Progress towards understanding the aetiology of major depression is compromised by its clinical heterogeneity. The variety of contexts underlying the development of a major depressive episode may contribute to such heterogeneity.

To compare risk factor profiles for three subgroups of major depression according to episode context.

Using self-report questionnaires and administrative records from the UK Biobank, we characterised three contextual subgroups of major depression: postpartum depression (3581 cases), depression following diagnosis of a chronic disease (409 cases) and a more typical (named heterogeneous) major depression phenotype excluding the two other contexts (34 699 cases). Controls with the same exposure were also defined. We tested each subgroup for association with the polygenic risk scores (PRS) for major depression and with other risk factors previously associated with major depression (bipolar disorder PRS, neuroticism, reported trauma in childhood and adulthood, socioeconomic status, family history of depression, education).

Major depression PRS was associated with all subgroups, but postpartum depression cases had higher PRS than heterogeneous major depression cases (OR = 1.06, 95% CI 1.02–1.10). Relative to heterogeneous depression, postpartum depression was more weakly associated with adulthood trauma and neuroticism. Depression following diagnosis of a chronic disease had weaker association with neuroticism and reported trauma in adulthood and childhood relative to heterogeneous depression.

The observed differences in risk factor profiles according to the context of a major depressive episode help provide insight into the heterogeneity of depression. Future studies dissecting such heterogeneity could help reveal more refined aetiological insights.

Adverse childhood experiences (ACEs) have a detrimental impact on short- and long-term mental and physical health. A growing body of research has indicated that the prevalence of suicidal phenomena is significantly higher among individuals with a history of ACEs. However, there is a lack of understanding about processes that result in ACEs leading to suicidal ideation when testing within a theoretical framework.

To develop and test a multidimensional model that would explain the association between ACEs and suicidal ideation in college students.

Data were obtained from a cross-sectional survey completed by 321 college students primarily recruited from universities in Ireland. Participants were aged 18–21 (n = 176) and 22–25 years (n = 145). An ACEs questionnaire, the Interpersonal Needs Questionnaire, which assessed thwarted belongingness and perceived burdensomeness, the CORE-10, which assessed psychological distress, and the Suicide Ideation Scale (SIS) were administered.

After controlling for gender and sexual orientation, results revealed a significant direct effect of ACEs on suicidal ideation such that more accumulated ACEs were associated with higher suicidal ideation (effect size 0.30; 95% CI 0.047–0.538). A significant indirect effect of ACEs on suicidal ideation through perceived burdensomeness and psychological distress, and thwarted belongingness and psychological distress, was observed (effect size 0.90; 95% CI 0.558–1.270).

Findings suggest that ACEs have a detrimental impact on college students’ mental health. Results highlight the potential benefits of ACE-informed interventions that target thwarted belongingness and perceived burdensomeness to countervail suicidal ideation in college students.

Clinical practice guidelines for schizophrenia and major depressive disorder have been published. However, these have not had sufficient penetration in clinical settings. We developed the Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment (EGUIDE) project as a dissemination and education programme for psychiatrists.

The aim of this study is to assess the effectiveness of the EGUIDE project on the subjective clinical behaviour of psychiatrists in accordance with clinical practice guidelines before and 1 and 2 years after participation in the programmes.

A total of 607 psychiatrists participated in this study during October 2016 and March 2019. They attended both 1-day educational programmes based on the clinical practice guidelines for schizophrenia and major depressive disorder, and answered web questionnaires about their clinical behaviours before and 1 and 2 years after attending the programmes. We evaluated the changes in clinical behaviours in accordance with the clinical practice guidelines between before and 2 years after the programme.

All of the scores for clinical behaviours in accordance with clinical practice guidelines were significantly improved after 1 and 2 years compared with before attending the programmes. There were no significant changes in any of the scores between 1 and 2 years after attending.

All clinical behaviours in accordance with clinical practice guidelines improved after attending the EGUIDE programme, and were maintained for at least 2 years. The EGUIDE project could contribute to improved guideline-based clinical behaviour among psychiatrists.

We present the case of SN, a 25-year-old woman with diagnosis of anorexia nervosa, OCD, Generalized Anxiety Disorder (GAD) and depression. She has extensive history of contact with mental health services spanning more than 10 years. She has had 1 inpatient stay in an eating disorders unit lasting more than 6 months. Her treatment included various classes of medications, psychological therapy and social prescribing with little or no benefit. She has been referred to rTMS. The aims of the study are to determine the effect of rTMS in treatment of a patient with depression comorbid with OCD, understand the value of q-EEG in rTMS treatment and to treat OCD symptoms using rTMS guided by QEEG.

SN had a total of 56 rTMS sessions targeting standard depression and anxiety areas; F3 (left sided excitatory) and F4 (right sided inhibitory). Following this her depression and anxiety improved but her OCD worsened. She then underwent a Q-EEG to be able to understand the physiological cause of her symptoms and suggest meaningful further neuromodulation that is tailored to her. This indicated dysregulation within the default mode network. Spindling beta waves were detected over the posterior electrode suggesting a tendency towards ruminations. There was clear hyperactivity in the supplementary motor area. SN had further 30 rTMS sessions targeting the OCD circuit (FC1 and FC2).

Rating scales showed a reduction in Patient Health Questionnaire-9 (PHQ-9) score from 22 to 14 (36%) in second course compared to an increase of PHQ-9 score from 9 to 15 (66.6%) in first course; indicating an overall 102% improvement in PHQ-9. It also showed reduction of Yale-Brown Obsessive Compulsive Scale (Y-BOCS) in second course from 34 to 8. It was not done in the first course but there was a clinical increase in OCD symptoms following the end of the first course. These results were corroborated clinically.

A repeat q-EEG showed that the areas previously highlighted in red at FC1 and FC2 had now all reverted to green, indicating normal neuronal connectivity.

rTMS can provide timely and adequate response to depression and anxiety especially one that has not responded adequately to medications and psychotherapy. Q-EEG is useful to direct the plan, create a personalized plan and achieve accurate results. The use of q-EEG, whilst useful, should be balanced with other considerations as financial constraints. It should be reserved to patients who have not responded favorably to standard rTMS treatment.

Norway introduced capacity-based legislation in mental healthcare on 1 September 2017 with the aim of increasing patient autonomy and legal protection and reducing the use of coercion. The new legislation was expected to be particularly important for patients under community treatment orders (CTOs).

To explore health professionals’ experiences of how capacity-based legislation affects healthcare services for patients whose compulsory treatment order was revoked as a result of being assessed as having capacity to consent.

Nine health professionals responsible for treatment and care of patients whose CTO was revoked owing to the new legislation were interviewed in depth from September 2019 to March 2020. We used a hermeneutic approach to the interviews and analysis of the transcripts.

The participants found that capacity-based legislation raised their awareness of their responsibility for patient autonomy and involvement in treatment and care. They also felt a need for more frequent assessments of patients’ condition and capacity to consent and more flexibility between levels of care.

The study shows that health professionals found that capacity-based legislation raised their awareness of their responsibility for patient autonomy and involvement in treatment and care. They sought closer dialogue with patients, providing information and advice, and more frequently assessing patients’ condition to adjust treatment and care to enable them to retain their capacity to consent. This could be challenging and required competence, continuity and close collaboration between personnel in different healthcare services at primary and specialist level.

Public support for the implementation of personalised medicine policies (PMPs) within routine care is important owing to the high financial costs involved and the potential for redirection of resources from other services.

We aimed to determine the attributes of a PMP most likely to elicit public support for implementation. We also aimed to determine whether such support differed between a depression PMP and one for cystic fibrosis.

In a discrete-choice experiment, paired vignettes illustrating both the current model of care (CMoC) and a hypothetical PMP for either depression or cystic fibrosis were presented to a representative sample of the UK public (n = 2804). Each vignette integrated varying attributes, including anticipated therapeutic benefit over CMoC, and the annual cost to the taxpayer. Respondents were invited to express their preference for either the PMP or CMoC within each pair.

The financial cost was the most important attribute influencing public support for PMPs. Respondents favoured PMP implementation where it benefited a higher proportion of patients or was anticipated to be more effective than CMoC. A reduction in services for non-eligible patients reduced the likelihood of support for PMPs. Respondents were more willing to fund PMPs for cystic fibrosis than for depression.

Cost is a significant factor in the public's support for PMPs, but essential caveats, such as protection for services available to PMP-ineligible patients, may also apply. Further research should explore the factors contributing to condition-specific nuances in public support for PMPs.

Coronavirus disease 2019 (COVID-19) has had a disproportionate impact on people with intellectual disability (PwID). PwID are at higher risk of mental illness and receive psychotropic prescribing ‘off licence' also, to manage distress behaviour. The lockdown and reduction of multidisciplinary face-to-face appointments had an impact on care delivery, the recourse possibly being psychotropic prescribing. It is imperative to comprehend the influence the pandemic had on psychotropic prescribing patterns to enable future planning.

The aim was to understand the impact of the pandemic by comparing psychotropic prescribing patterns during the England lockdown with the prescribing patterns before lockdown in specialist urban and rural psychiatric services for PwID.

Data was collected from Cornwall (rural) and London (urban) intellectual disability services in England as a service evaluation project to rationalise psychotropic prescribing. PwID in both services open across January 2020 to January 2021 were included. Baseline patient demographics including age, gender, ethnicity, intellectual disability level and neurodevelopmental and psychological comorbidities were collected. Baseline psychotropic prescribing and subsequent % change for each psychotropic group for the two services was compared using Pearson's chi-square and z-statistic (two tailed) with significance taken at P < 0.05.

The two centres London (n = 113) and Cornwall (n = 97) were largely comparable but for baseline differences in terms of presence of severe mental illness (37 v. 86, P < 0.001), challenging behaviour (44 v. 57, P < 0.05) and attention-deficit hyperactivity disorder (37 v. 3, P < 0.001). There was an overall increase in psychotropic prescribing during lockdown in urban as compared with rural settings (11% v. 2%).

The pandemic caused an increase in psychotropic prescribing associated with lockdown severity and urban settings. Team structures could have played a role.

Self-harm, including suicide, is common among prisoners. Staff attitudes and perceptions regarding self-harm may affect quality of care and patient safety.

To systematically review the experiences, perceptions and attitudes of staff in adult prisons regarding self-harm.

Systematic searches of EMBASE, Medline, PsycINFO and CINAHL databases were conducted, and supplemented by hand-searching and grey literature review, to identify relevant English-language articles published since the year 2000. Articles were screened by two authors and evaluated with standardised quality appraisal tools. Qualitative data were analysed thematically, whereas quantitative data were narratively synthesised because of high study heterogeneity.

Two thousand articles were identified, of which 32 were included, involving 6389 participants from five countries. Most studies were moderate (n = 15) or poor (n = 10) quality, and seven were rated as good quality. Staff frequently witnessed self-harm and described multiple perceived risk factors and causes of this. Perceptions that self-harm is ‘manipulative’ or ‘attention-seeking’ were associated with hostility toward prisoners and lower quality of care. Perceived barriers to preventing and managing self-harm included low staffing levels, prison environments and culture, poor staff confidence and insufficient training. The importance of multidisciplinary teamwork and building staff–prisoner relationships were highlighted. Staff occasionally experienced intense psychological reactions to self-harm, which resulted in adaptive or maladaptive coping that influenced their capacity to care.

There are mixed attitudes and perceptions toward self-harm among prison staff. Further training, support and resources are required to protect staff's well-being and improve self-harm prevention and management in prisons.

People with age-related macular degeneration (AMD) can report reduced mental health. There is also evidence that they struggle with daily tasks because of vision loss.

The purpose of this study was to assess the psychological impact of instrumental activities of daily living on people with simulated AMD.

Twenty-four normally sighted participants completed 12 household tasks, in a simulated home environment, under a moderate-to-severe AMD simulation. Participants’ psychological state was measured through self-report questionnaires and physiological measurements related to anxiety and stress. Tasks were completed twice, under counterbalanced vision conditions (normal and simulated AMD).

Linear mixed models on vision condition (normal versus simulated AMD) and trial order (trial 1 versus trial 2) revealed a significant large negative effect of the AMD simulation on time to complete tasks, and the anxiety, task engagement and distress self-reports (all P < 0.024, all ω2 > 0.177). There were also significant medium-large effects of trial order on time, task incompletion, task errors, and the anxiety and task engagement self-reports (all P < 0.047, all ω2 > 0.130), whereby the results improved during the second attempt at the tasks. No physiological measures were significant (all P > 0.05).

Completing instrumental activities of daily living under an AMD simulation had a negative impact on participants’ self-reported mental state. The observed trial order effects also illuminated how practice with tasks could ease anxiety and stress over time.

Experiencing traumatic life events is associated with an increased risk of common mental disorders (CMDs), but studies investigating this association within Indigenous populations are limited.

The aim of this study was to investigate associations between trauma and CMDs after controlling for other exposures.

Trauma exposures and CMD diagnoses were determined in a broadly representative sample of 544 Indigenous Australians, using a diagnostic clinical interview. Associations were determined by multivariate logistic regression.

Trauma exposure independently predicted CMDs. After adjustment for potential confounders, trauma exposure was associated with a 4.01-fold increased risk of a diagnosis of a CMD in the past 12 months. The increased risks were 4.38-, 2.65- and 2.78-fold of having an anxiety disorder, mood disorder or a substance use disorder, respectively. Trauma exposure and comorbid post-traumatic stress disorder was associated with a 4.53-fold increased risk of a diagnosis of a mood disorder, 2.47-fold increased risk of a diagnosis of a substance use disorder, and 3.58-fold increased risk of any diagnosis of a CMD, in the past 12 months. Experiencing both sexual and physical violence was associated with a 4.98-fold increased risk of a diagnosis of an anxiety disorder in the past 12 months.

Indigenous Australians experience significantly increased exposure to potentially harmful trauma compared with non-Indigenous Australians. Preventing and healing trauma exposure is paramount to reduce the high burden of CMDs in this population.

Waves 1 to 3 (March 2020 to May 2020) of the UK COVID-19 Mental Health and Wellbeing study suggested an improvement in some indicators of mental health across the first 6 weeks of the UK lockdown; however, suicidal ideation increased.

To report the prevalence of mental health and well-being of adults in the UK from March/April 2020 to February 2021.

Quota sampling was employed at wave 1 (March/April 2020), and online surveys were conducted at seven time points. Primary analyses cover waves 4 (May/June 2020), 5 (July/August 2020), 6 (October 2020) and 7 (February 2021), including a period of increased restrictions in the UK. Mental health indicators were suicidal ideation, self-harm, suicide attempt, depression, anxiety, defeat, entrapment, loneliness and well-being.

A total of 2691 (87.5% of wave 1) individuals participated in at least one survey between waves 4 and 7. Depressive symptoms and loneliness increased from October 2020 to February 2021. Defeat and entrapment increased from July/August 2020 to October 2020, and remained elevated in February 2021. Well-being decreased from July/August 2020 to October 2020. Anxiety symptoms and suicidal ideation did not change. Young adults, women, those who were socially disadvantaged and those with a pre-existing mental health condition reported worse mental health.

The mental health and well-being of the UK population deteriorated from July/August 2020 to October 2020 and February 2021, which coincided with the second wave of COVID-19. Suicidal thoughts did not decrease significantly, suggesting a need for continued vigilance as we recover from the pandemic.

Clozapine, a well-established treatment of choice for treatment-resistant schizophrenia is known to reduce suicidality, lessen the risk of tardive dyskinesia and reduce relapse risk. It contributes to a higher quality of life by reducing cognitive clouding. Patients taking Clozapine have improved social and work functioning. But Clozapine's significant side effects require regular, intense monitoring to minimize mortality and morbidity. To improve current practice of clozapine prescribing and monitoring, a systematic audit of service practices against guidelines of local hospital / Monash Health Clozapine patient management guidelines and the Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical practice guidelines will identify any deficits and inform measures to overcome them.

An audit was conducted to compare the current clozapine prescribing practice and monitoring process compared with local hospital / Monash Health Clozapine patient management guidelines and RANZCP clinical practice guidelines among clozapine prescribed patients in an Australian community mental health service.

Medical records of thirty-three eligible adult patients on clozapine were audited. All the patients were prescribed dosages within the recommended daily clozapine range. Clozapine was used for appropriate indications (treatment of treatment resistant-schizophrenia or schizoaffective disorder). Of the 33 patients, clozapine level was subtherapeutic on 54.5% of patients. 54.5% of patients were on an adjunct psychotropic with clozapine. Aripiprazole and sodium valproate were used by eight patients each, and nine patients were identified using selective serotonin reuptake inhibitors. The most common side effect was hypersalivation (57.6%), followed by weight gain (39.4%), sedation (21.2%) and constipation (12.1%). Monthly weight monitoring, physical examination, medical officer monthly review and full blood examination, at 97% compliance met these standards. However, monitoring of Body Mass Index (BMI) (66.7%) and six-monthly consultant reviews (42.4%) showed poor compliance (<70%) with the standards. Most metabolic blood investigations were in moderate compliance (70–90%) except for relatively high compliance for lipid profile (90.1%). Monitoring cardiac functions by echocardiogram were only 75.8% met the standard.

Most patients in this clinic receive recommended monthly monitoring practice but for BMI monitoring, six-monthly consultant review, most blood investigations and annual or 2 yearly echocardiogram findings indicated need for improvement. Polypharmacy of psychotropics increases the side effect burden and further increases the need to closely monitor the physical health and prescriptions of this cohort of patients. The next stage of this project will involve a codesign approach to developing a response to these findings that will be outlined here.

People living with intellectual and developmental disabilities (IDD) have suffered disproportionately in health outcomes and general well-being during the COVID-19 pandemic. There is emerging evidence of increased psychological distress. Increased strain has also fallen on clinicians managing the psychological needs of people with IDD, in the context of learning new technologies, staff shortages, reduced services and paused training opportunities.

To examine clinicians’ experiences of patient care, clinical management and the impact of care delivery.

A mixed fixed-response and free-text survey comprising 28 questions covering four areas (responder demographics, clinical practice, changes to local services and clinician experiences) was developed, using the STROBE guidance. It was disseminated through an exponential snowballing technique to clinicians in seven high-income countries. Quantitative data were analysed and presented with Microsoft Excel. Qualitative data were coded and thematically analysed, and presented with in-text quotations.

There were 139 respondents, mostly senior physicians (71%). Two-thirds reported over 10 years working in the field. Quantitative findings include increased clinician stress (77%), referrals (53%), patient distress presentations (>70%), patient isolation (73%) and carer burden (89%), and reduced patient participation in daily activities (86%). A third reported increased psychotropic prescribing. Qualitative analysis outlined changes to clinical practice, particularly the emergence and impact of telehealth.

In the countries surveyed, the pandemic has not only had a significant impact on people with IDD, but also their carers and clinicians. A proactive, holistic international response is needed in preparedness for future public health emergencies.

The volitional help sheet for self-harm equips people with the means of responding automatically to triggers for self-harm with coping strategies. Improving acceptability may be crucial to increasing effectiveness and reach. The Theoretical Framework of Acceptability (TFA) was developed to guide the assessment of intervention acceptability, but to date, no studies have applied the TFA to understand acceptability of interventions for self-harm.

To apply the TFA to (a) explore people's experiences of a brief intervention to reduce repeat self-harm; and (b) understand the most prominent aspects of intervention acceptability, to make recommendations for intervention refinements and successful implementation.

Sixteen semi-structured interviews were conducted with people who had previously self-harmed. The TFA informed a framework analysis in which findings were mapped onto the TFA.

Four TFA domains were identified that were associated with acceptability of the volitional help sheet for self-harm: affective attitude, burden, intervention coherence and perceived effectiveness. People were generally positive about using the volitional help sheet (affective attitude), understood the volitional help sheet and how it worked (intervention coherence), highlighted engagement as a motivating factor in using the volitional help sheet (perceived burden) and described how the volitional help sheet could be implemented by healthcare professionals (perceived effectiveness).

Further modifications could still be made, but it is hoped that this intervention provides a useful tool for individuals to construct their own personalised implementation intentions, and as part of longer-term support for preventing self-harm as delivered by healthcare professionals.

Distress after major incidents is widespread among survivors. The great majority do not meet the criteria for mental health disorders and rely on psychosocial care provided by their informal networks and official response services. There is a need to better understand their experiences of distress and psychosocial care needs.

The aims of our study were to enhance understanding of the experience of distress among people present at the Manchester Arena bombing in 2017, identify their experiences of psychosocial care after the incident and learn how to better deliver and target effective psychosocial care following major incidents.

We conducted a thematic analysis of semi-structured interviews with 18 physically non-injured survivors of the Manchester Arena attack, who registered with the NHS Manchester Resilience Hub.

Distress was ubiquitous, with long-lasting health and social consequences. Initial reluctance to seek help from services was also common. Early and open access to authoritative sources of information and emotional support, and organised events for survivors, were viewed as helpful interventions. Inappropriate forms of psychosocial and mental healthcare were common and potent stressors that affected coping and recovery.

This paper extends our understanding of how people react to major events. Provision for the large group of people who are distressed and require psychosocial care may be inadequate after many incidents. There is a substantial agenda for developing awareness of people's needs for psychosocial interventions, and training practitioners to deliver them. The findings have substantial implications for policy and service design.

Aggression and violent incidents are a major concern in psychiatric in-patient care. Nutritional supplementation has been found to reduce aggressive incidents and rule violations in forensic populations and children with behavioural problems.

To assess whether multivitamin, mineral and n-3 polyunsaturated fatty acid supplementation would reduce the number of aggressive incidents among long-stay psychiatric in-patients.

The trial was a pragmatic, multicentre, randomised, double-blind placebo-controlled study. Data were collected from 25 July 2016 to 29 October 2019, at eight local sites for mental healthcare in The Netherlands and Belgium. Participants were randomised (1:1) to receive 6-month treatment with either three supplements containing multivitamins, minerals and n-3 polyunsaturated fatty acid, or placebo. The primary outcome was the number of aggressive incidents, determined by the Staff Observation Aggression Scale – Revised (SOAS-R). Secondary outcomes were patient quality of life, affective symptoms and adverse events.

In total, 176 participants were randomised (supplements, n = 87; placebo, n = 89). Participants were on average 49.3 years old (s.d. 14.5) and 64.2% were male. Most patients had a psychotic disorder (60.8%). The primary outcome of SOAS-R incidents was similar in supplement (1.03 incidents per month, 95% CI 0.74–1.37) and placebo groups (0.90 incidents per month, 95% CI 0.65–1.19), with a rate ratio of 1.08 (95% CI 0.67–1.74, P = 0.75). Differential effects were not found in sensitivity analyses on the SOAS-R or on secondary outcomes.

Six months of nutritional supplementation did not reduce aggressive incidents among long-stay psychiatric in-patients.

Children with hearing loss are at increased risk of mental health conditions, including behavioural problems, but there is limited evidence about available mental health support.

We aimed to map the evidence on mental health support for children and adolescents with hearing loss.

Medline, Embase, PsycINFO and grey literature databases were searched until April 2021. Articles of any study design were eligible if they described an intervention supporting the mental health of children with hearing loss. No restrictions were placed on geography or publication date. Four reviewers independently screened results by title, abstract and full text. Study characteristics and outcome data were extracted, with results narratively synthesised.

From 5629 search results, 27 articles were included. A large majority of the studies (81%, n = 22) were from high-income settings, with two-thirds (67%, n = 18) conducted in the USA. Less than half (41%, n = 11) of the articles adopted experimental research designs, and the majority of studies included small samples. The interventions presented were diverse, with the majority either therapy based (30%, n = 8) or skills training (30%, n = 8). Interventions included ice-skating, parent–child interaction therapy and resilience training. When measured, interventions demonstrated at least some evidence of effectiveness, although this was not always assessed with gold-standard methodology.

The evidence is lacking in breadth, study quality and geographical spread. That said, what is available indicates a range of effective approaches to support the mental health of children with hearing loss. Additional research is needed to improve the breadth of evidence on mental health support for this population.

COVID-19-related restrictions on in-person contact in healthcare, increasing psychiatric illness during the pandemic and pre-existing shortages of mental healthcare providers have led to the emergence of telepsychiatry as an attractive option for the delivery of care. Telepsychiatry has been promoted as economical and effective, but its acceptance in low- and middle-income countries is poorly understood.

To explore the acceptance, experiences and perspectives of patients and healthcare providers in the uptake of telepsychiatry services in a middle-income country.

Focus group discussions were conducted on the WhatsApp platform with patients and care providers who have engaged in telepsychiatry. Data were analysed using a thematic approach.

Three main themes emerged from the five focus groups: (a) technical access, (b) user experience and (c) perceived effectiveness compared with face-to-face (in-person) interactions. Care providers reported challenges establishing rapport with the patient, particularly for initial sessions, maintaining privacy during sessions and detecting non-verbal cues on video. Patients cited internet connectivity problems, difficulty finding private space to have their sessions and cost as major challenges. Patients also felt in-person sessions were better for initial visits. Both patients and providers reported difficulties making insurance payment claims for telepsychiatry services. Overall, participants were mostly positive about telepsychiatry, citing its convenience and overall perceived effectiveness compared with in-person sessions.

Telepsychiatry is an acceptable platform for delivery of out-patient psychiatric services in a middle-income country. Patients and providers appreciate the convenience it offers and would like it integrated as a routine mode of delivery of care.

Current NICE guidance states that Children and Young People (CYP) with suspected Eating Disorders (EDs) should be immediately referred to specialist services on their first presentation to primary care. This audit assessed whether these standards were being met across Greater Manchester and what general practitioners felt would be helpful in supporting them to correctly refer patients. Aim 1: Analyse information from referral forms on all patients referred to Manchester Foundation Trust Community Eating Disorders Service (MFT-CEDS) from primary care between 17th December 2020 – 17th June 2021. Aim 2: Gain insight into how confident GPs in Greater Manchester feel identifying suspected EDs in CYP, their knowledge of guidelines regarding referral, and how they would like to be supported to improve referrals of suspected CYP-ED.

Quantitative data on all primary care referrals made between 17th December 2020–17th June 2021 were analysed. Referrals were classified as correct if they were made both immediately and directly to the correct service. Subgroup analysis of data by geographic region of Greater Manchester was also undertaken. Qualitative data were collected through a survey which was sent to General Practitioners across Greater Manchester. The survey assessed knowledge of current guidelines and views on what training materials could be helpful to improve the referral process.

A total of 69 patients were referred to MFT-CEDS by their GP between 17th December 2020 and 17th June 2021. 35% of GP referrals to MFT-CEDS were documented as being made correctly as per current guidelines. 43.5% of all referrals were not initially made to MFT-CEDS. 58% of referrals were documented as being made immediately. North and South Manchester had the lowest rates of correct referrals of 10% and 8% respectively. There were 10 survey respondents, of which the majority did not know current referral guidelines and did not feel confident in identifying suspected Eating Disorders in CYP.

The majority of primary care referrals of CYP with suspected eating disorders to MFT-CEDS were not made in line with current NICE guidance.

The following recommendations were made based on the findings of this audit:

1) Create an information document and video regarding identification and referral guidelines for suspected EDs in CYP, 2) Design an easy-to-use referral template for GPs, 3) Conduct interviews with GPs working in North and South Manchester to help identify what additional support they need, 4) Re-audit referral data once quality improvement measures have been in place for 6 months.