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Lamotrigine-induced DRESS syndrome with myelosuppression in a patient with bipolar disorder: case reportLamotrigine-induced DRESS syndrome is a potentially fatal drug reaction with variable clinical presentation and complications requiring early recognition and rapid response.
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The impact of the mental health treatment requirement (MHTR) service on psychological distress, mental health recovery-related quality of life, and shame of individuals convicted of a criminal offenceBackground: The Mental Health Treatment Requirement (MHTR) is a court sentencing option for individuals convicted of a criminal offence when there is a link between their mental health and offending which requires community-based treatment. To improve mental health and reduce reoffending, the MHTR service seeks to understand service users’ needs and goals and provides appropriate psychological therapy and connection with supportive community services. Aims: This study investigated the impact of an MHTR service on service users’ psychological distress, mental health recovery-related quality of life, and shame. Methods: The study design was open-label and did not have a control. Measures used were Clinical Outcomes in Routine Evaluation (CORE-34), Recovering Quality of Life (ReQoL-20), and Experience of Shame Scale (ESS). Participants: Twenty-one MHTR service user participants, thirteen males (62%) and eight females (38%). The ages ranged from 19 to 66 years, with an average age of 37 years. Results: At the end of the MHTR the CORE-34 and ReQol-20 scores significantly improved, with large effect sizes; all four CORE-34 domains (including “risk”) significantly improved. There was a significant improvement in ESS overall score with a moderate effect size; all three ESS domains significantly improved. CORE-34 reliable improvement was 76% and ReQoL-20 reliable improvement was 57%. CORE-34 remission rate was 24%. Conclusions: Improvements on the ReQoL-20 indicate the positive impact of MHTR on the individual’s mental health recovery, real-world functioning, and quality of life. CORE-34 improvements indicate a positive impact on reducing psychological distress and risk, which is associated with reducing reoffending. Improvements on the ESS indicate the positive impact of MHTR on reducing shame-related distress which is associated with reduced self-criticism, anger, and antisocial traits. Further research required has been identified. Evidence indicates that MHTR is effective in meeting its goals and should be appropriately resourced to meet demands.
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Implementation of AliveCor KardiaMobile electrocardiogram (ECG) 6-lead in an early intervention psychosis (EIP) service: a mixed-methods evaluation of completed ECGs outcomes and feedback from patients and staffBackground: Clinical guidance recommends that people with psychotic disorders are assessed for cardiovascular issues at least annually, at the start of antipsychotic medication and following medication changes such as dose changes and switching of antipsychotic medication. The AliveCor KardiaMobile 6-lead electrocardiogram (ECG) is a small, battery operated, hand-held portable ECG which has comparable accuracy to a 12-lead device and may be suitable, in particular for QTc monitoring, where it is not practical or preferable to use a 12-lead device. Purpose/Aim: To obtain patient and staff feedback on KardiaMobile and to quantify ECG completions within an early intervention in psychosis (EIP) service. Methods: A mixed-methods evaluation was undertaken, using patient and staff surveys, alongside data collection and analysis to report ECG completion. Results: The use of the KardiaMobile 6-lead in EIP was associated with improved ECG completion rates, enhanced compliance with antipsychotic monitoring guidance, and reduced patient refusal. Patient and staff feedback indicated that the KardiaMobile 6-lead was portable, accessible, easy and simple to use and was quicker, less intrusive, and more efficient than a standard 12-lead device. Conclusion: The findings support use of KardiaMobile 6-lead for better healthcare guidance compliance, safer prescribing, and better patient outcomes. By addressing the practical, emotional, and cultural barriers often associated with traditional portable ECGs, KardiaMobile fosters greater patient engagement and staff efficiency. A 12-lead device may be required in some cases and should be obtained at baseline if possible as it provides more comprehensive information and rules out pre-existing abnormalities, it is also indicated in specific clinical guidance. The addition of the KardiaMobile 6-lead offers flexibility and enhanced compliance with guidelines. It is essential that heart functioning assessment is undertaken to maximise compliance with guidelines, safety, and best patient outcomes, and that appropriate ECG assessment remains a priority of mental health services.
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How to treat someone suffering with PTSD following rape in adulthoodCognitive behavioural therapists and practitioners often feel uncertain about how to treat post-traumatic stress disorder (PTSD) following rape and sexual assault. There are many myths and rumours about what you should and should not do. All too frequently, this uncertainty results in therapists avoiding doing trauma-focused work with these clients. Whilst understandable, this means that the survivor continues to re-experience the rape as flashbacks and/or nightmares. This article outlines an evidence-based cognitive behavioural therapy (CBT) approach to treating PTSD following a rape in adulthood. It aims to be a practical, ‘how to’ guide for therapists, drawing on the authors’ decades of experience in this area. We have included film links to demonstrate how to undertake each step of the treatment pathway. Our aim is for CBT practitioners to feel more confident in delivering effective trauma-focused therapy to this client group. We consider how to assess and formulate PTSD following a rape in adulthood, then how to deliver cognitive therapy for PTSD (CT-PTSD; Ehlers and Clark, 2000). We will cover both client and therapist factors when working with memories of rape, as well as legal, social, cultural and interpersonal considerations. Key learning aims To understand the importance of providing effective, trauma-focused therapy for survivors of rape in adulthood who are experiencing symptoms of PTSD. To be able to assess, formulate and treat PTSD following a rape in adulthood. How to manage the dissociation common in this client group. To be able to select and choose appropriate cognitive, behavioural and imagery techniques to help with feelings of shame, responsibility, anger, disgust, contamination and mistrust. For therapists to learn how best to support their own ability to cope with working in a trauma-focused way with survivors of rape and sexual violence.
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Staff perceptions of the DIALOG tool and its use for early intervention in psychosis servicesEarly intervention in psychosis (EIP) services aim to delay or prevent the onset of severe mental health issues, including psychosis, and provide a stepped care approach for people experiencing emerging psychotic symptoms. The DIALOG service user-rated outcome and experience measure is used routinely in EIP services and provides a comprehensive assessment of service users’ quality of life, care needs and treatment satisfaction. This service evaluation explored staff’s perceptions of using DIALOG in one EIP service. Data were collected from 20 staff members (including 12 nurses) via a survey and a focus group. Themes extrapolated from focus group data were feasibility, engagement and facilitation. Findings showed that staff felt confident using DIALOG regardless of the number of years they had worked in the EIP service and that DIALOG supported person-centred conversations with service users. However, there was variability in how frequently DIALOG was administered and some staff regarded it as a tick-box exercise.
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The impact of COVID-19 lockdown and post-lockdown period on acute psychiatric admissions for emotionally unstable personality disorderThe COVID-19 pandemic negatively impacted the mental health of people with emotionally unstable personality disorder (EUPD), with reports of maladaptive coping mechanisms, reduced mental health support and quality of life. In this study, the authors examine the impact of COVID-19 lockdown and post-lockdown period on acute psychiatric admission rates in an NHS Trust in people diagnosed with EUPD. In addition, the authors analyse whether patient profiles and the seasonal pattern of admission were impacted by COVID-19 in this population. The study highlights the need for preventative clinical care pathways with increased access and service responsiveness, adjusted to fit local needs at times of confinement policies and additionally more research into seasonal patterns of admission in those with EUPD.
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Thyroid dysfunction in early psychosis: improving quality of carePeople in EIP services are frequently prescribed antipsychotic medication, and often in combination with other psychotropics, all with increased risk of thyroid dysfunction. Undiagnosed and diagnosed thyroid dysfunction can have potential significant implications on both clinical outcomes and treatment for patients with early psychosis. Here, the authors present a clinical practice guideline for the management of thyroid dysfunction in EIP.
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“Flow” Transcranial Direct Current Stimulation (tDCS) for depression treatment in a Community Mental Health Team (CMHT) service: depression, functioning, and health-related quality of life outcomesBackground: People who experience severe mental illness (SMI) have a high prevalence of depression symptoms, which is linked to worse functioning and quality of life. Research evidence indicates that transcranial direct current stimulation (tDCS) can reduce symptoms of depression. Flow FL-100 is a transcranial direct current stimulation (tDCS) device self-administered by a patient at home in combination with a software application that delivered wellbeing behaviour therapy training. Purpose/Aim: This study investigates if Flow can be introduced to a Community Mental Health Team (CMHT) service and the impact of Flow in treating depression. The study addresses the questions: “what are the depression reliable improvement and remission rates?” and “can Flow significantly reduce depressive symptoms and improve real world functioning (everyday, social and occupational functioning) and health-related quality of life?”. Methods: An open-label patient cohort design with no control group. Pre-intervention and 6-week follow-up intervention assessments using the participant self-report measures: Patient Health Questionnaire (PHQ-9), Work and Social Adjustment Scale (WSAS), and EuroQol five-dimension (EQ-5D-5L). Participants were 31 CMHT patients, 15 males and 16 females, with an age range of 21 to 64 years, and average age of 42 years. Results: PHQ-9 reliable improvement and remission rates were 51.61% and 12.9%, respectively. PHQ-9 scores significantly improved, from 20.9 (SD 5.55) to 14.6 (SD 7.33) at 6 weeks, with large effect size. WSAS scores improved from 31.3 (SD 6.02) to 22.5 (SD 11.43) at 6 weeks, with large effect size. EQ-5D-5L results showed significant improvements in the health index score, and three EQ-5D-5L dimensions (“mobility”, “self-care”, and “pain”). Conclusion: Flow tDCS treatment was integrated into a CMHT service and was found to be beneficial in terms of improving functioning and quality of life and reducing depression symptoms. Flow FL100 tDCS and wellbeing behaviour therapy training could be offered through all CMHT services to people with SMI to treat depression, enable better functioning, and improve quality of life.
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Self-administered “Flow” Transcranial Direct Current Stimulation (tDCS) depression treatment in a Crisis Resolution and home Treatment (CRT) service: functioning, and health-related quality of life outcomesBackground: Transcranial direct current stimulation (tDCS) has research evidence that it can reduce symptoms of depression. Flow FL-100 is a transcranial direct current stimulation (tDCS) device self-administered by a patient at home in combination with a software application that delivers wellbeing behaviour therapy training. Purpose/aim: The purpose of this study was to investigate if Flow can be introduced to a Crisis Resolution & Home Treatment (CRT) service and the impact of Flow in treating depression. The study addresses the questions: 1) “what are the depression reliable improvement and remission rates?” and 2) “can Flow significantly reduce depressive symptoms and improve real world functioning (every-day, social and occupational functioning) and health-related quality of life?”. Methods: An open-label patient cohort design with no control group. Pre-intervention and 6-week follow-up intervention assessments using the participant self-report measures: Patient Health Questionnaire (PHQ-9), Work and Social Adjustment Scale (WSAS), and EuroQol five-dimension (EQ-5D-5L). Participants were 49 CRT patients, 19 males and 30 females, with an age range of 20 to 66 years, and average age of 42 years. Results: PHQ-9 reliable improvement and remission rates were 57.1% and 14.3%. PHQ-9 scores significantly improved, from 23.1 (SD 3.44) to 14.8 (SD 6.82) at 6 weeks, with a large effect size. PHQ-9 suicide/self-harm related question significantly improved from 2.51 (SD 0.77) to 1.08 (SD 1.17), with a large effect size. WSAS scores significantly improved, from 33.6 (SD 5.22) to 21.9 (SD 10.82) at 6 weeks, with a large effect size. EQ-5D-5L results showed significant improvements in the health index score, global assessment of health EQ-VAS from 34.2 (22.26) to 51.6 (24.95), and three EQ-5D-5L dimensions (“self-care”, “usual activity”, and “anxiety/depression”). Conclusion: A CRT service effectively integrated Flow tDCS treatment. Flow was beneficial in terms of improving functioning and quality of life and reducing depression symptoms and thoughts of suicide/self-harm. Flow FL100 tDCS and wellbeing behaviour therapy training could be offered through all CRT services to treat depression, reduce thoughts of suicide/self-harm, enable better functioning, and improve quality of life.
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Conditionally Discharged Restricted Patients in a General Adult Community Mental Health SettingLittle is known about the proportion and patient profile of conditionally discharged patients supervised by general adult community mental health teams (CMHTs). In this study, the authors evaluate the number of patients and their demographic, clinical and risk profile, and current practice in terms of supervision and structures. Supervision in the community is time- and resource-intensive. There is a need for NHS Trusts to ensure adequate support and structures, supervision, training and joint working opportunity with forensic services to ensure safe quality care.
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Community treatment orders in an early intervention for psychosis serviceLittle is known about the use and effectiveness of community treatment orders (CTOs) in early psychosis. Here, the authors describe their service evaluation of patients within an NHS early intervention for psychosis service subject to CTO over a period of three years in order to evaluate the rates of CTO use, demographic, and clinical characteristics of those subject to CTO, as well as clinical outcomes. This study demonstrates how CTO use, where deemed necessary, can create real-life, positive outcomes for service users.
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A service evaluation of the Behavioural Treatment for Substance Abuse (BTSA) programme for forensic dual diagnosis populationsLiterature links mental health problems comorbid with substance abuse with increased recovery time. There is limited research evaluating the effectiveness of substance abuse treatments for dual-diagnosis patients. This project aimed to evaluate the effectiveness of the BTSA group with this population. Questionnaires measuring motivation, locus of control, confidence to abstain and self-efficacy were administered to six different cohorts of BTSA participants (N = 38) at baseline, post, and follow-up stages. In addition, participants from the most recent BTSA cohort (N = 4) attended a post-program focus group, to provide information about their experiences of the intervention. Statistical analyses revealed that participants’ confidence in their ability to manage substance abuse was significantly higher post group, but the hypotheses that there would also be significant improvements in participants’ self-efficacy, motivation, and locus of control following completion of the program were not supported. Thematic analysis identified three key themes relevant to participants, namely validation, psychoeducation and identifying progress. This project provided valuable insights into participants’ experiences of the group, highlighting what they had gained form the intervention, and the impact on them from having Recovery Champions working in conjunction with NHS staff to facilitate the intervention. Limitations are discussed, alongside recommendations for improving the program.
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Evaluating social drop-in facilities and their impact on social recovery in early intervention in psychosis services“Social recovery” is a long-cited aim within the UK early intervention in psychosis (EIP) services; however, there is a lack of evidence regarding existing social recovery provisions and how these can be improved. This paper aims to evaluate an existing social drop-in facility within an EIP team, ran within the Birmingham and Solihull Mental Health NHS Foundation Trust, and highlight the potential benefits of delivering such services for people diagnosed with first episode psychosis. Attendance and basic demographic statistics (age, gender and ethnicity of attendees) were collected over a period of 13 weeks. In addition, two semi-structured focus groups were conducted: one with EIP staff members (community psychiatric nurses and support workers) and the other with current service users, with both groups describing their satisfaction and experience of the drop-in facility and how it can be improved. Inductive thematic analysis was used to analyse data from both focus groups, with six overarching meta-themes being identified: reflection, environment, emotional experience, recovery, activities and interactions. Service users and staff reflected that the drop-in facility was an asset to the service, although work could be done to improve overall attendance. This paper explores how a social drop-in facility can provide a supportive, positive environment that aids recovery from psychosis for service users and improves working conditions for the EIP staff.
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Clinical practice guideline for clozapine use in patients with COVID-19National and local guidelines focus mainly on clozapine monitoring frequency, and actions based on full blood count results. Prescribing clozapine in the context of COVID-19-positive patients brings a complexity of challenge beyond this. In this article the authors put forward an example of a practical clinical guideline in this regard.
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Changes in parental sleep from pregnancy to postpartum: a meta-analytic review of actigraphy studiesSleep changes in new parents are widely observed but there is no extant meta-analysis of changes to sleep parameters in this group. We completed a meta-analysis of changes in actigraphy-measured parent sleep between pregnancy and the end of the first year of a child's life. A search of six databases was completed. Following review using predetermined inclusion and exclusion criteria, 16 papers were left for review. Data were extracted, analysed and each paper was reviewed for methodological quality. Where possible, subgroup analysis was completed based on time since birth and location of the study, and meta-regression of parent age. Parents' total sleep time and sleep efficiency were shown to decrease following the birth of a child, with wake after sleep onset increasing. This change was most notably observed in the first four weeks after birth. Up to 16 weeks post-birth, differences were still apparent, but sleep parameters were beginning to return to pre-birth levels. New parents experience a significant change in multiple sleep parameters following the birth of a child. Future data collection, using best practice actigraphy measurement, reporting a broader range of variables and including fathers, as well as mothers, is warranted.
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Automated virtual reality cognitive therapy versus virtual reality mental relaxation therapy for the treatment of persistent persecutory delusions in patients with psychosis (THRIVE): a parallel-group, single-blind, randomised controlled trial in England with mediation analysesBackground Persecutory delusions are a major psychiatric problem that often do not respond sufficiently to standard pharmacological or psychological treatments. We developed a new brief automated virtual reality (VR) cognitive treatment that has the potential to be used easily in clinical services. We aimed to compare VR cognitive therapy with an alternative VR therapy (mental relaxation), with an emphasis on understanding potential mechanisms of action. Methods THRIVE was a parallel-group, single-blind, randomised controlled trial across four UK National Health Service trusts in England. Participants were included if they were aged 16 years or older, had a persistent (at least 3 months) persecutory delusion held with at least 50% conviction, reported feeling threatened when outside with other people, and had a primary diagnosis from the referring clinical team of a non-affective psychotic disorder. We randomly assigned (1:1) patients to either THRIVE VR cognitive therapy or VR mental relaxation, using a permuted blocks algorithm with randomly varying block size, stratified by severity of delusion. Usual care continued for all participants. Each VR therapy was provided in four sessions over approximately 4 weeks, supported by an assistant psychologist or clinical psychologist. Trial assessors were masked to group allocation. Outcomes were assessed at 0, 2 (therapy mid-point), 4 (primary endpoint, end of treatment), 8, 16, and 24 weeks. The primary outcome was persecutory delusion conviction, assessed by the Psychotic Symptoms Rating Scale (PSYRATS; rated 0–100%). Outcome analyses were done in the intention-to-treat population. We assessed the treatment credibility and expectancy of the interventions and the two mechanisms (defence behaviours and safety beliefs) that the cognitive intervention was designed to target. This trial is prospectively registered with the ISRCTN registry, ISRCTN12497310. Findings From Sept 21, 2018, to May 13, 2021 (with a pause due to COVID-19 pandemic restrictions from March 16, 2020, to Sept 14, 2020), we recruited 80 participants with persistent persecutory delusions (49 [61%] men, 31 [39%] women, with a mean age of 40 years [SD 13, range 18–73], 64 [80%] White, six [8%] Black, one [1%] Indian, three [4%] Pakistani, and six [8%] other race or ethnicity). We randomly assigned 39 (49%) participants assigned to VR cognitive therapy and 41 (51%) participants to VR mental relaxation. 33 (85%) participants who were assigned to VR cognitive therapy attended all four sessions, and 35 (85%) participants assigned to VR mental relaxation attended all four sessions. We found no significant differences between the two VR interventions in participant ratings of treatment credibility (adjusted mean difference –1·55 [95% CI –3·68 to 0·58]; p=0·15) and outcome expectancy (–0·91 [–3·42 to 1·61]; p=0·47). 77 (96%) participants provided follow-up data at the primary timepoint. Compared with VR mental relaxation, VR cognitive therapy did not lead to a greater improvement in persecutory delusions (adjusted mean difference –2·16 [–12·77 to 8·44]; p=0·69). Compared with VR mental relaxation, VR cognitive therapy did not lead to a greater reduction in use of defence behaviours (adjusted mean difference –0·71 [–4·21 to 2·79]; p=0·69) or a greater increase in belief in safety (–5·89 [–16·83 to 5·05]; p=0·29). There were 17 serious adverse events unrelated to the trial (ten events in seven participants in the VR cognitive therapy group and seven events in five participants in the VR mental relaxation group). Interpretation The two VR interventions performed similarly, despite the fact that they had been designed to affect different mechanisms. Both interventions had high uptake rates and were associated with large improvements in persecutory delusions but it cannot be determined that the treatments accounted for the change. Immersive technologies hold promise for the treatment of severe mental health problems. However, their use will likely benefit from experimental research on the application of different therapeutic techniques and the effects on a range of potential mechanisms of action.
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Racialised minority women's experiences of psychological intervention across perinatal and maternal mental health services.Policies such as The Perinatal Mental Health Care Pathways document (2018) state mothers and birthing people experiencing psychological difficulties should have timely access to evidence-based psychological therapies. However, psychological distress often goes unidentified in racialised minority women and birthing people who have poorer experiences and outcomes within perinatal contexts compared to White women. Whilst limited research has focused on this within the perinatal period, there is greater recognition concerning how culturally sensitive practices can facilitate equity in care outcomes. This service evaluation aimed to explore racialised minority women's experiences of psychological intervention within a Perinatal and a Maternal Mental Health Service to evaluate service provision and inform service development. Semi-structured interviews with eight women who accessed psychological intervention were analysed using thematic analysis. Two superordinate themes were constructed, with findings suggesting participants had mostly positive experiences of psychological intervention. Cornerstones of therapeutic engagement comprised six subthemes: empathy, flexibility, the utility of psychological approaches, acknowledging family and community systems, points of difference and cultural context as a 'spotlight'. This theme encapsulated psychological therapist's relational and interventional approaches alongside participant preferences which influenced intervention experiences. Therapists were generally experienced as empathic and flexible although some participants desired greater flexibility relating to various practical aspects. Psychological approaches were experienced as beneficial although some wanted greater exploration of childhood trauma and found trauma-focused CBT emotionally demanding. Most participants preferred female therapists due to various socio-cultural reasons and felt systemic factors and their cultural context were acknowledged which enhanced the therapeutic relationship and outcomes where relevant with the inverse also apparent. History repeating itself comprised three subthemes (lack of representation, mistrust of the system and disorientation in help-seeking). This reflected mainly Black participants' negative healthcare experiences and structural racism. Therapeutic and organisational implications are discussed. Copyright © 2024, British Psychological Society. All rights reserved.
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What racialised aspiring clinical psychologists need from a mentoring schemeIt has been long recognised that there is an increased gap between the application and acceptance rates of racialised applicants to clinical psychology training in the UK, relative to White applicants. In 2020, Health Education England released funding for UK training programmes to develop mentoring schemes for aspiring clinical psychologists from racialised groups. This study was undertaken to explore how such mentoring schemes might best support racialised applicants. Three focus groups, comprising a total of 24 racialised aspiring, trainee, and qualified clinical psychologists, were undertaken to gather views regarding how a mentoring scheme could support racialised aspiring clinical psychologists. Data was analysed utilising reflexive thematic analysis. Three themes were developed: ‘Gaining Access to a White Profession – What’s the White thing to say?’ captured participants’ views that mentoring schemes should support mentees to present themselves in ways that fit with what selection assessors will be looking for. ‘A Safe Space to Explore the Impact of Racialisation’ related to the importance of mentoring schemes creating safe opportunities to make sense of the impact of racism within their career. ‘Troubling Whiteness’ spoke to the importance of mentees being empowered to think with other racialised individuals about ways they could actively address Whiteness within the profession and services. The three themes have implications for the delivery and evaluation of mentoring schemes for racialised aspiring clinical psychologists.
