Psychiatry through a Screen: Adapting Training for a New Reality?

The Covid-19 pandemic has had a profound impact on the way psychiatry is taught. Both the formal teaching components and the clinical placements pivoted to run in a virtual world. Students learnt psychiatry through a screen, either through online teaching sessions or remote clinical activity. Two medical students passionate to pursue a career in psychiatry (KB, FR) reflected with an undergraduate department faculty member (SB) upon their experiences of the adapted mental health block, how the delivery may have affected their motivations for psychiatry, as well as considering their learning on psychiatry training for a new, virtual reality.

Perspectives of GCSE students attending a psychiatry summer school in south London.

AIMS AND METHOD: This 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. RESULTS: Students 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 IMPLICATIONS: Targeting students at this early stage appears to be an underexplored positive intervention for improving both attitudes towards mental illness and recruitment to psychiatry.

Views from GP and Psychiatric trainees about getting experience in each other's specialty during training: A way to develop a shared culture?

The need to deliver holistic medical care that addresses both physical and mental health requirements has never been more important. The UK medical training system has been designed to provide all medical graduates with a broad experience of different medical specialities and psychiatry prior to entering specialist training. Furthermore there is a distinct crossover between Psychiatric and General Practice training, with programmes providing trainees with the opportunity to work alongside each other in the care of mental health patients. The video presentation will explain the UK medical training system in more detail, before going on to explore how the organisation of training may foster a shared culture among different specialities and how it could form a model for improving parity of esteem of medical and physical health care. In addition it will discuss the strengths and weaknesses of this system from a trainee perspective and will conclude with comments from eminent Psychiatrists whom have special interests in medical training and developingparity of mental and physical health care.

Co-Morbidity Part 2 - Neurobiology and Suicide Risk; Modelling the consequences of Bipolar and Anxiety Co-Morbidity.

We review the evidence that Bipolar Disorder with Comorbid Anxiety, Rapid Cycling Bipolar Disorder, Mixed Affective states, are all related to each other and to Dopamine Transmission in Bipolar Disorder. All these states are related to the presence of particular polymorphisms of the genes of the D2 and D3 receptors. All these states increase the risk of suicidality. Substance and alcohol abuse comorbid with bipolar disorder increases the risk of both Rapid Cycling and Suicidality. We present a model which demonstrates these relationships.

Audit of the prevalence of anxiety in bipolar disorder--a comorbidity that requires attention and action.

Bipolar affective disorder (BPD) frequently occurs with co-morbid mental health problems. This study shows that that the prevalence of co-morbid BPD and anxiety symptoms is especially high. This is important because for a person affected by both BPD and anxiety there is a negative impact on the symptoms, treatment response and recovery. A clinician faces particular treatment challenges when managing these co-morbid conditions due to a limited evidence base for effective interventions. The frequent occurrence of anxiety symptoms and BPD together has informed theories of the shared aetiology of these conditions.

Rationale for clinical interventions in prodromal psychosis. Are such interventions safe?

We compare the reported side effects of medication from the trials of prodromal psychosis treatment. We note that the side effects of antipsychotics are those described in the usual pharmacology of these substances and that the severity of side effects are dependent on dosage, with more side effects at higher doses. We report on the search for alternative compounds for the treatment of prodromal psychosis. Omega fatty acids and Cognitive Behavioural Therapy are certainly good adjuvant treatments for suspected prodromal psychosis. With further evidence they may be considered appropriate to use as monotherapy, particularly in the early prodrome. Treatment of prodromal psychosis continues to present a number of risks; therefore the decision to treat ultimately must depend on the symptoms presented by the individual.

An audit to compare patient factors (age, sex, social background & associated physical diagnoses) in people with refractory depression in a Bedfordshire Community Mental Health Team (BCMHT) being augmented with (A) mirtazepine, (B) atypical antipsychotics or (C) both.

In recent years, there has been particular interest in the use of augmentation as a strategy for the treatment of refractory depression. The purpose of this audit was to define patient factors among people receiving augmentation therapy with either mirtazepine or atypical antipsychotics. We searched an anonymised database of patients and identified those with receiving augmentation with mirtazepine (group A), atypical antipsychotics (group B) or both (group C). The audit reveals some interesting differences in patient factors between the three groups. Knowledge about such differences is useful in practical terms because it allows doctors in the BCMHT to target therapy for different patients towards their specific needs. However, the audit cannot explain the underlying reasons for these differences.

An audit to compare the efficacy of treatment (as indicated by discharge rates and reduction in suicidality) among patients with refractory depression in a Bedfordshire Community Mental Health Team receiving augmentation therapy with either mirtazepine or atypical antipsychotics.

In recent years, there has been particular interest in the use of augmentation. Potential augmentation regimes include the addition of atypical antipsychotics (e.g. risperidone/olanzapine) or other antidepressants (e.g. mirtazepine). The purpose of this audit was to compare patient outcomes between groups receiving different augmentation strategies. Overall we found that augmentation with mirtazepine resulted in better outcomes in terms of both discharge rates and in terms of reduction in suicidality than augmentation with atypical antipsychotics.

An audit to identify factors affecting response to treatment among depressed patients who have documented suicidal ideation/attempts in a Bedfordshire Community Mental Health Team.

INTRODUCTION: in recent years there has been a general move towards treating depressed patients in the community if at all possible. One factor that may reduce the likelihood of discharge from secondary care is suicidality (Butler et al. 2010). The aim of this audit was to identify factors associated with continued suicidality among patients in a CMHT. SUBJECTS AND METHODS: we searched an anonymised database of patients and identified all those with previously documented suicidal thoughts or attempts. We also noted the presence of factors such as alcohol problems, drug problems, augmentation therapy and 'other risk' factors (e.g. financial problems or homelessness). We then looked at clinical notes to find out whether or not, according to the latest clinic letter, patients were still reporting suicidality. This facilitated comparison of the aforementioned factors between the group of patients in which suicidality was still present (group N) and the group of patients in which suicidality was no longer a feature (group Y). RESULTS: of the 56 patients with suicidal thoughts or attempts there were 44 in group N (79%) and 12 in group Y (21%). Overall, alcohol problems, drug problems and 'other' risk factors were proportionally more common among group Y than group N, although sometimes the difference was marginal. Conversely, the percentage of patients on augmentation therapy was greater in group N than group Y. When considering individual diagnostic categories the above trends generally stood for the F32 category, although not necessarily for the F33 category. DISCUSSION: the audit provides an insight into the sorts of factors that might influence outcomes among depressed patients. However, there are limitations to the audit such as small sample size and lack of a fixed follow-up period. CONCLUSIONS: Although the results are suggestive, it is difficult to make firm conclusions about patient outcomes on the basis of this data. The audit provides a useful starting point, especially in considering the treatment of patients within the BECMHT. However, further research on a wider scale is required before more general conclusions can be made about factors influencing response to treatment among depressed patients.

An audit to identify factors that are more commonly associated with depressed patients on augmentation therapy under the Befordshire East Community Mental Health Team (BECMHT).

BACKGROUND: whilst it is important that we treat patients with depression in primary care if possible there are many patients with depression who will need the more expert support provided in secondary care. AIMS AND METHODS: an Anonymised Database held by the Bedford East Community Mental Health Team was studied to assess what factors were related to the use of Augmentation Strategies to treat resistant depression. RESULTS: of the total 282 patients 109 (38.7%) were on augmentation therapy. In the F32 and F33 group just over a third of the patients (35.8% and 37.1%) were on augmentation therapy and in the F41.2 group over a half of patients (56.7%) were on augmentation therapy. DISCUSSION: There does seem to be a relationship between the number of risk factors a patient has and the likelihood that they are on augmentation. Particularly strong factors are another psychiatric diagnosis and 'other suicide risk factors'. CONCLUSION: generally the patients coming to secondary care with more of the specified risk factors are more likely to need augmentation.

Depression Treatment by Bedford East Community Mental Health Team an Audit to assess how many patients in a Bedfordshire Community Mental Health Team might safely be transferred to Primary Care.

INTRODUCTION: Recently there has been pressure on Secondary Psychiatric services to discharge patients back into Primary care. This project is to show what depression treatments are used by Bedford East Community Mental Health Team (BECMHT) and therefore identify whether some of these patients could be appropriately managed in Primary care. SUBJECTS AND METHOD: We identified, using an anonymised database, patients being treated with different anti-depressant regimens in BECMHT. We compared these treatments with the steps described in NICE Guidelines, and other evidence based treatment modalities which we found on literature search. Based on this data, we attempted to predict which patients it might be safe to discharge to primary care for ongoing treatment. RESULTS: Many different combinations of medications were found. Many patients had other intercurrent mental health diagnoses. DISCUSSION: There are many possible evidence based treatments for depression which can be employed once those listed by NICE are exhausted. We review all of these. Some patients are, accordingly, on combinations of medication as augmentation strategies.It is responsible to only discharge patients into Primary care when their symptoms are controlled. CONCLUSION: We identified groups of patients who might be transferred back to primary care for maintenance treatment, provided that shared care protocols are in Place, and there is easy access to secondary care services should the need arise.

A comparison of outcomes of patients with depression, recurrent depression, and depression and anxiety within patients in a British CMHT.

INTRODUCTION: Many patients in Community Mental Health Teams have a diagnosis of depression F32, recurrent depression F33, and depression and anxiety F41.2, and such patients are often considered by team managers as being suitable for discharge to primary care. It is necessary to describe factors that influence outcomes, specifically discharge, in order to identify suitable patients who might continue their treatment in primary care. We aimed to assess the influence of suicidality, alcohol and drug abuse and augmentation strategies on the discharge status of patients treated by the Bedford East Community Mental Health Team (BECMHT) who have been diagnosed with depression in each of the three groups F32, F33, and F41.2. SUBJECTS AND METHODS: Using the team database, we identified 168 patients with depression F32, recurrent depressive disorder F33 and depression and anxiety F41.2. We then established their discharge status (discharged, enhanced CPA and normal CPA) and identified factors that may influence the discharge status (suicidal ideation, alcohol and drug problems and augmentation therapy). Outcome as measured by patient discharge and the prevalence of each factor was compared in the three groups. RESULTS: The group who had been diagnosed with a depressive episode, F32 , were less likely to be discharged and appeared to be more likely to suffer from alcoholism, illicit drug abuse, and suicidality. DISCUSSION: Arguably, the F32 group could be a more heterogeneous group of patients, F32 becoming a 'default diagnosis' into which both patients with a discrete 'depressive episode' and patients with a 'depressive episode plus other problematic factors' were put, while the F33 and F42.1 groups were more clear cut. CONCLUSION: Suicidality, alcoholism, and illicit drug use clearly impact on the outcomes of patients in the diagnostic groups studied.

Reduced intracortical inhibition and facilitation of corticospinal neurons in musicians.

Interhemispheric inhibition between motor cortices is reduced in musicians. In the present study we have assessed intracortical inhibition (ICI) and facilitation (ICF) within ipsilateral motor cortex in 15 musicians and 15 non-musician controls. Transcranial magnetic stimulation (TMS) was used to elicit muscle evoked potentials (MEPs) from left first dorsal interosseous (FDI) muscle at rest, and during voluntary index finger abduction (0.5 N). Paired TMS with subthreshold conditioning was used to test early ICI with interstimulus intervals (ISIs) 1-5 ms, and ICF with ISIs 8-15 ms. Suprathreshold conditioning was used to test late ICI with ISIs 100-200 ms. TMS thresholds were similar in musicians and controls both at rest and with weak voluntary activation of FDI, indicating that postsynaptic excitability of corticospinal neurons was similar in both groups. ICI was less effective in musicians with FDI at rest and active, but only with an ISI of 3 ms. ICF was less effective in musicians under both rest and active conditions, and this was independent of ISI. There were no differences in late ICI between musicians and controls. We conclude that ICI and ICF circuits which are activated by weak TMS have less influence on corticospinal neuron excitability in musicians. Because of the dependence on ISI, the most likely explanation for the reduced ICI in musicians is an alteration of the interaction between the ICI circuit and neural elements responsible for the later I-waves evoked in corticospinal neurons by TMS. Excitability of the neural elements producing early and late ICI is not altered in musicians. Reduced ICF in musicians could be due to reduced excitability of neurons responsible for ICF, or an altered balance of excitatory inputs to corticospinal neurons which favours neurons that are not acted upon by the ICF circuit. The reduced influence of ICI and ICF circuits on corticospinal neuron excitability in musicians is likely to reflect a training-induced adaptation. It is not clear at present whether these differences represent an adaptive change related to their extraordinary control of finger movements, or alternatively a maladaptive change induced by "overuse" of the hands from extensive training.