Elective alcohol detoxification admissions to Huntlyburn Ward

Prior to admission the Unitary Patient Record of Admission document will have been started by their community addictions nurse, who will document their background and past history. This should be confirmed with the patient by the admitting doctor and any additional details added as needed.

On Admission – by staff on ward

1. Nursing admission
1. Usual admission nursing assessment
2. Breathalyse
3. Urine dip
4. Urine drug screen (instant pot – if any positives also send lab sample)
5. Physical observations
6. Patients to be made aware of expectations and rules of ward and that they may be asked to provide a drug screen or be breathalysed further during their admission.
2. Medical admission
1. Check details and history on Unitary Patient Record of Admission (including medicine reconciliation)
2. Mental state examination
3. Full physical examination
4. ECG
5. Routine bloods for alcohol detox - FBC/ U&Es/ LFTs/ GGT/ Mg / PO4 / Ca / Glucose

1. 1. 1. If known concerns around liver function, then coagulation should be added
      2. If initial bloods show significantly deranged LFT’s (especially elevated bilirubin) additional testing of coagulation should be requested.

              f. Blood-Borne Virus testing

1. 1. 1. All patients should have blood sent for Hep / HIV screening unless undertaken within the last 6 months. If any report of a new high-risk exposure this should be repeated.

Example drugs charts showing 1^st line medications used are in Appendix 1.

Benzodiazepines

1^st line – Chlordiazepoxide

In medically assisted alcohol detox, the patient is required to stop alcohol intake abruptly, its effects are replaced by a benzodiazepine that has cross-tolerance in a safe and structured manner. This can be reduced at a rate that prevents withdrawal symptoms, but without promoting over-sedation, and ultimately stopped altogether. The process involves providing a large enough initial dose to prevent severe withdrawal symptoms including seizures, delirium tremens, severe anxiety or autonomic instability, but to withdraw the medication before physical dependence on its effects begins.

On Huntlyburn chlordiazepoxide is used 1^st line as the benzodiazepine to manage alcohol withdrawal. For elective admissions, a fixed reducing regime is used, this should always be prescribed and is contained in Appendix 2.

Alongside the fixed reduction, as required (PRN) chlordiazepoxide should be prescribed, with a maximum of 250 mg daily (including regular). If there is evidence of particularly severe withdrawal symptoms, discuss this with a senior doctor in BAS who may request this be increased to a maximum dose of 300 mg daily, or higher if appropriate, as well as considering any other management steps. Patients can request PRN doses from nursing staff if they are experiencing withdrawal symptoms, or these may be actively offered by nursing staff if they observe evidence of withdrawal. Nursing staff must use the Clinical Institute Withdrawal Assessment for Alcohol (CIWA - Ar) scoring to help them judge the severity of withdrawal that a patient is experiencing and to guide if PRN doses are needed (Appendix 3), a score of 10 or over generally indicates that a PRN should be given. CIWA score must be recorded in the notes prior to administration of any PRN doses and again 1hr after administration of the PRN dose.

Nursing staff should seek senior support if they are unsure if PRN doses should be administered or if they feel that PRN doses may be required during a fixed dose reduction.

Some patients, especially at the start of the detox, may struggle and need to repeat a previous day, for example restarting and repeating day one (chlordiazepoxide 30 mg QDS) the day following admission. There should be a low threshold for doing this, alongside allowing more liberal usage of PRN in the first 3 days. This is the highest risk period of the detox and more liberal chlordiazepoxide use lowers the risk of seizures or delirium tremens (DT’s) developing.

2^nd line – Diazepam

Diazepam can be used as an alternative to Chlordiazepoxide. It has a longer half-life than Chlordiazepoxide and can be more prone to accumulation and toxicity. It should only be used in place of Chlordiazepoxide where this has been specially requested by BAS. It should not be used where there is severe liver impairment. Diazepam 5 mg is approximately equivalent to 12.5 mg of Chlordiazepoxide. In addition to the reduction regime in Appendix 4 an as required dose of Diazepam 5 – 10 mg should be prescribed, total maximum of 100 mg in 24 hours.

In severe liver impairment

1^st Line – Oxazepam

Where patients have severe liver impairment (often most clearly evidenced by elevated bilirubin and deranged clotting functions) consideration should be given to using oxazepam, as this is shorter acting and renally excreted. Doses for this are approximately equivalent to chlordiazepoxide, regular monitoring is needed to ensure there are no breakthrough withdrawals, given the shorter half-life.

2^nd Line – Lorazepam

Use of lorazepam should be discussed with BAS to get advice around this if needed. Thiamine (including injectable thiamine)

Thiamine (including injectable thiamine)

Vitamin replacement is essential as a preventative measure against the onset of Wernicke’s Encephalopathy (WE). If untreated, WE progresses to Korsakoff’s syndrome. WE is a progressive neurological condition caused by thiamine deficiency. WE can occur in those who consume a large amount of alcohol, have a restricted diet and alcohol related reduced absorption of thiamine.

All elective inpatient admissions for alcohol detox should be treated as being at possible risk of WE and should be prescribed prophylactic thiamine, initially as injectable thiamine. Unfortunately, IVs are not available on Huntlyburn and so this should be done IM. The IM injection can be painful, but its importance should be explained to patients, and they should be supported to tolerate it if at all possible. It should be checked to ensure patients have not missed injectable thiamine doses, especially the first doses after admission; timings should be altered if needed, to ensure this is given.

Prescribe all patients injectable thiamine IM 200mg BD for 3 days.

Once injectable thiamine is stopped all patients should be prescribed oral thiamine 100 mg TDS. Any patient declining injectable thiamine should be prescribed oral thiamine from the outset. The patient’s decision to refuse injectable thiamine despite sufficient information should be clearly documented in their notes.

Acamprosate

There is evidence acamprosate reduces cravings to drink alcohol (licensed indication) and offers some neuroprotection during detox (unlicensed but agreed in Lothian and Borders – DO discuss with patient). It is routine practice on Huntlyburn to offer to start all elective admissions for alcohol detox on acamprosate. This can then if the patient wishes be continued following discharge to aid in relapse prevention.

The usual dose is 666 mg TDS. If weight <60kg, reduce dose to 666mg in the morning, 333mg afternoon and evening. Continue on discharge for up to 6 months. If very deranged LFTs (contraindicated in Childs-Pugh C) or renal insufficiency (creatinine>120 micromol/l) do not give. Use over the age of 65 is off label and should only be done if approved by a senior BAS doctor.

Other PRN Medications

Other medications that should be routinely prescribed for patients PRN as they may be required during detox include:

• Metoclopramide 10 mg PRN/max TDS (oral or IM) – For nausea or vomiting
• Loperamide 2 mg PRN/max QDS (oral) – For diarrhoea
• Diazepam 10mg PRN (rectal) – For seizure
• Treatment should be given if convulsion lasts longer than 5 minutes
• 10mg rectally - Can be repeated once after 10 minutes, if first administration does not terminate seizure
• Zopiclone 7.5 mg PRN/max ON – For insomnia
• Not to be continued out of hospital, unless it was prescribed prior to admission

Symptomatic Relief Policy

The Symptomatic Relief Policy (SRP) should be prescribed for all patients. It includes simple medications nurses can give without having to contact the duty doctor. Note, it includes paracetamol, if weight <50kg or patient on regular paracetamol, exclude from the SRP and ensure there is an alternative prescription on the Kardex.

Existing Benzodiazepine Prescriptions

If patients are already on another regular prescription of a benzodiazepine when admitted for a detox and are clear that they have been taking this reliably prior to admission, then this should be continued unchanged. The chlordiazepoxide should be prescribed as usual in addition to existing benzodiazepines. This should be clearly documented in the admission document by the patient's community mental health nurse but must be confirmed by staff on admission.

Existing benzodiazepines should only be altered where this is part of the plan from BAS or requested by BAS doctors during the admission.

• BAS senior doctors can be contacted to offer advice around the management of these patients.
• BAS senior doctors do not have allocated time to come and review elective detox patients on the ward and would only review them directly if there is an identified need. If review is thought to be needed this should be discussed with a senior BAS doctor and might be offered face to face, by video call or by phone.
• Initial bloods should be taken, and results will be chased by resident medical staff.
  • If any electrolyte abnormality is noted this should be treated and bloods repeated as a minimum 48hourly although may require daily. Please refer to guideline on electrolyte abnormalities.
  • Consider refeeding risk and oral electrolyte replacements, particularly Mg (if low, may contribute to withdrawal syndrome), bloods should be checked more frequently as needed and dietetics consulted.
  • If any bloods are significantly deranged these should be discussed with a senior BAS doctor and repeated, as necessary.
  • If initial bloods are mildly deranged these should be repeated prior to discharge.
• Patients who become physically unwell should be discussed with the BGH medical SpR. Such as those with signs of alcoholic hepatitis/ decompensated alcoholic liver disease / GI bleeding etc. If needed, patients should be transferred for further medical management at the BGH. If transferred and then deemed medically fit but requiring to complete detox they can be transferred back to Huntlyburn for this.
• A screening ACE III should be completed with all patients before discharge, but at the end of the detox once withdrawal symptoms are fully resolved. This can be done by any staff member who has been trained to complete the ACEIII.

All patients admitted for elective detox will be informal and are coming in on the basis that they wish to stop drinking and be detoxed. They should all be on standard passes but should be asked to stay on the ward for the first 72 hours, as this is the highest risk period of the detox. Following this they should be asked to coordinate passes with nursing staff, not being off for prolonged periods and ensuring they do not miss medications. We would not offer overnight passes prior to discharge home.

If patients request to self-discharge during their detox, unless there are any new concerns around their mental state, DT’s etc. they would be allowed to do so. Do not prescribe any benzodiazepines or additional medications to take off of the ward. BAS should be notified.

If patients use alcohol during their detox, then their detox has failed and they should be discharged. If patients return from pass and there is a suspicion of alcohol use staff should request to breathalyse them, refusal to allow this would usually be interpreted as evidence of alcohol use. If patients have been found to use, or returned having used, alcohol outside of daytime hours then, provided there are no management or behaviour concerns, it may be safer to allow them to stay on the ward overnight and be discharged the next day.

Patients admitted for elective detox do not usually require a full psychiatric discharge letter unless there have been complications or other issues during their admission. The template in Appendix 5 gives guidance as to the discharge letter. The GP should always be asked to repeat the bloods in 6 – 8 weeks of anyone who has been detoxed to ensure they are resolving and do not require further follow up.

If inappropriately managed, this carries a significant mortality rate and can result in permanent brain damage (Korsakoff’s psychosis) in 85% of survivors. As detailed above, all patients should be treated as at risk and be offered prophylactic injectable thiamine. The classical triad of signs (acute confusion, ataxia and ophthalmoplegia) only occurs in 10% of patients. Therefore, the triad cannot be used as the basis of diagnosis and a high index of suspicion is needed.

The presence of any one of the following signs should be sufficient to assign a diagnosis and commence treatment:

• Acute confusion (most common feature)
• Decreased consciousness level including unconsciousness or coma
• Memory disturbance
• Ataxia/unsteadiness
• Ophthalmoplegia (paralysis of the extraocular muscles that control the movements of the eye)
• Nystagmus (an involuntary rhythmic side-to-side, up and down or circular motion of the eyes)
• Unexplained hypotension with hypothermia.

In this situation ensure a course of injectable thiamine of 200mg BD by IM injection for 3 days then oral thiamine 100mg TDS ongoing.

If symptoms are not improving or the patient cannot tolerate IM injections twice daily, consideration must be given to transfer to the BGH to be given IV thiamine.

Delirium tremens usually emerges between day 2 and 3 (occasionally up to day 5) of alcohol withdrawal in a severely alcohol dependent individual. This is a medical emergency, with a mortality rate of 15-20% if untreated. Maintaining a high index of suspicion of the development of delirium tremens in those undergoing alcohol withdrawals is crucial.

Common symptoms include:

• increasing confusion, agitation, and disorientation
• severe tremor
• hallucinations (auditory, olfactory, and classically visual)
• delusional beliefs
• autonomic disturbance (tachycardia, hyperthermia, hypertension, tachypnoea)

Prevention of Delirium Tremens

Prevention of the onset of DTs is a key goal. Most cases of DTs can be prevented by more aggressive initial treatment with benzodiazepines. If patient presents with any of the following these will positively predict an increased risk of delirium tremens:

1. Previous history severe withdrawal / delirium
2. Tachycardia >100 bpm
3. CIWA > 15 with breathalyser alcohol reading > 50mg/100mls
4. Intercurrent infection e.g., chest infection / UTI
5. Temperature >38.9c

Patients using additional sedative medications e.g. benzodiazepines are also at higher risk.

For patients considered at risk,

1. Consider a “day 0” of Chlordiazepoxide 40mg QDS and then continue usual reduction following this.
2. Ensuring nursing staff are aware and request additional monitoring for withdrawal symptoms (consider hourly initially), supported by CIWA. With additional PRN Chlordiazepoxide used where indicated.
3. Ensure magnesium level checked and replacement commenced if low.
4. Correct any other electrolyte imbalances if required, especially hypokalaemia.

Management of Delirium Tremens

All patients thought to be in DTs should be discussed with a senior doctor. The measures listed may be difficult to maintain in a psychiatric setting on Huntlyburn. Delirium Tremens is a medical emergency and if patients deteriorate, they may require HDU/ITU care, there should be a low threshold for discussion with and transfer to the BGH, especially if any evidence of autonomic instability.

The inclusion of guidelines around patients remaining on Huntlyburn is not a suggestion or endorsement of these patients to remain in a psychiatric setting. However, if following discussion with BGH colleagues' the patients is felt able to be managed on the ward, the following can be considered.

Medication

Management requires the administration of adequate sedative doses of benzodiazepines. The aim is “front-loading” administering higher initial doses of benzodiazepine to achieve more rapid control. The object of treatment is to make the patient calm and lightly sedated but easily rousable. There is no maximum dose of benzodiazepines in DTs, however there must be awareness of the risk of overdosing and over sedation, which must be carefully monitored and consideration of transfer to a HDU/ITU setting considered.

• Consider giving initial doses of Chlordiazepoxide 30 - 50mg every 1 – 2 hours - aiming to achieve light sedation
• Then continue fixed dosing, may need adjustment based on response
• Continue use of additional PRN Chlordiazepoxide supported by CIWA scoring before administration of a PRN dose and 1hr after administering,

If no oral route:

• Consider Lorazepam 1 - 2 mg IM up to every hour, aiming to establish control of symptoms and allow oral dosing to resume

If there are prominent psychotic symptoms within the delirium:

• Consider Haloperidol 1 – 5 mg 8 hourly, either oral or IM.
  • ECG should be checked before giving to ensure normal QTc
  • If no ECG, consideration should be given to cardiac factors and risk benefit balance. Oral Olanzapine initially at 2.5mg is an alternative. IM Olanzapine should not be used as a 60-minute gap is needed between IM Olanzapine and a parenteral benzodiazepine.
  • Antipsychotics can lower the seizure threshold, and they do not treat the underlying alcohol withdrawal syndrome, they should not be used instead of adequate doses of benzodiazepines, but only alongside them.

Additional measures

1. Manage in a well-lit quiet room with reorientation chart and infrequent nursing changes (often requires 1:1 nursing.) Expert nursing care is a crucial element of safe management of delirium tremens.
2. Regular physical observations may initially need 1 -4 hourly.
3. Daily bloods for U&Es, Mg, blood glucose, LFT’s and FBC.
4. Maintain fluid balance chart, ensure fluid intake of at least 3L/day (may require IV – consider if transfer to the BGH is appropriate). The risk of dehydration and electrolyte disturbance are high.
5. Regular physical review by ward doctor to monitor for other emerging causes of confusion e.g., infection.
6. Treat every patient as incipient Wernicke’s - maintain injectable thiamine IM twice daily for 3 days (40% of WE cases emerge after episodes of delirium tremens).

Capacity and Legal status

• Patients in DTs may lose capacity to consent to medical treatment and assessment and consideration should be given to the use of a Certificate of Incapacity under Section 47 of the Adults with Incapacity (Scotland) Act 2000.
• If patients refuse to allow treatment requiring physical measures to administer it, or are actively seeking to leave, then they should be assessed to consider if detention under the Mental Health (Care and Treatment) (Scotland) Act 2003 is appropriate.
  • The BAS consultant may not always be available and if no other AMP is available an Emergency Detention Certificate may need to be considered initially.

The ward may be requested to start medications to support abstinence, either as part of the admission plan or by BAS doctors during the patient’s admission. There may be the need for repeat bloods or other investigations prior to these being commenced and whilst these will often have been previously discussed by their BAS keyworker. BAS would aim to have our own staff discuss these medications but may ask ward/sector medical staff to discuss and consent the patient around the use of these medications.

Acamprosate

Usually offered on admission, as described. It may increase continuous / cumulative abstinence by inhibiting glutamate NMDA receptor function. NICE recommends use for 6 months (stop if drinking persists for 4-6 weeks). A reduced dose is needed if under 60kg. Prescribing in the elderly is off label and may require a lower dose; there is poor evidence in over 65’s and a senior BAS doctor should have approved off label use.

Exclusion criteria:

• Known hypersensitivity to acamprosate or any of the tablet excipients.
• Renal insufficiency (serum creatinine >120 micromol/l).
• Severe hepatic failure (Childs-Pugh classification C).
• Pregnancy/lactation.
• The safety and efficiency of acamprosate has not been established in patients under 18 or over 65 and is therefore not recommended for standard use in these populations.

Naltrexone

Also licensed for use. It is an opioid blocker so cannot be used if patients are on opioids, and this must be discussed. Naltrexone is well tolerated and can reduce the rate of full relapse after having one drink. There is also evidence it can reduce the intensity of drinking days during a relapse. Started at 25mg on day 1 followed by 50mg ongoing once daily. If it causes nausea, the dose can be reduced to 25mg daily (unlicensed dose for this indication). There is no need for routine monitoring of bloods.

Exclusion criteria:

• Naltrexone should not be given to patients currently dependent on opioids as an acute withdrawal episode can be provoked.
• It should not be used in conjunction with any opioid medications. For example, it should not be used in patients with chronic pain that relies on opiate analgesia for pain control.
• Hypersensitivity to Naltrexone.
• Acute Hepatitis or liver failure. Not advised if pre-treatment baseline ALT value is greater than twice normal.
• Severe renal impairment.

Disulfiram

Disulfiram, often still known by the trade name Antabuse®, acts as a deterrent as patients experience side effects if they drink alcohol whilst taking it. These can range from facial flushing, vomiting, hypotension, hypertension or even (very rare if care taken to select patients appropriately) death. This reaction can be provoked up to as long as 7 days after stopping disulfiram.

It works by inhibiting aldehyde dehydrogenase, this is part of the pathway for the breakdown of alcohol and its inhibition leads to elevated levels of serum acetaldehyde and the “disulfiram reaction”. It does not have any effect on cravings to drink alcohol.

Before starting, repeat LFTs to ensure that they are improving, as well as a further ECG if any concerns around the initial trace on admission. It is contraindicated in heart conditions, family history of sudden death and some other conditions, including moderate cognitive impairment. It is also not recommended in people who self-harm or take overdoses as they can use the reaction as a dangerous form of self-harming. Patients also need to be counselled about hidden alcohol, such as in perfume or mouth wash, which can cause them to have a reaction. They need to check the back of toiletries for ingredients and require them to be alcohol free.

Whilst it can be given for the patient to take alone, the evidence is much better with supervision. Either as part of the “partnership” approach where family or someone living with the patient observes them taking it, or 3 x weekly at a community pharmacy. BAS should notify the ward of arrangements and if BAS will prescribe (often if going to be supervised at a pharmacy) or if the GP should be asked to prescribe on the discharge letter.

It can very rarely cause fulminant hepatitis so patients should be told to stop taking it if they feel ill, and to seek urgent medical attention. No monitoring blood tests are required while taking it.

Exclusion criteria:

• Short term memory impairment such that patient cannot understand / remember implications of being on Disulfiram.
• Heart disease: active or within the last 6 months; tendency to develop cardiac arrhythmias. In such patients, alcohol reaction could be fatal.
• Significant liver disease: Caution when bilirubin >25mmols and / or GGT > ten times normal and / or AST or ALT or AlkPhos > twice normal. This is a guide ONLY and must be taken in the context of other investigations. Raised bilirubin / deranged clotting may be of particular concern.
• Severe personality disorder, suicidal risk, or psychosis. In this case, referral to consultant psychiatrist for a full assessment of mental health and risk from resumption of alcohol is appropriate and may result in use of disulfiram.
• Previous allergic reaction to Disulfiram or any of the excipients.

Baclofen

Rarely used and not licensed. Largely used in patients with severe alcoholic liver disease who cannot take the other licensed medications. There is some suggestion that it helps people with anxiety, but the usual treatments for anxiety should be considered first. Would only be started if agreed with a senior BAS doctor.

For any of the above medications provide written information to the patient and use this to support resident medical staff if they are being asked to discuss these medications with the patient. Ensure that information provision, patient consent to treatment and a discussion on side effects and what to do if these occur is documented in the patient notes.

Leaflets can be taken from NHS Choice and Medication - https://www.choiceandmedication.org/nhs24

Acamprosate: https://www.choiceandmedication.org/nhs24/generate/pillacamprosateuk.pdf

Naltrexone: https://www.choiceandmedication.org/nhs24/generate/pillnaltrexoneuk.pdf

Disulfiram: https://www.choiceandmedication.org/nhs24/generate/pilldisulfiramuk.pdf

Baclofen: https://www.choiceandmedication.org/nhs24/generate/pillbaclofenuk.pdf

Patients admitted for elective detox generally do not require a full psychiatric discharge letter, a brief letter with clear details of any actions needed by the GP is usually sufficient. The template below gives guidance and suggestion of some standard wording, sections in Red are guidance and not to be included, any other wording shown is only a suggestion and should be amended or removed as needed. Patients where the admission has been more complex, for example – significant medical complications, DT’s, WKS or concerns around ARBD will need a comprehensive letter.

Circumstances of admission
Your patient was admitted for a planned alcohol detox under the care of the addictions service.

History of alcohol and drug use
Summarise briefly history from admission document, does not need to be in depth. Brief account of alcohol and drug history. Include details of previous detoxes and previous use of medications to support abstinence (acamprosate, naltrexone, disulfiram).

Social circumstances
Brief summary of social circumstances, major supports and relationships. Please ensure details of any social work input, care package or carers, significant financial problems, housing problems etc are mentioned

Medication on admission, sensitivities to medication, allergies
List medications prescribed on admission and allergies

Physical assessment on admission, including results of investigations
Summary of initial physical examination, including results of ECG and bloods. Ensure details of any features identified of liver disease are mentioned.

Treatment given and progress on the ward
Your patient completed a medically supported detoxification from alcohol in accordance with our usual inpatient protocol. This was uncomplicated. – Delete if not the case and give details of the detox, how tolerated and what was required.

Your patient was started on Acamprosate and wishes to continue this following discharge to reduce cravings to drink and support their ongoing abstinence.– Delete if not the case

Little else may be needed for an uncomplicated admission. However if there have been complications during the detox, these should be fully detailed.

Physical investigations during admission:
Add this section if needed. If bloods or other investigations were repeated prior to discharge then please detail these and mention significant results.

ACE-III
An Addenbrooke's cognitive examination III was completed prior to discharge on the xx/xx/xx to give a baseline.

Please give results of ACE-III done prior to discharge. If there were any obvious concerns around cognition or functioning these should be mentioned.

Risks
Other important information to highlight around risks, difficult social circumstances, children, concerns about vulnerability, management on the ward to reduce risk (e.g. constant obs needed, limitation of contact with vulnerable patients) etc.

Driving
Driving should have been discussed by anyone being admitted with their addictions key worker; however it should be clarified again during the admission that they understand they should not be driving and have been medically advised of this and the obligation to notify the DVLA if they hold a licence.

Ongoing management / actions requested from primary care

1. Please repeat bloods including LFT’s and GGT in 6 – 8 weeks to ensure these are normalising.
   
   Detail any other actions required by primary care please ensure to clearly list any new medications started and if these are to be continued by GP or are being prescribed by addictions. Examples:
   
   
2. Please can their GP continue Acamprosate 666mg three times daily
3. They have been started on Disulfiram 200mg daily, this will be prescribed by BAS and does not need to be prescribed in primary care.

Yours sincerely

Kyna Harvey, Clinical Pharmacist, NHS Borders

Adrian Mackenzie, Clinical Pharmacist, BAS, NHS Borders

Dr Rosemary Gordon, Consultant Addiction Psychiatrist

Sarah McFarlane, Senior Charge Nurse, Huntlyburn House, NHS Borders

Dr James Tidder, Consultant Addiction Psychiatrist, NHS Borders

Fiona Bennie, Team Manager, BAS, NHS Borders

Dr Gemma Berry, Resident Dr Lead, Huntlyburn House, NHS Borders

Dr Caoimhe Cooke, Core Psychiatry Trainee, BAS, NHS Borders