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SUMMARY Digital psychiatry has become increasingly important and understanding of certain aspects is essential for practising clinicians. This article discusses electronic patient records (EPRs), from their origins to current and future use, the growth and embedding of outcome measurements, the use of social media, and learning and research in virtual arenas.

SUMMARYThe first two articles in this series have shown the direction of travel for health and social care in England, and how the status quo in already stressed systems is not viable. It is difficult to disagree with the principles of ‘integrated care’, yet we currently lack evidenced models on which we might build. There is a need for experiential learning and sharing of experiences. This third article describes in more granularity the experiences, positive and negative, of an early-adopting integrating service in south-east London that incorporated aspects of the local authority and secondary care physical and mental health services. It provides structured guidance on which types of integration one might aim for, managing internal and external relationships, and discussion on evaluating progress.

Purpose In 1999, the national health service (NHS) was made responsible for the commissioning of prison health care. Mental health inreach teams (MHIT) were set up to mirror community mental health teams and provide secondary care to prisoners diagnosed with severe and enduring mental illnesses (SEMI). Since then, the provision of mental health care to prisoners without a diagnosis of a SEMI has been variable. A rapid review of NHS health care in prisons conducted by Public Health England (PHE) (2016) highlighted the need for provision to be more integrated and meet the needs of prisoners without a diagnosis of a SEMI. In response, an integrated mental health and substance misuse service was implemented within her majesty’s prison/young offenders institution Pentonville. This study aims to evaluate its impact and share lessons learned. Design/methodology/approach Routinely collected and anonymised data were reviewed for prisoners referred between 1 May 2018 and 31 December 2019. Data are presented on the quantity of referrals over time, and the type of support offered. Chi-square goodness of fit tests was conducted to determine whether the prisoners referred to the service were representative of the wider prison population in terms of age and ethnicity. Findings Referrals showed a general pattern of increase over time and were representative of the wider prison population in terms of age and ethnicity, indicating equitable access. Lessons learned are discussed. Demand for therapeutic and substance misuse services was higher than that for SEMIs. Notable was the high quantity of referrals which provides further evidence for the disparity between high need and limited provision within prison settings, particularly for therapeutic interventions. Originality/value To the best of the author’s knowledge, this is the first service evaluation of a recently implemented integrated and holistic model of prison mental health care in line with recommendations from PHE (2016).

The Royal College of Psychiatrists’ Medical Training Initiative (MTI) enables qualified foreign-trained psychiatrists to gain further experience within the UK National Health Service (NHS). This article summarises the observations of two Nigerian psychiatrists during their forensic psychiatry placements on the MTI scheme and two of their UK supervisors. It discusses similarities and differences between Nigeria and the UK in forensic psychiatry, including the use of mental health legislation, the scope of forensic psychiatry and elements of the pathway to qualification in both countries. It concludes with recommendations that could improve the robustness of the MTI scheme.

Purpose Prisons are uniquely challenging working environments. Staff are often exposed to direct and indirect trauma, impacting negatively on their mental well-being. Due to the limited research into prison staff experience, this paper aims to explore what staff find most challenging, how they cope, what support they would like and rewarding aspects of their work. Design/methodology/approach This service development project was facilitated through a staff well-being event. A qualitative approach was used and 74 staff members provided anonymised responses. An inductive and data-driven approach was used to analyse the data, and the trustworthiness of the analysis was considered using criteria established by Lincoln and Guba (1985). Findings Thematic analysis identified six themes, namely, the challenging nature of the work, interactions with prisoners, staff interactions, inadequate resources, staff support and development and coping strategies. Key findings include managing distress, self-harm and violence and limited resources presenting challenges. Role variety and opportunities to support prisoners were reported as positive. A variety of coping strategies were identified. Wider availability of supervision and reflective practice was suggested by staff. Practical implications Recommendations for increased staff support are made. Suggestions for future research investigating methods to increase rewarding aspects of work within prisons are given. Originality/value This analysis adds to the limited body of qualitative research investigating prison staff experiences; in particular, aspects of the work that they find rewarding such as the role variety and opportunities to make positive changes to prisoners’ lives. Novel coping strategies were identified, including cognitive reframing and behavioural strategies for managing stress, which could be encouraged to increase resilience.

Employee stress and related psychological strain is not only damaging for those that experience it, but is also costly for employers and society at large. This study aims to evaluate the effectiveness of individual-focused occupational health interventions in a comprehensive meta-analysis, improving the interpretability of results by analyzing the interventions' impact on specific outcome measures. A literature search of randomized control trials (RCTs) of stress management, health or wellness interventions in healthy workers was completed using PubMed, Scopus, Web of Science, PsycINFO, and PsycARTICLES. The following outcome measures were meta-analyzed: (a) Perceive Stress Scale (PSS), (b) General Health Questionnaire (GHQ), (c) State-Trait Anxiety Inventory (STAI), (d) Maslach Burnout Inventory (MBI), and (e) absenteeism. Forty-nine studies met the inclusion criteria and were included in a random-effects meta-analysis. There was a beneficial effect of interventions across all outcome measures (all p < .05) except for the MBI Personal Accomplishment subscale and absenteeism. The largest effect size (g = -0.65, p < .001) was observed with the PSS scale. For separate subanalyses considering intervention types, multimodal interventions had the largest impact on reducing state anxiety (g = -1.01, p = .02), followed by relaxation interventions reducing PSS levels (g = -0.75, p < .001) and cognitive interventions reducing PSS levels (g = -0.66, p < .001). This meta-analysis provides evidence that individual-focused occupational health interventions can have a significant effect on stress-related outcomes postintervention and at follow-up. It also suggests that the intervention's effectiveness varies based on the outcome measures used. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

SUMMARYThe phenomenon of acute behavioural disturbance (ABD) (also known as acute behavioural disorder or excited delirium) is an underrecognised and potentially life-threatening syndrome, and an emergency in psychiatric settings. Causes are discussed and the pathophysiology explained. The challenges faced by practitioners are highlighted, including how ‘standard’ control and restraint can exacerbate symptoms. Initial treatment strategies are suggested.

Intoxicated children and young people (CYP) attending the paediatric emergency department (PED) are typically under the influence of alcohol or established recreational agents such as cannabis or ecstasy. The last decade or so has seen an increase in the numbers of CYP in PED who have used novel psychoactive substances (NPS). In this review, we describe four different functional classes of NPS, their legal status, clinical effects, acute management and interventions to reduce harm.

SUMMARYDemands on health and social care are growing in quantity and complexity, with resources and staffing not projected to match this. The landmark NHS Long Term Plan calls for services in England to be delivered differently through integrated care systems (ICSs) that will better join commissioners and providers, and health and social care. The scale of these changes is immense, and the detail can feel confusing. However, they are important and will affect all clinicians in the public service. This three-part series provides a primer on integrated care, explaining why it is happening, how services are changing and why clinicians should get involved. In this first article we focus on the changing demographics, and the workforce and financial resources required to address these.

Debates within health care and public spheres have, at times, created a seeming 'divide' between biological and psychosocial determinants and management of mental health difficulties. The phrase 'medical model' is often held up as an example and is sometimes used pejoratively to infer over-reliance on biology and medication. Our objective was to explore inpatient mental health clinicians' perceptions of the definition and the application of a 'medical model' in contemporary mental health care. In this qualitative study, eighteen clinicians working in adult inpatient teams participated in three mixed focus groups. Data were analysed using framework analysis. Three core themes were identified: (i) power of a 'medical model' and authority of the medic; (ii) responsibility within, and reliance on, a 'medical model'; and (iii) integrated models of contemporary mental health care. Subthemes arose around organisational culture and low resources affecting the power of a 'medical model' and the value of multidisciplinary and person-centred approaches. The findings highlight the importance of recognising inter-professional dynamics and power gradients in mental health teams and organisations, as we begin to move towards more integrated models of collaboration and distributed leadership within the NHS.

SummaryWe describe the establishment and evaluation of a career-based mentoring scheme (PsychStart) for medical students interested in psychiatry. Medical students reported multiple benefits of mentoring, including enhanced personal and professional development, increased career and clinical knowledge, and broadened exposure to psychiatry. The mentoring scheme was also found to promote and sustain interest in the specialty. Further evaluation is required to determine the long-term effects of mentoring and how this may compare with other undergraduate enrichment activities. We conclude that mentoring in psychiatry could offer innovative solutions for improving recruitment and retention, and for supporting and valuing medical students who demonstrate an early interest in the specialty.

Background:Clozapine is the only medication licenced for treating patients with treatment-refractory schizophrenia. However, there are no evidence-based guidelines as to the optimal plasma level of clozapine to aim for, and their association with clinical and functional outcome.Objective:We assessed the relationship between clinical and functional outcome measures and blood concentrations of clozapine among patients with treatment-refractory psychosis.Methods:Data were reviewed in 82 patients with treatment-refractory psychosis admitted to a specialised tertiary-level service and treated with clozapine. Analysis focussed on the relationship between clozapine and norclozapine plasma concentrations and the patient’s clinical symptoms and functional status.Results:Clinical symptom improvement was positively correlated with norclozapine plasma concentrations and inversely correlated with clozapine to norclozapine plasma concentrations ratio. Clozapine concentrations showed a bimodal association with clinical improvement (peaks around 350 and 660 ng/ml). Clinical symptom improvement correlated with functional outcomes, although there was no significant correlation between the latter and clozapine or norclozapine plasma concentrations.Conclusion:Clozapine treatment was associated with optimal clinical improvement at two different peak plasma concentrations around 350 and 650 ng/ml. Clinical improvement was associated with functional outcome; however, functionality was not directly associated with clozapine concentrations. A subset of patients may require higher clozapine plasma concentrations to achieve clinical improvement.

Schizophrenia is often a severe and debilitating mental illness, frequently associated with impairments in social cognition that hinder individuals' abilities to relate to others and integrate effectively in society. Oxytocin has emerged as a putative therapeutic agent for treating social deficits in schizophrenia, but the mode of action remains unclear. This placebo-controlled crossover study aimed to elucidate the neural underpinnings of oxytocin administration in patients with schizophrenia. 20 patients with schizophrenia were examined using functional magnetic resonance imaging under oxytocin (40 IU) or placebo nasal spray. Participants performed a stochastically rewarded decision-making task that incorporated elements of social valence provided by different facial expressions, i.e. happy, angry and neutral. Oxytocin attenuated the normal bias in selecting the happy face accompanied by reduced activation in a network of brain regions that support mentalising, processing of facial emotion, salience, aversion, uncertainty and ambiguity in social stimuli, including amygdala, temporo-parietal junction, posterior cingulate cortex, precuneus and insula. These pro-social effects may contribute to the facilitation of social engagement and social interactions in patients with schizophrenia and warrant further investigation in future clinical trials for social cognitive impairments in schizophrenia.

The COVID-19 pandemic has extracted an enormous physical health toll on many millions worldwide, and the wider societal impact from economic turmoil, unemployment, social isolation and so forth continue to be measured. A less explored aspect has been the psychological impact on treating healthcare staff, with emerging evidence of ‘moral injury’ and mental illness for some. This review explores the evidence base for implementing a tiered model of care to minimise this and foster ‘post-traumatic growth’, and describes the authors’ implementation of this in the London Nightingale hospital, with lessons for the armed forces.

SUMMARYPart 1 of this three-part series on integrated care discussed the drivers for change in healthcare delivery in England set out in the NHS Long Term Plan. This second part explores the evolution of mental health services within the wider National Health Service (NHS), and describes important relevant legislation and policy over the past decade, leading up to the 2019 Long Term Plan. We explain the implications of this, including the detail of emerging structures such as integrated care systems (ICSs) and primary care networks (PCNs), and conclude with challenges facing these novel systems. Part 3 will address the practical local implementation of integrated care.

Medical recruitment and retention are national problems. Psychiatry has been more affected than many specialties, as a result of stigma from the public and other healthcare professionals. The Royal College of Psychiatrists has undertaken several initiatives to redress this, notably the ‘Choose Psychiatry’ campaign. In this editorial we argue that student-led university psychiatry societies are a wonderful but frequently untapped resource to help attract the brightest and best medical students to our profession. We describe the activities of three ‘Psych Socs’ across the UK and propose next steps to continue this work.

Purpose of review Cannabis enjoys a unique social status, widely perceived as a relatively harmless drug, with several benefits reported by the people who use it. Several jurisdictions have opened up access to cannabis to their populations for medicinal and/or recreational reasons. Given this changing regulatory environment, this article is intended to prompt debate about what is known about cannabis dependence and what has still to be revealed. Recent findings Evidence suggests that 1 in 10 cannabis users are at risk of developing dependence. However, investigation of the way risk is estimated and the diagnosis of cannabis use disorder is constructed highlight some methodological problems, which call into question the incidence and prevalence of this diagnosis. Summary There is scope to improve the way cannabis dependence is defined and counted in at-risk populations. Improving our understanding of this risk could lead to identifying who might be at risk of developing dependence prior to exposure to the drug.

SUMMARYSecond-generation antipsychotic medications (SGAs) have advanced the treatment of schizophrenia over the past 30 years. However, a number of potentially life-threatening cardiac side-effects associated with these treatments concern and can discourage prescribers from administering these evidence-based treatments. This review provides a practical, psychiatrist-oriented understanding of the relative frequencies, mechanisms, investigations and treatments associated with these cardiac toxicities. We aim to highlight that these are relatively rare complications of an effective class of drug and to promote the advantages of early involvement of cardiologists in the psychiatric multidisciplinary team to guide the investigation and management of these conditions.LEARNING OBJECTIVESAfter reading this article you will be able to: •understand the relative incidence of cardiotoxic side-effects of the various SGAs•perform preliminary investigations to diagnose the common cardiotoxic side-effects of SGAs•understand the treatments for these cardiac side-effects and the role of cardiologists involved the care of these patients.

Aims and methodTo understand the experience of companions of patients seen in the emergency department by liaison psychiatry teams. Participants were recruited via purposive sampling following a recent visit to the emergency department of an inner- or outer-London hospital. Semi-structured interviews were administered to all participants.ResultsTwo major themes were generated. The first concerned the appropriateness of the clinical space, in which ‘noise’, ‘privacy’ and the ‘waiting area’ were subthemes. The second was communication with staff, including subthemes of ‘wanting more information’ and a ‘desire to be more involved’.Clinical implicationsLiaison psychiatry services should consider appropriateness of the clinical space, promoting improved communication between staff and patients' companions, and a review of the information provided to companions in the emergency department. This research offers a novel perspective on liaison psychiatry and will enhance current understanding and clinical practice.

The term ‘opioids’ refers to both the natural compounds (‘opiates’) which are extracted from the opium poppy plant ( Papaver somniferum) and their semi-synthetic and synthetic derivatives. They all possess relatively similar biochemical profiles and interact with the opioid receptors within the human body to produce a wide range of physiological effects. They have historically been used for medicinal purposes, their analgesic and sedative effects, and in the management of chronic and severe pain. They have also been used for non-medicinal and recreational purposes to produce feelings of relaxation, euphoria and well-being. Over the last decade, the emergence of an illegal market in new synthetic opioids has become a major global public health issue, associated with a substantial increase in unintentional overdoses and drug-related deaths. Synthetic opioids include fentanyl, its analogues and emerging non-fentanyl opioids. Their popularity relates to changes in criminal markets, pricing, potency, availability compared to classic opioids, ease of transport and use, rapid effect and lack of detection by conventional testing technologies. This article expands on our previous review on new psychoactive substances. We now provide a more in-depth review on synthetic opioids and explore the current challenges faced by people who use drugs, healthcare professionals, and global public health systems.

Aims and methodCOVID-19 has forced many educational events to go ‘virtual’. We report on the first online student-run National Psychiatry Summer School (NPSS). Evaluation of the online format and content was undertaken through survey feedback from almost 400 attendees.ResultsThe NPSS positively affected attendees’ perceptions of psychiatry as a career choice. The virtual format was positively received, with benefits including breaking down traditional barriers of geography and cost.Clinical implicationsPost-COVID-19, a hybrid future of mixed virtual and face-to-face events is likely. Our work shows the viability of this and unique gains it might offer, and offers experiential learning on challenges encountered for others who wish to trial further virtual conferences.

SummaryIn mental health services, recovery constitutes a guiding principle that is endorsed in professional medical guidelines and has become central to mental health policies across the world. However, for many clinicians, it can be a challenge to effectively embed recovery concepts into professionally directed treatment of disease without distortion, and ostensibly away from what matters to those who use the services. We discuss the evolving and multifaceted concept of ‘recovery’, including illness narratives to frame our discussion. We demonstrate how integration between a person-directed management of illness and a professionally directed treatment of disease can converge, resulting in positive outcomes for people with mental illness.

COVID-19 has exposed the National Health Service (NHS) to the greatest challenge in its existence, highlighting the need for nimble, reactive and inclusive leadership. It is set against a backdrop of a workforce recruitment and retention crisis predicted to worsen in coming years. There is a need to do things differently in healthcare, including better diversity and distribution of leadership. We make the case for senior non-consultant doctors, in the UK more usually referred to as specialty and associate specialist or locally employed doctors. These skilled, experienced medics have much to offer yet are frequently overlooked, with little guidance or support from central organisations and medical colleges or within NHS Trusts themselves. In this commentary, we suggest ways this workforce might be better tapped into, to the benefit of patients and healthcare systems, as well as the doctors themselves.

COVID-19 has highlighted potential shortcomings in our approach to psychological health that had perhaps become the accepted status quo within cardiology. Importantly, the pandemic may offer a unique opportunity to redress them. During 2020, physicians have had to question their ability to deliver optimal care with scarce resources, limited knowledge, concerns about personal safety and, by extension, the safety of one’s family. For some, these challenges may have a lasting psychological impact. Encouragingly, many staff have acknowledged the potential effect of these pressures on their mental health, making short-term adaptations and promoting staff camaraderie. However, achieving long-lasting changes in our approach to supporting those affected could create a positive legacy to this pandemic. The idea of ‘moral injury’, originally recognised within the military, describes the psychological distress which may follow ethical or moral beliefs being challenged. Such situations can lead to overwhelming feelings of culpability, shame or anger, which increase someone’s vulnerability to develop, or exacerbate, mental ill health including post-traumatic stress disorder (PTSD) and depression.1 The attribution of moral injury to healthcare workers during the pandemic is increasingly recognised.2 Equally important is the concept of post-traumatic growth,3 which recognises that most people will survive and psychologically develop following these unwished-for experiences. Evidence shows that good organisational structures, management and psychologically savvy teamwork can calibrate this and push the needle more towards growth and away from injury. Although moral injury in cardiology has yet to be substantiated, evidence suggests that cardiologists report some of the highest levels of burn-out and work longer hours than other physicians. However, only 23% report being willing to seek professional help for feelings of depression or suicidality.4 This may result from a stoicism existing within cardiology where a culture of appearing impervious to pressure prevails and is lauded, suggesting that many …