Improving referrals to community mental health services in the liaison setting.

The East London Foundation Trust (ELFT) psychiatric liaison team (PLT) at Newham University Hospital (NUH) is responsible for referring adult patients they have reviewed, on to community mental health services on discharge where appropriate, and also to notify their existing team for follow-up on discharge when already under the care of a community service. This should then lead to appropriate ongoing management of the patient's mental health needs in terms of continued support and assessment of risk, further assessment of mental state, titration of medications and prevention of further admissions.Following an ELFT incident review where it was noted that a patient was not referred to community services on discharge, a retrospective case note review was undertaken over an 11-month period to define the baseline efficacy of current referrals. Quality improvement (QI) methods were used to understand the issue, create a more robust process and measure the improvements made. We set up regular QI Project meetings and we used driver diagram, process mapping, PDSA cycles and run charts. The change ideas included moving from a white board based system to using Microsoft Excel, CRS millennium patient lists, Microsoft TEAMS and additional admin support. We studied the results for the following 14 months.The percentage of patients being appropriately referred in terms of timeliness and correct documentation increased from a run chart baseline of 35% to 88% during the project period, and the number of patients with some evidence of referral having been completed increased from 83% to 100%.The previous system used was ineffective in managing onward referrals for mental health patients from PLT. QI methods have allowed sustainable improvement in both the percentage of patients referred and those correctly documented, improving follow up and care for mental health patients who are admitted to NUH.

Correction: Withdrawal from escalated cocaine self-administration impairs reversal learning by disrupting the effects of negative feedback on reward exploitation: a behavioral and computational analysis.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Withdrawal from escalated cocaine self-administration impairs reversal learning by disrupting the effects of negative feedback on reward exploitation: a behavioral and computational analysis.

Addiction is regarded as a disorder of inflexible choice with behavior dominated by immediate positive rewards over longer-term negative outcomes. However, the psychological mechanisms underlying the effects of self-administered drugs on behavioral flexibility are not well understood. To investigate whether drug exposure causes asymmetric effects on positive and negative outcomes we used a reversal learning procedure to assess how reward contingencies are utilized to guide behavior in rats previously exposed to intravenous cocaine self-administration (SA). Twenty-four rats were screened for anxiety in an open field prior to acquisition of cocaine SA over six daily sessions with subsequent long-access cocaine SA for 7 days. Control rats (n = 24) were trained to lever-press for food under a yoked schedule of reinforcement. Higher rates of cocaine SA were predicted by increased anxiety and preceded impaired reversal learning, expressed by a decrease in lose-shift as opposed to win-stay probability. A model-free reinforcement learning algorithm revealed that rats with high, but not low cocaine escalation failed to exploit previous reward learning and were more likely to repeat the same response as the previous trial. Eight-day withdrawal from high cocaine escalation was associated, respectively, with increased and decreased dopamine receptor D2 (DRD2) and serotonin receptor 2C (HTR2C) expression in the ventral striatum compared with controls. Dopamine receptor D1 (DRD1) expression was also significantly reduced in the orbitofrontal cortex of high cocaine-escalating rats. These findings indicate that withdrawal from escalated cocaine SA disrupts how negative feedback is used to guide goal-directed behavior for natural reinforcers and that trait anxiety may be a latent variable underlying this interaction.