The ‘at-risk mental state’ (ARMS) for psychosis has been critiqued for its limited prognostic ability and identification of a limited proportion of those who will develop a first episode of psychosis (FEP). Broadening the search for high-risk groups is key to improving population-level ascertainment of psychosis risk.

To explore risk enrichment in diagnostic, demographic and socio-functional domains among individuals referred to an early intervention in psychosis (EIP) service not meeting ARMS or FEP criteria.

A retrospective file review of 16 years of referrals to a tertiary EIP service in Ireland was undertaken. Diagnostic outcomes from standardised assessments (Structured Clinical Interview for DSM), demographic (age, gender, family history, nationality) and socio-occupational (relationship status, living status, working status) variables were compiled for those not meeting criteria. These were compared with individuals diagnosed with an FEP in the same period.

From 2005 to 2021 inclusive, of 2025 index assessments, 27.6% (n = 558) did not meet either FEP or ARMS criteria, which is notably higher than the 5.4% (n = 110) meeting ARMS criteria. This group had high psychiatric morbidity, with 65.4% meeting criteria for at least one DSM Axis I disorder. Depressive, anxiety and substance use disorders predominated. Their functional markers were poor, and comparable to the FEP cohort.

This group is enriched for psychosis risk factors. They are a larger group than those meeting ARMS criteria, a finding that may reflect EIP service configuration. They may be an important focus for further study in the search for at-risk populations beyond the current ARMS model.

The BMA's survey results (Caring for the Mental Health of the Medical Workforce, 2019) and HEE's NHS Staff and Learners’ Mental Wellbeing Commission report (2019) highlighted declining staff wellbeing. The COVID-19 pandemic has sharpened focus on this and the effects of moral injury on healthcare professionals. Shielding, social distancing and redeployment led to many medical trainees being increasingly isolated at a time of heightened anxiety and adversity. Psychiatry trainees tend to have good access to reflective groups, but this is not customary in other training programmes.

Intervention

“Trainees4trainees” was set up by trainees across specialties as a HEE-TV well-being project, led by the Deanery Trainee Improvement Fellow. Peer support groups are run on Zoom, facilitated by 2 trainees with special training in peer support. Psychiatry trainees have been involved in designing and facilitating groups and training facilitators from other specialties; facilitators have regular supervision from a consultant psychiatrist in medical psychotherapy. Trainees are supported to discuss challenging experiences and think about their emotional responses in a supportive and validating group.

Feedback

We are in the process of formal data collection to assess the impact of the intervention. Informal feedback suggests the groups are a powerful support to individuals who otherwise have no avenue to think about the psychological impact of their experiences. The groups have supported trainees to feel less isolated and bolstered their resilience.

Future plans

We have faced challenges in the practicalities of establishing and maintaining groups. We are working with Training Programme Directors to move towards running the groups in protected time within working hours and advocate that reflective groups, such as our peer support groups, are a key part of future medical and surgical Training Programmes.

The Neuropsychiatric Inventory (NPI) is predicated on the assumption that psychiatric symptoms are manifestations of disease. Biopsychosocial theories suggest behavioural changes viewed as psychiatric may also arise as a result of external behavioural triggers. Knowing the causes of psychiatric symptoms is important since the treatment and management of symptoms relies on this understanding.

This study sought to understand the causes of psychiatric symptoms recorded in care home settings by investigating qualitatively described symptoms in Neuropsychiatric Inventory-Nursing Home (NPI-NH) interviews.

The current study examined the NPI-NH interviews of 725 participants across 50 care homes. The qualitatively described symptoms from each of the 12 subscales of the NPI were extracted: 347 interviews included at least one qualitatively described symptom (n = 651 descriptions). A biopsychosocial algorithm developed following a process of independent researcher coding (n = 3) was applied to the symptom descriptions. This determined whether the description had predominantly psychiatric features, or features that were cognitive or attributable to other causes (i.e. issues with orientation and memory; expressions of need; poor care and communication; or understandable reactions)

Our findings suggest that the majority (over 80%) of descriptions described symptoms with features that could be attributable to cognitive changes and external triggers (such as poor care and communication).

The finding suggest that in its current form the NPI-NH may over attribute the incidence of psychiatric symptoms in care homes by overlooking triggers for behavioural changes. Measures of psychiatric symptoms should determine the causes of behavioural changes in order to guide treatments more effectively.

Despite growing concerns about mental health during the COVID-19 pandemic, particularly in people with pre-existing mental health disorders, research has shown that symptoms of depression and anxiety were generally quite stable, with modest changes in certain subgroups. However, individual differences in cumulative exposure to COVID-19 stressors have not been yet considered.

We aimed to quantify and investigate the impact of individual-level cumulative exposure to COVID-19-pandemic-related adversity on changes in depressive and anxiety symptoms and loneliness. In addition, we examined whether the impact differed among individuals with various levels of pre-pandemic chronicity of mental health disorders.

Between April 2020 and July 2021, 15 successive online questionnaires were distributed among three psychiatric case–control cohorts that started in the 2000s (N = 1377). Outcomes included depressive and anxiety symptoms and loneliness. We developed a COVID-19 Adversity Index (CAI) summarising up to 15 repeated measures of COVID-19-pandemic-related exposures (e.g. exposure to COVID-19 infection, negative economic impact and quarantine). We used linear mixed linear models to estimate the effects of COVID-19-related adversity on mental health and its interaction with pre-pandemic chronicity of mental health disorders and CAI.

Higher CAI scores were positively associated with higher increases in depressive symptoms, anxiety symptoms and loneliness. Associations were not statistically significantly different between groups with and without (chronic) pre-pandemic mental health disorders.

Individual differences in cumulative exposure to COVID-19-pandemic-related adversity are important predictors of mental health, but we found no evidence for higher vulnerability among people with (chronic) pre-pandemic mental health disorders.

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.

Moral injury (MI) refers to psychological distress resulting from witnessing or participating in events which violate an individual's moral code. Originating from military experiences, the phenomenon also has relevance for healthcare professionals dealing with wars, natural disasters and infectious diseases. The deontological basis of medicine prioritises duty to the individual patient over duty to wider society. These values may place healthcare professionals at increased risk of moral injury, particularly in crisis contexts where they may be party to decisions to withdraw or divert care based on resource availability.

We conducted a systematic review of medical literature to understand the extent and clinical and socio-demographic correlates of moral injury during the COVID-19 pandemic.

We conducted a systematic review of reports included in MEDLINE, PsycINFO, BNI, CINAHL, EMBASE, EMCARE and HMIC databases using search terms: “moral injury” AND “covid” OR “coronavirus” OR “pandemic”. We also searched Google Scholar and Ovid Database and conducted reference searching. We searched for published quantitative primary research as well as advance online publications and pre-print research. Findings are reported in line with Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA). Two authors independently assessed the included studies’ methodological quality using a seven-item checklist.

Our databases search identified 498 records and other sources identified 4 records. We screened 391 records after removing duplicates. 4 reports met our protocol requirements.

Three papers used cross-sectional designs. One reported longitudinal outcomes of their sample already described in one of the three papers. Only one study used a MI scoring system validated for healthcare professionals. Others used scoring validated in military populations. These papers reported outcomes from 3334 subjects, with a higher proportion of females. The largest study (3006 subjects) reported MI in 41.3% of their sample. Overall, factors associated with greater MI included: providing direct care to COVID-19 patients; sleep troubles; being unmarried; aged <30 years; female gender; and Buddhist/Taoist faith. Nurses reported a greater severity of MI than physicians. MI significantly correlated with anxiety, depression and burnout. The longitudinal study reported that more stressful and less supportive work environments predicted greater MI at 3 months follow-up.

The average quality assessment score of these studies was 4/7.

It is important that we are able to address moral injury awareness training as part of workforce preparedness and burnout prevention during the COVID-19 pandemic and other disaster responses across the globe.

Little is known about mental health risk factors in medical residents and doctors in Sub-Saharan Africa. Residents are at a greater risk of developing depression, stress and substance abuse than the general public owing to the stressful nature of their medical training. Poor mental health in residents leads to decreased clinical efficiency and training satisfaction; it can also lead to substance dependence, self-harm and suicide.Our primary aim was to ascertain depression prevalence among medical residents in Kenya's largest national teaching and referral hospital. Secondary aims were to analyze how depression was associated with perceived stress, perceived social support, substance use, and educational environment.

Self report questionnaires were administered in this cross-sectional survey to 338 residents covering eight specialties (Medicine, Psychiatry, Paediatrics, Obstetrics/Gynaecology, Anaesthesia, General Surgery, Cardiothoracic Surgery, and Ear Nose Throat Surgery). In addition to key sociodemographics, the Centres for Epidemiology Depression Scale - Revised, Perceived Stress Scale, Multidimensional Scale of Perceived Social Support, Alcohol, Smoking and Substance Involvement Screening Test, and Postgraduate Hospital Educational Environment Measure were used.

The mean participant age was 31.8 years and 53.4% were males. Most residents (70.4%) reported mild/no depressive symptoms 12.7% had moderate, and 16.9% had severe symptoms.High social support (71.8%) and moderate stress (61.6%) were reported by most residents. Almost half (46.3%) rated their educational environment as being more positive than negative. Out of 238 respondents 11.3% were at moderate risk of health and other problems due to cocaine use, while 13.3% (out of 240 respondents) were at risk due to alcohol. On bivariate analyses, we found significant correlations between depression, perceived stress, substance use, perceived social support, and educational environment. Multivariate analysis revealed that depression was strongly associated with: fewer hours of sleep (β = -0.683, p = 0.002), high perceived stress (β = 0.709, p < 0.001) and low perceived social support (β = -2.19, p < 0.001).

High perceived social support, low perceived stress, and less sleep were significantly associated with lower depression scores. A large proportion of residents were at risk of developing depression (29.6%). There were high levels of perceived social support (71.8%). A concerning proportion of residents used substances like alcohol and cocaine. This work is one of few that describe the mental health of an important and understudied population group in an LMIC. Priority must be given to protect and promote the mental health of such a vulnerable group.

Data collection and analysis were funded by Kenyatta National Hospital.

To determine the perceptions of Junior Doctors on whether formal training in risk assessment could help to reduce the number of completed suicides following medical contact.

Foundation trainees within the Great Western Trust were surveyed using a questionnaire. For those trainees that were not present on the acute hospital site, the same questionnaire was distributed by the postgraduate medical team to all trainees using survey monkey. The survey was left open for four weeks. The total response rate was 57/88 foundation trainees. Simple statistical analysis of the data was performed and outlined below.

87% of all the trainees have never done a rotation in psychiatry. 51% of foundation doctors have had between 1-5 patients with suicidal behaviour or ideations admitted under the care of a medical team on which they were the junior doctor and up to 26% have admitted to encountering greater than 10 such patients. Only 37% of foundation trainees who have managed patients with suicidal behaviours admitted to having had any formal training in mental health risk assessment. Foundation trainees report being only somewhat confident in the identifying of factors that make a person high risk of completing suicide. 63% of all foundation trainees would refer any patient who expressed suicidal ideation for formal psychiatric assessment. Majority of the trainees were ‘not so confident’ in their ability to assess a patient's risk of suicide and in offering any help to mitigate this risk. None of the trainees have the intention to pursue psychiatry as a medical specialty and majority (60%) intend to pursue medical specialties. 56% of the trainees felt that training foundation doctors formally to assess patient mental health risk, could reduce the percentage of patients with completed suicide following being seen for non-psychiatric reason.

The UK Foundation Program is a bridge that occupies that gap between undergraduate medical education and specialty training. It therefore an ideal opportunity for training clinicians in mental health risk assessment as one strategy to help reduce completed suicide following non-psychiatric health contact.

Due to the nature of their work, professional drivers face a considerable risk of developing depression and other mental illnesses. We sought to assess the prevalence and the factors influencing depressive symptoms among professional drivers in Saudi Arabia.

Using convenience sampling, we have conducted an interviewer-administered survey on 324 professional drivers in Qassim Region in Saudi Arabia using Depression subscale from the Depression, Anxiety and Stress Scale 21 (DASS-21). Participants were interviewed in their native language, and responses were outlined directly into an online form in English. Data were then extracted and analyzed using SPSS software.

Participants’ mean age was 38.6 years, and mean driving hours per day were 9.86 hours/day. The mean DASS-21 depression score among the professional drivers was 2.88. Overall, 21.9% of the included drivers had variable degrees of depressive symptoms, with 7.4% suffered from extremely severe symptoms. Depressive symptoms were influenced by the driver's nationality, educational level, vehicle type, driving years, BMI, presence of chronic medical conditions, physical activity, and sexual activity. Moreover, poor sleep quality increased the risk of developing depressive symptoms among the drivers by 31.9 times (OR: 31.9, CI: 9.03–112.63, P < 0.001).

Nearly one-fifth of professional drivers in Saudi Arabia (Qassim region) suffer from depressive symptoms. Unhealthy lifestyle practices (i.e. being obese and physically inactive) have been closely related to depressive symptoms. Education, sexual activity, type of driven vehicle, and the number of chronic conditions were also associated with depressive symptoms. Also, poor and fair sleep quality was strongly associated with the development of depressive symptoms as compared with excellent sleep quality. As drivers are always on the move and hardly reachable, we would propose psychological support and counseling to be administered via telemedicine services. Future research is needed to better comprehend the needs of this vulnerable population.

Differential attainment (DA) amongst Black and Minority Ethnic (BAME) medical students and postgraduate trainees including Psychiatry trainees has been extensively documented in medical education, with non-white medical students being 2.5 times more likely to fail high-stake examinations compared to their White counterparts. The Equality Act 2010 places a responsibility on public bodies such as Royal Colleges to address discrimination in training and assessment. Understanding DA in undergraduate medical education can help understand DA in the postgraduate setting. Consequently, this systematic review aims to detect the processes that enable and impede DA in UK undergraduate medical education.

Seven online databases including PubMed, Scopus, PyschInfo, and ERIC were searched. A formal grey literature search was also conducted. Inclusion criteria comprised studies dated from January 1995 to present and included UK undergraduate medical students. We present the preliminary findings from 13 papers, analysed to create a conceptual framework for a further mixed methods analysis. The studies were critically appraised for methodological quality.

Five key themes emerged from the preliminary analysis of 13 papers. BAME students experienced:

Being ‘divergent’: Not feeling part of the current organisational learning milieu

Lack of social capital: Difficulty in being absorbed into existing ‘networks’ of relationships in a manner that is ‘approachable’ and not ‘intimidating’

Continuum of discrimination: ‘Indirect’ impact of subtle communication processes in the learning environment undermining individual ‘belief’ in own performance

Institutional discriminatory factors: Culture, rules, norms, and behavioural routines of educators that lead to differential outcomes for learners

Lack of external support: Relative lack of interventions tackling DA.

The key finding of this review is that British BAME undergraduate medical students experience discriminatory behaviours early in medical schools that impact on personal, educational, and professional outcomes. These factors may need to be borne in mind by postgraduate training organisations such as the Royal College of Psychiatrists as they commence the challenging task of addressing DA.

To identify the number of patients currently on melatonin

To determine the average duration of use of melatonin in patients under the care of S-CAMHS in ABUHB

To investigate whether behaviour interventions were tried and reinforced from time to time

To identify any areas of improvement

Data were collected at St. Cadoc's hospital, in January, 2021. S-CAMHS database was used. Out of total 346 patient currently being managed with pharmacological therapies, 115 (33.2%) are currently on melatonin. 57/115 were randomly selected as a sample for this this project. Patient notes and EPEX software were also used to collect information regarding the sleep management practices.

During analysis, it was noticed that within the sample, only 46 patients were actively on melatonin. Melatonin is prescribed for sleep related issues in ASD (8/46), ADHD (15/46), ASD and ADHD (10/46), ADHD and mood disorder (0/46), ASD and mood disorder (6/46), ADHD and behaviour difficulties (2/46), ASD with behaviour difficulties (1/46), mood disorder (4/46).

39/46 patients are currently on melatonin for more than a year (85%). These patients also include 10 patients who have been using melatonin for 5 years or more.

35 patients (76%) reported improved sleep or some benefit from melatonin.

Evidence for implementation of parent-led sleep behavioural interventions:

Prior to commencing melatonin- Clear evidence available for 35 patients only (76%). These interventions were however not deemed helpful by most of the service users.

While prescribing melatonin- Clear evidence available for 39(85%) patients. Evidence base for melatonin was also discussed during this visit.

During last follow-up visit- Evidence available for 31 patients only (67%).

Majority of patients under S-CAMHS ABUHB remain on melatonin therapy for longer than one year. Most of these patients have reported benefit from this therapy and preferred to remain on it despite being informed about evidence base for melatonin. Also, there is evidence for implementation of sleep behavioural interventions prior to prescribing melatonin, however their benefit remains unclear.

Recommendations:

The quality of education on sleep hygiene offered should be assessed and improved if needed

Formal group sessions/workshops on sleep hygiene/parent-led sleep behavioural interventions at regular intervals might be useful in reducing the chances of long term polypharmacy or unlicensed drugs

Use of outcome measures such as Child Sleep Habits Questionnaire at intervals can be helpful in identifying any improvement from educational/pharmacological interventions

S-CAMHS database (for patients actively on medications) needs a review and update

Trait dissociation has not been examined from a structural human brain mapping perspective in healthy adults or children. Non-pathological dissociation shares some features with daydreaming and mind-wandering, but also involves subtle disruptions in affect and autobiographical memory.

To identify neurostructural biomarkers of trait dissociation in healthy children.

Typically developing 9- to 15-year-olds (n = 180) without psychological or behavioural disorders were enrolled in the Developmental Chronnecto-Genomics (DevCoG) study of healthy brain development and completed psychological assessments of trauma exposure and dissociation, along with a structural T1-weighted magnetic resonance imaging. We conducted univariate ANCOVA generalised linear models for each region of the default mode network examining the effects of trait dissociation, including scanner site, age, gender and trauma as covariates and correcting for multiple comparison.

We found that the precuneus was significantly larger in children with higher levels of trait dissociation but this was not related to trauma exposure. The inferior parietal volume was smaller in children with higher levels of trauma but was not related to dissociation. No other regions of interest, including frontal and limbic structures, were significantly related to trait dissociation even before multiple comparison correction.

Trait dissociation reflects subtle cognitive disruptions worthy of study in healthy people and warrants study as a potential risk factor for psychopathology. This neurostructural study of trait dissociation in healthy children identified the precuneus as an essential brain region to consider in future dissociation research.

Homosexuality was declassified as a mental illness in 1973 however LGBTQ+ (lesbian, gay, bisexual, transgender, queer inclusive) service users still face discrimination within modern mental health services. This project assessed homophobia and LGBTQ+ abuse among service users on an acute male psychiatric ward. Our aims were to quantify the incidence of abuse, to explore staff attitudes toward LGBTQ+ abuse and to identify targets to improve LGBTQ+ service users’ experience. We hypothesised that incidents of abuse are common and not always challenged or escalated using appropriate channels.

Using a mixed methods approach we explored staff perceptions of LGBT+ abuse: quantitative data were generated from a questionnaire survey and qualitative data from a focus group.

Rates of homophobic incidents were assessed by analysing clinical documentation from two inpatient samples (n = 20), covering 2020–21 and 2021–22.

Analysis of clinical documentation found three incidents from the 2020–21 sample and two from 2021–22; only one of these was reported via DATIX.

The survey captured the views of the ward team including nurses, healthcare assistants (HCAs), doctors and psychologists (response n = 13). Staff attitudes towards LGBTQ+ were rated as “positive” by 77% of responders and “neutral” by 23%; 100% stated it was their professional duty to respect and protect LGBTQ+ clients. Almost two-thirds (62%) had witnessed homophobia on the ward however a similar proportion (61%) had never directly challenged homophobia. Whilst all staff felt able to care for LGBTQ+ clients, and all were familiar with key LGBTQ+ terminology, only 50% felt they had received adequate training to fully support LGBTQ+ clients.

The focus group identified a nursing “lead” for LGBTQ+ issues and agreed to incorporate a “diversity statement” into ward admission rules. LGBTQ+ visibility measures were promoted including LGBTQ+ posters across the ward and staff uptake of the Rainbow Badge Initiative.

Our findings suggest homophobia is prevalent in the male inpatient psychiatric setting and management is suboptimal. Enhanced LGBTQ+ training is required to support staff to challenge every homophobic incident and escalate appropriately.

Simple steps to increase LGBTQ+ visibility are feasible and popular among staff. Future work should assess the impact of such interventions, however measuring change may be hampered by underreporting.

Further evaluations are needed to assess female wards and patient perspectives to build a full picture of inpatient LGBTQ+ abuse.

Defensive medical practice has become an increasingly global phenomenon and encompasses all medical specialties. In the UK it was defined in the case of Sidaway v Board of Governors of the Bethlem Royal Hospital [1985] UKHL 1 (21 February 1985) as “the practice of doctors advising and undertaking the treatment which they think is legally safe even though they may believe that it is not the best for their patient”. This narrative review surveys the literature to establish the forms in which defensive practice may manifest itself within psychiatry.

In this narrative review, various terms pertaining to defensive medical practice in psychiatry were searched in both medical and legal databases.

Though the literature in psychiatry compared to other medical specialties is more limited, some common themes occur across all jurisdictions surveyed. Defensive psychiatric practice included admitting the patient even though they may be managed within the community (as reported by 21% of psychiatrists surveyed in the North of England) and employing more coercive practice, either using the mental health legislation or implied or actual threats. Once hospitalised, defensive practice manifests itself by placing patients on higher levels of nursing observations than necessary.

Across inpatient and outpatient settings between one and two thirds of psychiatrists reported altering the way they document to attend to medicolegal considerations. Prescribing habits were also altered due to fears of litigation; an Israeli study found that almost half of psychiatrists surveyed reported they prescribed smaller doses of medication than what they felt was required to pregnant woman and ninety percent reported the same when it came to the treatment of elderly patients.

When looked at by seniority it was felt that junior doctors were more prone to admitting patients defensively than consultants. In this respect, psychiatry differs from most other medical specialties as, in general, the evidence suggests that increased seniority is more likely to lead to admission.

Defensive practice in psychiatry appears to be widespread and takes a number of different forms. However, the research in psychiatry is limited and does not explore key areas common to other medical specialties such as clinician avoidance of certain cases or increased use of diagnostic tests. Furthermore, there is little examination of how psychiatrists may utilise mental health legislation within their defensive practice.

Fahr's disease is a rare neurodegenerative disease with radiological findings of symmetrical and bilateral idiopathic calcifications of the cerebellum, periventricular white matter, and basal ganglia, characterized by the presence of neuropsychiatric symptoms.

We report a case of a 46-year-old male who presented with psychomotor agitation, aggression, restlessness, irritability, decrease need for sleep and psychotic symptoms including grandeur and mystical delusions. He had a previous history of an admission 4 years prior with a similar presentation. Computed tomographic scan of the patient demonstrated a bilateral calcification of globus pallidus. Laboratory investigation was unremarkable. Due to agitation, the patient started treatment with Haloperidol 10 mg and Levomepromazine 25 mg presenting resulting in important extra-pyramidal symptoms (EPS), namely marked motor rigidity. Subsequently, a switch was made to Olanzapine 5 mg with persistence of clinically significant EPS. A final switch was made to Aripiprazol 15 mg (gradually titrated) and a mood stabilizer was started (Sodium Valproate), with full clinical remission within a month and no signs of EPS.

The age of onset of manic symptoms in this patient is not suggestive of bipolar disorder (average age onset 25). On the other hand, Fahr's disease usually presents within the 4th and 5th decade of life. The clinical presentation usually involves motor symptoms (movement disorder and Parkinson like symptoms) and dementia, but purely psychiatric presentations have been described. The localization of calcifications also seems to have a clinical correlation, as Pallidal calcifications as the ones identified in our patient have been associated with manic symptoms. Idiopathic forms in which no metabolic or other underlying causes are identified, treatment is usually symptomatic, but one has to be cautious because these patients have an increased sensitivity to neuroleptics and can thus easily develop EPS.

Psychiatrists should consider Fahr's disease as a differential diagnosis in a manic episode, especially with a late age of onset, which is not suggestive of a bipolar disorder. This case also further emphasizes the importance of neuro-imaging in psychiatry and underlines the importance of a careful treatment approach in this type of patients because of an higher risk of developing EPS.

The authors hypothesised that medical students may be receptive to incorporating Virtual Reality (VR) within the psychiatric curriculum as a technological adjunct to existing teaching methods. Therefore, the aim was to evaluate medical students’ attitudes towards the role of VR in psychiatry education and training.

In this descriptive cross-sectional online survey, 76 medical students from all year groups across 10 medical schools in the UK answered a questionnaire consisting of 13 items regarding their views on the role of VR in psychiatry education and training, each on a 5-point Likert scale.

96.1% of respondents had received some level of education and training in psychiatry. 57.9% had never undertaken a VR experience before, yet 79.0% ‘agreed/strongly agreed’ that they would feel comfortable using VR at medical school.

71.1% ‘agreed/strongly agreed’ that experiencing the first-person perspectives of psychiatric patients in VR would enable them to develop greater empathy. 81.6% ‘agreed/strongly agreed’ that managing dangerous patient interactions in VR would increase their confidence in managing such interactions in real-world clinical settings. However, students were most ‘unsure’ about whether VR would reduce their anxiety (30.3%) and improve their interpersonal communication (27.6%) in real-world clinical settings.

The majority of students ‘agreed/strongly agreed’ that VR would make educational experiences more engaging (80.3%), improve understanding of content (63.1%), and better prepare them for clinical practice (64.4%).

Most significantly, 81.6% ‘agreed/strongly agreed’ that learning in VR would enhance experiential learning in ways that existing teaching methods outside of clinical settings cannot, and 84.2% ‘agreed/strongly agreed’ that they would rather learn from a mixture of VR plus existing methods over existing methods alone.

These findings demonstrate that medical students believe VR would improve engagement, understanding, and preparation for clinical practice.

VR holds the greatest potential in developing empathy for patients with mental illness and preparing students for dangerous patient interactions. However, further investigation is required to evaluate how educational experiences in VR translate to performance in real-world clinical settings.

In times of restricted access to clinical care, such as during the COVID-19 pandemic, VR could play a vital role in teaching psychiatry. The preference for VR to be added to existing teaching methods was the strongest held and most relevant belief to the aim of this study, indicating the readiness of medical students to accept VR into psychiatry education and training.

With growing numbers of countries legalizing euthanasia or assisted suicide (EAS), there is a debate as to whether EAS should also be available to people with severe, treatment-resistant mental illness. Excluding mental illness as a legitimate reason to receive EAS has been framed as discriminating against people with mental illness.

We examine whether approval or opposition to psychiatric EAS are related to stigma toward people with mental illness.

We asked a representative sample of the general population in Germany (N = 1515) whether they would approve of EAS for someone with severe, treatment-resistant mental illness. Stigma was assessed with the Value-Based Stigma Inventory (VASI), addressing rejection of people with mental illness in relation to different personal values.

A total of 19% of the German population approved of psychiatric EAS. Higher stigma scores were associated with greater approval of EAS (Spearman rank correlation coefficient, 0.28; P < 0.001). This association held true when controlling for sociodemographic variables. It was strongest for stigma related to perceived threats to one's security, reputation and meritocratic values.

Our results highlight that, although opposing psychiatric EAS is sometimes framed as discriminatory, approval of psychiatric EAS might also carry hidden, stigmatising motives. To avoid any unintended negative consequences for people with severe, treatment-resistant mental illness, any legislation on psychiatric EAS needs to be crafted with particular caution.