Psychiatric disorders are common in neurological in-patients, but they are under-recognised and undertreated. We investigated the frequency of detection of mental disorder and referral to psychiatric services in a regional neuroscience centre. The results were compared with the expected prevalence. All in-patient referrals received in 2014 from the in-patient wards of the regional neuroscience centre and acute neurological unit were reviewed.

A total of 129 ward referrals were identified; of these, 78 were from the regional in-patient neurological unit, which comprised 11.4% of the total of 679 admissions to that unit.

A spectrum of neuropsychiatric conditions were recognised by neurologists, but overall rates of recognition were low. To address the problem of under-recognition, routine screening with validated assessment tools can represent a cost-effective and acceptable method to detect psychiatric disorders in an in-patient neurological setting.

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To develop and pilot a clinician-rated outcome scale to evaluate symptomatic outcomes in liaison psychiatry services. Three hundred and sixty patient contacts with 207 separate individuals were rated using six subscales (mood, psychosis, cognition, substance misuse, mind–body problems and behavioural disturbance) plus two additional items (side-effects of medication and capacity to consent for medical treatment). Each item was rated on a five-point scale from 0 to 5 (nil, mild, moderate, severe and very severe).

The liaison outcome measure was acceptable and easy to use. All subscales showed acceptable interrater reliability, with the exception of the mind–body subscale. Overall, the measure appears to show stability and sensitivity to change.

The measure provides a useful and robust way to determine symptomatic change in a liaison mental health setting, although the mind–body subscale requires modification.

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Sleep disturbance is common on in-patient psychiatry wards. This study explored subjective and objective patterns of sleep disturbance and contributory environmental factors. Participants were recruited from mental health acute admission wards and had a range of subjective and objective assessments of sleep. Light intensity and noise levels were measured to characterise potential environmental causes for poor sleep.

We recruited 20 patients; 15% were high risk for obstructive sleep apnoea. Nineteen participants reported poor sleep quality on the Pittsburgh Sleep Quality Index, and 90% had significant sleep fragmentation with objective measures. Inside light levels were low (day <200 lux and night <10 lux). Night sound levels were 40–90 db.

Sleep disturbance was highly prevalent. Increased awareness of sleep disorders is needed. Modifiable environmental factors on the ward were implicated, therefore increased awareness and a change of approach to sleep disturbance in in-patient psychiatry is recommended.

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The Health of the Nation Outcome Scales (HoNOS) and its older adults’ version (HoNOS 65+) have been used widely for 20 years, but their glossaries have not been revised to reflect clinicians' experiences or changes in service delivery. The Royal College of Psychiatrists convened an international advisory board, with UK, Australian and New Zealand expertise, to identify desirable amendments. The aim was to improve rater experience by removing ambiguity and inconsistency in the glossary rather than more radical revision.

Changes proposed to the HoNOS are reported. HoNOS 65+ changes will be reported separately. Based on the views and experience of the countries involved, a series of amendments were identified.

While effective clinician training remains critically important, these revisions aim to improve intra- and interrater reliability and improve validity. Next steps will depend on feedback from HoNOS users. Reliability and validity testing will depend on funding.

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As part of a larger clinical trial concerning the use of transcranial magnetic stimulation (TMS) for treatment-resistant depression, the current study aimed to examine referral emails to describe the clinical characteristics of people who self-refer and explore the reasons for self-referral for TMS treatment. We used content analysis to explore these characteristics and thematic analysis to explore the reasons for self-referral.

Of the 98 referrals, 57 (58%) were for women. Depressive disorder was the most commonly cited diagnosis, followed by bipolar affective disorder. Six themes emerged from the thematic analysis: treatment resistance, side-effects of other treatments, desperation for relief, proactively seeking information, long-term illness and illness getting worse.

TMS has recently been recommended in the UK for routine use in clinical practice. Therefore, the number of people who self-refer for TMS treatment is likely to increase as its availability increases.

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To understand general practitioner (GP) reticence to refer older patients to a local Improving Access to Psychological Therapies (IAPT) service providing mostly cognitive–behavioural therapy (CBT)-based interventions. Semi-structured, hour-long interviews were conducted with eight GPs and then analysed by modified grounded theory and thematic analysis.

GP views regarding the treatability of older adults with CBT influenced their willingness to refer to a CBT-based IAPT service. Perceptions of local IAPT assessment processes being distressing and onerous to older patients also motivated referral inaction. GPs expressed a preference to treat depressed older patients themselves (with medication and psychological approaches such as watchful waiting).

Any strategy to increase referral rates of older adults to CBT-based IAPT services should address local GP concerns regarding assessment processes and the effectiveness of offered treatments.

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The clinical utility of the multidimensional Framework for Routine Outcome Measurement in Liaison Psychiatry (FROM-LP) has not previously been examined. We sought to establish whether referral accuracy and ability to achieve the reason(s) for referral to our liaison service improved after incorporating the Identify and Rate the Aim of the Contact (IRAC) scale of this tool into our referral process. We carried out a retrospective analysis of electronic case notes of all appropriate referrals to the team before and after this adaption.

Accuracy of referrals to our team improved from 73.8 to 93.7% following intervention. Referral requests that were fully achieved improved from 57.4 to 77.8%, and referral requests that were not achieved decreased from 26.2 to 6.4%.

The IRAC component of the FROM-LP measures what it was developed for, and thus has clinical utility supporting its widespread adoption across liaison services in the National Health Service.

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To assess the benefits of the introduction of routine vitamin D serum sampling for all patients admitted to a secure in-patient hospital in the North of England providing medium security, low security and rehabilitation services for offenders with intellectual and developmental disability. The vitamin D levels of 100 patients were analysed at baseline. Those with insufficient or deficient levels were offered treatment and retested after 1 year. Vitamin D levels were analysed in the context of level of security, seasonality of test and co-prescription of psychotropic medications.

Eighty-three per cent of patients had suboptimal vitamin D levels at initial test (41% deficient and 42% insufficient). This was seen among established patients and new admissions. Regression analysis of baseline vitamin D levels revealed no differences for levels of security, seasonality, whether patients were taking antipsychotic or anticonvulsant medication, or length of stay. Patients with deficiency or insufficiency were all offered supplementation. Those who opted in had significantly higher vitamin D levels at follow-up, compared with those who declined treatment.

Established and newly admitted patients in our secure mental health services had substantial levels of vitamin D insufficiency. In the light of the morbidities that are associated with deficient vitamin D levels, routine screening and the offer of supplementation is advisable.

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This study used data collected to describe the activity, case-load characteristics and outcome measures for all patients seen during a 6-year period.

The service reviewed 2153 patients over 6 years with referral rates and case-load characteristics comparable to those described in a previous study period. The team saw 82% of patients on the day they were referred. Data and outcome measures collected showed significant complexity in the cases seen and statistically significant improvement in Health of the Nation Outcome Scales (HoNOS) scores following service input.

The outcome measures used were limited, but the study supports the need for specialist liaison psychiatry for older adults (LPOA) services in the general hospital. The Framework of Outcome Measures – Liaison Psychiatry has now been introduced, but it remains unclear how valid this is in LPOA. It is of note that cost-effectiveness secondary to service input and training activities are not adequately monitored.

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Community treatment orders (CTOs) have been in used in England and Wales since November 2008; however, their effectiveness has been debated widely, as has the question of which methodology is appropriate to investigate them. This paper uses national data to explore the use of CTOs in England.

About 5500 patients are subject to CTOs at any one time. Each year, ~4500 patients are made subject to a CTO each year and ~2500 are fully discharged, usually by the responsible clinician; fewer than half of CTO patients are recalled, and two-thirds of recalls end in revocation. The low rate of CTO discharges by mental health tribunals (below 5%) suggests that they are not used inappropriately.

The introduction of CTOs in England has coincided with a reduction in psychiatric service provision due to the economic downturn. Pressures on services might be even more severe if patients currently subject to CTOs instead needed to be detained as in-patients.

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Dr Billy Boland is on the advisory board of the Money and Mental Health Policy Institute.

The Health of the Nation Outcome Scales for Elderly People (HoNOS65+) has been used widely for 20 years, but has not been updated to reflect contemporary clinical practice. The Royal College of Psychiatrists convened an advisory board, with expertise from the UK, Australia and New Zealand, to propose amendments. The aim was to improve rater experience when using the HoNOS65+ glossary by removing ambiguity and inconsistency, rather than a more radical revision.

Views and experience from the countries involved were used to produce a series of amendments intended to improve intra- and interrater reliability and improve validity. This update will be called HoNOS Older Adults to reflect the changing nature of the population and services provided to meet their needs. These improvements are reported verbatim, together with the original HoNOS65+ to aid comparison.

Formal examination of the psychometric properties of the revised measure is needed. However, clinician training will remain crucial.

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There is limited evidence on ethnic differences in personality disorder prevalence rates. We compared rates of people with personality disorder admitted to hospital in East London from 2007 to 2013.

Of all people admitted to hospital, 9.7% had a personality disorder diagnosis. The admission rate for personality disorder has increased each year. Compared with White subjects, personality disorder was significantly less prevalent among Black and other minority ethnic (BME) groups. Personality disorder was diagnosed in 20% of forensic, 11% of general adult, 8% of adolescent and 2% of old-age in-patients.

The increasing number of personality disorder diagnoses year on year indicates the increasing impact of personality disorder on in-patient services. It is important to identify and appropriately manage patients with a personality disorder diagnosis due to the significant strain they place on resources. The reasons for fewer admissions of BME patients may reflect alternative service use, a truly lower prevalence rate or under-detection.

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This paper presents a debate in which the authors participated at the World Psychiatric Association conference in Cape Town, South Africa in November 2016. Professor van Staden acted as chair and here, as at the debate, provides a rationale for debating a topic that many of those involved in mental health believe to be decided. The discussion that ensued demonstrated, however, that while the arguments have moved on they have not ceased. Who won? Well that depends how you look at it. A few in the audience shifted position towards the motion but the majority remained opposed. What do you think?

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To explore the use of the STOPP/START toolkit in older psychiatric in-patients with dementia. Clinical records and current drug charts were reviewed against STOPP/START criteria for all in-patients (n = 86) on six specialist dementia wards.

Benzodiazepines, antipsychotics and opiates were most commonly prescribed inappropriately. The most common unprescribed medication groups were statins, calcium supplements and vitamin D supplements. There was an overall reduction of 7% in comorbidities and 8% in the number of prescriptions. t-test showed a significant drop in average comorbidities between both audits, t(1) = 23.920, P = 0.027, and in average prescriptions per patient, t(1) = 28.808, P = 0.022. There was no difference in the number of patients receiving polypharmacy, t(1) = 7.500, P = 0.084, or receiving medication with a high risk of adverse drug reactions, t(1) = 6.857, P = 0.092.

The STOPP/START toolkit highlighted the importance of collaborative working between doctors, clinical pharmacists and nursing staff, and could provide old age psychiatrists with a structured tool to identify inappropriate prescribing of non-psychiatric medications.

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Vitamin D deficiency is increasing in the general population, and is linked with physical and mental illness. However, evidence on its prevalence in people with mental illness is limited. This study investigated vitamin D deficiency in 104 adult patients admitted to a psychiatric hospital in the UK.

Forty-nine per cent were vitamin D deficient (serum 25(OH)D <30 nmol/L), and a further 42.3% were vitamin D insufficient (<50 nmol/L). On admission, 8.7% of patients were vitamin D sufficient (>50 nmol/L). There were no statistically significant differences in mean serum vitamin D between different subgroups of mental illness.

Vitamin D deficiency is highly prevalent among individuals with severe mental illness admitted to hospital. Assessment and treatment of vitamin D deficiency should be considered in in-patients to protect musculoskeletal health. Further epidemiological and intervention studies are needed to investigate the role of vitamin D in the pathophysiology of mental disorders.

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