Cyberpsychiatry versus COVID-19: using video consultation to improve clinical care in an in-patient psychiatric unit.

The COVID-19 pandemic has resulted in unique challenges for in-patients across the National Health Service as visitors, both family and friends, are prevented from visiting patients owing to infection prevention and control measures. The Attend Anywhere platform was used as the basis of a quality improvement project to mitigate the detrimental effects of reduced social contact for patients. The use of video conferencing led to increased subjective satisfaction for both patients and healthcare professionals, thereby providing further evidence of the benefit that this emerging technology has on healthcare delivery.

Acute mental health presentations before and during the COVID-19 pandemic.

BACKGROUND: A number of community based surveys have identified an increase in psychological symptoms and distress but there has been no examination of symptoms at the more severe end of the mental health spectrum. AIMS: We aimed to analyse numbers and types of psychiatric presentations to inform planning for future demand on mental health services in light of the COVID-19 pandemic. METHOD: We analysed electronic data between January and April 2020 for 2534 patients referred to acute psychiatric services, and tested for differences in patient demographics, symptom severity and use of the Mental Health Act 1983 (MHA), before and after lockdown. We used interrupted time-series analyses to compare trends in emergency department and psychiatric presentations until December 2020. RESULTS: There were 22% fewer psychiatric presentations the first week and 48% fewer emergency department presentations in the first month after lockdown initiated. A higher proportion of patients were detained under the MHA (22.2 v. 16.1%) and Mental Capacity Act 2005 (2.2 v. 1.1%) (χ2(2) = 16.3, P < 0.0001), and they experienced a longer duration of symptoms before seeking help from mental health services (χ2(3) = 18.6, P < 0.0001). A higher proportion of patients presented with psychotic symptoms (23.3 v. 17.0%) or delirium (7.0 v. 3.6%), and fewer had self-harm behaviour (43.8 v. 52.0%, χ2(7) = 28.7, P < 0.0001). A higher proportion were admitted to psychiatric in-patient units (22.2 v. 18.3%) (χ2(6) = 42.8, P < 0.0001) after lockdown. CONCLUSIONS: UK lockdown resulted in fewer psychiatric presentations, but those who presented were more likely to have severe symptoms, be detained under the MHA and be admitted to hospital. Psychiatric services should ensure provision of care for these patients as well as planning for those affected by future COVID-19 waves.

Containing COVID: the establishment and management of a COVID-19 ward in an adult psychiatric hospital.

BACKGROUND: As the coronavirus disease 2019 (COVID-19) epidemic in the UK emerged and escalated, clinicians working in mental health in-patient facilities faced unique medical, psychiatric and staffing challenges in managing and containing the impact of the virus and, in the context of legislation, enforcing social distancing. AIMS: To describe (a) the steps taken by one mental health hospital to establish a COVID-19 isolation ward for adult psychiatric in-patients and (b) how staff addressed the challenges that emerged over the period March to June 2020. METHOD: A descriptive study detailing the processes involved in changing the role of the ward and the measures taken to address the various challenges that arose. Brief clinical cases of two patients are included for illustrative purposes. RESULTS: We describe the achievements, lessons learned and outcomes of the process of repurposing a mental health triage ward into a COVID-19 isolation facility, including the impact on staff. Flexibility, rapid problem-solving and close teamwork were essential. Some of the changes made will be sustained on the ward in our primary role as a triage ward. CONCLUSIONS: Although the challenges faced were difficult, the legacy they have left is that of a range of improvements in patient care and the working environment.

Assessing Digital Risk in Psychiatric Patients: Mixed Methods Study of Psychiatry Trainees' Experiences, Views, and Understanding.

BACKGROUND: The use of digital technology can help people access information and provide support for their mental health problems, but it can also expose them to risk, such as bullying or prosuicide websites. It may be important to consider internet-related risk behavior (digital risk) within a generic psychiatric risk assessment, but no studies have explored the practice or acceptability of this among psychiatrists. OBJECTIVE: This study aimed to explore psychiatry trainees' experiences, views, and understanding of digital risk in psychiatry. We predicted that clinician awareness would be highest among trainees who work in child and adolescent mental health services. METHODS: We conducted a cross-sectional survey of psychiatry trainees attending a UK regional trainees' conference to investigate how they routinely assess patients' internet use and related risk of harm and their experience and confidence in assessing these risks. We conducted focus groups to further explore trainees' understandings and experiences of digital risk assessment. Descriptive statistics and chi-squared tests were used to present the quantitative data. A thematic analysis was used to identify the key themes in the qualitative data set. RESULTS: The cross-sectional survey was completed by 113 out of 312 psychiatry trainees (response rate 36.2%), from a range of subspecialties and experience levels. Half of the trainees (57/113, 50.4%) reported treating patients exposed to digital risk, particularly trainees subspecializing in child and adolescent psychiatry (17/22, 77% vs 40/91, 44%;P=.02). However, 67.3% (76/113) reported not feeling competent to assess digital risk. Child and adolescent psychiatrists were more likely than others to ask patients routinely about specific digital risk domains, including reckless web-based behavior (18/20, 90% vs 54/82, 66%; P=.03), prosuicide websites (20/21, 95% vs 57/81, 70%; P=.01), and online sexual behavior (17/21, 81% vs 44/81, 54%; P=.02). Although 84.1% (95/113) of the participants reported using a proforma to record general risk assessment, only 5% (5/95) of these participants prompted an assessment of internet use. Only 9.7% (11/113) of the trainees had received digital risk training, and 73.5% (83/113) reported that they would value this. Our thematic analysis of transcripts from 3 focus groups (comprising 11 trainees) identified 2 main themes: barriers to assessment and management of digital risk, and the double-edged sword of web use. Barriers reported included the novelty and complexity of the internet, a lack of confidence and guidance in addressing internet use directly, and ongoing tension between assessment and privacy. CONCLUSIONS: Although it is common for psychiatrists to encounter patients subject to digital risk, trainee psychiatrists lack competence and confidence in their assessment. Training in digital risk and the inclusion of prompts in standardized risk proformas would promote good clinical practice and prevent a potential blind spot in general risk assessment.

Factors affecting implementation of digital health interventions for people with psychosis or bipolar disorder, and their family and friends: a systematic review.

Digital health interventions present an important opportunity to improve health care for people with psychosis or bipolar disorder, but despite their potential, integrating and implementing them into clinical settings has been difficult worldwide. This Review aims to identify factors affecting implementation of digital health interventions for people affected by psychosis or bipolar disorder. We searched seven databases and synthesised data from 26 studies using the Consolidated Framework for Implementation Research. Attitudes and beliefs about interventions were crucial factors for both staff and service users, with negative attitudes and scepticism resulting in a lack of motivation to engage with interventions or complete them. The complexity of the interventions was a barrier for people with psychiatric symptoms, low premorbid intelligence quotient, or minimal information technology skills. The accessibility and adaptability of interventions were key facilitators, but insufficient resources, finances, and staff time were barriers to implementation. Interventions need to be user friendly and adaptable to the needs and capabilities of people with psychosis or bipolar disorder, and the staff who support their implementation. Service users and staff should cofacilitate the process of developing and implementing the interventions.

Exploring the digital technology preferences of teenagers and young adults (TYA) with cancer and survivors: a cross-sectional service evaluation questionnaire.

PURPOSE: Digital technology has the potential to support teenagers and young adults (TYAs) with cancer from the onset of their disease into survivorship. We aimed to establish (1) the current pattern of use of TYA digital technologies within our service-user population, and (2) their preferences regarding digital information and support within the service. METHODS: A cross-sectional survey was administered as a paper and online self-completed questionnaire to TYAs aged 13-24 accessing outpatient, inpatient, and day care cancer services at a regional specialist centre over a 4-week period. RESULTS: One hundred two TYAs completed the survey (55.7% male; 39.8% female; 83.3% paper; 16.7% online; mean age 18.5 years [SD = 3.51]). Of the TYAs, 41.6% rated the importance of digital communication as "essential" to their lives. Half (51.0%) kept in contact with other patients they had met during treatment, and 12.0% contacted patients they had not met in person. Respondents wanted to receive clinical information online (66.3%) and use online chat rooms (54.3%). Future online services desired included virtual online groups (54.3%), online counselling or psychological support (43.5%), and receiving (66.3%) and sharing (48.9%) clinical information online. CONCLUSIONS: Young people with cancer are digital natives. A significant subgroup expressed a desire for digital resources from oncology services, though existing resources are also highly valued. Digital resources have potential to improve patient experience and engagement. IMPLICATIONS FOR CANCER SURVIVORS: There is considerable scope to develop digital resources with which TYAs can receive information and connect with both professionals and fellow patients, following diagnosis, through treatment and survivorship.

Caudwell Xtreme Everest: A prospective study of the effects of environmental hypoxia on cognitive functioning.

BACKGROUND: The neuropsychological consequences of exposure to environmental hypobaric hypoxia (EHH) remain unclear. We thus investigated them in a large group of healthy volunteers who trekked to Mount Everest base camp (5,300 m). METHODS: A neuropsychological (NP) test battery assessing memory, language, attention, and executive function was administered to 198 participants (age 44.5±13.7 years; 60% male). These were studied at baseline (sea level), 3,500 m (Namche Bazaar), 5,300 m (Everest Base Camp) and on return to 1,300 m (Kathmandu) (attrition rate 23.7%). A comparable control group (n = 25; age 44.5±14.1 years; 60% male) for comparison with trekkers was tested at/or near sea level over an equivalent timeframe so as to account for learning effects associated with repeat testing. The Reliable Change Index (RCI) was used to calculate changes in cognition and neuropsychological function during and after exposure to EHH relative to controls. RESULTS: Overall, attention, verbal ability and executive function declined in those exposed to EHH when the performance of the control group was taken into account (RCI .05 to -.95) with decline persisting at descent. Memory and psychomotor function showed decline at highest ascent only (RCI -.08 to -.56). However, there was inter-individual variability in response: whilst NP performance declined in most, this improved in some trekkers. Cognitive decline was greater amongst older people (r = .42; p < .0001), but was otherwise not consistently associated with socio-demographic, mood, or physiological variables. CONCLUSIONS: After correcting for learning effects, attention, verbal abilities and executive functioning declined with exposure to EHH. There was considerable individual variability in the response of brain function to sustained hypoxia with some participants not showing any effects of hypoxia. This might have implications for those facing sustained hypoxia as a result of any disease.

A qualitative study of online mental health information seeking behaviour by those with psychosis.

BACKGROUND: The Internet and mobile technology are changing the way people learn about and manage their illnesses. Little is known about online mental health information seeking behaviour by people with psychosis. This paper explores the nature, extent and consequences of online mental health information seeking behaviour by people with psychosis and investigates the acceptability of a mobile mental health application (app). METHODS: Semi-structured interviews were carried out with people with psychosis (n = 22). Participants were purposively recruited through secondary care settings in London. The main topics discussed were participants' current and historical use of online mental health information and technology. Interviews were audio-recorded, transcribed and analysed by a team of researchers using thematic analysis. RESULTS: Mental health related Internet use was widespread. Eighteen people described searching the Internet to help them make sense of their psychotic experiences, and to read more information about their diagnosis, their prescribed psychiatric medication and its side-effects. Whilst some participants sought 'expert' online information from mental health clinicians and research journals, others described actively seeking first person perspectives. Eight participants used this information collaboratively with clinicians and spoke of the empowerment and independence the Internet offered them. However nine participants did not discuss their use of online mental health information with their clinicians for a number of reasons, including fear of undermining their clinician's authority. For some of these people concerns over what they had read led them to discontinue their antipsychotic medication without discussion with their mental health team. CONCLUSIONS: People with psychosis use the Internet to acquire mental health related information. This can be a helpful source of supplementary information particularly for those who use it collaboratively with clinicians. When this information is not shared with their mental health team, it can affect patients' health care decisions. A partnership approach to online health-information seeking is needed, with mental health clinicians encouraging patients to discuss information they have found online as part of a shared decision-making process. Our research suggests that those with psychosis have active digital lives and that the introduction of a mental health app into services would potentially be well received.

Travelling to new heights: practical high altitude medicine.

Over 40 million people travel to high altitude for both work and pleasure each year, and all of them are at risk of the acute effects of hypoxia. This article reviews the prevention, diagnostic features and treatments of these illnesses.

Use of acetaminophen and the risk of self-reported allergic symptoms and skin sensitization in Butajira, Ethiopia.

BACKGROUND: Studies in developed countries suggest that acetaminophen use is associated with increased risk of asthma, but it is unclear whether this association is causal. OBJECTIVE: To determine the relation among acetaminophen use, asthma, and allergy, and to explore potential biases in acetaminophen use, in a developing country population. METHODS: We surveyed 7649 adults and children from Butajira, Ethiopia, collecting data on self-reported symptoms of allergic disease, skin sensitization to Dermatophagoides pteronyssinus and cockroach, acetaminophen use, and potential confounders. We then collected detailed data on indications for acetaminophen use and reasons for aspirin avoidance in a nested follow-up study. RESULTS: Allergic symptoms increased significantly with frequency of acetaminophen use, with odds ratios in those using >3 tablets in the past month relative to none 1.89 (95% CI, 1.51-2.36) for wheeze, 2.14 (1.72-2.67) for nocturnal shortness of breath, 2.52 (1.99-3.20) for rhinitis, and 1.90 (1.39-2.61) for eczema. Cockroach sensitization was also more common in the highest acetaminophen category (odds ratio, 1.40; 95% CI, 1.10-1.79), but D pteronyssinus sensitization was not. Less than 1% of participants with asthma or wheeze in our nested study reported avoidance of aspirin because of asthma symptoms. None volunteered using acetaminophen to treat allergic symptoms. CONCLUSION: There is a dose-related association between acetaminophen use and self-reported allergic symptoms in this population that is not a result of aspirin avoidance, reverse causation, or other bias. Acetaminophen may therefore be involved in the etiology of asthma and allergic disease.