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Lithium is a widely used and highly effective treatment for mood disorders, but causes poorly characterised adverse effects in kidney and endocrine systems. We aimed to analyse laboratory information system data to determine the incidence of renal, thyroid, and parathyroid dysfunction associated with lithium use. In a retrospective analysis of laboratory data from Oxford University Hospitals National Health Service Trust (Oxfordshire, UK), we investigated the incidence of renal, thyroid, and parathyroid dysfunction in patients (aged ≥18 years) who had at least two creatinine, thyrotropin, calcium, glycated haemoglobin, or lithium measurements between Oct 1, 1982, and March 31, 2014, compared with controls who had not had lithium measurements taken. We used survival analysis and Cox regression to estimate the hazard ratio (HR) for each event with lithium use, age, sex, and diabetes as covariates. Adjusting for age, sex, and diabetes, presence of lithium in serum was associated with an increased risk of stage three chronic kidney disease (HR 1·93, 95% CI 1·76–2·12; p<0·0001), hypothyroidism (2·31, 2·05–2·60; p<0·0001), and raised total serum calcium concentration (1·43, 1·21–1·69; p<0·0001), but not with hyperthyroidism (1·22, 0·96–1·55; p=0·1010) or raised adjusted calcium concentration (1·08, 0·88–1·34; p=0·4602). Women were at greater risk of development of renal and thyroid disorders than were men, with younger women at higher risk than older women. The adverse effects occurred early in treatment (HR <1 for length of treatment with lithium). Higher than median lithium concentrations were associated with increased risk of all adverse outcomes. Lithium treatment is associated with a decline in renal function, hypothyroidism, and hypercalcaemia. Women younger than 60 years and people with lithium concentrations higher than median are at greatest risk. Because lithium remains a treatment of choice for bipolar disorder, patients need baseline measures of renal, thyroid, and parathyroid function and regular long-term monitoring. None.

Lithium is a widely used and effective treatment for mood disorders. There has been concern about its safety but no adequate synthesis of the evidence for adverse effects. We aimed to undertake a clinically informative, systematic toxicity profile of lithium. We undertook a systematic review and meta-analysis of randomised controlled trials and observational studies. We searched electronic databases, specialist journals, reference lists, textbooks, and conference abstracts. We used a hierarchy of evidence which considered randomised controlled trials, cohort studies, case-control studies, and case reports that included patients with mood disorders given lithium. Outcome measures were renal, thyroid, and parathyroid function; weight change; skin disorders; hair disorders; and teratogenicity. We screened 5988 abstracts for eligibility and included 385 studies in the analysis. On average, glomerular filtration rate was reduced by −6·22 mL/min (95% CI −14·65 to 2·20, p=0·148) and urinary concentrating ability by 15% of normal maximum (weighted mean difference −158·43 mOsm/kg, 95% CI −229·78 to −87·07, p<0·0001). Lithium might increase risk of renal failure, but the absolute risk was small (18 of 3369 [0·5%] patients received renal replacement therapy). The prevalence of clinical hypothyroidism was increased in patients taking lithium compared with those given placebo (odds ratio [OR] 5·78, 95% CI 2·00–16·67; p=0·001), and thyroid stimulating hormone was increased on average by 4·00 iU/mL (95% CI 3·90–4·10, p<0·0001). Lithium treatment was associated with increased blood calcium (+0·09 mmol/L, 95% CI 0·02–0·17, p=0·009), and parathyroid hormone (+7·32 pg/mL, 3·42–11·23, p<0·0001). Patients receiving lithium gained more weight than did those receiving placebo (OR 1·89, 1·27–2·82, p=0·002), but not those receiving olanzapine (0·32, 0·21–0·49, p<0·0001). We recorded no significant increased risk of congenital malformations, alopecia, or skin disorders. Lithium is associated with increased risk of reduced urinary concentrating ability, hypothyroidism, hyperparathyroidism, and weight gain. There is little evidence for a clinically significant reduction in renal function in most patients, and the risk of end-stage renal failure is low. The risk of congenital malformations is uncertain; the balance of risks should be considered before lithium is withdrawn during pregnancy. Because of the consistent finding of a high prevalence of hyperparathyroidism, calcium concentrations should be checked before and during treatment. National Institute for Health Research Programme Grant for Applied Research.

AimsThis report describes the treatment of a patient with ketamine induced uropathy. This condition can be significantly debilitating due to its severe effect on the urinary system. This report outlines an interdisciplinary approach to the care of the patient involving addictions services, urology and primary care.MethodsThe patient presented with a history of inhalation of ketamine intermittently for four years and daily for three years. His highest daily use was 14 grams per day.He developed multiple urinary symptoms including dysuria, urgency, incontinence, haematuria and abdominal and urethral pain. He had significant weight loss and suicidal thoughts. After six years of use, he was reviewed by urology, however was discharged within a year, after missing appointments. Investigations included ultrasound which showed kidneys of normal appearance; flexible cystoscopy which showed a small bladder with acute bleeding and posterior wall ulcer; urodynamic studies showed overactive bladder.He attended a private, inpatient detoxification programme, however relapsed after this admission and self-referred to local addictions services. When assessed there, a detailed history and physical examination were completed. Baseline electrocardiogram and blood investigations were completed and were broadly normal.It was felt that a collaborative approach between addictions services, primary care, urology, and a regional addictions detoxification centre could help him manage his symptoms and achieve more sustained abstinence. Following interdisciplinary discussions, he was commenced on solifenacine to treat his urinary frequency, mirtazapine for his mood and buscopan for pain. Motivation interviewing approaches were used to help him reduce his ketamine use.ResultsKetamine is a synthetic drug with marked dissociative, stimulant and hallucinogenic properties. There has been a rising trend in adults entering treatment with harmful ketamine use in recent years. In 2023, 2,211 people entered treatment for harmful ketamine use in England, a fivefold increase from 2014. Ketamine induced uropathy would be expected to occur in a high proportion of these people. A survey of adolescents demonstrated that 60% of ketamine users had lower urinary tract symptoms. There are a range of medical and surgical options to treat ketamine induced uropathy but no clear agreed approach for its holistic management in the UK.ConclusionThis case report highlights the consequences of prolonged ketamine use on the urinary tract system. It highlights an example of effective interdisciplinary working between addictions services, primary care and urology. The authors recommend the development of nationally agreed guidelines on ketamine induced uropathy with emphasis on collaborative, inter-service working.

Aims: Ketamine use among young adults in England has increased significantly, with prevalence more than doubling in the past five years. Ketamine use disorder (KUD) is a disorder of regulation arising from repeated or continuous use of ketamine for at least three months. The systemic effects can include urinary, sexual, hepatic and cardiovascular dysfunction, memory impairment and mental illness. Although people who use ketamine constitute a smaller proportion of patients in addictions services compared with opioid or alcohol users, the complexity and morbidity of KUD dictates the need for interdisciplinary collaboration. In 2024, a collaborative effort between a local addiction and urology service was initiated to address KUD and ketamine uropathy (KU). Methods: Both services presented at the local Addictions Continuing Professional Development Day to share knowledge and develop staff understanding on KUD and KU. Meetings were held to evaluate local prevalence of KUD and KU, address barriers to treatment and develop easier referral pathways into both services. Best practice guidance on KU was reviewed and a new interdisciplinary treatment model implemented. Re-strategisation required clinician time and adjustments to clinic schedules. Results: In 2024, nine patients from Urology and 23 patients from the addiction service with ketamine use were seen. Key improvements included the establishment of a direct two-week referral pathway to Urology, development of referral and assessment proformas and initiation of monthly interdisciplinary team meetings. These changes aimed to reduce delays in initiation of treatment and improve co-ordination between services. However, the major challenge faced was a high attrition rate in the clinics. Areas identified as requiring further attention included management of weight loss and constipation, medication for symptomatic relief of ketamine withdrawal and cravings, safe analgesic alternatives, treatment of co-occurring mental illness and trauma, safeguarding and risk considerations and psychological therapeutic options. The embarrassment of urinary incontinence was identified as a barrier to appointment attendance. Conclusion: An interdisciplinary management approach is recommended to optimize patient care. Systemic complications of KUD and co-occurring mental illness should be treated simultaneously. Intensifying the support from Addiction Recovery Coordinators may improve attendance at appointments. Recommendations include more health worker education and staffing, early pain team involvement and provision of harm reduction advice. Peer-informed, ketamine-focused psychosocial programmes and national psychiatry guidelines for KUD are required. Our collaborative model demonstrates a significant step towards improving management of KU and KUD, however its impact on clinical outcomes will need further evaluation.

The widespread use of smartphones makes effective therapies such as cognitive-behavioural therapy (CBT) potentially accessible to large numbers of people. This paper reports the usage data of the first trial of Catch It, a new CBT smartphone app. Uptake and usage rates, fidelity of user responses to CBT principles, and impact on reported negative and positive moods were assessed. A relatively modest proportion of people chose to download the app. Once used, the app tended to be used more than once, and 84% of the user-generated content was consistent with the basic concepts of CBT. There were statistically significant reductions in negative mood intensity and increases in positive mood intensity. Smartphone apps have potential beneficial effects in mental health through the application of basic CBT principles. More research with randomised controlled trial designs should be conducted. None. © The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

AimsRe-audit for adherence of all inpatient wards at Park House Hospital to Trust Consent to Treatment policy. Improve hospital compliance to Trust Consent to Treatment policy. Reduce prescribing errors. Improve trainee confidence and knowledge of Consent to TreatmentMethods• Cross sectional audit.• Data collected between 8th and 12th November 2021• All wards in Park House Hospital• 5 patient records and medication charts reviewed per ward.• Proforma used.• Data analysed using Excel.• Interactive teaching on Consent to Treatment delivered by Dr McKnight to Core Psychiatry Trainees on 3rd July 2020.• Dr McKnight presented the original audit data and consulted the Pharmacists and Consultants to assess and improve ward systems for recording Consent to Treatment. (26th May and 30th April 2021).• Dr McKnight presented to Greater Manchester Mental Health, Mental Health Act and Mental Capacity Act Quality Improvement Group (30th June 2020).Results• No wards had 100% capacity forms documented, kept in medication charts and uploaded to Paris.• 7/9 wards had 100% compliance for completing T2/3/S62 forms.• 6/9 wards had 100% compliance rate for retaining the T2/3/S62 forms in the medication charts.• 78% T2/3/S62 forms were uploaded to PARIS.• 80% medication charts matched T2/3 forms.When Dr McKnight asked trainees, “Do you feel confident with your knowledge of consent to treatment” only 24% answered yes, 35% answered no and 41% a little.When asked, “Do you check Consent to treatment forms before prescribing?” 32% answered yes, 24% no, 34% sometimes and 10% that they didn't know what they were.During the post-teaching quiz, trainees were asked, “Has this teaching session improved your knowledge and confidence regarding Consent to Treatment?” 91% answered yes, 0% answered no and 9% answered a little.Discussion with Consultants and Pharmacists concluded that it may be beneficial for wards to include Capacity to Consent and Consent to Treatment within ward round proformasConclusion• The two main concerns of the initial audit and re-audit, relate to Treatment Capacity and Consent forms compliance and prescribing.• New trainees rotate into the Trust every 6 months and levels of knowledge surrounding Consent to Treatment varies depending on trainee experience. Trainees require teaching on Consent to Treatment as part of their induction and teaching programme.• Based on the multidisciplinary nature of ensuring compliance to Consent to Treatment the authors propose monthly ward auditing of Consent to Treatment, which they believe will lead to better compliance rates across the hospital.

AimsImprove confidence and experience of trainees performing preliminary medical reviews in the 136 suite.Improve patient safety by increasing trainee's confidence in responding to emergency scenarios, including crash calls of patients in the 136 Suite.To orientate trainees to the 136 suite and the emergency crash equipment, in order to better prepare trainees for emergency scenarios.BackgroundThe authors encountered a crash call in the 136 suite, in which a patient had concealed an opiate overdose. The patient was successfully resuscitated but concerns were raised by the junior doctors that they were unaware of what or where the emergency equipment was kept in the 136 suite. Following a debrief session, we established that junior doctors needed more orientation to the 136 suite and more teaching on performing preliminary medical reviews and responding to emergency situations.MethodTrainees, were asked to complete an anonymous, qualitative questionnaire with 16 questions asking about their confidence to respond to emergency situations in the 136 suite.Based on the feedback, an interactive teaching session was delivered two weeks later. The session covered a structured approach on how to perform a preliminary medical review and scenario-based teaching on emergency situations. Trainees were then shown the 136 facility, introduced to the lead nurse and shown the emergency crash equipment and drugs stores.Trainees were then re-consulted, with the same questionnaire to ascertain whether confidence and knowledge had increased.ResultFollowing initial induction, only 25% of trainees felt confident performing 136 Suite preliminary reviews. 50% of trainees had encountered crash calls at Park House Hospital, however 93% did not receive orientation of emergency equipment locations. Only 44% of trainees felt confident managing a crash call; reasons included feeling ‘rusty, little recent experience, not being familiar with the equipment’.Post-interactive teaching session, 89% now felt confident performing 136 Suite preliminary reviews. 100% knew where the crash equipment was located in the 136 Suite.ConclusionTrainees should receive a robust induction on how to perform 136 preliminary reviews and have orientation of the facility, including crash equipment during inductionTrainees require refresher training in addition to their basic life support training on common emergency scenarios encountered in psychiatric hospitals.A resuscitation skills training session is being organised for new trainees and hopefully incorporated into each forthcoming rotation.