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.

The project aimed to review the Trust Medical Appraisal policy and offer a platform to update the Trust policy locally and align it to a National recommendation in the Medical Appraisal Guide besides gathering consensus for change for other relevant issues to the Trust.

The project was undertaken as a part of the ‘Leadership and management fellowship Scheme’ sponsored by the Tees Esk and Wear Valley NHS Foundation Trust and conducted in collaboration with the Royal College of Psychiatrists, UK and Faculty of Leadership and Management, UK 2022–23 with data collection lasting from January till August 2023. The methodology consisted of drafting a document comparing the information from the review of the existing Trust medical appraisal policy and the guidance in the Medical Appraisal guide, drafting a questionnaire which covered the complex issues in the appraisal process and where the Trust medical appraisal policy was identified as having gaps which required further opinions to be generated for a possible revision to the policy, and gathering consensus opinions from focus group discussions for different groups of staff which included appraisers who are not managers, consultants who are not appraisers, medical managers who are not appraisers, consultants who are appraisers and SAS doctors who are not appraisers. The focus groups were conducted virtually as well as face to face groups and consensus opinions were then synthesised with information available from the guidelines to draft recommendations. The recommendations were then presented to the senior managers in the Trust appraisal process to seek feedback and approval.

The main recommendations that followed from the review were: to promote supportive and developmental nature of the appraisal process by making the process less document intensive by modifying appraisal portfolio and appraisal sections, educating staff on not duplicating information, promote verbal reflection, and modifying corporate supporting information section to reduce burden on doctors; maintaining 3 year appraiser turnover; avoiding line manager to be the appraiser of the appraisee; not sending appraisal summary to the line manager and considering how to facilitate communication and input of the line manager to the revalidation decision; clarifying requirements of supporting information for appraisal of particular group of doctors (Trust doctors, International Medical Graduates (IMG), academics, and on zero hour contracts); expand corporate supporting information to include General Medical Council (GMC)/Trust disciplinary and low level concerns; to promote wellbeing discussion by adding prompt for doctor to comment on their wellbeing; adding a wellbeing statement to the appraisal template and finally to add trainer accreditation statement to the appraisal template to facilitate reporting of trainer accreditation. Most of the recommendations were accepted by the Trust except one on expanding the corporate supporting information for doctors and addition of a wellbeing template in appraisal section.

The project served as a significant leadership experience in my training role to undertake a project driving a Trust-wide change in medical appraisal policy based on participative leadership, generating consensus and developing a phased action plan towards implementation.

Learning about and appreciating the use of Electroconvulsive therapy remains an integral part of the undergraduate psychiatry curriculum. The existing literature indicates that medical students frequently have unfavourable views regarding ECT and its adverse effects.

Therefore, this study aimed to introduce a new teaching tool that supplements traditional didactic ECT teaching with simulation-based procedural demonstration thus providing a real-life experience of an ECT room and subsequently evaluate the learning gains conferred by such a curriculum.

The demonstration was carried out by Clinical teaching Fellow with the help of a high-fidelity manikin and a live actor who played the role of the patient, in the ECT suite in Birmingham.

Participants of the study were fourth year medical students who completed a self-administered questionnaire before and after the simulation session. This survey was designed to explore changes in knowledge, attitudes, and perceptions of the students towards ECT and its side effects.

Within a cohort of 88 students, 52 students successfully completed the pre-session questionnaire, and 43 students completed the post-session questionnaire. Students reported a global improvement in knowledge regarding ECT, when comparing results from both questionnaires. Prior to the simulation, many students used negative terms to describe ECT such as ‘torture’, ‘barbaric’ and ‘uncontrolled’, suggesting outdated stigmas around ECT. However, after the simulation, many students expressed a positive change in opinion, describing ECT as ‘controlled’, ‘beneficial’ and effective’.

Additionally, students reported improved knowledge about the side effects of ECT, especially regarding pain, memory loss and brain injury. Many students reported that their initial apprehension had been addressed over the course of the ECT simulation. Many noted ECT was more effective and beneficial than originally thought and the process was less extreme and invasive than they believed.

The results of the study reflect that the use of simulated ECT within medical students can help disperse some of the stigma and myths regarding this treatment. Simulation can humanise the process and shift attitudes around ECT by allowing students to become fully immersed into an almost real-life scenario. It can also address knowledge gaps around ECT indications, process, risks, side effects and benefits. This will in turn help educate future clinicians have a better understanding about ECT in the treatment of severe mental illness, thus optimising the utilisation of this effective treatment. Furthermore, such technique can be a useful tool for demonstrating ECT to potentially wider group of students, trainees and other health practitioners.

The disruptive force of the COVID pandemic has highlighted the importance of leadership for all medical educationists to prepare the future workforce with the ever-changing healthcare practice. Early career medical educators must attain leadership skills as early as possible. The only way to learn leadership is through experiential learning, i.e. learning while leading. Therefore, this self-study is aimed to share the reflection on the journey of a psychiatrist specialist trainee from North Wales in leading different psychiatric educational projects.

This is self-study research on the reflective experience of working as a medical educational fellow while undergoing specialist training in psychiatry from January 2022 to December 2023. The data reflected were sourced from publications, end-of-project reports, meeting minutes, participant and peer feedback, personal records, educational portfolios, and appraisals.

Nine psychiatric educational quality improvement projects (QIPs) had been conceptualised and implemented, i.e. three series of mock exams (Special Preparation in CASC Exam), continuous coaching and mentoring in portfolio-based learning (Café of RCPsych Portfolio), continuous mentorship in academic writing (Mini North Wales-Academic and Research Clinic), continuous peer supervision in psychotherapy (Gogledd Cymru-Peer Supervision in Psychiatry), mock interview for job application, digitalisation of departmental induction, psychopathology training (3P: Psychopathology for Postgraduate Psychiatrists Trainee), and two international collaborative educational programmes (Perinatal Psychiatry Perinatal and Infant Psychiatry Educational Programme of Wales, Tanzania, and Malaysia; and Bhutan Old Age Psychiatry Educational programme). Five peer-reviewed publications had been completed while the other academic writings were ongoing. Three of the projects (33.3%) were expanded from a Welsh initiative to the whole United Kingdom and a bigger team was formed to ensure sustainability could be achieved. Two projects (22.2%) started as an international collaborative project. All projects provided opportunities for the members of the QIP to obtain workplace-based assessments and evidence for yearly appraisal while improving the educational experience of trainees and professionals in the field of mental health.

All challenges come with the opportunities to be innovative in problem-solving. Communication skills and people management are crucial for resource gathering and conflict resolution. Lastly, talent development is required as part of the effort to sustain all the projects.

Interventions to support people with autism are multidimensional, but primarily psychosocial in nature. These interventions include behavioural, educational and support therapies. Some psychotropic medications are used to manage medical and psychiatric comorbidities associated with autism, which interfere with daily social and occupational functioning or limit the implementation of psychosocial interventions. The aim of this study is to describe the trajectories of psychotropic medications in people newly diagnosed with autism according to sex and age.

This is a retrospective cohort study based on medico-administrative data from the Régie de l'assurance santé du Québec. The cohort included all people living in the province of Quebec (Canada) with a first diagnosis of autism (incident cases) recorded during hospitalisation or during a medical visit between January 2012 and December 2016 (index date: first diagnosis). Only individuals covered by the public prescription drug insurance plan one year before and one year after the index date were included. A patient was considered exposed to a drug from the date a prescription was claimed at a community pharmacy and for the time the drug was provided. However, as no information was available on inpatient drug, the drug trajectory represents the outpatient drug trajectory. The five classes of psychotropic drugs considered were: 1) anticonvulsants and mood stabilisers; 2) antipsychotics; 3) antidepressants; 4) anxiolytics/hypnotics; and 5) psychostimulants. Drug trajectories are represented using state sequence analyses.

The study cohort included 3284 people, of which 867 (26.4%) were females and 2417 (73.6%) were males. Overall, 51.6% of the cohort claimed a psychotropic medication in the year preceding diagnosis and 61.1% in the following year, with higher proportions among females and increasing with age. Psychostimulants were the most prescribed medications among people diagnosed at ages ≤12 years, while antipsychotic use increased considerably with age, becoming the most commonly prescribed medication among those diagnosed in adulthood (≥18 years), with use rates reaching as much as 80% among those diagnosed between 36 and 60 years. State sequence analyses demonstrate slight variations in the use of psychotropic medications over time, but significant variations by age category and sex.

Although psychosocial interventions are recognised by clinical practice guidelines as the cornerstone of interventions for people with autism, the use of psychotropic medications is widespread. This highlights a significant gap between the recommendations of these guidelines and what is observed in the real world.

FND can be considered as an umbrella term that includes range of motor and sensory system dysfunctions with genuine symptoms including paralysis, tremors, sensory disturbance, speech disturbance and seizure. Functional seizures usually termed as Non-Epileptic attack disorder (NEAD) can result in profound persisting disability. Brief bouts of unprovoked and uncontrollable laughter, spontaneous in origin, combined with facial contraction in the form of smile, is termed as ‘gelastic seizures’. Modafinil is a dopamine modulating molecule for which evidence is accumulating towards its cognitive enhancement role in multiple domains. Furthermore, it has been shown to promote hippocampal neurogenesis and synaptic plasticity in pre-clinical studies. We report a case of FND in which pharmacological (Modafinil) and non-pharmacological interventions (Brain retraining) resulted in resolution of symptoms of probable gelastic episodes.

A 50-year-old lady who was referred by consultant neurologist to our Neuropsychiatry pilot service with episodes of uncontrollable laughing, singing, screaming and suffering from staggering and imbalance. Following these episodes, patient described sleeping for hours to days with fatigue. Her husband first noticed low mood 12 years ago during post-natal period. Treatment with fluoxetine reportedly contributed to ‘cyclical highs and mood variations’. One year later, her ‘gelastic episodes’ started and continued to occur every 2 or 3 months and they were brought on by a range of factors including tiredness, menstrual periods and stress. Patient also reported atypical cognitive deficits such as ‘losing vocabulary’ and ‘stuck every couple of seconds’. Furthermore, detailed history confirmed possible traits of attention deficit and hyperactive thinking since her childhood.

Following a comprehensive assessment, the role of the brain in the manifestation of her symptoms was discussed and agreed upon. Strategies based on Cognitive Behaviour Therapy principles such as active distraction, brain retraining, engaging in therapeutic activities and expressive writing were discussed and agreed upon. Following detailed risk-benefit analysis, modafinil was initiated at 200 mg dose in the morning. Patient made a remarkable recovery nearly back to her baseline with resolution of her gelastic episodes and thus improvement in her mental state. She continues to be stable in the community.

This case highlights the importance of recognising and treating cluster of symptoms which might belong to the impulsive-compulsive spectrum. This further emphasises the role of dopamine-modulating agents such as modafinil along with brain-retraining strategies.

1. 1. To evaluate standards of practice regarding initiation and administration of covert medication(s), with comparison to the previous audit completed in January 2021.

2. 2. To highlight improvements and weaknesses requiring further recommendations for effective future practice.

This clinical audit assessed the current practice in Amber Ward (Old Age Ward for Dementia patients) against the same standards of practise used in the previous audit.

The Audit Checklist included 10 standards from Maudsley prescribing guidelines for Covert Medication Pathway.

A retrospective review of the paper and electronic records of 21 service users initiated on a covert medication plan between January 2021 and June 2022 was carried out.

A descriptive statistic on the data and presented results in tables comparing frequencies and percentages with the data from previous audit was then performed.

1. 1. An increase in percentage of documented evidence of covert medication plan being discussed with a relative with Lasting Power of Attorney or in a Best Interest Meeting to 95% (n = 20) from 85% (n = 12) in the previous audit.

2. 2. An increase in percentage of documented evidence of pharmacy input on covert medication administration plan to 100% (n = 21) from 47% (n = 7) in the previous audit.

3. 3. An increase in percentage of documented evidence of covert medication administration in the drug charts to 100% (n = 21) from 53% (n = 8) in the previous audit.

4. 4. An increase in percentage of documented evidence of covert medication review date on the covert medication initiation forms to 85% (n = 18) from 67% (n = 10) in previous audit.

5. 5. A decrease in percentage of documented evidence of MDT discussion prior to starting covert medication plan to 90% (n = 19) from 100% (n = 15) in previous audit.

This re-audit showed some improvement with 100% compliance in 4 out of 10 standards, however, there's still room for improvement to get the compliance to 100% across all the standards.

We therefore recommended strict adherence to existing covert medication initiation plan form, with particular attention to be paid to the standard of proper documentation of the details of MDT discussions around covert medication plan initiation, as there was surprisingly a reduction noted in this standard.

Finally, we recommended that another re-audit be considered within 2 years of completion of this re-audit.

Exposure to traumatic experiences during childhood and adolescence is a significant risk factor for the development of psychiatric disorders in adulthood. An estimated 50% of the worldwide incidence of depression and anxiety can be attributed to childhood maltreatment (Li et al., 2016). In addition, approximately one-third of psychotic experiences are attributable to a history of developmental trauma (McGrath et al., 2017). It is thought that long-lasting, trauma-induced adaptive changes in neurobiological function may lead to a predisposition towards pathophysiology (McCrory and Viding, 2015). However, the precise mechanisms through which developmental trauma exposure alters brain function on cellular and circuit levels remain poorly elucidated.

A systematic literature search and meta-analysis was performed to establish how dopaminergic functioning in adulthood is affected by developmental stress in rodents. Three databases, Medline®, Embase®, and PsycINFO®, were systematically searched initially on 2nd December 2023. Terms for three superordinate concepts (‘childhood’ terms, ‘trauma’ terms, and ‘dopamine’ terms) were combined. Cohen's d statistic was used for effect sizes. This protocol is pre-registered on PROSPERO® (ID: CRD42018106382).

A total of 104 studies met our inclusion criteria. Meta-analysis indicated that developmental stress exposure leads to complex and long-lasting effects in basal and post-amphetamine extracellular dopamine concentrations in the medial prefrontal cortex, amygdala, and nucleus accumbens. In addition, there is a significant downregulation of D1 receptors and upregulation of D2 receptors in prefrontal and striatal regions involved in threat and reward processing. Effect sizes ranged from 0.36 to 1.55.

These findings strongly suggest that dopaminergic dysfunction is a mechanistic link between developmental trauma and vulnerability towards mental illness in adulthood.

Outcome measurement is central to transforming mental health care by quantifying change, enabling comparison and driving improvement. In recognition of this, the Royal College of Psychiatrists (RCPsych) has established a working group on outcome measures, led by an Associate Registrar.

To support routine outcome measurement capture in clinical services, RCPsych has developed the ‘Outcome Measurement in Psychiatry’ report.

The working group intends to launch a survey of Members to:

1. 1) Understand psychiatrists’ current use of outcome measures.

2. 2) Understand psychiatrists’ views on barriers and facilitators to the use of outcome measures.

3. 3) Get feedback on the College Report.

The ‘Outcome Measurement in Psychiatry’ report was developed with input from all RCPsych Faculties and is scheduled for publication prior to the RCPsych International Congress.

Feedback will be sought on the ‘Outcome Measurement in Psychiatry’ report about whether the guiding principles are right, and if the College should be endorsing specific measures or advocating for the routine use of outcome measures. This will be used to guide future revisions of the report.

The working group believes the proposed survey will enable it to explore the facilitators and barriers to routine outcomes data capture both locally and nationally, including:

• • how to consider organisational drivers and buy in of clinical staff

• • digital enablement

• • understanding time points in a chronic relapsing remitting condition in the community vs. episode of therapy or hospital admission

• • clinical burden/benefit and buy in

• • training.

The group intends to use the intelligence gather to inform, influence and shape policy that promotes routine outcome data capture and publish its findings for wider dissemination.

Outcome measurement is a top priority for the RCPsych. A new Associate Registrar and working group is spearheading the College's work in this area, publishing guidance and conducting further research. Engagement and learning from our colleagues would provide critical intelligence to inform and influence future policy and strategy to enable routine outcome gathering embedded in mental health services.

The war-ridden northern part of Syria was struck by a powerful earthquake in February 2023 leaving thousands of people dead or injured. The consequences of the earthquake on people's mental health are harder to evaluate but are likely to be severe and long-lasting, especially as people have lived through years of war and devastation.

This poster reports on facilitating reflective practice groups, online, where Syrian mental health professionals in northern Syria explored the psychological impact of the earthquake on them as individual and as professionals.

The author facilitated a series of online reflective practice group meetings. Three distinct groups of mental health workers were formed, each group consisting of 6–12 participants. Each group met twice, each session lasting an hour and a half, resulting in 6 meetings that took place between the 25th of February and the 18th of March 2023. In the first session the group discussed the psychological impact of the earthquake on them as individuals, and in the second the psychological impact on them as professionals.

Thematic analysis was conducted on the discussions in the 6 reflective group meetings, resulting in three main themes: emotional responses, cognitive responses and helpful strategies. These themes are grouped detailed in terms of the impact of the earthquake on the personal and the professional lives of the participants.

Notwithstanding the limitations of this experience, it highlights the importance and value of group reflective spaces, as a way of helping mental health professionals process their emotional experiences in the aftermath of natural disasters.

1. 1. Evaluate user engagement.

2. 2. Evaluate safety.

3. 3. Evaluate efficacy.

   1. a. To reduce drinking.

   2. b. To address comorbid symptoms of anxiety and depression.

Study Population

Participants applied via social media, identifying as individuals seeking to change relationships with alcohol. Inclusion criteria: Aged >18, Alcohol Use Disorder Identification Test (AUDIT) score of 8–16, no history of withdrawal symptoms, or AUDIT score 16–20 but already abstinent for >14 days. Participants who had already been abstinent for >30 days excluded.

The Programme

Participants given unlimited access to Alma mobile application (app) for 4 weeks. Programme consisted of daily pledge to cut down drinking, drink diary to record alcohol use, weekly feedback on Generalised Anxiety Disorder-7 (GAD-7) scores and Patient Health Questionnaire-9 (PHQ-9) depression scores, unlimited access to mindfulness videos to manage cravings.

Statistical analysis

Mixed-effects linear regression used for analysis.

57 people volunteered for pilot study. 31 eligible to participate.

Engagement

Progressive weeks of programme showed attrition in user numbers. By end of 4-week programme, 77% (24/31) remained, 58% (18/31) submitted all data.

Safety

All participants asked if they had experienced no harm or distress from using app. 25 participants answered, 100% (25/25) responded “no”.

Efficacy

Self-reported capability to reduce drinking significantly increased over time (mean increase from baseline +0.3; p = 0.007). At week 4, 8/17 (47.1%) said that Alma had helped them cut down drinking a lot, and a further 8/17 (47.1%) said it helped them cut down a bit.

There was a trend for units drunk on the heaviest drinking day to reduce over time (−0.48 units) and total weekly consumption of units to reduce (−1.01 units), however not statistically significant. There was no trend for drinking days per week to reduce over time.

There was a significant reduction in PHQ-9 scores over time (−1.03; p < 0.001) and significant reduction in GAD-7 scores (−0.69; p < 0.001).

A total of 22/24 (92%) respondents said they would recommend Alma to friends and family, 1/24 (4%) would not.

• • Relatively high engagement with Alma compared with similar digital products.

• • Pilot study suggests Alma is acceptable, safe and shows potential efficacy in helping reduce alcohol intake and comorbid anxiety/depression, however interpretation limited by small sample size.

• • Next steps will be to widen user-base to facilitate larger studies, and gain further insights into factors influencing relapses by studying associations with health-related data from wearable devices and other user inputs.