One of the biggest challenges faced by the healthcare sector is devising ways of tackling No shows in the Clinics. Patients are classed as no-shows when they fail to attend scheduled appointments without prior notification to the Health Care Provider. Some factors contributing to clinic No shows amongst frail Older Adults include lack of transportation and non-availability of family members to bring them to the clinic. Along with this, forgetfulness and poor insight into their condition also can contribute to No shows. Memory clinics in Rumailah Hospital under Hamad Medical Corporation in Qatar are the leading specialized multidisciplinary clinics that carry out an assessment, diagnosis, and management of people presenting with Memory Concerns.

Implementation of Quality Improvement projects to tackle the No shows in the Geriatric Memory Clinics in Rumailah Hospital under Hamad Medical Corporation in the State of Qatar.

Various process improvement initiative based on LEAN methodology got implemented from January 2022 to reshape the service and reduce No shows

1. 1. Initial nurse triage contacts with the patients or their family members to identify any inappropriate referrals are signposted to the right service and offer appointments for the appropriate referrals at a date and time convenient for them

2. 2. Telephone triage by the Physician and Case manager of new cases offered a clinic appointment and conduct a brief assessment to agrees risk and order investigations prior to the initial appointment . Patient's requesting rescheduling and cancellations are dealt with immediately. In addition, any new slots which becomes available during this process are offered to other patients and their appointments are brought forward

3. 3. Nurses contact with the patient caregiver of the person with Dementia and remind them of the appointment a day before the appointment.

4. 4. Geriatric Memory Outreach Service to carry out home visits for patients who are unable to attend clinic appointments because of frailty, significant cognitive impairment, and mobility issues.

The No shows rates were as follows

2019 -26%.

2020 -13% (COVID-19 impact).

2021 -13%

Intervention was implemented in January 2022 and No Show reduced to 9% in 2022. This indirectly reduced the waiting time (from referral to Consultation) from three months to 5 weeks.

Innovative alternative Outpatient Service delivery balances the elimination of No Shows with enhanced outcomes by continuously improving all the workflow process

The Greater Manchester Mental Health trust standard on admitting patients states that “The patient will receive a comprehensive mental health & physical health assessment (including electrocardiogram (ECG) and routine admission bloods) commenced within 4 hours of admission”. It was observed that patients commonly do not receive admission blood tests or ECG. It was also identified that there is no current system for keeping track of those who have not received admission investigations or any guidance on re-offering them. The aims were therefore to: 1) Increase the proportion of patients being re-offered baseline physical investigations (blood tests and an ECG) after not receiving them on admission. 2) Increase the total proportion of patients receiving baseline physical investigations

The patients included were any male inpatients (n=41) across two wards between 23/05/22 and 17/06/22.

A list was created of all the patients who had not received admission investigations. Each patient had their notes searched to find out whether they had undergone blood tests and an ECG on admission. If they had not, their notes were searched to see if there was any evidence of them having been reoffered and/or done later. As patients were admitted, they were added to the list if they had not received admission investigations.

The list was taken to ward reviews with the intention of prompting a reoffer of investigations to the appropriate patients. Following the creation of the list, it was reviewed and updated weekly. After 4 weeks, percentages were calculated to determine if there had been an improvement in the proportion of patients being reoffered/receiving baseline investigations.

85.14% patients did not receive admission bloods. 83.79% did not receive admission ECG.

Prior to the introduction of the list, 90% of patients who did not have admission bloods were reoffered. 55.77% patients had baseline (admission or on reoffer) bloods taken. 85.72% patients who did not have admission ECG were reoffered. 78.85% patients had a baseline ECG.

During the 4 weeks following the introduction of the list, 97.5% patients who did not have admission bloods were reoffered. After 4 weeks, 85.14% of all patients had baseline bloods taken. 95% patients who did not have an ECG were reoffered. After 4 weeks, 86.49% of all had a baseline ECG.

Following the introduction of the list, the proportion of patients being reoffered baseline blood tests and ECGs increased.

The proportion of patients receiving baseline blood tests and an ECG also increased.

The management of alcohol withdrawal has become a national focus amongst psychiatry with recent POMH-UK audit data suggesting many aspects for improvement, whilst alcohol competencies have been reintroduced into the core training curriculum. The first part of this project was to evaluate the current standards of assessing and managing alcohol withdrawal on acute inpatient wards within Livewell South West and to survey doctors’ confidence levels in this area.

All admissions to the acute adult and older adult inpatient wards at Livewell SW between March and July 2022 were included in the initial data collection. An audit tool was designed to evaluate the initial assessment of alcohol use, the withdrawal risk and subsequent management. Guidance was provided to the authors assessing the records.

A survey to all doctors was conducted during a CPD session about this project which assessed confidence levels in the assessment and management of alcohol withdrawal.

On initiation of this project, it was noted there was no trust guideline or policy to manage those presenting with possible alcohol withdrawal symptoms.

120 patient admissions were assessed against the audit tool. Half of these (53%) had alcohol intake documented on admission.

11 patients (9%) were found to be at risk of alcohol withdrawal symptoms (n.b 46% too little data). 5 (45%) of these were identified promptly and 4 (36%) were given thiamine (1 parental, 3 oral). Only 4 out of the 11 (36%) were prescribed benzodiazepines, these 4 patients were also considered for referral to alcohol services. Relapse medications were not considered for any patients. No significant incidents were noted.

Generally, trainee doctors feel confident in recognising and managing alcohol withdrawal in acute hospital settings but have difficulties on psychiatric inpatient wards. A major reason stated for this was the difficulty distinguishing between psychiatric and alcohol withdrawal symptoms and also concerns surrounding prescribing benzodiazepines

This project identified a need for a trust policy which has subsequently been developed and is currently being ratified.

The initial baseline results show poor assessment of alcohol use and low confidence amongst doctors in assessing and managing alcohol withdrawal in this population. Several interventions have been identified that could be trialled to improve these results. Further training has been given to junior doctors involved in initial assessment and other interventions planned include posters, electronic prompts, nursing survey and education. Furthermore, patient focus groups are planned to understand patients’ perspective and help guide further training.

The aim of this project is to assess which specific laboratory tests where being requested to psychiatric patients in our trust prior to developing a new local guideline to help standardise the blood testing to improve quality of patient care and reduce wastage in NHS due to inappropriate blood tests. It also assessed financial implication of unnecessary blood tests.

There are several reasons for the purpose of blood tests:

• • To identify medical conditions that might be causing or contributing to a psychiatric presentation

• • Provide baseline for safer initiation of psychotropic medication that can cause adverse effects

• • To screen for medical problems who are less likely to attend primary care. Requesting blood tests is a clinical responsibility .Currently there is no formal guidance on which specific lab tests should be ordered for psychiatric patients and was felt a new local guideline was essential to rationalise blood testing

A survey was circulated to all wards and community mental health teams within our trust to get a clear insight about current practice.

The survey questions included:

• • Place of work?

• • What is included in routine blood tests list?

• • Who created and approved the blood list?

• • Where is the blood list kept?

• • When was it reviewed?

Results showed

• • Significant variation in blood test requesting within our trust emphasising need for standardization using evidence based methods.

• • Unnecessary repetition of blood tests like thyroid function and vitamin D levels against guidelines

• • Unwarranted blood test request when clinically not indicated like including Troponin and Creatine kinase in routine tests. The results were shared to all staff through meetings.

Recommendations were drawn to improve optimisation of resource use, communication between health professionals and the need for standardisation in requesting blood tests.

Misuse of certain drugs is a common precipitant of first-episode psychosis (FEP). Substance misuse is known to exacerbate psychotic symptoms, and it is unclear if substance misuse at the time of initial presentation impacts outcomes of care in FEP. Here, in this quality improvement project (QIP), we aimed to quantify the prevalence of drug misuse within an outpatient early intervention service (EIS) and determine the outcomes (in terms of time-to-discharge and discharge destination) of service users based on their substance misuse history.

In this QIP, we randomly sampled 100 patients referred to and discharged from an outpatient service for psychosis (Barnet EIS). We excluded patients who were referred to the service but were discharged due to referral rejection, non-attendance at psychiatry review and/or other reasons. Data regarding demographic and clinical information, the nature of substance misuse, and discharge destinations were obtained through a review of electronic health records, including GP letters and hospital notes. The time-to-discharge was defined as the time between referral acceptance and discharge from EIS. As this work is part of a QIP, written consent was not obtained to conduct this project.

Of 100 patients obtained from the discharged caseload, 38 patients were accepted and reviewed in Barnet EIS. 24 patients (63.2%) had no substance misuse history at the time of initial FEP, while 14 patients (36.8%) had some substance misuse history. Of the 14 patients with substance misuse, cannabis was most frequently used. The average age of patients was 27.2 ± 1.4 years old. The age of onset of psychosis was similar between patients with and without substance misuse (two-sample t-test, p = 0.74).

In terms of discharge destination, patients with and without substance misuse were discharged back to their GPs at similar proportions (chi-square test, p = 0.81). Finally, the number of days patients spent under the care of Barnet EIS was similar between patients with and without substance misuse (two-sample t-test, p = 0.54).

In this QIP, over 30% of patients presenting with FEP reported substance misuse. The most common recreational drug used was cannabis. Discharge destinations and the time spent in EIS were broadly similar between patients with and without substance misuse. The relatively high rates of substance misuse in FEP found in this study have important implications for commissioning additional services – such as urine drug testing or drug liaison services – within EIS teams.

To establish if the creation of a checklist of examination and investigations required within 24 hours of admission to Psychiatric ward had improved practice and patient care.

This was a snapshot audit. On 7th August 2022 I carried out a retrospective review of the case notes & results on electronic recording system to ascertain which investigations had been completed for all current in-patients on Ward 4, Dr Gray's Hospital, Elgin. I noted how soon after admission these tests had been completed.

I compared these data with results from a previous audit in January 2022 which had highlighted failings in meeting the standards recommended by Royal College of Psychiatrists. The initial audit led to the creation of an Admission checklist to improve practice. The results from August 2022 demonstrated the impact of the checklist.

On 7th August 2022, there were 18 inpatients in Ward 4. Duration of admission varied from 1 day to 1,259 days.

The 3 routine investigations of Physical Examination, ECG and Bloods were completed within 24 hours of admission much more reliably than the initial audit.

Bloods were completed in 100% of cases compared to 52.9% in January 2022. Physical Examination was completed in 94.4% compared to 76.4% in January 2022. ECG was also completed in 94.4% compared to 58.8% in previous audit.

There was a marked improvement in completion of examination, investigations and recording of the results since creation of a checklist. This could be due to increased awareness of the requirements aided by the visible prompt of the checklist on the ward.

Staff are recognizing that mental health cannot be viewed in isolation from physical health which improves the quality of care patients receive during admission. Any health needs can be identified early allowing time for referral if required.

Restrictive practice can include physical and chemical restraint and should be utilised as a last resort. It has been found to negatively impact patients causing psychological distress, re-traumatisation, and a sense of helplessness. Restrictive practice also negatively impacts staff, causing emotional distress, moral conflict and the risk of physical harm. Since 2018, there has been a drive to reduce restrictive practice in inpatient mental health wards across England by the National Collaborating Centre for Mental Health, which has been further developed by NHS England in 2021 within the Mental Health Safety Improvement Programme (MH-SIP). This study aims to reduce restrictive practice on a 10-bedded Medium Secure High Dependency Male Forensic Mental Health Unit over a 6-month period, incorporating staff and patient feedback and utilise QI methodology.

Number of total seclusion hours, seclusion episodes and secluded patients per day were measured at baseline utilising the Rio clinical system and continuously tracked during the study period. Interventions were discussed by a multi-disciplinary team including nurses, pharmacists, health care assistants, occupational therapists, psychologists, and doctors. Patients were invited to give feedback on restrictive practice during ward rounds. Potential interventions were then implemented utilising PDSA methodology with iterative changes tested and analysed. Staff and patients were also invited to complete surveys and semi-structured interviews to give further comments during the study.

Baseline data of monthly activity showed 3,758 total seclusion hours, 10 seclusion episodes and 5.3 seclusions per day. Iterative interventions included; (i) MDT discussions to support positive risk taking (ii) Improved collaborative care planning with patients (iii) Incident calendars for patients (iv) excel spreadsheet indicating progress towards leave / referral to stepdown ward and (v) improving transparency on impact of incidents on progress. Month 6 activity showed 174 total seclusion hours (95% reduction), 1 seclusion episode (90% reduction), and 1 average seclusion per day (82% reduction). A survey completed at the end of the study period showed all patients either strongly agreed or agreed that they understood the process for termination of seclusion, with 100% either responding between “neutral" to "strongly agree” that this had improved.

It was hypothesised that a more collaborative approach with positive risk taking could lead to the reduction of restrictive practice. The interventions enacted have significantly reduced the use of restrictive practice. Further study is recommended into these interventions to review if similar results can be replicated in other inpatient wards.

Following feedback from paramedics and staff, escorting patients to the A&E, concerns were raised when some information was missed during the verbal handover from patient/escorting staff to the ambulance/A&E staff. At times the purpose of the transfer was not clear. Essex Partnership University NHS Foundation Trust (EPUT) “Discharge and Transfer Clinical Guidelines” ( CG24) provides clear guidelines to staff when a person is transferred while in the care of the Trust to another service such as another acute trust or, discharged from EPUT services completely. However, there are no current guidelines available for transferring patients for clinical reasons: in case of emergency or acute medical condition, for specialist treatment or investigation. The standard was used: the “Ambulance handover to emergency care standard V1.0” created by Professional Record Standards Body (PRSB). 100% of patients should have a support letter from doctors with relevant information shared with paramedics or the A&E department on transfer to a general hospital. The scope of the audit was Peter Bruff Mental Health Assessment Unit and Ardleigh Acute Inpatient Ward.

The data were collected retrospectively from notes available on the electronic health record database (Paris). The audit tool focused on quantitative and qualitative data collection on patient transfer.

Inclusion criteria: all patients admitted to the Peter Bruff MH Assessment Unit (male and female) and the Ardleigh Ward (female) over the period from 1 September to 15 September 2022. All data were anonymised. Results were tabulated and presented in statistical form back to the clinical teams.

There were identified 18 male and 33 female patients on the Peter Bruff MH Assessment Unit. 2 patients were sent to the A&E via ambulance and 4 patients attended the A&E with staff escort. A support letter was available on one occasion. Compliance 17%.

Within the analysed period there were 15 female patients identified on the Ardleigh ward. 5 patients attended the A&E. A support letter was available on two occasions. Compliance 40%.

All transfers should be managed in a sensitive way ensuring all communication is clear, to promote robust information sharing between inpatient wards and A&E.

A template of the care summary and handover letter was created, which provided a standard structure of headings that is meaningful to clinicians and patients.

: Milk-alkali syndrome is a medical condition, which could present with psychiatric manifestations. It is caused by hypercalcemia resulting from the ingestion of large amounts of calcium and absorbable alkali. The core symptoms include hypercalcemia, metabolic alkalosis, and renal failure. Diagnosing this syndrome requires a high index of suspicion. The aim of this paper is to describe the case of Mrs. C who had psychotic symptoms because of Milk-Alkaline syndrome

Mrs. C was a 75-year-old white British female with a previous history of anorexia nervosa who has been clinically stable for more than 15 years. She was discharged by the community mental health services about 11 years ago but has been on a repeated dose of Gaviscon for about 8 years.

She presented to the accident and emergency (A and E) unit with a history of confusion, unsteadiness, paranoid beliefs, low mood, and reduced rate of speech. No history of infection or other physical health concerns. Routine blood showed increased calcium 3.41(2.2-2.60) and a reduced potassium level 2.9 (3.5-5.3). CT head scan did not show any acute changes.

She was stabilized and transferred to the ward for further management.

While on the ward, she had a diagnosis of Milk-Alkaline syndrome with psychiatric manifestation. Gaviscon was discontinued because the medics felt this was responsible for the electrolyte imbalance. She was also referred to the mental health liaison team (MHLT).

Following the mental health liaison team review, Mrs. C's psychiatric presentation was suspected to have been probably related to her medical condition. After a few weeks on the ward, her electrolyte became normalized; adjusted Ca 2.72 (2.2-2.6), serum ca 2.74(2.2-2.6). She had a follow-up review by the mental health team that showed her psychosis had also resolved. No medication was prescribed for her presentation. She was subsequently discharged from MHLT and referred to the GP for follow-up.

previous case-report have shown a suspected link between Milk alkaline syndrome and acute psychosis, although the reasons for this have not been understood. The current case further emphasized this link. What is not evident however is if there were other physical health issues that might have also contributed to the patient's initial presentation.

Diagnosis of Milk-Alkaline Syndrome requires a high index of suspicion, missing this could lead to inappropriate use of medication. As a psychiatrist, this case has shown the importance of adequate investigation before making a definitive diagnosis, especially in a psychiatric liaison setting.

Hashimoto thyroiditis was discovered by Hakaru Hashimoto in 1912 but became more recognized in the 1950s. It is an autoimmune disorder with an incidence rate of about 0.8/1000/year in men and 3.5/1000/year in women. The inheritance pattern of Hashimoto thyroiditis is not fully understood and diagnosing this condition could be challenging. Among many presentations, its effects on mental health can lead to a greater burden on a patient. There has been an increased report of acute psychiatric symptoms in this condition. Literature has described a wide spectrum of psychiatric manifestations occurring prior to, during, and after this illness. The aim of this report is to describe a woman with diagnosed psychosis secondary to Hashimoto's thyroiditis.

Ms S is a 22-year-old female who was admitted in January 2021 to the emergency department of Hospital B with a history of sudden behavioural changes: agitation, responding to unseen stimuli, and bizarre behaviour.

Her previous record reveals that she had a similar presentation in November 2019, managed with antipsychotics. The diagnosis at the time was unclear however; meningoencephalitis was suspected and later for NDMA encephalitis. After 4 months of admission to Hospital A, her behavioural changes remained unresolved but she was discharged to a care home with 2:1 support. She remained in the care home until further deterioration, which warranted a further admission to Hospital B.

Following a psychiatric review in Hospital B, she was initially diagnosed with an Acute psychotic episode with query cause and managed with IM Aripiprazole.

Due to physical health concerns and the unclear nature of her diagnosis, she was transferred to the acute medical ward and further investigation was requested.

Her result showed significantly elevated Thyroid Peroxidase Antibodies of 845 IU/ml (normal up to 24 IU/ml), lumbar puncture and NMDA antibody test were both normal, TSH level was raised to 6.73. Following further discussion with the medical team, a diagnosis of Psychosis secondary to Hashimoto's thyroiditis was made.

She was co-managed by the psychiatrist, endocrinologist and others.

Ms S became settled but due to residual psychosis, she was transferred to an inpatient psychiatric ward where her psychosis resolved, and was discharged back to the community mental health services.

As a result of the late diagnosis of her condition and delayed hospital stay, Ms. S developed a lot of mistrust for the services as she believe that the 19-month delay had significantly impacted her quality of life.

Diagnosis of psychosis secondary to Hashimoto's thyroiditis requires a high index of suspicion, missing this could lead to inappropriate use of medication and increased mobility.

Nonorganic visual loss, or functional blindness, is estimated to account for up to 5% of all presentations of blindness. This form of blindness can be ascribed to either a psychogenic aetiology or to malingering. Psychogenic blindness is often a manifestation of conversion disorder, in which a psychiatric condition impairs the normal physical functioning of the affected individual. This could lead to both motor and sensory defects, given that they are not better explained by an organic cause, which should be ruled out by investigations that prove an intact visual system. The individual would also commonly have an identifiable source of stress or trauma. Conversion disorders are less prevalent in older adults, and they may be missed where there are organic comorbidities.

A 67-year-old male with a recent history of stroke was diagnosed with a major depressive disorder, characterized by low mood, anhedonia, insomnia, fatigue, poor appetite, poor concentration, feelings of guilt, negative feelings about life, and hopelessness. Multiple social problems and family conflicts were identified as possible precipitating factors. Sertraline led to some good initial response, although it was later discontinued. A few months later, he developed severe depression with irritability and suicidal ideation, and he was repeatedly requesting euthanasia. At this point, there was a sudden loss of his vision. Following a thorough ophthalmology evaluation, neurological assessment, and investigations including MRI of the head, cortical blindness was ruled out. As a result, he was diagnosed with visual conversion disorder. After recommencing treatment for his depression with a psychotherapeutic approach as well as vortioxetine antidepressant medication, the visual loss resolved, and the issue has not recurred since then. There was also a significant improvement in his mood. He no longer feels suicidal and appears to be brighter and more socially interactive.

Uncertainty regarding aetiology might initially arise if the patient has a history of trauma or a pathological condition that could cause blindness, such as diabetic retinopathy or stroke, both of which would have been differential diagnoses in the patient in this case had they not been debunked by further investigations, which included neuro-ophthalmic assessments and radiographic studies. The patient's improvement with antidepressants and counselling further supports the diagnosis of visual conversion disorder.

Functional blindness, which is an aspect of conversion disorder, may be a representation of how detrimental undiagnosed and untreated depression could be.

Mental health comorbidity is higher in those with learning disability especially those who are within forensic services than the general population and diagnostic overshadowing is a particular problem. Hence, all behavioural or mental health related presentations are often attributed to the learning disability and vice versa without an adequate investigation of the causes of learning disability. This is a case report of a young male with mild LD with longstanding mental health and behavioural problem who was described as having a personality disorder in the community. Systematic diagnostic evaluation showed the presence of 22q11.2 Duplication Syndrome. While adding to the sparse literature on the behavioural and physical phenotype of the syndrome, it also allowed his mental health presentation to be re-formulated. This changed his treatment plan and outcome.

28-year-old, single, Caucasian male with delayed developmental milestones who was referred to Children Mental Health Services for behavioural difficulties and ADHD-like features. In early adulthood, behavioural problems continued with aggression towards others and was under the care of a community mental health team although with lack of diagnostic clarity and poor compliance. Violence towards self and others led to several short hospital admissions, mainly because he tended to discharge himself against medical advice. The predominant diagnostic formulation was one of a young man with mild learning disability + psychosis related to substance misuse + personality disorder. Facing multiple charges of assault, the court, on medical advice, gave him a hospital order to a medium secure unit for people with learning disabilities where he went through a detailed and systematic diagnostic evaluation that revealed several new findings. Based on this, he went through the 10-point-treatment programme.

Clinicians need to be aware of diagnostic overshadowing leading to misattribution and consequently poor treatment. In this case, the sensory impairments associated with 22q11.2 Duplication Syndrome affected his communication. His tunnel vision led him to bump into people in pubs and other public places giving impression of deliberate antisocial behaviour. The atypical autism, learning disability and co-existing mental illness further complicated the picture. Confirmation of the underlying genetic syndrome and its physical and behavioural phenotype led to a different diagnostic and psychological formulation from the earlier one which was based on a personality disorder. It also allowed more targeted treatment strategies and the patient could be discharged back to the community from a secure hospital setting.

22q11.2 Duplication Syndrome is a rare genetic syndrome that can cause learning disability. Its physical and behavioural phenotypic features described in literature, were all present in this patient. In addition, this case report highlights three previously unreported findings: Cochlear Nerve Atresia, Tubular Vision, the Characteristic groove and skin fold on the back of the scalp and the presence of a schizoaffective mental illness.

Catatonia is a psychomotor state characterised by a multitude of clinical signs such as abnormal movements, mutism and withdrawal. This condition is usually associated with medical and psychiatric aetiologies with potential of being life-threatening. It is usually managed with benzodiazepines, the commonest being lorazepam. In this piece of work, we would like to focus on the principles of care that should be considered whilst managing such presentations.

Case 1- 71, male with diagnosis of paranoid schizophrenia was brought to Emergency department (ED) via ambulance, as he was found ‘unresponsive’ in care home. On arrival, he was alert with GCS 11/15 and was observed to be mute, ‘gesturing’ and making purposeless movements. Following our assessment, he was administered 0.5mg of lorazepam whilst in resuscitation bay. Subsequently, he started making sounds and was given another dose of 0.5mg lorazepam. He then vocalised his thoughts and we established that his mental state had relapsed and he was harbouring paranoid delusions.

Case 2- 18, male with no prior psychiatric history was brought to ED by his parents following 3 day history of being mute, not ‘responding’, not eating or drinking and insomnia. On arrival, he was alert, pacing in the room, however remained mute. Following our assessment, he was given a 2 mg dose of lorazepam whilst in resuscitation bay as the initial 1mg showed minimal response. On later review, he was smiling, conversant and co-operative, thus allowing assessment of his unmasked mental state which was suggestive of first episode psychosis.

Following few hours, both patients reverted back to their original catatonic state.

Lorazepam can be used as a diagnostic measure in conjunction to a therapeutic intervention. A positive Lorazepam Challenge test confirms the diagnosis of catatonia. It must be borne in mind that Lorazepam is only used as a temporary holding measure to assess patient's unmasked mental state and they would need further monitoring and interventions to treat the underlying cause.

Lorazepam Challenge test can be safely used as an assessment technique for patients presenting in acute catatonia. This should be conducted in closely monitored environments namely, resuscitation bay, HDU or ITU with appropriate support and ongoing liaison with psychiatry team. Treating teams should be mindful of various patient characteristics including age, past treatment with benzodiazepines, psychiatric history to inform dose adjustments as necessary.

Disclaimer: Unable to obtain patient consent due to unstable mental state but ensured minimal patient identifiable data included.

Schizotypal disorder is characterized by pervasive patterns of odd behavior, appearance, or thinking. There is also a high degree of overlap in symptoms between schizotypal and borderline personality disorders. The following case describes a case of schizotypal disorder with borderline traits.

25-year-old female presented with history of mood fluctuations with recent low mood, anxiety and an ability to read other people's thoughts. She was admitted to hospital 4 years ago and was diagnosed with emotionally unstable personality disorder (EUPD) and mixed anxiety and depression.

She reported anxiety to leave the house due to referential and persecutory ideas, odd beliefs of being able to read people's minds and predict future. She lacked friends and also had fear of abandonment. There was intermittent impulsive self-harm behavior and reportedly harmed herself indirectly through casual sex in the past and also had two failed relationships. She denied illicit drug use. Childhood was uneventful, except that schooling was difficult due to anxiety. She was treated on Quetiapine, Fluoxetine and Promethazine. Further assessments confirmed added features of unusual perceptions, smelling things, superstitious ideas regarding colours and magical thinking. Dissociative episodes of her being a devil, expressing thoughts of slitting her throat were present.

As there was minimal improvement, Aripiprazole was tried. She had poor compliance with Aripiprazole due to the belief that it was poison. She herself requested depot injection, which was started. There has since been mild improvement in her paranoia, but social anxiety is persistent. Psychoeducation about the diagnosis was challenging, after which she accepted referral for psychotherapy.

The initial diagnosis of EUPD was inconsistent with other features like ideas of reference, strange beliefs, magical thinking, abnormal perceptions and social anxiety. On further assessments, a diagnostic clarification of schizotypal disorder was considered. This poses challenge in diagnosis and therapeutic approach due to the overlap of symptoms. Cognitive-perceptual distortions and affective symptoms of EUPD appear to overlap with disorganized and cognitive-perceptual symptoms of schizotypal disorder. Historically, borderline was separated from schizotypal personality disorder from an entity called borderline schizophrenia.

Schizotypal disorder is rarely seen as the primary reason for treatment in a clinical setting and can be misdiagnosed. The presence of co-morbid personality disorder traits can be challenging for the management decisions. It also has an impact on the individual and family for acceptance of the diagnosis and compliance to treatment.

Young people with moderate to severe mental health needs receive community services and/or referral to Child and Adolescent Mental Health Services (CAMHS). The NHS Long Term Plan acknowledges the importance of age-appropriate care for young people and, where needs are complex or severe, Tier 4 CAMHS specialist support may be considered. Whilst inpatient support is appropriate and helpful on occasion, research reflects potential risks and challenges (Cotgrove and Northover, 2021): The Gateway Programme is a multi-agency approach for professionals to provide consistent evidence-base and recommendations where young people's moderate to severe mental health difficulties combine with risk factors, including Tier 4 admission.

Working with multi-agency stakeholders, a tool was developed for commissioning, clinical, social care, education professionals, providing consistent, evidence-based approach to:

• • articulating current presenting difficulties

• • formulation

• • safeguarding concerns

• • actions

• • legal frameworks

• • confirmation of actions, contingency planning, timescales.

• • This is the SBAR Tool (Situation, Background, Assessment, Recommendations).

• • Gateway Meetings are a multi-agency model for Cheshire and Merseyside, to discuss SBARs and meet needs of young people with moderate to severe mental health difficulties or elevated risk of self-harm and suicide with:

• • risk of admission to/awaiting discharge from Tier 4 CAMHS

• • discharge from paediatric wards delayed

• • risk of care placement breakdown or custody.

• • Programme support for implementation, development and evaluation funded by Beyond Children and Young People's Transformation Programme

• • Since February 2022, 8 of 9 Local Authority Places established Gateway Meetings, with the Gateway Programme Team supporting the ninth

• • During this period, 67 Gateway Meetings reviewed 138 SBARs via multi-agency discussion. This reduced the requirement for escalation beyond teams at Place: unmet needs of children and young people are being addressed via discussion at Gateway. Connections between this activity and reduction in avoidable admissions are being explored

• • Gateway webpages and Community of Practice launched in 2022, sharing learning across teams and organisations.

Gateway stakeholder focus groups are co-producing evaluation reviewing:

• • outcomes for young people & their needs

• • avoidable admission/length of stay at Tier 4/A&E presentation/paediatric ward bed days

• • stakeholder relationships/use of resource.

Meanwhile, learning from the Gateway Model has included recognition of the complexity of implementation where interface between research, policy and practice is coherently explored in multi-agency settings.

In response, online material concerning Gateway will be complemented with recorded resources for professional learning during 2023, featuring clinicians, Local Authority colleagues and experts by experience, to further support busy professionals across different learning styles, to understand and engage with the model.

Bipolar disorder is one of the most common psychiatric illness, however the neurophysiologic basis remains unknown. Lateral ventriculomegaly is a well-recognized finding in bipolar disorder. Multiple-episode patients exhibited significantly greater ventricular volumes than first-episode patients. Traumatic brain injury is also an independent risk factor for the development of mania.We present to you a case where a patient with mania had the above mentioned risk factor and finding.

40 year old married lady hailing from a rural nuclear family presented with decreased sleep, increased talk, increased activity, elevated mood and overfamiliarity since 1 month. On further interviewing patient was found to have sustained mild head injury around 8 months ago .MRI study of the brain revealed mild lateral and third ventriculomegaly.A diagnosis of organic mania with a differential of mania with psychotic symptoms was made.

Ventriculomegaly in bipolar disorder has been reported but not in mania alone-its occurrence at illness onset or progression remains unclear. There is no literature on the prognostic value of the finding. Ventriculomegaly in our patient was found incidentally on MRI whether the finding was present prior to the head injury or is a post head injury change is unclear. There are studies which indicate development of posttraumatic ventriculomegaly in severe head injury. Nonetheless we cannot completely rule out a possibility of neurodevelopmental / neurodegenerative link in this case which maybe be independent of the head injury

There is a paucity of studies that focus on neurodevelopment and neurodegeneration as etiological basis for mania and affective disorders in general need to shift our focus on research in brain imaging in psychiatry

Dengue is caused by an arbovirus and is a common vector borne disease in south east Asia. Each year upto 400million people get infected with dengue and 40,000 die from severe dengue. Psychiatric symptoms following dengue fever is relatively uncommon. Mania is the most common psychiatric disorder reported followed by anxiety, depression and catatonia. We present to you a 19 year old girl who presented with psychosis 10 days post recovery from dengue

A 19 year old bachelors in commerce student hailing from rural south India from a middle socioeconomic family presented to us with fearfulness and decreased sleep since 1-2 days which was abrupt in onset and gradually progressive. MSE revealed a conscious and alert female with normal talk ,psychomotor activity and delusion of reference which was fleeting ,ill systematized ,hearing of voices was clear however the content of which was not elaborated upon.Her affect was fearful.Past history revealed an admission for dengue fever around 2 weeks prior to symptoms, course of which was uncomplicated and unremarkable. Diagnosis of Organic delusional disorder was made according to ICD 10 and she was started on Tablet Olanzapine 2.5mg and dose was escalated to 5mg after 3 days. Her symptoms remitted completely with 5mg and is currently doing well socially and academically

Psychiatric comorbidities of dengue fever including mania, anxiety, depression, and catatonia are mentioned in literature .The exact incidence of neuropsychiatric manifestation remains unknown due to lack of studies. Literature search revealed various case reports where patients have developed psychosis during acute phase of the illness, however we did not find any case report or studies similar to ours

Most literature on neuropsychiatric manifestations in dengue are limited to case reports. There is a need to conduct prospective follow up studies and inclusion of regular psychiatric evaluation during various phases of dengue fever

In 2020, 82 million people worldwide were forcibly displaced. In the same year, the UK received asylum applications for over 37,500 people. 76% of initial decisions made in the year to June 2022 have been grants of protection, meaning they have been awarded refugee status or humanitarian protection. However, many people wait years for a final decision on their claim. COVID-19 has exacerbated this issue and extended the backlog further. Most refugees are survivors – of transit, war, torture, trauma, loss. Recognition of the mental health needs of these survivors in countries of settlement is growing and with it an acknowledgment of the complexities faced. Despite finding relative security in their country of asylum, settlers are often faced with new psychosocial stressors as they simultaneously contend with the impact of their trauma in a foreign settings with cultural and language differences. Providing access to good quality mental health care, one that caters to these complexities, is essential.

We report the case of a 25-year-old, single, Tigrinya speaking, male Eritrean asylum seeker. In August 2022 he arrived into the UK in the back of a lorry having left Eritrea on foot three years previously having fled conscription. Whilst migrating, he was tortured, witnessed killings, was human trafficked and enslaved. Shortly after arrival in the UK he developed a psychotic illness and was admitted to an acute psychiatric ward. Treatment resistant schizophrenia emerged, clozapine was commenced and his condition improved.

The journey to clozapine was not smooth. His clinical presentation was complex, in the beginning we struggled to establish the source of his distress unsure of what was psychosis and what were symptoms of post-traumatic stress. We struggled to distinguish medication side effects from somatising. We struggled communicating, building trust, breaking down language and cultural barriers.

In order to treat the illness we had to understand it and our patient. We adopted a multidisciplinary approach to deliver, in the first instance, principals of psychological first aid: addressing the refugee agenda as part of meeting his basic needs. With time and thanks to a wonderful interpreter we were able to build trust, strong and safe lines of communication. Slowly we became better interpreters ourselves, more able to decipher his distress. The interpreter helped us to be more culturally competent, thus, building our connection stronger. As the young man's acute condition settled, he began to trust us and his psychosis abated.

Our case highlights the importance of holistic care when managing displaced individuals in psychiatric settings. Interpreters are invaluable to trauma informed practice, beyond facilitating verbal communication they can help us to understand the culture of the people we are supporting, helping us to provide connection beyond the words. Trust in the context of psychosis and trauma in a displaced individual is hard earned but should be prioritised.

There has been growing interest in regression among adolescents and young adults with Down Syndrome. Regression can also be referred to Acute Regression, Down Syndrome Regression Disorder (DSRD), Down Syndrome Disintegrative disorder (DSDD) or Unexplained Regression in Down Syndrome (URDS) and these terms are sometimes used interchangeably. Characterised by reduction in expressive language, decreased functional skills and reduced psychomotor activity, regression can result in a significant change in the long-term needs of these individuals. Reporting this case, we wanted to highlight challenges in diagnosing, treating and supporting young people with regression in Down Syndrome.

This is Case Study of a young adult with Down Syndrome presenting with symptoms of mood disorder, apathy, new-onset vocal tics and ritualistic behaviours and profound loss of expressive language - both verbal and sign language.

Diagnosis included ruling out physical causes for regression. The management remains largely symptomatic and aims to address as many as possible bio-psycho-social aspects of the concerning presentation.

Multitude of interventions and external events made it difficult to see what intervention was the most useful. Despite initial positive response to medication and behavioural strategies, a long term prognosis remains uncertain.

Clozapine is the treatment of choice in treatment resistant schizophrenia (TRS). Neutropenia is a potential life threating adverse effect associated with Clozapine treatment and one of the common reasons leading to discontinuation of Clozapine treatment. Clozapine associated neutropenia can be managed with Lithium or Granulocyte Colony Stimulating factor (G-CSF).Clozapine rechallenge in patients may often seem necessary and should follow a careful and balanced risk-benefit analysis. We present a case of a patient with TRS on Clozapine who developed neutropenia which responded to Filgrastim add on therapy and was successfully continued with Clozapine treatment.

A 29 year old female with a diagnosis of Schizophrenia since age 22 years had poor response to 4 different antipsychotics and 2 episodes of Neutropenia on separate occasions with Clozapine treatment. An inpatient Clozapine rechallenge was trialled due to poor response to the ongoing antipsychotic treatment which resulted in a decrease in the absolute neutrophil count to 1.7 *109/Litre.

An MDT decision was taken to continue Clozapine treatment with add on Filgrastim due to the severe psychopathology and poor quality of life. As per the advice from the haematologist Filgrastim injections at a dose of 30 million International Units were commenced on pro re nata (prn) basis whenever ANC dropped below 2.0*109/Litre. This strategy was successful and the patient did not develop agranulocytosis. Her psychotic symptoms also improved significantly and the patient was discharged to the community rehabilitation team.

Clozapine is often the last resort in treating refractory psychotic symptoms and this option may get limited due to adverse effects like Neutropenia and agranulocytosis. Add on therapy with G-CSF has been used in Clozapine rechallenge with various success rate and most of the supporting data are derived from case reports and case series. It is worth noting that regular and prophylactic G-CSF in absence of low neutrophil count is avoided which could mask a developing Clozapine induced Neutropenia and result in a steep drop in neutrophils.

Add on therapy with Filgrastim is a viable option when considering Clozapine rechallenge with previous history of Clozapine induced Neutropenia. It is important that a haematologist is consulted and the patient is monitored closely throughout the treatment.