The aim was to analyse and identify key themes in all reported “near miss” ligature incidents in South West London and St George's Mental Health NHS Trust between July-September 2024. The hope was to hereby uncover patterns to inform evidence-based changes and to drive improvements in patient safety, standards of care, patient experience and clinical outcomes in the Trust.

The total number of ligature-related incidents (from Ulysses) was 96 and 83 were included in the review. 13 incidents were excluded due to missing RiO number. Data was collected from RiO progress notes, demographic tab, inclusion records ad risk assessments by three resident psychiatry doctors. Data collected included demographic details, diagnosis, location of incident, level of observations, mental state at the time of the incident, ligature method, Mental Health Act status, substance misuse, number of previous admissions, and previous ligature incidents. The data collection tool was piloted and areas of unclarity discussed by all three data collectors and consensus reached.

Diagnostically, neurodevelopmental conditions were present in 65.1%, Emotionally Unstable Personality Disorder (EUPD) diagnosis in 53.0%, depression in 34.9%. In terms of other clinical risk factors: 89.2% had multiple psychiatric diagnoses, 73.5% were detained under the Mental Health Act (MHA), the mean number of psychiatric admissions: 4 ± 4, 51.8% were noted as aggressive, alcohol misuse was a factor for 18.1%, drug misuse for 15.7%. Looking at self harm history, 95.2% had a current history of deliberate self-harm (DSH), 98.8% had a historical risk of DSH, 94.0% had previously tied a ligature, and 97.6% had used alternative methods of self-harm. Social and Demographic Factors: 85.5% were unmarried, 79.5% were unemployed, 49.4% were on long-term sick leave, 24.1% lived alone, and 1.2% were homeless.

Thematically, there was notable over-representation of women and girls in reported incidents. nearly two-thirds of incidents involved individuals with a neurodevelopmental diagnosis (e.g., ASD, ADHD), and around half had an EUPD diagnosis.

Recommendations:

1. Improve Incident Documentation: develop clear guidelines to help staff include critical details.

2. Address Observations-Related Incidents: Reinforce active engagement and proximity. Observing staff to conduct environmental review including blind spots and support with co-developed shared ligature care plans which are regularly reviewed.

3. Strengthen Environmental Safety: Continue minimising ligature points, securing hazardous items (BP machine cables).

4. Support for Neurodevelopmental Diagnoses: provide targeted training for staff.

5. Support for EUPD: promoting DBT-informed approaches on wards.

7. Involving Patients in Next Steps: engage service users in future planning and prevention strategies.

8. Providing Holistic Debriefing for both patients and staff impacted by these incidents.

This work was presented in the Trust Learning and Improvement Group and an improvement plan developed.

The aim of our quality improvement project was to create an equitable and fair experience for psychiatry core trainees in Kent and Medway Mental Health NHS Trust (KMMH) who wanted to take part in our trust mock Clinical Assessment of Skills (CASC). This could be achieved by increasing candidate numbers and incorporating a quality assurance process.

KMMH runs a twice yearly mock CASC for resident psychiatry doctors. We mirror the Royal College of Psychiatrists(RCPsych) CASC exam as closely as we can with 16 stations, experienced actors and examiners in each station. We wanted to improve the quality of our mock CASC by aligning with RCPsych standardisation and increasing trainee satisfaction. Potential consequences of a poorly delivered training experience could result in trainees seeking training opportunities elsewhere, which has ramifications on building a sustainable and skilled workforce.

We sought stakeholder opinion (examiners, candidates, senior medical education staff). We gathered current performance data: examiners requested marking guidance, there was a 56% discrepancy in second marking of the same candidate and only 56% of candidates were satisfied with the current mock CASC provision. We completed a root cause analysis by creating a fishbone and affinity diagram. The main themes identified were: lack of candidate opportunities, lack of examiner marking guidelines and marking inconsistency. Countermeasures were constructed from stakeholders, bench marking and best practice. A pick chart was used to identify the most beneficial and achievable countermeasures which were then implemented: double candidate places, reduce examiner bias by providing training, standardise marking through guidance and standardisations process. We created standardised marking guidance for each station which was provided to examiners in subsequent mock CASCs.

100% of examiners felt confident marking stations. Examiner marking consistency also improved from 44% to 47%. 100% of examiners were satisfied with the marking guidance given (previously was 50%). 100% of candidates (n=21) were satisfied with the mock CASC and found it beneficial for their learning, an increase from 56% prior to ourinterventions.

Qualitative and quantitative data showed an improvement in trainee satisfaction and fairness of mock CASC with improved marking consistency. This provides evidence to embed standardisation process into future mock CASCs.

Dementia with Lewy bodies (DLB) is a neurodegenerative disorder that frequently presents with psychiatric symptoms, including depression, anxiety, psychosis, and suicidality, often before overt cognitive or motor deficits are apparent. Misdiagnosis as a primary psychiatric illness is common, and inappropriate exposure to antipsychotic medication can lead to severe adverse effects, including rigidity, hypersalivation, and profound functional decline. Early recognition of DLB in psychiatric settings is therefore critical. We present a case illustrating the diagnostic challenges of DLB initially presenting as late-onset psychotic depression with suicidal ideation.

A 66-year-old man with no previous psychiatric history presented with a first episode of severe depression with psychotic features and repeated suicidal ideation. He was found by his wife holding a knife with reported intent to self-harm and was admitted to an inpatient ward under the Mental Health Act. These symptoms emerged after an injury that ended his employment. Prior to admission, he had been independent in activities of daily living and lived with his family.

During admission, he experienced rapid functional decline, including reduced verbal output, psychomotor retardation, and new-onset urinary incontinence. He was treated for psychotic depression with trials of risperidone and aripiprazole, both of which caused severe extrapyramidal side effects, including rigidity and hypersalivation, necessitating discontinuation. He was subsequently managed with low-dose sertraline, with partial symptom control.

Neurological examination demonstrated hypomimia, hypophonia, shuffling gait with reduced arm swing, resting tremor, bradykinesia, axial rigidity, postural instability, and ideomotor apraxia. Cognitive assessment was limited by poor engagement but revealed marked day-to-day fluctuations in attention and functional ability. Collateral history also suggested Rapid eye movement sleep behaviour symptoms.

The combination of fluctuating cognition, parkinsonism, pronounced antipsychotic sensitivity, and neuropsychiatric features met McKeith (2017) criteria for Probable DLB. Magnetic resonance and Dopamine Transporter scan supported this diagnosis. The patient was referred to the cognitive disorders’ clinic and neurology for further assessment, after initiation of rivastigmine. Clozapine was subsequently started to treat persistent psychotic symptoms, on neurology advice.

This case demonstrates that DLB can present primarily as late-onset depression with psychotic features and suicidality, preceding clear cognitive or motor signs. Key clinical red flags include rapid functional decline, fluctuating cognition, parkinsonism, and severe sensitivity to antipsychotics. Early identification of these features is essential to prevent iatrogenic harm, guide safe pharmacological management, and enable timely referral to specialist services, including cognitive disorders clinics and neurology, for comprehensive assessment and long-term care planning.

The South West Yorkshire Partnership NHS Foundation trust (SWYT) policy on seclusion and long term segregation refers to Seclusion as ‘supervised confinement and isolation of a service user, away from other service users, in an area from which the service user is prevented from leaving, where it is of immediate necessity for the purpose of the containment of severe behavioural disturbance which is likely to cause harm to others.’ It is essential that they are afforded the procedural safeguards of the Mental Health Act Code of Practice. The SWYT trust policy provides clear recommendations on medical seclusion reviews.

The aim of the audit is to check the adherence to SWYT trust policy on medical seclusion reviews in a Psychiatric Intensive care Unit (PICU).

The SWYT trust policy on medical seclusion reviews has a seclusion toolkit which outlines the following timeframes for assessment: Initial medical review within an hour of seclusion, 4-hourly medical reviews till first Multidisciplinary (MDT) meeting, first MDT, independent MDT within 8-18 hours of seclusion, regular reviews thereafter (included 1 medical (non-RC) review, 1 Responsible Clinician (RC) review and 1 MDT till the end of seclusion. The RC MDT and RC medical review may be combined). The policy needs to be followed for seclusions initiated during out of hours/ weekends/bank holidays.

The list of all new seclusions in PICU from January 2025 to April 2025 was obtained from the Trust Performance and Business Intelligence team. An audit tool was prepared using the seclusion toolkit in the trust policy. The audit tool comprised of questions checking if the medical, MDT and Independent reviews were completed in a timely manner as per the trust guidance.

Data collection was done by members of the audit team. All the data was collected from electronic records.

Key successes:

1. In 92.7% cases, first MDT was completed within 08:00 to 22:00 the next day.

2. 95% seclusion reviews on bank holidays/ weekend and out of hours were adherent to the trust policy.

3. Non-RC medical reviews were completed daily for the duration of the seclusion in 87.2% cases.

Key concerns / areas for improvement:

1. Only 24.2% completion of independent MDT reviews during a period of seclusion.

2. 64.4% resident doctor reviews are done within 1 hour of commencement of seclusion.

3. Daily MDT reviews were completed in only 66.6% cases. This was noted to be due to incorrect documentation on the seclusion proforma.

This audit highlights high compliance for first MDTs and out of hours reviews but also highlights areas for improvement such as low rates of completion of independent MDT and initial 1 hour reviews. Recommendations included prompts for independent MDT reviews, including seclusion toolkit in new doctors’ induction training and discussing with Responsible Clinicians about accurate documentation of daily seclusion reviews.

Seclusion is a restrictive procedure and therefore ensuring adherence to trust guidelines on seclusion reviews is important.

Behavioural and psychological symptoms of dementia(BPSD) are very common in people with dementia, including Alzheimer’s disease.The prevalence is very varied,ranging from 25%-75%.There are many treatment options available including pharmacological and non-pharmacological methods.We present a patient with Alzheimer’s disease whose BPSD were successfully managed with the synthetic cannabinoid,Nabilone.

Mr. KS,a 73-year-old gentleman with multiple physical comorbidities and a family history of dementia,was admitted to the ward with complaints of worsening memory and functioning since a few months.He had severe irritability,agitation,verbal and physical aggression along with suspiciousness towards his family.On assessment, his mood was irritable with delusion of persecution;he was disoriented to time and place and had poor recent memory along with word-finding difficulties.Delirium was ruled out.Cognitive assessment was done using Standardised Mini-Mental State Examination and he scored 13/30.Brain imaging(MRI) showed mild vascular changes and medial temporal lobe atrophy score of 3.A diagnosis of Dementia in Alzheimer’s disease with late onset was made.Clinical Dementia Rating(CDR) Global Score showed 2 which meant moderate dementia and he was started on Memantine.BPSD symptoms continued to be severe in nature.Various non-pharmacological techniques(redirection,ABC method,activity engagement) were tried with minimal effect.Following this,medications such as lorazepam,melatonin,and trazodone were tried.Though there was partial improvement with trazodone,he continued to be severely agitated and aggressive.Hence,following discussion with the team including senior pharmacists,nabilone 500mcg daily was initiated.

Nabilone is a synthetic cannabinoid of delta-9 tetrahydrocannabinol(THC) which has weak partial agonist activity at Cannabinoid-1 and Cannabinoid-2 receptors.The use of nabilone in dementia for BPSD management is an off-licence indication.For this patient,NPI(neuropsychiatric inventory) was done and he scored 51 in frequency and severity score and 21 in distress score,with high scores in the domains of delusions,agitation/aggression,disinhibition,irritability/lability,and sleep and nightmare behaviour disorders.Following introduction of nabilone,his agitation and aggression improved significantly within 2 weeks.After 3 weeks,NPI was repeated and he scored 9 in frequency and severity score and 5 in distress score with improvement in all domains including care-giver distress.There was a trial to decrease his Nabilone to 250 mcg–however his behavioural symptoms worsened so he was put back on 500mcg.He is maintaining well on this dose.

There have been many trials looking into the effectiveness of nabilone in managing non-cognitive symptoms of dementia.In patients who have been tried on conventional treatment regimens and have had poor response,it is an effective option and can be considered in managing BPSD.We have successfully managed this patient with a low dose of nabilone with no significant long-lasting side-effects.

The prevalence of children and adolescents diagnosed with an eating disorder has recently increased, as has the prevalence of those diagnosed with autism. However, it is unknown whether there has been a corresponding increase in the proportion of young people admitted to inpatient mental healthcare facilities with eating disorders and/or autism in England. We aimed to: (1) examine referral patterns for child and adolescent mental health inpatient care involving a diagnosis of eating disorder and/or autism in the south of England from 2019–2025; and (2) describe the demographic and clinical characteristics of young people referred during this period.

We conducted a prospective cohort study involving all young people (aged <18 years) referred for inpatient mental health treatment between 1 April 2019 and 31 March 2025 in one geographical area in the south of England. We collected data relating to demographic (age, sex, ethnicity) and clinical (diagnosis/es at admission and discharge, time between referral and admission, length of stay, and Mental Health Act status.

A total of 1,447 referrals were made (81.9% female, 83.3% White) and 1,022 (70.6%) were admitted. The proportion of young people admitted with an eating disorder diagnosis fluctuated between 35.8% and 54.0%, and the proportion admitted with an autism diagnosis ranged from 9.9% to 17.4%. The proportion admitted with comorbid autism and eating disorder diagnoses increased consistently year-on-year from 1.9% (2019–20) to 15.9% (2024–25). Between 2019 and 2021, the proportion of admissions involving: 1) a diagnosis of autism and/or eating disorder; 2) a nasogastric feeding tube; 3) use of the Mental Health Act; and 4) a referral categorised as urgent all increased markedly.

We observed an eight-fold increase in the proportion of young people admitted with comorbid autism and eating disorder diagnoses between 2019 and 2025. We observed other trends in clinical presentations and outcomes, some of which may be related to the onset of the Covid-19 pandemic. Further research is needed to determine the longer-term trajectories and outcomes for young people referred for mental health inpatient care with a diagnosis of eating disorder and/or autism.

Evaluate current practice in diagnosis and management of neuro developmental disorders (NDD) including Autism (ASD) and Attention-Deficit-Hyperactivity Disorder (ADHD) in Early Intervention Psychosis (EIP) services across the UK given frequent comorbidity of ADHD/ASD and Psychosis.

Gather data on care provision, use of third sector services and ascertain training and confidence in NDD within EIP services.

Highlight the need for robust NDD training to facilitate diagnosis and management within mental health teams, reducing pressure on services.

An online survey was disseminated to members in EIP services through RCPsych General Adult faculty and the EIP network. Data collected included prefilled and free text responses regarding EIP team demographics, current NDD assessment practice, care provided (including medication), use of third sector services, level of NDD training and, confidence assessed on a Likert scale. Quantitative and Qualitative data was analysed to capture key themes.

55 responses from 36 trusts across England and Wales were received; 85% (n=46) were EIP teams, 60% serving mixed urban/rural populations.

ADHD: Assessment: 75% (n=41) referred externally for assessment, with only 9% (n=5) completing assessments within EIP teams. A further 13%(n=7) shared assessments with another trust team.

Pharmacology: 47% (n=26) relied on third sector prescribers to prescribe ADHD medication, 15% (n=8) prescribed within teams, whilst 30% (n=17) used shared care agreements or prescribed together with another trust team.

ASD: Assessment: 70% (n=39) of assessments were completed by external services; only 7% (n=4) were conducted within EIP teams.

Post-diagnostic support: 45% (n=25) only provided signposting advice and 19% (n=10) offered no support.

NDD Training: 49% (n=27) reported no formal NDD training, of the 40% (n=22) that did, qualifications included ADOS, ADI-R and DIVA. Key barriers were lack of NDD skills and training opportunities, alongside funding and commissioning constraints.

Confidence: Confidence in NDD assessment and management was moderate, average confidence was 3/5 (42%) with remaining 29% spread both ≤2 or ≥4.

Qualitative Responses: Frequent themes included limited training and diagnostic inability. Overwhelming number of EIP teams rely on external services for NDD assessment. Teams with NDD training found it beneficial to services overall; others highlighted necessity for enhanced NDD diagnostic skills.

The elevated risk of multiple adverse outcomes in this population highlights the critical importance of allocating resources for clinician training and upskilling in the diagnosis and management of NDD, equitable access to services, and effective screening, diagnosis, and treatment within existing EIP services.

Voyeurism represents a significant public safety concern in Singapore, ranking third amongst crimes of concern with a 9% increase in cases from 2023 to 2024. Despite its prevalence, limited research exists on the psychological profiles and risk factors of individuals engaging in voyeuristic behaviour in local contexts.

This study seeks to develop a foundational understanding of potential patterns and risk factors for voyeuristic acts in Singapore’s local context. It postulates that there are predictable, recurring patterns for how individuals engage in voyeuristic acts, with risk factors such as social isolation, dysfunctional interpersonal relationships, the lack of a meaningful romantic relationship, antisocial personality traits, and concurrent mental illness.

A retrospective medical records review was conducted of cases known to the Department of Forensic Psychiatry at the Institute of Mental Health, Singapore.

The study was approved by the National Healthcare Group Domain Specific Review Board, which granted waiver of informed consent (reference number 2024-4055). The study uses de-identified data in a secure manner that would not pose risk to study subjects.

Sample Selection: Records were reviewed for individuals who had engaged in voyeuristic acts, either allegedly or confirmed through legal conviction, between January 2023 and December 2024. No age restrictions were applied. These subjects presented to the department through one or more of the following routes: remand assessments, suitability for Mandatory Treatment Order, or follow-up after their release from prison.

Data Collection: Data was extracted from medical records covering their demographics, offending patterns, relationship history, social factors, mental health diagnoses, substance use, criminal history, and treatment history. Data was de-identified by an independent party before analysis to ensure confidentiality.

All 30 subjects were male (median age 28.5 years), with 73.3% having tertiary education. Social isolation was prevalent (68.8% of those with available data), alongside significant family dysfunction. The median number of voyeuristic acts was 3.5 per individual. Offending patterns were quite evenly divided between upskirting and toilet/shower voyeurism. Mental health diagnoses were present in 73.3% of participants, with Voyeuristic Disorder being most common (23.3%). Antisocial traits were rare, while substance use was virtually absent.

Voyeuristic behaviour in this clinical sample was characterised by interpersonal dysfunction rather than traditional antisocial risk factors. The high educational attainment and low antisocial traits suggest this represents a distinct subgroup of help-seeking individuals. Treatment interventions should prioritise addressing underlying interpersonal difficulties and attachment dysfunction rather than focusing solely on traditional risk factors.

Diagnostic systems for neurodevelopmental disorders, including DSM–5–TR and ICD–11, provide essential categorical classifications for clinical communication, service eligibility, and care planning. However, these systems offer limited capacity to explain the marked heterogeneity observed within diagnostic groups or to link diagnosis meaningfully to underlying neurocognitive mechanisms. In parallel, dimensional frameworks grounded in developmental neuroscience have generated substantial mechanistic insight yet remain difficult to operationalise in routine clinical practice. This gap between descriptive diagnosis and mechanistic understanding limits formulation, training, and translational consistency across clinical settings.

Aim

To propose a neurocognitive profile specifier framework that integrates developmental neuroscience constructs into DSM/ICD-based diagnosis using a shared, clinically usable language applicable across education, clinical practice, and service contexts.

This conceptual framework defines five neurocognitive profile domains consistently implicated in neurodevelopmental conditions: Social Cognition; Executive Function and Cognitive Flexibility; Reward and Motivation Sensitivity; Sensory Processing; and Emotional Regulation. Each domain is characterised using concise, developmentallyinformed specifiers (e.g. intact, variable, markedly impaired), derived from information routinely obtained during neurodevelopmental assessment, including clinical interview, collateral history, and standardised measures interpreted relative to developmental norms. The framework is designed to be applied following categorical diagnosis, preserving existing descriptive specifiers while adding a mechanistically coherent profile layer to clinical formulation.

The framework produces a concise neurocognitive profile embedded within the diagnostic formulation. Clinically, this supports clearer intra-diagnostic differentiation, improves multidisciplinary communication, and facilitates targeted intervention planning without reliance on biological markers not yet suitable for routine use. Across services and training settings, it provides a structured approach for teaching formulation and linking assessment findings to intervention strategies. In addition, the use of clinically familiar but mechanistically grounded domains facilitates alignment with neuroscience-informed research, supporting cumulative and translational understanding.

Neurocognitive profile specifiers offer a pragmatic means of aligning diagnostic practice with developmental neuroscience while preserving categorical classification. By contextualising diagnosis rather than replacing it, this framework supports more precise formulation, enhances educational clarity, and provides a scalable approach to personalised care in neurodevelopmental psychiatry.

In the light of limited relevant local literature, we planned our research to build a scientific database related to the immediate and sustained effects of this innovative treatment modality at our tertiary care hospital, in order to start ketamine clinic in our department . We didn’t find any research in Faisalabad, Pakistan on the subject, ensuring a more in depth understanding of the tolerability and acceptability of ketamine therapy in our patient population. The research findings will provide an insight into the effective use of ketamine therapy in cases of TRD

It was a non randomized trial held in department of psychiatry DHQ/ Allied Hospitals Faisalabad Medical University, Faisalabad, Pakistan.

Sample size : 30 ( purposive sampling)

The study started after approval from ethical review committee of FMU, Faisalabad. The patients fulfilling inclusion criteria were enrolled and informed consent taken. All patients received detailed informational care session about nature of IV ketamine therapy. IV ketamine was given in subanesthetic dose of 0.5mg/kg body weight in 100ml normal saline infusion over 60 minutes after an overnight fast and under supervision of an anesthetist. Pulse, Blood pressure and oxygen saturation was monitored during infusion to ensure safety . Patient was kept in recovery until fully conscious . 8 Treatment sessions were administered over 4 weeks . Patients were assessed using Hamilton Depression Rating Scale (HAM-D) after each dose, then 2 weeks and finally 1 month after last dose.

A 50% reduction in HAM-D scores at 1 hour after 1st dose was considered as treatment response.

Regarding treatment outcomes, IV Ketamine therapy demonstrated promising results. Out of 30 patients, 22 (73.3%) showed a positive response to ketamine therapy, whereas 8 patients (26.7%) didn’t respond. This finding indicates a relatively high efficacy rate of ketamine in managing TRD within the studied group

This study demonstrates that IV ketamine at a sub anesthetic dose produces rapid and substantial improvement in depressive symptoms among patients with TRD. The response rate of 73.3% is consistent with the global data, reinforcing ketamine’s role as a transformative intervention in modern psychiatric care.The persistence of symptom improvement at two weeks and one month follow up assessments suggests that repeated IV ketamine administration may offer short to medium term benefits in TRD Future researches with larger sample size, longer follow up and controlled designs will be essential to validate these findings and optimize clinical protocols for widespread implementation

Acute behavioural disturbance in older adults frequently presents diagnostic challenges, particularly when symptoms arise in the context of polypharmacy, physical illness, and sleep disruption. Delirium is often the initial working diagnosis in such presentations; however, evolving clinical features may indicate an underlying primary psychiatric disorder. Distinguishing between delirium and late-onset affective illness is especially complex in older adults with pre-existing psychiatric vulnerability and medication exposure.

This case describes a 67-year-old woman with a background of recurrent depressive disorder, anxiety, and obsessive–compulsive disorder who presented with acute confusion, severe insomnia, behavioural disorganisation, and pressured speech following recent changes to her analgesic regimen, including the initiation of tramadol.

The initial presentation was characterised by fluctuating cognition, psychomotor agitation, disinhibition, and paranoid ideation. A provisional diagnosis of medication-induced delirium with hypomanic features was made. Tramadol was identified as a likely precipitating factor, given its opioid and serotonergic properties and the patient’s increased vulnerability as an older adult.

Management initially focused on withdrawal of potentially offending medications, optimisation of physical health, and symptomatic treatment with antipsychotic and benzodiazepine medications. Due to impaired insight, behavioural disturbance, and risk of self-neglect, the patient required detention under the Mental Health Act for assessment and treatment.

Over the course of admission, features typically associated with delirium improved, including confusion and disorientation. However, the patient continued to demonstrate sustained mood elevation, reduced need for sleep, increased goal-directed activity, pressured speech, and intrusive behaviour, with preserved cognition. These symptoms were non-fluctuating and persistent.

Collateral history obtained during admission revealed a possible family history of bipolar affective disorder. In light of the clinical course and longitudinal observation, the diagnosis was revised to a manic episode, likely precipitated by medication exposure and sleep deprivation.

This case illustrates the diagnostic complexity of acute mental state changes in older adults, particularly in the context of polypharmacy and pre-existing affective disorders. While delirium is a common and appropriate initial diagnosis in such presentations, persistence of non-fluctuating manic symptoms following resolution of cognitive disturbance should prompt reconsideration of the diagnosis.

Tramadol has recognised serotonergic and noradrenergic properties and has been associated with both delirium and affective destabilisation, particularly in vulnerable populations. Sleep deprivation may have further contributed to the precipitation of mania. The presence of preserved cognition, sustained mood elevation, and increased goal-directed activity distinguished the evolving presentation from delirium and supported the diagnosis of late-life mania.

This case highlights the importance of longitudinal assessment, collateral history, and diagnostic flexibility when managing behavioural disturbance in older adults.

This case underscores the need to consider late-life mania in the differential diagnosis of acute behavioural disturbance in older adults, particularly when symptoms persist beyond the resolution of delirium. Medication exposure, sleep disruption, and affective vulnerability are important contributing factors. Careful longitudinal observation and willingness to revise initial diagnoses are essential to ensuring accurate diagnosis and appropriate treatment in this population.

ADHD is a neurodevelopmental condition which affects approximately 3-4% of UK adults. ADHD has been linked to a range of co-occurring conditions such as Autism, Substance use disorders and Anxiety.

The aim of this study was to examine the frequency of co-occurring psychiatric conditions among a cohort of adult patients diagnosed with ADHD at the Brighton and Hove Neurodevelopmental Clinic between June 2022 and June 2024.

Notes of 200 patients, who had received a diagnosis of ADHD by the Neurodevelopmental service (NDS) in Sussex Partnership Foundation Trust (SPFT) between June 2022 and June 2024, were reviewed using the Electronic Health Record system used by SPFT, and by using the Plexus software to review GP records.

We reviewed; ADHD referral, assessment, the first 3 NDS reviews post assessment, each patient’s GP record and any previous psychiatric clinic letters that were available to collect data on co-occurring or historic conditions.

Conditions that we recorded included current or historical substance misuse, Autism, Bipolar affective disorder (BPAD), Major Depressive Disorder (MDD), Generalised Anxiety Disorder (GAD), Post traumatic Stress Disorder (PTSD), Personality disorder (any kind and either an active or historic diagnosis). We also collected data on any history of psychosis.

This study was registered with and approved by SPFT Quality improvement support team (QIST).

Of the 200 records reviewed 173 had ADHD referrals, assessments and diagnoses. Of those records the mean age at diagnosis was 31.9 years, with a median age of 30.

The patients records included showed current or historical evidence of the above conditions in the following proportions; Substance misuse 29%, Autism 38% with a further 5.7% awaiting assessment, BPAD 7%, MDD 17.9%, GAD 18.5%, PTSD 19%, Personality disorder 19% and Psychosis 4.6%.

Our findings provided further evidence of the high rate of co-occurring Autism, Substance misuse, anxiety and depression in those who receive a diagnosis of ADHD in adulthood. This highlights complexity and burden of having ADHD diagnosis. It also indicates the need of revising the service model to ensure an appropriately trained workforce is able to provide comprehensive assessment and diagnosis as this is likely to provide patients with a better experience of care and outcomes.

The Section 136 (s136) suite provides a safe and controlled environment for individuals detained under the Mental Health Act (MHA), enabling timely mental health assessment whilst reducing stigma and distress. This audit assessed the s136 suite at Fieldhead Hospital in Wakefield. The audit evaluated compliance with local standard operating procedures (SoPs), including timeliness of MHA assessments, involvement of the Intensive Home Based Treatment Team (IHBTT), documentation, and communication with general practitioners (GPs).

A retrospective audit was conducted of adult patients admitted to the Wakefield s136 suite between September 2024 and September 2025. Data were extracted from SystmOne records. Inclusion criteria were adult patients admitted within the audit period; patients whose records were inaccessible were excluded. Standards assessed included patient demographics, community mental health team involvement, time from referral to assessment, MHA assessment outcomes, involvement of IHBTT, documentation of MHA assessments, and communication of outcomes to GPs

A total of 111 patients were identified, of whom 100 met inclusion criteria. Sixty percent of presentations occurred out of hours, and 55% of patients were known to Community Mental Health Teams (CMHTs), with nearly 60% of these under Enhanced Teams. While 60% of patients were assessed within four hours and 90% within twelve hours, IHBTT provided face-to-face input in only 45% of cases. Documentation compliance was high, with 99% of assessments recorded by Section 12 doctors. However, communication to GPs was low, with over 70% of discharged patients lacking documented GP correspondence.

The audit demonstrates good compliance with assessment timeliness and documentation standards but highlights significant gaps in IHBTT involvement and GP communication. Improved gatekeeping through consistent IHBTT face-to-face attendance, enhanced relapse prevention planning for patients under community teams, and mandatory communication of assessment outcomes to GPs are recommended to improve adherence to SoPs and continuity of care.

Lithium is a first-line mood stabiliser for bipolar disorder but has a narrow therapeutic index. Neuropsychiatric toxicity may occur even when serum lithium concentrations are near the therapeutic range, particularly in the presence of dehydration and acute kidney injury. This case study aims to highlight lithium-associated neuropsychiatric toxicity as an important and potentially overlooked cause of ongoing delirium in patients with bipolar disorder following acute medical illness.

A 74-year-old woman with bipolar disorder treated with long-term lithium therapy was admitted following collapse and acute onset confusion. On presentation, she was febrile, dehydrated, and disoriented, with clinical evidence of cellulitis, leading to an initial diagnosis of acute delirium secondary to sepsis. She was treated empirically with intravenous antibiotics and fluids. Despite improved inflammatory markers, her neuropsychiatric symptoms persisted.

Further investigations revealed mild hypernatraemia, persistent hypercalcaemia, acute kidney injury, and a mildly elevated serum lithium level but her parathyroid hormone levels were within the normal limit. CT and MRI of the brain revealed no acute intracranial pathology. Despite rehydration and resolution of infection, delirium and biochemical abnormalities persisted, prompting review of psychotropic medication.

Lithium toxicity precipitated by dehydration and acute kidney injury was identified as the most likely unifying diagnosis. Lithium dosage was reduced and intravenous bisphosphonate therapy was administered. Following intervention, renal function improved and serum lithium and calcium concentrations normalised. The patient demonstrated gradual and complete resolution of delirium, returning to her cognitive baseline without residual neuropsychiatric impairment at discharge.

This case illustrates that lithium-associated neuropsychiatric toxicity may present with persistent delirium despite near-therapeutic serum levels and apparent alternative medical explanations. Hypercalcaemia and renal impairment served as important diagnostic clues supporting lithium toxicity.

Lithium toxicity should be considered in patients with bipolar disorder who develop persistent delirium, particularly when dehydration and acute kidney injury are present. Near-therapeutic serum lithium levels do not exclude clinically significant neurotoxicity. Early review of psychotropic medication and renal function is essential to prevent delayed diagnosis and avoidable morbidity.

Maternal health encompasses wellbeing before, during, and after pregnancy, with thepostnatal period critical for physical and psychological recovery. Prevalence of postnatal depression (PND) is higher in Pakistan (28-63%) compared to the United Kingdom (UK) (15-20%).

This study aims to compare PND prevalence among Pakistanis, British Pakistanis, and the wider UK population in line with three objectives:

1) Exploring cultural factors influencing PND

2) Identifying factors driving higher prevalence in Pakistan

3) Evaluating support structures while proposing culturally sensitive interventions

This study combines a comparative narrative review of secondary sources with primary qualitative input. Epidemiological data and government reports were synthesised to compare prevalence and healthcare systems. Additionally, clinician perspectives were collected as a podcast providing cultural context. Short films were also interpreted to illustrate societal attitudes towards maternal mental health and explore lived experiences.

PND is influenced by the biopsychosocial model with cultural stigma, somatisation, and barriers to care being key drivers in Pakistan. Severe workforce shortages (0.19 psychiatrists per 100,000 compared to 11 per 100,000 in South London), high home birth rates (63%), and lack of routine postnatal checks exacerbate risks. Traditional practices like Chilla offer post-partum support but should be supplemented with structured services similarto the UK which provide postnatal checks and specialist mother and baby units (MBUs), although access remains unequal across the UK. Funding disparities persist with Pakistan allocating only 0.4% of its health budget to mental health compared to 8.1% by NHS England. These systemic gaps highlight the need for integrated and culturally sensitive approaches that address both clinical and societal factors of care.

Improving maternal mental health requires strategies combining psychiatry, public health, and cultural awareness. Recommendations include tailored cultural psychiatry training for UK professionals, increased funding for maternal mental health in Pakistan, and stigma reduction campaigns. Bridging clinical care and lived experience can reduce inequalities and enhance maternal wellbeing globally.

Healthcare providers working in conflict zones face unique occupational and psychological challenges that significantly impair sleep quality. In the Gaza Strip, prolonged exposure to violence and humanitarian crises exacerbates these challenges, yet data on the sleep health of this critical workforce remain scarce. This cross-sectional study aimed to assess the prevalence and patterns of sleep disturbances among healthcare providers at Nasser Medical Complex during the 2023–2025 Israel–Gaza conflict, and to examine associations between sleep quality and sociodemographic and occupational factors.

A cross-sectional study was conducted among 400 healthcare providers (70% nurses, 20% physicians, 10% non-medical staff) at Nasser Medical Complex from May to July 2025. Of 1000 eligible, 993 were approached; 400 participated (participation rate 40.3%). Participants completed the validated Arabic version of the Pittsburgh Sleep Quality Index (PSQI) and a sociodemographic questionnaire. Descriptive statistics, bivariate analyses, and multivariate regression were used to evaluate sleep quality and its predictors. Ethical approval: Palestinian Ministry of Health (Ref 2563158). No funding.

The PSQI demonstrated acceptable internal consistency (Cronbach’s alpha [value pending]). Thirty-five per cent of participants reported poor sleep quality (PSQI >5). Additionally, 40% reported sleeping less than 6–7 hours nightly. Sleep disturbances were frequent, including difficulty initiating sleep (50% reporting problems weekly or more), nighttime awakenings (60%), loud snoring (37.5%), and breathing pauses (20%). Physical discomfort during sleep–such as back pain and breathing difficulties–was prevalent.

Sleep disturbances are alarmingly common among Gaza’s healthcare providers in conflict settings. These findings underscore the urgent need for integrated mental health and sleep interventions, occupational health screenings, and infrastructural support to safeguard provider wellbeing and healthcare delivery sustainability in protracted crises.

Bitesize teaching is a short session delivered on a specific topic to enhance the knowledge and confidence of practitioners and to support practical application of clinical knowledge. In psychiatry, bite-size teaching has been suggested for training ward staff in physical health-related topics. However, it has been used in a wide range of topics in different teams. We intended to see the effectiveness of bite-size teaching across different professional groups in a range of clinical settings, covering a variety of topics relevant to mental health professionals.

We compared the change in knowledge of a topic and skill, confidence, and comfort level in performing a related task through a pre- and post-session assessment using the Teaching Effectiveness Questionnaire (TEQ), and open-ended questions about learning. The teaching sessions included different professional groups such as doctors, nurses, and allied health professionals; and covered various topics.

There were 149 attendee responses, over the range of topics covered in the bitesize teaching, e.g. role of exercise, green spaces and mental health, diagnostic formulation, metabolic disorder, suicidality management, dementia prevention, Mental Health Act, community treatment order, etc. in multiple sessions. Most of the attendees were doctors(65.1%), followed by nurses (17.4%), and the rest were allied health professionals. The content of the sessions was reported to be very good in 47.0%, and good in 37.6%; session delivery was observed as very good 50.3%, and good 38.9%. There were positive correlations between years of experience and knowledge, skill, and confidence in performing, comfort level, and teaching the task. Pre and post-teaching scores in these domains also positively correlated. Cronbach's alpha of the TEQ for the sample pre-teaching was 0.97, suggesting an excellent level of internal consistency. There were significant changes pre- and post-teaching session in all the domains, such as knowledge (3.3±1.1 vs. 4.0±0.8), skills (3.2±1.1 vs. 3.9±0.8), confidence (3.2±1.1 vs.4.0±0.8), comfort level (3.3±1.1 vs. 4.0±0.8), confidence in teaching others (3.0±1.1 vs. 3.8±1.0), respectively. The overall change was from 16.0±5.2 to 19.7±4.0 (p<0.001). This was consistent across topics and professional groups. Qualitatively, attendees perceived this method as a quick refresher of existing knowledge, and a source for relevant new information that is useful in clinical practice, especially while supporting patients and families.

It appears that the bitesize teaching is an effective method for training on diverse clinical topics. Post-session responses showed positive changes in domains of knowledge, skills, and confidence. Further studies are required about the persistence of the effectiveness over time.

Hyperglycaemia is common among psychiatric inpatients due to comorbid diabetes, medication side-effects, and challenges in self-care. Poor recognition and escalation increase risk of diabetic emergencies.

There is also the ongoing dilemma of Insulin misuse and poor glucose management, as a form of self-harm in a subset of psychiatry patients. These factors lead to increasing difficulties in managing patients with Diabetes admitted on inpatient wards.

This audit aimed to assess compliance with the Trust’s Inpatient Hyperglycaemia Guideline for episodes of blood glucose >15 mmol/L on an Acute male inpatient Ward in Nottinghamshire.

• • Retrospective audit of RiO electronic records

• • Records reviewed over a 6 month period, spanning January–August 2025

• • 30 hyperglycaemic episodes (>15 mmol/L) in 7 patients.

• • Results collected, organized and analysed using Microsoft excel.

• • Standards assessed: ketone testing, wellness status reviews, escalation to medic, clear documentation, insulin use and repeat monitoring.

• • Standards were devised based on the Nottinghamshire Healthcare NHS Trust’s “Inpatient guide for acute Hyperglycaemia in Diabetes Type 1 or 2”,

• • Ketones checked in14/30 (46.7%)

• • Wellness status documented in 14/30 (46.7%), NEWS2 recorded only 3/30(10%)

• • Escalation gaps: 7/25(23.1%) episodes with BG >18 mmol/L not escalated to a medic.

• • No documentation of pre-meal glucose review in all cases.

• • Insulin dosing appropriate in 36.7% of cases with an indication.

• • BG rechecked at 2h in 10/30(33.3%), at 4h in 7/30 (23.3%)

• • Cause identified in 10/30 (33.3%), mostly dietary

Compliance with inpatient hyperglycaemia management standards was variable, with significant gaps identified in ketone assessment, clinical monitoring, documentation of pre-meal trends, documentation of wellness status and escalation practices. These findings highlight the ongoing challenges of delivering consistent physical healthcare within mental health inpatient settings. Targeted system-level interventions, including staff education and structured patient-centred care planning, may improve adherence to guidelines and reduce risk of preventable metabolic complications.

This has led to ongoing collaborative plans to develop an individualised diabetes care plan template, along with improved referral systems to Diabetes specialist nurses.

Lithium is a highly effective mood stabiliser but has a narrow therapeutic index. Inadequate monitoring increases the risk of toxicity, renal impairment and thyroiddys function. Consequently, NICE and local shared-care guidelines mandate structured baseline assessment and regular biochemical monitoring for all patients prescribed lithium.

This quality improvement (QI) project aimed to systematically evaluate adherence to NICE and local guideline standards for lithium monitoring within the inpatient rehabilitation service at the Royal Edinburgh Hospital (REH). The project sought to identify specific gaps in baseline and ongoing monitoring, assess the timeliness and completeness of required investigations. A further objective was to use these findings to inform targeted, sustainable interventions to improve compliance with monitoring standards, enhance patient safety and reduce the risk of preventable lithium-related adverse events within this high-risk population.

A retrospective review was undertaken of all inpatients prescribed lithium across five rehabilitation wards at REH between July 2023 and July 2025. Ten patients met inclusion criteria. Data were extracted from electronic health records, the electronic prescribing system, laboratory results and Lothian Quality Improvement, Safety, Teaching, Supervision, Audit and Evaluation (QISTSAE) adverse event reports. Collected variables included patient demographics, lithium initiation, duration of treatment, the completion and timeliness of required monitoring investigations. Compliance was assessed against NICE guidance and local shared-care protocols.

Significant gaps in lithium monitoring were identified across the cohort. Urine albumin–creatinine ratio (uACR) testing, recommended for early detection of lithium-associated renal damage, was consistently absent in all patients reviewed. Serum calcium and thyroid function tests were missed in approximately 60% of cases. In addition, timeliness of monitoring was suboptimal, with several patients having overdue lithium levels, renal function tests or thyroid investigations. Renal function was not consistently rechecked following elevated lithium levels despite explicit guideline recommendations and over 10%of the results recorded supratherapeutic lithium concentrations during the review period, representing a clear safety concern.

Lithium monitoring within the inpatient rehabilitation setting was inconsistent and frequently failed to meet guideline standards exposing patients to avoidable risk. uACR testing, calcium monitoring and thyroid surveillance represented particular areas of deficit. These findings highlight the need for system-level interventions to support safer lithium prescribing.

Planned next steps include expansion of the project to other inpatient and outpatient services, development of standardised lithium initiation and monitoring order sets in collaboration with laboratory services, targeted educational interventions for multidisciplinary teams to improve awareness, compliance and patient safety.