Royal College of Psychiatrists

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The Northern Ireland Mental Capacity Act (MCA) fuses mental health and capacity legislation into a single legislative framework for involuntary treatment for all those aged 16 years and over. Impairment of decision-making capacity is a mandatory prerequisite for any interference in a person's autonomy without their consent. Such 'fusion' legislation, as described by Dawson and Szmukler (2008), has the potential to reduce discrimination in the law against psychiatric patients and would apply consistent ethical principles across medical law. This approach was recommended by the Bamford Review in 2007 and the MCA was passed by the Stormont Assembly in 2016. The legislation has not as yet been fully introduced and a phased implementation is being undertaken. This article describes progress so far and discusses measures that are required if the anticipated benefits of fusion legislation are to be realised.

This paper provides an overview of key concepts in evolutionary psychiatry, summarising major evolutionary explanations for mental illness and highlighting the potential of these perspectives to enhance assessment, diagnosis, explanation to the patient, treatment and prevention strategies. Expanding beyond conventional evolutionary approaches, we explore environmental influences on mental health and illness, emphasising the significant areas of convergence between evolutionary and environmental viewpoints. We then propose an integrated framework that combines insights from both perspectives, offering general principles for improving mental health outcomes at both individual and population levels. The discussion includes implications for general practice, public health and broader societal considerations, with particular reference to concepts such as biophilia and the emerging role of 'green care' in psychiatric practice.

SUMMARY Mirroring the general population, the number of medical students, doctors and, indeed, psychiatrists disclosing being neurodivergent is rising. These individuals commonly have a variety of strengths that can enhance their work, but these strengths may go unrecognised. All too often such individuals have been labelled ‘doctors in difficulty’. We begin this article with a review of contemporary thinking regarding neurodiversity, before considering specific issues facing neurodivergent doctors, specifically psychiatrists. We explore neurodivergent strengths and the evidence regarding career outcomes and mental health. We discuss the stigma that many neurodivergent psychiatrists face in the medical sphere and how difficulties may be reframed as unmet needs. We highlight initiatives that aim to change workplace culture, before discussing the concept of reasonable adjustments, alongside a wide range of practical suggestions of adjustments to consider, using the Autistic SPACE framework and the Royal College of Psychiatrists’ reasonable adjustments guidance. Finally, we consider how those in senior leadership roles can contribute to this field and provide role modelling and signposting to further information and support for neurodivergent doctors and their supervisors and line managers.

Healthcare workers face specific vulnerabilities for drug overdose due to their unique access to medications, clinical knowledge and work-related stress. This study aimed to understand the characteristics of fatal overdoses in healthcare workers with a view to providing guidance for preventative strategies. We retrospectively identified cases in England, Wales and Northern Ireland reported to the National Programme on Substance Use Mortality between 2000 and 2022 where decedents were working or studying within a healthcare setting at the time of their death or had previously worked in healthcare. Quantitative analyses were conducted to report summary demographics of decedents, the circumstances of deaths and the drugs involved. A qualitative thematic framework analysis was performed to identify and explore factors that may contribute to fatal drug overdose in healthcare professionals. In the identified cases, doctors were the most represented profession (48% of cases, n = 28/58) with opioids the drug class most often implicated in causing death (43% of cases, n = 25/58). Whilst there was scant evidence of recreational drug use in the identified cases (n = 3), hospital-only medications prominently featured [propofol in 29% (n = 17/58); midazolam in 10% (n = 6/58); neuromuscular blocking agents in 9% (n = 5/58)]. Qualitative analysis identified seven themes including accessing drugs from the workplace, use of skills and/or equipment for intravenous drug administration, obtainment of private prescriptions, diagnosed mental health conditions, recent events likely to have negatively impacted mental health, chronic pain and self-medicating and history of substance use disorder and/or overdose. The characteristics of fatal drug overdoses among healthcare workers in England, Wales and Northern Ireland appear to differ from those observed in the overall population of people who use drugs in the UK. To prevent such deaths, it is important that healthcare workers can access bespoke care and support tailored to the specific challenges that they face.

Psychotic disorders are severe mental health conditions frequently associated with long-term disability, reduced quality of life and premature mortality. Early Intervention in Psychosis (EIP) services aim to provide timely, comprehensive packages of care for people with psychotic disorders. However, it is not clear which components of EIP services contribute most to the improved outcomes they achieve. We aimed to identify associations between specific components of EIP care and clinically significant outcomes for individuals treated for early psychosis in England. This national retrospective cohort study of 14 874 EIP individuals examined associations between 12 components of EIP care and outcomes over a 3-year follow-up period, by linking data from the National Clinical Audit of Psychosis (NCAP) to routine health outcome data held by NHS England. The primary outcome was time to relapse, defined as psychiatric inpatient admission or referral to a crisis resolution (home treatment) team. Secondary outcomes included duration of admissions, detention under the Mental Health Act, emergency department and general hospital attendances and mortality. We conducted multilevel regression analyses incorporating demographic and service-level covariates. Smaller care coordinator case-loads and the use of clozapine for eligible people were associated with reduced relapse risk. Physical health interventions were associated with reductions in mortality risk. Other components, such as cognitive-behavioural therapy for psychosis (CBTp), showed associations with improvements in secondary outcomes. Smaller case-loads should be prioritised and protected in EIP service design and delivery. Initiatives to improve the uptake of clozapine should be integrated into EIP care. Other components, such as CBTp and physical health interventions, may have specific benefits for those eligible. These findings highlight impactful components of care and should guide resource allocation to optimise EIP service delivery.

Introduction: Autism spectrum disorder (ASD) is a neurodevelopmental condition that shares clinical features with chronic fatigue syndrome (CFS), a condition affecting the neurological and immune systems. Emerging evidence suggests a potential link between the two conditions, including shared genetics and neuropathology. However, there is a paucity of data and lack of conclusive evidence to draw any definite associations.Purpose: This review aims to gather available evidence to determine whether an association exists between autism and CFS and to report on published findings.Methodology: The search was conducted on databases PUBMED, MEDLINE and Google Scholar. Eligibility criteria included studies examining the association between autism spectrum disorder (ASD) and chronic fatigue syndrome (CFS). Exclusion criteria included 1) studies that reported on autism and chronic fatigue syndrome separately 2) studies that evaluated the association of autism with conditions other than CFS and 3) and studies that looked at the association of CFS with conditions other than autism. Non-English language studies were excluded.Results: A total of eight articles were reviewed for the study and the reported findings indicates the complex relationship between autism and co-morbid physical health conditions.Conclusion: This study highlights the need for enhanced awareness among mental health practitioners regarding the complex interplay between autism and co-occurring physical health conditions like CFS presenting in children and young people and appropriate management of physical health symptoms as part of the overall care plan.

Aims: Smoking contributes to poor mental health and increases inequalities in physical health and premature mortality. Smoking is a leading contributor to the 7–23-year lower life expectancy among people with severe mental illness (SMI) compared with the general population.In Wales, an estimated 14.1% of people are smokers. Smoking is much more common (33% prevalence) among people with mental health conditions and is even higher among those with SMI (40.5% prevalence).Welsh Government commissioned NHS Wales’ Joint Commissioning Committee and RCPsych Wales to develop a framework to help reduce smoking rates among people with mental health conditions in Wales.The framework sought to address three priority areas for action:Address misperceptions about smoking in mental health settings.Improve implementation of quitting strategies in mental health settings.Address the lack of data on smoking and quitting among people with SMI.Methods: In partnership with the Public Mental Health Implementation Centre; a review of data, current interventions, policy and strategy across Wales was undertaken.This was complemented by consideration of:Overview of current evidence-based strategies in Wales.Scaling evidence-based interventions for smokers with mental health conditions and SMI.Addressing misperceptions among smokers and health professionals.Upskilling mental health professionals to enable them to motivate and support quit attempts.Results: In addressing the three priority areas for action, the framework focused upon:Understanding local needs and assets.Working Together.Taking action for prevention of smoking, mental health promotion, and reducing inequalities.Evaluation and measuring outcomes.Additionally, a deficit in the following areas, led to several recommendations:Provide training resources for upskilling people working in mental health to support smoking cessation.Review and augment the implementation strategy for Help Me Quit and the Tobacco Control Delivery Plan to support people with mental health conditions.Improve accessibility to nicotine replacement therapy (NRT) and other smoking cessation medication. People wanting to quit should have access to more than one quitting aid.Address data gaps by collecting reporting information on rates of smoking, including among people with mental health conditions.Conclusion: Several next steps are necessary to reduce smoking among people with mental health conditions in Wales:Develop an implementation strategy for the Tobacco Control Delivery Plan to target people with mental health conditions including SMI.National campaigns promoting positive mental health should include messages about the mental health harms of smoking.Major gaps in data on smoking and quitting must be addressed.

BackgroundWomen from minoritised ethnic communities experience inequalities in access, experience and outcomes of psychological therapy. Understanding the factors associated with these inequalities could inform improvements to mental health services.AimsTo explore therapists’ experiences of providing treatment to women from minoritised ethnic communities, including insights on adaptations made at the delivery, content and wider organisation levels, and to gather suggestions about potential treatment improvements.MethodSemi-structured interviews were conducted with 13 therapists working in two National Health Service Talking Therapies for anxiety and depression services and who had experience of treating women from minoritised ethnic communities. Data were analysed using thematic analysis.ResultsThree high-order themes were identified: incorporating ethnicity and culture in the delivery of psychological therapies, challenges associated with delivering therapeutic interventions to women from minoritised ethnic groups and improvements to services that could support better access, engagement and outcomes for women from minoritised ethnic groups.ConclusionsFindings indicate that therapists viewed cultural adaptation and cultural sensitivity as important to the delivery of appropriate care for minoritised ethnic women. Challenges to appropriate care included limited service resources, communication and language barriers, stigma and existing access and engagement inequalities. Therapists suggested that, to deliver high-quality care and optimise outcomes, improvements are required in cultural sensitivity training, flexibility of service delivery, outreach work with communities to encourage uptake and reduce stigma, support for staff and workforce diversity.