The 10% access rate target for perinatal mental health services in the UK was introduced as part of NHS England’s broader strategy to expand and improve access to specialist perinatal mental health care. Within our organisation, the 10% target was actively discussed and various strategies had been implemented to achieve the target. It became evident that women with mental health difficulties on the milder spectrum, where primary care interventions were appropriate, a full new patient assessment (NPA) was not indicated. The hope was that a light assessment (LA) pathway would develop a more responsive pathway for referrals which would be more suitable for other services, it would allow signposting for mild and less complex referrals to the appropriate services in a more timely manner and it would allow clinicians to prioritise time on more complex presentations.

The aim was to implement a LA pathway to support the service to reach the 10% access target.

Consultation with other perinatal teams around the country followed. Concerns on balancing seeing milder cases while preventing team burnout were also shared by them and options for a less in-depth initial assessment in these cases were explored.

The NLFT service agreed to a trial of a LA pathway for mild cases. A LA template and guidance on its use, were created and subsequently discussed in service-wide meetings and adjusted according to feedback. It was formally implemented on 27 January 2025 with plan for feedback meeting in 4 weeks and total trial of 6 months.

The NLFT perinatal service, consists of 3 teams. Two different systems were implemented based on the preference of the individual teams, differing on the days/hours duty service isrun and the days LA appointments are scheduled. In both systems LAs could be converted to NPAs if it becomes evident during the appointment that the patient requires a more in-depth assessment.

For the period of the LA pilot from 27 January 2025 to 30 May 2025, the specialist perinatal service received 684 referrals. All referrals were accepted, unless they were out of borough or not within the perinatal period.

Of the 684 referrals received, 71 (10%) were allocated for a light assessment. 81% of the women allocated for light assessments attended their assessments. 15% (11) allocated for a light assessment, did not attend their assessment and were discharged and 2.5% (2) declined the assessment. Of the 2 that declined the assessment, one was discharged and 1 requested for an NPA, assessed and subsequently discharged. Of the 58 women who attended the LA, 74% (43) were assessed and discharged and 21% (15) were assessed and taken on. The data across the 3 teams were very similar, other than the number of days from triage to assessment. In the south team, the assessments were scheduled within 5 weeks from referral whereas in the west and east teams all assessments were scheduled within 3 weeks from referral.

Qualitative staff feedback was gathered via questionnaires. The main points brought up are as follows:

• • Better triaging guidance needed for newer staff.

• • More information needed on risks and more info in referrals.

• • If uncertain based on info on the referral form, request for more info, if still not sufficient refer for a full NPA.

• • LA’s are helpful for efficient signposting and time-saving. They work well when patients are appropriately triaged. Women are seen, sign posted and discharged in a week.

• • Seeing moderate to severe people quicker. People moved through the service quicker, reducing caseloads.

• • LAx template very clear.

LA are held by Duty, rather than individual clinicians. Better to be a little bit stressed on Duty for longer term gain.

Patient questionnaires were created and were sent out after the LA was conducted.

Setting up the LA pathway has allowed the team to broaden the number of women they see, while preventing team burnout and achieving better resource allocation to SMIs (serious mental illness).

Some of the challenges faced during this project include:

• • Unexpected loss of trust video-call system.

• • Some staff anxiety whether any important information was missed (this is managed by presenting cases at the weekly MDT).

• • Some of the LAs being re-referred (this is monitored and re-referrals are allocated an NPA).

• • Limited information on referrals.

• • Poor response rate on patient feedback questionnaires.

Other reflections and considerations:

• • Based on feedback on how the name “Light Assessment” can be perceived amongst other teams and patients, the service changed the name “Light Assessment” so as not to diminish the work being done.

• • Request readjusting the 10% target for the reduced birth rate in the area.

• • From 21/1/25 self-referral links were also implemented which improved the access rate to the service further.

Next steps:

The feedback overwhelmingly directed towards continuing with the light assessment pathway.

Improve the triage process to the appropriate assessment pathway and consideration of conducting education to referrers of the information needed. Following discussions, it was agreed that when receiving an inappropriate referral we would seek further information from the referrer before accepting it. The team continues to conduct teaching sessions to other teams and this will be highlighted during teaching.

Some NLFT perinatal teams experienced difficulties with primary care teams accepting the referrals from our team as their impression had been that once a referral was accepted by our teams for assessment, the referral would be appropriate for secondary care. The change in the way the team operates in accepting and managing referrals will be highlighted to them. Referrers will also be made aware to inform patients of how the team operates in order to manage expectations.

Details of the pilot were shared with other perinatal teams in LSPCA meetings. Other perinatal services have also reached out to our team and details of the light assessment pathway has been shared with them so that it can be implemented elsewhere.

Artificial Intelligence (AI) chatbots are now widely used and have broad applications. In a nationwide survey, 25% of the almost 11,000 13- to 17-year-olds sampled reported using chatbots for mental health support. Reports emerging in the media detail serious harms, including suicides, and what has been labelled ‘AI psychosis’.

A 13-year-old girl was brought to Accident and Emergency (A&E) by her parents with a 7-day history of coryza, total insomnia, fluctuating confusion, and bizarre behaviour. At assessment, she presented with tachycardia, low-grade fever, pressured speech, delusions of grandeur, thought broadcasting, and auditory hallucinations of ancestors and politicians.

The young person’s troubling use of AI chatbots was reported by her parents after they confiscated her phone. The parents discovered a chat log consisting of thousands of messages, starting three months before the A&E presentation. It was evident that the bot provided false information about how a romantic interest reciprocated the young person’s feelings, and when she asked about past lives and ancestral practices, the bot’s replies suggested that she had supernatural powers.

Extensive physical health investigations were facilitated through a paediatric admission; no underlying physical pathology was identified. The young person was treated with olanzapine and a short course of benzodiazepines. All manic symptoms resolved over the span of 3 weeks of intensive home treatment. The young person experienced a depressive episode around 2 months after the initial presentation. She received a diagnosis of bipolar affective disorder.

In this case, patient vulnerabilities, such as loneliness and past bullying, interacted with chatbot factors, particularly sycophancy,which quickly transformed factual searches into emotional interactions where the technology was anthropomorphised.

“I would stay up at night for 5 hours speaking to it, it was like a replacement friend”, the patient later reflected.

The chatbot also presented overtly false information with confidence and a perceived impartiality, an observed phenomenon of the technology known as hallucination.

Predisposing patient factors included a history of anxiety and depressive symptoms with suicidal thoughts, and a family history of affective disorder. Precipitating factors included mounting academic pressures and romantic rejections. Acutely, the patient was likely suffering from a viral illness and consumed highly caffeinated energy drinks.

This case identifies unregulated access to generative AI tools as an emerging risk for the precipitation and/ or perpetuation of serious mental illness in combination with other risk factors. The authors believe it to be the first report of its kind.

Mindfulness, Meditation and Yoga have an evidence base for improving emotional regulation – with little research looking at the impact on a Borderline Personality Disorder (BPD) cohort. We investigated whether a supplementary session programme could improve emotional regulation and thus symptomatology in BPD service users.

Our initial objective is to identify whether there is an evidence base to support the need for a ‘Mind, body connection’ programme. The subsequent objective is to further develop and improve the ‘Mind, body connection’ programme in response to feedback from the service users.

AIM 1. To establish whether there is benefit from a ‘Mind, Body connection programme’.

AIM 2. To establish further understanding of the holistic effects of the ‘Mind, body connection’ programme for service users.

Future AIM 1. To identify direct benefits of Yoga, Mindfulness and Meditation in BPD populations.

Future AIM 2. To develop a science backed programme to provide a supportive therapeutic practice for BPD patients.

A Thematic analysis was conducted to investigate the ‘Mind, Body Connection’ sessions with service users attending a bi-weekly Therapeutic Community at the Personality Disorder Hub. A 50 minute tape-recorded, in-depth, semi-structured interview took place which was then transcribed to allow for coding.

The theme of 'Greater Capacity to stay present' summarises how greater 'emotional regulation' and 'body awareness' can develop. Both ‘body awareness’ and emotional regulation’ proved to be double edged swords. By developing greater awareness of how your body holds emotions, participants reported greater ability to focus on the body and stay in control of emotions, but also a greater awareness of pain. Service users oppositions - transitioning from a state of doing to a state of being and difficulty around ‘self-dismissing’. Results were bidirectional - higher levels of emotional dysregulation impaired mindfulness practice but increased frequencies of mindfulness practice to >3 times a week was statistically significant in reducing emotional dysregulation symptoms.

The ‘Mind, Body Connection’ programme has a positive impact on service users – but significant support should be provided for its associated challenges. Recommendations; increasing the frequency of Yoga, Mindfulness and Meditation practice to>3 times per week, at home resources and guidance change to the management of BPD (development of patient informed supplementary sessions). Practice in the present underscores the ability to stay present in higher states of arousal in the future. Further research should investigate the process of ‘self-dismissal’ as a regulation adjacent skill.

High quality patient care in mental health services relies on a robust psychiatric workforce. However, unfilled posts and high staff turnover can become entrenched problems. Here we describe a unique and innovative strategy developed in Avon and Wiltshire Mental Health Partnership Trust, developed to support and retain advanced trainees and new consultants in the trust. This aimed to support consultants in their first 3–4 years of appointment and to develop consultant roles within the trust that would appeal to trainees.

The strategy was developed in response to recruitment and retention challenges. The strategy consisted of five elements, including 1) Roll-out of new consultant-specific induction, including a bespoke leadership development programme and leadership coaching for new consultants. 2) Funding and support of a research fellow to conduct qualitative research around experiences of the transition period between higher training and becoming a consultant. 3) Work around support and wellbeing of medical staff. 4) Development of a mentoring programme. 5) Development of compassionate leadership in the trust. Further details of each of the above interventions are described, including challenges faced and how these were overcome. Feedback and outcome measures are then described.

Arising from our work locally, we have generated several recommendations to support and retain advanced trainees and consultants within mental health trusts. We share experiences from developing and implementing these interventions locally. Sharing this information may help other mental health trusts nationally in addressing similar challenges.

We describe an innovative local strategy, developed to support and retain advanced trainees and new consultants in the trust. Future areas for development could include a) sharing successful approaches more widely with other trustsand b) further consolidation of local activities. Further consolidation locally would include promoting more widespread uptake of mentoring, including this being offered to advanced trainees in the two years prior to their completion of training, and continuing to develop cross-trust mentoring with neighbouring trusts.

Mental health-related stigma is a recognised determinant of psychological well-being,yet population-level evidence from the United Arab Emirates (UAE) remains limited. This study aimed to assess levels of perceived mental health stigma among residents of Abu Dhabi, examine socio-demographic correlates of stigma, and explore the relationship between stigma and psychological well-being among Emirati and expatriate populations.

A cross-sectional, population-based study was conducted among adult residents of the Abu Dhabi region. Participants completed a culturally adapted and validated Stigma-9 (STIG-9) questionnaire to assess perceived public stigma, and the World Health Organization Five Well-Being Index (WHO-5) to measure psychological well-being. Socio-demographic variables included age, gender, region of residence, nationality, education level, and household income. Descriptive statistics summarised stigma and well-being scores. Group comparisons examined demographic differences, and correlation analysis assessed the relationship between stigma and well-being. Statistical significance was set at p<0.05.

Overall perceived stigma levels were low (mean STIG-9 score 0.92 ± 0.89; median 0.89, IQR 0–1.67). Significant regional variation was observed, with participants residing in Al Ain reporting higher stigma scores than those in other regions. Females reported higher stigma than males (1.02 ± 0.89 vs 0.83 ± 0.88; p<0.001). Younger adults aged 18–29 years also demonstrated higher stigma scores (1.04 ± 0.93) compared with older age groups. Higher education level and higher household income were associated with increased perceived stigma, while no significant differences were observed by nationality.

Psychological well-being scores were generally high (mean WHO-5 score 74.21 ± 25.60; median 75, IQR 55–90). Males reported higher well-being than females (77.79 ± 24.90 vs 70.57 ± 25.79; p<0.001). Participants in the lowest household income group (<5,000 AED) reported the highest well-being scores (81.01 ± 24.99), while participants with postgraduateeducation reported lower well-being (60.77 ± 21.58). A strong inverse association was identified between perceived stigma and psychological well-being (r=−0.67, 95% CI −0.70 to −0.65; p<0.001).

While the study participants generally showed low perceived mental health stigma, notable variation existed across demographics and regions. Higher stigma was seen among younger adults, females, and those with higher socioeconomic status, reflecting complex sociocultural influences. The inverse link between stigma and well-being emphasises the need for stigma-reduction strategies as part of mental health promotion. Culturally tailored interventions for high-risk groups could support psychological well-being across UAE communities.

To assess the quality of mental capacity assessments completed on admission and compliance with Devon Partnership Trust’s Inpatient Admissions Standard Operating Procedure. This requires that each patient admitted to a mental health ward has an assessment of capacity to consent to treatment completed within 24 hours of admission. In line with the Mental Capacity Act (MCA) Code of Practice, capacity assessments should be decision-specific, include the four-part functional test of mental capacity, represent the least restrictiveoption and be made in the patient’s best interests where capacity is lacking.

Retrospective audit of clinical records for the most recent 30 patients admitted to the Beech Unit in Torbay, Devon until December 2025. Records were assessed according to the following audit criteria:

1. Assessment of capacity to consent to admission and treatment documented within 24 hours of admission

2. Nature of decision clearly documented

3. Use of the four-part functional test (ability to understand, retain, use or weigh up and communicate a decision)

4. Reference to least restrictive practice and best interests where patients lacked capacity

Every patient had a mental capacity assessment documented within 24 hours of admission (100%). The standardised MCA template (which prompts clinicians to document all parts of a capacity assessment) was completed for 90% of the patients and only half were completed in the timeframe. 90% of the records clearly documented the decision in question and 90% had clear documentation of the functional test. Fewer records contained the direct statements ‘least restrictive’ and ‘best interests’ (53%).

All patients (100%) had an assessment of mental capacity documented following admission to the ward, showing that clinicians have a good understanding of when the Mental Capacity Act should be considered, but timeliness of completing the MCA template could be improved. While the nature of decisions and use of the four-part test werewell documented overall, documentation around recording of best interests and least restrictive options could also be improved.

There are some limitations to this audit: variability in clinician documentation styles may affect interpretation of the data and retrospective data collection limits clarification of clinical reasoning.

Recommendations include targeted interventions to guide clerking doctors about when to complete MCA assessments and what should be included. It is recommended that the Trust’s standardised MCA template is used to improve the quality of documentation, as this prompts clinicians to address the key elements of a good capacity assessment.

Clozapine is associated with increased risk of metabolic syndrome. Regular monitoring, lifestyle and pharmacological interventions are recommended. Service-level evaluation is required to identify suboptimal care and inform quality improvement.

This cross-sectional service evaluation was conducted within a centralised clozapine clinic serving adult secondary care services across Suffolk. Clinical, physicalhealth, and weight-management data were extracted from electronic health records.

N=257; mean age 46.9 years (SD=12.4); 68.9% male; 35.2% smokers; 46.7% alcohol users (6.3% heavy drinkers); cannabis 0.8%; other drugs 1.6%; 33.7% reported constipation.

Mean body mass index (BMI) was 31.85 kg/m² (SD=7.05), with 54.5% meeting criteria for obesity and 29.2% classified as overweight. 12.6% met Hbs-540c criteria for prediabetes and 19.8% for type 2 diabetes (T2DM). 10.2% had elevated total cholesterol (>6.18 mmol/L), and 24.9% had blood pressure readings ≥140/90 mmHg. Clinician-recorded prevalences were 6.6% obesity, 9.7% prediabetes, 27.0% T2DM, 16.0% dyslipidaemia, 12.1% hypertension, and 5.5% cardiovascular disease.

Lifestyle advice was recorded for 22.7% of patients and pharmacological weight-management interventions for 7.1%. Although 14.8% of patients were prescribed adjunctive aripiprazole, this was documented specifically for weight management in only 10.5% of those. Metformin was prescribed in 25.2% of patients and was strongly associated with T2DM (p < .001). GLP-1 receptor agonists were used in 3.1% and were prescribed exclusively to patients with T2DM (p < .001). No patients were prescribed topiramate.

The multivariable linear regression model predicting BMI was statistically significant (p < .001). Higher BMI was independently associated with younger age, female gender, autism spectrum disorder/learning disability comorbidity, greater depressive symptom severity, higher systolic blood pressure, receipt of lifestyle advice or structured lifestyle intervention, and prescription of aripiprazole, valproate, or lamotrigine (all p ≤ .040).

There was marked discordance between BMI-defined obesity and clinician-recorded obesity or lifestyle advice (p < .001). Only 10% of patients meeting objective criteria for obesity had a documented obesity diagnosis, and only 29.7% had lifestyle advice recorded. Patients receiving lifestyle advice had significantly higher BMI than those who did not (p=.014), and those with a clinician-recorded obesity diagnosis also had higher mean BMI (although not significant). Together, these findings suggest that recognition and management of obesity occurred at higher BMI levels, rather than systematically once obesity criteria were met.

Obesity was common but inconsistently recognised and managed in clozapine-treated patients, with evidence of threshold bias. Systematic identification and management of obesity is needed within clozapine services.

Alcohol harm in the UK imposes a substantial clinical and societal burden, with 339,916 alcohol-specific hospital admissions recorded in 2023/24. Current pathways for identifying and supporting people at risk rely on self-identification of alcohol use.The aim of this work is to examine the extent to which self-identification as a “heavy drinker” aligns with clinically defined alcohol-risk levels and to identify the structural, stigma-related, and systemic barriers that prevent higher-risk drinkers from accessing appropriate support.

This analysis draws on nationally representative polling of 2,037 UK adults (mean age 48.77, SD=17.74, 52.33% female) applying the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) scoring to examine clinical risk, self-perception of drinking identity, barriers to accessing support, and systemic implications for service design.

Among adults meeting AUDIT-C criteria for increasing or higher risk (25.8%), 90% did not self-identify as a heavy drinker, with most describing themselves as “moderate” or “occasional” drinkers. This disconnect challenges the continuing reliance on self-referral and identity-based messaging within NHS and workplace pathways. Help-seeking was shaped primarily by systemic barriers: long NHS wait times (24.5%), stigma (24.1%), and the cost of private care (19.4%), while “not knowing where to go for help” ranked only sixth (16.9%). These findings contradict policy assumptions that awareness deficits are the primary obstacle. Exposure to alcohol harm extended far beyond the drinker: 49.3% of UK adults knew someone they considered a heavy drinker, indicating significant family, peer, and workplace impact and highlighting a missed early-intervention opportunity within social networks.

Self-identification is not a reliable gateway to care; stigma-laden service framing actively excludes the majority at clinical risk; and capacity constraints limit timely support even when motivation exists. These findings highlight the need for a shift toward routine use of the AUDIT-C in primary care, workplace health initiatives, and NHS Health Checks so that alcohol-risk detection no longer depends on individuals self-identifying as “heavy drinkers”. Services should adopt identity-neutral language, such as referring to “supported reduction” or “health optimisation”, to reduce the stigma that prevents many higher-risk drinkers from seeking help. Supporting families, friends, and colleagues to play a constructive role in early recognition and intervention when they observe escalating risk, is critical. Commissioning should prioritise rapid-access and digitally enabled models of support, to reduce long wait times and make care more accessible and discreet for people who face barriers related to work, geography, or stigma.

To improve the safety, effectiveness and staff experience of inpatient medical handover to at least 70% satisfaction ratings.

The pre-existing medical handover processes varied significantly across the five boroughs within the North London NHS Foundation Trust (NLFT), leading to issues with poor accessibility, information governance, audit capability and user experience.

A new, unified, Trust-wide handover platform could tackle these issues and support consistent resident doctor processes and communication.

Over successive phases, we developed and implemented more digitally mature handover platforms. In our final phase, this handover platform was in Rio, the Trust's existing Electronic Patient Record (EPR). Each phase contained multiple iterative PDSA cycles.

Phase 1: Initial Digital Handover Improvements (2021–2023)

Local QI projects at our two legacy Trusts (which later merged to form NLFT) sought to improve existing handover methods. One Trust introduced a Microsoft Teams list for handover.

Phase 2: Rio-Based Handover Pilot (May 2024–January 2025)

A working group was formed in May 2024, including the Trust’s Chief Clinical Information Officer (CCIO), RiO applications expert and three resident doctors. They collaboratively designed a new platform in RiO and a pilot was launched at a single inpatient site in January 2025.

Phase 3: RiO-Based Handover Full Rollout (January–June 2025)

In March 2025, a refined iteration of the RiO-based medical handover platform was rolled out across the remaining four inpatient sites in NLFT. Before rollout, stakeholder engagement sessions were held to train staff and promote awareness of the platform. After rollout, further sessions took place to gather informal feedback.

Formal staff survey feedback was gathered two months after Trust-wide implementation and showed significant improvement across all key measures. All measures are ratings out of 10.

Safe & Effective Handover (Old: 6.19 → New: 8.25), Ease of Access (6.25 → 8.44), User Experience (5.75 → 8.18), and Information Governance (4.70 → 8.56).

Trust-wide implementation of the new Rio-embedded medical handover led to positive staff survey feedback. This highlighted significant improvements in safety, effectiveness, user experience and information governance. The collaboration betweenresident doctors, digital teams, and clinical leaders served as a model for future multi-disciplinary QI projects. Resident doctor leadership on stakeholder engagement sessions was particularly effective in embedding the new platform culturally.

Long-term, opportunities exist to integrate other handovers into Rio, such as the emergency system handover, to further enhance patient safety and operational efficiency.

Background

People with severe mental illness experience significantly higher rates of physical morbidity and premature mortality, with diabetes mellitus being a major contributor. When psychotic symptoms impair insight and decision-making, refusal of essential medical treatment can present acute and recurrent risks. In such situations, clinicians must navigate the interface between the Mental Health Act (MHA) and the Mental Capacity Act (MCA), two statutory frameworks that were not designed to address sustained community-based enforcement of physical healthcare in the context of fluctuating mental capacity.

Case Report

We describe the case of a patient with a chronic psychotic disorder and insulin-dependent diabetes mellitus who repeatedly refused insulin during psychotic relapses, leading to recurrent episodes of diabetic ketoacidosis requiring emergency hospital admission. During periods of florid psychosis, the patient lacked capacity to make decisions regarding insulin administration, with refusal directly driven by delusional beliefs. Despite multidisciplinary involvement, optimisation of psychiatric treatment, and repeated capacity assessments, adherence could not be sustained in the community. Each crisis was managed reactively through emergency admission, with no clear mechanism for anticipatory or preventative intervention once the immediate medical emergency resolved.

Discussion

This case highlights a recurrent clinical and ethical dilemma at the MHA–MCA interface. While the MCA permits best-interests’ decisions during acute incapacity, it offers limited scope for proactive intervention when capacity fluctuates, and risk is foreseeable but not immediate. Conversely, the MHA allows compulsory treatment for mental disorder but does not clearly support sustained enforcement of treatment for physical illness, even when refusal is a direct consequence of psychosis. This case does not advocate for routine compulsory treatment of physical illness under the MHA. Rather, it illustrates a structural gap in existing legal frameworks when psychosis-driven refusal leads to repeated, predictable medical crises that are addressed only reactively.

Psychosis-related refusal of life-sustaining medical treatment exposes limitations in current statutory frameworks, particularly for individuals with recurrent incapacity and high physical health risk. Earlier, legally supported escalation: including proactive capacity planning, structured review of statutory options, and consideration of Court of Protection involvement may help reduce preventable harm and improve parity between mental and physical healthcare. This case underscores the need for clearer guidance and integrated approaches to managing sustained physical health risk in the context of severe mental illness.

The demand for adult Attention Deficit Hyperactivity Disorder (ADHD) assessments has surged while NHS capacity remains constrained by limited budgets, workforce shortages, and uneven specialist provision. Lack of national standardisation in ADHD pathways has created regional disparities, with waiting times ranging from two to five years–often termed the “ADHD postcode lottery.” Many patients turn to private clinics offering faster assessments, either self-funded or via the NHS Right to Choose pathway, which allows eligible patients to access approved private providers at NHS expense.

NICE guidelines (2018) state that “after titration and dose stabilisation, prescribing and monitoring of ADHD medication should be carried out under shared care protocol arrangements with primary care.” However, shared care implementation is inconsistent, with reported concerns among clinicians about private assessment validity and medicolegal implications of prescribing medications initiated outside NHS services. Without shared care arrangements, patients must either continue costly private prescribing or re-join NHS waiting lists for reassessment and treatment, risking abrupt treatment discontinuation.

This audit aimed to identify the prevalence of private ADHD diagnoses within the North Peterborough Adult Locality Team (PALT) caseload, determine how prescribing responsibility is managed, and assess alignment with NICE shared care guidance to inform local policy development.

Patient records were reviewed retrospectively using clinic letters and keyword searches (e.g., “ADHD,” “private,” “Right to Choose,” “shared care”). Data collected included demographics, route of diagnosis, treatment status, prescribing arrangements, and shared care documentation.

Of the 325 patients reviewed, 2 (0.6%) had received private ADHD diagnoses, both in 2022. Both were female, aged 39 and 47, one British and one African-Asian. The first accessed diagnosis via NHS Right to Choose and was managed under shared care between her private psychiatrist and GP for two years until discontinuing medication. The second obtained a self-funded private diagnosis but reverted to the NHS ADHD clinic treatment waitlist due to costs; subsequent delays in accessing treatment led to her returning to private care.

We identified a low prevalence of private ADHD diagnoses within the caseload. While the smaller cohort precludes generalisation, Right to Choose facilitated successful shared care, whereas self-funded pathways resulted in treatment delays. No mechanism exists for privately diagnosed patients to access NHS treatment without joining standard waiting lists, undermining the rationale for expedited private diagnosis and perpetuating treatment gaps. Further audit in a larger cohort is recommended to inform local policy development.

Schizophrenia is associated with abnormalities in mismatch negativity (MMN), an event-related potential linked to sensory memory and information-processing deficits. MMN has been widely studied as a biomarker for disease progression. This review and meta-analysis examines the magnitude of MMN abnormalities in schizophrenia and explores factors associated with these effects. In addition, this study evaluates a large language model approach for automated data extraction, with potential applications for future meta-analyses.

MEDLINE, Embase and PsycINFO databases were searched from inception to 14 November 2025. A total number of 2493 articles investigating auditory MMN in patients with an established diagnosis of schizophrenia, first-episode psychosis, high-risk groups, and first-degree relatives was identified. Manual data extraction was compared to an automated data extraction using OpenAI’s GPT5 model. The mean effect size of auditory MMN in patients compared to controls was calculated. Subgroup analyses for deviant type and auditory paradigm were conducted. The effects of age, sex, illness duration, symptom severity and antipsychotic dose were analysed.

A total of 140 studies were included in the analysis. Compared to the controls, patients with schizophrenia showed reduced auditory MMN amplitudes (g=0.72, 95% CI [0.63–0.82]). MMN impairment increased significantly (p<0.0001) across illness stages from high-risk individuals (g=0.37) to first-episode psychosis (g=0.50) and chronic schizophrenia (g=0.85). Subgroup analyses by deviant type and auditory paradigm showed no statistically significant differences in effect sizes. Auditory MMN amplitude was not significantlyreduced among first-degree relatives. Meta-regression analyses found that both antipsychotic dose (p<0.0001) and illness duration (p<0.0001) significantly moderated MMN effect sizes, while sex, symptom scales’ scores and patient age were not significant modulators. OpenAI’s GPT5 model accurately extracted data across 95% of fields.

This large meta-analysis confirms that auditory MMN amplitude is reduced in schizophrenia and modulated by both duration of illness and antipsychotic dose. This is present in high-risk groups, intensifying with progression to first-episode psychosis and chronic schizophrenia. These findings reinforce MMN as a potential biomarker of neurophysiological dysfunction in schizophrenia across stages of illness. Additionally, automated data extraction provided promising feasibility for accelerating future large-scale meta-analytic workflows.

Administration of clozapine is challenging in treatment-resistant schizophrenia (TRS) patients who refuse to take it orally; enforced treatment with clozapine, either naso-gastrically (NG) or intramuscularly (IM), may be required in such situations. There are a few existing case-series and reports in this area. This service evaluation aimed to add to this pool of data and to understand the illness profile of patients who received IM clozapine, tolerability, their longer-term outcomes etc.

The evaluation was of a retrospective longitudinal observational nature and included all patients under the care of Mersey Care NHS Foundation Trust who were prescribed IM clozapine from 01/01/2017 till 31/12/2023. Pseudonymised data was derived from the patient records.

The sample included a total of 30 patients. All patients suffered from chronic psychotic illnesses. Average duration of psychotic illness prior to being prescribed IM clozapine was 19 years. 80% of patients were in seclusion or segregation at the time of IM clozapine being prescribed. Over 40% patients suffered from cardiometabolic or other physical comorbidities. 21 of the patients (70%) belonged to the initiation group and were prescribed IM clozapine to initiate and establish the patient eventually on oral clozapine. 10 (47.6%) of them accepted oral clozapine without receiving any injections. 9 of the patients (30%) belonged to the maintenance group and were prescribed IM clozapine as an adjuvant to maintain their compliance. A total of 428 doses of IM clozapine were given in the study to 17 patients, and each dose was given as 1-2 injections. 7 patients (41.2%) who received IM clozapine developed injection-site nodules or lumps without abscess; average number of doses received was 43. 10 patients (52%) required restraints by PMVA-trained staff; these were uneventful. Around 90% of patients in the initiation group were established on oral clozapine at end of follow-up. Around 2/3rds of patients in the initiation group who established on oral clozapine had seclusion/ segregation terminated, moved to lower securitymeasures and were on clozapine at time of discharge.

Administration of IM clozapine is fairly safe and well tolerated and it should be prescribed in patients earlier in their course of treatment-resistant-schizophrenia where oral compliance is not possible: nearly half of initiation group accepted oral clozapine without a single IM injection, improvement in patient outcomes was noted and majority were established on oral clozapine. Rotation of injection sites is recommended to prevent and avoid injection site nodules.

Care homes were noted to refer residents with Behavioural and PsychologicalSymptoms of Dementia (BPSD) without behavioural charts, which limited the development of appropriate care plans. Some referrals were also made to secondary mental health services before trial of local behavioural strategies. This project aimed for 80% of referrals to Kent and Medway Mental Health Trust for BPSD to include a medication chart and completed behavioural chart prior to assessment. A further aim was to design and deliver training on Dementia, BPSD and effective behavioural chart completion within two pilot care homes, with the longer-term intention of reducing referrals.

A multidisciplinary team (MDT) mapped the referral pathway and collected baseline patient data, including whether behavioural charts were provided on referral, and chart quality from psychology and medical perspectives. A 3-hour MDT training package was developed, combining presentation, written materials and interactive case discussion. Topics included understanding Dementia, recognising behaviours experienced as challenging, communication strategies, use of behavioural charts with example walkthroughs, and approaches to supporting wellbeing and quality of life. Training was delivered on-site in two pilot homes, with staff encouraged to cascade learning. Trust referral screeners were also asked to request missing behavioural charts. Equivalent referral data was collected post-training.

Thirteen attendees provided feedback. All rated the training 10/10 for usefulness. Self-rated understanding of Dementia improved from 4.2/5 to 5/5, and confidence with completing behavioural charts improved from 6.8/10 to 9.8/10. Attendees included HCAs, Team Leaders and Managers. Qualitative comments highlighted learning around triggers for behaviours that challenge, completion of behavioural charts and behavioural strategies to potentially use for their residents with Dementia.

At baseline, 16 referrals for BPSD were accepted over four weeks in March, with two including behavioural charts. Requested charts from the two pilot homes scored low for structure (1.6/5) and clinical usefulness (1.4/5). After the training, five referrals were accepted over four weeks in June, none from the pilot homes. In the following two months, no new patients were taken on from one pilot home and two from the other, one accompanied by a completed behavioural chart. Although new patient numbers decreased, too few charts were therefore submitted to evaluate quality improvement.

The training was well received and increased staff confidence. Wider rollout is recommended, though individual home-based delivery was resource-intensive. An annual centralised session may be more efficient.

Distinguishing primary functional disorders from psychiatric illness arising secondary to chronic physical symptoms remains a significant clinical challenge, particularly when structural pathology is absent. Failure to make this distinction risks premature psychological attribution, diagnostic overshadowing, and invalidation of patient experience. Although ICD-11 offers updated frameworks for understanding disorders at the brain–body interface, their application to complex presentations requires careful clinical judgement to avoid misinterpretation of psychiatric risk.

Case Report

We present a case that illustrates this diagnostic tension. A 48-year-old woman with high premorbid functioning and no prior psychiatric history developed a progressive multisystem physical illness following international travel. Symptoms included gastrointestinal dysmotility, bladder dysfunction, autonomic instability, and sleep disruption. Despite extensive investigation, no unifying structural or neurodegenerative diagnosis was identified.

As the physical illness persisted, the patient developed a severe depressive syndrome with suicidality. Notably, affective symptoms emerged only after the onset of physical decline and fluctuated in parallel with physiological distress, rather than following an autonomous psychiatric course.

This case highlights the importance of distinguishing primary functional disorders from psychiatric illness that is reactive to chronic physical dysfunction. Contemporary models conceptualise functional conditions as disorders of brain–body interaction, characterised by altered interoceptive processing and maladaptive predictive mechanisms. In such cases, these processes are central to symptom generation and represent appropriate targets for psychiatric intervention.

By contrast, secondary psychiatric illness arises in response to prolonged physical uncertainty, loss of bodily predictability, and erosion of trust in physiological functioning. In this context, the depressive syndrome does not account for the physical symptoms but develops as a consequence of them. Temporal sequencing is therefore a key diagnostic marker. Failure to recognise this distinction risks premature psychological attribution, erosion of the therapeutic alliance, and misinterpretation of suicide risk. In such cases, suicidality is often driven by existential distress related to persistent physical suffering and fear of irreversible decline, rather than affective pathology alone.

Not all distress associated with unexplained physical symptoms is somatoform. Psychiatry’s role is not to resolve medical uncertainty through psychological explanation, but to locate distress accurately within the patient’s causal narrative. Careful formulation, grounded in phenomenology and temporal sequencing, is essential for ethical practice and effective risk management - and in cases such as these can prove to be life saving

Melatonin is an endogenous hormone used to manage insomnia in children with neurodevelopmental disorders. Within the Tees, Esk & Wear Valleys NHS Foundation Trust, the Shared Care Guideline (PHARM-0025-V5) mandates specific standards for prescribing and documentation. Following an initial audit in March 2024 that identified partial compliance, this re-audit aimed to assess progress in the York CAMHS ADHD team’s adherence to these guidelines.

A retrospective clinical re-audit was conducted between October 9th and 12th 2025. Data were collected from 50 electronic patient records (CITO) for children diagnosed with ADHD who were commenced on Melatonin between March 2024 and October 2025. The audit tool assessed five key criteria: documentation of prescribing rationale, provision of oral/written information, advice on short-term use/treatment breaks, and adherence to correct licensed formulations (Adaflex/Slenyto).

Significant improvement was noted in prescribing correct formulations, rising from 70% in the first cycle to 90% (45/50). Documentation of the rationale for formulation switches also improved to 50% (2/4 applicable cases). However, compliance remained low in other areas:

Prescribing Rationale: Stable at 76% (38/50) compared to 77% in the first cycle.

Information Provision: Recorded evidence of oral/written information declined from 33% to 18% (9/50).

Short-term Use Advice: Remained low at 8% (4/50) compared to 10% in the previous cycle.

The re-audit demonstrates that targeted feedback effectively improved technical prescribing adherence regarding medication choice. However, a significant “documentation gap” persists concerning patient-centered communication and review planning. Proposed actions include delivering team-teaching sessions to emphasize the necessity of documenting patient discussions and implementing standard phrases in electronic notes to ensure comprehensive record-keeping.

Clozapine-induced gastrointestinal hypomotility (CIGH) is a serious and potentially life-threatening adverse effect, with constipation representing an early warning sign. During clozapine titration, clinical attention may be disproportionately focused on haematological monitoring, risking under-recognition of gastrointestinal side effects. This audit aimed to assess adherence to Trust guidelines for monitoring constipation following clozapine titration in a working-age adult inpatient setting. It was hypothesised that formal completion of Glasgow Antipsychotic Side Effect Scale for Clozapine (GASS-C) at 30 days post-titration would be limited. Secondary objectives were to explore whether constipation was identified and documented through alternative clinical means and whether appropriate treatment was initiated when constipation was present.

A retrospective audit was undertaken across working-age adult inpatient wards at Farnham Road Hospital. Patients registered with the Clozaril Patient Monitoring Service between October 2023 and October 2024 were identified with support from the hospital pharmacy clozapine service. Patients aged over 65 years and those maintained on an established dose of clozapine were excluded. Electronic patient records were reviewed to determine whether GASS-C had been completed at 30 days following clozapine titration, whether constipation was documented elsewhere in clinical notes at that time point, and whether laxatives had been prescribed.

Fourteen patients were identified, of whom eight met inclusion criteria (six male and two female). GASS-C was completed at the 30-day endpoint in three patients (37.5%). Constipation was documented in the clinical notes of six patients (75%), and seven patients (87.5%) were prescribed laxatives. The modal clozapine dose reached at 30 days was 300 mg.

This audit demonstrates that formal monitoring for constipation using GASS-C following clozapine titration is inconsistently implemented. However, constipation was commonly identified and treated through routine clinical documentation, suggesting awareness of risk despite poor adherence to the recommended monitoring tool. Embedding GASS-C into clozapine titration workflows may support more consistent and systematic monitoring. A re-audit is planned to assess the impact of these interventions.

This project aimed to explore the experiences and acceptability of individuals prescribed clozapine regarding both traditional 12-lead ECGs and the handheld Kardia Mobile 6-lead ECG device.

Initial data on 12-lead ECG compliance was analysed across two clozapine clinics using Business Intelligence. 213 patients were prescribed clozapine; however, only 40% (n=85) had an ECG recorded within the previous 12 months.

A quantitative survey using Likert scales was developed and distributed to patients attending clozapine clinics. Participants were offered the handheld Kardia Mobile 6-lead ECG and subsequently completed the patient survey. All participants had previously been offered a standard 12-lead ECG as part of their annual physical health monitoring. A total of 37 patients participated.

Ethical approval was not required as this project was classified as a clinical audit; approval was granted by the KMMH Clinical Audit and Effectiveness Committee (Ref: 6689-25).

Of the 37 participants; 16% reported finding 12-lead ECG’s difficult or very difficult, 38% reported it was neither easy nor difficult, and 46% reported it was easy or very easy. In contrast, 97% of participants reported the Kardia 6-lead ECG to be easy or very easy, with only 3% reporting it as neither easy nor difficult. These findings suggest the handheld ECG was perceived as significantly more convenient and acceptable than the traditional 12-lead ECG.

When asked about preference, 84% of participants strongly preferred the Kardia 6-lead ECG over the traditional 12-lead ECG, and 92% reported they would be more likely to consent to the 6-lead ECG. However, confidence in the accuracy of the Kardia device varied: 21% of participants rated their confidence at moderate or below, while 78% reported high or very high confidence. This indicates that although acceptability and likelihood of consent were high, some uncertainty regarding diagnostic accuracy remains.

The findings demonstrate that the Kardia 6-lead ECG was perceived as more convenient and more acceptable than the 12-lead ECG, with a strong association between ease of use and increased willingness to consent to monitoring. This suggests that the introduction of handheld ECG devices may help address existing barriers to ECG completion in community clozapine clinics and potentially improve annual monitoring rates.

However, it is important to note that the results also highlight while overall confidence in the 6-lead ECG was high, a notable minority expressed uncertainty, emphasising the need for clear patient education and communication regarding the reliability and limitations of handheld ECG devices.

There is increasing evidence that suggests that different subtypes of major depressive disorders, particularly treatment-resistant depression and anhedonia-predominant forms, have dysregulation in reward processing and chronic neuroimmune activation. Low-dose naltrexone (LDN), which is administered at low doses (1–5 mg/day), modifies both the signalling from the body’s endogenous system and the inflammatory pathways of microglia and thus can be used as a potential therapeutic for depression. This mechanistic systematic review aims to evaluate the dual mechanism of Low Dose Naltrexone in Treatment-Resistant Depression. This study aims to provide an analysis of the human clinical and biological effects of low dose naltrexone (LDN) in depression based upon a mechanistic convergence framework.

Human studies examining the effects of LDN on outcomes such as mood, fatigue, pain, quality of life, inflammatory markers, or opioid-related variables, published in PubMed, EMBASE, Scopus, Web of Science, the Cochrane Library, or Google Scholar, wereidentified. The quality of randomized controlled trials was evaluated according to the Risk of Bias 2 tool, and the quality of non-randomized studies was evaluated according to the Risk Of Bias In Non-randomized Studies–Instrument (ROBINS-I). Results from studies of human subjects were synthesized narratively using a mechanism-based approach.

Improvements in quality of life, fatigue, and mood-related symptoms in disorders characterized by immune activation and central sensitization (e.g. fibromyalgia, multiple sclerosis) were observed across randomized trials, observational cohorts, and case reports after administration of LDN. Biomarkers of inflammation (pro-inflammatory cytokine levels) were lower in human studies after administration of LDN. Indirect indicators of enhancement of endogenous opioid function (e.g. improved pain tolerance, decreased consumption of analgesics and psychotropics) were also reported in human studies after administration of LDN. The mechanisms by which LDN exerts these beneficial effects occur in the same patient population and therefore suggest a biological convergence of immune suppression and opioid-mediated reward modulation.

The results from the literature support a “Dual Mechanistic Model” where LDN suppresses inflammation by activated microglia and at the same time increases signalling of endogenous opioids, both of which have been implicated in the pathophysiology of depression and anhedonia. Thus there is a strong mechanistic basis for testing LDN as a treatment for patients who have failed to respond to current treatments for depression.

This quality improvement project aimed to strengthen the timeliness, consistency and quality of post-fall medical assessments and documentation across older adult inpatient wards. National standards, including NICE Quality Standard 86 and Royal College of Physicians’ recommendations, emphasise prompt review and comprehensive assessment following inpatient falls. Local incident reviews, however, indicated delays in medical examination, inconsistent documentation, and variation in practice. The project aimed to evaluate current practice, identify gaps, and inform the development of an improved post-fall medical review template, as well as contribute to the revision of the Trust’s Falls Policy.

A retrospective review of 30 inpatient fall incidents was conducted across six older adult mental health wards at the Julian Hospital and Carlton Court Hospital over a three-month period. Data were extracted from incident reports and clinical records, focusing on:

• Whether a post-fall medical review was completed.

• Time from fall to medical assessment.

• Completeness and quality of documentation.

• Differences between witnessed and unwitnessed falls.

• Variation by time of day.

Performance was compared against NICE QS86 (statements 4, 5, 6), Trust Falls Policy C86, and national audit benchmarks.

Medical reviews were not consistently completed, with approximately 40% of falls lacking documented medical assessments. Among documented reviews, median time toassessment was 8.7 hours, within the 12-hour standard but indicating avoidable delay, especially for unwitnessed falls and out-of-hours incidents. Documentation quality varied significantly, with omissions in neurological examination, pain assessment, medication review, and rationale for monitoring. Reviews conducted during evening/night shifts tended to be shorter and less comprehensive. Unwitnessed falls showed higher rates of missing neurological observations and inconsistent application of Trust guidance. Overall, substantial variation existed across wards.

The current post-fall medical assessment practice showed significant gaps in both timeliness and documentation quality, creating potential risks for undetected injuries. This highlighted the need for a more structured and standardised approach across older adult psychiatric wards.

Based on the findings of this QI project, a new, user-informed post--fall medical review template was developed to support clearer, more comprehensive documentation. Alongside this, a wider rewrite of the Trust’s Slips, Trips and Falls Policy (C86) is underway. This ongoing work aims to make the policy more detailed, practical, and clinically informative, ensuring staff have clearer guidance when managing both witnessed and unwitnessed falls.

Next steps include staff engagement, implementation of the revised tools, and a re-audit after three months to measure improvement in timeliness, consistency, and quality of post-fall medical care.