Abstract
KL01 MENTAL HEALTH GLOBAL ACTION PROGRAMME OF WORLD HEALTH ORGANIZATION
Shekhar Saxena
World Health Organization (WHO) is mandated to provide global leadership and technical assistance to countries in matters related to health. Mental health is one of the priorities of WHO. In 2002 following the publication of World Health Report 2001 on mental health, WHO began the Global Action Programme (mhGAP) with the endorsement of World Health Assembly. This programme has resulted in enhancing the awareness among general public and policy makers towards mental health and has provided information, evidence and technical guidance for mental health care, especially in low and middle income countries. The phase two of mhGAP, being launched in 2007 is designed to take the agenda forward by supporting countries to scale up essential mental health services towards decreasing the treatment gap for mental disorders that remains surprisingly high. The programme has identified 8 priority disorders and conditions that cause the maximum burden and developed an intervention package for them, that is evidence based and feasible. It has also identified priority countries for implementation of the package and indicators to monitor the progress. WHO plans to develop global and country-level partnerships to generate resources necessary for mhGAP.
KL02 MENTAL HEALTH REFORM IN CHINA
Yan Jun, Yu Xin, Liu Jin
Confucianism and 5000 years history don't make Chinese immune to mental health disorders. In fact, the 1.3 billion population can amplify any, even tiny, mental health problems. However, the available resources are quite limited: there are ∼1140 mental health facilities, ∼134 thousands of beds, and ∼16383 psychiatrists to provide mental health service and this service is mainly taking place in institutions.
With strong will, powerful administration, and increasing financial resources, Chinese government can implement almost any impossible missions. The importance of mental health was gradually aware of by policy makers after the year of 2000. In April 2002, the first multi-ministry joint project established after the founding of P. R. China, the Mental Health Plan (2002–2010) was signed by the Ministry of Health, the Ministry of Security, the Ministry of Civil Affairs, and the China Disabled Person's Federation, with “government led, society attended, prevention dominated, treatment combined, focally intervened, broadly covered and legally administrated” as principles of mental health service in China. In September 2004, the Proposal on Further Strengthening Mental Health Work that had been agreed by the Ministry of Health, the Ministry of Education, the Ministry of Security, the Ministry of Civil Affairs, the Ministry of Justice, the Ministry of Finance and the China Disabled Person's Federation was transmitted in the name of the General Office of the State Council to all departments of and all institutions directly under the State Council (including the People's Congress, National Committee of the Chinese People's Political Consultative Conference, the Supreme Court and the military), and to provincial governments. This Proposal is regarded as the mental health policy in China.
There are almost no ideal model of delivery of mental health service in this world we can copy to use for such a huge population, but the reforms having taken place in some other countries do give China many inspirations. A bilateral international collaboration was firstly set up between Peking University and Melbourne University. The biggest challenge was how to change the “hospital centered mental health service” to the “patient centered” one. The reform began with a national mental health project: a community mental health program was conducted in 60 demonstration areas in 30 provinces, funded by Ministry of Finance. In 2005, it was only a training program for mental health human resources, particularly in communities; in 2006, it was an intervention program for the patients with violence or risk of violence, including community case management, crisis intervention, emergent hospitalization, etc. until now, over 6000 patients are recruited into this program and more patients are under medical supervision.
China is changing in every aspect and the speed of change is faster than expected. Although mental health reform has taken place in many countries, China still needs to find its own way to solve its unique problems. In this difficult, sometimes painful reform process, international collaboration can play a crucial role and this collaboration will not only benefit China, but its partners as well.
KL03 FAMILY WORK IN MENTAL HEALTH CARE: CURRENT STATUS AND FUTURE CHALLENGES
Gráinne Fadden
The evidence for the effectiveness of family work has been available for over thirty years and has been built on over the past three decades. Psychoeducational family approaches are among the most robust in mental health, a fact confirmed in numerous meta-analyses and reviews.
There are different approaches to helping families including individual family work, multi-family groups, relatives support group and self-help programmes organised through family groups. However, many clinicians are unfamiliar with the evidence in relation to which approaches have what effects or benefits for families. There is often confusion, for example, about whether or not the service user needs to be involved in the family sessions in order for the approach to be effective.
There have been recent welcome innovations in many mental health services whereby family members play key influential roles in shaping service developments through participating in interview panels, training and planning committees. Some services employ family members as Carer Consultants.
In spite of these developments and the strong evidence-base, family work worldwide is proving difficult to implement in a consistent manner. There are pockets of excellent practice. There are other areas where family work is implemented for a while, then slips when an innovator or committed advocate leaves the service. There are particular difficulties in the developing world. The current situation is that family approaches are not available on a widespread basis, and clinicians and teams struggle to implement family work more than they do with individual therapies. The reasons for this will be outlined in the presentation.
The main challenge is how to have family services available at the point of contact whether that is a crisis team, a community team, assertive outreach team or inpatient services. The developing countries present different challenges.
In her presentation, Dr Fadden will discuss the current status of family work, what the main obstacles to implementation are, and how to overcome them into the future. She will draw on examples from different parts of the world.
KL04 MENTAL HEALTH AND HUMAN RIGHTS–AN INDIGENOUS AUSTRALIAN PERSPECTIVE
Tom Calma
Abstract not available at the time of printing.
KL05 OUTCOMES OF MODERN TREATMENTS IN SCHIZOPHRENIA
Wolfgang Fleischhacker
Abstract not available at the time of printing.
KL06 EARLY INTERVENTION IN PSYCHOTIC AND MOOD DISORDERS IN YOUNG PEOPLE
Patrick McGorry
Mental and substance use disorders are among the most important health issues facing society. They are by far the key health issue for young people in the teenage years and early twenties, and if they persist, they constrain, distress and disable for decades. Epidemiological data indicate that 75% of people suffering from an adult-type psychiatric disorder have an age of onset by 24 years of age, with the onset for most of these disorders – notably psychotic, mood, personality, eating and substance use disorders– mainly falling into a relatively discrete time band from the early teens up until the mid 20s, reaching a peak in the early twenties.
In recent years, a worldwide focus on the early stages of psychotic disorders has improved the prospects for understanding these complex disorders and improving their short term and longer term outcomes. This reform paradigm has also illustrated how a staging model may assist in interpreting and utilising biological data and refining diagnosis and treatment selection. There may be broader lessons for psychiatric research and treatment, particularly in the field of mood disorders. This brief overview will focus on the need for a new approach to youth mental health with special emphasis on psychotic and severe mood disorders. The contribution of Australian research to this process will be highlighted.
KL07 PREVENTION OF PTSD BY EARLY TREATMENT: JERUSALEM SYSTEMATIC OUTREACH STUDY
Arieh Shalev
Because it has salient onset and typical early symptoms post-traumatic stress disorder (PTSD) should be a target for preventive interventions. However, in recent disasters, terrorist attacks and wars prevention was marginally efficient. Data on comprehensive prevention programs is missing, and thus the efficiency of early intervention is unknown. This presentation discusses the design, the implementation, and the outcome of a systematic outreach program for trauma survivors in Jerusalem. About 8200 trauma survivors were screened for early symptoms, 5300 were interviewed by telephone, within days of a traumatic event, 750 were assessed by clinicians, and treatment was recommended to over 400 among them and started within four weeks of the traumatic event. The study compares twelve weeks of cognitive behavioral therapy (CBT), cognitive therapy, escitalopram, placebo and waitlist control on symptom severity and prevalence of PTSD at the end of treatment, and four- and 14 months later. It also compares early and late CBT – the latter being administered to the waitlist control group about four months from the traumatic event. The results show a short- and long-term efficacy of trauma–focused early therapies and moderate differences between early and late CBT. They also teach us about subjects’ willingness to engage in clinical contacts and start an early treatment, on subjects’ acceptance of specific treatment modalities, on the long-term effect of declining help, and on the error term of interviewers and therapists’ early diagnoses and prediction. A systematic outreach is feasible, has a reasonable cost, and reduces the rates of PTSD in survivors at high risk for developing the disorder.
KL08 FROM CONSULTATION-LIAISON PSYCHIATRY TO MULTIPLE AND COMPLEX NEEDS
Graeme Smith
Behind the term consultation-liaison psychiatry (CLP), a name coined in North America, lies a complicated and conflicted history that is ongoing and is played out in different ways in different countries under different names such as “psychological medicine”, “psychosomatics”, “general hospital psychiatry”, “psychosomatic psychiatry”, “psychiatry of the medically ill”, and “liaison psychiatry”. These expressions represent attempts to name the target clinical problem or population, or the way and place in which service is delivered. The unresolved problem of terminology reflects the conflict about the relationship of mind and body, of physical and psychiatric symptoms, and about how this interface should be addressed. The problem is reflected in the varying degrees to which the field has achieved specialty status, and also the variations in the extent to which psychiatry training programs require exposure to CLP. The same tensions and diversity are seen in nursing and psychology, and the degree of integration of all disciplines in service teams varies enormously.
Whatever CLP services are called, their target population is large. Mental health censuses have established that physical/psychiatric comorbidity and somatisation, the things in which CLP specialises, are the commonest forms of psychiatric presentation in the community. Complex presentations of all types are becoming the norm in medical practice. This rapidly changing nature of patient presentation, both in hospital and in the community, has forced a change in the delivery of medical care and in turn has influenced the way in which CLP services are constructed. The focus now is on complexity of both presentation and care.
While it may appear that integrated care of those with complex illness is a self-evident necessity whose proper application will result in better health outcomes achieved as economically as possible, uncritical application of integrated interventions for which there was apparently good research evidence has produced disappointing results. This has prompted health care providers and theorists to revisit the underlying concepts and methodologies used. The result is a call for more rigorous theory, and more rigorous testing of implementation in the clinical setting. There is a realisation that the complexity of both the presentation and the intervention is such that existing methods of study need to be complemented by in-depth exploration using non-traditional methods including qualitative ones. Recent developments in theoretical constructs give promise of better answers to the question, “what works for whom in what context?” This gives CL psychiatrists, psychologists and nurses a new opportunity to show their expertise in the biopsychological approach. In Europe such practitioners have been able to do what Engel did not; they have operationalised the biopsychological model and tested its validity in the care of complex patients. Others in the field are working with systems theory models which accept that in complexity, the scientific method needs to be complemented by chaos theory. CL psychiatrists have known this for a long time, and are now finding a new way of inserting themselves into the mind/body split. CLP is moving towards becoming a specialty of expertise on multiple and complex needs.
KL09 NEW PERSPECTIVES ON INTERNATIONAL CLASSIFICATION AND DIAGNOSIS
Juan Mezzich
Abstract not available at the time of printing.
KL10 GLOBALISATION AND PSYCHIATRY
Norman Sartorius
Globalization has powerful effects on all societies and on medicine, including psychiatry. The lecture will examine these effects and draw conclusions about the changes that are likely to happen in the organization and provision of mental health care. It will also address the steps that psychiatry should take to make the most of globalization and increase its value to social development.
KL11 EPIDEMIOLOGY OF AGEING AND DEMENTIA IN LOW AND MIDDLE INCOME COUNTRIES – THE 10/66 POPULATION-BASED STUDIES
Martin Prince
KL12 PATIENT CENTRED CARE IN AGED MENTAL HEALTH: DREAM, DELUSION OR DILEMMA?
Pamela Melding
Governments all over the world are promoting the concept of Patient Centred Care. Intuitively, this ideology seems right to many people and especially to patients who feel disenfranchised by health systems. But is patient centred care a current reality in Psychiatry of Old Age? Are systems moving towards this concept? The evidence that patients are at the centre of their own health care is lacking. There is very little evidence that elderly patient views are taken into consideration in designing health services or making decisions. International studies show that there is still a long way to go.
Services may feel committed to patient centred care and believe this is what they do but when dealing with the hard dilemmas of clinical reality the practice of patient centred care as the patient would wish it, may be very difficult indeed. Evidence is obviously important in decision making but can be difficult in social situations e.g. whether to place an elderly person in a rest home or not or prevent premature discharge, when decisions are made more on opinion and values than evidence. A internet decision making tool “The Values Exchange” can be used to collect the opinions and values of a variety of clinicians, consumers and other stakeholders on some classical dilemmas of psychiatry of old age to assist in making informed decisions. If we are to have real patient centred care in aged psychiatry there are some challenges ahead!
KL13 UPDATE ON COGNITIVE TREATMENTS: FROM THEORY TO APPLICATION
Paul Salkovskis
Cognitive-behavioural treatments are now the treatment of choice for most common mental health problems. The reasons for the progression of this rapidly evolving approach from a much derided newcomer to the field to its present dominant position are briefly considered. These include (i) The emphasis on the importance of empirical grounding in (continuing) treatment development and the requirement for an evidence base in clinical practice (ii) an emphasis on “normalizing” the patients’ experience and enabling the person to choose to change rather than treating their disease (iii) the way that CBT allows therapy to be both time limited and structured yet highly flexible in application and (iv) the acknowledgement of specificity linked to, but going beyond, diagnostic categories.
The theory and application of CBT is presented as a delicate balance between clinical art and clinical science. The way in which the interaction between theory, research and practice can be used to help people to rid themselves of psychiatric problems will be illustrated drawing upon clinical examples in anxiety disorders. This section of the presentation will seek to identify the way in which carefully focused techniques can be applied in a non-prescriptive way to maximize therapy efficiency and reduce the likelihood of problems. Although this presentation is necessarily brief, the issue of the treatment of “complex problems” (including personality disorders) will be briefly addressed.
Promising future directions for research are also explored; it is suggested that the emphasis now needs to be placed on the importance of developing and implementing strategies which will be effective in reducing the prevalence of common psychiatric disorders.
KL14 PARTNERSHIPS FORMING INNOVATIVE PRACTICES IN MENTAL HEALTH SERVICE DELIVERY IN AUSTRALIA
Lyn Littlefield
The Australian Government has recently expended considerable effort and funding on the establishment of major initiatives that facilitate mental health professionals using a team-based approach to offer services to Australians with mental health problems. The aim is to provide increased, affordable access for the large number of mental health consumers who would benefit from services from Psychologists, Psychiatrists and Mental Health Nurses complementing the roles of General Practitioners in the primary care system. The concepts and system parameters involved in the ‘Better Outcomes in Mental Health Care’ and the ‘Better Access to Mental Health Care’ Initiatives will be described, followed by an overview of their implementation and amount of uptake by both mental health professionals and consumers. The success of these very innovative initiatives delivered across Australia and the challenges in their establishment and implementation will be discussed. The contribution of the recently formed Mental Health Professionals Association, comprising the Royal Australian and New Zealand College of Psychiatry, the Royal Australian College of General Practice, the Australian Psychological Society and the Australian College of Mental Health Nursing, as a unique body facilitating the major mental health professions working together to develop and deliver interdisciplinary training at local level across Australia will be highlighted to show the potential benefits of the team-based approach to mental health service delivery.
KL15 CHANGING THE WORLD: COMPREHENSIVE CONTINUOUS INTEGRATED SYSTEMS OF CARE FOR MENTAL HEALTH AND SUBSTANCE DISORDERS
Kenneth Minkoff
Individuals with co-occurring disorders are associated with poor outcomes and high costs throughout the service system yet have been traditionally defined as “misfits” rather than priorities within all systems of care. Recently, the United States SAMHSA has begun to make system strategies to address the needs of these individuals a priority, and has funded system incentive grants (COSIG) in seventeen states to create system change to support integrated treatment. System development activities have also begun to take place in a variety of Canadian provinces, including Manitoba, British Columbia, and Ontario. This presentation reviews examples of systems difficulties faced by individuals with co-occurring psychiatric and substance disorders in public and private settings, and identifies research based principles of successful treatment intervention for these individuals in the context of a parallel disease and recovery integrated conceptual framework that uses a common language that makes sense from the perspective of both the addiction field and the mental health field. The presentation then illustrates the application of these principles to the design of a strategy for the resolution of these systems difficulties through the development of a comprehensive, continuous, integrated system of care (CCISC) for psychiatric and substance disorders that maximizes use of all existing resources to initiate integrated treatment, and develops expectations that all programs achieve Dual Diagnosis Capability to provide properly matched services within existing resources to the individuals with cod that they already are serving. This model is recognized by SAMHSA as a best practice, and is being utilized in 14 of the seventeen COSIG states.
The workshop discussion then illustrates a systematic process for implementing this model, building on work in over 30 states and three Canadian provinces, utilizing simultaneous interventions at the system, program, clinical practice, and clinician levels, and reports on progress of various system changing initiatives from different parts of the US and Canada.
To identify eight principles of evidence based treatment intervention upon which to base the design of a comprehensive, continuous, integrated system of care. To describe the components of a CCISC, and discuss the application of these concepts in Australia. To identify funding strategies to maximize use of existing resources for developing Dual Diagnosis Capable treatment of dual diagnosis. To delineate potential change strategies in Australia at the federal, state, program, clinical practice, and clinician competency levels to implement a CCISC at any level of the system.
KL16 METHAMPHETAMINE INDUCED PSYCHOSIS
Robert Ali
Amphetamines were first used extensively for both therapeutic and non medical purposes during World War II and in the post reconstruction period. As their use became more widespread, a public health problem. Along with the global escalation of misuse of illicit drugs during the last few decades, misuse of amphetamines is persisting, spreading to previously unaffected countries, and revived in countries where it was once brought under control.
Methamphetamine use is associated with a range of serious adverse health effects, including neurotoxicity, cognitive impairment, cardiovascular pathology serious risk of contracting HIV and psychiatric sequelae. The extent and risk of these harms is related to how the drug is taken. Previous research found that rapid routes of administration such as injecting and smoking methamphetamine are more likely to cause dependence, poor physical health, psychological distress and crime.
Psychiatric symptoms are common among methamphetamine users. Almost half of a sample of current users were diagnosed or treated for a mental health problem and these problems had occurred commonly after the commencement of regular amphetamine use. A recent study of regular methamphetamine users found that 13% screened positive for psychosis. Methamphetamine users who were dependent on the drug were three times more likely to have experienced psychotic symptoms than non-dependent methamphetamine users.
Methamphetamine psychosis is perhaps the most concerning aspect of the current methamphetamine situation. Methamphetamine use can induce a brief toxic psychosis characterised by persecutory delusions and hallucinations. Other manifestations of psychosis can include stereotyped repetitive behaviour, disorganised speech and illogical tangential thoughts. Presentations often involve severe agitation, can require chemical and physical restraint, and in some cases, police intervention. Symptoms typically last hours to days and then subside. In some instances however, symptoms run a more chronic course lasting up to several months and recur in the absence of drug intoxication.
There is little empirical evidence on which to base treatment approaches for methamphetamine induced psychosis. Most published evidence consists of case reports or small open label studies. Treatment guidelines based on best available current evidence and expert opinion will be presented.
KL17 PSYCHIATRIC NURSING WORKFORCE IN THE UNITED STATES
Barbara Drew
The primary purpose of this presentation is to describe the demographics, education, and practice of psychiatric mental health (PMH) registered nurses in the United States. While I will include a description of RNs without advanced degrees, the focus of the presentation will be on the findings of a survey of certified PMH advanced practice registered nurses (APRNs). The survey was conducted during March, 2007 by a task force that was formed by the American Psychiatric Nurses Association and the International Society of Psychiatric Nursing. The American Nurses Credentialing Center provided the task force with the email addresses of 6,184 certified PMH APRNs; approximately 1,605 emails bounced back. We had 2010 respondents with 1899 providing usable data, effectively resulting in a 41% response rate. The data provide the most comprehensive information about PMH APN practice in the U.S. to date. I will also briefly address particular challenges to the practice of PMH nursing in the U.S. including: aging of the nursing workforce, confusion regarding the Clinical Nurse Specialist and Nurse Practictioner roles, shortages of providers of mental health services to particular populations, and variations in regulation of practice across states. Some of these difficulties likely resonate with experiences in other countries; others may be unique to the U.S.
KL18 CHALLENGES, POLITICS AND PARTNERSHIPS TO IMPROVE MENTAL HEALTH CARE – IT IS ABOUT STEPPING UP AND BEING PART OF THE SOLUTION
Frances Hughes
There are challenges in mental health; important to this is the ability to translate those challenges into viable sustainable solutions. This requires an understanding of working in different ways, relationships and partnerships are key to successful strategies to address mental health in the future.
Frances will use her own experience and research to describe the linkages between politics, partnerships and health care this will include her work internationally within the pacific as the WHO Pacific Island Mental Health Network facilitator, doctoral research-political case study and her practice as a mental health nurse in a NGO- community mental health service in New Zealand.
Opportunity to connect with policy will make us more effective with the ultimate goal being to improve the health of our nations. Clinicians inherently have a vast amount of skill and experience which can be brought to the policy arena. However, many of these opportunities have been missed. We need to realise the importance of their involvement in engaging with policy. To do so will give the power to really change things, ultimate goal of course is to contribute to strategies that improve the health of our nations.
KL19 THE WORLD'S CHILDREN – ADVOCACY FOR CHILDREN'S RIGHTS AND MENTAL HEALTH
Louise Newman
Many of the worlds’ children experience chronic poverty, deprivation and trauma. Child abuse and maltreatment is a global phenomena of unknown magnitude and frequently coexists with community violence and breakdown, The social and economic risk factors associated with mental disorder and developmental problems are particularly relevant when we look at global patterns of disorder in children and this reflects the vulnerability of children to biological and psychological adversity and their exclusion from social and political participation. The rights of children espoused by the United Nations Convention on the Rights of the Child remain elusive in the majority of nations.
Responses to children and families seeking asylum exemplify the risks to children and the need for professionals to continue to advocate for the rights of the child. The Australian experience of detention of children and families seeking asylum and experiencing trauma has raised serious ethical and political issues and highlights the need to consider a humane response to the problem of the worlds dispossessed.
Abuse and maltreatment of children remains at once one the most significant contributing factors to the burden of mental disorders, and also the least addressed in terms of preventive strategies and interventions. Mental health professionals have a crucial role in advocating for the rights of children and vulnerable families and communities.
KL20 THE NEURODEVELOPMENTAL IMPACT OF TRAUMA AND NEGLECT IN CHILDHOOD
Bruce Perry
The development of a child is profoundly influenced by experience. Adverse experiences such as abuse, neglect or exposure to violence can shape the organization of the brain which, in turn, influences the capacity of the brain to help a child think, act, behave and feel. The influence of any experience – traumatic, adverse, therapeutic or educational – depends upon the age of the individual. The impact of any event is likely to be most profound on the systems in the brain which are most rapidly developing. Therefore, depending upon the specific time in development that the traumatic event takes place as well as the specific nature of adverse experience, a range of problems can arise; including delayed development to impulsivity to severe emotional problems. Understanding the origins of these problems and how they can be identified and addressed is one of the major challenges for clinicians working with maltreated and traumatized children. This presentation will describes the development and implementation of an assessment, staffing and intervention approach coined the Neurosequential Model of Therapeutics used by The Child Trauma Academy and its partners when working with traumatized and maltreated children.
KL21 CONFLICTS OF INTERESTS IN PSYCHIATRIC RESEARCH AND PRACTICE
Mario Maj
A conflict of interests occurs when a professional (e.g., a physician) is unduly influenced by a secondary interest (e.g., financial gain, political commitment, or the desire to favour a relative or friend) in his decisions concerning the primary interest to which he is committed (e.g., the health of the patients, the progress of science or the education of students). Since the early 1980s, one specific type of conflicts of interests has been extensively covered in the medical literature, i.e., the financial conflict of interests (conflict between the primary interest represented by the health of the patients or the progress of science and the secondary interest represented by financial gain). This type of conflict of interests has been largely discussed and documented also in the field of psychiatry. The many, sometimes subtle, ways by which a psychiatrist can be influenced in his prescribing habits by his relationships with drug companies, or a researcher can be influenced by these relationships in his scientific activity, have been described, with the support of some empirical evidence. Several possible remedies to this problem have been proposed, including disclosure of potential conflicts and the adoption of a code of conduct by both physicians and drug companies. On the other hand, it has been pointed out that the current discussion on this issue is “affectively charged”, that the pharmaceutical industry is virtually the only source of development of new therapeutic agents, and that as far as these agents are effective there is an obvious convergence of interests between psychiatrists, companies, patients and patients’ families. Other types of conflicts of interests are beginning now to be discussed. There is emerging evidence concerning how the allegiance to a treatment modality (in particular, a psychotherapy or a psychosocial intervention) may influence the results of empirical studies concerning that treatment, thus colliding with the primary interest of validity of research. There is also a small body of literature concerning political commitment as a source of conflict of interests. The issue of conflicts of interests in psychiatry is probably more complex and multifaceted than commonly believed.
KL22 PSYCHIATRISTS SHOULD NOT CONSULT ON THE INTERROGATION OF DETAINEES
Steven Sharfstein
In May 2006, the American Psychiatric Association passed a position statement that stated, “No psychiatrist should participate directly in the interrogation of person held in custody by military or civilian investigative or law enforcement authorities whether in the United States or elsewhere. Direct participation includes being present in the interrogation room, asking or suggesting questions or advising authorities on the use of specific techniques of interrogation with particular detainees.” This position statement was prompted by ethical concerns about detainees being held in Guantanamo Bay, Cuba, and the role of physicians on Behavioral Science Consultations Teams (so called “Biscuit” teams) in consulting with authorities on proper interrogation techniques. The position statement elaborated on a long-standing APA ethical position against torture. This paper will elaborate on a physician psychiatrist's duties to “do no harm” and “to alleviate suffering.” It will also expand the concept to include the type of interrogations that have occurred in Guantanamo, Cuba, and elsewhere as contrary to our ethical core. We must respect human rights and dignity in this unprecedented era of the “War on Terror.”
KL23 TOLKEIN II: A MODEL OF COST-EFFECTIVE MENTAL HEALTH TREATMENT
Gavin Andrews and the Tolkien Team
KL24 WHAT IS PSYCHOSIS: TRACKING ITS ONTOGENY AND THE ROLE OF THE ENVIRONMENT
Jim van Os
There is exciting new evidence that first episode schizophrenia may be conceived as the outcome of an adolescent developmental trajectory and, more proximal to the onset, of subclinical psychotic experiences that precede the clinical syndrome. The epidemiology of schizophrenia consequently is focusing more and more on stages of pre-schizophrenia in the general population, and strategies for following and understanding its course. However, still very little is known about the social, cognitive and genetic parameters of early subclinical psychotic experiences. We will discuss data showing that the onset of psychosis may be productively conceptualized as the abnormal persistence and deterioration of a normal, developmental expression of psychosis in the general population. The factors involved in producing an abnormal persistence can be traced so cognitive-attributional processes and gene-environment interactions.
KL25 MENTAL HEALTH CARE AND POLICY DEVELOPMENT IN DEVELOPING COUNTRIES: REDEFINING THE ROLE OF SPECIALIST
Vikram Patel
The recent Lancet Series on Global Mental Health and population based studies in developing countries clearly demonstrate a massive treatment gap for mental disorders in these countries. At the same time, there is a severe shortage of mental health resources and, at the current rate of training mental health specialists, there is no prospect of meeting mental health care provider needs in any developing country for the foreseeable future. In this lecture, I propose that there is a need for radical review of the role of mental health specialists in mental health care in developing countries and, indeed, in low resource settings in developed countries as well. There is an urgent need to focus on ‘task-shifting’ where most direct service provision is handed over to non-specialist health workers, including lay persons in the community. There is burgeoning evidence that such task-shifting is an effective model for treatment of mental disorders, provided the non-specialist health workers are given adequate training and supervision. This lecture will consider some of this recent evidence and consider the implications for redefining the role of specialists from predominantly providing services to four specific roles: first, as trainers for a new generation of health practitioners of diverse backgrounds; second, supervision and support to community and primary health care teams; third, to carry out research in the priority mental health research areas for the region; and finally, of being an advocate to raise the public profile of mental illness and the rights of the mentally ill. Aping a model of care which relies on enormous human and financial resources will not only be unfeasible for the foreseeable future, nor is it affordable or necessarily more effective than low-cost community and primary care models. Policy development in mental health care in developing countries will need to reinforce this radically different view of the primary role of mental health specialists as their training will need to go beyond clinical care and cover the skills needed to be effective trainers, supervisors, researchers and advocates.
KL26 THE GROWING DEPRESSION EPIDEMIC – WHAT DOES IT MEAN FOR PRIMARY CARE?
Tony Kendrick
‘Depression will become the second leading cause of disability worldwide by 2020’. ‘World Health Organisation says 30% of people will be depressed by 2010’. ‘Call for action on depression epidemic’.
Headlines like these reflect the perception that depression is an increasingly prevalent and pressing problem in both developed and developing countries. In the USA the prevalence of major depression has apparently doubled, and mental health outpatient attendances have tripled, within a decade. World wide, the projected levels of depression pose an enormous challenge to primary care, as specialist mental health services could never hope to tackle the problem, even in the richest countries.
Finally, the author will raise the question of what practitioners can do to help prevent depression through mental health promotion and lobbying for social change.
KL27 DOMESTIC VIOLENCE THE HIDDEN EPIDEMIC: IMPLICATIONS FOR PIMARY AND MENTAL HEALTH CARE
Kelsey Hegarty
Intimate partner violence and abuse is a common hidden problem for women presenting to primary care and mental health care. It is as common as asthma, diabetes or depression but has not received the same amount of attention in education, research, practice or policy. Women who experience Intimate partner abuse are more likely to experience mental and physical health symptoms and diagnoses. It is a major cause of morbidity and mortality in the Australian community. Only recently has attention been paid in community campaigns to violence against women. In clinical settings it still receives very little attention, even compared with child abuse.
Utilising literature reviews and data from several studies this presentation will discuss this major public health issue for women in the Australian community. In particular, it will describe how common it is in clinical practice and the association between intimate partner abuse and mental and physical health in women attending primary care and mental health care. This part is straightforward, what is not as clear is how health practitioners should be responding to this hidden epidemic. Should we be screening all women? How should we be asking women? Should we be asking men? How should we respond if women disclose intimate partner abuse? Who else should be involved in the care? How do we keep women and children safe? What evidence do we need in this under researched area?
These questions and more will be discussed and women's expectations and experiences of care will be highlighted. In particular, how to respond to women before disclosure, at disclosure and afterwards. Women who have been abused show enormous strength and resilience on their varied pathways to recovery. Health practitioners need to be alert to this underlying psychosocial issue that causes significant health issues for many women who they see on a day to day basis. The hidden epidemic has to be addressed if we are to ensure children grow up in safe and non violent households.
KL28 SUICIDE PREVENTION STATE OF THE ART: AN INTERNATIONAL PERSPECTIVE
Diego De Leo
This presentation will examine international suicide trends, highlighting issues involved with death certification procedures and their impact on published figures. Countries with operating national strategies will be examined in details, with emphasis on possible associations between current suicide rate evolution and implementation of suicide prevention strategies. Recent advances from studies will also be discussed and their potential implications for wider implementation commented. Indications from large co-operative international efforts will be central to the presentation, together with the description of the main features of the new World Health Organization effort in the Western Pacific Region: the START Study (Suicide Trends in At-Risk Territories). Special emphasis will be paid to the numerous socio-cultural influences on suicidal behaviours.
KL29 COMMUNITY RESPONSE TO SUICIDE PREVENTION
Lakeshmi Vijayakumar
Suicide prevention strategies in developing countries like India are at a nascent stage of evolution, hampered by inadequate human and economic resources for mental health services. Hence community response to initiatives and interventions play a crucial role in suicide prevention. The work of Sneha in increasing awareness about suicide in the community, identifying those at risk and initiating culturally appropriate and cost effective strategies will be discussed.
Volunteers, professionals and community gatekeepers collaborated to design the interventions which were initiated in Srinivasapuram, a coastal hamlet devastated by tsunami. An intervention program for the children (n=65) revealed that children in the intervention group expressed positive emotions (F = 8.044, p = 0.005) and were more likely to desist from smoking (F = 6.102 p = 0.003) than controls (n=70). In a non-randomized control design the usefulness of volunteer delivered befriending sessions for the bereaved was assessed. A significant association between intervention and improvement in BDI (adjusted B (SE)):−.53 (2.44) p = 0.000 and GHQ adjusted B (SE): −.52 (1.81) p −0.001 was found. Suicidal attempts were also significantly reduced following intervention.
Reduction of suicidal behaviour can be achieved by commitment and collaboration of the community.