Recent Submissions

  • Social trust and COVID-appropriate behavior : learning from the pandemic

    Kar, Brajaballav; Kar, Nilamadhab; Madhu, Panda (Wolters Kluwer, 2023)
    Introduction: General trust and trust in various social institutions/agents are argued to positively influence the outcome, more so, in a crisis. Mitigating a crisis requires actions from individuals, family, friends, co-workers, various policymaking, and implementing agencies, media, and other agencies with whom people interact. In the COVID-19 situation, people individuals did not have a choice but to access essential services even with the risk of infection. Personal experiences also guide individuals' trust in various social groups and are responsible for taking individual action of protecting themselves in the pandemic. To what extent people trusted various social groups and observed appropriate behavior is investigated in this research. Methods: Responses were collected through a structured, web-based questionnaire where respondents self-reported their trust in various social agents and the extent to which they observed COVID-appropriate behavior. Respondents primarily belonged to the eastern part of India. Results: This study finds significant demographic differences in observing appropriate behavior leading to an identification of a vulnerable group. Second, trust in the inner group (family, friends, neighbors, and co-workers among others) is least important whereas trust in professionals and administrative institutions is the most important. Trust in the central government, media, and politicians among others is counterproductive to observing the appropriate behavior. Conclusion: People repose higher trust in professionals and administrative institutions in a crisis situation. Professional and administrative leadership helps in more effective crisis management leading to better behavioral compliance of the public. Any other leadership may be ineffective or counter-productive.
  • Ethnic differences in dose and levels of Clozapine : exploring need for any specific monitoring needs

    Jiwanmall, Stephen; Kar, Nilamadhab; Obuobie, Akua; Maiti, Tanay; Lester, Deborah; McClaughlin, Kerry; Hanson, Thomas (Cambridge University Press, 2023-07-07)
    Aims: Clinical research shows that compared to Caucasian patients, Asian patients appear to have a lower clozapine dose requirement for clinical efficacy. Hence, appropriate dose adjustment should be considered in Asian patients receiving maintenance clozapine therapy. Secondly, studies in the UK report that Asian patients with treatment-resistant schizophrenia were less likely to receive clozapine than Caucasian patients. The objectives of this study were to find out the ethnic difference in dose and levels of clozapine in ethnic minority patient (BME (Black and minority ethnic) populations and to explore if there is a need for any specific monitoring. Methods: Demographic (age, gender, and ethnicity) and clinical variables (diagnosis, clozapine dose, plasma level of clozapine and nor-clozapine, smoking status, side effect profile, and physical comorbidities) were collected from the electronic patient records and analysed. Results: The sample consisted of 66 (56.4%) Caucasians, 22 (18.8%) Asians, 21 (17.9%) African-Caribbean, and 8 (6.8%) mixed ethnicity patients. Their age range was 19-80, with an average of 46.9 ±11.9 years. Among the ethnic groups, age, clozapine, nor-clozapine level and QTc were comparable, except for the dose of clozapine; Caucasian had the highest dose (414.8±140.0 mg), followed by African-Caribbean (373.8±163.7 mg), Asian (333.8±121.2 mg) and mixed (260.7±110.7 mg) (F3.68, p<0.05). The difference remained significant when all the BME groups were combined as well. Side effects such as hypersalivation, drowsiness, blurred vision, polyuria, sore throat, headache, vomiting (none), dizziness, difficulty passing urine, urine incontinence, flu-like symptoms, nausea, were comparable among ethnic groups. There was no difference in smoking among the groups. Considering comorbidities compared to BME, Caucasians had significantly lower rate of hypertension (27.1% vs 9.1%, p<0.01); diabetes (18.6% vs 4.5%, p<0.05), however dyslipidemia (5.1% vs 3.0%) was comparable. In addition to the above, the dose of clozapine was positively correlated with clozapine and norclozapine levels (p<0.05). Clozapine and norclozapine levels correlated significantly (p<0.001). Age was negatively correlated with norclozapine assay (p<0.05) and positively with the number of cigarettes. It appears as the age increases, the number of cigarettes goes up, and norclozapine levels come down. Conclusion: There are a few variations of clozapine prescribing in different ethnic groups. Although the Caucasians had higher doses, they had comparable blood levels. A higher proportion of BME patients on clozapine had hypertension and diabetes, emphasizing metabolic risk. Our study findings suggest clozapine monitoring should look into ethnicity related risk factors.
  • Risk factors related to driving : a review of clinical practice evaluating and addressing fitness to drive among psychiatric inpatients

    Fraser, Alastair; Chandra, Pallavi; Sundhar, Reka; Kar, Nilamadhab (Cambridge, 2023-07-07)
    Aims: Mental illness is linked with a higher risk of dangerous driving; e.g. patients with neurotic disorders have 50% more accidents than controls and 10% of drivers involved in accidents have reported feeling suicidal. The Driver and Vehicle Licensing Agency (DVLA) have provided guidance related to fitness to drive for those with mental illness. In this context we intended to study the risk factors associated with psychiatric inpatients related to driving and whether concerns have been documented in clinical reviews. Methods: Case notes of 100 randomly selected psychiatric inpatients in one calendar month were evaluated including: their driving status; concerns regarding driving based on their clinical status (Diagnosis, Medications, Side effects); any clinical advice given and communication with DVLA in the previous one year, were ascertained from electronic records. Missing values were not included in calculation. Results: The sample consisted of 51 female and 49 male patients (mean age 39.7±13.5 and 39.1±12.7 respectively), with the majority 69% from Caucasian ethnicity; 64% were informal. There was no difference noted in driving status based on ethnicity or legal status on admission. On admission 33% of patients reported that they were not driving, 12% were driving, 2% refused to answer and in more than half (53%) driving status was not documented. Considering some of the risk factors for driving, persistent alcohol use was noted in 39.8%, drug use in 34.4%, personality disorder 37%, attention deficit hyperactivity disorder or autistic spectrum disorder in 4%, being on medications with side effects that may impair driving 80.8%, having side effects that impair driving 10%, and suicidality 54.5%. Only in a minority of cases were fitness to drive related issues discussed in their last review (3%), in progress notes (1%), or in discharge notes (2%). There was no documentation related to communication with the DVLA for any patients. Conclusion: The results suggest there is a need to record the driving status of psychiatric inpatients and to discuss driving related concerns when considering mental state, medications and side effects. Information related to driving should be given to patients, and DVLA should be notified as appropriate. This might help in improving safety related to driving by psychiatric patients.
  • A quality improvement project to increase junior doctors’ satisfaction with handover process using Microsoft teams (MS Teams) as a platform

    Gupta, Aradhana; Narula, Amitav; Patel, Devika; Arifin, Mohamad; Wheeldon, Helen; Ajayi, Ayomide; Sachdeva, Gagandeep; Aung, Nay (Cambridge, 2023-07-07)
    Aims: To improve junior doctors’ satisfaction with handover process to >70% over a period of 10 weeks. Methods: Baseline level of overall satisfaction with current handover practice was measured through a survey using Likert scale. Using the same scale, the team also looked at: 1. Degree of confidence in tasks being completed 2. Degree of confidence in handover being confidential 3. Degree of confidence in handover being sufficient for medico-legal purposes Part of the survey also asked junior doctors using free text comments on how handover is currently carried out between shifts. The results from the survey were analysed and suggestions were considered for improvement. A new method of handover using MS Teams was trialled. During subsequent PDSA cycles change ideas were adopted to improve engagement with the new process and allow for safe handovers. On a weekly basis, post-intervention level of overall satisfaction with the new handover process was measured using the same Likert scale. Other measurements measured weekly included: 1. Percentage of handovers completed using the agreed template 2. Percentage of handed over jobs being acknowledged to signify receipt of handover Results: Pre-intervention, verbal handover was the most frequent way of handing over (85.7%) followed by WhatsApp/text messaging (64.3%) and paper (42.9%). Baseline level of overall satisfaction of handover process is 21.4%. At the end of PDSA Cycle 1, this increased significantly to 78% and by week 10 (end of PDSA Cycle 2) it rose to 92%. Pre-intervention, 35.7% of junior doctors reported feeling confident in the handed over tasks being completed. 28.5% were confident that the handover process is confidential and 14.3% that it is sufficient for medico-legal purposes. Post-intervention, 100% of the handovers are completed using a standardised template and 100% of the tasks were being acknowledged by the appropriate team members. Conclusion: Prior to this intervention the process of junior doctor handover was not uniform and led to near-misses. This created confusion hence opportunities for errors to occur which can compromise patients’ care. Following the introduction of MS Teams as the handover platform, overall satisfaction from junior doctors on the handover process has increased significantly. Moreover, it provides a clear record of handovers taking place which ensures accountability, safety and continuity of patients’ care.
  • Prevalence and comparison of the profile of patients who did not attend (DNA) their appointments through face-face, pre-pandemic vs. telephonic consultations, pandemic at the complex care service-South, Wolverhampton - a service evaluation

    Kuppili, Pooja P; Jeyanathan, Jeyagajani; Odogwu, Nwamaka; Rashid, Amina; Susmit, Roy (Cambridge, 2022-06-20)
    Aims: Patients who do not attend the appointments (DNA) pose a significant financial burden on the health care system. During the COVID-19 pandemic, there has been a shift from face-face to telephonic consultations. Our hypothesis was that pandemic can affect the prevalence of profile of clients who DNA. With this background, the aim of the current service evaluation was to assess the prevalence and profile of patients who did not attend their appointments through face-face consultation and telephonic consultations at the Complex care service south [CCS-South], Wolverhampton over a period of one year. Methods: Retrospective evaluation of records of DNA appointments at CCS- South, Wolverhampton of Face-face appointments during March 17th 2019- March 16th 2020 [Pre-pandemic group] and telephonic consultations during March 17th 2020 – March 16th 2021 [pandemic group] was done. Prevalence of DNA was calculated as the number of DNA in CCS South/ number of DNA in total CCS × 100. Student t test, Mann U Whitney test, Chi square test were used to analyse the data. Results: The number of DNA in the pandemic group (625) was significantly higher than the pre-pandemic group (376) [χ2 = 86.31, p <0.00001]. Males had significantly higher DNA in pre-pandemic group (59.52%) whereas females had significantly higher DNA in the pandemic group (66.76%) [χ2 = 72.97, p <0.00001]. The mean (SD) age of clients in the pandemic group was 41.17 (12.39) years was significantly lower than the mean (SD) age of clients in the pre-pandemic group, 42.87 (13.72) years [t = 1.97; p = 0.049]. There was an increase in the Caucasian British (49.73% vs 38.40%) and Asian (29.52% vs 26.41%) in the pandemic group compared to pre-pandemic group. There was a decrease in the African-Caribbean group (10.11% vs 16.11%) and the mixed/other/unstated group (10.64% vs 19.20% vs) in the pandemic group compared to pre-pandemic group. It was the first DNA for twenty-four service users in the pre-pandemic group and none in the pandemic group. Those in the pandemic group (6.39 (6.79)) had significantly higher mean (SD) number of previous DNA than the pre-pandemic group (5.41 (7.50) [U = 98145; W = 293770; Z= -4.40; p = 0.000). There was no significant difference between the time of the appointment in both groups. Conclusion: There was an increased number of DNA during the pandemic period and the profile of those who DNA during the pandemic was of that a female with a mean age of about 41 years with previous DNAs.
  • Re-audit of blood monitoring of lithium in outpatients of working age under Dudley mental health services

    Bridgewater, Peter; Kumar, Praveen (Cambridge, 2023-07-07)
    Aims: Lithium remains the first line mood stabilising therapy recommended by NICE for Bipolar Disorder and an important treatment option for augmentation of the treatment of Depression. Lithium has a strict monitoring requirement due to long term impact on Renal, Thyroid function and risk of toxicity due to a narrow therapeutic range. This Re-Audit aimed to assess improvement in Lithium Blood monitoring in working age adults in Dudley following an initial 2021 audit. Methods: We used the standards set by NICE CG185- Bipolar Disorder Assessment and Management. We agreed a standard of 3 monthly monitoring of lithium levels due to the number of indications for 3 monthly monitoring to ensure safest practice. We also agreed to standards for 6 monthly monitoring of Urea and Electrolytes (U&Es) and Thyroid Function Tests (TFTs). An additional standard was agreed that at every outpatient review Lithium blood results should be reviewed and documented. A sample of 40 patients was gathered from the 8 outpatient sector teams. We used Rio notes system for demographic, diagnosis and clinical information and blood results systems EMIS and ICE for blood results over a period of November 2021- November 2022. Results: There was a noted minor improvement to compliance with 3 monthly monitoring, overall increasing from 10% to 17.5%, but this result is still poor. The number of patients who had 4 or more Lithium blood tests over the 12 month period was more of a positive increase, to 32.5% from 17.5% in the previous audit cycle. There was also an improvement in the mean number of lithium blood tests per patient from 2.67 to 3.3. For U&Es 90% of patients were monitored 6 monthly while for TFTs 85% of patients were monitored 6 monthly. There was a slight reduction in documentation of blood results at clinic review, reducing to 62.5% from 67.5% in the initial audit. Conclusion: While the progress is positive, the results are still far below where the trust would like to be. We considered whether frequency of outpatient review, poor awareness of 3 monthly monitoring standards and a lack of formal system to remind or ensure patients are monitored appropriately. It was agreed that measures to ensure compliance such as a lithium blood monitoring clinic may be useful to improve compliance with monitoring.
  • Translation of recovering quality of life (ReQoL) to Gujarati : for use in mental health services

    Vankar, Kodarbhai V; Lakdawala, Bhaveshkumar M; Kar, Nilamadhab (Geriatric Care and Research Organisation, 2022-01)
    The Recovering Quality of Life (ReQoL) scale is a short scale for routine clinical use in mental health services. Its shorter 10-item version in English was translated and validated in Gujarati, an Indian language, spoken in the western state of Gujarat in India. The translation process involved following process: forward and back-translation, pilot-testing involving patients, review and reconciliation steps. The linguistic issues encountered during the translation process were addressed. The Gujarati version of ReQoL was considered linguistically acceptable for use in patients with mental illness. It is expected that ReQoL Gujarati version will add to QOL instruments in Gujarati language which can be used in routine clinical practice.
  • Prescribing of psychiatric drugs in pregnancy : a review of current practice in a community mental healthcare setting

    Kar, Nilamadhab; Hickling, Lucy (Cambridge, 2022-06-20)
    Aims: Prescribing of psychotropic medications in pregnancy is still considered a ‘grey area’ in clinical practice. National Institute for Health and Care Excellence (NICE) in the UK suggests that the decisions should be person-specific, considering the risks to both the mother and unborn child, and the patient is supported to make an informed decision. It is important to explore the use of psychotropic medications during pregnancy, or lack of it, and its subsequent impact on maternal mental health. It was intended to review the decisions expectant mothers are making regarding taking psychiatric medications during pregnancy, and the associated clinical outcomes. Their mental capacity for taking decisions was also checked. Methods: A retrospective audit of case notes of patients (n = 16) known to community psychiatric team (CMHT) and specialist perinatal mental health (PNS) services in Wolverhampton, who notified their pregnancy between December 2020 and December 2021. Demographic and clinical data were collected from the electronic records. Results: The sample had a mean age of 28.8 ± 6.3 years (range: 19 to 39 years), and 68.8% of them were Caucasian. A wide range of psychiatric diagnoses were present, most (62.5%) had comorbid diagnoses; and 25% had substance use, most commonly cannabis. Mean duration of gestation at the review following notification of pregnancy was 14.5 ± 7.7 (range: 6 to 29) weeks. It was observed that 25% were not taking psychiatric medications prior to pregnancy, 43.8% stopped taking their medication prior to the psychiatric review, most stopping abruptly, and 31.2% had continued their medication. The medications included aripiprazole, olanzapine, quetiapine, venlafaxine, sertraline and promethazine. Following the review, only 18.8% continued their medications. Of the 13 (81.3%) patients who were not taking medications, 9 (69.2%) had adverse mental health outcomes, with 2 (15.4%) patients requiring inpatient care. However, later 8 (61.5%) started taking medications whilst under the care of PNS. All of them had mental capacity to decide regarding their psychiatric treatment at the review. Conclusion: Most psychiatric patients avoided taking psychotropic medications initially during pregnancy, however, a considerable proportion restarted their medications following review with the perinatal psychiatry team. The majority of patients who did not take medications had negative mental health consequences. It is important to develop an evidence base about the use of psychiatric medications in pregnancy and the associated short and long-term outcomes that may help the quality of information shared with patients.
  • Psychosis treatment in the context of tetralogy of Fallot and prolonged QTc

    D'Souza, Dina; Kar, Nilamadhab; Jiwanmall, Stephen (Wiley, 2023-05-10)
    We present a case of a 27-year-old Caucasian male with a background of surgically corrected tetralogy of Fallot (TOF) and pulmonary valve regurgitation, who presented with psychotic symptoms. The case presented a challenge in treatment due to the patient's cardiac history and ongoing cardiac-related health problems with prolonged QTc before initiation of the antipsychotic drug. Treatment included careful monitoring of ECG while on antipsychotics, which led gradually to improvement in his mental state. The case highlights the possibility of a link between TOF and psychosis, the vulnerability of such patients to their treatment and the importance of multidisciplinary support for cardiac side-effects.
  • Translating recovering quality of life scale to Punjabi : a cultural and linguistic validation study

    Sethi, Sujata; Singh, Prabhmeet; Uppal, Devpriya; Parkash, Ravi; Kar, Nilamadhab (GeriCaRe, 2022-04)
    The Recovering Quality of Life (ReQoL) scale, developed in the UK is an appropriate instrument for routine clinical use in mental health services. It has been translated to many languages in India and elsewhere. The translation and linguistic validation process of the ReQoL scale to Punjabi, an Indian language spoken in many Northern states of India, was undertaken by a team of mental health professionals at Post Graduate Institute of Medical Sciences, Rohtak, India. The standard process of translation and review was followed. A pilot study involving 10 patients with mental illness was conducted and their suggestions were incorporated in the translation process. The linguistic issues encountered during the process were addressed. The translated Punjabi version of ReQoL was considered acceptable by the patients and clinical team. It appears that ReQoL-10 in Punjabi can be used in the mental health services as an outcome instrument in psychiatric clinical practice and research.
  • Remote clinical assessments and management during COVID-19 : views of the patients and clinicians about the future preferences

    Kar, Nilamadhab; Cheung, Lai-Ting; Jiwanmall, Stephen (Cambridge University Press, 2022-06-20)
    Aims: During the COVID-19 pandemic most clinical services changed to remote consultation and management to minimise virus transmission by direct contact. As the social distancing and restrictions have eased with greater control of the pandemic, the nature of consultations is going to change. At this juncture we intended to understand the perception and satisfaction of patients and clinicians on remote consultations and management during COVID-19 and to determine their preference about clinical engagement in the future. Methods: This was a trust-wide anonymous survey conducted through SurveyMonkey. It involved both patients and mental healthcare staff (MHS) and explored about the quality and satisfaction in remote consultations, option to patients, and use of remote consultations in future. Clinicians were sent the online link to complete, with a reminder two weeks later. The patients were explained during their appointments about the survey, those who agreed to participate and gave informed consent, their responses to the questions were recorded. Results: The sample consisted of 78 patients and 107 MHS representing adult, old age, children and adolescent and intellectual disability subspecialties. Most (92.4%) participants had participated in remote consultations and understood the reason behind it. Around a third (32.7%) of MHS and 46.2% of patients felt strongly satisfied in remote consultations, and together with satisfaction these were 56.1% v 71.8% respectively (p < 0.05). The quality of the remote consultations were considered somewhat (11.2% v 23.1%) or a lot better (8.4% v 15.4%) by MHS and patients respectively (p < 0.05). Majority (82.7%) felt that an option should be given to patients for the type of consultation, face to face or remote. After the pandemic, the preference for psychiatric consultations were primarily face to face (30.3%), primarily remote (8.6%) and a mixture of the two (61.1%); there were no difference between patients and MHS. However while 71.4% doctors, 70.8% other clinicians (occupational therapists and psychologists) and 75.0% of clinical managers opted for mixture of face to face and remote, 26.9% of nurses opted for that. Background subspecialty, age group, ethnicity, experience of remote consultation with GP or hospital doctors, attendance or admission to general or psychiatric hospitals during pandemic, disabilities, or having COVID-19 did not influence the suggestion for the future consultation type. Conclusion: Following the pandemic, both clinicians and patients express a preference for a mixture of face to face and remote consultations; and an option regarding that should be given to the patients
  • Evaluation of early neuro-imaging requests for dementia diagnosis in Wolverhampton Memory Assessment Service (MAS)

    Prasanna, Aparna; Mandair, Kuljit; Ling, Clare (Cambridge University Press, 2022-06-20)
    Aims: The Wolverhampton Memory Assessment Service (MAS) is nurse led and accepts referrals from primary and secondary care settings. There has been a rapid rise in the number of referrals as well as an increase in demand to provide a timely diagnosis. This poses a challenge to meet the national aspiration of referral to diagnosis in 6 weeks. The aim is to improve access to neuroimaging in order to avoid delays to diagnosis and management. Methods: In January 2022, a retrospective sample of three groups of newly referred patients to MAS between 1st June-31st October 2021 was selected, each group consisting of 15 patients. A dedicated tool was used to collect data. MAS follows NICE standards for neuroimaging in dementia guidance. In Group 1 scans were not requested at referral but were requested after initial nursing assessment, in Group 2 scans were available at initial referral and in Group 3 scans were requested by the MAS Consultant Psychiatrist upon receipt of referral. Results: In group 1; 47% of patients have still not had a scan (with a waiting time of approximately 6 months) and 73% have not been given a diagnosis. Three patients were given a diagnosis due to exceptional circumstances and therefore the results of these patients can be disregarded. In group 2, all (100%) patients had a scan either prior to the referral (73%) or requested by GPs at the time of referral (27%). 80% of patients have been given a diagnosis. The average days from referral to diagnosis was 82 days. Patients not given a diagnosis yet was due to cancellation/awaiting appointments. In group 3, all (100%) patients have had a scan and 67% of patients have been given a diagnosis. The average days from referral to diagnosis was 102 days. Patients not given a diagnosis yet was due to cancellation/awaiting appointments. Conclusion: Implementing a pathway whereby clinicians can either have access to prior neuroimaging or refer appropriate patients for scans at the point of referral, significantly reduces waiting times to diagnosis and management within a timely manner. This reduces carer burden and provides increased support from appropriate services as well as reducing the chances of patients ending up on crisis pathways. There is a need to implement an integrated care pathway that is responsive and accessible to all patients.
  • “It's all in the head”. Well! not always : mental health patients are not immune to physical pain

    Javed, Asma; Sharma, Rajasee (Cambridge University Press, 2023-07-07)
    Aims: Emotionally unstable personality disorder (EUPD) patients are known to frequently present to acute hospitals with pain symptoms. Multiple pain syndromes like fibromyalgia, chronic fatigue syndrome etc. are also commonly diagnosed in this group of population. It can be difficult to differentiate psychosomatic pain from physical pain during these hospital presentations. Failure to exclude physical causes of pain can lead to inadequate pain relief and missed serious diagnosis. Methods: We describe a 29-year-old lady known to have Type 1 Diabetes, chronic pancreatitis and past history of several overdoses. She was being supported by Home Treatment Team (HTT) before coming to the hospital. She presented to the Emergency Department (ED) after ingesting 40 tablets of Pregabalin. She was referred to mental health liaison service for ongoing suicidal thoughts. On assessment, she admitted taking multiple overdoses to relieve her of severe abdominal pain. Her pain symptoms had been attributed as attention seeking behaviour. She disclosed feelings of rejection and abandonment by hospital staff. Liaison team negotiated with emergency department staff to complete a physical health examination that revealed tenderness and guarding in the abdomen. She was booked for elective cholecystectomy after surgical review. However, she had to be admitted from ED for laparoscopic cholecystectomy because of worsening of pain and vomiting. She was referred to Pain Management Team after surgery. The team was cautious in providing her with pain medications considering past history of overdoses. She was unable to tolerate pain and voiced thoughts of overdose. We liaised with Pain Management Team to optimise her analgesics and arranged daily supervision of pain medications with HTT Results: Our patient's physical symptoms of acute cholecystitis and frequent overdoses with pain medications were attributed to her personality disorder that resulted in dismissal of her real pain that “Its is all in the head”. This led to persistent pain affecting her mental health. Conclusion: Patients diagnosed with EUPD should be carefully assessed to exclude organic causes of pain before attributing their symptoms to mental health disorders. A thorough assessment and treatment of physical symptoms can improve their mental health as well as reduce attendance in health facilities.
  • Physical health monitoring before commencing regular antipsychotics in a Psychiatric Intensive Care Unit (PICU) - a quality improvement project

    Divyanish, Divyanish; Channa, Afshan (Cambridge University Press, 2021-06-18)
    Aims: To compare the practice in a PICU setting against the standard practicing guidelines before commencing antipsychotics with regards to: 1. Physical examination 2. ECG 3. Baseline blood investigations 4. Physical health conditions 5. Family history of medical conditions. Method: Data were collected from the PICU, Black Country Healthcare NHS Foundation Trust which covers four different hospital sites. 37 patients were admitted in PICU from 1st March 2020 to 30th September 2020, out of which 30 were included. 6 case notes were not available and one patient was admitted twice, thus case notes for only one admission was included in data collection. The standard guidelines for PICU outline that each admitted patient should have physical examination, vitals monitoring and baseline investigations including routine blood tests and ECG within first 24 hours. The data were collected as per standards retrospectively within two weeks from case notes in health records. Investigations were accessed through electronic information system for current inpatient admission and 12 months prior to the admission to the PICU. Result: Mean age of the sample (n = 30) was 34.26 years. 37% of patients had physical comorbidities and a family history of medical conditions was documented for only 3% of cases. A large proportion of inpatients (53%) refused to have blood investigations before treatment and only 13% of blood investigations were completed before commencing treatment. Only 7% of patients consented to an ECG prior to commencing treatment. 27% of patients had a physical examination, including vitals, before starting treatment, a further 37% had just their vitals taken within 24 hours of admission and 20% refused any form of physical examination during their inpatient admission. 7% of cases had complications due to a lack of investigation. Conclusion: Although there are standard guidelines for the PICU setting, it has been noted that these guidelines aren't always implemented. Multiple factors have a role to play such as: non-consenting patients, inaccessibility of previous records, initial assessment forms being incomplete including assessment of mental capacity and lack of follow-up with physical investigations by both primary care and secondary mental health services. As per findings, a few recommendations were proposed to meet the standards.
  • An audit of planned follow-up following discharge from four Black Country CRHTs

    Horton, Gemma; Pegg, Joanna; Undre, Suhail; Bridgwater, Peter; Odogwu, Nwamaka (Cambridge University Press, 2023-07-07)
    Aims: It is well established in the evidence base that mortality and suicide risk increases following discharge from an inpatient admission, leading to the national implementation of ‘72 hour follow-up’. However, there is little data examining outcomes following discharge from an admission to a Crisis Resolution & Home Treatment Team. Following a number of noted Serious Untoward Incidents at a trust level, we sought to examine the standard of follow up post discharge from all four Black Country CRHTs (Dudley, Walsall, Sandwell and Wolverhampton) in order to improve policy and thus patient outcomes. Methods: The caseloads for all four CRHTs for the period of 1st-31st December 2021 were obtained. The clinical notes system RIO was searched and scrutinised for each patient to determine when the patient's next planned follow-up following discharge from that particular spell in CRHT took place. This was compared to the audits standard: all patients discharged from CRHT should receive some form of planned follow-up in the 3 month period post discharge. Results: All of the patients discharged from Wolverhampton CRHT received 72 hour follow-up as conducted by members of their own team, however despite this 12% of the total caseload were either lost to long term follow-up or went into crisis before planned follow-up could take place. With regard to Dudley and Sandwell, only 51% and 47% of patients respectively were routinely followed-up within 3 months. A total of 30 patients across all 4 CRHT's went into crisis before planned follow-up took place. One patient ended their life 4 months following discharge from the CRHT; no planned follow-up took place. All of Walsall CRHTs patients were followed up on discharge unless they were discharged directly back to their GP. Conclusion: Timely, regular and robust follow-up embedded in the community mental health team is paramount to the provision of safe psychiatric care. This audit has also uncovered the need for follow-up for patients discharged from CRHT to their GP, as this cohort of patients is sizeable. However we argue that a one off ’72 hour/7 day follow-up’ is insufficient when reducing morbidity and mortality, and robust long term care plans and regular follow-up should instead be a feature of longer term community mental health care.
  • Stress, anxiety, and depression : a comparative study of perceptions of patients in the ICU, other wards and their family caregivers in a low middle income country

    Kar, Nilamadhab; Tripathy, Swagata (Elsevier, 2022-02)
    Developed countries report higher ICU-related mental-health complications. The absence of non-ICU comparators limits interpretation and comparability across socioculturally diverse populations. Having found low levels of mental health complications in our ICU patients, we compared anxiety, depression, posttraumatic stress symptoms (PTSS), quality of life (QOL), and self-reported stressors in ICU (n ¼ 28), ward (n ¼ 34) patients and family caregivers (n ¼ 30) in a cross-sectional study in a tertiary teaching hospital. Hospital Anxiety and Depression Scale (HADS), Impact of Events revised IES-R, European Quality of Life 5 Dimensions 3 levels (EQ5D 3L) were used. Clinically relevant anxiety, depression (HADS 8), and PTSS (IES-R 30) were comparable amongst the ICU patients (46.4%, 46.4%, 10.7%), ward patients (53.3%, 30.0%, 6.7%), and caregivers (55.9%, 29.4%, 0%) respectively. Avoidance as PTSS subgroup was significantly higher in ICU patients and caregivers. IES-R scores were significantly less when only the ICU experiences were considered. QOL was significantly worse in ICU patients. Self-reported stressors were comparable in the groups; however after correcting baseline factors, un employment contributed significantly to higher PTSS, anxiety and depression. While the rates of anxiety/depression were similar, lower PTSS in comparison to reports from developed countries suggest future studies to focus ICU experience, confounding non-clinical stressors and cultural issues.
  • Awareness of fitness to drive guidance amongst doctors in Black Country Healthcare NHS Foundation Trust : a survey

    Sundhar, Reka; Chandra, Pallavi; Fraser, Alastair; Kar, Nilamadhab (Cambridge University Press, 2023-07)
    Aims: Psychiatric patients have a higher risk of road traffic accidents than others. The Driver and Vehicle Licensing Agency (DVLA) has provided guidance on different psychiatric conditions and medication that would impact driving. The General Medical Council and Royal College of Psychiatrists advice doctors to notify the DVLA when patients unfit to drive fail to inform the DVLA themselves. In this context, it was aimed to study the awareness of doctors regarding DVLA guidance and its use in their clinical practice. Methods: We conducted a survey about doctors’ awareness of guidance on Fitness to Drive via an online questionnaire. Likert type scoring ranging from strongly agree to strongly disagree was used to assess the (i) awareness of DVLA guidance for psychiatric patients, (ii) confidence in advising patients, (iii) feeling it is a job requirement to advise patients on driving; and (iv) checking the driving status and if patients have informed DVLA where necessary. This included questions on years of experience in medicine, current grade and subspecialty of Psychiatry. Results: The sample consisted of 78 doctors, from various grades from Foundation Year 1 trainees to Consultants; working in different Subspecialties in Psychiatry. There were 36 trainees, 12 middle grades, 28 consultants and 2 ‘other’ doctors. The average year of experience of the responding doctors was 14.2±11.0 years with a range of 1-38 years. Majority (62.8%) of doctors responded that they are aware of the DVLA guidance for psychiatric patients; however 47.5% reported having confidence to advise patients on DVLA guidelines. Considerable proportions (79.5%) of doctors felt that as psychiatrists, it was their job to give advice on driving; but only 50% said they check the driving status and whether patients have informed the DVLA when necessary as part of routine practice. When using the Likert scale, comparing to other subspecialties, General Adult Psychiatrists responded that they check driving status less routinely (p<0.05), however there was no difference in other areas evaluated. Trainees’ responses indicated less awareness (p<0.001), confidence (p<0.001), and checking of driving related issues routinely in clinical practice (p<0.005). Conclusion: The survey results suggest variation in awareness of Fitness to drive guidance for psychiatric patients and their use in routine clinical practice amongst doctors. While trainees would need more information and training to increase their confidence, there is a need for all psychiatrists to use the guidelines in regular clinical practice.
  • Mental health concerns in outpatients during COVID-19 pandemic : comparison between psychiatric and general hospital clinics in an Indian population

    Kar, Nilamadhab; Mohapatra, Satyakam; Behera, Tikina; Sahoo, Sajata (Weston Medical Publishing, 2022)
    We intended to compare mental health concerns in patients attending a general hospital clinic with that of patients attending a psychiatric clinic during the coronavirus disease 2019 (COVID-19) pandemic. We specially wished to know about the perceived stress, worries, possibility of anxiety and depression, and the quality of life (QOL) of the patients. In a cross-sectional study, we used two screening questions for depression, Generalised Anxiety Disorder-2 (GAD-2) scale for anxiety, Perceived Stress Scale (PSS) for stress, nature and degree of worries in a 0–10 scale, and QOL in a 1–10 scale. Majority (75.5 percent) of outpatients had moderate to high level of stress, 76.5 percent were screen positive for depression, and 42 percent for anxiety. Psychiatric patients had significantly higher perceived stress, level of worry, and lower QOL to those with physical illness and were screen positive for depression (99 percent v 54 percent) and anxiety (68 percent v 16 percent), respectively. Patients with major physical illnesses had significantly higher stress levels and anxiety compared with those without. Fear of getting the infection, loss of job, and financial issues were the major worries along with social stigma. The results highlighted the need for screening mental health concerns in general hospital and psychiatric outpatients during the COVID-19 pandemic and facilitate appropriate interventions.
  • Leaving the past behind: exploring the adverse childhood experiences of males detained to a secure specialist deaf inpatient mental health service

    Webb, Elanor L.; Baker, Kevin; Morris, Deborah; Nawab, Zahra; Gencarelli, Benedetta L.; Worsfold, Jemima (Taylor & Francis, 2023-08-23)
    Deaf people, and those who engage in criminal offending have independently been identified as groups at risk for childhood trauma, though consideration of their intersectional impact is limited. The adverse childhood experiences (ACEs) of 26 males detained to a deaf secure mental health service were explored. Overall, 92.3% of participants had experienced an ACE. Most participants had experienced multiple adversities (Median = 6), with 73.1% exposed to four or more, and 57.7% exposed to six or more. Most participants (76.9%) had experienced both child maltreatment and household adversity. The most prevalent ACEs were emotional neglect and parental separation (76.9%). Participants who had been subject to a care order reported more child maltreatment ACEs (p = .02). Given the pervasive ACE histories of deaf people in secure mental health services, the integration of trauma-informed practices within an environment that is sensitive and responsive to the complex trauma needs of this population is of paramount importance.
  • P-1371 - A survey of psychiatrists' attitude toward electroconvulsive therapy

    Cho, K (Elsevier, 2012)
    Introduction: Electroconvulsive therapy (ECT) was first used in the United Kingdom in 1939. Although its use has been declined for several decades, it is given to about 11,000 people a year. ECT is commonly used in depression in the majority of patients, but occasionally used for catatonic schizophrenia and severe mania. Unfortunately, there have been issues raised regarding its negative impacts on memory capacity of the patient. Aims and objectives: ECT until now has gained the support of most professional psychiatric associations, although there are still some health professionals who are doubtful about its effectiveness. The aim is to find out psychiatrists' attitude toward ECT in the Dudley and Walsall Mental health Partnership NHS Trust in The UK. Method A self administered mail survey was used to gather demographic data and information on attitudes toward ECT. 11 questions were use. Results :•About 60 % responded the mail survey. •Respondents have mean age of 47. •Consultants and middle grade doctors are major participants. •About 96% administered ECT before.•100% think that ECT should be available to their patients and 96% found that ECT is useful. 88% believed that ECT is safe.•79% would consider ECT for themselves or family member if indicated. Conclusion: Most had the positive attitude toward ECT and they believed that ECT was safe alternative treatment for their patients and would consider for themselves and their family members regardless of whether they had ever administered ECT. Therefore the majority of psychiatrists in our trust supported the use of ECT.

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