Children and adolescents with psychosis are more likely to have a poor prognosis and to experience treatment resistance, than adults. This is associated with a reduced quality of life, as well as increased care needs and economic cost. Clozapine is recommended for treatment-resistant psychosis because of greater efficacy than other antipsychotics, however this can be insufficient. Clozapine can be augmented with a range of different treatments, however there is relatively little data available for this in children and adolescents.

A systematic search was carried out of four databases (Embase, Medline, PsycInfo, CINAHL) from inception to February 2026, to identify studies of pharmacological and non-pharmacological clozapine augmentation strategies in children and adolescents, including psychotherapeutic or psychosocial interventions, neuromodulation, and nutritional or dietary supplements. To be eligible for inclusion, patients in the study needed to be prescribed clozapine prior to initiation of the adjunctive treatment, and to have outcome measures recorded before and after augmentation. The study was registered on PROSPERO (CRD42024564242).

Nine studies were found that reported on children or adolescents (n=59) receiving medications, ECT or other neuromodulation techniques to augment clozapine. The majority (6/9) were case reports or case series, retrospective chart reviews and one pilot RCT. Some clinical improvement was reported for a majority of patients in the included studies, however this was mostly short-term. No reports were found on adjunctive psychotherapeutic or psychosocial intervention, nor nutritional or dietary supplementation.

Some clozapine augmentation strategies may be effective in children and adolescents, but available evidence is limited and very weak. Of note, the search identified a number of studies which could not be included due to lack of outcome measures. This highlights the potential importance of routinely collected outcome data, in building an evidence base for rare presentations. Research into psychotherapeutic or psychosocial treatments was also lacking. Further high-quality, prospective research is needed to address this gap.

Acute mental health wards are emotionally intense environments where patients may experience sudden anxiety, distress, agitation, or feeling overwhelmed. In these moments, engagement with verbal therapy can be difficult, and staff often need safe, non-pharmacological options that support rapid emotional regulation while maintaining therapeutic connection.

Virtual Reality (VR), supported by Artificial Intelligence (AI), is increasingly used in healthcare, but it remains uncommon in routine acute mental health practice. This case study describes how an AI-supported VR programme was introduced at Cygnet Harrow as part of standard clinical care and explores feasibility, clinical usefulness, and early outcomes for patients and staff.

Cygnet Harrow introduced a VR therapeutic programme in partnership with XR Health, using Meta Quest 3 headsets integrated into routine ward care. Importantly, the intervention was delivered as part of Occupational Therapy (OT) activity and therapeutic engagement, rather than as a formal research project.

Staff received structured training covering safe equipment use, patient support, and how to embed VR meaningfully into daily OT-led interventions. Sessions were individualised and voluntary: patients experiencing acute anxiety accessed calming environments (e.g., nature-based, breathing-focused spaces), while those managing agitation accessed grounding-based environments designed to reduce distress and promote emotional regulation.

The VR system generated automated session reports including session duration, engagement indicators, and repeated session patterns, supported by AI-based analytics. Over a six-month implementation period, outcomes were monitored using routinely recorded staff-rated parameters: agitation (0–10), mood distress (0–10), and therapeutic engagement (0–10), alongside qualitative documentation of willingness to participate in wider therapeutic activity.

Eleven patients participated over six months (n=11), completing 94 sessions in total. Attendance was strong, with 82% session completion, and there were no serious adverse events.

Across the cohort, clear improvements were observed. Average agitation scores reduced from 7.1 to 4.2 (mean reduction −2.9 points). Mood distress reduced from 7.8 to 5.0 (mean reduction −2.8 points). Therapeutic engagement increased from 3.6 to 6.4 (mean increase +2.8 points).

In addition 8 out of 11 patients (73%) showed increased willingness to engage in broader therapeutic activity following VR sessions, including 1:1 OT engagement, psychology work, and group interventions. Staff reported VR was particularly useful for patients who were withdrawn, highly distressed, or reluctant to participate through traditional approaches. AI-generated summaries provided objective supporting information that complemented clinical observations and informed MDT decision-making.

AI-supported VR was feasible, safe, and clinically meaningful when delivered as part of routine OT activity in an acute mental health setting. It provided a practical non-pharmacological option for emotional regulation during crisis and supported improved engagement with wider treatment. With continued implementation, this approach may be transferable across other acute services.

Structured assessment frameworks can enhance quality of clinical assessment and improve patient care, but must be feasible to deliver consistently in psychiatric settings. Acute inpatient wards face fluctuating acuity, staffing pressures and competing clinical priorities, which can limit the implementation of structured assessments. The Mental State Examination (MSE) remains central to psychiatric assessment but few tools have been evaluated for routine use in ward environments. MINDY is a structured mental state and risk assessment tool intended for routine inpatient use.

The aim was to evaluate the feasibility of implementing MINDY on an acute psychiatric ward. We hypothesised that MINDY could be delivered consistently during routine clinical practice with acceptable completion rates and minimal item-level missing data.

This was a service-evaluation, retrospective and case-note review of clinical records on Opal Ward, Newham Centre for Mental Health - acute adult psychiatric inpatient service. Over a two-week period, three resident doctors completed MINDY assessments for patients under a single consultant team during clinical work, with one study day excluded due to staffing pressures. Implementation outcomes included rates of assessment completion, reasons for missed assessments and item-level completeness within submitted MINDY forms. Temporal trends across the study period and inter-individual variation were explored descriptively. All material was anonymised prior to analysis in accordance with NHS information-governance and General Data Protection Regulation (GDPR) policies. Analysis was performed by a fourth-year medical student, focusing on feasibility and implementation.

Of 66 expected assessments, 48 were completed (72.7%) across the two-week period. Reasons for 18 missed assessments included: patients on short-term leave (11/18; 61.1%), patient refusal (5/18; 27.8%) and lack of interpreter availability (2/18; 11.1%). Completion rates for MINDY assessments varied between individuals, ranging from 66.7% to 100%. No assessments were missed because of incomplete forms as item-level completeness within all completed MINDY assessments was 100%.

In routine acute inpatient practice, MINDY demonstrated good feasibility. Nearly three-quarters of expected assessments were completed despite operational barriers, patient leave and refusal. Crucially, when assessments were undertaken, all core items were completed, indicating strong usability and low administrative burden for clinicians. These findings support MINDY as a deliverable ward-based tool for repeated use in inpatient environments. Future work should focus on strategies to reduce missed assessments and evaluating scalability across multiple wards and clinician groups. Once validated, MINDY could be delivered by the wider multidisciplinary team, improving feasibility.

Simulation training is a type of experiential learning where individuals practice skills and decision-making in a safe, artificial environment that mirrors real-world scenarios.Transition points in medical careers, such as the step up from Core to Specialty Training in Psychiatry, are often viewed in a negative anticipatory fashion by doctors about to undertake a role change. A simulated workshop was created, with the aim to support Core Psychiatry Trainees (CTs) to develop their confidence in acting as the Specialty Registrar (SpR).

A pilot session was delivered at an Oxleas local Core Trainee teaching day. CTs were requested to bring cases that they had previously discussed with a SpR when on-call. 20 trainees in attendance were split into four groups, each with a Registrar/Consultant facilitator. In each group, the more senior CTs were asked to role play as the SpR, with the junior CTs presenting their cases to them. Feedback was provided on the content and communication skills of the CTs discussing their cases, and on the management plans of the CTs acting as the SpR. Additionally, to add to the fidelity of the simulation, vignettes of common scenarios requiring SpR input out-of-hours had been pre-prepared and the CTs taking on the SpR role were also asked to provide their advice on these situations.

A QR code for a survey was displayed immediately after the session finished. 15 Core Trainees responded (~75% completion rate), with all CTs reporting that the workshop was useful and engaging. Moreover, there was a considerable increase in trainee confidence of taking on the role of a SpR following the simulation, although final confidence levels remained mixed. Participants fed-back that they liked the concept, the structure and interactiveness of the session, as well as the realism of the scenarios. Feedback from the facilitators also echoed that of the CTs.

This was a successful pilot workshop utilising simulation to increase the confidence of Core Psychiatry Trainees in stepping up to the role of a SpR. Ideas forimprovement include the addition of scenarios illustrating dilemmas regarding the use of the Mental Health Act, as well as the option of a debrief between CTs and SpRs following the class where any on-call concerns can be discussed. Given the strong positive response, further work will be undertaken to refine the simulation session, with the ambition to continue its delivery locally, alongside rolling it out regionally.

This report details the forensic admission of Ms X, a woman in her 40s, following an index offence of Grievous Bodily Harm (GBH) driven by fixed persecutory beliefs. It underscores the clinical challenge of identifying Autism Spectrum Disorder (ASD) when masked by “social camouflaging” or obscured by somatic comorbidities. Historically, Ms X’s difficulties were attributed to Chronic Fatigue Syndrome and depression. At the same time, her forensic presentation was initially diagnosed as “Delusional Disorder,” illustrating the risks of diagnostic overshadowing in forensic risk assessment.

Ms X presented with persistent beliefs that an online group had compromised her devices and that neighbours were surreptitiously filming her. These beliefs culminated in her confronting neighbours while armed. On admission, her presentation diverged from primary psychosis; she exhibited limited conversational reciprocity, sensory hypersensitivities (noise and olfaction), and a narrow, obsessive preoccupation with cyber-security. A retrospective developmental history revealed core ASD traits missed due to female-typical compensation strategies, including long-standing social aversion and ritualistic behaviours. This led to a formal diagnosis of ASD, replacing the previous diagnosis of primary Delusional Disorder.

The clinical formulation reframed Ms X’s “delusions” as intense manifestations of autistic cognitive style. Her beliefs were formed through a concrete, literal interpretation of ambiguous stimuli; for example, interpreting the online phrase “I see you” as evidence of physical surveillance. Her inherent cognitive rigidity rendered these beliefs resistant to challenge. Furthermore, deficits in Theory of Mind caused her to misattribute neutral or ordinary environmental actions as intentional threats. Consequently, the index offence was formulated as a reactive defence rooted in neurodevelopmental rigidity and emotional dysregulation, rather than a psychotic break.

This case highlights the imperative for forensic practitioners to screen for masked ASD in women, particularly when intense somatic or mood symptoms are present. Understanding ASD-related rigidity is crucial for accurate risk formulation and legal mitigation. Management must shift from traditional antipsychotic protocols toward integrated, specialised psycho-social interventions–such as Neurodevelopmental Outreach Services–focused on building ASD-specific insight and adaptive coping mechanisms.

To identify patient- and staff-reported barriers and facilitators influencing transition from monthly to 2-monthly aripiprazole long-acting injectable (LAI) therapy within an Adult Mental Health Outpatient Service, and to use these findings to design interventions to improve the consistency and quality of patient–clinician discussions.

Structured, anonymous surveys were administered to patients receiving monthly Aripiprazole LAI (n=11) and multidisciplinary staff involved in LAI prescribing or administration (n=23). Surveys included Likert-scale items and free-text questions exploring understanding, willingness, confidence, perceived barriers, and facilitators. Quantitative data were analysed descriptively, and free-text responses reviewed thematically. Findings informed staged interventions tested through Plan–Do–Study–Act (PDSA) cycles.

Patients: Most had long-term monthly LAI exposure (55% >5 years). Understanding of differences between monthly and 2-monthly LAI was limited (45% reporting “not at all” or “a little”). Willingness to switch was polarised: 45% not willing, while 45% willing or very willing. Key concerns included fear of relapse (18%), concern that the injection may not remain effective for two months (27%), fewer clinical contacts (27%), and prolonged side effects (27%). Perceived benefits included fewer injections (73%), increased convenience/flexibility (55%), and fewer clinic visits or reduced travel (45% each). Over half (55%) requested more information, and 36% reported greater willingness to switch if better informed.

Staff: Although 87% of staff were aware of the 2-monthly formulation, 43% had never discussed it with patients. While 52% felt confident discussing the option, only 26% felt confident with clinical switching considerations, and 43% reported low clarity regarding practical steps such as the Named Patient Registration Form. Common barriers included patient resistance (35%), fear of relapse or destabilisation (35%), concern regarding sustained effectiveness (30%), reduced clinical monitoring (26%), and lack of patient education materials (35%). Facilitators included patient leaflets (78%), structured guidance or checklists (57%), clear explanation of benefits and risks (>55%), and staff training or induction (70%).

Baseline patient and staff data demonstrate that transitions to 2-monthly aripiprazole LAI are limited not by lack of awareness, but by gaps in patient understanding, clinician confidence with clinical and practical switching considerations, and absence of consistent education and process tools. The co-designed intervention–comprising a communication protocol, staff checklist, patient leaflet, targeted staff training, and peer-supported patient education–targets these modifiable gaps. This QIP highlights the value of aligning patient and staff perspectives to strengthen shared decision-making and improve consistency in LAI care, with implications for future service-level optimisation.

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique used at home and delivers mild electric currents, applied through two pads on the forehead. It does not have the side effects associated with antidepressant medication, is highly acceptable and easily offered through primary care. Research studies show that tDCS can significantly improve sleep quality and provide insomnia remission. Rates of insomnia remission of between 22–50% have been seen. The aim of the project was to assess effect of ‘Flow’ tDCS on insomnia in primary care patients.

Intervention: tDCS for 30 minutes, for five sessions per week for four weeks. Baseline and follow-up scores collected. Interviews with GPs and 14 participants about their experience.

Significant improvements on 1. Sleep: Insomnia Severity Index (ISI); 2. Depression: Patient Health Questionaire-9 (PHQ-9); 3. cognitive functioning: Perceived Deficits Questionnaire (PDQ-5); Quality of Life (EQ-5D-5L); and real-world functioning: Work and social adjustment (WASA). Patients have described improved quality of life, reduction in insomnia symptoms, improved sleep, improved mood, better meaningfulness/engagement in life, and better educational, social and work functioning. The project showed that offering tDCS was feasible and effective.

Evidence about the improvement with tDCS could expand NHS treatment for millions of people who experience insomnia. Having a new effective treatment in the NHS that can be used at home could be life-changing for people with insomnia. Providing a non-pharmacological choice in primary care is essential.

Severe mental illness (SMI) is associated with significant cardiovascular disease due to a combination of lifestyle factors, metabolic effects of antipsychotic medications and reduced access to preventive healthcare. This quality improvement project (QIP) wasconducted to enhance cardiovascular risk assessment in patients with SMI by improving the efficiency and consistency of QRISK score documentation.

This study was conducted over two cycles involving patients admitted with SMI to a general psychiatric unit. Cycle 1 covered a five-month period (December 2024–May 2025), and Cycle 2 a four-month period (July 2025–October 2025). Cardiovascular risk was assessed using QRISK®3 (2018) tool, with eligible patients aged 25–84 years included. Thirty patients were analysed in Cycle 1 and 27 in Cycle 2. Data were retrospectively collected from patient’s electronic records and physical health parameters. Following baseline assessment, a standardised algorithm was implemented to improve consistency of QRISK calculation. Cycle 2 reassessed outcomes to evaluate the impact of this intervention.

In Cycle 1, 30 patients with severe mental illness (SMI) were included, of whom 70% were male. In contrast, Cycle 2 comprised 27 patients, with females accounting for 59% of admissions. The age range was 26–75 years in Cycle 1 and 32–63 years in Cycle 2. Schizophrenia was the most common diagnosis in both cycles (36% in Cycle 1 and 33% in Cycle 2), followed by bipolar affective disorder (20% and 18%, respectively). Aripiprazole was the most frequently prescribed antipsychotic in both cycles (37% in Cycle 1 and 25% in Cycle 2).

During Cycle 1, QRISK scores were not documented for 15 patients (50%). Following implementation of the clinical algorithm, this improved in Cycle 2, with only 5 patients (18.5%) lacking a recorded QRISK score. In Cycle 1, a total of 8 patients were identified as having QRISK scores >10%, of whom 2 had not been documented. In Cycle 2, 6 patients had QRISK scores >10%, with no patients missed, following intervention.

This QIP highlighted the importance of routine QRISK assessment in patients admitted with SMI, who are at increased risk of cardiovascular disease. Implementation of a structured clinical algorithm significantly reduced missed QRISK calculations, improving identification of high-risk individuals. Continued staff education and strengthened collaboration between mental health and primary care services may further enhance follow-up and long-term cardiovascular risk management in this population.

Antipsychotics may be prescribed for severe behavioural and psychological symptoms of dementia (BPSD) but carry significant risks. National and local guidance recommends structured assessment, documentation, regular review, and timely deprescribing.

This audit assessed compliance with Nottingham Area Prescribing Committee guidance EG019 and National Institute for Health and Care Excellence guidance NG97 within the Newark and Sherwood Older Adult Community Mental Health Team.

We hypothesised that initial clinical assessment would show high compliance, while structured monitoring documentation would be inconsistent.

A retrospective audit was conducted using the RiO electronic clinical record system. A Clinical Record Interactive Search identified patients with a diagnosis of dementia initiated on antipsychotic medication by the Newark and Sherwood Older Adult Community Mental Health Team between 1 October 2023 and 1 October 2024. Diagnoses included International Classification of Diseases, Tenth Revision (ICD-10) codes F00–F04 and G31.8.

The audit tool was a locally developed audit proforma derived from the standards from the two guidances (EG019 and NG97), and it assessed documentation of symptom assessment, risk evaluation, discussion of risks and benefits, use of the Antipsychotics in Dementia Assessment and Monitoring Form, review intervals, and consideration of deprescribing. Compliance was reported descriptively as percentages.

Of 114 records screened, six met inclusion criteria.

• • Target symptoms were identified and quantified in 100% of cases, and contributing factors for distress were explored in all patients.

• • Delirium was considered in 83%, and modifiable factors were addressed in 83%.

• • Lewy body or Parkinson’s disease dementia was considered in all cases.

• • Risk of harm to self or others was documented in 67%

• • Discussion of risks and benefits with patients or carers was documented in 83%.

• • Medication review occurred in 100%, with dose reduction or discontinuation in 17%.

• • Review at or before six weeks occurred in 80% of eligible cases, with a documented rationale for continuation in 60%.

• • Regular six-weekly review and consideration of deprescribing were each evident in 60%.

• • Notably, the completion of the Trust Antipsychotics in Dementia Assessment and Monitoring Form occurred in 0%.

This audit demonstrates good compliance with recommended clinical assessment and cautious prescribing for BPSD but identifies a critical gap in structured monitoring, with no use of the Trust-mandated monitoring form. Documentation of ongoing review and rationale for continuation was also inconsistent. These findings support targeted education, improved induction processes, and system-level changes to embed structured monitoring. A re-audit, including baseline physical health monitoring, is planned.

Background:

Foetal Alcohol Spectrum Disorder (FASD) is under-recognised in Children in Care (CiC), Adopted Children (AC) and those on Special Guardianship Order (SGO) known to Child and Adolescent Mental Health Services (CAMHS. While neurodivergent conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), or behavioural problems are recognised, underlying neurocognitive impairments associated with Prenatal Alcohol Exposure (PAE) remain rarely explored. This case series aims to describe the neurocognitive profiles of children diagnosed with FASD identified via local diagnostic pathways, in the CiC specialist CAMHS ‘Symbol’ team.

Case Report:

Of the four children reviewed on the neurodevelopmental care pathway, three received a multidisciplinary diagnosis of FASD. Assessments included detailed mental health assessment, developmental and family histories, school reports and information collated from CiC medical records, OT (Occupational Therapy), SALT (Speech and Language Therapy), EP (Educational Psychology) reports and social care records. Standardised cognitive assessments (WISC-V -including full-scale IQ and domain-level profiles) and Adaptive Behaviour Assessment System (ABAS) were completed. Particular attention was given to variability across cognitive domains, adaptive functioning, and discrepancies between verbal ability, working memory, processing speed and fluid reasoning. The Scottish SIGN guidance was used to guide diagnostic process.

Discussion:

There was variability in overall cognitive functioning across the children assessed, ranging from Mild Learning Disability to Low Average cognitive ranges. Across cognitive domains, there was great variability, with the majority showing relative strengths in Verbal Comprehension. There was variability in the Working Memory domain across assessments, and all children showed significant relative impairments in Processing Speed, Fluid Reasoning and Visuo-Spatial domains. This “spiky profile” contributed to diagnostic overshadowing, as average/ low average full-scale IQ scores sometimes masked clinically significant cognitive impairments at domain level. The ABAS often revealed gaps between cognitive abilities and real-world functioning.

Conclusion:

FASD may be under-diagnosed in CAMHS populations, particularly where children present with complex needs and uneven cognitive profiles. Awareness of “spiky” neurocognitive patterns and systematic multidisciplinary assessment can improve diagnostic accuracy and inform educational and therapeutic support. The ABAS, alongside cognitive assessments are important in identifying domains of difficulty in the real world. Early identification has significant implications for care-planning, family understanding and psychological support in receiving a diagnosis of FASD.

To examine whether psychedelic-like states of consciousness can be induced through brain stimulation techniques, evaluate their potential advantages over pharmacological psychedelics, and explore how stimulation-assisted psychotherapy may offer a clinically viable model for mental health treatment.

A structured narrative review was conducted using PubMed and PsycINFO,examining peer-reviewed studies of non-invasive and invasive brain stimulation techniques, including transcranial magnetic stimulation (TMS), transcranial alternating current stimulation (tACS), transcranial direct current stimulation (tDCS), and deep brain stimulation (DBS). Literature describing subjective phenomenology, neuroimaging findings, and therapeutic outcomes was reviewed alongside evidence from psychedelic-assisted psychotherapy to enable mechanistic comparison. Findings were synthesised thematically with reference to clinical relevance.

Across multiple studies, targeted brain stimulation was shown to induce transient alterations in perception, emotional salience, self-experience, and cognitive flexibility–phenomenological features overlapping with psychedelic states. Neuroimaging and electrophysiological data indicate that both psychedelic states and brain stimulation modulate large-scale brain networks, particularly through reduced dominance of the default mode network, increased global connectivity, and altered thalamocortical and corticolimbic signalling.

Unlike pharmacological psychedelics, brain stimulation avoids systemic drug exposure, reducing risks of prolonged perceptual disturbance, pharmacokinetic unpredictability, substance interactions, and psychosis precipitation related to serotonergic agonism. Stimulation parameters can be titrated, paused, or terminated in real time, offering enhanced safety, reproducibility, and clinical governance.

Importantly, evidence from psychedelic research indicates that therapeutic benefit is primarily mediated through psychotherapeutic processes–such as insight generation, emotional processing, and narrative restructuring–rather than the altered state alone. Brain stimulation may similarly act as a catalyst for psychological change by transiently increasing neural and cognitive flexibility, thereby enhancing responsiveness to psychotherapy across conditions including depression, trauma-related disorders, and addiction.

Brain stimulation techniques may offer a controllable, non-pharmacological means of accessing key neural and psychological mechanisms associated with psychedelic states, while mitigating many drug-related risks. When integrated with structured psychotherapy, stimulation-assisted models may provide a pragmatic translational pathway for harnessing psychedelic-relevant mechanisms within existing mental health services. Further research is required to establish optimal stimulation parameters, safety profiles, and disorder-specific applications before routine clinical use.

Bodily distress disorder (BDD) involves presence of excessively distressing somatic symptoms to which individuals direct excessive attention despite repeated contacts with healthcare providers or even if another condition is causing the symptoms,paying excessive out of proportion attention to symptoms. BDD is more prevalent following Covid-19, but data from Asia remains sparse. Thus, this study is done to determine the prevalence of BDD among patients seeking outpatient treatment at Colombo North Teaching Hospital (CNTH), Sri Lanka.

We conducted a cross-sectional study recruiting consecutive, consenting patients attending the outpatient department (OPD) of CNTH from April to June 2025. Presence of somatic symptoms were determined by applying Bradford Somatic Inventory. Relationship of somatic symptoms to bodily distress disorder, depression or anxiety was determined according to ICD–11 criteria through clinical interviews by a senior registrar in psychiatry. In patients diagnosed with BDD lack of an adequate biological explanation for symptoms or in patients with established medical conditions contributing to symptoms, degree of attention to symptoms being excessive despite appropriate clinical examination, investigations and reassurance was confirmed by the Consultant Physician in charge of OPD.

We studied 236 patients (female 83.1%, mean age 62±11.8 years, educated up to orbelow grade eleven–83.1%, residency urban or suburban–89%). Prevalence of somatic symptoms was 94.1%. Out of those, BDD was diagnosed in 28.1%, depressive disorder in 14.3% and anxiety disorder in 7.1%. Prevalence of BDD was higher in females 29.1% compared with males 15% (Chi square 3.4,pvalue 0.06) and higher in people with education up to or below grade eleven–27.0% when compared with above grade eleven–25.0% (Chi square 0.7, p value 0.79). BDD was higher in people below 60 years (Chi square 5.6, p value 0.18) and in people residing in urban, and suburban areas (Chi square 11.0, p value 0.00). Number of comorbidities is positively correlated with BDD status. Most common two presenting symptoms were aches and pain (41.8%) and lack of energy/fatiguability (37.2%). Majority of those with BDD were on polypharmacy therapy (60.3%) and 22.2% were on analgesics.

Prevalence of BDD among this whole sample of people seeking outpatient treatment at a tertiary care hospital in Sri Lanka was 26.7%. Age below 60years, urban and suburban residency,multi-morbidity were significantly associated with BDD.

To evaluate the implementation and mental health outcomes of physical activity-based interventions within contexts specifically relevant to Wales.

We aimed to identify existing gaps in the literature, explore implications for local clinical practice, and provide a strategic solution for common mental health settings.

We sought to establish a framework for action and quality statements to embed physical activity within routine mental health care.

Prioritise action that will support the improvement of the physical health of people with severe and enduring mental health conditions, reducing the mortality gap between people who have severe and enduring mental health conditions and those that do not. This is inkeeping with aspirations of Welsh Government’s Mental Health and Wellbeing Strategy Delivery Plan 2025–2028.

We utilised a multi-faceted methodology, including a structured mapping and narrative analysis of the broader international evidence base alongside a systematic review of Wales-specific evidence.

The systematic search followed PRISMA guidelines, targeting databases such as MEDLINE, PubMed, and PsycINFO using key terms like “mental illness”, “exercise”, and “Wales”.

Grey literature sources were also analysed to capture real-world practical challenges. Articles were screened, with inclusion limited to those published after 2007 to remain consistent with modern legislative definitions.

The findings indicate that physical activity interventions significantly improve mental wellbeing across various settings in Wales, including community-based programmes, secure units, and exercise referral schemes.

Key benefits identified include reduced symptom severity for both common mental disorders and severe mental illness (SMI), improved sleep quality, and mitigation of premature mortality risks.

However, significant barriers to implementation were identified:

• Systemic Barriers: Limited funding, a shortage of qualified physical activity professionals, and insufficient training for healthcare staff.

• Individual Barriers: Low motivation, poor baseline physical health, and low self-esteem among service users.

• Environmental Barriers: The “obesogenic” nature of secure inpatient units, which often lack the flexibility or resources to prioritize physical activity.

Integrating physical activity into mental health services is essential but requires a shift in clinical culture and investment.

We propose four Quality Statements to guide leaders, emphasising collaborative design with physical activity professionals, inclusive programming for diverse needs, equitable care in secure settings, and sustainable investment in community programmes.

Effective implementation depends on moving toward a person-centred, evidence-informed approach that addresses both social and commercial determinants of health.

Dissociative identity disorder (DID) is characterised by the existence of two or more distinct identities within an individual, affecting their consciousness, behaviour, and memory. Accounting for only 1% of the psychiatric population, it is a rare and often controversial diagnosis. This case report describes the diagnosis of DID in a neurodivergent adolescent from an ethnic minority background, whose assessment was complicated by layers of complexities. Through his journey within the mental health services in England, the successes and challenges in supporting the needs of young people in similar circumstances will be discussed. All identifying details have been anonymised.

Joseph is a 14-year-old asylum seeker of Black ethnicity who arrived in the UK at age 9. Known to the mental health service from age 13 for low mood, he was reviewed following a suicide attempt by jumping from a bridge. Joseph, however, stated that it was not him but ‘Karl’ who took the leap. This behaviour was initially hypothesised to be part of autistic thinking or passivity phenomena of an emerging psychotic episode. Joseph continued to describe being in distinct personality states across various contexts, and his mother corroborated episodes of dissociation involving behavioural changes and memory disruption. A diagnosis of DID was made following multiple specialist assessments.

Joseph’s care involved multi-agency collaboration between a range of specialist teams across the public sector. The Crisis team provided a swift response and intensive follow-up during periods of escalated risks. The Outreach team, which specialises in engaging young people who are difficult to reach, built rapport with Joseph at home. Educational and social care agencies played active roles in navigating uncertainties regarding Joseph’s legal status. Engaging with a young autistic person required persistence and skill. Understanding the family’s cultural and religious backgrounds was crucial for differentiating culturally congruent experiences from those that were pathological and distressing. A key barrier to planning management from the formulation was the gaps in services and training to address such intricate presentation holistically.

While DID may not be a commonly encountered diagnosis, the context which this case brings is a familiar one: ethnic minorities constitute 18% of the UK population; autism is diagnosed in 3% of adolescents; dissociative disorders have a prevalence of 10% in the clinical population and are strongly associated with trauma. Resource allocation for training professionals to become trauma-informed, culture-aware, and neurodivergence-sensitive across mental health and non-mental health services would therefore be essential.

Autism Spectrum Disorder (ASD)-related catatonia presents a significant diagnostic and management challenge, due to the overlap between catatonic features and core autistic traits. Adolescents with ASD appear to be at increased risk of catatonic deterioration often triggered by psychosocial stressors and underlying neurobiological factors. This case describes a 16-year-old female adolescent whose catatonia was primarily driven by underlying autism, illustrating the crucial role of ASD-related mechanisms in both her deterioration and recurrence. Current literature review reveals a small number of documented adolescent catatonia cases indicating limited clinical and research consideration to this population.

A multidisciplinary treatment approach integrating pharmacological, psychological, and environmental strategies was implemented. Pharmacological management included Lorazepam (1 mg BD) targeting motor symptoms, alongside Olanzapine (5 mg ON) and Sertraline (150mg OD) to address comorbid anxiety, emotional dysregulation, and behavioural rigidity. Regular physical health monitoring remained unremarkable throughout. Additionally, the adapted for children version of the Bush Francis catatonia scaled was utilised to measure symptoms. Psychological interventions focused on anxiety reduction, restoration of independence, and development of structured daily routines. Environmentally, a low-arousal setting was prioritised with consistent 1:1 support as part of Level 3 observations. This provided containment, predictability, relational stability and reduced sensory overload. Collaborative multidisciplinary working and graded Section 17 leave facilitated a smooth transition back to the community.

A clinical decline was observed when Lorazepam was tapered and observation levels reduced to Level 2 (15-minute checks). Catatonic features including behavioural “stuckness,” delayed motor initiation, increased ritualistic behaviour, and reduced self-care re-emerged. Marked improvement was observed following the reintroduction of 1:1 support as part of Level 3 observations and an increased Lorazepam dose. This clear temporal association emphasises that environmental structure and sustained relational support are as critical as pharmacological treatment.

This case highlights the importance of recognising catatonia as a treatable manifestation of ASD. The clinical course established how ASD specific neurobiological vulnerabilities impacted to the initial deterioration and subsequent relapse. Recovery was dependent not only on benzodiazepine responsiveness but also on maintaining consistency, predictability, and therapeutic connection. A formulation driven, multidisciplinary approach balancing pharmacological, psychological, and environmental interventions is essential for sustaining improvement and preventing relapse in autistic adolescents with catatonia.