Maudsley NHS Foundation Trust Research Articles

Employees with mental health problems: Survey of UK employers' knowledge, attitudes and workplace practices

To investigate whether employers who have experience of hiring people with mental health problems differ significantly from those without such experience in terms of knowledge, attitudes and behaviours regarding mental health in the workplace, and the concerns which they report about employing people with mental health problems. We also examine whether non-workplace social contact is associated with the above variables. A telephone survey was conducted with a randomly selected sample of British employers. The sample included a similar number of human resource managers and managers/executive employees in other roles. 502 employers took part. Having employed someone with a mental health problem was associated with closer non-workplace social contact. Those with experience of employing applicants with mental health problems had significant differences in knowledge (regarding the law), and behaviour (having a policy on hiring applicants with disabilities) but not in attitudes. Non-workplace social contact may be useful to consider in understanding hiring practices. The nature of social contact at work and possible lack of impact of this contact on employer attitudes and concerns warrants further study. Greater support is needed for employers to understand the law regarding mental health problems in the workplace.

Pseudocataplexy and Transient Functional Paralysis: A Spectrum of Psychogenic Motor Disorder

Pseudocataplexy and Transient Functional Paralysis: A Spectrum of Psychogenic Motor Disorder

The economic impact of mental health stigma and discrimination: A systematic review

People with mental illness face stigma and discrimination in a variety of settings which can have an economic impact. The aim of this paper was to identify literature on the economic impact of mental illness stigma. A systematic review of the literature identified 30 papers from 27 studies by searching electronic databases and hand searching reference lists. Mental illness stigma/discrimination was found to impact negatively on employment, income, public views about resource allocation and healthcare costs. Stigma and discrimination regarding mental health problems lead to adverse economic effects for people with these conditions. Interventions that reduce stigma may therefore also be economically beneficial.

Hidden perspectives in cloth: the making of the Bethlem Tapestry

This month the South London and Maudsley NHS Foundation Trust is to unveil the ‘Bethlem Tapestry’—an expressive depiction of patient experience from the hospital’s Psychosis Unit

Use of psychotropics among looked after children: an audit in the Borough of Lambeth.

Background Looked after children and young people (LAC) have higher incidence of mental health problems than non-looked after children. Many mental health difficulties are missed in this group, in particular the effects of trauma and loss and the resulting depression. LAC often move between placements, which further disrupts their care and therapeutic interventions. NICE recommends that in most mental health disorders, children and adolescents should receive specific psychological therapies as first-line treatment, before medication. This standard should apply to LAC. Setting The audit was conducted in the Lambeth CLAMHS, a specialist mental health team working with LAC. Question To ascertain if Lambeth LAC (living in the borough) are receiving psychotropic medication without CLAMHS input and as their only treatment. (All LAC who are on psychotropic medication should have been offered psychological treatments first.) Methods A questionnaire was sent out to Lambeth general practice (GP) surgeries to find out what medications children were prescribed, if any. When children were prescribed psychotropic medication checks were made to ascertain whether they were receiving input from mental health services. Results LAC were seen in 67 different GP surgeries across Lambeth. Responses from 63 surgeries relating to 145 children (87.34% of the total number) were received. Conclusions There were no LAC in Lambeth who were prescribed psychotropic medication without a CAMHS service being involved. All the patients that were on psychotropic medication were known by CLAMHS or another child and adolescent mental health service within the South London and Maudsley NHS Foundation Trust. This is in accordance with NICE recommendations.

Don’t forget the carers

This month’s edition of BJW features an article by Eunice Adeshokan, Jonathan Radcliffe and Laura Bird from South London and Maudsley NHS Foundation Trust. The theme is working in collaboration with carers of people with mental health problems.

Revamped trust website promises visitors access to a garden of delights

South London and Maudsley NHS Foundation Trust’s recently-relaunched website reflects its change of focus in recent years. Dan Charlton explains why this redeveloped site is much more than just another public service homepage

COMMUNITY TREATMENT ORDERS, ETHNICITY, CONDITIONS AND PSYCHOTROPIC MEDICATION: THE FIRST SIX MONTHS (N = 126)

Background: Community treatment order (CTO) legislation was initiated in November 2008 in England and Wales. Due to high rates of uptake, a shortage of second opinion appointed doctors (SOADs) to complete authorization of medication within the given timeframe for CTOs was soon identified. A strong link in the use of CTOs in combination with antipsychotic long acting injections (LAIs) has been previously identified. LAI use for patients with schizophrenia is 35% on UK acute inpatient wards. The aims of this cross-sectional observational study in the first year of CTO legislation were to (i) identify patient characteristics for those commenced on a CTO; (ii) identify the nature of psychotropic medication prescribing at CTO initiation. Hypothesis: patients with schizophrenia have higher than average rates of LAI use as compared with national prescribing data. Methods: The setting was the South London and Maudsley NHS Foundation Trust in London, United Kingdom, which provides secondary care level psychiatric services for a local population of 1.1million people, plus specialist tertiary referral inpatient facilities and forensic wards. Consecutive sampling was conducted for all patients whose CTO was registered in the Trust. Only the first CTO for each patient was included. Data for 126 patients from the first six months of data collection is presented (03/11/08-30/04/09). Measures included: sociodemographic variables, psychiatric diagnosis, CTO date of initiation, statutory reasons and stated conditions, psychotropic medication and date of Second Opinion Appointed Doctor (SOAD) authorization for medication. Results: There was geographical variability in rates of CTO use between the 4 geographical sub-regions. 52% of the 126 patients were of black ethnic origin. 52% had stated conditions regarding their place of residence and 37% were required to allow access into their homes. 99% were prescribed an antipsychotic, 27% a mood stabilizer, 8% an antidepressant, 5% a benzodiazepine. First generation antipsychotic LAIs were the most commonly prescribed group of antipsychotics (40%). 69% of those with schizophrenia on a CTO were prescribed an antipsychotic LAI. Regarding antipsychotic doses, the mean BNF% dose was 60.6% (sd 39.1 range 2.5%-183.3%). 8% of the total sample had antipsychotic (combined) doses exceeding 100%BNF dose limits. 10% were prescribed two antipsychotics. Prior to CTO initiation, 21% were LAI-naive and 78% were clozapine naive. SOAD certification of medication occurred approximately 2 months after CTO initiation (mean 59.9 days, sd 39.1, range 1-175 days). For 24% of the sample, SOAD certification was not completed within the first 6 months. Discussion: Variation in CTO use exists for geographical areas but not for ethnic diversity once other factors such as rates of hospital detention are considered. Conditions of CTOs may not follow the least restrictive principle, particularly for requirements regarding a patient's place of residence; clearer guidance for setting of conditions is required. The finding of 69% of those with schizophrenia on a CTO being prescribed an LAI is double that reported in national prescribing data. SOAD authorization of medication commonly occurs after the legal deadline and a small proportion did not achieve SOAD certification before the CTO expired.

Whole team training to reduce burn-out amongst staff on an in-patient alcohol ward

In 2005 the alcohol in-patient ward at South London and Maudsley NHS Foundation Trust participated in a 2-day training programme designed to reduce levels of burn-out amongst staff. The training intervention was derived from a large-scale project that focused on in-patient and community mental health staff in five European countries. A research component was built into the work, with levels of staff burn-out being measured prior to the training intervention and 1 month afterwards, using the Maslach Burn-out Inventory (MBI). The team were able to identify four sources of stress at work. A 1-month follow-up using the MBI showed that levels of emotional exhaustion and depersonalization had been reduced and feelings of personal accomplishment at work risen. Staff identified four main sources of stress at work. These were: (i) group-work; (ii) dealing with complex clients; (iii) effectively evaluating the shift; and (iv) client aggression. The implications of whole team training is discussed in the context of staff working with high turnover clients.

Once-monthly paliperidone injection for the treatment of schizophrenia

Paliperidone palmitate is a new long-acting antipsychotic injection for the treatment of acute and maintenance therapy in schizophrenia. Paliperidone (9-hydroxyrisperidone) is the major active metabolite of risperidone and acts at dopamine D2 and serotonin 5HT2A receptors. As with other atypical antipsychotics, it exhibits a high 5HT2A:D2 affinity ratio. It also has binding activity as an antagonist at α1-and α2 adrenergic receptors and H1 histaminergic receptors, but has virtually no affinity for cholinergic receptors. Paliperidone palmitate has been shown to be effective in reducing Positive and Negative Syndrome Scale total scores in four short-term trials in acute schizophrenia. It was also effective as maintenance therapy in a long-term trial in which time to recurrence of symptoms was significantly longer in paliperidone-treated patients compared with placebo. In addition, paliperidone was shown to be noninferior to risperidone long-acting injection in one study, but this noninferiority was not established in another longer study comparing the two drugs. Treatment should be initiated with 234 mg on day 1 and 156 mg on day 8, followed by a recommended monthly maintenance dose of 39–234 mg based on efficacy and tolerability. Paliperidone palmitate is generally well tolerated, although it can cause weight gain and a rise in prolactin levels, which is generally greater in women than in men. Overall, paliperidone palmitate may have advantages over other currently available long-acting injections, and therefore may be a useful alternative for the treatment of schizophrenia, although further long-term trials comparing it with active treatments are warranted.

The South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLAM BRC) case register: development and descriptive data

BackgroundCase registers have been used extensively in mental health research. Recent developments in electronic medical records, and in computer software to search and analyse these in anonymised format, have the potential to revolutionise this research tool.MethodsWe describe the development of the South London and Maudsley NHS Foundation Trust (SLAM) Biomedical Research Centre (BRC) Case Register Interactive Search tool (CRIS) which allows research-accessible datasets to be derived from SLAM, the largest provider of secondary mental healthcare in Europe. All clinical data, including free text, are available for analysis in the form of anonymised datasets. Development involved both the building of the system and setting in place the necessary security (with both functional and procedural elements).ResultsDescriptive data are presented for the Register database as of October 2008. The database at that point included 122,440 cases, 35,396 of whom were receiving active case management under the Care Programme Approach. In terms of gender and ethnicity, the database was reasonably representative of the source population. The most common assigned primary diagnoses were within the ICD mood disorders (n = 12,756) category followed by schizophrenia and related disorders (8158), substance misuse (7749), neuroses (7105) and organic disorders (6414).ConclusionThe SLAM BRC Case Register represents a 'new generation' of this research design, built on a long-running system of fully electronic clinical records and allowing in-depth secondary analysis of both numerical, string and free text data, whilst preserving anonymity through technical and procedural safeguards.

Riverscross: a soap opera

As part of their provision for children and adolescents, South London and Maudsley NHS Foundation Trust (SLaM) provides acute and elective inpatient and day patient care for young people aged between 12 and 18 years at the Snowsfields Unit at Guy's Hospital. An important aspect of the unit's work consists of supporting young people to continue their engagement with education, and a curriculum is provided by the Bethlem and Maudsley School that focuses on positive re‐engagement with self, others and, by extension, with mainstream education. There is a strong cross‐curricular emphasis on personal, social, health, emotional literacy and creative education, alongside the consolidation of basic skills for living (literacy, numeracy, ICT and life skills).

The South London and Maudsley NHS Foundation Trust and Oxleas NHS Foundation Trust Prescribing Guidelines, 9th Edition

This new edition of the Maudsley NHS prescribing guidelines may very well contribute to safer, more rational and more responsible current psychopharmacotherapy if applied correctly. It is authored by the chief pharmacist at the Institute of Psychiatry at the Maudsley and King's College London, the chief pharmacist at Imperial College London, and the late Robert Kerwin Professor of Clinical Neuropharmacology and consultant psychiatrist at the Institute of Psychiatry (obituary: BJCP 2007; 63: 765–6). Consisting of eight chapters, it offers the reader practical guidance on the most frequently prescribed drugs in the pharmacological treatment of the major psychiatric disorders. Utilizing the taxonomy of the DSM-IV, the psychoses (including schizophrenia and catatonia), bipolar disorder, depression (including psychotic depression), anxiety, children and adolescent psychopharmacotherapy, substance abuse and so-called ‘special patient groups’ are covered. Also, ample prescription guidelines are provided based on those of the British NICE guidelines. Many recent literature references refer to research by experts, with selected ones singled out for further reading. The guide devotes its first chapter to plasma concentration monitoring of psychotropic drugs. Generally its interpretation leads to confusion in clinical practice. However, this chapter provides a conceptual introduction to its practice and increases awareness that the relationship between plasma drug concentrations and clinical efficacy in psychiatry remains to be established in some cases. Sound overviews are provided on antipsychotics, antidepressants, lithium and anticonvulsants. Also many concise tables for quick reference are provided per group of drugs. Many of these are pretty much standard, including names, indications, maximal dosages and most common side-effects. However, by having added information on less well known but potentially important side-effects and information on potential drug–drug and CYP450 interactions, these tables are rendered up-to-date and relevant, without obscuring clarity. Additionally, advice is provided on switching of drugs (including antidepressants and antipsychotics), focusing primarily on the process of switching rather than the guidelines dictating when and to which drug to switch. Although the latter may seem useful, the underlying rationale of switching these drugs based on PD and PK characteristics is not sufficiently clarified. Useful information is provided on the effects of alcohol, nicotine and caffeine which can influence the pharmacology of psychotropics in many psychiatric patients. Unexpectedly, the stagnation in innovative drug development for the treatment of depressive disorders again becomes apparent from these chapters. Importantly, the authors give side-effects of all featured drugs a prominent role. Not only the traditional side-effects associated with most commonly prescribed drugs (e.g. QT-interval prolongation with antipsychotics and sexual dysfunction with SSRIs) but also potentially dangerous ones of which the impact is increasingly being recognized. These include weight gain and features of the metabolic syndrome which have been acknowledged since the advent of atypical antipsychotics. Also, chapters on SSRI-induced hyponatraemia and SIADH, SSRIs and bleeding, and the effects of antidepressants on cardiac function (including their effects on heart rate, blood pressure, arrhythmias and the myocardium) are informative. These may increase physicians' awareness of lesser well-known adverse effects when prescribing antidepressants. Additionally a chapter is devoted to the interaction between electro-convulsive therapy (ECT) and antidepressants, focusing mainly on their pharmacodynamic effects on ECT. The special patient groups remain to be mentioned. These are patients with psychiatric disorders who more often than not pose problems to the application of psychopharmacological treatment guidelines. They encompass patients who are pregnant and lactating, patients with epilepsy, renal and hepatic impairment, HIV and AIDS and patients using psychotropics during the peri-operative period. Providing relevant information on clinical management, it pays attention to both altered dynamic and kinetic characteristics. The addition of potential drug–drug and CYP450 interactions, combined with basic pharmacodynamic and pharmacokinetic characteristics of psychiatric drugs, make this book relevant. However, it is a pity that no overviews of known CYP450 and SERT polymorphisms are provided. This may be important for future individualized drug therapy since their role is increasingly being recognized in inadequate drug response and therapy resistance in psychiatry. Although the most current information on psychiatric drugs can always be found electronically, this text is excellent for scenarios in which this might not be possible. Generally speaking, this 9th edition is concise and clinically relevant. However, it is quite bulky and not the kind of reference to carry around on ward rounds. It is intended as a reference guide but may also contribute to the consolidation of previously attained knowledge of clinical psychopharmacology. As a prescription guide it can be useful combined with existing (but not only NICE) guidelines, in both pharmacological treatment of major mental disorders and in consultation-liaison psychiatry.

Antipsychotics preferred by mental health professionals

Bleakley et al ( Psychiatric Bulletin , March 2007, 31 , [94-96][1]) reported a survey of professional opinion (including 65 doctors) from the Maudsley NHS Foundation Trust on antipsychotic medication. They found that aripiprazole, olanzapine and risperidone were popular. We undertook a similar

HORMONES OF THE ANTERIOR LOBE OF THE PITUITARY GLAND

<h3>Abstract</h3> <h3>Objectives</h3> The recent COVID-19 pandemic has disrupted mental healthcare delivery, with many services shifting from in- person to remote patient contact. We investigated the impact of the pandemic on the use of remote consultation and on the prescribing of psychiatric medications. <h3>Design and setting</h3> The Clinical Record Interactive Search tool (CRIS) was used to examine de-identified electronic health records (EHRs) of people receiving mental healthcare from the South London and Maudsley (SLaM) NHS Foundation Trust. Data from the period before and after the onset of the pandemic were analysed using linear regression, and visualised using locally estimated scatterplot smoothing (LOESS). <h3>Participants</h3> All patients receiving care from SLaM between 7^th January 2019 and 20^th September 2020 (around 37,500 patients per week). <h3>Outcome measures</h3> The number of clinical contacts (in-person, remote or non-attended) with mental healthcare professionals per week Prescribing of antipsychotic and mood stabiliser medications per week <h3>Results</h3> Following the onset of the pandemic, the frequency of in-person contacts was significantly reduced compared to that in the previous year (β coefficient: −5829.6 contacts, 95% CI −6919.5 to −4739.6, p&lt;0.001), while the frequency of remote contacts significantly increased (β coefficient: 3338.5 contacts, 95% CI 3074.4 to 3602.7, p&lt;0.001). Rates of remote consultation were lower in older adults than in working age adults, children and adolescents. Despite this change in the type of patient contact, antipsychotic and mood stabiliser prescribing remained at similar levels. <h3>Conclusions</h3> The COVID-19 pandemic has been associated with a marked increase in remote consultation, particularly among younger patients. However, there was no evidence that this has led to changes in psychiatric prescribing. Nevertheless, further work is needed to ensure that older patients are able to access mental healthcare remotely.