socio-emotional development have shown that there can be conflicting effects from using screen-based media or from exposing them to it. The study explored the relation between unsupervised use of digital screen time with student mental health and behavioral problems.
MethodsIt was a cross sectional descriptive study approached primary and secondary school going children from grades 2–8 (age 6 to 14 years), purposively selected six schools consist of three English and Bangla medium schools from Dhaka city. A total of 420 students along with their parents were enrolled by clustered random sampling. Study explored the effect of the unsupervised screen time on student mental health and social wellbeing through semi structured questionnaires, Strength and Difficulties Questionnaire (SDQ), Pittsburgh Quality of Sleep Scale (PSQI), Spencer Children Anxiety Scale (SCAS) and Development and Wellbeing Assessment Scale (DAWBA).
ResultsStudents used various forms of digital screens for 4.6 hours every day, and 56% of them used these devices without parental supervision or monitoring. English Medium students spend significantly more time on screens on a daily average (5.5 hours) compared with students at Bangla Medium schools (3.7 hours). 21.2% students had mental health concern, this percentage was higher in the unsupervised group (56.2%) than in the supervised group (43.8%). In the unsupervised group, students experienced higher levels of emotional difficulties (15.7%), behavioral difficulties (28.3%), hyperactivity behavior difficulties (17.4%), peer relations difficulties (28.8%), and pro-social behavior difficulties (6.7%) compared with supervised group. 83.3% of students in the supervised group found higher levels of anxiety compared with the unsupervised group (16.7). In the unsupervised group, 15.4% of the students had experienced sleeping problems, compared with 14% in the supervised group.
ConclusionThese results suggest an impact of unsupervised screen time on the prevalence of mental health problems among students. Appropriate screen usage may be a major intervention target to improve children's mental health and wellbeing.
Rapid Tranquillisation Practice and Debriefing; an Observational Study in Adult Psychiatric Inpatients
- Georgina James, Asif Mir
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S191
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Rapid Tranquillisation (RT) is the administration of parenteral sedation to de-escalate situations where patients may harm themselves and/or others. RT is a restrictive intervention potentially breaching patients’ human rights and is reserved for situations where other measures have failed. NICE guidelines (NG10) state that once immediate risks are managed, post-RT incident debriefing of patients and staff should be conducted. This study examines concordance with NG10 at an adult inpatient psychiatric unit and explores ways to improve compliance and patient/staff experience.
MethodsAdult psychiatric inpatients (aged 18–65) who received single or multiple RT therapy during the admission study period (October 2023) were included. Data collected from Electronic Patient Records and chart review included gender, age, ward type, date of RT and drug(s) administered. Following RT, anonymised data was collected on the presence, nature and details of debriefing.
Results49 adult psychiatry patients were admitted during the study period and there were 32 episodes of RT use in 9 patients (18.4% of inpatients). 56.7% of these occurred on general wards and 43.8% on psychiatry intensive care, with 6 patients (66.7%) >1 episode. Intramuscular drugs used included one or more of lorazepam (78.1% of patients), haloperidol (25%), promethazine (21.9%) and aripiprazole (9.4%). After 46.9% (15/32) of RT episodes debrief was offered, and occurred in 28.1% (9/32); 40% (6/15) of those offered debrief did not participate. 52.4% (11/21) of female patients were offered debrief with 81.8% (9/11) uptake, compared with 36.3% (4/11) of male patients offered with 25% (1/4) uptake. No accounts were taken from patients’ advocate, carer or witnesses. Details of debriefs conducted were documented in 33.3% (3/9). Reasons for not conducting debriefing were documented in 43.5% (10/23). The most common reason given was “not clinically appropriate”. During debriefs, no patients were offered information leaflets about the RT medication used. Finally, staff debriefing occurred in 31.3% (10/32) of episodes.
ConclusionCompliance with NG10 guidelines for debriefing inpatients following RT was low and was worse in male than female patients. Staff debriefing was poor and no witness or advocate accounts were utilised. These findings may be due to the stressful ward environment or disrupted patient-professional relationship immediately following RT administration. Understanding the reasons for the gender differences in uptake, patient, staff or environmental factors contributing to lack of debriefing will allow interventions and improve holistic patient care following RT. Information and awareness of RT therapy should be available for patients more readily on ward admission and following RT.
Pilot Study Examining the Potential Efficacy of Music-Based Activities for People Living With Dementia in a Hospital Setting
- Neha Abeywickrama, Mel N. Ellul Miraval, Hari Subramaniam, Qadeer Arshad, Elizabeta B. Mukaetova-Ladinska
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, pp. S15-S16
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Pharmacological treatment of Behavioural and Psychological Symptoms of Dementia (BPSD) is of limited benefit. The addition of non-pharmacological interventions is often essential for optimal symptom control. Music is a viable way to help patients communicate and improve quality of life. This study aims to find the most effective way to use music on a busy dementia ward.
Methods17 inpatients (aged 63–93 years) took part over a five-week period. Music with projected lyrics was individualised and based on their preferences. Instruments (e.g., maracas) were used in some group sessions. We used the Neuropsychiatric Inventory Questionnaire (NPI-Q) and Music in Dementia Assessment Scales (MiDAS) to evaluate patients’ behaviour before and after musical intervention.
ResultsOf NPI-Q scores, a significant difference between mean scores before and after the music intervention was found. Specifically, Delusion, Motor Disturbances, and Agitation scores were significantly reduced after music intervention. Of MiDAS, significant differences were found in Interest, Response, and Enjoyment during specific intervals.
ConclusionA multisensory inpatient environment was effective in delivering music-based activities and managed behavioural symptoms in the short term to people with advanced dementia. Its use for inpatient wards must be further investigated as an economical and personalised non-pharmacological therapeutic tool for patients with dementia.
Dementia in the United Arab Emirates: Factors Affecting the Time From Symptom Emergence to Formal Diagnosis
- Syed Fahad Javaid, Zubaida Shebani, Gabriel Andrade
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S48
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Dementia is a debilitating neurodegenerative disorder that can negatively impact the lives of those affected and their families. Providing safe and person-centered care for individuals living with dementia is a global need with particular emphasis on providing individuals and their families with a rapid diagnosis of their condition following the commencement of symptoms. This study aimed to establish the mean duration of cognitive symptoms before a formal diagnosis of dementia is given in the United Arab Emirates (UAE). We also studied demographic and symptom-specific factors affecting the time for dementia to be formally diagnosed. Our study examined a global issue through a more localized lens to identify areas for improvement.
MethodsThe study involved extracting and analyzing anonymous data from the electronic medical records of dementia patients at Al-Ain Hospital, UAE. Following ethical approval, the data for individuals diagnosed with any form of dementia from 01/01/2010 to 31/12/2019 were extracted using a set of related diagnostic codes. A short questionnaire was completed for every record that matched the search criteria. Demographic information was collected in addition to details of diagnosis, presenting symptoms, comorbidities, and medications.
A two-tailed independent t-test was conducted to assess the effect of demographic characteristics (gender, nationality, and age) on the time to receive a diagnosis of dementia. A one-way ANOVA was conducted to assess the effect of initial symptoms, including forgetfulness, agitation/aggression, and hallucinations, on the time taken to receive a diagnosis.
ResultsOut of the total sample of 825, 442 (53.6%) were females, with 518 (63%) being Emirati citizens. The mean age of the studied sample at the time of diagnosis was 78 years (SD = 11.1). Alzheimer's dementia, 335 (40.6%), was the most common subtype diagnosed. The mean duration of symptoms (DUS) before formal diagnosis was 34.6 months (SD = 28.8). A statistically significant relationship was found between age and DUS, with those over 70 years of age at the time of diagnosis more likely to have a longer DUS (p < 0.001). There was a statistically significant mean difference in the DUS and some initial symptoms, namely agitation/aggression(p < 0.001), lability (p < 0.003), disinhibition (p < 0.001), and hallucinations (p < 0.001).
ConclusionTo our knowledge, this is the first study of its kind in the UAE. Future investigation in this area is much needed, and this study will provide the foundations for dementia awareness campaigns encouraging early presentation to the services.
No financial sponsorship has been received for this study.
Time From Diagnosis of Lewy Body Dementia to Death: Retrospective Study Exploring Patients Within Humber Older People's Mental Health Services
- Sunday Adeoye, Manorama Bhattarai
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S180
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Lewy Body Dementia (LBD) is the second commonest dementia. It accounts for around 7% of dementia cases in secondary care. Studies have shown that LBD patients have an accelerated trajectory towards death when compared with other forms of dementia. Studies have suggested that LBD cases, as compared with Alzheimer dementia, have accelerated cognitive decline, more comorbid conditions, a higher mortality rate, greater service use and poorer quality of life. Most previous studies of LBD have been based on select research cohorts, so less is known about the naturalistic patterns, characteristics, and outcomes of the disease in routine clinical settings.
The aim of the study is to determine the average duration from the time of diagnosis to death among patients with Lewy body dementia in OPMH to understand the prognostic pattern of LBD in our locality.
Objectives
1. To determine the commonest age of diagnosis and death of patients diagnosed with LBD in OPMH.
2. To explore sociodemographic distribution of patients within the study population.
3. To determine the time from diagnosis to death of patients diagnosed with LBD in OPHM.
4. To determine the common psychotropics combinations used in management of LBD in our psychogeriatric unit.
MethodsThis is a retrospective cross-sectional study of all the patients with diagnosis of LBD that presented to Humber Older People Mental Health Services in Hull. The sample consisted of electronic records of all 39 patients under the team but only 38 met the inclusion criteria. Patients’ records were reviewed and information such as gender, ethnicity, age at diagnosis, age at death or age at recruitment if alive, and psychotropic medication they are/were on was retrieved from the records. The time from diagnosis to death was obtained by subtracting age at diagnosis from age at death and this is recorded in years.
ResultsThe result showed that majority of our patients were male and about 68.4% of our patients received their diagnosis between the age of 70 and 84 years and that 59.3% of them died within 5 years of receiving their diagnosis. The result also showed that the commonest psychotropic prescribed for LBD patients were single anticholinesterase inhibitor (donepezil or rivastigmine).
ConclusionThis study showed that majority of patients died within 5 years of receiving their diagnosis of Lewy body dementia. This underscores the fatality and mortality associated with Lewy body dementia. More needs to be done in developing strategies to ensure improved awareness of Lewy body dementia in our community.
A Pilot Study to Assess Suicidal Risk in Women Reporting Domestic Violence to a Law Enforcement Agency in South India
- Lakshmi Keerthana Thatavarthi, Hari Priya Chintala
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
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- 01 August 2024, pp. S86-S87
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In a recent national study in India, 35% of women reported experiencing domestic violence. The association between domestic violence and mental health outcomes especially suicidal risk has been less studied in Asia especially in India. With this context in mind, we aimed to establish a preliminary prevalence of suicidal risk in women reporting domestic violence using self-injurious thoughts and behaviors as proxy measures. We also wanted to probe the feasibility of assessing suicidal risk in a community center for vulnerable women with limited access to referral care and to determine the acceptability of safety plans as well as referral to a hospital setting for women with increased suicidal risk.
MethodsA single center cross-sectional pilot study was conducted among 50 females who have officially reported Domestic Violence. The participants had reported this domestic violence to a ‘SHE Teams’ center in Telangana state, India, which is a women safety surveillance initiative launched by the state government. HARK (Humiliation, Afraid, Rape, Kick) questionnaire to assess the type of domestic violence experienced and SITBI (Self Injurious Thoughts and Behaviors Interview) questionnaire to evaluate the type of self-harm in victims were used.
ResultsIt was found that 100% of the study population experienced emotional abuse, 50% sexual abuse, 74% physical abuse and 80% of them were afraid of their partners. It was also found that 64% had suicidal ideation, 40% had made a suicidal plan, 22% made suicidal gestures, 34% have attempted to commit suicide at least once. 12% had thoughts of Non-Suicidal Self Injury and 10% have committed Non-Suicidal Self Injury. Women who were unemployed and those who were harassed for dowry/endowment by the spouse or spouse's family had a statistically significant association with elevated suicidal risk. 17 participants were referred to a psychiatrist in the nearby hospital and 32 requested for shelter in fear of future violence.
ConclusionDomestic violence is a risk factor for poor mental health among women and suicide is one of the main causes of premature death in this population. To prevent more suicides in women, identifying risk and referral of domestic violence victims should be an essential part of health care systems apart from adequate legal support. This pilot study provides preliminary data for a future study of risk factors mediating suicidal risk in women who are victims of domestic violence and to develop targeted interventions as well.
A Case Study of Cognitive Impairment Associated With Levetiracetam
- Stefan McKenzie, Kalyan Seelam
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S283
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In patients with cognitive impairment, it is important to assess the possible impact of medications on cognition. Levetiracetam is an antiepileptic medication used in the management of epilepsy. Its effect on cognition is unclear.
MethodsWe present a case study of a 57-year-old female who developed cognitive impairment associated with levetiracetam.
She was referred to Memory Services from her GP due to cognitive impairment. Her past medical history included an optic nerve glioma which was surgically removed followed by radiotherapy, and meningiomas which were managed with stereotactic radiosurgery. She had no previous psychiatric history.
Following a first seizure, she was started on levetiracetam 250 mg BD. Over the following months, she developed worsening symptoms of poor memory, fatigue and lethargy, sleeping excessively, headaches, and subsequently, low mood and occasional suicidal thoughts. Levetiracetam dose was halved. When seen in Memory Services 3 months later, it was reported that there had been a gradual but partial improvement in her symptoms since the dose reduction. Addenbrooke's Cognitive Examination (ACE-III) score was 67/100. Short form mood scale was 3/15, below the threshold for depression. Blood tests were normal. MRI Head showed meningiomas and diffuse white matter hyperintensities, both unchanged from previous imaging.
The patient then started lamotrigine and stopped levetiracetam. On follow up (2 months after initial memory assessment), ACE-III score improved to 80/100 and it was reported that her symptoms had completely resolved.
ResultsIn this case, there is evidence to support a causal link between levetiracetam and the patient's cognitive impairment – there was a temporal relationship, dose response relationship, and reversibility, which are all in the Bradford Hill criteria for causation. Other causes were considered and deemed less likely, including depression; the mood symptoms were not the predominant symptoms and developed after the other symptoms, and the patient scored below the threshold score for depression on short form mood scale.
Regarding the aetiology in this case, one hypothesis is that there may have been risk factors that made this patient more susceptible to cognitive side effects from the biological effects of levetiracetam, such as previous neurosurgery and radiosurgery. Another hypothesis is that the levetiracetam may have triggered an atypical depressive episode which manifested predominantly with memory symptoms and tiredness.
ConclusionThis case study highlights the importance of reviewing medications when assessing cognitive impairment, and of obtaining a clear timeline of symptoms. There is a need for further research looking at the effect of levetiracetam on cognition.
Audit on PRN Prescriptions in Adult Inpatient Female Ward
- Alka Adhikari, Syeda Shah, Maya Dhaliwal, Ayesha Chalaby
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- Journal:
- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S211
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Aims
Pro re Nata (PRN) psychotropic medication prescription and administration play a crucial role in addressing patients’ immediate needs and medical care plans in acute mental health services. However, regarding the appropriate indication, use, and documentation of PRN medication prescription, review, and administration practices should be as per NICE guidelines to ensure patient safety and care quality.
This audit will encompass an evaluation of PRN medication prescription in acute inpatient psychiatry as per NICE guidelines and a reaudit after recommendations implementation.
MethodsWe made 8 sets of questionnaires based on The National Institute for Health and Care Excellence (NICE) guidelines recommendation for PRN prescription as per local trust policy. We collected data from 28 patients in the acute inpatient mental health unit for the first cycle. Data was collected from patients' records which included medicine charts, progress notes, and MDT reviews. We analyzed data from the first cycle and implemented changes in Clinical practice. This includes including these guidelines in junior doctor induction, weekly discussion with team pharmacist, adding prompts in medication chart, and weekly review of PRN medication in ward MDT. After 2 months we collected data of 25 patients for reaudit.
ResultsWe analyzed first-cycle data, which required improvement as per AUDIT standard compliance. We implemented recommendations before reaudit. We found there were significant improvements in some areas of concern, although this was not 100 percent audit standard. This area includes a review of PRN medication prescriptions in the last 7 days (25 percent in the first cycle, 56 percent in reaudit), grouping them if both oral and intramuscular formulations were prescribed to avoid overdose (7.2 percent, 28 percent), documentation of minimum (10.7 percent, 24 percent) and maximum dose (100 percent, 100 percent) of PRN within 24 hours, documentation of indication (100 percent, 96 percent).
ConclusionThe findings of this audit and recommendations after the first cycle of audit contribute to enhancing quality of PRN medication prescription practice in acute inpatient mental health services for health care professionals. Addressing potential areas of prescription, administration, and review and providing valuable recommendations and insight for improvement of patient safety and best clinical practice.
Audit of Resuscitation Equipment in a Mental Health Setting – Resulting in Trust-Wide Action
- Natasha Knowles, Noori Husain
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- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S243
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The aim of this audit was to review the availability of recommended resuscitation equipment in Prospect Park Hospital (PPH), a psychiatric hospital based in Berkshire.
The objective was to improve patient safety standards and address staff concerns by ensuring that recommended resuscitation equipment was accessible and fit for purpose.
Our hypothesis was that the current standard of resuscitation equipment at PPH was unsatisfactory.
Background
This review followed concerns by doctors who struggled to obtain the necessary equipment required for emergency situations, particularly during their out of hours shifts.
This project was significant as within the previous year there had been two incident reports and extensive anecdotal evidence of equipment failure/absence.
Whilst each ward had been tasked with completing a weekly checklist issued by the Resuscitation team, these had not been audited to ensure that standards were being met.
MethodsData was collected from ten locations at Prospect Park Hospital from 9th May to 15th May 2023.
Information was obtained by two doctors visiting the specified wards, reviewing the resuscitation bag equipment based on the standardised checklist.
The standards used were from local trust policy and Resuscitation Council UK policy.
Results7/10 locations did not meet the standards for resuscitation equipment, including missing or expired equipment such as adrenaline, suction devices and oxygen masks.
4/10 wards had not completed the weekly emergency drug checklist within the stipulated time frame.
70% of staff completed checklists were incorrect.
ConclusionOur hypothesis was proven to be correct, in that the current standard of resuscitation equipment at PPH was unsatisfactory.
We worked closely with the Resuscitation lead to recommend improvements, including an updated, more detailed checklist, a standardised procedure for ward managers and regular future audits.
Due to the significance of the findings, this has since been re-audited and is in the process of being rolled out Trust-wide, including all inpatient and community settings.
As a result of this audit, the Resuscitation team have been granted additional staffing to action these changes and increased their remit to monitoring equipment in addition to training.
These findings demonstrate that it is vital that the recommended resuscitation equipment is available and suitably maintained, particularly in a community hospital setting with limited resources where it can be life-saving.
Treatment Trajectories of Young People With Emotion Dysregulation Engaging in Dysregulated Behaviours: An Exploratory Study
- Bibire Baykeens, Martina Di Simplicio
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- Journal:
- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S182
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Dysregulated behaviours are prevalent amongst young people worldwide. Emotional dysregulation plays a key role in these behaviours. Several psychiatric disorders have significant elements of emotional dysregulation, making it a potentially effective transdiagnostic therapeutic target. Dialectical behaviour therapy (DBT), mentalisation-based therapy (MBT), and schema therapy (ST) can effectively manage emotional dysregulation, however access may be limited in clinical practice.
We aimed to explore whether young people with emotional dysregulation engaging in dysregulated behaviours receive support for emotion regulation. We hypothesised that those with emotionally unstable personality disorder (EUPD) will have a higher prevalence of self-harm, disordered eating, and/or substance misuse and more referrals for DBT, MBT, or ST than those with bipolar disorder, autism, attention deficit/hyperactivity disorder (ADHD), schizophrenia, or schizoaffective disorder.
MethodsDe-identified clinical records from the West London NHS Trust on 2,413 16- to 25-year-olds with an ICD–10 diagnosis of EUPD, bipolar disorder, autism, ADHD, schizophrenia, and/or schizoaffective disorder were obtained through Akrivia. Chi-squared tests were performed.
ResultsYoung people with bipolar disorder had the highest prevalence of self-harm, disordered eating, and substance misuse (88.35%, n = 182), χ2 (4, N = 3138) = 39.14, p < 0.001, but the lowest number of references to DBT, MBT, or ST. Those with EUPD had the highest number of references to DBT, χ2 (4, N = 2585) = 886.75, p < 0.001, MBT, χ2 (4, N = 2585) = 81.63, p < 0.001, or ST, LR (4, N = 2585) = 21.03, p < 0.001.
ConclusionThere could be an unmet need for psychological interventions for young people with bipolar disorder. A more transdiagnostic approach to offering psychotherapies that target emotional dysregulation should be applied in clinical practice.
A Quality Improvement Project to Improve Staff Confidence in Managing Incidences of Patient Violence and Aggression on the Neurosciences Wards
- Isabel Staffurth, Rahima Hoque, Bea Duric, Marianna Rogowska, Sotiris Posporelis
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- Journal:
- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, pp. S134-S135
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Incidents involving patient violence and aggression are a common occurrence on the neurosciences wards. Many staff do not know how to de-escalate or manage such incidents, leaving them vulnerable and unsupported. This project was designed to increase mean staff confidence by at least 2 points (on a scale of 1–10) regarding confidence and satisfaction in managing patient violence during a 6-week period.
MethodsUsing Plan-Do-Study-Act (PDSA) quality improvement methodology, we carried out a preliminary survey on 2 neurosciences wards. Multidisciplinary staff were interviewed about their confidence (on a scale of 1–10) in managing violence. The survey and interview assessed which measures were already in place on the wards, such as Datix reporting and referral pathways. The first intervention focused on preventing patient violence with informative posters on referral pathways and verbal de-escalation techniques; these were distributed throughout the wards and staff were notified via email. Follow-up surveys were collected, enquiring whether staff had seen the posters and how their confidence levels have changed. The second intervention was implemented 2 weeks later and focused on post-incident support. We distributed leaflets on Critical Incident Staff Support and sent an email link to a verbal de-escalation playlist. Follow-up surveys were collected again to track changes in staff confidence and satisfaction. Weekly electronic clinical record searches were recorded to track the number of incidences of patient aggression during the same 6-week period.
ResultsStaff confidence (N = 24) in verbally de-escalating violence and aggression increased by 1.1 and 1.75 points for Wards A and B, respectively. Of the 6 staff members who were followed up, only 1 experienced a 2-point increase from baseline in confidence in verbal de-escalation; 1 staff member experienced a 1-point increase, 3 experienced no change, and 1 reported a 1-point decrease. Staff satisfaction in management of violence on their wards increased by 1.04 and 1.75 points for Wards A and B, respectively. Staff confidence in knowing which team to refer patient violence to increased by 1.167 and 1.07 points for Wards A and B. Incidences of patient violence reported on EPIC decreased by 8 episodes for Ward B and increased by 2 episodes for Ward A.
ConclusionLow-cost, simple intervention techniques are largely ineffective in improving staff confidence in handling violence. During verbal feedback, most staff agreed that training and simulation-based days would be useful. Ward managers should seek to include well-structured training to improve staff confidence.
Evaluating Improvement Collaboratives in Quality Improvement Projects: Design Variations and Their Impact
- Geetika Singh, Mehtab Ghazi Rahman, Isaac Obeng, Lucy Palmer, Janet Seale
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- Journal:
- BJPsych Open / Volume 10 / Issue S1 / June 2024
- Published online by Cambridge University Press:
- 01 August 2024, p. S161
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Aim: To compare and evaluate three improvement collaboratives designs in terms of tangible and non-tangible benefits.
Background: Leading health systems have invested in substantial quality improvement capacity building, but little is known about the aggregate effect of these investments at the health system level.
Collaborative learning is one of the educational approaches of using groups to enhance learning through working together. Research shows that collaborative experiences that are active, social, contextual, engaging and student-owned leads to deeper learning.
MethodsCNWL organised three collaborative programmes with varying duration and distinct approaches to team selection, wrap-around support mechanisms, training design and post-collaborative QI support.
These three virtual collaborative programmes were co-designed with service users and carers to support 24 teams each in planning, delivering and sustaining improvements aligned with the Trust's Strategic Priorities.
All programmes provided knowledge on the Model for Improvement and co-production, enabling frontline ownership of safety solutions while building organisational QI capacity and capability.
Each collaborative was divided into Planning and Delivery phases. The evaluation, which covers a 3-year period, compares programme metrics to assess effectiveness, impact and identify areas for improvement.
ResultsIncorporating cognitive diversity is crucial in improving the learning process. Collaboratives play a vital role in achieving this, as they bring together different services, staff, and SU&C to drive improvement.
The benefits of collaborative work in quality improvement extend beyond the project data, as it can lead to positive unintended consequences such as a shift in team culture and the adoption of an improvement mindset. These outcomes gained on the journey should be evaluated and celebrated. Moreover, collaboration fosters a culture and platform for sharing and spreading learning beyond the team/service.
However, it is important to take the time to consider and compare different designs of collaboratives during the scoping phase. Factors such as the duration of the collaborative programme, the need for additional wrap-around support and the selection of measures to evaluate the programme should be carefully considered before proceeding.
Effects of changes
1. Comparing different collaborative designs identified the key enablers to a successful project. They were application process brought teams together that were ready and willing to improve; targeted wrap-around support to Sponsors, SU&Cs, Coaches and having decision gateways in design enabled focused and candid conversations about team progression.
2. Collaborative with longer time frame were more resource intensive but had a greater positive impact on safety culture, successful projects and sustained gains than the shorter duration.
3. CNWL Added Value framework evaluated tangible and non-tangible benefits, i.e. staff experience, safety and learning culture, patient experience, streamlined processes and efficiencies gained.
ConclusionIt is important to look at the local context when designing a collaborative with their clinical setting.
A consideration should be based on resources available to support the entire duration of collaborative and what are the desired outcomes of the collaborative.