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  • Sex differences in attention-deficit hyperactivity disorder diagnosis and clinical care: A national study of population healthcare records in Wales

    Sayal, Kapil (2024)
    BACKGROUND: Population-based studies have observed sex biases in the diagnosis and treatment of attention-deficit hyperactivity disorder (ADHD). Females are less likely to be diagnosed or prescribed ADHD medication. This study uses national healthcare records, to investigate sex differences in diagnosis and clinical care in young people with ADHD, particularly regarding recognition and treatment of other mental health conditions. METHODS: The cohort included individuals diagnosed with ADHD, born between 1989 and 2013 and living in Wales between 2000 and 2019. Routine primary and secondary healthcare record data were used to derive diagnoses of ADHD and other neurodevelopmental and mental health conditions, as well as ADHD and antidepressant medications. Demographic variables included ethnicity, socioeconomic deprivation and contact with social services. RESULTS: There were 16,458 individuals diagnosed with ADHD (20.3% females, ages 3-30 years), with a male-to-female ratio of 3.9:1. Higher ratios (4.8:1) were seen in individuals diagnosed younger (<12 years), with the lowest ratio (1.9:1) in those diagnosed as adults (>18). Males were younger at first recorded ADHD diagnosis (mean = 10.9 vs. 12.6 years), more likely to be prescribed ADHD medication and younger at diagnosis of co-occurring neurodevelopmental conditions. In contrast, females were more likely to receive a diagnosis of anxiety, depression or another mental health condition and to be prescribed antidepressant medications, prior to ADHD diagnosis. These sex differences were largely stable across demographic groups. CONCLUSIONS: This study adds to the evidence base that females with ADHD are experiencing later recognition and treatment of ADHD. The results indicate that this may be partly because of diagnostic overshadowing from other mental health conditions, such as anxiety and depression, or initial misdiagnosis. Further research and dissemination of findings to the public are needed to improve awareness, timely diagnosis and treatment of ADHD in females.
  • Scalability, test-retest reliability and validity of the Brief INSPIRE-O measure of personal recovery in psychiatric services

    Slade, Mike (2024)
    INTRODUCTION: Mental health services have transitioned from treating symptoms to emphasizing personal recovery. Despite its importance, integrating personal recovery into clinical practice remains work in progress. This study evaluates the psychometric qualities of the Brief INSPIRE-O, a five-item patient-reported outcome measure assessing personal recovery. METHOD: The study collected data from 2018 to 2020 at the Mental Health Services, Capital Region of Denmark, using an internet-based system examining 8,192 non-psychotic patients - receiving outpatient treatment. MATERIALS: This study evaluated the Brief INSPIRE-O and used measures of symptomatology (SCL-10), well-being (WHO-5), and social functioning (modified SDS). RESULTS: The study population comprised 76.8% females with a mean age of 32.9 years, and diagnoses included anxiety (28%), depression (34%), and personality disorder (19%). The mean Brief INSPIRE-O score (39.9) was lower than the general population norm (71.1). The Brief INSPIRE-O showed acceptable test-retest reliability (0.75), scalability (0.39), and internal consistency (0.73). Correlations with other mental health criteria were in the expected direction for symptomatology (-0.46), well-being (0.60), and social functioning (-0.43) and remained consistent across diagnoses. DISCUSSION: The Brief INSPIRE-O demonstrated strong psychometric qualities and could be recommended as a measure of personal recovery for use in both research and clinical practice. Its strong theoretical basis and short completion time make it suitable for use for research. Incorporating Brief INSPIRE-O into clinical assessment will further support the process of mental health systems re-orientating towards personal recovery.
  • Population attributable fractions of modifiable risk factors for dementia: A systematic review and meta-analysis

    Stephan, Blossom C.; Cochrane, Louie; Kafadar, Aysegul H.; Brain, Jacob (2024)
    BACKGROUND: More than 57 million people have dementia worldwide. Evidence indicates a change in dementia prevalence and incidence in high-income countries, which is likely to be due to improved life-course population health. Identifying key modifiable risk factors for dementia is essential for informing risk reduction and prevention strategies. We therefore aimed to estimate the population attributable fraction (PAF) for dementia associated with modifiable risk factors. METHODS: In this systematic review and meta-analysis, we searched Embase, MEDLINE, and PsycINFO, via Ovid, from database inception up to June 29, 2023, for population-derived or community-based studies and reviews reporting a PAF value for one or more modifiable risk factor for later-life dementia (prevalent or incident dementia in people aged ≥60 years), with no restrictions on dementia subtype, the sex or baseline age of participants, or the period of study. Articles were independently screened for inclusion by four authors, with disagreements resolved through consensus. Data including unweighted and weighted PAF values (weighted to account for communality or overlap in risk) were independently extracted into a predefined template by two authors and checked by two other authors. When five or more unique studies investigated a given risk factor or combination of the same factors, random-effects meta-analyses were used to calculate a pooled PAF percentage estimate for the factor or combination of factors. The review protocol was registered on PROSPERO, CRD42022323429. FINDINGS: 4024 articles were identified, and 74 were included in our narrative synthesis. Overall, PAFs were reported for 61 modifiable risk factors, with sufficient data available for meta-analysis of 12 factors (n=48 studies). In meta-analyses, the highest pooled unweighted PAF values were estimated for low education (17·2% [95% CI 14·4-20·0], p<0·0001), hypertension (15·8% [14·7-17·1], p<0·0001), hearing loss (15·6% [10·3-20·9], p<0·0001), physical inactivity (15·2% [12·8-17·7], p<0·0001), and obesity (9·4% [7·3-11·7], p<0·0001). According to weighted PAF values, low education (9·3% [6·9-11·7], p<0·0001), physical inactivity (7·3% [3·9-11·2], p=0·0021), hearing loss (7·2% [5·2-9·7], p<0·0001), hypertension (7·1% [5·4-8·8], p<0·0001), and obesity (5·3% [3·2-7·4], p=0·0001) had the highest pooled estimates. When low education, midlife hypertension, midlife obesity, smoking, physical inactivity, depression, and diabetes were combined (Barnes and Yaffe seven-factor model; n=9 studies), the pooled unweighted and weighted PAF values were 55·0% (46·5-63·5; p<0·0001) and 32·0% (26·6-37·5; p<0·0001), respectively. The pooled PAF values for most individual risk factors were higher in low-income and middle-income countries (LMICs) versus high-income countries. INTERPRETATION: Governments need to invest in a life-course approach to dementia prevention, including policies that enable quality education, health-promoting environments, and improved health. This investment is particularly important in LMICs, where the potential for prevention is high, but resources, infrastructure, budgets, and research focused on ageing and dementia are limited. FUNDING: UK Research and Innovation (Medical Research Council).
  • A short-term “behavioural support” service for autistic adults without an intellectual disability: a pilot evaluation

    Clifford, Adam; Camps, Deena (2024)
    Purpose A region’s transforming care partnership identified that autistic adults without an intellectual disability (ID) may be falling through gaps in services when presenting with a significant emotional and/or behavioural need in the absence of a mental health diagnosis. The region’s intensive support teams (ISTs) for adults with ID therefore piloted a short-term “behavioural support service” for this population. The purpose of this paper is to evaluate this pilot. Design/methodology/approach This study represents a mixed-methods service evaluation over a four year pilot period. The quantitative component examined referral rates and demographic data of accepted and declined referrals; and length of referral episodes and Health of The Nation Outcomes Scores (HoNOS) for accepted referrals. The qualitative component used thematic analysis to identify key themes relating to reasons for referral, clinical/therapeutic needs, and the models of support that most informed assessments and interventions at individual and systems levels. Findings The ISTs accepted 30 referrals and declined 53. Most accepted referrals were male (83%), and under 24 years old (57%). Average HoNOS scores were above the thresholds generally associated with hospital admission. Key qualitative themes were: transitional support; sexual risks/vulnerabilities; physical aggression; domestic violence; and attachment, trauma and personality difficulties. Support mostly followed psychotherapeutic modalities couched in trauma, attachment and second- and third-wave cognitive behavioural therapies. Positive Behaviour Support (PBS) did not emerge as a model of preference for service users or professionals. Originality/value This project represents one of the first of this type for autistic adults without an ID in the UK. It provides recommendations for future service development and research, with implications for Transforming Care policy and guidance.
  • Commentary on “Stakeholder experiences of deprescribing psychotropic medicines for challenging behaviour in people with intellectual disabilities”

    Clifford, Adam; Omokanye, Mariam; Bagalkote, Deval (2024)
    Purpose This paper aims to provide a commentary response to “Stakeholder experiences of deprescribing psychotropic medicines for challenging behaviour in people with intellectual disabilities”. Design/methodology/approach The commentary provides some evidence-based perspectives on the risks and challenges of psychiatric drug-withdrawal, emphasising the importance of the patient experience in deprescribing decisions. It also makes the case for clinical clarity and carer-engagement in optimising deprescribing outcomes for individuals. Some clinical reflections are provided. Findings Whilst efforts to reduce the overmedication of people with learning disabilities are welcomed, there is lacking evidence around this population’s experience of adverse effects from psychiatric deprescribing decisions, including differentiating between withdrawal and relapse effects. Clinical clarity and carer engagement are key to safe and effective prescribing, although in reality, this can be challenging. Originality/value This paper will be of value to all professionals with a role in the effective deprescribing of psychiatric medications with and/or for people with intellectual disability. It provides perspectives on aspects of stakeholder experience that warrant further consideration and research.
  • Forensic mental health: Envisioning a more empirical future [In press]

    Tully, John; Whiting, Daniel (2024)
    Summary Forensic mental health services provide crucial interventions for society. Such services provide care for people with mental disorders who commit violent and other serious crimes, and they have a key role in the protection of the public. To achieve these goals, these services are necessarily expensive, but they have been criticised for a high-cost, low-volume approach, for lacking consistent standards of care, and for neglecting human rights and other ethical considerations. A key concern is an insufficient evidence base to justify common practices, such as restricting leave from hospital and detaining patients for long periods. There is also insufficient quality evidence for core interventions, including psychological therapies, pharmacotherapy, and seclusion and restraint. The causes for this evidence deficit are complex but include insufficient investment in research infrastructure and fragmentation and isolationism of services, both nationally and internationally. In this Personal View, we highlight some of the major gaps in the forensic mental health evidence base and the challenges in addressing these gaps. We suggest solutions with implications at clinical, societal, and public health policy levels.
  • Patient participation in mental health care - perspectives of healthcare professionals and patients: A scoping review

    Watson, Emma (2024-06-20)
    AIM: This scoping review aims to synthesize findings from fourteen selected articles to provide a comprehensive understanding of patient participation in mental healthcare. METHOD: The review analyzed articles employing various qualitative methodologies, including interviews and observations, to explore patient and healthcare professional perspectives. Articles were selected based on their relevance to the topic of patient participation in mental health care. RESULTS: The analysis revealed diverse perspectives on patient participation. Patients' preferences varied, with some preferring shared decision-making while others preferred minimal involvement. Barriers to shared decision-making included fear of judgment and substance misuse concerns. Strategies to manage disagreements and foster trusting relationships were identified. Challenges in implementing patient and public involvement in mental health services were noted, including stigma and inadequate professional training. Interprofessional collaboration was deemed fundamental, although fragmented care pathways and communication breakdowns persisted. Structural conditions and professional expectations significantly influenced patient participation, with a paternalistic approach perpetuating power imbalances. CONCLUSION: Despite challenges, the findings underscored the importance of empowering patients in treatment decision-making, promoting collaborative relationships, and addressing barriers to enhance patient-centered care in mental health settings. Insights from this review contribute to the discourse on patient-centered care, emphasizing the need for holistic approaches prioritizing patient dignity and well-being.
  • Magnetic resonance imaging connectivity features associated with response to transcranial magnetic stimulation in major depressive disorder

    Briley, Paul M.; Webster, Lucy; Liddle, Peter F.; Morriss, Richard K. (2024-06-17)
    Transcranial magnetic stimulation (TMS) is an FDA-approved neuromodulation treatment for major depressive disorder (MDD), thought to work by altering dysfunctional brain connectivity pathways, or by indirectly modulating the activity of subcortical brain regions. Clinical response to TMS remains highly variable, highlighting the need for baseline predictors of response and for understanding brain changes associated with response. This systematic review examined brain connectivity features, and changes in connectivity features, associated with clinical improvement following TMS in MDD. Forty-one studies met inclusion criteria, including 1097 people with MDD. Most studies delivered one of two types of TMS to left dorsolateral prefrontal cortex and measured connectivity using resting-state functional MRI. The subgenual anterior cingulate cortex was the most well-studied brain region, particularly its connectivity with the TMS target or with the "executive control network" of brain regions. There was marked heterogeneity in findings. There is a need for greater understanding of how cortical TMS modulates connectivity with, and the activity of, subcortical regions, and how these effects change within and across treatment sessions.
  • Inclusivity and decolonisation of the post-graduate public health curriculum: Reflections from a student-led approach

    Bethea, Jane (2024)
    The future of successful public health practice requires public health students to be educated within a decolonised curriculum that challenges the historical biases and inequalities that are deeply embedded within global public health and society. In this commentary, we reflect on what it can mean and why it's important to decolonise and diversify a public health curriculum. We describe how we used a student-led approach to begin this process, and share recommendations that are applicable to national and international curricula.
  • Identification of youth at clinical high-risk for psychosis: A community-based study from India

    Katshu, Mohammad Z. (2024-05-28)
    AIM: A two-stage process, wherein self-report screening precedes the structured interview, is suggested for identifying individuals at clinical high-risk for psychosis (CHR-P) in community samples. Aim of this study was to screen a community youth sample from India for CHR-P using the two-stage method. Specific objectives were to assess concordant validity of the self-report measure and predictive validity of the two-stage method. METHODS: Based on probability sampling, 2025 youth aged 15-24 years were recruited from one rural and one urban area of Telangana, a Telugu-speaking state in India. Telugu version of the PRIME Screen-Revised (PS-R) and structured interview for psychosis-risk syndromes (SIPS) were used. CHR-P positive and negative cohorts were followed-up for transition to psychosis at 3-monthly intervals. RESULTS: One hundred ten individuals screened positive on PS-R. SIPS conducted on 67 out of 110 individuals confirmed 62 (92.54%) to be CHR-P positive. PS-R showed 98.41% sensitivity and 90.74% specificity. Among CHR-P positive, three participants transitioned to psychosis in 15 months. The hazard ratio for psychosis transition was 11.4. CONCLUSIONS: Screening accuracy of PS-R in the community youth sample in Telangana is optimum. The hazard ratio for psychosis transition in the community identified CHR-P indicates good predictive validity for the two-stage method.
  • Exploring access to support services for medical students: Recommendations for enhancing wellbeing support

    Hawsawi, Aisha A; Nixon, Neil L.; Stewart, Emily; Nixon, Elena (2024)
    BACKGROUND: Medical students have reported facing unique challenges in their academic journey that can have a significant impact on their mental health and wellbeing; therefore, their access to support services and wellbeing resources has been deemed crucial for dealing effectively with the various challenges they tend to face. While previous research has highlighted certain barriers affecting medical students' help-seeking and access to wellbeing support more generally, there is a pressing need for more in-depth research into the factors that may hinder or facilitate medical students' acceptability and uptake of the wellbeing resources available to them within institutional contexts. The current study aims to explore students' perceptions and utilization of wellbeing interventions and welfare resources within a medical school setting, as well as the factors influencing their help-seeking attitudes or behaviours. Additionally, it seeks to instigate medical students' deeper reflections on potential enhancements that could be applied to wellbeing resources so that they are better suited to address their needs. METHODS: This study employed a qualitative design, involving semi-structured interviews and a series of focus groups with medical students at the University of Nottingham (UK). Post-interview, focus groups were deemed necessary to gain deeper insights into emerging findings from the interviews regarding students' views on wellbeing support services. Qualitative data from the interviews was subjected to thematic analysis while a hybrid thematic analytic approach was applied for the focus group data in order to allow for both pre-defined themes from the interviews and newly emerging patterns to be identified and analysed in a combined manner. RESULTS: Twenty-five participants took part in the semi-structured interviews and twenty-two participants were recruited in a total of seven focus groups. Thematic analysis findings identified several key barriers to medical students' accessing wellbeing resources, including difficulties in finding relevant information, lengthy processes and difficulties receiving prompt help in urgent situations, learning environment issues, confidentiality concerns, and stigma around mental health. Student suggestions for the enhancement of wellbeing provision were centered around proposed improvements in the format that the relevant information was presented and in the structure underlying the delivery of support services. CONCLUSION: The study findings shed light on multi-faceted factors contributing to medical students' challenges in accessing support services; and provided a deeper understanding of medical students' wellbeing needs through a consolidation of their recommendations for the implementation of practical steps to address these needs. These steps can potentially inform key medical education stakeholders so that they can actively and proactively foster more supportive environments that may help improve medical students' help-seeking, as well as their acceptability and uptake of wellbeing services.
  • Experience of CBT in adults with ADHD: A mixed methods study

    Horrocks, Matthew; Hall, Charlotte L.; French, Blandine (2024)
    INTRODUCTION: The National Institute for Health and Care Excellence (NICE) recommends Cognitive-Behavioural therapy (CBT) as the psychotherapeutic treatment of choice for adults with Attention Deficit Hyperactivity Disorder (ADHD) in the UK. However, the literature often refers to adapted CBT programs tailored for ADHD and provides limited insight into how adults with ADHD experience and perceive this form of treatment in routine clinical practice. METHODS: This mixed-methods study aims to explore ADHD individuals' experience and perception of CBT delivered in routine clinical practice, to gain a better understanding of this treatment's helpfulness and perceived effectiveness. RESULTS: A survey (n=46) and semi-structured in-depth interviews (n=10) were conducted to explore the experience of CBT and its perceived effectiveness in managing ADHD. The interviews were analysed using thematic analysis and the survey was synthesised using descriptive narratives. The thematic analysis highlighted three key themes: difficulties with the CBT framework, difficulties with CBT therapists, and consequences of CBT. The survey highlighted similar findings. Participants described the CBT framework as, generic, rigid, and too short, and described the CBT therapist as unspecialised, unempathetic, and not sufficiently adapting CBT to ADHD-related difficulties. DISCUSSIONS: Overall, participants found non-adapted, generic CBT in the UK to be unhelpful, overwhelming, and at times harmful to their mental well-being. Therefore, it is necessary for clinical bodies in the UK, while following the indicated NICE guidelines, to be mindful of adapting CBT delivery of CBT, to be most effective for people with ADHD and to mitigate potential harm.
  • Effective induction of higherspecialist trainees in Nottinghamshire Healthcare NHS Foundation Trust

    Nisa, Zaib; Krishnan, Deepa B.; Junaid, Kehinde; Lankappa, Sudheer; Clarke, Tracey (2024)
    Introduction An effective induction is a crucial welcome for trainees. When done well, it will encourage them to utilise many learning opportunities available and ensure a smooth and supported transition to working in a complex, unfamiliar environment. (GMC Report 2020) Effective induction improves trainees’ satisfaction, performance, mental health, attendance, and they will feel welcomed and valued. Make clinical errors less likely which in turn improves patient safety. Increase retention and recruitment. Background I started my higher specialist training in General Adult Psychiatry in Nottingham (East Midlands Deanery) in August 2021 and there was no trust induction organised for HSTs. Having completed my Core Psychiatry training in a different Deanery, I was new to the Trust and the Deanery. Being new to the trust, remote working during the pandemic and no formal trust induction on the top meant that several higher trainees felt isolated and unsupported. I raised these concerns and shared the challenges with my Educational Supervisor who suggested that I lead on a QI project to improve the induction process for Higher trainees. Aims and objectives of the research project or activity To set up an effective Induction programme for future Higher Specialist Trainees in Nottinghamshire Healthcare NHS Foundation Trust. Method or approach I started with scoping exercise and reviewed the literature and policies around induction and found a key report from the General Medical Council (GMC) published in June 2020. I discussed my project idea with Dr Kehinde Junaid (DME) and Dr Deepa Krishnan (Consultant Psychiatrist, QSIR Associate) who agreed to supervise me and provide supervision with QI methodology. I carried out a stakeholder analysis and after discussion with medical education department, medical staffing and DME it was agreed to set up an Induction Programme in collaboration with all stakeholders. Following the initial stakeholder analysis, I devised a survey based on the GMC (2020) report. Survey was sent to all the HSTS working in the trust and mixed methods (qualitative & quantitative) approach was used. Findings After group and individual emails and multiple reminders, 50% of total HSTs completed the survey in 2021. Overall, the results of the 2021 survey showed very poor satisfaction and most trainees said they didn’t receive any induction. 50%-90% of HSTs did not receive information in 2021, in most of the key areas even after one month of starting work. Several consultation meetings were held with stakeholders between May to July 2022 to plan changes. Two key deliverables were agreed: Induction Booklet (delivered through this current project, I updated the original induction booklet offered to core trainees, FY and GPST doctors. I added sections relevant to higher trainees in close discussion and collaboration with medical education & medical staffing) A bespoke induction for higher trainees (Although this was delivered by Medical Education & medical staffing team, I played a crucial role in ensuring that there is a trainee voice in designing the agenda for the induction programme) New Induction plan implemented in August 2022. I carried out a post-implementation survey to assess impact of change. Results of survey showed improvements in all areas of induction. I have presented the comparative results of induction surveys in 2021 and 2022, to stakeholders and it was agreed: To continue with bespoke induction programme for higher specialist trainees (led by medical education and medical staffing) To update Induction Booklet (due to some changes in trust sites, trust leads and areas to be covered during on-calls). Revised Induction plan was implemented in Aug 2023. Key messages Leading this project has helped me: To learn about QI project management & the importance of early stakeholder engagement for a sustainable change. To make an improvement in important skills such as communication, team working, leadership and management. In organising a sustainable induction programme along with induction booklet for future HSTs. Attaining DrQI training from our trust QI team. Next steps are are reviewing this year’s post implementation survey results and sharing these with stakeholders to plan changes accordingly for induction programme in future.
  • Characterising illness stages and recovery trajectories of eating disorders in young people via remote measurement technology (STORY): A multi-centre prospective cohort study protocol

    McDonald, Sarah; Staton, Amelia (2024)
    BACKGROUND: Eating disorders (EDs) are serious, often chronic, conditions associated with pronounced morbidity, mortality, and dysfunction increasingly affecting young people worldwide. Illness progression, stages and recovery trajectories of EDs are still poorly characterised. The STORY study dynamically and longitudinally assesses young people with different EDs (restricting; bingeing/bulimic presentations) and illness durations (earlier; later stages) compared to healthy controls. Remote measurement technology (RMT) with active and passive sensing is used to advance understanding of the heterogeneity of earlier and more progressed clinical presentations and predictors of recovery or relapse. METHODS: STORY follows 720 young people aged 16-25 with EDs and 120 healthy controls for 12 months. Online self-report questionnaires regularly assess ED symptoms, psychiatric comorbidities, quality of life, and socioeconomic environment. Additional ongoing monitoring using multi-parametric RMT via smartphones and wearable smart rings ('Ōura ring') unobtrusively measures individuals' daily behaviour and physiology (e.g., Bluetooth connections, sleep, autonomic arousal). A subgroup of participants completes additional in-person cognitive and neuroimaging assessments at study-baseline and after 12 months. DISCUSSION: By leveraging these large-scale longitudinal data from participants across ED diagnoses and illness durations, the STORY study seeks to elucidate potential biopsychosocial predictors of outcome, their interplay with developmental and socioemotional changes, and barriers and facilitators of recovery. STORY holds the promise of providing actionable findings that can be translated into clinical practice by informing the development of both early intervention and personalised treatment that is tailored to illness stage and individual circumstances, ultimately disrupting the long-term burden of EDs on individuals and their families.
  • Elderly offenders at Wathwood Hospital: perspectives and practicalities

    Chaudhry, Sidra; Hayes, Gwilym D. (2021)
    Aims. The following project explores where Wathwood Hospital stands in provision of services to its elderly patients. Background. The only dedicated forensic medium secure unit for elderly offenders in England is the St. Andrews medium secure unit in Northampton with only 17 beds. Due to the limited beds, other units must accommodate elderly patients, which raises the question whether these units can provide the appropriate services for this very vulnerable population. Method. Inclusion Criteria: Male >55 years of age Admitted from 2012 onwards (from when database was maintained) Data were gathered using patient electronic records including index offence, mental disorder, physical health comorbidities and discharge destinations. Patient identifiable data were anonymized to protect their identities. A staff survey was also conducted to find their perspective on managing elderly patients and whether Wathwood Hospital had the appropriate resources for elderly offenders in their area of work. Result. A total of 220 referrals were searched with only 9 patients >55 years. Index offenses, mental disorder diagnoses, physical comorbidities including cognitive assessments in the form of memory tests and brain imaging were also collated for identified patients from electronic patient records. Index offences included violence against person, arson, homicide, robbery, threatening behaviour and dangerous driving and affray. Diagnoses included learning disability, delusional disorder, paranoid schizophrenia, bipolar affective disorder, alcohol dependence, personality disorder and depressive disorder. Patients had multiple comorbidities such as diabetes, COPD, hypertension, coronary artery disease and musculoskeletal problems. Out of the nine admitted patients, only six had an ACE with an average score of 70.83. Five patients had brain imaging, with two normal results and the others showing some degree of atrophy and ischemic changes. Discharge destinations included medium secure units, low secure unit and prison. One patient unfortunately died during admission and four are still inpatients. A staff survey conducted showed their perspective on the challenges in managing elderly patients and whether Wathwood Hospital had the appropriate resources for them to work with elderly offenders in their area of work. All results will be explained through tables and graphs. Conclusion. It's evident that there are challenges in managing elderly patients in units not specifically designed to manage them. This is also due to the lack of geriatric training and resources available to allied health care professionals to carry out their respective work. It's therefore crucial we formulate more inclusive strategies to address these challenges.
  • Impact of community treatment orders on inpatient bed usage in assertive outreach team

    Iheonu, Chinyere (2021)
    Aims. To examine the impact of using Communty Treatment Orders (CTO) of the Mental Health Act on use of inpatient care in Assertive Outreach team. Background. Currently there is little evidence of the efficacy of community treatment orders (CTOs), and in particular with patients who use the Assertive Outreach service. One large randomised controlled study found no impact on use of inpatient care while a naturalistc study found significant impact. Method. Our primary outcome was the number of admissions with and without a CTO comparing each patient with themselves before CTO and under CTO( mirror-image ). Our secondary outcomes were the number of bed days, and the percentage of missed community visits post-discharge. We also looked at the potential cost savings of a reduction in inpatient bed usage. Result. All the 63 patients studied over period of 6 years had a severe and enduring mental illness. The use of a CTO was linked to a significant reduction in the number of admissions (mean difference = 0.89, 95% CI = 0.53-1.25, P < 0.0001) and bed days (mean difference = 158.65, 95% CI = 102.21-215.09, P < 0.0001) There was no significant difference in the percentage of missed community visits post-discharge. Looking at the costs, an average cost for an inpatient Assertive Outreach bed per day in the local Trust was 250, and there were 8145 bed days saved in total, making a potential saving of just over 2million, during the study period. Conclusion. This study suggests that the implementation of CTOs using clinical judgment and knowledge of patients can significantly reduce the bed usage of Assertive Outreach patients. The financial implications of CTOs need to be reviewed further, but this study does suggest that the implementation of CTOs is a cost-effective intervention and is economically advantageous to the local Trust.
  • The improvement of the quality of medical reviews of patients in seclusion in Rampton Hospital

    McPhail, Emma (2021-06-21)
    Aims. Improve and standardise the quality of medical seclusion reviews (MSRs). Acknowledge existing good practise. Highlight areas for improvement. Improve the awareness of doctors performing MSRs of the requirements in the Mental Health Act Code of Practice (MHA CoP) Background. MSRs are an essential clinical tool to ensure safe and consistent patient care. Patients detained in seclusion can be at heightened risk of poor mental and physical health, in addition to being a risk to themselves and others. There is clear guidance in the MHA CoP regarding what areas require to be covered in a MSR. Method. A retrospective audit of all MSRs in September 2019 across all patients within all directorates within Rampton Hospital was undertaken. 281 inpatients were identified within Rampton Hospital, and 61 of these patients were found to have had seclusion in September 2019. A total of 439 MSRs were identified for these patients. The standard applied was the MHA CoP guidance for MSRs: 1) MSRs should be conducted in person, and should include: 2) Review of physical health 3) Review of psychiatric health 4) Assessment of the adverse effects of medication 5) Review of observations required 6) Reassessment of medication prescribed 7) Assessment of the patient's risk to others 8) Assessment of the patient's risk of self-harm 9) Assessment of the need for continuing seclusion 100% compliance with targets or a reason why it was not possible was expected to be documented. Result. The results show there is a large variation in compliance with the MHA CoP. The area with the highest compliance was the completion of reviews in person-(99.3%). The criterion with the average worst compliance was whether the need for physical observations was reviewed-(4.3%). Physical health was reviewed in 86.1% of cases, in contrast to psychiatric health at 38.3%. The adverse effects of medication and reassessment of medication prescribed were recorded in only 8.9%. The risk from the patient to others was recorded in 25.3%, whereas risk to self was recorded in 10.7%. The need for continuing seclusion was recorded in 72.7%. Conclusion. The quality of MSRs at Rampton Hospital is currently inadequate. Improvement in practice is required to meet accepted standards and ensure safe, consistent patient care. Ways to improve this are being considered, including improving the knowledge of the MHA CoP and providing a MSR template.
  • Anxiety levels during COVID 19 pandemic in primary and secondary doctors in UK

    Mittal, Shweta (2021)
    Aims. The study aims to examine the severity of anxiety in primary and secondary doctors in the UK during first wave of COVID-19 pandemic. Method. An online General Anxiety Disorder-7 (GAD7) survey was distributed during the first wave of COVID-19 pandemic (April-May 2020) to doctors in primary and secondary care in the UK. Seven closed-ended questions were included in the questionnaire. Respondents were to indicate how frequently they experienced specific issues in the previous fortnight: Feeling nervous, anxious, or on edge; being unable to stop or control worrying; worrying too much generally; trouble relaxing; being so restless that it's hard to sit still; becoming easily annoyed or irritable, feeling afraid of something awful happening. Participants were required to tick one of four choices for each of the seven parameters - not at all (0), several days (1), more than half the days (2) and nearly every day (3). A person with minimal or no anxiety will score less than 5. The survey was anonymous and circulated in professional online doctors' forums. Participation was voluntary and no incentives were given. Result. 273 completed surveys were received; 120 doctors were in primary care and 153 were in secondary care. Average GAD7 score was 6.4 in primary care and 7.9 in secondary care. 57% of primary care doctors and 66% of secondary care doctors reported score of 5 or more, representing at least mild anxiety symptoms. 22% doctors in primary care and 31% doctors in secondary care reported GAD7 score of 10 or more, indicating moderate to severe anxiety. One in ten doctors in both primary and secondary care reported severe anxiety due to the ongoing COVID-19 pandemic. Conclusion. The finding of more anxiety in secondary care doctors might be because general practitioners could resort early in the pandemic to remote consultations along with inadequacy of resources, greater exposure to suffering/deaths of patients and colleagues in hospital and perceived risk of catching COVID-19 infection. Results are limited due to relatively low numbers and it would be useful to replicate this study on a larger scale. Doctors are less likely to acknowledge their mental health difficulties due to stigma associated with mental health. Many employers have psychological support systems in place for their staff, but it is questionable if affected individuals are willing to receive this support. This paper; therefore, calls for creating open anonymous platforms for professionals to get access to appropriate support to address their anxiety.
  • Core psychiatry trainees views on MRCPsych course structure and delivery at East Midlands Deanery

    Yanson, Ian J. (2021)
    Aims. The RCPsych curriculum for core training in Psychiatry (2013) requires each Deanery to run regional MRCPsych teaching programme. The East Midlands School of Psychiatry run a local MRCPsych course aimed at all core psychiatry trainees in the deanery. Before the pandemic, the course took place between two venues - Nottingham and Leicester. During the pandemic, the course was delivered via Microsoft teams. We aimed to collect the feedback from trainees regarding the course to help shape the MRCPsych Course programme according to their training needs. Method. We devised an online Microsoft forms questionnaire which included: Level of training Number of exams passed Relevance of MRCPsych content to clinical practice and membership exam Usefulness of mock exams, simulation scenarios and workshops towards clinical and exam practice Overall experience of the course Which additional sessions they would like to be included The effect of COVID-19 on their ability to attend in MRCPsych programme These forms were sent to all the trainees in the region via email. Result. Out of 44 trainees, 9 responded. 66.6% of the trainees who responded were CT1 and 33.3% CT2. 45% had passed Paper A and 55% had not passed any exams. 78% of them agreed and 11% strongly agreed that course was relevant to the clinical practice. 55.6% agreed that course was relevant to membership course. 44.4% agreed and 11% strongly agreed that mock exams were useful. 66.7% agreed and 11% strongly agreed that simulation case scenarios and workshops were useful for exam and clinical practice. 22.2% strongly agreed and 33.3% agreed that sessions were engaging and motivating. Overall experience of MRCPsych exam was rated as excellent (11%), good (55%), satisfactory (22%) and poor (11%). Suggestions to add additional sessions included antiracism in psychiatry, more mock exams, practical management of cases, to organise more interactive sessions on Microsoft teams, in-depth coverage of exam topics, to organise full day teaching sessions instead of half day. 33.3% of trainees commented that COVID-19 had impacted on their ability to attend the exam as initially face to face sessions were cancelled till end of May 2020 and when started there were technical issues with the online platform Conclusion. Consider feedback received in modifying aspects of the MRCPsych course To share the results with trainers and course tutors Arrange relevant mock exam sessions Include the topics suggested by trainees and improve the experience of online learning by making it more interactive Limitations: small sample size.
  • A service evaluation of the national high secure deaf in-reach service

    Kaler, Gurpreet (2022)
    Aims. The National High Secure Deaf Service at Rampton Hospital provides inpatient assessment, treatment and rehabilitation for D/deafz* males living with a range of difficulties including complex responses to trauma, mental health difficulties and/or learning disabilities. In 2011, the Deaf Prison In-Reach Service was established in conjunction with Yorkshire Specialist Commissioning Group and Nottinghamshire NHS Trust aiming to provide specialist support to D/deaf prisoners. * 'D' = Deafness as a culture, 'd' = deafness as a medical disability. Methods. The team evaluated the service to raise awareness of the specific needs of D/deaf prisoners by identifying and describing characteristics, demographics, trends and patterns within existing data as well as highlighting the nature of offences, prevalence of trauma and length of time over tariff. A secondary aim was to identify areas for development to adequately meet the needs of D/deaf prisoners. Results. After reviewing data for 29 prisoners (female = 3, male = 26), the most common source of support offered by the DPRIS was signposting (over 50%), followed by direct individual work (with nursing or psychology), assessment and consultancy. Since 2011, the DPRIS has assessed 30 individuals and completed over 717 prison visits for assessments and interventions. Whilst this has been acknowledged as a small number, it has been attributed to the difficulties locating D/deaf prisoners and lack of awareness regarding the DPRIS. Currently, referrals to the DPRIS come from prison healthcare staff, but this fails to address the wider specialist needs of this population: basic communication needs, occupational needs and risk reduction work. It also excludes individuals unknown to healthcare. Direct engagement with the DPRIS included: focused risk reduction work, anger management, mental health monitoring, and 1:1 psychology work. Prior to involvement from the DPRIS, five individuals declined to engage in prison therapy. With support from the DPRIS, two were transferred to more appropriate placements, one was recommended for transfer (not transferred) and one received mental health monitoring (nursing). One continued to decline which could be attributed to potential (lack of) motivation/readiness. This evaluation supports the need for specialist interventions to ensure equitable access to recovery and rehabilitation. Conclusion. What Next? It is hoped that the unique needs of this population will be communicated amongst professionals and steps will be made to address these as previously recommended in reports from the BDA (2016) and the Howard League.

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