Regular Symposia

RS01 GRADUATE PSYCHIATRIC TRAINING: AN ASIAN PERSPECTIVE

Pedro Ruiz, Mario Maj, Ken Kirby, Parameshvara Deva, Mitsumoto Sato, Bruce Singh

The World Psychiatric Association (WPA) took up itself in the late 1990s the initiative to plan, design, and implemented an institutional program on the subject of a “Core Postgraduate Training Curriculum in Psychiatry”. The conceptualization of this program grew from the realization that educational institutions dedicated to the training of graduate residents in psychiatry were not meeting the unique and current needs that existed, from a training and psychiatric care point of view, in many areas or regions of the world. It was also obvious that educational institutions in some parts of the world lacked the technical skills and professional manpower to entertain curriculum changes along these lines. Over five years has passed since this WPA postgraduate training curriculum was introduced to the field during the XII World Congress of Psychiatry held in Yokohama, Japan, in August 2002.

In this symposium, we will address the current problems and needs that exist today with respect to the training of psychiatric residents in Asia, as well as the psychiatric care implementations derived from still existing problems in this very relevant educational area in the field of psychiatry. Potential solutions will also be presented and discussed. Hopefully, fully, this symposium will help to improve the psychiatric education and the quality of psychiatric care currently offered in Asia.

RS02 BROAD BASES FOR INTERNATIONAL CLASSIFICATION AND DIAGNOSIS: TOWARDS A GLOBAL CONSORTIUM OF NATIONAL GROUPS

Ihsan Salloum, Juan Mezzich, Javier Saavedra, Michael Botbol, Miguel Jorge, Yan Feng Chan

Psychiatric diagnosis and classification is an essential tool of our profession to be able to communicate, educate our colleagues, conduct research, and advance our field. Thus, the broadest possible participation in this process is crucial to our profession and ultimately to be able to provide the best possible care for our patients. Future classification and diagnostic models fully reflective of the wide spectrum of needs, realities, and cultures, requires the broadest and full engagement of our profession throughout the world. Fundamental to achieving our goals, is the development of both, the best nosological system available, and the application of the most clinically useful diagnostic model. Beyond the active participation of our membership and the active collaboration with the WPA Scientific Sections and Institutions, engagement of WPA member societies, national, regional, and international organizations and other stakeholders is essential to achieving that goal. The aim of this symposium is to present the emerging global network on psychiatric diagnosis and classification and to outline, from various perspectives around the world, fundamental contemporary issues in classification and diagnosis of psychiatric disorders.

THE WPA CLASSIFICATION SECTION AND THE COORDINATION OF THE GLOBAL CONSORTIUM

Ihsan Salloum

AMERICAS PERSPECTIVES

Javier Saavedra

EUROPEAN PERSPECTIVES

Michael Botbol

THE ROLE OF THE WPA SCIENTIFIC SECTIONS

Miguel Jorge

ASIAN PERSPECTIVES

Yan Feng Chan

RS03 PSYCHOTHERAPY SECTION SYMPOSIUM: EVOLUTIONARY PSYCHIATRY: FINDING THE FUTURE IN THE PAST

Daniel R. Wilson, Gary Galambos, Rovert Kaplan

This Symposium has been endorsed by the WPA Psychotherapy Section as an official activity.

Context: Evolutionary psychiatry can bridge the gap between neuroscience, psychiatry and psychotherapy. These papers show how evolutionary models may allow this to occur. That pathology might have adaptive traits with evolutionary survival value is not widely appreciated in conventional medicine. Within medicine itself, psychiatry and related studies – until quite recently – have remained almost wholly unenlightened by the evolutionary perspective. Certainly the sway of rather unreconstructed Freudian concepts long endured, but it is more accurately the corrective force of genetically informed neuroscience that has moved psychiatry forward more recently.

Objectives: This Symposium will explore how the evolutionary perspective, merging Freudian and biological psychiatry, is beginning to shed light on both proximal and ultimate causes of diverse psychopathology, with implications ranging from molecular genomics to clinical psychotherapy.

Key messages: With this, Darwinism is now situated to capture the more direct attention of physicians, psychiatrists and biomedical researchers. Darwinian perspectives move both psychodynamic and biological psychiatry toward enhanced understanding human behavior in its boundaries with disease, its adaptive roles and therapeutic potentials that therein lie.

Conclusion: However, much current evolutionary psychology is overly (1) dependent on theoretic inference, (2) derivative of the far more proximal mechanisms of social psychology, and/or (3) lacking in empirical evidence, particularly related to genes & brains. This symposium reviews empirical evolutionary epidemiology pertinent to neuropsychiatry, with particular emphasis on affective and psychotic disorders.

A USABLE EVOLUTIONARY CLASSIFICATION SYSTEM FOR MENTAL DISORDERS

Gary Galambos

Aims: It is proposed in this paper that incorporating evolutionary models of mental order and disorder is essential to an upgraded psychiatric classificatory system, to bridge the gaps left by DSM, the four standard methods explaining mental disorders implicit in contemporary psychiatry (disease, dimensional, behavioural and life-story perspectives) and the biopsychosocial (BPS) model. Evolutionary models examine ‘why’ we are susceptible to developing maladaptive mental and behavioural phenomena, rather than focusing on ‘what’ has gone wrong and ‘how’, and thus avoid reductionism and over-simplification.

Methods: Deficiencies in the existing models (DSM and the biopsychosocial) are revealed. Evolutionary models of mental disorder proposed by evolutionary psychologists and psychiatrists are examined. Then an evolutionarily-based classificatory system is unveiled, which aims to be a pragmatic upgrade to the biopsychosocial model: “The Malfunction-Dysregulation-Asocialisation (MDA) Model”. Disorders of Malfunction result from localised or non-localised cerebral dysconnectivity due to genetic vulnerability and/or injuries of the developing central nervous system. Disorders of Dysregulation result from dysregulation of normal brain mechanisms leading to failure to achieve specific biosocial goals of the entire organism. Disorders of Sociability are characterised by behaviours that are deviant from the individual's community but are adaptive for their genes. Natural Selection is argued to have equipped homo sapiens with lifespan-specific archetypal propensities to navigate biosocial imperatives that facilitate inclusive fitness. Organism-specific archetypal disruption is grouped alongside the three general evolutionary explanations to increase specificity by identifying functional impairment caused by the disorder. Some common DSM-IV mental disorders are test driven using the DSM-MDA evolutionary classification system to demonstrate the benefits of the system for both reliability and concept validity.

Results: The MDA model places DSM disorders and the BPS model within an evolutionary framework. The model maintains a BPS framework to make the evolution from an atheoretical to a theoretical classification system easier and avoids the Descartian dualism inherent in BPS model and DSM. “Malfunction” correlates with “Bio”, “Dysfunction” with “Psycho” and “Sociability” with “Socio-cultural”. It is proposed that each DSM disorder may have more than one possible aetiological basis.

Conclusions: The MDA evolutionary classification system permits maintenance of DSM-IV diagnostic reliability whilst gaining the benefit of concept validity.

ORIGIN OF HUMAN NATURE: LATERALITY, SCHIZOPHRENIA AND THE SHAMANIC STATE

Robert M. Kaplan

Context: The Speciation Event is now dated to 200 000 years (200 ky). However the behaviour we would recognise as typical of ‘modern’ humans arose in Africa during the Middle Stone Age, circa 200–50 ky.

Objectives: This paper examines neurological changes that evolved in order for the brain of homo sapiens to become recognisably modern. Postulated changes arose from a mutation on X/Y chromosomes, leading to variable degrees of lateralisation of the brain.

Key messages: A lateral shift of the brain, causing a right-left torque, with significant expansion in the left temporo-occipital region, allowed the development of language, the manifestation of symbolism. The first evidence of use of language is the use of complex stone tools, and spiritual and religious activities manifesting in rock art and bone engraving. Demography and neuropathology of schizophrenia provide a valuable insight into the origin and cause, not only of the illness, but the essential creative, spiritual and artistic nature of humans. A number of studies link schizophrenia, schizotypy and increased creativity with decreased left/increased right hemisphere dominance. This shows that schizophrenia is not an illness of humans, but perhaps THE illness of humans.

Conclusions: Hunter-gatherer shamanism attests to the universal tendency of humans to extend the boundary of the self while in an altered state of consciousness (ASC). The phenomena of hunter-gatherer shamans is a human constant, arising from the substrate of the brain. The majority of shamanic individuals are normal in that they do not have neuropsychiatric disorders. The phenomena that are intrinsic to shamanism reveals how critical a factor it was in hunter-gatherer life as a prelude to the development of a settled society.

EVOLUTIONARY EPIDEMIOLOGY IN NEUROPSYCHIATRY

Daniel R. Wilson

Context: Much current evolutionary psychology is overly (1) dependent on theoretic inference, (2) derivative of the far more proximal mechanisms of social psychology, (3) lacking in empirical evidence, particularly related to genes & brains.

Objectives: To further consider implications deriving from evolutionary epidemiological neuropsychiatric data, particularly as related to new avenues in psychotherapeutic theory and practice.

Key messages: Moreover, a number of studies link genes expressive of bipolar phenotypy to a variety of traits germane to Darwinian selection – including social dominance, scientific genius, religiosity, artistic creativity and suicide. First reviewed are studies of well-known artists and their family psychiatric histories that associate bipolarity in general and mood cycling in particular with artistic genius and productivity. Then considered is how treatment may be optimized to balance symptom control with creativity and other adaptive features is addressed.

Conclusions: Psychotherapuetic and ethical considerations, made more pressing amid progress in molecular genomics of psychopathology, are more readily managed from an evolutionary epidemiological perspective.

EVOLUTIONARY PSYCHIATRY: CRITICAL COMMENTS

Daniel R. Wilson, Gary Galambos, Robert M. Kaplan

Critical comments and discussion.

RS04 PSYCHOTHERAPY SECTION SYMPOSIUM: EVOLUTIONARY EPIDEMIOLOGY IN NEUROPSYCHIATRY: FROM GENOME TO PATIENT CARE

Daniel R. Wilson, Antonio Preti, Mark Erickson

This Symposium has been endorsed by the WPA Psychotherapy Section as an official activity.

Context: That pathology might have adaptive traits with evolutionary survival value is not widely appreciated in conventional medicine. Within medicine itself, psychiatry and related studies – until quite recently – have remained almost wholly unenlightened by the evolutionary perspective. Certainly the sway of rather unreconstructed Freudian concepts long endured, but it is more accurately the corrective force of genetically informed neuroscience that has moved psychiatry forward more recently.

Objectives: This Symposium will explore how the evolutionary perspective, merging Freudian and biological psychiatry, is beginning to shed light on both proximal and ultimate causes of diverse psychopathology, with implications ranging from molecular genomics to clinical psychotherapy.

Key messages: With this, Darwinism is now situated to capture the more direct attention of physicians, psychiatrists and biomedical researchers. Darwinian perspectives move both psychodynamic and biological psychiatry toward enhanced understanding human behavior in its boundaries with disease, its adaptive roles and therapeutic potentials that therein lie.

Conclusion: However, much current evolutionary psychology is overly (1) dependent on theoretic inference, (2) derivative of the far more proximal mechanisms of social psychology, and/or (3) lacking in empirical evidence, particularly related to genes & brains. This symposium reviews empirical evolutionary epidemiology pertinent to neuropsychiatry, with particular emphasis on affective and psychotic disorders.

“HITCHHIKING ALLELES”: INDIRECT HEREDITY OF SCHIZOPHRENIA AND RELATED PSYCHOSES

Antonio Preti, Daniel R. Wilson

Background and objective: How does a disorder, likely to impair both survival and fertility, maintain higher prevalence than any spontaneously occurring mutation rate and have a hereditary basis? Epigenetic mechanisms have been proposed to reconcile such conflicting evidence.

Methods: Literature investigating indirect heredity of schizophrenia was reviewed. Both Medline and PsychINFO (1967–2005) were searched using the word ‘schizophrenia’ or ‘psychosis’ with the following terms: genetics, heredity, epigenetic, evolution, adaptation. Manual searching was also used to retrieve further relevant papers.

Results: Three main classes of hypotheses have been forwarded to explain persistence in the general population of severe mental disorders with a higher prevalence than the spontaneous mutation rate: (1) obstetric complications with a genetic basis, leading to the recurrence of both the risk factor of unwanted pregnancy and of the disorder resulting from foetal brain damage; (2) group/kin selection, allowing in the group the permanence of alleles favouring effects that, beyond some disadvantages at an individual level, are beneficial to the group to which the mutated member belongs; (3) heterosis (ala’ sickle cell anaemia, where heterogeneous carriers are relatively better protected against malaria infection the agent expressing pressure on selection, than non-carriers).

Conclusions: Indirect heredity might explain some of the inconsistencies of the disorder, such as its prevalence at a higher rate than the spontaneous mutation rate despite evident hampering of survival, and repeatedly reported observation some relatives of patients diagnosed with schizophrenia excel in many artistic and scientific fields.

EVOLUTIONARY EPIDEMIOLOGY IN NEUROPSYCHIATRY

Daniel R. Wilson, Antonio Preti

Context: That pathology might have adaptive traits with evolutionary survival value is not widely appreciated in conventional medicine. Within medicine itself, psychiatry and related studies – until quite recently – have remained almost wholly unenlightened by the evolutionary perspective.

Objectives: Darwinism is now situated to capture the more direct attention of physicians, psychiatrists and biomedical researchers. Darwinian perspectives move both psychodynamic and biological psychiatry toward enhanced understanding human behavior in its boundaries with disease, its adaptive roles and therapeutic potentials that therein lie.

Key messages: Intra-species competition stratifies populations in terms of reproductive fitness in each generation with two basic alternatives as described by mathematical biology: escalation, Hawk, or de-escalation; Dove (evolutionary stabilized strategies; or ESS Maynard Smith, 1982). Variations on these strategies are part of what defines both entire species genomes and polymorphisms therein (Krebs and Davies, 1981).

Conclusion: The Hawk-Dove ESS exemplifies deeply canalized neuromentalities entirely compatible with both the basic and clinical science germane to manic-depression and psychosis (Price, 1996), the prevalences of which are rendered even more robustly adaptive when epidemiological calculations are corrected for suicide.

EVOLUTIONARY EPIDEMIOLOGY AND NEUROPSYCHIATRY: CRITICAL COMMENTS

Mark Erickson

Context: Much current evolutionary psychology is overly (1) dependent on theoretic inference, (2) derivative of the far more proximal mechanisms of social psychology, (3) lacking in empirical evidence, particularly related to genes and brains.

Objectives: To further consider implications deriving from evolutionary epidemiological neuropsychiatric data, particularly as they relate to new avenues in psychotherapeutic theory and practice.

Key messages: Moreover, a number of studies link genes expressive of bipolar phenotypy to a variety of traits germane to Darwinian selection – including social dominance, scientific genius, religiosity, artistic creativity and suicide. First reviewed are studies of well-known artists and their family psychiatric histories that associate bipolarity in general and mood cycling in particular with artistic genius and productivity. Then considered is how treatment may be optimized to balance symptom control with creativity and other adaptive features is addressed.

Conclusions: Psychotherapuetic and ethical considerations, made more pressing amid progress in molecular genomics of psychopathology, are more readily managed from an evolutionary epidemiological perspective.

RS05 MENTAL HEALTH AND HUMAN RIGHTS

Michael Dudley. Louise Newman, Sarah Mares, Jon Jureidini, Derrick Silove, Zachary Steel, Kathleen Maltzahn

Context: While mental health has always involved consideration of human rights, through concerns such as the ethics of psychiatric diagnosis and of involuntary treatment, in recent years the arenas of mental health and human rights have increasingly intersected. Governmental misuses of psychiatry and abuses of vulnerable groups under the Nazis and in the former Soviet Union brought health and human rights concerns into proximity. Today, under both totalitarian and liberal democratic regimes, psychiatry continues to be used for managing perceived social deviance, dissent or ‘bad’ behaviour. Torture is arguably making a comeback, and re-emerging problems such as people trafficking and sex slavery, with their attendant mental health problems, require urgent action. Western scientific, evidence-based approaches to mental health face the challenge of bridging the enormous cultural differences in conceptualizing and healing mental disorders across diverse settings in the “majority” non-western world. In Australia, the conjunction of health and human rights concerns has been highlighted by the plight and mental health of detained asylum-seekers, raising the question of how mental health professionals should behave in the face of such abuses.

Objectives: This symposium will sample a limited selection of current mental health problems with human rights considerations, against the backdrop of global and professional change.

Key messages and conclusions: Mental health professionals’ engagement with social issues is crucial if we want to shape what is happening (i.e. being proactive), rather than being reactive. Mental health professionals may learn skills to identify and respond to situations where rights need to be respected and fulfilled.

RS06 PSYCHIATRY AND PHYSICAL ILLNESS

Said Azim, Michelle Riba, George Christodoulou

Psychosomatic medicine is a growing sub-specialty in psychiatry. This field is a good example of how working together can improve the mental and physical health. In the last decade the importance of this branch of psychiatry became more evident and is included now as a subspecialty in many universities and psychiatry departments; holding a special exam and certificate.

This symposium is going to discuss the updates of psycho-oncological research, and the relation of psychiatry to cardiology, dermatology, rheumatology and intensive care unit; also possible other liaison – Psychiatry disciplines.

The knowledge in these domains is going to be updated reflecting the most recent views and researches in this substantial field to mental and physical health.

PSYCHE AND SOMA INTERACTIONS

George Christodoulou, Vassilis Kontaxakis, Nikos Christodoulou

Soma and psyche interact and cross-talk in a variety of ways, degrees, combinations and forms.

The interface of somatic and psychological symptoms can take a variety of forms, as follows:

Psychological symptoms as a reaction to somatic illness

Psychological symptoms as an expression of psychological distress

Somatic symptoms as an expression of psychiatric illness

Psychological symptoms as an expression of somatic illness (organic psychosyndromes)

Somatic illness produced by combined action of organic and psychosocial contributors (psychosomatic illness)

Depression is a typical paradigm of psyche and soma interactions. In this presentation the protean character of this illness will be emphasized, and the somatic conditions behind which depression is hiding will be highlighted, namely alcoholism, substance abuse, “accidentitis”, anorexia, bulimia, sexual dysfunction, hypochondriacal symptoms, “unexplained” symptoms, abnormal illness behavior, chronic fatigue, deliberate omission of measures to sustain life, giving – up complex, demoralization, “vital exhaustion” etc.

Furthermore, the association of depression with medical illness will be emphasized and the “agreement” of patient and physician not to deal with psychological problems but only with their somatic manifestations will be discussed.

RS07 INCREASING AWARENESS AND REDUCING THE BURDEN OF DEPRESSION IN THE COMMUNITY: AN AUSTRALIAN RESPONSE

Lisa Allwell, Leonie Young, Michael Baigent, Nicole Highet

beyondblue: the national depression initiative is a national, independent, not-for-profit organisation working to address issues associated with depression, anxiety and related substance-use disorders in Australia. It was established in 2000 and is supported by the Australian and all State and Territory Governments, private companies and community-based organisations.

Prior to the establishment of beyondblue, Australia had no unified national approach to tackling depressive disorders. beyondblue's activities have led to improvements in community depression awareness:

beyondblue provides the community with accurate community information

Reduces of stigma and discrimination for people with depression

Encourages discussion and debate

Provides information, context and forum to stimulate dialogue

beyondblue works in partnership with health services, schools, workplaces, universities, media and community organisations, as well as people living with depression, to bring together their expertise around depression. This symposium will outline beyondblue's strategies and priorities:

Community awareness and destigmatisation: beyondblue has undertaken a range of strategies to increase community awareness and reduce stigma. This has included the development of community service announcements, media training and liaison, using high profile persons to promote their lived experience. beyondblue has also developed tools to monitor changes in depression literacy in the community over time, and outcomes from this will be detailed.

Consumer and carer: Includes conducting extensive research with consumers and carers into the lived experience of persons living with depression, anxiety, bipolar disorder and related illness. Key achievements in advocacy include rewriting guidelines around insurance to reduce discrimination for those with a history of depressive/anxiety disorders.

Prevention and early intervention: includes a wide range of specific programs across the lifespan. These include a national postnatal depression program has revealed the high rates of antenatal depression and has resulted in policy to ensure antenatal screening is part of routine care. A national schools based initiative has been implemented in selected schools (compared with controls) to examine impact on mental health literacy in secondary schools across Australia. Workplace programs have been developed, piloted and extended to increase the capacity of organisations to identify and appropriately manage depression and related disorders across the workplace, whilst the role of folate, exercise, education materials in the prevention of depression in the elderly is also being evaluated.

Primary care reform: included the provision of training and national healthcare reform to ensure public access to adequate psychological and medical healthcare for the treatment and management of depression and related disorders in the community.

Targeted research: across all program areas has revealed important implications for future areas of extension and policy reform.

This symposium will include presentations from beyondblue's CEO, Clinical Advisor and a Senior Program Manager and will provide an overview of the workings and community achievements of beyondblue to date and key directions for the future.

SUPPORTING MENTAL HEALTH IN THE COMMUNITY

Leonie Young

beyondblue has built partnerships across governments, health, mental health, community, public and private sectors – and internationally. This paper will outline beyondblue's strategies in the following key priority areas:

Increasing community awareness of depression, anxiety and related substance-use disorders and addressing stigma, encouraging people to seek help

Working with people living with depression, promoting their needs and experiences of depression and stigma with policy makers and service providers in the healthcare system

Developing prevention and early intervention programs around depression

Improving training and support for GPs and other healthcare professionals around depression

Initiating and supporting depression-related research

REDUCING THE BURDEN OF DEPRESSION IN AUSTRALIA: A CLINICAL RESPONSE

Michael Baigent

beyondblue has the capacity to keep evolving the way Australians think about depression, encouraging new diections particularly in early intervention and research, and to inform decsion-makers on funding allocation to ultimately improve health outcomes. This paper will outline the role of beyondblue's Clinical Advisor including:

Provision of clinical advice

Responding to the media on clinical matters relating to depression, anxiety and related disorders

Provision of strategic research advice

Representation on national key advisory groups

DEPRESSION LITERACY IN THE AUSTRALIAN COMMUNITY

Nicole Highet

This paper will overview the key activities of beyondblue; the national depression initiative in the promotion of mental health literacy in the Australian community by demonstrating the outcomes of longitudinal research conducted.

Furthermore, the presented research assesses attitudes of older and younger adults regarding health problems and treatments across the lifespan, as well as replicating some measures used in international research to evaluate stigma with respect to depression in the wider community.

In addition to highlighting the outcomes of this research over time, the presentation will also demonstrate how these findings have been integrated in the development of new campaigns. The importance of working collaboratively with the media to promote these health messages will also be discussed and validated from the research.

Conclusions: This presentation will outline the health promotion activity and changes in depression literacy over the past 5 years in Australia and provide information on new areas assessed. In addition, the implications of these findings on media activity, as well as current and future directions will be discussed.

RS08 COGNITIVE-BEHAVIOURAL TREATMENT OF OBSESSIVE-COMPULSIVE DISORDER AND RELATED COGNITIVE STYLES: OUTCOMES AND TREATMENT PROCESSES

Michael Kyrios, Clare Rees, Maja Nedeljkovic, Sarah Egan, Paul Salkovskis, David Castle

Background: Obsessive-Compulsive Disorders (OCD) is a common psychiatric disorder with high degrees of associated comorbidity and disability. Psychological models have led to the development of cognitive-behavioural approaches to the treatment of OCD and its associated cognitions. However, continuing research is required to improve outcomes for particular presentations, to improve our understanding of treatment processes, and to improve the dissemination of CBT.

Aim: This symposium aims to highlight the effectiveness of cognitive behavioural treatments for OCD and associated cognitions, and the need for ongoing research to improve our understanding of treatment and dissemination processes.

Method: This symposium brings together 5 papers on various aspects of the psychological treatment of OCD. The first paper presents the results of a meta-analysis of group treatments for OCD, while the following two papers examine predictors of symptomatic amelioration following individual CBT. The fourth paper examines the usefulness of a treatment that targets a specific cognitive style associated with OCD, anxiety and mood disorders, while the final paper examines a model for improving the dissemination of CBT for OCD through primary care.

The symposium will:

describe contemporary cognitive models of OCD;

describe cognitive-behavioural treatments for OCD and an associated cognitive style;

outline outcomes following CBT for OCD;

examine predictors of outcome following CBT for OCD;

examine models for disseminating CBT for OCD in primary care; and

discuss the implications for ongoing treatment-based and more general research on OCD.

Conclusions: Following presentation of the five studies, Professor Paul Salkovskis has agreed to discuss and contextualise the findings.

GROUP PSYCHOTHERAPY FOR OBSESSIVE-COMPULSIVE DISORDER: A METAANALYSIS

Clare Rees

Background: INDIVIDUAL CBT is currently recognised as the treatment of choice for obsessive-compulsive disorder (OCD). Despite this, there is growing recognition of the need to improve access to effective treatments and also to take into account the economic costs of delivering such treatments.

Aims: This study sought to determine the efficacy of group-based cognitive and behavioural treatments (CBT) for OCD.

Methods: A comprehensive metaanalysis was conducted on all available published studies which employed a control group comparison.

Results: A modest number of studies were identified that met these criteria and resulted in a large effect size based on Cohen's conventions. The results support the efficacy of group CBT for OCD. However, the limited number of studies compared to individual CBT limits conclusions.

Conclusions: Results are discussed in terms of the potential costs and benefits of this approach to treatment.

PREDICTION OF OUTCOME FOLLOWING INDIVIDUAL MANUALISED COGNITIVE-BEHAVIOR THERAPY FOR OBSESSIVE-COMPULSIVE DISORDER

Michael Kyrios, Celia Hordern, Maja Nedeljkovic, Sunil Bhar, Richard Moulding, Guy Doron

Background: Research has supported the efficacy of cognitive-behaviour therapy (CBT) in treating obsessive-compulsive disorder (OCD). However, relatively little research has examined outcome prediction and treatment processes.

Aim: This study sought to examine predictors of outcome following individual manualised CBT for OCD.

Method: Seventy-nine participants with OCD undertook a 16-week intervention and were assessed at four time points (initial presentation, pre-treatment following an average 10 week waitlist period, the conclusion of treatment, and 6-to-12 month follow-up) using a range of measures. The major outcome was the self-rated YBOCS.

Results: Intention-to-treat analyses for the total sample indicated that the treatment was effective. Two thirds of participants responded to treatment, with few relapsers at follow-up. OCD severity at assessment and pre-treatment was the most consistent predictor of end-treatment and follow-up outcome. Initial anxiety and depression levels also featured in the prediction of outcomes. Pre-post treatment symptomatic change also exhibited moderate to high magnitude correlations with cognitive change, especially in OCD-relevant cognitions. After controlling for pre-treatment OCD severity, a regression with change indices found that pre-post YBOCS change was predicted by pre-post changes in anxiety and perfectionism/intolerance for uncertainty. Non-responders were more anxious, while relapsers could not be distinguished on the basis of pre-treatment variables or treatment changes, with the exception of self-ambivalence.

Conclusions: CBT is an effective treatment for OCD, and furthering our understanding of who does or does not respond to treatment remains a challenge for clinical decision-making. The present findings have important implications for assessment and treatment are discussed.

RELATIONSHIPS AMONGST SYMPTOMATIC, NEUROPSYCHOLOGICAL AND OTHER COGNITIVE CHANGES FOLLOWING COGNITIVE-BEHAVIOURAL TREATMENT FOR OBSESSIVE-COMPULSIVE DISORDER.

Maja Nedeljkovic, M. Kyrios, Richard Moulding, Guy Doron

Background: Neuroscientific and cognitive-behavioural research have both identified cognitive factors associated with obsessive-compulsive disorder (OCD). Specific neuropsychological deficits, confidence in memory, and beliefs such as an inflated sense of personal responsibility and perfectionism have all been shown to be associated with OCD symptoms. However, little research has examined changes in these cognitive factors following treatment, nor how their fluctuations may be differentially related to symptomatic change. Such research may help disentangle causal relationships between OCD symptoms and the range of cognitive factors, and help identify predictors of treatment outcome.

Aim: This study aimed to examine the relationship between changes in OCD symptoms, neuropsychological deficits, and cognitions following cognitive-behaviour therapy (CBT) for OCD.

Method: OCD subjects undergoing a cognitive-behavioural program were assessed pre- and post-treatment with a range of neuropsychological, cognitive and symptomatic measures.

Results: Findings provided evidence of symptom amelioration, as well as changes in neuropsychological and cognitions following CBT. There was little evidence for a direct relationship between neuropsychological changes and symptom amelioration, but stronger evidence for a direct relationship between treatment-related changes in symptoms and cognition, including meta-memory. Cognitive and neuropsychological predictors of outcome were also found.

Conclusions: The study provided some support that fluctuations in cognitions, including metamemory, were closely associated with OCD changes, supporting expectations based on cognitive theories of etiology. On the other hand, neuropsychological deficits in OCD may be epiphenomena rather than etiological determinants.

GROUP COGNITIVE-BEHAVIOURAL TREATMENT OF PERFECTIONISM

Sarah Egan, Suzanne Stout

Background: Perfectionism is elevated across a range of disorders including anxiety disorders, eating disorders and depression. Perfectionism is a prominent feature in many individuals with obsessive compulsive disorder (OCD) and has also been identified as a maintaining factor of OCD. It is also known that perfectionism can interfere with response to psychological treatments, for example, being a predictor of poorer response to standard psychological treatments for depression. There have been a limited number of studies that have evaluated individual cognitive behavioural treatments (CBT) for perfectionism, and to date no studies have evaluated the effectiveness of group CBT for perfectionism.

Aims: This study aimed to investigate the effectiveness of an eight session theory driven group CBT for perfectionism.

Methods: An A-B single case experimental design series with repeated measures and three week pre and post baseline periods was utilized with adults with a DSM-IV diagnosis of either an anxiety disorder (e.g., OCD) or depression. Outcome measures included anxious and depressive symptomatology and perfectionism. Data was analysed by assessing the clinical significance of changes and the Reliable Change Index (RCI: Jacobson & Truax, 1991).

Results: Results will be discussed in terms of clinical significance of changes in perfectionism and reductions in anxious and depressive symptoms. Group cognitive behavioural treatments for perfectionism may hold promise in directly changing perfectionism which can be a maintaining factor of anxious and depressive symptoms.

Conclusion: These preliminary findings suggest that further research is warranted in a randomised controlled trial of group CBT for perfectionism.

DISSEMINATING COGNITIVE-BEHAVIOURAL THERAPY FOR OBSESSIVE-COMPULSIVE DISORDER THROUGH PRIMARY CARE

Michael Kyrios, Barbara Jones

Background: Most people with obsessive compulsive disorder (OCD) first present in primary care. Until recent government initiatives, Cognitive Behaviour Therapy (CBT) had not been readily available in primary care. However, these initiatives do not appear to have made a difference for those with OCD.

Aim: This study aimed to identify and deal with barriers to accessing CBT for OCD in primary care, and to develop models of collaboration between General Practitioners (GPs) and psychologists in providing CBT.

Method: Data from focus groups, interviews, and a new questionnaire were also conducted with stakeholders (GPs, psychologists and consumers) to identify barriers and obstacles in accessing CBT for OCD. Subsequently, training modules and on-line resources for GPs were implemented, and three models integrating clinical psychologists into the primary care setting were developed and evaluated.

Results: All stakeholders agreed that there was a general lack of knowledge about OCD within primary care requiring training and resources for clinicians. Specialist psychological treatments for people with OCD were difficult to access, and a more targeted program that integrates clinical psychologists into the primary care setting was required. Of the three models that were developed, referral to a clinical psychologist specializing in OCD was by far the most popular model amongst GPs, and was associated with excellent outcomes and high degrees of satisfaction amongst consumers.

Conclusions: Provision of training and resources for GPs, and a pathway of care effecting easy referral to OCD specialists led to positive outcomes for those presenting to primary care with OCD.

RS09 PATTERNS OF ALCOHOL CONSUMPTION AND MANAGEMENT SYSTEMS IN DIVERSE COUNTRIES: ROLES OF GENDER AND SOCIO-CULTURAL ENVIRONMENT

Sawitri Assanangkonrnchai, Meera Vaswani, Yong Sung Choi, Susumu Higuchi, Robert Ali

Alcohol consumption is common and alcohol problems affect individuals from all sections of society regardless of their cultural background, educational background, religion, gender or age. Over the past decades, a number of treatment options have been developed for people with alcohol use disorders and considerable progress has been made both in pharmacological and psychosocial interventions for alcohol dependence. Alcohol treatment programs in many countries have incorporated a range of cultural and religious related modalities, such as referencing “the god or higher power” in the Alcoholics Anonymous 12-step program in western countries, and Buddhist concepts in some treatment programs in eastern countries. A gender difference in drinking behaviour is apparently universal. Compared with women, throughout the world, men are more likely to drink, consume more alcohol, are more likely to have alcohol-related problems and also more likely to seek and receive treatment for their alcohol-related problems. In order to understand alcohol consumption and its consequences, and develop effective intervention programs for alcohol-related disorders, a more complete understanding of social and cultural influences on the differences in drinking between men and women would almost certainly provide illuminating information.

The central aim of this symposium is to examine the roles of gender and socio-cultural environments within and across cultures in diverse Asian countries in the following areas: patterns and context of alcohol consumption, prevalence of alcohol-related problems, the relationship of social and cultural factors to alcohol consumption and related problems and the characteristics of alcohol treatment systems.

Featured speakers: Dr Sawitri Assanangkornchai will address recent treatment outcome research for alcohol dependence published in international journals during 2005-2007. She will also review some outstanding psychosocial treatment programs in Thailand in which Buddhist concepts have been incorporated. Dr Meera Vaswani will present the history and current patterns of alcohol consumption, current substance use treatment systems and the impact of changing cultural mores and values on alcohol consumption in India, a multi-ethnic country in transition between many traditions and the modern world. Dr Yong Sung Choi will describe the cultural background and present situation of alcohol consumption and alcohol dependence treatment and rehabilitation system in Korea, with a special focus on the characteristics of female alcoholics. Dr Susumu Higuchi will present the clinical characteristics and treatment outcomes of inpatients with alcohol dependence, based on the results from a nationwide survey of specialized treatment hospitals in Japan. And finally, Dr Robert Ali will compare what is offered in these presentations with some additional information about the patterns and systems in Australia.

It is hoped that this symposium and these presentations will serve as a valuable resource to mental health researchers, treatment providers, policy makers and those involved in alcohol and mental health work, who are charged with the formulation of effective prevention and treatment programs in various countries.

TREATMENT OF ALCOHOL DEPENDENCE: REVIEW OF CURRENT LITERATURE

Sawitri Assanangkornchai, Manit Srisurapanont

Background: Alcohol dependence is one of the most common psychiatric disorders, which contributes to devastating consequences on health and society. A number of treatment options, including pharmacological and psychosocial interventions, have been developed for acute management and relapse prevention for alcohol-dependent individuals.

Aims: This presentation summarizes current research on the management of alcohol dependence, including pharmacotherapy and psychosocial interventions.

Methods: The treatment-outcome research for alcohol dependence, in particular randomized-controlled trials published during 2005–2007, was critically reviewed.

Results: Naltrexone, both in the forms of daily oral and long-acting injection, has demonstrated high efficacy in reducing alcohol consumption in the context of behavioral therapy. In contrast to most previous studies, recent research has not supported significant treatment benefits of acamprosate over placebo. The combined use of naltrexone and acamprosate appeared to be safe and well tolerated but there was no additional therapeutic benefit. Many medications have been evaluated for the treatment of alcohol dependence with and without other psychiatric co-morbidity, including those that interact with dopaminergic, serotonergic, cholinergic, glutamate and/or GABA systems. With the exception of topiramate, there are currently no new, effective medications, being discussed in the literature. Most psychosocial interventions, e.g. social behavior and network therapy, cognitive behavioral therapy and motivational enhancement have not shown significant differences in drinking outcomes between treatment groups.

Conclusion: Progress has been made with treatment for alcohol-dependent individuals. However, more research is needed in developing newer medications and psychosocial interventions in alcohol-dependent populations and to improve the strategies to engage patients in continuing care.

PATTERNS OF ALCOHOL CONSUMPTION AND MANAGEMENT IN INDIA

Meera Vaswani, Atul Ambekar

Context: India, with her long cultural heritage, does not fit into the usual conceptualization of abstinent, ambivalent, permissive or over-permissive cultures. Historically, in the vedic times alcohol use was permissible to warrior communities but prohibited for the upper and elite communities – Brahmins. In the Moghul period, though Islam prohibited alcohol, it became a part of the court-life, with rulers freely indulging in drinking.

Objective: To present the current situation of alcohol consumption and management in India.

Key messages: About 21% of the male population in India can be categorized as current users of alcohol. There is no adequate data on female drinking, however it can be safely stated that prevalence of alcohol use among women is much less than men, though this may be gradually changing. Overall only a small proportion of the population drinks but those who do tend to do so heavily.

The health sector in India is well aware of the harms associated with drinking. Alcohol-dependent individuals constitute the largest group among those seeking treatment for substance-related problems. At a policy level, though the constitution of India directs the state to promote prohibition, the sale of alcohol remains a major source of revenue for the government, notwithstanding the fact that government spends a much larger amount on health and social consequences of alcohol use.

Conclusion: India remains a culture-in-transition in many respects including its pattern of alcohol consumption. The health sector has the responsibility to remain geared up to face the enormous challenge posed by alcohol use.

ALCOHOL–RELATED PROBLEMS AND INTERVENTION STRATEGIES IN SOUTH KOREA

Yong Sung Choi

Context: Several problems are faced in attempting to implement alcohol-related intervention strategies in Korea. These include the generally drug-friendly culture and reckless drinking behavior, poor public awareness of the seriousness of alcohol problems, a poor management system for alcohol-related diseases, lack of interconnection between services and rehabilitation facilities, lack of alcohol-related research and information systems, and insufficient government budget in the alcohol-related health sectors.

Objective: To present the situation in South Korea of alcohol-related problems and interventions and the characteristics of alcoholic patients in comparison with non-alcoholic individuals.

Key messages: Statistics show that education level and economic and occupational status of alcoholic patients were significantly lower than of the non-alcoholic group. There were no significant differences in terms of reasons for drinking and substance use and personality traits as measured by mean MMPI T-scores between the male and female patient groups, but the female patient group was different from the female non-alcoholic group. They are more impulsive and antisocial and are more prone to have marital problems, anxiety, insomnia or other affective problems.

There have been some positive developments with regard to prevention and control of alcohol problems, including the promotion of a local society-centered problem solution strategy, a systematic and integrated primary, secondary and tertiary prevention-based approach, the promotion of accurate knowledge, awareness and practice against alcohol harm, cultivation of self–help control capability and self support, and firm cooperation between private companies, institutions and public organizations in controlling the problems.

CLINICAL CHARACTERISTICS AND TREATMENT OUTCOMES OF INPATIENTS WITH ALCOHOL DEPENDENCE: RESULTS FROM A NATIONWIDE SURVEY OF SPECIALIZED TREATMENT HOSPITALS IN JAPAN

Susumu Higuchi, Sachio Matsushita, Tomohiro Miyakawa, Takefumi Yuzuriha, Yoshiro Kochi, Motoichiro Kato, Hiroshi Suwaki, The Japan Collaborative Clinical Study on Alcohol Dependence

Background: Although there are estimated to be 0.8 million patients with ICD-10 alcohol dependence (AD) in Japan, few comprehensive studies have been conducted regarding treatment and rehabilitation of these patients. We therefore established a study group and conducted several nationwide surveys on this issue.

Aims: In this part of the study, the analysis focused on clinical characteristics and treatment courses and outcomes of patients with AD who were hospitalized in nationwide specialized treatment hospitals.

Methods: We identified 92 hospitals that provide specialist treatment and were willing to participate in this study. These hospitals were estimated to account for approximately 60% of total hospitals of this kind. In each hospital, surveys on clinical characteristics and treatment of up to 25 patients who were consecutively hospitalized within the fixed study period were conducted. Treatment services and 6-month outcomes after discharge from hospitals were also assessed.

Results: Fifty hospitals (54%) responded and provided data on 860 inpatients (females 15%). Of these, 13% showed delirium tremens, 10% misused other substances, 9% had comorbid mood disorders and 11% had a past history of crimes on ASI. Cognitive decline on CDR was identified in 44% of patients aged 60 years or older. Benzodiazepines were used in 70%, antidepressants in 25%, and antipsychotics in 24% of the patients on admission. The 6-month outcome could be evaluated in 80% of them.

Conclusion: This study provided basic information to better understand the current status and to establish consensus-based evidence on treatment of AD in Japan.

RS10 CHALLENGES IN COMMUNITY-BASED REHABILITATION

Prem Chopra, Tae-Ywon Hwang, Sudipto Chatterjee, Chih-Yuan Lin

The provision of care for patients with severe mental disorders must be relevant to the social context. Models of community care will need to be adapted to suit local communities. Whilst there may be common elements to community care, there is no generic service model that has universal application, especially when considering the needs of patients with severe mental disorders living in low and middle income countries (LAMIC). The process of deinstitutionalisation has not been uniform across different communities and has been inevitably shaped by the social and political context. It is important to recognize that the process of deinstitutionalisation also involves the integral steps of the development of resources and community services which enable patients to avoid or minimize future hospital care.

This symposium will explore the adaptation of models for community mental health care in different settings. Research from India, Korea, Taiwan and Australia will be presented to provide insights into the need to adapt the provision of community care to different contexts. Mental health policy and service provision need to be informed by intervention studies using appropriate measures regarding the outcomes of people living with psychotic disorders in different community setting.

COMMUNITY-BASED REHABILITATION IN INDIA

Sudipto Chatterjee

Background: There is an enormous gap in the provision of treatments for persons with severe mental disorders (SMD) living in rural communities of Low and Middle Income Countries (LAMIC) like India. Community Based Rehabilitation (CBR) is a potential option of service delivery for severe mental illnesses that may be appropriate in resource poor settings.

Aims: To evaluate whether the Pati CBR program was effective, accessible and acceptable in meeting the needs of persons with SMD in the program area.

Methods: All persons with SMD who entered the program since 2002 were evaluated at baseline for socio demographic, clinical and disability measures (IDEAS). The follow up assessment was completed in 2006 using process indicators, socio economic indicators of improvement and the current IDEAS score.

Results: Two hundred and fifty six persons with serious mental illness were part of the program [schizophrenia (55.6%), Bipolar I disorder (21.7%) and other psychosis n = 43 (16.8%)]. The sample had chronic (mean duration7.7±4.9 years) and highly disabling illnesses; 97% of subjects had baseline IDEA score indicative of moderate to severe disability.

Service users continued with the program in adequate numbers and it was effective in reducing disabilities and promoting favorable social and economic outcomes. Improved outcome was independently associated with being married, gradual onset of illness, absence of reported stigma, less economic difficulties, compliance with medication and adherence to the program.

Conclusions: CBR is an effective, accessible and acceptable method of service provision in resource poor rural settings of LAMIC.

COMMUNITY BASED PSYCHOSOCIAL REHABILITATION IN KOREA

Tae-Yeon Hwang

After passage of Mental Health Law in 1995, mental health services have been provided in the community through Community mental health centers, Rehabilitation Facilities (including group home, vocational training center, living skills training center). Medical insurance reimbursement for Day Hospital started in 1994, but still reimbursement for the rehabilitation program or family education is so small that many hospitals of clinics cannot afford to hire mental health professionals for rehabilitation services. CMHCs were established as a public-private collaborating model between Public Health Centers and Private Mental Hospital or University Hospitals. A total of 36,142 patients with chronic mental illness are presently administered by 137 community mental health centers, which provide a list of diversified services in 2006 Continuous increasing number and budgets of community mental health centers are contributed to spreading PSR programs nationwide.

Ministry of Health and Welfare provided one-year training programs for the mental health professionals that several thousands psychiatric nurses, social workers, and clinical psychologists are working in the mental health field. Marked increase in the number of mental health professionals are reported every year. Number of psychiatrists is 2,089, psychiatric nurses 1,782, psychiatric social workers 778, and clinical psychologists 295 who are working in the mental health field in 2006.

Most of the psychosocial rehabilitation programs are ran by the mental health professionals and families are very active for the family psychoeducation and empowerment program for the consumers. But deinstitutionalization has not been successful, and has even regressed because social infrastructure needed to support the patients with treatment and basic needs has still not been established.

For the evaluation of the out-comes of community-based rehabilitation services, CMHCs in Seoul City developed computerized program, MHIS (Mental Health Information System) for data gathering, analyzing, and using information to improve the quality of mental health services in Metropolitan Seoul area. Outcomes showed improved functions, skills, self-esteem, and quality of life throughout the programs. Recent study for the effectiveness of CMH Services on the number and length of hospitalization, symptoms and functioning in people with SPMI, we found that number of hospitalization was reduced from 0.52 to 0.29 (p<.001), length of hospitalization was also reduced from 58.8 to 34.2 days (p<.001), significant improvements in symptoms by BPRS (p<.001) and functioning by GAF (p<.001) one-year follow-up after participation of psychosocial rehabilitation program in CMHC. Another study for the effectiveness of family psychoeducation and empowerment program for schizophrenic patients showed positive outcomes. So I can conclude that Psychosocial Rehabilitation Programs in the community mental health setting are very effective in reducing the number and length of hospitalization, improving symptoms and functioning in people with severe mental illness and their families.

COMMUNITY-BASED REHABILITATION, YULI MODEL, TAIWAN

Chih-Yuan Lin

The aim of the Yuli community rehabilitation model is to help the long-stay inpatients of Yuli Veterans Hospital (YLVH) reintegrate into the local community, Yuli, though which is not their original community. The major components of Yuli model have been holistic medical services, intensive case management, employment-oriented rehabilitation program and long-term residential program before 2006. Since May 2006 we added a new component into this model, that is, social club program.

This social club program is a joint venture with the local church, which embraces the evangelical mission to help the psychiatric inpatients of YLVH reintegrate into local community. This program was launched in a brand-new building called Euodia, which was built by the church for helping drop-out junior high students at weekday nights and weekend. The Euodia, which is adopted from the Bible and means perfume from the havens is right next to traditional market and provides an atmosphere of freedom and openness. The patients, 80 persons now, receive vocational training, run the café, organize club activities on their own, hang out in the market, join the fellowship programs provided by church, etc. They have many opportunities for casual social contacts with the people who visit Euodia for various purposes and thus reinforcing their social etiquette.

The essence of this program is connecting the rehabilitation services with social resources embedded in the local social network (non-profit organization in this case) and thereby help patients develop supportive social relationship naturally. Furthermore, many rehabilitation activities are built in the routine operation and special programs of the organization. This design makes the patients have as many opportunities as possible to contact with the people who work, visit and hang around in the organization. All of the Euodia social club members are receiving the services of all the four components of Yuli model concurrently. Actually, social club program works together with all the four components synergistically to meet the patients’ needs for stable employment, residential services, therapeutic relationship and social network, and ensure the continuity of care across time and functioning areas.

This program enriches patients’ life and broadens their social networks beyond the employer-employee relationships in the employment-oriented rehabilitation program, the peer relationship in the residential program or the therapeutic relationship in treatment settings. According to the narratives of many patients this program rekindles hope, confidence and happiness in their life. Also, the church feel satisfied with the success of having frequent meaningful and caring contact with the patients, many of whom became converted through their services. Since last Christmas the church people were very delighted to invite the patients to their homes for meals. There were 12 households inviting 40 patients during Christmas holidays last year and 18 households inviting 56 patients during the Easter holidays this April. No more fear and stigma but good will and care.

This program also opens another window for the workers of YLVH to see the possibilities of diversifying and enriching the services by collaborating with the local non-profit organizations, not only the local businesses for employment. We don't need to rely on our own resources only. Instead, we can explore the good will and resources already embedded in the social networks, especially the well-operated organizations with similar mission of helping people. This program, owing to substantial collaboration and interaction with the local church, infuses new life and energy into Yuli community rehabilitation model and sets the workers’ creativity free from old patterns of thinking and working.

UNMET NEEDS OF FORMER LONG-STAY PATIENTS IN MELBOURNE

Prem Chopra

Background: Several longitudinal studies now confirm that schizophrenia has a variable long-term outcome. Former long-stay patients are a unique group with significant needs. Few studies to date have assessed the long-term outcomes and unmet needs of this group of patients in the Australian setting. Community Care Units (CCUs) provide residential rehabilitation appropriate to the needs of this group. CCUs and similar settings provided former long-stay patients the opportunity of residence in the community. However the focus of CCUs has now changed and many former long-stay patients have been discharged to alternative accommodation; whilst follow-up studies suggest that level of functioning and HRQoL may improve in the short-term, only a minority of patients are able to progress to independent living.

Aims: To examine the outcomes of the initial cohort of 18 patients with long-term psychotic disorders admitted to the CCU using an integrated approach with clinician and self-report measures as well as a detailed analysis of medical records.

To examine whether the outcomes of this group of patients are unique to this service setting or consistent with findings from other studies.

Methods: The longitudinal outcomes of a cohort of 18 former long-stay patients with chronic psychotic disorders who were the original residents of the Community Care Unit (CCU), a residential rehabilitation setting in St. Vincent's Mental Health Service, were assessed 7.5 years following their admission to the CCU using a combination of clinician assessments obtained from case records, and qualitative analysis of research interviews.

Results: Members of this cohort of former long-stay patients were found to suffer significant disability. Only one patient was able to achieve independent living in the community. Although many patients demonstrated some improvement in their level of functioning and community integration with significant support, this was not maintained following their discharge from the CCU. Many patients had the experience of moving from one residential care setting to another. There is a risk of “reinstitutionalisation” within services that are not specifically designed for the care of patients with severely disabled patients; furthermore such patients may return to acute inpatient psychiatric hospitals and require long-term hospitalisation. The following key unmet needs were identified: (1) Promotion of independence (2) Stability in accommodation (3) Stability in social networks (4) Consistency of care (5) Addressing the theme of loss.

Conclusions: This group of patients represent the minority of patients with psychotic disorders in the post-deinstitutionalisation era who require long-term supported care. The following recommendations are made to address their unmet needs. Greater attention is needed to develop the independence of these patients within the setting of supported care. Stable supported accommodation is essential. There is a need for more attention to expanding patients’ support networks coupled with improving links with community resources. Development of these networks will in turn reduce dependence that patients may have on clinicians and residential care settings over a longer period of time. Furthermore consistency of follow-up must be considered a priority. Finally the theme of loss is pervasive in this group of patients and may lead to a sense of demoralisation if not addressed.

This study has relevance to other settings where the process of deinstitutionalisation may be at different stages of development; whilst community mental health care is appropriate for the majority of patients, it is important to provide appropriate longer term care for more severely disabled patients. Mental health policy and service provision need to be informed by intervention studies using appropriate measures regarding the outcomes of people living with psychotic disorders in the community setting.

RS11 RAPID URBANIZATION: IMPACT ON MENTAL HEALTH

Jitendra Trivedi, Norman Sartorius, Juan Mezzich, Giovanni Caracci, Haroon Rashid Chaudhry, Naotaka Shinfuku, Bruce Singh

Globalisation is defined as ‘crossing borders’, is not a new phenomenon. Indeed, people have moved around the world, probably since time immemorial, and one need look no further than the Bible for confirmation that many of the reasons for these movements were the same then, millennia ago, as they are today: economic, to seek a better way of life and a higher standard of living (economic migrants); fleeing conflict and persecution (asylum-seekers); and to conquer and colonise.

Urbanization in developing countries involves changes in social support and life events which have been shown to affect mental health; mainly depression and anxiety, particularly among low income women. Although depressive and anxiety disorders have a high prevalence and account for a large proportion of visits to primary health services there is little international health research in this field. The determinants, extent and outcome of the association between urbanization and mental health requires multi-disciplinary research by social scientists, social psychiatrists and public health professionals.

An appreciation of different conceptual models and associated methods is required before effective research can begin. A well-intentioned willingness to share the knowledge and educational courses developed in the West should not become a patronising attempt to impose the findings and practices of industrialised countries on those working in very different situations. Part of the solution might be to use to the full the knowledge and experience of mental health professionals who are part of the immigrant community and to remove some of the barriers to their professional integration.

Other issues such as the avoidance of environmental determinism; the separation of macro-social and micro-social variables; the weakness of urban/rural comparisons of mental health; the role of rural to urban migration; the debates about cross-cultural psychiatry; and the policy-relevance of research, all need consideration in the development of research into this rapidly emerging, but relatively neglected problem. The consequent rural-to-urban migration brings with it a series of problems and expectations. Blue et al. ([1995]) have elegantly demonstrated increased rates of common mental disorders in the urban slums of India, Brazil and Chile. This increase is related to social factors – poor housing and its related infrastructure and economic problems.

The loss of social support resulting from migration to urban areas brings its own problems. Another danger of globalisation worth bearing in mind is the drive to homogenisation that derives from the culture of consumerism (Moreiras, [1998]). Clinicians must also be aware of the relocation of languages in cultures as a result of globalisation (Mignolo, [1998]). The links between languages and the boundaries of humanity have shaped the ideas of literature, the cultures of scholarship and civilisation itself. The articulation of languages and their cultures have reduced barriers to communication. The growing ‘Anglicisation’ of the world is obvious. It is possible that such globalisation may be causing cultures to become more fundamentalist and restrictive, which might in itself contribute further to stress and psychological morbidity.

IMPACT ON MENTAL HEALTH BY RAPID URBANIZATION IN WESTERN AND CENTRAL ASIA

Haroon Rashid Chaudhry

IMPACT ON MENTAL HEALTH BY RAPID URBANIZATION IN SOUTHERN ASIA

Jitendra Trivedi

IMPACT ON MENTAL HEALTH BY RAPID URBANIZATION IN EASTERN ASIA

Naotaka Shinfuku

IMPACT ON MENTAL HEALTH BY RAPID URBANIZATION IN AUSTRALASIA AND THE SOUTH PACIFIC

Bruce Singh

RS12 OCCUPATIONAL PSYCHIATRY SECTION: WORKING TOGETHER FOR MENTAL HEALTH IN THE WORKPLACE

Jacques Metzer, Satoru Shima, Liliana Guimarães, Anthony Winefield

Two of the most important contributors to mental health are the workplace itself (or the lack of a workplace) and the events which may occur within it. In this symposium a number of authors from three countries come together in reporting research and data from the unemployment perspective, stressful events in the workplace, and interventions and suggestions to alleviate deleterious effects. While there is a focus on specific details in each of the presentations, an attempt is also made to address implications for policy development to promote mental health in the workplace, including fostering political recognition that work, the workplace or the lack of these can engender either good or bad mental health.

JOB RESOURCES AND DEMANDS AS PREDICTORS OF MENTAL HEALTH AND DETERMINATION TO CONTINUE IN THE WORKPLACE: ROLES OF CONNECTEDNESS AND ENGAGEMENT

Jacques C. Metzer, Ngan Huynh

Background: In many previous studies, job demands have been found to be predictive of mental health status and intent to continue in a job through the psychological mediating variable of burnout. In a new psychological model, (JDR), an additional and separate motivating pathway from job resources through the psychological variable of engagement is also predictive of intent to continue and job satisfaction. In volunteer populations, evidence indicates a similar psychological variable of connectedness appears being protective against burnout.

Aims: In volunteer populations, both engagement and connectedness may play a separate role to burnout in predicting mental health and intent to continue. In addition, an expanded measure of connectedness will be tested.

Method: A questionnaire, measuring the above constructs and variables is being administered to obtain 200 responses from several volunteering populations in South Australia.

Results: These are expected to be available at the symposium, and will include evidence for or against the existence of the hypothesised pathway. It is expected also to demonstrate the structure and performance of the expanded connectedness measure.

Conclusion: Predicting mental health and other outcomes in the workplace using valid measurable variables is an important step towards influencing intervention and policy in the workplace.

JOB LOSS AND MENTAL HEALTH – ONLINE COUNSELING AT PUBLIC JOB-MATCHING CENTERS

Satoru Shima

Since the year of 1998, the number of suicidal victims has risen dramatically, almost 30% up compared with the previous years. The characteristics of the growing population consist of unemployed, middle-aged men, living in a mega city, and divorced. Based on those facts, a new support system for those people with job loss has been set up in 2006 funded by the Ministry of Health, Labor and Welfare.

The present paper will describe the background of those people who seek help and the contents of their difficulties. In 2006, the first trial was carried out in two prefectures, Tokyo and Saitama for 10 weeks. In 2007, the second trial was started in April across Japan.

A significant proportion of people with job loss were depressed and needed medical care, although they were often facing financial difficulties which could be a big obstacle to see a psychiatrist. Moreover, they seem to suffer from not only psychiatric handicaps including depression, but also from social skill deficits including communication skill. Accordingly, a well-designed approach including both medical care and psycho-social intervention would be needed for those people with job loss.

BURNOUT SYNDROME AND QUALITY OF LIFE IN THE MILITARY POLICE AND “CIVIL” POLICE OF CAMPO GRANDE – MS, BRAZIL

Liliana A. M. Guimarães, Vânia Maria Mayer, Ignez Charbel Stephanini, Heloisa Bruna

Background: Every career has its stress load which leads to physical and emotional exhaustion. Researches demonstrate that the policemen face stressful situations as they are subjects of violence, tension and risks and as a consequence being exposed to the Burnout Syndrome (SB).

Aims: This study characterized/ compared the occurrence and the levels of the Burnout Syndrome and Quality of Professional Life of the Military Police (PM) and “Civil” Police (PC) from Campo Grande – MS (Brazil).

Method: The Method used was the comparative and analytical description from a population of N = 2321 (PM)-randomized sample of n = 240 (148 M; 92 F) and N = 966 PC with n = 234 (127 M; 107 F). Instruments used: MBI-Maslach Burnout Inventory (Maslach; Jackson, 1988) and QVP – 35 Questionnaire of Professional Quality of Life (Cabezas, 1999).

Results: The sample consisted of Military Policemen and “Civil” policeman. Civil status, sexes, rank, level of study (High School for the PM, University degree for the PC) were considered. The PC showed more perception of the Work Load and Intrinsic Motivation and less perception of Professional Life Quality and PC had a higher score in all the dimensions than the PM. In addition, the Regression demonstrated that in the PCs’ QVP there are more variables which influence the SB than in the PM.

Conclusion: The results confirm the level of physical and emotional exhaustion these professionals have to face, PC being more affected.

UNEMPLOYMENT AND ADOLESCENT MENTAL HEALTH

Anthony Harold Winefield, Jacques C. Metzer

Background: Data are presented from a longitudinal study of school leavers beginning in 2001. A cross-section of schools was sampled: metropolitan, rural, public, private, coeducational, single-sex. Our 1980s 10-year longitudinal study sampled only metropolitan coeducational public schools.

Aims: The aims were to examine the causal link between mental health and unemployment by studying school leavers in the final compulsory year of school and again, two years later. Since 2001 the official unemployment rate has been low in Australia (around 5%), whereas in the early 1980s it was high (around 10%). Some have suggested when unemployment is low, the poor health of unemployed people is explained by them being unemployable (selection). However, when unemployment is high, their poor mental health is likely to be a consequence of their employment status (exposure).

Methods: Participants completed a questionnaire while at school and again in subsequent years. Measures included self-esteem, neuroticism, psychological distress and suicidal ideation.

Results: There were no at-school differences on any of the measures. However, those who later became unemployed showed significant declines, whereas those who later became employed or continued with full-time study showed no change.

Conclusion: The results supported the exposure hypothesis, although the pattern of results differed from our earlier study where the later differences were largely due to improvements in the employed and further study groups (with no change in the unemployed). A possible explanation is that the real level of unemployment is much higher than the official statistics suggest.

RS13 BUPRENORPHINE: EXPERIENCES IN AUSTRALIA, MALAYSIA, AND THE UNITED STATES

Nicholas Lintzeris, Salina Aziz, Frank Vocci

Buprenorphine (BPN), a partial opioid agonist for the treatment of opioid dependence, is being used in a number of countries around the world. This symposium will compare and contrast the models of this very promising treatment being used in 3 different countries: Australia, Malaysia, and the United States.

BPN was introduced for treatment of opioid dependence in Australia in 2001 and buprenorphine-naloxone (Suboxone) in April 2006. In general, the regulations, clinical procedures, and funding mirrored methadone treatment in Australia already available in both government funded clinics and primary care settings. While take-home medication is available for stable patients, the majority of BPN treatment is delivered in primary care settings with general practitioners and community pharmacists involved in supervised dispensing.

In Malaysia, BPN was introduced with little structure into private settings and there is a small but growing clinic-based methadone system.

In the United States, no medication for opioid dependence treatment in the private physician's office had been available for 80 years until BPN was approved for this purpose in 2002 with requirements for 8 hours prior specialized training. Prior to this, the only agonist treatment was via regular attendance at methadone clinics with limited take-home permitted. BPN (Suboxone) is now primarily prescribed by psychiatrists and primary care physicians and to a very limited extent by methadone programs. As a result, the demographics are very different.

The experiences in these three countries should provide valuable information to the international community on the best ways to utilize this new treatment.

RS14 ROYAL COLLEGE OF PSYCHIATRISTS SESSION

Bruce Singh, Rachel Jenkins, Sheila Hollins, Dhushan Illesinghe, Helen Chiu, Amgad Tanaghow, Dinesh Bhugra

The Royal College of Psychiatrists has recently moved to encompass a structure to acknowledge its widespread membership by creating six international divisions. During this session members of the college executive will describe the new structure and the college's new initiatives in international mental health. Fellows of the College who belong to the Western Pacific Division will describe the potential opportunities this new structure offers to the region. The sessions will end with a general discussion as to the future involvement of the Western Pacific Division in Australia and the region.

INTRODUCTION TO THE SESSION

Bruce Singh

THE COLLEGE MOVE TO AN INTERNATIONAL STRUCTURE

Rachel Jenkins

COLLEGE INITIATIVES FOR INTERNATIONAL MENTAL HEALTH

Sheila Hollins

AN AUSTRALASIAN PERSPECTIVE

Dhushan Illesinghe

AN ASIAN PERSPECTIVE

Helen Chiu

A VICTORIAN PERSPECTIVE.

Amgad Tanaghow

TRAINING INITIATIVES OF POTENTIAL RELEVANCE TO THE REGION

Dinesh Bhugra

GENERAL DISCUSSION

To seek the views of Members on what contributions are being made and what more can be done by the College in this Region to psychiatric training, clinical practice, service planning, policy and research.

RS15 DIAGNOSIS AND CLASSIFICATION OF MOOD DISORDERS

Peter R. Joyce, Gordon Parker

HOW SHOULD MOOD DISORDERS BE MODELLED…?

Gordon Parker

Currently, official classificatory systems for modeling the depressive disorders are weighted to a dimensional model, with parameters of severity, duration and recurrence. Any severity-based model requires cut-offs to determine ‘cases’ and ‘non-cases’ and is necessarily imprecise. In imposing a set of criteria for ‘major depression’, the DSM model has resulted in ‘major depression’ being viewed as synonymous with ‘clinical depression’. Further, major depression is frequently conceptualized as an entity or a specific category, when in reality it more subsumes a number of differing conditions, with differing causes and likely differential responses to differing treatments. However, once such a category has been created, it is difficult to specify causes and differential treatments for the multiple constituent disorders. The DSM model since DSM-III has, however, also allowed some depressive sub-types (i.e. psychotic depression, melancholic depression). Such a mixed model suggests a concession to a sub-typing model when there is sufficient evidence to argue for a depressive sub-type but, when there is limited evidence, then recourse to a dimensional model is adopted. The ICD system is quintessentially a dimensional model.

It is likely that the next set of official classificatory systems will resort fully to dimensional models as they disallow arguments about whether a particular condition has been appropriately circumscribed or not and even whether it truly exists. This will certainly occur for the personality disorders, and where a dimensional model (assessing the severity of a particular personality style and of disordered functioning) is likely to be an advance. However, this speaker will put the argument that a general dimensional model for the depressive and bipolar disorders is both flawed and limiting, leading to a lack of research findings and failure to demonstrate treatment differentiation effects.

It was once wisely observed that “to understand depression is to understand psychiatry”. The speaker will argue that no single model – whether dimensional or categorical – is appropriate for operationalising the depressive disorders, when the evidence suggests that some are categorical and some are more dimensional in their character. He will emphasise the sterility of a purely dimensional model for mood disorders.

DIAGNOSIS AND CLASSIFICATION OF MOOD DISORDERS IN DSM-V AND DSM-VI

Peter R. Joyce

For any diagnostic system to be useful, and go beyond description, it must provide us with information which informs us about aetiology and/or outcome. DSM-III and DSM-IV have provided us with reliability; the challenge for DSM-V and DSM-VI will be to provide validity. For DSM-V this will not be achieved. Believers in DSM-III have impeded progress towards a valid classification system, so DSM-V needs to retain continuity with its predecessors to retain reliability and enhance research, but position itself to provide a valid system by DSM-VI.

It is useful therefore to consider what we ‘know for sure’ about mood disorders, which will need to be retained for a future valid diagnostic system. It is also useful to reflect upon areas in which we desperately need validation data.

We ‘know for sure’ that:

Depressive syndromes are common.

Depressive syndromes are more common than manic syndromes.

Depressive and manic syndromes are not mutually exclusive (i.e. mixed states exist).

Manic syndromes may ‘drive’ depressive syndromes (“the higher you go the bigger the crash”).

Genes are important aetiological risk factors for both depressive and manic syndromes. These genes may not be the same.

The genes for depressive syndromes overlap with the genes for negative affect (e.g. neuroticism or harm avoidance) personality traits.

Early life experiences, childhood abuse and neglect and adverse recent life events are aetiological risk factors for depressive syndromes.

Hormonal changes during adolescence increases risk of depressive syndromes.

Depressive syndromes are risk factors for suicide attempts and suicide.

Depressive symptoms and syndromes are major contributors to an impaired quality of life.

Depressive syndromes improve with a variety of placebo, psychotherapeutic and psychopharmacological treatments.

Depressive syndromes predict future depressive syndromes.

Maintenance treatments can prevent future recurrences.

Residual depressive symptoms predict recurrence.

The DSM-IV criteria for a major depressive episode of five symptoms over 2 weeks is not valid; the DSM-IV criteria for a manic episode is also not valid.

Some mood syndromes show a seasonal pattern.

Some mood syndromes are linked with the menstrual cycle.

The depressive syndrome specifers of atypical and psychotic have some validity.

The depressive syndrome specifer of melancholia is poorly defined, is not stable over recurrent episodes and lacks aetiological or outcome validity.

Some mood syndromes are chronic, and their likelihood of improvement (especially without active treatment) is less than for non-chronic syndromes.

The postpartum time is a high risk period for onset of mood syndromes.

Mood disorders are associated with disturbances of circadian rhythms.

Future perspectives on classification will likely include the concepts of diseases, dimensions, behaviours and life stories. There will also be improved evolutionary perspectives on why mood syndromes exist and are so common.

By DSM-VI these syndromes will not be called mood syndromes, as mood/affect is not the primary abnormality, but an epiphenomena. It is more likely we will have diagnostic criteria for:

An anhedonic syndrome (retarded depression)

An anxious dysphoric syndrome (anxious depression)

An activated syndrome (mania)

An agitated syndrome (mixed states)

There will be a mix of categorical and dimensional features in these new criteria. Furthermore, these newly defined syndromes will have distinct neuroimaging and biomarker correlates which will allow for diagnostic confirmation or exclusion of the syndrome. Genetic and biological markers will aid the prediction of the best tailored treatment for each individual patient.

The ‘personality’ disorders commonly associated with mood syndromes will be reduced to four clusters, defined as:

Asthenic (cluster C avoidant/dependent)

Anankastic (obsessive)

Asocial (schizoid)

Antisocial (cluster B)

RS16 HUMAN RIGHTS AND INDIGENOUS MENTAL HEALTH: IMPLICATIONS FOR THE NORTHERN TERRITORY

Helen Milroy, Ngaire Brown

Context: The role of a human rights framework in protecting the rights of the mentally ill and for Indigenous peoples has received increased attention over recent years. In 2007, Australia has made unprecedented changes to legislation to allow government intervention in Indigenous communities in the Northern Territory following the release of the Little Children are Sacred Report. Although the interventions are designed to reduce sexual abuse of children, tackle alcohol and drug use as well as other issues associated with social dysfunction immediately, many commentators have expressed concern over the nature of the changes and the potential for unintended adverse consequences for indigenous peoples and their communities. How to protect the rights of children, families, and communities in association with the Indigenous rights agenda is now under the spotlight. Implications for the future of Indigenous affairs and how to sustain long term improvements in Indigenous health, education, welfare and social justice is under intense debate. Safeguarding cultural heritage and identity for the wellbeing of future generations is also of great concern.

Objectives: The three speakers will focus their papers on the current human rights and Indigenous rights issues associated with the legislative changes and interventions in the Northern Territory, the potential impact on health and wellbeing and the issues associated with addressing child sexual abuse and transgenerational trauma in Indigenous communities within legislative and mental health frameworks.

Key messages: Both immediate and long term solutions are required to address the current burden of disadvantage and dysfunction in Indigenous communities. Adopting human rights and Indigenous rights perspectives in interventions are essential for ensuring the survival, wellbeing and sustainability of Indigenous communities.

HUMAN RIGHTS AND THE NORTHERN TERRITORY CONTEXT

Ngaire Brown

DEALING WITH SEXUAL ABUSE AND TRANSGENERATIONAL TRAUMA IN THE INDIGENOUS CONTEXT

Helen Milroy

RS17 EARLY MENTAL HEALTH INTERVENTION FOLLOWING TRAUMA: SERVICE DELIVERY IMPLICATIONS

Meaghan O'Donnell, Richard Bryant, Alexander Holmes, Arieh Shalev, Mark Creamer

Psychiatric disorders such as posttraumatic stress disorder and depression, and persistent pain represent serious outcomes following trauma. These symptoms are often severe and persist for many years, having major impacts on quality of life. Unfortunately the majority of those who experience these symptoms fail to get adequate treatment for their disorders. Early intervention models have the advantage of identifying patients prior to the development of chronic psychopathology, and in facilitating participation in evidenced based practices. In this symposium we present 4 studies that comment on aspects of early psychological and psychiatric intervention, and their implications for service delivery models.

TREATING ACUTE STRESS DISORDER

Richard Bryant

The majority of people who meet criteria for acute stress disorder (ASD) subsequently develop chronic posttraumatic stress disorder (PTSD). Although previous cognitive behaviour therapy studies for ASD have demonstrated the efficacy of CBT in reducing subsequent PTSD, significant proportions of participants drop out of exposure-based therapy. Although exposure is not a significant cause of drop-out in more chronic PTSD, acutely traumatized people appear susceptible to not tolerating exposure. This study aims to increase the effectiveness of treating ASD by evaluating non-exposure-based treatment. Specifically, ASD participants were randomly allocated to either (a) prolonged exposure (PE), (b) cognitive restructuring (CR), or (c) wait-list control (WL). Therapy comprised five weekly sessions of individual therapy. PE comprised education, imaginal exposure, in vivo exposure, and relapse prevention. CR comprised education, identification of cognitive errors, daily monitoring of thoughts and affective states, and to modify thoughts by Socratic questioning, probabilistic reasoning, and evidence-based thinking. Manualized treatments were followed and independent fidelity checks were conducted. Blind assessments were conducted at 3 months, 6 months, and 12 month post-treatment. Data will be presented on 93 participants who completed treatment and 6-month follow-up assessment. Intent-to-treat analyses indicate that participants in PE displayed greater PTSD reduction than participants in CR, who in turn had greater reductions than WL. The findings will be discussed in terms of potential public health applications for early intervention strategies after trauma.

PILOTING A STEPPED CARE, EARLY INTERVENTION MODEL OF SERVICE DELIVERY TARGETING MENTAL HEALTH FOLLOWING TRAUMATIC INJURY

Meaghan O'Donnell, Mark Creamer, Peter Elliott, Richard A. Bryant, Alex Holmes, Steven Ellen, Rodney Judson, Thomas Kossman

The mental health consequences of surviving traumatic injury are substantial with over 21% of injury survivors meeting diagnostic criteria for one or more psychiatric disorders at 12 months following injury. The majority of injury patients, however, fail to engage in mental health care or evidenced based mental health care.

The aim of this study was to investigate, in part, the effectiveness of a stepped care model of early intervention in the identification, prevention and treatment of posttraumatic stress symptoms (PSS) and depression symptoms that develop following traumatic injury. The study commenced in October 2006 and will be completed in July 2008. Consecutive weekday admissions to the trauma services at two level 1 hospitals were screened for high risk for posttraumatic stress and depression. Those at high risk were reassessed at 4 weeks post injury and those with psychiatric symptomatology above a threshold were randomly assigned into early intervention or usual care groups. Early intervention consisted of up to 10 sessions of an evidenced based, flexible, manualised, cognitive behavioural therapy that specifically addressed psychological adjustment to surviving a traumatic event as well as the consequences of the event (including disability, disfigurement, and pain). Detailed records were kept to document barriers to care, and rationales for patients refusing to participate in the study or refusing to participate in therapy. Results and discussion will centre around the viability of the proposed model of service delivery.

SERVICE MODELS FOR EARLY INTERVENTION IN PERSISTENT PAIN AFTER TRAUMA

Alex Holmes, Owen Williamson, Malcolm Hogg, Carolyn Arnold, Meaghan O'Donnell, Paul Myers, Thomas Kossman, Rodney Judson

Persistent pain is common after serious injury and is associated with disability and psychiatric disorder. Patients with co-morbid persistent pain, psychiatric disorder and substance abuse present a particularly difficult management challenge. Risk factors for the development of chronic pain after injury have been identified and share some similarities with those predicting psychiatric disorder after traumatic injury. The degree to which persistent pain can be predicated by measures taken at the time of injury is yet to be established. Research is currently being conducted in aims to address this question. Understanding the risk factors for chronic pain after injury is the first step in developing early intervention strategies directed at high risk populations. These strategies most likely will need to work closely with programs aiming to intervene early with patients at high risk of psychiatric disorder. The potential structure of service models will be dependent on the psychometric properties of predictive methods, resources and local systems of health care delivery. Models need to be assessed regards their efficacy in reducing long term morbidity as compared with traditional methods of case identification through primary care. Difficulties with patient adherence to preventative programs need to be acknowledged and strategies devised to maximise participation.

PREVENTION OF PTSD BY EARLY TREATMENT

Arieh Y. Shalev

We report a 4 years study of systematic outreach and prevention of PTSD by early treatment. 5200 civilian survivors of traumatic events were evaluated by telephone, one week after trauma, for early symptoms of acute stress disorder. Clinically significant distress was identified in 1929 (of which 1770 were evaluated again, seven months later); 744 were subsequently evaluated by clinicians and 280 were randomized to receive either 12 weeks of early treatment (prolonged exposure (PE) or cognitive therapy (CT) or an SSRI or placebo pill) or wait 12 weeks for delayed treatment (PE). 49% of those interviewed by telephone declined an offer to see a clinician. 24% of those seen by a clinician did not start treatment. Similar rates of recovery from PTSD were found for CT, PE and late PE. About a third of the subjects on the waitlist recovered without treatment. Subjects who declined treatment were worse than those who accepted treatment if they were women, were older, were victims of terrorist attacks or if they sought treatment on their own. The presentation will outline the implications of this program for service utilization, the qualities of prediction achieved by telephone screening and clinical interviews, and the rationale for systematic outreach and early treatment for survivors of traumatic incidents.

DISCUSSION

Mark Creamer

The papers will be followed by an opportunity for general discussion with audience participation encouraged.

RS18 NOVEL BRAIN STIMULATION APPROACHES IN THE TREATMENT OF PSYCHIATRIC DISORDERS

Paul B. Fitzgerald, Colleen Loo, Julian Troller, Stephen Miller

Context: The last decade has seen the progressive development of several methods for invasive and non-invasive stimulation of the human brain and the progressive development of studies to test the applicability of these methods for the potential treatment of psychiatric and neurological disorders.

Objectives: The aims of this symposium are to review the potential use of a variety of novel forms of brain stimulation in the treatment of neuropsychiatric disorders. These will include deep brain stimulation, transcranial direct current stimulation, vagal nerve stimulation and caloric stimulation.

Key messages: Psychiatry is likely to be faced over the next 10 years with a dramatic escalation in the availability of therapeutic forms of brain stimulation. At this stage a number of highly novel approaches of brain stimulation in various stages of development or gradually moving into clinical use. Vagal nerve stimulation is supported by several large trials and has now become clinically available in some Western countries although there are questions remaining about the degree of efficacy of this technique. Deep brain stimulation is invasive but appears to have significant potential as an alternative to destructive forms of psychosurgery for patients with highly refractory disorders who have not responded to other treatments. There are few studies with transcranial direct current stimulation in psychiatric disorder so far bust this appears to be a highly promising technique for a variety of reasons that will be described in the symposium. Caloric stimulation is a very old medical procedure that appears to have some interesting potential therapeutic benefits that require systematic investigation.

Conclusion: Brain stimulation techniques are likely to be increasingly used in the treatment of psychiatric disorders. Thorough research is required to establish the efficacy of each individual technique and to establish its safety prior to widespread dissemination of these approaches.

USE OF THE DEEP BRAIN STIMULATION IN THE TREATMENT OF PSYCHIATRIC DISORDERS

Paul B. Fitzgerald

Context: Various methods of invasive and destructive psychosurgery have been used in the treatment of highly refractory psychiatric disorders for the last 50 years. Because of the unacceptable nature of side-effects associated with these procedures and their historical context, they have mostly faded from use. Deep Brain Stimulation (DBS) is a technique that involves the implantation of very small electrodes into a localized area of the brain connected to a pacemaker type device. DBS stimulation is designed to disrupt or augment activation of local and / or connected brain regions to ameliorate brain disorders. DBS is widely used in the treatment of Parkinson's disease and a number of other neurological disorders. Recently, a number of groups internationally have conducted small studies to test the use of DBS in the treatment of refractory obsessive compulsive disorder and treatment resistant depression.

Objectives: Two overview the rationale and use of DBS in psychiatric disorders including a focus on treatment resistant depression.

Key messages: DBS is a technique that is likely to be restricted in used to a very small percentage of patients but appears to have the potential to be life changing for a small group of patients with highly refractory psychiatric disorders.

Conclusion: Considerable further research is required to establish the place of DBS in the therapeutic armamentarium of biological psychiatry. This research should proceed cautiously and be informed by developing models of brain dysfunction in disorders such as depression.

TRANSCRANIAL DIRECT CURRENT STIMULATION FOR THE TREATMENT OF DEPRESSION: A RANDOMISED, DOUBLE-BLIND, SHAM-CONTROLLED TRIAL

Colleen Loo, Philip Mitchell, Perminder Sachdev, Gin Malhi

Background: Transcranial direct current stimulation (tDCS) uses a weak current applied across the scalp to non-invasively and focally stimulate targeted cortical regions. Subjects are awake throughout the procedure and there is no seizure involved. Several studies have reported positive results in depressed patients receiving prefrontal anodal tDCS.

Method. Depressed subjects were randomly assigned to receive 5 sessions of sham or active tDCS, then allowed to continue to a maximum of 10 active tDCS sessions. Anodal tDCS was given second daily for 20 minutes, at 1 mA intensity to the left prefrontal cortex. Subjects and raters were blind to treatment group. Mood and neuropsychological functioning were rated at baseline and after each five sessions.

Results: The study is in progress. Preliminary results suggest that active tDCS is superior to sham in treating depression.

Conclusion: tDCS is painless and may have potential as an antidepressant treatment.

VAGUS NERVE STIMULATION IN DEPRESSION AND EPILEPSY: EFFICACY, CORRELATES AND LESSONS

Julian Trollor

Background: Although Vagus Nerve Stimulation (VNS) has an important role in epilepsy treatment, its mechanisms of action are poorly understood. Treatment Resistant Depression (TRD) is relatively common in psychiatric practice and may be responsive to VNS. Our understanding of the effects of acute and chronic stimulation of the vagus nerve may assist the understanding of neurobiological mechanisms involved in both epilepsy and depression treatment.

Aims and methods: To evaluate and compare the literature on the efficacy, correlates and proposed mechanisms of action of VNS in Epilepsy and TRD.

Results: Early clinical observations and subsequent prospective studies indicated that VNS had the potential to improve mood in patients with epilepsy. Subsequent studies have evaluated the effect of VNS in treatment resistant major depression. These initial studies indicate a significant short and long-term benefit of VNS on mood. There is emerging evidence that VNS is associated with alteration of CSF concentrations of various neurotransmitters and altered neuronal excitability. Furthermore, VNS impacts on functional activity of brain areas within the limbic system.

Conclusion: There is parallel and emerging evidence of the efficacy of VNS in epilepsy and TRD. There is mounting evidence of modulation of neurotransmission and functional activity in specific brain regions which may be of relevance to affective regulation and seizure suppression.

CALORIC VESTIBULAR STIMULATION: FROM DIAGNOSIS TO THERAPY?

Steven M. Miller, Trung T. Ngo

Context: Caloric vestibular stimulation (CVS) is widely known as a neurodiagnostic technique. Less well known are its effects on a range of cognitive and clinical phenomena, mediated through activation of contralateral temporo-parietal, anterior cingulate and insular cortex. Such effects include temporary amelioration of post-lesional attentional neglect, anosognosia, somatoparaphrenia and motor neglect. CVS also temporarily reduces pain associated with spinal cord injury, complex regional pain syndrome and phantom limb, and there are reports of sustained pain reductions in post-stroke thalamic pain syndrome. Together with colleagues, we have utilized CVS to explore mechanisms of binocular rivalry, a visual phenomenon whose temporal dynamics we also found to be abnormally slow in bipolar disorder. These latter findings led to predictions of therapeutic utility of left-ear (right-hemisphere) CVS in mania and right-ear (left-hemisphere) CVS in depression. The prediction for mania has been preliminarily confirmed in a published case study.

Objectives: The effects of CVS will be reviewed as will the neurobiological rationale for application of the technique in a range of psychiatric, neuropsychiatric and neurologic disorders. Methodological issues will also be discussed.

Key messages: Reports of temporary and some sustained effects of CVS raise the issue of its potential therapeutic utility, in addition to its neurodiagnostic and exploratory neurobiological utility.

Conclusion: Further research is warranted on the potential therapeutic efficacy of CVS, particularly regarding repeated administration protocols. This is especially so given it is easy to apply, non-invasive, safe, free of substantial side-effects, inexpensive, and readily available in developing countries and rural settings.

RS19 INTERNATIONAL PERSPECTIVE ON OUTCOME MEASUREMENT

Tom Trauer, Torleif Ruud, Bernd Puschner, Graham Mellsop, Mike Slade

Context: Outcome measurement (OM) is now an integral part of mental health service delivery in several countries, and some of the leading tools, such as the Health of the Nation Outcome Scales (HoNOS) have been widely studied. Successful implementation of OM requires a “culture shift” for most services, and progress has been variable.

Objectives: The objective of this symposium will be to present and compare implementation and research in OM in five countries: Australia, New Zealand, United Kingdom, Norway and Germany by leading local clinicians, researchers and educators. Presentations will cover progress to date, including development of OM aids and new research, as well as particular local factors that promote OM or serve as barriers.

Key messages: OM can be seen as part of an evidence-based approach to the delivery of health care. Common factors that affect the systemic changes involved in OM include leadership, resourcing, and the level of information technology sophistication.

Conclusion: Those attending this symposium will gain perspective and awareness on the current status of OM in five developed countries. The latest methods and technologies will be described. Opportunities and challenges will be presented, and the ways in which these have been handled will be compared.

OUTCOME MEASUREMENT; A RANDOMISED CONTROLLED TRIAL

Mike Slade

Context: Following a national pilot exercise, a ‘pyramid of benefits’ for outcome measurement has been proposed in England. However, in practice standardised outcome measures are not routinely used in adult mental health services in England.

Objectives: An epidemiologically representative randomised controlled trial of a longitudinal intervention was undertaken in London. The aim was to identify the benefits, moderators and mediators at the patient level for routine use of outcome measures.

Key messages: Routine outcome assessment is most likely to bring benefits at the patient level if viewed as a means of structuring patient-clinician communication. Regular use of outcome measures leads to earlier intervention, reducing hospitalisation costs and saving money. Premorbid IQ is a moderator of the effectiveness of routine outcome assessment – patients with higher premorbid IQ had higher quality of life and lower unmet needs. Patient-rated unmet needs are a mediator for the relationship between clinical care and subjective quality of life.

Conclusion: Routine use of outcome measures has the potential to benefit patients.

USE OF BRIEF OUTCOME MEASURES IN EMERGENCY PSYCHIATRIC SERVICES

Torleif Ruud

Context: Measuring outcome as an ongoing process in emergency psychiatric services is a challenge. High work pressure, short treatment periods and involvement of many staff members in relation to each patient makes it more difficult to get complete and reliable data. Instruments need to be short and easy to learn and use.

Objectives: To use the short instruments Health of the Nation Outcome Scale (HoNOS) and split Global Assessment of Functioning (GAF, with separate scales for symptoms and functioning) as outcome measures in a multicentre study where many clinicians were involved as raters at admission and discharge of patients in acute wards in three months and in crisis resolution teams in twelve months.

Key messages: The short instruments HoNOS and split GAF showed significant improvement for most patient groups. The number of missing scores were higher than in other treatment settings, but showed large variation that seemed to be related to the number of clinicians involved in the rating and how carefully the project were monitored in the ward or team.

Conclusion: Short outcome instruments may be used successfully in emergency psychiatric services over time, but the process need to be monitored carefully to get complete and reliable data.

NEW ZEALAND PERSPECTIVES AND INITIATIVES IN OUTCOME MEASUREMENT

Graham Mellsop

Context: New Zealand mental health services have committed to the introduction of standard outcome measures.

Objectives: To describe the Mental Health Standard Measures of Assessment and Recovery (MH-SMART) initiative, which arose out of the New Zealand Mental Health Classification and Outcomes Study, and to discuss future directions.

Key messages: Reliable assessments underpin the ability to measure change in clinically relevant health status. No single measure can represent all relevant variables. Wherever possible in assessing outcomes, measures reflecting the consumers' help-seeking intent should be sought.

Conclusion: The measurement of change should be regarded as only one part of a larger and dynamic process.

FEASIBILITY AND EFFICACY OF OUTCOME MONITORING AND MANAGEMENT IN PEOPLE WITH SEVERE MENTAL ILLNESS

Bernd Puschner, Dorothea Schöfer, Carina Knaup, Thomas Becker

Context: Outcome management has been suggested as a promising strategy to improve quality of mental health care. However, many attempts to implement routine assessment and feedback of outcome suffered from lack of clinician and patient acceptance.

Objectives: To ascertain feasibility and efficacy of assessment and feedback of treatment outcome in people with severe mental illness.

Method: The cluster-randomised trial “Outcome monitoring and outcome management in inpatient psychiatric care” (EMM) started in June 2005. 294 participants have been recruited among patients admitted to a large psychiatric hospital in rural Bavaria. These were asked to provide information on treatment outcome on the Outcome Questionnaire 45 via weekly computerised assessments. Patients and clinicians in the intervention group received continuous feedback of outcome.

Results: Patients were willing and able to provide outcome data on a regular basis. Clinician acceptance was mixed. First findings on the effect of feedback on patient-rated outcome during the inpatient stay will be reported.

Key messages: Outcome monitoring and management is feasible in people with severe mental disorder. Regular feedback of outcome to users and staff can contribute to a more effective allocation of treatment resources.

Conclusion: Strategies need to be developed to improve use of routinely collected treatment outcome data in mental health care.

ROUTINE OUTCOME MEASUREMENT IN AUSTRALIA: AN OVERVIEW

Tom Trauer

Context: Australia began the process of introducing routine outcome measurement into its public mental health services in the mid-1990s; all such services have been collecting and reporting this information since 2003. Outcome measures are also collected in private psychiatric hospitals.

Objectives: To consider some of the lessons learned in this process.

Key messages: Experience has shown that uptake, enthusiasm, and compliance with routine outcome measurement have been variable. Factors associated with success and failure include: clinical leadership, suitable information systems, long time frames, realistic resourcing, major investment in training, consumer involvement and representation, the development of user-friendly reports; and ongoing research and development.

Conclusion: The introduction of routine outcome measurement into a service system involves a major cultural shift. Clinicians and consumers need to be persuaded of the value of the outcome measurement.

RS20 COMMUNITY MENTAL HEALTH DEVELOPMENT IN THE ASIA–PACIFIC

Chee Ng, Xiangdong Wang, Helen Herrman, Yan Jun, Yutaro Setoya, Tae-Yeon Hwang, Suarn Singh, M. L. Somchai Chakrabhand, Altanzul Narmanakh, Shekhar Saxena

International trends in mental health services reform have included the reduction of large mental institutions, the shift from hospital to community care, the development of community treatment teams, closer links with community agencies, and the provision of mental health care as part of primary health care services. Based on international guidelines to advance mental health services, many countries in the Asia-Pacific have established health policy and guidelines including the provision of contemporary community mental health care. However, the delivery of quality and appropriate mental health care remains an ongoing challenge for both low and high income countries in the region. Difficulties in implementation of comprehensive community service models include funding issues, integration with primary care services and community agencies, and the collaboration between public and private health systems. Furthermore, the shortage of adequately trained workforce in mental health continues to impede the progress of mental health reform as community mental health service system is largely dependent on sufficient and skilled manpower for service delivery. A wide network is emerging in the region to build working relationships and partnerships to support culturally appropriate policy frameworks and training for the implementation of mental health services. The Asia-Pacific Community Mental Health Development project has been established to promote best practice in community mental health care through use of knowledge exchange and current experience in the region. Several papers will be delivered by mental health leaders from Asian countries in this symposium to outline existing policy and current practice with the aim of sharing of useful information relevant to promoting mental health in the community and improving service delivery in the Asia-Pacific region.

COMMUNITY MENTAL HEALTH IN CHINA

Yan Jun, Ma Hong, Liu Jin, Yu Xin

On 30 September 2004, Mental Health Program was included as the only non-infectious disease program into national public health program. In December 2004 started the “686 Program” named after the 6.86 million training fund appropriated by the Ministry of Finance. National Mental Health Center in CCDC took charge of this program which aimed at providing patient-centered services and built both national and foreign consultant groups.

In 2005, 60 demonstration areas of monitoring and intervention for psychoses were built in 30 provinces in China, covering a population of 43 millions (19.5 millions in urban areas and 24 millions in rural areas). Totally 419 training courses were held and 30574 people trained. National computerized case database was also built.

In 2006, this program received the second fund of 10 million RMB. In May 2006, the General Office of Ministry of Health announced a document titled “Notice about Improving Implementation of National Monitoring and Intervention Program for Psychoses”. Leading groups and program offices have been set, and networks for psychoses, local comprehensive teams have been built. Near 12300 people including 579 psychiatrists were involved. Both the quality control system and the record keeping system were built. By December 31 2006, a total of 65149 patients were registered and archived, 21564 patients with violence tendency followed up periodically, 9182 poor patients with violence tendency provided free medication, 2639 person-times of violent behaviors provided free crisis management, and 1038 poor patients with violent behaviors provided free hospitalization.

The budget of 2007 is 15 million RMB, which support the continuing work in 60 sits. A systematic training on case management is being conducted jointly with University of Melbourne, St Vincent's Health and Chinese University of Hong Kong. Day care stations located in three hospitals of Beijing, Shanghai and Guangzhou will undertake exploration of hospital-based rehabilitation to make rehabilitation criteria and working procedures for patients’ real return to the community.

The changing of the mental health service model goes well so far. This program will surely be carried on in the future thoroughly.

COMMUNITY MENTAL HEALTH IN JAPAN

Yutaro Setoya, Tadashi Takeshima

Recently, Japanese government released a report called “Future Direction of Mental Health and Welfare Policy”, which states its basic principle as “Shift from inpatient centered treatment to community based health, medicine and welfare”. Following this report, national reports and amendments to the existing laws were released, and rapid change in mental health system has occurred. However, there are still many issues to be solved. When you look around Japan, some issues are solved in certain area which provides good and unique practice.

In this presentation, I will briefly discuss current situation and issues in mental health in Japan, and will introduce four best practices in the community mental health. These practices were recommended from the experts in mental health and the Ministry of Health, Labour, and Welfare in Japan. First is the very unique consumer oriented service, second is about an area which care management is successfully used, third is about a community practice which has good result in discharging long stay patient from the hospital, and fourth is a hospital based community partnership practice.

We hope these practices to be informative and helpful, and to have some influence to other countries and regions.

CURRENT SITUATION AND NEXT STEPS TO DEVELOPING COMMUNITY MENTAL HEALTH SERVICES OF KOREA

Tae-Yeon Hwang

Korea is quickly developing a comprehensive mental health service system in each community and the government has invested in a community-based, public mental health system rather than in an institution-based system, but the average length of stay in mental hospitals is still too long. In order to reduce the length of stay, more residential facilities are needed. However, social stigma against by many of the people in Korea makes it difficult to reintegrate people with mental disorders into the community that the government plans to develop another 10-year mental health plan, up to the year 2017. The new government plan will develop policy on mental health promotion to provide mental health services for general population, suicide prevention, program for substance abuse and program for people in the early stage of psychosis.

The next steps to develop mental health services in Korea will be to improve community-based, public mental health services, as well as the monitoring system in each catchment area and province. Also, linkages with the primary health care system, the education system, and the judicial system should be strengthened through trainings and distribution of information about mental health. In order to transforming a mental health system with limited resources, the government should develop and establish a monitoring and information system of good quality and efficiency. Finally, there should be a program of long-term, ongoing research that examines the effectiveness of the country's mental health services.

COMMUNITY MENTAL HEALTH DEVELOPMENT IN MALAYSIA

Suarn Singh, Cheah Yee Chuang, Nor Hayati Ali, Ahmad Rasidi M. Saring

With medium level of resources available for mental health service, Malaysia has taken a balanced care approach for community mental health development. The way forward is downsizing psychiatric institutions, opening up more acute psychiatric beds in general and district hospitals, assessing needs of patients and managing appropriately in the community. This is aided by a hospital based community psychiatry service which consists of provision of acute and assertive care at patient's home, including the follow-up of “patients with high level needs”. Once the patient is stable and the level of care and needs can be downgraded, the case is discharged to the primary care setting at the Health Centre. The Health Centers are also gradually being equipped to do home visits and trace defaulters of follow-up appointments.

Self help groups and NGOs have assisted towards the direction of care in the community with trained carers, volunteers and families on managing and coping with mental illness. With the introduction of the new Mental Health Act provision for community care by the private and government sector will be further streamlined and enhanced.

This model of community care services is being replicated, strengthened and integrated in most psychiatric settings. The general outcome is positive in reduction of hospital stay, reduced rehospitalization and increased client satisfaction and better quality of life. This paper discusses the development of three practice models for community psychiatry care in Malaysia, namely urban, semi-urban & institutional settings.

COMMUNITY MENTAL HEALTH: THAILAND COUNTRY REPORT

M. L. Somchai Chakrabhand

The Mental Health Policy in Thailand is developed by Department of Mental Health, which mainly emphasize the integration of mental health services into public health services. The integration of mental health is implemented into five levels of public health services, namely, self care in family level, primary health care level, primary medical care level, secondary medical care level, and tertiary medical care level. The capacity building to empower public health personnel as well as mental health professionals had been developed. There are many training courses for various groups of mental health specialists such as mental health and psychiatric specialists, medical and psychiatric nurses, psychologists, psychiatric social workers and occupational therapists. All psychiatric institutes provide the service according to a standard of service qualify control, which is called Hospital Accreditation.

Community Mental Health in Thailand has been developed since 1964 due to the shortage of mental health personnel to provide service to coverage Thai population. It was initiated by sending mental health mobile team to provide service in the area which people were not accessible to mental health institutes. During the primary health care period, the mental health was added to be one component. Then the establishment of psychiatric unit in general hospitals were encouraged. The important principle of community mental health in Thailand is to collaborate with the networks and key factors are accessibility and sustainability. The important strategy is to promote mental health status of the people and also to prevent them from mental health problems through enhancing capability of related personnel. Mental health technologies were developed as the tool for transferring mental health knowledge and skills.

The meaning of community mental health in Thailand is mental health service that is provided to the community, at the community, by community participation, and follows the needs of the people in the community. The community mental health is composed of mental health promotion, prevention, treatment, and rehabilitation.

The best practice on family and community preparation for complicated psychiatric patient care by network team in the public health system, the family participation in taking care of psychiatric patient, the mental care in school system, and mental health care in Tsunami disaster, are examples of community mental health programs in Thailand. These programs were implemented based on principle, strategies and all programs are collaborated with the networks.

COMMUNITY MENTAL HEALTH IN MONGOLIA

Altanzul Narmanakh

RS21 MENTAL HEALTH MANPOWER IN A GLOBAL ECONOMY: BRAIN-DRAIN OR BRAIN-GAIN

Richard Warner, Vikram Patel, David Ndetei, S. Rajkumar, Rachel Jenkins

Context: The migration of mental health professionals from less developed countries to richer countries involves both ‘push’ factors, for e.g. the individual's search of better employment opportunities, as well as ‘pull’ factors, for e.g. the targeted recruitment drives by rich country employers. This migration poses a new threat to already severely under-resourced mental health systems in less developed countries and raises concerns about the ethics of health human resource recruitment by rich countries.

Objectives: This symposium will examine the issue of mental health human resources in an increasingly globalized world where talent and skills are now a commodity in the market-place. Arguments in support of the freedom of individual practitioners to migrate to seek better professional and personal opportunities are weighed against a global ethical imperative for equity and justice, to limit recruitment from less developed countries and thus ensure that already well-resourced health systems do not damage fragile ones in the global marketplace.

Key messages: The symposium is envisaged to comprise short presentations by speakers from both ends of the migration spectrum. We hope these presentations will serve as fodder for a debate to generate consensus on key ethical issues around the migration of health human resources. We expect that the debate will consider not only the issues of individual rights versus social obligation, but also issues about internal brain-drains (for e.g. from rural to urban areas, from public to private sector) and brain-drain between less developed countries. We hope the consensus statement which will emerge from this debate will focus on how to address the critical shortage of mental health human resources in all countries, and how migration of health resources may be reversed.

Conclusions: The migration of health human resources is a global phenomenon which is unlikely to be reversed without a simultaneous appreciation of the rights of individual practitioners and the ethical obligations of richer health systems towards less fortunate systems. This symposium will aim to tackle these issues and aim to generate a consensus statement for further discussion in the WPA.

RETURNING THE DEBT: WHAT SHOULD RICH COUNTRIES DO TO INVEST IN HEALTH CAPACITY IN DEVELOPING COUNTRIES?

Vikram Patel

Context: There is growing concern about the impact of the migration of mental health professionals from already under-resourced health systems of developing countries to rich countries.

Objectives: In this presentation, I consider the obligations of recipient countries-particularly the UK, Australia, New Zealand, the USA and Canada in the English speaking world. These countries owe a debt to developing countries who provide trained mental health professionals to strengthen their mental health systems.

Key messages: The recipient countries, in effect, import these highly skilled resources at no cost-without the nurses and doctors from developing countries, their health systems would collapse. I argue that, in a globalizing world where social justice and equity are driving principles for a fair global order, rich countries must compensate the countries they owe for their health human manpower. This debt should be repaid by investment in developing new mental health capacity in those countries. I will describe some initiatives led by UK mental health professionals to invest in the mental health capacity of developing countries to serve as examples of what individuals or small organizations have been innovating, mostly driven by personal motivation and zeal, to build mental health capacity.

Conclusions: Through these narratives, which were documented in a recent paper1, I demonstrate that a variety of approaches are being attempted to “return the debt”. These now need to be scaled up through systematic support from health systems in rich countries to broaden their scope and ensure their sustainability.

OVERSEAS TRAINED PSYCHIATRISTS AND RURAL ISSUES

S. Rajkumar

Background: There have been successive waves of migration among doctors for several decades. Despite restrictions in the migration processes, psychiatrists moved from low income countries to developed nations. This process of persistent mobility prevails within and between countries.

Complex factors propel migration. Wealthy countries attract talent from poor countries. This led in some cases to en mass recruitment of doctors, a policy that caused much strife for policy makers.

Objectives: This presentation clarifies the challenges faced and contributions made by overseas trained psychiatrists in rural areas of Australia.

It covers the migration process, factors in source and recipient countries, the pull and push phenomena; ‘repel ‘and ‘retain’ factors that influence brain drain and brain gain. The contrasts of individual and societal expectations vis-à-vis the regional needs and human resource factors are discussed.

Key messages: Emigration often encourages skill creation than skill loss.

Needs and expectations of different nations vary and so do those of rural and remote areas.

The complex migration process impacts on one's identity.

There is a need for active supervision and support for these psychiatrists.

There are excellent policies planned by RANZCP – the peak psychiatry college.

Conclusion: There ought to be a fulfillment of natural aspirations and rights of psychiatrists to learn, explore and benefit from better facilities. Migration is a reality and providing barriers will not be productive. It is equity of health care in rural and remote areas that needs a co-ordinated, systematic global management.

MENTAL HEALTH MANPOWER IN A GLOBAL ECONOMY

David Ndetei

Context: The migration of health care workers is not a new phenomenon, but the increasing number of health professionals moving abroad in recent years is a matter that has raised much concern and gained global attention. Psychiatry as a discipline remains one of the most seriously affected areas as a serious shortage continues to be experienced in the number of specialists who have to cope with increasingly greater numbers of mentally disturbed patients. Migration may have beneficial monetary returns to their countries of origin but although the home country may gain from remittances, such transfers do not necessarily go to the health system or to public coffers.

Objectives: To review and assess the magnitude and trends of migration of health workers in the overall context of Human Resources for Health (HRH) dynamics in Kenya and determine the effectiveness of the current measure and policies to manage migration.

Key messages: The study will provide a detailed analysis on the magnitude and trends of the internal, regional and international migration of HRH in Kenya which will aid in the establishment of a common data collection system on migration, guidelines for integration and assist in evaluating the relevance of the migration factor presently and in the near future.

Conclusions: One of the major influences on the migration trends witnessed is inequitable distribution of opportunities for upward mobility for health professionals. There is need for policies to curb this increasing movement of workers from resource limited settings.

HUMAN RESOURCE FLOWS – AN ISSUE OF GLOBAL SOCIAL RESPONSIBILITY

Rachel Jenkins

Context: Mental disorders are common everywhere with broadly similar prevalence rates in all regions of the world, yet there are huge disparities in the human resource available to meet the need. Countries in the west have 1 psychiatrist between 2,000 (e.g. Iceland, Denmark) to 10,000 (e.g. UK, Eastern Europe) population, while low income countries have, on average, one psychiatrist per 1,000,000 population, and this ratio in practice is often much worse outside the capital city where one psychiatrist may be responsible for 5,000,000 population and in some regions the service may be run solely by psychiatric nurses. Disparities in psychiatric nurses are similar.

Objectives: This talk discusses the ethics of active international recruitment by western countries of human resource from low income countries.

Key messages: The human rights to health of the populations in low income countries need to be considered as well as the freedoms of health professionals.

Conclusion: Rich countries have global social responsibilities to low income countries and their aid to those countries should far exceed the net flow of resource from low income to rich countries.

RS22 NEW HORIZONS IN PSYCHIATRIC ETHICS: THE OMNIPRESENCE OF ETHICS IN PSYCHIATRIC PRACTICE AND RESEARCH

Michael Robertson, Sidney Bloch, Garry Walter, Chris Pantelis

Given that psychiatry, both clinical and research, is inevitably influenced by values stemming from social and cultural norms embedded in the context within which it operates, almost everything psychiatrists do in treating patients and advancing knowledge, are inextricably bound up with questions about what is the right and wrong thing to do in particular circumstances. Thus, ethical issues arise in every sphere of the professional pursuit. In this symposium, this pervasiveness of ethics is demonstrated with presentations on the place of moral concepts in coming to a sound judgment and on the ethical dimension of publishing, trauma and the prescribing of psychotropic medication.

THE PLACE OF CARE IN PSYCHIATRIC ETHICS

Sidney Bloch

All moral quandaries in clinical practice are typified by profound feelings in patient, family and psychiatrist. In this presentation, it is argued that this emotional feature of the encounter requires much greater attention than has been paid to it hitherto. The merits of care ethics as elaborated on by Annette Baier, a relatively new approach in moral philosophy, are advanced to realize this goal in association with a cardinal construct in David Hume's philosophy that “sentiment” is an essential preliminary to moral action. Finally, it is argued that this perspective is best complemented by the well-established principle-based approach to ethical decision-making.

ETHICAL ISSUES IN SCIENTIFIC PUBLISHING IN PSYCHIATRY

Garry Walter

The ethics of publication is generally overlooked in the field of psychiatric ethics. This presentation – relevant to editors, authors, reviewers and readers – addresses a range of ethical problems, including conflict of interest, bias, publishing fraudulent or inhumane research, redundant publication, plagiarism, concerns about authorship, and insensitive use of language.

PSYCHIATRIC ETHICS AND POST-TRAUMATIC STRESS DISORDER

Michael Robertson

The ubiquity of trauma in human experience places it at the intersection of a variety of discourses and narratives, which vary between, and within, societies and cultures. This presentation will focus on the ethical implications of psychiatrists applying the construct of post-traumatic stress disorder (PTSD) to the care of survivors of psychological trauma.

ETHICAL ASPECTS OF PSYCHOTROPIC DRUG PRESCRIBING

Chris Pantellis

Given the inherent risks of using psychotropic medication, ethical issues such as “Primum non nocere” – first of all, do no harm, and the process of informed consent as part of respecting autonomy, permeate every clinical encounter in which there is a possible role for pharmacotherapy. Further complications ensue in circumstances where patients’ mental states are so abnormal as to preclude their participation in providing informed consent and enforced treatment is the only alternative option. This presentation will examine these aspects of clinical decision-making and offer the clinician a series of useful guidelines.

RS23 AUSTRALIAN GUIDELINES FOR THE TREATMENT OF ADULTS WITH ACUTE STRESS DISORDER AND POST-TRAUMATIC STRESS DISORDER

David Forbes, Mark Creamer, Andrea Phelps, Richard Bryant, Alexander McFarlane, Grant Devilly, Lynda Matthews, Beverly Raphael, Chris Doran

This symposium will present the recently developed Australian guidelines for the treatment of adults with acute stress disorder (ASD) and posttraumatic stress disorder (PTSD). The ASD and PTSD guidelines are currently the only mental health guidelines endorsed by the Australian National Health and Medical Research Council (NHMRC). The symposium will outline the guideline development process, including establishment of the reference panels and conduct of the systematic evidence reviews, and will discuss the planned dissemination process. Key recommendations from each section of the guidelines will be outlined and clinical issues and implications discussed. These sections include: Strategies to prevent the development of PTSD; psychological and pharmacological interventions for ASD and PTSD; sequencing treatment in the context of comorbidity; and issues in psychosocial rehabilitation. The guidelines will have significant implications for all mental health practitioners, particularly psychiatrists working with traumatised clients and for organisations responsible for organising and providing services to people exposed to trauma. Ample time will be allocated to questions and discussion.

BACKGROUND TO THE DEVELOPMENT OF THE AUSTRALIAN GUIDELINES FOR THE TREATMENT OF ADULTS WITH ASD AND PTSD

David Forbes, Tracy Merlin, Skye Newton

This paper outlines the background to, and the process of development, of the guidelines. It will include a discussion of the existing international guidelines, the establishment of the expert panels, the selection of research questions, and the nature and conduct of the evidence review.

RECOMMENDATIONS FOR PSYCHOLOGICAL INTERVENTIONS FOR ADULTS EXPOSED TO TRAUMA AND ADULTS WITH ASD AND PTSD

Richard Bryant, Grant Devilly, Lynda Matthews

This paper provides a brief summary of the evidence review of the psychological treatment literature and outlines the key recommendations for psychological interventions for adults exposed to trauma and adults with ASD and PTSD. The presentation also addresses the sequencing of treatment in the context of comorbidity and raises issues for consideration in the implementation of the recommendations. Recommendations for psychosocial interventions will also be outlined.

RECOMMENDATIONS FOR PHARMACOLOGICAL INTERVENTIONS FOR ADULTS EXPOSED TO TRAUMA AND ADULTS WITH ASD AND PTSD

Alexander McFarlane, Mark Creamer

This paper provides a brief summary of the evidence review of the pharmacological treatment literature, outlines the key recommendations for pharmacological interventions for adults exposed to trauma and adults with ASD and PTSD, and raises issues for consideration in the implementation of the recommendations.

GUIDELINE DISSEMINATION AND WHERE TO FROM HERE

Mark Creamer, Andrea Phelps

Development of clinical practice recommendations is only the first step. Dissemination of the guidelines to practitioners, service planners, and the public is the next challenge for the guideline development group. A broad range of strategies will be outlined to reach the diverse audiences for whom the guidelines are important.

DISCUSSION

Beverley Raphael

The papers will be followed by an opportunity for general discussion with the guideline development group on issues relating to the development of the recommendations and their application to psychiatric practice.

RS24 MENTAL HEALTH PROGRAMS FOR CULTURALLY DIVERSE SOCIETIES

Harry Minas, Laurence Kirmayer, Steven Regeser Lopez

Context: Most societies around the world have populations that are culturally diverse, although such diversity is reflected in health policies and programs in only a small number of countries – all wealthy countries that receive large numbers of immigrants and refugees. Three of the most culturally diverse nations are Australia, Canada and the United States of America.

Objectives: The objective of this symposium is to explore a number of examples of specific programs that have been developed with the aim of improving the response to the mental health needs of diverse societies. The examples – from Australia, Canada and the United States-are of a program that intends to improve the capacity of the Vietnamese community in Melbourne to respond to mental health problems in the community; an evaluation of a cultural consultation service in Montreal; a training program to improve the cultural competence of clinicians in California; and the approach to implementation of state cultural diversity policy in Victoria.

Key messages: The objective of providing effective, acceptable, equitable mental health services in culturally diverse societies is far from being achieved. There is a continuing need for attention at all levels of the service system, including policy and its implementation, development of appropriate models of service provision, ensuring that the clinical workforce has the necessary skills, and constructive engagement of immigrant and refugee communities. There is also a great need for rigorous evaluation of programs so that system reform and development is informed by the best available evidence.

Conclusion: This symposium will explore theoretical and practical aspects of different approaches to service provision, will present examples of approaches to improvement in service provision from Australia, Canada and the United States, and present evidence of effectiveness of such approaches.

MENTAL HEALTH FIRST AID TRAINING FOR THE VIETNAMESE COMMUNITY IN MELBOURNE

Harry Minas

Context: The Vitenamese community in Melbourne is one of the larger communities of immigrants, many members of which came to Australia as refugees in the 1970s and 1980s. Despite the fact that mental health problems are acknowledged as a significant issue in the community Vietnamese people in Victoria make use of public mental health services at a much lower rate than do the Australian-born. It has become clear that a substantial need is to improve the capacity of the community to recognise mental health problems and to respond appropriately when problems are detected-including referral, when this is appropriate, to specialist mental health services. A key strategy asdopted by a group of young Vietnamese mental health professionals has been to run a series of Mental Health First Aid training programs for key members of the community.

Objectives: The objectives of the Mental Health First Aid training is to enable key members of the Vietnamese community to recognise mental health problems and mental disorders, to provide appropriate initial assistance and to refer when necessary.

Key messages: Four such training programs – conducted in Vietnamese – have been completed in Melbourne, with each program training approximately 40 people. The effectiveness of this training has been evaluated, focusing on changes in knowledge about, and attitudes towards, mental illness.

Conclusion: The results of the evaluation of the Vietnamese Mental Health First Aid training program will be presented and the possible value of extending this program to other immigrant and refugee communities will be discussed.

CULTURAL CONSULTATION AS A STRATEGY TO ADDRESS DIVERSITY IN CANADA'S MULTICULTURAL SOCIETY: IMPLICATIONS FOR POLICY, TRAINING AND SERVICES

Laurence J. Kirmayer

Context: Canada's increasingly diverse population poses a challenge for mental health services. Although immigrants as a group tend to be healthier than the general population when they migrate, this advantage erodes over time, possibly due to stress and inadequate social support. In addition, for some groups, including refugees, young women, minority youth and many Aboriginal communities, sociocultural factors are associated with increasing health disparities over time. There is evidence in Canada for under utilization of mental health services and inappropriate diagnosis and treatment.

Objectives: To address this, we developed a Cultural Consultation Service (CCS), based at a general hospital, which brings together consultants from psychiatry, psychology, family medicine, nursing, social work, anthropology and specific ethnocultural communities to assess clinical problems and provide a cultural formulation that can guide subsequent intervention.

Key messages: This paper presents an evaluation of 400 cases seen by the CCS, to identify patterns of referral, key themes in cultural formulations, recommendations, and referring clinician satisfaction. Cultural consultation serves both as a clinical intervention and as an opportunity for knowledge translation and transfer to improve the cultural competence of referring clinicians. Integrating specialized consultation into the general health care system may partially obviate the need for specialized services.

Conclusion: The cultural consultation model has implications for policy, training, services and treatment. The CCS provides a useful setting for multidisciplinary training and supports research on the cultural formulation and culturally responsive methods of intervention and treatment.

SHIFTING CULTURAL LENSES: AN OVERVIEW AND EVALUATION OF THE FEASIBILITY AND ACCEPTABILITY OF A PROCESS MODEL OF CULTURAL COMPETENCE TRAINING

Steven Regeser Lopez, Linda Garro, Alex Kopelowicz

Context: In the United States, there are disparities in mental health care for persons of racial and ethnic minority groups. Many clinicians are required to receive cultural competence training as one way to address these disparities. Oftentimes this training focuses on culture as defined by values, beliefs and practices of specific minority groups.

Objectives: We provide an overview of a cultural competence training model that we developed that focuses on cultural processes rather than “cultural” groups. In this model we encourage clinicians to establish collaborative relationships with their patients and develop shared narratives regarding the patient's problem definition, helper model, explanatory model, and treatment method. In addition, we encourage clinicians to consider the individual patient's experience in their local social world. We carried out an initial evaluation of the feasibility and acceptability of this training as a one-day workshop for one hundred clinicians in a Midwestern city in the United States. A brief post-training evaluation was administered that included both quantitative and qualitative measures.

Key messages: The cultural competence training was well received. Open ended comments revealed an appreciation for a clear model of cultural competence, one that focuses on working to develop a shared understanding of the patient's narratives. Also, clinicians commented favorably on the multiple training methods, including the discussion of cases, both of the participants and the workshop leader.

Conclusion: The Shifting Cultural Lenses Training shows promise in helping clinicians learn to bridge the cultural divides in working with culturally diverse communities.

IMPLEMENTING THE CULTURAL DIVERSITY PLAN FOR VICTORIAN SPECIALIST MENTAL HEALTH SERVICES

Harry Minas

Context: The Victorian Government's social action plan, A Fairer Victoria, outlines a commitment to developing culturally inclusive public policies, ensuring equitable access to mainstream services, and delivering culturally competent services. The Cultural diversity plan for Victoria's specialist mental health services 2006–2010 has been developed to meet the challenge of providing mental health services that are accessible and appropriate to all members of Victoria's diverse population.

Objectives: The Cultural diversity plan encourages mental health services to move away from a special project approach to cultural and linguistic diversity to an approach that considers consumers’ cultural and language needs in everything they do, from the day-to-day practices of mental health workers to service planning, design and evaluation. The objective of the paper is to examine implementation challenges and strategies.

Key messages: While three agencies (Victorian Transcultural Psychiatry Unit, Victorian Foundation for Survivors of Torture, and Action on Disability within Ethnic Communities) are charged with key responsibilities in implementation of the plan, the responsibilities of the Mental Health Branch, Department of Human Services, and of Area Mental Health Services, in ensuring the provision of effective and culturally appropriate services are clearly articulated for the first time.

Conclusion: This paper will outline the approach being taken by key statewide agencies and mental health services to work collaboratively to implement the Cultural Diversity Plan.

RS25 PERSONALITY/TREATMENT INTERACTIONS IN MENTAL, PHYSICAL AND INTELLECTUAL DISABILITY DISORDERS

Peter Tyrer, Roger Mulder, Helen Seivewright, Nick Bouras

Context: Personality disorders are frequently discussed as though they were separate from other mental disorders. Of course, they are not and comorbidity of mental disorders and personality difficulties in all their forms is the most common form of presentation in clinical practice. This joint symposium of three sections of the WPA links together the influence of personality across intellectual (learning) disability, medically unexplained symptoms and depressive disorders and shows the importance of thinking about personality status in the management of all mental disorders.

Objectives:

To describe a range of disorders (aggressive behaviour in intellectual disability, health anxiety and medically unexplained symptoms, and depressive disorders) in which the label of'personality disorder' is frequently attached as an alternative or subdividing factor

To describe the value of the randomised controlled trial in determining the impact of personality

To reach conclusions over the best management pathways for these groups

Key messages: New data will be presented about all these disorders that illustrates both the handicaps of sloppy use and real benefits of the term'personality disorder' in these conditions.

Conclusion: When personality assessment is made in an informed and reliable way there are considerable benefits to the management of patients with chronic mood disorders, bodily expressed anxiety symptoms and intellectual disability.

THE NACHBID STUDY: A RANDOMISED CONTROLLED TRIAL OF HALOPERIDOL, RISPERIDONE AND PLACEBO IN AGGRESSIVE CHALLENGING BEHAVIOUR IN LEARNING DISABILITY

Peter Tyrer, Nick Bouras

Background: Aggressive behaviour in people with developmental disorder (DD) is associated with a wide range of disorders from autism to antisocial personality disorder. Treatment with antipsychotic drugs is often first line treatment but there is a very limited evidence base for the effectiveness of this treatment. We therefore planned a multicentre trial of risperidone, haloperidol and placebo medication in this condition.

Aims: Our intention was to recruit 120 patients from three sites in the UK with randomisation of patients with both intellectual disability and aggressive behaviour to one of the three treatments with weekly recording of aggressive episodes over a six month period.

Methods: Randomised controlled double-blind controlled trial with three parallel treatment arms.

Results: Although our intention was to recruit 120 patients over 2 years but only 86 patients were recruited from 10 major centres, including Queensland, Australia, with 1% having borderline (IQ 70–75), 35% mild, 48% moderate, and 16% severe developmental disorder. The results are currently being analysed and will be described at the meeting.

Conclusions: Awaited following results.

PERSONALITY DISORDER AND THE OUTCOME OF DEPRESSION: AN UPDATE

Roger Mulder, Simone Kool, Tony Johnson, Peter Tyrer, Giles Newton-Howes, Jack Dekker, on behalf of the Personality Disorder Depression Outcome Group

Background: Depression is commonly associated with degrees of personality disturbance. W examined whether such disturbance has an impact on outcome in both the longer and shorter term as the literature on this subject is contradictory.

Aims: To carry out a meta-analysis of all good quality randomised controlled trials or cohort studies in which both depression and personality status was examined using an accepted instrument at baseline and outcome of depression measured similarly.

Methods: Systematic meta-analysis of all papers identified using a comprehensive research strategy.

Results: Previous studies of the partners in this research group have been somewhat contradictory with personality disorder having a negative impact on depression outcome in some studies and in others having much less effect. We have therefore joined forces to widen the scope of the enquiry. The results will be presented at the meeting.

Conclusions: Awaited following results.

PREVALENCE OF HEALTH ANXIETY AND MEDICALLY UNEXPLAINED SYMPTOMS IN GENERAL PRACTICE AND HOSPITAL CLINICS

Helen Seivewright, Roger Mulder, Peter Tyrer

Background: Medically unexplained symptoms (MUS) and health anxiety (HA) are common in patients attending medical clinics with up to a third of all attendances being for one of these conditions. Many of these people are described as having personality disorders. We have investigated the prevalence of MUS and HA using two new scales.

Aims: To assess prevalence of high health anxiety (HA) and medically unexplained symptoms (MUS) and compare across different medical specialities and primary care.

To attempt to validate a new scale for MUS: the Schedule for Evaluating Persistent Symptoms (SEPS) scale.

To assess the degree to which high HA and MUS persist in the absence of treatment., with HA recorded using the Health Anxiety Inventory (HAI) and MUS using the SEPS scale, and the extent of agreement between the two scales.

Methods: Up to 900 out-patients from departments of cardiology, respiratory medicine, gastroenterology and endocrinology to be recruited for the study in Mansfield, Nottinghamshire, England and Christchurch, New Zealand, and from three general practice settings in the East Midlands (UK) are invited to (i) complete the SEPS and HAI, (ii) allow their case notes to be examined, and (iii) optional consent to allow contact again after six months to repeat their questionnaires to determine if their symptoms were still medically unexplained.

Results: Not yet available-study ongoing but will be completed by September, 2007.

Conclusions: Awaited following results.

PERSONALITY DISORDER IN ADULTS WITH INTELLECTUAL DISABILITY

Nick Bouras, Geraldine Holt, Elias Tsakanikos

Background: Although the diagnosis of personality disorder in people with intellectual disability is particularly important for clinical decision management, its prevalence in this particular population remains uncertain.

Aims: This study was designed to explore the prevalence of the primary diagnosis of personality disorder in a large sample (N = 806) of adults with intellectual disabilities referred to specialist mental health services in South East London.

Method: The eligibility criteria for the study were identical with the referral criteria, i.e. an ICD-10 diagnosis of mental retardation (F70-73) and significant social impairment. Participants were between the ages of 16 and 86 years of whom 60% were male. Behavioural problems, as well clinical and socio-demographic characteristics, were examined in relation to clinical decision management.

Conclusions: Awaited following results.

RS26 CHALLENGES IN THE CONCEPTUALISATION AND CLASSIFICATION OF NEUROTIC AND PERSONALITY DISORDERS

Vladan Starcevic, Aleksandar Janca, Mohan Isaac, Jonathan Laugharne, Dusica Lecic-Tosevski, David Castle

Background: There has been a growing dissatisfaction with how “neurotic” and personality disorders are conceptualised and classified. Suggestions for changes range from further splitting of the existing diagnostic categories by creating new subtypes and new diagnostic entities to combining them in different ways within broader and/or overarching concepts. The way in which these disorders will be conceptualised in the future classification systems will influence not only psychopathology, but have important treatment implications.

Objectives: This symposium first aims to revisit general issues in the classification of mental disorders, especially as they apply to “neurotic” and personality disorders. Further goals are to overview the problems and controversies in the areas of anxiety and somatoform disorders, posttraumatic stress disorder (PTSD) and related syndromes, and personality disorders. Possible solutions and directions for future diagnostic conceptualisation and classification will be presented for each of these groups of disorders.

Key messages: Cultural aspects need to be paid more attention to when diagnosing most conditions that currently belong to the “neurotic” and personality disorders. Novel multiaxial evaluations would provide a more comprehensive assessment of this domain of psychopathology. The boundaries between the diagnostic entities need to be more firmly established in order to increase their clinical utility and validity. A tension between the categorical and dimensional conceptualisation can be eased only if their advantages and disadvantages are fully recognised and a compromise made to include both models in different proportions, when it is deemed scientifically appropriate to do so. As far as the anxiety disorders are concerned, the main challenges are to establish clearer “external” boundaries with depressive disorders and to re-examine to what extent “internal” boundaries between various anxiety disorders naturally divide the putatively distinct conditions. The membership status of certain disorders within both the anxiety and somatoform disorders has been called into question, which will require their novel “placement” within the classification systems. The somatoform disorders face radical changes, including a possibility of their disappearance as a separate nosological group, “merging” of some of their current members with disorders from other groups, reconceptualisation of their relationship with somatic illnesses, and changing their name. The concept of PTSD is being increasingly criticised on grounds of the ever-widening definitions of trauma, internal heterogeneity, unclear relationships with depression and other mental disorders, and misuse. Therefore, a considerable effort will be needed to demonstrate whether PTSD is a credible and valid psychopathological entity. The main issues in the area of personality disorders are their relationships with and delineation from “mental state disorders”, and the manner in which they should be conceptualised. While the dimensional model has clear advantages, the categorical approach still has a role to play in this area of psychopathology.

Conclusions: The changes in the way “neurotic” and personality disorders are conceptualised and classified are inevitable. To the extent that such changes are research-driven, within a conceptually coherent framework, they will represent an important advance in our understanding of these common mental disorders.

DIAGNOSIS AND CLASSIFICATION OF NEUROTIC AND PERSONALITY DISORDERS IN A CROSS-CULTURAL PERSPECTIVE

Aleksandar Janca

Context: Discussions about forthcoming revisions of current classificatory systems are underway and a number of proposals have been made to enhance their cross-cultural applicability.

Objectives: To review existing limitations in the cross-cultural applicability of ICD-10 and DSM-IV classifications, focusing on diagnostic categories of neurotic and personality disorders.

Key messages: There are a number of conceptual issues embedded in the current classification of neurotic and personality disorders, which limit their applicability across cultures and settings. Examples include application of the linear concepts of time and severity and their use as operational and classificatory principles.

Conclusions: Some basic theoretical concepts embedded in the ICD-10 and DSM-IV classifications require revision and extensive evaluation in different cultures and settings.

WHAT WILL HAPPEN WITH THE ANXIETY DISORDERS IN THE FUTURE PSYCHIATRIC CLASSIFICATIONS?

Vladan Starcevic

Background: It is presumed that the main characteristic of the anxiety disorders is the presence of pathological anxiety. To what extent this is the case for all conditions within anxiety disorders has been questioned. A common overlap with depression and frequent development of depressive disorders on the background of anxiety disorders have cast some doubt on the conceptual independence of anxiety disorders.

Objectives: To present issues and controversies surrounding the diagnostic conceptualisation and classification of the anxiety disorders and review the proposed options for changes.

Key messages: Recent research has consistently distinguished “fear disorders” (consisting of panic disorder and phobic disorders) from “distress disorders” (consisting of depressive disorders and generalised anxiety disorder [GAD]). The boundaries between various “fear disorders” remain fluid, and it is debatable whether they represent distinct conditions. An alternative longitudinal conceptualisation views various “fear disorders” as a manifestation of the relatively specific vulnerability, which is expressed differently at different ages in the same vulnerable persons. It is not clear whether posttraumatic stress disorder (PTSD) will remain classified along with “fear disorders”, while obsessive-compulsive disorder (OCD) is increasingly regarded as having little in common with other anxiety disorders.

Conclusions: In the future, the more narrowly defined “fear disorders” (or “fear circuitry disorders”) seem likely to replace the current group of anxiety disorders. Because GAD may have more in common with depressive disorders, it may be classified with them. The nosological status of PTSD is unclear at present, and OCD is likely to be classified separately.

DIAGNOSTIC AND CONCEPTUAL CONTROVERSIES IN POSTTRAUMATIC STRESS DISORDER AND RELATED SYNDROMES

Jonathan Laugharne

Context: Posttraumatic stress disorder (PTSD) was introduced as an operationalized diagnosis in the DSM III (1980) classification. The diagnostic criteria were modified for DSM IV (1994) and the definition of the traumatic stressor widened. PTSD appeared in ICD 10 (1992) along with a new category of Enduring Personality Change After Catastrophic Experience (EPCACE), which attempts to capture longer term persistent dysfunctional adaptation to traumatic experiences. The DSM system has no equivalent to EPCACE although new categories such as Complex PTSD and Disorder of Extreme Stress Not Otherwise Specified (DESNOS) have been suggested.

Objectives: To outline the historical development of these existing categories, evidence supporting them and major criticisms which include the inappropriateness of including aetiology within the definition of a psychiatric syndrome, and the critique of PTSD as a sociopolitical construct. The utility of newly proposed posttrauma syndromes will be reviewed in the light of current evidence.

Key messages: Defining and categorizing the clinical effects of extremely stressful experiences represents a significant challenge which should be engaged with in the context of a rapidly developing research field and associated evidence base.

Conclusions: PTSD has limitations as a concept and a diagnosis but has provided a useful basis for the current debates around the conceptualising and categorizing of posttraumatic psychopathology. Defining the personality and behavioural changes associated with repeated early life trauma remains an issue of important and ongoing debate.

DIAGNOSTIC AND CLASSIFICATORY APPROACHES TO MEDICALLY UNEXPLAINED SOMATIC SYMPTOMS: SOME RECENT DEVELOPMENTS

Mohan Isaac

The group of conditions characterized by bodily symptoms and concerns that cannot be fully accounted for by a medical diagnosis is referred to as somatoform disorders. Ever since its first introduction in the 3rd edition of the diagnostic and statistical manual of the American Psychiatric Association in 1980, somatoform disorders have been a controversial and problematic group. While the significance of this group of disorders is widely accepted due to its high prevalence in a variety of settings all over the world, the disability caused and the enormous amount of health resources consumed, its underlying concept, terminology and classification have drawn much debate and controversy. The debate on classification of somatoform disorders is getting more crystallized, in the run up to the next phase of revision to the classificatory system.

The proposals for revision range from minor changes to radical overhauling of this group of disorders as well as its total abolition and reclassification. The suggested changes include alteration of symptom thresholds, lowering the number of subgroups, splitting and merging of certain disorders, combining and redistribution of some subcategories, label changes, new terminology and addition of new criteria. A number of psychological concepts and variables such as symptom expectation, symptom catastrophizing and somatosensory amplification have been proposed for consideration as important criteria. The revised classification should contribute to greater integration of psychiatry into general medical practice.

The presentation will critically review the ongoing debate on classification of somatoform disorders.

PERSONALITY DISORDERS – ADVANCES AND PROBLEMS OF NEW CLASSIFICATIONS

Dusica Lecic-Tosevski

The concept of personality disorder has evolved over the years, and in the last two decades research in this field has shown a substantial growth. However, in spite of the proclaimed progress, this area is still full of controversies and confronts psychiatrists with the limitation of their art. Whilst there are many advantages of DSM and ICD classification systems (atheoretical concepts, multiaxial diagnostic approach, polythetic criteria), there are also some disadvantages in them. The proposed criteria are overlapping and multiple diagnoses frequent, and personality disorders still retain the lowest reliability of any major category of mental disorders. Borderline personality disorder is the most controversial category and the dilemma of whether it is a separate entity or level of functioning is still unresolved. For maximal effectiveness in the light of our current knowledge, an optimal classification of personality disorders should include both a categorical approach to different types of personality constellations and dimensional approach that refers to the degree of severity of these disorders and the internal relations of the subgroups to one another. In the light of complexity of this diagnostic category, we believe that it is necessary to define the general conditions for their diagnostics, and propose the borderline level of functioning typical for all personality disorders.

RS27 MENTAL HEALTH CARE IN THE SUB-SAHARAN AFRICA: ‘OPPORTUNITIES AND CHALLENGES’ – ZONE 14

Fred Kigozi, Solomon Rataemane, Frank Njenga, David Basangwa

The burden of disease due to mental disorders is on the increase the world over. The situation is worse in Africa especially in the Sub-Saharan region which has been bedevilled by civil strife and armed conflict together with the HIV/AIDS pandemic.

In spite of the above contribution to the disease burden, the region has an acute shortage of both human and financial resources. It further faces challenges resulting from the disparity between urban and rural communities which will require innovative approaches to address the numerous challenges faced by mental health workers. Sub-Saharan Africa has to generate evidence-based research programs to develop best practice in dealing with mental health issues.

The symposium will focus on the various aspects of interventions from the Universities, Public Institutions and Government in integrating mental health into Primary Health Care in the Eastern and Southern Africa regions.

INTEGRATING OF MENTAL HEALTH INTO PRIMARY HEALTH CARE IN AFRICA – A UGANDA CASE STUDY

Fred Kigozi

The majority of the developing countries globally and indeed the African countries, have been undertaking reforms of the mental health policies and strategies to improve access and equity for the community to mental health in general and psychiatric services in particular. This has been in conformity with the philosophy for health policies which emphasize decentralization of services to the districts, community care as well as integrated delivering of health services particularly for district health services. Uganda, one of the poor countries in Sub-saharan Africa, has been implementing its Health Sector Strategic Plan in which mental health has been identified as a major priority.

The guidelines from the Alma Ata (1978) and WHO recommendations were important during the formulation of the current strategy. However despite embracing the philosophy and having developed sound policy and implementation programs, practical realities and challenges are being experienced on the ground. The need for research and evidence-based approach is needed to evaluate the success of the programs, which appear to be lacking in most developing countries and indeed worse in Africa.

The paper will review some of the evidence available with a case for Uganda, discuss the challenges and propose a way forward.

ROLE OF AFRICAN UNIVERSITIES IN PROMOTING RESEARCH AND DELIVERY OF QUALITY MENTAL HEALTH CARE

Solomon Rataemane

PSYCHOSOCIAL EFFECTS OF TRAUMA/CIVIL STRIFE IN SUB-SAHARAN AFRICA

Frank Njenga

The continent of Africa has suffered much trauma in the last five decades, initially as a result of wars of independence, later as the consequences of dictatorial regimes that replaced the political leaders of independence, and more recently in civil and international wars, best exemplified by Sudan, Somalia and Sierra Leone. The 1994 Genocide in Rwanda brought world attention to Africa, just as the Darfur war in the Sudan continues to do so.

In addition, droughts, famine, flooding, earthquake and even the Indian Ocean Tsunami, have all had an impact on the mental health of the African.

This paper reviews the literature on PTSD in Sub-Saharan Africa as it relates to the various traumas and finds very high levels of PTSD. The implication of this finding with regard to provision of services with very limited resources in nations just emerging from conflict will be discussed.

Conclusion: Africa is a highly traumatized continent with a high burden of disease due to PTSD and with very limited resources to deal with this mental health crisis.

TOWARDS A REGIONAL TREATMENT PROTOCOL FOR ALCOHOL/DRUG ABUSE

David Basangwa

Use of alcohol and drugs has been in existence for thousands of years. These items have of late become a source of public health concern in many nations. However also noted are the marked social and economic effects in many societies.

Global alcohol consumption has increased in the recent decades with most of the increase occurring in developing countries and giving an overall global disease burden of 4 percent. (WHO 2002).

Similarly, abuse of narcotic substances is said to be on the increase the world over with developing nations experiencing increasing use of hard drugs from the traditionally known abused substances like marijuana.

Alcohol and drug related harm in Africa is particularly worrying considering the rampant lack of resources and treatment facilities, absent or ineffective policies and legislation among others.

Considering the increasing number of drug related cases in Africa with the associated challenges caused by the common civil strife and the rampant HIV/AIDS pandemic, it is important that people who develop drug related complications are able to access quality and affordable treatment so as to become recovered and fully functional and productive citizens once again.

The paper will discuss the move towards developing a common treatment protocol in Eastern Africa, aimed at offering standard guidelines for use in the region in managing persons suffering with problems of addiction.

RS28 POLICY AND PRACTICE IN COMMUNITY MENTAL HEALTH IN THE ASIA–PACIFIC

Chee Ng, Bruce Singh, Sophal Chhit, Rangaswamy Thara, Yulizar Darwis, Kim-Eng Wong, Erin Chia-Hsuan Wu, Hung Se Fong, Shekhar Saxena, Xiangdong Wang

Efforts in the Asia-Pacific region have been made to develop community-based mental health services in line with the recommendations in the World Health Report (WHO, 2001). Community psychosocial rehabilitation facilities provide better and earlier care, help preserve the human rights of mental illness sufferers, and limit the stigma of mental health treatment. Globally however, community care facilities exist in 68.1% of countries (Atlas Report 2005). In several regions, including South-East Asia, such facilities are only available in about half the countries. Where present in Asian countries, community mental health services are not equally available and is often restricted to a few areas within the country. Furthermore, the sociocultural factors in the Asian countries do not appear to allow ready application of ‘Western-type’ community mental health models of care. Locally appropriate and culturally sensitive models of care are needed to implement sustainable mental health services that are embedded in local community infrastructures. The Asia-Pacific Community Mental Health Development project has been set up to explore diverse local models or approaches to community mental health service delivery in the region. Consensus derived from the experiences across the region will help develop to a shared understanding of key principles and components in community mental health care that is culturally and regionally compatible. Reports from the participating Asian countries will be presented by key country representatives who will also outline future implementation of practical models in the region. Such information exchange based on regional practices and solutions to problems is useful in building appropriate community-based mental health care in the future.

INTEGRATED APPROACH OF MENTAL HEALTH IN PUBLIC SECTOR: EXPERIENCE FROM CAMBODIA

Sophal Chhit

When Cambodia was a war torn country, mental health care services were destroyed by the Pol Pot Regime. Of the 1,000 medical doctors trained prior to 1975, less than 50 survived; of which none were mental health professional. With supports from the Oslo University and other international institutions and external resources, mental health development began re-building from 1994. Cambodia started with many objectives such as training mental health specialist, training physicians and nurses in basic mental health care, and developing mental health services in general hospitals, and other community mental health facilities.

Despite great achievement in mental health human resources and services in a short time, Cambodia still need sustainable development through an integrated approach. The faculty of medicine and nursing school now offers mental health specialty training; basic mental health training is incorporated into the undergraduate medical and nursing training; and mental health care has been integrated into general health care services delivery through complementary package of activities (CPA) and minimum package of activities (MPA), based on health coverage plan. As a result, mental health specialists play a role in service delivery, training, and planning development, and a new generation of medical doctors and nurses are able to provide basic mental health care for mentally ill patients, and mental health care services are provided at general hospitals and health centers.

However, due to low human resources at health center level, this integrated approach imposes a heavy burden on health center where the capacity is limited, so an appropriate balance needs to be achieved.

COMMUNITY MENTAL HEALTH IN INDIA

Rangaswamy Thara

Community psychiatry has had a fairly long history in India. Two nodal centres, NIMHANS in Bangalore and PGI, Chandigarh had demonstrated CMH projects almost 2-3 decades ago. This was followed by the National Mental Health Programme with its admirable agenda of integrating mental health with primary care. However, even after two decades, this programme is yet to establish itself in all parts of the country, with multiple reasons cited for its non-implementation. With the 10th 5 year plan of the Government of India allotting more resources and funding, it can be expected that district level mental health programmes will fill the gap in treatment in the community. Simultaneously there has been an upsurge of community based activities by the non-governmental sector. NGOs have been active in several south Indian and few north Indian states and have employed various strategies to facilitate community involvement in mental health care. Community based services now serve the chronic mentally ill, those with minor mental morbidity like depression and anxiety, persons with intellectual disabilities, and substance abuse. Research on a wide array of subjects as explanatory models for mental illness in rural and urban areas, pathways to care, factors determining help seeking behaviour including the role of religious and traditional healing methods, cost effectiveness of community based programmes have also helped to sensitize professionals and policy makers to the importance of community care. The Schizophrenia Research Foundation (SCARF), an NGO in Chennai has been running several community based programmes in urban slums and rural areas including an ongoing program in the tsunami affected regions of Cuddalore and Nagapattinam. The basic tenets of SCARF'S programmes have been the involvement of the local community and utilization of existing community resources such as NGOs, teachers, opinion leaders and religious heads as catalysts of the programme.

COMMUNITY MENTAL HEALTH IN INDONESIA

Yulizar Darwis

The World Health Report 2001 – Mental Health: New Understanding New Hope made ten overall recommendations for development of mental health systems in countries.

These principles make Indonesia to change the mental health policy from institutional care to community care.

Community care has a better effect than institutional treatment on the outcome and quality of life of individuals with chronic mental disorders. Shifting patients from mental hospitals to care in the community is also cost-effective and respects human rights. Community-based services can lead to early intervention and limit the stigma of taking treatment.

Large mental hospitals will be replaced by community care facilities, backed by general hospital in-patient units, psychiatric beds and home care support, which meet all the needs of the ill that were the responsibility of those hospitals. Provide treatment and psychotropic drugs in primary care is a step which enables the largest number of people to get easier and faster access to services.

COMMUNITY MENTAL HEALTH IN SINGAPORE

Kim-Eng Wong

Singapore has made significant progress in its community mental health programme since the last update in May 2006 in Perth.

The National Mental Health Policy has been completed and in its wake, funds have been injected to drive some key areas over the next few years. These key areas include mental health promotion, integrated mental health care, the increase and development of mental health manpower, and the development of mental health research.

Mental health promotion now enjoys as much prominence as physical health promotion; mental health professionals work closely with public health professionals in planning national programmes for school children right up to the elderly, to increase their mental resilience and strengthen positive mental health.

Starting this year, community mental health teams have been set up for school children, adults and the elderly, in certain sectors of the island. The plan is to fan out the service to all sectors of the island over the following years, after the necessary appropriate professional manpower is increased. Singapore needs to double its number of psychiatrists over the next 10 years, as well as to train more clinical psychologists and mental health nurses. Due recognition is given to the family physician, who plays a crucial role in receiving stable chronic patients for long-term follow-up treatment.

Meanwhile downsizing of the sole state psychiatric hospital continues, with another 200 stable long-stay patients discharged to a community residential facility.

The government's support is generous and timely; the mental health professionals can only be motivated and excited.

COMMUNITY MENTAL HEALTH IN TAIWAN

Erin Chia-Hsuan Wu, Ming-Jen Yang, Joseph Jror-Serok Cheng, Chang-Jer Tsai, Steve Chih-Yuan Lin, Keh-Ming Lin, Chiao-Chicy Chen

Till the end of 1970s, mental health services had for long been a relatively underdeveloped area in Taiwan. After the Taipei City Psychiatric Center (TCPC), funded by Dr EK Yeh in 1969, successfully innovated the first integral community mental health programs for the capital city, the Department of Health granted a 15-year project to establish the psychiatric care network for distributing mental health care throughout Taiwan (1986–2000).

There were two events, the Mental Act enacted in 1990 as well as the National Health Insurance Program launched in 1995, significantly influenced the development of community mental health. The former represents great progress in respect of human rights and ethical practice for all mental health professionals. The later, with a wide coverage, reimburses the medical expenditure for treating mental illness, including psychiatric rehabilitation. However, the payment system gave an impetus to the rapid growth of hospital-based services, rather community care.

Following TCPC model, the community rehabilitation programs were traditionally hospital-based, but more innovating rehabilitation programs have developed to meet the various needs among communities. Furthermore, under the rapid changing of the society, it turned to be big challenges to integrate the increasing demands, for instance, care for people with common mental disorders, and suicide prevention work etc., for the unmet needs in the community mental health services. In addition, the psychiatric rehabilitation was also in the process of transforming, no matter hospital-based or community-based, in which the core was to more closely meet the consumers’ need.

COMMUNITY MENTAL HEALTH IN HONG KONG

Hung Se Fong

RS30 RURAL MENTAL HEALTH SERVICE DEVELOPMENT – EFFECTIVE MODELS OF CARE

Sadanand Rajkumar, Tarek Okasha, Roy Kallivayalil, Fred Kigozi, Lakshmi Vijayakumar

Context: There is a widening gap in service development between highly industrialised and low income countries in regard to rural mental health care. Evidently this gap prevails even more so within each country with populations undergoing considerable epidemiologic and demographic transition. Rural areas are not homogenous and differ from one another reflecting changes in some social systems, culture, economics and environmental conditions. The WPA Section on Rural mental health attempts to address some of these rural issues through this symposium.

Objectives: The presenters will examine the rural challenges as it prevails globally and address how effective models of mental health care have developed in rural settings. These would be illustrated with examples from Australia where good models exist and India, China, Egypt and Uganda where rural populations are predominant. It would cover a broad spectrum of interventions from mental health promotion, illness prevention, care and rehabilitation.

Key messages: Efficacy models of care are few and difficult to implement under optimal programme conditions but there are, often unpublished or under-reported effective models of rural mental health care that have relevance to people at risk under normal practice conditions. Possibly some of these interventions are replicable across nations.

Conclusions: Populations in rural and remote communities suffer several adverse environmental situations that impact on health and illness. This symposium will provide a framework for service development relevant to rural settings, drawing lessons from effective models of interventions such as NGO initiatives; public-private enterprises; GP shared care models in primary care and newer available models of care across countries.

PROMOTION AND PREVENTION MODELS IN RURAL MENTAL HEALTH

Sadanand Rajkumar

Background: Rural settings have diverse groups of people spread over vast and changing socio-cultural situations. Often they are traditional, isolated and culturally discrete. Those in poor income countries rely for health issues on traditional healers and alternative therapies. Others have better access to modern medicine. Several nations do not have a mental health policy, let alone a promotion and prevention policy. This presentation focuses on special populations of remote and rural areas.

Objective:

The focus is on effective models of mental health promotion and illness prevention appropriate for rural areas with comparison between programmes for ageing and dementia between Australia and India.

It takes into account the intrinsic culture of rural settings.

It examines socio-economic factors and demographic changes, ecological crises, globalisation and internal migration.

Key messages:

It is difficult to extrapolate models of care which are efficacious in one setting to a different rural situation.

The locus of mental health promotion practice needs to move from an individual perspective to one involving community.

Voluntary agencies have a major role in implementing mental health promotion and illness prevention.

Sustainable impact is possible only with significant participation from local people.

Conclusion: A major competent of models of care is prioritising mental health promotion and illness prevention. Global, national and local models of effective strategies need replication in rural settings, where the cultural milieu and the mental health literacy remain a considerable challenge. Garnering inter-sectoral support is needed in bringing about a change in the overall Well-Being of rural people.

MENTAL HEALTH SERVICES IN EGYPT – A RURAL PERSPECTIVE

Tarek Okasha

Six hundred years ago, before Europe had mental health services in general hospitals, Egypt had such a service in Kalawoon hospital in Cairo, with 4 wards; surgery, medicine, ophthalmology and psychiatry. In 1942 Egypt started to implement the concept of psychiatric services in general hospitals.

Egypt lies on the Mediterranean Sea; part of it lies in Africa and part of it (Sinai) lies in Asia. Egypt is considered an African, Mediterranean, Arab and a Middle Eastern country at the same time. Egypt is one million square kilometers, with a population of 70 million.

97% of Egyptians live on 4% of the land mainly in the Delta region and the Nile valley. The population density in Egypt is 59/ sq. km, while the population in Cairo is about 15-16 million in the daytime, and approximately 12 million during the night. The population density in Cairo is 31,697 / sq. km, Cairo is considered one of the most crowded cities in the world.

Egypt is divided into 26 governorates and has around 130,000 doctors, 1000 psychiatrists, 250 clinical psychologists and 1355 psychiatric nurses. Psychiatric services are provided through general hospitals, state hospitals, university hospitals and private hospitals amounting to about 9000 beds. Egypt is moving towards primary care in psychiatry through general practitioners and this has been incorporated into the National Mental Health Program for the past 12 years, rather than community care, which is not feasible because of financial, cultural and religious beliefs. This presentation will review the mental health services in Egypt at the moment together with future plans with emphasis on services in the rural areas.

REHABILITATION SERVICES IN RURAL AREAS FOR MENTALLY ILL: SHARED CARE MODEL FROM INDIA

Roy Abraham Kallivayalil

Mental health is not a priority area in many developing nations. India is not an exception. Less than 2% of health budget is earmarked for mental health services. Many Indian States are ahead of others in health care delivery. Kerala State in South India is a notable example, where health indices are almost at par with developed countries like UK an USA. The life expectancy in Kerala for females is 74.5 and more males 72. The infant mortality rate is as low as 10.

However, the investment on mental health continued to be poor. This led to some committed NGOs taking lead to look after the mentally ill. The Navajeevan and the Mariasadan centres are two such success stories. In a bold initiative, Government run Medical College's Post graduate Department of Psychiatry decided to provide outreach services to these two centres. We are analyzing the clinical profile and the experience with 400 patients in these two centres, run almost entirely without government funding. Lay people, social workers and public spirited individuals make liberal donations to cover the expenses. This is a historical success story of people's initiative in mental health and a model for low cost, high quality psychiatric services in rural areas.

CHALLENGES IN DELIVERING MENTAL HEALTH SERVICES IN RURAL SUB-SAHARAN AFRICA

Fred Kigozi

Delivery of Mental Health services has been a big challenge in Sub-Saharan Africa. It is even a bigger challenge when it comes to meeting the mental health needs of rural populations in the Region. The low prioritization of mental health amidst very scarce resources for the overall delivery of general health care in general, complicates the effort being undertaken by the few mental health professionals in the Sub-Saharan Africa.

In addition, there are issues of a very poor infrastructure and lack of other complimentary services acting as a dis-incentive for the competent personnel to work in such remote areas. Most governments have in line with the Alma Ata 1978 and WHO recommendations, adopted mental health as part of the Essential Minimum Health Care Package to be delivered at all levels of health care in all the health policies and health Sector Strategic plans and programmes.

All the above issues will be discussed giving the progress so far attained by Uganda as an example of Sub-Saharan Africa with very limited resources. The recommendations and way forward will be highlighted in light of our experience.

RURAL SUICIDE IN INDIA – NATIONAL POLICIES AND NGO INITIATIVES

Lakshmi Vijayakumar

Around 70% of over one billion Indians depend on rural agriculture for their livelihood. One third of world farmers are in India but as majority are subsistence farmers they contribute to only 22% of GDP.

Over 100,000 people end their lives by suicide in India and about 15% of suicides are by farmers and farm workers. The last decade has witnessed a phenomenal increase in farmer's suicide. The suicide rate of farmers has increased by annual compound growth rate of 3.9 from 1997. The suicide rate of farmers is 30% higher than the general suicide rate.

Farmers’ suicide are highest in the semi arid regions of South India. Almost two thirds of farmer's suicide are from four states, in the region and the suicide rate of farmers is double the general rate. Majority of farmer's suicide occur between 30–59 years of age mostly among men and majority are head of households which causes major social, economic and psychological distress. Eighty percent of farmer's suicide are by ingestion of pesticides. The easy availability, lethality, lack of antidote and inadequate and inaccessible health services contribute to the high mortality of pesticide suicides in India.

A variety of factors have been associated with farmers suicide, like debt trap, drought, crop failure, changing crop pattern, reduced governmental support, reduced credit, inadequate market support etc.

Many commissions have been formed to address this issue and considerable progress has been made in certain regions. However, farmer's suicides continues to rise which requires concerted and cooperative action from the policy makers, planners, mental health professionals, economists, agricultural and chemical industry, farmers, NGO's and others to address this burning issue.

RS31 PSYCHIATRIC SERVICES AT TIMES OF TRANSITION – DILEMMAS AND CHALLENGES

Dusica Lecic Tosevski, Jiri Raboch, Livia Vavrusova, Antoni Novotni, Michel Botbol

Development of psychiatry is different in European countries and depends on many factors involving economic development, professional resource availability, national priorities and the particular culture. In addition to that, some countries are facing prolonged stress and difficulties due to civil conflicts, continuous political upheaval and social transition, with increasing prevalence of mental disorders. A movement towards renewal of collaboration, reform of psychiatry and harmonisation of mental health policies has started in Central and Eastern European countries, as well multicentric research studies. However, the times of transition gives specific features to organisation of mental health care and psychiatric services. Advances, dilemmas and challenges of Central European countries regarding mental health care will be discussed, and compared to western countries. Given the irreversible trend toward globalization and the growing complexity of our field, international collaboration will become one of the main challenges for the next decade.

DILEMMAS IN THE CZECH REPUBLIC

Jiri Raboch

There was no period of rapid deinstitutionalization in the Czech Republic, but the number of psychiatric beds was substantially reduced in the last decade. However, in recent years this trend has stopped. In the year 2002 we had 21 psychiatric hospitals with 10.045 beds and 33 psychiatric units in general hospitals with 1546 beds. Every psychiatric hospital has a catchment area of about 1 million inhabitants. The distance from a patient's home is sometimes up to 200 km. Officially only chronic patients should be hospitalised in these facilities. However, due to the lack of acute beds in general hospitals about 1/3 of their capacity is occupied by acute admissions. The average length of hospitalisation despite its decline in the last decade remains high, being 80 days in psychiatric hospitals and 22.5 days in general hospitals. 99% of psychiatric beds are state owned. The higher number of beds in our country can be explained both by the tradition of in-patient care in central Europe and by the fact that psychiatry is substituting lacking social care and community services. It is estimated, that about up to one third of the patients are hospitalised for social reasons, e.g. mentally retarded, patients with chronic schizophrenia or old sick people without accommodation, relatives and other social support. There are no official statistics regarding community psychiatry. Thanks to the European research project EDEN (European Day Hospital Evaluation) we know more about the functioning of day care centres in our country which will be presented.

IMPLEMENTATION OF GREEN PAPER ON MENTAL HEALTH IN SLOVAKIA

Livia Vavrusova, Eva Palova

From the perspective of Slovak psychiatry, the introduction of an EU strategic policy is welcomed. To make the EU strategic policy objectives more relevant there is an agreement that priorities of mental health have to be defined more specifically as this way they create misunderstandings concerning competencies. We have to emphasize that there are mental illness which will not resolve purely by development of social measures and that there are necessities for hospital care and alternative psychiatric care should be further developed. Serious and enduring mental disorders, many of which may have biological basis, will never resolve with social strategy alone. Some conditions will continue to present and require medical care strategies necessitating psychiatric and associated specialist professional skills. It remains at times an effective, safe and cost efficient care strategy. We have a considerable concern that there is no mention of policies to develop specialist training or the maintenance of high quality in respect of training gain no mention. Sufficient resources should be allocated to research on prevention and promotion in mental healthcare as well as for the search of the causes of mental disorders. Especial emphasis should be placed on the transfer of scientific results into clinical practice. Although primary prevention is of utmost importance the improvement of the social environment in other relevant areas of primary prevention will not prevent most of the mental disorders. Thus, talking about the mental health of the population cannot exclude the healthcare system and the treatment of mental illness.

MENTAL HEALTH SERVICES AND MENTAL HEALTH ECONOMICS IN MACEDONIA

Antoni Novotni

The author will discuss main problems which mental health services in our country are faced with. We'll focus on lack of new generation antipsychotics and antidepressants on the market in Macedonia and low standards of our patients as a factor which interfere with the compliance (and drop-outs) of any applied pharmacotherapy. A part of presentation will focus on current situation (number of psychiatric hospitals, beds, available psychiatrists …) and reforms in our mental health system – transition from medicocentric-patocentric system (with big asylum hospitals and use of coercive hospitalization) to community based mental health system. The low input of the health care budget going into mental health care, and specifics of mental health economics in general, will be discussed. This presentation will shortly elaborate situation with education, MH projects and MH programs. The priorities of mental health service in our country, underlined in our NMH Policy, would be discussed.

ADVANCES AND CHALLENGES OF MENTAL HEALTH CARE IN SERBIA

Dusica Lecic-Tosevski

Disastrous events in the country and the region caused 13.5% increase of mental and behavioural disorders in the last few years, thus making them the second largest public health problem (after cerebro-vascular diseases). The overall morbidity and mortality are on the rise. Intense acute and chronic stress, as well as the accumulated traumas caused significant psychological sequelae, especially to vulnerable people. Due to prolonged adversities health system has deteriorated and is facing specific challenges. However, the reform of mental health care has been initiated, with a lot of positive movements such as preparation of the National policy for mental health care as well as the Law for protection of mentally ill individuals. The transformation of mental health services in accordance with Helsinki declaration has started and it has eleven steps, with an accent on community care, antistigma campaigns and continuous education. Service provision, number of professionals working in services, funding arrangements, pathways into care, user/care involvement and other specific issues based on the assessment carried out by the National Committee on Mental Health are reported.

A VIEW FROM THE WEST

Michel Botbol

Western Europe political stability and economic profile contrast with those of most central European countries. Nevertheless, Western European Psychiatry is facing drastic changes.

In spite of very strong resistances, globalization of theoretical and practical references account for many of these changes that are also affected by the profound modifications of Europe political frame, mainly through the European Community becoming the new pertinent level for stake holders in mental health. The example of France will be brought to show the attempt that are made to bridge the gap between tradition and modernity in this new context.

RS32 ASSERTIVE COMMUNITY TREATMENT: INTERNATIONAL PERSPECTIVES ON EVIDENCE, IMPLEMENTATION AND PRACTICE

Carol Harvey, Helen Killaspy, Lindsey George

Context: Assertive Community Treatment (ACT) focuses on patients with serious mental illness, particularly those who have experienced frequent hospital admissions and have difficulties engaging with services. Clinical and cost-effectiveness of ACT have been demonstrated in numerous randomised controlled trials, mostly in the USA (Stein, 1980; Marshall, 1998), with successful replications and service evaluations in Australia and elsewhere (e.g. Hoult, 1986). Meta-analyses of home-based treatment models suggest that certain features of the ACT model may be more important in achieving successful client outcomes (Catty, 2002). In relative contrast, UK studies have suggested little advantage for ACT over “usual care” from community mental health teams (e.g. Killaspy, 2006). One possible explanation for reported differences in efficacy may be international differences in the implementation of ACT. Variations in implementation of ACT may also provide further clues about effective components of the model.

Objectives: This symposium will: provide a brief summary of the evidence for ACT in the USA and elsewhere; describe ACT implementation in various countries (Australia, Canada, UK and USA), highlighting the similarities and differences in the model in each setting; and, draw out the implications for ACT effectiveness and practice, emphasising the most likely active ACT ingredients, through a panel discussion.

Key messages: There are variations in implementation of the ACT model both within and between countries. Some of this variability may be captured by existing fidelity measures such as the Dartmouth Assertive Community Treatment Scale (DACTS) (Teague, 1998). Comparisons of ACT between different countries and with usual community mental health care provide growing support for the notion of “active ingredients” of the ACT model. Postulated active ingredients include: integrated health and social care; small caseloads; home visiting; and, the team approach. Persistent engagement with clients also appears to be an important part of the model. However, it is not yet fully understood how best to achieve or measure this.

Conclusions: International studies of the implementation of ACT may continue to enhance our understanding of differences in efficacy and effectiveness. It is suggested that further research into ACT should focus on effective components of the model rather than solely focusing on program fidelity.

COMPARISON OF THE IMPLEMENTATION OF ASSERTIVE COMMUNITY TREATMENT IN MELBOURNE, AUSTRALIA AND LONDON, ENGLAND

Carol Harvey, Helen Killaspy, Salvatore Martino, Sarah White, Stefan Priebe, Christine Wright, Sonia Johnson

Background: Differences in implementation of assertive community treatment (ACT) may explain variability in reported efficacy.

Aim: We aimed to investigate differences in ACT implementation between Melbourne and London.

Methods: We gathered data on team organisation, staff and client characteristics from four Melbourne ACT teams using almost identical participant sampling and data collection methods to the Pan London Assertive Outreach studies of 24 London ACT teams.

Results: Three of four Melbourne teams made over 70% of their client contacts “in vivo” compared with only one third of comparable London teams. Melbourne teams scored more highly on team approach. Three quarters of all clients were admitted in the preceding two years but Melbourne clients had shorter stays.

Conclusion: Differences in implementation of “active components” of home treatment models such as home visiting and the team approach may explain international differences in ACT efficacy. Existing fidelity measures may not adequately weight these important elements of the model.

CASE MANAGEMENT AND ASSERTIVE COMMUNITY TREATMENT – EVIDENCE AND IMPLICATIONS FOR PRACTICE

Alan Rosen, Kim T. Mueser, Maree Teesson

Objectives: This paper aims to describe how case-management has become an integral component of the care of people with severe psychiatric disabilities, and to update briefly the evidence base for standardization, efficacy, effectiveness, and cost-effectiveness for case management, particularly Assertive Community Treatment (ACT). Evidence on psychiatric case management and particularly its Assertive Community Treatment (ACT) variant, may have implications for change in clinical practice.

Method: The current evidence-base for case management (particularly for ACT) will be reviewed, drawing on the evidence base in North America, Australasia and Britain, to examine trends and concerns arising from the evidence on case management (including ACT,) which have important implications for practice.

Results: There is strong evidence for the fidelity standardization, efficacy, effectiveness and cost-effectiveness of case management in psychiatry, particularly if it conforms to ACT models. There are significant methodological problems and concerns affecting implementation arising from evidence-based studies and reviews of case management, including ACT.

Conclusion: On the evidence, the ACT model of Case Management is one of the most effective systematic models for organizing clinical and functional interventions in psychiatry today. ACT was designed for the most functionally impaired subset of service users with severe and persistent mental illnesses. But it is not a case of “one size fits all” and other less intensive case management models may be effective for populations with less severe symptoms and disabilities. While the evidence-base supporting ACT and some of its variants is robust, there are some concerns arising from these studies which have marked implications for practice.

The more effective case management systems meet more of the ACT fidelity criteria, are often non-coercive; do not rely on compulsory orders, may rely on a wider range of interventions than just ensuring medication adherence, including vocational and substance abuse rehabilitation; have other evidence based interventions in their content, and more mobile in-vivo interventions, involve individual as well as team case management, may involve service users as direct service-providers, have an interdisciplinary workforce and support structure within the team, which also provides some protection from work-related stress or “burn-out”.

RS33 WHAT IS RECOVERY? AN AUSTRALIAN PERSPECTIVE

Ingrid Ozols, Jenny Burger, Margaret Leggatt, Barbara Robb, Julian Freidin, Marie Piu, Michaela Amering, Caroline Crosse, Arana Pearson, John Watkins

Recovery from a mental illness is viewed by some as an outcome measure, a restoration through some means to the same condition prior to onset of illness or injury. Others view recovery as a new way of living and being.

Recovery is a personal process, at times, a deeply painful healing of the soul, a transformation, a journey of self-discovery. It is about new learnings, new ways of thinking.

In some respects the journey is a lone one, no one else can “do the hard yards,” but it cannot be done in total isolation, support and encouragement is vital.

The therapeutic relationship with a mentally ill person and their psychiatrist or health care professional cannot be understated.

The ideal facilitation for recovery is a partnership based on trust, mutual sharing and one which encourages carers to join and enhance the process.

There is increasing awareness that a wide range of skills and experiences is needed to assist an individual recover from mental illness and it's impact on the person and their family. The role of the psychiatrist can and should be part of the debate about what is helpful. Moving from a traditional model of psychiatrist/clinician as the primary helper, consumers, carers and other community representatives argue for and encourage discussion about where clinical knowledge sits in regard to recovery.

This innovative symposium will initially bring together a carer, a consumer and a clinician to give their views and explore the potential of building commonality of purpose. The symposium will then open up to provide a range of “snapshots” from specific perspectives on recovery pathways. These will include: a Maori consumer working as a Recovery Professional, a priest who works with people with complex needs and as an advocate for them, an employer, a traditional psychiatrist, a psychiatric disability rehabilitation support service worker; an Asian viewpoint, a political perspective, and a transcultural worker.

Members of the audience will be invited to actively contribute to the facilitated discussion.

The aim of the symposium is to challenge the views of clinicians, consumers and carers and to open up pathways for a collaborative approach to recovery.

RECOVERY – A JOURNEY OF SELF-DISCOVERY

Ingrid Ozols

“Imagine a butterfly caught in a spider's web frantically trying to escape. The more the brightly coloured creature flutters and panics, the more enmeshed it becomes. Terror and paralysis sets in. The butterfly is unable to move or fly, awaiting impending doom. Being caught helplessly in a sticky web is an apt metaphor to describe an episode of clinical depression”. Through my recovery I have learned how to negotiate the spider's web and to befriend the spider in so doing discovering strength through vulnerability.

CARERS AND RECOVERY

Barbara Robb

When mental illness hits it disrupts the lives of every one it touches. Research indicates that being a carer increases levels of stress, depression and anxiety, creates financial and relationship burden.

When family and friends stay actively engaged, the ill person is more likely to avoid some of the more devastating outcomes of mental illness such as social alienation, homelessness and the development of chronic relapse patterns.

This session will briefly consider the challenges and barriers to the caring role and discuss what assists in carer resilience and recovery.

A PSYCHIATRIST'S VIEW ON WORKING WITH HOMELESS PEOPLE SUFFERING MENTAL ILLNESS

Julian Freidin

People suffering both mental illness and homelessness often have been in contact with psychiatric services and found the experience unhelpful. The challenge for the clinician who wishes to assist these people is to find ways to engage with them and understand that their needs and wishes may be different from those of the clinician. If agreement can be reached on what is a helpful, the clinician can then assist the process of recovery.

WHAT IS RECOVERY? A PERSPECTIVE FROM CARERS OF CULTURALLY AND LINGUISTICALLY DIVERSE BACKGROUNDS IN AUSTRALIA

Marie Piu

‘Recovery’ suggests one thing to mental health service providers and another to CALD carers. This is because of different cultural understandings of the causes and treatment of mental illness. The clinical encounter needs to have built-in flexibility to resolve such misunderstandings and to give carers a meaningful role in the treatment of their loved ones. CALD carers cry out for understanding and compassion. They need to express what they believe is happening, to vocalise their distress and air their confusion. The system needs to rise to the challenge.

FORUM ON RECOVERY

Michaela Amering

The European Union has with the European Commission's Green Paper on Mental Health set an ambitious agenda regarding a participatory approach towards achieving new mental health goals. Many clinicians do wish to use these great opportunities to fight stigma and discrimination and to develop services and therapeutic relationships according to the emerging evidence-base of recovery-orientation. However, ongoing political and practical support is needed in order to advance and fully exploit new forms of co-operations with consumers, families and activists on all levels in order to implement necessary changes to overcome reductionistic frameworks and to improve and integrate mental health care.

ROLE OF EMPLOYMENT IN RECOVERY FOR PEOPLE WITH A PSYCHIATRIC DISABILITY

Caroline Crosse

This session will highlight how employment should not only be viewed as a goal of rehabilitation but as part of the process, providing a platform from which recovery can take place.

Employment gives us a sense of purpose, connection and identity. It is not until these over-used terms are absent from our lives that we fully appreciate their importance. For people with a psychiatric disability, a group who often feel abandoned by the rest of the community, a job can be a lifeline. It is the community saying yes to the individual, confirming their value to, and place in, society.

TRAINING THE AUSTRALIAN MENTAL HEALTH SECTOR FOR RECOVERY: APPROACHES IN PRACTICE AND POLICY

Arana Pearson

Context: The mental health services in Australia have a focus on recovery in the third national mental health plan.

Objectives: The question ‘what does recovery mean’ and ‘what does a recovery focused mental health system look like’ is discussed with particular reference to training the sector. The policy of including a consumer perspective within mental health has been a feature of this development.

Key messages: The lived experience of recovery is a key value and knowledge base for the development of the Australian mental health sector and community.

Conclusion: The paper will examine whether mental health sector has had a fundamental shift in developing a recovery focussed service.

SPIRITUALITY, HEALING AND RECOVERY

John Watkins

Recovery is a highly individual, deeply personal undertaking which necessarily involves every facet of a human being's existence – body, mind and soul. The essential nature of recovery remains a mystery which defies simplistic definition and certainly does not lend itself to wholesale commodification. Although the literal meaning of the word psychiatry is the “healing of the soul”, the notion of healing is now rarely spoken of in the context of mental health. An holistic approach acknowledges the importance of grounded spirituality and, in so doing, recognises that every human being is on their own unique journey of healing and recovery.

RS34 THE MENTAL HEALTH FIRST AID PROGRAM IN THE ASIA–PACIFIC REGION

Anthony Jorm, Betty Kitchener, Len Kanowski, Yuriko Suzuki, Harry Minas

Context: Mental Health First Aid is the help provided to a person developing a mental health problem or in a mental health crisis. The first aid is given until appropriate professional treatment is received or until the crisis resolves. Because members of the public generally lack mental health first aid skills, a Mental Health First Aid training program was developed in Australia 2001.

Objectives:

To give an overview of the training program developed in Australia;

To describe studies evaluating its effectiveness;

To describe cultural variations of the course;

To describe planned extension of the course to Japan;

To describe the development of mental health first aid guidelines for Asian countries.

Key messages: The first aid model has been successfully applied to early intervention for mental health problems in Australia and other Western countries. The concept may also be applicable in some Asian countries. There needs to be cultural adaptation for this to successfully occur.

Conclusion: The mental health first aid model has spread to several countries over quite a short period. It has the potential to become a world-wide training approach but needs cultural adaptation for this to occur.

OVERVIEW OF THE MENTAL HEALTH FIRST AID PROGRAM

Betty Kitchener

Context: The Mental Health First Aid course was developed in Australia and has found rapid acceptance with the public.

Objectives: To describe the reasons for developing the course and to account for the success of this training model.

Key messages: Many members of the public want to help people developing mental disorders or in crisis situations, but are uncertain what to do. Because they are familiar with the first aid model for medical emergencies, the extension of the first aid concept to mental health has occurred easily. Another factor in its success has been the partnership model, whereby the originators of the course partner with a variety of organizations that can maintain it at a local level. A third factor to its success is its rigorous evaluation.

Conclusions: It is possible the Mental Health First Aid Certificate will become a requirement for certain occupations such as teaching, the police force and welfare workers.

EVALUATION OF THE MENTAL HEALTH FIRST AID PROGRAM

Anthony Jorm

Background: Mental Health First Aid training needs to be evaluated for effectiveness and continually improved.

Aim: The talk will describe several studies on effectiveness and recent work to develop mental health first aid guidelines.

Methods: Two randomized controlled trials and a qualitative study have been completed with members of the public. A trial of Mental Health First Aid training of secondary teachers is currently underway. Guidelines are being developed using Delphi studies of the expert consensus of clinicians, consumers and carers.

Results: The completed trials show that training increases mental health literacy, reduces stigma and increases helping behaviour. The Delphi studies show that diverse expert groups can come to a consensus about appropriate first aid actions for developing mental disorders and crisis situations.

Conclusions: A key feature of the Mental Health First Aid program is the close interaction between training development and research.

CULTURAL ADAPTATIONS OF MENTAL HEALTH FIRST AID TRAINING

Len Kanowski

Context: The Mental Health First Aid course requires cultural adaptation to make it relevant to diverse groups.

Objectives: To describe cultural adaptations of the course and its spread to a range of other countries.

Key message: Within Australia the course has required cultural adaptation for the Vietnamese Australians and the Aboriginal and Torres Strait Islander peoples. There have also been adaptations in other countries: UK, Hong Kong, Canada, Finland, Singapore and US.

Conclusion: It shows the model is adaptable to a range of cultures and health systems.

ADOPTATION OF MENTAL HEALTH FIRST AID IN JAPAN

Yuriko Suzuki, Ryoko Sato, Daisuke Fujisawa, Takahiro Kato, Kotaro Otsuka

Context: Mental Health Fist Aid is widely adopted in Australia and countries in Asia. From previous studies, non-mental health professionals showed greater social distance to people with mental illness, although they have greater chance to encounter the people with mental health problem in health care settings.

Objectives: To develop and implement a pilot program using Mental Health First Aid for postgraduate medical doctors to increase mental health literacy of non-mental health professionals.

Key message: From qualitative study of service user's perspective, they experienced discrimination in negative way in the area of physical health. From health professionals’ perspective, the mental health literacy among non-mental health professionals is limited. In Japan, after an introduction of postgraduate medical training from 2004, training period in psychiatry is an avenue to increase mental health literacy of non-mental health specialists in their early career.

Conclusion: We will describe the formative process of the pilot program, with identifying target population, modification of educational materials with relevance to medical professionals who are not necessary interested in mental health, and design of the evaluation study This formative study will facilitate future development and dissemination of Mental Health First Aid in wider global context.

DEVELOPMENT OF MENTAL HEALTH FIRST AID STANDARDS IN ASIA

Harry Minas, Steven Klimidis, Anthony Jorm, Robyn Langlands, Claire Kelly, Betty Kitchener

Background: Mental Health First Aid is a program that has been developed, rigorously evaluated and widely adopted in Australia. The program has been adapted for application in a number of different cultural contexts. While work is currently being done to establish standards for provision of mental health first aid for mental disorders based on consensus of experts Australia, New Zealand, the United Kingdom, Canada and the USA, no such standards exist for Asian cultures.

Aim: The aim of this project is to establish standards for provision of mental health first aid for xxx in Asian countries.

Methods: The project is using the Delphi technique to survey expert opinion as to the best way to support someone who may be experiencing a psychotic episode. The Expert Panel is composed of 28 psychiatrists who are graduates of the International Mental Health Leadership Program and who work in Cambodia, China, Hong Kong, Indonesia, Japan, Korea, Malaysia, Mongolia, Sri Lanka, Taiwan, Thailand, and Vietnam.

Results: Data collection has been completed and results are being analysed.

Conclusion: We will be able to present conclusions as to whether standards derived from a panel of expert Asian psychiatrists and standards derived from an expert panel from Australia, New Zealand, the United Kingdom, Canada and the USA are similar or different. This will have implications for the application of the mental health first aid method in Asia.

RS35 IMPROVING MENTAL HEALTH CARE FOR PEOPLE WITH DEMENTIA, THEIR CAREGIVERS AND RESIDENTS OF NURSING HOMES

John Snowdon, Johannes Wancata, Siegfried Weyerer, Anne Margriet Pot, Daniel O'Connor

Context: Most residents in nursing homes have dementia, and over one third have depressive disorders. Behavioural and Psychological Symptoms of dementia (BPSD) are reported to be common in nursing homes. However, availability and quality of mental health services in nursing homes are sub-optimal in many areas of the world.

Objectives: This symposium aims to draw attention to strategies that should result in improved mental health care for people with dementia, their caregivers and residents in nursing homes. By examining the validity and utility of depression screening tools when administered in nursing homes, it is intended to provide impetus for regular use of the Geriatric Depression Scale (GDS) and/or the Cornell Scale for Depression in Dementia (CSDD) in order to identify and intervene in cases of clinically significant depression. We also examined use of psychotropic medications in nursing homes. Use of non-pharmacological interventions in treating BPSD have been reviewed, and an innovative approach to achieving'mastery over dementia' has been examined while attempting to reduce depression and negative impacts among caregivers.

Key messages:

The GDS (for those scoring 15+ on the MMSE) and CSDD have proved valid in revealing cases of depression in nursing homes, that can benefit from appropriate treatments.

Antipsychotic drugs are widely used in German nursing homes. Use of psychotropic drugs is an independent risk factor for falls in residential facilities.

A range of non-pharmacological strategies is available as alternatives to medications in treating BPSD and should be considered.

Information, self-help and counselling can help reduce depression and feelings of burden among caregivers of persons with dementia.

Conclusion: The symposium discusses findings and initiatives that will help spur the development of improved mental health services for those residing in nursing homes, those with BPSD and depression, and those caring for people with dementia.

CRITERION VALIDITY OF THE GERIATRIC DEPRESSION SCALE IN NURSING HOMES: A META-ANALYSIS

Johannes Wancata, Maria Weiss, Barbara Marquart, Rainer Alexandrowicz

Background: The Geriatric Depression Scale (GDS) was specifically developed for the elderly, considering typical problems of depression assessment among this population.

Aim: The purpose was to perform a comprehensive meta-analysis of the criterion validity of the GDS in nursing homes.

Methods: MEDLINE, other electronic search tools and previously publishes reviews were used to search for published studies. The following studies were excluded: samples with less than 50 participants, no clear external case criterion, telephone-versions and psychiatric samples.

Results: Of the 173 papers read, 45 studies fulfilled the above mentioned criteria and could be included for detailed analyses. Of all GDS-15 studies in nursing homes the mean sensitivity was 0.897 and the mean specificity was 0.741. All GDS-30 studies in nursing homes taken together, the mean sensitivity was 0.746 and the mean specificity 0.750. For the GDS-15 as well as the GDS-30, the mean sensitivity in nursing homes was significantly higher than among outpatients, while the mean specificity was significantly lower in nursing homes. Mean sensitivity and specificity of the GDS-30 did not differ significantly from that of the GDS-15.

Conclusion: A large proportion of validity studies had to be rejected from analyses because of methodological flaws. In contrast to other screening tools, in nursing homes the GDS does not perform worse as compared to outpatients.

VALIDITY AND UTILITY OF THE CSDD IN NURSING HOMES

John Snowdon, Richard Fleming

Background: An expert panel recommended screening for depression in nursing home residents some 2 to 4 weeks after admission and at least every 6 months thereafter. Use of the Cornell Scale for Depression in Dementia (CSDD) is preferred for residents with moderate or severe dementia.

Aims: To assess whether the CSDD is being used in Australian aged care facilities (ACFs) as recommended, to assess its validity, and to note findings from studies that have used the CSDD.

Methods: Staff of Australian nursing homes were asked about use of depression screening tools in their facilities. In a separate study, the CSDD was administered to one quarter of the residents of 168 ACFs in Australia. Thirty-one subjects were rated on the 15-item Geriatric Depression Scale and CSDD, and were clinically assessed by an old age psychiatrist. Other studies using the CSDD were reviewed.

Results: CSDD scores of 8 or more were recorded for 40.5% of the 1084 high-care (nursing home) residents and 25.4% of low-care residents. CSDD and GDS scores correlated satisfactorily (r = 0.6), and those residents identified as clinically depressed scored high on the CSDD. Results were comparable with those from other studies. Few Australian nursing homes use the CSDD on a regular basis to monitor for depression.

Conclusion: Use of the CSDD in nursing homes facilitates recognition of cases of depression and could be used in monitoring response to treatment.

DETERMINANTS AND CONSEQUENCES OF PSYCHOTROPIC DRUG USE IN GERMAN NURSING HOMES

Siegfried Weyerer, Martina Schaufele

Background: The appropriate use of psychotropic drugs in nursing homes is a problem of increasing concern.

Aims: To determine the patterns and consequences (e.g. risk of falling) of psychotropic drug use in nursing homes. Furthermore, to study the use of psychotropic drugs among persons with dementia in special care units (SCU) and in regular integrative units (RU).

Methods: All residents (N = 1922) in 20 randomly selected old age homes in Mannheim were examined. The types and dosage of medication actually taken were recorded together with information on functional impairment and falls. Additionally, the use of psychotropic drugs was determined among dementia patients in SCUs and in RUs.

Results: 58.0% of the residents had used psychotropic drugs: 37.4% antipsychotics, 12.7% antidepressants, 10.9% tranquilizers and 8.0% hypnotics/sedatives. There was a highly significant relationship between psychotropic drug use and subsequent falls (OR = 1.6; 95% CI: 1.2–2.1). The overall use of psychotropic drugs among dementia patients in SCUs (77.9%) and in RUs (76.3%) was very similar. However, there were striking differences with regard to the use of antipsychotic drugs (RUs: 63.4%; SCUs: 41.2%) and antidepressants (RUs: 13.0%; SCUs: 23.6%).

Conclusion: Our data from Germany confirm the wide-spread use of psychotropic drugs among the residents of nursing homes. The findings suggest that the use of psychotropic drugs constitutes an independent risk factor for falls in old-age homes.

PSYCHOSOCIAL TREATMENTS OF BEHAVIOR SYMPTOMS IN DEMENTIA: A SYSTEMATIC REVIEW OF REPORTS MEETING QUALITY STANDARDS

Daniel O'Connor

Dementia is often complicated by behaviours like aggression, wandering and noisiness. The number and severity of these behavioural changes correlate strongly with carer burden and consequently with admission to aged residential facilities where rates are typically very high.

Antidepressant, antipsychotic and analgesic medications are often effective where behaviours stem from co-morbid major depression, delusions or pain. In remaining cases, antipsychotic medications are preferred by most psychogeriatricians. Their effectiveness is limited, however, and all of them have side-effects. Alternative approaches that seek to relieve behavioural symptoms by means of social, psychological and nursing interventions warrant serious scientific scrutiny. Such interventions include aroma, behaviour management, music, massage, recreation, personalized dementia care and simulated family presence.

This presentation will summarise the findings of a recent systematic review of 26 studies of psychosocial interventions. All of the papers met strict criteria relating to research quality. The systematic review was funded by the Australian Government through the Dementia Collaborative Research Centre and is intended to guide clinical practice in Australia.

MASTERY OVER DEMENTIA: ONLINE COUNSELING FOR FAMILY CAREGIVERS OF PEOPLE WITH DEMENTIA

Ann Margriet Pot, L. Dorland, J. Grolleman, H. Riper, M. Blom, J. Vuister

Context: The problems of family caregivers of people with dementia have been studied extensively. The results show a negative impact on mental health, varying from feelings of burden to psychiatric disorders including depression. Results of studies on the treatment of caregivers’ psychological problems are less clear-cut. They show no or only modest benefits.

Objectives: In this presentation the development of an innovative online treatment, i.e. ‘Mastery over dementia’, for family caregivers of people with dementia will be presented. The website treatment is primarily focused on diminishing the burden of caregivers, in stead of decreasing depression in the first place as in other treatments. In addition, it is an adaptive treatment, that can be modified in scope and intensity to fit the person and his/her needs. In these ways, it tries to overcome some of the shortcomings of existing treatments (Zarit and Femia, 2007).

Key messages: The three components of the treatment are provision of information, motivation towards self-help, and counseling. The rationale and some innovative technological aspects will be discussed.

Conclusion: ‘Mastery over Dementia’ is a product of the Netherlands Institute of Mental Health and Addiction in collaboration with Geriant, providing outpatient mental health care for people with dementia and their family members, and the patient organisation Alzheimer Netherlands.

RS36 TREATMENT MODALITIES OF SUBSTANCE USE DISORDERS IN DIVERSE SETTINGS

Chiao-Chicy Chen, Keh-Ming Lin, John Tsuang, Chih-Ken Chen, Kazufumi Akiyama, Shih-Ku Lin

Context: Substance use disorders (SUDs) are world-wide bio-psycho-social problems which cause tremendous economic burden. The treatment of SUDs and co-occurring mental disorders is a great challenge to psychiatrists. However, in the context of diverse culture, the treatment modalities of SUDs are varied. For example, in Taiwan, the patients with psychotic disorders are rarely seen co-morbid with SUDs. Most of the patients with SUDs, in particular opioid addiction and/or psychostimulant addicts (mainly methamphetamine) are incarcerated because they are viewed as criminals. In United States, the situation is different, for the substance abuse by patients with mental illnesses is quite common, with studies showing that psychiatric patients are five to six times more likely to develop alcohol and /or drug abuse problems than general population. In Japan, the psychiatrists have spent a lot of time dealing with methamphetamine-induced psychotic disorder, due to high prevalence of methamphetamine abuse.

Objectives: The purpose of this symposium is to invite four experts in Pacific Rim countries, namely, two from Taiwan and one from Japan and the US, to talk about their experiences in this field. Professor John Tsuang will talk about the treatment of co-occurring disorder patients in public in the US. Professor C.-K. Chen will raise the relationship between the co-occurring disorders and recidivism among incarcerated drug users in Taiwan. Professor K. Akiyama and his colleagues will discuss their experiences on the pharmacological treatment of methamphetamine psychosis. Professor S.-K. Lin will review the history of pharmacological management of drug abuse in Taiwan.

Key messages: Through the presentations, the authors will demonstrate their experiences in dealing with those patients with SUDs co-morbid with physical and/or mental illness. They find that either it is difficult in treating these patients in the mental health settings, or the recidivism rate is high in detention centers. They also discover that the response of psychotic symptoms to pharmacological treatment may predict the outcome.

Conclusion: The treatment of SUDs is not straight ward. There are still a lot of clinical studies to be conducted in order to establish a suitable modality which may meet the needs in different cultural background and diverse settings. This symposium provides some clues in dealing with these challenges.

TREATMENT OF CO-OCCURRING DISORDER PATIENTS IN PUBLIC SECTOR

John W. Tsuang

Context: Substance abuses by patients with mental illnesses are quite common, with studies showing that some psychiatric patients are 5-6 times more likely to develop alcohol and/or drug abuse problems as compared to those in the general population. The attempts to treat these co-occurring disorder patients with traditional modalities in the public sector have been unsuccessful.

Objectives: The purpose of this talk is to describe the development of an outpatient integrated dual diagnosis treatment program with aims to help patients remain abstinent and psychiatrically stable.

Key messages: The presenter will discuss the difficulties of treating co-occurring disorder patients either in a mental health setting or in a drug/alcohol treatment program. He will explain some of the basic principles in the development and daily running of an integrated dual diagnosis treatment program in the public sector. He will describe the development of the Harbor/UCLA Dual Diagnosis Treatment Program. He will conclude by summarizing some of the essential components in a dual diagnosis treatment program.

Conclusion: We want to describe the benefit of using an integrated treatment program to treat these co-occurring disorder patients. By discussing the development and the essential components this program, we hope to provide a model for others to emulate and to be better equipped to treat this population.

CO-OCCURRING DISORDERS AND RECIDIVISM OF INCARCERATED DRUG USERS IN TAIWAN

Chih-Ken Chen, Shu-Chuan Chiang, Shih-Ku Lin

Context: One of the most frustrating aspects of substance abuse treatment is the high rate of relapse after treatment. Besides, drug abusers are at increased risk for several comorbid conditions, such as one or more forms of psychiatric and physical illnesses.

Objectives: We set out to characterize psychiatric and physical comorbidity, particularly HIV and HCV infection, in incarcerated illicit drug users in Taiwan, and to examine the relationship between drug use behaviors and subsequent recidivism.

Key messages: The recidivism rate was 64.7% for methamphetamine users and 80.1% for heroin users during a 5-year follow-up period after detoxification at a detention center in Taiwan. Psychiatric comorbidity was commonly seen among these incarcerated illicit drug users. The focus of concerns for methamphetamine users was psychosis, while that for heroin users was HIV and HCV infection. Risk factors for methamphetamine-induced psychotic disorder included patterns of drug use, premorbid personality, familial loading of psychosis, and some genes in the dopamine system. Among IDUs, 25.9% tested positive for HIV, 78.2% for HCV.

Conclusion: Recidivism rates of illicit drug users in Taiwan after detoxification in the detention center were substantially high. The efficacy of detoxification programs in detention centers in Taiwan requires re-evaluation. Implementing harm reduction programs, particularly an effective prevention strategy for IDU-driven HIV in Taiwan is urgent.

PHARMACOLOGICAL TREATMENT OF METHAMPHETAMINE PSYCHOSIS WHICH ENDURES IN INCARCERATED ABUSERS

Kazufumi Akiyama, Atsushi Saito, Takashi Watanabe, Yoshinori Saeki, kazutaka Shimoda

Methamphetamine (METH) is a major psychostimulant abused in Asian/Pacific countries. Culminating evidence has indicated that long-term abuse of METH predisposes its users to psychosis that persists despite long-term abstinence. It remains unknown whether persistent psychosis in METH abusers may represent emergence of vulnerability to psychosis or may be simply attributable to the presence of co-morbid psychiatric disorders. The present study investigated clinical symptoms and pharmacological treatment in 80 female incarcerated patients who suffered from persistent METH psychosis and referred to psychiatric consultation. Patients exhibited psychosis at long-term abstinence from the last self-injection of METH: 1-6 months (n = 18); 7-12 months (n = 33); 13–18 month (n = 11); 19–24 months (n = 9); more than 25 months (n = 9). 20 patients experienced episodes of psychotic relapse. Either risperidone or haloperidol was assigned to patients as a first-line antipsychotic. When extrapyramidal symptoms occurred, haloperidol was replaced by risperidone or perospirone. Doses of various antipsychotics were gauged based on the equivalent mg dosage of haloperidol. Occasionally, antidepressant and mood stabilizer were required to improve affective symptoms. Eligible 32 patients underwent interviews biweekly or bimonthly either until they were discharged or at most for 120 months to measure symptoms using a 24-item Brief Psychiatric Rating Scale (BPRS) consisting symptom dimensions (positive, negative, manic and depression/anxiety). These eligible patients exhibited apparent difference in prognoses during pharmacological treatment. It seems likely that liability to extrapyramidal symptoms and refractory affective symptoms impede total improvement. These results suggest that both psychotic and affective symptoms are involved in therapeutic response and prognosis of METH psychosis.

PHARMACOLOGICAL MANAGEMENT OF DRUG ABUSE

Shih-ku Lin, Chiao-Chicy Chen, Wen-Su Lien

Context: Drug abuse is a chronic and relapsing disorder, needing both psychosocial and biological interventions to alleviate the adverse consequence to least.

Objectives: Here we review the pharmacological treatments that have been used in Taiwan and the trend of medications introduced in recent years.

Key messages: The concept of maintenance therapy of opioid dependence dated back to almost eighty years ago when Dr Du set out a “licensed” policy for opium addicts, where they can purchase a limited amount of opium from the authorities. This policy had gained controversial opinions, yet the results were promising. Tramadol has been widely used as a detoxification medication when the surge of heroin abuse began during the 90s. In the management of heroin withdrawal, lofexidine has been studied with good response but not launched yet. Dextromethorphan and venlafaxine were used as add-on medications with moderate effects. In maintenance, naltrexone has been introduced for highly motivated heroin addicts and also for alcoholics but it is not available at present. Methadone and buprenorphine were introduced recently due to aggravation of HIV infection in intravenous drug users. In methamphetamine psychosis, we have tried quetiapine in a case series with moderate effect. Antabuse is the most powerful medication for alcoholism maintenance and also will be, as well as memantine, tried on methamphetamine dependence maintenance as anticravings.

Conclusion: There are still rooms for pharmacological development to treat drug abuse, both in detoxification and maintenance managements.

RS37 HIV AND PSYCHIATRIC ILLNESS

Mark Jeanes, Cath Hill, Tom Wojicki, Olga Vujovic

Over 35 million people worldwide are infected with HIV. The psychiatric consequences include organic brain syndromes and psychological disorders. HIV also poses a range of challenges in health care delivery. This symposium will be presented by the members of the Victorian HIV Psychiatry Team who will specifically outline the following. The infectious diseases physician associated with the team will provide an update and overview of the recent developments in medical treatments for HIV. Our psychologist will outline the application of specific psychological therapies in this setting. Our consultation and liaison nurse will cover the role of liaison in a complex network of service providers. The team psychiatrist will discuss aspects of providing concurrent medical and psychiatric treatments and reflect on health care delivery issues that have arisen.

RS38 USING AUSTRALIA'S LONGITUDINAL STUDY RESOURCES TO UNDERSTAND THE ORIGINS AND CONSEQUENCES OF CHILD AND ADOLESCENT OF MENTAL DISORDERS

George Patton, Anthony Mann, Ann Sanson, Craig Olsson, Steve Zubrick

Epidemiological studies of the onset of mental disorders have continued to highlight the significance of disorders with an onset in early life. New findings on the onset and course of the major functional disorders of adulthood have brought a greater focus on the need for interventions in children and young people. In particular, recognition that incidence rates of affective disorders, substance dependence, psychosis and eating disorders are highest in the years between puberty and the mid-twenties has continued to provoke discussion about the origins of these disorders in early life. The US National Comorbidity Survey Replication has suggested that around a half of common mental and behavioural disorders commence between the ages of 7 and 24 years but with considerable variability between categories. Impulse control disorders (including conduct disorder and ADHD) and to a lesser extent anxiety disorders most commonly begin in the pre-pubertal years. Substance use and affective disorders most commonly begin in adolescence and young adulthood. This is the rationale for an investment in better understanding the potentially modifiable causes of these disorders, work that in turn underpins effective prevention. So too these recent findings have raised questions about the course and consequences of these early onset disorders. This information is important to understand which disorders require treatment as well as what treatment models may be most effective in younger children and also for adolescents and young adults.

Longitudinal studies are among the most powerful strategies for providing information on causes and consequences of child and adolescent problems. In this respect few countries have the wealth of longitudinal data that we have in Australia around mental and behavioural disorders. These studies include the Victorian Adolescent Health Cohort Study (VAHCS), the Raine Study, the Australian Temperament Study (ATP), the International Youth Development Study (IYDS). These cover development from the pre-birth through to the late 20′s.

The symposium will present work from collaboration across these four cohort studies to address questions of:

the early life antecedents of mental disorders appearing in later childhood and adolescence

the course and consequences of child & adolescent mental disorders in young adulthood

the scope for undertaking genetic and epigenetic investigations within the context of such longitudinal studies

It is a model of collaboration which may be replicable in other countries with multiple longitudinal data sets.

RS39 CLASSIFICATION OF PSYCHIATRIC DISORDERS AS VIEWED BY PSYCHIATRISTS, GENERAL PRACTITIONERS AND CLINICAL PSYCHOLOGISTS

Graham Mellsop, Benedetto Saraceno, Janice Wilson, C. Banzato, Naotaka Shinfuku, Norman Sartorius, Juan Mezzich, R. Lutchman, S. Lillis

In the context of approximately 100 years of evolution of our official Psychiatric Classificatory Systems (or 200 years since Pinel) work is commencing on the ICD-11 and DSM-V. There are also the complementary WPA efforts towards a person-centred integrative diagnosis.

During 2006 and 2007 a number of linked projects are being conducted, seeking the views of major stakeholders on global aspects of our present classification systems and on their user requirements of a classificatory or diagnostic system. The major emphasis has been on collecting and collating the views of practising Clinical Psychiatrists, but in acknowledgement of the amount of psychiatric morbidity known to require management in primary care and the multidisciplinary aspects of modern day psychiatry, the requirements and opinions of General Practitioners, Clinical Psychologists and Nurse Case Managers are of interest.

MULTICENTRE INTERNATIONAL STUDY OF THE VIEWS OF PSYCHIATRISTS ON GLOBAL ASPECTS OF CURRENT AND FUTURE CLASSIFICATORY SYSTEMS

C. Banzato, G. Mellsop, N. Shinfuku, M. Nagamine, S. Abdul Aziz, N. E. C. Pireira, G. Dutu

This study will report data from a survey of Brazilian, Japanese, New Zealand and Malaysian psychiatrists.

PERSPECTIVES ON PSYCHIATRIC CLASSIFICATION FROM EAST ASIA

Naotaka Shinfuku, M. Nagamine, Zou Yi-Zuang, Yong Sik Kim

This study will report data from China, Taiwan, Korea and Japan. Essentially the same methodology as the study of Mellsop et al. above, but with some local alterations to their questions and issues addressed.

CLASSIFICATORY REQUIREMENT OF GENERAL PRACTITIONERS IN PRIMARY CARE

S. Lillis, G. Mellsop, M. Emery

There is increasing awareness that General Practitioners may not use standard classification systems such as DSM or ICD when diagnosing or managing those with mental health issues. This research was designed to understand the utility of DSM and ICD in the work of general practitioners. We also sought to gain insight into the process of diagnosis in mental illness that is used by general practitioners and to explore what fundamental principles would promote a classification system that would have high utility and high acceptance in the general practitioner community.

CLINICAL PSYCHOLOGISTS OPINIONS ON STRENGTHS AND WEAKNESSES OF CURRENTLY UTILISED CLASSIFICATORY SYSTEMS

R. Lutchman, J. McClintock, G. Mellsop, L. Gaffaney, K. Galyer

This project investigates the perceptions and opinions of New Zealand Psychologists on the current classification system. It explores usefulness, its impact on clinical practice, and evaluates its relevance in psychological assessments, formulation and treatment. This study also hopes to investigate future developments of classifications. The method used for this investigation was a questionnaire format following focus group discussions. Questionnaires were posted to all registered psychologists in New Zealand to ensure that the study has a representative sample. The results will be presented.

RS40 PSYCHIATRIC TRAINING AND ACCREDITATION: EVIDENCE AND EXPERIENCE IN DIFFERENT PERSPECTIVES

Levent Kuey, Paul Hodiamont, Julian Freidin, Allan Tasman

This symposium, organized by the WPA Southern Europe Zone Representative and the UEMS Section and Board of Psychiatry, will review some evidence and experience on psychiatric training and accreditation systems in different perspectives. It is a fact that there is a marked variability in the content and quality of psychiatric training across the world, and furthermore, striking variability is experienced in the accreditation systems. The first challenge is the limitation of the relevant data on training. In addition to that, the problems pertaining to the identity of the psychiatrist and its professional roles and limits are reflected in various training programs. The available data and current situation in training and accreditation experiences in the world, in Europe and in Australia and New Zealand will be reviewed by the presenters and will be discussed by a prominent expert in this field.

PSYCHIATRIC TRAINING IN EUROPE

Paul Hodiamont

The rules for psychiatric training in Europe are part of the European system for postgraduate medical education in general. This system is rooted in thinking on globalization and quality. With respect to medicine in Europe, the political, ideological and economic dimensions of globalization will be discussed. The growing awareness of interdependence and the related efforts to arrive at unrestricted movement of persons and goods within the European Union gave rise to EU Directives formulating criteria for the quality of doctors and to the Charter on Training of Medical Specialists. Common principles of psychiatric training in the EU will be reviewed.

DEVELOPMENTS IN PSYCHIATRIC EDUCATION IN AUSTRALIA AND NEW ZEALAND: WORKING IN A POLITICAL ENVIRONMENT

Julian Freidin

The Royal Australian and New Zealand College of Psychiatrists is in the unique position of providing the one pathway for local medical graduates into specialist psychiatric practice in two countries. This has led to tension between the needs of the community for increasing numbers of psychiatrists and the need to maintain high clinical standards. Several major government reviews have endorsed this ongoing role of the College and led to a better understanding of the complex relationship between medical education, work force and politics. Ongoing working relationships between the college and government will be essential in maintaining an adequate number and clinical standard of psychiatrists. A recent expansion of the College's educational activity, into supporting overseas trained psychiatrists adjust to the local practice environment, demonstrates both the complexity and the benefits from engaging with the political process.

PSYCHIATRIC TRAINING IN THE WORLD

Levent Küey

There is a marked variability in the content and quality of psychiatric training across the world. Even before aiming to reach to a consensus on a set of minimum standards for psychiatric education, the review of the current data shows our limited evidence. The training programs, which theoretically should be constructed according to the desired competencies of a psychiatrist, need to consider the universal and unique challenges that psychiatry and the identity of the psychiatrist face. Based on the data provided by the Atlas Project of WHO-WPA on Psychiatric Education and Training Across the World (2005), this presentation will analyze the features of the current training programs in an effort to figure out some common trends. Discussion will further be focused on the identity and the roles and limits of a psychiatrist.

UEMS AND THE PSYCHIATRIC ACCREDITATION SYSTEM IN EUROPE

Paul Hodiamont

The European system for the accreditation of Continuing Medical Education, nowadays seen as an integral part of the medical education continuum, has a long history. It began with Napoleon promulgating a law (1803) obliging practicing doctors to improve their skills. Before World War II there were opportunities for CME in most European countries, but the CME activities were very different in many respects. The mobility of doctors fuelled attempts to seek a common policy and standards regarding CME. In 1994 the UEMS Management Council approved the Charter on CME of Medical Specialists in the EU. This Charter will be discussed from the perspective of the practical problems in the accreditation process for psychiatric CME activities.

RS41 PERINATAL MENTAL HEALTH AND THE TRANSITION TO PARENTHOOD

John Cox, Miri Keren, Sam Tyano, Gisèle Apter, Bryanne Barnett

This symposium will highlight the current global importance of, and increased scientific evidence that, the mental health of the parents before, during and after childbirth is a crucial determinant of future wellbeing of the parents as well as the infant. The symposium will highlight current knowledge about the diagnosis and management of ante-natal and post-natal mental disorder as they may affect the development of the foetus and the growth of the infant. The importance of perinatal mental health was recognised in the World Health Report 2005, ‘Make every mother and child count’, which drew attention to the lack of co-ordination between ante-natal and post-natal health services.

The speakers will also reflect on the public health policy implications of new data in this field including the evidence, which has led to a new government initiative in the United Kingdom, that supportive interventions during pregnancy in vulnerable families can have beneficial effects on temperament and cognitive ability of the growing child.

This symposium will launch the WPA institutional programme on parent and infant mental health.

PREPARATION FOR PARENTHOOD IN CONTEMPORARY SOCIETY: CULTURES IN TRANSITION

John Cox

This paper will highlight the values and changes in family life in the last decades, which affect parenting, the provision of social support and Maternal New-born and Child Health Services.

It is proposed that the beneficial effect on maternal mental health of regular supportive visits by community workers replaces that provided formerly by traditional structures-including grandparents.

The prevention and treatment of perinatal mental disorder are public health priorities in rich and poor countries. These disorders are prolonged and triggered by poverty and personal adversity, and affect the emotional and cognitive development of the infant.

The paper will conclude with a summary of the World Psychiatric Association's Institutional Programme on Parent and Infant Mental Health, and the United Nations Development Goals for 2015.

TRANSITION TO PARENTHOOD: NORMAL AND ABNORMAL PATHWAYS

Miri Keren, Sam Tyano

While Winnicott has described the “maternal primary preoccupation”, Leckman has recently found neurobiological correlates linked to this very special psychic state that reflects transition to parenthood in the first two months after delivery, in fathers as well as in mothers. Stern has contributed an additional dimension by describing the content of this psychic change under what he named “the maternal constellation”. Finally, Raphael-Leff has observed the patterns of maternal and paternal reactions to the pregnancy itself. We will apply these concepts to formulate the dynamics of several clinical vignettes of parents referred with their infants who developed symptoms in reaction to the parents’ difficulty to make the transition.

BIRTH: UPHEAVAL AND ADAPTATION

Gisèle Apter, Nicole Garret-Gloanec

Pregnancy and birth are essential developmental steps in the life of parents that most often create family, social, emotional, psychological and physiological upheaval. A limited but intense period of change, pregnancy, is followed by a period of active adaptation to the reorganization triggered by the arrival of a new infant (or infants). In most western countries and specifically in France, this period is also one of facilitated (and free) access to medical facilities. However, psychiatric and psychological assessments are still far from being standard procedure. Considering the major impact personality disorders and maternal prenatal and postnatal depression have on infant development and maternal health, it seems a major issue to enhance feasible assessment and care in our public health systems. We will describe examples of novel experimental experiences in the perinatal mental health system, including institutionalized partnership with maternity wards, emergency perinatal psychiatric team intervention and mother-infant psychiatry clinics. This setting will be put in perspective with the French mental health system and infant public health policy. How this specific experience may help development of perinatal mental health care policies in other public mental health settings will be discussed.

PERINATAL HEALTH: A PUBLIC PRIORITY

Bryanne Barnett

Early intervention and prevention are now accepted as feasible in mental health and illness. What can be offered and to whom? Many programs are briefly funded; some persist and some disappear, seemingly regardless of efficacy. For sustainability of effective programs, the many initiatives addressing the needs of vulnerable families during pregnancy and early postpartum may require careful revision of the roles and aspirations of the various stakeholders. A variety of agencies (health and other services and community groups) are involved and consideration of how each might best participate in a collaborative effort is often one of the missing steps. Sometimes this is because the underlying issues for the family are poorly understood; sometimes it is because of disparate funding sources or philosophies. These issues will be offered for discussion.

RS42 THERAPY COUNTS AND ART MATTERS

Eugen Koh, Bradley Shrimption, Rosalind Hursworth, Dinah Dysart, Tadashi Takeshima

This symposium explores the role of art in mental health promotion. There has been a growing interest in recent years in the different roles art may play in promoting a greater awareness of mental health issues in the general community. The art of people who experience mental illness can be a powerful medium that lends itself to giving the general public insight into such experiences. Demystification of mental illness is one of the first steps in countering the prevailing fear and stigma in the community towards people with mental illness.

In the first paper, Eugen Koh, Director of the Cunningham Dax Collection, will give a brief overview of this Collection and its exhibition programs for schools and the general public which aim to promote a greater understanding of mental illness and mental health issues. He will be joined by Brad Shrimpton and Rosalind Hursworth of the Centre of Program Evaluation from The University of Melbourne in presenting a preliminary report on an independent evaluation of the various programs of the Cunningham Dax Collection.

The second paper is by Dinah Dysart, an independent writer/editor and art curator with extensive experience in the field of art. Dysart recently curated a large successful exhibition in Sydney entitled, “For Matthew and Others: Journeys with Schizophrenia”. In this paper, Dysart will discuss how art about mental illness can be made by people with an experience of mental illness as well as by those without such experience. She will argue that both forms of art can assist in the exploration of mental health issues and that a distinction between artists on the grounds of the presence or absence of mental illness may not be particularly helpful.

The third paper, by Dr Tadashi Takeshima, considers some of the issues presented above from a cross-cultural perspective.

PROMOTING AN UNDERSTANDING OF MENTAL ILLNESS THROUGH ART. AN OVERVIEW AND EVALUATION OF THE CUNNINGHAM DAX COLLECTION

Eugen Koh, Bradley Shrimpton, Rosalind Hursworth

The Cunningham Dax Collection is one of the world's largest collections of art by people with mental illness, consisting of over 12,000 works. The aim of the Collection is to foster awareness and understanding of mental illness amongst the general community to counter the problem of stigma. One way this has been achieved is through school partnerships with the training of Victorian VCE Psychology teachers as well as education tours for school students and outreaching touring exhibitions in the community.

Dr Eugen Koh, the Director of the Cunningham Dax Collection will give a brief overview of its aims and activities.

In 2007, the Centre for Program Evaluation was commissioned to undertake a review of the collection in relation to the impact of such partnerships and programs. The specific aims of the review have been to determine the relevance, effectiveness and impact of the Collection and whether it has been able to demystify mental illness. This paper aims to discuss the progress of the evaluation.

Methods used within the review have been participant observation, interviews, focus groups and surveys of program participants. Results determined to date will be presented and preliminary conclusions drawn.

ART MATTERS: THE PERSPECTIVE OF ART HISTORY AND CRITICISM

Dinah Dysart

Madness is a subject like any other subject which can be (and is) embraced by visual artists, poets, writers, and performing artists.

It can be tackled by people with an illness or by those with an intellectual interest in the subject gained through personal connection or through pro-active research. Although people with a mental illness have an important contribution to make they do not have exclusive rights to the subject. There are many great artists in the pantheon of visual art, literature and theatre whose works of art focus on this theme. They may, or may not, have had a mental illness – but it is their art that matters.

It is not particularly helpful to differentiate between artists with an illness and those who engage with the subject for other reasons, unless the material is to be used for diagnostic purposes.

Art is about communication. What matters is whether the artist has something important to say and how powerfully is it expressed.

Good art always has something significant to communicate.

A category such as ‘Outsider Art’ places emphasis on technique acquired by unconventional or untutored means and tends to diminish or trivialise the importance of the content. It stigmatises the participants and isolates them from serious critical attention.

EXHIBITION OF PICTURES DRAWN BY MENTALLY DISORDERED

Tadashi Takeshima

We are planning to exhibit pictures drawn by mentally disordered people. We have run a small organization to support the drawing activity of mentally disordered since 2004. We are hoping that the activity may not only be a source of vitality for mental patients, but also a help to us in educating public. We wish to exchange information on similar activities in this opportunity, too.

RS43 ADAPTATION AND MENTAL HEALTH OF MIGRANTS

Fumitaka Noda, Lumie Kurabayashi, Koichiro Otsuka, Harry Minas

In North America and Europe, the issues of adaptation and mental health of immigrants and refugees have been long discussed. Along with the globalisation of the world there has been a great increase of migrants including travelers, business people, interracial marriage couples, students, academics and migrating workers across countries. It is very important to know how they are mentally fine and how they seek help when they get mentally ill. For those who are living in the “borderless world”, traditional scheme of mental health care for immigrants and refugees may not be well applied. As we have to shift the concept from “biculturalism” to “multiculturalism” in present world, we have to have some paradigm shift for providing appropriate mental health care for migrants. Australian service system for immigrants and refugees has been well organized and presents a good model for future care for the migrants. Although the number of migrants is very small and comprehensive mental health services are not yet established in Japan, the situation of Japan can suggest what, in near future, should be needed in various parts of the world to provide the care for the migrants. Two speakers from Japan and one from Australia will present for this session.

HELP-SEEKING BEHAVIOUR IN MENTAL HEALTH OF ETHNIC MINORITIES IN JAPAN

Fumitaka Noda, Yu Abe, Takayo Inoue, Lumie Kurabayashi, Chizuko Tezuka

Objective: It is assumed that the most appropriate mental health services for the ethnic minorities will be established by closely investigating their help-seeking behaviors in the community.

Method: By using survey methods, help-seeking behavior of Latin American, Vietnamese and Cambodian people in Japan has been researched. In order to compare those behaviors with people in their home countries, the control studies were done in Peru, Vietnam and Cambodia.

Result: The striking difference of behaviors was found between Latin Americans and Asians and their attitudes have been brought in Japan.

Conclusion: It is suggested that we have to consider the approach and form of provision of mental health services depending on ethnic communities. The details will be discussed in the session.

DIFFERENCE OF STRESS FACTORS BETWEEN SHORT-STAY GROUP AND LONG-STAY GROUP AMONG JAPANESE EXPATRIATES

Lumie Kurabayashi, Takamasa Saito, Mitsuru Suzuki, Fumitaka Noda

Objective: The aim of this study is to clarify the relationship between psychosocial stress factors and duration of stay among Japanese expatriates in Düsseldorf, Germany, Ho Chi Minh City, Vietnam and Vancouver, Canada.

Methods: The same self-administered questionnaires containing GHQ-12 and seventeen stress factors were distributed and collected through the Japan Chamber of Commerce and Industry in each city. Excluding permanent residents and insufficient answer sheets, 531 subjects in Düsseldorf, 108 in Ho Chi Minh City and 79 in Vancouver were obtained, which adds up to 718 subjects altogether.

Results: The mean age (SD) of the subjects was 40.7 (8.13), mean duration of stay was 45.9 (51.31) months, and mean GHQ score was 1.87 (2.67). The subjects were divided into four groups according to their length of stay. The longer their stay, the smaller their GHQ scores were. Multiple regression analyses were conducted with the 17 stress factors, age, sex, city, and language ability as explanatory variables, and GHQ scores as dependent variables. The results showed that among the group staying less than seventeen months, amount of work, medical services, climate, and interpersonal relationship between Japanese people were the factors related to GHQ scores while among the group staying more than 57 months, however, interpersonal relationship between local people and recreations were the main explaining factors.

Conclusion: It is suggested that the stress factors are different according to the duration of stay. Further studies are needed to promote mental health of the newly arrived expatriates to different cultures.

MENTAL HEALTH OF JAPANESE-BRAZILIANS IN JAPAN

Koichiro Otsuka, Lincoln Miyasaka, Keisuke Tsuji

Background: The number of Japanese-Brazilians, one of the largest migrant groups in Japan, has increased in the last decade and their psychological and social problems as foreigners have come to the forefront. However, community-based mental health studies of this group are very few in number.

Aims: To assess the mental health status of Japanese-Brazilians living in a local community in Japan and to compare the findings with those in Japanese-Brazilians living in Brazil.

Methods: A comparative community-based mental health survey was conducted from November 1997 to April 1999 on a randomly selected sample of Brazilians of Japanese descent living in a city in Brazil (n = 213) and on the entire Japanese-Brazilian community of a local city Japan (n = 158), using the self-reporting questionnaire (SRQ-20). Analysis was done by chi2, Fisher and multiple logistic regression.

Results: Scores indicating probable cases of minor psychiatric disorder, were found in 3.2% of the community in Brazil and 17.8% (OR = 7.01) of the community in Japan. The sociodemographic data in Japan indicated that those with high SRQ-20 scores were most likely to be female, young (16–29 years old), low income, and previous students in Brazil.

Conclusion: The mental health status of Japanese-Brazilians, especially of the younger generation, in Japan may be generally worse than that of Japanese-Brazilians in Brazil. We examined the relationship between the various mental health problems in Japanese-Brazilians in Japan and their sociocultural characteristics as ethnic return migrants.

USE OF MENTAL HEALTH SERVICES BY IMMIGRANTS IN VICTORIA: 1995/96 AND 2004/05

Harry Minas, Yvonne Stolk, Steven Klimidis

Background: More than a decade of research across Australia has shown that ethnic communities have consistently lower rates of access to public inpatient and community mental health services; a higher proportion of involuntary admissions; and higher proportions who are diagnosed with a psychosis, relative to the Australian-born population.

Aims: The aim of the current study was to investigate whether disparities in access and treatment for ethnic communities in Victoria had changed over time and following interventions to improve culturally sensitive practice in mental health services and increase ethnic communities’ awareness of support available from mental health services.

Methods: Analysis of relevant census data and Victorian community mental health and acute inpatient case registers for 1995/96 and 2004/05.

Results: Previously identified disparities generally persist and, in some ways, the gap between access rates for Australian-born and overseas-born has increased. The implications of these findings for policy and service development will be presented in the context of the recently released state policy document “Cultural diversity plan for Victoria's specialist mental health services 2006–2010”.

RS44 PHARMACOTHERAPY OF METHAMPHETAMINE ADDICTION

Ahmed Elkashef, Frank Vocci, Jason White, James Shearer, Jari Tihonnin

Background: Methamphetamine addiction is a world wide problem. It has been estimated that 35 million people abuse methamphetamine, making it second only to cannabis in terms of abuse prevalence. Currently there are no approved medications for the treatment of methamphetamine addiction. Relapse rates are high with behavioral therapies, making finding an effective medication an urgent task.

Aims: This symposium will include four presentations that will include data from ongoing or completed clinical trials and an update on medications targets for stimulants addiction.

Methods/results: Dexamphetamine is being tried in an ongoing study in Australia for methamphetamine addiction. Subjects were randomized to receive dexamphetamine up to 110mg/day or placebo capsules for a period of three months. Outcome measures included medication safety, treatment retention and amphetamine use evaluated by self-report and hair analysis. An interim analysis on subjects recruited to date, 20 in the placebo group and 10 in the dexamphetamine group showed that subject retention was not significantly different between groups, There were significant reductions in self-reported methamphetamine use between baseline and follow-up within each group. Based on hair analyses, there was a decrease in methamphetamine use from baseline to follow-up in both groups (86% of subjects in the dexamphetamine group and 70% of subjects in the placebo group). Recruitment for this study is ongoing.

The second study report will be on the effects of modafinil in methamphetamine dependence. This study has so far recruited 82 methamphetamine dependent persons through two clinics in inner city Sydney, Australia between July 2006 and April 2007. Subjects were randomised equally to modafinil (200/mg day) or placebo for 10 weeks plus a brief cognitive behavioural intervention. Critical outcomes to be reported between groups will be medication retention (using MEMS cap readers), weekly craving (using a validated brief multidimensional amphetamine craving scale) and weekly urinalysis. An effect size will be estimated based on the urinalysis results over the 10 week treatment period. Side effects, adverse events, and other self reported health, social, psychological data and psychosocial compliance will also be presented.

The third report is from the completed multi-site trial of bupropion for methamphetamione addiction. 151 patients were randomized to bupropion 150mg SR twice daily or placebo. Primary outcome is percentage of patients with methaphetamine free week. Results showed a trend for efficacy for the total sample favoring bupropion (p = 0.09), however a subgroup analysis showed a significant effect for bupropion in the mild users (p = 0.02).

The fourth presentation will discuss medications candidates in the pipeline to treat stimulants dependence e.g. vigabatrin and rominanbant.

Conclusion: These studies show promising early signals for burpropion, and amphetamine for methamphetamine addiction. Preclinical and clinical data suggest that vigabatrin, rominanbant, and modafinil are promising candidates for the treatment of methamphetamine addiction.

RANDOMIZED CONTROLLED TRIAL OF d-AMPHETAMINE MAINTENANCE FOR TREATMENT OF METHAMPHETAMINE DEPENDENCE

Jason White, Wendy Wickes, Marie Longo

Maintenance treatment of methamphetamine/amphetamine dependence has been implemented in the UK and elsewhere, but to date studies of this intervention have had significant limitations. These include small sample sizes, retrospective data, absence of control groups and sole reliance on self reports of the drug use. The degree of dosing supervision has varied between studies as has the use of conventional vs slow-release formulations. The present study was designed to test the efficacy and safety of once daily, supervised administration of an orally administered slow-release d-amphetamine formulation in people dependent on methamphetamine. Patients were randomized to receive slow-release d-amphetamine or placebo capsules. All received cognitive behavioural therapy designed for stimulant users. The initial d-amphetamine dose was 20 mg (or equivalent number of placebo capsules), increasing in 10 mg increments up to a maximum of 110 mg per day. Increments were based on severity of withdrawal experienced by the patient, consistent with other maintenance therapy approaches. Following dose stabilization, patients were maintained for a period of 3 months and then the dose decreased to zero over a period of 1 month. Assessment occurred at entry, during and a the end of maintenance and at follow-up, 2 months after completion of treatment. Outcomes included retention on the program, methamphetamine use evaluated by self report and hair analysis, general health status and medication safety. Data will be reported from an interim analysis on the sample of patients recruited to date.

RANDOMISED PLACEBO CONTROLLED TRIAL OF MODAFINIL (200 mg/day) IN METHAMPHETAMINE DEPENDENCE

James Shearer, Craig Rodgers, Donna Brady, Ingrid van Beek, John Lewis, Rebecca McKetin, Richard P. Mattick, Shane Darke, Alex D. Wodak

Modafinil is a novel non-amphetamine type stimulant that has shown value in the treatment of cocaine dependence in the US and methamphetamine withdrawal in Australia. The pharmacological action of modafinil is unknown. It has specific glutamatergic and GABAergic activity that may account for its wakefulness, arousal, attention and anti-craving effects. This study has so far recruited 82 methamphetamine dependent persons through two clinics in inner city Sydney, Australia between July 2006 and April 2007. Subjects were randomised equally to modafinil (200/mg day) or placebo for 10 weeks plus a brief cognitive behavioural intervention. Critical outcomes to be reported between groups will be medication retention (using MEMS cap readers), weekly craving (using a validated brief multidimensional amphetamine craving scale) and weekly urinalysis. An effect size will be estimated based on the urinalysis results over the 10 week treatment period. Side effects, adverse events, and other self reported health, social, psychological data and psychosocial compliance will also be presented. This will be the first presentation of trial data from this study and likely the first presentation of data from any randomised placebo controlled trial of modafinil in methamphetamine dependence. The trial was funded by the Australian Government Department of Health and Ageing, trial medication was supplied as a grant by Cephalon Inc of the United States.

BUPROPION FOR THE TREATMENT OF METHAMPHETAMINE DEPENDENCE

Ahmed Elkashef, Ann Anderson, Richard Rawson, Edwins Smith, Shou-Hua Li, Frank Vocci, Tyson Holmes, William Haning, Denise Wise, Jan Campbell

Background: Methamphetamine addiction is a major public health problem worldwide for which there is no effective medication.

Aims: Bupropion, an approved antidepressant with monoamine uptake inhibition properties and mild stimulant effect, was tested for efficacy in reducing methamphetamine dependence.

Methods/results: A double-blind placebo-controlled study, with 12 weeks of treatment and a 30-day follow-up. Five outpatient substance abuse treatment clinics, west of the Mississippi. 151 treatment-seekers with DSM-IV diagnosis of methamphetamine dependence were consented and enrolled. Seventy-two participants were randomized to placebo and 79 to bupropion SR 150mg twice daily. Patients were required to come to the clinic three times per week for assessments, urine drug screens, and 90-minute group psychotherapy. The primary outcome was the change in proportion of participants having a methamphetamine-free week. Secondary outcomes included urine for quantitative methamphetamine, subgroup analyses for balancing factors and co-morbid conditions, addiction severity, craving, risk behaviors for HIV, and use of other substances. The GEE regression analysis showed that the estimated rate of increase in the probability of a non-use week over the 12-week treatment period was greater for bupropion than for placebo, but not statistically significant (p = 0.09). Mixed model regression was used to account for multiple comparisons among the factors balanced at randomization (site, gender, level of baseline use, and level of symptoms of depression). This subgroup analysis showed the bupropion group had a significant effect compared to placebo, among males who had a lower level of methamphetamine use at baseline (p < 0.0001). Co-morbid depression and ADHD did not change the outcome.

Conclusions: These data suggest that bupropion, in combination with behavioral group therapy, was effective for the treatment of participants with low-to-moderate methamphetamine dependence, mainly in males, regardless of their co-morbid condition.

EMERGING MOLECULAR TARGETS FOR THE TREATMENT OF STIMULANT DEPENDENCE

Frank Vocci

Currently, there is no approved pharmacotherapy for the treatment of stimulant (cocaine or methamphetamine) dependence. Neurobiological evidence is accumulating that chronic stimulant intake produces dysregulations in multiple brain systems; it's hypothesized that modulation of these changes will be therapeutic. The reward system is one of the main targets of stimulants. Initially, the reward system can be driven to a hyper-dopaminergic state with stimulants. Chronically, the reward system appears to be in a hypodopaminergic state following cocaine administration. Changes in receptor sensitivity accompany the chronic administration of stimulants. The D1 receptor system appears to be hyporesponsive, while the D2 and D3 receptor subsystems appear to be hyperresponsive following cocaine self-administration. Interestingly, the D2 dopamine receptor density appears to be downregulated while the D3 receptor density is upregulated. Thus, D1 agonists or D3 dopamine antagonists would be hypothesized to modulate the dopamine system back towards normal. Another approach to modulating brain systems altered by stimulants is to increase the strength of the inhibitory systems. Vigabatrin (GVG) is a GABA-transaminase inhibitor that increases GABA levels. GVG has been shown to antagonize stimulant induced increases in striatal dopamine as well as modulate behaviors associated with drug cueing and drug intake. GVG is currently being evaluated clinically in stimulant users. The stress system is also dysregulated by chronic stimulant administration. This system utilizes Corticotropin Releasing Factor (CRF) as one of its main transmitters. CRF antagonists have been shown to alter drug-seeking responses in stressed animals, suggesting that they might have similar effects in stimulant users.

RS45 ADDICTION: BRAIN DISEASE WITH MEDICAL AND SOCIAL COMPLICATIONS

Nahla Nagy, Afaf Khalil, Nasr Loza, Amani Haroon, Haroon Rashid Chaudhry

Substance use disorder is a universal problem. As a brain disease, lots of research focused on the brain circuits involved in addiction, neurotransmitter, receptor changes and co morbid psychiatric diseases. In this presentation we will discuss the biochemical changes associated with addiction including, cortisol, ACTH, prolactin, serotonin and dopamine metabolites, liver, renal functions and lipids to highlight the impact of addiction on general health. Cross cultural aspects of addiction plays an important factor determining the type of substance abuse, the mode of intake and therapeutic modalities. Different polices of treatment ranging from complete abstinence, use restriction, legalization and harm reduction, each of which shows areas of successes and limitations. Families of addicts may be part of the biological and social factors contributing to the problem, moreover their coping as caregivers affect the prognosis of our patients. Substitution therapy especially with methadone, LAMM and buprenorphine is widely used in Western countries. Studies showed benefits of decreased side effects of opioid dependence.

NEUROPSYCHOLOGICAL AND BIOLOGICAL PERSPECTIVES IN SUBSTANCE ABUSE DISORDER

Nahla Nagy, Abd el Nasr Omar, Samir Abo el Magd, Soad Gomah, Mona Mansour, H. A. Mekkawy

Background: Substance use disorder has neuropsychological and biochemical complications.

Method: We examined 100 patients diagnosed according to the DSM IV-TR as mental and behavioral disorder secondary to substance abuse disorder using MMPI for personality, impulsivity scale, aggression scale, electroencehalography and laboratory tests for assessment of serum lipids, liver, renal functions and neurotransmitter metabolite levels.

Results: Showed high scores on the feminity/masculinity scales of MMPI, increased levels of impulsivity associated with EEG changes as 26.7% had focal epileptic changes and abnormalities in laboratory investigations correlated to the type of substance and duration of abuse.

Conclusion: Treatment plans for substance abuse must consider comorbid medical and psychological disease.

CROSS CULTURAL ASPECTS OF ADDICTION

Afaf Khalil, Farouk Loteif, Nahla Nagy, Heba El Shehawy, Bavly Samir

Background: Substance abuse is a mental disease with socio-cultural implications.

Method: We reviewed the text for cross-cultural aspects of addiction with special emphasis on Arab countries.

Results: Showed geographical, economical, cultural norms and religious beliefs and emigration determines the type of substance abused, mode of intake, social restrictions/acceptance and therapeutic programs.

Conclusion: Cross-cultural aspects of addiction should be considered when comparing international studies as one type of treatment may be effective in one culture but gives different results when applied elsewhere.

POLICES OF MANAGEMENT OF SUBSTANCE ABUSE

Nasr F. Loza

Background: Treatment of substance abuse includes preventive measures for high risk groups, pharmacological therapies and rehabilitation programs.

Method: We reviewed the text for different therapeutic modalities and national polices for management of substance abuse problems.

Results: Showed wide range of therapeutic programs starting at one end with complete abstinence as the goal of therapy and ending with harm reduction at the opposite end with law enforcement polices, free market legalization, product restriction and market regulation lying in between.

Conclusion: Each therapeutic program has its success rate and limitation. International guidelines are recommended.

FAMILIES OF SUBSTANCE ABUSE PATIENTS: AETIOLOGICAL FACTORS AND COPING STRATEGIES

Amani Haroon, Mohamed Ghanem, Nahla Nagy, A. hmad Saad, Mona Mansour, Heba El Shehawy, Maissa Eid

Background: Substance use disorder has great burden on caregivers dealing with those patients.

Method: We examined the wives of 80 patients diagnosed as substance abuse disorder according to the DSM IV-R for psychiatric morbidity and coping skills.

Results: Showed high levels of impulsivity, anxiety and depression in the wives which correlated positively with physical abuse, sexual dysfunction and opium injection in the husbands. The financial problems had the higher scores as life stressors.

Conclusion: Care should be given to families of addicts during treatment as their suffering affect prognosis of illness.

SUBSTITUTION THERAPY IN ADDICTION: APPLICABILITY IN DEVELOPING COUNTRIES

Haroon Rashid Chaudhry, Nahla Nagy

Background: Substitution therapy forms one model of therapeutic strategies in addiction.

Method: We reviewed the text for references about substitution therapy and evaluating successes and limitations.

Results: Showed methadone and LAMM as synthetic narcotic used in treatment opioid dependence has several advantages in reducing withdrawal symptoms, injectable heroin and criminal activity, yet in itself causes dependence. Promising data appears with the use of Buprenorphine as mixed agonist-antagonist.

Conclusion: Substitution therapy in addiction is still limited in developing countries due to cultural and economical aspects.

RS46 MAORI MENTAL HEALTH IN TE RAU HINENGARO (THE NEW ZEALAND MENTAL HEALTH SURVEY): INDIGENOUS PERSPECTIVES ON THE SURVEY PROCESS, FINDINGS AND PATH TO POLICY

Joanne Baxter, Te Kani Kingi, Rees Tapsell, Melanie Sargent

Context: Te Rau Hinengaro: the New Zealand Mental Health Survey (NZMHS) was the first survey to measure mental disorders in New Zealand that included a representative sample of Maori adults. The survey team included a Maori research team and a Kaitiaki group and aimed to ensure that the research process was consistent with Maori views and that the findings would inform on Maori mental health providing valuable information to base policy, service delivery and practice on. Maori mental health is considered a priority both within mental health and within Maori health spheres.

Objectives: The objectives of this symposium are for the Maori researchers involved within the survey to describe: what we did, what we found, implications for mental health gain for Maori and what we learnt regarding research and future challenges for research translation into action. In addition, Maori mental health policy makers will describe issues in using findings from Te Rau Hinengaro to inform policy in the future.

Key messages: Having a Maori research team and Kaitiaki group was invaluable to the process (everyone learnt from this). Findings showed an increased prevalence of mental disorders among Maori, particularly among the young. The completion of the survey has not put an end to the research and much analyses remain and in order to translate the research findings into positive health gains for Mâori. Policy makers are working with the evidence to better inform policies to achieve mental health gain for Maori.

Conclusion: Te Rau Hinengaro showed that it is possible to measure mental disorders in indigenous Maori with a range of strategies (sampling, statistical, community consultation etc). The study further revealed the need to consider cultural perspectives in the design of research methodologies and especially those which have high indigenous representation. The completion of the survey provides a useful contribution for the identification of informed strategies for Mâori mental health development for public health, clinicians, services (primary and secondary) and policy makers.

TE RAU HINENGARO, THE NEW ZEALAND MENTAL HEALTH SURVEY: ADDRESSING INDIGENOUS ISSUES WITHIN THE RESEARCH PROCESS

Te Kani Kingi, Rees Tapsell, Joanne Baxter, Mason Durie

Context: Te Rau Hinengaro, the New Zealand Mental Health Survey was the first mental health survey in New Zealand to describe Maori mental health. Incorporated within the overall design of research were a number of innovative strategies and approaches aimed at facilitating Mäori involvement within the study, to ensure that issues of cultural significance were identified and adhered to, and to provide a framework through which Mäori data could be analysed, stored, and safeguarded.

Objectives: The objectives of this presentation are to explore the nature and extent of Mäori involvement within Te Rau Hinengaro. Mäori were involved at three distinct levels within the study – as Researchers, as Participants, and as part of an advisory or Kaitiaki group. The relationships between these groups and with the broader research team were critical to the overall success of the study and further demonstrated a unique and innovative approach to the design of large epidemiological studies.

Key messages: The study revealed the need to consider cultural perspectives in the design of research methodologies and especially those which have high indigenous representation.

MAORI MENTAL HEALTH IN TE RAU HINENGARO, THE NEW ZEALAND MENTAL HEALTH SURVEY

Joanne Baxter, Rees Tapsell, Te Kani Kingi, Mason Durie

Context: Te Rau Hinengaro was the first survey to measure mental health in a representative population of Maori in New Zealand. A key driver was to inform mental health policy and the health sector on Maori mental health need.

Objectives: The first objective of this part of the symposium is to describe selected findings from Te Rau Hinengaro of particular importance for Maori health including: prevalence of mental disorders, levels of comorbidity, levels of severity and contact with health services. The second objective of this paper is to discuss implications of these findings for Maori health gain including from public health and clinical perspectives.

Key messages: Information gathered from Te Rau Hinengaro provides valuable knowledge for the interventions spanning from public health and health promotion to clinical settings.

Conclusion: There is significant mental health need among Maori consistent with previous concerns. Te Rau Hinengaro provides a valuable platform for identifying and prioritizing these needs at a community and primary care level and for reducing inequalities.

TE RAU HINENGARO – THE PATH TO MAORI MENTAL HEALTH POLICY

Melanie Sargent, Rees Tapsell, Te Kani Kingi, Joanne Baxter

Context: Improving Maori Mental Health and reducing inequalities is Government priority reflected in Te Tahuhu – Improving Mental Health 2005-2015 The Second New Zealand Mental Health and Addiction Plan. Launched in 2006, Te Rau Hinengaro: the New Zealand Mental Health Survey provides a valuable resource for policy development to improve Maori mental health.

Objectives: This part of the symposium will provide an overview of the development of Te Rau Hinengaro as a resource for policy making to improve Maori mental health.

Key messages: The findings of Te Rau Hinengaro confirm the direction of current policy for mental health and addiction in New Zealand focused on specific population groups, including Maori. Te Rau Hinengaro also now provides an opportunity to further develop policy to inform funding and planning based on Maori population need.

Conclusions: Te Rau Hinengaro: the New Zealand Mental Health Survey (NZMHS) was the first survey to measure mental disorders in New Zealand that included a representative sample of Maori adults. The findings confirm current policy and provide a platform for future development.

RS47 DEVELOPMENTS IN THE PROMOTION AND EVALUATION OF PRIMARY CARE MENTAL HEALTH EDUCATION

Linda Gask, Andre Tylee, Yu Xin, Alla Zacryoeva

Context: Across the world, the vast majority of mental health problems are managed in the primary care setting. A cornerstone of the policy of WHO has to be support the primary care physician in this role, and the WPA has be extensively involved in the development of training and educational materials aimed at primary care.

Objectives: In this symposium we propose to focus on development in education for primary care mental health in different countries and consider how such training has been evaluated.

We will focus on recent developments and potential challenges in delivering and evaluating widespread training in mental health for physicians in primary care and general medical settings in China and Russia; on the Trailblazer's programme, which has been exported to Australia and New Zealand, and training GPs in the management of medically unexplained symptoms, (the Reattribution model) which has been widely exported to other countries and more recently subjected to rigorous evaluation in Europe.

Key messages: There are considerable challenges inherent in setting up and running effective training and educational programmes in primary care. Many of these are common across different cultures, some are specific to particular nations and health care systems.

Conclusions: We can capture information about the number of doctors that have been trained in an educational programme, and obtain feedback from participants and tutors. Data can be collected on changes in knowledge, attitudes and skills as a result of the training. However the greatest test is whether training brings about changes in the actually processes of delivery and outcomes of care for patients. Evidence of an impact on the latter remains limited for educational interventions.

THE TRAILBLAZERS INITIATIVE

Andre Tylee

Context: Trailblazers began a decade ago and has spread throughout England and to New Zealand and the USA. The focus is on service development and uniquely it is designed for paired participants from different disciplines. Originally, participants were from general practice and mental health services (e.g. GPs, primary care nurses, psychiatrists and mental health nurses), but it soon expanded to any relevant group such as social workers, prison staff, managers etc. Time is spent on understanding roles and perspectives of participants and their project. Pairs are expected to have a service that they want to improve by making plans, trying them out and reporting successes and failures to their peers and tutors who act as “critical friends”.

Objectives: Trailblazer groups usually consist of 8 pairs who in addition, jointly determine topics for shared learning. Pairs meet over three separate residential modules over 6-9 months to allow time between modules for developing services. Groups usually meet in a retreat like atmosphere to promote reflection away from the working environment.

Key messages and conclusions: It has been a challenge to evaluate the initiative as projects are heterogeneous and there have been several short term evaluations of individual cohorts by external organisations. Such evaluations have been short term and unable to capture the longer term personal development that many participants have attributed to the programme. Many participants have become leaders in the field, even perhaps when their projects may have been less successful in the short term. These aspects of the programme will be discussed.

EDUCATION FOR PRIMARY CARE MENTAL HEALTH IN CHINA

Yu Xin

Context: The education for primary care mental health in China is quite a different picture. Since the referral system is well established and the qualification of primary health workers is not satisfactory, patients in community often go to the tertiary hospitals directly for medical help. However, there are very few psychiatric departments in general hospitals, therefore neurologists or internal medical physicians are the main targets of our education of mental health. Education for physicians in other specialties will have more difficulties such as: specialists are reluctant to take knowledge from other field; specialists are only willing to learn something easy (easy to diagnosis, easy to manage); lastly, even if specialists understand the knowledge, they hardly put it into practice due to various reasons (too busy to take full history of patients with mental health problems, need to rule out medical conditions first, difficult to persuade patients to take antidepressants, more concerns about drug side effects and interaction).

Objectives: To describe developments in the implementation and evaluation of primary care mental health education in China.

Key messages and discussion: We started to train specialists 5 years ago and seemed not to change the prescription pattern too much. Depression recognition rate and treatment rate in general hospitals are not raised up remarkably. Fluoxetine still takes 95% market share in general hospitals. The training goal, training method, and training targets need to be carefully considered in order to improve the mental health service for patients.

TEACHING OF DEPRESSIONS ON THE DEPARTMENT OF FAMILY MEDICINE OF THE URAL STATE MEDICAL ACADEMY, RUSSIA

?lla G. Zakryoeva, O. Lesnyak, David Goldberg, Linda Gask

Context and objectives: Since October 2003, the first 125 internists from the various districts of the Sverdlovsk Region have been trained in the course “Mental Health in PC” at the Ural State Medical Academy. They are now engaged in the PC system. The results of the training of 87 doctors were analyzed using the Attitude to Depression Questionnaire (by professor sir D. Goldberg). Both the pre-training and post-training answers (collected in two months after completion of training and their actual work in the PC) were statistically processed by nonparametric criteria using SPSS for Windows 8.0.and analyzed.

Key messages: Before training 62% of doctors answered that they never or seldom carried out depression and anxiety diagnostics. 87% of doctors answered that they discovered 0–10 patients per month with depression and USS. 89% of respondents prescribed sedatives, vitamins to these patients whereas only 18% and 15% of doctors prescribed antidepressants (depression and USS acc). After training percentage of doctors diagnosing depression and prescribing antidepressants to the patients with depression and USS increased for certain (p = 0,037, ? = 0,001, correspondingly). Older doctors started the course from a lower knowledge base than younger doctors, but acquired more knowledge. Theoretical knowledge of both depression and USS increased dramatically, and great changes occurred in the way that these patients were managed.

Conclusion: Mental health skills training have been provided to Russian GP with positive impact on theoretical knowledge and self-reported management.

IMPROVING THE MANAGEMENT OF PEOPLE WITH MEDICALLY UNEXPLAINED SYMPTOMS IN PRIMARY CARE: EVALUATION OF THE REATTRIBUTION TRAINING MODEL

Linda Gask, Richard Morriss, Chris Dowrick, Peter Salmon, Sarah Peters, Graham Dunn, Anne Rogers, Barry Lewis

Background: The Reattribution training intervention for the management of medically unexplianed symptoms has been used in many countries and recently been evaluated in three European studies.

Aims: To determine if Reattribution Training improves the quality of patient-doctor communication and other outcomes in patients with persistent medically unexplained symptoms.

Methods: Cluster randomised controlled trial with the practice as unit of randomisation carried out ion general practices in North-West England, United Kingdom. Six hours of training on reattribution delivered by four health professionals to all general practitioners in eight practices; no training in eight practices.

Results: With training, the quality of doctor-patient communication improved overall (31% versus 2% most consultation consistent with reattribution, odds ratio 53.8, 95% confidence interval 4.6 to 632.4; p = 0.002) and at three stages of reattribution (feeling understood, group difference = 2.1, 1.1 to 3.0; p < 0.001; broadening the agenda, difference = 0.9, 0.3 to 1.6; p = 0.007; making the link, difference = 1.0, 0.5 to 1.4; p < 0.001]. There were trends with training for more patients to be satisfied (odds ratio 3.5, 0.9 to 14.4; p = 0.08) and to know the cause of their symptoms (odds ratio 2.2, 0.9 to 5.3; p = 0.08). Training was associated with worse quality of life (health thermometer, difference = − 0.9, −1.6 to −0.1; p = 0.027) and a trend for increased anxiety (odds ratio 2.4, 0.9 to 6.6; p = 0.10) with no effects on depression or health contacts.

Conclusions: Practice-based training in reattribution substantially improved the quality of doctor-patient communication but did not improve patient outcome.

RS48 EXERCISE, SPORT AND PSYCHIATRY SECTION SYMPOSIUM

Said Azim, David Baron, Samir Aboulmagd

There is now well established evidence about the importance of the mental state on physical exercise and sports. The athlete's state of mind, his motives, fears and ideas have a significant and direct impact on his performance. At the same time, participation in sports affects the mood, thinking; and personality of the individual; it also does help in prevention of psychiatric illness and promotes mental health, well being and quality of life.

This symposium is going to discuss the relation and impact of mental illness on athletes, physical injuries and their psychological effects; the exposure of athletes to stress, sports and doping, the effect of anabolic steroids on sports and exercise; as well as gender differences in exercise and sports.

RS49 RESEARCH IN OLD AGE PSYCHIATRY IN ASIA – SOME CURRENT ACTIVITIES

Edmond Chiu, Yu Xin, Helen Chiu, J. P. Hwang, Kua Ee Heok, Guk-Hee Suh

Old age psychiatry is a relatively new discipline within psychiatry in the Asian region. As this International Congress is being held in the Asian-Pacific region, this Symposium will place a focus on current research activities being undertaken in Asia.

Speakers are leaders in the field in their respective countries and will offer to participants a snap shot of the research efforts through the reporting of a chosen project. This will showcase the emerging liveliness and strong commitment of old age psychiatry in Asia thus adding to the continuing development of the WPA in this region.

RS50 EFFECTIVE AND HUMANE PSYCHIATRIC NURSING: TIDAL MODEL

Tsuyoshi Akiyama, Bridget Hamilton, Cath Roper, Ayumi Kanda, Poppy Buchanan-Baker, Phil Barker

Context: Regarding psychiatric care, the crucial issues are how to develop an effective and humane care and to help developing effective consumer advocacy movements.

Professor Phil Barker developed a psychiatric nursing model called Tidal model. Tidal model makes most of the experience of the person who has the problem, avoiding usage of medical language which objectifies and classifies the person into a disease. There are both practical and theoretical features: the model uses the Tidal metaphor to address theoretical and ethical issues. It includes many tools that prompt different kinds of conversations between nurses and consumers. It draws on elements of solution-focused and narrative therapy approaches, cognitive-behavioural psychology and psychodynamic theory. This model can be practiced by psychiatric nurses and primary care workers, and is currently used in Australia, Denmark, Eire, England, Finland, Germany, Japan, New Zealand, Scotland and Wales.

Objectives: The participants will understand how Tidal model can be included in care for a person who has the problem.

Key messages: Tidal model works with community mental health care and collaborates extremely well with the advocacy movements. The persons cared through Tidal model can speak eloquently how they support themselves and others in the problem. In this respect Tidal model can effectively facilitate anti-stigma movement by the consumers.

Conclusion: Tidal model can empower the consumers, psychiatric nurses and primary care workers and help reduce stigma. Tidal model provides an opportunity for the best partnership for practice.

POWER OF STORY IN THE TIDAL MODEL OF MENTAL HEALTH RECOVERY

Phil Barker

The Tidal Model is recognized, internationally, as a key theory within mental health nursing, and is one of the few models of mental health recovery to have been subjected to rigorous evaluation. The Tidal Model is presently the focus of over 100 projects in several countries across a range of settings – from acute care and addictions, through rehabilitation and forensic units, to the care of people with early stage dementia. The Tidal Model focuses on helping the people (patients) to tell the story of their psychiatric breakdown, so that they can begin to explore what ‘needs to be done’ to begin the voyage of recovery.

In this presentation I provide an overview of the theoretical basis of the Tidal Model and describe some of the emerging qualitative and qualitative research findings, which illustrate the effects of introducing the model into clinical practice.

THE TEN COMMITMENTS: PHILOSOPHICAL VALUE BASE OF THE TIDAL MODEL

Poppy Buchanan-Barker

The Tidal Model represents an optimistic view of mental health, believing that ‘recovery’ is possible for many people, although what ‘recovery’ will mean, differs from one individual to the next. Philosophically, the Tidal Model asks specific questions about people with mental health problems: ‘What does it mean to be a person?’ ‘What is the nature of the person's experience of mental distress?’ And ‘what is recovery?’

The practice of the Tidal Model is based on a set of philosophical assumptions – the Ten Commitments-which were developed collaboratively with people involved in the both the delivery, and the receipt, of Tidal care. This presentation summarises the Ten Commitments and illustrates how each one is used in the practice of the Tidal Model.

THE TIDAL MODEL – NARRATIVE AND MEANING MAKING

Cath Roper

For the past 4 years, the tidal model has featured in the post graduate mental health nursing curricula at the University of Melbourne, through the subject taught by the consumer academic. The attraction to directing students to this model lies in three principal areas.

First, the model recognizes the importance of the person's own experience, and seeks to understand and use that language. Second, there is a clear recognition of the expertise that the person has and brings with them in any encounter. Third, the tidal model embraces meaning making, and metaphor. Combined, these three aspects of the model afford a strong counterpoint to traditional medical approaches, and consequently reposition both the person in care and the person providing the care.

THE TIDAL MODEL INTERVIEW WITH A JAPANESE DEPRESSIVE PATIENT

Ayumi Kanda

Case X. Age 36. Married. No children. Professional school graduate. Employed at a company run by his father. X has had repeated episodes of depression and been on sick leave for four years. He was admitted at Kanto Medical Center to receive modified Electro-convulsive therapy and intensive psychotherapeutic care.

Tidal model interview: X knew and had a high expectation for the tidal model interview. #1: X wrote a very detailed report of his illness. The goal for X was identified as return to work and we discussed what concrete things he could do to attain this goal. #2: It was not easy for X actually to find out concrete things. He also said that it is difficult for him to say “No” to others. #3: X was scheduled to stay out at his home, but his talk continued to focus on the past, his work and the course of illness. #4: X said that it became easier for him to reflect on his condition, including hypomanic mood, through the tidal interview. #5: X expressed some anxiety before discharge, reflected on his perfectionist tendency and discussed his plan to tackle with the adaptation to the outer life.

Discussion: With some difficulty, X utilized the tidal model interview to reflect on his difficulty.

THE STRATEGY OF BRIDGING AND THE ISSUE OF POWER SHARING IN THE TIDAL MODEL

Bridget Hamilton

Within the key Tidal Model text, the authors elaborate a strategy of engagement they have called bridging. Drawing on ethnographic fieldwork data in an acute inpatient setting, this paper offers an illustration of bridging between a nurse and person in care. This example is used to anchor a broader discussion of the way power relationships might be negotiated between the person and the clinician, using the Tidal Model.

RS51 STRESS AND THE HEART: PHYSIOLOGICAL BASIS FOR THE DEVELOPMENT OF PSYCHOGENIC HEART DISEASE

Gavin Lambert, Tye Dawood, Murray Esler, David Barton

Context: Until recently it was thought that no more than 50% of clinical coronary heart disease was explicable in terms of classical cardiac risk factors such as dyslipidemia, cigarette smoking, high blood pressure and diabetes. Recent large scale epidemiological studies have increased our understanding of the mechanisms generating cardiac risk and have provided evidence indicating that psychosocial factors, particularly depressive illness (MDD), anxiety states, and acute and chronic mental stress are involved here, “triggering” clinical cardiovascular events, and possibly also contributing to hypertension and atherosclerosis development.

Objectives: To provide the audience with an up to date analysis of the underlying mechanisms responsible for the generation of psychogenic heart disease.

Key messages:

Epidemiology of psychogenic heart disease (Dawood)An up to date review of the literature documenting cardiac risk in MDD, anxiety disorders and acute and chronic mental stress

Psychogenic heart disease – Mechanisms of cardiac risk (Esler)Examination of biological mechanisms including genetic, epigenetic, autonomic nervous system, atherogenesis

Brain monoamines and neurotrophins – Links to heart disease risk (Lambert)Working out the central nervous system drivers involved in generating cardiac risk and examining the impact of altered neurotrophic support on brain monoaminergic function

Mind-Heart interactions with therapy (Barton)Detailing the effects of therapy, both pharmacological and behavioural, on cardiac risk

Conclusion: There is a clear need to identify the underlying mechanisms responsible for the development of psychogenic heart disease. Further knowledge of the mechanisms responsible for generating cardiac risk may pave the way for novel and perhaps relatively simple therapeutic strategies (e.g. beta-blockers, statins, central sympathoinhibition with imidazoline binding drugs) to be administered in order to modify cardiac risk. Defining therapeutic interventions that reduce cardiac risk will be an important step forward in alleviating the burden of disease on the community.

EPIDEMIOLOGY OF PSYCHOGENIC HEART DISEASE

Tye Dawood

An up to date review of the literature documenting cardiac risk in MDD, anxiety disorders and acute and chronic mental stress.

PSYCHOGENIC HEART DISEASE – MECHANISMS OF CARDIAC RISK

Murray Esler

Examination of biological mechanisms including genetic, epigenetic, autonomic nervous system, atherogenesis.

BRAIN MONOAMINES AND NEUROTROPHINS – LINKS TO HEART DISEASE RISK

Gavin Lambert

Working out the central nervous system drivers involved in generating cardiac risk and examining the impact of altered neurotrophic support on brain monoaminergic function.

MIND-HEART INTERACTIONS WITH THERAPY

David Barton

Detailing the effects of therapy, both pharmacological and behavioural, on cardiac risk.

RS52 PSYCHIATRY FOR THE PERSON

Juan Mezzich, George Christodoulou, Helen Herrman, Ihsan Salloum, Allan Tasman, J. K. Trivedi, Levent Kuey, Michel Botbol

WPA's initiative on Psychiatry for the Person was established by the 2005 General Assembly. It seeks to affirm the person in context at the center of diagnosis, clinical care and health promotion. Its goals can be summarized as the promotion of a psychiatry of the person, by the person, for the person and with the person. The key features of the program and emerging activities will be presented and discussed.

CONCEPTUAL BASES

George Christodoulou

PERSON-CENTERED DIAGNOSTIC MODEL

Ihsan Salloum

CLINICAL CARE CURRICULA

Allan Tasman

PUBLIC HEALTH

Helen Herrman

PERSON-CENTERED ASIAN PERSPECTIVES

J. K. Trivedi

RS53 INVOLUNTARY OUTPATIENT COMMITMENT: INTERNATIONAL EVIDENCE

David Muirhead, John Dawson, Lisa Brophy

Context: Involuntary Outpatient Commitment or Community Treatment Orders (CTOs) represent an important contemporary development in mental health services and legislation internationally. CTOs have been utilised extensively in Victoria, particularly since the mid 1990s along with a significant shift from institutional to community-based care. Elsewhere, CTOs have tended to be introduced more recently in a much more contested environment with stronger links to measures to deal with risk issues, such as Brian's Law in Canada and Kendra's Law in New York. A recent Cochrane review questioned the evidence that CTOs lead to improved outcomes for recipients compared to standard care (Kisely, Campbell and Preston, [2005]). This is despite studies that have found evidence to support improved outcomes for CTO recipients and their carers (Muirhead et al, [2006], Dawson et al, [2003]). Dawson et al (2003) suggest that there are serious difficulties in finding ethical and lawful research designs. Also results are difficult to generalise across jurisdictions that have such differences in quality and availability of community based psychiatric services.

Objectives: This symposium will: enable presentation and discussion of recent qualitative and quantitative research seeking to gather evidence regarding the effectiveness and impact of CTOs. International comparisons will be made which enable these findings to be understood in the context of the service delivery environment.

Key messages: While randomised controlled trials regarding CTOs are difficult to conduct and, because of their limitations, difficult to interpret and generalise, there are many attempts being made to attempt to understand more about CTOs and gather evidence regarding the impact of their use. This will make an important contribution to ongoing policy debates and encourage best practice in CTO implementation. Policy and practice in CTO implementation is inevitably informed by the characteristics of local service delivery environments.

Conclusions: CTOs are an increasingly prevalent feature of modern mental health legislation and practice in countries throughout the world. Because of the significant ethical and legal implications they represent it is vital that research into the impact and effectiveness of CTOs be supported and encouraged.

EFFECTIVENESS OF COMMUNITY TREATMENT ORDERS FOR TREATMENT OF SCHIZOPHRENIA IN AUSTRALIA: CLINICAL AND SOCIAL OUTCOMES

David Muirhead, Graham Ingram, Carol Harvey

Background: In recent years the use of Community Treatment Orders (CTOs) has been increasing and in an increasing number of jurisdictions around the world. The clinical effectiveness and ethical validity of their use has continued to be the subject of controversy.

Aims: This study examined effectiveness of CTOs used in the treatment of patients with schizophrenia when oral or depot antipsychotic medication was prescribed.

Method: This was a naturalistic retrospective mirror-image study. The sample consisted of patients with schizophrenia (n = ?93) treated on a CTO and divided into two subgroups: patients treated with oral antipsychotic medication (n = ?31), and patients treated with depot medication (n = ?62). Data were gathered via file review using a questionnaire.

Results: Findings included significant increased number of service contacts, decreased number of admissions, decreased length of stay, decreased crisis team referrals, decreased other episodes of relapse, decreased violent episodes, decreased episodes of homelessness and improved quality of relationship with family. No significant change was found in number of self-harm attempts, number of accommodation changes, best employment status or frequency of contact with family. Similar patterns of results were found in both subgroups.

Conclusions: This study provides further evidence that CTOs may be effective in improving the outcome for selected persons with schizophrenia and some evidence that they may enhance the outcome for selected patients with schizophrenia on oral antipsychotic medication.

COMMUNITY TREATMENT ORDERS: QUALITATIVE EVIDENCE FROM NEW ZEALAND

John Dawson

Context: The Otago Community Treatment Order (CTO) study explored the experiences and perceptions of 42 involuntary outpatients under New Zealand's CTO regime, and the views of their psychiatrists, nurses and family members. A particular focus of questioning was the advantages and disadvantages of such a regime. Nearly 200 interviews were conducted concerning the specific position of people recently treated under involuntary outpatient care.

Objectives: This paper summarises the participants' views and relates them to the findings of qualitative studies of similar outpatient commitment regimes in Canada and the USA.

Key messages: Considerable support was found among all groups of participants for the use of involuntary outpatient care, particularly compared to other alternatives. Many dilemmas were also identified in the operation of the regime. These arise at every step in the process, from initial selection of candidates for a CTO to their final discharge to voluntary care.

Conclusion: The degree of conflict that exists between the views of different stakeholders concerning the operation of a well-embedded CTO regime could easily be over-stated.

RS54 OVERCOMING THE STIGMA OF PROGNOSTIC NEGATIVISM IN MENTAL HEALTH CARE

Michaela Amering, Heather Stuart, Norman Sartorius, Richard Warner, Helen Glover

Context: Prognostic scepticism is an important source of negative attitudes towards psychiatry, mental health professionals and towards persons in psychiatric treatment.

Objectives: This symposium will try to clarify the question whether and how this unjustified and harmful situation can be tackled efficiently.

Key messages: Heather Stuart will provide an overview over common forms of stigma and social exclusion with a special focus on the role of attitudes towards effectiveness of treatments and assumptions regarding the course of mental disorders. Norman Sartorius will present the vital issue of iatrogenic stigma and will suggest strategies to reduce this central source of stigma. Dick Warner will set out to correct some of the myths around the course of severe mental illness such as schizophrenia and discuss contexts of integration and recovery. Helen Glover will highlight the obstacles and chances of a paradigm shift towards recovery from mental illness in users, families and providers of services. Finally, Michaela Amering will start the discussion from the point of view of the concepts of resilience, health promotion and prevention.

Conclusion: A shift from the demoralizing prognostic scepticism towards a rational and optimistic attitude is warranted. The great possibilities of therapeutic alliances that support the promotion of resilience and mental health resources of persons with mental health problems need to be proudly exploited and expanded.

STIGMA AS A BARRIER TO RECOVERY

Heather Stuart

Context: Stigma can be defined as a negative, stereotypical attitude toward people with a mental illness that may be a precursor to discriminatory practices. Stigma is a major barrier to recovery, whether recovery is conceptualized as clinical improvement, greater social functioning, or enhanced personal empowerment.

Objectives: This presentation will provide an overview of common forms of stigma and social exclusion with a special focus on the role of attitudes towards the effectiveness of treatments and assumptions regarding the course of mental disorders.

Key messages: At the level of the mental health system, stigma retards mental health reform and treatment improvements. At the level of social interaction, stigma creates social distance and exclusionary practices, making it difficult for people who have a mental illness to fully participate in community life. For people who have a mental disorder, stigma erodes self-esteem, self-efficacy, and interferes with an individual's ability to successfully mange their illness.

Conclusion: These three mechanisms interact to promote disability and social disadvantage.

STIGMA AND DISCRIMINATION RELATED TO MENTAL ILLNESS: THE ROLE OF HEALTH CARE WORKERS

Norman Sartorius

Context: Stigma attached to mental illness (and the discrimination that is usually linked to it) represents the central obstacle to the improvement of mental health care.

Objectives: To review how stigma not only affects the lives of the persons who have the mental illness but also all that is related to it – the families of the mentally ill, the institutions where they receive treatment, the medications that are used in the field of psychiatry and staff that works in this field.

Key messages: There are different ways in which stigma related to mental illness can be prevented, diminished or even removed: among them there are several that depend on the behaviour and activities of staff working in the field of mental health. At present staff are often not aware of their contribution to the stigmatisation nor of the ways in which they could help to reduce it.

Conclusion: Reviewing both of these areas suggestions will be made about what could be done to optimise the role of health workers with respect to stigmatisation and consequent discrimination of people with mental illness.

EVIDENCE CONCERNING RECOVERY FROM SCHIZOPHRENIA

Richard Warner

Context: A common popular and professional misconception of concerning schizophrenia is that recovery from the illness is rarely possible.

Objectives: This presentation will offer evidence that recovery from schizophrenia occurs frequently.

Key messages: A meta-analysis of studies of outcome from schizophrenia in Europe and North America throughout the twentieth century reveals that there has always been a substantial social and complete recovery rate from the illness. The recent International Study of Schizophrenia confirms this finding and expands on it with respect to both the developed and the developing worlds.

Conclusion: Prognostic negativism about recovery from schizophrenia is not justified.

UNPACKING RECOVERY BASED PRACTICE: MOVING OUR FOCUS BEYOND SYMPTOMATOLOGY (ALONE)

Helen Glover

Context: Recovery and Recovery oriented service delivery has taken centre stage as a driving principle of practice within many mental health services. The individual effort required in recovery involves more then the amelioration or alleviation of symptoms.

Objectives: This presentation discusses the tensions of practice required to create and sustain recovery oriented service delivery and practice.

Key messages: The recovery narratives of those with a lived experience and lived experienced informed research highlight the required effort of recovery being much more to do with a person's ability to self manage rather then being managed. This effort could be described more fully as: being able to self determine a life not limited by the illness; taking personal responsibility and ownership for all aspects of life; appreciating the self as an active agent in change; making meaning of what helps and hinders, reclaiming a life beyond the identity of illness, including the roles we have taken as result of the illness and its treatment environments.

The invitation to systems of care who name themselves as recovery oriented need to similarly demonstrate how their practices and processes support the individual efforts of recovery and not inadvertently inhibit such efforts.

Conclusion: Recovery based practice cannot be manualised nor prescribed. It seeks to move from externally interpreting and determining solutions and opportunities for people to creating environments where a person‘s sense of internal realisation and ownership of their recovery is ultimately self directed a, self managed and self determined.

RS55 EARLY PSYCHOSIS PREVENTION AND INTERVENTION CENTRE LONG-TERM FOLLOW-UP STUDY OF FIRST EPISODE PSYCHOSIS: OUTCOME FINDINGS AND IMPLICATIONS FOR POLICY AND CLINICAL PRACTICE

Lisa Henry, Henry Jackson, Patrick McGorry, G. Paul Amminger, Cathy Mihalopoulos

The long-term follow-up study is the central investigative tool to assess course and natural history of an illness and ultimately informs us about the efficacy of provided treatments. Knowledge concerning the longitudinal course and outcome of a disorder provides crucial information for patients, families, clinicians, and researchers. The most effective method for examining the course and outcome of psychotic disorders is to assemble a representative cohort at first psychiatric contact and subsequently conduct standardized, longitudinal assessments. The last two decades has witnessed the emergence of follow-up studies focusing upon first episode psychosis (FEP) and first episode schizophrenia cohorts. Such prospective first-episode studies provide the opportunity to assess prognosis among a cohort, at the same phase of illness, free from the confounding effects of previous treatment interventions or secondary disability. While this body of research has sought to elucidate the correlates of outcome in psychosis, the limitations of non-representative FEP studies with sampling biases, small samples sizes and short follow-up periods, impedes generalizability and validity of the results.

In an attempt to address the above methodological shortcomings, the Early Psychosis Prevention and Intervention Centre (EPPIC) Long Term Follow-up Study, was designed to investigate a large, epidemiologically representative, multi-diagnostic FEP cohort derived from a frontline public mental health clinical program servicing a geographically defined catchment area. The purpose of the study was firstly to describe the course of outcome of illness and secondly, to examine predictors of clinical and functional outcome several years after initial diagnosis and treatment.

The study provides a naturalistic, prospective follow-up of a large cohort of 723 consecutive FEP patients, a median 7.4 years after initial presentation to a specialist early psychosis service in Melbourne, Australia.

Baseline inclusion criteria were age between 14 and 30 years, a DSM-III R and from 1994, a DSM-IV diagnosis of a psychotic disorder (schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder, bipolar disorder, major depressive disorder with psychotic features, brief reactive psychosis/ brief psychosis and psychosis not otherwise specified), informed consent for research participation, living in the defined catchment in the western suburbs of Melbourne, adequate English-language comprehension, and experiencing the first treated episode of psychosis with less than 6 months of prior neuroleptic medication. Exclusion criteria were primary organic mental disorder, intellectual disability, drug and/or alcohol induced psychosis and epilepsy.

The long-term follow-up assessment included interviews with participants, family members, members from the psychiatric treatment team or general practitioner and perusal of the current and/or past psychiatric medical records. Standardised demographic, diagnostic, clinical and functioning assessments were used.

At the long-term follow-up, information was collected on 90.0% (651) of the total cohort of 723 participants. Follow-up interviews were conducted on 484 (66.9%) participants (90.2% face-to-face; 9.1% telephone; 0.7% written); 128 (17.7%) refused to be interviewed, 74 (10.2%) could not be contacted, and 37 (5.1%) were deceased.

The symposium presents a range of findings from the EPPIC long term follow-up study.

EARLY PSYCHOSIS PREVENTION AND INTERVENTION CENTRE LONG-TERM FOLLOW-UP STUDY OF FIRST EPISODE PSYCHOSIS: CLINICAL AND FUNCTIONAL OUTCOMES AT 7.5 YEARS

Lisa Henry, G. Paul Amminger, Meredith G. Harris, Henry Jackson, Hok P. Yuen, Susy M. Harrigan, Helen Herrman, Patrick. McGorry

Background: The long-term outcome of individuals with first episode psychosis, who have received specialised early psychosis treatment strategies from illness onset, remains undetermined.

Aims: We aim to examine the long-term clinical and functional outcome of first-episode psychosis.

Methods: Analyses involved 593 participants from the EPPIC Long Term Follow-up Study (Henry et al., 2007). Standardised assessments were used at follow-up to assess participants’ demographic characteristics, axis I diagnosis, clinical and work/social functioning.

Results: At follow-up the mean age of the cohort was 29.2-years and 68.5% were male. The majority of the cohort was living independently. Proportions of individuals diagnosed with schizophrenia, schizoaffective disorder, affective psychosis, and other psychosis were 60.7%, 9.3%, 19.9% and 10.1% respectively. Comparisons between the diagnostic groups found the schizophrenia group to have significantly higher Brief Psychiatric Rating Scale (total, psychotic subscale) and Schedule for Assessment of Negative Symptoms (total) mean scores and significantly lower GAF, SOFAS and Quality of Life Scale mean scores than the other diagnostic groups at follow-up. In the most recent 2 years, 50.6% of individuals with schizophrenia, 61.1% with schizoaffective disorder, 72.1% with affective psychosis, and 78.6% with other psychotic disorders reported some level of paid employment. Considering the illness course over the most recent two years, the majority (45.81%) reported never being actively psychotic, 32.1% a continuous course and 19.3% an episodic course.

Conclusions: A specialised early intervention service program might result in better functional outcomes.

EARLY PSYCHOSIS PREVENTION AND INTERVENTION CENTRE LONG-TERM FOLLOW-UP STUDY: PREDICTORS OF VOCATIONAL FUNCTIONING 7.5 YEARS AFTER A FIRST PSYCHOTIC EPISODE

Patrick McGorry, Meredith G. Harris, Lisa Henry, G. Waghorn, Susy M. Harrigan, Orli S. Schwartz, Amy L. Prosser, Simone F. Farrelly, Henry Jackson

Background: Historically, individuals with psychotic disorders have been found to have poor vocational functioning. Predictors of long term vocational functioning in a cohort of first episode psychosis individuals, who received specialist early psychosis treatment, is unknown.

Aims: To identify correlates of vocational functioning in a first episode psychosis sample 7.5 years after presentation at a specialized early psychosis treatment service.

Methods: Analyses involved 180 participants from the EPPIC Long Term Follow-up Study (Henry et al, 2007). At treatment entry, demographic and clinical variables were administered. At 7.5-year follow-up measures included the WHO Life Chart Schedule (to assess course of illness, treatment history, and duration of receipt of a disability support pension (DSP)), and the Structured Clinical Interview for DSM-IV.

Univariate and multivariate logistic regression analyses were used to estimate the effects of demographic, clinical and treatment variables on two outcomes: current employment; and durable employment.

Results: Some 45% were employed at follow-up, and 53% reported recent durable employment. Multivariate analyses showed that, after controlling for other variables, current employment was negatively associated with continuous or episodic illness course characterized by worsening trajectory or incomplete remissions, disrupted education, and receiving a DSP for longer than 2 years. Diagnosis of schizophrenia, receipt of a DSP and disrupted education were negatively associated with durable employment.

Conclusions: Educational attainment appears to be an important predictor of vocational outcome in the Australian labor market. The inverse relationship between DSP and employment supports other research that such payments may act as a disincentive to employment.

STABILITY OF SYMPTOMATIC REMISSION IN FIRST EPISODE PSYCHOSIS: RESULTS FROM THE EPPIC LONG TERM FOLLOW-UP STUDY

G. Paul Amminger, Lisa Henry, Susy M. Harrigan, Meredith G. Harris, Henry Jackson, Patrick McGorry

Background: Recently the Remission in Schizophrenia Working Group devised an operational definition of remission defining clinical remission according to a threshold of severity of selected rating scale items (Andreasen et al., 2005). The stability of remission over a longer time period has not yet been investigated in a large epidemiological cohort of individuals with first episode psychosis.

Aims: We aim to determine the rates and stability of symptomatic remission in individuals with a first episode psychosis at two time points, 1-year and long-term follow-up (median = 7.7 years).

Methods: We applied the symptomatic remission criteria (severity criteria) proposed for the Brief Psychiatric Rating Scale (BPRS) in the sample of the EPPIC Long Term Follow-up Study (Henry et al., 2007). Individuals who had BPRS ratings on 7 required items (grandiosity, suspiciousness, unusual thought content, hallucinatory behavior, conceptual disorganization, mannerisms/posturing, blunted affect) at both time points were included in the analysis (n = 253).

Results: At 1-year follow-up, 64.8% (164) individuals met remission criteria. At long-term follow-up, 58.1% (147) individuals met remission criteria. One hundred and twelve (44.3%) individuals were in remission at both time points. Of the 89 individuals not meeting remission criteria at 1-year, 39.3% (35) attained remission at study endpoint, and 31.7% (52) of the 164 initially remitted patients were no longer in remission at long-term follow-up.

Conclusion: A substantial proportion of individuals with first episode psychosis experience stable symptomatic remission.

IS THE SHORT-TERM COST-EFFECTIVENESS OF AN EARLY PSYCHOSIS PROGRAM MAINTAINED AT LONG TERM FOLLOW-UP?

Cathy Mihalopoulos, Meredith G. Harris, Lisa Henry, Susy Harrigan, Henry Jackson, Patrick McGorry

Background: Despite considerable interest and investment in early psychosis services scant attention has been paid to the economic evaluation of such services. A one-year evaluation of the cost-effectiveness of the EPPIC model concluded that EPPIC was a dominant intervention compared to historical care in that it was cheaper and more effective, however no published studies have evaluated the longer term effects of a model of early intervention in terms of both outcomes and costs.

Aims: This study examines whether the cost savings and outcomes associated with EPPIC persist beyond the one year timeframe.

Method: The study uses a historical control design. A sample of 51 participants who presented to EPPIC in 1993 was individually matched (on age, sex, diagnosis, premorbid adjustment and marital status) with 51 participants admitted to the precursor service (the'pre-EPPIC' service) between 1989 and 1992. Participants were followed up at one year, then again approximately 7.5-years after inception. A representative sub-sample of 65 participants were interviewed at follow-up. Data describing psychiatric service use, medication type, duration and dosage were collected via interviews with patients and informants, electronic databases, and medical records. Economic evaluation methodology will be used to assess the costs, benefits and incremental cost-effectiveness ratios of the two interventions.

Results: The previous cost-effectiveness analysis found that the EPPIC sample incurred lower health service costs and had better outcomes compared to the pre-EPPIC control group.

Conclusion: This study will help answer whether the EPPIC model of care maintains'value for money' over a longer period.

EARLY DETECTION AND OPTIMAL TREATMENT MAY IMPROVE OUTCOME IN EARLY-ONSET SCHIZOPHRENIA: EVIDENCE FROM THE EPPIC LONG-TERM FOLLOW-UP STUDY OF FIRST EPISODE PSYCHOSIS

G. Paul Amminger, Lisa Henry, Susy M. Harrigan, Meredith G. Harris, Henry Jackson, Patrick McGorry

Background: Previous research has suggested that poor outcome is typical in early-onset schizophrenia (EOS) which manifests before the age of 18 years. However, no study to date has compared the long-term outcome of EOS vs. adult-onset schizophrenia (AOS) attending the same, specialized treatment program.

Aims: To examine the long-term clinical and functional outcome of a first episode cohort of EOS vs. AOS.

Methods: Some 290 individuals were diagnosed at baseline with schizophrenia-spectrum disorders. Independent samples t-tests were used to compare EOS and AOS groups on psychopathology and outcome measures at long-term follow-up. Statistical tests were two-tailed. P values of 0.05 or less were considered statistically significant.

Results: EOS was found in 31 (10.7%), AOS in 259 (89.3%) of individuals in the sample. T-tests indicated no significant group differences on BPRS total, BPRS psychotic subscale, SANS total, and SOFAS mean scores. In contrast to an expected poorer outcome, individuals with EOS were characterized by significantly better functioning (GAF and SOFAS) and higher quality of life (QLS) at 7.4 year follow-up as compared to individuals with AOS.

Conclusion: The present findings emphasize a much more optimistic view on the long-term outcome of EOS which may be related to early detection and the specialized treatment program provided by EPPIC. These results also suggest that younger patients might stand to profit more from the treatment approach offered by such a service, particularly in terms of enhancement of their functioning and quality of life several years subsequent to treatment entry.

RS56 LATE-LIFE DEPRESSION IN GENERAL PRACTICE; WHAT SHOULD WE DO?

Els Licht-Strunk, Osvaldo Almeida, Kenneth Wilson, Ngaire Kerse

It's well-known that depression has a high prevalence in older general practice patients and that it is associated with increased morbidity, mortality and high health care costs. This makes it a highly relevant subject and therefore researchers have been focusing on studies on recognosing and treating depression in this age group. Although treatments, both medication and psychotherapy, have shown to be effective in treating late-life depression, still about one in three patients develops a chronic course. This prognosis is worse than in younger adults, suggesting that dealing with depression in older patients is more complicated than dealing with depressed younger adults. Doctors and researchers have been hypothesising on possible explanations for this. One of the reasons might be that a lot of older patients have somatic comorbidity, which makes diagnosing depression more difficult. Furthermore, drug-treatment can be complicated by contra-indications and interactions with other medication. Another reason might be that older patients find it difficult to talk about emotions and don't express their depressed mood to their doctors.

We can conclude from the above that depression is a highly prevalent and treatable condition in older patients. However, in daily clinical practice we do not succeed in curing these patients. What's going wrong? Should we improve recognition for example by screening the older population? Or should we intervene even earlier by identifying patients at risk, trying to prevent depression? But how can we prevent treating patients who do not need treatment, i.e.'false positives' and those with a self-limiting course? Could we identify patients at risk for poor depression outcome? And what treatment would be best? Were trials for treating late-life depression efficacy or effectiveness studies? What can we learn from them for daily practice?

In the present symposium we will address these questions using recent research results on late-life depression on prevention, course and treatment. We will discuss what implications these results may have for daily clinical practice and future research plans.

NO MORE DEPRESSION! CAN WE REALLY PREVENT DEPRESSION IN LATER LIFE?

Osvaldo P. Almeida, Jon Pfaff, Orla Tyson, Jane Pirkis, Leon Flicker, Nicola Lautenschlager, Moira Sim, Brian Draper, John Snowdon, Robert Goldney, Gerard Byrne, Nigel Stocks, Ian Wilson, Ngaire Kerse

Background: Depression in later life has been associated with numerous risk factors: life events, impoverished social network, smoking, sedentary lifestyle, obesity, cardiovascular disease, hypertension, diabetes, high plasma homocysteine, among others.

Aims: (1) to review the likely contribution of risk factors to the presence of depression in later life; (2) to determine the effectiveness of two different approaches to disease prevention: ongoing treatment with antidepressants and management of risk factors.

Methods: 12-month prospective study of 21,819 adults aged 60 years or over in contact with 383 Australian general practitioners. The diagnosis of depression was based on assessment with the PHQ-9 and DSM-IV criteria. The use of antidepressants was systematically recorded at baseline, as was the social network, smoking, physical activity, financial burden, BMI, alcohol consumption and medical history for cardiovascular events.

Results and discussion: To be presented at the meeting.

DOWNWARDS OR UPWARDS? THE COURSE OF DEPRESSION IN LATER LIFE

Els Licht, Trynke Hoekstra, Jos Twisk, Marten de Haan, Harm van Marwijk, Aartjan Beekman

Background: Little is known about the course of depression in older primary care patients. Existing (longitudinal) studies often use data of only two measurements, which do not take into account the possible fluctuating course of depression over time. Therefore, studies using repeated measurements are needed to characterize the course of symptoms over time.

Aims: To identify different course types of depression in older primary care patients.

Methods: A longitudinal observational study, follow-up three years. Patients 55 years and older visiting GPs in the Netherlands with a score of 5 or more on the Geriatric Depression Scale (GDS-15 items) were included. Depression was measured every six months using the Primary Care Evaluation of Mental Disorders (PRIME-MD) and Montgomery Åsberg Depression Rating Scale (MADRS). Patient characteristics were collected using validated questionnaires.

We used (longitudinal) latent class analysis to identify different subgroups in the course of depression, using the MADRS at seven time points as a continuous outcome.

Results: 234 patients with a major depression and 154 patients with a subthreshold depression participated. 299 (77%) had more than 50% of all measurements. Analysis yielded four subgroups representing distinct courses in patients with major depression: recovering, persistent mild, fluctuating and chronic. At the conference we will show characteristics of patients in different subgroups.

Conclusion: Our results show sensible and clinically relevant subgroups. Identifying patients with different prognosis may be useful in making treatment decisions in daily clinical practice.

IS THERE A MAGIC PILL TO TREAT DEPRESSION?

Kenneth Wilson, P. Mottram

The aim of the presentation is to provide an evidence-based review of the literature concerning the drug treatment of depression in older people. The review will refer to the clinical implications of two Cochrane meta-analysis that we have conducted, examining the treatment efficacy of antidepressants and comparing their side effects in older people in community settings. Evidence will also be drawn from trials that have examined the role of antidepressants in the long term treatment of depression in older people living in the community. We will draw on our experiences of conducting a double blind, placebo controlled trial of sertraline in the prevention of relapse and examine other related trials with view to exploring both duration and dosage of treatment. We intend to discuss the implications of our own studies and draw on relevant evidence and guidelines relating to clinical practice with regard to first, second and third line treatment options and longer term management of moderate to severe depression in older people.

NON-PHARMACOLOGICAL TREATMENTS OF DEPRESSION

Ngaire Kerse, Karen Hayman

Background: Depression management is complex for older people as co-morbidities, disability and the increased importance of the psychosocial context complicate both recognition and treatment. Disability levels lead to depression, and depression leads to disability, creating a downward spiral for older people. Physical activity and exercise programmes benefit individual health conditions, overall quality of life, and may improve mood. Community and social interventions as well as psychological interventions have an important and underrated role in management.

Aim: Present a review of non-pharmacological interventions for depression in late life.

Outcome: A review of the literature of the association between physical activity and depression, and interventions for late life depression, particularly commenting on key trials of physical activity, psychological and community interventions will be presented. Depression related outcomes from intervention trials of activity promotion and from the Auckland Gerontology Group, conducted both in residential care and the community setting, will be presented.

Implications: An increased understanding and utilisation of the range of management options for older people with depression may improve outcomes.

RS57 COLLABORATIVE CARE FOR DEPRESSION: EVIDENCE, ACCEPTABILITY AND IMPLEMENTATION

Linda Gask, Simon Gilbody, David Richards, Jane Gunn

Context: Depression is a major health problem causing substantial disability and set to become the second largest cause of global disability by 2020. However, care for depression continues to be sub-optimal worldwide. The most successful intervention to date for improving the quality of care for depression, at least from studies primarily carried out in the United States of America, is Collaborative Care. This is a complex organisation strategy which includes 1) a multi-professional approach to patient care; 2) a structured patient management plan; 3) scheduled patient follow-ups; 4) enhanced inter-professional communication.

Although collaborative care improves outcomes over usual care (references [1–3]) two recent systematic reviews found small to medium mean effect sizes of either 0.24 (95% CI 0.17 to 0.32)([4]) or 0.40 (95% CI 0.20 to 0.60) ([5])The effects associated with individual studies varied significantly, reflecting variation in the content of these ‘complex’ interventions.

Although there have been calls for the implementation of collaborative care in the UK and elsewhere ([6]), these have not been supported by UK clinical guidelines and may be premature when it is not known exactly which models of collaborative care work best, and whether the model will generalise outside the US setting.

Objectives: a) To systematically review the evidence for collaborative care in treatment of depression b) Present new evidence from the UK and Australia concerning the effectiveness and acceptability of collaborative care c) Examine issues that must be addressed before collaborative care can be adopted in routine practice.

COLLABORATIVE CARE AND THE TOTALITY OF RANDOMISED EVIDENCE: APPLYING CUMULATIVE META-ANALYSIS TO AN EVOLVING TECHNOLOGY

Simon Gilbody

Background: Collaborative care has emerged as the most effective means of organising and delivering primary care for depression. The co-ordination and enhancement of care borrows much from chronic disease management models and was essentially developed in within US managed care systems. We sought to assess the totality of randomised trials in this area to see how evidence had emerged and evolved over time.

Methods: We pooled data from 37 trials (based upon 12,000+ participants). These were sequentially added according to year of publication using cumulative meta-analysis, to demonstrate how evidence had evolved over time. Underlying sources of heterogeneity were explored using meta-regression.

Results: The overall clinical effect size at six months was modest (standardized mean difference = 0.24), but persisted for at least two years post-intervention. Sufficient randomised evidence had emerged by the year 2000 to demonstrate beyond conventional levels of statistical significance that collaborative care is effective compared to care as usual. Effect size was directly related to the ability of collaborative care to enhance medication concordance, and several possible ‘active ingredients’ of collaborative care emerged. More recent trials have successfully extended this model of care to populations with co-morbid physical illness and depression.

Conclusion: Although collaborative care is effective in the context of well conducted (largely US) trials, it remains unclear how collaborative care should be implemented, and whether the effectiveness can be seen in non-US healthcare settings.

COLLABORATIVE CARE FOR DEPRESSION: PROCESS AND OUTCOME RESULTS FROM A UK TRIAL

David Richards, Michael Barkham, Peter Bower, Linda Gask, Simon Gilbody, Karina Lovell, Anne Rogers, David Torgerson, and the ECD team

Background: Despite a substantial evidence base, the complexity of collaborative care models for depression leaves many questions unanswered. We do not know which precise elements should go into the collaborative care melange and how these elements should be organised and delivered. Problems of dissemination of the model are further compounded by the uncertainty of applying a predominantly US-developed evidence base to other nations’ health systems.

Methods: We report the first UK study of collaborative care for depression, in which we constructed a culturally and organisationally appropriate clinical protocol and tested its feasibility, acceptability, fidelity and effect size in primary care.

Results: We found that the introduction of case managers into primary care offering support, medication management and a low-intensity psychological interventions to people with depression had a large effect size compared to usual care. The essential components, the acceptability to patients and clinicians and the role of collaborative care in stepped approaches to psychological treatment access will be outlined. Methodological choices in the design of definitive randomised trials of complex interventions such as collaborative care will also be discussed.

CONSUMER VIEWS ON THE ELEMENTS OF COLLABORATIVE CARE

Jane Gunn, Renata Kokanovic, Caroline Johnson, Ella Butler, Maria Potiriadis, Christopher Dowrick, and the RE-ORDER team

Background: Collaborative care models for the management of depression have been developed in the USA over the past 2 decades and have provoked considerable interest from other Western countries looking for better ways to manage depression. Collaborative care involves: a multi-professional approach to patient care, use of structured management plans/guidelines, proactive and scheduled patient follow-ups and enhanced inter-professional communication. There are little published data on views on collaborative care for depression held by people receiving treatment in the primary care setting. Re-order (Re-organising care for depression and related disorders in the Australian Primary Health Care setting) is a large multidisciplinary project that focuses attention on the perspectives of health care provision of a large cohort of people experiencing depressive symptoms, in order to develop best practice models for depression care relevant to primary care in Australia.

Aims: To examine the response of people experiencing depressive symptoms to a range of elements common in collaborative care models as they apply in the primary care setting.

Methods: Structured Computer Assisted Telephone Interviews with 588 participants in a longitudinal study. Interviews included participants’ views on concepts and causes of depression and their experiences of health care services use. Here we report on their views about completing symptom checklists in the waiting room to assist the Doctor to make a diagnosis; receiving phone calls as follow-up; involvement of practice nurses in depression care; co-location of psychologists and having a written plan detailing the steps needed for recovery.

Results: We will provide results of content and thematic analysis of the interviews.

COLLABORATIVE CARE FOR DEPRESSION: THE PROCESS OF NORMALISATION IN A UK HEALTHCARE SETTING

Linda Gask and the ECD team

Background: In the context of calls for the routine implementation of collaborative care for depression in healthcare settings, this paper will explore the process of normalisation of collaborative care in the UK setting, utilizing data from the Enhanced Care for Depression (ECD) trial carried out in 2005-6. The Normalization Process Model (devised by Carl May) is a theory of the social processes involved in embedding complex interventions in health care.

Methods: Secondary analysis of 60 transcriptions of individual interviews and focus groups carried out with patients, general practitioners, community mental health nurses, psychologists, psychiatrists and practice nurses before, during and after a randmoised controlled trial of collaborative care for depression.

Results and discussion: There was disagreement about the impact of the telephone on the patient-professional relationship, but the overall content of the intervention (behavioural activation, medication management, use of written materials) was highly acceptable. Implementation in the health care system however raised issues in terms of clarification of risk management and clinical responsibility, the skill-set and professional background required for the role of case manager and protocols for sharing of information between professionals. Of considerable interest was the uncertainty revealed about the willingness of healthcare professionals to assume new working practices, and how the new service might be implemented within existing commissioning and funding arrangements in the British NHS.

RS58 EVALUATION AND MANAGEMENT OF AGGRESSION IN PSYCHIATRIC PATIENTS

Jiri Raboch, Jan Vevera, Eva Ceskova, Paul E. Mullen

Psychiatrists should be able to evaluate and treat violent patients. A number of studies indicate that approximately 10–15% of the patients seen in psychiatric hospitals manifested violent behaviour toward others just before being admitted to these institutions. Learning how to evaluate and manage violent patients is important not only for the safety of society and of patients in treatments settings but also for the safety of mental health professionals who themselves are at high risk of being assaulted. Broad spectrum biological as well as environmental factors interact to produce violent behaviour in humans. We shall discuss the role of genetic factors (COMT polymorphisms) in men with antisocial personality disorder. Psychosis increases the potential for violent behaviour. Schizophrenia is most frequently found in patients with psychosis and violence. This may not be the case in those suffering from the first psychotic break down. We have evaluated a group of men with first-episode schizophrenia who were treated with atypical antipsychotics. Use of coercive measures to control violent behaviour of patients is very sensitive issue. Comparison of its use in 12 European countries and in Israel showed similarities as well as differences among individual EUNOMIA (European Evaluation of Coercion in Psychiatry and Harmonisation of Best Clinical Practice) centres reflecting different cultural traditions, different legal systems and various structure and quality of mental health care.

GENETIC FINDINGS IN IMPULSIVELY VIOLENT OFFENDERS

J. Vevera, R. Stopková, M. Bess, T. Albrecht, H. Papezová, I. Zukov, J. Raboch, P. Stopka

Background: It is hypothesized that modulation of aggression is implemented by an equilibrium between serotonin that raises the threshold for overt aggressive response to environmental stimuli, and catecholamines that have an opposite effect. High noradrenergic activity and low activity of the enzymes that catabolize catecholamines are associated with aggressive behavior. The enzyme catecholO-methyltransferase (COMT) plays a key role in prefrontal cortical functioning in that it accounts for most of the degradation of dopamine.

Aims: To analyse the influence of three COMT polymorphisms on violent behavior in prisoners with Antisocial Personality Disorder (APD) to find whether those polymorphisms might act as a predictor of violent antisocial behavior.

Methods: We conducted an association study comparing 47 male repeatedly sentenced for impulsive violent attacks diagnosed with APD with 43 healthy male controls matched on education. Three COMT polymorphisms were analysed: two on exon 4: COMT 158 Met/Val and COMT 146 Val/Ala, and one on the 6th exon, a single nucleotide C insertion/deletion at the 3’ untranslated region of the COMT gene.

Results: The logistic regression analysis revealed that among three studied polymorphisms (146 Val/Ala, 158 Met/Val, insC/delC), only allele T of the 146 Val/Ala polymorphism was significant predictor of being violent offender (adjusted for effects of other polymorphisms: p = 0.017).

Conclusions: Our findings provide the first support that COMT is a modifying gene that plays a role in determining interindividual variability in the proclivity for violent behaviour in subjects without major mental disorder.

AGGRESSIVITY IN FIRST-EPISODE SCHIZOPHRENIA

E. Cesková, R. Prikryl, T. Kasparek, H. Kucerová

Background: Psychosis is associated with a higher rate of aggressivity.

Aims: The aim of the study was to examine in detail aggressivity and its dynamics in patients with first-episode schizophrenia.

Methods: Males hospitalised for the first time with the diagnosis of first-episode schizophrenia (n = 175) were comprehensively assessed. The psychopathology was evaluated using PANSS before treatment (on admission), at the end of acute treatment (at discharge). Aggression was defined using items hostility and associated items – excitement, poor impulse control, tension (e.g. factor excitement of the PANSS). They were treated openly with second generation antipsychotics, risperidone being the drug of the first choice.

Results: On admission, mean values of hostility and other items of the excitement factor were low (2–3) and decreased significantly further at discharge. For symptoms presence a minimal score of 4 was required. Both hostility and associated symptoms were observed in less then 1/3 of the patients. Correlations with other symptoms were explored too. On average all symptoms were significantly reduced within 6 weeks after admission.

Conclusions: First-episode schizophrenia is characterized by pronounced acute treatment response. After the first psychotic episode the course of disease is highly variable. Many patients relapse, are non-compliant and develop co morbidity (substance dependence). All these factors may influence later manifestation of aggressivity. This confirms the suggestion that the period after the first psychotic manifestation is a critical one.

COMPARISON OF THE CLINICAL USE OF COERCIVE MEASURES DURING HOSPITALISATION ACROSS THE EUNOMIA STUDY SITES

J. Raboch, T. W. Kallert, L. Kalisova and EUNOMIA team

Aims: The aim of this presentation is to compare general practice of the application of coercive measures in psychiatric facilities in 12 European countries and in Israel.

Methods: Detailed data concerning individual coercive measures – physical restraints, the use of seclusion and forced medication were gathered. In this presentation only data regarding involuntarily admitted patients were included.

Results: In the group of 2 587 involuntarily admitted patients (average age: 38,2±11,1) coercive measures were used in 32,2% of them (in 55% of men and 45% of women). The frequency of the use of coercive measures in individual centres varied substantially between 9,1% in Slovakia and 59,2% in Poland. In the majority of patients more than one coercive measure was applied. In nine centres the most frequent measure used was forced medication (mainly typical antipsychotics and benzodiazepines) and in four centres physical restraint. Seclusion was available in six countries and not very frequently used. The main reason for application of coercive measures was aggression against others. Coercive measures were usually ordered by a psychiatrist. In all countries patients were informed about reasons, duration and form of the measure.

Conclusions: Coercive measures were usually ordered by a psychiatrist. In majority of countries only members of medical staff were present at the time of their application; but in some countries relatives and police were also involved.

RS59 EVIDENCE ON TRIAL: PILOTING OF CLINICAL ALGORITHMS FOR DEPRESSION AND SCHIZOPHRENIA

David Barton, David Codyre, Peter McGeorge, Karin Myhill, Peter Norrie, Michael Paton, Lynette Rose, Alan Rosen, Andrew Wilson, Harry Lovelock, Audrey Holmes, Juliette Begg

Background: Publication and dissemination alone of evidence-based guidelines has little impact on closing evidence-practice gaps. Previous research has found that barriers to guideline implementation often relate to systems factors such as work process issues, access to effective treatments, and cost/time issues. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has developed a series of six clinical practice guidelines and associated tools, including summary algorithm brochures.

Aim: The aim of the current project was to determine the usability and face-validity of the algorithm brochures in actual practice settings.

Methods: The schizophrenia and depression algorithm brochures were selected as the focus for a pilot project involving thirteen participant mental health services across Australia and New Zealand.

Results: The results from these pilots show that attitudes to the brochures were generally very positive with most respondents reporting the brochures as useful tools. Barriers encountered to implementation most frequently related to organisational and systems constraints. A lack of available resources to provide psychosocial interventions was identified as a barrier at almost all participant services.

Conclusion: The results of the pilots show that the summary algorithm brochures were viewed as useful clinical tools with barriers to implementation most often being reported as relating to systems factors. The findings from the project will assist the refinement of the existing resources and will inform the development of a broader strategy for implementation. This project is a valuable stepping stone to continuing initiatives to reduce the gap between evidence and practice and to continue to develop quality medicine, for practitioners and for consumers and their families.

RS60 OUTCOMES OF DEPRESSION: INTERNATIONAL PERSPECTIVES ON THE IMPACT OF PRIMARY CARE

Jane Gunn, Christopher Dowrick, Andre Tylee, Tony Dowell

Background: Depression is the single largest cause of disability burden in Australia and is mainly managed in primary care/general practice. The proposed symposium draws together four international observational studies which will present descriptive data on the progression, management and outcomes of depression managed in primary care across more than 12 countries.

Aim: To discuss how the findings from these studies could guide primary care mental health system reform.

Method: The symposium will:

describe the psychiatric, physical health, quality of life and social characteristics of the three cohorts of people experiencing depressive symptoms and how they vary over time

examine the separate and interacting roles of socioeconomic adversity, psychological adversity and medical care in explaining the recurrence or persistence of depression

document the health care use, treatments, health outcomes and experiences of the three cohorts

compare the experiences, health care use and outcomes for those with a diagnosis of major depression versus depressive symptoms

explore the impact of antidepressant medication on the Quality of life (QoL)

explore the impact of treatment choice on QoL

explore the effectiveness of case finding

Following presentation of the studies there will be a discussion around the findings and delegates will be encouraged to consider how these findings could guide primary care mental health system reform.

DIAGNOSIS, MANAGEMENT AND OUTCOMES OF DEPRESSIVE SYMPTOMS COHORT STUDY IN AUSTRALIAN PRIMARY CARE

Jane Gunn, Gail Gilchrist, Helen Herrman, Kelsey Hegarty, Grant Blashki, Dimity Pond, Michael Kyrios, and the DIAMOND team

Background: Diamond is a prospective 3-year cohort study of the characteristics, service/treatment use and health outcomes of patients identified with depressive symptoms from Australian general practice.

Aims: To: 1) describe the psychiatric, physical health, quality of life and social characteristics of patients identified with depressive symptoms. 2) document the health care use, treatments, health outcomes and experiences of care of the cohort. 3) describe the predictors of recovery and persistence of symptoms at 3, 6, 9, 12, 24 and 36 months and 4)explore the relationship between psychiatric, physical health, social characteristics and quality of life and health care use and outcomes.

Methods: 30 GPs sent a screening survey to 600 randomly selected patients aged 18-75yo whom they had seen in the past year. Patients are assessed at baseline, 3, 6, 9, 12, 24 and 36 months for demographic characteristics, psychiatric and medical conditions, social support, social participation, childhood abuse, domestic violence, substance use, recent life events, quality of life, health status, health care utilisation, satisfaction with and trust in general practice care. A telephone interview is undertaken at one year asking about their experiences of depression and health care.

Results: Cohort consists of 791 patients with depressive symptoms. 564 (71.3%) female. 49.0% (356/726) met DSM-IV 12-month criteria for major depressive disorder and 10% (75) met DSM-IV criteria for dysthymia. 153 (21%) had a co-morbid substance use problem; 142 (18%) had co-morbid panic syndrome; 202 (26%) had co-morbid anxiety syndrome; 543 (69%) had a co-morbid chronic physical health problem.

Conclusions: Baseline results and 3-month outcomes will be presented at the conference.

PERSISTENCE AND RECURRENCE OF DEPRESSION: THE IMPACT OF SOCIAL AND PSYCHOLOGICAL ADVERSITY AND THE ROLE OF MEDICAL CARE

Christopher Dowrick, Helen Page, Margaret Whitehead, Peter Salmon, Odd Steffen Dalgard, Patricia Casey, Britta Sohlman, Graham Dunn, Chris Shiels and the ODIN team

Background: The Outcomes of Depression International network (ODIN) is a European collaboration studying the prevalence and outcomes of depressive disorders identified in the community in Finland, Ireland, Norway, Spain and UK. The original study identified 420 people with depressive disorders in these centres, between 1997 and 1999. See e.g. Dowrick C et al BMJ 2000,321,1450–4; Ayuso J et al Br J Psych 2001,179,308-316. We are currently undertaking a follow-up study of this cohort in four of the five centres.

Aims: Of this follow-up study are: 1) To examine the separate and interacting roles of socioeconomic adversity, psychological adversity and medical care in explaining the recurrence or persistence of depression. 2) To interpret the findings to inform policy and practice in the health care system. 3) To enable a future epidemiological study by providing estimates of rates of persistence and recurrence, and by identifying specific hypotheses about the interaction of the three areas of the study.

Methods: 1) Quantitative: using a combination of postal self-rated instruments followed by telephone interview, we are collecting data on trajectory of depression and current status; socioeconomic adversity; psychosocial adversity; medical care. 2) Qualitative: A purposive sub-sample of Stage 1 responders is invited to take part in a semi-structured interview, to elicit their accounts of depression and its treatment. The interview schedule is structured to enable discussion of the interactions between the three sets of variables (psychological, social deprivation and medical factors) and of the mediators of effects of each type of variable.

Results: We have collected quantitative data from 191 of the original cohort, and qualitative data from 24 interviews. These data will be analysed and the main findings presented to the conference.

FACTORS INFLUENCING DEPRESSION ENDPOINTS RESEARCH STUDY: BASELINE AND SIX MONTH FINDING

Andre Tylee and the FINDER study group

FINDER Study is a 6-month, collaborative European, prospective, observational study of health outcomes associated with treatment of depression across 12 countries.

Aims: Of this study are: 1) To estimate the Quality of life (QoL) at baseline and at 3 and 6 months after antidepressant medication has been commenced. 2) To describe the relationship between the collected variables at baseline (cross-sectional analysis) 3) To describe the impact that baseline factors and treatment choice has on QoL (and outcome measures) at 3 and 6 months.

Methods: Patients aged 18 years and over, presenting in the normal course of care and with either their first or a new episode of depression clinically diagnosed by their GP/specialist and who were about to receive antidepressant treatment were recruited from 437 sites throughout Europe. Baseline measures included demographic data, psychiatric and medical history, medication history, co-morbid chronic medical conditions and functional syndromes, co-morbid pain, quality of life and health care resource utilisation. They were again assessed at 3 months (±1 month) and 6 months (±1 month).

Results: Data from 3468 patients was available for analysis (mean age 46.8 sd 14.7, 68.2% females). Mean duration of depressive illness was 8.5 years with mean age of 38.4 (sd 14.7) at first episode. 55.6% of patients had other psychiatric disorders, the most frequent was anxiety/panic disorder (51.1%). 38.2% of patients had received antidepressant medication in the previous 2 years. From a descriptive point of view patients enrolled in the study receiving antidepressant treatment improved their depression and QoL over the course of 6-month follow-up. Further results will be presented controlling for important baseline variables to better evaluate QoL over time.

NATURE AND OUTCOME OF DEPRESSIVE DISORDER IN NEW ZEALAND GENERAL PRACTICE: THE MAGPIE STUDY

Tony Dowell

Background: The Mental Health in General Practice Investigation (MaGPie) is an observational cohort study investigating the nature, prevalence, outcomes and management of common mental health problems in New Zealand general practice.

Cross sectional and 1 year prospective follow up data from patients with depression will be presented.

Method: Consecutive patients from a random sample of GPs in the Lower North Island of New Zealand were screened using the General Health Questionnaire (GHQ-12). A stratified random sample of patients was selected, based on GHQ strata, and invited to participate in an in-depth interview to assess their psychological health. The interview schedule included the Composite International Diagnostic Interview (CIDI-one month assessment and follow up at 1 year. General Practitioner assessment of psychological status was obtained and qualitative interview data from both patients and GP's relating to the diagnosis and management of mental health problems.

Results: Seventy of the 78 (90%) eligible randomly selected general practitioners agreed to participate. GHQ screening questionnaires were completed by 3414 of 3687 (93%) eligible general practice attenders. Of the 1151 selected for interview based on the GHQ 775 patients were recruited for cross sectional study, and results from 603 (78%) patients available for analysis at 1 year. Using the CIDI, 18.1% of the sample reached the diagnostic threshold for depression.

Quantitative and qualitative data will be presented to explore the following themes:

The nature of depression in New Zealand general practice.

The stability of the diagnosis of depression over time.

The effectiveness of case finding.

The relationship between treatment intervention and outcome.

RS61 COMPLEMENTARITY BETWEEN PUBLIC AND PRIVATE SERVICES: INTEREST OF THE FRENCH MODEL FOR PSYCHIATRY

Antoine Besse, Jean-Jacques Laboutiere, Nicole Garret-Gloanec, Herve Grainer

The French health service presents the characteristic to be shared between private and public resources, both equally financed by the Sécurité Sociale, and therefore accessible to anyone.

This context had favoured the development of many kind of care structures in the field of psychiatry. Some of them are wide open to general cares, others offer very specific treatments; both are related to a dense network of stand-alone practitioners in town.

Aims:

Present the French psychiatric system

Present the place of the various actors (general practitioners, psychiatrists, psychologists, nurses and social workers)

Underline the comlementarity of the various structures

Illustrate the interest of this model through a clinical case

Key messages:

Psychiatry implies the recourse to various professionals

Its effectiveness supposes an opening on the city, in particular on teachers and social workers

A high level of quality supposes to preserve a diversity of therapeutic answers requiring the existence of specialized structures

The freedom of the patient to choose as much as possible the professionals who will look after him is of utmost importance in the observance of the treatments

Conclusion: For more than 40 years, this system has sort to be organized in a network in order to offer each patient the most adapted cares. This network organization widely differs from many systems which are structured in levels, each level offering more and more elaborated therapeutic answers. Nevertheless, we think the horizontal organization of the French model is more coherent with the characteristics of the mentally ill person.

COMPLEMENTARITIES IN THE FRENCH MENTAL HEALTH SYSTEM

Jean-Jacques Laboutiere

The main characteristic of the French health system is the fact that private and public structures are equally financed by the Sécurité Sociale.

This allowed a great variety of care structures from stand-alone practitioners to specialized in-patient care units.

The second characteristic is the will of all these structures to build a network in which the patient can find the appropriate responses to his needs.

PUBLIC PSYCHIATRIC SYSTEM: MISSIONS AND CHARACTERISTICS

Nicole Garret-Gloanec

The public psychiatric system in France remains the backbone of the whole system.

It offers mainly in-patient structures, each of them being responsible for a catching area.

Therefore, besides the historical mission, this develops always more out-patient structures.

This paper underlines how this public system fulfils its missions in a complementary way with private structures.

PRIVATE HOSPITALIZATION: NEEDS AND PURPOSES

Hervé Granier

Besides the public in-patient structures, France counts more than 100 private hospitals.

This paper analyses the needs for such structures and how they collaborate with the public system.

THE ‘MÉDICO-SOCIAL’ SECTOR: A SPECIFIC TOOL POR CHILD AND TEENAGERS PSYCHIATRY

Antoine Besse

Médico-social is the name of a particular sector of care characterized by the fact that the care is integrated into the social work.

It concerns in-patients as well as out-patients, of any age but its effectiveness is more evident with children and teenagers.

The author, who is also medical director of an out-patient medico-social centre, reviews the main characteristics of this sector and its articulation with the whole psychiatric system.

RS62 CULTURE AND ITS SIGNIFICANCE FOR THE FORENSIC ASSESSMENT, TREATMENT AND REHABILITATION OF MAORI IN NEW ZEALAND

Rees Tapsell, Charles Joe, Nick Wiki, Trudi Field

Maori are the indigenous people of Aotearoa, New Zealand and suffer significant socioeconomic disadvantage and health disparities (when compared to non Maori) across a wide range of domains. Despite being 15% of the population, Maori make up 50% of the forensic psychiatric and correctional populations and research suggests that their progress through, and ultimate outcomes following forensic rehabilitation lag behind those of non Maori.

This symposium will describe the establishment of Tane Whakapiripiri, a 10 bed inpatient, purpose built minimum security forensic rehabilitation unit that incorporates best practice psychiatric rehabilitation with a strong traditional Maori cultural milieu and a range of culturally specific programmes.

The model has a strong cultural values base with a number of traditional principles governing the ways in which collective order and balance are maintained. It proscribes a series of important processes and rituals that are based on those values and which set the framework for the ways in which people are related and connected to one another, to their history, ancestors and the spirit world and to their natural surrounds.

Central to this model is the importance of developing and consolidating a strong sense of cultural identity and, through this, engaging with all aspects of rehabilitation and gaining a new sense of meaning and belonging in life. The authors will describe how using traditional Maori teachings and philosophies has applicability for the general tasks of rehabilitation as well as the specific task of rehabilitating violence in Maori, as a model for other indigenous and minority populations around the world.

The presenters will describe the service implications and demands for the establishment of such a model from clinical, cultural, and general philosophical perspectives.

Finally the paper will describe the development and implementation of an outcomes tool that uses and idiographic methodology for gathering data about the progress and outcomes for patients in terms of psychiatric, legal and cultural indicators.

RS63 MENTAL HEALTH AND WELL-BEING OF INDIGENOUS INFANTS, CHILDREN, ADOLESCENTS AND THEIR FAMILIES

Hinemoa Elder, Helen Milroy, Janice Beazley, Hemi Witihera, Riwai Wilson

The provision of mental health services for Indigenous infants, children, adolescents and their families is a challenge of significance. The development of Indigenous models of care within mainstream service settings which embody the values and practices of Indigenous families is a complex task. This symposium examines a number of key examples from a range of settings. The principles and key determinants of the developmental processes and the maintenance of the fidelity of these services will be discussed. A number of invited speakers from Australia and New Zealand will present their models of care with the aim of inviting discussion about how mental health services and practitioners can work together to improve the mental health outcomes for Indigenous children.

HE KAAKANO; A SEED. DEVELOPING A MAORI TEAM WITHIN A CAMHS IN SOUTH AUCKLAND

Hinemoa Elder

“E kore au e ngaro, he kaakano I ruia mai, I Rangiatea” is a Maori whakatauki or proverb that says “I can never be lost, I am a seed born of greatness from Rangiatea”

He Kaakano is the name of a new Kaupapa Maori team within a Child and Adolescent District Health Board Mental Health Services in South Auckland, New Zealand. It has ten members, from the disciplines of Child and Adolescent Psychiatry, Clinical Psychology, Nursing, Occupational Therapy, Social work and Family Therapy.

This paper describes the seeds of ideas, energy and emotional health both within the community and the organisation that lead to the teams development. Implementing strategies to support the development and maintenance of Maori processes within a non-Maori service are described.

The Maori community's perception of CAMHS as a service focussed on psychopathology rather than emotional health was identified as a target for intervention and a challenge to work differently. Current partnership projects with a range of other providers including NGO's, Schools and a Teen Parenting Unit illustrate interventions based on identifying emotional health needs and resources within the community.

RS64 THE CHALLENGE OF REFORMING PSYCHIATRIC HOSPITAL CARE IN ASIA: FOUR CASE STUDIES

Alex Cohen, Mohan Isaac, Kate Johnston-Ata'Ata, Chih-Yuan Lin, Jayan Mendes, Harry Minas

Context: The large hospitals that dominate psychiatric care in Asia are among the most enduring effects of 19th and early 20th Century colonialism. The British established a system of hospitals in India, Singapore, and Hong Kong, and the Dutch did much the same in Indonesia. The situation in China was slightly different – the original impetus for hospitals coming from Western religious missionaries – but ultimately had the same result. At the very least, the care and treatment offered in these hospitals do not conform with the recommendation of the WHO's World Health Report 2001 to downsize mental hospitals, to shift patient care into the community, and to depend on general hospitals for treatment of acute psychiatric conditions. At the worst, and as documented in reports by the National Human Rights Commission of India (1999) and in TimeAsia (2003), the care offered by and the conditions in the large hospitals of Asia are, too often, less than ideal and marked by human rights violations. Therefore, improving conditions in the psychiatric hospitals of Asia and moving toward mental health systems that provide high quality care represents one of the great challenges facing Asian and global psychiatry.

Objectives: This symposium will provide a forum for the presentation and discussion of case studies of reform in four large Asian hospitals:

The Shanghai Mental Health Centre: Changes in service provision during the economic reform era as perceived by mental health personnel (Ms. Kate Johnston-Ata'Ata, University of Melbourne)

From a state mental hospital to a training and research institute: The story of NIMHANS, Bangalore, India (Dr. Mohan Isaac, University of Western Australia)

Beyond the walls: The Yuli model of community reintegration for long stay inpatients (Dr. Chih-Yuan Lin, Yuli Veterans Hospital, Taiwan)

Remodeling a mental hospital into an institute of psychiatry in Sri Lanka (Dr. Jayan Mendes, Angoda Mental Hospital, Colombo, Sri Lanka)

Discussant: A/Prof Harry Minas, Centre for International Mental Health, University of Melbourne

Symposium Chair: A/Prof Alex Cohen, Department of Social Medicine, Harvard Medical School

Key messages: Reforming and improving hospital care in Asia is possible. However, there is no single strategy. Achieving reform will depend on local conditions.

Conclusion: These case studies provide examples of how reform has been achieved in India, Sri Lanka, the People's Republic of China, and Taiwan. We believe these examples of successful strategies of reform will motivate others to undertake reform efforts at other hospitals in Asia.

FROM A STATE MENTAL HOSPITAL TO A TRAINING AND RESEARCH INSTITUTE: THE STORY OF NIMHANS, BANGALORE, INDIA

Mohan Isaac

Context: In 1848, during the British colonial period, the Bangalore Lunatic Asylum was established for “insane native patients.” Soon after World War I, the name of the facility was changed to the Bangalore Mental Hospital. Following India's independence, a centre for training psychiatrists and allied mental health professional was established at the hospital and, in 1974, the training centre and the hospital, together, were rechristened the National Institute of Mental Health and Neuro Science (NIMHANS).

Objectives: To highlight the key steps of the reform process, during the past three decades. These steps include: starting of round the clock out patient and follow-up services, opening of ‘closed’ wards, actively involving relatives and family members in inpatient care, starting of new and innovative facilities such as ‘short stay wards’, ‘family wards’ and ‘day care services’, making the rehabilitation activities more meaningful, encouraging formation and active involvement of carer organizations and starting of community based extension services. There has also been an emphasis on provision of quality training in various fields of mental health and research on issues relevant to the country.

Key messages: Today, NIMHANS produces the most and arguably the best psychiatrists in India, and is one of the premier psychiatric institutions in Asia.

Conclusion: NIMHANS has been transformed from an overcrowded, archaic mental hospital with a large proportion of involuntary, chronic long-stay patients to an active, multi-disciplinary, treatment, training and research centre.

SHANGHAI MENTAL HEALTH CENTRE: CHANGES IN SERVICE PROVISION DURING THE ECONOMIC REFORM ERA AS PERCEIVED BY MENTAL HEALTH PERSONNEL

Kate Johnston-Ata'Ata

Background: China's health and mental health systems have changed dramatically since the establishment of the PRC, in particular since the economic reforms that began in 1978. Accounts (in English) of these changes, including their relation to mental health services in Shanghai and at the Shanghai Mental Health Centre (SMHC) are numerous, but contain little information about how systemic changes have had consequences for SMHC.

Aims: To explore the economic reform era changes in the provision of psychiatric services in Shanghai and at the SMHC from the perspective of mental health professionals.

Methods: An exploratory study using qualitative data collection methods. Data collection included semi-structured interviews with key informants (n = 12) from SMHC and other mental health organisations, as well as analysis of selected documents.

Results: Participants held positive perceptions about reform era developments such as the re-introduction of medical insurance in Shanghai, increased government focus on awareness-raising and prevention, and greater emphasis on research and education. Concerns centred on the impact of limited government funding, cost controls and rising salary expenditures on the income-generation/patient care balance, the prospects for rebuilding community-based services, and the capacity of the existing system to meet demand.

Conclusion: Shanghai mental health professionals are aware of the significant limitations of their mental health system and the role of the SMHC within this, have an ambitious change agenda, and are working to exploit the limited avenues available to them for advancing this agenda.

BEYOND THE WALLS: THE YULI MODEL OF COMMUNITY REINTEGRATION FOR LONG STAY INPATIENTS

Chih-Yuan Lin

Context: Yuli Veterans Hospital (YLVH) has long been known as the last resort for the most dysfunctional and treatment-resistant mentally ill patients from all over Taiwan.

Objectives: This case study of YLVH introduces its from a notorious asylum to a unique model of psychiatric rehabilitation.

Key messages: For the past 12 years, YLVH has been developing a reform project that not only renovates the infrastructure and facilities of the hospital, but also diversifies and enriches the service programs for patients, most of whom are long stay inpatients. All the initiatives focus on balancing hospital-based and community-based care and ensuring the continuity and appropriateness of care to meet the psychiatric and social needs of patients, including helping them become active participants in the local community. The community reintegration program consists of four components: holistic medical support, intensive case management, employment-oriented rehabilitation program, and long-term residential program. The ultimate goal of the reform project is to make the hospital and the town of Yuli a therapeutic community for patients where they can find care, respect, safety and support.

Conclusion: The Yuli model is a feasible and effective model of how to transform a large, custodial hospital into a therapeutic community that offers a range of services and the possibility of community reintegration.

REMODELING A MENTAL HOSPITAL INTO AN INSTITUTE OF PSYCHIATRY IN SRI LANKA

Jayan Mendes

Context: The Mental Hospital, Angoda is the main state institution in Sri Lanka for people with severe mental illness. It has approximately 1500 patients, of whom 40% are chronically ill. To improve the rehabilitation services of the hospital, the Sri Lankan Ministry health contracted with BasicNeeds, a small NGO, to set up a Horticulture Therapy Pilot Project to enable more sustainable rehabilitation.

Objectives: The main aims of the Pilot Project are to begin the process of de-institutionalise by training staff in therapeutic techniques and patients in life skills, work habits and skills for income generation.

Key messages: In the period April 2003 to December 2005, 67 destitute male patients were involved in the programme. As a result, 5 have returned home and 16 have found jobs, mostly living-in at the workplace. Thirty-seven acute patients (7 of whom were women) in danger of being abandoned by their families, have also been involved in the project. Of these, 14 have returned to their homes.

Conclusion: Initially, there was resistance from hospital staff, both clinical and administrative, but attitudes have gradually changed. Plans are now underway to expand the project to a larger site, run on more commercial lines, where rehabilitated patients can work for a small wage. Supported accommodation units will be built nearby to enable people to be discharged from hospital to a more homely environment.

RS65 PSYCHIATRY MEETS TECHNOLOGY: WHAT DOES THE EVIDENCE TELL US AND HOW CAN WE USE IT TO INFORM PUBLIC HEALTH INTERVENTIONS DESIGNED TO BUILD CAPACITY IN YOUNG PEOPLE?

Jane Burns, Carolyn Morey, Louise Ellis, Michelle Blanchard, Rebecca Coleman

Context: With 75% of mental illness beginning before age 25 it is essential that we increase young people's capacity to manage adversity and improve access to professionals. Mental health services face a challenge in reaching young people, with 60 to 70% at risk not seeking help and often taking 5-15 years to access treatment. With its unique ability to connect people, the Internet and related technologies offer opportunities to engage those young people not seeking professional help.

Objective: Technology such as websites, mobile phones and computer games hold great appeal for young people and are widely used by them. Their potential in preventive interventions for mental health is not well researched. This symposium explores the role of the Internet as a means of promoting and preventing mental health difficulties and enhancing the delivery of mental health services.

Key message: Features such as online game based CBT, professionally facilitated and peer moderated community forums promote help seeking and connect young people at risk with local services including GP's and mental health professionals. Technology can also be utilized to build the capacity of professionals to engage with young people improving compliance with treatment. The Internet provides opportunities for all young people to develop skills, better understand mental health difficulties and manage adversity, complementing traditional mental health support.

Conclusion: This symposium presents research which challenges preconceived ideas about the Internets role in mental health prevention and service delivery. It explores opportunities for organizations looking to take services developed in Au into international settings.

THE REACH OUT! ONLINE COMMUNITY FORUM: AN INNOVATIVE AND INTERACTIVE MODEL OF ADDRESSING MENTAL HEALTH ISSUES IN AUSTRALIA WITH THE ACTIVE INVOLVEMENT OF YOUNG PEOPLE.

Carolyn Morey, Marianne Webb, Jane Burns, Philippa Collin, Michelle Blanchard

Context: Despite the growing use of the Internet by young people there is a paucity of information exploring its potential to provide an online service that reduces stigma, facilitates help seeking and improves mental health. It is generally acknowledged that unsupervised online forums or chat rooms hold real and significant dangers for young people. Risks can include; the possibility of attracting adults who may take advantage of vulnerable young people; the possibility of contagion with members organising suicide pacts, or describing suicidal and self-harm intentions and methods; and young people ruminating about feeling depressed. There is also a concern that members will receive incorrect or harmful advice, and that because they receive support online, they will not be motivated, nor recognise the need and advantages, of seeking face-to-face support from a mental health professional.

Objective: This paper describes the Reach Out! Online Community Forum, an asynchronous moderated bulletin board, developed in consultation with, and facilitated by, young people aged 16 to 25, using the current evidence base and best practice models in mental health intervention and clinical practice.

Key message: The risks of unsupervised forums pose serious, but manageable, challenges to organisations that wish to harness the power of the Internet to improve young people's mental health.

Conclusion: While anecdotal evidence from both young people and mental health professionals suggests that the Reach Out! online community is a positive, unique and helpful online experience for young people, there is a need for further research to determine its effectiveness and to ensure that participation in the forums is not detrimental to the mental health of young people.

USING THE INTERNET AND GAME BASED TECHNOLOGIES TO PROMOTE YOUNG PEOPLE'S MENTAL HEALTH. REACH OUT! CENTRAL

Carolyn Morey, Jonathan Nicholas, Marianne Webb, Jane Burns

Context: Although one in five young people in Australia experience a mental health problem, seventy percent do not access a mental health service or receive any kind of mental health care. At the same time, the Internet and related technologies are increasingly playing a role in young people's help seeking with research demonstrating that young people actively seek health information and referrals online.

Objective: The presentation will outline some of the evidence which informed the development of ROC, provide a brief walk-through of the program and present some findings from a preliminary evaluation.

Key messages: The Inspire Foundation has built on the success of it's Reach Out! Web site (www.reachout.com.au) by launching Reach Out! Centre (ROC), an online game-based program that promotes positive mental health for young people utilizing techniques grounded in cognitive behavioral therapy. ROC enables young people to identify and work through issues such as depression, anger or anxiety themselves, increasing their coping skills.

Conclusion: It is intended that ROC can be used to support clinicians in their work with young people as well as engage some of the 70% of young people experiencing a mental health difficulty who do not currently seek professional help.

EXPLORING THE OPPORTUNITIES FOR CLINICIANS TO ENGAGE AND IMPROVE COMPLIANCE OF YOUNG PEOPLE IN TREATMENT USING INTERNET BASED TECHNOLOGY

Rebecca Coleman, Jane Burns, Louise Ellis, Carolyn Morey

Background: Currently, 60% of disability in 15–34 year olds is due to mental disorders, with 75% commencing before age 25. The delay between onset and provision of effective treatment ranges from 5–15 years. Reach Out!, a web-based mental health service for young people aged 16–25, has been accessed by 5.5 million users since 1998. User profiling indicates that 38% of visitors intend to seek help from a mental health professional after visiting the site.

Method: This study utilizes quantitative and qualitative data collected through online surveys and focus groups to examine professionals’ perceptions of the internet as a valid tool to compliment existing treatment, information requirements, technical capability and professional development needs.

Results: The results will consider: (a) the role the internet can play in the clinical care of young people; (b) the professional development needs and opportunities for professionals to use internet based technology; (c) how web-based services such as Reach Out! can support clinicians; and (d) the opportunities the internet offers to engage young people currently not seeking professional help.

Conclusion: This study will increase our understanding of the ways in which mental health professionals can utilise the internet to engage young people.

BRIDGING THE DIGITAL DIVIDE: MARGINALISED YOUNG PEOPLE'S USE OF INFORMATION COMMUNICATION TECHNOLOGY

Michelle Blanchard, Jane Burns, Atari Metcalf

Context: Information and communication technologies (ICTs) play an increasingly significant role in the key social and economic determinants of young people's mental health and well being. Wyn et al. (2005) emphasised the potential for the internet to influence the health, economic and social outcomes of young people, however suggested that many young people in under-served communities do not have access to this technology or the skills to use it.

Objective: To consider marginalised young people's use of the internet and the opportunities to use the Internet and related technologies to promote social connectedness, mental health and well being in marginalized communities.

Key messages: Funded by the Victorian Health Promotion Foundation (VicHealth), the Inspire Foundation has embarked on the Bridging the Digital Divide: Victorian Youth Action Project. This project seeks to increase ICT access, capability and confidence among young people who experience diverse forms of structural inequality and disadvantage, with particular focus on strengthening the social and civic connections that build social capital. The first phase of the project involved semi-structured interviews and focus groups with 97 young Victorians experiencing marginalization, including those from Indigenous, culturally diverse and low socio-economic backgrounds, as well as those experiencing discrimination as a result of being same-sex-attracted, gender diverse or living with a disability.

Conclusion: These findings challenge traditional notions of the ‘digital divide’ and suggest that marginalized young people aged 16 to 25 might be much more technologically savvy than originally thought.

TAKING AN ONLINE ADOLESCENT SUICIDE PREVENTION SERVICE GLOBAL: OUTCOMES OF A STUDY EXAMINING THE FEASIBILITY OF TAKING AN AUSTRALIAN WEB-BASED YOUTH MENTAL HEALTH PROGRAM TO THE US AND BEYOND

Jane Burns, Jonathan Nicholas

Context: Reach Out! (www.reachout.com.au) is an Australian web-based mental health service for young people aged 16–25. Launched in 1998, Reach Out! was the first website in the world with the express purpose of reducing youth suicide. Since formally partnering with myspace.com and using viral marketing visits have risen from an average of 130 000 to 240 000 per month. In 2006, Inspire Foundation in partnership with the American Australian Association and the Bridgespan group undertook a feasibility study to examine the viability of developing Reach Out! in the US and other countries.

Objective: This paper will present evidence of the potential role that the internet and related technology can play in reducing suicidal behaviour among young people worldwide. It will present evidence on the effectiveness of Reach Out! in improving youth mental health and provide suggestions as to how other countries may utilise the internet, working with the Inspire Foundation, to reduce suicide and mental health difficulties.

Key message: By 2020 mental health and related disorders will be the second leading cause of disease and disability. This paper explores the potential of taking a web based service to the US and beyond. It uses the United states as a case study mapping the mental health needs amongst teenagers in US, examining youth access to community based services and exploring possible models for developing Reach Out! in the US.

Conclusion: If we are to impact on the mental health and well being of young people it is essential that we look to the settings in which they spend time. The role of the Internet in reducing significant psychiatric morbidities should be explored.

RS66 MENTAL HEALTH PROFESSIONALS' ASSOCIATION: SUPPORTING A COORDINATED AND COLLABORATIVE FORUM FOR ISSUES AFFECTING MENTAL HEALTH PROFESSIONALS

Julian Freidin, Kim Ryan, Morton Rawlin, Lyn Littlefield

The Mental Health Professionals Association (MHPA) was convened in early 2006 by The Royal Australian and New Zealand College of Psychiatrists as a way of supporting a coordinated and collaborative forum for issues affecting the four key professional groups involved in mental health care, particularly in the context of the Council of Australian Governments’ (COAG) mental health package and the federal government's Better Access initiative.

The MHPA includes representation from the Royal Australian and New Zealand College of Psychiatrists, The Royal Australian College of General Practitioners, the Australian Psychological Society and the Australian College of Mental Health Nurses.

As a collaborative of the key representative and standard setting bodies for the mental health professions, the MHPA is ideally placed to liaise with government regarding investment in the mental health workforce and mental health care delivery. The partnership provides an unprecedented level of project sponsorship that aims to deliver high yield, value for money outcomes for the Australian Government. Equally it will provide the basis for highly effective support networks and education for the combined professional groups.

This symposium will discuss the work of the MHPA to date, including details of a multidisciplinary training package being developed to provide psychiatrists, general practitioners, psychologists, paediatricians, social workers and occupational therapists with the support required to use the new (and existing) relevant Medicare Benefits Schedule (MBS) item numbers in an appropriate, effective and efficient manner. The symposium will also detail how the professions can provide input to the work of the group.

THE RANZCP VIEW ON COLLABORATIVE MENTAL HEALTH CARE

Julian Freidin

The RANZCP has changed its outlook in recent years to move from an inwardly focussed organisation primarily concerned with the training of psychiatrists and the maintenance of clinical standards to an outwardly focussed organization promoting improved mental health care in Australia and New Zealand. This has required an intrinsic understanding of the value that comes from partnerships and collaboration across the sector. The providers of mental health care, and their professional organizations, are in a unique position which creates opportunity to work with both community and government.

The history of the change in focus, leading to the development of a pro-active policy agenda for RANZCP, will be briefly discussed. This led to the development of the MHPA and a collaborative approach to negotiating increased access to Mental Health providers for all Australians. Further challenges and the development of a political agenda will be discussed.

THE WAY OF THE FUTURE – TEAM-BASED MENTAL HEALTH CARE IN THE COMMUNITY: THE ROLE OF THE GENERAL PRACTITIONER IN RELATION TO THE OTHER KEY MENTAL HEALTH PROFESSIONALS

Morton Rawlin

Since 1 November 2006, psychologists and other allied mental health professionals including social workers and occupational therapists, are now able to access Medicare rebates under the ‘Better Access’ initiative where the client's general practitioner has prepared a GP Mental Health Care plan. Psychiatrists are also being supported to see more new patients under this initiative and are encouraged to involve GPs more in the management of patients where appropriate.

These new arrangements present an opportunity for GPs to work more closely and collaboratively with the other mental health professionals to improve community access to mental health professionals and outcomes for people living with mental disorders in the community.

This presentation from the Royal Australian College of General Practitioners aims to address the importance of ‘team based’ care in the provision of primary mental health care in the community. It will also explore the need for team-based training for the different professional groups, specifically around the knowledge and skill bases and roles and responsibilities of these ‘teams’ in order to recognize and treat mental illness. The presentation will draw upon both statistical data around the ‘burden of disease’ (Beach Data) and existing general practice models of integrated primary and secondary mental health care at a local level.

MENTAL HEALTH NURSES, GPs AND PSYCHIATRISTS – PARTNERS IN CARE FOR PEOPLE WITH SERIOUS MENTAL ILLNESS

Kim Ryan

Mental health is a significant issue facing the Australian community. There are about 1/2 a million people living with a severe mental disorder in Australia at any point in time. People with serious mental illness are most at risk of failing to access an appropriate range of services because of their persistent psychiatric symptoms, their level of disability and/or their isolation from family and other social support networks.

In July 2006 the Council of Australian Governments (COAG) agreed to a National Action Plan on mental health 2006-2011, out of which came a number of reform initiatives. To meet the recognised gap in clinical case management of people with severe mental illness treated outside the public health sector, the Mental Health Nurse (MHN) Incentive Program was developed. The program will be rolled-out nationally on 1 July 2007.

The intention of the MHN Incentive Program is for MHN's to develop partnerships with General Practitioners and Psychiatrists, collaborating to deliver better-coordinated care to those in our community with a serious mental illness and complex needs. It is envisaged that such partnerships will increase efficacy of community-based support, reduce the need for acute inpatient services and lead to improved health outcomes for the mental health client.

This paper will discuss the development of the incentive program and its uptake by nurses, GPs and Psychiatrists including policy development, evaluations from nursing reference groups, feedback from GPs and Psychiatrists, and progress to date.

THE CONTRIBUTION OF PSYCHOLOGISTS TO THE TEAM-BASED APPROACH TO MENTAL HEALTH

Lyn Littlefield

The Federal Government's ‘Better Access’ Initiative, which provides consumers with improved access to mental health treatment, particularly through Medicare, has shown enormous demand for psychological services. The initiative fosters a team-based approach involving general practitioners, psychiatrists, paediatricians, psychologists, mental health nurses and allied health professionals working together to deliver mental health services in primary care. This paper will discuss the latest information on the uptake of the Medicare items providing access to psychological services, and the processes and challenges for psychologists involved in the implementation of ‘Better Access’. Discussion will focus on the role of psychologists and their interface with the other mental health professions, within the wider workforce context.

RS67 FAMILY INTERVENTIONS IN MENTAL HEALTH SERVICES: INTERNATIONAL EXPERIENCE OF IMPLEMENTING EVIDENCE-BASED WORK WITH FAMILIES

Brendan O'Hanlon, Gráinne Fadden, Radha Shankar, Carol Harvey, Colin Riess, Tina Marty, Simon Marty, Justine Solamano, Deb Nielson

Context: The shift from institutional to community-based treatment of mental health problems means that families are the main source of care and support for people diagnosed with schizophrenia. Until recently, little attention has been given to how to effectively involve families in the treatment of their mentally ill relative (Magliano et al, [2005]). There is now strong evidence that working with families results in improved outcomes for people experiencing schizophrenia and their families (Pharoah et al, [2004]). Benefits include reduced relapse for patients and enhanced family functioning (Cuijpers, [1999]). Family work brings about resolution of long-term problems and assists both patients and their families to move on with their lives. Across the world however, most mental health services do not work with families as a routine practice.

Objectives: This symposium will: review the evidence for the effectiveness of working with families using a range of Family Interventions (including Behavioural Family Therapy, BFT); summarise the international literature on implementation of these Family Interventions; discuss the successes and challenges of implementing family work in Australia and Europe; and, introduce the experiences of, and benefits associated with, participating in Behavioural Family Therapy (BFT) in an Australian mental health service through a panel consisting of a patient, relative, clinician and service manager.

Key messages: The key question regarding Family Interventions is not whether these approaches are effective for patients and families but rather how best to implement them in routine mental health care. Well-established programs to implement Family Interventions in the UK and elsewhere have yielded useful learning about successful implementation. A recent evaluation of the process of implementation in Australia provides further insight into what promotes the use of the BFT model (such as improved client assessment, improved relationships between families and clinician) as well as the obstacles to routine use (such as time, finding ‘suitable’ families, existing levels of family contact and clinician confidence). Family interventions in mental health services appear to enrich the experiences of patients, families and clinicians. They have the potential to generate significant benefits but also pose challenges for each of these groups.

Conclusions: There is growing knowledge of how to best assist mental health services to incorporate Family Interventions into clinical practice and a need for continuing creativity and perseverance in ensuring their widespread dissemination.

CURRENT ISSUES AND CHALLENGES FOR FAMILY WORK IN MENTAL HEALTH

Gráinne Fadden

Context: The first studies of family work were published some thirty years ago. The effectiveness of psychoeducational approaches to working with families became clear in the 1980′s with the publication of a series of papers describing randomised controlled trials. In the 1990′s there were numerous 2nd generation studies describing outcomes in various cultural settings as well as variations in how these were delivered, such as the development of multi-family groups. At the same time, voluntary services and mental health services, conscious of the impact of mental health problems on family members, supported the development of carer education and support programmes.

Objectives: This presentation will: summarise the family work approaches currently in use, and the benefits and limitations of each; outline the differences between psychoeducational approaches, carer support groups and multi-family groups; highlight key issues around implementation of family work; and, summarise the current situation in Europe in relation to family work.

Key messages: Family education and support programmes are beneficial in reducing stress in family members. However, to be effective in terms of relapse reduction, interventions must include the consumer, either in individual family work or multi-family groups. Implementation of family approaches is the biggest challenge facing services.

Conclusion: The question of what type of family work is beneficial for which families and in what way is confusing. This presentation will provide clarity for delegates, and will summarise current key issues in relation to family work.

‘THIS IS FANTASTIC BUT … … …’: MENTAL HEALTH STAFF EXPERIENCES OF USING A FAMILY INTERVENTION IN ROUTINE PRACTICE

Brendan O'Hanlon, Amaryll Perlesz, Carol Harvey, Colin Riess

Context: The key question regarding family interventions is not whether these approaches are valuable for consumers and families but rather how to implement them in routine mental health care.

Objectives: This paper presents the findings to date of a process evaluation of Building Family Skills Together conducted as part of a Masters Thesis. A thematic analysis of the issues raised in Mentoring Groups (designed to support implementation) gives an insight into case managers’ experiences as they attempt to learn and practice Behavioural Family Therapy as part of their case management role.

Key messages: The process evaluation identifies what promotes use of the model (such as improved client assessment and improved relationships with families and clinician) as well as the obstacles to routine use (such as time, finding ‘suitable’ families, existing levels of family contact and clinician confidence).

Conclusions: The presentation concludes with a consideration of how to assist mental health staff to incorporate family interventions in their clinical practice.

EXPERIENCE OF BEING INVOLVED IN BEHAVIOURAL FAMILY THERAPY: A CONSUMER, FAMILY MEMBER, CLINICIAN AND SERVICE MANAGER PERSPECTIVE

Colin Riess, Tina Marty, Simon Marty, Justine Solamano, Deb Nielson

Context: The introduction of family interventions within routine mental health care predictably has important consequences for the families receiving these interventions. There are also ramifications for the clinicians who need to incorporate work with families into their practice and service managers who need to change service operation to enable the provision of family work.

Objectives: This panel discussion aims to explore and better understand the experiences of a consumer, family member, clinician and service manager as Behavioural Family Therapy is introduced to a mental health team providing case management services to people experiencing a serious mental illness.

Key messages: Implementing significant changes in practice in mental health care occurs at a number of different levels and will have important and different impacts on each of the ‘stakeholders’. The introduction of family work will have implications for the relationships within families, the relationship between consumer and clinician and between the clinician and family members. As the momentum of change increases there are also likely to be challenges for the relationship between clinicians and their service managers.

Conclusions: Exploring the experience of consumers, family members, clinicians and service managers provides a rich, multi-perspective view of the process of changing practice in mental health.

RS68 COMPULSION, CAPACITY AND MENTAL HEALTH LAW

George Szmukler, Michaela Amering, Jeff Swanson, Wolfgang Rutz, John Dawson, John Lesser

Context: Important debates are occurring in many countries concerning the place of compulsory psychiatric treatment.

Objectives: This symposium will examine recent developments in mental health law in a number of legislatures, especially in respect of evolving criteria for the use of compulsion in treatment (both for detention in hospital as well as mandated outpatient treatment), as well as measures aimed at reducing the need for such compulsion.

Key messages: Recent developments in mental health law in a number of countries will be described.

Developments aiming to reduce the need for compulsion, including ‘advance statements’ (requests or instructions made by a patient, when capable, which are to come into play during a future relapse of illness when the patient is no longer able to express his or her wishes) will be discussed. A variety of types of ‘advance statements’ will be considered including ‘psychiatric advance directives’, ‘joint crisis plans’ and ‘crisis cards’.

The increasingly prominent debate in some countries concerning the role of decision-making ‘capacity’ in mental health law will be examined, including the case that without such a criterion for involuntary treatment, those with mental disorders are discriminated against, and suffer a lack of respect for their ‘autonomy’ that non-psychiatric patients are accorded.

Finally an outline will be presented of a comprehensive legislative framework covering all patients, whether suffering from ‘mental’ or ‘physical’ disorders, in which the respective strengths of ‘capacity’ based schemes and ‘civil commitment’ based schemes are combined.

Conclusions: Mental health law is undergoing change at an unprecedented pace. Reform may be an important tool for reducing discrimination and stigma.

PSYCHIATRIC ADVANCE DIRECTIVES AND OUTPATIENT COMMITMENT IN THE US: THE ACQUAINTANCE OF STRANGE BEDFELLOWS

Jeff Swanson

Context: Psychiatric advance directive (PAD) statutes have proliferated in the United States in parallel with the rise of outpatient civil commitment (OPC) policies. While PADs and OPC advocates represent overlapping stakeholder groups and share many common goals, their priorities differ. Mental health consumer organizations have promoted PADs as a vehicle for self-determination and choice, and as a remedy for coercion. In contrast, some family groups and clinicians are leery of PADs and tout OPC as serving the best interests of persons who lack mental capacity, and as a remedy for patient violence. How do PADs and OPC fit together, if at all?

Objectives: Summarize major types and features of PADs and OPC statutes. Examine their functional differences and similarities as mechanisms for ensuring treatment continuity and patient wellbeing. Describe ways in which PADs and OPC may be incompatible vs. potentially complementary legal instruments.

Key messages: OPC policies could incorporate values of patient-centered care, consumer choice, and shared decision-making. Facilitated PADs may help some consumers become more engaged in their own treatment as they build a better working alliance with clinicians—perhaps even while receiving mandated or leveraged mental health services.

Conclusion: PADs and OPC are “facts of life” under current and emerging mental health law and policy in the U.S. While these instruments might appear to be motivated by contradictory principles, they are not necessarily incompatible schemes; there is room to develop complementary practice in OPC and PADs within the same systems of care, and possibly for the same people.

MENTAL HEALTH LEGISLATION DISCRIMINATES AGAINST PEOPLE WITH MENTAL DISORDERS

George Szmukler

Context: This paper provides a background to the paper by Dawson in this symposium in which the general form of a comprehensive statute governing involuntary treatment is outlined.

Objectives: The arguments are presented for a comprehensive statute dealing with the involuntary treatment of all forms of mental impairment or disability which result in impaired decision-making capacity.

Key messages: Conventional forms of mental health legislation for persons with ‘mental disorders’ permit involuntary treatment according to a different set of rules to persons with ‘physical disorders’. Mental health legislation ignores the question of ‘capacity’ for decision-making. Autonomy thus fails to receive the respect accorded to non-mentally ill patients.

Mental health legislation also commonly treats the ‘protection of others’ as a ground for involuntary treatment in hospital. The separate ends represented by ‘paternalism’ and ‘public protection’ are confused, with the result that those with ‘mental disorder’ are uniquely liable to a form of preventive detention in hospital before committing an offending act. The rest of us do not tolerate such a potential violation of our civil liberties. This has become further compounded in recent years, notably in England and Wales, by mandated risk assessment of all patients in contact with mental health services.

Conventional mental health legislation is discriminatory, and reinforces stereotypes of the mentally ill as inherently incompetent and dangerous.

Conclusion: A non-discriminatory approach to involuntary treatment of those with mental disorders must be generic, covering impaired decision-making in association with disorders from any cause.

THE FUSION OF INCAPACITY AND MENTAL HEALTH LEGISLATION: WHAT PROVISIONS SHOULD THE NEW LAW CONTAIN?

John Dawson

Context: Introduction of a single piece of legislation covering the treatment of both ‘physical’ and ‘mental’ illnesses, based on general incapacity (or competency) principles, has been suggested by participants in recent law reform debates in several western countries.

Objectives: This paper describes the legal framework for comprehensive legislation of this type and considers in some detail the legal provisions it should contain. First, it examines the distinct functions and characteristics of the usual (i) incapacity (or adult guardianship) regime, and (ii) civil commitment (or mental health) legislation. Principles are then proposed for their ‘fusion’ into a single legislative scheme.

Key messages: Legislation combining the particular strengths of both incapacity and civil commitment schemes could be readily constructed, based, for example, on the incapacity criteria found in the Mental Capacity Act 2005 for England and Wales.

Conclusion: Such legislation would be an important step in reducing unjustified legal discrimination against mentally disordered persons. Consistent ethical principles would then be applied across all the full field of medical law.

DISCUSSION

John Lesser

Mr Lesser will discuss the papers presented in this symposium, drawing on his recent review of international developments in mental health law.

RS70 MAKING DEPRESSION RESEARCH IMPACT ON CLINICAL PRACTICE: THE BEYONDBLUE EXPERIENCE

Lisa Allwell, David Clarke, Michael Baigent, Leon Piterman, Bruce Tonge

beyondblue: the national depression initiative supports targeted applied research into depression, anxiety and related disorders. In addition to this, it aims to increase community awareness of depression, reduce stigma, provide information, encourage prevention and early intervention and improve training and support for the primary care sector in helping people with depression. In this symposium we will present four examples of work supported by beyondblue, with a focus for discussion being how we can make research improve outcomes for depressed people.

DEPRESSION AND ALCOHOL: MANAGING THE COCKTAIL

Michael Baigent

Depression is abundantly common in our community as is drinking alcohol. Depression together with alcohol dependence occurs more commonly than one would expect. The outcomes of treatment of people dually affected vary enormously between individuals suggesting there is likely to be subgroups within this relatively large and poorly defined group. However, once alcohol dependence is established it needs to be addressed as well before significant changes in the individual can be expected. Current research and significant gaps in our knowledge will be highlighted.

THE TIME FOR A FUTURE: EFFECTIVE TREATMENTS AND PREDICTORS OF OUTCOME FOR YOUTH DEPRESSION

Bruce Tonge

Depression in adolescents is a serious illness which carries a risk of suicide. We have empirical evidence that cognitive behaviour therapy (CBT) is an effective treatment, but we need to determine if augmentation with an antidepressant improves outcome. This study evaluates CBT, Sertraline and combined CBT and Sertraline treatment of depressive disorders in 73 adolescents, treated in the Time for a Future Adolescent Depression Program. Participants were randomly allocated to one of the three treatments and treatment outcome measures administered before and after acute treatment and at a 6 month follow up. Following acute treatment, all treatment groups demonstrated substantial improvement which was maintained at the follow-up. Contrary to predictions, the combined treatment was not superior to either treatment alone. Compared with antidepressant medication alone, adolescents receiving CBT demonstrated a superior acute treatment response. Possible explanations are discussed. CBT remains the first line of treatment.

COMPUTERS; BUILDING CAPACITY IN PRIMARY CARE, IMPROVING ACCESS TO EVIDENCE-BASED TREATMENT FOR PATIENTS

Leon Piterman

This presentation will describe the story of computers in primary care; firstly in education and secondly as adjunctive therapy for depression. Increasingly general practitioners are being required to diagnose and treat depression and anxiety disorders. Ways of increasing capacity within primary care include training of GPs and better access to psychological therapies. On line interventions offer interesting opportunities in this area.

DEPRESSION AND CARDIAC FAILURE: A STEPPED CARE INTERVENTION

David Clarke

Depression is common in people with heart disease and increases morbidity and impairs functioning. Pilot data from the Chronic Heart Failure Program, on a sample of 74 patients, showed that 23% exhibited ‘self-management’ behaviour at admission to the program; and this rose to 70% at 12 months. At one month 55% of patients were depressed; this reduced to 41% at 3 months and 32% at 12 months. At 12 months still significant numbers were depressed and not using disease self-management. Regression analysis showed that depression was the main predictor of quality of life at 12 months. Data will be presented of a project of integrated care aimed at increasing self management and reducing depression.

RS71 EPIDEMIOLOGY OF MENTAL DISORDERS IN THE COMMUNITY AND IN NON-PSYCHIATRIC SERVICES

Johannes Wancata, Oye Gureje, Siegfried Weyerer, R. Thara, Vikram Patel

Mental disorders are common and the number of mentally ill will rise in the next decades because of the increasing life expectancy. Frequently, mental disorders have a variety of negative consequences. For example, mental disorders increases the risk for nursing home admission and for impairments in everyday life. The family caregivers of mentally ill suffer a lot of burden. The presence of depression often delays the recovery of physical disease. Alcohol addiction and abuse are common disorder. Often, disorders such as dementia, depression and anxiety disorders are often not recognized by primary care workers.

DIAGNOSTIC CRITERIA INFLUENCE DEMENTIA PREVALENCE

Johannes Wancata, Anne Börjesson-Hanson, Svante Östling, Karin Sjögren, Ingmar Skoog

Background: Epidemiological studies report differing prevalence rates.

Aims: The objective of this study was to compare the prevalence of dementia using different diagnostic systems, and to investigate the influence of the different diagnostic components on the prevalence.

Methods: A general population sample of 1019 elderly living in Gothenburg, Sweden, was investigated by using the Comprehensive Psychopathological Rating Scale as well as specific assessments relevant for dementia diagnoses. Diagnoses were given according to the 9th and 10th version of the International Classification of Diseases (ICD-9, ICD-10) as well as the 3rd revised and 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R, DSM-IV). Further, “historical” criteria for dementia were applied as had been used in older studies.

Results: DSM-IV dementia occurred most frequently (9.6%), followed by dementia according to “historical” criteria (7.4%), DSM-III-R (6.3%), ICD-10 (3.1%) and ICD-9 (1.2%). The kappa values for the agreement between the diagnostic systems were between 0.166 and 0.810. The requirement of both long-term and short-term memory impairment in DSM-III-R and personality changes in ICD-10 explained most of the differences. When these requirements were held constant, DSM-III-R, DSM-IV, ICD-10 and “historical” criteria identified predominantly the same persons as demented (kappa 0.810–1.000).

Conclusions: Prevalence of dementia varied widely depending on diagnostic classification system used. For DSM-III-R, DSM-IV, ICD-10 and “historical” criteria, the definitions of personality changes and combinations of memory impairment lead to differing prevalence rates, while the definitions of other intellectual functions have little impact.

DETERMINANTS OF QUALITY OF LIFE OF ELDERLY NIGERIANS

Oye Gureje, Lola Kola, Oladapo Olley, Ebenezer Afolabi

Background: Quality of life (QoL) is central to the mental health and wellbeing of elderly persons.

Aims: To identify factors that determine the quality of life of elderly persons living in developing societies undergoing rapid social changes.

Method: The Ibadan Study of Aging is a community study of elderly persons aged 65 years and over. Respondents (n = 2152) are Yoruba-speaking community-dwelling elderly persons, selected using a multi-stage stratified clustered sampling, who participated in face-to-face assessments conducted by lay trained interviewers. Assessment of quality of life was conducted with the World Health Organization Quality Life instrument, brief version (WHOQoL-Bref). Respondents were also evaluated for depression, functional disability, pain and medical conditions, as well as social network, support and engagement.

Results: Demographic, health, and social factors were differentially related to physical, psychological, social and environmental domains of QoL. Economic status, place of residence, functional disability, self-perception of health, and social network and engagement were among the most salient factors for QoL. As a group, social factors, especially those relating to isolation, were the most consistent determinants of QoL, being more influential than health-related factors.

Conclusion: Quality of life of the elderly is determined by multiple factors. In a society undergoing rapid social changes, some changes reflecting attenuation of family networks and social engagement may be impacting negatively on the QoL of elderly persons.

USE OF PHYSICAL RESTRAINTS AMONG DEMENTIA PATIENTS IN NURSING HOMES: A COMPARISON OF SPECIAL SEGREGATIVE CARE AND REGULAR INTEGRATIVE CARE

Siegfried Weyerer, Martina Schäufele

Background: It is well known that physical restraints are frequently used in nursing homes, particularly among dementia patients. At present, approximately two-thirds of all residents in nursing homes in Germany suffer from some type of dementia.

Aims: To determine the patterns of and the risk factors for the use of mechanical restraints among persons with dementia in special care units (SCU) and in regular integrative units (RU).

Methods: In a cross-sectional and prospective longitudinal study (follow-up period: six months) over 80% of all residents (n = 744) of SCUs in the city of Hamburg (admission criterion: mobile dementia patients with behaviour problems) were examined and compared to a group of residents in RUs in the city of Mannheim. Primary features such as behavior problems, functional impairment, and mechanical restraints (bedrails /belts or other fixing to bed/chair) were assessed by qualified nursing staff.

Results: Based on a period of four weeks, the prevalence of the use of belts was significantly lower in SCUs (7.3%) compared to RUs (19.1%). A similar pattern was found for the use of bedrails (SCUs: 22.0%; RUs: 40.1%). Controlling for confounding variables, severity of dementia was a significant risk factor for the use of belts, whereas mobility was a protective factor.

Conclusion: The use of physical restraints was significantly lower among dementia patients in SCUs and was not associated with a higher risk of falling.

CLINICAL PEDIGREE STUDY OF TAMIL BRAHMINS IN INDIA

R. Thara, Bryan Mowry, Sujit John

Background: There is a growing body of strong evidence showing that genetics has a major role to play in the etiology of schizophrenia.

Aims: The present paper is a pedigree study on the Tamil Brahmin population of South India (identified as genetic isolates) with sporadic and familial cases of schizophrenia. The study compares the symptoms, level of functioning/resulting disability, course of illness and demographics between Tamil Brahmin families with familial cases of schizophrenia and sporadic cases. The study was conducted at the Schizophrenia Research Foundation, India in collaboration with the University of Queensland Australia.

Method: Over 200 Tamil Brahmin families were identified and recruited. Of these 103 families with 213 Affected Sib pairs (ASPs) classified as familial cases of schizophrenia (Sz) and 100 families with 100 affected individuals classified as sporadic cases of Sz. DSM-IV diagnosis of schizophrenia – consensus diagnosis for all 313 cases. Information was gathered using the FIGS and the DIGS.

Results: Familial cases of Sz were compared with sporadic cases of Sz on their symptoms (SAPS & SANS), functioning (GAS), clinical details (age of onset, duration of illness, etc) and personal demographics (age, gender, marital status, education, e Age at assessment). Some of the interesting findings were that the familial cases were older, had a later age of onset of illness, longer duration, had a larger sibsize and had more of negative symptoms.

Conclusions: Familial cases differ from sporadic cases in several domains.

SOCIAL DETERMINANTS OF COMMON MENTAL DISORDERS IN WOMEN: EVIDENCE FROM THE STREE AROGYA SHODH PROGRAM IN GOA, INDIA

Vikram Patel

In most studies, women have been found to be at greater risk to suffer common mental disorders (CMD) than men. Although both biological and psychosocial explanations have been offered to explain this increased risk, the evidence base strongly favors the latter. There is limited research on the risk factors for CMD in women in low-income countries. This lecture will present data from a large population based cohort study of women aged 18 to 50 years, living in a primary health centre catchment area in Goa, India. The study involved the participation of 2494 women, and collected data on mental health, social factors and reproductive and sexual health. Participants were reviewed at 6 and 12 months. Thus, the study was able to generate results on the risk factors for CMD from both cross-sectional and longitudinal data1,2. Multivariate analyses demonstrated the strong risk for CMD associated with economic disadvantage (for e.g. low household income) in both analyses; many of the other factors, particularly those indicative of gender disadvantage, were associated with CMD but only in cross-sectional analyses. These analyses suggest that relative poverty is a major social determinant for CMD, and that other factors indicative of social disadvantage (such as gender based violence) may lie on the pathway between poverty and CMD. Public mental health policies should focus on improving access to mental health care for poorer women who bear a disproportionate burden of depression in the population.

RS72 LIVING PARTNERSHIPS IN REFORMING MENTAL HEALTH SERVICES

Vivienne Miller, Roger Gurr, Alan Rosen, Maree Teesson, Douglas Holmes, Kevin Kellehear, Lynne Dunbar, Roberto Mezzina, Peter McGeorge, Leonie Manns, Kim Mueser, Richard Warner, Paul Fanning

Context: An organisation that exemplifies real partnership between all the mental health professions, consumers, families and managers is The MHS Conference (The Mental Health Services Conference Inc.). The MHS has been a major contributor to the dissemination of knowledge about mental health service innovations, updates, research and training over the past 17 years, in Australia and New Zealand. The MHS is committed to mental health service reform which promotes recovery and citizenship for people with mental illness or disorder, and their families.

Objectives: Conference participants will:

1. Gain a rich understanding of the journey and obstacles involved in achieving real partnership between service providers, consumers and families in delivering optimal mental health care, in an organisation such as The MHS.

2. Learn about some important aspects of partnerships mental health services in Australia, Italy and USA.

Key messages: Through collaboration and partnerships, mental health service reform can assist consumers to become full citizens of the community. The MHS conference as a living example of interdisciplinary partnership between people from different professions, consumers and families. It is a forum for debate and promotion of service reform, leading to the development of an informal movement. After a very brief introduction to the organisation, a number of presentations by mental health experts (clinicians and consumers) will follow. Each of these presenters has an association with The MHS – either as a committee member or a previous keynote speaker. Some questions that will be asked are: “Partnership or pretence – how real or illusory are the partnerships with consumers and family/carers in our services? How can we safeguard and build resources (financial and human) to sustain mental health service reform?

Conclusions: There are ample precedents in mental health service reform for employing a partnership model, with valued roles for professional service providers, consumers and families and emerging evidence to suggest that this is an appropriate trail to blaze.

BENCHMARKING BEST PRACTICE: EMERGING EVIDENCE FROM THE ITALIAN REFORMS (TRIESTE) AND THEIR EUROPEAN REPLICATIONS

Roberto Mezzina

There is a tension in psychiatry. Policy documents such as the Helsinki Declaration, EU Green Paper, prioritise the struggle against social exclusion, discrimination and stigma. In contrast to these policies asylums are still considered legitimate by much of the psychiatric establishment. Even where large institutions have been closed down, there is often no clear change in the social mandate. Psychiatry still uncritically operates in ways that control deviant behaviours of social conditions (e.g. immigrants, the poor) and hence remain at the edge of the integration process. In countries such as Italy where great reforms in de-institutionalisation have been initiated, a number of contradictions and new possibilities have opened, in regard to the citizenship rights of people with mental health problems. In Trieste in particular, radically innovative practice has made a positive change to the relationship between professionals, users (consumers) and services. In almost every country a certain number of positive experiences in community mental health have grown and multiplied. These experiences can be defined as not only evidence- based, but also ‘values-based’. What they have in common is the investment in the person and his/her whole experience as a member of the community. Practical on-site training workshops are offered by community mental health, providing expertise in value-based deinstitutionalisation. This paper will describe emerging evidence about common features and differences which are often related to specific national and local contexts or to different philosophies and service choices.

PARTNERSHIPS FOR PREVENTION AND TREATMENT

Richard Warner

Context: There are a number of social problems, such as infant abuse and juvenile behaviour problems that can lead to tragic outcomes and high social cost.

Objective: To outline programs that deal with multisystem social problems in a cost-effective way.

Key messages: Through partnerships with criminal justice, child protection services, schools and substance abuse services, mental health agencies can build effective prevention and treatment programs. One example, presented by the speaker, is a program to prevent child abuse and neglect; another is a program to prevent jail recidivism of adults with mental illness; and a third is a program to prevent the out-of-home placement and incarceration of children and adolescents.

Conclusions: Improved outcomes and overall cost savings from these programs are significant.

LEADING, MANAGING AND RESOURCING MENTAL HEALTH SERVICES

Paul Fanning

The National Action Plan 2006–11 for Mental Health Services in Australia has committed Governments at all levels to increased funding, development and reform of mental health services in Australia. It is essential that the opportunities are not squandered, that key policy objectives are implemented and that increased funding goes to where it is designated. Governments not only have a responsibility to make resources available but also to ensure that there is adequate protection of the mental health budget in what is a cash-strapped health system. Mental health services in Australia require strong, consistent and visionary leadership at a national, state and Area Health Service level. Clinical leaders, planners and business managers must be empowered to work together to ensure the development of sustainable and comprehensive mental health service systems in which there is true budget protection, reporting and accountability.

RS73 PARTNERSHIPS FOR POLICY AND PRACTICE: A NATIONAL ACTION PLAN FOR PERINATAL MENTAL HEALTH

Nick Kowalenko, Marie Paule Austin, Bryanne Barnett, Belinda Horton, Leonie Young, Anne Buist

Background: beyondblue: the national depression initiative has funded a consortium to develop a National Action Plan (NAP) by the end of 2007 to address depression and related difficulties in women during pregnancy and in early parenthood.

This initiative follows beyondblue's earlier four year research project showing that high rates of emotional distress exist among pregnant women (8.9 per cent) and new mothers (15.7 per cent).

The outcomes of beyondblue's earlier research on postnatal depression are being translated into national policy and practice.

The NAP will underpin the long term goal of establishing comprehensive assessment and early intervention programs nationally.

Aim: The NAP aims to:

Increase community awareness of perinatal mental health

outline a national program to be integrated into existing practice and funded adequately

Method: The consortium is developing a NAP, informed & advised by:

i) a national Steering Committee & other governance structures

ii) working parties addressing the implementation of routine assessment, pathways to care & training

iii) a national stock take of perinatal mental health policy & practice

iv) the outcomes of focus groups with practitioners policy makers, consumers and families

v) other activities

Results: The draft National Action Plan will be available by the end of 2007, with an approved implementation process.

Conclusion: Strategic partnering with a broad range of health providers, government, funders, and academics has successfully developed a draft National Action Plan, to address a national mental health priority, with beyondblue.

PARTNERSHIPS FOR POLICY AND PRACTICE: A NATIONAL ACTION PLAN FOR PERINATAL MENTAL HEALTH

Bryanne Barnett

The perinatal period (conception to one year after childbirth) offers many opportunities for early intervention, prevention and health promotion both in physical and mental health fields. Many aspects of physical wellbeing for the mother, the foetus and the infant actually depend primarily on the mother's social and emotional wellbeing,; the two being inextricably linked. Many health services in Australia and internationally became aware during the 1980s of the significance of postnatal depression in this context and attempted to screen for the disorder in a systematic fashion; often in the vain hope of antenatal prediction leading to prevention of postnatal depression. Subsequently it became clear that antenatal depression and also anxiety disorders were common problems and that maternal mental health needed to be viewed in broader terms than simply the presence or absence of diagnosable mental illness. Collaboration across a variety of disciplines was essential to a process where the ideas, training and support were initially offered by specialist mental health, but the clinical setting for universal and routine implementation needed to be midwifery, maternal and child health nursing, general practice, obstetrics, and social work, inter alia. The development and evaluation of one method of assessment of mental health, Integrated Perinatal Care, during pregnancy and the first postpartum year, will be described.

QUALITY PATHWAYS TO CARE IN THE NATIONAL PLAN FOR PERINATAL MENTAL HEALTH

Nick Kowalenko

A guiding principle of the NAP is to provide a comprehensive approach to perinatal mental health care coordinated across primary, secondary and tertiary settings.

A broad outline of how this might best be achieved is outlined in the plan, and is founded on the role of the primary mental health care sector.

How the secondary and tertiary sector best integrate with this, and other care sectors is probably best determined by more local planning, informed by the nature of local resources.

An initial baseline national “snapshot” of existing services has been conducted.

The National Action Plan has identified that practice guidelines, partnerships with consumers, building organisational capacity, benchmarking processes, and service evaluation can enhance the development of quality pathways to care.

THE BEYONDBLUE PND INITIATIVE 2001–5: IMPLICATIONS FOR HEALTH PROFESSIONALS IN THE MANAGEMENT OF “SCREEN POSITIVE” WOMEN

Anne Buist

Context: In 2001-5 beyondblue sponsored an initiative that screened over 40,000 women. This project was the basis for stage two, the national Perinatal Depression Initiative.

Objectives: The initial project aimed to assess feasibility and acceptability of screening, and associated needs of staff and ways for women to access help.

Key measures: Women (85%) generally found screening easy and acceptable. However issues of accepting treatment were an issue for a significant number of women. A subsequent qualitative study found issues of stigma, difficulties in recognition and not wanting to be seen as a bad mother were key issues in preventing women seeking help.

Conclusions: Primary care and obstetric services need to consider the issues women have in being diagnosed with depression when managing postnatal women; this can be included in training, an important arm of the overall package of screening, to ensure women access early intervention.

THE AUSTRALIAN BEYONDBLUE NATIONAL ACTION PLAN FOR PERINATAL MENTAL HEALTH

Marie Paule Austin

Background and method: The Australian beyondblue National Perinatal Mental Health Action Plan (the Plan), will underpin the long term goal of establishing comprehensive psychosocial assessment and pathways to care across Australia.

The Plan will recommend:

A national communications and consultation strategy for key stakeholder engagement

A community awareness campaign targetting perinatal and infant mental health

Outline a national program for routine, universal psychosocial assessment undertaken by primary health care professionals and to be integrated into existing practice

Recommend minimum workforce training standards and packages

Recommend models for pathways to care (including for specific population groups).

Once the Plan is approved in 2008, the implementation process is expected to begin.

Discussion: Strategic partnering with a broad range of health providers, government, funders, and academics has successfully contributed to the development of this National Action Plan, to address a national mental health priority, with beyondblue. This paper will outline the key strategies and activities for implementation of a national approach to the early identification and intervention of perinatal mental health distress and related disorders.

CONSUMERS AS PARTNERS IN THE NATIONAL ACTION PLAN

Belinda Horton

PANDA, the Post and Antenatal Depression Association, is a Victorian, statewide, not for profit association working for women and their families affected by antenatal and postnatal mood disorders. Since 1985 PANDA has built on its consumer roots to become an acceptable, accessible and confidential telephone Helpline. PANDA receives calls for support, education and referral from women experiencing mild through to severe distress and depression as well as calls from their partners, family and friends.

All callers talk to staff and volunteers who have been personally touched by perinatal mood disorders, thus providing powerful peer to peer support and education. By sharing experiences about the impact of perinatal mental illness in their lives, women and their families are able to gain greater insight, to learn alternative and constructive approaches to dealing with the impact of the mental illness and to know that recovery is possible.

PANDA has drawn on this extensive experience as a consumer delivered service in its contribution to the development of the National Action Plan. This paper discusses a range of strategies that empower women and their families to be informed consumers of the services and processes being recommended within the National Action Plan to ensure that they can access and stay engaged with services in pathways to care. Strategies to facilitate the engagement of women and their families in the National Action Plan and its recommendations are vital to greater recovery outcomes and reduced impact of mental illness.

RS74 EAST MEETS WEST: CULTURE, WRITING AND THE MIND

Jennifer Harrison, Satoshi Kato, Adriana Rivas, Ekaterina Sukhanova, Sergio J. Villaseñor-Bayardo, José R. Reyes-Rivas

This symposium by the WPA Section on Literature and Psychiatry offers an interdisciplinary look at selected sociocultural paradigms having a direct influence on mental health. Relevant literary works from different cultures across the world will be analyzed not only as a source of information on dominant social values but also as a factor that contributes to the development and self-perception of a society.

CREATIVITY AND MELANCHOLIA IN THE PROCESS OF JAPANESE WESTERNIZATION

Satoshi Kato

Beginning with the 1869 Meiji Revolution, Japan embraced Western civilization in order to transform itself into an industrialized nation modeled after developed Western countries. Intercultural conflicts brought on by profound socio-cultural changes were experienced by members of the Japanese society as a feeling of loss. In studying the creative processes of Japanese writers, the author attaches importance to the melancholic element originating from this intercultural conflict. In this presentation, Soseki Natsume, a representative Meiji-era writer, will be discussed from this perspective. Natsume suffered from ‘neurasthenia’, a condition that would now be diagnosed as a major depressive disorder. At a conference in 1905, he declared that the Japanese people would be forced to suffer a spiritual void by embracing Western civilization, a view that may have been based on his own melancholic experiences. We consider that Natsume's writings seeking self-conviction exhibit a function of self-healing for a depressive disorder. Thus, the case of Natsume could illuminate the relationships between creativity and depressive disorders, and between creativity and intercultural conflicts.

PAIN AND PROBLEMS TASTE BETTER WITH BREAD: FOOD AND PSYCHOPATHOLOGY IN LATIN-AMERICAN LITERATURE

Adriana Rivas

In Latin American culture, food plays an important role that goes beyond its nutritional value. Food has a cohesion social factor in family, work and even political life, besides its well-known use as catalyst of emotions, sadness, joys and anxiety. Good and bad news are announced at the kitchen table, where a piece of chocolate, wine, bread, cheese, a smile, and a tear may all be mixed. These images had been widely used and referred to by such authors as Miguel de Cervantes Saavedra, Jorge Luis Borges and Julio Cortázar, whose writings implicitly acknowledge that in some cultures it is difficult to separate an emotional event from the alimentary ritual.

The pathology of alimentary behavior has always provoked a controversy as to whether it is the biological phenomenon of food is which determines its physiopathology or the disturbance of normal physiology causes a modification of behavior. There exists enough evidence about the links between alimentary capacity and serotonin modification, anxiety and carbohydrates, as well as about the anxiolitic properties of chocolate and stimulating properties of coffee.

The relationship between the metabolic effects and the emotional expression is a topic that had recently come to the attention of scientists. Literature has long recognized this insoluble connection, and therefore can be used to advance understanding of the food-feeling relationship.

COMRADE HAMLET: A PSYCHOSOCIAL PORTRAIT OF THE SOVIET INTELLIGENTSIA

Ekaterina Sukhanova

The seminal novel by Andrei Bitov's “The Pushkin House” will be used to discuss the effects of a totalitarian regime on the development of individual identity. Bitov depicts a society in which the links to the country's history, intellectual tradition and even to one's own family legacy are all artificially severed. Language ceases to be trusted as it is perceived as a tool of propaganda rather than means of creative liberation. The “new man” promised by social engineering turns out to experience identity diffusion, emotional lability and intense dependence on others. The protagonist of “The Pushkin House,” described in a way reminiscent of an extended case study, reflects the immaturity of his society, in which dichotomous thinking is fostered. Ironically, it is when the protagonist of the novel is finally able to gain a critical distance to himself and take responsibility for his proper actions, that his functioning within that society is threatened.

“PASO DEL NORTE”: MEXICAN WRITERS AND MIGRATION

Sergio J. Villaseñor-Bayardo, José R. Reyes-Rivas

This presentation explores the topic of migration, roots, and spatial symbolism in the work of the Mexican writer Juan Rulfo. For migrants in Mexico, “going north” has many symbolic meanings: a new stage in life, a step-up on the social ladder, a better quality of life. The title of a short story by Juan Rufo, “El Paso del Norte”, alludes to many colloquial expressions linked to the “North”.

However, this experience of migration can also be a painful one. Some of Rulfo's characters leave their homes with the intent to go back, leaving their possessions to be safeguarded until their return. Others ultimately choose not to migrate because of their fear of being uprooted, of “not being able take their dead loved ones with them.” The lack of roots is also seen as linked to misogyny. At times, his characters are forced to plant their roots elsewhere. Institutions such as “El Colegio de México”, the National Autonomous University of Mexico and others Mexican universities have offered help to the exiles, for example to the Spanish during the Franco regime, the Chileans fleeing from Pinochet or the Argentineans persecuted by the military regime. The topic of migration and its effects on the psyche thus plays a prominent role in Mexican literature.

MIND, PHRASE & FABLE

Jennifer Harrison

Both fables and poems have their origin in oral tradition. Having influenced each other throughout history, both reflect a culture's efforts to retain knowledge of itself through memory. Both are porous and accretive, as they soak up the influences of their times. Poems and fables are reinterpreted continually in order to illuminate social challenges. In addition, both poems and fables absorb those influences coming into a culture or society from elsewhere. Neither fable nor poem is an accurate record of history but they both possess and process meaning. Both have the ability to travel through time and to be regarded as valuable by future societies—or to lose their significance. This paper will explore the history of these two literary forms, highlighting the poem/fable as a vigorous literary form within contemporary Australian poetry.

RS75 MENTAL HEALTH LEGISLATION SCENARIO IN SOUTH ASIA

J. K. Trivedi, George Christodoulou, Harischandra Gambheera, Roy Abraham Kallivayalil, Pureza Trinidad Onate, Kua Ee Heok, H. M. Syamsulhadi

Mental health legislations codify and consolidate the fundamental principles, values, goals, objectives and mental health policy. Such legislation is essential to guarantee that the dignity of patients is preserved and that their fundamental rights are protected.

In WHO health REPORT (2001) it was reported that 67% of countries in South-east Asia have mental health legislation and rest 33% have no such law. Central government of India declared 1st April 1993, as the day on which MENTAL HEALTH ACT 1987 came into force in all states and union territories.

Countries including Indonesia, Bangladesh, Thailand, Malaysia, Myanmar, still have Mental Health Act based on British Lunacy Act. Legislation should ensure the introduction of mental health into primary health care. In South Asian countries like India and Bangladesh delivering mental health services through primary health services is the most viable strategy.

Mental health care law should have these basic principles, which includes:

Respect for dignity, autonomy and liberty – In this confidentiality should be maintained and there has to be provision for involuntary admissions.

Professionalization of mental health services – Internationally accepted medical standards should be adopted for better care and treatment.

Protect fundamental rights.

Non discriminatory – No discrimination on the basis of race, religion, caste and color.

Least restrictive environment – There should be decreased institutional placement and increased community services.

(Regional work shop on Mental health legislation, Galle, Srilanka, May, 2001).

South Asian countries need a modern mental health law that gives priority to protecting the rights of persons with mental disorders, promotes development of community-based care and improves access to mental health care.

MENTAL HEALTH LEGISLATION: COMPARISON OF SOUTH ASIAN AND WESTERN COUNTRIES

Pureza Trinidad Onate

MENTAL HEALTH LEGISLATION IN SOUTH ASIAN COUNTRIES: SHORT COMINGS AND POSSIBLE SOLUTIONS

Harischandra Gambheera

MENTAL HEALTH LEGISLATION-DOES IT FACILITATE OR HINDER MENTAL HEALTH CARE IN COUNTRIES OF SOUTH ASIA

Saroja Krishnaswamy

EVALUATION OF MENTAL HEALTH LEGISLATION IN SOUTH ASIAN COUNTRIES: ARE WE STILL LIVING IN THE PAST

Roy Abraham Kallivayalil

MENTAL HEALTH LEGISLATION: HOW TO IMPLEMENT IN SOUTH ASIAN COUNTRIES?

J. K. Trivedi

RS76 ETHICAL ISSUES IN PSYCHIATRY: A DIACHRONIC CONSIDERATION

George Christodoulou, Michel Botbol, Said Abdel Azim

The existing moral theories in Psychiatry (Virtue ethics, Casuistry, Deontological theory, Utilitarianism, Principlism and Ethics of care) and their relevance to psychiatric clinical practice are discussed. The advantages and disadvantages of each of these theories are considered and it is pointed out that they should be regarded as complementary rather than antithetical.

Codes of Ethics in Medicine and Psychiatry existing from ancient times to the present are briefly reviewed and their similarities and differences are highlighted. Controversial issues like exposure of incompetent colleagues, responsibility to the state, societal duties of the psychiatrist etc arising from these codes of Ethics are discussed. Recurring topics, like turning to experienced colleagues if needed (awareness of limitations), the “do no harm” Hippocratic dictum, confidentiality and priority of the well-being of the patient are highlighted.

Lastly, hot issues like external donations and relations with industry, the double agent role of the psychiatrist, involuntary hospitalization and ethical aspects of research are presented and briefly discussed.

THEORIES AND CODES OF ETHICS IN PSYCHIATRY: A DIACHRONIC APPROACH

George Christodoulou

Ethical standards in Medicine and Psychiatry are subject to change according to social, financial and political circumstances and the prevailing public attitude concerning ethics. Yet, there are certain features that have resisted time and can, as a consequence, be considered “diachronic” These features will be highlighted in this presentation.

The prevailing Moral Theories in Psychiatry and their relevance to clinical practice will be reviewed. These theories are the following:

Virtue Ethics

Casuistry

Deontological Theory

Utilitarianism

Principlism

Ethics of Care

The advantages and disadvantages of these theories will be highlighted and it will be pointed out that they should be regarded as complementary rather than antithetical.

Codes of Ethics existing from ancient times to the present will be briefly reviewed, their similarities and differences will be highlighted and issues like exposure of incompetent colleagues, responsibility to the state and societal duties of the psychiatrist will be discussed. Awareness of the limitations of the physician, the “do no harm” Hippocratic principle, confidentiality and priority of the well-being of the patient will be highlighted and discussed.