To develop a responsive and sustainable template for long-term course evaluation for PsychED Up

To obtain rich, meaningful and specific feedback across multiple domains which can be translated into course improvements

To work collaboratively with students interested in medical education having previously participated in the course

To empower current students with the knowledge that their input is valuable

PsychED Up is an innovative extra-curricular course for 3rd year medical students at King's College London delivered by psychiatry trainees, senior students and actors. It is in its second year of running and focuses on the hidden curriculum in medicine, exploration of holistic care and communication skills at the mind-body interface. Input from people with lived experience is used to shape teaching.

Embedded evaluation in course development sessions thus engaging the entire faculty in evaluation processes at the start of the new term

• Decided evaluation focus

• Face-to-face discussions

• Survey for faculty to determine what specific feedback content would be most useful

• Finalised the questionnaire

• Collaborative design and refinement of questions, confirmed sub-sections and scope of questionnaire

Revised questionnaire:

• Included rationale at the start

• Tailored questions so faculty have more useful responses

• Greater quantity of prompted questions

• Specific questions for large group presentation, small group teaching, actors’ performances and students’ reflections

• Thoughtful combination of quantitative ratings and open-space questions

• Reduced time between course sessions and obtainment of feedback

• Quality and quantity of feedback

• High response rates: 32/30 (2 duplicates) mid-term, 29/30 end-of-term

• High-quality filling of open-space feedback allowed consolidation of themes to improve the course

Co-designing the feedback form with previous students from the course and faculty brought focus to the questions. They were more specific and were organised into sub-sections for different domains. This led to responses that were relevant, enriched with depth and breadth and provided faculty with richer, more personalised responses. More detailed reflections in feedback were thought to be due to better student understanding of the rationale for questions, and knowledge that their input would help improve the course. We have set up a robust system for collecting long-term feedback for PsychED Up. We will continue to make iterative amendments, and supplement questionnaire feedback with focus groups.

Excess hypothalamic-pituitary-adrenal (HPA) axis activation is common in people with major depression and generalised anxiety disorder. We sought to determine whether higher circulating levels of the glucocorticoid cortisol are causally related to the expression of anhedonia-like and anxiety-like behaviours in marmosets.

Four marmosets (two male, two female) took part in the study. Cortisol and saline control injections were administered intramuscularly and salivary cortisol samples were taken before and after injections to determine if circulating cortisol levels changed from pre- to post-injection. To measure anhedonia-like behaviours, we trained marmosets on an appetitive Pavlovian conditioning paradigm, where animals learn to associate two anticipatory auditory cues (conditioned stimulus + or conditioned sitmulus -, CS+ or CS-) with the presence or absence of food reward (unconditioned stimulus + or unconditioned stimulus -, US+ or US-). Using cardiovascular telemetry probes and video cameras, we recorded animals' cardiovascular and behavioural arousal in freely moving conditions, comparing the injection of saline control versus 5mg/kg, 10mg/kg or 20mg/kg intramuscular cortisol. To measure anxiety-like behaviours, we used a human intruder (HI) paradigm, where marmosets are confronted with an unfamiliar human in their home cage. We recorded their behaviour on video cameras after saline control or 20mg/kg intramuscular cortisol. We used an exploratory-factor analysis (EFA) to determine how marmosets' behaviours towards the intruder loaded onto an 'anxiety-like' score. We then compared these scores under saline control versus cortisol conditions. Significance was set at p < 0.05.

Unlike saline control, we found that subcutaneous injections of 20 mg/kg cortisol successfully elevated peripheral cortisol concentrations to levels equivalent to peak circadian concentrations (p = 0.023). In the appetitive setting, 5 mg/kg, 10 mg/kg and 20 mg/kg cortisol injections blunted anticipatory (CS+ induced) increases in behavioural arousal (p = 0.004) but did not alter anticipatory cardiovascular arousal. Consummatory behavioural and cardiovascular arousal also remained intact. In the HI test, 20 mg/kg cortisol injections moderately increased anxiety towards the intruder as measured by an increase in marmosets' EFA-derived anxiety-like scores (p = 0.035).

In marmosets, elevated peripheral cortisol levels are causally related to the behavioural features of blunted reward anticipation together with elevated anxiety-like behaviours characteristic of mood and anxiety disorders. Future work will characterise the neuroimaging changes induced by elevated peripheral cortisol levels and identify the regions of the prefrontal cortex contributing to HPA axis regulation and dysregulation.

To examine the therapeutic efficacy and effectiveness of cognitive behavior therapy and pharmacotherapy in the treatment of Major Captagon (Fenethylline) Dependence.

A 41 outpatients males selected for the study, diagnosed as they are suffering from Captagon Dependence according to the DSM-5, with mean age 34.58 ± 5.11. The sample was divided into three experimental groups, (A) (N = 14) treated by cognitive behavior therapy (CBT) and pharmacotherapy in combination. (B) (N = 13) treated by CBT alone. (C) (N = 14) treated by pharmacotherapy alone. All groups were assigned to four measurements, one for the baseline before any treatment interventions, one post-treatment evaluation and two for follow-up within a short and long time. Non-parametric statistics were used to analyze the data collected by SPSS.

There is no significant intra-group differences were found in terms of baseline assessment. There was no significant discrepancy between the first and the second group except in the term of reducing Captagon craving, as it was clearer in the first group in comparison with other groups. There was a clear significant discrepancy between the first and third groups, for all the study variables and it is phases of assessment especially follow-up. There was a clear degree of differences among the second and the third group, through the different phases of post-assessment, which refers to the great efficacy and effectiveness of CBT in Treating Captagon Dependence CBT was proved to be more effective than pharmacotherapy in the treatment of Captagon Dependence. The combination of CBT and pharmacotherapy was more effective than each other alone in the treatment of Captagon Dependence and Relapse Prevention.

Available evidence suggests that cognitive–behavioral therapy is an effective intervention method for psychological aspects of automatic thoughts, depression, negative health beliefs, craving, and relapse prevention, although its efficacy in reducing Captagon (Fenethylline) dependence.

The pharmacological management of women with bipolar disorder in the perinatal period is challenging. This population has a high recurrence rate, but some medications can be a concern in pregnancy and breastfeeding. Little is known about prescribing practices in perinatal services, and the impact of medication on recurrence rates.

The aims of this study are: 1) to describe the use of medication in women with bipolar disorder in the perinatal period and 2) to evaluate the impact of medication on the rate of postpartum recurrence.

Clinical data were collected from pregnant women with a diagnosis of bipolar disorder in the nine participating centres in the UK and who were not experiencing an episode of illness entering the postpartum period. Using a proforma, data were collected for the period between conception and three months postpartum: sociodemographic, reproductive, the severity of illness, medication and recurrence.

Data were analysed for association using χ2 tests and logistic regression.

In this sample of 167 women, 91 (55%) were taking medication at delivery: 62 (37%) antipsychotics, 41 (25%) antidepressants, and 25 (15%) mood stabilisers. In 12 cases medication was reduced before delivery. Of those who were taking medication at delivery six decreased of stopped after delivery and one increased the dose. 42% of women in this sample experienced a recurrence, with 30% of the sample experiencing a manic/psychotic episode. There was no significant association between taking medication and recurrence χ 2(1) = 0.07, p = 0.79. There continued to be no association in a multivariable analysis when adjusted for parity, severity (previous admissions, age at first treatment, bipolar subtype), type of medication during pregnancy and immediate postpartum changes aOR 0.33 95%CI [0.03; 3.40], p = 0.35.

A high number of women with bipolar disorder are taking medication before delivery and in the majority, antipsychotics are prescribed. The postnatal recurrence rate in both medicated and unmedicated women is high. These results are in line with existing literature. Further work is needed in larger samples to provide clinical guidance for women and their clinicians.

Depression is the single largest contributor to global disability. However, effective treatments are currently lacking, resulting in a significant burden of treatment-resistant depression (TRD). Psilocybin, a serotonergic psychedelic, found as the active compound in 'magic mushrooms', has been proposed as a novel therapeutic avenue for TRD. We aimed to evaluate the future feasibility and implications of psilocybin as a new antidepressant therapy.

We reviewed and critically analysed the available literature on the efficacy and safety of psilocybin as a treatment for depression, and the potential pharmacological and psychological mechanisms of the therapeutic benefit. We discussed the relative contributions to this therapeutic effect of the pharmacological drug treatment, placebo effects, and the context and parameters of the psychotherapeutic experience. We reviewed legal, social, and economic barriers to primary research and clinical implementation.

Psilocybin in combination with psychotherapy has been shown to be safe and effective in TRD. Its mechanism of action in TRD has not been fully elucidated, however reviewing functional neuroimaging studies demonstrated disparate short and long-term modifications of default mode network connectivity, suggested to represent a ‘reset’ mechanism of acute modular disintegration and subsequent reintegration which restores normal function, reviving emotional responsiveness.

Research suggests psychedelic treatment induces lasting personality, belief and attitude changes. The psychedelic drug itself, the context of the psychotherapeutic experience, and the post-drug integration therapy all appear to have a significant role. Preparation prior to treatment, the environment, context and support during the psychedelic experience itself, and the following long-term integration and support process must be considered.

Despite novel findings Psilocybin is a Schedule I drug; this imposes a persisting ethical barrier to clinical use. Prohibition of psilocybin results in high costs of drug supply, and potential for harmful drug-seeking behaviours. Therefore, complex socio-political factors currently limit wider implementation.

Psilocybin in combination with psychotherapy is safe and effective in TRD. The interacting and elusive therapeutic mechanisms have implications for clinical implementation. Preparation prior to treatment, the physical and social environment in which the psychedelic experience takes place, and long-term integration and support are considered to play a significant role. Optimisation of these parameters and cost-benefit analyses are required prior to this being feasible as a widely available therapy. Systemic legislative, political and social change will also be key to enable widespread clinical use. The promise of this therapy on a background of inadequate current antidepressant treatments indicates these must be a priority.

Pharmacological management of Obsessive-Compulsive Disorder (OCD) presents a challenge in modern psychiatry. While most patients respond preferably to serotonin re-uptake inhibitors (SRI), the response is usually delayed by several weeks leading to an insufficient short term management of anxiety. It is also frequently inadequate and needs higher doses and augmentation in many instances. Investigating newer pharmacological strategies to address such treatment gaps has always been of interest. Buspirone is a novel anxiolytic medication with additional weak antidepressant and poor anti-psychotic effects. It is the only medication in its category, i.e. azapriones. It has comparable anti-anxiety efficacy to that of benzodiazepines without their sedating or habit forming effects, and has been demonstrated to moderate serotonin and other monoamine neurotransmission with a favourable safety profile.

We reviewed the literature pertaining to the use of Buspirone in OCD for both as a primary anti-obsessive agent and for a potential secondary role in management of chronic anxiety and/or anxiety disorders comorbid to OCD.

The results of a number of case reports and open trials have been positive while controlled trials have shown contradictory results. In a double blind RCT comparing clomipramine and buspirone, significant improvement was found in both groups with no differences between the two. Further two trials observing buspirone augmentation of clomipramine and fluoxetine treatment respectively, in a double-blind placebo controlled design reported significant improvement in the treatment as opposed to the placebo arm. Another double-blind placebo controlled study of buspirone augmentation of fluvoxamine resistant patients did not show significant benefits as an anti-obsessional agent, but notable anxiolytic effects were reported. In all the trials buspirone was largely well tolerated and did not pose any significant interactions with other psychotropic agents or dependence potential.

Buspirone is a pharmacologically unique agent with a good safety profile. Given the robust anxiolytic effects of this Peron along with complex neurotransmission modulatory effects coupled with a favourable tolerance and dependents profile might make buspirone an attractive novel pharmacological agent for augmentation in OCD . Further controlled studies to better establish effectiveness and deciphering if certain patients may respond to its use over others, are warranted

To examine the factors that relate to antipsychotic prescribing in general practices across England and how these relate to cost changes in recent years.

Antipsychotic medications are the first-line pharmacological intervention for severe mental illnesses(SMI) such as schizophrenia and other psychoses, while also being used to relieve distress and treat neuropsychiatric symptoms in dementia.

Since 2014 many antipsychotic agents have moved to generic provision. In 2017_18 supplies of certain generic agents were affected by substantial price increases.

The study examined over time the prescribing volume and prices paid for antipsychotic medication by agent in primary care and considered if price change affected agent selection by prescribers.

The NHS in England/Wales publishes each month the prescribing in general practice by BNF code. This was aggregated for the year 2018_19 using Defined Daily doses (DDD) as published by the World Health Organisation Annual Therapeutic Classification (WHO/ATC) and analysed by delivery method and dose level. Cost of each agent year-on-year was determined.

Monthly prescribing in primary care was consolidated over 5 years (2013-2018) and DDD amount from WHO/ATC for each agent was used to convert the amount to total DDD/practice.

Description

In 2018_19 there were 10,360,865 prescriptions containing 136 million DDD with costs of £110 million at an average cost of £0.81/DDD issued in primary care. We included 5,750 GP Practices with practice population >3000 and with >30 people on their SMI register.

Effect of price

In 2017_18 there was a sharp increase in overall prices and they had not reduced to expected levels by the end of the 2018_19 evaluation year. There was a gradual increase in antipsychotic prescribing over 2013-2019 which was not perturbed by the increase in drug price in 2017/18.

Regression

Demographic factors

The strongest positive relation to increased prescribing of antipsychotics came from higher social disadvantage, higher population density(urban), and comorbidities e.g. chronic obstructive pulmonary disease(COPD). Higher %younger and %older populations, northerliness and non-white (Black and Minority Ethnic (BME)) ethnicity were all independently associated with less antipsychotic prescribing.

Prescribing Factors

Higher DDD/general practice population was linked with higher %injectable, higher %liquid, higher doses/prescription and higher %zuclopenthixol. Less DDD/population was linked with general practices using higher %risperidone and higher spending/dose of antipsychotic.

Higher levels of antipsychotic prescribing are driven by social factors/comorbidities. The link with depot medication prescriptions, alludes to the way that antipsychotics can induce receptor supersensitivity with consequent dose escalation.

Paliperidone palmitate long-acting injectable (PPLAI) initially requires two loading doses of 150 and 100 mg on days 1 and 8 (± 4 days) intramuscularly. In clinical practice, different PPLAI initiation patterns have been observed. The aim of this study is to describe different PPLAI onset patterns in hospitalised patients diagnosed with schizophrenia.

A naturalistic, transversal, retrospective, descriptive study was carried out. Patients were recruited in the adult inpatient unit of Hospital Universitario Jiménez Díaz (Madrid, Spain) from November 2012 to February 2021. During this period, a total of 357 patients were treated with PPLAI, 172 of them were diagnosed with schizophrenia and, among these, 24 received an atypical onset pattern during hospitalization. Different PPLAI onset patterns, PPLAI dose at discharge and number of days hospitalised were analysed. This study followed the Declaration of Helsinki principles and was approved by the Local Ethics Committee. All participants gave written informed consent.

The sample presents 24 patients (17 men, 7 women) that represents 6.72% of a global sample, with an average age of 40.21 years (men 35.59 years vs. women 51.43 years). In this study, different PPLAI onset patterns were described: those receiving 150-150 mg represent 25% of the sample (n = 6), as do those receiving 100-75 mg, also representing 25% of the sample (n = 6). The rest of the onset patterns were: 150-75 mg (20.83%, n = 5), 100-100 mg (12.5%, n = 3), 150-75 mg (4.16%, n = 1), 100-50 mg (4.16%, n = 1), 75-100 mg (4.16%, n = 1), and 75-75 mg (4.16%, n = 1). The average hospital stay is 17.88 days. The PPLAI maintenance dose at discharge was 104.17 mg/month. The group of patients who received two doses of 150 mg (150-150 mg) had an average length of stay of 27.67 days compared to the rest of the patients who had an average length of stay of 15.12 days, this difference being statistically significant (p = 0.010). The 150-150 mg group was discharged with a mean maintenance dose of 141.67 mg versus the other patients who needed a mean maintenance dose of 91.18 mg, which was also statistically significant (p = 0.001).

The most used pattern of atypical onset of PPLAI in this sample is 150-150 mg and 100-75 mg. Patients treated with 150-150 mg loading pattern are hospitalized for a longer period and needed higher maintenance dose at discharge. Further studies are needed.

A variety of pharmacotherapies have been used to assist the psychotherapy process as “adjunctive therapies.” These drugs are used in an acute, targeted fashion, such that they are explicitly delivered in the context of psychotherapy for anxiety, mood and substance-dependence disorders (SUDs). Our narrative review highlights the potential of medically-assisted psychotherapy by outlining the current state of research on few of these medications and describing the basic science that supports their use.

Firstly, we researched an assortment of medications that have been used off-label to enhance psychotherapy, and selected a few that have received the most empirical attention in preclinical and clinical-trial settings. Our review of clinical trials focused on three of the most common psychiatric ailments. For all studies reviewed, we identify the strengths and weaknesses of the data supporting the use of the medications for the three aforementioned disorders.

D-cycloserine: accelerates the process of associative emotional learning, enhancing exposure therapy in the treatment of various anxiety disorders, including obsessive-compulsive disorder and posttraumatic stress disorder. Limited studies are available on efficacy in treating SUDs.

Intranasal oxytocin: accelerates memory retrieval-extinction procedures used in posttraumatic stress disorder, and promotes prosocial cognition and behaviour, facilitating a therapeutic alliance. Sufficiently powered studies and safety studies are required before strong conclusions can be made.

Propranolol: interrupts the reconsolidation of memories (leading to maladaptive learned responses) involved in posttraumatic stress disorder during memory-reactivation therapy sessions, but there is little evidence that this drug can be used for depression or SUDs.

Psychedelics: may effect the brain's default mode network, engendering a transformative experience that is often followed by a reduction in psychiatric symptoms. 3,4-methylenedioxymethamphetamine may additionally modulate the amygdala response in a way that allows for reprocessing of traumatic memories, and improves the therapeutic alliance. Anxiety, mood, and SUDs appear to be positively influence by traditional and non-traditional (ketamine) psychedelics.

Although the efficacy of the medically-assisted psychotherapies reviewed is still under investigation, we propose that these novel treatment approaches may be preferred over traditional psychopharmacological treatments due to the presence of fewer chronic side effects, as well less toxicity and abuse potential. Furthermore, these adjunctive pharmacotherapies may help to reinforce the psychotherapeutic alliance and may ultimately yield better long-term treatment outcomes. If at least some of the adjunctive pharmacotherapies outlined in this review are found to be clinically efficacious and safe, patients will benefit from having more treatment options available to them in the future.

Schizophrenia is a serious developmental psychiatric disorder with a neurodegenerative component that causes marked deterioration in social relationships and ability to work. Present treatments are not satisfactory. Meta-analysis of placebo-controlled studies in acute schizophrenia shows that only a minority of patients have a good response to current antipsychotic medications. Therefore, there is a need for more effective psychopharmacologic treatments for this disorder.

The purpose of this paper is to provide new interpretations of existing data to provide a scaffolding for the development of novel drug targets for the treatment of schizophrenia. The causes of schizophrenia are most likely heterogeneous and involve both genetic and environmental factors. The authors examined a wide range of purported causes of schizophrenia to identify a common biochemical pathway that would contribute to this disorder. This review specifically did not consider pathways that supported the dopamine hypothesis of schizophrenia since historically drugs focused on dopaminergic mechanism, as noted in the aims, have not been successful for many patients with schizophrenia.

Two prominent schizophrenia-associated factors that have been widely studied with significant supporting evidence are stress and inflammation. Stress and inflammation share a common biochemical pathway that converges on the kynurenine pathway of the metabolism of tryptophan, an essential amino acid. At one end of the pathway, recently hospitalized patients with schizophrenia have been found to have low plasma tryptophan levels, whereas chronic schizophrenics have not, suggesting stress- and/or inflammation-induced increased metabolism of tryptophan. At the other end of the pathway, there is increased level of cerebrospinal fluid kynurenic acid in patients with schizophrenia as compared with healthy controls. Salivary kynurenic acid is associated with stress intolerance in schizophrenia. Importantly, natural occurring compounds in this pathway have significant CNS effects that include neurotoxicity and altered neural transmitter behavior.

Stress and inflammation, both associated as causes of schizophrenia, are linked by a common biochemical pathway involving kynurenine. Examination of specific elements of the kynurenine pathway may aid in the identification of drug targets for schizophrenia.

Dementia is estimated to affect 50 million people worldwide, with around 60% of these cases attributable to Alzheimer's disease (AD). One of the common behavioural and psychological symptoms associated with AD is psychosis. Psychosis, experiencing delusions or hallucinations, can be one of the most distressing ordeals for patients with AD, as well as those around them. Effectively managing these symptoms can lead to a vast improvement in life quality. Currently, there are no medications specifically licensed in the UK for the treatment of psychosis in AD. To help guide clinical practice, we reviewed the evidence underpinning the pharmacological treatment of psychosis in AD. The aim of the study was to positively influence clinical practice and thereby improve the life quality of this patient group.

An advanced PubMed search was used to identify studies which investigated the pharmacological treatments for acute psychosis in people with AD. Papers included were double blind, placebo controlled, randomised controlled trials specifically for AD dementia. Papers must have reported their findings using a specific psychosis subscale (PS); examples being “Behavioural Pathology in AD” (BEHAVE-AD-PS), “Brief Psychiatric Rating Scale” (BPRS-PS), and “Neuropsychiatric Inventory - Nursing Home Version” (NPI-NH-PS). Populations of both outpatients and residential patients were accepted. 14 papers, comprising some 3237 patients, were included and critically analysed in the final review.

Risperidone (BEHAVE-AD-PS: -1.3 [p = 0.004] & -1.9 [p = 0.039]; BPRS-PS: -0.5 [p = 0.08]) and aripiprazole (NPI-NH-PS: -1.0 [p = 0.169] & -1.8 [p = 0.013]) successfully reduced psychosis symptoms in patient populations. However, these medications were associated with a statistical increase in severe adverse events including strokes and cognitive decline. Pimavanserin (NPI-NH-PS: -1.9 [p = 0.045]) also offered a notable reduction in psychosis symptoms, but was associated with increased agitation/aggression. Whilst commonly used in clinical practice, quetiapine, olanzapine, and haloperidol showed negligible therapeutic changes compared to placebo using multiple psychosis subscales. Olanzapine and haloperidol were associated with increased rates of severe adverse events including extrapyramidal symptoms. Quetiapine showed limited side effects.

Risperidone and aripiprazole offer effective means to help AD patients cope with psychosis, but these medications also come with an increased risk of developing life-threatening complications. They should, therefore, be administered judiciously. Pimavanserin shows early promise in treating this group of patients, with no life-threatening adverse effects associated with its use. Further research is required before endorsing the use of pimavanserin. There is little evidence to support the therapeutic use of quetiapine, olanzapine, and haloperidol in this patient population. No financial sponsorship declared.

To evaluate physical health monitoring standards in patients on Clozapine in the community.

Standards

NICE and BNF guidelines for patients on established clozapine treatment advise annual monitoring of weight, waist circumference, pulse, blood pressure, fasting blood glucose, HbA1c, blood lipids and overall physical health assessment. Full blood count is monitored 1-4 weekly.

In the management of schizophrenia, antipsychotic medication remains the cornerstone of treatment. Patients affected carry a significant physical health burden with a reduced life expectancy of 10-25 years. Factors that contribute include sedentary lifestyles, consequent obesity and cardiovascular disease, disengagement from health services, a higher incidence of suicide and the physical side effects of antipsychotic medication. For these reasons, comprehensive routine physical assessment of patients on antipsychotic treatment is of central importance.

This audit is a retrospective study of patients known to South Kensington & Chelsea Community Mental Health Team (CMHT). Patients (n = 48) were audited from the Clozapine clinic SystemOne database over a one year period (October 2018-2019) to assess annual monitoring of full blood count (FBC), urea and electrolytes (U&Es), lipid profile, liver function tests (LFTs), HbA1C, thyroid function tests (TFTs), clozapine levels, ECG, and general physical and mental health review.

Of the 48 patients, one was transferred to a different service so was excluded (n = 47 total).

All (100.0%) of the patients had annual FBC tests. All but one (97.9%) of the patients had a physical health review including blood pressure, pulse, weight and BMI measurement. Three quarters (74.5%) received annual U&Es and LFTs. Almost two thirds of patients had annual lipid and HBA1c screening (63.8%) and over half the cohort had annual TFTs (61.7%). Regarding annual multidisciplinary mental health review, this was performed for the majority of the patients (70.2%).

Contrastingly, only a quarter of the patients received annual screening of glucose and Clozapine levels (27.7% for both). Only 12 patients had annual ECG (25.5%).

Following review it is clear that most parameters were monitored annually in a majority of patients. However, shortcomings were detected, specifically annual ECG and waist circumference monitoring.

In order to ensure comprehensive monitoring of mental and physical health of patients on Clozapine, flow charts of tests and reviews needed for each patient were written up clearly and will be included in the management pathway for every patient on Clozapine. This was agreed to minimise missing any step, particularly annual ECGs.

Transition from CAMHS to AMH is recognised as a potential struggle for young people who suffer with poor mental health. In response to the 2017-19 NHS CQUIN project, LPT organised a monthly working group to establish the best transition process & deliver the CQUIN project.

It is estimated that more than 25,000 young people transition each year. It is reported that this process is often handled poorly, which can result in repeat assessments and emergency admissions for this large cohort of service users at a critical stage in life. The result is that young may go on to develop more severe problems in the absence of an appropriate transition service.

Cohort of service users eligible for transition (17yrs 6months) was identified. They were referred from CAMHS to AMH with a transition plan and referral letter. A face-to-face transition meeting was arranged which included the patient, carer & clinicians from sending & receiving services. A clinical audit was completed to ensure that care was transferred to AMH post-18th birthday of the patient. The process was followed up by pre- and post-transitions surveys.

From 110 identified service users 46% had joint-agency transition meeting and 79% had transition plan in place. 72% felt prepared to transition to AMH and 89% felt their transition goals were met. Positive comments have been received from service users.

Link workers were identified to facilitate the transition process. Flow chart was established and disseminated across LPT. Services that need an improvement will be targeted and monitored. LPT will host an event for patients and carers to involve them in enhancing the transition process.

Mental health transition-related disengagement is a major public health problem. This study aims to review children in care (CIC) and adopted children's transitions from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS). This study aims to illustrate the often overlooked complexities that are associated with this population's transitions.

It is hypothesised that this population is at an increased risk for disengagement post-transition. Such is hypothesised as a result of the population's increased prevalence of complex mental health problems, neuro-developmental needs and developmental trauma. This population would benefit from a transition (optimal), as opposed to a transfer of care (suboptimal).

This retrospective case study included young people from Lewisham CAMHS's team for looked after and adopted children. Optimal transition was evaluated using four criteria: continuity of care, parallel care, a transition planning meeting and information transfer.

A total of 34 cases (male = 14, female = 20) were included, 88% of which were CIC (12% were adopted children). 85% of the cases included reports of at least one form of abuse and/or neglect. 59% of the cases were categorised as having more than one diagnostic group of mental health problems.

30% (n = 11) of the cases were discharged and were not recorded to have re-engaged with Lewisham AMHS. 12% of the cases had an outcome as 'unknown' due to miscellaneous reasons.

Only 18% (n = 6) of the cases had an ‘optimal’ transition. 18% (n = 6) had a suboptimal transfer and of those cases, 66% (n = 4) did not engage with AMHS beyond three months post-transfer. 21% (n = 7) were re-referred to Lewisham AMHS after being discharged from CAMHS. None of the re-referred cases engaged with AMHS post-referral.

In conclusion, these findings demonstrate that this population is highly complex and can often experience suboptimal transitions from CAMHS to AMHS. Anything less than an 'optimal' transition yields a low ratel of therapeutic engagement. Recommendations for clinical practice includes an extended period of ‘overlap time’ between CAMHS to AMHS for CIC and adopted children. This overlap period will enable mental health practitioners to provide more informed and consistent support that incorporates the needs of CIC and adopted children. Such a provision will enhance therapeutic engagement and subsequently, promote better outcomes for CIC and adopted children. These findings have important resource implications for both CAMHS and AMHS teams.

All patients discharged from our Paediatric Liaison Team will have an electronic discharge summary sent to their GP within 24 hours by January 2020.

Writing a GP discharge summary is an essential part of patient care and is a patient safety issue if not completed on time. The NHS England Standard Contract states discharge summaries should be completed and sent to a GP within 24 hours of discharge. Baseline data showed our median time between discharge and a GP summary being sent off as 3 days and a baseline survey of staff in our team rated our discharge summary process as inefficient and time consuming. At baseline our discharge summary was typed on a word document which was then emailed to admin staff who would print and post to the GP. Our electronic patient record had an inbuilt discharge notification function that generates and sends summaries via email to the GP that other teams in the trust were already using.

We utilised the Model for Improvement Quality Improvement methodology. Initially we created a driver diagram breaking the process of discharge summary writing into its constituent components to generate change ideas. We then tested out these out in plan, do, study, act (PDSA) cycles whilst continually collecting data using a shared team spreadsheet to monitor for change.

We found that switching to electronically sent discharge notifications improved our time from discharge to a summary being sent to the GP from a median of 3 days to 1 day. We noticed that alongside a shared team spreadsheet monitoring when summaries were written we also reduced variation of time between discharge and a summary from a range of 0-27 days (with an outlier of 161) to 0-9 days.

On average the time from discharge to a summary being written met the standard and we reduced the variability of time delay by using an electronic notification. However only 56% of summaries were sent within the 24 hour limit. Key factors for continued variability identified during regular team meetings included overall caseload of patients, amount of staff on shift and technical issues with the form. Our plan for sustainability is to discuss monthly in the team meeting any discharges that took longer than 1 day and target further PDSA cycles to these issues.

In March 2020, when the COVID-19 outbreak emerged, Technology Enabled Care (TEC) Cymru went into partnership with the Welsh Government and CWTCH Cymru to offer a safe solution to protect the NHS and the public by developing and rolling-out a National Video Consulting (VC) Service on an All-Wales basis.

The aim was to quickly develop and roll-out an NHS-approved communication platform (Attend Anywhere) to all primary, secondary and community care services, and into care homes, prisons, dentistry, optometry and pharmacy to offer video consultations to patients.

The NHS Wales Video Consulting (VC) Service used a robust mixed methodology of surveys and interviews with patients, families and professionals. The real-time quality improvement approach was invaluable to the team as findings continually informed the approach and direction.

Based upon 10,000 survey responses from patients and professionals, and more than 300 interviews the results demonstrate that video consulting is consistently high in satisfaction, clinical suitability and acceptability across a wide range of patient demographics and clinical specialties in Wales. The key findings are

Very high in patient and clinician satisfaction (slightly higher in patients).

Clinically suitable across a wide range of specialties, care sectors and Health Boards.

Very high in patient and clinician satisfaction (slightly higher in patients).

High acceptability of VC, which is believed to be associated to the ‘Welsh Way’ of digital implementation processes.

Consistent data patterns across patient demographics (age, gender, urban/rural location).

Consistent data patterns across clinical settings and Health Boards.

There is large appetite for VC in Wales, with high potential of sustainability and long-term use beyond COVID-19. The service is now working with clinicians, patients, carers and policy makers to explore the long-term use and sustainability of video consultations in Wales

To provide guidance for the management of mood disorders, both depressive and bipolar disorders, based on scientific evidence supplemented by expert clinical consensus.

It is the EIT responsibility to monitor a patient's physical health and the effects of anti-psychotic medication for at least the first 12 months.

The update has been developed in a consistent manner to the 2015 guideline. The composition of the working group has remained largely the same as has the process to evaluate the evidence and synthesise the findings. To approach the update, the working group identified areas within the 2015 guideline where significant changes had occurred, for example the development of new therapies or where thinking and practice have changed and new ideas have emerged. Recommendations were reviewed in light of any new findings and evidence. As only some sections of the 2015 guideline have been updated/revised, the time taken to develop the update has been considerably shorter. Public consultation and peer review informed the final version.

This led us to review the mechanism in the team for arranging and reviewing these investigations.

The mood disorders clinical practice guideline update addresses both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework supplemented by expert clinical consensus.

There have been long-standing concerns about communication and safety on the Bethlem site out-of-hours due to its size, acuity and the number of specialist services; these issues were exacerbated by the COVID-19 pandemic. A Quality Improvement Project was designed to address communication and safety concerns from the on-call team at the Bethlem Royal psychiatric hospital out-of-hours through the introduction of weekend safety huddles.

Daily weekend safety huddles were introduced to improve communication regarding workload, acuity, new admissions, seclusion reviews, deteriorating patients; and to improve team cohesiveness and trainee support out-of-hours.

The QIP team involved the deputy medical director, the associate director for speciality units, consultants, the college tutor, specialty registrars and core psychiatry trainees. Prior to initiating the huddles, the QIP team met to decide which specialties to involve, to agree on an agenda and liaise with other sites regarding existing huddles. Once the huddles began in April 2020, the team met periodically to agree next courses of action and to troubleshoot. The huddles initially involved acute services and eventually included CAMHS, Forensic, Older Adults, Specialist Units, all on-call consultants, the on-call registrar, two core trainees, the psychiatric liaison manager and the duty senior nurse.

Data were gathered throughout the QIP using Likert scale surveys which were sent to all junior doctors on the out-of-hours rota. Paper surveys were used initially but were later replaced with Microsoft Forms to ensure anonymity.

The percentage of respondents who answered “most of the time” or “all of the time” increased across all parameters when comparing data from before and after implementation of the safety huddles.

These results included improvement in: understanding of workload and acuity (9% before vs 69% after), discussion of new admissions on site (4% before vs 90% after), discussion of patients with deteriorating mental health (35% before vs 90% after) and physical health (22% before vs 83% after), understanding of number of patients in seclusion (61% before vs 93% after) and feeling part of a cohesive “on-call” team (17% before vs 86% after). In addition, the results suggested a reduction in frequency of safety concerns on site (83% answered at least “sometimes” before vs 62% after).

The results of the final survey demonstrated a measurable and positive impact on communications between the out-of-hours team, improved team cohesiveness and a reduction in safety concerns. The lessons learnt also influenced decisions made in formatting safety huddles at other trust sites.

A rigorous and systematic patient feedback system is important for identifying gaps, improving the quality of care and encouraging patient involvement in service delivery. In the Adult Complex Needs Service of the Tavistock Clinic, a tertiary psychotherapy centre, only 5% of patients have provided feedback when requested. This Quality Improvement (QI) project aimed at improving the return rates of the Experience of Service Questionnaire (ESQ) and the CORE Outcome Measure by 10% within a year.

The QI methodology was used to help identify factors contributing to the low response rate, including views amongst stuff about how such feedback, and the method of its delivery, might affect a psychoanalytically-informed treatment. Previously these forms were posted or handed out in person. In the first Plan-Do-Study-Act (PDSA) cycle, the method of distribution was changed by sending out the questionnaires to patients electronically, using an online survey platform. In the second PDSA cycle, the CORE-34 questionnaire was replaced with a shorter version, the CORE-10. This was in order to test our hypothesis that a shorter questionnaire would result in an increase in the response rates.

In the first cycle of change, 197 patients were emailed for both the CORE-34 and ESQ and a total return rate of 31% was achieved. This signified an increase of 26% in the response rate. Overall more ESQ forms were completed (35% uptake) compared to CORE-34 forms (28% uptake). In the second cycle 199 patients were emailed with the CORE-10 and ESQ forms. The response rate was 21% and 18% respectively. Although the response rates decreased slightly in the second PDSA cycle the results indicated that this method of distribution was capturing a greater range of patients who had not previously provided the service with this sort of feedback.

Sending out the outcome measures electronically and adopting shorter versions of the CORE questionnaire increased the feedback response rate significantly, and provided the service with useful data as to patients' experience of their treatment journey here.

To improve the structure, quality and experience of medical student placements in Community Child and Adolescent Mental Health Services (CAMHS). To increase the likelihood of pursuing a career in Psychiatry or CAMHS by 50% over their 3 week placement.

There is evidence in the literature of the widely variable medical student experiences when it comes to Psychiatry placements. Medical students from Kings’ College London (KCL) have a 3 week placement in Lambeth Community CAMHS services. Despite this being a good opportunity for learning and development, the feedback from students reports that they often feel lost and were unable to fulfil the potential of the placement. The main challenges reported were identifying beneficial educational experiences and gaining clinically relevant exposure. This exposure includes getting involved beyond observation and following a patient longitudinally. These challenges will likely have a knock-on effect on their attitude towards Psychiatry and overall enjoyment of CAMHS placements when there is already a struggle to recruit trainee Psychiatrists.

A structured and immersive educational placement was designed through consultation with previous students, the multidisciplinary team and the university program directors. This included:

• • A new induction

• • Having a role in initial assessments of young people

• • Formalised medical and psychology teaching

• • Communication sessions

• • Case discussions in a ‘grand round’ format providing opportunity for end of placement assessment

Pre placement questionnaires were used to assess the student's initial level of knowledge, expectations from the placement and motivation or interest in a career in CAMHS. Post placement questionnaires were used to assess any change in the above baseline scores. Brief, online feedback was collected after every clinical activity and was used to assess the interest and utility of each attended session during the placement. The questionnaire feedback was analysed and using these data, adjustments were made to improve the program for the next students in a “Plan-Do Study-Act” quality improvement methodology format. We analysed whether improving placement experience and learning affected students’ interest in careers in Psychiatry.

The Quality Improvement Project is currently on-going and results are pending. So far, there is an improvement in student attendance and engagement following the introduction of induction, structure and active involvement in case management.

The COVID-19 pandemic has resulted in community services having significantly reduced face to face contact, therefore our proposed changes for future cycles include various virtual elements. Ensuring medical students have access to online platforms such as Microsoft teams is vital in ensuring an effective medical student placement can be established Although the change to more remote working has been challenging , it is vital that medical students gain appropriate clinical experience during their Psychiatry placement to support further developments in Psychiatric recruitment.