Schools in the UK are required to provide frontline mental health promotion and prevention to adolescents, but with few resources. School-hosted mHealth is one option which could meet needs. This study co-designed and feasibility tested a self-help, school hosted, digital intervention for adolescents showing early symptoms of deteriorating mental health.). Via extensive co-design, we produced a youth-targeted web-app (MindMate2) and a low-intensity parent component (Partner2U). Feasibility was tested in four UK high schools with n=31 young people (15-17y). We specified rules for progression to an effectiveness trial, tested candidate primary outcome measures and conducted an exploratory cost- effectiveness analysis. Co-design produced MindMate 2 U to be a six-week, self-help, smartphone-delivered program targeting risk and protective factors for adolescent mental health. Young people's MindMate2U account is set up by school after which they progress independently through six topics of their choosing. User ratings (n=19) and post- intervention interviews (n=6) showed resource acceptability. We met our recruitment, retention and pre-post measure completion targets and identified the Strengths and Difficulties Questionnaire as the most sensitive outcome measure. This study established the feasibility of a co-designed, mental health app as a low-burden, school-hosted resource for symptomatic young people and opens up new possibilities for the integration of mHealth in schools. Support via schools to parents of symptomatic young people may need to be universal rather than targeted. Following some refinements of MindMate2U, a phase 2 randomised controlled trial is warranted to test its effectiveness.
People diagnosed with serious mental illness (SMI) live 10‐20 years less than the general population, due in part to co‐existing physical illness linked to lifestyle factors. To inform individualised care plans to promote healthy lifestyles, it is important to understand the views of people diagnosed with SMI. To truly understand their lived experience, research methods should allow participants to set the agenda for discussion, enhancing engagement and empowerment in the research process. To use a participatory research approach to capture what healthy lifestyle means to people who are diagnosed with SMI. Eight people diagnosed with SMI participated in six, weekly focus groups using Photovoice. Data were analysed using thematic analysis. The overarching theme was ‘mental health is the main priority’ and the other themes were barriers to a healthy lifestyle, represented as a vicious cycle, and three themes which were facilitators ‐ the importance of place, meaningful activities and the importance of others. The methodology allowed participants to choose images that reflected their lived experience. The themes describe the interaction of physical and mental health and practical barriers and will inform the design of individualised care plans. In co‐designing care plans, mental health nurses should draw on peoples’ preferences and explore the barriers identified in this study.
Background: Cognitive Behavioural Analysis System of Psychotherapy (CBASP) is an evidenced based treatment model for chronically depressed patients. Aims: The main aim of this service evaluation was to assess the acceptability and clinical impact of CBASP for chronic depression within an Improving Access to Psychological Therapies (IAPT) service. Method: Routinely collected data were analysed for all patients that received CBASP treatment focussing on the recovery rates of these patients in terms of depression, anxiety and social functioning. Interviews were conducted with patients who had recently been discharged from CBASP therapist within one month of the follow-up date, explore their experiences of therapy. Results: Outcome data for 27 patients suggested substantial reduction in scoring on measures of depression and anxiety following CBASP treatment. Across all interviews it was clear that patients developed an insight and understanding of how their behaviours affect the outcome of interpersonal situations. Conclusions: Results from this service evaluation suggest that CBASP is acceptable to service users and has a positive clinical impact in terms of IAPT recovery targets for anxiety, depression and social functioning.
Objective Continuous performance tests are widely used to aid diagnostic decision making and measure symptom reduction in adult ADHD clinical populations. The diagnostic accuracy of the Quantified Behavior Test plus (QbTest+), developed to identify ADHD populations as an objective measure of ADHD symptoms, was explored. Methods The utility of the QbTest+ was investigated in a clinical cohort of 69 adult patients referred to a specialist ADHD clinic in the UK. Results Scores from the QbTest+ failed to differentiate between patients diagnosed with ADHD and those who did not receive a diagnosis after full clinical assessment. Conclusions Based on our findings, we recommend clinicians are cautious when interpreting results of the QbTest+ in clinical populations. This study highlights the need for investigation into the lack of validation of commonly used objective measures in ADHD populations.
Background Schizophrenia endophenotypes may help elucidate functional effects of genetic risk variants in multiply affected consanguineous families that segregate recessive risk alleles of large effect size. We studied the association between a schizophrenia risk locus involving a 6.1Mb homozygous region on chromosome 13q22–31 in a consanguineous multiplex family and cognitive functioning, haemodynamic response and white matter integrity using neuroimaging. Methods We performed CANTAB neuropsychological testing on four affected family members (all homozygous for the risk locus), ten unaffected family members (seven homozygous and three heterozygous) and ten healthy volunteers, and tested neuronal responses on fMRI during an n-back working memory task, and white matter integrity on diffusion tensor imaging (DTI) on four affected and six unaffected family members (four homozygous and two heterozygous) and three healthy volunteers. For cognitive comparisons we used a linear mixed model (Kruskal–Wallis) test, followed by posthoc Dunn's pairwise tests with a Bonferroni adjustment. For fMRI analysis, we counted voxels exceeding the p < 0.05 corrected threshold. DTI analysis was observational. Results Family members with schizophrenia and unaffected family members homozygous for the risk haplotype showed attention ( p < 0.01) and working memory deficits ( p < 0.01) compared with healthy controls; a neural activation laterality bias towards the right prefrontal cortex (voxels reaching p < 0.05, corrected) and observed lower fractional anisotropy in the anterior cingulate cortex and left dorsolateral prefrontal cortex. Conclusions In this family, homozygosity at the 13q risk locus was associated with impaired cognition, white matter integrity, and altered laterality of neural activation.
Neurosyphilis can mimic many neurological and psychiatric disorders. Though several of its varied central nervous system manifestations can be measured clinically and by neuroimaging, they are non-specific. Thus, this mimicry and the relative rarity of the illness in the present era make the diagnosis elusive. However, neurosyphilis is readily treatable; therefore, it must be considered a diagnostic possibility in the routine workup of early-onset dementia. This case report is of a young man presenting with psychosis and cognitive impairment. His brain scan showed hippocampal atrophy, a finding not often seen in neurosyphilis but more common in Alzheimer’s disease. Without awareness of the various causes of mesiotemporal atrophy, clinicians may erroneously diagnose cases such as this one as a neurodegenerative disorder.
Rheumatoid arthritis (RA) is a multisystemic autoimmune disease that predominantly affects synovial joints. It causes marked disability, reduces health-related quality of life, and leads to high mortality. The diagnosis of RA is often made by standard criteria, and the management of this condition is usually undertaken according to the established guidelines. In resource-poor settings, the diagnosis and management of RA are hampered by diverse factors such as late presentation, inadequate trained personnel, poor healthcare infrastructure, low socioeconomic status, poor access to both conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics, and a high burden of infectious diseases such as tuberculosis, hepatitis, and human immunodeficiency virus. There is a need to establish registries in these settings to provide adequate information on the pattern, medication, and long-term outcome of RA in resource-poor countries in order to provide a practical and evidence-based management guide for rheumatologists, which is appropriate for these settings.
In this chapter we introduce the concept of spiritually competent practice as a way of avoiding disputes about the definition of spirituality and avoiding confusion with religion. Spiritually competent practice is described. It involves compassionate engagement, supporting people in sustaining a sense of meaning and purpose even when it is challenged by suffering and illness. It addresses the whole person as a unique individual, in the context of their family and cultural connections. As well as specific competencies it requires personal qualities, including the capacity to form I-Thou relationships and a managerial system that enables practitioners to attend to personal as well as technical aspects of healthcare. An ontological model for lifelong learning through reflective practice is presented. Availability and Vulnerability, a framework relating to personal qualities and specifically developed in research with APNs, is described and illuminated by a case study. This can also be understood within the overarching description of spiritually competent practice. We have looked briefly at how to take into account cultural issues without forgetting that individuals within a culture also have their own personal understanding of what spirituality means to them which is not necessarily congruent with their cultural background.
Background Lower limb ulceration is a common cause of suffering in patients and its management poses a significant burden on the NHS, with venous leg ulcers (VLUs) being the most common hard-to-heal wound in the UK. It is estimated that over one million patients in the UK have lower limb ulceration, of which 560,000 were categorised as VLUs, with a cost burden of over £3 billion each year. Objective The aim of this service evaluation was to assess the effects of implementing a self-care delivery model on clinical outcomes with the intention of limiting face-to-face health professional contact to one appointment every 6 weeks. Method A suitability assessment was conducted and a cohort of patients were moved to a self-care delivery model. Patient data were collected, anonymised and independently analysed, comparing time to healing against data on file from a previous report. Results This highlighted that, in 84 of the 95 patients selected, the VLUs had healed by week 24 on the pathway, a further 10 patients' VLUs had healed by week 42 and only one remaining patient reached 42 weeks without healing. Conclusion These results support the hypothesis that patients with VLUs can self-care and deliver clinical effectiveness. It is recommended that all services explore the possibility of introducing a self-care model for VLU care.
Objective To provide evidence of the effectiveness of a brief relapse prevention intervention using implementation intentions (Self-Management after Therapy, SMArT), following remission from depression and to identify effective relapse prevention strategies. Method The SMArT intervention was provided to 107 patients who were recovered after psychological therapy for depression. Relapse events were calculated as reliable and clinically significant increases in PHQ-scores. Sixteen patients receiving the intervention and eight practitioners providing it were interviewed. Framework Analysis identified seven themes which highlighted effective relapse prevention strategies and effective implementation of the SMArT intervention. Results Relapse rates at the final SMArT session (four months after the end of acute stage therapy) were 11%. Seven themes were identified that supported effective self-management: (1) Relationship with the practitioner—feeling supported; (2) Support networks; (3) Setting goals, implementing plans and routine; (4) Changing views of recovery; (5) The SMArT sessions—mode, content, timing, duration; (6) Suitability for the person; and (7) Suitability for the service. Conclusion The study provides some support for the effectiveness of the SMArT intervention, although a randomized controlled trial is required; and identifies important relapse prevention strategies.
Psychogenic non-epileptic seizures (PNES) superficially resemble epileptic seizures, but are not associated with abnormal electrical activity in the brain. PNES are a heterogeneous entity and while there is increasing interest in the characterisation of PNES sub-groups, little is known about individuals with PNES who have an intellectual disability (ID). ID is a lifelong condition characterised by significant limitations in cognitive, social and practical skills. ID (commonly with comorbid epilepsy) has been identified as a risk factor for developing PNES. However, people with ID are often excluded from research in PNES. This has unfortunately resulted in a lack of evidence to help inform practice and policy for this population. This narrative review synthesises the currently available evidence in terms of the epidemiology, demographic and clinical profile of adults with PNES and ID. There is a particular focus on demographics, aetiological factors, PNES characteristics, diagnosis and treatment of the condition in this population. Throughout this article, we critique the existing evidence, discuss implications for clinical practice and highlight the need for further research and enquiry. What emerges from the evidence is that, even within the sub-group of those with ID, PNES are a heterogeneous condition. Individuals with ID and PNES are likely to present with diverse and complex needs requiring multidisciplinary care. This review is aimed at the broad range of healthcare professionals who may encounter this group. We hope that it will stimulate further discussion and research initiatives.
Background: Weight gain and obesity are significantly linked to mental illness. There have been different theories trying to explain weight gain to psychiatric inpatients, such as physical inactivity and lifestyle, the effect of psychotropic drugs, increased food intake triggered by depression, and comorbidity between mental illness and obesity. The current research is a longitudinal and cross-sectional study collecting the electronic records of weight of psychiatric inpatients in a period spanning from one to ten years to address these theories. Methods: We collected the electronic records relative to weight measurement that are conducted weekly and relative to 240 non-forensic psychiatric inpatients (124 males and 116 females) and for a period from 1 to 10 years. Mean ages for males was 39.65 years (SD=±11.66) and females 40.88 years (SD=±13.73). They accessed a psychiatric inpatient service in the United Kingdom. The coefficient of determination R2 calculated the time variation in bodyweight in the period span, while the Chi-square statistic evaluated the differences in outcomes. Results: Our longitudinal study shows that R2=0.17 (95% CI=0.14-0.20) for males and 0.27 (95% CI=02.0-0.34) for females. There was a statistically significant difference between the R2 (c2: p<.05) for both genders. The average Body Mass Index (BMI) for male psychiatric inpatients was 27.05 (SD=±5.92), corresponding to WHO Overweight Class. The average BMI for female psychiatric inpatients was instead 31.21 (SD=±7.73), corresponding to WHO Obesity Class I. The difference in BMI was statistically significant for both genders (c2: p<.001). Discussion: In our study, only 27% of the difference in body weight in females and 17% in males was explainable by the time variable with a small to moderate effect size. Our findings appear to support the theory that overweight and morbid obesity might be comorbid with psychiatric illnesses and independent from the therapeutic regimen. Overall, females' BMI is more pathological. Conclusion: During lengthy admissions, only modest changes in body weight were observed in our research. Our findings would suggest that metabolic syndrome and therefore elevated BMI, overweight, and obesity might be comorbid with psychiatric illnesses and might be independent of the length of admissions.
Introduction On completion of a medical degree, junior doctors in the UK undergo a 2 year Foundation Programme. Since 2016, 45% of Foundation Programme doctors are required to undertake a psychiatry placement during foundation training. During this time, recruitment to Core Psychiatry Training has fluctuated, dropping to a 69% fill rate in 2017. Methods With the support of the Royal College of Psychiatrists, Health Education England and the UK Foundation Programme Office, a large-scale study was formulated utilising semi-structured focus groups. These exploring participant experiences help to understand how and if the psychiatry foundation placements are valuable, and their potential influence on a trainee choosing psychiatry as a career. A framework analysis was used to analyse data. Results Seventy-four participants across 10 foundation schools in England participated. Experiences and perceptions were split into three broad themes; pre-placement, during placement, and post-placement. Within these, 12 sub-themes emerged. Doctors valued independence and responsibility especially if accompanied by a level of support from seniors. They also enjoyed working as part of a multi-disciplinary team. However, there were clear issues around staffing levels, stigma attached to psychiatry, and out of hours working. Discussion The pre-placement perceptions of psychiatry as a specialty as well as the trainees’ personal priorities for career selection were influenced by psychiatry placement experiences. The results have important implications for the recruitment to the specialty and need to be considered when designing and constructing placement aims.
Background Individuals with Anorexia Nervosa (AN) typically struggle in social and emotional contexts. An Integrated Group Based approach for the delivery of MANTRA - The Maudsley Anorexia Nervosa Treatment for Adults – extends current NICE recommended therapy by augmenting treatment with opportunities for experiential practice in a group context. A feasibility case series, delivered across three NHS community services is presented. Methods The design was a case series of four Integrated Group MANTRA treatments delivered across three NHS sites ( N = 29). Feasibility data of: retention, acceptability and effectiveness; alongside the qualitative capture of participant experiences of treatment is presented. Results Primary outcomes suggest treatment acceptability. Participants committed to treatment with only 2 dropouts. There was significant change with medium effect sizes for eating disorder cognitions and symptoms (as measured by the global score on EDEQ) and BMI. Core themes emerging from qualitative analysis captured the value of the relational aspect of the treatment, the incorporation of experiential methods, and the opportunity to draw on the support of the group members to reduce shame and stigma. Conclusions An Integrated Group based MANTRA approach is a feasible and effective alternative intervention for community Eating Disorder services.
UK National Guidelines stress the importance of reducing waiting times for mental health assessments and interventions for children. They stress the importance of early help, multidisciplinary working, and collaboration with families regarding treatment plans. We piloted a new assessment model (CARM) within a CAMHS service to: reduce non-attendance rates and subsequently waiting times; increase staff and patient satisfaction; and improve the quality of assessment. All waiting list patients and new referrals over a three-month period were contacted to self-book an hour session to meet two clinicians who utilised collaborative reflection and formulation to produce a care plan (CARM). Results revealed that non-attendance rates dropped from 33% over the month prior to CARM to 7% during CARM. Satisfaction levels were high. Qualitative feedback regarding satisfaction revealed the most common themes was feeling listened to and having the opportunity to listen to staff reflections. The themes of staff satisfaction included ‘feeling more supported’ and ‘feeling safer in their decision making’. All assessments were completed in the one appointment. A formulation-driven care plan was developed and discussed with the family. This approach has the potential to make services more effective, efficient and satisfying for both staff and families.
Aims The current audit aims to assess the compliance with Prescribing Observatory for Mental Health (POMH-UK) guidance on monitoring of metabolic side effects of patients prescribed antipsychotics. Compliance was monitored to ensure that all patients prescribed continuing antipsychotics have their body mass index (BMI), blood pressure, blood glucose and lipids checked within the expected time limits of minimum once per year. Background Patients diagnosed with Schizophrenia rank amongst the worst of chronic medical illnesses in terms of quality of life. This may in part be due to the use of long term antipsychotic medications, in particular the use of atypical antipsychotics which have been increasingly associated with metabolic side effects including hypertension, weight gain, glucose intolerance and dyslipidaemia. These side effects are related to the development of both diabetes mellitus and cardiovascular disease and can lead to increased mortality and morbidity, affecting compliance and engagement to healthcare services. Despite the availability of clinical guidelines, monitoring and screening of metabolic side effects in patients prescribed antipsychotics continues to be suboptimal. Method The audit involved a review of electronic records relating to physical health monitoring of patients at two acute inpatient units from January-March 2019. Demographic and clinical variables were collected which included ethnicity, diagnostic grouping as well as current medications. Data were collected on evidence of screening for hypertension, BMI, blood glucose and lipids. Descriptive statistics were applied to study the clinical features of the sample and examine whether performance met clinical practice standard. Result The audit overall demonstrated partial compliance with POMH-UK guidelines with a total of 31 patients admitted on long term antipsychotics. Of these patients, 86% were prescribed atypical antipsychotics with 14% prescribed typical antipsychotics. Screening only occurred in 68% of patients for lipid profile with only 71% for BMI and 74% for blood glucose. Blood pressure had the highest compliance rate of 87% of patients being screened. Conclusion Early identification and monitoring of complications from metabolic syndrome may decrease the risk of more serious health outcomes and improve patients’ quality of life. However in clinical practice, standards are not always met in accordance with best practice recommendations. Requirement of a tailored guideline for physical health monitoring with weekly planned interventions as well as adequate training and awareness of healthcare staff is imperative to drive improvement and increase adherence rates.
Aims Opioid dependence has high risks and opioid substitution treatment (OST) improves outcomes and reduces deaths. Attendance at addiction specialist prescribers may be limited, particularly in rural areas. Telemedicine, such as videoconferencing, can reduce travel and improve access and attendance. Pre-COVID-19, we started a telemedicine service for patients with opioid dependence, prescribed opioid substitution treatment, requiring addiction specialist prescriber consultations. We present patient experience and assess whether patients recommend telemedicine. Method Health Research Authority approval for Randomized Controlled Trial of Telemedicine versus Face-to-Face (control) appointments in large semi-rural community addictions service (2500km2) using a modified Hub-and-Spoke (outreach). Adult opioid dependent patients prescribed OST and attending outreach clinics recruited. Participants received two consultations in group. Telemedicine delivered using Skype-for-business videoconferencing. Patients attended outreach clinic, where an outreach worker undertook drug testing and telemedicine conducted via the outreach workers laptop. Specialist addiction prescribers located remotely, at the Hub. Patients self-completed NHS Friends and Family Test (FFT) immediately after appointment, separate from the wider research study. Data collected Sept 2019– March 2020 (pre-COVID-19 lockdown), Microsoft Excel analysis, with qualitative thematic free-text analysis. Result Thirty completed FFTs were received, of which all participants were ‘extremely likely’ (n = 19;67%) or ‘likely’ (n = 11;37%) to recommend the Telemedicine service to friends or family, if they needed similar care. Two themes for reasons for recommending the service were; 1. Convenience (reduced travel, reduced travel time and reduced travel costs) and 2. Supportive Staff (including listening, caring and good support). One patient mentioned ‘it is a convenient way to communicate with medical staff, saving time and effort’. Regarding Telemedicine appointments, most participants responded that the timing of telemedicine appointments was good (n = 26;87%), given enough information (n = 30;100%), enough privacy (n = 28;93%), enough time to talk (n = 30;100%), involved as much as they wanted (n = 25;83%), given advice on keeping well (n = 28;93%), and NHS staff were friendly and helpful (n = 29;97%). No participants thought they were treated unfairly. When asked what went well, patient themes were: 1. Everything and 2. Communication (including listening and explaining). One patient stated ‘Everything better, telemedicing good, heard it well, everything improved this year’. In terms of what the service could do better, there were no issues identified. Conclusion The Telemedicine in Addictions service was overwhelmingly highly recommended by patients. Patients recommended the service because of convenience and supportive staff. The use of telemedicine is acceptable to patients and could be considered more widely. Due to COVID-19, this technology may be beneficial access to addiction services.
Aims Early assessment, diagnosis and management for people living with dementia is essential, both for the patient and their carers. We recognised delays in established local pathways when patients had unplanned acute hospital admissions preventing them from attending memory diagnostic appointments. The Psychiatric Liaison Team (PLT) Memory Pathway was introduced as we had the skills and expertise to resume the process and to find new undetected patients. Our aim was to determine how well the newly implemented PLT Memory Pathway follows the standards outlined in the National Institute of Health & Care Excellence (NICE) Clinical Guideline 97 (CG97): Assessment, management and support for people living with dementia and their carers. Method A retrospective analysis of all PLT referrals from July 2018 to February 2020 (20 months) was performed to identify patients on the community memory pathway and those with possible undetected cognitive impairment. Data were collected from electronic patient records which included demographics, primary and collateral history, cognitive testing and imaging, dementia type among others. Results were analysed using Microsoft Excel. Result 41 patients were included (59% female). 80% of patients were referred for memory problems or confusion. 63% had previous referrals to a memory service and was on the community memory pathway at the time of the referral. 34% were on anticholinergic medication but in only 14% were this documented as reviewed. 100 % were offered and had head imaging. A finding worthy of note was the absence of any from the ethnic minority background. 63% of patients were given a memory diagnosis and 34% had anti-dementia medication started. Patients’ families were made aware of the diagnosis in 83% of cases, due to the absence of next of kin details in the patient record. Primary Care was made aware in 100% of cases; post-diagnostic support was 100%. Conclusion The PLT is well placed to bridge the service gap between the acute care trust and established community memory services when dealing with patients with dementia. A dedicated Memory Pathway has helped to close this gap and adherence to NICE CG97 standards was good, but there is room for improvement. A particular focus will be on improving documentation of anticholinergic medication review and exploration for the absence of ethnic minority patients. Aiming to achieve 100% family involvement is also recommended. This study has been submitted to the Royal College of Psychiatrists' Faculty of Old Age Annual Conference 2021.
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