Observation of telepsychiatry service in a teaching hospital of eastern Nepal during COVID-19 pandemic

Considering the geographical complexity and adversity, online communication and consultation are viable method in Nepal. The COVID-19 pandemic has accelerated the already starting trend of use of these technologies in medicine. In BPKIHS, telemedicine efforts were already initiated; lockdown rather warranted its maximum use. Here is an account of the observation made in telepsychiatry service provided by a consultant psychiatrist of its department of psychiatry. It is an institute-based observation noted for all the telepsychiatry consultations in 9 random duty days of the COVID-19 pandemic. Basic necessary information was noted down in a semi-structured proforma, like: socio-demographic, clinical information and advice provided. There were 104 subjects; 73 follow-up and 31 new: 60 male and 44 female cases. Clients of multi-ethnic groups were the most from urban, then semi-urban and least from rural areas. More consultations were for young age-groups and from nearby districts of Sunsari. Mood, somatic (sleep), anxiety were the top presenting complaints and 8/104 clients had suicidal symptoms. Maximum follow-up cases were improving. The most common diagnoses were: Mood (Depression and Bipolar), Anxiety, Psychosis and Substance use disorders. Most common treatment advices included: Antidepressants, Antipsychotics, Benzodiazepines and Counseling/psycho-education. Telepsychiatry is a viable method of delivering service even during the pandemic.

Improving quality and assessment of referrals to the Enfield Crisis Resolution and Home Treatment Team (ECRHTT)

AimsTriaging referrals to crisis resolution and home treatment teams is a significant undertaking requiring experienced and dedicated staff. We observed that the volume of inappropriate referrals to ECRHTT was high, and that staff processing these often felt inexperienced or lacking in confidence to discharge them back to the referrers and signpost them to appropriate services.The aims of this quality improvement project (QIP) were: a)to reduce the number of inappropriate referrals received by the teamb)to reduce the number of inappropriate referrals accepted by the teamThis would significantly improve access and flow to the service and facilitate better patient care.MethodA pilot study was first completed of the quality (appropriateness/ inappropriateness) and source of all referrals to ECRHTT in January 2019 (n = 177).Subsequently, the consultant psychiatrist for ECRHTT based himself within the assessment team. He was able to closely monitor the referrals, at the same time as providing medical input to patients at their first point of contact. To evaluate the impact of this intervention, the percentage of inappropriate referrals accepted pre- and post-change was compared by re-auditing all referrals received in February 2019 (n = 175).Further interventions were instigated to improve referral quality. These included continuation of psychiatric medical input to the assessment team, teaching sessions for GPs and the crisis telephone service, and weekly meetings with psychiatric liaison and community mental health teams (CMHTs). Change was measured by reassessing the quality of all referrals made to ECRHTT in February 2020 (n = 215).Result46.9% of inappropriate referrals to ECRHTT were accepted in January 2019 compared to 16.9% in February 2019 following the addition of medical input to the assessment team. The absolute difference was 30% (95% CI: 14%–44%, p < 0.001).71% of referrals from GPs were inappropriate in January 2019 compared to 36% in February 2020 post-intervention (difference 35%, 95% CI: 8.84%–55.4%, p < 0.05). Inappropriate referrals from CMHTs decreased from 55.5% to 12% (difference 43.5%, 95% CI: 9.5%–70.3%, p < 0.05). Overall, the percentage of inappropriate referrals fell from 38% to 27.4%, a difference of 10.6% (95% CI: 1.3%–19.8%, p < 0.05). The percentage of inappropriate referrals from liaison teams did not change significantly.ConclusionThis piece of work shows that better engagement with referral sources significantly improved the quality of referrals made to ECRHTT. Interventions included medical input at the point of referral, teaching sessions for general practitioners as well as ongoing liaison with referring teams.

Validation of SAD PERSONS Scale in Thai Tertiary Context

Objective: To examine the validity of the SAD PERSONS scale (SPS) and item analysis in a Thai tertiary setting.Material and Methods: One hundred and twenty-six inpatients were recruited from a psychiatric ward. Patients were interviewed by a consultant psychiatrist and assessed a variety of suicide risk factors. The SPS was blindly performed by a psychiatric resident. The psychometric properties of SPS was executed by comparing the assessment results.Results: A cut-off point of SPS was at 2/3 in assessing current high suicide risk with the sensitivity 79.0% and specificity 35.0%. While the specificity of cut-off point 4/5 was greater than 90.0%, sensitivity was only 27.0%. Parameters that correlated the high risk of suicide were only depression and statement of future suicide intent.Conclusion: For the purpose of suicide prevention, a sensitivity of screening scale is essential. SPS failed to identify the majority of those requiring high intensity psychological intervention though it shows the high specificity of suicide risk. The instrument should not be applied to screen self-harm patients presenting to general hospitals.

Integration Of Anesthesia Into ECT: A Hospital- Based Study On MECT From Anesthesiologist Point Of View

Introduction: MECT is a unique procedure where psychiatrist and anesthesiologist work together as a team. It is estimated that annually, approximately 1 million patients receive ECT worldwide. Due to association of physical complications like long bone and vertebrae fractures with direct ECT, anesthesia has been integrated into ECT. MECT is now the globally accepted standard mode of ECT. This study was done to see the Socio-demographic and clinical profile of patients receiving MECT. Material And Method: This is a hospital-based study done in BG hospital and Research Centre, Pokhara, Nepal for the duration of 12 months; from Baisakh, 2074 to Chaitra, 2074. A total of 50 consecutives cases that received MECT were enrolled after written informed consent for the ECT from the patients’ caretaker. The patient’s details, diagnosis and the numbers of cycles of MECT thus applied till clinical improvement were noted during the study period. MECT was administered on alternate days. The assessment of clinical improvement was done by the consultant psychiatrist. Following the protocol, each cycle of MECT was applied by consultant psychiatrist in the presence of the consultant anesthesiologist. Results: The total number of cases enrolled were 50. Out of 50 cases, 41 (82%) were male and mean age was 30.60 ± 10.13 years. The most common indications for MECT were BPAD (74%). The number of cycles of modified MECT applied on the individuals ranged from 6 to 18 cycles. Majority of the cases (78%) seem to have a clinical improvement after 6 cycles of modified ECT. There was no complication that warranted the termination of MECT. Conclusion: MECT when used judiciously is safe and leads to better clinical improvement.

5 Models of the world: from perception to hallucination

Paul Fletcher is Wellcome Investigator and Bernard Wolfe Professor of Health Neuroscience at the University of Cambridge. He is also Director of Studies for Preclinical Medicine at Clare College and Honorary Consultant Psychiatrist with the Cambridgeshire and Peterborough NHS Foundation Trust. He studied Medicine, before carrying out specialist training in Psychiatry and taking a PhD in cognitive neuroscience. He researches human perception, learning and decision-making in health and mental illness.We do not have direct contact with external reality. We must rely on messages from the sense organs, conveying information about the state of the world and our bodies. These messages are not easy to decipher, being noisy and ambiguous, but from them we have to construct models of the world. I will discuss this challenge and how we are very adept at creating a model of reality based on achieving a balance between what our senses are telling us and our expectations of what should be the case. This is often referred to as the predictive processing framework.Relying on this balance comes at a cost, rendering us vulnerable to illusions and biases and, in more extreme cases, to creating a reality that diverges from that experienced by others. This can arise for a variety of reasons but, at the root, I suggest, lies the nature of the brain as a model-building organ. Though this divergence from reality – psychosis – often seems inexplicable and incomprehensible, I suggest that a few core principles can help us to understand it and offers ways of thinking about how phenomena like hallucinations can be understood. Interestingly, the framework suggests ways in which apparently similar phenomena like hallucinations can arise from distinct alterations to the function of a predictive processing system.

The psychiatrist as philosopher: an appreciation of Dr Séamus Mac Suibhne (Sweeney) (1978–2019)

Dr Séamus Mac Suibhne (Sweeney), consultant psychiatrist and writer, who died on 8 September 2019, was a unique, much admired figure in Irish psychiatry. His interests ranged from clinical care to philosophy, from medical education to history, from innovative technology to the natural world. He was a dedicated family man as well as a doctor, scholar and writer who moved between academic fields with ease and erudition. As a clinician, he consistently placed compassion at the centre of care. Séamus’s work appeared in the Lancet, BMJ, British Journal of Psychiatry, International Journal of Social Psychiatry and Irish Journal of Psychological Medicine, among other publications. He also wrote for the Guardian, Spectator, Scotsman and Times Literary Supplement. Séamus had a particular passion for better acknowledgement and treatment of mental illness among psychiatrists, and his compelling advocacy on this theme is one of his lasting legacies.

A ssessment of Suicide Risk : Practical Issues

Suicide is a major public health problem worldwide with complex multifactorial origins. More than 800,000 lives worldwide are lost to suicide every year, and Asia accounts for more than 60% of such deaths. India has seen a steady increase in the incidence of suicidal deaths in the last five decades.1 The estimated suicide-related death rate in India is 21/100,000, which is nearly twice the global average (11.4/100,000) and translates into more than 230,000 lives lost annually.2 Assessment of suicide risk is of utmost importance and is considered one of the key area and responsibilities of a consultant psychiatrist.