To map emerging evidence on how endogenous female sex hormones influence ADHD symptom trajectories and treatment response, and to prioritise a concise, pragmatic research agenda that can be taken forward by clinicians and researchers.

We carried out a targeted narrative review of recent reviews, cohort studies, mechanistic reports and pragmatic clinical series published in the last decade. Selection emphasised studies that reported cycle-linked symptom data, used within-subject comparisons, incorporated endocrine assays, or described medication-adjustment strategies. The goal was to identify consistent clinical signals, methodological weaknesses, and high-yield research priorities rather than to perform an exhaustive systematic search.

Across menstrual, peripartum and perimenopausal windows a consistent clinical signal emerges: many women with ADHD report predictable worsening of attention, executive function and affective regulation during low-oestradiol states (late luteal/menstrual phase, early postpartum, and perimenopause). Mechanistic work indicates that oestrogen modulates dopaminergic and noradrenergic circuits implicated in attention and cognitive control, providing biological plausibility for these observations. Small within-subject and pragmatic reports suggest stimulant efficacy and tolerability may vary by cycle phase and that some clinicians achieve symptomatic benefit with cycle-timed dose adjustments; however, these data are preliminary. The literature is dominated by observational designs, retrospective self-report, small samples, inconsistent outcome measures and sparse serial hormone sampling. These limitations constrain causal inference and generalisability. Perinatal evidence highlights postpartum vulnerability but lacks robust registries linking medication decisions to maternal and infant outcomes. Perimenopausal findings are emerging but heterogeneous.

There is sufficient signal to warrant routine clinical enquiry about symptom cyclicity and to adopt a cycle-aware, flexible management approach in practice. To move from signal to guidance we recommend three priority studies: (1) short prospective menstrual-cycle cohorts with daily symptom tracking and serial oestradiol/progesterone assays; (2) within-subject medication response trials comparing follicular and luteal phases with pharmacokinetic sampling; and (3) perinatal registries documenting medication choices and maternal-infant outcomes. Implementing this focused agenda will accelerate translation of hormonal mechanisms into practical, gender-sensitive ADHD care.

Behavioural variant frontotemporal dementia (bvFTD) is characterised by early and progressive changes in behaviour, personality and executive functioning. Neuroimaging and biomarkers can support diagnosis, these investigations may be normal in the early stages, increasing diagnostic uncertainty and potential misattribution to primary psychiatric illness. In such cases, a comprehensive neuropsychiatric assessment and collateral history remains key to diagnosis.

A woman in her 50s was referred to neuropsychiatry with a 3-year history of disinhibition, emotional blunting, aggression, repetitive behaviours, and decline in social functioning. Assessment included neuropsychological testing (ACE-III and RBANS Update), brain MRI, FDG-PET, DAT scan, EEG, and CSF analysis (including autoimmune and infectious panels). Genetic testing was also undertaken. The case was reviewed by a dementia Neuroradiology multidisciplinary team and nuclear medicine consultant.

Despite clear and progressive behavioural and functional deterioration, structural and functional neuroimaging, EEG, and CSF investigations were initially unremarkable. Neuropsychological testing demonstrated multi-domain cognitive impairment, with particularly marked deficits in visuospatial ability and memory (≤1st percentile on RBANS). Behavioural features included public disinhibition, rigidity, aggression, loss of empathy, and impaired insight. No primary psychiatric disorder, delirium, or alternative neurological diagnosis was identified. A clinical diagnosis of probable bvFTD was reached based on the behavioural profile, collateral history, and progression. Minimal symptomatic improvement was observed with the prescription of Quetiapine and Carbamazepine. Subsequent genetic testing identified a pathogenic C9orf72 hexanucleotide repeat expansion, confirming the diagnosis.

This case highlights how behavioural variant frontotemporal dementia may be diagnosed clinically despite normal imaging and biomarker studies, with genetic testing serving as confirmatory tool. Careful behavioural evaluation, collateral history, and longitudinal follow-up remain essential in complex neuropsychiatric presentations. This case supports early consideration of genetic testing in diagnostically challenging cases of suspected bvFTD.

BACKGROUND

Neurological deterioration during alcohol detoxification is commonly attributed to alcohol-related complications, particularly Wernicke’s encephalopathy, withdrawal syndromes or side effect of detox treatment.While such diagnostic pathways are clinically appropriate, they may predispose to premature diagnostic closure. This case highlights the risk of diagnostic overshadowing when alternative neurovascular pathology presents with overlapping features.

AIMS

1. To examine diagnostic challenges associated with recurrent falls and neurological symptoms during inpatient alcohol detoxification

2. Highlight the clinical overlap between Wernicke’s encephalopathy and thalamic stroke, necessitating early neuroimaging

3. Emphasise the importance of structured reassessment and vigilance during week-two detox complications.

A retrospective single-case clinical analysis was undertaken within an inpatient addiction detoxification unit. Clinical records, nursing observations, withdrawal monitoring tools, medical reviews, and neuroimaging reports were examined to reconstruct the diagnostic trajectory, differential formulation, and escalation decisions.

Case Presentation:

A 60-year-old man was admitted for planned alcohol detoxification, reporting daily consumption of approximately 14 units of lager with a Severity of Alcohol Dependence Questionnaire (SADQ) score of 28. He had no prior detoxifications, no history of delirium tremens, and no active psychiatric comorbidity. Past medical history included thrombocytopenia and abnormal liver function tests attributed to non-alcoholic fatty liver disease. Baseline physical examination was unremarkable.

During week two of detoxification, he developed recurrent falls preceded by dizziness and a “funny head” sensation. One episode occurred after rising from bed; another followed standing from the toilet. There was no loss of consciousness, seizure activity, or incontinence. Subsequent review identified a new broad-based gait,nystagmus, left upper limb hypertonia, and subtle postural weakness, although other cranial nerve examination and speech remained intact. Cognitive biases (anchoring to withdrawal, premature closure, and diagnostic overshadowing) were identified as potential contributors to delayed escalation. Initial differentials included Wernicke’s encephalopathy, hypotensive episodes related to antihypertensive use, high dose in detox reducing regime and transient ischaemic attack. The patient initially declined emergency transfer due to lack of confidence in emergency department waiting times, but was urgently escalated for acute hospital assessment and a brain scan following clinical concern.

Emergency department evaluation noted nystagmus, gait ataxia, and memory impairment. MRI revealed anacute right thalamic infarct, with additional cerebellar microhaemorrhages and chronic small-vessel disease. The thalamic lesion explained the patient’s gait disturbance, postural instability, and subtle motor changes, which had initially mimicked Wernicke’s encephalopathy.

Outcome:

The patient was transferred to neurology, commenced on stroke-appropriate management, and referred for physiotherapy. He continued relapse-prevention work with our community alcohol services and was started on acamprosate. This case demonstrates how acute stroke can present with symptoms easily misattributed to alcohol withdrawal syndromes, underscoring the need for repeated assessment and a low threshold for neuroimaging when the clinical picture evolves.

This case underscores the potential for neurovascular events to mimic alcohol-related neurological syndromes during detoxification. Thalamic infarcts may present with gait disturbance, cognitive change, and ocular signs that overlap with Wernicke’s encephalopathy. Clinicians should maintain a broad differential when new focal signs, persistent/new ataxia, or incomplete response to thiamine therapy emerge. Early neuroimaging is essential to avoid diagnostic delay and optimise neurological outcomes.

The objective of this audit is to establish the baseline of how much physical health monitoring is being completed in a general adult outpatient mental health team for patients with severe mental health illnesses (SMI) in accordance with NICE Guidelines.

Data were collected from CMHT records and the Welsh Clinical Portal for patients who attended outpatient appointments in a CMHT in North Wales over a two-week period in September 2025.

Inclusion criteria:

Patients with a diagnosis that falls under SMI.

Patients prescribed antipsychotics or Lithium.

The Welsh Clinical Portal will be accessed to identify patients who have received a full or partial physical health check from primary care

Out of the 29 patients studied, the following parameters were monitored:

Pulse in 30.4%, Blood Pressure in 56.5%, Weight in 20.7%, Hbs-653C/Glucose in 41.4%, Liver Function in 58.6%, Renal Function in 65.5% and Lipids in 58.6%.

Of the 4 patients who required prolactin testing, 75% had their prolactin monitored.

Comparing patients on Lithium or Clozapine (11 patients) (as they were monitored in dedicated clinics) vs those on other antipsychotics (18 patients), weight was monitored in 45.5% vs 5.6%, Renal Function in 45.5% vs 77.8%, Liver Functions in 36.4% vs 72.2% HbA1c/Glucose in 27.3% vs 50.0% and Lipid Profile 45.5% vs 66.7%.

Comparing High Metabolic Risk Patients (on Olanzapine=5, Quetiapine=7 and Clozapine=3) vs those not on those (14), the monitoring of the parameters was -Weight: 18.8% vs 23.1%, Hbs-653c/Glucose: 50.0% vs 30.8%, Renal function: 75.0% vs 53.8%, Liver Functions: 68.8% vs 46.2% and Lipid Profile: 62.5% vs 53.8%.

Of the patients prescribed Lithium (9/29), Lithium levels were measured ≥4/year in 1/9 (11.1%), Urea and Electrolytes ≥2/year in 6/9 (66.7%), and Thyroid Function ≥2/year in 4/9 (44.4%).

Monitoring of physical health parameters has considerable scope for improvement among patients with SMI in CMHT. Compared with patients prescribed Clozapine or Lithium, those not receiving these medications had their weight monitored more frequently. Interestingly, Renal function, Liver Function, Hbs-653c/Glucose, and Lipids were monitored more closely in the latter group, even though patients receiving lithium and clozapine had dedicated clinics.

The CMHT is planning to allocate a dedicated health worker to monitor all patients with SMI being prescribed antipsychotics. Concordance with the monitoring protocol will be reassessed after this intervention.

The RCPsych Recruitment and Retention Charter identifies good quality inductions and creating a culture of belonging as strategies to improve workforce wellbeing.

The North Central and East London Child and Adolescent Psychiatry Higher Training (NEL CAP HT) scheme incorporates 19 placements across four different trusts. After thepandemic, inconsistent one-hour online inductions were provided by current trainees for new starters without formal protected time.

To address uncertainty towards placements, anxieties when starting on-call work and to prevent risk to patient safety, a quality improvement project was undertaken:

• • To improve NEL CAP trainee onboarding experienceby developing a standardised, mandatory, in-person induction.

• • To improve morale, build trustand cohesiveness amongst trainees and trainers.

Cycle 1 (August 2025) evaluated transition from fragmented online inductions to a structured half day, in-person session. Surveys measuring trainee confidence in onboarding andon-call experiences were completed by both previous trainees who had experience of online inductions and the new starters (n= 15).

Cycle 2 (January 2025) incorporated feedback from Cycle 1 to plan a full day in-person induction involving senior trainees and trainers, enriched with simulation case scenarios and a Microsoft Teams repository of relevant policies and protocols.

Quantitative data:

• • Confidence in managing out of hours on-calls increased by 16%.

• • Confidence in understanding the scheme structure and individual placements increased by 15%.

Qualitative themes:

Moving from an online to in-person induction led to a shift from trainees feeling isolated and anxious at the start of joining the scheme, to a sense of connectedness and reduced on-call anxieties.

Trainees frequently cited peer interaction and presence of trainers in the in-person induction as the most helpful part of their onboarding experience.

In-person induction improves the scheme onboarding experience for trainees by reducing their anxieties and ensures patient safety. Trainer presence in higher trainee induction boosts morale and improves psychological safety for new starters. A formal full day induction incorporating timely changes to the scheme and on-call workflows using simulation-based learning, is expected to further enrich content delivery.

The Bradford District Care NHS Foundation Trust IMG Network delivered a face-to-face workshop for International Medical Graduates (IMGs) on 29 September 2024, followed by a virtual workshop via MS Teams on 12 September 2025.

Both sessions focused on supporting IMGs in understanding career progression, one of the eight key pillars of IMG support. The workshop content was informed by the framework outlined in the School of Psychiatry Yorkshire and Humber Deanery’s Life in the UK as an IMG–A Psychiatrist’s Journey, ensuring alignment with regional expectations.

This Quality Improvement project built upon the 2024 in-person workshop to expand its impact. The primary aim was to determine whether a virtual format could improveattendance, offer greater accessibility, reduce costs, and compare favourably with in-person approach. By evaluating engagement and perceived value across both formats, the project explored whether virtual delivery could serve as a sustainable model for ongoing IMG support.

Focused areas of the workshop remained the same namely leadership, portfolio management, reflective practice, coaching and preparing for ARCP.

Workshop delivery transitioned from in-person to virtual (via Microsoft Teams).

Pre-and post-workshop surveys were conducted to quantify attendee experience and evaluate learning outcomes.

Cost to the trust was compared from 2024 in-person workshop with 2025 online workshop.

Direct costs for the 2025 virtual workshop were minimal and difficult to quantify. However, virtual delivery eliminated venue booking costs, avoided travel and mileage claims and reduced carbon footprint. For comparison, the 2024 in-person workshop cost was £1750 (venue and related expenses).

There was an increased average attendance from 10 (2024) to 26 (2025).

Virtual model of delivering workshop via MS Teams was more cost-effective, environmentally sustainable, and generated better attendance with wider regional participation without compromising on the educational quality of the workshop as demonstrated by post-workshop survey feedback.

Positive post-workshop feedback also supported and favoured continued provision of virtual IMG development workshops in comparison with in-person workshop.

• • To characterise patterns of problematic online gaming in autistic adults with mild ID within a locked rehabilitation ward.

• • To identify behavioural escalation triggers and staff interaction factors associated with gaming-related incidents.

• • To evaluate the impact of a structured, formulation-driven “gaming access plan” on incidents and engagement outcomes.

A prospective service evaluation was conducted in a locked rehabilitation inpatient service for adults with autism and mild ID. A structured pro-forma was implemented over a 12-week period to capture: (i) gaming access patterns (device type, duration, online vs offline), (ii) antecedents and triggers (including demand type and staff response style), and (iii) outcome measures (incidents, PRN administration, sleep disruption, and engagement in OT/rehabilitation activities).

Following baseline data collection, a standardised intervention was introduced comprising a personalised gaming plan (agreed daily access windows, visual time-limits, low-arousal staff scripts, and a supported transition routine), paired with consistent MDT implementation and alternative regulation activities. Descriptive statistics and pre/post comparisons were used.

Twelve Male patients were included (mean age 26 years). Online competitive multiplayer games were the most common activity (75%), and 67% of patients demonstrated daily gaming exceeding 4 hours. Gaming was predominantly used as an emotional regulation strategy and as an escape from demands.

Across baseline weeks, 61% of recorded incidents were temporally linked to gaming access or restriction. The most frequent escalation triggers were: (1) being asked to stop gaming mid-session (42%), (2) demand introduction during gaming (medication, hygiene, meetings) (28%), and (3) connectivity/game performance issues (e.g., lag, ranked loss) (18%). Escalation was more likely when limit-setting was delivered using direct instruction without warning compared with collaborative low-arousal approaches.

Following implementation of the structured gaming plan, total incidents reduced from 78 to 48 over comparable time periods (38% reduction). PRN use reduced by 29%, and OT engagement improved from 54% to 71% of planned sessions attended. Sleep disruption linked to late-night gaming reduced, with fewer recorded episodes of nocturnal dysregulation.

Problematic online gaming is a clinically significant driver of distress and behavioural escalation within autistic adults with mild ID in locked rehabilitation. Incidents were most consistently associated with transitions, demand introduction, and loss of gaming-related control. A structured, autism-informed gaming plan with consistent low-arousal staff implementation was associated with meaningful reductions in incidents and PRN use, alongside improved rehabilitation engagement. This work supports the integration of gaming formulations into Positive Behaviour Support planning and highlights the need for further research into gaming disorder phenotypes in inpatient autism/ID services.

This project aims to improve primary care clinicians’ understanding of modifiable dementia risk factors and increase the frequency of dementia prevention discussions within routine consultations. The hypothesis was that a concise, fact-based educational intervention would improve clinicians’ knowledge, confidence, and willingness to provide dementia risk reduction advice. An initial pilot phase has been completed, and based on this scoping work, we aim to expand the project especially across our immediate region with a target of 150 respondents.

The pilot phase originally included an online questionnaire anonymously completed by 50 primary care clinicians (GP trainees and registered GPs). It assessed clinicians’ current use of prevention advice, knowledge of dementia-specific modifiable risk factors, and perceptions of dementia preventability. Respondents then received a targeted educational package (post-survey submission) summarising up to date dementia risk evidence, including findings from the 2024 Lancet Commission, key modifiable risk factors, and practical clinical resources.

While the initial pilot was completed in November 2025, survey expansion to roughly 150 clinicians will take place between January and May 2026, with full results intended for dissemination by the end of May ahead of conference.

Pilot findings showed that while 74% of clinicians believed dementia is preventable, only about 42% routinely discussed prevention in consultations. Clinicians widely addressed cardiovascular risks with 96% compliance while risks specific to dementia were less frequently recognised. Significant knowledge gaps evident include: 66% were unsure aboutthe importance of hearing and vision loss; 50% were uncertain about the role of high HDL cholesterol; 54% did not know whether treating hearing loss reduces dementia risk; 80% were unaware of the increased risk among minoritized or low socioeconomic groups; and 86% were unsure whether risk reduction remains achievable in the presence of genetic predisposition. These results will be further evaluated and validated during the expanded phase, with the full dataset submitted at the time of final presentation.

The pilot phase of this survey reveals significant gaps in clinicians’ understanding of modifiable dementia risk factors. Expanding the project to a larger cohort will strengthen the validity of this pilot assessment findings. Small-scale educational interventions can positively influence clinical practice with a potential to support improvement of long-term cognitive health outcomes while integration of dementia prevention discussions particularly relating to hearing loss, cardiovascular health, lifestyle behaviours, and environmental risks may substantially enhance population level cognitive health. Ongoing evaluation and the broader adoption of prevention prompts within clinical templates are planned to ensure sustained and scalable improvements.

Aims (Background)

Clozapine is associated with severe gastrointestinal hypomotility, constipation, ileus, and bowel obstruction through anticholinergic and antiserotonergic mechanisms. Tirzepatide, a dual glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonist, delays gastric emptying and intestinal transit as part of its pharmacodynamic effect. Both agents independently impair gastrointestinal motility, yet their combined use is increasing as tirzepatide is prescribed to manage clozapine-associated metabolic dysfunction.

We hypothesised that the pharmacological combination of clozapine and tirzepatide may produce additive gastrointestinal hypomotility, increasing the risk of small bowel obstruction (SBO) in vulnerable patients.

Methods (Case Report)

We describe a single case (n=1) of a 54-year-old Black British woman with paranoid schizophrenia treated with clozapine since 2016, type 2 diabetes mellitus, and chronic constipation despite regular laxative therapy. Her medical history included extensive abdominal surgery for sigmoid volvulus with subtotal colectomy and ileostomy in 2012, followed by reversal in 2013.

Tirzepatide was initiated in March 2025 by the diabetes team for poor glycaemic control. Weight, glycaemic indices, clinical presentation, and radiological findings were reviewed using electronic health records.

Results (Discussion)

Following initiation of tirzepatide, significant metabolic improvement occurred, with weight reduction from 71.5 kg to 64 kg and Hbs-782c improvement from 86 mmol/mol to 43 mmol/mol within four months.

In May 2025, approximately two months after starting tirzepatide, the patient was admitted with acute abdominal pain and vomiting. Computed tomography (CT) imaging demonstrated markedly dilated small bowel loops (up to 63 mm) with an abrupt transition point, consistent with SBO. A second SBO occurred in October 2025, again confirmed radiologically with dilated loops and a transition point, without evidence of malignancy, perforation, or ischaemia.

There was no documented history of SBO in the years preceding tirzepatide initiation. Both episodes were managed conservatively. Tirzepatide was discontinued following the second obstruction.

Conclusion

This case highlights a potential pharmacodynamic interaction between clozapine and tirzepatide, resulting in additive gastrointestinal hypomotility and recurrent SBO in a high-risk patient. While tirzepatide provided substantial metabolic benefit, its use alongside clozapine may pose significant gastrointestinal risk. Careful patient selection, baseline bowel assessment, and close monitoring are essential when prescribing GLP-1/GIP agonists to individuals receiving clozapine.

The global burden of dementia is escalating rapidly, with prevalence estimates rising from 57.4 million in 2019 to a projected 152.8 million by 2050. This increase carries profound economic implications; direct and indirect costs are forecasted to consume approximately 0.5% of global GDP by 2050. Health economic evaluation can support efficient allocation of resources but key challenges remain in determining what outcomes are valued and how. We discuss critically the role of the life course approach in informing health economic evaluations.

Various methods exist for determining the relative costs and benefits of different treatment approaches. Relatively simple methods use pre-determined quality of life values for different stages of dementia to model the ‘utilities’ generated by treatment. The more recent ICECAP approach includes a broader range of outcomes than just health states by considering aspects of capability.

Despite these innovations in determining health outcome measures challenges remain. Models must account for complex interactions between symptoms, disease progression and quality of life. Another challenge is accounting for the “Proxy-Patient” gap, where caregiver reports often diverge from patient experiences. Furthermore,economic models can struggle with the valuation of “process utility” and the difficulties of extrapolating data from brief clinical studies into long-term disease models spanning many years.

The Life Course Approach:Our work proposes integrating a ‘life course’ perspective into health economic approaches to better understand dementia within the context of a patient’s entire life. By utilizing the concepts of “Trajectories and Transitions”,economists can evaluate how dementia disrupts expected life paths–such as the loss of a planned retirement or the inability to fulfil the role of a grandparent. Additionally, the concept of “Linked Lives” offers insight into the social interdependencies that shape the “Proxy-Patient” gap. Qualitive methods offer an important lens to investigate these problems.

Incorporating life course and qualitative approaches could provide a more robust framework for valuing preferences in dementia. By capturing the impact of disrupted life expectations and social interconnectedness, economic analyses can more accurately reflect the true impact of the disease, leading to more equitable and efficient resource distribution.

Hyponatremia is a well-recognised adverse effect associated with several classes of antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) and serotonin–noradrenaline reuptake inhibitors (SNRIs). Older adults are at increased risk due to age-related physiological changes in renal function, reduced homeostatic reserve, polypharmacy, and the presence of multiple comorbid medical conditions. In the Psychiatry of Old Age inpatient setting, undetected hyponatremia can result in significant clinical consequences, including acute confusion, increased risk of falls, seizures, and overall increased morbidity and length of hospital stay. National and international prescribing guidance, including the NICE guidelines and the Maudsley Prescribing Guidelines, therefore recommend regular serum sodium monitoring in high-risk populations, particularly following the initiation or dose adjustment of antidepressant medication. The aim of this audit was to evaluate compliance with recommended sodium monitoring standards within the Psychiatry of Old Age inpatient unit.

A retrospective clinical audit was conducted involving all currently admitted inpatients aged 65 years and older on the Psychiatry of Old Age unit who were initiated on antidepressants or experienced antidepressant dose changes during their admission. Data were collected using a standardized audit tool through review of electronic health records, prescription charts, and the laboratory information system. Variables recorded included patient demographics, antidepressant type and dosage, dates of antidepressant initiation or dose escalation, dates of serum sodium measurements, and documentation of abnormal sodium results with associated clinical management.

All patients included in the audit were prescribed antidepressant medication, most commonly mirtazapine and venlafaxine. Baseline urea and electrolyte (U&E) testing was completed for all patients at the time of admission, demonstrating good compliance with admission assessment standards. However, follow-up monitoring within the recommended two to four weeks following antidepressant initiation was documented in only 50% of patients. Antidepressant doses were increased during admission in 50% of patients, yet follow-up U&E monitoring within four weeks of dose escalation was performed in only 16% of cases, indicating a significant gap in adherence to guideline recommendations.

Following presentation of the audit findings to the multidisciplinary team, a quality improvement intervention was implemented. Reminder stickers were introduced into each patient’s file to prompt clinicians to arrange timely sodium monitoring following antidepressant initiation or dose changes. Educational discussion also took place to reinforce guideline awareness and highlight the clinical risks associated with hyponatremia in this population. A second cycle of the audit is currently underway to assess the effectiveness of these interventions and determine whether compliance with sodium monitoring standards has improved.

The NEWS2 tool is integral to post-admission physical health monitoring, guiding baseline assessment and early detection of deterioration. It standardises observation recording and escalation. Trust Standard Operating Procedure and the Physical Health Policy provide detailed guidance for assessment, recording, and escalation, in alignment with NICE standards. Following an initial audit identifying documentation and escalation gaps, recommendations were implemented, including standardisation and increased electronic recording. This re-audit assesses the impact of these interventions.

Aim and Objectives

• • To compare re-audit results with the previous audit to assess progress against Trust standards.

• • To evaluate the impact of initial audit recommendations on correct NEWS2 utilisation.

• • To identify persistent issues in NEWS2 monitoring or recording and inform further action.

• • To enhance patient care and safety.

We conducted a comprehensive review of each section of NEWS2 charts using the same proforma as the initial audit for 35 patients admitted to wards 6 and 7 at Harplands Hospital over three weeks. Patients were aged 68–91 years with near-equal gender distribution, no pregnancies. Findings were analysed using SPSS and compared to both Trust standards and previous audit results to assess improvements in NEWS2 monitoring and recording.

In the re-audit, NEWS2 charts were completed on admission for 33/35 patients, compared with 37/39 previously. Electronic recording predominated, with all 35 patients having electronic charts, 12 of whom also had paper charts; previously, electronic charts were often left unfilled.

Documentation quality improved markedly: patient demographics, date, time, and assessor name were completed in 100% of charts. Previously, 12 charts were incomplete, 9 had illegible entries, 6 missing signatures,12 incomplete sections, 9 lacked demographics, 13 had date/time missing. All physiological observations, including blood glucose, were accurately recorded, paper chart dots joined, and NEWS scores correctly calculated for all patients. Two patients scored ≥3 on ACVPU, with appropriate Glasgow Coma Scale documentation, compared to incomplete GCS recordings in two charts previously.

Weekly NEWS monitoring occurred in 31/35 patients; the remainder had documented clinical justification. Escalation improved: NEWS scores 1–4 were reviewed by nursing staff in 20/21 escalated cases (previously inconsistently reviewed), and all scores >4 were escalated to medical staff, with emergency services contacted if medics were unavailable.

Implementation of previous recommendations improved consistent and correct NEWS2 use, supported by electronic documentation. Appropriate escalation of clinically significant scores strengthened patient safety. Performance improved across all domains, meeting Trust and national standards. Findings have been disseminated, with ongoing efforts to sustain performance.

This systematic review aims to synthesize the current literature on Artificial Intelligence (AI)-based interventions for improving sleep outcomes in individuals with neuropsychiatric conditions, excluding those with a primary diagnosis of insomnia.

This paper is a systematic review conducted in accordance with the PRISMA 2020 guidelines, with two independent reviewers conducting all stages using a double-blind method and conflicts being resolved after each section. A comprehensive electronic search was performed across EMBASE, Medline and PubMed using MeSH terms for Artificial Intelligence, Sleep and Neurological/Neuropsychiatric Conditions. Studies included were English-language, peer-reviewed primary research published between 2022 and November 2025, focusing on AI-based interventions for sleep outcomes in individuals with neuropsychiatric conditions (excluding primary insomnia). Data extraction used the Joanna Briggs Institute (JBI) systematic review framework.

Five studies met the inclusion criteria with wide variations in study type. Sample sizes ranged from 65 to 540 across studies conducted in the UK, USA and Australia. The interventions ranged from AI-based chatbots, mobile apps, wearable devices and sociallyassistive robots. Positive and statistically significant increases in participant engagement were observed, with two papers reporting interactive AI groups attending up to two additional sessions on average (b=1.65, p<0.001) and using the intervention up to 3.8 times longer (p<0.01) compared to the control group. However, overall sleep-related outcomes were mixed; the intention-to-treat analysis in the US randomised control trial (Paper 4) found no statistically significant difference, but post hoc analysis showed significant improvements in sleep quality in the high-device adherence subgroup. Conversely, a cluster randomised control trial (Paper 5) showed no evidence of improved sleep patterns but did note a significant reduction in daytime and night-time motor activity.

Positive and statistically significant increases in participant engagement were observed with the use of artificial intelligence interventions. However, the increased engagement did not result in statistically significant improvements in overall sleep outcomes. The effectiveness of AI interventions is limited by the lack of robust research and universally low sample sizes. Whilst AI interventions have shown to improve engagement, there is currently insufficient evidence to suggest AI interventions improve sleep outcomes in the population group studied.

Drug resistant first episode psychosis in a 17-year-old adolescent male with autism spectrum disorder presents with a significant diagnostic and therapeutic challenge especially with associated physical comorbidities. Medication intolerance, persistently low white cell count, partial response and early relapse after discharge remain the prominent risks. This case highlights the complex nature of therapeutic decision making and discharge planning in a high-risk young person.

A 17-year-old adolescent male who was admitted to the in-patient CAMHS unit with a 14-month history of progressive psychotic symptoms characterised by chronic auditory and visual hallucinations, paranoid delusions; alleging his parents to be impostors; depressed mood, anhedonia, and social withdrawal. With a diagnosis of autism spectrum disorder, history of significant trauma, years of school bullying and street robbery. He has a past medical history of cardiac arrest with unknown aetiology and on treatment with implantable cardioverter defibrillator.

During initial admission, he was polite, compliant with treatment although with partial insight. Family support was robust, and leave was utilized with no significant adverse incidents. Despite participation in ward activities his affect remained predominantly flat with persisting psychotic symptoms albeit with less intensity. Pharmacological management remained challenging, initially commenced on aripiprazole, titrated to 15mg which was discontinued due to significant restless legs symptoms requiring procyclidine. Olanzapine was initiated and gradually increased to a maximum of 12.5 mg with partial stabilization necessitating discharge to the community.

Weeks following discharge, worsening complex delusions and commanding hallucinations and high-risk behaviours in the community was noted. These include fire-setting and possession of weapons.

This led to re-admission and risperidone was trialled and gradually titrated to 5 mg with marked elevation of prolactin with minimal improvement.

Giving treatment resistance, clozapine was considered and is being approached cautiously due to his history of cardiac arrest, persistently low white cell counts and hyperprolactinemia with close psychiatric and cardiology consultation followed with gradual risperidone taper.

This case illustrates the complexity in managing treatment resistant first-episode psychosis in autistic adolescent with significant physical comorbidities.

Careful antipsychotic selection, robust discharge planning, and intensive multidisciplinary follow-up are essential to reduce relapse and serious harm.

Suicidal and homicidal behaviors are typically assessed as distinct risk domains, despite overlapping psychopathology in psychosis and severe mood disorder. We introduce the new concept Suicide by Proxy as a psychodynamic formulation in which homicide (or attempted homicide) represents a displaced enactment of suicidal intent when direct self-destruction is inhibited. Drawing on Freudian models of internalized aggression, persecutory superego dynamics, and object-related conflict (Oedipal/Electra configurations), we aim to illustrate how self-directed destructive drive may be externalized toward a symbolic other.

Three retrospective forensic psychiatric case reports were analyzed using a psychodynamic framework. All cases involved severe mental disorder (schizophrenia-spectrum or major depressive episode with psychotic features), documented suicidal ideation and/or attempts, and a homicide or attempted homicide. Data sources included clinical interviews, collateral histories, medical/legal records, and psychological testing (including MMPI and SIMS). Identifying details were removed or altered to preserve confidentiality without changing clinical meaning.

Case 1:A 26-year-old man with paranoid schizophrenia and persecutory delusions purchased a firearm intending suicide but reported inability to act. He subsequently killed an unknown man in a mosque, then left the weapon beside the body. The act is conceptualized as displacement of self-destruction onto an authority-linked symbolic target, enabling rebellion against a persecutory superego without direct suicide or parricide.

Case 2:A 39-year-old woman with psychotic depression and intense suicidal communications stabbed her sleeping father after planning to kill herself in his presence, then attempted self-stabbing. This is formulated as a negative Electra configuration: ambivalent attachment and rage toward a passive betrayer father, with psychosis collapsing boundaries between self-attack and object-attack.

Case 3:A 36-year-old woman with schizophrenia, shaming maternal criticism, and relapsed hallucinations broke a mirror and attempted to attack her mother with glass while concealing suicidal intent. The mother is conceptualized as a proxy self-representing the rejected, humiliated part of the patient targeted for annihilation.

Across cases, homicidal acts functioned as symbolic self-attacks emerging from internalized aggression, persecutory superego pressures, and unresolved parental-object conflict. Suicide by Proxy may help forensic clinicians integrate suicidality into violence formulations, prompting dual-screening for suicidal and displaced homicidal risk in severe mental disorder. Further empirical work is needed to test the model beyond case-series evidence.

To evaluate the effectiveness of case management for children and young people (CYP) with mental disorders, substance use, or neurodevelopmental conditions, and to identify components and contextual factors associated with improved outcomes.

This was a systematic review and multi-level meta-analysis of randomised controlled trials (RCTs). Databases were searched from inception to June 2025. Reference lists and prior reviews were hand-searched for additional studies. Eligibility criteria: RCTs involving participants aged 5–18 years with mental health, substance use, or neurodevelopmental conditions, comparing case management (or equivalent) to treatment as usual, waiting list, or a less intensive model in community/outpatient settings. Outcomes extracted were clinical and social outcomes (which included any outcomes related to symptoms and functioning), service use (which included any outcomes related to the numberof service contacts or treatments given, excluding differences in treatments offered due to the experimental conditions), satisfaction, and cost-effectiveness. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Cochrane RoB 2 tool. Effect sizes (Hedges’ g) were pooled and meta-analyses were conducted for clinical and social outcomes and service use, applying a multilevel model to account for effect-size clustering within and between studies. Narrative review was conducted for satisfaction and cost-effectiveness. The certainty of evidence was rated using GRADE.

Fourteen studies were included, comprising 16 comparisons, most of which were conducted in the United States. Case management was associated with a small improvement in clinical and social outcomes (Hedges’ g=0.15; 95% CI 0.02 to 0.28) and a moderate increase in service use (g=0.68; 95% CI 0.20 to 1.17). Heterogeneity was high. Economic analyses suggested potential cost-effectiveness through reduced out-of-home placement and treatment dropout. Evidence for satisfaction was mixed. There were some concerns or high risk of bias in 10 out of 14 studies. The certainty of evidence using GRADE was very low for clinical and social outcomes and low for service use.

The review indicates that case management can improve engagement and service use among CYP with complex mental health needs, though clinical benefits are modest, and evidence quality is limited.

Acute inpatient services are experiencing increasing pressure on bed capacity, alongside a growing need for efficient and sustainable use of resources. As services transition towards the NHS ‘Home First’ approach, there is a need to critically review existing practices to further optimise patient flow and reduce discharge delays.

This service evaluation looked at how three acute general adult psychiatric wards in Sheffield utilised brief daily board meetings referred to as ‘Purposeful Inpatient Admissions’ (PIPA) meetings, and weekly multidisciplinary team (MDT) meetings. Phase 1 of the project aimed to gain an understanding of staff views on the existing daily PIPA/weekly MDT model. These findings will inform the development of the new ‘Daily Planning Meeting’ model and provide a meaningful comparator for phase 2 of the service evaluation following implementation.

An anonymised baseline survey was distributed via Microsoft Forms to staff across the three wards to capture multidisciplinary perspectives. The 21-question survey included Likert-scale and free-text items exploring views on the current model, including workload, communication, service user experience and suggestions for improvement. It remained open for three weeks between November and December 2025. Data were exported to Excel for quantitative and qualitative analysis.

Forty-six staff members responded, with nurses and medics comprising 63%, reflecting ward workforce composition. 52% of respondents found the current PIPA/MDT model ‘somewhat helpful’. 70% reported that PIPA/MDT ‘sometimes’ identified clear care goals. 57% thought that the current model ‘sometimes’ improved relationships with patients whilst 67% felt that it ‘sometimes’ enabled patient and family involvement. 9% of respondents felt the current model ‘never’ supported enthusiasm or engagement in patient-centred care. Most respondents agreed all professional roles should attend MDTs regularly.

Thematic analysis highlighted perceived benefits of the current model which included structured multidisciplinary collaboration, task prioritisation and shared decision making. However, significant challenges were identified. Both meetings were frequently described as time consuming. Communication gaps within and across teams, limited community team involvement and inconsistent patient and family engagement were recurrent themes. Staff advocated for clearer documentation processes, enhanced patient involvement and streamlined meeting structures as ways to improve the current model.

Phase 1 identified key strengths and limitations of the PIPA/MDT model. Recommendations include defining professional roles and responsibilities, improving task allocation and documentation as well as protecting time for meaningful patient engagement. Early involvement of community teams and encouraging patient and family participation are central to supporting the NHS Home First approach and improving patient flow.

Chronic alcohol dependence increases the risk of alcohol withdrawal syndrome, requiring prompt identification. Despite this, no locally endorsed clinical guidelines currently exist to support clinicians. This audit aims to evaluate the adequacy of alcohol screening and initial clinical assessment at admission to an acute psychiatric inpatient service, focusing on the identification and management of AUD, alcohol dependence, and alcohol withdrawal, and compares current practice with international standards.

A retrospective audit of all acute psychiatric admissions in March 2025 was conducted. Data were extracted in line with the American Society of Addiction Medicine Clinical Practice Guideline for Alcohol Withdrawal Management, including documentation of alcohol use, clinical history, withdrawal features, and relevant investigations. All data were anonymized following ethical approval.

Of the 217 total admissions, 190 patients were included in the final analysis. Among the analyzed cohort, alcohol use was documented in 132 patients (70%), with 36 individuals (27.3%) confirming regular consumption.

Notably, medical and surgical comorbidities were recorded in 100% of cases (n=36), followed by age at 95.6% (n=35), and suicide risk assessments at 91.7% (n=33). Clinicians also frequently screened for other substance use (100%) and history of mental illness (88.9%). Regarding consumption patterns, while the quantity of alcohol was frequently noted (88.9%), details regarding the duration of dependency and the specific time of last consumption were documented in only 8.3% of files.

Despite the use of CIWA-A scoring in 66.7% of regular users, documentation for previous withdrawal delirium, history of withdrawal seizures, and observed autonomic activation during the initial interview all stood at 0%.

Furthermore, urine toxicology was performed for 63.9% of patients. Metabolic and infectious screening was inconsistently and were documented as following; LFTs 52.8% (n=19), Albumen 41.67% (n=15), INR 27.8% (n=10), Ethanol 36.11% (n=13), Pregnancy test 10% (n=1 out of females in the cohort) and HIV and Hepatitis Screen within 5 years 55.56% (n=20).

In this retrospective audit, significant shortcomings were identified. These findings indicate incomplete adherence to internationally recommended assessment standards and may limit the early identification of alcohol withdrawal risk. Implementation of a locally adapted alcohol assessment guideline consistent with international best practice is therefore warranted. Re-audit is recommended to assess changes in clinical practice and to evaluate associations with patient-related outcomes. No financial support was received for this study.

This quality improvement project was aimed at enhancing the clinical discussion and documentation of side effects of psychotropic medications in psychiatry community settings to 100% over a span of 12 months.

This quality improvement project was carried out at the early intervention service Limbrick Centre. Sample included looking at 20 patients' first medical review under the EIS. The selection process was randomly done. Patients with a primary diagnosis of first-episode psychosis were selected using their hospital number. The audit included all patients who were referred to the EIS from 1 July to 31 December 2024. Anonymised patient data were used in line with the quality improvement initiative of this project and therefore informed consent was not applicable. Data was retrospectively obtained from outpatient electronic records over six months on patients who were newly prescribed psychotropic medications. The key standard for the baseline measurement was whether the communication of at least one side effect of a newly prescribed medication was documented by the doctor in the patient's electronic records. If electronic entries stated that side effects were 'discussed', these entries were not considered as objective evidence of discussions. The criterion for appropriate documentation was clear descriptions of specific side effects discussed and the minimum number of side effects that a doctor should discuss was set at one.

A random sampling method for data extraction was used, using the random number function in Microsoft Excel. Psychotropic medications included antidepressants, antipsychotics, benzodiazepines, mood stabilizers and hypnotics. Data was analysed using Microsoft Excel.

Forty percent of service users’ medical reviews had documentation of side effects of psychotropic medications. Sixty percent of service users’ medical reviews did not have documentation of side effects of psychotropic medications. Although out of this 60%, some doctors had written side effects discussed but the actual side effect discussed was not documented which therefore excluded these data.

This project served as a reminder that robust documentation of patient communication is at the very core of good clinical practice. Shared decision making involving patient in treatment decisions and embedding robust documentation into practice, in addition to enhancing care, confers added benefits to both individual healthcare providers and their employers through the potential diminution of medico-legal risks.