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The user experience of ambulatory assessment and mood monitoring in bipolar disorder : systematic review and meta-synthesis of qualitative studiesBackground: Mood monitoring and ambulatory assessment hold promise for supporting self-management and data collection in bipolar disorder (BD), but the effectiveness of these depends crucially on the preferences and perspectives of those who use them. To date, these user experiences have not been systematically synthesized. Objective: This study aimed to explore and synthesize qualitative evidence on the user experience of mood monitoring and ambulatory assessment in BD, with a focus on identifying barriers and facilitators for both individuals with BD and clinicians, as well as the intended purposes of these tools. Methods: We conducted a systematic review and meta-synthesis of qualitative and mixed-methods studies reporting on ambulatory assessment and mood monitoring in BD (PROSPERO CRD42023396473). A total of 8 electronic databases were searched. Studies were appraised using established criteria for qualitative research. First- and second-order constructs were extracted, and a third-order synthesis was developed using the Noblit and Hare meta-ethnographic approach. Results: A total of 20 studies comprising 2365 participants met inclusion criteria. We identified 9 overarching themes: adverse effects, barriers to use, facilitators to use, perceived purpose, sharing with others (positive and negative), clinician concerns, clinician suggestions, and desired features. Users reported both benefits and harms. Some experienced increased insight, behavioral change, and relapse prevention skills, while others reported emotional burden, repetitive content, and worsened mood or anxiety. Preferences varied widely, but a strong, consistent emphasis was placed on personalization, including the ability to control what is tracked, when and how it is shared, and the level of engagement with health care providers. Passive data collection was often seen as less intrusive and more sustainable. Sharing data was sometimes seen as empowering, especially when it enabled communication with trusted individuals or clinicians, but also raised concerns around autonomy, misinterpretation, and privacy. Clinicians echoed many user views but raised additional concerns about liability and interpretability of data. Participants also highlighted the need for onboarding or support to aid comprehension and effective use. Conclusions: This review highlights the complexity and diversity of user experiences with ambulatory assessment and mood monitoring in BD. While many found these tools valuable for fostering insight, self-management, and relapse prevention, others found them burdensome or confronting. User engagement appears closely tied to perceived control, relevance, and personal fit. These findings underscore the need for flexible, user-centered design in future interventions. Customizability should be prioritized—including what is monitored, how feedback is delivered, and whether data is shared externally. Incorporating onboarding and adaptive feedback could help users better understand and apply their data to better self-manage. By aligning interventions more closely with user preferences and lived experience, ambulatory assessment and mood monitoring protocols may achieve greater uptake, engagement, and ultimately, a more effective intervention. Trial Registration: PROSPERO CRD42023396473; https://www.crd.york.ac.uk/PROSPERO/view/CRD42023396473
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Magnetic resonance spectroscopy metabolites as biomarkers of Alzheimer’s DiseaseAbstract Background Magnetic resonance spectroscopy (MRS) is a non-invasive method of evaluating metabolite levels in the cerebral cortex. Measurable metabolites can provide markers of neuronal damage, glial activation and, neurotransmission, pathological features of Alzheimer’s disease. Here we sought to establish the effectiveness of several metabolites as biomarkers for Alzheimer’s disease. Method 198 participants with a single-voxel 1H MRS scan were enrolled (n = 170 participants living with Alzheimer’s disease, n = 28 healthy controls). All participants underwent 3-tesla magnetic resonance imaging and cognitive assessment with the Alzheimer’s Disease Assessment Scale–Cognitive Subscale (ADAS-cog). An experienced radiographer placed an 8cm3 voxel within the posterior cingulate cortex for single-voxel 1H MRS acquisition. Scans were then processed to evaluate levels of N-acetylaspartate, myo-inositol, choline, and glutamate. Creatine peak was additionally evaluated as a reference. N-acetylaspartate/creatine, myo-inositol /creatine, choline/creatine ratios and glutamate were compared between Alzheimer’s participants and controls to calculate the effect size. Correlations were then performed between metabolite ratios and ADAS-cog scores. Result N-acetylaspartate/creatine effectively distinguished between Alzheimer’s patients and healthy controls (Cohens D = 0.83) with a lowered ratio in Alzheimer’s participants. Elevated glutamate signal and myo-inositol/creatine ratios were also displayed in Alzheimer’s patients (Cohens D = 0.62 and 0.69, respectively). Choline/creatine ratio displayed no significant difference between groups (Cohens D = 0.26). Lower N-acetylaspartate /creatine and glutamate correlated with higher ADAS-cog scores (r = -0.29, p < 0.001, CIs: -0.42 to -0.14 and r = -0.30, p < 0.001, CIs: -0.44 to -0.16, respectively). Myo-inositol and choline failed to correlate with cognitive impairment. Conclusion N-acetylaspartate, a signature of neuronal damage, is an effective biomarker of Alzheimer’s disease and associated cognitive decline. Enhanced glial activity, measured with myo-inositol, was shown in Alzheimer’s disease, suggesting that glial-reactivity markers deserve consideration in the diagnosis of Alzheimer’s disease. Glutamate demonstrated the strongest association with cognitive impairment, despite showing a smaller effect size than N-acetylaspartate and myo-inositol in distinguishing between Alzheimer’s patients and controls. Together we establish MRS is a useful, non-invasive biomarker of several pathological processes involved in the development of Alzheimer’s. Evaluation of N-acetylaspartate, glutamate, and myo-inositol may aid in the diagnosis of neurodegenerative disease, detecting markers undetectable by conventional MRI methodology.
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Do glial-reactivity and cerebral blood flow modulate cerebral glucose metabolism in Alzheimer’s disease?Background Alzheimer’s disease is a devastating neurodegenerative disorder with a complex pathogenesis. One main pathological feature utilised in diagnosis is neurodegeneration or neuronal injury, which is reflected in reductions in cerebral glucose metabolism measured by [18F]Fluorodeoxyglucose ([18F]FDG) positron emission tomography (PET). Here we evaluated the involvement of glial reactivity measured with magnetic resonance spectroscopy (MRS) and cerebral blood flow measured with arterial spin labelling (ASL) on [18F]FDG PET as a measure of cerebral glucose metabolism. Method 123 people living with early Alzheimer’s disease who completed baseline evaluations on the evaluating liraglutide in Alzheimer’s disease trial were enrolled. Participants completed [18F]FDG PET scans with arterial input, T1 weighted MRI, single-voxel 1HMRS, and pulsed ASL scans at Imperial College London Clinical Imaging Facility. The Totally Automatic Robust Quantitation in NMR (TARQUIN) package was used to process MRS scans and identify the concentration of myo-inositol within the posterior cingulate cortex (PCC), a marker of glial activation. Oxford-ASL was utilised to process ASL and quantify cerebral blood flow in the PCC. Finally, spectral analysis was performed on the [18F]FDG PET scans to assess the cerebral metabolic rate of glucose in the PCC. Result Pearson’s correlations were performed between the cerebral metabolic rate of glucose, cerebral blood flow and glial activity measured by the level of myo-inositol in the PCC. Increased cerebral glucose metabolism was correlated with higher myo-inositol in this sample of Alzheimer’s disease participants. In contrast, cerebral blood flow was not associated with cerebral glucose metabolism. Conclusion Here we demonstrate that increased glial reactivity contributes to [18F]FDG PET signal in the early stages of Alzheimer’s disease. In response to early neuronal injury, astrocytes and microglia may become activated and enhance regional rates of glucose consumption. Hence, the contribution from these cells in addition to neurons should be considered in interpreting [18F]FDG PET as a measure of cerebral glucose metabolism. Interestingly, cerebral blood flow did not influence glucose metabolism. Microglia and astrocyte reactivity may contribute to an increase the cerebral glucose metabolism while neuronal loss and synaptic function may contribute to lower glucose metabolism measured by [18F]FDG in the early stages of Alzheimer's disease.
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Adverse events of mood monitoring and ambulatory assessment in depression and bipolar disorder : systematic review and meta-analysisBackground: Mood monitoring and ambulatory assessment offer improvements in measuring mood and behavior for mental health research and clinical practice. However, concerns about adverse effects and usability may hinder their implementation. Objective: This systematic review and meta-analysis assessed the prevalence of adverse events, barriers and facilitators to use, and suggestions for improvement in quantitative mood monitoring studies involving people with depression and bipolar disorder. Methods: We conducted a systematic review and meta-analysis of 77 quantitative studies that used mood monitoring or ambulatory assessment in depression and bipolar disorder, assessing adverse events, barriers and facilitators to use, and suggestions for improvement. Adverse events data were pooled to identify prevalence. Results: Of the 77 studies, 15 (19%) reported adverse events, and 20 (26%) reported usability issues. Pooled prevalence of adverse events was 0.04 (95% CI 0.03-0.06; P<.001). Specific adverse effects included increased burden or stress (0.04, 95% CI 0.02-0.07; P<.001), mood worsening (0.02, 95% CI 0.01-0.02; P=.001), self-harm (0.05, 95% CI-0.02 to 0.10; P=.007), and hospitalization (0.06, 95% CI 0.04-0.09; P=.26). The top facilitators were perceived helpfulness and ease of use, the top barriers included technical challenges and the time-consuming nature of the interventions, and the top suggested improvement was personalization. Conclusions: A small number of mood monitoring or ambulatory assessment users experienced negative psychological effects; however, we were unable to infer causality. Due to the severe underreporting of adverse events as well as heterogeneity and publication bias in the included studies, there was limited certainty in the prevalence, duration, and severity of these adverse events. More systematic monitoring of adverse events is needed to optimize safety and usability. Many mood monitoring protocols may require additional development to decrease adverse events and improve acceptability.
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Working Diagnoses : a pilot studyAims: Mental Health and Neurodevelopment Resource Group (MHNRG) are planned to replace Mental Health Clustering. However, they are broad diagnostic groupings which will potentially have limited benefit in relation to evaluating outcomes, health inequalities, pathways, and interventions. In addition to mandatory completion of MHNRG, local services have the option to collect additional categorical data which led to the introduction of Working Diagnoses. This is a pilot study to trial Working Diagnoses to test its functionality and feasibility. Method(s): The aim of the Working Diagnoses is to create an accessible form on the electronic patient record allowing assessors to select a list of up to four working diagnoses via a drop-down menu. Following consultation with clinicians from differing psychiatric specialities, a list of 53 separate working diagnoses were agreed upon which were individually mapped to their respective ICD-11 diagnostic codes and Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) to make it future proof. The pilot was conducted within the local Crisis Resolution and Home Treatment and Primary Care Mental Health teams. A live and secure Microsoft Excel document with a list of the working diagnoses through a drop-down menu was created. Assessors consisting of both doctors of various grades and psychiatric nurses within the teams were briefed on the aims and objectives of the pilot study. At this stage, it is not intended for the diagnostic data to flow into the Mental Health Services Data Set (MHSDS). Result(s): 127 patients referred to the teams between November to December 2023 were included in the pilot study and allocated their working diagnosis; 66 received one diagnosis, 52 received two and 9 received three diagnoses and none received four. All presentations were able to be satisfactorily described by the Working Diagnoses options. The general feedback from assessors who participated in the study reported that it was simple and easy to use despite having limited formal training. Conclusion(s): We believe that mental health services require granular details of a person's presentation if we are to effectively commission, transform and manage our services. Though other options could be utilised, implementing a limited categorical diagnostic list appears to be an acceptable, effective, and efficient method of gathering the information that has been missing in mental health services locally. The next steps will be to trial this to other services within the wider trust.
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Venous Thromboembolism (VTE) risk assessment in acute inpatient mental health wards in Sherwood Oaks and Millbrook Unit (now Blossomwood Unit), Nottinghamshire Healthcare NHS Foundation TrustAims: To assess compliance with the trust policy and NICE guidelines on VTE risk assessment for new admissions into the acute psychiatric wards in Millbrook and Sherwood Oaks mental hospitals, Nottinghamshire NHS Foundation Trust. Method(s): A retrospective audit looked at case notes of patients aged 20-80 years, admitted within a 2 weeks period across 8 wards in April 2023. This was re-audited in April 2024 after all recommendations were actioned. Infornation was collated and manually analysed. Data collected included but not exclusive to date of admission, date VTE risk assessment was done and the level of VTE risk identified. These were compared with the standard criteria which were the trust policy 02.21 - 'Patients who are admitted should have VTE risk assessment within 24 hours of admission' and the NICE guidelines NG(82) 2019 - 'Assess all acute psychiatric patients to identify their risk of VTE and bleeding as soon as possible after admission to hospital or by the time of the first consultant review'. Result(s): The first cycle found that only 69.3% of the patients admitted were assessed on admission (with 50% assessed within 24 hours of admission) whereas 30.7% were not assessed throughout the duration of their admission. The second audit cycle showed remarkable improvements. 80.5% were assessed for VTE risk (63.9% within 24 hours of admission) whereas 19.5% were not assessed. The level of risk was categorized into low, moderate and high risk using Well's scoring system. 69% of patients who were assessed in the first cycle, had low risk but risk of 31% of the cohort of patients audited were unknown because they were not assessed. In the second cycle,80.5% had low risk whereas 19.5% of the patients fell under the unknown category due to not having been assessed. Conclusion(s): The importance of VTE risk assessment in acute inpatient wards can never be overemphasized. Studies show that psychiatric inpatients are likely to be at an increased risk of VTE due to - use of psychotropic agents, reduced mobility, dehydration as a result of self-neglect or suicidal attempts, prolonged restraints, sedation, co-morbid physical health problems etc. There are still lapses in our patient management that need to be considered in order to provide an outstanding patient care and safety.
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Investigating adherence to the 2022 NICE vitamin D management guidelines on MHSOP (Mental Health Services for Older People) wardsAims: Vitamin D deficiency is a widespread problem in older people with reduced ability for production, along with risk factors such as indoor living. Improving adherence to the vitamin D guidelines is a simple and cost-effective method of potentially reducing falls, morbidity and mortality in older patients with risk factors. Aim is to assess whether vitamin D deficiency is identified and managed appropriately according to the 2022 NICE vitamin D guidelines. Standard: 1. All patients to have vitamin D level tested on admission. 2. All patients with vitamin D level of 50 and below to be prescribed vitamin D as per guidelines. 3. If calcium deficiency co-exists with vitamin D deficiency, patients to be prescribed replacements for both as per guidelines. 4. All patients to be referred for specialist services if vitamin D deficiency presents with the following: eGFR <30, hypercalcaemia, or granulomatous conditions. Method(s): The audit was registered with the Trust following discussion with the ward managers and consultants. All inpatients on two MHSOP wards on the day of data collection were included. Using an audit questionnaire, retrospective data was collected from electronic patient notes, paper drug charts and electronic blood reporting system. Data was analysed on Excel. The re-audit occurred six months later following intervention. Interventions following the initial audit involved designing a vitamin D awareness poster for the wards, meetings with the ward pharmacist and presentation at the local MHSOP clinical effectiveness meeting to raise awareness. Result(s): First cycle: 34 patients were included. 30 out of 34 (88%) patients had their vitamin D levels tested on admission or had a recent level. Out of the 30 patients who had recent vitamin D levels on record, 15 patients had adequate vitamin D levels, seven had insufficient levels, and eight had deficient levels. Out of the 15 patients who had insufficient or deficient levels, nine patients (60%) were prescribed vitamin D. One patient who required specialist services did not get referred. Second cycle: 33 patients were included. 31 patients out of 33 (94%) had vitamin D testing on admission. Out of the 31 patients, 12 patients had deficient or insufficient vitamin D levels requiring prescription. Nine out of these 12 patients (75%) were prescribed vitamin D. Conclusion(s): Following simple interventions to raise awareness, the re-audit results showed improvements in vitamin D testing on admission as well as improved management. Ongoing communication with pharmacists and rotating resident doctors is required to sustain awareness and improve adherence.
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In children and adolescents (ages 6-17) with attention deficit hyperactivity disorder (ADHD), how does viloxazine extended-release (ER) compare with placebo or other ADHD medications in terms of improving ADHD symptoms, adverse events and treatment discontinuation rates? A systematic reviewAims: In this systematic review, the effectiveness and safety of viloxazine ER in the treatment of ADHD in children and adolescents aged between 6-17 years will be assessed. Method(s): This review identified articles through a systematic approach using PubMed, EMBASE, and the Cochrane Library. Randomized controlled trials with viloxazine ER in an active comparator condition versus placebo or other stimulant/nonstimulant ADHD drugs were included. The first set of outcomes for assessing efficacy was a decrease in the severity of ADHD symptoms as measured by the ADHD-RS-5 and CGI-I scales. Safety outcomes comprised comparability in the rates of adverse events and treatment discontinuation rates. Result(s): A meta-analysis showed that viloxazine ER is effective in managingADHDsymptoms compared with placebo at 10-12 weeks. Very few side effects were reported with this medication and those reported were mostly mild to moderate in nature. Mild side effects were noted to be decreased appetite, somnolence, and headache. The rates of treatment disappearance were similar compared with other oral ADHD drugs. Conclusion(s): The research implies that viloxazine ER may be useful to paediatric patients with ADHD as a new treatment approach. We hypothesize that its profile of being an NRI and 5-HT2B antagonist may be beneficial for patients who have not shown sufficient improvement with more common treatments. The use of once daily dosing of the extended release formulation may enhance compliance compared with drugs taken more than once per day. In a general manner, viloxazine ER seems to be a safe and efficacious therapy in children and adolescents affected by ADHD. Because it has a unique mechanism of action and can be taken once daily, it complements other ADHD medications well. More prospective, multicentre trials of longer duration are, therefore, required to determine the success and risks of the technique in the long run.
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In adults with severe psychiatric disorders, how does the option of assisted dying compared with standard psychiatric care or palliative care impact patient autonomy, quality of life, and ethical considerations : a comprehensive meta reviewAims: This systematic review sought to compare the effect of assisted dying options on self-determination, patients' quality of life, and specific/ethical concerns including suicidality for adults with severe psychiatric disorders and psychiatric or palliative care. Method(s): The data sources gathered for this review were PubMed, EMBASE, CINAHL and Cochrane databases. The search terms consisted of different forms of assisted dying to which various forms of psychiatric and mental health-related terms were added. The papers were restricted to systematic reviews and meta-analyses as these give high-quality evidence. Out of 343 studies after strict criteria such as ROBINS 1, ROB2 and AMSTAR, only 3 studies qualified for the review. The review centred on adults with severe psychiatric disorders, specifically patients with eating disorders who had assisted dying between 2012 and 2024. Result(s): The present review estimated that at least 60 individuals with eating disorders who received assisted dying between 2012 and 2024 were reported across 10 peer-reviewed studies and 20 government reports. Clinical rationales for granting assisted dying requests fall into three main domains: non-treatability, prognosis and request of the patient. Most of the reports highlighted two aspects: that the patients had a terminal or untreatable disease, as well as sufficient decision-making abilities. Still, only a few reports were available for the government and many of them failed to provide adequate data on psychiatric conditions. The review showed that there were significant gaps in reporting assisted deaths for psychiatric patients and ministers questioned accountability and patient safety. Some clinical justifications were void of rigour or evidence indicating the plausibility of the irremediability or lack of decisional capacity in psychiatric relatedness. Conclusion(s): The findings of this systematic review can be concluded as indicating the lack of procedural clarity and strengthened precaution measures for assisted dying in the field of psychiatry. The results imply the applicability of the ethical principles as well as clinical considerations call for incremental case-by-case analyses. The study should be extended to propose improved reporting systems for assisted dying and to confirm clinical justification for several patients who received help in psychiatric practices, with the consideration of patient rights and safety.
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How do individuals with bipolar disorder experience ecological momentary assessment and mood monitoring? A systematic review and qualitative meta-synthesisAims: Advancements in smartphone technology and wearable devices allow for novel ways to monitor behaviour, mood, and mental state, as well as to develop new interventions. Understanding the perspectives and preferences of individuals with bipolar disorder (BD) is essential for the success of these mood monitoring interventions and for Ecological Momentary Assessment (EMA) as a data collection method. This systematic review and meta-synthesis aimed to explore the user experience of mood monitoring and EMA, including the barriers and facilitators for both individuals with BD and clinicians, as well as the intended purposes of these tools. Method(s): A systematic review and meta-synthesis of qualitative studies were conducted (PROSPERO: CRD42023396473), focusing on the experiences of participants, users, and clinicians with mood monitoring and EMA in BD. Eight electronic databases were searched, and mixed-methods studies were included. A metasynthesis approach was used to analyse the data, employing first-, second-, and third-order constructs, guided by Noblit & Hare's meta-ethnography framework. Studies were assessed for the risk of bias in qualitative research. Results were checked for coherence by individuals with lived experience and psychiatrists. Result(s): The search identified 23,515 papers. A total of 20 studies using 12 different EMA protocols were identified and included in the meta-synthesis, from which nine overarching themes emerged: adverse effects, barriers to mood monitoring, facilitators of mood monitoring, the purpose of mood monitoring, negative experiences of data sharing, positive experiences of data sharing, clinician-related barriers and concerns, clinician-related facilitators and suggestions, and desired features. Conclusion(s): This review highlights key factors that can enhance user experience, engagement, retention, usability, and acceptance of EMA and mood monitoring protocols for individuals with BD. A central finding is that users strongly value control over their data, with an emphasis on customisability and personalisation. Many users were sceptical about involving formal mental health services and preferred to use the tool as an aid for self-managing their condition in highly personal and iterative ways. We also report key adverse effects experienced by individuals with BD when engaging in mood monitoring, which may need to be addressed by incorporating additional therapeutic elements into the intervention-for example, subjective worsening of mood and the monitoring process serving as an unhelpful reminder of their mental illness.
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The effect of the ketogenic diet on aggression and violence in patients with severe mental illness : a systematic reviewAims: The aim of this systematic review was to explore the existing literature on the impact of the ketogenic diet on aggressive and violent behaviour in patients with serious mental illness and the potential mechanisms involved, with the hypothesis that the ketogenic diet can reduce aggression and violence in this patient population. The ketogenic diet has proven to be useful as a therapeutic to reduce some clinical symptoms of certain neurological and psychiatric conditions, so this review was interested to determine if there were any correlations in impacts on behaviour in similar patient populations. Method(s): Following the PRISMA guidelines, a systematic review was conducted of the bibliographic databases MEDLINE, PsycINFO, Scopus, Web of Science, Cochrane Library, PubMed and Open Grey. The sources retrieved were narrowed down using specific inclusion and exclusion criteria and quality appraisal of the relevant sources was carried out using the Joanna Briggs Institute critical appraisal tools. Result(s): Of the 32 sources included in the final review, 26 of these, when linked together by association, supported the concept of the ketogenic diet reducing aggression either directly or indirectly via metabolites upon which the ketogenic diet can impact. Increased beta- hydroxybutyrate, gamma-aminobutyric acid and brain-derived neurotrophic factor were all observed when following the ketogenic diet and were, in most cases, associated with reduced aggression. Conclusion(s): Despite the limited literature available on the topic, the majority of the relevant sources supported the notion that the ketogenic diet could generally reduce aggression, an observation that could often be replicated in psychiatric settings. The conclusions made in this review were mostly formed by making associations between the available sources, so future research would need to be conducted with the specific focus of observing the impacts of the ketogenic diet on behaviour in psychiatric settings. Randomised controlled trials should be conducted in both inpatient and outpatient settings to enable further systematic reviews and metaanalyses to evaluate the ketogenic diet's potential for use as a nonpharmacological therapeutic in prescribing and patient care.
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Clinical audit : supporting post detox abstinence : discussion of relapse prevention medications by community addiction services prior to referral for inpatient detoxificationAims: Without a plan to support ongoing abstinence, detoxification ("detox") could increase, rather than reduce, risks to a patient. Before referring for inpatient detox from alcohol or opioids, community teams are expected to discuss relapse prevention medications (RPMs) with patients, as part of their wider support plan. This clinical audit examined whether RPMs were mentioned in referrals by community teams to our inpatient detox unit. Method(s): We examined referrals for patients admitted to The Level Nottingham inpatient detox unit between 1 January and 31 August 2024. Of a total of 215 patients that completed opioid or alcohol detox, a random sample of 50 were selected, stratified according to referring team. Referral forms and running notes were used to assess compliance with the following criteria: 1. Referring teams mention RPMs (whether to be considered or not considered). 2. Referring teams provide blood test investigations. There was no previous literature or audit to specify a standard, so, given the importance of the issues under consideration, this was set as 100% for each criterion. We also extracted: whether patients were planned to go to residential rehabilitation after detox, and, where relevant, which RPMs were mentioned and time from blood test results to referral and to admission. Result(s): 68% of referrals were for alcohol, and 24% for opioid, detoxification (2% were for alcohol and opioid, and 6% for other substances). 40% of referrals for alcohol, and 77% of referrals for opioid, detoxification did not mention RPMs. 29% of referrals for alcohol, and 31% of referrals for opioid, detoxification did not mention RPMs and were not planned to go to residential rehabilitation (considered as some of these settings do not accept patients on RPMs, focusing solely on psychosocial support). 48% of referrals for any detoxification did not have blood test results available. Where blood test results were available, median time from test results was 22 days to referral and 85 days to admission. Conclusion(s): During the study period, an estimated one-third of referrals for alcohol or opioid detoxification did not mention RPMs (and were not going to residential rehabilitation post inpatient stay). Approximately half of admissions did not have blood test results available. The above is likely to delay the prescription of RPMs, and potentially increase the risk of relapse post-detoxification. Recommendations to increase performance include discussions with referrers, changes to the referral form, and changes to referral screening.
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Co-producing a survey on prospective acceptability of neuromodulation for mental health conditions with lived experience expertsAims: Non-invasive brain stimulation ("neuromodulation") techniques, including transcranial magnetic stimulation (TMS) and transcranial electrical stimulation (TES), are used to modulate brain excitability and connectivity. TMS is approved for treating depression in the United Kingdom and preliminary evidence suggests that combining TMS and TES may enhance therapeutic effects. While neuromodulation is generally well-tolerated in research settings, its acceptability among the broader patient population remains unclear due to limited exposure, awareness, and information accessibility. Understanding prospective acceptability, defined as the perceived appropriateness of an intervention before its application, is crucial for improving treatment uptake and addressing concerns about safety and feasibility. We aimed to coproduce a survey with lived experience experts to assess the acceptability of individual and combined neuromodulation techniques among potential service users. Method(s): The study was co-developed with our Neuromodulation Experts-by-experience Advisory patient and public involvement (PPI) group. We underwent three rounds of iterative feedback to refine the survey focus, structure, and questions. A scoping review of existing literature on prospective acceptability of neuromodulation techniques informed the content, alongside the Theoretical Framework of Acceptability. Given the novelty of combined (TMS +TES) neuromodulation, no prior informational materials exist. PPI members advised it was critical to produce accompanying videos and leaflets to briefly illustrate the different neuromodulation techniques. The video scripts and leaflet content were produced in collaboration with three PPI members who tried the neuromodulation techniques, to avoid rehearsed scripts and ensure honest reviews of the techniques. Result(s): The final survey version was adapted to maximise clarity of questions, engagement, and completion rates. The survey incorporated questions on awareness, perceived effectiveness, ethical considerations, and practical burden of different neuromodulation techniques. Online and paper versions of the survey were created to ensure accessibility. We successfully produced three information videos within 90-second target duration featuring PPI members and lead researchers. We developed a supplementary infographic leaflet for enhanced comprehension and accessibility. Conclusion(s): Engaging stakeholders through PPI was instrumental in developing the survey to ensure accessibility and relevance for diverse participants with lived experience of mental health conditions. End-user involvement in the design process improved survey comprehensibility, highlighting the importance of coproduction in developing effective research tools. Findings from this survey will provide insights into the acceptability of novel neuromodulation techniques, ultimately informing future clinical implementation and patient-centred research strategies.
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A case of depersonalization-derealization disorderAims: Background: Depersonalization-derealization disorder (DPDR), classified under ICD-11 code 6B66, involves persistent or recurrent experiences of depersonalization, derealization, or both. Depersonalization refers to a sense of detachment from one's thoughts, emotions, or body, whereas derealization involves perceiving the external world as unreal or distorted. These symptoms cause significant distress or impairment, are not attributable to other mental disorders, substance use, or medical conditions, and occur while reality testing remains intact. Method(s): Case Report. An 18-year-old female A-level student presented with a two-year history of frequent episodes in which her surroundings, including people and familiar environments, felt unreal. These episodes varied in duration and were highly distressing, particularly during emotional extremes such as heightened happiness or stress. Symptoms were most pronounced in the evenings or when she was unoccupied, leading to emotional breakdowns. Despite these experiences, she remained aware of her own reality, with disturbances centred on external perceptions. Her symptoms began following a nine-month psychiatric hospitalization. Prior to admission, she experienced unexplained gastrointestinal symptoms, and in the absence of an identifiable physical cause, she was diagnosed with conversion disorder. The hospitalization was distressing due to frequent invasive procedures, a perceived sense of blame for her condition, and feelings of entrapment. She subsequently developed post-traumatic stress disorder (PTSD), characterized by flashbacks, nightmares, and avoidance of medical settings. However, DPDR symptoms persisted outside of PTSD-related re-experiencing episodes, causing ongoing distress and impairment. Result(s): Discussion: This case highlights the complex interplay between DPDR and PTSD, particularly following medical trauma. While dissociative symptoms frequently occur in PTSD, ICD-11 differentiates DPDR as a distinct disorder when symptoms persist beyond re-experiencing episodes. In this case, the patient's prolonged hospitalization, combined with perceived invalidation and invasive interventions, likely contributed to the development of DPDR as a maladaptive dissociative response. The exacerbation of symptoms during emotional extremes aligns with research indicating that dissociation may function as an affect regulation mechanism. Trauma-related dissociation has been linked to disruptions in emotional processing, potentially interfering with adaptive coping strategies. This underscores the importance of targeted psychological interventions to reduce distress and improve functional outcomes. Conclusion(s): A trauma-informed, multidisciplinary approach is essential in managing this patient's complex presentation. Psychological interventions such as EMDR or trauma-focused CBT should be integrated with ongoing medical care to address both dissociative symptoms and physical health concerns. Collaborative management between psychiatric and medical teams will be crucial in promoting long-term recovery, enhancing her psychological resilience, and improving overall quality of life.
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An audit of metabolic monitoring compliance in patients initiated on antipsychotics across general adult wards in the East MidlandsAims: The Lester Tool mandates baseline monitoring parameters for patients starting new antipsychotics or having their current antipsychotic regimen changed. These parameters include blood pressure, haemoglobin A1c (HbA1c)/fasting plasma glucose, lipids, lifestyle review, waist circumference, and weight, along with weekly weight monitoring for six weeks consecutively. This audit was initiated in response to concerns about rapid weight gain observed in many patients after starting certain antipsychotics. It aims to assess compliance with the Lester Tool to address the potential risks of metabolic syndrome in these patients. The audit seeks to understand the pattern of antipsychotic prescriptions as a secondary objective. Method(s): The audit was registered and ethically approved by the local research and audit department. A retrospective review of electronic health records and medication charts was conducted for 38 patients residing in two male and two female inpatient wards in the East Midlands between 17 June 2024 and 26 June 2024. Baseline parameters were audited to determine if they were measured within one week of antipsychotic initiation, and weekly weight checks thereafter. Waist circumference measurement at baseline was excluded due to concerns about its potential impact on patient self-esteem. Result(s): Among baseline monitoring parameters, blood pressure had the highest compliance at 89.5%, followed by HbA1c/glucose (65.8%), lipids (57.9%), lifestyle review (55.3%), and weight monitoring (36.8%). Weekly weight follow-up compliance was low, with only 5.9% of patients meeting 100% compliance, and 41.2% of patients having no documented weight follow-up within six weeks. Non-compliance reasons were poorly documented. Risperidone was the most prescribed antipsychotic (N=9), followed by olanzapine (N=8), zuclopenthixol (N=7), and quetiapine (N=6). Olanzapine and risperidone were most frequently initiated in male wards, while zuclopenthixol and quetiapine were more common in female wards. Conclusion(s): The audit identified significant gaps in compliance with the Lester Tool, which poses a risk to patients' physical health due to the metabolic side effects of antipsychotic medications. The findings underscore the need for better documentation and communication regarding baseline and follow-up measures. Recommendations include increasing awareness of baseline blood requirements during admission, improving electronic health record functions (e.g. alerts for weekly weight checks and a drop-down to document weight check refusals), and enhancing coordination in monitoring patient weight following planned home leaves. A re-audit is ideal once the recommendations have been implemented.
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Audit of melatonin use across child and adolescent mental health services (CAMHS) in LincolnshireAims: To establish baseline data on melatonin use. To compare the patterns of use with national guidelines. To make recommendations to the teams. Method(s): A retrospective audit of patient records under the CAMHS services in Lincolnshire was undertaken to identify patients on melatonin as of June 2024. Data was collected from medical records between June and July 2024. Patients under 19 years and prescribed melatonin were included. Patients previously on melatonin but discontinued by June 2024 were excluded. This audit was inspired by the POMH melatonin audit. Result(s): 54 patients were identified, 23 males and 31 females. About half of the patients had been on melatonin for over one year (n=25). Autism/autistic spectrum disorder was the most common diagnosis/comorbidity - 36 patients, 29 patients had an anxiety disorder, 21 patients had diagnosed/comorbid hyperkinetic disorders, 12 patients had mood disorders while 14 patients did not have a diagnosed neurodevelopmental disorder. In 84.6% of prescriptions, evidence-based non-pharmacological measures were tried first. The target symptom(s) for melatonin treatment was clear in 55.6% of cases. Sleep latency was the most common target, followed by reducing night-time awakening. Licensed melatonin preparation was used in 46.3% of prescriptions. The preparation was however not clearly documented in most of the cases. (Licensed use covers insomnia with autism spectrum disorder (Slenyto), insomnia with Smith-Magenis syndrome (Slenyto), insomnia associated with behavioural disorders in children and adolescents (Adaflex)). 86.7% of prescriptions were reviewed for efficacy within 3 months while tolerability (side effects) was reviewed in 46.7%. The need for continuing melatonin treatment was reviewed annually in 80.8% of cases while tolerability was reviewed in 30.8%. Conclusion(s): The audit revealed high rates of prescription in certain areas of the county, it also showed that documentation of indication and target symptoms was not always available, similarly review of tolerability (side effects) was not always available. The findings were presented to the CAMHS consultants. The high rates were thought to be related to shift in practice over time, perhaps due to consultants shortage. Documentation of efficacy was more often done than review of tolerability. One reason for this could be that melatonin was being monitored by the community paediatrics team or the GP. The need for clear documentation can therefore not be overemphasized. The audit did not consider those who were able to stop melatonin. This could be useful to support patients.
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Are patients aged 18-25 reviewed after one week of starting a selective serotonin reuptake inhibitor in a primary care setting?Aims: The National Institute for Health and Care Excellence (NICE) recommends that individuals aged 18-25 or those at increased risk of suicide should be reviewed within one week of initiating or increasing a selective serotonin reuptake inhibitor (SSRI) dose. This study aimed to assess compliance with these guidelines in primary care, identify barriers to timely reviews, and evaluate changes following a previous audit. Method(s): A retrospective review was conducted using SystmOne to identify patients aged 18-25 who started an SSRI between 1 December 2023 and 15 July 2024 in a Nottingham GP surgery. Data collected included the time from SSRI initiation to a booked and completed review, as well as instances of non-attendance (DNA). Findings were compared with a prior audit (1 August-24 November 2023) to assess improvements and ongoing challenges. Following the first audit cycle, results were shared and discussed within the practice, prompting greater awareness from all members of the multidisciplinary team (MDT) upon current guidance and performance. Result(s): In the initial audit, none of the 21 eligible patients had a review booked within one week, with an average booking time of 20 days and 30 days to an actual review. In the re-audit, 36 eligible patients were identified, with a slight improvement in booking time (19 days) and review completion (23 days). Three patients (8.3%) had a review scheduled within the recommended one-week timeframe. The main barrier remained appointment availability, with a shortage of GP slots limiting one-week follow-ups. High DNA rates persisted, with 14 patients missing their reviews in the re-audit. No standardised approach to DNAs was implemented, with some patients receiving multiple recall attempts and medication re-issues, while others had no further action documented. Conclusion(s): Over this one-year period, noticeable improvements were observed in both booked and actual SSRI review times. However, most patients still did not receive a timely review. Limited appointment availability and inconsistent follow-up for DNAs remained significant challenges. Expanding the role of other healthcare professionals, such as pharmacists, to conduct initial medication reviews could improve guideline compliance and reduce GP workload. Establishing a standardised protocol for DNAs, ensuring a set emergency medication supply and a timely follow-up, is essential to improving patient safety and treatment outcomes.
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Reflections on using the power threat meaning framework on an acute inpatient male wardThis reflective piece examines the authors’ experiences of introducing the Power Threat Meaning Framework on a men’s acute inpatient ward aiming to promote more collaborative psychologically informed approaches to understanding distress Working within a system traditionally dominated by the medical model the authors consider how the Ptmf offered a shared language for understanding distress in ways that emphasised personal meaning power dynamics contextual factors. The paper reflects on the, opportunities challenges of applying the Ptmf in this setting, including tensions between psychological diagnostic, approaches the importance of relationship-building, curiosity cultural sensitivity. The authors also describe how the, Ptmf can inform trauma-aware practices help shift team discussions around, formulation care planning. The paper concludes with thoughts on the implications for clinical work, team collaboration broader application of the, PTMF.
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Living with mental health issues: citizen science project on self-management strategiesPeople living with mental health issues use a range of self-management strategies. Most strategy recommendations have been developed by clinicians and researchers, so they may not reflect the full range of approaches used in practice. A citizen mental health science methodology can address this bias in strategy identification. We co-created a list of 77 pre-defined self-management strategies, and 1116 public contributors (n = 468 mental health service users, n = 497 lived experience not using services, n = 151 no lived experience) living in the United Kingdom completed an online survey identifying their use of each strategy, and identifying extra strategies. A wide range of pre-defined strategies were used by contributors, with differences in usage patterns identified between the three groups. 401 distinct extra strategies were identified. The active use of avoidance as a self-management strategy was more common than anticipated, including avoiding alcohol, social media, thinking about problems, other people, and mental health services.
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An Investigation of the effects of α- and β-Frequency neural entrainment using tACS on phase-aligned TMS-Evoked corticospinal excitabilityPURPOSE: Deep brain stimulation (DBS) is an effective treatment for many brain disorders (e.g., Parkinson's disease), has a favorable adverse effect profile, and can be particularly effective for individuals with treatment-resistant symptoms. DBS is, however, inaccessible for most individuals, is extremely expensive, and is not considered suitable for children and adolescents. For these reasons, noninvasive alternatives to DBS, such as transcranial magnetic stimulation (TMS), are increasingly being sought to treat brain health conditions. Unfortunately, current TMS approaches exhibit large intra- and inter-subject variability in their efficacy, which limits their use clinically. One likely reason for this is that TMS is invariably delivered without reference to ongoing brain activity (i.e., open loop). METHODS: We propose that the efficacy of stimulation might be improved, and the variability of its effects reduced, if stimulation could be synchronized with ongoing brain activity. To investigate this, we used transcranial alternating current stimulation (tACS) to induce entrainment of brain activity at two frequencies (α = 10 Hz and β = 20 Hz), and we delivered single-pulse TMS that was temporally aligned with the phase of each tACS oscillation. To investigate the effects of tACS-phase-aligned TMS, we measured motor-evoked potentials (MEPs). FINDINGS: Our findings confirm that for α- and β-tACS, both corticospinal excitability and inter-trial variability varied as a function of tACS phase. Importantly, however, the tACS phase angle that produced maximum TMS-evoked excitability was different for α- and β-tACS, coinciding with the negative peak (trough) for α-tACS and the positive peak (peak) for β-tACS. CONCLUSION: These findings confirm that aligning noninvasive brain stimulation to ongoing brain activity may increase the efficacy of TMS and reduce the variability of its effects. However, our results illustrate that the optimal phase of the tACS cycle at which to deliver TMS may vary for different tACS frequencies.
