Clinical guidance indicates that methadone doses of 60–120mg are therapeutic as opioid substitution therapy (OST). Audit was completed to understand why patients open to Newcastle Treatment and Recovery (Addictions) are being prescribed doses below 60mg and to identify areas for improvement.

285 patients were identified via prescription software as currently prescribed <60mg methadone. A random sample of 50 cases was obtained for audit during signing of routine prescriptions. Case sample was adjusted to ensure even distribution between keyworkers. Review then completed of prescribing card and clinical entries in the last 6 months. Standards included reason for subtherapeutic dosing and evidence of instability with use of illicit opioids, or other substances (excluding alcohol or cannabis), alongside secondary outcomes.

54% of cases were found to currently be undergoing a change in their dose – mostly reducing though 2 increasing and 2 preparing to switch to buprenorphine. The remaining 46% were maintained on a consistent dose of methadone below 60mg. Of these 8 were advised to change their dose but this was declined. The remaining 15 had no additional advice recorded and remained on sub-therapeutic dose. Of 50 cases 8 were unstable with regards illicit opioid use, 21 were using other substances (1 gabapentin with the remaining using cocaine). For those using illicit opioids 63% were advised of an increase but declined whilst 25% were not advised of any change in their OST. Of those using other substances 48% had no change in OST considered whilst a further 10% continued with a reduction.

The audit found that a proportion of cases prescribed a sub-therapeutic dose were being maintained on this dose. Most concerning was the proportion of patients who were not advised to increase despite use of illicit opioids but also the proportion who were not following advice from their keyworker. Additional concerns highlighted uncertainty in practice around the role of OST in those who remain using other substances, in particular cocaine. Department of Health guidance recommends that doses in these cases should be optimised which would mean at least targeting therapeutic range. Recommendations made included to develop further training to ensure consistency of practice as well as requiring that all patients on sub-therapeutic doses of methadone should be booked for strategic care plan reviews at a minimum of 6 monthly.

To evidence accurate completion and online upload of DNACPR, Adults with Incapacity (AWI) and Hospital Anticipatory Care Plan (HACP) paperwork at the point of admission across two old age psychiatry wards at Queen Margaret's Hospital, NHS Fife.

We identified which of our 36 inpatients required DNA CPR, AWI and HACP forms, compared with those who actually had this documentation in place, correctly completed, in their paper notes. When documents were present, we confirmed whether they were also uploaded to Morse (NHS Fife's psychiatry electronic notes system).

Data were collected on August 25th 2023 for cycle 1. A Multidisciplinary team meeting was held in each ward to consider strategies for improving performance, and 11 weeks were allocated for intervention design and implementation, before data collection was repeated on November 10th 2023.

The primary outcome was whether DNA CPR, AWI and HACP documentation were correctly in place across both wards. Completion rates of all forms improved between the two cycles, as did compliance with online upload (secondary outcome) and correct completion of all fields (secondary outcome).

Since our interventions (improving availability of forms, peer education regarding correct completion of forms, ward round prompts to review paperwork, streamlining workflow for scanning), there was a marked improvement in performance on both wards 1 and 4. For patients who were assessed to need an AWI form, form completion increased from 93.3% and 94.4% for each ward respectively, to 100% on both wards. Required fields on the form were completed in 71.4% and 76.5% for each ward respectively in August, increasing to 88.2% and 100% in November. DNA CPR forms were present for appropriate patients in 100% and 88.9% of cases on the two wards in August 2023, with 75% and 62.5% uploaded to Morse. This improved to 100% presence and 100% upload rates in November 2023. HACP forms were present in 100% and 83.3% of cases on the two wards in August, but were available online in 0% and 20% of cases respectively. This improved to 100% completion of HACP forms on both wards, with 100% and 91% respectively available online in November.

A combination of peer education, MDT learning, readily available forms, ward round review and awareness-raising across medical, nursing and administrative staff improved rates of accurate completion and online upload of DNA CPR, AWI and HACP paperwork.

Mental health conditions have wide ranging impacts on individuals, including in their ability to safely drive. Attention, impulse control, judgement, and psychomotor reaction times are some of the ways in which mental health conditions and psychotropic medications impair ability to drive. To ensure safety of patients and other road users, the Driving and Vehicle Licencing Agency (DVLA) provides guidance to clinicians and patients regarding fitness to drive. The General Medical Council (GMC) also states that doctors have a duty to inform patients that their condition and/or medication can impact driving ability.

To evaluate compliance with DVLA and GMC guidelines, an audit was conducted to assess: 1) whether patients’ driving status was established; 2) whether patients were advised to inform the DVLA; and, 3) whether they were advised to inform their insurance company. This was subsequently re-audited after introducing recommendations to improve compliance.

Each audit cycle reviewed the 30 most recent discharges from an adult general psychiatry inpatient unit before and after intervention. Online notes, multi-disciplinary team (MDT) minutes and discharge summaries were reviewed to assess whether the above criteria were met. Following the initial audit cycle, results were presented at Trust-wide teaching, and driving status was added to an MDT template as a prompt to discuss this with patients. A second cycle was completed four months afterwards.

Results of the first cycle (pre-intervention) showed driving status was established in 73% (n = 22) of patients. Of the drivers, 90% (n = 9) were advised to tell the DVLA, whilst only 9% (n = 1) were advised to tell their insurance company. Post-intervention, 67% (n = 20) of patients had driving status established, whilst 100% (n = 11) of drivers were subsequently advised to inform the DVLA, and 64% (n = 7) advised to tell their insurance company.

Clinicians have a legal and ethical duty to discuss driving status with patients. Failure to do so could have significant consequences on both individual and wider public safety. This audit showed that in clinical practice, key legal requirements were not being fulfilled. Whilst staff education and changes to MDT templates increased the number of drivers being advised to tell the DVLA and insurers, it had little impact on establishing driving status. Therefore, further changes were made to the discharge letter template to remind staff to assess patients’ driving status, and to enable community team follow-up. A third cycle of the audit is currently ongoing to evaluate this change.

To establish the proportion of CMHT Preston service users with schizophrenia who met the NICE standard (CG 178) of being offered clozapine after inadequate response to treatment with at least two antipsychotic drugs.

Inclusions – Service users on the CMHT Preston caseload with schizophrenia who attended outpatient clinic between January and June 2023.

Exclusions – Organic psychosis and non-schizophrenic/unspecified psychosis.

Sample size – 50.

Sampling – First 50 service users with established diagnosis of schizophrenia.

Data collection – Retrospective case-note audit from electronic patient records.

Data analysis – Quantitative.

45 service users (90%) met the clozapine eligibility criteria of not responding adequately to or tolerating at least 2 other antipsychotic medications while 5 service users (10%), did not meet the criteria. The proportion of eligible service users who were offered clozapine, and therefore met the standard, was approximately 64%, representing 29 out of the 45 eligible service users. Approximately 36%, representing 16 eligible service users, were not offered clozapine. In one isolated case, a service user who had only 1 previous antipsychotic trial and therefore did not meet the eligibility criteria, was offered clozapine. No reason was given in 13 out of the 16 service users who were not offered clozapine despite meeting the eligibility criteria. In the remaining 3 service users in this group, 2 were not offered clozapine because of cardiac problems and 1 was not offered because of significant history of poor compliance with antipsychotic medications. Furthermore, 25 eligible service users (86%) of those who were offered clozapine went on to initiate it with only 4 service users (14%) in this group not going ahead to initiate clozapine. In all 4 service users who did not initiate clozapine after being offered, the reason given was that the service users declined it.

The findings from this audit indicate that a considerable proportion (64%) of CMHT Preston service users with schizophrenia are being offered clozapine in line with the NICE standard, and 86% of those offered went on to initiate clozapine. However, there is room for improvement in terms of offering and ultimately initiating clozapine in a timely manner as evident from the findings which highlighted an average of three antipsychotic trials before eligible service users were offered clozapine. The existing established local clozapine community initiation pathway can potentially be optimised to improve clozapine access and ultimately enhance clinical outcomes for this subset of service users.

To confirm that 100% of patients treated by Electroconvulsive Therapy (ECT) have weekly assessment of mental state via Montgomery–Åsberg Depression Scale (MADRS).

To confirm that 100% of patients treated with Electroconvulsive Therapy (ECT) have regular assessment of their cognition before treatment and every 4 treatment sessions via the Montreal Cognitive Assessment Scale (MOCA).

This Audit included all service users attended ECT suite regularly at Worcestershire Specialist Mental health services over a period of 12 months between April 2022 and April 2023.

Twenty patients were included in this audit for whom data was collected from both electronic and paper records to analyse the percentage of compliance with the Electroconvulsive Therapy Accreditation service (ECTAS) standards with regards to the recommended weekly assessment of mental state via MADRS and the recommended regular assessment of cognition before treatment and every 4 treatment sessions via the MOCA Scale.

The Audit included 20 patients having ECT treatment done regularly over a year.

Overall, 87.32% of the patients were found to have MOCA assessment done before their first ECT session and every 4 treatment sessions as per guidelines. While 96.29% of the patients had MADRAS assessment done weekly or every two treatment sessions as per guidelines.

Regarding MOCA assessment, it has been found that 80% of the patients had MOCA done before their first treatment session. 94.73% of the patients had MOCA done after their 4th treatment session. 89.47% of the patients had MOCA done after their 8th treatment session. And 84.61% of the patients had MOCA done after their 12th treatment session.

With regards to MADRAS, 100% of the patients had MADRAS done before the start of the treatment. 90% of the patients had MADRAS done after the second treatment (1st week). 100% of the patients had MADRAS done after 4th treatment (second week). 100% of the patients had MADRAS done after 6th treatment (third week). 93.33% of the patients had MADRAS done after 8th treatment (4th week). 92.85% of the patients had MADRAS done after the 10th treatment (5th week).

Overall, ECT practice at Worcestershire Specialist Mental health services has been found to be in compliance with the ECTAS guidelines.

The majority of patients had MOCA assessments done regularly every 4 weeks with the highest compliance found to be after the first 4 treatment sessions and the lowest compliance was for the MOCA assessment done before the start of the ECT treatment.

In terms of MADRAS assessment, there was an overall adherence with the guidelines with very few patients missing MADRAS assessment only once over their course of treatment.

Graves’ disease, an autoimmune illness, is one of the most common causes of thyrotoxicosis and often presents with classic symptoms of hyperthyroidism. However, patients can rarely present for the first time with psychiatric symptoms, including psychotic and mood symptoms or a combination of both, and there is limited data on the most effective treatment.

Here, we report the case of a 24-year-old black British female who had no previous psychiatric or medical history, presenting for the first time with one week history of poor sleep, disordered thought, and bizarre and violent behaviour towards family. Collateral history describes her premorbid personality as “anxious and perfectionist”, with the only recent stressors identified being preparations for her best friend's wedding. Her mental state on presentation was remarkable for tangential and circumstantial speech, incongruent affect, and lack of insight into illness. She was admitted to an acute adult ward under Section 2 of the Mental Health Act (MHA) after being “medically cleared” but before the results of her thyroid function tests were available.

She was transferred back to the acute medical ward a day into psychiatric admission, where she was treated medically for thyrotoxicosis and discharged with the support of the Home Treatment Team after an almost complete recovery in her mental state. Initial symptoms recurred two weeks after discharge, culminating in another admission cycle initially to a psychiatric unit under the MHA, where she was treated with oral risperidone and a medical ward for further medical investigations. Her mental state improved significantly again, and she was discharged home to the concerted care of both a community mental health team and follow-up with the endocrinology team. On outpatient psychiatric review a year following discharge, the patient remains stable in her mental state and has achieved a euthyroid state with plans to taper off and withdraw risperidone gradually.

This case shows the importance of a thorough physical health assessment and investigation before making psychiatric management decisions. It also points out the drawback of the divide between physical and mental health services, the impact this has on patient care and experience within the National Health Service, and the mixed success of medical management in controlling psychiatric symptoms.

This case describes the rare presentation and successful management of psychosis induced by thyrotoxicosis in a female patient with Graves’ disease. It highlights the need for prompt, interdisciplinary care to diagnose and safely manage such patients correctly.

Postpartum psychiatric disorders are almost certainly common among women in Pakistan but accurate estimates of the prevalence of these disorders are difficult to obtain because of cultural norms and lack of awareness that may result in women underreporting such disorders, or them not being recognised because of lack of reliable screening tools and resources.

The aims of this case study are to report a case of an attempted suicide by self-immolation in a multiparous woman with recurrent puerperal psychosis, highlighting the cultural/religious barriers which often result in delayed help, and call attention to the need for awareness and screening.

A 35-year-old multiparous woman, hailing from low socioeconomic background in the outskirts of Dera Ghazi Khan, was admitted to the burns unit of our hospital after setting herself on fire. Psychiatric consultation was sought after obtaining a detailed history from the family members. She had given birth to her fifth child (2nd son) two weeks previously via spontaneous vaginal delivery (SVD). Soon afterwards, she developed low mood and was crying all of the time. She also developed feelings of excessive guilt and worthlessness and started praying excessively and asking for forgiveness of others. At times, she talked about wanting to end her life because she thought she was worthless, sinful, and didn't deserve to live. She also wouldn't come close to her newborn, care for him or even touch him. Her family members had also observed her talking to herself when she was alone.

According to her brother, she had a previous episode shortly after giving birth to her fourth child (1st son) 2 years before. The family believed at first that it was a result of an “evil eye” because she had “finally” given birth to a son after giving birth to three daughters in a row. The patient's mother took her to a faith healer which did not result in any improvement. When her condition deteriorated, they took her to a psychiatrist in their hometown who started her on psychotropic medication. Her condition improved after a few months.

After this baby her symptoms were reported to be much more severe with active suicidal ideation. Her family members couldn't take her to that same doctor because he had moved to another city. Also her previous prescriptions were lost so they had no record of the medication the patient had been on before. In addition the patient's mother was totally against the idea of taking her to a medical doctor and was determined to take her to faith healers instead, which further contributed to the delay in her getting medical help. Two weeks after giving birth to her second son she locked herself in her bedroom and set herself on fire. Her family members rescued her and took her to ER. She sustained injuries to her neck, chest, and arms. A diagnosis of puerperal psychosis was made taking into account her history and her mental state examination. She was started on psychotropic medication along with analgesics and antibiotics.

No matter where a woman lives, postpartum psychiatric disorders are a serious issue that can negatively impact a woman's quality of life and well-being if not addressed and treated properly. While these disorders receive adequate attention in developed countries, it is a largely neglected issue in Pakistan, but one that deserves our attention. It can have serious implications if proper medical help is not sought early like in this case. It is, therefore, recommended that all pregnant women who present to their GPs/obstetricians/midwives for antenatal checks should be screened for perinatal psychiatric disorders with a validated instrument and educated accordingly.

As this patient had a previous episode of puerperal psychosis, she was at a very high risk of this relapse and it could have been prevented, or treated early after the birth if this fact was widely known and recognised.

(A photograph of the patient's burn wounds taken after skin grafting will be added to the poster once the abstract is approved. No financial sponsorship. The work was conducted with appropriate ethical and governance safeguards, which also include obtaining family's consent.)

We would like to report a case of pseudo bulbar affect during recovery from locked in syndrome due to brainstem stroke.

We present a lady in her early 60s who developed pseudobulbar affect during recovery from locked in syndrome. MRI brain confirmed brain stem infarct. No personal or family history of mental illnesses was noted. Neurological examination on our rehabilitation unit confirmed dense weakness in all four limbs. She would cry even when family gave her good news or made jokes with her. This appeared to be the only method of expressing her emotions she had; however, it was unclear if this was aligned to her internal emotional experience.

Through clinical observation and using the Testing Emotionalism After Recent Stroke-Questionnaire (TEARS-Q) measure of emotionalism we identified that pseudobulbar affect was present, and intervention should be considered. The patient also stated that her crying was not always aligned with her emotional experience, but laughter was. The Clinical Outcome Routine Evaluation (CORE-10) was also used to screen out other potential psychological difficulties including depression. The assessment indicated she was experiencing low levels of psychological distress.

We initiated fluoxetine and clonazepam was given to help with spasticity and sleep. Our non-pharmacological measures included sitting with the emotional expression and not asking her to stop, encouraging her to take deep breaths and modelling this and when she presented as calmer supporting her to identify if her emotional expression was in line with her internal emotional experience and using different communication strategies to explore this and support her to have her needs met. If the crying persisted mid communication, staff supporting her would reorientate her to what she had been attempting to communicate and encourage her to continue, which she would be able to do. All staff were asked to do this during their interactions with the patient to support identification of emotional alignment. Significant reduction in emotional misalignment was noted following the implementation and increased use of external communication aids. Within a few months her distressing crying episodes reduced and neurologically she improved.

Pseudo bulbar affect is a distressing condition that can occur during recovery from locked in syndrome. Diagnosis can be confirmed by ruling out other common conditions like anxiety or depression. Treatment includes both non-pharmacological and pharmacological measures best provided by a specialist multidisciplinary team.

Patients with severe mental illness (SMI) are at greater risk of poor physical health with higher prevalence of obesity, cardiovascular disease, diabetes and higher premature mortality than the general population. The reasons are complex and interventions are multifaceted. Obesity is highly prevalent in the general population and pharmacological and surgical treatments have become more widely available; however, SMI patients may face barriers accessing these. This case highlights specific factors for consideration in managing a patient on lithium therapy undergoing sleeve gastrectomy to balance the risk of lithium toxicity with risk of relapse. Currently, there is limited clinical experience of managing lithium in this context.

49 yr old female diagnosed with schizoaffective disorder well-maintained for several years on aripiprazole depot and 800mg lithium carbonate (Priadel) with therapeutic levels in treatment range (0.4–0.8mmol/L). Severe obesity (BMI 41kg/m2) despite dietary modifications and metformin trial, and recently diagnosed with diabetes. Family history of cardiovascular disease and diabetic related complications with early mortality were additional factors in her request for bariatric surgery. Multidisciplinary discussion including patient, psychiatrist, mental health pharmacist, specialist bariatric dietician and GP prior, to ensure sharing of relevant information pertinent to re-titration and monitoring of lithium therapy and risks of toxicity and relapse.

Patient underwent sleeve gastrectomy with discontinuation of lithium 72 hours prior to surgery. Stomach pouch capacity reduced to 120ml and advised daily fluid intake 500–1000ml in first two weeks. Lithium therapy re-commenced when fluid intake adequate and renal function within normal limits. Formulation changed to liquid for 6–8 weeks to avoid disruption to the healing line, and the dose gradually re-titrated with close monitoring of serum lithium levels. Stabilised on reduced dose of 400mg Priadel at 3 months with therapeutic levels. At 6 months BMI reduced to 32kg/m2, antihypertensive and metformin discontinued and maintained remission of schizoaffective disorder.

Sleeve gastrectomy is an increasingly common procedure to treat obesity, with potential long-term positive physical health outcomes and reduction in mortality which may have a role in addressing health inequalities for SMI patients. Psychiatrists need to be aware of key aspects of bariatric surgery particularly relating to safe and effective prescribing of psychotropic medication including potential change to liquid or orodispersible formulation in the post-operative period, close monitoring of serum lithium levels in the short and medium term due its narrow therapeutic index, and consideration of longer-term dose adjustments due to ongoing weight loss.

We present a case of suspected Kluver-Bucy syndrome in an adolescent male, following a SARS-CoV-2 (Covid-19) infection. To the best of our knowledge, KBS has not been associated with Covid-19 before.

A 15-year-old male with a background of autism spectrum disorder (ASD) was reviewed in a children and adolescent mental health outpatient clinic. The young person was non-verbal, and history was taken from his next of kin. In the last four weeks, he had developed acute onset hyperphagia with weight gain (88th percentile for age), new onset physical and verbal aggression, and hyperorality, whereby the young person was exploring household objects with his mouth. A degree of hypersexuality was also noted in the form of rubbing and touching of the genital area.

There was no history of trauma or epilepsy; recent traveling or environmental change; psychosocial stressors or new medications, operations, or immunisations in the past year. The young person had a Covid-19 infection the month before the symptoms started. He was immunised against Covid-19 and this was the second time he contracted the infection, the first being 1 ½ years ago with full recovery.

The sudden onset of hyperphagia, aggression, hyperorality, and hypersexuality with the only known precipitating factor the recent Covid-19 infection, raised clinical suspicion for Kluver-Bucy syndrome. Six months later, the symptoms were milder but still present and no other cause had been identified. Due to ASD features, visual field testing, brain imaging, or routine blood tests were either not possible or required sedation and are being arranged with the support of his general practitioner.

Kluver-Bucy syndrome is a rare neurological disorder characterised by a distinct constellation of behavioural and cognitive symptoms resulting from bilateral lesions or dysfunction in the temporal lobes, particularly the amygdala. Patients often exhibit alterations in their behavioural repertoire, including hyperorality, hypersexuality, disinhibited behaviour, and visual agnosia. The presentation has been associated with temporal lobe infarcts, epilepsy, and herpes simplex encephalitis. The differential diagnosis was based on the fulfilment of clinical criteria for KBS, while other differentials included metabolic causes or behavioural manifestations related to ASD. Although investigations to explore other causes of symptoms are still being arranged, clinical suspicion for KBS was based on the presence of diagnostic criteria and the recent viral infection.

Research is needed to identify potential associations between SARS and neuropsychiatric manifestations, while clinicians should be aware of the possibility of such complications.

16 year old male with previous diagnoses of autism spectrum disorder and severe anxiety disorder was referred to Child and Adolescent Mental Health Services (CAMHS). His presentation included increasing anxiety, difficulty articulating his thoughts and emotions, difficulty completing tasks, school non-attendance, reduced food intake and possible auditory hallucinations. Risperidone was trialled in the community however refused after 5 days due to “brain fog”. He was seen by CAMHS community team twice weekly for 3 months prior to his emergency detained admission to adolescent psychiatric inpatient unit, due to no oral intake for 72 hours.

Family history included schizophrenia, bipolar disorder, depression and anxiety.

Upon admission, symptoms observed included reduced verbal communication, psychomotor retardation, low mood, agitation, sleep difficulties, ambitendency, echolalia and poor oral intake. He had a Bush-Francis rating score of 8 and given a working diagnosis of catatonia. He responded positively to a lorazepam challenge therefore commenced on 1mg of lorazepam twice daily. Despite increasing doses, the catatonia worsened with severe psychomotor retardation, “psychological pillow” and nil food or fluid intake with Bush Francis score of 18. ECT was arranged as an emergency treatment but put on hold while tolerating all food and fluids requirements via nasogastric tube. Lorazepam dose was titrated to 3mg three times daily but signs seen of benzodiazepine toxicity therefore dose was reduced and ECT arranged for treatment resistance. Improvement seen on reduced dose prior to receiving ECT, therefore ECT put on hold again. His lorazepam dose was titrated up at a slower rate to 4mg three times daily which he was able to tolerate. His catatonia fully resolved at 12mg. Once stable, lorazepam dose was very gradually decreased until stopped. No evidence of catatonia returned.

Medical and psychiatric causes of catatonia were explored.

Two positive blood anti-NMDA receptor tests two months apart; both 1/10 titre. This was discussed with the specialist neurology team in Oxford who advised this was an incidental finding with no clinical implication (1% of healthy population are positive).

Throughout admission, possible fleeting psychotic and depressive symptoms were noted, including not trusting food, hallucinations, worries about contamination and apathetic mood. However, these all improved as the catatonia was treated.

There was no clear underlying psychiatric or medical illness identified as a cause of the patient’s catatonia. Catatonia has a higher prevalence in people with autism. At discharge he was well and reintegrated back to community life without requiring further medication.

A recent Cochrane review published in December 2023 concluded that “no trials found that interventions to reduce anticholinergic burden led to any other improvements in cognition compared to usual care”. We describe the case of a 62-year-old lady who developed significant cognitive decline following the initiation of a low dose of procyclidine, which was rapidly reversed upon stopping the medication.

We present the case of a 62-year-old lady with a diagnosis of schizo-affective disorder, whose symptoms had been stabilized on a regime of lithium carbonate 500mg nocte, sulpiride 400mg BD and fluoxetine 20mg OD. When the patient presented to the outpatient clinic, she was noted to have bilateral coarse tremors and slight cogwheel rigidity. Procyclidine was started at a dose of 5mg OD to manage these extrapyramidal side-effects.

Following this, family members reported that the patient had difficulty initiating and following conversations. Short-term memory was affected and she was observed to have reduced attention span. These problems were reportedly getting worse with time, with a simultaneous decline in functional abilities. She was no longer able to carry out her daily shop, and family members ensured that she was no longer driving as they had concerns about her road safety. She stopped taking procyclidine after 1 month and notably, these problems ceased within one week of stopping the medication.

Cognitive testing confirmed that the patient was cognitively intact after procyclidine was stopped. The patient scored 96 on the ‘Addenbrooke's Cognitive Examination’ scale, which falls within the normal range. The ‘Instrumental Activities of Daily Living’ scale was administered to assess functioning at the time of the cognitive impairment. This returned a score of 1/8, indicating that there was significant functional impairment secondary to cognitive impairment when prescribed procyclidine. The ‘Informant Questionnaire on Cognitive Decline in the Elderly’ was administered to objectively quantify the extent of cognitive decline as noted by family. This returned a score of 4.3, confirming that the patient's cognition had indeed been worse when compared with her baseline.

Our case report highlights the rapid improvement in cognition with the removal of anticholinergic burden in a 62-year-old female. Our report can, therefore, be a harbinger for more robust trials to determine the efficacy of interventions to reduce anticholinergic burden in preserving or improving cognition.

It is important to monitor for any change in cognition when prescribing anticholinergic medication in at-risk individuals.

Ornithine transcarbamylase (OTC) is an enzyme of the urea cycle catalyzing the condensation of carbamyl phosphate and ornithine to form citrulline. OTC deficiency leads to elevated serum ammonia and presents as different neurological or psychiatric symptoms. OTC deficiency is an X-linked inborn error of metabolism and most cases occur in neonatal period with severe presentation. Lesser known is the late-onset form that remains latent from infancy and only presents with intriguing symptoms mimicking psychiatric disease in adulthood.

Case report.

We describe a case of adult-onset OTC deficiency in a 40-year-old man with borderline intellectual functioning and a psychotic episode following a protein rich meal. The case was first diagnosed as undifferentiated schizophrenia, until the genetic study was carried out.

Awareness of the adult onset ornithine transcarbamylase deficiency being a rare but possible differential diagnosis in a patient with acute psychiatric symptoms with hyperammonemia. Organic causes such as cerebral, metabolic, toxic causes of psychosis should be actively sought especially when encountering cases of acute psychosis.

Capgras syndrome is the most common of the delusional misidentification syndromes. It is characterised by the delusional belief that a familiar person has been replaced by an identical imposter. Capgras syndrome is associated with functional conditions, like psychosis, but also with a range of organic conditions such as dementia, brain injury and Parkinson's disease.

The COVID-19 pandemic created a unique situation where patients were unable to see their relatives in person, resulting in their only form of contact being via telephone or virtually.

We present a case of a 70 year old lady Mrs W, who was admitted with first episode psychosis. She developed Capgras syndrome during her admission, based purely in the auditory modality of talking to her husband on the telephone. She was firm in her conviction that he was an imposter, mainly based of ‘a different tone’ and using ‘different words’. Showing a photograph of her husband was met with full and appropriate recognition. Given that a significant minority of elderly patients with a Capgras delusion have an organic aetiology, neuroimaging and extended laboratory investigations, including auto-antibodies for limbic encephalitis, were performed which were unremarkable.

With psychotropic medication, the Capgras delusion resolved, and on discharge she recognised her husband when they met again.

The aetiology of Capgras syndrome remains unclear, although a range of causes have been suggested. Early psychodynamic theories related to conflict between love and hate towards the relative, which could be relevant in functional conditions but may have less significance in organic conditions.

Other theories examine Capgras syndrome as a mirror of prosopagnosia, where people have difficulties recognising familiar faces. This would indicate a pathological process affecting visual pathways. However, our case challenges this theory, suggesting that deficits in other sensory modality pathways may also contribute.

Although rare, our case is not entirely unique; several cases of Capgras syndrome in people with blindness have been reported. However, our case differs in that our patient was able to recognise photos of her husband despite misidentification based on auditory cues. As Mrs W did not have visual impairment, it is unclear if she would have presented with the more classical visual misidentification in the absence of the unique circumstances of the COVID-19 pandemic.

Capgras syndrome is classically associated with misidentification based on visual cues, however a growing number of case reports challenge this. Further investigation is required to create theories that encompass other sensory modalities.

Attention Deficit Hyperactivity Disorder (ADHD), is a neurodevelopmental condition affecting both children and adults, with a global prevalence estimated to be around 5% in children and 2.5% in adults, significantly impacting daily functioning, academic performance, and interpersonal relationships.

Glycogen Storage Disease Type 1A (GSD1A) is a rare metabolic disorder that occurs in approximately 1 in 100,000 births. It is characterized by accumulation of excessive glycogen and fat in the liver and kidneys that can result in growth retardation.

The aim is to increase knowledge of pharmacological management of ADHD in patients with GSD1A.

Our patient is a 16-year-old boy with both diagnoses of GSD1A and ADHD.

GSD1A is treated with a special diet of frequent small servings of carbohydrates which must be maintained day and night throughout life, given via PEG tube.

ADHD symptoms cause functional impairment and affecting his school attainment requiring treatment. However, stimulant medication, such as methylphenidate, which are first- and second-line treatments, can cause appetite suppression that would increase the risk of fatal hypoglycaemia in GSD1A.

The literature review of case reviews with similar presentations, aiming to confirm the absence of contraindications for prescribing methylphenidate in patients with GSD1A, showed no identified contraindications, and relevant papers were not found.

Collaboration with the metabolic disorders team at Great Ormond Street Hospital was established to verify the absence of contraindications and facilitate potential adjustments to feeds if necessary.

Short-acting methylphenidate was administered to mitigate appetite suppression and enable prompt reversal of potential side effects, owing to its brief half-life. This approach also aimed to facilitate regular dietary intake.

Gradual bi-weekly dosage increments of 5mg, coupled with vigilant side-effect monitoring, lead to enhanced attention and concentration, ultimately contributing to improved school attainment.

Trial of short acting methylphenidate to ensure limited appetite suppression and allow opportunities for regular dietary intake. Slow dose titrations and weekly monitoring for response and side effects is vital. This young man's ADHD was successfully and safely treated.

This case shows that with careful liaison and planning, methylphenidate can be safely prescribed to patients with GSD1A. Our experiences show that using short-acting preparations of methylphenidate initially allows slow and careful titrations.

Restorative justice (RJ) is the process of bringing together offender and victim in the aftermath of an offence. Handled correctly, there can be substantial benefits for both parties. Communication is typically direct with an RJ facilitator from the criminal justice system, but the Crown Prosecution Service makes reference to the option of “shuttle mediation”, with the RJ facilitator relaying information indirectly between parties.

The use of RJ in forensic psychiatry has been limited, with reasons including concern for the patient offender's vulnerability, impact on their mental state from the stress of facing their victim, and unpredictability of response. Adaptation of the “shuttle mediation” model with use of a trusted mental health professional may help to overcome many such obstacles.

Patient A committed his index offence of murder at age 22. During his mandatory life sentence, he developed schizophrenia and was transferred to a secure hospital. His illness proved treatment resistant and many years passed before he was discharged to the community on life licence following Parole Board release. Although generally stable, he was easily overwhelmed by stressful situations, in which he could struggle to articulate his thoughts.

His victim’s wife and daughter enquired about the possibility of restorative justice. A's probation officer liaised with A's consultant psychiatrist. A was considered unsuitable for direct approach, but following discussion with an RJ facilitator, a proxy model was agreed upon. This was based on shuttle mediation but with the consultant psychiatrist acting as shuttle, or proxy, for A.

The aims of the family were elicited in advance. Capacitous consent to information sharing was obtained from A, with boundaries of what would be shared clearly agreed. Information A wished to share with the family was established, including verbatim quotes.

Following the RJ meeting, feedback from the victim's family and A was strongly positive. The victim's family reported a sense of peace and closure from the experience. A's longstanding anxiety, with feelings of guilt and self-blame reduced. Both parties expressed gratitude for the meeting and did not find the use of a proxy negated the benefits of the experience.

This case report demonstrates that a proxy model of restorative justice is feasible and can be successful for patient offenders with severe and enduring mental disorder. The potential benefits to patient and victim suggest that it could be considered more widely as an option in forensic psychiatry settings.

The scandal of sub-postmasters wrongly accused by the post office of offences relating to the faulty IT Horizon system is of ongoing media prominence.

Since May 2021 I have undertaken personal injury medico legal assessments at the request of a solicitor representing those falsely accused and convicted of offences by the post office. Their convictions had been quashed in the court of appeal.

I interviewed fourteen individuals, age range 35 to 70 years, five women and nine men. Ten had brought claims for Malicious Prosecution. The remaining four sub-postmasters were part of the historical financial shortfalls scheme set up for those who had not been prosecuted but were applying for compensation.

Of the ten convicted sub-postmasters, four spent periods in prison and the remaining six were given suspended or community sentences. Those in prison were often separated from young children by distance or withholding family members.

I assessed to what extent and in what way their mental health and that of their families had been adversely affected as a result of their experiences.

Assessments were undertaken remotely, including speaking with a family member.

ICD 10 diagnostic criteria were used.

All of the cases revealed evidence of psychopathology at the time of the allegations or convictions and continued to varying degrees subsequently.

A diagnosis of PTSD was made in five cases, Adjustment Disorder in 2 cases, Dysthymia in one case and depressive illness in eight cases. In only four cases had the disorders resolved.

Four of the five cases of PTSD had evidence of a past psychiatric history prior to becoming sub-postmasters. Past history included depression, impulsive overdose, eating disorder, problems related to gambling and abuse of alcohol and cocaine.

Both sub-postmasters who had been accused of taking money due to faulty software and those who had been wrongly convicted had high rates of psychopathology.

These findings are consistent with the only other study of the psychological effects on sub-postmasters which found high rates of psychopathology in both accused and convicted individuals.

Existing diagnostic criteria were limited in capturing the suffering of individuals who had endured such complex trauma so a narrative description including the effects on family members was also used.

This study of the mental health of falsely accused sub-postmasters demonstrates a high degree of psychopathology which may require therapeutic intervention.

Self-harm affects around 20% of all young people in the UK. Treatment options for self-harm remain limited and those available are either non-specific or long and costly and may not suit all young people. There is an urgent need to develop new scalable interventions to address this gap.

Imaginator is a novel imagery-based intervention targeting self-harm initially developed for 16–25-year-olds. It is a blended digital intervention delivering Functional Imagery Training (FIT) via therapist sessions and a smartphone app. In this study we piloted a new version of Imaginator extended to adolescents from age 12 after co-producing a new app with a diverse group of young people experts-by-experience.

We aimed to assess feasibility of delivering Imaginator in Children and Adolescent Mental Health Services (CAMHS) and adult secondary mental health services and gather young people's feedback on the intervention

Participants were recruited from West London NHS Trust Tier 2 CAMHS and adult Mental health Integrated Network Teams (MINT) teams. They underwent a baseline screening and were allocated to a therapist for three face-to-face FIT sessions in which the app was introduced followed by five phone support sessions. Outcome assessments were conducted after completing therapy, approximately 3-months post-baseline, including questionnaire measures and a qualitative feedback interview.

Qualitative data were analysed using a co-produced thematic analysis method with lived experience co-researchers.

Thirty-four participants were referred (31 female, 2 male, 1 transgender; mean age = 18.4), of which 30 met inclusion criteria and completed screening. Out of 25 who started therapy 16 completed the intervention. Only 15 completed the quantitative outcome assessment, and 10 the interviews. There was an overall reduction in number of self-harm episodes over 3-months from pre- to post-intervention

Five main themes were identified: Imaginator therapy impact, mental imagery acceptability and efficacy, usefulness and usability of the app, integration of the app in therapy and need for improvements. Young people found Imaginator helpful at improving their mental health, in particular the use of mental imagery techniques. The app was overall well received but improvements were suggested.

Our study suggests that Imaginator can be extended to adolescents, is acceptable and has potential as a brief intervention reducing self-harm in young people under mental health services. A future RCT is needed to robustly test the intervention efficacy, after considering issues around high attrition in outcome measures.

The aim of this study is to explore the off-label use of atropine, administered sublingually, for the management of clozapine-induced sialorrhea in a patient who showed inadequate response to commonly used agents. The investigation stems from a clinical scenario where traditional approaches failed, prompting an exploration of alternative and cost-effective options to alleviate sialorrhea associated with clozapine therapy in a patient of lower socio-economic status.

Mr. A, a 29-year-old with bipolar affective disorder, experienced persistent sialorrhea during clozapine treatment, resistant to trials with trihexyphenidyl and glycopyrrolate. Following a brief discontinuation of clozapine, the patient relapsed into a manic episode, leading to hospitalization. Despite the re-initiation of clozapine, sialorrhea reoccurred. Various doses and combinations of trihexyphenidyl and glycopyrrolate were ineffective, with affordability issues limiting the latter. As sialorrhea persisted, clozapine dose reduction was necessary. Attempts with different antipsychotics were made, and valproate sodium was increased, but sialorrhea remained problematic.

Given the patient's unique case and previous medication failures, an off-label use of atropine via a sublingual route was done after obtaining informed consent. Quantitative measurement of sialorrhea was conducted using a sialometry machine. The patient underwent a trial with sublingual atropine drops, and the salivary rate significantly decreased, indicating a potential efficacy in managing clozapine-induced sialorrhea.

The discussion encompasses the challenges faced in managing clozapine-induced sialorrhea in the presented case. Traditional agents, including glycopyrrolate and trihexyphenidyl, proved ineffective or were hindered by affordability issues. The subsequent reduction of clozapine dose compromised overall treatment efficacy. The introduction of atropine eye drops via sublingual administration emerged as a novel approach, demonstrating a reduction in salivary rate without notable adverse effects except elevated heart rate 2 hours after administration of atropine. The unique pharmacological properties of atropine, despite being an off-label use, provided a potential avenue for addressing persistent sialorrhea.

In conclusion, the off-label use of atropine via the sublingual route showed promise in alleviating clozapine-induced sialorrhea in this particular case. Despite demonstrable efficacy in pre and post-sialometry, the clinical challenges and practical considerations associated with atropine's use in this context raise concerns. The case underscores the need for alternative strategies in managing medication-induced side effects, especially when standard interventions fail. Further research is warranted to explore the broader applicability and safety of this approach in a larger cohort.

Anxiety disorders are common in Autistic Spectrum Disorder (ASD) patients. There are limited resources dedicated to ASD and mental health services are not equipped to adapt assessment and treatment protocols to address their needs. Adaptations to diagnosis and treatment are discussed in a single case study of an autistic patient with anxiety disorders. In addition, effectiveness of providing adapted versus standard treatment is evaluated.

This study describes a 45-year-old, single, employed male diagnosed as autistic at age 37. He was referred for a second course of Cognitive Behavioural Therapy (CBT) for anxiety disorders consisting of agoraphobia with panic; blood injury phobia; needle phobia; dental phobia; claustrophobia. The duration of symptoms was 35 years. The main impairments to functioning were inability to use public transport; attending healthcare appointments; going to public places; returning to office-based working.

Questionnaires routinely completed at assessment and end of treatment: Montgomery–Åsberg Depression Rating Scale (MADRS); Beck's Anxiety Inventory (BAI); Beck's Depression Inventory (BDI). Adapted treatment with CBT included an extended assessment which helped differentiate anxiety symptoms from ASD. Main CBT adaptations included development of skills for the patient to identify and express emotional experiences and thoughts with the focus on physical sensations and behaviour. Graded exposure items were linked to concrete aims or interests and structured to fit around the patient's routine daily activities. Clinical data was analysed and compared outcomes from the initial standard and subsequent adapted treatment.

The patient's response to the initial course of standard CBT showed a 14% increase in anxiety and 14% increase in symptoms of depression on self-rated measures. The subsequent adapted CBT showed a 31% improvement in anxiety and a 16% improvement in symptoms of depression on self-rated measures.

This case report supports literature describing the need to adapt standard assessment and treatment to differentiate experiences related to ASD from discrete anxiety disorders, although there may be some overlap. The promising results support using adapted CBT to ensure appropriate treatment of anxiety disorders in autistic people.