To assess adherence to recommended baseline physical, laboratory, and additional investigations within 24 hours of admission in psychiatric inpatients, identify gaps, implement targeted interventions, and evaluate improvement in compliance.

ET AL AUTHORS :

6. Dr. Muhammad Zubair - General Practitioner- muhammadzubair1103@gmail.com

A closed-loop quality improvement audit with a repeated cross-sectional design was conducted in the Psychiatry Department over 2 months. Fifty patients were included: 25 pre-intervention and 25 post-intervention phases. Pre-intervention data were collected retrospectively from patient records for physical examination (general + systemic), vital signs, BMI/weight, ECG, standard laboratory tests (CBC, LFTs, RFTs, serum electrolytes, fasting lipid profile, fasting glucose, viral markers), and special/indicated investigations (pregnancy test, urine drug screen, TFTs).

Documentation of findings in clinical notes was also assessed. Interventions included staff education sessions, standardized admission checklists, reminders during ward rounds, and coordination with laboratory and ECG services. Post-intervention data were collected prospectively using identical criteria to measure improvement.

Pre-intervention (n=25): Physical examination was documented in 72%, vital signs in 80%, ECG in 52%, and BMI/weight in 60%. Laboratory investigations showed completion rates of80% for CBC and LFTs/RFTs, 84% for serum electrolytes, 68% for fasting lipid profile and glucose, and 72% for viral markers. Pregnancy testing was completed in 7.7% of eligible females, urine drug screening in 0% of indicated cases, thyroid function tests in 20%, and documentation of findings in 56%.

Post-intervention (n=25): Physical examination improved to 92% (+20%), vital signs to 96% (+16%), ECG to 80% (+28%), and BMI/weight to 88% (+28%). Completion of CBC and LFTs/RFTs improved to 96% each (+16%), serum electrolytes to 92% (+8%), fasting lipid profile and glucose to 84% (+16%), and viral markers to 88% (+16%). Pregnancy testing in eligible females increased to 85% (+77.3%), urine drug screening to 75%, thyroid function testing to 80% (+60%), and documentation of findings to 92% (+36%).

Baseline compliance with physical health investigations within 24 hours of psychiatric admission was variable, with significant gaps in ECGs, metabolic screening, special investigations, and documentation. Following targeted interventions, substantial absolute improvements were observed across all domains, particularly in ECG performance, metabolic monitoring, pregnancy testing, thyroid function testing, and documentation quality. This audit demonstrates that structured educational and system-based interventions can significantly enhance physical healthcare delivery in psychiatric inpatient settings. Ongoing re-audit is recommended to sustain improvements and ensure patient safety.

The Advice and Guidance Service for Young Adult Mental Health Service (age 18–25) in Suffolk was established in October 2024 to support GPs with quick and effective treatment advice through a non-face to face platform in managing young adults with mental health difficulties.

No formal evaluation of the service had been conducted since the commencement of the service in October 2024.

The aim of this service evaluation project was to understand the use of the service; its effectiveness and any barriers associated with its use.

Data around the use of Advice and Guidance service by GP surgeries in both East and West Suffolk region was collected from the eReferral System (eRS) portal.

Specific Evaluation Questions were used to get feedback regarding the awareness and user experience of the A&G service for YAMHS in Suffolk from the GP trainees who work closely with GPs in various GP surgeries in Suffolk.

There were a total of 82 referrals to Suffolk YAMHS via the Advice and Guidance Service and the number of referrals was limited to less than 12 each month.

It was evident that the service was being used by various GP surgeries in both East and West Suffolk.

When looking at the outcomes for these referrals, it was evident that 61 out of total 81 A&G referrals were returned with advice. Among the remaining 20 A&G referrals, 18 were converted into a full referral to the YAMHS team and 2 were returned to the referring GP requesting further information regarding the cases for the team to be able to provide any advice or guidance.

When looking into the barriers for use, unawareness of the existence of the service was a major factor.

An information leaflet was created and sent out to all the GP surgeries in Suffolk via email. Copies of the information leaflet were handed out to the GP trainees attending the West Suffolk GP teaching programme to increase awareness and encouragement towards the service.

The A&G service for YAMHS holds the potential to be an extremely helpful service for the GPs and secondary mental health services in reducing the number of referrals and unnecessary waiting times for cases where quick and effective treatment advice can be appropriately provided through a non-face to face platform.

The barrier in using the Advice and Guidance service for YAMHS was unawareness of the availability of the service among the GPs and their trainees.

We believe that increasing awareness of the service in primary care would greatly increase the use of the service.

In 2021, in order to optimise the quality of informant questionnaires, the local memory service introduced the Brief Informant Questionnaire (BIQ), consisting of five short prompts that allow family members or carers to share their observations about memory changes, daily functioning, behaviour, and any potential risks such as safety concerns. As part of this, we asked the simple binary question “Do you think it is dementia”.

Aim:

• • To evaluate the accuracy of a single item on the BIQ by comparing the informant’s response with the clinical diagnosis following comprehensive assessment.

• • Data was collected from the 50 randomly selected patients who attended the local memory clinic from 2022 to 2024. 5 informants did not provide the response to the question “Do you think it is dementia?” and they were not included. As such, 45 cases were included in the final analysis.

• • In scenario 1, only definite “Yes” and “No” responses were used to evaluate the diagnostic performance.

• • In scenario 2, “Not sure” responses were combined with “Yes” responses.

Scenario 1:

Patient had dementia and informant agreed: 28/29 Sensitivity: 96.5%

Patient did not have dementia and informant agreed: 5/5 Specificity: 100%

Positive Predictive Value: 28/28=100%

Negative Predictive Value: 5/6=83.3%

Scenario 2:

Patient had dementia and informant agreed or was not sure: Sensitivity: 34/35=97.1%

Patient did not have dementia and informant agreed or was not sure: Specificity: 5/10=50%

Positive Predictive Value: 34/39=87.1%

Negative Predictive Value: 5/6=83.3%

The BIQ demonstrates very high sensitivity in both analysis scenarios (96.5% and 97.1%) and a strong positive predictive value (100% and 87.1%), indicating that an affirmative response was highly indicative of a true dementia diagnosis.

When “not sure” responses were grouped with “yes,” the specificity decreased, reflecting reduced ability to identify non-dementia cases.

Although the number of negative cases was small, the findings suggest that the BIQ performs reliably within the current assessment pathway and is clinically useful.

Completing this questionnaire prior to the initial assessment helps ensure that relevant information is available from the start, improves the quality and efficiency of the assessment process, and supports more person-centred assessments and care planning.

Overall, these findings provide evidence to support the use of this single item from the BIQ across wider memory services as an aid to identifying possible dementia.

Effective clinical handover is essential for patient safety within mental health inpatient hospitals. However, concerns were raised at medical resident–senior forums highlightinginconsistent handover quality between ward staff and on-call medical doctors. Although handover policies existed, they did not clearly address interdisciplinary communication or clinical escalation pathways. This prompted a quality improvement (QI) project aiming to improve structure, clarity and consistency in handover practice. The aim was to improve quality and consistency of clinical handovers between ward staff and on-call doctors, and to implement a clearer, standardised interdisciplinary handover process.

A mixed-methods baseline assessment was completed in 2024 involving questionnaires for nursing and medical teams, multidisciplinary process mapping, and root-cause analysis via fishbone methodology. Key issues identified included lack of structure and key information within handovers, unclear urgency or action required, and uncertainty around escalation routes if on-call phones are unanswered. Interventions selected through PICK chart analysis included: SBAR simulations delivered on pilot wards, SBAR prompt posters, embedding SBAR within junior doctor induction, developing a clinical escalation protocol with matrons, appointing locality SBAR champions (from multidisciplinary backgrounds) and trust-wide communication via screensavers and intranet SBAR resources. Questionnaire data was again collected in 2026.

Following implementation of the interventions, ward staff reported overall improvements in handover quality. Good–Excellent ratings for doctor-to-ward handovers increased from 53% to 75% and use of structured approaches by doctors increased from 44% to 50%. Staff understanding of patients following handover rose from 82% to 93%. Self-rated handover confidence (≥8/10) increased from 56% to 82%, with staff attributing this to training, experience and improved clarity of information. 93% of staff self-reported sometimes or always using handover structure. Ward managers on pilot simulation wardsreported improvements in regular SBAR use and staff confidence several months afterwards. Doctors reported fewer poor-quality handovers from wards, though improvements are still needed. The proportion reporting no structure to ward handovers reduced from 92% to 50% and 94% of doctors self-reported using a handover structure themselves. Further areas that still required improvement included variable on-call phone signal, and lack of clarity from some ward handovers.

Co-designed interventions like SBAR training, visual prompting, clear escalation pathways and locality champions improved confidence, structure and standardisation in interdisciplinary handovers. Sustaining these improvements will require continued reinforcement, wider simulation rollout and senior leadership support, reflecting the challenge of changing communication culture. Following these results, the inpatient handover policy has been updated and distributed trust-wide.

Stigma involves the devaluation of individuals based on personal attributes and can lead to discrimination, social exclusion, and poorer mental health outcomes, strongly shaped by cultural and social norms. The United Arab Emirates (UAE) provides a unique context to examine mental illness stigma, particularly among university students and healthcare-related groups, where stigma may hinder help-seeking and care delivery. This study aimed to quantify levels of mental illness-related stigma and examine socio-demographic and occupational correlates among university students, medical professionals and allied health workers in the UAE.

We conducted a cross-sectional, questionnaire-based study using the nine-item Stigma-9 Questionnaire (STIG-9) to assess perceived public stigma towards people with mental illness (total score 0–27; higher scores indicate greater stigma). Participants were recruited via non-probability sampling at a federal university and multiple tertiary hospitals in the UAE, using email invitations to participate in an anonymous online survey. Demographic variables included gender, age group, nationality, continent of origin, marital status, religion, family income, caregiver experience, occupation/status, type of activity and place of study/work. Descriptive statistics summarised sample characteristics and STIG-9 scores. Independent-samples t-tests and one-way ANOVA with Tukey post hoc tests compared mean stigma scores across groups; significance was set at p<0.05.

A total of 510 participants completed the questionnaire; 70.4% were female, and 48.0% were Emirati. Most were aged 16–25 (43.5%) or 31–40 (24.9%). 42.2% were healthcare providers or administrators, 40.0% were undergraduate students, and 17.8% were postgraduate students. The mean STIG-9 score was 17.5 (SD 5.64), indicating substantial perceived stigma in this educated cohort. Age was significantly related to stigma (F(4,505)=2.52, p=0.04): 16–25-year-olds reported higher stigma than 31–40-year-olds (mean difference 1.81, p=0.031). Emirati participants scored higher than non-Emiratis (t(508)=2.33, p=0.02, Cohen’s d=0.21). No significant differences in stigma were found based on gender, nationality, marital status, religion, income, caregiver experience, occupation, study/work location, or when comparing medical vs. non-medical students, undergraduate vs. postgraduate students, or healthcare groups.

Mental illness stigma is common among university students and healthcareprofessionals in the UAE, despite high education levels. Higher stigma among younger adults and Emirati nationals indicates cultural and generational influences. Culturally informed anti-stigma education in universities and healthcare training, especially for younger Emiratis, could reduce stigma, enhance help-seeking, and promote equitable mental healthcare.

No financial sponsorship has been received for this study.

Clozapine is the recommended medication for patients with treatment resistant schizophrenia and uniquely effective with the absence of extrapyramidal side effects. However, clozapine discontinuation is common in clinical practice with clinicians resorting to treatments with supported by lower quality evidence.

We aimed to identify the reasons for discontinuation of clozapine retrospectively for a duration of 30 years in a large mental health trust. We also intend to develop guidance and training for clinicians to ensure the safe and effective use of clozapine as underutilisation and delay in commencement are a priority both locally and internationally.

Using the Clozapine Patient Monitoring System (CPMS), between 1994 and 2024, patients who discontinued clozapine due to any reasons were identified. Electronic patient records were then reviewed to detail the reasons and whether it was decided by the clinician or the patient. We also noted the timeline of stopping clozapine since the initiation.

Data collected also included demographic characteristics, mental health diagnoses, comorbidities, additional medications, side effects noted while on clozapine, date of starting and ending clozapine and strategies for managing the side effects. For those patients with neutropenia, additional data were gathered separately.

A total of 1184 patients were started on clozapine during the study period. Out of these, 225( 19%) patients discontinued at various timeline in the course of treatment up to 31 August 2024 and their data were analysed.

The number of patients discontinued were mostly during the early 3 months( 38.2%) and after one year( 35.1%).Adverse effects account for 72% (n=62), 62% (n=37) and 48% (n=38) of discontinuations at <3months, 3-12 months and >12 months respectively suggesting those are the primary cause of discontinuation up to 12 months with other factors becoming equally important beyond 12 months.

Clinicians are consistently more likely to discontinue clozapine than patients (61% of total discontinuation)

Twenty-eight patients stopped due to red results. Interestingly, neutropenia accounts for more discontinuation than sedation.

The percentage of patients discontinued clozapine were less compared to previous research evidence. Most patients could potentially have continued clozapine, by proactive management of the adverse effects and better psychoeducation.

We will be recommending education and training events for all clinicians involved in clozapine management to discuss further strategies so that clozapine can be utilised promptly by the clinicians with confidence.

Rapid tranquillisation (RT) is widely used to manage acute agitation in psychiatric inpatient settings when non-pharmacological strategies fail. Older adults represent a particularly vulnerable population due to frailty, multimorbidity, polypharmacy, and age-related pharmacokinetic and pharmacodynamic changes, which increase the risk of adverse drug events.

Despite routine clinical use, most evidence regarding RT practice is derived from mixed-age adult populations, with limited age-specific guidance for elderly psychiatric inpatients. This systematic review aims to evaluate the evidence available and assess its applicability to older adults.

Aim was to systematically review and evaluate global evidence on the efficacy and safety of pharmacological rapid tranquillisation strategies in older psychiatric inpatient settings.

1. To compare the effectiveness of different RT pharmacological agents and combinations.

2. To evaluate reported adverse outcomes associated with different RT pharmacological agents.

3. To identify gaps in age-specific evidence, targeting older persons and international practice variations.

A systematic literature search of PubMed, EMBASE and related databases, Cochrane Library, grey literature and reference lists was conducted following PRISMA 2020 guidelines. Randomised control trials evaluating pharmacological RT agents for acute agitation in psychiatric or emergency settings were included.

Outcomes of interest included sedation efficacy, time to tranquillisation and adverse events. Risk of bias was assessed using the Cochrane RoB 2 tool. Due to inconsistent reporting of quantitative outcomes and a lack of elderly-specific data, a formal meta-analysis was not done.

Fifteen high-quality RCTs were identified, all involving mixed-age adult populations, none exclusively enrolled older psychiatric inpatients (>65 years).

Midazolam consistently demonstrated a faster onset of sedation compared with antipsychotic or benzodiazepine monotherapy. Combination regimens, particularly haloperidol plus promethazine or lorazepam, were more effective than monotherapy in achieving rapid tranquillisation and reducing the need for additional medication. Adverse events were generally infrequent; however, haloperidol monotherapy was associated with a higher rate of extrapyramidal symptoms, and midazolam with transient respiratory depression in some studies.

The absence of RCTs that are age-specific, targeting older persons, limits the direct applicability of existing evidence to older psychiatric inpatients. Current RT practicesfor older adults are largely extrapolated from general adult data, despite the heightened safety risks associated with this population. Inconsistent outcome reporting further restricts quantitative analysis.

There is a critical lack of elderly-specific evidence to guide rapid tranquillisation in psychiatric inpatient settings. Future research should prioritise age-stratified trials with standardised outcome reporting to inform safer, evidence-based practice.

We aimed to explore the characteristics of referrals to an NHS outpatient neuropsychiatry service, define patient pathways, and identify interventions provided.

We included all new referrals to the service between 1/10/2024 and 31/01/2025. We examined electronic clinic records (Rio) retrospectively and extracted anonymised data using an NHS-approved online data-collection tool (‘Gather’). We used ‘Gather’ and Excel for data analysis, employing descriptive statistics. 165 records were reviewed.

93% of referred patients were of working age, with 4 referrals aged under 18.Most were female (64%) and 80% were white British. 129 patients had working status recorded: 52% received welfare benefits. 75% had social support; mostly from family. Most referrals came from Primary Care and Neurology.

70% of referrals had a functional neurological disorder (FND) (30% non-epileptic attack disorder (NEAD), 40% other FND). Other diagnoses included epilepsy (n=8), traumatic brain injury (n=1), Huntington’s disease (n=2), MS (n=2) and Tourette's/tic disorder (n=4). 103 patients (62%) had previous psychological history and 59% had previous mental health service contact. 67% were prescribed psychotropic medications at referral. The most common comorbid mental health problem was anxiety (45 patients, 27%), 37 patients had depression (22%). 16 patients were autistic (10%). 70% had previous physical health problems; 39% previous neurological problems, 18% non-neurological problems and 43% both.

All referrals received multidisciplinary team (MDT) review; 52% of referrals were accepted following this. Mean waiting time between received referral and MDT discussion was 10 days. Most patients (52%) had documented investigations at referral. Of these, 81% had brain imaging or EEG completed. Mean waiting time for initial assessment/triage was 52 days; most patients were triaged by specialist nurse. 14% of referrals were discharged post-triage, mostly to primary care/self-help. Average length of stay within the service was 233 days. During the period evaluated, 19% of patients were receiving psychotherapy (11% 1:1 therapy, 8% group). 16 patients were referred to neurophysiology. 36% were prescribed medication during their treatment, mostly antidepressants. Of discharged patients, 67% were discharged to GP and 15% to community mental health services.

Referrals to the community neuropsychiatry service were characterised by complex comorbidities and clinical challenges. A significant percentage of referrals involved functional neurological presentations, with psychiatric comorbidities and social vulnerabilities. Clients received multiple types of interventions. The findings emphasise the importance of multidisciplinary assessments and integrated care pathways to address the needs of this population and guide future service development.

Additional authors: Dr Sylvia Fatunla, Prof Rafey Faruqui

Regulation 28 of the Coroners and Justice Act 2009 enables coroners in England and Wales to issue Prevention of Future Death (PFD) reports when systemic risks are identified. Organisations must respond within 56 days outlining actions taken. Although aimed to prevent future deaths, there is paucity of evidence in regard to the effectiveness of Regulation 28.

This review aimed to map published analyses of mental health- and suicide-related PFD reports, identify recurring systemic concerns, and assess whether Regulation 28 functions as an effective preventive mechanism.

A scoping review was conducted using Arksey and O’Malley’s framework to synthesise heterogeneous evidence. Database used were Embase, Medline and Psychinfo (from 2010–2013) with search terms: Regulation 28; Mental Health; suicide; prevention of future death.

• Included studies were those that:

• Analysed Regulation 28 PFD reports.

• Focused on suicide, mental health-related deaths, medicines implicated in suicide, autism-related deaths, or organisational learning.

A narrative synthesis identified cross-cutting structural domains including communication, risk assessment, service access, prescribing, workforce capacity, and governance.

The search identified 8 studies to include in the scoping review.

Recurring themes were consistent across populations:

Communication failures – poor inter-agency information sharing and discharge planning.

Inadequate risk assessment – incomplete documentation and over-reliance on risk tools.

Barriers to access – long waits, rejected referrals, and crisis care gaps.

Staffing and training deficits – workforce shortages and limited suicide prevention training.

Medicines-related risks – opioids (40%) and antidepressants (30%) frequently implicated.

Policy non-compliance – failure to follow existing procedures.

Response rates to PFDs were inconsistent (as low as 58% in some analyses), and no enforcement mechanism exists. Similar concerns recur across years, suggesting limited demonstrable preventive impact.

Regulation 28 consistently identifies modifiable systemic failings and functions effectively as a diagnostic learning tool. Whilst Regulation 28 holds preventive potential, the effectiveness remains unclear. Its preventive capacity is constrained by weak oversight, inconsistent accountability, and absence of outcome tracking. Without mandatory oversight, standardised reporting, and measurable outcome tracking, PFDs risk remaining a mere procedural issue rather than effectively preventing future deaths.

In summary, though Regulation 28 has theoretical preventive potential, stronger national coordination, mandatory implementation monitoring, and integration into regulatory frameworks are required to translate coronial learning into measurable reductions in mental health-related mortality.

The Mental Health Crisis Assessment Centre (MHCAS) at St Charles Hospital is a newly established acute psychiatric service within CNWL NHS Foundation Trust. Initial clinical and operational processes relied on parallel documents across multiple applications, highlighting the need for a safer and more efficient solution in a high-pressure clinical environment.

Aim 1 – Achieving Safe Digital Implementation: Successfully design and implement a safe, standardised digital handover tool using existing NHS IT infrastructure.

Aim 2 – Achieving Efficiency & Productivity: Demonstrate measurable improvements in clinical efficiency, workflow productivity, and multidisciplinary communication.

Aim 3 – Achieving Sustainability & Governance: Embed the digital handover tool into clinical governance processes to achieve sustainable “business as usual” practice.

The MHCAS Digital Handover Tool was developed using three applications within the NHS Microsoft 365 infrastructure: SharePoint Lists, Power Automate, and Power BI. Share Point Lists replaced three legacy handover documents with a single ‘master’ patient list serving as the central operational record. Power Automate automated routine administrative tasks. Power BI dashboards drew live data from the patient list to provide real-time visibility of operational activity, patient flow, and internal performance indicators, creating a unified digital handover and monitoring system.

Evaluation focused on system adoption, data quality, efficiency, and operational performance. Quantitative measures included weekly patient entries, number of active users, documentation update frequency, estimated administrative time savings, and referral-to-arrival times. These measures were continuously captured and visualised through live Power BI dashboards throughout the first quality improvement cycle. Qualitative feedback on staff experience, communication, and perceived value was collected at cycle completion.

Six-week outcomes (15/12/2025–25/01/2026) included:

• Weekly patient entries increased from 15 to 61.

• 27 active multidisciplinary users.

• Documentation updates increased from 10.5 to 12.6 per patient per day.

• Data completeness >98%.

• All legacy handover documents retired within one week.

• 30% reduction in administrative workload.

• Median referral-to-arrival time reduced from 15 to 6 hours (60% reduction) despite increased referrals.

• 100% (9/9) staff reported improved communication and reduced administrative burden.

The MHCAS Digital Handover Tool demonstrates that meaningful digital transformation in acute mental health services can be safely achieved using existing NHS infrastructure and governance frameworks. The intervention delivered measurable efficiency gains, improved operational oversight, enhanced clinical safety, and improved staff experience. Live operational data supports continuous quality improvement, while early stakeholder engagement facilitated rapid adoption. The approach is scalable and replicable, with discussions underway regarding application across inpatient, crisis, and liaison services. Beyond providing a more efficient and modern alternative to the current handover tool, the project highlights the largely untapped potential of automation already available and applicable to NHS systems.

Background/Rationale

The military coup in Myanmar in February 2021 caused widespread disruption to medical education. Many psychiatry trainees and trainers joined the Civil Disobedience Movement (CDM), resulting in the suspension of formal postgraduate psychiatry training nationwide and posing a serious threat to the future psychiatric workforce. In response, Myanmar CDM psychiatrists, supported by the psychiatrist diaspora, developed an alternative pathway to sustain postgraduate psychiatry training in a conflict setting.

Aims/Objectives

To restore postgraduate psychiatry training while maintaining academic standards, clinical competency, and professional integrity through an innovative, digitally enabled, and internationally supported training model.

Biweekly online Continuing Medical Education (CME) sessions commenced in March 2021. By September 2023, CDM psychiatrists collaborated with retired academics and diaspora psychiatrists from the United Kingdom, United States, and Australia to develop a formal curriculum. The programme was finalised in December 2023 and approved by the Federal Health Professional Council and Interim University Councils. An online Master of Medical Science (Psychiatry) programme was launched on 15 January 2024. The programme focused on clinical knowledge development through weekly Zoom lectures and Moodle-based learning, and clinical skills development through supervised practice, CME case discussions, and workplace-based assessments. Research training was deferred due to safety concerns.

Trainee engagement was monitored through assignment completion, participation in synchronous teaching, and completion of supervised clinical attachments. Ten trainees enrolled. Assignment completion reached 100%, participation in teaching was at least 75%, and clinical attachment completion exceeded 90%. Between April and May 2025, seven trainees completed final assessments, including multiple-choice examinations and virtual clinical examinations with live assessors and simulated patients. All seven trainees passed and were certified as qualified psychiatrists. A 360-degree evaluation demonstrated high satisfaction among trainees, supervisors, and assessors.

Despite severe disruption, Myanmar’s CDM psychiatrists successfully revitalised postgraduate psychiatry training using a decentralised, digitally enabled, and internationally supported model. This experience demonstrates that high-quality postgraduate psychiatry education can be sustained in fragile and conflict-affected settings and offers a scalable framework for global mental health workforce development.

Acknowledgements: We acknowledge all Civil Disobedience Movement (CDM) mental health professionals in Myanmar and the Myanmar psychiatrist diaspora worldwide for their collective leadership, academic contribution, and unwavering commitment to sustaining postgraduate psychiatry training under conflict conditions.

Dissociative Identity Disorder (DID), previously known as Multiple Personality Disorder, is characterised by the presence of two or more distinct personality states, often arising as a coping mechanism for severe and prolonged trauma. Based on the structural dissociation theory, Phase-Oriented Therapy is currently the treatment model recommended by the International Society for the Study of Trauma and Dissociation. It comprises three phases: Phase 1 (Stabilisation), Phase 2 (Trauma Processing) and Phase 3 (Integration and Rehabilitation). Despite its clinical significance, the evidence base remains limited, with phase-specific strategies underexplored. This review examines how dissociative parts are managed throughout the three phases of Phase-Oriented Therapy in individuals with DID, emphasising therapeutic goals, key techniques used, clinical challenges and treatment outcomes.

A narrative review was conducted using the SPIDER framework. Literature was sourced from databases such as PubMed, Wiley, EBSCO and Google Scholar using terms related to DID and Phase-Oriented Therapy. Included studies consisted of case reports, observational studies, systematic reviews and clinical guidelines.

Phase 1, the stabilisation phase, was consistently identified as foundational, with therapeutic aims including safety, emotion regulation and psychoeducation. Reported outcomes included improved affect regulation and self-control. However, many patients struggled to progress beyond this phase due to a significant level of symptoms or early dropout.

Phase 2 focused on trauma processing through exposure-based and cognitive restructuring techniques, including inner communication and grief processing. Outcomes included greater affect tolerance, reduced self-blame and improved internal communication between parts. However, several studies noted delayed symptom improvement, with treatment effects often emerging only during follow-up.

Phase 3 emphasised self-integration, functional adaptation and acceptance of functional multiplicity, defined as cooperative coexistence of parts without complete fusion. Patients showed improvements in daily functioning and a renewed sense of purpose, though some residual dissociative symptoms remained at the end of treatment.

Across studies, common challenges included high attrition rates, underdiagnosis and limited access to therapists trained in dissociation-specific approaches. Variations in treatment length,intensity and manualisation also contributed to inconsistent outcomes.

Phase-Oriented Therapy offers a structured, trauma-informed and clinically meaningful approach to managing DID. While current evidence highlights its clinical value, significant gaps remain, particularly around phase transition criteria, long-term outcomes and treatment standardisation. Future studies should prioritise controlled trials, longitudinal follow-up and more precise definitions of phase progression to strengthen the empirical foundation for this treatment model.

22q11.2 deletion syndrome (22q11.2DS), the most common chromosomal microdeletion disorder, is associated with a heterogeneous presentation including congenital anomalies and later-onset conditions, such as cognitive delay, behavioural changes, psychiatric disorders, autoimmune diseases, and palatal, gastrointestinal, and renal abnormalities (1). Assessing mental health changes is often complex due to overlapping physical and psychiatric symptoms, contributing to diagnostic uncertainty. Distinguishing psychiatric relapse from challenging behaviour or physical health complications, such as pain or infection, requires careful assessment and highlights the importance of a multidisciplinary approach.

Mr X is a 30-year-old male with mild intellectual disability secondary to 22q11.2DS and paranoid schizophrenia. He presented with several weeks of behavioural changes, including social withdrawal, fixed gaze episodes, “barking” vocalisations, erratic sleep, incongruent smiling, and attempts to leave his supported living accommodation. This was despite no apparent triggers and full adherence to risperidone. Investigations identified subclinical hypothyroidism, mild anaemia, suspected inflammatory bowel disease lost to follow-up, and recurrent otological pathology. Repeat neuroimaging was unremarkable. He had a history of positive response to temporary uptitration of risperidone during periods of relapse. There were clinical signs in keeping with psychotic relapse, however on this occasion uptitration of risperidone was not beneficial and resulted in upper extremity rigidity and increased drooling. Speech & Language Therapy input helped to clarify Mr X’s communication needs. Over time, episodes became shorter, less frequent & trigger-specific.Sleep improved with introduction of modified-release melatonin. Mr X has had a tympanoplasty, results are pending from an electroencephalogram, he is awaiting gastroenterology review and a sleep clinic assessment.

This case demonstrates the diagnostic complexity of psychiatric presentations in adults with 22q11.2DS, particularly in the context of intellectual disability and multimorbidity. Individuals with 22q11.2DS carry one of the highest known molecular risks for schizophrenia (prevalence 23.53–41%) (2), but behavioural, psychiatric and physical health factors increase the risk of diagnostic overshadowing. Adults with intellectual disability experience significant healthcare inequalities, with higher rates of avoidable mortality (3,4,5). For Mr X, proactive advocacy and coordinated multidisciplinary assessment were crucial in identifying organic contributors, supporting functional recovery, and avoiding inappropriate pharmacotherapy.

Behavioural and psychiatric changes in adults with 22q11.2DS can reflect complex interactions between bio-psycho-social factors. Advocacy, multidisciplinary input and judicious psychotropic prescribing are essential for holistic management. Mr X’s case reinforces the importance of person-centred, integrated care in navigating diagnostic uncertainty and optimising outcomes for individuals with intellectual disability and 22q11.2DS.

Large language models (LLMs) are increasingly evaluated and deployed in healthcare, yet unrecognised bias risks reinforcing inequities. This risk is particularly salient in psychiatry, where biased outputs could influence risk formulation, diagnostic reasoning, triage, and therapeutic communication. We examined whether and how bias is evaluated in studies of medical applications of LLMs, and summarised methodologies, reporting practices,and limitations of current bias detection and mitigation approaches to support safe and trustworthy implementation.

We searched databases (EMBASE, MEDLINE, PsycINFO, PubMed, ACL Anthology, ACM Digital Library, arXiv, medRxiv, and bioRxiv; 2017–June 2025), following PRISMA guidance. After de-duplication, >1,800 records were retrieved for title/abstract screening. We assessed 3,664 full-text articles against pre-specified eligibility criteria. Studies were included if they evaluated a medical application of an LLM and reported any explicit bias assessment. Studies that otherwise met eligibility for medical LLM evaluation but did not assess bias were recorded separately to quantify the evidence gap. Screening and data extraction were conducted by multiple reviewers with disagreements resolved by discussion. We extracted specialty (including psychiatry), use case (e.g. decision support, documentation, patient communication), evaluation setting (benchmark/vignette vs clinical data), protected attributes and bias targets assessed, bias methods/metrics, and mitigation strategies proposed or tested. Findings were synthesised narratively with descriptive counts across specialties and use cases.

Of 3,664 full texts screened, 278 studies met inclusion by explicitly assessing bias. A further 757 studies evaluated medical applications of LLMs and otherwise met eligibility criteria but did not report any bias assessment, indicating that most medical LLM evaluations omit bias evaluation. Included studies spanned clinical decision support, medical documentation, patient communication, education, and biomedical research across multiple specialties. Bias assessment rates varied by specialty: psychiatry 21/180 (11.7%), radiology 7/107 (6.5%), and oncology 5/51 (9.8%). Bias assessments most commonly examined demographic bias (gender, race/ethnicity, age) and variation in symptom or diseasepresentation. Methodologies included prompt-based probing (e.g. clinical vignettes), counterfactual testing, and red teaming to elicit biased responses; statistical comparisons of performance across groups (including fairness-adjusted performance metrics such as the FAP score); and clinician-led safety evaluation frameworks assessing output suitability. Proposed mitigation strategies included more diverse training data, reinforcement learning with human feedback (RLHF), direct preference optimisation, and ongoing human oversight.

Despite rapid growth in medical LLM research, explicit bias assessment remains inconsistent and frequently absent. Standardised, transparent bias evaluation across patient populations, tasks, and clinical contexts is needed to support safe implementation and ensure equitable provision.

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

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

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

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

The primary objective of this baseline audit was to evaluate the performance of mentalhealth and substance misuse services across all five Welsh prison sites against evidence-based quality standards.

The study sought to identify models of care, highlight areas of best practice, pinpoint thematic gaps requiring additional strategic resource or funding, and inform the development of a future network for prison mental health and substance misuse services in Wales.

The audit utilised a peer-review methodology developed by the Quality Network for Prison Mental Health Services (QNPMHS). Each service underwent a two-month self-assessment against 238 standards, followed by an intensive in-person review visit between September 2024 and July 2025.

Data collection involved 92 semi-structured interviews with frontline staff, prison colleagues, and patients, alongside environmental tours and documentation reviews. Compliance was measured against Mental Health (MH) standards and the 2024 Substance Misuse Treatment Framework.

Visits were undertaken by the College Centre for Quality Improvement (CCQI), commissioned by RCPsych Wales as part of the Prison partnership agreement between Welsh Government and HMPPS.

The audit revealed variable compliance levels, with average scores of 62.8% for mental health and 57.7% for substance misuse standards. Key findings included:

• • Service Models: Most services follow a nurse-led model, with significant gaps in access to psychology, occupational therapy, and psychiatry.

• • Substance Misuse: Only one prison (HMP Berwyn) maintained a full clinical SM team, while others relied on single practitioners managing high caseloads.

• • Neurodiversity: While “whole-prison” neurodiversity support managers exist, healthcare teams lack the commissioning to provide formal assessments or diagnoses for ADHD and Autism.

• • Operational Barriers: Challenges included a lack of confidential consultation rooms, insufficient IT resources, and inconsistent provision of monthly clinical supervision.

While pockets of good practice exist, particularly in collaborative duty worker roles, the Welsh prison estate faces systemic challenges regarding clinical multidisciplinary input and specialist pathways.

The report recommends immediate investment in specialist Substance Misuse staff, formalising neurodivergent care pathways, and enhancing clinical working environments.

Implementing adapted assessments for older adults and ensuring monthly clinical supervision are critical priorities to improve the quality and safety of care.

The review provides critical insight, informing the development of a future network for prison mental health and substance misuse services in Wales, commissioned by Welsh Government.

- Evaluating the current practice for management of insomnia in inpatient settings.

- Assessment of the current use of CBT- Insomnia for the treatment of sleep disorders in inpatient settings.

- Comparing the current practice with the NICE guidelines.

A retrospective review of electronic medical records of 45 patients who were currently admitted in the inpatient unit over a period of two weeks of data collection.

For each patient, documentation was examined to determine:

• Whether insomnia was reported or observed

• Whether sleep difficulties were noted in clinical records

• Whether nonpharmacological interventions (e.g., sleep hygiene) were offered

• Whether behavioural therapy (CBTI), which is considered the first line of treatment.

treatment for chronic insomnia was offered or signposted

• Whether hypnotic medication was prescribed, and if so:

Type of medication

Documentation of indication

Presence of review or stop dates

Out of the 45 current in-patients audited during the initial assessment of electronic records, 26 (58%) complained of sleeping difficulties; an additional 4 patients were observed to have sleeping difficulties according to the records. This makes the totalprevalence of insomnia 30 (66.6%). Of these patients, 23 (76.6%) had proper documentation of insomnia in their notes. As management, non-pharmacological interventions such as sleep hygiene discussion were done in 11 out of 30 (36.6%), and no patients (0%) were offered or signposted towards CBT-I. Pharmacological interventions of offering hypnotic medications were offered to 26 out of 30 (86.6%). The hypnotic medications offered included Z-drugs and/or in combination with benzodiazepine and antihistamines. None of the patients (0%) adhered to all criteria of NICE guidelines and Local Trust Policy (classifying insomnia according to duration of symptoms, trial of non-pharmacological intervention before using medications, clear indication documented before starting hypnotics, periodic review and documentation of stop date for said medications)

This audit highlights the need for a structured and consistent approach to managing insomnia across the hospital. Establishing a simple, standardized care pathway–prioritizing non-pharmacological strategies and applying a cautious, clearly justified approach to hypnotic prescribing–has the potential to enhance patient safety, minimize the risk of hypnotic dependence, and promote higher-quality clinical care. Ensuring insomnia is managed systematically and in line with NICE recommendations will support more effective and sustainable outcomes for our patients.