The traditional ‘one size fits all’ model within secondary care mental health (MH) settings of regular appointments scheduled by a clinician at defined intervals isn't always responsive to an individual's changing needs. Previous reviews have shown significant levels of patient and clinician satisfaction with Patient initiated models of review in a variety of healthcare settings but its use within secondary care MH settings has been relatively limited. We describe the development and implementation of a Patient initiated follow-up (PIFU) pathway within MH services in NHS Greater Glasgow and Clyde (GG&C).

The pathway was developed by a small working group of clinicians with input from local management and eHealth colleagues with an emphasis on the principles of Realistic Medicine. There was input from peer support workers and the Mental Health network, a local service user organisation, into the development of the pathway. The pathway underwent a ‘test of implementation’ within three adult CMHT's with support from the development group. Feedback from the test sites was used to modify the pathway and ultimately support the wider rollout of the model across all seventeen CMHTs within NHS GG&C over the course of 2021. Formal evaluation of the pathway, including patient and clinician satisfaction, service utilisation as well as safety measures, is due to be undertaken at 12 months after full implementation.

The tests of implementation identified a range of factors that needed to be considered as part of the introduction of a PIFU model into MH settings.

Patient choice and shared decision making along with other clinical factors such as level of insight, availability of other supports, shared risk assessments and current clinical need were identified as relevant patient related factors. Clinician related factors included concerns about applicability within MH settings, perception of risk, increase in workload and appropriate identification of suitable patients. Regular meetings between the clinicians in the test sites and members of the development group as part of the implementation process helped address clinicians concerns and ultimately supported uptake of the model.

Our experience highlighted the potential for a personalised approach to care planning in empowering patients have a more active role in the way they access services as part of their recovery journey. It also highlighted patient and clinician related factors that need to be considered for a successful adoption of the model.

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.

The Royal College of Psychiatrists’ Fair Deal (RCPsych 2008) highlighted the far-reaching impact of stigma and discrimination on the lives of people with mental illness. The pervading nature of stigma has been acknowledged in recent national and international mental health policies (WHO). The World Health Organisation reiterates people affected by mental illness should not suffer social exclusion and marginalisation due to stigma.

A sixty-year-old gentleman presented to the Emergency Department following self-inflicted stabbing to the neck resulting in pharyngeal tear and surgical repair. Previous psychiatric history included inpatient admission on Section 2 following a major depressive episode. On this admission, inpatient psychiatric review elicited three months of psychotropic medication non-adherence due to difficulties the patient had encountered in acquiring repeat medications from his GP. He had relapsed into alcohol misuse as a coping mechanism culminating in a suicide attempt at home with a knife. Upon recommencing of sertraline and risperidone during admission, he was assessed as euthymic with low risk to self. The patient had been previously abstinent from alcohol and described religion as a protective factor. Prior to discharge, the patient's GP stated he must present to the surgery in person with a form of identification. This is despite CQC guidance stipulating practices should not refuse patients registration if proof of identity cannot be produced.

This case illustrates the socioeconomic factors increasing likelihood of suicide including forensic history, low financial status, unstable housing and lack of social support. Substance dependence is a risk factor that can be reduced by supporting patients in accessing specialist misuse input from inpatient and community teams. The patient reported fear of stigmatisation and criminalisation which led to the avoidance of seeking treatment, deterioration in mental health and severe clinical consequences. It is imperative marginalised patients with mental illness can access quality health care and this starts with GP registration.

Forensic mental health patients experience multiple stigmas impacting on well-being including social, institutional and media stigmatisation and high levels of internalised stigma. The Time to Change campaign focused on changing attitudes and behaviour however evaluation illustrated difficulties in tackling this issue. Healthcare professionals should be mindful to avoid stigmatising language and actions to ensure fairness in care. There is a need for the medical profession to continue striving for a tangible shift in attitudes. Advocating for those with mental illness can enhance quality of life for vulnerable patient groups.

Ataque de nervios is a culture-bound syndrome among individuals of Latin descent.The case study presents an ataque de nervios case triggered by unique stressors in a transgender female of Mexican origin. This case also highlights the critical features of ataque de nervios, and discusses the challenges in diagnosis, classification and management.

47-year-old transgender (male to female) woman was admitted to an acute female inpatient unit following a presentation of erratic behaviour and a collapse episode under mental health act. During her observation and assessment period, multiple ataque episodes were observed with characteristic features triggered by gender phobic comments. After ruling out the organic causes and ruling out other differentials, she was diagnosed with ataque de nervios. She completed her treatment and continues to remain on remission.

The case presents a rather recognized presentation of ataque de nervios, however, the unique triggers rooted from her gender identity are more relevant to the current 21st century social context which is also an important ongoing discussion topic in psychiatry. The themes are also good presentation of the evolving psychosocial context of the specialty.

Further study is needed to examine the relationship between ataque de nervios and gender identity, as well as the relationship to cultural, demographic, environmental, and personality factors.

A 46-year-old man has a diagnosis of schizoaffective disorder complained of intermittent abdominal pain for many years. Due to this, he had been reviewed by the GP and he was prescribed medication to help with his intermittent abdominal pain.

Over the years the abdominal pain gradually worsened. He also has communication issues due to language barriers and was unsettled for most of his assessment.

His past medical history includes a duodenal ulcer, infected swollen legs and recurrent urinary tract infections.

He continued to have pyrexia despite being on regular paracetamol. Following his second episode of pyrexia, he was referred to the hospital for further investigation.

This was found to be acute acalculus cholecystitis, with possible cholecystocolic fistula and pneumonia. He was managed conservatively with intravenous antibiotics and is awaiting cholecystectomy.

Behavioural change in people with mental illness need not necessarily be linked to their mental state as it can very well be the atypical manifestation of physical illnesses- some of which could be fatal. Prompt recognition and referral to acute medical or surgical services is essential. Staff need training in bias, diagnostic overshadowing and atypical presentations in those with mental illness which will help reduce rates of avoidable morbidity and premature mortality.

In any case physical illnesses may not present typically. Acalculous cholecystitis is a rare type of gall bladder inflammation and the cause in Mr X's case is not clear. At times of COVID-19, with the anxieties around exposure to hospitals and infections, it is important to be aware of this and ensure that people with worrying physical symptoms are promptly referred whether or not it is considered to be related to COVID-19.

Due to the pandemic, we were cautious on the ward and community about COVID-19 and preventing catching and spreading the infection. During all this, patients change of behaviour shouldn't be alluded to deterioration of mental health and mental health professionals should also consider ruling out physical causes for the change of presentation.

We present outcomes of a newly developed Community Rehabilitation team (MhIST) using the context of Jen's personal story. Jen is a 31-year-old student and freelance journalist. This story encompasses her journey from inpatient rehabilitation services to the community, completed with support from MhIST.

“For nearly four years, I was sectioned under the Mental Health Act as an inpatient in hospital. As I had been denied my fundamental liberties for so long, the prospect of leaving hospital for good and enjoying total freedom was both exhilarating and terrifying. How would I fare in the community, living on my own? Would I be lonely? Would I relapse? Would I survive?”

Upon leaving hospital, I immediately received intensive support from MhIST. They were the bridge between the gulf that was hospital and the community. Since leaving hospital, I have been relishing my freedom. I enjoy meeting up with my friends after so long apart. I have volunteered at The Storyhouse, a local arts venue. The Spider Project – a non-clinical community mental health service in Chester - has also provided me with fulfilling activities from yoga to creative writing. The MHIST team have not only kept me well but, most importantly, helped me thrive. Leaving hospital has been an adventure. It has been a joy to regain my independence and freedom. To live rather than to exist. Life is amazing. Long may it continue.”

MhIST provides an intensive rehabilitation and recovery service, delivering bespoke packages of care to individuals. This is achieved using key working and a shared team approach, outcome focused goal-based interventions, weekly reflective/formulation meetings, and a focus on social rehabilitation. Patients referred to MhIST will have a high level of complexity plus severe, treatment refractory symptoms, with impaired social, interpersonal and occupational function and high support needs. They may have co-occurring mental health conditions including substance misuse or neurodevelopmental disorders.

MhIST is a new service and has been active for around 6 months. The first 10 patients referred have been from acute wards (3), community mental health teams (1), and inpatient rehabilitation wards (6). 60% of patients are currently housed in independent accommodation.

Jen's story narrates the experience she encountered during transition from inpatient rehabilitation services to the community. This was completed with support from MhIST, a new community rehabilitation service which provides an intensive rehabilitation and recovery service.

The National Institute for Health and Care Excellence (NICE) guidance on the management of behaviour that challenges in autism, is that medication should be considered when psychosocial or other interventions cannot be delivered because of the severity of the behaviour. In our experience of working in Secure and Specialist Learning Disability, there are also times when challenging behaviour continues despite non-pharmacological interventions being optimised. There is (limited) evidence that clozapine should be considered for the management of aggression in patients with autism not improved by first-line antipsychotic drugs.

We present two cases of female patients with autism and learning disability, both of whom had been detained for a long period under the Mental Health Act 1983. Both continued to present with significant aggression despite non-pharmacological treatment being optimised. The aggression did not respond to first-line antipsychotic drugs, nor other psychotropic medication. They were started on clozapine.

In the first case, that of a 32-year-old, aggressive incidents reduced from a mean of 15 per month to 5 per month. The use of physical restraint reduced from 10 episodes per month to 5 per month. Staff reported that aggression was less severe than previously. Due to the improvement, the patient began having access to escorted community leave.

In the second case, that of a 31-year-old, incidents of aggression requiring floor restraint reduced from a mean of 30 episodes per month to 15 per month. The average monthly duration of restraint reduced from 29.5 minutes to 18.5 minutes. Although difficult to quantify, the staff team consistently reported that her level of arousal at times of incidents was less. Her engagement levels also increased. She became more tolerant of people being in her living space and actively sought out contact with staff.

Clozapine resulted in a reduction in aggression and arguably, improved quality of life, for the two patients described. We make recommendations on when clozapine could be considered for treatment resistant aggression in autism and what should be done before this. We also provide guidance on how a therapeutic trial should be conducted, in line with Stopping Over Medication of People with a Learning Disability, autism or both with psychotropic medicines (STOMP-LD).

It is reasonable to consider clozapine for aggression in autism when all other interventions have failed. It may result in meaningful change and improved quality of life.

The aim of this audit is to look at the presentation of women who were pregnant or less than one-year post-partum presenting with psychotic symptoms in the A&E Department, general hospital and calls to crisis line, particularly with the fact that the pandemic impact remains on the nation. Our aim was to ensure that all referred patients were assessed within the first 24 hours, all the assessments were completed face-to-face, a biopsychosocial assessment was completed for each patient and an outcome was agreed on and clearly documented in the notes.

All referrals to West Essex access and assessment team from the A&E department, the general hospital and calls logged to crisis line were included. Data were collected prospectively over a six-month period from mid-November 2020 to mid-April 2021. For the purpose of this audit, an identification form was designed and disseminated to access and assessment and crisis teams to identify illegible patients. Our data collectors then used the main audit tool to gather the data.

In total, our sample included sixteen patients who met our criteria over the six months period. There was only one patient who was out of area. Most of the patients were of white British ethnicity (ten out of sixteen) and other six patients were five white other and one of Asian origin. The mean maternal age in our sample was 27.3 years old and the majority of the referrals came from the labour ward in Princess Alexandra hospital (57%). The two main outcomes of our audit were to check the response time and the way the initial assessment was carried over. Our results show that the team responded to all referrals on the same day with no delays. All the assessments were carried out in a face-to-face fashion in the general hospital apart from one assessment that came through the crisis line and this was carried out in the patient's home.

From our data we can identify that the access and assessment team met the standards we set for this audit. This fulfills the recommendations of MBRRACE-report and the RCPsych. One of our recommendations was to provide educational sessions to the emergency department in the general hospital to raise awareness on psychotic presentation during perinatal period.

This Service Survey is a part of a Quality improvement project which aims to :1- To assess the extent of the problem regarding accessing Adult ADHD assessment and treatment by getting the views of clinicians.2- Evaluate negative impact on care coordinators of the delay in accessing timely and effective diagnosis and treatment of ADHD; This will: a-Increase understanding of the care needed by this patient group. b-Clarify current practice and any difficulties staff face in condition management when diagnosis not confirmed i.e. outline training needs. c-Determine if waiting time for diagnosis results in iatrogenic harm (deterioration driven by ‘unmet need’). 3-Inform the development of an alternative pathway of care; thus: a-Reduce inequality of healthcare access for those with this neurodevelopmental condition. b-Reduce stigma. c-Improve service user health and well-being. d-Support families and carers. e-Reduce social costs to individual and community. f-Support community staff and increase knowledge and effectiveness.

Methods of the service survey part:

1. 1. Service survey: Sent to 21 consultants who are working in Adult CMHT.

2. 2. Service Satisfaction survey for all of the Redcar & Cleveland Affective disorder team's clinical staff members (18).

11 consultants responded out of 21 (52%)

Approximate number of the diagnosed ADHD patients / team varied between 7–80 patients.

Wait time for an ADHD assessment varied between 12 -30 months.

Number of patients/ team waiting for assessments by the specialist team 2- 27 patients.

50% of the consultants reported significant delays between referral to the services and initiation of treatment 6–36 months.

All consultants reported commencing treatment of ADHD, if a patient already had the diagnosis.

9/11 (82%) consultants reported making the initial diagnosis and treating ADHD patients in CMHTs. However, all consultant reported the need for further training in assessment and management of ADHD patients.

6/11 (55%) consultants stated that ADHD patients should be managed in CMHTs provided they are care coordinated by another clinician.

All 3 staffs responded out of 18 staff, reported un satisfaction with the current service provision.

1. 1. The current service model is not able to meet the increasing demand for the services and leading to significant delay in accessing appropriate treatment.

2. 2. There is a need to improve competencies of community mental health teams to manage these patients.

3. 3. This survey will be used to model a new care pathway.

Development of an eating disorder in childhood has been shown to predict sleep disturbance in adulthood. Both the National Institute of Health and Care Excellence (NICE) and the wider scientific literature support interventions to help support patients with their sleep. The aim of this project was to evaluate the perceived benefits of the Sleep and Dreams Group to adult patients with anorexia nervosa (AN) on a specialist eating disorders unit.

Adult patients with severe AN on an inpatient specialist eating disorders unit attended a 6 session, once weekly group on a voluntary basis. The therapeutic group included psychoeducation around sleep hygiene, and an experiential component focusing on sleep/dreaming context of inpatient treatment of severe AN.

All participants(n = 6) either agreed or strongly agreed that their understanding of sleep and dreams had improved. Quality of sleep strongly improved in 20% of participants, however, the remainder reported no significant change in this domain. Despite this, 80% of participants agreed or strongly agreed they got what they wanted from the group, finding the content of the psychoeducation material slightly positive or very positive. The total program length was thought to be appropriate, with 80% describing this as very positive.

The impact of the group on quality of sleep was variable, these results indicate that the value of the group to participants was found in the intergroup processes as evidenced by positive evaluation. This is of particular relevance to severe AN, where interpersonal deficits are often seen and from a treatment perspective in addressing the isolating nature of the disorder. Suggestions for improvement included bolstering the interactive component, and assessing participants regarding eligibility for dream discussion to aid formulation work of the unit.

Balint groups were initially set up to meet the needs of GPs in better understanding the emotional aspects of complex doctor-patient relationships. They have since been taken up in the training of psychiatrists, GPs, and medical students, having been shown to improve communication skills and sensitise participants to their own psychological processes. Working as a Care Coordinator in a Forensic Community team is a highly challenging role where, by definition, there is the spectre of risk of harm to others. There is very little published data on the use of Balint groups in nursing populations, even less so in the Forensic mental health setting. The aim of this project was to evaluate a longitudinal Balint group for mental health professionals in the Forensic service of Cambridge and Peterborough NHS Foundation Trust, and to report on the perceived benefits to attending in terms of personal and professional development.

The evaluation used a standardised mixed methods approach, with the sample consisting of members of the Forensic South Community Service Balint group n = 5. For the evaluation period the job roles were solely clinical nurse specialists, taking a snapshot of the group between September 2020 and January 2022. The group met monthly for one hour virtually, led by Dr Arends, a specialist registrar in psychiatry with appropriate training in Balint leadership. The format in sessions was in keeping with the Balint method, as per The Balint Society, emphasising confidentiality. Data were gathered via survey tool, adapted from the literature using Likert scales and white space questions to identify barriers and facilitators.

Participants scored the group highly across the board in terms of acceptability, clinical impact, and fidelity measures. Notably 60% strongly agreed and 40% agreed the group was a safe place to express and process anxieties and frustrations about their work. All participants either agreed or strongly agreed the group had changed the way they think and practice, and that they felt able to consider their clinical encounters in a new light.

Facilitators identified were of increased team working through cohesion and notably of increased appreciation for the functional and symbolic elements of the symptoms their patients presented with, suggesting that the value of the group existed in its providing of space to metabolise the often intense demands of Forensic patients, together and as a team. The main theme within barriers to the group processes were external in terms of other clinical demands requiring prioritisation.

The worldwide prevalence of Attention Deficit and Hyperactivity Disorder (ADHD) in the adult population is estimated to be 2.5%. Prevalence studies have shown rates to be consistently around ten times higher in the prison population, but there is less known about secure psychiatric hospital populations. ADHD has relevance as a predictor for offending, for challenging behaviours when incarcerated, for lower quality of life and high costs for both the NHS and prison systems. This service evaluation aimed to establish estimated prevalence of ADHD within one male medium secure unit.

A cross sectional review of computerised medical records for all service users on the male medium secure forensic unit took place, to identify those who met inclusion criteria. Service users who were too acutely unwell or had an established or pending diagnosis of ADHD were excluded.

The Brief Barkley Adult ADHD Rating Scale (B-BAARS), a 5 minute screening questionnaire, was given to service users to complete. Anonymised responses were converted to electronic format and the compiled results analysed.

There were 125 service users at the time of information gathering, with 112 eligible according to inclusion and exclusion criteria. 2 of the excluded service users already had an ADHD diagnosis. 70 service users out of those approached, agreed to take part in the screening (62.5%). 2 out of 70 (2.9%) service users met criteria for a possible diagnosis of ADHD.

Using the B-BAARS, 2.9% of service users on the male medium secure forensic unit reported clinically significant symptoms suggestive of a diagnosis of ADHD. This estimate is significantly lower than other studies in prison settings. When combined with the figure for service users with a pre-existing diagnosis, however, the figure is still higher than in the general population (5.5% compared to 2.5%), and illustrates that screening tools can have a useful function in forensic settings.

There may have been methodological issues with this evaluation, including the self-reported nature of symptoms, the comparatively high level of functioning required to complete the questionnaire and the low response rate amongst the service users.

This evaluation serves to increase awareness about ADHD in the forensic population in general. It also highlights the value of this simple screening tool, or one similar, to clinical teams on the forensic wards. The screening tool could be further utilised in low secure and women's services to establish if results are similar amongst these populations.

Whilst the majority of age groups are seeing a decline in numbers in prison custody, the older male population continues to rise year on year. This unexpected trend has led researchers to investigate the needs of this particular cohort in more detail and start to question if the prison estate is able to care for the specific needs of the ageing population. This primary research specifically, looks to investigate what relationship, if any knowledge and attitudes to dementia have on how the confidence in practice levels of non-healthcare prison staff

This research, in a specific, applied context considers the relationship between attitudes toward the prison estate alongside knowledge and attitudes toward dementia in general and the potential relationship these may have on confidence levels. To do this, the research scored individuals’ responses against the dementia knowledge assessment scale, attitudes to the prison estate and general attitudes toward dementia. These three independent variables were measured both overall and individually against individual confidence in practices scores. 50 individuals participated with differing roles and length of service in the prison estate

The results of the study found that the overall model was significant. Of the three independent variables, it was found that positive attitudes to dementia were the most influential predictor of confidence. Knowledge of the condition and attitudes to the prison estate, the second and third independent variable however were not significant predictors of confidence in practice levels. Overall, the results indicate that there is a relationship between knowledge, attitudes, and confidence in delivery of dementia care in the prison estate as an overall model.

The main objective of this study was to determine the knowledge and attitudes to dementia of non-healthcare prison staff and if that knowledge and those attitudes had an impact on confidence in practice levels. It could be argued that this research has fulfilled its primary aim, reporting that knowledge about and attitudes toward dementia scores are a significant predictor of knowledge of the condition in non-healthcare-based staff.

To determine the utilization of mental health (MH) services, antipsychotic use and weight gain 3 years after discharge from an Early Intervention Service (EIS).

A retrospective anonymized survey was conducted of the trust electronic records of patients discharged from Barnet EIS in April to May 2018. 25 case records were identified of which 4 were excluded due to relocation out of area. Information was reviewed from the time of referral to 3 years post discharge. Data included patient demographics, number of referrals to home treatment team (HTT), inpatient admissions, medication and cardiometabolic parameters (weight and HbA1c) during this period.

21 records were analysed - 13 males, 3 females, average age of 24 years. 12 patients had been discharged to primary care of which 5 were re-referred to community mental health team (CMHT) during the 3 year follow-up. 9 patients were discharged to the CMHT of which 4 were later discharged to primary care.

There was no significant difference in the number of referrals to HTT and hospital admissions in the GP and CMHT follow-up groups (50% and 33%; 56% and 44% respectively). At the time of discharge from EIS 67% were on antipsychotic medication. At 3 year follow-up 90% in CMHT group continued antipsychotics. There was an average of 15.6 kg weight gain while under EIS with further 11.7 kg gain over the next 3 years under CMHT care. According to available data for those still in contact with MH services, no patients newly met criteria for pre-diabetes or diabetes. No records were available on our system pertaining to GP discharges.

We discuss the impact of EIS on affecting future MH service contact. There were a similar number of future MH referrals regardless of initial discharge destination. We consider whether there may be a different quality of these contacts that need further inspection.

The majority discharged continued taking antipsychotic medication and experienced considerable weight gain. This significant ongoing weight gain in a group of young people only starting to use MH services is of great concern due to negative cardiometabolic impact. It highlights the need for urgent proactive attention to ensure the best physical and mental health for these patients.

During the COVID-19 pandemic most clinical services changed to remote consultation and management to minimise virus transmission by direct contact. As the social distancing and restrictions have eased with greater control of the pandemic, the nature of consultations is going to change. At this juncture we intended to understand the perception and satisfaction of patients and clinicians on remote consultations and management during COVID-19 and to determine their preference about clinical engagement in the future.

This was a trust-wide anonymous survey conducted through surveymonkey. It involved both patients and mental healthcare staff (MHS) and explored about the quality and satisfaction in remote consultations, option to patients, and use of remote consultations in future. Clinicians were sent the online link to complete, with a reminder two weeks later. The patients were explained during their appointments about the survey, those who agreed to participate and gave informed consent, their responses to the questions were recorded.

The sample consisted of 78 patients and 107 MHS representing adult, old age, children and adolescent and intellectual disability subspecialties. Most (92.4%) participants had participated in remote consultations and understood the reason behind it. Around a third (32.7%) of MHS and 46.2% of patients felt strongly satisfied in remote consultations, and together with satisfaction these were 56.1% v 71.8% respectively (p < 0.05). The quality of the remote consultations were considered somewhat (11.2% v 23.1%) or a lot better (8.4% v 15.4%) by MHS and patients respectively (p < 0.05). Majority (82.7%) felt that an option should be given to patients for the type of consultation, face to face or remote. After the pandemic, the preference for psychiatric consultations were primarily face to face (30.3%), primarily remote (8.6%) and a mixture of the two (61.1%); there were no difference between patients and MHS. However while 71.4% doctors, 70.8% other clinicians (occupational therapists and psychologists) and 75.0% of clinical managers opted for mixture of face to face and remote, 26.9% of nurses opted for that. Background subspecialty, age group, ethnicity, experience of remote consultation with GP or hospital doctors, attendance or admission to general or psychiatric hospitals during pandemic, disabilities, or having COVID-19 did not influence the suggestion for the future consultation type.

Following the pandemic, both clinicians and patients express a preference for a mixture of face to face and remote consultations; and an option regarding that should be given to the patients.

Developing psychotherapeutic competencies is an essential part of psychiatric training. All core trainees in LYPFT until 2021 saw a patient for Psychodynamic Psychotherapy. The pandemic led to unprecedented changes to clinical practice and medical education. In LYPFT all face-to-face appointments in the Medical Psychotherapy Service were paused in March 2020. Patients were offered the choice to continue therapy remotely or postpone therapy. Supervision was also moved to a remote format. Face-to-face psychotherapy sessions resumed from August 2020, with new departmental procedures around infection control and the use of PPE. This project aimed to establish the junior doctors’ experience of delivering psychodynamic psychotherapy in LYPFT during the COVID-19 pandemic.

The project was carried out via a two-step methodology: Firstly with an online survey which included a quantitative analysis of the impact of the pandemic; and secondly via semi-structured interviews with a resultant thematic analysis.

22 junior doctors who were invited to participate, 15 completing the survey (68%). Four patients had deferred therapy; the mean length of deferral was 2 months. Ten respondents had sessions cancelled due to infection or self-isolation. Face-to-face delivery was experienced by 13 respondents, 5 respondents had delivered therapy via phone and 6 had delivered therapy with PPE. Thirteen were concerned about attaining their psychotherapy competencies. Seven preferred face-to-face supervision, and 4 preferred remote working.

Thematic Analysis of the semi-structured interviews identified three themes regarding the impact of the COVID-19 pandemic on Junior Doctors experience of Psychodynamic Psychotherapy, with sub-themes detailed below. Throughout the themes, the challenges and difficulties with delivering therapy in the COVID-19 pandemic, as well as areas of good practice and opportunities were identified.

The Work of Therapy (Remote Therapy, PPE and Therapy, COVID-19-related)

1. 1. The Structure of Therapy (COVID-19 Guidance, Setting/Frame of Therapy, Boundaries of Therapy)

2. 2. The Therapist's Training (Supervision, Attaining Competencies, Loss of Training Experience)

Recommendations:

1. 1. To create a short guide for junior doctors delivering Psychodynamic Psychotherapy during a pandemic.

2. 2. To consider the types of supervision delivery within the Medical Psychotherapy Service

3. 3. To ensure there is space for junior doctors within the Medical Psychotherapy department or a private space within their base placement, should remote therapy be required.

4. 4. To ensure future plans related to possible pandemic restrictions address the need for good quality and strong internet connections/WIFI

1. To evaluate clinicians’ experiences of the newly implemented remote ASD assessment process (due to COVID-19), including the long-term sustainability and potential standardisation of this approach; 2. To establish areas for improvement in this process and make further recommendations.

Members of the Neurodevelopmental MDT completed an online survey, whereby feedback was collected regarding the use of the Child Observation of Social Communication (COSC), which had been adapted for online use from the standardised Autism Diagnostic Observation (ADOS) Schedule by a senior Psychologist[.Participants also responded to questions on other assessment domains, including the Developmental, Dimensional and Diagnostic interview, feedback and formulation meetings. Questions included their comfort with performing the assessment, theirs views on the quality of care provided and any difficulties they faced. Survey data were collected on two occasions: between November and December 2020 and between July and August 2021.

Positive Experiences

63% of respondents in November-December 2020 reported that COSC was a good alternative whilst standardised ADOS was unavailable. This increased to 100% in July-August 2021. Quality of care delivered by COSC was rated to be the same as ADOS in 70% of participants November-December 2020; 25% felt quality of care delivered by COSC was better than ADOS in July-August 2021. 73% of participants reported they would continue to use the remote assessment in the November-December 2020 survey. This increased to 88% in July-August 2021. 33% of the clinicians were very comfortable with administering the COSC in July-August 2021, 56% were somewhat comfortable.

Negative Experiences

27% of the clinicians reported being somewhat uncomfortable with administering the COSC assessment in November-December 2020; 11% remained somewhat uncomfortable in July-August 2021. 30% of the participants rated the quality of care delivered by COSC worse than ADOS in November-December 2020. 37.5% rated this to be worse in July-August 2021. 77% of the respondents had technical or organisational difficulties, which could result in missing non-verbal cues during the assessment.

Clinicians’ experiences improved over time and with practice (34% had delivered over 10 COSC assessments in July-Aug 2021). A hybrid model may increase the quality of care of the approach, as well as careful selection of cases which would be suitable for an online assessment. There is scope for the continued use of the remote ASD pathway, taking into account patient and clinician preferences, however patient feedback will be necessary as a next step in this evaluation.

Identification of a psychosis risk syndrome to aid reduction of transition to a FEP is an important focus of worldwide research. ARMS for psychosis was defined by Yung and McGorry in 1996. UK EIP services were mandated to identify and ‘treat’ ARMS in the ‘Implementing the Early Intervention in Psychosis Access and Waiting Time Standard: Guidance' 2016. Sussex EIP services developed such an ARMS service with a 1-year pathway of assessment, intervention as indicated, and monitoring from 2017. Sussex serves a population of approximately 1.4 million, including areas with both low and high social deprivation indices. Transition rates from ARMS to FEP in recent studies have suggested widely varying rates of 8–17% of transition in a two-year period, notably less than initially identified by Yung et al. We aimed to establish the rate of transition to FEP within 12 months from identification of ARMS in Sussex EIP services.

A retrospective study was conducted on all patients on the ARMS pathway, across five EIP services in Sussex, between Jan 2017-Oct 2021. The primary outcome measure was operationally defined transition to FEP; secondary outcome measures included clinical features and use of clinical services.

71 cases were identified as meeting ARMS criteria, with mean age 21.4yo; range 14–35, from a total new caseload of 447 over this period.

ARMS subcategories identified 4 state/trait, 55 attenuated psychosis and 12 BLIPS. Comorbidity was more common than not; mood disorders were identified in 17 cases. 23 cases met not in education, employment or training (NEET) criteria.

All cases received full care coordination by lead practitioners. 19 cases were prescribed atypical antipsychotics. 18 cases received formal CBT.

4 of the 71 cases transitioned to FEP within 12 months at mean time 35 weeks; range 28–45 weeks. 2 had attenuated symptoms and 2 experienced BLIPS. 3 were initially NEET.

We report a very low transition rate to FEP of 6% in this service, consistent with other such UK services. Whilst the ARMS sample is low in number, a clear impact on EIP service case management is identified. Risk saturation is arguably required to justify continuing this ARMS pathway, achievable by primary focus on the BLIPS subgroup. Wider review of UK ARMS services is required to reduce dilution of EIP service models and reduction of their well evidenced effectiveness.

The NHS Long-Term Plan includes the perinatal mental health objective: by 2023/24 ‘Maternal Mental Health Services’ will be available across the country to provide psychological therapy for those who experience mental health difficulties directly arising from birth trauma and or/perinatal loss. We achieved early implementer status via application to NHS England and, using transformation funding received, ‘Thrive’ was piloted in East Kent. A gap in service provision was identified: some existing primary care services provide intervention for this cohort, however some people remain in psychological distress but do not meet the criteria for specialist perinatal mental health secondary care services; these secondary care services are not commissioned to support those who have experienced perinatal loss. Thrive is co-delivered by a mental health trust and acute healthcare trust; NICE recommended psychological interventions are provided by Psychological Therapists, Specialist Mental Health Midwives and a Peer Support Worker. The aim of this project was to evaluate the effectiveness of the Thrive pilot in reducing PTSD symptomology whilst also collating feedback from patients, their families and healthcare staff across the maternity system, in order to adapt the service offer for full county rollout.

40 people who received care from Thrive from 11th January 2021 to 31st December 2021 were included in this evaluation.

Data were collected retrospectively at the end of each period of care via:

Clinical outcomes measures (quantitative):

• • PCL-5: a 20-item self-report measure assessing the 20 DSM-5 symptoms of PTSD.

• • CORE-34: a universal method of establishing well-being and risk.

• • HoNOS (Health of the Nation Outcomes Scales): a measure of the health and social functioning of people with severe mental illness.

• • 100% of patients improved following Thrive intervention: PCL-5 (significant change = a reduction in score by 10–20 points has been met) / CORE-34 (clinically significant change =score above 10 initially and below 10 after intervention).

• • Clinical improvement: HoNOS = 100% of patients improved following Thrive intervention.

Evaluation has evidenced the effectiveness of Thrive in successfully treating those with PTSD symptomology arising from their maternity experience. Post-treatment measures indicate that the level of trauma symptomology and the impact of psychological distress on the functioning of patients who have received intervention from Thrive has reduced to a sub-clinical level in all cases.

As more emphasis is placed on a move from the traditional hospital-based practice to care in the community, CMHTs are becoming the main channel for delivering specialist care in England. Access to most CMHTs occurs via written referrals, which vary significantly in content and quality. Such variability and inconsistency with the information provided can impact on the triage process and delay access to treatment for patients, making the process unnecessarily protracted and time consuming. One key factor that would drive the success and survival of CMHTs is how they gate-keep their service. This starts by adopting formal strategies when vetting and screening referrals. The aims were to determine if NW CMHT is responding to referrals appropriately, to consider if service users received good quality correspondence about referral decisions and if the outcomes of such meetings were properly documented.

The NW CMHT consists of 4 pods (A to D) and the audit included all GP referrals assessed by pod B over a month. A sample size of 28 referrals was included in the audit and the referrals were from 16 different GP practices. Data were obtained from patient electronic records and entered onto a SmartSurvey form for ease of collection prior to results being analysed.

32% of referrals came from two GP surgeries. Areas of good practice included all referrals being discussed within 4 days of receipt, and 50% reviewed by the next day. For referrals identified as needing further information and discussion, this was also done quickly between 2–5 days of receiving the referral. Also 68% of service users (SU) had a letter sent out to them within 2–5 days. It was unclear in 75% of referrals whether the SU was aware of the referral to NW CMHT and the reasons for the referral were only ‘fully’ documented in 57%.

The vast majority of GP referrals were treated in a timely manner, even if additional data gathering was needed and multiple referral discussions had. Recommendations included addressing the lack of consistency in documentation of referral discussions, developing effective ways to cut back on clinical time lost gathering what should be standard information, and education of GP practices around making good quality referrals. It was felt that a review of the referral forms would be beneficial, however a barrier to this change was that this is a trust wide form and there would need to be consensus across all CMHT localities.