Differential attainment (DA) amongst Black and Minority Ethnic (BAME) medical students and postgraduate trainees including Psychiatry trainees has been extensively documented in medical education, with non-white medical students being 2.5 times more likely to fail high-stake examinations compared to their White counterparts. The Equality Act 2010 places a responsibility on public bodies such as Royal Colleges to address discrimination in training and assessment. Understanding DA in undergraduate medical education can help understand DA in the postgraduate setting. Consequently, this systematic review aims to detect the processes that enable and impede DA in UK undergraduate medical education.

Seven online databases including PubMed, Scopus, PyschInfo, and ERIC were searched. A formal grey literature search was also conducted. Inclusion criteria comprised studies dated from January 1995 to present and included UK undergraduate medical students. We present the preliminary findings from 13 papers, analysed to create a conceptual framework for a further mixed methods analysis. The studies were critically appraised for methodological quality.

Five key themes emerged from the preliminary analysis of 13 papers. BAME students experienced:

Being ‘divergent’: Not feeling part of the current organisational learning milieu

Lack of social capital: Difficulty in being absorbed into existing ‘networks’ of relationships in a manner that is ‘approachable’ and not ‘intimidating’

Continuum of discrimination: ‘Indirect’ impact of subtle communication processes in the learning environment undermining individual ‘belief’ in own performance

Institutional discriminatory factors: Culture, rules, norms, and behavioural routines of educators that lead to differential outcomes for learners

Lack of external support: Relative lack of interventions tackling DA.

The key finding of this review is that British BAME undergraduate medical students experience discriminatory behaviours early in medical schools that impact on personal, educational, and professional outcomes. These factors may need to be borne in mind by postgraduate training organisations such as the Royal College of Psychiatrists as they commence the challenging task of addressing DA.

To identify intramuscular rapid tranquilisation (IMRT) events in all >65 years inpatients in Sussex Partnership NHS Foundation Trust (SPFT) and to establish whether accompanying documentation meets SPFT guidelines. This is a re-audit, initial data were collected in 2016. Multimodal intervention has been implemented since initial data collection. In psychiatric inpatients IMRT should be administered as a last resort to calm acutely disturbed patients after verbal de-escalation and an offer of oral medication has failed. IMRT can cause physical health complications and impact therapeutic relationships. Quality improvements made since initial data collection were: an IMRT treatment algorithm for >65s, a teaching package for staff, IMRT prescription area on medicine cards and post IMRT physical monitoring forms – in line with updates to trust IMRT policy.

Retrospective case note audit cycle of 119 patients. Electronic and paper records were reviewed for inpatients >65 years on 1/9/2019. Records were examined for instances of IMRT– the following features were noted: diagnosis; verbal de-escalation; oral medication offered prior to IMRT; IMRT prescription location; and post-IMRT monitoring. Descriptive statistics were performed. This audit was approved by the trust audit committee.

There were 34 RT events in 17 patients, reduced from 83 RT events in 20 patients in 2016. De-escalation was attempted in 62% versus 34% in 2016, oral medication offered first in 71% versus 59% in 2016. Physical monitoring was fully completed in 50% of instances in 2019, an improvement from 23% in 2016.

Education, a new treatment algorithm, medicine card changes, and IMRT physical monitoring forms have improved adherence to trust standards. There was a 49% reduction in IMRT events in 2019 versus 2016. De-escalation is being performed more frequently, and oral sedation offered in more cases. The physical monitoring of patients has improved.

Out-of-hours (‘on-call’) work can be perceived by junior doctors to be a daunting experience, associated with feeling unprepared and less supported. Simulated on-call programmes have been used to great effect in medicine and surgery to improve junior doctors’ skills in task prioritisation, interpersonal communication and confidence on-call. However, few psychiatry-specific programmes exist.

We aimed to: i) Develop a psychiatry specific virtual-on-call programme, ii) Investigate if the virtual-on-call programme improved confidence amongst junior trainees in key areas of psychiatry practice.

The Psychiatry Virtual-On-Call programme commenced in December 2020. It involves attending an introductory on-call lecture, followed later in the rotation by a 2-hour simulated on-call shift. All trainees are expected to attend during their attachment and the simulated shifts are ongoing. During the shift, trainees are ‘bleeped’ with different psychiatry specific tasks. They work through the tasks, using local intranet policies and telephone advice from the on-call psychiatry registrar. Due to COVID-19 the sessions were delivered virtually. Participants completed a questionnaire evaluating confidence in ten domains, rated on a Likert scale from 0–10. Questionnaires were completed at four time-points during the programme; pre- and post-introductory lecture and pre- and post-simulated shift. Scores were compared using Mann-Whitney U tests. Significance was defined as P < 0.05 with Bonferroni correction applied for multiple testing.

Twenty-nine trainees attended the introductory lecture, 25 and 21 trainees completed the pre- and post-lecture questionnaire respectively. A non-significant improvement in confidence was reported in three domains: seclusions reviews, prescribing, detention under the mental health act.

At the time of writing, ten trainees had attended the on-call shift. All participants completed a pre- and post-session questionnaire. The on-call shift was a useful learning experience (median score 9), and significantly increased perceived preparedness for on-call work from 3/10 to 7/10 (p < 0.001). Confidence was significantly improved in seven domains, most markedly in seclusion reviews, prescribing and mental health act tasks.

The psychiatry virtual-on-call programme fills a niche in the training curriculum and is perceived by trainees to be a useful learning experience. The introductory lecture improved confidence in several domains, but not as effectively as the on-call shift. The on-call shift was well received by participants and significantly improved confidence in 7/10 domains. In summary, the virtual-on-call experience improves preparedness for out-of-hours psychiatry work. Follow-up of participants at the end of their psychiatry rotation will ascertain if they felt the programme to be useful during out-of-hours work.

This study examined lithium results and requesting patterns over a 6-year period, and compared these to guidance.

Bipolar disorder is the 4th most common mental health condition, affecting ~1% of UK adults. Lithium is an effective treatment for prevention of relapse and hospital admission, and is recommended by NICE as a first-line treatment.

We have previously shown in other areas that laboratory testing patterns are highly variable with sub-optimal conformity to guidance.

Lithium requests received by Clinical Biochemistry Departments at the University Hospitals of North Midlands, Salford Royal Foundation Trust and Pennine Acute Hospitals from 2012–2018 were extracted from Laboratory Information and Management Systems (46,555 requests; 3,371 individuals). We categorised by request source, lithium concentration and re-test intervals.

Many lithium results were outside the NICE therapeutic window (0.6–0.99mmol/L); 49.3% were below the window and 6.1% were above the window (median [Li]:0.61mmol/L). A small percentage were found at the extremes (3.2% at <0.1mmol/L, 1.0% at >1.4mmol/L). Findings were comparable across all sites.

For requesting interval, there was a distinct peak at 12 weeks, consistent with guidance for those stabilised on lithium therapy. There was no peak evident at 6 months, as recommended for those <65 years old on unchanging therapy. There was a peak at 0–7 days, reflecting those requiring closer monitoring (e.g. treatment initiation or results suggesting toxicity).

However, 77.6% of tests were requested outside expected testing frequencies.

We showed: (a) lithium levels are often maintained at the lower end of the NICE recommended therapeutic range (and the BNF range: 0.4-1.0mmol/L); (b) patterns of lithium results and testing frequency are comparable across three sites with differing models of care; (c) re-test intervals demonstrate a noticeable peak at the recommended 3-monthly interval, but not at 6-monthly intervals; (d) Many tests were repeated outside these expected frequencies (contrary to NICE guidance).

Lithium was first found to have an acute antimanic effect in 1948 with further corroboration in the early 1950s. It took some time for lithium to become the standard treatment for relapse prevention in bipolar affective disorder. In this study, our aims were to examine the factors associated wtih the likelihood of maintaining lithium levels within the recommended therapeutic range and to look at the stability of lithium levels between blood tests. We examined this relation using clinical laboratory serum lithium test requesting data collected from three large UK centres, where the approach to managing patients with bipolar disorder and ordering lithium testing varied.

46,555 lithium rest requests in 3,371 individuals over 7 years were included from three UK centres. Using lithium results in four categories (<0.4 mmol/L; 0.40–0.79 mmol/L; 0.80–0.99 mmol/L; ≥1.0 mmol/L), we determined the proportion of instances where, on subsequent testing, lithium results remained in the same category or switched category. We then examined the association between testing interval and proportion remaining within target, and the effect of age, duration of lithium therapy and testing history.

For tests within the recommended range (0.40–0.99 mmol/L categories), 84.5% of subsequent tests remained within this range. Overall 3-monthly testing was associated with 90% of lithium results remaining within range compared with 85% at 6-monthly intervals. At all test intervals, lithium test result history in the previous 12-months was associated with the proportion of next test results on target (BNF/NICE criteria), with 90% remaining within range target after 6-months if all tests in the previous 12-months were on target. Age/duration of lithium therapy had no significant effect on lithium level stability. Levels within the 0.80–0.99 mmol/L category were linked to a higher probability of moving to the ≥1.0 mmol/L category (10%) than those in the 0.40–0.79 mmolL group (2%), irrespective of testing frequency. Thus prior history in relation to stability of lithium level in the previous 12 months is a predictor of future stability of lithium level.

We propose that, for those who achieve 12-months of lithium tests within the 0.40–0.79mmol/L range, it would be reasonable to increase the interval between tests to 6 months, irrespective of age, freeing up resource to focus on those less concordant with their lithium monitoring. Where lithium level is 0.80–0.99mmol/L test interval should remain at 3 months. This could reduce lithium test numbers by 15% and costs by ~$0.4 m p.a.

To review the ECGs of all patients referred to MAT services over the preceding 5 year period.

Neurodegenerative conditions such as Alzheimer's Disease can be treated with Acetylcholinesterase Inhibitors (AChEI) to slow down cognitive decline. Side effects of AChEIs include bradycardia, syncope and cardiac conduction disorders. An electrocardiograms (ECG) is completed prior to memory assessment team (MAT) medical assessments to screen for those who may be at risk of the cardiac side effects of AChEIs. ECGs may be included in the initial referral to the service or completed by the MAT. Given the predominantly elderly population referred to the MATs service, other incidental abnormalities are to be expected. Not all MAT referrals that are screened by memory nurses reach the threshold to be reviewed by the medical team and therefore not all ECGs are routinely reviewed, potentially missing clinically significant abnormalities.

A total of 1795 patients were identified as being referred to a single mental health unit in the North West on England over a five-year period. 781 (44%) of the patients had an ECG completed by the MAT, of which 452 (58%) showed an abnormality. Significant abnormalities that were previously unknown to the patients’ primary care provider include eight cases of Atrial Fibrillation (AF), four cases of Trifasciular Block, and 19 cases of Left Ventricular Hypertrophy (LVH). 64 (8%) of patients who had an ECG by the MAT had a bradycardia.

In addition to identifying abnormalities that could interfere with memory medication, this audit showed that over half of the ECGs completed by the MAT had an atypical trace. Cardiology was consulted to identify which abnormalities were considered clinically significant and if not already known, the general practitioner (GP) was informed. A change in the local service means that all ECGs completed by the MAT are now screened at point of filling into the notes, so any future abnormalities are identified and followed up immediately.

Few studies have investigated the COVID-19 pandemic's effect on children and adolescents with obsessive compulsive disorder (OCD), who are thought to be particularly vulnerable. This study aims to investigate whether the COVID-19 pandemic is associated with increased referral of young people with OCD in one area of London and determine if COVID-19 has been associated with change in symptom severity and treatment offered in recent years.

A retrospective study was conducted using clinical service data investigating 58 young people (8–17 years) referred and assessed in CNWL NHS Foundation Trust CAMHS, before and during the COVID-19 pandemic in 2020 (months March–October 2018–2020). Changes in symptom severity were measured using the health of the nation outcome scale for children and adolescents (HoNOSCA). Total HoNOSCA and three HoNOSCA items were used; emotional symptoms, family relationships and school attendance. Patient clinical records were reviewed to assess if COVID-19 had exacerbated OCD symptoms. The type of treatment offered (cognitive behavioural therapy -CBT- only vs combined CBT and medication) was also compared. Analysis was carried out using Chi-square, Kruskal–Wallis and Mann–Whitney U tests.

26 (5.62%) initial assessments to CAMHS were related to OCD in 2020, compared to 12 (1.30%) and 20 (2.27%) assessments pre-pandemic (2018 and 2019), showing a significant increase in the proportion of OCD cases (X2 (1, N = 58) = 20.3, p < .001). There was no significant difference in total HoNOSCA, emotional, family relationships, or school attendance scores on initial assessment. However, 69.2% of clinical records in 2020 showed symptom worsening over the COVID-period, compared to 30.8% of cases assessed pre-pandemic.There was a significant difference between the type of treatment offered before and during COVID-19 (X2 (2, N = 58) = 12.7, p = .002), with a higher proportion of patients who were referred to CAMHS for OCD but discharged without treatment before the pandemic (37.5% vs 0%). While CBT only remains the most frequent treatment offered, combined treatment was more frequent during the pandemic, although this difference was not significant.

The proportion of OCD-related initial assessments in CAMHS increased during the pandemic despite the overall number of referrals falling. Furthermore, fewer cases were discharged without treatment in CAMHS during this period. Given this, and that many were reported to have deteriorated during the pandemic, services will likely need to address the increased burden of more severe cases. Further research is warranted to assess the generalisability of our findings.

This evaluation aimed to identify patient, practitioner and infrastructural barriers to initiation of clozapine treatment in patients with treatment-resistant schizophrenia (TRS). In response to recent research supporting use of clozapine as the most effective treatment for patients with TRS, concerted efforts have been made to establish why clozapine is underutilised in the NHS. Following a study conducted by South London and Maudsley NHS Foundation Trust, which identified barriers and made recommendations, this evaluation aimed to identify barriers to initiation of clozapine in patients under the care of Mersey Care NHS Foundation Trust.

This evaluation also aimed to make further recommendations to increase use of clozapine in Mersey Care's TRS patients and assess whether there have been any differences to concerns about clozapine initiation compared to previous evaluations.

An online questionnaire containing a series of Likert scales was e-mailed to all Consultant Psychiatrists in Mersey Care NHS Foundation Trust. The questionnaire asked Consultants to rate how often they felt a range of barriers interfered with successful initiation of Clozapine treatment. The barriers chosen were based on the 2019 systematic review “Barriers to using clozapine in treatment-resistant schizophrenia.”

Nineteen consultant psychiatrists completed the online questionnaire. All 19 indicated they either “agreed” (16%) or “strongly agreed” (84%) that they were confident in diagnosing TRS. This was a significant increase compared to the South London and Maudsley evaluation, with only 81% of participants in that study being “fairly familar” or “very familiar” with clozapine guidelines.

Furthermore, concerns about inadequate blood testing facilities appear to have been addressed, with no participants in this evaluation staing there were insufficient blood testing facilities. However, 53% of Consultants who completed this evaluation stated they “often” (37%) or “very often” (16%) have patients who refuse clozapine because of the requirement for regular blood testing. Refusal to agree to required blood testing was the commonest reason identified for failure to initiate clozapine in TRS patients. This was consistent with the results from the South London and Maudsley study.

Those Mersey Care consultants surveyed identified that providing patients with further information about clozapine would be the most valuable intervention to increase likelihood of uptake of clozapine in the treatment of TRS. Significant progress has been made in improving the likelihood that clozapine can be successfully initiated, especially in the removal of practitioner barriers. This evaluation suggests interventions should now be aimed at reducing patient barriers to initiation of treatment.

To assess the frequency of prescription of psychotropic medication in patients with a primary diagnosis of emotionally unstable personality disorder (EUPD) following admission to Clock View Hospital, an inpatient unit in Mersey Care NHS Foundation Trust.

A retrospective analysis of the electronic (RiO) record of 50 patients discharged from Clock View Hospital between 1 January 2020 and 1 November 2020 was performed to assess prescribing practice.

Twenty-five patients with a diagnosis of EUPD and no associated psychiatric comorbidities were included in the sample, as well as 25 patients with a diagnosis of EUPD and associated psychiatric comorbidities.

80% of the 25 patients with EUPD and associated psychiatric comorbidities were prescribed psychotropic medication prior to admission to hospital (56% an antidepressant, 24% a mood stabiliser, 60% an antipsychotic and 8% a benzodiazepine). 64% of patients were prescribed two or more psychotropic medications. 28% were initiated on new psychotropic medications following admission. For four of the seven prescriptions commenced on psychotropic medication, prescribing practice was as advised in Mersey Care's EUPD guidelines.

Of the 25 patients with EUPD and no associated psychiatric comorbidities, 96% of the patients were prescribed psychotropic medication prior to admission to hospital (56% an antidepressant, 20% a mood stabiliser, 72% an antipsychotic and 12% a benzodiazepine). 68% of patients were prescribed two or more psychotropic medications. Following admission, 28% of patients were initiated on new regular psychotropic medications. For five of the eight prescriptions for new psychotropic medication, prescribing practice was as advised in Mersey Care's EUPD guidelines.

78% of the 50 patients were prescribed as required (PRN) psychotropic medication. In 21 patients, PRN medication was prescribed for longer than one week.

There is a higher rate of prescribing of antipsychotic prescription in those EUPD patients with no psychiatric comorbidities compared to associated psychiatric comorbidities (72% vs 60%). Surprisingly, there was a lower rate of psychotropic polypharmacy in those with psychiatric comorbidities.

Use of PRN psychotropic medication for longer than a week was higher in those patients with psychiatric comorbidities compared to those without psychiatric comorbidities (58% vs 50%). Benzodiazepines were overwhelmingly the most consistently prescribed PRN medication for patients with EUPD.

One action to consider would be highlighting the importance of trialling psychologically-minded interventions and supportive psychotherapy prior to initiation of psychotropic medication. There also needs to be consideration to use of the sedative antihistamine promethazine as a first-line PRN medication for acute agitation.

Delirium is a common medical problem with a prevalence of over 50% in over 65s admitted to general hospitals (1,2) . Delirium is linked with poor clinical outcome, including increased risk of falls, prolonged admissions and an overall increased risk of morbidity and mortality (2,3,4). Delirium in older adults is also associated with an increased rate of cognitive decline, future risk of cognitive decline and a risk of depression (5,6,7). There is potential to improve clinical practice by improving assessment and management of delirium. It is imperative that where delirium is detected, it should be clearly documented to aid handover to primary care providers and medical teams (8,9).

The standard for this audit was set according to SIGN 157 (9). Data were collected retrospectively from consults sent to a liaison psychiatry of old age service within an acute hospital setting. The medical discharge summaries from July to December 2019 were reviewed. Two key data points were collated, the diagnoses of delirium by either medical or liaison psychiatry team and the inclusion of this diagnosis in the patient discharge summaries. An updated delirium protocol was devised and introduced in the hospital setting in January 2020 to include tools for effective diagnosis of delirium and instruction to include this diagnosis if made in patient's discharge summaries. Re-audit was initiated following the introduction of the updated delirium protocol for the period of January to March 2020.

A total of 116 patients were assessed from July to December 2019. 102 discharge summaries were available for review for the purpose of this audit. Prior to the introduction of the updated delirium protocol, delirium was diagnosed by the liaison team in 57% of all referrals. Delirium was underdiagnosed by medical teams in 73% of those subsequently diagnosed. The diagnosis of delirium was present in 42% of all discharge summaries to primary care providers. Subsequent to the introduction of the updated protocol, delirium was diagnosed in 48% of all liaison referrals during the time period specified. The proportion of under-diagnosis of delirium by medical teams stayed at 73%, the diagnosis of delirium was present in 53% of discharge summaries.

The recognition and diagnosis of delirium in the general medical setting continues to be a key issue in the management of older adults. The importance of this diagnosis and it's associated after effects needs to be disseminated amongst all care providers. Greater efforts to enhance these aspects of delirium management in the acute hospital setting are required.

Our aim was to identify current practice for Lithium monitoring for >65s in NHS GGC and assess compliance to local Lithium monitoring guidelines.

A retrospective analysis was undertaken of patient data (demographics, diagnosis, biochemistry results) with Caldicott approval at two points over the course of 2018/19. For the first analysis, old age Community Mental Health Teams (CMHTs) were approached and asked to provide a list of their patients on Lithium. This was then assessed for compliance to Lithium monitoring guidelines.

For the second analysis, pharmacy provided data for every patient in the health board dispensed lithium, regardless of whether they were open to a CMHT or not. We were then able to identify patients who we had not picked up on our initial analysis, and re-assess the entire data set for compliance to Lithium monitoring guidelines.

From our first analysis, 13 CMHTs identified 155 patients on Lithium. There was a high variability in how these patients were identified. 44% of patients were monitored by CMHTs who took bloods and chased them, 38% were monitored by GPs who were prompted by CMHTs in routine clinic letters, and 14% were monitored by GPs who were prompted by CMHTs more assertively using a lithium register. Overall, Lithium plasma monitoring was done well irrespective of method (91%), however compliance to the local standards was poor (58%) with proactive CMHT prompting GPs appearing to be the most effective method (71%).

In our second analysis, we identified 508 patients >65 in NHS GGC prescribed Lithium. Of those, 44% were open to old age psychiatry, 25% general adult psychiatry and 19% were not open to anyone. Of those open to old age services, only 58% had been identified in the previous audit. Lithium monitoring compliance was better in those open to a CMHT versus those not (61% to 23%), and better in CMHTs where monitoring was done by CMHTs rather than GPs. For each CMHT, there were roughly 7 patients per catchment area on Lithium not open to psychiatry.

Lithium monitoring does appear to be highly variable and not particularly compliant with local standards. CMHTs have inconsistent methods of identifying patients prescribed Lithium. There are a significant number of patients not open to old age CMHTs prescribed Lithium, and these patients have poorer compliance to Lithium monitoring. Of patients open to CMHTs, CMHT-led monitoring appears superior to other forms.

Doctors’ mental health is a national concern – the General Medical Council, British Medical Association and Health Education England pledge to improve their well-being. Well-being has no common definition, instead pathogenic measures such as burnout are published as a demonstration of doctors’ wellbeing. Yet, the relationship between burnout and wel-being has not been explored.

to investigate the relationship between burnout and well-being.

they are negatively associated, but not opposites.

An online cross-sectional national survey was distributed to doctors of all grades and specialties via the Royal Colleges and doctor organisations. The Oldenburg Burnout Inventory (OLBI) measured burnout, and the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) measured well-being. Correlation coefficients between total scores of these measures estimated the relationship. Additionally, semi-structured interviews explored personal definitions of wellbeing and its relationship with burnout. Thematic analysis was carried out.

64 doctors completed the OLBI and WEMWBS. Comparing the total scores for the questionnaires with Spearman's rho indicates a moderate negative correlation (rs= –0.658, p = 0.00, n = 64). Total scores were made into binary variables, a Chi-square test showed that a low WEMWBS score (<40) and a very high risk OLBI score (≥2.85 exhaustion and ≥2.6 disengagement) were statistically significantly associated (X 2 (1, N = 64) = 4.232, p = 0.04). Three themes emerged from the 10 interviews conducted: the importance of networks/relationships outside work; scepticism towards the proposal of an NHS wellbeing check-in; and how participants do not strive to improve their wellbeing until its decline.

This research demonstrates that wellbeing and burnout have only a moderate negative correlation when using commonly employed measurement tools. Therefore, measures of burnout are not a surrogate for wellbeing. Further research could adopt a salutogenic approach by using the WEMWBS to monitor doctors’ wellbeing and could explore interventions to increase well-being, rather than waiting for its decline.

Social isolation and living alone have been associated with increased suicidality in older adults. During the SARS-CoV-2 pandemic, older adults were advised to keep isolated and maintain social distancing. Lockdown periods in England may have led to increased isolation and loneliness in older people, possibly resulting in an increased rates of DSH and suicide. This study aimed to explore whether numbers of older adults referred to liaison services with deliberate self harm changed during the SARS-CoV-2 pandemic.

Reason for referral and total number of referrals to liaison services for older adults data were collected across 6 mental health trusts who had access to robust data sets. Data were collected prospectively for three months from the start of the UK national lockdown and for the corresponding 3 month period in 2019, via trust reporting systems. This study was registered as service evaluation within each of the participating mental health trusts.

Overall numbers of referrals to older adult liaison services went down, but the proportion of referrals for older adults with DSH increased. Across the six mental health trusts there there were a total of 2167 referrals over the first three month lockdown period in 2020, and 170 (7.84%) of these referrals were for deliberate self harm. During a corresponding time period in 2019, there were a total of 3416 referrals and 155 (4.54%) of these referrals were for deliberate self harm

Although numbers of referrals for older adults with delberate self harm appeared to stay the same, the severity of these presentations is not clear. Outcomes of referrals and severity of self harm could be explored by examining individual case records. As there have been subsequent lockdowns the data collection period should also be extended to include these. Triangulation with national and local datasets on completed suicide is planned.

The dementia register is designed to keep a record of all patients diagnosed with mild cognitive impairment (MCI) or dementia. Following diagnosis, a ‘notification of diagnosis’ form should be completed and the patient added to the register. The register is used to collate figures and to assess capacity and demand on services.

Our baseline audit revealed suboptimal completion of these forms, therefore we initiated a quality improvement project. Our aim was to achieve completion of the ‘notification of diagnosis’ forms in 50% of new memory patients seen in clinic and diagnosed with MCI or dementia, within 3 months.

A baseline audit of a random sample of 52 patients, from the 380 patients on the memory clinic list was analysed. 40 of these 52 patients had a diagnosis of MCI or dementia and when cross-matched with the dementia register, only 12 (30%) of the 40 were on the register.

We designed an improvement project which focused on improving awareness of the process and facilitating ease of completion of the form, for example, by placing the form in all new patients’ notes. Our results were then monitored and reviewed on a monthly basis for 3 months, to assess the impact of these changes.

Each month, the percentage completion of the 'notification of diagnosis' forms was calculated for new memory patients diagnosed with MCI or dementia in clinic. In the first month of the project (November 2020), 75% completion of forms was achieved. This was a significant improvement from baseline. In December, 66.7% completion was achieved (plus one patient was already on the register) and in January 2021, there was 50% completion (plus one patient was already on the register).

The results showed an improvement in the completion of forms from baseline, and we did reach the initial aim set at 50% by 3 months. However, the trend of the results showed a steady decline in percentage completion of forms over the 3 month period. We noted that over time the forms were no longer consistently placed in the new patients’ notes, reducing accessibility to the forms. Other potential factors include a reduction in enthusiasm/ a decline in prioritisation of this project over time. Suggestions have been made to facilitate ongoing improvement and the results will continue to be reviewed.

Staff mental health is a major determinant of a well-functioning health system that has become ever more important during the COVID-19 pandemic. Poor mental health is the most common reason for NHS staff sickness absences, usually accounting for 25% of all reported sick leave. At a time when the NHS most needs an available and efficient workforce, government and NHS employers lack the necessary evidence to inform decisions about how best to support the mental health needs of its staff. In this report, we share our experience and the initial figures from a newly developed multidisciplinary assessment and treatment service for NHS staff.

The Staff Mental Health Service (SMHS) at the Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) launched in September 2020. The SMHS is commissioned by the Cambridgeshire and Peterborough sustainability and transformation partnership and is accessible to the 25,513 staff based at five NHS trusts within the region. The service received 235 referrals within 5 months of the launch. All patients had a first clinical contact within three working days and more than 80% had their initial assessment within two weeks. The SMHS clinical team is comprised of consultant psychiatrists, senior clinical psychologists, specialist mental health nurses, and an occupational health nurse set to provide rapid access, confidential, evidence-based treatments for the NHS staff. As part of service evaluation within CPFT, we collected routine screening data (Patient Health Questionnaire-9 (PHQ-9), Generalised Anxiety Disorder-7 (GAD-7), and Posttraumatic Symptom Check List – 6 (PCL-6)) from patients completing the initial assessment (n = 130).

According to the initial figures (n = 130) from a diverse group of healthcare staff, on average the patients presented with moderate level of depressive symptoms (PHQ-9: 16.22 ± 5.94). Anxiety levels were in moderate to severe range (GAD-7: 13.45 ± 4.70). Average score of PCL-6 checklist for traumatic stress symptoms was higher than the established cut-off (>14): 19.43 ± 5.65.

The Staff Mental Health Service offers an innovative, multi-disciplinary rapid assessment and treatment clinic for NHS staff. The demand for the service has been immense, reaching double the number of predicted referrals. Initial data suggested high rates of moderate to severe depression, anxiety, and traumatic stress symptoms in healthcare workers. Our clinical observations was that many healthcare workers have had longstanding significant mental health conditions that saw deterioration during the COVID-19 pandemic. We hope that our experience in the SMHS will help inform models across the UK to address the clear unmet need for staff mental health.

To assess the profile of Sleep pattern, Psychiatric comorbidity and problematic electronic gadget use and explore demographic factors and correlations in children and adolescents with ADHD and Autism.

Hypothesis: There are statistically significant problems and associations across sleep pattern, psychiatric comorbidity and gadget use in children and adolescents with autism and ADHD.

Literature highlights increasing global trends and emerging concerns over the problematic use of electronic gadgets and sleep related problems in children and adolescents with autism and ADHD. There is sparse literature on the profile of sleep patterns, psychiatry comorbidity and problematic gadget use in children and adolescents with autism and ADHD from developing countries.

This was an observational study conducted at the Child and Adolescent Psychiatry Clinic, Department of Psychiatry at a tertiary care Institution under the STS ICMR Project 2019 with Institutional Ethics Clearance. Apriori Sample size calculated was 70. Children and adolescents diagnosed with autism or ADHD as per ICD 10 criteria, fulfilling the inclusion criteria and willing to participate in the study were included. Informed consent was obtained from caregivers. Sleep Disturbance Scale for Children, Self Designed Parent based Problematic Electronic Gadget Use Scale, Vanderbilt ADHD scale, Indian scale for Assessment of Autism and the Child and Adolescent Psychiatry Clinic structured Performa were the tools for data collection. The results were analyzed with descriptive tests, chi square test and multiple logistic regressions using SPSS.

Mean age of the sample was 9.1 years and majority (57%) were boys. Forty nine patients had ADHD and 21 patients had Autism. Problematic gadget use was higher in children ranging from 6 to 15 years of age and 12.8% had severe levels of problematic gadget use. 34.3% patients experienced severe problems in initiating and maintaining sleep. Oppositional-Defiant disorder was the most common comorbidity, predominantly inattentive type (76.4%) was the most common subtype of ADHD and mild autism (54.3%) was the most common type of autism in the sample. There were statistically significant associations (p < 0.05) between age and gadget use; hyperactive subtype of ADHD and problems with initiating and maintaining sleep and ADHD subtype, sex profile and problematic gadget use.

We conclude that sleep problems, psychiatric comorbidity and problematic gadget use are prevalent with statistically significant associations in children and adolescents with autism and ADHD as per our study findings. Our study has relevant clinical, research and policy implications.

To identify whether staff from the PATH Early Intervention in Psychosis (EIP) Service routinely ask female service users of child bearing age about their plans for pregnancy, whether risks of medication in pregnancy are routinely discussed and whether contraception is routinely discussed.

In May 2019, a report was run capturing all female PATH service users of child bearing age (16-50 years) who were on the pathway at this time. This totalled 177 service users, all of whom were included in the sample. We used the search terms “pregnant”, “pregnancy”, “having children”, “contraception”, “conceive”, “baby”, “conception”, “miscarriage”, “abortion”, “IVF”, “still born” to interrogate the patient records . Auditors searched case notes, clinic letters, recent physical health assessment and recent wellbeing plan for evidence as to whether staff had asked about pregnancy plans, contraception, offered a referral to the Community Perinatal Team, and discussed risks about medication in pregnancy.

Of the 177 service users, 34 were asked whether they had plans for pregnancy (19%). Of the 177 service users, 28 were given advice regarding contraception (16%). Of the 34 service users who were asked about pregnancy plans, 27 did have plans for pregnancy. Of these 27 service users, 15 were offered a referral to the Community Perinatal Team (56%). Of the 27 service users who did have plans for pregnancy, 12 received advice and or information about risks of antipsychotic medication in pregnancy (44%).

It is clear that PATH staff are not routinely having discussions with female service users of child bearing age about their plans for pregnancy or contraception; this audit has identified that this occurs in less than 20% of cases. Of service users that did have plans for pregnancy, only 56% were offered a referral to the Community Perinatal Team; we should strive for this to be 100% so service users can access specialist support and advice. Work is underway to include information on pregnancy in the PATH service information leaflet to ensure women referred to PATH expect staff to ask them about their plans for pregnancy and contraception. Questions about pregnancy planning and contraception are to be embedded in the Trust's Physical Health Assessment care document to act as a prompt for staff. Finally, the topics of pregnancy and contraception in women with psychosis have been incorporated into the PATH physical health training programme which will be delivered with support from the Community Perinatal Team.

With an overarching aim of decreasing the incidence of non-attendance in psychiatric outpatient clinics, this service evaluation was intended to explore the profile of non-attenders. Specifically, the clinical, risk and demographic features of patients who did not attend their psychiatric outpatient appointments were compared with those of attenders. The outcome of patients who did not attend was also studied.

All the consecutive non-attenders (n = 32) in November 2020 in a psychiatric outpatient clinic were compared with 32 consecutive attenders. The groups were compared based on clinical features (diagnosis, medical treatment, psychological treatment, care programme approach, first contact), risk profile (self or others) and demographic features (age, gender, ethnicity, accommodation, occupation, benefits). The non-attender sample was also analysed to consider the outcome after their missed appointment, following local Trust protocols.

The overall rate of patients who did not attend their appointment was 22%. There was a statistically significant difference between the age and gender of non-attenders. Males were less likely to attend their appointment than females (p = 0.024). The mean age of patients who did not attend their appointment was 36.4 compared with 44.8 years in the attenders (p = 0.005). There were a few clinically relevant findings. Around one third (34%) of patients who did not attend their appointments had a history of risk of self-harm noted in previous appointments. The results also showed that 75% of individuals who did not attend their outpatient appointments were unemployed. There were no significant differences based on the type of treatments (depot injections, lithium, clozapine, antipsychotics or antidepressants) patients received. Patients who did not attend were more likely to have a mood disorder (59% compared with 40%), and less likely to have a psychotic disorder (25% compared with 44%). Of the patients who did not attend, all were appropriately contacted as per the local Trust guidelines via a letter, and were provided with appointments where appropriate; 34% of non-attenders were discharged from services.

Non-attendance at psychiatric outpatient appointments is a concern, particularly for younger and male patients. Considering the clinical risks associated with this patient population, efforts need to be taken to improve their engagement with mental health services. Future studies may explore patients’ perspectives of non-attendance and how to ameliorate any hindrances to attending.

We wanted to discover the time delay between the initial assessment of service users referred to a Community Mental Health Team (CMHT) and suspicion that they had an Autistic Spectrum Disorder (ASD). We wanted to know whether early use of a screening questionnaire could significantly reduce this delay.

About 1% of the UK population have ASD and the rate is higher among service users within CMHTs. Although CMHT staff are trained to recognize service users with ASD, often the diagnosis is only suspected when service users do not make progress with standard treatment. Early recognition of ASD informs a treatment pathway individualised for people with ASD. Brief screening instruments for ASD can help clinicians decide whether to refer someone for a full diagnostic assessment. The fifty question Autism Questionnaire (AQ50) and ten question Autism Questionnaire (AQ10) both perform well as a screen for ASD.

All referrals from two adult CMHTs to a specialist Wiltshire Autism Diagnostic service (WADS) over a 2.5 year period were ascertained from a referral database. 24 service users referred from the CMHTs were identified. We determined from their records: (A) overall time between initial CMHT appointment and referral to WADS, (B) time between initial CMHT appointment and screening test (when used), (C) time between screening test and referral to WADS.

For all 24 cases, the average time between initial CMHT appointment and referral to WADS was 186 days. 18 of the 24 service users completed a screening questionnaire prior to WADS referral (AQ10 or AQ50 or both); 16 of these had positive screening tests. The average time between initial CMHT appointment and use of screening test was 164 days. The average time between screening test use and referral to WADS was 32 days.

Our results demonstrated the average time taken from CMHT staff first seeing a patient to suspecting ASD and referring to a specialist diagnostic team was about 6 months. However, after a screening questionnaire had taken place, the time to referral was only around one month. We propose that screening is considered at an earlier opportunity; ideally during (or prior to) the first appointment with the CMHT in order to reduce the time before a referral to a specialist diagnostic team is made. This would enable treatment in a care pathway which incorporates the diagnosis of ASD at an earlier stage.

Psychosis is a major mental illness with first onset in young adults. The prognosis is poor in around half of the people affected, and difficult to predict. The few tools available to predict prognosis have major weaknesses which limit their use in clinical practice. We aimed to develop and validate a risk prediction model of symptom non-remission in first-episode psychosis.

Our development cohort consisted of 1027 patients with first-episode psychosis recruited between 2005 to 2010 from 14 early intervention services across the National Health Service in England. Our validation cohort consisted of 399 patients with first-episode psychosis recruited between 2006 to 2009 from a further 11 English early intervention services. The one-year non-remission rate was 52% and 54% in the development and validation cohorts, respectively. Multivariable logistic regression was used to develop a risk prediction model for non-remission, which was externally validated.

The prediction model showed good discrimination (C-statistic of 0.74 (0.72, 0.76) and adequate calibration with intercept alpha of 0.13 (0.03, 0.23) and slope beta of 0.99 (0.87, 1.12). Our model improved the net-benefit by 16% at a risk threshold of 50%, equivalent to 16 more detected non-remitted first-episode psychosis individuals per 100 without incorrectly classifying remitted cases.

Once prospectively validated, our first episode psychosis prediction model could help identify patients at increased risk of non-remission at initial clinical contact.