Maudsley Hospital

SummaryFrom the impact of armed conflict and political violence to the neuropsychiatric consequences of neglected tropical diseases, Latin America has a unique profile of region-specific risk factors that mean it is not always well-served by neuropsychiatric practice developed in high-income regions. Here, we review the region-specific neuropsychiatric characteristics of traumatic brain injury, stroke, epilepsy, dementia, functional neurological disorder, infectious diseases, environmental health risks, and substance use. Additionally, we identify structural challenges for neuropsychiatric health and suggest pathways to develop a specifically Latin American neuropsychiatry as a cross-disciplinary, multi-professional field based on practical steps to strengthen research capacity, training, clinical practice, and care delivery. Latin America should be a priority for neuropsychiatry, and we argue for a Latin American neuropsychiatry that has much to offer the region and much to contribute worldwide.

Overcontrol is a transdiagnostic phenotype which has been associated with restrictive eating disorders and depression. It is characterised by traits such as cognitive and behavioural inflexibility, risk aversion, suppression of emotional expression, reduced reward sensitivity and higher temperamental anxiety. Two aspects of the overcontrol phenotype (inflexibility and the suppression of emotional expression) have been particularly linked with poorer mental health. Additionally, social connectedness has been shown to protect against mental health symptom severity. The current study aimed to test whether the relationship between these factors and mental health symptom severity, namely, eating disorder and depression, is mediated by social connectedness. Routine data were collected for adolescents with restrictive eating disorders presenting to either outpatient or intensive day programme treatment in a specialist eating disorder service. Four cross-sectional mediation analyses were planned. The first two models aimed to test the mediating role of social connectedness on the relationship between inflexibility (model 1) and the suppression of emotional expression (model 2) on eating disorder symptom severity. The second two models aimed to test the mediating role of social connectedness on the relationship between inflexibility (model 3) and the suppression of emotional expression (model 4) on depression symptom severity. Baseline weight and comorbid mental health symptom severity were controlled for in each model. The sample consisted of 109 adolescents (mean age = 15.21 years, 96.3% female). Current findings indicate that social connectedness did not statistically mediate the relationships between inflexibility and eating disorder symptom severity (model 1; Path ab β = .02, 95% bootstrap CI0.0002-0.05). The planned analysis examining the relationship between the suppression of emotional expression and eating disorder symptoms (model 2) was not tested as the variables did not significantly correlate. Findings also indicated that social connectedness statistically mediated the relationships between both inflexibility (model 3; Path ab β = .82, 95% bootstrap CI 0.33-1.40) and the suppression of emotional expression (model 4; Path ab β = .38, 95% bootstrap CI 0.13-0 .69) on depressive symptoms. Findings suggest targeting social connectedness, as is the case in Radically Open Dialectical Behaviour Therapy (RO DBT), may be a useful way to improve treatment outcomes for young people with restrictive eating disorders and co-morbid depressive symptoms. This fits with qualitative data that shows that taking a holistic approach during treatment, as opposed to being overly symptom focused, is needed and valued by young people and their family members.

<h3>Background</h3> Wilson’s disease (WD) can present with purely hepatic, neurological or psychiatric symptoms and also as multiple combinations of these three. There are very limited data on the psychiatric pattern of symptoms of WD and the consideration of WD in the psychiatric assessment. South London and Maudsley NHS Foundation Trust (SLaM) is an international leader in mental health and is the largest provider of secondary mental health services in the UK receiving receive referrals from a wide and diverse catchment area. Our work investigates considerations of WD at SLaM and the pattern/overlap of symptoms at presentation of WD. <h3>Methodology</h3> We utilised the Clinical Records Interactive Search system at SLaM and hospital episodes statistics data to collect new referrals from 2017 to 2019. This also allowed us to gather patient demographics, blood tests and the nature of the psychiatric presentation. Statistical analyses were conducted using Excel, R, and STATA. <h3>Results</h3> We identified 56,606 new referrals to SLaM over the 2 year period. 9.5% had liver function (LFT) and 0.1% had ceruloplasmin (Cp) requested, with only 27 of the abnormal LFT also having Cp requested. 81 patients were identified as diagnosed with WD on electronic records. Figure 1 shows their top 5 combination of symptoms. 16,575 patients in our cohort had these ‘higher risk’ symptoms. Of these, 19% had blood tests requested, 5.4% had abnormal LFT and only 0.27% had LFT and Cp requested. 36 patients were referred after WD was diagnosed (mean time 5.56 years), and 21 were referred before diagnosis (mean time 6.64 years). Using generalised linear modelling, no association was found between age, gender, deprivation score, or ethnicity and the length of time to diagnosis. <h3>Conclusion</h3> The phenomenology of the presentation is of interest with many of the symptoms being likely linked to the subcortical nature of the disease pathology. We conclude that the psychiatric presentation in WD differs from the type of presentation seen in depressive or psychotic conditions and key differences in symptoms identified may be of use to aid diagnosis of WD. Our data indicate that WD remains under-screened among psychiatric patients, with only a small percentage (0.1%) being evaluated for the condition. It also highlights that 29% of new referrals were linked to a combination of ‘higher-risk psychiatric symptoms.’ We suggest that any patient with raised liver function +/- a combination of ‘higher risk’ symptoms should be screened with Cp as minimum standard of care.

BackgroundA significant proportion of young people do not respond to NICE recommended treatment for anorexia nervosa: Family Therapy (FT-AN). Evidence is building for the effectiveness of day programmes as an alternative to inpatient admissions for young people whom traditional community treatment has not benefited. One day programme that has been found to be effective is the Intensive Treatment Programme (ITP) of the Maudsley Centre for Child & Adolescent Eating Disorders in London, UK. However, limited data are available on how caregivers of young people attending experience such a day programme.MethodAnonymous feedback was completed via online survey by 64 caregivers over a 5-year period (2018–2023) on discharge from ITP.ResultsFive main themes emerged: (1) Clarity and consistency are key; (2) Skills and practical support; (3) Collaborative relationships; (4) Layers of change; (5) It wasn’t all great.ConclusionsExpanding our understanding of caregiver experiences is important given the FT-AN model holds expectations that “the family is needed as a resource” and that caregivers should “take a lead in managing their child’s eating”. It is hoped that increased understanding will lead to services continuing to improve the support they provide.Supplementary InformationThe online version contains supplementary material available at 10.1186/s40337-025-01312-z.

Cognitive remediation (CR) is an evidenced-based intervention, but is not consistently included in clinical guidelines, nor implemented widely in mental health services, and is still not fully accepted as a psychological therapy. This is despite demonstrating a boost to recovery, and reductions in health care costs. We describe potential issues as CR matures into a widely accepted and used psychological therapy by drawing on high-quality evidence from reviews and meta-analyses and specifically highlight how CR uses therapeutic formulation, similar to other psychological therapies, to address specific client needs. Most evidence is for those with a diagnosis of schizophrenia, but we also consider CR benefits for other mental health conditions. Data emerging from different health systems are, at last, providing information on how CR is used, disseminated and practice standards maintained. This may be the information needed to support further implementation, expansion, and consolidation of CR use globally.

Objective: Despite the UK national guidance for Managing Emergencies in Eating Disorders (MEED) being widely used, little is known about how the guidance has been embedded into clinical practice or implemented across services. Methods: Clinicians (n = 13) working in community child and adolescent eating disorder services and medical wards were interviewed about their experience of using the MEED guidance in their clinical practice. Open-ended questions were used. Reflexive thematic analysis was used to analyse interview data. Results: Reflexive thematic analysis of responses identified three main themes. These were the following: (1) a common language, (2) looking beneath the surface, and (3) refeeding syndrome—a rare event in youth. These themes evidenced the important role of the MEED guidance in child and adolescent eating disorders and highlighted both the benefits and limitations of the current guidance. Conclusions: This study demonstrated that MEED was most helpful as a tool to clearly communicate acuity of medical risks between services, aiding multi-agency working required to manage both physical and mental health risks of young people with AN. The absence of parameter risk stratification and the lack of consistency on refeeding guidance across adolescent and adult guidance were highlighted as areas that future research should focus on.

Abstract There has been limited consideration of the training and support needs of therapists from minoritised ethnic backgrounds. This study quantitatively evaluates a novel application of self-practice/self-reflection (SP/SR) to CBT therapists from minoritised ethnic backgrounds. The study aimed to explore the impact of the SP/SR programme on (1) therapists’ skills in working with ethnicity in their clinical practice; (2) their ethnic identity development; and (3) their perceived levels of personal and professional wellbeing, during the intervention and at follow-up. A multiple baseline single case experimental design was adopted. Measures were developed and adapted for this evaluation and weekly outcomes relating to therapist skill development, ethnic identity development, and personal and professional wellbeing were collected. The outcomes of six participants were analysed using visual and statistical analysis. The results indicated that the SP/SR programme significantly improved therapist skills in identifying and addressing similarities and differences in ethnicity within therapy during the intervention. Improvements were also seen across other skills, ethnic identity developmental and wellbeing outcomes between the baseline and SP/SR phases, with some participants showing significant improvements. Outcomes from the follow-up phase presented a more mixed picture. Therefore, the findings give some support for the SP/SR programme in developing therapist skills in working with ethnicity, as well as highlighting differential outcomes for participants related to their levels of experience and engagement. The findings may have possible implications for the personal and professional development of ethnically minoritised therapists, as well as future quantitative SP/SR research. Key learning aims (1) To provide an overview of self-practice/self-reflection (SP/SR) and its theoretical underpinnings. (2) To summarise the current issues around the development of cultural competence, particularly for therapists from minoritised ethnic backgrounds. (3) To introduce and describe a novel SP/SR programme for CBT therapists from minoritised ethnic backgrounds. (4) To highlight the importance of considering ethnicity within clinical practice, both in terms of the provision of culturally competent therapy as well as to support the personal and professional development of therapists from minoritised ethnic backgrounds.

This case report discusses the treatment of a 42-year-old male with over a decade of treatment-resistant obsessive-compulsive disorder (OCD) and comorbid major depressive disorder (MDD). The patient underwent various pharmacological and psychotherapeutic treatments, including multiple antidepressants and cognitive-behavioral therapy (CBT), yet experienced only partial symptom relief. At baseline, the patient’s depressive symptoms were severe, with a Hamilton Depression Rating Scale (HAM-D) score of 28, and his obsessive-compulsive symptoms were marked, with a Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score of 34. Due to the chronicity and severity of symptoms, his treatment plan was adjusted to include a high dose of duloxetine, a serotonin-norepinephrine reuptake inhibitor (SNRI), which was gradually titrated to 180 mg/day with close monitoring. Within weeks of this dose adjustment, the patient experienced significant improvements in both depressive and obsessive-compulsive symptoms. The patient sustained these improvements over six months, reporting enhanced functional capacity and quality of life with minimal side effects, with his HAM-D and Y-BOCS scores reduced to 8 and 12, respectively. This case highlights the potential benefits of high-dose duloxetine in complex, treatment-resistant cases and underscores the value of combining pharmacotherapy with CBT to achieve durable outcomes. The report adds to emerging evidence suggesting that supratherapeutic dosing of SNRIs may be a valuable option for patients unresponsive to standard treatments. Further research is encouraged to evaluate the broader applicability and safety of this approach.

Abstract Traditional liberal democratic theories of protest can readily account for protest violence against others or their property, and are quick to denounce and criminalize such actions. However, protests that involve self‐harm are harder to frame; they neither engage the harm principle, nor threaten a sovereign state of ostensible peace. Under liberal legalism, capacitous and consenting protesters should not have their rights of expression interfered with in such cases. However, in England and Wales, legal responses to self‐harming violence nevertheless emerge, not necessarily within a public order framework, but through a risk‐averse, medicalized lens. Co‐authored by a legal academic and a practising psychiatrist, this article argues that mental health practitioners, the police, and the courts engage in a ‘paternalistic pivot’ in self‐harming protest cases, which undermines human rights protections that are ordinarily afforded to protesters who are not causing a threat to others or their property.