Aims: Clozapine is recommended for treatment-resistant schizophrenia after two other antipsychotics have failed. We discuss a case of clozapine toxicity on therapeutic dose and its complications due to multifactorial causes.

Methods: 60 years Caucasian female, diagnosed with Paranoid Schizophrenia in the early 80s and on clozapine since 2000. Her mental health had been stable since and she was on 375 mg/day. There were some residual symptoms but otherwise functioning well with support. She was admitted to General Hospital with pneumonia, weight loss and altered bowel habits but nil sinister found. Her clozapine was missed for 72 hours and she developed rebound psychosis. Clozapine was re-titrated to 300 mg/day as her clozapine levels were 720 mcg/L before admission. She was discharged on the 300 mg/day however she was readmitted to General Hospital within a few months after sustaining a fracture of the femur and underwent surgery. Clozapine assays showed high levels of 1882 mcg/L with MR 2.68. She had ongoing symptoms suggestive of delirium. She was investigated for possible infections, drug interactions, and liver issues and initiated on lamotrigine for seizure prophylaxis. The clozapine dose was gradually reduced with regular monitoring of levels and side effects. She later developed stroke-like symptoms, with a normal CT scan. The clozapine dose was reduced to 100 mg/day as clozapine toxicity can mimic stroke/TIA. Repeat levels were 483 mcg/l. The patient’s mental and physical health remained stable after this.

Results: Clozapine is an effective antipsychotic agent with a dose range of 200 mg/day to 450 mg/day, the maximum licensed dose up to 900 mg/day. In clinical practice, the dose of clozapine is usually adjusted to provide plasma concentrations of 350–600 mcg/L. Acute infection can increase clozapine levels by reduced expression of CYP1A2 due to increased inflammatory cytokines and increase in a-1 acid glycoprotein. Acute infection and illness can lead to significantly increased clozapine levels and presumed toxicity, but symptoms of toxicity may be minimal or absent as the concentration of unbound drug is not increased. Certain drugs such as antibiotics and enzyme inducers can also affect levels.

Conclusion: Drug monitoring of clozapine is not a routine practice; certain clinical situations warrant multiple comorbidities, increasing age, polypharmacy, infections (pneumonia), and recent surgery, if poor (reduced) clozapine metabolism is suspected. Monitoring can help minimise the risk of toxicity. Patients should be evaluated for dose-related side effects such as constipation, seizures, cardiac arrhythmias and seizure prophylaxis should be considered if very high clozapine plasma levels.

Aims: Clozapine is the most effective treatment in patients with treatment resistant Schizophrenia as recommended by the National Institute of Health and Care Excellence (NICE). This case study aims to explore a patient’s journey in mental health services during the relapse of his mental illness and the significance of reconsidering clozapine in patients who responded well to the medicine before.

Methods: 35-year-old male diagnosed with Paranoid Schizophrenia admitted to the acute ward following relapse of his mental illness. He had many admissions under sections in the past and was tried on several antipsychotics. Historically he has shown non-compliance with his medications and poor engagement with the mental health services. In the current presentation, he was found to be floridly psychotic with paranoid and persecutory delusions. He mentioned that people were coming to his flat through the walls and injected him with drugs. He was prescribed clozapine in his last admission as he met the criteria for treatment resistant Schizophrenia. During his stay, we tried him on a combination of non-clozapine antipsychotics due to the history of poor drug compliance. Since he didn’t show any response after trying other antipsychotics for a longer period of time, the team decided to restart him with clozapine. Patient showed a good response following this.

Results: In the above case scenario, though the patient previously responded well to clozapine, the team was reluctant to restart clozapine because of the following reasons: history of poor drug concordance, sudden withdrawal of clozapine leads to various side effects like withdrawal associated psychosis and catatonia, cholinergic rebound and rarely it causes serotonergic symptoms. The pharmacological profile of clozapine is complex as it induces a range of neuronal changes at the receptors particularly when taken for a prolonged period of time. Evidence suggests that these neuronal changes are responsible for the occurrence of withdrawal symptoms on clozapine discontinuation.

Conclusion: Evidence suggests that one third of patients with schizophrenia are treatment resistant and clozapine is the treatment of choice for refractory psychosis. Although the literature says that sudden stoppage of clozapine is associated with an array of withdrawal symptoms, it is important to consider restarting the patient with clozapine, especially if they showed a good response in the past. This case study also highlights the good practice for communicating with patients about the significance of clozapine, its effect and withdrawal symptoms due to discontinuation which helps treatment adherence.

Aims: For patients prescribed methadone wishing to access buprenorphine ORT, the current practice is to reduce the methadone dose to 30/40 ml and cessation of methadone for 48 hrs prior to the switch. This exposes these patients to risk of psychological, physical distress or relapse into non-prescribed opiate use.

Using guidance published by the Canadian Journal of Addiction we adapted this to a local UK setting to evaluate its implementation into regular service provision.

We aim to demonstrate effective transition, in a series of patients prescribed methadone onto sl (sublingual) buprenorphine, without adverse effects/precipitated withdrawal or the requirement of methadone dose reduction nor 48 hour abstinence from methadone, in community-based settings.

Methods: We collected outcomes on 12 patients (dose range 26 ml – 90 ml of methadone daily), 12 of whom successfully transitioned from methadone to buprenorphine ORT via buprenorphine Microdosing Bridging Method.

We enquired and assessed for precipitated opiate withdrawal symptoms using a daily modified SOWS/COWS and psychological response throughout the transition period.

Patients were initiated onto buprenorphine initially using transdermal 20 mcg/24 hr buprenorphine patches over the first 48 hrs of treatment, after which urine was tested. Once the urine screen showed buprenorphine, oral initiation of sublingual buprenorphine began on Day 1 at 400 mcg daily and increased according to the following schedule:

Day 2: Usual dose methadone daily, buprenorphine 0.8 mg.

Day 3: Usual dose methadone daily, buprenorphine 1.2 mg.

Day 4: Usual dose methadone daily, buprenorphine 1.6 mg.

Day 5: Usual dose methadone daily, buprenorphine 2.0 mg.

Day 6: Usual dose methadone daily, buprenorphine 4 mg daily.

Day 7: Usual dose methadone daily, buprenorphine 6 mg daily.

Throughout this period, the patients’ methadone dose remained at their pre-transition dose. The last dose of methadone was administered when the patients were administered 6 mg sl buprenorphine daily on Day 6. The following day, patients were administered 8 mg sl buprenorphine with subsequent dose titration to achieve optimal daily dose.

Results: 12 patients achieved the transition from methadone to buprenorphine without experience of precipitated opiate withdrawal or adverse psychological effect.

Conclusion: Transition from methadone to sl buprenorphine without requiring prior dose cessation or reduction of methadone up to 90 ml daily is safe, effective and practical in a community-based and acute care setting. This provides methadone ORT patients the option of accessing buprenorphine ORT over a short period of time (10–14 days) without the experience of precipitated opiate withdrawal, and can be undertaken in a variety of community settings.

Aims: Temporal Lobe Epilepsy (TLE) is the most common symptomatic cause of partial epilepsy worldwide. It can present with vague symptoms including affective disturbances, personality changes, sensory disturbances, altered consciousness etc., which can confound diagnosis. Overt focal or tonic-clonic seizures are present in only 60% patients. It manifests with psychotic symptoms in around 5%. This case report describes how undiagnosed TLE with psychotic symptoms led to grave consequences.

Methods: We present a 52-year-old male who was found to have killed his father and was subsequently diagnosed with TLE. This diagnosis was later found to be directly implicated in the act. When arrested on suspicion of homicide he presented with several psychotic symptoms and severe agitation in custody. He was then detained under the Mental Health Act to a high secure psychiatric hospital. He had no formal psychiatric or medical diagnosis prior to his arrest but it was noted that he had presented on multiple occasions to secondary neurology and psychiatric services over the preceding 10 years with vague but consistent symptoms which were labelled as night terrors. These included clouding of consciousness, affective disturbance, night terrors, suicidal ideation, and isolated aggressive outbursts. Following his hospital admission, he was assessed by neurologists and was diagnosed of TLE after his EEG clearly demonstrated abnormalities in line with the diagnosis. The gentleman’s psychiatric symptoms resolved entirely when he was treated adequately for TLE with an anti-epileptic (lamotrigine). At trial, he was found not guilty of murder by reason of insanity and received a hospital order with restrictions.

Results: TLE is a treatable neurological disorder but is associated with a risk of heightened violence especially if misdiagnosed. In this patient, repeated opportunities were missed in diagnosing and treating TLE in a timely manner. Potential differentials that can confound TLE diagnosis include night terrors, functional psychosis, anxiety disorders, affective disorders, substance misuse etc.

Conclusion: TLE can have far-reaching and life-altering consequences. To obviate these, it is recommended that repeated presentations with unexplained neurological and psychiatric symptoms in outpatient or emergency settings should trigger robust assessments and multi-specialty liaison. It would be beneficial to develop a protocol to trigger a thorough evaluation of suspected TLE cases with a lower threshold to investigate them than what is currently practised. This could involve earlier and wider utilisation of electro-encephalogram (EEG) (ambulatory or residential).

Aims: New onset psychosis in the elderly is rare with lifetime prevalence rates of 0.3–1%. Schizophrenia occurs in 0.1–0.5% of the elderly, however more common causes of new onset psychosis include dementia, delirium, drug-induced psychosis, and primary psychiatric disorders, most commonly depression. More than 50% of patients with Alzheimer’s disease experience psychotic symptoms and 70% develop delusions, in particular, persecutory type. Visual hallucinations are the most common type of hallucination occurring in 80% of patients with Lewy Body dementia. Second person auditory hallucinations occur in schizophrenia-like psychosis, however musical hallucinations where one perceives music without an external source are rare.

Methods: An 84-year-old female patient with no psychiatric background reported a 2-month history of musical hallucinations, causing distress and poor sleep. Patient denied hearing voices and other modalities of hallucinations. The musical hallucinations were not lateralised to either ear or side of space but experienced as external. Delirium was ruled out and patient’s medications were screened for anticholinergics and sedative-hypnotics. Patient had good cognition and a CT head excluded organic causes. The patient appeared distracted by the musical hallucinations, however, was not agitated and her mood was euthymic with congruent affect. No evidence of mood disorders ruled out psychotic depression and other affective disorders with psychotic symptoms. No thought disorders or delusions were present. Antipsychotics quetiapine and amisulpride proved no benefit for the patient.

Results: The patient’s presentation showed no clear reversible pathology and was unresponsive to antipsychotics. Musical hallucinations was given as a diagnosis of exclusion.

A musical hallucination is a type of auditory hallucination involving the perception of music without an external source. Patients are usually female, over 60 and subdivided into those with hyperacusis, psychiatric disorders, focal brain lesions, epilepsy and intoxication. Our patient was female and over 60 with presbycusis.

Musical hallucinations are proposed to be due to abnormal autonomous activity in the auditory brain systems responsible for normal music imagery. Sensory auditory deprivation or acquired peripheral deafness leads to impoverished auditory input and spontaneous activity occurs within the network for the perception and imagery of music.

Conclusion: This case report describes a rare phenomenon of musical hallucinations in an elderly patient. It identifies important diagnoses to exclude including delirium, dementia and other organic causes. The patient was female, over 60 yrs and diagnosed with presbycusis, characteristic of patients with musical hallucinations. The patient showed no improvement with antipsychotics and so treatment consisted of psychoeducation.

Aims: We report on an Afghan refugee is in his 30s who presented to a Community Mental Health Recovery Service (CMHRS) with a two year history of visual and auditory disturbances and distressing persecutory beliefs revolving around 'Jinn'. This led to significant distress, a decline in functioning and shared experience with his wife also complaining of similar events.

Methods: Our patient’s symptoms commenced when he and his family moved into a new property and believed that his house was possessed by 'Jinn'. He had moved from Afghanistan to the UK as a refugee, speaking predominantly in Farsi and a practising Muslim. Examples of his experiences which he attributed to the ‘Jinn’ included; hearing noises in the house, seeing a broken cup and bathroom toiletries on the floor, and seeing a male figure during the night described as ‘frightening, headless and with claws’.

We conducted a thorough assessment and encompassed cultural and spiritual components of his health, liaising with their refugee support worker and involving our Trust multifaith team and a Farsi-speaking psychiatrist.

Affective conditions, Post Traumatic Stress Disorder and folie à deux were considered during the assessment period and felt that Adjustment Disorder reflected the current presentation. Precipitating factors included moving to UK, change in culture, and lack of local provisions to accommodate his faith such as no local access to a Mosque or Halal food shops.

Psychotropic medication was not indicated and the patient declined psychological therapy. Following movement of housing to an Afghan community, there were no further concerns expressed in relation to Jinn. The patient was subsequently discharged back to their GP.

Results: This case highlights the important influence religion and culture can have in symptom formation and how altered perceptions can be interpreted subjectively. The patient’s distress of migrating, separation from family and friends and change of cultural environment are likely to contribute to the patient’s experiences.

Symptoms of possession can overlap with mental illnesses and can be a socially accepted explanatory model of disease in non-Western cultures in expressing distress and conveying conditions including depression, bipolar disorder and anxiety along with stress and marital hardship.

Conclusion: Our patient’s diagnosis of Adjustment disorder highlights the importance of a holistic approach to psychiatric assessment. A better understanding of symptom formation within trans-cultural psychiatry could minimise the risks of subsequent misdiagnosis and inappropriate medication prescription. Correct formulation means we can support patients in accessing appropriate religious and spiritual resources and care where appropriate.

Aims: Avoidant Restrictive Intake Disorder (ARFID) is characterised by insufficient intake, for reasons unrelated to body image concerns, but is strongly associated with autism spectrum disorder (ASD). It causes weight loss, nutritional deficiencies and physical health consequences, which can be fatal, as seen in the tragic 2021 case of Alfie Nicholls. Despite ARFID’s impact, there are no national guidelines and treatment recommendations are limited, advising psychological interventions and nutritional counselling.

Methods: A male in his thirties with ASD and restricted eating, resulting in multiple admissions for malnutrition, including to intensive care, was readmitted with electrolyte disturbance and dehydration. Numerous psychiatric assessments concluded his restrictive eating to be ASD-associated ARFID. Despite psychological and nutritional support throughout his life, he was unable to maintain a healthy BMI and developed chronic malnutrition. Similarly, during this admission after four months of dietetic input, nasogastric feeding, which he found difficult to tolerate, and psychological intervention, he lost weight, causing recurrent infections, persistent anaemia and perforated gallbladder secondary to gallstones. Long-term enteral feeding (LEF) had not previously been explored, so there were multi-disciplinary team discussions, deciding a percutaneous endoscopic gastrostomy (PEG) would be in his best interests. This enabled him to reach a safe weight for discharge, continue to gain weight, improve his general health and minimise readmission risk.

Results: Decision-making is challenging due to a lack of research on ARFID management and the role of LEF. The treatments currently recommended are sometimes inappropriate in concurrent ASD, due to restricted thinking and social interaction difficulties, as demonstrated here. There is hesitance to start LEF in psychiatric diagnoses, like ARFID, as the underlying issue is not tackled. However, ASD, a lifelong developmental disability, is often driving ARFID, so psychological interventions alone may be ineffective. This particularly applies to adults with ARFID as psychological interventions were found to be less effective than in children/adolescents. Therefore, in severe malnutrition despite intervention, LEF benefits likely outweigh the risks. Psychological support should continue whilst LEF improves nutrition, offering possible earlier discharge to an environment more conducive to improving oral intake and general mental health.

Conclusion: ASD-associated ARFID requires a different therapeutic approach to ARFID alone. Although the initial priority should be meeting nutritional requirements orally, LEF should be considered in severe individual cases to improve quality of life, reduce admissions and reduce mortality, but further research is required to improve outcomes.

Aims: Long-acting buprenorphine has been explored in context of its use in opioid dependence, however its potential for managing self-harm behaviour is limited. Self-harming behaviour often signals extreme emotional distress. This case report brings an insight into the effectiveness of injectable buprenorphine in a person with extreme self-harm behaviour.

Methods: Miss SD, 30-year-old single, unemployed woman, with history of emotional abuse, sexually abused by father from the age 6–8 and mother having difficulties with alcohol abuse. She has been involved with Psychiatric services from the age of 13 and had several Psychiatric hospital admissions, transfer to low secure Forensic unit and step down to supported accommodation. Having difficulties with self-harming behaviours, suicidal thoughts or attempts and aggression towards staff. Self-harm behaviour included cutting, overdoses, ligatures; to an extent she needed multiple surgical interventions for cutting, inserting glass and glueing the genitalia multiple times, along with glueing nose and lips.

Over the course her diagnoses included EUPD, PTSD, Depressive disorder, transient Psychotic episodes, alcohol dependence and polysubstance misuse.

Due to escalating behaviour she was trialled on injectable buprenorphine as off-licence use for self-harming behaviour. We have compared the data of 2 years on injectable buprenorphine to history prior to that.

Initiation on buprenorphine treatment had a dramatic improvement in Miss SD given the number of incidents of both alcohol use and self-harm.

Results: Buprenorphine treatment had a greater reduction in self-harming behaviour in Miss SD. There have been only 1–2 episodes of self-harm per year since she started on buprenorphine i.e, in last 2 years, when compared with the several episodes a week. In addition the number of hospital admissions reduced to 2 brief admissions, compared with several admissions including long stay in Low Secure Unit.

Recurrent self-harm can have an endogenous opioid response, and in the long term the pattern is similar to addiction.

Buprenorphine is a partial μ-opioid receptor agonist and a potent kappa antagonist, and treatment with long-acting opioid antagonist could block the reward of enhanced endogenous opioids caused by self-harming behaviours and subsequently lead to their extinction.

Conclusion: A retrospective case study of Miss SD since the initiation of buprenorphine suggests this may be an alternative therapeutic option to treat people with significant Self-harming behaviour with functional impairment. In addition it is much safer as it causes less respiratory depression than other opioids.

The evidence is promising, however more research is needed to review the effectiveness, establish efficacy, and safety.

Aims: This project investigates whether mother and baby music sessions in the inpatient perinatal mental health setting can effectively reduce maternal anxiety, improve mood, and strengthen the mother–baby bond. It aims to review existing literature and reflect on the practical implementation of a pilot music group within a mother and baby unit (MBU).

MBUs are specialist inpatient wards which keep mothers united with their babies during treatment to maintain the mother–baby bond. Therapeutic activities vary across units, but music groups have been explored as a potential intervention to improve maternal mental health and bonding.

Methods: A literature review was conducted, identifying 8 relevant studies. The pilot music group, based on supporting literature, consisted of 6 weekly hour-long sessions, involving singing nursery rhymes and improvisation. Participants included 15 mothers with various mental health conditions. Reflections from the author/session lead and staff present were recorded to evaluate the intervention.

Results: Literature showed improvements to maternal anxiety and maternal mood after attending singing groups however the populations studied in most papers did not reflect those with more severe mental health conditions and few showed statistical significance. Bonding improvements were consistently noted across studies, often assessed through qualitative feedback or bonding scales. The pilot sessions were well-received, with mothers reporting relaxation and enjoyment. However, practical challenges emerged, not alluded to in previous literature, including cultural relevance of songs, emotional triggers, and varying levels of engagement amongst mothers with differing mental health conditions.

Conclusion: Music groups show promise as a therapeutic intervention for enhancing maternal mental health and bonding, reflected in those who attended the pilot music group. Quantitative research on its benefit in more unwell mothers admitted for treatment is still required. Challenges such as emotional triggers and the inclusion of diverse patient populations were identified in this pilot and efforts should be made to mitigate this in further interventions of a similar nature. Future research should focus on mothers with severe illness, particularly those admitted to MBUs, and explore the long-term impact of music groups as a routine intervention to support maternal–infant bonding during treatment.

Aims: Epilepsy can present with a wide range of neuropsychiatric manifestations. A seizure episode may take the form of motor convulsions, complex abnormal behaviours or unusual subjective experiences.

Seizures originating in different anatomical locations take characteristic forms, however, there is considerable overlap in the presentation.

Frontal lobe seizures are characterised by motor phenomena which may include complex posturing and behavioural automatism which tend to begin and end abruptly.

This condition is of particular importance to psychiatrists, due to the bizarre nature of automatic behaviour. They may be mistaken as dissociative phenomena or psychotic disorders.

Methods: A 55-year-old female who was previously well, presented to the psychiatric service following episodic disorganised behaviour for two weeks duration. For example, she had cooked rice three times per meal without an apparent reason. Also, she had started collecting a large number of vegetables repeatedly in a shopping centre without a clear purpose. At that time her husband had to forcefully stop her. When inquired later she was unable to recall these events. Family members also noticed that the patient is having episodic repetitive facial movements without losing consciousness.

General physical and neurological examination was normal. Her EEG showed right frontal sharp waves which progress into generalised spikes, suggestive of frontal lobe epilepsy with secondary generalisation. The contrast CT brain was normal. Haematological tests including random blood sugar, serum electrolytes, full blood count, serum calcium levels and the ECG were normal. Intravenous phenytoin sodium was given to control repetitive seizures at the onset.

Subsequently, oral sodium valproate was commenced. She responded well, and symptoms disappeared within a couple of days.

Results: Epilepsy presenting as behavioural and psychiatric manifestations is common but can be easily overlooked. Frontal lobe epilepsy with common aetiology like post traumatic, tumours and genetic causes can have complex seizure semiology.

Overall frontal lobe seizures tend to begin and end abruptly, are brief and frequent. They show a tendency to occur at night and in clusters. Motor phenomena which may include complex posturing and behavioural automatism are usually the most conspicuous feature.

This patient had several bizarre behaviours which could be complex behavioural automatism. The bizarre nature of automatism means that they can often be mistaken for non-epileptic dissociative seizures as well as another psychiatric diagnosis like mania or psychosis.

Conclusion: Our patient highlights the unusual way of presentation of frontal lobe seizures. Clinicians need to be aware of this presentation to minimise possible misdiagnosis and mismanagement.

Aims: Prosopometamorphopsia is an extremely rare phenomenon where the individual perceives facial distortions in self or others. “Demon face syndrome” and “Alice in Wonderland syndrome” are some lay terms coined to describe this condition.

Methods: We report a case of a male in his thirties, married, and a father of one, who presented to the psychiatry unit perceiving distorted facial features of self (autoprosopometamorphopsia) for eight years with exacerbation since last year. He alluded to his reflection in the mirror as the face of a demon. This resulted in significant social avoidance and rumination of other people’s perceptions of his appearance. At the time of presentation, he was having a severe depressive episode with significant occupational and functional decline and was consuming excessive alcohol as a maladaptive coping strategy.

When the symptom first appeared eight years ago while working in the military, he perceived similar distortions in a co-officer’s face in addition to his face, which culminated in him resigning from the forces due to the distress. He did not seek medical treatment, and symptoms went into spontaneous remission after a few months. He was satisfactorily functioning until a year ago.

Apart from prosopometamorphopsia, he did not have any other psychotic symptoms or symptoms suggestive of manic episodes. He was diagnosed with anti-NMDA encephalitis one year ago and had suffered seizures. He reportedly lost the neuroimaging and treatment records related to this episode.

Results: The patient was initially diagnosed of Body Dysmorphic Disorder (BDD) and had been treated with adequate trials of antidepressants with very poor response. Due to the severity of depression, functional decline and previous poor response to antidepressants, he was treated with electroconvulsive therapy (ECT) during his current admission. During the one-month post-discharge evaluation, he showed satisfactory improvement and was continued on imipramine 150 mg and olanzapine 20 mg in the night. He was also on topiramate 50 mg nocte from the neurology clinic.

Conclusion: Existing literature reveals that prosopometamorphopsia has an organic basis with malfunctioning brain facial recognition systems playing a critical role in its manifestation. In this patient, a history of NMDA encephalitis suggests neuropsychiatric aetiology. Lack of response to conventional treatment for BDD and good response to ECT indicates that this condition is a different entity warranting tailored treatment.

Aims: With this systematic review, an attempt will be made to systematically compare the efficacy and side effects of Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) in Chronic Pain Conditions in terms of functional improvement and quality of life with placebo.

Methods: The relevant studies were included after conducting a literature search in OVID, PubMed/MEDLINE, EMBASE/SIGLE, CINAHL, and Web of Science. Randomized controlled trials that compared SNRIs in chronic pain were included in the review. In the assessment of study quality, the Cochrane Risk-of-Bias tool was used. A number of data extractors and analysts were used in the study so as to reduce possible bias in the study results.

Results: Duloxetine appeared to be the SNRI with the best therapeutic efficacy profile across different chronic pain types and aetiologies such as osteoarthritis, fibromyalgia, and chronic low back pain. It showed reasonable effectiveness in alleviating pain magnitude and enhancing motor activity. The results were consistent between standard and higher doses of single administration 60 mg. Duloxetine demonstrated a significant reduction in pain when compared with placebo. An improvement in functional status and quality of life measured through self-reported scales was also noted. This trend was more pronounced in the treatment of the patients on SNRI compared with those on placebo.

Conclusion: Duloxetine appears to be effective for chronic pain conditions and may help reduce pain intensity, increase functional status and improve the quality of life. Even though rigorous trials indicate that these drugs are superior to placebo after 8–16 weeks, long-term effect and safety profiles are not very clear, and more long-term studies are needed to understand the durability and application of the drugs in clinical practices. Further research should prospectively investigate the efficacy in long-term pain, different comorbid conditions, and include predictors of SNRI response.

Aims: This study through systematic review approaches and meta-analysis aimed to determine safe drug options for treating male sexual dysfunction due to erectile dysfunction by comparing sildenafil, tadalafil, vardenafil, mirodenafil, coenzyme Q and testosterone.

Methods: Systematic review methodology was used to retrieve data from complete database searches done in PubMed/MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Randomized controlled trials research designs with adult male participants who presented with erectile dysfunction on sildenafil, tadalafil, vardenafil, mirodenafil, coenzyme Q and testosterone were included as part of the review. The Cochrane Risk of Bias version 2.0 was utilized by two independent reviewers for assessing bias risk and extracting data. Sensitivity analysis was used to reduce the risk of bias.

Results: Phosphodiesterase inhibitors type 5 (PDE 5) are the most effective medications for erectile dysfunction (ED). Participants on sildenafil had effective erections between 77–84% at doses of 50–100 mg and tadalafil emerged as the “Weekend pill” because of its 36-hour maximum effect duration of action. The concentration-focused activity along with higher potency values of vardenafil make it superior to other PDE5 inhibitors. The newly developed therapeutic medication mirodenafil exhibits better PDE5 selectivity than existing drugs within its operational mechanism. Minor variations were noted as a cohort of participants preferred tadalafil above sildenafil. Testosterone supplementation is beneficial for when monotherapy with a PDE5 inhibitor has not been effective.

Conclusion: Being the first-line treatment for erectile dysfunction, PDE5 inhibitors should be prescribed based on the distinctive pharmacological attributes they possess. Medical treatment selection methods must take into account both the need of patients as well as their preference. The recent introduction of mirodenafil medication has opened new possibilities in the medical treatment of ED. The effectiveness of ED treatment brings optimistic outcomes to the quality of life to hundreds of millions of men across the globe and further studies will drive medical progress to improved treatment modalities including stem cell therapy.

Aims: Ketamine and behavioural activation (BA) reduce levels of anhedonia in major depressive disorder (MDD), though neither resolves anhedonia. Combining these treatments could yield additive or even multiplicative benefits.

This poster summarises the development of a PhD fellowship proposal, discussing: (1) the initial patient and public involvement (PPI) interviews, exploring views on participation in ketamine research; (2) the resulting proposal, assessing the feasibility of a trial augmenting BA with IV ketamine for MDD and anhedonia.

Methods: 1. One-to-one PPI interviews were conducted with seven participants from a previous study of ketamine in treatment-resistant depression. Questions addressed (a) volunteering reasons, (b) positives to retain and areas to improve and (c) research objectives opinions.

2. Participants with MDD and anhedonia will be recruited from the community and local primary care services (GP and NHS Talking Therapies). A planned feasibility parallel-group randomised controlled trial will compare IV ketamine with BA (n=20), against midazolam with BA (n=20). Participants will attend eight visits (including one-month follow-up) over 10–12 weeks, receiving 3 ketamine or midazolam infusions in between 6 BA sessions. Feasibility of study procedures and collection of outcome measures will be assessed.

Results: A key motivator for participants to volunteer was hope that ketamine would improve depression symptoms. Some were curious about ketamine’s effects. They wished to support research into depression treatments.

Most participants experienced a stark difference between ketamine and midazolam (placebo). They described feeling more open, malleable and involved in the world after ketamine.

Participants suggested future studies retain a focus on treating participants as individuals rather than a ‘number’ and allowing unrushed sessions. They thought clinician-led interviews helped reflect on symptom changes.

Participants found the consent process thorough. However, some suggested it should be clearer that mood changes from ketamine may not last. They recommended providing audiovisual materials on the ketamine experience/infusion room to support preparation. They suggested a check-in between infusion sessions and a final session to discuss onward referrals, medication advice and signposting to low-cost counselling and integration groups.

Most thought ketamine could enable better use of therapy time and that therapy could help make sense of thinking changes post-ketamine. Other suggestions for research included duration of symptom relief post-ketamine, treatment accessibility including in primary care, and medication side effects.

Conclusion: PPI interviews supported combining ketamine with psychotherapy. They provided key insights on improving study procedures to support research into augmenting primary care therapies for depression treatment.

Aims: The global demographic transition has led to a growing ageing population. Neurodegenerative disease prevalence is high in the elderly, as aged brains accumulate molecular and cellular damage. Protein misfolding and aggregation are pathological processes underlying neurodegeneration, as seen in dementia. This coupled with oxidative stress, disrupted ubiquitin-proteosome system and neuroinflammation may contribute to neuronal damage/death. Lewy Body dementia (LBD) collectively refers to Parkinson’s disease (PD), Parkinson-disease dementia and dementia with Lewy bodies (DLB). It is characterised by Lewy Body (LB) deposits in the central nervous system, predominantly compromised of misfolded α-synuclein protein. Disease-modifying therapy (DMT) targets underlying protein misfolding and promotes LB clearance.

To review international trials on DMT safety, tolerability and efficacy in DLB.

To consider the molecular basis for protein misfolding and DMT in DLB.

Methods: Two international registries (ClinicalTrials.gov; EU clinical trials register) were consulted to identify agents being tested in completed, ongoing and recruiting trials. Both databases were searched by disease “Lewy body dementia” or “LBD” or “alpha-synuclein pathology” and study type “interventional” for phase I–III trials. Trials solely investigating diagnostic biomarkers, approved symptomatic DLB treatment or PD without dementia symptoms were excluded from final analysis.

Results: 11 trials were found studying DMTs for DLB. 10 out of the 11 trials were in phase II and one in phase I. The main agents investigated were tyrosine-kinase inhibitors (TKIs), phosphodiesterase-9 inhibitors, β-adrenergic agonists, and β GCase chaperones. Primary and secondary outcome measures were “safety/tolerability of agent”, “changes in cognitive function” or “changes in serum/CSF α synuclein levels”. Results from a phase I trial demonstrated a 3.85 and 3.5-point increase in mini-mental state examination scores at 6 months with nilotinib doses 300 mg and 150 mg, respectively. Contrastingly, only slight reduction in CSF/plasma α-synuclein was observed. Phase II trials for bosutinib versus placebo showed no significant difference in cognitive function. Trials for ambroxol, a β-GCase enzyme enhancing inhibitory chaperone, remain in recruiting stages but have proven drug tolerability due to fewer side effects. Data on CSF biomarker changes in DLB was unavailable.

Conclusion: Current understanding of protein misfolding in α-synucleinopathies suggests that a single DMT may be insufficient in mixed pathology. Cocktail therapy targeting various misfolded proteins may be necessary for a cure. DMTs have limited use as most patients are diagnosed with advanced DLB. Sensitive diagnostic biomarkers with high specificity are required for accurate DLB diagnosis in the prodromal phase, a critical window for protein misfolding reversal with DMT.

Aims: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) such as semaglutide are considered breakthrough drugs in the management of diabetes and obesity. Beyond their metabolic benefits, these pharmacological agents interact with biological pathways that may influence brain function, and are therefore increasingly being investigated for possible repurposing in psychiatric and neurological disorders. This review aims to synthesise pre-clinical and clinical evidence on the effects of GLP-1RAs across a range of cognitive and mental health conditions, comprehensively assessing their therapeutic potential and translational implications for psychiatric practice.

Methods: A systematic literature search was conducted across multiple databases, using a broad search algorithm to maximise the scope of the evidence synthesis. Two researchers independently screened titles and abstracts, assessed full texts for eligibility, and extracted relevant data. Results were considered in a narrative and visual synthesis based on emerging categories: studies were divided into mechanistic and clinical evidence, and organised based on broad diagnostic domains (cognitive disorders, substance use disorders, psychotic disorders, mood and anxiety disorders, and eating disorders). Clinical evidence, including meta-analyses, randomised controlled trials (RCTs), and observational studies, was critically appraised and ranked by hierarchy of evidence.

Results: The main themes emerging from the 280 pre-clinical and 96 clinical studies identified consist of the potential benefits of GLP-1RAs in neurocognitive disorders (reducing dementia risk and cognitive impairment in various cohorts) and in substance use disorders. Mechanistic evidence suggests these are mediated through their multimodal neuroprotective effects (including via anti-inflammatory pathways) and by dopaminergic modulation of reward mechanisms, respectively. In psychotic disorders, GLP-1RAs primarily mitigate antipsychotic-induced metabolic side effects, with minimal evidence for direct effects on psychosis itself. Findings in mood and anxiety disorders are inconclusive, with some studies reporting antidepressant properties while others show no clear benefit. Evidence in eating disorders is scarce, but suggests GLP-1RAs may influence binge-eating behaviour, aligning with pre-clinical findings on their influence on appetite and reward regulation.

Conclusion: Extensive pre-clinical literature on GLP-1RAs provides strong mechanistic support for their putative benefits in Psychiatry, particularly in cognitive and reward-related disorders. However, clinical studies have yet to fully confirm these effects, highlighting the need for high-quality, targeted trials to distinguish direct mental health effects from secondary metabolic improvements. As enthusiasm about the promise of GLP-1RAs continues to grow in both the scientific community and in the media, it is crucial to approach their adoption in Psychiatry cautiously, and focus on robust translational research to establish their long-term efficacy and safety in patients with mental health conditions.

Aims: Parkinson’s disease (PD) is a progressive neurodegenerative disorder that primarily affects motor function but also impairs cognitive and emotional regulation. Dopaminergic therapy, commonly used to treat motor symptoms, can lead to complications such as impulse control disorders (ICDs), compulsive behaviours, and dopamine dysregulation syndrome (DDS). These complications often result in significant deterioration of patients’ quality of life. This dissertation aims to investigate effective interventions for managing ICDs and compulsive behaviours in PD patients on dopaminergic treatment while minimizing the risks of motor symptom deterioration and other neuropsychiatric consequences.

Methods: This systemic literature review examines a wide range of interventions for managing ICDs and compulsive behaviours in PD patients. A comprehensive search was conducted across major medical and psychological databases to identify studies evaluating pharmacological and non-pharmacological treatments. The review focused on interventions such as clonidine, atomoxetine, cognitive behavioural therapy (CBT), and subthalamic nucleus deep brain stimulation (DBS). Inclusion criteria were studies published in peer-reviewed journals within the last two decades that specifically addressed the treatment of ICDs and compulsive behaviours in PD patients receiving dopaminergic therapy.

Results: The review found that several interventions show promise in managing ICDs and compulsive behaviours without exacerbating motor symptoms. Clonidine and atomoxetine, both of which affect norepinephrine pathways, have been identified as potentially effective pharmacological options for controlling impulsivity and compulsive behaviours. CBT has been highlighted as an effective psychological intervention, particularly in improving patients’ coping mechanisms and reducing maladaptive behaviours. Additionally, deep brain stimulation of the subthalamic nucleus has demonstrated positive effects on reducing impulsivity in PD patients, though its use remains primarily for motor symptom management. However, the evidence remains inconclusive regarding the optimal approach for balancing treatment of both motor and non-motor symptoms.

Conclusion: The management of ICDs and compulsive behaviours in PD patients remains complex due to the delicate balance between controlling motor symptoms and minimizing dopaminergic side effects. While pharmacological interventions such as clonidine and atomoxetine, as well as non-pharmacological treatments like CBT and DBS, offer potential benefits, further research is needed to refine these approaches. Additionally, more tools are required for the comprehensive risk assessment of ICDs and compulsive behaviours to guide clinicians in tailoring treatments that safeguard both motor function and mental well-being, ultimately improving patient quality of life.

Aims: Memantine, an N-methyl-D-aspartate receptor antagonist, is primarily approved for the treatment of Alzheimer’s disease and other forms of dementia. However, multiple studies have explored its potential applications in psychiatric disorders. This literature review aims to evaluate existing evidence on the efficacy of memantine in conditions such as trichotillomania, skin picking disorder, depression, bipolar disorder, obsessive-compulsive disorder, ADHD, autism spectrum disorder, substance use disorder, schizophrenia, and reducing cognitive effects of electroconvulsive therapy. The review hypothesizes that, based on available literature, memantine may have therapeutic potential across these psychiatric disorders, particularly as an adjunct treatment.

Methods: A literature search was conducted using PubMed from 2020 to 2025 (5 years), employing the search strategy ((Memantine) AND (Psychiatry)) NOT (Dementia). This literature review was conducted by screening 27 searched titles. The inclusion criteria encompassed systematic reviews, meta-analysis and randomised controlled trials. Exclusion criteria included animal and cell studies, case studies, reviews, editorials, case reports, and letters to editors. A total of 23 papers were included in this review and 4 were excluded as they focused on conditions outside the scope of this review.

Results: Emerging evidence from the 23 selected studies (9 RCTs, 8 systematic reviews, 2 meta-analyses, and 4 combined systematic reviews with meta-analyses) suggests that memantine may be beneficial across various psychiatric disorders, particularly as an adjunct. Most of the available literature points towards a positive response of using memantine in conditions like trichotillomania, skin picking disorder, depression, bipolar disorder, obsessive-compulsive disorder, ADHD, autism spectrum disorder, substance use disorder, schizophrenia, mitigating cognitive effects of electroconvulsive therapy, and other conditions. However, the number of studies per disorder that met the inclusion criteria was limited. This highlights the lack of extensive research for individual disorders and the need for further clinical validation.

Conclusion: Memantine’s NMDA receptor antagonism offers a promising yet underexplored therapeutic approach in psychiatry. While preliminary findings suggest potential benefits across multiple psychiatric disorders, the number of high-quality studies per condition remains very limited, with most disorders represented by only three or four studies meeting the inclusion criteria. This underscores the need for more randomized controlled trials with larger sample sizes to validate its efficacy, refine dosing strategies, and assess long-term safety. Expanding research in this area is crucial to clarify memantine’s role in psychiatric practice and prevent its underutilization.

Aims: The menopausal transition, marked by a sharp decline in oestrogen, is increasingly recognised as a critical period for new onset of psychosis or worsening symptoms in women with pre-existing schizophrenia, yet treatment strategies remain largely overlooked. Oestrogen’s profound neuroprotective effects – modulating dopaminergic, serotonergic, and glutamatergic pathways, and mediating neural apoptosis – suggest that hormone-based therapies could revolutionize the management of menopause-associated psychosis (MAP) and exacerbation of pre-existing schizophrenia in peri- and post-menopausal women. However, concerns over the long-term risks of hormone replacement therapy (HRT), including breast and uterine cancer and cardiovascular disease, have hindered its widespread adoption. In contrast, the emergence of selective oestrogen receptor modulators (SERMs) have offered a novel, safer alternative with a potentially broader therapeutic window. This review synthesises the current evidence, explores the differential efficacy of hormone therapies including HRT and SERMs, compares response between the above populations of peri- and post-menopausal women with psychosis, and identifies gaps in the literature that warrant further investigation. To our knowledge, this is the first literature review specifically comparing efficacy of HRT vs SERMs in the peri- and post-menopausal population of women with psychosis.

Methods: To address the questions posed about (1) efficacy of SERMs vs HRT in (2) menopause-associated psychosis vs menopausal women with pre-existing schizophrenia, the authors searched PubMed databases from years 1990 to 2025, with various combinations of the following terms: schizophrenia, late-onset schizophrenia, psychosis, late-onset psychosis, menopause, perimenopause, postmenopause, menopause-associated psychosis, oestrogen, estradiol, raloxifene, HRT, and SERMs. Over 743 relevant abstracts were found, and narrowed down to 72 reviews and experimental studies to be included in this review. Studies were selected based on their applicability to answer the authors’ questions.

Results: This comprehensive review reveals that both HRT and SERMs significantly alleviate not only psychotic but also cognitive and negative symptoms, with SERMs demonstrating superior long-term safety and sustained efficacy, as well as a longer therapeutic window of action. Crucially, differences in treatment response between menopause-associated psychosis and pre-existing schizophrenia suggest that hormonal interventions must be tailored to their underlying pathophysiological mechanisms.

Conclusion: These findings challenge the current paradigm of psychosis treatment in menopausal women and underscore the urgent need for large-scale, longitudinal studies to refine dosing strategies, assess long-term psychiatric and cognitive outcomes, and explore potential synergies between hormonal and antipsychotic therapies. Expanding research in this area could redefine psychiatric care for midlife women, offering more personalised and effective treatment pathways.

Aims: Recent research has focused on the inflammatory cascade as a key culprit in the aetiology of Bipolar disorder. We hypothesized that celecoxib, via its anti-inflammatory properties, may have a therapeutic role in mood disorder. The present study was a 4 weeks, open label case-control trial of celecoxib in patients of Bipolar mania as an adjunctive therapy to mood stabilizer and antipsychotic and to see its effect on IL-6 levels to objectively validate the improvement caused by celecoxib using this inflammatory marker.

Methods: This was a hospital-based, prospective, case-control study using purposive sampling. The study consisted of 50 participants of over 18 years of age, of which 25 received celecoxib (200 mg/day) adjunctive therapy to sodium valproate and a second generation antipsychotic while the other 25 received treatment as usual for 4 weeks. 25 healthy controls were also taken to measure and compare baseline serum Interleukin 6 levels. The Young Mania Rating Scale (YMRS), Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression – Severity scale (CGI-S) were used to assess severity of symptoms at baseline and at 4 weeks. The serum Interleukin 6 level was measured at baseline and at 4 weeks using an ELISA kit.

Results: The patients in each of the groups were comparable with respect to the socio-demographic, clinical characteristics and laboratory parameters at baseline. Interleukin 6 levels in the patient groups were significantly elevated when compared with healthy controls. Repeated measures ANOVA showed significant effect on treatment × time interaction on YMRS [F (1, 48) = 104.69, p<0.001] BPRS [F (1, 48) = 9.298, p = 0.004] and CGI-S [F(1, 48) = 65.774, p<0.0001] scores. YMRS, BPRS and CGI-S scores significantly decreased at 4 weeks in Bipolar patients receiving celecoxib in comparison to Bipolar patients receiving treatment as usual. There was a significant decrease in the serum Interleukin 6 (p<0.001) while on treatment with celecoxib adjunctive when compared with treatment as usual. The baseline Interleukin 6 levels correlated significantly with the improvement in symptoms (p<0.009) and the baseline score on YMRS scale was a predictor of the improvement.

Conclusion: This study found that celecoxib used as an adjunctive therapy with sodium valproate and antipsychotic in the treatment of Bipolar mania shows improvement in the manic and psychotic symptoms. It also significantly lowers Interleukin 6 levels of participants which were raised when compared with the healthy controls.