Cancer incidence rates in the UK have increased by more than a third over the last four decades, so the likelihood of requiring concurrent chemotherapy and clozapine is increasing. In this situation clinicians are faced with a clinical conundrum: to stop clozapine and risk a psychotic relapse, or to continue clozapine and risk a potentially fatal agranulocytosis. This case report describes how a multidisciplinary team (MDT) worked together to balance the mental and physical health needs of a patient.
Aims and MethodA questionnaire was distributed to patients in a psychiatric hospital in Birmingham, UK, to identify the factors that affect their satisfaction with the ward round.ResultsThe questionnaire was completed by 42 patients (53% response rate). Waiting time was the only variable to be significantly correlated with total score of patient satisfaction. Regression analysis also identified diagnosis and patients meeting their consultant before the first ward round as significant predictors of patient satisfaction.Clinical ImplicationsReducing waiting time and ensuring that the consultant meets the patient before the first ward round would make a significant improvement to the in-patient experience, without causing much disruption to standard clinical practice.
Macho rhubarbEDITOR,-Tim Albert's editorial 1 raises some important questions about communicating through journals. I share his concerns about the purpose and process of writing and publishing scientific articles. Distorting the tortuous IMRAD structure, I express some of mine in a poem. My misgivings about the methodology of writing the text include the apparently common practice of recycling old paragraphs and papers, grafting on the issue of the day and dressing the whole in the current macho style. For the record, I wrote my poem willingly, in my leisure time and for fun. Macho rhubarbProtocol for writing a scientific paper AbstractIn essence writing rhubarb is cathartic.Keywords MeSH, MaCHo, words, recycling.Introduction Editors choose rhubarb papers.(Doc K)Authors aim to please them.Most have failed.(Doc K; Doc K)We oVer something new. AimsWe aim to coax an editor to print our narrative of innovative work -a trial which fails to find a case or [curewhich would, if published, raise [awareness and, if widely cited, make us known. MethodMadly deeply uncontrolled.[Haphazardly we take n samples from our papers; pick the rhubarb, wash it, dock it; sprinkle newer references to spice it, [ (Doc K; Doc K) add a slice of topical debate.(Doc K)We stew and taste it, cut and paste until politically correct. There are a number of factors contributing to a poor response rate. Stocks and Gunnell 1 studied the influence of the characteristics of the GPs and confirmed that there are such diVerences between responders and nonresponders. However, other factors may also influence response rates, for instance the method of distribution of the questionnaires. Results WithWe would like to share the results of a study carried out to investigate the eVect of diVerent methods of distribution on response rates. We performed a questionnaire study related to psychiatry, investigating GPs in two similar geographical areas, Solihull and Warwickshire, both in the West Midlands.The questionnaires were posted to GPs in Warwickshire, with prepaid envelopes provided for reply. The GPs in Solihull received their questionnaires delivered by hand by one of the researchers, and replies were collected from the surgery by the same person two weeks later.The postal response rate was 50%, while the response rate from the hand delivered area was 60.3%. These results were significant (p=0.05, 2 = 5.860, Yates's correction = 5.330).These results show that the method of delivering and collecting questionnaires by hand significantly improves response rates. It also has a number of other advantages, such as an improvement in the researcher's knowledge of the area under study, their relationship with GPs and reducing costs of the study. We would encourage others to consider this method of questionnaire distribution in the future. Neonatal nicotine withdrawal syndromeEDITOR,-We have been assessing the recent in utero exposure to tobacco smoke in newborns from the Barcelona cohort of the AMICS study (Asthma Multicentre Infants Cohort Study). 1The nursing...
Aims and Method In order to assess the current provision for patients who misuse opiates in primary care, the discrepancy between this, and government expectations and the resources required to bridge this gap, a purpose-designed questionnaire based on the Department of Health guidelines was distributed to all general practitioners (GPs) in Solihull and Warwickshire (n=379). Data were analysed with the Chi-squared, Fisher's exact, Mann–Whitney U and Kruskal–Wallis tests, using the computer software SPSS version 10. Results Replies were received from 205 GPs, representing 77.2% of the practices. Only 12 GPs (6%) provided all four key services studied and 71 (34%) provided none of these services. One hundred and six GPs (51.7%) had read the guidelines. Of these, 51 (49%) were not willing to change their practice. Forty-one (39.4%) were prepared to change their practice, but only with additional resources. The main resources identified as necessary were shared care and training. Clinical Implications There is a huge gap between current provision and government expectations, which may be unrealistic. If this gap is to be bridged, then resources should be targeted to shared care and training for GPs.
AimsTo evaluate compliance within a Community Mental Health Team (CMHT) to the NICE guidelines for the management of depression.BackgroundReducing the prevalence of depression continues to be a major public health challenge.Given the complexity and recurrent nature of the condition, the NICE guideline CG90 is an invaluable resource to aid the effective management of depression. Here we present an audit of adherence to this guideline within a CMHT.MethodA retrospective electronic casenote review of all patients diagnosed with depression between January 2016 and October 2019 under the care of a Birmingham CMHT (n = 35), assessing key performance areas including: quality of assessment and coordinated care, risk assessment, choice of pharmacological and psychological treatment using the stepped care model and appropriate crisis resolution planning.ResultKey results include: The majority of patients were Caucasian (63%). Ages ranged from 27 to 69 (mean age 48 years old).Severity of disorder was typically moderate (46%) or severe (48%). Of those with a diagnosis of severe depression, 41% had associated psychotic symptoms.Psychiatric comorbidity was high (49%), of which generalised anxiety disorder was the most common (59%).Referrals were typically from primary care (77%). Approximately half (51%) had reported suicidal thoughts according to the referral.A quarter of patients (26%) were seen by CMHT within 8 weeks of referral; 20% of referrals however waited over 12 months before being assessed.Risk assessments were out of date for 71% of patients.100% of patients had a crisis plan noted within their most recent clinic letter; however, none of these met the required standards.Polypharmacy was common (60%), with 34% prescribed two antidepressants. Use of lithium augmentation was uncommon, with only one patient prescribed this. 43% were prescribed an antipsychotic; of which, 29% had appropriate physical health monitoring completed.Over half of patients (60%) had been referred to psychology services; of these, 38% had either completed or were in ongoing treatment at the time of review.ConclusionCMHTs manage the care of individuals with depression who have high levels of active symptoms and disability, psychiatric comorbidity, care requirements, and complex treatment plans. Pharmacological management was broadly in line with guidelines, and rates of referral to psychology were satisfactory. Risk assessment and crisis planning are clear areas in need of urgent attention in order to comply with guidelines and ensure patient safety.
Aims and MethodIn order to assess the current provision for patients who misuse opiates in primary care, the discrepancy between this, and government expectations and the resources required to bridge this gap, a purpose-designed questionnaire based on the Department of Health guidelines was distributed to all general practitioners (GPs) in Solihull and Warwickshire (n=379). Data were analysed with the Chi-squared, Fisher's exact, Mann–Whitney U and Kruskal–Wallis tests, using the computer software SPSS version 10.ResultsReplies were received from 205 GPs, representing 77.2% of the practices. Only 12 GPs (6%) provided all four key services studied and 71 (34%) provided none of these services. One hundred and six GPs (51.7%) had read the guidelines. Of these, 51 (49%) were not willing to change their practice. Forty-one (39.4%) were prepared to change their practice, but only with additional resources. The main resources identified as necessary were shared care and training.Clinical ImplicationsThere is a huge gap between current provision and government expectations, which may be unrealistic. If this gap is to be bridged, then resources should be targeted to shared care and training for GPs.
AimsTo describe the changes in complexity and management of individuals with schizophrenia in a community mental health team (CMHT) over a three year period.BackgroundIt is often believed that individuals receiving care from CMHTs are those with low levels of complexity and risk, and are relatively stable, with more complex individuals being managed by assertive outreach or other specialist teams. Here, we describe changes in the complexity, comorbidity, service-usage and management, of patients with a diagnosis of schizophrenia in a CMHT between 2016 and 2019.MethodData were collected from an electronic patient record system (RiO) for all individuals with schizophrenia in a CMHT in Birmingham (n = 84 in 2016, n = 71 in 2019), examining demographic variables, comorbidity, use of mental health services and current management.ResultKey findings included: - •63% were managed through care programme approach (CPA) in 2016, compared to only 31% in 2019.•21% had required home treatment or inpatient care in the preceding 12 months in 2016; this had improved to 8.5% in 2019.•Significant levels of psychiatric comorbidity, including addictions with almost half of patients (46.5%) having a known history of substance use in 2019, compared to only 15.5% noted in 2016.•Pharmacological management has remained broadly similar; in 2016 21% patients were taking a combination of 2 antipsychotics compared to only 10% in 2019 and 25% were taking clozapine in 2016 (21% in 2019). 39% were prescribed a long acting antipsychotic injection in 2016, compared to 32% in 2019.•In 2016, medication was being prescribed in the majority of cases within secondary care (55%) patients and in primary care in only 21%. GPs have now taken on greater prescribing responsibility in 2019, prescribing in 44% of cases, with 47% being prescribed by the CMHT.ConclusionThe acuity and management of individuals with a diagnosis of schizophrenia under the care of a CMHT has changed over a 3 year period. It is positive to note the reduced use of crisis services and lower rates of polypharmacy. There is a reduction in the proportion of patients receiving management through CPA, and a move towards more medication being prescribed in primary care. The reasons for this change are however unclear and may reflect change in available resources, given that more than half of this group receive clozapine or long acting injections, and have high levels of comorbidity.
AimsTo evaluate the use of antipsychotics, and high dose antipsychotic treatment (HDAT) in psychiatric inpatient unitsBackgroundThe Royal College of Psychiatrists published a consensus statement on high dose antipsychotic medication in October 1993. Such treatment carries an increased risk of adverse effects including towards ventricular tachycardia and sudden death.MethodA retrospective case note review of all male patients on acute adult inpatient units in a psychiatric hospital in South Birmingham on a date in June 2018 (n = 45) including review of electronic patient records and prescriptions. This was compared with the results of an earlier study, with identical methods, undertaken in June 2015.Result•In both 2015 and 2018, only a minority of patients (20% and 11% respectively) were informal.•In both 2015 and 2018, the majority of inpatients had a diagnosis of schizophrenia (54% and 67%)•In both 2015 and 2018, 93% inpatients were prescribed antipsychotic medication.•In 2015, 56% patients were prescribed HDAT. This reduced in 2018 to 16%.•This reduction in use of HDAT was almost entirely due to a reduction in the prescription of PRN antipsychotic medication.•In terms of regularly prescribed antipsychotic medication, in both years, the most commonly prescribed drug was flupentixol, with a range of other second generation oral and long acting medications being prescribed, usually at doses within BNF limits.Between the two years, there was a substantial change in the prescribing of PRN antipsychotics. In 2015, 59% individuals were prescribed at least one PRN antipsychotic (27% were prescribed two). In 2018, this reduced to 40% prescribed at least one, and only 2% being prescribed 2 PRN antipsychotics. In both years, oral quetiapine was a common choice (39% patients in 2015 prescribed oral quetiapine, and 34% in 2018). In 2015, 39% patients were prescribed oral or intramuscular aripiprazole, while this reduced to 7% in 2018.ConclusionThe vast majority of psychiatric inpatients were being prescribed antipsychotic medication. Prescription of high dose antipsychotic medication was common in 2015, and this was largely attributable to high levels of prescribing of PRN antipsychotics. Following an educational programme for junior doctors and ward nurses, and the introduction of electronic prescribing, we achieved a significant change in practice, particularly in the prescribing of PRN antipsychotics, which has reduced our patients’ risk of receiving high dose antipsychotic medication.
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