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Aims and method With increasing recognition of the prevalence and impact of perinatal mental health (PMH) disorders comes a responsibility to ensure that tomorrow's doctors can support families during the perinatal period. Online surveys seeking information about the inclusion of PMH education in undergraduate curricula were sent to psychiatry curriculum leads and student psychiatry societies from each university medical school in the UK between April and September 2021. Results Responses were received from 32/35 (91.4%) medical schools. Two-thirds reported specific inclusion of PMH content in the core curriculum, typically integrated into general adult psychiatry or obstetric teaching. Students at the remaining schools were all likely to be examined on the topic or see perinatal cases during at least one clinical attachment. Clinical implications PMH education offers an opportunity for collaboration between psychiatry and other disciplines. Future work looking at educational case examples with objective outcomes would be valuable.

ObjectivesThis study reports preliminary findings on the prevalence of, and factors associated with, mental health and well-being outcomes of healthcare workers during the early months (April–June) of the COVID-19 pandemic in the UK.MethodsPreliminary cross-sectional data were analysed from a cohort study (n=4378). Clinical and non-clinical staff of three London-based NHS Trusts, including acute and mental health Trusts, took part in an online baseline survey. The primary outcome measure used is the presence of probable common mental disorders (CMDs), measured by the General Health Questionnaire. Secondary outcomes are probable anxiety (seven-item Generalised Anxiety Disorder), depression (nine-item Patient Health Questionnaire), post-traumatic stress disorder (PTSD) (six-item Post-Traumatic Stress Disorder checklist), suicidal ideation (Clinical Interview Schedule) and alcohol use (Alcohol Use Disorder Identification Test). Moral injury is measured using the Moray Injury Event Scale.ResultsAnalyses showed substantial levels of probable CMDs (58.9%, 95% CI 58.1 to 60.8) and of PTSD (30.2%, 95% CI 28.1 to 32.5) with lower levels of depression (27.3%, 95% CI 25.3 to 29.4), anxiety (23.2%, 95% CI 21.3 to 25.3) and alcohol misuse (10.5%, 95% CI 9.2 to 11.9). Women, younger staff and nurses tended to have poorer outcomes than other staff, except for alcohol misuse. Higher reported exposure to moral injury (distress resulting from violation of one’s moral code) was strongly associated with increased levels of probable CMDs, anxiety, depression, PTSD symptoms and alcohol misuse.ConclusionsOur findings suggest that mental health support for healthcare workers should consider those demographics and occupations at highest risk. Rigorous longitudinal data are needed in order to respond to the potential long-term mental health impacts of the pandemic.

Aims and MethodThis study evaluated a pilot psychiatry summer school for GCSE students in terms of participant experience, effects on attitudes to mental illness and perception of psychiatry as a career option. This was done using the Community Attitudes towards the Mentally Ill scale, career choice questionnaires and a discussion group following the week-long programme attended by 26 students.ResultsStudents were significantly more likely to choose psychiatry after the summer school (P = 0.01). There were statistically significant changes in scores for social restrictiveness (P = 0.04) and community mental health ideology (P = 0.02). Qualitative analysis generated four themes: variation in expectations, limited prior knowledge, perception of the summer school itself and uniformly positive attitudes to psychiatry after the summer school.Clinical implicationsTargeting students at this early stage appears to be an underexplored positive intervention for improving both attitudes towards mental illness and recruitment to psychiatry.

The Psychiatry Early Experience Programme (PEEP) is a novel enrichment activity at Kings College London medical school. Throughout their five-year degree, students shadow trainee psychiatry doctors. The study aimed to evaluate whether more regular early exposure affects attitudes towards psychiatry. Forty first-year medical students joined PEEP and completed a baseline survey, including questions on demographics, current top three choices of medical specialty and the 30-item Attitudes Towards Psychiatry questionnaire (ATP-30). Participants completed annual follow up surveys, incorporating free-text questions about what students had learned and whether their views about psychiatry had changed. Over three years there was a sustained improvement in mean ATP-30 scores (8.27 points higher at three years than at baseline [95% CI 2.86-13.7, T=3.2, p=0.005]). There was no significant difference between baseline specialty choice and specialty choice at three-year follow-up. At three years there was a 55% response rate. There was no significant association between non-responders at three years and baseline ATP-30, specialty choice or demographic factors. Thematic analysis of qualitative data suggested that PEEP challenged preconceptions towards psychiatry and highlighted its relevance in medicine. The results offer some support that exposure to clinical psychiatry through longitudinal shadowing experiences can sustain positive attitudes. Areas for development include using a control group and following-up participants to the point when they specialize. It remains unclear whether it is most effective to select participants based on established commitment to psychiatry or to try to influence students who are still undecided.

Background\ud Cannabis is the most commonly used illicit substance amongst people with psychosis. Continued cannabis use following the onset of psychosis is associated with poorer functional and clinical outcomes. However, finding effective ways of intervening has been very challenging. We examined the clinical and cost-effectiveness of adjunctive contingency management (CM), which involves incentives for abstinence from cannabis use, in people with a recent diagnosis of psychosis.\ud \ud Methods\ud CIRCLE was a pragmatic multi-centre randomised controlled trial. Participants were recruited via Early Intervention in Psychosis (EIP) services across the Midlands and South East of England. They had had at least one episode of clinically diagnosed psychosis (affective or non-affective); were aged 18 to 36; reported cannabis use in at least 12 out of the previous 24 weeks; and were not currently receiving treatment for cannabis misuse, or subject to a legal requirement for cannabis testing. Participants were randomised via a secure web-based service 1:1 to either an experimental arm, involving 12 weeks of CM plus a six-session psychoeducation package, or a control arm receiving the psychoeducation package only. The total potential voucher reward in the CM intervention was £240. The primary outcome was time to acute psychiatric care, operationalised as admission to an acute mental health service (including community alternatives to admission). Primary outcome data were collected from patient records at 18 months post-consent by assessors masked to allocation. The trial was registered with the ISRCTN registry, number ISRCTN33576045.\ud \ud Results\ud Five hundred fifty-one participants were recruited between June 2012 and April 2016. Primary outcome data were obtained for 272 (98%) in the CM (experimental) group and 259 (95%) in the control group. There was no statistically significant difference in time to acute psychiatric care (the primary outcome) (HR 1.03, 95% CI 0.76, 1.40) between groups. By 18 months, 90 (33%) of participants in the CM group, and 85 (30%) of the control groups had been admitted at least once to an acute psychiatric service. Amongst those who had experienced an acute psychiatric admission, the median time to admission was 196 days (IQR 82, 364) in the CM group and 245 days (IQR 99, 382) in the control group. Cost-effectiveness analyses suggest that there is an 81% likelihood that the intervention was cost-effective, mainly resulting from higher mean inpatient costs for the control group compared with the CM group; however, the cost difference between groups was not statistically significant. There were 58 adverse events, 27 in the CM group and 31 in the control group.\ud \ud Conclusions\ud Overall, these results suggest that CM is not an effective intervention for improving the time to acute psychiatric admission or reducing cannabis use in psychosis, at least at the level of voucher reward offered.

ObjectivesThis study reports preliminary findings on the prevalence of, and factors associated with, mental health and wellbeing outcomes of healthcare workers during the early months (April-June) of the COVID-19 pandemic in the UK.MethodsPreliminary cross-sectional data were analysed from a cohort study (n=4,378). Clinical and non-clinical staff of three London-based NHS Trusts (UK), including acute and mental health Trusts, took part in an online baseline survey. The primary outcome measure used is the presence of probable common mental disorders (CMDs), measured by the General Health Questionnaire (GHQ-12). Secondary outcomes are probable anxiety (GAD-7), depression (PHQ-9), Post-Traumatic Stress Disorder (PTSD) (PCL-6), suicidal ideation (CIS-R), and alcohol use (AUDIT). Moral injury is measured using the Moray Injury Event Scale (MIES).ResultsAnalyses showed substantial levels of CMDs (58.9%, 95%CI 58.1 to 60.8), and of PTSD (30.2%, 95%CI 28.1 to 32.5) with lower levels of depression (27.3%, 95%CI 25.3 to 29.4), anxiety (23.2%, 95%CI 21.3 to 25.3), and alcohol misuse (10.5%, 95%CI, 9.2 to 11.9). Women, younger staff, and nurses tended to have poorer outcomes than other staff, except for alcohol misuse. Higher reported exposure to moral injury (distress resulting from violation of one’s moral code) was strongly associated with increased levels of CMDs, anxiety, depression, PTSD symptoms, and alcohol misuse.ConclusionsOur findings suggest that mental health support for healthcare workers should consider those demographics and occupations at highest risk. Rigorous longitudinal data are needed in order to respond to the potential long-term mental health impacts of the pandemic.HighlightsWhat is already known about this subject?Large-scale population studies report increased prevalence of depression, anxiety, and psychological distress during the COVID-19 pandemic.Evidence from previous epidemics indicates a high and persistent burden of adverse mental health outcomes among healthcare workers.What are the new findings?Substantial levels of probable common mental disorders and post-traumatic stress disorder were found among healthcare workers.Groups at increased risk of adverse mental health outcomes included women, nurses, and younger staff, as well as those who reported higher levels of moral injury.How might this impact on policy or clinical practice in the foreseeable future?The mental health offering to healthcare workers must consider the interplay of demographic, social, and occupational factors.Additional longitudinal research that emphasises methodological rigor, namely with use of standardised diagnostic interviews to establish mental health diagnoses, is necessary to better understand the mental health burden, identify those most at risk, and provide appropriate support without pathologizing ordinary distress responses.

AimsTo explore if attending a psychiatry summer school would change the understanding of school students as to what the word ‘Psychiatry’ represents.BackgroundThe Institute of Psychiatry, Psychology and Neuroscience (IoPPN) and the local mental health trust, South London and Maudsley NHS Foundation Trust (SLaM) ran a free five-day summer school for 16-year-old school students, who had just completed their GCSE exams, from state and private secondary schools within South-East London.MethodWe asked all 26 student attendees to anonymously write down as many single words relating to ‘Psychiatry’ as they could think of. They were given approximately 5 minutes to complete this and they were asked to do this at the beginning of the first day and at the end of the final day of the summer school. These words were then transcribed with the number of times each word was submitted being documented. This information was then formatted into a word cloud, with the size of the word varying according to how many times it had been submitted.ResultAt the start of the summer school, the students submitted a total of 208 words which included a total of 94 distinct words. Of these, the 2 most common were brain (n = 15) and mental (n = 10). At the end of the summer school, the students submitted a total of 199 words which included a total of 100 distinct words. The 2 most common were psychosis (n = 12) and forensic (n = 8). Of the words submitted pre-summer school, there were 8 distinct words that described positive attributes of psychiatry – such as ‘helping’. This increased to 17 distinct positive words post-summer school.ConclusionWe note from our outcomes that the number of words submitted by the students pre and post the summer school were similar but the words submitted most frequently differed. The most common words submitted post the summer school were more consistent with medical terminology than those submitted pre the summer school, which suggests that their knowledge of this had increased. The increase in the number of distinct positive words submitted at the end of the summer school implies that the students had a more positive view of psychiatry following the summer school.

Aims and methodWe aimed to audit the documentation of decision-making capacity (DMC) assessments by our liaison psychiatry service against the legal criteria set out in the Mental Capacity Act 2005. We audited 3 months split over a 2-year period occurring before, during and after an educational intervention to staff.ResultsThere were 21 assessments of DMC in month 1 (6.9% of all referrals), 27 (9.7%) in month 16, and 24 (6.6%) in month 21. Only during the intervention (month 16) did any meet our gold-standard (n = 2). Severity of consequences of the decision (odds ratio (OR) 24.4) and not agreeing to the intervention (OR = 21.8) were highly likely to result in lacking DMC.Clinical implicationsOur audit demonstrated that DMC assessments were infrequent and poorly documented, with no effect of our legally focused educational intervention demonstrated. Our findings of factors associated with the outcome of the assessment of DMC confirm the anecdotal beliefs in this area. Clinicians and service leads need to carefully consider how to make the legal model of DMC more meaningful to clinicians when striving to improve documentation of DMC assessments.

The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder. There is a focus on three key interventions: de-escalation, pharmacological interventions pre-rapid tranquillisation and rapid tranquillisation (intramuscular and intravenous). Most of the evidence reviewed relates to emergency psychiatric care or acute psychiatric adult inpatient care, although we also sought evidence relevant to other common clinical settings including the general acute hospital and forensic psychiatry. We conclude that the variety of options available for the management of acute disturbance goes beyond the standard choices of lorazepam, haloperidol and promethazine and includes oral-inhaled loxapine, buccal midazolam, as well as a number of oral antipsychotics in addition to parenteral options of intramuscular aripiprazole, intramuscular droperidol and intramuscular olanzapine. Intravenous options, for settings where resuscitation equipment and trained staff are available to manage medical emergencies, are also included.

On the 9We conducted a single-arm, pre-post comparison study on participants who attended the KCL Psych Soc event. Validated stigma scales on knowledge (Mental Health Knowledge Schedule (MAKS)), attitudes (Community Attitudes towards the Mentally Ill (CAMI)) and behaviour (Reported and Intended Behaviour Scale (RIBS)) were administered before and immediately after exposure to the event.27/27 (100%) of participants recruited responded. There was a statistically significant difference in the pre-MAKS score compared to the post-MAKS score (p=0.0003), the pre-RIBS score compared to the post-RIBS score (p=0.0068) and in the pre-CAMI score compared to the post-CAMI score (p=0.0042).There were statistically significant reductions in stigma in the domains of knowledge, attitude and behavior following exposure to the KCL Psych Soc event and no adverse effects were reported. Our study revealed that a brief intervention made a highly significant impact and maybe useful in challenging the stigma around post-natal mental illness. However, more research in this area is required to determine if the changes are sustained before we can consider rolling out and scaling up such an initiative nationally and internationally.

There are higher levels of psychological distress in healthcare professionals and students compared to the general population. Yet, despite the availability of effective treatment, many in this group continue to suffer in silence. Fear of exposure to stigmatization has been identified to be a major barrier to accessing and using mental health services. King's College London Undergraduate Psychiatry Society (KCL PsychSoc) organized an event entitled, 'What does bipolar disorder even mean? Psychological distress: How can we challenge the stigma?'. Healthcare professionals who themselves recovered from psychological problems and a mental health advocate with first-hand experience of psychological distress were invited to deliver talks followed by an interactive question and answer session.We conducted a single-arm pre-post comparison study. People who attended the KCL Psych Soc event were recruited to participate. Validated stigma scales on knowledge (Mental Health Knowledge Schedule (MAKS), attitudes (Community Attitudes towards the Mentally Ill) and behavior (Reported and Intended Behavior Scale (RIBS)) were administered on participants before and immediately after exposure to the event.44/44 of the participants recruited completed the study (100% response rate). There were statistically significant changes in the respondents' scores for all 3 stigma scales (p value MAKS0.0001, p value CAMI0.0001, p value RIBS=0.0011).As far as the authors are aware, this is the first study to date of an anti-stigma intervention comprised of healthcare professionals with first-hand experience of psychological distress. The KCL PsychSoc event was associated with statistically significant changes in the respondents' scores in all three of the stigma scales. More robust research in this area is needed before scaling up similar anti-stigma initiatives.

Aims and method We aimed to audit the documentation of decision-making capacity (DMC) assessments by our liaison psychiatry service against the legal criteria set out in the Mental Capacity Act 2005. We audited 3 months split over a 2-year period occurring before, during and after an educational intervention to staff. Results There were 21 assessments of DMC in month 1 (6.9% of all referrals), 27 (9.7%) in month 16, and 24 (6.6%) in month 21. Only during the intervention (month 16) did any meet our gold-standard (n = 2). Severity of consequences of the decision (odds ratio (OR) 24.4) and not agreeing to the intervention (OR = 21.8) were highly likely to result in lacking DMC. Clinical implications Our audit demonstrated that DMC assessments were infrequent and poorly documented, with no effect of our legally focused educational intervention demonstrated. Our findings of factors associated with the outcome of the assessment of DMC confirm the anecdotal beliefs in this area. Clinicians and service leads need to carefully consider how to make the legal model of DMC more meaningful to clinicians when striving to improve documentation of DMC assessments.

Objective: To determine the preference of substance misusers for the terms ‘patient’, ‘client’ and ‘service user’ in the context of their contact with health professionals, if they consider substance misuse problems to exist appropriately under the category of mental health problems and if they consider themselves to have mental health problems. Methods: A self-completion questionnaire was administered to 150 National Health Service and private in- and outpatients with alcohol, drug and smoking problems. Results: The majority (54%) preferred the term ‘patient’, felt substance misuse problems was a category of mental health problems (59%), even though the majority (62%) did not consider themselves to have a mental health problem. Broadly similar preferences were found for those attending drug services and alcohol services whilst those attending the smoking cessation service were less likely to consider it an appropriate location or description. Discussion: The majority of substance misusers preferred to be called ‘patients’. The location of substance misuse services within mental health provision was widely tolerated.

BackgroundIt has been suggested that adults with medically unexplained physical symptoms experienced greater ill-health then others (either in themselves or their families) during childhood.AimsTo test these hypotheses.MethodWe used data from the Medical Research Council (MRC) National Survey of Health and Development, a population-based cohort study established in 1946 (n=5362). Subjects were followed from birth in 1946 until 1989 (age 43 years). As outcome, we used operationally defined medically unexplained hospital admissions at age 15–43 years. Exposure variables included childhood illness, and illness in parents during the childhood of the subjects.ResultsThe risk set (n=4603) comprised individuals still in the Survey at age 15. Ninety-five unexplained hospital admissions were identified. Subjects whose mothers reported below-average health in the father were at increased risk of subsequent unexplained admissions. Below average reported health in the mother was not associated with this increased risk. Defined physical diseases in childhood were not associated, but persistent abdominal pain at age 7–15 years was.ConclusionsUnexplained hospital admissions are associated with certain childhood experiences of illness, but defined physical illness in childhood is not a risk factor.

STUDY OBJECTIVE—Relative risks are frequently used to convey how strongly outcomes like mental illness and suicidal behaviour are associated with personal characteristics like ethnic background. This study examined whether RRs for deliberate self harm (DSH) in ethnic groups vary between small areas according to their ethnic mix. DESIGN—Small area study of DSH rates in ethnic groups, by local ethnic density, using negative binomial regression. SETTING—73 south London electoral wards, 1994-1997. SUBJECTS—1643 people attending casualty after DSH. MAIN RESULTS—African-Caribbean and Asian DSH rates, relative to the white population, varied between wards. A linear model indicated a decline by factors (relative rate ratios) 0.76 (95% confidence intervals (CI) 0.64 to 0.90) and 0.59 (95% CI 0.36 to 0.97) respectively per SD increase in the local size of these minority populations. However, for both groups, an inverted U shaped curve provided a better fit for the link between the relative DSH rate in these groups and their local population density. CONCLUSIONS—The DSH rate of minority groups relative to the white group is low (suggesting protection) in some areas, and high (suggesting risk) elsewhere. This has implications for management of suicidal behaviour in ethnic groups but also for interpretation, and policy implementation, of research on risk for suicidal behaviour, and, probably, many other outcomes. Relative risks or rates are not stable indicators of association in psychiatric epidemiology. Keywords: deliberate self harm; ethnic density

Sir: We agree with McCaffery et al ( Psychiatric Bulletin , September 2002, 26 , 332-334) that there is little consensus among psychiatrists as to how to manage intoxicated patients when they present. We collected questionnaire data from 164 health professionals — 53 psychiatrists, 56 psychiatric