Black Country Partnership NHS Foundation Trust

ABSTRACT Orexin A and orexin B are neuropeptides that play an important role in regulating physiological functions such as stress response, reward, energy, and arousal. Orexin receptor antagonists (ORAs), such as nivasorexant, are a new class of medications targeting the orexin system. Nivasorexant is a selective orexin-1 receptor antagonist (OX1R) that was developed to avoid dual receptor antagonists. We aimed to conduct this systematic review to evaluate the safety and efficacy of nivasorexant and to explore the potential clinical uses in psychiatry. Relevant databases were searched to identify studies focused on nivasorexant’s pharmacokinetics, pharmacodynamics, safety, efficacy, and clinical uses in humans. Out of 34 articles identified, five articles were included. Preclinical evidence suggested a promising role for nivasorexant in modulating compulsive behaviors due to its high selectivity for OX1R and lack of significant sedation. Clinical investigations have provided insights into its pharmacokinetic profile and generally favorable safety. While initial efficacy findings for a specific psychiatric indication were not definitively met, exploratory analyses suggest that patient characteristics might influence treatment outcomes. Furthermore, nivasorexant’s metabolic profile indicates potential for drug interactions, requiring careful consideration in clinical practice. Nivasorexant’s potential for addressing disorders is characterized by dysregulated reward processing, where maintaining alertness is desirable, based on its selective mechanism and tolerability. However, this review is limited by the current volume of clinical data, the scope of studies conducted, and the generalizability of findings across diverse patient populations. Further rigorous clinical validation is needed to fully ascertain its therapeutic potential and optimal application in psychiatry.

In a tragic plane crash involving an Air India flight from Ahmedabad to London, over 265 people lost their lives till the available report by the evening of June 13, 2025.[1] Although it is claimed that travelling by air is comparatively safer than other modes, several major plane crashes have been documented in India over the past five decades.[2] These catastrophic events not only affect the individuals, who are directly affected by these, but also a huge number of people get indirectly affected because of air travel and related work [Figure 1]. The closer one is to the center, the greater the likelihood of psychological issues. In other words, this model explains the different levels of vulnerability of people affected by or witnessing a plane crash regarding psychological manifestations.Figure 1: Extended psychological impacts of a plane crashPersonal and financial losses, bereavements, complicated bereavements, along with the potential for stress-related psychiatric disorders, are all possibilities. There are few studies that suggest post-traumatic stress disorder (PTSD),[3,4] depression,[5,6] anxiety and substance use, and so on. Studies suggest many cabin crew and other members of aviation industry develop chronic psychiatric problems following experience of plane accidents.[7,8] While it is obvious there would be stress-related disorders, however there is hardly any research on the mental health consequences of the people and their family members affected by aviation disasters, the severity, long-term persistence, support they received, if any, and what would be useful. This letter aimed to warrant the academic attention of various stakeholders of mental health. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Aims: Non-attendance (DNA) at appointments wastes NHS resources and can indicate potential risk, making it essential for Trusts to have robust policies to safeguard young people and reduce recurrence. As part of the National Health Service (NHS) process, organisations are required to have a ‘Was Not Brought’ (WNB) policy to address situations where children are not seen. This audit aimed to assess Clinician’s adherence with the Trust’s DNA/WNB policy and reduce WNB rates.Methods: The audit was conducted in two cycles, analysing retrospective data from 50 patient case notes (on RIO) using a pre-determined data tool based on the Trust’s policy at each cycle.Cycle 1 (August to October 2023) focused on DNA/WNB appointments and included an analysis of 8 patient survey responses, based on the policy 'Protocol for Managing DNA and Cancellations’ in Dudley and Walsall CAMHS.Following our recommendations, a new policy was drafted, adopted and shared across the Trust.Cycle 2 (September to November 2024) audited DNA/WNB appointments and incorporated a staff survey (20 responses) based on the new policy 'CAMHS WNB Standard Operating Procedure'.Results: Audit revealed moderate compliance (over 50%) in documenting DNA/WNB appointments, contacting families, and rescheduling appointments across both cycles.However, compliance was poor (≤40%) in key areas, such as documenting risk assessments, reviewing case notes, attempting to engage with the child, completing lateral checks, sharing rescheduled appointments with GPs/referrers/other agencies, and obtaining SMS consent for appointment reminders.WNB rates were 8.3% in Cycle 1 and 9% in Cycle 2. The patient survey revealed that common reasons for WNB included forgetfulness, lack of awareness of the appointment, and illness. Respondents suggested SMS reminders 48 hours before appointments.The staff survey showed that 45% were unaware of the updated WNB policy, and 30% did not know about the new messaging reminder system and so were not using it.Conclusion: Overall, the Trust policy is generally followed for documenting DNA/WNB appointments and rescheduling; compliance remains poor in areas like risk assessments, engaging with the child, and sharing rescheduled appointments with other agencies.There is a need for improved documentation and adherence to the WNB policy. The Trust should implement a reminder system to update clinicians on policy changes and prioritize messaging to families to improve appointment attendance.

Aims: In obsessive-compulsive disorder (OCD), treatment non-response is common with recommended medications; hence there is a need to investigate the role of alternative agents. It was intended to evaluate the evidence base involving ondansetron as a treatment strategy for OCD in adults, considering its role as a 5-HT3 receptor antagonist primarily in the limbic system.Methods: Various electronic databases (PubMed, CINAHL, EMBASE, PsycInfo, Cochrane, Clinical Trials Registers, and PROSPERO) were searched for articles with keywords of ‘ondansetron’, ‘obsessive-compulsive disorder’ or ‘OCD’, and ‘clinical trial’, in the English language, published up to October 2024.Results: Nine studies were included in this systematic review. Studies used Yale–Brown Obsessive Compulsive Scale (YBOCS) scale for assessment and ondansetron mostly as an augmenting drug. More than half of the studies (five out of nine) had patients with treatment-resistant OCD, and serotonin reuptake inhibitors as the active drug. All trials reported improvement in OCD with ondansetron augmentation, except the study which involved chart review for treatment-resistant OCD. The improvement was observed as early as two weeks following ondansetron augmentation. The reported range of decrease in YBOCS score from baseline in various studies has been 23.2–55%. Treatment response was reported between 37–86.4%. Improvement was noticed in both OCD and treatment-resistant OCD groups. Discontinuation of ondansetron led to worsening of symptoms which was reported in two studies. Overall adverse effects of ondansetron were mild to moderate in degree, with no major clinical concerns, and were generally well tolerated. Commonly reported side effects were constipation, headache, diarrhoea, decreased appetite, dizziness, insomnia, anxiety, nervousness, sweating, dry mouth, muscle cramp and sexual dysfunction. Available studies have major limitations which are mostly small sample sizes and short duration of trials.Conclusion: Current evidence suggests ondansetron may be beneficial in the treatment of OCD and treatment-resistant OCD, mostly as an augmentation agent; however the evidence is scarce to draw any firm conclusion. Further trials with adequate sample size and duration are required.

Aims: The primary aim of the re-audit was to identify specific areas where key components of the NCISH guidelines were not consistently applied in the care of patients who died by suicide. By addressing these gaps, the Trust seeks to ensure that NCISH-recommended standards are embedded into practice across all patient care pathways. Our objectives were to assess the level of compliance with NCISH standards across all localities where patients died by suicide, evaluate whether the care provided aligns with National Standards and extract key lessons from the cases audited to drive improvements in care delivery and patient safety.Methods: This was a PAN Trust re-audit. A retrospective collection of data was done, and a sample was provided by the trust’s Serious Incident & Inquest Manager. The criteria were any patient known to the trust who completed suicide between April 2022 and March 2023, in line with NCISH guidelines. This collection saw 33 cases, however only 32 cases were audited, as one was withdrawn. This was an increase from the previous 2 years. The cases were split between team members for data collection, and for each case the RiO patient notes and incident reports were used to fill out the audit tool on Microsoft Excel. Data was analysed by the quality improvement team.Results: The audit revealed that no patients died as psychiatric inpatients, but six suicides occurred within three months of discharge. Most were males in their 60s, single, unemployed, and living alone, with depressive illness as the primary diagnosis. Common methods included hanging and self-poisoning, with most suicides occurring at home. Many patients received treatment, though risk assessments and follow-up practices were inconsistent, with structured tools used in only three cases. Lessons learnt emphasize the need for timely, structured post-discharge care, better crisis intervention, enhanced staff training, improved communication between services, and increased access to dual-diagnosis and mental health resources.Conclusion: Post-Review Changes:Risk assessments now use formal tools, with improved documentation and training on difficult conversations. Collaboration between GPs and mental health services has improved.Recommendations:Strengthen post-discharge follow-ups within three months. Provide suicide prevention training for GPs and staff. Increase home monitoring for high-risk patients, especially in Dudley. Launch male-focused mental health campaigns addressing stigma. Enhance inter-service collaboration between GPs, community mental health services, and crisis teams for seamless care coordination. Address systemic resource gaps like staffing and waiting lists.

Aims: Electroconvulsive therapy (ECT) is an effective treatment modality used to manage a variety of different psychiatric conditions including treatment-resistant schizophrenia, depression and catatonia. Different teaching methods have been employed by educational institutions to teach healthcare students about ECT, however synthesis of this evidence is lacking. Several sources cite that there is negative stigma and attitudes towards ECT amongst Healthcare Professionals (HCPs). Teaching within undergraduate curricula may improve knowledge surrounding ECT, further reducing negative associations.Methods: Using pre-determined search terms, a large language model was used to screen relevant databases (including ERIC and CINAHL), identifying 5,550 studies, 453 of which were duplications, leading to a total of 5,097 relevant studies. Pre-agreed strict inclusion and exclusion criteria were applied, and 19 studies were identified suitable for inclusion. Another 14 studies were reviewed again due to conflicting views, of which 7 were deemed suitable, totalling 26 relevant studies for inclusion. These texts were analysed in their entirety. Both qualitative and quantitative data was gathered, and this was heterogenous in nature. Qualitative data was thematically analysed.Results: Diverse teaching techniques and interventions were identified, and these were successful to varying degrees. These interventions included: the development and creation of new educational modules centred around ECT; real time ECT demonstrations; teaching sessions paired with specialised technology enhanced learning interventions hosted remotely by consultant psychiatrists. A plethora of different interventions centred around improving knowledge of ECT amongst healthcare students varied in creativity, and even included a Hollywood depiction of ECT.Educational interventions focusing on the improvement of students’ experience whilst on psychiatric placements correlated with a global positive improvement in knowledge levels regarding ECT. Video-based educational interventions were well received by students, and an improvement in attitude and knowledge regarding ECT was noted. Passive interventions, including didactic based teaching interventions described a notable positive shift in attitudes amongst students regarding ECT. However, some studies reported that the longevity of this improvement in knowledge and attitudes may be short-lived, affecting its translation to future medical practice.Conclusion: This systematic review highlights the need to improve education of ECT amongst healthcare students, to ensure that future clinicians are well equipped with relevant knowledge concerning this important treatment modality. Ultimately interventions that strive to improve knowledge of ECT and induce positive experiences with students, helps to reshape attitudes towards this treatment modality and future clinical practice.

Aims: This audit aims to assess whether the anticholinergic burden is being appropriately considered in the management of patients referred with cognitive difficulties to East Hub Older Adult community mental health team.Methods: A retrospective audit was conducted on the medical records of 49 patients referred from the Memory Assessment Clinic to the East Hub Older Adult CMHT over a one-year period. Data was collected using an audit tool that included patients with diagnosed dementia or cognitive decline, excluding those with substance abuse disorders. The primary focus was on whether anticholinergic burden (ACB) scores were assessed and whether medication regimens were optimized in line with NICE guidelines. The ACB score was calculated using acbcalc.comResults: The audit revealed that 24% of patients with an ACB score greater than 3 had no documented evidence of an assessment of their anticholinergic burden or any medication optimization. This suggests that the East Hub Older Adult CMHT is not consistently adhering to NICE guidelines in the management of anticholinergic medications in older adults at increased risk of cognitive decline.Conclusion: This audit highlights the need for more rigorous evaluation of anticholinergic drug use in our clinical practice to reduce the risk of cognitive decline in older adults. It underscores the importance of anticholinergic medications as a modifiable risk factor for dementia, emphasizing the need for healthcare providers to prioritize reducing anticholinergic burden in this population. The findings suggest that alternative medications should be considered for patients with high anticholinergic burden. These results were disseminated Trust-wide, with a plan to conduct re-audit to evaluate whether changes have been implemented in our clinical practice.An advanced tool to calculate the ACB score using medichec.com was agreed by the clinical lead of Dementia and Frailty for use in daily clinical practice by the various older adult clinical teams in BSMHFT.

Rail and road accidents are common in India and are extremely stressful life events. Many accident survivors develop stress-related mental health problems but do not get psychotherapeutic support. We intended to analyse the needs and types of techniques for the psychotherapeutic support of the survivors of the 2023 train accident in Odisha and to reflect on how the services can be facilitated. It was a qualitative, mixed-method, narrative study based on the interview of a sample of 11 survivors of the train accident. It was observed that the survivors and their families had many unresolved psychological issues related to the trauma of the train accident and its consequences. The survivors articulated their mental health concerns holistically in a comprehensive way. It appeared that their psychotherapeutic needs were unmet. Examples of psychological interventions needed were psychoeducation, relaxation, supportive and cognitive therapies, and specific trauma-focused cognitive behavioural therapy. Many challenges in providing psychotherapies were identified, such as limited awareness about the need for psychotherapeutic intervention, affected persons in geographically highly dispersed areas, unavailability of psychotherapeutic services or personnel in most places, and lack of resources. The train accident survivors have immense psychotherapeutic needs, but these are mostly unmet. Modifying the provision methods to tele-psychotherapy and training other healthcare personnel such as nurses, and counsellors might help the resource-scarce situation.

PurposeThis paper aims to focus on concerns unique to international medical graduates (IMGs) and doctors from global majority groups pursuing a career in psychiatry in the UK. It specifically addresses challenges affecting the differential attainment of IMGs in passing the Clinical Assessment of Skills and Competencies (CASC) examination – the final assessment for attaining Membership of the Royal College of Psychiatrists, affording entry to specialty training programmes.Design/methodology/approachReflections are provided on learning from a CASC examination preparatory course specifically developed for IMGs in psychiatry, particularly those from global majority groups. The rationale for the course is set out as well as some of the challenges in designing and developing the course.FindingsBy reflecting on the experience of developing the course, the intersection of medical education, differential attainment and cultural disparities in training is addressed, alongside the role of group practice in exam preparation and support tailored to the needs of IMGs from global majority groups.Originality/valueThe reflections provided illuminate possible means of innovation to support the progression of IMGs and doctors from global majority backgrounds in the CASC, as a high stakes examination in medical training, and to support action to improve overall outcomes for this community in the field of psychiatry.