To evaluate compliance within a Community Mental Health Team (CMHT) to the NICE guidelines for the management of depression.

Reducing the prevalence of depression continues to be a major public health challenge.

Given the complexity and recurrent nature of the condition, the NICE guideline CG90 is an invaluable resource to aid the effective management of depression. Here we present an audit of adherence to this guideline within a CMHT.

A retrospective electronic casenote review of all patients diagnosed with depression between January 2016 and October 2019 under the care of a Birmingham CMHT (n = 35), assessing key performance areas including: quality of assessment and coordinated care, risk assessment, choice of pharmacological and psychological treatment using the stepped care model and appropriate crisis resolution planning.

Key results include:

• The majority of patients were Caucasian (63%). Ages ranged from 27 to 69 (mean age 48 years old).

• Severity of disorder was typically moderate (46%) or severe (48%). Of those with a diagnosis of severe depression, 41% had associated psychotic symptoms.

• Psychiatric comorbidity was high (49%), of which generalised anxiety disorder was the most common (59%).

• Referrals were typically from primary care (77%). Approximately half (51%) had reported suicidal thoughts according to the referral.

• A quarter of patients (26%) were seen by CMHT within 8 weeks of referral; 20% of referrals however waited over 12 months before being assessed.

• Risk assessments were out of date for 71% of patients.

• 100% of patients had a crisis plan noted within their most recent clinic letter; however, none of these met the required standards.

Over half of patients (60%) had been referred to psychology services; of these, 38% had either completed or were in ongoing treatment at the time of review.

CMHTs manage the care of individuals with depression who have high levels of active symptoms and disability, psychiatric comorbidity, care requirements, and complex treatment plans. Pharmacological management was broadly in line with guidelines, and rates of referral to psychology were satisfactory. Risk assessment and crisis planning are clear areas in need of urgent attention in order to comply with guidelines and ensure patient safety.

A 53-year-old male was admitted with non-resolving Priapism for 36 hours and was reviewed for advice regarding his psychotropic medications. He previously took Viagra about 2 days ago, and had an erection which resolved spontaneously. He underwent penile aspiration in the hospital which provided relief. Following that, he developed signs of infection which was treated with IV antibiotics. He was then waiting for further surgical correction.

He has a background history of psychotic illness and been treated with Quetiapine, Mirtazapine, Sertraline and Zopiclone, which were kept on hold during his admission. He reported that he currently suffers from depression and signs of psychosis, which take the form of auditory hallucinations and paranoid delusions.

He has been taking Viagra occasionally for years, but has not experienced side-effects like this before. He is a social drinker and previously smoked cannabis.

From the above scenario, there appears to be two clinical questions:

1. 1. Are the current medications responsible for his priapism?

2. 2. What medication(s) would be a suitable alternative if his priapism was indeed caused by his current drug regimen?

The major causes of Priapism are: direct trauma; haematological diseases; neurological diseases; cerebrovascular diseases; Medications; TPN and Neoplasm. Apart from medication side-effects, these other causes were ruled out.

The Summary of Product Characteristics for mirtazapine, sertraline, quetiapine and zopiclone were studied for their relative risk of causing priapism, and this is summarised below:

• • Mirtazapine: unknown

• • Sertraline: rare

• • Quetiapine: rare

• • Zopiclone: not listed

However, a paper by Salonia et al found that all the above medications except Zopiclone can increase the risk of priapism. Internationally published case reports also list priapism-associated medications as: risperidone; quetiapine; sildenafil; mirtazapine; citalopram; chlorpromazine and olanzapine.

Anti-psychotics cause priapism by Alpha-1 blockade and anticholinergic actions. Most of the antipsychotics have anticholinergic action. The medication which demonstrates the least alpha-1 blockade is Amisulpride which acts by blocking dopaminergic receptors in the brain.

Thus, it is clear from the above discussion that Amisulpride has the least possibility to cause Priapism. The patient was advised to take low dose Amisulpride and afterwards, no other complications were noted.

Globally, human rights violations experienced by persons with psychosocial, intellectual or cognitive disabilities continue to be a concern. The World Health Organization's (WHO) QualityRights initiative presents practical remedies to address these abuses. This paper presents an overview of the implementation of the initiative in Ghana.

The main objective of the QualityRights initiative in Ghana was to train and change attitudes among a wide range of stakeholders to promote recovery and respect for human rights for people with psychosocial, intellectual and cognitive disabilities.

Reports of in-person and online training, minutes of meetings and correspondence among stakeholders of the QualityRights initiative in Ghana, including activities of international collaborators, were analysed to shed light on the implementation of the project in Ghana.

In-person and online e-training on mental health were conducted. At the time of writing, 40 443 people had registered for the training, 25 416 had started the training and 20 865 people had completed the training and obtained a certificate. The team conducted 27 in-person training sessions with 910 people. The successful implementation of the project is underpinned by a committed partnership among stakeholders, strong leadership from the coordinating agency, the acceptance of the initiative and the outcome. A few challenges, both in implementation and acceptance, are discussed.

The exposure of the WHO QualityRights initiative to a substantial number of key stakeholders involved in mental healthcare in Ghana is critical to reducing human rights abuses for people with psychosocial, intellectual and cognitive disabilities.

The main objective was to determine whether quality of sleep is associated with burnout among undergraduate medical students at the University of Nairobi.

The null hypothesis in our study population was; 'There is no significant association between poor sleep quality and burnout'.

In a pressure prevailing environment, medical students find themselves in a vicious cycle of cutting down on sleep in attempts to cope and adjust to increasing workloads. Students with poor sleep quality have been found to perform worse in their board exam and have strained social engagements. Ultimately, this chronic sleep deprivation may lead to burnout which may cause diminished sense of accomplishment and impaired professional conduct, that may be carried on to the career as a physician. High levels of burnout have been associated with suicides.

The sample size obtained was 384 and participants were selected by a mixed sampling method. Data collection was through self-administered questionnaires. Scales used for this study were the Pittsburg Sleep Quality Index(PSQI) and the Oldenburg Burnout Inventory(OLBI).

Ethical considerations were adhered to and approval obtained from the Kenyatta National Hospital-University of Nairobi(KNH-UON) Ethics Board. Data entry and analysis was by SPSS v23. Data from 336 questionnaires were deemed fit for analysis.

With a response rate of 87.5%, the prevalence of poor sleep quality and burnout were 69.9% and 74.7% respectively. There was a significant positive association between poor sleep quality and female gender, clinical years of study, living with family, poorly perceived socio-economic state and poor subjective academic performance. In addition, being female, younger, pre-clinical years, living independently off-campus and poor subjective academic performance were significantly associated with higher levels of burnout.

Burnout had a significant correlation with poor sleep quality. Daytime functioning, a component of sleep quality had the highest correlation with components of burnout, disengagement and exhaustion. Overall, 57% of the respondents had both poor sleep quality &burnout, while only 12% were good sleepers with no burnout. Furthermore, having poor sleep increased the risk of having burnout by 2.8times. It is crucial that students adopt better sleeping habits to reduce the risk of burnout.

With the high prevalence of poor sleep quality and burnout, peer-support groups and peer-led mentorship programs are recommended within this population to help deal with expectations, challenges and difficulties encountered within the course of medical education, in addition to preparing for the early future careers.

Physiological brain function depends on tight glucose regulation, including transport and phosphorylation, the first step in its metabolism. Impaired glucose regulation is increasingly implicated in the pathophysiology of Alzheimer's disease (AD). Glucose hypometabolism in AD may be at least partly due to impaired glucose transport at the blood-brain barrier (BBB). Glucose transporters (GLUTs) are an integral component of the BBB. There is evidence of a significant reduction in vascular and non-vascular forms of GLUT1 and GLUT3 in AD brains compared to age-matched controls. Glucose transport, as well as phosphorylation, appears to be a rate limiting step for glucose metabolism in the brain. We have reviewed the literature on glucose transport abnormalities in AD and the effect such abnormalities have on the brain.

Published literature between 1st January 1946 and 1st November 2019 was identified using EMBASE and MEDLINE databases and titles and abstracts were scanned. Human studies (autopsy and imaging) and data from animal models were included while reviews, letters and cellular or molecular studies were excluded from the search.

Autopsy studies in AD patients show significant reductions in GLUT3 in areas of the brain closely associated with AD pathology. Patients with AD and diabetes showed greater reductions of GLUT1 and GLUT3. A longitudinal study showed significant reductions in GLUT3 levels which correlated with greater amyloid-β (Aβ) and neurofibrillary tangle pathological burden in participants with AD pathology at post-mortem but without evidence of cognitive dysfunction in their lifetime. Some studies showed increased GLUT1, with others showing reduced GLUT1, levels in AD brain. A newly recognised GLUT12 appears to be increased in AD. Animal studies showed similar results with GLUT1 and GLUT3 knockout animal models exhibiting AD pathology, while overexpression of GLUT1 or treatment with metformin decreased Aβ toxicity in a Drosophila model of AD. GLUT2 levels were increased in both human AD brain and in an animal model of AD. Imaging studies using fluorodeoxyglucose [18F]FDG with positron emission tomography (FDG-PET) in AD subjects show reductions in glucose transport and glucose metabolism in areas most affected in AD. A small randomised control trial showed anti-diabetic medications improved the glucose transport in AD subjects.

GLUTs play a significant role in AD pathology with evidence suggesting that GLUT3 reductions may precede the onset of clinical symptoms, while GLUT2 and GLUT12 may have a compensatory role. Repurposing anti-diabetic drugs shows promising results in both animal and human studies of AD.

Depression is highly prevalent in children and adolescents in Pakistan, yet, factors affecting depression have not been widely studied. This study aims to assess the demographic and clinical characteristics of depression in children and adolescents and identify associations between parental marital status and confounding factors for depression.

A descriptive retrospective study was undertaken at the Aga Khan University Hospital in Karachi, Pakistan. Patient records of children and adolescents (aged under 18 years), presenting to the psychiatry clinic with depression from 2015-2019 were reviewed. The diagnosis of clinical depression was made based on clinical assessment according to international guidelines. Patients whose medical records had missing information were excluded. Data were analysed using IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, N.Y., USA). Continuous data are presented as mean +/- standard deviation, whereas categorical data are presented as percentages (%). Pearson Chi-square test of association has been used to assess the association between parental factors and confounding factors. In instances where Pearson's Chi-square test could not be applied, Fisher's exact test is used instead. Associations at p <0.05 (95% confidence limit) are considered statistically significant.

A total of 133 participants were included, of which 78 (58.6%) were female, and 55 (41.4%) were male, with a mean age of 15.5 +/- 2.4 (Range: Ages 4–18). The population had a 50.4% prevalence of suicidal ideation, 21.1% of self-harm, 15% of substance abuse and 14.3% of suicide attempts. Academic stress (54.9%), inter-parental conflict (30.1%) and child abuse (29.3%) were the most common confounding factors reported. Other confounding factors include a family history of depression (20.3%), experience of bullying (16.5%) witnessing domestic violence (16.5%), substance abuse (15.0%) and experiencing sexual abuse (6.0%). There is a statistically significant association between children having parents with non-intact marriages and experiencing sexual abuse (p < 0.001, Odds Ratio (OR) = 21.48), having a family history of depression (p < 0.001, OR = 7.04), child abuse (OR = 3.78). Children of non-traditional (not living with both parents) families were more likely to witness domestic violence (p < 0.001, OR = 4.28), have a family history of depression (p < 0.001, OR = 3.44), abuse substances (OR = 3.20) and experience child abuse (OR = 2.48).

This study identifies factors that may put children at an increased risk of developing depression and performing high-risk behaviours. The findings can help develop better screening programs and counselling for children and adolescents, allowing prevention and ensuring early diagnosis and care.

Modern psychometric methods make it possible to eliminate nonperforming items and reduce measurement error. Application of these methods to existing outcome measures can reduce variability in scores, and may increase treatment effect sizes in depression treatment trials.

We aim to determine whether using confirmatory factor analysis techniques can provide better estimates of the true effects of treatments, by conducting secondary analyses of individual patient data from randomised trials of antidepressant therapies.

We will access individual patient data from antidepressant treatment trials through Clinicalstudydatarequest.com and Vivli.org, specifically targeting studies that used the Hamilton Rating Scale for Depression (HRSD) as the outcome measure. Exploratory and confirmatory factor analytic approaches will be used to determine pre-treatment (baseline) and post-treatment models of depression, in terms of the number of factors and weighted scores of each item. Differences in the derived factor scores between baseline and outcome measurements will yield an effect size for factor-informed depression change. The difference between the factor-informed effect size and each original trial effect size, calculated with total HRSD-17 scores, will be determined, and the differences modelled with meta-analytic approaches. Risk differences for proportions of patients who achieved remission will also be evaluated. Furthermore, measurement invariance methods will be used to assess potential gender differences.

Our approach will determine whether adopting advanced psychometric analyses can improve precision and better estimate effect sizes in antidepressant treatment trials. The proposed methods could have implications for future trials and other types of studies that use patient-reported outcome measures.