Berrywood Hospital

There has been a lack of in-depth interviews investigating patient experience of ketamine treatment for depression. We examined participants’ pathways to receiving ketamine infusion to treat their depression, and their responses to, lived experiences of, and attitudes towards ketamine treatment. Qualitative methods were used to conduct in-depth interviews with 13 patients (6 male; 7 female) diagnosed with treatment resistant depression (TRD) with experience of receiving ketamine treatment for depression. Interpretative phenomenological analysis (IPA) was employed. For the majority of participants ketamine infusion causes a reported initial ‘high’, enhanced perception, and dissociative experience; followed by a lifting of mood and a reduction in or removal of suicidal ideation and depression symptoms lasting around 3–6 days. This leads to a reported increase in motivation, socialisation, and activity. All participants valued the therapeutic alliance with clinicians which enhanced the treatment experience and all advocated treatment access for those with depression who have not responded to other treatments. Small numbers, purposive sample, participant self-selection, and single site recruitment limit generalisability. Ketamine for depression can have many beneficial effects, and it is potentially life-transforming for some. Ketamine may be a source of hope for patients for whom other treatments have not been effective. For some, ketamine is not tolerated or does not have anti-depressive effects. Further qualitative in-depth exploration of patient experience and consideration of how ketamine depression treatment access can be appropriately made available are warranted.

BACKGROUND: People with severe mental illnesses die up to 20 years earlier than the general population, with cardiovascular disease being the leading cause of death. National guidelines recommend that the physical care of people with severe mental illnesses should be the responsibility of primary care; however, little is known about effective interventions to lower cardiovascular disease risk in this population and setting. Following extensive peer review, funding was secured from the United Kingdom National Institute for Health Research (NIHR) to deliver the proposed study. The aim of the trial is to test the effectiveness of a behavioural intervention to lower cardiovascular disease risk in people with severe mental illnesses in United Kingdom General Practices. METHODS/DESIGN: The study is a cluster randomised controlled trial in 70 GP practices for people with severe mental illnesses, aged 30 to 75 years old, with elevated cardiovascular disease risk factors. The trial will compare the effectiveness of a behavioural intervention designed to lower cardiovascular disease risk and delivered by a practice nurse or healthcare assistant, with standard care offered in General Practice. A total of 350 people will be recruited and followed up at 6 and 12 months. The primary outcome is total cholesterol level at the 12-month follow-up and secondary outcomes include blood pressure, body mass index, waist circumference, smoking status, quality of life, adherence to treatments and services and behavioural measures for diet, physical activity and alcohol use. An economic evaluation will be carried out to determine the cost effectiveness of the intervention compared with standard care. DISCUSSION: The results of this pragmatic trial will provide evidence on the clinical and cost effectiveness of the intervention on lowering total cholesterol and addressing multiple cardiovascular disease risk factors in people with severe mental illnesses in GP Practices. TRIAL REGISTRATION: Current Controlled Trials ISRCTN13762819. Date of Registration: 25 February 2013. Date and Version Number: 27 August 2014 Version 5.

OBJECTIVE: To explore the lived experience of becoming cared for and the impact this has on the identity and sense of self of women with Alzheimer's disease. METHOD: Eight women with mild-to-moderate Alzheimer's disease were interviewed in Northamptonshire, England, on two separate occasions about their experiences relating to needing assistance with instrumental activities of daily living (IADL) tasks. Interpretative phenomenological analysis was the approach used to underpin this research. RESULTS: Changes in the women's identity affected by the increased need for assistance with IADL tasks were expressed in terms of: who I am; unhappy being me; fighting to remain me; I'm not the same, but it doesn't worry me; and acceptance and contentment. CONCLUSION: This study offers an alternative perspective to the view that all women with Alzheimer's disease experience becoming cared for as a negative event in their lives. Some factors universally perceived as being a result of Alzheimer's disease may be a normal part of the life course.

BACKGROUND: Tailoring is a frequent component of approaches for implementing clinical practice guidelines, although evidence on how to maximise the effectiveness of tailoring is limited. In England, overweight and obesity are common, and national guidelines have been produced by the National Institute for Health and Care Excellence. However, the guidelines are not routinely followed in primary care. METHODS: A tailored implementation intervention was developed following an analysis of the determinants of practice influencing the implementation of the guidelines on obesity and the selection of strategies to address the determinants. General practices in the East Midlands of England were invited to take part in a cluster randomised controlled trial of the intervention. The primary outcome measure was the proportion of overweight or obese patients offered a weight loss intervention. Secondary outcomes were the proportions of patients with (1) a BMI or waist circumference recorded, (2) record of lifestyle assessment, (3) referred to weight loss services, and (4) any change in weight during the study period. We also assessed the mean weight change over the study period. Follow-up was for 9 months after the intervention. A process evaluation was undertaken, involving interviews of samples of participating health professionals. RESULTS: There were 16 general practices in the control group, and 12 in the intervention group. At follow-up, 15.08 % in the control group and 13.19 % in the intervention group had been offered a weight loss intervention, odds ratio (OR) 1.16, 95 % confidence interval (CI) (0.72, 1.89). BMI/waist circumference measurement 42.71 % control, 39.56 % intervention, OR 1.15 (CI 0.89, 1.48), referral to weight loss services 5.10 % control, 3.67 % intervention, OR 1.45 (CI 0.81, 2.63), weight management in the practice 9.59 % control, 8.73 % intervention, OR 1.09 (CI 0.55, 2.15), lifestyle assessment 23.05 % control, 23.86 % intervention, OR 0.98 (CI 0.76, 1.26), weight loss of at least 1 kg 42.22 % control, 41.65 % intervention, OR 0.98 (CI 0.87, 1.09). Health professionals reported the interventions as increasing their confidence in managing obesity and providing them with practical resources. CONCLUSIONS: The tailored intervention did not improve the implementation of the guidelines on obesity, despite systematic approaches to the identification of the determinants of practice. The methods of tailoring require further development to ensure that interventions target those determinants that most influence implementation. TRIAL REGISTRATION: ISRCTN07457585.

Summary Up to 40% of people with depression do not recover following standard treatments such as medication and psychotherapy. Transcranial magnetic stimulation (TMS) is a treatment used worldwide for adult patients with severe clinical depression when antidepressants have repeatedly failed to control their symptoms. This article explains the use of TMS in clinical practice.

Foreign Body Airway Obstruction (FBAO) is a medical emergency that can result in death, particularly if swift, appropriate action is not taken. It can be a frightening experience for all involved. DeChoker, an Airway Clearance Device (ACD), might provide an additional alternative in the management of choking; however, limited evidence around its safety and effectiveness makes adoption controversial. Objectives: An independent evaluation to explore the experiences of health and care professionals who used DeChoker in real-life adult choking emergencies, focusing on the product's safety, efficacy and ease of application. Design: Retrospective mixed methods case study, with multiple embedded units of analysis. Setting: UK adult care homes. Participants: Twenty seven incidents of adult choking emergencies self-reported by care home staff where DeChoker was used. This data was augmented by an in-depth exploration of four individual choking incidences. Results: The choking victim's ages range: 45 to 101 years (mean 79.8 years). The device was reported to have successfully removed the obstruction in 26 of 27 cases, with very few complications or adverse events reported. In 21 of 27 incidents (78%) the victim was not required to visit Accident and Emergency. Qualitative data indicated nursing home staff found the DeChoker easy to use and valued its presence as an adjunct to current guideline procedures. Conclusion: There is a dearth of evidence surrounding the management of choking and little innovation in this area for five decades. This retrospective evaluation contributes to discussion regarding the role ACDs might play in the management of choking, particularly in cases where current choking management guidance are ineffective, insufficient, inappropriate or impractical (e.g., frail or movement restricted people). The interview data presents a view from care home staff that the DeChoker, as an ACD, contributed to saving the life of choking victims.

BACKGROUND: Autism spectrum disorder (hereafter, autism) is a common neurodevelopmental condition. Core traits can range from subtle to severe and fluctuate depending on context. Individuals can present for diagnostic assessments during childhood or adulthood. However, waiting times for assessment are typically lengthy, and many individuals wait months or even years to be seen. Traditionally, there has been a lack of standardization between services regarding how many and which multidisciplinary health professionals are involved in the assessment and the methods (diagnostic tools) that are used. The COVID-19 pandemic has affected routine service provision because of stay-at-home mandates and social distancing guidelines. Autism diagnostic services have had to adapt, such as by switching from conducting assessments in person to doing these fully via telehealth (defined as the use of remote technologies for the provision of health care) or using blended in-person or telehealth methods. OBJECTIVE: This study explored health professionals' experiences of and perspectives about conducting telehealth autism diagnostic assessments, including barriers and facilitators to this, during the COVID-19 pandemic; potential telehealth training and supervision needs of health professionals; how the quality and effectiveness of telehealth autism diagnostic services can be enhanced; and experiences of delivering postdiagnostic support remotely. METHODS: A total of 45 health professionals, working in varied settings across England, participated in one-off, in-depth semistructured qualitative interviews. These were conducted via videoconferencing or telephone. Altogether, participants represented 7 professional disciplines (psychiatry, medicine, psychology, speech and language therapy, occupational therapy, nursing, and social work). The data were then analyzed thematically. RESULTS: Thematic analysis indicated the following 7 themes: practicalities of telehealth, telehealth autism diagnostic assessments, diagnostic conclusions, clinical considerations, postdiagnostic support, future ways of working, and health professionals' experiences and needs. Overall, telehealth autism diagnostic assessments were deemed by many participants to be convenient, flexible, and efficient for some patients, families, and health professionals. However, not all patients could be assessed in this way, for example, because of digital poverty, complex clinical presentation, or concerns about risk and safeguarding. Working remotely encouraged innovation, including the development of novel assessment measures. However, some participants expressed significant concerns about the validity and reliability of remotely assessing social communication conditions. CONCLUSIONS: A shift to telehealth meant that autism diagnostic services remained operational during the COVID-19 pandemic. However, this method of working has potentially affected the parity of service, with people presenting with clinical complexity having to potentially wait longer to be seen or given a diagnostic opinion. There is also a lack of standardization in the provision of services. Further research should identify evidence-based ways of enhancing the timeliness, accessibility, and robustness of the autism diagnostic pathway, as well as the validity and reliability of telehealth methods.

Unpaid carers, in the UK, are estimated to contribute 132 billion pounds to society, often at a cost to their own physical and mental wellbeing. Therefore, various governmental directives since 1995 have focused on recognizing the significant contribution made by carers by improving their involvement in services. Carer research within mental health has focused primarily on general mental health and acute settings. Relatively little is known about the experiences and needs of carers of forensic psychiatric inpatients currently using inpatient care. This qualitative study aimed to examine the experiences of this group and ascertain their needs. Four carers took part in a focus group and two carers were interviewed individually. Thematic analysis was used and identified four themes: navigating the mental health system, impact of caring, what helps? and experience of current inpatient forensic service. Findings suggest that some improvements have occurred over the past few years in support for carers and in service provision for their loved one’s treatment. However, more improvements are urgently needed because carers continue to experience emotional burden, feeling excluded by services, and strain from their caring responsibilities. Implications for future research and guidance for service providers and policymakers are discussed.

OBJECTIVES: There is a lack of research informing service delivery for older forensic mental health patients. This study explored service provision in forensic mental health inpatient and community services in England, investigating what is required for progress in terms of quality of life, health, wellbeing, recovery and reduced risk, and the barriers and facilitators associated with this. METHODS: Semi-structured interviews were undertaken with 48 members of staff working with older forensic mental health patients in secure inpatient units or the community in England. Data were analysed using thematic analysis. RESULTS: Two global themes 'What works' and 'What doesn't work' were identified comprising themes representing environmental, interpersonal and individual factors. 'What works' included: positive social support and relationships; individualised holistic patient-centred care; hub and spoke approach to patient care; and suitable environments. 'What doesn't work' included: absence of/or maladaptive relationships with family and friends; gaps in service provision; and unsuitable environments. CONCLUSIONS: For older patients to progress to improved quality of life, health, wellbeing and reduced risk, multilevel and comprehensive support is required, comprising a range of services, interventions, and multidisciplinary input, and individualised to each patient's needs. The physical environment needs to be adapted for older patients and provide a social environment that seeks to include supportive families, friends and expert professional input. A clear patient progression pathway is required; this must be reflected in policy and provision.

Objective Negative attitudes towards Electro Convulsive Therapy (ECT) persist, despite the evidence of its clinical efficacy and benefits. This is partially due to negative media portrayals, inaccurate information and prohibitive consent processes. The aim of this study is to review patient ECT experience literature and report patients’ perspective of their ECT experience. Methods A patient data and insight platform was employed to gain patient satisfaction and patient feedback statements of their experiences of ECT in an UK National Health Service (NHS) provider. Results Patients feel well informed, involved in decisions made about them, treated with dignity and respect, and treated well by the staff; and almost all patients would recommend the hospital delivering ECT. Findings show that interactions with staff have a positive effect on patient satisfaction and experience. Patients describe how ECT gave them their lives back again and prevented suicide attempts. Conclusion The study highlights the importance to patient’s satisfaction and experience of staff’s engagement, relaying information, friendliness, support, and compassion. The results provide information to both patients and prescribers regarding patient’s experience of ECT. It is important to acknowledge that the patient experience of ECT literature identifies that patients frequently report memory loss.

Older forensic psychiatric patients (defined as aged 50 or over) have complex needs and require specialized treatment to enable recovery and reduce risk. Little is known about what service provision is available for this population, so a scoping literature review was undertaken to establish the extent of service provision and if services are specifically modified or designed for this population. The literature was searched through academic journal databases and Google Scholar, and outputs were screened for suitability and assessed for quality. Eight studies (four qualitative, four quantitative) were included in the review. Studies were mixed in terms of methodological quality, and with several limitations. Qualitative data provided perceptions regarding positive (e.g., sufficient types of therapy) and negative (e.g., lack of age-appropriate services) aspects of interventions. Quantitative data were descriptive, focusing mainly on identifying provision available (e.g., art therapy, violence reduction) and where needs were not being met (e.g., physical needs, education). Results indicate little provision in place adapted specifically for older forensic psychiatric patients. Findings highlight the need for further research to understand and effectively implement interventions and service provision for older forensic mental health patients to ensure practice is evidence based.

BACKGROUND: Published evidence indicates the value of repetitive transcranial magnetic stimulation (rTMS) for generalized anxiety disorder in patients with treatment-resistant depression (TRD). As a part of routine clinical service, patients with TRD received right dorsolateral prefrontal cortex (DLPFC) inhibitory rTMS immediately prior to left DLPFC depression treatment delivered according to a US Food and Drug Administration protocol. METHODS: A retrospective investigation of routinely collected data between 2016 and 2018 was undertaken. Measures used were the clinicianrated Clinical Global Impressions-Severity (CGI-S) scale and Hamilton Depression Rating scale (HAM-D), and the patient-rated Generalized Anxiety Disorder scale-7 (GAD-7) and Patient Health Questionnaire (PHQ-9). The outcome data of 61 patients with TRD were analyzed. The sample included patients with comorbid psychiatric diagnoses. RESULTS: Response and remission rates, respectively, were 17.1% and 27.3% on the GAD-7; 20.7% and 12.5% on the HAM-D; 19% and 24% on the PHQ-9; and 20% and 23.5% on the CGI-S. Post-treatment scores significantly improved on the GAD-7, HAM-D, and CGI-S scales, with medium to large effect sizes (.61, .62, and .86 respectively). CONCLUSIONS: Results indicate the potential value of rTMS in treating anxiety in patients who are referred for rTMS for TRD. Well-designed and adequately powered randomized controlled trials are required to determine clinical recommendations.

The findings are discussed in relation to previous research, noting that culturally-inclusive models of transition, increased access to diverse, inclusive community spaces and further research in this field is needed to improve healthcare experiences.

There is growing evidence for the use of social prescribing as a means of facilitating healthy lifestyle behavior changes by linking patients to sources of support in the community. However, there are gaps in understanding about what works to facilitate and enable this behavior change i.e. , the mechanisms of actions underpinning social prescribing delivery. This study used a qualitative approach involving interviews with 18 Social Prescription Link Workers (SPLWs). Reflective thematic analysis was used to analyze the data. Through this, an overall theme of “Theoretical underpinning: Solution-focused and strengths-based” was identified. This was made up of sub-themes relating to mechanisms underpinning: the SPLWs’ role (comprising asking questions, motivational interviewing and the therapeutic alliance); the patients’ role, (empowerment and active engagement); and the approach adopted (solution building, goal and action orientated). To formalize this, a framework could be developed for SPLWs that encapsulates the solution-focused strengths-based approach for application within social prescribing. This framework can then be embedded into practice facilitating more successful healthy lifestyle behavior change for social prescribing patients.

Background: For patients suffering from primary or metastatic cancer above the middle thoracic vertebrae, refractory pain management still remains a great challenge. Theoretically, inserting a catheter tip into the cisterna magna may be a promising solution. However, at present, there have been no reliable data regarding this novel technique. We therefore investigated the efficacy and safety of an advanced approach for pain relief in a specific population. Methods: Thirty participants from two hospitals received the intrathecal deliveries of opioid to either one of two sites: cisterna magna (n = 15) or lower thoracic region (n = 15). Pain relief (visual analogue scale, VAS), quality of life (short form (36) health survey, SF-36) as well as depression (self-rating depression scale, SDS) were assessed in the follow-up visits and compared between the two groups. Results: Patients receiving intrathecal morphine delivery to cisterna magna achieved greater pain improvement indicated as significant decrease of VAS scores at day 1 and 7, and achieved better improvement in physical function (day 7 and 30), role physical (day 7 and 30), body pain (day 7, 30 and 90), general health (day 7, 30 and 90), vitality (day 7, 30 and 90), social function (day 90), role emotional (day 7 and 90), mental health (day 7, 30 and 90) and SDS (day 1 and 7). Conclusions: Intrathecal morphine delivery to cisterna magna might be an effective and safe technique for patients suffering from cancer at the middle thoracic vertebrae or above to control refractory pain. Trial registration: No. ChiCTR-ONN-17010681.

Gideon Felton and Suheib Abu-Kmeil review findings of an opinion survey on the separation of male and female patients in mental health settings

More than 90% of prisoners have one or more mental health disorders, and it has been found that most prison systems are ill-equipped to provide appropriate mental healthcare. This article describes a pilot study that aimed to increase magistrates’ awareness of mental health and learning disabilities in court, the use of appropriate community sentences, mental health treatment requirements and community options for vulnerable defendants.A team made up of staff from a vulnerable persons focus group and nurses from Northamptonshire Healthcare NHS Foundation Trust liaison and diversion team presented awareness-raising sessions to magistrates and other court staff during lunch breaks at four courts in Northamptonshire. After the sessions, participants said they were better informed and more likely to use appropriate community sentences including mental health treatment requirements and community options. It is hoped that the sessions will help to reduce the number of vulnerable people being sent to prison in Northamptonshire and instead they will be given more appropriate sentences along with the treatment and support they may need.

Accessible summary A series of stand‐alone groups were offered on an assessment and treatment ward for adults with learning disabilities. The group ran for 9 weeks and involved session themes of relaxation, sensory and physical activities. All individuals involved reported to have found the sessions useful and enjoyable. All staff involved reported that the sessions were helpful for the participants. The sessions helped individuals to improve their mood following the session. The sessions provided a practical way of introducing therapeutic activity to the ward and developing therapeutic relationships. Summary This audit is intended to investigate the effectiveness of a series of stand‐alone groups delivered on an inpatient unit for individuals with learning disabilities. Our ward is a specialist assessment and treatment unit that provides brief admissions for clients with a learning disability, mental health difficulties and/or challenging behaviour. The aim of the unit is to develop an understanding of the presenting difficulties, formulate an appropriate intervention plan and implement this with the aim of successfully discharging the client back into the community following the shortest possible admission. Group interventions facilitated on the unit were drawn from a variety of evidence and best practice guidelines relating to specific interventions for individuals with a learning disability (Adv Psychiatr Treat, 11, 2005, 355) and more general interventions within inpatient settings (Clin Psychol Forum, 2009, 200). Nine sessions focused on a variety of relaxation, sensory and physical activity tasks. The objective of the audit is to investigate to what extent these interventions are perceived as helpful and enjoyable by clients and by staff, to investigate any positive effect on client's mood and to determine whether any particular activities were rated more favourably than others. Additional aims of the audit are to further understand some of the practical issues related to delivering group‐based interventions in an inpatient environment, to engage ward staff in the delivery of therapeutic activity and to investigate the use of groups as an effective way of developing therapeutic relationships.

Literature links mental health problems comorbid with substance abuse with increased recovery time. There is limited research evaluating the effectiveness of substance abuse treatments for dual-diagnosis patients. This project aimed to evaluate the effectiveness of the BTSA group with this population. Questionnaires measuring motivation, locus of control, confidence to abstain and self-efficacy were administered to six different cohorts of BTSA participants (N = 38) at baseline, post, and follow-up stages. In addition, participants from the most recent BTSA cohort (N = 4) attended a post-program focus group, to provide information about their experiences of the intervention. Statistical analyses revealed that participants’ confidence in their ability to manage substance abuse was significantly higher post group, but the hypotheses that there would also be significant improvements in participants’ self-efficacy, motivation, and locus of control following completion of the program were not supported. Thematic analysis identified three key themes relevant to participants, namely validation, psychoeducation and identifying progress. This project provided valuable insights into participants’ experiences of the group, highlighting what they had gained form the intervention, and the impact on them from having Recovery Champions working in conjunction with NHS staff to facilitate the intervention. Limitations are discussed, alongside recommendations for improving the program.

Aims We report on a case of depression where genetic testing was used to determine potential treatment modalities. Methods The patient is a 78-year-old man who had suffered from depression for 55 years. He had a serious episode in 2002. He developed a further depressive episode in 2018 which did not respond to paroxetine. He was offered TMS and was initially treated in the NHS and subsequently in the private sector. He went into remission with TMS and continues to remit with TMS however his depression became unstable and it was clear that the paroxetine was having no effect. He agreed to have a genetic test, a buccal mouth swab was taken and posted to gensense in the United States. An 18 page document and a half hour session with gensense are included in the cost of the test. The results of his genetic test and suggestions regarding treatment are detailed below. SLC6A4 L(G)/S serotonin transporter indicating a less favourable response to SSRI medication (20% response versus 40% response). SNRI medication may be useful. BDNF Val/Met Met carriers may have poor response to SSRIs and an improved response to SNRI's and TCA's. Met carriers have a 3 times better response to exercise than Val/Val MTHFR A/A variant, this results in a 70% reduction) in the ability to convert folate to methyl folate (required for the manufacture of serotonin). Taking L-methylfolate supplementation (7.5mg) may improve serotonin production and provide a 2 times increase in response rate to antidepressants. COMT Val/Val variant indicates improved response with brain stimulation therapy such as ECT and TMS CACNA1C A/A variant which increases the anteromedial and amygdala activity and increased neuronal activity as a result of increased calcium channel receptors. This variant is associated with more depression, OCD and anxiety. Using lithium, sodium valproate and lamotrigine could be potentially useful in this group. Results The patient's antidepressant was switched from Paroxetine to Venlafaxine XL 150 mg, he started taking L methyl folate supplements (7.5mg daily) and was put onto sodium valproate 250 mg 3 times a day. His HAM-D went from 39 in December 2022 to sub-baseline by the end of January 2023. He also started regular mild exercise and daily use of tDCS (Sooma and Flow). Conclusion We conclude that genetic testing can be a useful clinical tool and can be helpful in deciding which treatments may benefit.