Psychiatric Team Research Articles

Hypothyroidism in a Psychiatric Outpatient Population of People With Intellectual Disabilities.

Hypothyroidism is a chronic health condition which causes physical, cognitive and psychiatric symptoms. The prevalence of hypothyroidism in adults with intellectual disabilities is under researched. Hypothyroidism was examined among 463 patients within an outpatient intellectual disability psychiatric team. Clinic records were utilised for this study, including sociodemographic, psychiatric and physical health diagnoses. Among the 463 patients, 43 (9%) had hypothyroidism. Compared to those without hypothyroidism, the hypothyroid group were significantly older, more likely to be female, and had increased rates of high cholesterol, diabetes, Down's Syndrome and dementia. Rates of hypothyroidism within this cohort of patients with intellectual disabilities were high (9%). The results suggest hypothyroidism in intellectual disability should be the focus of prospective research, in larger, more representative samples. This study indicates a need for increased awareness of, and resources for hypothyroidism in health services.

Community mental health care in Croatia: Mobile team for psychosocial support in the community

Abstract The Republic of Croatia has initiated numerous reforms in the mental health care system in the community. Within the framework of EU JA Implement, a mobile team was formed to provide interventions in the community, that is, in the homes of persons discharged from psychiatric hospitals. The mobile team was formed during 2023. The team includes: one psychiatrist, leader and coordinator of the mobile team, three graduate nurses, a case manager, a social worker, three experienced experts who are employed in the team as peer workers, and one social pedagogue and psychologist. The wider composition of the team includes a psychiatrist who provides outpatient psychiatric treatment, who is familiar with the individual recovery plan and, if necessary, participates in the development of the plan. The goal of establishing a mobile team is to implement an individual recovery plan in the community, that is, in the patient’s home, using biopsychosocial interventions, with the aim of better and faster recovery of the user and inclusion in the community, as well as prevention of rehospitalization and disability. Before the patients home visits, the experts in the team were trained. 15 patients were included in the pilot project, with whom 96 home visits or interventions were carried out in the time period from the establishment of the team to April 2024. As a result of the effectiveness of the pilot project, in 2024, in accordance with the Strategic Framework for the Development of Mental Health until 2030, the Republic of Croatia adopted a new network of health institutions, within which 30 mobile psychiatric teams and 24 psychological teams at the primary level of health care are planned. Empowerment of users, engagement of people with experience in the implementation of interventions, increase in mental health literacy of the population and destigmatization are additional results of the implementation of mental health protection in the community through JA impleMENTAL.

What does it take to offer high-quality, community-based, accessible mental health care in Lebanon?

Background: Armed conflict, economic collapse, the 2020 explosion, the COVID-19 pandemic, and persistent political and social instability have had severe impact on mental health in Lebanon. Aim: To highlight the critical elements for setting up a free community-based mental health care centre in Lebanon. Methods: Following the Beirut blast in 2020, a non-government organization started providing free, essential, personcentred, and holistic mental health care to residents in Lebanon through a multidisciplinary team of psychiatrists, psychologists, social workers, and mental health nurses. Results: During its first year of operation, the health centre provided 5392 free mental health consultations to 590 beneficiaries. Majority (67%) of the beneficiaries were female, and nearly half (45%) were aged 18–24 years. The most prevalent mental health disorders were major depressive disorder, generalized anxiety disorder and post-traumatic stress disorder. Beneficiaries self-reported a 70% improvement in depression and a 76% improvement in anxiety after 3 months of treatment. Conclusion: Based on our experience, we advocate the community-based model as an effective approach to delivering mental health interventions and recommend a continuous evaluation of its impact in community settings.

MCT bij ouderen

The number of elderly in our society is increasing. Psychiatric problems are common in this population. For adults aged 18 to 65, there already is psychiatric crisis home treatment for patients experiencing a psychiatric crisis at home. However, this did not yet exist in Belgium for adults over the age of 65. Since the 1st of November 2021, people over 65 who are experiencing a psychiatric crisis in the region of the Ghent-Eeklo-Flemish Ardennes Mental Health Care Network (PAKT) can rely on psychiatric crisis home treatment. For this reason, it was investigated whether this treatment is effective and cost-effective. There are currently no studies available on this subject. For this reason, different sub-aspects were considered. The effectiveness and cost-effectiveness of long-term psychiatric home treatment teams in elderly & adults and of psychiatric crisis home treatment teams (MCT) in adults older than 18 years were assessed. Finally, we looked for the characteristics of adults who were included for psychiatric crisis care at home and whether these are present in adults older than 65 years. Since there are no studies on MCT in the elderly, it is not possible to draw conclusions on the subject. However, a general trend is noted in the studies whereby the treatment always appears to be effective and often also cost-effective. However, further research is needed to confirm that this will also be the case for MCT for the elderly in Belgium.

A creative approach to psychoeducation for ADHD in adults

A group-based online psycho-education program for adults with attention deficit hyperactivity disorder (ADHD) and their families has been set up by a multi-professional psychiatric team. Feedback from users has mainly shown benefits in terms of improving self-esteem, destigmatization and accessibility to care. This suggests a real interest in developing this care offer in the pathway of ADHD adults.

Criteria for evaluating the effectiveness of psychiatric home care-mobile team: A systematic review of the literature.

To explore criteria evaluating the effectiveness of psychiatric home care-mobile team practices, that have been developed widely in the last decades. Systematic review of the literature. We included 24 studies published between January 2010 and October 2023. CINAHL, APA PsycInfo, Embase, Scopus and PubMed. The evaluation criteria differed according to the studies: impact on hospital stay, symptomatic clinical impact, repercussions on functioning, quality of life, analysis of profitability, safety, therapeutic alliance and finally, cooperation network. The variability of the criteria used to judge the effectiveness of psychiatric home care-mobile team practices shows their richness and diversity, and the absence of standardisation. The variability of the criteria used to judge the effectiveness of psychiatric home care-mobile team practices supports a qualitative and multidisciplinary approach, with enhanced teamwork. Psychiatric home care-mobile team practice have widely developed in the last years and their effectiveness need to be evaluated. Our main finding is that there is a rich variety of practices and that evaluation criteria are very diverse, thus not standardised. We suggest using a mixed-method approach to capture the subjective experience of patients and caregivers. These findings also highlight the significance of institutional cooperative work and call for a redefinition of team construction. The authors adhered to PRISMA guidelines. No patient or public contribution.

Providing psychiatric diagnosis and intervention in patients with chronic medical illness in the community: A novel collaboration between the Psychiatry team and the community team in a Singapore restructured hospital

IntroductionHome nursing and medical services have an established role in delivering chronic medical care to populations which face difficulty accessing physical clinics. Those with chronic medical conditions and reduced mobility face a higher likelihood of suffering from psychiatric co-morbidity. However, till date there has been limited research done on home-based psychiatric care in this population.Since 2021, the Psychiatry department of Tan Tock Seng Hospital (TTSH) has been collaborating with TTSH Community Health Team (CHT) to manage potential psychiatric issues in community patients.These patients would be discussed in a weekly multidisciplinary setting. If indicated, home visit by both teams for home-based assessment and treatment would be arranged, allowing for detection and treatment of psychiatric illness.ObjectivesTo demonstrate that the collaboration between the psychiatry team and CHT leads to diagnosis and treatment of psychiatric illness in a population that might otherwise have been unable to access psychiatric services.Methods We performed a retrospective study on all referrals from the CHT to the psychiatry team, within the 2-year period of August 2021 to August 2023. We collected demographic information, psychiatric history prior to referral, reason for referral, outcome of multidisciplinary discussion, and outcome of the home visits (including diagnoses made, and medications initiated).ResultsA total of 92 patients were referred by the CHT to the psychiatry team. Most were elderly with multiple medical co-morbidities; of note, a history of stroke was present in 24 of the referred patients.Common reasons for referral include suspected mental illness, risk assessment, and management of behavioural issues. 28 of the referred patients did not have a prior psychiatric history at the point of referral. Among these, home visits involving the psychiatric team were done for 16 patients. 11 (68%) of these home visits led to diagnosis of a new psychiatric illness. 9 of these patients were initiated on psychotropic medications in the home setting.ConclusionsA significant proportion of patients (68% of home visits without prior psychiatric diagnosis) were newly diagnosed with psychiatric illness, allowing early psychiatric intervention to be delivered. This was achieved in a population with a high prevalence of multiple medical comorbidity and barriers to clinic-based psychiatric evaluation and treatment.We propose future comparative studies into how the collaboration between the psychiatric team and community health team can improve the quality of life and caregiver experience of patients with chronic medical problems, as well as how the service had improved the confidence of the community health team in identifying and managing patients with possible psychiatric issues.Disclosure of InterestNone Declared

Case series and Literature review – Clozapine Induced Transient Myocarditis. Clinical characteristics and outcomes

Introduction Clozapine is a second-generation atypical antipsychotic medication used in patients with treatment-refractory schizophrenia. Its use is limited due to its associated adverse effects, including myocarditis. These adverse effects may have variable presentations, such as myocarditis transient or persistent, and a generalized inflammatory process. Thus, clinical monitoring to inform accurate diagnosis is essential to avoid unnecessary discontinuation of clozapine, leading to psychiatric decompensation.ObjectivesTo review clinical features of clozapine induced Myocarditis and accurately identify signs and symptoms attributed to be most specific for myocarditis and determine at what stage clozapine should be discontinued.Methods We conducted a literature review on PubMed, MeSH, google scholar and Mount Sinai’s Levy Library using keywords, clozapine, drug related side effects, adverse reaction, myocarditis, treatment resistant schizophrenia. Review of two cases series was done.Results A review of 15 articles that addressed the cardiac complications of clozapine was performed. This review provides a base on variable clinical characteristics and outcomes of clozapine –induced Myocarditis. It showed patients who had myocarditis ruled out, demonstrated high prevalence of systemic signs of inflammation such as fever, malaise, tachycardia and elevated c-reactive protein. However, despite clozapine maintenance in most, this systemic response subsided without any intervention. A nonspecific inflammatory response is common when initiating clozapine, this inflammatory “clozapine storm’ occurs within the first month of initiation and is not necessarily predictive of myocarditis. These patients were monitored closely. Those confirmed with clozapine- induced myocarditis using echocardiography and cardiac magnetic resonance imaging were managed with dose reduction, laboratory monitoring, vital signs check, with early initiation of beta-blockers without discontinuation of clozapine, with improvement in their laboratory results and vital signs. Those with progressive clinical signs of myocarditis required immediate cessation of clozapine.Conclusions We are proposing a critical need for a multidisciplinary team of psychiatrists, cardiologists and pharmacists collaborating to prevent premature termination of clozapine in cases of treatment-refractory schizophrenia. Our cases showed middle aged patients with treatment - refractory schizophrenia, presenting with symptoms suggestive of clozapine induced- myocarditis, few weeks after initiation. Clozapine was continued with close monitoring, as symptoms resolved. Though clozapine is associated with myocarditis, with proper knowledge on guidelines for monitoring patients, it can mitigate unnecessary discontinuation of clozapine in those patients.Disclosure of InterestNone Declared

Electroconvulsive therapy: the perspective of the informal caregiver in the decision-making process

Introduction Despite the importance of electroconvulsive therapy (ECT) as treatment, it remains one of the most controversial and misunderstood treatments. Negative media representations, primitive practice in the past and fear for electricity results in fear that extends beyond other therapies. Research on the perspective and role of informal caregivers (IC) in the process of ECT is limited. Most research focuses on relatives’ attitude or knowledge of ECT measured with questionnaires. However, profound understanding of their perspective can facilitate the role of physicians (or psychiatrists) in guiding patients and their IC through the decision-making process of ECT.Objectives The aim of this study was to describe the perspective of informal caregivers in the decision-making process in ECT treatment.MethodsA qualitative phenomenological study was set up. Semi-structured interviews were held with IC of patients who are treated with ECT. Purposive sampling was based on maximum variation. All interviews were fully transcribed and thematic analyses took place. Trustworthiness was guaranteed by e.g. researcher triangulationResults In nine interviews were held with partners, children and parents of patients. The interviews had a mean duration of 102 minutes and interviewing proceeded until saturation of the most important themes was reached. During the interviews it became clear that the decision-making process of ECT is strongly influenced by the illness-trajectory and context of living with the mental health problems of the patient. IC describe their life and that of the patient as ‘trying to survive’. The proposal of ECT is seen as a way out of this unendurable situation. The perceived responsibility of the IC in the informed consent process to ECT adds to this burden. The IC worry, feel uncertain and fear to do wrong. Nonetheless ECT seems to be a beacon of hope. Trust in the psychiatrist as a competent professional who wants the best for the patient seems more important than having an answer to all of their questions. After the ECT has been started, IC establish a framework to evaluate the side-effects and effectiveness of ECT. This framework is based on how they experience the patient in daily life and on what they define as ‘the patient becoming a bit more himself again’. IC weigh the effects and side-effects to support the continuation of ECT. However, if patients clearly express that they experience side-effects that are too hindering, IC follow the patient if he or she wants to stop ECT.ConclusionsOur study gives an insight in the perspective of the IC of patients undergoing ECT. It could be helpful for IC if the psychiatric team repeats information stepwise and takes the burden of responsibility perceived by the IC into account. The framework used by IC to evaluate the effects of ECT could be a valuable addition to the clinical evaluation of the ECT treatment.Disclosure of InterestNone Declared

A Challenging Conundrum; Learning Disability, Schizophrenia and Autism - a Case Report

IntroductionPsychiatric disorders are common in patients with learning disabilities. There are also patients with the triad of autism, schizophrenia and learning disability. Patients with this background can be admitted to general hospitals for psychiatric or non-psychiatric reasons.We are presenting a case who had a very complicated clinical course and her discharge planning was challenging.ObjectivesThe objective of this work was to show the challenges in the investigation, medical management, and discharge planning of the patients with concomitant learning disability, schizophrenia and autism.MethodsWe scrutinized the patient’s casenotes, including blood results and all relevant imaging. We paid a particular attention to all the entries from the psychiatry team, general medical doctors, oncologists, learning disability team and discharge planners.ResultsThe lady had a protracted 4-month inpatient admission throughout which she was physically and verbally aggressive to hospital staff. She was deemed to lack capacity for hospital admission and treated in her best interests under Mental Capacity Act (MCA), frequently requiring sedation with Haloperidol and Lorazepam. Following consultation with the local Psychiatrist her medications were altered to: Risperidone 2 mg BD, Diazepam 5 mg OM, 5 mg afternoon and 10 mg evening, Procyclidine 5 mg BD, Chlorpromazine 25 mg BD, Promethazine 25 mg OD PRN, and Midazolam 10 mg buccal PRN.A change in her clinical condition was noted by the Psychiatry team; increased agitation, confusion and dysarthria. A repeat blood test was advised, due to patient refusal this took weeks to achieve despite the use of buccal Midazolam following Anaesthesiologist advice. Although blood tests were not significantly deranged, she was treated for presumed urinary tract infection with a course of antibiotics. A urine sample was unobtainable.She reported right breast pain and underwent a mammogram. This showed a hypoechoic lesion 8x7x9 mm. Following consultation with a Breast Surgeon and Oncologist, Letrozole was replaced with Tamoxifen. The Psychiatric team concluded that the clinical deterioration with dysarthria was related to anxiety, associated with Autistic patients. The movement disorder was deemed secondary to antipsychotics exacerbated by stress and anxiety.The patient’s discharge planning was complex. She was declined by numerous care homes. At time of writing, she remains an inpatient.ConclusionsThe management of patients with a triad of Learning Disability, Schizophrenia and Autism is extremely difficult, particularly within an acute medical setting. Physical deterioration could be related to medication adverse effects or change in environment. Anxiety and stress are linked to these conditions. The challenging behaviour that these patients often have will make discharge planning very difficult as specialised care homes to accommodate these unique patients are very limiteDisclosure of InterestNone Declared

Influence of General Health on Quality of Life by the Caregiver and Burden Care as a Mediator: Bayesian Estimator Structural Equation Analysis

Objectives: To test structural equation models of General Health on quality of life by the caregiver and burden care as a mediator. Methods: The quality of life scale was administered to 297 caregivers of persons with schizophrenia. The models were examined using maximum likelihood confirmatory factor analysis (ML-CFA) and Bayesian structural equation modeling (BSEM). The path analysis with direct and indirect effects was discussed in the model. Results: The results reveal that the models fit well for evidence-based. The BIC 1412.998 < 3161.387, DIC 1365.247 < 3094.673, and WAIC 1370.802 < 3094.651 were the lowest BIC of the models and displayed a simple and parsimonious factor-loading pattern. Conclusions: Overall, both of the scales demonstrated excellent measurement properties supporting its relevance to comprehensively measure caregivers' impact and burden on persons with schizophrenia. Psychiatric and mental health care teams and clinical researchers could use the quality of life scale to generate strategies to support the family caregiver and measure the multidisciplinary treatment team interventions' outcomes.

Addictions in the elderly: the viewpoint of an IPA working in EMPSA

Many elderly people live well and at home, but some require somatic and psychiatric care. Mobile psychiatric teams for the elderly are called upon to intervene with people aged 65-70 and over who are experiencing psychological distress. Among senior citizens, addictive disorders are very common, and are associated with psychiatric and geriatric co-morbidities. Alcohol, tobacco and benzodiazepine use disorders require holistic, individualized care, based on identification, prevention and referral, aswell as training and coordination of professionals and caregivers.

Effectiveness of information technology assisted relapse prevention program on relapse among people who live with severe mental disorders.

Severe Mental Disorders (SMDs) cause mental health worldwide challenges because of several relapses and extensive recovery periods of hospitalization, which put a lot of economic and social burden on families and governments. Therefore, interventions are necessary to decrease the relapse of these disorders. This study was conducted to investigate the effect of Information Technology Assisted Relapse Prevention Program (ITAREP) on relapse among people who live with SMDs. This study was a randomized clinical trial with intervention and control groups. ITAREP is a remote intervention based on monitoring the Early Warning Signs (EWS) to decrease the number of potential relapses. Using convenience sampling, people with SMDs admitted to Sina Juneqan Psychiatric Hospital and their caregivers were recruited in this study and randomly allocated to the control and intervention groups. Two checklists of the EWS for the patient and the patient's caregiver were used for monitoring the relapse signs. Data were collected at baseline and 90 days after discharge and were analyzed using t-test and Chi-square statistical tests and linear regression in SPSS software. Fifty-two patients who lived with SMDs participated in this study (26 in the intervention group and 26 in the control group). The two groups were homogeneous regarding age, gender, type of mental disorder, and duration of the disorder. Forty-two males and ten females participated in this research. Most of the participants were diagnosed with schizophrenia. The results showed that the number of relapses in the intervention group was significantly lower than in the control group in the post-test. Social workers, as the case managers and a member of the interdisciplinary psychiatric team, can actively perform follow-up measures after discharge using ITAREP, and it can be expected that these interventions will reduce the number of relapses among patients who live with SMDs.

Network Table

Network tables: Integrated care for people with severe psychiatric disorders.
 Since 2010 there is the Psy107 initiative in Mental Health Care in Belgium. Aim is to downsize the number of people in Psychiatric Hospitals and to make a shift towards care in the community by organizing Networks of Mental Care and Circuits of Care.
 The result of this shift is that people with severe psychiatric disorders are less hospitalized and for a shorter time. They stay longer in their natural environment. This means that first line professionals and mobile psychiatric teams are confronted with more complex situations and crises. Some show health care avoidance behaviour and are hard to reach. 
 This is where the “Network-tables” come in: on a monthly basis a ‘Network table’ is convened. A group of professionals from the general first line, the specialized second line and residential third line – all with affinity with mental disorders - come together for a multidisciplinary consultation. 
 A first line professional - who is confronted with a complex case or with health care avoidance behavior – can present his case to this ‘Network Table’. The partners round the table all have different specializations and the transdisciplinary approach, the look at the case from different perspectives helps to find solutions that wouldn’t have been found without this collaboration. 
 The aim of these Network Tables is to put the patient/client in the center and formulate some realistic goals. The ambition is to come to specific actions and make clear arrangements about who will be responsible for short term actions and for the continuity of care. It is also possible that the mobile healthcare professional visits the patient/client, for a few times, for making contact and exploring the problems.
 The Network Tables started a year ago. The cases that are presented, come from different first line actors: social housing organization, social workers, jobcoaches… So far the Network tables managed to find solutions for all the cases. 
 All the participants were a bit surprised that working together can make such a big difference in finding solutions. Needless to say that these positive results are a powerful incentive to continue this new initiative.

Evaluating mental health decision units in acute care pathways (DECISION): a quasi-experimental, qualitative and health economic evaluation.

People experiencing mental health crises in the community often present to emergency departments and are admitted to a psychiatric hospital. Because of the demands on emergency department and inpatient care, psychiatric decision units have emerged to provide a more suitable environment for assessment and signposting to appropriate care. The study aimed to ascertain the structure and activities of psychiatric decision units in England and to provide an evidence base for their effectiveness, costs and benefits, and optimal configuration. This was a mixed-methods study comprising survey, systematic review, interrupted time series, synthetic control study, cohort study, qualitative interview study and health economic evaluation, using a critical interpretive synthesis approach. The study took place in four mental health National Health Service trusts with psychiatric decision units, and six acute hospital National Health Service trusts where emergency departments referred to psychiatric decision units in each mental health trust. Participants in the cohort study (n = 2110) were first-time referrals to psychiatric decision units for two 5-month periods from 1 October 2018 and 1 October 2019, respectively. Participants in the qualitative study were first-time referrals to psychiatric decision units recruited within 1 month of discharge (n = 39), members of psychiatric decision unit clinical teams (n = 15) and clinicians referring to psychiatric decision units (n = 19). Primary mental health outcome in the interrupted time series and cohort study was informal psychiatric hospital admission, and in the synthetic control any psychiatric hospital admission; primary emergency department outcome in the interrupted time series and synthetic control was mental health attendance at emergency department. Data for the interrupted time series and cohort study were extracted from electronic patient record in mental health and acute trusts; data for the synthetic control study were obtained through NHS Digital from Hospital Episode Statistics admitted patient care for psychiatric admissions and Hospital Episode Statistics Accident and Emergency for emergency department attendances. The health economic evaluation used data from all studies. Relevant databases were searched for controlled or comparison group studies of hospital-based mental health assessments permitting overnight stays of a maximum of 1 week that measured adult acute psychiatric admissions and/or mental health presentations at emergency department. Selection, data extraction and quality rating of studies were double assessed. Narrative synthesis of included studies was undertaken and meta-analyses were performed where sufficient studies reported outcomes. Psychiatric decision units have the potential to reduce informal psychiatric admissions, mental health presentations and wait times at emergency department. Cost savings are largely marginal and do not offset the cost of units. First-time referrals to psychiatric decision units use more inpatient and community care and less emergency department-based liaison psychiatry in the months following the first visit. Psychiatric decision units work best when configured to reduce either informal psychiatric admissions (longer length of stay, higher staff-to-patient ratio, use of psychosocial interventions), resulting in improved quality of crisis care or demand on the emergency department (higher capacity, shorter length of stay). To function well, psychiatric decision units should be integrated into the crisis care pathway alongside a range of community-based support. The availability and quality of data imposed limitations on the reliability of some analyses. Psychiatric decision units should not be commissioned with an expectation of short-term financial return on investment but, if appropriately configured, they can provide better quality of care for people in crisis who would not benefit from acute admission or reduce pressure on emergency department. The systematic review was registered on the International Prospective Register of Systematic Reviews as CRD42019151043. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/49/70) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 25. See the NIHR Funding and Awards website for further award information.

P195: The evolution of a community mental health team in Singapore: Community Psychogeriatric Programme

Mental health issues in the elderly were often overlooked in the past, with mental illness often being underdiagnosed, undiagnosed or misdiagnosed. As such, mental healthcare in the elderly was often insufficient, leading to significant adverse outcomes in individuals and caregivers, as well as an added burden to the healthcare system.The Community Psychogeriatric Programme (CPGP) was set up in Changi General Hospital in 2007 to serve the Eastern Region in Singapore. CPGP comprises of a multidisciplinary team of psychiatrists, psychologists, nurses, medical social workers, occupational therapists, a physiotherapist and administrative executives. The programme objective is to provide community mental health services for early detection and treatment of psychogeriatric disorders and to allow aging-in-place within the community. This is achieved through collaborating with social and healthcare agencies, as well as caregivers, to meet the needs of the elderly to maintain them in the community for as long as possible.Over the past 16 years, the proportion of Singapore’s population aged 65 and above have grown, mental health literacy in Singapore has improved, and community mental healthcare providers have increased. CPGP’s community partnerships multiplied, including social eldercare agencies such as dementia daycare centres, general medical practitioners in Primary Care Clinics and Community Hospitals, and residential facilities such a sheltered homes and nursing homes. The CPGP team pivoted to focus more heavily on networking with community partners, training and upskilling them with knowledge of geriatric mental healthcare and empowering them to provide care and support in the community setting. The goal was to right-site care, promoting early detection and intervention in the community. Home based consultations or nursing home consultations, including telepsychiatry, were reserved for elderly patients who really could not access specialist psychogeriatric outpatient services in the hospital.Looking back on the work CPGP has done, this is a reflection of our journey, reviewing the strategies we have employed to improve community psychogeriatric care, our achievements thus far, and the challenges we have been faced with as the healthcare landscape evolved in Singapore.

Impact of Board Certified Psychiatric Pharmacists on improving urinary tract infection antibiotic appropriateness at an acute psychiatric hospital.

Urinary tract infections (UTIs) are one of the most common indications for antibiotic use; patients with psychiatric disorders have a greater risk for UTI compared with patients without these disorders. However, there is little guidance on how best to manage antibiotic therapy in psychiatric hospitals. This study assessed the impact of a Board Certified Psychiatric Pharmacist (BCPP)-driven guideline on managing UTI treatment in an acute psychiatric hospital. The guideline was developed by the psychiatric pharmacy team and distributed to internists, psychiatrists, and pharmacists. Preintervention data were assessed for patients admitted between November 30, 2019, and February 23, 2020; postintervention data were assessed from February 25, 2020, to April 24, 2020. All patients ages 13 years and older who were admitted and had orders for an antibiotic to treat a UTI were included in this study. Appropriate UTI management was defined as an appropriate agent, dose, route, and frequency per the treatment guideline. Additionally, the following criteria were to be ordered and assessed to be deemed appropriate: urinalysis, urine culture, complete blood count, basic or complete metabolic panel, temperature, and subjective symptoms. Before intervention, 19.0% of antibiotic orders were appropriate; after intervention, 46.7% of antibiotic orders were appropriate (P = .048). The implementation of a BCPP-driven treatment algorithm was associated with a significant increase in appropriate antibiotic regimens for the treatment of UTIs in patients admitted to a psychiatric hospital.

Eating disorders and type 1 diabetes mellitus – case reports

Type 1 diabetes and eating disorders, especially anorexia and bulimia, are increasingly common in children and adolescents. The coexistence of these diseases is both a diagnostic and therapeutic challenge. Focusing on food, both in terms of its quality and quantity, is one of the basic aspects of diabetes treatment, but also one of the integral elements of eating disorders. The article presents two cases of patients with type 1 diabetes who developed eating disorders. In one case, the reason was the patient’s fear of gaining weight after starting insulin therapy. In the other case, anorexia developed independently of the diagnosis of diabetes, but its emergence was masked as an attempt to improve glycaemic control. The need for cooperation between the diabetes team and the psychiatric team is also highlighted. In addition, we present methods to avoid weight gain that are typically used by diabetic patients.

Is self-inflicted amputation to the upper extremity a contraindication to replantation?

Contraindications to replantation include severe medical or psychiatric comorbidities. Recently, authors have suggested that due to the improving therapeutic options for patients with psychiatric decompensation, this should no longer be listed as a contraindication to replantation. Despite this, authors continue to list severe psychiatric comorbidities as a contraindication to replantation. This case series and review of the literature discusses this complex topic and provides recommendations regarding the management of patients following upper extremity self-inflicted amputations. The authors present two cases of self-inflicted upper extremity amputations. The cases depict the acute management and the outcomes of these patients. The authors also reviewed the literature to present the available literature on this topic. The first case is a 64-year-old male who deliberately amputated his left hand with a table saw while suffering postictal psychosis. He underwent replantation. The patient was co-managed by the surgical and psychiatric team postoperatively. The patient expressed gratitude for his replantation after being treated for his psychoneurological condition. The second case is that of a 25-year-old male who deliberately amputated his left forearm using a Samurai sword. The patient's limb was successfully replanted. In the post-anesthesia care unit, the patient experienced extreme agitation, and during this event, he reinjured the left forearm. He was again taken urgently to the operating room to revise the replantation. Once psychiatrically stabilized, the patient was thankful for the care he received. The management of upper extremity self-inflicted amputations is controversial and difficult to establish as this presentation is rare. We present two cases which illustrate some of the nuances in the care of these patients. Our review suggests that psychiatric diagnosis be viewed as a comorbidity and not a contraindication to replantation. Thus, an informed consent discussion should be performed with the patients and, as needed, a member of the psychiatric team in order to decide whether to replant or not.

Quality Improvement Project to Co-Produce Effective Triangulated Communication Between Inpatient Psychiatric Team, Community Mental Health Teams, Patients and Carers to Help Patient Involvement and Positive Step Down Discharge Planning

AimsThe aim of the QI project was to promote patient involvement, choice and recovery using effective communication and collaborative planning. To achieve this, we aimed to ensure that patient's voice remained central to the decision making process in meetings . Using 5-Why QI methodology, the MDT of Delfryn-House—a private 28-bedded rehabilitation unit, reviewed the communication interruptions between the internal and external CMHT (especially after the pandemic), which in turn was hampering patients’ progress towards positive discharge. It was also noticed that patients' attendance was significantly dropped and they were not showing interest in their CPA/CTP meetings, as they were not seeing any benefits of them. The MDT planned the project to improve the communication for continuity of care and to have better involvement of patients, their families and external teams.MethodsThe Intervention project, based on QI model-of-improvement, established that effective communication was the main aim, to be achieved with new change ideas. The outcomes were both qualitatively and quantitatively measured e.g.using feedback questionnaires from CMHT and patients and carers, attendance and discussion of discharge goals for the admitted patients. Driver diagrams were used for change ideas e.g. Microsoft teams invites to all teams for the patient review and care plan review meetings, MDT adding the progress feedback to the patient review meeting proforma to be shared internally and externally prior to the meetings, informing the care coordinators prior to change in Mental health act status, same day email to CCOs about medication changes, incidents, safeguarding, and ensuring discharge goals are discussed at every meeting. Satisfaction surveys to the CMHTs and patients were conducted pre- and post-intervention. Qualitative data were collated, helping to generate quantitative statistical analysis of the satisfaction ratings. The attendance of meetings and positive discharge from the unit were also used to measure the outcomes.ResultsThere was significant improvement in both commissioners and CMHT's satisfaction of improved communication from Delfryn House. There was increase in attendance (44% by patients, 20% by carers, 64%by CMHT and 40% by Commissioners). There was increase (45%) in patients reading and signing their care plans. A notable increase in positive stepdown discharge plans were noted, however, as the QI project was run in a rehabilitation unit requiring longer admissions, there were not many actual discharges to show a noticeable difference.ConclusionThe QI-project helped in establishing clearer pathways towards positive discharge and continuity of care, signifying the importance of effective communication between teams and co-producing the care plans and meeting agendas with the patients and their carers.