Diagnosis on the way out – personality on the way in? Priorities in treatment in child and adolescent psychiatry

The scientific basis for practice in child psychiatry has developed apace. And has thrown up several quandries for an accepted paradigm for good practice anchored to the diagnostic schema developed in adult psychiatry. This paper hopes to stimulate discussion about where alternative paradigms might lead us on a path to precision medicine as applied to child psychiatry.

Research by Psychiatric Trainees and Early Career Psychiatrists—Results of a Survey From 34 Countries in Europe

Clinical psychiatric practice should be intricately linked with research work. Although psychiatric trainees and early career psychiatrists (ECPs) are in the frontline of clinical services, little is known about how much access they have to research opportunities. A semi-structured questionnaire of 35 questions—exploring research goals achieved, facilitators and barriers as well as personal context—was sent to psychiatric trainees and ECPs across Europe. The survey was disseminated through the local committees of the main professional psychiatric societies in Europe. A total of 258 individuals working in 34 European countries participated. The majority (69.8%) were psychiatric trainees within training in adult psychiatry. Most participants (69.0%) were highly interested in research, but faced major obstacles toward their research activities, such as lack of time and funding. They were highly satisfied with mentoring and publishing papers. Only half of the participants, however, had already published a scientific article, and only a few have been able to contribute to randomized clinical trials (20.9%). A large proportion of participants (87.2%) reported to conduct research after or during a mixture of working hours and after working hours. Only one tenth ever received a grant for their work. These findings highlight that the key barriers for the performance of research are lack of time and funding. Psychiatric trainees and ECPs are motivated to perform research but need support and regular opportunities.

Supporting general adult psychiatry higher trainees to develop research competencies: a training improvement project

AimsEvidence shows that research-active trusts have better clinical patient outcomes. Psychiatric trainees are required to develop knowledge and skills in research techniques and critical appraisal to enable them to practice evidence-based medicine and be research-active clinicians. This project aimed to evaluate and improve the support for developing research competencies available to general adult psychiatry higher trainees (HT) in the North-West of England.MethodGeneral Adult HT in the North–West of England completed a baseline survey in November 2019 to ascertain trainee's experience of research training provision. The following interventions were implemented to address this feedback:A trainee research handbook was produced, containing exemplar activies for developing research competencies and available training opportunities, supervisors and active research studies.The trainee research representative circulated research and training opportunities between November 2019 – August 2020.Research representatives held a trainee Question and Answer session in September 2020.All General Adult HT were asked to complete an electronic survey in November 2020 to evaluate the effect of these interventions.Result18 General Adult HT completed the baseline survey in November 2019. 29.4% of trainees thought they received enough information on research competencies and 88.9% wanted more written guidance. 38.9% of trainees knew who to contact about research within their NHS Trust and 33.3% were aware of current research studies. Identified challenges for meeting research competencies included lack of time, difficulty identifying a mentor and topic and accessibility of projects.20 General Adult HT completed the repeat survey in November 2020. 50% of trainees wanted to be actively involved in research and 35% wanted to develop evidence-based medicine skills. A minority of trainees aimed to complete only the minimum ARCP requirements. All trainees thought the handbook was a useful resource for meeting research competencies and would recommend it to other trainees. In trainees who received the handbook, 94.7% thought they had received adequate support on meeting research competencies and 94.7% knew who to contact about research in their trust. 68.4% of trainees would like further written guidance on meeting research competencies. Trainees highlighted ongoing practical difficulties with engaging with research and concern about lacking required skills for research.ConclusionTrainees are motivated to engage with research on various different levels, not purely for ARCP purposes. Simple interventions can help trainees feel adequately supported with meeting research competencies. Further work to support trainee involvement in research and improve trainee confidence in engaging with research is required.

An audit: fitness to drive assessment in inpatients of general adult and old age psychiatry

AimsTo determine if fitness to drive is assessed on admission and discharge, if applicable, and for this to be documented during clerking and on discharge notifications.To determine if patients are being educated about the impact of their condition on the ability to safely drive.To ascertain if patients are aware of the duty to inform the DVLA if they for any reason are not fit to drive.BackgroundRisk factors include social, behavior and iatrogenic factors such as social withdrawal, increased likelihood of substance abuse and side effects of anti-psychotic medication.MethodThis trust wide audit involved the random sampling of a total of 71 case notes, 4 case notes per Consultant team in general adult psychiatry and old age psychiatry across Dudley and Walsall sites (total of 3 sites). A data collection tool was developed and included relevant questions regarding fitness to drive. Data were collected between October and December 2019.Result18/49 patients had physical health screening prior to medication initiation.ConclusionAn important aspect of good medical practice is to educate patients about their condition, this includes their fitness to drive as this can be affected both by their diagnosis and medication. It is clear that clinicians also need to be educated about this responsibility to ensure assessment is performed especially on inpatient discharge.

Experience of tele-psychiatry during COVID-19 amongst doctors working in a mental health trust: A survey

AimsThere is paucity of information about perspectives of psychiatrists about telemedicine practice during COVID-19 pandemic. It was intended to explore the experience of doctors using tele-psychiatry for provision of clinical care during the COVID-19 pandemic in a Mental Health Trust covering four cities in West Midlands, UK.MethodThe study was conducted as an anonymized questionnaire survey. A 10-item questionnaire was designed with items related to the clinical outcomes, challenges and provider satisfaction when using tele-psychiatry. It had mostly yes/no dichotomous responses along with the scope for making additional comments for each question. An online link of the questionnaire was sent via email to doctors of all grades working across the Black Country Healthcare NHS foundation Trust, in the West Midlands. The survey was open between July and October 2020; and monthly reminders were sent.ResultThe questionnaire was sent out to 159 doctors and 34 responded (response rate of 21.3%). Just over 50% had used both telephone and video consultations, whereas 47.1% responders had used telephone only. More than half (55.8%) reported that the tele-psychiatry affected clinical outcomes; and it was considered positive in around half (52.9%). Most (73.5%) of the responders found that limitations or challenges of using technology impacted on delivery of care remotely. However 64.7% psychiatrists were satisfied with the process overall; and 79.4% reported that they would like to use tele-psychiatry in the future as well.Survey captured many observations from the psychiatrists. Positive comments from the psychiatrists included expedited delivery of care, reduced non-attendance rates, as well as successful multidisciplinary meetings. Challenges in specific sub-specialties such as Child and Adolescent Psychiatry or Older Adult psychiatry were reported where complete assessments were not achieved successfully. The process was felt to be appropriate in general for stable or follow-up patients in comparison to new or acutely unwell patients. There was some worry expressed about missing out non-verbal cues which assist with mental state examination.ConclusionInspite of a low response rate, the survey provided some understanding about the experience of doctors practicing tele-psychiatry during pandemic. While technological challenges were acknowledged, tele-psychiatry seemed to have been accepted by a majority of doctors who are also willing to continue it in their future clinical practice. There is a need to explore in a larger sample involving both patients and clinicians about the beneficial effects of tele-psychiatry that can be incorporated in the usual psychiatric practice.

Audit of follow-up within 7 days on discharge from the mental health unit, Forth Valley Royal Hospital

AimsTo determine compliance with the new discharge policy of review within 7-days for all General Adult Psychiatry patients discharged from Forth Valley Royal Hospital.BackgroundIt is well established that there is an increased risk of suicide following discharge from Inpatient Psychiatric Wards. This risk is significantly increased in the first month, and particularly high in the first week.In their 2016 Guidance, NICE recommends follow-up within 7 days of discharge. It is not known whether seven day follow-up reduces suicide risk but it is clearly an opportunity for risk assessment and management during a particularly risky period.This standard was adopted by the General Adult Wards in Mental Health Unit at Forth Valley Royal Hospital in April 2019.MethodAll discharges from Wards 1, 2 and 3, Forth Valley Royal Hospital were reviewed during three distinct, month-long periods:November 2018 (prior to the introduction of the new discharge policy)May 2019 (shortly after the introduction of the new discharge policy)September 2019 (six months after the introduction of the new discharge policy)A list was obtained from Medical Records of all General Adult patients discharged in these periods. The paper and electronic records were checked for each patient, and the first scheduled care episode post discharge was taken as follow-up.ResultIn the1st round of audit (November 2018): 41 patients were discharged and 26 patients (64%) received follow-up within 7 days.In the 2nd round of audit (May 2019): 46 patients were discharged, 39 patients (84%) received follow-up within 7 days.In the 3rd round of the audit (September 2019), 50 patients were discharged and 49 (98%) received follow-up within 7 days.ConclusionThere has been a clear improvement in the provision of follow-up on discharge from the General Adult Psychiatry Wards in Forth Valley Royal Hospital.The new discharge policy was implemented in April 2019 and a “Discharge Pause” was introduced (initially a sticker, now an electronic form) to be completed by the medical team at the point when it was decided to discharge.Community Mental Health Teams have also been reminded of their need to facilitate seven day follow-up as a priority. A flowchart was produced in May 2019, which provided guidance as to who should provide the seven day follow-up.

Lithium monitoring in patients over 65 in NHS Greater Glasgow and Clyde

AimsOur aim was to identify current practice for Lithium monitoring for >65s in NHS GGC and assess compliance to local Lithium monitoring guidelines.MethodA retrospective analysis was undertaken of patient data (demographics, diagnosis, biochemistry results) with Caldicott approval at two points over the course of 2018/19. For the first analysis, old age Community Mental Health Teams (CMHTs) were approached and asked to provide a list of their patients on Lithium. This was then assessed for compliance to Lithium monitoring guidelines.For the second analysis, pharmacy provided data for every patient in the health board dispensed lithium, regardless of whether they were open to a CMHT or not. We were then able to identify patients who we had not picked up on our initial analysis, and re-assess the entire data set for compliance to Lithium monitoring guidelines.ResultFrom our first analysis, 13 CMHTs identified 155 patients on Lithium. There was a high variability in how these patients were identified. 44% of patients were monitored by CMHTs who took bloods and chased them, 38% were monitored by GPs who were prompted by CMHTs in routine clinic letters, and 14% were monitored by GPs who were prompted by CMHTs more assertively using a lithium register. Overall, Lithium plasma monitoring was done well irrespective of method (91%), however compliance to the local standards was poor (58%) with proactive CMHT prompting GPs appearing to be the most effective method (71%).In our second analysis, we identified 508 patients >65 in NHS GGC prescribed Lithium. Of those, 44% were open to old age psychiatry, 25% general adult psychiatry and 19% were not open to anyone. Of those open to old age services, only 58% had been identified in the previous audit. Lithium monitoring compliance was better in those open to a CMHT versus those not (61% to 23%), and better in CMHTs where monitoring was done by CMHTs rather than GPs. For each CMHT, there were roughly 7 patients per catchment area on Lithium not open to psychiatry.ConclusionLithium monitoring does appear to be highly variable and not particularly compliant with local standards. CMHTs have inconsistent methods of identifying patients prescribed Lithium. There are a significant number of patients not open to old age CMHTs prescribed Lithium, and these patients have poorer compliance to Lithium monitoring. Of patients open to CMHTs, CMHT-led monitoring appears superior to other forms.

Improving physical health form completion on a general inpatient adult ward

AimsThe government's Five Year Forward View Plan for Mental Health has set a target for 280,000 people with severe mental health problems to be offered screening and appropriate intervention based on physical health risk stratification, including obesity, diabetes and heart disease. As such, physical health review for patients on a general inpatient adult psychiatry ward includes routine blood tests for cholesterol levels and HbA1c. They are recorded together in a Physical Health (PH) Form in the patient's electronic record and used to stratify cardiovascular risk factors and risk of diabetes. If a patient declines these blood tests it should be recorded on the PH form.This study aims to improve the completion of Physical Health forms to ≥95% by within a 4-month period on a general adult inpatient psychiatric ward.MethodPH form completion was measured using Tableau Software for a 4-week period as a baseline then fortnightly during the study. PH form completion required HbA1c and cholesterol levels to be inputted, or to be marked as declined where the patient had declined these tests. Potential interventions were discussed by clinicians and implemented using PDSA cycles with iterative changes tested and analysed. PH form completion was re-audited monthly for a 6-month period.ResultBaseline data showed 61.54% of patients had physical health forms completed (n = 26; 61.54% with HbA1c, 76.92% with cholesterol completed). Iterative changes and improvements included; (i) paper list to track PH form completion, (ii) table on Microsoft Word, (iii) Excel spreadsheet, and (iv) a conditionally formatted Excel spreadsheet. The conditionally formatted Excel spreadsheet was colour-coded to show completed elements as green and incomplete elements as red.Paper lists increased PH completion to 84.85% (n = 33). Word table increased PH completion to 96.43% (n = 28). Excel spreadsheet had PH completion of 96.67% (n = 30). Colour coded excel spreadsheet increased PH completion to 100% (n = 28). This was used as standard practice with sustained 100% completion in November (n = 34) and December (n = 39). The improvement was sustained to January 2021, although there was a decrease to 97.7% (n = 30).ConclusionIt was hypothesised an intervention to track completion of PH forms would improve completion rate. The use of a colour-coded conditionally formatted Excel spreadsheet improved PH form completion to 100% within an 8-week period and a sustained increase of >95% 6 months after the study began. This study recommends the use of such an electronic record keeping system to assist with PH form completion.