UK medical students report high levels of stress, in particular within the coronavirus pandemic: 46% have a probable psychiatric disorder; almost 15% consider suicide; 80% describe support as poor or moderately adequate. Our aim was to propose a novel conceptual framework for the implementation of effective interventions to reduce their stress and support wellbeing.

A systematic review of MEDLINE, PsycINFO and CINAHL databases was undertaken with appropriate search terms, supplemented by reference searching. Published quantitative and qualitative primary research was included. Findings were reported in line with Preferred Reporting Items for Systematic Reviews and MetaAnalyses.

Records identified through database searching 2,347; additional records 139; records following removal of duplicates 1,324. Full text studies included 41: ‘Curriculum and Grading’ (n = 4); ‘Mindfulness and Yoga’ (n = 11); ‘Stress Management/Relaxation’ (n = 13); ‘Behavioural Interventions’ (n = 3); ‘Cognitive & Self-awareness Interventions’ (n = 2); Mentorship (n = 3); ‘Education, Screening and Access to care’ (n = 3); ‘Multifaceted Interventions’ (n = 2).

Effective interventions include those that reduce academic stress through grading changes and supporting transition to clinical training; resilience enhancing interventions such as mindfulness, yoga, CBT, group based exercise and relaxation; peer mentorship; faculty mentorship when actively engaged by the mentor; reducing stigma; improving detection; and improving access to treatment.

Outcomes for clinical year students were less promising, suggesting interventions may be insufficient to combat clinical stressors.

We propose a framework for implementing these effective interventions through ‘Ecological and Preventative’ paradigms. The former highlights an individual's interaction with their sociocultural environment, recognising multiple levels of influence on health: individual, interpersonal, institutional, community, and national. At each level the framework of primary, secondary and tertiary prevention can be applied.

Primary Prevention (intervening before health is impacted): reducing academic stress; resilience interventions; mentorship; peer support; brief interventions to avoid progress to established disorders.

Secondary Prevention (reducing prevalence of disorder): early detection through staff training and screening; treatment referral pathways; reciprocal arrangements if peers are placed within local settings.

Tertiary Prevention (reducing impairment): reasonable adjustments, communicated between placements

This recognises that medical students require a range of interventions at multiple levels to reduce stress, promote wellbeing and manage the spectrum of mental health difficulties they may encounter. The ecological framework also acknowledges the reciprocity of individuals being influenced by and influencing their environment, which aligns with the concept of co-production.

Prompt treatment with medication and intensive psychosocial support are interventions that have been shown to improve function and prognosis in patients with First Episode Psychosis. NICE guidelines state that patients with a first episode of Psychosis should remain on an antipsychotic medication for 1–2 years to reduce risk of relapse, yet most patients stop long before 2 years. This systematic review explores the comparative time to all cause discontinuation of antipsychotics, often used as a marker of real-world treatment effectiveness, in First Episode Psychosis patients.

A literature search was performed across multiple healthcare databases from 1980 to present day in the English Language. Inclusion criteria covered patients with a First Episode of Psychosis aged 14 years and over, and studies that were randomised controlled trials or observational in nature. The primary outcome measure was time to discontinuation of antipsychotic medication. Bias was assessed using the GRADE approach.

11 studies and 3840 patients were included in the review. Seven studies were randomised clinical trials; three were blinded, and four open-label. The remaining four were observational studies. All but one of the studies had a minimum follow-up period of one year (with a maximum of three years). Due to significant methodological heterogeneity across studies, it was not possible to perform meta-analysis. Narrative analysis of the results showed that Olanzapine performed ranked best, and wasbeing taken for the longest time period by patients, followed by Risperidone.

Multiple reviews exist on the efficacy of antipsychotics in First Episode Psychosis, but this is the first one to focus on time to discontinuation as a distinct outcome measure. The review encompasses a large sample size across North America, Eastern Asia and Europe. The interaction of time to discontinuation of antipsychotics with associated symptom levels and medication doses remains an area for further research. The review highlighted the significant differences in statistical methodology across studies in this emerging field, and the need for standardisation in ongoing research. Whilst effectiveness may therefore be greatest for olanzapine, this is outweighed in current guidance by its least favourable metabolic adverse effects profile.

It has been shown that the glucocorticoid receptor NR3C1 gene can be methylated (“switched off”) in response to early adversity. Methylation has also been linked to physiological changes in the body's response to stress by changing the sensitivity of the hypothalamic-pituitary-adrenal (HPA) axis. In adults, associations have been made between NR3C1 methylation and borderline personality disorder, depression and post-traumatic stress disorder. Environmental and social co-variates increase with lifespan so establishing cause and effect is difficult. Studies in children, then, may illuminate patterns to inform current hypotheses.

This paper reviews the literature on children and adolescents linking glucocorticoid gene receptor NR3C1 to the psychopathology of mental illness. Findings are presented in an accessible manner to engage people less familiar with genetics and to inform frontline clinicians of this quickly growing area of research.

MEDLINE and PsychINFO were searched for relevant peer-reviewed original research using the following keywords and associated mesh terms: NRC31, glucocorticoid receptor gene, methylation, epigenetics, child, adolescent, trauma, psychopathology, gene expression.

14 studies were identified involving 5475 young people. Degree of NR3C1 methylation was associated with severity of early life adversity. Methylation was linked with psychopathology including borderline personality disorder, internalising symptoms and externalising symptoms with sex differences. The most consistent association was with depression. Methylation seems to modulate the interaction between environment and genetics with the suggestion that the effect may be protective in some cases. However, longitudinal genetic sampling was only conducted in one study.

Heterogeneity of studies in the epigenetics field are discussed but should not detract from future possibilities. The hope is to identify therapeutic targets or monitor response to treatment as we work to better understand the biology of developmental psychology, mental illness and resilience. There is a growing understanding that epigenetic modifications likely change over time and clinical significance is most likely dictated by changes at multiple gene locations. Thus future research may need to move away from single gene research typically employed in favour of longitudinal whole genome studies in larger population studies.

It is time that clinicians integrate the concepts of “epigenetic adaptation to environmental stress” with “nature vs. nurture” in their psychoeducation with families. To understand that one's problems might be the symptom of environmental mismatch, and potentially reversible too, can bring validation and hope to families.

To compare the neurodevelopmental profiles of Albanian street children to those predicted by the Coventry grid.

A street children's centre had requested help to meet children's emotional needs. No program exists for children experiencing ongoing complex trauma. With input from widely-experienced consultant psychiatrist and consultant psychologist, a very low-intensity program of coping skills was piloted. Extensive anonymised notes were taken as part of the piloting.

The Coventry grid is a clinical tool comparing patterns of difficulties typically seen in autistic spectrum disorder (ASD) versus attachment difficulties. It's based on clinical experience and invites ongoing feedback.

12 Children aged 5–12 years completed the two-week program. The notes were examined for their relevance to areas of the Coventry Grid.

The children showed both traits typical of ASD and of attachment problems. Identifying emotions was impossible for the youngest group (5–7 years); while the older groups could say whether someone was likely to feel “good” or “bad” but struggled to differentiate further.

Fantasy and symbolic play were hard for the younger children. If asked to imagine a situation, they replied “but that's not happening”. One child constantly hugged a stuffed doll, but couldn't use it for play. Both younger groups found it hard to imagine a safe-place, though they could say what they wanted in it (chocolate and a working lightbulb). The oldest group all chose a real place related to the centre.

Generalising was difficult for all the children. The older children could say whether a story character was a good friend, but not apply this to real life. The youngest children were told a story about a dangerous stranger. Afterwards, the children said they would still go away with strangers as only the man in the story had said he wanted to harm children.

The younger children were diffusely attached, but the boys’ eye contact, gesturing, and language were normal in all age groups. All children formed friendships easily, played in a group and were intensely loyal to siblings. They didn't show restricted interests, distress at changes to routine or sensory difficulties. They showed good awareness of the widely divergent social rules at the centre and at home.

The children showed a mix of traits usually associated with attachment difficulties and those usually associated with ASD. They may be different from UK clinic samples as they continued to experience severe trauma.

The video-based free social media app, TikTok, has grown in popularity during the COVID-19 pandemic, with half of British children using Tik Tok regularly. With more than 2 billion downloads, it was the most downloaded app of 2020. Child and Adolescent Mental Health Services (CAMHS) is currently found on TikTok via the hashtag #CAMHS. The aim of this study was to explore how CAMHS is represented on TikTok through reviewing the hashtags associated with CAMHS and exploring the themes of videos with the #CAMHS hashtag.

The Tik Tok app was downloaded and a search for the hashtags which featured the word #CAMHS was undertaken. A thematic analysis of the top 100 most popular uploaded videos featuring the #CAMHS was conducted. The number of likes, views and shares of the videos featuring each theme was recorded.

Videos with the hashtag #CAMHS had 203.9 million views, followed by: #camhsmeme(s) totalling 43.1 million views, #camhsjokes with 21.4 million views and #camhskids, 12.5 million views. The top 100 most popular videos represented 24% of total viewed videos with the hashtag #CAMHS.

The most popular recurrent themes associated with the hashtag #CAMHS in our sample were: raising awareness of mental health symptoms and management (40% of videos), reference to self-harm (27% of videos) and negative perception of CAMHS (27% of videos).

Raising awareness of mental health symptoms and management had the most likes (3,694,700) and views (17,435,900). This was followed by videos with themes of reference to self-harm (3,006,300 likes and 14,382,700 views). The most shared themes were: reference to suicide (shared 56,763 times) and videos which portrayed a theme of negative perception of CAMHS (40,628 shares). Videos with themes of a negative perception of CAMHS also garnered 1,762,500 likes and 8,666,900 views.

CAMHS is actively represented on TikTok through freely accessible unregulated videos. Videos with themes of raising awareness of mental health symptoms and management can potentially allow young people to share their experiences. Nonetheless, popular hashtags such as #CAMHSmemes and #CAMHSjokes, as well as videos featuring themes of negative perception of CAMHS, could potentially undermine the reputation of CAMHS to existing and future service users. The content of these videos should be taken seriously by CAMHS clinicians as it can potentially provide an insight into service users’ experiences of CAMHS on a scale that has not been observed before. Presently these videos are not screened or modulated by the NHS CAMHS service.

To suggest a link between sertraline and urinary side effects in a Sheffield Child and Adolescent Mental Health Service population.

Evidence suggests that Serotonin has an important role in bladder control through central and peripheral neurological pathways. Increased serotonergic activity leads to parasympathetic inhibition, which results in urine retention. It is through this mechanism of action and their effect on pre-synaptic serotonin 1A and peripheral 5-HT3 receptors that SSRIs were observed to have anti-enuretic effect. At low 5-HT concentrations, micturition is inhibited whereas at high levels, an excitatory effect is achieved. This may suggest a dose-dependent relationship between Sertraline and urinary side effects.

Inclusion criteria:

Under 18 years of age

On Sertraline

Reported urinary side effects

Exclusion criteria:

Above 18 years

Not on Sertraline

Associated urinary problems

Did not report urinary side effects

Clinical records of eligible patients were accessed to gauge temporal relationship between initiation of sertraline and reported urinary side effects.

Three cases were identified in the authors’ clinical practice at Sheffield CAMHS that were suggestive of a link between sertraline and urinary side effects.

It's important for clinicians to bear in mind the genitourinary side effects of SSRIs, which may be debilitating for patients in the CAMHS population. It's equally important for us as clinicians to educate young people and their parents about these potential side effects and how they can be managed. It has also been observed that higher doses of Sertraline have shown a possible link between onset of urinary side effects.

Psychiatric disorders are increasingly prevalent and present as a comorbidity in many hospitalized patients. Studies have demonstrated that the presence of comorbid psychiatric conditions (CPC) is associated with worsened inpatient outcomes. Emergency surgical admissions and the impact of CPC on their outcomes has not been studied in Ireland to date. This study aims to provide a comprehensive analyses of the relationship between a wide range of psychiatric comorbidities and surgical presentations.

The Hospital In-Patient Enquiry (HIPE) and prospectively maintained electronic patient records were used to identify all surgical emergency admissions between 31st August 2019 and 1st September 2020 to Mayo University Hospital, Ireland. Patient demographics, comorbidities, primary diagnoses, length of stay (LoS), discharge destination, and surgical interventions were recorded. Subgroup analyses were performed examining LoS variation in the type of surgical presentation. Physical comorbidities were scored using the Charlson Comorbidity Index (CCI). Statistical calculations were performed using SPSS.

A total of 995 admissions were recorded. The presence of CPC increased the overall mean LoS by 1.9 days (p = .002). This trend was observed in both operative and conservative management. Significant increase in LoS was noted in patients with a comorbid depression (2.4 days, p = .003), dementia (2.8 days, p = .019), and intellectual disability (6.7 days, p = .007). Subgroup analysis revealed greater LoS in patients with CPC diagnosed with non-specific abdominal pain (1.4 days, p = .019), skin and soft tissue infections (2.5 days, p = .040), bowel obstruction (4.3 days, p = .047), and medical disorders (18.6 days, p = .010). The odds of nursing home or convalescence as a discharge destination was 2.44 (95% CI: 1.37–4.35, p = 0.002) in patients with CPC and the odds of self-discharge against medical advice in this population was 4.89 (95% CI: 1.43–16.70, p = 0.005). No significant difference was observed in mortality and readmission rates.

Psychiatric comorbidities significantly impact length of hospital stay and influence discharge planning in surgical inpatients. Greater vigilance is required in providing care for patients with psychiatric comorbidities, particularly those with depression, dementia and intellectual disability. Better optimisation of facilities and a more personalised approach to patients with CPC are required to improve inpatient outcomes and resource allocation.

To assess the nature and extent of Theory of Mind (ToM) impairments post-TBI.

Electronic databases searches included PubMed/MEDLINE, PubMed Central, Scopus, PsychArticles, PsychINFO, Web of Science, ProQuest Central, and Wiley Online Library databases. Only studies conducted on adult patients with TBI compared with healthy controls published in English in peer-reviewed journals were considered. Reference lists were manually checked for additional studies. 19 studies were identified.

Marked moderate-to-severe ToM deficits in adults post-TBI were observed across all severities of injury and chronicity. ToM deficits were documented across tasks and reflected a hierarchy where performance worsened significantly as tasks progressed in complexity. Despite supportive factors, certain aspects of ToM impairment, such as ability to detect and interpret non-literal speech and judge appropriateness of context remained affected in the subjects.

ToM deficits represent a robust finding in adults with TBI. The chronicity of TBI requires a long-term view and is complicated by the fact that ToM deficits are invisible and difficult to understand. Perceptive-taking deficits faced by TBI sufferers has bio-socio-economic implications. This review also discusses implications for basic and clinical neuropsychology and rehabilitation efforts. Further research is needed, particularly in the form of large, longitudinal studies that mimic day-to-day interactions, to inform/support rehabilitation programs.

The aim of this study is to systematically investigate the demographic and disease predictors of cognitive and behavioural phenotype in the largest cohort of children with NF1 published to date. Based on previously published research, we examine the potential role of demographic predictors such as age, sex, SES, parental NF1 status as well as the neurological complications such as epilepsy and brain tumours in NF1 associated cognitive/ behavioural impairments.

In this cross-sectional study design, participant data were drawn from two large databases which included (i) A clinical database of all patients with NF1 seen in a clinical psychological service from 2010 to 2019 and (ii) A research dataset from two previously published studies (2,8). The complex National NF1 service based within Manchester regional genetic services is set up for individuals with complex NF1 (https://www.mangen.co.uk/healthcare-professionals/clinical-genomic-services/nf1/) in the North of the UK. Children were referred to the psychological services by NF1 clinicians if psychological assessment was warranted based on parental reports. In order to reduce clinic referral bias, the clinical sample was supplemented by including participants that were seen solely for the purposes of research studies within our centre.

Relative to population norms, 90% of the NF1 sample demonstrated significantly lower scores in at least one cognitive or behavioral domain. Family history of NF1 and lower SES were independently associated with poorer cognitive, behavioral and academic outcomes. Neurological problems such as epilepsy and hydrocephalus were associated with lower IQ and academic skills.

Cognitive and behavioural phenotypes commonly emerge via a complex interplay between genes and environmental factors, and this is true also of a monogenic condition such as NF1. Early interventions and remedial education may be targeted to risk groups such those with familial NF1, families with lower SES and those with associated neurological comorbidities.

Alterations in cerebral blood flow (CBF) may contribute to the development of depression, and serve as a novel biomarker. The aim of this review is to summarise and synthesise the available evidence on alterations in cerebral haemodynamics in depressive disorders relative to healthy control populations.

MEDLINE (1946- present), EMBASE (1947– present), Web of Science (1970–present), PsycINFO (1984–present), CINAHL (1976–present) and CENTRAL were searched using a predefined search strategy. Studies which compared the cerebral haemodynamics of adult patients (>18 years old) with depressive disorders against healthy controls (HC), by any imagining modality, were included. Studies with varying severity and chronicity of depressive disorder were included. A meta-analysis was conducted in four groups: 1) CBF (ml/min/100g) 2) Cerebral blood flow velocity (CBFv) (cm/s) 3) Combined CBF and CBFv 4) Ratio of uptake of radiotracer. A random effects model was used and heterogeneity and publication bias were assessed. Data are presented as mean difference (MD) or standardised mean difference (SMD) and 95% confidence interval (95% CI). A narrative synthesis of the remaining studies was performed.

87 studies met the inclusion criteria. CBF (ml/min/100g) was significantly reduced in patients with depression compared to HC (15 studies, 538 patients, 416 HC, MD: −2.24 (95% CI −4.12, −0.36), p = 0.02, I2 = 64%). There were no statistically significant differences between patients and controls in the other three outcomes. CBFv (cm/s): 6 studies, 305 patients, 198 HC, MD: −1.23 (95% CI −6.10, 3.64, p = 0.62, I2 = 65%. Combined CBF and CBFv: 20 studies, 804 patients, 573 HC, SMD: −0.16 (95% CI −0.32, 0.01), p = 0.06 I2 = 51%. Ratio of uptake of radiotracer: 3 studies, 60 patients, 53 HC, MD: −0.11 (95% CI −0.11, 0.11), p = 1.00, I2 = 0%). The narrative synthesis revealed varying results, with many studies identifying a decrease in CBF in depressed patients compared to controls, but other studies identifying an increase, or mixed results. Multiple regions of impairment were identified, including the anterior cingulate cortex and prefrontal cortex.

There was a statistically significant reduction in CBF in depressed patients compared to controls. The narrative synthesis revealed varying results, however specific regions of interest have been identified. Further research is needed to explore the effect of antidepressant medication, utilising different imaging modalities, and at different levels of disease severity.

In 2020, India was one of the worst affected countries by COVID-19. As the pandemic spread, creating undue pressure on health care workers (HCWs), there was an urgent need for the development of appropriate interventions to protect their mental health. This study aims to study the effect of COVID-19 on the mental health of anaesthesiologists in India and factors that influence their coping behaviour.

The study was designed as a semi-structured, descriptive, cross-sectional, online open survey and conducted on Google forms between 21st May and 20th June 2020, among practicing anaesthesiologists across India. The participants were recruited by sending messages to their emails and through social media platforms. It created a small number of international respondents, who were also included (India = 301, rest = 23). The self-designed questionnaire had 30 questions in the form of multiple choices, checkboxes, linear scales and short comments. Informed consent was recorded at the outset. Details such as demographic characteristics, place and nature of work, pandemic related changes in duration or pattern of work, psychological symptoms during and after working hours, fears about quarantine, were collected in the survey. Statistical Analysis was performed using Statistical Package for Social Sciences (SPSS Statistics for Mac Version 21.0 IBM Corp., USA)

Among the 324 participating anaesthesiologists, a prevalence rate of 64.8% for stress, 51.2% for anxiety and 65.7% for depression was noted, which was double the rate from pre-pandemic studies. Those between the ages of 30 and 50 (p = 0.010 OR:2.191) and working in government run (p = 0.045 OR:2.564) COVID-19 hospitals in India (p = 0.002 OR:2.018), were particularly stressed (33.3%) and anxious (38%) than the rest. Increased workload, contracting the virus and becoming an infectious source to their family (88.6%) were their prime concern. Formulating standard operating procedures (SOP) (66.7%) and procuring personal protective equipment (PPE) (56.2%) were some of the challenges faced at work. Most of them recommended a congenial workplace (68.8%) and family support (60.8%) to help them work through their anxiety and fear, while a few reported considering leaving their career (34.8%) from fear of monetary loss and burn out (53.8%).

COVID-19 has changed the professional and personal life of anaesthesiologists in India. Irrespective of their workplace, their fears and challenges remain universal. Early identification of anxiety and depression and providing appropriate psychological support will prevent deep and enduring damages to the lives of these professionals.

Do psychiatrists believe children are growing up in psychopathogenic environments that significantly contribute to mental ill- health? If so, do they feel empowered to change those environments? If not, how can psychiatrists be given a role where they can create meaningful change? Finally, how much responsibility can psychiatry usefully take for changing psychopathogenic environments?

We define psychopathogenic environments as environments that predispose to mental ill-health. It is the psychological environment we live in - including income, the way we interact with others (e.g. social media, bullying), what we do with our free time, pressures at school and expectations of our peers. It is not discrete events (e.g. trauma) and stretches beyond life at home (where many ACE's occur).

Self-harm presentations to medical professionals amongst teenagers are on the rise, Universities report a fivefold increase in disclosure of mental health conditions in the last decade. Here we consider if psychopathogenic environments are part of the cause of these changes.

A 10-item questionnaire distributed to Child and Adolescent Psychiatrists in NHS Lothian, NHS Grampian and Manchester University NHS Trust via a consultant in each Trust.

All 14 respondents said psychopathogenic environments are “very important” contributors to mental ill-health. 13/14 say the environments have got worse in the last 10 years. 13/14 responded negatively about whether psychiatrists could change them. When given white space to tackle the problem they suggested changes were needed from Government including against poverty / inequality, education, public health nudges, more resources, MDT working and better access to leisure facilities. Given specific choices, 11/14 identified influencing Government as a major way forward.

This group of psychiatrists believe psychopathogenic environments are; 1) a very important contributor to mental ill-health 2) getting worse but 3) feel largely powerless to tackle it. It is a problem they think is important and want to engage in, but lack time, resources and struggle with the complexity of the problem. How therefore, can psychiatrist show leadership in this area? The two perspectives to consider how to empower psychiatrists to help create change are 1) how they can influence the environment for individual patients, 2) how they can influence public policy and government to make wider changes.

Is this the job of psychiatrists? Not alone, but as agents they have a unique insight and authority as both a lens for and director of these environments.

To describe and compare psychoactive substance misuse help-seeking among transgender (trans) and cisgender (cis) participants from a large multi-national cross-sectional survey.

Trans people experience stressors related to their minority status which have been associated with increased rates of psychoactive substance use and related harm. Despite this, there is a paucity of evidence relating to the treatment needs of trans people who use psychoactive substances, beyond a small body of literature describing a culture of transphobic hostility in general substance misuse services. This paper aims to describe and compare psychoactive substance misuse help-seeking among trans and cis participants from a large multi-national cross-sectional survey.

Over 180,000 participants, recruited from the world's largest annual survey of drug use - the Global Drug Survey (GDS) - during 2018 and 2019, reported use of a range of psychoactive substances in the preceding 12 months. Five gender groups (118,157 cis men, 64,319 cis women, 369 trans men, 353 trans women and 1,857 non-binary people) were compared, using Chi-square and z-tests with Bonferroni correction, on items relating to the desire to use less psychoactive substances and the need to seek help to achieve this. Respondents from GDS 2018 were also assessed for substance dependence. Binary logistic regression was used to compare gender groups on self-reported substance dependence to frame the help-seeking analyses.

Trans respondents (n = 1,710) to GDS 2018 were significantly more likely than cis respondents to report use of illicit substances (OR = 1.66-2.93) and dependence on cannabis (OR = 2.39), alcohol (OR = 3.28) and novel psychoactive substances (OR = 4.60). In the combined GDS 2018 and 2019 dataset, there were no significant differences between trans (n = 2,579) and cis (n = 182,476) participants on the desire to reduce substance use. However, among those who did report wanting to use less, non-binary people and trans women were most likely to want help to achieve this.

Trans respondents reported a greater need for help with reducing substance use than cis respondents. Given the deficit of specialist services for psychoactive substance users who are trans, there is a need for a more thorough understanding of the barriers and facilitators to their engagement in general substance misuse services. In the interim, substance misuse service providers require education about gender minority status to help meet the needs of trans clients.

To understand the prevalence, patterns and correlates of substance use among transgender adults.

Minority stress theories suggest that the increasing rates of discrimination experienced by transgender people are precipitants of substance use. This is likely exacerbated by an inadequate provision of trans-inclusive substance misuse services. However, the exclusion of transgender people from the general substance misuse literature makes it difficult to determine the extent to which gender minority status influences substance use. A systematic review was undertaken to better understand the prevalence, patterns and correlates of substance use among this group.

In accordance with the PRISMA guidance, a literature search was conducted to 29th May 2019 on PubMed, PsycINFO, EMBASE and Global Health databases. Primary quantitative studies, published in the English language, that reported the prevalence, patterns or correlates/risk factors of substance use by trans people were included, with no restriction on methodological design.

651 unique records were identified by the search and 40 studies were included in the synthesis. While there was some suggestion of excess risk of substance use among trans people, there was insufficient evidence to estimate prevalence or quantify the risk of substance use among transgender people, relative to a cisgender population. However, this review identified several gender minority related correlates of substance use which are of relevance to clinicians working with transgender patients, including transphobic discrimination or violence, unemployment and sex work, gender dysphoria, high visual gender non-conformity and intersectional sexual minority status.

There are currently significant gaps in the trans substance use literature, relating to the disproportionate investigation of transgender women with multiple intersectional disadvantages, who are not representative of the wider trans community. However, there is sufficient evidence to recommend screening for substance use when individuals report high levels of gender minority stress and to consider the use of integrated trauma-informed psychosocial interventions when managing problematic substance use in the transgender adult.

Changes in the severity of tics in Tourette's syndrome (TS), as seen with variations in the intensity or frequency of tics, can be moderated by a variety of independent factors such as external or internal stimuli. Identifying such moderators has important clinical implications as it can aid clinicians in adjusting interventions. Hence, based on our previous review of tic-severity moderators, we developed a clinical inventory of moderating variables for motor and vocal tics for inclusion in the new version of the Queen Square Proforma for Tourette's Syndrome to aid initial assessments in the National Tourette Syndrome Service's Outpatient Clinic for Adults.

A review of tic-severity moderators was previously carried out by the authors to investigate the kinds of moderators and their worsening, improving or neutral effects on tic severity. Based on this a semantic thematic analysis of the identified moderators was carried out and themes were developed based on appropriate and relevant MeSH terms in order to create the categories and items of the clinical inventory.

Seventy-three different tic severity moderators were identified, the most common being exercise, sleep, peer victimisation, psychosocial stress, watching TV, academic activities and distraction. Twenty-nine themes emerged from the thematic analysis which were then used to update the clinical inventory of tic severity moderators. The review also highlighted the subjectivity of these moderators’ effects on tic severity as some moderators were tic-worsening in some individuals and tic-improving or neutral in others, which is contrary to the current dichotomous understanding.

The updated clinical inventory of tic severity moderators invites researchers and clinicians to be more aware of the existence, variability and subjective effects of these tic severity moderators in individuals with TS, as these have been previously looked in a dichotomous way. By better identifying tic-severity moderators and their worsening, improving or neutral effects on tic severity this clinician rated inventory will have potentially important, direct implications for the management and treatment of tics.

To explore the relationship between weight, BMI and differentiated white cell count in patients with anorexia nervosa that have commenced refeeding protocols.

Hypotheses:

• 1. Weight and BMI will be positively correlated with differentiated white blood cell measures.

• 2. Regression analyses will indicate that differentiated white blood cell measures can predict weight and BMI.

Anorexia nervosa is a serious mental illness with the highest psychiatric mortality rate. It is characterised by an extreme overvaluation of body image and a preoccupation with weight loss that is achieved through calorie restriction, purging or laxative abuse. The eventual malnutrition that is as a result of self-starvation causes significant negative physical sequelae. One such consequence is the detrimental effect that starvation has on the immune system, leading to bone marrow suppression and cytopenias. In obesity, weight loss has been shown to cause reductions in differentiated white blood cell counts, which are often reduced in anorexia. No studies to date have explored whether weight is related to white blood cell count in anorexia, despite being a common finding in patients.

All subjects were inpatients or ex-inpatients on an eating disorder unit in the Wirral, NW England. Subjects were assessed according to an inclusion criterion. 12 consecutive weekly weights, BMIs and differentiated white blood cell measures were collected for analysis in SPSS. Correlational and regression analyses were then performed to examine the relationship between variables.

302 data points from 26 individuals were used in the final analysis. Weight and BMI both moderately positively correlated with white cell count, r = 0.364 p < 0.001 N = 302 and r = 0.521 p < 0.001 N = 302, respectively. Weight and BMI also moderately positively correlated with all differentiated measures of white blood cell count. Linear regression revealed a significant regression equation between weight, BMI and white blood cell count: (F (1,301) = 22.482, p < 0.001) R2 = 0.69 and (F (1,301) = 112.244 p < 0.001) R2 = 0.272, respectively.

We have demonstrated that there is a moderately positive relationship between weight, BMI and differentiated white blood cell measures. Furthermore, in line with our hypotheses, differentiated white blood cell measures have some power to predict weight and BMI. This further implicates the effect that starvation and anorexia nervosa have on the immune system. It also highlights the possibility that it might be possible to use immunological markers in order to deduce whether weights have been falsified by those with anorexia nervosa.

To explore the impact of the March 2020 lockdown restrictions on the cardiometabolic risk factors of male forensic and rehabilitation inpatients in one NHS trust in the United Kingdom.

Retrospective data from September 2019 to September 2020 (six months before and after the 23 March 2020 lockdown) was collected by evaluating the health records of male patients in a low secure forensic ward and two rehabilitation units.

The number of patients with BMI values within the study period was 34 while the number of patients with blood results was 26. This study showed that the average BMI six months before the start of the March lockdown was 29.8 kg/m2 while the average BMI at the end of six months after the lockdown was 31.8 kg/m2.

The results from the 6-month interval before the March 2020 lockdown (M = 0, SD = 0) and the 6- month interval after the March 2020 lockdown (M = 0.9, SD = 4.16) indicate that the March 2020 lockdown resulted in an increase of BMI, t (5) = 2.42, P = 0.036. The result is significant at p < 0.05

8.8% of patients had an increase in their doses of antihypertensive agents after the lockdown whereas no patients had an increase of dose before the lockdown. 7.7% of patients had an HBA1c of more than 48 mmol/L after the lockdown compared to 3.8% before the lockdown. The serum triglycerides and total cholesterol levels also increased after the lockdown with an average increase of 0.17 mmol/L and 0.25 mmol/L respectively. The average serum HDL levels decreased after the lockdown with an average decrease of 0.06 mmol/L.

There appears to be a positive correlation between the onset of the March 2020 lockdown and an increase of BMI, worsening of blood pressure, glycemic control and lipid metabolism.

Limitations

1. (1) Waist circumference was not measured during the study period preventing us from examining all of the features of metabolic syndrome.

2. (2) This study did not look at the levels of physical activity (such as access to section 17 leave) and dietary habits before and after the March 2020 lockdown which may explain the results found.

To raise metabolic awareness of the impact of the lockdown restrictions on cardiometabolic risk in people with SMI and the general public.

Recruitment into psychiatry remains a major issue nationally despite recent progress with the #choose psychiatry scheme. Here we look to establish why Northern Ireland (NI) has been able to have 100% fill rates by speaking to the people who have work in the frontline of psychiatry. What is done differently in NI and are there lessons that could benefit other regions?

NI presents itself as an anomaly – In a region that only attracts 31.8% of F2s to enter into any training programme, Core psychiatry has been consistently oversubscribed for many years. One difference is the allocation of trainees in the Foundation programme. NI offers psychiatry placements to 33% of F2 doctors with none in the F1 year.

All doctors of any grade working in psychiatry who had been through the Foundation programme since 2006 were asked to complete a survey on their foundation experience and reasons for choosing a career in psychiatry using SurveyMonkey technology. Qualiative and quantiative data was collected and analysed.

in total 67 doctors from CT1 to Consultant and SAS doctors responded, including over 60% of all current trainees, providing a huge amount of information. Remarkably, 45% of psychiatry doctors working in NI surveyed hadn't considered a career in psychiatry until their foundation placement. NI is the only region in the UK that does not have an F1 placement in Psychiatry. Over 80% of doctors here feel that this is a positive. White space answers revealed other aspects of training that positively influenced them to choose psychiatry including a reputation for high quality training, as well as close links between the local medical school, the local brach of the Royal College of Psychiatrists and the NI deanery.

This study is the first to examine the reasons behind psychiatry's success in NI. The quality of the training scheme locally and presence of an excellent training to service provision balance were also mentioned. This study supports the presence of psychiatry in the F2 year only.

The aim of this survey was to assess any fluctuations in anxiety levels experienced by mental health workers during the COVID-19 pandemic and the association between these changes and variables of information dissemination, risk management, and managerial support.

A survey was created to assess variables of information dissemination, risk management, and managerial support. The GAD-7 was employed as measure for anxiety during and pre the pandemic The survey was conducted online via an anonymised questionnaire and disseminated by management through the heads of various disciplines within the mental health work force, using the local email portal in the Cork region. It was made available for research participation for a period of one month(JULY).

Following this stage, the reported data were analysed utilizing paired samples t-test, Pearson's correlations, and a hierarchical regression. Demographic variables were controlled for during analysis.

102 mental health healthcare workers participated in the survey (81.2% Female, 18.8% Male). The mean GAD-7 total scores for Pre-COVID-19 doubled in the during COVID-19 condition. The largest effect can be seen on the GAD-7 facet of “feeling afraid as if something awful might happen” with pre-COVID-19 GAD-7 mean scores more than quadrupling during COVID-19 conditions.

Managerial support had a moderate negative relationship with GAD-7 scores during the COVID-19 pandemic. Information dissemination total scores also had a moderate positive correlation with managerial support total scores and perceived risk/safety total scores. There was no correlation found between the GAD-7 total scores during COVID-19 pandemic and Information dissemination total scores nor Risk/safety total scores. Childcare was a concern for 64% of staff that it was applicable to; 45% of these staff considered altering work hours; 17% reported issues from management regarding these requests.

Mental health workers have seen a dramatic increase in anxiety since the COVID-19 pandemic, particularly in the context of expecting something bad to happen. Managerial support appears to be a protective factor for increased anxiety levels in this population. Childcare has been a predominant concern and altering working hours to accommodate this has been problematic for almost 1 in 5 mental health workers. Staff satisfaction with information dissemination positively affects perceived managerial support and perceived risk management.

This study is limited by the utilization of a novel self-created measure for examining variables specific to the COVID-19 pandemic and to the employment of a retrospective measure to obtain baseline anxiety scores of staff members before the pandemic.

We set out to examine the differences in metabolic profiles of at risk (overweight) patients across commonly used atypical antipsychotics (Olanzapine, Risperidone, Clozapine). We hypothesized that Olanzapine and Clozapine group will have more metabolic abnormalities compared to Risperidone.

Cardiovascular diseases remain the leading cause of morbidity and mortality among people with schizophrenia. Since the introduction of atypical antipsychotics, there is cumulative evidence of their association with metabolic abnormalities. Clozapine and Olanzapine are known to constitute the highest metabolic risks amongst atypical antipsychotics.

This study is based on the data of 67 subjects recruited into a 12-week open-labelled trial looking at the effects of adjunctive Aripiprazole in atypical antipsychotics for weight reduction and improvement in metabolic profile. Metabolic profiles including weight, waist circumference, fasting blood glucose, HbA1c, serum total, HDL and LDL cholesterol levels and triglycerides were measured at baseline. The measurements were then compared across the different subgroups of atypical antipsychotics. The definition of metabolic syndrome proposed by the Third Report of the National Cholesterol Education Program Expert Panel (Adults Treatment Panel III) was used.

The atypical antipsychotics were grouped into Olanzapine (n = 27), Risperidone (n = 24) and Clozapine (n = 16). More than 50% of clozapine-treated and Olanzapine-treated overweight patients were demonstrated to have metabolic syndrome at baseline. There was a statistically significant difference in serum triglycerides (p = 0.012), LDL (p = 0.046) and HbA1c (p = 0.045) across the three groups as demonstrated by one-way ANOVA. A Tukey post hoc test showed that both the Olanzapine (p = 0.032) and Risperidone (p = 0.013) groups demonstrated statistically significant lower serum triglycerides when compared to Clozapine. Interestingly, the mean serum HbA1c was significantly lower in Clozapine when compared to Olanzapine group (p = 0.045), perhaps reflecting the closer monitoring of fasting blood sugar in clozapine patients. When controlled for age and BMI, the significant differences in serum triglycerides remain between Clozapine and Risperidone groups [but not for serum HbA1c]. There were no statistically significant differences across the groups with respect to other metabolic parameters.

At baseline, metabolic dysregulation was demonstrated in all subgroups of overweight patients. As hypothesized, patients on Olanzapine and Clozapine groups fared worse than Risperidone. Further studies examining long term effects of atypical antipsychotics in a larger sample of patients are warranted to confirm these findings. These findings have clinical significance in terms of choosing the first antipsychotic for drug naïve patients or where there is no clinically significant difference in efficacy.