Does Risperidone Long Acting Injectable Depot (RLAI) Reduce number of Admissions to Hospital.

BACKGROUND: Adherence to treatment is a major issue in relapse prevention in schizophrenia. Injectable depot has been claimed to improve non-adherence. A study in the North of England has shown that risperidone long acting injectable form has reduced number of admissions and number of days stayed in hospital. Our study aimed to replicate the previous study in the South of England. METHODS: A retrospective study was conducted in the South Essex Foundation University NHS trust. We selected every fifth patient on the Hospital Pharmacy list for risperidone long acting injectable (RLAI). We collected information on. Age, sex, diagnosis and medication ,regular follow up, investigation of each patient which included weight, FBS, S. lipid and hormones at the start of treatment, at three months and six months intervals. We recorded reasons for starting RLAI. Number of antipsychotics prescribed before RLAI, illness duration, number of admissions and days stayed in hospital in each episode before and after RLAI. Patients were included if they stayed for one year or on RLAI. RESULTS: We reviewed 65 case notes. The most common reason for starting RLAI was non compliance. 80% of our sample had the illness for more than five years. Half of them had physical morbidity. After RLAI was commenced there was a significant association with number and length of admissions. CONCLUSIONS: We have found an association between prescription of RLAI and reduction in number and length of admission. This needs to be confirmed in a randomised controlled trial.

Psychiatric Manifestation of Patients with Epilepsy in Mosul, Iraq.

BACKGROUND: It has been proven that physical morbidity is related to psychiatric illness. Some physical illnesses are more related to psychiatric morbidity compared to others. Epilepsy is considered one of them, as patients who suffer from epilepsy has disturbances of consciousness and this leads to a variety of psychological disturbance in addition to the psychological and social impact of the illness. AIMS: To identify risk factors and psychiatric morbidity in epilepsy, in order to try to manage it and improve outcome of this illness and enhance quality of life. METHODS: Patients who were referred to the department of Neurology at Mosul Teaching hospital from primary care centres between October 2012 and February 2013 and consented to participate in the study, were checked and if they fulfilled the criteria for the diagnosis of epilepsy, they were interviewed and their sociodemographic data were recorded, the hospital anxiety and depression questionnaire (HAD) was administered. Results were input in a computer programme and software statistical programme Minitab version 14.1 was utilised to analyse these data. RESULTS: The whole sample was 100 patients. 55 females and 45 males were included. Mean age was 30 years. Mean duration of illness was 5.5 years. Mean HAD score was 17. Male patients were a little bit older but there was no statistically significant difference compared to females and they both scored similar HAD score. There was no difference between urban and rural population with regards to HAD score. The results showed statistically significant correlation between age and duration of the illness and HAD score. DISCUSSION: The present study showed that there is a correlation between epilepsy and psychiatric morbidity. It has confirmed that females are more affected compared to males, which is expected as compared to the general population. It has also confirmed that psychiatric morbidity is positively related to epilepsy as it showed that the duration of illness has increased the psychiatric morbidity. CONCLUSION: Psychiatric morbidity is a neglected area in the management and care of physical illnesses, especially, epilepsy, where patients may get stigmatised and traumatised in the society. They may live in constant fear of having a fit. Assessing and managing the psychiatric morbidity of such patients will be reflected on the outcome of the illness and improve the quality of life of patients.

Psychiatric Manifestation of Patients with Bronchial Asthma in Mosul, Iraq.

AIMS AND METHODS: To identify risk factors and psychiatric morbidity in bronchial Asthma. Patients who consented to participate in the study, were checked for bronchial asthma. They were interviewed and their sociodemographic data were recorded, the hospital anxiety and depression was administered. Results were inputted in a computer programme and software statistical programme Minitab version 14.1 was utilised to analyse these data. RESULTS: It showed statistically significant correlation between age, duration of asthma and HAD score. IMPLICATIONS: Psychiatric morbidity is a neglected area in the management and care of physical illnesses, especially, bronchial asthma, where patients may get very worried and scared during acute attacks when they feel that they may suffocate. Assessing and managing the psychiatric morbidity of such patients will be reflected on the outcome of the illness and improve the quality of life of such patients.

Critical Analysis of Psychiatrists' Opinion in GP Referral letter.

BACKGROUND: Primary and secondary care communication is the cornerstone of patient's care. Proper dialogue should be established. The shared care protocol was an attempt to try to fill gaps and build bridges. METHODS: A special form was designed to collect information about psychiatrists' opinion on GPs' referral letter to psychiatric services. It contained 14 items, each item was marked as essential, can be included or irrelevant. This form was sent electronically to psychiatrists in South Essex University NHS Trust. They are 98 in total. It was inputted on Excel data sheet and was analysed. RESULTS: 44 psychiatrists responded. All respondents agreed that reason for referral is essential. Concise description of the condition, risks and current medication were rated as essential in more than 90%. Past medical history, past psychiatric history and current physical health were essential in 79%. DISCUSSION: All professionals involved should participate in evaluating and refining communication. Psychiatrists' opinion in GPs letters is paramount as they are the recipients and their assessments and future management plan should be geared to address the GP's concerns. This is shown clearly by the psychiatrists agreeing that reason for referral should be included in all letters, followed by what the GP has already done and what risks the patient presents. CONCLUSION: Improving communication between health professionals, improves patient's care, saves time and money, and in addition prevents duplication of investigation and procedures.

A Completed Cycle Audit of Psychiatric Discharge Summaries.

BACKGROUND: Patients discharge summaries are important as they record a vital miles stone in patients' care. Their accurate record improves patients' care and clarifies communication between different health professionals. METHODS: 60 Discharge summaries from different consultant psychiatrists' case load were audited. The results were analysed and presented with recommendations to improve them a format was suggested. A reaudit of 62 discharge summaries was carried out by the same team after three years in the same catchment area but the practice has changed to inpatient and community. RESULTS: Improvement in most of the areas audited occur in the reaudit which indicates the usefulness of audit in improving clinical practice which a pivotal part of clinical governance. DISCUSSION: This completed audit cycle has proven that clinical practice has been reviewed and methods of improving it have been implemented. It has been noted that more items were reviewed and added to the second cycle which should be condoned. CONCLUSION: Discharge summaries are important clinical documents in secondary and primary care communications. They are helpful for secondary care staff as they good references for people in out of hours services and Accident and Emergency. Good quality discharge summaries improve patients care and make it easy to manage clinical risk.

Sociodemographic and clinical features of patients with depressive disorder in Khartoum, Sudan.

BACKGROUND: It's known worldwide that depression is becoming a major health problem and its prevalence is increasing. The main objective of this study is to find out the prevalence of depression among patients attending a general psychiatric clinic, and study their sociodemographic and clinical features. METHODS: Files of patients attending a private psychiatric clinic in Khartoum in the period June 2005-June 2010 were reviewed. Only those with a diagnosis of depression were chosen, sociodemographic date and clinical features were documented and results were shown below. RESULTS AND DISCUSSION: Total numbers of patients with depression were 137 (11.4%). Females were more than males (56.2%), the majority are between ages 41-60 (40.9%), married (65%), (14.9%) had family history of psychiatric disorders and (52%) had a previous history of psychiatric treatment. Depressed mood is the commonest symptom (98.5%), loss of interest (91.9%), reduced energy (57%), guilt feelings (17.9%) and (35.8%) of our samples expressed suicidal ideations. The commonest type of somatic symptom is generalized aches and pain (30.7%), (18%) were psychotic. CONCLUSION: The present study is a retrospective descriptive study, based on a private psychiatric clinic sample. It provided a useful baseline for more comprehensive field based studies, to try to aid planning and development of services to meet the needs of the population.

Case identification of severe mental illness in Maidstone--a semi-rural setting.

BACKGROUND: The prevalence of severe mental illness is known to be greater in urban than in rural areas. Less studied are differences between the patients themselves and, more specifically, their use of psychiatric services. METHODS: The prevalence of severe mental illness was determined in semi-rural Maidstone in Kent by case identification register. Patients who met the OPCRIT diagnosis criteria were interviewed with the Multi-Site Collaboration Study (Case ID Schedule for Maidstone) which consists of five sections. RESULTS: 140 patients were identified with severe mental illness in the Maidstone area; their mean age was (42.85 years SD + 12.11). Most of the sample were born in England (94%), 34.5% were married or living with partners, 87.9% were living with no supervision, 37.1% had no qualification, 48.9% were unemployed. 45.7% suffer from schizophrenia, 21.4% suffer from depression, 13.6% suffer from schizoaffective psychosis and 20% suffer from other forms of psychosis. 99.3% were in touch with the services during the index period, 30.7% needed in-patient treatment, 82.12% attended out-patient clinic, 82.12% had community psychiatric nurse input, 17.1% have ever been charged with a crime and 15.7% have been ever convicted with a crime. 52.9% were receiving depot injection. CONCLUSION: The prevalence of severe mental illness in Maidstone (3.8/1000) is less than inner city areas (7.7/1000). Maidstone patients were at a higher level of functioning and made more use of available psychiatric services.

Checking physical care of people on risperidone long term injectable depot.

AIMS AND METHODS: To assess the existing physical care of patients with severe mental illness and whether it has complied with national protocols and guidelines. Medical notes of patients who has been on risperidone long acting injectable depot for a year were reviewed and a form was filled with the information of each patient including weight, physical examination, fasting blood sugar (FBS), Serum lipid (S.L.), pulse, blood pressure and ECG liver function tests (LFT). 50% had comorbidity with other physical illness, at the start of treatment, at three months and six months intervals. RESULTS: 65 notes were reviewed. 70% males. 70% between 18-50 years. 80% had the illness more than 5 years and 50% more than 10 years. The following was done baseline: 50% had physical examination. 25% had pulse, blood pressure and ECG. Body weight 10%. Triglycerides 20%. Urea and electrolytes (U&E) 15%. 40% had their liver function tests (LFT). 50% had comorbidity with other physical illness. The following were done on six monthly maintenance measures: Only 5% had maintenance ECG. LFT 10%. U&E 30%. Triglycerides 5%. CLINICAL IMPLICATIONS: Physical illnesses are neglected areas in the care of the severely mentally ill patients. It is an important area in the management of severe mental illness. Proper physical assessment and regular follow up should be adopted. Promotion of healthy living and eating, exercise and monitoring weight should be recommended. All these measures may improve the physical health of severely mentally ill patients and improve the total outcome of these illnesses.

Clinical outcomes of depot and well being clinic. Results of physical health care checks.

AIMS AND METHOD: To establish the level of physical care of people suffering from severe mental illness attending a psychiatric depot clinic. 37 Records of patients who were on long acting injectable antipsychotics, were reviewed to establish their physical care arrangement against the POMT-UK standards,and also to establish the type of antipsychotics, whether they suffer from metabolic syndrome, or whether other physical illness has been recorded. RESULTS: Records lacked any reference to baseline arrangements of physical monitoring. 22% suffered from diabetes and 75% of them were identified by The Depot and Well Being clinic (DWBC), 73% had abnormal lipid profile 59% were identified by (DWBC). 22% suffer from hypertension, all of them were identified by (DWBC). CLINICAL IMPLICATION: Physical care is an important aspect of care of people with severe mental illness total care. This study has demonstrated that this area is still not looked after adequately. Improvement in this area will improve the global outcome for these patients.

A critical review of patients under Section 5(2) of the Mental Health Act of 1983.

BACKGROUND: Patients who suffer from mental illness within the definition of the Mental Health Act of 1983 and present a risk to themselves, to other people or at risk of self neglect or deterioration, can be detained under section. Section 5(2) applies for patients who are already admitted to hospital and express their wish to leave against medical advice. It requires the recommendation of one medical practitioner. It gives the power to detain them for 72 hours in hospital for further assessment. To safeguard malpractice of this section, trusts have developed policies and procedures which define good medical practice within the legal framework of the MHA 1983. AIMS: To evaluate current medical practice and insure that it complies with trust's policies and procedures and applies good medical practice. METHODS: Medical case notes of patients admitted from 1.1.07-30.6.07 and were detained under Section 5(2) were reviewed. A special form was devised to collect information from the notes. It included age, sex, marital status, occupation, diagnosis, history of violence, history of drug and alcohol abuse and circumstances of their detention were obtained. RESULTS: 44 patients were identified. 40% were men, 65% above the age of 50 years; 52% were sectioned after hours or at the weekends. Measures to persuade patients to stay as informal patients were taken by 16%. 55% were sectioned by the on-call doctor. 68.5% exhibited threatening behaviour. 30% had self neglect, 13% were a risk to others, 26% had a deliberate self harm risk. 60% had moderate to severe suicidal risk and ideation. 68% did not have mental health capacity to give consent for admission. 60% had been assessed in the first 24 hours of their section. 60% were converted to Section 2,3 of the Mental Health Act. 25% stayed as informal patients and 7% were discharged. DISCUSSION: Female patients were more likely to be put on Section 5(2), which was against expectation. Older people were more likely to be put on section 5(2), which was again against expectation. Majority of patients were a risk to themselves and only 13% were a risk to other people. Nearly two-thirds were assessed within 24 hrs from the section, which we commend our services on. 60% needed to be transferred to different sections which indicates that 40% of the sample could have been managed more efficiently without warranting section 5(2). CONCLUSION: Section 5(2) is a useful legal framework when it is used efficiently. This study has shown that current clinical practice could be improved by applying the least restrictive measures by giving patients more choice and empowering them in clinical decision making.

Antipsychotic prescribing before clozapine in a community psychiatric hospital: a case note review.

OBJECTIVES: To examine whether prescribing Clozapine was delayed in Treatment Resistant Schizophrenia (TRS), and elucidate possible reasons for this. METHODS: A retrospective Case note review was done. The main outcome measured was the mean maximum theoretical delay in starting Clozapine. In analyses, mean values were compared using an unpaired, 2-sided Student t-test. The association between duration of illness and theoretical delay was analysed by scatterplot and Pearson correlation coefficient. RESULTS: 42 case notes were reviewed. Mean age of subjects was 40.1 years. The mean maximum theoretical delay in all patients was 5 years. A statistically significant longer delay was found in patients over 30 years, patients diagnosed with TRS before 1991,and for patients before the introduction of Risperidone. Delay was significantly shorter for patients admitted to a psychiatric hospital more than once a year. CONCLUSION: There is a strong indication that Clozapine was not introduced at the earliest opportunity. Factors contributing to the delay include the patient's age, using sequential antipsychotic trials, and the failure to identify TRS. The use of Clozapine appears to have been adopted more in recent years, with a delay of five years to Clozapine for those diagnosed pre-1991, reducing to two years for those diagnosed pre-2003. SIGNIFICANT OUTCOMES: Mean average delay of prescribing clozapine was 5 years. Statistically significant delays in patients over 30 years of age. LIMITATIONS: There was no evaluation of: Reasons for co-prescribing of antipsychotics. Reasons for delay in prescribing Clozapine, e.g. prescriber inexperience, patient choice, risk of non-compliance etc. Evidence of treatment resistance, and whether primary or secondary in onset.

Analysis of clinical observation on acute psychiatric wards.

BACKGROUND: Clinical observation is very important to manage risk of people who are acutely ill on psychiatric wards. It is always an area of dispute between different specialities and disciplines in serious untoward incidents (SUI). Three levels of observations have been applied on acute psychiatric words. Assessing practice is important to help to identify any area needs improving. METHODS: A questionnaire was developed by HN to collect demographics. Medical notes on Westley and Grangewater wards were reviewed. Excel Microsoft Office World Computer Programme was used to analyse the results. RESULTS: 57% were men. 62% were above 41 years of age. Majority were suffering from schizophrenia and schizoaffective disorders 61%. 64.28% were admitted as formal patients. 31.42% were on level I observation.62.53 were informal. 54.76% were risk to themselves, 28.57% risk to others. 82.3% were on level II observation, 31.42% formal and 68.50% informal. 21.32% were on level III observation. 66.66% were formal and 66.66% had an incident before this level. CONCLUSION: This study have shown that patients are assessed properly before they go on any level of care. Some patients need to go on level III as they pose a risk mainly to other people. Regular reviews of patients, especially on high level of observation should be done more promptly, as being on observation is not a comfortable experience to go through and applying the least restrictive practice should always be sought and adopted.

Trends of admissions of conversion disorder in Mosul Iraq.

AIMS: Our study aims to make inferences from inpatient admission of conversion disorder with regards it's age and sex distribution, clinical presentation, yearly distribution of admission and morbidity of conversion disorder in comparison to total psychiatric admissions. It also compares it's results with those of previous studies in this country, neighbouring countries and western studies. METHODS: A case notes review was done for admissions of this disorder for five years in Mosul University Hospital. The data were inputted into SPSS programme and analysed. The statistical analysis was by t-test, Anova and regression. RESULTS: Two hundred seventy five patients were admitted during the period; 224 women and 51 men. The majority of men came from Urban areas compared to 58% of women. Single status was over represented; 59% compared to 34% married. Women formed 82% of the singles, 90% of the widows and 83% of the divorced. Pseudo-fits was the most frequent diagnosis. There was no significant change in the number of yearly admissions apart from the first year. The proportion of conversion disorders compared to total psychiatric disorders admissions was 7.4%. IMPLICATIONS: Results were consistent with national studies but showed higher figures than neighbouring countries. What was interesting was that, results were consistent with figures in United Kingdom before 1950.

Psychological Distress and Anxiety Levels Among Health Care Workers at the Height of the COVID-19 Pandemic in the United Arab Emirates.

Objectives: Providing medical care during a global pandemic exposes healthcare workers (HCW) to a high level of risk, causing anxiety and stress. This study aimed to assess the prevalence of anxiety and psychological distress among HCWs during COVID-19. Methods: We invited HCWs from 3 hospitals across the United Arab Emirates (UAE) to participate in an anonymous online survey between April 19-May 3, 2020. The GAD-7 and K10 measures were used to assess anxiety and psychological distress. Logistic regression models assessed associations between knowledge, attitude, worry, and levels of anxiety and psychological distress. Results: A total of 481 HCWs participated in this study. The majority of HCWs were female (73.6%) and aged 25-34 years (52.6%). More than half were nurses (55.7%) and had good knowledge of COVID-19 (86.3%). Over a third (37%) of HCWs reported moderate/severe psychological distress in the K10 measure and moderate/severe anxiety (32.3%) in the GAD-7, with frontline workers significantly reporting higher levels of anxiety (36%). Knowledge of COVID-19 did not predict anxiety and psychological distress, however, HCWs who believed COVID-19 was difficult to treat and those who perceived they were at high risk of infection had worse mental health outcomes. Worry about spreading COVID-19 to family, being isolated, contracting COVID-19 and feeling stigmatized had 1.8- to 2.5-fold increased odds of symptoms of mental health problems. Additionally, HCWs who felt the need for psychological support through their workplace showed increased odds of psychological distress. Conclusion: HCWs in the UAE reported a high prevalence of psychological distress and anxiety while responding to the challenges of COVID-19. The findings from this study emphasize the public, emotional and mental health burden of COVID-19 and highlight the importance for health systems to implement, monitor, and update preventive policies to protect HCWs from contracting the virus while also providing psychological support in the workplace.

Psychiatric morbidity among patients on haemodialysis in the Mosul district of Iraq.

Patients on chronic haemodialysis experience a wide range of physical and psychological stresses. The specific sources of stress include: loss or threatened loss of possessions; relationship problems (e.g. staff-patient relationships, changed roles within the family); restrictions related to physical health status and the dialysis regimen; loss of body function and impaired body image; increased dependency and aggression; the threat of death; impairment of vocational function and financial security; and decreased participation in leisure, social and community activities (Phipps & Turkington, 2001). A review of psychological maladjustment in patients on haemodialysis found that about 55% exhibited significant emotional distress, a prevalence three to five times that found in the general population (Aghanwa & Morakinyo, 1997). The present study aimed to ascertain the prevalence of psychiatric morbidity among patients attending a renal dialysis unit in Mosul, Iraq.