EVALUATING THE EFFECT OF DESVENLAFAXINE AND PAROXETINE ON THE CYP2D6-MEDIATED BIOTRANSOFORMATION OF CODEINE TO MORPHINE
Dr Susan Baird-Bellaire1
, Dr Stéphan Chalon1, Dr Jeffrey Paul2, Dr Alice Nichols2
1
Wyeth Pharmaceuticals, Paris, France
2
Wyeth Research, Collegeville, Pennsylvania
Background: The analgesic effect of codeine is largely dependent on its biotransformation via CYP2D6 to morphine, so coadministration of CYP2D6 inhibiting antidepressants may impede the efficacy of codeine.
Objectives: The CYP2D6-mediated biotransformation of codeine to morphine was assessed using desvenlafaxine (administered as desvenlafaxine succinate) and paroxetine.
Methods: This randomized, open-label, 3-period, crossover study enrolled healthy subjects. During period 1, a single dose of codeine 60mg was administered. In period 2, subjects received desvenlafaxine 100mg or paroxetine 20mg for 8 days, on the 7th day they received codeine 60mg concomitantly. Subjects received the alternate treatment combination during period 3. The primary outcomes were the mean area under the concentration-time curve to the last measurable concentration (AUCT) of morphine and codeine.
Findings: The AUCT of morphine was lower for paroxetine/codeine (0.2 ng∗hr/mL) compared to codeine alone (6.6 ng∗hr/mL) and desvenlafaxine/codeine (6.1 ng∗hr/mL). The mean difference in morphine AUCT with codeine alone was significantly greater in relation to those receiving paroxetine/codeine (7.2ng∗h/mL; P<0.01), but differences between codeine alone and desvenlafaxine/codeine (0.6ng∗h/mL) did not reach statistical significance. No difference was observed in the AUCT of codeine between those receiving codeine (349 ng∗hr/mL) and desvenlafaxine/codeine (348 ng∗hr/mL), but an increase was observed for paroxetine/codeine (382 ng∗h/mL).
Conclusions: The biotransformation of codeine to morphine was not significantly impacted by the coadministration of desvenlafaxine 100mg, as assessed by exposure to morphine; however, when paroxetine 20mg, a CYP2D6 inhibitor, and codeine were coadministered morphine exposure was significantly reduced.
Supported by Wyeth Research
“WELCOME TO THE COUNTRY” AT THE OCCASION OF EDUCATIONAL ACTIVITIES FOR PSYCHIATRISTS IN QUEENSLAND – AN OBSERVATION REGARDING THE FREQUENCY OF THE USE OF THE DIDGERIDOO
Dr Klaus Martin Beckmann
1,2
1
Medical School, Griffith University, Logan, Queensland, Australia,
2
Evolve Therapeutic Services, Logan, Queensland, Australia
Background: Continuous professional development (CPD) is salient for the maintenance of professional standards (MOPS). Psychiatrists of all levels of seniority and subspecialties are encouraged to join. There are numerous occasions available. Training occasionally might start with the “welcome to the country”.
Objectives: Collect evidence as to how frequently a training opportunity might have an indigenous welcome.
Methods: Take a log of whether an indigenous welcome occurred, or not occurred – during an identified time interval. Limit observations to non Queensland Health training opportunities. Limit the specified time interval to March 2008 and the subsequent 8 months.
Findings and Conclusions: Only a minority of CPD occasions had an indigenous welcome. However at the few occasions when a member of the local indigenous group did welcome: the musical performance was astonishing for its high level of proficiency and the kind words used to welcome were an emotionally moving and humbling experience.
DESCRIPTIVE MODELING OF THE NEUROBIOLGY OF ADDICTION
Dr Joanne Ferguson
1, Ms Karen Vance2
1
Drug Health Service Concord Hospital, NSW, Australia, University of Sydney, Sydney, Australia,
2
Masters in Design, University of Technology Sydney, Australia
Abstract: A visual model of addiction from neurobiological perspective is presented. This model was developed for teaching and use with patients around the neurobiology of the physiological features of dependence especially relapse and reinstatement. Comments and review are welcomed as part of evolution of the model.
Background: Visual models are often helpful to staff and patients to describe features of dependence and associated adaptions eg tolerance, reinstatement and relapse. The biological components of these characteristics are often overlooked in treatment planning. Neurobiology research in addiction continues to clarify to the neurological changes which evolve and remain with dependence and models need flexibility to incorporate developments.
Objectives: A simple visual model to describe neurobiology of dependence.
Methods: A review of the literature and recent developments was undertaken. A model then evolved from discussions and diagrams. These models have been discussed with staff and clients and then modified.
Findings and Conclusions: The neurobiology research is complex and changing but models can be simplified without losing important content and be useful to clients to explain the biology of addiction. Heuristic modeling offers opportunity to adapt as research elucidates the neurobiology further.
SUBSTANCE USE IN YOUNG PEOPLE WITH FIRST EPISODE PSYCHOSIS IN ADELAIDE
Dr Levina Clark
1, Prof Cherrie Galletly2, Ms Lesley Legg3, Ms Lynn James4, Dr Julie Connor5, Ms Tracy Air6
1
Child and Adolescent Mental Health Services, Adelaide, Australia,
2
The University of Adelaide, Adelaide, Australia,
3
Southern Adelaide Health Service, Adelaide, Australia,
4
Central Northern Adelaide Health Service, Adelaide, Australia,
5
The University of Adelaide, Adelaide, Australia
Comorbid drug and alcohol use is frequently observed among young people with first episode psychosis (FEP). A case note audit was conducted of patients aged 18-30 years who presented for the first time with a psychotic disorder to the mental health services in Adelaide, South Australia. South Australia does not have dedicated first episode psychosis services so patients were assessed and treated at general adult inpatient and community facilities. The audit investigated the recording of information related to drug and alcohol use. We also looked at the recording of interventions offered to those patients who had significant drug and alcohol problems. The majority of FEP case notes did contain a drug and alcohol history, and high rates of drug use were noted. The most commonly used drugs were cannabis and amphetamines. The recorded information may underestimate the extent of substance use within young people with first episode psychosis, as clinicians may have failed to assess drug and alcohol use, or may have asked about this but not recorded their findings. The results of the current study support previous literature that has identified high levels of substance use (marijuana and amphetamine use in particular) in individuals during their first presentation with a psychotic disorder. It is likely that substance abuse is making a significant contribution to the clinical presentation of many young people with early psychosis in Adelaide.
PSYCHIATRIC PROFILE OF SERIOUS OFFENDERS WITH SERIOUS MENTAL ILLNESS
Dr Vikas Garg, Dr Narian Nambiar
James Nash House South Australia
Background: Many Serious offenders who have committed murders and has sentenced to life who also have concurrent mental illness are a unique population to study. Here I am aiming to study some patients who were under my care whilst working at James Nash House. The management of such patients requires a unique MDCP involving many agencies such as Department of Justice, Department of Corrections, Mental health services, Housing, and few other community departments.
This is a descriptive study attempting to explore this unique group and the results will be discussed.
AN OPEN-LABEL, 6-MONTH OBSERVATIONAL STUDY OF PATIENTS WITH SCHIZOPHRENIA OR SCHIZOAFFECTIVE DISORDERS RECEIVING RISPERIDONE LONG ACTING INJECTION
Dr Harry Hustig
1, A/Prof Richard Newton2, Dr Phil Nyst3
1
Glenside Hospital, Eastwood, South Australia
2
Frankston Hospital, Frankston, Victoria
3
Royal Brisbane and Women's Hospital, Brisbane, Queensland
Background: Risperidone long acting injection (RLAI) has been shown to be effective in the treatment of schizophrenia and schizoaffective disorders.
Objectives: To document the efficacy and safety in a naturalistic setting following the initiation of RLAI.
Methods: This was a multicentre observational study of patients with schizophrenia or schizoaffective disorders for whom a clinical decision had been made to initiate treatment with RLAI. Assessments were conducted at baseline, 3-months and 6-months. The outcomes measured were the Clinical Global Impression of Severity (CGI-S), Global Assessment of Functioning (GAF), the BMI of the subject, and dose of RLAI at each visit.
Findings: 107 subjects were enrolled in this study and 73 completed all visits. Mean CGI-S scores were improved from baseline (4.3, SD 1.13), at 3-months (3.7, SD 1.07) and 6-months (3.5, SD 1.19) (both p<0.0001). Mean GAF scores were improved from baseline (45.5, SD 13.81) at 3-months (51.2, SD 15.04) and 6-months (54.1, SD 16.33) (both p<0.0001). The mean BMI increased from 27.76 kg/m2 at baseline, to 28.98 kg/m2 at 3-months and 29.49 kg/m2 at 6-months (p<0.05). One third (33%) of subjects remained on their initial dose for 6-months, and of those who had dose adjustment, most were made in the first 3-months (43.7%). Three subjects withdrew due to adverse events.
Conclusions: Severity and functioning improved in patients with schizophrenia and schizoaffective disorder treated with RLAI, which was well tolerated. This study was sponsored by Janssen-Cilag Australia
DO CTOS REDUCE RE-HOSPITALISATIONS? RESULTS FROM AN AUDIT
Dr Kannan Kallapiran, Dr Anoop Sankaranarayanan
1
Hunter New England Mental Health Service
2
University of Newcastle
Background: Community Treatment Orders, regarded as a product of deinstitutionalisation, is a coercive legal order that sets out the terms under which a person must accept treatment, which is implemented by a mental health facility that has developed an appropriate treatment plan for the individual person. CTOs have been in use in many countries for a number of years. Over this period, there has been much debate and dilemma, both within and without the profession. Whilst the family of patients are in favour of CTOs, patients generally have contradictory feelings about CTOs. Research till date is divided about whether CTOs are effective in reducing hospitalisation.
Objectives: The aim of our study was to evaluate the effectiveness of CTOs in reducing hospitalization.
Methods: This study was part of an audit of all patients who were on CTOs in Hunter Valley Mental Health Service. All patients who were on a CTO on the 31st of July 2008 were included in the study. Hospitalisation was the primary outcome variable. The number of hospitalizations one year prior and following commencement of the CTO was studied
Findings: There were a total of 28 patients on CTO. 82% were male, and 93% were on a depot preparation. 75% of the sample used substances other than cigarettes and alcohol, with 57% of them using cannabis.
Conclusion: The impact of CTOs on admission rates will be discussed; we will comment on the existing controversy based on our results.
ASSESSING THE PHARMACOKINETICS OF VENLAFAXINE ER 75 MG AND DESVENLAFAXINE 50 MG IN CYP2D6 EXTENSIVE AND POOR METABOLIZERS
Cecelia Kane
1, Dr Alice Nichols1, Kristen Focht1, Mr Qin Jiang1, Dr Sheldon Preskorn2, Dr Ted Burczynski1
1
Wyeth Research, Collegeville, Pennsylvania
2
Clinical Research Institute and University of Kansas School of Medicine, Wichita, Kansas
Background: CYP2D6 metabolic polymorphisms have been shown to decrease plasma concentrations of certain antidepressant medications.
Objectives: To evaluate the impact of CYP2D6 extensive (EM) or poor metabolizer (PM) genotypes on the pharmacokinetics of single doses of venlafaxine extended release (ER) and desvenlafaxine (administered as desvenlafaxine succinate) in healthy adults.
Methods: In this open-label, crossover study, subjects were administered, in randomized sequences, single doses of venlafaxine ER 75mg and desvenlafaxine 50mg. CYP2D6 genotyping was performed using internally developed and commercially available assays. Geometric means for area under the plasma concentration-versus-time curve (AUC) and peak plasma concentration (Cmax) were calculated. Comparisons between EMs and PMs were made using a 2-tailed Wilcoxon exact test.
Findings: No carry-over effect was observed between treatment sequence groups. The AUC and Cmax of desvenlafaxine in subjects receiving desvenlafaxine 50mg were comparable between EMs (n = 7; 2455 ng∗h/mL and 83 ng/mL) and PMs (n = 7; 2702 ng∗h/mL [P = 0.38; EMs vs PMs] and 101 ng/mL [P = 0.26; EMs vs PMs]). However, significant differences (P<0.05) in desvenlafaxine AUC (EMs: 2534 ng∗h/mL; PMs: 465 ng∗h/mL) and Cmax (EMs: 90 ng/mL; PMs: 17 ng/mL) were observed between EMs and PMs receiving venlafaxine ER 75mg. Additionally, AUC and Cmax ratios of desvenlafaxine:venlafaxine for subjects receiving venlafaxine ER 75mg were significantly higher for EMs (7.5 and 4.0) than PMs (0.5 and 0.4; P≤0.001).
Conclusions: The pharmacokinetics of desvenlafaxine 50mg was not significantly impacted by CYP2D6 polymorphisms, whereas PMs receiving venlafaxine ER 75mg had significantly lower desvenlafaxine plasma concentrations compared to EMs. Supported by Wyeth Research
EVALUATING THE MAINTENANCE OF EFFECT OF DULOXETINE IN PATIENTS WITH DIABETIC PERIPHERAL NEUROPATHIC PAIN
Dr Katarina Kelin
1, Dr Vladimir Skljarevski2, Dr Durisala Desaiah3, Prof Qi Zhang3, Dr Amy S. Chappell3, Dr Michael J. Detke3, Dr Jorge L. Gross4
1
Eli Lilly Australia, Sydney, Australia,
2
Lilly Research Laboratory, Indianapolis, USA,
3
Eli Lilly and Company, Indianapolis, USA,
4
Centre De Pesquisas Em Diabetes, Porto Alegre, Brazil
Background: Approximately 10-20% of the patients with Diabetic Peripheral Neuropathy (DPNP) develop painful symptomatology that require acute and maintenance treatment.
Objectives: This open-label study is designed to evaluate the maintenance of effect of duloxetine 60 mg once daily over 26 weeks of therapy in patients with DPNP who responded to 60 mg duloxetine treatment after 8 weeks of acute therapy.
Methods: Patients with symmetric sensorimotor diabetic peripheral neuropathy were treated with duloxetine 60 mg QD for 8 weeks. Responders continued on 60 mg QD (maintenance treatment arm), and nonresponders were escalated to 120 mg QD (rescue treatment arm) for 26 weeks. The primary efficacy measure was change from baseline (Week 8) to endpoint in the patient-rated BPI 24-hr average pain score for patients entering maintenance phase only. Secondary efficacy measures included BPI-S, BPI-I, SF-MPQ, PGI-I, and CGI-S. Vital signs and TEAEs were collected.
Findings: The change of BPI 24-hr average pain score from baseline to endpoint was 0.35 with 0.79 as the upper bound of the 97.5% CI which is less than the prespecified noninferiority margin of 1.5 (P<.001). Most BPI-S and BPI-I scores were slightly increased, with no significant difference from zero except for the pain right now (mean change, 0.48, P=.026) and normal work (0.63, P=.016) scores. TEAEs and vital signs were similar to those reported in randomized DPNP studies of duloxetine.
Conclusion: Following 8 weeks of acute therapy, duloxetine 60 mg QD maintained its efficacy in the management of DPNP for 26 weeks and was well tolerated.
ESTIMATION OF MINIMUM CLINICALLY IMPORTANT DIFFERENCE OF PAIN IN FIBROMYALGIA
Dr Katarina Kelin
1, Dr Philip J Mease2, Dr Michael Spaeth3, Prof Daniel J Clauw4, Prof Lesley M Arnold5, Dr Laurence A Bradley6, Dr I Jon Russell7, Dr Daniel K Kajdasz8, Dr Daniel J Walker8, Dr Amy S Chappell8
1
Eli Lilly Australia, Sydney, Australia,
2
Swedish Medical Center and University of Washington School of Medicine, Seattle, USA,
3
Practice for Internal Medicine/Rheumatology, Graefelfing, Germany,
4
University of Michigan Medical Center, Ann Arbor, USA,
5
University of Cincinnati College of Medicine, Cincinnati, USA,
6
University of Alabama at Birmingham, Birmingham, USA,
7
University of Texas Health Science Center at San Antonio, San Antonio, USA,
8
Lilly Research Laboratories, Indianapolis, USA
Background: The minimum clinically important difference (MCID) in clinical assessments represents the amount of change that is not just statistically significant but also clinically meaningful to a patient.
Objectives: This work aims to determine MCIDs for a commonly used pain scale, the Brief Pain Inventory (BPI), in patients with fibromyalgia (FM).
Methods: Pain was assessed across 4 randomized, double-blind, placebo-controlled studies of duloxetine for treatment of FM. The MCIDs for the BPI average pain score and the BPI severity score were determined. Pain items were graded on a 0- (no pain) to 10- (pain as bad as you can imagine) point scale. Within-group MCIDs were determined by anchoring against the Patient Global Impression of Improvement (PGI-I) scale. The difference in mean change from baseline to endpoint in BPI scores between patients indicating “no change” (clinically stable, N = 240) and “much better” (considered minimal clinical improvement, N = 249) determined the PGI-based MCID.
Findings: Baseline pain scores were similar in both stable and minimally improved groups for the PGI-I–anchored evaluations (BPI average pain, 6.5; BPI severity, 6.3). The PGI-based MCID was 2.1 points for BPI average pain and 2.2 points for BPI severity, corresponding to a 32.3% and 34.2% reduction from baseline. All p-values were <.001.
Conclusions: Anchor-based within-group MCIDs for both BPI average pain and BPI severity scores in FM patients were consistent with those determined for other forms of chronic pain, namely absolute changes of about 2 points or a 30%-50% reduction from baseline.
INFANT HEAD GROWTH IN MALE SIBLING PAIRS WITH AND WITHOUT AUTISM SPECTRUM DISORDERS
Palak Majmudar, Dr John Constantino, Alex Bottini, Dr Molly Arvin, Dr Yamini Virkud, Dr Paul Simons, Dr Ed Spitznagel
Washington University School of Medicine
Background: Previous research has inconsistently suggested that children with autism may experience accelerated head growth (HG) in infancy. Limitations of prior studies have variously included low sample size, lack of contemporaneous control subjects, possible confounding effects of mental retardation, and genetically uninformative study designs.
Objectives: We examined infant HG trajectories among sibling pairs in both autism-affected and autism-unaffected families.
Methods: We retrospectively obtained serial head orbito-frontal circumference measurements documented by pediatricians of: a) 48 sibling pairs in which one (n = 28) or both (n = 20) sibs were affected by an autism spectrum disorder (ASD); and b) 85 control male sibling pairs in which neither child was affected.
Results: Average rate of HG of ASD subjects was slightly accelerated compared to controls, but the difference did not reach statistical significance. Among siblings of ASD-affected children, rate of head growth did not predict categorical classification (affected versus unaffected with ASD) or autistic severity. Sibling intra class correlation for rate of head growth was highly statistically significant in both autism-affected and autism-unaffected families, but the magnitude of that correlation was significantly stronger among autism-affected families (ICC=.63) than among controls (ICC=.26), p<.01. DICUSSION: In this quasi-longitudinal study, meaningful predictions about autistic impairment could not be made from measurements of HG in infancy within ASD-affected families. Infant head growth trajectory appears familial in both ASD-affected and unaffected families. These data support the notion that head growth trajectory might constitute a candidate endophenotype (inherited, but possibly not an independent correlate) of autism.
AN INDIRECT COMPARISON OF THE EFFICACY AND SAFETY OF DESVENLAFAXINE AND VENLAFAXINE USING PLACEBO AS THE COMMON COMPARATOR
Mr James Meaney1
, Vanessa Xavier1, Trish Palmer1, Dr Kristina Coleman2, Ms Libby Radalj2
1
Wyeth Australia Pty Ltd, Sydney, Australia
2
Health Technology Analysts Pty Ltd, Sydney, Australia
Background: Desvenlafaxine is a new SNRI antidepressant, and is the active metabolite of venlafaxine, formulated as a succinate salt.
Objectives: Compare the efficacy and safety of desvenlafaxine 50 to 200 mg/day and venlafaxine 75 to 225 mg/day, which are the approved dosage ranges for both products in Australia.
Methods: A literature search was conducted (Medline, Embase, and Wyeth databases) to identify placebo-controlled studies in the treatment of major depression. The pivotal efficacy outcome measure was a non-inferiority comparison of the mean change in HAM-D17 score from baseline. Safety comparisons included an evaluation of the total number of adverse events, and drop-out rates due to adverse events.
Findings: For mean HAM-D17 change from baseline using a Mixed Model Repeated Measures analysis, the pooled Weighted Mean Difference (WMD) was −2.81 (−3.72, −1.91; p<0.001) for desvenlafaxine and −2.61 (−3.17, −2.05; p<0.001) for venlafaxine. An indirect Bayesian analysis adjusted for baseline HAM-D17 score showed no significant difference between the two treatments (WMD −0.27; −1.17, 0.65). A standard indirect comparison of any adverse events showed no significant difference between desvenlafaxine and venlafaxine (Relative Risk [RR] 1.01; 0.96, 1.06; p = 0.70 and Risk Difference [RD] −0.01; −0.05, 0.03; p = 0.59). Standard indirect comparisons of both nausea and drop-outs showed potential differences between treatments, with the RD analyses suggesting a trend in favour of desvenlafaxine (nausea: RR 0.97; 0.77, 1.22; p = 0.80/RD −0.07; −0.12, −0.01; p = 0.02; and drop-outs due to adverse events: RR 0.86; 0.58, 1.29; p = 0.48/RD −0.04; −0.08, 0.00; p = 0.06).
Conclusions: Desvenlafaxine is non-inferior to venlafaxine in terms of efficacy, and may have some tolerability advantages.
SUBJECTIVE WELL-BEING: A KEY OUTCOME IN MENTAL HEALTH PROMOTION
Dr Kaveh Monshat1
,2, Dr Jane Burns1,2, Dr Dianne Vella-Brodrick3, Prof Helen Herrman1,2
1
University of Melbourne, Australia
2
Orygen Youth Health, Melbourne, Australia
3
Monash University, Melbourne, Australia
Background: Subjective well-being has been studied rigorously for several decades. Various indices for its measurement have been developed and it is now deemed a critical intervention outcome in mental health promotion.
Aims: To define the concept of “subjective well-being” (SWB) and its boundaries, and assess the value of interventions aimed at its improvement and their place within the overall mental health promotion framework.
Methods: A review of the literature was conducted using the MEDLINE, PsycInfo and CINAHL databases. This was augmented with medical, psychology and public health expert opinion.
Results: Subjective well-being may be measured within such domains as “preference satisfaction” (fulfilling desires), “hedonic” (experiences of pleasant feelings), “evaluative” (self-assessment), “flourishing” (autonomy, personal growth, self-acceptance, life purpose, mastery and positive relatedness) and “resilience” (in the face of adversity). Neurobiological correlates of SWB are distinct from those that merely signify the absence of mental ill health. Robust evidence connects improving SWB with enhanced social and occupational function as well as mental and physical health. A mental health promotion framework aiming to improve SWB would ideally combine building individual emotional skills-through cognitive behavioural approaches, resilience enhancement strategies and “positive interventions” (e.g. mindfulness, gratitude)-with an attempt to influence the social determinants of health.
Conclusions: Subjective well-being is a well characterised and measurable construct. Both individual-focussed and “social determinants of health” approaches have a role in its enhancement. A combination of interventions derived from illness treatment models and those promoting positive mental health may be used with individuals.
POSITIVE PSYCHOLOGY: ADVANCING SOME TIME-HONOURED MEANS TO MENTAL WELL-BEING
Dr Kaveh Monshat1
,2, Dr Dianne Vella-Brodrick3, Dr Jane Burns1,2, Prof Helen Herrman1,2
1
University of Melbourne, Australia
2
Orygen Youth Health, Melbourne, Australia
3
Monash University, Melbourne, Australia
Background: Over the past decade a new area of research and practise has focussed on positive enhancement of mental well-being alongside prevention and treatment of illness.
Aims: To review the conceptual foundations and experimental research in positive psychology and delineate its role in mental health promotion and clinical psychiatric practise.
Methods: A literature search using the term “positive psychology” as well as related key words such as “strengths”, “flow” and “flourishing” was conducted using PsycInfo, MEDLINE and CINAHL. Additionally, advice was sought from local and overseas opinion leaders.
Results: Positive psychology is a rapidly growing field generating interest in various health and non-health sectors such as mental health promotion, clinical psychology and psychiatry and educational and organizational psychology. A key aim in positive psychology is to rigorously study the broad range of methods touted to lead to happiness or “well-being”. There is evidence to show that well-being is underpinned by more than simply “feeling good” but includes a sense of engagement and meaning also. At the proximal or individual level, many techniques (e.g. identifying and mobilising strengths) have been found effective in controlled studies of non-clinical populations. Patients with depressive and anxiety disorders participating in positive psychology RCTs have also experienced significant symptom alleviation. This has led to the emergence of “positive psychotherapy”.
Conclusions: Positive psychology aims to develop and study the effectiveness of techniques designed to promote mental well-being. An exciting development, of interest to psychiatrists, is the contribution these interventions can make to psychotherapy for depressive and anxiety disorders.
EXAMINING SLEEP-WAKE PATTERNS IN PATIENTS WITH PARKINSON'S DISEASE AND MILD COGNITIVE IMPAIRMENT (MCI)
Dr Sharon Naismith, Simon J. Lewis, Dr Louisa Norrie, Prof Ian Hickie, A/Prof Naomi L. Rogers
Brain & Mind Research Institute, University of Sydney, Sydney, Australia
Background: Sleep-wake and circadian disruption are commonly reported in a number of neurodegenerative disorders, including Mild Cognitive Impairment (MCI) and Parkinson's Disease (PD). These disorders are also associated with significant neuropsychological deficits and depression. We are currently exploring the relationship between disease state, circadian disruption, sleep-wake disturbance, cognitive performance and psychiatric symptoms in patients with MCI and PD.
Methods: To date, n = 7 patients with a clinical diagnosis of MCI, (mixed amnestic and non-amnestic MCI) and N = 5 patients with PD have been studied. Patients wore a wrist actigraph (AWSpectrum, MiniMitter, OR) and completed a sleep-wake diary for 14 days. All participants also underwent neuropsychological assessment and completed directed sleep questionnaires.
Findings: Bivariate correlation across all patients showed significant associations between self rated sleep latency and an assessment of verbal learning (r = 0.65, p<0.05) and depression (r = 0.8, p<0.05). A significant correlation was also observed in all patients between poor memory and duration of actigraphically defined wake periods after sleep onset (r = 0.6, p<0.05). Comparing actigraphy data for the disease groups revealed that the MCI cohort exhibited greater wake periods after sleep onset (t = 3.9, p<0.001) and sleep bouts then the PD patients (t = 7.2, p<0.001).
Discussion: These findings suggest that although there are some shared traits of sleep-wake disturbance evident between these two disorder groups, patterns of circadian disturbance appear to be distinct between pathologies. Further objective (e.g. polysomnography) and neuropsychological data would be able to further delineate these associations.
CAN A HEALTHY BRAIN AGEING GROUP PROGRAM IMPROVE COGNITION IN LATE-LIFE DEPRESSION?
Dr Sharon Naismith, Kerri Diamond, Dr Louisa Norrie, Ms Veronica Vatiliotis, Ms Phoebe Carter, Prof Ian Hickie
Brain & Mind Research Institute, University of Sydney, Sydney, Australia
Background: Late-life depression is associated with cognitive deficits that are predictive of disability and treatment resistance. Deficits in executive functioning, memory and processing speed often persist despite pharmacological intervention and are predictive of dementia longitudinally.
Objectives: To investigate the effects of a Healthy Brain Ageing group program incorporating both psychoeducation and cognitive training on cognitive functions in older people with a history of depression.
Methods: Participants with a history of late-life depression underwent psychiatric and neuropsychological assessment at baseline and after participation in the Healthy Brain Ageing groups. Groups were conducted every week for 10-weeks. The first hour provided psychoeducation in an interactive format. Sessions included memory and other cognitive strategies, information about controlling vascular risk factors, diet and exercise, depression and anxiety and sleep. The second hour used the Neuropsychological Educational Approach to Remediation to target an individual's cognitive strengths and weaknesses. This approach uses computer games that are intrinsically motivating and enjoyable.
Findings: Eleven participants (mean age = 68.4, sd = 8.4) completed the groups. Repeated measures analyses showed significant improvements across the areas of processing speed, learning, memory and executive functions.
Discussion: These preliminary results show promise for the Healthy Brain Ageing Program in the area of late-life depression. A larger sample size and inclusion of a control group will be required to evaluate the effects of this program more comprehensively. Additionally, the specific contributions of cognitive training and psychoeducation require further analysis.
ECT REKINDLES PHARMACOLOGICAL RESPONSE IN SCHIZOPHRENIA
Dr Roman Onilov1
, Dr Harry Hustig2
1
Department of Psychiatry and Narcology, State Medical and Pharmaceutical University “Nicolae Testemitanu”, Chisinau, Republic of Moldova
2
BM BS Flinders University, FRANZCP, Royal Adelaide Hospital, SA, Australia
Institution where the study was carried out: Initially, the observation study was performed at the Clinical Psychiatric Hospital, Chisinau, Republic of Moldova and subsequently at the Glenside Campus Mental Health Service, Adelaide, Australia.
Objective: The aim of our naturalistic-observational study was to determine the efficacy and utility of ECT in clinical population of individuals with schizophrenia where pharmacological response was suboptimal.
Methods: The cohort comprised 27 patients suffering from schizophrenia with refractoriness to antipsychotic agents and with severe, disabling symptoms. They only interventional assessing tool was CGI-S performed at the base line and at the end of the treatment.
Results: The administration of ECT resulted in overall clinical improvement reflected in CGI scales and descriptions in clinical notes. On 12 months follow-up period 10 patients (37.1%) maintained improvement and were able to continue with pharmacological therapy only, suggesting its rekindling effect, especially with Clozapine. Conversely, 17 patients (62.9%) deteriorated and required an additional course of ECT to maintain improvement. In some cases maintenance ECT treatment was required. The group who engaged in self harming behaviour at baseline demonstrated they were more likely to relapse into psychosis at the end of the first course of ECT, their self harming behaviour abated, especially when maintenance ECT was undertaken.
Conclusions: Although limited by lack of control group, small sample size, heterogeneous symptom profiles and various concurrent neuroleptic agents the ECT proved as valuable and safe augmentative procedure, when unsatisfactory response to pharmacological interventions had been demonstrated prior to interventions. This effect was evident despite the chronicity of the illness.
THE SIGNIFICANCE OF UNDERSTANDING INTERPERSONAL DYNAMICS IN ASSESSMENT AND MANAGEMENT OF PERSONALITY DISORDERS
Ms Rada Nedeljkovic, Dr Sathya Rao
Spectrum, Personality Disorder Service for Victoria, Melbourne, Australia.
Background: Whilst dealing with patients suffering from personality disorders, interpersonal dynamic factors can significantly influence the accuracy of assessment and treatment response. However in clinical practice the interpersonal dynamic factors are insufficiently recognised. This often leads to inaccurate assessment of diagnosis, risk and focus of treatment.
Objective: To emphasize the significance of interpersonal dynamics in the assessment and management of personality disorders in public mental health systems.
Methods: Retrospective Exploratory Case Study. Three patients who were referred to Spectrum, personality disorders service for Victoria, were studied in depth and the patient-clinician-system interpersonal dynamics were explored and the guiding principles were identified and applied in assessment and management. Results and implications will be discussed.
Conclusions: This study raises awareness about the potential benefit of recognising the interpersonal dynamics in assessment and management of personality disorders in public mental health systems in the Australian context.
FOCUSSING ON SERVICE PROVISION AND PROGRAM DEVELOPMENT WITHIN A DRUG AND ALCOHOL SETTING
Dr Neelofar Rehman, Ms Susan Cavarra, Helen Dankowski, Raelene Pearson, Christine McCreery-Iddles, Dr Patrick Tolan
St John of God Pinelodge Clinic, Dandenong, Victoria.
This symposium will discuss the various aspects of service provision and program development within the context of a Drug and Alcohol Program in Victoria. The first paper will highlight the need to focus on the systemic context for developing policies around patient management and service provision in an in-patient setting. The second paper will present the findings from an in-patient survey which highlights the patients’ level of satisfaction with reference to various services. The third paper will discuss the process of developing a Dialectical Behaviour Therapy (DBT) informed therapy group program and present preliminary findings from the three initial pilots. The fourth paper will highlight the process for developing an advanced skills program for the individuals who had completed the initial DBT informed group therapy program. The fifth paper will discuss the process of developing a Mindfulness Based Cognitive Behaviour Group Therapy program for the prevention of relapse and present preliminary findings from the three pilots. Additional discussion will be generated around service provision, program development, and future research implications.
QUALITY CIRCLE – THE PROCESS OF DEVELOPING CONTENT OF AND PROCEDURE FOR SERVICE DELIVERY
Ms Susan Cavarra, Dr Neelofar Rehman, Helen Dankowski, Raelene Pearson, Christine McCreery-Iddles, Dr Patrick Tolan
St John of God Pinelodge Clinic, Dandenong, Victoria
Background: Escalating difficulties in containing a complex population presenting with substance abuse/dependence, and often a comorbid psychiatric condition, were recognised. The two most influential contributing factors were: inconsistent implementation of procedures, and discrepancies within the existing documentation around behavioural guidelines for patients.
Objectives:
Work across stakeholders from various disciplines (e.g. medical, nursing, psychologists) using a systemic framework
Review the existing documentation and obtain feedback regarding the need for revision and changes
Review the procedural guidelines of other similar inpatient facilities
Prepare a first draft and circulate amongst the relevant stakeholders for feedback
Integrate feedback and further develop a manual which will serve as the primary source for developing the protocol for triage, ongoing patient management and behavioural guidelines
Ensure that the content of the final document reflects the Values of the organisation and provides a rationale for each of the behavioural guidelines
Provide a template for the delivery of services in a manner that reflects the Values of the organisation
Procedure: The above mentioned objectives were achieved through forming a multidisciplinary committee which met periodically. These meetings highlighted the need for an ongoing review of the policy documents and the value of a collaborative approach. The final document is arranged into various sections, each specifying relevant behavioural guidelines.
PATIENT SATISFACTION WITH A MULTIFACETED IN-PATIENT DRUG AND ALCOHOL PROGRAM
Ms Susan Cavarra, Dr Neelofar Rehman, Dr Patrick Tolan, Christine McCreery-Iddles
St John of God Pinelodge Clinic, Dandenong Victoria
Background and Objectives: A three month survey was conducted to assess the level of patient satisfaction with the content and structure of a Drug and Alcohol In-patient program within a small non-for-profit hospital in Victoria. This highly structured holistic program utilises the skills of a psychiatrist, registrar, alcohol and drug counsellor, social worker, art therapist, massage therapist, dietician, general practitioners, nurses, pastoral counsellors and psychologists.
Method: On discharge, patients completed an anonymous qualitative and quantitative questionnaire which assessed their level of satisfaction with i) the program overall, ii) structure of group programs, iii) variety of groups; and iv) self-reported improvement. The quantitative component measured responses on a five-point Likert scale and the qualitative component was comprised of open-ended questions.
Findings and Conclusion: The vast majority of patients were satisfied or extremely satisfied with the content and structure of the program. Similarly the vast majority of patients reported that their understanding of addiction and strategies to prevent relapse, as well as confidence and motivation for staying abstinent, had greatly improved. All findings will inform future planning and continuous quality improvement.
DIALECTICAL BEHAVIOUR THERAPY INFORMED THERAPY GROUP PROGRAM FOR SUBSTANCE ABUSE AND DUAL DIAGNOSIS
Dr Neelofar Rehman, Ms Susan Cavarra
St. John of God pinelodge Clinic, Dandenong, Victoria
The usefulness of Dialectical Behaviour Therapy (DBT) for patients with substance abuse has been recognised (e.g. Linehan et al., 2002). The present paper discusses the process of developing a DBT informed group therapy program for day patients presenting with a history of substance use and dual diagnosis in a Drug and Alcohol setting. Guided by the Dialectical Behaviour Therapy Skills Training Manual (Linehan, 1993), Dimeff, Koerner, and Linehan (2002), McMain, Sayers, Dimeff, and Linehan (2005), and McKay, Wood, and Brantley (2007), an eight session skills training program was developed and implemented. The groups were closed and included both male and female participants. This program was piloted with three groups. The qualitative data from the first two pilots assisted the refinement and further development of the third pilot. This paper discusses key aspects and preliminary findings. Future directions with reference to program development and implementation will be highlighted.
ADVANCED SKILLS TO MANAGE EMOTIONS
Dr Neelofar Rehman, Ms Susan Cavarra, Dr Patrick Tolan
St. John of God Pinelodge Clinic, Dandenong, Victoria
An eight week Dialectical Behaviour Therapy (DBT) informed therapy group program was piloted for day patients in a Drug and Alcohol setting. Feedback indicated a need for an additional program with specific emphasis on Mindfulness and Emotion Regulation skills. In response to this feedback, a six week group therapy program was developed. This program was also informed by DBT Skills Training Manual (Linehan, 1993), and McKay, Wood, and Brantley (2007). A prerequisite for participation in this program was completion of the eight week DBT informed program. The group was closed and participants included both males and females with a history of substance abuse and dual diagnosis. The participants’ feedback indicated that the review of previously learned skills and introduction of additional skills to regulate emotions was helpful. This paper discusses the process of developing this program and its content. Future implications with reference to incorporating DBT informed therapy programs within Drug and Alcohol settings will be explored.
MINDFULNESS BASED COGNITIVE BEHAVIOUR THERAPY (MBCBT) FOR PATIENTS WITH SUBSTANCE ABUSE AND DUAL DIAGNOSIS
Dr Neelofar Rehman, Ms Susan Cavarra
St John of God Pinelodge Clinic, Dandenong, Victoria
Research (e.g. Witkiewitz, Marlatt, & Walker, 2005) indicates the value of Mindfulness based approaches in preventing relapse among patients presenting with substance abuse. In an effort to develop and deliver evidence based practice, a Mindfulness Based Cognitive Behaviour Group Therapy (MBCBGT) component was introduced into the in-patient program in a Drug and Alcohol setting. The quality satisfaction in-patient survey indicated the usefulness of this approach.
This paper discusses the process of developing a MBCBGT program for the day patients in a Drug and Alcohol setting. The program has been piloted three times with three different groups of patients during 2008. Participants included both males and females presenting with a history of substance abuse and dual diagnosis. Groups were closed and the number of patients varied for each pilot with 4 to 6 participants in each group. Quantitative and qualitative data was collected pre and post implementation of each group and the patient feedback was incorporated into the subsequent pilot. This paper presents the preliminary findings and key aspects of this program.
AUDIT OF DISCHARGE SUMMARIES
Dr Itoro Udo1
, Bolaji Badejo2, Dr Michael Morris1
1
St. Luke's Hospital, Carlow/ Kilkenny Mental Health Services, Ireland,
2
Adelaide & Meath Hospital, Dublin, Ireland
Background: Discharge summaries form an important communication tool between hospitals and primary care providers. Omitting important information from summaries could adversely affect continuity of care in the community. Discharge summaries aid review of patients in outpatient's clinics, day hospital and during readmissions. High quality summaries will enhance the perception of psychiatric services by primary care providers, managers and other agencies.
Objectives: We assessed the standard of discharge summaries done in the Carlow/Kilkenny Mental Health Services against departmental guideline.
Methods: A total of 120 summaries were studied representing consecutive series of 20 summaries from each of 6 sectors. The study period was from 1st January 2007 to 30th June 2007.
Results: Areas of strength were the documentation of ‘History of Presenting Complaint’ (99.5%), ‘Treatment Plan’ (97.5%), ‘Course in Hospital’ (94.17%). Areas where standards were poor were ‘Substance/Alcohol History’ (16.66%), ‘Risk Factors’ (16.67%), ‘Physical Examination’ (22.30%), ‘Medication on Admission’ (27.60%), ‘Mental State on Discharge’ (35%). 16% of summaries were done within 5 working days of patient discharge.
Conclusion: Compared with previous audits, important standards such as ‘Mental State on Discharge’ are still being omitted from summaries. Non-Consultant Hospital Doctors need supervision on letter writing/ summarising and should own dictaphones.
DANGER IDEATION REDUCTION IN OCD CHECKERS: A PILOT STUDY
Ms Lisa Vaccaro, Ms Bethany Wootton, Dr Mairwen Jones, A/Prof Ross Menzies
University of Sydney, Sydney, Australia
Background: Cognitive theories (e.g. Carr, 1974; Foa & Kozak, 1986; Freeston, Rheaume, & Ladouceur, 1996; Jones & Menzies, 1997; Salkovskis, 1985; Woods, Frost, & Steketee, 2002) implicate specific maladaptive beliefs in the mediation and maintenance of the obsessions and compulsions that exemplify Obsessive Compulsive Disorder (OCD).
The identification of inflated danger expectancies (Jones & Menzies, 1997) – beliefs about the probability and costs of harm – informed the development of a novel psychological treatment-Danger Ideation Reduction Therapy (DIRT)-by researchers at The University of Sydney (Jones & Menzies, 1998).
Randomised Controlled Trials (RCT) support the validity of this approach in Obsessive Compulsive Washing (Jones & Menzies 1998; Krochmalik, Jones, Menzies & Kirkby, 2004).
Methods: We adapted DIRT for Obsessive Compulsive Checkers and piloted this treatment package in 3 patients.
Findings: Outcome data for all 3 patients, post treatment and at follow-up, demonstrated decreases in scores on all measures. Clinician-rated scores of OCD symptom severity showed patients were considered “recovered” and symptoms were no longer causing them dysfunction with work and social roles or activities. These scores are comparable with other clinical outcome studies of treatment for OCD (e.g. Foa, Liebowitz, Kozak, et al. 2005; de Haan, van Oppen, van Balkom, et al. 1997; O'Connor, Aardema, Robillard, et al. 2006)
Conclusions: These findings are most encouraging and suggest that the DIRT-FC package produces large and clinically significant improvements in OC checkers. Further support for DIRT-FC is being sought in a randomised controlled trial.
Carr, A. (1974). Compulsive neurosis: A review of the literature. Psychological Bulletin, 81, 311–318.
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35.
Foa, E. B., Liebowitz, M. R., Kozak, M.J., Davies, S., Campeas, R., Franklin, M. E, Huppert, J.D., Kjernisted, K., Rowan, V., Schmidt, A. B., Simpson, H.B., Tu, X. (2005). Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive–compulsive disorder. American Journal of Psychiatry, 162, 151–161.
Freeston, M. H., Rhéaume, J., & Ladouceur, R. (1996). Correcting faulty appraisals of obsessional thoughts. Behaviour Research and Therapy, 34, 433-446.
de Haan, E., van Oppen, P., van Balkom, A. J. L. M., Spinhoven, P., Hoogduin, K. A. L., Van Dyck, R. (1997). Prediction of outcome and early vs. late improvement in OCD patients treated with cognitive behaviour therapy and pharmacotherapy. Acta Psychiatrica Scandinavia, 96, 354-361.
Jones, M. K., & Menzies, R. G. (1997). The cognitive mediation of obsessive-compulsive handwashing. Behaviour Research and Therapy, 35, 843-850.
Jones, M. K., & Menzies, R. G. (1998). Danger Ideation Reduction Therapy (DIRT) for obsessive-compulsive washers. A controlled trial. Behaviour Research and Therapy, 36, 959-970.
Krochmalik, A., Jones, M. K., Menzies, R. G., & Kirkby, K. (2004). The Superiority of Danger Ideation Reduction Therapy (DIRT) over Exposure and Response Prevention (ERP) in Treating Compulsive Washing. Behaviour Change, 21, 251–268.
O'Connor, K. P., Aardema, F., Robillard, S., Guay, S., Pe′lissier, M-C., Todorov, C., Borgeat, F., Leblanc, V., Grenier, S., Doucet, P. (2006). Cognitive behaviour therapy and medication in the treatment of obsessive–compulsive disorder. Acta Psychiatrica Scandinavia, 113, 408–419
Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23, 571-583.
Woods, C. M., Frost, R. O., & Steketee, G. (2002). Obsessive–Compulsive (OC) symptoms and subjective severity, probability, and coping ability estimations of future negative events. Clinical Psychology and Psychotherapy, 9, 104–111.
DURATION OF TREATMENT AND SELF-REPORTED SIDE EFFECTS OF LOW DOSE RISPERIDONE IN YOUNG PEOPLE
Dr Simon Byrne1
, Prof Garry Walter2, Dr Glenn Hunt3, Ms Nerissa Soh4, A/Prof Michelle Cleary5, Dr Paul Duffy6, Dr Geoff Crawford7, Dr Peter Krabman8, Dr Patrick Concannon9, Prof Gin Malhi10
1
Research Assistant, Northern Sydney Central Coast Health, Sydney, Australia,
2
Professor of Child and Adolescent Psychiatry, Discipline of Psychological Medicine, University of Sydney, and Area Clinical Director, Child and Adolescent Mental Health Services, Northern Sydney Central Coast Health, Sydney, Australia,
3
Senior Research Fellow, Discipline of Psychological Medicine, University of Sydney and Research Unit, Sydney South West Area Mental Health Service, Sydney, Australia,
4
Research Officer, Child and Adolescent Mental Health Services, Northern Sydney Central Coast Health, Sydney, Australia,
5
Clinical Nurse Consultant, Research Unit, Sydney South West Area Mental Health Service, Sydney, Australia,
6
Pediatrician in private practice, Sydney, Australia,
7
Pediatrician in private practice, Sydney, Australia,
8
Medical Director, Coral Tree Family Service, Northern Sydney Central Coast Health, Sydney, Australia and child psychiatrist in private practice, Sydney, Australia,
9
Pediatrician in private practice, Sydney, Australia,
10
Head, Academic Discipline of Psychological Medicine, Northern Clinical School, University of Sydney, Sydney, Australia.
Background: There appears to be increasing use of atypical antipsychotics in young people, yet much to learn about the side-effects of these medications.
Objective: We aimed to describe risperidone-related side-effects, and duration of treatment, in a cross-section of young people taking low dose risperidone, using a self-report measure.
Methods: The Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS) was completed by 66 patients aged between 6 and 18 years who had been taking low dose risperidone (0.25mg to 2.20 mg a day) for up to 13 years.
Findings: Generally, young persons seemed to tolerate risperidone well and reported low levels of side-effects. Longer exposure to risperidone was associated with higher side effect levels, particularly for the psychic (pertaining to mind and emotion) and extrapyramidal subscales. The most common complaints related to psychic side-effects, such as tiredness, difficulty concentrating, difficulty remembering things and increased dreaming.
Conclusions: Although young people appear to generally tolerate risperidone well, unwanted effects emerge or worsen the longer the medication is taken. Clinicians need to monitor the side effects of patients taking low doses of risperidone and maintain vigilance in those who have been taking the medication for extended periods.
BUILDING AN ELECTRONIC PSYCHIATRIST
Dr Philip Wiren
Private Practitioner, Sydney, Australia
This presentation is basically a demonstration of a computer program that I have developed which can be used to ‘electronically’ write-up psychiatric case notes. The program is basically menu driven and an entire patient's history can be written-up by typing in as few as 10-15 actual words (all other data is entered by choosing various items from the program's menus). Importantly the program has considerable inbuilt analytic capacity and is able to (1) reach a diagnosis, and (2) formulate a suggested management plan; both of which the clinician may then edit. The program has now been tested in a clinical setting for over a year and the letters that it compiles used in routine correspondence. Interestingly these letters are ‘naturalistic’ enough to lead to the assumption by those who receive them that they were in fact written by a human (this includes solicitors as the program has the capacity to write letters in the form of court reports). Finally the program has a series of embedded ‘notes’ that it will relate to each individual case which may be used for educational or similar purposes.
