Abstract
A HIGHER STANDARD OF REPORT WRITING
Alcorn D
Senior Lecturer, Department of Psychiatrity, University of Queensland; Consultant, Medical Consultants Australia
Legal and compensation agencies frequently request psychiatrist report writers to provide a percentage disability rating. An understanding of disability and impairment terminology, symptom impact on activities of daily living, recreational and work function; the applicable compensation system and the principles of impairment assessment are critical to providing ethical, scientifically grounded and common-sense answers to such agencies. There will also be a discussion of further training opportunities.
THE PROBLEMS WITH PROBLEM GAMBLING
Allcock C
Cumberland Hospital, Sydney
This paper will review some of the contentious areas concerning current views of pathological/problem gambling. Overlap between debates about this topic and debates in related fields, such as alcohol problems, will be demonstrated.
Areas addressed will be questions such as is gambling an impulse disorder? Is it an addiction? Is it an illness? Some points about management, especially the possibility of controlled gambling, will be covered. The author will present evidence for personal views that while some problem gamblers are impulsive, gambling generally is not an impulse disorder. It will also be argued that current models of addiction do not fit easily with this behaviour, that an illness model is hard to sustain and that controlled gambling can be achieved, but rarely and at considerable risk.
IS YOUR ALZHEIMER'S DISEASE RISK GOING UP IN SMOKE?
Almeida O
Department of Psychiatry and Behavioural Science, University of Western Australia, Queen Elizabeth II Medical Centre, Perth
PREVENTION IS A PUBLIC HEALTH PROBLEM
Andrews G
St Vincent's Hospital, Darlinghurst, Sydney, New South Wales
Sometime after estimating the cost of schizophrenia we were asked to go back and estimate the benefit that might accrue of one could prevent the disorder and, as might be expected we found that prevention was cheaper than cure, and that a cure was cheaper than a maintenance treatment. And this is the received wisdom behind the current worldwide program for vaccination and immunization. But it is not all straight forward. While great efforts are being made to develop a vaccine for AIDS because of the cost offset, no efforts are being made towards an equally practical vaccine for dengue fever, the cost offset would not justify the investment.
In mental health Burrows and Raphael edited one of the first major texts on prevention. A major report from the US Institute of Medicine defined three aspects of prevention: universal prevention given to all, risk factor amelioration, and indicated prevention given to those with symptoms but who do not presently meet criteria for a disorder. In Australia we have had much discussion, but there is no countrywide adoption of any prevention program. A good idea but no priority, given we are all faced with the unmet demands of those who are already sick. We are currently half way through an NHMRC project to calculate the cost effectiveness of current treatment and to model the cost effectiveness of ideal treatment, as if we all carried out the College guidelines. At this stage, and I can't see it altering, the findings are that even if we all did everything right and all patients complied we would still be left with half the burden of mental disorders unaverted. So we either have to have a new generation of wonder treatments or we have to get serious about prevention.
Last year we (Kessler, Ustun and Andrews) did a scoping exercise for WHO to determine the risk factors for mental disorders that could be identified in the Burden of Disease report and that could be a focus for the 2002 WHO World Health Report which will be on avertable risk factors. Broadly speaking we thought that the risk factors for mental disorders could be grouped into Deprivation, Temperament and Adversity and, for many, a combination of all three.
There is an extensive prevention literature and a number of programs of demonstrated efficacy. Unfortunately there are no programs in which the cost effectiveness has been demonstrated to the point where they could form the basis for a National program. We need such data, for left to their own devices departments of health will stay in the rut of direct patient services.
THE USE OF ZUCLOPENTHIXOL ACETATE IN THE MANAGEMENT OF ACUTE PSYCHOSIS
Barnes C
Fremantle Hospital, Perth
Castle D, Preston N
Fremantle Hospital, Perth
Zuclopenthixol Acetate (Clopixol-Acuphase) is a potent neuroleptic, which has a rapid onset of action and is intended for the treatment of acute psychosis, mania and exacerbation of chronic psychosis. There has been much controversy in the literature about the benefits that Zuclopenthixol Acetate (ZA) has over conventional treatment of acute behavioural disturbance in acute psychosis. The Cochrane Library Review reported no benefits over “standard treatment”. There has been a call in the literature for better studies on its use and for the development of clinical guidelines and with the development of novel parenteral antipsychotics a review of ZA current role in this area is required.
This naturalistic open prospective study investigated factors influencing the choice of ZA as compared to “as required” (PRN) medication in management of acute behavioural disturbance in patients admitted to a psychiatric intensive care unit (PICU). The study compared the expected degree of response of targeted symptoms and behaviours to ZA by medical staff, to those observed by nursing staff over a fourhour period. It looked at factors influencing a patient's score on a global level of disruption scale and the frequency that patients gave their consent to both ZA and PRN medication.
Nursing staff completed a questionnaire each time they administered a PRN medication or ZA. They recorded demographic details, mental health act status, use of illicit drug use, diagnosis, type, dose and route of the medication given and symptoms or behaviours which were being targeted. They then documented some details about consent and then recorded the response of the targeted symptoms over four hours. Medical staff completed a separate questionnaire each time they prescribed ZA indicating the symptoms and behaviours that they were targeting and the degree of response that they expected. They also recorded whether or not the patient had been given the opportunity to consent and if ultimately they had consented.
189 episodes of PRN medication administration were documented; 12 of these episodes occurred in seclusion. Men were younger and received more PRN. 25 patients received ZA during the same period (F=4, M=17). 88% of PRN medication was given orally. Those receiving ZA scored lower on a global level of disruption scale than those receiving PRN and were more likely to have consented to their treatment. The scores on the global level of disruption scale showed no statistical correlation to either diagnosis, use of illicit substances, gender or age. There were differences between nursing and medical staff's expectations of the effect of ZA. Medical staff were more likely to target symptoms for ZA which were observed to have a reduced level of effect compared to symptoms targeted by nursing staff.
THE VAGS: A NEW AUSTRALIAN INSTRUMENT FOR THE DETECTION OF PROBLEM GAMBLING
Battersby M, Ben-Tovim, Estermann A, Tolchard B, Dickerson M
The VAGS—A Now Australian Instrument for the Detection of Problem Gambling
The authors have been commissioned by the Victorian Casino Gaming Authority (VCGA) to develop a questionnaire to detect problem gambling in the community. Previous questionnaires, eg the SOGS have been developed in the United States based on the DSM IIIR diagnosis of pathological gambling The essential features and conceptual model of pathological gambling have not been established. The VCGA adopted the concept of problem gambling and its definition based on harm. Within this framework the authors used innovative and step wise psychometric processes to develop a pilot questionnaire. The questionnaire has been administered to a community and treatment sample. This paper will describe the underlying factors found within the concept of problem gambling and the 20 items of the VAGS. Validation with the SOGS and calibration using the clinical categories of problem and borderline problem gambler will also be described.
COMPLIANCE IN THE TREATMENT OF ALCOHOL DEPENDENCE WITH NALTREXONE
Bhattacharyya B
Consultation/Liaison, Liverpool Hospital, Sydney
Jurd SM, Latt NC
Drug and Alcohol Services, Royal North Shore Hospital
Godwin P (was in private practice, now deceased)
Balit C
Medical student, University of Sydney
This study set out to determine the parameters relevant to compliance in alcohol dependent patients taking naltrexone in a clinical trial. We sought not only the rate of noncompliance, but also the reasons for it. We performed a mail out survey using a 25-item questionnaire, sending it to 101 patients involved in a randomised controlled trial of the efficacy of naltrexone in alcohol dependence. Subjects receiving the mail out were in most ways typical of outpatients with alcohol dependence. They were 45+/–10 years old, mainly male (69%), and 48% were in a marital relationship. Despite good education—75% had 12 or more years of education, 41% were unemployed. Questions included general ones about whether medication compliance was an issue and more specific ones about reasons for missing doses, and parallel questions about compliance with suggestions to attend Alcoholics Anonymous and counselling. We received 52 responses, yielding a response rate of 51.4%. Compliance rates were consistent with other studies of compliance in chronic conditions. Asked in three separate questions, (Did you ever forget? How many days missed? And did you take tablets every day?) each time a compliance rate of just over 60% was found, providing grounds for a claim of internal validity. Of those who did report missing doses, the most common reasons were forgetting (23%), side effects (15.4%), wanting to drink again (15.4%), feeling better (11.5%), deciding tablets were no longer needed (9.6%) and feeling worse (9.6%). Compliant patients often developed a routine, folding their medication into their other daily habits of eating, sleeping and smoking. Provision of information in the consultation room or in written form was perceived as helpful by some. Regular appointments and interpersonal support were also seen to support compliance. Compliance with medication did not predict compliance with psychosocial interventions. We conclude that rates of compliance and the issues related to compliance are no different in alcohol dependence than in other chronic conditions.
ASSESSING AND FORMULATING THE FAMILY IN GENERAL PSYCHIATRY
Bickerton A, Nair J
Division of Mental Health, Sutherland Hospital
Mottaghipour Y
Division of Mental Health, Sutherland Hospital
Extensive research and policy exists supporting the benefits of involving families in the care of mentally ill patients. However the reality is that few clinicians have experience or training in family work and hence families remain unseen.
To address this situation the Working With Families project of the Sutherland Hospital Division of Mental Health has been developed over the last three years. This workshop has been developed out of the authors’ extensive experience training multidisciplinary staff on this project.
This workshop focuses on building on the clinical skills of the clinician to incorporate basic family work skills and hence to empower the clinician to feel more confident in working with families. The Pyramid of Family Care (Mottaghipour & Bickerton 2000), a hierarchical framework for intervening with families will be introduced. Small group work focussing on “famous family” clinical vignettes will form the basis for the development of skills. Documentation of family assessment and intervention plans will be described.
To gain some understanding of the needs of families and the benefits of working with families as part of everyday general psychiatry practice. To develop an understanding of the Pyramid of Family Care which provides a framework for involving families in the everyday practice of adult mental health clinicians. To develop practical skills in connecting, assessing and planning with families. To be aware of options for developing further skills in working with families.
A PREDOMINANTLY PSYCHOSOCIAL APPROACH TO CHALLENGING BEHAVIOUR IN DEMENTIA
Bird M
Centre For Mental Health Research, Australian National University, Canberra
Challenging behaviour associated with dementia remains a major reason for home carer stress and the usual reason family members surrender care to residential facilities. Here what often becomes even more difficult behaviour causes equivalent stress to nursing staff. Many cases are managed or even prevented by empathic caring and nursing skills, and common sense. Unfortunately many are not and, despite lipservice to the ideal of non-pharmacological methods, cases which have to be referred on to health professionals tend to be treated predominantly with psychotropic medication, especially anti-psychotics. Many reviews have focussed on the drawbacks of excessive reliance on the pharmacological approach, including only modest efficacy and serious side effects.
This paper first uses case studies to draw out key features of the predominantly psychosocial approach, where medication is used as an occasional adjunct rather than the other way round. Data from an intervention study where medication was used as the front-line treatment in less than 10% of cases will be presented to show that this approach may be more cost effective than relying primarily or exclusively on psychotropic medication. Finally, examples will be presented showing how the careful hypothesis testing approach, which is the essence of non-pharmacological methods, is being put into everyday clinical practice in a few services around Australia.
ALL THAT GLITTERS IS NOT GOLD; ALL THAT IS POST TRAUMATIC IS NOT POST-TRAUMATIC STRESS DISORDER
Boulnois J
MB ChB (Bristol) LRCP MRCS DPM MRC Psych FRANZCP
A community psychiatrist, albeit living and working in “paradise” ponders the meaning of recent assaults upon his clinical boundaries. The last few months have been far from uneventful out here in the community; Mental Health Week somehow made it to the middle pages of the Gold Coast Bulletin, just; Jeff Kennett was appointed depression supremo; most of our local private hospitals found psychiatric inpatients uneconomic barred admission and denied admission rights; the one remaining facility, the one remaining, rather small, facility in paradise appointed a clinical supremo who lived in New Zealand; not one drug company gave me as much as a calendar; and the Federal Minister of Health declared that depression should be treated by general practitioners which the Government would consider funding.
Oh dear, quo vadis, another identity crisis looms! Shall I succumbto 15-minute consultations and oodles of SSRI's, or join the “40 patients syndrome” and see the same cohort of the worried well endlessly… ? Or shall I endeavor to ponder this down grading, even trivializing of community mental health and endeavor to see it in perspective, or not, after all retirement looms around the corner, so I have been told, my coronary arteries need all the help they can get, and I certainly don't want to catch a dose of “stress”, even if I believed in it…. Baliant's “collusion of anonymity” appears now to be well set in institutionalized concrete, and abdication by the silent majority to the seemingly powerful minority appears well neigh complete.
But in spite of all I am still convicted on the belief that it is only through listening to the still small voice of the soul of the community that it will ever be possible to re set the balance in terms of addressing the real causes of a human race increasingly bereft of either meaning or a sense of belonging, however that message is communicated.
Within the wilderness that community is becoming are to be found much in the way of riches in terms of insight, if anyone would care to listen; ignore such messages at a cost, give power over to horizontal psychology, which soon will be able both to explain and justify all that is neurobiology, and the genome, with the almost inevitable genuflection before the alter of psychopharmacology.
Victor Frankl, freshly emerged from Alshvitch, prophesied, as we know, that the emotional vacuums that were to come, maybe had come, would be characterized by “depression aggression and addiction” the only laboratory that he needed lay outside his front door. There is a sickness in the soul of our community, a sickness that is being denied, and I would wish to set that balance straight by exploring precisely what the above might mean in terms of relevance to all of us who are concerned with the heightened level of suffering within our community.
THE ASSESSMENT OF DISABLEMENT IN PATIENTS WITH PSYCHOTIC DISORDERS: AN EVALUATION AND COMPARISON OF OBJECTIVE AND SUBJECTIVE MEASURES
Chopra P
St Vincent's Mental Health Service; Department of Psychiatry, University of Melbourne
Couper J, Herrman H
St Vincent's Mental Health Service; Department of Psychiatry, University of Melbourne
MOODGYM: A WEB-BASED INTERVENTION FOR THE TREATMENT AND PREVENTION OF DEPRESSION
Christensen H
Centre for Mental Health Research, Australian National University, Canberra
Griffiths K
Centre for Mental Health Research, Australian National University, Canberra
MoodGYM was developed by the CMHR and is currently accessible on the web. It consists of five modules, a workbook, downloadable relaxation and meditation audio, and interactive extras including an interactive game. It presents cognitive-behaviour therapy, using the experiences of the on-site characters, through flashed diagrams and via structured exercises. The program is designed to be accessed by individuals independently but could be used as an adjunct to therapy in clinical practice. The assessment of MoodGYM proceeds in three stages. Stage 1 involves process evaluation of the developing site by young people and by mental health professionals, and pilot testing of the assessment instruments. Stage 2 involves assessment in a randomised controlled trial (including both process and outcome measures). Stage 3 incorporates the assessment and dissemination of the evaluated site. Assessments from Stage 1 will be presented at the conference.
IS AGE KINDER TO THE MORE ABLE
Christensen H
Higher education has been posited as protective of cognitive decline, either because the rate of decline is slower in the more highly educated or the start of decline is delayed. Latent growth models provide improved methodology to examine this issue.
The sample consisted of 887 participants aged 70-93 years in 1991 and followed up in 1994 and 1998. Latent growth models and standard regression techniques were used to examine the rate of cognitive decline in four cognitive measures while controlling for health status and sex. A delayed start model was examined by incorporating interaction effects in a regression model.
Neither the latent growth models nor the regression techniques revealed a slower rate of decline for the more highly educated. The proportion of the highly educated showing no change was no larger than the proportion of the less well educated. There was no significant age by education interaction effects, no chronologically later accelerations in the rate of change as a function of education, and no differences in rate of decline between the first measurement interval and the second. Education may not be protective of cognitive decline although it is associated with long-term individual differences in level of functioning. The discrepancy between our study and others may be attributable to attrition effects, follow-up length, sample age, scaling artefacts and negative publication bias. Most importantly, practice effects may favour the better educated and hence account for the supposed protective effect in many longitudinal studies of cognitive change.
A STUDY OF THE ADOLESCENT POPULATION MANAGED BY THE SOUTH WESTERN SYDNEY AREA TERTIARY ADOLESCENT MENTAL HEALTH TEAM
Clark G
South Western Sydney Area Adolescent Mental Health Team, New South Wales
South Western Sydney Area Adolescent Mental Health Team (SWSAAMHT) is a community-based, tertiary adolescent mental health team. The team has been operating independently forapproximately 18 months. Very little information is available about the mental health problems of the population of the SWS area. The complex and diverse characteristics of the area are described in the study. This study gathered data from those files which were managed and closed to describe a number of characteristics of the population referred to SWSAAMHT. This includes demographic data, diagnostic data, comorbidity patterns and service usage patterns. The study reveals a young population (mean age 14.1years) with a high level of behavioural problems (33% of primary diagnoses), psychoses (7%) and family conflict (62% with co-morbid diagnosis of parent/child relational conflict). Prevalence of some disorders is much higher than expected whilst others are significantly lower. This study represents the first step in attempting to understand the characteristics of the clinical population serviced by SWSAAMHT and how the unique characteristics of this area are expressed in relation to the mental health problems of its adolescent population.
MENTAL HEALTH EDUCATION AND TRAINING FOR THE RURAL PRIMARY CARE CLINICIAN
Clarke D
Monash University, Department of Psychological Medicine; University of Melbourne Centre for Palliative Care; Centre of Excellence in Remote Psychological Medicine, Broken Hill
There have been difficulties attracting and retaining professionals in remote and rural areas. Studies have suggested the causes in part to be a perception of isolation, Lack of available professional development incentives, lack of available peer consultation and the need to combat the tyranny of distance to access these. The Australian National Rural Health Strategy set out as a priority commitment for education, training and supporting such activities for remote and rural workforce, delivering education and training as close as possible to the workplace and maximising potential for use of interactive technology.
This presentation focuses on education and training of rural general practitioners in Victoria using face to face and interactive technology to deliver this program. The use of University backed programs have been accepted in rural areas that this training and education programs have been use. Outcome studies have suggested that offering of similar programs have resulted in enhancement of competence and confidence in managing patient's mental health problems and helped attracting and retaining practitioners to rural areas.
DEMORALISATION IN PSYCHIATRIC PRACTICE
Clarke D
This workshop will explore the concept of demoralisation and its relationship to depressed states, loss of hope and suicidal ideation. Demoralisation is an experience of ‘not coping’ leading progressively to feelings of impotence, helplessness, impaired sense of self-efficacy, hopelessness and despair. Shame and hopelessness can lead to suicide. Hope and optimism protect against it. Demoralisation is to be differentiated from depression. A series of presentations will be used to consider the application of the concept in a number of different clinical settings. This presentation will deal specifically with ‘demoralisation: what it is and how to treat it’.
UNEMPLOYMENT AND SUICIDE AMONG 25–64 YEAR OLDS: SOME RESULTS FROM THE NEW ZEALAND CENSUS MORTALITY STUDY
Collings S
Dept of Psychological Medicine, Wellington School of Medicine, New Zealand
Blakely TA
Dept of Public Health, Wellington School of Medicine, New Zealand
Suicide, especially youth suicide, has become an acknowledged public health issue in New Zealand and internationally. The risk of suicide has been shown to be highest in low socioeconomic groups, although the nature of this association has been poorly understood. Evidence is beginning to accumulate, however, in support of a strong association between unemployment and suicide, independent of other socioeconomic factors [Lewis, 1998 #3021]. This paper describes the relationship between unemployment and suicide in New Zealand.
The New Zealand Census Mortality Study (NZCMS) provides an opportunity to examine the associations with suicide as a cause of death, at the level of a national population, and in a large sample. The NZCMS involves linking census to mortality records, using anonymous and probabilistic record linkage methods [Blakely, 2000 #4173]. A cohort study was created of the entire New Zealand population (1991 census), followed up for mortality in the subsequent three years. The results presented here exclude deaths in the first six months to mitigate against health selection effects, and exclude census respondents where data for education, household income, labour force status and car access are incomplete. The analyses were conducted separately by sex for 648,750 males (282 suicide deaths) and 667,182 females (88 suicide deaths) aged between 25–64 years.
Controlling just for age and ethnicity, the odds ratio of suicide death among the unemployed compared to the employed was 2.70 (95% CI = 1.84-3.95) for males and 2.86 (95% CI = 1.19-6.85) females. It is possible that other measures of socioeconomic status such as education, income and car access may be either mediators or confounders of these associations. However, analyses controlling for these later variables only reduced the excess odds ratio by 21% for males (OR 2.35, 95% CI = 1.57–3.53), and by 15% for females (OR 2.58, 95% CI 1.04–6.38). This association between unemployment and suicide deaths is stronger than that for other causes of death in the NZCMS, particularly after controlling for other socioeconomic factors.
These results suggest a strong link between unemployment per se and suicide. This may offer some support to the idea of psychosocial mechanisms such as feeling integrated with the community, or feeling one can influence one's lifecourse, affecting suicide rates. Policies that reduce unemployment may reduce suicide rates.
A MANUAL OF MENTAL HEALTH CARE IN GENERAL PRACTICE: DEVELOPMENT AND FUTURE TRAINING OPTIONS
Davies J
Logan-Beaudesert Mental Health Service
Groom G
Australian Divisions of General Practice
In June 2000, the Commonwealth Department of Health & Aged Care published, “A Manual of Mental Health Care in General Practice”. The book was distributed nationally through divisions of general practice and mental health services.
The aim of this presentation is to outline the development of the book and plans for the further development of a training kit to facilitate its optimum utilisation.
The book grew out of the case-conferencing project, a series of eight twohour seminars in which around a dozen general practitioners met with two psychiatrists from the Logan-Beaudesert Mental Health Service. The first hour comprised a presentation and discussion on a focus topic. In the second hour, a psychiatrist interviewed a patient of one of the general practitioners in front of the group. In order to minimise the amount of time spent on didactic presentation and maximise the time spent on discussion, lecture notes were prepared for the general practitioners to read prior to the sessions. The book developed out of these notes.
While the book on its own may be a useful resource, it will not on its own lead to an increase in general practitioner's skills. For this reason, a training kit is being developed. Skills-training requires active participation in the learning process with general practitioners practising and obtaining feedback on various interview and intervention techniques. The training kit will enable users to practice important techniques such as observing videotaped model interviews, discussing videotaped interviews by the general practitioners themselves, practising scripted role-plays with colleagues and/or actors. Topics to be covered include the assessment of depressive, anxiety and somatoform disorders, and the assessment of suicidalitiy. Therapeutic skills will include the reattribution of somatic symptoms, structured problem-solving, grief counselling, breaking bad news, relaxation techniques, exposure, response prevention and goal-setting. The presenters will discuss the proposed development of the skills training kit and an implementation plan to complement the distribution of the book.
PATIENT OUTCOMES, SERVICE USE AND COST OF CARE
De Castella A
Dandenong Psychiatry Research Centre, Monash University, Melbourne, Victoria
The Schizophrenia Care and Assessment Program (SCAP) is a prospective, observational, international study to assess the clinical, functional, quality-of-life and economic outcomes of clients with schizophrenia in routine clinical practice. Subjects are assessed every six months and followed longitudinally for three years. The aim of this presentation is to share some of the results from the Australian arm of the study, inwhich 350 subjects have been enrolled. A range of instruments is used to collect information including disease specific outcomes, (PANSS, MADRS, AIMS and Simpson Angus scales) level of functioning (GAF), quality of life (QLS), and public safety and welfare. The SCAP Health Questionnaire (SCAP__HQ), developed expressly for this study, collects information on a broad range of outcomes. Clinical outcome data is presented for baseline (N=300), 6months (N=200) and 12months (N=100) assessments. In addition, extensive and detailed information is collected on health care service utilization. At this stage complete resource utilisation data are available for the first 6-month period. The direct costs of treating schizophrenia for our sample were calculated for the first 150 subjects enrolled in the study and are presented.
DEPRESSED AUSTRALIA: THE NATION ON THE COUCH
De Saxe I
Roseville, Sydney, New South Wales
PROBLEM GAMBLING: COMORBIDITY WITH PROBLEM DRINKING AND OTHER CONTEMPORARY RESEARCH
Dickerson M
Tattersall's Chair in Psychology; School of Psychology, University of Western Sydney
Surveys of clients attending treatment services for either alcohol or gambling related problems show such high levels of co-morbidity that there are implications for service development. Other recent research that explores the psychological processes that may generate the subjective sense of impaired control that is central to problem gambling is also briefly reviewed. This includes the impact of low doses of alcohol, prior mood and automaticity as demonstrated by the Stroop effect. This work is considered in the theoretical context of addictive behaviours as portrayed in Addiction, (96) January 2001.
MANAGEMENT OF BEHAVIOURAL DISTURBANCER AND DILIRIUM
Draper B
Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Randwick
Behavioural disturbances are commonly associated with dementia and delirium in the hospitalised elderly. Such disturbances may include aggression, wandering, restlessness, vocal disruption and sexually inappropriate behaviour. These behaviours are frequently the reason for referral to CL psychiatry. Unfortunately, there is a temptation for CL psychiatry to reduce the referral to a diagnostic issue, rather than to provide specific advice about managing the behaviour. This tends to annoy the referring team. Of course, the basis of any management advice is accurate assessment and diagnosis. This may include the need for further investigations, the determination of the presence or absence of comorbid depression and psychosis, and the identification of environmental and physical discomfort risk factors for the behaviour. Management approaches may include psychopharmacology, education of staff and family, environmental changes and nursing strategies. Discharge planning is important and may include community services, advice on appropriate placement and arrangement of psychogeriatric follow-up where required.
A FIVE-YEAR FOLLOW-UP STUDY OF THE USE OF CLOZAPINE IN COMMUNITY PRACTICE
Drew L,∗ Hodgson DM, Griffiths KM
∗Department of Psychological Medicine, Canberra Clinical Soho, Canberra
This paper aims to present data on the use of clozapine use in an entire cohort of psychiatric patients in a community. It examines the clinical and financial outcomes five years after clozapine was first prescribed to each of 34 subjects in the Australian Capital Territory.
This study extends to five years a previous three-year follow-up study undertaken in the Australian Capital Territory. Experience during the two years before clozapine was prescribed is compared with experience in the following five years on the basis of a retrospective review of official records. Data included hospital admissions, hospital and hostel bed use (bed days), an estimate of treatment costs, living circumstances and employment status. In addition treating psychiatrists reported the presence of side-effects and their impressions of clinical change since clozapine was prescribed.
Full data were available for 33 subjects; and bed day and clozapine use data were available for 34. Demographically, and in terms of dosage and side-effects, our sample was comparable with those of other studies of clozapine use except for the brevity of the index hospital stay and much less prior hospital use. In years 4 & 5 after clozapine was prescribed there were further significant clinical improvements and further reductions in hospital admissions, hospital bed use, hostel bed use, and treatment costs both by the total cohort and by persons (n = 22) continuing on clozapine through to the end of year 5. Similar, but smaller, changes occurred in 9 persons who discontinued using clozapine. However, three other persons who discontinued clozapine did poorly, were not helped by other treatment, and spent most ofyears 4 & 5 postclozapine in hospital. Three of the 42 persons who were eligible for admission to the study had serious side-effects from the use of clozapine necessitating its withdrawal. There were no deaths from suicide.
The findings of significant clinical improvement and reduced treatment costs, increasing up to five years after the commencement of clozapine in community practice, lend support for the use of clozapine in community practice. However, positive changes in a majority of patients who discontinued clozapine (perhaps reflecting the use of new atypicals and changes in the quality of service delivery) imply the need for the use of clozapine to be selective: for patients not responding adequately to other measures.
TELEHEALTH AS A TOOL FOR A MORE EQUAL DISTRIBUTION OF MENTAL HEALTH CARE TO REMOTE AND RURAL POPULATIONS—OUTCOME STUDIES IN EFFICACY, EFFECTIVENESS AND EFFICIENCY OF TELEPSYCHIATRY IN AUSTRALIA
D'Souza R
Senior Lecturer, The University of Sydney; Director, Centre of Excellence in Remote Psychological Medicine, Broken Hill, New South Wales
Telehealth has the potential to revolutionise the availability of health care resources to remote and rural populations. In Mental health delivery telehealth certainly can be used as a tool to offer a more equitable distribution of mental health resources to remote and rural areas, where traditionally this area has been poorly served both by the public and private providers. Research studies in treatment outcomes, satisfaction of patients, clinicians and economic evaluation in the use of Telemedicine are reviewed. The use of Telemedicine in Mental Health promotion, education, prevention, case identification, early intervention, treatment, discharge planning and after care for rural psychiatric patients has been used successfully.
In conclusion it is found that Telemedicine can be useful in offering comprehensive mental health care for this group of patients, whose psychiatric needs have traditionally been poorly met. Using the results of these studies to plan future services would mean offering best practice based on best evidence, which would result in best outcomes for rural and remote patients with psychiatric problems.
A CASE CONTROL STUDY IN THE USE OF TELEMEDICINE FOR DISCHARGE PLANNING AND TREATMENT ADHERENCE IN REMOTE AND RURAL PATIENTS
D'Souza R, Gay Harvey, Dorina Rich, Jan Sanderson
A NATURALISTIC ADAPTIVE STUDY OF QUETIAPINE IN REMOTE AND RURAL PATIENTS WITH PSYCHOSIS
D'Souza R, Hustig H, Andersen L, Sangha K
TELEHEALTH IN RURAL AND REMOTE MENTAL HEALTH: A REVIEW OF THE USE OF TELEPSYCHIATRY IN EDUCATION, TRAINING, TREATMENT, DISCHARGE PLANNING AND A HEALTH ECONOMIC EVALUATION OF THE TELEMEDICINE SERVICE
D'Souza R
Senior Lecturer, The University of Sydney; Director, Centre of Excellence in Remote Psychological Medicine, Broken Hill, New South Wales
Hustig H
Far West Area Health Service, Mental Health and Department of Rural Health, University of Sydney, Broken Hill
Montgomery W
Statewide Mental Health Services Glenside Campus, Eastwood, SA
SPIRITUAL NEEDS IN PSYCHIATRIC PRACTICE
D'Souza R, Heady A, Rich D, Sanderson J
Spirituality in recent times has become an area that has been discussed at important professional meetings and conferences. This area in the past has been alienated by the world of psychiatry. There is increasing awareness across professions of the importance the area of spirituality and religiosity holds to many patients. There have been suggestions and research validating the incorporation of aspects of spirituality and religiosity into multidisciplinary assessments and interventions for patients with psychological and physical illness.
IMAGING OF POST-TRAUMATIC STRESS DISORDER
Durrell A
Psychiatry Research Unit, Royal Prince Alfred Hospital, Camperdown
Athanasakos H, Balendra K
Psychiatry Research Unit, Royal Prince Alfred Hospital, Camperdown, NSW
The application of Functional Brain Imaging to the study of acute PTSD is an exciting area of Psychiatry research. In this fMRI studyof 6 patients with Acute PTSD and 6 controls we utilised trauma specific audio-visual stimuli which was delivered to patients and controls during the capture of their fMRI images. Comparisons of neocortical and subcortical brain regions were made between patients and controls groups. The results of such comparison include significant differences in the pattern of activation seen between the two groups. In particular the relatively depressed levels of occipital cortex activation in the patient group coupled with a relatively increased level of Limbic activation is hypothesised to represent a protective inhibitory limbic reflex. Such a reflex would provide afferent limitation to the neocortical regions thus limiting the risk of excitotoxic damage to the neocortex and potentially provide researchers with biological markers of Acute PTSD.
PSYCHOPATHOLOGY IN TOURETTE DISORDER: PART OF THE SYNDROME OR COMORBIDITY?
Eapen V∗, Fox-Hiley P, Banerjee S, Robertson MM
∗Associate Profess of Child Psychiatry, Faculty of Medicine, UAE University, Alain, United Arab Emirates
Tic symptomatology and related clinical characteristics were studied in 148 consecutive TS subjects attending a specialized Tourette clinic in the UK. Associations between clinical variables and psychopathology were explored separately in the child and adult cohorts. 91 adult patients and 57 young subjects aged below 16 years, were evaluated using standardised rating scales for Tourette syndrome and other psychiatric rating scales.
The mean age at onset of TS was 7.3 years (SD=3.4). The male female ratio in our cohort was 1:2.3. Significantly more males had an earlier age at onset of TS and history of birth complications. Obsessive Compulsive Behaviours (OCB) in the patient was positively correlated with presence of Attention Deficit Hyperactivity Disorder (ADHD), Self Injurious Behaviours (SIB) and family history of OCB. There was positive correlation between SIB and coprophenomenon, echophenomenon, aggression and ADHD. In the child cohort, significantly higher levels of depression and obsessionality were found when compared to controls and this excess persisted after adjustments for the effects of age, gender and co-morbidity between depression and obsessionality. With regard to adult psychopathology, principal components factor analysis using varimax rotation yielded 2 components namelythe “obsessionality” and “anxiety/depression” component, which accounted for 72% of the variance.
These results support the high occurrence of depression and obsessionality in TS patients but debate continues as to whether these behaviours are an integral part of the syndrome, or a function of co-morbidity. Future studies should attempt comprehensive evaluation in TS subjects in order to clarify the biological and behavioural aspects of TS as well as to elucidate the differences among patients with respect to psychopathology, severity impairment and natural history.
BENZODIAZEPINE RECEPTORS ABNORMALITIES IN POST-TRAUMATIC STRESS DISORDER: A POSITRON EMISSION TOMOGRAPHY STUDY
Ellen S
The Alfred Hospital
Morris P
Gold Coast Integrated Mental Health Service
Olver JS, Constant E, Norman TR, Tochon-Danguy HJ, Ignatiadis S, Burrows GD, Reutens D
Austin & Repatriation Medical Centre/University of Melbourne
McFarlane AC
University of Adelaide
Neurobiological studies have identified indirect evidence of neuroreceptor and neuroendocrine abnormalities in anxiety disorders, and of particular interest, Post-Traumatic Stress Disorder. The GABABenzodiazepine receptor complex is of particular interest as it is an important modulator of stress responses in animals and humans, and it has been shown to have a central role in other anxiety disorders such as Panic Disorder. Positron Emission Tomography (PET) has recently been used to estimate the density of GABA-BZD receptors (Bmax) and the affinity of these receptors (Kd) in vivo using the BZD antagonist PET ligand [11C]-flumazenil.
This study aims to compare the Bmax and Kd of BZD receptors in subjects with PTSD, Panic Disorder, and normal control subjects. 13 male subjects with war-related PTSD and 13 age and sex matched subjects with Panic Disorder, and 13 controls between the agesof 44 and 65 were successfully scanned. A Partial Saturation Method was used in which a tracer dose of [11C]-flumazenil is intravenously co-injected with non-radioactive flumazenil to obtain Bmax Kd images, and BP (binding potential) images. Regions of interest were chosen in 12 cortical and subcortical brain regions. Bmax and Kd values were calculated from Scatchard plots per pixel. Analysis of variance and statistical parametric mapping methods were used to determine significant changes in Bmax and Kd between subject groups.
The binding potential for benzodiazepine receptors was higher in the PTSD group than both the Panic and Control groups. The difference was greatest in the cerebellar, lateral temporal, occipital, and prefrontal areas. The increase in BP was primarily due to a greater receptor affinity in these areas. The Panic group had a similar BP to controls, but lower Bmax and Kd. The differences were not explained by differences in alcohol consumption or depression.
These results suggest that either there is a conformational change in the GABA-BZD receptor or a change in the genetic material coding for the receptor protein in patients with PTSD. It is possible these changes pre-date trauma exposure and act as a risk factor for PTSD. Alternatively the increased affinity of the receptors may be a consequence of the condition. Further imaging and molecular biological studies are required to explore these possibilities.
THE EARLY START PROGRAM FOR AT RISK FAMILIES
Fergusson D
This talk will present an account of the development of the Early Start program. Early Start is a program of home visitation and family support for at risk families. The development of the program grew out of research from the Christchurch Health and Development Study and local concerns about children in at risk family situations. Pilot research has been conducted and a randomised trial is underway.
NOVEL CLINICAL INTERVENTION FOR CHILDREN WITH SEVERE ANXIETY AND DEPRESSION
Flory V
Maroondah Hospital Child and Adolescent Mental Health Service, Victoria
A novel clinical intervention, Emotionally Attuned Parenting, is being trialed for severe depression and anxiety in children. Depression and anxiety are common psychiatric disorders and are associated with dysfunctions in behaviour, academic performance, social and family relationships and significant risk for adult psychiatric disorders [1,2,3]. In clinical settings, children with depression and anxiety are often unresponsive to treatment and have comorbid psychiatric disorders [4]. No treatment has been established as effective for severe depression and anxiety in children.
Anxiety and depression are associated with dysfunctional parent-child interactions that are characterised by a lack of warmth, punitiveness, criticism, lack of support and more abuse compared with normalcontrols [5,7]. Furthermore, the frequent dissonance between child and parent reports of internalising disorders indicates it is not uncommon for parents to be unaware of their child's emotional state [6].
Clinical interventions for children need to be mindful of developmental contexts and parental involvement is related to increasedeffectiveness [7]. Emotionally Attuned Parenting is a novel clinical intervention that is designed to improve parent-child interactions and increase parental understanding of their child's emotions.
Pilot data is now being collected to explore the effectiveness of Emotionally Attuned Parenting as a treatment for children with severe depressive and anxiety disorders.
Comparison of pre and post treatment diagnoses shows that 2 of the 3 cases no longer met diagnostic criteria for the disorders they had pre treatment and 1 case showed a reduction in diagnoses.
FUTURE OF PSYCHIATRY
Sir David Goldberg
Professor Emeritus, Institute of Psychiatry, King's College, London
Although the most exciting areas of likely future change will be in neuroscience and information technology; the most important process which will limit change and modify clinical working practices is “cost containment”. This is practised by all health systems, either by severely limiting the mental health budget as in developing countries, by modifying the working practices in developed countries with centrally planned and funded services, or by “managed care”. However, the shoe is likely to pinch in different degrees, and in different places. My remarks will cover likely service developments in both England and Australia and New Zealand.
THE GENESIS OF ANXIETY AND DEPRESSION
Sir David Goldberg
Despite the opinions of geneticists to the contrary, the case will be argued that shared family environment is not as unimportant as they would have us believe. The ways in which genetic factors exert an influence on anxiety and depressive disorders will be described, by various GxE interactions, and by genetic mediation of personality controlling the kinds of life events different people experience. Factors that release episodes of illness will be described, as well as those social factors that promote recovery.
DO PSYCHIATRISTS HAVE A LEADING ROLE IN SUICIDE PREVENTION?
Goldney R (chair)
Professor, Adelaide University, Gilberton, South Australia
The aim of this symposium is to explore contemporary arguments for and against the more formal development of a College Interest Group on suicidal behaviour.
For over two hundred years suicidal behaviour has attracted the attention of a number of practitioners from different disciplines. Its generally accepted definition includes not only suicide and attempted suicide, but also suicidal ideation, and therefore it is a common phenomenon in all psychiatric conditions.
Suicidal behaviour is a major public health issue, and to the present time organisations such as the International Association for Suicide Prevention, the American Association for Suicidology, and Suicide Prevention Australia have provided venues for those interested in its prevention. However, the College has not addressed suicidal behaviour specifically.
Whenever one specific area is addressed, issues of funding and turf arise. Indeed, this issue has broad implications in the sense that there is inevitably overlap between any National Mental Health Strategies and more specific suicide prevention initiatives.
This symposium will allow speakers to address up to date clinical, research and administrative reasons both for and against pursuing a more formal interest group within the college. After a brief historical perspective by Bob Goldney, Janice Wilson will note the administrative importance; Diego De Leo, the research imperative; and Ernest Hunter the benefits that have flowed to indigenous groups by focussing specifically on suicidal behaviour. By way of contrast, Simon Hatcher will refer to the sociological nature of suicide; Stephen Rosenman will address public health issues; and Fiona Judd will note the need to retain a broad clinical perspective.
LIVER TRANSPLANT PSYCHIATRY
Gribble R
Royal Prince Alfred Hospital, Camperdown, NSW
The objective of this workshop is to provide trainee psychiatrists, transplant psychiatrists and other psychiatrists interested in the field with an update on transplant psychiatry issue.
Experienced transplant psychiatrists will provide an overview of their particular field, an update on research, and a personal account of how they actually go about their task. There will be a particular emphasis on the use of screening and monitoring instruments such as the Transplant Evaluation Rating Scale, the Structured Interview for Renal Transplantation, the SF-36 and the Patient Health Questionnaire.
Professor Graeme Smith:
Renal and pancreas transplant psychiatry
Dr Sandra Hacker:
Heart and Lung transplant psychiatry
Dr Robert Gribble:
Liver transplant psychiatry
THE QUALITY OF WEB-BASED INFORMATION ON THE TREATMENT OF DEPRESSION
Griffiths K
Centre for Mental Health Research, The Australian National University, Canberra
Christensen H
Centre for Mental Health Research, Australian National University
This paper aimed to evaluate the quality of website information on the treatment of depression, identify potential indicators of content quality, and establish if accountability criteria are indicators of content quality. A cross-sectional survey of 21 frequently accessed depression websites were examined. The main outcome variables were: (i) site characteristics; (ii) quality of content—concordance with evidence-based depression guidelines (guideline score), appropriateness of other relevant site information (issues score), subjective rating of site quality (global score); and (iii) accountability—conformity with core disclosure standards (silberg score), quality of evidence cited in support of conclusions (level of evidence score). Although the sites contained useful information, their overall quality was poor, the mean guideline, issues and global scores being only 4.7 out of 43 (range 0 to 13), 9.8 outof 17 (6 to 14), and 3 out of 10 (0.5 to 7.5) respectively. Sites typically did not cite scientific evidence in support of their conclusions. The guideline score correlated with the two other quality of content measures. However, none of the content measures correlated with the Silberg accountability score. Content quality was superior for sites owned by organisations and sites with an editorial board.
SHARED MENTAL HEALTH CARE AND THE DIAGNOSIS AND MANAGEMENT OF COMORBIDITY IN PRIMARY CARE: THE REAL PICTURE
Groom, G
Australian Divisions of General Practice
Holmwood C, Ben-Tovim D
Primary Mental Health Care Australian Resource Centre
Roche A
National Centre for Education and Training on Addiction
Riley G
University of Western Australia
Jackson Bowers E, Nicholson S
Primary Mental Health Care Australian Resource Centre
PSYCHIATRIC MORBIDITY OF 15 PEOPLE INJURED IN THE GLENBROOK TRAIN CRASH OF 1999
Hampshire R
Sydney, New South Wales
Fifteen people who had been involved in the Glenbrook Train Disaster of 1999, and were seeking compensation, were psychologically assessed, using a semi standardized psychiatric interview, Spielberger, Beck and Trauma self rating inventories. The majority suffered from Post Traumatic Stress Disorder, with co-morbid depressive and anxiety disorders. Treatment suggestions were made, and prognoses offered. All patients were followed up one year later. Generally, and often despite appropriate therapy, outcome has been worse than predicted. Interpersonal and social morbidity has been particularly high, effecting over 90% of the cohort. Around two thirds had a worsening of their axis 1 symptoms.
This data adds to a growing body of evidence that suggests, unexpectedly perhaps until recent years, a high level of morbidity associated with one off, critical incident trauma.
VIETNAM VETERANS—30 YEARS ON
Harding D
Clinical Psychologist, Wesley Mental Health Services
The US Vietnam Veteran's Readjustment Study and similar papers in the Australasian psychiatric literature highlighted many aspects of the mental and physical health needs of servicemen from the Vietnam conflict. This cohort of men and women and now in their 6th and 7th decades and recent evidence has highlighted significant problems in the realm of medical comorbidity, disturbed interpersonal functioning and trans-generational transmission of psychopathology in families of veterans. This paper will highlight these issues and discuss how contemporary treatment programs attempt to address the broader scope of these problems.
POLICIES TO SUPPORT PSYCHIATRISTS
Heins T
Bega, New South Wales
Policies to support the work of psychiatrists and other mental health workers in delivering services in rural areas have not been developed by State and Commonwealth governments or by the RANZCP. This symposium aims to generate practical policy ideas. It has been developed following a request from the Country Psychiatrists Association of New South Wales.
Four psychiatrists from Tasmania (Dr Marianne Haughton), Western Australia (Dr Chris Lobarti), Victoria (Professor Fiona Judd) and New South Wales (Dr Michael Paton), representing private practice, staff specialists, academic posts and sessional VMOs will share their experiences and thoughts on helpful policies. The Director of Mental Health at Broken Hill (Mr Stuart Riley) will speak on planning issues and the progress of their pilot integrated care project.
Ms Joanna Davidson, National Manager, Office of Rural Health, Commonwealth Department of Health and Aged Care will speak on current and developing Commonwealth policies. Dr Keith Mayne will discuss policies in the RANZCP Maintenance of Professional Standards Program for meeting the needs of rural psychiatrists. The College needs channels of representation for rural psychiatrists and more effective linkages with existing State Country Psychiatrist Associations.
NEW NON-PHARMACOLOGICAL APPROACHES TO THE TREATMENT OF PROBLEM ALCOHOL CONSUMPTION
Dr John E Helzer
Professor of Psychiatry, Health Behaviour Research Centre, USA
There is an impressive array of non-pharmacological approaches to problem drinking and alcoholism. As briefly reviewed in this presentation, recent non-pharmacological (behavioral) approaches include motivational enhancement, coping skills training, cognitive-behavioral training, and others. Unfortunately, evidence of efficacy is not so impressive. However, there is growing evidence that one behavioral approach, so-called “brief intervention”, is highly effective. Ironically it is also the least complex and simplest of the behavioral treatments to perform.
Behavioral interventions are especially important in medical settings. There is evidence that roughly 50% of patients’ health problems are caused by preventable behavioral factors. Problem alcohol is an important case in point. First, problem drinking is prevalent in medical populations. Second, the medical consequences of problem drinking are substantial. While primary care may be an ideal environment for non-pharmacological approaches, the current, reimbursement structure makes compensation for behavioral intervention difficult. This is probably one reason that brief alcohol intervention is grossly underutilized despite strong evidence of its efficacy. Hopefully it's not too facetious to suggest that one reason BI by a primary care provider is so effective is because it is so unexpected.
One way of taking advantage of the power of behavioral interventions while bypassing the reimbursement conundrum is to mobilize physicians to engage patients in self-guided interventions. Aproviderinitiated “ultra-brief intervention” could be followed by a patient self-guided intervention as a long-term reinforcement. The availability of such patient-guided interventions could not only amplify the overall therapeutic benefit but might also encourage providers to be more vigilant about heavy drinking and more willing to at least initiate the self-intervention process.
For the past several years our research team has been experimenting with Interactive Voice Response (IVR) as a tool for both natural history studies and for intervention. IVR is essentially a method for interaction between an individual and a computer through the medium of a telephone using the touch-tone keypad. Typically an automated script poses questions following a branching logic format and the caller keys in responds. Using a short (approximately two-minute) IVR interview, we followed the progression of alcohol consumption in a group of 33 heavy drinkers for two years. Each subject was asked to call the IVR daily to report their consumption for the previous 24 hours and answer a few other questions about stress, mood, partner drinking, etc. Participants were paid a small sum for each call in a reinforcement schedule that encouraged regular calling. Approximately 95% of the over 24,000 calls were received during the two year period. Although it was not the focus of the study, we observed a decrease in overall consumption in the second year of calls compared to the first. We are now systematically testing the potential of IVR as a self-guided supplement to primary care brief intervention in a randomized controlled trial. Preliminary data from this study will be presented along with results from the 2-year study.
A CONTRY PTSD PROGRAM FOR VIETNAM VETERANS—DEMAND, SUPPLY AND LOGISTICAL ISSUES
Howard S
PTSD Program, Austin and Repatriation Medical Centre, Victoria
The Austin and Repatriation Medical Centre in Heidelberg, Victoria has conducted treatment programs for Vietnam veterans suffering from PTSD since 1994. The twelve-week PTSD programs were initially held on the Repatriation Campus utilising a combined inpatient/ outpatient model. Subsequently, day hospital and outpatient programs have been developed to provide greater range of options and flexibility for participants and clinicians.
It became clear that around 50% of referrals to the PTSD Program came from regional Victoria and that this posed a significant problem of access to services for many country veterans. In response to this, the Country PTSD Program was developed. This involved providing a twelve-week PTSD Program using the day hospital model in regional areas. To date there have been four programs held in Mildura, two in Warrnambool and one in Mount Gambier.
Our most recent experience of setting up and conducting a program in Mount Gambier is informative regarding issues of demand for and supply of specialised psychiatric care in isolated regional areas as well as demonstrating the types of logistical issues that are involved in this process. This paper examines these issues in detail and reports anecdotal feedback from the veterans involved, from veteran organisations, health professionals and the general community in this area. The aim of this paper is to provide information about this experience in the context of an increasing recognition of the demand/ supply mismatch regarding both general and specialised psychiatric services in regional areas and to generate discussion about future directions in this regard, in light of the logistical issues encountered.
MENTAL HEALTH IN RURAL WATER SHED AREA
Hustig H
Director Statewide Mental Health Services, South Australia
Establishing a fulltime presence of service providers, telemedicine services challenge the premise that providers must be physically present. Similarly the availability of a visiting psychiatrist working in consultation liaison style model with a multidisciplinary local community mental health team and concurrent service for general medical practitioners supported by telemedicine supervision of mental health care may provide part of the service which would be provided by a local resident psychiatrist in a rural area. Though suboptimal in some ways, especially in terms of local community integration, there are also benefits in the patient's experience knowing details over transference issues, family and personal conflict fly out as the visiting psychiatrist leaves avoiding uncomfortable community encounters. The additional benefits to addressing the special needs of rural people and support when dealing with centrally based rehabilitation services and follow up for people who relocate to the city from country areas especially minority groups like the gay community or those with severe psychiatric disorders including severe personality disorder. This paper is a reflection of the toils, fears, and joys of 15 years of rural psychiatry to the South East region of South Australia.
AN INSTRUMENT TO MEASURE VIOLENCE
Jager A
Senior Lecturer in Forensic Psychiatry, Hobart
There is a well-established association between mental illness and violent acts. There is no agreed measure of violence. This research aimed to develop an instrument whose reliability and validity was then tested.
The author reviewed the literature and performed qualitative and quantitative research using forensic mental health staff and adult and adolescent members of the general public to develop the Violence Checklist (VCL). The first phase of research occurred in Canada. In Australia, the VCL was applied to a “violent” group of 48 adult offenders and a “non-violent” group of 83 orchestra members, school teachers and mental health staff.
The VCL is a 12-item interviewer-applied questionnaire with 4 time scales: last week, month, year and lifetime. It demonstrated adequate validity in all time scales, to discriminate between a violent and control group and adequate test-retest reliability (0.944), internal consistency (0.68–0.82) and inter-rater reliability (1.0).
The VCL is an instrument which will find clinical and research applications in general and forensic psychiatry, correctional and other populations, subject to replication of these findings.
TELEPSYCHIATRY AS AN ICD-10 TEACHING TOOL
Janca A
University of Western Australia, Perth
As of 1 July 1999, all psychiatric diagnoses in Western Australia should be recorded and coded using ICD-10. The majority of Western Australian mental health professionals are not familiar with ICD-10 diagnostic and coding rules. At the request of the Health Department of Western Australia, an ICD-10 educational program was developed and adapted for the delivery over Western Australian telepsychiatry network.
A telepsychiatry ICD-10 workshop was organised involving 105 mental health professionals from 15 remote and rural sites in Western Australia. An ICD-10 telepsychiatry workshop questionnaire containing participant information and course evaluation forms was distributed to the participants and collected data were analysed using qualitative and quantitative research methods.
The results showed that only about 25% of the remote and rural mental health professionals had some previous knowledge of ICD-10; in comparison, more than 70% of them were familiar with DSM-IV and were using it in their everyday clinical work. After the telepsychiatry training, more than 90% of the participants evaluated the ICD-10 workshop as useful and relevant to their needs, and provided the teachers with a number of helpful suggestions on how to apply and deliver telepsychiatry-based education and training more effectively.
IMPLICIT MEMORY IN SCHIZOPHRENIA
Kaiser RH
Department of Psychiatry and Behavioural Science, University of Western Australia
Many studies have been undertaken to determine cognitive deficits in schizophrenia; however, it is a relatively recent development that memory is not a unitary cognitive function of human mind. Declarative or explicit memory requires conscious awareness, involves the subjective sense of recollection, and encodes factual knowledge as well as autobiographic information. Implicit or procedural, nondeclarative memory refers to experiences whose source is largely out of the individual's awareness, but influences the person's behaviour. It is a preconscious stage of information processing and includes skill learning, habit learning, conditioning and priming. The term priming refers to a facilitation of the ability to detect or identify stimuli, based on recent experience with those stimuli; implicit memory can be assessed mainly through priming tasks and tests regarding motor skill learning. A deeper knowledge about implicit memory is relevant for the understanding of the development of schizophrenia and schizophrenia spectrum disorders; however, implicit memory also appears to play a major role in personality disorders and dissociative disorders. Most studies, to date, have shown that implicit memory is spared in schizophrenia, whereas explicit memory is commonly impaired, however, there are some studies that have shown impaired implicit memory in schizophrenia. The presentation summarises the research to date, and tries to answer the question as to whether there is a dissociation between implicit and explicit memory functions inpatients suffering from schizophrenia. It also outlines the presenter's own projects in this field of research, and addresses particularly the significance of the questions
i. whether implicit memory is different in schizophrenic patients at the time they are acutely psychotic, compared to being psychopathologically asymptomatic, ie. whether deficits in implicit memory are more likely to be due to the illness (implicit memory as a trait marker) or to the symptomatology (implicit memory as a state marker), or whether there are no deficits at all, and
ii. whether implicit memory is different in schizophrenic patients who experience their first psychotic episode, compared to those who suffer from schizophrenia for more than two years, because one possibility for the controversial findings could be that explicit memory becomes impaired early after the onset of the disorder, whereas implicit memory might be affected later, during the course of the illness.
Finally, the presentation will outline the relation of the results regarding implicit memory to other neurocognitive findings in schizophrenia, as well as its clinical relevance and implications.
PSYCHIATRIC ABUSES IN THE SOUTH AFRICAN DEFENCE FORCE DURING THE APARTHEID ERA
Kaplan R
Forensic Psychiatrist and Medical Writer, Wollongong, New South Wales
During the long years of apartheid in South Africa, doctors were part of a system of systematic state abuse of prisoners.
Over a period of close to two decades, homosexual conscripts of both sexes were culled from the military ranks and subjected to crude electric shock therapy based on rudimentary behaviour therapy principles. When this failed, male and female subjects were subjected to sex changes Possibly 900 sex-change operations were carried out [a rate of about 50 a year for 18 years] under the auspices of the SADF. It is unique for such operations to be done under the auspices of the military, with many, possibly all, of the procedures performed in military hospitals. Once the operations were completed, subjects were discharged from military service, their birth certificate changed and given new identity papers. Some were discharged before the sex-change had been completed, leaving them in an uneasy state of limbo; they are now trying to get the military to pay the cost of completing the procedure.
The approach followed by the SADF to homosexuals has overtones of coercive and punitive treatment. Homosexuality was officially regarded as subversive and unacceptable by the SADF but, in practice, attitudes were ambiguous and inconsistent. The psychiatrists involved were not only ignorant, but also functioned as an extension of the military ethos. It is doubtful that the sex-change operations proceeded with informed consent; some conscripts were below the legal age of consent. Drug abusers, homosexuals, political and conscientious objectors and the seriously mentally ill were regarded as “deviants” in need of psychiatric cure. Narco-analysis was a favoured treatment in addition to electric shock therapy. Drug users were incarcerated, subjected to extreme discipline, amounting to hard labour, the logic apparently being that this would cure them of their drug problem.
In 1995, the Medical Association of South Africa issued a public apology for past wrongdoings. The South African medical profession needs to unambiguously demonstrate that there will never again be medical complicity in torture or other human rights abuses.
To maintain credibility there must be a full and open inquiry, the offenders brought to justice and a regulatory system established to ensure that such atrocities do not occur again in future. Anything less will be a serious injustice.
MAD, BAD AND DANGEROUS TO KNOW: MEDICAL SERIAL KILLERS
Kaplan R
The disturbing careers of Harold Shipman and Michael Swango.
The phenomenon of medical serial killers is not new and goes back at least 150 years.
The murderous activities of Dr Harold Shipman [now credited with over 300 deaths] and, to a lesser extent, Dr Michael Swango [thought to have killed up to 60 people] have added a new dimension to the phenomenon.
Dr Shipman was regarded as a dedicated general practitioner who was always available to his elderly patients. Yet when Shipman wanted to get rid of a patient, he simply injected them with a lethal dose of diamorphine, told the relatives they had died unexpectedly of complications and altered the case records on his computer.
The conviction of Dr Shipman for murder of 15 patients caused a sensation in the UK and prompted calls for more regulation of medical practitioners. A subsequent epidemiological study estimated that he was responsible for at least 300 deaths during his career, making him one of the world's most successful serial killers.
Michael Swango, the son of a Viet Nam veteran who collected photos of car accidents, was known to medical student colleagues as “OO7 licence to kill”. Swango had a penchant for poisons, which he tried out on his friends and ambulance colleagues. Several patients died under highly suspicious circumstances during his internship. Despite serving a prison sentence for several years, he was able to continue to train in neurosurgery and later psychiatry. As the net closed on him, he moved to a mission hospital in Zimbabwe. He was only arrested through a slip-up when changing planes on his way to work in Saudi Arabia. After serving a three-year sentence, Swango pleaded guilty to several murders to avoid the death penalty and now faces life in prison.
Serial killers are usually motivated by two factors: money and sex. With Shipman and Swango, neither factor was implicated and it must be assumed that both were psychopathic personalities who relished their power over life or death.
It is suggested that there are elements of the Munchausen Syndrome in reverse occurring with medical serial killers.
If there is one certainty, it is that medical serial killers will present in future, although hopefully not too frequently.
IMPROVING ACCESS TO MENTAL HEALTH SERVICES: FOCUSSING ON THE RELATIONSHIP WITH GENERAL PRACTITIONERS
Keller A
Division of Mental Health, Sutherland Hospital, New South Wales
Sara G
Division of Mental Health, Sutherland Hospital
Access to public mental health services has long been recognised as problematic within the current paradigm of service delivery. Equity of access—on the basis of a person's risk and disability rather than their presumed diagnosis, their mode of referral or systemic idiosyncrasies—is rarely achieved. Consequently, those attempting to refer themselves or others to mental health services for assessment and/or treatment are frequently dissatisfied with the service provided. As the largest single group of health professionals referring patients to mental health services, general practitioners should be specifically targeted in an effort to restore their confidence in the system.
As a means of instigating a broad range of service changes, the Division of Mental Health at Sutherland Hospital developed a new team to perform the functions of triage and assessment (the “Access” team), which commenced operations in July 1999. As part of its launch, the local community of GPs was explicitly targeted and informed about the new team. As well as providing a commitment to deliver a responsive, accessible service of high quality, there was an acknowledgement that the previous system had been inadequate and had frequently let them and their patients down. An emphasis was placed on maintaining the primary role of the GP and the need for the regular flow of information between services. Certain benchmarks were outlined—that referrals from GPs would receive priority andthat 90% of referrals from GPs should be seen by the team within 1 week. This paper will outline the process for engaging the local community of GPs in the development and promotion of the new team, as well as present data demonstrating the impact of the Access team on GP referral rates and GP levels of satisfaction.
WHEN THE FAMILY OBJECTS: AN ETHICAL DILEMMA IN COMMUNITY PSYCHIATRY
Keller A
It is now common practice in community psychiatry to promote the involvement of families in the assessment and treatment of persons with a mental illness. The relationship between the mental health service and the family ranges from providing psychoeducation, support and even family therapy, right through to co-opting the family as part of the broader ‘treatment team’. Traditional constraints, such as a rigid interpretation of the patient's right to confidentiality, are now regarded as ethically flawed and likely to lead to poorer outcomes if families are systematically excluded from the process of engagement and treatment planning. It is almost universally acknowledged that involvement of a patient's family in the management of mental illness is desirable in the vast majority of cases, and should proceed unless there are strong indications to the contrary.
In many clinical situations, the family is desperately seeking treatment for an ill relative, often in the face of vehement opposition from that person who is ill. In such circumstances, the family is usually eager to co-operate with the mental health service to bring about effective treatment—even if that means a period of involuntary hospitalisation is necessary to deliver that treatment.
But what about the families who object to the involuntary treatment of their family members? Who stand beside their children or spouses with psychosis and insist that nothing is wrong, and refuse to engage with the mental health service?
In this paper, an argument will be presented that the attitudes of a family towards treatment of their ill relative may be the critical element that determines whether involuntary treatment is ethically justified. Using a series of clinical vignettes as illustration, it will attempt to persuade that if there are no overriding acute risk issues, then the ethical basis of involuntary treatment lies in the probability of being able to deliver effective treatments that modify longer term risks. The objections of a family can, to varying degrees, significantly diminish the probability of such treatments being effective and may even render them counter-productive.
INTERNET-DELIVERED EARLY INTERVENTION FOR ANXIETY
Kenardy J
Associate Professor, School of Psychology, University of Queensland
McCafferty K, Rosa V
University of Queensland, Australia
The Internet is seen as a medium for the delivery of healthcare that offers benefits beyond usual media such as printed materials and faceto- face contacts. These include improved access, and “intelligent” information presentation, for example the use of hyperlinks. In this study university students at risk of anxiety disorders were randomly allocated to an Internet-based cognitive-behavioural program that addressed cognitions and behaviours that were maladaptive, or a delayed-treatment control. In total 78 participants were recruited into the study, risk assessment was based on scores on the Anxiety Sensitivity Index (ASI). Those with clinical disorders were excluded from the study and directed to appropriate care. The six-session program was accessed by participants from home or from the university. It was password protected and it was possible to track usage of the site for individuals. Those in the Internet group improved significantly compared to the delayed treatment group on measures of depression, negative and catastrophic thinking. These changes maintained at follow-up. There was a non-significant trend (p<.10) in the difference on the ASI between the two conditions. These results suggest that an early intervention program delivered via the Internet is feasible, however it is unclear how changes resulting from use of such a program.
3-D MODELLING OF BEHAVIOUR IN PSYCHIATRIC TREATMENT
Kirkby KC
Professor of Psychiatry, University of Tasmania, Hobart
Recent advances in software have made 3-D modelling accessible for research into computer-aided treatments. Traditionally psychiatry has relied primarily on words and gesture to describe and communicate. This can now be augmented with visual scenarios, delivered on a computer or via the Internet. Examples are presented of interactive 3-D scenarios used to instruct subjects in exposure techniques to public stimuli and triggers of OCD rituals. An overview of treatment outcomes using virtual reality techniques illustrates the clinical utility of these methods.
LORAZEPAM INDUCED IMPAIRMENT OF LEARNING
Kirkby KC, Matthews A, Martin F
Benzodiazepines are known to be associated with the side effect of anterograde memory impairment, and are commonly being taken by patients referred for behaviour therapy. Many treatment centres require withdrawal from benzodiazepines before entering treatment. Conditioning has been shown to occur in the presence of benzodiazepine, so habituation may be expected to occur during exposure therapy concurrent with benzodiazepine use. However the mechanism of action of exposure is subject to debate, as to whether the physiological change of habituation, or a cognitive change through the patient's response to behavioural experiments involved in exposure, are the prime mediators of change. For example confronting a spider may lead to a realisation that the spider is not harmful as imagined, and a reappraisal of the context. Further, self help models of care, including the common use of self-exposure homework, require acquisition and consolidation with practice of behavioural strategies. The patient learns how a given behaviour, such as prolonged exposure, results in reduction of anxiety to the stimulus, that is a response contingency. We have use a computer-aided vicarious exposure (CAVE) program to investigate the effects of a single dose of a benzodiazepine on learning of behavioural strategies in a non-clinical sample. Twenty-four students received either 2.5mg lorazepam or placebo orally. Subjects completed a series of neuropsychological tests pre- and post-drug anda 45-minute session on the CAVE program post drug and, drug free, a week later. The CAVE program simulated treatment of a washing ritual by exposure to dirt. Post-drug, subjects taking lorazepam showed impaired word recall (episodic memory) with preservation of word fluency (semantic memory) and digit span (concentration). Compared to the placebo group, the lorazepam group on the CAVE program showed reduced enactments of routines of exposure with response prevention by 51% post drug, and 49% a week later on no drug. This was not due to an overall reduction of activity on the program, rather to failure to respond to contingencies of the program (scoring points and habituating modelled anxiety response in response to enacting exposure). The use of interactive computer models of behaviour is a new tool for the study of cognitive factors relevant to treatment.
DEVELOPMENT OF ONLINE SCREENING ASSESSMENTS FOR ANXIETY DISORDERS
Kirkby KC, Teng CTM, Martin F, Daniels BA
Development of on-line screening assessments for anxiety disorders The development of Internet based treatment methods poses a challenge for established assessment methods. Whilst pen and paper tests can be computerised, for example the CIDI diagnostic interview, tests which involve equipment and therapist observation require more ingenuity. In the field of anxiety disorders, a commonly used test of phobic avoidance is the Behaviour Assessment Test (BAT). For example, in spider phobia the BAT typically involves a series of steps including approaching and handling a live spider. Subjects rate subjective anxiety at each step. Early research on automated BATs used slide images where the stimulus, such as a spider, is presented as a static image of increasing size. Following this lead we have developed a computer-delivered BAT using segments of a video filmed ‘over the shoulder’ during a live BAT. On the screen, subjects are given a brief written description of each step, click a button to play that step, then rate their subjective anxiety. Using this method, we compared high-fearful (n=32) and low-fearful (n=32) students, based on FSS scores on the spider item, who completed three types of BAT in balanced order. These were live BAT, video BAT, and slide BAT, the latter two delivered by computer. The slide BAT showed a static image of increasing size at each step. Both video and live BATs were highly discriminating between the two groups, the slide BAT to a lesser extent. Subjects were able to undertake most steps of the video BAT, whereas on the live BAT most subjects stopped short of touching a container containing a live huntsman spider. The highest anxiety ratings were in the video BAT group, on scenes of handling a spider. On balance the live BAT was superior in terms of fewer steps completed but the video BAT had advantages in tapping subjective anxiety across a wider range of behaviours. Further research is required to examine video BAT sensitivity to response to treatment, and to examine cognitive variables mediating anxiety responses to the different BAT conditions. With further development a suitable BAT for on-line assessment is a feasible goal.
ADMISSION HISTORY PRIOR TO FIRST INPATIENT DIAGNOSIS OF BIPOLAR DISORDER
Kirkby KC, Daniels BA, Mitchell PD, Hay DA, Bowling A
Diagnosis in psychiatry is primarily based on observed and reported patterns of illness, both syndromally and in terms of course of illness. Diagnostic heterogeneity is common and may be informative as part of the longitudinal pattern of illness. The current study examines the time course and diagnoses of psychiatric admissions prior and subsequent to a first hospitalisation for a diagnosis of bipolar disorder. The prior admission histories (over the period 1965-1989) of 1167 patients who had been hospitalised in State mental health facilities in Tasmania with their first admission with diagnosis of bipolar disorder between 1983 and 1989 were examined. Five hundred and forty two (46.4%) patients had at least one previous hospitalisation with a psychiatric diagnosis other than bipolar disorder. Two prominent groups emerged; one group which had primarily a history of prior admissions with diagnoses of depression over one to three years, and a second which mainly had previous admissions for schizophrenia, over a longer period than those with a primarily depressive history. The group with a history of schizophrenia were significantly younger and had a greater number of admissions prior to the first bipolar disorder diagnosis than the depression group. There appeared to be three distinct patterns of prior presentations in those patients admitted with a diagnosis of bipolar disorder. The findings for prior depressive histories may reflect the natural course of illness or be in part related to antidepressant induction of mania in individuals with a bipolar diathesis. The development of manic symptoms after a sustained period of schizophrenia has been described by other authors. We propose to further delineate these various illness history findings through case note review.
COMPARING MEDICALLY EXPLAINED AND NONMEDICALLY EXPLAINED SYMPTOMS IN PLASTIC SURGERY OUTPATIENTS
Kisely S
University of Western Australia; Fremantle Hospital, Western Australia
Morkell D, Jovanovic J
University of Western Australia; Fremantle Hospital
1. patients attending plastic surgery outpatient clinics for cosmetic reasons would have higher rates of dysmorphic concern and psychiatric morbidity than the comparison group, and
2. that the association between dysmorphic concern and psychiatric morbidity which would be independent of possible confounding factors on multivariate analysis.
CLINICAL INTERVIEWS USING TELEPSYCHIATRY: A PRELIMINARY SURVEY OF PATIENT SATISFACTION
Kisely S, Wearne D, Burling M
University of Western Australia; Coastal & Wheatbelt Mental Health Service
Telepsychiatry in Western Australia has been largely used for the teaching & supervision of mental health professionals. This presentation describes:
1. the use of telepsychiatry in clinical interviews by the Coastal & Wheatbelt Mental Health Service (C&WMHS), and
2. the results of a patient satisfaction survey.
C&WMHS covers an area of 116000 sq km incorporating 27 shires, 92 towns and villages and numerous large farms. The major centres can be several hundred kilometres apart (Northam, Merredin, Moora, Gingin, and Lancelin). As there are, at most, two visiting psychiatrists each available for a maximum of two days per week, telepsychiatry enables patients to be assessed without the need for several hours of travel. Northam and three satellite centres in the C&WMHS (Merredin, Moora, Quairading) each have a telepsychiatry unit. The visiting psychiatrist consults from Northam, the unit being located in their office. The visiting psychiatrist can either have face to face interviews for people from the districts which are close enough to access the Northam office or consults via the telepsychiatry link for those further away. The three satellite centres have a room specifically designated for telepsychiatry consultations. Usually, the caseworker discusses the case with the psychiatrist first, and then introduces the individual. The caseworker can either remain in the room or leave during the subsequent consultation. After the consultation, feedback is given to the caseworker, and arrangements made via the local pharmacy for the prescription of any medication.
ASSESSING THE INTERNET AS A SOURCE OF INFORMATION ON CHRONIC FATIGUE SYNDROME: A SURVEY OF 225 SITES
Kisely S
DO COMMUNITY TREATMENT ORDERS WORK? A RETROSPECTIVE MATCHED CONTROL COHORT DESIGN FROM WESTERN AUSTRALIA
Kisely S,∗ Preston N, Xiao J
∗University of Western Australia, Fremantle Hospital, Health Department of Western Australia
ASSESSING THE PRIMARY CARE PARTNERSHIP IN ROCKINGHAM-KWINANA
Kisely S
University of Western Australia; Fremantle Hospital, Western Australia
Horton-Hausknecht J, Miller K, Tait A, Bostwick R, Mascall C
Primary Care Mental Health Unit, University of Western Australia; Palm Springs Medical Centre; Rockingham-Kwinana Psychiatric Services, Rockingham-Kwinana Division of General Practice
TEACHING CONSULTATION-LIAISON PSYCHIATRY TO MEDICAL STUDENTS
Kisely S
University of Western Australia; Fremantle Hospital, Western Australia
1. the relevance of physical & psychiatric co-morbidity, and somatisation for the vast majority of students who will be going into hospital or general practice;
2. the opportunity of seeing non-psychotic disorders;and 3. understanding the interaction between Axis 1 2 & 3 disorders.
The aim of this paper is to explore the place of consultation-liaison psychiatry in the undergraduate medical curriculum.
DEMORALISATION AND DISTRESS IN CANCER PATIENTS
Kissane D
Monash University Department of Psychological Medicine, University of Melbourne Centre for Palliative Care; Centre of Excellence in Remote Psychological Medicine, Broken Hill
This workshop will explore the concept of demoralisation and its relationship to depressed states, loss of hope and suicidal ideation. Demoralisation is an experience of ‘not coping’ leading progressively to feelings of impotence, helplessness, impaired sense of self-efficacy, hopelessness and despair. Shame and hopelessness can lead to suicide. Hope and optimism protect against it. Demoralisation is to be differentiated from depression. A series of presentations will be used to consider the application of the concept in a number of different clinical settings. Dr Kissane's presentation will specifically address demoralisation and existential distress in cancer patients.
PEACEKEEPERS: APPROACHING TREATMENT
Kruse D
PTSD Program, Veteran's Psychiatry Unit, Austin & Repatriation Medical Centre
The ARMC veteran's psychiatry unit has been running PTSD treatment programs for groups of veterans over the past six years. In this paper I plan to investigate and document the outcome for peacekeepers referred for programatic treatment of PTSD over that period of time. Some peacekeepers have declined or been unavailable for intensive programatic treatment for a variety of reasons. Others have been included in predominantly Vietnam Veteran treatment cohorts. Others have participated in diverse cohorts of predominantly peacekeepers. Some of these groups have been treated in the inpatient setting, while others have been treated as day patients.
In the presentation of both assessment outcome data for all referred peace keepers and the follow-up data for those who have entered and completed PTSD treatment programs, this paper will highlight some of the practical and mental health issues facing the “younger veteran” of “peacekeeping” and humanitarian type missions.
ESTROGEN: A POTENTIAL TREATMENT FOR SCHIZOPHRENIA
Kulkarni J,∗ de Castella A, Riedel A
∗Dandenong Psychiatry Research Centre, Monash University, Melbourne
Estrogen has been show in animal studies to modulate both the dopamine and serotonin neurotransmitter systems, which are the main neurotransmitters implicated in the pathogenesis of schizophrenia. A three-arm double blind placebo controlled study was conducted using adjunctive 50 mcg, 100 mcg and placebo transdermal patches in 44 women with schizophrenia. Results show that womanreceiving 50 mcg estradiol had a greater improvement in their psychotic symptoms compared to the placebo group (p < 0.05). There were no significant differences between the 50 mcg and placebo group in pituitary hormone levels. Women receiving 100 mcg estradiol made the greatest improvement in both positive and negative symptoms (p < 0.05). The 100 mcg group had lower mean LH and higher mean prolactin levels than the other two groups (p < 0.05). A small substudy showed that in 4 women with acute mania, 100 mcg adjunctive estrogen worsened psychotic symptoms (p < 0.05). Adjunctive estrogen provided better treatment of acute severe psychotic symptoms in women with schizophrenia. Of interest is also the possibility that estrogen appeared to worsen symptoms of mania suggesting that anti-estrogens may be useful in treating mania.
WHAT IS THE ROLE OF CONSUMERS AND CARERS IN TRAINING?
Lammersma J (chair)
joined by members of the Community Liaison Committee (Australia) of the Board of Professional and Community Relations
In the Review of Training, Examination and Continuing Education Paper, accepted by General Council in 2000, Recommendation 8 deals with consumer and carer involvement in Basic Training. It states
i. During each year of basic training trainees must participate in at least one approved activity that demonstrates a commitment to consumer and carer involvement in mental health.
ii. During each year of basic training trainees must participate in at least one approved activity that demonstrates an understanding of the role of the non-government sector and other community organizations in mental health provision.
iii. Branch Training Committees must, in consultation with local consumer and carer groups, ensure that each training program has significant input by consumers and carers during basic training.
This workshop will be led by members of the Community Liaison Committee and discuss how this recommendation can be implemented. It will discuss how to prevent tokenism and how to ensure meaningful consumer and carer input.
What opportunities do exist for trainees to interact with consumer and carer groups? How may trainees go about fulfilling the criteria in a practical manner?
This will be an interactive workshop for consumers and carers and psychiatrists and trainees.
At the conclusion of the workshop, recommendations will be forwarded to the Training Committee.
AN OUNCE OF PREVENTION: ANXIETY DISORDERS
Lampe L
Lecturer, Clinical Research Unit for Anxiety, University of New South Wales, Sydney
Anxiety disorders cost the Australian health system $239 million in 1993-1994, about 8% of the total budget for mental disorders, including mental retardation, developmental disorders and drug and alcohol. It has been estimated that even if every affected individual received and was compliant with the optimal treatment delivered with the utmost efficiency it would still only be possible to avert 50% of the economic burden of anxiety disorder. Most of the burden of mental disorders is due to years lived with the disorder, not because of years of life lost. It is well recognised for a large number of medical disorders that prevention offers considerable savings for the economy and the quality of life of the individual. There are strong indications that this might be true also of a number of mental disorders. Three types of prevention have been identified, including universal prevention delivered to the whole population at risk, selective prevention delivered only to the group in the population at high risk, and indicated prevention where the intervention is delivered to high risk individuals who are identified as having subthreshold features of a disorder. Risk factors for anxiety disorders have been identified and are easily measurable. Studies have also reported the identification of children with subthreshold features indicative of high risk for anxiety disorder and have further demonstrated the effectiveness of an intervention program in this group. A similar program is currently being tested in an Australian setting. The implications of this body of research for reducing the burden of anxiety disorders will be discussed.
OUTCOME OF PANIC DISORDER AND AGORAPHOBIA TREATED IN A NATURALISTIC CLINICAL SETTING
Lam-Po-Tang J
Consultant Psychiatrist, Paddington, New South Wales
Objective: To assess the outcome of treatment of a cohort with Panic Disorder or Agoraphobia in a naturalistic clinical setting, using clinical practice guidelines as a guide to psychiatric intervention, and using standardised outcome instruments to measure outcome.
METABOLISM IN COGNITIVE IMPAIRMENT: A PET STUDY
Lautenschlager N
Senior Lecturer of Old Age Psychiatry, University of Western Australia, Dept Psychiatry and Behavioural Science
Drzezga A
Technische Universitaet Muenchen, Dept Nuclear Medicine, Germany
Kurz AF
Technische Universitaet Muenchen, Dept Psychiatry and Psychotherapy, Germany
THE CHANGING FACE OF RURAL HEALTH AND PRACTICE: AN AUSTRALIAN PERSPECTIVE
Lyle D
Department of Rural Health Broken Hill, The University of Sydney
Working and living in a rural and remote area is distinctly different from the professional and social experiences that are familiar to the majority of Australians who live in or close proximity to large cities. In Australia rural communities are geographically distinct, dispersed and generally small in size—most with populations are between 200-5,000. The health of the rural population, particularly the Indigenous peoples, is poorer than their city counterparts, and access to health services is limited. These factors have made it difficult to attract and retain health professionals. For example the pressures of rural practice have resulted in around 10% of general practitioners leaving these smaller communities each year, with very few Australian graduates replacing them. Major government sponsored initiatives over the past decade have been focused on addressing these problems. They are aimed at improving the health of Indigenous peoples, developing flexible and coordinated services that meet the needs of rural communities, attracting and retaining a skilled and responsive workforce, and providing an adequate research and information base on rural health issues. A centrepiece of this strategic approach is the establishment of a national, integrated network of academic facilities, 10 rural clinical schools and 10 multidisciplinary departments of rural health. The early indications are that by moving academic infrastructure and human resources to the bush we have begun to change the face of rural health and practice in a sustainable and positive manner.
EFFICIENCY OF HIGH DOSE (DOUBLE DOSE) ECT
Lyndon RW
Northside Clinic, Greenwich, Sydney, New South Wales
For several years psychiatrists in Australia and some European countries have been able to treat patients with doses of ECT which are double the doses previously available. Initially restricted to 504 mC output, modern machines can be adapted to deliver up to 1007mC. This has been achieved by increasing the pulse width of the stimulusto 1.5 ms. The rationale for using very high doses has been to produce better, more efficacious seizures in those patients whose seizure threshold rises above 504mC during the course of treatment. Such high seizure thresholds are most commonly seen in the elderly, particularly elderly males. One disadvantage of very high doses is an increase in cognitive impairment. Recent research suggests that a shorter, rather than longer pulse width is more efficient for seizure induction, suggesting that efficiency may actually be lost when longer pulse widths are used, such as when using the “double dose” option of machines available in Australia.
THE TIME COURSE OF ANTIDEPRESSANT RESPONSE TO TRANSCRANIAL MAGNETIC STIMULATION
Lyndon RW
Repetitive transcranial magnetic stimulation (rTMS) has been extensively investigated as a treatment for several psychiatric illnesses, principally depression. Results, although generally positive, have been mixed. Placebo controlled trials have demonstrated either a modest effect for TMS or have failed to show separation between active and placebo treatments. A major methodological limitation to TMS studies has been the restriction of the period of treatment to two weeks, mainly because of regulatory requirements imposed by the United States Federal Drug Administration. A study from Tasmania (Pridmore 2000) revealed that recovery rates improves when the treatment course extended beyond two weeks. The current study investigates the possibility that in keeping with other antidepressant treatments, including ECT, the antidepressant efficacy of TMS may become more noticeable over a two to four week treatment period than has been observed in studies limited to two weeks.
CONVERSION PARAPLEGIA
Macleod S
Psychiatric Consultation Service, Christchurch, New Zealand
The literature on conversion symptoms (which is predominantly in the psychiatric rather than general medical literature) generally refers to chronic cases, tends to be anecdotal, analytically opinionated and of questionable scientific validity. Cases known to the author accumulated over 15 years as visiting psychiatrist to the Burwood Spinal Unit are presented and the deficiencies in the literature are highlighted.
If medically unexplained symptoms are determined to be psychogenic in aetiology there is a spectrum of diagnostic terminology used including hysterical elaboration of symptomotology, abnormal illness behaviours, acute conversion symptom, chronic conversion symptom, factitious symptom, and malingering. Acute conversion symptoms are a distinctly different clinical entity to chronic conversion symptoms. Since Briquet's classic description in 1859 of hysterical states there has been a progressive shrinking of the diagnostic criteria, and now pseudo-neurological symptoms are generally viewed as the only symptoms that meet DSMIV diagnostic criteria. Neurologists examining acute cases comment upon the high prevalence, the association with acute stressful situations, and favourable prognosis. Psychiatrists attending chronic cases note the “fixation” of symptoms by coexistent characterological, affective and organic disorder, the rarity of the disorder, and the poor prognosis. Neurological diagnostic accuracy has been considerably enhanced through modern scanning techniques. Neurophysiological investigations are of interest and supportive of the need to consider the biopsychosocial pathological influences, particularly in acute cases.
The proposal that acute and chronic conversion symptoms be considered as distinct disorders, as are grief and depression, acute and chronic pain, acute stress disorder and post traumatic stress disorder, with different pathogenesis, is presented. Reinterpreting the literature in accordance with clinical observation, rather than within a specific theoretical framework: allows an understanding of the prognostic variables in motor conversion symptoms, supports clinically merely reassuring patients with acute symptoms and indicating an expectation of spontaneous resolution, and accounts for the and generally ineffective management strategies in chronic cases.
Perhaps a fuller understanding of motor conversion symptoms may allow improved comprehension of the medically unexplained symptoms of for example pain and fatigue. Conversion paraplegia is a condition in which a definite psychogenic diagnosis maybe established, which is clinically a much more difficult task in many other conversion symptoms, thus is an ideal clinical model to study conversion phenomena.
Diagnostic and management features of six cases of definitively diagnosed conversion paraplegia will be presented to support the need to conceptualise acute and chronic conversion symptoms as distinct clinical entities.
DESIGNING AND IMPLEMENTING A DATABASE DRIVEN DISCHARGE SUMMARY FOR AN AGED CARE PSYCHIATRY INPATIENT SERVICE
McKay RG
Braeside Hospital NSW
This paper will describe one year's experience of designing, and implementing the use of, a database driven discharge summary system for an Aged Care Psychiatry inpatient service. There is a well-recognised need to optimise continuity of care between inpatient services and General Practitioners. Hospital discharge summaries are an important element in maintaining this continuity. Significant deficiencies were identified in the hospital's existing handwritten proforma discharge summaries and alternative options considered. A brief literature review revealed previously nominated key elements of discharge summaries. These included drug details, plan, diagnosis, admission summary, results of investigations, and what the patient or relatives have been told. No available discharge summary proforma contained these details or appeared appropriate for local needs. A printed discharge summary utilising the ‘Access’ database and ‘Word’ word processing software was designed to reliably include these elements with optimal legibility. To most efficiently utilise staff time it was hoped to utilise the database to generate medical admission notes, other reports and, in the future, form the basis of a system maintaining a cross-sectional record of patients to assist if patients re-present. The system has been found to improve the content and legibility of discharge summaries whilst maintaining the practise of their completion prior to patient discharge. Data will be presented to support this. The database has been utilised to also complete Guardianship reports but further utilisation has been prevented to date due to limitations of time available for development and the technical support required to address confidentiality issues. The completion of the database based discharge summaries has been found acceptable to registrars within a sub-acute setting but improved utilisation of the data entered would be required to make wider utilisation viable. A proposed system for such improved utilisation will be presented. This would entail maintaining a confidential database of the patient's clinical history and most recent presentation, which would be edited at key periods of a patient's management by a service (such as admissions, discharges or major community reviews). This could then be utilised to generate admission and discharge summaries, guardianship or other reports, and a clinical database for service review or research. It would also allow for the potential to generate additional discharge (or other) summaries targeted at families or support agencies with minimal additional workload.
THE PREVALENCE OF PSYCHIATRIC DISORDERS AMONG VIETNAMESE CHILDREN AND ADOLESCENTS IN PERTH, WESTERN AUSTRALIA
McKelvey R
Director, Division of Child & Adolescent Psychiatry, Oregon Health Services University, Portland, United States of America
SHOCKING TREATMENT! FROM RHETORIC TO REASON?
Melding P
Mental Health Services for Older People, Takapuna, New Zealand
Throughout the world, there is a well-organised, vociferous lobby group of people, often disaffected former patients, who have taken upthe ‘cause’ of banning ECT. There are websites dedicated to the cause, books and circulating stories of the ‘shock’, ‘horror’ variety. Lobbyists present petitions to Parliaments, enlist influential supporters, are able to entice the media into writing sensationalist articles and who seem vindicated by graphic movie portrayals of a type of psychiatric practice that many of us have never known. Yet today, ECT uses highlysophisticated 21st Century technology that calculates and monitors the safest stimulus for the patient. It is very different in reality to the public portrayal. However, despite the advances, public and media conceptions of ECT seem not to have progressed one iota; they are still out of the 1950's. The anti-ECT ‘cause’ seriously undermines our ability to use the treatment wisely and well, as it negatively influences not only legislators but patients, families and even some clinicians. Complaints laid against practitioners of ECT to the various authorities such as Medical Councils are not uncommon. Not surprisingly, such threats put practitioners off prescribing the treatment. How should we respond to these negative public perceptions?
There is an urgent need for data that can provide reasonable evidence to argue the case for ECT. We need to be able to objectively demonstrate that for older people with severe depression, ECT can be transforming and life saving.
This presentation will address the early results from a study of ECT in older people. In contrast to the rhetoric emanating from the anti ECT lobby, our findings are that the treatment is very effective in about 66% of patients and that memory loss is transient and reversible. Our findings indicate that patients with primary depression do well, those with other psychiatric pathology have less good outcomes.
We hope that the study will eventually balance the rhetoric with some reasoned evidence with which to enlighten the general public.
A STOLEN LIFE: A PERSONAL CHAPTER IN ABORIGINAL HISTORY (VIDEO)
Milroy G
Consultant Child and Adolescent Psychiatrist
On the surface, Glad appears to have had a successful life. She raised five high achieving children, owned and managed a profitable business, teaches cultural awareness in schools, organises festivals, and is an accomplished artist and story teller. Underneath this successful life however, lies the tragic story of an Aboriginal woman forcibly removed from her mother, placed in an orphanage and barred from her own cultural heritage. Glad has made a lifelong journey through grief to find her family, her country and her cultural identity.
Part of Glad's story is presented in a 25 minute video documentary that traces Glad's early beginnings at Parkerville Children's Home and the final journey 70 years on to her homeland in the Pilbarra to search for surviving brothers and sisters. The story confronts the reality of stolen children, lost lives and the profound grief that still exists. It also offers a journey of healing through reconnection with the land and the people, understanding Aboriginal spirituality, and the release from the artificial family created for her. The journey however, is never-ending and the legacy is left for subsequent generations.
Currently in my work as a Consultant Child and Adolescent Psychiatrist, I continue to see the trauma and grief carried through generations of Aboriginal children. Glad is also my mother and both Glad and I will be available following the documentary to discuss the impact of this part of Aboriginal history from both a personal and psychiatric point of view.
VICARIOUS OR NOT SO VICARIOUS TRAUMATISATION IN INDIGENOUS CHILDHOOD DEVELOPMENT
Milroy H
Indigenous children continue to suffer the burden of disadvantage already experienced by their families. Some in the wider community cannot understand why this is so given the new opportunities available to them. Transgenerational transmission of trauma is clearly a complex issue but one of the mechanisms that can potentially perpetuate the trauma is the process of vicarious traumatisation. For many Indigenous children, living with the reality of Indigenous history may in fact be significantly traumatising in its own right. I have attempted to look at the model of vicarious traumatisation, post-traumatic stress disorder as well as modifiers of trauma in children to begin to understand the ongoing effects in our Indigenous children today. By identifying some of the potential mechanisms involved, we may be better able to understand the behaviours as well as the needs of our Indigenous youth and provide a more successful service to Indigenous families.
DESTIGMATISING MENTAL ILLNESS AMONGST ADOLESCENTS
Moore K
Mental Illness Education ACT Inc
Wylde-Brown M, Bone L
Mental Illness Education ACT Inc
Mental Illness Education ACT has been drawing on the personal experiences of consumers and carers to promote good mental health—and destigmatise mental illness—amongst adolescents in the ACT since 1994. The volunteer presenters undergo an initial 12-hour intensive training period to learn the contents of the sessions and classroom skills, and receive regular follow-up training and support throughout the school year. The sessions cover the basic facts about mental illness; factors that can contribute to their development; the five major psychiatric conditions (clinical depression, anxiety disorders, eating disorders, bipolar disorder and schizophrenia); and the impact of mental illness upon the family and friends of consumers. They also provide resources to give students and teachers access to further information and assistance regarding mental health issues. Twenty presentersdelivered 81 sessions to 1646 students (aged 15-18 years) in 16 ACT schools during the 1999-2000 financial year. Additional sessions were given to Canberra Youth Music, The Junction Health Centre for young people, YWCA youth workers, teachers at Daramalan College and during the 2000 Australian Science Festival. Feedback from teachers and students alike is consistently very positive. Both groups emphasise the importance of discussing mental illness openly, and say that the personal stories make the clinical information accessible to the audience. For example, students sometimes approach the volunteers after class to talk, often for the first time, about concerns they have for themselves or their friends. The program was awarded the National Winner Health of the 1999 National Australia Bank CommunityLink Award in 1999.
INVOLUNTARY TREATMENT OF SCHIZOPHRENIA IN THE COMMUNITY: CLINICAL EFFECTIVENESS OF COMMUNITY TREATMENT ORDERS WITH ORAL OR DEPOT MEDICATION IN VICTORIA
Muirhead D,∗ Ingram G, Harvey C
∗North West Area Mental Health Services, Brunswick, Melbourne, Victoria
PREVENTING THE LONG TERM ILL EFFECTS OF CHILD ABUSE
Mullen PE
There are well-established associations between sexual, physical and emotional abuse during childhood and a range of adult psychopathology as well as social and interpersonal problems. The mediation of these associations is complex involving the interaction between the direct impact of the abuse and both the prior, and subsequent, development of the child victim. Those elements which mitigate the impact of abuse such as a confiding relationship with a carer, school success and later positive peer relationships are open to encouragement and augmentation. In those children whose abuse comes to light at, or soon after, the event direct therapeutic interventions can probably reduce long-term sequelae.
This presentation will argue for a program of secondary prevention based on a developmental perspective and aimed at reducing the longterm effects of child abuse.
A HIGHER STANDARD OF REPORT WRITING
Nothling M, Skinner Y
Private Practice, Brisbane
The authors will present results of research on 249 independent medicolegal reports which were prepared for the Pituitary Hormones Trust Account Advisory Board in 1999. The presentation will involve an explanation of the reasons for establishment of the Board, the considerations by the Board and trends which emerged in examination of the reports. The reports have been submitted by psychiatrists from all States of Australia. Items covered will include the addressing of relevant issues by the reporting psychiatrist, the range and style of reports received, and difficulties that arose for such a Board depending on the type of report received from the individual psychiatrists. The reports were analysed with respect to whether certain basic criteria were addressed or not and the results of this analysis will be presented. Gender issues which emerged in the reports will be discussed.
Recommendations as to criteria to be included in such reports will be addressed and discussed.
NEW PHARAMACOTHERAPY
O'Brien C
The discovery of the role of the endogenous opioid system in the mechanism of action of alcohol led to the application of naltrexone to aid in the treatment of alcoholism. The great majority of controlled studies have repeatedly found that naltrexone significantly reduces the relapse rate to alcoholic drinking when combined with a rehabilitation program. New data will be presented on the long-term use of naltrexone as well as preliminary information on clinical trials utilizing the depot preparation. Acamprosate is used in Europe and is being studied in the US in combination with naltrexone. Recent preliminary data suggest a role for ondansatron, a 5HT3 antagonist in the treatment of early onset alcoholism.
AN A-Z OF DEPRESSION MAPPING: THE ANATHEMA OF THE NEW ZEITGEIST
Parker G
University of NSW, Kensington
In this paper, current views about depression classification will be briefly criticized before considering a broader model and its particular application to the melancholic sub-type, with data demonstrating how the ‘ageing brain’ not only influences the phenotypic expression of melancholia but may have distinct influences on the effectiveness of varying antidepressant drug classes.
PRIMARY CARE PSYCHIATRY
Paterson T
Adelaide Northern Division of General Practice, Northern Mental Health Service
Seiboth C
Adelaide Northern Division of General Practice
Nagesh R
Northern Mental Health Service
The prevalence of mental health illness in South Australia has been identified as about 20%. Those identified as having a mental health illness are significantly more likely to use tertiary health services and accident and emergency departments and, significantly more people who reported a mental health condition are totally unable to carry out their normal duties.
Primary Care Psychiatry—The Last Frontier identified that, of those Australians who meet the criteria for a mental disorder, only one third seek treatment. Three quarters of these seek help from their general practitioner (Andrews et al 1994)
The joint Mental Health Project of the ANDGP and the Northern Mental Health Service (NMHS) explored alternative strategies to identify and treat patients with Mental Health Disorder. The project also explored alternative types of psychiatrist and general practitioner interaction.
An explicit objective of the project was the development of adequate and clinically relevant evaluation methods.
The specific objectives of the project were: To increase general practitioner's skills to recognise mental health disorders in patients in the primary care settings. To increase the skills of general practitioners to manage patients with mental health disorders. To assist general practitioners to utilise appropriate clinical pathways.
Participating patients were asked to complete the 14 item, self report Hospital Anxiety & Depression Scale (HADS) developed by Zigmond & Snaith in1983.
The General Practitioners rated the severity of the mental health condition(s) of their patients using the 12 item Health of Nations Outcome Scale (HoNOS).
Patients had the HADS readministered three months after the Joint Consultation. In addition, patients were invited to complete a questionnaire to evaluate the Joint Consultation process. Participating GPs were asked to complete the HoNOS three months after the joint consultation to reassess the psychiatric symptomatology of the patients. The GPs were also asked to complete a questionnaire to evaluate the joint consultation process.
REMOTE, RURAL AND REGIONAL PSYCHIATRY: A SOLUTION TO PSYCHIATRIST SERVICE PROVISION
Paton MB
Consultant Psychiatrist, Greater Murray Health Services
Large M
Consultant Psychiatrist, Greater Murray Health Services
It is our view that the supply of psychiatrists to rural and regional areas is no longer an issues of availability, but one of cost and technological infrastructure.
We propose a model of supply of psychiatrist services to the regional public psychiatric sector of the State of New South Wales, which is sustainable indefinitely and offers high quality services through clinician links with metropolitan teaching hospital mental health services.
We have demonstrated that regional centres with acute inpatient services can be effectively run utilising a coordinated team of onceweekly visiting medical officers, with a continuous telephone on call facility.
The major obstacle to the provision of this type of service is political, with cost concerns generally presented as the argument against the model by service providers. Consumer response is invariably positive. The recent AMWAC survey of psychiatrist manpower has clearly documented the gros maldistribution of psychiatrist services. A paramount ethical question for the College is presented by this model. Can we continue not to supply psychiatrist services where there are virtually none, when there is a viable solution available now?
WILL CLINICAL PRACTICE GUIDELINES COOK THE PSYCHIATRIC GOOSE?
Prager S
Department of Psychological Medicine, Monash University
The aim of this presentation is to provide a critical analysis of the aetiology (causation) of clinical practice guidelines (CPGs) in Australian psychiatry, and the consequences for the administration and delivery of psychiatric services.
The literature relating to the development, implementation and audit of CPGs in Australian psychiatry is reviewed, with particular reference to the National Health and Medical Research Council's Guidelines for the Development and Implementation of Clinical Practice Guidelines.
The ethical, legal, administrative and funding consequences of CPGs are clarified. The possible constructive and destructive effects of College sponsored CPGs on the delivery of psychiatric services are made explicit.
A CONTROLLED STUDY OF PSYCHOEDUCATIONAL FAMILY INTERVENTION IN RURAL CHINESE COMMUNITY FAMILIES OF SCHIZOPHRENIC PATIENTS
Ran M∗, Lai-wan Chan C, Meng-ze Xiang, Ming-sheng Huang, You-he Shan, Lan-ting Guo, Si-gan Li, Zong-ren Liu, Yun Wan
∗Associate Professor, Institute of Mental Health, First University Hospital, West China University of Medical Sciences
MENTAL HEALTH CARE FOR RURAL AND REMOTE POPULATIONS AND INDIGENOUS MENTAL HEALTH POLICY AND PROGRAMS
Raphael B
Director of Mental Health, New South Wales Australia
Mental health issues in rural and remote communities may present in complex ways. Cultural issues are central for indigenous communities. Perceptions of illness and stigma, history of trauma and loss, racism, and current stressors complicate the mental health picture and add to the burden. Drug & Alcohol co-morbidity with mental health problems further complicate assessment and management. Providing services, issues of privacy and burnout, distance, and roles of mental health workers in communities are often additional challenges. Education, support and career development for indigenous mental health workers are further important aspects. Research into rural and remote mental health and into the mental health needs and care systems for indigenous peoples requires much further development.
THE RELATIONSHIP BETWEEN CHILD ABUSE AND SCHIZOPHRENIA: CAUSAL, CONTRIBUTORY OR COINCIDENTAL?
Read J
Senior Lecturer, Clinical Psychology, Department of Psychology, The University of Auckland, New Zealand
This paper first reviews the research literature demonstrating a powerful statistical relationship between child abuse between childhood sexual and physical abuse and psychosis in general and schizophrenia in particular. Beyond the high prevalence of abuse in these populations the relationship between abuse and specific symptoms such as auditory hallucinations is discussed. Unpublished data on 200 outpatients are presented, showing that hallucinations and other psychotic symptoms are significantly more likely to occur in abused than non-abused patients.
Factors inhibiting acknowledgement and scholarly discussion of this body of knowledge are discussed, including:
1. a rigid adherence by some researchers and clinicians to a simplistically applied biological paradigm,
2. the documented failure of many clinicians to take abuse histories in general and particularly in the case of clients with diagnoses indicative of psychosis,
3. the tendency to rediagnose away from psychosis if abuse is identified,
4. the fear of returning to a ‘family-blaming’ stance of the 1970s,
5. the belief that abuse disclosures in this population are frequently delusional.
The nature of the relationship is then discussed. Most of the studies demonstrating the relationship are correlational leaving unanswered the directionality of any causal relationship. The possibility of confounding variables (eg family dysfunction, parental psychiatric history, substance abuse) is discussed, along with the notion that the relationship might be explained by the possibility that the children in question are displaying early signs of psychopathology which render them more at risk for abusive discipline within the family and sexual abuse from strangers.
A Traumagenic Neurodevelopmental Model of schizophrenia is then presented. This model hypothesises that child abuse can elicit longlasting changes in the hypothalamic-pituitary-adrenal (HPA) axis resulting, via damage to the homeostatic stress-regulation processes, in the heightened sensitivity to stressors found in most people diagnosed schizophrenic as adolescents or adults. The model draws support from the similarities between the documented effects of early trauma on the developing brains of children and the structural and biochemical abnormalities found in adults diagnosed schizophrenic.
It is recommended that, regardless of clinicans’ views on the unresolved question of the nature of this now well documented relationship, full psychosocial histories—including trauma issues—be taken from all clients in order to facilitate accurate formulations and appropriate treatment planning.
THE NEED FOR TRAINING AND POLICY GUIDELINES FOR TRAUMA INQUIRY AND RESPONSE?
Read J
This paper first reviews the research literature documenting the relationships between childhood trauma (particularly physical and sexual abuse) with a wide range of diagnostic categories in adulthood. In addition a recent New Zealand study finding that child abuse is a stronger predictor of suicidality in adults than a current diagnosis of depression will be presented.
The international literature assessing the extent to which clinicians are asking about abuse will be summarised. These studies indicate that at least 70% of abuse is undetected by routine clinical practice. It also seems that men and more seriously impaired patients are less likely than others to be asked about abuse. The smaller body of literature describing clinician response to disclosures of abuse will also be reviewed.
The paper goes on to describe the development and recent implementation of an abuse policy for mental health units in one area of Auckland's public health system. As well as providing guidelines for best practice in the areas of abuse inquiry and response, this policy includes the mandatory training of all mental health staff in this area. This one-day training programme, piloted and evaluated during 2000, includes both knowledge-based learning and utilises role plays to enhance clinical practice.
CONSTITUTION, CONFLICT AND CONTEXT IN THE PATHOGENETIC GRID-AND THE PHILOSOPHY OF CAUSES AND CONSEQUENCES
Reichard O
Springwood, New South Wales
i. To build a theory of causation for 21st Century Psychiatry on a more integrated bio-psycho-social basis, by creating a multi-axial dynamics (MAD) which is more comprehensive, more critical yet more concise. Using a multi-axial grid (MAG) which correlates the multi-factional dimensions (of Causations) along spectra (of psychopathology) rather than on rigid categories.
ii. To argue and demonstrate that the increasingly scientific standards of clinical science can help to further differentiate diagnosis, therapy and prevention with greater precision and thereby achieve the humanitarian aims of a more personalised psychiatry in a holistic approach by relying on the Philosophy of Psychiatry as our guiding light.
Ontology: which delineates unambiguously the domain of it's facts. (Which has been greatly disputed during it's history.
Epistemology: which deals with the way we arrive at knowledge to decide the validity and reliability of our facts and findings, which is made even more difficult in psychiatry as ‘fictions’ are part of it's facts!
Therefore only a comprehensive multi-axial-grid (M.A.G.) can clarify pathogenetic mechanisms.
MAGNETIC RESONANCE SPECTROSCOPY IN AFFECTIVE DISORDERS
Reutens S,∗ Sachdev P, Malhi G
∗Fellow, Senior Registrar, Neuropsychiatric Institute, Prince of Wales Hospital, Randwick, Sydney, New South Wales
Magnetic resonance spectroscopy (MRS) is a non-invasive means of determining brain neurochemical alterations in psychiatric disorder. A body of literature is accumulating on the application of MRS for studying the pathophysiology of mood disorders.
The objective was to report recent MRS research in affective disorders; and to investigate its utility for predicting response to antidepressant treatment in unipolar depression.
1. A MEDLINE literature search was undertaken to review MRS research in affective disorders. Another MEDLINE search was conducted to determine if predictors of treatment response in depression had been found using other neuroimaging modalities.
2. A study has commenced to examine whether MRS has predictive value for response to antidepressant medication in unipolar depression. Another aim of this study is to document biochemical differences between depressed and healthy subjects. Subjects with DSM-IV unipolar depression undergo 1H-MRS analysis of the anterior cingulate, left dorsolateral prefrontal cortex and left caudate prior to commencing antidepressant treatment. The subjects are reassessed after 6 weeks to determine if they have responded to medication. The MRS variables associated with subsequent response or non-response will be assessed by logistic regression analysis and correlated with neuropsychological and clinical parameters tested at baseline.
INTERNET-BASED TREATMENT FOR PANIC DISORDER
Richards J
Professor, School of Behavioual and Social Sciences and Humanities, University of Ballarat
Klein B, Archbold T
School of Behavioural and Social Sciences and Humanities, University of Ballarat
Recent data suggest that 9.7% of the Australian community experiences a diagnosable anxiety disorder during any twelve month period. Of these, just over one in four seek professional assistance for their condition with the majority consulting their general practitioner. Only a small minority seek specialised mental health assistance. People in regional Australia with an anxiety disorder are particularly disadvantaged because of scarce specialist mental health resources and relative geographical isolation. Afflictingapproximately 2.4% of the community, panic disorder (with or without agoraphobia) imposes considerable psychological and economic burdens on the community. To address the mental health needs of people in regional Australia with this anxiety disorder, we have developed an Internet-based treatment for panic disorder. The treatment involves two main components—the presentation of a detailed cognitive behavioural program for panic disorder on our web-site together with therapist assistance provided through the Internet for people participating in the program. We are presently conducting a controlled trial of this intervention where it is being compared to the use of a standard, print-based CBT manual coupled with therapist assistance by telephone. Preliminary results from our evaluation will be presented as will our experiences in establishing this Internetbased treatment.
CONTEMPORARY ISSUES IN THE MENTAL HEALTH OF THREE GENERATIONS OF AUSTRALIANS AT WAR: CONTEMPORARY ISSUES IN THE MENTAL HEALTH OF OLDER VETERANS
Robertson M
Consultant Psychiatrist, Mayo-Westley Centre, Taree
Around 700,000 men and women served during the 1939-45 conflict. 40,000 were killed and 66,500 were wounded. This paper will consider the current problems encountered in the clinical care of the mentally ill older veteran including issues of medical comorbidity, developmental psychopathology and management.
The paper will also consider the nature of traumatic stress typically encountered by Australian servicemen and women during the Second World War, as well as a descriptive study of the increasingly common syndrome of later onset Post Traumatic Stress Disorder in a cohort of older Australian veterans, demonstrating the particular prominence of intrusive PTSD symptomatology. A brief discussion regarding potential psychodynamic and psychobiological models of the syndrome will follow.
INTERVENTION FOR CANNABIS USE IN SCHIZOPHRENIA: RESULTS FROM A PILOT STUDY
Rolfe TJ,∗ Williams S, Fitzgerald PB, Kulkarni J
∗Department of Psychology Medicine, Monash University, Melbourne, Victoria
Cannabis is widely used by people with Schizophrenia. While there is still debate as to the possible adverse consequences of this, there is a need to develop interventions for those people who wish to cease or reduce their cannabis use. This study aims to explore the use of a specific, individualised intervention, delivered by a Psychiatrist, in conjunction with standard care.
Participants were recruited by advertising within the service and in conjunction with other studies. Over a twelve-month period thirteen people were recruited into the intervention group and nineteen into a comparison group. The comparison group received standard care plus research involvement. All participants were confirmed as having Schizophrenia using the SCID-R. Monthly ratings using the PANSS, MADRS QOLI and cannabis rating scales (CAUSE and CUES) were continued for twelve months or for the duration of follow-up. Intervention was conducted on a weekly basis initially. Assessment was followed by identification of targets that were monitored using the CAUSE and CUES. Maintenance of engagement, harm-reduction and family/carer involvement are important underlying principles.
No differences are apparent between the intervention group and comparison group with respect to age, gender and illness/cannabis use duration. The number of months of no cannabis use was halved in the intervention group. In the intervention group, three cannabis users stopped altogether, five reduced their use, while none increased their use. In the comparison group, one ceased use, one decreased use and one increased use, in the majority use was unchanged.
Results from this pilot study are encouraging and demonstrate that some change in cannabis use can be achieved with relatively little effort. Clinical guidelines are currently being developed to allow further development of interventions.
TRAUMA AND POST-TRAUMATIC STRESS DISORDER VIEWED THROUGH A POPULATION LENS
Rosenman S
Centre for Mental Health Research, Australian National University; Canberra Psychiatry Group
Dissatisfaction with the diagnosis of post-traumatic stress disorder grows from uncertainties about the specificity of the clinical picture and the role of trauma. Information drawn from diagnosed populations can be misleading. We do not know if the experience of trauma always produces disorder, or if people experience trauma without subsequent disorder. We do not know if trauma produces a specific disorder or produces a variety of disorders. If some people do not develop disorder and some develop disorders other than post-traumatic stress disorder, what determines this variation.
The National Survey of Mental Health and Wellbeing comprehensively questioned a stratified sample of 10,000 Australian households for symptoms. It also included questions about the lifetime experience of trauma.
These rich data give a clearer indication of the range of traumatic experience in the Australian population than has been available to this time. This paper gives an account of these data: the community experience of trauma and its relations to symptoms as well as specific syndromes and disorders.
SUICIDE PREVENTION—POPULATION HEALTH APPROACHES
Rosenman S
Identification of individuals at risk of suicide is a strategy of suicide prevention which cannot be demonstrated futile.
Alternative “population-based” approaches built on our knowledge of risk factors offers a more profitable approach. This examines the proof of the futility of individual approaches. It looks successful application of population-based approaches in other medical disciplines (injury prevention and cardiovascular disease) and proposes how this may be used in suicide prevention.
THE THERAPIST AS REPOSITORY IN ANOREXIA NERVOSA
Russell J
Department of Psychological Medicine, University of Sydney, Northside Clinic
The young patient with anorexia nervosa has a long and difficult struggle as does her family. Hostility abounds in the patient at attempted removal of the ego syntonic symptom and from the patient and her carers at the ostensible incompetance of her therapist. The patient too may be the target of hostility from family members which impinges upon the developmental tasks of achieving autonomy and identity. Amongst other things the latter might precipitate the act of moving on often from the initial therapist regardless of whether treatment goals have been achieved or not. The patient and sometimes her family not infrequently seek to leave the illness or parts thereof with somebody, most often the former therapist—hence the repository function. Ideally the patient's negative emotions will be metabolised and processed but time might be short relative to the trajectory of the illness and even in recovered patients there is often a considerable residuum. The repository function is activated in both positive and negative ways which contribute to therapists’ strong and often polarised views about these patients. Understanding and managing this perverse role of the therapist is important not only for the patient's continuing progress but also for the therapist's mental health.
NAG TAIE RUA: BICULTURALISM IN PSYCHIATRY IN NEW ZEALAND
Ryan E
Director of the Adult General Mental Health Services, Canterbury Region New Zealand
Dr Erihana Ryan is a Maori psychiatrist, and has worked for over two decades in the development of Maori mental health services. She heads Te Korowai Atawhai, the specialist Maori Mental Health in Christchurch, New Zealand and participates in a wide range of national and international activities in this area. She is also the Clinical Director of the Adult General Mental Health Services for the Canterbury region, and a community psychiatrist.
In a pattern commonly experienced by indigenous peoples the Maori of New Zealand suffered significant destruction of the cultural, social and economic stability of their communities after arrival of settling immigrants in the first half of the nineteenth century. Initial risk of extinction was reversed by public health service development settling a pattern of Maori community and whanau (family) development. Nonetheless the socio-economic disparities continue to beset Maori, and the challenges for mental health services are to incorporate methods that have proved effective from the past, with primary focus on traditional perspectives of health that incorporates the basis of collectively, the primacy of spirituality and identify as a determinant of health and well-being.
beyondblue… A LEAP INTO THE BLUE BEYOND?
Sainsbury P
Director, Division of Population Health, Central Sydney Area Health Service; Adjunct Associate Professor, Department of Health and Community Medicine, University of Sydney
Depression is a major cause of disability in Australia and it is pleasing to see that it is beginning to receive appropriate attention from health service researchers, planners and providers. beyondblue, the national depression initiative, is a commendable development.
To realise its potential, however, beyondblue has some significant problems to handle: Do we really know how to manage depression effectively? Even when we do know what to do, do we know how to get health professionals to do it? Is there sufficient political commitment to improve the social problems that are the fundamental causes of many patients’ depression and to alleviate its discriminatory social consequences?
This paper examines these questions and comes to some not very encouraging conclusions.
RISK AND BENEFITS OF CHANGING FROM DEPOT TO ATYPICAL ANTIPSYCHOTICS
Samuel M
Department of Psychiatry, Fremantle Hospital, Western Australia
Addis SR, Kisely S, Roberts AP, Alderon D
Department of Psychiatry, Fremantle Hospital
The advent of atypical antipsychotics has been an important advance in antipsychotic medication, as they appear to be as effective in treating positive symptoms but have fewer less severe side effects than traditional antipsychotic drugs.
Depot formulations of atypical agents are not available to clinicians yet. There has therefore been trend to switch patients, particularly those with extrapyramidal side effects, from depot formulations to oral atypical. As yet there is minimal published information on the outcome of this treatment change.
MORE THAN OUTCOMES—MEASURING THE PERFORMANCE OF MENTAL HEALTH SYSTEM
Sara G,∗ Snars J
∗Division of Mental Health, Sutherland Hospital, Sydney, New South Wales
USES AND LIMITS OF TECHNOLOGY IN PROVIDING SPECIALIST SUPPORTS TO GPS
Sara G, Gomez F, Minto G, Keller A
YOUNG PSYCHIATRISTS AND TRAINEES: WHAT LIES AHEAD
Professor Norman Sartorius
University Hospitals of Geneva, Switzerland
This session is an opportunity for young psychiatrists and trainees to discuss and debate the many challenges we face, as individual psychiatrists and as a profession. All attendees will be given a series of contentious questions as they enter the session. After some introduction and an international perspective from Professor Sartorius, attendees will be asked to vote on each question and the results of this poll will be used to facilitate further discussion of these issues from all in attendance.
MONITORING LIVING KIDNEY AND COMBINED PANCREAS AND KIDNEY TRANSPLANT PATIENTS USING THE SF-36
Smith GC
Monash University, Depart of Psychological Medicine; University of Melbourne Centre for Palliative Care, Centre of Excellence in Remote Psychological Medicine, Broken Hill
Trauer T
Monash University Depart Psychological Medicine and Southern Health
ABORIGINAL AND MAORI SUICIDE: A PORTRAIT OF LIFE AND SELF-DESTRUCTION
Tatz C
Visiting Professor of Policies, Division of Humanities, Macquarie University
The aim of the study was twofold: first, to a arrive at an understanding of Aboriginal and Maori youth suicide in their particular historic, geographic, legal, social and political contexts; second, to develop a model towards both explanation and alleviation of an escalating incidence of young suicide.
Between July 1997 and June 1999, the author-a social scientist and historian-undertook intensive fieldwork in 55 locations in New South Wales and the Australian Capital Territory and, for comparison, examined current research into, and strategies for alleviation of, Maori youth suicide. He conducted 388 interviews, with, amongst others, Aborigines and Maori, non-indigenous personnel working with communities, police, coroners, inquest officers, psychiatrists, suicidologists and mental health and youth workers in both countries. Documentary research was conducted in local coroners’ and in State Coroners’ offices. His conclusion is that an anthropology of suicide rather than a psychology or sociology of suicide is more relevant and valuable in these particular domains.
The data show that the Aboriginal youth suicide rate in New South Wales is at least double that of the Australian rate for the 15 to 24-year cohort: 48 per 100,000 as opposed to 24/100,000. Given the serious under-reporting of suicide generally, and given the added difficulty of Aboriginal (and Maori) definition, the rate is more likely treble the national figure. There is an increasing pattern of suicide among those under 15, yet adherence to a WHO statistical classification excludes child suicide.
The author's report to the Australian Criminology Council, Aboriginal Suicide is Different, presents 20 major strategies for alleviation: they embrace an educational focus on historical, legal, political, social and cultural factors which impinge, uniquely, on Aboriginal and Maori youth suicide. This paper appeals for a much wider disciplinary focus than the current public health and ‘mental health’ models, neither of which has succeeded in reducing the high rates of suicide in the 15to 24-year-old cohort. It also contends that the oft-quoted statement in the literature that ‘most researchers agree that 90 per cent or more suicides have mental disorders’ does not apply to Aboriginal suicides or parasuicides. A criticism is offered of the proposition that biochemical and/or genetic research may help understand ‘indigenous’ suicide. The author presents evidence in favour of a separate Aboriginal and Maori suicidology. Within that framework, a cultural and social approach, rather than a biomedical one, is more likely to achieve an alleviation (rather than prevention).
RANZCP AND MHWG RESPONSE TO AUSTRALIAN MEDICAL WORKFORCE ADVISORY COMMITTEE
Tobin M
Director, Mental Health Services, Department of Human Services, Adelaide, South Australia
The AMWAC report provides Psychiatrists with a number of major challenges. These relate to improving access to specialists, greater role for consultation psychiatry, adequacy of supply and distribution of psychiatrists, and strengthening psychiatrists relationship with General Practice.
One important issue is the need to revisit the issue of improving relationships between private practitioners and the public sector. For it's part the National Mental Health Working Group, which comprises all the state Directors of MH, has acknowledged the need for greater flexibility in terms and conditions of employment of psychiatrists if we are to attract more psychiatrists into innovative models of practice.
Dr Jonathon Phillips, Dr Margaret Tobin and Prof Ross Kalucy will present an overview of the AMWAC report, and engage the audience in some discussion about possible responses. They will then present some initial thinking about strategies for the future.
COMMITMENT TO PRACTICE IMPROVEMENT
Tobin M & the Quality Improvement Committee
A presentation of multiple projects—a variety of work from different clinical perspectives and across public and private, individual and group practice will be discussed. Ho Hum Quality Improvement—let's take another look.
Quality Improvement (QI) is a widely used term across psychiatry and mental health, but it has many different interpretations.
Some of the most common responses to introduction of the term include; “something that is to do with accreditation”, a “bureaucratic process”, and “all my clinical work is always of the highest quality so why would I be interested in improving quality”.
The RANZCP QI Committee is interested in bringing Quality alive for a wide variety of psychiatrists across individual and service system practice. To do this we will deliver an interactive workshop where indicators for quality are discussed and debated. People who are cynical and skeptical can come along and throw us their challenges. We will describe what some of the other medical Speciality Colleges are doing, and we will inform fellows about Australian initiatives such as the Australian Safety and Quality Council. Our aim is to engage a broad group of fellows in developing an understandable and engaging approach to quality which will then be used to sponsor some specific activities in different practice settings in 2001-2002.
DEMORALISATION IN ADOLESCENTS
Vance A
Monash University, Depart of Psychological Medicine, University of Melbourne Centre for Palliative Care Centre of Excellence in Remote Psychological Medicine, Broken Hill
This workshop will explore the concept of demoralization and its relationship to depressed states, loss of hope and suicidal ideation. Demoralization is an experiFence of ‘not coping’ leading progressively to feelings of impotence, helplessness, impaired sense of self-efficacy, hopelessness and despair. Shame and hopelessness can lead to suicide. Hope and optimism protect against it. Demoralization is to be differentiated from depression. A series of presentations will be used to consider the application of the concept in a number of different clinical settings. This presentation will specifically address demoralization in distressed adolescents.
COMMUNITY TREATMENT ORDERS REDUCE PSYCHOSOCIAL HAVOC: A 4-YEAR CONTROLLED TRIAL
Vaughan K
Department of Psychological Medicine, University of Sydney, Hornsby Ku-Ring-Gai Hospital, New South Wales
Neil McConaghy, Cherry Wolf, Craig Myhr and Terry Black Department of Psychological Medicine, University of Sydney, Hornsby Ku-Ring-Gai Hospital
The objective of this study was to investigate the readmission rate, the level of patient disturbance and community care associated with readmission following Community Treatment Orders (CTOs) in New South Wales.
The method was medication non-compliance, number of clinical services and duration of disturbed behaviour preceding hospitalisations preceding, during and following a CTO were compared for all patients given CTOs within a four-year period and a matched comparison group.
Within the CTO group patients receiving depot medications showed high compliance and a significantly reduced readmission rate compared to that of patients receiving oral medications. Although the level of services in the three months following discharge were comparable for patients on CTOs and the comparison group, in the two months prior to hospitalisations during CTOs compared to those before or after CTOs, patients received more frequent consultations, and showed a shorter duration of medication non-compliance and disturbed behaviour.
Conclusions were that depot medication may reduce rehospitalisations more then oral medications during CTOs but the real benefit of CTOs may be their promotion of earlier and possibly more frequent readmissions in the CTO group, which shortens the disturbance associated with illness recurrence.
THE EFFECT OF ROUTINE USE OF A DEPRESSION RATING SCALE ON THE DIAGNOSIS OF MAJOR DEPRESSION IN ADOLESCENTS
Walter G, Rey JM, Grayson D, Mojarrad T
THE HUMBLE CASE REPORT
Walter G, Rey JM, Dekker F
“UNWILLINGLY TO SCHOOL”: CHARACTERISTICS AND OUTCOME OF ADOLESCENTS WITH SCHOOL REFUSAL
Walter G, McShane G, Rey JM
INSOMNIA AND ABNORMAL ILLNESS ATTITUDES: THE RELEVANCE OF SOMATISATION
White R
Department of Psychiatry, Royal Prince Alfred Hospital
Bearpark HM, Elliott L, Hunt GE
Royal Price Alfred Hospital, Central Sydney Area Health Service; University of Sydney
There has been little published research on the belief and attitudes of insomniac patients. In particular, it appears that there have been no published studies that use scales specifically designed to elicit abnormal illness attitudes or behaviour.
In other words, the responses of the experimental group suggested that they were more conscious of body sensations and symptoms and their implications of illness. They were more inclined to believe that their symptoms would impair their mental concentration, their capacity to work and capacity to enjoy their lives. Experimental subjects more often reported that they were likely to seek multiple health opinions and treatments. The investigaotrs note that these illness attitudes approximate some definitions of somatisation.
The Spielberger Trait Anxiety the CES-D (modified) differentiated the two groups at probability levels of p < 0.001 and p < 0.05 respectively. The IAS—W (worry about illness) scale differentiated the two groups at a level which approached, but did not achieve, statistical significance p+0.085.
MENTAL HEALTH FOR ISOLATED POPULATIONS AND ISOLATED REGIONS—THE FLYING PSYCHOLOGIST
Williams R
Royal Flying Doctor Service of Australia, Queensland Section
In 1995 a one-year project under the National Mental Health Strategy investigated the feasibility of providing mental health services in conjunction with the Royal Flying Doctor Service. The project confirmed a need for psychological, clinical and education services to remote locations and demonstrated that such services could be provided in conjunction with the RFDS. In 1996 the RFDS (Queensland Section) created a position for a psychologist within their organisation, a first in Australia, and position responsibilities fell under the areas of education, personal support, clinical service delivery and further research.
This paper reports on initiatives under these areas focusing particularly on service delivery and the production of an interactive educational CD-ROM to teach health professionals psychological skills.
The RFDS mental health program has undergone further expansion with the employment of another psychologist to focus on clinical service provision and the commencement of a project to raise mental health literacy in rural and remote residents.
This paper explores issues and solutions to the challenge of providing mental health services to very remote locations in the Australian ‘outback’.
COMPARISON AND CONTRAST: CBT, DBT AND THE CONVERSATIONAL MODEL
Williamson M
Central Coast Mental Health Service, Gosford, NSW
Cognitive Behaviour Therapy and Dialectical Behaviour Therapy are both multimodal therapies derived from laboratory based Learning Theory modified by clinical experience and research. The Conversational Model of Hobson and Mearee (Psychodynamic Interpersonal therapy) is largely clinically derived from Self-experience and interpersonal resonance in the treatment of the severe personality disorders. It belongs to the broad field of Self-Psychology which has emerged in the last thirty years from the psychoanalytic-psychodynamic tradition. The Conversational Model is one of the most validated of all psychotherapies. This paper will compare and contrast the salient features of each model. Emerging models of Self are identified in the Cognitivist movement and seen to be implicit in Dialectical Behaviour Therapy.
CLINICAL CARE ON THE INTERNET
Yellowlees PM
Department of Psychiatry, University of Queensland; KFI Mental Health Centre, Royal Brisbane Hospital
This paper will focus on the various clinical and ethical, legal and technical issues of importance to those practitioners who wish to provide clinical services over the Internet. It will focus specifically on the Doctor Global consumer held electronic record (www.doctorglobal.com), and how this can be used as a base for Internet health service delivery. The practice of medicine over the Internet encourages a very strong consumer perspective, and is likely to have far-reaching effects within the healthcare industry during the next millennium, as health planners and providers concentrate less on bricks and more on clicks.
THE VIRTUAL DOCTOR/PATIENT RELATIONSHIP
Yellowlees PM
As e-health, particularly involving the Internet, becomes increasingly integrated into good psychiatric practice, so the doctor/patient relationship will inevitably change. Patients, increasingly empowered by good quality information, and learning how to avoid the bad, in the move away from the industrial age of medicine to the information age, will more frequently drive the relationship. Psychiatrists need to understand how to integrate electronic healthcare processes into their normal day-to-day practice, which e-health practice guidelines to use, how this form of care will impinge on traditional practices, and what are the ethical implications. The Internet will be one of the most important causes of change in the psychiatric practice over the last 100 years, bringing more of a patient focus and greater health promotion opportunities in our workplace. Psychiatrists are the ideal clinicians to exploit the new communications technologies for the benefit of patients and these approaches will not only mainstream the practice of psychiatry further into the area of general medicine, but give us the opportunity to properly teach our medical and surgical colleagues how best to integrate important psychiatric concepts, such as transference and countertransference, into their normal practice. Psychiatrists should embrace these new technologies, research their sensible application carefully and show real leadership in employing them for the common good.
Author Index
Alcorn D A1
Allcock C A1
Almeida O A1
Andrews G A1
Barnes C A1
Battersby M A2
Bhattacharyya B A2
Bickerton A A2
Bird M A3
Boulnois J A3
Chopra P A3
Christensen H A4
Clark G A4
Clarke D A4
Collings S A4
Davies J A5
De Castella A A5
De Saxe I A5
Dickerson M A5
Draper B A6
Drew L A6
D'Souza R A6, A7
Durrell A A7
Eapen V A8
Ellen S A8
Fergusson D A8
Flory V A8
Goldberg D A9
Goldney R A9
Gribble R A9
Griffiths K A9
Groom G A9
Hampshire R A10
Harding D A10
Heins T A10
Helzer JE A10
Howard S A11
Hustig H A11
Jager A A11
Janca A A11
Kaiser RH A11
Kaplan R A12
Keller A A12, A13
Kenardy J A13
Kirkby KC A13, A14
Kisely S A14, A15, A16
Kissane D A16
Kruse D A16
Kulkarni J A16
Lammersma J A16
Lampe L A17
Lam-Po-Tang J A17
Lautenschlager N A17
Lyle D A17
Lyndon RW A18
Macleod S A18
McKay RG A19
McKelvey R A19
Melding P A19
Milroy G A19
Milroy H A20
Moore K A20
Muirhead D A20
Mullen PE A20
Nothling M A21
O'Brien C A21
Parker G A21
Paterson T A21
Paton MB A21
Prager S A21
Ran M A22
Raphael B A22
Read J A22
Reichard O A23
Reutens S A23
Richards J A23
Robertson M A23
Rolfe TJ A24
Rosenman S A24
Russell J A24
Ryan E A24
Sainsbury P A25
Samuel M A25
Sara G A25
Sartorius N A25
Smith GC A25
Tatz C A26
Tobin M A26
Vance A A27
Vaughan K A27
Walter G A27
White R A28
Williams R A28
Williamson M A28
Yellowlees PM A28