RSS 1.0Coventry and Warwickshire Partnership NHS Trust
Sub-communities within this community
Recent Submissions
-
Factors Associated With Length of Hospital Stay for Forensic Psychiatric Inpatients With Intellectual DisabilitiesIntroduction: The aim of this study was to examine factors associated with length of stay within a psychiatric hospital for patients with intellectual disabilities who have a forensic history. Methods: Data about 111 patients were gathered retrospectively from historical records for the period of February 2011 to March 2021. Negative binomial regression was then used to examine the relationship between selected predictor variables and length of stay. Results: Patients who were older upon admission and those who had received psychological therapies or positive behavioural support (PBS) had a significantly longer length of stay. Those with a diagnosis of a neurodevelopmental disorder had a significantly shorter length of stay. All other predictors were not statistically significant. Conclusions: There was evidence of a clinical improvement at discharge and those with autism or ADHD had a shorter length of stay. Similar studies with larger sample sizes should be completed across England.
-
Co-designing a peer support programme for carers of people treated under the Mental Health Act: views from stakeholdersBackground Relatives/friends (carers) of people who are involuntarily admitted to a psychiatric hospital report high levels of stress, feelings of isolation and exclusion from their patient’s care. One-to-one peer support is widely implemented for patients, facilitating mental health recovery. Preliminary evidence reports that peer support may benefit carers too, but a one-to-one peer support programme to help carers when their relatives/friends are in hospital has not been developed. Objective To explore carers’, patients’, and professionals’ views on what an accessible, feasible and helpful one-to-one peer support intervention should consider for carers of patients treated under the Mental Health Act (MHA) in England. Method Nineteen one-to-one interviews were conducted online with five carers, four patients, four clinicians, four independent mental health advocates and two behaviour change experts. Participants had experience of either being treated or supporting someone treated under the MHA within the last 10 years. Audio recordings of the interviews were transcribed, and data were analysed using thematic analysis. Results Five themes were identified: (a) carer availability and awareness; (b) peer support flexibility; (c) early promotion of peer support; (d) appropriate training and support for peers, and; (e) anticipated impact of peer support. Carers’ lack of time and awareness of support were reported as key barriers to accessing peer support. To address this, participants emphasised the need for early introduction of support following patients’ hospitalisation and flexible delivery through various communication channels. They also highlighted the need for robust, interactive training for peer supporters. Expected benefits included improved carer and peer supporter wellbeing and increased carer knowledge and empowerment. Conclusions These findings highlight the need for structured training for peer supporters and a flexible, accessible peer support programme for carers. The findings can inform evidence-based co-production of a carer peer support programme for use in England, which could improve carer wellbeing, knowledge and empowerment.
-
QI 1327 Improving the Post-Diagnostic Offer for Adult Neurodevelopmental ServicesAim: To improve the post-diagnostic offer to patients waiting specialist assessment and intervention as well as improving the efficiency of staff resources and time. Following assessment and diagnosis of Autism or ADHD by the assessment team, the standard post-diagnostic offer is able to be accessed by all. In addition, assessing clinicians can also refer for individual Occupational Therapy (OT) and/or Speech & Language Therapy (SLT) as required. Following a big increase in referrals, the significant impact on wait times led to the need for improvements within this service. Kat and Sarah used a number of QSIR tools to support the project such as: Process Mapping which is usually undertaken with a range of people involved in the process, and enables you to create a visual picture of how the pathway currently works, capturing the reality of the process, exposing areas of duplication, waste, unhelpful variation and unnecessary steps. Run Charts are displays of data over time, shown in graph form, similar to SPC Charts, and can be useful to analyse and understand variation in a system. Stakeholder Analysis which enables you to identify everyone who needs to be involved in your change project, and assess how much time and resources you give to maintain involvement and commitment. It is a way to engage a wide variety of people such as clinicians, admin staff, patients and user groups in order to deliver your project. Project Impact: A total of 116.5 hours of staff time has been saved each month, saving approximately £2891.53
-
A novel way to understand and communicate the burden of Antipsychotic Prescribing for Adults across Specialist Intellectual Disability Services in England and Wales: the APHID feasibility study protocolBackgroundThe stopping overmedication of people with a learning disability, autism, or both (STOMP) programme was launched in 2016 in response to concerns about the over-prescribing of medication in people with intellectual disability. The programmes focus has been on the withdrawal of antipsychotic treatment for the individual person than the service or dosage optimisation. It could be that cumulative service level antipsychotic treatment converted and presented as chlorpromazine units could allow for comparison of services on how antipsychotic treatment is being utilised and allow for comparing of practices between services in different regions. The aim of this feasibility study is to explore if cumulative service scores of antipsychotic treatment burden could define prescribing patterns across different specialist intellectual disability services in England and Wales, focused on those on ≥2 antipsychotic treatments. There is no evidence to use ≥2 antipsychotic treatments for any individual.MethodsThe study is a feasibility cross-sectional study investigating service antipsychotic treatment cumulative burden at seven annual time points, 2017-2023. De-identified data for adult patients with intellectual disability under the care of specialist intellectual disability services in receipt of ≥2 oral and/or long-acting IM (intramuscular) injectable (depot) antipsychotic treatments are included. Demographic and clinical data will be collated, in addition to information on the prescribed antipsychotic treatments. The data will be evaluated for data completeness and will be inputted into the Statistical Process Control tool. Outcomes will be measured using a combination of methods including descriptive analysis (including mean, standard deviation and percentage values), and a mixed effects regression model, to determine changes in chlorpromazine equivalent dose values over time. ResultsSeven England and Wales National Health Service intellectual disability services are recruiting up to 490 people. There were recognised challenges in identifying the relevant eligible cohort across services and administering a common set of outcome measures. Discussion This study is intended to inform decisions to design a wider registry that would involve antipsychotic treatment prescribing data for patients across multiple sites nationwide. Developing a de-identified database using routinely collected data, without the requirement for informed consent, comes with unique benefits and challenges.
-
Lipid disorders in HIV patients: what about raised HDL-cholesterol?No abstract available
-
Rabbit Syndrome: Update on aetiology and management for pharmacists, psychiatrists and dentistsRabbit syndrome (RS) is an involuntary movement disorder, characterized by fast and fine movements of oral and masticatory muscles along the mouth vertical axis in the absence of tongue involvement. RS prevalence varies between 2.3% to 4.4% and could result from the administration of antipsychotics and antidepressants. In case of second generation antipsychotics, there is a reduced risk of RS compared with first generation antipsychotics with mainly isolated literature case reports especially with the use of risperidone as antipsychotic. RS affects only the buccal region, with the possible involvement of the basal ganglia, in particular the substantia nigra. The management of RS include reduction or change of the psychotropic treatment and use of anticholinergic medications such as trihexyphenidyl. Although RS is rare and easily treatable, it is essential that dentists and psychiatrists could distinguish this syndrome from other movement disorders such as tardive dyskinesia.
-
A Commentary on Lipid Disorder and HDL-Cholesterol in HIV Patients: Changing TrendsWith the advent of highly active antiretroviral therapy (HAART) there have been remarkable improvements in the survival of HIV patients. However, complications in the form of dyslipidaemia, insulin resistance, bone problems and liver and kidney disorders have been found to be more noticeable compared to AIDS defining illnesses. The continuous exposures of antivirals of different class with different side effects profile have led to a new trend of problems.
-
The Effect of Low Dose Oral Vitamin D on Bone Mineral Density Changes in HIV Patients: 36 Months Follow UpBackground: A high incidence of vitamin-D deficiency and abnormal bone mineral density (BMD) is reported among Human Immunodeficiency Virus (HIV) infected patients. The study highlighted the effect of oral low dose vitamin-D replacement in patients with a known vitamin- D deficiency on the levels of vitamin-D [25 (OH)D], parathyroid hormone (PTH) and Bone Mineral Density (BMD) of hip and spine. Methods: Patients took a daily low dose of 800IU of vitamin-D. The following details were collected on all patients: demographics, CD-4 cell count, viral load, fracture risk factors, treatment history, corrected calcium, alkaline phosphatase (ALP), Parathyroid Hormone (PTH) (intact PTH), vitamin D 25(OH)D, inorganic phosphate and BMD of hip and spine at baseline, 12 and 36 months. Results: Our Cohort consisted of 86 patients. Patient details included: mean age 42.8 (+/-7.7) years, 48 (55%) females 64, (74%) black African, CD-4 count 440.7 (+/-180.8) cells/dL, plasma VL 1.6 log (+/-2.3) copies/mL, duration of illness 80.9 (34.1) months, duration of exposure to antiretroviral 65.2 (+/-27.9) months. At baseline, no difference in BMD of hip or spine was observed, however, a higher PTH (0.001) in patients taking Tenofivir and a lower vitamin-D was noticed in patients taking Efavirenz. After 36 months, patients on vitamin D replacement (n=44) had a significant increase in vitamin- D level (15.4 +/-10.4 vs 104.1+/-29.1 p=0.0001), lower PTH (6.3 +/-3.4 vs 4.4 +/-1.4 p=0.0001) ALP (108.9+/-78.8 vs 90.6+/-45.8 p=0.05) but no change in corrected calcium (2.13 +/-0.1 vs 2.16 +/-0.34 p=0.5) and BMD of spine (1.039+/-0.226 vs.1.027+/-0.211, p=0.77), and BMD of hip (1.020 +/- 0.205 vs. 1.039, p=0.61). In a multivariate logistic regression analysis that included all significant variables, vitamin-D replacement independently was associated with increase in vitamin- D level (OR 2.08, CI 1.03, 4.12, p=0.005), decrease in PTH level (OR 0.53, CI 0.35, 0.82, p=0.04), but not with change in corrected calcium, alkaline phosphatase, BMD of hip or spine. Conclusion: After 36 months of follow up, the replacement of low dose once daily oral vitamin-D in the treatment experienced HIV infected patients with vitamin-D deficiency can increase vitamin- D level, reduce PTH level without any change in BMD of spine and hip.
-
Malignancies Spectrum in the Era of Modern HAARTIn the current highly active antiretroviral therapy (HAART) era, studies suggest AIDS defining malignancies (ADM) are decreasing and non- AIDS defining malignancies (NADM) are increasing. We aimed to review all types of malignancies and risk factors in our HIV cohort over a period of ten years. Methods T his was a retrospective cohort study of all malignancy diagnoses and risk factors collected (2004-2014) from two teaching hospitals in the Midlands, United Kingdom. The demographic data and clinical features were collated and the primary end point of survival analysed. Secondary endpoints included risk factors for ADM compared to NADM. Results 111malignancy diagnoses 63 (54%) ADM and 48 (46%) NADM identified. Survival was worse once diagnosed with a NADM. About half of the ADM and a third of the NADM had a new HIV diagnosis at the same time or soon after the malignancy diagnosis. Haematological malignancies were the commonest malignancy in both groups. Oncogenic virus was an independent predictor of ADM risk . Conclusions Despite new and improved HAART regimens, ADM remain high in newly diagnosed HIV individuals and NADM are on the rise in those on longstanding HAART with stable HIV. Not only continuing HIV testing in new ADM as per the indicator conditions, but it is also important to increase HIV testing in new diagnoses of NADM such as all haematological malignancies and lung cancer.
-
Charles Bonnet syndrome: an important differential diagnosis in new onset hallucinationsThe onset of new visual hallucinations in a patient with a longstanding history of bipolar disorder is extremely rare and when seen is often attributed to the pre-existing condition. A case of 73 year old male is presented here who developed new onset visual hallucinations on a background of stable mental health and was treated with multiple inpatient admissions and extensive antipsychotic therapy. He was later diagnosed to have Charles Bonnet Syndrome. Had visual loss been considered and treated earlier in the diagnostic process, the patient could have avoided the distress of these admissions, side effects of medication, radiation exposure from imaging and above all would have received appropriate treatment sooner. Furthermore, the Mental Health Services would have saved the cost of inpatient stay. It is therefore better to consider Charles Bonnet Syndrome as a differential diagnosis even in patients with well-established mental illness if they develop new onset visual hallucinations. This case report examines why the diagnosis of Charles Bonnet Syndrome can be missed, and its impact on geriatric patients.
-
Assessment of the Impact of Schizophrenia on Healthcare Resource Use Among Patients with Cardiometabolic Conditions in England: Insights from Big Data AnalysisObjectives Having schizophrenia increases the risk of developing cardiometabolic conditions, increasing costs and complicating management. This retrospective cohort study among patients with cardiometabolic conditions in England aimed to determine the impact of comorbid schizophrenia on primary and secondary healthcare use, and on the costs of nonelective inpatient admissions, as well as whether this burden is influenced by the number of a patient’s cardiometabolic conditions. Methods Primary and secondary healthcare use data were collected from the Clinical Practice Research Datalink and Hospital Episode Statistics databases, respectively. Adults with ≥1 cardiometabolic condition(s) were grouped according to the conditions, and whether they had schizophrenia. Healthcare resource use, and costs of nonelective admissions were calculated for patient with/without schizophrenia and any, 1, 2, 3, or 4 cardiometabolic condition(s). Results were adjusted for age and sex. Abstract Results Patients with comorbid schizophrenia had 68% more GP appointments (18.09 versus 11.07 appointments/patient/ year), 19% more prescriptions (4.20 versus 5.06 prescriptions/ patient/year), 21% more outpatient appointments (7.94 versus 6.60 appointments/patient/year), 189% more A&E attendances (2.31 versus 0.80 attendances/patient/year), and 127% more nonelective inpatient admissions (1.69 versus 0.77 admissions/patient/year) than those without. The higher number of nonelective admissions represented £1,420.36 increased spending/patient/year, translating into a potential spend of more than £31M annually. Schizophrenia was associated with higher secondary care resource use after adjusting for the number of cardiometabolic conditions. Conclusions Among patients with cardiometabolic conditions, comorbid schizophrenia is associated with higher primary and secondary healthcare resource use and cost, even after adjusting for the number of cardiometabolic conditions.
-
Systematic Review and Meta-Analysis: The Association Between Newer-Generation Antidepressants and Insomnia in Children and Adolescents With Major Depressive DisorderObjective: To examine the association between newer generation antidepressants and insomnia as an adverse event (AE) in the treatment of children and adolescents with major depressive disorder (MDD). Method: A systematic search was performed in major databases (inception to August 31, 2023) to retrieve double-blind, placebo-controlled, randomized controlled trials (RCTs) evaluating the safety of 19 antidepressants in the acute treatment (initial 6-12 weeks) of children and adolescents ≤18 years of age with MDD (primary analyses). RCTs in anxiety disorders and obsessive-compulsive disorder (OCD) were retrieved from a recent meta-analysis and included in complementary analyses. A mixed-effects logistic regression model was used to compare the frequency of insomnia in the antidepressant relative to the placebo group. Risk of bias was evaluated using the Cochrane Risk of Bias 2 tool. Results: In total, 20 trials in MDD (N = 5,357) and 8 trials in anxiety disorders and OCD (N = 1,271) evaluating selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) were included. In MDD, antidepressant treatment was associated with a modest increase in the odds of insomnia compared with placebo (odds ratio [OR] = 1.65, 95% CI = 1.21-2.27, p = .002), with no significant difference between SSRIs and SNRIs. The RCTs showed low risk of bias or minor concerns for the assessment of insomnia. The odds of treatment-emergent insomnia were significantly lower in MDD (OR = 1.62; 95% CI = 1.21-2.15) compared to anxiety disorders and OCD (OR = 2.89; 95% CI = 1.83-4.57) for treatment with SSRIs (p = .03). Among individual antidepressants with evidence from ≥3 studies, sertraline had the highest OR (3.45; 95% CI = 1.91-6.24), whereas duloxetine had the lowest OR (1.38; 95% CI = 0.79-2.43). Conclusion: Children and adolescents are at a modestly increased risk for experiencing insomnia during the first 6 to 12 weeks of treatment with SSRIs and SNRIs. Antidepressant- and disorder-specific variability in the risk of treatment-emergent insomnia may be relevant to consider in clinical decision making. Study preregistration information: The association between newer generation antidepressants and insomnia in children and adolescents with major depressive disorder: a meta-analysis of randomized controlled trials; https://www.crd.york.ac.uk; CRD42023330506.
-
Clozapine-induced hepatitis confirmed by rechallengeClozapine is an atypical antipsychotic that holds a unique role in the management of treatment-resistant schizophrenia. Well known side-effects include agranulocytosis and myocarditis but associated hepatic disorders are less familiar and listed under ‘rare or very rare’ by the British National Formulary.1 However, a transient elevation of transaminases has been estimated to affect up to 50% of patients treated with clozapine.2 This article describes a patient with minimally elevated LFTs who subsequently developed symptomatic hepatitis following the initiation of clozapine therapy.
-
Improving physical healthcare provided to psychiatric inpatients at an acute mental health trustPsychiatric patients are at high risk of developing physical health complications. This is due to various factors including medications prescribed, life style choices and diagnostic overshadowing. Admission to a psychiatric unit provides a prime opportunity to review a patient's physical healthcare. We noticed prior to the commencement of this project that this opportunity was not always being used in the inpatient unit, with one in four patients at baseline data collection having no physical health checks. This is despite clear guidance laid out in the trust policy 'Physical Examination of Service Users during Admission to Hospital'. We aimed to improve compliance with these checks to 100%. A number of prior audits in this area had failed to sustain improvement. Therefore, we proposed a quality improvement approach involving a series of plan do study act cycles, in order to test and review processes prior to implementation. The first cycle involved simplification of the paper-based documentation used for physical health checks, which resulted in minimal improvement by 5%. The second cycle involved combining this documentation with the history taking proforma resulting in an overall improvement in compliance to 90%. We learnt that a move away from the more widely used audit towards a more holistic approach of quality improvement allowed an informed continuum of change to take place which likely led to sustained improvement. Post implementation data collected at 1 month revealed compliance remained at 90%. Our initial 100% target was perhaps unrealistic, as there are also longstanding underlying cultural issues around physical healthcare in psychiatric patients that are complex to address and beyond the scope of this project.
-
The experiences of inpatient nursing staff caring for young people with early psychosisBackground Early intervention services aim to improve outcomes for people with first episode psychosis and, where possible, to prevent psychiatric hospital admission. When hospitalisation does occur, inpatient staff are required to support patients and families who may be less familiar with services, uncertain about possible outcomes, and may be experiencing a psychiatric hospital for the first time. Aims Our study aimed to understand the process of hospitalisation in early psychosis, from the perspective of inpatient nursing staff. We were particularly interested in their experiences of working with younger people in the context of adult psychiatric wards. Methods Nine inpatient nursing staff took part in semi-structured interviews, which were transcribed and then analysed using interpretative phenomenological analysis. Results Five themes are outlined: ‘it’s all new and it’s all learning’; the threatening, unpredictable environment; care and conflict within the intergenerational relationship; motivation and hope; and coping and self-preservation. Conclusions The phenomenological focus of our approach throws the relational component of psychiatric nursing into sharp relief. We reflect on the implications for organisations, staff, families and young people. We suggest that the conventional mode of delivering acute psychiatric inpatient care is not likely to support the best relational and therapeutic outcomes.
-
Telepsychiatry in intellectual disability psychiatry: literature reviewAims and Method The aims of this review were to explore the effectiveness and patient and provider acceptability of telepsychiatry consultations in intellectual disability, contrasting this with direct face-to-face consultations and proposing avenues for further research and innovation. Computerised searches of databases including AMED and EMBASE were conducted. Results Four USA studies of intellectual disability telepsychiatry services have been reported. The majority (75%) focused on children with intellectual disability. Sample sizes ranged from 38 to 900 participants, with follow-up from 1 to 6 years. Outcome measures varied considerably and included cost savings to patients and healthcare providers, patient and carer satisfaction and new diagnoses. Clinical implications The innovations summarised suggest a requirement to further explore telepsychiatry models. Despite some promising outcomes, there is a relative dearth in the existing literature. Further studies in other healthcare systems are required before concluding that telepsychiatry in intellectual disability is the best approach for providing psychiatric services to this population.
-
Insulin resistance and obesity, and their association with depression in relatively young people: findings from a large UK birth cohortBackground Depression frequently co-occurs with disorders of glucose and insulin homeostasis (DGIH) and obesity. Low-grade systemic inflammation and lifestyle factors in childhood may predispose to DGIH, obesity and depression. We aim to investigate the cross-sectional and longitudinal associations among DGIH, obesity and depression, and to examine the effect of demographics, lifestyle factors and antecedent low-grade inflammation on such associations in young people. Methods Using the Avon Longitudinal Study of Parents and Children birth cohort, we used regression analyses to examine: (1) cross-sectional and (2) longitudinal associations between measures of DGIH [insulin resistance (IR); impaired glucose tolerance] and body mass index (BMI) at ages 9 and 18 years, and depression (depressive symptoms and depressive episode) at age 18 years and (3) whether sociodemographics, lifestyle factors or inflammation [interleukin-6 (IL-6) at age 9 years] confounded any such associations. Results We included 3208 participants. At age 18 years, IR and BMI were positively associated with depression. These associations may be explained by sociodemographic and lifestyle factors. There were no longitudinal associations between DGIH/BMI and depression, and adjustment for IL-6 and C-reactive protein did not attenuate associations between IR/BMI and depression; however, the longitudinal analyses may have been underpowered. Conclusions Young people with depression show evidence of DGIH and raised BMI, which may be related to sociodemographic and lifestyle effects such as deprivation, smoking, ethnicity and gender. In future, studies with larger samples are required to confirm this. Preventative strategies for the poorer physical health outcomes associated with depression should focus on malleable lifestyle factors.
-
Characterisation of quality-of-life and it’s utility as a descriptor of health outcomes for people with profound intellectual disabilitiesThe purpose of this review is to source the available evidence about quality-of-life for people with profound intellectual disability, identify the tools used to assess and measure this, explore the research methods used to study this, and identify any gaps in knowledge.
-
Anal incontinence following childbirth injury: The GP’s roleOne in five people who have a vaginal birth will develop anal incontinence in the 5 years following delivery. Many of them will suffer in silence, reluctant to raise the issue with healthcare professionals and unsure of where to turn to for help. Although an obstetric complication, it is a condition which often initially presents in primary care and is largely managed by GPs. The Ockenden review in 2022 found a significant lack of clinical training in postnatal care and GPs have reported a lack of confidence in supporting patients postnatally. Over the past decade, there has been a 3-fold increase in obstetric anal sphincter injuries. This article aims to raise awareness of anal incontinence post childbirth injury as a clinical issue and to encourage GPs to address this proactively within consultations. After reading this article, GPs should have improved confidence in managing this issue within primary care and an understanding of what resources are available to improve their clinical knowledge in this area.
-
Underlying biological mechanisms of emotion dysregulation in Bipolar DisorderDifficulties with emotion regulation (ER) are a key feature of Bipolar Disorder (BD) contributing to poor psychosocial and functional outcomes. Abnormalities within emotion processing and regulation thus provide key targets for treatment strategies and have implications for treatment response. Although biological mechanisms and ER are typically studied independently, emergent findings in BD research suggest that there are important ties between biological mechanisms and the disturbances in ER observed in BD. Therefore, in this narrative review, we provide an overview of the literature on biological mechanisms underlying emotional dysregulation in BD including genetic and epigenetic mechanisms, neuroimaging findings, inflammation, hypothalamic-pituitary-adrenal (HPA) axis dysfunction, neuroplasticity and brainderived neurotrophic factor (BDNF), and circadian rhythm disturbances. Finally, we discuss the clinical relevance of the findings and provide future directions for research. The continued exploration of underlying biological mechanisms in ED in BD may not only elucidate fundamental neurobiological mechanisms but also foster advancements in current treatment strategies and the development of novel targeted treatments.
