Depression is a leading cause of disability, contributing to the global burden of disease. Low- and middle-income countries (LMICs) carry over 80% of this disease burden. There are high rates of depression in men in Pakistan. Paternal depression is often overlooked and is an under-researched area. Fathers are at risk of depression particularly if their partner is depressed. There is a need for integrated partner inclusive interventions to improve both parent and child outcomes including overall child development. Therefore, this nested qualitative study aims to identify barriers in transition to scale up an innovative low-cost partner inclusive culturally adapted psychosocial intervention for depressed fathers through a process evaluation from the perspective of fathers.

This qualitative study was nested within a cluster randomized controlled trial, with depressed fathers of young children (0–3 years) recruited from 18 towns in Karachi, Pakistan. Face to face or digitally audio-recorded interviews were conducted with depressed fathers (N = 24) from the intervention arm of the trial at end of intervention period (i.e., 4-month post-baseline). The intervention involved twelve sessions of a parenting intervention called Learning Through Play integrated with group Cognitive Behaviour Therapy and manual content from “Focus on Fathers”. Interviews were guided by a semi-structured topic guide to explore perceived usefulness of the intervention with particular focus on exploring any additional benefits or challenges of engaging partners into the intervention. Interviews lasted approximately an hour. Data were analysed using the principles of Framework Analysis. A concurrent analysis of initial interviews directed towards further interviews until data saturation.

Analysis highlighted perceived usefulness of the intervention such as improvement in mood, engagement in routine tasks, healthy thinking patterns, increased attachment with child, improved relationship with the family, improvement in parenting knowledge and more positive attitudes towards child development, supporting partners in household chores, and recommendation to promote this partner inclusive parenting program throughout the country.

Addressing depression in parents is hugely important due to its adverse impact on both parents and children. This low-cost parenting program supported fathers in their parenting role along with improvement in psychological well-being. This has also informed barriers and facilitators to implement the LTP plus parenting program and the possibilities to roll out the intervention at national level.

The NICE guidelines NG97 (1.5) currently recommend to consider memantine in addition to acetylcholinesterase inhibitors in the management of moderate to severe Alzheimer's dementia, if tolerated, as opposed to the mono-therapeutic management with either class of drug. This management practice was adopted by the trust and updated on Trust guidelines.

I noted that most of the patients on follow up in memory clinic, had a generic diagnosis of dementia subtypes, without a mention of the degree of severity of the illness and as such, on monotherapy.

Aim

This audit serves to establish the practice in recent years, if patients diagnosed with dementia, were diagnosed, and managed according to the severity of their condition.

If not, for necessary changes to be implemented in practice and a re-audit carried out.

The audit was conducted in February 2023 as a retrospective study. We analysed records of 60 patients seen for a diagnostic appointment in Middlesbrough Memory Service between January 2020 and December 2020.

All referrals made to the memory clinic within 2020 were retrieved from trust electronic records and 5 patients were selected at random from each month using the google random number generator, and analysed on Excel.

The most common dementia diagnosis was mixed dementia (Alzheimer's + vascular disease) with 40% of diagnoses, followed by Alzheimer's disease at 39%, while Lewy body dementia was least diagnosed at 8%.

Assessment: Only 46 records completed the dementia diagnostic pathway (initial assessment, ACE III, CT scan alongside pre-referral blood screen), the other 14 patients were unable to complete this pathway due to functional decline.

Severity of illness: Of the patients evaluated, only 7% had the severity of disease in their diagnosis, which were all Moderate severity. 93% had generic diagnosis.

Pharmacological Treatment: 46 out of 60 patients evaluated, were on medication.

And all were on monotherapy, irrespective of disease severity, with majority being on anticholinesterase inhibitors (Donepezil) being the first and most popular choice.

Severity of disease condition were not identified or documented.

The use of combination therapy is yet to be considered at the diagnostic stage. This should be implemented before discharging a patient with moderate to severe disease. Although, local best practice is to offer this as early as moderate disease is identified.

Combination therapy is yet to be adopted in the organic pathway.

At a time of increased pressures across the whole forensic estate, The Orchard Clinic Medium Secure Unit faced the additional challenge of having to close multiple acute admission beds.

This led to challenges in determining how to triage patients in the face of multiple external pressures, frustrations for clinicians managing severely ill patients in prison and human rights concerns for those unfit to stand trial but remanded to custody to await a bed.

The need for an objective tool to aid triage decisions became apparent. We therefore piloted the use of the DUNDRUM triage urgency manual, a structured professional judgement tool to aid triage decisions for forensic units.

The aims of introducing this tool were to ensure decisions are more consistent and reliable, ensure scientifically valid items are not forgotten, make decision making processes more transparent, demonstrate equality of access to services and reduce chance of serious error.

This audit reviewed all acute admissions to The Orchard Clinic between Aug 22–Aug 23. This covered a period 6 months prior to the introduction of the tool and 6 months after.

In order to determine if the use of the tool improved our triage making decisions the Dundrum score was retrospectively calculated for admissions and those on the waiting list during the first 6 month period of the audit. The same information was recorded for those following the introduction of the tool in the second 6-month period.

Prior to introduction of the DUNDRUM, the team's triage decisions were not in line with validated tools, those with lower DUNDRUM scores were prioritised over those with higher scores. Following introduction of the tool our triage decisions improved. Common themes emerged when we analysed the reasons why our triage decisions were out of line with validated tools. These included patients in hospital settings taking precedence over those in prison, patients admitted without prior discussion at bed management meetings, legal urgency taking precedence over clinical and lack of available HDU space.

Prior to the introduction of the DUNDRUM triage urgency manual the audit demonstrates that the team's triage decisions were not in line with validated tools. This improved following training and use of the tool at bed management meetings. The Orchard Clinic has now formalised use of this tool within bed management meetings. We are currently in the process of re-auditing over a 12-month period.

Individuals with intellectual disability (ID) exhibit elevated health needs when compared with the general population. There is a higher vulnerability to long-term conditions. A scoping review identified that individuals with ID exhibit a distinct pattern of multiple long-term conditions (MLTC) that is different to the general population. Findings highlight health challenges faced by individuals with ID, emphasising the need for targeted and early interventions to address their unique healthcare needs.

This study utilises a professional advisory panel (PAP) and patient and public involvement (PPI) group to form a consensus on relevant long-term conditions for people with ID. Machine learning algorithms are employed to identify long-term conditions in a large, population-based data repository covering the whole of Wales revealing a comprehensive range and prevalence of long-term conditions in a sample of 13,361 adults with ID.

A consensus on relevant long-term conditions for people with ID was formulated through iterative review followed by revision by PAP and PPI group. PAP comprised a multidisciplinary team with relevant expertise including General Practitioners, a Consultant Psychiatrist, nurses, pharmacists, and data analysts. The PAP worked in collaboration with a PPI group, comprising three groups of experts by experience: people with ID, family or informal carers of people with ID, and professional carers of people with ID.

This study utilises machine learning algorithms in the Secure Anonymised Information Linkage (SAIL) databank to identify the range and prevalence of long-term conditions in ID. SAIL is an anonymised, population-based data repository, comprising billions of anonymised records across Wales. This study included 13,361 ID adult patients.

Following iterative review and revision by the PAP and PPI group, a consensus of 40 long-term conditions relevant for people with ID was identified. Prevalence rates for each condition were calculated. Ten most prevalent conditions were recorded as mental illness, reflux disorders, epilepsy, chronic airway diseases, hypertension, thyroid disorders, chronic arthritis, chronic kidney disease, diabetes, and anaemia.

Consensus on relevant long-term conditions for the general population developed through previous studies is not relevant for the ID population. This is the first effort at creating a full range of long-term conditions for individuals with ID, utilising a population-based data repository. It is possible to do this in partnership with PAP and PPI groups. Along with prevalence, impact of ageing and gender, and hospitalisation as outcome data, this study describes challenges associated with interpreting data captured by Read Codes and ICD–10 codes.

The primary aim was to analyze three months of admissions to Rowan Ward PICU (February 22 to April 2022) according to NAPICU's 2014 criteria, followed by implementing recommendations and conducting a re-audit (November 2022 to January 2023) to assess their impact. Secondary objectives included examining the link between prior PICU admissions and higher readmission rates, even when not clinically necessary.

Methods involved assessing each admission against NAPICU's criteria and reviewing the reason for admission (RFA) for appropriateness. Data collection utilized various sources, including SystmOne, Mental Health Act assessments, and referral documents. Collaborative analysis with the PICU consultant was conducted due to the subjective nature of RFA interpretation.

Results from the initial audit revealed that 12 out of 36 patients (33%) were deemed unsuitable for PICU admission, with 8 having prior PICU admissions (67%). Only 22% had documented multidisciplinary team (MDT) discussions. In the subsequent audit, 9 out of 38 patients (24%) were deemed unsuitable for PICU admission, with 2 having prior admissions (22%). Only 3% had documented MDT discussions.

There was a reduction in inappropriate admissions from 33% to 24% in the subsequent cycle. This improvement was linked to the implementation of recommendations from the first audit, such as introducing a standardized referral form, enhancing consultant-to-consultant communications, and forming a PICU outreach team. While the initial findings indicated higher readmission rates for patients with prior PICU admissions, this trend lessened in the subsequent evaluation. However, there is still insufficient documentation of Multidisciplinary Team (MDT) discussions, highlighting the need for a re-audit to accurately assess any changes.

This audit aimed to understand the practice of advance care planning with regard to cardiopulmonary resuscitation (CPR) in an older adult inpatient setting and to ultimately improve practices to conform to nationally set standards.

The aims of the audit were:

1. (1) To determine the prevalence of advance care planning decisions relating to CPR in patients admitted to two older adult psychiatric wards at Thurrock Community Hospital.

2. (2) To confirm that the practice of discussion and documentation of ‘Do Not Attempt Cardiopulmonary Resuscitation' (DNA-CPR) decisions is consistent with current national standards.

First, we scrutinized whether the patient's preferences for CPR as a life-sustaining treatment were documented or known to the primary care physician at the time of admission, and whether there was a DNA-CPR order in place at the time of admission.

Next, we looked at whether a discussion about CPR was facilitated with the patient (or those close to the patient) during the admission, whether the patient was involved in the discussion surrounding CPR and the reasons for their exclusion (if excluded), and at what point in time during the admission this discussion was carried out and whether it was properly documented.

Finally, we assessed the level of completion of the DNA-CPR form itself.

Total sample: 38 patients.

13 out of 38 patients (34.21%) had a DNA-CPR form in place.

10 out of 13 DNA-CPR forms (76.92%) were complete in all aspects.

Discussion relating to DNA-CPR was not carried out in 29 out of 38 patients (76.32%) during their current admission.

Mental Capacity Assessments and Best Interest meetings were not documented as having been carried out as was necessary in the 4 patients (0%) who did not have a designated Lasting Power of Attorney.

Discussions about advance care planning and DNA-CPR were not being carried out in a timely manner as per the national guidelines.

Introduction: Second-generation antipsychotics are widely used in psychiatry but are associated with weight gain. Obesity is more prevalent in mental illness and may contribute to the mortality gap. Non-pharmacological management of antipsychotic-induced weight gain (AIWG) has limited success whilst pharmacological treatment typically involves antidiabetic medications that psychiatrists have less experience with. Recent developments in the field have shown promise with using centrally-acting opioid receptor antagonists (CORAs) at treating AIWG.

Objective: Review and synthesise the available RCT evidence on the efficacy of CORAs at treating AIWG.

Methodology: Four databases (Medline, Embase, PsycINFO, Cochrane) were searched, from database inception to present, for RCTs using CORAs (naloxone, naltrexone, samidorphan) to reduce AIWG. Our primary outcome sought was weight change in kilograms, with secondary outcomes of change in percentage of body weight, waist circumference and 7% or 10% weight change thresholds. We used random-effects meta-analysis due to study heterogeneity.

A total of 450 articles were found (319 post-deduplication), of which seven met criteria (samidorphan = 4, naltrexone = 3, naloxone = 0) including n = 1,416 patients. On meta-analysis, change in body weight (kg) for CORAs as a class was statistically significant (RE = 1.37 kg; 95% CI: 0.51, 2.24). However, change in BMI was not statistically significant (RE = 0.61kg/m2; 95% CI: −0.56, 1.78). Remaining analysis was only available for samidorphan, which showed statistically significant improvement in change in body weight (%) (RE = 1.81%; 95% CI: 1.07, 2.55), absolute risk of weight gain ≥7% (RE = 12.41%; 95% CI: 6.55, 18.27), absolute risk of weight gain ≥10% (RE = 10.83%; 95% CI: 5.46, 16.21), and change in waist circumference (RE = 1.50 cm; 95% CI: 0.32, 2.67).

Evidence is strongest for samidorphan, though CORAs as a class remains poorly researched and the benefits are modest. Additionally, samidorphan is currently only available in the combination medication olanzapine-samidorphan and the literature reflects this. Further research is needed to examine its efficacy in AIWG from other antipsychotics.

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterised by the core symptoms of hyperactivity, impulsivity, and associated functional impairment. Psychostimulants are the most commonly prescribed medication for ADHD in children and adolescents. The use of psychostimulants in children and adolescents requires close supervision in a specialist clinic. The decision to commence psychostimulants should be made jointly with the young person, their parents, carers, and healthcare professionals. It is critical to provide age-appropriate information and discuss treatment's possible benefits and side effects.

This audit aimed to appraise the psychostimulant prescribing practice in children and adolescents in psychiatric outpatient clinics in Al Ain Hospital, United Arab Emirates. We analyzed compliance against the standards set out in The National Institute for Health and Clinical Excellence (NICE) Guideline 87 concerning the diagnosis and management of ADHD in children and young people.

This hospital-wide audit involved a retrospective review of case notes. A questionnaire was developed to capture the required information anonymously. The audit sample comprised 366 service users with a diagnosis of ADHD followed up in the child psychiatry clinic between January 2018 and December 2019. We chose this pre-Coronavirus Disease 2019 (COVID-19) period when services ran as usual. Data collection took place between September and November 2023.

Out of 366, 298 (85%) patients were males, with 181 (55%) being Emirati citizens. The sample age ranged between 5 and 17 years, with a mean of 9.8 years. Psychostimulants were prescribed in 327 (89%), with methylphenidate being the most commonly used medication. All but one case had documentation of discussion about medications' indications and side effects. However, only 40 (12%) cases had a discussion documented about the importance of following a healthy lifestyle, while 5% had no discussion about the right to revisit their decision about the treatment.

This audit has identified areas for improvement in practice, including the need to develop local guidance on prescribing psychostimulants in children and adolescents with a diagnosis of ADHD. We recommend enhanced staff training to improve the quality of discussion with the young person and their family before starting psychostimulant therapy, including clear documentation of the decision-making process. We suggest electronic reminders to inform the patients about the importance of following a healthy lifestyle. We will re-audit the practice after one year of implementing the above action plan.

No financial sponsorship has been received for this evaluative exercise.

Very early onset schizophrenia is considered a rare and severe form of schizophrenia, with onset before age 13. Early initiation of antipsychotics significantly improves outcomes and prognosis. Treatment refractory status is not uncommon and clozapine currently remains the most effective option in this scenario. However, approximately 40–70% of antipsychotic-resistant patients do not respond, or respond only partially to clozapine. Additionally, many patients stop clozapine due to side effects, many of which are due to its active metabolite, nor-clozapine. Since clozapine-resistant patients have limited alternative treatment options, augmentation strategies must be considered.

This case study highlights one such augmentation strategy using fluvoxamine. Fluvoxamine inhibits CYP450 1A2 isoenzymes reducing the risk of the metabolite induced side effects and synchronously increasing plasma concentrations of clozapine.

The case study is of a 13-year-old female diagnosed with paranoid schizophrenia characterized by second and third person auditory hallucinations, delusions of persecution, paranoid pseudo-community, impulsive aggression and cognitive decline. She screened negative for developmental disorders, metabolic and genetic anomalies and medical co-morbidities. She had failed trials of two atypical antipsychotics. Clozapine was subsequently initiated and optimized to 500 mg/day (Serum Clozapine of 981 mcg/L). Partial improvement in symptomatology was observed. However, dose adjustments were difficult throughout due to side effects of clozapine and pharmacological agents such as Metformin, Lamotrigine, Ipratropium Bromide and Propranolol were used prophylactically to mitigate the side-effects. The polypharmacy, social isolation, excessive sedation and emerging obsessive-compulsive symptoms contributed to secondary negative symptoms. Low-dose fluvoxamine was subsequently used as an augmentation strategy following which improvement was noted.

Several studies have shown that co-administration of fluvoxamine may increase the steady-state serum concentrations of clozapine by a factor of 5. Optimizing the serum ratio of Nor-clozapine and clozapine levels, thereby, reduces the need for aggressive polypharmacy. Low doses of fluvoxamine inhibit the CYT activity, enough to raise the level of clozapine even when the dose of clozapine is reduced by 50% which is the target going forward for this patient.

Although current practice guidelines recommend clozapine mono-therapy for treatment resistant schizophrenia, augmentation of clozapine with fluvoxamine can be considered for those who do not respond adequately to clozapine mono-therapy or cease treatment due to its side effects. However, considering the unpredictable effect on clozapine plasma levels, concomitant use should ideally be initiated in facilities like a pediatric intensive unit where close surveillance is possible especially for side effects such as myocarditis especially in adolescents.

To systematically review current quantitative evidence for psychological and behavioural outcomes for children with drug-resistant epilepsy being treated with either the ketogenic diet (KD) or vagal nerve stimulation (VNS).

The review was conducted with a systematic review methodology and the Preferred Reporting Items for Systematic Reviews (PRISMA) tool. The methodology was developed by the author using the PICOS (population, intervention, comparison, outcome, study, design) framework.

Eligibility criteria included children up to 18 years old with epilepsy treated with KD or VNS, and studies which assessed psychological and behavioural outcomes, with validated tools, before and after treatment. Any quantitative design was included. Review articles, meta-analyses, case studies, and case series without a reported mean were excluded. Searches were conducted in four main databases (GlobalHealth, Medline, PsychInfo, Embase) and two grey literature databases (Scopus, Web of Science).

Duplicates were screened using automated processes and then manually. Titles and abstracts were reviewed against eligibility criteria, followed by full texts. Risk of bias was assessed using tools appropriate for the study (the Risk of Bias-2 tool for randomised controlled trials, the JBI checklist for quasi-experimental studies, and the JBI checklist for case series). Included articles were grouped by intervention and by study design for data extraction.

22 studies were identified: 11 for KD, comprising of two randomised controlled trials, one retrospective quasi-experimental study, one retrospective study, two prospective studies, one cross-sectional survey, and four case series; and 11 for VNS, comprising of one randomised controlled trial, two longitudinal observational studies, one prospective observational study, one retrospective study, and six case series.

These studies included a total of 655 participants (523 KD, 132 VNS). There was weak evidence for an improvement in cognitive and behavioural outcomes with both KD and VNS although most studies had methodological weaknesses and were at risk of bias. For both interventions, some studies showed that improvements in outcomes were not related to improvement in seizures, or to reduction in medications.

The evidence base for cognitive and behavioural outcomes following KD or VNS treatment is limited and studies are generally weak and underpowered. Psychological measures used across studies are heterogeneous and difficult to compare. There are little data, but studies raise the possibility that both VNS and KD may affect psychological and behavioural outcomes independently of their effect on seizures. This review supports the need for further research into this area with larger, methodologically robust studies.

Section 136 of the Mental Health Act 1983 allows for a person who appears to a constable to be suffering from a mental disorder and needing immediate care to be removed to a place of safety (POS) for their protection or the protection of others.

The legislation recommends that prior to making a decision to detain on Section 136, the constable must, if practicable, consult mental health services for information to guide decision making.

The 136 suite is the preferred POS except for patients requiring urgent medical treatment in which case the Emergency Department (ED) is preferred. If the 136 suite is unavailable, then alternatives like the ED may be used.

This audit examines the use of the Birmingham City Hospital Emergency Department as a POS following Section 136 detention, the adherence to the aforementioned legislation and the outcomes of the assessments.

The audit was approved by the clinical governance team and a list of all Birmingham City Hospital patients detained under Section 136 for a three-month period (January–March 2022) was retrospectively obtained. Clinical records were examined, and the relevant data was extracted from the clinical notes.

Information including the reason for use of the ED as a POS, police contact with mental health services prior to detaining, time taken prior to assessment, reasons for mental health act assessment (MHAA) delays, and outcomes were collected and collated using Microsoft Excel.

The ED at City Hospital was used a place of safety for 80 patients in this period. In 52.5% of cases the ED was used as a place of safety due to lack of space at the POS. Contact with mental health services prior to detention was documented in only 29% of cases. The average time for a MHAA to take place in the period under review was 11.5 hours. Only 20% of these cases ended up detained under the mental health act.

The results show poor adherence in the use of Section 136 to the recommendations of the legislation. Improvements are needed on time taken for assessments and use of ED as a place of safety due to unavailability of beds at the s136 suite. The police should be re-educated on the importance of contacting mental health services prior to detaining patients on Section 136. The audit result was presented at a clinical governance meeting and repeat audits are planned across all the emergency departments in Birmingham.

Wales is the only member of the home nations without Specialist Eating Disorders Training (SEDT) and does not currently have any Specialist Eating Disorder Units (SEDU). This has resulted in varied exposure and experience to eating disorder (ED) psychiatry within psychiatrists working in Wales. Patients with ED have the highest mortality out of all conditions in psychiatry and with hospital admissions for ED on the rise it is important that we understand current attitudes towards ED and use this data to improve understanding and services provided for these patients.

The aims of this project are to

1. 1. Gauge the experience and knowledge of eating disorders of psychiatrists in Wales.

2. 2. Examine attitudes towards management of different risks and which individuals should manage what aspects of care regarding eating disorders.

3. 3. Identify future avenues of development for eating disorders services in Wales.

An online survey was sent to the 518 members in the Royal College of Psychiatrists in Wales mailing list identifying their current position within psychiatry, experience in working with ED patients and then different questions regarding their attitudes towards ED, ED management, their opinions on development of SEDT posts and their opinions on the development of SEDU in Wales.

There were 36 anonymous responses from doctors working in or around psychiatry in Wales. Responses were collected between March and April 2022 with the survey taking on average less than 5 minutes to complete.

36 individuals answered the survey with consultant/SAS (Senior) level doctors making up 69% of responses, the remaining 31% being psychiatry or GP trainees. Senior doctors mostly comprised general adult or CAHMS specialists, but other specialities were also present. 75% of responses reported some expertise in ED. 50% reported they were confident in the management of ED however there were varying responses when asked about the management of physical health in ED. 89% of responses indicated they would like to see the development of ED psychiatry posts and 78% of responses would like to see the development of SEDU in Wales for severely ill patients.

Many of the responses indicated some exposure to ED however 50% of responders did not feel confident in the management of ED. The development of ED psychiatry posts and SEDU would likely aid in increasing confidence of ED management.

• • To find out discrepancies around community treatment order section paperwork and renewal hearings.

• • Explore if CTO is helpful in delaying relapse of mental illness.

All inpatients from general adult male and female wards in the North East Essex area in the last 3–5 years who were detained under section 3 of the Mental Health Act and were discharged on a Community treatment order were included. All included patients were followed up for a period of two years and data was reviewed to know if the standard guidelines regarding the CTO paperwork completion and renewal hearings were followed.

Data about episodes of further recalls to hospital, further revocation or discharges on CTO during that two year period for these patients is included.

Information about the timely filling of the CTO forms and uploading on the system upon readmission is explored wherever applicable.

Finally, the time duration between discharges and each readmission is explored.

Total no. of patients: 13, Male: 10, Female: 3

Out of the 13 patients,

One had 4 readmissions in the consequent two year period (Days since last discharge – 158, 80, 14, 365 days), duration of each admission: (39, 9, 71, 53) days.

Two had 2 readmissions (on days 623 and 80: On day 65 and 9), Duration of each stay (6 and 90 days; 80 and 164 days).

Four patients had 1 readmission (on days 683, 133, 30, 723) and duration of stay is (14, 33, 1510 and 1460 days).

Six patients never had any admission.

As for the tribunal hearing, one patient's tribunal hearing was missed, one of them did not attend, one had his CTO rescinded and one was admitted soon after. Rest of the patients had their regular timely hearings and were regularly reviewed in the community.

Out of 13, only 3 patients had appealed against the CTO, had tribunal hearing.

Out of 13 patients, only one patient had his CTO lapsed and he had two readmissions during the 2 years follow up.

Delay in admission following recall was due to section 135 being issued.

CTO3 paperwork was missing in two cases.

A second CTO3 or recall notice was issued in 4 cases, in 1 case, reason was not documented, in 2 cases, patient agreed for informal stay but later did not comply with care plan. In one case, reason was not documented.

CTO paperwork are missed in rare cases and could be avoided by reminders from Mental Health Act Office.

CTO renewal hearings take place regularly as per mental health act guidelines, though in rare cases, meeting is missed. This could be avoided by having patients discharged on CTO to be booked for timely reviews beforehand.

The audit is too small and is inconclusive to indicate if CTOs prevent readmissions and relapses and hence future study with more sample size is called for.

Repetitive Transcranial Magnetic Stimulation (rTMS) is a non-invasive brain stimulation recommended by NICE for treatment of depression with minimal side-effects and a high patient acceptability. Our aim was to assess the effectiveness of rTMS in real world clinical service in alleviating symptoms of depression and anxiety.

All patients receiving rTMS in our Centre for Neuromodulation Services (CNS) received 5 daily treatment sessions a week for a period of 5 weeks (25 sessions in total). All patients routinely completed PHQ-9, BDI-II and GAD-7 measures before and after the course of treatment. The scores on these measures were retrospectively analysed using paired-sample t-test.

All 15 patients completed the PHQ-9 and GAD-7 scales while 10 patients completed BDI-II. Eleven patients (73%) had improved PHQ-9 scores post-treatment with average improvement of 5.5 points which was statistically significant [paired-sample t-test: t(14) = 3.019, p = 0.009]. Nine patients (90%) had improved BDI-II scores post-treatment with average reduction of 36% from baseline which was statistically significant [t(9) = 3.681, p = 0.005]. Eleven patients (73%) had improved GAD-7 scores post-treatment, with average reduction of 4 points. This reduction was also statistically significant [t(14) = 3.038, p = 0.009]. Improvement in all measures was also of a level that would be considered clinically significant for these measures. All patients tolerated the treatment well with no patients dropping out due to side effects.

With the limitation of relatively small sample size, our initial analysis indicates that rTMS treatment offered in real world clinical service is effective in treating symptoms of depression. Although our protocol was not intended to treat anxiety, our patients had remarkable improvement in anxiety symptoms as well.

In the intensive care unit (ICU), delirium occurs in up to 80% of patients on mechanical ventilation. Delirium is associated with an increased risk of morbidity and mortality, long-term cognitive decline, and risk of reintubation. This initial audit aims to identify areas of improvement in the early detection, prevention, and management of delirium in the ICU of the general hospital following trust guidelines.

In this baseline audit, data was collected about all inpatients on admission over a 7-week period (81 patients in total). The parameters audited were in accordance with trust guidance on the management of delirium and compliance to this was recorded. Parameters included: the correct use and documentation of screening tools, type and cause of delirium, pharmacological and non-pharmacological management, and other demographics such as sensory impairment and length of stay. Confused patients handed over verbally during ward rounds were also assessed again at the time, with documentation and parameters reviewed.

Of the 81 inpatients in the ICU, 20 were observed with delirium during their stay. The documentation of delirium via the CAM-ICU screening tool was incorrect in 25% of patients with delirium (PWDs). Furthermore, behaviour (including sleep) was only monitored for 15% of PWDs and 0% had a complete “This is me” document (support tool for patient-centred care).

Sensory aids were not available for 50% of PWDs and 25% of this group had drug/alcohol dependence. A diagnosis of delirium was only formally documented in 40% of PWDs and of these, 15% had the type of delirium documented. Only 8 PWDs received a specific management plan, with 6 PWDs receiving haloperidol or lorazepam for agitation. Non-pharmacological managements were not documented.

The average length of stay in the hospital was 20% longer in PWDs compared with non-delirium patients, with 10 deaths in the ICU; 50% of these being PWDs.

There is a lack of accurate documentation and a lack of medical optimisation for PWDs, which may lead to missed delirium diagnosis, greater risk of mortality and longer hospital stays. The results highlight a need for further education about delirium in the ICU, to increase awareness for better detection, prevention and promotion of appropriate delirium management and formal documentation as per trust guidelines. Furthermore, a need to consider alternative pharmacological management for delirium, specifically in the ICU where lorazepam and haloperidol may not be suitable in consideration of anaesthetic drug interactions and respiratory support requirements.

Presentations of severe Eating Disorders (ED) to the Tertiary Eating Disorders Specialist Service (TESS) in Lanarkshire have increased in recent years. Our criteria has also expanded to include severe Avoidant-Restrictive Food Intake Disorder (ARFID), increasing demand for a multidisciplinary team (MDT) approach for patients at high physical risk with less typical ED presentations. Medical Emergencies in Eating Disorders (MEED) recommends MDT working and development of pathways to support these patients.

The “EDIT subteam” was thus developed in March 2023, comprising: TESS psychiatrist, TESS GP, dietician, assistant practitioner, and TESS psychologist.

For TESS patients at high physical risk, high risk of hospitalisation, and who would benefit from a trial of “stepping up” treatment, we aimed to employ coordinated MDT intervention to 1. optimise community treatment, 2. regularly review risk and 3. reduce need for hospital admission.

Each patient was discussed at a weekly MDT meeting attended by EDIT subteam, where risk assessment and management plan was agreed.

6-month review was conducted using meeting minutes, staff survey and group discussion, with consideration given to: number of patients prevented from requiring hospital, number of patients admitted to hospital and consideration if different levels of intervention could have prevented this, staff satisfaction and review of the MDT complement.

22 patients – 17 female, 5 male – were included on EDIT for the first 6 months. At point of step-down from EDIT, 13 had ongoing TESS community input, 5 were admitted to hospital, 3 were discharged from TESS and 1 transferred to Community Mental Health Team.

Most EDIT patients received input from multiple domains of the MDT. Given baseline low admission rates and complexity of patient presentation, we were unable to determine how many hospital admissions were prevented, but consensus was that overall, a higher level of care was provided. It was not felt that different levels of intervention could have prevented any of the 5 admissions. Staff feedback was positive: EDIT improved communication, provided job role diversification, contained and shared risk, improved awareness of care plans and resulted in better-considered onward referrals.

Areas for improvement included a lack of Occupational Therapy and nursing, and concern about EDIT patients skipping waiting lists.

The EDIT subteam provides an avenue for high risk patients to be regularly discussed in an MDT setting – although impossible to empirically quantify if admissions were reduced, consensus within TESS was that the introduction of EDIT has improved community treatment for this group of patients.