Clozapine is the treatment of choice in treatment resistant schizophrenia (TRS). Neutropenia is a potential life threating adverse effect associated with Clozapine treatment and one of the common reasons leading to discontinuation of Clozapine treatment. Clozapine associated neutropenia can be managed with Lithium or Granulocyte Colony Stimulating factor (G-CSF).Clozapine rechallenge in patients may often seem necessary and should follow a careful and balanced risk-benefit analysis. We present a case of a patient with TRS on Clozapine who developed neutropenia which responded to Filgrastim add on therapy and was successfully continued with Clozapine treatment.

A 29 year old female with a diagnosis of Schizophrenia since age 22 years had poor response to 4 different antipsychotics and 2 episodes of Neutropenia on separate occasions with Clozapine treatment. An inpatient Clozapine rechallenge was trialled due to poor response to the ongoing antipsychotic treatment which resulted in a decrease in the absolute neutrophil count to 1.7 *109/Litre.

An MDT decision was taken to continue Clozapine treatment with add on Filgrastim due to the severe psychopathology and poor quality of life. As per the advice from the haematologist Filgrastim injections at a dose of 30 million International Units were commenced on pro re nata (prn) basis whenever ANC dropped below 2.0*109/Litre. This strategy was successful and the patient did not develop agranulocytosis. Her psychotic symptoms also improved significantly and the patient was discharged to the community rehabilitation team.

Clozapine is often the last resort in treating refractory psychotic symptoms and this option may get limited due to adverse effects like Neutropenia and agranulocytosis. Add on therapy with G-CSF has been used in Clozapine rechallenge with various success rate and most of the supporting data are derived from case reports and case series. It is worth noting that regular and prophylactic G-CSF in absence of low neutrophil count is avoided which could mask a developing Clozapine induced Neutropenia and result in a steep drop in neutrophils.

Add on therapy with Filgrastim is a viable option when considering Clozapine rechallenge with previous history of Clozapine induced Neutropenia. It is important that a haematologist is consulted and the patient is monitored closely throughout the treatment.

Neuroleptic malignant syndrome (NMS) is a rare condition experienced by patients taking typical and/or atypical antipsychotic medications. There are well-established diagnostic criteria for NMS. However, differentiating it from serotonin syndrome and malignant hyperthermia—particularly in the intensive care setting--is problematic and thus remains a diagnosis of exclusion. A case report of a patient with atypical NMS in intensive care is described and the subsequent learning points gleaned from the patient are presented.

A 28 year-old female was admitted to the intensive care unit (ITU) following a self-inflicted traumatic injury. The patient was known to local mental health services and her medical history includes personality disorder, anxiety and depression. Regular psychiatric medications prior to hospitalization included flupentixol and quetiapine. Remifentanil was administered in a continuous infusion for sedation as the patient was intubated and ventilated. Valproic acid and levetiracetam were given for seizures.

Repeated spikes in temperature, rigidity and slightly elevated creatine kinase (CPK) were observed in the patient. Autonomic dysfunction was also noted; the patient experienced bradycardic episodes that increased in frequency and duration. On two occasions, this resulted in asystole and cardiopulmonary resuscitation (CPR) had to be commenced with return of spontaneous circulation following CPR. Mental status changes were unable to be assessed due to ongoing sedation of the patient. On the advice of the clinical pharmacist, remifentanil was switched to fentanyl. Quetiapine and flupentixol were also discontinued after consulting with the psychiatric team. In addition, the patient responded quickly to dantrolene administration and to active cooling.

Main diagnostic criteria for NMS include hyperthermia, rigidity, mental status changes and autonomic dysfunction. The definition of atypical NMS includes three of these four criteria. Serotonin syndrome was ruled out as the patient was not taking any selective serotonin reuptake inhibitors (SSRI) nor selective serotonin-norepinephrine reuptake inhibitors (SNRI). Malignant hyperthermia was also considered as the patient had received a volatile anaesthetic gas, isoflurane, for sedation purposes; however, symptoms persisted long after it was stopped.

Atypical NMS is a diagnosis of exclusion that must be considered in patients in an intensive care setting who experience refractory hyperthermia. A multidisciplinary team is essential in caring for critical care patients who exhibit symptoms of NMS, including psychiatry, neurology, and clinical pharmacy.

Strictly speaking, occupational therapy interventions in mental health help clients through different activities to improve and develop skills that allow them to become increasingly independent and self-sufficient. Occupational therapy evaluation includes areas such as activities of daily life, play/leisure, productivity, study, work, and social participation. Occupational therapy also considers the impact of the context on the areas mentioned, but usually does not include the psychodynamic aspects of the client.

Male patient in his early thirties who was suffering an acute psychotic episode. He was experiencing a mystical delusion, with grandiose ideas of personal significance and delusions of reference. His mood was elevated, in consonance with the content of his thoughts. He was disorganised and needed help to maintain his daily routine. He said that he was experiencing a Maslow's Peak-Experience not a psychotic episode although he acceded to take medication. In an attempt to avoid involuntary admission to a mental health clinic (he refused to be admitted, as did his family), we tailored a home approach, with the inclusion of an occupational therapist on the team. Our first approach was unfruitful. Our attempts to help him to organize himself and his daily routine did not work. He was so fixated with his delusional project that any other idea or plan was rapidly discarded. So, we decided to change our approach and took his delusional project as the activity to organise and plan about. We agreed with him that we were going to help him with his project, but that there were no guarantees of success. Occupational therapy interventions helped him organise his project step by step and accept the frustration that his plan was impossible to achieve. Eventually, the episode ended with no need of admission.

Changing the focus of the occupational therapy interventions, paused the interventions that were aimed at activities of the daily life, and taking the delusional project as the main and the most important activity of the client at this point allowed us to build a stronger therapeutic alliance and helped the client deal with the psychotic process and tolerate the constraints of reality.

The introduction of a psychodynamic point of view in the planning of occupational therapy interventions enriches the realm of occupational therapy and allowed, in this case, a flexible and creative approach that opened the path to a home treatment plan avoiding involuntary admission.

Emotionally unstable personality disorder (EUPD) patients are known to frequently present to acute hospitals with pain symptoms. Multiple pain syndromes like fibromyalgia, chronic fatigue syndrome etc. are also commonly diagnosed in this group of population. It can be difficult to differentiate psychosomatic pain from physical pain during these hospital presentations. Failure to exclude physical causes of pain can lead to inadequate pain relief and missed serious diagnosis.

We describe a 29-year-old lady known to have Type 1 Diabetes, chronic pancreatitis and past history of several overdoses. She was being supported by Home Treatment Team (HTT) before coming to the hospital. She presented to the Emergency Department (ED) after ingesting 40 tablets of Pregabalin. She was referred to mental health liaison service for ongoing suicidal thoughts. On assessment, she admitted taking multiple overdoses to relieve her of severe abdominal pain. Her pain symptoms had been attributed as attention seeking behaviour. She disclosed feelings of rejection and abandonment by hospital staff. Liaison team negotiated with emergency department staff to complete a physical health examination that revealed tenderness and guarding in the abdomen. She was booked for elective cholecystectomy after surgical review. However, she had to be admitted from ED for laparoscopic cholecystectomy because of worsening of pain and vomiting. She was referred to Pain Management Team after surgery. The team was cautious in providing her with pain medications considering past history of overdoses. She was unable to tolerate pain and voiced thoughts of overdose. We liaised with Pain Management Team to optimise her analgesics and arranged daily supervision of pain medications with HTT

Our patient's physical symptoms of acute cholecystitis and frequent overdoses with pain medications were attributed to her personality disorder that resulted in dismissal of her real pain that “Its is all in the head”. This led to persistent pain affecting her mental health.

Patients diagnosed with EUPD should be carefully assessed to exclude organic causes of pain before attributing their symptoms to mental health disorders. A thorough assessment and treatment of physical symptoms can improve their mental health as well as reduce attendance in health facilities.

Functional cognitive disorders (FCDs) refer to conditions where patients present with persistent problematic subjective memory complaints that are not consistent with their observed level of cognitive functioning. The demonstrated symptoms are also not in keeping with a recognized psychiatric or neurodegenerative process. FCD is likely to be underdiagnosed in clinical practice with the place-holder label of mild cognitive impairment being used in some cases due to lack of clarity about its symptomatology. In this paper, we describe two cases whose presentations were suggestive of FCDs.

Mrs X, 53 years old female not previously known to mental health services referred for increasing difficulties with her memory over 2 years which she believed was impacting her activities of daily living. She has a history of ischaemic heart disease, fibromyalgia, Insulin-dependent diabetes mellitus, depression, and polycystic ovarian syndrome. On assessment MOCA = 15/30, and MMSE = 25/30.

Mr Y, 57 years old male not known to mental health services. Although, has been treated for anxiety and depression by GP. He presented with a 3-year history of struggling with his memory. He reported being forgetful of appointments and he has to paste sticky papers on the fridge for reminders. Similarly, he has a diagnosis of Fibromyalgia and essential hypertension. On Assessment MOCA – 19/30 and MMSE – 25/30.

FCDs can be quite challenging because the clinical picture overlaps with other neurodegenerative conditions. Typically, patients report issues around memory function in the absence of relevant neuropathology and with evidence of inconsistency between symptoms reported and observations at assessment. Regarding our cases, the primary presenting issues were increasing difficulties with memory, and forgetfulness. Other noteworthy observations were a mismatch between their scores in the MOCA, MMSE, their level of functioning, and reported memory problems. Neurological examinations and neuroimaging were not suggestive of any neurodegenerative disorders. A differential diagnosis of functional cognitive disorder was considered due to the discrepancies between symptoms reported, the level of their functioning, observations at assessments as well as absence of relevant neuropathology on imaging.

FCD is a condition that is common in clinical practice but underdiagnosed. Hence, it is imperative that clinicians keep this diagnosis in mind when patients present with memory difficulties that do not meet the diagnostic criteria for dementia and is not due to a recognized medical or psychiatric condition. Correctly identifying and diagnosing FCD can positively impact patient outcomes.

Prostate cancer accounts for more than a quarter (27%) of male cancer cases, making it the most common form of cancer in UK males. Androgen deprivation therapy (ADT) is the mainstay of treatment for prostate cancer. Its aim is to reduce the level of androgens which stimulate cancer cell growth, in turn reducing prostate cancer symptom burden over longer periods. Although the clinical benefits of androgen deprivation therapy have been well documented, the physical, and in particular psychological, side effects of this treatment are lesser reported and can be debilitating.

We present the case of an 84 year old male referred to Old Age Psychiatry outpatients for a one year history of low mood and tearfulness with no response to two antidepressant trials. The patient was receiving six-monthly injections of Decapeptyl (Triptorelin), a hormone therapy for prostate cancer. The patient's main presenting complaint was of bouts of tearfulness that were difficult to control and often mood incongruent. He reported low energy and reduced motivation; however other biological depressive symptoms were not endorsed.

Depression and marked emotional lability have been reported by men who receive ADT for prostate cancer. This can be a cause of confusion or shame for patients, subsequently impacting interpersonal relationships and social functioning. Other side effects of ADT can lead to further negative psychological effects, including weight gain, gynaecomastia and genital shrinkage. It is possible that the side effects of this treatment are poorly recognized by clinicians initiating and managing it.

In conclusion, patients commencing ADT should be informed of the possibility of psychological side effects and encouraged to report any symptoms that arise. It is important for urologists, psychiatrists and GPs to be mindful of the possible link between this treatment and new onset mood and emotional symptoms in patients.

The purpose of sharing this case is to bring attention to the complexities in implementing legal framework for children and adolescents as well as the serious shortages of in-patient adolescent psychiatric beds, which can adversely affect the mental health of young people.

A young girl with a diagnosis of Depressive Disorder and Disordered Eating was treated by community mental health team for two years. She took an overdose and was admitted to a private NHS funded in-patient adolescent psychiatric unit, where she was placed on Section 2 of Mental Health Act. After two months she was transferred to an out of area psychiatric bed. While on home leave she took another overdose and needed admission in High Dependency Unit. When medically fit she was moved back to psychiatric unit. After two months she was moved to a local in-patient unit. Due to dietary restriction she was commenced on nasogastric feed. At that point the local psychiatric unit could not provide the support she needed and she was transferred to another in-patient adolescent unit in the region. After being an in-patient for 18 months when her condition improved a discharge planning meeting took place. She was still on nasogastric feed and sometimes had to be restrained. The local and regional in-patient and crisis consultants suggested that she should be discharged under Community Treatment Order. The community consultant took legal advice. The legal advice was that the provision of nasogastric feeding in the community without young person's consent would be likely to be unlawful and a violation of her Article 3 rights under the European Convention of Human Rights. Such restraint would be likely to amount to an unlawful deprivation of liberty and a breach of her Article 5 rights under the European Convention of Human Rights.

It is deeply concerning that she had to be moved between four in-patient units during one episode of in-patient admission due to lack of appropriate bed availability. Due to her age and complexities in the case, legal advice had to be taken because the consultants involved failed to agree on the appropriate application of legal framework.

This case clearly highlights the need to address the issue of adolescent in-patient psychiatric bed shortages as well as the importance of educational programmes aimed at improving the knowledge and skills of professionals on the application of legal framework in children and adolescents.

HD is an autosomal, dominantly inherited, neurodegenerative disorder which can present with cognitive, motor and behavioural symptoms. Recent studies suggest that obsessive compulsive disorder (OCD) symptoms, although not common, may precede or coincide with symptoms in patients with HD. We present a case of an adolescent boy presenting with symptoms of OCD, for 4 months duration, in background of three years diagnosis of HD.

A 15-year-old boy from South India, presented with recurrent, intrusive thoughts of sexual content, consistent with obsessions and some instances of compulsions in the form of avoiding to do deviant sexual act like fetishism, and having excessive worries about an act he had done earlier for 3 months duration (supported by high scores on Yale-Brown Obsessive Compulsive Scale; Y-BOCS). Patient had normal birth and development and had no past history of psychiatry disorder, however there was family history of HD in multiple first and second-degree relatives. He was on treatment for movement symptoms of HD, diagnosed 3 years back and was on Tetrabenazine for 2 years. Initial psychiatric assessment found the symptoms to be consistent with OCD due to Huntington's disease, according to Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The patient was admitted to the mental health unit and was started on Fluoxetine, titrated to a dose of 20mg daily for symptoms of OCD.

Subject showed an excellent response to fluoxetine with complete remission of OCD symptoms within 4 weeks of treatment. The relationship between OCD and HD has been little-investigated, despite the fact that both diseases are associated with striatal dysfunction and that the number of case reports of obsessive-compulsive symptoms either preceding the clinical onset of HD or during later stages of the disease is increasing. For example, Dewhurst et al. reported “obsessional features” in 7 of 102 patients at onset of HD.

Firm conclusions to explain this result cannot be drawn. However, a hypothetical involvement of the serotonergic system, suggested by the excess of OCD, seems supported by the response of said subject to fluoxetine. It may be worth further exploring the value of the psychiatric picture in selecting the appropriate treatment for at least some cases of HD. Anecdotal evidence suggest that SSRIs alone or in combination with atypical antipsychotics like olanzapine may be useful for these patients. However, these hypotheses need further testing.

According to NICE guidelines, fluoxetine is a first-line antidepressant for the management of depression in children and adolescents. There has been little discussion on urticaria occurring after 4 weeks on fluoxetine. Urticaria is defined as an itchy skin lesion "with localised oedema and is surrounded by redness which is also known as a wheal and flare phenomenon". In most urticarial scenarios, the trigger which is usually an allergen leads to an increase in levels of histamine among other chemicals into the skin.

We present the case of a 16-year-old young person with no previous history of skin conditions, who developed urticaria 4 weeks after starting fluoxetine for depressive disorder. No other trigger could be identified. On discontinuing fluoxetine, the rash gradually declined over time and completely resolved ten days later. On further enquiry, the patient reported eating at least one chocolate bar a day. He did admit to receiving a large amount of chocolate just before the rash began and hence was possibly eating more than his usual amount at the time. Furthermore, the rash occurred at the point when steady-state levels of fluoxetine were believed to have just been reached.

Adverse effects of medication have always been a challenging part of managing patients. Although rash that develops acutely after starting fluoxetine has been published so far, literature on rash that develops after 4 weeks on treatment is limited. Cederberg et al (2004) and Gahir (2021) described the association of SSRIs (fluoxetine and sertraline) and chocolate (which contains serotonin) leading to an itchy hive-like rash. In these cases, discontinuation of the SSRI and use of antihistamine led to a resolution of symptoms.

We report a case who developed urticaria 30 days on fluoxetine without any other identifiable triggers. Aspects of this case to support a possible rash caused by chocolate-fluoxetine interaction include the rash occurring when the patient was consuming chocolate (quantities possibly increased immediately prior to the onset of rash), rash occurring when steady-state levels of fluoxetine had just been reached, no other identifiable trigger to explain the rash in the history and the slow resolution of the rash which can be explained by the long half-life of fluoxetine.

This report highlights the importance of being mindful of this rare dermatological side effect of fluoxetine despite it occurring weeks after initiation. Patients should also be made aware of this possible side effect and its association with consuming chocolate.

This case highlights an atypical presentation of a patient with known history of Bipolar Affective Disorder who experienced rapid mood changes and atypical neurological symptoms after he was tested positive for COVID-19.

Here we present a 63 years old male patient who was an inpatient in low secure forensic unit and has a history of Bipolar Affective Disorder. Patient reported that he started to experience COVID-19 symptoms and was tested positive on 12th April 2020. It was observed that patient experienced low mood, flat effect, anhedonia and decreased appetite for more than a month after he was tested positive. According to his medical records, he experienced significant mood changes suggesting major depression and manic/hypomanic episodes, 4 times to be specific, over 6 months period after having diagnosed with COVID-19 which is correlated with diagnostic guidelines for Rapid cycling Bipolar Disorder. Patient was observed to experience 1 major depressive episode over period of 6 months before his COVID-19 diagnosis. He also reported experiencing neurological symptoms such as tremor, numbness and unsteadiness on one leg. Although it was found that his lithium level was above therapeutic range at the beginning of these symptoms, even after successful reduction of Lithium dose, patient continued to experience these symptoms for another month. There were no gross abnormalities in physical examination and his blood results were not significant. In addition to Electroencephalogram (EEG); Computed Tomography (CT) scan, Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA) were conducted and the results were all insignificant. During this time, he was fairly compliant with his medications. Additionally, his mood was stabilised only partially with the medications he was taking. He did not have any other major environmental, psychological or physical changes that might explain his rapid mood cycling.

Authors considered various different causes for this patient's fluctuating mood. One confounding factor that was considered was blood lithium levels. However, that was proven to be irrelevant since patient continued to experience mood changes and neurological symptoms with therapeutic lithium levels. Also no other organic reasons were found that could explain his neurological symptoms.

Although, authors consider that longer observation period and other confounding factors could affect findings, they cannot confidently reject the impact of COVID-19 infection on patients with enduring mental illness and recommend further research which could lead to more comprehensive guidelines

We report on a case of depression where genetic testing was used to determine potential treatment modalities.

The patient is a 78-year-old man who had suffered from depression for 55 years. He had a serious episode in 2002. He developed a further depressive episode in 2018 which did not respond to paroxetine. He was offered TMS and was initially treated in the NHS and subsequently in the private sector. He went into remission with TMS and continues to remit with TMS however his depression became unstable and it was clear that the paroxetine was having no effect. He agreed to have a genetic test, a buccal mouth swab was taken and posted to gensense in the United States. An 18 page document and a half hour session with gensense are included in the cost of the test. The results of his genetic test and suggestions regarding treatment are detailed below.

SLC6A4 L(G)/S serotonin transporter indicating a less favourable response to SSRI medication (20% response versus 40% response). SNRI medication may be useful.

BDNF Val/Met Met carriers may have poor response to SSRIs and an improved response to SNRI's and TCA's. Met carriers have a 3 times better response to exercise than Val/Val

MTHFR A/A variant, this results in a 70% reduction) in the ability to convert folate to methyl folate (required for the manufacture of serotonin). Taking L-methylfolate supplementation (7.5mg) may improve serotonin production and provide a 2 times increase in response rate to antidepressants.

COMT Val/Val variant indicates improved response with brain stimulation therapy such as ECT and TMS

CACNA1C A/A variant which increases the anteromedial and amygdala activity and increased neuronal activity as a result of increased calcium channel receptors. This variant is associated with more depression, OCD and anxiety. Using lithium, sodium valproate and lamotrigine could be potentially useful in this group.

The patient's antidepressant was switched from Paroxetine to Venlafaxine XL 150 mg, he started taking L methyl folate supplements (7.5mg daily) and was put onto sodium valproate 250 mg 3 times a day. His HAM-D went from 39 in December 2022 to sub-baseline by the end of January 2023. He also started regular mild exercise and daily use of tDCS (Sooma and Flow).

We conclude that genetic testing can be a useful clinical tool and can be helpful in deciding which treatments may benefit.

Angioimmunoblastic T-cell lymphoma (AITL) is a rare (2%) and aggressive form of Non-Hodgkin lymphoma, with poor prognosis and median overall survival under 3 years. Most patients with AITL present at an advanced stage (3 or 4). Neuropsychiatric manifestations of lymphoma, though rare, have been reported as associated symptoms. We present a case of successfully treated Stage 2 AITL, whose rare presentation, of florid affective and atypical psychotic phenomena without neurological deficit, eluded clinical detection of AITL for months.

A 58 year-old gentleman with a history of Major Depressive Disorder, presented to hospital with a second episode of generalised tonic clonic seizure, following 4 months of manic disorganised behaviour and multimodal hallucinations.

Atypical psychotic features (preserved insight, multimodal hallucinations resistant to high dose anti-psychotics) and new systemic symptoms prompted suspicion of underlying organic pathology. CT Thorax Abdomen and Pelvis uncovered enlarged bilateral common iliac and external iliac lymph nodes, and small sub-centimetre retroperitoneal nodes. Eventually, Stage 2 Angioimmunoblastic T-cell lymphoma (Pattern 1 & 2), with concomitant psychosis with atypical features, was diagnosed.

Olanzapine 10mg ON and 2.5mg OD PRN, Sodium Valproate EPILIM CHRONO 300mg BD and Diazepam 10mg ON were continued over 6 rounds of chemotherapy and autologous stem cell transplant. The patient remains in remission.

Neuropsychiatric manifestations of lymphoma are rare and usually associated with Central Nervous system (CNS) lymphoma. Here, we observe Stage 2 AITL (without CNS involvement), can present with neuropsychiatric symptoms in the absence of neurological deficits.

We found the combination of Olanzapine, Sodium Valproate and Diazepam to be effective in managing secondary neuropsychiatric symptoms.

Limbic Encephalitis is an important consideration for similar cases despite this patient not meeting the qualifying criteria (unremarkable neuroimaging and EEG).

This case highlights the importance of a thorough history, documenting and understanding the patient's psychopathology (both reported and observed), and differentiating atypical psychotic features which raise suspicions for underlying organic pathology.

This case is an an eye-opener for psychiatric and non-psychiatric clinicians. It reminds us to remain vigilant in such florid psychiatric presentations and highlights the importance of thorough organic workup and psychiatric medications that may be used to successfully address psychosis secondary to lymphoma.

We hope to contribute to the increasing awareness and broadening literature of psychiatric disturbance as initial manifestations of malignant illnesses, and the association between psychiatric manifestations and the rare form of lymphoma, AITL.

Serotonin reuptake inhibitors (SSRIs) are commonly used to treat obsessive-compulsive disorder (OCD). In the UK, sertraline and fluvoxamine are the only SSRIs licensed for use in young patients with OCD. There is currently limited evidence suggesting an increased risk of urinary incontinence with SSRI use. Literature in children and adolescents is even more scarce, with only a few published case reports of SSRI-induced urinary symptoms. This case report adds to the pre-existing evidence in support of the previous suggestion on sertraline-induced urinary incontinence.

A 14-year-old girl with a diagnosis of OCD was treated with a combination of cognitive behavioural therapy (CBT) and sertraline, which was gradually titrated in steps of 25 mg fortnightly. There was a noticeable improvement in her OCD symptoms soon after the medication was initiated. However, a few days after sertraline was increased to 100 mg, she started to report urinary incontinence, urgency, and frequency, both daytime and nighttime, which significantly impacted her quality of life. She denied other urinary symptoms or change in fluid intake. Investigations for diabetes mellitus and urinary tract infection were negative. It was therefore concluded that her urinary incontinence was related to an increase in sertraline dosage, and she was advised to take an alternating dose of 75 mg and 100 mg daily. The symptoms resolved shortly afterwards, and sertraline was subsequently titrated up to 150 mg daily without any issues.

Due to its rare encounter, the association between the use of sertraline and urinary incontinence has only been quantified in a single retrospective study with an adjusted risk ratio of 2.76 (95% CI 1.47–5.21). A clear temporal relationship of symptoms, its occurrence after the dosage increase, and rapid resolution after dose reduction confirmed the role of sertraline in the development of urinary incontinence in this case. Consistent with a previous case report, the dose-dependent effect was also implied. This phenomenon might be explained pharmacologically by sertraline's serotonergic activation, which can potentiate neuromuscular cholinergic transmission in the detrusor muscle, and dopaminergic activation, which can stimulate urine micturition. However, the exact mechanism remains unclear.

Although sertraline-induced urinary side effects occur relatively infrequently, clinicians should be aware of and actively look for these side effects, especially in patients who are prescribed SSRIs at higher doses. It is also important to exclude other causes that may contribute to urinary incontinence.

Neuroleptic Malignant Syndrome (NMS) is a rare, life-threatening complication of antipsychotic medication. There are no gold standard tests to diagnose NMS, however various diagnostic criteria have been suggested. NMS is typically reported in patients who have recently commenced an antipsychotic or had a change in dose. This case report describes an elderly female who developed NMS after being treated with the same dose of antipsychotic for 7 years. We aimed to establish whether similar cases are commonly reported, and what the key learning outcomes are.

This case presents an 82-year-old female taking the same dose of zuclopenthixol for 7 years. She was admitted with increased confusion and was initially prescribed antibiotics for a possible infection. She later became pyrexial and developed hypertonia, at which point NMS was suspected. Her creatinine kinase titre was significantly elevated, and her antipsychotic was discontinued. A potential trigger was a significant rectal bleed occurring a few weeks prior with no other obvious triggers noted. She was switched to quetiapine but developed NMS again when this dose was increased.

There are few reports of NMS occurring in patients taking a long-term and stable antipsychotic dose. One case describes NMS developing after 30 years on Clozapine with no clear trigger. Another reports NMS after 7 years on Olanzapine, however this was triggered by dehydration. This case is an example of NMS in an elderly patient with a complex medical history who was initially misdiagnosed with sepsis before NMS was suspected. This shows the importance of considering NMS not only in those who have recently commenced antipsychotics or recently changed dose, but also those who have been stable on medication for a number of years. In suspected NMS, we should aim to stop relevant medication immediately and commence conservative management. It is important to highlight these atypical presentations so that NMS can be recognised without delaying treatment, thereby reducing mortality and improving patient outcomes

This report highlights the importance of considering NMS in patients who have been prescribed the same dose of antipsychotic for an extended period. Awareness of potential risk factors such as medical comorbidity that may trigger an episode of NMS even in those on established antipsychotic treatment is vital. Symptoms may mimic infection and it is important to raise awareness of atypical presentations to effectively identify, and treat, NMS earlier to improve outcomes.

Selective serotonin reuptake inhibitors play important role in treatment of various psychiatric disorders. Commonly prescribed SSRIs include Sertraline and Fluoxetine. Fluoxetine has a high level of serotonin reuptake inhibition and a prolonged half-life. SSRIs can increase the risk of gastro-intestinal bleeding. A recent systematic review suggested an increased risk of intracranial bleeding in patients taking SSRIs. Psychiatric patients on SSRIs may present with menstrual disorders. Currently, there is limited information on its effect on menstrual cycle. The aim of this study is to explore the possible association between Fluoxetine and menorrhagia.

Case Study ,29 years old, female patient, diagnosed with mixed anxiety and depression ICD-10 F41.2. No previous medical history of menstrual disorders. She started sertraline medications, initial dose of 50 mg, which was gradually titrated to 150 mg. After 12 weeks, Sertraline was discontinued due to limited effectiveness and was started on fluoxetine 20 mg. Dose was gradually titrated to 40 mg, Menorrhagia for 14 days was reported. Physical examination was unremarkable. A period of discontinuation of fluoxetine attempted leading to partial resolution of symptoms. However, 2 weeks later after careful examination of the risks and benefits, Fluoxetine was re-introduced. A trial of Tranexamic Acid 1 gm t.ds. for five days at the expected date of menstruation was initiated.

Patient had no changes in her scheduled menstrual bleeding when she was using Sertraline. However, after 2 weeks of initiating 20 mg of fluoxetine the patient reported heavy prolonged bleeding with estimated 100% increase in volume and duration of the scheduled bleeding. Dose titration to 40 mg, led to further increase in the severity and duration of the bleeding. Changes in platelet function tests was reported 3 months after initiation of treatment; however, the results remained within the normal range. Tranexamic Acid 1 gm t.ds. for five days led to significant reduction in the severity and duration of bleeding.

Using the WHO-UMC Causality Categories to explore association of the study findings, it is likely/ probable that Fluoxetine is associated with menorrhagia. A likely dose effect association was observed. Possible explanation of the increased risk of bleeding relates to its inhibitory action on platelet aggregation. However, Fluoxetine can be used safely for long term when Tranexamic acid was add. Tranexamic Acid has primary effect on thrombin generation; Its secondary effects is on improving platelet function and coagulation factors, leading to successful reduction in duration and severity of the bleeding.

Moral Injury is a strong cognitive and emotional response occurring upon witnessing, participating in, or failing to prevent an act that goes against one's ethical code. This has been linked with Post Traumatic Stress Disorder, Depression, Suicidality, and Anxiety, amongst others. Data on its association with Schizophrenia are however lacking. Trance and Possession Disorders defined by the ICD-10 refers to a group of disorders involving temporary loss of both the sense of personal identity and full awareness of the surrounding with individuals acting in some cases as if taken over by another personality, spirit, deity, or force with reports of such states occurring in primary psychotic disorder. This case presentation describes a 22-year-old male whose first episode of schizophrenia was preceded by moral injury

A 22-year-old male Nigerian with a strong conservative Christian religious upbringing and a history of receiving a prophecy against having intercourse with women. He started showing symptoms of a mental illness a month after attaining coitarche with a lady. This presentation was characterized by irrelevant speech, intrusive flashbacks and unusual beliefs (excessive guilt, ill health). 7 months after, he was presented to the hospital with above symptoms and disorganized behavior characterized by beliefs of being possessed by four different people, shouting in different voice textures, throwing himself on the floor. We kept in view a diagnosis of schizophrenia and placed him on oral Olanzapine 5mg nocte following which he made significant improvement within 2 weeks with no memory of the event.

Different factors can be considered in the aetiopathogenesis and presentation of symptoms in this patient. According to Williamson V. et. al; An Individual's experience of moral injury may lead to feelings of shame or guilt which was present in this patient (delusion of guilt). The pathogenic effect of culture and religion(e.g through prophecy against intercourse with women) may account for this illness. Moreso, pathoplastic and pathoreactive effects of culture could be said to have contributed significantly to the presentation of a psychotic disorder with trance and possession state as a reaction to moral injury.

Moral Injury, not previously considered to be associated with primary psychotic disorder may not only possibly precipitate a primary psychotic disorder but also show cultural/religious differences in phenomenology.

Further studies are therefore required to explore these associations.

A 53-year-old male was admitted with non-resolving Priapism for 36 hours and was reviewed for advice regarding his psychotropic medications. He previously took Viagra about 2 days ago, and had an erection which resolved spontaneously. He underwent penile aspiration in the hospital which provided relief. Following that, he developed signs of infection which was treated with IV antibiotics. He was then waiting for further surgical correction.

He has a background history of psychotic illness and been treated with Quetiapine, Mirtazapine, Sertraline and Zopiclone, which were kept on hold during his admission. He reported that he currently suffers from depression and signs of psychosis, which take the form of auditory hallucinations and paranoid delusions.

He has been taking Viagra occasionally for years, but has not experienced side-effects like this before. He is a social drinker and previously smoked cannabis.

From the above scenario, there appears to be two clinical questions:

1. 1. Are the current medications responsible for his priapism?

2. 2. What medication(s) would be a suitable alternative if his priapism was indeed caused by his current drug regimen?

The major causes of Priapism are: direct trauma; haematological diseases; neurological diseases; cerebrovascular diseases; Medications; TPN and Neoplasm. Apart from medication side-effects, these other causes were ruled out.

The Summary of Product Characteristics for mirtazapine, sertraline, quetiapine and zopiclone were studied for their relative risk of causing priapism, and this is summarised below:

• • Mirtazapine: unknown

• • Sertraline: rare

• • Quetiapine: rare

• • Zopiclone: not listed

However, a paper by Salonia et al found that all the above medications except Zopiclone can increase the risk of priapism. Internationally published case reports also list priapism-associated medications as: risperidone; quetiapine; sildenafil; mirtazapine; citalopram; chlorpromazine and olanzapine.

Anti-psychotics cause priapism by Alpha-1 blockade and anticholinergic actions. Most of the antipsychotics have anticholinergic action. The medication which demonstrates the least alpha-1 blockade is Amisulpride which acts by blocking dopaminergic receptors in the brain.

Thus, it is clear from the above discussion that Amisulpride has the least possibility to cause Priapism. The patient was advised to take low dose Amisulpride and afterwards, no other complications were noted.

The prevalence of Attention Deficit Hyperactivity Disorder (ADHD) in children with Cerebral Palsy (CP) is 19%. Whilst there is evidence that methylphenidate is an efficacious first line therapy for patients with ADHD, there is a lack of literature describing atomoxetine use in ADHD with comorbid CP.

Here we report the case of a 17-year old Caucasian female with ADHD and CP. The patient was referred to Child and Adolescent Mental Health Services (CAMHS) for ongoing anxiety following extensive orthopaedic surgery, which was managed with sertraline and concurrent Cognitive Behavioural Therapy.

A CAMHS assessment led to her subsequent diagnosis of ADHD resulting in an initial treatment of low-dose methylphenidate (Ritalin). This was discontinued after four days due to progressive headache, tachycardia, and unilateral leg restlessness. The patient was hesitant to commence lisdexamfetamine, a second line stimulant medication, due to the possibility of similar adverse side effects.

Atomoxetine (20mg/day) was commenced for a month then increased to 30mg/day. After five months, it was discontinued. The patient reported no significant improvements to attention or concentration, but reported a later onset of escalating anxiety prior to discontinuation. Consultation revealed that the patient's anxiety may be attributed to biopsychosocial factors unrelated to pharmacotherapy, but could not discount the possibility that this was a side effect of atomoxetine. Following the discontinuation of atomoxetine, the patient and her carer were amenable to trialling lisdexamfetamine.

Previous data have demonstrated that patients with CP have lower tolerance to particular pharmacological agents, therefore atomoxetine was started at a low dose (20mg/day) to permit a gradual titration up to the recommended therapeutic dose. Worsening anxiety whilst on atomoxetine (30mg/day) may be a result of one or a combination of the following: (1) long-term side effect, (2) subtherapeutic dose response, (3) identified precipitating and perpetuating psychosocial factors, particularly in the school setting.

The case report demonstrated an acceptable safety profile for the use of atomoxetine in a young person with ADHD and comorbid CP. The expected therapeutic benefits of atomoxetine for ADHD may have been offset by extenuating biopsychosocial factors. Further research is needed to determine whether there exists a causal relationship between atomoxetine therapy and worsened anxiety within this patient group. Furthermore, this case highlights the importance of understanding the complexities of ADHD treatment in patients with confounding environmental factors and comorbid neurological disorders.

1. 1. To evaluate the knowledge and experience of staff members working in inpatient units at Oxleas NHS trust on the topic of healthcare of gender diverse service users.

2. 2. To improve the admission process for gender diverse service users by creating an admission checklist, increase awareness and provide training when possible.

A questionnaire with 11 questions was sent to different staff member groups. The questions assessed their knowledge of the policies for gender diverse service users and their clinical experience in dealing with this group of service users when being admitted to inpatient wards.

25 members of staff completed the questionnaire. Of those, 52% were not aware of the existence of a specific policy for admitting and treating gender diverse service users at Oxleas. From the respondents who knew about the policy, 60% did not know where to find it. 44% of all respondents do not ask service users for their preferred name, gender and pronouns when they are admitted to an inpatient ward. From those who ask service users, 45% do not document service users’ chosen name, pronouns and gender identity on RiO (the digital record system used at Oxleas). 68% of participants do not know how to change the demographics information on RiO for service users. When asked about the allocation criteria for inpatient beds, 24% replied that it should be done according to the service user's assigned gender at birth, while 8% responded that they should be allocated to any available bed. 40% of staff members reported that trans service users can not easily access daily personal products on the ward that are related to their trans-specific health needs. 72% of those who responded do not know what specific services or organisations to direct this group of service users to in case they need any further support. 56% of staff do not feel confident in dealing with trans specific needs and 88% have not received any training on the area from the Trust.

Although the Trust has created a specific policy for gender diverse service users, staff members’ knowledge of such policy is sub-optimal. Moreover, there is a lack of training available to staff on inpatient wards, which is reflected in their lack of confidence in working with this group and the lack of knowledge around external services to refer these service users to. In response to this, we have implemented some changes. Pronoun preference has been added to RiO and we have encouraged staff members to use it when completing demographics. An admission checklist specific to gender diverse service users was created and shared within the organisation. We scheduled teaching sessions on this topic, however, these did not go forward due to lack of attendance.

Review of the outcomes from a local EIP service, in terms of symptom control employment status at referral and discharge, admissions whilst under the care of the service physical health status at discharge, discharge was back to primary care or secondary care

Sample of service users discharged from EIP services over the past 2 years between March 2020 and March 2022 was collated

Recovery

Good proportion -84% had good symptomatic recovery at time of discharge based on discharge letter

Discharge to primary care

Low proportion -Only 26% were discharged onwards to secondary mental health services such as recovery teams or community mental health teams and rehabilitation services.

74% discharged to primary care

Review of notes indicate that patient is still within primary care 6-12 months post discharge

Employment

A jump of 16% in employment. At start of EIT input only 40% had employment and at pint of discharge 56% of sample had employment

Inpatient admission

Admissions whilst under the service were seen in 54% patients in total; out of this number just over half (55%; )were admitted to inpatient unit only once

Smoking and Substance misuse

Only 24% were known smokers at discharge; 6%) were misusing multiple substances including smoking, alcohol, cannabis and cocaine at the time of discharge

Physical health and metabolic syndrome

Only 2% had diagnosed hyperlipidaemia at discharge

Early Intervention in Psychosis input lead to good symptom control and resolution of psychosis leading to higher rates of discharge to primary care alongside improved physical health substance misuse employment outcomes.