OP01 BIPOLAR AFFECTIVE DISORDER
A DOUBLE BLIND RANDOMISED PLACEBO CONTROLLED TRIAL OF N-ACETYL CYSTEINE AS A GLUTATHIONE PRECURSOR IN BIPOLAR DISORDER
Michael Berk
Background: There is evidence that oxidative stress and glutathione deficiency occurs in bipolar disorder. Glutathione is a major endogenous free radical scavenger. N-acetyl cysteine (NAC) is a precursor of glutathione.
Aims: The aim of this study is to examine the adjunctive efficacy and tolerability of NAC in the treatment of bipolar disorder.
Methods: Individuals with bipolar disorder were studied in a randomised, double-blind, multicenter, placebo-controlled study. They were treated with NAC (1g BID) as an add-on to their usual treatment over a 24 week interval followed by a 4 (±2) week washout. Rated outcomes included the Montgomery Asberg Depression Rating Scale (MADRS), the Bipolar Depression Rating Scale (BDRS), Young Mania Rating Scale (YMRS), Clinical Global Impression (CGI) improvement and severity scales, CGI modified for bipolar disorder (CGI BP), Global Assessment of Functioning Scale (GAF), Social and Occupational Functioning Assessment Scale (SOFAS), SLICE LIFE and LIFE RIFT scales and Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q).
Results: The sample size was 75. NAC was associated with significant improvements on the BDRS, MADRS, CGI-BP, GAF, SOFAS, Q-LES-Q, LIFE RIFT and SLICE LIFE at trial endpoint (week 24), which were no longer evident after treatment discontinuation (week 28). Treatment emergent adverse events did not differ between groups. Effect sizes at endpoint were in the medium to high range.
Conclusions: This study provides evidence for oxidative stress as a contributory and novel mechanism of disease, and supports NAC as a novel treatment, with particular efficacy in depression.
BIPOLAR DISORDER: ROLE OF SLEEP IN POSTPARTUM RELAPSE
Anne Buist, Justin Bilstza
Background: A high rate of relapse has been noted for bipolar disorder in the early postpartum period; as well this time is the first episode for some women of a postpartum psychosis, thought to be a bipolar variant. This project, of which the preliminary findings are presented here, seeks to examine the role if any sleep has in relapse.
Method: Women were recruited who had a history of bipolar or postpartum affective psychosis, who were currently pregnant and willing to participate. Control women were matched for age, parity and marital status and recruited from the Mercy antenatal clinic. Women were seen in each trimester of pregnancy, and up to three months postpartum with questionnaires, sleep diary and sleep monitor.
Results: 32 women have been recruited to the study, 16 in each group. Of those in the study group only two were on no medication, four on antidepressants only and 10 on mood stabilisers. Five women relapsed, three after two months postpartum. Women in the two groups did not differ significantly on age, time of pregnancy at recruitment, marital status or parity. We are currently analysing sleep data: control women appear to have increased time awake after lights out and a higher alcohol intake. Further data will be presented at the conference.
Conclusions: This is preliminary data from a study looking at sleep in bipolar relapse postpartum. Later relapse of some women may be related to early postpartum close management and support of sleep that drops off as the baby ages but still requires overnight feeds.
QUALITY OF LIFE OF PARTICIPANTS WITH BIPOLAR AND SCHIZOAFFECTIVE DISORDER IN AN AUSTRALIAN COHORT: RESULTS AFTER TWELVE MONTHS
Jayashri Kulkarni, Michael Berk, Paul Fitzgerald, Anthony de Castella, Sacha Filia, Kate Filia, Seetal Dodd, L. Berk, Frances Biffin, Katarina Kelin, Meg Smith, A. Brnabic R. E. Granger, W. Montgomery
Background: The Bipolar Comprehensive Outcomes Study (BCOS) is a 2-year, observational study of participants with bipolar I or schizoaffective disorder.
Aims: To examine the clinical, functional, and economic outcomes associated with ‘real-life’ treatment.
Methods: Participants (n = 239) prescribed mood stabilisers were assessed at 3-month intervals for 12 months using the EuroQol instrument (EQ-5D), the 36-Item Short-Form Health Survey (SF-36), DIP (Diagnostic Interview for Psychosis) and SLICE/LIFE to examine quality of life.
Results: Participants’ overall health state improved after 12 months according to EQ-5D overall ([mean±SE] 70.3±1.28 vs. 66.4±1.30 baseline, best imaginable health state 100, p =.005) and utility (0.80±0.02 vs. 0.74±0.02, perfect health 1, p=.095) scores. Overall SF-36 mental scores were significantly increased after 12 months (36.8±0.84 vs. 41.1±0.88, p<.001) although physical scores were relatively unchanged (46.7±0.68 vs. 47.7±0.69, p=.047). More participants were satisfied/very satisfied with their overall health after 12 months (56.2% vs. 46.8% baseline; SLICE/LIFE total: 2.13±0.04 vs. 2.42±0.04, p<.001). The unemployment rate had decreased (29.3% vs. 17.6%) and mental illness prevented fewer participants from working (17.6% vs. 7.3%). During the 12-month period, 28.0% of participants were hospitalised at least once, staying an average of 26.8 days, although fewer participants required hospitalisation at 12 months than baseline (0.0% vs. 7.1%).
Conclusion: The results suggest that people undergoing treatment for bipolar and schizoaffective disorders largely experience improved or unchanged quality of life after 12 months observation. Data at 24 months will allow us to examine emerging trends that can be further explored.
ROLE OF QUETIAPINE IN THE MANAGEMENT OF ACUTE BIPOLAR DEPRESSION: A NEW OPTION FOR BOTH BIPOLAR I AND BIPOLAR II PATIENTS
Richard Weisler
Objective: Although current guidelines recommend either lithium or lamotrigine as first-line agents for management of acute depressive episodes associated with bipolar disorder, clinicians recognize that certain patients with depressive symptoms may respond less favorably to standard therapy. Published data on the treatment of these patients, including those with bipolar II disorder or rapid cycling bipolar depression, are sparse. Recent well-designed studies report that olanzapine monotherapy, olanzapine- fluoxetine combination, and quetiapine monotherapy improve depressive symptoms in patients with bipolar disorder.
Method: The BOLDER I and BOLDER II trials examined the efficacy and tolerability of quetiapine monotherapy at fixed doses of 300 or 600 mg/d in patients with bipolar II depression.
Results: Analysis of combined data for bipolar I and II patients in the BOLDER trials (n = 321, ITT population) shows that quetiapine had a significantly greater improvement in mean MADRS total scores relative to placebo at each assessment from baseline to Week 8. Changes from baseline to Week 8 for quetiapine 300 and 600 mg/d were −17.09 and −17.86, respectively, versus −13.31 for placebo (P = 0.005 and P = 0.001 versus placebo). Improvements in mean HAM-D scores from baseline to Week 8 were also significantly greater with both quetiapine doses (−14.33 and −15.04) than with placebo (−11.33; P = 0.001 and P < 0.001, respectively). Anxiety symptoms assessed by HAM-A also showed significant improvement. Patients (bipolar I or II) with (n = 82) or without (n = 239) a rapid-cycling course (n = 82 and 239, respectively) demonstrated significant improvements in MADRS total score. Adverse events, including dry mouth, sedation, and somnolence, were generally mild to moderate in intensity.
Conclusions: In these two large controlled, randomized trials, quetiapine monotherapy demonstrated significant efficacy for the treatment of acute depressive episodes in difficult-to-treat patients with bipolar II disorder and bipolar I disorder, including those with a rapid cycling disease course. Suicidal thoughts as assessed by the MADRS item showed significant improvements at both doses of Quetiapine.
Educational objective: At the conclusion of this presentation, the participant should be able to recognize that quetiapine may be a viable option in managing patients with difficult-to-treat bipolar depression, including those with bipolar II disorder. The impact of quetiapine treatment on the MADRS suicide item will also be discussed.
Literature Reference 1
Calabrese JR, et al: A randomized, double-blind, placebo-controlled trial of quetiapine in the treatment of bipolar I or II depression. Am J Psychiatry 2005; 162(7):1351–60.
Literature Reference 2
Thase M, et al: Confirmation of the efficacy of quetiapine monotherapy in bipolar depression in a second double-blind, placebo-controlled study: the BOLDER II study, presented at the XXVth Biennial CINP Congress. Chicago, Illinois, July 9–13, 2006.
GLUTATHIONE DEPLETION AS AN ANIMAL MODEL OF SCHIZOPHRENIA
Olivia Dean, Maarten van den Buuse, Michael Berk, David Copolov, Ashley Bush
Background and aims: Depletion of brain glutathione, the primary antioxidant, has been shown in psychiatric illnesses including schizophrenia and bipolar disorder. The current project investigated the effect of brain glutathione depletion on behaviour in rats and mice alone and in combination with amphetamine treatment. N-acetyl cysteine was used to potentially restore the brain glutathione deficit.
Methods: Sprague-Dawley rats or C57Bl/6 mice were treated with 2-cyclohexene-1-one (CHX) to deplete brain glutathione. D-amphetamine sulphate was used to induce hyperlocomotion and potentially increase oxidative stress in the brain. Spatial working memory was assessed with the Y-maze procedure and locomotor hyperactivity was assessed using video analysis.
Results: Both rats and mice administered with CHX showed significant brain glutathione depletion in the frontal cortex and striatum. D-amphetamine treatment in combination with CHX administered to mice led to an increase in locomotor hyperactivity, however this was not significantly different from amphetamine controls. CHX treatment disrupted spatial working memory in both species. N-acetyl cysteine (NAC) successfully restored the brain glutathione deficit in rats.
Conclusions: Glutathione may be valuable target for further investigations into the oxidative biology of the pathology of psychiatric illnesses including schizophrenia and bipolar disorder. Animal models may be useful in investigating the role of glutathione depletion in psychiatric illness and identify potential drug targets. NAC has been shown to effectively restore brain glutathione levels.
BIPOLAR AFFECTIVE DISORDER WITH CO-MORBID SUBSTANCE MISUSE AND CRIMINAL OFFENCES
Ehab Ali Sorketti Koriana, Stephen Jampunathan
This study was designed to:
Assess the prevalence of criminality among a sample of psychiatric patients with bipolar affective disorder with co-morbid Substance misuse in Malaysia.
To examine the association between offending and contact with the criminal justice system in individuals with bipolar affective disorder and abusing drugs.
Method: The study was designed as a retrospective case control study.
Sixty patient diagnosed as bipolar affective disorder, and had history of criminal offences was matched to 60 patient of the same sex, age and primary diagnosis of bipolar affective disorder being discharged from a general psychiatric ward in HBUK.
Diagnoses established according to DSM-IV and ICD10 criteria.
Case-notes were reviewed to collect data regarding social life, criminal record and service used.
the data was analyzed using the SPSS Version 12.
Results: About 93% of the patients who committed criminal offences and abused substance were males. Only 7% were females.
The patients with bipolar affective disorder who were criminal and abused drugs are 71.7% compared to 20% who abuse drugs only in the control group.
It was proved that there is significant association between bipolar affective disorder patient who abused substance and criminal offending, this group of patients have higher tendency to be more violent, aggressive and to commit criminal offences P = 0.001.
OP02 VIOLENCE AND DEVIANCE IN PSYCHIATRY
VIOLENCE IN IRAQ: PSYCHOLOGICAL VIEW
Mohammed Lafta
Each year, over 1.6 million people worldwide lose their lives to violence.
Violence is among the leading causes of death for people aged 15–44 years worldwide, accounting for 14% of deaths among males and 7% of deaths among females.
When violence is prolonged, it undermines the social and economic conditions of communities and nations.
The consequences of armed conflict are especially devastating. The loss of parents, children, spouses, etc. is emotionally traumatic, and may have serious economic consequences for surviving members of the families as well.
Iraq with a history of bloody violence is not lucky through what it has subjected to occupation, invasion, destruction, killing, deportation, and elimination during the previous centuries.
There are several cornerstones of violence in Iraq which need to be discussed in details.
Non-violence education is very crucial for the future of Iraq.
PSYCHOLOGICAL MAKEUP OF MUSLIM SUICIDE BOMBER
Aftab Khan
Context: Suicide bombing by Muslims has become a global phenomenon. The issue is widely debated, but I am unaware of any psychodynamic explanation; yet, on the principle of psychic determinism there has to be a specific mechanism to explain this apparently irrational act on an individual's part.
Objective: Formulate a psychodynamic theory to understand the mind of a Muslim suicide bomber through direct and indirect evidence augmented with examples from my psychiatric practice and everyday observations in Pakistan.
Key messages: As children, suicide bombers are violently taught Islam without recourse to independent thinking, which results in unconscious rage towards the authority figure, development of a fragile ego, a harsh superego, and an exquisite susceptibility to guilt, followed by a deranged experience of puberty and adolescence ultimately leading to identity foreclosure. They cannot deal with their mortality and ‘the unknown’, and experience low self worth and a lack of purpose. Martyrdom is strongly conceived as redeeming, glorious, and is sometimes their only ego-Ideal.
Conclusion: When such an individual comes across an opportunity where unconscious murderous rage towards the authority figure can be displaced onto the perceived oppressor, suicide bombing becomes a viable option. It gratifies the murderous rage (of the id) and soothes the superego (with martyrdom, the ego-Ideal), while the weak ego is unable to intervene where the id and the superego have joined hands. The other psychological benefit is the end of a supposedly meaningless life. The issue of mortality is also put to rest by becoming instantly immortal.
ASSESSMENT AND TREATMENT BY GENERAL PSYCHIATRISTS OF OUTPATIENTS WITH PARAPHILIAS
R. Gregg Dwyer, Fabian Saleh, Crystal Kim
Paraphilias are psychiatric disorders characterized by deviant sexual thoughts, fantasies, urges, or behaviors. Persons with paraphilias who act on their thoughts or cravings in a manner contrary to legal standards may be identified as sex offenders. Assessment of persons with paraphilias requires a comprehensive evaluation of their developmental, educational, social, employment, general medical, psychiatric, substance use, and legal histories. Adjunct methods include laboratory testing, physiological assessment, and cognitive testing. Treatment of persons with paraphilic sexual behavior also requires a comprehensive approach encompassing psychological modalities and, for some patients, also biological therapies. This presentation will focus on the initial assessment and treatment planning for persons with paraphilias who are outpatients of general psychiatrists. Evidence-based methods will be presented with references to recent research literature.
FEMALE SEX OFFENDERS' EXPECTATIONS OF TREATMENT
Louanne Lawson
Sexual abuse of children by women is relatively rare. Perhaps as a result, limited attention has been paid to female sex offenders. Treatment programs for women are generally modifications of male-oriented programs and do not take into account the women's perspective on treatment. This study was designed to remediate that deficit. Individual and focused group interviews were conducted with 14 women convicted of a hands on offense against a child. Three umbrella questions were asked: a) What can people do to help you? b) What would you like to change about yourself? c) What kind of treatment would help you deal better with men? Data were analyzed by content analysis and constant comparison. The participants reported that they want therapists to be available when they want to talk, show respect, and help them prevent future problems. The women would like therapists to help them see things from someone else's point of view and help them accept and correct their mistakes. They reported serious problems understanding why men thought they could abuse women and children and would like to find ways to protect themselves and their children from men's drinking and abuse. In general, the participants thought that treatment should focus on alleviating the psychological suffering they experience as a result of being convicted of a sexual offense. They had limited insight into therapists’ and community members’ expectations regarding treatment-related behavioral changes. They would like therapists to treatment with respect and not judge them on the basis of their convictions.
A SYSTEM FOR CLASSIFYING FEMALE CHILD MOLESTERS
Louanne Lawson
It has long been assumed that female sex offenders differ from male offenders in terms of their characteristics, motivations and behaviors. This perception may be changing. Five female sex offender taxonomies have been developed in the past 25 years but little subsequent testing has been done to confirm the taxonomies’ usefulness in categorizing female offenders outside the original studies. Further, male-specific taxonomies have not been tested with female offenders. Until a valid taxonomy emerges, prevention efforts, police investigations, adjudication, risk assessment and treatment activities will be hampered. This study was designed to categorize female offenders according to both male- and female-specific taxonomies to determine which, if any, can be considered valid and reliable. Risk assessment records from 75 female offenders were coded using criteria from each of six taxonomies. The data were analyzed by path analysis. Results indicate that Prentky, Knight and Lee's Massachusetts Treatment Center (MTC:CM3) two axis typology, developed for classifying male sex offenders, correctly classified more of the female offenders than any of the other taxonomies.
OP03 CULTURAL ISSUES IN DIAGNOSIS AND TREATMENT
DSM-IV OUTLINE FOR CULTURAL FORMULATION: “THE CULTURE OF EMOTIONS”
Francis Lu
Cultural assessment in clinical psychiatry is essential as part of good clinical care. Trainees and residency training programs in the United States must meet ACGME requirements to include sociocultural issues as part of the integrative case formulation. The DSM-IV Outline for Cultural Formulation (pages 843–844) provides a concise clinical tool for cultural assessment. It consists of 5 sections: 1) Cultural Identity, 2) Cultural Expressions and Explanations of Illness, 3) Cultural Stressors and Supports, 4) Cultural Elements of the Clinician-Patient Relationship, and 5) Overall Cultural Assessment for Differential Diagnosis and Treatment Planning. “The Culture of Emotions” DVD (2005, 58 minutes) is an introductory overview of the Outline. After a short prologue, the five sections are described followed by short commentaries from a total of 23 cultural psychiatry experts, which explicate each section. This new DVD originated from the 2002 videotape written, directed and produced by Harriet Koskoff; Dr. Lu served as the Executive Scientific Advisor. It is described at www.fanlight.com and has been shown at the annual meetings of the American Psychiatric Association, American Psychological Association, Society for Study of Psychiatry and Culture, American Association of Directors of Psychiatry Residency Training, and the American Counseling Association among other venues.
CROSS-CULTURAL DIFFERENCES IN SOMATIC PRESENTATION IN PATIENTS WITH GENERALIZED ANXIETY DISORDER
Sharad Man Tamrakar, Elizabeth Hoge, Kelly M. Christian, Namrata Rawal, Mahendra K. Nepal, Mark H. Pollack, Naomi M. Simon
Previous cross-cultural studies of depressive disorders have found a greater somatic focus in Asian population, but little is known about how the expression of distress in anxiety disorders differs between cultures.
To determine the differences in somatic symptoms in Generalized Anxiety Disorder (GAD) between American and Nepali subjects.
We examined anxiety symptoms in patients with Generalized Anxiety Disorder in urban mental health settings in Nepal (n = 30) and in the US (n = 23). Participants completed the Beck Anxiety Inventory (BAI), and the overall score, somatic (i.e. feeling hot, hands trembling) and psychological (i.e. fear of worst happening or nervous) subscales, as well as single symptom item ratings were compared for the two groups.
While there was no difference in overall severity of the BAI, the Nepali group scored significantly higher on the somatic subscale (t = 1.33, p < 0.02), while the American group scored significantly higher on the psychological subscale (t = 3.27, p < 0.002). Examples of somatic items that were significantly greater in Nepali patients include indigestion, dizziness, choking, and trembling.
Patients with GAD in Nepal had a higher level of somatic symptoms and a lower level of psychological symptoms than patients with GAD in the US. Although stigma may in part explain the difference in somatic focus, this traditional explanation for cultural differences is less likely to be present in this study as both groups presented to a mental health clinic. Other possible explanations include differences in cultural traditions of describing distress and differing models of mind-body dichotomy.
“KAPOK” AND POST-TRAUMATIC STRESS DISORDER
Theresia Citraningtyas, Richard O'Kearney, Beverley Raphael
Context: The word “trauma” has been adopted into Bahasa Indonesia with a meaning similar to the word “kapok” (Javanese/colloquial Bahasa Indonesia). With numerous natural and man-made disasters and subsequent aid and psychological interventions, the two words often appear in clinical practice and general conversations in Indonesia and need to be clearly understood to avoid misperception.
Objectives: To conduct a cross-cultural comparison of the Indonesian concept of “trauma” (as adapted), “kapok”, and the major psychological theories and DSM-IV-TR criteria of Post-traumatic Stress Disorder (PTSD); to explore the cultural context; to gain insight into local control efforts.
Key messages: Similar to the Indonesian concept of “kapok”, the word “trauma” is commonly used in Bahasa Indonesia to reflect learned avoidant behaviour resulting from one or more unpleasant experiences of sufficient but not necessarily extreme levels. “Kapok” carries an element of active learning where avoidance is the decided final outcome, while “trauma” implies higher levels of arousal and less element of choice, and can be temporary. These concepts do not necessarily imply intrusive or numbing symptoms. A non-emotive neutral composure is commonly preferred and conditioned in the cultural context.
Conclusion: The “kapok” cultural perception of the natural human response to unpleasant events gives insight into and explains the local conceptualisation of traumatic response and potential recovery efforts.
PATTERN OF TRADITIONAL HEALING AMONG PSYCHIATRIC PATIENTS IN ASSAM, INDIA
Dipesh Bhagabati, Mythili Hazarika, Debashis Ray
Supernatural cause of mental illness is prevalent is prevalent among different communities of the world. In India also many patients go to faith healers for amelioration of their ailments.
The present study was undertaken to study the pattern of traditional healing in psychiatric patients in the state of Assam, India. One hundred psychiatric patients attending out patient facilities of Psychiatry Department of a medical college hospital were taken for the study. A comparative group was taken from General Medical OPD of the same hospital. The patient and a close care-giver was interviewed to collect data. It was observed that when compared to general medical patients, significantly more number of psychiatric patients went to traditional healers (p < 0.0001) before attending psychiatry opd. The number of healers attended by them was also higher.
Observations were made regarding aetiology, diagnostic terminology used and management procedures advised by faith healers in both groups of patients.
In conclusion it can be observed that in planning community care of psychiatric patients the role of traditional healers cannot be ignored. To prevent chronicity of mentally ill patients traditional healers could be a part of the referral system as more often than not they are the first contacts with these patients.
ASSESSING MENTAL HEALTH TRANSCULTURALLY: VALIDATION OF PSYCHOMETRIC INSTRUMENTS IN BRAZIL
Carlos Zubaran Jr, Juan Mezzich
Background: Research on migration and mental health emerged in the 19th century when immigrants were depicted as people “without friend in a strange land” for whom “hope yields to anxiety”. Ødegard (1932) observed high rates of breakdown among migrants adapting to a host society. Individuals from minority groups tend to experience distress due to their status of subordinate and may present themselves with different symptoms of mental and physical illnesses. In effect, minority patients tend to receive distinct psychiatric diagnosis. Unfortunately, the majority of psychometric tools are not adequately standardized for clinical and research use in different cultures.
Aims: These are results of an international study developed to test and validate in Brazil three instruments designed to evaluate personal health status (PHS), quality of life (MCQI) and bicultural issues (MEBS).
Methods: Instruments were translated to Portuguese taking into account semantic and cultural equivalence. Sample: 120 volunteers (90 patients and 30 health care professionals). RESULTS: All instruments yelled significant internal consistency. A significant difference (p < 0.001) was detected between the means of patients and health professionals. A ROC analysis established a cut-off score of 6 for the Portuguese version of PHS (PHS-Pt). MQLI-Pt was well accepted by patients and health professionals alike. A significant Pearson correlation was attained between the MQLI-Pt and the PHS-Pt. Significant results were obtained with the Portuguese version of MEBS as well.
Conclusion: The psychometric tools designed to evaluate health status, quality of life and biculturality can be adapted efficiently to different languages and cultures.
OP04 GENDER DIFFERENCES IN PSYCHIATRY
GENDER DIFFERENCE IN PSYCHIATRISTS; THE INTERNATIONAL PERSPECTIVE FROM YOUNG PSYCHIATRISTS
Naoki Hashimoto, Yayoi Koizumi, Ryoko Sato, Takahiro Kato, Kumi Uehara
There has been a steady increasing of the number of women choosing the practicing psychiatrists as a career and the role of the female psychiatrists becomes more and more important. Some study in the US and Canada indicated that there were many gender differences in the practice characteristics and career as a psychiatrists, and the clinical training as a psychiatrists but there are no former studies like these in East Asian countries, as far as we know.
This time, we had made the questionnaire survey about the awareness of the psychiatrists and the training of clinical psychiatry. Then we analyzed their results in relation to gender differences.
The survey about the awareness of the psychiatrists reveal that more male psychiatrists had the experience of the attendance of nationwide scientific meeting and writing the scientific paper as a first author. Male psychiatrists were more likely to be interested in psychopharmacology than female ones. When their patients did suicide, or when they wanted to throw up their job, female psychiatrists were more likely to talk with their boss or colleagues about their problem. The survey of clinical training revealed that male psychiatrists were more confident that they could make an appropriate order of MRI test or that of electroencephalography test, and they could realize the results of these tests correctly than female psychiatrists.
We continue the questionnaire survey now and in the symposium we will show the newest results and will argue more detail about such differences and its buck ground.
GENDER DIFFERENCE IN PSYCHIATRIC PRACTICE AMONG YOUNG PSYCHIATRISTS IN TAIWAN
Erin Chia-hsuan Wu, Hung-chun Lai, Yin-yei Chen, Chiao-chicy Chen
Objectives: The aim of this study was to explore the practice characteristics, activities, career plans and satisfaction of male and female young psychiatrists.
Methods: We delivered a questionnaire, which was designed by the Japanese Young Psychiatrist Organization, to the practicing psychiatrists in Taiwan. The data was analyzed coupling with the data gathering by qualitative-research approach, i.e. in-depth interview.
Results: There has been a steady increase in women choosing psychiatry as a medical specialty in Taiwan. As the results of our study, male and female psychiatrists had some differences in theoretical orientation and subspecialty practice. They made different ranking in the fields which they're interested and showed difference in considering the priority of activities. Though there was no significant difference in the satisfaction with career between male and female psychiatrists, different difficulties encountered during practice by both genders were described in our study.
Conclusions: Men and women practicing psychiatry in Taiwan showed a number of differences in taking significant other's opinion when career planning, reasons of academic engagements, time spending in private affairs, and help seeking pathway. The different difficulties encountered by female and male psychiatrist in their practice, which reflected the social expectation on different genders, were thought to be considerably influenced by culture effects
GENDER DIFFERENCES IN THE PSYCHIATRISTS; THE COMPARISON OF THE EASTERN AND WESTERN COUNTRIES
Kumi Uehara
Recently, women are becoming a notably greater part of the psychiatric workforce. The percentage of psychiatrists who are women rose sharply all over the world. Despite the increase of women choosing psychiatry as a medical career, there is few prior study exploring potential differences between male and female psychiatrists with respect to clinical practice characteristics, specialty trainings, academic activities including research or training, and satisfaction with career.
Some studies reported in western countries indicate there were several gender differences among these points, but few in eastern. Moreover there are no prior studies considered these differences from international perspectives.
First, we would like to introduce the prior studies concerning about gender differences in Psychiatry. Almost all of the prior studies were reported in western countries.
Second, in 2007 April in Korea” the WPA Regional Meeting”, and in 2007 May in Japan” the Congress of the Japanese Society of Psychiatry and Neurology”, we already had the international symposiums about the same topics in the eastern side. Symposists from India, Korea, Taiwan and Japan presented their situations of own countries. So we also would like to introduce these international discussions form eastern countries.
Through this presentation, we would like to compare the results of western countries with these of eastern, and reveal the common or different points though this work in the international points of view.
OP05 INDIGENOUS MENTAL HEALTH
TOUCH AND SEE AND HEAR (AND DANCE): INNOVATIVE MULTIMEDIA IN INDIGENOUS HEALTH
Ernest Hunter, Helen Travers, Lucinda Gamble, Pelham Steven, Gibson Julie
Indigenous health in Australia is poor by comparison to the mainstream and to that of Indigenous populations in other anglo-settler societies. It is compounded for remote Indigenous populations by higher levels of social disadvantage (including access to the educational and information technology means to engage with a globalised world) and the challenges of remote area service provision. This talk will describe an innovative use of information and multimedia technologies to provide health information to remote Indigenous communities through a means supporting democracy of access – audio-feedback touch-screen computers adapted for minimal literacy. By engaging communities in the conceptualisation and production of materials to address locally identified health priorities, and drawing on principles of ‘forum theatre’ and community development, the project has generated significant collateral outcomes relating to pride and a sense of agency. HITnet is a network of touch-screens located in Indigenous communities that currently contains modules on diabetes, substance use, child health, nutrition, sexual health and community activities. Current modules in production address self harm and mental health. In addressing the ‘digital divide’ this project also seeks to address the broader social and health divides experienced by Aboriginal and Torres Strait Islander Australians.
INDIGENOUS HEALTH, A SYSTEMIC APPROACH TO THE DEVELOPMENT AND IMPLEMENTATION OF KAUPAPA MAORI SERVICES WITHIN A MAINSTREAM SERVICE
Phyllis Tangitu
Background: Maori Mental Health development in New Zealand has been a progressive journey.
The first “kaupapa” (indigenous based) mental health services were established in New Zealand in the 1980s. These services provided an opportunity for indigenous philosophy, frameworks and models to work within and alongside western approaches.
Maori mental health services in New Zealand have advanced, and inpatient services, kaupapa services within mainstream settings and Non-Government Organisations (NGO) have flourished.
Aims: This presentation aims to provide an overview of New Zealand's journey in Maori mental health, highlight the developments across the continuum of mental health care; examine Maori philosophy, practice and delivery; more importantly how this approach has benefited Maori and contributed to overall Maori health development.
The presentation will be made using a mode of delivery components including power point presentation, the use of music, and an example of Maori models in practice.
MEDICO-CULTURAL CONSIDERATIONS IN TREATING PSYCHOTIC DISORDERS IN INDIGENOUS AUSTRALIAN POPULATIONS
Marshall Watson
Context: Indigenous Australians experience higher rates of mental illness than the wider Australian population. Indigenous Australians also have the unique experience of dispossession which contributes to the pathogenesis and prognosis of illnesses. In addition to the stress of being an Indigenous member of society, there is the further stress associated with having a mental illness. With disorders such as psychosis, treatment itself can have serious consequences; of particular concern is the use of atypical antipsychotics and hence possible metabolic syndrome in a population that already experiences significantly higher rates of cardiac disease, diabetes and lower life expectancy. The extension of the therapeutic paradigm to include culture is also important as the maintenance of culture can itself be healing. Maintaining cultural integrity through reconnection with family and country can facilitate cultural rehabilitation of the people enabling them to better function as community members and better cope with illness.
Objective: To outline and highlight important medical and cultural issues in addressing the treatment of psychotic disorders in Indigenous Australians.
Key messages: The multiple determinants of Indigenous health – physical, psychological, social and cultural – warrant due consideration in understanding and treating psychosis in Indigenous Australians. The importance of including an appropriate cultural history and utilising a team approach in management will be discussed.
Conclusion: Indigenous Australians are a high risk population in terms of mental illness and in dealing with disorders such as psychosis there are both medical and cultural considerations that need to be addressed in order to assist with prevention of complications and relapse prevention.
A GUBBAH PSYCHIATRIST REFLECTS ON WORKING IN ABORIGINAL MENTAL HEALTH
Neil Phillips
Context: The health and mental health of indigenous Australians is very poor compared to non-indigenous Australians and mental health issues lie at the heart of many physical health problems. Of necessity, non-Indigenous psychiatrists and other mental health professionals are involved in providing and improving mental health care for indigenous Australians and this can only be done through close and active involvement with indigenous mental health professionals and services. Although this work is often very rewarding, conventional approaches will prove troublesome and must be modified or discarded.
Objectives: This paper draws upon the author's 20 years of experience in Aboriginal mental health and from the literature to discuss how a psychiatrist can be welcome and useful in assisting with the mental health care of indigenous people. It is the objective of the paper to guide others who are entering the field or who occasionally provide care for Aboriginal and Torres Strait Islander Australians.
Key messages:
Good intentions are not sufficient
It is essential that psychiatrists working in the area respect indigenous culture and understand their own cultural and personal biases and habits
Discard the idea that non-indigenous psychiatrists have all the answers
The best work will be done when the clients of the service, the indigenous professionals and the psychiatrist are enjoying their contact and common humanity
Conclusion: There are joys and pitfalls for non-indigenous psychiatrists who work in indigenous contexts and it is worth learning how to do this work well.
A MULTI-LEVEL APPROACH TO INVOLVING MAORI IN AN INTERNET-BASED INTERVENTION FOR DEPRESSION
Dannette Marie, Shyamala Nada-Raja
Recovery via the Internet for Depression (RID) is a trans-Tasman, collaborative project involving a replication of a randomised controlled trial of an online version of cognitive behavioural therapy (CBT) for depression. Results from research undertaken in Australia and other nations indicate that the internet is an effective medium for the administering of CBT and depression literacy programmes for those at risk of developing depression. This Dunedin-based study has been designed to test the effectiveness of providing an internet-based intervention for depression and other related problems in the New Zealand context.
Recent evidence from New Zealand shows that Maori continue to be over-represented in national psychiatric indices. Maori experience higher rates of depression and depression related problems such as anxiety, self-harm, and suicide and are therefore identified as a high-risk New Zealand population group. Given the over-representation and heightened risk of Maori developing depression and depression related problems, Maori involvement in the RID project features as an integral component of this three-year study.
This paper provides an overview of a multi-level approach taken by the RID investigators to ensure that specific concerns of Maori are taken into consideration while at the same time ensuring that the research meets the best scientific standards of empirical research. Preliminary procedural methods used in RID are described within the context of obtaining evidence-based information about Maori involvement in an internet-based intervention for depression. The brief overview provided is a companion paper to another to be presented, which outlines the study in more detail.
DESIGN AND VALIDATION OF A CULTURAL MEASURE OF MENTAL HEALTH OUTCOME
Te Kani Kingi
Context: Instruments for measuring the outcomes of treatment and care can usefully assist clinical practice, service delivery and design, as well as resource allocation. The utility of any instrument however relies on its capacity to measure outcomes of significance and which ideally reflect both the needs of clinicians and the desires of patients. Added to this is the idea that “preferred” patient outcomes may be influenced by cultural factors and that generic measures of outcome might in fact miss outcomes of both clinical and cultural relevance.
Objectives: This presentation discusses the design and development of Hua Oranga (literally translating as the “fruits of well-being”) a Maori measure of mental health outcome. In particular, the presentation considers the validation of this instrument as well as the various challenges encountered when attempting to measure atypical concepts and preferences.
Key messages: While many measures of outcome are routinely used within clinical settings there is a need to consider what range of outcomes are measured and the extent to which cultural factors might influence ideal and preferred outcomes.
Conclusion: Although numerous challenges exist, it is possible to construct a measure of outcome which clinically relevant, technically valid, and culturally sound.
OP06 DEPRESSION
THE ASSOCIATION BETWEEN TYPE OF PHYSICAL ACTIVITY AND DSM-IV MOOD DISORDER IN YOUNG AUSTRALIAN ADULTS
Charlotte McKercher, Michael Schmidt, Kristy Sanderson, George Patton, Alison Venn
Background: Epidemiologic studies suggest that physical activity is associated with decreased prevalence of mood disorder. It is unclear, however, whether this association depends upon the type of physical activity performed.
Aims: To evaluate the cross-sectional association between type of physical activity (occupational, leisure time, active commuting, garden/household) and mood disorder in a national community sample.
Methods: Participants were 2,063 adults (aged 26–36 years) who attended clinics in the Childhood Determinants of Adult Health study. Outcome was 12-month DSM-IV diagnosis of mood disorder from the self-administered CIDI-Auto (version 2.1). Physical activity was measured via self-report using the long International Physical Activity Questionnaire. Categories of physical activity (hrs/wk) were defined by quintile cut-points. Prevalence ratios (PR) from log-binomial regressions were adjusted for age, smoking, income and BMI for females and age, smoking, marital status, occupation, education and physical health for males.
Results: For females, a significant negative association between leisure time physical activity and prevalence of mood disorder was observed [PR = 0.46, 95% CI (0.25–0.83) for highest versus lowest physical activity category]. In contrast, occupational physical activity was significantly and positively associated with mood disorder [PR = 2.07, 95% CI (1.30–3.28) for highest versus lowest physical activity category]. Significant associations were not observed for other activity types and no significant associations were observed in males.
Conclusion: These findings suggest that the types of physical activity participated in and the context in which they are performed are potential determinants of mental health outcomes in young women.
DEVELOPING EVIDENCE AROUND MINDFULNESS BASED COGNITIVE THERAPY
Graham Meadows, Frances Shawyer, Paul Martin, Fiona Judd, Leon Piterman, Carolyn Martin, Catharine McNab, Zindel Segal
Context: Mindfulness Based Cognitive Therapy (MBCT), an indicated preventive intervention for major depressive disorder (MDD) delivered through group instruction, combines meditative exercises with CBT techniques. Following two RCTs in Canada and the UK demonstrating efficacy, a multi-centre randomised controlled trial of MBCT versus Treatment As Usual (TAU) is exploring effectiveness, transportability and cost effectiveness in Victoria Australia (NHMRC grant 436897).
Objectives:
To review evidence for efficacy of MBCT and that for possible iatrogenic effects.
To present a proposed model for effects of MBCT that might help guide the developing research agenda.
To discuss methodological issues including efforts through experimental design to moderate the confounding influence of resentful demoralisation in TAU groups
To consider issues of international coordination in research on a novel psychotherapeutic technique.
To describe work on developing a multi site research network in Victoria supporting effectiveness and pragmatic studies.
Key messages:
MBCT is a promising intervention particularly for people who have had at least three episodes of MDD.
Effects of Combining medication and MBCT are of interest but empirical data is lacking.
Local, national and international cooperation regarding research on novel psychological treatments of studies can increase the pace with which the information base improves and with which issues of transportability and cost effectiveness are addressed.
Conclusion: Evidence regarding MBCT is rapidly accumulating and this work illustrates how local and international collaborations can improve design of studies and accelerate development of empirical evidence regarding novel treatments.
ROLE OF MUSIC THERAPY IN DEPRESSIVE DISORDERS
Ashish Rana, Kishan Chand Gurnani
Background: Music Therapy is the structured use of music experiences to facilitate positive changes in human behaviour but its effects for treating depressive disorders have not been explored.
Aims: To study the effect of Music therapy as an adjuvant on patients suffering from depressive disorder who have not responded to drug therapy.
Method: Patient with diagnosis of major depressive disorder not responding to antidepressants given for 8 weeks were randomly assigned to two groups. One group received individual sessions of Music therapy with same medication and other group was given either new group of antidepressants or drug adjuvant. Patients were assessed on HAM-D scale from baseline up to 12 weeks on regular intervals.
Results: Of 40 eligible patients randomized to two groups the average HAM-D scores decline was statistically significant in both groups but on comparing of decline between two groups, it comes out to be statistically significant only after 12 weeks of music therapy. However multivariate analysis and overall decline of HAM-D did not demonstrate better improvement among those randomized to music therapy but suffered less number of side effect profile. Qualitatively, music therapy was accepted positively by majority of patients.
Conclusion: It is a first randomized control trial of Music Therapy added to pharmacological treatment of depressive disorder and compared results showing that on persistent association with music therapy, patients were giving better response than only drug therapy. A multi-centric, large numbered and longer follow up study is required for further proof to support this study.
ATYPICAL SYMPTOMS IN HOSPITALISED PATIENTS WITH MAJOR DEPRESSIVE EPISODE: FREQUENCY, CLINICAL CHARACTERISTICS, AND INTERNAL VALIDITY
Florian Seemüller, Florian Wickelmeier, Michael Riedel, Hans-jürgen Möller, Verena Henkel
Objective: The objective was (1) to assess the frequency of atypical depression (AD) in depressed inpatients; (2) to compare relevant clinical features of patients with atypical and nonatypical depression (Non-AD); (3) to evaluate the meaning of single psychopathological symptoms with special respect to mood reactivity.
Method: Diagnoses of 1073 inpatients were assessed according to DSM-IV using SCID and AMDP (Association for Methodology and Documentation). Diagnosis of atypical depression was defined according to criteria of the DSM-IV specifier for AD. All patients were rated using HAMD-21.
Results: A high percentage of patients met criteria for AD (15.3%, 95% CI 13.0–17.9%). Women were more likely to suffer from AD (OR = 1.54, p = 0.037). There were no significant differences between AD and Non-AD patients regarding age, HAMD total baseline score, and diagnosis of any bipolar illness.
In terms of psychopathology patients with AD were significantly more likely to suffer from somatic anxiety, somatic symptoms, guilt, genital symptoms, depersonalisation and paranoid symptoms as defined by HAMD-21. Mood reactivity was not found to be significantly associated with the presence of two or more additional symptoms of AD.
Conclusion: (1) Frequency of AD may be underestimated, especially in inpatient samples. Further studies of inpatient samples are recommended. (2) Quality of distinct anxiety symptoms may be different in both groups, with AD patients being more likely to suffer from somatic symptoms and somatic anxiety. The presence of psychotic symptoms in depressed patients might not exclude a diagnosis of AD. (3) The mandatory presence of mood reactivity for diagnosis of AD diagnosis needs further consideration, concerning its validity for the concept.
AUSTRALIAN NEWSPAPER JOURNALISTS’ KNOWLEDGE AND BELIEFS ABOUT POSTNATAL DEPRESSION: DO THEY HAVE THE WRITE! IDEA?
Lara Bishop, Helen Christensen, Kathy Griffiths
Background: Research has consistently demonstrated that the media are a primary source of information about mental illness for the public and are influential in shaping people's perceptions about mental illness. However, there has been little investigation into the mental health literacy (MHL) of journalists.
Aim: To gauge the knowledge and beliefs (MHL) of Australian newspaper journalists about Postnatal Depression (PND), depression and schizophrenia, including their help seeking preferences, knowledge about causes and treatments, levels of discrimination and stigma, and the role of the media in Australia.
Methods: A MHL postal survey was sent to journalists in 2003/2004, who were randomly assigned to one of three groups to receive a survey with a vignette of “Mary” who was experiencing PND, depression or schizophrenia.
Results: Responses were received from 636 journalists. PND was correctly identified by 98% of journalists who received the PND vignette and 26% (men included), acknowledged that they had personally experienced PND. Multiple logistic regressions predicting helpfulness of professionals, medications, lifestyle modifications and sources of information demonstrated that the following were likely to be helpful for PND; chemists, social workers, reading about people with similar problems, undergoing electro-convulsive therapy, consulting a website, book or health educator, or emailing an expert. However, antidepressant medication, psychiatrists and increasing physical activity were significantly less likely to be endorsed for PND.
Conclusion: Interventions to increase MHL about PND should focus on decreasing negative perceptions about health professionals, particularly psychiatrists. There is also a need to promote evidence-based treatments such as antidepressant medication.
STUDY OF DEPRESSION IN WOMEN USING HORMONAL CONTRACEPTIVES IN INDIA
Asis Krshna Acharya
Objective: Oral contraceptive use may be associated with sub-clinical depressive syndromes was observed by Bancroft and Sartorius in 1990. In the Indian scenario women of the child bearing age who are diagnosed as suffering from depressive disorders, dysthymia, or mixed depressive anxiety disorder often unfolds a history of receiving oral contraceptives for last 6 months. Another striking fact is that some another group of women, revealed having had permanent sterilisation in the past.
Methods: A total 156 women were diagnosed as per DSM-4TR diag. criteria of major depressive disorder, dysthymic disorder and depressive disorder NOS. They were carefully screened for their history of contraceptive methods used. There were four types of response. Category1) permanent sterilisation, usually tubectomy. Cat-2) using oral contraceptives for period longer than 6 months. Cat-3) couples using coitus intereptus method. Cat-4)no contraception or even unware of contraceptive methods clearly.
Results: Cat-1, women shows predominately anxiety disorders or somatic symptoms without much organic basis.(5)cases of child death after permanent ligation was noted.3 of them were found to be suffering from major depressive disorder (MDD). Cat-2, those using oral pill (76) shows 32 MDD,31Disthymic disorder, and 13 others depressive disorderNOS (mixedanxiety-dep.4,post partum depression 7 and bipolar disorder, most recent episode depressive. Cat-3,shows highest no. of anxiety disorder both panic and genaralised, o.c.d., phobic anxiety disorder etc. In cat-4, depresiveD, bipolar depression, MDD, disthymia, and other anxiety mixed depression were noted mainly.
Conclusion: MDD-recurrent, disthymic disorder and mild depressive symptoms are noted much more in cat2 compared to all other groups. this may confirm a relation between long term use of oral pills, that leads to mood changes towards depression.
OP07 METABOLIC ISSUES AND PSYCHIATRY 1
PREVALENCE OF AND RISK FACTORS FOR DIABETES IN PEOPLE WITH SEVERE MENTAL ILLNESS
Alexander John, Radhakrishnan Koloth, Stephen Lim, Johny Augustine
Background: Research evidence suggests a prevalence of around 15% diabetes in schizophrenia. The focus in recent years on the role of atypical antipsychotics has led to neglect of evaluation of traditional risk factors in the genesis of diabetes in schizophrenia. Evaluation of diabetes in other forms of severe mental illness has received scant attention.
Aims: To study the prevalence of diabetes and various risk factors for its development in Australians suffering from severe mental illness.
Method: We assessed systematically sociodemographics, psychiatric illness and treatment related variables and medical history of 208 randomly selected adult patients with severe mental illness. Fasting blood sugar and lipids were estimated. Statistical anaysis was performed using SPSS.
Results: Prevalence of diabetes was 10.1% in our sample. Analyis revealed that increasing age, abnormal waist circumference, low HDL Cholesterol, raised triglyceride level, total duration of illness, lack of exercise and unhealthy diet had significant association with diabetes. Prevalence of diabetes was similar among the various psychiatric groups and use of atypicals didn't confer additional risk. Logistic regression analysis revealed that age, waist circumference, low HDL, high triglyceride level, and duration of illness predicted diabetes status.
Conclusion: The prevalence of diabetes in our sample is higher than general population prevalence of diabetes in Australia. Diabetes appears to be common among people with severe mental illness and not unique to schizophrenia. Traditional risk factors, rather than use of atypicals, could explain most of the risk associated with development of diabetes in severe mental illness.
CITALOPROM AND FLUCXETINE FOR DEPRESSION IN DIABETES; A RANDOMIZED CONTROLLED TRIAL
Habibollah Khazaie, Mehrali Rahimi, Mansor Rezaei, Alireza Ahmadi
Objective: Depression is prevalent in patients: with diabetes. It is associated with poor glycemic control and is linked to an increased risk for diabetic complications. In this study, we assessed efficacy of fluoxetine and citaloprom for depression in patients with diabetes.
Research design and method: In this double blind study, 40 patients with diabetes (type II) and major depressive disorder were randomly assigned to two groups of 20 patients. The first group received daily doses of fluoxetione (up to 40 mg/day) and second group were given daily doses of citalopram (up to 40 mg/day). The Beck Depression Inventory (BDI) and psychiatric interview were used to measure the severity of depression and to determine the percentage of patients who achieved substantial improvement or complete remission. Hb A1c levels and FBS were obtained to monitor glycemic control.
Results: Reduction in depression symptoms was significant in both groups.
(Citalopram groups: BDI 11.84 in 8th week versus 25.26 in baseline p < 0.001, and fluoxetine group BDI 26.2 in 8th week versus 12.2 in baseline, P < 0.001). Additionally, trends toward reduction in Hb A1c were observed in both groups, (Citalopran groups: HbA1c 6.65 in 8th week versus 8.24 in baseline, p<.001 fluoxetine groups HbA1c 5.75 in the 8th week versus 7.67 in baseline; p<.001).
Conclusions: Fluoxetine and citaloprom effectively reduces the severity of depression in diabetic patients. Our study demonstrated that after only 8 weeks, this treatment also produced a trend toward better glycemic control.
NUTRITION AND EXERCISE BEHAVIOR AMONG PATIENTS WITH BIPOLAR DISORDER
Edward Post, Amy Kilbourne, Dana Rofey, John McCarthy, Deborah Welsh, Frederic Blow
Background: There have been few studies of nutrition and exercise behaviors among patients with bipolar disorder.
Aims: Based on national sampling of patients receiving care in the Veterans Affairs (VA) system, we compared nutrition and exercise behaviors among individuals diagnosed with bipolar disorder, schizophrenia, and those without diagnoses of serious mental illness (SMI).
Methods: We conducted a cross-sectional study of patients who completed the VA's Large Health Survey of Veteran Enrollees section on health and nutrition in Fiscal Year 1999 and who either received a diagnosis of bipolar disorder (N = 2,032) or schizophrenia (N = 1,895), or were included in a random sample of non-SMI VA patients (N = 3,065). We compared nutrition and exercise behaviors using multivariable logistic regression, controlling for socio-economic and clinical factors, and adjusting for patients clustered by site using generalized estimating equations.
Results: Patients with bipolar disorder were more likely to report poor exercise habits, including infrequent walking (OR = 1.33; p<.001) or strength exercises (OR = 1.28; p<.001) than those with no SMI. They were also more likely to self-report suboptimal eating behaviors, including having fewer than 2 daily meals (OR = 1.32; p<.001) and having difficulty obtaining or cooking food (OR = 1.48; p<.001). Patients with bipolar disorder were also more likely to report having gained >10 pounds in the past 6 months (OR = 1.59; p<.001); and were the least likely to report that their provider discussed their eating habits (OR = 0.84; p<.05) or physical activity (OR = 0.81; p<.01).
Conclusion: Greater efforts are needed to reduce the risk of poor nutrition and exercise habits among patients with bipolar disorder.
OBESITY AND MENTAL DISORDERS IN THE GENERAL POPULATION
Kate Scott, Magnus McGee, Elisabeth Wells, Mark Oakley Browne
Background: Prior investigations into whether there is a relationship between obesity and mental disorders in the general population have produced contradictory findings and have typically focused on major depressive disorder.
Aims: To investigate: (i) the associations between mental disorders (in particular the anxiety disorders) and obesity in the general population; (ii) potential moderators of those associations (ethnicity, age, sex and education).
Methods: A nationally representative face-to-face household survey (Te Rau Hinengaro: The New Zealand Mental Health Survey) was conducted with 12,992 participants 16 years and over, achieving a response rate of 73.3%. Maori and Pacific peoples were over-sampled. Mental disorders were measured with the Composite International Diagnostic Interview (CIDI 3.0). Height and weight were self-reported. Obesity was defined as a body mass index (BMI) of 30 kg/m2 or greater.
Results: Obesity was significantly associated with any mood disorder (OR 1.23), major depressive disorder (OR 1.27), any anxiety disorder (OR 1.46), and most strongly with some individual anxiety disorders such as post-traumatic stress disorder (PTSD) (OR 2.64). Adjustment for the comorbidity between anxiety and mood disorders made little difference to the relationship between obesity and anxiety disorders (OR 1.36), but rendered the association between obesity and mood disorders insignificant (OR 1.05).
Conclusion: Stronger associations were observed between anxiety disorders and obesity than between mood disorders and obesity. The association between PTSD and obesity is a novel finding but comprehensible in light of other research on the role of anxiety and eating pathology.
OP08 REPRODUCTIVE AND RENAL MEDICINE
IMPLICATIONS OF PREGNANCY, PERSONALITY AND CULTURAL FACTORS FOR CHINESE WOMEN'S GRIEF REACTION TO REPRODUCTIVE LOSS
Elsie Yan, Catherine Tang
Background: Reproductive loss refers to the termination of pregnancy due to miscarriage, elective abortion, stillbirth, or neonatal death. Being a major life event affecting women, their partners, and other family members, it has been estimated that as many as one-third of the pregnant women experience reproductive loss.
Aims: The present study examined the implications of pregnancy, personality, and cultural factors for women's grief reaction to recent reproductive loss.
Method: A total of 255 Hong Kong Chinese women who suffered various forms of reproductive loss were individually interviewed on their pregnancy characteristics, antenatal emotional attachment to the indexed fetus, negative affectivity, gender role internalization, and grief reaction to the loss.
Results: Hierarchical multiple regression analysis was conducted to understand the relations between pregnancy, personality and cultural factors and women's grief symptoms. The model accounted for 48% of the variance with antenatal emotional attachment, negative affectivity, and gender role internalization predictive of women's grief symptoms even after controlling for their age and number of surviving children.
Conclusion: The present study found that women who experienced a strong sense of antenatal emotional attachment, who had high level of negative affectivity, and internalized gender roles to a large extent report more intense grief symptoms. Limitations and implications of this study will be discussed.
MEDITATION AS A PSYCHOBEHAVIOURALL MANAGEMENT TOOL FOR MENOPAUSAL SYMPTOMS, ATTENTION DEFICIT HYPERACTIVITY DISORDER AND ASTHMA
Ramesh Manocha
We designed a series of studies to assess the effects of meditation as a stress reduction strategy for a variety of different health problems. Each of progressively higher methodological rigour.
Menopausal symptoms: Fourteen subjects experiencing menopausal symptoms, who were not on any other treatments were enrolled into a twice weekly, 8 week meditation programme. Significant improvements in all measures (behavioural, quality of life and symptoms) occurred at post treatment. Changes in vasomotor symptoms, especially hot flushes, were most prominent:. A significant decrease in mean hot flush frequency of 67%(p<.05) at post-treatment and 57% (p<.05) at follow-up. Kupperman's Index score decreased by 58%(p<.05) at post-treatment and 40% (p<.05) at follow-up.
Attention deficit hyperactivity disorder
in children: Forty-eight children with formal diagnosis of ADHD were enrolled into a twice weekly, 6 week meditation programme. Children receiving treatment were compared to children who were awaiting entry into the programme. Children experienced an average 35% reduction on symptom severity (p<.005), as measured by Connors, compared to the quasi-control group (waiting list).
Asthma: Fifty-eight adults with moderate to severe asthma were randomly assigned to either meditation or stress management. Measures included AQLQ, Lung Function, Airway Hyperresponsiveness (AHR), Symptom Diary and POMS. Significant improvements occurred in AHR, POMS and mood scale of AQLQ.
The Sahaja Yoga meditation technique utilises a “mental silence” orientated understanding of meditation, which differs from the consensus western definition of meditation as a method of reducing stress. Perhaps because of this, our studies clearly show it to be associated with a specific effect.
CAN SEXUAL RISK TAKING RESULT IN MENTAL HEALTH PROBLEMS?
Sandhya Ramrakha, Charlotte Paul, Nigel Dickson, Melanie L. Bell, Terrie E. Moffitt, Avshalom Caspi
Background: Cross-sectional associations exist between sexual risk taking and mental health problems. Few studies have examined the mental health consequences of sexual risk taking using a prospective design.
Aims: To examine associations between (1) early sex (before age 16 years) and anxiety, depression, conduct and substance dependence disorders at 18 years, (2) multiple sex partners between ages 18 to 20 and 21 to 25 years, and anxiety, depression and substance dependence disorders at 21 and 26 years respectively and (3) acquisition of a sexually transmitted infection between 21 and 26 years and anxiety, depression and substance dependence disorders at 26 years.
Methods: Associations were estimated by logistic regression analyses using data from the Dunedin Multidisplinary Health and Development Study, a prospective cohort from birth to adulthood. Adjustment was made for prior psychiatric disorder.
Results: No significant associations were found between sexual risk taking and anxiety or depression. Early sex was associated with later conduct and substance dependence. Sex with multiple partners was associated with later substance dependence, an association stronger in females than males. Acquisition of a sexually transmitted infection was also associated with later substance dependence.
Conclusion: The observed prospective association between sexual risk taking and later substance dependence was independent of prior psychiatric disorder. Psychosocial factors that might explain this relation include general risk taking tendencies, shared context and motivation to use substances to reduce cognitive dissonance around sexual risk taking.
NON-DIRECTED DONOR ASSESSMENT IN KIDNEY TRANSPLANTATION
James Hundertmark, Toby Coates, Graeme Russ, Stephen McDonald
Background: The Queen Elizabeth Hospital (TQEH), South Australia provided Australia's first non-directed kidney donor program. Psychiatric assessment of future organ recipients has been part of transplantation since the early in the course of the transplantation process. In the last decade the process of non-directed kidney donation has become used. By contrast with cadaver or live directed donation, the newer method involves a healthy donor giving an organ to an existing transplant program with no knowledge of the organ's eventual recipient.
Aims: There is relatively little published material regarding the process of the psychiatric evaluation of prospective non-directed donors. The paper aims to explore the process of non-directed donor psychiatric assessment.
Methods: Three relevant de-identified cases will be presented. Several other programs will be compared with TQEH's service.
Results: Significant factors in seeking to donate were identified including seeking atonement through donating, defending against terminal illness and the exploration of marked personal altruism.
Conclusions: Non-directed kidney donation is a relatively novel process which still requires further analysis from a psychosocial perspective. Psychiatric assessment is a vital aspect of the work up for non-directed kidney donation.
THE PSYCHIATRIST'S ROLE IN ASSESSING LIVE DONORS FOR RENAL TRANSPLANTATION - THE QUEENSLAND EXPERIENCE
Paul Pun
Context: This presentation describes the experience of a consultation-liaison psychiatrist in providing screening and assessment services for live kidney organ donors for transplantation. The Princess Alexandra Hospital is the only centre in Queensland that performs renal transplants, resulting in the building up of specialist skills and expertise in this complex area.
Key messages: Similarly, it is argued that the psychological screening of potential kidney donors is a sub-specialist skill, requiring an understanding of the medical and surgical complexities of the enterprise, a psychodynamic understanding of motivation and relationships, and an ethical appreciation of donor autonomy versus freedom from coercion.
Conclusion: A liaison psychiatrist is ideally placed to bridge these important domains. Examples will be presented of how a psychiatric perspective can shed light on “Good Samaritan” donations, the complexities of familial coercion to donate, as well as the psychological health of donors prior to and following transplantation.
OP09 DEVELOPING AND IMPLEMENTING SERVICE
IMPLEMENTING A TRANSITIONAL DISCHARGE MODEL: KNOWLEDGE TRANSLATION ISSUES
Cheryl Forchuk, William Reynolds, Elsabeth Jensen, Mary-Lou Martin, Siobhan Sharkey, Susan Ouesley, Patricia Sealy, Georgiana Beal, Evelyn Vingilis
The transitional discharge model (TDM) facilitates effective psychiatric hospital discharge for individuals with a mental health problem from hospital to community. The model is based on provision of therapeutic relationships from inpatient staff and peer supporters, to ensure a safety net throughout discharge and community reintegration processes.
TDM was developed through the Bridge to Discharge project (Forchuk, Chan et al., 1998). 38 long-term stay clients were successfully “bridged” from hospital, saving $500,000 (CAN). Forchuk, Martin, Chan & Jensen (2005) further tested the model in a RCT design using 26 tertiary care psychiatric wards. In year 1, they found length of stay on intervention wards decreased by 116 days per person saving over $12 million (CAN).
Despite the positive client/systems outcomes, TDM has not been easy to implement. TDM requires many changes in traditional, relational and policy practices. This study examined the barriers and facilitators to implementing a best practice related to transitional discharge care in psychiatric settings.
The study used a delayed implementation design with 40 psychiatric hospital wards. This occurred in three waves; each wave of wards implementing TDM and completing staff focus groups identifying barriers and strategies to implementation. Strategies were refined for each subsequent wave of implementation. Ward level data was collected through client interviews at discharge and one-month post-discharge to determine degree of implementation on all wards.
Barriers identified by staff include; workload/educational demands, interpersonal team conflicts, role clarity, changes in resource persons. Strategies include; on-site champions, ongoing administrative support, education strategies, person-specific implementation, intervention vale.
IMPLEMENTING MODELS OF CARE AND ACHIEVING FIDELITY IN THE REAL WORLD
Bridget Hamilton, Tom Trauer
Context: In the public mental health sector, several models of care show evidence of effectiveness, at a social level for consumers and at an economic level for the organisation. Through successive refinements, these models now include measures of fidelity, so that services may assess how they measure up. But there are diverse obstacles to any service robustly implementing a defined model of care.
Objectives: This paper explores challenges to sound implementation, by addressing two questions:
what does implementation of change to an existing service model really look like?
how does a service muster evidence for fidelity with the new model?
Key message: This paper tracks the implementation of the Strengths model of case management in a local Australian mental health service, as a case example of the process of service change and evaluation. We tease out obstacles and challenges to demonstrating fidelity to the model in everyday practice. These include: the conflict between the service mandate and the non-negotiable aspects of the model; the pitfalls of incrementally implementing change in an existing service; the complex requirements of research ethics in public mental health care; and the problems of attempting to use for research purposes, data systems that are designed for internal quality monitoring.
Conclusion: We offer strategies to improve the prospects of achieving fidelity. These include: investing heavily in targeted training for clinical staff and key managers, collaborating with other services using the same model and attracting external research skills to strengthen the program of evaluation.
COMPARISON OF ASSERTIVE COMMUNITY TREATMENT PROGRAMS IN INNER URBAN REGIONS IN AUSTRALIA AND THE USA
Dan Siskind, Elizabeth Wiley-Exley, Frances Dark
Background: Assertive Community Treatment (ACT) is a service delivery model designed to provide an integrated approach to care for the severally mentally ill. Strict guidelines on service provision have been developed, and fidelity scales created to determine how closely ACT programs align with these guidelines. Despite this standardization, ACT teams often have to adapt as available resources and the communities they serve may differ greatly.
Aims: We compared two ACT teams in inner urban regions of Australia and the USA, looking at patient and team characteristics and regional demographics. With a better understanding of these individual and programmatic characteristics in different global regions, we can gain a greater understanding of the adaptability of the ACT model.
Methods: We analysed and compared data on: 1. Patient characteristics-diagnosis, ethnicity, education, hospital days, medication use, comorbities and social functioning; 2. Demographics of the two regions – catchment population, employment rates, homelessness, involvement in criminal justice system, ethnic mix, average income, and age and; 3. Team characteristics – patient load, staff turnover rate, psychiatrist hours, number of weekly contacts and patient turnover.
Results: The ACT teams surveyed had both adapted to serve their patient populations. Although both meeting fidelity criteria, they differed in aspects of patient and team characteristics, reflecting the underlying demographics of the regions, and affiliations to the mental health systems in Australia and the USA.
Conclusions: The ACT model is now used globally, and has adapted to suit the environments in which it operates.
KNOWLEDGE TRANSLATION STRATEGIES USING THE “THINKING ABOUT EPILEPSY” PROGRAM AS A CASE STUDY
Alexandra Martiniuk, Canadian Epilepsy Alliance
Context: Knowledge translation is essential because it is known that research findings are often ignored. For example, according to one study examining this issue, of 70,000 research projects on education only 70 had any influence on education policy and practice.
Objectives: This presentation will outline the role of partnerships and strategies for translating knowledge into action. To do so, an example of knowledge translation from the published “Thinking about Epilepsy” education program will be used. This will include a discussion of iterative frameworks for knowledge translation as well as a list of practical activities to assist in the movement of knowledge to action. Using the “Thinking about Epilepsy” program context this will include a discussion of partnerships and/or opportunities with the University of Western Ontario, Ontario School Boards, Canadian Epilepsy Alliance, International League Against Epilepsy and International Bureau of Epilepsy. University-community research partnerships, and other partnerships, may both help and hinder the research to action aim. A discussion of “helping” and “hindering” factors, timing, audience and techniques for knowledge translation will be discussed.
Key messages: Evidence, implementation, policy development, community linkages, epilepsy, stigma
Conclusion: Research informed policies should be seen as secondary outputs from research; distinguished from the primary outputs of research projects such as the publication of results in journals and presentations at conferences, but albeit just as important and deserving of at least equal time and effort. A better understanding of the steps involved in doing so may assist researchers in taking these important steps with research findings.
OUTCOMES OF A SERVICE DELIVERY MODEL OF PSYCHOSOCIAL TREATMENT FOR PEOPLE WITH MENTAL ILLNESS, A CONTROLLED TRIAL
Monica Gilbert, Carolynne Holdsworth
Context: There is strong evidence to support the importance of adjunctive psychosocial therapies to improve outcomes for people with mental illness.
Objectives: This study looks at improving the capacity to deliver psychosocial therapies to people with mental illness utilising a service delivery approach.
Key messages: The model, Collaborative Therapy (CT), incorporates consumers, clinicians and services to work systematically towards the achievement of optimal health outcomes. It utilises a manualised psychosocial intervention focussing on education and skills development designed to be delivered within current case management models and service delivery pathways. CT includes comprehensive assessment, evidence based intervention and relapse prevention algorithms that enable a more proactive approach to the provision of mental health services.
Conclusion: The Collaborative Therapy Unit has evaluated the effectiveness of this service delivery model for people with mental illness that provides effective and sustainable psychosocial treatments in clinical practice.
A controlled study was undertaken in the Australian Capital Territory during 2003–2005. Outcome measures already used within the services (HONOS and LSP) were used to evaluate the effectiveness of Collaborative Therapy for individuals (12 months pre-CT vs 12-months post-CT) and services (Intervention vs control).
Results indicate clients who were engaged in CT have clear improvement in symptoms measured by HONOS scores (p-value of <0.0005) and improvement on the LSP.
CT demonstrates that service delivery models, incorporating a structured psychosocial intervention as part of routine treatment, have better outcomes in symptoms and function compared to standard service delivery in mental health settings.
LEARNING WORKING TOGETHER: AN INDIVIDUAL TRAINING AND A SERVICE LEVEL INTERVENTION
Torleif Ruud, Tore Sørlie, Ole-Bjørn Kolbjørnsrud, Karin Blix Flage
Context: A national model for two years local training programs for mental health workers from community mental health centers and primary care in the same geographic area has been developed and run in Norway by SEPREP since 1999.
Objectives: The goals are to improve knowledge and understanding of psychoses, clinical skills, abilities to build and maintain relations with patients, and collaboration between services. The training consists of lectures, supervision in small groups on their own clinical work, and discussion of theory in small groups to integrate theory and practice. Mental health workers from community mental health centres and primary care in the same geographic area are trained together in order to improve their working together. User organizations are involved in the training programs both on a national and local level.
Key messages: The training programs are a unique combination of individual training and service level intervention on working together across levels of care. Since 1999 a large portion of mental workers have been trained in more than half of the community mental health centers' catchment areas in Norway. A prospective evaluation has shown significant improvements in self-perceived competence in most the goals for the individual training, and an external evaluation has shown the program to be successful for the individuals and as a service level intervention.
Conclusion: The model with local on site training programs across service levels is a model that would be useful also in other countries.
OP10 A DOUBLE BLIND, PLACEBO-CONTROLLED RANDOMIZED TRIAL OF LOW-DOSE RISPERIDONE, COGNITIVE-BEHAVIOUR THERAPY, AND SUPPORTIVE THERAPY IN YOUNG PEOPLE WITH SUBTHRESHOLD SYMPTOMS AT INCIPIENT RISK OF PSYCHOTIC DISORDER: SIX MONTH OUTCOME DATA
Patrick McGorry, Lisa Philips, Barnaby Nelson, Shona Francey, Steven Leicester, Hok Pan Yuen, Magenta Simmons, Kathryn Baker, Annette Thampi, Alison Yung
Background: Intervention during the prodromal phase of psychotic disorders is aimed at delaying or preventing the onset of psychosis in already symptomatic high risk patients. The PACE Clinic at ORYGEN Youth Health has conducted a second randomized controlled trial under double blind conditions comparing the effectiveness of low-dose risperidone (0.5–2.0 mg/day) and intensive CBT-based psychological treatment versus placebo and intensive CBT-based psychological treatment versus placebo and a control psychological treatment (supportive therapy). The trial consisted of a 12-month treatment phase, followed by a 12-month follow up phase.
Aims: The primary outcome was the proportion of patients meeting onset of psychosis criteria during the treatment and follow up phases. Secondary outcomes included improvement on dimensional measures of symptoms, distress, functioning and quality of life.
Method: 116 participants (mean age = 18.13 years, male = 40%) meeting ultra-high risk (UHR) criteria were randomized to the three treatment groups. A further 46 participants were not randomized but consented to research monitoring.
Results: At the six month follow up point, 93 (80%) participants remained in the trial, 66 (71%) of whom remained adherent to trial medication. Eight participants had made the transition to first episode psychosis. There were no differences in rate of transition to psychosis or on other outcome measures between the randomized groups or between the randomized and monitoring groups. All groups improved on symptom and functioning measures.
Conclusion: The lack of difference in outcome between the treatment groups indicates that benign treatments may be sufficient as a first step in the UHR population. Twelve-month outcome data is currently being analysed and will be reported in future publications.
CLINICAL CHARACTERISTICS OF YOUNG PEOPLE AT ‘ULTRA HIGH RISK’ OF DEVELOPING PSYCHOSIS WHO PROGRESS TO PSYCHOTIC DISORDER: TRANSITIONED CASES FROM THE PACE CLINIC
Magenta Simmons, Barnaby Nelson, Alison Yung
Background: Over the past fifteen years, significant advancements have been made in the areas of early intervention and prevention of schizophrenia and other psychotic disorders. In the mid-1990s, valid and reliable criteria were developed to identify those considered to be at ‘ultra high risk’ (UHR) of developing a first episode of psychosis (FEP). Since then, research has mainly focused on UHR intervention strategies. However, it is important to continue research into characteristics of UHR clients who develop a psychotic disorder, in terms of diagnosis, comorbidity and time to transition.
Aims:
To report on diagnoses and comorbidity in UHR clients who transition to FEP.
To report the mean time between referral to PACE and transition to FEP, and to compare this with previous UHR cohorts.
Method: A clinical file audit was conducted for UHR clients seen at the PACE Clinic who transitioned to FEP from July 2000 to June 2006.
Results: The highest represented psychotic diagnosis was schizophrenia (52.2%), followed by psychosis NOS (32.6%) and then mood disorders with psychotic features (15.2%) (BPAD 8.7%, MDD with PF 6.5%). Of secondary diagnoses, mood disorders were the highest represented (48.9%), followed by anxiety disorders (31.9%), and substance use disorders (10.6%) (8.5% had no secondary diagnosis). Mean time to transition was 237 days.
Conclusion: This study is the largest known analysis to date reporting on the clinical characteristics of UHR transition cases. Most transitioned cases developed schizophrenia. Time to transition was similar to previous UHR cohorts. UHR criteria continue to predict onset of schizophrenia within 1 year.
NEUROPROTECTIVE EFFECTS OF LOW DOSE LITHIUM IN INDIVIDUALS AT ULTRA-HIGH RISK FOR PSYCHOSIS. A LONGITUDINAL MRI/MRS STUDY
Gregor Berger, Stephen Wood, Margaret Dell'Olio, Clare Hamer, Lisa Phillips, Barnaby Nelson, Graeme Jackson, Christos Pantelis, Husseini Manji, Patrick McGorry
Background: Preclinical and clinical data suggest that lithium is neuroprotective, probably already at subtherapeutic doses. Longitudinal imaging studies in emerging psychosis provide evidence that structural brain changes occur during the peri-onset phase of psychotic disorders.
Aims: The objective of this pilot study was to investigate if the neuroprotective properties of low dose lithium may counteract microstructural and metabolic brain changes proposed to occur in individuals at ultra-high risk (UHR) for psychosis.
Methods: Hippocampal T2 relaxation time (HRT) and proton magnetic resonance spectroscopy (1H-MRS) was performed prior to initiation and after three months of treatment in 11 UHR patients receiving low-dose lithium and 10 matched UHR patients receiving supportive counselling only. HRT and 1H-MRS percentage change scores were related to clinical outcome.
Results: HRT differentiated low-dose lithium treated patients from patients receiving supportive counselling only (p = 0.018). No significant group × time effects were seen for any brain metabolites as measured with 1H-MRS, although N-acetyl aspartate (NAA), myo-inositol, creatine and choline all increased with lithium administration and decreased or remain unchanged in subjects receiving supportive counseling only, without reaching level of significance. Microstructural and metabolic hippocampal percentage changes scores correlated with symptomatic improvement.
Conclusion: The HRT and metabolic brain changes in the low dose lithium treated UHR group suggests that low dose lithium may have neuroprotective properties in subjects with an emerging mental illness and may have the potential to delay, or in some cases even prevent the progression to a full-blown psychotic disorder. Larger controlled clinical trials using neuroprotective agents such as low dose lithium in UHR populations seem justified.
RCT OF OMEGA 3 FATTY ACIDS IN ADOLESCENTS AT ULTRA-HIGH-RISK FOR PSYCHOSIS
G Paul Amminger, Miriam R Schäfer, Kostas Papageorgiou, Susy Harrigan, Gregor E. Berger, Patrick McGorry
Evidence that fatty acid deficiencies or imbalances may contribute to neurodevelopmental disorders warrants investigation on the therapeutic efficacy of omega-3 fatty acids in prodromal schizophrenia and other psychoses.
We conducted a randomized, double-blind, placebo-controlled trial testing the effects of 1.5 g/day omega-3 fatty acids (0.84 g/day eicosapentaenoic acid, EPA; 0.7 g/day docosahexaenoic acid, DHA) administered as a supplement in 81 adolescents (mean age = 16.4, SD = 2.1) with subthreshold symptoms at incipient risk for progression to a first-episode psychosis. This “at-risk-mental-state” was classified by the criteria of Yung et al (2005). Psychiatric measures included PANSS, MADRS, and GAF. Supplementation was administered for 12 weeks. Transition to psychosis was operationally defined, based on Yung et al.'s criteria, using cut-off points on PANSS subscales, (4 or more on hallucinations, 4 or more on delusions, and 5 or more on conceptual disorganization), and the frequency of symptoms (at least several times a week) and their duration (more than one week). Chi-square test and t-test were used for group comparisons. Statistical tests were two-tailed. P values of 0.05 or less were considered significant.
At 12-month follow up 2 (4.9%) of 41 individuals in the EPA/DHA group and 11 (27.5%) of 40 in the placebo group met exit criteria for psychotic disorder. A Chi-square exact test indicated a significant group difference (exact p = 0.006).
The positive findings of this first RCT indicate a potentially important role for omega-3 fatty acids as treatment in subthreshold states. The findings, however, need replication and warrant longer term observation.
CANNABIS USE AS A COMPLICATION IN PSYCHOLOGICAL TREATMENTS FOR PEOPLE AT ULTRA-HIGH RISK OF PSYCHOSIS: EARLY FINDINGS FROM THE DEPTH TRIAL
Mike Startup, Vaughan Carr, Amanda Baker, Ulrich Schall, Helen Stain, Sean Halpin, Sandra Bucci
Context: Now that it is possible to identify young people who are at ultra-high risk of developing a psychotic disorder within a year, the development of effective treatments to prevent such outcomes has become urgent. Controlled trials to date suggest that cognitive behaviour therapy (CBT) may be as effective as medication but more trials with better methodology are needed.
Objectives: The DEPTh project is a randomised controlled trial comparing the effectiveness of CBT and person-centred therapy for the prevention of psychosis. It is being conducted on two sites in New South Wales: the Hunter Valley and the Greater Western Area. The CBT is modelled on a manual developed in the UK. That form of CBT has been shown in one trial to be effective in preventing transition to psychosis but it does not include any techniques that specifically focus on the reduction of substance abuse even though such abuse, especially of cannabis, is known to be common among people who are ultra-high risk, and cannabis use has been found in prospective studies to be associated with the later onset of psychosis.
Key messages: We have adapted French and Morrison's CBT by integrating it with a manual for motivational interviewing (MI) with young cannabis users. The therapist's task with MI is to create a set of conditions that will enhance the client's own motivation and commitment for change.
Conclusion: The ways in which CBT and MI are integrated in the DEPTh project will be illustrated with case material.
OP11 SERVICES, CARERS AND COMMUNITY
SOCIAL CAPITAL AND ADOLESCENT MENTAL HEALTH: THE ROLE OF FAMILY, SCHOOL AND NEIGHBORHOOD
Jayme Day, Ming Wen
Mental health during adolescence is a salient predictor of quality of life in adulthood. Social capital has been proposed to be a positive social resource promoting mental health in adolescence. However, little work has been done to simultaneously evaluate various aspects of social capital spanning multiple social domains of adolescents. This study examines the relative effects of social capital at the family-, school- and neighborhood-level on adolescent mental well-being and internalizing problems while also evaluating the potential differential effects of social capital for immigrant status. Using the 2003 California Health Interview Survey, we found that family social capital, specifically parental presence, adolescent perceptions of parental knowledge of their whereabouts, and perceived caring for the adolescent's welfare independently exerted significant and positive influences on adolescent mental health net of the effects of school- and neighborhood-level social capital. Social capital within the school was not significant for adolescent mental health. Several neighborhood-level measures for social capital are included and perceived informal social control and social cohesion among neighbors were found to be inversely related to adolescent internalizing problems, while only informal social control was positively related to adolescent mental well-being. This study found that both family and neighborhood-level social capital were important positive indicators for adolescent mental well-being, demonstrating the importance of evaluating multiple social domains for adolescent development. Interaction effects of family immigrant status were tested and are found to have significant differences for the influence of family, school, and neighborhood social capital on adolescent mental health.
SETTING UP A CHILD PSYCHOTHERAPY SERVICE TO MEET COMMUNITY NEEDS
Erica Echstein, Colleen Lovell
This paper describes the early experience of setting up and operating a child psychotherapy service in the regional city of Ballarat, Australia. The service is a recent addition to Pomegranate House, a community psychology service established to address the mental health needs of disadvantaged families and individuals. The primary objective of the child focussed service has been to fill an identified gap in existing services, with primary emphasis on provision of psychoanalytically-informed psychotherapy for children between 5 and 12 years who have experienced neglect, abuse, and trauma. Working with local Paediatricians and staff within the Family Support Innovations Project (a community program set up to minimise use of child protection services), clinicians have sought a range of ways to build effective working relationships with referrers and community agencies. Some of the early challenges of setting up the service have included developing the service model, working cooperatively with referrers and the community, and effectively evaluating psychotherapy process and outcome. Learning to date has included a growing awareness that working collaboratively necessitates facilitation of multi-directional communication and feedback flows within the organisational network. Developing a deeper understanding of the respective desires, anxieties, challenges, and disappointments of referrers, the children, and their families/caregivers has also been important. Regular clinical supervision, peer review, and varied evaluative processes have represented the main means of working through intra-organisational, inter-organisational, and therapeutic material. Creating an environment where there is openness to learning from experience is perceived as pivotal to the continuing development of the child psychotherapy service.
CARING FOR THE FUTURE. IMPLEMENTING A PREVENTIVE PROGRAMME FOR THE CHILDREN OF PARENTS WITH A PSYCHIATRIC DISORDER IN THE NETHERLANDS
Leo Vanmolkot
Context: The RIAGG Midden Limburg (RML), a community mental healthcare centre situated in the south of the Netherlands, participates in a nationwide drive to implement a prevention programme aimed at the children of parents with a psychiatric disorder (KOPP). This programme was initiated through the national Trimbos Institute, which is dedicated to developing and applying knowledge to the policy and practice of mental health care, addiction care and social work. It cooperates herein with Norway, Finland and Denmark. RML provides outpatient specialist mental healthcare for a region with 150,000 inhabitants.
Objectives: To reach out to KOPP in our centre and offer them and their parents standardized short-term interventions. To extend this proactive process to primary care, municipal services and schools.
Key messages: Starting five years ago with an enthusiastic workgroup we now provide customized counselling to individual families, video home-training for young mothers, a child-rearing course for parents, family-intervention (Beardslee method) and age group-specific do/chat groups. RML-personnel receive training in these standardized methods. Thematic professional gatherings are held. Alliances are maintained with other specialist mental healthcare institutions. A regional conference initiated the expansion to municipal services, schools, primary healthcare and the regional addiction care institute.
Conclusion: A regional preventive KOPP-programme can be successfully implemented starting with a core of enthusiastic mental healthcare professionals, provided they receive adequate funding, national backup and long-term support from local management.
INCORPORATING FAMILY MEMBERS IN MENTAL HEALTH CARE IN DEVELOPING COUNTRIES
Hwa-Young Lee, Min-Soo Lee
The symptoms of mental disorder have an impact on everyone in his or her family. The family members are worried about exacerbation or relapse of symptoms, violence, worsening of intrafamiliar relationship, and financial problems. The families of mentally ill people are affected not only by the mental illness itself of their family member but also by both the poverty and social stigma. They need the support of suitable programs for the families.
Contrary to advanced countries, families have been partners in the care of patients in developing countries. Especially, the oriental culture have emphasized on the togetherness, unity, and harmony within the family system. The families want to take up the following roles: First, families need support from the professionals to acquire the skills of care, crisis support in emergencies, as well as emotional support to maintain the cohesion of the their families. Second, they want to help themselves by forming self-help groups. Third, they want the true relationship and partnership with the professionals, and that the professionals consider the experience of the family as an essential part of the future program and policy.
The mental health programs are consisted of family psychoeducation, family visit nursing, family counseling, and contact with social welfare agencies. The mental health programs incorporating family members seem essential and effective in eastern developing countries. According to the outcome analysis, these mental health programs promoted improved clinical outcomes, satisfaction, and higher rates of recovery amongst the patients and the family members. We need to systematize and organize the mental health activities and give a feedback to the mental health workers by research results and consulting.
PERSONAL HELPERS AND MENTORS PROGRAM
Evan Lewis
Context: New workers in mental health community sector.
Objectives: To promote the new Personal Helpers and Mentors Program in the mental health sector.
Key messages: The Australian Government announcement of $1.9 billion in new funding for mental health initiatives included $554.7 million for the Australian Government Department of Families, Community Services and Indigenous Affairs (FaCSIA) to implement community mental health services via the non-government sector.
The funding is for $284.8 million over five years for the Personal Helpers and Mentors Program to assist people with a severe functional limitation resulting from a mental illness to manage their daily activities and access a range of supports; $45.2 million over five years to deliver flexible projects to assist families, children and young people affected by mental illness; and $224.7 million over five years to provide respite places to assist carers of people with a severe mental illness or intellectual disability.
The Personal Helpers and Mentors Program will begin in May 2007. This presentation will provide an update on the Personal Helpers and Mentors Program, and will highlight early learning from the demonstration sites. An update on the other FaCSIA measures will also be provided.
Conclusion: The increased focus by Government on mental health services in the community sector recognises the importance of non-clinical services in assisting people with mental illness to begin a path of recovery.
SUPPORT EXPERIENCED AND NEEDED BY MINORITY GROUP (STRICTLY ORTHODOX JEWISH) FAMILIES WITH SPECIAL NEEDS CHILDREN
Kate Loewenthal
Background: Strictly-orthodox Jewish communities are scattered world-wide, and have a distinctive educational system, sex-segregated, with focus on traditional religious study. Special needs include cognitive and learning difficulties, emotional and behaviour problems, and impairments such as sight, hearing and mobility.
Aims: This study aims to identify the support needs of special-needs children and their families in this minority group, examine the extent to which these are met, and scope for further services.
Methods: The study draws together information from previous studies, supplemented by semi-structured interviews. The material is used to identify needs and the extent to which these have met, from the perspectives of the children, their families and professionals.
Results: Preliminary analysis indicates that difficulties in meeting special needs include cultural and communication barriers in accessing services, lack of cultural sensitivity in service provision, cultural stigmata in defining a child as having special needs, and lack of resources, particularly lack of statutory support. Examples of each are given.
Conclusion: Recommendations include improved dissemination of information in the community about the range of special needs and how these can be met, including information about accessing and communicating with existing services. There is also scope for improved resources within the schools serving this community, and for family support within the community. Some findings have implications for service provision in other minority groups.
OP12 EPIDEMIOLOGY
ANXIETY, DEPRESSION AND MORTALITY: THE HUNT STUDY
Arnstein Mykletun, Ottar Bjerkeset, Robert Stewart, Michael Stewart, Simon Overland, Martin Prince
Background: Depression is reported to be associated with increased mortality, but underlying mechanisms are uncertain. Associations between anxiety and mortality are also uncertain.
Aims: We investigated hypothesized associations between anxiety, depression and mortality over a 3–6 year period.
Method: We utilized a unique link between a large population survey (HUNT-2, n = 61,349) and a comprehensive mortality database. Anxiety and depressive symptoms were ascertained using HADS.
Results: Case-level depression increased mortality. However, case-level anxiety hardly attenuated mortality, and the association between anxiety symptoms and mortality was U-shaped. Anxiety comorbid with depression was associated with lower mortality compared to depression alone. Associations between depression and mortality were partly explained by somatic symptoms and conditions.
Conclusions: Depression is risk factor for mortality comparable in strength to smoking. Anxiety reduces mortality in co-occurrence with depression. The U-shaped association implies higher mortality in those with the lowest symptom loads of anxiety.
INCIDENCE OF SCHIZOPHRENIA IS NOT DECLINING
Raimo K. R. Salokangas, Anna-Maija Koivisto, Helena Rantanen, Hannu Oja, Matti Joukamaa
Background: Since 1980s, several reports have suggested that the incidence of schizophrenia is decreasing. These results have been based on data of hospital registers. However, changes in capacity of mental hospitals have not always been taken into account.
Aims: Our aim was to calculate annual first admission rates for patients with schizophrenia and compare them with psychiatric beds available during the area when the number of bed in mental hospitals sharply decreased in Finland.
Methods: From the National Hospital Discharge Register, we identified 27 352 15 to 64 year old patients admitted for the first time for schizophrenia to mental hospital in Finland between 1980 and 2003. Annual rates per 100 000 people were calculated and compared with annual numbers of hospitalised patients and mental hospital days.
Results: Annual incidence for schizophrenia decreased from 56.2 in 1980 to 26.4 in 1990, stayed stable between years 1990 and 1998 and slightly increased thereafter (27.0 in 1998 and 33.0 in 2003). Annual incidence of schizophrenia correlated more strongly with numbers of hospitalised patients (r = 0.958) and hospital days (r = 0.848) than with year (r = −0.711).
Conclusion: Annual incidence of hospitalised schizophrenia is at least partly a function of number of mental beds available. Since the beginning of 1990s, annual incidence of hospitalised schizophrenia in Finland seems to be increased, not decreased.
NITHSDALE SCHIZOPHRENIA SURVEY: TWENTY-FIVE YEAR REVIEW
Somashekara Shivashankar, Susan Telfer, Mathew McKinnon, Jeyarani Arunagiriraj, Robin McCreadie
Background: In recent years there has been shift to ‘community care’, introduction of atypical antipsychotic drugs and psychosocial interventions in care and management of people with schizophrenia.
Aims: We report the impact of these changes to determine whether indeed the lot of people with schizophrenia has improved.
Method: In Nithsdale, South-west Scotland, the population with schizophrenia was identified in 2006, replicating the study carried out in 1981. The clinical and social variables were determined and compared with 1981 population.
Results: The study identified 205 people with schizophrenia (point prevalence 3.7/1000 general population) out of which 131(64%) were interviewed. 21(16%) were in-patients, 33(25%) day-patients and 68(52%) out-patients(28%,17% and 32% in 1981). 72(55%) male and 59(45%) female, mean age 53 years(range 22–89).
The mean length of illness was 24 years (range 5 months-74 years) and the mean total length of in-patient stay was 6½ years (range 0–67 years).
With regard to mental state, delusions were present in 52(40%) patients, hallucinations 39(30%), incoherence of speech 14(11%), flatness of affect 41(31%) and poverty of speech 12(9%) (26%,10%,8%,45% and 29% in 1981). 39(30%) had tardive dyskinesia (31% in 1981) while 38(29%) showed parkinsonism with bradykinesia 25(19%), rigidity 25(19%), tremor 16(12%), autonomic symptoms 10(8%) and akathisia 4(3%) (31% with 29%,21%,23%,4% and 2% in 1981).
Conclusions: With the evidence of shift to community care with fewer in-patients and more day and out-patients, the schizophrenia population in 2006 showed more positive symptoms, fewer negative symptoms with minimal difference in side-effect profile compared to1981.
THE PSYQOL QUALITY OF LIFE INSTRUMENT
Jeff Richardson, Helen Herrman, Graeme Hawthorne, Stuart Peacock, Cathy Mihalopoulos, Issy Schweitzer, Angelo Iezzi
Background: With limited resources, economic evaluation is inevitable. When quality of life is important Quality Adjusted Life Years (QALYs) are used to measure benefits. Available multi attribute utility instruments are not very sensitive to the health states associated with psychiatric interventions. The PsyQoL will fill this gap.
Aims: (i) to extend the extant Assessment of Quality of Life (AQoL 2) instrument to increase its sensitivity in the context of psychiatric interventions; (ii) to incorporate patient preferences in the final instrument.
Methods: The project involves six stages: (i) construction of an item bank from other instruments, focus groups, and expert opinion to obtain a ‘short list' of items; (ii) a ‘construction survey’: administering the items to both psychiatric patients and the general population; (iii) psychometric modelling of data to obtain a ‘descriptive instrument’ (questionnaire); (iv) a weights survey to obtain utility scores for items and item responses using the Time Trade-off method; (v) (a) multiplicative and (b) econometric modelling of the utility scores to obtain a scoring (utility) algorithm; (vi) establishing population norms.
Results: By August 2007, 470 patients and 200 general population individuals completed the construction survey and analysis for the descriptive instrument completed. 800 TTO interviews (Stage iv) had commenced.
Conclusion: The PsyQoL project will create a questionnaire (descriptive instrument) and an algorithm (utility instrument) which will allow description of psychiatric health states and their conversion to utility scores in a way which will allow comparative economic evaluations of psychiatric and other interventions.
THE MENTAL HEALTH CLINICAL COLLABORATIVE – CLINICIANS WORKING TOGETHER FOR SERVICE IMPROVEMENT
Sally Plever, Brett Emmerson
Aims: The Mental Health Clinical Collaborative (MHCC) was established in October 2005 with the aim of applying collaborative breakthrough series methodology (USA Institute of Healthcare Improvement) to improve the inpatient treatment of Schizophrenia in acute public mental health facilities. Since this time all eligible sites have voluntarily worked together to develop clinical indicators to support service improvement initiatives in their local areas.
Methods: Fifteen sites have participated in the development of 11 clinical indicators. Data for six indicators has been extracted from existing hospital databases and two service audits, using scannable form technology, have provided the remaining indicator data. Reports on clinical indicators are available to members via a secure intranet site.
Results: Data across 15 sites has provided benchmark information indicating a state average length of stay between 12–38 days with an associated 28 day readmission rate of 10.5–26%. At discharge, Risperidone is the most frequently prescribed antipsychotic medication at an average dose of 4mg, and antipsychotic polypharmacy rates are on average around 13%. Information on psychosocial indicators is also available however small numbers limit the ability to draw conclusions.
Conclusion: Member sites have been provided with access to clinically relevant information on 11 healthcare indicators and have come together across three forums to openly discuss service improvement challenges and ideas. The impact of the collaborative on service improvement is too early to assess, as services have only just commenced planning and implementing service improvement activities. However, the MHCC has demonstrated considerable achievements in standardising data collection, improving data quality and engaging clinicians.
OP13 METABOLIC ISSUES AND PSYCHIATRY 2
WEIGHT GAIN AND ASSOCIATED FACTORS IN A COHORT OF PRIVATE PSYCHIATRIC INPATIENTS
Deidre Smith, Jenny Mcgennis, Virginia Tuckwell, Kathleen Crowley, Kay Maguire, Chee Ng, Issac Schweitzer
Context: The consequences of obesity on morbidity and mortality have long been recognised. Adverse outcomes including hypertension, cardiovascular disease, type II diabetes, sleep apnoea, and cancer have been attributed to excess weight.
There has been a significant increase in BMI for all age groups and both genders in the general population over the last three Australian National Health Survey's; (1989–2001), A recent study in suburban Melbourne found that residential address influences exercise, diet and weight; furthermore, obesity is more prevalent amongst persons with serious mental illness. This is most noteworthy with the increased use of atypical antipsychotics.
Objectives: This naturalistic study aimed to examine the association between postcode, diagnosis, medication type, weight, height, abdominal girth, glucose metabolism, hyperlipidemia, hypertension, smoking, alcohol intake, sleep apnoea and readiness to change behaviour in patient's admitted to a private psychiatric clinic in Melbourne, Australia.
Key messages: Preliminary analysis of the data showed that whilst the majority of the patients had affective diagnosis more than half of the patients were also being treated with an atypical antipsychotic and at least a quarter of the patients had a history of hypertension and dyslipidaemia. 31% were classed as “obese” and 41% “overweight”.
Conclusions: Life style factors, monitoring patient's physical co-morbidities, clinicians prescribing patterns and targeted interventions are all important factors in helping to reduce the potential detrimental effects of weight gain and whilst the atypical antipsychotics and schizophrenia have been highlighted less attention has been paid to other disorders for which atypical antipsychotics are sometimes prescribed.
ADIPOSITY IN DEPRESSIVE AND ANXIETY DISORDERS: GEELONG OSTEOPOROSIS STUDY
Lana Williams, Julie Pasco, Felice Jacka, Seetal Dodd, Michael Berk
Background: Previous research has demonstrated a relationship between adiposity and psychiatric illnesses, although findings are equivocal.
Aim: This study investigated the association between depression, anxiety and indices of adiposity in a community sample of 879 women aged 20–80yr.
Methods: Depressive and anxiety disorders were diagnosed utilising a clinical interview (SCID-I/NP). Anthropometric measurements (weight, height, waist circumference), activity levels, medication use and dietary intake were recorded. Fat mass was determined from whole body dual energy absorptiometry.
Results: There was no difference in%body fat, physical activity or energy intake between the depressed and non-depressed; however there was a difference in age [48 (IQR 35–60) vs. 51 (37–65)yr, p = 0.05], current smoking status (19% vs. 13%, p = 0.04), weight (74.8±16.0 vs. 71.5±15.2 kg, p = 0.007), waist (89.7±13.4 vs. 87.6±13.8 cm, p = 0.05), BMI (28.4±6.2 vs. 27.3±5.6 kg/m2, p = 0.02) and fat mass (30.4±12.0 vs. 28.1±11.1 kg, p = 0.01). There were no differences in any study parameters in those with anxiety disorders. Age and activity level-adjusted mean (95%CI) values for depressed vs. non-depressed were: weight 76.2 (74.0–78.5) vs. 73.3 (71.8–74.8) kg, waist 91.4 (89.4–93.3) vs. 88.4 (87.2–89.7) cm, BMI 29.1 (28.3–30.0) vs. 28.0 (27.4–28.5) kg/m2, fat mass 31.9 (30.2–33.5) vs. 29.6 (28.5–30.6) kg and%body fat 40.5 (39.3–41.7) vs. 38.9 (38.1–39.7); all p < 0.05. Further adjustment for antidepressant use, smoking status, energy intake and anxiety did not affect the relationships.
Conclusions: Adiposity was greater among those with depression independent of age, activity levels, energy intake, antidepressant use, anxiety and smoking status; however no relationship was detected in those with anxiety.
THE ASSOCIATION OF ADULT BODY MASS INDEX AND HEIGHT WITH ANXIETY, DEPRESSION, AND SUICIDE IN THE GENERAL POPULATION: THE HUNT STUDY
Ottar Bjerkeset, Pål Romundstad, Jonathan Evans, David Gunnell
Objective: To investigate the association of BMI and height with suicide, anxiety, and depression.
Method: Prospective cohort study of 74,432 men and women aged 20+ years who participated in the Nord-Trøndelag Health Study, Norway in 1984–86 (HUNT 1). Anxiety and depression were measured with the Hospital Anxiety and Depression rating scale (HADS) in 1995–7. Participants were followed up until 31st of December 2002.
Results: There were 183 suicides. Suicide risk decreased with increasing BMI in men and women. In models controlling for a range of psychological, social, and lifestyle factors the hazard ratio per standard deviation (SD) increase in BMI was 0.82 (95% CI 0.68 to 0.99). In contrast, in the subset of participants (n = 44,396) with HADS measures, BMI at baseline (1984–6) was positively associated with depression. In fully adjusted models the odds ratio for depression per standard deviation increase in BMI (HADS-D > 8) was 1.11 (95% CI 1.07 to 1.15). In fully adjusted models there was no association of height with the incidence of suicide or depression.
Conclusions: Raised BMI is associated with an increased risk of depression but reduced risk of suicide in men and women. Mechanisms underlying these differing associations require clarification.
THE 2-ITEM AND 20-ITEM VERSIONS OF THE PITTSBURGH INSOMNIA RATING SCALE: DESIGN METHODS AND INITIAL MODELING
Douglas Moul, Evelyn Mai, Melissa Shablesky, Anne Germain, Jean Miewald, Daniel Buysse, Paul Pilkonis
Background: The 65-item Pittsburgh Insomnia Rating Scale (PIRS) has favorable psychometric properties, but needs to be shortened.
Aims: 1) To design 2-item (PIRS2) and 20-item (PIRS20) versions for epidemiological and clinical applications, and 2) to model them with existing data.
Methods: Subjects numbered 287 (216 patients with insomnia, 71 control subjects; 116 males, 171 females; aged 49±19 years) spanning a spectrum of severity. PIRS items with low item-total correlations or with high correlations with depression or anxiety scores were removed. Graded response modeling in MULTILOG 7 estimated item-level discrimination and threshold parameters. Using this data, Items were selected for the PIRS2 and PIRS20. The new versions were then modeled with the existing data.
Results: The PIRS2 (range 0–6) contained the items asking about sleep satisfaction and poor energy due to poor sleep. Its Cronbach's alpha coefficient was 0.77. It had good test-retest and treatment-responsiveness characteristics. A cut-off score of 2 was 88% specific and 96% specific for insomnia caseness. The PIRS20 (range 0–60) was linear with the PIRS2. Its alpha coefficient was 0.95. A cut-off score of 20.5 was 86% specific and 99% specific for insomnia caseness. The PIRS20 test information standard error was small across a broad intermediate range of insomnia severity.
Conclusions: The new versions are the first insomnia rating scales designed from appraisal of item response theory data. The PIRS2 has potential use in epidemiological studies. The PIRS20 mirrors the interpretive customs of other psychiatric scales, has superior measurement precision, and is freely available.
OP14 NEW FINDINGS FROM SURVEYS, REGISTRIES AND CLINICAL DATABASES
FINANCIAL HARDSHIP AND COMMON MENTAL DISORDERS: LONGITUDINAL STUDY OF A LARGE COMMUNITY SURVEY
Peter Butterworth
Background: A social gradient in the prevalence of common mental disorders is well established and is evident using a variety of measures of social status. Economic deprivation or financial hardship has been proposed as one key factor in this relationship.
Aims: To use longitudinal data to investigate the relationship between financial hardship and a continuous measure of common mental disorders, and to differentiate social selection and social causation hypotheses.
Method: Hierarchical multilevel modelling of data from 8204 respondents who completed the first four waves of a large-scale national household panel survey (the HILDA Survey). The Mental Health Inventory from the SF-36 was used as a measure of common mental disorders. Data were clustered within individuals (4 waves), households and area (Census Collection District).
Results: Variance components models were consistent with expectations and demonstrated adequate stability in mental health scores over time and limited variance at the area level. Experience of financial hardship remained strongly associated with poor mental health after controlling for other risk factors and covariates. While between-person measures of experience of hardship had a strong effect, within-person variability in hardship was also significantly associated with variability in mental health. Further analysis examined hardship at the household and area levels, lagged effects, and assessed heteroskedasticity between different sub-populations in intra-individual variability in mental health over time.
Conclusion: The association between financial hardship and poor mental health reflects both selection and causative effects. These findings have implications for social policy programs and strategies to address social exclusion.
TE RAU HINENGARO THE NEW ZEALAND MENTAL HEALTH SURVEY: INDIVIDUAL AND AREA LEVEL SOCIODEMOGRAPHIC CORRELATES OF MENTAL DISORDER AND HEALTH SERVICE USE
Mark A. Oakley Browne, J. Elisabeth Wells, Magnus A. McGee
Background: Te Rau Hinengaro The New Zealand Mental Health Survey provides important and not previously available information for the adult NZ population.
Aims: To describe the prevalences of common mental disorders, psychological distress, and patterns of health service use by individual and area level sociodemographic correlates.
Methods: A nationwide face-to-face household survey of residents aged 16 years and over was undertaken between 2003 and 2004. A fully structured diagnostic interview, the World Health Composite International Diagnostic Interview (CIDI 3.0) was used to obtain DSM-IV diagnoses. Psychological distress was measured with the Kessler 10-item scale. The 2001 NZ Census definitions were used for sociodemographic correlates. There were 12 992 completed interviews. The overall response rate was 73.3%.
Results: Prevalences are higher for people who are disadvantaged, whether measured by educational attainment, equivalized household income or using the small area index of deprivation (NZDep2001). Scores on the Kessler 10-Item Scale (K10) of psychological distress were higher for females, younger people, people with fewer educational qualifications and lower household income. Scores on the K10 also differed significantly by the NZDep2001, with more deprived areas having higher mean scores than less deprived areas. Prevalence of disorder and K10 scores were not correlated with urban or rural residence. People with lower educational attainment and people resident in rural areas had lower rates of visits to the mental health specialty sector.
Conclusions: In the adult NZ population socioeconomic disadvantage, but not rural-urban residence, is correlated with higher rates of mental disorder and psychological distress.
IS THERE AN EFFECT OF DISABILITY PENSION AWARD ON RECIPIENTS’ HEALTH?
Simon Øverland, Nick Glozier, Max Henderson, John Gunnar Mæland, Matthew Hotopf, Arnstein Mykletun
Background: In high income countries, up to 12 percent of the working age population receive permanent disability benefits. Mental illnesses are among the leading causes of work disability. There is minimal information on the consequences of this major event.
Aim: To examine the effects on health and quality of life of being awarded a disability pension.
Methods: The population based Hordaland Health Study (HUSK, N = 18 581) in Western Norway 1997–99 was linked to complete disability benefits registries running from 1992–04. We employed a natural experiment design and compared the health and quality of life of disability pensioners at different time periods from seven years before to seven years after disability pension award.
Results: Disability pensioners (n = 1 087) reported more somatic illness, somatic and mental symptoms, and worse HRQoL than the remaining sample (n = 17 494), both seven years before and seven years after disability pension award. Somatic illness was stable over the disability pension process, though with an increase in medication after award. However, we found a significant non linear increase in symptoms and a fall in HRQoL approaching the award, with a subsequent normalisation afterwards. For most measures, the level of health problems was equal 3–7 years before compared to 3–7 years after award.
Conclusion: There is a significant, but temporary, increase in symptoms and a fall in HRQoL around the time of the disability pension award. Prolonging this period, or repeated pension assessments, may have unintended adverse effects
UNDER-TREATMENT OF MENTAL ILLNESS AMONG PEOPLE GRANTED DISABILITY PENSION. THE HUNT STUDY, NORWAY
Simon Øverland, Nick Glozier, Arnstein Mykletun
Background: Mental illness has overtaken musculoskeletal problems as the main cause of disability benefits or its equivalent throughout OECD countries. Mental health problems are considered undertreated, a world wide phenomenon with up to half of cases in developed countries reporting no treatment. The mere societal costs in disability expenditure underline the importance of identifying ways of preventing further increase in disability benefits.
Aim: To examine under-treatment prior to disability pension awards for mental illnesses.
Methods: Through a unique linkage of the Nord-Trøndelag Health Study (HUNT 2) and the Norwegian National Insurance Administration, this historical cohort study examines the extent of treatment for mental illness among those who, within five years prior to participation in the health survey, were awarded a disability pension for mental illness.
Results: Of 1 918 awards of disability pension during follow up, 403 (21%) were for mental illness. Of the 301 participants granted disability pension with a mental illness as the primary diagnosis, 25% (19–29) report never having sought help, compared to 53% (43–63) among the 102 with a mental secondary and disability contributing diagnosis (χ2=28.26, df = 1, p<.001).
Conclusions: These data suggests an undertreatment of mental illnesses also prior to disability pensioning as 32% report never having sought help for mental health problems before being permanently withdrawn from the work force due to these problems. Whether increasing access to evidence based psychological therapies ameliorate the rising economic burden and social exclusion of adults with mental health problems remains to be seen.
UNDERSTANDING TERTIARY MENTAL HEALTH SERVICE NEEDS: DEVELOPING AND USING A COMPREHENSIVE CLINICAL DATABASE
Caili Wu, Paul Dagg, Carol Ward, Marie-Claire Baril, Amy Thibeault, Jennifer Klages
Clinical databases have been proven to have many potential benefits such as providing evidence for evaluative research, planning and managing service. Tertiary service needs in psychiatry are not well defined. To fully understand the target population and their care needs, a comprehensive clinical database has been developed at a tertiary mental health facility since its opening. Hillside Center is a 44-bed in-patient tertiary psychiatric facility located in British Columbia, Canada. Hillside Center includes three programs to serve different patient populations: Geriatric Psychiatry Program, Adult Psychiatry Program, and Neuropsychiatry Program. A wide range of data such as patient demographic information and clinical care needs is collected into the database on regular ongoing base. Each individual admitted to Geriatric Psychiatry Program and Neuropsychiatry Program is assessed at admission, every three month afterwards, and on discharge with a series of widely used psychiatry assessment tools and several Hillside Center inventories based on target symptoms, behaviors, medication, and mental health service history. Data is coded into SPSS in the way to allow detail and in-depth statistic analysis. Results from the database are used to describe and define the patient population that uses tertiary service, to better assess needs to assist discharge planning; to track general treatment progress; to help to establish program evaluation mechanism; and to foster various clinical research. Our preliminary experience demonstrates that a comprehensive clinical database is useful at least in describing tertiary patient population and care needs, providing information on outcome of care, and tracking treatment progress.
OP15 BASIC RESEARCH
ACTIVATION OF THE HPA AXIS FOLLOWING SSRI ADMINISTRATION IN PATIENTS WITH MDD
Tye Dawood, David Barton, Elisabeth Lambert, Alan Tilbrook, Jan Loose, Murray Esler, Deepak Haikerwal, David Kaye, Gavin Lambert
Background: Major depressive disorder (MDD) has been linked with hypothalamic-pituitary-adrenal (HPA) axis activation.
Aims: To investigate the interactions between the sympathoadrenal system and HPA axis in MDD. Further, to identify the actions of selective serotonin reuptake inhibitors (SSRIs) on these systems.
Methods: Nineteen patients with MDD, but otherwise healthy, and 18 healthy controls were recruited from the community for plasma cortisol, ACTH and adrenaline measurements. Following 12 weeks of SSRI treatment, levels of these hormones were again measured in MDD patients.
Results: Compared with control subjects, patients with MDD had considerably higher state (32±2 vs 58±2, p = 0.001) and trait (33±2 vs 63±1, p = 0.001) anxiety scores. Indicative of HPA axis activation, plasma cortisol concentrations were significantly increased in untreated MDD [53(37-68) in controls and 69(64–92) in MDD, p = 0.01, median (25–75 percentile)]. Following treatment, state and trait anxiety levels were reduced in MDD patients (p = 0.001). Consistent with the decrease in anxiety scores, arterial adrenaline concentrations decreased in MDD (49±6 pg/mL to 36±5pg/mL, p = 0.05). Surprisingly, and contrary to adrenaline concentrations, cortisol concentrations increased following therapy (to 103±60 ng/mL, p = 0.075). Plasma ACTH levels also increased slightly after treatment. No correlations between HPA axis activity, symapthoadrenal activity and degree of depression or anxiety were observed, except for a significant relationship between plasma cortisol and ACTH following SSRI administration (r = 0.7, p < 0.01).
Conclusion: These results indicate that the HPA axis and sympathoadrenal system are dissociated in untreated and SSRI-treated MDD.
METHYLATION STATE, ALTERNATIVE SPLICING, AND EXPRESSION PROFILE OF TRKB IN FRONTAL CORTEX OF SUICIDE COMPLETERS
Carl Ernst, Adolfo Sequeira, Xiaoming Deng, Vesselina Deleva, Amanda Pomeranski, Alain Gratton, Guy Rouleau, Remi Quirion, Moshe Szyf, Gustavo Turecki
While much of the effort to understand the neurobiology of depressive states and suicide has focused on neuronal processes, recent studies suggest that astroglial dysfunction may play an important role. TrkB. T1 is expressed in astrocytes and BDNF/TrkB signaling has been linked to mood disorders. We tested the hypothesis that TrkB.T1 expression is downregulated in suicide completers and that this downregulation is mediated by an epigenetic process. We used 2 independent samples for initial screening and replication. Sample 1 (N = 20) was initially screened using the HG-U133A,B chipset, while sample 2 (N = 19) was investigated using the HG-U133plus2 chip. Initial studies focused on dorsolateral frontal cortex using a microarray screening approach for extreme expression differences across subjects. Results were validated by qRT-PCR and Western Blot. Animal experiments were performed to control for drug and alcohol effects. Genetic and epigenetic studies were carried out by direct sequencing and bisulfite mapping. We found that 35% of suicides from both samples demonstrated significant decreases in three different probe sets specific to TrkB. T1. These findings were generalizable to other frontal regions, but not to the cerebellum. The decrease in TrkB was specific to the T1 splice variant. Our results were not accounted for by substance comorbidity or by reduction in astrocyte number. We found no effect of variation in a 2500 bp promoter region or at relevant splice junctions; however, we detected an effect of methylation state at particular CpG dinucleotides on TrkB. T1 expression. These results demonstrate a reduction of TrkB. T1 in a subpopulation of suicide completers.
METHYLATION ANALYSIS OF REGULATORY REGIONS OF SCHIZOPHRENIA CANDIDATE GENES
Richard Saffery, Jeff Craig, Brian Dean, Debra Foley, Craig Olsson, Colin O'Donnell
Schizophrenia shows a high degree of heritability (estimated at 85%1), with evidence for a contribution of many different environmental factors to disease aetiology. However, at present, causality and mechanism remain generally unclear. Mounting evidence of specific epigenetic alterations in schizophrenia is beginning to emerge.
DNA methylation is of particular interest in psychiatric diseases because it can modulate gene expression in the absence of alterations to DNA sequence and may therefore partly explain the environmental contribution to these disorders. We have investigated the methylation status of several candidate gene regulatory regions in the dorsolateral prefrontal cortex (DLPFC) of post-mortem human (80 schizophrenics and 80 matched controls) using MassArray Epityping technology. To date, we have identified several distinct changes in the methylation levels in the COMT, Reelin, and PRODH gene regulatory regions in DLPFC tissue associated with the schizophrenic phenotype. Several other genes showed slight changes in methylation levels, while others showed no differences between diseased and normal brain tissue. However, significant variation at single CpG dinucleotides appears more common than larger regions of altered methylation. We are currently investigating the biological significance of this methylation through the use of appropriate gene expression and other functional assays.
STRESS EFFECTS ON THE LIMBIC SYSTEM: RELEVANCE TO TEMPORAL LOBE EPILEPSY AND ITS PSYCHOPATHOLOGY
Michael Salzberg, Gaurav Kumar, Nigel Jones, Sandra Rees, Margaret Morris, Dennis Velakoulis, Terence O'Brien
Context: The hippocampus and amygdala are of interest to both epileptology and psychiatry, due to their involvement in mesial temporal lobe epilepsy (MTLE) and in various forms of psychiatric disorder. Both neural structures are affected by stress: rodent and primate studies have shown structural and functional effects in these regions and the mechanisms (involving roles of glucocorticoids, CRH and glutamatergic transmission) have been extensively investigated. Stress also is implicated in the occurrence of affective disorders, possibly in part through such mechanisms. However, evidence for a role for stress in MTLE is limited. We suggest stress contributes to both epileptogenesis and to its accompanying affective disturbance. In addition, early life stress has enduring neuroendocrine and neurobiological effects (“programming”), which may create vulnerability to both limbic epilepsy and to affective disorder.
Objectives: To describe our studies into the effects of stress on limbic epileptogenesis using amygdala electrical kindling epileptogenesis, an animal model of human MTLE. To describe both the effects of stress applied in adult life as well as the effects of early postnatal stress on susceptibility to epileptogenesis and behavioural disturbance.
Key messages: Concurrent stress accelerates kindling epileptogenesis. Early life maternal separation stress causes enduring susceptibility to kindling epileptogenesis.
Conclusion: The causation of MTLE and its psychiatric comorbidities is a complex, multi-stage, ill-understood process. Neurobiological and neuroendocrine stress mechanisms have the potential to affect this process at several stages. Such research may afford useful insights into both MTLE and its psychopathology and into affective disorder more generally.
OUR EYEBALLS – DUAL VIBRATION/LIGHT SENSORS
Ashley Willis
Context: Perceptual theory is currently non-existent, and as it's dubious if scientific method alone is capable of deconstructing consciousness, it may be time to accept “unorthodox” methods.
Sensations: I have felt
S1. Sound waves reverberating in the left vitreous humour – whose intercese of interference accorded exactly with when I perceived external musical rhythms. A standing-wave was transmitted up the optic nerve, which was returned.
S2. Rapid free-form blinking syncopating exactly with when violin notes were perceived.
These were felt separately, but as any movement of the ocular muscles must distort the eyeball, and vice-versa, it's reasonable to expect these represent an integrated system.
Discussion: This implies that
The eyeballs double as vibration sensors
Acts of perception can occur outside the CNS
This demonstrates how internal physiological stimulation correlates an external reality.
Calibrated parametric modelling may
Provide scientific verification of the eyeball's vibration capabilities
Help explain the eyeball's physiology – which conventionally, remains paradoxical.
For example, an intact sclera should aid 3D harmonics; the cornea's layering and eyeball saccades may well advantage vibration sensing/perception.
Conclusion: Studying the eyeball's vibration capabilities may greatly aid our understanding of perception, the interlinking of the senses – light and sound may be sensed only millimetres apart!-and the sensory systems synergy with the CNS.
Could this be developed into real theory, provide clarity and be universally applicable?
I ask for your response.
OP16 WORKING IN MENTAL HEALTH
EVALUATION OF A STRUCTURED TRAINING PROGRAM IN PSYCHOTHERAPEUTIC SKILLS USED IN CLINICAL INTERVIEWS FOR PSYCHIATRY AND CLINICAL PSYCHOLOGY RESIDENTS
Alejandra Ana García Rosales, Alberto Fernández Liria, Beatriz Rodríguez Vega, Débora Ortiz-Sánchez, Isabel Baldor-Tubet, Carlos González-Juárez, Carmen Bayón
Background: Research on evaluation of training programs of skills used in clinical interviews in psychotherapy is very scarce. Although there is an agreement that teaching would follow competence evaluation, the outcome of the formation may be evaluated in terms of acquired competences, there are no programs supported by empirically demonstrated effectiveness, and there is not consensus about any reliable instruments for assessing these programs.
Methods: The current study evaluates a training program based on a structured manual on psychotherapeutic skills for clinical interviews, using a randomized, controlled and blind design. Two types of assessment instruments are used: a paper-pencil questionnaire based on clinical cases and a videotape of a role-playing interview. Both of them are administered before and after the training program. The experimental group consists of 135 psychiatry residents from 12 teaching units of psychiatry in Spain. To control the improvement that could be attributed to the training received during the residency, we compared the experimental group with a control group formed by 35 residents from three teaching unit.
Results: The concordance between the evaluators is high (index K = 0,832). The experimental group shows a statistically significant improvement compared to the control group, with both the instruments.
Conclusions: Data support the efficacy of this type of training program and the convenience to include this activity in tutorial programs. The study adds a contribution to which is the best method used to measure the outcome in terms of competence.
THE LINGERING MENTAL HEALTH CONSEQUENCES OF CHORNOBYL: AN UNBIASED APPRAISAL
Johan Havenaar, Evelyn Bromet, Nathan Tinlte, Semyon Gluzman
Background: Since the nuclear power plant catastrophe at Chornobyl (Ukraine) in 1986, four studies have documented higher levels of psychological symptoms and/or poorer self-assessed health among exposed populations in the region (Bromet and Havenaar, 2006). Most of these studies had Chernobyl as its focus, which may have influenced the results.
Aim: The present study aims to investigate the impact of Chornobyl and other stressors on diagnosable mental health, alcoholism and physical well-being.
Methods: In 2002, a national probability sample of 4,725 respondents ages 18 and older were interviewed with the WMH version of the Composite International Diagnostic Interview (WMH-CIDI). Respondents where classified according to the level of radioactivity of area they lived, currently or in the past. we assessed whether the groups with higher exposure had more mental health problems and more worries about their own health, or their children's health as a consequence of the accident.
Results: Respondents who had lived in a contaminated zone in the past had increased risk of mental health symptoms and poor subjective health rating. The findings in the respondents who still live in areas with relatively high levels of radioactive contamination show a similar picture.
Conclusions: Long-term consequences of Chernobyl were observed in an unbiased sample of the general population of Ukraine.
EFFECTS OF SHIFTS ON THE RISK OF MOTOR VEHICLE CRASHES AND SLEEP PROBLEMS AMONG IRANIAN HOSPITAL WORKERS
Habibollah Khazaie, Masoud Tahmasian, Erfan Naghshbandi
Introduction: Health workers ability to provide high quality care can be adversely affected by many factors such as sleep deprivation due to their shifts. On the other hand, sleep deprivation is associated with increased risk of serious medical errors and motor vehicle crashes.
Methods: At first, we collected demographic data from hospitals workers. So we divided 663 volunteers to “shift workers and non-shift workers” groups. They met Global Sleep Assessment Questionnaire for sleep problems and ask them about documented motor vehicle crashes after their shifts.
Results: There is a significant difference between our groups in post-shift crash rate (P = 0.005) and severity of crash (P = 0.047)., On the other hand shift workers suffered from daily sleepiness (P = 0.000), insufficient sleep (P = 0.000) and sleep apnea (P = 0.009) versus non-shift workers.
Discussion: This study showed that there is high correlation between shift works and some sleep problems. Those sleep problems can affect clinical performance and may be an important factor in patient safety and health worker's well being. Also the risk of fatigue-related crashes, threaten shift workers.
CO-MORBID CHRONIC SINUSITIS AMONG OUT DOOR PSYCHIATRIC PATIENTS
Afridi Muhammad Iqbal, Muhamamd Usman, Saifur Rehman, Shoukat Ali
Background: Sinusitis, an inflammatory disease of the sinus, affects about 14 percent of the population. Chronic sinusitis, lasting more than eight to 12 weeks is characterised by constant headaches, and generalized fatigue and malaise leading to disturbed performance. Since the condition mimics psychiatric disorders, the present study is an attempt to explore its morbidity.
Aims: To assess the prevalence of co-morbid sinusitis among door psychiatric patients.
Methods: A cross-sectional study, carried out at NMI (Neuro-spinal Medical Institute), Karachi, Pakistan, during 2005.
All consecutive and consenting cases that approached for psychiatric consultation during six years were assessed. They were assessed on detailed history, mental state examination and physical examination supported with laboratory and radiological investigations. Criteria of ICD-10 were used for associated psychiatric diagnoses.
Results: Five thousand forty three consecutive cases that approached for psychiatric consultation were assessed. One hundred fifty four (3.05%) consenting cases with chronic sinusitis were inducted in this study. Among them 85(55%) cases were male and 69(45%) cases were female. Their mean age + SD were 31.95 + 11.79 years with age range of 13–85 years. Most of them (74%) were married. 61(39.61%) of the cases were have substance use especially tobacco. The most frequent ICD-10 diagnoses were F3 (Mood Disorder = 59%), followed by F4(Stress/Neurotic Related Disorder = 29%).
Conclusion: As evident from this study, co-morbidity of chronic sinusitis is prevalent among out door psychiatric patients especially among cases with affective and neurotic disorders. Such co-existence necessitates concomitant therapeutic interventions, for the better out come/prognosis.
OP17 IN DISASTER AND TRAUMA MENTAL HEALTH
PSYCHIATRIC AFTERMATH OF THE CHERNOBYL DISASTER IN CLEAN-UP WORKERS
Konstantin Loganovsky, Johan Havenaar, Evelyn Bromet
Background: The mental health impact of Chernobyl is the largest public health problem caused by the accident to date. However, mental health of clean-up workers, who faced the greatest radiation exposure and threat to life, have not been systematically evaluated.
Aims: To evaluate the long-term effects of Chernobyl on mental health of clean-up workers (liquidators) in Ukraine.
Method: We conducted standardized psychiatric interviews using the Composite International Diagnostic Interview (CIDI) with 295 clean-up workers and 397 controls 16–18 years after the accident and report on common psychiatric disorders, suicide ideation and severe headaches. We also examined days lost from work and exposure severity.
Results: Prior to the Chernobyl accident, consistent with the healthy worker effect, the clean-up workers had significantly lower rates in anxiety and alcohol disorders. The clean-up workers had significantly higher post-Chernobyl rates of depression (18.0% vs 13.1%) and suicide ideation (9.2% vs 4.1%) after the accident, but not alcoholism or intermittent explosive disorder. In the year preceding interview, rates of depression (14.9% vs 7.1%), PTSD (4.1% vs 1.0%), and headaches (69.2% vs 12.4%) were elevated. Affected liquidators with depression and PTSD lost more work days than affected controls. Exposure level was associated with current somatic and PTSD symptom severity.
Conclusions: Long-term consequences of Chernobyl accident on mental health were observed in clean-up workers. A further study is needing that should endeavor to collect more objective measures of exposure and physical health, consider possible cognitive impairment and psychotic symptoms, and conduct more rigorous psychiatric evaluations.
A SEMI-QUALITATIVE APPROACH TOWARDS UNDERSTANDING GRIEF AMONG DISPLACED ADOLESCENTS IN POST-TSUNAMI ACHEH
Tuti Iryani Mohd Daud
Background: When disaster strikes, loss and displacement occur. The Asian Tsunami 2004 left a huge impact to many due to its unexpectedness, mass destruction and loss shared across the region. A qualitative approach allows an exploration of response among survivors from a local perspective.
Aims: This study aimed to explore grief-related experiences of displaced adolescents two months post tsunami in Acheh.
Methods: This is a retrospective study based on the data obtained by mental health volunteers for MERCY mission 9. Adolescents placed at one school and one orphanage center located in Banda Acheh completed Sentence Completion Test. The qualitative data were analysed using envivo version 2.0.
Results: Analysis of the questionnaires from one hundred and nineteen adolescents (male 35%, female 65%, age range 10–19 years old) showed that the general themes of sadness, loss and separation of loved ones and homes still predominate. Other distinctive themes were religious coping, witnessing catastrophe and missing dead bodies of the loved ones.
Conclusion: While grief is a natural process that may not warrant professional help, findings of this study implied the importance of cultural competence. The needs of mental health response may also differ according to the characteristic of the disaster. While provision of psychological support should be made available to the minority of the vulnerable survivors, we need to recognize the variation and distinctive features of grieving in each disaster event,
MALINGERING POST-TRAUMATIC STRESS DISORDER IN A LEGAL SETTING
Agnieszka Ederveen-Grochowska
Every human action is value-driven. Individuals are, however, free to choose to deviate from the rules and values of the society. Complaints and illness behaviours are to a great extent influenced by individual beliefs, attitudes and expectations as well as by social factors. The conflict of values in a medical setting is readily recognized in the case of illness deception. The essential feature of malingering is the intentional production of false or exaggerated physical or psychological symptoms, motivated by external incentives such as financial gain in insurance claims. Malingering, motivated by avoidance of criminal prosecution, should also be suspected in a medico-legal context of presentation.
A growing number of civil and criminal court cases involves claims of post-traumatic stress disorder (PTSD). The prevalence of malingering PTSD seems to be underestimated because of the low diagnostic discrimination of posttraumatic symptoms. The valid forensic psychiatric assessment of PTSD requires an evaluation of previous medical records, diagnostic interview with the examinee and evaluation of the social functioning. The diagnostic methodology includes a description of the traumatic event and classification of symptoms that are consistent with PTSD.
In this presentation I would like to give some guidelines for assessment of PTSD in a legal setting.
CHILDREN OF PARENTS WITH MENTAL ILLNEES AND SEVERE TRAUMA: IS THERE A DIFFERENCE?
George Halasz
Despite some areas of controversy, the growing literature attests to the reality of the long term impact, individually and across generations, of extreme trauma endured by survivors of genocide, to date the Holocaust being most intensively studied.
Mindful of the serious potential risks posed to survivors, their offspring and non-direct descendants re-exposure in therapy can trigger, interventions need to focus on two aims: first, to provide a psychological safety net for the family as a priority, given that memory of massive trauma can be activated by re-exposure during therapy; second, to prevent as far as possible that original trauma, post-traumatic stress disorder (PTSD) or its complications also impacting on the mental health professionals (counsellors, psychologist or psychiatrist).
My presentation details the lessons learnt both from direct long-term family work in a clinical setting where the presentation is often of a young patient with ‘mental illness’, and the conceptual shift needed for the framework to work with inter-generational trauma transmission. As a child psychiatrist with both personal familiarity as well as clinical experiences of Holocaust survivor families, I apply clinical skills-individual, family and intergenerational – to the models of stress and trauma literature. The principles guiding the development of treatment of extreme psychological trauma is focused on the task to provide ‘reparative moments’ through ‘intergenerational dialogue’.
In summary, current therapy conceptualizes the necessary elements of treatment in such encounters, some lasting only a few seconds, as the ‘reparative moments’ which will be illustrated with a case study.
OP18 CONSUMERS
DEVELOPMENT OF A COMMUNITY PSYCHOTHERAPY SERVICE: KEEPING THE PATIENT IN MIND
Erica Echstein
Psychoanalytically informed thinking provides the framework for reflecting on the development of a Community Psychology Service in the regional city of Ballarat. Pomegranate House provides psychotherapy to people with mental health issues who are unable to access these services elsewhere in the community. The conceptual phase that took place two years before the service commenced was a complex process involving four collaborating organisations and their attempt to reach agreement on the target group and treatment model. This paper examines four key themes reflected in this process. It is suggested that the patient who is now the focus of treatment reflects the existence of unconscious mental processes during this developmental phase. Psychologists pay careful attention to unconscious processes in working with patients and how the therapist and patient influence one another in their interactions. An attempt is made to understand the unconscious processes as they were enacted in the collaborative endeavours of the four organisations involved in developing Pomegranate House. Of particular interest is how, by evolution rather than design, Pomegranate House has developed into a specialist service offering psychoanalytically informed psychotherapy. The complexities and problems that have arisen as a result of this development have highlighted the need to pay attention to phenomena such as unconscious phantasy and transference. If these processes are not the subject of dynamic scrutiny in inter and intra organisational discussions they have the potential to undermine the ongoing development and functioning of any community service.
CONSUMER CARER SERVICE INVOLVEMENT: LESSONS LEARNT
James Hundertmark, Lyn English
Context: Governance in modern mental health must involve consumers and carers at all levels. The Queen Elizabeth Hospital, South Australia developed a Consumer and Carer Steering Committee in order to assist in decision making and provide high level feedback to a mental health service for 200,000 plus in the western suburbs of Adelaide.
Objectives: The development, progress and difficulties involved in the functioning of the steering committee over a three year period will be outlined. Issues discussed include member selection, conflict with service demands, negotiating service evaluation and working through major re-organization.
Key messages: Selection of consumers and carers for service involvement is a complex process. There are conflicting demands on consumers and carers by contrast with administrators. Service evaluation and re-organization represent unique challenges for consumer/carer involvement in mental health governance.
Conclusion: Governance in modern mental health benefits from consumers and carer involvement. However a range of consumer/carer issues may arise which need to be identified and understood in order to fully benefit from the process.
CONSUMER COMPANION PROJECT
Parinitha Jayashankar, Deen Minter, Erin Carnachan, Neville Thompson, Shirley Wigan, Vaidyanathan Kalyanasundaram
Context: The consumer companion project is a collaborative and an innovative initiative jointly undertaken by the Southside Health Service District, Bayside Mental Health and the Bayside Initiative Group (BIG) Inc., which is an independent non-government organisation and consumer initiative. The project is funded by Queensland Health and supported by a memorandum of Agreement between the above organisations.
Objectives: The purpose of the project is to support consumers of the acute inpatient unit of Bayside Mental Health Service during their admission, orientation and discharge processes.
The project is a peer support service that acknowledges the value of lived experience of mental illness. By using personal stories and experiences the consumer companions have demonstrated that they can empower others to move towards self-directed recovery by offering hope, inspiration, role modelling and self-determination. The project has been evaluated by an external consultant and found to have a positive impact and recommended to be replicated in other areas of mental health.
Key messages: The journey of recovery can be an enriching and valuable experience in empowering self and others.
The consumer companion programme challenges the stigma of the stereotyping of person with mental illness as hopeless and dependent.
Conclusion: The consumer companions working alongside the mental health staff in an autonomous role transforms the mental health service and adds a valuable dimension to service delivery.
INSIDE OUT AND OUTSIDE IN: WORKING WITH CONSUMERS
Joseph Leong, Harris Ng
As in many countries, in Singapore-persons with psychiatric disability had been kept away from the hustle and bustle of Singapore's growth. Things have begun to change.
I remembered seeing a patient who came to me and shared “Dr Leong, I have listened to you and took my medicines – now I am well but what is the use? People still look down on me and it is so difficult to get a job” That was 8 years ago and frankly as a doctor, I felt helpless too.
Over the last 8 years, the Institute of Mental Health has expanded its psycho-social rehabilitation services. The establishment of Stepping Stones (a 30 bedded in-patient psychiatric rehabilitation ward) and the expansion of Occupational Therapy Department with multiple milieu for vocational rehabilitation blazed the path for community re-integration.
Last year, we have started out-patient rehabilitation clinic in our attempt to follow up on patients and assess patients referred from other community partners. I would present 2 patients’ stories – one motivated to work but struggling with cognitive deficit, another battling stigma and seeking acceptance to find a meaningful role for himself in society.
There is still much more room for improvement and progress. With the advance of Community Psychiatry and excellent partnerships with different government ministries and volunteer welfare organization, there is hope that consumer and caregiver groups will grow from strength to strength.
OPTIMIZING COMMUNITY LINKAGES THROUGH INCLUSION: IMPROVING THE QUALITY OF LIFE FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES
Judy Lupart, Vianne Timmons
Introduction: Inclusion is a term that has a number of interpretations. Professionals or caregivers have defined many of these interpretations with little or no input from those individuals who live with a disability. Inclusion can also hold different meanings dependent on the age of the individual. An accepted definition of inclusion is where adults and children with disabilities learn, play, and work in their community with their neighbours.
Purpose: To examine the inclusive experiences children and adults with developmental disabilities have encountered in school, work, and leisure settings.
Methods: In this qualitative study, a lifetime approach to inclusion from the perspective of children and adults ranging in age from 4 to 50 plus with intellectual disabilities, was explored. Overall the researchers have interviewed 60 participants, 60 guardians, 30 teachers, and 30 employers or service workers. Interviewing the people involved in the lives of those with the disability offers a holistic perspective of the strengths and challenges individuals with disabilities face on a day-to-day basis.
Results: For this presentation, the researchers will be presenting selective findings from the full set of interviews. The themes and trends identified in the stories of these individuals will be explored. Analysis of community linkages on quality of life and policy implications is presented.
Conclusions: The stories of individuals with disabilities will help shape and influence policy and practice surrounding inclusion.
MENTAL HEALTH ADVOCACY IN MALAYSIA: THE PROGRESSIVE ROLES OF CONSUMERS AND FAMILY ORGANIZATION
Ruzanna ZamZam, Abdul Kadir Abu Bakar, Marhani Midin
Context: Promotion to develop strong and independent mental health advocacy movement throughout the world is now being one of the important steps for service reform. As Malaysia is now working towards further development and implementations of mental health program, involvement of consumers and families is an important step to combat stigma and ensure an adequate service delivery. In the past recent years, Malaysia has made a significant advocacy effort.
Objectives: This paper is meant to describe and share the experiences of Malaysian consumers, family and mental health professionals in making a progress in mental health advocacy. It will describe the roles of consumers and family in making vital steps in advocacy related actions.
Key messages: Mental health advocacy process can be varied and performed in many form depending on the contextual strengths and opportunities of each country. As in Malaysia, the relatively strong family support system can be seen as one the significant strengths that promotes mental health advocacy. Apart from providing opinions to the government and educating the public, this advocacy process has also provided a good ground for improvement of self-esteem to the Malaysian consumers and families. Though the challenges are many, these have been tackled effectively.
Conclusion: The invaluable experience in Malaysian mental health advocacy has strengthened the belief that advocacy is a very important process in mental health reform. It is hope that sharing this experience can contribute to a better understanding of advocacy of Malaysian context and strengthening advocacy movements in other developing countries.
OP19 DEPRESSION AND MEDICAL ILLNESS
THE IMPORTANCE OF DYSTHYMIA FOR THE RELATIONSHIP BETWEEN DEPRESSION AND MEDICAL DISORDERS
Bernhard Baune, Riccardo Caniato, Klaus Berger
Background: Recent research suggests a role of dysthymia in addition to MDD in the relationship between depression and medical disorders.
Aims: To investigate the association between dysthymia and various medical disorders and to evaluate the contribution of dysthymia to general functioning, disability and health service utilization in subjects with medical disorders in the general adult population.
Methods: In 4,181 participants of the Germany National Health Survey 12-months prevalences of MDD and dysthymia were assessed (CIDI). Medical disorders, general functioning, health service utilization and disability days were assessed by a study physician.
Results: Odds ratios for the association between dysthymia and MDD respectively and medical disorders were up to two times higher in dysthymia than in depression (except allergy). Dysthymia had a stronger (OR, 1.84; 95%CI, 1.11–3.03) association with coronary heart disease than unipolar depression (OR, 1.43; 95%CI, 1.0–2.07). Contrary, unipolar depression (OR, 2.13; 95%CI, 1.22–3.75) showed a higher odds ratio for the link with stroke than dysthymia (OR, 1.90; 95%CI, 0.84–4.30). While in subjects with comorbid medical disorders, physical functioning was reduced similarly in dysthymia and MDD, mental functioning was markedly reduced in dysthymia as opposed to a moderate reduction in subjects with MDD. Participants with dysthymia either had similar or more doctor visits and more disability days as compared to MDD.
Conclusion: Dysthymia has a larger impact on mental functioning in medical disorders than MDD. In the medically ill, dysthymia should be treated as a separate diagnostic entity in various medical diagnosis leading to specific treatment recommendations.
WHICH FACTORS PREDICT THE PERSISTENCE OF DSM-IV ANXIETY, DEPRESSIVE AND SOMATOFORM DISORDERS IN THE MEDICALLY ILL 3 MONTHS POST HOSPITAL DISCHARGE?
Maria McKenzie, David Clarke, Dean McKenzie, Graeme Smith
Background: Psychiatric morbidity is common in the hospitalized medically ill. Despite this, psychiatric disorders are often not recognized or treated in medical inpatients, partly due to a belief that such disorders will resolve after amelioration of the acute illness. Few follow-up studies have been conducted in the medically ill. Predicting outcome in this population may have important implications for clinical practice.
Aims: To explore whether DSM-IV depressive, anxiety and somatoform disorders persist in a sample of 312 hospitalized medically ill patients 3 months post hospital discharge and which factors predict persistence of disorder.
Methods: The sample comprised medical inpatients who were cases on the 36-item GHQ. Patients were interviewed using the Monash Interview for Liaison Psychiatry – a structured psychiatric interview for the medically ill. Questionnaires eliciting socio-demographics, defense styles, illness behaviour and coping modes were administered. Baseline global assessment of functioning (GAF) was conducted. Follow-up interviews were conducted 3 months after hospital discharge. Best subset logistic regression was employed to find the best combination of predictors of persistence of psychiatric disorder.
Results: Anxiety disorders were more persistent than depressive and somatoform disorders. Family psychiatric history, more education, being female, lower baseline GAF, increasing age and few close relationships predicted persistence of depressive disorders. Lower baseline GAF predicted persistence of anxiety disorders. More education, greater use of acceptance-resignation and a higher hypochondriasis score predicted persistence of somatoform disorders.
Conclusion: Screening, early detection and treatment of psychiatric disorder in the medically ill are warranted to improve outcome.
MENTAL-PHYSICAL COMORBIDITY IN AN ETHNICALLY DIVERSE POPULATION
Kate Scott, Magnus McGee, David Schaaf, Joanne Baxter
Background: The relationship between mental disorders and chronic physical conditions is well established, but the possibility of ethnic group differences in mental-physical associations has seldom been investigated.
Aims: This study investigated ethnic differences in associations between four physical conditions (chronic pain, cardiovascular disease, diabetes, respiratory disease) and 12-month mood and anxiety disorders.
Methods: Te Rau Hinengaro: The New Zealand Mental Health Survey was a nationally representative household survey with 12,992 participants 16 years and over, with a response rate of 73.3%. This study is of the subsample of 7,435 who were assessed for chronic physical conditions (via a standard checklist), and compares Maori, Pacific and Other New Zealanders. DSM-IV mental disorders were measured with the Composite International Diagnostic Interview (CIDI 3.0).
Results: The ethnic groups differed significantly in prevalences of both physical and mental disorders, but almost no ethnic differences in mental-physical associations were found. Independent of ethnicity, associations were observed between chronic pain and mood and anxiety disorders, cardiovascular disease and anxiety disorders, respiratory disease and mood and anxiety disorders.
Conclusions: Despite differences in mental and physical health status between ethnic groups in New Zealand, mental-physical disorder associations occur with considerable consistency across the groups. These results suggest that whatever factors are conducive to the development of a mental disorder from a physical disorder (or vice versa), they are either unaffected by the cultural differences manifest in these ethnic groups, or, any cultural factors operating serve to both increase and decrease comorbidity such that they cancel each other out.
EMERGENCY MENTAL HEALTH SERVICE DELIVERY IN CANADA
Ian Dawe
Recent demographic and clinical changes, such as the increased appreciation of the role of medical disease in altered mental status, the epidemic of alcohol dependence and other substance related disorders, and the increasing reliance of the seriously and persistently mentally ill on psychiatric emergency departments for primary levels of care and treatment, have accentuated the role of emergency psychiatrists and ensured the continuing importance of the emergency psychiatry service to growing numbers of clients. Along with the increased numbers of patients being seen, the complexity and service requirements of these patients have increased considerably. The deinstitutionalization movements of the recent past, along with growing concerns over inappropriate, costly hospitalizations, have prompted planners and designers of mental health services to expand and innovate to ensure that emergency services are accessible, available, integrated and systematized, offer multidisciplinary and interprofessional approaches, and ensure effective communication between clients and providers. This presentation will provide an overview of current models of emergency mental health service delivery and offer commentary on future directions within the Canadian health care context.
Learning objectives: Participants will become familiar with the current shape and future directions of emergency mental health service delivery in Canada.
WHAT HAPPENS AFTER SELF-HARM?
Simon Hatcher, Cynthia Sharon, Nicola Collins
Background: Self harm presenting to hospital is common and important because of the link to suicide. We have just completed a randomised controlled trial of nearly 600 people receiving problem solving therapy after self harm which provided us with an opportunity to describe what was the usual treatment for people who self harm.
Aims: There were two aims to this study, the first was to review the recent literature on outcomes after self harm and secondly to describe treatment as usual in four centres in New Zealand.
Methods: We identified studies published in the last seven years reporting outcomes of individuals who presented to hospital with self harm. Secondly we used hospital databases and self report to describe what services the people enrolled in the control arm of the trial received after they self harmed.
Results: The literature suggests that the five year mortality in this group of patients with an average age in their early 30ís is between 10 and 15%. Only about half of this is due to suicide, other premature deaths are due to accidents and various health events. Patients who received “treatment as usual” in the study had very little follow up after they self harmed and this was not related to how suicidal they were at presentation.
Conclusions: Health services response to self harm is inadequate given the high mortality in this young age group. Studies of interventions in self harm should report all hospital contacts and all causes of mortality. This may generate novel ways of intervening after self harm.
OP20 DUAL DIAGNOSIS
THE ROLE OF CAUSAL ATTRIBUTIONS IN INFLUENCING CAREGIVER OUTCOMES IN EARLY PSYCHOSIS WITH A CO-MORBID SUBSTANCE USE DISORDER
Kerrie Clarke, Grace Couchman
There has been an increasing focus in the research literature on the high rates of co-morbidity between early psychosis and substance use disorders. This paper examines the effect that pre-morbid substance use has on the way that the caregivers of young people with an early psychosis make causal attributions. Previous research has shown these caregivers experience more distress and burden and are more likely to make attributions that generate higher levels of hostility and rejection. Thus the influence of pre-morbid substance use on caregiver causal attributions needs careful analysis to predict caregiver and client outcomes.
This paper will present a theoretical overview of the models utilized in caregiving research and a framework to understand the role of causal attributions in caregiver cognitions. It will examine the integration of caregiver cognitive models to inform best practice treatment. The paper will show that caregiver causal attributions may be more predictive of caregiver and client outcomes than many other factors.
This paper highlights the psychological elements of caregiver behaviour and their importance in determining caregiver and client outcomes. It presents an integrated model and fulfils a current field need to address dual diagnosis client recovery and associated family functioning. An integrated model provides an opportunity for effective interventions aimed at healthier caregiving relationships.
CO-MORBID PSYCHIATRIC DISORDERS IN CLIENTS ADMITTED WITH SUBSTANCE MISUSE TO A GENERAL HOSPITAL IN KINGSTON, JAMAICA
Winston De La Haye, Patrice Whitehorne, Monica Panton, Ken-Garfield Douglas
Background: Co-morbid psychiatric disorders impact on the management of substance abusers.
Aim: To describe the demographic characteristics, pattern of substance misuse and co-morbid psychiatric disorders in clients admitted to the Detoxification and Early Rehabilitation Unit of the University Hospital of the West Indies.
Method: Data from clients admitted between January and December 2005 were disaggregated using retrospective chart extractions and analyzed using the Statistical Package for the Social Sciences, Version 13.0.
Results: A total of 158 clients were admitted, with 144 (91.1%) males and 14 (8.9%) females. The mean age was 33.3±12.85 years, range 14-77 years (p = 0.000). The majority (115, 72.8%) was single and from the capital, Kingston (86, 54.4%), with 70 (49.3%), completing secondary level education or higher. The mean length of stay was 12.4±6.46 days. The main drugs of onset were nicotine and cannabis (68, 43.3% each), (p = 0.000), and the main drug of impact crack cocaine (84, 53.2%), (p = 0.000). A combination of nicotine, alcohol, cannabis and crack cocaine misuse (38, 24.1%) was the most common diagnosis (p = 0.000). A co-morbid psychiatric illness was identified in 50 (31.6%) clients (p = 0.000). Of these, the common diagnoses were major depressive disorder (13, 26%), schizophrenia (12, 24%), cannabis induced psychosis (12, 24%), bipolar disorder (7, 14%) and conduct disorder (5, 10%).
Conclusion: There is a high prevalence of co-morbid psychiatric disorders in this sample of substance abusers. Substance abusers in Jamaica should be screened for co-morbid psychiatric disorders.
NEUROPSYCHOLOGICAL ASPECTS OF DRUG ABUSE IN SCHIZOPHRENIA
Krzysztof Krysta, Irena Krupka-Matuszczyk, Adam Klasik
Background: There are many factors which can influence the cognitive functioning in schizophrenia, like the type of treatment, and comorbid use of substances. The number of patients with “dual diagnosis’; in both psychiatric and addiction treatment systems is increasing. Among them there is a large group of subjects suffering from schizophrenia with a comorbid addiction to drugs like opiats, amphetamins, cannabis.
Aims: The aim of this study is find out if there are differences in cognitive functioning in patients addicted and not addicted to psychoactive substances.
Methods: A group of 80 schizophrenic subjects underwent the examination, both men and women. 40 of them never used illicit drugs, the other 40 also matched criteria of drug addiction, mainly mixed addiction to different drugs. Each group included 37 men and three women. The addicted group was examined after a six-week period of detoxification and treatment in a therapeutic community, to avoid a direct influence of the used drug on the results. A battery of neuropsychiatric tests was used, which included TMT A and B, Stroop test – RCNb and NCWd version. Psychopatological symptoms were measured with the PANSS scale.
Results: No significant differences in cognitive functioning between two examined groups were found, which is consistent with some of the studies found in the literature.
Conclusion: This result may be a good predictor for this group in terms of their possible chances of successful rehabilitation, as cognitive functioning is often correlated with social functioning.
RELATIONSHIP BETWEEN CANNABIS USE AND THE PREVALENCE OF PSYCHOTIC SYMPTOMS AMONG DEPENDENT METHAMPHETAMINE USERS
Rebecca McKetin, Miriam Wyzenbeek, Dan Lubman, Sharon Dawe, Robert Ali
Background: Methamphetamine is a psychomimetic drug, and heavy use is associated with a high prevalence of psychosis relative to the general population. A large proportion of methamphetamine users also engage in heavy cannabis use, which may further increase their vulnerability to psychotic symptoms.
Aim: To determine whether cannabis use is associated with an elevated prevalence of psychotic symptoms among dependent methamphetamine users.
Method: A survey of 182 methamphetamine treatment entrants from the Sydney and Brisbane regions. Past month prevalence of Suspiciousness, Unusual Thought Content or Hallucinations was assessed using the Brief Psychiatric Rating Scale.
Results: Almost half of the sample (49%) reported a symptom of Suspiciousness, Unusual Thought Content or Hallucinations in the past month. Relative to participants who had not used cannabis in the past month, the odds of these symptoms being reported by participants who had used cannabis less than daily, and daily, was 2.1 (95% CI 0.9-4.7) and 3.1 (95% CI 1.4-7.5) respectively. These odds ratios were adjusted for a self-reported diagnosis of schizophrenia and frequency of methamphetamine use in the past month.
Conclusion: Cannabis use is associated with an elevated prevalence of psychotic symptoms among dependent methamphetamine users.
DUAL DIAGNOSIS IN LONDON: MOTIVATIONS FOR, AND SOCIAL CONTEXT OF SUBSTANCE USE AMONGST THE MENTALLY ILL
Peter Phillips, Sonia Johnson
Background: Substance use among the mentally ill has become more usual than exceptional, and dual diagnosis is a significant problem associated with adverse outcomes.
Aims: This study investigated the prevalence of dual diagnosis among adult in-patients; their substance use patterns, self-reported motivations for use, and the impact of hospitalisation on their substance use.
Methods: The clinician rated Alcohol and Drug Use Scales were used to identify all working age in-patients with psychotic illness with current or recent substance use. Participants were interviewed using self report of substance use, use situation inventories, and a self-medication measure.
Results: According to staff reports 129 (49%) met the criteria for substance use disorders. The mean age of those with dual diagnosis was 34, and 72% were male. Eighty-three (81%) reported they had continued to use substances on an in-patient ward during their current admission. Most participants were detained, and a wide variety of substances and use methods were employed by participants. A factor analysis of use situations data produced six motivational factors for use (negative personal and social states, pleasant social conditions, reward, social interaction and boredom, social acceptance and medication side-effects), and a k-means cluster analysis produced a seven cluster solution indicating sub-groups with differing motivations.
Conclusions: The prevalence of dual diagnosis in this sample of in-patients was high and exceeds previous UK community studies. Further examination of motivations for use, coupled with use patterns and socio demographic characteristics is a fruitful source for prevention and development of treatments at an individual level.
COMPARING TREATMENT OUTCOME IN THREE TYPE OF FACILITIES IN METHADONE MAINTENANCE THERAPY AMONG OPIATE DEPENDENCE IN MALAYSIA
Salina Aziz, Baizury Bashah, Salmah Nordin, Raminder Kaur, Norliza Che Mi, Rushidi Ramly
Prior to 2001 treatment of heroin addiction was mainly run through 28 government-run rehabilitation centers under the Ministry of Internal Security. Relapse rates were typically very high within the first year of release from these centers; usually between 70% and 90%. Other than the obvious social, legal and psychological complications of continued heroin abuse there came the added consequence of diseases transmitted via sharing of infected needles; particularly HIV and Hepatitis C. The number of HIV-positive people in Malaysia has increased dramatically in recent years. From only 4 cases in 1986, it has risen to a total of 992 cases by 1990 and 51,256 by 2002. Malaysia is a country with a HIV epidemic that primarily affects IVDUs. As of the end of 2001, 76 per cent of all reported HIV infections were to be found among IVDUs.
Hence forth the government has called upon all the relevant agencies involved in the management of drug addicts for a total paradigm shift in the management of heroin dependence clients. Since early 2005, methadone has been re-registered for use in Malaysia. Harm reduction initiatives was introduced in Malaysia and the piloting of methadone substitution therapies in 3 treatment setting/facilities was implemented i.e. hospital, community health clinic and private practitioner.
Results: Showed that the outcome of those getting treatment from community health clinic had a better outcome compared to hospital base (specialized).
OP21 BRAIN STIMULATION
STRATEGIES TO MINIMISE COGNITIVE EFFECTS: BIFRONTAL AND ULTRABRIEF PULSEWIDTH RUL ELECTROCONVULSIVE THERAPY
Colleen Loo, Bill Lyndon, Patrick Sheehan, Melissa Pigot
Background: Electroconvulsive therapy (ECT) is a highly effective treatment for depression, but its use is limited by the risk of associated cognitive side effects. This study aimed to investigate the relative effectiveness and cognitive side effects of ECT given in four different forms, varying in electrode placement and pulsewidth.
Aims: This study aims to determine the relative benefits of four different forms of ECT, in terms of effectiveness and cognitive side effects.
Method: Depressed inpatients referred for ECT in a psychiatric clinic in Sydney were recruited after giving informed consent. Subjects received the form of ECT prescribed by their treating psychiatrist (bitemporal at 1.5 times seizure threshold (1.5 ST), bifrontal at 1.5 ST, right unilateral at 5 ST, or right unilateral with ultrabrief pulsewidth at 6 ST). Mood (MADRS) and neuropsychological functioning (digit span, Rey Auditory Verbal Learning Test, Rey figure, Word generation, STROOP, Autobiographical Memory Interview) were assessed at baseline, after 6 ECT and at the end of the ECT course.
Results: The study is in progress and preliminary results (mood, neuropsychological function, seizure indices) will be presented.
Conclusion: All four forms of ECT appear effective, but preliminary results suggest some forms may be advantageous in terms of a lower rate of cognitive side effects, particularly bifrontal ECT and right unilateral ECT with ultrabrief pulsewidth.
DOES THE TYPE OF ANAESTHESIA MAKE A DIFFERENCE TO ECT OUTCOME?
Isaac Schweitzer, Anna Ingram, Chee Ng, Michael Saling, Greg Savage
The effects of the type anaesthesia used for ECT administration has been little studied. Different anaesthetic agents have greater or lesser affects on the convulsive threshold; it is therefore likely that such differential effects will significantly affect the nature of the seizure with implications for response to treatment and cognitive side effects. This paper will review the current literature pertaining to this clinically important aspect of ECT delivery.
Data of a study recently completed by the authors will be presented. The comparative effects of propofol (n = 18) and thiopental (n = 12) were examined in patients with Major Depression who participated in a larger study comparing three ECT types. Depression rating scales and a battery of neuropsychological tests were administered before ECT, after 6 treatments, at treatment endpoint and one month follow up. Compared with thiopental, use of propofol was associated with inferior response rate after 6 treatments (p=.035), at treatment endpoint (p=.057) and one-month follow up (p=.03). Use of propofol was also associated with significantly worse neuropsychological functioning at all time points. These findings suggest that propofol is less favourable than thiopental in terms of both efficacy and neuropsychological side effects up to one month follow up. This contradicts current clinical trends, which favor propofol due to its good early recovery. There is a critical need for further research in this area and current research directions will be discussed.
REVIEW OF RESEARCH ON COGNITIVE SIDE EFFECTS AFTER ELECTROCONVULSIVE THERAPY
Anna Ingram, Isaac Schweitzer, Michael Saling, Chee Ng, Greg Savage
Context: Cognitive impairment remains a common side effect of electroconvulsive therapy (ECT) and is a source of concern for both patients and mental health professionals alike. For patients, it may represent a fear prior to treatment; after treatment the presence of cognitive side effects may result in inconvenience or even distress for some patients. The level of impairment has been shown to vary according to different technical parameters of ECT, including but not limited to, electrode placement, dosage and waveform. As such, modification of technical parameters to minimise these side effects has been a central aim of much research in the area.
Objectives: The aim of this presentation is provide a review of research examining cognitive side effects of modern forms of ECT, with particular focus on the pattern of cognitive dysfunction after ECT and the associated recovery process.
Key messages: The majority of research in this area has focused assessment on memory function after ECT. Specifically, ECT can result in both anterograde and retrograde memory impairments. However, non-memory cognitive domains, while less commonly examined, are also impacted by the treatment. Furthermore, while considerable recovery has been observed within weeks of treatment completion, there is evidence of relative long term impairment for some patients, especially in the domain of retrograde memory.
Conclusion: The pattern of cognitive impairment post ECT may initially represent a more generalised cognitive dysfunction rather than primarily memory disturbance. However, there appears to be considerable variation in the speed of recovery for the different cognitive domains.
EEG BASED STIMULI MAY MODIFY THE EFFECT OF REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION IN THE TREATMENT OF DEPRESSION
Greg Price, Joseph Lee, Nathan Gibson, Geoff Riley
Background: There is considerable interest and debate about the efficacy of particular parameters to be used when applying rTMS stimuli in the treatment of depression. Comparison has been made with fast (5Hz,10Hz,15Hz,17Hz) versus slow, individual alpha frequency, and theta burst stimulation. Linking of stimuli to the background EEG was developed in ERP field, and we report the initial application of this process to rTMS stimuli.
Method: A standard treatment of 5 seconds at 10Hz, compared with interactive treatment that applies TMS stimuli when a selected pattern is detected in the background EEG. Both treatments comprised 40 trains, LDLPFC, 100%MT for 20 sessions. The methods are compared in terms of clinical ratings (HamD21, BDI), after a four-week treatment.
Results: There was a combined improvement, regardless of treatment type, in HamD21 and in BDI scores, although no adjustment was made for previously reported placebo effects. The improvement in HamD21 score with interactive treatment was more than for standard treatment (t = −1.5,p=.14), as well as in BDI (t = −1.7,p=.12). Using a 25% decrease in HamD as cutoff for clinical improvement, 6/14 improved with standard parameters, and 10/12 with the interactive technique (OR = 6.7;95%CI = 1.05–42.4).
Conclusion: This rTMS trial evaluates clinically, stimulus patterns derived from “theta burst” research (Huang et al., 2005), and interactive ERP research (Rahn, 1993) to determine whether such patterns are more efficacious. These stimulus pattern data show that the EEG interactive method is compatible with the requirements of an rTMS clinical trial, and leads to greater improvement in clinical scores than the standard treatment.
OP22 EPIDEMIOLOGY AND ILLNESS COURSE
EPIDEMIOLOGY OF SCHIZOPHRENIA IN MALAYSIA
Salina Aziz, Hayati Ali, Abdul Aziz Abdullah
Background: The National Mental Health Registry was developed since 2003 to collected data on new cases of schizophrenia. It provides detailed information about the profile of persons with schizophrenia who presented for the first time to various psychiatric and mental health services providers throughout Malaysia.
Results: From January 2003 till December 2004 there were a total of 4684 cases (2254 in 2003 and 2430 in 2004) registered with the NMHR. Mostly were males (65%) and most patients are single; and those married contributed only 25% of the total. Only 30% of the cohort had some form of jobs with 17% having full time employments. The mean DUP from analysis of data was 32 months, with a median of 12 months. Diabetes and hypertension are the two most common medical illnesses suffered by nearly 50% of all patients’ with medical illness. Most patients were started on oral medication; and typical antipsychotic seems to be the most commonly prescribed drug (53–62%). Depot medication was used in about 20–28% of the registered cases. Only 20% of all registered cases were treated with atypical antipsychotic.
Conclusion: In Malaysia patients with schizophrenia tend to present late, usually brought by family for treatment and nearly half needed hospitalization. Most of them are single and unemployed; and have comorbidity of substance abuse that could further render their recovery from their illness. Their duration of untreated psychosis is long (32 months). Typical antipsychotic seems to be the most commonly prescribed drug – (53–62%).
EFFECTIVENESS OF DAY CARE AND ANTIPSYCHOTICS FOR DISCHARGED PATIENTS WITH SCHIZOPHRENIA
Ken Mayahara, Yoshio Matsumoto, Junichi Hirakawa, Hiroto Ito
Aims: To examine the effectiveness of psychiatric day care (DC) and antipsychotics for discharged patients with schizophrenia.
Methods: Using systematic sampling, the subjects were 2,770 patients with schizophrenia who met the DSM-IV diagnostic criteria discharged from 527 psychiatric hospitals in Japan between April 2004 and March 2005. Of the patients, 735 received DC during the 6 months after discharge (DC group) and 2,035 did not (non-DC group). We retrospectively examined patient characteristics, frequency of receiving DC, prescribed antipsychotics, and readmission for 18 months after discharge.
Results: Cox regression analysis revealed that the DC group stayed in the community significantly longer than the non-DC group after adjustment for factors including age at onset and examination, number of previous admissions and the Global Assessment of Functioning (GAF) Scale. In the DC group, there was a tendency that patients who received atypical antipsychotics stayed in the community longer than patients who received typical antipsychotics. In both the DC and non-DC groups, patients who received one antipsychotic (monotherapy) stayed in the community significantly longer than patients who received two or more (polypharmacy).
Conclusions: These results suggest that day care could prevent readmissions of discharged patients with schizophrenia. Atypical antipsychotics and monotherapy should be further examined as a potentially important benefit.
PREVALENCE OF MENTAL HEALTH PROBLEM AT THE RURAL POPULATION OF URAL REGION, RUSSIA
Alla Zakroyeva, Alexander Solodovnikov, Olga Andriyanova, Linda Gask
Objectives: This paper describes the prevalence of depressive (D), anxiety disorders (A), alcohol abuse problems and smoking status and their associations for people at a rural population of the Ural region.
Method: The 520 rural respondents were asked using questionnaires to assess their demographic, social status, life quality (LQ) parameters (by SF-36), the probability of depressive, anxiety disorders (by GHAD), prevalence of somatic diseases, pain syndromes, their smoking status, and alcohol-abuse problems, clinical characteristics, blood pressure etc based on population randomized study.
Results: The parameters “50% probability of D” (and A) are 0,35 and 0,42 acc. The prevalence of D and A generally rises with the age until age of 70 years, than declines non-statistically for depression and continues to rise non-statistically for anxiety disorders. Most indices of quality of life (LQ) decline progressively with the age but don't differ statistically between women and men. Symptoms of D (and A) at women occur 1,2 (and 1,3) times more often, than at men and their expressiveness has a strong negative correlation with the indexes of LQ and is associated with some characteristics of somatic status. A high prevalence of alcohol abuse and smoking was not found but this may be due to the questionnaire design as people didn't want to answer openly.
Conclusions: Depression and anxiety disorders have high prevalence, especially for elder people, are strongly related to quality of life, and are associated with the other important indexes of somatic health at the rural population in Russia.
COURSE OF PERSONALITY DISORDERS OVER A TEN-YEAR FOLLOW-UP PERIOD
Natalia Chernyak
Personality disorders are defined as enduring patterns of maladaptive behaviors and traits that are stable over time. The aim of this study was to prospectively examine the course of personality disorders over a 10-year follow-up period in aspect of analysis of dynamic shifts.
We retrospective study of 100 male patients with personality disorders was completed at the Irkutsk Regional Psychiatric Hospital. These individuals were deemed not fit to serve Army due to personality disorders diagnosed in 1993-1995. The age of patients was 29-32. We based our research on the results of primary clinical the follow-up period and additional psychological examination using the psychometric scales MMPI, level of neurotic and psychopathic, volition disorders scale, personality scale of anxiety manifestation, rigidness level measurement, impulsivity scale (IS) by Plutchic.
Having analyzed the results of the research, three basic types of clinical dynamics were defined, with predictors of their course. The first regression type is the most favorable characterized by complete social adaptation, absence of clinical dynamic shifts and comorbid psychiatric pathology. The second type is stable; may be characterized by stable trait constellations that fluctuate in degree of maladaptive expression, it manifests partial social adaptability, dynamic shifts in forms of highly emotional type disorders caused by trigger mechanisms. The third type is progression; it is characterized by social maladaptive, presence of dynamic shifts in forms of psychopathic phases, comorbid due to psychoactive substance use.
Comprehension of clinical dynamics with predictors of personality disorders course needs to be considered for the purposes of treatment and rehabilitation.
AUDIT OF BENZODIAZEPINE PRESCRIPTION IN A COMMUNITY MENTAL HEALTH TEAM IN UK
Arunima Ghosh Nodiyal, Niraj Ahuja
Background: To enable good practise, National Services Framework requires assessment at national level to which benzodiazepine prescribing confines to guidelines.
Aims: To study benzodiazepine prescription in an Outpatient Clinic, aiming to identify shortcomings and changing practice.
Methods: The audit was conducted at an Outpatient Clinic in North Tyneside, UK. All the 245 patient's files were audited for benzodiazepine prescription over the past 1 year. The standards were on the basis of the Committee on Safety of Medicines guidelines, DOH Document (1999), and local guidelines. A semi-structured proforma was designed for collecting data on demographic variables, diagnosis, substance use, frequency, duration of prescription, documentation of risks, driving and sleep hygiene advice.
Results: Benzodiazepine co-prescription was seen in 25% of patients, with more than half being women. Two thirds of patients were over 50 years. 31% had a diagnosis of mood disorder, 20% of schizophrenia and 12% of personality disorders. Three-fourths received benzodiazepines for more than a month. More than half were not followed up regularly and three fourths did not have a plan of discontinuation documented in their medical notes. Advice about driving, alcohol and sleep hygiene was not documented in most medical notes.
Conclusion: Benzodiazepines were prescribed for longer than recommended in a significant number of patients, without plans for discontinuation, lack of advice on sleep, alcohol and driving in a majority of patients. The aim is to reaudit following recommendations made.
IS CHILD PSYCHIATRY FOR SALE?
George Halasz
I examine the epidemiology and purported causes for ‘epidemic’ of Attention Deficit Hyperactivity Disorder (ADHD) from 1995–2005. The evidence suggests that child psychiatry's ethical foundation to ‘first do no harm’ have been gradually eroded when we assess the cardinal symptoms of hyperactivity, inattention and impulsivity.
To reclaim our professional credibility we need to face a daunting challenge: to debunk the myth that ‘ADHD’ is an ‘illness’. We must declare that the letters ‘A’, ‘D’, ‘H’, ‘D’ stand for a complex set of symptoms caused by many conditions which include head injury, learning difficulties, anxiety and panic disorder, post traumatic stress disorder (PTSD), chronic sleep disturbance and attachment disorders.
Our profession must remain vigilant to discriminate between the semblance of similarities between ADHD symptoms caused by different conditions which require special skills to assess beyond eliciting DSM listed criteria. Symptomatic treatment, often the standard approach to ADHD, is no substitute for the treatment of the underlying conditions. The fact often overlooked is that the ‘performance enhancing’ qualities of the ADHD medication often masks the cause.
To challenge the widely held notion of ADHD being an authentic illness would likely upset many people. But to reify symptoms as a false illness is no longer tenable in light of the accumulated research evidence. This medical truth has been sold at a heavy cost. When will the price become too high for our culture, for the generation of children whose mental health has been impacted by that sale of medical truth?
OP23 ANXIETY
PERFORMANCE ANXIETY IN EVERYDAY LIFE AND CLINICAL PRACTICE
David M. Magder, Edna W. Magder
Context: There are many every day and clinical situations in which anxiety can influence performance, either enhancing it or seriously sabotaging it. Competitive sports, stage performances, giving a talk, taking an exam, preparing for surgery, complying with medications, marriage conflict, major psychiatric disorders are only a few. In 1908, Yerkes and Dodson published a study with rats looking at their performance in a stressful situation. They described an inverted U shaped curve showing the relationship between performance and stimulus strength. Since the late 1940′s, psychologists have extrapolated the relationship to a law linking performance and stress, the Yerkes-Dodson law. However, the link with psychopathology and psychotherapy is seldom made.
Objectives: In this presentation, at the centenary of the original experiment by Yerkes and Dodson, the applicability of the Yerkes-Dodson data to psychological difficulties will be outlined. For the patient as well as the physician, anxiety and its consequences can be subtle or obvious, easily overlooked or impossible to miss.
Key messages: The aim of this presentation is to give pointers on recognizing signs of relevant performance anxiety in one's patients, interpreting its origins, meaning and impact, and some approaches to management. The role of suppression in contributing to the consequent psychopathology will be outlined. References will be made to the psychological literature and case vignettes presented.
Conclusion: An understanding of the Yerkes-Dodson Law will lead to more efficient interventions in brief or long term psychotherapy for anxiety and depression.
POST-TRAUMATIC STRESS DISORDER AND ASSOCIATED RISK FACTORS IN CANADIAN PEACEKEEPING VETERANS WITH HEALTH-RELATED DISABILITIES
Donald Richardson, James Naifeh, Jon Elhai
This study investigated post-traumatic stress disorder (PTSD) and its associated risk factors in a random, national Canadian sample of United Nations peacekeeping veterans. Participants included 1016 male veterans (age <65 years) who served in the Canadian Forces from 1990 to 1999, selected from a larger random sample of 1968 veterans who voluntarily completed an anonymous general health survey conducted by Veterans Affairs Canada in 1999. Survey instruments included the PTSD Checklist-Military Version (PCL-M), Center for Epidemiological Studies-Depression Scale (CES-D), and questionnaires regarding life events in the past year, current stressors, sociodemographic characteristics, and military history. We found that rates of “probable” PTSD (PCL-M scores > 50) among veterans was 10.92% for veterans deployed once and 14.84% for those deployed more than once. The rates of “probable” clinical depression (CES-D score >16) was 30.35% for veterans deployed once and 32.62% for those deployed more than once. We found that in multivariate analyses, “probable” PTSD rates and PTSD severity were associated with younger age, being unmarried and number of deployments. PTSD is an important health concern in the veteran population. Understanding such risk factors as younger age and unmarried status can help predict morbidity among trauma-exposed veterans.
QUALITY OF LIFE CHANGES AMONG PATIENTS WITH OBSESSIVE-COMPULSIVE DISORDER IN INDIA
Shruti Srivastava, Manjeet Singh Bhatia
Background: Obsessive-compulsive disorder (OCD) is the fourth most frequent diagnosis in psychiatry. Patients with OCD suffer from obsessive thinking and compulsive behavior, which has a great impact on their everyday life.
Objective: Subjective quality of life (QoL) in patients with OCD was examined and compared to the general Indian population.
Methods: We measured quality of life(QOL) changes in thirty OCD outpatients longitudinally for six months using WHOQOL-BREF, Hindi version. Socio- demographic data were recorded for all patients. Symptom severity was measured using the Yale- Brown Obsessive Compulsive Scale(YBOCS). Comparisons were made between baseline, three months and six months scores of psychiatric outpatients and scores of general Indian population.
Results: Compared with that of the general population, the QoL of patients with OCD was significantly lower in the domains physical well-being and psychological well-being. YBOCS scores significantly improved with treatment, as did scores on Qol subjective indexes. We found significant association between changes in YBOCS scores and QOL scores.
Conclusions: These findings indicate that all aspects of QOL are markedly affected in individuals with OCD and are associated with OCD severity.
SCHIZO-OBSESSIVE DISORDER: A DISEASE WITHOUT A DIAGNOSIS
Debashis Ray, Tiindivanan Sudhir, Dipesh Bhagwati, Partha Dutt, Ranadip Ghoshroy, Prabir Paul, Gautam Saha
Background: Obsessive/compulsive features are known to be associated with schizophrenia. There seems to be an overlapping confluence in the phenomenology of schizophrenia and obsessive-compulsive disorder. The authors propose that concealed in this continuum is a separate and syndromal nosological entity.
Method: 100 consecutive patients (63 males and 47 females) without past history of diabetes insipidus, spina bifida and without family history of obsessive-compulsive disorder, who received a DSM-IV-TR diagnosis of schizophrenia, were followed up over a 12-month period. Psychotropics like clozapine etc., which are known to induce obsessive/compulsive psychopathology, were avoided. Baseline and fortnightly Young-Brown's Compulsive Obsessive Scale (YB-COS) was employed. Scale for Assessment of Positive Symptoms (SAPS) and Scale for Assessment of Negative Symptoms (SANS) were also administered fortnightly.
Results: Seven patients (2 males and 5 females) were subsequently excluded as they had to be administered clozapine. Obsessive–compulsive features were found in 30.1% (28/93) patients. The incidence and severity of these symptoms were significantly higher in females than in males. Positive formal thought disorder, delusions, inattention and poverty of speech showed a statistically significant positive correlation with the severity of obsessive-compulsive symptoms.
Conclusion: The possibility of “Schizo-obsessive disorder” as an independent diagnostic entity is becoming progressively stronger and may also have a different set of neurobiological substrates specific to it.
OP24 PSYCHIATRIC NURSING PRACTICE ISSUES
OPEN DOORS: INVITATIONS TO SELF-GOVERN IN ACUTE PSYCHIATRIC UNITS
Bridget Hamilton, Cris Mileshkin
Background: In Australia and internationally, public psychiatry services are under pressure from lawyers and policy makers to lock acute units. Yet considerable human rights concerns and staff deskilling can be associated with locking units. This paper details conditions and practices that offset the need for this coercive step, in everyday inpatient care.
Method: Our argument for keeping wards open is supported by data from an 18 month ethnographic study, in two metropolitan acute wards. Each ward had facilities to care for up to three patients in a locked high dependency area and 19 patients in the main, open areas of the wards. The majority of patients were involuntarily admitted. Fieldwork focussed on the practice of 11 psychiatric nurses.
Results: The study identified ward conditions and nursing practices that minimised the risk of patients absconding. Psychiatric nurses subtlely re-shaped behaviour, to keep patients safe. Nurses minimised their direct control over patients and instead routinely used discreet surveillance, phatic conversation and purposeful activity, supported by an engaging group program. Correspondingly, patients were inclined to self-monitor and self-manage, in order to enjoy freedom of movement.
Conclusion: In the research setting, attention was paid to nursing practices and routines that offset the risk of patients absconding. The open front doors presented an invitation for nurses and patients to share decision making and control of patient conduct. Whilst locking doors represents a common-sense response to risk management, this blunt mode of control can compromise skilful care and undermine patients’ own steps toward recovery.
THE WORKPLACE AND SELF-HELP: STORIES FROM NURSES WHO HAVE A MENTAL ILLNESS
Terry Joyce
Context: This paper reviews a qualitative PhD study that used face-to-face individual interviews to examine the workplace experiences of 29 nurses in New South Wales, Australia who have a mental illness.
Objectives: The aim of the study is to explore how nurses make meaning about mental illness and the mindsets and practices they employ in resisting stigma and discrimination at the workplace.
Key message: As nurses with a mental illness, they crossed over the metaphoric boundary that separates nurses from patients. Consequently, most participants experienced the stigma of mental illness. For the majority of the nurses this issue adversely affected their decision whether to disclose their illness to others. The manner in which they managed their illness and achieved role expectations was in the main, influenced by the degree of managerial support and collegiality.
It was clear that overall, nurses who have a mental illness work in an unsupportive environment and are likely to benefit from a self-help support group. Hence, the initiation of an e-mail support group specifically for Australian nurses. This group also includes members from New Zealand. Nurses from the US and Canada have expressed interest in joining.
Conclusion: An outcome of their mutual support is a clearer view of how nurses with a mental illness can work in partnership with policy makers and employers, to develop or reform policy and practices which can enhance workplace support for nurses experiencing mental health problems.
NON-MEDICAL PRESCRIBING OF ANTIPSYCHOTIC AGENTS BY SPECIALLY TRAINED MENTAL HEALTH NURSES
Sai Lu, Terence McCann, Eileen Clark
Background: Non-medical prescribing by nurses is becoming common in some countries, but limited attention has been paid to ascertaining mental health service users’ attitudes towards mental health nurses being authorised to prescribe antipsychotic medications.
Aims: The broad aim of the study was to assess the attitudes of service users towards non-medical prescribing of antipsychotic agents by specially trained mental health nurses.
Methods: A non-probability sample of service users (n = 81) diagnosed with schizophrenia took part in the study using the Factors Influencing Neuroleptic Medication Taking Scale. Participants were recruited by case managers in community mental health centres in the Western Metropolitan Region of Melbourne and the Grampians Region of Victoria, Australia.
Results: There was uncertainty about whether mental health nurses should have prescriptive authority, and the majority felt that this approach to prescribing made no difference to their medication taking. Younger participants were more likely than older participants to favour nurses being permitted to discontinue their prescribed medication. Most considered their relationships with mental health nurses as satisfactory. Most were satisfied with the way mental health nurse case managers responded to their concerns regarding antipsychotic medications and the perceived knowledge of these nurses about medications.
Conclusions: The results draw attention to service user support for non-medical prescribing by specially prepared mental health nurses. They highlight the need for nurses to be properly educated to assume this important role. Attention is drawn to the requirement for further research into several related areas, such as the cost-effectiveness of mental health nurse prescribing.
A LITTLE BIT OF UNDERSTANDING, A HEAP OF BENEFIT: EARLY FINDINGS OF AN INTERVENTION STUDY TO RAISE UNDERSTANDING OF SELF-INJURY AND PREPARE EMERGENCY NURSES TO USE A SOLUTION FOCUSED MODEL OF CARE
Margaret McAllister, Wendy Moyle, Stephen Billett, Melanie Zimmer-Gembeck
Background: In Australia, the most common site service used by self-injurers is the emergency department. Even though nurses are the key clinician available to such patients, nurses have usually received no special training to identify and address the needs of these clients. A recent study found that nurses feel ill-prepared, lack clear frameworks for practice and are thus vulnerable to subtle discourse tensions such as managing versus caring, and diagnosing versus understanding. Often, they feel unable to effectively care.
Aims: In order to try to assist nurses and patients, an intervention study was implemented in two large Departments of Emergency Medicine in Queensland.
Methods: The study used a combination of methods to gather and analyze data. Firstly, emergency nurses were interviewed to understand their existing knowledge about self harm including experiences in providing care including an intervention to determine perceptions of self-harming patients. Following this, case study scenarios were used to ascertain nurses’ response to self-harming patients. An educational intervention was provided to develop further understandings and practices associated with self-harming patients. Finally, a further phase of case studies was used to ascertain the effectiveness of the educational intervention.
Findings: This paper describes the intervention and discusses the early findings that indicate a growing knowledge base, improved attitudes and increased feelings of personal competence.
STRIVING TO CONNECT: LISTENING TO ADULT CHILDREN OF PARENTS WITH SERIOUS MENTAL ILLNESS
Kim Foster
Background: Empirical research has identified adult children of parents with serious mental illness (ACOPSMI) as being at higher risk of developing mental illness and/or psychosocial problems than the general population. There is evidence, however, that these risks may be mediated by factors such as social and interpersonal supports and the development of resilience.
Aims: Due to limited research into adult children's subjective experience of growing up with parents with serious mental illnesses, the present study aimed to describe the experiences of ACOPSMI, and to deepen understandings of the family life in which mental illness occurs.
Methods: Using a qualitative design, a purposive sample of 9 ACOPSMI took part in a lengthy unstructured interview which explored their experiences. Using autoethnography, the researcher's own experience of being ACOPSMI was also included in the study, giving a total of 10 participants. Verbatim interview transcriptions were thematically analysed using van Manen's (1990) analytic approach.
Results: Four themes of the experience of being ACOPSMI were uncovered. These were Being Uncertain – ‘you'd think this roller coaster is never going to stop’; Struggling to Connect – ‘we were super close and now we're not’, Being Responsible – ‘I think I grew up in a hurry’ and Seeking Balance – ‘I had to be in control of the situation’.
Conclusion: Although ACOPSMI can experience difficulties; with information, support and partnership with others, particularly mental health professionals, the future for them is by no means determined. A family-focused approach can be of significant benefit to both parents and children.
OP25 RESEARCHING THE IMPACT OF TREATMENT PROGRAMS
GROUP PROGRAMS IN A YOUTH MENTAL HEALTH SERVICE
Marni Luxmoore, Sue Cotton, Gina Woodhead, Dianne Albiston, Hanna Schotten, Patrick McGorry
Background: The ORYGEN Youth Health Group Program is a comprehensive outpatient program that provides group interventions to specialized clinics such as the Early Psychosis Prevention and Intervention Centre (EPPIC) and Youthscope (Mood and Anxiety, and emerging Borderline Personality Disorders).
Aims: This study has four aims: first, to describe the characteristics (demographic, diagnostic, presenting problems, reasons for referral) of patients who were referred to the Group Program; second, to evaluate client outcomes by assessing goal attainment and changes in SOFAS and Rosenberg Self-Esteem Scores; third, to establish whether there are any differences between patients with psychotic and non-psychotic disorders with respect to reasons for referral, presenting problems and clinical outcomes; fourth, to determine whether there are any differences between patients who are referred to the program but who did and did not attend.
Method: The current study involves extraction and analysis of data that is stored in the Group Program Clinical Database pertaining to 212 patients of ORYGEN who were referred to the Group Program between the 03 July 2001 and 25 November 2003.
Results: Clients referred to the group program were mainly students or unemployed, and the main reasons for referral included relationships and communication, vocational/educational issues, time use, and symptom management. Details on clients’ outcomes and differences between clients with psychotic and non-psychotic disorders in terms of service utilisation will also be discussed.
Conclusions: Group interventions are an effective and developmentally appropriate treatment option for young people with mental illness.
CHALLENGES AND STRATEGIES FOR ENGAGING YOUNG PEOPLE INTO GROUP PROGRAMS
Gina Woodhead
ORYGEN Youth Health includes an extensive group program as part of a comprehensive mental health service of up to two years duration for young people aged between 15–25 years residing in the Western suburbs of Melbourne.
The recovery group program focuses on enhancing client strengths as well as addressing individual goals and interests. Up to 18 different groups are offered each week. Areas most relevant to young people and addressed by the group program include; peer support, social relationships, creative pursuits, psychoeducation and vocational skills.
Current service audits suggest that over one third of clients are referred to the group program, however a number of them refuse to attend.
There are several possible explanations for lack of engagement and these include; symptoms, fear and stigma. However, feedback from clients engaged supports that the benefits of attending outway initial hesitation and fear.
Taking this into account group program clinicians are pro-active about engaging new clients into the program. Although relevant literature for this population is scant, strategies utilised are commonly developed from behavioural principles.
This paper will address possible reasons for non-attendance and will then focus on specific areas of intervention that may increase engagement. These include; developing a therapeutic relationship, offering continuity of care, creating a youth friendly environment, the collaborative setting of goals; and the provision of age-appropriate, fun activities. Finally, examples of specific behavioural strategies utilised will be presented.
‘BLAZING SADDLES’: THERAPEUTIC HORSEBACK RIDING FOR YOUNG PEOPLE WITH MENTAL ILLNESS
Sue Cotton
Background: Animal Assisted Therapy (AAT) has been used for centuries to facilitate physical and mental health in humans. Therapeutic horseback riding, one form of AAT, has been shown to be effective in reducing anxiety and levels of depression, improving self-esteem, self-confidence, self-image, mastery, interpersonal skills, and motivation, in psychiatric populations.
The ‘Blazing Saddles’ therapeutic horseback riding program has been created through a unique partnership between ORYGEN Youth Health (a mental health service for young people) and Riding for the Disabled – Victoria (RDAV).
Aims: The aim of this study is to evaluate both short- and long-term benefits of the 10-week ‘Blazing Saddles’ program for young people with mental illness with respect to psychological (reducing depression, anxiety, stress, self-esteem, mastery), functional (quality of life), and social well being (social connectedness).
Method: Participants were recruited through the Group Program at ORYGEN Youth Health and are aged between 15–25 years of age. ‘Blazing Saddles’ was conducted over a 10-week period at one of the RDAV's Centres. Participants develop their riding skills, and learn horsemanship (i.e., how to tack up a horse, grooming, health care). A battery of questionnaires is completed at baseline, at the end of the 10-week program, and at 6 months follow up.
Results: A combination of qualitative and quantitative pilot data will be presented.
Conclusions: This study is unique and provides promising preliminary data about the therapeutic benefits of ‘Blazing Saddles’, warranting larger-scale investigations.
OUTDOOR ADVENTURE FOR YOUNG PEOPLE WITH MENTAL HEALTH ISSUES
Lori Schell, Marni Luxmoore, Sue Cotton
Background: ORYGEN Youth Health (OYH) provides early intervention clinical services to young people aged 15–25 with severe mental health issues, including both psychotic and non-psychotic disorders. The Group Program at OYH provides a range of developmentally appropriate group interventions including an Outdoor Adventure Group (OAG). Adventure Therapy is the use of challenging adventure experiences to facilitate therapeutic change and can assist with issues such as low self esteem and social isolation.
Aim: The study proposed that those who attend an 8-week OAG (vs. those who attend a variety of centre-based groups) experience an increase in self-esteem, social connectedness, and a sense of mastery and achievement.
Method: A pre- and post-design was used to measure change in personal goals and measured outcomes. This data will also be compared to the control group to determine if there are differences across the groups. Participants also completed a feedback form at the end of the OAG, which will provide additional information about their experience in the group.
Results: Both quantitative and qualitative results will be presented and implications for future research will be discussed.
Conclusions: Important developmental tasks can be severely disrupted when a young person experiences mental health issues, resulting in social and psychological isolation and reduced self-esteem. Group interventions, such as Adventure Therapy assist young people in overcoming these disruptions and provide peer interaction and sense of belonging.
A LONGITUDINAL STUDY OF THE EFFECTIVENESS OF DEMOCRATIC THERAPEUTIC COMMUNITY DAY SERVICES FOR PEOPLE WITH PERSONALITY DISORDER
Wally Barr, Kate Hellin, Suzanne Hodge, Andy Kikcaldy
Background: Whilst there is evidence that residential and five-day democratic therapeutic community (DTC) services can be effective for people with personality disorder, there remains a question whether these same principles can successfully be transferred to non-residential settings in the community with once-weekly meetings. This paper reports results from the quantitative element of a study of four of the DTC day services developed by the Therapeutic Community Service North in the north of England.
Aims: The evaluation is intended to establish the long-term impact for people with personality disorder of one day per week day services that have adopted the DTC model.
Methods: The design is both quantitative and qualitative and the full evaluation is taking place over three years. The study has established baseline measures of the functioning and service satisfaction of service users who currently attend one of the four day services under study and is tracking changes in service user functioning at a further six assessment points over the following three years. As well as service users, other participants in the baseline and 12 month assessments are former service users, staff, service user consultants and those in a position to refer people to the services.
Results: Results reflect a number of improvements in the mental health, self-harming behaviour and social functioning of service users.
Conclusion: First-year results indicate several problematic issues but also a number of more positive findings.
EXPLORING THE EXPERIENCE OF MENTAL HEALTH PROFESSIONALS
Rachel Rossiter, Toni Schofield, Michael Hazelton
Background: Despite the development of effective therapies for treating clients with borderline personality disorder (BPD), research continues to describe the difficulties that many mental health professionals experience when working with clients with BPD. A discourse of therapeutic pessimism remains apparent. Dialectical Behaviour Therapy (DBT) as developed by Linehan has been the treatment model of choice in a public mental health service in NSW Australia for seven years. A project undertaken in a semi-rural region of this service was designed to implement DBT as a treatment option for clients with BPD. Evaluation of the education program undertaken to prepare clinicians to deliver DBT suggested that the impact of practising as a DBT therapist was greater than anticipated.
Aim and method: A qualitative research project designed to explore the experience of mental health professionals practising as DBT therapists was commenced in July 2005. In-depth, semi structured interviews were conducted with clinicians practising as DBT therapists.
Results: Data analysis revealed a marked shift in perspective from ‘management to treatment’. Participants described positive professional and personal impacts of training and practising as DBT therapists. Enhanced capacity for self-awareness and ‘living life to the full’ was described by a number of participants.
Conclusions: This initial research suggests that the practice of DBT by clinicians can generate a positive shift in both personal and professional identities that translates into a more optimistic and humanistic approach to clients diagnosed with BPD. Such a change may represent a significant challenge to the prevailing mental health discourse and practice associated with BPD.
OP26 CULTURAL, SPIRITUAL AND FAMILY
INTER-SECTORAL COLLABORATION AND INTER-DISCIPLINARY RESEARCH – WORKING TOGETHER FOR BETTER MENTAL HEALTHCARE TO CALD COMMUNITIES
Bibiana Chan
Background and aims: Studies of primary care services by culturally and linguistically diverse (CALD) communities in Australia have revealed a low rate of consulting psychiatrists but a high percentage of mental health cases under bilingual GPs’ care. Under-utilisation of mental health services and high involuntary admissions by Chinese-Australians reflect a huge gap in service. A study combining qualitative and quantitative methodology was undertaken to examine this service gap.
Methods: Australians (n = 143) and Chinese (n = 441) were surveyed; and 16 community focus groups were conducted in Cantonese, Mandarin and English. A standardised measure (SL-ASIA) and self-ratings of Australian identities were used to assess participants’ acculturation level. Depressive experiences (e.g. symptoms, explanatory models and help-seeking strategies) were reported. Comparisons were drawn between Australians and Chinese at various levels of acculturation.
Results: Research findings indicated a pressing need to adopt a collaborative model. Mental health services sectors: the Health System, the Psychological Service, and Socio-cultural Support should collaborate more closely and there should be substantial overlap between the different sectors indicating the importance of inter-disciplinary knowledge.
Conclusions: More interdisciplinary research is required to foster better health care and to identify priority areas of services for CALD communities. Implications for managing clinical depression at a global level will also be discussed.
NECESSARY CHANGES FOR MAORI MENTAL HEALTH SERVICE DELIVERY TO ENSURE CHANGE
John Grigor, Wiremu Nia
Despite the widespread provision of culturally focused speciality Maori Mental Health Services, with the emphasis on service provision by Maori for Maori, there is yet little evidence that the inexorable rise of mental ill health in Maori has halted or slowed. First admission rates and readmission rates continue to rise both in acute and in forensic psychiatry settings.
The authors have been identifying factors in diagnosis and treatment which fall outside the conventional paradigms and which they believe make a vital difference in outcomes.
They believe that the approach must recognise that Maori, the world's greatest and most persistent travelers, attend more to background detail than any individual in the foreground and that the learning of verbs as the first words, emphasises a different focus on interaction between people than the individuals themselves. Western focuses on the individual mean less and the focus returns to the family, extended family and tribe. This change in emphasis is critical and family involvement is central to therapy. Before this can begin, the restoration of morale requires all the energy and strength of workers in the area as they undo the loss of land, culture, language and identity. The presenters will demonstrate, by case example, successful outcomes.
A MAHITAHI (COMMUNITY AND CLINICAL) CULTURAL APPROACH
Donny Rangiaho
Context: Maori comprise 17% of the New Zealand population and twice the percentage of high and complex mental health presentations within the country. Within the local region of Counties-Manukau, Auckland, NZ Mahitahi Trust has developed outstanding success in working collaboratively with Maori mental health and addictions clinical services in both Child, Youth and Adolescent and Adults, to deliver complimentary support services to clients (tangata whaiora) and families (whanau).
Objects: In respect to Maori who predominantly present with high and complex needs, collaboration had to be entered into to ensure the following:
Cultural aligned community support services to compliment clinical support this target group
Ensure strong continuity of services delivery across mental health sector for Maori
Broker community engagement for Maori with other government services i.e. Department of Welfare, Housing, Primary Care, Education and training
Key messages: The efforts of working together between community and clinical services require attention to these approaches:
Building trusting relationships evidenced with competence and willingness to engage
Creating shared resources to support client (tangata Whaiora) need
Developing a complimentary and retainable sector workforce between community and clinical services
Conclusion: Working together and building partnerships have invariably highlighted success to clients (tangata whaiora) through the following outcomes:
Cost efficiency
Workforce management
Volume management
Service coordination
Higher engagement rates
Reduced service duplicity
RELIGION AND MENTAL HEALTH
Margreet De Vries-Schot
In 1994 the 4th edition of the Diagnostic and Statistic Manual of Mental Disorders added the category V62.89 ‘religious or spiritual problem’. The reason is that religious and spiritual themes represent important dimensions of life and therefore deserve attention in (mental) health care.
In order to assist (mental) health care workers in their daily work, it is necessary to clarify the concept ‘healthy religiosity’ for making it possible to assess a person's faith in (mental) health care.
A study of scientific literature in the field of psychiatry, psychology and theology was undertaken. Subsequently, a 50-items questionnaire was presented to a panel of psychologists/psychiatrists and theologians according to the Delphi-method. After two rounds 23 items reached consensus, which can be used as criteria for the assessment of a person's faith.
Of those criteria 21 could be clustered in three factors: ‘Orientation to higher values out of a sense of inner freedom’, ‘Trust in God pervades the entire life’, ‘Responsibility for fellow humans and creation’.
Based on the conclusions, a vision on interpersonal care and its relevance for (mental) health care and pastoral care, is unfolded. It is proposed that justice be done to all relevant dimensions of human existence by extending the biopsychosocial model to a biopsychosocialspiritual model, abbreviated BPSS.
FAMILIES AND MENTAL DISORDERS-CHALLENGES
Jitendra Trivedi, Saroja Krishnaswamy, Min-Soo Lee, Jim Crowe
No person, society or country is immune to mental disorders. The impact of these disorders on psychological, social and economic well being is quite severe. Around 450 million people in the world suffer from psychological problems and mental disorder. About 25% people are affected by behavioural disorders during their lives. Five of the ten leading causes of disability and premature death worldwide are psychiatric conditions. The South Asian region is the most populous with 23% of the world's population and amongst the poorest regions in the world. There is growing epidemiological evidence of a high burden of mental disorders. Rates of disorders such as depression and anxiety reported from the region are amongst the highest in the world.
There are various researches which validate the role of family and other informal supports in the care of chronically ill psychiatric patients. It has led to understand and focus our attention in knowing the dynamics of the situation and making an attempt to discover ways for improving the outcome of the illness. Family studies have explored the burden that caregiver experience that their loved ones are suffering from psychiatric disorders in the form of perception of strain, reduced morale, anxiety and depression (Robins et al.,1982). The major concerns include disruptions during acute episodes, fear of violence, worsening of marital relationship, financial and legal problems. The recent studies have shown that the relatives or family members of the chronic mentally ill patients want more information and involvement in treatment decisions, good relationship with the care providers, good co-ordination among the services and more intensive and supportive interventions.
During the past two decades, the trend has changed in treating psychiatric patients. The policy of treating patients in their family settings reduces the cost and may help early recovery and prevent chronic relapses. The family has to face new challenges with this changing trend. During this symposium we will discuss few of these challenges associated with mental disorders especially in South Asia.
FAMILY FUNCTIONING PREDICTING TREATMENT OUTCOMES IN VETERANS
Lynette Evans, Malcolm Hopwood
Background: The role of family functioning in treatment outcomes of Vietnam veterans with Posttraumatic Stress Disorder (PTSD) has to date not been investigated (except by the current authors in a previous paper).
Aims: This study sought to examine family functioning at Time 1 to predict PTSD subscales (arousal, avoidance, intrusion) symptoms, and the sub-scales of the GHQ (anxiety, depression, social, somatic) at Times 2 (9 months) and 3 (21 months) post-treatment.
Method: Veterans (n = 307 at 9 months, and n = 246 at 21 months) completed questionnaires on the above measures at intake, prior to the commencement of treatment. They then took part in an individual treatment program. Nine months and 21 months post treatment the outcome measures were re-administered. Results: Family functioning in veterans at Time 1 was a good predictor of level of self-reported PTSD symptoms both 9 months and 21 months (with the exception of the intrusive symptom scale at 21 months). The GHQ subscales of anxiety and depression were also good predictors at 9 months although less effective at 21 months.
Conclusions: Veterans with PTSD with functional families are more likely to benefit from treatment whereas veterans with dysfunctional families have more problematic outcomes in terms of treatment. Focusing on the relationship between treatment and family functioning may provide valuable insights into possible future interventions.
OP27 PHARMACOTHERAPY
EVALUATION OF AUSTRALIAN PATIENTS FROM THE e-STAR SURVEY: 24-MONTH INTERIM ANALYSIS FROM THE e-STAR DATABASE
Tim Lambert, Brett Emmerson, Harry Hustig, Michael John Povey, Annette Lam, Belinda Butcher
Background: e-STAR is an ongoing web-based, long-term prospective observational study of medication usage patterns and outcomes of patients initiated with long-acting risperidone.
Aim: To evaluate the 24-month outcomes of patients entered onto this registry from interim data.
Methods: Data from 348 Australian patients with =1 recorded piece of information at 24-months post initiation with long-acting risperidone were extracted from the e-STAR database. For this analysis, p was set at 0.01.
Results: At 24-months, the mean dose of long-acting risperidone was 43.4 mg, compared to 26.5 mg at baseline; 25.8% of patients were administered 25mg, 25.4% administered 37.5 mg and 37.1% administered 50 mg doses.
Clinical Global Impression-Severity (CGI-S) and Global Assessment of Function (GAF) scores were available for 325 patients. The mean±SD CGI-S score decreased significantly from 4.5±1.1 at baseline to 3.7±1.1 and 3.6±1.1 at 12- and 24-months, respectively (p < 0.001 versus baseline). At baseline the mean±SD GAF score was 42.2±14.6, increasing to 55.5±16.0 and 58.9±15.3 at 12- and 24-months, respectively (p < 0.001 versus baseline).
Hospitalisations decreased from 1.22 new hospitalisations per year during the 12-months before long-acting risperidone initiation to 0.8 and 0.69 after 12- and 24-months, respectively, of long-acting risperidone treatment.
A reduction in benzodiazepine use was observed, with no changes in antidepressant, mood-stabiliser or somatic medication use. A reduction in anticholinergic use was also observed (p = 0.018).
Conclusions: Previously reported early improvements in function, symptom control and hospitalisation continued to 12- and 24-months following initiation on long-acting risperidone treatment.
N-ACETYL CYSTEINE AS A GLUTATHIONE PRECURSOR FOR SCHIZOPHRENIA: A DOUBLE-BLIND, RANDOMIZED, PLACEBO-CONTROLLED TRIAL
Michael Berk, Ashley Bush, David Copolov, Olivia Dean, Kristy Lu, Paul Katz, Ian Schapkaitz, Murray Anderson-Hunt, Fiona Judd, Michel Cuenod
Background: Antioxidant defences and brain glutathione levels are decreased in schizophrenia, with unknown relevance for this disorder. N-acetyl cysteine (NAC) is a safe, orally bioavailable precursor of glutathione.
Aims and methods: In a randomized, double-blind, multicenter, placebo-controlled study, we evaluated people with schizophrenia who were treated with NAC (1g BID) as an add-on to their antipsychotic medication over a 24 week period, followed by a 4 week washout. The primary outcomes were change in Clinical Global Impression (CGI) Severity and Improvement scales, and change on the Positive and Negative Symptoms Scale (PANSS) over the study period. Secondary outcomes included general functioning and extrapyramidal side effects rating scores.
Results: 140 participants were randomly assigned to treatment. NAC treatment led to a significant improvement over the study period in CGI-Severity (CGI-S, mean difference [NAC-placebo; 95% confidence intervals], −0.26 [−0.08, −0.44], p = 0.004), and CGI-Improvement (CGI-I, −0.22 [−0.03, −0.41], p = 0.025) scores compared to placebo treatment. NAC induced a significantly greater improvement compared to placebo treatment on PANSS Negative (−1.83 [−0.32, −3.33], p = 0.018), PANSS General (−2.79 [−0.20, −5.38], p = 0.035) and PANSS Total (−5.97 [−1.51, −10.44], p = 0.009) scores at Week 24 when compared to baseline. NAC treatment also produced a significant improvement in akathisia. Effect sizes at endpoint were 0.43 on the CGI-S, 0.52 for the PANSS negative subscale, 0.57 for the PANSS total, consistent with moderate effects.
Conclusion: The observation of moderate effect sizes in a relatively refractory cohort indicates that NAC is an effective augmentation strategy for chronic schizophrenia.
CLOZAPINE: A RETROSPECTIVE ANALYSIS ON AGGRESSIVE BEHAVIOR IN A HIGH SECURE HOSPITAL
Inti Qurashi, E. Silva
Background: Violent behavior is a significant problem in most psychiatric hospital settings. There is evidence that Clozapine, an atypical antipsychotic medication, effectively reduces violent and aggressive behaviors regardless of the underlying psychiatric diagnosis.
Aims: To determine an association between the use of clozapine and incidence of aggression in a High Secure Forensic Hospital in the United Kingdom using real-life outcome measures.
Method: We identified a retrospective cohort of 39 patients who i) had consistently taken clozapine as antipsychotic monotherapy for schizophrenia for 6 months ii) had a minimum 6 month inpatient stay prior to starting Clozapine iii) had at least one aggressive incident in the six months prior to Clozapine initiation.
Clinical notes and adverse incident databases were reviewed to record aggressive incidents for the 12 month period both before and after clozapine initiation.
Results: Of our sample of 39 patients: 23 (59%) showed a reduction in incidents of all kinds. For 14 (36%) incidents stopped entirely. The total of all incidents declined markedly. One outlier with multiple incidents had started neuro-rehabilitation 16 weeks after clozapine (and a significant reduction in incidents). When this patient's results were excluded the trends remained. Statistically significant reductions (p < 0.05; wilcoxon test) were achieved for violent incidents and verbal aggression.
Conclusions: Clozapine is associated with clinically meaningful reduction in aggression.
CLOZAPINE ASSOCIATED CARDIOTOXICITY: FINDINGS FROM BARWON HEALTH
Joanna Fitzsimons, Tim Lambert, Seetal Dodd, Christos Pantelis, Bill Kuluris, Tom Callaly, Michael Berk
Background: Clozapine has a unique efficacy profile that to date has not been matched or enhanced by other second-generation antipsychotics. However, the risk of life threatening adverse effects associated with clozapine treatment remains. Myocarditis and dilated cardiomyopathy are acknowledged adverse effects associated with clozapine treatment and pose a serious risk to patients, yet a dearth of investigation in this area remains.
Aims: The current study aims to investigate changes in cardiac functioning, specifically left ventricular (LF) functioning, in patients treated for the first time with clozapine.
Methods: Transthoracic echocardiograms were conducted on seventy-four clozapine naïve patients, prior to commencing clozapine treatment (Time 1) and were repeated after 6 to 12 months (Time 2), as part of routine cardiac monitoring. Patient psychiatric and medication history were documented, as were full white blood count and myocardial markers.
Results: Analyses of LV shortening, LV systolic functioning, LV size and overall cardiac functioning revealed a non-significant trend towards an increase in cardiac dysfunction from Time 1 to Time 2. A significant decrease in LV shortening was seen when comparing a group of clozapine-naïve patients with a group of long-term treated patients (p < 0.001).
Conclusions: While a trend towards an increase in cardiac dysfunction with clozapine treatment is reported, further investigations need to be conducted. Establishing a clearer understanding of this link will help patients and clinicians balance the risk of cardiac problems and improved psychopathology and help to institute cardiac monitoring guidelines for patients treated with clozapine.
ADJUNCTIVE NALTREXONE DECREASES FLUOXETINE SERUM CONCENTRATION IN PATIENTS WITH MAJOR DEPRESSION AND ALCOHOLISM
Ihsan Salloum, J. R. Cornelius, L. Kirisci, A. Douaihy, J. Perel
Background: The use combined medications is an emerging paradigm for the treatment of comorbid major depression and alcoholism. Combined medications may provide an incremental, additive or synergic, effect on treatment response, an antagonistic interaction may also occur.
Aims: The aim of this study was to examine potential interaction of adjunctive naltrexone on fluoxetine plasma concentrations and the impact of such interaction on treatment response.
Methods: This double-blind, placebo-controlled study examined the effects of combined medications with the use of naltrexone as an adjunct to fluoxetine for comorbid diagnoses of Major Depression (MD) and Alcohol Dependence (AD). The sample included 80 subjects who were assigned to either naltrexone (dose 50 mg/day) + fluoxetine (dose range 20–60mg/day) or placebo + fluoxetine
Results: The naltrexone group had significantly lower total fluoxetine + norfluoxetine plasma levels compared to placebo (t = 2.90, df = 431, p=.004). Furthermore, time to MD remission was predicted by treatment group (t = − 2.257; p = 0.029) and by an interaction term of group by total fluoxetine /norfluoxetine levels (t = − 2. 690; p = 0.01). Also, there was a significant positive correlation between fluoxetine dose and a number of MD outcomes.
Conclusions: These results point to possible interaction between treatment group (+naltrexone), fluoxetine plasma levels and depression response, suggesting a potential antagonistic interaction between fluoxetine and naltrexone. It also suggests the usefulness of fluoxetine for depression in comorbid major depression and alcoholism.
OP28 YOUNG PEOPLE AND DRUGS
FAMILY FUNCTIONING AND PSYCHOLOGICAL PROBLEMS AS RISK FACTORS IN ADDICTION
Sajida Agha, Syed Irfan
The purpose of the present research was to determine the role of family functioning and psychological problems of drug addicts and non addict by assessing the difference between the two groups. After detailed literature review it was hypothesized that scores on the variable of communication, affective expression and control among family members of addicts will be high than non addicts. Furthermore scores on the variables of anger control problems, emotional distress and positive self will also be high of addicts.
Sample of present research consisted of 240 adolescents divided into two groups of 120 addicts and 120 non addicts from different socio economic status.
General scale of Family Assessment Measure-Version III (FAM-III) was administered in order to measure the level of communication, value and norms whereas dyadic Relationship Scale was used to measure affective expression and control among the family members of addicts and non addicts. Renold Adolescent Adjustment Screening Inventory was administered in order to assess anger control problems, emotional distress and positive self in addicts and non addicts.
t-test was calculated in order to determine the difference in the level of communication, value and norms, affective expression and control among families of addicts and non addicts. Furthermore difference in anger control problems, emotional distress and positive self between the addicts and non addicts was determined by calculating t-test.
Result showed significant differences on the variables among the family members and there is also a significant difference between addicts and non addicts. Avenues for further research have also been suggested.
THE ROLE OF SUBSTANCE ABUSE IN ‘THE SIMPSONS’
Hannah Mendelson, Gil Poznanski
Context: Following on from the successful presentation of a general overview of mental health issues depicted in The Simpsons, at the May RANZCP Annual Congress, this presentation will explore the portrayal of substance abuse in the series.
Objectives: To explore how substance abuse issues – particularly alcohol abuse – are depicted in popular culture. To use this exploration as a means of reflecting upon how the general community sees these issues.
Key messages: Conference sessions can be both fun and informative.
Conclusion: Alcohol use and abuse are a significant source of humour in The Simpsons. However, the humour is both satirical and slapstick, reflecting a likely ambivalence in the general community about alcohol and the toll it takes.
DRUG USE BY YOUNG PEOPLE IN BAGHDAD
Hafidh Mohammad Frahan
Background: Psychoactive substances have a long history in the region now known as Iraq at least 5400 years ago. Although the current situation in Iraq is worlds apart from the problems with which Hammurabi grappled, the use and control of psychoactive substances remains an important concern as the fundamental laws of Iraq are now being written. This paper presents the first study of substance use prevalence rates conducted since the fall of Saddam.
Method: The total randomized 620 of 14–21 year old male and female adolescents (320 from 8 secondary schools, 300 from two different industrial areas) in Baghdad City was studied from 25 Oct to 25 Dec 2004. Randomized sample was interview by using semistructured schedules based on DSM-IV for substance use disorder (SUD), Series of nonparametric procedure were conducted to explored the characteristic of past month drug use, as well as investigated the determinants of SUD among respondents were characterized in terms of sociodemographic data using SPSS 11.5 software version.
Result: Past month prevalence of drug use 27.9% (n = 173), (45% of them were single use, 55% were polydrug use). Drug uses in sample study are age sensitive, 87% come from low socioeconomic state, and 62.4% of drug uses are nonstudents (from industrial areas). Benzodiazepines are common drug use (60% for diazepam. 9% for clonazepam), followed by NSAID 42% of drug user, while 22% and 16% of drug user are consumption Benzhexol in the form market name (artane), and (parkisol) respectively.
The polydrug user may concurrently be consuming one drug (63.6% with benzodiazepines. 46.7% with Benzhexol), while concurrently consuming two drugs are (25.8% with benzodiazepines, 48.9% with Benzhexol).
The drug use are strongly associated with smoking cigarette and alcohol drinking (68.2% of drug user are smoking cigarette, and 36% are drinking alcohol). Relief of tension 79%, followed by enjoyment 16%, then affect of friend 5% was main causes of drug use. Most of drug uses were come from street 70%, then from pharmacy without prescription 28%, while 2% of drug use comes from pharmacy with prescription. Nearly 1/3 of drug uses were continous of schooling, while 2/3 were leave school.
Discussion: Consistent with other study which is found that 3.4% for age 14 year and 25.9% for age 19 year and Inconsistent, found female participant were less likely to use drug. Consistent with other study, drug use were more common use for young of industrial areas than young of secondary schools.
Consistent to other study which found 43.4% was polydrug use related to benzodiazepines involved, while 19.1% single benzodiazepines use. Consistent to other study, was found 63.6% for benzodiazepine pulse 1 drug, 25.8% for benzodiazepines pulse 2 drugs, while 6.1% for benzodiazepines pulse 3 drugs.
Consistent with other study, Benzhexol user were consumption 22% of Benzhexol (artane). 16% of Benzhexol (parkisol). Consistent with other study, 27.7% polydrug use related to Benzhexol involved, 1.2% single Benzhexol use.46.7% were consumption Benzhexol pulse 1 drug, 48.9% for Benzhexol pulse 2 drugs, and 4.4% for Benzhexol pulse three drugs. Consistent with other studies, there were significant correlation between smoking and drug use (68.2% of drug user were smoking cigarette), and between drug use and alcohol drinking (36% of drug use were consumption alcohol). drug use, cigarette smoking, and alcohol consumption were associated more with males than females, 67.6% (67% for male, 0.6% for female) were polysubstance use. Consistent with other studies, 38% were young continous of school, 38% were left school due to repeated failure 24% due to low socioeconomic state.
Conclusion: Although the current situation in Iraq is worlds apart from the problems with which Hammurabi grappled, the preliminary results revealed that we are face big challenge in the form prevalence of SUD among young in spite of absence of prevention, treatment and rehabilitation programs.
Suggestion:
Health workers and law-enforcement agencies should take note the above findings.
Preventive and therapeutic strategies for the reduction of cigarette smoking, illicit drug, and alcohol use and abuse among adolescents must be submitting an application.
We are need comprehensive studies for different types of substances and psychoactive drugs
SUBSTANCE USE AMONG CHILDREN AND ADOLESCENCES WITH DEPRESSIVE DISORDER
Afridi Muhammad Iqbal, Muhammad Ali Afridi, Musarrat Hussain
Background: Substance use among children and adolescents occurs on a spectrum from experimentation to dependence. The consequences range from none to life threatening, depending on the substance, its dose and the frequency of use and the associated diagnosis especially depressive disorder.
Keeping in mind all these factors the present study is done in order to understand the association of substance use among depressed patents below 18 years of age.
Aims: To assess substance use children and adolescences with Depressive Disorder.
Method: It was a cross-sectional study carried out in a psychiatric clinic at Karachi, over a period of 3 years (2001–2004). All consecutive cases below the age of 18 years were inducted in this study. Diagnostic Criteria of ICD-10 was used after detail history on semi-structured proforma designed for this purpose.
Results: A total number of 400 consecutive cases below the age of 18 that approached for psychiatric consultation were inducted in this study. After applying the ICD-10 diagnostic criteria, 100(25%) of them were found to be suffering from depressive disorder. 54% were females and 46% males,
Substance use according to the order of frequency was as under; opium(13%), beetle/chalia(9%) and cigarette smoking(8) patterns of presentation was pain 55%, insomnia 33%, fear 16%, weakness 14% and aggression.
Conclusions: As evident from this study substance use is common among children and adolescents with depressive disorder. Although experimentation and occasional usage are common then actual drug dependence but the consequences can be life threatening especially depressed case with suicidal tendencies.
PSYCHOLOGICAL CORRELATES OF CYBER ADDICTION AMONG HONG KONG ADOLESCENTS
Nelson C. Y. Yeung, Catherine S. K. Tang, Francis Y. L. Cheung
Given that cyber addiction on adolescents’ mental health has been one of the most concerned issues of clinicians, educators and parents, understanding the factors associated with adolescents’ cyber addiction can contribute to the design of effective intervention to promote healthier internet usage. This study aims to explore the effects of sensation seeking personality, tendency to comply with peer norms, perceived benefits of developing online relationships, life satisfaction and emotional support from immediate environment on the development of cyber addiction.
Using a cross-sectional design, 3,238 secondary school students (56.3% were male, 43.7% were female) in Hong Kong were surveyed. Apart from major psychological variables, participants’ demographic information was also considered in the analyses.
Results from logistic regressions showed that participants who were male, who reported a higher sensation seeking tendency, who had a greater tendency to comply with peer norms, who perceived greater benefits in developing online relationships, who reported lower life satisfaction, who perceived less social support from immediate environment were more likely to develop cyber addiction.
This study explored the risk factors and protective factors for developing cyber addiction. Therapies targeting at discussing the pros and cons of developing online relationships, enhancing life satisfaction and facilitating social support from immediate environment may reap benefits in promoting healthier internet usage among adolescents.
OP29 MORBITITY, MORTALITY AND HARM REDUCTION
HARM, HOPE AND HEROIN: A GROUP APPROACH TO REDUCING HEROIN OVERDOSE IN CENTRAL LONDON
Peter Phillips, Chris Glover, Teresa Allan, Mary Ellen Khoo
Background: Heroin overdose deaths represent an increasing public health problem, and in many countries remain the most common cause of death among heroin users.
Aims: This study used group psycho-education methods to assist injecting heroin users in preventing, and responding to overdose.
Method: An ‘OD Prevention’ group was advertised in a prescribing service and associated primary care unit. The group intervention took place over one afternoon (3.5 hours), and trained participants in recognising, and responding to heroin overdoses (defining overdose, discussing known risk factors and on-site instruction in cardio pulmonary resuscitation (CPR). Participants were all heroin users in service contact with the primary care unit, drug dependence unit, or hostels for the homeless. Participants completed pre and post group questionnaires concerning their personal experience of overdose, the witnessing of other's overdoses and fatalities, their current response in overdose situations, and their overall confidence in helping others who have overdosed.
Results: One hundred and seven people attended the group in total. Forty two percent had witnessed others’ overdose, and 29% had witnessed one or more deaths subsequently. After the group intervention more participants reported feeling ‘quite or very confident’ in managing an OD situation, confident in undertaking CPR with someone who had overdosed, and were less likely to pursue ‘folklore’ remedies to overdose.
Conclusions: Using psycho-educational group approaches can be an effective tool in attempts to prevent and respond to heroin overdoses, and is seen as useful by users.
EPILEPTIC SEIZURES IN PATIENTS ABUSING DEXTROPROPOXYPHENE: A REPORT OF 23 CASES FROM NORTH INDIA
Debasish Basu, T. Harish, O. P. Jhirwal, S. K. Mattoo
Background: Dextropropoxyphene (DPP), a mild synthetic opioid, is often abused as a psychoactive substance. A number of patients with DPP abuse attending our de-addiction centre provided history of epileptic seizures precipitated shortly after ingesting a higher-than-usual dose of DPP.
Aims: To document and analyze the cases of DPP-induced seizures, attending a drug de-addiction clinic in north India.
Methods: We analyzed the case files of all patients with DPP abuse registered in our centre from May 2001 till July 2003.
Results: Out of 111 such patients, 23 (20.7%) had history of seizures, in contrast to only 2 out of 61 primary codeine abusers (3.3%) and 1 out of 72 buprenorphine abusers (1.4%), and none out of 108 heroin and 68 natural opioid abusers. They had been abusing DPP for a median period of 3 years and a median typical dose of 10 capsules (=650 mg) per day in divided doses. The seizures were mostly characterized as generalized tonic-clonic seizures (87%), occurring after a median of 30 minutes following a median intake of 8 DPP capsules at one time. Nobody had seizures during a drug-free period. EEG and CT scans were mostly normal. These patients did not differ on any variable from those DPP abusers who did not have seizures (n = 88).
Conclusions: DPP-induced seizures are common. The awareness of this phenomenon has implications for diagnosis and management.
DUALLY DIAGNOSED ALCOHOLICS: CONTRIBUTION INTO THE PROBLEM OF CLINICAL POLYMORPHISM OF THE DISEASE
Nikolay Bokhan
In development of concept of dual determination of clinical polymorphism of alcoholics, three variants of dual pathology in 375 patients with alcoholism of state 2 associated with exogenous-organic brain impairment of traumatic (group I; n = 210); hypertensive (II, n = 90) and vertebrogenic (syndrome of spinal cord artery) (III, n = 75) genesis have been distinguished.
In patients of group I pathological inclination for alcohol and withdrawal syndrome were formed at a reliably earlier age against the background of premonitory subcompensated social adjustment – in 62,2% of cases associated with presence of excitable traits of the character. Dominance of psychopath-like variant of degradation resulted in total and persistent disturbance of social functioning. Initial referral to a doctor of patients is associated with excessive character of alcoholization and deviant behavior.
In group II, later formation of alcoholism in 26,7% of cases was preceded by psycho-disadaptive disturbances conditioned by premonitory anxious constitution of the personality. Asthenic-depressive states include cardiophobic and hypochondriac components – a cause of initial referral of patients to an addiction psychiatrist. Social adaptation has a relatively subcompensated character.
For patients of group III, intermediate tempo of acceleration of progression of alcoholism has been identified with obligation of diencephalic psychovegetative, psychosensory and severe psychoorganic cognitive disorders against the background of asthenic variants of change of the personality.
Distinguishing the dual variants allows differentiating the internal limits of clinical polymorphism of alcoholics.
A SHORT NEUROPSYCHOLOGY SCREENING EXAMINATION IN DETOXIFIED ALCOHOL DEPENDENTS
Arun Gupta, Pratima Murthy, Shobhini Rao, Dr Gopukumar, Prabhat Kumar Chand
Background: Chronic ingestion of alcohol triggers deficits in certain neuropsychology functions. These deficits may not be picked up in routine cognitive assessment.
Aim/objective: To develop a short neuropsychology screening examination from standardized available neuropsychology tests.
Method: The subjects were 90 male detoxified, alcohol dependent individuals between the age 20–55 years. An average of 21 days from the last drink each individual was given set of neuropsychology tests assessing attention, memory, planning, semantic fluency and visuospatial construction. The tests were chosen from NIMHANS neuropsychology battery which is standardized in the Indian population (N = 540).
Results: After Factor analysis and sensitivity (50% subjects showing deficits in that neuropsychology test) three tests were chosen for short neuropsychology screening examination. These were Finger Tapping test, Auditory verbal learning test and Verbal N back test.
Conclusions: The short neuropsychology screening examination may be useful to screen for cognitive deficits in early abstinent alcohol dependents who may need a more detailed neuropsychology examination.
BUPRENORPHINE VERSUS CLONIDIN IN THE TREATMENT OF OPIATES WITHDRAWAL: A DOUBLE BLIND RANDOMIZED CONTROLLED TRIAL
Naghmeh Jafary Nia, Bahman Salehi, Fariba Ghebleh
Background: Different agents and method for opioid withdrawal have been tried but none has proven to be perfect.
Aim: Compare the ability of Buprenorphine and Clonidin for opiate withdrawal detoxification.
Method: A total of 76 patients who had DSM IV criteria for opioid dependence up on completion of informed consent randomly assigned for treatment with Buprenorphine or Clonidine in 10-days double-blind clinical trial.
The highest daily dose of oral clonidine and Intra muscular Buprenorphine was respectively 1.2 mg and o.7mg on fourth day of detoxification. Drug abused and relapse had been checked with Thin Layer Chromatography on weeks 4 and 8 after detoxification.
Results: Buprenorphine and clonidine were equally effective in treating the symptoms. However, Buprenorphine showed a significant superiority over clonidine in the management of physical symptoms. Hypotension and headache was significantly more in clonidingroup (P < 0.05)
Although drowsiness have seen in 23 of 38 subjects in Clonidine group, only one subject in Buprenorphine group had this symptom (P = 0.0001) Sweeting was the only significantly higher sign in Buprenorphine group (P = 0.001) Non significant but more presentation of constipation was also seen in buprenorphine group during days 2–6. No significant difference was seen in the rates of opioid-positive urine tests
In Buprenorphine group, 2 subjects and Clonidine group, 6 subjects had relapses 8 weeks after detoxification.
Conclusion: Buprenorphine with controlled treatment protocol might be a novel therapeutic agent for opiate withdrawal syndrome instead of making dependency. However, larger study to confirm our results is warranted.
KINETICS, ISOFORMS AND DIAGNOSTIC VALUE OF GLUTAMATE DEHYDROGENASE ACTIVITY IN SERUM OF ALCOHOLICS
Matej Kravos, Ivan Malešic
We still do not know such reliable biochemical markers for alcoholism whose sensitivity and specificity would be high enough to be relied on.
We wanted to determine increased glutamate dehydrogenase (GLDH) serum activity, to found out rapid GLDH kinetics, to confirm existence of GLDH from endoplasmic reticulum in serum of alcoholics and to determine its diagnostic value compared to other markers.
GLDH was assed in 238 inpatient alcoholics. A blood sample was taken to every subject three times: on admission, after 24 hours and after 7 days. We established our own reference activities for GLDH in serum, i.e. up to 124.0 nkat/L (male), 64.5 nkat/L (female).
Alcoholics were ascertained to have higher mean GLDH (men 351.53 nkat/L, women 296.08 nkat/L), the higher, the less elapsed time there was after latest alcohol intake. There was an increased GLDH in 65.5% (72.2% with those who had last consumed alcohol within 48 hours) of alcoholics. Of all markers was fastest decrease after a break in alcohol consumption confirmed at GLDH.
We found on average 32.4% thermo-stable and 67.6% thermo-labile GLDH, what means that almost one third of serum GLDH originates from rough endoplasmic reticulum and rest from mitochondria. It is an absolutely new finding.
The intelligent data analysis using the decision tree induction method was used as diagnostic help with almost 85% accuracy (79.3% sensitivity, 90.5% specificity).
We estimate that increased GLDH in sera of alcoholics and its fast decrease after total abstinence has been restored are specific for alcohol addiction and applicable in diagnostics.
OP30 POPULAR CULTURE AND MEDIA
CRICKETERS AND MENTAL HEALTH CONCERNS
James Hundertmark
Background: Mental health professionals have an obligation to work to diminish the stigma associated with conditions they treat. The universality of mental health concerns can be demonstrated through an analysis of famous cricketers.
Aims: Test cricket is used to illustrate mental health issues present in Australia through the years.
Methods: A social, historical and biographical analysis of test cricketers demonstrates the existence of mood disorders, suicide and drug and alcohol issues.
Results: A worrying association between alcohol consumption and cricket clubs is identified. Mood disorders are described in several famous players from different eras. There is some evidence that cricketers are more likely to kill themselves than the general population. The tendency to bipolar illness may give some players a creative and eccentric spark. Retirement and being dropped from the team are clearly times of significant stress for players with associated mental health consequences.
Conclusion: Like all individuals test cricketers experience mental health concerns. It is suggested that through an analysis such as this the stigma of mental illness can be diminished. In order to lessen the impact of a high-level sporting career, there may be opportunities for education of future elite players.
PSYCHIATRY AND THE CINEMA
Linda Kader
The fields of motion pictures and modern psychiatry have been mutually and curiously interested in each other for a long time. These two fields emerged at about the same time. On one hand, films are fascinated with doctors in general, psychiatrists in particular. On the other hand, psychiatry deals with human beings and their experiences which are always the centre-point for majority of films. This seemingly benign interface takes on a life of its own and creates a concept of ‘movie/cinema psychiatry’ in modern man's vocabulary. Over the years, complexities and controversies have arisen due to various portrayal of mental health professionals, depiction of ECT treatment, use of drugs by film characters, psychotherapy, psychoanalysis and suicide. These interfaces between psychiatry and cinema and their impact would be critically reviewed with an emphasis on Australian and New Zealand cinema. An attempt will also be made to understand the impact of cinema psychiatry among the youth population since there is a global phenomenon around early psychosis prevention and de-stigmatisation of mental illnesses and it's almost time to address how psychiatry is reflected in the big-screen.
MASS MEDIA AS A SOURCE OF TRAUMA AFTER ARMAVIA JET CRASH IN MAY 2006 IN SOCHI
Armen Soghoyan, Kachatur Gasparyan
The aim of this presentation is to show the influence of trauma on the psychological well being of the general population after mass media reports.
The following steps were important: creation of “Hot line” psychological help services for the families of the victims and also for general population; public education; professional education; publication of materials such as a children and grief.
Different stages of post traumatic stress reactions were observed: up to mid June, 40th Day memorial mass, acceptance by the family members loss as a reality; the mourning process continues recurring, sometimes re-experiencing the tragedy of the event, anger as psychological reaction after traumatic loss.
Those families who were not able to find the remains of their loved once having longer denial and mourning processes.
The main sources of the news and their 24 hours a day reports about increased details of the private lives of the families who lost a member, detailed and repetitive visual coverage of jet crash. Data and statistical analysis of the calls showing that less then 10% of the calls are from the families of the victims and the rest was from general population.
Mass media and in most of the cases television can be a powerful influence in developing post traumatic reactions, not necessarily disorders.
MEDIA CONSTRUCTION OF GENETIC RISK INFORMATION ABOUT MAJOR DEPRESSION, BIPOLAR DISORDER AND SCHIZOPHRENIA IN AUSTRALIAN NEWSPRINT BETWEEN 1996 AND 2006
Alex Wilde, Bettina Meiser, Philip Mitchell, Catriona Bonfiglioli, Peter Schofield
Context: The news media are a primary source of health and science information for the public as well as scientists and clinicians. Articles relating to psychiatric genetics have steadily increased in frequency in the Australian media over the past 10 years. Despite widespread coverage the public may not be well informed due to miscommunication of key complexities of the topic.
Objectives: This study investigates how the Australian print media frame genetic risk information about major depression, bipolar disorder and schizophrenia. Over 300 articles published in the Australian print media between 1996 and 2006 are qualitatively analysed according to media frames including: genetic determinism; genetic susceptibility; gene-environment interaction; media prophesy-genetic optimism and pessimism; and application of genetic risk knowledge in psychiatry and perceived ethical implications.
Key messages: The media form an essential bridge between clinicians and the public for conveying information about the genetics of psychiatric disorders. Miscommunication in the media arises when journalists confuse genetic risk with certainty; overstate the significance of genetic findings; oversimplify the facts; or when scientists fail to emphasise that their hypotheses require further testing.
Conclusion: To our knowledge no previous study has analysed the framing of psychiatric genetics in the Australian print media. The media are a powerful vehicle for communication through which clinicians and scientists involved in psychiatric genetics can positively influence the public's mental health.
OP31 AGED MENTAL HEALTH: CARERS AND SERVICES
PATTERN OF MENTAL DISORDERS IN TWO OLD AGED HOME IN A RURAL INDIAN DISTRICT
Asis Krshna Acharya
Objectives: Prevalence of mental disorders and co-morbid physical disorders are here studied in one male and in one female old age home to asses their pattern in a rural Indian community.
Method: In two old age home situated at a distance of 50 km away from the district head qrtr‘s under the patronage of one Hindu mission trust this was undertaken. Persons aged 65–75 were included in this study. 50 men and 50 women were only taken in this study. Alzheimer's disease assessment scale, geriatric depression scale and c.g.i scales are some of the scale used. Along with them, history and examination, and few bio-chemical and blood tests done.
Results: Mental disorders were found to exist in very high rates (45%). depression, dementia, late onset delusional disorders, anxiety disorders, phobic anxiety disorders, are some of the major I.C.D-10 Diagnosable disorders. In comparison males shows more dementia and anxiety – phobic disorders. Co-morbid physical disorders most commonly found are 1) hypertension, 2) diabetis mellitus, 3) rheumatoid arthritis and other locomotor dysfunction 4) renal and urinary problems in men and genito urinary disturbances in female.
Conclusion: A sizable no. of inmates in old age home members suffer from significant mental and physical disorders. and there is need for an enhanced psychiatrist and other physician and societal service in a regular basis and more social support than that is existing at present.
PSYCHIATRIC MORBIDITY AMONG OLD AGE GROUP PEOPLE: A STUDY AT OUT PATIENT DEPARTMENT OF TERTIARY HOSPITAL
Sultana Algin, Shahida Chowdhury, J. S. Nahar
Background: The life expectancy is increased all over the world. Awareness building and to provide better geriatric psychiatric service is need to be our current concern.
Aims:
To see the psychiatric morbidity and related socio-demographic variables.
Planning for better geriatric psychiatric services.
Methods: This prospective study carried out at OPD of tertiary hospitals at Dhaka in Bangladesh from 1-2-07 to15-4-07. 50 patients of age group of 55 and above were randomly selected. Semi-structured questionnaires applied to see the socio-demographic variables and DSM–1V was used for clinical assessment. Results obtained were statistically analyzed.
Result: Among 50 patients 58% female, 42%male, they were suffering from depression (48%), 24% from schizophrenia and schizophrenia like disorder, 12% from bipolar affective disorder, 8%from dementia, and 6%other disorders. Out of this patients 54%were housewives, 26% having retired life, 20% are in service, 86% were poorly educated.62% people came from rural area, of low socioeconomic classes (68%). Among them 24% are independent but 44% are partially and 32%are fully dependent for financial and logistic support on their children. Hypertension, Diabetes was found in 36% patients.
Conclusion: Psychiatric illness is ignored in geriatric group Female suffers more, as they are dependent and poorly educated. So providing better geriatric psychiatric services and improving psychosocial support may help them.
CONTINUITY AND REWARDS IN THE CAREGIVING ROLE IN DEMENTIA: A CROSS-CULTURAL QUALITATIVE STUDY
Sube Banerjee
Cultural variation exists in the outcomes of caregiving in dementia. Cultural attitudes may account for differing caregiving appraisals and coping strategies found within minority ethnic groups. We completed a qualitative study, using in-depth individual interviews with 10 black Caribbean, 10 south Asian and 11 white British carers of people with dementia to reveal attitudes towards caregiving. These were tape recorded, transcribed and subject to content analysis using best-practice grounded theory. We examined impacts of variation in fulfillment, coping strategies and attitudes towards informal and formal support. Carers were categorised as holding a predominantly traditional or non-traditional ideology, according to conceptualisation of caregiving as natural, expected and virtuous. “Traditional” ideology helped minimise disruption felt by carers and engendered continuity, enabling carers to derive rewards from the relationship and caregiving. Conversely, “non-traditional” carers experienced a pervasive sense of conflict, feeling that the relationship was lost and that their lives were on hold. Caregiving threatened to obscure meaningful aspects of their lives, yet provided few new rewards. The wider family emerged as pivotal in informing attitudes, and need to be engaged to promote caregiving. The findings underline the importance of supporting “non-traditional” carers in maintaining valued, non-caregiving roles. “Traditional” carers expressed confidence in the availability of informal and formal support. This belief provided greater comfort than actual support, which carers were keen to limit, prioritising loved-ones needs over their own. These findings suggest that specific and non-specific cultural attitudes towards the caregiving role exist, which require specific service responses.
DEVELOPMENT AND USE IN CLINICAL PRACTICE OF A DISEASE-SPECIFIC MEASURE OF HEALTH RELATED QUALITY OF LIFE IN DEMENTIA
Sube Banerjee
Background: Health-related quality of life (HRQL) is a multi-dimensional concept reflecting individual subjective perception of the impact of a health condition on life. They provide one approach to the measurement of overall impact and subjective impact. Not including broad outcome measurement, can lead to the positive effects of treatments being overlooked or negative effects being missed.
Method: So can HRQL be measured in dementia with adequate validity and do such data add value to our understanding of dementia and its interventions? Concerns are considered and discussed in the light of the available evidence illustrated using data from the development and use DEMQOL.
Results: First the development of the DEMQOL system is reviewed. Second its correlations with dementia severity, activity limitation and other clinical variables are presented. Finally its use in service evaluation is presented to discuss what measures of HRQL add.
Discussion: There is a need for broad measures of overall impact of interventions in dementia. We can now measure HRQL in dementia using specifically-designed tools. However, there are inherent problems in accessing HRQL in dementia and this means that a particularly careful approach to instrument development and use is needed. It appears cognition and activity limitations are not the same as HRQL. HRQL also appears not to be just affect (they are not the same construct) or behavioural disturbance. HRQL needs to be measured as and for itself. It is complementary to the measurement of discrete specific outcomes and both should be used in evaluation of interventions in dementia.
ROLE OF FORMAL AND INFORMAL SUPPORT IN THE PSYCHOLOGICAL HEALTH IN LATER LIFE
Natalie Chan, Kaarin Anstey, Tim Windsor, Don Byrne, Mary Luszcz
Background: Functional limitation in later life has been found to be associated with poorer psychological health including higher rates of depression and anxiety. One factor that has consistently been found to be effective in offsetting these negative effects is informal social support. In contrast, very little is known about the possible protective role of formal support despite the growing demand in the community for these services.
Aims: To investigate whether both formal and informal support play a protective role in buffering the deleterious effects of functional limitation on psychological health. The effect of gender was also examined.
Methods: Sample consisted of 1933 community-dwelling individuals aged 65 years and over from Wave One of the Australian Longitudinal Study of Ageing. Multi-group structural equation modelling and confirmatory factor analyses were undertaken to investigate the buffering effect of different types of support on depressive symptoms.
Results: Receipt of support was found to protect against the effects of functional limitation on depressive symptoms regardless of support type.
Conclusions: Formal support, as well as informal support, plays a protective role in maintaining the psychological health of older adults who are experiencing physical health declines. This suggests that formal services such as home and community care provide an important intervention point.
PROFILES OF PSYCHIATRIC AND SUBSTANCE USE DISORDERS AMONG OLDER ADULTS
Scott Novak, Eric Johnson, Tania Robbins, Celia Hybels, Mark Zimmerman
Background: Internationally, adults aged 55 or older represent the largest growing demographic category. Yet, little is known about the patterns and features of psychiatric disorders during this developmental period of advanced age.
Aims: To estimate the 12-month prevalence, co-morbidity, and severity of independent and medically induced DSM-IV psychiatric and substance use disorders, and associated risk factors.
Methods: Subsample of older adults (age 55+, n = 13,420) enrolled in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a representative, in-person probability sample (age 18 +) in the United States (2001–2002). The AUDADIS-IV was used to generate DSM-IV classifications for mood, anxiety, and substance disorders.
Results: Over 12.7% (pop est. 7.5 million) of older adults in the U.S. met the criteria for a mood or anxiety disorder in the past year, with multiple disorders occurring in 25% of these cases. Social phobia (5.5%) and depression (4.9%) were the most prevalent disorders. About 10% (pop est. 800,000) of all past year mood or anxiety disorders was a direct result of medical illness. Alcohol (2.3%) and prescription drug (1%) disorders were observed. Approximately 25% of all disorders had onset age 55 or later. Females consistently had higher rates of disorders compared to males.
Conclusions: The occurrence of mental disorders appears common during later life, is more prevalent in females, characterized by single disorders and an average onset prior to older adulthood. However, late onset disorders, primarily medically induced, are also widespread. Screening and intervention efforts should consider the unique mental health needs of older adults.
OP32 PREVENTING LATE LIFE MENTAL DISORDER
CARDIOVASCULAR RISK PROFILE AND SUBSEQUENT DISABILITY AND MENTAL WELL-BEING: THE ZUTPHEN ELDERLY STUDY
Erik Giltay, Frans Zitman, Daan Kromhout
Background: Healthy aging consist of optimising life expectancy as well as physical and mental well-being.
Aims: To study whether ‘classic’ CVD risk factors are responsible for impaired physical and mental well-being.
Methods: In a cohort study with 15 years of follow-up, 545 (59.2%) of 887 men (aged 64 to 84 years) had complete data and were free of pre-existing CVD and cancer. A high CVD risk status was defined as having at least 2 of the following 5 risk factors: body mass index =30.0 kg/m2, presently smoking, hypertension (systolic blood pressure =160 mmHg, diastolic blood pressure =95 mmHg, or use of antihypertensive medication), serum cholesterol =6.5 mmol/L, and diabetes mellitus. Self-rated health, dispositional optimism, disability and depressive symptoms (by the Zung self-rating depression scale) were assessed every 5 years.
Results: The high-risk (n = 230) vs low-risk group (n = 315) had higher rates of all-cause (age-adjusted hazard ratio 1.48; 95% confidence interval [CI]: 1.20–1.82) and CVD mortality (1.67, 95% CI: 1.25–2.24). High-risk status was also associated with more functional disability at 5, 10 and 15 years (odds ratios of 2.00, 95% CI: 1.25–3.20; 2.51, 95% CI: 1.36–4.65; and 2.45, 95% CI: 0.91–6.61, respectively), adjusted for baseline age, self-rated health and dispositional optimism. Risk status was not associated with self-rated health, dispositional optimism or depressive symptoms at follow-up.
Conclusions: Combined ‘classic’ CVD risk factors are not associated with impaired self-rated health or mental well-being in elderly men, but are predictive of functional disability and mortality.
LIFESTYLE AND DIETARY CORRELATES OF DISPOSITIONAL OPTIMISM IN MEN: THE ZUTPHEN ELDERLY STUDY
Erik Giltay, Johanna Geleijnse, Frans Zitman, Brian Buijsse, Daan Kromhout
Background: Dispositional optimism is associated with lower risk of cardiovascular mortality through a largely unknown mechanism.
Aims: To study whether dispositional optimism is associated with healthy lifestyle and dietary habits.
Methods: In 773 of 887 (87.1%) elderly community-living men with complete data, dispositional optimism was associated with potential correlates at baseline and during follow up every 5 years up to 15 years using multilevel analysis.
Measurements: Dispositional optimism was assessed using a 4-item questionnaire, and the participants' food consumption patterns were assessed by a cross-check dietary history method.
Results: A high level of dispositional optimism was associated with more physical activity (P < 0.001), non-smoking (P = 0.02), and higher intakes of alcohol (P = 0.046), fruit (P = 0.01), vegetables (P = 0.01), and whole-grain bread (P = 0.01), independently from age, education, living arrangement, self-rated health, cardiovascular disease, diabetes mellitus, cancer and body mass index, as well as total energy intake (for dietary factors). Moreover, optimists were younger (P < 0.001), better educated (P = 0.004), more often living together (P < 0.001), had a better self-rated health (P < 0.001), and were more often free of cardiovascular disease (P = 0.001) and diabetes mellitus (of borderline significance, P = 0.06).
Conclusion: Dispositional optimism in elderly men is associated with healthy lifestyle and dietary habits. A low level of optimism may indirectly affect proneness to cardiovascular death via unhealthy behavioral choices.
ENHANCING MEMORY FOR HEALTHY SENIORS: AN INDEPENDENT LEARNING PROGRAM PRELIMINARY EVALUATION
Lydia Hohaus
Background: Memory failures are one of the most common and distressing complaints of ageing, yet interventions which could readily improve memory performance are not generally available in Australia. Since 2001, the Optimising Memory Program for Healthy Seniors has been offered in workshop mode in Brisbane. It has proved very popular and successful in improving everyday memory performance of seniors.
Aims: The major aim of this study was to demonstrate significant memory enhancement with completion of the new Enhancing Memory for Healthy Seniors Independent Learning Program, based on the original Optimising Memory Program.
Method: Thirty older adults who wished to improve their memory were recruited to participate in the new 10 week program. Participants were screened for depression and cognitive impairment and were then given a battery of neuropsychological measures of memory to assess verbal paired associates memory, the ability to recall names and faces, and shopping lists. In addition participants completed a self-rating measure of memory performance. Participants were then given the new program, and were provided with regular telephone support as they completed each week. Alternate forms of the same battery of measures were administered at the conclusion of the program.
Results: A series of paired t-tests were conducted. These showed significant improvement on all memory measures had occurred.
Conclusion: Despite the limitations of this small study, the results are very promising. They suggest seniors are willing and able to benefit significantly through participation in a new cost-effective memory enhancement program with minimal professional support.
PREVENTING MEMORY LOSS
Philip Morris
Memory complaints are a common problem. Although memory complaints can affect all ages, they are more common in older people, and the aging of the Australian population means that memory problems will become an increasingly important clinical issue. Early diagnosis and treatment is essential for effective management to restore memory to previous levels of function and to prevent deterioration. The Memory Clinic has been established in recognition of a need for a systematic and specialized approach to the diagnosis and management of memory disorders. The initial consultation involves a medical review, a mental health assessment, and a memory and cognitive screening evaluation. Further comprehensive assessment procedures include a touch screen, computer-based diagnostic and baseline neuropsychological assessment of memory and cognitive function, laboratory tests, EEG/QEEG, ECG, structural and functional brain imaging tests (CT/MRI, SPECT, Doppler carotid ultrasound), and interviews with family or carer. At a second consultation the results of all tests are reviewed with the patient (and family/carer) and a diagnosis determined. A personalized management plan is then developed. A unique 12 Step Memory Management Program is offered to reduce risk factors for memory loss and to enhance protective factors for preserving memory function. At further consultations the plan is monitored and reviewed in collaboration with the GP/local doctor. This presentation will describe the operation of the clinic and present results of an evaluation of the first 100 patients managed by the clinic.
OP33 DRUG POLICY, WORKFORCE AND SERVICE DEVELOPMENT
PRESCRIPTION PATTERNS OF PHYSICIANS FOR BENZODIAZEPINES AND THEIR IMPLICATIONS FOR POLICY ON ABUSE PREVENTION
Asif Ahmed
Background: Benzodiazepines are the most widely prescribed psychotropic agents, primary care physicians and non- psychiatrists being the main prescribers. The most common pattern of abuse is considered to be when patients receiving benzodiazepines for medical reasons take more than is prescribed and thus inappropriate use is a cause for concern.
Aims: The aims of the study were to identify the prescription patterns of physicians for benzodiazepines and to make policy recommendations towards prevention of abuse based on the findings.
Methods: In a tertiary care teaching hospital, the database of prescriptions generated in 26 OutPatient Departments (OPDs) over a period of one year was analysed keeping in view the aims of the study.
Results: Of a total of 80,715 prescriptions made in the year 2006, benzodiazepines figured in 3,365 (4.15%) prescriptions. Alprazolam was the most commonly prescribed benzodiazepine occupying the 29th rank out of a total hospital formulary of 616 drugs prescribed drugs. It was most commonly prescribed in the Cardiology OPD, 8.64% of all cardiology prescriptions, followed by Neurosurgery OPD (8.4%) and Psychiatry OPD (7.39%). Clonazepam, the 109th most prescribed drug figured in 2.52% of the hospital prescriptions with 12.93% in Psychiatry OPD and only 0.11% in cardiology OPD. Similarly, Diazepam 60th drug was maximally prescribed in Orthopaedics OPD (7.55%), Psychiatry OPD (2.95%) and Cardiology (1.31%).
Conclusions: It emerges from the study, there is a scope for guidelines rationalizing the prescriptions of benzodiazepines aimed at reducing the risk of abuse, which is discussed in the paper.
THE IMPROVEMENT OF GENERAL PRACTIONERS’ APPROACHES TO THE PATIENTS WITH ALCOHOL RELATED PROBLEMS: A RANDOMIZED CONTROLLED EDUCATIONAL TRIAL
Yildiz Akvardar, Reyhan Uçku, BelgIn Ünal, Berna Akdede, Türkan Günay, Köksal AlptekIn, Gül Ergör, ZelIha Tunca
Excessive alcohol consumption and alcohol related problems are significant public health problems worldwide. It is aimed to assess the primary health care working general practioners’ knowledge, attitude and behavior related to the detection of risky alcohol use and brief intervention and to investigate the effect of education on these aspects.
General practioners working in the Konak region (n = 226) were separated into intervention and control groups with 1:2 ratio and randomized according to the health centers. Sixty two general practioners participated in the intervention group and 73 in the control group. One hour didactic lecture + a video example of brief intervention + skills training with role playing + intervention materials (physician education booklet + patient self-help brochures + Alcohol Use Disorder Identification Test (AUDIT) + follow-up forms) were provided to intervention group. Control group had didactic lecture only. Participants answered a questionnaire related to knowledge, attitude and behavior before the implementation of the programme. The same questionnaire was applied at the end of the education sessions and at the 2.5 month follow-up.
Pre-intervention knowledge, attitude and behavior scores were similar between groups. A significant increase was observed in knowledge post-intervention scores in advantage of control group. In spite of the decrease in knowledge scores at the 2.5 month follow-up, a significant increase related to pre-intervention scores was established. No significant difference was observed in attitude and behavior scores.
Some improvement in knowledge had been provided by the education programme.
SETTING THE BACKDROP: THE PROBLEM OF ACCESS TO QUALITY HEALTHCARE FOR SUBSTANCE ABUSE, AND A PROPOSED SOLUTION IN THE INDIAN CONTEXT
Debasish Basu, Arun Misra, Suresh Kumar
Context: Substance abuse is a major problem in India. Access to standard healthcare service by people with addictive disorders is very limited, due to several problems such as lack of awareness, infrastructure and proper referral pathways. Drug de-addiction, counselling and rehabilitation centres set up by the government are woefully inadequate. Stigma associated with drug abuse, traditional belief systems, superstitions, availability of local indigenous ‘treatments’, and mushrooming of quality-uncontrolled private treatment centres all further complicate the scenario. The problem of limited access is more acute in rural and less well-connected areas. This gives rise to various types of inappropriate practice, e.g., by quacks, and by those with vested interests. On the other hand, government hospitals and approved centres often remain under-utilised. Thus, there is a clear mismatch between the heavy demand and the limited supply of resources.
Objectives: To set up a ‘Pyramid Model’ consisting of three interlinked programs for substance abusing persons, and to study its impact on increasing the access to healthcare for these people. The Pyramid has a broad community ‘base’; a second intermediate level; and a ‘tip’ based at a tertiary-care government-approved centre.
Key message: The currently existing government-sponsored system of centralized access in limited and hospital-based locations is insufficient to meet the challenge. Innovations and improvisations in the system are needed.
Conclusion: It is important to improvise the existing healthcare delivery system in order to maximize access by those with substance abuse problems.
OPPORTUNITIES AND CHALLENGES IN INTEGRATING COMMUNITY DEADDICTION CLINIC AND TERTIARY SPECIALTY CENTRE INTO THE PYRAMID MODEL OF DEADDICTION SERVICE DELIVERY
Suresh Kumar
Context: A multipronged pyramid model has been conceptualized and operationalized for making available deaddiction services to the hitherto unreached community. In continuity with the two previous presentations, the present paper discusses the Levels 2 [once-a-week community deaddiction clinic operating from a district hospital for which area of operation of Level 1 is the catchment area] and 3 [state-of-the-art de-addiction centre as a part of a tertiary care multispecialty hospital situated near the community deaddiction clinic] of this model.
Objectives: The Level 2 objectives are to provide continuity of care [weekly follow up assessment and treatment] to the beneficiaries of Level 1 [attendees of deaddiction camps], general and specialty health care as well as emergency services, and refer difficult cases to Level 3. The Level 3 objectives are to receive, on daily basis, difficult cases from Levels 1 and 2, and to do the diagnostic assessment and/or comprehensive management of the cases thus received.
Key messages: After the integration of Levels 1 and 2, the number of beneficiaries at level 2 has expanded to more than twice. Further, the patients feel secure and empowered that they have access to the best possible care for their addictive problem.
Conclusion: The Levels 2 and 3 seem to be complementary to each other and jointly seem complementary to Level 1, thereby making a useful model of care stretching from initial sensitization and identification [at level 1] through subsequent routine care [at level 2] to, finally, specialized care [at level 3], where required.
REACHING THE UNREACHED: AN EXPERIMENT WITH COMMUNITY LEVEL ACTIVITIES TO ENHANCE ACCESS TO SERVICES FOR SUBSTANCE ABUSE IN INDIA
Arun Misra, Suresh Kumar, D. Basu
Context: In view of the existing mismatch between demand and supply of resources and access to standard treatment for addictive disorders in India, the proposed ‘Pyramid Model’ should help to connect the broad community ‘base’ with the tertiary-care ‘tip’.
Objectives: To study the impact of community level interventions integrating with the pyramid model of care delivery system.
Description of Community based interventions: This broad base of the pyramid model constitute multi-pronged awareness programme with the help of community resources, e.g., development of a sense of responsibility on the part of the community and voluntary organizations in supporting the process of treatment and rehabilitation. Intervention also involves screening and identification of cases with addiction problem and initiate outpatient level services at doorstep of the community and facilitating long term engagement at district level and tertiary care hospital. This includes primarily community ‘camps’ and awareness interactive programmes with special targeted population, e.g., schools and industrial workers.
Key message: Since 2004, more than 26 camps and interactive programmes with target populations were held and more than 600 hundred cases were identified and treated at the stage of level 1 of this pyramid model. There was more than two and half fold increase in the patients seen at level 2 (Catchment area outreach clinic) since then.
Conclusion: The study shows that level 1 of the integrated pyramid model approach to care delivery system of addiction promises improved healthcare delivery system by maximizing access for those who are ready to utilize services.
OP34 THERAPY, RESOURCES AND CREATIVITY: ARE THERE LINKS?
PSYCHOTHERAPY APPLYING BUDDHIST MEDITATION TECHNIQUES, PARTICULARLY ‘MINDFULNESS’
Sylvia Barber
Buddhist influences in psychotherapy have been developing over the last 60 years, particularly in the West (USA), since World War II and the Tibetan Diaspora (1959). The extraction of techniques using ‘mindfulness’ practices based on ‘watching the breath’ and ‘paying attention’ informs clinical applications and evidence-based studies, especially in depression, stress and cancer (Segal & Teasdale, Kabat-Zinn).
Meditational practices have a diverse topology, and are not homogeneous. Their origins are in the Buddhist tradition of oral and written teachings.
Practices applied in the clinical situation are non-secular and the therapist need not be a Buddhist. However, training is required from an experienced practitioner/supervisor. All practices have an essential essence to calm the mind, develop awareness, concentration and analysis of our inner work and its relationship to the external.
Buddhism's view is that meditation is the link between intellectual knowledge and the desired change in one's attitude. Studies have shown the ability of meditation to change autonomic measures (heart rate and respiratory rate). Recent neuro-scientific research using fMRI is attempting to clarify the changes seen in long-term meditators and their benefits (Davidson, Lutz). Other studies (PET) are examining neurotransmitter changes (Dopamine).
Benefits are also seen in an improved therapeutic alliance. Further exploration is ongoing in the interface between Buddhism and psychotherapy (Epstein, Safran).
More research is needed to determine the long-term impact of mental training on the elimination of destructive emotions and the maintenance of wellbeing and happiness.
THE LIVED EXPERIENCE OF ART THERAPY WITH INTERNATIONAL STUDENTS
Barbara Davis
The present study investigates international students’ lived experience of art therapy. The demands of study in a foreign university, combined with a persistent need to adjust to language and new ways of being increase the likelihood for depression, isolation and anxiety in international student sojourners. As international students typically shy away from mental health seeking behaviours it is difficult to establish appropriate, culturally sensitive methods of therapy. Maladjustment if left unchecked can manifest in pathology. A phenomenological approach is introduced to determine how therapeutic art serves the universal language of emotion. The present study focuses on an innovative method to address self-exploration and personal growth through therapeutic art. Recognising that international students from non-western cultures struggle to communicate in a second language and adjust to new cultural ways of being, the intention was to introduce a non-threatening style of therapy. Therapy focused on everyday concerns that all people experience, such as time management, goal aspirations, and so on. Rich contextual data linking art works to English as second language (ESL) narratives show how therapeutic art can assist sojourners to access and work through emotion experience. Data supporting how participants perceived art therapy is also discussed. This study has implications for theory and practice. From a research point of view this study endorses the need to establish therapeutic methods that target everyday adjustment as a preventive measure of mental health with international student sojourners. In practical terms it introduces non-threatening ways to help sojourners explore and normalise experience.
AN EVALUATION OF ONLINE MENTAL HEALTH RESOURCES FOR ADOLESCENTS IN AUSTRALIA
Tim Edwards-Hart, Andrea Chester
Background: Young people accept and embrace the internet as an integral part of daily life. The implications and possibilities of the internet for addressing adolescent psychopathology, however, are only just beginning to be explored. Mental illness is a major problem in adolescence that is insufficiently addressed by current mental health strategies, with significant long-term consequences. There are features of the internet that seem ideally suited to addressing some of these needs. Although prior research suggests adolescents seek mental health information online, no independent assessment has yet been made of the resources available to them.
Aims: To determine the mental health resources currently available online for adolescents in Australia and review the nature and quality of that material.
Method: Seventeen adolescent mental health websites in Australia were reviewed using DISCERN and a new website evaluation tool, SEAT, which was developed for this study.
Results: The majority of sites included information on mood, anxiety and psychotic disorders, although little information regarding treatment was provided. The content provided was passive, with little use of multi-media or community functions. Quality varied, but was generally low, and less than 50% of sites acknowledged external accreditation.
Conclusion: As the quantity and range of mental health material available online continues to grow, it is important to ensure that it is trustworthy and presented in a mode that adolescents are likely to use. Findings have relevance for clinicians considering referring adolescents to online material and for raising awareness of the information adolescents may access prior to consultations.
ATTITUDES TOWARD FACE-TO-FACE AND ONLINE COUNSELING, AND WILLINGNESS TO SEE A COUNSELOR
Alexandros Georgiadis, Angelos Rodafinos
Background: Online counseling has become a clinical tool due to the popularity the access of internet to remote locations. Many web sites provide online counseling services in US and EU free of charge or for a fee. It appears that South East European countries, which are somewhat behind in technology and attitudes compared to Western and North European countries, will follow that trend in the next few years. However, the empirical evidence examining the attitudes towards face-to-face counseling and online counseling in the area is scarce.
Aims: Hence, this study aimed to explore the attitudes of students towards counseling and online counseling, and their willingness to see a counselor.
Methods: Greek and International undergraduate and postgraduate business, computer science and psychology students (N = 127) enrolled in a private English college, completed self-report measures of Attitudes Toward Seeking Professional Psychological Help (ATSPPH-SF), and Willingness to See a Counselor (WSC), both for face-to-face and online counseling.
Results: Overall, participants expressed positive attitudes and willingness to see a counselor, more so for face-to-face compared to online counseling. As expected, reported attitudes were significantly more positive than willingness. Both attitudes and willingness to see a counselor varied as a factor of gender, major of studies, and past counseling experience.
Conclusion: The prospects of online counseling in SEE countries are positive. Future studies should focus on how online counseling could become a more friendly-user medium in order to be more readily available, because of the easiness, low cost and the anonymity that it offers.
RELATIONSHIP BETWEEN CREATIVITY AND TENDENCY TOWARD MENTAL DISORDERS AMONG THE UNIVERSITY STUDENTS OF THE UNIVERSITIES IN TEHRAN
Mahshad Mohammad Noori
According to Freud's theory the origin of creativity refers to the conflicts of unconscious mind. Psychologists that came after Freud had different opinions about Freud's theory. They reduced the effects of primary processes; moreover, explained that the origin of creativity refers to subconscious mind. Several principal studies performed in the era preceding the systematic ordering of the more recent classification (DSM IV and ICD 10), show among creative and famous individuals a prevalence of severe mental disorders, significantly higher than among the general population.
The goal of this research was to study the relationship between creativity and mental disorders among the undergraduate university students in pure science and humanistic science of the universities in Tehran.
In this research we found out some similarities. The subjects were 253 students of universities in Tehran. Selection was in cluster manner, random sampling. The following instruments were used: MMPI and Abedi's creativity test. Two groups of variables were tested. Eight clinical criteria of mental disorders of MMPI and four criteria of creativity. Research design was quasi – experimental, field correlation type study. Statistical tests were correlation test and regression analysis. The results showed that there were negative and significant relations between depression and creativity, and between psychasthenia (Pt.) and creativity (p < 0.01). The best predictors of creativity were Pt. And Sc. (schizophrenia) criteria that Pt. had negative coefficient and Sc. had positive coefficient.
It seemed that when these personality factors such as: self – confidence, relaxation, sense of security and normal approach to life come along with the tendency toward schizophrenia, person's creativity is increased.
WHAT BUILDINGS AND LANDSCAPING CAN DO FOR YOUR PATIENTS, STAFF, VISITORS AND MENTAL HEALTH OUTCOMES
Michala Lander, Penelope Coombes
Australia is currently enjoying a building boom in health facilities including mental health. The quality of these buildings has significant impact on mental health outcomes and the quality of life of patients, staff and visitors.
This presentation will discuss the findings of literature reviews that investigated the effect of the built and natural environment of mental health units on the quality of life of the patients, staff, visitors and mental health outcomes.
Evidence confirms that mental health facilities that are designed using ‘supportive design’ methods-those that are designed with specific reference to the needs of patients, staff and visitors-deliver positive outcomes:
Generally enhanced quality of life benefits to health care patients and visitors
Improved clinical outcomes for patients
May achieve cost and operational efficiencies to the wider mental health care system
Design features that contribute to these outcomes include:
An environment that is ‘home-like’
Patients having control over their environment
Gardens for healing
Appropriate artificial and natural light
Views onto natural environments
An environment that reduces unnecessary noise
Importantly, the benefits of the built and natural environment on quality of life and mental health outcomes should not be underestimated in the design and development of mental health facilities.
OP35 PRACTICE AND THE LAW
REDUCING SECLUSION IN ACUTE PSYCHIATRIC INPATIENT SETTINGS: A NEED FOR STRONG LEADERSHIP
Stephen Elsom, Cadeyn Gaskin
Background: Seclusion is of limited therapeutic value and can be a harmful and traumatic experience for psychiatric consumers. Many psychiatric facilities have made substantial efforts to eliminate seclusion or reduce this practice to negligible levels.
Aims: To review the research on seclusion-reduction initiatives in psychiatric facilities.
Methods: We reviewed the peer-reviewed, English-language literature on seclusion reduction initiatives. We sourced 16 papers that focused on seclusion reduction initiatives and in which pre- and post-seclusion data were reported. Opinion-based papers and research that focused solely on pharmaceutical methods to reduce seclusion were excluded from our review.
Results: Successful seclusion reduction initiatives typically involved senior management implementing multiple changes within the facilities. Although commonalities exist with regard to the interventions used in these facilities to reduce seclusion (e.g., treatment plan improvement, monitoring seclusion episodes, changing the therapeutic environment), the ways in which these initiatives were combined tended to be unique to each organisation. State-level organisations sometimes provided the impetus for such changes to be made. There is strong evidence that changes made to psychiatric facilities were effective in reducing or eliminating seclusion.
Conclusion: Seclusion reduction in psychiatric facilities requires strong leadership from senior management. Sometimes leadership from state-level organisations accelerates a seclusion reduction agenda.
POLICE USE OF TASERS IN MENTAL HEALTH EMERGENCIES
Brian McKenna
In 2006 Police in New Zealand commenced a trial of Taser stun guns in frontline policing. Amongst the groups targeted for use of the Taser were people in mental health crisis. The trial provided an opportunity to evaluate the psychological impact of the use of Tasers on people in mental health emergencies and others. This presentation discusses a research study designed to use the Impact of Events Scale to measure the psychological impact of use of Tasers. Despite use of Tasers in the United States and other countries for over a decade, there are no studies into psychological impact of these weapons.
APPLICATION OF MENTAL HEALTH LEGISLATION IN NEW ZEALAND
Anthony O'Brien
This presentation will outline a PhD study into application of mental health legislation in New Zealand. The study will use epidemiological methods to map the use of mental health legislation and qualitative methods to study clinicians' reasoning in making decisions on civil commitment.
MENTAL HEALTH NURSES IN STATUTORY ROLES
Brian McKenna
Mental health legislation introduced in New Zealand in 1992 created a number of generic statutory roles. These include Duly Authorised Officer, Responsible Clinician, Second Health Professional, and Director of Area Mental Health Services. Where previously statutory roles had been the exclusive province of medical practitioners, the 1992 legislation reserved few roles exclusively for medical practitioners. This presentation will outline research into nurses’ involvement in statutory roles. While some nurses feel uncertain about their preparation and readiness to assume stautory roles, others have integrated these roles into their professional nursing identity. We discuss implications for the development of these roles, and for increasing nurses' involvement in the role of Responsible Clinician.
ARE NURSE PRACTITIONERS REALLY THAT DIFFERENT? EXPLORING THE EXPANDED PRACTICE ROLES OF COMMUNITY MENTAL HEALTH NURSES IN VICTORIA
Brenda Happell, Stephen Elsom
The move from institutional to community-based mental health care in Australia has substantially altered the practice of most mental health professions. The boundaries between professions are now less distinct. The community nursing role enjoys significant autonomy in practice and decision making. This paper describes the findings of a study conducted to determine the extent to which the community nursing role has expanded into areas usually considered the exclusive domain of the medical profession (such as prescription of medication). A cross-sectional correlational design with a self-administered questionnaire was administered to community mental health nurses working in metropolitan, regional and rural areas in Victoria, Australia. In total, 154 nurses completed questionnaires (52% response rate). Just over half of the nurses always administered medication exactly as prescribed by doctors. Making suggestions or recommendations to a doctor that medication doses be adjusted was commonly undertaken by respondents. It is concluded that psychiatrists and community mental health nurses need to work collaboratively about identifying their respective knowledge and skills in terms of how they take responsibility for client care.
OP75 COMMUNITY TREATMENT ORDERS AND COMPETENCE TO CONSENT
Duncan Milne
Background: Prominent topics in mental health law debate internationally are the introduction of Community Treatment Orders (CommTOs), and the role of competence in civil commitment. Studies have examined the competence of people compulsorily admitted to hospital, but no studies have looked at the competence of people subject to a Community Treatment Order. This study piloted the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) in a NZ community sample.
Methods: Ten people subject to a CommTO, and a matched sample of 10 service users not subject to any order were interviewed. Demographic data and HoNOS scores were collected. The MacCAT-T was administered.
Findings: 70% of people subject to a CommTO had some deficit in decision-making ability, compared with 20% of people not subject to an order. This difference was statistically significant (p=.004). Cognitive problems on the HoNOS were related to decisional deficits (p=.027). Other demographic factors were not significant. The MacCAT-T performed well, with all items being easily understood and responded to by participants.
Conclusion: Some people subject to a CommTO were clearly competent to consent to treatment, while some people not subject to an order probably weren't. It is hypothesised that people with cognitive problems or disagreement with the need for treatment may be more likely to find themselves subject to an order. Law reform should reflect the need to protect the incompetent and address some inconsistencies and gaps relating to consent procedures. The clinical and policy implications are discussed and some recommendations for future research are made.
OP36 MIGRATION AND MENTAL HEALTH
PSYCHOLOGICAL DISTRESS AMONG IMMIGRANTS IN OSLO: FINDINGS FROM THE OSLO HEALTH STUDY
Suraj Bahadur Thapa, Edvard Hauff
Background: Migration to high-income countries is ever increasing, and the previous research findings regarding mental health of immigrants are mixed.
Aims: To compare psychological distress between immigrants from high and low- and middle-income countries living in Oslo, and investigate whether pre- or post-migration factors could explain any such differences in distress levels.
Methods: A cross-sectional survey with self-administered questionnaire was conducted in 2000–2001 in a sample of almost 18 770 adults living in Oslo. Of them, there were 812 immigrants from high-income countries and 1434 immigrants from low- and middle-income countries who participated. The Hopkins Symptom Checklist (HSCL-10) was used to measure psychological distress.
Results: The prevalence rates of psychological distress among immigrants from high and low-and middle income countries were 10.3% and 24.3%, respectively. Unadjusted odds ratio (OR) of distress among immigrants from low-and middle-income countries was 2.38 with 95% confidence interval (CI) 1.73–3.29. The first adjustment (socio-demographic variables) hardly attenuated the difference reported (adjusted OR 2.25, 95% CI 1.58–3.21), the second adjustment (socio-demographic and pre-migration variables) reduced the difference (adjusted OR 1.86, 95% CI 1.28–2.69) while the last adjustment (socio-demographic and pre- and post-migration variables) attenuated the difference below the level of significance (adjusted OR 1.33, 95% CI 0.88–2.01).
Conclusion: Both pre-migration and post-migration factors were associated with distress. However, the post-migration factors in the host country better explained the difference in psychological distress. This shows that the adverse living conditions are more strongly associated with psychological distress among immigrants from low-income countries living in Norway.
MENTAL HEALTH OF MIGRANT WORKERS IN CHINA: PREVALENCE AND CORRELATES
Daniel Fu Keung Wong
Background: This study aimed to examine the prevalence and the socio-demographic correlates of mental health of migrant workers in Shanghai China.
Methods: A total of 475 migrant workers from four major districts in Shanghai were recruited through a survey design with stratified random sampling. Male and female migrant workers were identified as mentally healthy or unhealthy using the Brief Symptom Inventory (BSI). Socio-demographic characteristics and migration stress were explored as correlates of the mental health of the migrant workers.
Results: A total of 73 migrant workers could be classified as mentally unhealthy (25% for men and 6% for women). Male migrant workers who were married (OR 6.16, 95% CI 1.83–20.70), manual laborers (OR 1.56, 95% CI 0.97–2.51), and experienced more stress in “financial and employment-related difficulties” (OR 2.75, 95% CI 1.47–5.14) and “interpersonal tensions and conflicts” (OR 4.18, 95% CI 1.55–11.25) were more likely to be mentally unhealthy, whereas the female migrant workers who experienced more stress in “interpersonal tensions and conflicts” (OR 6.52, 95% CI 0.83–51.14) were more likely to have poor mental health.
Conclusion: The findings provide information for the prevention of mental illness among migrant workers in China. The implications and limitations are also discussed.
SPECIAL PSYCHIATRIC NEEDS OF REFUGEE CHILDREN
Anna Datta, Justin Frewen
Background: The consequences of political violence for refugee children are multi-dimensional. Exposed to traumatic events they often develop psychological distress. Broad cultural attitudes and values of their homelands play significant role in nature and incidence of trauma they experienced. This trauma can be aggravated by new host communities’ lack of comprehension of their actions and behaviour.
Aims: Through available literature
Assess impact of socio-cultural context and environment upon treatment for alleged psychiatric problems of refugee children from different cultures.
Assess coverage of a range of issues including, categorisation of child affected by cultural and social misunderstandings; communication difficulties due to immigrant children's lack of cultural and/or linguistic abilities; impact of host culture upon child; role of ‘racism’ in tendency to believe refugee child has mental problems more quickly than with a ‘local’ child; lack of stable nuclear family unit and/or apprehension of involvement in treatment process; refugee families expectations differing from host communities’ treatment objectives.
Methods: Rigorous review of pertinent literature in English language since 2000 with particular emphasis on refugee children in Australia. Research will include hardcopy and internet literature.
Results: Problems associated with refugee children are generally multi-dimensional and require additional assistance through family oriented mental health services.
Conclusion: Ever increasing number of conflicts worldwide results in greater numbers of people displaced and forced to move abroad. This situation leads to an increase in psychological distress and related problems and hence need for further work in this area.
EFFECTS OF IMMIGRATION AND RESETTLEMENT ON THE MENTAL HEALTH OF SOUTH-ASIAN COMMUNITIES IN MELBOURNE
Ahmed Munib
Background: This PhD research project explored the relationship between post-migration experiences and psychological well-being within the Indian and Bangladeshi communities in Melbourne, Australia.
Aims: This study aimed to examine personal accounts of adjustment and acculturation in a foreign society and the impact on mental health. The study focused on coping strategies and psychosocial protective mechanisms impacting successful and unsuccessful resettlement and emotional well-being.
Method: The researcher conducted individual in-depth interviews with thirty-eight adult Australian permanent residents/citizens born in India and Bangladesh. The personal experiences of South-Asian migrants and the psychological consequences of resettlement in Australia were qualitatively explored, with identification of multiple themes and sub-themes. The qualitative results were complemented by correlation analysis, focusing on the discussion salience of themes/sub-themes described by participants.
Results: The results indicated that social isolation, alienation, non-recognition of professional skills, experiences of racial discrimination, cultural incongruity and disconnection, and inadequate English language competency, all contribute to psychological distress, adjustment difficulties and even repatriation to the country of origin. Co-ethnic density, social support/networking, intra-family cohesion, and retention of religious/cultural values/norms were associated with hybrid acculturation, acclimatization and successful resettlement in the host country. Networking with the local Australian society and acceptance of migrants were identified as promoting socio-cultural integration, and exerting a protective effect against psychological distress in South-Asian migrants.
Conclusion: The findings highlight that complex cultural and cross-cultural processes, in addition to other factors, are important in relation to post-migration psychological distress, and in determining the outcome of relocation and settlement in a new country.
NEED ADOPTED TRANSCULTURAL TRAINING IN SWEDEN
Henrik Wahlberg, Anne Johansson Olsson, Inger-Johanne Larsson
Sweden has become multicultural. 50 years ago Sweden was ethnically homogenous with one language and a St Claus for all. The share of the population with a foreign background has increased from 4% to 16%.
The County Council of Stockholm, in charge of all the health services for 2 million, has founded the Transcultural Center (TC) for postgraduate training and consultation of the staffs.
To adopt the training curricula to the needs of the staffs, 2 investigations were carried out, one targeting the Primary health care and the other one Psychiatry. Information was gathered from all professions through randomized telephone interviews using a structured form.
The need of Cultural competence is obvious. Many units use interpreters daily, written material translated to different languages is rare and 80% of the staff states that they need more knowledge about cultural aspects in their work.
All patients – also newly immigrated – are served by the units in the vicinity. Anyone of the staffs may receive a patient with a different cultural background. Thus all the staffs require cultural competence focused on practical knowledge and clinical skills.
The staff, who themselves have a different cultural background, was frequently assigned to patients from other cultures. They were perceived as “experts on cultures” just because of their own different background.
There is a huge need for training – not always recognized – in transcultural issues to ensure high quality services for all. The investigations will lead to a reformulation of the TC's training curricula.
OP37 PSYCHO-ONCOLOGY AND INFECTIOUS DISEASE
“EXPERIENCE OF ILLNESS” IN ONCOLOGIC PATIENTS WHO HAVE RECEIVED PSYCHOTHERAPY AND IN THOSE WHO HAVE NOT
Alejandra Ana García Rosales, Pablo Orgaz, María Diéguez, Guadalupe Torres, Isabel Mirapeix, Ana Hospital, Ángela Palao, Carmen Bayón, Beatriz Rodríguez Vega
Objectives: In this study, we have analysed whether the “experience of the illness” of oncologic patients suffering depression is different in patients who have received psychotherapy compared with patients who have not.
Introduction: in the cualitative methodology, descriptive data based on the person's own statements is obtained.
Method: Using the Hospital Anxiety and Depression Scale (HADS) we select ten oncological patients with HADS > 11 and confirm depression diagnostic with a clinical interview. We randomize the patients and distibute them in two groups: The first group receives a combinated treatment (psicotherapy and ISRS) and the second one ISRS alone. Then, two discussion groups are organised where semiestructured questions about ilness experience, quality of life and their opinion of the psychiatric treatment are discussed. Their comments are transcribed and codified with the ATLAS-Ti program, through which codes and categories are created. We compare the categories and test whether there are differences between both groups.
Results: issues regarding symptoms are predominant in the statements of patients belonging to the contol group. This group also experiences the ideas of cancer and death in a more devastating way. The group that has been treated with psychotherapy understands depression as natural consequence of cancer, and has a more positive approach to certain changes cancer has caused in their lifes.
This study is part of a broader investigation project being conducted in the La Paz and the Principe de Asturias hospitals and financed by the FIS (PI 050737),.
PSYCHOSOCIAL CORRELATES OF PROGESTERONE RECEPTORS IN BREAST CANCER
Peter Pregelj, Maja Primic-Zakelj, Milan Licina, Zvezdana Snoj
The diagnosis of cancer may lead to psychological distress with anxiety and depression. Several investigators have found a correlation between psychosocial factors and tumor levels of ER and PR while others have not. The aim of this study was to investigate psychosocial characteristics of patients with high or low PR expression in breast cancers. The study was performed at the Institute of Oncology Ljubljana and 325 patients with primary breast cancer participated in the study. Patients were divided in two subgroups according to progesterone receptors expressed in breast cancers. We did not observe differences in demographic characteristics between subgroups. However, the subgroup of patients with progesterone receptor poor breast cancers expressed depression, as measured by the Hospital Anxiety and Depression scale, to a smaller degree (4.7±4.1) than the subgroup of patients with progesterone receptor rich breast cancers (5.8±4.1). The difference was rather small but statistically significant (t = 2.1; df = 236.7; p < 0.05). In contrast, we did not observe any correlation between anxiety and progesterone receptor status. Differences between the subgroups according to family history of mental disorders were observed (chi = 4.7; df = 1; p < 0.05). In the subgroup of patents with PR-poor breast cancers; 13% of patients had a family history of mental disorders compared with 23% of patients with PR-rich breast cancers. Depression expressed by patients with primary breast cancers could be influenced by progesterone receptor status of the tumors; however psychosocial factors could be influenced by other factors such as cancer treatment and family history of mental disorders.
INDIVIDUAL ADJUSTMENT AND DEPRESSION IN A SAMPLE OF PATIENTS WITH CANCER
Alejandra Ana García Rosales, Pablo Orgaz, Fernando Mora, Guadalupe Torres, Isabel Mirapeix, María Diéguez, Ángela Palao, Ana Hospital, Carmen Bayón, Beatriz Rodríguez Vega
Background: The prevalence of Depressive Disorders in the oncologic population highly varies between 1,5% and 50%. Psychologic variables are frecuently related to suffering of Depresive Disorders in oncologic patients. And from these, the psychological coping style in the face of the heavy stress of diagnosis and the personality variables related to cognitive and conductual strategies which are employed as the way of facing the situation. The present study is included on a more wide one (FIS PI n°: 050737; FIS PI05/2062).
Aims: The aim of our study is to analyse the relation between personality dimensions and adjustment mechanisms in a sample of oncologic patients.
Methods: We selected a sample of 79 patients diagnosed of colon, breast and lung non metastatic cancer on ambulatory treatment. We have compared 40 patients diagnosed of Depressive Disorder (DSM-IV) with 39 patients that did not. In order to assess the adjustment we employed the MAC (Mental Adjustment Cancer questionnaire) and to assess the personality dimensions we employed TCI-R (Clonninger Temperament and Character Inventory).
Results: We detected that depressed patients show adjustment mechanisms characterized by avoidance, helplessness/hopelessness and less fighting spirit. They also had personality dimensions characterized by high scores in harm avoidance and low scores in reward dependence. Persistente and self-directedness personality dimensions are linked to adjustment mechanisms based on helplessness/hopelessness and fatalism in the sample of depressed patients whereas they are linked to higher fighting spirit in those patients without depression.
Conclusions: Our result supports the importance of the assessment of adjustment and personality.
A COMPARISON BETWEEN PRISONERS LIVING WITH AND WITHOUT HIV INFECTION IN MALAYSIA
Muhammad Muhsin Ahmad Zahari, Nor Zuraida Zainal, Mohamed Hatta Shaharom
There are established facts that psychiatric disorders and HIV infection are linked and both run at higher rates in prisons. HIV-infected prisoners who accounted for 5% of total prisoners in Malaysia not only presented with higher risk of deviant behaviours but also pose an increase risk of HIV spread among prisoners, prison's staff and the general population. Psychiatric care in HIV-infected prisoners is crucial in preventing deterioration in high risk behaviours.
This cross-sectional descriptive study aimed to compare the psychiatric, substance, criminal and sociodemographic profiles of HIV-infected prisoners with other prisoners in a Malaysian prison. This study comprised of 200 prisoners of each HIV-infected and non HIV-infected groups. They were randomly selected and interviewed using sociodemographic and SCID-1 (a diagnostic tool) questionnaires.
The results showed the prevalence of the life-time psychiatric disorders in HIV-infected and non HIV-infected prisoners were 42% and 38% respectively. Psychotic disorders and substance-induced psychosis were more prevalence among HIV-infected prisoners while affective disorders were higher in non HIV-infected prisoners. There was a strong association (odds ratio = 51) between HIV-infected prisoners and the use of illicit drugs. This association was supported by the significantly higher prevalence of history of polysubstance use and intravenous drug use among HIV-infected prisoners. The offences committed by HIV-infected prisoners were predominantly substance-related offences whilst non HIV-infected were associated with offences against human.
In conclusion HIV-infected prisoners represent a distinct group in the incarcerated system. Therefore the implementations of comprehensive psychiatric services are helpful in minimising the risk of deviant and high risks behaviours among HIV-infected prisoners.
H2M: A GP-FOCUSSED MULTIDISCIPLINARY TEAM FOR PATIENTS LIVING WITH HIV AND HEPATITIS C
Peter Sternhell, Jodie Butler, Kurt Andersson-Noorgard
Context: HIV and Hepatitis C are chronic illnesses with significant psychiatric morbidity. Inner-city Sydney has a high prevalence of HIV and Hepatitis C and has several high-quality general practices that meet these patients’ medical needs. While some can afford private psychiatry and psychology services, many live on limited incomes and rely on public mental health care. The general adult mental health service is swamped by acute presentations that demand a rapid response, leading to restricted services to patients with less acute disorders, such as the high-prevalence disorders of anxiety, depression and substance abuse.
Objectives: The HIV, Hepatitis C and Mental Health (“H2M”) service consists of a 1.0 FTE Clinical Nurse Consultant, 1.0 FTE Clinical Psychologist, 0.25 FTE Psychiatrist and 0.4 FTE Receptionist based in the Department of Consultation-Liaison Psychiatry at St Vincent's Hospital. The service structure, patient characteristics and management methods will be described.
Key messages: This specialist service concentrates on consultation and liaison with doctors managing patients with complex needs. It has enhanced links and services available for local GPs. Most of the GPs have become more confident in assessing and managing mental health problems and enjoy the opportunity for informal discussion of patients.
Conclusion: H2M has enhanced the quality of mental health care for people living with HIV and Hepatitis C and improved GP satisfaction and confidence in managing psychiatric morbidity.
OP38 COGNITIONS, MEMORIES AND PSYCHOTHERAPY
RECOVERED MEMORIES – REAL, NOT REAL?
Sylvia Barber
Controversy exists concerning ‘recovered memories’ in individuals, both young and older, who believe they have been sexually abused earlier in life. There had been a ‘flood’ of such reports in the late 1980s and 1990s in Australia, leading to concerns about the regulation of psychological practice. These individuals ‘recover’ these memories (false) usually with the assistance of a ‘recovered memory therapist’, usually a psychologist. Frequently, the consequences have been catastrophic when the individual later retracts, resulting often in attempted or completed suicide, shattering families. Accused perpetrators, initially jailed, some later released (after retraction) have ruined lives.
The ‘false memory system’ (FMS) is the term for the hypothesis describing the state of mind where sufferers have vivid false memories of abuse in childhood. DSM IV does not recognise FMS.
The British False Memory Society (BFMS) has stated that the accuser making false allegations should face the full force of criminal law.
A vignette is presented to highlight diagnostic difficulties.
Jane, a 60-year-old retired professional, underwent intensive therapy to recover lost memories. She rapidly deteriorated in the last year, isolating herself from family and friends. On admission to hospital, she was fearful and suicidal, believing she had been abused by her father, stepfather, brother and priest, extending this to abuse of grandchildren and daughter (by husband and a neighbour). ‘Memories’ disappeared on Olanzapine but depression and shame remain, being unable to face the family disruptions.
FSM affects all in society, resulting in financial, social and professional costs.
ARE EVERYDAY PROSPECTIVE MEMORY IMPAIRMENTS ASSOCIATED WITH EXCESSIVE TEENAGER DRINKING?
Thomas Heffernan, Janice Bartholomew, Terence O'Neill, Steve Holroyd, Jon Ling
Background: Alcohol is a commonly used substance by teenagers in the UK, yet little research has investigated the possibility of deficits in prospective memory (PM: memory for future intentions) being associated with excessive alcohol use in teenagers.
Aims: This study addresses this by comparing excessive drinkers with low-dose/alcohol-free teenagers aged between 16–19 years on self-reported everyday PM. whilst controlling for age, strategy use, and other substance use.
Methods: A non-experimental design was used. An opportunity sample of 108 students studying at College/University in the North East of England participated. 45 participants were identified as ‘excessive alcohol users' (ingesting above 21/14 units of alcohol per week for males/females respectively over a period of 1 year or more) and 63 were identified as ‘low dose/no-alcohol controls' (ingesting above these amounts over 1 year or more (incorporating 9 non-users). Each participant completed the self-report prospective memory questionnaire (PMQ) – which measures everyday memory lapses (eg how often one forgets to post a letter, lock one's door, etc.) and a Substance Use Questionnaire – which was used to measure weekly alcohol use and other substance use.
Results: A series of one-way ANOVAs revealed that the excessive alcohol user group was older, smoked more cigarettes and used more cannabis, than the control group, with no difference in strategy use. A MANCOVA revealed that, after controlling for age, cigarette use and cannabis use, the excessive alcohol user group reported significantly more long-term, short-term and internally-cued, PM lapses.
Conclusion: Deficits in everyday PM are associated with excessive drinking in teenagers.
EFFECT OF PSYCHOTHERAPY AND PHARMACOTHREAPY ON COGNITIVE FUNCTIONING IN PATIENTS WITH ANXIETY DISORDERS
Krzysztof Krysta, Adam Klasik, Maciej Matuszczyk, Zdzislawa Pilarz, Irena Krupka-Matuszczyk, Jacek Przybylo
Background: Anxiety symptoms might be due to a reduction of neuroplasticity in the cerebral structures responsible for emotions control.
Aims: The aim was to compare the selected cognitive functions in patients with diagnosed anxiety disorders.
Methods: Participation in the study was restricted to individuals with a diagnosis of an anxiety disorder (according to ICD-10: F-40-F48, with the exclusion of F42). 60 patients participated in the study, divided into 3 groups of 20 patients treated with pharmacotherapy, psychotherapy or both. The antidepressant administered for pharmacotherapy was tianeptine, and the psychotherapy was a series of group psychodynamic sessions. The patients were examined first in the beginning of the treatment, and then after 8 weeks of the therapy. Cognitive measurements were performed using Signal and CORSI tests, being a part of the Vienna Test System.
Results: Statistical analysis embraced results for three groups: with psychotherapy only – Group I, with combined psychotherapy and pharmacotherapy – Group II, with pharmacotherapy only – Group III. CORSI test results analysis: In the examination done after the end of therapy the significant improvement was found in Group II and III, and the greatest improvement was found in group II. SIGNAL test results analysis: In the examination done after the end of therapy the significant improvement was found in Group II and III, and the greatest improvement was also found in group II.
Conclusions: In the 8 week observation the best improvement of short-term memory and attention processes was found in the group in which combined psychotherapy and pharmacotherapy was applied.
INVESTIGATING THE SIGNIFICANT SYMPTOMS OF THE PSYCHOTIC DISORDERS BY PANSS AND RSPS
Hossein Ghamarigivi
Background: By investigating the symptoms of the positive and negative syndrome scale (PANSS) among patients with schizophrenia, Kay and Sevy (1990) reached to five factors namely negative, positive, disorganization, excitement and anxiety-depression. A rating scale for psychotic symptoms (RSPS) is another measure that was developed by Chourinard and Miller (1999).
Aims: To investigate the factor structures of PANSS and RSPS in psychotic disorders and to determine the discrimination abilities of these measures.
Methods: This study is descriptive-analytical. 272 inpatients with Schizophrenia, schizoaffective disorder, major depression and bipolar mood disorder were selected. The raw data were analyzed by Factor analysis, discriminate analysis and t test.
Results: Findings show that among the patients with schizophrenia, 40% of variance was determined by six factors on RSPS. This analysis in the group with schizoaffective disorder on RSPS showed that 24% and 11% of the variance had been loaded by extrasensory delusion and somatic hallucination respectively. The factor analysis of the RSPS in mood disorders indicated that vestibular and motor hallucination and distractibility are the significant factors. This analysis in schizophrenia spectrum on PANSS showed that irritability and severe preoccupation and in patients with mood disorders the tension and relationship disorder are main factors respectively. Discriminate analysis identified that PANSS and RSPS in 47.1% and 63.2% have correctly classified the groups respectively.
Conclusion: The findings show that the factor analysis of PANSS in schizophrenia doesn't reveal the mentioned five factors in the previous studies. Findings on the bases of RSPS on schizophrenia spectrum and mood disorders are correspondent with other studies.
THE NEW AND IMPROVED GRIFFITHS MENTAL DEVELOPMENT SCALES – EXTENDED
Natalie Knoesen
Background: The Griffiths Mental Development Scales-Extended Revised (GMDS-ER), a developmental assessment tool for children aged 0–8 years, has recently been revised and restandardised on a contemporary British sample. Assessment measures play a pivotal role in the early identification of developmental delays and therefore it is important that measures, like the GMDS-ER, are reliable and valid for their intended purpose(s).
Aims: To explore the reliability and construct-related validity of the 6 Subscales of the GMDS-ER, focusing specifically on gross motor development (Subscale A).
Methods: A cross sectional design using quantitative and qualitative methods was employed to determine the psychometric rigor of the Scales, utilising a random sample of 1026 children and 16 gross motor development experts respectively. Internal consistency coefficients and standard error of measurement estimates were used to determine reliability, while a facet analysis, literature control and factor analysis provided evidence for construct-related validity.
Results: Satisfactory reliability coefficients (0.65 < α < 0.97) and factor structures were found across the 6 Subscales. In particular, a 7-construct model of gross motor development was proposed to aid more in-depth interpretations of developmental strengths and weaknesses in balance, gross body coordination, gross visual-motor coordination, rhythm, power and strength, agility and flexibility and depth perception.
Conclusion: e new GMDS-ER does represent a psychometrically sound tool for the developmental assessment of children aged 0–8 years. Clinicians will be able to use the seven-factor construct model to make more in-depth interpretations of a child's gross motor strengths and weaknesses which, in turn, may aid in more accurate diagnoses, early identification and remediation of developmental delays.
OP39 PROFESSIONAL DEVELOPMENT IN PSYCHIATRIC NURSING
DEVELOPMENT AND FUTURE FOCUS OF TE AO MARAMTANGA (NEW ZEALAND COLLEGE OF MENTAL HEALTH NURSES)
Anthony O'Brien, Heather Casey, Hineroa Hakiaha
Background: Te Ao Maramatanga (The New Zealand College of Mental Health Nurses) Inc was established in 2004 to succeed the New Zealand Branch of the Australian and New Zealand College of Mental Health Nurses.
Aims: The aims of this presentation are to:
outline the New Zealand context of mental health nursing
describe key activities of the College
discuss challenges currently facing the profession
outline objectives to be addressed in the next decade.
Methods: The history of the College and professional representation of mental health nursing in New Zealand will be presented. Presenters will discuss the College's commitment to partnership under New Zealand's Treaty of Waitangi. Presenters will also describe the College's engagement in professional mental health nursing issues, including its own policy development, endorsement of standards of practice, workforce development, and submissions on policy issues.
Results: The College has the essential organisational features and infrastructure to lead the profession of mental health nursing in a mental health environment that presents many challenges to nurses and other health professionals. These include bicultural governance through the role of Kai Whakahaere and the Maori Caucus, a regional branch structure, and Boards of Professional Practice, Education and Research.
Conclusion: Te Ao Maramatanga has developed as a professional organisation that represents mental health nursing issues at all levels of clinical practice and policy development. Continuing development of a responsive mental health sector requires to emerging trends in mental health.
HUARAHI WHAKATU – DUAL COMPETENT PROFESSIONAL DEVELOPMENT PROGRAM FOR MENTAL HEALTH NURSES
Maria Baker, Kirsty Maxwell Crawford
Context: The development of Dual Competencies has taken a key precedence within New Zealand's Mental Health and Addiction workforce sector further accentuated by National Health Strategies (Mental Health Commission, 1998; Te Rau Matatini, 2001; Ministry of Health, 2006).
The interpretation of dual competency may differ amongst Mental Health and Addiction groups. However; this presentation will define ‘Dual Competency’ as a term closely linked to the vision created from within Maori Mental Health services; of developing an equally culturally and clinically skilled workforce; that would respond and appreciate the whole person who is Maori and is requiring of mental health service assistance.
Objectives: The first of the two key objectives of this presentation will be to demonstrate a Maori Mental Health Nursing professional development and recognition program that has deliberately incorporated cultural and clinical competencies/processes.
The second objective will be to share the early findings from the pilot of this dual competency based program that occurred with twenty Maori Mental Health Nurses using a qualitative methodology.
Key message: Huarahi Whakatu Maori Mental Health Nursing Professional Development and Recognition program is the first dual competency based program.
Conclusion: The findings from the pilot will provide information about dual competency development amongst Maori Mental Health Nurses by exploring the effectiveness of the Huarahi Whakatu professional development program. The implications of such may be the basis for subsequent higher level studies involving dual competency, workforce and Nursing development.
STUDENT NURSES' OPINIONS ABOUT PSYCHIATRIC NURSING AND MENTAL ILLNESSES IN TURKEY
Leyla Baysan Arabaci, Olcay Çam
Background: The reactions that a society has developed against mental illnesses and against people who work in the psychiatric field also have a significant effect on health care workers as members of that society.
Aims: This research was planned for the purpose of examining the opinions of student nurses, about psychiatric nursing and mental illnesses.
Methods: This methodological and descriptive type of research was conducted between January and June 2007 with 220student nurses at Izmir Dokuz Eylül University and Ege University Nursing and Health Sciences Schools who had completed the theoretical and practical portion of psychiatric course. The data were collected, after receiving necessary permission, using three self-report questionnaire forms. A high score from the tools expresses negative beliefs about mental illness and positive opinions about psychiatric nursing. Data were analyzed using number-percentage distribution, ANOVA and t-test.
Results: It was determined that 99.1% of nursing students were female and 46.4% of the nursing students had chosen nursing themselves. Although 29.1% stated that they wanted to work in psychiatric nursing after graduation, 52.2% evaluated the psychiatric nursing theoretic information they received to be inadequate for clinical practice. The nursing students' Beliefs about Mental Illnesses Inventory score mean was 2.38±0.76 (Max:5) and their mean score from the form that examined their opinions about psychiatric nursing was 3.59±0.62 (Max:5).
Conclusion: The overwhelming majority of student nurses didn't want to work as psychiatric nurses after graduation. The students' opinions about psychiatric nursing affected whether or not they wanted to work as psychiatric nurses(t = 3.55, p < 0.01).
RETURN TO MENTAL HEALTH NURSING PRACTICE – FEASIBILITY PROJECT
Brian McKenna, Tony O'Brien, Katey Thom
Background: In New Zealand, there is a shortage of mental health nurses. Since the introduction of the Health Practitioners Competency Assurance Act (2003), registered nurses who have been out of practice for five or more years are required to provide evidence of their competency to the Nursing Council in order to obtain a practising certificate and re-enter the workforce. Return to nursing programmes have been implemented throughout the country, however, these programmes do not target or attract mental health nurses.
Aims: The aim of this research (to be completed in May) is to determine the feasibility of a regional mental health nursing ‘Return to Practice’ programme.
Method: A summary of current return to nursing practice programmes nationwide and their usage was completed. Semi-structured telephone interviews were undertaken with key stakeholders to identify potential providers and funding options for return to mental health nursing programmes (n = 22). In order to estimate the potential demand for return to nursing practice programmes, an anonymous survey of non-active nurses in the Northern Region was conducted (n = 1720). Finally one focus group with service users will take place to discuss the final recommendations.
Results: Yet to be concluded.
Conclusion: The intent of this project is to determine the feasibility of a regional return to mental health nursing programme. The structure and content of such a programme will be suggested.
DEVELOPING AND ASSESSING MENTAL HEALTH NURSING COMPETENCIES: A PRACTICE DEVELOPMENT PROJECT IN A RURAL SERVICE
Val Goodwin, Peter Fahy
Context: Standards of nursing practice in mental health care have been set, and competencies reflecting these standards developed by professional bodies. However, tools by which competency can be measured are not always readily available. Assessment of clinical competency supports the delivery of care in assuring all stakeholders of the professional and clinical competence of staff. Placing competency based assessment in a practice development framework provides the opportunity for nurses to self-assess in a supportive environment.
Objectives: This paper describes the conduct and evaluation of the first two parts of a five stage practice development activity. This included the development of assessment tools for six core mental health nursing competencies by an advisory group, and the use of the tools by 54 clinicians from two rural services.
Key messages: Evaluation showed that the majority of clinicians successfully completed assessment of competency in two core practice elements at first attempt. A high level of comfort with the process was also identified by participants. The success of this part of the program indicated a willingness by staff to embrace the concept of competency based assessment. This was despite initial concerns about potential barriers to implementation such as staff anxiety or rostering practices.
Conclusion: Competency based assessment tools provide an effective way of assessing nursing practice in mental health settings. The introduction of these tools in a practice development framework enhances their acceptability by experienced mental health nurses.
AN INTERVENTION DESIGNED TO REDUCE THE USE OF SUMMARY EXECUTION IN ACUTE PSYCHIATRIC INPATIENT SETTINGS
Stephen Elsom, Cadeym Gaskin, Cath Roper
Context: Although it may seem preposterous to consider the need to reduce the use of summary executions in acute psychiatric inpatient settings because practitioners simply would not consider using such inhumane treatment, it is sobering that many mental health professionals do not hesitate to use seclusion.
Objectives: We draw attention to the assumption that underlies the thinking of many mental health professionals that seclusion is acceptable simply because it is available.
Key messages: The letter of the law (seclusion is legal) is frequently given precedence over the spirit of the law (seclusion should used as a method of last resort, if at all). The availability of seclusion as an intervention makes its use inevitable. Although sufficient checks and balances exist in society to prevent psychiatric staff from adding summary executions to their “treatment” paradigms, legislators need to set the bar much higher. Outside intervention, in the form of legislation, is needed because the mental health professions seem incapable of discontinuing the use seclusion despite evidence of the trauma it causes to both patients and staff and despite the lack of evidence that it achieves any desirable outcomes.
Conclusion: The use of seclusion is unacceptable and should be as impossible and unthinkable as summarily executing our patients. By the use of what would seem, at first glance, an absurd analogy between seclusion and summary execution we highlight the need for a shift in policy and legislation regarding the use of traumatising interventions.
OP40 MENTAL HEALTH POLICY AND TRAINING ACROSS CULTURES
SENSITIVITY OF MENTAL HEALTH POLICY AND SERVICES TO CULTURE, GENDER, CONFLICT AND HUMAN RIGHTS CONSIDERATIONS: CASE STUDY FROM THE SOLOMON ISLANDS
Ilse Blignault, Anthony Zwi, Anne Bunde-Birouste, George Malefoasi, Anthony Veke
Background: Armed conflicts and natural disasters are common in Asia and the Pacific. In their aftermath, psychosocial and mental health needs are significant and policy and services changes are frequent. The work presented here is part of a larger, comparative study that aims to improve the evidence base for mental health policy formulation and implementation in the Solomon Islands and Timor-Leste.
Aims: To determine to what extent issues such as culture, gender, conflict and human rights are incorporated in mental health policy in the Solomon Islands and how mental health and psychosocial services respond to these issues.
Methods: Research, including key-informant interviews, documentary analysis and participant observation, was conducted at three levels: policy, service delivery and community. Questions from The Health and Peacebuilding Filter (2006) were adapted to examine the extent to which services were sensitive to culture, gender, conflict and human rights.
Results: Informants’ understanding of the concepts of culture, gender, conflict and human rights were determined by socio-cultural context and their position within the health system. These issues were not routinely considered in formulating policy or planning services, but they were not overlooked by health and community workers or communities. Other issues that communities considered important were trust and good governance.
Conclusion: Sensitivity to culture, gender, conflict and human rights—and trust and good governance—must be understood and addressed at both macro and micro levels to ensure mental health services are “accessible, relevant and useful to the people”, contributing to a broader health and government agenda of peacebuilding.
JAPANESE MENTAL HEALTH SYSTEM REFORM
Harry Minas, Yutaro Setoya, Tadashi Takeshima
Context: Japan has the highest number of psychiatric beds per capita in the world and mental health care relies heavily on inpatient care. However, recently the Japanese government has released mental health policies and laws relevant to mental health in rapid succession. This mental health system reform is aimed towards deinstitutionalization and community mental health.
Objectives: The objective is to examine mental health system reform in Japan since 2002 when the report “Future Direction of Mental Health and Welfare Policy” stated its basic principle as “Shift from inpatient centered treatment to community based health, medicine and welfare”. Following this report a number of national reports and amendments to the existing laws were released.
Key messages: The biggest change in community services has resulted from the enactment of “the law to support the independence of people with disability”. This new law has five main aims; (1) to streamline the response to three disabilities (i.e. mental, intellectual and physical), (2) to put greater emphasis on user-oriented services, (3) to enhance support for employment, (4) to clarify the process for access to benefits, and (5) to secure financial sources.
Conclusion: This presentation describes the current situation of mental health services in Japan, the content of the mental health system reform process, areas that require more attention and change, and aspects of the Japanese cultural context that promote or constrain the process of mental health system reform.
PARTNERING WITH ASIA: CHALLENGES FOR A VICTORIAN MENTAL HEALTH SERVICE
Margaret Goding, Jennifer Smith
Context: Implementing community-based mental health care is a challenge for Asian-Pacific countries, just as it is for Australia. St Vincent's Mental Health has been privileged to work in partnership with China, Malaysia, Korea and other Asian nations to further develop their mental health services. Participation in a consortium with The University of Melbourne – Asia Australia Mental Health (AAMH), and in the Post-graduate Overseas Training (POST) Program, has enabled us to share the journey from institutional to community care, working with government and mental health leaders to develop programs, implement quality and evaluation processes and to train staff of all disciplines.
Objective: To outline a frame-work for successful collaboration in mental health service development with our Asian neighbours.
Key messages: Working with other countries brings great rewards for a public mental health service: widening our cultural perspectives, extending our understanding of our own service models, thinking creatively about how to modify and adapt to the many and varied Asian contexts, and last, but by no means least, the satisfaction of being able to make a significant difference in the lives of people experiencing mental illness.
To do this well requires excellent organisation and planning, preparation of staff, and the right partners.
Conclusion: The paper will describe the St Vincent's Mental Health framework for supporting our international activities, some of the achievements of our partnerships and lessons to be learnt.
TEACHING PSYCHOTHERAPY TO CROSS-CULTURAL RESIDENTS IN THE USA
Subhash Bhatia, Shashi Bhatia, Supriya Bhatia
Background: The global economies, advances in communication technology, ease of travel between the continents and changes in immigration patterns have drawn clinicians and patients from different cultures closer. We are often asked to assess and treat patients from cultures different from our own. It is expected that these trends will grow. Therefore we need to develop cross-cultural psychotherapy training curriculum to meet the training need of our residents and clinical care needs of our patients.
Aims: In the USA International Medical Graduates (IMGs) occupy over 25% of all residency positions and about 43% of all psychiatry residency positions in the USA. The authors will present information for teaching psychotherapy to cross-cultural residents.
Methods: We reviewed the contemporary literature about acculturation patterns and challenges it creates for IMGs, cultural defenses, resistances, transferences and counter transferences as well as racial and cultural stereotypes and biases and how it impacts psychotherapy training.
Results: Psychotherapy training of IMGs requires understanding the culture of their origin in contrast to culture of supervising faculty. This training for IMGs is facilitated by supervisors adopting an empathic, non-judgmental supportive and nurturing approach, appreciating and validating (if relevant) residents’ culture specific observations and interpreting transferences and boundary issues. Availability of mentoring programs, specialized psychotherapy seminars tailored to the needs of IMGs can enhance psychotherapy skills, knowledge and experiences. Integration of pharmacotherapy and psychotherapy curriculum can be valuable.
Conclusions: The model discussed can be effective and rewarding both for the residents and supervisors.
SOCIOCULTURAL ISSUES IN US PSYCHIATRY RESIDENCY TRAINING PROGRAMS: 2007 ACGME ACCREDITATION STANDARDS
Francis Lu
As the United States has become more culturally diverse and globally linked, training in US psychiatry residency training programs has also moved to incorporate cultural competence. This presentation reviews the new 2007 Accreditation Council for Graduate Medical Education (ACGME) accreditation standards for US psychiatry residency training programs focused on sociocultural issues. This revision updates the 2001 standards by incorporating the six ACGME core competencies as specified for psychiatry into the standards. Five of the six core competencies discuss sociocultural issues: patient care, medical knowledge, interpersonal and communication skills, professionalism, and systems-based practice. For the first time, “disparities in mental health care” has been included. Implications for training and curricular development are discussed.
WHY DOES A CULTURE CARE FOR ITS CITIZENS THE WAY IT DOES?
Kenneth Khoury, Richard Raspa
Context: A psychiatrist and folklorist analyze cross-cultural health-care changes in five countries: US, Scotland, Poland, Brazil, and China. We hypothesize that mental health practices arise from root metaphors, icons beneath the surface of social institutions.
Objectives: To understand ways mental illness and care are cultural constructions.
Societies ad dress tensions between growing health needs of expectant populations and limited resources. We: 1) suggest why a specific culture cares for vulnerable citizens the way it does; 2) describe how iconic metaphors of cowboy (US), clown (Poland), bureaucrat (China), soccer player (Brazil), clan member (Scotland) play out tension between resources and delivery; 3) illustrate how metaphors shape solutions to mental health delivery.
Key messages:
Cultural themes clarify the movement between collective and individual responsibility in health systems.
Figures of the clown, bureaucrat, cowboy, soccer player, and clan member represent systems of thinking and action that are inflected throughout social institutions and inform medical practice. The soccer figure, for instance, embodies the power of the dodge–overcoming obstacles that threaten to defeat goal directed behavior. In Brazil, when a hospital cannot provide anti-psychotic drugs, psychiatrists must rely upon the dodge, the capacity to avert defeat by finding non-institutional ways through a field of scarce resources.
Conclusions: Root metaphors:
Explain ways a society deals with tension between limited resources and expanding care expectations.
Reveal solutions to difficult health delivery problems that arise from the deeper layers of a culture, from the fiduciary hold on what a society regards as compelling.
OP41 SOMATOFORM DISORDERS
CHRONIC PAIN REDUCTION AND RELAPSE PREVENTION: INTERACTIVE VOICE RESPONSE AS A THERAPEUTIC TOOL
Magdalena Naylor, Erin Roland, Frances Keefe, John Helzer
Background/aim: To test whether the Therapeutic Interactive Voice Response (TIVR) system can be used to prevent relapse into pain behavior.
Method: Following 11 weeks of CBT fifty subjects with chronic pain were randomized to two groups. Twenty-five subjects participated in 4 months of TIVR, while control group of twenty-five subjects received standard care only. TIVR is an automated phone system designed to reinforce pain coping skills learned in group CBT. TIVR has four components: daily self-monitoring questionnaire, didactic review of coping skills, behavioral rehearsals of coping skills, and monthly therapist feedback. All four components can be accessed on demand via touch-tone phones.
Results: Between-group analysis (ANCOVA) revealed significant differences at both 4 and 8 month follow-ups for most of the outcomes, notably MPQ Typical Pain (p < 0.001), CSQ Control Pain (p < 0.0003), TOPS Pain Experience (p < 0.0001), and SF-36 Physical Composite (p < 0.001). For all variables outcomes were superior for the TIVR group. There was no significant difference in opioid medication use from baseline at all follow-ups. Within subject repeated measures multiple regression analyses of the daily self-monitoring TIVR questionnaire revealed that daily practice of relaxation techniques was associated with improvement in coping (p < 0.001), reductions in stress (p < 0.001) and pain (p < 0.05). An increase in coping skills used per day was associated with reductions in emotional distress (p < 0.0001), stress (p < 0.0001) and improvement in coping (p < 0.0001).
Conclusion: Results demonstrate that TIVR can be used to decrease pain, improve coping and decrease relapse into pain behavior. These results are not a consequence of differential medication use.
THE RELATIONSHIP BETWEEN PRIOR PSYCHIATRIC DISORDER AND CHRONIC FATIGUE SYNDROME. EVIDENCE FROM A BRITISH NATIONAL BIRTH COHORT STUDY
Samuel Harvey, Michael Wadsworth, Simon Wessely, Matthew Hotopf
Background: Increased rates of psychiatric disorder have been reported in those diagnosed with chronic fatigue syndrome (CFS) or myalgic encephalomyelitis (ME), but the direction of causation in this relationship has not been established.
Aims: To test the hypothesis that individuals with self-reported CFS/ME have increased levels of psychiatric disorder prior to the onset of their fatigue symptoms.
Methods: 5362 participants were prospectively followed with various measures of personality, psychiatric disorder and fatigue collected over the first 43 years of their life. CFS/ME was identified through self report during a semi-structured interview at age 53 years.
Results: 34 (1.1%, 95% confidence interval 0.8 – 1.5%) of the 3035 subjects assessed at age 53 years reported a diagnosis of CFS/ME. CFS/ME was more common amongst females, but there was no association between CFS/ME and either social class, social mobility or educational level. Those with psychiatric illness between the ages of 15 and 36 years were more likely to report CFS/ME later in life with an odds ratio (adjusted for sex) of 2.65 (95% confidence interval 1.26 to 5.57, p = 0.01). Increased levels of psychiatric illness, in particular depression and anxiety, were present prior to the occurrence of fatigue symptoms. There was a dose-response relationship between the severity of psychiatric symptoms and the likelihood of later CFS/ME. Personality factors were not associated with a self reported diagnosis of CFS/ME.
Conclusions: This temporal, dose-response relationship suggests that psychiatric disorders, or shared risk factors for psychiatric disorders, are likely to have some aetiological role in CFS/ME.
ABNORMAL ILLNESS BEHAVIOUR: A CRITICAL REVIEW
Issy Pilowsky
Since it was first formulated in 1969 the concept of abnormal illness behaviour (AIB) has been responded to in a variety of ways; positive and negative. It was a concept introduced as a response to the controversy over the nature and even existence of ‘hysteria’ and led to a ‘general classification’ of AIB and to the Illness Behaviour Questionnaire (IBQ) in 1976. The latter generated two second order scores (Disease Affirmation (DA) and Affective Disturbance (AD). The AD has been stable and tends to predict outcome in conditions such as chronic pain and fatigue syndromes. At times the AIB label used, inappropriately to attach to any somatic complaint associated with anxiety and depression. The AIB definition also provides criteria for diagnosis which may be too exacting in clinical practice. There seems little doubt that context has a striking influence on the nature of illness behaviour. The three major settings in the literature are general practices, general hospitals and psychiatric services.
COMPUTERIZED TELEPHONE-BASED THERAPEUTIC TOOL FOR CHRONIC PAIN REDUCTION AND RELAPSE PREVENTION
Magdalena Naylor, Erin Roland, Shelly Naud, Frances Keefe, John Helzer
Background/aims: To test whether the Therapeutic Interactive Voice Response (TIVR) system can be used to prevent relapse into pain behavior.
Method: Following 11 weeks of CBT fifty subjects with chronic pain were randomized to two groups. Twenty-five subjects participated in 4 months of TIVR, while control group of twenty-five subjects received standard care only. TIVR is an automated phone system designed to reinforce pain coping skills learned in group CBT. TIVR has four components: daily self-monitoring questionnaire, didactic review of coping skills, behavioral rehearsals of coping skills, and monthly therapist feedback. All four components can be accessed on demand via touch-tone phones.
Results: Between-group analysis (ANCOVA) revealed significant differences at both 4 and 8 month follow-ups for most of the outcomes, notably MPQ Typical Pain (p < 0.001), CSQ Control Pain (p < 0.0003), TOPS Pain Experience (p < 0.0001), and SF-36 Physical Composite (p < 0.001). For all variables outcomes were superior for the TIVR group. There was no significant difference in opioid medication use from baseline at all follow-ups. Within subject repeated measures multiple regression analyses of the daily self-monitoring TIVR questionnaire revealed that daily practice of relaxation techniques was associated with improvement in coping (p < 0.001), reductions in stress (p < 0.001) and pain (p < 0.05). An increase in coping skills used per day was associated with reductions in emotional distress (p < 0.0001), stress (p < 0.0001) and improvement in coping (p < 0.0001).
Conclusion: Results demonstrate that TIVR can be used to decrease pain, improve coping and decrease relapse into pain behavior. These results are not a consequence of differential medication use.
OP42 ADOLESCENT DEPRESSION AND RISK TAKING BEHAVIOUR – CHALLENGES FOR EFFECTIVE INTERVENTION
FAMILY FACTORS, DEPRESSION AND HIGH-RISK BEHAVIORS AMONG CHINESE ADOLESCENTS IN HONG KONG
Hang-wai Chui, Antoinette Marie Lee, Stephanie Marie Sze-MunM Lau, Daniel Yee-Tak Fong, Peter Wing-Ho Lee, Sunita M. Stewart, Tai-Hing Lam
Background: Many high-risk behaviors first develop during adolescence. While the role of family in the development of these behaviors is well acknowledged, the specific family factors involved remain to be clarified. Depression is associated with both family problems and high-risk behaviors. The relationship among family factors, depression, and high-risk behaviors also requires further investigation.
Aims: We examined the relationships of specific family factors (parental monitoring, family conflict, family structure and relationship with parents) and depression, with a range of high-risk behaviors.
Methods: A cross-sectional survey of 6,051 adolescents (aged 12–19) from 17 high schools in Hong Kong was conducted. Seven high-risk behaviors (smoking, alcohol use, drug use, early sex, wrist-cutting, suicidal attempt, violence) were the main outcome variables.
Standardized self-administered questionnaires were used to assess family variables and depression. Their relationship with both the total number of high-risk behaviors and each of the behaviors were examined.
Results: Family conflict, parental divorce/separation, low parental monitoring, and depression were associated with greater number of high-risk behaviors. After controlling for demographic variables and depression, parental monitoring was associated with decreased risk of all behaviors while conflict with mother increased except suicidal attempt. Parental divorce/separation was associated with increased risk of drinking, violence and suicidal attempt. Having lost parents was a risk factor for early sex. Conflict with father was associated with increased risk of wrist-cutting only. Low parental warmth was not associated with any behavior.
This project was supported by a grant from the RGC CERG scheme (HKU 7435/03M).
ANTIDEPRESSANTS, SUICIDE AND DEPRESSED ADOLESCENTS: INTERPRETING CHANGING EVIDENCE IN CLINICAL PRACTICE
Michael Dudley, Dusan Hadzi-Pavlovic, Joseph Rey, Doug Andrews, Tania Perich
Aims: To identify, from voluminous evidence on efficacy and safety in new generation antidepressants (NGAs) with depressed children and adolescents, practical clinical strategies for acute phase antidepressant treatment.
Methods: A pragmatic survey of studies and reviews since January 2003.
Results: New evidence about NGAs questions their efficacy for depressed children and adolescents, and associates them with a slight but not insignificant increased risk of self-harm and suicidal thoughts, which seems especially associated with starting treatment, but also at other times. This has dispelled any illusion that their prescription can be casual or unsupervised and has resulted in severe public health warnings about their use. However, even more recent evidence suggests that NGAs may be effective in depression especially of moderate-severe intensity, in related anxiety and obsessive disorders, and that NGAs are effective in preventing youth suicide.
Conclusions: Concern about the dangers of NGA treatment should now be balanced with emerging evidence regarding the dangers of non-treatment. NGAs have a concurrent role with education, self-care and psychological treatments if depression is marked or severe. Patients should be warned about NGAs’ off-label status, side-effects (including ‘activation’, suicidality, emotional blunting, manic switches), the need for adherence and avoiding abrupt discontinuation, and should be regularly monitored. The shift in recent evidence suggests that while extra risks of self-harm with NGAs warrant warnings and monitoring, in moderate to severe clinical depression the risk may be less than that of suicide if they are not used.
RISK FACTORS FOR SELF-HARM AMONG AN ETHNICALLY DIVERSE SAMPLE OF EAST LONDON ADOLESCENTS
Emily Klineberg, Kamaldeep Bhui, Charlotte Clark, Stephen Stansfeld
Background: Research on self-harm in adults in the UK has shown ethnic differences in rates and risk factors. In adolescent research, evidence is mixed about ethnic differences in self-harm and the role of cultural stressors.
Aims: To examine psychological and cultural risk factors for self-harm in a multi-ethnic adolescent sample.
Methods: A representative sample of East London secondary school students aged 13-16 years participated in a longitudinal study (n = 1014). Self-ascribed ethnicity, depressive symptoms, racist bullying and recent migration were assessed in self-report questionnaires. Phase 2 included acculturative style questions, based on identification with own or other ethnic groups for friendship and clothing choices. Self-harm was assessed in Phase 3 only.
Results: The prevalence of self-harm at Phase 3 was 12% (n = 122); of which 80.3% were female. Preliminary analysis shows prospective associations between depressive symptoms and self-harm (OR3.3; 95%CI 2.1–5.1). Asian-British participants had increased odds for self-harm (OR2.7; 95%CI 1.3–5.7), compared with White-British participants. This ethnic difference remained significant with adjustment for gender and depressive symptoms; however it reduced with adjustment for clothing choice with family. Those reporting assimilated clothing style with family showed increased odds of self-harm in adjusted analyses (OR3.4; 95%CI 1.3–8.9).
Conclusion: Depressive symptoms and gender predict self-harm in this ethnically diverse adolescent sample. There was mixed evidence for culturally salient variables. The increased risk in Asian-British participants and those reporting assimilated clothing style with family may indicate intergenerational conflict or that for some young people, identification with more than one culture functions as a source of stress.
CONSEQUENCES OF ADOLESCENT DEPRESSION: SUBSTANCE USE IN YOUNG ADULTHOOD
Maria McKenzie, Craig Olsson, Tony Jorm, George Patton
Background: Current understanding of the developmental implications of early onset depression across the life course is limited, despite the high prevalence, morbidity and recurrent nature of this disorder. Previous research suggests that depressed adolescents are at significantly increased risk of adverse psychosocial outcomes. However, this research is constrained by small clinical samples, short follow-up, retrospective age of onset estimates and a lack of prospective data.
Aims: To investigate the consequences of adolescent depression in young adulthood (age 24 years).
Methods: Participants were drawn from a 15-year longitudinal study of 2000 young Australians followed across 9 waves of data collection from 14 to 28 years (Victorian Adolescent Health Cohort Study). A two-stage screening process identified adolescents with sub-clinical depressive symptoms (n = 709) and clinical depression (n = 93) as part of a nested case-control study. Substance use outcomes were examined at age 24 years, adjusting for gender.
Results: There was a 2- to 3-fold increase in the odds of reporting tobacco, alcohol and cannabis dependence among participants with adolescent sub-clinical and clinical depression, respectively. There was a 2 fold increase in the odds of reporting past 12 month amphetamine, cocaine and ecstasy use among participants with adolescent sub-clinical depressive symptoms, and a 2- to 6- fold increase in the odds of reporting a drug and alcohol consultation in the past 12 months for participants with adolescent sub-clinical and clinical depression, respectively.
Conclusion: Adolescent depression is strongly associated with adverse psychosocial outcomes in young adulthood. Findings have implications for clinical practice and policy.
‘ENGAGING THE UNENGAGEABLE’: ASSERTIVE OUTREACH WITH HIGH-RISK YOUTH
Carsten Schley, Sandra Radovini
Background: Whilst assertive outreach has a strong evidence base in adult psychiatry, its effectiveness in youth mental health is unknown.
Aims: To explore client characteristics and treatment effects in a group of difficult to engage, ‘high-risk’ young people aged 12 to 24 years, seen by the Intensive Mobile Youth Outreach Service (IMYOS, ORYGEN Youth Heath) in Western Metropolitan Melbourne.
Method: The clinical files of 47 clients seen between September 2000 and 2004 were audited retrospectively, targeting demographic and treatment outcome data prior to and during IMYOS involvement.
Results: Clients typically presented with traumatic childhoods, disrupted education, repeated treatment dropout and ‘high-risk’ behaviours, including suicidal ideation (79%), violence (72%), deliberate self-harm (66%), substance abuse (66%) and criminal behaviour (53%). Most prevalent clinical disorders at referral (according to DSM-IV) were mood, attention-deficit/disruptive behaviour, substance-related, and anxiety disorders. Additionally, 38% of clients fulfilled criteria for an emerging or full-threshold personality disorder, most commonly borderline personality disorder traits. Results on treatment outcomes showed a significant reduction in most risk variables over an average of 12 months, and significantly lower admissions rates and inpatient days compared to the 12 months prior to IMYOS referral. At the end of treatment, there was a reduction in number of clients suffering from clinical disorders and in average number of disorders per client.
Conclusions: Based on retrospective audit data, there is evidence to support that Assertive Outreach with young people is likely to decrease ‘risk’ and hospital use, and to have a positive effect on mental health.
OP43 SMOKING, GAMBLING AND ADDICTIONS IN OTHER SETTINGS
TEMPORAL RELATIONSHIPS BETWEEN WAR DEPLOYMENT AND SUBSEQUENT PSYCHOLOGICAL DISORDERS
Dean McKenzie, Mark Creamer, Alexander McFarlane, Helen Kelsall, Andrew Forbes, Jillian Ikin, Malcolm Sim
Background: Although there has been a substantial body of literature on psychological health in veterans of the 1990/1991 Gulf War, there has been little research into the pattern of post-war onset and temporal progression of psychological disorders such as alcohol abuse or dependence, major depression and PTSD, in this or other veteran groups.
Aims: To examine the progression of psychological disorders developing in Australian veterans post-Gulf War, in order to identify their sequence, the period in which they are most likely to develop, and whether this differs according to potential risk factors such as military rank.
Methods: The Australian Gulf War Veterans’ Health Study included the retrospective collection of CIDI DSM-IV diagnostic and age of onset data on 1,232 male Royal Australian Navy Gulf War veterans. Analyses included discrete time survival analyses.
Results: Alcohol abuse or dependence is the most frequent psychological disorder to appear post-Gulf War, followed in frequency by depression and PTSD. In veterans with two or more post-Gulf War diagnoses, anxiety disorders, and alcohol abuse or dependence, tend to precede affective disorders.
When timing of post-Gulf War symptom onset is divided into four-year phases, symptoms peak in the first four years and then subside. Statistically significant interactions, involving phase and rank, and phase and time of deployment, were observed.
Conclusion: These findings may aid veteran and defence organisations in the planning of effective mental health management and prevention policy, particularly in regard to symptoms of alcohol misuse or avoidant behaviours, which may lead to further psychological ill-health.
PATTERN OF COMORBID TOBACCO USE AMONG OUTDOOR PSYCHIATRIC PATIENTS
Afridi Muhammad Iqbal, Ali Ali, Afridi M. Ali, Samina Bano
Background: Tobacco use is a common both in men (47.5%) and women (10.3%) despite the fact that it causes serious but preventable health problems. A cigarette is the only legally available consumer product that kills through normal use especially in the developing countries.
The present study aims to assess co-morbidity with psychiatric disorders in order to so that appropriate therapeutic-cum preventive measures can be chalked out keeping mind the cytochrome p450 enzyme system.
Aims: To assess the pattern of Tobacco use among outdoor psychiatric patients in relation to ICD-10 of World health Organization (WHO).
Methods: This study was carried out at Neuro-Spinal Medical Institute (NMI), Karachi, Pakistan; 2005. It was a Cross-sectional study. All 1091 consecutive cases that approached for psychiatric consultation during 2005 were assessed. The diagnostic criteria of ICD-10 WHO was used.
Results: A total number of 1091 consecutive cases of any gender were approached. N = 339 (n = 223 male [66%] and n =116 [34%] female) were using tobacco in any form (Smoking, Paan, & Niswar). 153(45.01%) cases of them were found to be suffering from affective disorder; 89 (26.25%) cases had neurotic/stress related disorders and 27(7.96%) cases had psychotic disorders and remaining (70 [21%]) had other mental disorders. In addition to that 99(29%) of total 339 cases had physical co-morbidity:
Conclusion: The study has assessed the association between tobacco use in relation to socio-demographic and psychiatric co-morbid physical disorders according to ICD-10. It suggests that tobacco users have clear relationship to mental/physical disorders. It has an implication in prevention and better therapeutic intervention in tobacco users with ailments.
SMOKING AND MENTAL ILLNESS: MYTHS, MISCONCEPTIONS AND NEGLECT
Mark Ragg, Tanya Ahmed, Wendy Oakes
Introduction: People with mental illness are more likely to smoke than the general population. There are many entrenched beliefs as to why this is so. We sought to examine the evidence on which these beliefs are based.
Methods: We carried out literature review (MEDLINE search from 1995 to January 2007, searching reference lists, searching key authors).
Results: Smoking is common among people with mental illnesses. Smoking-related diseases such as heart disease and cancer are the leading causes of death for people with mental illness. Smoking causes enormous financial difficulties for people with few resources.
Yet smoking is frequently ignored, and sometimes encouraged, by the mental health workforce. Staff rarely discuss smoking with people with mental illness, and even more rarely help them quit.
There is evidence that people with mental illness want to quit smoking, and are capable of quitting smoking. There is evidence that people with substance abuse disorders benefit from quitting smoking. There is also evidence that non-smoking policies in institutions do not cause the problems anticipated with aggression or behaviour control, and within months are actually welcomed by both staff and patients.
In summary, it is clear that smoking does enormous harm to people with mental illness, and there is no evidence it does tham any good. It causes stress, rather than relieves it, it does not treat the mental illness and has little or no impact on medication side-effects. It should be discouraged.
Discussion: These findings will overturn much of the standard practice in Australia regarding people who smoke and have a mental illness.
PSYCHOSOCIAL CHARACTERISTICS OF CHINESE TREATMENT-SEEKING PROBLEM GAMBLERS
Catherine So-kum Tang, Anise Wu, Joe Chan
Background: In Chinese societies, gambling has been a national pastime and a way of life. Excessive gambling is generally not considered a psychiatric illness. There is also a lack of prevention and treatment services for problem gambling.
Aims: Current research about problem gamblers is mainly conducted in English-speaking nations. We aimed to investigate psychosocial characteristics of Chinese problem gamblers.
Method: 952 Chinese treatment-seeking gamblers completed a self-report assessment form which included demographics as well as gambling-related information and problems.
Results: Participants reported an average of 12 gambling-related problems on the Chinese version of the South Oaks Gambling Screen (SOGS: Lesieur & Blume, 1987). About 82% of participants had argued with their family over gambling, 50-78% had wanted to stop gambling but did not think they were able to do so, 48% lost time from work, 30% had borrowed money from loan sharks to gamble or to pay gambling debts, and 17% sold their personal or family properties to get money for gambling or repayment of gambling debts. About 70% of participants experienced emotional distress, 39% reported insomnia, 24% complained of somatic discomfort, 24% lost motivation to work, and 15% had suicidal thoughts. Participants with higher SOGS scores were more likely to start gambling at a younger age, engage in multiple types of gambling activities, accumulate greater gambling debts, lose motivation to work, and report greater emotional distress, somatic complaints, and suicidal thoughts.
Conclusion: More vigorous and innovative strategies should be devised to increase Chinese problem gamblers’ participation in treatment programs.
DRUG-SPECIFIC COGNITIONS AND EMPLOYMENT AMONG CHRONIC DRUG ABUSERS: A TWO-YEAR FOLLOW-UP STUDY
Anise Man Sze Wu, Catherine Tang
Background: Employment has been identified as a potent criterion of substance abuse treatment outcome due to its financial and psychosocial meanings to a person. However, drug abusers often suffer from sub-employment and unemployment (Campbell et al., 2003), and research concerned with investigating the social-cognitive influences in maintaining employment is lacking.
Aim: This study systematically studied a multivariate model relating drug-specific cognitions (including abstinence self-efficacy, beliefs of substance use, and perceived public discrimination against drug abusers) on job attitudes, which in turn influencing employment at the 2-year follow-up among Chinese chronic drug abusers.
Method: The present study was a two-year longitudinal study on employment among Chinese chronic drug abusers, who had used illicit drug(s) for at least 5 years. There were 491 participants (416 men and 75 women) at Wave 1 and 280 (232 men and 48 women) at Wave 2. The number of days employed over a year was assessed at Wave 2 to indicate participants’ employment. Their drug-specific cognitions and job attitudes were measured by validated inventories such as 42-item Situational Confidence Questionnaire (SCQ) (Annis, 1987).
Results: Multiple regression analysis indicated that job attitude significantly explained 25% variances of employment at the same wave. Moreover, self-efficacy, beliefs of substance use, and perceived discrimination also significantly predicted job attitudes and thus employment two-year later.
Conclusion: Drug-related cognitions significantly influence the employment of substance abusers. The implications of these findings for cognitive treatment and employment rehabilitation of substance abusers will be discussed.
PSYCHOSOCIAL EVENTS AS PREDICTORS OF RELAPSE IN EARLY-MIDDLE-AGED ALCOHOL DEPENDENTS: A RETROSPECTIVE ANALYSIS IN RELAPSERS VS NON-RELAPSERS
Neatu Narang, Shubhra Nautiyal
Background: Relapse is one of the hallmarks of alcohol abuse and dependence constituting therapeutic challenge throughout the life of an alcoholic. Life events research related to alcoholism is rather less well explored area. Discrete stressful life events and chronic stressors play a role not only in development of alcoholism but also in relapse. Relapsers were found to have experienced twice as many negative and only half as many positive events as compared to abstainers. Studies on correlation of stressful life events with alcoholic relapse have yielded contradictory associations.
Aims: This study is an effort to elucidate the contribution of psychosocial events towards relapse in alcohol dependents.
Methods: 100 diagnosed male patients of Alcohol Dependence admitted to teaching Army hospital psychiatry unit for treatment of relapse, along with 100 age and socio-demographically matched controls (abstainers), were administered Armed Forces Life Events Scale (modification of Presumptive Stressful Life Events Scale) and screening batteries. Statistical analysis of data was carried out by employing t-test and Non-parametric Mann Whitney test.
Results: Statistically significant differences between relapsed and non-relapsed groups were detected in number of undesirable events (p=.0001) and stress scores of undesirable events (p=.002) experienced over previous one year.
Conclusions: Our findings suggest that multiple adverse life events and soldiers living alone are key factors potentiating relapse in alcohol dependents. Life events often do influence alcohol use patterns and hence application of appropriate cognitive-behavioral therapeutic measures and coping skills play a paramount role in prevention and early intervention in alcoholic relapse.
OP44 PSYCHIATRIC NURSING PRACTICE
SUPPORTING THE MENTAL HEALTH NEEDS OF PEOPLE LIVING WITH HIV/AIDS IN A COMMUNITY NURSING ENVIRONMENT
Jacqui Allen, Russell Nunn, Adam Hamilton
Background: In 2006, 63% of 141 people living with HIV/AIDS receiving nursing care from a large Melbourne community nursing provider experienced co-morbid mental health and/or drug and alcohol problem/s with depression, anxiety and non-dependent drug abuse the three most frequently occurring diagnoses. To improve care for HIV/AIDS clients, a 12-month trial of a Mental Health Drug and Alcohol Clinical Nurse Consultant within an existing HIV/AIDS team was initiated.
Aim: To develop, trial and evaluate an advanced practice community Mental Health Drug and Alcohol Clinical Nurse Consultant role in HIV/AIDS care.
Methods: A quantitative and qualitative evaluation was undertaken to appraise role effectiveness. Key components of the role comprised assessment, care planning, referral and care partnerships with nurses, and medical and allied health practitioners. Data were collected from clients, carers and health professionals. Client assessment data were compared with follow-up data at 6-8 week intervals, and included validated standardised measures of mental health difficulties (both self-report and clinician rated), and drug and alcohol usage patterns. Pre and post client quality of life was also captured using a validated standardised tool. Additionally, interviews and focus groups were conducted with stakeholders.
Results and conclusion: Quantitative and qualitative findings will be presented. Recommendations for policy and practice in regards to continuation and refinement of the role and partnerships between community nursing and mental health services will be presented based on evaluation findings.
INTEGRATING ADDICTIONS, MENTAL HEALTH AND HARM REDUCTION CONTENT INTO A PRIMARY CARE NURSING CURRICULUM
Nancy Campbell-Heider, Janice Feigenbaum, Deborah Finnell
Background: Responding to the clarion call for increasing the focus on addictions, mental health, and principles of harm reduction in advanced practice primary care curricula, a team of nursing faculty conducted two studies to: (1) identify the type and frequency of addictive care activities performed by advanced practice nurses in New York State; and (2) the prevalence of addictions related diagnoses recorded on clinical logs by a cohort of family nurse practitioner students. The purpose of the studies was to assess the need for increasing the addictions content in a family nurse practitioner (FNP) graduate nursing program that would allow for early assessment, brief interventions, and harm reduction activities related to the spectrum of addictions and their co-occurring physical and mental health disorders.
Methods: Data supported the need for improved assessment of addictions, especially history taking, in primary care. Students were under diagnosing and under treating alcoholism, illicit substance use and abuse, anxiety and eating disorders but were diagnosing and treating depressive conditions at a rate above the expected national population rates.
Discussion: The findings of both aspects of the project highlighted the current gaps in the FNP's clinical education and practices related to the early assessment of addictions and co-occurring disorders, motivational interviewing, brief interventions and harm reduction.
Clinical implications: Harm reduction, addictions problems, and co-occurring mental health issues are essential to, but neglected in primary care. This situation can be addressed through more educational focus on these problems in graduate nursing and other clinical curricula.
MENTAL HEALTH AND ADDICTION NURSING PROFESSIONAL SUPERVISION PROJECT IN NEW ZEALAND
Brian McKenna, Val Williams, Katey Thom
Background: In New Zealand, the Ministry of Health (2006) in “Mental Health Nursing and its Future: A Discussion Document” recommended the development of a national professional supervision model for mental health nurses. This is to ensure a standardised approach to quality supervision provided to nurses, which will hopefully impact positively on service user outcomes.
Aim: This presentation will report on contracted research to be completed in October, that constitutes the fist step in delivering outcomes that meet these intentions.
Method: A literature review of best practice models of supervision involving computerised and manual based searches of medical and nursing publications and material will be undertaken. Furthermore a mail survey of all District Health Boards and 7 Non-Government Organisations will be conducted to scope present supervision models and processes used. This survey will include items to determine the number of nurses receiving supervision; the characteristics of those providing professional supervision; views of the effectiveness of the professional supervision that is currently being provided; and the accountability the supervision programmes have with service user structures.
The outcome of these findings will be presented to an expert reference group of major stakeholders to determine the best practice model.
Results: Not competed to date.
Conclusion: A model will be determined that will be the bases of the next phase of the research, which will be to evaluate this “best practice” model of supervision in two District health Boards in New Zealand
PSYCHIATRIC NURSES’ ATTITUDES TO ANTIPSYCHOTIC DEPOTS IN HONG KONG, AND COMPARISON WITH LONDON
Maxine X. Patel, Frederick Yeung, Peter Haddad, Anthony S. David
Background: Antipsychotic depot prescribing practices by psychiatrists show international variation and are influenced by nursing staff. Psychiatric nurses’ attitudes to depots have only been explored in the United Kingdom.
Aim: To investigate international variation with a cross-sectional attitudinal study for Hong Kong psychiatric nurses.
Method: A pre-existing UK questionnaire on clinicians’ attitudes and knowledge regarding depots was updated. Participants were 98 psychiatric nurses who attended an academic meeting.
Results: The majority of Hong Kong psychiatric nurses reported favourably as 83% regularly acted as an advocate for patients and 84% have sufficient training, but only 40% felt involved in treatment decision-making. They believed that (i) most patients always prefer to have oral (vs depot) (80%); (ii) depots compromise patient autonomy (32%); (iii) force is sometimes required when administering a depot (40%); (iv) patients’ friends and family were more accepting of depot (vs oral) (69%). Those who currently administered depots, were more likely to have less favourable non-patient focussed attitudes than those who did not (mean 61% vs 65%, p = 0.012). When compared to a former sample of London community psychiatric nurses, Hong Kong nurses had less favourable patient focussed attitudes (mean 56% vs 60%, p = 0.051) and non-patient focussed attitudes regarding depots (mean 63% vs 69%, p < 0.001).
Conclusions: Hong Kong psychiatric nurses respect their role in depot administration but an important minority have concerns regarding patient autonomy and coercion. International variation exists and encompasses aspects for both the patient and the depot formulation per se. Our participants welcome further involvement in treatment decision-making.
NURSING STUDENTS IDENTIFY STRESSORS FOLLOWING TWO MAJOR NATURAL DISASTERS
Sudha Patel, Ardith Sudduth
Background: It was observed immediately following Hurricanes Katrina and Rita that students seemed to be experiencing stress which may creates an imbalance in the physiological and psychological equilibrium in nursing students.
Aims: The purpose of the study was to explore the stressors experienced by students and to gain insight into the learning needs as well as the teaching/learning strategies that assisted the students’ academic achievement.
Method: A qualitative design was used. Four hundred fifty nursing students completed a questionnaire and respond to an open ended question about their lived experiences and feelings about Hurricanes Katrina and Rita in the Fall of 2005.
Result: The data were organized into eight categories: Academic, Behavior, Coping, and Damage to property, Empathetic responses, Family impact, Guilt, Physical problems. From these categories, two major themes emerged such as powerlessness and decreased academic performance.
Conclusions: Students who have experienced the impact of two major hurricanes were eager to share their stories of their lived experiences. This study revealed that students were very resilient and kept on going and meeting the demand of the academic curriculum despite their personal losses and grief. Several students at the end of their stories thanked the researchers for the opportunity to express their feelings and tell us how they were coping. Students identified adjustments to teaching and learning strategies that faculty quickly adapted that helped them meet their learning needs.
VIOLENCE RISK ASSESSMENT IN MENTAL HEALTH TRIAGE: A WORKS IN PROGRESS RESEARCH PRESENTATION ON DEVELOPING CLINICAL GUIDELINES FOR PRACTICE
Natisha Sands, Marie Gerdtz, Stephen Elsom
Background: Mental health triage services are integral to Australian mental health service delivery, in that they provide the primary interface between the community and mental health services. On a global level, there is a growing trend to utilise mental health triage service models as a way of providing consumers with access to 24 hour mental health care across vast geographical regions. At present, violence risk assessment in mental health triage lacks a suitable evidence base and clear guidelines.
Aim: This paper presents the findings of Phase One of a study that aims to develop Clinical Guidelines for Violence risk assessment in mental health triage. The project is funded by the Mona Menzies Post Doctoral Grant, Nurses Board of Victoria.
Method: The project utilises the NHMRC methodology for developing Clinical Guidelines. Following the completion of the systematic review, expert panels of triage clinicians and consumers will be used to further refine the draft guidelines. The guidelines will then be formally piloted tested by mental health triage nurses across two major metropolitan hospitals.
Results: The Systematic review established the highest level of evidence in violence risk assessment, which has been graded according to its quality, relevance and strength. The results are presented in the form of draft Clinical Guidelines.
OP45 NEUROLOGY AND PSYCHIATRY
THE IMPORTANCE OF MOOD IN DETERMINING RETURN TO WORK AFTER STROKE
Nick Glozier, Maree Hackett, Craig Anderson
Background: No population based studies have examined return to work after stroke. Participation in paid employment is vital to a person's mental well-being and role in society, and is often a key goal of rehabilitation.
Methods: The third Auckland Regional Community Stroke (ARCOS) study was a prospective, population-based, stroke incidence study undertaken in New Zealand during 2002–2003. Following a baseline assessment early after stroke, data were collected on physical function, employment status, and mood according to the GHQ-28 on survivors at one and six months follow-up. Logistic regression was used to determine the predictors, including that of abnormal mood, on return to paid work on follow-up.
Results: Among 1423 patients registered with first-ever strokes, there were 238 previously in paid employment who survived to one month and 176 (74%) of them completed the GHQ-28. Only 94 (53%) of these 176 people returned to paid work at six months. Abnormal mood at 28 days predicted failure to return to work (OR 3.5; 95% CI 1.7–7.3) after adjusting for age, sex, ethnicity, co-morbid vascular risk factors, dependency, education level, and part-time employment status. The latter three variables were the only other independent predictors of post-stroke employment.
Conclusions: About half of previously employed people return to paid employment after stroke, with abnormal mood being a crucial determinant of this outcome. Appropriate management of both emotional and physical outcomes from stroke would appear necessary in optimizing recovery and ability to return to work in younger adults.
WHAT HAPPENS TO PATIENTS WHEN THERE IS NOTHING WRONG? A FOLLOW UP STUDY OF PATIENTS REFERRED TO A LIAISON PSYCHIATRY SERVICE WITH MEDICALLY UNEXPLAINED SYMPTOMS
Simon Hatcher
Background: Medically unexplained symptoms are important because they are common, they are associated with significant disability and their management is often unsatisfactory. Previous follow up studies have been small, on select populations and with no comparison group.
Aims: The aim of this study was to follow up a cohort of patients referred to a liaison psychiatry service in a district general hospital and to find out if they developed disorders which explained their presenting symptoms and to describe their service use.
Methods: We identified patients with medically unexplained symptoms diagnosed by physicians and surgeons referred to the liaison psychiatry service at North Shore Hospital in Auckland between 1997 and 2005. A comparison group of people referred to the service without medically unexplained conditions were also identified and matched for age, sex and date of presentation. Using national morbidity and mortality data we identified service use and diagnosis for these two cohorts between 1997 and 2006.
Results: There appears to be a low rate of misdiagnosis in people with medically unexplained symptoms consistent with other studies. The group identified as having medically unexplained symptoms used over 12000 hospital days during their follow up. There is some evidence in this study that referral to liaison psychiatry significantly decreased this hospital use.
Conclusions: Few people identified by physicians with medically unexplained symptoms are misdiagnosed. This group uses considerable health resources despite having no disease to explain their symptoms. Referral to liaison psychiatry may significantly reduce this burden and may increase quality of care.
PSYCHIATRIC COMORBIDITY IN A COMMUNITY SAMPLE OF PATIENTS WITH EPILEPSY
Cameron Lacey, Mike Salzberg, Helene Roberts, Wendyl D'Souza
Background: Existing knowledge of psychiatric comorbidity in epilepsy is limited by the sampling bias of mostly hospital based studies.
Aims: To characterise psychiatric comorbidity in a community sample using the Tasmanian Epilepsy Register recruited from the Australian national prescription database.
Method: Following TER enrolment all patients underwent direct telephone interviewing by trained interviewers unless aged <13 years or having an intellectual disability. Psychiatric comorbidity was assessed with the K10. The K10 is a ten item extensively validated population screening instrument for serious psychiatric illness. Logistic regression analysis was performed to assess factors predictive for psychiatric illness.
Results: Of 1180 initially enrolled on the TER, 847 were eligible for K10 administration (43 withdrew, 36 died, 90 aged < 13 years, 164 with intellectual disability) and 660 (78%) underwent interviewing. Thirty percent of subjects were likely to have a psychiatric disorder (K10 score > 20) and 8% were likely to have a severe psychiatric disorder (K10 score > 30). Predictive factors of psychiatric illness were female gender (OR 1.91, 95%CI 1.27–2.86) alcohol abuse (OR 2.92, 95%CI 1.25–6.78), being injured during a seizure (OR 1.62, 95%CI 1.06–2.45), number of antecedent CNS events (OR 1.3, 95%CI 1.15–1.50) and a family history of seizures (OR 1.58, 95%CI 1.06–2.45).
Conclusion: Psychiatric illness is common in community-treated patients with epilepsy. Risk factors include female gender, alcohol abuse, seizure related injuries, a family history of seizures and antecedent CNS events. Previously proposed risk factors including age of onset, duration of seizures and anticonvulsant type were not associated with psychiatric illness in this community sample.
PSYCHIATRIC SYMPTOMS IN BRAIN DAMAGE
Irene Jakab
Context: Specific psychiatric symptoms occurring in organic brain damage of different etiologies.
Objectives: To call attention to the presence of anxiety and aggression as a consequence of brain damage.
Key messages: Regardless of the etiology of the brain damage and regardless whether diffuse or localized damage, the main psychiatric consequences are the same.
Conclusion: Be ready to assess and treat the psychiatric symptom in cases of brain damage at any age. Three cases will illustrate the occurrence of the main psychiatric symptoms of the anxiety and aggression caused by brain damage either in childhood or at an adult age, in addition to cognitive deficits of various degree of severity. One case of herpes encephalitis, one case of poliomyelitis encephalitis, and one case of severe traumatic brain injury are discussed, each with long-term follow up.
CNS THEORIES AND FACTORS ON DYSPNEA PRODUCTION
David Busse Olive, Mario Araña Suarez
Aims: Review of dyspnea-Anxiety relationship.
Methods: Psychophysiology components of the respiratory act, in the different types from dyspnea, and the mechanisms of production of the Dyspnea maintained by the Theory of the Motor Control and the theory of unsuitable extension-tension of respiratory muscles.
Results: The dyspnea manages to appear sometimes, without defined organic cause; reflecting, sometimes a well defined organic cause. However the whole mechanisms of the symptoms, and the dyspnea itself are not known. They are not enough understood.
Conclusion: The perception of dyspnea turns out to be more prominent than the gravity of the discomfort caused by dyspnea.
Key messages: Measuring dyspnea needs further research on the psychophysiological elements involved in its production.
OP46 DISTINGUISHING AMONG MENTAL ILLNESSES: THEIR TREATMENTS AND EFFECTS
NEUROPSYCHOLOGICAL MODELS OF ADOLESCENT PSYCHOPATHOLOGY: UTILISING OLFACTORY FUNCTION TO MAP ONSET AND NATURE OF PROGRESSION OF ILLNESS
Warrick Brewer, Stephen Wood, Patrick McGorry, Christos Pantelis
Context: Neuronal maturation following posterior-anterior trajectories during development provides a framework for review of the limited data reflecting the “time-staggered development” of lower-to-higher-order olfactory functions (acuity, discrimination, memory, identification).
Objectives: To demonstrate how mapping the differential maturation of various olfactory functions may enhance understanding of the onset and progression of developmental disorders such as ADHD and Schizophrenia: -disorders in which we have reported olfactory identification deficits.
Key messages: We discuss the hypotheses that insult to neuronal structures that are nearing maturity during childhood may have a greater impact on olfactory functions that also mature at that time (e.g. olfactory acuity and memory), relative to those functions maturing later during adolescence (olfactory identification). Therefore, those disorders whose onset occurs during adolescence may impact more on those olfactory domains that have not yet matured (e.g. olfactory identification), thereby manifesting as “developmental arrest”. Further, the impact of pre- or peri-natal insults, as evident in disorders like schizophrenia for example, is considered in terms of the interaction between brain maturation and the olfactory processes relevant to the disorder. Thus, early neurodevelopmental insults affecting olfactory-related neural systems may only become manifest as olfactory deficits at a time when such function would normally be reaching maturity (“growing into deficit”).
Conclusion: Olfactory assessment is an important tool for mapping the onset and progression of developmental disorders mediated by compromise of fronto-limbic circuitry.
ASSOCIATION BETWEEN PSYCHOTIC EXPERIENCES AND DEPRESSION IN A CLINICAL SAMPLE OVER SIX MONTHS
Joe Buckby, Alison Yung, Elizabeth Cosgrave, Eoin Killackey, Kathryn Baker, Sue Cotton, Patrick McGorry
Background: Psychotic-like experiences (PLEs) are used to identify individuals considered to be at Ultra High Risk (UHR) of, or prodromal for, psychotic disorder. They are also common in the general population and in clinical samples of non-psychotic individuals. Depression has been found to be an important factor in mediating outcome in those with Psychotic Like Experiences (PLEs) in both community and UHR populations. It is associated with increased risk of transition to psychotic disorder in the UHR group, and with need for care in relation to PLEs in community samples. In this study we aimed to examine the 6-month outcome of PLEs in a sample of help-seeking young people aged 15 to 24 years in relation to their level of depression.
Method: Subjects (n = 140) were assessed at baseline and 6 months for PLEs and depression. PLEs were measured by the Community Assessment of Psychic Experiences (CAPE). Depression was assessed as a continuous measure using the Mood and Anxiety Symptom Questionnaire (MASQ) and categorically according to DSM-IV diagnosis of mood disorder.
Results: PLEs reduced in conjunction with an improvement in depression level and with remission of diagnosis of mood disorder.
Conclusion: It is important to assess depression in those with PLEs and consider the need for treatment of the comorbid depressive syndrome. This may reduce the risk of worsening of PLEs and transition to psychotic disorder.
DISTINGUISHING BETWEEN ANXIETY AND DEPRESSION THROUGH SELF-REPORT IN YOUNG HELP-SEEKERS
Joe Buckby, Alison Yung, Elizabeth Cosgrave, Eoin Killackey
Background: There is marked overlap between the syndromes of Depression and Anxiety. This has led some researchers to conclude that they are essentially the same disorder. In opposition to this continuum theory is the Tripartite Model of Affect which proposes that although anxiety and depression share symptoms of general distress, that they can be distinguished. Specifically, they argue that Depression is characterised by low levels of Positive Affect (PA) and that Anxiety is characterised by high levels of Physiological Hyperarousal (PH). The Mood and Anxiety Symptom Questionnaire (MASQ) was designed to specifically measure both the shared features and the unique components of anxiety and depression. Research with clinical populations of adults have cautioned that anxiety and depression may not be easily differentiated through self-report. The present study investigated whether this finding would be replicated in a sample of young help-seekers.
Methods: Young people (aged 15–24) who were consecutively referred to a public mental health service were completed the MASQ and a diagnostic interview.
Results: The disorder-specific scales significantly discriminated Anxiety (61.0%) and Depression (72.8%), however the predictive accuracy for presence of Anxiety Disorders was very low (29.8%).
Conclusion: Depression may be validly detected through a specific measure of these symptoms but anxiety was only weakly predicted. These results have implications for researchers and clinicians planning the use of screening tools for anxiety and depression.
NEUROLOGIAL SOFT SIGNS IN SCHIZOTYPAL PERSONALITY PRONENESS AND ITS RELATIONSHIP TO NEUROCOGNITIVE DEFICITS
Raymond Chan
Background: Neurological soft signs have been demonstrated in patients with schizophrenia and their nonpsychotic relatives. However, it is not known whether the increased prevalence of soft signs is related to schizophrenia-like personality trait.
Aims: This study attempted to examine the prevalence and type of neurological soft signs in schizotypal personality disorder (SPD) and its relationships to neurocognitive deficits.
Methods: 93 psychometrically defined SPD cases were screened by the Schizotypal Personality Questionnaire (SPQ) and were recruited for this study. Moreover, this study also recruited 103 schizophrenia cases and 75 healthy controls. The Cambridge Neurological Inventory (CNI) was used to assess neurological soft signs in motor coordination, sensory integration, and disinhibition. Another comprehensive neurocognitive battery was implemented to all participants.
Results: The findings showed that (1) Psychometrically defined SPD participants had a higher rate of neurological soft sign than healthy controls but less than patients with schizophrenia; (2) SPQ subscales and factors were correlated with motor coordination, sensory integration and total soft sign; (3) Psychometrically defined SPD participants were impaired in verbal memory and working memory, and a trend to be impaired in semantic initiation and inhibition.
Conclusions: It appears that the neurological soft signs are also associated with the SPD cases when measured in general population, which suggests that neurological soft signs are distributing along the continuum of risk for schizophrenia. Moreover, these signs were associated with neurocognitive deficits in SPD cases suggesting a common neural substrates between these “supposedly” similar markers of neurocognitive deficits in schizophrenia spectrum disorders.
SAFETY OF ANTIDEPRESSANTS USE BY PILOTS: AN AUSTRALIAN STUDY
Kathleen Griffiths, James Ross, Keith Dear, David Emonson, Len Lambeth
Background: It is commonly assumed that antidepressant use by pilots may compromise aviation safety. Accordingly, most aviation regulatory authorities require the suspension of medical certification while a pilot is taking antidepressants. However, there is little data to inform such policies. Since 1997, in contrast to other jurisdictions, Australia has permitted the controlled certification of pilots taking antidepressants. This study investigates the safety record of these pilots in comparison with a matched group of pilots not prescribed antidepressants.
Methods: Safety records (accidents and incidents) of all holders of Australian aviation medical certificates who were prescribed antidepressants between January 1993 and July 2004 (n = 481) were compared with those of a randomly selected matched comparison group. Data was analysed using covariate adjusted conditional logistic regression.
Results: There were no significant differences in the rate of accidents or incidents in the antidepressant and comparison groups. Each had a total of 5 accidents during the period in which the antidepressant group was prescribed medication (p>.05). Total accidents for the entire study period were 18 (antidepressant group) and 15 (comparison group (p>.05). There were 131 incidents for the antidepressant group and 113 among controls (p=.40). There was a non-significant trend towards a higher number of accidents and incidents among the antidepressant group in the period prior to commencing antidepressants.
Conclusion: There was no evidence in this study that antidepressant use results in poorer safety outcomes among pilots. Although the results must be treated with caution, they are of clear relevance to aviation regulatory policy makers internationally.
OP47 ADOLESCENT MENTAL HEALTH – FOCUS ON EATING DISORDERS AND WORKING IN INPATIENT ADOLESCENT UNITS
ISLAMIC BASED COGNITIVE BEHAVIOUR THERAPY OF DEPRESSIVE ADOLESCENTS
Rizal Abu Bakar, Jamayah Saili
This study investigated the effectiveness of incorporating Islamic-based psychotherapy aspect in reducing depressive symptoms among Muslims in Melbourne, Australia. Thirty clients with Major Depressive Disorder were randomly assigned to the study and control group. Both groups received standard treatment of Brief Cognitive Therapy (BCT) for depression but study group receive additional Islamic-based psychotherapy (IBP). Clients were followed up and assessed periodically for three months. Results indicate that clients receiving IBP show accelerated improvement in depressive symptoms than those in control group.
MODIFYING DIALECTICAL BEHAVIOUR THERAPY TO AN ACUTE ADOLESCENT INPATIENT SETTING
Lavina D'Silva, Josephine Anderson
Background: A modified version of a Dialectical Behaviour Therapy (DBT) program was developed for an adolescent in-patient setting. The program was designed for young people who presented with a wide range of psychiatric disorders. Many of the participants were at risk of harm to themselves or others and approximately 60% were hospitalised under mental health legislation.
Aims: To determine the feasibility and clinical utility of implementing a modified DBT model in an adolescent in-patient unit, and to compare rates and severity of aggression and self-harm preceding and following introduction of the model.
Method: Daily nursing reports, client files and incident registers over a twelve-month period were reviewed to collate data on rates and severity of aggression and self-harm on the unit over the six months preceding introduction of the DBT model and the six months following introduction of the model.
Results: Preliminary quantitative results found a reduction in rates and severity of critical incidents on the ward.
Conclusion: This study supported the usefulness of a modified DBT program in the treatment of adolescents, with a wide range of psychiatric disorders, admitted to an adolescent in-patient setting.
EVALUATION OF THE PERSONALITY FEATURES OF SPANISH ADOLESCENTS WITH EATING DISORDERS
Alejandra Ana García Rosales, Montserrat Graell Berna, Ángel Villaseñor Monterroso, Mar Faya Barrios, María Carmen Martínez Cantarero, Gonzalo Morandé Lavin
Background: This study has been carried out in an Eating Disorders National Unit.
Aims: To study the personality profile of subtypes of ED adolescents.
Methods: 76 ED patients (age: 15.31±1.53 y.) hospitalized are assessed. We evaluate the personality profile by Millon Adolescents Clinical Inventory (MACI). We present the maladaptive personality profiles and the comparisons with MACI personality scale scores (personality style) for purging and no-purging ED (t student). We have performed a logistic regression analysis to study which MACI scales were predictive of restrictive vs. purgative subtype.
Results: DSM-IV diagnosis: 44 (57,8%) restrictive anorexia nervosa (RAN), 14 (18,4%) purgative anorexia nervosa (PAN), 9 (11,8%) bulimia nervosa (BN) and 9 (11.8%) ED not otherwise specified. Comorbidity Axis II is diagnosed in 34 (44,7%). MACI: Maladaptive profile was displayed in: 34 (79%) of RAN: Conforming 18 (41,8%), Submissive 12 (27,9%), Dramatizing and Inhibited 11 (25,5%). 12 PAN (85%): Borderline Tendency 10 (44.4%) and Oppositional 5 (35,7%). 7 BN (77,7%). Means of MACI Personality Scale Scores statistically significant in Restrictives: Conforming (p > 0.00) and Submissive (p > 0.05). In Purgatives: Borderline Tendency (p > 0.01), Oppositional (p > 0.01), Unruly (p > 0.03). Submissive (OR: 7,4) and Conforming (OR: 4,7)scales predict restrictive subtype. Oppositional (OR:15,78) and Borderline (OR: 2,43) scales predict purgative subtype.
Conclusions: The prominent personality profiles were present in 75% of adolescents with ED assessed during the acute phase of disorder. Restrictive scored higher than purgatives on Conforming and Submissive, and Purgatives on Borderline Tendency, Oppositional and Unruly personality style.
TREATMENT OUTCOMES: A PROSPECTIVE STUDY TO IDENTIFY THE CHARACTERISTICS OF ADOLESCENT PATIENTS WHO DO WELL AND NOT SO WELL ON REFERRAL TO AN INPATIENT UNIT
John Mathai, Angela Bourne
Context: This prospective study hopes to answer the questions: What are the patient characteristics that predict good or poor outcomes after treatment on an inpatient adolescent unit? What are the effects of the patient's sex, age, diagnosis, and length of stay in predicting outcomes? What role does substance abuse play in treatment outcome?
Objectives: Our objective is to test these hypotheses:
Patients with psychosis will have the best outcomes
Patients with borderline personality disorder and/or substance abuse disorder will have the worst outcomes
Patients with oppositional defiant disorder/conduct disorder will exhibit no change.
Key messages:
Inpatient services are very expensive and the effective use of limited resources is paramount.
There is little evidence as to what type of patient benefits most from treatment and we need specific information for the unique context of Banksia.
The results will help in determining the type of patient this treatment is most beneficial to and the areas where treatment needs to be improved.
This study will inform the type of admissions to the unit in the future and assist referrers in inpatient admission.
Ultimately, through this process, we hope to improve the wellbeing and care of young people with serious mental health problems.
Conclusion: Conclusions will depend on the results of the statistical analyses and will be available by July 2007.
BASELINE DATA FROM A RANDOMISED CONTROLLED TRIAL DESIGNED TO REDUCE SUICIDE RISK AMONG YOUNG HELP-SEEKERS: THE ORYGEN POSTCARD STUDY
Jo Robinson, Sara Gook, Ross Evans, Liz Cosgrave, Kath Baker, Tony Jorm, Patrick McGorry, Alison Yung
Background: Suicidal behaviour is prevalent among young people and is a key risk factor for suicide. Yet many young people who are referred to a specialist service for treatment do not meet criteria and remain untreated. Evidence suggests that receipt of a regular letter or postcard can reduce suicidal behaviour among at-risk adults.
Aims: To reduce suicide risk among adolescents who have sought help from a specialist mental health service via receipt of a regular postcard.
Methods: The study employs a randomised control design. Participants are 200 young people referred but not accepted into ORYGEN and who have a history of suicide risk. Participants are assessed at baseline; measures include the SCID I, a range of suicide measures, a measure of hopelessness, self-esteem, help-seeking and perceived social support. Participants are also asked to suggest 3 sources of help that they find effective in times of crisis. They are then randomised into a treatment and control group. The treatment group receive a monthly postcard for 12 months, which enquires after their wellbeing and reminds them of the sources of help identified at interview. Participants will be followed up at 12 and 18 months. Baseline data collection will be complete by May 2007.
Results and conclusions: This paper will describe the project and will report the baseline data including the prevalence of different types of suicidal behaviour; the demographic and diagnostic profile of the participants; help-seeking patterns and the sources of help identified.
VISUAL ATTENTION AND REACTION TO ULTRA-THIN MAGAZINE FASHION IMAGES AMONG FEMALE YOUNG ADULTS: AN EYE-TRACKING APPROACH
Steven Thomsen, Cari Breckenridge, Lisa Harding, Valori Infanger
The study used an integrated head-eye tracking system to examine the eye movements of a group of 110 college-age women as they viewed magazine advertisements containing images of ultra-thin models. Our objectives are to examine of how these advertisements are viewed and to observe which elements of the advertisements were of greatest interest to our participants. Specifically, we will examine increases and decreases in cognitive activity as measured through eye movement, pupillary reaction, and fixation duration. We recently completed the data collection phase of this study. We are now in the data analysis stage. Using a between-subjects, factorial design, we will test our primary hypothesis that a woman's level of anorexic risk (as measured by the Mizes Anorectic Cognition Scale), the degree to which she has internalized the socio-cultural preference for thinness (as measured by the Social Attitudes Toward Appearance Scale), and her inclination toward making social comparisons (as measured by the Physical Appearance Comparison Scale) will influence cognitive and physiological reaction to the images. We hope to demonstrate the effectiveness of eye-tracking systems in studying the media's role in the psychopathology of disordered eating. In particular, we anticipate that our findings will contribute to our understanding of the media's role and impact in social-comparison processes common among anorexic patients.
OP48 CHILDHOOD LONGITUDINAL STUDIES, LITERATURE REVIEW AND THE PREDICTORS OF LATER OUTCOMES OF MENTAL HEALTH
ADOLESCENT TOBACCO AND ALCOHOL USE: ASSOCIATIONS WITH ACADEMIC PERFORMANCE, ILLICIT SUBSTANCE USE, DEPRESSION AND SUICIDALITY
Elizabeth Cosgrave, Alison Yung, Dan Lubman, Kathryn Baker, Joe Buckby, Gennady Baksheev, Adrienne Brown, Carrie Stanford, Katherine Godfrey, Patrick McGorry
Background: Tobacco and alcohol use are major public health problems. The most significant risk period for onset of their use is in adolescence, placing users at high risk of a range of adverse health outcomes, such as illicit substance use, substance use disorders, depressive disorders and suicidality. It is important to understand the links between tobacco and alcohol use and these health outcomes, in order to prevent, delay, or minimise the impact that they have on young people during such a critical stage of their lives.
Method: 881 secondary school students (mean age 15.5 years) were recruited from secondary schools in the Western metropolitan region of Melbourne, Australia. Participants were assessed via questionnaire.
Results: 41% of participants had tried smoking. 70% of participants had tried more than a few sips of alcohol at least once, and 22% of participants had engaged in binge drinking at least once in the past month. 7% of participants had tried cannabis at least once in the past year. 18% of participants had seriously considered suicide in the past year. Results of multivariate logistic regression indicated that early alcohol use (prior to 13 years) was associated with an increased likelihood of illicit drug use, high levels of depressive symptoms, suicidal ideation and poor academic performance.
Discussion: While prevention of adolescent alcohol use may be an unrealistic goal, given its prevalence, it may be that delaying the onset of drinking alcohol may result in significant mental health benefits in young people.
FEMALE DELINQUENCY AND CRIME INTO YOUNG ADULTHOOD; DIFFERENCES BETWEEN INTENSIVE MENTAL HEALTH SERVICE USERS AND GENERAL OFFENDERS
Maryann Davis, Steven Banks, Bernice Gershenson, William Fisher, Albert Grudzinskas
Little is known about justice system involvement of female youths in intensive mental health (MH) services. Identifying their arrest risk onset, peak, and offset provides practitioners information about when to intervene and with whom.
Aims: Describe within-individual longitudinal arrest patterns from ages 8-24 in this population. Determine whether their arrest patterns differ from general offender females in ways that have practice implications.
Methods: Using statewide administrative data from the Massachusetts Department of Mental Health (DMH) and Massachusetts’ juvenile and criminal courts a database was constructed that contained juvenile and criminal arrest histories to age 25 for females born 1976-79. DMH females were adolescent service users (n = 738), Non-DMH females had no DMH database records (n = 34,436). Massachusetts Census 2000 provided the size of the general female population. Developmental trajectory modeling was used to group individuals’ patterns of offending over time (trajectories) into “clusters” of those whose trajectories are similar, and describe trajectories. Trajectory comparison methods minimized the greater Non-DMH cohort size.
Results: DMH females were far more likely to be arrested by age 25 than Non-DMH females (46% vs. 22%) and to be arrested at multiple ages (28% vs. 7%). Analyses revealed eight justice system trajectories among those with multiple ages of arrest. Trajectories varied on level of involvement and timing of onset/offset/peaks. Non-DMH females comprised at least 93% of each trajectory cluster.
Conclusions: Concern about justice system involvement of female youths in intensive MH services is justified. Implications of trajectory findings for timing and type of intervention will be discussed.
BEST PRACTICE LITERATURE REVIEW – CHILDREN AND ADOLESCENTS AGED 0–15 WITH EMERGING AND FIRST EPISODE/FIRST BREAK MENTAL HEALTH PROBLEMS
JoAnn Elizabeth Leavey, Monica Flexhaug, Tom Ehmann
Background: The current understanding of first episode and emerging mental health problems for young persons less than 16 years of age is limited because of a scarcity of controlled studies focusing on this population. Although it appears logical and appealing, the early psychosis programs that assist young people aged 16–24, usually have little or no mandate to extend their models of care to younger age groups.
Aims: The current literature review examines what best practice frameworks do exist in order to optimize care for those experiencing a first episode of severe psychiatric disorder or showing signs of an emerging or first break mental health episode.
Methods: A best practice literature review process was undertaken which included specified search parameters in order to maintain a manageable scope of documentation for review while addressing issues of demographics and prevalence, mental health disorders, innovative service delivery, examples of emerging research and service gaps and issues evident in the literature.
Results: Themes from the paper in the following categories will be presented-Issues Identified in the Literature; Need for Evidence-Based Practice in Clinical Settings; Gaps in Service Delivery; Prevention; Access and Waitlists; Knowledge Uptake Challenges; Summary of Current Clinical Themes.
Conclusion: Considerations and Recommendations for Next Steps will be discussed.
THE IMPACT OF IMPAIRED CHILD AND ADOLESCENT MENTAL HEALTH ON THE YOUNG ADULT OUTCOMES
Jake M. Najman, Mohammad R. Hayatbakhsh, Gail M. Williams, Michael O'Callaghan, William Bor
Background: While some children first experience symptoms of mental illness before the age of 5, many other children experience their first symptoms of mental illness during puberty. Little is known about the overall health and developmental outcomes for children who experience early age of onset of mental illness.
Aims: This paper examines the young adult health, well-being and health related lifestyles of children with early onset mental illness. Children with early onset mental illness are followed up when they reach young adulthood.
Methods: Data are taken from a pre-birth cohort study which has prospectively followed some 4000 children from early pregnancy to 21 years of age. Data on child mental health were obtained from the Achenbach Child Behaviour Checklist administered at 5 and 14 years of age. Young adult outcomes of mental illness are described in four broad categories: (i) employment and academic performance; (ii) health related lifestyle; (iii) young adult mental illness; and (iv) quality of life.
Results: Children with early evidence of impaired mental health have lesser employment and educational outcomes, adopt a less healthy lifestyle (more tobacco and alcohol use), they have high rates of mental illness in adulthood and a lower quality of life.
Conclusions: Children with early age of onset of mental illness have a wide range of adverse educational, employment, mental illness and quality of life outcomes. There is clearly a need for programs in early childhood and adolescence to interrupt the impact of childhood mental illness on adult life course outcomes.
POVERTY IN EARLY CHILDHOOD AND ADOLESCENCE: IMPACTS ON CHILD MENTAL HEALTH
Jake M. Najman, Michelle Heron, Mohammad R. Hayatbakhsh, Gail M. Williams, Michael O'Callaghan, William Bor
Background: Many studies have confirmed that poverty and/or socioeconomic disadvantage are associated with mental health impairment in children and adolescents. However little is known about the extent to which the timing and duration of exposure to poverty contribute to declines in child and adolescent mental health. There is the possibility of sensitive periods during which exposure to poverty has a greater impact on child mental health.
Aims: To determine whether exposure to family poverty at particular times or cumulatively over the period from pregnancy to adolescence impacts on child mental health.
Methods: Data for this paper are derived from a longitudinal pre-birth prospective cohort study of mothers and their children. For this paper, data are taken from pregnancy, the 6 month, 5 year and 14 year follow-ups. Some 3600 mothers and their children provided useable data.
Results: Poverty experienced during pregnancy, at 6 months, at 5 years and at 14 years predicts child mental health outcomes (using the Achenbach CBCL and YSR). Adjustment for some confounders and poverty at other times suggests that poverty in pregnancy and at the 14 year follow-up independently predict child mental health (anxiety/depression) at the 14 year follow-up. There is also a linear trend such that the longer the duration of exposure to poverty, the greater the impact on child mental health.
Conclusions: The duration of child exposure to poverty predicts the degree of impairment of child/adolescent mental health. Reductions in poverty may improve child mental health.
PREDICTING PROGNOSIS FOR THE CONDUCT PROBLEM BOY: CAN FAMILY HISTORY HELP?
Barry Milne
Background: Many boys with conduct disorder (CD) develop life-course persistent antisocial behavior. However, other boys exhibit childhood-limited or adolescence-limited CD symptoms and escape poor adult outcomes. Prospective prediction of long-term prognosis in pediatric and adolescent clinical settings is difficult. Improved prognosis prediction would support wise allocation of limited treatment resources.
Aims: To evaluate whether family history of psychiatric disorder can predict long-term prognosis among conduct-problem boys.
Methods: Participants are male members of the Dunedin Study, a longitudinal birth cohort of 1,037 children (52% male). Four conduct-problem subtypes were defined using prospective assessments between ages 7 and 26 years: a ‘low’ class (45%) characterized by low levels of antisocial conduct problems; a ‘childhood-limited’ class (25%) whose antisocial behaviour was limited to childhood; an ‘adolescent-onset’ class (20%) whose problems emerged during adolescence; and a ‘life-course-persistent’ class (10%) who initiated antisocial behaviour early and persisted into adulthood. Family-history interviews assessed mental disorders for three generations: the participants’ grand-parents, parents and siblings.
Results: A family history of externalising disorders distinguished between boys with life-course persistent versus low, childhood-limited and adolescent-onset conduct problems. A simple three-item family-history screen of maternal-reported alcohol abuse was associated with life-course persistent prognosis in our research setting, and should be evaluated in clinical practice.
Conclusions: Brief family-history questions may assist clinicians in pediatric settings to refine the diagnosis of CD and identify children who need treatment most.
OP49 DEMENTIAL AND CARERS
ADJUSTMENT TO ACQUIRED PHYSICAL DISABILITY AND ITS IMPACT ON THE CAREGIVERS
Evelyn Andolo
This study has focused on the impact of acquired disability and its effects on the quality of life of 71 individuals who at one point in their lives experienced traumatic incidences that led to their physical condition. The study also examined the impact of the disability on 112 caregivers.
The quality of life of people with acquired disability is affected as they cope with their condition. Key issues discussed include: Adjustment that occurs in the individual's life; relationships between people with acquired disability, significant others and other primary care givers; societal provision for rehabilitation; attitudes and perceptions of people with acquired disability and the care givers regarding the disability and background information.
The information will be useful for policy makers, medical staff, teachers and social workers because it will enable them to improve the quality of life of the individuals and the community.
Qualitative and quantitave data was collected and analyzed. The tools used were questionnaires and indepth interviews. From research findings, more than two thirds of the caregivers (65%) reported positive change of attitude. The length of experience of the caregivers enhanced their service. Reports from the PWADs indicated that 68% benefited from the rehabilitative processes such as counseling 49%, physiotherapy 32% assistive devices 68%.
It is hoped that the information that is collected will be useful for the policy makers and the implementers in the government and the non profit making organizations to enhance the lives of the PWADs and the caregivers.
DELINEATING THE BARRIERS: ASSESSMENT, DIAGNOSIS AND MANAGEMENT OF DEMENTIA IN GENERAL PRACTICE
Elyssa Joy, Dimity Pond, Samantha Ross, Claire Grealy
Background: Previous research shows that General Practice is important in the assessment, diagnosis and management of patients with dementia, as many older people attend their general practice regularly.
Aims: To delineate the barriers to best practice through focus group interviews with GPs and Practice Nurses regarding their current and proposed practice in dementia assessment, diagnosis and management in General Practice.
Methods: GPs and PNs were recruited through advertisements and professional networks in Newcastle, Sydney and Melbourne. A qualitative descriptive study using focus group interviews was conducted in each city. Approximately 5 focus groups (3 GP, 2 PN) were conducted across all sites. Each focus group consisted of approximately 4–8 participants (same or mixed sex) and ran for between 2–3 hours.
Results: Preliminary results will be reported; specifically the barriers identified by GPs and PNs in the assessment, diagnosis and management of dementia in General Practice.
Conclusion: The present study is part of a plan to enhance the assessment, diagnosis and care of people with dementia in general practice through the identification of barriers to best practice.
THE DETECTION OF DEMENTIA BY AUSTRALIAN GENERAL PRACTIONERS
Dimity Pond, Charles Bridges-Webb, Justin Beilby, Henry Brodaty, Jane Gunn, Karen Mate, Nigel Stocks
Background: General practioners (GPs) play a critical role in the diagnosis and management of dementia, as >80% of elderly people attend their GP regularly.
Aims: To determine whether use of a brief cognitive impairment screening tool (GPCOG) and training of GPs in dementia management guidelines can improve diagnostic rates, management and patient outcomes.
Methods: GPs and ∼2,000 of their patients aged 75+ will be recruited from four Australian cities. GPs will be randomized by practice to either a control or intervention group, and will audit each of their patients and report any suspected or confirmed dementia. All participants will then be assessed by a research nurse using several instruments: GPCOG, CAMCOG, Geriatric Depression Scale, WHOQOL-BREF, GP Assessment Questionnaire. After training, intervention GPs will administer the GPCOG to each patient in the study. GPs will continue to care for their patients as they see fit. Participants with dementia will be re-interviewed 12 months later.
Results: The recruitment phase of the trial will be completed by November 2007. Baseline measures will be reported including the incidence of dementia; rate of detection of dementia by GPs; acceptability of screening for dementia with GPCOG for both patients and GPs.
Conclusion: This study will inform on the effectiveness and acceptability of screening for dementia; and the effectiveness of additional GP training in detection and management of dementia.
THE EFFECT OF A PRIMARY CARE PRACTICE-BASED DEPRESSION INTERVENTION ON MORTALITY IN OLDER ADULTS: A RANDOMIZED TRIAL
Edward Post, Joseph Gallo, Hillary Bogner, Knashawn Morales, Julia Lin, Martha Bruce
Background: Few studies have evaluated whether an intervention can modify the increased risk of death associated with depression.
Aims: To test whether a primary care practice-randomized intervention could modify risk of death through improved depression care.
Methods: The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) enrolled 1226 participants through a two-stage depression screening of randomly sampled patients from 20 practices in three cities. Depression care managers worked with primary care physicians to provide algorithm-based care. Depression status was confirmed through clinical interviews, and vital status determined at 5 years using the National Death Index.
Results: At baseline, 396 persons met criteria for major depression and 203 for clinically significant minor depression. After median follow-up of 52.8 months, 223 patients had died. Depressed patients in intervention practices were less likely to have died than were patients in usual care (adjusted hazard ratio [HR] = 0.67, 95% CI [0.44, 1.00]). The interaction of intervention condition with depression status (major versus minor) was statistically significant (p = 0.031). For persons meeting criteria for major depression in intervention practices, the risk of death over the follow-up interval was attenuated compared to usual care (adjusted HR = 0.55, 95% CI [0.36, 0.84]). No effect of care management was found for persons with minor depression (adjusted HR = 0.97, 95% CI [0.49, 1.92]).
Conclusion: Older primary care patients with major depression in practices implementing depression care management were less likely to die over the course of a 5-year interval than were patients with major depression in usual care.
THE REGENERATE STUDY: USING A STRENGTH TRAINING PROGRAM TO ENHANCE THE PHYSICAL AND MENTAL HEALTH OF CHRONIC POST STROKE PATIENTS WITH DEPRESSIVE SYMPTOMS
Jane Sims, Mary Galea, Karen Dodd, Nick Taylor, Jacques Joubert, Lynette Joubert, Sean Jespersen
Background: People commonly experience depression following a stroke, with implications for prognosis and recovery. The study explores whether a progressive resistance training (PRT) program for poststroke depression can reduce depressive symptoms and improve mental health, physical and social function and quality of life amongst chronic (6–12 months) stroke survivors.
Aims: The aim was to assess whether a 10 week, community-based PRT program reduces poststroke depression in chronic stroke patients.
Method: Participants were screened for depressive status (Patient Health Questionnaire, PHQ-9). Depression severity and history were confirmed by psychiatric assessment. Eligible people (n = 45) were randomly allocated to PRT or a waiting-list comparison group. The PRT program consisted of two high intensity sessions/week for 10 weeks at a community-based venue. Depressive status, physical and mental health, functional status and quality of life were measured at baseline, 10 weeks and six months using established, validated tools. Muscle strength was assessed using 1 repetition maximum (1-RM) for upper and lower limbs.
Results: Trial participants’ median age was 69 years: 27 were male. At baseline, mean scores on the PHQ and CES-D were 10.5 (SD 4.7) and 19.2(SD 9.1) respectively. Compared to the control group, PRT participants have demonstrated significant improvements in 1-RM testing. Many have chosen to continue with the program.
Conclusion: Factors influencing the intervention's feasibility in a community-based setting will be reported, plus the results of the final analyses. The goal is to improve participants’ health and functionality, enabling future access to mainstream exercise programs already available in the community.
A SHORT COUNSELING MODEL TO HELP PEOPLE IN RELATIONSHIPS
Vincent Poon
This eclectic approach is based on years of counseling experience by the author. The model will help physicians/counselors manage couples with relationship problems.
The process is divided into 3 stages. The first stage is to help the couple to understand themselves and each other. Here the individual's developmental life phases of dependence, independence, and interdependence; and areas of physical, psychological, social and spiritual development are explored. Answers to these questions will enable each person to know the self and the other better. The second stage of counseling is to help the two people work on enhancing and complementing each other in the relationship. Attempts are made to help each individual to accept and appreciate the differences as unique and to work on how to use each person's strength to complement one another. The goal is to collaborate and not to control or prove superiority over the other. The counselor will help the couple to develop joint and common goals and expectations; and to prod the couple to start working out changes. The final stage of this model is to follow up on progress by emphasizing on the positive behaviors and changes and using a solution-focused approach to guide them along the right path.
OP50 MODELS OF CARE
EVALUATING THE IMPLEMENTATION OF INNOVATIVE PRIMARY MENTAL HEALTH CARE INITIATIVES IN DIVERSE NZ COMMUNITIES
Sue Garrett, Lynn McBain, Tony Dowell, Catherine Collings, Eileen McKinlay
In common with other OECD countries, in New Zealand there is a high prevalence of common mental disorders.
In 2001 the New Zealand Primary Health Care Strategy emphasised the importance of local interpretations of health policy to meet the needs of New Zealand's diverse communities. To enhance the development of primary mental health services, the Ministry of Health sought proposals from Primary Health Organisations (PHOs) for new initiatives tailored to local needs. Twenty-six different projects received funding, representing 41 PHOs.
PHOs were given significant autonomy to develop their own type and style of initiative depending on local need. Agreement to an external evaluation was built in as part of contracts between the Ministry of Health and PHOs. The broad evaluation objectives were to 1) ascertain the extent to which initiatives reduced health inequalities and improved health outcomes, 2) determine the effectiveness of the different types of service delivery, and 3) identify key positive and constraining elements of the service innovations to inform the future development of primary mental health services.
This presentation will review the types of initiatives and cover some of the issues encountered while trying to evaluate a diverse range of primary mental health service models using a non-experimental, mixed method approach.
CONSULTATION LIAISON FOR MENTAL HEALTH SYMPTOMS AND DISORDERS IN PRIMARY CARE: A SYSTEMATIC REVIEW
Sarah Hetrick, Alexandra Parker, Rosemary Parker
Background: Mental health disorders are common (Henderson et al 2000; Kessler et al, 2005), however, treatment is received only by a minority and often many years after the initial onset of illness (Andrews et al 2001; Wang et al 2005). For those who do receive treatment it is most commonly from their primary health care provider (PCP) (Parslow & Jorm 2000). Enhancing primary mental health care using a consultation-liaison (C-L) model has been argued to increase access to effective treatment by improving skills and confidence of the PCP. C-L involves consultation between the PCP and the patient and ongoing contact between the PCP and a mental health care provider. However, the evidence of effectiveness of C-L for improving mental health outcomes is lacking.
Aims: This study examines the efficacy of consultation-liaison for mental health disorders in primary health care, with emphasis on youth, given that the age of onset of most adult-type mental health disorders is before 24 years (Kessler et al 2005).
Methods: A Cochrane systematic review and meta-analysis of randomised controlled trials and controlled before and after studies of C-L.
Results and conclusion: The results will be discussed in terms of the extent to which enhancing primary mental health care through C-L improves access to mental health care, increases the likelihood of mental health disorders being treated at earlier stages, and leads to better patient outcomes (McGorry et al 2006; Sackett et al 1991).
AN INTEGRATED MODEL FOR THE DELIVERY OF SPECIALIST MENTAL HEALTH CARE IN GENERAL PRACTICE SETTINGS
Sean Jespersen
Context: People with serious mental illness are frequently discharged from specialist services to primary care where they are at risk of receiving suboptimal treatment. Anxiety and depression are common in primary care, and it may be beneficial for these conditions to be treated by a general practitioner. Many general practitioners are reluctant to treat people with mental health problems because they consider specialist services inaccessible and unresponsive. Mental health services are increasingly reconsidering their relationships with primary care providers.
Objectives: A three-phase service development project has been underway in the Consultation and Partnerships team of the Werribee Mercy Mental Health Program since 2004. Results from Phase 1 and Phase 2 program evaluations are presented for the information of other services currently involved in the redevelopment of their primary care programs. The results also identify several principles relating to the interface between psychiatry and primary care that are of more general interest. An integrated model and preliminary outcomes from Phase 3 are presented.
Key messages: Mental health services should include general practitioners in all phases of patient care. Engagement with a general practitioner is a core objective of active specialist treatment and resources must be directed towards the provision of shared care once patients are no longer active clients of psychiatric services.
Conclusion: Mental health services must provide general practitioners with more than education and token clinical support. Future initiatives must integrate primary and specialist care so that meaningful clinical services are available to general practitioners.
CHRONIC DISEASE MANAGEMENT FOR DEPRESSION: A NEW APPROACH TO CARE
Nick Kates
Context: Care of individuals with chronic health problems such as depression is often fragmented, with many individuals receiving no treatment during a year, and only a small percentage of those who do receive guideline-based treatments or follow through with treatmjent plans. Addressing these problems requires comprehensive changes to systems of care – usually primary care – to better respond to the needs of individuals with enduring problems.
Objectives: This workshop reviews the reasons for needing to look at new approaches to the management of depression, and outlines 10 key changes that can be incorporated into any primary care setting (or mental health program) to improve clinical outcomes.
Key messages: A new paradigm of care is required, with a population focus, the ability to monitor all individuals in that population during and after treatment, and support for patients to manage their own care. Key components of this model include the ability to detect individuals with depression, an identified care co-ordinator or manager, a registry of all individuals in a clinic or practice with depression, pro-active follow-up or recall, and increased support for self-management. Each specific intervention needs to be supported by other system changes if it is to be optimally effective.
Conclusion: Redesigning systems of care in primary care and mental health clinics can increase the effectiveness of specific interventions and lead to better outcomes including improvement in symptoms and functioning, increased community tenure, increased compliance with treatment and reduced health care costs.
THE INTERFACE BETWEEN PRIMARY CARE AND MENTAL HEALTH CARE PROVIDERS
Mohammad Khayrolomoor
Backgrground: While there has been considerable literature about the models of interactions between GPs and mental health services, there is little reference to the views of GPs about their satisfaction with mental health services.
Aims: The aims of this paper are to present the result of a survey of GPs in a metropolitan area in Australia about their satisfaction with local mental health services. Further, the major problems highlighted by GPs are presented.
Method: A Short questionnaires was devised to obtain the views of GPs. The GPs were asked to complete the questionnaire while being visited by a GP Liaison Officer.
Results: One hundred twenty six (126) of 196 GPs visited completed the questionnaires, providing a response rate of 64.3%. The rate of satisfaction with interaction and general communication with the mental health service was 42.5%, with some GPs mentioning recent improvement. The main problems mentioned by the GPs were lack of communication and feed back, access to services and availability of staff (mainly doctors) to discuss cases.
Conclusion: The above results indicate only moderate degree of GP satisfaction with the local mental health services. It is proposed that the creation of the position of GP Liaison Officer at metropolitan mental health services can address the problems identified by GPs, which would lead to improved communication/liaison, service delivery and better outcome for clients.
THE REMISSION EVALUATION AND MOOD INVENTORY TOOL PROJECT – TOWARD A BROADER MEASURE OF DEPRESSION REMISSION FOR PRIMARY CARE
Donald Nease, James Aikens, Kurt Kroenke, Michael Klinkman
Background: Despite calls to treat depression to remission, the concept of remission remains narrowly defined in terms of freedom from DSM-defined depression. However, these criteria fail to capture the full impact of depression upon patients’ lives.
Aim: To develop an empirically-based, brief self-report measure of depression remission that can ultimately be used in routine primary care.
Methods: Secondary data analysis and iterative expert input was used to develop a draft measure for testing in a broad sample of 1000 primary care clinician-identified depressed patients from two sites in the Midwestern United States. In order to reduce the draft measure, we used multivariable regression analysis of responses, with a composite measure of self-assessed remission as the dependent variable. This regression analysis was performed in derivation and validation samples, obtained through a random split.
Results: Analysis yielded a 5 item measure that explains significant variance in self-assessed remission, after accounting for depressive symptoms. Items in the measure, measure happiness, contentedness, emotional control, isolation and pain. The scale is reliable (? = 0.78) and its total score is normally distributed.
Conclusion: Depression remission is a multidimensional concept that includes important dimensions beyond depressive symptoms. These dimensions can be measured using a self-report instrument feasible for routine primary care. Pending longitudinal validation, this new instrument is a promising depression management tool.
OP51 PSYCHOSIS ADVANCES
COGNITIVE FUNCTION IN SCHIZOPHRENIA ASSOCIATED WITH DRUGS ABUSE
Juan Carlos Navarro-Barrios, Inmaculada Esteban-Pinos, Dolores Carretero, María Luisa Gonzalez, Anselmo Canabate-Prados
Aims: To describe the profile the patients with hospitalization in the Day's Hospital of Hospital of Motril (Granada-Spain) with diagnosis of schizophrenia and drugs abuse, and its probable cognitive damage.
Methods: Descriptive study of all the patients admitted between May 2006 and May 2007, with data of the clinical histories: age, sex, psychiatric comorbidity, socio-demoraphic variables, drug use, and hospitalization. The subjects used the COGLAB computerized neuro-psychological test to evaluate probable cognitive deterioration.
Results: 98% are male. The main group was between 19 and 27 years, with a high percentage of patient “cannabinoids” consumers: alone or in association (36%), that is in contradiction with the benign character that is attributed. There is a high percentage of subjects with associate psychiatric comorbidity (dual pathology, mainly personality disorder type borderline), and a minimum percentage of re-hospitalization (<2%). Polytoxicomania is very frequent, particulary the association of alcohol and cocaine or cannabis. Cognitive deterioration was significant in about 60% of patients (in all the sub-groups).
AN OPEN RANDOMIZED, COMPARATIVE STUDY OF EFFICACY AND SAFETY OF RISPERIDONE AND HALOPERIDOL IN SCHIZOPHRENIA
Sharad Man Tamrakar, Mahendra Kumar Nepal, Naba Raj Koirala, Vidya Dev Sharma, Chitra Kumar Gurung, Shailendra Raj Adhikari
Background: Last decade witnessed numerous trials comparing second generation antipsychotics and conventional antipsychotics in the treatment of schizophrenia, but most of them have been conducted in the western population only.
Aims: This study compared the efficacy and safety of risperidone versus haloperidol in the Nepalese context.
Methods: Patients with the diagnosis of schizophrenia were randomly assigned to receive risperidone 4–6 mg per day and haloperidol 10-20 mg per day, and were followed up for 6 weeks. Assessments were done on the day of the diagnostic interview and days 7, 14, 28 and 42. During the assessment periods Positive and Negative Syndrome Scale (PANSS) and Udvalg for Kliniske Undersogelser (UKU) side effects rating scale were applied.
Results: Both risperidone and haloperidol were associated with substantial baseline- to- endpoint reduction in symptom severity. After one week of treatment as well as the end point of the study, the improvement in schizophrenia with risperidone was significantly better than haloperidol in terms of PANSS- total Score, negative subscale score and general psychopathology subscale score. The side effects profile did not show significant differences except in extrapyramidal symptoms. Thirty-eight percent of risperidone treated patients had to resort to anti-parkinsonian treatment compared to 78% in haloperidol treatment group.
Conclusion: In Nepal too, risperidone was quicker and better then haloperidol and risperidone had a better safety profile. This is important, because extrapyramidal side effects of neuroleptics are responsible for non-compliance and increased cost in terms of us of anti-parkinsonian medication.
PREVALENCE, RECOGNITION AND IMPACT OF ANXIETY DISORDERS IN THOSE WITH PSYCHOSIS AND SUBSTANCE USE DISORDER
Katie Wyman, James Chamberlain, Monica Gilbert, David Castle
Background: The dual diagnosis of substance use and psychosis is common and a number of treatment programs target this comorbidity. The term dual diagnosis may be misleading as research suggests that people with substance use and psychosis often experience a further diagnosis such as anxiety.
Aims: This study examines the prevalence of anxiety in a sample of people with dual diagnosis; the relationship between anxiety and other psychopathology; and, the rate that anxiety was identified by client's case managers.
Method: Data was collected from 87 outpatients identified by their case manager as having psychosis and substance use. Participants were administered the Mini International Neuropsychiatric Interview (MINI), Montgomery and Asberg Depression Rating Scale, Brief Psychiatric Rating Scale, Severity of Dependence Scale, World Health Organisation Quality of Life Scale and Locus of Control of Behaviour Scale. Their case managers completed the Health of the Nation Outcome Scales (HONOS).
Results: 56% of participants had one or more anxiety disorders. Those with anxiety disorders compared to those without had greater psychiatric symptomatology and a poorer quality of life. Similarly the number of anxiety disorders was associated with psychopathology and quality of life; with more anxiety disorders being associated with worse outcomes in these domains. Case managers did not identify anxiety in 38% of clients who had an anxiety disorder according to the MINI.
Conclusion: Anxiety in people with psychosis and substance use is an important area for further research and clinical attention.
SMOKING: A NEGLECTED RISK FACTOR AND INTERVENTION TARGET
Michael Berk
Smoking is an important risk factor for major psychiatric disorders. This presentation will highlight a number of unpublished data sets. The first is a meta-analysis of controlled trials of olanzapine in bipolar disorder, which shows that smoking status is a significant predictor of a poorer treatment response. Data from a 2 year follow up study of 240 individuals will be presented, stratifying for smoking status and highlighting the impact of smoking on ourcome. Prospective epidemiological data showing the impact of smoking at baseline on the subsequent development of depression after a 10 year follow up will also be presented. These novel data sets will show a consistent pattern that smoking is a risk factor for the development of mood disorders, a marker predicting an adverse illness course, and a predictor of poorer treatment response. This is of substantial clinical imortance, and suggests that aggressive targetting of smoking status as a component of routine care is clinically indicated.
DEVELOPMENTS IN THE TREATMENT OF PSYCHOSES
Nicholas Keks, Judy Hope, Rajan Thomas
Context: There have been significant recent innovations in the pharmacological treatment of schizophrenia, mania and psychotic depression. This symposium will focus on long acting injectable atypical antipsychotics in comparison to oral atypicals, tranquilization with atypicals for psychotic agitation, and use of atypicals in psychotic depression.
Objectives: a) To present findings from an open study comparing long acting injectable risperidone and olanzapine in patients with relapse schizophrenia over a 12 month period. b) To evaluate research findings in use of atypicals as tranquillisers in agitated psychoses. c) To report experience with aripiprazole in psychotic depression.
Key messages: Long acting injectable risperidone and oral olanzapine at comparable efficacy and tolerability in patients with relapsed schizophrenia treated for 12 months. Some atypicals, particularly quetiapine and olanzapine, are demonstrating utility as tranquillisers in agitated psychoses. Our experience with aripiprazole depressive psychoses will be reported.
Conclusion: Long acting injectable risperidone is proving to be a significant advance in treatment of schizophrenia. Some atypicals may be preferable to benzodiazepines for the treatment of agitated psychoses. Aripiprazole may be useful in depressive psychoses.
OP52 POLICY AND PRACTICE
“TOWARDS A GENTLER SOCIETY”
Graham Burrows, Stanley Robb, Peter Bosanac, Megan McQueenie
The Mental Health Foundation of Australia, which has been active in pursuit of mental health promotion for the past 25 years, has established a number of different partnerships. This presentation will discuss “Towards a Gentler Society”, the Anti-Violence Society”, Partnerships in Health Promotion”, “Embrace the Future: Mental health and wellbeing for young Australians”, the “National Depression Awareness Campaign”. It will address issues that occur between professionals, consumers, the community and politicians. The various successes and failures, issues of importance to Victoria and Australia, the National Projects, and relationships between other organisations.
GP PSYCH SUPPORT: A NATIONAL ADVISORY SERVICE
Julian Thomas, Morton Rawlin
The GP Psych Support service is an Australian Government funded clinical mental health support service, which is operated by The Royal Australian College of General Practitioners. The service enables general practitioners to submit a question via telephone, facsimile or through a secure website and receive advice on clinical issues encountered from a psychiatrist within 24 hours.
GP Psych Support is an excellent example of technological innovation in health care. The service makes maximum use of internet and mobile phone technology to provide a responsive advisory service for GPs in an area of health which has suffered from workforce shortages and poor access to support.
This brief presentation provides an overview of the service and its functionality, and describes the types of questions that have been answered by the psychiatrists in the last 12 months.
A COLLABORATION FOR GENERAL PRACTICE EDUCATION AND TRAINING
Julian Thomas, Morton Rawlin, Brian Kable
The General Practice Mental Health Standards Collaboration (GPMHSC) was established in 2002 as a multidisciplinary body charged with defining standards for professional development in mental health for GPs, and promoting the uptake of such training by GPs.
The GPMHSC represents a ‘new frontier’ of collaboration at a national level, including representatives from rural and urban general practice, and the professions of psychiatry and psychology. Importantly, the GPMHSC also includes strong community representation from both mental health consumers and mental health carers.
This presentation aims to provide an outline of the GPMHSC's major achievements to date and provide key data on the uptake of education and training in mental health care by Australian general practitioners since 2002.
The GPMHSC is operated by The Royal Australian College of General Practitioners with funding from the Australian Government.
DEVELOPING NATIONAL SCOTTISH STANDARDS FOR INTEGRATED CARE PATHWAYS IN MENTAL HEALTH
Rosie Cameron, Sean Doherty, Mark Fleming
NHS Quality Improvement Scotland (QIS) is publishing National Standards for Integrated care Pathways (ICPs) in 5 mental health conditions. QIS will utilise the ICP model as a means to develop, improve and monitor the quality for those using and providing mental health services.
Consultation with service providers and users underpins development of the standards, set in 3 main areas:
Process standards (how ICPs are developed e.g. user and carer involvement, application of process mapping, clinical leadership, management support, etc)
Care standards (key features of pathways to include interventions for each of the conditions)
Service standards (how ICPs are implemented and what evidence is needed to demonstrate the impact of variance analysis on improving services).
Emphasis of development and implementation of the ICPs lies with local NHS Boards to ensure they are developed with local ownership and to meet the needs of local populations. To ensure accreditation by QIS, the local ICPs must incorporate the national standards and evidence improvement in the quality of care provided. To aid local development and implementation of ICPs a toolkit is being developed containing the standards, evidence summaries, ICP development methodology and additional materials and support.
National ICP Co-ordinators will facilitate the implementation of the toolkit.
The project management approach, being all inclusive (multi-disciplinary, multi-agency, involving service users and informal carers) and being consultative and facilitative with health board areas in the development of the evidence based standards, has resulted in these standards being pivotal to mental health service redesign in Scotland.
PREVENTING HOMELESSNESS AMONG MENTAL HEALTH PATIENTS DISCHARGED FROM PSYCHIATRIC WARDS TO SHELTERS
Cheryl Forchuk, Richard Csiernik, Jeffrey Hock, Elsabeth Jensen, Shani Kingston-MacClure, Michele Van Beers, Rebecca Vann, Evelyn Vingilis
The issue of individuals with mental illnesses being discharged directly from a psychiatric ward to a shelter or the street has rarely been discussed in the professional literature. In our community it was determined this happened at least 194 times per year. Without addressing this issue, there is a risk of escalating the disastrous effects of these situations.
This project developed and tested an intervention to prevent homelessness due to discharge from a psychiatric hospitalization directly to shelter or streets. Participants who were randomized into the intervention group were provided with immediate social support and assistance in accessing housing upon discharge in addition to receiving assistance in paying for their first and last month's rent though Ontario Works or Ontario Disability Support Program. Data was collected from all participants before discharge, as well as at 3 and 6 months after discharge, in order to track information such as housing status, and housing costs.
This project challenges normal policies related to housing and start-up fees, and questions whether or not a change in those policies can reduce homelessness. The results of this project showed that all individuals who were in the intervention group attained and maintained housing, whereas all but one individual in the control group did not attain housing and remained homeless at the six-month period. The exception joined the sex trade to avoid homelessness. These results were so dramatic that randomizing to the control group has stopped and discussions are currently underway to routinely implement the intervention.
ROUTINE OUTCOME MEASUREMENT: COUNTING BEANS OR IMPACTING LIVES?
Brenda Happell, Cath Roper
The effectiveness of mental health service delivery is increasingly becoming a priority. Routine outcome measures have been introduced as a mechanism to determine effectiveness and demonstrate outcomes (or lack of) for consumers of services. However, current measures have been criticised for lacking relevancy in the areas consumers consider valuable and important. This paper describes the findings of a qualitative study which explored the utility, effectiveness, and assumptions underlying routine outcome measures used by Victorian mental health services from the perspective of service users. Focus groups were used as the method for data collection. The three main themes to emerge from the data were: assumptions behind routine outcome measures; consumer concerns with routine outcome measures; and Consumer Perspective: purpose, process and principles. These findings suggest that the current process for measuring outcomes should be revised and that consulting with consumers directly will likely prove to be of greater value than developing alternative instruments.
OP53 THE ENVIRONMENTAL, HEALTH KNOWLEDGE AND WELLBEING
MENTAL HEALTH AND ENVIRONMENTAL POLLUTION
Faina Ingel
The main idea of the communication is that the next vicious circle exists: environmental pollution negatively influences upon human mental health inducing abnormal (disadaptative) stress reaction, which increases genome susceptibility to other negative influences, what became one of the reason of cancer. For support this idea: i) the correlations between dioxin contents in human blood (adults and children) and level of psychological depression, anxiety and overfatigue will be demonstrated; ii) the comparison of emotional stress expression among workers of chemical plants and workers of other industry will be done; iii) because it is well known that tumors may arise from cells with damaged genome, the correlations between human emotional stress expression and chromosome aberration in blood lymphocytes, as well as UDS DNA will be present; iiii) additionally will be shown that speed of proliferation of human blood lymphocytes in culture and asymmetric division of the cells are bind with expression of emotional stress. Is any entrance of this circle?
POSITIVE EMOTION AND FUNCTIONAL STATUS IN PERSONS WITH STROKE
Margaret Ottenbacher, Ivonne Berges, Kenneth Ottenbacher
Background: Accumulating evidence indicates the beneficial effects of positive emotion on health and general well-being in older age. Less evidence is available on whether positive emotion supports recovery after an acute medical event such as stroke.
Aim: To examine the association between positive emotion at discharge from in-patient medical rehabilitation and functional status at a 3 month follow up interview.
Methods: A longitudinal study using information from the Stroke Recovery in Underserved Patients database. The study included 856 persons aged 55 or older with stroke admitted to an in-patient medical rehabilitation in the U.S. Information was collected during in-patient medical rehabilitation stay and 3 months post discharge.
Results: The mean age of the sample was 72.9 years (SD = 9.6), 51.2% were men and 52.8% were married. The sample was mostly non-Hispanic white (79.3%), followed by non-Hispanic black (14.9%) and Hispanic (5.8%). Most had 12 or more years of schooling (78.5%). The average length of stay was 20.2 days (SD = 10.1). In multivariate regression analyses discharge positive emotion score was significantly associated with higher overall functional ability (b = 0.85, SE .24, p=.0005) as well as with higher motor (b = 0.52, SE .20, p=.01) and cognitive (b = 0.35, SE .06, p=.0001) function after adjustment for relevant risk factors.
Conclusion: Our results suggest positive emotion is associated with improved functional status in persons with stroke. Findings have implications for stroke recovery programs and suggest the need to include measures of positive emotion in patient assessments.
MENTAL HEALTH LITERACY IN A CANADIAN GENERAL POPULATION SAMPLE
JianLi Wang
Background: The Canadian Senate committee recommended national efforts to improve mental health literacy and anti-stigma campaign in the general population. However, the levels of mental health literacy in the Canadian population are unknown.
Aims: To assess the levels of depression literacy in the general population in Alberta, Canada.
Methods: Random Digital Dialing and Computer Assisted Telephone Interview methods were used to select and collect data from household residents in Alberta in 2006. In this study, 3084 participated in the interviews (response rate = 75.2%).
Results: Among the participants, 75.6% could correctly recognize depression based on a case vignette. To help someone with depression, 45.8% reported that a person with depression could be best helped by seeing a doctor. Women, younger people and those with a higher education level were more likely to recognize depression than men, older people and those who were at a low education level. Women and participants who had more years of education were less likely to have had stigmatizing attitudes toward depression than men and those with less education. Participants who could correctly recognize depression were less likely to have stigmatizing attitudes.
Conclusion: Compared to recent Australian studies, Albertans are more likely to recognize depression. There are gender and age differences in mental health literacy. The correlation between knowledge and stigma suggests that improved knowledge about major depression may reduce stigma. Promotion and education may also lead to better self-management and accessing mental health services.
PSYCHIATRIC DISORDERS FOLLOWING TRAUMATIC BRAIN INJURY
Rochelle Whelan-Goodinson, Jennie Ponsford, Fiona Grant
Following traumatic brain injury (TBI), high frequencies of depression, anxiety and substance use disorders have been found. However, no known Australian studies have used structured clinical interviews based on DSM criteria to establish both pre- and post-TBI psychiatric diagnoses, predictors of post-TBI disorders and the impact on outcome.
For the current study, 100 participants with mild to severe TBI were recruited. Average age at assessment was 37.18 years (range 19–74), average time post-injury was 2.98 years (range 0.5–5.5 years). Measures used were the Structured Clinical Interview for DSM-IV diagnoses, Hospital Anxiety and Depression Scale, Alcohol Use Disorders Identification Test, Drug Abuse Screening Test, Glasgow Outcome Scale – Extended and the Sydney Psychosocial Reintegration Scale.
The frequency of many disorders rose from pre-injury to post-injury: depression from 17% to 46%; anxiety from 13% to 38% and psychotic disorders from 1% to 3%. Current rates of depression and anxiety were high (31% and 35% respectively). Two percent had a current psychotic disorder. Rates of substance use disorders fell from 41% pre-injury to 21% post-injury. However, this is still significantly higher than the general population. Co-morbidity of disorders was high.
The association between pre-injury and post-injury psychiatric problems, predictors and psychosocial outcome is discussed.
OP54 EVALUATING SERVICE DEVELOPMENTS: FROM PRIVATE PRACTICE TO HOMELESS SERVICES
THE NORWEGIAN MODEL FOR COMMUNITY PSYCHIATRY – A USEFUL MODEL?
Torleif Ruud
Context: Making mental health services more available and more coordinated with other community services are major elements in a national plan for mental health in Norway.
Objectives: Community mental health centers (CMHCs) with an average population of 65 000 in their catchment areas are developed to bring specialized mental health services closer to where the patient lives. These centers provide outpatient services, day treatment, crisis intervention, short-term and long-term inpatient treatment, and services by mobile teams. The emphasis on local inpatient units is a feature not found in many other countries, and this raises the question whether this is useful or not. Characteristics of inpatient units in the CMHCs are described and analyzed, and the services are compared with mental health services in other European countries using European Service Mapping Schedule (ESMS). Both the services of the CMHCs and the collaboration with primary care have improved over the last years. But there are still great variations in resources and services, and a long way to go before the model is fully implemented everywhere.
Key messages: The Norwegian models with CMHCs with local inpatient units may be useful, especially in rural areas. But considerable resources are still needed to implement it.
Conclusion: There is a need for comparative studies between the Norwegian model and other models in order to clarify the usefulness of the Norwegian model for CMHCs.
EFFECTIVENESS OF COMMUNITY MENTAL HEALTH SERVICES ON THE NUMBER AND LENGTH OF HOSPITALIZATION, SYMPTOMS AND FUNCTIONING IN PEOPLE WITH SEVERE MENTAL ILLNESS
Jonggook Lee, Tae-yeon Hwang, Young Moon Lee
Background: Since the legislation of the mental health act in 1995, community mental health services in Korea have been significantly developed. Especially community mental health centers have played a major role in providing comprehensive services to the people with severe mental illness over the past 10 years. In order to develop and maintain the mental health programs, it is essential to prove the effectiveness of the services.
Aims: This study was conducted to investigate the effectiveness of community mental health services on the number and length of hospitalization, symptoms and functioning in people with severe mental illness.
Methods: The subjects were the people with severe mental illness who newly registered at community mental health centers of Gyeonggi province in Korea in 2005 and had maintained registration for at least one year. The centers assessed their clients with the number and length of hospitalization, during one year before and one year after registration. BPRS and GAF were assessed at the time of registration and one year after registration. Paired t-test was used to analyze the data.
Results: The subjects were 928 people with severe mental illness from 26 centers. Mean number of hospitalization was reduced from 0.52 to 0.29(t = 5.486, p<.001). Mean length of hospitalization was also reduced from 58.8 to 34.2 days(t = 5.903, p<.001). There were significant improvements in BPRS(t = − 3.692, p<.001) and GAF(t = 4.014, p<.001) scores at one-year follow-up after registration.
Conclusions: Community mental health services are very effective in reducing the number and length of hospitalization, improving symptoms and functioning in people with severe mental illness.
COLLABORATIVE MODELS OF COMMUNITY BASED CARE: INDEPENDENT LIVING ALTERNATIVES FOR THE “HARDER TO HOUSE”
Rachel Louttit, Paul Clenaghan, Suzanne Hall, Diana Priest, Julie Harrison
Objectives: The Transitional Housing program located in the Inner West of Sydney is targeted towards people with mental health problems in need of stable and affordable, independent housing for a two year transitional period.
The project is a collaboration between the Sydney Southwest Area Mental Health Service, two social housing providers, and the NSW Department of Housing.
Key messages: The key difference between this project and unsupported social housing tenancies is the inclusion of consumers who have significant levels of disability related to illness which impacts on their capacity to demonstrate independent living skills and may impact on their capacity to engage voluntarily in treatment and psychosocial support programs.
Conclusion: It is hypothesised that this model, based on the principles of prompt access to housing and collaborative service delivery can be replicated by other social housing agencies and area health services. The strength of the model lies in its cost effective use of existing services in conjunction with an integrative, holistic approach to meeting consumer's individual housing and support needs.
PRESENTING A NEW MENTAL HEALTH PROGRAM FOR HOMELESS POPULATION AT BARCELONA CITY, SPAIN: THE “SENSE SOSTRE TEAM”
Sergio Alvarez-Silva
Context: We're starting a new program, in the city of Barcelona (Spain), called “Equip Sense Sostre” (ESS), which means, “Homeless team”. The ESS is a recently created working group, including three psychiatrist, two psychiatric nurses and four case managers.
Objectives: This novel program has its origin ten years ago, in a pilot project with the participation of one psychiatrist and one psychiatric nurse. Since January 2007, the increasing interest shown by the Barcelona City Council resulted in the implementation of this program. Most of the clinical practice is performed on-site within social centres and streets.
The goal is to provide high-quality psychiatric assistance to the home-less community in the city of Barcelona, being based in the current literature.
The recent increase of the program's resources and objectives, make necessary a clear definition of the objectives, vision, values and specific action protocols, according to the day-to-day clinical experiences.
Key messages:
A new mental health program for home-less community is presented.
We've reviewed several programs showed in the scientific literature.
Different models described for the attention of this population will be discussed.
Conclusion: We aim to speak about our project in order to set a discussion space, which could be so profitable for us and for everyone who wants to take part on it.
STUDY OF CHARACTERISTICS OF MENTAL PATIENTS IN PRIVATE PRACTICE
Ahm Mustafizur Rahman, Ah Mohammad Firoz, Enayet Karim, Faruq Alam
Background: In Bangladesh stigma about mental patients are highly prevalent. Even the physician from other disciplines are reluctant to refer the patient to a psychiatrist. But the situation is gradually improving. Characteristics of patients and other related factors have been shown in this study.
Referral pattern, socio-demographic parameters and clinical profile of patients were collected from the records of the private chamber of a psychiatrist from January 2002 to December 2006.
A total of 1396 patients attended the private chamber of the psychiatrist for a period of 5 years, of which 850 (60.89%) are male and 546 (39.11%) are female. Majority of patients are from middle class (93.05%). Patients who once become cured or got remission or their relatives referred the maximum number of patients (50.79%). Number of patients referred by physicians are 495 (35.46%), of which Neurologists referred 249 (50.30%). Almost all types of neurotic and psychotic patients were consulted upon including epilepsy, mental retardation and sexual dysfunction.
Patients referred to psychiatrist by general practitioner or specialists other than neurologists are not very encouraging. Patients referred by neurologists are much more encouraging indicates a very close link between psychiatry and neurology in private practice. Necessary steps and exchange programme can be undertaken between psychiatrists and other disciplines of medical science for the better screening and service of mental patients.
MONITORING THE QUALITY OF SERVICES IN MANAGEMENT OF PATIENTS WITH SCHIZOPHRENIA IN A UNIVERSITY PSYCHIATRIC HOSPITAL
Menan Rabie, Afaf Hamed, Mona Mansour, Nevine Elnahhas
Background: Psychiatrists must show that the right thing is done when it is needed. Quality assurance means both measuring the level of care provided and, when necessary improving it. High quality is actually less costly than the waste and rework that characterizes poor quality processes. Quality assurance is a pathway, not a destination; the activity is open-ended and never completed.
Methods: A retrospective study: we monitored mental health services provided to 62 patients with schizophrenia who were previously admitted to Ain Shams University Psychiatric Hospital, by reviewing their inpatient files, outpatient clinic records, and compare them to preset standards and guidelines.
Results and conclusion: Quality assurance is an important concept in all mental health services and can be assessed through the 5A. system: availability, accessibility acceptability appropriateness and accountability. As regard to institute of psychiatry most of the services are available and accessible. Acceptability and accountability are partly present due to over crowding of the catchment area. Most of services are appropriate and in agreement with standards. However frequent and continuous auditing must be the rule, for the institute to attain best outcome records?
OP55 SERVICES FOR MENTAL HEALTH AND SUBSTANCE ABUSE
IMPROVING SERVICE PATHWAYS FOR DUAL DIAGNOSIS CLIENTS
Petra Staiger, Marita McCabe, Lina Ricciardelli, Wendy Cross, Greg Young, Anna Thomas, Caroline Long
Background: It has been argued that many clients with a dual diagnosis are falling between the gaps of the health care system. In particular, this is the case for those individuals with anxiety and depressive disorders as they are often excluded from accessing mental health services.
Aims: The rationale behind this project is that careful and informed planning is required in order to develop clear pathways of care between primary and secondary services.
Method: This project has five stages: interviews with key informants in the field; a literature review; interviews with dual diagnosis clients, developing a service plan model for these clients and finally conducting a preliminary evaluation of this service plan. This presentation reports on consumer (N = 31) and stakeholder (N = 28) perspectives of the current Australian system, barriers to effective treatment and suggestions for improvements.
Results: Analysis showed that practitioners believe the complex needs of this client group are largely unaddressed. Consumers reported concerns regarding lack of referral information, and difficulties when entering the system. Respondents offered suggestions to counter these barriers and contributed ideas towards the development of an improved model of care. These included collaborative services, more prevention and early intervention strategies to reduce pressures on acute services and comprehensive and standardised assessment, especially in primary care services and other entry point services.
Conclusions: The final aspect of the presentation is to report on stage four which draws on the findings so far and presents an integrated model of care for dual diagnosis clients.
SUBSTANCE USING MOTHERS AND DEPRESSION (SUMMIT) – THE DEVELOPMENT OF A MULTI PROFESSIONAL INTERVENTION
Gail Gilchrist, Susan Nicolson, Jacqui Cameron, Paddy Moore, Megan Galbally
Background and aims: SUMMIT aimed to collaboratively build on the existing service framework in Melbourne by determining the key components for an intervention to address the complex needs of pregnant and maternal drug users.
Methods: Data from in-depth pre (n = 9) and post natal interviews (n = 6) with chemically dependent consumers from a specialized maternity service in Melbourne; interviews and case studies with their community and hospital carers (n = 13); interviews with methadone prescribing GPs (n = 8), the views of an expert panel and a review of the literature, were triangulated to determine the key components of the complex intervention.
Results: The triangulation of these data identified consensus across the following key components: longer term care/extended postnatal care; access to wider range of services and treatment options, especially access to mental health services, and drug treatment including relapse prevention, pharmacotherapy, detoxification, and rehabilitation; parenting support, childcare and respite services; case management in pregnancy and after birth; shared care/co-ordinated care; multidisciplinary care; continuity of care; effective communication/information sharing with other service providers; consistency of information, knowledgeable staff; flexibility of services, compassionate and non judgemental staff; and attention to wider issues, especially access to housing.
Conclusion: Existing services in Melbourne should be enhanced in both pregnancy and in the early parenting years to build a service model that incorporates the key components identified by SUMMIT and that can be trialed to test whether the intervention improves long term outcomes for drug-affected families.
A PSYCHOSOCIAL MODEL SUPPORTING THE COMPLEX NEEDS OF OLDER PEOPLE WITH ALCOHOL RELATED BRAIN INJURY
Alice Rota-Bartelink, Bryan Lipmann, Sonia Berton, Helen Small, Malcolm Hopwood
Context: For years, community service providers have been frustrated with the lack in availability of long-term specialised supported accommodation for older people, particularly older homeless people, with severe acquired brain injury (ABI) and challenging behaviours. Although the incidence of ABI (particularly alcohol-related brain injury) is far wider than being confined to the homeless population, it is frequently misdiagnosed and very often misunderstood.
Wintringham is an independent welfare company which provides secure, affordable, long-term accommodation and high quality services to older homeless people. The high incidence of alcohol abuse among our residents has led us to adapt our model of care to accommodate an increased complexity of need. However, there are some individuals with severely affected behaviours which still challenge Wintringham and arbias's capacity to provide adequate support.
Objectives: The gap in the provision of highly specialised long-term supported accommodation for older people with severe alcohol-related brain damage (ARBD) is the driving force behind this project. We aim to further develop and improve the current Wintringham model of care to facilitate the complex care needs of older people with advanced ARBD and associated challenging and/or antisocial behaviours and to document and trial a purpose-designed model.
Key message: Mainstream aged residential services are currently failing older people with special and complex care needs particularly those associated with ARBD.
Conclusion: We will report on a project which will develop and trial a specialised model of residential care that can be reproduced or adapted by other service providers to support older people with ARBD.
PARALYSIS IN NEW ZEALAND SERVICE DELIVERY: A TRIUMPH OF IDEOLOGY OVER SCIENCE
John Grigor
Following deinstitutionalisation, New Zealand has retained relatively few psychiatric beds. It does have ample, innovative downstream funded beds provided by “not for profit” charitable trusts. These have differing criteria depending on acuity, gender, ethnicity and complexity. Those with complex needs have difficulty in accessing these beds and perverse funding incentives leave less unwell patients remaining in high dependency beds lest they be replaced with somene more acute. Government policy has separated illness and treatment from accommodation and community programmmes and is reluctant to give back to psychiatry the control of community facilities. Mentally ill are treated in the 21 District Health Boards, each with multiple sub specialised programmes.
These services have grown adroit at protecting their own patch as they await a community bed. Prisoners wait in prisons for forensic beds which in turn await rehabilitation beds. Acute inpatient stays balloon or people are taken off the Mental Health Act so each sub service can survive. So much energy is consumed at these multiple interfaces that the overall direction of treatment is lost.
This paper identifies further survival strategies in a dysfunctional system and suggests remedies requiring “buy in” from all stakeholders.
THE FUTURE OF MENTAL HEALTH SERVICES: A PROPOSED COMPUTER SIMULATION
Kristina Dammasch, Christfried Toegel, Graham Horton
In Germany, mental health policy development and planning of services are influenced more by pressure groups than by serious trend research. A suitable computer simulation of psychiatric services is virtually non-existent. For these reasons we are developing a simulation model that will allow reliable and impartial prognoses about mental health services in order to support planners and researchers.
For this purpose we are currently identifying parameters and processes of the German mental healthcare system, and analyzing dependencies on external variables such as demography and economics. The resulting simulation model will be a representation of relevant aspects of the system, and it will enable detailed analysis of its behaviour. By making implemented parameters and their mathematical relationships adjustable, it will be possible to define different simulation scenarios for answering a large variety of what-if-questions.
Interesting scenarios may be for example: “If a remedy for disease X is developed in 2010, the number of required hospital beds will decrease by Y percent p.a.” or in regard to current discussions in Germany: “Shortening hospital stays for mental disorders by X days won't have an effect on national mental health.” Based on the first development stage of our model, preliminary simulation results actually suggest that the therapeutic outcome is not dependent on the length of hospital stays. Future scenarios must be analyzed to estimate the influence on factors as comorbidity or quality of care.
We believe that the implemented simulation model will make a contribution to current trend research and planning of psychiatric services.
OP56 PRIMARY CARE
DILEMMAS AND DISTRESS OR DISORDERS AND DEPRESSION? DEALING WITH EXISTENTIAL CRISES IN PRIMARY CARE AND PSYCHIATRIC SETTINGS
Christopher Wurm, Mila Vukov, Mat Gelman
Context: Recognising normal forms of emotional distress is a vital part of good health care but many doctors have no way to make sense of distress other than seeing it as a part of illness. Family Physicians are well placed to offer support and assistance in stressful situations, which may not necessarily lead to a psychiatric disorder. How well do we deal with spiritual and philosophical dilemmas in everyday practice? Are our ways of defining problems helpful? Do they allow for cultural diversity and patient autonomy? Can we do harm by telling someone they have a mental illness? Primary care physicians readily recognise depression, but sometimes prescribe medications to those who do not need them.
Objectives: To examine the contributions made by Existential Psychotherapy, especially Viktor Frankl.
To outline ways in which clinicians can recognise and respond appropriately to distress arising from existential needs or conflicts.
Key messages: People have long been asking physicians questions, which previous generations would have taken to their religious leaders. Sometimes these will be because of Major Depressive Disorder, Borderline Personality Disorder, or Dysthymia, but there will also be those who neither have, nor need a DSM IV diagnosis. Financial incentives based on “Evidence-based Medicine” are likely to shape the way health services are delivered in primary care and in specialist settings, but may disadvantage some potential clients. As people continue to seek medical help when they experience all forms of distress, we need to ensure that the help provided is appropriate
REGULAR PSYCHOTROPIC MEDICATION FORUMS PROVIDE AN ENVIRONMENT CONDUCIVE TO CONNECTION, COMMUNICATION AND COMPLIANCE IN MENTAL HEALTH PATIENTS
Nga Tran, David Castle, Cynthia Nguyen
Provision of psychotropic medication information is a key concept in psychiatric patient care. It is of great importance to ensure that appropriate and accurate medication information is provided in accordance with patients’ requirement to achieve a consistent outcome that improves patients’ quality of life.
St. Vincent's Mental Health (SVHM) has established an active relationship with mental health patients by coordinating an ongoing weekly medication forum. With the initiative of the Chair of SVH Psychiatry and inpatient mental health pharmacists, the weekly forum has been sustained with the aim of gaining patient trust, enhancing understanding of mental illness and psychotropic medications, and consequently maximising adherence.
Medication forums are conducted on a weekly basis for the maximum duration of one hour and the SVMH – Medication Fact Sheets are distributed at each session. This often stimulates topics for active discussion, thus enhancing patient enthusiasm and knowledge of their medications. All patients are invited to attend and participate in an open forum – a collaborative constructive discussion, involving both medical professionals as well as patients. Particular patients are encouraged to attend on the recommendation of the multidisciplinary team and carer on the basis of medication concerns, side effects experienced, and limited understanding into the perceived benefits.
Preliminary evaluation indicates that psycho-education via medication forum encourages patients to actively participate in discussion about their medications, and consequently promotes patient adherence and ensures ongoing mental health.
PSYCHOEDUCATIVE VIDEOS FOR FAMILIES OF SCHIZOPHRENIC PATIENTS LIVING IN RURAL AREAS
Elsa Stiberg, Reidun Olstad
Context: Psycho-educative therapy in families with one person suffering from schizophrenia has been proven to be effective in preventing relapses of the disease. Running groups for parents or siblings of schizophrenic patients is difficult in scarcely populated rural areas due to low incidence of the disease and large travel distances.
Objectives: The main purpose of the project was to develop videos for use in individual families of schizophrenic patients in remote areas. Videos were aimed at giving information to relatives about psychosis, giving examples of how to deal with the disease in the family and give examples of different treatment methods. Three videos with authentic local patients, parents/siblings were produced. In addition health professionals participated, giving information and comments.
Key messages: The videos have been implemented in Northern Norway during the last? years, and experiences are positive. Local nurses have been presenting the videos and provided possibilities for discussion of the content. By seeing these videos the families can recognise the experience and feelings of other parents despite being the only family with this kind of problem in the area. The videos have also been used for teaching purposes for professionals working in remote areas and students in the field.
Conclusions: In a part of the country where the distances to hospitals are large, videos which provide information, support and ways of coping in a stressful everyday life has proven valuable for use for individual families with one person suffering from schizophrenia.
THE CONSOLIDATION PATHS OF MNEMONIC PROCESSES, THE IMPORTANCE OF SIMPLIFIERS, THE HEALING CAPACITY
Assunta Lepri, Fabrizio Ciappi, Paolo Susini, Alberto Trequattrini
The consolidation paths of mnemonic processes, in a deficit condition related to the access to memory and cognitive maps.
In mnemonic processes, the importance of simplifiers is heavily supported by a great amount of data collected in recent years concerning Alzheimer research.
We are supporting a thesis in which individual simplifiers are immensely important in acute moments where mnemonic and cognitive processes are very important in the restarting of the cortical control in the moment of some psychopathological event which requires an intensive treatment in emergency or in a general hospital; where a stay in hospital conditions, removing the patient from his/her context (eg, house, family), and a loss of Simplifiers (eg, objects, well-known places, people dear to the) can't do anything other than damage.
Our reference Mental Health Department includes an area of 8 boroughs and about 80.000 inhabitants.
About 5000 patients attend the main health care centres – 1,400 elderly, more than 700 minors, and 2,800 adults.
There have been no psychiatric hospitals in Italy since 1980 after the passing of Italian law #180. Instead, people are living at home, cared for by family members, or in small psychiatric communities, usually not more than 30 people.
The majority of patients are outpatients.
Conclusion: Hospitalization can affect the healing capacity.
LAY BELIEFS ABOUT THE CAUSES OF MENTAL ILLNESS AMONGST NIGERIANS
Abiodun Adewuya, Rogers Maknajuola
Objective: Although views about causation are strongly associated with stigmatizing attitude towards mental illness, the beliefs of the lay public in sub-Saharan Africa have not been adequately studied. We aimed to evaluate the lay beliefs of a section of Nigerians as regards the causes of mental illness.
Methods: Participants (n = 2078) from three different communities (rural = 658, semi-urban = 712, urban = 708) completed questionnaires on sociodemographic details, familiarity with the mentally ill and their beliefs regarding causes of mental illness.
Results: The most endorsed causes of mental illness include misuse of substances/alcohol (72.3%), witchcraft/evil spirits (61.9%), life stresses (43.1%) and heredity (38.3%). On the average supernatural causes were most endorsed (48.9%), then psychosocial causes (43.9%) and lastly biological causes (30.4%). Significant association was found between belief in psychosocial causation and living in urban area (OR 1.6, 95% CI 1.3–2.0), higher educational status (OR 1.9, 95% CI 1.3–2.8) and having ever cared for the mentally ill (OR 2.1, 95% CI 1.4–3.2). A belief in biological causation was associated with higher occupational status (OR 2.2, 95% CI 1.3–3.8), higher educational status (OR 5.1, 95% CI 3.2–8.0) and having a family member with mental illness (OR 1.5, 95% CI 1.2–1.8). Lastly, a belief in supernatural causation was associated with age over 50 years (OR 2.2, 95% CI 1.8–3.7) and living in a rural area (OR 2.7, 95% CI 2.0–3.9).
Conclusion: Current effort to fight stigma in sub-Saharan Africa should incorporate the beliefs of the community and focus on educating the public on the causes of the mental illness.
PSYCHOLOGICAL MORBIDITY IN PATIENTS WITH ACNE, PSORIASIS AND ATOPIC DERMATITIS
Parker Magin, Dimity Pond, Wayne Smith, Alan Watson, Susan Goode
Background: There is a considerable literature (from specialist dermatology practice) suggesting marked psychological sequelae of skin diseases.
Aims: To examine the relationship of acne, psoriasis and eczema with psychological morbidities in patients recruited from general practice and specialist dermatology practice.
Methods: Patients from general practices and dermatology practices with the three diseases (n = 108) had disease-severity assessed and completed measures of overall psychological disturbance, anxiety, depression, self-consciousness, social anxiety, neuroticism and extraversion-introversion. Demographic data and self-ratings of disease-severity were collected. Control patients (n = 96) without skin disease were recruited from the same general practices as subjects with skin diseases.
Results: On univariate analyses, patients with skin disease had significantly higher levels of overall psychological disturbance, public self-consciousness and neuroticism. There were no differences in psychological measures between specialist and general practice patients, or between subjects with different diseases. On multivariate analyses, the significant differences did not persist.
Conclusion: It is likely that the disparity of the findings of two sets of analyses is due to confounding in the relationship of skin diseases with psychological morbidity. There is a considerable literature offering evidence for an association of skin diseases with psychological morbidity. But previous studies have methodological limitations, often being uncontrolled and rarely using multivariate methods to adjust for potential confounders in the relationship.
“Personality” was a significant variable in all regression models of psychological outcomes. Like previous studies in this area, ours was cross-sectional. Elucidation of the respective, interrelating roles of skin disease, personality development and psychological morbidity will require prospective studies.
OP57 FORENSICS
THE PROBLEM BEHAVIOUR PROGRAM
Danny Sullivan, Michael Daffern
The Problem Behaviour Program is a specialist statewide community based forensic mental health service. It provides specialist forensic consultations for regional mental health services, clinicians operating in the private sector, welfare and support agencies, and criminal justice services. It also provides psychological and psychiatric treatment for some patients.
In general, the population offered treatment are those with problem behaviours who seem to be at high risk of harming others, whose mental health needs cannot be met elsewhere, who present as being willing to attempt treatment, and who seem likely to benefit from treatment. More specifically, the PBP directs services to those individuals known to have engaged in one or more of the following ‘problem behaviours’: serious physical violence, stalking or threats to kill or harm others, adult sexual assault and rape, child molestation and chronic indecent exposing, collection and possession of child pornography, fire-setting and querulous (vexatious) complaints.
This presentation introduces the function and operation of the Problem Behaviour Program. It also includes a description of those patients seen for assessment and treatment and describes the nature of psychological treatments offered. Case file review and analysis of the Problem Behaviour Program database is relied upon to determine the outcome of treatment, which will be described.
FEMME FATALE: VIOLENT OFFENSES COMMITTED BY WOMEN
Susan Hatters Friedman, Renee Sorrentino, Joy Stankowski
Context: Violence by women can have a substantial impact on home life. Women, especially when they are the primary caretakers of children, are responsible for a large percentage of child abuse. Less common, but similarly destructive, are cases of intimate partner violence perpetrated by women toward their partners.
Objectives: At the conclusion of this workshop, participants will better understand the scope of female violent offenders and risk factors, and appreciate the mental health professional's capacity to intervene or prevent.
Key messages: Though men commit most homicide, perpetrators of filicide (child murder by parents) have a more even sex distribution. In fact, neonaticide (murder of the newborn within the first 24 hours of life) is most frequently perpetrated by the mother. Commonly occurring factors will be discussed in a comprehensive review of the maternal neonaticide and filicide literature.
Further, women may kill their intimate partners for various reasons, including self-protection from victimization. Demographic and diagnostic factors associated with women as perpetrators of intimate partner violence will be discussed.
Although men commit the majority of sexual offenses, research indicates that females commit approximately one-fifth of the sex offenses against children. Research about female sex offenders, evaluation, pathophysiology, and treatment will also be explored.
Discussion/conclusions: Violent crimes committed by women, including family violence, child murder, and sex offenses, will be discussed in detail. Discussion will be focused upon the mental health professional's potential role in detection of risk factors and prevention of these types of violence.
CULTURAL AND PSYCHIATRIC FACTORS ASSOCIATED WITH CRIMINAL BEHAVIOUR AMONG WOMEN PRISONERS IN MALAYSIA: A LITERATURE REVIEW
Muhammad Muhsin Ahmad Zahari, Cherrie Galletly, Kenneth O'Brien, Paul Mullen
There is a wide gap in the knowledge of criminal behaviour among women. Most research on criminal behaviours has centred on male gender because prisons are largely filled up by male prisoners. Although over the past decades the numbers of female prisoners increase worldwide there is a dearth of research, especially in the east, in looking at the roots of the problems.
Female prisoners could be analysed from different lenses. While there are adequate supporting evidences towards making mental health as a priority in delivering health services to female prisoners it is still unclear about the mental health's contributions to criminal behaviours. Culture and acculturation might be one of the roots of the increase of female criminal behaviour in the east. In the past, some cultural ethos that widely accepted in the society might have protected women from criminal behaviours.
This literature review will examine the complex relationships between culture, psychiatry and criminal behaviour among female prisoners particularly in Malaysia. Upon the analysis of the results the entanglement between psychiatric and cultural factors in female criminal behaviour in Malaysia can be extricated.
MULTIDISCIPLINARY APPROACH TO THE TREATMENT OF SEVERE AXIS-II PATHOLOGY IN WOMEN'S CORRECTIONAL FACILITIES
Vladimir Bokarius, Stephanie Neuman, Patricia Johnson, Lou Donaldson
The Valley State Prison for Women is the world's largest female correctional facility. Axis -II, cluster B disorders are common mental health problems among incarcerated females. The socioeconomic burden of these disorders is immense, and deeply impacts all prison staff: custody, medical, and mental health personnel. There is little evidence-based data of successful treatment, but optimal results have been obtained from structured psychotherapy, combined with psychopharmacotherapy. We present a multidisciplinary approach to treating this pathology in the setting of the Secure Housing Unit (SHU), a division for particularly violent inmates who have committed crimes within the prison. We present two cases of notorious inmates, known throughout the California correctional system for their long-standing aggressive behavior, involving injury of self and others. In male prisons there SHU inmates with serious mental illness are housed in special Psychiatric Services Units (PSUs). However, until January 31st 2007, there were no PSUs in California female prisons. We followed our subjects from August 2006 to February 2007. Four separate specialties: custody, medicine, psychiatry, and psychology were combined in a team to control these outrageous females. The treatment was based on DSM-IV diagnosis, biopsychosocial and psychodynamic formulation, and neuropsychiatric testing. The results included a significant decrease in self-destructive, assaultive, and manipulative behavior and a decrease in emotional lability among the subjects. Promising progress with these patients suggests that a multidisciplinary approach is the optimal strategy for treating Axis II personality disorders in prison, which could serve as a model of PSU operation throughout female correctional facilities.
OP58 SUICIDE, VIOLENCE AND CULTURE
INCIDENCE, TRENDS, FOLLOW-UP OF SERIOUS ATTEMPTERS AND REPEATS, AND TRANS-CULTURAL COMPARISONS OF SUICIDAL BEHAVIOUR: THE WHO/START STUDY
Diego De Leo
Recorded suicide rates in the Western Pacific region are among the highest in the world. Despite this, understanding of suicide in the region is modest. Limited knowledge is mostly due to scarcity of data availability, as this is not routinely collected by many countries. The Western Pacific is an area of great socio-economic diversity with important variations in culture and traditions. Available evidence suggests that not only is suicide increasing, but trends and patterns clearly differ from western models. The Suicide Trends in At-Risk Territories (START) study is run by the WPRO (Manila) with the technical coordination of the Australian Institute of Suicide Research and Prevention, and it endeavours to investigate suicidal behaviours in the region. The study seeks to establish reliable assessments of the incidence of both fatal and non-fatal suicidal behaviour and gain an understanding of the underlying causes of them. This is meant to be done with four components of the study: a monitoring part involving the registration of all suicidal deaths and behaviour, an intervention model for attempters in line with the SUPRE-MISS protocol, a standardized psychological autopsy investigation, and a follow up component focusing on medically serious suicide attempters. Currently the START study has finalized the translations of the assessment batteries after having conducted a four- day training workshop for principal investigators. It is expected that this study will contribute significantly to the establishment of a powerful network of investigators in the area, and to the effective appraisal of different cultural settings in suicide prevention.
“THE PEOPLE MAKING SUICIDE PREVENTION PROGRAMS HAVEN'T GONE OUT AND SOURCED FROM YOUNG PEOPLE WHAT IT IS THAT THEY WANT”: A CROSS-CULTURAL STUDY ON HELP-SEEKING AND SUGGESTIONS FOR YOUTH SUICIDE PREVENTION
Erminia Colucci, Harry Minas
Background: There is a paucity of cross-cultural research on youth suicidal behaviour and a corresponding need to study cultural aspects of suicidal behaviour in order to enhance the cultural appropriateness of suicide prevention/intervention strategies.
Aims and methods: This study explored meanings, cultural representations, attitudes, values and beliefs regarding youth suicide in 700 young (18–24 years old) at-least second generation Italians, Indians and Australians. Data were collected through a multi-method approach, using a questionnaire with structured and semi-structured questions (e.g. case scenarios, word association, attitude scale, open-ended questions) and focus groups.
Results: An overview of the study will be presented, focusing on findings about participants’ help-seeking strategies and suggestions on what should be done to prevent youth suicide. Both in the survey and in the focus groups, when participants were asked with whom they would talk if they were thinking about taking their own life, the overall most frequent answer was no one, followed by friends and family and, last, professionals. But there were some differences between country groups. In particular, professional help appeared to be a more important option for Australians than Italians and Indians. While students suggested similar youth suicide prevention strategies (e.g. education/awareness about suicide, help-services available and, to a lesser extent, seeking and receiving help; talking more about suicide reducing the taboo; more and better counselling/support services and help-lines; give reasons to live for), there were differences in the details of the strategies, and some suggested strategies were culturally-specific.
Conclusion: Implications of these findings for suicide risk assessment and prevention will be presented, focusing in particular on youth suicide prevention strategies suggested by participants.
TIME TO TACKLE MISGUIDED THINKING ABOUT SUICIDE
Naoki Watanabe, Peg LeVine
Suicide can be prevented. Since 2002, Aomori Prefecture has had the unfortunate distinction of being ranked second only to Akita Prefecture on a nationwide tally of suicide rates. We recently conducted a survey into suicide awareness among the residents of a local community. Thirty percent of residents between 40 and 69 said suicide could not be helped in some circumstances. The results indicate that many people tolerate suicide as an inevitable fact of life. Unfortunately that sort of thinking is not isolated. Changing ill-informed attitudes must therefore be our top priority if we are to get serious about this country's suicide problem. The center is organizing lectures and programs in which psychiatrists and volunteers offer tips about how to invest greater meaning in life, and deal with stress. We are also staging plays and picture-story shows, and circulating videos about the issue. The programs will be aimed separately at adults and children. In a number of elementary and junior high schools, children are using musical instruments under the direction of therapists to learn how to communicate their feelings in music. We should create an environment that makes it easier for people to express their feeling; where support is always close by. The power of local communities to remove mental barriers and build new human relations is the key to preventing suicides.
MENTAL HEALTH PROBLEMS AFTER A STABBING INCIDENT IN SCHOOL
Naoyasu Motomura, Masahiro Iwakiri, Yozo Takino
Background: A tragic incident occurred in a local school. A man intruded an elementary school and stabbed eight students and injured 15 students and teachers. Many students witnessed the scene and they have suffered from much psychological trauma.
Aim: Assessment of mental health problems of victims.
Subjects and methods: Subjects were 537 students in a school where the incident occurred and the control subjects were 1089 students from other two elementary schools. We assessed the mental health problems of children by use of physical symptoms questionnaire and the parent report of children's reaction to stress developed by Fletcher. Furthermore, we assessed students’ experience in incident. Assessment was done two months after the incident.
Results:
Physical symptoms of students: Most of children complaint one of following symptoms; loss of appetite, fatigue, headache, stomachache, finger sucking, fever, skin rush, enuresis etc.
Mental health problem of students: Students in a local school demonstrated mental health problems more severe compared with controls subjects. And 6 or 7 year old students in a local school demonstrated severe symptoms.
Students’ experience in this incident: Results showed that 6 and 7 year old children were highly exposed to trauma and mental health problems.
Conclusion: Younger students were highly exposed to traumatized experience and demonstrated mental health problems.
HRAKIRI REVITED: A RETROSPECTIVE CASE STUDY OF SELF STABBING
Andrew Gerard, Gregory de Moore, Christopher Ryan
Background: Harakiri literally means “belly-cut”, being derived from the Japanese word. Originally it was a form of ritual suicide in feudal Japan.
Aims: This study builds on a pilot study of self-stabbing (10 cases) by Patel and de Moore (1994). Our aim was to categorize cases of self-stabbing in order to find a clinically useful way of managing these presentations in the future.
Method: So far thirty cases have been identified from the total number of referrals to the Consultation-Liaison Service at the Westmead Hospital, Sydney between 1996 and 2006. This was based on a detailed review of case notes.
Results: The first group (12 out of 30 cases, (40%)) were mainly young men who were not psychotic at the time of stabbing. They were usually intoxicated (alcohol/other substances) with antisocial personalities and ambivalent suicidal intent. The second group (10 of 30,(33%)),were actively psychotic during the event. There was clear suicidal intent. They responded to inpatient treatment of their psychosis.
The third, newly identified group, were not psychotic at the time of self-stabbing. However they had a clear syndrome of Depression with high suicidal intent. They responded to antidepressants. This new group was not identified in the original study.
Conclusion: Knowledge of these clinically distinct groups may be applied to patients who present with self-stabbing and improve the clinician's assessment and management of such cases.
ALCOHOL USES AND DOMESTIC VIOLENCE: MATCHING CASE-CONTROL STUDY
Ronnachai Kongsakon
Introduction: Domestic violence is an important social problem which affects the stability of the family institution.
This research was study the causes and factor relating to domestic violence.
Method: The method used in this study is matching case-control study. The population of this study was one hundred of families that have domestic violence compare with one hundred of families that do not have domestic violence.
The instruments consist of personal interview form, Statistics used for data analysis are percentage and consider the relationship between alcohol used and domestic violence by ODD Raito.
Result: The results show that alcohol used associated with domestic violence and the proportion of wives violence was 83 percent. The proportion of families without domestic violence used alcohol was 56 percent. Associated with alcohol used and domestic violence found that ODD Raito was 3.84, alcohol used proved to be significantly to domestic violence. (P-Value < 0.001)
Conclusion: Results of the study revealed that alcohol used is the factor associated with domestic violence in Thai society. The proportion of families that used alcohol has opportunity to occur domestic violence more than families do not uses alcohol was 3.84 times.
OP59 NEURO-COGNITIVE FUNCTION
NEUROPSYCHOLOGICAL CHANGES IN DEPRESSED PATIENTS TREATED WITH TIANEPTINE
Krzysztof Krysta, Adam Klasik, Irena Krupka-Matuszczyk, Jacek Przybylo, Magdalena Klasik
Background: The literature reports suggest a beneficial effect of antidepressants on cognitive functions in depressive patients.
Aims: The aim was to compare the selected cognitive functions in patients with diagnosed depressive disorders treated with tianeptine.
Methods: 20 patients meeting the ICD-10 criteria of depressive disorders (F32, F33), aged between 18 and 50, were included. In neuropsychological examinations the following procedure was kept to: the first examination on the day before the first dose of tianeptine, the second examination a month after the first dose, and the third examination three months after the first dose. Cognitive functions measurements were performed using Signal, CORSI and RT tests, being a part of the computer-based Vienna Test System (VTS).
Results: In CORSI, Signal and RT tests the statistical analysis revealed that the difference of the average measured values between the first and the second, the second and the third and the first and the third test were statistically significant. The only significant correlation between the intensity of depression and the neuropsychological tests results was found in relation to Signal Test variable. The correlation was negative.
Conclusion: Our study showed an improvement in the assessed cognitive functions. It is interesting that the cognitive processes studied by the authors showed no significant correlation with depression scores (HDRS). Lack of such correlation may suggest that cognitive function improvement in patients treated with tianeptine is effected not exclusively by the subsidence of depression symptoms.
TNF DEFICIENCY HAS A NEGATIVE IMPACT ON COGNITIVE FUNCTION
Bernhard Baune, Heinrich Koerner
Background: Recent evidence suggests a role for tumor necrosis factor alpha (TNF) in functioning of the central nervous system (CNS) due to its neurotoxic but also neuroprotective effects.
Aims: The aim of this work was to examine the effect of deficiency of TNF (TNF − /−) and its main receptors (TNF-R1-/- and TNF-R2-/-) on cognition.
Methods: A standardized survey on cognition-like behavior assessing object and spatial retention memory, cognitive flexibility and learning effectiveness was used among B6.WT and B6. TNF gene targeted mice strains (B6.wild-type, B6. TNF-/-, B6. TNF-R1-/-, B6. TNF-R2-/- mice). Non-parametric tests were used to evaluate the variation of cognitive function across mice strains and to make specific group comparisons i.e. between B6.WT and B6. TNF-/-.
Results: Cognitive performance such as object and spatial retention memory varied significantly across all mice strains. B6. TNF-/- mice performed significantly poorer on object retention memory function as compared to B6.WT mice. B6. TNF-/- mice had poor cognitive flexibility. All gene-targeted B6. TNF mice strains had a poor learning effectiveness as opposed to B6.WT mice with a successful learning strategy. Both B6. TNF-R1-/- and B6. TNF-R2-/- mice strains were related to a moderate reduction of cognitive performance.
Conclusion: The absence of TNF was related to poor cognitive functioning. Low-levels of TNF appear essential for the development of normal cognitive function. Further work is required to assess the mechanisms underlying this effect. TNF receptors are nonspecifically involved in moderate reduction of cognitive function.
PERFORMANCE OF THE PATIENTS WITH MAJOR DEPRESSIVE DISORDER IN THE REMISSION PHASE IN A NEUROPSYCHOLOGICAL TEST BATTERY, SHIRAZ, IRAN
Ali Alavi, Hasan Haghshenas, Seyyed Masoud Mousavi Nasab
Introduction: Depressive disorders involve about 20 percent of women and 12 percent of men and are associated with several neuro-cognitive deficits. On the other hand, it has been reported that the patients with major depressive disorder are free of symptoms in the inter-episodic period. The objective of this study was to evaluate the performance of the patients with major depressive disorder in the remission phase in a neuropsychological test battery.
Methods: In a descriptive analytical study, as a part of a larger study, performance of 20 patients with major depressive disorder in the remission phase and 30 normal controls were evaluated with a Persian version of neuropsychological test battery by a laptop computer. The test battery included tests of reaction time (visual and auditory for each hand), word and figure recognition, visual field searching, tapping, binary choice, Stroop's test, signal detection in visual field, Raven's IQ, verbal IQ, and seashore rhythm recognition.
Results: There were significant differences in the performance between groups in tests of reaction time (except visual reaction time in left hand), word and figure recognition, visual field searching, tapping, Stroop's test, signal detection in visual field, Raven's IQ, verbal IQ, seashore rhythm recognition (in all of them P value < 0.05). In the other tests there were not any significant differences between the two groups (P value > 0.05).
Conclusion: The deficits in the executive functions (and therefore the deficiencies in frontal and temporal lobes of the brain) of the patients with major depressive disorders continue in their remission phase and need special attention.
COGNITIVE FUNCTIONING IN PATIENTS SUFFERING FROM SCHIZOPHRENIA TREATED WITH AMISULPRIDE
Krzysztof Krysta, Adam Klasik, Irena Krupka-Matuszczyk, Marek Krzystanek, Beata Tredzbor, Malgorzata Janas-Kozik
Background: Many clinical studies proof that amisulpride is effective in the treatment of positive and negative symptoms of schizophrenia. The analysis of the literature shows little evidence of a beneficial effect of amisulpride on cognitive functions.
Aims: The authors decided to examine the cognitive functioning of patients with paranoid schizophrenia treated with amisulpride for 12 months.
Methods: 12 patients with paranoid schizophrenia, according to DSM-IV were recruited to the study. The analysis of the influence of amisulpride on cognitive functions in paranoid schizophrenia embraced monitoring of selected functions (tests Signal, CORSI and RT being a part of the computerized version of the Vienna Test System) during a 12-month pharmacotherapy with amisulpride.
Results: The results achieved by the patients in the CORSI test, which diagnoses the processes of memory and learning show a statistically significant improvement of the memory processes during a 12-month therapy with amisulpride. No statistically significant changes concerning the mechanisms of learning were found. The results of the RT test show that until the fifth assessment the patients with schizophrenia achieved much worse results concerning the reaction time. A significant improvement happened since the sixth assessment and was then present until the end of the study. In the Signal test no statistically significant changes concerning attention processes were found during the 12-month therapy with amisulpride.
Conclusions: A chronic therapy with amisulpride may improve certain cognitive processes (short-term memory, memory span, and attention). Amisulpride in higher doses may have lower efficacy in the treatment of cognitive dysfunctions in paranoid schizophrenia.
THE ETHICS OF NEUROSCIENCE AND THE NEUROSCIENCE OF ETHICS: IMPLICATIONS FOR PSYCHAITRIC PRACTICE
Michael Wong
Context: Neuroscientists now have available an array of technologies for exploring the life of the brain and for revealing the behaviour of our conscious selves.
Objectives: This study aims at exploring these developments and asking about the ethical implications for psychiatric practice of being able to observe and manipulate brain behaviour.
Key messages: The Ethics of Neuroscience-The new brain analysis methods allow for what are called ‘monitor and manipulate’ processes. This means measuring and influencing our emotion, thought and behaviour through intervention at the neurobiological level. This raises serious ethical questions about the appropriateness of undertaking various neuroscience related activities including neuro-cognitive enhancement, forensic neuro-imaging and neuro-protection.
The Neuroscience of Ethics – This looks at whether advances in neuroscience research provide a scientific, naturalised account of basic ethical issues such as the notion of personal identity, self agency and moral judgement. It involves addressing whether ‘neuronal man’ is a conscious, intentional rational agent capable of voluntary action, whether neuroscience provides a more accurate and successful way of explaining human behaviour related to moral and criminal responsibility and whether psychiatry will ultimately be reduced to neurology and that the reasons for feeling angry, anxious, depressed and paranoid will be usefully, if not fully, explained by our brain states.
Conclusion: The challenge from neuroethics, as formulated by Flanagan and Moreno, is how to reconcile humanistic and scientific views of personal identity and self agency and ways to bridge neuroscience and ethics to promote a psychiatric practice that is both evidence based and ethical.
OP60 BORDERLINE PERSONALITY DISORDER
INTERPRETING THE “GOTHIC LOLITA” FASHION OF JAPANESE BORDERLINE PERSONALITY DISORDER PATIENTS
Shuhei Okamoto
Background: “Gothic Lolita” fashion is a mixture of Western rock music culture and original images of bizarre tastes in Japanese culture.
Some borderline personality disorder (BPD) patients obsessionally prefer to wear the “Gothic Lolita” fashion, especially in rural Japan. I will report two cases with BPD disorder who have changed their clothes among psychoanalytical sessions.
Case reports: Case-1, A 25 year old female patient with multiple suicidal episodes who suffered severe trauma from step father's violence will be reported. She changed her clothes after her confession about child-age painful experience.
Case-2, A18 year old female patient with BPD who admitted to the psychiatric emergency ward after threatening her parents with a knife will be reported. After one session, when she talked about her fashion and relieve her tension, she had not cared about her appearance.
Discussion: From the psychopathological aspects, we can deduce not only a meaning of self-harm behavior of this eccentric fashion in the closed Japanese rural community but a sense of self-defensive mechanism by their projection of “ego-dystonic” feelings. I will also discuss this phenomenon from views of both Lacanian analyst, Eugenie Lemoine Luccioni and Japanese philosopher, Kiyokazu Washida.
Conclusion: Patient's fashion sometimes has an important message to therapists in their cultural context and this subject is also related to the psychoanalytical concept of “Intersubjectivity”.
CONNECTION IS THE CURE
Glenn Siegel, Mary Pittman
The presenters’ extensive experience in the programmatic treatment of personality disorders has led them to re-conceptualize this diagnostic category as disorders of relationship. The common denominator in all relational disorders is varying degrees of disconnection from self and others. This state of disconnection is expressed through psychiatric symptoms, interpersonal disruption, and self-destructive behaviors. An innovative treatment model based on relational values has been developed and successfully implemented to guide individuals with relational disorders toward developing authentic connection to self and others. The model will be discussed in depth with an example of case history application. The simplicity of the paradigm to be presented demystifies the therapeutic process and creates a culture of collaboration between patient and therapists(s). The content of this workshop is expected to stimulate discussion and re-evaluation of traditional therapeutic approaches to the treatment of personality disorders.
QUETIAPINE REDUCES IMPULSIVITY AND AFFECTIVE SYMPTOMS IN BORDERLINE PERSONALITY DISORDER
Frederique Van den Eynde, Vesile Senturk, Caroline Vogels, Cornelis van Heeringhen, Kurt Audenaert
Introduction: The literature on quetiapine use in the treatment of Borderline Personality Disorder (BPD) is limited. We aimed to investigate the efficacy of quetiapine on impulsivity and affective symptoms in BPD.
Methods: BPD patients (DSM-IV-TR) were included in this 12-week open-label study with a flexible daily dose of quetiapine (100-800 mg). Patients had no antipsychotic treatment 8 weeks before the study. Measurements of impulsivity and related disorders consisted of patient-rated questionnaires [(Buss-Durkee Hostility Inventory (BDHI), Barratt Impulsiveness Scale (BIS)] and neuropsychological assessment [(Stroop color word task (SCWT) and IOWA Gambling Task (GT)]. To assess affective lability (Affective Lability Scale, ALS), anxiety (Spielberger State and Trait Anxiety Inventory, STAI), anger (Spielberger State and Trait Anger Inventory (STAXI)) and depressive symptoms (Beck Depression Inventory, BDI), patient-rated questionnaires were administered.
The results were analysed with a mixed linear model, with age and gender as confounders.
Results: Thirty-two (25 females; 7 males, mean age 28.4 years) completed the study. Scores on BDHI (11.4, SD 2.0; p < 0.001), BIS (20.3; 3.6; p < 0.001), ALS (0.78; 0.14; p < 0.001), BDI (25.7; 4.6; p < 0.001), STAI (20.2; 3.6; p < 0.001), STAXI (8.0; 1.4; p < 0.001) and SCWT interference (31.2; 5.5; p < 0.001) reduced, whereas performance on the GT (−15,6; 2.8; p < 0.001) improved. The mean dose of quetiapine was 412.5 mg.
Discussion: The results of our study suggested that quetiapine is efficacious in the treatment of impulsivity and affective symptoms in BPD. The limitations of this open-label design should be taken into account. Further investigations are needed to confirm these results.
OP61 THERAPEUTIC ENGAGEMENT
CHAOS TO CLARITY: SURVIVING THE TORNADO OF MENTAL ILLNESS
Cheryl Forchuk, Evelyn Vingilis
A workshop held in late 2006 was developed to raise awareness of the concept of Interprofessional (IP) education and collaboration with a focus on mental health and housing/homelessness. Students and faculty members at the University of Western Ontario (UWO) from the health disciplines of: Psychology, Psychiatry, Medicine, Social Work, Nursing, Occupational Therapy and Physiotherapy, along with community members and clients from mental health agencies, were invited to attend a 2-hour workshop called “From Chaos to Clarity: Surviving the Tornado of Mental Illness”. Participants initially were exposed to a dramatic play displaying societal responses to mental illness, the ‘Chaos’. This was followed by a collaborative activity called a “conversation café” composed of 7-food stations with a focal question at each. This approach provided opportunities for participants to network, collaborate, and engage in a participatory evening. Examples of questions posed were: What would successful IP collaboration look like in practice?; What would be the key elements in incorporating IP education into the curriculum of the health disciplines?; How should a client experience IP collaboration in their care? All responses were recorded on flipcharts and consequently used as preliminary data. Participants were asked to complete a brief survey consisting of three general questions related to IP education and collaboration and a feedback form at the end of the event. Results demonstrated that although everyone felt strongly about the importance of IP education and collaboration, it is not presently well established within the health disciplines. Actual findings will be reported in the session.
TWO BUCKS FOR THE BUS: SUPPORT ENABLING ACTIVE RECOVERY
Emma Martin, Dil De Silva
Context: Support Enabling Active Recovery (SEAR), a new system of mental health service provision designed to facilitate improved health and quality of life outcomes for people disengaged from service systems.
Objectives: To present SEAR, a model of service provision pioneered by the Homeless Health Outreach Team, based in Brisbane, Queensland. SEAR combines assertive outreach, interagency collaboration and a multidisciplinary team approach to provide a new practice framework that is innovative, holistic and meets the primary, mental health and dual diagnosis needs of the homeless population. SEAR draws from several current frameworks of service provision: the model of Assertive Community Treatment; the Recovery Approach; and Therapeutic Alliance. These frameworks have been explored in a literature review and along with the model, will be discussed utilising a case study. The presentation demonstrates that assertive outreach, interagency collaboration and a multidisciplinary team approach are successfully implemented within SEAR providing a practice framework that effectively addresses the dynamic needs of individual clients while maintaining ongoing engagement with services.
Key messages: The presentation will explore unconventional applications of common practice frameworks (therapeutic alliance, assertive community treatment and the recovery approach) within a new model of service delivery, SEAR. An understanding of how SEAR provides a new means to efficient, effective and ongoing service delivery to marginalised and disengaged populations will be provided.
Conclusion: SEAR is a creative and innovative and new model of service provision that has the flexibility to shift and change with individual clients providing a solid, consistent foundation for intervention and recovery.
CASE STUDIES WITH REAL PEOPLE TO FACILITATE INTERPROFESSIONAL EDUCATION
Cheryl Forchuk, Evelyn Vingilis
Interprofessional education requires students from different disciplinary backgrounds to learn together as a team in providing care. In an interprofessional project on Homelessness/Housing and mental health a case method to facilitate learning was used. Often cases are presented by “simulated patients” who act the part of a client. An advantage is that “real” patients are not burdened by learners, but a disadvantage can be the depth of understanding from the simulation. An alternative approach was developed with a consumer-survivor group, CanVoice. Members created the cases, based on personal experiences, and presented them at workshops. The aim was to: display the complexities of mental illness in context of a “real” individual versus a hypothetical case study; emphasize client-centered practice; and empower clients with mental illness. CanVoice clients helped facilitate four educational sessions, told their stories and formulated three case studies for educational exercises. Feedback related to client involvement, was very positive, with many requests to have clients at all project events. Participants enjoyed the depth of knowledge and experience, the feedback and impact they could provide. When simulated patients were used instead, participants reported finding the experience “unrealistic,… ineffective” if the mock patient was unaware of the “real” story behind the patient. A focus group with CanVoice members revealed these experiences to be positive, as they felt listened to, respected and empowered. The findings demonstrate the advantages of involving “real” clients in interprofessional education initiatives and health disciplines.
TRAINING OUR PSYCHIATRISTS – ‘THE CONSUMER EXPERIENCE’
Wanda Bennets, Bill Moon
It is now mandatory that psychiatric registrars complete an ‘approved’ activity equal to 4 hours per year with respect to “The consumer experience’. The consumer training consultant Wanda Bennetts and consumer consultant Bill Moon have developed a tiered and coordinated approach to fulfil this training requirement for psychiatric registrar trainees at NorthWestern Mental Health. This tiered approach offers a graduated and substantial training package to the trainees at NWMH that follows sequentially each year and has now been running and very positively evaluated for more than 3 years. We will outline how that training was developed and show you the results of three years of evaluations filled out by the trainee participants. In summary, this paper will show you how we went about developing a substantial training package and how valuable it was perceived to be by the participants.
PP10 DECONSTRUCTING SEVERE MENTAL ILLNESS
Norbert Andersch
Background: ICD-10 and DSM-IV have forced their unsound approach on the majority of national health systems. Without a shared definition what mental illness is, nor an understanding of the character of interaction between biological and social properties, a new version of both classification systems poses a serious danger to the wellbeing of patients and the future of the profession.
Aim: The research agenda towards DSM-V and ICD-11 will have to open up to a transparent, democratic, scientific and interdisciplinary discussion process. The focus of research will have to shift from investigating undefined properties of mental illness to ontology of different transcultural patterns of mental and social formation, from which a concept of disorder can only be deduced thereafter.
Methods: The presentation reviews the Agenda and Research Planning Conferences for DSM-V and the WHO-consultations on ICD-11. It compares this efforts to the conceptual interdisciplinary work of Neurologists, Psychiatrists and Philosophers (Goldstein, Kronfeld, Cassirer, Leuner, Conrad) in the 20th century, which have continously been sidelined by mainstream-psychiatry. To establish an ontology of'mental formation', i.e. to research comprehensively whether a system of'invariable transcultural basic patterns' of human development does exist, is a prerequisite for all future classification systems.
The author presents a'Matrix of Mental Formation', based on a variety of'Levels of Worldmaking', emerging from the constant tension between individual autoregulation and its symbolic link to cultural agreement. It deconstructs the making and loss of'selfevidence'.
OP62 CHALLENGES IN CHILD PSYCHIATRY
ASD FROM THE SECOND TO THE FOURTH YEAR OF LIFE
Katarzyna Chawarska
Background: Rising awareness of the early symptoms of Autism Spectrum Disorders (ASD) as well as efforts to monitor progress of infants with familial risk for ASD leads to an increasing number of 12-24 month old infants being referred for a differential diagnosis. Clinicians face a new challenge of making diagnostic differentiations earlier than ever. Thus, better understanding of the early expression of ASD and changes over time is essential.
Methods: Fifty infants were assessed prior to 24 months by a team of experienced clinicians with standard assessment instruments including the Mullen Scales, Autism Diagnostic Observation Scales-G (ADOS-G), Autism Diagnostic Interview-R (ADI-R), and Vineland Adaptive Behaviors Scales in the second and fourth year of life.
Results: Symptoms of autism and PDD-NOS were pronounced and stability of the ASD diagnosis was high. Comparison of concurrent parental report and direct observation revealed discrepancies in severity ratings of key dyadic social behaviors. Changes in communication reflected acquisition of language accompanied by the emergence of its unusual characteristics. Symptoms of social dysfunction were relatively stable over time, so was the severity of stereotyped behaviors. There was also considerable variability in the outcome was related both to the early history as well as overall levels of functioning.
Conclusions: The study provides support for stability of clinical diagnosis of ASD but highlights heterogeneity of expression and outcome within the group.
BACK TO THE FUTURE – RECLAIMING BIOCHEMISTRY FOR PSYCHIATRY
Stephanie Fryar-Williams
Context: Since many mental health practitioners and Psychiatrists undertook their medical training, Biochemistry, has significantly moved forward in its understandings of systemic biochemical pathways and their relationship to neuro-transmitter synthesis.
As a result, it is now possible to manipulate various neuro-transmitter production-systems by modifying specific aspects of cell-based biochemistry pathways. This is particularly the case where a genetic disadvantage renders one or other aspect of the cell machinery incapable of producing sufficient neuro-transmitters (such as occurs in depression), or leaves the cell stuck in an neuro-transmitter over-production state, such as occurs in psychosis.
Objectives: To explore evidence for:
Systemic bio-chemical pathways relevant to neuro-transmitter production.
Common genetic disadvantages that disable the bio-chemical machinery related to mental illness.
New biochemical markers for such disorders.
Biochemical-pathway repair-strategies that restore neuro-transmitter function.
Consumer response to biochemical intervention.
Outcomes.
Key messages:
Biochemistry has significantly advanced and new biochemical markers are now available to detect some metabolic disease states that lie behind some developmental disorders and mental illnesses.
Reclaiming the biochemical legacy of Medicine and using it to diagnose and shape future interventions in mental health, is not only an appropriate future endeavour for Psychiatry, but also carries potential for early intervention, increased consumer acceptance, increased treatment compliance and more complete patient recovery outcomes.
WHAT ABOUT THE CHILDREN? PROVIDING CARE FOR CHILDREN AND ADOLESCENTS WITH MENTAL ILLNESS WITHIN A GENERAL PAEDIATRIC UNIT
Brenda Happell, Kerry Reid-Searle, Lorna Moxham, Julie Kahl, Trudy Dwyer
The increased prevalence of mental illness within the general health care system is becoming increasingly acknowledged. However, the relevant research tends to focus primarily on adult and aged persons services and is primarily conducted in metropolitan areas. The absence of specialist child and youth inpatient mental health services has resulted in an increased number of children and adolescents diagnosed with mental illness being admitted to general paediatric units. The literature suggests that nurses without specialist mental health services find the care of people experiencing mental illness to be difficult and challenging, but there is no published research which examines this issue from a paediatric perspective. This paper presents the findings from a participatory research project (PAR) that aims to promote mental health care in a general paediatric unit. Findings from focus groups conducted with nurses employed in a paediatric unit in Rockhampton Queensland will be presented. Preliminary data analysis suggests that while nurses have a positive attitude towards children and adolescents with mental illness, they do not consider themselves adequate skilled to provide the quality of care required.
OP63 INCORPORATING TRADITIONAL HEALTH PRACTITIONERS IN PRIMARY MENTAL HEALTH CARE IN UGANDA
Catherine Abbo, Elilialilia Okello, Seggane Musisi, Christine Tusaba
Background: Traditional healers (TH) manage 80% of rural inhabitants in Uganda, 40% of whom have mental health problems and who, evidence shows, use both modern and traditional healing systems. However, these two systems operate independently and often antagonistically.
Aim: This paper will present preliminary results of a cross-sectional descriptive study that investigated ways of how to categorise TH's practices into three broad themes: harmful, useful and innocent; and how to incorporate the useful ones into modern primary mental health care while stopping harmful ones.
Method: The study used both qualitative and quantitative methods involving interviewing sampled traditional healers, holding Focus Group Discussions and key informant interviews with purposively selected community leaders and health workers. Consecutive patients were interviewed using SRQ-25 questionnaires to determine the prevalence and types of mental disorders presenting at randomly sampled HCIVs and TH's shrines in the four districts of Rakai, Ntungamo Wakiso and Kampala.
Results: The types and prevalence of mental health problems presenting in these PHC settings were determined and the methods of their management respectively described, recorded and will be presented as well as the ideas and acceptability of incorporating TH in modern Primary Mental Health Care.
Conclusion: These findings may provide information for use in planning mental health services, making policies regarding the role of THs in modern primary mental health care and their regulation; thus possibly creating the category of Traditional Mental Attendants.
PRIMARY CARE AND MENTAL HEALTH IN LIBERIA
Femi Adefabi
The Primary Care and Mental Health Situation in post-war Liberia has tremendously increased in recent times. The increase is due to the traumatic and tragic events during the fourteen years of civil war.
The post traumatic stress disorder, presently experience by the survivors of the victim with no primary care (Psychiatric attention). Studies have revealed that the continuous abuse of illicit drugs is a prime risk factor for the increase in mental health illness in Liberia.
With absolutely no primary care. There is no psychiatry facility available here to address the alarming mental health issues.
Mentally ill youths ex-combatants are patrolling in and around the cities with violent and life threatening behaviors.
The aim of our organization, Liberian National Association for Suicide Prevention (LNASP) is to increase awareness of mental health issues in Liberia. To identify the risk factors, call public attention on mental health situations and address primary care situation within the mental health sector.
LNASP, conducted a survey on the mental health situation, by volunteers, contacted with major hospitals. Cases of mental health were reported from January-December, 2005. From these major hospitals, the patients were diagnosed with drug abuse, and resulting to mental illness. The risk factor of the drug abuse resulted to suicide according hospitals reports.
LNASP realized that drug abuse has increase during and after the civil war.
In conclusion, Liberia does not yet has official strategies for mental health, LNASP is working on a blueprint for this strategy to be realized early 2008.
INTEGRATION OF MENTAL HEALTH IN PRIMARY HEALTH CARE IN EGYPT
Ahmed Heshmat Mohamed
The need for a strategy for mental health in primary care, stems from the burden of mental disorders in primary care, their cost to society, the restricted availability of specialist care and the unique positioning of the primary care facilities. Therefore the Mental Health Programme in Egypt in cooperation with Health Sector Reform Programme of MOHP set out a plan for integrating mental health into primary care.
The protocol is tailored to Egypt's cultural and social context. It is designed to meet local needs and to use the strengths of existing services and personnel.
The strategy addresses issues of basic training, continuing education, good practice guidelines, supply of medication, support and supervision, health information systems, liaison between primary care and specialist care, and links to other sectors.
Steps followed for integrating Mental Health in Primary Health Care:
MOHP included Mental Health in the Basic Benefit Package of the family health practice
Some psychotropic drugs were included in the essential drug list
Guidelines prepared for Mental Health in Primary Health Care for physicians, based on WHO Guidelines and with permission, also, training curricula, for physicians, nurses and social workers/health educators
Plan for piloting the integration of mental health in Family Health System made in collaboration with the Health Sector Reform Programme
Training conducted in five Governorates applying the Family Health system as pilot
Follow-up and supervision
Referral system developed
PHC mental health information system developed/integrated in the national mental health information system
PROVISION OF PRIMARY MENTAL HEALTH CARE IN AUSTRALIA: THE BETTER OUTCOMES IN MENTAL HEALTH CARE PROGRAM
Jane Pirkis, Bridget Bassilios, Justine Fletcher, Fay Kohn, Grant Blashki, Philip Burgess
Background: Australia's primary care sector is a lynchpin in the delivery of mental health care. The Better Outcomes in Mental Health Care (BOiMHC) program is a national initiative that began in 2001 and is designed to better equip the primary care sector for this role. The Access to Allied Psychological Services (ATAPS) component of the BOiMHC program enables GPs to refer patients to allied health professionals (predominantly psychologists) for evidence-based care, via 111 projects being run by Divisions of General Practice.
Aims: This presentation aims to report on some of the key findings from the ongoing evaluation of the ATAPS projects.
Method: The evaluation has run in parallel to the ATAPS projects since they began. It has drawn on information from a number of data sources, including projects’ local evaluation reports, a minimum dataset, several purpose-designed surveys, interviews and focus groups, and case studies.
Results: The ATAPS projects have been extremely well received by GPs and allied health professionals. The projects have delivered high quality care to a significant numbers of patients with depression and anxiety, many of whom may not previously have been able to access such care for geographical or financial reasons. The projects are achieving positive outcomes for these patients in terms of reduced symptomatology, increased levels of functioning and improved quality of life.
Conclusions: The ATAPS projects are having a positive impact on a range of levels, and may provide some useful lessons for primary mental health care delivery in other countries.
PRIMARY CARE AND MENTAL HEALTH NEEDS IN FOUR FRENCH REGIONS
Vivianne Kovess-Masfety, Gwénaëlle Le Breton-Lerouvillois, Fabien Gilbert
In the context of resource planning, a large four region survey was commissioned by the French ministry of health.
The survey was conducted by phone using the CIDI SF one year plus impairment, SF 36 and use of care, on 20762 persons in regions contrasted for their levels of resource.
Population was divided into three main exclusive categories: mental health needs (psychological distress and DSM IV diagnostic with mild impairment) 26%, psychiatric needs (co morbid diagnostic or severe impairment) 7.7% or no needs.
For those with mental health needs 39.9% had a contact with a general practitioner whose 24.4% had contact with a GP only, 13.4% with a non medical mental health provider, 10.2% had contact with a psychiatrist and 53% with one of those.
For psychiatric needs 62.7% had contact with GP whose 25.8% are GP only; 27.6% had contact with non medical mental health provider and 27.8% has a contact with a psychiatrist and 78.8% had contact with one of those.
All these contacts rates differ according to the regions and within regions; a mapping system allows to contrast density of the primary care and psychiatric care resource and the level of need completion.
FIVE-YEAR EXPERIENCE OF OF A DIPLOMA COURSE IN COMMUNITY PSYCHOLOGICAL MEDICINE FOR PRIMARY CARE DOCTORS
Tai Pong Lam
Context: The Family Medicine Unit, in conjunction with the Department of Psychiatry, of the Faculty of Medicine, the University of Hong Kong launched a one-year part-time Postgraduate Diploma in Community Psychological Medicine for primary care physicians in September 2002. This was in response to the increasing number of patients with psychological problems in Hong Kong and the fact that there are currently 185 specialist psychiatrists serving the 7 million people in Hong Kong (as at the end of 2006), that is 2.6 psychiatrists/100,000 people, which is much less than that of most developed countries.
Objectives: To describe the experiences gained from the first five years of running the course.
Key messages: Almost 120 doctors have graduated from this course and they are contributing a significant input the mental healthcare in Hong Kong. The students generally had a positive learning experience. They also found their skills in psychological medicine much enhanced. Learning centres are now established in different regional hospitals in Hong Kong in order to allow small group clinical teaching while, at the same time, reduce travelling time for the students. Information technology is also used to facilitate teaching and learning, as well as to encourage communication among teachers and students.
Conclusion: The diploma course has contributed positively to the provision of mental health in the community.
OP64 CHALLENGING ISSUES IN PRIMARY CARE
INTIMATE PARTNER VIOLENCE AND HEALTH IN PREGNANCY
Stephanie Brown, Ellie McDonald, Kelsey Hegarty, Jane Gunn
Background: The Maternal Health Study is a prospective cohort study investigating the health and well-being of 1507 women during pregnancy and after the birth of their first child.
Aim: To investigate the association between intimate partner abuse prior to and/or during pregnancy and maternal health during early pregnancy.
Methods: 1507 eligible women were recruited to the study and completed a baseline questionnaire between 10–22 weeks gestation. Participants are followed-up at 3, 6, 9, 12 and 18 months postpartum. The baseline questionnaire included standardised measures of urinary and faecal incontinence, sexual health, depression and intimate partner abuse.
Results: 15.6% of women had been afraid of an intimate partner prior to pregnancy, and 3.1% reported they had been afraid of their partner since the start of pregnancy. Women who had experienced abuse prior to pregnancy or during pregnancy were more likely to be younger, unmarried, have a low income, to be smoking or recently quit smoking, and to have had one or more terminations prior to this pregnancy.
Women who were afraid during pregnancy were more likely to report back pain, vaginal bleeding, anxiety, depression, severe urinary incontinence, and moderate or severe faecal incontinence compared with women who had never been afraid of any partner. Women who experienced abuse prior to but not during pregnancy also reported higher rates of back pain, anxiety, depression and incontinence.
Conclusion: Fear of an intimate partner, before pregnancy or during the early stages of pregnancy, is associated with worse physical and psychological health in early pregnancy.
PARTNER VIOLENCE IN WOMEN SEEKING PSYCHIATRIC OUTPATIENT CARE – A QUALITATIVE INQUIRY
Pradeepa Dasanayake
Partner Violence is a common phenomenon that crosses all social, racial and ethnic boundaries. Though widespread and not a new phenomenon, the subject of PV is relatively under explored in Sri Lanka. Literature points towards high correlation of PV with psychological distress, mental illness and suicidal attempts. So far no research has been carried out on PV in a psychiatric population in Sri Lanka.
The aim of this study was to identify the nature and extent of partner violence (PV) among females seeking psychiatric out patient care and impact on mental health of the victims.
This qualitative study was carried out in a sample of female psychiatric patients who attended the outpatient department of the Psychiatric Unit of National Hospital in Sri Lanka. The patients who have been exposed to PV during the previous six months were identified for in-depth interview.
All the victims had experienced significant physical and emotional abuse, while three had reported sexual abuse. Majority of the respondents was depressed while somatisation was a common presentation. Posttraumatic Stress Disorder was a prominent finding in one woman. Six women responded with suicidal behaviour and two attempts were nearly fatal. All the women seemed to endure the abuse chronically despite their negative feelings towards partner.
It could be concluded that PV is a burning problem, presumably highly prevalent in Sri Lankan mentally ill population causing them immense distress. Although still under recognised, PV could be life threatening either as an effect of direct physical injury or secondary to psychopathology.
HOW DO PSYCHOTHERAPISTS RESPOND TO A PREVIOUSLY UNDERSERVED GROUP OF PATIENTS REFERRED FROM PRIMARY CARE?
Sunny Collings, Sue Garrett, Eileen McKinlay, Lynn McBain, Tony Dowell
Background: Over the next five years there will be a significant increase in the volume and intensity of mental health provision in New Zealand's primary care sector. To initiate this change a variety of new primary care mental health initiatives were developed. Most included fully funded access to time-limited psychological therapies for people with identified need but for whom services were not previously accessible. The attributes of the psychotherapy workforce in NZ are not well known, and the majority work in private practice, with a variable but generally minimal explicit link with primary care patient populations. This study is part of a Ministry of Health evaluation.
Aims: To describe the workforce responding to new demand created by these intitiatives, to identify training needs for both psychotherapists and referring primary care practitioners, to investigate participating psychotherapists’ views about the practicality, viability and clinical effectiveness of providing therapies in this new context.
Methods: Participating therapists (>100 at abstract submission) were surveyed by mail with a questionnaire comprising categorical and free response questions. Participation in evaluation is part of the contractual agreement.
Results: Simple descriptive statistics showing the workforce characteristics and theoretical orientations will be reported. Adaptations of technique and general therapeutic approach will be discussed. The self-identified training needs of therapists, and their views on the educational needs of primary care referrers will be ascertained, particularly in relation to adequacy of referral information, and appropriateness of referrals.
Conclusion: The results will inform developments in New Zealand's primary mental health strategy.
CLINICAL EVALUANION OF COMOBID DISORDERS
Alexander Kim
Objectives: To study the influence of the phenomenological approach in classifications DSM-III, DSM-IV and ICD-10 on diagnostics of the phenomenon of comorbidity.
Methods: The sample consisted of 75 patients from 19 to 65 years of age, who were surveyed at outpatient clinics in Bishkek. Standardizing scale of depression, standardizing scale of anxiety scale, and the Sheehan Quality of Life Questionnaire.
Results: According to the results, a prevalence of complaints of palpitation (16,8%), headaches (16.8%), breathing complications (10.8%), pain and discomfort in chest (10.8%), and weakness and fatigue (8.4%) were reported. The prevalence of a somatic pathology in these systems obviously reflects the psychosomatic nature of comorbidity, and allows one to draw analogies to the diagnostic instructions of heading F-4, ICD-10.
According to the received results, the majority of patients (66.15%) testified that their anxiety level was raised, both reactive, and personal. the severity of level of depression for the majority of patients corresponded to the norm (61.5%). For patients with accompanying mental disorders, the parameters of quality of life was considerably low (p <0.05) in sections both psychological and physical. The parameters demonstrate a presence of co morbidities, in which the patient's “somatisation” is an appeal for help.
Conclusion: “Somatisation” is an appeal for help. The presence of disturbing affect, allows to assume about functioning the clinical-psychological mechanisms promoting formation secondary somatisations. In structure of comorbidity somatic disorders, secondary somatisations is realized more often, in variants presented somatisations and pseudo-somatisations. The intensity and duration of a disturbing component in the structure of comorbidity somatic infringements represents the mechanism of active physiological reactions causing stabilization of a phenomenon of somatisations for patients with somatic disorders. Secondary somatisation is the clinical-psychological mechanism causing formation of clinical typology shown somatisations and pseudo-somatisations, which have adaptable characteristics and conduct to leveling hipotimics affect, in the structure of comorbidity somatic disorders.
SHORT AND LONG TERM EFFECTS OF MEDITATION ON MENTAL HEALTH OF FULL TIME WORKERS SEEKING HELP FOR WORK STRESS
Ramesh Manocha
This presentation is the synthesis of two important studies assessing the acute and long term effects of meditation on stress and mental health:
First, a survey of 350 long-term meditators (greater than 2 years regular meditation using the Sahaja Yoga meditation technique) from around Australia was conducted assessing mental health and quality of life using the Kessler 10 (K10). The K10 data indicated that the meditating sample had a significantly larger proportion of subjects who were at low risk of mental health problems compared to the background population. Importantly, a highly significant correlation was found between frequency of reported “meditative experience” and mental health scores in the K10 (r = 0.37, p<.001) even after controlling for standard confounders.
Second, a double-blind randomized controlled trial of meditation as management strategy for work stress compared to both relaxation and a waiting list control was conducted. 178 full time workers were recruited. They completed the GHQ 28 at baseline and postintervention. There was a statistically significant improvements for the meditation group compared to both the active control and control group in the median differences for the GHQ score (p<.05). The results suggest that the meditation technique is a specifically effective strategy for reducing stress and improving mental health.
Taken together, these two studies demonstrate that meditation is effective in reducing stress and improving mental and physical health. Moreover, the benefits of long term practice of meditation are associated with frequency of practice and depth of experience.
OP65 EARLY PSYCHOSIS
FIRST EPISODE PSYCHOSIS: MEDICATIONS AND CLINICAL PRESENTATION IN AL AIN, UNITED ARAB EMIRATES
Hamdy Moselhy Fouad, Mohammed Omar Salem, Saeed Yousef
Objective: The primary aim of this work was to examine the socio-demographic, clinical correlates, the effect of medical treatment on the first episode psychosis in an Arabic country.
Method: A retrospective case note review, looking at first episode psychosis who were admitted to the in-patient psychiatric ward in Al Ain general hospital over 5 years.
Results: 161 patients with first episode psychosis were reviewed. In the 5-year period under the study, 161 aged 13–45 years with history of first episode psychosis were admitted to the psychiatric ward. They established a different clinical diagnoses according to ICD 10: 69 patients (42.9%) had a diagnosis of acute psychotic episode, 35 patients (21.7%) had a diagnosis of manic episode, 31 patients (19.3%) had a diagnosis of schizophrenia, 16 (9.9%) had depression with psychotic symptoms, 3 (1.9%) drug dependence, 1 (0.6%) persistent delusional disorder, and in 6 (3.7%) patients the data were missing.
The mean age was 27.5 years (13–45 years) (SD = 6.6), male/female ratio (110/49, 68.3%/30.4%). There was a significant relationship between duration of untreated psychosis (DUP) and outcome, where the longer the DUP the more existence of residual symptoms on discharge (χ2=18.515, df = 6, p=.005). In addition there was a significant relationship between social withdrawal symptom prior to admission and residual symptoms on discharge. In addition, there was a positive significant relationship with the use of the combination of antipsychotics and mood stablizer in outcome.
Conclusion: Results of this study indicate that DUP, clinical features and type of medications may determine the outcome of first episode psychosis.
QUALITY OF LIFE AMONG FIRST-EPISODE SCHIZOPHRENIA PATIENTS TREATED WITH CONVENTIONAL OR ATYPICAL ANTIPSYCHOTICS
Kok Yoon Chee, Salina Abdul Aziz, Kim Leng Yeoh
Introduction: Quality of life has recently been emphasized in the management of schizophrenia. Many profitable organization-funded and non-funded clinical trials have been published addressing the effect of antipsychotics on improving quality of life and clinical and health outcomes of the patients, especially among the atypical antipsychotics (AAs). AAs have been claimed superior to conventional antipsychotics (CAs) in many ways, including improvement of quality of life. However, recently some of the pragmatic clinical trials have dispute this claim. Currently there is no data from Malaysia addressing this issue pragmatically.
Objectives: To test the hypothesis that there is no difference in quality of life among patients treated with either AAs or CAs. Secondary objectives included examining the difference in subjective quality of life in these 2 groups and re-examining all the outcome variables with sulpiride being analyzed separated from AAs.
Methods: This is an observational cross-sectional study. A total of 124 patients with first-episode schizophrenia were recruited from Hospital Kuala Lumpur. They were identified by NMHR during diagnosis and interviewed after at least 1 year of treatment by their respective clinicians. Main outcome measures were WHOQOL-BREF.
Results: There were no significant differences between groups in study in terms of subjective quality of life. Conclusion: In people with first-episode schizophrenia who have been compliant to treatment, there is no advantage after at least 1 year of treatment in terms of quality of life in using AAs or CAs.
PATERNAL AGE EFFECT ON THE EARLY OUTCOME OF FIRST EPISODE SCHIZOPHRENIA
Cindy Chiu, Eric Chen, C. W. Law, Christy Hui
Background: Multiple aetiological factors have been implied in schizophrenia and its outcome. Results from recent works are suggestive of a paternal age effect on the risk of schizophrenia. How this may affect schizophrenia outcome was not previously studied. We hypothesis advanced paternal age to have an effect on the outcome of schizophrenia.
Method: 191 patients with first episode schizophrenia and their relatives were interviewed for parental ages, socio-demographic factors at birth, birth rank, family history of psychotic disorders and obstetric complications. Outcome measures at the end of the first year of treatment included negative symptoms, number of relapses, and occupational functioning.
Results: We performed correlation for paternal age and the key outcomes. A significant association was detected for relapse and paternal age. No correlations between paternal age and occupational functioning or negative symptoms were found. Further exploration with hierarchical regression analysis supported contribution from paternal age but not for other factors. Analysis between different paternal age groups found a significantly higher relapse rate with paternal age over forty. Results did not support a maternal age effect.
Discussion, conclusion and implications: Advanced paternal age is associated with a higher tendency for relapse within the first year. Such effect is unlikely to be mediated through less effective parental supervision or non-compliance. Timing of relapse was not measured. No effect is found for negative symptoms or occupational functioning. Lack of association with negative symptoms may be due to the relatively short duration of study period.
THE EPISODE II RELAPSE PREVENTION STUDY
John Gleeson, Darryl Wade, Sue Cotton, Mario Alvarez, Daniela Spiliotacopoulos, Donna Gee, Tracey Pearce, Kingsley Crisp, David Castle, Monica Gilbert
Background: Between 70–90% of young people with first-episode psychosis (FEP) suffer a psychotic relapse 5 years after commencement of treatment. CBT for relapse prevention warrants evaluation in this population.
Aims: The aim of the EPISODE II study is the evaluation of CBT for relapse prevention following remission from FEP in young people. The principal hypothesis is that CBT relapse prevention therapy (RP) plus treatment as usual (TAU) will result in reduced relapse and rehospitalization rates at 2 years follow-up compared with TAU alone. Secondary outcome measures include co-morbid symptoms and psychosocial functioning. This paper reports findings at the end of the treatment phase.
Method: Between November 2003 and May 2005 FEP patients and their families were recruited from EPPIC and randomized to treatment as usual (TAU) or to TAU plus RP. Patients were assessed by a blind rater at six time points at 6-montly intervals.
Results: 213 patients were approached to participate and 86 consented. 81 of these patients completed the baseline assessment and 41 were randomized to RP and 40 to TAU. At baseline there were no significant differences between the groups on demographics, primary diagnoses, or symptom severity. The RP group had higher rates of cannabis abuse disorders. End of treatment complete-case comparisons on secondary outcome measures indicated significantly lower scores on depression and negative symptoms in the RP group compared with the TAU group.
Conclusions: CBT shows promise over and above specialist FEP care for remitted patients.
AGGRESSIVE BEHAVIOUR IN FIRST EPISODE PSYCHOSIS
Kimberlie Dean, Elizabeth Walsh, Craig Morgan, Arsime Demjaha, Paola Dazzan, Kevin Morgan, Tuhina Lloyd, Paul Fearon, Peter B. Jones, Robin M. Murray
Introduction: To examine the prevalence and correlates of aggressive behaviour leading to service contact in a large epidemiological sample of patients with first episode psychosis in the UK (AESOP Study).
Methods: The main reasons for presentation to services were examined for those recruited to a UK-based first episode psychosis study based in South East London and Nottingham during the period 1997–1999. Aggressive behaviour at first contact with services was investigated in relation to socio-demographic, past offending, clinical, service contact and symptomatology domains.
Results: Of the 495 patients included in the current study, almost two-fifths (39.2%; n = 194) were aggressive at first contact with services; approximately half of those were physically violent (n = 103). Young age, African-Caribbean ethnicity, and a history of previous violent offending were found to be independently associated with overall aggressive behaviour. Those with a diagnosis of manic psychosis were found to be at greater risk of aggression than those with schizophrenia. Individual manic symptoms were also significantly associated with aggression both for the whole sample and for those diagnosed with schizophrenia. The factors differentiating violent from non-violent aggressive patients included male gender, social class, and past violent offending but not symptomatology.
Discussion: Aggressive behaviour was a frequent precipitant for presentation to services with first episode psychosis. Socio-demographic and past offending factors were associated with aggression and were also able to identify those presenting with more serious violence. A diagnosis of manic psychosis and the presence of manic symptoms increased risk.
OUTCOME OF SUICIDAL IDEATION AND BEHAVIOUR IN A YOUNG HELP-SEEKING POPULATION OVER TWO YEARS
Elizabeth Cosgrave, Jo Robinson, Katherine Godfrey, Yuen Hok Pan, Eoin Killackey, Kathryn Baker, Joe Buckby, Alison Yung
Background: Suicidal behaviour, is associated with negative outcomes, including completed suicide.
Aim: To examine the prevalence of suicidal behaviour in a sample of referrals to a youth psychiatric service and to investigate its stability of suicidality over 2 years.
Method: 140 people (mean age 17.8) who were referred to a youth psychiatric service (82 accepted for treatment (RA group), 58 not accepted (RNA group) were assessed.
Results: 57% reported considering suicide and 39% attempting suicide in the 12 months prior to referral. Participants who reported suicidal ideation were significantly more likely than non-suicidal participants to have multiple Axis I diagnoses and lower levels of functioning. At 2-year follow-up there was a significant reduction in suicidality in the RA group, but not in the RNA group.
Conclusions: Suicidality is prevalent among young people referred to psychiatric services. Even brief contact with services results in a reduction in suicidality over 2 years.
OP66 MENTAL HEALTH SERVICES IN DIFFERENT SETTINGS
OVERSEAS TRAINED PSYCHIATRISTS FROM DOVELOPING COUNTRIES IN VICTORIA, AUSTRALIA: CHALLENGES AND SUPPORTS
Raju Lakshmana
Context: Overseas Trained Psychiatrists (OTPs) from developing countries form a significant proportion of medical workforce in Victorian public mental health system. They face unique challenges in adapting to their professional roles and Australian culture (social and professional). This is in the climate of a broader health workforce shortage in Australia especially in public, rural and remote health systems.
Objectives: Systematic review literature concerning IMGs and OTPs in Australia and other developed countries.
Identify specific issues facing OTPs from developing countries in Victoria by surveying OTPs at various stages of their career.
Understand the resources available for them by evaluating websites, policies and procedures of RANZCP and AMC. Interviews with key officials in RANZCP, Medical Practitioners Board of Victoria (MPBV) and Australian Medical Association (AMA), and employers to enhance the understanding of systemic issues pertaining to OTPs.
Key messages: OTPs from developing countries face specific challenges in their professional and personal lives when they migrate to Australia. There is an attempt to support them in this acculturation process by state and national professional bodies. Employers have a central role in this process.
Conclusion: OTPs from developing countries help bridge the gap in public mental health care system in Victoria (Australia). The employers and national professional bodies should work collaboratively with them in understanding and addressing their needs in the context of unique challenges they face in both personal and professional roles. This investment can reap significant rewards for Australian community when these OTPs settle down and continue to provide specialist services in Australia.
INTELLECTUAL DISABILITY AND MENTAL DISORDER: GENERIC MENTAL HEALTH SERVICES OR SPECIALISED CARE?
Jenny Torr
Context: People with intellectual disabilities have higher rates of mental health disorders than the general population. In the United Kingdom ‘learning disability psychiatry’ is a recognised psychiatric subspecialty, with a specialist training program. Specialist services are provided by regional ‘learning disability’ mental health teams. The situation in the United Kingdom is the exception to the rule. In other developed countries the policy, whether implicit or explicit, is that people with intellectual disabilities and mental health disorders are to access generic mental health services.
Objectives: This paper will: 1. Examine the policy and practice of generic service provision and whether generic services meet the mental health needs of people with intellectual disability 2. Explore alternative models including parallel specialist services or a tiered approach to meeting basic to highly specialised need.
Key messages: Generic service provision is underpinned by the deinstitutionalisation and demedicalisation of care and the policy and practice of “normalisation”. Generic mental health services fail to meet the mental health needs of people with intellectual disability. The status quo is maintained by misunderstanding of the principle of normalisation and the real needs of people with intellectual disability, economic imperatives of governments, and both professional and community disinterest. An emerging human rights based movement argues for “right to the right health care”, including mental health.
Conclusion: A tiered approach to meeting mental health needs of people with intellectual disability combines “normal” and “specialised” care based on the care needs. However there are major challenges in service integration and professional training.
CASE STUDY OF AN AUDIT OF A RURAL MENTAL HEALTH SERVICE
Andrea Boros-Lavack
Context: An audit of the existing Model of Service Delivery of Toowoomba Mental Health Service (MOSD 2002) is described. This rural mental health service is a mix of community/inpatient and institutional. The main structural change in the MOSD 2002 was the establishment of a bureaucratic organisational structure where managers and team leaders were expected to manage clinical service provision and improve patient outcomes. There are difficulties with recruiting and retaining psychiatrists and with organisational culture and clinical issues that are adverserly affecting the quality of care. The clinical director is expected to be accountable for professional standards and clinical leadership without authority in these roles.
Objectives: To examine of the impact of an audit on a rural mental health service and identify priorities for problem solving. This is a descriptive case study. The author examines the whole review process on the organisation, staff, patient and community, including media functioning.
Key messages: To follow when results released. Concerns about the lack of psychiatrist input into reviews of community patients as per national mental health standards were alredy raised. This highlights the importance of the organisational structure and culture for the service, as managers are unable to provide a clinical service without psychiatrists.
Conclusion: It is expected that one of the conclusions would be to change the organisational structure as the current structure is incompatible with good mental health care, affecting staffing, organisational cultre and service issues. The management structures have to be redefined after the core clinical functions of the service are determined.
FORWARD OR REARWARD? PSYCHIATRIC SERVICE PROVISION TO DEPLOYED AUSTRALIAN DEFENCE FORCE MEMBERS EMBEDDED WITH UNITED STATES MILITARY FORCES IN BALAD, IRAQ DURING (RECONSTRUCTION AND REHABILITATION OF IRAQ) IN 2005 PERATION CATALYST
Stuart Sakerv
Context: The relative merits of forward and rearward psychiatric service provision have been debated since the First World War. The experience of a an Australian psychiatrist embedded as a general medical officer with a small group of other Australian Defence Force health personnel within a United States trauma hospital in Balad Iraq in 2005 illustrated some of the contrasts between these two approaches.
Objectives: To describe levels of psychiatric service provision available to United States and Coalition Forces at Logistics Support Area, Anaconda, Balad, Iraq in terms of the principles of forward psychiatry.
To describe the barriers to Australian Defence Force personnel in accessing these services and the formal and informal alternatives mental health systems available to them with a focus on concepts of risk, disorder and stigma.
Key messages:
Categorical concepts of disorder rely on occupational dysfunction, social dysfunction or social dysfunction.
The principles of forward psychiatry seek to avoid occupational dysfunction by achieving rapid return to work, this being both an outcome and a part of ongoing treatment.
Compulsory evacuation with rearward psychiatric treatment may cause occupational dysfunction and an increase in subjective distress.
Consolidation of symptoms may occur with long-term implications for members
Evacuation is not always the safest thing to do.
Conclusions: Psychiatric service provision in the Australian Defence focuses on occupational outcomes. Psychiatrists will often not be physically available to deployed forces however the style of immediate psychological first-aid to soldiers and the attitudes of commanders and health-care providers with regard to labeling and evacuation requires examination.
ASSESSMENT AND MANAGEMENT OF DUAL DISABILITY
Margaret Graham
This presentation will provide an overview of the assessment and management of psychiatric disorder in people with intellectual disability.
It will highlight the issues that people with intellectual disability and their carers and medical carers face in the diagnosis and management of psychiatric disorder in people with intellectual disability.
Specific issues covered will include how intellectual disability can alter the presentation of psychiatric disorders, diagnostic tips, the role of carers in facilitating diagnosis, principles of management and specific management.
POLICE MOBILE CRISIS SERVICES: A COMPARATIVE APPROACH TO EVALUATION
Cheryl Forchuk, Elsabeth Jensen, Mary-Lou Martin, Rick Csiernik, Evelyn Vingilis
Currently, in Canada, there has been an increase in contacts between the police and individuals with mental illness. Consequently, Police Mobile Crisis services are becoming more popular in Ontario, particularly after the success of the Crisis Outreach and Support Team (COAST) program in Hamilton, Ontario. Unfortunately, we do not have a good understanding of the essential components, processes, and outcomes for these services. Therefore, this is an issue that needs to be addressed as new police mobile crisis teams are emerging with variations in structure and organization.
By employing a case study approach, we can compare and contrast police crises models in three different regions: Chatham-Kent, Haldimand-Norfolk, and Hamilton. Quantitative systems level data will include a description of the communities served, frequencies of emergency room and police calls, satisfaction surveys and open-ended questions. To obtain qualitative data, we are carrying out participant observation, focus groups and interviews within each site with families, consumers and services providers. We are expecting a sample size of 180 participants, with 60 participants in each group (consumer, family members and service providers). From this case comparison method, it will give us rich data in order to understand the similarities and differences between these police mobile crisis models. Moreover, it will help us identify key issues regarding the development of successful police mobile crisis services in Ontario. The presentation will focus on the participant observations and focus groups.
OP67 DESIGN AND TECHNOLOGY
RECOVERY VIA INTERNET FROM DEPRESSION: FORMATIVE EVALUATION
Shyamala Nada-Raja
Background: Depression is a major risk factor for self-harm and a leading cause of disability. About half the number of people affected by depression do not come to the attention of health services and many do not think it is necessary. Cognitive behaviour therapy (CBT) is an effective way to alleviate depression. Recent randomised controlled trials (RCT) in Australia of internet-based CBT and depression literacy (DL) programmes have reported promising results.
Aims: To adapt for New Zealand a proven Australian internet-based interactive and personalised CBT and DL programme and determine its effectiveness to reduce depression and anxiety, self-harm, and alcohol misuse, and enhance quality of life in the general population.
Methods: In the first year, formative evaluation involving focus groups with the target populations were completed. In the following two years an RCT with 700 or more participants will be conducted to test the effectiveness of online CBT and DL versus a credible control condition for each of the mental health measures listed above.
Results: An overview of the trial and provisional findings from the formative evaluation will be presented.
Conclusion: Formative evaluation is critical for any trial and in particular, for one that addresses sensitive health issues with vulnerable populations. It can help to maximize the reach and effectiveness of the content and delivery of the interventions. A companion paper will illustrate its importance and relevance for Maori in this trial.
VIRTUAL PSYCHIATRIC COMMUNITIES AND THEIR IMPACT ON THE ESTABLISHMENT
Deeta Kimber
Over the past four years the psychiatric trainee community of Australia and New Zealand have been linked via the website www.anzapt.org and a monthly email newsletter. During this time there have been many changes to the way training and assessment has been conducted in our community with regular expressions of confusion or distress around this topic.
The availability of easy to operate open source software, that provides a website and discussion forum, have enabled easy and quick methods for this community to exchange information of all types from how to pass exams to up coming training regulation changes or a space to synthesize opinions around their emerging professional identity. It has also enabled international psychiatry trainees with similar curricula and experiences to exchange their information and join this community.
Digital technologies and the ease of digital publishing have enabled a dispersed community to interact with and support each other, form opinion as an advocacy group and professional cohort in a way that was not previously possible. This medium of professional communication, collaboration and publication is likely to develop further to become an integral part of any psychiatry training community. The role and scope that digital technologies play in the life of a professional community such as this is significantly influenced by the new directions internet and digital publishing technologies are heading, which ever increasingly includes videoconferencing and streaming or MP3 sound files.
GETTING THE DESIGN AND BUILD OF PSYCHIATRIC CARE FACILITIES RIGHT
Duncan White
Context: Following many years of successful project management within the concept, design and build of dedicated psychiatric facilities there are clearly lessons still to be learned.
The commissioners of care facilities and their contractors must bridge a special relationship to generate subtle answers to the challenge of defining the role and impact that the built environment has on our patients and staff.
Objectives: To define the ‘lessons learned’ from a diverse range of built solutions, that have successfully developed a creative use of space, shape and ambience to promote and deliver exemplary care.
Key messages: It's so easy to get it wrong and it can take years for care staff to try and ‘design-out’ of the Organisations operational profile the damage done – if it can ever really overcome the catastrophe of vague concepts, poor design, badly executed builds and the low morale and decimated expectations that result.
Conclusion: There are ways to deliver a successful built environment – why don't we do it often enough?
How mental Health practitioners can win through the arcane world of Business Consultancy, Accountants, Architects, Builders, ignorance, stupidity, bureaucracy and downright disinterest to get the best possible built environment for their patients.
COST-EFFECTIVENESS OF TREATMENTS FOR BIPOLAR DISORDER IN THAILAND – A SPICE PROJECT
Dan Siskind, Harvey Whiteford, Stephen Lim, Theo Vos, Pudtan Panthunane, Jane Kim
Background: Low and middle-income countries are increasingly realizing the magnitude of the potential health and economic benefits associated with treatment of Bipolar Disorder. To aid countries in policy decisions, there is a need for cost-effectiveness analysis of treatments for Bipolar Disorder contextualized to developing countries. The SPICE (Setting Priorities using Information on Cost-Effectiveness) project aims to provide essential health information to guide priority setting in the health sector; a core part of this project focuses on Mental Health using data collected in Thailand.
Aims: This study utilizes data collected in Thailand from the SPICE project to evaluate the cost-effectiveness of bio-psycho-social treatments for Bipolar disorder, including mood stabilisers, anti-psychotics (both typical and atypical) and psychosocial interventions such as cognitive behavioural therapy, group therapy and family interventions.
Methods: We developed a Markov model of the natural history of Bipolar Disorder, using epidemiological and economic data from the Thailand and other developing countries, where possible. We estimated lifetime costs, quality-adjusted life expectancy (QALY), and cost-effectiveness for each bipolar disorder treatment intervention.
Results: Under various assumptions of coverage, compliance, and costs, we found that older mood stabilising medications and Lithium had cost-effectiveness ratios that were generally lower than Thailand's GDP per capita, and therefore can be considered cost-effective treatments for Bipolar Disorder.
Conclusion: Upscaling treatments such as Lithium and older mood stabilisers may be a cost-effective way of reducing the burden of bipolar disorder in Thailand, and may have implications for treatment in peer developing world countries.
OP68 PSYCHOSOCIAL INTERVENTIONS FOR PSYCHOSIS
REASONING STYLES OF PATIENTS WITH RESISTANT DELUSIONS: A STUDY INVOLVING COGNITIVE BEHAVIOURAL THERAPY
Vlasios Brakoulias, Robyn Langdon, Gordon Sloss, Max Coltheart, Russell Meares, Anthony Harris
Aims: As delusions have been associated with specific reasoning anomalies and cognitive behavioural therapy (CBT) has been shown effective in modifying delusions, we aimed to assess whether changes in reasoning style mediate response to CBT in patients with delusions resistant to medication.
Method: Forty patients with medication resistant delusions were referred from psychiatric outpatient clinics. Seventeen patients were accepted into a short CBT programme that targeted their delusions. Probabilistic reasoning, attributional biases and theory-of-mind (ToM) were assessed pre- and post-treatment. Outcome was measured using ratings of delusional conviction, preoccupation and distress at the beginning of each session.
Results: Fourteen patients completed the programme. Delusional conviction was reduced in eleven with eight having reductions of greater than 50%. Younger age, shorter length of illness and better insight predicted outcome. Reasoning biases were present and despite some inconsistent evidence of improvement in verbal ToM tasks with CBT, they did not predict outcome and were largely unchanged by CBT.
Conclusion: CBT is helpful in the treatment of resistant delusions. Abnormal reasoning styles in patients with resistant delusions mark a vulnerability that is largely unchanged by CBT.
HELPING VOICE HEARERS TO COPE BETTER: A SKILLS-TRAINING GROUP PROGRAM FOR FAMILY CAREGIVERS BASED ON COGNITIVE BEHAVIOUR THERAPY FOR PSYCHOSIS
Janet Maxwell, John Farhall, Thomas Matyas
Background: The treatment of persisting psychotic symptoms with cognitive behaviour therapy is now established as an evidence-based treatment. However, the availability of such treatment is limited, and relies on the agreement of the patient to attend appointments. Family caregivers are often in an excellent position to support their ill relative due to their well-established relationship and frequent contact. However, many carers feel ill-equipped to assist a relative in managing complex problems such as those associated with auditory hallucinations (voices).
Aim: This study piloted a novel skills-based group training program for carers based on cognitive behavioural therapy for psychosis principles which aimed to promote more effective responses by carers during their regular interactions with their relative who hears voices.
Method: Eight carer-consumer dyads participated in the study. Carers attended the 10-week (25-hour) program, and completed measures of subjective burden (Involvement Evaluation Questionnaire) and emotional expression (Family Questionnaire) over a 30-week period which included baseline, intervention and follow-up phases. Carers also recorded the assistance they gave their relative on a daily basis during the intervention phase. Their ill relatives completed weekly symptom interviews (PsyRATS) and self-esteem (Rosenberg) and insight (Birchwood) scales over the same 30-week period. Analyses were conducted for each dyad using time-series methods.
Results: The training program was rated highly by all participants. Improvements in symptoms and carer emotional expression ranged from none to considerable across different dyads. Qualitative data showed considerable improvements in carer-consumer communication.
Conclusion: There may be benefits in training carers in evidence-based management of persisting hallucinations.
OVERCOMING STIGMA OF MENTALLY ILL IN THE AREA OF EMPLOYMENT
Anna Biela, Andrzej Cechnicki
Background: Working for mentally ill is an important factor in coming back to the community but there are several obstacles in getting a job like employers’ prejudice and/or patients believes. Department of Psychiatry of Jagiellonian University led the study which were aimed on investigating to what extent patients with schizophrenia anticipate and experience discrimination, and how they estimated stigma in the area of employment.
Subjects and method: A total of 202 patients with schizophrenia (ICD 10) were interviewed by Angermeyer Questionnaire. The average age was 40 yrs, the average number of hospitalizations was 6.
Results: The majority of respondents anticipated and experienced discrimination mainly in interpersonal relations and employment. In the area of employment: Anticipation: 76% of the interviewed patients believe that employers do not employ the mentally ill, 70% say when seeking employment one should not mention mental illness, but more than 57% think that one should make an effort to find employment. Subjective experience: 70% attempted to undertake employment. Within this number, 31% did not obtain it when they revealed they were mentally ill.
The response of this situation are social firms which join several important elements of the successful rehabilitation. Their social firm solution is the small hotel in downtown, which functions as a part of the hotel infrastructure in Kraków. 25 people with long-term schizophrenia problems are employed. The presentation ends up with 7min film.
Conclusion: The employment of patients suffering from schizophrenia is still a great task which should be undertaken in psychiatric rehabilitation.
WORKING! RESULTS OF A RANDOMISED CONTROLLED TRIAL OF INDIVIDUAL PLACEMENT AND SUPPORT IN FIRST EPISODE PSYCHOSIS
Eóin Killackey, Henry Jackson, Patrick McGorry
Background: The top priority of people with mental illness is participation in the open labour market. In first episode psychosis (FEP) unemployment rates of 40–50% are commonly found. In schizophrenia, unemployment rises to 70–95%. Individual Placement and Support (IPS) is a vocational intervention which has been trialled successfully in populations with chronic serious mental illness in the USA.
Aims: To date there has been no published randomised trial of IPS in FEP. This study aimed to examine the efficacy of IPS in a RCT with people with FEP.
Methods: Clients of the Early Psychosis Prevention and Intervention Centre (EPPIC) who wished to work were randomised to treatment as usual (TAU) (n = 21) or TAU + IPS (n = 20). Participants were assessed at baseline and after six months on symptomatic, demographic and functional measures. Raters were blinded. The IPS condition involved working with an employment consultant who was integrated with the mental health team. Her role involved rapid job searching pre, and support post, employment.
Results: In the IPS condition 90% of participants had a good vocational outcome compared with 10% in the TAU condition. Income and duration of employment results also significantly favoured the IPS group. Reliance on benefits reduced in the IPS group but not the TAU group over this time. Results examining symptomatic and quality of life results will also be presented.
Conclusion: IPS is an effective way to address vocational needs in FEP. This may have long term benefits for decreasing unemployment and social marginalisation in schizophrenia.
A CASE OF RECOVERY
Keith Mahar
Keith Mahar B.B.A. is the third generation male in his family to experience Bipolar Disorder. He has shared his personal story of mental illness with high school classes since 2002 as a Volunteer Educator as part of MIEACT's School Education Program, a research program by the University of Canberra to reduce stigma of mental illness and increase mental health literacy.
The context of the presentation is for a person to share his personal story of the catastrophic effects of suffering psychosis and severe depression on his life, the process and methods used to effectively manage his mental illness and ultimately recover a satisfying quality of life.
Objectives: Include addressing the benefits of a biopsychosocial approach to management and recovery, noting what worked best and what did not, the pitfalls and successes encountered.
Key messages: Recovery is a unique process but some key things for me-learning about the illness, importance of persistence, finding and following effective treatments, insight into early warning signs, managing stress, hope, maintaining a healthy regime, especially a regular sleep pattern, taking small steps, patience, part-time work, becoming a volunteer, reducing one's self-stigma.
Conclusion: Recovery does not mean cure, which means a constant monitoring process, continuation of treatment, the knowledge to know your own mind, respect its limits and how to slow down as required, and the wisdom to act upon your knowledge, time and time again. Also to appreciate the peace from living without major symptoms and the satisfaction of rebuilding one's life.
OP69 MENTAL HEALTH SERVICES FOR YOUTH
IMPROVING THE MENTAL HEALTH OF YOUNG PEOPLE THROUGH SERVICE REFROM – THE HEADSPACE INITIATIVE
Craig Hodges, Amelia Callaghan, Sian Lloyd, Patrick McGorry, Matt O'Brien, Peter Orchard, Rosemary Purcell, Maree Sidey, Chris Tanti
Context: The aim of headspace, the National Youth Mental Health Foundation, is to reduce the impact of mental ill health and substance use in young people aged 12–25 years. This is being achieved through improvements in mental health service reform informed by the latest evidence on youth mental health.
Objectives:
To establish key service partnerships in communities across Australia
To provide young people with access to a range of services in a youth friendly environment
To encourage young people and their families to seek help earlier through raising awareness in the community about mental health
To collect and build on the best available evidence-based practice in youth mental health through the Centre of Excellence
To build the capacity of professionals who work with young people through the provision of the latest evidence and training.
Key messages:
Have we got the right service system in place to meet the needs of young people experiencing depression, anxiety and substance use issues?
What are the challenges ahead in further developing youth mental health services and how can we meet these challenges?
Conclusion: This paper will provide an overview of headspace and how it is supporting a number of Communities of Youth Service that aim to improve services to young people with mental health and substance use issues. It will focus on developing service models at a local level which have a prevention and early intervention focus as identified by the local community and the research literature.
DEVELOPING URGENT/EMERGENCY FIRST INTERVENTION HOSPITAL-BASED BEST PRACTICES FOR THE CHILD AND ADOLESCENT POPULATION AGED 0–15
JoAnn Elizabeth Leavey
Context: This program development information will address some of the strengths and difficulties encountered when attempting to build a best practice evidence-based urgent/emergency clinical program for early onset of mental health problems for hospitalized clients 0–15 years of age.
Objectives: 1) to illuminate the processes undertaken 2) to explore the strengths and areas of difficulty experienced 3) discuss transforming a traditional clinical program into one that is multi-disciplinary and evidence-based 4) discuss directing clinical practices and treatments based on outcome measures.
Key messages: Identify current strengths and weakness in best practices in this area. Take home lessons learned in the process of our program development.
Conclusions: Discuss lessons learned during this process and report on progress to date.
DEVELOPMENT OF CHILD AND ADOLESCENT MENTAL HEALTH SERVICES IN SOUTH ASIAN COUNTRIES: A STRATEGIC PLAN
Mohammad Sayadul Islam Mullick
In South Asia, roughly 45% of the population is under the age of 18 years. Few studies in the South Asian countries suggest that 12–20% of children have psychiatric disorders. The pattern of psychiatric disorders in children resembles that identified in developed world, with preponderance of anxiety disorders and increased trend of behavioural disorders that are severe enough to result in substantial distress and social impairment, thereby warranting treatment. In these countries with few mental health professionals, there is a vast gap between need and provision that must be addressed.
The mental health services for young people in South Asian countries are inadequate and not well organized. There are scarcity of manpower, logistic support and multidisciplinary approach. Further mental health of South Asia differs from the Developing countries in many aspects. Therefore, child and adolescent mental health services for the South Asian countries will likely to be different from Western model. The objectives of this paper are to highlight the main issues that are present to develop feasible child and adolescent mental health services in South Asian countries. It identifies strengths, resources, challenges and opportunities, and proposes a structure of child and adolescent mental health services in South Asia for adopting a child and adolescent policy and action plan to move from a strategy of such services to reality. World Psychiatric association have critical role in establishing dialogues, coordinated initiatives, assistances and partnership to address these issues in this part of the Globe.
EVOLVE THERAPEUTIC SERVICES – MEETING THE COMPLEX NEEDS OF CHILDREN AND YOUNG PEOPLE IN THE CHILD PROTECTION SYSTEM THROUGH A FORMALISED, INTERAGENCY FRAMEWORK
Janet Martin, Penny Brassey
Evolve Therapeutic Services is a new state-wide specialist child and youth mental health service in Queensland funded by the state government child protection agency to work exclusively with children and young people in the child protection system who have severe psychological and behavioural problems.
This specialist model of service delivery is based on the current best available evidence for the provision of therapeutic interventions for this target population. The program provides an intensive, community-based service response to meet the level and complexity of need of the target population, and is underpinned by a formalised, collaborative interagency framework involving the Queensland government departments of Child Safety, Health, Disability Services and Education. Foster Carers and other placement providers are considered critical partners in the provision of support to the children engaged in the therapeutic response.
This paper will outline the program's model of service delivery, including a demonstration of the critical success factors essential for effective and sustainable collaboration. Evidence from an external evaluation of the interagency framework will be utilised.
The target population will be described through an analysis of the first 200 children and young people referred to the program, and the outcomes achieved to date will be highlighted.
The program highlights the importance of partnerships for practice when responding to the complex needs of children who have severe psychological and behavioural problems secondary to experiences of trauma.
ESTABLISHING YOUTH EARLY PSYCHOSIS SERVICES
Richard Bell
Context: Young people experiencing the onset of psychosis have been identified as one specific group requiring early intervention and specialist treatment programs to ensure optimal outcomes. In 2003, the Victorian Mental Health Branch commenced funding for streamed Youth Early Psychosis Services (YEPS) throughout Victoria. To support this initiative, EPPIC Statewide Services were funded to provide consultation, training and resources to the YEPS in order to facilitate the development of evidence based best practice in early psychosis.
Objectives: To describe the issues raised during consultation in the early phase of service development which focussed on developing models which, could respond appropriately to young people at risk of developing psychosis, provide a specialised intervention for up to 3 years for young people who develop psychosis and could attend to the needs of their carers.
Key messages: As the new funding was provided for additional community clinicians, models were developed, which were both integrated into the existing mental health service, while also supported streamed interventions. Integration enabled an effective pathway of care from the referral, through acute services and into the community YEPS. Services highlighted the challenges associated with identifying and responding to the prodrome of psychosis and also reviewed the implication of providing three years of care on the size of caseloads and quality of care in this critical period.
Conclusion: Consultation between EPPIC Statewide Services and YEPS provided a constructive forum to discuss challenges and develop the foundation of effective services for young people with early psychosis.
OP70 STUDIES OF COMMUNTIY CARE AND STIGMA
WHERE MENTAL HEALTH IS HEADED TODAY-EXPERIENCES FROM BOSNIA AND HERZEGOVINA
Nermana Mehic-Basara, Amina Mehic, Ismet Ceric
Mental health always associates us on healthy spirit, pure thought, reasoning, and care for others. The most beautiful examples of humanity and also worse examples of human cruelty are seen simultaneously at one place during the recent war in Bosnia and Herzegovina, and showed what an human being can be to another.
In this paper we will present overcoming mechanisms for war caused disorganization of the health system and it's transformation into a contemporary model of community based psychiatry. Besides building of the numerous mental heath centers, goals for the Reform of Metal Health system in Bosnia and Herzegovina are primarily decentralization and sectorization of psychiatric services, comprehensiveness, equality, availability and intersectorial cooperation.
This research is descriptive, retrospective and analytical.
Achieved results within the implementation of the Reform are contained in the evaluation of functioning for the 40 Mental Health Centers in Federation of Bosnia and Herzegovina and 22 in Republic of Srpska.
We have received assistance to achieve primary goals from many international organizations such as World Bank, WHO, Swedish SweBiH, Health Net International from Holland, who were the true partners to the Ministries of Health of Federation of Bosnia and Herzegovina and Republic of Srpska, and also to the Expert group for the implementation of the community mental health strategy.
Nowadays, despite very difficult and complex political and economic situation, we can say that we have formed network of Community Mental Health Centers in the whole country, and thanks to this we have a role of country leader within the Stability Pact Project for the South East European Region.
DEINSTITUTIONALIZATION IN SINGAPORE
Cheng Lee
The care of mentally ill patients has shifted from mental state hospitals to the community. The move to community care emphasises on improving the quality of life for patients, destigmatising mental illness and promoting self-sufficiency. In Singapore, the Institute of Mental Health and Woodbridge Hospital (IMH/WH) is the main mental health service leader. The process of deinstitutionalization has progressed more cautiously in Singapore. Since early 2000, IMH/WH has transformed itself from a 3000 bedded hospital to the present 2000 beds. There is also emphasis in providing psychosocial rehabilitation programmes for both outpatients and inpatients. IMH/WH launches the Assertive Community Treatment (ACT) programme in 2003. The inpatient psychiatric rehabilitation programme focuses on symptom and medication management to equip patients with basic conversational skills to prepare them for living in the community.
There are also external agencies who have declared an interest in helping patients to reintegrate back into the society. They often bring along new and quite different perspectives on the needs of those with mental illness. Such organizations help to cover the service gaps in the areas of supported housing, vocational training, social rehabilitation and patient-support groups.
MENTAL HEALTH SERVICES IN DEVELOPING COUNTRIES: UNMET NEEDS AND MODELS OF SERVICE DELIVERING
Nahla Nagy
At the conclusion of this workshop participants should be able to:
Explain unmet needs for patients, their caregivers and working staff in the mental health field.
Recognize govermtal polices for community service planning. An Egyptian Experience.
Understand non govermental approach for rehabiltation for mental health patients.
Pakistan Model, Fountain House.
Summary: Mental health services in developing countries still lack national information from population studies, suffiecient and flexibility of distributing resources. The cultural concerns about stigma of mental illness opens the gate for traditional healers for interference with service delivery. Primary care physicians are not adequately trained to detect, refer and treat mild to moderate cases. There is weak coordination between the academic sector and the general health sector.
Integrated mental health services into primary care accompained with health education for both patients and health care providers help to increase the awarness and get best results from available resources for effective treatment and prevention.
Fountain house in Lahore, Pakistan is a residential place for rehabilitation of mentally ill, totally run by nongovermental funds as a successful model for community health services.
DOES STIGMA KEEPS PERSONS WITH SCHIZOPHRENIA AWAY OR ON PSYCHIATRIC TREATMENT?
Terence Yow
Persons with mental illness not only have to cope with their illness, they have to carry the additional burden of stigma, which is extremely crippling.
This quantitative study follows 90 respondents with schizophrenia over a one-year period to understand how they may differ in the way they perceive and feel about stigma and how it affects their compliance towards psychiatric treatment.
Using the “Perceived Devaluation-Discrimination Scale”, respondents perceived stigma to have an impact on their employment, social interaction and self-esteem. The “Feelings Related to Stigma Scale” shows that respondents strongly feel misunderstood by others and feel different and ashamed because of their illness.
The results show no significant co-relationship when stigma is correlated with chronicity and psychiatric relapse. This implies that their length of treatment and the number of hospitalization does not affect the way they perceive stigma.
There is a significant positive co-relationship between respondents’ perceive stigma and their compliance to treatment. This reflects that patients are more compliant to treatment when they have a higher perception of stigma.
In my earlier study, secrecy is a highly endorsed coping strategy among patients with schizophrenia. Compliance to treatment may help patients remain symptom-free and more effectively keep their illness a secret. There is as such great motivation to remain on treatment, so that they are able to better integrate into society.
The study challenges existing mental health practices and propose strategies to clinical intervention, advocacy, public education and social policies.
THE IMPACT OF CHANGING THE TERM FOR SCHIZOPHRENIA ON THE IMPLICIT ATTITUDE AMONG THE GENERAL PUBLIC IN JAPAN
Hidehiko Takahashi, Takashi Ideno, Shigetaka Okubo, Hiroshi Matsui, Kazuhisa Takemura, Eisuke Matsushima, Masato Matsuura, Motoichiro Kato, Kunihiko Asai, Yoshiro Okubo
Background: The Japanese Society of Psychiatry and Neurology decided to change the term for schizophrenia from “seishin bunretsubyo”, explicitly indicating ‘mind-split disease’, to “togo shitchosho”, literally meaning ‘dysfunction of integration’. The former term has been said to lead the public to the misunderstanding and stigmatization of individuals with schizophrenia. Most stigma research relies on questionnaires that require individuals to report personal beliefs. This information is useful but is subject to response bias from social desirability. One measure designed to minimize response bias is the Implicit Associations Test (IAT), the method widely used to assess implicit attitudes associated with many characteristics, including age, race, gender.
Aims: We aimed to examine the impact of changing the term for schizophrenia on attitudes for schizophrenia among college students in Japan using explicit and implicit measures.
Methods: To assess explicit attitudes, 24 participants rated their attitude about mental illness by Link's devaluation-discrimination-scale. A computerized version of the IAT was used to assess automatic associations of “seishin bunretsubyo” with “criminal” vs. “victims” relative to “diabetes”. Another version in which “seishin bunretsubyo” was replaced by “togo shitchosho” was also tested.
Results: There is no significant correlation between explicit scale and IAT measures. Old term “seishin bunretsubyo” was strongly associated with “criminal” vs. “victim” than diabetes. This association of new term “togo shitchosho” was significantly weaker than that of old term.
Conclusion: The strategy of changing the term for schizophrenia seems to be successful in tempering negative bias for this disorder in Japan.
RENAMING SCHIZOPHRENIA
Toshimasa Maruta, Makio Iimori
In 2002, The Japanese Society of Psychiatry and Neurology changed the official name of “schizophrenia” (seishinbunretsu-byo: split mind disease) to a term meaning “loss of coordination disorder (to-go-schitcho-sho)”. This was officially recognized by the Japanese Ministry of Health and Welfare in 2005, and the former term is now no longer in use. The effect of merely changing a possibly stigmatic term to something new may be moot, yet there has been discussion on whether a change in the English terminology would be clinically and scientifically desirable.
To attempt to gain insight into the thinking concerning this point among international psychiatric authorities, we carried out a questionnaire, sent to members of the Section on Classification, Diagnostic Assessment and Nomenclature of the World Psychiatric Association. Only approximately 25% responded, perhaps because of the sensitive/political/clinical implications of the main question – whether the term “schizophrenia” is stigmatic and should be changed. Of the 50% who did respond, a slightly greater number (10, 50%) wished the term to be changed than those who did not (35%) and 2 (10%) gave ambiguous answers and 1(5%) gave none.
However, regardless of whether the respondents were for, against, or equivocal, there was a strong common refrain – there must be greater education of the public concerning the varieties of conditions that this term (or its successor) is used to cover. The comments of all the responders (psychiatry experience 5–50 years) indicated that this is an extremely important topic in terms of improving patient care in future.
OP71 PERINATAL PROBLEMS FOR INFANTS AND MOTHERS
THE NEURO-COGNITIVE DEVELOPMENT OF CHILDREN FOLLOWING IN UTERO EXPOSURE TO ANTI-DEPRESSANTS: OUTCOMES AT BIRTH AND 18 MONTHS
Megan Galbally, Helena Sandahl, Andrew Lewis, Anne Buist, Elaine Kelly, Amanda Williamson, Gillian Opie
Background: This paper presents findings from the Victorian Registry for Psychotropic Medication in Pregnancy (VPR). The VPR was established in 2004 as a means of collecting data on patients taking antidepressant medication in pregnancy and the postpartum period. It is based at the Mercy Hospital for Woman, Melbourne.
Aims: The aim of this study is to determine whether there are long lasting effects on children of exposure to antidepressant medication during pregnancy and thereby enhance the treatment options for women suffering from depression.
Methods: A prospective controlled study was conducted which recruited 34 women taking anti-depressant medications (SSRIs, SNRIs and NaSSAs) and an equal number of non-medicated pregnant women to act as a control. Measures of maternal depression, coping, service use and medication dosage were taken antenatally and compared to measures of neonatal withdrawal at birth, and cognition, motor, language and behavioural adjustment at 18 months of age.
Results: Neonatal results confirm previous findings that antidepressants do not seem to be associated with teratogenesis. Medium differences were found in neonatal weight. Large differences were found in neuro-behavioural symptoms suggesting that infants may be experiencing serotonin discontinuation syndrome which resolved at one month follow up. Data from the 18 month follow are currently being analysed.
Conclusions: Treatment options for antenatal depression should be carefully considered in the light of the impact of in utero exposure to anti-depressants leading to possible neuro-developmental sequela. These need to be balanced against the documented impact of poorly treated post-natal depression for both mothers and their children.
NEUROCOGNITIVE EFFECTS OF PRENATAL EXPOSURE FOLLOWING THE CHERNOBYL ACCIDENT
Tatiana Loganovskaja, Konstantin Loganovsky, Stanislav Nechayev, Yekaterina Antipchuk, Mariya Bomko
Background: The UN Chernobyl Forum has outlined that effects on the developing brain must be at the focus of particular attention as since the developing brain is extremely radiosensitive.
Aims: To assess the cognitive and neurophysiological effects in children irradiated in utero as a result of the Chernobyl accident.
Methods: 100 children acutely exposed in utero as a result of the Chernobyl accident and 50 their non-exposed classmates were examined at age of 11–13 years old with clinical neuropsychiatric tests, psychometry (WISC), conventional and quantitative EEG, and visual evoked potentials. Individual prenatal doses of internal exposure were reconstructured for all examined children by ICRP Publication 88. Individual prenatal doses of external exposure were reconstructured using real dosimetric data (dose rate, behavior factor, etc).
Results: Exposed children had more neuropsychiatric disorders, left brain neurological signs, minor physical anomalies, lower full scale IQ and verbal IQ, IQ discrepancies with verbal decrement, disorganized EEG-patterns with pathological activity lateralized to left fronto-temporal area, excess of lateralized to left fronto-temporal region delta- and beta-power with depression of tetha- and alpha-power, and interhemispheric inversion of the visual information processing. Together with confounding factors, mother's mental health, and stress, prenatal irradiation contributed to these effects.
Conclusion: Dose-related characteristic cognitive and neurophysiological features may testify to disrupted development of dominant brain hemisphere following prenatal exposure to ionizing radiation as a result of the Chernobyl accident. Prenatal brain damage is discussed at the frame of neurodevelopmental hypothesis of schizophrenia as one of implication.
A NEW VENUE FOR SUICIDE PREVENTION – IMPLICATIONS FOR PRE-AND POSTNATAL CARE
Ellenor Mittendorfer Rutz
Context: Besides the well known risk factors for youth suicidal behaviour, evidence from different cohort studies suggest that risk for suicidal behaviour can be determined even very early in life, namely during the prenatal and perinatal period.
Objectives: The paper will both mention the various studies analyzing early life exposure and youth suicidal behaviour as well as discuss models for prevention.
Key messages: Several parental factors like low maternal education, teenage and single parenthood, multiparity and prenatal, maternal psychopathology and substance abuse have been linked to an increase in youth suicidal behaviour. In addition low birth weight and short birth length adjusted for gestational age were found to increase the risk for suicidal behaviour, particularly by violent means. Relations between pre-and perinatal complications, and later suicidality, could be due to neurodevelopmental impairment, increased vulnerability to environmental stressors and modified programming of hormonal systems particularly an alternation in serotonin.
Conclusions: Various forms of programs for early intervention during ante- and post-natal care in this group of psychosocial risk pregnancies are available. Experience from intervention studies show that various predictors of suicidal behaviour like psychiatric symptoms and poor cognitive development could be improved by early intervention for infants with low birth weight and preterm birth coming from psychosocial risk families. Effective collaboration between the various sectors within health care and social services is crucial for early detection and adequate intervention with regards to the psychosocial and mental problems the children of parents with mental illness and suicidal behaviour may have to face.
COMPARISON OF MATERNAL FETAL ATTACHMENT BETWEEN PRIMGRAVIDAS AND PREGNANT WOMEN WITH PREVIOUS FETAL OR NEONATAL DEATHMASHAD UNIVERSITY HEALTH CENTER, YEAR 2006
Simin Taavoni, Mina Aahadie, Tahereh Ghanjie, Fatemeh Hoseinie
The previous fetal or neonatal death may have a negative effect on the adaptation of a woman for her new pregnancy.
Aim: To assess and comprise maternal fetal attachment (MFA) of primgravidas and pregnant women with previous fetal or neonatal death.
Methods: A tow-group comparative design and non randomized sampling method (sequential) was used. We collected 120 Iranian pregnant women, who were in the 3rd trimester of their planned current pregnancy, with a basic education and between the ages of 20–40 years. 40 of samples had previous fetal or neonatal death (without any live child) and 80 of them were primigravidas women. The tools of this study had two main parts: personal demographic and pregnancy information form, and MFAS.
Results: A significant difference was found in the 5 subscales of the MFAS between the primigravidas and pregnant women with previous fetal or neonatal death. The average of maternal fetal attachment in the primigravidas women was more than second group. The independent t-test also showed a significant difference between two groups (p = 0/000).
Coclusion: Due to decrease of maternal fetal attachment in the pregnant women with previous fetal or neonatal death, it sounds it is necessary to plan supportive, educational, guidance, and counseling program for the mentioned high risk group.
PERINATAL MENTAL HEALTH: A CRUCIAL DETERMINANT OF INTERNATIONAL DISPARITIES IN MATERNAL MORTALITY AND MORBIDITY
Jane Fisher
Context: WHO's Making Pregnancy Safer Initiative addresses economic, sociodemographic, health status and health service factors associated with pregnancy-related mortality and morbidity. Pregnancy illness and childbirth complications are the most prominent risks to life, but there is little consideration of mental health as a determinant of maternal mortality and morbidity. Most perinatal mental health research is from rich industrialised countries. The estimated prevalence of 10%–15% Major Depression in pregnant women and mothers of newborns is cited widely. Ethnographic studies in developing countries conclude that culturally prescribed peripartum customs, giving dedicated care, honoured status; relief from normal responsibilities and social seclusion for mother and newborn are psychologically protective.
Objectives: The objective was to review the available evidence about the prevalence and determinants of common perinatal mental disorders in low income countries.
Key messages: A systematic review found that mental health makes a substantial contribution to maternal mortality and morbidity in resource poor countries. Suicide is a notable cause of maternal mortality and perinatal depression is two to three times more common than in rich countries. Prevalence is highest among the poorest women with least access to health services. Risk factors include lack of reproductive choice and unwanted pregnancy, crowded living conditions, criticism, coercion or violence in intimate relationships, gender disparities in access to education and employment, cultural preference for male children and poor physical health, in particular iron deficiency and anaemia.
Conclusion: International disparities in maternal mortality and morbidity require the integration of mental health into Making Pregnancy Safer Initiatives.
OP72 SUICIDE PREVENTION
SEPARATION AS A POWERFUL RISK FACTOR FOR SUICIDE
Diego De Leo
Introduction: While separation appears to be a major risk factor for suicide, there is currently limited information on this issue. This study investigated the effects that marital status, age and gender may have on suicide risk.
Methods: The risk of suicide by marital status, age and gender was determined by a maximum likelihood, linear regression model which compared the Queensland population to the Queensland Suicide Register, a large dataset of all suicides during the period 1994–2004. The likelihood of dying by suicide was estimated against the reference group of married females aged 65+.
Results: Separation, for males and females, represented the highest risk for suicide, with the relative risks for separated males and females being at least 4 times higher than any other category. The relative risks for separated males was particularly high. For males in the age group 15–24 the relative risk was up to 22 times higher and in the age group 25–44 eleven times higher than the reference population. While the difference between males and females dropped in the 45 to 65 year-old age group, the risk for males still remained more than five times higher than in females. This study did not find any evidence that a pre-existing psychiatric illness could (even partly) explain these associations.
Discussion/conclusions: The study highlighted a great variation in the relative risks across different age and marital status groups, which suggests that the impact of age, gender and marital status on suicide risk should not be studied in isolation. Furthermore, the process of separation may play an important role in the development of suicidal thoughts and behaviours. While different theories have been forwarded to explain these associations, there is currently limited empirical data on this issue. Considering the current increase in divorce rates and de facto ‘marriages’, and the large proportion of suicides that are associated to relationship breakdowns, a better understanding of how the transition from marriage to separation and/or divorce may affect the development of suicidal behaviours could have a powerful effect in reducing suicide rates.
SUICIDAL BEHAVIOUR IN QUEENSLAND RAIL SYSTEM
Diego De Leo
Introduction: Although statistically rare, rail suicide is a highly lethal method, with reported fatality rates as high as 71%–94%. Fatal and non-fatal suicidal behaviour though this method in Queensland are the object of this presentation.
Method: Data were obtained from the Queensland Suicide Register, with the co-operation of QLD Rail.
Results: Over the period of 1990–2004, 8,220 suicides were recorded in the Queensland, including 161 suicide incidents on the QLD Rail network (mean suicide rate 0.32 per 100,000). On the average, there were 11 suicides per year, and despite some fluctuations in annual numbers of cases, no significant increasing or decreasing trends were observed. Males comprised the majority of rail suicides (79.5%) and the mean age of a person dying in a result of collision with a train was 32.1 years of age (age range of 14 to 82 years). 40.4% of victims had at least one known psychiatric diagnosis. Also, almost half of rail suicides had a known history of inpatient or outpatient psychiatric treatment (20.5% and 24.8%, respectively). Almost half of rail suicides died while lying or sitting on track (47.2%). Time of the day, day of the week, and seasonal patterns are also discussed. Eighteen cases of suicide attempts resulting in injury were recorded over the period of 1993–2006 (mortality rate of 88.7%). Other non-fatal suicidal behaviour included 70 cases of aborted suicide attempts and 67 cases of suicide threats. The estimated average cost of a suicide incident to the Qld Rail Passenger Services Group is $11,607.16.
Conclusions: A number of recommendations derived from this study and will be presented.
INTERVENTIONS TO PREVENT SUICIDE AND SUICIDAL BEHAVIOUR: A SYSTEMATIC REVIEW
Wally Barr, Maria Leitner, Lindsay Hobby
Background: In December 2002 the Scottish Executive launched Choose Life, the National Strategy and Action Plan to prevent suicide in Scotland. To support this, a literature review was commissioned from a British research team to identify and evaluate available interventions to prevent suicide and suicidal behaviour. The resulting systematic review commenced late in 2005 and finally reported early in 2007.
Aims: The overall aim was to provide a comprehensive systematic review of international research evidence on the effectiveness of interventions aimed at preventing suicide and suicidal behaviour.
Methods: The review followed the core principles of systematic review methodology.
Results: A Scoping Review was first conducted to provide a narrative overview of the nature and structure of the available literature in this area, together with quantitative information on patterns observed in the literature. A total of 200 primary empirical studies and 37 prior systematic reviews met the full inclusion criteria for the review and a Final Report was drawn up. This incorporated the key outcomes and messages to be taken from the Scoping Review, together with outcomes from the more in-depth exploration of the highest quality data currently available.
Conclusion: The review represents the most comprehensive overview of the intervention literature currently available. This paper will outline the main findings of the review, focusing on the very broad range of interventions that have been found to be the most and the least effective in preventing suicide and suicidal behaviour.
SELF HARM IN FIRST EPISODE PSYCHOSIS: FINDINGS FROM THE ÆSOP STUDY
Samuel Harvey, Kimberlie Dean, Craig Morgan, Elizabeth Walsh, Paula Dazzan, Kevin Morgan, Tahina Lloyd, Paul Fearon, Peter Jones, Robin Murray
Background: Self harm is a predictor of future suicide in individuals with schizophrenia. There is limited knowledge about self harm amongst those with psychosis, especially individuals with affective psychosis and those in the early stages of their illness.
Aims: We aimed to establish the prevalence, nature, motivation and risk factors for self harm in individuals with first episode psychosis.
Methods: Episodes of self harm were identified amongst those recruited to the ÆSOP study. The prevalence of self harm occurring in the context of a first psychotic episode was established. The nature and motivation for such self harm was described and a range of potential risk factors were examined.
Results: Of the 498 participants, 56 (11.2%) had engaged in self harm between the onset of psychotic symptoms and their first presentation to services. The independent correlates of self harm were: belonging to social class I or II, having a diagnosis of depressive psychosis and suffering a period of untreated psychosis longer than 66 days. Increased insight was also associated with risk of self harm. With the exception of depressed mood, individual symptoms did not influence the risk of self harm.
Conclusions: A significant number of patients with first episode psychosis were found to have engaged in self harm. A different set of fixed and malleable risk factors appear to operate in those with first episode psychosis compared to other patient groups. Reducing treatment delay and modifying disease attitudes may be key targets for suicide prevention in this group.
REASONS AND PSYCHOSOCIAL STRESSORS IN PARASUICIDES
Ehab Sorketti
Objective: The aim of this study is to compare between self-poisoners and self-cutters in term of:
The sociodemographic profiles.
The clinical presentation.
The psychosocial stressors, motives and reasons for attempted suicide.
Method: In a sample of 77 patients admitted to UMMC, who had completed a questionnaire and a self-report, those who had deliberately cut themselves (n =25) were compared with those who had taken overdoses or a poison (n =52).
Results: More patients who cut themselves than those who took overdoses said they wanted to die (56.7% versus 43.2%, p<.001) and wanted to find out if someone loved them (7.7% versus 92.3%, p = 0.03). Self-cutters were more likely than self-poisoners to say that they had wanted to punish themselves (66.7.0% versus 33.3%, p = 0.009). and (73.1%) self-Poisoners tried to get relief from a terrible state of mind versus (26.9%) Self-cutters, p=.018). The age- and sex-specific suicide rates for women were highest in the 20–24-year-old age group. In this study we found that self-poisoners tend be diagnosed as adjustment disorder P = 0.001 as in Table 2, we found that twenty-four patients who attempted suicide had major depressive disorder (MDD), and 38 patients who harm themselves are diagnosed as adjustment disorder.
Conclusions: There are differences between the’ motives for overdoses and for self-cutting. The often impulsive nature of these acts (especially self-cutting) means that prevention should focus on encouraging alternative methods of managing distress, problem-solving, and help-seeking before thoughts of self-harm develop.
UTILISATION OF SERVICES AND UNMET NEEDS IN SUICIDE COMPLETERS
Johanne Renaud, Monique Seguin, Alain Lesage, Gustavo Turecki
There exists little systematic research, with the exception of audit and coroner's reports or media scandals following a suit, on the adequacy of services for youths at risk of suicide. We measured the utilisation of services and unmet needs in the past twelve months of the lives of 12–25 year-old suicide victims and normal controls in the province of Quebec, Canada. Using the psychological autopsy method, we established diagnosis and determined the needs for services at the individual, program and system levels according to a panel of experts. Our preliminary results (n = 24; suicide completers; n = 13; controls) show expected high psychopathology rates such as mood disorders (46.6%), substance abuse/dependence (48.3%), and personality disorders (48.8%) in suicide completers. Prevalence rates for services utilisation in the past year showed that 25.0% of suicide completers had been in contact with 1st-line medical services (15.4% in controls), 29.2% with school/psychosocial professionals (15.4% in controls), 20.8% with specialist mental health and addiction services (0% in controls), and 4.2% with voluntary sector (0% in controls). Contrasts with needs for services demonstrated that 54.2% of suicide completers should have received 1st-line medical services (15.4% in controls); 50.0%, school/psychosocial services (7.7% in controls); and 45.8%, specialist mental health and addiction services (0.0% in controls). In conclusion, unmet needs are high for specialist mental health and addiction services in suicide completers, but also for 1st-line medical and school/psychosocial services. Programmatic and systemic unmet needs for improved coordination and continuity of care and training are also highlighted.
OP73 TREATMENT EVALUATION/HUMAN BEHAVIOURS
PREVALENCE, COURSE AND RISK FACTORS OF DISORDERED EATING DURING PREGNANCY AND IN THE POSTPARTUM PERIOD
Antoinette M. Lee, Siu Keung Lam, Stephanie Sze Mun Lau, Hang Wai Chui, Daniel Yee Tak Fong, Chi Wai Kwan, Catherine S. Y. Chong, Lawrence C. H. Tang
Background: Eating disorders are most prevalent among women of childbearing ages. Yet little is known of this problem among pregnant women. Nevertheless, pregnancy is a high-risk period given the inevitable weight gain and body shape changes, and the enormous developmental challenges faced by pregnant women.
Aims: Our study examines the prevalence and course of disordered eating across different stages of pregnancy, and identifies its risk factors among pregnant women.
Methods: Using a prospective longitudinal design, 384 pregnant women attending a regional hospital in Hong Kong were assessed with the Eating Attitudes Test-26, the EDI Body Dissatisfaction subscale, and the Hospital Anxiety Depression Scale at first clinic presentation. They were reassessed during the second and third trimesters, and at 6-weeks and 6-months postpartum.
Results: About 5.1% and 5.5% of women had antenatal and postpartum disordered eating respectively in at least one assessment. Prevalence was highest in first trimester (3.9%) and at 6-weeks postpartum (5%). Symptoms generally decreased from first to third trimester but increased sharply at 6-weeks postpartum, decreasing again at 6-months postpartum. Body dissatisfaction was the strongest risk factor in nearly all stages. Depression increased the risk in the antenatal stages. Surprisingly, weight gain and BMI were not predictors in any stage.
Conclusions: Disordered eating among pregnant women is common but often overlooked. It is more associated with subjective body dissatisfaction and depression than with objective indices of weight changes. Partnership between psychiatrists and obstetricians should be encouraged in addressing this important problem which affects both the mother and the baby.
THUMBSUCKING AND MAMMALIAN ONE-TEAT PREFERENCE
Elsie Mobbs
The logical flaws in the current explanations of fixated thumbsucking are:
The need to suck: This does not explain why infants fixate on one sucking object, one digit out of ten, and will refuse replacement sucking objects.
Hunger: There is no nutrition in thumbs, and thumbsucking will also occur after feeds.
It is necessary normal development: Margaret Mead, Anthropologist, noted that in societies where babies have free access to the breast then thumbsucking does not occur.
It does no harm: Skin excoriation and facial malocclusions which occur are not uncommon problems resulting from thumbsucking.
It occurs as part of learning: The emotional fixation on the one chosen sucking object, self-sucking, is mirrored across the mammalian spectrum if animals are human reared. Self-sucking was a behavioural feature of the infant monkeys in the Harlow experiments when deprived of maternal care.
The phenomenon of mammalian oral imprinting is a better explanation for thumbsucking.
“Bonding” is adult social behaviour. “Attachment” is behaviour of the older infant who recognises the mother as being differentiated from the environment. Mammalian “imprinting” is behaviour of the newborn and is an emotional oral attachment to a part of the mother.
A premature mammalian oral imprint can occur evidenced by babies born with sucking callouses on the chosen digit: this would be a fatal pathology for mammals other than problem solving human mammals. One-teat preference is exhibited across the mammalian spectrum.
ADDITIONAL ADJUNCTIVE TREATMENTS REQUIRED FOR CESSATION OF BENZODIAZEPINE USE AS CURRENT APPROACHES DO NOT IMPROVE OUTCOME
Jan Parr, David Kavanagh, Ross Young, Geoffrey Mitchell
Background: A qualitative study of benzodiazepine users who were prescribed benzodiazepines by their General Practitioner (GP) typically found that within a short period of time of commencing, they felt addicted because of adverse symptoms when they tried to stop them. The same study also identified that some GPs were more likely to maintain prescribing if the patient was dependent on the drug or displayed little motivation to change.
Aims: A range of approaches have been trialled to assist individuals to cease long-term benzodiazepine use, however, there is little information available on the effectiveness of those approaches. A meta-analysis was undertaken to assess whether there was any relationship between the various approaches and cessation rates.
Methods: The studies included in the meta-analysis compared adjunctive treatment, either additional medication or the use of psychological skills training with gradual dose reduction alone. An assessment of the quality of the studies was also undertaken.
Results: Current adjunctive treatments do not provide individuals with a greater chance of ceasing benzodiazepine use than can currently be achieved through a gradual dose reduction program alone. There was no relationship between the quality rating of the studies and the cessation rates reported.
Conclusion: Additional comprehensive treatment approaches are required if a greater number of individuals who wish to cease long-term benzodiazepine use are able to do so.
DOSED VERSUS PROLONGED EXPOSURE IN TREATING FEAR: EMERGING EVIDENCE OF A LESS AVERSIVE TREATMENT ALTERNATIVE
C. Richard Spates, Stacey Waller, Ellen Koch, Sophie Rubin, Katherine Porter, Kellie Edmonds, Lauren Frye, Jennifer Ritter
Background: Prolonged Exposure (PE) represents a well-researched empirically supported therapy for PTSD and other anxiety disorders. Yet several investigators along with selected clinical observations indicate it is less chosen by therapists as a treatment of choice. Its standing as empirically supported therefore has not enhanced its selection as a preferred frontline intervention.
Aims: The present line of research sought to determine if any advantages accrue to Dosed Exposed (DE) versus PE and to supply explanations of observed differences based on current theory.
Methods: The first investigation (A) assigned forty adults diagnosed with social phobia to analogue models of either imaginal versions of prolonged exposure (PE), dosed exposure (DE), enhanced dosed exposure (EDE), or negative ITI dosed exposure (NDE).
In a follow-up study (B) the previous procedures were replicated and a mindfulness-enhanced DE strategy was evaluated. In a third investigation (C), in vivo DE was compared to in vivo PE.
Results: Study A found habituation was achieved for each of the four conditions, however DE and EDE produced results with less overall aversive arousal for clients.
Study (B) replicated the previous findings and the mindfulness strategy further enhanced outcomes for DE.
Study (C) showed both interventions were efficacious but DE offered advantages of more simultaneously uniform effects across all dependent measures.
Conclusions: Dosed exposure produced results in the treatment of social anxiety comparable to prolonged exposure, but with additional advantages. The results challenge presumptions held for PE concerning the necessity of sustained aversive arousal. Implications for drop-out and acceptability are discussed.
OP74 DEVELOPMENTS IN ACUTE MENTAL HEALTH CARE: TRIAGE
IMPROVING CARE OF PERSONS WITH MENTAL HEALTH CONCERNS IN AN EMERGENCY DEPARTMENT WITH THE INTRODUCTION OF A MENTAL HEALTH TRIAGE AND CRISIS COUNSELLOR: AN EVALUATION
Evelyn Vingilis, Kathleen Hartford, Kristine Diaz, Beth Mitchell, Raj Velamoor, Marnie Wedlake, Dawn White
Background: The past three decades have seen changes in service provision for persons with mental health concerns. Two changes were the increasing role of the general hospital emergency department (ED) as gatekeeper of the mental health service system and the decreasing importance of psychiatric hospital admission units. Moreover, the gatekeeper and service provision functions have also evolved. Past ED treatment decisions were to hospitalize or not while, in recent years, persons with mental health concerns could have access to a comprehensive array of inpatient, outpatient and community services. Concomitant with service provision changes, the rates, scope and complexity of needs of persons with mental health concerns attending EDs have been increasing. In response to this, the London Health Sciences Centre in Ontario, Canada, developed a partnership with the London Mental Health Crisis Services to introduce a mental health triage and mental health crisis counsellor in ED.
Aim: To evaluate an ED's use of a mental health triage and crisis counsellor for persons presenting with mental health concerns.
Method: Mixed method (qualitative and quantitative), multiple measures.
Results: Significant pre- and post-intervention reductions for wait time, security incidents and hospital admissions were found. Follow ups with a community agency, medications and a psychiatrist increased post-intervention, while follow ups with detox decreased post-intervention.
Conclusions: The qualitative and quantitative findings are congruent with other studies supporting the use of properly implemented mental health triage and crisis counsellors to improve the care of persons with mental health concerns.
HOW ARE OUR PATIENTS? RESEARCH FOR COURSES AND OUTCOMES FOR PATIENTS AFTER THEIR FIRST HOSPITALIZATION IN ACUTE MENTAL DISEASES UNIT
Maria Cristina Turola, Francesca Bergami, Vasiliki Kotrotsiou, Simona Venturini, Paolo Verri
Italian Law dating back at 1978 reformed the psychiatric assistance, leading to the closure of mental hospitals giving place to local assistance. Now there are psychiatric units called SPDC, dedicated to severe and critical pathologies, provided with 15 beds, in main hospitals.
The SPDC of Ferrara, established from 1979, providing assistance to 350 000 inhabitants, has carried out in 28 years 10611 hospitalizations involving 3753 patients.
The unit cooperates togheter with local assistances, day centers and local rehabilitative residences. Every patient history in every single premise is recorded in an unique computerized system.
The purpose is to analyze the course of every single patient and of groups of patients after the hospitalization, in order to study the outcomes and highlight possible positive or negative prognostic and therapeutic factors.
Quantitative parameters such as further hospitalization, total amount of time spent in hospital, therapies carried aout, type and intensity of assistance, possible deaths and its causes are all taken in account. Moreover, through provided schedules, present-day conditions, living standards, social and working environment are assessed, valuing patient's opinion, the one of their family and that of the team.
Results prove the efficacy of the psychiatric assistance model granting privilege to local assistance, minimizing the hospitalization.
A REVIEW OF 1664 CONSECUTIVE ADMISSIONS TO ACUTE ADULT INPATIENT PSYCHIATRIC UNITS AT SOUTHERN HEALTH
Michael Wong
Background: Timely delivery of quality service to people in crisis (WHO Collaborating Centre for Evidence in Mental Health Policy: Acute Inpatient Psychiatric Care, 2003) through a multidisciplinary team approach (Firth-Cozens, 1998) involving consumers and carers (Epstein & Wadsworth, 1994) and in collaboration with community service providers and stakeholders (Rohde, 1997) is a clinical goal that is evidence based but difficult to achieve in real clinical setting.
Aim: The study aims to characterize admissions/separations to/from acute inpatient psychiatric units in the post-deinstitutionalization era.
Method: Clinical Management Interface (CMI) data at Southern Health Adult Mental Health Program between 1 July 2004 and 30 June 2005 were analyzed retrospectively (number of admissions, length of stay, diagnosis, Mental Health Act status and case management).
Results: There were 1664 separations during the study period, involving 1196 patients. Half of them were discharged within 2 weeks and 25% stayed more than 4 weeks. Nearly 75% were admitted only once and about one in ten were admitted 3 times or more. Nearly 60% suffered from a psychosis. Two out of three were admitted involuntarily and more than 40% were discharged on a Community Treatment Order. Only 25% were linked to a case manager on discharge.
Conclusion: The acute inpatient psychiatric units are serving very unwell patients under very challenging conditions nowadays. The data highlight the presence of special patient subgroups that require the use of specific management strategies.
PARTNERSHIPS: PSYCHIATRISTS IN PRIVATE PRACTICE AND OUTREACH TREATMENT
Marion Grimwade, Deidre Smith, Sybil Gibson, Rowan McIntosh, Isaac Schweitzer
Context: The Melbourne Clinic provides psychiatric clinical treatment via an Outreach Program for the patients of psychiatrists in private practice over the whole of metropolitan Melbourne. The Outreach Program provides general and specialist services to a caseload of 300 both privately insured and compensable patients. The Program was established in 1999 with the support of health insurance companies and the Commonwealth of Australia to improve the continuum of care and reduce reliance on in-patient treatment.
Objective: The current project aimed to firstly evaluate the impact of the Outreach Program on bed days used, frequency of admissions and length of stay at three psychiatric clinics linked with The Melbourne Clinic. The second aim was to assess the willingness of psychiatrists in private practice to accept referrals of patients with complex needs. And finally the project sought to assess the patient's, carer's and psychiatrist's satisfaction with the service.
Key messages: The provision of Outreach Program has reduced the bed-day stay thereby reducing the cost of health care. It was found that psychiatrists feel supported in managing complex cases in the community consistently rating over 80% satisfaction and referrals usually increase once they have experienced the partnership. Patients rated the service highly and carers generally felt satisfied with the support.
Conclusion: Combining outreach community based care with the treatment offered by psychiatrists in private practice can substantially reduce the cost of psychiatric care and it is a component in the continuum of care is highly valued by psychiatrists, patients and carers.
A PUBLIC PRIVATE PARTNERSHIP IN PSYCHIATRY – AN OPPORTUNITY TO MAKE A DIFFERENCE
Deidre Smith, Peter Doherty, Amgad Tanaghow, Chris Brooks, Issac Schweitzer
Background: A key platform of the Australian Second National Mental Health Plan and National Standards for Mental Health Services was the development of public private partnerships in psychiatry (PPP). Whilst acknowledging the importance of this strategy a recent study noted a number of significant barriers for example; communication, role identification and responsibilities. Notwithstanding this a new pilot PPP was devised which involved the allocation of three beds in a private psychiatric facility – The Melbourne Clinic; for use by public patients.
Aims: The study aimed to examine the characteristics of the first eighty consecutively admitted public patients and the expectations and attitudes of the multidisciplinary staff team caring for the patients during their inpatient stay.
Method: Public patients who met the inclusion criteria were referred from a centralised point within a primary mental health team for inpatient treatment under the care of a designated psychiatrist. A retrospective audit of the patient's medical record was undertaken and compared to similar group of private patients matched for age and gender. A short questionnaire was designed specifically for the study to elicit staff opinions.
Results: Whilst there was considerable initial anxiety amongst staff the results showed that the project had been very successful despite the high levels of co-morbidity, acuity and suicidal ideation/behavior in the patients.
Discussion: PPP health related projects have proliferated globally in recent years with mixed results but they have been external to psychiatry. It appears however that the provision and experience of this PPP has been both effective and rewarding.
OP75 MENTAL HEALTH SERVICES IN LOW AND MIDDLE INCOME COUNTRIES: UNDER-RESOURCED, UNDER-PERFORMING?
Digvijay Goel
The inadequacies of mental health services in low and middle income group (LAMI) countries is often attributed to inadequate allocation of resources. This may not be wholly true. Experience in India suggests that a top-down approach to planning, divorced from ground realities, poor governance, managerial incompetence and unrealistic expectations from low-paid/poorly motivated primary health care personnel play an important role and may result in the failure of even adequately funded programmes. The ambitious National Mental Health Programme (NMHP), launched with great fanfare in 1983 and aimed at providing basic mental health service through the existing primary health care system, using the Bellary model, failed to achieve any of its targets over the subsequent decades. In early 2001 the NMHP was radically revamped, with over seven-fold increase in budgetary allocation, and was re-launched as part of the country's 10th Five Year Plan (2002–2007) with high expectations. Unfortunately, however, the programme faltered on the rocks of techno-managerial underperformance and the initial momentum was lost. The reasons for this failure are analysed from an insider's perspective and possible remedial strategies for the future suggested. While the experience documented in the paper is country-specific and relates to India, a nation of over one billion people with one of the fastest growing economies in the world, it may have useful lessons for other LAMI countries.
CLINICAL PATHWAYS ENHANCE CARE AND CLINICAL OUTCOMES IN A TERTIARY PSYCHIATRIC HOSPITAL
Ying Mee Mok, Rathi Mahendran
Background: The hospital first introduced its clinical pathway (CP) in 2002 to 1. provide coordinated, safe and quality care and 2. have measurable evidenced based practices.
There are eleven CPs now.
Aim: To describe the role of CPs in enhancing care and clinical outcomes.
Method: Data from CP (2003 to 2006) were evaluated for number of patients placed on pathways, length of stay (LOS), unplanned readmission rates and resource utilization.
Results: Over the 3-year period there was a significant increase in the use of CPs for clinical care, for example, 732 to 1683 CPs for relapsed schizophrenia. Overall increase was 69.2%. Besides this, there was a decrease in the average length of stay (ALOS) for patients with various diagnoses. For example, for those on the Relapsed Schizophrenia CP, ALOS fell from 21.1(2004) to 20.1 days (2006), for Major Depression CP 10.2(2004) to 7.7 days (2006) and for Mania/Hypomania CP 15.5(2005) to 13.5(2006). The decrease in ALOS resulted in review of clinical programs to make them relevant to patients’ needs; for example the Alcohol Dependence Program was reduced from 28 days to 21 days. The rate of readmission within 28 days of discharge from hospital (unplanned readmission) was 4.74% (2004) 3.9% (2006) and 3.7% (2006). This is below the hospital's KPI of 9%.
Conclusion: CPs cannot replace clinical judgment but they enhance care and outcomes. CPs encourage multidisciplinary teams to work together to draw up care plans to deliver effective care to the patient.
CONSUMER AND CARER-LED SERVICE QUALITY EVALUATION PROJECT
Rosemary Callander, Anna Crowley, Lei Ning, Pam Brisbane, Bianca Childs, Tony Salter
While consumer involvement in mental health service delivery has increased in the past 20 years, there are few examples of consumers’ and carers’ involvement in the evaluation of mental health services that go beyond responding to questionnaires or taking part in focus groups. In August 2006 the Victorian Government funded the Victorian consumer and carer peak bodies to conduct a twelve-month consumer and carer-led pilot project to evaluate experiences of care in Mental Health Services. The project team, comprised of consumers and carers, conducted consultation groups with consumers and carers at eight pilot sites around the state to develop survey questions and methods that would be most relevant to them. In partnership with the Victorian Mental Health Branch and participating pilot services survey processes were developed and implemented. A questionnaire was administered, primarily through telephone interviews, with a random sample of consumers and carers across the eight pilot sites. In addition, interviews and focus groups were conducted with a sample of consumers and carers across each of the pilot sites to elicit a more in-depth understanding of the findings from the questionnaire. Processes were also developed to improve reporting and use of information about consumer and carer experience to contribute to service planning and ongoing quality improvement. This project demonstrates how consumers and carers can be effectively and professionally involved in implementing new strategies to improve the quality of mental health services. It highlights the value of enhanced communication and partnerships between consumers, carers, service providers and relevant governing bodies.
MENTAL ILLNESS IN CANADA: CHALLENGES IN REDUCING CARER COSTS
Linda Cook, Norah Keating
Background: Approximately one in five Canadians experience mental illness at some point in life. Family and friends carers often are profoundly impacted because they give care and assistance. Much research has been conducted on psychological, social and physical outcomes of caring, but less is known about economic costs related to employment, out of pocket expenses and unpaid labour.
Aim: The purpose of this research was to identify economic costs to family/friend carers and to evaluate how current federal and provincial government programs might reduce them.
Methods: A secondary analysis of a Health Canada national survey of family and friend carers in the community provided information on costs of care. A policy impact analysis provided information on how public programs might reduce economic costs of ‘high impact’ carers.
Results: Highest impact carers were those who were likely to incur multiple high economic costs: husbands, mothers, and daughters. Public programs have little impact on carer costs because they do not acknowledge the nature of disability involved or the trajectory of caring. Some high impact carers may be excluded from benefit.
Conclusions: Severity, chronicity and episodic nature of many mental illnesses are not addressed well in current disability programs resulting in high costs for the carers and sustained dependency of the person with mental illness. An overhaul of disability programs for consistency and improved applicability to persons with mental illness is needed.
OP76 CHILD AND ADOLESCENT MENTAL HEALTH – WORKFORCE AND OTHER ISSUES
ENHANCING CHILD AND ADOLESCENT PSYCHIATRY COMPETENCE IN THE WORKFORCE
Shashi Bhatia, Subhash Bhatia, Daniel Wilson
Background: The shortage of child and adolescent psychiatrist is global phenomenon. In the USA one in five children is afflicted with psychiatric disorders but only 20–25% are able to access needed services. This gap is projected to worsen in the year 2020.
Aims: To discuss strategies to increase number of child psychiatrists and/or to enhance training of pediatricians, primary care providers and general psychiatrists for child psychiatry care.
Methods: We have implemented a few strategies such as (1) identification of medical students interested in child psychiatry and help develop and sustain their interest through mentoring, medical student psychiatry interest groups and national mentorship via fellowship programs by the American Academy of Child and Adolescent Psychiatry, (2) implementation of integrated general and child psychiatry training, (3) active consultation to or successful co-location with collaborative pediatricians and primary care practices (including consultation and liaison to pediatric residents and faculty or through behavioral pediatric clinics), and (4) facilitation of training board certified pediatricians through post-peds-portal-project for added certification in child and adolescent psychiatry.
Results: With this effort we have seen increase in number of students interested in psychiatry. However it is too early to yet see an increasing availability of child and adolescent psychiatrists.
Conclusions: The shortage of child and adolescent psychiatrist is real and well accentuate in future decades especially for at risk, poverty-stricken rural populations unless academic psychiatry mobilizes innovative strategies.
STEP UP – A PROGRESSIVE INITIATIVE
Murugan Manickavasagam, M. Papakumari, P. Jeyachandran, B. S. Viruthagirinathan, G. Menon
Background: Children are the most important assets of any country. The WHO report on mental health estimates a global burden of serious emotional disturbances in children and adolescents at 15%. In India, few studies done in this field.
Our pilot study done on 80 children in one school was a success and identified behavioral and emotional problems in few of these children.
Aim: Our prospective follow up study will assess school children between the ages of 9–11, in 100 schools in Tamilnadu (India) to identify any underlying problems in the child that may hamper his performance. Following the assessment, children will be offered both medical and psychological help as required and the family would also be supported.
Method: 100 Schools selected from Tamilnadui and students of grade 6 aged between 9 −11 will be assessed using Columbia mental maturity scale, Connors Rating Scale and a learning disability questionnaire. Children identified with any problems will further be assessed individually. We will also identify 3 students each from the top and low end of the performance percentile and 1 from the median. These children would be evaluated in detail using the Stanford Binet Scale to assess the relation of their performance to their intelligence.
Conclusion: This study would help assess the current performance of our children and help them step up to the next level. We could educate the teaching staff on better handling of children requiring special help. It would also help in narrowing down the academic inequalities among the children.
WAS YOUNGER CHILD IN THE CLASS ASSOCIATED WITH EMOTIONAL PROBLEMS?
Wireeon Supatkiat, Boonchai Nawamongkolwatana
Background: Studies have found differences in the emotional problems of school-aged children according to when they were born, which may be due to seasonal risk factors affecting fetal or child emotional development or to the child's relative age within their school year.
Aims: This study was aimed to study the effect of relative age within school year to emotional problems in isolation from seasonal influences, in a tropical country-Thailand.
Methods: We compared 588 psychiatric clinic attendees aged between 6–17 years who received diagnoses of emotional problems (depression, anxiety or adjustment disorders) with 910 students in the same age range attending a local state school in the lower North-eastern region of Thailand. Both groups were classified into the oldest, middle, and youngest relative age groups depending on their date of birth in relation to school entry cut-off.
Results: The youngest relative age group were 20% more chance to be referred as emotional problems to the psychiatric clinic when compared to the oldest relative age group, after adjusting for chronological age and gender (x2 = 3.46, p-value = 0.081).
Conclusion: Young relative age was associated with being referred as emotional problems. It may reflect social, emotional and cognitive immaturities in the child that increase the stress associated with school attendance. Insufficient allowance by adults for chronological age in younger children may contribute to any increase risk of emotional problems. To increase adults’ awareness of the issue of relative age within school year may influence on Thai student's mental health at population level.
WERRY CENTRE: CHILD AND ADOLESCENT MENTAL HEALTH WORKFORCE DEVELOPMENT FIVE YEARS ON
Sue Treanor, Debbi Tohill
Context: Infants, children, young people and their families who have access to a highly skilled, well supported and effective mental health and addictions workforce.
The Ministry of Health, Mental Health Directorate has recognised the need for significant action to address workforce and skills shortages and has contracted the Werry Centre to undertake national workforce development within the child and adolescent mental health sector.
Objectives: This presentation will discuss what we have learnt so far as we address the five imperatives of workforce development:
Workforce Development Infrastructure
Organisational Development
Retention and Recruitment
Training and Development
Research and Evaluation
These imperatives need to be considered in the context of health sector workforce shortages generally. They are accentuated for the child and adolescent mental health sector as a comparatively small and highly specialised workforce.
Key messages: Innovations identified in the child and adolescent mental health sector clearly have benefits that may be applied to other specialist workforces in the Health and Disability Sectors.
This presentation will highlight the initiatives undertaken by Werry Centre over the past five years and reflect on the role of national workforce organisations as leaders and catalysts for workforce change.
OP77 PATTERNS AND PREDICTORS OF MENTAL HEALTH IN PRIMARY CARE
QOL AND AFFECTIVE DISORDER'S PATTERNS. MIGRATION AND MH IN BARCELONA
David Bussé Olivé, Raul Ducet Texeira, Maria Carmen Martínez-Altarriba, Belen Rueda Hernandez, Mónica Manzano, Amelia Samperio, Isabel Vidiella, Antonia Galofré, Ricardo Parra, Pilar Esteras
Aims: Spanish study on local and cultural patterns in affective disorders in order to improve Barcelona's 2007 Declaration of Cultural Psychiatry.
Methods: Qualitative and epidemiological research on Affective, Adjustment and Anxious (SCID+ DSMIV) patients attended in multicentric settings in an European inner city settings. MANSA's Spanish Scale and HAM-A. Randomised autochthonous (N = 86) vs. migrant population (N = 79).
Results: No relevant differences are found on sociodemographical data. HAM A scores ratings have not shown any difference between groups relating birth's place, even thought primary care clients shown less pathology but more somatic features. Attendees seen by the psychiatrist observed major diagnosis and higher severity.
Conclusion: No relevant differences are found between sociodemographical data, neither for clinical patterns depending on the place of birth. Sample size and tendencies observed risk to misinterpret diagnosis and clinical features due to unknown factors. Research on cultural factors, and professional education sensibilisation is need worldwide to accept cultural differences. Cultural competence of professionals is essential. Adjustment Disorders prevail in migrants. Migrants with prior Psychiatric History are usually sent to Community Psychiatric Team.
INFLUENCE OF SOCIAL TIES ON HELP SEEKING FOR DEPRESSIVE SYMPTOMS
Sandra Davidson, Jane Gunn, Chris Dowrick
Background: Although numerous studies have demonstrated a positive relationship between social ties and depressive symptoms the causal pathways linking the two are unclear. One explanation may be that people who have high levels of social support and strong social networks are more likely to seek treatment from formal health services.
Aims: This paper will review the literature on the relationship between social ties and primary health care service use for depressive symptoms.
Methods: A literature review was conducted using the exploded MeSH headings: ‘social support’, ‘deprssion’, ‘mental health sevices’ ‘primary health care’, and ‘patient acceptance of health care’.
Results: There is conflicting evidence on how social ties are associated with health service use for depressive symptoms. One reason for the discrepancy is that measures of social ties and measures of health care use have been inconsistent across studies and few studies have assessed a broad spectrum of social ties.
Conclusion: There is some evidence to suggest that strong social support and social networks are associated with increased use of health services. However, contradictory findings suggest that people with weak social ties may be more likely to use formal health services, possibly in an attempt to fill the gap in their social ties. Further research is necessary to clarify the nature of the relationship between social ties and health service use. Understanding the direction of the relationship may be helpful in designing targeted interventions for people with depression.
OBSERVATIONAL STUDIES OF DEPRESSION IN PRIMARY CARE: WHAT DO WE KNOW?
Gail Gilchrist, Jane Gunn
Aims: A systematic review of observational studies of depression among adult patients in primary care determined: the nature and scope of the studies published; their methodological quality; the identified recovery and risk factors for persistent depression, and patients’ treatment and health service use patterns.
Methods: Searches were conducted in MEDLINE, CINAHL and PsycINFO for articles published in English during 1985–2006.
Results: 40 articles from 17 observational cohort studies were identified. 9 studies followed almost 3,000 patients for less than 12 months, 6 followed almost 4,000 patients for 12 months, and two followed over 500 patients for longer than 12 months. Methodological limitations were common including: selection bias of patients and physicians; small sample sizes (range 35–108 at baseline and 20–59 at follow-up); and short follow-up times, limiting the extent to which these studies can be used to inform our understanding of recovery and relapse. Risk factors for persistence of depression identified in this review are: severity and chronicity of the depressive episode, the presence of suicidal thoughts, antidepressant use, comorbid physical illness, poorer self-reported quality of life, lower self-reported social support, negative life events, lower education level and unemployment.
Conclusion: Despite the growing interest in depression being managed as a chronic illness, this review identified only 17 observational studies of depression in primary care, most of which have included small sample sizes and been relatively short-term. Future research should be large enough to investigate risk factors for chronicity and relapse and should be conducted over a longer time frame.
DETECTION OF MENTAL DISORDER IN PRIMARY CARE: A NATURALISTIC STUDY
Sana Hawamdeh
Background: The ways that GPs manage and make referral decisions for psychological problems are curial for provision of mental health care. It is unclear exactly how patients are being managed in primary care or what factors are associated with referral to psychiatric services. Psychiatric research in the UAE has identified significant shortcomings in detection rates, raising concerns that a large proportion of mental health problems go unrecognized and untreated.
Purpose: The present study examines how patients are managed in primary care, determine which patients are referred and those not, in terms of primary care consultation rate and degree of co-morbid illness.
Method: Computerized records and referral letters were read for patients in primary care centres in Sharjah, UAE.
Results: GPs diagnosed a mental health problem in 9% of 1089 cases examined and 86% of these patients were managed in primary care alone. Affective disorders are more frequently diagnosed than anxiety disorders or alcohol abuse. The chances of psychological GP diagnosis have few indications to help them distinguish patients with a psychiatric morbidity from others, as long as the patients themselves do not express more explicit clues to the condition.
Conclusion: Greater psychiatric co-morbidity may be associated with referral to psychiatric services. Public mental health education is badly needed.
SOMATOFORM SYNDROMES AT THE ANXIETY-DEPRESSIVE DISORDERS AND PSYCHOSOMATIC DISORDERS
Alexander Kim
Objectives: 2181 patient was surveyed within the limits of the clinical-epidemiological research.
Methods: The sample of research had made 324 patients, who were surveyed at the National center of cardiology and therapy and polyclinics of Bishkek, and also psychosomatic disorders unit of Center of Mental Health.
Results: The total prevalence of somatoform disorders in the studied contingent of patients of public medical network was 20,2%.
According to the developed criteria, from this number of patients somatoform disorders were generated within organ somatisations (hyperventilation syndrome, irritable colon syndrome, Da Costa syndrome) at 11,4% (248 patients), at the others of 8,8% (191 patients) – somatoform disorders with dissociative radical.
Conclusions:
Somatoform syndrome marks pathogenetic and forecasting comorbidity at organ somatisatizing and causes verification of typology of comorbidity, as mechanism optimizing opportunities of approaches at studying a clinical-psychological phenomenon of somatisations.
The clinical-psychological phenomenon of somatisations, from a position of somatoform syndrome, is one of variants of personal reaction to frustration that facilitates integration psychiatry and internal medicine and modifies theoretical basis ICD-10, allowing to order and, probably a little, to alter heading F 4.
PATTERNS AND PREDICTORS OF TREATMENT CONTACT AFTER FIRST ONSET OF PSYCHIATRIC DISORDERS
Raza Rahman, Moin Ansari, Abdul Ghani
Objective: To study patterns and predictors of treatment contact (Health seeking behavior) after the first onset of ICD-10 psychiatric disorder.
Methods: This is a retrospective study. The record of patients who had attended psychiatric Out- patient department at Isra University Hospital and Civil Hospital Karachi from January 2002 to February 2004. A proforma was developed on which demographic characteristics, diagnosis, delay and reason of delay in psychiatric contact after first onset of psychiatric disorder was recorded. Diagnosis had already been done on the basis of ICD-10, using present state examination Urdu version. This fact eliminated experimental bias.
Results: There was great variation across disorders in probability of treatment contact in sample size of 1208 patients and most treatment contacts were delayed. the average delay time was 3 year. Probability of treatment contact was directly related to age at onset. The effects of socio-demographic variables were modest and inconsistent across disorders. The delay was a little more among female than among male and was more in urban than rural population. The stigma seems to have little effect on delay in psychiatric consultation. The family system (nuclear/joint) has no effect on probability of psychiatric consultation delay. Among the 4 reasons in delay for 1st psychiatric contact lack of awareness was found to be the most common reason followed by un-reached facility than un-affordability and gender discrimination.
Conclusions: The delay was pervasive in majority of people with the psychiatric disorders considered. Most common reason of delay was found to be the lack of awareness about psychiatric illness.
