Regardless of comorbid personality disorder there is value in use of ECT for treatment resistant depression. We present a case of a patient with treatment resistant depression and dependent personality disorder.

There is evidence that ECT used to treat depression with a comorbid personality disorder has poorer outcomes. Ferrea et al., 2023, found poor response rates in comorbid personality disorder as opposed to depression alone, with increased risk of relapse, but still showed a remission rate of 1 in 3 and 50% response rate. However, most of the studies included didn’t differentiate the type of personality disorder, leaving us without clear evidence around the impact of dependent personality disorder specifically.

We present a case of a 78-year-old female patient with diagnoses of recurrent depressive disorder and generalised anxiety disorder. The patient had two admissions in two years under the mental health act with similar presentations in keeping with severe depression. In the community she was being investigated for autism, underlying cognitive impairment, dependent personality disorder and being treated for recurrent depression and generalised anxiety disorder which didn’t fully remit in the 2 years she was open to the service.

She is followed through admission and investigations to a course of treatment with Bilateral ECT lasting for 12 sessions.

On Montgomery-Åsberg Depression Rating Scale the patient scored 34 before starting ECT treatment, and after completing the course scored 20. Clinical global impression rating rose from 6- severely ill, before course of ECT to 4- moderately ill, following.

Despite the potential multiple contributing diagnoses, the patient’s mental state and presentation improved in response to treatment with ECT.

There is evidence of benefit in switching and augmenting antidepressants in older adults where there is treatment resistance (Lenze et al. 2023). This case supports the hypothesis that in treatment resistance in the elderly population we should persevere up to and including the use of ECT, until remission is achieved.

There’s a lack of research looking specifically at the impact of comorbid dependent personality disorder on efficacy of ECT for depression. Most of the existing evidence focusses on Emotionally unstable personality disorder.

This case study supports the hypothesis that there is evidence of treatment response with the use of ECT for treatment resistant depression regardless of comorbid dependent personality disorder.

National standards require that adults start to receive help within four weeks of referral, which may include advice, support, or an initial assessment. Nevertheless, meeting this standard has been increasingly challenging for the Barnet West Community Mental Health Team due to rising referral volumes and clinical complexity. This project initially aimed to increase the proportion of referrals receiving first contact within 28 days by ≥10% over 1 year. As cycle 1 surpassed this target, cycle 2 aimed for a further ≥20% over 6 months.

Stakeholder consultation suggested that establishing a non-clinical Referral Coordination team could improve access without increasing clinician workload. The team would provide proactive early telephone contact to gather information, assess risk, and escalate or relay clinician advice where required.

In cycle 1, Foundation Year doctors piloted the Referral Coordination role. To minimise impact on their training, they contacted only incomplete or high-risk referrals.

Following demonstrated safety and benefit, cycle 2 employed 2 non-clinical workers to form a dedicated Referral Coordination team. They contacted all new referrals and reviewed outcomes at weekly multidisciplinary meetings.

The primary outcome measure was the proportion of referrals receiving first contact within 28 days of referral. Patient satisfaction with waiting times was measured as a secondary outcome via telephone survey. Due to high referral volumes, outcome measures were collected for a random sample of 50 patients per cycle.

Baseline data showed that only 24% of referrals were contacted within 28 days. Median time to initial contact was 51.5 days (range 307, IQR 53), and 34% of referrals reported satisfaction with waiting times.

In cycle 1, 44% of referrals were contacted within 28 days, with a reduced median wait of 31.5 days (range 284, IQR 73); satisfaction increased to 48%. In cycle 2, 96% were contacted within 28 days, with a median wait of 5 days (range 41, IQR 4); satisfaction was reported by 44%. Notably, only 21% reported dissatisfaction whilst 15% abstained, stating they had not wished to be referred.

The Referral Coordination team was successful in achieving near-universal timely contact. It also acted as an early warning system for clinical risk and reduced competing demands on doctors. Patient satisfaction did not correspond directly with access, suggesting influence from contextual factors such as patient expectations. Future work mayexplore additional drivers of patient experience to ensure service changes deliver meaningful benefit for patients and carers.

To evaluate the quality and timeliness of Internal Medicine (IM) referrals, documentation, and follow-up for psychiatric inpatients with medical comorbidities; to identify gaps in liaison between Psychiatry and Internal Medicine; to implement targeted interventions; and to assess improvement following these interventions.

A closed-loop clinical audit was conducted over a 4 month period in the Department of Psychiatry, Gulab Devi Teaching Hospital, Lahore. Two audit cycles were completed. A total of 35 psychiatric inpatients with identified medical comorbidities were included in each phase (pre- and post-intervention). Data were collected retrospectively from admission clerking notes, inpatient progress notes, and IM referral records.

Audit standards were based on good clinical practice for the management of medical comorbidities in psychiatric inpatients. Parameters assessed included: identification of medical comorbidities, IM referral made, documentation of indication for referral, attachment of relevant vital signs or laboratory investigations, timeliness of referral, documentation of IM review, documentation of IM management plans, and implementation of IM recommendations.

Interventions included introduction of a standardized IM referral proforma, targeted reminders to psychiatry junior doctors regarding referral and documentation, reinforcement of combined verbal and written handover of IM advice, and use of a ward-round checklist toensure review and implementation of IM recommendations. Post-intervention data were collected using the same methodology.

Pre-intervention (n=35):

IM referrals were made in 65.7% of eligible patients. Documentation of referral indication was present in 78.3%, and relevant investigations were attached in 60.9%. Same-day referral occurred in 39.1%. IM review was documented in 42.9%, IM management plans in 37.1%, and IM recommendations were implemented in 31.4%. Complete referral-review-action loops were achieved in 28.6% of cases.

Post-intervention (n=35):

IM referral rates increased to 88.6% (+22.9%). Documentation of referral indication improved to 93.5% (+15.2%), and attachment of relevant investigations to 87.1% (+26.2%). Same-day referrals increased to 71.0% (+31.9%). Documentation of IM review improved to 80.0% (+37.1%), documentation of management plans to 74.3% (+37.2%), and implementation of IM recommendations to 71.4% (+40.0%). Complete referral-review-action loops increased to 68.6% (+40.0%).

This audit identified significant baseline gaps in liaison, documentation, and follow-up of medical comorbidities in psychiatric inpatients. Following simple, structured interventions implemented over a 3–4 month period, substantial improvements were observed across all domains. These findings highlight the effectiveness of low-cost, system-based measures in strengthening Psychiatry–Internal Medicine collaboration and improving patient safety. Continued re-audit is recommended to sustain improvements.

Electroencephalography (EEG) is frequently used within psychiatric services to support diagnostic clarification in presentations such as first-episode psychosis, suspected seizure disorders, dissociative episodes, catatonia, and complex neurodevelopmental conditions. In many low- and middle-income countries (LMICs), EEG services are embedded within psychiatry departments and support both psychiatric and neurological referrals. This audit aimed to evaluate EEG utilisation, documentation quality, and diagnostic yield within a psychiatry-led service, benchmarked against international standards, and to identify areas for quality improvement.

A retrospective service audit was conducted of all EEGs performed between 2019 and 2024 in the Department of Psychiatry and Behavioural Sciences at Allied II Hospital, Faisalabad, Pakistan. The department provides EEG services for both psychiatric and neurological referrals. Data were extracted from the departmental EEG reporting system and analysed using Python and Microsoft Excel. Variables examined included annual EEG volumes, recording duration, wake versus sleep recordings, diagnostic outcomes, and completeness of clinical documentation. Findings were benchmarked against guidance from the International Federation of Clinical Neurophysiology (IFCN), American Clinical Neurophysiology Society (ACNS), and NICE.

A total of 2,670 valid EEGs were analysed over 6 years. Annual EEG volumes remained stable, including during the Covid-19 pandemic, demonstrating sustained service delivery, with activity increasing to 503 EEGs in 2024. Overall, 13.9% (n=405) of EEGs showed abnormal findings, 85.8% (n=2,494) were normal, and 0.2% had unclear outcomes, consistent with expected diagnostic yield. Wake EEGs accounted for 69.8% of recordings, while 28.4% included sleep recordings, indicating appropriate use for paediatric and complex cases; sleep-wake state was unclear in only 1.6% (n=47). The mean EEG duration was 25.2 minutes (median 19.0 minutes, IQR 16–23 minutes) showing satisfactory adherence to standards, with some recordings below recommended minimum durations. Documentation quality was generally strong, with missing data only limited to weight 12.8%, height 4.0% and gender 0.4%

This audit demonstrates that EEG services delivered within a psychiatry-led department in an LMIC largely comply with international standards, with appropriate diagnostic yield and sustained utilisation over six years. Overall documentation quality was high, Identified areas for quality improvement include ensuring minimum recording durations, improving structured data entry, and refining referral practices to optimise diagnostic efficiency. An action plan has been implemented, with re-audit planned within 12–18 months to assess impact.

This audit compares the old and new referral forms to determine whether the redesigned version captures the required data more effectively, whether certain fields are unnecessary, and whether further improvements are needed. It also explores whether the older form encouraged more information or whether both forms still fall short in key areas.

Data were obtained from stored copies of liaison psychiatry referrals submitted to University hospital of Limerick. A total of 100 referrals were reviewed. Two samples were created:

Baseline audit included 50 referrals randomly selected from January to April 2024 (using the old referral form)

Re Audit 50 included referrals randomly selected from January to April 2025 (using the redesigned referral form)

Data were collected and analysed. Each referral was reviewed against the predefined checklist of required data items derived from the 2025 redesigned referral form.

A structured Excel spreadsheet was used to record the presence or absence of each criterion for all referrals. Analysis was performed to compare completion rates between the old and new forms, assess compliance with the working standard, and identify areas requiring further refinement.

Overall, the redesigned referral form demonstrated significant improvement in the completeness and consistency of information provided across nearly all domains.

The new referral form showed compliance for patient identifiers and referrer details. In contrast, the old form showed inconsistent completion rates for key administrative data, particularly GP details, referring doctor, referrer contact number, and email.

Medical status, suspected psychiatric symptoms, duration, and pattern of symptoms were better captured in the new form compared to the old form.

Cognitive screening items such as alertness, AMT4 score, and counting months backwards were rarely recorded in the old referrals but were captured with much higher consistency in 2025.

The reason for admission was well documented in both forms, though more consistently in the new version.

Documentation of previous psychiatric diagnoses, current psychiatric medications, and attempts to treat prior to referral improved markedly with the new form. These elements were commonly missing or incompletely described in the old referrals.

Risk documentation was among the most significant improvements

The redesigned 2025 referral form clearly improved the completeness of information submitted to liaison psychiatry, as demonstrated by the higher documentation rates across nearly all criteria. However, despite these improvements, several challenges remain that impact the practical usability and clinical value of the referral information received. This audit will inform a new service and quality development project.

High “Did Not Attend” (DNA) rates in mental health care lead to poorer patient outcomes and significant financial costs. In Community Mental Health Teams (CMHTs), high DNA rates are not uncommon due to the complexity of patient needs and operational pressures. Within the Anxiety, Depression, Affective, Personality Disorders and Trauma (ADAPT) service in Bromley East, a baseline DNA rate of approximately 25% represented a significant clinical and operational challenge. This project aims to reduce DNA rates from 25% to 20% within 4 months (Oct 2024–Feb 2025).

A local service evaluation was initially conducted using a multi-modal approach, including staff interviews, data analysis in collaboration with the administration team, andpatient questionnaires. Three PDSA cycles were subsequently implemented. The first two focused on improving staff understanding of DNA documentation. Intervention 1 involved an email and discussion in the multidisciplinary team meeting, outlining accurate DNA reporting and important considerations. Intervention 2 included posters in staff offices for reinforcement. Intervention 3 targeted patient behaviour with posters in the reception area and leaflets distributed. Weekly DNA rate percentages were retrospectively collected.

The interventions did not result in a sustained decrease in DNA rates (median=22.7%). The run chart indicated common-cause variation, suggesting that week-on-week changes were due to random variation.

No sustained or significant decrease in DNA rates was observed. Incorrect documentation was likely overestimated as a contributing factor. The limited impact of low-intensity interventions highlights the multifactorial nature of attendance behaviour within CMHT populations, including operational constraints, difficulties in contacting first-appointment non-attendees, and broader bio-psycho-social factors.

Future work should prioritise early stakeholder involvement and targeted, engagement-focused strategies rather than infrastructure-focused reminders alone. While digital tools may offer additional support, they are unlikely to be effective without parallel investment in personalised, relational, and system-level change. Importantly, improving attendance metrics alone does not necessarily equate to improved care.

Although the project did not achieve its initial target, it increased staff awareness, prompted multidisciplinary discussion, and provided valuable learning in quality improvement methodology. Reporting negative or neutral findings is vital to avoid repeating ineffective strategies and to inform the development of more effective future interventions.

To explore the main barriers facing Palestinian mental health professionals conducting inpatient psychiatry research in Palestine.

A qualitative approach, through unstructured interviews with medical professionals who worked on academic papers at Bethlehem Psychiatric Hospital (BPH).

Four themes of challenges to inpatient psychiatric research in Palestine were identified:

Theme 1: Ethical Dilemmas: Inpatient psychiatry comes with complicated ethical issues, including involuntary treatment, safeguarding and capacity assessments. This makes studying hospitalized patients, often in relapse, prospectively or during admission difficult, and often impossible. Participants interviewed reported that obtaining consent is difficult as it connects to patients’ capacity details, which requires access to medical records.

Theme 2: Systematic Healthcare and Documentation Issues: Mental health services and protocols at BPH have been constantly changing, adapting to resources and demand. This is reflected in documentation; admissions had different forms and therefore, information is not homogeneous throughout the years. Further complicating the already tedious manual data collection from the paper-based system. Despite the growth and interest in Palestinian psychiatry academia, it still lacks awareness, education, institutional support, and funding.

Theme 3: Clinical Setting: Being the only standing inpatient psychiatric facility in Palestine, the hospital’s wards are frequently crowded, under-resourced, and understaffed. Participants reported that many medical and psychological investigations and interventions are not available, and data collection needs to go through delicate paths to not “stand in the way” of patient care. BPH is a stand-alone psychiatric facility. Meaning there is no integrated system that connects it to other medical wards or outpatient clinics. This limits studying cases or phenomena that overlap with other specialties, and restricts outcome assessment and continuity of care.

Theme 4: Sociopolitical issues: The volatility of politics in Palestine renders all aspects of life unpredictable: from roadblocks to safety concerns, and patients’ mistrust in existing institutions. Writing about Palestinian mental health demands navigating medical “neutrality” without compromising critical social determinants of health. Finally, social challenges, including stigma, socioeconomic disparities, accessibility issues and cultural beliefs and misconceptions, hold patients and families back from sharing their information with investigators.

Several hurdles prevent the publication of inpatient psychiatric research in Palestine. Researchers must be culturally sensitive and prioritize patient care and safety in vulnerable populations. The role of systematic change remains pivotal.

People with severe mental illness (SMI) die on average 15–20 years earlier than the general population, largely due to poor physical health. NICE guidance mandates annual physical health checks (PHCs) for individuals with SMI, including the “Core 6” parameters (alcohol and smoking status, blood pressure, body mass index, lipid profile and HbA1c or blood glucose). NICE also requires regular physical health monitoring for those prescribed antipsychotic medication. This audit aimed to assess PALT’s compliance with NICE standards and identify barriers to completion.

A retrospective clinical audit was conducted. 100 patients under the care of PALT for at least 12 months who were prescribed antipsychotic medication were included. Data was obtained from patient records between March–April 2025. Outcomes measured included completion of coded annual SMI PHCs, completion of Core 6 components, antipsychotic monitoring blood tests, and ECGs within the preceding 12 months. Engagement with PALT and evidence of invitation to SMI PHCs were also recorded. Results were analysed and compared against NICE standards and previous audits.

Overall, 59% of patients had an SMI PHC in the preceding 12 months, despite 98% engaging with PALT during the same period. Among those without a completed PHC, 95% had recent contact with PALT. Of the 41% who did not attend SMI PHC, only 34% had documented evidence of invitation.

Completion of individual ‘Core 6’ components was higher, ranging from 78–84%. Annual antipsychotic blood test monitoring showed good compliance at 79–84%, demonstrating improvement from previous audits. However, only 63% had an annual ECG. Even for antipsychotics with moderate-high risk of respective side effects, metabolic monitoring was suboptimal (46%), and prolactin monitoring was low (27%).

Although compliance with antipsychotic blood monitoring is improving, completion of annual SMI PHCs remains suboptimal. Better completion of individual ‘Core 6’ components suggests that this activity is being carried out, but in a fragmented manner. The high engagement with PALT relative to SMI PHC completion suggests a missed opportunity to integrate PHC with mental health appointments. Our recommendations focus on improving awareness and accurate identification of patients requiring SMI registration and physical health monitoring as well as strengthening communication with primary care and the SMI PHC team. Additionally, building capacity within PALT to deliver physical health assessments, blood tests and ECGs, may improve engagement and completion. Continued audit and wider dissemination of findings is needed for sustained improvement in physical healthcare for people with SMI.

Body Integrity Dysphoria (BID) is a rare disorder characterised by a persistent sense of incongruence between bodily anatomy and experienced identity. ICD-11 situates BID within disorders of bodily experience, whereas DSM-5-TR lacks explicit diagnostic recognition, often leading to misclassification as body dysmorphic disorder, psychotic illness, or affective pathology. Extreme self-directed bodily modification remains exceptionally uncommon and poses profound diagnostic, ethical, and risk-assessment challenges.

We describe a 71-year-old retired engineer with a lifelong pattern of non-psychotic, non-suicidal self-amputation. He had previously undergone medically indicated above-knee amputation due to osteomyelitis and deliberate mid-forearm self-amputation with an axe in midlife, preceded by longstanding discomfort with the limb and followed by subjective relief and euphoria. Approximately five years later, he developed persistent thoughts of genital amputation. These thoughts persisted for 15 years, were internally compelling but not delusional, and were unaccompanied by concerns regarding genital appearance or function, hallucinations, or depressive syndrome (PHQ-9=0; GAD-7=3). He repeatedly sought psychiatric and primary care support, expressing difficulty understanding his experiences and enquiring whether surgical intervention could be medically justified to minimise harm. He received antidepressant medication and psychological therapy.

Despite chronic ideation and a previous history of self-amputation, repeated clinical risk assessments concluded that imminent self-harm was unlikely, largely due to the absence of suicidality, affective instability, or behavioural escalation. Following his mother’s death, he executed a meticulously planned penile self-amputation after informing emergency services. Post-operatively, he reported relief and pride, without regret or depressive symptoms.

Phenomenologically, this presentation aligns more closely with BID than with body dysmorphic disorder or affective illness. Unlike body dysmorphic disorder, distress was not rooted in perceived defect or appearance but in a fundamental disturbance of bodily identity. Unlike suicidal self-harm, the act was purposeful, planned, and directed toward identity resolution rather than death. This case exposes limitations in contemporary risk frameworks, which prioritise acute, dynamic indicators of risk while undervaluing the clinical significance of chronic, identity-driven ideation. The persistence of symptoms was interpreted as stability rather than progressive consolidation of intent.

This case underscores the need for phenomenologically informed, longitudinal approaches to psychiatric risk assessment and greater conceptual clarity regarding BID within diagnostic systems. Disorders of bodily identity can culminate in irreversible outcomes that evade conventional predictive models, highlighting the necessity of rethinking how risk, chronicity, and identity-related psychopathology are conceptualised in psychiatry.

This audit evaluated the Sheffield Health Partnership University NHS Foundation Trust’s (SHPU) adherence to standards for patients receiving Electroconvulsive Therapy (ECT) as outlined by the Electroconvulsive Therapy Accreditation Service (ECTAS) guidelines. The primary objective was to assess the documentation of consent, capacity, target symptoms, and cognitive side effects throughout the treatment course and follow-up phases. Secondary objectives were to identify any improvement in compliance compared with previous audits, and assess whether high quality ECT was being delivered, as determined by statistical analysis of changes in measures of target symptoms and cognitive side effects.

A retrospective audit was conducted on all patients who underwent ECT between December 2022 and December 2024 (N=16). Data were extracted from electronic records to measure compliance with standards for documentation of consent and capacity, and completion of validated scales including the Montgomery–Åsberg Depression Rating Scale (MADRS), Mini-Addenbrooke’s Cognitive Examination (mini-ACE), Clinical Global Impression (CGI), and Item 17 of the Comprehensive Psychopathological Rating Scale (CPRS). Bonferroni corrected paired t-tests were performed on mean assessment scores pre- and post-ECT.

Demographics were comparable to previous datasets. Documentation of legal framework and consent prior to each treatment met SHPU/ECTAS standards. Baseline monitoring achieved 100% compliance for all measures but declined during the treatment phase, falling below 75% by course completion. One-month follow-up showed minor improvement in adherence, followed by successive reductions in months two and three. Analysis of missing data found patients receiving inpatient ECT had more missing data per person on average (11.5 vs. 8.2 for outpatient treatment). Our findings suggest similar compliance to monitoring compared with previous local and national audits. Locally delivered ECT remains efficacious: mean MADRS scores reduced from 42.1 to 21.3 (p<0.01), and mean CGI scores improved from 5.5 to 2.5 (p<0.01). Objective cognitive scores (mini-ACE) significantly increased from a mean of 19.7 to 23.9 (p<0.01), and subjective memory measures (CPRS) showed no statistically significant change.

Findings show that while the service delivers clinically effective treatment with robust initial safeguarding, longitudinal monitoring remains inconsistent. Proposed interventions include the ECT team assuming responsibility for post-treatment monitoring to minimise variability driven by inpatient pressures/discharges to community teams during follow up, updates to local ECT documentation processes to minimise missing data, and establishing ‘ECT Champions’ within referring teams to improve communication and follow-up adherence.

GP connect is an NHS digital service that allows approved professionals to access patient GP records and provides essential information such as their current medication. Information relating to current medication is vital for clinical decisions and patient safety, particularly when patients present to a new service such as A&E. The clinical risks associated with a lack of information can be even more significant when medications such as clozapine, lithiumand other antipsychotics are being prescribed.

Increasingly, secondary care services are prescribing various psychotropics under shared care arrangements. This QI project sets out to assess the accuracy of GP records in noting shared care medications, barriers to recording these and potential solutions. Several primary care services are relying on AI tools to summarise letters and both opportunities and threats relating to this are discussed.

120 records were reviewed for patients under a community mental health team in Telford, Shropshire. These patients constituted one consultant’s case load.

Each patient’s psychotropic medication on their GP connect medication list was reviewed against the most recent correspondence sent to the GP by secondary care.

55 of 120 patients had an inaccurate medication record on GP Connect, constituting a total of 77 inaccurately recorded psychotropic medications. Secondary care was the prescriber for 75 of these medications. Out of the 77, there were 55 psychotropics which were not recorded at all. The remaining inaccuracies included inaccurate doses or showing a discontinued psychotropic as a current repeat. The clozapinestatus of 7 patients and lithium status of 2 were not recorded on GP Connect, and 16 depot medications were missing.

Liaison with primary care, including the pharmacy team, was done to identify solutions to rectify these inaccuracies in the GP records, and to develop processes to ensure they are aligned to include secondary care prescribing.

This QI project evidences significant challenges with prescribing across services and access to uniform information. This can have serious implications on patient safety particularly in medical emergencies. In the current climate with pressures on both primary and secondary care, closer liaison with primary care that goes beyond sharing correspondence is needed, including development of joint pathways. Several GP practices are utilising AI tools to review incoming correspondence which can be useful, however agreed protocols are required to facilitate this.

People with autism often exhibit heightened sensitivity to environmental stimuli, including social and emotional cues. Exposure to maladaptive behaviours in peers may act as a powerful trigger, influencing emotional regulation and behavioural responses. This case highlights the impact of environmental modelling on self-harm behaviours in a student with autism.

We present the case of a student with autism, who developed self-injurious behaviours following exposure to a peer engaging in self-harm at college. The patient demonstrated increased emotional distress, repetitive rumination on the observed behaviour, and subsequent imitation of the act. No acute psychotic symptoms or major mood disorder were identified. The onset of self-harm appeared temporally linked to the environmental exposure rather than internal psychopathology.

This case illustrates the vulnerability of autistic people to social modelling and environmental influences. Heightened empathic sensitivity, difficulties with emotional regulation, and concrete thinking styles may contribute to the internalization and replication of observed behaviours. Early recognition of environmental triggers, particularly within college settings, is crucial. Interventions focused on environmental modification, psychoeducation for caregivers and educators, and autism-adapted emotional regulation strategies were associated with a reduction in self-harm behaviours. This case emphasizes the importance of multidisciplinary collaboration and proactive monitoring of peer-related stressors in autistic populations.

This case underscores the profound environmental sensitivity of people with autism and the potential for peer behaviours to precipitate self-harm through social modelling. Clinicians, caregivers, and educators should remain vigilant to environmental risk factors and prioritize early intervention, college-based collaboration, and psychoeducation. Increased awareness of these vulnerabilities may help prevent self-injurious behaviours and promote safer, more supportive learning environments for students with autism.

A psychiatric inpatient admission can be the most challenging part of navigating mental illness. Patients are often at their most vulnerable when facing the unknowns of an admission. Patients are usually oriented to the wards through conversation, a quick tour or written material provided at the time of admission. These existing interventions vary in delivery and uptake and standardised, accessible orientation materials remain scarce. This quality improvement project (QIP) evaluated the impact of a co-produced animated orientation video on patients’ perceived knowledge and anxiety around admission. Secondary aims included exploring experiences of existing orientation interventions, identifying anxiety sources and knowledge gaps, and gathering feedback.

This mixed-methods QIP was conducted at two acute mental health wards for adults at the Whiteleaf Centre, Aylesbury. An animated orientation video was co-produced by the in-patient transformation team, clinicians, and experts-by-experience. A brief questionnaire was designed with inputs from service users and administered to patients admitted between July and November. Pre-determined exclusion criteria were: declined participation, in seclusion, not oriented, and >48 hours since admission. Patients rated knowledge and anxiety on single Likert items pre- and post-video, and answered open-ended questions about anxiety sources, knowledge gaps, existing interventions, and video feedback. Quantitative data were analysed using Wilcoxon signed-rank tests.

Of 31 patients approached, 20 were included (14 male, 6 female; age range 17–63; mean 36.1 years); 80% were experiencing their first admission. At baseline, 55% reported anxiety and 35% reported that they did not know what to expect upon admission. Helpfulness of existing interventions varied: ward tour 82% (14/17), one-to-one chat 86% (12/14), patientinformation pack 50% (8/16). 85% (17/20) found the video helpful. Knowledge improved significantly (median 3.0 to 4.0; W=55.0, p=0.001); anxiety showed a favourable but non-significant trend (median 4.0 to 3.0; W=6.0, p=0.125), with no patient reporting increased anxiety. Themes that emerged highlighted reassurance, clarity about facilities, and structured orientation as strengths. Suggestions included adding content on leave arrangements, treatment types, and ward-specific information. The animated format was highlighted as a strength by some patients (2/20) and a distractor by others (3/20).

A co-produced orientation video is an acceptable and effective intervention for improving knowledge of what to expect during psychiatric inpatient admission. Iterative refinement of video design and content can further tailor it to meet patients' needs.

Suicide remains one of the leading causes of death worldwide. It kills over 700,000 people every year. The most crucial steps to prevent suicide throughout the world are the accurate identification and good recording of suicidal risk. The Columbia-Suicide Severity Rating Scale (C-SSRS) is a validated tool that is commonly recommended in the evaluation of suicidal thoughts and behaviors, but clinical practitioners are experiencing difficulties in practicing it in an effective way, especially in emergency departments and psychiatric clinics. The psychiatry residents are typically the first to be consulted, and they have an instrumental role in conducting and recording the suicide risk assessment. This clinical audit was to evaluate how properly the psychiatry residents documented their suicide risk assessments using the C-SSRS as a standard.

A retrospective clinical audit at the department of psychiatry was organized. The researchers examined the psychiatric records of adult patients seen by residents during a three-month period. A standardized audit checklist based on C-SSRS criteria was used to evaluate the documentation of suicidal ideation, suicidal behavior, intensity and frequency of thoughts, use of C-SSRS, risk stratification, protective factors, and safety planning. The reporting of ideation and behavior and the use of a structured tool were expected to be 100% according to compliance standards, while risk level and safety planning were expected to be 90%.

A total of 118 patient charts were analyzed. Most of the notes (79.7%) indicated that the patients entertained suicidal thoughts, and only 47.5% of the notes indicated that the patients attempted suicidal behavior. Only a paltry 25.4% of the hospital records included the extent or frequency of the suicidal thoughts. The application of the Columbia-Suicide Severity Rating Scale was only documented in one case, equal to 0.8%. Almost all of the cases never provided risk level, protective factors, and safety plans, standing at 2.5%, 0.8%, and 0.8%, respectively. The lack of documentation was consistent throughout all residency training levels, and it was not an experience-based problem.

The audit found that the medical records of the patients were not adequate. A validated tool to evaluate suicide death risk was not utilized. There is an urgent need to train residents, adjust the suicide evaluation, and introduce the ideas of C-SSRS into electronic records and review them regularly. Recording proper notes is a vital aspect of suicide prevention that keeps patients safe. It allows hospitals and staff to provide more effective care.

Ketamine misuse is an emerging public health concern, with increasing reports of severe physical and psychological complications. Chronic use is associated with hepatobiliary and urinary tract injury, often linked to ketamine’s metabolic pathways and toxicological effects (1-3). This report describes the complications and treatment outcomes of a young adult with severe ketamine dependence admitted to a specialist detoxification unit in South Wales.

A 25 year old British male with severe ketamine dependence (up to 8 g/day) presented with abdominal pain, urinary frequency, jaundice, and weight loss. Initial investigations revealed markedly deranged liver enzymes and raised creatinine. He was diagnosed with ketamine induced cholangiopathy (2) and cystitis, conditions well documented among chronic abusers (3). Despite initial improvement during detoxification, he relapsed shortly after discharge, escalating use to approximately 90 g and requiring ICU admission for ketamine overdose with emerging multiorgan failure. After medical stabilisation, he was readmitted for detoxification and demonstrated improved motivation and abstinence, with plans for residential rehabilitation.

Management followed general principles of substance-dependence treatment due to the absence of ketamine-specific guidelines (4). Oxazepam was used to manage withdrawal due to hepatic impairment, alongside analgesia for bladder pain. Mirtazapine was prescribed for mood symptoms, and the patient engaged in relapse-prevention therapy and occupational support.

Ketamine addiction has risen significantly across the UK, with documented multisystem toxicity including hepatobiliary injury, bile duct fibrosis, and cholangiopathy (1-3). Renal and lower urinary tract damage are similarly common in chronic users (3). This case demonstrates how rapid deterioration and multiorgan failure can occur following relapse, underscoring the need for sustained support after detoxification.

Ketamine abuse can cause severe and potentially irreversible liver and kidney damage. Relapse following detoxification carriesrisk of multiorgan failure. Sustained abstinence and structured follow-up are essential.

Eating disorders (EDs) and non-suicidal self-injury (NSSI) frequently emerge during adolescence and often co-occur, particularly in bulimia nervosa and anorexia nervosa binge-eating/purging subtype. Although both behaviours are widely understood as maladaptive strategies for managing distress, the specific psychological functions of NSSI within ED populations remain insufficiently synthesised. This review aims to consolidate current evidence on the functions of NSSI among adolescents with EDs, drawing on theoretical frameworks such as Nock and Prinstein’s four-function model and emerging literature on affect regulation, self-punishment, interpersonal communication, and identity processes.

A systematic search of PsycINFO, Embase, MEDLINE, and the Behavioural and Psychological Sciences Collection (2019–2024) was conducted using terms related to eating disorders, non-suicidal self-injury, and adolescence. Eligible studies included peer-reviewed empirical research reporting primary data on NSSI functions among adolescents with a diagnosed ED. Two reviewers independently screened studies, extracteddata, and resolved discrepancies through discussion. Extracted variables included study design, demographic characteristics, NSSI typology, and identified NSSI functions. A thematic synthesis approach was used to generate descriptive and analytical themes.

Eight studies met inclusion criteria, representing clinical, community, and longitudinal designs. Samples were predominantly female adolescents, with ED presentations largely characterised by binge-purge behaviours. NSSI methods included cutting, scratching, burning, hitting, and ED-specific self-endangering behaviours such as laxative misuse, insulin manipulation, and psychogenic polydipsia. Across studies, NSSI served multiple overlapping functions. The most consistent was emotion regulation, where self-injury was used to reduce overwhelming affect or alleviate emotional numbness. Other prominent functions included self-punishment, relief from dissociation, interpersonal signalling of distress, and responses to atypical cognitions such as quasi-psychotic experiences. Several studies also indicated that ED behaviours themselves may carry direct self-harm.

NSSI in adolescents with EDs is multifunctional and closely intertwined with the emotional, cognitive, and interpersonal difficulties characteristic of this population. Understanding these functions is essential for developing targeted, function-focused interventions that offer safer alternatives to the needs currently met through self-injury. Further research is needed to clarify how NSSI and ED behaviours interact over time and to guide more effective treatment approaches

Psychiatric inpatients face elevated risk of venous thrombo-embolisms due tosedation, antipsychotic use and reduced mobility. Following a serious incident involving a patient death from VTE complications, we aimed to increase VTE risk assessment completion within 14 hours of admission (KPI standard) from 74.7% to over 90% at St Charles Hospital and CNWL NHS Foundation Trust by November 2025.

We conducted three PDSA cycles between November 2024 and November 2025, analysing 975 admissions across 8 psychiatric inpatient wards. Baseline compliance was 74.7% with 7.4% of patients never assessed.

Root cause analysis using fishbone diagrams identified gaps in staff awareness, competing clinical priorities and absence of electronic system prompts.

Cycle 1: We targeted education through training sessions reaching 80% of staff, resident doctor forums and targeting resident doctor inductions.

Cycle 2: We corrected the Tableau dashboard (data analytics platform) and started weekly automated emails for underperforming wards. With the aim of increasing data visibility.

Cycle 3: Implemented a mandatory soft-stop prompt in the SystmOne electronic patient record–which is triggered after prescribing. This was deployed as a regional trust-wide quality improvement intervention which affected all the inpatient beds at the CNWL trust (excluding CAMHS).

Education and awareness failed. Compliance fell 2.2 percentage points to 72.5%.

The data analytics dashboard visibility achieved partial improvement, raising compliance by 5.1 percentage points to 77.6%.

The semi-mandatory electronic prompt delivered the greatest impact, improving compliance by 9.6 percentage points to 87.2%.

Median time to assessment fell by 42%, from 1.30 hours to 0.76 hours.

The mean time fell from 58.1 to 9.1 hours; this indicates that there are far fewer extreme outliers who never receive VTE assessments.

Out-of-time assessments fell from 17.9% to 7.8%.

Overall compliance (comparing baseline to post cycle 3) rose from 74.7% to 87.2%.

The trust-wide implementation ensured consistent standards and an improvement in KPI across all inpatient wards.

The system level change delivered better results than targeting human factors. Making VTE assessment semi-mandatory through an electronic prompt embedded into the clinical workflow and proved to be the best intervention. In addition the placement in the clinical workflow was designed to avoid prompt fatigue on the electronic systems and to ensure emergency prescribing was not interrupted.

This approach may benefit other mental health trusts seeking to improve VTE compliance. Further specific guidance on implementation can be provided for SystmOne orientated trusts.

In a New Zealand psychiatric unit, of the 96 female patients (of reproductive age) started on sodium valproate, only 29 had pregnancy tests (1). Given the potential teratogenic effects associated with psychotropic medications alongside the potential for patients to have engaged in greater risk-taking behaviour, for instance when manic, it is essential that pregnancy and contraceptive status are considered in this patient group.

The purpose of this audit was to evaluate the screening for pregnancy and relevant gynaecological history of new female admissions (of reproductive age) to the Bradgate mental health unit in Leicester.

A prospective audit was conducted of new female admissions of reproductive age to the Bradgate Mental Health Unit over a month. The patients’ medical records were evaluated and the data required for the audit was extracted from the records covering the first 2 weeks of admission.

A data collection tool was developed to record the information. This included whether a pregnancy test was conducted and whether a gynaecological history was taken.

A total of 28 new female admissions of reproductive age were admitted between 1st September and 1st October 2025. Of the 28 patients, only 14.3% (4/28) of patients had a pregnancy test within the first 2 weeks of admission. Additionally, 7.14% (1/28) of patients were asked if there is a chance of pregnancy during the clerking process and this patient subsequently had a pregnancy test. Only one patient was asked about their last menstrual period. None of the patients were asked about if they were on contraceptives or if they were sexually active. Finally, 53.57% (15/28) of patients were up to date with their cervical screening.

In conclusion, this audit demonstrates that the assessment of pregnancy and related screening from women of a reproductive age was inconsistent and often missed entirely. Very few patients had documented pregnancy testing within 2 weeks of admission with none having sexual activity, contraceptive use or the last menstrual period dates recorded. This gap in assessment and documentation poses a risk to patient safety and suggests a need for a systems-based approach to standardise pregnancy screening. Potential strategies include raising staff awareness in the form of informative posters, presentations and potentially changes to prescribing software so that pregnancy status is considered prior to prescribing medications. Re-auditing following implementation of these interventions will determine if compliance has improved.

Starting university is often the most significant challenge a young person faces - together with new freedoms, there are significant challenges. We present a case illustrating how this challenge led to the development of restricted eating, which together with delayed detection and disrupted continuity of care, led to critical malnutrition with life-threatening complications.

We present the case of a 19-year-old university student who exhibited deliberate restriction of eating in her first year of university. ‘New year, new me’ - she initiated a restrictive diet and intense exercise regime of attending the gym six days a week. Rather than being weight-loss focussed, she described it as a mechanism of coping with loneliness - difficulty relating to older, final-year housemates - and environmental barriers to nutrition such as an unhygienic shared kitchen and perceptions that cooking for one was wasteful.

Parental concern at the end of her first year prompted a General Practitioner telephone consultation, followed 4 weeks later by a blood test showing hypokalaemia resulting in an Emergency Department admission. She was discharged in three days with a meal plan and a promise of a dietician follow-up call which was not fulfilled. Her parents, insistent on familial dining culture, discontinued the meal plan after one day. Subsequently, she was admitted to an acute hospital under the Medical Emergencies in Eating Disorders (MEED) pathway.

This case demonstrates deliberate restriction of eating emerging as an unintended consequence of attempts to regain control during a vulnerable transitional period. The move to university introduced psychosocial stressors including loneliness, disrupted routines, and environmental barriers to nutrition, aligning with literature which suggests that transitional phases increase eating-disorder risk. Service-level shortcomings, including delayed primary care assessment, fragmented follow-up, and limited continuity between acute and community services, contributed to missed opportunities for early intervention. A key paradox observed was the patient’s desire for structure and external regulation of eating illustrated through her requests for a structured meal plan, alongside significant distress when this control was imposed through nasogastric feeding. This highlights the conflicts of autonomy, control, and treatment engagement in eating disorders. Addressing these tensions requires coordinated, student-centred care pathways that integrate medical, psychological, and social support.

Deliberate restriction of eating may develop insidiously during the transition to university, reinforced by loneliness, environmental barriers, and fragmented healthcare provision. Early recognition, and integration between primary care, acute services, and university support systems are essential to prevent progression to severe medical compromise.