To audit VTE risk assessment compliance across psychiatric inpatient wards at three different sites within Surrey and Borders Partnership NHS Foundation Trust (SABP), and to highlight the importance of completing VTE risk assessments for psychiatric inpatient safety and care as set out by NICE guidelines (2019).

Numbers of VTE risk assessments completed (within 24 hours, and those completed any time during inpatient stay) and VTE risk assessments not completed were collected via SABP electronic mental health records. Percentage compliance for each ward and hospital involved in the study were calculated. Chi square statistical t tests were conducted using Excel to check for associations between type of ward (older adult and working age) and VTE risk assessment completion.

A total of 3004 patients were included in the study. Ages ranged from 18–82 years of age, and both males and females included in the study. A total of 2060 were working age (WA) patients (aged 18–64 years) and 944 were older adults (OA) (aged > 65 years).

Across all three sites, more than 90% of all inpatients admitted between May 2018 and October 2020 did not have a formal VTE risk assessment completed. Across all sites, less than 1% of all inpatients had a completed VTE risk assessment done within 24 hours, as recommended by the NICE guidelines. Older Adult wards showed better compliance with VTE risk assessment completion with 38% of patients on one OA ward having had a completed VTE risk assessment, and 28% on another completed OA ward. Being admitted to an OA ward was strongly associated with VTE risk assessment completion (p < 0.05).

OA wards have hosted QI programmes with regards to VTE risk assessment which may be why VTE risk assessment was more likely to have been completed on OA wards. VTE risk assessment compliance overall is inadequate across all sites included in the study. Recommendations include further education for all ward staff on how, why and when VTE risk assessment should be completed, greater accessibility of an improved VTE risk assessment form and for QI initiatives on OA wards to be rolled out on WA wards. These findings have been presented and discussed at regional Trust teaching days, and this audit will be repeated in one year.

People who are forced to leave home often experience emotional suffering and may be disproportionately subjected to risk factors for suicide. Although it is a grave concern for the global public health community, it has not been understood in Ethiopia.

This study aims to assess the prevalence and factors associated with suicidal ideation and attempts among war-affected internally displaced people in northwest Ethiopia, 2022.

From 23 May to 22 June 2022, a cross-sectional study design was conducted, and a sample of 765 participants was selected through simple random sampling. A structured interview was employed to collect data. Suicidal ideation and attempts were assessed using the Composite International Diagnostic Interview.

Out of 751 interviewed participants with a response rate of 98.2%, the magnitude of suicidal ideation and attempt was 22.4% (95% CI: 19.5%, 25.4%) and 6.7% (95% CI: 5.1%, 8.7%), respectively. People of female gender, having depression, family with a history of mental illness, and poor social support were significantly associated with both suicidal ideation and attempts. Furthermore, post-traumatic stress symptoms and the death of a family member were significantly associated with suicide ideation and attempt, respectively.

At least one in five of the displaced people in this population had experienced suicide ideation, and one in fifteen had attempted suicide. Therefore, strengthening early detection and intervention for individuals is recommended, especially for females with depression, post-traumatic stress symptoms, family with a history of mental illness, poor social support and the death of family members.

Psychiatric readmissions cause a burden on the healthcare system, incur a monetary cost and cause additional distress to acutely unwell patients. This project explores the use of the free-text of electronic patient records to predict inpatients in psychiatric hospitals at risk of readmission using predictive models generated by machine learning.

Free-text was extracted from the electronic patient records of patients admitted to hospitals in Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) during the five years 2015–2019 inclusive. The anonymised records were obtained via the CRIS (Clinical Record Interactive Search) database. A total of 17208 records were extracted.

The free-text entered by clinicians during an admission was extracted and processed using techniques of natural language processing to generate input vectors suitable to be used with machine learning algorithms. tf-idf (term frequency-inverse document frequency) vectors were used.

A selection of algorithms were used to train predictive models. Two-thirds of the records were used as training data with the remainder as test data. Baseline model performance was assessed and then best-performing candidates underwent hyperparameter optimisation using five-fold cross-validation to improve performance. Bayesian optimisation was used to automate hyperparameter tuning during cross-validation. Hyperparameters were optimised on the log loss function. As the dataset was imbalanced with negative instances outnumbering positive instances to a significant degree, various techniques such as random undersampling of negative instances in the training data were used to deal with class imbalance throughout this process. Following cross-validation, the best-performing models underwent performance analysis.

Models were used to make predictions on the test data. Performance was assessed using F1-measures, precision-recall curves and the average precision metric (equivalent to area under the precision-recall curve). These metrics were chosen due to their suitability in assessing models trained on imbalanced datasets.

The best F1 score obtained was 0.233 using a Random Forest model trained using unigram tf-idf vectors of 500 token dimension.

The best average precision obtained was 0.157 using a Support Vector Machine trained using unigram tf-idf vectors of 2000 token dimension.

Both the above results required the use of random oversampling of positive instances to improve performance on the imbalanced dataset.

The performance indicates that the models generated are unlikely to have significant practical utility. Nevertheless, this exploratory project has produced a processed dataset with knowledge about its characteristics. This could be used for the further development of models using more complex techniques such as language modelling using neural networks.

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.

Unique challenges have been faced by women in the perinatal period during the COVID-19 pandemic and the impact of this is compounded for women suffering from mental illness. This service evaluation looked at different aspects of the treatment pathway on a specialist inpatient psychiatric Mother and Baby Unit during the pandemic to identify what changes occurred.

Data were collected for all admissions to the unit between January 2019 and October 2020, with the beginning of the pandemic being defined as on or after 1st March 2020. Information was collected retrospectively from electronic clinical notes on ethnicity, length of stay, diagnosis, mental health act use and restrictive practice, medication, psychology, occupational therapy and social services involvement.

There were 114 admissions to the MBU during the study period. 4 were parenting assessments rather than acute psychiatric admissions and were excluded from the analysis, giving a sample of 110 women. 58% (62/110) were classed as “pre-pandemic” and 43.6% (48/110) were “during pandemic”. 95.45% (105/110) of women were postpartum 4.55% (5/110) were pregnant. Mean length of stay was shorter during the pandemic at 44 days, compared to 61 pre-pandemic. There was greater use of the mental health act during the pandemic: only 43.75% of patients were informal throughout admission, compared to 70.97% pre-pandemic. Mean duration of detention was shorter at 25 days (32 pre-pandemic). Psychotic illness made up a greater proportion of diagnoses during the pandemic: 56% (27/48) compared to 44% (27/62) pre-pandemic. The next most common diagnostic group was mood and anxiety disorders, which made up 29% (14/48) of diagnoses during the pandemic, but 43% (27/62) pre-pandemic. Outcomes as measured using the Health of the Nation Outcome Scale showed a mean improvement between admission and discharge of 6.65, compared to 5.15 pre-pandemic. HONOS scores were higher on admission during the pandemic (12.83, vs 10.88), suggesting a higher level of acuity.

During the COVID-19 pandemic on this Mother and Baby Unit, length of stay was shorter, a greater proportion of patients were detained under the mental health act (although length of detention was shorter) and psychotic illness was more prevalent. This study demonstrates that there were differences in this perinatal inpatient population during the pandemic and this may be a reflection on the wider impact of COVID-19 on perinatal mental health.

Tourette's Syndrome (TS) is a neurodevelopmental disorder, which often presents in childhood and is hallmarked by motor and vocal tics. Obsessive-Compulsive Disorder (OCD) is a chronic neuropsychiatric condition characterised by intrusive thoughts and time-consuming repetitive behaviours. Research suggests that 15-20% of adult patients with TS will also meet the diagnostic criteria for OCD. Both illnesses appear to have neurobiological similarities but a differing course and clinical response to pharmacological treatments.

Despite this, research into optimal management of adults with co-occurring TS or other tic disorders and OCD remains sparse. Comorbidities, are known to be poor predictor of response to selective serotonin reuptake inhibitors (SSRI) monotherapy in OCD and are often associated with treatment-refractory OCD. Similarly SSRI monotherapy in patients with OCD and comorbid TS can sometimes worsen motor tics (1 in 2000) and fail to improve OCD symptoms. In this review, we aim to evaluate evidence on the management of patients with co-occurring TS and OCD and address an important knowledge gap in clinical practice.

This review was conducted in accordance with PRISMA Guidelines. We performed a search using PubMed, Cochrane Library and PsychINFO using the following Boolean Input “Tourettic-OCD” OR “tic-related OCD” OR ((OCD OR “obsessive-compulsive” OR “obsessive compulsive”) AND (Tourette OR “Tourette's” OR Tourettes OR tic))”. The search was conducted until January 2020. We then screened the articles of systematic reviews to extract additional studies from their reference lists.

1888 studies were identified, of which 15 clinical trials were included in our systematic review. The presence of tics in patients with OCD are a major predictor for treatment-refractory OCD and a lack of improvement following monotherapy with SSRIs. Dual therapy with an SSRI and antipsychotics (particularly risperidone) are associated with improved outcomes in OCD patients with tics and TS patients with obsessive-compulsive symptoms. However, conjoint therapy with neuroleptics and SSRIs was only investigated when OCD burden was unsatisfactory following SSRI monotherapy.

There are clinical implications when a patient with OCD also has a chronic tic disorder. The findings indicate the need for further research, particularly in the form of a larger cohort in randomised controlled trials, to determine when it is best to initiate patients with OCD and comorbid tic disorders on a dual antipsychotic-SSRI management strategy. Further evidence should also be done to determine other characteristics that predict an improvement to conjoint SSRI/neuroleptic therapy for effective symptom reduction.

Vitamin D deficiency is common among people with Intellectual and Developmental Disability (IDD) and is linked to worse health outcomes.

Our aims were to re-evaluate vitamin D testing and supplementation among inpatients with IDD, examine any correlates with physical health conditions including COVID-19 and make recommendations for the current regime of supplementation and testing within inpatient IDD services.

The study population comprised inpatients who were in any of the Northgate Hospital IDD inpatient services in Northumberland, UK. The wards sampled were the Medium Secure Unit, Low Secure Unit, Hospital Based Rehabilitation Wards and Specialist Autism Inpatient Service. Records of all inpatients between January 2019 and July 2020 were examined for 25-hydroxyvitamin D [25(OH)D] level, ward area, supplementation status, test seasonality, medication, and health status.

We performed a correlation to see whether there was an association between vitamin D level and length of time on treatment. In addition, comparison of the replete and inadequate group for age, ethnicity, seasonality, ward location and psychotropic medication was undertaken.

Data on physical health risk factors, obesity and COVID-19 infection were also collected. The physical comorbidities were described in order to evaluate whether any emerging patterns relating to COVID-19 infection were emerging.

There were 67 inpatients in Northgate IDD services on 1 January 2019, with 11 further patients admitted up to the end of the sampling period on 31 July 2020. Nineteen patients were discharged during that period, so the sample comprised 78 patients.

Ages were comparable across three of the ward areas, except for an older group of patients in the hospital-based rehabilitation setting. Mean 25(OH)D level for supplemented (800IU/day) patients was 75nmol/l (SD 20) compared to 40nmol/l (SD 19) in the non-supplemented group (p < 0.001).

Thirty-eight percent of those who were inpatients during the first wave of the COVID-19 pandemic developed symptoms, but the small sample size could not establish vitamin D levels as a predictor of outcome.

Our findings show that clinicians continue to offer vitamin D supplementation for inpatients, at a dose of 800IU (20μg) per day.

The mean vitamin D levels we observed were higher for those on supplements compared to our 2013 baseline data, whereas patients not on supplementation now had levels akin to those found previously. Vitamin D (800IU/day) supplementation is effective but adequacy of the nationally recommended dose of 400IU/day is unclear. Links to COVID-19 merit further research.

Clozapine has several effects on the genitourinary system including enuresis and an overactive bladder (OAB). However, little if any has been written about its effect in causing OAB and its prevalence. Typical feature of OAB is urinary urgency associated with urinary frequency in the absence of urinary tract infection or other obvious pathology. Having 8 voids or more in 24 hours in addition to urinary urgency is strongly suggestive of OAB. AB developed AOB while being treated with clozapine.

AB is 33 years old white lady with a well-established diagnosis of emotionally unstable personality disorder. She has been in mental health services from her late teens. She has had a trial of several antipsychotics, both oral and depot and has had a number of DBT sessions and one EMDR with limited effect. Prior to this episode, AB has had two successful trials of clozapine, one resulting in her longest period (9 months) of living in the community in 1998.

AB was started on clozapine again in 2021, she developed urinary frequency. She requested it to be stopped. Her condition deteriorated such that she needed intensive care unit. AB was again started on clozapine. She developed urinary frequency once more when the dose reached 250 mg. She did not have infection. For one week, her urinary frequency ranged from 36–66 in 24 hours. It was more evident in the day time. There was no incontinence. AB remained in her room close to her toilet. She stopped engaging in her therapy, she did not mix with others and did go out. She tried a number of medications-aripiprazole, oxybutynin and desmopressin with no benefit. Pseudoephedrine was started at 15 mg twice a day, eventually reaching 30 mg three times a day. Within two weeks, the urge disappeared and the frequency normalised. Six months on, AB remains well and has not reported any side effects.

Pseudoephedrine, an indirect alpha-adrenergic agonist successfully normalised AB's urinary frequency. It was evident so within few days though the maximum benefit was noted within two weeks. This is in agreement with what is reported in cases with enuresis

Very little is known about clozapine induced OAB. It had a severe negative impact on AB, who failed to engage in her therapy and her social life. Pseudoephedrine brought relief within a short period of time. In case of OAB and when stopping clozapine is not an option because of underlying severe mental disorder; think of pseudoephedrine.

Questions have been raised regarding differences in the standards of care that patients receive when they are admitted to or discharged from in-patient units at weekends.

To compare the quality of care received by patients with anxiety and depressive disorders who were admitted to or discharged from psychiatric hospital at weekends with those admitted or discharged during the ‘working week’.

Retrospective case-note review of 3795 admissions to in-patient psychiatric wards in England. Quality of care received by people with depressive or anxiety disorders was compared using multivariable regression analyses.

In total, 795 (20.9%) patients were admitted at weekends and 157 (4.8%) were discharged at weekends. There were minimal differences in quality of care between those admitted at weekends and those admitted during the week. Patients discharged at weekends were less likely to be given sufficient notification (48 h) in advance of being discharged (OR = 0.55, 95% CI 0.39–0.78), to have a crisis plan in place (OR = 0.65, 95% CI 0.46–0.92) or to be given medication to take home (OR = 0.45, 95% CI 0.30–0.66). They were also less likely to have been assessed using a validated outcome measure (OR = 0.70, 95% CI 0.50–0.97).

There is no evidence of a ‘weekend effect’ for patients admitted to psychiatric hospital at weekends, but the quality of care offered to those who were discharged at weekends was relatively poor, highlighting the need for improvement in this area.

To complete an audit cycle to investigate: trainees’ experiences of SI involvement since 2017, perceptions of current support systems and trust facilitation of learning from SIs and the impact of the interventions implemented following the 2017 survey.

In 2017, data were collected from trainees working in psychiatry within two London trusts to examine the nature of their involvement in serious incidents (SIs), their experience of the process following an SI and their knowledge of the support systems available to them. Due to concerning results from this, several interventions were put in place in accordance with trainees’ suggestions.

Cross-sectional surveys were e-mailed to trainees of all grades in July 2019, including GP and foundation doctors, working within two mental health trusts. These built upon the 2017 surveys, additionally enquiring about demographic information and the personal and training consequences of SIs on trainees.

61 (15% of all trainees) returned the survey with 41 (67%) respondents unable to recall any SI related teaching during induction and 47 (77%) not having received a written guidance document on SI procedures.

24 (39%) had been involved in an SI. Only half felt adequately supported by the trust at internal investigation. Knowledge of the available internal and external sources of support ranged from 38-71% however these sources were rarely utilised. 12 (60%) trainees did not feel that learning had been facilitated following an SI and almost none had been informed of internal investigation outcomes.

Respondents who gave a low (1-4/10) rating of support from their NHS Trust were more likely to have been informed about the incident in person, been invited to team-based support or been aware of the variety of sources of support available, when compared with respondents who scored their Trust support more highly. Suggestions for improvements made by trainees included opportunities to observe coroners’ inquests and a peer support scheme from colleagues with experience of SI involvement.

Unfortunately, trainees did not report much improvement in their experiences compared those in the 2017 survey, and a large proportion continued to feel unsupported. Interventions had not been as widely circulated as intended and only half of trainees had been invited to team-based support. Possible further interventions include increasing email communication to trainees following SIs and setting up a peer support scheme. We are in the process of organising a coroner's inquest observation programme for trainees.

To evaluate if patients referred to Ealing Liaison Psychiatry Service (ELPS) with co-existing substance use are being appropriately identified as per NICE guidelines.

Patients with co-existing substance misuse have greater morbidity and mortality and it is therefore important to identify these patients to optimise their management. NICE recommends that all patients are asked about their substance use.

Anecdotally, our team felt we were doing a good job of identifying and managing such patients but we had no objective evidence of this.

Completed a retrospective audit looking at a sample of patients referred to ELPS over two weeks in December 2019.

A training session for ELPS was then held to highlight the initial audit results and NICE guideline recommendations.

We then repeated the audit over two weeks in March 2020.

Initial audit (100 patients):

Only 69% of patients asked about substance use. From those asked, 50-65.2% were using a substance, most commonly alcohol.

None of the patients over the age of 80 were asked about substance use vs 79.5% of patients aged 20–40 years.

55% of females vs 81% of males were asked about illicit substances.

33.3% of ward referrals vs 74.2% of Emergency Department referrals asked about substance use

Re-audit (53 patients):

Significant improvement across all areas

93% now asked about substance use

60% of over 80s, 96% of females and 85% of ward referrals were now being correctly asked about substance use

We were surprised to find that we were initially not meeting NICE standards regarding asking patients about their substance use.

Acknowledging this problem during our training session proved to be effective.

This knowledge will help us develop our care pathways with our Acute colleagues and the Drug and Alcohol Liaison Service.

The need for social distancing during the COVID-19 pandemic has led medical schools to make use of video conferencing platforms in their Objective Structed Clinical Exams (OSCE) for the first time. Additionally the suspension of OSCE's in 2020 due to the pandemic ,has meant this cohort of final year students have never been examined on psychiatry skills. Our aims were to assess if our student psychiatry society (PsychSoc) run OSCE could help to prepare medical students for novel virtual stations ahead of their final examinations, and how this format of mock examination could be improved in the future.

Our PsychSoc (QUB Mind Matters) hosted a virtual mock psychiatry OSCE for 24 final year medical students using the video conference platform Zoom, approximately 1 month before their finals. The OSCE comprised 4 stations each lasting 8 minutes, and covered psychiatric history taking, risk assessment and drug counselling. Stations were marked by psychiatry trainees in individual breakout rooms to closely simulate real examination conditions. A post-event online questionnaire was distributed to all participants. 5-point Likert scales and free text responses were used to gather feedback regarding the content and delivery of the mock. A response rate of 100% was achieved (n = 24).

The feedback from students was overwhelmingly positive, with 100% (n = 24) agreeing/strongly agreeing that the mock OSCE left them feeling more prepared for their final exam. 95.8% (n = 23) agreed that the opportunity to practice virtual OSCE stations improved their confidence, and all 24 students agreed/strongly agreed that they would like more practice of virtual OSCE stations. A common theme that emerged when asked how our mock could have been improved was the need for a group feedback session covering common pitfalls in addition to individual feedback.

The lack of clinical experience and shift towards online learning has led to increased stress around clinical exams in the student population. PsychSocs can supplement formal teaching by providing students the opportunity to practice virtual communication and history taking skills that are not always covered in their undergraduate curriculum. However, as a psychiatry society our mock only assessed psychiatry skills, many of which may be relatively well suited to an online format. We would welcome further evaluation of the applicability of student run virtual mock OSCE's to other specialties. We have demonstrated that PsychSocs can offer much needed practice for students through mock OSCE's and have highlighted ways to enhance their delivery.

Service users taking long-acting injectable antipsychotics (LIAs) may experience recurrence of symptoms as they approach trough levels within a steady-state cycle. Limited research exists around symptom variation between peak-to-trough plasma concentrations of LIA inter-dose intervals. Different LIAs have variable rates of change in dopamine receptor occupancy during this peak-to-trough variation due to differing elimination half-lifes. It is unclear what rate of change in D2 blockade is tolerated by patients at present, which this trial aims to determine through observing symptom severity differences during peak-to-trough variation.

A real-world observational longitudinal cohort study is proposed. Inclusion criteria would be working-age adults (18–65 years) who have received five consecutive and timely LIA administrations of a consistent drug and dose. The study would exclude anyone with significant hepatic or renal impairment, anyone on concurrent oral antipsychotic medication or anyone deemed not to yet be within steady-state plasma levels of their LIA medication.

Serum assays for drug level will be obtained at both peak and trough concentrations during an LIA cycle. Expected timings for peak levels will be determined by derived tmax values from existing pharmacokinetic literature for individual drugs. Trough levels will be taken within 24 hours of the next LIA administration being due. Plasma drug concentrations will then be used to calculate expected striatal D2 blockade using EC50 values and maximal occupancy for individual drugs derived from existing PET scan data.

Symptom severity will be assessed by completing Positive and Negative Symptom Scores (PANSS) questionnaires with service users at the time of both peak and trough plasma concentrations of LIA. The difference in these scores will then be plotted alongside the difference in expected D2 blockade derived from plasma drug concentrations.

We hypothesize that the rate of D2 occupancy change would correlate with symptom severity differences in an exponential manner, in that drugs with shorter elimination half-life would have greater difference in symptom severity between peak and trough. We expect that service users would be able to tolerate such change to a degree without significant emergence of symptoms; the trial aims to determine the threshold for what most service users can tolerate, which may then assist in guiding how to effectively reduce and discontinue medications.

This outlines a research protocol to monitor response to pharmacokinetic variation within inter-dose intervals of LIA medication, which may ultimately aid service users in reducing and discontinuing antipsychotics.

Depression is a fairly common finding among end-stage renal disease (ESRD) patients on hemodialysis and is an independent risk factor for morbidity and mortality. The psychiatric manifestations of the disease may affect their compliance to medications and alter sleep quality that is often overlooked by nephrologists. This translates into poor quality of life and poorer disease prognosis. Thus, Our study aims to assess the prevalence of depression and its association with compliance to medical therapy and sleep quality among ESRD patients on hemodialysis.

In this cross-sectional study, a total of 288 hemodialysis patients with a confirmed diagnosis of ESRD were evaluated for depression using Patient Health Questionnaire-9 (PHQ-9) scale. Only the patients with moderate to severe depressive symptoms on PHQ-9 were further evaluated for sleep quality and compliance to medications using the Pittsburgh Sleep Quality Index (PSQI) and Drug Attitude Inventory-10 (DAI-10) respectively. The characteristics of ESRD patients with depression were also assessed. Median PHQ-9, DAI-10, and PSQI scores were calculated and the correlation between study variables was assessed using spearman's correlation.

Of the 288 included participants, 188 (65.27%) had depression as evaluated via PHQ-9. Of these 188 patients, 114 were males while 74 were females. A total of 113 (60.01%) of the depressed patients had poor compliance with medication while 137 (72.87%) patients had poor sleep quality. Higher PHQ-9 scores were positively correlated with disease duration, dialysis years, and time between diagnosis and therapy (r = 0.41, 0.39, and 0.43 respectively) and negatively with marital and employment status (r = −0.32 and −0.49 respectively). Spearman's correlation matrix showed that PHQ-9 scores were negatively correlated with DAI-10 but positively correlated with PSQI scores.

The study indicates a high prevalence of depression among ESRD patients on hemodialysis. Poor sleep quality and non-adherence to medications are extremely common among ESRD patients with depression. These psychiatric components must be considered to optimize medical treatment and improve the quality of life in this subset of patients.

Due to the high rates of mental disorder in prison there have been a number of initiatives to divert mentally disordered offenders out of custody. One of these is the Mental Health Treatment Requirement (MHTR): a criminal sentence available as part of a Community Order, offered as an alternative to short-term custodial sentences in an attempt to address recidivism and encourage concordance with community psychiatric treatment. In spite of the prevalence of mental disorder amongst offenders, MHTRs represent less than 1% of all community sentences. Here we aim to identify obstacles to the use of the MHTR at sentencing and to suggest ways of overcoming them.

A literature review and brief case series will be used to identify and illustrate what may be obstructing or limiting the use of the MHTR. The terms ‘MHTR’ and ‘Mental Health Treatment Requirement’ were searched on Google, Google Scholar, Athens, and PubMed, and results analysed for recurrent themes. The issues encountered clinically by one of the authors who referred three defendants for MHTRs in psychiatric sentencing reports in 2021 were reviewed with the same purpose.

The main barriers to the use of the MHTR which were identified were issues related to a lack of clinician awareness and experience, homelessness and housing, and service structure and provision. There may be a reluctance for Community Mental Health Teams (CMHTs) to accept offenders onto their caseloads, and there are challenges in obtaining assessments and recommendations for MHTRs. There are difficulties in securing an MHTR for homeless defendants on remand for whom identifying housing prior to sentencing, and thus a CMHT to supervise the MHTR, can be challenging. The MHTR assessment and referral process is more lengthy and cumbersome than that for most other disposals, leaving the defendant awaiting sentencing (potentially in custody) while the referral is processed.

Suggested solutions to improve access to the MHTR include increasing clinician awareness and confidence by providing teaching and training, and multi-agency meetings to enhance communication and create an understanding amongst professionals of duties, roles, and responsibilities. Initiatives to identify housing for homeless remand prisoners before their release, as well as ensuring the availability of community services to supervise treatment, would overcome some of the obstacles identified and increase availability of the MHTR. Funding for additional staff to conduct the assessment and referrals process would also be likely to improve uptake.

Clozapine is associated with a risk of severe adverse events for which there are current monitoring systems are in place; however, there are no established regimens for monitoring of clozapine plasma levels. Recent Medicines and Healthcare products Regulatory Agency (MHRA) guidance advises clozapine levels should be monitored in certain clinical situations where toxicity may be suspected. This audit aimed to evaluate current practice of clozapine level monitoring within one Local Mental Health Team (LMHT).

Electronic (RiO) records of 41 patients (33 male, 8 female; aged from 27 to 76 years; mean age 45 years) registered to the ZTAS system within the Nottingham City Central LMHT were reviewed. 46% had been on clozapine for over 16 years. 73.3% of patients were within clusters 12 and 13; 25.4% of patients were in cluster 11, with one patient in cluster 8. Dates of clozapine plasma level tests for each patient between 2006 and 2020 were found on the electronic NoTIS system, along with clozapine, norclozapine and total clozapine levels. Concurrent clozapine dose and regimens were obtained from pharmacy records from 2018 onwards.

273 clozapine plasma levels were conducted between 2006 and 2020. The average interval between levels taken was 10 months, 2 weeks but had a wide range, the shortest interval being 2 days, the longest being 13 years. 88 levels taken were >600 ug/L, suggesting increased toxicity risk. 108 levels were <350 ug/L, suggesting possible sub-optimal dosing or non-compliance. Statistical tests on correlation coefficient, although statistically non-significant (R = 0.37), showed a positive trend between total clozapine dose and the plasma level between all 3 parameters (i.e. clozapine, norclozapine and total clozapine).

There does not appear to be any routine plasma clozapine level monitoring throughout the LMHT with an average interval between tests of 10 months. There was a non-significant but positive trend between total daily dose of clozapine and clozapine level. 32% of clozapine levels returned were higher than the recommended level. We would recommend as suggested in the guidelines from MHRA, clozapine plasma levels should be monitored in certain clinical situations with increased toxicity risk. Trough levels should be taken with records of time of previous dose taken. Limitations of this study included a small sample size (41 patients) with data collection reliant on electronic systems. It was unclear if these results represent trough levels, making values difficult to interpret. Multifactorial impact on clozapine metabolism causes wide patient variability in plasma levels.