This case report describes a forensic psychiatric patient presenting with treatment-resistant schizophrenia and serious interpersonal violence complicated by poor adherence to oral medication who was treated successfully with two concurrent long-acting depot antipsychotics.
Treatment response was measured for a 6-month period at 6-weekly intervals, post-initiation using the Positive and Negative Symptoms of Schizophrenia with Excited Component score (PANSS-EC), Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression Scale (CGI).
At 6 months, the presentation was found to have markedly improved. The overall PANSS-EC score was reduced by 43.9%, with reductions in Positive Symptom and Excited Component subscales most evident. BPRS Score was reduced from 81 at baseline to 47 at 18 weeks. There was improvement in the patient’s level of cooperativeness, aggression and engagement in ward therapeutic activities.
Although concurrent use of two depot antipsychotics requires further exploration, there is potential benefit for patient groups presenting with treatment-resistant schizophrenia and poor compliance. Due to risk of serious adverse effects which are difficult to reverse with long-acting formulations, we recommend this option be reserved for this complex patient population and exclusively in care settings allowing close physical health monitoring.
We aimed to explore psychiatry trainees’ perspectives on clinical teaching and supervision as well as how this might be improved.
New Zealand trainees (n=51) completed online the Maastricht Clinical Teaching Questionnaire (MCQT) and three open-ended questions.
The majority rated ‘agree’ or ‘strongly agree’ to all items of the MCQT. Weaknesses in the feedback process including observation, feedback provision, and formulating learning goals were highlighted. College training requirements and workplace environment were identified as factors impacting on clinical teaching and supervision.
A model was proposed to enhance awareness of the various factors involved in the feedback process.
This paper provides a review of the rates of self-harm and repeated self-harm among young people. It describes some of the risk factors associated with these behaviours and summarises some of the barriers to delivering optimal treatment.
The review concludes that there is an urgent need for the delivery of respectful and evidence-based practice to all young people who present with self-harm. In addition, improved monitoring of self-harm presentations to hospitals across Australia is required in order that robust data are collected and the impact of practice change can be reliably assessed.
To outline current understanding and recommended treatments for paraphilic or sexual deviant disorders in adolescents and youth.
An overview of the diagnosis, development and scope of paraphilic disorders. Evidence and an algorithm for pharmacological treatments in youth are outlined.
Paraphilic disorders are relatively common in adolescents and youth, with fantasies and urges preceding the onset of deviant behaviour by a handful of years. Research in youth is sparse, but the available evidence supports that paraphilic disorders respond favourably to psychological and pharmacological treatments.
The detection of paraphilic disorders in adolescents and youth presents a window of opportunity, where treatment may be provided before deviant behaviour occurs, potentially reducing the future incidence of sexual abuse.
Psychiatry has ignored history, anthropology, sociology and literature in the search for enlightenment regarding suicide. Our objective was to determine what, if anything, Aesop’s fables had to teach us about suicide in around 600 BCE. Aesop’s account is around two centuries older than the oldest text (Herodotus: The histories) previously examined by our group.
We examined two translations of Aesop’s fables, seeking accounts fitting the following categories: (1) suicidal thinking, (2) suicidal behaviour without fatal consequences, and (3) suicidal behaviour with fatal consequences.
One account fitting each of these categories was identified. The triggers were: (i) self-doubt and criticism, (ii) unpleasant predicament (constant fear), and (iii) inescapable physical pain.
Evidence indicates that around 600 BCE, suicide was practised as a means of coping with self-doubt and criticism, unpleasant predicaments and inescapable physical pain. Recent scientific evidence confirms these observations.
It has been proposed that legislation for same-sex marriage has a positive mental health benefit. The purpose of this paper is to review and evaluate the empirical and conceptual links between same-sex marriage and mental health.
There are substantive methodological issues in the four surveys and comparisons undertaken. Difficulties with the validity of the evidence are discussed. Conceptual difficulties in the arguments relating to victimisation as well as the psychology of marriage are highlighted. It was concluded that it is premature to make claims of causality vis-a-vis same-sex marriage legislation and mental health.
To determine the rate of presentations for suicidal ideation and deliberate self-harm in the Kimberley region of Western Australia, characterized in terms of age, gender, rates of repetition and engagement with community mental health services.
An observational study of health service presentations over 12 months. Setting: 10 sites across the region with police services were included, capturing the overwhelming majority of self-harm presentations in the region. Participants: all Indigenous presentations were analyzed. Of the 433 individuals who presented, 361 were Indigenous. Main outcome measures: suicidal phenomena, including suicidal ideation and any type of deliberate self-harm regardless of intent.
Analysis suggests a broadly similar age and sex stratification of self-harm in this population compared with international reports. The rates, however, are 5–20 times higher than those reported in non-Indigenous populations in Australia and abroad, depending on whether the comparison rate is calculated from population surveys or hospital presentations.
Prevalence of suicidal phenomena is very high and is likely to be much higher than estimated by this hospital based study. Such high prevalence suggests that a population level intervention is required in addition to interventions involving clinical services.
The objective of this study was to determine whether a ‘housing first’ permanent supported accommodation was effective in improving housing stability, continuity of care and reducing mental health admissions for persons experiencing chronic homelessness with psychosis.
A quasi prospective cohort study of 42 chronic homeless persons with psychosis accommodated in a new purpose built facility in central Melbourne. Accommodation stability, mental health service contacts and psychiatric admissions were compared across the 2 years prior, the first 2 years of placement and the 2 years after leaving.
The mean number of mental health admissions in the first 2 years of accommodation was less (0.56, SD = 1.0) when compared with in the 2 years prior to accommodation (1.0, SD = 1.4, p = 0.05). There was an increase in the mean total number of days admitted in the 2 years after having left the supported accommodation, (33.3 days, SD = 86.7, p = 0.043)
The accommodation of chronic homeless persons with psychosis in a ‘housing first’ permanent supported accommodation lead to increased housing stability and optimism, improved continuity of care and reduced psychiatric admissions.
Complex treatment decisions can be suboptimal due to lack of a reliable decision-making model, a need this paper aims to meet.
A model for making complex treatment decisions is introduced.
The utility of the proposed method is demonstrated by making a complex treatment decision involving evaluation of clozapine treatment in a treatment-resistant patient.
The proposed method implemented as a software tool can provide a framework for shared decision-making involving the patient.
Recently, Indigenous academics have evolved an Indigenist discourse that centralises Indigenous ‘ways of knowing, being and doing’. Through this dialogue, Indigenous ‘ways of knowing and being’ augment Western biopsychosocial treatments.
This paper outlines the authors’ clinical encounters with young people from the Koori community and ongoing consultation with Koori community Elders in Victoria that led to engaging young people and their families in an Indigenist dialogue.
The Indigenist dialogue facilitates deeper engagement in the therapeutic process, opportunities to mirror and reflect on young people’s experiences, and drawing parallels between Western health interventions and Aboriginal cultural ways of doing health and being healthy.
The young people and their families evince greater faith in the management process and a deeper focus, centred awareness and knowledge of their Cultural rights and responsibilities. Future developments should include a systematic database with qualitative and quantitative data to support its evaluation and iterative development and improved community engagement to ensure holistic health gains are maintained.
To examine the differences in the physical health of Indigenous and non-Indigenous patients with severe mental illness (SMI) undergoing psychiatric rehabilitation.
An audit of the physical health of patients (n = 361) in all publicly funded residential rehabilitation programs in Queensland was carried out in late 2014. Data collection focused on clinical and lifestyle factors associated with physical health.
The prevalence of smoking, substance use and type 2 diabetes in Indigenous patients was significantly higher than rates found in non-Indigenous patients. Metabolic syndrome was also significantly higher in indigenous patients, with 66% of Indigenous patients compared to 46% of non-Indigenous patients meeting criteria for metabolic syndrome.
Patients with SMI in residential rehabilitation programs have poor physical health. Our findings underscore the need for clinicians to develop and evaluate interventions aimed at improving the metabolic profile of those with SMI in residential rehabilitation programs. Historical factors and cultural traditions need to be considered when designing lifestyle interventions for Indigenous patients.
We aimed to investigate the effectiveness of a day visit in changing attitudes towards a high-security forensic psychiatric hospital, with regard to the current recruitment difficulties in psychiatry.
Broadmoor Hospital, a UK high-security psychiatric hospital, runs day visits for medical students, led by doctors. At the beginning and the end of the day students wrote their responses to the question, ‘What do you think of Broadmoor?’ Attitudes and themes were identified, and their prevalence was analysed.
The responses of 296 students were initially analysed; however, 19 responses had to be excluded because they were illegible or incomplete. Before the visit, 15 responses were rated as positive, 169 neutral and 93 negative. After the visit, 205 responses were positive, 69 neutral and three negative. The themes that changed markedly following the visit were those indicating a change to favourable attitude.
A single day visit was shown to be effective in altering the attitudes of medical students towards forensic psychiatry within a high-security psychiatric hospital.
We examined the extent to which ethnicity, cannabis and alcohol use could predict prevalence of violence and self-harm in an inpatient psychiatric sample.
We collected demographic and clinical data in a series of 141 adult psychiatric inpatients in Hamilton, New Zealand. The Alcohol Use Disorders Identification Test (AUDIT) and Cannabis Use Disorders Identification Test, Revised (CUDIT-R) were used to measure substance use. Clinical assessment and file review were used to verify histories of self-harm and violence.
It was found that 66% had a history of violence, 54% of self-harm, and 40% of both; only 20% had neither. Cannabis use was found to significantly predict lifetime history of violence (p = 0.02); other independent variables (gender, age, ethnicity, alcohol use, psychiatric diagnosis) did not. Self-harm was strikingly predicted by female gender (p < 0.001), as well as by measures both of cannabis (p = 0.025) and alcohol use (p = 0.036); age, ethnicity and diagnosis did not reach significance. Less than 10% of patients were engaged with drug or alcohol services.
Cannabis use is a significant predictor of lifetime violence among the severely mentally ill, while both alcohol and cannabis use predict self-harm. Few affected patients receive specific treatment for substance use comorbidity.
We aimed to explore aspects of the removal of hanging points from correctional facilities.
An argument can be made that individuals have a right to die/suicide. The United Nations holds that except for freedom of movement, prisoners have the same rights as non-prisoners. The rights of the individual and the duty of many custodial institutions are in conflict. This introduces a conundrum; when all hanging points are removed from correctional facilities, prisoners without mental disorder, but with a sustained wish to die, will not be able to achieve that end, while non-prisoners will be well able to do so.
Despite high levels of alcohol use, drug use and risky behaviors, rates of help-seeking amongst young people are typically low. This study explored the profile of young people (under the age of 25 years) completing an online screen, assessing substance use problem severity and wellbeing in comparison with adults completing the same screen, so as to inform development of better targeted approaches for this in-need population.
Between 2012 and 2014, an online alcohol and drug screen was promoted across Australia on a national online counseling service. The screen assessed severity of substance use, mental health and wellbeing.
A total of 2939 screens were completed between December 2012 and May 2014, with 18% completed by young people. Young people reported a high severity of substance use problems (44% reported likely drug dependence) and reported significantly poorer mental health and wellbeing than adults completing the screen. This suggests that there is a population of young people in need of support who could be initially engaged through online screening.
Online screening should be a key component of engagement strategies for adolescent and early adult help-seeking.
This paper reviews the importance of transition to adult services for young people with ADHD.
Different models are described and evidence sought for their effectiveness in clinical practice.
Models of care for children with ADHD include specialised mental health services, individual paediatricians and child and adolescent psychiatrists. Although it might be expected that transition would be to equivalent adult teams or specialists, studies have shown that transition may not run smoothly, and the adult services are frequently inadequate. This may result in attrition from treatment or discharge to the general practitioner.
Adult mental health services for transitioning young people with ADHD are under-resourced. The way forward may be a generic ADHD specialist or service, treating ADHD across the lifespan and avoiding the need for transition.
We describe a case whereby a 15-year-old female with treatment-resistant obsessive-compulsive disorder (OCD) was treated with methylphenidate for co-morbid attention deficit hyperactivity disorder (ADHD). The ADHD-OCD co-morbidity has often been overlooked clinically due to conflicting opinions about their underlying neurobiology and treatment options.
In this adolescent with co-morbid ADHD and OCD, we observed that the adjunctive use of methylphenidate resulted in enhanced treatment response to both psychological and pharmacological interventions for OCD. This case highlights the need to identify and treat co-morbid ADHD in OCD cases where progress has stalled.
The objective of this study was to inform planning for similar events, our aim was to describe planning undertaken by Brisbane Mental Health Services for the 2014 G20 Summit and the impact of the Summit on service use.
We analysed routinely collected service data comparing presentations and discharges for the same time period in two consecutive years.
While presentations to mental health services increased from the previous year across a five-month period (including the month of G20), the week of the G20 Summit showed little change.
Our findings will be useful to other services that prepare for major events, such as G20. Our experience shows that, with detailed planning and extra resources, the G20 Summit passed without any major mental health incidents or major increase for mental health presentations.
The objective of this study was to disseminate advice imparted to early career psychiatrists by a panel of senior colleagues at a Royal Australian and New Zealand College of Psychiatrists symposium, reflecting on things they wished they had known at the earlier stage in their careers.
Key themes were extracted from notes taken at the symposium, where opinions were expressed by three senior psychiatrists.
There are components in building a sustainable career as a psychiatrist, which include considering one’s work environment and relationships with colleagues; self-care, mentorship and reflective practice; and seeking opportunities to teach and research for career progression.
The mentorship and advice from senior colleagues can be highly influential. In order to sustain a career that has reward, meaning and longevity, psychiatrists would do well to pay attention to aspects of self-care, stay connected to their loved ones, seek an optimal work–life balance and take an interest in their long term career plans.
Mental health problems are a leading cause of health-related disability during adolescence. The objectives of the current study were to investigate whether participating in an adventure education programme (AEP) increased adolescents’ resilience and elucidate how social connectedness contributes to any increase.
Adolescents who participated in the AEP had their resilience measured on the first (Time 1) and last day (Time 2) of a 10-day voyage. Perceived social support and sense of belonging were also measured at Time 2. A control group of adolescents, who did not take part in the voyage, also had their resilience assessed at two time points, 10 days apart.
Adolescents who participated in the AEP, but not those in the control group, displayed an increase in resilience from Time 1 to Time 2. Further, the increase in resilience was related to the adolescents’ sense of belonging, and this effect held when controlling for perceived social support.
These findings demonstrate the positive impact AEPs have on adolescents’ resilience and a mechanism through which this occurs.
To provide information relevant to decision-making around the timing of attempting the centrally administered summative assessments in the Royal Australian and New Zealand College of Psychiatrists (RANZCP) 2012 Fellowship Program.
We consider the new Competency-Based Fellowship Program of the RANZCP and its underlying philosophy, the trainee trajectory within the program and the role of the supervisor. The relationship between workplace-based and external assessments is discussed. The timing of attempting centrally administered summative assessments is considered within the pedagogical framework of medical competencies development.
Although successful completion of all the centrally administered summative assessments requires demonstration of a junior consultant standard of competency, the timing at which this standard will most commonly be achieved is likely to vary from assessment to assessment. There are disadvantages attendant upon prematurely attempting assessments, and trainees are advised to carefully consider the requirements of each assessment and match this against their current level of knowledge and skills.
Trainees and supervisors need to be clear about the competencies required for each of the external assessments and match this against the trainee’s current competencies to assist in decision-making about the timing of assessments and planning for future learning.
There has been a growing interest in psychiatry enrichment programmes such as summer schools and institutes for medical students in the last 10 years. Evaluation of enrichment programmes shows that they can be an effective method of increasing students’ interest in psychiatry as a career. However, despite initial enthusiasm and motivation within an academic department, establishing a programme can be a daunting task. The aim of this paper is to provide a background of how to establish and implement a psychiatry summer school or institute. The steps that can be taken to establish and implement a psychiatry enrichment programme such as a summer school or institute are described and discussed. This includes how to structure a programme, content to include, costs and budget, programme promotion, selection of students and programme evaluation.
Establishing an enrichment programme can provide academic departments of psychiatry with the opportunity to demonstrate excellence and innovation in teaching and positively promote psychiatry to students and other non-medical academics involved in medical education. For students interested in psychiatry, enrichment programmes have the potential to extend interest and knowledge beyond the curriculum and encourage serious consideration of psychiatry as a career.
Recently, meta-analytic studies have suggested a positive relationship between initial severity and magnitude of treatment efficacy. The aim of the current study was to develop a mathematical model to test the assumption concerning the role of initial severity in treatment response.
A number of experimental artificial datasets were developed on the basis of three different scenarios which reflect a pre-determined effect of initial severity. They were used to test for correlations at the patient level as well as at the meta-analysis level (trial level).
The results suggested that in all scenarios and analyses the correlations were so high that a ceiling effect was obvious. The testing concerned changes from baseline, but not differences between arms.
Overall the data suggest that the question concerning the role of initial severity cannot be answered. Any allegations on such a role are based on flawed methodology and do not take into consideration the true nature of data.
The objective of this study was to describe the method and relevance of infant observation as a unique and powerful learning tool for psychiatrists.
Infant observation provides a privileged entry into an infant’s internal world to observe its earliest mental life. Weekly consecutive observations of the mother–baby dyad, combined with the process of supervision, enable identification of emergent and changing patterns in the relationship. The discipline of observation encourages attunement to the nuances of relationships, which provides a potent tool for application in other clinical settings.
We aimed to find and explore the earliest available New South Wales asylum medical records to identify any management or therapeutic data that might be of interest to the psychiatric field.
The earliest known existing records of New South Wales asylum data are from Tarban Creek Asylum. After almost two centuries the preserved records allow insight into treatment used in early colonial Australia, including the scarcely remembered seton therapy. This finding highlights the importance of preserving historical records. It also demonstrates the necessity and/or evolving wish within the colony to care for patients with perceived mental health difficulties based on a shared medical culture inherited from techniques used in Britain.
This article discusses Transference-Focused Psychotherapy, a contemporary evidence-based and manualised form of psychoanalytic psychotherapy for borderline personality disorder. Transference focused psychotherapy has evolved from decades of research in the object-relations approach developed by Professor Otto Kernberg and his collaborators. It is being adopted increasingly throughout North and South America and Europe, and this article explores the role its adoption might play in psychiatric training as well as public and private service provision contexts in Australia.
Transference focused psychotherapy is readily applicable in a range of training, research and public and private service provision contexts in Australia. A numbers of aspects of current Australian psychiatric training and practice, such as the Royal Australian and New Zealand College of Psychiatrists advanced training certificate, and the Australian medicare schedule, make it especially relevant for this purpose.
The principles and practices underpinning a newly established community residential rehabilitation unit are described.
Residential rehabilitation in mental health has largely operated under the same model of care for 25 years following the closure of the asylums. In keeping pace with the growing recovery movement led by consumers and their carers a new partnership model of care that promotes social inclusion and quality of life was considered desirable.
This audit examined the demographics of Indigenous Australians dying by suicide in the Kimberley region of Western Australia during the period 2005–2014.
This is a de-identified retrospective audit of reported suicide deaths provided to Kimberley Mental Health and Drug Service during the period 2005–2014. Variables such as age, sex, method of suicide, previous engagement with mental health services, locality and ethnicity were assessed.
Indigenous suicide rates in the Kimberley region have dramatically increased in the last decade. There is also an overall trend upwards in Indigenous youth suicide and Indigenous female suicides.
These findings highlight the need for culturally informed, and youth focussed, suicide prevention interventions within the Kimberley region.
This article reviews recent trends in the provision of psychiatric services to the emergency departments of tertiary hospitals in Australia, involving the establishment of specialised in-reach or liaison services as well as various forms of short stay unit attached to emergency departments. The Emergency Psychiatry Service at Flinders Medical Centre, South Australia, is described as a case example. Its specialised models of assessment and clinical care are described, highlighting how these are differentiated from more traditional models in inpatient, community and general hospital consultation–liaison psychiatry.
Emergency psychiatry, and in particular the application of specialised psychiatric models of in-reach service and short stay units, is an increasingly important and growing field of psychiatry that warrants further exploration in research. The Emergency Psychiatry Service at Flinders Medical Centre has developed a distinct group of assessment and treatment approaches that exemplifies this growing field.
Violence risk assessment assumes a critical medico-legal role addressing offender/patient needs and informing forensic mental health decision making. Yet questions remain over the cross-cultural applicability of such measures. In their current form, violence risk instruments may not reflect the unique life and cultural experiences of Indigenous Australians rendering them culturally unsafe.
To realize equitable forensic assessment, it is necessary to ascertain whether there are cultural differences across risk factors for violence and that risk instruments are validated as culturally appropriate. Greater cross-cultural rigour in forensic mental health risk assessment, research and practice is proposed.
The aim of this paper is to present a case of paliperidone-induced Pisa syndrome and provide treatment experience.
The case report is combined with a review of the literature.
A 37-year-old man had been diagnosed with paranoid-type schizophrenia for about 10 years. He received three-month treatment of paliperidone extended release (ER) at 6 mg per day, but showed a progressively Pisa-like physical position. We initially added an anticholinergic drug, but saw no improvement. The paliperidone ER was replaced by olanzapine at 10 mg per day, and the Pisa-like symptom improved after 1 month of the drug replacement.
We propose olanzapine as a possible replacement choice for patients with paliperidone-related Pisa syndrome.
To illustrate the neuropsychiatric and imaging findings in a confirmed case of voltage-gated potassium channel antibody limbic encephalitis.
Case report and review of the literature.
A 64-year-old man presented with several months’ history of obsessive thoughts and compulsions associated with faciobrachial dystonic seizures. He had no significant past medical and psychiatric history. Physical examinations revealed only mildly increased tone in the left upper limb. Bedside cognitive testing was normal. Positron-emission tomography showed intense symmetrical uptake in the corpus striatum. No underlying malignancy was identified on whole body imaging. Magnetic resonance imaging, lumbar puncture and electroencephalogram were normal. Serum voltage-gated potassium channel antibodies were strongly positive. The patient had a favourable response to antiepileptic drugs, oral steroids and immunotherapy.
Voltage-gated potassium channel limbic encephalitis characteristically presents with neuropsychiatric symptoms and temporal lobe seizures. Positron-emission tomography–computed tomography can be a useful adjunct to the clinical and biochemical work-up.
The objectives of this study were to examine the experiences of dual-trained child psychiatrists and paediatricians in Australia and New Zealand and inform the review of the Dual Fellowship Training Programme by the Royal Australian and New Zealand College of Psychiatrists and Royal Australasian College of Physicians.
All dual-trained child psychiatrists and paediatricians and current trainees were electronically surveyed in 2015.
Seven out of eight specialists (88%) and four out of six trainees (67%) responded. Six (55%) completed or were undertaking training as part of the Dual Fellowship Training Programme. Most respondents entered dual training without difficulty, found the transition from paediatrics to adult psychiatry challenging, and were reassured by their decision to undertake dual training on reaching advanced training in child psychiatry. Benefits and downsides of dual training were noted during and following training. A significant proportion of specialists (55%) were working in hospital-based environments, especially consult liaison services, suggesting that they added long-term value to both the fields of child psychiatry and paediatrics.
The Dual Fellowship Training Programme remains a valuable vehicle for gaining skills in paediatrics and child psychiatry. There is support for its continuation by previous and current participants.
To assess, among clozapine users, the rates of monitoring, presence and treatment of metabolic syndrome and its components.
A chart review was conducted of all clozapine users who were followed up in community mental health clinics at two Metro South Health Hospitals over a 1-year period. Metabolic syndrome was diagnosed according to the International Diabetes Federation criteria.
We included 251 clozapine users. Only 43.4% (109/251) had data collected for all five metabolic syndrome parameters. Among these people, 45.0% (49/109) met criteria for metabolic syndrome, while 61.2% (30/49) of those with metabolic syndrome were offered appropriate treatments. Correspondence with primary care providers occurred in only 18.7% (n = 47). Non-pharmacological interventions, such as motivational interviewing and education about healthy lifestyle alternatives, occurred in 49.8% (n = 125).
There is growing awareness of the importance of metabolic monitoring, however, there remain specific gaps in the collaborative work among mental health services, primary care providers and clozapine users, to ensure appropriate physical health interventions.
To determine the average duration of treatment at a community-based anxiety disorders clinic.
Data were collected on primary disorder, the presence of co-occurring disorders and treatment length (both in terms of number of sessions and weeks of therapy) for 248 consecutive clients.
The mean number of sessions was 13, and average treatment length was 29 weeks. There was substantial variation in treatment duration (range for number of sessions = 1–128, range for treatment duration = 0–186 weeks).
Clients with anxiety disorders were often treated in relatively few sessions, in line with randomised controlled trials (RCTs). However, a number of clients required many more sessions and were treated for a longer period of time than clients in RCTs. Health services should be cautious in mandating limits to therapy duration for anxiety disorders given the wide range in the duration of treatment for clients in our sample.
The aim of this small case series is to describe four cases of severe mania, where ultrabrief pulse electroconvulsive therapy (ECT) was used as a primary mode of treatment.
A retrospective file review was undertaken of four patients identified as having received ultrabrief pulse ECT for severe mania. The outcome measures for treatment efficacy were the Young Mania Rating Scale (YMRS) and Clinical Global Impression (CGI).
All the patients showed significant clinical improvement. A comparison of pre- and post-treatment YMRS and CGI scores showed a dramatic decrease in all four cases. However, one patient was shifted to brief pulse ECT due to inadequate response.
Ultrabrief pulse ECT may be an effective treatment in cases of severe mania. Due to the very small number of cases in the current case series, no specific conclusions regarding efficacy may be drawn; however, larger, controlled studies would be indicated.
The Mental Health Act 2007 (NSW) (MHA) was recently reformed in light of the recovery movement and the United Nations Convention on the Rights of Persons with Disabilities. We analyse the changes and describe the impact that these reforms should have upon clinical practice.
The principles of care and treatment added to the MHA place a strong onus on clinicians to monitor patients’ decision-making capacity, institute a supported decision-making model and obtain consent to any treatment proposed. Patients competently refusing treatment should only be subject to involuntary treatment in extraordinary circumstances. Even when patients incompetently refuse treatment, clinicians must make every effort reasonably practicable to tailor management plans to take account of any views and preferences expressed by them or made known via friends, family or advance statements.
A single case report on cannabinoid treatment for treatment-resistant Tourette syndrome (TS).
Our subject received 10.8 mg Tetrahydocannabinol and 10 mg cannabidiol daily, in the form of two oro-mucosal sprays of ‘Sativex®’, twice daily. Assessment was pre-treatment and at week one, two, and four during treatment. He completed the Yale Global Tic Severity Scale as a subjective measure, and was videoed at each stage. The videos were objectively rated by two assessors, blind to the stage of treatment, using the Original Rush Videotape Rating Scale.
Both subjective and objective measures demonstrated marked improvement in the frequency and severity of motor and vocal tics post-treatment. There was good interrater reliability of results.
Our results support previous research suggesting that cannabinoids are a safe and effective treatment for TS and should be considered in treatment-resistant cases. Further studies are needed to substantiate our findings.
Use of synthetic cannabinoids is associated with significant physical and psychological harms. This research quantified reported toxicities from published reports and assessed the influence of size of the reported study population on rates of symptom reporting.
Systematic review of published case reports and case series of toxicity associated with use of synthetic cannabinoids.
Symptoms associated with synthetic cannabinoid toxicity were reported for 3695 individuals, predominantly young males. Symptoms included physiological (e.g. tachycardia, hypertension, nausea/vomiting), emotional (e.g. agitation, irritability, paranoia), behavioural (e.g. drowsiness, aggression) and perceptual (e.g. hallucinations) domains. Most common symptoms were tachycardia (30.2% of cases), agitation (13.5%), drowsiness (12.3%), nausea/vomiting (8.2%) and hallucinations (7.6%). Death or serious medical complications were uncommon (e.g. death 0.2%, stroke 0.1%, myocardial infarction 0.09%). Case reports/smaller case series (n<10) reported statistically significantly higher rates for 29/34 symptoms than larger case series (n≥10), which could represent selection bias.
Symptoms of synthetic cannabinoid toxicity are variable and cover a number of physical and psychological domains. Symptom reporting varies by study population size. Due to the variable presenting symptoms of synthetic cannabinoid toxicity, clinicians in emergency services should consider synthetic cannabinoid toxicity when evaluating young adult male patients presenting with unexplained agitation or cardiovascular symptoms.
The objective of this study was to assess the effectiveness of single session therapy in meeting the needs of young people and their families on first presentation to a mental health service.
We conducted a quantitative analysis of routinely collected data using self- and family member-reported session and outcome rating scales.
Both young people and their family members rate single session therapy sessions highly. In addition, both young people and their families rate the young person’s mental health and well-being to have improved after the single session therapy intervention, with mothers rating the young person’s improvement most highly.
Single session therapy is an effective tool in improving both self- and parent-rated individual, interpersonal, social and overall well-being for young people presenting to a mental health service.
This clinical update review focuses on the classification and description of common neuropsychiatric manifestations in Parkinson’s disease (PD).
We conducted a systematic search of the literature using Pubmed and selected the most recent and relevant papers for this review.
Neuropsychiatric manifestations in PD are are very frequent and may arise from an abnormal psychopathological response to the disease, neurobiological changes related to the disease itself, complications of treatments or a combination of all of these.
Neuropsychiatric symptoms may precede the motor clinical presentation of PD. Early recognition is essential.
The objective of this study was to offer some personal observations as to how melancholia can be diagnosed and differentiated from the non-melancholic depressive conditions.
Personal clinical and research-based observations are presented following a critique of common current strategies.
The paper offers views on the most differentiating clinical features, argues for adding illness course variables to symptoms and provides details of the Sydney Melancholic Prototypic Index, a measure with a high overall classification rate in differentiating melancholic and non-melancholic depression.
Greater precision in differentiating melancholic from non-melancholic depression is advanced by weighting signs and symptoms of psychomotor disturbance, as well as including illness correlates and family history in the diagnostic process.
Negative perceptions about psychiatric treatment are likely to affect treatment adherence. We compared attitudes of patients with psychiatric illness and those of medical patients towards psychiatric treatment.
Both patients with psychiatric illness and medical patients (controls) were shown a printed copy of two vignettes depicting major depression and generalized anxiety disorder. They were asked for their perceptions on the utility, effects and possible side effects of psychiatric medications, as well as the utility of psychotherapy in treating major depression and generalized anxiety disorder. Responses between psychiatric patients and medical patients were compared using appropriate statistical tests, including logistic regression.
Patients with psychiatric illness were more likely than medical patients to endorse the utility of medications in treating major depression and generalized anxiety disorder (p<0.001). Those with psychiatric illness were more likely to endorse the utility of psychotherapy in treating major depression (p=0.004). Both groups of patients were of the view that psychotherapy would benefit generalized anxiety disorder. Older and lesser educated patients held negative beliefs about medications.
While patients with psychiatric illnesses endorsed favourable attitudes toward medications (p<0.001), the older and lesser educated were more likely to hold negative views (p<0.05). Psychoeducation should be tailored to the needs of older and lesser educated patients.
The process of applying the principles of the Neurosequential Model of Therapeutics (NMT) as a practice framework in an Adolescent Day Program and Adolescent Inpatient Unit is described.
NMT as a practice framework guided construction of a neurobiologically sensitive group therapy program whereby specific group therapies can be selected to target a young person’s specific clinical needs within the context of a broader mental health treatment plan. The practice framework has been practical, logical and feasible to implement and may encourage other child and adolescent mental health services to consider the application of neuroscience-informed models such as NMT.
Research on crime victimisation in the mentally ill has focused on middle aged cohorts with long-standing illness and functional disability. The rates and correlates of victimisation in young cohorts is largely unknown.
Participants (n=776) were aged 12–25 years attending headspace centres in Australia, who consented to a clinical interview and provided self-reported data regarding lifetime victimisation.
A quarter of the sample (24.5%) reported crime victimisation, including 18.5% who experienced violent victimisation (mainly physical or sexual assault) and 14.1% non-violent crime. Both forms of victimisation were associated with illicit substance use, sexual orientation, and young adult age, while male gender was specifically associated with non-violent victimisation. Participants who reported violent victimisation were significantly more impaired both functionally and clinically than those reporting non-violent victimisation or no victimisation.
Young people with mental ill-health are vulnerable to criminal victimisation, particularly violent assaults, although the lifetime rates of victimisation are substantially lower than those observed in older cohorts with serious mental illness. Effective, early intervention to address modifiable factors may reduce the risk of further victimisation.
Complementary medicines are readily available and becoming increasingly popular. Acetyl-
Given the high rates of obesity among people with mental illness, it is possible ALC may be utilised in the hope of aiding weight loss. This case highlights the importance of psychiatrists maintaining open communication with their patients about use of complementary medicines, and the risks and benefits of their use.
A recent study reported an 8% increase in bipolar diagnoses in public and community mental health services in New South Wales from 2003 to 2014, an increase interpreted by the authors as reflecting increasing diagnostic boundaries of bipolar disorder, and bipolar II in particular. If valid, we would expect an increase in hospital admissions for hypomania as well as for mania and so analysed a relevant dataset to test that hypothesis.
Data were examined for 27,255 individuals hospitalised in NSW psychiatric hospitals over a 14-year period (2000–2014) for ICD-10 diagnosed mania or hypomania and with analyses examining rates of hospitalisation/per year for both mania and for hypomania.
While overall admissions for mania and hypomania increased over the study period by 16.4%, admissions for mania increased by 31.0% and admissions for hypomania actually decreased by 32.1%.
The increased rate in admissions of those with a bipolar disorder appears to reflect a trend over more than four decades. The hypothesis that any increase in the diagnostic boundaries of bipolar II disorder would be associated with an increase in hospitalisation rates was rejected, with the converse trend being identified.
Suicide risk assessment is variably taught and learnt by health professionals. The literature indicates that training programs of this fundamental competency need to be enhanced. To facilitate teaching and learning of this core clinical skill, we propose a novel visual metaphor in order to conceptualize suicide risk factors. The design of the proposed visual metaphor was informed by the Cognitive Load Theory to enhance deep learning of the various suicide risk factors.
The visual metaphor depicting suicide risk factors can potentially improve memory and recall. It activates prior knowledge and is based on educational theory informed design principles.
This study identified barriers to and facilitators of mental health (MH) and alcohol and drug (AOD) comorbidity services, in order to drive service improvement.
Participatory action research enabled strong engagement with community services, including Aboriginal and refugee groups. Surveys, interviews and consultations were undertaken with clinicians and managers of MH, AOD and support services, consumers, families, community advocates and key service providers. Community participation occurred through consultation, advisory and working party meetings, focus groups and workshops.
Barriers included inadequate staff training and poor community and workforce knowledge about where to find help. Services for Aboriginal people, refugees, the elderly and youth were inadequate. Service fragmentation (‘siloes’) occurred through competitive short-term funding and frequent re-structuring. Reliance on the local hospital emergency department was concerning. Consumer trust, an important element in engagement, was often lacking.
Comorbidity should be core business of both MH and AOD services by providing consistent ‘no wrong door’ care. Non-governmental organisations (NGOs) need longer funding cycles to promote stability and retain skilled workers. Comorbidity workforce training for government and NGO staff is required. Culturally appropriate comorbidity services are urgently needed. Despite the barriers, collaboration between clinicians/workers was valued.
The objective of this article is to offer a personal perspective on managing melancholia by interpreting both the limited salient evidence base and offering clinical observations.
It is suggested that medication needs to be prioritised, that not all antidepressants are equally potent for those with melancholia and that as response to a single antidepressant alone (especially a narrow-spectrum one) is low, management commonly requires broader-spectrum antidepressant drugs and augmentation strategies.
We aim to explore the phenomenon of suicide by driving one vehicle into another, and draw attention to the cost to occupants of targeted vehicles.
We examined academic literature, court and newspaper reports, and online sources.
Driver suicide may be achieved by colliding with a fixed object or another vehicle. When a second vehicle is targeted, the occupants of that vehicle experience property loss, and potentially physical and psychiatric injury, or death. Driver suicides are associated with death of another person, in 11.3% of cases. Some suicidal individuals are able to act with great consideration for the consequences of their actions.
Every effort must be made to help suicidal people with mental disorders or other predicaments. There is a need for public discussion of suicide by targeting an oncoming vehicle. It is less likely that suicide drivers who target other vehicles are unable to choose and more likely they have not considered the consequences of their actions.
There is significant multidisciplinary work contributing to the implementation of trauma informed care (TIC) into mental health policy and practice in Australia. Within psychiatry, there may be potential confusion about how to navigate the integration of TIC into a speciality built upon treating psychological distress; creating dismissive reactions of a patronising approach and paradoxical radicalism. This paper aims to discuss the need for psychiatry to view TIC as a significant and urgent paradigm shift required to integrate existing knowledge about the prevalence and effects of trauma into a progressive articulation of the relational and interpersonal underpinnings of modern psychiatric practice; and to lead and support its widespread implementation.
Active consideration of the intent of TIC may aid in reducing misunderstanding and misaligned resistance while allowing services and individuals an important opportunity to reflect on how to deliver mental health treatment that is universally sensitive to the dynamics of trauma in the care environment.
Youth mental health disorders are rising across the world. Mindful Parenting could be a potential tool to promote youth mental health. The primary distinction between Mindful Parenting programs and other behavioral parenting programs is the focus on emotional literacy and compassion. However, this emerging field has gaps in its theory and evidence. In order to objectively evaluate the impact of Mindful Parenting, it is important to identify how it promotes change. This theoretical paper aims to articulate the key change processes of Mindful Parenting that promote positive outcomes.
A literature review was conducted to synthesize the change processes outlined by different authors in the field.
Key processes argued to promote Mindful Parenting were aligned with five main categories, namely attention, intention, attitude, attachment and emotion. More specifically the change processes were listening, emotional awareness, emotional regulation, attentional regulation, attunement, attention to variability, intentionality, reperceiving, compassion and non-judgmental acceptance.
This preliminary analysis attempted to understand how Mindful Parenting fosters change and transformation. Whilst there are numerous change processes, the essence of Mindful Parenting appears to be the ability to be responsive to a child’s needs.
Despite possessing considerable relevance for planning and delivery of effective rehabilitation interventions, systematic evaluation of cognitive function is often ignored in clinical practice. This paper describes a successful method for measuring cognitive function and the nature of cognitive deficits (CD) in people with schizophrenia admitted to psychiatric rehabilitation services.
Data on the cognitive functioning of consecutive patients with schizophrenia / schizoaffective disorder admitted during a 5-year period to a public in-patient rehabilitation facility was collated retrospectively and analysed. The Brief Assessment of Cognition in Schizophrenia (BACS) was used to evaluate cognitive function.
It was possible to administer the BACS to 122 of 135 consecutive admissions. The mean composite score on the BACS was 1.8 standard deviations below the norm, and 43% had moderate or severe CD. The BACS sub-tests of list learning and symbol coding revealed more severe deficits.
The study indicates that evaluation of cognitive function using brief instruments is feasible in psychiatric rehabilitation settings. Global and domain-specific CD were prevalent among people with schizophrenia. In view of the strong association of cognitive functioning with community functioning and rehabilitation outcomes, further studies exploring the feasibility and utility of routinely evaluating cognitive function are warranted.
This paper aims to describe the prevalence, assessment and management of affective disorders as well as functional (non-epileptic) seizures in people with epilepsy.
This paper comprises a selective review of the literature of the common affective manifestations of epilepsy.
Affective disorders are the most common psychiatric comorbidity seen in people with epilepsy and assessment and management parallels that of the general population. Additionally, people with epilepsy may experience higher rates of mood instability, irritability and euphoria, classified together as a group, interictal dysphoric disorder and resembling an unstable bipolar Type II disorder. Functional seizures present unique challenges in terms of identification of the disorder and a lack of specific management.
Given their high prevalence, it is important to be able to recognise affective disorders in people with epilepsy. Management principles parallel those in the general population with specific caution exercised regarding the potential interactions between antidepressant medications and antiepileptic drugs. Functional seizures are more complex and require a coordinated approach involving neurologists, psychiatrists, general practitioners, nursing and allied health. There is very limited evidence to guide psychological and behavioural interventions for neurotic disorders in epilepsy and much more research is needed.
This clinical update review focuses on treatment approaches of neuropsychiatric manifestations in Parkinson’s disease.
We conducted a systematic search of the literature using Pubmed and selected recent and relevant papers for this review.
Neuropsychiatric symptoms in Parkinson’s disease usually require optimization of levodopa therapy as a first step. Most psychotropic drugs can be used in Parkinson’s disease, however there is still lack of an evidence base due to limited studies and difficulties in diagnosis of neuropsychiatric disorders. Non-pharmacological treatments have also proved effective in Parkinson’s disease. Cognitive impairment requires special consideration.
Management of neuropsychiatric manifestations in Parkinson’s disease is complicated by the lack of evidence. Treatment should be individualized and benefits and risks must be balanced.
Residential patients diagnosed with borderline personality disorder were evaluated to determine whether borderline personality disorder-focused psychotherapy reduced prescribing, personality disorder and co-morbid symptom severity.
Psychotropic prescriptions were measured at admission, discharge and 1 year later in 74 female participants with one or more personality disorder diagnosis and co-morbid mood disorders. Changes in pharmacotherapy were examined in the context of improvements in borderline personality disorder and/or co-morbid disorder symptom severity. Residential treatment included individual and group psychotherapy for borderline personality disorder. The Structured Clinical Interview for DSM-IV was used to confirm the borderline personality disorder diagnosis and associated co-morbid conditions. The Beck Depression Inventory was completed at each time point.
A significant reduction in the incidence and severity of self-rated depression as well as clinician assessed personality disorder, including borderline personality disorder, was accompanied by a reduction in prescription of psychoactive medications.
Three to six months of intensive borderline personality disorder-specific psychotherapy showed lasting benefit with regard to symptom severity of personality disorders (borderline personality disorder in particular) as well as depressive symptoms. This improvement corresponded with a reduction in prescriptions for psychoactive medications, which is consistent with current thinking regarding treatment for borderline personality disorder.
The aim was to use an educational environment measure to learn more about our postgraduate psychiatry education program, in order to gain further insights into areas for development. The educational environment includes such things as atmosphere and facilities. A secondary aim was to explore if different types of trainees experienced any aspects of the educational environment differently.
The education environment measure used was able to reveal areas of the educational environment which trainees did not feel were adequate, as well as differences between how different trainees perceive some aspects of the educational environment. This allowed us to understand where improvements which we had not previously considered should be made to the educational environment.
We investigated the role of biological and psychosocial risk factors in the development of psychotic disorders with regards to immigrant status. Our hypothesis was that biological risk factors are more predictive of psychosis in non-immigrants, whereas psychosocial risk factors play a bigger role in immigrants.
A retrospective audit of admissions between December 2013 and June 2014 in an Australian adult inpatient unit was conducted, focussing on patients with psychotic disorders. We analysed the association between immigrant status, and biological and psychosocial variables.
For biological risk factors, non-immigrants had significantly more family history of psychotic disorders (p = 0.021), illicit drug use (p = < 0.001) and alcohol use (p = < 0.001). For psychosocial risk factors, immigrants were more likely to have experienced a traumatic event (p = 0.022). With regards to age of index presentation, age at onset of psychotic disorder, proportion of males and dysfunctional family background, there was no significant difference.
Retrospective data in this report suggests that the development of psychotic disorders in immigrants and non-immigrants may be different.
The objective of this study was to examine the presentations of patients by ambulance, under Section 20 of the NSW Mental Health Act of 2007, to a hospital emergency department (ED) with a 24-hour Mental Health Team.
Patient records between December 2013 and December 2014 were audited and analysed in Excel.
There were 47 such presentations: 51% required a mental health admission. Patients required management for up to six of the nine identified mental health and physical problems. As the number of clinical problems in these patients increased, the length of their stay and the likelihood of discharge to home increased. The need for psychiatric admission did not appear to prolong their length of stay, though chemical sedation did. The availability of an ED mental health team did assist in achieving a length of stay that was in keeping with Australian National Emergency Access Target guidelines.
A 24-hour ED mental health team provided specialised assessment and management for patients, alongside the necessary emergency medical intervention. This team assisted in easing the increasing pressure on the ED and minimising the patients’ length of stay. The team redirected patients requiring admission, facilitated timely discharge of others and revoked Section 20 when less restrictive care was appropriate.
We aim to consider issues relevant to psychiatry raised by the television series, Transparent.
Psychiatry’s disturbing history regarding the lesbian, gay, bisexual, transgender and intersex (LGBTI) community shares many aspects with the group’s persecution by the National Socialist regime in Germany. The medicalised ‘otherness’ conferred on LGBTI patients, latent homophobia and transphobia, and lack of culturally sensitive clinical services for these people represent a major ethical challenge for modern Australasian psychiatry.
The present review aims to describe the main steps for completing a psychiatric PhD thesis with success.
A selective review of the literature and the author’s experience as a psychiatrist completing a PhD.
Deciding upon a topic, choosing a mentor, organising your time, persevering and remaining motivated are the key elements.
Preparedness and diligence lead the way towards a PhD. This advice is also relevant for those undertaking research at any stage of their career.
This opinion piece encourages mental health researchers and clinicians to engage with mental health issues among tuberculosis patients in the Asia-Pacific region in a culturally appropriate and ethical manner. The diversity of cultural contexts and the high burden of tuberculosis throughout the Asia-Pacific presents significant challenges. Research into tuberculosis and mental illness in this region is an opportunity to develop more nuanced models of mental illness and treatment, while simultaneously contributing meaningfully to regional tuberculosis care and prevention.
We overview key issues in tuberculosis and mental illness co-morbidity, highlight ethical concerns and advocate for a regional approach to tuberculosis and mental health that is consistent with the transnational challenges presented by this airborne infectious disease. Integrating tuberculosis and mental health services will go a long way to addressing the needs of vulnerable populations and stopping the transmission of one of the world’s biggest infectious killers.
The authors outline the difference between content and performance standards and the rationale for standard setting at a medical college. The principles of the college’s standard setting processes for the written and objective structured clinical examination summative assessments are discussed in greater detail.
There is no evidence of any single standard setting method to be the best. Multiple methods exist and will have varied results when applied. The judgement of a panel of subject experts remains an important component of the standard setting process.
This study examined the correlation between smoking habits and psychopathology status, as well as the impact of confounders such as body mass index and gender.
A total of 134 non-smokers and 152 smokers were enrolled in this study. We measured psychopathology features using Symptom Checklist 90-Revised. We ran logistic regression models testing the smoking–psychopathology association, controlling for body mass index and gender.
Smoking was positively correlated with depression, interpersonal sensitivity, hostility, somatization, paranoid ideation and psychoticism (P<0.05). Adjusting for body mass index and gender, the results remained largely unchanged, with a slight independent effect of body mass index.
Our data suggest that smoking is a stronger predictor of psychopathology than body mass index and gender.
To briefly examine shortcomings in the foundation concepts that underlie theory and thought in contemporary psychiatry and to argue that these shortcomings mislead research and practice.
Psychiatry stands on a complex of ideas and concepts that cannot be reduced to a satisfying or unifying underlying conceptual system or idea. The ideas and concepts have been patched together ad hoc and function until things go wrong. Growing professional dispute and public disquiet indicates that things are going wrong. I suggest that professional philosophers need to be engaged in the necessary infrastructure repairs.
Clozapine is the gold-standard antipsychotic medication for treatment-refractory schizophrenia (TRS). However, one potentially lethal side effect of clozapine, as with other antipsychotics, is neuroleptic malignant syndrome (NMS) which could present differently in clozapine therapy. ‘Atypical NMS’ is a recognised variant of NMS with less rigidity and delayed elevation of creatine kinase; this variant is associated with clozapine.
A case from the author’s clinical practice was reviewed.
A 67-year-old man with TRS was treated with clozapine. Unfortunately, his physical condition deteriorated and he presented with atypical NMS, which initially was treated as presumable urinary tract infection.
Atypical NMS is associated with clozapine. This case exposes the potential difficulties in diagnosis, and highlights the importance of considering less common diagnoses in acutely unwell psychiatric patients.
The objective of this study was to describe functioning and clinical activities of the St George Acute Care Team and how it compares to the typical crisis resolution model of care.
Descriptive data including demographics, sources of referral, type of clinical intervention, length of stay, diagnoses and outcomes were collected from records of all patients who were discharged from the team during a 10 week period.
There were 677 referrals. The team’s functions consisted of post-discharge follow-up (31%), triage and intake (30%), case management support (23%) and acute community based assessment and treatment (16%). The average length of stay was 5 days. The majority of patients were diagnosed with a mood (23%) or a psychotic (25%) disorder. Points of contrast to other reported crisis resolution teams include shorter length of stay, relatively less focus on direct clinical assessment and more telephone follow-up and triage.
St George Acute Care Team provides a variety of clinical activities. The focus has shifted away from the original model of crisis resolution care to meet local and governmental requirements.
The objective of this study was to explain the reasons for taking a religious and spiritual history, which is often neglected by psychiatrists, and to introduce some religious and spiritual assessment tools to assist those psychiatrists who feel inexperienced in this area.
Religious and spiritual assessment enhances quality of patient care. Training programs for psychiatry registrars need to include modules on religious and spiritual assessment of patients.
This paper aims to analyse in a philosophically informed way the recent National Institute of Mental Health proposal for the Research Domain Criteria (RDoC) framework.
Current classification systems have helped unify psychiatry and the conditions that it is most concerned with. However, by relying too much on syndromes and symptoms, they too often do not define stable constructs. As a result, inclusions and removals from the manuals are not always backed by sound reasons. The RDoC framework is an important move towards ameliorating matters. This paper argues that it improves the current situation by re-referencing constructs to physical properties (biomarkers for disorders, for example), by allowing theoretical levels within the framework, and by treating psychiatry as a special case of the cognitive sciences.
We aim to describe the burden associated with smoking as a risk factor for suicidal behaviors among patients with psychosis.
We calculated the Population Attributable Risk (PAR) associated with smoking and other known modifiable risk factors for suicidal behaviors for participants (N=1812) who took part in the Australian Survey of High Impact Psychosis (SHIP). A combined PAR for the seven identified modifiable risk factors was calculated.
Smoking contributed to 21% of the suicidal behaviors in this sample; together, the seven factors contributed to 86% of all attempted suicide in this cohort.
Smoking may exert a role either directly or indirectly. Evidence indicates that smoking is associated with psychological, biochemical and neurobiological changes that are in turn implicated in smoking. Suicidal behaviors are nevertheless complex behaviors needing multi-faceted approach.
The objective of this study was to increase recognition of ultra-rapid metabolising status as a cause of treatment-resistant depression and consider management options.
The incidence of ultra-rapid metabolising status is not rare in patients who fail to report improvement with antidepressant medication. Two broad options are available for identifying ultra-metabolising status. While there are several management options available to the clinician, combination therapy is likely of low utility while there are risks associated with mega-prescribing. As the literature is limited, clinician observations about alternate strategies would be welcomed.
The structure and scoring of the Health of the Nation Outcome Scales (HoNOS) has been open to debate. Most studies have relied on factor analytic approaches to investigate HoNOS structure. Our aim is to investigate HoNOS using methods from item response theory.
Completed HoNOS forms from patients receiving mental health treatment in the community and also inpatients were subjected to Mokken analysis, which is a non-parametric form of item response theory. Confirmatory factor analysis was then used to investigate these scales.
Two scales with the same items were found in both samples; however, the inpatient sample scored higher on both scales. The first scale contained three items (10, 11, 12) from the social scale, and the other was related to depression (2, 7, 8). Confirmatory factor analysis showed that a two scale structure had better fit statistics than other suggested structures.
HoNOS might best be conceived as two scales measuring aspects of social adjustment and depression.
Regina v Presser [1958] VR 45, is the most seminal case regarding fitness to plead for accused persons in Australia and New Zealand. It is not widely understood that Presser was a 14-year-old boy with intellectual disability. We aim to describe a clearer narrative regarding Edward John Presser.
Review of attainable newspaper reports framed within an historical context of fitness and relevant case law.
Presser’s narrative is described in greater detail than previously understood by clinicians and lawyers. Ramifications for fitness assessment are discussed including doli incapax and human rights considerations.
The Presser criteria are widely applied; however, the case involved a 14-year-old boy with intellectual disability. Greater awareness of Presser’s narrative assists clinicians providing expert evidence regarding fitness to plead for adolescents and persons with intellectual disability.
Delusional infestation may present as a primary disorder or secondary to another disorder (e.g. schizophrenia). In this report we focus on the issue of inadequacies in mental state examinations leading to diagnostic uncertainty.
Case studies were identified for this review through searching the academic databases MedLine, PSYCInfo and PubMed. We developed a template that contained 36 headings and independently examined each case study report. Our percentage agreement for the first 42 case studies we reviewed was 91%.
We identified diagnostic uncertainty due to inadequacies in the reporting of mental state examinations.
Clinicians need to provide mental state information to an adequate standard that would allow confirmation of a diagnosis of delusions of infestation or exclude other possibilities.
NewAccess is a Low Intensity Cognitive Behaviour Therapy (LiCBT) early intervention pilot, for mild to moderate depression and anxiety. In November 2015 the Australian Government Review of Mental Health Programmes and Services specifically highlighted the program, stating, "Primary Health Networks will....be encouraged and supported to work towards better utilisation of low intensity ‘coaching’ services for people with lesser needs, building on evaluations of programmes such as the NewAccess model of care, and the Improving Access to Psychological Therapies model of stepped care implemented in the United Kingdom." NewAccess runs in three sites (Adelaide, Canberra and North Coast New South Wales) based on the successful UK Improving Access to Psychological Therapies (IAPT) model. NewAccess involves training in evidence-based interventions, regular clinical supervision and recording outcome measures every session. Key performance indicators include functional recovery,loss of diagnosis, return to employment and early intervention.
Adaptation to Australia accommodated contextual issues such as geographical isolation and infrastructure of the healthcare system. Initial recovery rates and projected economic viability for NewAccess are very promising, supporting wider adoption of an IAPT model across Australia. In addition it has resulted in the emergence of a new Australian workforce in community mental health with the LiCBT ‘Coach’.
The objective of this study was to explore the correlates of a single-item Self-Rated Mental Health Question in people with schizophrenia, in order to achieve a better understanding of what it is measuring.
A cross-sectional survey was conducted exploring the responses of 71 adults with schizophrenia to a single-item Self-Rated Mental Health Question and the relationship with psychological distress, illness perception, and self-rated general health. Measures included the 10-item Kessler Psychological Distress Scale, the Brief Illness Perception Questionnaire, and the single-item Self-Rated Health Question.
People with schizophrenia who reported poorer levels of mental health on a single-item Self-Rated Mental Health Question were more likely to have: higher levels of psychological distress; depressive and anxiety symptoms; and negative illness perceptions, especially a lack of perceived personal control over their illness. There was a moderate positive correlation between self-rated mental health and self-rated general health.
The single-item Self-Rated Mental Health Question is a predictor of important clinical features in people with schizophrenia. As such, there are implications for health services, with a possible role as a brief, easily administered screening tool for the detection of clinical vulnerability.
The objective of this article is to provide a portrait of prefrontal lobotomy performed at the Royal Prince Alfred Hospital, Sydney by the Head of Neurosurgery Dr Rex Money and to describe Dr Money’s role in the promotion of psychosurgery in Sydney.
We draw attention to an oral presentation by Dr Rex Money in 1951, a journal article written by Money, archival information held at the Royal Prince Alfred Hospital, including Dr Money’s accounts of his travels and his reports regarding neurosurgery – both internationally and in Australia.
Dr Rex Money performed a series of 13 prefrontal lobotomies between 1945 and 1951, and presented the theoretical basis for his series, his operative procedures and the outcomes at the annual meeting of its medical officers’ association.
Notwithstanding various deficiencies in his clinical research, Money’s descriptions give a relatively comprehensive account of one of the first series of prefrontal lobotomies performed in Australia. The current article also describes Dr Money’s contributions to the promotion of psychosurgery in Sydney, and illustrates the participation of a senior neurosurgeon and of a major Sydney teaching hospital during the psychosurgery saga.
The objective of this study was to describe the advent of prefrontal lobotomy in Sydney and, less comprehensively, its introduction into Australia.
Reference to journal articles, books, reports and archival data held at the Royal Prince Alfred Hospital and via internet searches, interviews and personal memory.
This paper describes the arrival of psychosurgery in Sydney in the mid-1940s, and less comprehensively, its arrival in other Australian cities.
In New South Wales, from 1945 or 1946, prefrontal lobotomies were conducted in private clinics and in public hospitals but, because of legal and practical hurdles, it is unlikely that psychosurgery was performed in mental hospitals prior to December 1958. This paper gives some details regarding the participation of neurosurgeons and of the major public hospitals in psychosurgery, and touches on the attitudes within the Australian medical profession towards this dramatic new therapy.
The place of monoamine oxidase inhibitors (MAOIs) in psychiatry is reviewed, and the question posed as to whether they are now justifiably disregarded by prescribers.
Multiple databases (PubMed, Medline, Embase, Cochrane) were interrogated to provide an overview regarding the use, efficacy and toxicity of MAOIs. Data regarding funded use of these agents in New Zealand were obtained from PHARMAC.
Evidence supports the use of MAOIs in major depressive disorder, certain anxiety disorders and, to lesser extent, bipolar depression. Older non-selective agents, such as phenelzine and tranylcypromine, have distinctive efficacy in ‘atypical’ and treatment-resistant depression, but at the cost of serious tolerability problems. Their relegation and perception by clinicians as ‘last resort’ medications – if considered at all – has occurred in the context of various concerns, notably dietary restrictions, potential adverse drug interactions and the usual requirement for divided doses.
Sufficient evidence supports consideration of MAOIs in treatment-refractory and atypical depressive disorders, and in social anxiety disorder. Psychiatrists in training need to gain experience in using these agents.
Medication non-adherence is observed in many patients with schizophrenia. We investigated the effects of educational intervention on patient awareness of the adverse effects of their medication for patients with schizophrenia.
Inpatients with schizophrenia (N=87) in two Japanese hospitals were allocated to two groups, one that was aware of the adverse effects of medications and one that was unaware, according to their responses to the question ‘In the past month, have you experienced any adverse effects from your medications?’ Then, they were questioned about adverse effects.
Only 27.6% of patients recognized the adverse effects of their medications. After pharmacists educated them and showed them a list of adverse effects, the prevalence of recognition increased dramatically (≤96.6%). Most patients with schizophrenia clearly did not recognize the adverse effects of their medications. When patients experienced discomfort they tended to stop taking their medications.
Adverse effects are a common risk factor for discontinuation of medication, so early detection and reporting of such effects may result in them being addressed sooner. Considering the risks of relapse caused by discontinuation of medication, healthcare professionals should actively educate patients with schizophrenia about dysphoria and manage adverse effects.
The objective of this study was to evaluate a specialised service designed to improve parenting capacity, child safety and family functioning in the context of parental mental health, drug and alcohol and child protection concerns.
Client data was collected over a period of 3 years and 3 months, including demographic characteristics, service usage, presenting issues and pre and post revised North Carolina Family Assessment Scale (NCFAS-G) scores.
A significant improvement between intake and discharge occurred on the majority of the 58 NCFAS-G subscale items (32/58). In particular, most significant change occurred in the domains ‘family safety’ (p < 0.001) and ‘family interactions’ (p < 0.001).
Specialised programs can assist families with child safety concerns suffering from mental health and/or drug and alcohol problems.
The aim is to identify the role and scope of Accredited Exercise Physiologist (AEP) services in the mental health sector and to provide insight as to how AEPs can contribute to the multidisciplinary mental health team.
A modified Delphi approach was utilised. Thirteen AEPs with experience in mental health contributed to the iterative development of a national consensus statement. Six mental health professionals with expertise in psychiatry, mental health nursing, general practice and mental health research participated in the review process. Reviewers were provided with a template to systematically provide feedback on the language, content, structure and relevance to their professional group.
This consensus statement outlines how AEPs can contribute to the multidisciplinary mental health team, the aims and scope of AEP-led interventions in mental health services and examples of such interventions, the range of physical and mental health outcomes possible through AEP-led interventions and common referral pathways to community AEP services.
AEPs can play a key role in the treatment of individuals experiencing mental illness. The diversity of AEP interventions allows for a holistic approach to care, enhancing both physical and mental health outcomes.
Schizophrenia typically has a fluctuating course; rehospitalisation is common. We studied associations between discharge variables and subsequent two-year rehospitalisation rates.
Using a New Zealand national database, we obtained rehospitalisation rates and bed days for 451 patients with schizophrenia discharged from three inpatient facilities between July 2009 and December 2011.
Nearly half (44%) of the cohort were rehospitalised within two years. Patients over 50 were less likely [hazard ratio (HR) = 0.58, 95% confidence interval (CI) = 0.35–0.97, p = 0.04] to be rehospitalised. Patients whose index admission included compulsory treatment appeared more likely (HR = 1.3, 95% CI = 0.98–1.71, p = 0.06) to be rehospitalised and spent longer rehospitalised (p = 0.05). Those whose index admission was three weeks or longer were less likely (HR = 0.53, 95% CI = 0.39–0.72, p = 0.001) to be rehospitalised. Antipsychotic types, routes and dosages were not significantly associated with rehospitalisation rate, except for those prescribed clozapine (HR = 0.61, 95% CI = 0.41–0.89, p = 0.01).
Rehospitalisation rates were higher for patients under the age of 50 and those with shorter index admissions; the latter finding requires further study. Other than the beneficial effect of clozapine, the type and route of prescribed antipsychotics did not significantly affect rehospitalisation rates.
The objective of the current study was to provide a contemporary review of electroconvulsive therapy (ECT) practice in Far North Queensland, Australia.
Demographic, diagnostic and treatment characteristics were extracted from the hospital files of people who received ECT between 2011 and 2013. Data were quantitatively analysed and described.
Depressive illnesses were the most common indicator for treatment. However, psychotic illnesses also made up a large proportion of treated cases. The technical aspects of treatment were commensurate with previous Australian findings except for the higher incidence of bifrontal ECT and maintenance treatment.
Further research is needed across Australia to determine whether the findings of the current study represent changes in Australian ECT practice.
Aripiprazole long acting injection (ALAI) is now available, and this paper aims to assist clinicians in deciding when to use ALAI.
Aripiprazole is a partial dopamine agonist with low sedation, relatively favourable metabolic profile and a tendency to lower, rather than raise, prolactin. Available for over a decade, aripiprazole has been increasingly recognised by many clinicians as a useful option in the treatment of psychoses. ALAI is a suspension of crystalline aripiprazole in water which takes 5–7 days to reach steady state after an initial intramuscular injection. Monthly injections achieve steady state in four months. Studies have demonstrated that ALAI is effective in aripiprazole-responsive patients. ALAI was generally well tolerated, but more prone to cause extrapyramidal side-effects than the oral form. ALAI has not been compared with other depots. Although the recommended starting dose is 400 mg, it is likely that there will be significant inter-individual dose variation. Dose optimisation in each patient will be necessary for best effectiveness and tolerability. ALAI is currently appropriate for aripiprazole-responsive patients who need a depot, but clinicians are likely to try ALAI in patients who have been on other depots, particularly in whom weight gain and hyperprolactinaemia have been problematic.
The psychiatric assessment of potential liver transplant recipients is becoming increasingly common in clinical practice. In such assessments, the psychiatrist is invited by the transplant team to assess the patient prior to the patient receiving a transplant liver to identify factors that could predict an unsuccessful post-transplant course, whether this is from a psychiatric or physical perspective. This review examined published research from 2000 to 2014 on psychological risk factors predicting post-transplant physical and psychiatric complications.
Based on the strength of the evidence available, our review identified four risk factors: mood disorders; social supports; substance misuse; and alcohol dependence. These factors could potentially provide a framework to guide the evaluation and prediction of psychological and physical complications post-liver transplantation.
To develop and test a self-reported scale designed to measure the antecedents of depression.
Participants of the Sustainable Mastery of Innovative Lifelong Exercise (SMILE) Tai Chi program were invited to complete the scale for antecedents of depressive symptoms. The scale included questions regarding events/factors the participants have experienced over the past three months and preceded their depressive symptoms. The reliability of the questions was assessed using the Cronbach’s alpha. Principal components analysis was used to examine if there were domains of interest across the scale questions.
A total of 126 participants completed the scale. The scale had a good internal consistency (Cronbach’s α = 0.82). Principal components analysis identified three components (life events, psychosocial problems, and physical/health problems) in the scale and the components detected the root categories of depression in more than 56% of the cases.
This simple self-administered scale has proven to provide a reliable measure for the antecedent factors of depression in the SMILE Tai Chi cohort; further validation of the scale in different settings is encouraged.
There has been widespread interest from the public and media in the potential of ketamine as a novel treatment for depression. This paper reviews whether current evidence supports the use of ketamine for the clinical treatment of depression.
Clinical trials have investigated the use of intravenous ketamine for the treatment of depressive symptoms over the past 15 years. However, there remain many unanswered questions regarding its effectiveness, safety, and the route, dose and regimen for repeated administration. Experts have also raised concerns regarding ketamine’s adverse effects, abuse potential and the risk of addiction. At this stage, the use of ketamine in the treatment of depression remains in the realm of research settings.
This study examined the patterns of direct observation of patients by nursing staff (‘nurse specials’) and compared those required for mental health/drug health (MH/DH)-related presentations to other patient groups in different care settings.
A retrospective review of nurse special shifts requested during the 2014 calendar year at an urban teaching hospital.
Hospital-wide 14,021 8-hour nursing shifts were ordered for special observation of patients, an average of 39 per day. Of these, 30% were requested for MH/DH-related presentations, with the majority (70%) required for medically unstable patients. However, of the 1917 shifts required in the emergency department, 1841 (96%) were for MH/DH presentations compared to 76 (4%) for patients with unrelated medical conditions (odds ratio 98.2; 95% confidence interval 77.71–124.06, P<0.0001).
In contrast to the rest of the hospital, emergency department-based nurse special requests were significantly more likely to be for MH/DH presentations. This figure represents a considerable staff and financial burden and may be reduced by diversion or more rapid transfer of such presentations to an appropriate inpatient ward.
Antipsychotics are the cornerstone of schizophrenia management. There is substantial literature on their efficacy and optimal use. Doubts remain, however, regarding the translation of this knowledge into day-to-day practice. This study aimed to investigate antipsychotic prescribing in three New Zealand regions and its relationship to clinical guidelines and patient characteristics.
We studied 451 patients discharged from inpatient units with a diagnosis of schizophrenia or a related disorder (International Classification of Disease, version 10) between July 2009 and December 2011. Available information included patient demography, legal status, prescribed medications, duration of index admission and prescriber’s country of postgraduate training and years of postgraduate experience.
There was a high rate (33.7%) of multiple antipsychotic prescription, and lower than expected clozapine use (20%); Maori were prescribed clozapine more frequently than non-Maori (24% vs. 13%, respectively). Compulsory treatment was associated with more use of injectable medication and increased length of stay in hospital. Clinician characteristics did not significantly influence prescribing.
Observed prescribing practice aligned with existing guidelines except for antipsychotic polypharmacy and clozapine under-utilisation.
To critically examine the self-report measures most commonly used in Australian mental health research in the last 10 years.
A critical interpretive synthesis was conducted using seven outcome measures that were identified as most popular in 43 studies from three mental health journals.
Results suggest that the amount and type of language used in outcome measures is important in both increasing the accuracy of the data collected and fostering positive experiences of data collection for participants.
Results indicate that many of the measures most often used in Australian mental health research may not align with the current contemporary philosophy of mental health clinical practice in Australia.
Our objective was to report and describe a case of quetiapine-induced dystonia in an older lady with psychosis. Quetiapine is a second-generation antipsychotic and known to be rare in causing extrapyramidal side effects with rates similar to placebo.
There have been few documented cases of quetiapine-induced dystonia. It is important to be vigilant and consider the development of dystonia in patients who may not fit the typical risk profile.
Our aim was to develop a framework for clinical decision-making that can be used to take into account risk in an era of recovery and rights.
We developed a framework influenced by civil liability law to develop a guide for clinical decision-making which emphasises collaboration, clarification of the available information and communication of decisions as essential components of recovery-oriented risk management.
Published scientific literature on cycle acceleration over the course of bipolar disorder has been equivocal. The present analysis aimed to find whether episode duration and cycle lengths become shorter over the course of bipolar disorder with predominantly manic polarity.
The present study comprised 150 patients diagnosed with bipolar I disorder using SCID-I for DSM-IV TR. The course of illness was charted according to the NIMH Life Chart Methodology – Clinician Retrospective Chart (NIMH – LCM CRC). Spearman correlation was used to assess the relationship of episode duration and cycle length with the number of episodes.
The mean age of the sample was 37.8 years and the average duration of illness was 13.4 years. Unipolar mania comprised 52.7% of the sample. The episode duration and the cycle length decreased with increasing number of episodes (r=–0.245, p<0.001 & r=–0.299, p<0.001 respectively).
The present study suggests that over the course of bipolar I disorder, cycle length and episode duration become shorter.
Existing suicide risk assessment policies and guidelines do not specify whether the risk to be assessed is absolute, relative to other patients or relative to the same patient at an earlier time.
We utilised the results of a recent study of inpatient suicide to explore the implications of each of the above types of risk.
No interpretation of the current requirements for suicide risk categorisation of psychiatric inpatients can lead to information that might usefully guide clinical decision-making.
Policies and guidelines requiring suicide risk categorisation of inpatients should be withdrawn. The College should delete the mandatory entrustable professional activity requiring risk assessment.
Developing a formulation is an important method of understanding the people we treat. Writing a formulation need not be seen as burdensome or difficult. Our objective is to provide a framework for the formulation process to make it more accessible for beginners.
We describe a method that beginners can adopt easily and then build upon as their experience and knowledge broadens.
The primary objective was to calculate the number of self-inflicted burn injuries of all admissions in an Australian hospital burns unit. The secondary objectives included examining the demographic profile, length of stay and co-morbidity of mental illness in these cases compared with the total admissions to the burns unit.
A retrospective study of medical records was conducted at a tertiary burns unit over a 5-year period.
A total of 33 self-inflicted burn injury cases were identified which represented 2.2% of all burns unit admissions. These patients were 70% male, the average age was 36.1 years and 11 were born overseas, which was similar to the profile of all admissions. Twenty-four (73%) patients were diagnosed with a mental illness, compared with 14% for all admissions. The average length of stay was 52 days, compared with the burns unit average of 12 days.
While the percentage of self-inflicted burn cases of all burns unit admissions was low, these cases have a greater burden of care due to their longer admission time and higher frequency of co-morbid mental illness. This finding supports the need for close involvement of consultation liaison psychiatry teams within a burns unit.
Neuropsychiatric presentation in paratyphoid fever is not a well-known entity. In countries such as Australia, where the prevalence of enteric fever is one of the lowest, this presentation seems to be unlikely.
We present a case that demonstrates the importance of considering this possibility in Australian context in returned travellers.
A young male, who recently returned to Australia from his home country in South East Asia, presented with abnormal behaviour in the context of febrile illness. His behaviour was characterised by grandiosity, aggression, hallucinatory behaviour and paranoia, along with disturbed biological functions. Detailed inpatient assessment revealed him to be suffering from Salmonella Paratyphi A infection and psychotic illness because of his general medical condition. Although his fever and inflammatory markers responded to antibiotics, antipsychotics were required for treatment of his mental health problems.
This case demonstrates that paratyphoid fever, which is considered to be a less common variant of enteric fever, can present with neuropsychiatric manifestations.
The purpose of this study was to investigate restraint use in Australian emergency departments (EDs).
A retrospective audit of restraint incidents in four EDs (from 1 January 2010 to 31 December 2011).
The restraint rate was 0.04% of total ED presentations. Males and females were involved in similar numbers of incidents. Over 90% of restrained patients had a mental illness diagnosis and were compulsorily hospitalised. Mechanical restraint with the use of soft shackles was the main method used. Restraint was enacted to prevent harm to self and/or others. Median incident duration was 2 hours 5 minutes.
In order to better integrate the needs of mental health clients, consideration is needed as to what improvements to procedures and the ED environment can be made. EDs should particularly focus on reducing restraint duration and the use of hard shackles.
This paper describes the implementation of a state-wide clozapine management system to improve the quality of care for those with treatment-resistant schizophrenia. This intervention includes standardised forms, computer-based monitoring and alerting and nurse-led clinics for stable consumers.
Methods used during system development included medical record and clinical information system audit, consensus review of available evidence and qualitative review of existing forms, systems and stakeholder opinion.
Nurse-led monitoring safely reduced medical outpatient appointments by 119 per week in metropolitan public clinics. In the 15 months following the implementation of all interventions, mortality associated with physical illness not related to malignancy was reduced from an average of 5 deaths per year to one.
Differing interpretations of clozapine guidelines have contributed to confusion around monitoring. Standardised documentation has helped to increase understanding and improve protocol adherence. A regular training programme has increased basic knowledge of risks and protocols. Computer-based documentation and alerting systems have improved communication between hospital and community-based teams and prompted early intervention reducing the risk of adverse events. These factors have combined to help improve outcomes in clozapine management. Nurse-led clinics are a safe and efficient alternative for monitoring clozapine treatment.
To review the characteristics of all patients presenting with a first episode of psychosis between the ages of 16 and 65 years to an adult area mental health service.
The early psychosis programme at St Vincent’s Hospital Melbourne treats all patients presenting in the early stages of psychosis between the ages of 16 and 65 years. A database was developed to capture the demographic and diagnostic characteristics of the group. The characteristics of those with an onset under 26 years were compared with those with a later onset.
A large proportion (55%) of those presenting with first episode psychosis presented after the age of 25 years. There were a higher number of cases of depression with psychotic features in the older onset patients (notably so for those over 40) and a trend towards greater metabolic morbidity.
Older patients presenting with a first episode of psychosis are relatively understudied but appear to have certain distinguishing qualities. Understanding the needs of these patients is important in tailoring optimal treatment packages and service responses.
Investigate feasibility and development of a linkage intervention to the evidence-based Individual Placement and Support (IPS) approach to supported employment (SE) for patients with schizophrenia on a mental health unit who want to work in competitive employment.
Literature review about the evidence-based IPS approach to SE in schizophrenia and why it might not be implemented in mental health services. Analysis of 10 adult mental health unit multidisciplinary staff interviews for categories in the literature review of IPS implementation barriers and whether these barriers could be overcome.
There was lack of full staff knowledge of the IPS approach to SE. However, all staff knew respect for patient choice was paramount, community employment programs existed for the disabled, an outreach linkage process to such a program and ongoing support for people with schizophrenia would be required. There was staff ambivalence about SE for patients with schizophrenia.
Despite staff ambivalence about SE for people with schizophrenia there was still enough staff knowledge and openness to shape an IPS linkage intervention from a staff perspective.
To investigate psychiatry trainees’ confidence in their role as teachers, their perceptions of support and preferences for a program to support this role.
Psychiatry trainees in New South Wales (NSW) (Australia) in the first three years of psychiatry training (N = 118) were invited to complete a survey which included demographic data, self-assessment of teaching confidence and perceptions of support for teaching.
A total of 63% (N = 74) agreed to participate. Overall, 62% percent of participants regarded teaching as an important part of their role, 46% felt supported in the role by their training supervisors, but only 18% regularly discussed their teaching role in routine supervision.
Psychiatry trainees viewed teaching as part of their role. They reported a low level of formal training in teaching skills and perceived a low level of support from supervisors. Registrar training needs to address trainees’ competencies in a range of teaching skills along with supervisor support. Further research is required to assess the impact of a teaching program on teaching performance and learner outcomes.
Restrictive interventions (seclusion, physical restraint, and use of acute/p.r.n. sedation) may have negative effects on patients. Identifying factors associated with use of restrictive interventions and examining their effect on admission outcomes is important for optimising inpatient psychiatric care.
This study documented use of restrictive interventions within a child and adolescent psychiatric inpatient unit for 15 months. Two models examined predictors of use of restrictive interventions: (i) incident characteristics; and (ii) patient characteristics. The relationship between use of restrictive interventions and global clinical outcomes was also examined.
Of 134 patients admitted during the study period (61.9% female, mean age=13.8±2.9 years), 26.9% received at least one restrictive intervention. Incident factors associated with restrictive interventions were: physical aggression, early admission stage, and occurrence in private space. Patient factors that predicted use of restrictive interventions were developmental disorder and younger age. Use of restrictive interventions was not associated with increased length of stay or diminished improvement in global symptom ratings.
Further research is needed to identify best practice in children at high risk for receiving restrictive interventions.
To describe the core components of the Early Psychosis Prevention and Intervention Centre service model as the template agreed with the Australian Federal Government for national upscaling. The Early Psychosis Prevention and Intervention Centre model of early intervention has two main goals: to reduce the period of time between the onset of psychosis and the commencement of treatment and to bring about symptomatic recovery and restore the normal developmental trajectory as early as possible.
The Early Psychosis Prevention and Intervention Centre comprises three elements of service provision for young people experiencing a first episode of psychosis: (i) early detection; (ii) acute care during and immediately following a crisis; (iii) recovery-focused continuing care, featuring multimodal interventions to enable the young person to maintain or regain their social, academic and/or career trajectory during the critical first 2–5 years following the onset of a psychotic illness. It does this via a combination of 16 core components, which provide a flexible, comprehensive, integrated service that is able to respond quickly, appropriately and consistently to the individual needs of the young person and their family. Innovative service reforms, such as Early Psychosis Prevention and Intervention Centre, that recognise the value of early intervention are crucial to reducing the impact of serious mental illness on young people and their families and, ultimately, on our society.
Community treatment orders (CTOs) have been used in New Zealand since 1992 and are now used in most Commonwealth countries. There is little research on the rate of use of CTOs in New Zealand. This study compares the prevalence of CTO use across New Zealand’s 20 health districts and makes comparisons with international prevalence rates.
New Zealand Ministry of Health reports provided data on rates of CTO use in New Zealand between 2005 and 2011. International rates were obtained from published reports and academic literature on CTO use.
Rates of CTO use in New Zealand show marked and persistent regional variation over the period of data collection. National average rates increased from 58 per 100,000 in 2005 to 84 per 100,000 in 2011. Rates of use of CTOs are increasing internationally. New Zealand’s CTO use is high by international comparisons.
New Zealand’s high and increasing rate of CTO use by international standards raises questions about the delivery and functioning of mental health services, and about mental health service users’ experience of mental health care. The high rate of CTO use needs to be addressed as a human rights issue as well as a clinical issue.
to critically review the potential effect of the public reporting of pharmaceutical company payments to healthcare professionals on the relationship between medicine and industry.
this review is based on an examination of the ‘Transparency Model’ put out recently for consultation by Medicines Australia.
public reporting in itself will neither sharpen the boundaries between medicine and the pharmaceutical industry nor restore public confidence.
focusing on payments for clinical research and on the larger payments to healthcare professionals would lead to a better understanding of the interplay between science and marketing.
To describe the process and impact of a service-level intervention on metabolic monitoring and follow-up of patients of a mental health service who were prescribed clozapine, and describe the metabolic health of these patients.
The intervention – Let’s Get Physical – involved designating two months annually as ‘physical health months’, during which revised service protocol required metabolic monitoring for all eligible patients. Mixed methods were used to assess rates of monitoring at baseline, during the two physical health months, and follow-up and factors influencing practice. Data was analysed using a descriptive statistics and framework approach.
Monitoring was completed for around two thirds of eligible patients during each physical health month, representing a statistically significant increase (approximately fourfold) from baseline. Perceptions regarding scope of practice and perceived competency managing metabolic abnormalities were key determinants of clinicians’ practice. Low rates and inconsistency of follow-up were observed.
Let’s Get Physical is cost effective in enhancing adherence to monitoring guidelines. The use of clinical algorithms supporting timely response to abnormalities should be considered. Ongoing education, role clarity and dedicated resources are required if psychiatrists are to contribute meaningfully to improving the physical health of people with mental illness.
To describe the development, design and function of an innovative international clinical research network for neuroimaging research, based in Australia, within a joint state health service/medical school. This Australian, US, Scandinavian Imaging Exchange (AUSSIE) network focuses upon identifying neuroimaging biomarkers for neuropsychiatric and neurodegenerative disease.
We describe a case study of the iterative development of the network, identifying characteristic features and methods which may serve as potential models for virtual clinical research networks. This network was established to analyse clinically-derived neuroimaging data relevant to neuropsychiatric and neurodegenerative disease, specifically in relation to subcortical brain structures.
The AUSSIE network has harnessed synergies from the individual expertise of the component groups, primarily clinical neuroscience researchers, to analyse a variety of clinical data.
AUSSIE is an active virtual clinical research network, analogous to a connectome, which is embedded in health care and has produced significant research, advancing our understanding of neuropsychiatric and neurodegenerative disease through the lens of neuroimaging.
This study examined differences in the types of mental health research that were conducted in the states and territories of Australia in 2008. Differences in both the disorder focus (e.g. depression, psychosis) and goal or methodology (e.g. epidemiological, biological) of published papers were examined. The structural differences underlying research output were examined by comparing output with funding and research infrastructure.
A random sample of 1008 Australian-authored mental health research publications and all 126 competitive mental-health related research grants from 2008 were coded in terms of their state or territory of origin, disorder focus and research goal.
Victoria and the Australian Capital Territory had the highest per capita rates of mental health research publications in 2008, while Tasmania and the Northern Territory had less per capita output. Research in New South Wales had greater focus on substance use and anxiety disorders, while Victoria was dominant in research on affective disorders and psychosis. Research in Queensland and Western Australia was broader in scope. Research output was more closely linked with number of successful grants than amount of funding.
State and territory support for mental health research may have important implications for research output.
The objective of this article is to examine national trends in prescribing second-generation antipsychotic (SGA) medications to Australian children and youth (0–24 years) and to report deficiencies in available data.
We conducted a retrospective review of government data on all dispensed SGA prescriptions between 2002 and 2007. Scripts were converted to defined daily dose (DDD)/1000 population/day using census data. Trends in utilisation of dispensed SGAs were analysed by gender and age.
The total amount of SGAs dispensed to children (0–14 years) remained stable over the five-year study period. In 2007, according to available data, total SGA medication dispensed to Australian children equated to fewer than three in 10,000 children receiving the equivalent of a standard adult dose of medication each day.
In contrast to many other countries, the dispensed use of SGA medication in Australian children and youth has remained relatively stable. In our opinion, this is almost certainly because of limitations in data collection and accessibility. Given the safety concerns associated with SGAs prescribed to children and young people and the need to improve the quality use of medicines, it is essential that methods are developed in Australia to accurately capture prescribing of SGAs to Australian children and youth.
Public, consumer and professional views about attention deficit hyperactivity disorder, its assessment and treatment – especially with medication – remain a highly contested domain. Parents in particular express disquiet with services. One response to this tension is a multidisciplinary evaluation. Parental and education perceptions of this process have not been evaluated previously. A community multidisciplinary approach was assessed in terms of diagnostic outcomes and client satisfaction.
A comprehensive multidisciplinary structured assessment of the first 50 referred children with severe attentional problems was documented. Demographic and symptom/behavioural profiles, developmental history and indicated multi-disciplinary evaluation were recorded. A team consensus process arrived at diagnostic classification. Post-assessment satisfaction of parents and school staff was surveyed.
Thirteen children (26%) were diagnosed with attention deficit hyperactivity disorder and three commenced stimulants. The majority of parents and educators were satisfied with the service.
A multidisciplinary assessment clinic for children presenting with attention problems resulted in minimal prescribing. Overall, education staff and parents were satisfied with the service. The model may be a suitable response to the multiple concerns in the community.
To characterise patients and their outcomes following referral to a Statewide psychiatric intensive care service.
This study conducted a medical audit for patients referred to the Statewide service during the first four years of operation (2007–2011). Demographics and the presence of alcohol and other drug and forensic comorbidities were documented along with the treatment received prior to and during admission.
In the first four years of operation, 58 referrals were received, 41 resulting in admission and seven in secondary consultation delivered to the referring inpatient psychiatry service. Admitted patients were most commonly experiencing a psychotic illness, had high levels of substance comorbidities and antisocial personality traits, required lengthy admissions (mean days = 41.5), and were in most cases successfully discharged back to the referring inpatient psychiatry service or the community. Significant reductions in clinician-rated difficulties measured via the Health of the Nations Outcome Scale were found at discharge, and despite the significant presenting aggression risk, few attempted or actual assaults occurred.
Improved outcomes were achieved with patients deemed unsafe for psychiatric care in high dependency units in other Victorian acute mental health services through management by an acute service that has developed special expertise in this area.
Neurocognitive deficits are a core symptom domain of schizophrenia, occurring in 75–90% of people with this diagnosis and influencing long term functional outcomes. This article aims to describe the pilot implementation of cognitive remediation therapy in two large public mental health services and detail changes made to the delivery of this therapy after this trial.
Cognitive remediation therapy provides an evidence-based approach to targeting cognitive deficits but the translation of this therapy from a research setting to clinical practice has not been well evaluated.
This paper applies a psychoanalytic perspective to notions of workplace stress.
At its most extreme, workplace stress can evoke a crisis of conscience, and its sequelae include psychosis and suicide.
The incidence of Asperger’s syndrome is reported as above average in young people presenting with gender dysphoria. Patients with Asperger’s syndrome, however, are prone to obsessive preoccupations. This paper points out that the apparent dysphoria may in some cases prove to be a transient obsession.
Cases from the author’s clinical practice were reviewed.
Two young men with histories suggesting Asperger’s syndrome presented with strong convictions of gender dysphoria, asking for hormonal and surgical treatment. Treatment was withheld and after several years both came to repudiate their ’transgender phase’.
Patients asking for sex reassignment should be assessed for indications of Asperger’s syndrome. Irreversible treatments should be withheld until it is clear there is a genuine issue of transsexualism.
To explore aspects of prestige in the bipolar disorders.
Conceptualisation around bipolar spectrum disorders is in its infancy, in particular with relation to their neurobiological and evolutionary underpinnings. While research has privileged proximate causation, a separate, nascent dialogue in relation to the ‘aboutness’ of affective syndromes exists. Arguably, affective disorders can be considered in relation to the social group phenomena of self-esteem and prestige. A conceptualisation of Panksepp’s PLAY and Thayer’s energetic arousal systems combined- Hedonic Energetic Social Engagement- can be invoked as a mechanism for bipolarity. This has been acted upon by prestige competition to create a selection pressure for prestige. In this model, bipolar spectrum conditions evolved as a by-product of this process.
Suicide bereavement research can help facilitate greater understanding of the impact of suicide and potential risks for others. As there is limited research on the experience of young people who lose a friend to suicide, the aim of this exploratory study was to consider specific psychological factors for such bereaved young people.
Ten young people who had experienced the suicide death of a friend completed self-report measures to assess levels of depression, anxiety, coping and prolonged grief.
Participants reported increased levels of stress, depression, reduced coping capacity and prolonged grief symptoms that have continued considerably beyond the death of their friend.
Psychological distress for young people bereaved by a friend’s suicide is of concern given the developmental changes and life transitions associated with this age group. Implications include the significant health and wellbeing challenges associated with suicide bereavement for young people. The outcomes support a more proactive response from mental health and support services.
The objective of this study was to explore how a support group in Victoria, Australia, that has been set up for doctors and medical students with substance use disorders is perceived by group members.
Past and present participants were surveyed anonymously regarding their attitudes to the group and its role in their recovery.
Respondents overwhelmingly valued the support group, seeing it as an integral and essential part of their recovery and on-going health.
It is recommended that such support groups for doctors who have substance use disorders be more widely available in jurisdictions other than Victoria.
Australian public mental health services have seen a rapid adoption of risk assessment into clinical practice over the past decade. It is timely to review the role of risk assessment in clinical practice, evidence for its validity and to explore its role in clinical decision-making.
There is little evidence to support the current form of risk assessment used in public mental health. The continued focus in risk may lead public psychiatrists into a bind where their specialist role is defined by a capacity that they do not fully possess. Further work is required to find ways of demonstrating our attention to the possibility of adverse outcomes whilst maintaining our skills and capacity to manage mental illness with complexity and balance within the limitations of rational decision-making.
The purpose of this study was to measure the effectiveness of two alternative care pathways for managing patients treated with clozapine.
Medical records for 90 clozapine patients managed via three care pathways were audited for a 24 month period (30 per group). The three care pathways established to manage patients prescribed clozapine include: (1) remaining in public mental health service case management; (2) transitioning to general practitioner–mental health service shared care; or (3) transitioning to private psychiatry sole care. Demographic, illness, medication compliance, service utilisation and performance on clinical outcome measures were collected in the 12 months prior to and following transition.
Across both the private psychiatry and general practitioner (GP) shared care transitioned groups, only one patient had a psychiatric hospital admission in the 12 months following transition, and transitioned patients also had fewer mental health service clinician contacts. Good medication compliance, better skills of daily living, lower levels of illicit substance abuse and a lower intensity of case management history were seen in transitioned patients.
Transitioning appropriate patients taking clozapine to less intensive care pathways like private psychiatrists and GP shared care can be effectively achieved if appropriate supports are in place for both the clinicians and their patients.
The purpose was to investigate a perception that clients of a rehabilitation team constitute an ‘easy’ group of patients, who should be managed outside public sector community psychiatric service settings.
A caseload equalisation tool was used to compare the case manager workload in the community team and the rehabilitation team of a community mental health service.
Caseload scores of clients of community and rehabilitation teams were not significantly different. Nor was there any significant difference in client complexity, time that case managers spent with clients or liaison activity.
The primary sector, even with non-government organisation support, is unlikely to be able to meet the needs of the group of patients who were being managed by the rehabilitation team.
Traditional indigenous society promoted the social and emotional well-being of indigenous men through the meeting of men in daily life and during ceremonial times. There is an increasing recognition that men’s groups use similar mechanisms to enhance the social and emotional well-being of participants and their communities. This paper seeks to increase understanding of the processes and impacts of contemporary indigenous men’s groups from an indigenous doctor’s perspective.
Review of published and unpublished literature and reflections on the primary author’s experiences within several indigenous men’s groups using a participatory action research model were used to examine how participation within these groups can improve social and emotional well-being.
There is a scarcity of published data on the distribution, activities and outcomes of indigenous men’s groups. Published qualitative and experiential observations suggest that they contribute to improved social and emotional well-being for participants, their families and communities.
Men’s groups may be a good adjunct to the outpatient care of indigenous patients. As the published literature is entirely qualitative, mixed methods evaluation using appropriate and sensitive measures would assist in systematically capturing the impacts and outcomes of men’s groups. Such evaluations could enhance programme longevity and encourage the referral of patients by mainstream mental health practitioners.
The formal assessment of a person’s capacity for making reasoned decisions is an infrequent and usually unappealing clinical task. The purpose of this paper is to dissect the task, consider the component parts, clarify those aspects that can be problematic and highlight those that remain so.
The paper reviews the concepts, terminologies and dilemmas around alcoholism, insight, lack of insight, denial, judgement, will, decisional capacity and competence.
Assessments of patients suffering from alcoholism (or any other dyscontrol problem such as deliberate self-harm, problem gambling or eating disorders) are likely to evoke unease because of the interweaving of potentially disputable phenomenological, clinical, ethical, semantic and legal aspects. Familiarity with the concepts and terms around decisional capacity helps to orientate clinicians in their work. There remain some particular conceptual issues that are in need of further scholarly attention.
To describe the organisational, clinical and pragmatic features of a GP liaison service established by the Division of Mental Health in the Darling Downs Hospital and Health Service catchment to facilitate the care of rural patients and improve communication between primary and specialist care.
The GP liaison service was created using funding from the Commonwealth STP initiative to provide weekly registrar clinics to primary care providers in the Darling Downs. The service was eagerly accepted by providers who saw patient benefits outweighing financial considerations. Expectations of a greater level of care than the assessment and advice provided reflects the large unmet need for mental health services in rural areas. GPs expressed enthusiasm for true collaborative care, such as case management overseen by the public mental health service but based at GP offices.
To consider the role of specialty trainees as clinical teachers of medical students in psychiatry.
We discuss the role of specialty trainees as teachers and approaches to improving their skills and capacity, giving examples from the local and international literature and our own experience as psychiatry medical educators.
Good clinical teaching is crucial for medical students’ learning but sharp increases in numbers combined with economic and workforce pressures have stretched capacity. Specialty trainees do much of the medical student teaching during their clinical placements but infrequently receive instruction on how to teach. The two common approaches to increasing capacity are, first, establishing education rotations for individual trainees and, second, providing workshops to improve trainees’ confidence and skill. Psychiatry trainees surveyed in New South Wales welcomed the role of teacher and the opportunity to improve their teaching capacity. Further support from supervisors, health services and medical schools is needed to assist trainees in their teaching role.
The role that trainees play as clinical teachers should be acknowledged and supported. Further development of research and scholarship in medical education is needed to determine how best to teach trainees to teach.
The aim of this clinical review was to investigate the effectiveness and safety of the practice of antipsychotic poly-pharmacy (AP) in the long-term management of hospitalised patients with insufficient response to antipsychotic monotherapy.
The databases Medline, PsycINFO, Embase and Scopus were searched. Studies were required to include inpatients with long-term, treatment-resistant schizophrenia on maintenance AP. The search was restricted to systematic review studies.
The review yielded four studies of interest that showed no categorical advantage for maintenance AP for the population of interest. However, clozapine combination faired marginally well. Particular weaknesses of the present literature are low number of participants, and inadequate monitoring of potential adverse effects. The evidence on the risks and benefits of maintenance AP is not generally considered adequate to warrant a recommendation for its use in routine clinical practice in psychiatry.
This review provides a synthesis of the evidence on the maintenance use of AP for hospitalised patients with long-term, treatment-resistant schizophrenia. The results show both no support for AP with some marginal benefit for clozapine combination therapy, and methodological weaknesses of the included studies. These findings have clinical implications for treatment decisions and suggest that sufficiently powered studies are needed.