Abstract
S1 EARLY INTERVENTION, CLINICAL STAGING AND YOUTH MENTAL HEALTH: SYNERGISTIC PARADIGMS SHIFTS IN MENTAL HEALTH CARE
Orygen Youth Health Research Centre, University of Melbourne, Parkville. Victoria.
Early Intervention for emerging mental and substance use disorders has great potential to reduce the harm, suffering and functional impairment flowing from these disorders which typically declare themselves during the transition to independent adult life. The heuristic value of clinical staging will be proposed as a strategy to enhance the utility of diagnosis in the early stages of disorder and as a framework for intervention trials and neurobiological research. Blending the clinical epidemiology of onset with developmental psychiatry and modern thinking on “emerging adults” and “transition age youth” underpins a practical reform agenda which has led to the establishment of a 12–25 youth focus for mental health service provision.
This symposium will describe these paradigms and how they support one another and report of national and international progress in reform. The presentations cover conceptual, structural and clinical aspects of the development of a progressive approach to the provision of care for emerging mental and substance use disorders in young people and to their families. Progress with headspace and state based reforms in youth mental health will be described and new data relating to early intervention in psychotic, mood, substance and personality disorders will be presented.
S2 BUSHFIRES PAST AND PRESENT: WHAT DO WE LEARN?
University of Adelaide
The tragic bushfires in Victoria highlight the challenges and risks of living in outer suburban and rural Australia. Planning and sustaining post-disaster mental health services poses many challenges for those in both clinical and administrative roles. However, much can be learned and gained from the services that are put in place that have relevance to other trauma victims. The Ash Wednesday bushfires in 1983 are one of the most studied disasters and the lessons learned will be reflected upon in the setting of this recent fire. One of the critical issues in dealing with disaster-affected communities is to anticipate the barriers to care and to develop strategies that assist in access through primary health care. General practitioners are the most trusted people for support in the aftermath of such events and should be supported by post-disaster services. Recently, the 808 children who I studied after the Ash Wednesday fires have been followed up 21 years later and the impact on adult development and psychological health have been examined. It appears that the fires had a major impact in the social development of the children. The prevalence of other traumatic events in the general community meant that there was no major difference in the prevalence of psychiatric disorders. The implication of these findings will be discussed and the way in which disasters need to be construed as only one of multiple of traumatic events that affect communities within their lifetime.
SELF MANAGEMENT IN RURAL AND REMOTE MENTAL HEALTH SETTINGS
Rural and remote settings are vulnerable to high prevalence of mental illness. The impact of drought, climate change and the recent financial crisis superimposed on limited access to services, a workforce under pressure, and the many particular stresses on Indigenous communities will continue to create high levels of need. Self management skills allow clients to identify their own ill health, intervene early, and take positive steps toward avoiding relapse or minimizing the impact of their illness.
A number of specific attributes of rural and remote settings render them particularly apt for the introduction of self management strategies. Such strategies promote self sufficiency, which may not only be the preferred personality style of the remote and rural client but also a necessity for the practitioners in the field. Self management strategies are pertinent when ‘one-off’ consults are most likely and opportunistic interventions are needed. Lengthy interviews, regular reviews and complex treatment plans may be particularly unsuitable for rural and remote clients who travel far for care or have reluctance to seek help. Finally, national campaigns may either not be well disseminated in these settings or else well understood leading to persistent high stigma related to mental illness and limited mental health literacy.
This paper will discuss self management as best practice, the link between recovery approaches and self management, specific strategies for self management with Indigenous people, self management and the Better Access Medicare initiatives, and a framework for self assessment of self management practice.
SUSTAINABLE TELEPSYCHIATRY – WALKING THE TALK
Country Health SA
This paper reviews Telepsychiatry services at a State-wide service – the Rural and Remote Mental Health Service in South Australia showing sustained growth over time. Theoretical models for service sustainability and factors promoting sustainability will be investigated with evidence from a literature search and local Telepsychiatry data collated over the last 10 years. Consultation with Rural and Remote staff was utilised to distil factors underpinning growth and sustainability.
The paper will present evidence from the 9 publications that were identified in relation to sustainable Telepsychiatry which has relevance in providing services in “changing times”. Sustainability and significant growth was demonstrated within Rural and Remote Telepsychiatry service. Evidence for reasons of sustained growth i.e. 1) Consultation-liaison based service delivery. 2) Co-location and integration of the Telepsychiatry unit with the inpatient unit and telephone triage service. 3)
Employment of full time staff specialists dedicated to Telepsychiatry. 4) Employment of a full time Telepsychiatry coordinator. 5) Allocation of psychiatrists to specific regions 6) Triaging referrals and minimising the delay to assessment will be presented.
The paper will have significant relevance for service delivery across rural Australia.
THE‘TOP END’ EXPERIENCE OF RECRUITMENT AND TRAINING OF REGISTRARS IN THE NORTHERN TERRITORY
1 Lecturer Flinders University, Chair NT Branch Training Committee
2 Chair Recruitment and Retention Subcommittee
The rural rotation for registrars in the ‘Top End’ offers an interesting and privileged opportunity to meet and work with an array of remote indigenous people, families and communities. Cultural factors intermingle with significant psychiatric morbidity to create a unique & fascinating assessment and treatment environment. The location of a capital city surrounded by truly remote locations enables a ‘real’ rural and remote training experience, but also a level of support, supervision, resources and infrastructure – the ‘best of both worlds’?
However, there are still challenges with recruitment and retention. Is a rural and remote training experience seen by trainees as ‘exciting’ or as too much ‘hard work’? Are there any differences in practice? Are the differences in practice helpful or seen as a distraction from passing exams? Can trainees in the Northern Territory do all their training in the Top End?
S3 SLEEP DISORDERS IN PATIENTS WITH PSYCHIATRIC ILLNESS
1 Melbourne University, Victoria, Australia
2 International Institute of Psycho Pharmacology, Melbourne, Australia
3 Auckland University, Auckland, New Zealand
4 Private Practice, Melbourne, Australia
5 Western General Hospital, Victoria, Australia
SLEEP DISORDERS IN PATIENTS WITH PSYCHIATRIC ILLNESS
Senior Lecturer Department of Psychological Medicine
Most if not all psychiatric disorders have accompanying sleep dysfunction. Mood and anxiety patients invariably suffer from insomnias. Nightmares are common in PTSD patients. Dementia sufferers, bipolar patients and schizophrenia patients have circadian rhythm shifts. Most psychiatric medications also have effects on the sleep architecture. This session will review the relationship between psychiatric disorders and sleep as well as the effects of medications on sleep.
NON – PHARMACOLOGICAL MANAGEMENT OF INSOMNIA
In this part of the symposium the focus will turn to non-pharmacological approaches to the management of insomnia. General measures including sleep hygiene, behavioural approaches such as sleep restriction and stimulus control therapy, the use of bright light, and cognitive techniques will be covered. The use of these techniques in depressed insomniacs and group treatment approaches will also be mentioned.
PHARMACOLOGICAL MANAGEMENT OF INSOMNIA
Sleep Medicine Physician, Melbourne, Australia
The choice of drugs available for the treatment of insomnia has been limited, and hypnotics have only been indicated for short term use in insomnia. However, new agents with novel mechanisms of action are becoming available, changing the approach to pharmacotherapy in insomnia. In addition, data on adjunctive use of hypnotics together with anti-depressants for the treatment of co-morbid insomnia has highlighted the need to specifically treat insomnia occurring with anxiety or mood disorders.
S4 AN UPDATE ON THE CURRENT USE OF REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION TREATMENT FOR DEPRESSION
Alfred Psychiatry Research Centre, The Alfred and Monash University, Melbourne, Australia.
PRELIMINARY REPORT COMPARING TRANSCRANIAL MAGNETIC STIMULATION DELIVERED THREE TIMES PER WEEK VERSUS FIVE TIMES PER WEEK
1 The Adelaide Clinic, Adelaide, South Australia, Australia
2 The University of Adelaide, Adelaide, South Australia, Australia
This paper reports a study into an emerging physical treatment in psychiatry: Transcranial Magnetic Stimulation. This study is being conducted in a private hospital where a TMS service for patients with Major Depression has been established by Ramsay Health Care. The presenters will describe the process of setting up a new TMS service. It is unclear whether TMS should be spaced, like ECT, or is effective when given more frequently. We will report preliminary data for the first nine months of a study comparing two TMS regimes in the treatment of Major Depression.
S5 HYPOTHETICAL: ADVERSE INCIDENTS AND HOW THEY AFFECT PSYCHIATRISTS WORKING IN THE PUBLIC SECTOR
1 RANZCP – Network of Public Sector Psychiatrists
2 Freelance Health Journalist
3 University of Sydney
4 MIGA
5 Director Mental Health Canberra
6 Coroner's Office
Increasingly Psychiatrists working in the public sector are involved in clinical adverse incidents such as suicides. Occasionally these incidents are picked up by the press, usually fuelled by an unhappy carer and the psychiatrist's care is openly questioned. The resultant investigation by either the Coroner and/or the Health Complaints Commission is usually lengthy and stressful for the psychiatrist involved.
With the use of a ‘Hypothetical’ scenario (facilitated by David Barton), the Network of Public Sector Psychiatrists and panel presenters will be exploring the issues faced by public sector psychiatrists. Discussion will include:
Risk Assessment and Good Documentation; Medical Defence Organisation; Managing the Media; Impact/Affects on Medicos; Possible Mentoring Program for College Fellows Participants are advised that this will be an interactive workshop with questions and discussion from the audience encouraged.
S6 PARALLEL PARENT AND CHILD THERAPY (PACT): A PSYCHOTHERAPEUTIC INTERVENTION FOR PARENT-CHILD DYADS CAUGHT IN INTERGENERATIONAL CYCLES OF NEGLECT AND ABUSE
Southern Adelaide Health Service-Child and Adolescent Mental Health Services (SAHS-CAMHS) South Australia
S7 CRUISING THROUGH THE FELLOWSHIP – PASSING THE LONG CASE
Consultant Psychiatrist, Gosford Hospital, Northern Sydney Central Coast Area Health Service, Gosford, Australia
A PATIENT WHO HAS SUBSTANCE USE DISORDER: HOW TO PASS THE OCI AND HOW TO MANAGE IN PRACTICE
1 NorthWest Mental Health Program, Melbourne Health, Melbourne, Australia
2 Committee member, RANZCP Section of Addiction Psychiatry
3. Swan Adult Mental Health Service, North Metropolitan Area Mental Health Service, Perth, Australia
S8 INNOVATIVE STRATEGIES TO INCREASE ACCESS TO PSYCHOLOGICAL INTERVENTIONS
University of Technology
Access to specialist mental health services is restricted outside major urban centres, and consumers frequently have to travel long distances to attend face-to-face sessions. Difficulties in accessing high-quality, culturally appropriate interventions are amplified by remote location, poverty and cultural difference, with indigenous populations being particularly disadvantaged. Travelling practitioners and telehealth offer only partial solutions, as does telephone-based treatment. Workshop training for local practitioners increase awareness, but have limited utility in improving routine services. Academic detailing or supervision should provide greater translation to practice, but while there is some data in support of the approach, improvements to routine practice are not always seen. Providing practitioners with highly structured materials and offering adjunctive treatments by internet or post have potential to increase the quality of care. However, challenges remain in ensuring that local practitioners routinely use these supports. Recent results on improving care in rural and remote areas are discussed in relation to evidence on effective dissemination of improvements to routine practice in rural and remote settings.
EXPERIENCES OF A RESIDENTIAL PSYCHIATRIST IN RURAL SOUTH AUSTRALIA
Toowoomba and Darling Downs Health Services District, Toowoomba, Australia
RURAL PSYCHIATRY – THE MEDIUM IS THE MESSAGE
This comment by Marshall McLuhan in the seventies is pertinent to the massive developments that have occurred in practice of psychiatry in rural and remote areas in the last twenty years. The advent of computers with their attending internet and email, mobile phones, teleconferences and videoconference facilities for a number of purposes has revolutionised the practice of psychiatry, particularly in the areas of ongoing education, research and management. Communication in rural and remote areas is of critical importance and the physical distances for service delivery are often so overwhelming to contemplate that they have often prohibited care except for the severely mentally ill. The advent of communication via satellite is bringing the highest quality metropolitan level care to isolated people. These services are particularly relevant for Child and Adolescent mental health-now the most isolated and the youngest members of the community can have their OCD or social phobia successfully treated online. The huge development of Community Service Organisations (previously NGOs) and the excellent communication now possible with these organisations has resulted in massively improved prevention, education and rehabilitation in rural settings. Hopefully we may retain the essential body of knowledge in psychiatry as new communication media continue to develop in future years.
PUTTING RURAL AND REMOTE CHILD AND ADOLESCENT MENTAL HEALTH PRACTITIONERS ON THE MAP IN WESTERN AUSTRALIA
Acting Clinical Director WA Country Health Services, Child and Adolescent Mental Health Services
For the last eight years, the Child and Adolescent Mental Health Telepsychiatry Service, part of a larger Mental Health Clinical and Educational Telepsychiatry Service in Western Australia, has run a clinical and supervision programme for Child and Adolescent Mental Health (CAMHS) practitioners from a variety of disciplines across the state. There are approximately 40 such practitioners spread across WA, an area of 2.5 million sq. Km divided into seven health regions, with only one rurally based child and adolescent psychiatrist. From this telepsychiatry service, a unique intra-service linkage (Network Meeting) was developed within the programme, so that all sites could meet together monthly, using video-conferencing, for educational and networking purposes.
Previous presentation of data has demonstrated that this programme is used extensively. Data has also been presented demonstrating client satisfaction and satisfaction of practitioners in terms of enhancement of their clinical skills and satisfaction with their work often in very remote situations.
An Acting Clinical Director, a new position, has now been appointed to Rural and Remote CAMHS in WA, with responsibility for maintaining the services. The budget is however retained regionally. Recruitment and retention of appropriately trained staff is a core issue. This problem is currently being addressed in a number of ways.
An important aspect of the monthly Network Meetings is that the rural and remote CAMHS practitioners have a forum from which to have an influence on decision-making. There is now a Clinical Director who can represent them on all relevant senior executive committees. Increasingly, CAMHS practitioners, at times lone practitioners in a team of Adult Mental Health clinicians, are represented on their local executives also.
There has never been a Training Progamme in Child and Adolescent Psychiatry to meet the needs of these practitioners. A new teaching programme has commenced this year using video-conferencing and problem-based learning, with no extra funding. It is hoped that this will continue on a regular basis, and will be refined and adequately funded in the future.
S9 ANTIDEPRESSANTS AND SUICIDAL BEHAVIOUR
1 Adolescent Service, Prince of Wales Hospital, Sydney
2 The Lundbeck Institute, Copenhagen
3 Discipline of Psychiatry, University of Adelaide
Since the introduction of the SSRIs there have been reports of suicidal behaviour in association with antidepressants. This has led to professional, community and regulatory authority concern. Intense and rigorous investigation of this potential association has provided re-assuring data. These presentations will explore the present state of our knowledge in this important clinical debate.
ANTIDEPRESSANTS AND SUICIDE: WHAT THE MEDIA DON'T REPORT
Discipline of Psychiatry, University of Adelaide
There has been intense media scrutiny of antidepressants and their potential association with suicidal behaviours. It is a complex area, and simplistic and sensational media reports have aroused community concern. Less often reported are the potential benefits of antidepressants, and the reassuring information that has arisen from detailed large scale pharmaco-epidemiological investigations.
ANTIDEPRESSANTS AND SUICIDE: THE RESULTS OF A “NATURALISTIC MEDIA-INITIATED CROSS-OVER STUDY”
The Lundbeck Institute, Copenhagen, Denmark
ANTIDEPRESSANTS, SUICIDALITY AND YOUNG PEOPLE (<24 YEARS)
Adolescent Unit, Prince of Wales Hospital, Sydney, Australia
This presentation will review latest developments and highlight controversies regarding efficacy and safety in this contentious area, with particular reference to clinical practice. An attempt will be made to also consider some of the medico-legal challenges that this area can present for practitioners.
S10 RECENT ADVANCES IN BRAIN STIMULATION TREATMENTS: TMS, DCS AND ULTRABRIEF PULSEWIDTH ECT
University of New South Wales; St George Hospital; Sydney, Australia
Three new developments in brain stimulation treatments for depression are reviewed: Transcranial Magnetic Stimulation (TMS), Direct Current Stimulation (DCS), and ultrabrief pulsewidth Electroconvulsive Therapy (ECT). Transcranial magnetic stimulation is emerging into clinical practice as a treatment for depression. Means of increasing the efficacy of TMS will be discussed, including simultaneous bilateral TMS, twice-daily treatment and use of a monophasic waveform. There are promising early trials showing antidepressant effects with Direct Current Stimulation, a painless and non convulsive form of stimulation. In ECT, use of an ultrabrief pulsewidth has dramatically reduced cognitive side effects, but may also be associated with a reduction in efficacy. Original research in the above three novel therapies will be presented.
THE USE OF ULTRA-BRIEF PULSE WIDTH ELECTROCONVULSIVE THERAPY AS A STANDARD TREATMENT PROTOCOL
Flinders Medical Centre, Adelaide, South Australia
S11 PUBLISHING DOWN-UNDER: ESSENTIALS FROM YOUR EDITORS
1 Christchurch School of Medicine
2 University of Sydney
Publishing is seen as a daunting prospect by many. The editors of the Royal Australian and New Zealand College of Psychiatry's two journals will de-mystify the process. Professor Peter Joyce, Editor of Australian and New Zealand Journal of Psychiatry and Professor Garry Walter, Editor of Australasian Psychiatry, will provide advice and comment on the writing and publication process. This will include issues of how to get started, using language respectfully, authorship, and potential ethical pit-falls, and will allow ample time for interaction.
S12 APPROACHES IN THE MANAGEMENT OF SOMATISATION DISORDERS AND CHRONIC PAIN
1 Flinders Medical Centre, Adelaide, South Australia
2 Royal Brisbane Hospital, Brisbane, Australia
Session One
The workshop will provide an update on current concepts for understanding somatisation disorders and chronic pain including neuroplasticity learning and cognitive theories. Treatments will include comprehensive assessment, psychotherapy and medication. Chronic disease self management. Motivational enhancement and containment strategies will be emphasised.
Session Two
A workshop on negotiating a rational management approach to somatisation disorders will be conducted.
S13 ADOLESCENTS AND THE F WORD (FORENSICS): A SNEAK PEEK
1 Adolescent Forensic Psychiatry, Justice Health, Sydney, Australia
2 ACT Mental Health, Canberra, Australia
3 University of New South Wales, Sydney, Australia
Neurobiological substrates Equine assisted psychotherapy Biological treatments in sexual deviance Factors associated with Court diversion Pitfalls in risk assessment A tale of two subspecialties
The development of executive functions and their disorders parallel vulnerability to offending in young people. Innovation involves methodological rigour to prevent idiosyncrasy. Methodology requires creativity to avoid sterile endeavour. Selective serotonin re-uptake inhibitors are a useful adjunct to youth sexual offender programs. Complexity arising from legal and health care systems may hamper much needed diversion for mentally ill youth. Instruments for the assessment of risk in youth cannot be divorced from high-quality clinical judgment. Subspecialty integration is possible but difficult.
S14 SCHIZOPHRENIA SYMPOSIUM RECENT RESEARCH IN SCHIZOPHRENIA – WHAT DO WE REALLY KNOW?
University of Adelaide
There are surprisingly few well-proven facts, supported by solid evidence, about schizophrenia. This presentation reviews recent research focussing on aetiology, pathophysiology, disease expression, prevention and treatment of schizophrenia. This talk includes discussion of the hypotheses, controversies, facts and artifacts arising from this research.
ANTIPSYCHOTIC NEWS: IT'S FORM(ULATION) OVER FUNCTION
University of Sydney
The main advance in antipsychotic drug therapy has been in the development of new delivery systems, including various depot and slow release formulations. The science underlying these new formulations is presented, along with a clinical guide to their use.
WHY ARE PEOPLE WITH SCHIZOPHRENIA DYING SO YOUNG, AND WHAT CAN WE DO ABOUT IT? MEDICAL PROBLEMS IN SCHIZOPHRENIA.
University of Melbourne
There is a heavy burden of physical health comorbidity in people with schizophrenia, and it is estimated that such individuals die on average 10-15 years younger than they should, largely because of under-treated medical morbidities. This talk will outline the extent of such morbidities in people with schizophrenia, and suggest ways in which they could be better managed. The talk will also detail a local study of people with schizophrenia and related disorders, that assessed their attitudes to weight gain and the impact on their quality of life.
PSYCHOSOCIAL TREATMENTS IN SCHIZOPHRENIA – THE ROAD TO REHABILITATION (AND RECOVERY?)
Central Northern Adelaide Health Service
Much of the treatment of schizophrenia, particularly in it's more chronic forms takes place in community mental health facilities. The negative syndrome of schizophrenia and a client's social and occupational position in society have long been recognised as important predictors of morbidity and recovery from schizophrenia but are not strongly responsive to medication alone and a wide range of treatment strategies have been developed over the decades in recognition of this. In recent years there has been a growing body of research systematically evaluating the different psychological and social strategies and these will be reviewed together with how this fits into the current public and private mental health landscape.
S15 LIVING IN INTERESTING TIMES: FROM AN INDIGENOUS PERSPECTIVE
1 President Australian Indigenous Doctors Association
2 Co-chair Indigenous Healing Foundation
This symposium will address the theme of the conference through a number of current initiatives and political developments in regard to Indigenous affairs. The three invited speakers will consider the context of Indigenous health and mental health in light of the national Apology, the Close the Gap campaign, the Northern Territory Emergency Response intervention and the signing of the United Nations declaration on the rights of Indigenous peoples. There have been substantial changes nationally and internationally in relation to Indigenous affairs and how these will ultimately impact on the mental health and wellbeing of Indigenous Australians is yet to be determined. The historic Apology by the prime-minister in 2008 marked a new way forward for understanding the impact of historical trauma on Indigenous peoples and the announcement of a Healing Foundation in 2009 appears to represent a commitment to recovery. What role psychiatry has to play within a healing framework warrants consideration given the complexities involved in post-genocide recovery for a population group and the broader role of reconciliation. This topic will be addressed by Mr Gregory Phillips recently appointed to co-chair the Indigenous Healing Foundation. Prior to the Apology however, was the historic decision to suspend the racial discrimination laws to allow for the Northern Territory Emergency Response to address sexual abuse and other issues relating to the state of Indigenous people. The real impact of the intervention is unclear. Dr Tamara Mackean will present the preliminary findings of the Health Impact Assessment of the NTER on Indigenous people in the Northern Territory with particular focus on wellbeing. Finally, the historic signing of the United Nations declaration on the rights of Indigenous peoples globally represents a watershed in the political landscape regarding Indigenous peoples and again signals a new way forward for considering what constitutes the mental health and wellbeing of Indigenous Australians. This topic will be addressed within the Australian context and the commitment of government to Close the Gap in life expectancy, educational achievement and employment opportunity. In summation, the topics will be considered in regard to the role of psychiatrists and mental health services in recovery and reconciliation.
S16 THESE ARE SOME OF MY INTERESTING THINGS: PSYCHIATRISTS WORKING IN “ALTERNATIVE” ROLES
1 Central Northern Adelaide Health Service, Adelaide, Australia
2 Discipline of Psychiatry, University of Adelaide, Australia
3 Public Advocate of South Australia
4 University of Otago, Christchurch, New Zealand
5 McKesson Asia-Pacific, Sydney, Australia
S17 COLLEGE PSYCHOTHERAPY SUPERVISION
1 Cert Child Psych, Consultant Psychiatrist and Psychotherapist, Past Chair Section of Psychotherapy (Victorian Branch)
2 Senior Lecturer University of Sydney, Consultant Psychiatrist and Psychotherapist, NSW Director of Advanced Training in Psychotherapy
3 Consultant Psychiatrist and Psychotherapist, Chair Binational Section of Psychotherapy
Explore some guidelines for supervision Remind Fellows about RANZCP guidelines for the Psychological Methods Case. Encourage supervisors and trainees to think about supervision in a helpful way
Dr Jeff Streimer will speak about the goals of supervision. What do we want our psychotherapy trainees to learn from the long case? Is it possible to be more specific? He will outline some ways of thinking about this.
The symposium will then consider some difficult problems in supervision, using prepared vignettes. A small group discussion will be observed by the large group who will then be invited to comment.
S18 EMERGING FRONTIERS AND CLINICAL CHALLENGES IN POST TRAUMATIC STRESS DISORDER
The first part symposium will provide an update on emerging issues of interest in the understanding of the aetiology course and risks for posttraumatic stress disorder. A combination of data from epidemiological studies is demonstrating that PTSD is the most prevalent anxiety disorder in our community using ICD-10 criteria. The recent Australian National Mental Health and Wellbeing Survey showed that it has a prevalence of 6.4%. Increasingly however, it is recognised that other psychiatric disorders arise as a consequence of exposure to traumatic stress. Emerging findings in the area of neuro-imaging highlighting the widespread abnormalities of information processing in PTSD will be presented. Future treatment development will depend on identifying the unique patterns of hyperarousal and stress sensitisation that underpin the psychopathology of PTSD.
The second part will highlight how psychological aftermath of disaster and trauma has been the subject of increasing attention, with mental health practitioners expected to provide interventions for both acute and chronic presentations of conditions such as posttraumatic stress disorder (PTSD). This presentation will begin with an introduction to the field from a historical perspective, before reviewing the key phenomenological and epidemiological aspects of posttraumatic mental health conditions. In recent years, our understanding of evidence-based treatments for these conditions has developed dramatically, with practice guidelines appearing in the US, the UK, and Australia. The presenters will discuss the development of, and key recommendations from, the Australian NHMRC Guidelines for the treatment of PTSD, with particular reference to their application in routine clinical settings. The presentation will be illustrated with case material and there will be ample time for audience questions and discussion.
S19 LEADERSHIP AND MANAGEMENT: MODELS OF CARE FOR INTERESTING TIMES
1 Eastern Health, Melbourne, Australia
2 Austin Health, Melbourne, Australia
3 Peninsula Health, Melbourne, Australia
4 Barwon Health, Geelong, Australia
5 University of Melbourne, Melbourne, Australia
Mental health services are increasingly reviewing existing models of service delivery and considering alternative ways of providing high quality, resource efficient and consumer focused care. In addition to ever growing clinical demands, increased competition for an aging workforce and the imperative to meet incongruous key performance indicators, services also face the challenge of adjusting to shifts in mental health policy and legislation. Furthermore, the task of integrating better with other providers of mental health care, particularly in the primary care sector and Psychiatric Disability Rehabilitation Support Services, is not a simple one in a system that appears structured to promote fragmentation rather than integration and continuity of care. It is extremely important that psychiatrists, particularly those in leadership and management positions within the public mental health system, are a part of this process of reviewing and redeveloping clinical services.
This symposium will present a number of service development projects that have attempted to design, implement and evaluate innovative and potentially controversial models of care. It is anticipated that these presentations will provoke lively discussion with two main goals. Firstly, the symposium aims to stimulate interest amongst psychiatrists to take up leadership and management functions and become involved in the design and development of new models of care. Secondly, it is hoped that the symposium will precipitate further thinking regarding new models of care that balance the realities of the environment in which we work with the requirements of good clinical governance and the expectations of consumers and their families.
S20 WINE AND PSYCHIATRY
1 Consultant psychiatrist, Private Practice
2 Manager, Health and Regulatory Information, The Australian Wine Research Institute
3 Retired Renal Physician and Winemaker, Barrett Wines
IN VINO VERITAS
This introductory presentation discusses, in a mixture of prose and images, the link between wine and psychiatry from a number of perspectives. Unashamedly pro-wine in its orientation, the presentation begins by discussing the numerous benefits of wine consumption on mental health, with supporting quotes from various famous wine consumers from Martin Luther to Napoleon Bonaparte. The final section debates the concept that wines have a personality, a psyche, and presents various images and quotes in support of this argument. Overall the presentation is a not too serious discussion that should be of interest to all those who enjoy the fruit of the vine
WINE AND MENTAL HEALTH
This presentation provides the scientific component to the symposium, looking at the various issues surrounding wine and mental health, both good and bad.
THE TRANSITION FROM MEDICO TO WINEMAKER
Dr Barrett, one of South Australia's leading renal physicians, retired some years ago to establish Barrett Wines in the Adelaide Hills. Now recognized as one of the Australia's foremost producers of pinot noir, chardonnay and sauvignon blanc, Dr Barrett will tell his story before (hopefully) providing a tutored tasting of his wines (this component is yet to be finalized – numbers may be restricted).
S21 RANZCP BOARD OF RESARCH SYMPOSIUM “ISSUES IN INDUSTRY SPONSORED CLINICAL TRIALS”
RANZCP Board of Research
Clinical trials of any potentially appropriate treatment for mental health disorder remain one of the cornerstones of evidence based medicine. Such trials yield important information about the efficacy and safety of any putative treatment, pharmacological, psychological or other. For pharmacological treatments the process of clinical trials required for registration of new medications is an appropriately time consuming and costly task. As a result, most new pharmacological agents enter the market with efficacy and safety information derived predominantly, if not entirely, from industry sponsored clinical trials.
The meaningful and ethical performance of these studies is thus an important issue for clinicians and consumers to have confidence in new treatments.
This workshop aims to introduce trainees and newer researchers to the area of clinical trials. Areas of focus will include the role of clinical trials, trial design and the potential issues involved in participation in a clinical trial as an investigator. An interactive format is anticipated.
S22 EMERGENCY PSYCHIATRY: NEW BROOMS FOR 21ST CENTURY CLOSETS EMERGENCY PSYCHIATRY: LESSONS FROM THE ‘URBAN COALFACE’
St Vincent's Mental Health Service, Sydney, Australia
The demand for Emergency Department (ED) based psychiatric services is a recent phenomenon caused by structural changes in mental health service (MHS) provision, driven by deinstitutionalization and community care. This trend has been most acute in inner-urban areas. We present a range of quantitative data and descriptive information regarding integrated emergency psychiatric services at St Vincent's Hospital, Sydney.
Dr Tietze will provide a historical overview of liaison services to the St Vincent's ED and the development of the Psychiatric Emergency Care Centre (PECC), with emphasis on mental health clinicians’ changing experiences in the ED environment.
Prof Wilhelm will present data from a retrospective chart review of three groups of consecutive mental health presentations to the ED, taken before and after the PECC's introduction, analysing demographic trends, the impact on ED and mental health services with service changes, and the care models that have been utilised by the PECC team.
Mr Hudson will describe the innovative St Vincent's service model, the key role played by nursing staff both within the PECC and in ED liaison, and the integration of PECC with emergency medical and nursing services.
Dr McGeorge will analyse the impact of integration of ED, inpatient and community-based acute psychiatric services as well as presenting data on how these have affected the prevention and management of critical incidents in a high-risk urban setting.
In conclusion the presenters will draw together general lessons learned from the overall St Vincent's experience that may assist in development of emergency psychiatric services elsewhere.
S23 TREATMENT OF EATING DISORDERS: COSTS, IMPACT ON CARERS AND THE PATIENT WITH LONG-STANDING ANOREXIA NERVOSA.
AN EXAMINATION OF THE RELATION BETWEEN TREATMENT FOR ANOREXIA NERVOSA AND THE CARER'S PSYCHOLOGICAL DISTRESS.
1 Flinders University
2 Institute of Psychiatry London
A RANDOMISED CONTROL TRIAL OF NONSPECIFIC SUPPORTIVE CLINICAL MANAGEMENT (NSCM) VERSUS COGNITIVE BEHAVIOUR THERAPY (CBT) IN LONGSTANDING ANOREXIA NERVOSA
1 University of Sydney, Sydney, Australia
2 University of Chicago, Chicago, USA
3 St Georges, University of London, London, UK
4 University of Western Sydney, Sydney, Australia
5 North Dakota State University, Fargo, US
6 University of Newcastle, Newcastle, Australia
7 University of Otago, Christchurch, New Zealand
8 Temple University, New York, Japan
THE RELATIVE COSTS OF ADMISSIONS FOR EATING DISORDERS: A CASE REGISTER POPULATION STUDY.
1 University of Western Sydney, Sydney
2 University of Sydney, Sydney
S24 CONSUMER-CLINICIAN RESEARCHERS EXPLORING TOGETHER THE CONSUMER NARRATIVES OF THE “STRENGTHS MODEL” OF CASE MANAGEMENT WITH CHALLENGES & LESSONS LEARNED IN UTILIZING CONSUMER RESEARCHERS IN THE RESEARCH.
St Vincent's Mental Health Service-Melbourne, Victoria, Australia.
-generate more meaningful research / interview questions. -elicit different research responses -allow freely / open speaking to the topic -and create less fearful and non-judgemental dialogue.
A “Research Reference Team” of similar design of people to the former team was also formed to assist with the research process.
A Booklet will be published with narratives and findings. This will enhance training of Case Managers.
DEVELOPING A CONSUMER PERSPECTIVE ACADEMIC PROGRAM
Consumer Perspective Academic Program, Centre for Psychiatric Nursing, School of Nursing and Social Work, University of Melbourne, Australia
Present an outline of the Consumer Perspective Academic Program at the University of Melbourne. Present a teaching case study to demonstrate the application of the discipline of critical consumer perspective Present Proximity, the Consumer Perspective Academic Program website and clearing house
Gain an understanding of ‘critical consumer perspective’ Find out how to access a range of consumer perspective materials relating to education and research
S25 MAY YOU LIVE IN INTERESTING TIMES
ALSO INTRODUCING A NEW DISEASE CALLED “A PATHOLOGICAL ABSENCE OF DOUBT”
1 Emergency Mental Health, Flinders Medical Centre, Adelaide, Australia
2 NSW Government Alcohol Educational Taskforce & Health Consultant to Client Solutions
3 University of Otago, Christchurch, NZ
4 Brain & Mind Research Institute, Camperdown, Australia
The origin of the phrase “May You Live in Interesting Times” is said to be ancient Chinese origin although Chinese academics don't accept this. It has also been considered to be Arabic. In more recent times it was attributed to Karl Yung and most recently to the author Eric Russell. Whatever the case it probably means something like “May you experience much upheaval and trouble in your life”. The clear indication being that “uninteresting times” of peace and tranquillity, are more life enhancing.
The phrase came to mind because of an event within the organising committee of the South Australian Congress. A group in the committee (I haste to add here three of these are in my department are friends and highly regarded as individuals, academics and clinicians as indeed with those outside my department) decided there should be no pharmaceutical sponsorship of the conference by the pharmaceutical industry. The argument mainly centred on ethical principles and rested on the well known evils and sins of Big Pharma. This being the case the argument could be presented with considerable clarity and simplicity. Some appeared to agree with this option, some didn't care and some disagreed. For myself, I thought the issue was very complex and need much more thought. This carried with it for me the elements of “interesting times”.
By way of introducing the theme of this discussion by a group of four speakers including myself, Prof Kalucy, Trish Worth, a very seasoned Federal Politician and two eminent senior psychiatrists, Prof Ian Hickie and Prof Peter Joyce. I put forward an opening statement which examines a new disease which I think brings together the element of the “interesting times” in which we live in the health sector. Each of the speakers will approach this from their own perspective. The disease is called “A PATHOLOGICAL ABSENCE OF DOUBT”. Like all good DSM111 defined diseases, it has a minimal number of criteria of which I will outline eight; usually all are present in this disorder but at least four are essential.
In investigating the disorder systematically and looking at its prevalence and evolution, it is noted that it was once thought to only exist in doctors and widely believed to be most common in orthopaedic surgeons. Subsequently it was realised that it had become common in senior nurse management. Over the last decade it has become more prevalent in the managerial classes in general in the health sector. In turn, the managerial classes have themselves become “particularly prevalent”. A recent article in the weekend newspaper of the second to last weekend in February noted that there are now more people in health management positions than there are nurses. A struggle for power might thus be clearly recognised as driver of this disorder. It may be that the disease, A Pathological Absence of Doubt, could in later times diminish once the new groups have formed a clear identity.
It is not completely differentiated by gender but perhaps to some extent by age in that it is especially common in those under the age of 50.
It has been noted to have evolved in parallel with the contemporary style of “presidential” politics. It may be one of the first diseases that are principally driven by the prevailing political culture.
The essential features of the DSM criteria are –
The presence of certainty is essential. This can be real or perceived as possibly defensive. It may be situational dependant in that it can disappear when a person is not at work. A heightened capacity for inventing words, acronyms and phrases which appear at first sight to carry meaning, but on inspection are found to be convenient carriers of desired policy and obscurers of motives is noted. Examples might include words such as “transparent”, “open”, “networking”, “recovery”, “nurse-led teams”, multidisciplinary teams”, consulting widely”, “policy modelling”, healthcare modelling’, “prioritising” and “benchmarking”. A typical sufferer of this disease has a sore neck. This is particularly the case in the management sector. This results from looking over ones shoulder to make sure one is not going to upset the Minister or the CEO, or the Senior Management or Junior Management according to level of management one lives in. This sore neck is associated with a degree of a concern ranging from total and manifest distrust of any non management agency or person e.g. a clinician who might have an interest in the outcome of health deliberations or worse expertise in the matter. It is unusual for the victim to focus on consumer needs or the health needs of care providers but under certain circumstances they might focus on perceived consumer demand when it has political meaning or opportunity. A typical sufferer has a deeply ingrained capacity to avoid thoughtful advice and reflection from experienced health workers and clinicians. This is especially the case if the clinician is senior in status. An equally entrenched capacity to ignore or selectively attend to evidence based research or well structures surveys or outcome studies is noted. A heightened capacity to see ones point of view as one of moral rectitude and hence “ethical” is usual in this syndrome. Those not in agreement therefore are by definition “unethical”. Those, perhaps like the present speakers who are often simply unsure, are seen as beneath contempt. A special expertise in answering questions authoritatively and crisply (e.g. in less than 10 seconds) with answers which may or may not bear any relation to the question depending on the circumstances. An uncanny capacity to induce counter transference responses characterised by perplexity, blankness of mind and/or an inexpressible rage and despair.
It is possible that the syndrome is also contributed to by the famous Parkinson's Law observation. Parkinson's Law was first described in the Second World War when a large administrative organisation responsible for streamlining the allied effort in defeating Nazi Germany was formed. At one period sadly, the Chief of Committee who was an Air Vice Marshall, went on leave, his Deputy, an Army Colonel fell sick and the Colonel's Deputy and Air Force Wing Commander was called away on urgent business and Major Parkinson was left to soldier on. At that point an odd thing happened – nothing at all! The paper flood which characterised this organisation ceased and the war went on regardless. As Major Parkinson later mused, “there never had been anything to do; we just had been making work for each other”. This led to his general law which states that “work expands to fill the time available”.
The speakers are all very experienced in public endeavour and in attempts to initiate what might in a modest sense be considered noble endeavours. Each of them will address the nature of this disorder in their own manner bringing their own experience to bear on our “interesting times”.
S26 PLAY, THE DEVELOPMENT OF SELF AND LINKS TO CREATIVITY
1 NSW Institute of Psychiatry, Sydney, Australia
2 University of Newcastle, Newcastle, NSW
The presenters explore the importance of play in development and its links to creativity and will consider the impact of disruptions or distortions to playful experience on the developing self and the clinical implications of this.
HOME IS WHERE WE START FROM
This paper will use images and stories to consider the developmental significance of early play, what it is and how it develops, with particular reference to the work of Winnicott, Bowlby and Fonagy & colleagues Home is the place where we first learn to play. It is an actual as well as an imagined and remembered place. We carry it with us and revisit in different ways throughout our lives. Winnicott believed that the capacity to live creatively is the retention throughout life of something that belongs properly to infant experience. Play and creativity involve risk and exploration. The infant's developing capacity to play requires the caregiver's tolerance and facilitation. This paper will explore these issues and encourage reflection about the contemporary relevance of Winnicott's work in this area, in particular his notion of “creative living”, asking what does it mean to be at home with ourselves, how might play be a part of this, and what are we and our children at risk of losing without time and encouragement to play and take risks? An earlier version of the paper was presented as an invited talk at the National Gallery of Australia in conjunction with the exhibition Home at Last.
LOST IN THE MIRROR
The early origins of the self are discussed in terms of current neurobiological and psychoanalytic models of parental mirroring and processing of the infant's experience and communication. Play is a communication with the other and the discovery of space and distance. Psychoanalytic models of self development are in many ways spatial theories and focus on the construction of a flow of lived experience in relation to an observing other. The self develops around a core of shared emotional experiences. Lacan describes the other aspect to the self as the alienation of experience in an image of coherence and sees this as an existential given of human life. A coherent self is essentially an illusory experience and the disjunctions between self and experience are the places of construction of the unconscious, loss and desire. To play is to create and recreate a sense of ongoing existence and connection to the observing other. Recent interest in mirror neurons focuses on their role as the neurobiological underpinnings of empathic function. The mother is not a perfect mirror and brings to her play with the infant her own history of being parented, wished beliefs and desires for the infant and marks her interactions as different. This difference is important for the developing distinction between self and other. Interactions in which there is fusion of experience between parent and infant risk ‘loss’ of the infant self in the parental self. Clinical examples will illustrate early distortions of self development in dyads with maternal borderline disorder.
S27 QUALITY ASSURANCE AND PEER REVIEW IN FORENSIC PSYCHIATRY: THE VICTORIAN EXPERIENCE
Department of Psychological Medicine, Monash University, Melbourne, Victoria
During 2005 the Victorian WorkCover Authority (VWA) initiated a quality assurance programme with the aim of reviewing and assessing reports prepared by approved independent medical examiners appointed pursuant to the relevant legislation. The VWA approached the various learned Colleges for nominations of clinicians to act as consultants in developing the most appropriate methodology for the quality assurance and peer review. The author was one of the three nominees by the RANZCP Victorian Branch Committee, and acted as Convenor of the Forensic Psychiatry Review Panel until the end of 2008.
After reviewing the relevant literature and published guidelines for the preparation of psychiatric medico-legal reports the Panel decided that the RANZCP guideline for the preparation of medico-legal reports was the most appropriate, and de-identified psychiatric reports – selected by insurance agents managing workers’ compensation claims on behalf of the VWA-were evaluated and rated using that guideline as a model.
The peer review found that many reports reviewed by the Panel were deficient in mental state examination. While the letter sent out by the VWA to psychiatrists advising them of the Panel's concerns was inappropriately legalistic, confrontational and threatening in its tone, the responses from individual psychiatrists were marked by anger towards the VWA and intemperate personal attacks and abuse directed towards their colleagues who had been nominated by the College to act as Panel members and peer reviewers.
This presentation will highlight the methodology used by the Psychiatry Review Panel, the most egregious deficiencies in mental state examination that came to the Panel's notice, and what has been termed by Gutheil and Simon as the ‘narcissistic dimension of expert witness practice’. The presentation will also offer suggestions for future quality assurance and peer review programmes that might minimise the problems that emerged during the process in Victoria.
NEONATICIDE: A CHALLENGE FOR PSYCHIATRY AND SOCIETY
Mason Clinic, Auckland, New Zealand; and Case Western Reserve University School of Medicine, Cleveland, USA
Neonaticide, murder of the infant in the first day of life, is distinct from other types of child murder. The day with the lifetime highest risk of being murdered is the first day of life. Neonaticide is difficult to prevent by its very nature. Mothers commit the vast majority of neonaticides, and suicide is extremely rare. Our review of studies in the developed world found that perpetrators often had no premorbid psychiatric illness, no prenatal care, and experienced denial or concealment of pregnancy. Another small subset of neonaticide offenders exists; a Finnish study indicated that while some perpetrators have personality disorders, a small subset were psychotic at the time and had different demographic characteristics.
International responses to the problem of neonaticide will be described, including anonymous birth options, Safe Haven laws, judicial bypass, and Infanticide laws. European ‘anonymous birth options’ and American Safe Haven laws have similar goals. The first Safe Haven law was in 1999 and versions have since been adopted in all American states. Mothers depositing infants in “Safe Havens” may remain anonymous without risk of prosecution. Though there are criticisms of Safe Haven laws, the efforts are worthwhile if they are able to save a few babies’ lives. Infanticide laws, which exist in two dozen nations, traditionally allow a woman who kills her infant in the first year of life to be charged with infanticide (akin to manslaughter) rather than murder. This paper describes the phenomenology of neonaticide, its prevention, and the intersection of psychiatry and the law.
PERSONALITY TRAITS OF PRISON INMATES AND THEIR VULNERABILITY TOWARDS DIFFERENT PSYCHOPATHOLOGIES
1 Centre for Clinical Psychology, University of the Punjab, Lahore, Pakistan,
2 Sadaqat Clinic, Jail Road, Lahore, Pakistan
S28 RANZCP BOARD OF RESEARCH SHOWCASING RESEARCH “RECENT REAEARCH IN AUSTRALIAN AND NEW ZEALAND IN BIPOLAR DISORDER
RANZCP Board of Research
Bipolar disorder is a common disorder in our community, with conservative estimates placing the lifetime prevalence at 2 to 3%. As well as causing chronic disability and great distress, bipolar disorder is also frequently cited as the most lethal of psychiatric disorders, with a 15% lifetime suicide rate.
After a number of decades of moderate development, significant growth in the level of research interest in bipolar disorder has occurred over the last decade. Major areas of new development include issues related to the diagnosis; genetic aetiology; neurobiology as understood through neuroimaging and treatment issues such as early intervention and biological and psychological management.
This symposium will highlight several of the major Australian and New Zealand contributions to this development and continues the Board's tradition of honouring research work in the RANZCP community.