Oral Presentations

PROGRESSION IN EPILEPSY STUDY: NEUROPSYCHIATRIC ASPECTS

Dr Sophie Adams ¹, A/Prof Terence O'Brien², Dr Michael Salzberg³, A/Prof Lei Wang⁴, Dr Dennis Velakoulis⁵

¹ Melbourne Neuropsychiatry Centre

² University of Melbourne

³ St Vincent's Hospital

⁴ Washington University

⁵ Royal Melbourne Hospital

Introduction: Patients with focal epilepsy(FE) have high rates of psychiatric co-morbidities. The effects of underlying neuropathology, epilepsy progression and psychopathology remain unresolved. Hippocampal high-dimensional mapping techniques(HDM) can generate detailed surface maps showing subtle shape changes not always reflected by volume differences.

Aims: To investigate psychiatric, neurological and neuroimaging progression in patients with FE.

To use HDM mapping techniques to investigate associated shape deformation changes.

Method: 35 patients with FE from original cohort seen at RMH between 1993 and 2004 have been prospectively assessed. They underwent epilepsy and medication history, SCID, QOLIE and NEO. Their past MRIs have been obtained. Separate sub-cohort with 2 MRI scans underwent HDM mapping to produce volumes and surface maps. Maps comparing change at time 1 and time 2 were created.

Results: 35 patients were seen (mean age 39, female 56%, age onset epilepsy 17, history of depression 66% and psychosis 16%, GAF 67 and QOLIE 67.2). Rates of depression were significantly higher in patients with MTS than other types of FE(73% vs 59%, p < 0.05).

MRI analysis shows ipsilateral hippocampal volume reduction over time in MTS (mean volume change of 8.8%). There is significant correlation between scan interval and change in ipsilateral volume(r = 0.84 p< 0.05). HDM maps reveal greatest change in head and inferior surface of the ipsilateral hippocampus.

Conclusions: Our preliminary data is suggestive of hippocampal progression in MTS and shows a high rate of psychiatric illness in all seizure types. HDM may be an important tool in understanding longitudinal hippocampal changes associated with chronic neurological and psychiatric disorders.

TALKING HEADS – IT'S ABOUT PARTNERSHIPS MAINLY OR HOW TO SUCCEED IN COAG BY REALLY TRYING?

Dr John Allan ¹, Ms Debbie Fawcett¹, Ms Cathy O'Toole², Ms Rhonda Clark³, Ms Phillipa Harris⁴

¹ Townsville Integrated Mental Health Services

² Advance Employment

³ SOLAS

⁴ Mental Illness Fellowship of North Queensland

Context: Psychiatry in our regional city has a complex history. Many improvements have been through the direct involvement of very committed small NGO's and consumer & carer groups. In 2006, our district Mental Health Services and its major partners decided to reposition themselves to meet the challenge of increasing community controlled service provision and to take maximum advantage of State and Federal funding opportunities. We were concerned that the carefully nurtured local providers could be swallowed up by larger outside organisations and that not much was being offered for direct involvement of consumers. The new peak local body “Talking Heads – It's about mental health” includes NGO's, consumer & carer groups, Indigenous providers and the division of GP's is a clearinghouse for action.

Objectives: To describe the creation, aims and functioning of Talking Heads. To present review data from interviews with key players and surveys. To explore how public mental health services deal with the new landscape.

Key Messages: Generally Talking Heads has been well received. It has had some success in its implicit goal of making it easy for funders and providers to commit to new services. New partnerships have contributed to the success of funding bids. There are some problems. Not everyone wants to join an organisation based on cooperation and free sharing of information. The system still resists consumer involvement as service providers.

Conclusion: Partnership arrangements have greatly improved. We would recommend this course of action especially for regional areas.

PATIENT'S AND RELATIVE'S ASSESSMENT OF INSIGHT AND THE BENEFITS OR OTHERWISE OF COMPULSORY TREATMENT

Dr John Allan ¹, Ms Larrisa Hallam²

¹ Townsville Integrated Mental Health Services

² St Vincent's Mental Health Services

Background: Insight describes the person's understanding of mental illness. It is multidimensional. Clinicians, patients and their relatives can have different views on insight. This is especially true when the Mental Health Act is invoked. Previous work has shown that on admission, relatives and clinicians are generally congruent on views of patient insight but fractionate across dimensions especially on symptom awareness and awareness of treatment issues. This agreement also decreases over time. Patient agreement with compulsory treatment is associated with higher insight.

Aims: This study explored the views of patients, relatives and clinicians across six dimensions of insight and the relationship to compulsory treatment to find possible improvements.

Methods: Forty-four patients were followed up within 12 months of compulsory admission, along with their relatives and current clinicians. Current insight was assessed with SAI-E, SUMD for relatives, and patient self-ratings. Data about MHA experience and current attitudes was collected from all three.

Results: Seventy percent of relatives and 82% of clinicians could see clear benefits from compulsory treatment compared with 55% of patients. Relative's confidence in compulsory treatment fell over time while the patients maintained similar views. There were many negative issues about process and effectiveness. Patients and relatives agreed about symptom awareness and awareness of the effects of the illness for patients. Relatives showed some variation from clinician's views on patient insight, particularly in the awareness of treatment dimensions.

Conclusion: Families and patients can contribute to understanding views about and improving compulsory treatment.

A BRIEF INTERVENTION MODEL FOR NON-EPILEPTIC SEIZURES BASED ON COGNITIVE ANALYTIC THERAPY (CAT)

Dr Oscar Alvarez ¹, Dr Denis Velakoulis¹, Dr Terence O'Brien¹, Mrs Louise Mc'Cutcheon², Dr Michael Salzberg³, Dr Sophie Adams¹

¹Royal Melbourne Hospital

²ORYGEN

³St Vincent's Hospital

Background: Non-Epileptic seizures (NES) are a significant yet unrecognized cause of disability. Psychological factors play a mayor role and there is a need for interventions that can be provided within resource-limited mental health service.

Aims: Develop a brief intervention for NES based on CAT integrating cognitive, dynamic and interpersonal aspects.

Methods: 12-session CAT was offered to 5 patients diagnosed with NES in order to identify patterns of interpersonal relations (reciprocal roles) and common cognitive and behavioral traps (procedures). 15 additional patients were discussed using a CAT framework. Qualitative review of this data was employed to develop a “template map” for use in briefer therapy.

Results: Patients with NES related to primary carers and significant others in stereotyped ways that were associated with unacceptable emotions such as anger. Self-assertion and individuation were often intolerable and NES allow for the expression of these emotions as well as gaining control and eliciting care.

A template map with common reciprocal roles and procedures was produced based on the analysis of interactions with important others and the perception of counter-transference. Maps were welcomed by patients and allowed for rapid identification of negative emotions in therapy avoiding the re-enactment of judging and controlling roles. Patients became more self-aware noticing and tolerating negative emotions more. This was correlated with reduction in NES.

Conclusions: It's possible to design a “template map” for use in brief therapy. A CAT-informed model could be safely and effectively delivered by psychiatrist in training. This is the basis for evaluation of CAT-based brief intervention in a future RCT.

INSURANCE CLAIMS AND LITIGATION – LEGAL PATHWAYS FOR HELP

Dr Georgiana Antoce

Private Practice, Conolly Clinic

Factors involved in compensable injuries will be reviewed with discussion of the interface between work factors, pre-morbid conditions and systemic issues involved. Specific emotional states resulting from work injuries are discussed from the dynamic perspective of loss/ expectation/ suppressed needs and a search for validation. Insurance claims for psychological injuries could be regarded as a valid clinical pathway in the provision of care for a specific population group (i.e. with high use of suppression and obsessional defense mechanisms).

DIAGNOSTIC ENTITIES AS MOTIVATORS OF SOCIAL DIALOGUE

Dr Georgiana Antoce

Private Practice, Conolly Clinic

Reflections on the frequency and associated features of PTSD and Depression as diagnostic categories in clinical practice will open a broader discussion on social and political implications. Issues like social support mechanisms, the role of art in day to day life, transcultural dimensions, different forms of linguistic interpretation of human experience (i.e. labelling, stigma, science, spirituality) and other relevant aspects will be reviewed. Attempts to understand the generally human experience presented in clinical situations from a perspective of integration rather then isolation one can invite a review of the social image considered “desirable” at this stage.

THE DIFFICULTIES IN DIFFERENTIATING AUTISM FROM SCHIZOPHRENIA IN ADULTS

Dr Chad Bennett ¹, Mr Stephen Edwards ²

¹ Victorian Dual Disability Service

² Melbourne Health

Significant progress has been made in the diagnosis and management of less severe forms of autism spectrum disorder. Traditionally, the diagnosis of autism was given where criteria for the developmental disorder were clearly satisfied and the level of associated disability significant or severe. A group exists who exhibited fewer or less severe symptoms and were not judged as autistic but in whom current clinical practice would now allow a diagnosis within the milder range. Analysis of clinical activity data have indicated that some members of this population were diagnosed with a psychotic illness in their adolescence and treated in the adult public mental health services. The aim of the paper is to illustrate the difficulties in the differential diagnosis between autism and schizophrenia in adults by outlining some of the service system issues and comparing and contrasting the disorders on the following dimensions; the nature & classification of the disorders; the developmental history and clinical presentation; the history and mental state; the response to treatment; the course of the disorder.

On the basis of the discussion above an attempt is made to identify the similarities and distinguishing characteristics of the two disorders and to examine how these can be accounted for in the assessment process.

MENTAL HEALTH AND WELLBEING ACROSS CULTURES – THINGS ARE NOT ALWAYS AS THEY SEEM

Dr Pamela Bennett

University of Auckland

Background: I returned to Aoteoroa/New Zealand in 2000, after 20 years as a psychiatrist in Melbourne, at the request of my late father. I was shocked by the situations I observed on a daily basis as a clinical psychiatrist working in the public mental health services. Compared to when I left, there were now relatively few Maori staff, and a very high proportion of patients, especially in acute inpatient, settings were Maori. Maori seemed more likely to attract a diagnosis of psychosis and to be admitted involuntarily. My observations were supported by anlyses of data pertaining to acute psychiatric inpatient units. This paper brings together the findings of ongoing externally funded research projects which explore the reasons for the current situation and ways to irectify it.

Aims:

To describe a method developed to examine Maori views of mental health and wellbeing.

To describe Maori views of mental health identified using this method.

Methods:

Two video scenarios were produced, depicting depression and psychosis.as defined by the DSM-IV-R.

The scenarios were validated and piloted.

The scenarios were used to determine the views of Maori from a range of backgrounds, of the conditions depicted.

Results: Maori views of the conditions presented in the scenarios differed markedly from those of western psychiatry.

Conclusion: There are marked differences between the views of Maori and those of western psychiatry with respect to mental health and wellbeing. These difference need to be further elucidated and taken into account when planning and delivering mental health services in New Zealand wher Maori are 15 per cent of the population.

ETHNIC NEUTROPENIA AND CLOZAPINE

Dr Amanda Bray

Cumberland Psychiatric Hospital

Context: Clozapine often provides a superior antipsychotic effect for patients with treatment-resistant schizophrenia. Unfortunately, many patients lose access to this drug due to a fall in neutrophils. This is illustrated in the case history of a young Palestinian man who experienced several years of psychosis, serious violence and self harm after clozapine was withdrawn due to neutropenia.

Objectives: This paper examines the condition known as benign ethnic neutropenia, which commonly causes a harmless reduction in neutrophils in certain ethnic groups, including people of African and Middle Eastern descent.

Key Messages: Members of ethnic groups affected by this condition are immigrating to Australia in increasing numbers. Insisting that all clozapine patients achieve neutrophil counts in a normal range established in white populations could result in non-white patients being inappropriately denied access to clozapine.

Conclusion: In applying the current normative values to all ethnic groups, clozapine monitoring organisations may be permitting considerable preventable morbidity, and leaving themselves open to accusations of racial discrimination.

RECENT DEVELOPMENTS IN THE TREATMENT OF COMPULSIVE DISORDERS: TRICHOTILLOMANIA

Prof Graham Burrows ¹, Dr Don Jefferys², Dr Kathleen Moore²

¹ University of Melbourne/Austin Health

² Deakin University

Trichotillomania (TTM) is a common psychiatric illness with marked chronicity and comorbidity that significantly impacts on psychosocial functioning and physical features of the sufferer. Patients have been studied, with the Impact of Trichotillomania Scale and Discomfort Scale to assess the psychosocial morbidity associated with the condition. Twenty-eight women with the diagnosis participated in this study. The results will be presented. When undertaking the initial assessment of the suffering, determining the specifics of the psychosocial impact should occur, as such factors will exacerbate the illness and impede recovery.

Treatment studies, to date, using behavioural and pharmacological interventions alone or simultaneously, are equivocal with few showing a sustained cessation of hair-plucking. This paper will report on 10 patients who have been treatment resistant Trichotillomania, the use of atypical neuroleptic, resulted in a cessation of hair-plucking significantly.

INTEGRATING PSYCHIATRY INTO THE MBBS DEGREE

Prof John Bushnell ¹, Dr Warren Kealy-Bateman², A/Prof Lyndal Parker-Newlyn

¹ University of Wollongong

² SESIAHS and University of Woolongong

Introduction: The University of Wollongong is delivering a new medical degree with a focus on addressing the workforce needs of regional, rural and remote communities in Australia.

Aim: to describe an approach to medical education that is designed to develop knowledge, skills and professional behaviours in psychiatry. These components underpin the delivery of competent and effective medical care of the mental health issues in the communities within which the students will work.

Method: The strategies adopted involve the integration of mental health issues into a case-based approach where psychiatric problems occur both as the primary focus of the consultation or as a secondary focus of a medical problem.

Results: We describe the range of content and learning methods employed, consider the linkage to underlying pedagogy, and review student feedback on a curriculum that addresses needs of students to learn about both low and high prevalence psychiatric disorders encountered in general medical practice and in mental health services.

Conclusions: The delivery to undergraduate students of knowledge, professional behaviour and skills that form the framework of knowledge and competencies underpinning psychiatry can be delivered in a format that is effective because it integrates the learning of psychiatry with the learning of medicine.

COMMUNITY OUTCOMES OF FORENSIC PATIENTS WHO HAVE KILLED

Dr Andrew Carroll

Monash University

Background: The development of safe and ethical services for mentally disordered homicide offenders is a major public health challenge. Previous research has demonstrated the value of carefully monitored community treatment by specialist teams after discharge from hospital.

Aims:

Describe the characteristics of Forensic Patients with an index offence of homicide released from secure care in Victoria between 1991–2002.

Describe their community outcomes in their first 3 years post-release

Methods: Cases were ascertained from a Statewide database. Background characteristics and community outcomes were coded from case notes. Risk assessment profiles on structured scales were ascertained, based on file information available at the time of discharge.

Results:

26 patients met criteria.

Mean length of stay was over 11 years.

Risk assessment profiles suggested that most were at low risk of violence at discharge.

Reoffending was rare: only one case of minor assault occurring in the 3 year follow-up period.

Readmission to hospital was common: 12 patients required readmission to hospital, of whom 6 were readmitted for more than 12 months.

Conclusion: Safe and effective community management of mentally ill homicide offenders is feasible. Further research is required to ensure that the community achieves optimum outcomes whilst avoiding excessively long, expensive hospital stays. Recent developments in forensic psychiatric rehabilitation and risk assessment may help to achieve these aims.

TAPPING INTO THE SOCIAL CAPITAL OF ‘COLLECTIVELY-ORIENTATED’ COMMUNITIES TO ADVANCE DESTIGMATIZATION OF MENTAL ILLNESS – THE CASE OF AUSTRALIAN-CHINESE

Dr Bibiana Chan

Australian-Chinese Psychologists Association

Introduction: The National ‘beyondblue’ campaign launched in 2000 has led to a remarkable increase in the mental health literacy of Australians. De-stigmatization of clinical depression is almost complete.

Aims: The aim of this study was to evaluate mental health literacy and explore views on mental illness among Chinese-Australians.

Methods: A mixed-method study was undertaken in Sydney. 385 Chinese and 143 Australian matched controls were surveyed quantitatively on their mental health literacy. The qualitative arm consisted of 16 focus groups held at community centres (across wide socio-economic backgrounds) exploring views on mental illness. Suinn-Lew Self-identification Acculturation Scale was administered to measure acculturation level. Questionnaires were available in Chinese and English, semantic translation was adopted where appropriate.

Results: Recognition of the core symptoms of depression was unrelated to level of acculturation. However, while Low-acculturated Chinese were better at recognising ‘somatic’ symptoms than Highly-acculturated Chinese, the latter were better at identifying ‘cognitive’ symptoms. Qualitative analyses revealed that informants ‘hanging onto Chinese values’ to build resilience against mental distress. They also considered non-medical services such as community support groups to be helpful in linking Chinese to clinical services. Informants across different cultural groups revealed that a certain level of trust was required to disclose negative emotions. Stigma on mental illness and stigma attached to ‘seeking professional help’ were seen as responsible for delays in contacting clinical services.

Conclusions: Culture plays a crucial role in shaping help-seeking behaviours. This study suggests that policy makers may benefit from working collaboratively with community organisations to reduce stigma on mental illness and clinical services.

SCREENING FOR BORDERLINE PERSONALITY DISORDER IN OUTPATIENT YOUTH

Dr Andrew Chanen, Martina Jovev, Danica Djaja, Emma McDougall, Hok Pan Yuen, David Rawlings, Henry J Jackson

Background: Young people with borderline personality disorder (BPD) commonly seek help but often go unrecognized. Screening offers a means of identifying individuals for more detailed assessment for early intervention and for research.

Aims: This study compared the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD), Borderline Personality Questionnaire (BPQ), the BPD items from the International Personality Disorder Examination Screening Questionnaire and the BPD items from the Structured Clinical Interview for DSM-IV Axis II disorders (SCID-II) Personality Questionnaire.

Method: 101 outpatient youth (aged 15-25 years) completed the screening measures and were interviewed, blind to screening status, with the SCID-II BPD module. The screening measures were re-administered two weeks later to assess test-retest reliability.

Results: All four instruments performed similarly but the BPQ had the best mix of characteristics, with moderate sensitivity (0.68), the highest specificity (0.90), high negative predictive value (0.91) and moderate positive predictive value (0.65). Compared to the other three instruments, the BPQ had the highest overall diagnostic accuracy (0.85), a substantially higher kappa (0.57) with the criterion diagnosis, the highest test-retest reliability (ICC = 0.92) and the highest internal consistency (□ = 0.92). The only clear difference to emerge in the Receiver Operator Curve (ROC) analysis was that the BPQ significantly outperformed the MSI (p = 0.05).

Conclusion: Screening for BPD in outpatient youth is feasible but is not a replacement for clinical diagnosis.

REFLECTIONS ON OUR EXPERIENCE OF FACILITATED DISCHARGE FROM A MENTAL HEALTH SERVICE

Dr Terence Chong, Dr Sean Jespersen, Ms Kelly Gray, Dr Tony Donegan

Werribee Mercy Mental Health Program

Introduction: Many patients with mental illness are treated in the primary care setting. Resource limitations mean that mental health services often need to discharge patients into primary care to allocate resources to those with the highest clinical need.

Aims: To review the research evidence around the process of facilitated discharge from mental health services and describe our experience of this.

Methods: A brief literature review of facilitated discharge was performed. Clinical characteristics of 21 discharged and 21 non-discharged patients from the local shared care service were compared in a retrospective file review. The results of a survey of 31 patients in a facilitated discharge program are also described.

Results: Discharged patients had a higher level of function. There was a trend towards discharged patients being more likely to be female and employed with less chronic illness, involuntary treatment, behavioural symptoms, depot medication, triage contact, service contact with the family, and more mood disorder. Of the 10 survey respondents, 60% reported feeling better compared with their last contact with the service, 70% felt not having contact was a good thing and most saw their doctors regularly and reported a good relationship. Some respondents reported family relationship difficulties.

Conclusions: The results trend towards a more clinically stable group being discharged. There is the suggestion that patients have responded positively to discharge. Given the increasing pressure on resources, more research needs to be undertaken into effective models of facilitated discharge.

INTEGRATION BETWEEN SPECIALIST MENTAL HEALTH SERVICES AND PRIMARY CARE: A 12-18 MONTH COHORT STUDY TO EVALUATE A PRIMARY MENTAL HEALTH TEAM'S PROGRAM AND BARRIERS TO THE EFFECTIVE MANAGEMENT OF HIGH PREVALENCE DISORDERS IN GENERAL PRACTICE SETTINGS

Dr Terence Chong, Dr Sean Jespersen, Ms Kelly Gray

Werribee Mercy Mental Health Program

Introduction: Primary Mental Health Teams (PMHT) were set up in Victoria to support the primary care sector in managing high prevalence disorders. These teams provide education as well as consultation-liaison and targeted short term interventions such as psychotherapy. There is little research into the effectiveness of the PMHT initiative.

Aims: To evaluate the effectiveness of the PMHT in treating the patients referred to it and to identify the factors that predict better patient outcome and barriers to recovery.

Methods: As part of the assessment process, all patients seen by the PMHT are routinely asked to complete validated assessment scales and other questionnaires prior to their initial appointment. This study will invite patients to complete a similar set of scales and other questionnaires 12-18 months after their assessment. This information will be combined with referrer feedback and patients’ clinical and demographic characteristics to address the aims above.

Results: Patients of our PMHT have been found to be significantly disabled with illness tending towards chronicity that has not responded to primary care treatment. Preliminary results from patient and referrer feedback 3 months after assessment has shown a trend towards patients having improvement in mental health and satisfaction with the service, 74% at least partially attending follow-up and 89% at least partially having suggestions implemented.

Conclusions: It is envisaged that the early results of the 12-18 month follow-up to be presented will be similar to the preliminary 3 month feedback results and add to the evidence around the effectiveness of the PMHT model.

THE EVOLUTION OF CPD

Dr Arran Culver, Dr Jeremy Stone

RANZCP CME Committee

The College CPD Program exists within a context of rapid development in application of adult learning strategies, advances in CPD programs offered by other colleges, and opportunities afforded by technology. This sits within a wider political environment of expectations regarding recertification, professional audit and lifelong learning for medical professionals. Within this environment, the RANZCP Continuing Professional Development Program must have its own process of continuous improvement, with a focus on effectiveness and efficiency.

This presentation will outline the proposed re-development of the College CPD Program, within a framework of lifelong learning processes and consistency between pre and post fellowship education strategies. Issues such as competencies based assessment, the regulatory environment, educational resources, collegial support and development of individual learning plans will be discussed.

The goal of the CPD program is to provide fellows with a high quality, flexible and effective resource which meets the needs of fellows, registration bodies and the community.

USE OF SIMULATION TECHNOLOGIES IN ELECTRO CONVULSIVE THERAPY (ECT) TRAINING. A SOUTHERN HEALTH EXPERIENCE

A/Prof Saji Damodaran ¹, Dr Sathya Rao¹, Dr Marcelo Rosenstein²

¹ Monash University/Southern Health

² Southern Health

Often psychiatric patients are anxious while receiving ECT treatment. Providing hands on training to clinicians in such an anxiety provoking situation is challenging. ECT training programs generally provide only a limited practical training experience due to above factors. ECT Simulator machine assisted ECT training enables training programs to provide clinicians with extensive hands on experience on an ECT simulator mannequin on which one can learn different types of seizure activities, titration techniques, electrode placements, various types of EEG read outs and even make mistakes and learn from experience. One can then have hands on experience on real patients with greater degree of confidence and practice under supervision.

Objective: To describe and demonstrate the role of ECT simulator machine in practical hands on ECT training.

Methodology: A description of the ECT simulator machine and practical demonstration of the machine would be presented. We would also share our experience in using the ECT simulator in providing practical ECT training at Southern Health ECT training program, which is a state wide licensed Training program that is accredited by the Chief Psychiatrists Office of Victoria.

Conclusion: ECT simulator can assist extensively in providing practical training to clinicians.

ELEPHANT IN THE ROOM. MORTALITY IN MENTALLY ILL

A/Prof Saji Damodaran ¹, Ms Anne Doherty²

¹ Monash University/Southern Health

² Southern Health

Introduction: Mental health services across the world have undergone substantial reforms and improvements over the past decades. This is mainly driven by improvement in the treatment methods, enhancement of service delivery systems and significant financial investment by improved infrastructure and human resources. However despite these improvements in the service system there is a steady increase in the number of reports suggesting an increase in the mortality in mentally ill. This is attributed to the increased physical comorbidity in mentally ill, poor socio-economic situation and barriers to access timely and proper health services.

Aim: Is to review the current literature on mortality in mentally unwell and discuss the possible causes and suggest a revised model of service response to improve the life expectancy in mentally ill people.

Method: A limited literature review of the recent systematic reviews and meta-analysis on mortality in mentally ill was conducted using key words mortality, schizophrenia and mentally ill using Ovid medline for papers published from 1950. Manual cross reference was done to identify related papers

Results: The most recent reviews reported an increase in the mortality in mentally ill and are showing an increased gap over the past decades. This is despite an increase in the service investments, primary care collaborations and improvement in the interventions.

Discussion: This alarming increase in the mortality and shameful reduction in the life expectancy requires a serious review of the current service models. The current fragmentation of mental health and general health services should be minimised and general practitioners and physicians must become an active member of the mental health services. General practice and primary care resource should be utilised to improve the general health of our patients so that they enjoy the life expectancy that all others have taken for granted. Services should collocate with general practitioner (GP) services or include GP as part of the health team.

CLINICAL CORRELATES OF TOURETTE SYNDROME ACROSS CULTURES: IMPLICATIONS FOR PHENOTYPIC PRESENTATIONS

Prof Valsamma Eapen ¹, Prof Mary Robertson²

¹ UNSW

² UCL Medical School

Introduction: While Tourette Syndrome (TS) has been researched extensively in the western populations, the clinical correlates and associated features are less well known in other populations and cultures.

Aim: To compare the clinical correlates of TS across two cultures.

Methods: A consecutive series of 35 childhood TS patients of Arab descent ascertained from UAE was compared with 35 age and gender matched Caucasian patients from London, UK for demography, family history, clinical features, and co-morbid conditions.

Results: Rates of occurrence of Obsessive Compulsive Disorder (OCD) and Attention deficit Hyperactivity Disorder (ADHD) were similar in the two cohorts. However the cohorts differed with lower recognition rates and perceived impairment in the UAE as compared to UK; this persisted after adjusting for severity. Coprolalia which was higher in the UK cohort was noted to correlate with the severity of TS. Co-morbid Oppositional Defiant Disorder and Conduct Disorder were also higher in the UK cohort (54% and 21% respectively) as compared to the UAE cohort (12% and 3% respectively) but this was not linked to any other clinical features or severity.

Conclusion: The findings illustrate the similarity in the core clinical symptoms between the two populations, thus emphasising the underlying biological and genetic basis for the occurrence of these symptoms. However, the potentially complex and challenging co-morbid conditions such as behavioural and conduct disturbance that are often encountered in the western population seem to be the result of environmental and other modulating factors. This finding has implications for our understanding of TS phenotypes.

INDIGENOUS MENTAL HEALTH IN MAINSTREAM SERVICES – MAKING IT WORK IN RURAL SOUTH AUSTRALIA

Dr Ken Fielke, Dr Nigel Cord-Udy

Rural and Remote Mental Health Service

The Adelaide based Rural and Remote Mental Health Service (RRMHS) was established in 1996 and has become the major supplier of mental health services to Country SA.

Over the last three years extensive efforts have been undertaken at RRMHS to improve access and responsiveness of the service to indigenous patients.

This paper reports on a number of the key strategies at RRMHS including:

The establishment, roles and functions of the, ‘Indigenous Team’ embedded within RRMHS.

Addressing cultural competence and cultural safety and improvements in inpatient services.

Expansion of clinical services including:

Outreach visits in partnership with the Royal Flying Doctors Service and Aboriginal controlled health services.

Telepsychiatry ‘virtual’ outreach.

In reach services and the development of an exchange program.

Co-ordination of services to the APY Lands in northern South Australia.

Exploration of the role of traditional healers in acute mental health service settings.

Development of a generalised advanced trainee position in indigenous mental health.

Development of a peer support group.

Development of the staff training document.

We reflect on the progress and challenges encountered to date and explore potential future directions for further development of the services.

REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION IN THE TREATMENT OF DEPRESSION – WHERE ARE WE AT AND WHERE TO FROM HERE?

Prof Paul Fitzgerald

Alfred Psychiatry Research Centre

Context: Transcranial magnetic stimulation (TMS) is a non-invasive means of stimulating nerve cells in superficial areas of the brain, utilising a pulsed magnetic field generated by a coil held close to the scalp. Over the last 12 years, repetitive TMS (rTMS) applied to the dorsolateral prefrontal cortex (DLPFC) has been actively investigated as an alternative intervention for patients with treatment resistant depression (TRD).

Objectives: To review the current state of research into the use of rTMS in the treatment of depression including a number of recent research findings.

Key Messages: Most trials have suggested that standard unilateral left sided rTMS has greater antidepressant efficacy than placebo, but concerns regarding response rates and clinical relevance of results continue to be expressed. Response appears to be enhanced with sequential bilateral treatment approaches and the use of neuro-navigational targeting.

Conclusion: Recent research suggests that it appears possible to enhance rTMS treatment methods in ways that will make clinical utilization of the technique possible. This should lead to greater clinical applicability and value.

MATERNAL DELUSIONAL DISORDER IN THE CHILD PROTECTION SYSTEM

Dr Teresa Flower

Monash University

Delusional disorder is a diagnosis that is often neglected in the clinical setting. it has been discussed in forensic settings but usually in the context of threats of violence or querulous litigants. The impact of the disorders on the family of the identified patient is rarely considered. This paper will present four cases of maternal delusional disorder encountered in the child protection setting. These cases caused considerable difficulties to the agencies concerned and involved lengthy court cases involving numerous delays and adjournments. In this manner the process did not reflect the best interests of the child who was the subject of the proceedings.

Child protection agencies often struggle with these cases aware that the mother is ‘not right’ but unable to identify the problem. Mental health services were often unhelpful, remaining unengaged as the mothers appeared'plausible'. The child at the centre of the protection application is often left in limbo, subject to a range of inappropriate behaviours stemming from the mother's delusions.

This paper will consider treatment options and a more streamlined approach for dealing with querulous mothers. The paper will also consider the role of the psychiatrist in the proceedings and the possible conflict of interest between assessing, forming a diagnosis of the mother and making recommendations whilst safeguarding the best interests of the child. This role may also lead to some vigorous discussions with service providers.

WHERE ARE ALL THE CHILDREN NOW?: EXPERIENCES OF ADULT CHILDREN OF PARENTS WITH SERIOUS MENTAL ILLNESS

Dr Kim Foster

James Cook University

Background: Adult children of parents with serious mental illness (ACOPSMI) are at higher risk of developing mental illness and psychosocial problems than the general population. However, evidence from previous studies suggests these risks may be mediated by protective factors and the development of resilience.

Aims: Due to limited understandings of adult children's subjective experiences 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: Drawn from a larger study using an interpretive qualitative design, a purposive sample of 10 ACOPSMI took part in a lengthy unstructured interactive (narrative) interview 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’. In this paper, the theme of Being Uncertain in particular is explored.

Conclusion: Although ACOPSMI can experience chaotic childhoods and adult lives which may be complicated by a sense of uncertainty and a range of interpersonal difficulties; with information and support from mental health professionals the future for them is by no means bleak. A family-focused approach can be of benefit to them and their families.

THE PORTRAYAL OF ADDICTION IN THE AUSTRALIAN PRINT MEDIA

Dr James Foulds

Canterbury District Health Board

Objective: To examine how the concept of addiction is currently portrayed in the print media in Australia.

Methods: A search of articles printed in Fairfax newspaper publications between 2002 and 2006 inclusive was conducted using the Fairfax online database. Articles with a headline containing words beginning with the stem addict-were identified.

Results: 245 articles were identified. Various forms of opioid addiction were the most commonly mentioned specific addiction (52 articles, 21%). Alcohol and nicotine addiction were referred to in 13 (5%) and 9 (4%) articles respectively. Gambling addiction was referred to in 20 articles (8%).

Conclusion: Newspapers associate the concept of addiction most readily with opioid use and to a lesser extent gambling. Alcohol and nicotine use, the most important addictions from a public health perspective, are less often explicitly identified as being addictions.

Recreational activities such as fishing, reading novels and watching television are also identified as potentially addictive, suggesting that the print media endorses a broad view of addiction.

TO VISIT OR NOT TO VISIT-DILEMMAS IN PROVIDING PSYCHIATRIC SERVICES TO DETAINEES IN IMMIGRATION DETENTION

Dr Andrew Frukacz

Private Practice

In this presentation I will talk about my experiences as a psychiatrist providing services to detainees at immigration detention centres between 2000 and 2007. During this time I visited centres in Victoria and South Australia but the major part of my work was done at the Baxter detention centre outside of Port Augusta in the mid north of South Australia. The work involved assessing detainees who had been referred either by mental health staff at the centres or by the general practitioners who were visiting the centres, and providing treatment where appropriate.

In late 2005 the story of Cornelia Rau came to light which had as one of its effects the focusing of attention on the adequacy of mental health services to detainees of immigration detention centres. Questions were even raised as to the appropriateness of providing psychiatric services to the detainees whilst they were still in detention.

After briefly describing the nature of working in a detention centre, the types of psychopathology seen and the treatments provided, I will then go on to talk about some of the ethical dilemmas faced in the provision of such services.

NEW EXTENDED BIOMARKERS OF RELEVANCE TO PREVENTATIVE PSYCHIATRY

Dr Stephanie Fryar-Williams

Youth In Mind

Biochemistry has moved ahead a lot in the last 25 years.

We now have a thorough knowledge of the pathways relating to neurotransmitter synthesis and metabolism as well as extended pathways of relevance to these processes.

Through screening tests across these biochemical pathways it is now possible to

predict likelihood of mental illness occurring

predict likelihood of medication response

assess prognosis and likely future disability

Statistical analysis of biomarkers within a patient population during 2007 revealed

psychiatric diagnostic threshold is reached with 4 or more abnormal biomarkers

significant correlations between abnormalities and key psychiatric symptoms.

Furthermore, these understandings have tremendous potential to change the way we view Psychiatry, approach our patient's presenting symptoms, effect more durable symptom-reduction for treatment-resistant cases, and alert us to cases where assertive early intervention is warranted.

A USABLE EVOLUTIONARY CLASSIFICATION SYSTEM FOR MENTAL DISORDERS

Dr Gary Galambos

St John of God Health Care NSW

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

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

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

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

SELF-STABBING: A RETROSPECTIVE CASE STUDY

Dr Andrew Gerard ¹, Dr Greg de Moore², Dr Chris Ryan²

¹ St George Public Hospital

² Westmead Hospital

Background: This study builds on a pilot study of self-stabbing (10 cases) by Patel and de Moore (1994).

Aims: Our aim was to categorise cases of self-stabbing in a way which was clinically meaningful. This information could be used in managing these presentations in the future.

Method: Forty two cases were identified from the total number of referrals to the Consultation-Liaison Service in Sydney over an 8 year period. This was based on a detailed review of case notes.

Results: The first group (22 of 42 cases, (52%)) were mainly young men who were not psychotic at the time of stabbing. Usually these persons had antisocial personalities, were intoxicated at the time of stabbing and had ambivalent suicidal intent. The second group (15 of 42 cases, (36%)) were actively psychotic during the intent with clear suicidal ideation. They responded to inpatient treatment of their psychosis.

The third group (5 of 42(12%) was not identified in the original pilot study. These patients had a clear syndrome of depression with high suicidal intent but were not psychotic they responded to antidepressants.

Conclusion: Knowledge of these clinical distinct groups may improve the clinician's assessment and management of cases of self-stabbing.

PEER REVIEW NETWORKS FOR RURAL PSYCHIATRISTS BY VIDEOCONFERENCE

Prof Jim Greenwood ¹, Ms Rachael Williams²

¹ UNSW

² RANZCP WA Branch

Background: The Rural Interest Group of the RANZCP have presented several approaches to continuing education for rural and remote psychiatrists over the last three years. The current project has been to enable isolated psychiatrists to conduct interactive peer review in real time by videoconference across Australia.

Aim: To enable support, interaction, education and practice improvement for psychiatrists who otherwise would be unable to experience peer review on a regular and frequent basis because of their isolation.

Methods: All rural and remote psychiatrists were offered an opportunity to participate in this project. Many had participated in the previous Continuing Education Project reported at the last Congress on the Gold Coast. Consequently a considerable data base had been created and benefits already confirmed of this technique. Use of a Videoconference Provider and funding for the costs had been successfully piloted previously. The project officer was able to continue with this project to assist the development of goals and evaluation methods.

Results: Approximately 60 Psychiatrists enrolled and participated in this project. The geographical distribution was across all states and territories and peer groups of between four and eight participants were created by interest and practice types. The benefits were significant as measured by the outcome evaluation.

Conclusion: This project adds to the growing evidence base that Continuing Professional Development is beneficial for practitioners and patients in isolated locations. Further, it supports presence of practitioners in locations that otherwise might be unattractive. Outcome assessment indicates that further CPD will be well supported and necessary to maintain psychiatric presence in isolated locations.

INSIGHT IN PSYCHIATRY: IS THERE A NEURO-COGNITIVE BASIS?

Dr Saibal Guha

Toowoomba Hospital

Context: Over the last 15 years or so, considerable interest has been generated in empirical explorations of insight in patients with mental illness, mainly in relation to psychotic disorders. However, the concept of “insight” may be different from the phenomenological expression of “insight”, and probably spans across most of the known disorders in Psychiatry. Current research has focussed mainly on expressing the relationship between insight and other clinical variables, such as: severity of psychopathology, compliance with medications, general outcome; and more recently, neuropsychological impairments.

Objectives: In this day and era, Clinical Psychiatry is gradually attempting to find neurobiological correlates to most psychological entities. While a large number of studies are available exploring relationships between patient's insight and various other clinical variables, only a few focussed on neuropsychological impairment and neuro-radiological correlates. The aim of this review paper was to explore, and highlight, available data on neuro-cognitive and brain structural impairment, as a basis for ‘poor insight’ across a range of psychopathologies.

Key Messages: The relationship between insight and cognitive function remains unclear, though a hypothesis can be presented as to why the results are difficult to replicate and not definitive

Structurally, various brain areas have been implicated for poor insight, but the data overall remains inconsistent and mixed.

Conclusion: It is important that to develop a better neuropsychiatric understanding of insight, some of the conceptual issues around this term needs in-depth clarification. However, a few other interesting concepts around understanding “insight” are raised in this paper, including their possible neuro-biological correlates.

SECLUSION REDUCTION: POLICY DRIVE, GAPS IN THE SCIENCE AND RESULTS OF A 3-POINT INTERVENTION IN A VICTORIAN INPATIENT UNIT

Ms Bridget Hamilton, Prof David Castle

St. Vincent's Mental Health

Background: The World Health Organisation and National Mental Health Policy in Australia target reducing the use of seclusion in public inpatient settings, follow a decade of seclusion reduction (S/R) policies and projects in the USA. Many US studies report raw seclusion data, making event rates difficult to compare and giving no attention to changes in patient profiles over time. In 2007/8 seclusion reduction is the focus of several government funded projects in Australia.

Method: This paper reports on S/R interventions and outcomes at St. Vincent's Mental Health, Melbourne, based on an NH&MRC funded project. The service has developed and implemented an S/R plan based on widely reported “S/R core strategies”. The seclusion data used to measure outcomes is derived from statutory reporting of events to the Victorian Department of Human Services (DHS).

Results: Using ‘seclusion events per 1000 occupied bed days’ as the primary outcome measure, we compared 2007 quarterly seclusion data with 2006 baseline data. This measure allows ready comparison across services of different sizes and bed configurations. We found that in 2007 seclusion was reduced by 49% (2006 µ per quarter = 32.7; 2007 µ = 16.7, (p = 0.007)). This reduced seclusion rate compared favourably with the DHS reported 2006 statewide mean of 34.3 events (/1000 occ. b-d/quarter), for all 27 acute units.

Discussion: Though the goal of seclusion reduction is laudable, the lack of robust analysis of seclusion data internationally makes it difficult to discern what works. Our project, tailored to an Australian service setting, aims to provide useful evidence to services wishing to invest in S/R efforts.

THREAT ASSESSMENT IN YOUNG PEOPLE

Dr Scott Harden, Ms Melissa Branjerdporn

Child and Youth Forensic Outreach Service

Introduction: A range of services dealing with young people are often faced with the difficulty of evaluating threatening statements or actions that the young person has made or is reported to have made. Services often have no literature-based structured and systematic way of responding to such events.

Aim: The child and youth forensic outreach service for central and southern Queensland has attempted to assist with this gap in service.

Method: A literature review was undertaken examining the available literature in the field of adolescents presenting with verbal threats or threatening behaviour towards others. Following the literature review a workshop and tool was developed based on the available information. The workshop was then piloted with senior staff from child and youth mental health services and further refined for delivery.

Results: The workshop has been delivered in a number of settings and reports on participants and the perceived effectiveness of the workshop in increasing their ability to cope with these very difficult circumstances will be examined.

Conclusions: The development of this workshop and assessment tool is an early step in assisting services and individuals to attempt to make an appropriate response to young people who potentially pose a threat to others.

TUNING IN TO KIDS: IMPROVING CHILDREN'S EMOTIONAL COMPETENCE THROUGH A PARENTING INTERVENTION

Dr Sophie Havighurst

Mindful: Centre for Training and Research in Developmental Health

Skills in understanding emotions, using them appropriately in relationships, and regulating their intensity and expression are key skills children need to equip them well for life. While some school based interventions are starting to target social and emotional competence in the curriculum, family and parent interventions have been lagging in their attention to this area – with few if any published reports of parent focused programs that help children learn emotional competence. Tuning in to Kids is an innovative approach to helping parents tune in to their children's emotional experience and teach them about feelings and their expression. Parents are also taught skills in understanding and regulating their own emotions – which has an important influence on the family's emotional climate. An evaluation of Tuning in to Kids in Australia has found that many parents can learn to respond to emotions in their children in attuned, appropriate ways – even parents who seem to be resistant and seemingly unaware of the value of their child's emotional experiences. These changes in parents have been found to result in improved child emotional competence, and reduced behaviour and anxiety problems. This presentation will provide an overview of the theoretical and empirical basis for Tuning in to Kids and examine some of the strategies taught to parents in the program.

ASSESSMENT OF HEALTH RELATED QUALITY OF LIFE IN PEOPLE WITH MULTIPLE SCLEROSIS

Dr Alex Holmes ¹, Dr Lavinia Spain², Prof Trevor Kilpatrick², Dr Niall Turbridy³, Dr Sophia Adams²

¹ University of Melbourne

² Royal Melbourne Hospital

³ St Vincent's Hospital, Ireland

Introduction: A number of physical and psychological factors have been shown to affect health-related quality of life (HRQoL) in patients with MS. Among these, the role of illness perceptions has not been established as an independent factor.

Aims: This study aimed to determine the relative impact of physical factors (illness severity, duration, age, fatigue and pain) and psychological factors (mood, cognition and illness representations) on each domain of the SF-36.

Method: 580 patients with confirmed MS were assessed cross sectionally in a designated research clinic.

Results: Categorical regression analysis showed that a combination of physical and psychological factors predicted 38-71% of variance in HRQoL. Illness perception was shown to have an independent effect on HRQOL in MS. EDSS was a significant determinant in all domains except for Mental Health. Subjective factors contributed to the subjective reporting of physical function. Depression, although less common than anxiety, had a greater effect on function in all domains except Emotional Role Functioning and Mental Health.

Conclusion: The underpinnings of health related quality of life differ between domains in people with MS. Depressive symptoms, anxiety symptoms and negative illness perceptions are targets for specific psychological interventions aimed at improving HRQOL in subjects with MS.

ALCOHOL PROBLEMS IN THE ELDERLY: A DAY HOSPITAL STUDY

A/Prof Mal Hopwood, Dr Richard Bonwick, Dr Klaire Wallace

Austin Health

Context: Epidemiological studies suggest that 2-3% of elderly people in the community experience alcohol-related problems, with higher rates of 6-7% observed in psychogeriatric populations. However, despite the frequency of such problems in the elderly, alcohol abuse (AA) and alcohol dependence (AD) have long been neglected by psychiatric services. In addition, the frequency, impact, and treatment of alcohol-related problems in this population have been the focus of little research to date.

Objectives: In order to obtain a greater insight into the presentation and management of alcohol use disorders in a local psychogeriatric population, a file review of 270 consecutive admissions to an Older Veterans' Day Hospital was performed.

Key messages: A frequency analysis of diagnosis at admission revealed that 13.3% of patients (n = 38) satisfied DSM-IV-TR (2000) criteria for a diagnosis of either AA or AD. The group included 34 male veterans of World War II and the Korean War, and four female war widows (Mage = 75.4 years; SDage = 4.7 years). Neuropsychological testing revealed a high rate of frontal/executive cognitive deficits (78.9%), while biochemical and haematological abnormalities that are frequently associated with heavy long-term alcohol consumption were also noted. However, despite the availability of numerous pharmacotherapeutic and psychosocial strategies, few patients had been treated for alcohol-related problems prior to admission.

Conclusion: The findings of the study support the contention that alcohol use disorders occur frequently in psychogeriatric populations, while also suggesting that the elderly may be undertreated when such problems arise.

PTSD IN THE ELDERLY: AN OVERVIEW OF TREATMENT OUTCOMES IN A SAMPLE OF OLDER VETERANS

A/Prof Mal Hopwood, Dr Richard Bonwick, Dr Paul Collier, Dr Klaire Wallace

Austin Health

Context: The management of Posttraumatic stress disorder (PTSD) in veterans of the Vietnam War has been the subject of extensive research. In comparison, few studies have focused on the evaluation of treatment strategies for older veterans, who typically experienced combat-related trauma in either the Second World War, or the Korean War. Given that the lifetime prevalence of PTSD in this population approximates that observed in younger veterans, a systematic evaluation of the impact of current interventions on the symptomatology of older veterans was seen as a worthy focus of investigation.

Objectives: The primary aim of the study was to investigate the treatment gains of older veterans who have completed an outpatient PTSD program conducted by a unit specialising in the treatment of older veterans. This program focuses on increasing the veteran's understanding of the impact of trauma on himself and his family, and enhancing extant coping mechanisms.

Key messages: In a sample of N = 155 older veterans, significant reductions in PTSD symptomatology were noted, as assessed on the PCL (pre-program M = 57.12; post-program M = 51.69; p<.001). Changes were observed in all three subscales of the PCL, indicating reductions in re-experiencing phenomena, avoidance/numbing, and hyperarousal. Moreover, the effect size of the change in total PCL score across each time period was substantial, and exceeded similar estimates of change in younger veteran samples.

Conclusions: The observed changes in trauma-related symptomatology provide strong evidence for the role of programmatic interventions directed towards the management of PTSD in older veterans.

THE MANAGEMENT OF MENTAL HEALTH FOLLOWING TRAUMA: A PILOT STUDY INVESTIGATING TREATMENT OUTCOMES IN A SAMPLE OF VICTORIA POLICE

A/Prof Mal Hopwood, Dr Klaire Wallace, Mr Tony McHugh, Dr Arthur Velakoulis

Austin Health

Context: In 2003, a specialist service was developed for the assessment and treatment of civilians suffering post-traumatic stress disorder (PTSD). Drawing on experience gained in the treatment of veterans, this unit has conducted several program-based interventions for a range of civilians, including emergency service workers such as police officers and ambulance workers. Conducted over a period of 12 weeks, each cohort of 5-6 program participants completes a range of integrated modules, including education and trauma-focused work.

Objectives: The primary goal of the study was to conduct a preliminary analysis of treatment outcomes in a sample of police officers who have competed a trauma-focused program conducted by the specialist treatment service (N = 28). Key outcome measures include changes in trauma-related symptomatology, depression, anxiety, anger, and alcohol use.

Key outcomes: An overview of baseline scores on key measures revealed high levels of depression, anxiety, and alcohol use, in addition to the symptoms of PTSD. Preliminary analysis of treatment gains over the course of the program revealed significant reductions in measures of PTSD (p<.001), depression (p=.005), anxiety (p=.004), and anger (p=.003).

Conclusions: While findings must be interpreted within the context of the small sample size, it is suggested that program participation resulted in gains across a number of clinical domains. Indeed, Police Officers reported a degree of symptom improvement that compares favourably with that observed in veteran populations.

AN EVALUATION OF THE EFFECTIVENESS OF THE ACUTE PHASE OF AN OUTPATIENT ALCOHOL MANAGEMENT PROGRAM FOR VETERANS WITH CHRONIC PTSD

A/Prof Mal Hopwood, Ms Maureen Peck, Dr Klaire Wallace

Austin Health

Context: Approximately 75% of veterans with chronic PTSD satisfy diagnostic criteria for a substance use disorder at some stage during their lives, with the majority of Vietnam veterans reporting that the substance in question is alcohol. Given the prevalence of alcohol use disorders in this population, a local unit specialising in the treatment of veterans has developed an Outpatient Alcohol Management Program that targets the symptoms of excessive alcohol use within a treatment environment that also recognises the wider role of trauma in the onset and maintenance of substance use. The Alcohol Program has two stages. The first, ‘acute’, treatment phase, aims to reduce alcohol consumption, encourage a sense of self-efficacy and increase active coping behaviours.

Objectives: The goal of the study was to evaluate the effects of program participation on measures of alcohol use, depression, and situational confidence in a sample of veterans with chronic PTSD (N = 142).

Key messages: Results reveal a significant reduction in problematic alcohol use (pre-program AUDIT: M = 21.05; post-acute phase AUDIT: M = 14.47; p<.001). Significant changes were also observed in levels of depression (p=.005), and situational confidence (p<.001).

Conclusions: This preliminary study provides support for the efficacy of an outpatient Alcohol Management Program for veterans with PTSD. In line with prediction, a significant reduction in alcohol use was observed. Further, it would appear that the ability to limit, or abstain from, alcohol is linked with wider changes in affect and self-efficacy.

THE SOUTH AUSTRALIAN PSYCHIATRISTS INDUSTRIAL DISPUTE OF 2007

Dr James Hundertmark

Southern Mental Health

Context: Psychiatrists need to become increasingly aware of the medico-political context in which they operate. As specialists we are relatively few in number but need to influence very large government and non-government systems in order to further the interests of both our profession and our patient population. In 2007 South Australian psychiatrists experienced a tumultuous period of dispute with the state government which lead to brief strikes, the submission of mass resignations and a formal industrial arbitration. The dispute will be used to outline some of the potential lessons we may learn about our current political environment and how to negotiate it.

Objectives: The paper will outline the background, build-up and arbitration of the psychiatrists dispute. The paper will attempt to analyse some of the forces at play in the development of the dispute. The presenter will outline the impact of the dispute on psychiatrists and the system in South Australia (SA). Potential lessons from the dispute will be shared with the audience.

Key messages: Psychiatrists now work in a complex medico-political environment which they cannot afford to ignore. Issues related to psychiatrist morale feed directly into the training environment and influence trainees and the intake numbers in our profession. There is a tension between the public and private psychiatry systems in Australia based which can be partially resolved by addressing some of the current public sector workforce issues. Overseas trained doctors bring an additional complexity to the current political and training tensions in Australia and other countries.

Conclusions: While it can be argued that industrial action goes against the code of ethics that doctors adhere to, psychiatrists functioning in a flawed mental health system cannot continue to ignore it's deficits if they reach a critical point. Whilst the SA industrial dispute caused great strain and tension for those in the profession and the other staff and consumers around them, the government eventually agreed to improved staffing and salary increments for psychiatrists as well as recognising the urgent need to continue to improve the South Australian mental health system.

PROMOTION OF PHYSICAL HEALTH IN THE MENTALLY ILL

Prof Mohan Isaac, Ms Ann Bates, Ms Vivien Kemp

University of Western Australia

Background: The HealthRight project is a direct outcome of the Duty to Care report (2001) which highlighted the physical plight of the mentally ill. This report was based on a study which had been undertaken by the University of Western Australia covering the period 1980-98 and including approximately 240,000 mentally ill people. The study established that people with mental illness die more frequently than others in the general population from preventable physical illness, notably heart disease – at 16% of excess deaths, and double the number of excess deaths due to suicide − 8%.

Aims: This presentation will illustrate how the HealthRight project has worked to develop a physical health promotion strategy targeted specifically at people with mental illness and aimed at creating awareness and at attending to physical health needs.

Method: This strategy includes a peer support service which has helped the target population to access GPs and to make lifestyle changes. The project has been collaborative involving UWA, NGO's, public mental health services, consumers and divisions of general practice. Resources have been developed based on art works produced by people with mental illness, covering the themes of smoking, nutrition, alcohol consumption and physical exercise. These resources have been disseminated in a variety of ways including the development of a website and information cards.

Results: have included numbers of people quitting smoking, losing weight, accessing GPs, and a greater awareness of the need to attend to physical health exists in the public and non-government sectors.

CONSUMER PARTICIPATION IN MENTAL HEALTH SERVICES: DEVELOPMENT OF A PILOT PEER SUPPORT SERVICE IN WESTERN AUSTRALIA

Prof Mohan Isaac, Ms Ann Bates, Ms Vivien Kemp

The University of Western Australia

Introduction: Australian National Mental Health Plan (2003-08) recommends involvement of consumers and carers at all levels within the mental health services. Reports from few countries show that persons with severe mental disorders can be involved in various aspects of service delivery in a meaningful manner.

Aim: To pilot test the feasibility of involving users of mental health services (peer supporters) to deal with physical health needs of adults with severe and enduring mental illnesses

Method: The peer support service was trialled at 3 sites-2 public sector adult mental health clinics and third a street doctor service. Collaboration with two mental health NGOs was established. Staff of mental health services were sensitized to work with trained peer supporters. Issues for the training of peer supporters were identified, a training programme and a resource kit for trained peer supporters were developed.

Results: 23 users of mental health services were trained to become peer supporters. Of them, 6 were employed as peer supporters at three sites. 32 clients were referred, of whom 25 opted to receive peer support. At the end of 6 months, the project was successful at 2 sites in helping clients to recognize the importance of attending to physical health needs by taking necessary steps such as making contact and visiting GPs, carrying out regular physical exercises, paying attention to diet and reducing/quitting smoking. Several barriers and enabling factors were identified.

Conclusion: Clinician education, addressing issues of confidentiality and role clarity are critical to the success of peer support programme.

LOOKING AFTER THE MENTAL HEALTH OF OUR OWN PROFESSION: ISSUES AND CHALLENGES

Dr Kym Jenkins, Dr Matthew Frei, Ms Cheryl Wiles, Prof Greg Whelan

Victorian Doctors Health Program

Content: this paper presents an overview of the work of the Victorian Doctors Health Program

Objectives: to outline the nature and frequency of the mental health problems faced doctors attending the program.

Issues and challenges in looking after doctors as patients are discussed and illustrated with case examples.

Key messages:

doctors are still not “good” at being patients: occupational pressures and personality traits predispose to mental health problems and make accessing care more difficult.

ethical concerns regarding duty of care, confidentiality and protection of the public are paramount:

Conclusion: those in the medical profession deserve optimal mental health care for their own benefit, for the good of there patients and the profession.

A HOMEOSTATIC MODEL OF SELF-HARMING BEHAVIOUR

Dr Luke Johnson

Noarlunga Health Services

Introduction: Self-harming behaviour, most often in the form of deliberate self-harm, is an important symptom of multiple mental disorders that comprises a substantial part of the work of emergency department and mental health services. Deliberate self-harm is usually defined to include intentional behaviours such as cutting or burning, but does not usually include culturally acceptable self-harming behaviours and other risk taking behaviours that have a high likelihood of resulting in personal injury.

Aim: Patients who engage in self-harming behaviour can be frustrating and difficult to treat, as they may appear unpredictable and unresponsive to therapy. The model aims to assist the therapist and the patient identify appropriate treatment strategies and assess the likely outcomes of various interventions.

Method: Developmental, cognitive and behavioural factors that contribute to self-harming behaviour are integrated in an explanatory format.

Results: Examples of how the model can be used to anticipate responses to various treatment options are then presented.

Conclusions: This model adds to the relatively few currently available explanatory models for self harming behaviour.

PREDICTORS OF RAPID RE-INCARCERATION IN YOUNG DETAINEES WITH PSYCHIATRIC DIFFICULTIES REFERRED FOR COMMUNITY MENTAL HEALTH FOLLOW-UP

Dr John Kasinathan, Dr Claire Gaskin

Adolescent Health, Justice Health

Background: Little was known about the characteristics and outcomes of juvenile detainees treated for psychiatric illnesses in NSW juvenile custody and subsequently referred to community mental health services (CMHS) upon release from custody. Anecdotally, such detainees seemed to quickly re-enter custody, though actual numbers were not known.

Aims: To identify demographic and mental health trends for this population, rates of subsequent incarceration and predictors of a rapid return to custody.

Method: A retrospective audit of the health files of 51 young detainees consecutively referred to CMHS upon release from custody between 1 January 2005 and 31 December 2007. Earliest dates of return to custody were determined.

Results: 47% were Indigenous. 43% were from regional communities. Substance misuse was high: alcohol 82%, cannabis 100% and amphetamines 59%. 39% were suicidal and 18% homicidal in custody. 57% satisfied diagnostic criteria for schizophrenia.

76% returned to custody in the follow-up period, 31% of which was to adult jail.

A Kaplan-Meier survival analysis found the median time to re-incarceration was just below 4 months. Linear regression analyses found that diagnoses of schizophrenia and bipolar disorder, a family history of mental illness and temporary accommodation on release predicted a rapid return to custody (p<.01). The length of time treated prior to release predicted a longer stay in the community (p=.02).

Conclusions: These valuable findings involving this vulnerable population should assist service planning, delivery and hopefully better integration into community care.

WHEN THE TEXTBOOK ANSWERS BACK: A REFLECTION ON PSYCHIATRIC LEARNING VIA THE INTERNET

Dr Deeta Kimber

Bendigo Health

Traditional psychiatric learning has clustered around a favoured text book, specialty journals and a targeted lecture series.

In the last 5 years there has been a dramatic change in the breadth, depth and quality of psychiatry information available via the internet using digital based technologies.

When this is coupled with easy to establish virtual psychiatric communities, increasing internet use expertise and a wide choice of visual and audio formats, the learning possibilities are vast.

Experience with the Australian and New Zealand Association of Psychiatrists in Training website, anzapt.org, indicates that didactic style learning moves to a conversation style with the potential for a new “voice”.

It has become easy to transcend geography and learn from sources all over the globe, but language still presents similar barriers.

Sorting and organization of information becomes increasingly important with the skill of scholarly discrimination becoming key.

Information becomes re-classified as free or paid and a new order of information privileging occurs through search engine accessibility.

This new paradigm can challenge how the psychiatric profession and educational community define professional identity and practice.

THE POWER OF “FREE HUGS” AS SEEN THROUGH AN INFANT MENTAL HEALTH LENS

Dr Deeta Kimber

Bendigo Health

http://www.youtube.com/watch?v=vr3x_RRJdd4

In late 2007 a three-minute video was posted on You Tube depicting a man offering free hugs in the Pitt St Mall in Sydney. It rapidly spread throughout the world as a political metaphor for peace and caring and a means of soothing modern life dislocation. Comments written in response to the video reflected a sense of being moved, often to tears and inspired by its basic humanity.

This paper explores the power of this video to connect with people in a deeply felt and authentic manner through an Infant Mental Health lense, exploring non-verbal communication, particularly gaze, gesture, and the co-regulated inter subjective space between strangers as they approach one another to hug.

The authentic non-verbal expression of loneliness, a moment of meeting and then embrace, activates powerful primal needs and emotions that we identify with strongly through our common human link.

The political power of this video lies in the repeated lived experience of seeing something different as we view the act of the hug and it's approach, with strangers and authority figures.

This is a powerful reminder of the importance of gaze, expression and gesture as ingredients of an authentic emotional connection, whether experience or watched. They serve to tell a true relationship story about hope and change.

THE HEALTHRIGHT PEER ADVOCACY AND SUPPORT SERVICE

Dr Jean King ¹, Dr Sue Jackson ²

¹ HCSG Ltd

² Perth & Hills Division of General Practice

Background: Lawrence, Holman & Jablenskys’ Duty to Care report (2001) found that people with mental illness die from preventable physical illnesses at a higher rate than the general population. The HealthRight project which was developed at the University of Western Australia in response to the Duty to Care research, has as one of its goals to trial a peer support service assisting participants to attend to their physical health needs. The trial is established in two sites in the Perth area and this presentation will focus on the service run in collaboration with the Street Doctor Service and a local non-government agency.

Aims: The presentation introduces and discusses the HealthRight Peer Advocacy and Support Service from the perspective of a peer supporter. The aim is to provide listeners with details of the kinds of physical health issues that have been addressed through one-on-one support.

Method: Case studies will be used to illustrate how individuals have been assisted to make lifestyle changes such as quitting smoking, engaging in physical exercise and achieving weight loss.

Results: The results of the trial have surpassed the expectations of all concerned and will be presented. The presentation will also discuss how peer support has increased engagement with health services by reducing physical and psychological barriers.

Conclusion: The HealthRight peer support service is highly relevant to the Department of Health Consumer Participation Plan and the successes have created a new level of consumer involvement in the recovery process.

SHORT-TERM PSYCHODYNAMIC PSYCHOTHERAPY FOR SOMATIC DISORDERS: SYSTEMATIC REVIEW AND META-ANALYSIS OF CLINICAL TRIALS

Prof Steve Kisely ¹, Dr Allan Abbass¹, Dr Kurt Kroenke²

¹ Dalhousie University

² Indiana University School of Medicine

Introduction: Somatic symptom disorders are common and costly to both sufferers and the healthcare systems. Effective treatments for the range of these disorders have been lacking. Individually provided short-term dynamic psychotherapies (STDP) show promise in clinical trials.

Aim: A literature review to find randomised and non-randomised studies of STDP therapies for symptom disorders in databases and references of studies.

Method: Two review team members had to agree the study met inclusion criteria. Outcomes of interest were psychological symptoms, physical symptoms, social-occupational function, healthcare use and treatment continuation.

Results: We identified 23 studies for a broad range of somatic disorders. Eighteen focused on a specific system or condition while 5 included somatic or somatoform symptoms in general. Thirteen were randomised trials and 10 were case series with pre-post outcome measurement. Of included studies, 21/23 (91.3%), 11/12 (91.6), 16/19 (76.2%) and 7/9 (77.8%) reported significant or possible effects on physical symptoms, psychological symptoms, social-occupational function and healthcare utilization respectively. A meta-analysis of 13 studies revealed significant effects on physical symptoms, psychiatric symptoms and social adjustment which were maintained in long term follow-up. Using random effects modelling some of these relationships were lost in the follow-up periods. There was a significantly greater rate of treatment retention in the STDP group versus controls.

Conclusion: Short-term Psychodynamic Psychotherapy appears effective for a range of medical and physical conditions underscoring the role of patient's emotional adjustment in overall health. Future research should include further randomised and clinical effectiveness studies with attention to healthcare use and cost effects.

AN EPIDEMIOLOGICAL STUDY OF PSYCHOTROPIC MEDICATION AND OBESITY-RELATED CONDITIONS USING ADMINISTRATIVE DATA

Prof Steve Kisely, Ms Martha Cox, Ms Leslie-Anne Campbell, Dr David Gardner

Dalhousie University

Introduction: Weight gain is a well-known side-effect of many psychotropics. There are less data on the over-65s even though they are more likely to receive psychotropics than younger populations. It is possible they may differ in terms of obesity-related conditions secondary to psychotropics, especially as increasing age is independently associated with both diabetes and hypertension.

Aim: To compare the incidence of two potentially obesity-related conditions (diabetes and hypertension) in psychiatric patents receiving the following psychotropic drugs with those not receiving them: antipsychotics, antidepressants and mood stabilisers. Method: A nested case-control study of a population-based cohort of all psychiatric patients in contact with either specialist services or primary care using administrative data from Nova Scotia, Canada (population = 1 million).

Results: We identified 608 cases of diabetes and 1056 of hypertension, as well as an equal number of controls for each condition. Amitriptyline, SSRIs and olanzapine were associated with an increased risk of presenting with hypertension after 6 months of prescription. Olanzapine was also significantly associated with diabetes after 6 months (OR = 2.35 (95%CI = 1.11 = 5.82)). We found no statistically significant differences in the cases and controls in terms of potential confounders with the exception of socio-economic class and schizophrenia in hypertension, but not diabetes.

Conclusion: Our results suggest that the association of psychotropics and obesity related conditions applies to the over-65s as well as younger populations. Within drug classes, there are drugs that have a greater association than others, and this may be a factor when choosing a specific agent.

ETHICAL AND LEGAL ISSUES ARISING FOR MENTAL HEALTH CLINICIANS AND INSTITUTIONS REGARDING CREATIVE WORKS MADE BY PEOPLE WITH AN EXPERIENCE OF MENTAL ILLNESS

Dr Eugen Koh

Adult general psychiatry

Creative works are made by people with an experience of mental illness in a variety of contexts. A significant proportion of works are made in clinical settings. Historically, mental health clinicians and institutions have tended to keep these works as part of their clinical records. In situations where works were made specifically as part of treatment their clinical status is supported by legal opinions. Health record and privacy legislations are most relevant in these situations. Many argue works that are not made as part of treatment or art therapy should be considered as art. In this situation, copyrights and moral rights legislations relating to artworks apply.

The status of works made by people with an experience of mental illness is complex and has significant legal and ethical ramifications. Mental health clinicians and institutions may have in their possessions works made by their patients. What are their responsibilities with regard to these works with regard to the legislations highlighted above? What are their responsibilities if they choose to exhibit these works? Should they display the name of the patient/artist as required by the moral rights of the artist or should they conceal the name because of the need for confidentiality? Upon retirement, should clinicians discard the works in their possession or should they return them to their patients? Should they donate these works to a gallery to display as art or to an organization that display them for educational purposes? Should these works be displayed at all without the consent of the patient/artist?

This paper intends to address these complex questions.

COGNITIVE-BEHAVIOURAL THERAPY FOR ADULTS WITH ADHD

Dr Dusan Kolar

Montreal Children's Hospital, McGill University

Attention-deficit/hyperactivity disorder is a highly prevalent neurobiological disorder. Controlled prospective follow-up studies of ADHD have demonstrated persistence of symptoms into adolescence in 60-85% of individuals diagnosed in childhood. A recent epidemiological study indicated the prevalence of adult population ADHD of about 4%.

Treatment options for ADHD usually include pharmacotherapy and psychotherapeutical modalities. The literature on psychosocial treatment of adult ADHD is sparse. There are no large controlled treatment studies, which explore the use of CBT in adults with ADHD. The results of the MTA study showed that medication treatment is significantly superior to behavioural therapy for ADHD symptoms in children with ADHD.

Although the literature on children does not support the use of CBT alone, the more advanced developmental stage, greater cognitive and emotional maturity and greater motivation of the adults are important reasons for attitude that CBT may be more effective in adults with ADHD.

The results of CBT studies in adult ADHD will be discussed in the presentation. The techniques which could be effective in adult patients with ADHD will be presented, including author's own experience.

We are focused on CBT designed for a small therapy group. Manuals for cognitive behavioural group therapy exist now. The organizational skills training and time management are the basic components in the most CBT programs for adult ADHD. Anger management, stress inoculation training, cognitive reframing, and relationship management are important modules addressing many other issues that face adult patients with ADHD.

“HE NEVER BACKS ME UP” AND “SHE DOESN'T GIVE ME A CHANCE”: THE IMPORTANCE OF THE “SUPPORTING PARENT” ROLE IN THE FORMULATION OF AND INTERVENTION WITH THE CONFLICTED PARENTS OF CHILDREN WITH EMOTIONAL AND BEHAVIOURAL DIFFICULTIES

Dr Peter Krabman

Coral Tree Family Service

In this presentation, we share some observations and impressions from our inpatient work with families where parents are in conflict with each other as well as with their child. In particular, we focus on the role which each parent has come to play whilst the other is taking an agent role with the children. Using theory and a number of clinical cases, we describe common patterns of engagement with or disengagement from the “supporting parent” role. We then discuss how these observations can serve as both a fruitful area for pragmatic behavioural intervention, and a “way in” for us to explore with the couple the strengths and vulnerabilities of their relationship, and its impact on each of them as people and as parents.

Parents often experience recurrent conflict when one “tries to help” the other deal with a child's difficulty, or have moved beyond this to minimise conflict by tag-team parenting or the alienation of one member of the couple from the parenting role. The main hands-on parent can take an exclusive/ controlling or an incompetent role, whilst the mostly-absent parent can be the wittingly or unwittingly undermining armchair expert or intimidating/ decisive circuit-breaker. Each parent is often both resentful of their role and resistant to change. Differing parental family-of-origin parenting experiences, misperception or miscommunication, parent-child alliances, broader relationship issues and the ambivalence of one or both parents about staying in the relationship can contribute to the disruption of the “supporting parent” role.

We endeavour to assist couples to move from mutual disrespect, animosity & entrenched positions to find respect for each others' perspectives, and to work on a shared parenting approach which they can back each other up in implementing.

SEVERE MENTAL ILLNESS AS A RISK FOR BLOOD-BORNE VIRUSES AND SEXUALLY TRANSMITTED INFECTIONS – PRELIMINARY FINDINGS

Dr Katerina Lagios ¹, Prof Frank Deane²

¹ SWAHS

² University of Wollongong

Introduction: Patients with severe mental illness (SMI), are at an increased risk of HIV because of high-risk behaviours with previous studies reporting markedly elevated HIV and HCV prevalence rate for patients with SMI.

Aim: To identify the level of risk for blood borne viruses (BBV) and sexually transmitted infections (STI) for inpatients with severe mental illness in the western suburbs of Sydney, Australia.

Method: Patients with severe mental illness admitted to the acute stay wards of Cumberland Hospital and aged over 18 were eligible. Enrolment occurred after their admitting psychiatrist deemed they were stable and able to give informed consent. Part I assessed demographic, medical, psychiatric, sexual and drug behaviours. Part II assessed prevalence of STIs and or BBVs by urine testing, serology or use of recent test results.

Results: About 100 patients have been enrolled so far and some results have been able to be compared to a recent large Australian telephone survey “Sex In Australia”. Patients with SMI were less sexually active less likely to have a regular relationship ever, more likely to be involved in risky sexual behaviour. Patients with SMI were less likely to have had preventative vaccinations, previous STI/BBV screening aside form HIV testing. Drug behaviours were also more pronounced especially cigarettes, marijuana and injecting drug use including unsafe injecting and sharing of drug paraphernalia. So far there is a high prevalence of HCV identified and HBV and HIV at lower rates.

Conclusions: This study is continuing recruitment. Patients with SMI are at risk for STIs and BBVs because of risky sexual and drug behaviours and with little preventative health for them as seen by the rates of BBVs in this group so far.

GOOGLE MD: A SURVEY OF INTERNET USAGE BY PRIVATE PRACTICE PATIENTS

Dr John Lam-Po-Tang ¹, Dr Diana McKay²

¹ The Paddington Practice

² Prince of Wales Hospital

Introduction: There is limited information about the prevalence of mental health related internet usage by consumers of mental health services, and how this may influence decision making.

Aim: To survey mental health-related internet usage in a sample of Australian private practice patients.

Method: Cross-sectional self-report survey undertaken in two large group psychiatric practices in Sydney.

Results: A total of 194 respondents completed surveys. Of the sample, 96% had internet access, and 78% had used the internet to search for mental health information. The most commonly sought information pertained to symptoms (62%), diagnosis (57%), treatment (62%) and side effects (62%). Only 10% accessed online therapy. The information was considered “very” or “fairly” reliable by 69% of the sample. Only 30% discussed the information with their psychiatrist, and 31% reported that the information influenced their decision-making.

Conclusions: Mental health-related internet usage is very common in private practice patients. Information is perceived as reliable in quality by the majority, and subjectively influences decision-making in a significant proportion. However, it is unlikely to be discussed with the treating psychiatrist.

MENTAL HEALTH AND THE COMMUNITY

Dr Donald Lawrence

We all need to belong, feel affirmed in a community, hopefully have an identifiable role. (Teacher, Postman, Busdriver). The community will also have “landmarks”, a church, a school, a tree lined park. All these create the concept of community.

Each one living there will have a sense of a reliable familiar place. A good place to live and play and sleep. Good mental health. And all this structure is established and supported and maintained by government.

And it can also be altered unsupported and dramatically changed by government.

Often without any research into the psychosocial impact of such change on the community, their mental health.

Railway stations closed. Bank branches closed. Schools closed. Hospitals closed. Big stores opened and little stores closed.

In Sydney a support centre for the homeless concerned about the conversion of Callan Park into student apartments.

Over 20 schools closed in the ACT contributing significantly to an announced budget surplus of $200,000.000.

Two villages, north and south of Canberra, historically established both had their school closed. Furthermore a regulation passed preventing the villages opening a privately funded school.

No longer such a good place to live and play and sleep. Not good mental health.

Psychiatrists, dealing with mental health, are singularly well placed to give good advice about good mental health to governments.

THE OVERT AND COVERT EXERCISE OF POWER IN SUPERVISION

Dr Joanna MacDonald

University of Otago, Wellington School of Medicine

Introduction: The training of psychiatrists in the Royal Australian and New Zealand College of Psychiatrists (RANZCP) has been described as an apprenticeship model, with supervision considered central to that training. However, supervision has never been defined. Similarly, it is not clear why supervision is individual and for a minimum of one hour each week, or what happens during that hour.

Aim: The author has undertaken extensive research that aimed to explore and clarify what happens during the mandated individual supervision hour; how supervision contributes to the production of psychiatrists; and why it was configured as it was.

Methods: The research involved collecting data by means of interviews and focus groups, and audio taping fifty hours of supervision sessions. A thematic analysis was undertaken.

Results: This analysis suggested inter alia that supervision in the RANZCP can be conceptualized as an exercise of disciplinary and other forms of power, which can be expected to produce psychiatrists who conform with the behaviour and attitudes of their supervisors and therefore of Fellows of the RANZCP. In this presentation I will describe some of the mechanisms by which power was exercised.

Conclusions: The mechanisms by which power is exercised in supervision are myriad and largely unrecognized. Such mechanisms raise questions about whether trainees can be expected to give meaningful feedback about their supervision. As a corollary, the unrecognised exercise of power may mirror psychiatrists’ interactions with their patients/consumers and similarly render meaningful discussion and feedback considerably more challenging for consumers/patients than is acknowledged.

BEHIND CLOSED DOORS: THE AFFILIATIVE FUNCTION OF SUPERVISION

Dr Joanna MacDonald

University of Otago, Wellington School of Medicine

Introduction: The training of psychiatrists in the Royal Australian and New Zealand College of Psychiatrists (RANZCP) has been described as an apprenticeship model, with supervision considered central to that training. However, supervision has never been defined. Similarly, it is not clear why supervision is individual and for a minimum of one hour each week, or what happens during that hour. Supervision has largely been a mysterious process.

Aim: The author has undertaken extensive research that aimed to explore and clarify what happens during the mandated individual supervision hour; how supervision contributes to the production of psychiatrists; and why it was configured as it was.

Methods: The research involved collecting data by means of interviews and focus groups, and audio taping fifty hours of supervision sessions. A thematic analysis was undertaken.

Results: Considerable uncertainty was expressed by supervisors and trainees regarding what supervision ‘should be’. One finding, inter alia, was that supervision served an affiliative function for the supervisors, and provided a private space in which to express attitudes and opinions that may not be publicly acceptable. This function has not been reported previously in the literature. Such a function may be particularly necessary with the loss of daily opportunities for collegial affiliation that were available in the past in the psychiatric hospitals. This affiliative function provides some explanation of the privacy and secrecy of the supervision hour.

Conclusions: The affiliative functions of supervision need to be recognized and allowed for in any proposals for change to supervision.

NEUROLEPTIC-INDUCED MOVEMENT DISORDERS IN PSYCHOTIC PATIENTS WITHIN NORTHLAND DHB: ETHNIC VARIATION

Dr Hossam Mahmoud, Dr Gloria Johnson, Ms Valletta Tawhai

Northland DHB, New Zealand

Introduction: There is a common perception within the New Zealand mental health community that patients from a Maori background develop more side effects, particularly movement disorders after treatment with neuroleptics.

Aims: This study investigated the point prevalence of extrapyramidal movement disorders in patients with chronic schizophrenia and related disorders who are currently treated by Northland DHB mental health services. The study also investigated evidence of variation in the point prevalence of these disorders based on the ethnicity of the patients (Maori and non Maori).

Methods: 151 patients, who were receiving antipsychotic medication, which had been commenced at least 3 months previously, were recruited as participants for the study using randomised computer software. Ethnicity was documented using self-identification. Standardised assessment tools were used to assess EPS

Results: Approximately 54% had symptoms on at least one of the measuring scales. The analysis failed to show any statistically significant differences based on ethnicity (Maori and non Maori). However, the Maori subgroup was younger and there was trend for Maori to score more highly on some subscales.

Conclusion: The findings suggest that the prevalence of neuroleptic-induced movement disorders in psychotic patients within Northland DHB is similar to the documented international figures1 (up to 60%). The findings also indicate that there is no significant difference based on ethnicity between Maori and non Maori in terms of overall prevalence of movement disorder.

WHAT DO WE KNOW ABOUT TRAUMA AND LOSS IN C&A CLINICAL POPULATIONS?

Dr Virginia McAndrew

Academic Unit of Psychological Medicine, ANU

Context: Child and Adolescent Mental health problems are prevalent with reported rates varying from 14% to 26% internationally. Multiple risks for Child and Adolescent Mental health problems have been identified. Vulnerability results from a person-environment interaction. Individual characteristics and family and environmental factors interact to exacerbate vulnerabilities or to promote resilience.

Objective: This paper will examine the literature currently available on grief, loss and trauma in child and adolescent populations

Key message: Issues of grief loss and trauma have a significant impact on children's vulnerability to mental health problems, yet there is limited information about the prevalence of these in clinical populations in this age group.

Conclusion: More information is needed to ascertain the prevalence of grief loss and trauma in children and adolescents so that appropriate community resources can be allocated to address their needs

THE USE OF PATIENT SIMULATION IN NEUROPSYCHIATRY

Prof Harry McConnell

Griffith University

Context: Patient simulation is used as a teaching method in a variety of surgical specialties for teaching procedures and has been shown to be an effective means of teaching, bringing the subject to life for the students. This presentation will review the various platforms used for patient simulation and our experience to date in using them in Australia in different settings to teach Neuropsychiatry. We will also explore its potential use as a mechanism for both understanding and for preventing medical error.

Objectives:

to review the available platforms for patient simulation ad their potential use in neuropsychiatric teaching

to review our experience in Australia with the use of patient simulation as a teaching tool in Neuropsychiatry

to review the potential for this tool in prevention of medical error in the clinical practice of neuropsychiatry

Key Messages:

Patient simulation can be approached in many different ways for teaching using a variety of platforms.

Learning is more engaging for the students and analysis of the interactions can lead to a better understanding of clinical reasoning and medical decision making.

Both pros and cons of using this method of teaching will be reviewed.

Conclusion: Patient simulation is a highly interactive and effective means of teaching and has many advantages over more traditional methods of pedagogy, particularly in Neuropsychiatry

PSYCHIATRIC COMORBIDITY IN EPILEPSY

Prof Harry McConnell

Griffith University

Context: People with epilepsy (PWE) manifest psychiatric problems for many reasons. PWE may present with ictal psychiatric phenomena including psychosis, depression and panic disorder. Post ictal presentations are common and may mimic major depression and schizophrenia but have a different aetiology, treatment and prognosis. The interictal disorders include schizophrenia-like psychosis of epilepsy (SLPE) and interictal dysphoric disorder. Sometimes the underlying lesion may be the primary cause of psychiatric morbidity, or the seizures and psychosis may both result from a primary metabolic disorder. Antiepileptic drugs (AEDs) frequently cause adverse effects which manifest with psychiatric symptoms and may mimic primary psychiatric disorders. AEDs also commonly interact with psychotropics and complicate both the psychiatric and neurological treatment.

Objectives:

to look at the role of psychiatric co-morbidity in epilepsy and its aetiological relationship to treatment, underlying causes of seizures and to the social and stigma related aspects faced by PWE

to look at the role of iatrogenic causes and medical error in the diagnosis and management of psychiatric co-morbidity in epilepsy

to review the complex interactions of AEDs and psychotropic medications

to review recent guidelines for the diagnosis and treatment of these disorders

to present proposals for clinical and research opportunities in this field

Key Messages:

Psychiatric co-morbidity in PWE is a frequent scenario for error in diagnosis and treatment

Conclusion:

Good communication between neurologists, psychiatrists and GPs is critical for psychiatric care of PWE

MENTAL HEALTH RESEARCH ACROSS CULTURES – AN ETHICAL DILEMMA?

A/Prof Jane McKendrick

Faculty of Medical and Health Sciences, University of Auckland

Introduction: In recent years there has been a great deal of discussion about whether the ethical guidelines for health researchers based on western values are applicable across cultures. It is well documented that there are significant cultural differences between and within western countries with respect to ethics. These differences are even more marked between western and non western cultures, including indigenous cultures. For example, in some non western countries it has been difficult to establish the Human Ethics Research Committees necessary to allow international studies to be conducted.

This paper discuss the ethical issues which arise when working across cultures, with particular reference to the conduct of psychiatric research.

Aim: To demonstrate that ethical guidelines developed for the conduct of research in'western' cultures are not necessarily appropriate for use in different cultures.

Method: This paper is informed by:

A critical examination of the literature pertaining to ethical guidelines for medical research in western countries, in particular their applicability across cultures.

The authors' experience of clinical and research work with indigenous peoples in Australia, New Zealand and Canada. Vignettes derived from clinical work and research will be used to illustrate key issues.

Results: There are important differences in ethics and values across cultures. These issues need to be addressed within the research process. Consultation between the researchers and members of the communities in which the research is to be conducted is essential.

Conclusions: The conduct of research which takes into account the ethical values and principles of non western partners is crucial as countries such as Australia and New Zealand becomes increasingly multicultural. Ethical research across cultures involves ongoing dialogue (what is to be done? how should it be done? who should do it?) and a preparedness to make changes to protocols as required to meet the standards and needs of the particular community or cultural group.

EMBRACING INTERNET TECHNOLOGY – A MODEL FOR PROVIDING PSYCHIATRIC CONSULTATIONS ONLINE

Dr Gregory McKeough

etherapystat.com

Context: Use of the internet for sale of goods has revolutionised commerce in areas where internet access is readily available. Provision of services online is now in its infancy, but offers numerous advantages to both customers and providers. Australian psychiatrists have been early adopters of teleconsultation. Utilisation to date has been primarily in the public sector to provide consultation to remote locations using public health infrastructure and relatively expensive modes of communication using multiple ISDN lines.

Objectives: To discuss ways in which mental health teleconsultation could be made widely available to any consumer with a computer and a broadband connection.

Key Messages: Mental health consultations vie the internet are likely to increase significantly as awareness of possibilities increases amongst consumers and providers. Already there are sites presenting users with an interface which allows them to choose an appropriate mental health professional, make appointments and process payment. Consultations will generally be by live videoconferencing using secure, inexpensive and widely available technology. Users benefit from convenience of consultations in privacy of their own home or office. They also incur no transport, parking or accommodation costs and will in general be able to choose from a range of therapists rather than just those available locally. Therapists benefit from having minimal practice costs, complete flexibility about how often and when they work, a very high level of personal security and the ability to work from any location with a broadband connection.

Conclusion: Online consultations pose a range of challenges and opportunities for psychiatrists and consumers.

THE “UTE” CLASSIFICATION OF PSYCHIATRIC DISORDERS

Prof Graham Mellsop

Waikato Clinical School, University of Auckland

After presenting a brief summary of difficulties and inadequacies in the presently used ICD 10 and DSM 4 classificatory systems, a model of something more useful will be presented. The reasons for some significant changes will be outlined.

The approach presented will aim to be a continuous improvement on the present systems with particular gains in effectiveness and efficiency. It will draw heavily on relevant subspecialty expert opinion.

The proposition put forward is the author's own and not to be taken as reflecting the views of any ICD 11, WHO planning groups with which he may be associated.

THE ZOO IN THE ROOM – A BRIEF EXPLORATION OF ANIMAL ASSISTED THERAPY

Dr Hannah Mendelson

Context: Animal-assisted therapy is becoming more and more accepted, as evidence for its efficacy mounts up. Indeed, Psychiatry was one of the very first disciplines to utilize animal-assisted therapy, starting in the 18th century.

Objectives:

Define various forms of animal therapies

Outline the history of the therapeutic use of animals, with a particular emphasis on their historical use in the practice of Psychiatry

Canvass the range of healthcare settings for which evidence has been gathered

Key Messages:

There are a variety of forms of animal therapy, of which “animal assisted therapy” is a particular kind

There is growing evidence of the value of animal therapy in a variety of healthcare settings, including psychiatric rehabilitation

Conclusion: There is a need for more research in this area, with a variety of potential therapeutic possibilities. Co-operation among various agencies-and some lateral thinking in the area of psychiatric rehabilitation-has many exciting possibilities.

SIDNEY FREEDMAN – THE EPITOME OF “THE PSYCHIATRIST”

Dr Hannah Mendelson

Context: M∗A∗S∗H was an incredibly successful television show that ran between 1972 and 1983, and remains a regular staple on both free-to-air and cable television. Many memorable characters are portrayed, and the resident psychiatrist, Dr Sidney Freedman, is one of them.

Objectives: To explore the qualities of the character that make Sidney Freedman so popular, and to ponder whether they may hold useful lessons to the current generation of psychiatrists, particularly those still in training.

OLD, BUT NOT OLD ENOUGH?

Dr Ramon Mocellin, Dr Mark Walterfang, Dr Dennis Velakoulis

Melbourne Neuropsychiatry Centre

Introduction: Although changing demographics in the wider population are mirrored in those with chronic mental illness, meeting the care needs of these groups as they age can be quite different

Aim: The following case series aims to illustrate the problems of ageing individuals with chronic mental illness and how existing services may fail to address the particular medical, accommodation and cognitive problems they experience. Hopefully some discussion will be generated on how best to address this issue.

Method: A series of four cases are presented in detail to illustrate these issues.

Results: A 61 year old single man was referred for admission to his area's psychogeriatric nursing home (PGNH). He had a long history of Bipolar Affective Disorder which was largely treatment resistant. He was agitated, grandiose, voided inappropriately and had features of severe tardive dyskineasia, but had spent much of the past 18 months in hospital. There was service related conflict with respect to the most appropriate accommodation and when that may be available. A 56 year old woman had a diagnosis of Frontotemporal dementia. She presented with disinhibited behaviour and hyperphagia which was resistant to pharmacotherapy. Although waitlisted for PGNH, it was unlikely a bed would be available for 12 months and she was discharged to mainstream Residential care service which were unable to cope with her needs and behaviour. Two further similar cases are described.

Conclusion: The capacity of psychiatric and other services to meet the needs of this complex group of patients is dependant on the flexibility of entry criteria, historical precedents, level of clinical and management skills, geographic factors and often decisions taken by individuals outside entry criteria. As such patients become more prevalent future planning is required to design systems that meet their needs.

CEREBRAL VASCULITIS AND CONVERSION DISORDER: MUTUALLY EXCLUSIVE?

Dr Ramon Mocellin, Dr Mark Walterfang, Dr Dennis Velakoulis

Melbourne Neuropsychiatry Centre

Introduction: Neurological disorders with intermittent and indistinct symptoms can present as phenocopies of somatoform disorders. It is often the way in which the patient and their family react to such symptoms that assist in clarification of diagnosis.

Aim: The following case aims to demonstrates that this distinction can be very difficult and the diagnostic processes involved.

Method: A case is presented in detail to illustrate these issues

Results: A 22 year old single woman was referred from Neurology outpatients with a request for diagnostic clarification of intermittent left hemiplegia and parastheisias. She had a past history of chronic fatigue syndrome and juvenile rheumatoid arthritis. She described a three year history of intermittent altered sensation on the left side of her body particularly involving upper leg arm and face. These symptoms had worsened over the past 12 months and had become associated with migrainous headaches. Several admissions and investigations had failed to demonstrate a cause. There were a number of conflicting interpretations of neuroimaging findings. These symptoms had resulted in ongoing functional impairment and was in the context of conflict with her parents.

Conclusion: The assessment and diagnostic process will be discussed with reference to the parallel and complex issues of subtle abnormalities on investigation and the potent transference and countertransference which influenced their interpretation. Discussion of the historical data regarding the eventual diagnosis of organic diseases in patients with somatoform disorders will also be raised.

HOW CAN NON-GOVERNMENT PSYCHIATRIC DISABILITY AGENCIES HELP REDUCE SMOKING AMONG PEOPLE WITH MENTAL ILLNESS?

Ms Kristen Moeller-Saxone

University of Melbourne

Introduction: Australia is hailed internationally for its ‘public health success story’ in tobacco control. According to the OECD cigarette smoking rates in the Australian population have halved over the last 20 years (from 35% in 1983 to 17.7% in 2004) largely because of the “policies aimed at reducing tobacco consumption through public awareness campaigns, advertising bans and increased taxation”. However smoking prevalence rates in this group are repeatedly cited as anywhere between 50% −88%. Tobacco control researchers use the Diffusion of Innovations model (Rogers, 2002) to account for the slow uptake of the smoking cessation message by groups in the community such as people from lower socio-economic groups and people with a mental illness. To speed up innovation, this model recommends the use of peer networks and'champions'. The non-government psychiatric disability support sector is an ideal place to implement these innovations because it is already strongly geared to peer networking.

Aim: To survey a major non-government agency to assess smoking rates and interest in reducing or quitting smoking among consumers. Method: A brief questionnaire was developed and implemented. Interviews were also conducted with people who had successfully quit smoking.

Results: Smoking rates appear to be stable at around four times that of the general population. High rates of illegal tobacco smoking may support the self-medication hypothesis and help alleviate financial pressures. There is a high level of interest in reducing and quitting smoking among consumers.

Conclusions: Interest in reducing and quitting smoking is high and psychiatrists may benefit from referring patients to non-government support agencies to help address smoking issues.

TRENDS IN PRESCRIBING PRACTICES IN AN URBAN COMMUNITY MENTAL HEALTH CLINIC 2004–2007

Dr Kaveh Monshat, Dr Bridget Carty, Dr Peter Bosanac, Dr James Olver

Austin Health

Background: Recent availability of new psychotropic agents and formulations as well as expanded indications for previously available agents has had an impact on prescribing patterns in community psychiatric practice.

Aims: To compare psychotropic prescribing patterns in a community mental health clinic over several years.

Methods: Sequential cross-sectional file review of prescribed psychotropic medication and diagnoses were conducted. Data were collected in late 2004 (N = 276) and early 2007 (N = 343), with an interval of 2.5 years.

Results: The vast majority of patients suffered from DSM-IV schizophrenia and related disorders (82% in 2004, 84% in 2007). A majority of patients received atypical antipsychotic medications (91% in 2004, 82% in 2007). Significantly increased use of long-acting risperidone (2% to 14%) and non-benzodiazepine hypnotics (3% to 8%) over the two and a half year period have been paralleled by significant decreases in long-acting typical antipsychotics (9% to 3%) and benzodiazepine hypnotics (5% to 3%), respectively. Use of all non-antipsychotic mood stabilisers declined, with lithium showing a much more significant decrease than valproate (Li 9% to 2% vs Val 15% to 11%).

Conclusions: Changes in prescribing patterns of antipsychotics and hypnotics appeared to parallel the availability of agents with reportedly better side-effect profiles. Increasing use of atypical antipsychotics as mood stabilisers is a likely explanation for a decline in other mood stabilisers. Clinician preference, based on a perception of lower toxicity, may account for the differential decline in lithium versus valproate use.

USE OF PRIMARY CARE MEDICAL AND DENTAL HEALTH SERVICE PROVISION IN SCHIZOPHRENIA: A PRELIMINARY REPORT FROM THE “SCOPE” PROJECT

Dr Richard Mullen, Dr Chris Gale, Dr Tess Patterson

University of Otago

Background: Schizophrenia is commonly associated with poor physical health and reduced life expectancy. Much of this burden of ill health can be understood in terms of lifestyle factors, social adversity, and adverse pharmacological events. In addition, we suspect that individuals with schizophrenia are infrequent users of primary care services.

Aims: We aim to assess use of primary care medical and dental services, and uptake of influenza vaccination, cervical screening and mammography in community living individuals with schizophrenia.

Methods: The Schizophrenia: outcomes, psychosis, experience (ScOPE) project will interview a community sample of 100 individuals with a clinical diagnosis of schizophrenia, covering indices of mental and physical ill health, quality of life and recovery, and service use.

Results: Preliminary findings will be presented. We expect to find that people with schizophrenia have little contact with primary healthcare providers.

Conclusions: Increased use of primary medical and dental health care services may mitigate against the elevated burden of medical and dental ill health experienced by individuals with schizophrenia.

OUTCOMES OF A RELAPSE PREVENTION TRIAL IN INDIGENOUS MENTAL ILLNESS

Dr Tricia Nagel, Ms Valerie Thompson

Menzies School of Health Research

Background: AIMHI NT is a five year NHMRC funded project which has been working in remote Aboriginal communities with Aboriginal Mental Health Workers (AMHWs) for five years. We have been developing psycho education resources which incorporate Indigenous perspectives of mental illness.

Aims: This study brought together a focus on relapse prevention and best practice in mental health service delivery in remote settings. It targeted Indigenous clients, carers, and AMHWs. A range of assessment, psycho education, and care planning resources were developed and incorporated into a focused brief intervention. The study then implemented a randomised trial of the intervention in two remote health centres, seeking to compare the effectiveness of the intervention with treatment as usual.

Methods: Forty-nine (49) clients with mental illness were recruited and randomised to an ‘early treatment’ group, and a ‘late treatment’ group, Client outcomes were assessed six monthly for eighteen months using Health of Nation Outcomes Scale (HoNOS), Life Skills Profile (LSP), Severity of Dependence Scale (SDS) and Partners in Health (PIH) scales. The study aimed to assess differences between the outcomes of the two groups and changes in outcome over time.

Results: The treatment showed significant improvement in outcomes in comparison with treatment as usual.

Conclusion: The study provides a strategy for managing Indigenous people with mental illness and comorbidity.

GETTING PUBLISHED IN PSYCHIATRY: A TRAINEE'S PERSPECTIVE FOR TRAINEES

Dr Bradley Ng

Gold Coast Mental Health Service

Context: Publishing anything in psychiatry may seem like a daunting task initially, but it is a very satisfying accomplishment. As well as making a small contribution to the psychiatric literature, it assists in establishing a career and encouraging academic development.

Objectives: To present some strategies to get published drawn from the author's experience.

Key Messages: One does not need to be in an academic centre to be published. Identifying mentors and supportive consultants and remaining alert for potential topics are the first steps. Keeping up to date with the literature helps to identify areas of controversy and discussion. Be prepared for frustrations and the occasional editor that just does not see your point! However, perseverance and the targeting of the correct journal usually pays dividends.

Conclusion: Publishing early in one's career is possible and very rewarding.

PSYCHOSTIMULANTS AND GENERAL PSYCHIATRY: A REVIEW OF THE RECENT LITERATURE

Dr Bradley Ng ¹, Dr Angela O'Brien²

¹ Gold Coast Mental Health Service

² Waitemata DHB

Context: Psychostimulants are a broad class of drugs that reduce fatigue, promote alertness and wakefulness, and have possible mood enhancing properties. In modern psychiatric practice, their use has been limited to Attention Deficit Hyperactivity Disorder, and sleep disorders such as narcolepsy. Despite this, research about psychostimulant use has continued in general psychiatry, especially in the treatment of depression and fatigue.

Objectives: The following presentation will review the recent literature regarding psychostimulant use in general and consultation liaison psychiatry.

Key Messages: There is limited evidence to support the use of psychostimulants, either as monotherapy or as an augmentation agent, in major depression. Two recent trials of modafinil as an augmentation agent were unconvincing. There is preliminary evidence to suggest that modafinil may be helpful in bipolar depression. Methylphenidate may have a limited role for depression in the elderly, medically unwell and palliative care. Trials of various psychostimulants for fatigue in multiple sclerosis, chronic fatigue syndrome and cancer have been disappointing.

Conclusion: The use of psychostimulants continues to be limited and cannot be routinely recommended in depression. It remains a medication of last resort in medical and palliative care situations or when other biological treatments are contraindicated or intolerable. The treatment of bipolar depression with modafinil remains promising.

There are no conflicts of interest.

CASE REPORTS REMAIN USEFUL: SEROTONIN SYNDROME FROM METHYLENE BLUE AND ANTIDEPRESSANTS

Dr Bradley Ng ¹, Dr Rhea Liang², Dr Andrew Cameron²

¹ Gold Coast Mental Health Service

² Middlemore Hospital

Context: The usefulness and validity of case reports is controversial and many leading psychiatric journals no longer publish full case reports. However, they remain important in describing rare phenomena and drug interactions that have potentially serious sequelae.

Objectives: To report a case of autonomic, neurological and neuromuscular instability following methylene blue infusion for parathyroidectomy, to advance the argument for a diagnosis of serotonin syndrome, and to consider this diagnosis in previous, unexplained reports of adverse reactions amongst patients undergoing parathyroidectomy using methylene blue.

Key Messages: Methylene blue has previously been considered a relatively benign agent in routine surgery, but several case reports have highlighted adverse reactions. Most of the patients were on serotonin reuptake inhibitors, leading to the hypothesis of previously undiagnosed serotonin syndrome.

Conclusion: An interaction between methylene blue and serotonergic agents may give rise to the serotonin syndrome. This adverse reaction has only been highlighted after several case reports had been published and has implications in psychiatry, surgery and anaesthesia. Case reports continue to have an important role in psychiatry, but clinicians need work objectively and with other disciplines.

INTERNATIONAL MENTAL HEALTH DEVELOPMENT IN ASIA-PACIFIC

A/Prof Chee Ng ¹, Ms Julia Fraser², Ms Bronwen Merner¹, Ms Margaret Goding³, Prof. Bruce Singh⁴

¹ St Vincent's Mental Health

² Asialink

³ St Vincent's Health

⁴ University of Melbourne

Context: Mental health services are generally inadequately developed in the Asia-Pacific region. As the proportion of socioeconomic burden caused by neuropsychiatric disorders continues to increase (Patel et al, Lancet, 2008), developing countries in the Asia-Pacific are looking to Australia for collaboration in developing and implementing mental health reform.

Objectives: Asia-Australia Mental Health, a consortium formed principally by The University of Melbourne and St. Vincent's Health, are working in partnership with mental health policy makers and leaders across the Asia-Pacific to facilitate the development of community mental health service models that are both culturally sensitive and based on best practice principles. The POST Program, part of the International Unit of Psychiatry, University of Melbourne, complements such work by offering clinical training fellowships for Asia-Pacific mental health clinicians seeking to strengthen their skills in community mental health development.

Key Messages: Initiatives such as Asia-Australia Mental Health and the POST Program can play a key role in the regional development of culturally and locally adapted models of community mental health care. Such international collaboration is maximised when: it is based on principles of genuine partnership; multi-level engagement (from front-line clinicians to policy makers); and bilateral government support.

Conclusion: The Asia-Pacific region includes countries at all stages of community mental health reform. Australia, having already undergone fundamental changes to its mental health system, can play a significant role in facilitating the capacity of countries in the region to progress their own mental health reform via an innovative collaborative network in the region.

THE RELATIONSHIP BETWEEN GDP AND DUP

Dr Olav Nielssen ¹, Dr Matthew Large², Dr Saeed Farooq³

¹ St Vincents Hospital Sydney

² The Paddington Practice, Sydney

³ Lady Reading Hospital, Peshawar, Pakistan

Background: The duration of untreated psychosis (DUP), the period between the first onset of psychotic symptoms and treatment, has an important influence on the outcome of schizophrenia.

Aims: Our aims were to compare the published studies of DUP in low and middle income (LAMI) economies with the DUP of high income (HI) economies, and examine a possible association between DUP and per capita income.

Method: We used five search strategies to locate studies of the DUP from LAMI economies published between January 1975 and January 2007. We then examined the relationship between DUP and measures of economic activity, which was assessed using the LAMI classification of economies and gross domestic product purchasing power parity (GDP ppp).

Results: The average Mean DUP in studies from LAMI economies was 125.0 weeks compared to 63.4 weeks in studies from HI economies (p = 0.015). Within the studies from LAMI economies Mean DUP fell by 6 weeks for every thousand dollars of GDP ppp.

Conclusion: There appears to be an inverse relationship between income and DUP in LAMI economies. The cost of treatment is an impediment to care and subsidised antipsychotic medication would improve the access to treatment and the outcome of psychotic illness in LAMI economies.

TACHYPHYLAXIS WITH SSRIs

Dr Manjula O'Connor

Collins St Medical Centre

Clinical Experience with a large number of cases is highlighted by presenting 6 cases who demonstrated diminishing response to SSRIs with consequent steady increase in dose. Worsening in mental state and a picture of atypical depression was noted. Possible theoretical reasons are presented. Management strategies based on theory are discussed.

MOOD MATTERS: IMPLEMENTING CLINICAL GUIDELINES FOR MOOD DISORDERS

Dr Nick O'Connor ¹, Prof Gin Malhi², Dr Michael Paton¹, Ms Danielle Adams¹

¹ Northern Sydney Central Coast Health

² University of Sydney

Introduction: The New South Wales Health Tracking Tragedy Report 3 (2007) reported a survey of the medical records of 100 patients of mental health services with a diagnosis of depression who had died by suicide in the NSW. The Report found some significant gaps in the treatment received by these patients when compared with the RANZCP clinical guidelines for depression.

Aim: The Mood Matters project is a joint initiative by Northern Sydney Central Coast Health and the University of Sydney to explore the barriers clinicians encounter in adhering to treatment guidelines and to implement strategies for improved treatment outcomes.

Method: The Mood Matters project uses clinical services redesign methodologies such as examining the patient journey, to redesign service delivery to this important patient group.

Results: The Project components include the development of a set of Area Health Service treatment guidelines informed by the RANZCP and other evidence based treatment guidelines; a professional development and support; use of technologies, group and self-help strategies to deliver psychosocial interventions, and evaluation of the delivery of care post-intervention using a ‘bundles of care’ methodology.

Conclusions: The Mood Matters project provides a model for the implementation of treatment guidelines in mental health services.

“‘ALLO ‘ALLO ‘ALLO, WHAT ‘AVE WE ‘ERE THEN”

Dr Jeremy O'Dea ¹, Dr Olav Nielssen², Dr Danny Sullivan³, Mr Marcelo Rodriguez⁴, Dr Matthew Large⁴

¹ The Paddington Practice

² St Vincent's Hospital and the Paddington Practice, Sydney

³ Victorian Institute of Forensic Mental Health

⁴ Private Practice, Sydney

The internet has proved to be an effective medium for disseminating child pornography and linking people interested in viewing child pornography. The possession of internet child pornography is a relatively new offence with limited knowledge to date concerning the people who seek this material. However, increasing numbers of men have been charged with these offences and referred for psychiatric assessment. This paper presents the clinical characteristics of a group of 58 men who were either charged with or presented for treatment in relation to child pornography offences, and who were assessed by 4 clinicians who specialise in the assessment and treatment of sex offenders.

Examination of the findings using a cluster analysis revealed that child pornography offenders appear to consist of at least 2 distinct groups. One cluster included older, higher functioning men with few previous convictions, who were mostly detected by electronic surveillance and were often found to possess large quantities of images of prepubescent children. The second cluster were younger, had smaller quantities of pornography, were more likely to have presented for treatment after discovery by family members and often had disabling psychiatric disorders. This second group more frequently reported a history of sexual abuse, and were more likely to have had a prior conviction for a sex offence and to have committed a contact offence involving a child.

The paper will explore issues of risk assessment and risk management of this group, including whether the possession of child pornography is sufficient of itself to establish the diagnosis of paedophilia according to the criteria in DSM IV TR.

Whilst more needs to be known about persons who access child pornography in order to better understand the risks they may present and to develop appropriate treatment and risk management programs, this study suggests that child pornography offenders may form a mix of at least 2 groups. A group of older, less psychiatrically impaired offenders who may carry a lower risk of committing contact offences despite what appear to be specific paedophilic interests, and a group of younger offenders with psychiatric disorders who may carry a higher risk of contact offences and need a more comprehensive treatment approach to remedy a range of psychosocial deficits as well as treatment aimed at addressing their specific sexual interest in children.

THE PSYCHOANALYSIS OF FREUD AND THE SEDUCTION HYPOTHESIS

Dr Michael Plastow

Alfred Child and Adolescent Mental Health Service

Freud's abandonment of the seduction hypothesis has been criticised from some areas as implying that Freud chose to ignore child sexual abuse. Such critiques can be seen as confusing the domain of material history with the plane of fantasy and desire. It is proposed that it is precisely Freud's abandonment of the seduction hypothesis which is able to distinguish the two and establishes psychoanalysis as a separate epistemological field from that of objective science. This paper aims to take up the question of the abandonment of the seduction hypothesis both in relation to the history of psychoanalysis as well as in regard to Freud's self-analysis. From here the question of the seduction hypothesis and its abandonment will be examined in its application to what transpires in each and every analysis and therefore in its contribution to psychoanalytic theory.

OUT OF THE MOUTH OF BABES: AUSTRALIAN CHILDREN AND ADOLESCENTS SPEAK OF LIVING AND DYING WITH A LIFE LIMITING CONDITION

Dr Marie-Therese Proctor ¹, Prof Sue Nagy², Dr Michael Stevens¹, Dr Bruce Lord¹, Dr Libba O'Riodan¹

¹ Children's Hospital at Westmead

² University of Technology, Sydney

Background: It is a rare opportunity to observe and speak with children and adolescents with life limiting conditions and so gain insight into the lives. Their vulnerability is often characterized by rare and difficult-to-diagnose conditions, significantly shortened life spans with compromised quality of life. Their childhoods are scattered with periods of hospitalization, missed developmental milestones and a loss of innocence as they address the reality of life with illness.

Aims: To explore the lives of ill children: their illness journey, their hopes, concerns, and health care related experiences.

Methods: We present findings from a large Australian qualitative study exploring families’ experiences of caring for children diagnosed with life limiting conditions. Ninety-one family members (parents, ill children, well siblings and extended family members) from 29 families with one or more ill children participated in home based, in-depth unstructured, audio-taped interviews.

Results: They spoke about how conditions such as muscular dystrophy, cystic fibrous, cancer, leukaemia, neuro-degenerative and genetic disorders impact upon family life, at the level of the individual, the nuclear and extended family units. Health care professionals are afforded a unique opportunity to learn directly from currently living and recently deceased seriously ill children and adolescents’ experiences, as they reflect upon their lives and the uncertainty of their future.

Conclusions: Health care professionals are invited to reflect upon how they might manage psychosocial, educational and healthcare needs of such seriously ill children and adolescents.

IN NEED OF SUPPORT: RECOGNISING THE CARE ROLES AND CONTRIBUTION OF EXTENDED FAMILY MEMBERS IN FAMILIES CARING FOR CHILDREN WITH LIFE LIMITING CONDITIONS

Dr Marie-Therese Proctor ¹, Prof Sue Nagy², Dr Michael Stevens¹, Dr Bruce Lord¹, Dr Libba O'Riodan¹

¹ Children's Hospital at Westmead

² University of Technology, Sydney

Introduction: Presently little is known about the role extended family members play in the provision of care and support of children with life limiting illnesses.

Aim: To investigate the nature and extent of family support and to identify challenges and tensions experienced by extended family members in such cases.

Methods: We present evidence from a large Australian qualitative study of extended families caring for a child with a life-limiting condition. Ninety one family members from 29 families with ill children participated in home based, in-depth open ended, audio-taped interviews speaking about how life limiting illness affected family life, at the level of the individual; the nuclear and extended family units.

Results: Analyses indicated that family members often play a crucial supportive role. Though willing to ‘lend a hand’, extended family members reported emergent needs of their own, indicating uncertainty as to whom they could turn, when the child's illness caused them personal distress. Other challenges reported included uncertainly regarding capacities and boundaries in help and care for the ill child, well sibling and parents and concerns about the longer term welfare of the family following the death of the ill child.

Conclusions: These findings invite reconsideration of what defines ‘family’ within paediatric heath, while highlighting when and in what ways extended family members might themselves be in need support as part of the ill child's support system.

HELPING PATIENTS TO TAKE CONTROL OF BIPOLAR DISORDER: THE ROLE OF AN ONLINE PSYCHOEDUCATION PROGRAM

Dr Judith Proudfoot ¹, Prof Gordon Parker¹, A/Prof Vijaya Manicavasagar¹, A/Prof Meg Smith²

¹ Black Dog Institute and School of Psychiatry, University of New South Wales

² University of Western Sydney

Introduction: After receiving a diagnosis of bipolar disorder, some patients go through a period of disbelief and/or denial during which poor treatment adherence, inadequate self-management and high relapse rates are common. Once patients accept their diagnosis, they can be assisted to develop helpful illness perceptions and self-management strategies to control their condition, instead of it controlling them.

Aim: The aim of this study is evaluate the impact of an online psycho-education program to help individuals online psycho-education program to help individuals with newly-diagnosed bipolar disorder adjust to their diagnosis and learn to control of their illness.

Method: A randomised controlled trial is being conducted. 300 patients diagnosed with bipolar disorder within the last 12 months are randomly assigned to receive the 8-module online program consisting of information, education and self-help exercises, in addition to continuing to receive their regular treatment. The online program is administered with and without email assistance from Informed Supporters, people with bipolar disorder who are effectively controlling their illness and who are trained to provide practical support to newly-diagnosed patients. The two online education conditions are compared with a control condition receiving online information over 8 sessions.

Results: Preliminary data from the RCT will be presented. In addition, information about the difficulties experienced by patients following their diagnosis of bipolar disorder, as discussed online with their Informed Supporters, will be profiled in the presentation.

CHRONIC FATIGUE SYNDROME FROM A “CONSUMER'S” PERSPECTIVE

Ms Margaret A Purcell

Private

Chronic fatigue syndrome (CFS) is a low prevalence disorder which the author has had since 1999. The intention of this paper is to explain the difficulties arising before diagnosis and to delineate treatments that have been effective, partially successful, and of no help.

Stress was a precipitating factor and the initial treatment was for depression. Antidepressants and psychological therapies were trialled, providing little assistance. The atypical nature of the illness made the treating psychiatrist suspect a different illness, leading to the diagnosis being made. The most problematic symptoms have been disabling fatigue exacerbated by activity, disturbed sleep patterns, “brain fog”, and physical pain. Strong suicidal urges followed. Unfortunately, due to a lack of understanding of the syndrome, many health professionals are unable to respond appropriately when urgent help is required.

Pacing of activity and lifestyle modification has been of great assistance, though challenging. Adrenal, thyroid, and pituitary growth hormones have been helpful. Other treatments have been explored with varying outcomes. The cost of “off label” prescriptions has been a hurdle.

The persistent nature of the illness has resulted in a total of over eight months of hospitalisation. However, with better symptom control the author has been able to better perform her role in the health sector and pursue higher studies, hence making a contribution to society.

As a consumer of mental health services it was found that there is limited support in respect of CFS. Greater acceptance and better understanding of the disorder will help fellow sufferers in the community.

PSYCHOTROPIC DRUG USE IN THE MANAGEMENT OF BORDERLINE PERSONALITY DISORDER

Dr Sathya Rao, Ms Rosemary Thomas, Ms Sharon Snodon

Spectrum

This is a naturalistic study that looks at the pattern of Psychotropic drug use in the treatment of Borderline Personality Disorder (BPD).

Objective: This study looks at the pattern of Psychotropic drug use during the natural course of treatment of patients with BPD presenting to a personality disorders service. The study looks at the pattern of Psychotropic drug prescription at admission, at the time of discharge from the treatment program six months later and at follow-up one year later.

Methodology: 74 patients with a diagnosis BPD admitted to the treatment program formed the sample of the study. A list of Psychotropics used as reported by patients at admission, at discharge, and at follow-up one year later were recorded.

Results: Thirty-two patients provided data for the three time points. Statistical tests found no significant differences on numbers of medications, diagnoses or depression scores between this group and those who were lost to follow-up or end of treatment evaluation. The mean number of medications reduced from admission to treatment end and then further decreased during follow-up to become significant with a large effect size.

Conclusion: The number of psychotropics used by patients who undergo an intensive residential psychotherapy program reduced during treatment and then had further reduced by one year follow-up.

PSYCHIATRY IN THE ‘LAND OF THE SPHINX’- IS AN OVERSEAS ELECTIVE JUSTIFIED?

Dr Sanil Rege

Northern Sydney and Central Coast Mental Health

Context: There have been concerns raised about the difficulties in providing mental health services to ethnic minorities and cultural differences in the understanding of psychiatric illness and treatment. It is becoming increasingly common for psychiatrists to treat patients with cultural backgrounds different from their own. Thus the need to incorporate culture into psychiatry is crucial. I propose the incorporation of overseas electives within psychiatric services and training programs to facilitate training in transcultural psychiatry.

Objectives: Descriptive account of a 6 month sabbatical in Egypt to highlight the diversity of benefits in incorporating such projects within psychiatric training programs.

Key Messages: An overseas elective offers an exciting and innovative practical experience to broaden one's personal and professional experience of psychiatry and obtain a different perspective on cultural variations of mental illness. It also promotes an understanding of health service management in low and middle income countries and offers the opportunity to contribute to their healthcare at a minimal cost.

Conclusion: An overseas sabbatical can be a valuable experience for a psychiatrist. It however needs to be implemented at an optimal period of a psychiatrist's career and with minimal disruption to local services. Training schemes and employers could give more opportunities for interested trainees to undertake sabbatical training arrangements in other countries. This in turn would go a long way in producing culturally capable psychiatrists for the wide range of ethnic minorities in Australia.

ANTIPSYCHOTIC INDUCED WEIGHT GAIN IN SCHIZOPHRENIA: MECHANISMS AND MANAGEMENT

Dr Sanil Rege

Northern Sydney and Central Coast Mental Health

Context: Weight gain has become a particular concern in individuals with psychiatric illness and the recent debate has focused on patients with schizophrenia. Much of this weight gain is attributed to antipsychotic medications. There has been a substantial increase in the number of studies investigating the mechanisms and management of antipsychotic induced weight gain since 2002.

Objectives: Presentation of the evidence based on a comprehensive literature review of the mechanisms and management of antipsychotic induced weight gain to inform clinical practice.

Key Messages: There is a hierarchy in the weight gain potential of antipsychotic medications. The most effective strategy is for prevention of weight gain is the choice of antipsychotic medication with low weight gain potential. In individuals with established weight gain and metabolic issues switching to an antipsychotic agent with lower weight gain potential and / or lifestyle modifications with physical activity are most effective in promoting weight loss. The case to prescribe pharmacological treatments for weight gain is weak.

Conclusion: Weight gain in schizophrenia is associated with significant physical and psychological morbidity. Achieving an optimal trade off between effectiveness and side effects of antipsychotic agents although difficult is achievable. This should be based on three main principles. Firstly, a shared decision making model between the patient, clinician and carer(s). Secondly, a commitment to baseline and follow up monitoring of metabolic parameters. Thirdly, the adoption of clear structured protocols and greater collaboration between various health professionals from psychiatric and medical specialist services.

INTERFERON THERAPY AND DEPRESSION: IS THE SECRET IN THE GENES?

Dr Samuel Ritz ¹, Prof Roger Mulder²

¹ Waitemata DHB

² Canterbury DHB

Background: Psychiatric symptoms, and specifically depression, are reported in up to 44% of patients receiving interferon therapy for treatment of Hepatitis C. These symptoms have been associated with poor compliance, treatment discontinuation, impaired quality of life, and a suicide rate of up to twenty times the expected rate.

Multiple hypotheses exist about the underlying mechanisms, although the role of tryptophane depletion in the first few weeks of therapy, brought about by induction of the enzyme indoleamine 2,3-dioxygenase by proinflammatory cytokines, seems to be the most likely. Rapid depletion of Tryptophan has been shown to precipitate depressive symptoms in well, untreated individuals who are vulnerable to depression. Given the reported association between specific SNP's on the novel TPH2 gene and depression, it is possible that these SNP's play a pivotal role in failure of postsynaptic upregulation at times of fluctuating tryptophan levels. Confirmation of this association will aid pre-treatment identification of patients at risk of developing mood changes.

Aims:

To follow a cohort of patients with hepatitis C in order to investigate the relationship between interferon therapy and changes in mood and related symptoms of anxiety, irritability and fatigue.

To see whether polymorphisms in the tryptophane-hydroxylase 2 (TPH2) gene, are associated with cases of depression

Methods: Clinician and self-rating assessments with the MADRS as the primary mood outcome measure. Genetic assays done at week 12.

Results: The study is currently recruiting and data of the first 30 patients suggest 30% of patients develop significant mood changes. We are awaiting results of the initial genetic assays and hope to present these initial findings as pilot data.

Conclusion: Clinical implications and findings will be discussed.

PRODROMAL PSYCHOSIS: A CONCEPT THAT MAY NEED TO BE DESTROYED TO BE SAVED

Dr Stephen Rosenman

Private Practice

Background: We believe that psychosis must have a prodrome. Identifying the prodrome would allow ‘pre-emptive psychiatry’ (with its disquieting contemporary resonance). Psychiatrists have long aspired to ward off illness with treatment before it appears, and the, as yet unsuccessful, project has been enthusiastically renewed in studies around the world.

Through a forest of methodologically different studies, we glimpse the prodrome project failing again. If it fails, can something be salvaged?

Objectives: To look at the conceptual problems not just the empirical uncertainties of prodromal psychosis.

Conclusion: Empirical prediction based on phenomena will not succeed and neither preventive success nor failure can be identified. Sensitivity and specificity tradeoffs exact unacceptable costs.

More importantly, ‘future psychosis’ is an empty validation of present symptoms. The question of prodrome descends into circular debate. The debate cannot be solved and should be dissolved.

Better to scrap the predictive model and look more closely at the identification and care of present symptoms in their own right rather than as markers of an imagined covert or future process.

Key message: Conceptual problems invalidate the prodromal psychosis model.

The prodromal psychosis concept may be best destroyed but its components salvaged for better use.

MAJOR DEPRESSION IS NOT A MENTAL PROCESS

Dr Stephen Rosenman

Private Practice

Background: “Try not to think of understanding as a ‘mental process’ at all – for that is the expression that confuses you.” With this enigmatic counter-intuition, Ludwig Wittgenstein closes the most subtle of a number of arguments that should shake our accustomed concepts of the mental processes underlying psychiatric diagnoses.

Explanatory models, from psychological dynamics though genetic linkage to imaged neuropsychiatric mechanics, repeatedly fail to produce any ‘cause’ that lasts longer than the next disconfirmatory study. This is attributed to the empirical failure of a ‘young science’ or its inadequately developed models or tools. This may not be so.

Objective: To explicate the above argument in relation to ‘depression’ as example.

Conclusion: A psychiatric diagnosis does not point to an identifiable mental process in the patient but is inscribed onto a ‘family’ of behaviours whose relations with each other need not reflect any underlying common process. Causal studies will continue to fail to identify regular neural correlates, genes or biochemistry of patients with ‘depression’. This is not an empirical failure but a conceptual confusion and a misapprehension of the explanatory enterprise. “The existence of an experimental method makes us think we have the means of solving the problems that trouble us; though problem and method pass each other by.”

Key messages: ‘Depression’ is not a mental process.

The failures of explanatory models are due not to failures of technique but to conceptual confusion.

The confusion accounts for the barrenness of models in psychiatric knowledge.

MENTAL HEALTH NURSE INCENTIVE PROGRAM FOR PSYCHIATRISTS – ENHANCING YOUR SERVICE

Ms Kim Ryan

Australian College of Mental Health Nurses

Introduction: As a part of the COAG reform agenda in 2006 the then Prime Minster announced a significant boost to support mental health care in Australia. $1.9 billion over 5 years was committed. Part of this reform was the allocation of $191.6 million of new funding for providing services by mental health nurses in collaboration with general practitioners and psychiatrists.

An incentive payment was established so that general practices, private psychiatrists, and other appropriate organizations would be able to engage or retain mental health nurses to assist in the provision of coordinated care for people with severe mental disorders.

Aim: The Mental Health Nurse Incentive Program (MHNIP) was implemented 1 July 2007. It has provided scope for a variety of models to be established for psychiatrists to work with mental health nurses. A joint presentation by a psychiatrist and nurse will address navigating the process of setting up MHNIP and showcase how the MHNIP allows for the integration of the program within a private practice framework.

WHY THE “RISK OF HARM” CRITERION FOR INVOLUNTARY TREATMENT SHOULD BE REMOVED FROM OUR MENTAL HEALTH ACTS

Dr Christopher Ryan ¹, Dr Matthew Large, Dr Olav Nielssen², A/Prof Robert Hayes³

¹ University of Sydney & Westmead Hospital

² University of Sydney & University of New South Wales

³ University of Western Sydney

Introduction: An obligatory risk of harm criterion in a mental health act demands that before a person with a mental illness may receive non-voluntary treatment that person must be judged to pose a danger to themselves or others. All Australian States and Territories (except South Australia and arguably Victoria) contain an obligatory risk of harm criterion.

Aim: To demonstrate that obligatory risk of harm criteria should be removed from mental health legislation and replaced with provisions that focus on a person's capacity to consent to treatment and whether or not the treatment would be beneficial.

Method: We use ethical argument and recent empirical evidence to show that such criteria likely a significant impediment to care to some people with a mental illness and that they unfairly discriminate against people with mental illnesses both in terms of limiting access to care and spreading the burden of risk.

Results: There are strong ethical and empirical arguments for the removal of such criteria from Australia's mental health legislation.

Conclusions: Psychiatrists should lobby for this form of mental health law reform both at the state, territory and national level.

PREVENTION OF ALCOHOL DEPENDENCE BY LEGISLATIVE CONTROL OF ALCOHOL: UNMET NEED OF PUBLIC HEALTH POLICY?

Dr Sahoo Saddichha ¹, Dr Narayana Manjunatha², Prof Christoday RJ Khess²

¹ WHO India

² Central Institute of Psychiatry, India

Background: Even though prevalence of alcohol use in the world is very high, it has not been brought under legal control contrary to other substances like opium, cocaine, cannabis etc.

Aim: To demonstrate similarities in both alcohol and opioid dependence by comparing and contrasting the course of clinical dependence.

Methods: Consecutively admitted patients in the period of August 2005 to May 2006 in Centre for Addiction Psychiatry, Central Institute of Psychiatry, Ranchi, India with ICD-10 (DCR) diagnosis of alcohol dependence syndrome or opioid dependence syndrome were recruited for the study and administered the alcohol or other drug (opioid) section of SSAGA-II respectively and data entered in corresponding tally sheet.

Results: Total sample size was 150, of which 112 consented to participate. 81(72%) were alcohol dependent and 31 (28%) were opioid dependent. Mean ages of the patients of alcohol dependence for opioid dependence was 35.16 + 10.2 compared to 26.09 + 5.65 years. Mean age of onset of alcohol and opioid use were similar (18.72 + 6.84 & 20.73 + 3.93 years respectively). Patterns of dependence were also similar for both substances, from first criteria to dependence (0.49 years for alcohol versus 0.64 years for opioids), and from appearance of second criteria to dependence (0.24 years versus 0.28 years).

Conclusion: This study found similarities in both alcohol and opioid dependence and recommends alcohol to be treated at par with opioids and calls for legislations for the control of alcohol uniformly across the world, as a public health policy, on the lines of the Framework Convention for Tobacco Control.

PSYCHIATRIC EMERGENCY CARE CENTRES: EVALUATING A NEW SERVICE MODEL

Dr Grant Sara ¹, Ms Anne Hall¹, Dr Kevin Wolfenden²

¹ InforMH, Mental Health and Drug and Alcohol Office, NSW Health

² Mental Health and Drug and Alcohol Office, NSW Health

Introduction: NSW is implementing Psychiatric Emergency Care Centres (PECCs) in metropolitan general hospital EDs. These are small (4-6 bed) inpatient units within EDs, providing 24 hour mental health staffing, assessment, and brief inpatient care.

Aim: To evaluate the first year of operation of PECC services against three goals; (1) improving quality of care, (2) reducing delays in service access, and (3) developing a sustainable service model.

Methods: A multimodal evaluation of seven PECC units, including clinical data collection, data linkage, surveys of PECC consumers and carers, surveys of PECC and ED staff, clinical file review and facility inspections.

Results: Information was collected on 8222 presentations. PECCs appeared to improve access to specialist mental health staff, documentation of risk, access to clinical records and involvement of families in care. Consumers and carers reported high levels of satisfaction. There were few serious incidents.

PECCs appeared to reduce delays in accessing mental health beds and to shorten total time in the ED. Short admissions to associated mental health units were reduced.

The PECC model appeared sustainable; satisfaction of PECC and ED staff was high, with positive staff retention. Bed day costs were equivalent to other acute inpatient units.

Conclusions: PECC services appear to be a viable model for mental health care in the emergency department. Challenges for PECCs include the separation of mental health care from the ED, with implications for ED staff skills and the physical assessment of persons with apparent mental health problems.

THE ST VINCENT'S PECC: A NEW MODEL OF PSYCHIATRIC EMERGENCY CARE

Dr Tad Tietze, Dr Peter McGeorge

St Vincent's Mental Health

Psychiatric emergency services are a recent phenomenon due to structural changes in mental health service (MHS) provision, driven by deinstitutionalization and community care. There is a paucity of high-quality data evaluating the wide range of existing service models, usually governed by local needs and developed ad hoc. One (controversial) model has been short-stay, inpatient Psychiatric Emergency Care Centres (PECCs).

We describe one such PECC, co-located with the St Vincent's Hospital Emergency Department (ED) in Sydney.

We present a literature review of papers describing psychiatric emergency services, a qualitative description of the PECC's operation, analysis of data on MHS delivery to the ED, and preliminary data from a retrospective record review of consecutive mental health presentations to the ED.

The experience of the Liaison Psychiatry service to the ED led to the development of a uniquely collaborative model with responsibility shared between the MHS and ED. The PECC led to marked improvements in MHS delivery to the ED, as well as high levels staff and patient satisfaction. Records analysis delineated the numbers, demographic characteristics and presenting problems seen by the ED, as well as recording the MHS’ ability to efficiently service a rapidly growing number of presentations within appropriate care pathways.

The St Vincent's PECC has produced significant improvement in MHS delivery, with data on local characteristics allowing assessment of the model's generalisability. The authors are in the process of analysing more detailed data and urge the use of a similar research program to evaluate other PECCs.

CHANGE IN PSYCHOPATHOLOGY FROM CHILDHOOD TO ADULTHOOD: THE AUSTRALIAN CHILD TO ADULT DEVELOPMENT (ACAD) STUDY

Prof Bruce Tonge ¹, Dr Kylie Gray¹, Prof Scott Hofer², Dr Andrea Piccinin², Prof Andrew Mackinnon³, Dr Daniel Bontempo², Prof Stewart Einfeld⁴, Prof Trevor Parmentor⁴

¹ Monash University

² Oregon State University, USA

³ Orygen Research Centre, The University of Melbourne

⁴ University of Sydney

Comorbid mental health problems complicating intellectual disability (ID) are a common and costly public health problem. Although behavioural and emotional problems are known to begin in early childhood, we know little of how these problems evolve over time. We examined the course of psychopathology in a representative population of children and adolescents with ID followed over 14 years. The sample consisted of 470 young people, aged 5-19.5 years at commencement of study. Changes over time in behaviour and emotional problems were modelled with growth curve analysis. High initial levels of behavioural and emotional disturbance declined only slowly over time, remaining high into young adulthood. Using multivariate growth curve modelling, associations among initial status and rates of change in the behaviour and emotional problems from childhood through adolescence, and into early adulthood and indicators of the mental health of parents were also examined. These analyses indicated moderate interdependence in level of psychopathology, with evidence for associations among change in the child's social relating problems and the mental health of the parent. Whilst the results do not indicate any causal directions, there is clearly a relationship between child behaviour and parent mental health, particularly parent anxiety and depression. Professionals need to be alert to the mental health needs of parents, particularly for signs of anxiety and depression. A focus on incorporating adequate support and treatment for families, along with programmes to maximize optimal development of young people with intellectual disability, is needed, together with behavioural supports in educational and early vocational settings.

YOUNGER ONSET DEMENTIA PRESENTING AS PSYCHOTIC ILLNESS: CLINICOPATHOLOGICAL CASE SERIES

Dr Dennis Velakoulis ¹, Prof Catriona McLean², Dr Ramon Mocellin¹, Prof Christos Pantelis¹, Dr Mark Walterfang¹

¹ University of Melbourne and Melbourne Health

² Alfred Hospital and National Neural Tissue Facility, University of Melbourne

Patients with schizophrenia are routinely screened to exclude'organic' illness. Very rarely the schizophrenic illness is a prodrome of a neurodegerative condition. There have been very few studies which have investigated the clinicopathological correlates of such cases. Four patients who had presented with schizophrenia or bipolar disorder and who came to pathological examination after death are described. The clinical and pathological diagnosis was of frontotemporal dementia. These observations may have implications for our understanding of major psychotic illnesses and highlight the importance of screening for organic causes of psychosis.

PSYCHIATRIC PRESENTATION OF CJD IN AN ADOLESCENT

Dr Dennis Velakoulis, Dr Ramon Mocellin, Dr Mark Walterfang

University of Melbourne and Melbourne Health

We present the case of an adolescent with a familial history of CJD who presented with psychiatric symptoms prior to the ultimate diagnosis of CJD. The clinical, neurological and psychosocial issues related to this case are discussed.

EVALUATING CLINICAL OUTCOMES OF ECT ACROSS A LARGE URBAN MENTAL HEALTH NETWORK; DATA FROM THE NORTH WESTERN MENTAL HEALTH / MELBOURNE HEALTH ECT DATABASE

Dr Dennis Velakoulis, Dr Ramon Mocellin, Dr Mark Walterfang, Nicole Ah Yick

Royal Melbourne Hospital and North Western Mental Health

While clinical outcome for individual patients undergoing ECT are monitored and assessed by the patient's treating clinicians, evaluating the overall outcomes within a clinical service is a more challenging undertaking. The establishment of an ECT database across four area mental health services within North Western Mental Health has allowed the collation of detailed data regarding the practice of ECT. Information over a 12 month period from this database has been combined with routinely collected outcome data (HONOS) to investigate the relationship between HONOS outcomes and the use of ECT. Recommendations regarding the routine and standardised evaluation of ECT outcomes are made.

ECT IN THE MEDICALLY UNWELL: WHERE, WHEN AND HOW?

Dr Dennis Velakoulis, Sophia Adams, Ramon Mocellin, Mark Walterfang

Royal Melbourne Hospital and North Western Mental Health

While processes for the administration of ECT are generally well defined for patients with acute psychiatric illness, the presence of significant medical illness raises issues at a clinical, service and inter-disciplinary level. We describe some of the challenges and pitfalls of ECT in the medically unwell patient together with recommendations for the management of this small but important group of patients.

ADOLESCENT OBSESSIVE-COMPULSIVE DISORDER HERALDING CHOREA-ACANTHOCYTOSIS

Dr Mark Walterfang, Dr Andrew Evans, Dr Ramon Mocellin, Dr Dennis Velakoulis

Melbourne Neuropsychiatry Centre

We describe one female and two males who each developed childhood/adolescent obsessive-compulsive disorder as a prelude to the development of a typical picture of chorea-acanthocytosis (ChAc). In each patient, the caudate nucleus showed dramatic atrophy; post-mortem neuropathological analysis of one patient demonstrated almost total neuronal loss and gliosis of the caudate and putamen, with the cortex being entirely spared. The role of the caudate in compulsive phenomena, and the predilection for neurological disorders with onset in adolescence to present as major mental illness, is discussed. Disruption to the flow of information in the lateral orbitofrontal loop (LOFL) leads to disruption of the circuitry that modulates goal-directed behaviour, and tends to lead to dysregulated and compulsive phenomena. Patients with ChAc who present initially psychiatrically show a unique predilection for the development of obsessive-compulsive phenomena. On the basis of the current evidence and previous findings, we suggest that ChAc can be understood as a disorder whose clinical presentation reflects an interaction between the disease process and the individual's neurodevelopmental stage with both initial interrupted neurodevelopment, and supervening neurodegeneration.

DEPENDENT PERSONALITY DISORDER

Ms Chris Watson

Spectrum Personality Disorders Service for Victoria

Context: Dependent personality disorder is very common in our client populations. It is a very common co-morbid diagnosis with borderline personality disorder. Some of the most complex situations we have been involved with have been with those with dependent personality disorder.

Key message: Much of the research about personality disorder has focussed on borderline personality disorder. The treatments developed have also been for this disorder. However, it may be that dependent personality disorder develops differently and requires a different intervention. It may explain why some people do not do well in treatment programs designed for borderline personality disorder.

Objectives: This paper will explore the aetiology of dependent personality disorder, the course, and some beginnings of a discussion about what might be required to treat dependent personality disorder. Data from Spectrums longitudinal study will be presented, looking at the course of the dependent personality disorder within a program designed primarily to treat borderline personality disorder.

Conclusion: There are some ways of approaching this disorder that can manage the situation before the individual and treating system become entrenched in an unhelpful exchange.

METAPHYSICAL SPIRITUALITY AND PSYCHIATRY: A DYSFUNCTIONAL RELATIONSHIP

Dr Sid Williams

Several NSW Health Services

Context: The naming of the 2006 RANZCP Congress, “Cell2Soul” suggested that metaphysical spirituality is an appropriate issue for consideration in the theory and practice of psychiatry

Objectives: To raise some questions about, and outline some potential pitfalls in, an association between psychiatry and religious or metaphysical paradigms.

Key messages: The term “spiritual” has a number of meanings, some metaphysical and some not metaphysical. When associated with metaphysical concepts and beliefs this term refers to matters which are by their nature ineffable and enigmatic. If terms such as spirituality are to be included in the psychiatric lexicon some agreement about their meanings is necessary. However the intensely personal, subjective, religious and cultural connotations of these terms and the powerful faith and belief systems associated with them renders them difficult to discuss.

When these terms include reference to metaphysical phenomena they are, by definition, placed beyond the ken of ordinary mortals, including psychiatrists. Nevertheless, for psychiatrists to examine and understand individual patients as whole persons we need to include an understanding of and respect for the patient's subjective experiences and beliefs, including those concerning these issues, whether metaphysical or not.

A metaphysical view of the world and of humankind may interfere with a scientific view. When held by a psychiatrist it can also provide potential for boundary crossing or violation.

FACTORS ASSOCIATED WITH LENGTH OF STAY AT AN ACUTE PSYCHIATRIC INPATIENT FACULTY: A CASE CONTROL STUDY

Dr Jianyi Zhang, A/Prof Carol Harvey, Ms Carol Andrew

North West Area Mental Health Service

Aims: Factors associated with length of stay (LOS) were investigated, especially how LOS may be influenced by clinical practice and system issues.

Methods: A case control study was embedded in a retrospective cross-sectional clinical file audit of 226 randomly selected episodes of admission during a twelve-month period. A total of 286 variables were collected and analysed, which included socio-demographic, clinical and clinical practice/system variables.

Results: Logistic regression analyses showed that 10 variables were associated with LOS: 3 variables predicted prolonged stay and 7 variables predicted shorter LOS. Seclusion during the index admission, accommodation problems and living in an area lacking community services predicted longer stay. Variables that predicted shorter stay were being a migrant from non-western countries, having completed high school, having a drug and alcohol-related diagnosis, admission directly related to a crisis, adjustment disorder, cluster B personality disorder, and having recently transferred care. Several variables thought to be powerful predictors of LOS were found not to be so. They included living alone, living in marginal accommodation, LOS of previous admission, chronicity of illness, diagnosis of schizophrenia, severity of illness, risk on admission. Also the quality of inpatient or community care did not influence LOS.

Conclusions: LOS is multifactorially determined. Behavioural manifestations of illness resulting from a combination of factors and lack of social support structures predicted prolonged LOS. Good clinical practice did not necessarily translate to a shorter LOS. Therefore, LOS is predictable, but not readily modifiable within the clinical domain.

FACTORS ASSOCIATED WITH THE RISK OF READMISSION AT AN ACUTE PSYCHIATRIC INPATIENT FACILITY: A RETROSPECTIVE COHORT STUDY

Dr Jianyi Zhang, A/Prof Carol Harvey, Ms Carol Andrew

North West Area Mental Health Service

Aims: This study aimed to investigate the predictors for the risk of readmission to an acute psychiatric inpatient unit.

Methods: A retrospective cohort study was embedded in a cross-sectional clinical file audit of 178 randomly selected patients who had at least one admission during a twelve-month study period. All patients were retrospectively followed up for at least 12 months. A total of 286 variables were collected and analysed.

Results: Eighty-two patients (46 percent) were readmitted during the follow-up period. Cox regression analyses showed 9 variables were related to the risk of readmission. Six of these variables increased the risk of readmission. They included the number of previous admissions, risk to others at the time of index admission, contact with emergency department post-discharge, alcohol intoxication and ECT treatment. More active and assertive treatment in the community post-discharge decreased the risk of readmission, eg, involuntary treatment, reviewing the individual service plan and transferring to a new treating team. Patients’ socio-demographic characteristics, a diagnosis of a major psychiatric illness, length of previous admission or index admission, or the clinical practice and care provided at the inpatient unit did not influence the risk of readmission.

Conclusions: A sub-population of patients who require frequent psychiatric admission is identifiable. Quality of inpatient care does not influence the risk of readmission, which therefore raises a question about the validity of using the rate of readmission as an outcome measure of psychiatric inpatient care. Good psychiatric practice within the community following discharge likely reduces the risk of readmission.