Publications by authors named "Sean Cross"

27 Publications

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Effectiveness of simulation in psychiatry for nursing students, nurses and nurse practitioners: A systematic review and meta-analysis.

J Adv Nurs 2021 Aug 11. Epub 2021 Aug 11.

Public Health Department, School of Medicine, University Paris Saclay, INSERM 1018, CESP, Villejuif, Ile-de-France, France.

Aims: Mental disorders constitute one of the main causes of disease and disability worldwide. While nurses are often at the frontline of mental health care, they have limited access to dedicated psychiatric training opportunities. Simulation training may foster the development of the appropriate competencies required when supporting people with mental disorders. To evaluate the effectiveness of simulation training in psychiatry for nursing students, nurses and nurse practitioners.

Design: Systematic review and meta-analysis.

Data Sources: Eight electronic databases, trial registries, key journals and reference lists of selected studies were searched from inception to August 20, 2020 without language restriction.

Review Methods: We included randomized and non-randomized controlled studies and single group pre/post studies. Cochrane Risk of Bias tool 2.0 was used for randomized controlled study appraisal, and the Medical Education Research Study Quality instrument was completed for all other studies. Meta-analysis was restricted to randomized controlled studies. The other studies were synthesized narratively. The main outcomes were based on Kirkpatrick levels.

Results: A total of 118 studies (6738 participants) were found. Interventions included simulated patients (n = 55), role-plays (n = 40), virtual reality (n = 12), manikins (n = 9) and voice simulations (n = 9). Meta-analyses based on 11 randomized controlled studies found a significant large effect size on skills at immediate post-test for simulation compared with active control; and a small and medium effect size on learners' attitudes for simulation compared with inactive control, at immediate post-test and at three-month follow-up respectively. Three quarters of non-randomized controlled studies and pre/post-tests assessing attitudes and skills showed significant differences, and three quarters of participants in randomized controlled studies and pre/post-tests showed significant differences in behaviours. Among the few studies assessing people with mental health outcomes, almost all reported significant differences.

Conclusion: These findings support the effectiveness of simulation training in psychiatric nursing throughout professional development grades, despite heterogeneity in methods and simulation interventions.
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http://dx.doi.org/10.1111/jan.14986DOI Listing
August 2021

Psychosocial impact of the COVID-19 pandemic on 4378 UK healthcare workers and ancillary staff: initial baseline data from a cohort study collected during the first wave of the pandemic.

Occup Environ Med 2021 Jun 28. Epub 2021 Jun 28.

Department of Psychological Medicine, King's College London, London, UK.

Objectives: This study reports preliminary findings on the prevalence of, and factors associated with, mental health and well-being outcomes of healthcare workers during the early months (April-June) of the COVID-19 pandemic in the UK.

Methods: Preliminary cross-sectional data were analysed from a cohort study (n=4378). Clinical and non-clinical staff of three London-based NHS Trusts, including acute and mental health Trusts, took part in an online baseline survey. The primary outcome measure used is the presence of probable common mental disorders (CMDs), measured by the General Health Questionnaire. Secondary outcomes are probable anxiety (seven-item Generalised Anxiety Disorder), depression (nine-item Patient Health Questionnaire), post-traumatic stress disorder (PTSD) (six-item Post-Traumatic Stress Disorder checklist), suicidal ideation (Clinical Interview Schedule) and alcohol use (Alcohol Use Disorder Identification Test). Moral injury is measured using the Moray Injury Event Scale.

Results: Analyses showed substantial levels of probable CMDs (58.9%, 95% CI 58.1 to 60.8) and of PTSD (30.2%, 95% CI 28.1 to 32.5) with lower levels of depression (27.3%, 95% CI 25.3 to 29.4), anxiety (23.2%, 95% CI 21.3 to 25.3) and alcohol misuse (10.5%, 95% CI 9.2 to 11.9). Women, younger staff and nurses tended to have poorer outcomes than other staff, except for alcohol misuse. Higher reported exposure to moral injury (distress resulting from violation of one's moral code) was strongly associated with increased levels of probable CMDs, anxiety, depression, PTSD symptoms and alcohol misuse.

Conclusions: Our findings suggest that mental health support for healthcare workers should consider those demographics and occupations at highest risk. Rigorous longitudinal data are needed in order to respond to the potential long-term mental health impacts of the pandemic.
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http://dx.doi.org/10.1136/oemed-2020-107276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8245285PMC
June 2021

Simulation Training in Psychiatry for Medical Education: A Review.

Front Psychiatry 2021 21;12:658967. Epub 2021 May 21.

Epidemiological and Public Health Research Centre, Villejuif, France.

Despite recognised benefits of Simulation-Based Education (SBE) in healthcare, specific adaptations required within psychiatry have slowed its adoption. This article aims to discuss conceptual and practical features of SBE in psychiatry that may support or limit its development, so as to encourage clinicians and educators to consider the implementation of SBE in their practice. SBE took off with the aviation industry and has been steadily adopted in clinical education, alongside role play and patient educators, across many medical specialities. Concurrently, healthcare has shifted towards patient-centred approaches and clinical education has recognised the importance of reflective learning and teaching centred on learners' experiences. SBE is particularly well-suited to promoting a holistic approach to care, reflective learning, emotional awareness in interactions and learning, cognitive reframing, and co-construction of knowledge. These features present an opportunity to enhance education throughout the healthcare workforce, and align particularly well to psychiatric education, where interpersonal and relational dimensions are at the core of clinical skills. Additionally, SBE provides a strategic opportunity for people with lived experience of mental disorders to be directly involved in clinical education. However, tenacious controversies have questioned the adequacy of SBE in the psychiatric field, possibly limiting its adoption. The ability of simulated patients (SPs) to portray complex and contradictory cognitive, psychological and emotional states has been questioned. The validity of SBE to develop a genuine empathetic understanding of patients, to facilitate a comprehensive multiaxial diagnostic formulation, or to develop flexible interpersonal skills has been criticised. Finally, SBE's relevance to developing complex psychotherapeutic skills is much debated, while issues such as symptom induction in SPs or patients involvement raise ethical dilemmas. These controversies can be addressed through adequate evidence, robust learning design, and high standards of practice. Well-designed simulated scenarios can promote a positive consideration of mental disorders and complex clinical skills. Shared guidelines and scenario libraries for simulation can be developed, with expert psychiatrists, patients and students involvement, to offer SPs and educators a solid foundation to develop training. Beyond scenario design, the nuances and complexities in mental healthcare are also duly acknowledged during the debriefing phases, providing a crucial opportunity to reflect on complex interpersonal skills or the role of emotions in clinicians' behaviour. Considered recruitment and support of SPs by clinical educators can help to maintain psychological safety and manage ethical issues. The holistic and reflexive nature of SBE aligns to the rich humanistic tradition nurtured within psychiatry and medicine, presenting the opportunity to expand the use of SBE to support a range of clinical skills and workforce competencies required in psychiatry.
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http://dx.doi.org/10.3389/fpsyt.2021.658967DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8175985PMC
May 2021

The Use of in situ Simulation in Healthcare Education: Current Perspectives.

Adv Med Educ Pract 2020 27;11:893-903. Epub 2020 Nov 27.

Maudsley Learning, South London & Maudsley NHS Foundation Trust, London, UK.

In situ simulation is the practice of using simulated scenarios in a clinical environment itself rather than in training facilities to promote learning and improved clinical care. The use of in situ simulation has been increasingly used to train healthcare staff in dealing with emergencies, resuscitation and clinical skills. The aim of this study is to provide an overview of the themes, perspectives and approaches to in situ simulation for educational purposes with healthcare staff. The literature search included studies describing and evaluating in situ simulations with an educational component. We carried out a narrative synthesis and extracted data on the clinical setting, the simulation purpose, design, evaluation method and impact. In situ simulation has proved useful in a range of different specialties for skills improvement and team development. Simulation design ranges in terms of fidelity, duration and topic. No specific design has shown to be the most efficient. However, adopting a design that fits into the specific centers resources, educational needs and clinical demands is the most important consideration.
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http://dx.doi.org/10.2147/AMEP.S188258DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7707431PMC
November 2020

Simulation in psychiatry for medical doctors: A systematic review and meta-analysis.

Med Educ 2020 08 9;54(8):696-708. Epub 2020 Jun 9.

Epidemiological and Public Health Research Centre, Villejuif, France.

Context: Most medical doctors are likely to work with patients experiencing mental health conditions. However, educational opportunities for medical doctors to achieve professional development in the field of psychiatry are often limited. Simulation training in psychiatry may be a useful tool to foster this development.

Objectives: The purpose of this study was to assess the effectiveness of simulation training in psychiatry for medical students, postgraduate trainees and medical doctors.

Methods: For this systematic review and meta-analysis, we searched eight electronic databases and trial registries up to 31 August 2018. We manually searched key journals and the reference lists of selected studies. We included randomised and non-randomised controlled studies and single group pre- and post-test studies. Our main outcomes were based on Kirkpatrick levels. We included data only from randomised controlled trials (RCTs) using random-effects models.

Results: From 46 571 studies identified, we selected 163 studies and combined 27 RCTs. Interventions included simulation by role-play (n = 69), simulated patients (n = 72), virtual reality (n = 22), manikin (n = 5) and voice simulation (n = 2). Meta-analysis found significant differences at immediate post-tests for simulation compared with active and inactive control groups for attitudes (standardised mean difference [SMD] = 0.52, 95% confidence interval [CI] 0.31-0.73 [I  = 0.0%] and SMD = 0.28, 95% CI 0.04-0.53 [I  = 52.0%], respectively), skills (SMD = 1.37, 95% CI 0.56-2.18 [I  = 93.0%] and SMD = 1.49, 95% CI 0.39-2.58 [I  = 93.0%], respectively), knowledge (SMD = 1.22, 95% CI 0.57-1.88 [I  = 0.0%] and SMD = 0.72, 95% CI 0.14-1.30 [I  = 80.0%], respectively), and behaviours (SMD = 1.07, 95% CI 0.49-1.65 [I  = 68.0%] and SMD = 0.45, 95% CI 0.11-0.79 [I  = 41.0%], respectively). Significant differences in terms of patient benefit and doctors' behaviours and skills were found at the 3-month follow-up.

Conclusions: Despite heterogeneity in methods and simulation interventions, our findings demonstrate the effectiveness of simulation training in psychiatry training.
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http://dx.doi.org/10.1111/medu.14166DOI Listing
August 2020

Simulation in psychiatry for medical doctors: A systematic review and meta-analysis.

Med Educ 2020 08 9;54(8):696-708. Epub 2020 Jun 9.

Epidemiological and Public Health Research Centre, Villejuif, France.

Context: Most medical doctors are likely to work with patients experiencing mental health conditions. However, educational opportunities for medical doctors to achieve professional development in the field of psychiatry are often limited. Simulation training in psychiatry may be a useful tool to foster this development.

Objectives: The purpose of this study was to assess the effectiveness of simulation training in psychiatry for medical students, postgraduate trainees and medical doctors.

Methods: For this systematic review and meta-analysis, we searched eight electronic databases and trial registries up to 31 August 2018. We manually searched key journals and the reference lists of selected studies. We included randomised and non-randomised controlled studies and single group pre- and post-test studies. Our main outcomes were based on Kirkpatrick levels. We included data only from randomised controlled trials (RCTs) using random-effects models.

Results: From 46 571 studies identified, we selected 163 studies and combined 27 RCTs. Interventions included simulation by role-play (n = 69), simulated patients (n = 72), virtual reality (n = 22), manikin (n = 5) and voice simulation (n = 2). Meta-analysis found significant differences at immediate post-tests for simulation compared with active and inactive control groups for attitudes (standardised mean difference [SMD] = 0.52, 95% confidence interval [CI] 0.31-0.73 [I  = 0.0%] and SMD = 0.28, 95% CI 0.04-0.53 [I  = 52.0%], respectively), skills (SMD = 1.37, 95% CI 0.56-2.18 [I  = 93.0%] and SMD = 1.49, 95% CI 0.39-2.58 [I  = 93.0%], respectively), knowledge (SMD = 1.22, 95% CI 0.57-1.88 [I  = 0.0%] and SMD = 0.72, 95% CI 0.14-1.30 [I  = 80.0%], respectively), and behaviours (SMD = 1.07, 95% CI 0.49-1.65 [I  = 68.0%] and SMD = 0.45, 95% CI 0.11-0.79 [I  = 41.0%], respectively). Significant differences in terms of patient benefit and doctors' behaviours and skills were found at the 3-month follow-up.

Conclusions: Despite heterogeneity in methods and simulation interventions, our findings demonstrate the effectiveness of simulation training in psychiatry training.
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http://dx.doi.org/10.1111/medu.14166DOI Listing
August 2020

Neopterin formation through radical scavenging of superoxide by the macrophage synthesised antioxidant 7,8-dihydroneopterin.

Free Radic Biol Med 2020 05 5;152:142-151. Epub 2020 Mar 5.

Free Radical Biochemistry, School of Biological Sciences, University of Canterbury, Christchurch, New Zealand; Department of Radiology, University of Otago Christchurch, New Zealand; European Organization for Nuclear Research (CERN), Geneva, Switzerland. Electronic address:

Clinical measurement of neopterin has been extensively used as a marker of inflammation but the in vivo mechanism generating neopterin is poorly understood. Neopterin is described as the oxidation product of 7,8-dihydroneopterin, a potent antioxidant generated by monocyte/macrophages in response to interferon-γ. While peroxyl and hydroxyl scavenging generates dihydroxanthopterin, hypochlorite efficiently oxidises 7,8-dihydroneopterin into neopterin, but this reaction alone does not explain the high levels of neopterin seen in clinical data. Here, we examine whether superoxide scavenging by 7,8-dihydroneopterin generates neopterin. U937 cells incubated with oxLDL showed a time dependent increase superoxide and 7,8-dihydroneopterin oxidation to neopterin. Neopterin generation in oxLDL or phorbol ester treated U937 cells or human monocytes was inhibited by apocynin and PEG-SOD. Addition of the myeloperoxidase inhibitor 4-aminobenzoic acid hydrazide (ABAH) had no effect of the superoxide generation or neopterin formation. 7,8-Dihydroneopterin reacted with superoxide/hydroxy radical mixtures generated by X-ray radiolysis to give neopterin. Formation of neopterin by superoxide derived from the xanthine/xanthine oxidase system was inhibited by superoxide dismutase. Neopterin formation was inhibited by apocynin in phorbol ester treated human carotid plaque rings in tissue culture. These results indicate that 7,8-dihydroneopterin scavenges superoxide and is subsequently oxidised into neopterin in cellular and cell-free experimental systems.
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http://dx.doi.org/10.1016/j.freeradbiomed.2020.03.002DOI Listing
May 2020

Predictors of Disagreement Between Diagnoses From Consult Requesters and Consultation-Liaison Psychiatry.

J Nerv Ment Dis 2019 Dec;207(12):1019-1024

Department of Mental Health, Santa Casa Medical School.

We evaluated disagreement between reported symptoms and a final diagnosis of depression, anxiety, withdrawal, psychosis, or delirium through regression models assessing individual and combined diagnoses. Highest disagreement rates were reported for services classified as others (88.2%), general surgery (78.5%), and bone marrow transplant (77.7%). Disagreement rates varied widely across different diagnoses, with anxiety having the highest disagreement rate (63.3%), whereas psychosis had the lowest disagreement rate (10.6%). When evaluating kappa coefficients, the highest agreement occurred with diagnoses of withdrawal and psychosis (0.66% and 0.51%, respectively), whereas anxiety and depression presented the lowest values (0.31% and 0.11%, respectively). The best-performing predictive model for most outcomes was random forest, with the most important predictors being specialties other than the ones focused on single systems, older age, lack of social support, and the requester being a resident. Monitoring disagreement rates and their predictors provides information that could lead to quality improvement and safety programs.
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http://dx.doi.org/10.1097/NMD.0000000000001018DOI Listing
December 2019

An evidence based framework for the Temporal Observational Analysis of Teamwork in healthcare settings.

Appl Ergon 2020 Jan 15;82:102915. Epub 2019 Aug 15.

The Florence Nightingale Faculty of Nursing, Midwifery and PalliativeCare, King's College London, London, UK.

Objective: Effective teamwork is critical to patient safety across multiple healthcare settings. However, current observational tools assessing teamwork performance tend to be developed for specific settings or tasks and do not capture temporal features of interaction. This study aimed to develop a valid and reliable observational teamwork behaviour framework, which is based on healthcare practice, applicable across a variety of healthcare contexts and can be used to capture temporal team dynamics.

Methods: Team interactions were audio-visually recorded during routine simulation training at two large clinical education centres specialising in physical and mental healthcare. The framework was based on theoretical models of teamwork and was developed in three steps: 1-micro analysis of verbal and nonverbal behaviour during recorded scenarios (n = 20); 2-iterative test and refine cycles; 3-final behavioural framework applied to a cohort of acute emergency scenarios (n = 9) by two raters to assess inter-rater agreement.

Results: The framework contains twenty-three specific verbal and nonverbal behaviours that can be identified during observations. Behaviours are grouped conceptually based on their function resulting in thirteen behavioural functions, which cluster into five overarching teamwork domains. Inter-rater agreement was excellent (Cohen's Kappa = .84, SE = 0.03).

Conclusion: We present a valid and reliable behavioural framework, grounded in teamwork theory and empirical observations of clinical team behaviour. This framework enables analysis of the nuances and temporal features of clinical practice in depth and across a wide range of clinical contexts and settings. Use of this framework will advance our understanding of teamworking in healthcare.
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http://dx.doi.org/10.1016/j.apergo.2019.102915DOI Listing
January 2020

Knee replacement surgery significantly elevates the urinary inflammatory biomarkers neopterin and 7,8-dihydroneopterin.

Clin Biochem 2019 Jan 3;63:39-45. Epub 2018 Nov 3.

School of Biological Sciences, University of Canterbury, Christchurch 8140, New Zealand; Department of Radiology, University of Otago Christchurch, PO Box 4345, Christchurch 8011, New Zealand. Electronic address:

Context: Knee arthroplasty surgery is significant trauma, leading to an activated immune system causing inflammation and oxidative stress. Many current biomarkers are invasive, costly, and often slow to analyse, limiting their use for rapid inflammatory measurements.

Objectives: We have examined the use of urinary neopterin and total neopterin in knee arthroplasty patients to non-invasively measure oxidative stress and inflammation from immune system activation. We aim to validate the use of these biomarkers for quick, cost effective and predictive measurements of post-surgical inflammation assessment.

Methodology: 19 Knee arthroplasty patients were analysed pre-operatively and for a defined post-operative period to determine the urinary levels of neopterin and total neopterin (neopterin +7,8-dihydroneopterin) using high performance liquid chromatography with fluorescence detection. These results were then compared to a control group of 20 participants with normal knee function.

Results: 7,8-Dihydroneopterin was stable in urine over 12 h when refrigerated. Knee arthritis was associated with an increase in pre-operative neopterin (oxidative stress) and total neopterin (inflammation). The subsequent arthroplasty surgery generated a significant increase neopterin and total neopterin. Both biomarkers were reduced immediately post-operatively, before becoming elevated on the following days. There was no clear evidence of an association between initial neopterin and total neopterin levels and a patient's level of inflammation during in-hospital recovery.

Conclusions: The stability of 7,8-dihydroneopterin in urine allows for its use as an inflammatory marker. Urinary neopterin and total neopterin provided a fast, non-invasive, and simple measure of oxidative stress and inflammation after knee arthroplasty.
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http://dx.doi.org/10.1016/j.clinbiochem.2018.11.002DOI Listing
January 2019

Interprofessional simulation training for community mental health teams: Findings from a mixed methods study.

J Interprof Care 2018 Nov 24;32(6):762-770. Epub 2018 Aug 24.

Department is Maudsley Simulation, South London & Maudsley NHS Foundation Trust, London, UK.

Community mental health teams (CMHTs) in England face mounting service pressures due to an increased focus on out-of-hospital care. Interprofessional working is essential to providing good mental healthcare in community settings. Simulation training is underused in mental health, despite strong support for its improvement of clinical skills, confidence, teamwork, and interprofessional collaboration in other healthcare settings. This study aims to evaluate the impact of simulation training on community mental health professionals. An interprofessional simulation training course on assessment and team working skills for community mental health professionals was developed and delivered at a time of service reorganisation in South London services, including changes to job roles and responsibilities. In total, 57 course participants completed a survey that measured perceptions of knowledge and confidence, as well as a general view of the course. Eight participants took part in further semi-structured interviews 2-3 months after the course to provide perceptions about this experience's subsequent impact. There were statistically significant increases in knowledge and confidence scores with large effect sizes. Thematic analyses of open-text survey and interview data identified emergent themes of interprofessional understanding; attitudes in clinical practice; staff well-being; the value of reflection; opportunity for feedback; and fidelity to clinical practice. Simulation training can improve confidence and knowledge in core skills and team working for CMHTs. Participants reported benefits to key areas of community mental healthcare, such as interprofessional collaboration, reflective practice, and staff well-being. Findings represented individual and team learning, as well as subsequent changes to clinical practice, and were related back to the interactive and reflective nature of the simulation. Implications are highlighted concerning the use of interprofessional simulation training in mental health, particularly relating to staff well-being, attitudes, and interprofessional working.
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http://dx.doi.org/10.1080/13561820.2018.1511524DOI Listing
November 2018

Induced macrophage activation in live excised atherosclerotic plaque.

Immunobiology 2018 Aug - Sep;223(8-9):526-535. Epub 2018 Mar 23.

Free Radical Biochemistry Laboratory, School of Biological Sciences, University of Canterbury, Private Bag 4800, Christchurch, New Zealand; Department of Radiology, University of Otago Christchurch, PO Box 4345, Christchurch, New Zealand. Electronic address:

Atherosclerotic plaques are complex tissues containing many different cell types. Macrophages contribute to inflammation, formation of the necrotic core, and plaque rupture. We examined whether macrophages in plaque can be activated and compared this to monolayer cells. The volume of calcium in the plaque was compared to the level of macrophage activation measured by total neopterin output. Carotid plaque samples were cut into 3 mm sections and cultured for up to 96 h. Live sections were stimulated with interferon-γ, phytohaemagglutinin or phorbol 12-myristate 13-acetate. Macrophage activation and oxidative stress were monitored by total neopterin (oxidized and non-oxidized 7,8-dihydroneopterin) and neopterin levels every 24 h for up to 4 d. The calcium content of two plaques was investigated by spectral imaging. Direct stimulation of macrophages in plaque sections with interferon-γ caused a sustained increase in neopterin (p = .037) and total neopterin (p = .003). The addition of phorbol 12-myristate 13-acetate to plaque had no significant effect on total neopterin production (p = .073) but increased neopterin (p = .037) whereas phytohaemagglutinin caused a significant increase in both neopterin and total neopterin (p = .0279 and .0168). There was an inverse association (R = 0.91) between the volume of calcium and macrophage activation as measured by total neopterin production in stimulated plaque tissue. Resident macrophages within excised carotid plaque activated either directly or indirectly generate the biomarkers 7,8-dihydroneopterin and neopterin. Macrophage activation rather than the oxidative environment is associated with plaque calcification.
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http://dx.doi.org/10.1016/j.imbio.2018.03.002DOI Listing
April 2019

Integrating mental and physical health care: the mind and body approach.

Lancet Psychiatry 2018 05 9;5(5):387-389. Epub 2018 Feb 9.

The Mind and Body Programme, King's Health Partners, Guy's Hospital, London SE1 9RT, UK; Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK.

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http://dx.doi.org/10.1016/S2215-0366(18)30044-0DOI Listing
May 2018

Interprofessional Simulation Training to Promote Working With Families and Networks in Mental Health Services.

Acad Psychiatry 2018 Oct 2;42(5):605-612. Epub 2017 Nov 2.

Maudsley Simulation, London, UK.

Objective: Working with the families and networks of patients with mental illness has significant benefits. There are, however, numerous barriers to this way of working, meaning that it is not universally privileged in mental healthcare services. This study evaluated the impact of an interprofessional simulation (IPS) course on working with families and networks on participants' confidence, attitudes, and perceived future clinical practice.

Methods: A one-day IPS course pairing high-fidelity scenarios with reflective debriefs was developed. Simulated patients were engaged to portray patients and family members. Participants were mental health professionals from a variety of medical, nursing, and allied health professional backgrounds (n = 105). A mixed-methods approach to data collection was adopted, comprising pre- and post-course quantitative data on confidence and attitudes towards working with families and networks, and post-course qualitative data on participant experience and learning. Paired samples t tests and thematic analysis were conducted on the respective data sets.

Results: Participants' overall confidence and attitude scores showed statistically significant improvements with large and medium effect sizes, respectively. Thematic analyses identified several perceived improvements in areas related to the following: personal professional development, interprofessional and team working, and patient care and experience. Key pedagogical features of IPS were also highlighted.

Conclusions: These findings support the use of IPS to improve clinicians' capabilities in undertaking systemic work while also supporting its ability to alter clinicians' ways of working in general. The importance of interprofessional and team working for this was also highlighted. Longitudinal evaluation of the training's impact on clinical practice is warranted.
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http://dx.doi.org/10.1007/s40596-017-0840-zDOI Listing
October 2018

Managing medical emergencies in mental health settings using an interprofessional in-situ simulation training programme: A mixed methods evaluation study.

Nurse Educ Today 2017 Dec 21;59:103-109. Epub 2017 Sep 21.

Maudsley Simulation, South London & Maudsley NHS Foundation Trust, Lambeth Hospital, SW9 9NT, UK.

Background: In the UK, people with severe mental illness die up to 20years earlier than the general population, prompting increased focus on physical health in mental illness. However, training for mental health inpatient staff to meet patients' physical health needs has not received the same attention, with physical health training often being reactive and lacking evidence of effectiveness.

Objectives: To evaluate an interprofessional, in situ, simulation training intervention for managing medical deterioration in mental health settings. Investigating the impact of training on: 1. Participants' knowledge, confidence, and attitudes towards managing medical deterioration; and 2. Incident reporting, as an objective index of incident management. Participants' perceptions of the impact on their practice were qualitatively explored.

Design: This evaluation employed a mixed-methods pre-post intervention design.

Participants & Settings: Fifty-three healthcare professionals participated including: mental health nurses, psychiatrists, healthcare assistants, and activity co-ordinators from two busy psychiatric triage wards in South London, UK.

Methods: The intervention comprised eight half-day sessions delivered weekly across two wards. Structured surveys assessed participants' knowledge, confidence, and attitudes towards medical deterioration pre and post training. Participants' experience of training was qualitatively captured through post-course surveys and focus groups three months post training. Incident reporting rates for seven-month periods pre and post training were compared.

Results: Following training, participants showed significant improvement in knowledge (p<0.001), confidence (p<0.001), and attitudes towards (p<0.02) managing medical deterioration. Incident reporting increased by 33% following training. Participants' reported improved confidence in managing medical deterioration, better understanding of effective communication, improved self-reflection and team working, and an increased sense of responsibility for patients' physical health.

Conclusions: Interprofessional, in situ simulation training for medical deterioration yielded promising outcomes for individuals and teams. Simulation is an under-used training modality in mental health, offering a holistic training approach with the potential to provide educational and clinical benefits while supporting workforce resilience.
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http://dx.doi.org/10.1016/j.nedt.2017.09.009DOI Listing
December 2017

Frequent users of Mental Health Liaison Services within Emergency Departments.

Psychiatry Res 2017 12 12;258:194-199. Epub 2017 Aug 12.

Department of Psychological Medicine, Kings College Hospital, Denmark Hill, London SE5 9RS, UK.

This study aimed to use nuanced statistical methods in a large UK sample to identify and explore the factors associated with different types of frequent user of Emergency Departments (EDs) who are referred to Mental Health Liaison Services (MHLS). A retrospective 5-year longitudinal study was conducted of all attenders (n = 23,718) of four London EDs who were referred to their MHLS. Longitudinal group-based trajectory analysis of monthly MHLS referrals enabled identification of factors which may contribute to membership of the resulting groups. Analysis revealed six clusters representing distinct attendance patterns; three clusters of these were identified as frequent attender groups (occasional, intermediate, heavy) containing 1119 people (4.7%). This 4.7% of the sample accounted for 24.2% of all admissions. Factors significantly related to membership of each of these groups were: having been involuntarily detained under the Mental Health Act, a higher number of care coordinators, and a diagnosis of substance abuse. The study revealed three clusters of frequent ED users with a MHLS referral who were more likely to have certain clinical and social care needs. A small proportion of clients identified as frequent users (4.7%) were responsible for nearly a quarter of all admissions (24.2%) during this timeframe.
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http://dx.doi.org/10.1016/j.psychres.2017.08.006DOI Listing
December 2017

Neuroleptic malignant syndrome following catatonia: Vigilance is the price of antipsychotic prescription.

SAGE Open Med Case Rep 2017 31;5:2050313X17695999. Epub 2017 Mar 31.

Department of Psychological Medicine, King's College Hospital, South London and Maudsley NHS Foundation Trust, London, UK.

Objectives: To describe a case of neuroleptic malignant syndrome following antipsychotic treatment of catatonia, highlighting the potentially serious complications of this rare adverse drug reaction.

Methods: We present a case report of a patient who developed this syndrome with various sequelae.

Results: The patient developed neuroleptic after being treated with lorazepam and olanzapine for catatonia. He subsequently developed the complications of rhabdomyolysis, acute kidney injury, pulmonary embolism, urinary retention and ileus. He received high-dose lorazepam, anticoagulation and intravenous fluids. Antipsychotic medication in the form of haloperidol was reinstated with no adverse effect, and he went on to make a full recovery.

Conclusions: This case illustrates the potential life-threatening complications of neuroleptic malignant syndrome and the need for a low index of clinical suspicion. It also highlights the lack of evidence for treatment of catatonia, including the use of antipsychotics.
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http://dx.doi.org/10.1177/2050313X17695999DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5406192PMC
March 2017

Misidentification of mental health symptoms in presence of organic diseases and delirium during psychiatric liaison consulting.

Int J Psychiatry Clin Pract 2017 Sep 22;21(3):215-220. Epub 2017 Mar 22.

a Department of Mental Health , Santa Casa Medical School , São Paulo , Brazil.

Objective: To identify predictors of misidentification of organic mental disorders and delirium in patients undergoing psychiatric liaison consultation.

Methods: Data were collected at Santa Casa de São Paulo between July of 2009 and March of 2013. We included in our analysis all inpatients for whom the requesting service judged that a psychiatric consultation was required for a possible mental health condition. Outcomes of interest were the instances of misidentification where a condition was initially deemed to be of a psychiatric nature, whereas the final diagnosis by the liaison psychiatric team was of an organic disease or delirium. Our predictors were the clinical specialty of the requesting service, requester and patient characteristics. A series of generalised linear models were used to evaluate misidentification risks.

Results: A total of 947 subjects met our inclusion criteria, 14.6% having a final liaison diagnosis of organic mental disorder and 8.1% of delirium. Older patients were significantly associated with increased risk of misidentification for both organic conditions (OR 3.01 - 95% CI 2.01, 4.5) and delirium (OR 3.92 - 2.4, 6.39).

Conclusions: Educational interventions in general hospitals focused on preventing psychiatric misdiagnosis should target in-hospital services where patients tend to be older.
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http://dx.doi.org/10.1080/13651501.2017.1301483DOI Listing
September 2017

Treat as one: care of physically ill patients who also have a mental health condition.

Br J Hosp Med (Lond) 2017 Mar;78(3):126-127

Clinical Researcher, National Confidential Enquiry into Patient Outcome and Death, London.

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http://dx.doi.org/10.12968/hmed.2017.78.3.126DOI Listing
March 2017

The physiological response to cold-water immersion following a mixed martial arts training session.

Appl Physiol Nutr Metab 2017 May 17;42(5):529-536. Epub 2017 Jan 17.

b Free Radical Biochemistry Laboratory, School of Biological Sciences, University of Canterbury, Private Bag 4800, Christchurch, New Zealand.

Combative sport is one of the most physically intense forms of exercise, yet the effect of recovery interventions has been largely unexplored. We investigated the effect of cold-water immersion on structural, inflammatory, and physiological stress biomarkers following a mixed martial arts (MMA) contest preparation training session in comparison with passive recovery. Semiprofessional MMA competitors (n = 15) were randomly assigned to a cold-water immersion (15 min at 10 °C) or passive recovery protocol (ambient air) completed immediately following a contest preparation training session. Markers of muscle damage (urinary myoglobin), inflammation/oxidative stress (urinary neopterin + total neopterin (neopterin + 7,8-dihydroneopterin)), and hypothalamic-pituitary axis (HPA) activation (saliva cortisol) were determined before, immediately after, and 1, 2, and 24 h postsession. Ratings of perceived soreness and fatigue, counter movement jump, and gastrointestinal temperature were also measured. Concentrations of all biomarkers increased significantly (p < 0.05) postsession. Cold water immersion attenuated increases in urinary neopterin (p < 0.05, d = 0.58), total neopterin (p < 0.05, d = 0.89), and saliva cortisol after 2 h (p < 0.05, d = 0.68) and urinary neopterin again at 24 h (p < 0.01, d = 0.57) in comparison with passive recovery. Perceived soreness, fatigue, and gastrointestinal temperatures were also lower for the cold-water immersion group at several time points postsession whilst counter movement jump did not differ. Combative sport athletes who are subjected to impact-induced stress may benefit from immediate cold-water immersion as a simple recovery intervention that reduces delayed onset muscle soreness as well as macrophage and HPA activation whilst not impairing functional performance.
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http://dx.doi.org/10.1139/apnm-2016-0582DOI Listing
May 2017

The physiological response to cold-water immersion following a mixed martial arts training session.

Appl Physiol Nutr Metab 2017 May 17;42(5):529-536. Epub 2017 Jan 17.

b Free Radical Biochemistry Laboratory, School of Biological Sciences, University of Canterbury, Private Bag 4800, Christchurch, New Zealand.

Combative sport is one of the most physically intense forms of exercise, yet the effect of recovery interventions has been largely unexplored. We investigated the effect of cold-water immersion on structural, inflammatory, and physiological stress biomarkers following a mixed martial arts (MMA) contest preparation training session in comparison with passive recovery. Semiprofessional MMA competitors (n = 15) were randomly assigned to a cold-water immersion (15 min at 10 °C) or passive recovery protocol (ambient air) completed immediately following a contest preparation training session. Markers of muscle damage (urinary myoglobin), inflammation/oxidative stress (urinary neopterin + total neopterin (neopterin + 7,8-dihydroneopterin)), and hypothalamic-pituitary axis (HPA) activation (saliva cortisol) were determined before, immediately after, and 1, 2, and 24 h postsession. Ratings of perceived soreness and fatigue, counter movement jump, and gastrointestinal temperature were also measured. Concentrations of all biomarkers increased significantly (p < 0.05) postsession. Cold water immersion attenuated increases in urinary neopterin (p < 0.05, d = 0.58), total neopterin (p < 0.05, d = 0.89), and saliva cortisol after 2 h (p < 0.05, d = 0.68) and urinary neopterin again at 24 h (p < 0.01, d = 0.57) in comparison with passive recovery. Perceived soreness, fatigue, and gastrointestinal temperatures were also lower for the cold-water immersion group at several time points postsession whilst counter movement jump did not differ. Combative sport athletes who are subjected to impact-induced stress may benefit from immediate cold-water immersion as a simple recovery intervention that reduces delayed onset muscle soreness as well as macrophage and HPA activation whilst not impairing functional performance.
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http://dx.doi.org/10.1139/apnm-2016-0582DOI Listing
May 2017

Integrating mental health simulation into routine health-care education.

Lancet Psychiatry 2016 Aug;3(8):702-703

Maudsley Simulation, South London & Maudsley NHS Foundation Trust, London SW9 9NT, UK; Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK. Electronic address:

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http://dx.doi.org/10.1016/S2215-0366(16)30100-6DOI Listing
August 2016

Characteristics of people who rapidly and frequently reattend the emergency department for mental health needs.

Eur J Emerg Med 2016 Oct;23(5):351-5

aDepartment of Psychology and Psychotherapy, Maudsley Hospital bDepartment of Biostatistics, Institute of Psychiatry, Psychology and Neuroscience cDepartment of Psychological Medicine, Kings College Hospital, London, UK.

Objective: This paper identifies the characteristics of emergency department (ED) attendees with a referral to their Mental Health Liaison Service (MHLS) who are at increased risk for rapidly reattending, attending frequently, or attending intensely at this service (which is defined here as rapid and frequent reattendance).

Methods: A retrospective 5-year longitudinal study was conducted of all visitors (n=24 010) attending four busy EDs with a referral to their MHLS from the beginning of 2009 until the end of 2013. A Cox proportional hazards regression was used to identify factors associated with intense use, and a negative binomial regression was used to identify factors associated with frequent attendance.

Results: People with certain characteristics were more likely to make 'intense' use of mental health emergency services, which we define as shorter time to reattendance and a higher number of visits over 5 years. The people more likely to make intense use are more likely to have certain clinical diagnoses such as substance misuse, stress disorder, personality disorder and learning disability, to have certain social characteristics such as not being in a relationship, or living alone, and to have healthcare issues such as having been detained under the Mental Health Act and having a greater number of care coordinators over 5 years.

Conclusion: Individuals with certain clinical and social characteristics were significantly more likely to reattend EDs and have referral to MHLS rapidly and frequently (i.e. intensely).
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http://dx.doi.org/10.1097/MEJ.0000000000000349DOI Listing
October 2016

Improving the diagnosis of physical illness in patients with mental illness who present in emergency departments: consensus study.

J Psychosom Res 2015 Apr 24;78(4):346-51. Epub 2015 Jan 24.

Health Service and Population Research Department, King's College London, Institute of Psychiatry, Psychology and Neuroscience, 16 De Crespigny Park London SE5 8AF, UK.

Objective: The aim of this study was to establish consensus among clinicians in order to produce recommendations to optimise the diagnosis of physical illness in patients with mental illness who present in Emergency Departments (EDs).

Method: A list of recommendations was derived from qualitative interviews conducted with 39 doctors and nurses working in EDs in four general hospitals in England. Using a modified nominal group technique, we then asked a selected group of 15 doctors and nurses to take part in a group discussion with two voting rounds in order to decide which recommendations are most beneficial and feasible.

Results: Five recommendations met the a priori criteria to be considered 'strongly supported'. These included: having a psychiatric liaison team staff available 24 hours a day in the vicinity of the ED; developing detailed guidelines regarding intoxicated patients and regarding parallel assessment of patients by both ED and psychiatric staff; and having regular meetings between representatives of both departments.

Conclusion: In addition to suggesting specific recommendations, the study stresses the advantages in increasing the accessibility of psychiatric staff in the ED but also identifies challenges regarding joint work and division of responsibilities between them and the ED acute team.
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http://dx.doi.org/10.1016/j.jpsychores.2015.01.010DOI Listing
April 2015

Ethnic differences in self-poisoning across South London.

Crisis 2014 Jan;35(4):268-72

Health Service and Population Research Department, Institute of Psychiatry, King's College London, UK

Background: Self-poisoning (overdose) is the commonest form of self-harm cases presenting to acute secondary care services in the UK, where there has been limited investigation of self-harm in black and minority ethnic communities. London has the UK's most ethnically diverse areas but presents challenges in resident-based data collection due to the large number of hospitals.

Aims: To investigate the rates and characteristics of self-poisoning presentations in two central London boroughs.

Method: All incident cases of self-poisoning presentations of residents of Lambeth and Southwark were identified over a 12-month period through comprehensive acute and mental health trust data collection systems at multiple hospitals. Analysis was done using STATA 12.1.

Results: A rate of 121.4/100,000 was recorded across a population of more than half a million residents. Women exceeded men in all measured ethnic groups. Black women presented 1.5 times more than white women. Gender ratios within ethnicities were marked. Among those aged younger than 24 years, black women were almost 7 times more likely to present than black men were.

Conclusion: Self-poisoning is the commonest form of self-harm presentation to UK hospitals but population-based rates are rare. These results have implications for formulating and managing risk in clinical services for both minority ethnic women and men.
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http://dx.doi.org/10.1027/0227-5910/a000258DOI Listing
January 2014

How we developed an emergency psychiatry training course for new residents using principles of high-fidelity simulation.

Med Teach 2013 Oct 5;35(10):797-800. Epub 2013 Sep 5.

Central and North West London NHS Foundation Trust , UK.

New psychiatry residents must rapidly acquire new clinical skills and learn to work effectively with new colleagues. In medical and surgical specialties, high-fidelity simulation with structured debriefing is widely used, but so far this has not been applied to psychiatry. We have developed a one-day simulation-based training course for emergency psychiatry which incorporates clinical and team-working skills training. Five scenarios covering key psychiatric emergencies are delivered in a purpose-built simulation facility. Patients are played by an actor or a high-fidelity manikin. Each scenario is followed by a 45-minute group debrief. Evaluation of a pilot group found that the course was well received and improved participants' workplace confidence. We are now planning to expand the course, provide it to all new residents and conduct further evaluation.
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http://dx.doi.org/10.3109/0142159X.2013.803522DOI Listing
October 2013

Psychiatric aspects of acute withdrawal from gamma-hydroxybutyrate (GHB) and its analogue gamma-butyrolactone (GBL): implications for psychiatry services in the general hospital.

Int J Psychiatry Clin Pract 2013 Jun 12;17(2):154-6. Epub 2013 Apr 12.

Department of Liaison Psychiatry, South London and Maudsley NHS Foundation Trust, London, UK.

Objective: The objective of this study was to describe the psychiatric symptoms, management and outcomes in a consecutive series of patients being managed medically for symptoms of withdrawal from gamma-hydroxybutyrate (GHB) and its analogue gamma-butyrolactone (GBL) in a general hospital setting.

Methods: A toxicology database was used to identify patients presenting with a history suggestive of withdrawal from GHB and analogues. Electronic and paper medical records were searched for demographic features, neuropsychiatric symptoms, psychiatric management while in hospital and overall outcome.

Results: There were 31 presentations with withdrawal from the drugs involving 20 patients. Of these 17 (54%) were referred to and seen by the liaison psychiatry team. Anxiety (61.3%) and agitation (48.4%) were the most common symptoms. Of the 17 cases seen by the liaison psychiatry team, 52.9% required close constant observation by a mental health nurse and 29.4% required to be detained in hospital under mental health legislation.

Conclusions: The significant proportion of patients presenting with neuropsychiatric symptoms and requiring intensive input from the liaison psychiatry team during withdrawal from GHB and its analogues points to the importance of close liaison between medical and psychiatric teams in managing these patients in the general hospital.
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http://dx.doi.org/10.3109/13651501.2013.784790DOI Listing
June 2013
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