Obstructive sleep apnoea (OSA) is a common sleep disorder linked to significant psychological issues, particularly depression and anxiety. The relationship between OSA and these mental health conditions is complex and has not been thoroughly studied in the Omani population.

This study aimed to assess the prevalence of depression and anxiety in patients diagnosed with OSA at Almasarra Hospital (AMH) in Oman and to identify related socio-demographic and clinical factors.

This cross-sectional study involved 108 patients diagnosed with OSA, with data collected during routine follow-ups at AMH. Structured questionnaires were used to gather demographic information and responses to the Hospital Anxiety and Depression Scale (HADS). Statistical analyses included descriptive statistics, Pearson correlation, and regression models to identify predictors of depression and anxiety.

The study found that 22.2% of participants exhibited depressive symptoms, while 17.6% showed anxiety symptoms. A significant positive correlation was found between anxiety and depression scores (r=0.680, p<0.01). Regression analysis revealed that higher BMI and employment status were significant predictors of both depression and anxiety (p<0.05). The mean age of participants was 38.35 years, with a notable prevalence of overweight/obesity (mean BMI=32.31). While sleep severity indices showed only marginal associations, psychosocial factors appeared to have a greater impact.

A significant proportion of Omani patients with OSA experience symptoms of depression and anxiety, which are interconnected and influenced by lifestyle factors. Incorporating mental health assessments into routine OSA management may enhance patient outcomes and overall quality of life.

Antipsychotics are frequently prescribed for behavioural and psychological symptoms of dementia (BPSD), despite well-established associations with increased cardiovascular morbidity and mortality. National and international guidelines recommend careful baseline cardiovascular assessment, ECG monitoring, metabolic screening, and documentation of risk–benefit discussions when initiating antipsychotics in older adults. Patients with dementiarepresent a particularly vulnerable group, often with multiple cardiovascular risk factors, yet adherence to monitoring standards remains variable.

The aim of this audit is to evaluate compliance with recommended cardiovascular risk assessment, monitoring, and documentation standards in dementia patients prescribed antipsychotics across inpatient mental health services.

A retrospective audit was conducted across three wards in two hospitals. Twenty inpatients with a diagnosis of dementia who were prescribed antipsychotics for BPSD were included. Data was extracted from electronic medical records, focusing on baseline cardiovascular history, physical observations, ECG monitoring, metabolic investigations, documentation of QTc intervals, ongoing monitoring, medication review, and evidence of documented cardiovascular risk discussions. Standards were derived from NICE guidance and local trust policies.

The mean age at admission was 77.3 years, with an average length of stay of 192.6 days. All patients were detained under the Mental Health Order (Northern Ireland). Antipsychotics prescribed included risperidone (n=9), olanzapine (n=5), quetiapine (n=4), and haloperidol (n=2). Six patients had a documented cardiac history, though one was not recorded on admission. Hypertension was present in eight patients, diabetes in three, and atrial fibrillation in three.

Baseline physical observations were largely completed, with blood pressure, heart rate, and weight recorded in 19 of 20 patients. However, ECG monitoring was inconsistent: only eight patients had an ECG on admission, and just three had an ECG performed before or within 72 hours of antipsychotic initiation. QTc was documented in six patients, with appropriate action taken in the single case of prolongation. Metabolic monitoring was incomplete, with HbA1c checked in only 11 patients and ongoing metabolic monitoring documented in seven. While medication was reviewed regularly in MDT meetings for all patients, there was no documentation in any case of cardiovascular risks or risk–benefit discussions relating to antipsychotic use.

This audit demonstrates significant gaps in cardiovascular risk assessment and documentation of risk–benefit discussions in dementia patients prescribed antipsychotics. Although routine observations and medication reviews were consistently performed, adherence to guideline-recommended cardiovascular monitoring was poor. Future targeted interventions could include increasing awareness amongst staff, standardized prescribing checklists, and electronic prompts, are required to improve patient safety and ensure compliance with best practice.

1. To examine the referrals from the Inverness General Practice (GP) to the Community Mental Health Team (CMHT) in line with available referral guidelines and to ascertain reasons for referral rejections.

2. To propose and implement recommendations towards improving outcomes.

Two cycles of clinical audit was completed for patients referred from the GP to the CMHT in January - June 2024 (first cycle) and May - October 2025 (second cycle). Electronic records of all 1048 patients referred during both audit cycles were reviewed and examined against the NHS Highland CMHT referral guidelines. Reasons for referral rejections were further explored. These Outcomes were discussed at the Primary Care/Secondary care Mental Health Interface Meetings and the NHS Highland CMHT referral guidelines were updated. Following this, the second cycle of the audit was completed.

During the first cycle, the CMHT received 421 referrals, out of which 214 (51%) were accepted and assessed while 194 (46%) were rejected largely for reasons of insufficient information,symptoms severity not being sufficient for secondary care input and no clear role for the CMHT.

Six (6) months after the CMHT referral guidelines was updated and GPs were encouraged to use it as a basis for referral to the CMHT, the second audit cycle was completed, with the CMHT receiving 627 referrals during this period, with 439 (70%) accepted while 188 (30%) were rejected.

This reflects about 19% improvement in the number of referrals meeting referral criteria and being accepted for further assessment by the CMHT and 16% decrease in number of rejected referrals, when compared with the first audit cycle.

Undesirable referral outcomes, like referral rejections, are a significant concern within the NHS and can lead to delays in patient care, administrative inefficiencies and compromised health outcomes. It can also negatively impact the working relationships between healthcare providers involved in sending and managing referrals.

It is therefore important to understand the reasons behind referral rejections and to reflect on how to address this to ensure that patients are able to access professional care when needed. Understanding these challenges within the NHS context is crucial to devising effective solutions to mitigate referral rejections.

Artificial intelligence (AI) possesses the capacity to fundamentally alter the landscape of dementia care. Nevertheless, for such instruments to achieve efficacy, they must be meticulously crafted to accommodate the heterogeneous requirements of patients, caregivers, and healthcare practitioners. The LUMEN project (Large Language Model for Understanding and Monitoring Elderly Neurocognition) is in the process of developing an AI-assisted instrument for dementia evaluation, which employs a Large Language Model to derive structured collateral histories from relatives or caregivers of patients. The co-production with stakeholders is paramount to affirming that LUMEN is not merely clinically efficacious but also user-centred and culturally pertinent across varying demographic groups.

A succession of two co-production workshops has been executed with caregivers, and patient groups representatives. Participants have been recruited from a spectrum of cultural, linguistic, and digital backgrounds, with deliberate partnerships established with community organizations, particularly those representing underserved populations. These workshops concentrated on assessing LUMEN’s interface, linguistic clarity, and cultural relevance. Participants interacted with the LUMEN prototype, offering feedback regarding language, interface functionality, and overall user experience. Employing a ‘Think Aloud’ methodology, participants vocalized their immediate reactions during their interaction with the tool, enabling facilitators to gather valuable data concerning usability and engagement. Feedback was audio recorded, transcribed, and systematically analysed through thematic analysis, thus identifying critical themes and patterns that illuminate challenges pertaining to language, interface design, and cultural sensitivity.

Ten themes and 44 sub-themes were identified, most relating to language accessibility, question design, cultural and social appropriateness, role assumptions, and system usability. Over one-third of sub-themes were rated high priority and almost 90% were deemed actionable, indicating substantial scope for redesign. Participants highlighted medical jargon, compound and ambiguous questions, culturally biased assumptions (for example, gender roles and technology use), unclear intended user (self vs carer), and rigid response formats as key barriers to acceptability. Strengths included the potential to complete LUMEN at home, inclusion of carer wellbeing, and capacity to capture nuanced information when free-text fields worked well.

Co-production with people living with dementia, carers, and professionals revealed that LUMEN’s acceptability depends on simplifying language, clarifying question framing around change from baseline, improving usability, and culturally adapting content. The high proportion of actionable findings demonstrates the practical value of think-aloud co-production for optimising AI-enabled dementia assessments and provides a roadmap for iterative redesign towards more equitable, user-centred tools.

High-Dose Antipsychotic Therapy (HDAT) is associated with increased risk of adverse physical health outcomes and requires robust monitoring in line with Royal College of Psychiatrists (RCPsych) guidance and local Trust policy. This audit aimed to:

1. Assess compliance with Sussex Partnership NHS Foundation Trust (SPFT) HDAT physical health monitoring policy.

2. Assess compliance with theRCPsychconsensus statement on HDAT monitoring.

3. Identify patterns of antipsychotic polypharmacy within a community rehabilitation cohort.

A cross-sectional audit was conducted in December 2025 within the East Sussex Rehabilitation Pathway (ESRP), part of SPFT. The cohort included adults aged 18–65 receiving care from a community rehabilitation team in Eastbourne. Medication records were reviewed, and the antipsychotic high-dose calculator was used to identify patients prescribed HDAT in accordance with BNF criteria. Data were collected from electronic patient records (Carenotes) and HDAT monitoring forms. Variables included diagnosis, ethnicity, number of antipsychotics prescribed, and completion of recommended HDAT monitoring (blood tests, ECG, weight/physical observations, GASS side-effect scale, and HDAT documentation).

Eleven patients met criteria for HDAT, representing approximately 18% of the rehabilitation caseload. The majority were White British (64%).

Paranoid schizophrenia was the most common diagnosis (64%), followed by schizo affective disorder (27%) and persistent delusional disorder (9%). Most patients (73%) were prescribed two antipsychotics, while 27% were prescribed three, indicating a high prevalence of antipsychotic polypharmacy.

Compliance with HDAT monitoring was variable: blood tests and weight/physical observations were completed in 45% of patients, ECGs in 27%, GASS was offered in 27%, and HDAT documentation was fully up to date in 36% of cases.

HDAT use within this community rehabilitation cohort was relatively common and largely driven by antipsychotic polypharmacy in patients with severe and enduring psychotic illness. Monitoring compliance was inconsistent and fell short of RCPsych and local policy standards. These findings highlight the need for improved identification of HDAT, better utilisation of monitoring tools, and strengthened multidisciplinary oversight to ensure safe, high-quality care. Findings were presented to the multidisciplinary team, and an action plan for improvement was formulated, with re-audit planned in six months.

The aim of this clinical audit was to evaluate adherence to national guidelines and standards for antipsychotic prescription monitoring in children and young person attending CAMHS Devon, identifying areas for improvement and ensure that they receive safe and effective treatment. It was a re-audit of clinical audits that was done between June 2019 and February 2020 [3]. We aim to provide the various clinical indications and diagnoses for prescribing the antipsychotics, as well as to evaluate the quality of care and the standard of monitoring of antipsychotic prescribing. Our objective was to improve the quality of care and physical health monitoring of children and young person who are prescribed antipsychotic medications. This will contribute to ensure that children and young person receiving antipsychotic medications receive safe, high quality and effective care

This audit was registered with DPT NHS trust clinical improvement team in September 2024 after attending a drop-in session with them for guidance and necessary support. Our evidence-based standards were POMH-UK audit of 2010 and 2012, CAMHS audit, 2019 and NICE guidelines. This was a retrospective re-audit looking at the records of all children and adolescents under the care of the entire Devon CAMHS teams currently prescribed antipsychotic medications.

We screened the records of all the caseloads [N=743 cases] that were opened to the 24 clinicians/prescribers working across the 3 CAMHS teams in CFHD, looking through their clinical notes on the electronic records [SystmOne and archives of carenotes]. We subsequently selected cases [n=74] of children and adolescents who met our inclusion criteria of been prescribed antipsychotic medications within the period of interest, July 2023 to August 2024. The data collected were similar [with slight modification] to the previous audits and this was compiled and analysed using Microsoft excel. The data was collected in this way in order to make it easy for comparisons.

• • Demographic details.

• • Psychiatric diagnoses.

• • Information about other clinical indications.

• • Information about antipsychotics and other medications currently prescribed.

• • Information about physical health screening and side effect monitoring.

• • Information about medication review.

Comparisons were also made between the data from this audit and the previous ones POMH 2010, 2012 and Devon Audit, 2019.

We found a good standard of practice in terms of adequate documentation of the clinical indications and reasons for prescribing antipsychotic medications for about 10% [n-74] of children and young person attending our service. Regarding mental health diagnoses, off licence prescriptions and targeting specific symptoms, 65% [n-48] of cases prescribed antipsychotics had confirmed diagnosis of ASD and about 10% had ICD 10 diagnosis F20-29. About 59% of the prescriptions and oversight were done and under the supervision of consultant Child and Adolescent Psychiatrists. Aripiprazole was the most prescribed antipsychotic in 35% of cases and Melatonin in 46% of other medications prescribed. Evidence of physical health screenings were documented in almost 91% of those on antipsychotic medications. The most common side effects reported were weight gain [12%], tiredness [7%] and elevated Prolactin level in [3%]. There was no documented evidence of formal assessment of extrapyramidal side effect in all the cases and in 9% of cases there was no evidence of at least one physical health checks within the period of audit. All the identified 74 cases had medication review and there was no use of typical antipsychotic or polypharmacy prescription, which would be considered as a safe prescribing practice.

The selection of antipsychotics for children and adolescents should include an evaluation of their individual therapeutic benefits, safety profiles and an approval status as per national formulary for use in this population.

An Emergency Detention Certificate (EDC) can be issued by any registered medical practitioner in Scotland. An EDC authorises detention of a person with a likely mental disorder in hospital for up to 72 hours. The granting of an EDC poses significant restrictions on a patient’s liberty and rights. It is therefore crucial that the completion of EDCs meet both sufficient clinical and legal requirements.

The aim of this quality improvement project is to systematically evaluate EDCs issued across 2 sites in NHS Lanarkshire over a defined time period to identify any areas for improvement. Ultimately, we aim to improve compliance with completion of EDCs in line with the principles of the Mental Health Act.

EDCs across NHS Lanarkshire in a 6-month period were obtained. A standardised scoring system was devised to evaluate each EDC against a minimum criteria. The standardised scoring system utilised by the three reviewers generated a total score of 28, with a higher score reflecting a higher quality of EDC completion.

Data regarding the practitioner who completed the EDC and if Mental Health Officer consent was sought was also obtained.

A total of 125 EDCs were identified. 8 EDCs utilised the incorrect form and so were excluded. 117 EDCs were reviewed. We found a range of scores from 16 to 28. The average score was 23.

EDCs were completed by doctors from a range of settings. 51.3% of EDCs were completed by psychiatry resident doctors or psychiatry consultants, 11.1% by GPs and 37.6% by resident doctors in medical wards. The average score for EDCs completed by doctors working in psychiatry was higher at 24.2. EDCs completed by doctors working in medical wards and by GPs scored 22.1 and 20.2 respectively. 35% of EDCs completed had MHO consent. Of the EDCs that had MHO consent, 53.6% EDCs were placed by doctors working in psychiatry.

Completion of EDCs remains suboptimal and there is still work to be done in improving the quality of EDC completion. EDCs are generally completed to a higher standard by doctors working in psychiatry which may be due to a range of factors includingteaching on EDC completion and regular informal feedback. MHO consenting to the granting of an EDC continues to remain low at 35%.

This quality improvement project highlights the need for teaching and education tools as anintervention to improve the standard of completion of EDCs.

Over 90% of patients with depression report troublesome sleep-wake disturbances, and patients with depression are more likely to have comorbid sleep disorders such as insomnia. They also display small but significant deficits in a variety of cognitive domains, and both sleep and cognitive problems can persist into remission. Sleep disturbances also adversely affect cognition, however due to heterogeneity of methods and results in the extant literature, further research is required to assess how sleep disturbances affect cognition in depression.

Forty participants aged 18–65 with unipolar depression and 40 gender- and age-matched controls were recruited to this naturalistic observational study. Baseline measures of mood and sleep were completed, and participants then wore a triaxial accelerometer (actigraph) and completed a sleep diary. At the second study visit 14 days later participants completed a battery of neuropsychological tasks, including the Psychomotor Vigilance (PVT), Continuous Performance (CPT), Digit Symbol Substitution (DSST), and Trail-Making-Test (TMT).

Following exclusions, 34 participants in each group were included in the final analysis. In the depression group the average age was 49.5, 53% were female, and 94% White British Ethnicity. 44.1% were diagnosed with comorbid disorders (e.g. anxiety) and were prescribed a median 2 psychotropic medications. Eight patients were not currently depressed as assessed by the Hamilton Depression Rating Scale. The depression group were significantly more likely to report insomnia symptoms than controls, and although there was no difference in the average hours of night-time sleep (depression=6.39, control=6.69), the depression group had a significantly lower Sleep Regularity Index and more nights of short sleep (depression=6, control=4). There were no significant group differences between the primary outcomes PVT and CPT, however the depression group demonstrated significantly slower DSST and TMT-A performance. There were few significant correlations between sleep and cognitive variables, with the strongest observed between insomnia symptoms and slower DSST performance. Multiple regression analyses showed that insomnia symptoms, but not actigraph-measured hours of sleep, moderated the relationship between depression symptoms and PVT performance.

In this study, participants with depression reported significantly more insomnia, and had a less regular sleep schedule than controls. There were no group differences on the primary outcome sustained attention tasks, but the depression group demonstrated significantly slower psychomotor processing. The relationship between depression symptoms and sustained attention was moderated by insomnia symptoms but not average hours of sleep.

Recreational ketamine use and treatment-seeking for associated complications is increasing in England. Complications of ketamine dependence can be debilitating, leading to continued dependence and surgical intervention. However, treatment remains under-researched, with lacking understanding of those seeking treatment or requiring specialist inpatient detoxification. This study aims to analyse demographic and clinical characteristics of an inpatient ketamine detoxification population in the north of England between January 2016 and September 2025, with the aim to inform public health strategies and aid prevention efforts.

This retrospective cross-sectional study was conducted using routinely collected clinical data for patients that attended for ketamine detoxification at the Chapman Barker Unit (CBU), a regional specialist inpatient detoxification treatment service in Greater Manchester, UK. Patients were identified using clinical logbooks and the Patient Registration and Information System (PaRIS). The primary analysis included 59 patients admitted for ketamine detoxification. Comparative analyses were conducted between the ketamine-only detoxification patients (n=23) and the ketamine plus polysubstance detoxification patients (n=36) to explore the relationship between ketamine dose and physical harms.

Ketamine detoxification admissions increased between 2016 and 2025. One third occurred between January and August 2025. Most patients were male, younger, WhiteBritish, heterosexual, single and unemployed with traumatic experiences and criminal justice involvement. Mean age of ketamine use was 18 years with 5.2 years of usage. Most inhaled ketamine, and mean daily usage was 5.4g, with higher dose in those experiencing lower urinary tract symptoms. Anxiety, depression, suicidal ideation and past suicide attempts were common, along with concerning urological pathologies in particular ketamine bladder syndrome, cystitis, nasal damage and hydronephrosis. Cravings and anxiety were common withdrawal symptoms. Alanine transaminase (ALT) levels increased from admission to discharge. Ketamine-only detoxification patients were more likely to be single, use higher ketamine doses, inhale ketamine, experience depression, have ketamine bladder syndrome and hydronephrosis. PTSD was more prevalent in polysubstance patients. Diazepam reducing regimes were the standard detoxification approach. Most patients completed detoxification.

Ketamine detoxification admissions are increasing, with a predominantly young population with prolonged high-dose ketamine usage, associated urological pathology and hepatic injury. Specialist inpatient detoxification is successful, and further evidence-based treatment and relapse prevention protocols are required. Targeted public health campaigns should raise awareness of the physical, psychological and social harms associated with ketamine dependence.

Outcomes in schizophrenia vary widely, with a possibility of recovery. Besides symptomatic improvement, functional improvement is a key component of recovery and is a robust outcome indicator in patients with schizophrenia. Improvement in function leads to better self-esteem and quality of life. National Institute for Health and Care Excellence (NICE) guideline CG178 directs providers to document the daytime activities and occupational outcomes for patients with schizophrenia, thus assessing how they are functioning. This work was intended to assess and analyse the documentation of functionality in this patient population during routine clinical appointments.

This was a clinical audit. Data was collected from digital patient care records including clinic letters. A predesigned questionnaire was utilised for the assessment and documentation of the psychosocial and occupational functioning of 30 consecutive patients with schizophrenia. Each patient had been attending community mental health team clinics for at least one year.

The average age of the sample was 46.0 ± 11.5 years (range 21-67). The mean duration of illness was 15.3 ± 9.8 years (range: 1-42), suggesting that most patients had chronic illness. The cohort included 20 (66.7%) male and 10 (33.3%) female patients, from a range of ethnic backgrounds: 36.7% Caucasians, 26.7% Asians, 20.0% Afro-Caribbean, and others. In routine clinical practice, the assessment and documentation of variables indicating the functional status of patients with schizophrenia were extremely varied and, overall, appeared inadequate. There were no specific scales used to assess patient functioning. Most of the patients had functional impairments in various domains including work, leisure activities, relationships, activities of daily living, and social interaction. However, there were examples of productive engagement with paid and unpaid work in a few patients. Various factors that might contribute to functional impairment were observed, such as physical and mental comorbidities, disabilities, substance misuse, educational underachievement, adverse living conditions and social isolation. In addition, lack of interest in work and refusal to seek employment support were also noted.

Despite available interventions and support, functional impairments in multiple domains continue to impact patients with schizophrenia. There is a need to assess and record the functioning of these patients routinely during clinical interactions. Use of structured and validated metrics may be helpful. In addition to symptomatic improvement, the functionality of the patients is an appropriate indicator of the effectiveness of treatment and degree of therapeutic benefit. Functionality can therefore be used as an outcome measure.

To improve induction to medical seclusion reviews (MSRs) for Resident Doctors (RDs) rotating into psychiatry in Derbyshire Healthcare NHS Foundation Trust (DHCFT).

Concerns were previously raised by rotating RDs in DHCFT regarding induction to seclusion and feeling unprepared for leading MSRs. Seclusion, as restrictive practice with potential large impacts on our patients, is closely audited both nationally and locally as per the Mental Health Act Code of Practice. Many RDs are not psychiatry trainees and are therefore unfamiliar with the process. Nursing staff within the trust had also reported concerns regarding safety awareness of RDs during MSRs particularly soon after newly rotating into the trust.

We developed a video of a mock scenario encompassing all aspects of a MSR including timing and structure of reviews based on both local guidelines and the Mental Health Act Code of Practice. This video was recorded within a seclusion suite to demonstrate the layout. This was shown to current RDs 3 months into their rotation. A survey wascompleted on previous experience of seclusion, confidence of completing seclusion reviews, whether had been previously inducted on seclusion and preparedness to complete MSRs prior to viewing the video. Results were compared with a follow-up survey after viewing the video assessing its impact.

Of the 29 respondents to the initial survey; 79% (n=23) reported having no previous induction to seclusion. Respondents were a mixture of Foundation Doctors, GP trainees, Psychiatric Core trainees and Psychiatric Higher Specialty trainees. Mean confidence completing seclusion reviews was 2.66/5. 93% (n=27) of respondents stated they were not prepared enough to complete a MSR after induction. 22 reponses were received to the follow-up survey. Mean confidence completing seclusion reviews increased to 4.23/5. 100% of respondents stated a video on seclusion in induction would be helpful.

This video has demonstrated a novel, relevant and sustainable approach to delivering induction for RDs surrounding a unique aspect of psychiatry which had previously been insufficient in preparing newly rotating RDs for completing seclusion reviews. This video is being further shared with East Midlands School of Psychiatry so that it can contribute to shared learning across other trusts within the region.

Clinic letters are a key method of communication between secondary mental health services, primary care, and patients. However, traditional psychiatry clinic letters are often lengthy, clinician-centred, and difficult for readers to quickly identify key information and actions. This sits at odds with national priorities emphasising patient-centred care, shared decision-making, and improved collaboration across healthcare interfaces.

Informal feedback within our service suggested that existing clinic letters lacked clarity and accessibility for both general practitioners (GPs) and patients.

This quality improvement project aimed to design and implement a structured, patient-addressed clinic letter template and to evaluate its impact on satisfaction with letter length, layout, ease of understanding, and content among GPs and patients.

A structured clinic letter template was developed through multidisciplinary discussion, informed by best-practice guidance and principles of patient-centred communication. Key features included clear headings, concise language, explicit action points, and written directly to the patient, with GPs copied into correspondence.

GP satisfaction with clinic letters was assessed before and after implementation using a brief feedback survey. Respondents rated satisfaction with letter length, layout, ease of understanding, and content as satisfied, neutral, or dissatisfied. Following implementation, patient feedback was also collected, as patients did not routinely receive clinic letters prior to this project.

GP satisfaction was assessed pre- and post-intervention (n=6 pre; n=8 post); patient feedback was collected post-intervention (n=12).

Following implementation of the structured clinic letter template:

• • GP satisfaction withletter lengthincreased from17% to 100%.

• • GP satisfaction withletter clarityincreased from50% to 100%.

• • GP satisfaction withletter contentincreased from33% to 87%(neutral responses reduced from 50% to 0%).

• • GP satisfaction withlayoutincreased from17% to 88%(neutral responses reduced from 50% to 0%).

Patient feedback demonstrated 100% satisfactionwith letter length, clarity, content, and layout.

Routine sharing of clinic letters with patients represented an additional improvement post-intervention, improving transparency and patient involvement.

Implementation of a structured, patient-addressed clinic letter template led to substantial improvements in GP and patient satisfaction with letter length, clarity, content and layout. This project demonstrates how simple, low-resource changes to written communication can support patient-centred care and improve collaboration across the primary–secondary care interface, aligning with national strategic priorities for mental health services.

To investigate the personality profiles of heroin addicts in Pakistan using the Eysenck Personality Questionnaire (EPQ) and to explore how personality traits such as extraversion, neuroticism, and psychoticism relate to substance abuse within the sociocultural and economic context of the region.

A cross-sectional study in Islamabad (May 2023–May 2024) assessed 300 heroin-dependent individuals (sample size calculated using the WHO calculator), aged 18–60, in rehabilitation centres. Participants were selected using purposive sampling to meet study criteria. The Eysenck Personality Questionnaire measured extraversion, neuroticism, and psychoticism. Data were collected via self-administered questionnaires andanalysed in SPSS v29; Chi-squared tests determined significance (p < 0.05). Ethical approval was obtained from the institutional review board of Islamabad Medical and Dental College, and all participants provided informed consent.

Data was collected from 300 participants aged 18–60. Overall, heroin addicts had a mean extraversion score of 12.4 (SD = 4.8; range 5–20), neuroticism 17.6 (SD = 5.2; range 7–25), and psychoticism 8.3 (SD = 3.9; range 2–15), indicating average sociability, high emotional instability, and moderate aggression.

Age group differences were significant: the 18–30 group had the highest scores for extraversion (13.2), neuroticism (18.4), and psychoticism (9.1), followed by 31–45 (11.5, 17.0, 8.0) and ≥46 (11.0, 16.8, 7.5) (p = 0.02–0.04). Addiction duration was inversely related to scores: participants with <1 year of addiction scored highest (extraversion 13.5,neuroticism 19.0, psychoticism 9.5), 1–5 years scored moderately (12.0, 17.8, 8.3), and >5 years scored lowest (11.2, 16.5, 7.8) (p = 0.01–0.03).

Gender differences were not statistically significant: males had mean scores of 12.5, 17.5, and 8.4; females had 12.0, 18.0, and 8.0 for extraversion, neuroticism, and psychoticism, respectively (p > 0.05).

Heroin addicts in Pakistan exhibit high neuroticism and moderate extraversion and psychoticism, with younger individuals and those with shorter addiction duration showing higher trait levels. These findings underscore the need for personalized interventions, such as CBT, DBT, peer support, and medication-assisted treatment, to address emotional instability and improve recovery outcomes. Policymakers should prioritize individualized treatment strategies and support further research to enhance rehabilitation effectiveness.

The DVLA (Driver and Vehicle Licensing Agency) rules require patients with psychiatric diagnoses such as psychosis, mania, or depression to stop driving and/or notify the DVLA. Despite this, patients are often discharged without being informed of these legal responsibilities. There was no standardised approach within our trust to ensure this guidance was communicated clearly and consistently.

This project aimed to improve the communication of DVLA driving restrictions to psychiatric inpatients being discharged on medications or with a diagnosis that may impair fitness to drive.

We created clear, patient-friendly DVLA information leaflets, covering psychosis, mania/hypomania, and depression, based directly on the latest DVLA guidance. These were uploaded to the Trust resource page. A prompt was also added to the electronic discharge summary to remind clinicians to check that the relevant guidance has been provided.

The leaflets provided a simple, visible solution that improved staff confidence in advising patients. Feedback from members of the team highlighted that easy access to up-to-date, printable resources removed uncertainty around DVLA requirements. Discharge summaries more frequently included DVLA advice, and patients were consistently provided with relevant written information.

Introducing guidance leaflets within the trust enabled a sustainable, straightforward solution to a long-standing gap in discharge communication. This project improved DVLA compliance, patient safety, clinician confidence, and could be easily replicated across other wards and trusts. We plan to expand this project to other mental health services, such as the Crisis Resolution and Home Treatment Team (CRHTT). This will include adapting the existing leaflets to suit community and crisis settings, ensuring patients consistently receive appropriate DVLA advice across all points of care.

Adult patients are expected to understand, retain, weigh and use information to make a decision about their illness. When patients refuse recommended medical investigations, clinicians have a clinical, ethical, and legal responsibility to assess and record decision-making capacity. Failure to do so may compromise patient safety and expose clinicians and organisations to medico-legal risk. This quality improvement project aimed to assess whether decision-making capacity assessments were documented when psychiatric patients declined standard admission investigations, which included physical examinations, electrocardiograms (ECGs), and blood tests.

A cross-sectional audit was conducted involving 18 adult patients admitted over the audit period. Data was collected retrospectively from clinical records and reviewed to determine patient acceptance or refusal of admission investigations and whether decision-making capacity assessment was documented at the time of refusal. Patients who accepted all investigations were included to provide context for overall practice, with focused analysis on those who refused one or more components of physical examination, ECG, or blood tests.

13 of the 18 patients agreed to all admission investigations. Five patients refused at least one component of the recommended investigations. Among these five patients, there was no documented evidence of a decision-making capacity assessment at the time of refusal, resulting in a 0% documentation rate. This result revealed a significant gap between expected standards of care and current clinical practices. The absence of recorded capacity assessments raises concerns regarding informed refusal, patient autonomy, and medico-legal accountability. Possible contributory factors include time pressures in acute settings, limited clinician awareness of documentation requirements, and the absence of structured prompts within clinical documentation systems.

This audit demonstrated inadequate documentation of capacity assessments when patients refused admission investigations. Targeted quality improvement interventions are required such as, improving clinician education on capacity assessments, documentation practices, incorporation of capacity prompts into admission proformas, and re-audit to assessimprovement. Strengthening documentation of capacity assessments will support ethical clinical decision-making, safeguard patient autonomy and reduce medico-legal risk.

Sodium Valproate is widely used in the treatment of epilepsy and is also commonly prescribed for psychiatric disorders, particularly Bipolar Disorder. Enuresis associated with sodium valproate has been reported in paediatric populations with epilepsy, and in a case report involving a paediatric patient with Bipolar Disorder. However, data in the adult psychiatric population remains limited.

This is a case report of a 20 year old gentleman diagnosed with Unspecified nonorganic psychosis. He had a four month psychiatric admission with first episode psychosis, which included 2 months in Psychiatric Intensive Care Unit (PICU). He was initially started on Olanzapine, which was titrated up to 20mg per day, however there was no response. Due to significant aggression, Sodium Valproate was introduced and increased up to 2500mg nocte. Due to lack of response with Olanzapine, antipsychotic medication was initially changed to Haloperidol during which he developed oculogyric crises which necessitated dose reduction. Due to persisting psychotic symptoms, it was changed to Zuclopenthixol. At discharge, he was on Zuclopenthixol depot 350mg every two weeks, Sodium Valproate 2500mg nocte and Procyclidine 5mg three times a day.

During follow up in the community by the Early Intervention Service, he was noted to have extrapyramidal side effects due to which the dose of Zuclopenthixol was reduced and Procyclidine was increased. He also reported nocturnal enuresis every night. There were no other urinary symptoms, and he had not had urinary incontinence or enuresis in the past. Initially, the dose of Sodium Valproate was split to 1000mg in the morning and 1500mg at night with a view to reduce nocturnal sedation, however the symptom persisted. The dose of Sodium Valproate was then reduced to 1000mg twice a day after which nocturnal enuresis resolved completely. During subsequent follow-ups, the dose of Sodium Valproate was reduced further, with a plan to gradually reduce and stop it in the long term. He remained free of psychotic symptoms during the period of follow up, without recurrence of enuresis.

The onset on nocturnal enuresis following initiation of Sodium Valproate, and resolution following dose reduction suggests a possible association between the two. This is in accordance with previous reports indicating enuresis as a dose related side effect of Sodium Valproate.

Nocturnal enuresis is a potentially under recognised side effect of Sodium Valproate. Clinicians should screen for this adverse effect as it may significantly impact quality of life and treatment adherence.

Resident doctor handbooks are a key system-level resource supporting safe, effective working and trainee induction. Within Lancashire and South Cumbria NHS Foundation Trust (LSCFT), variation was identified between the East and Central psychiatry locality handbooks, reflecting differences in site coverage and resulting in gaps in essential information. This inconsistency risked inefficiency, uncertainty, and increased anxiety for new starters. The aim of this quality improvement project was to improve the consistency, accessibility, and reliability of resident doctor information by identifying and addressing variation in handbook content and standardising guidance across the East and Central localities.

A baseline comparison of the East and Central resident doctor handbooks was undertaken to identify missing content, inconsistencies, and areas lacking sufficient detail. Content was reviewed against key trainee domains, including emergency management, risk and legal processes, physical health responsibilities, and routine ward duties. Identified gaps informed a structured programme of handbook revision. Iterative updates were discussed with the Central locality educational lead and reviewed with the consultant body at consultant meetings and within monthly college tutor meetings. Finalised content was reviewed with the East locality educational lead to validate accuracy and ensure parity across both handbooks.

The intervention resulted in a standardised handbook structure and improved content parity across the East and Central localities. Previously missing sections were added to the Central handbook, new clinically relevant sections were introduced to both handbooks, and existing sections were expanded to improve clarity and usability. Updates focused on psychiatric and medical emergencies, management of acute disturbance, risk and legalprocesses, physical health assessment, and practical ward guidance. Positive feedback was received from educational leads in both localities and from the consultant body, alongside informal positive trainee feedback regarding clarity and usability. The revised handbooks were distributed to new starters in August 2025, with planned redistribution to subsequent cohorts in February 2026.

This quality improvement project successfully addressed unwarranted variation in resident doctor handbook content across two psychiatry localities through standardisation and educational lead(s) co-production. Improving the consistency and accessibility of trainee information supports safer working, enhances trainee experience, and reduces uncertainty for new starters. Future work will include extending the intervention to the North locality, incorporating additional clinically relevant content such as venous thromboembolism assessment guidance, and ensuring parity across specialty-specific handbooks, including learning disability and forensic services.

Background

Women admitted to Psychiatric Intensive Care Units (PICU) frequently present with complex trauma histories, emotional dysregulation and heightened sensitivity to coercion, confinement and interpersonal authority. While restrictive boundaries may be required to maintain safety, poorly implemented or inflexible restrictions risk re-traumatisation, escalation of distress and disruption of therapeutic engagement. There is limited literature exploring how boundary implementation itself influences safety and engagement for women in PICU.

Aim

To explore how boundary-related clinical decisions influenced safety, emotional regulation and engagement in women admitted to PICU, and to identify gender-sensitive, trauma-informed approaches perceived by clinicians as helpful in practice.

Methods

A qualitative service evaluation using reflective thematic analysis was undertaken involving three anonymised female PICU admissions detained under the Mental Health Act. Cases were purposively selected to illustrate differing trajectories following boundary implementation: escalation, de-escalation and neutral outcomes. Data were derived from contemporaneous clinical documentation and multidisciplinary team reflections. The evaluation aimed to generate practice-based learning rather than generalisable outcomes.

Direct service-user interviews were not conducted to avoid placing additional demands on patients during acute admission. Findings reflect clinician interpretations of observed patterns of response to boundary setting.

Results

Three key patterns emerged:

Collaborative and relational boundary setting was associated with reduced agitation and improved engagement.

Blanket or rigid restrictions were more frequently linked with trauma re-experiencing, protest behaviours and escalation.

Necessary restrictive interventions, when poorly communicated, negatively affected dignity and delayed therapeutic re-engagement, even when clinically justified.

Gender-sensitive negotiation, preservation of autonomy where safe, and compassionate communication appeared clinically impactful.

Discussion

The findings suggest that in female PICU populations, how boundaries are enacted may be as influential as what restrictions are applied. Trauma-informed, collaborative approaches may mitigate escalation while maintaining safety. A reflective boundary-decision framework is proposed to support proportionality, transparency and restoration of autonomy.

Conclusion

Boundary implementation in female PICU settings has important implications for safety, emotional regulation and therapeutic alliance. Gender-sensitive, trauma-informed boundary practices may support safer care and improved engagement. Future work should incorporate co-produced evaluation and service-user perspectives to strengthen the evidence base.