Abstract
College Colloquium: The Future of Post-Graduate Training
Adler R
Psychiatrist, Adolescent Forensic Health Service, Women's & Children's Health Care Network, Melbourne, Victoria
This year the College Colloquium will focus on the future of Post-Graduate Training for Psychiatry in Australia and New Zealand. This is the final stage of the broad consultation with College Fellows and Trainees conducted by Bob Adler on behalf of the Project Team of the RANZCP Review of Training, Examinations and Continuing Education.
Congress delegates are invited to participate actively and vigorously in this plenary, we want the body of psychiatrists and trainees to have a say in the future of our College. Congress delegates will have received a copy of the third and final paper “Preparing Psychiatrists for the Century of the Mind”, published in the March Edition of Australasian Psychiatry. This is the key background paper for this colloquium and will be taken as read by all speakers.
The Colloquium will begin with a Plenary, chaired by Professor Peter Ellis, Chair of the Fellowships Board and the Project Team. It will comprise five presentations outlining the core skills we might expect in a young graduating psychiatrist in 2010.
Workshops following the plenary will explore the cultural, psychological, biological, and training issues in more detail and feed back their conclusions to Bob Adler and the Project Team. The final submission to the General Council of the College has been delayed until after the Congress to give College members another opportunity for input into this important project.
Agzarian N, Katsikitis M, Fallo T, Sobhanian F, Amirghiasvand M, Barrett R
The Effects of Relocation and Family Functioning on Iranian Refugee Families
Medical Student, Royal Adelaide Hospital, South Australia
Alexander T
Public/Private Psychiatry: Collaborative Care between Private Psychiatrists and an Area Mental Health Service
St. Vincent's Mental Health Service, Melbourne
Ali R, McGregor C, Christie P, Darke S
Heroin Overdose: Responding to the Epidemic
Drug and Alcohol Services Council of South Australia; National Drug and Alcohol Research Centre, University of New South Wales, Sydney
Allan J A, Farmer S
Insight into Schizophrenia – how Important are Patients and Relatives Views?
Townsville Integrated Mental Health Service; Department of Psychiatry, North Queensland Clinical School, University of Queensland
There has recently been a revival of interest in the concept of insight into psychotic illness. Clinicians experienced in the treatment of schizophrenia often encounter the situation where their belief that their patient has a mental illness is not shared by their patient. The differences of opinion between patients and their care givers about the nature of mental illnesses has led to the common use of legal orders for involuntary treatment as many patients “lack insight”. The general public, our patients, their family members and clinicians often have differing perceptions of mental illness, about its cause and effect or proposed interventions. Yet this range of beliefs and discrepancies has until recently not been systematically studied, usually just assumed as part of “clinical wisdom” or “popular misconceptions”. “Insight” is a term which describes the person's understanding of the nature of mental illness and is therefore at the heart of any conceptual framework that would allow these differences to be assessed. Assessment of insight is a standard part of the clinical process of the mental state examination and appears in all major textbooks. There are however, no universal guidelines or accepted definitions of insight in clinical psychiatry.
Patients with schizophrenia admitted to an acute psychiatric unitwere given three standardised measures of insight (Schedule for the Assessment of Insight – Expanded Version (SAI-E), Scale to Assess Unawareness of Mental Disorder (SUMD), and the Markova & Berrios Scale) and the clinician's usual method of assessing insight, as well as measures of psychopathology (PANSS) and other clinical parameters. (Diagnostic Interview for Psychosis). Additionally, the insight measures were adapted for use by relatives and significant others, allowing a three way comparison of insight between relatives and patients and clinicians. The preliminary results suggest that different methods of measuring eg self-report or clinician administered, relate to different dimensions of insight or understanding and that insight is a multidimensional concept. The usual clinical measurements miss important aspects of understanding, particularly unconventional ways of responding by patients. The views of relatives differ from clinicians and patients. By adding this information there is an extended usefulness to the concept of insight which may allow for a more comprehensive assessment of insight.
Allcock C
Gambling Symposium
Cumberland Hospital, Parramatta, New South Wales
Following the publication of the AMA Position Statement on the Health Effects of Problem Gambling, the College requested Dr Clive Allcock, in collaboration with a number of other Fellows, to develop a Position Statement on Problem Gambling and Psychiatric Co-morbidities. Clive Allcock will present the draft College Position Statement on Problem Gambling by focusing on the psychiatric history of problem gambling starting with the writings of Dostoevsky, its acceptance as a psychiatric diagnosis by the APA through DSM III. This paper will describe a range of psychiatric comorbidities which often co-exist and contribute to a problem gambling and highlight some of the treatment options for clinical practice. It is intended that the draft position statement will be presented to the College General Council meeting in May for its approval.
Allnutt S
Sex Offenders: Can Psychiatrists Contribute to their Rehabilitation?
Deputy Director, The Mason Clinic, Avondale, Auckland NZ; Hon Clin Sen Lecturer, University of Auckland, New Zealand
The public is increasingly turning to psychiatry to assist in dealing with individuals who manifest difficult and deviant behaviors in the community. Most jurisdiction sex offenders who have the opportunity to enter rehabilitation programs utilise group, cognitive behavioural therapeutic methods and relapse prevention. There is little to no involvement of psychiatrists in the rehabilitation of sex offenders in these environments. While this may be appropriate given that their risk to the community remains contained while incarcerated, psychiatrists may be able to make a contribution to the management of these individuals in the community. This paper will review the evidence for the effectiveness of rehabilitation of sex offenders and the nature of the contribution that psychiatry can make.
Allnutt S, Chaplow D
The Principles of Forensic Report Writing & Giving of Expert Testimony
Deputy Director, The Mason Clinic, Avondale, Auckland NZ; Hon Clin Sen Lecturer, University of Auckland, New Zealand
Writing medico-legal reports and giving expert evidence is a challenging task. Most psychiatrists will be expected to do so at some point in their careers. A thoughtful, well-structured report written ethically, can be a rewarding professional endeavour. Forensic psychiatric evidence is one of the few ‘windows’ to psychiatry, in a way that reflects on the profession. Such evidence, whether in the form of expert testimony or written report, represents the psychiatrist's professional opinion that colleagues and others can refer, with consequences. It is important that information is accurate, relevant, and ethical. In writing medico-legal reports or giving testimony, psychiatry deviates from traditional ethics. In addition, such activities reflect not only on the individual psychiatrist, but also on the profession as a whole. It is important that psychiatrists who write reports or give testimony have a good understanding of the process and are competent and ethical. The aim of this workshop is to provide an update of principles of forensic report writing and giving of testimony, to guide and assist psychiatrists working within the forensic arena. The workshop comprises of the following:
Review of the relationship between the law and psychiatry.
Review of ethical principles that are relevant to Report Writing.
Basic Principles around Report Writing.
Manner in which expert testimony should be given.
Amir N, Kusumawardhani A, Mangindaan L, Lazuardi S, Purba J
Dreams about Male Sexual Organs among Females with Latah
Penelitian Genetik pada Skizofrenia, Indonesia
Andrews G, Henderson S, Hall W
Comorbidity, Disability and the Need for Treatment for DSM-IV Psychiatric Disorders in An Insured Population
The World Health Organization Collaborating Centre for Mental Health and School of Psychiatry, University of New South Wales at St Vincent's Hospital, Sydney
Andrews G, Sanderson K, Slade T, Issakidis C
Why Does the Burden of Disease Persist? Relating the Burden of Anxiety and Depression to Effectiveness of Treatment
WHO Collaborating Centre for Mental Health, and School of Psychiatry, UNSW at St Vincent's Hospital, Sydney
Why does the burden of mental disorders persist in established market economies? There are four possibilities; the burden estimates are wrong, there are no effective treatments, people do not get treatment, people do not get effective treatments. Data from the Australian Survey of Mental Health and Wellbeing about the two most common mental disorders, generalized anxiety disorder and depression, will be used to address these issues. The burden of mental disorders in Australia is third in importance after heart disease and cancer, and anxiety and depressive disorders account for more than half of that burden. The efficacy of treatments for both disorders has been established. Forty percent of people with current disorders sought no treatment in the previous year, and only 45% were offered a treatment that could have been beneficial. Treatment was not predictive of disorders that remitted during the year. The burden persists for two reasons: too many people do not seek treatment, and when they do. efficacious treatment are not always used effectively.
Ash D J
Generalised Anxiety Disorder – An Update
North Western Mental Health Service, South Australia
The past 50 years have witnessed a significant change in the models for conceptualising anxiety disorders, with a shift from psychodynamic formulation to models relying on more rigorous application of the scientific method.
In DSM-III, Generalised Anxiety Disorder was essentially a residual diagnosis and received rather less attention than other anxiety disorders such as panic disorder, social phobia and obsessive compulsive disorder.
Recently there has been a resurgence of interest in Generalised Anxiety Disorder with controversy over the relationship of the anxiety disorders in general and Generalised Anxiety Disorder in particular to the depressive disorders and unresolved questions about the nosological status of Generalised Anxiety Disorder. This presentation reviews the implications of the changing definitions of Generalised Anxiety Disorder (DSM-III – DSM IV/ICD 10), the empirical basis for Generalised Anxiety Disorder, the relationship of Generalised Anxiety Disorder to the depressive disorders, aetiological theories including the current conceptual models of pathological worry and Generalised Anxiety Disorder, and recent developments in pharmacotherapy and cognitive-behavioural therapy of Generalised Anxiety Disorder.
The review concludes with tentative recommendations for the further development of treatment programmes and future research.
Austin M P, Mitchell P
Psychotropic Medications in Pregnant and Breast-Feeding Women: A Review of the Literature and Treatment Guidelines
Mood Disorders Unit and Department of Liaison Psychiatry, Prince of Wales Hospital, Sydney; Lecturer, School of Psychiatry, University of New South Wales, Sydney
To review all studies and case reports examining the impact of psychotropic medications taken during pregnancy and breastfeeding, on infant outcome.
To provide clinicians with clinical guidelines for the use of psychotropic medication in pregnancy and breast-feeding, both acutely and prophylactically.
Pregnancy: Several hundred infants exposed to SSRls and TCAs have now been studied in a small number of prospective, controlled, non-randomised, studies. Findings suggest that neither the SSRls nor the TCAs cause major congenital anomalies. Conversely, results from small, often less methodologically rigorous studies suggest that benzodiazepines, lithium, anticonvulsants and chlorpromazine do lead to an increased rate of congenital anomalies. Studies of longer-term neurobehavioural sequelae are very limited but at present do not indicate any adverse effects.
Breast-feeding: On the basis of findings from a small number of prospective controlled studies, the use of SSRls, TCAs, carbamazepine, sodium valproate and short-acting benzodiazepines in breast-feeding is relatively safe. High dose antipsychotics should be avoided as they may be associated with developmental delays. The potential for neonatal toxicity with lithium is significant.
Austin M P, Mitchell P, Goodwin G
Neurocognitive Deficits in Depression: A Clue to Underlying Pathogenesis?
Mood Disorders Unit and Department of Liaison Psychiatry, Prince of Wales Hospital, Sydney; Lecturer, School of Psychiatry, University of New South Wales, Sydney
Ayonrinde O A
Ethnic and Cultural Dimensions in Therapeutic Transactions
Maudsley Hospital, London, United Kingdom
Ayonrinde O A, Osinowo T O
Mental Health Service models in a Multicultural Society: Dominoes, Dice or Chess?
Maudsley Hospital, London, United Kingdom
Increased mobility of people across national and cultural boundaries has led to demographic shifts in many communities. Of importance is the need for clinicians to be aware of associated service delivery issues. Differences in the access and utilisation of mental health services have been recognised among different ethnic groups in multicultural societies. Pathways to care may be tortuous with diverse or complex presentations of core psycho-pathologies.
Advocates of culturally sensitive mental health services emphasise the importance of key elements such as effective communication, understanding idioms of distress, and cultural contextualisation of signs and symptoms. Furthermore, factors such as self-ascribed ethnic identity, discriminatory experiences, taboos, gender and age may affect service uptake.
Beyond the patient, geographical, social, political, financial, policy and personnel factors may also determine the availability and quality of mental health services.
The “domino” (one service suits all), “dice” (chance), and “chess” (specialised function) models of multicultural psychiatric services in the United Kingdom are described. The impacts of these models on individual, community and national mental health are highlighted. Innovative non-statutory and indigenous cultural service models in the United Kingdom are also described.
Anthropological and cross-cultural awareness in medical education, primary care, policy and service provision are essential to reducing unrecognised burdens of psychiatric morbidity in culturally diverse populations.
Barnett R, Vance A, Maruff P, Luk E, Costin J, Pantelis C
Executive Function and ADHD: Stimulant Medication and Better Executive Function Performance in Children
Mental Health Research Institute of Victoria; LaTrobe University, Victoria
Battersby M
Dyspnoeaphobia: A New Anxiety Disorder?
Department of Psychiatry, Flinders Medical Centre, Bedford Park, South Australia
Evidence is presented that DSM IV diagnostic criteria do not describe the anxiety related symptoms and behaviours which occur in people with chronic respiratory illnesses. The author devised an alternative diagnostic system which was based on the presence of anxiety, panic and avoidance. 60 subjects with chronic obstructive airways disease (COAD) referred for assessment for home oxygen were assessed using a semi-structured interview to make this diagnosis and a series of questionnaires assessed personality, anxiety, depression, purpose in life, quality of life and disability and handicap. The same subjects were assessed 12 months later using the same instruments. The results showed that 69% of the subjects showed one level of respiratory anxiety, that this worsened over time and that the presence of respiratory anxiety was a greater predictor of disability and handicap and reduced quality of life than physiological measures. These findings give support to the existence of a specific phobia, the fear of shortness of breath –dyspnoeaphobia. The implications for other internal physiological cues related to chronic medical conditions becoming phobic stimuli is discussed.
Battersby M, McDonald P, Frith P, Pearce R, McGowan C, Pols R, Melino M, Harvey P, Fox J, Conroy P, Allen K, Reece M, Collins J, Widdas P, Kalucy L, Esterman A, Tsouros G, Heard A
The SA Healthplus Coordinated Care Trial: Developing an Outcomes Based System of Care. Psychiatric Outcomes and Implications for Mental Health Services.
Department of Psychiatry, Flinders Medical Centre, Bedford Park, South Australia
The SA HealthPlus Coordinated Care Trial was designed to produce improved health outcomes within existing resources. The model of care developed included patient centred care planning based on patient defined problems and goals and an evidence based care plan which allocated services over 12 months. One hundred service coordinators were trained to use the problem and goals approach, and 4500 patients were allocated to intervention and control groups across 3 metropolitan and 1 rural area of South Australia. Psychiatric co-morbidity proved to be a major factor in the diagnosis, management and outcome in the 8 projects. Outcomes will be presented using SF-36, problems and goals ratings, disability and handicap and service utilisation data. Implications for developing outcome based models of care which incorporate continuous clinical improvement in mental health services, and the role of psychiatrists in community management of chronic medical illness will be discussed.
Battersby M, Scurrah M, Tolchard B
A Systematic Study of Suicidal Ideation and Behaviour in a Cohort of Patients with a Diagnosis of Pathological Gambling Presenting to a Hospital Based Gambling Treatment Service
Department of Psychiatry, Flinders Medical Centre, Bedford Park, South Australia
Beckwith A R, Herriot P
The Rate of Habituation of the autonomic Nervous System Response to Unconditioned Auditory Stimuli in Pathological Gamblers – a Pilot Study
Cleland House, Glenside Campus, Royal Adelaide Hospital, South Australia
Berrios G
The Neuroimaging of Mental Symptoms: Their Scylla or Charybdis?
Department of Psychiatry, Cambridge University, Addenbrooke's Hospital, England
The availability of powerful research techniques such as neuroimaging, neuropsychology and molecular genetics holds renewed hope for the understanding of mental disorders. This is not, of course, the first time that psychiatry is promised imminent success. Similar claims were made during the 19th century in relation to optical microscopy and neuropathology, and during the 20th century when EEG, psychopharmacology, air ventriculography and CAT scan first appeared. Like now, these old technologies were also good at attracting all the research moneys and in creating many an academic reputation; and also noxious in that they effectively condemned clinicians as fuddy-duddies. Once again, clinicians are being asked to provide patients for neuroimagers, molecular biologists, etc. The task is not easy. For example, due to the way in which inference is optimised in modern group statistics, sample homogeneity remains a desideratum. If so, the question is whether this is achievable in terms of current descriptions of mental symptoms and diseases (i.e. descriptive psycho-pathology). The answer is that it may not be. For years, all involved in this business have assumed that the psychiatric object of inquiry is real, recognizable, unitary and stable (like stones, daffodils or horses). From this it followed that the old descriptions, tinkered with to achieve ‘reliability’, sufficed.
Things, however, are more complicated than this. Firstly, the fact that mental disorders are ‘neurobiological’ in origin does not make them more stable than any other world denizen. With the rest of objects they have to, and do, change, except that we do not notice it for we live in a different time frame. Historians of psychology and psychiatry, however, know otherwise: behaviour in general, and mental symptoms and diseases in particular are constructs changing in time, and hence their descriptions require periodic calibration. Undertaking the latter happens to be the role of clinicians. Secondly, and irrespective of the changing nature of the objects themselves, there is evidence that the descriptions themselves are not sub specie æternitatis: the way we talk about mental symptoms and diseases is closely related to the social and scientific needs of our time. 19th century descriptions were governed by the level of detail required by light microscopy and morbid anatomy and hence there is no guarantee that these descriptions (which we still use) will remain adequate for current research techniques. One question follows, are 19th century definitions of mental symptoms useful covariates for current PET scan or fMRI studies?
A useful starter here is: are all currently known mental symptom susceptible to PET neuroimaging? If not, why not? Is it simply a lack of research ingenuity or does it concern some specific features of the symptoms themselves? And if the latter, are these features in re or are they dependent upon the quality of the descriptions? For example, why have hallucinations been so much favoured by PET scanners and not, say, delusions? Is it perhaps because hallucinations are episodic, have end-points and are tokenizable? Is it also because delusions have blurred margins and we have no idea whether they are tokens, beliefs, predispositions, or memories or just empty speech acts?
To these issues the historical, conceptual and empirical methodology of descriptive psychopathology is being applied with advantage. Clinicians are going back to the drawing board to design the new descriptions that neuroimaging, and for that matter genetics (where such descriptions are euphemistically called ‘phenotypes’), require. This research is essential and should be adequately funded for without it current investigative techniques, however powerful, will draw the proverbial blank.
Beumont P, Russell J, Marks P
Teaching Non-Psychiatrist Medical Practitioners about Anorexia Nervosa
Department of Psychiatry, University of Sydney, New South Wales
There are many stake-holders in the current debate about eating disorders, and considerable variation in the perspectives adopted towards them. However, they do remain medical problems and this is particularly true for anorexia nervosa, a serious illness with major psychiatric and physical morbidity, a chronic course, and a mortality rate of close to 20% at 20 years. For various reasons, anorexia nervosa has become de-medicalised over recent decades. Yet all doctors should know how to recognize and treat this serious condition.
The aim of the present workshop is to present the authors’ experiences in respect to teaching non-psychiatrist doctors about anorexia nervosa. The new problem-based graduate degree in medicine at the University of Sydney has provided an opportunity to provide an innovative approach to the teaching of medical students. Anorexia nervosa features prominently in two sections of the course. The very first problem case that the student encounters in the course is that of an adolescent girl who presents with features of anorexia nervosa. The theme is revisited during the psychiatry term in Year 3, where the same young woman is presented 3 years into her illness. Both cases emphasize the need for physical and psychological approaches in medicine, and both introduce themes relevant to basic medical science, public health and community issues, doctor patient relationships and personal development.
A project funded by the NSW Department of Health is directed at setting up a collaborative shared-care program for patients with anorexia nervosa throughout the State, bringing together general practitioners with health professionals with specialized skills in the area. The curriculum for this education project, the means by which it will be assessed, and its extension so as to provide a continuum of care for patients, will be presented.
The workshop should appeal not only to psychiatrists who treat eating disorder patients, but also to those who are interested in medical student education and continuing psychiatric education for general practitioners.
Bickerton A, Mottaghipour Y, Sara G, Woodland L
Creating a Family-Friendly Culture in An Adult Mental Health Service
Sutherland Division of Mental Health, Sutherland, New South Wales
The National Mental Health Plan suggests that families should be involved in the management of all patients with mental illness. Additionally, there is an extensive body of research attesting to the importance of family involvement and the efficacies of specific interventions (eg psychoeducation).
But the reality is that few professionals involved in the care of adult clients with a mental illness have had any specific training in working with families. Services have been traditionally individually focussed and cultures of confidentiality have inadvertently actively marginalised families.
The “Working With Families” Project of the Sutherland Division of Mental Health was developed to address this situation. Key objectives of the project were to increase the capacity of the service to work with families and to decrease the distress and burden experienced by families. Specific training initiatives have included workshops for different professional groups (eg. registrars, inpatient nursing staff), Family Consultation Sessions (in vivo training using a one-way screen) and Working with Families Breakfasts (a divisional multidisciplinary training forum). The project has incorporated evaluation and outcome measures. This workshop will focus on our experience of creating a family-friendly culture. We will look at a number of different levels within the system important in achieving a cultural shift. These include a framework for organisational change in which clinician training takes place. A pyramid of family care will be discussed which provides a basis for training staff in working with families. We will also illustrate the trainer's role in engaging staff member's interest in working with families and draw out the parallel processes in staff's capacity to engage families.
This workshop will be of particular interest to professionals who have a role in training, supervision or organisational management.
Aim: Participants in this workshop will gain an understanding of the strategies needed to implement a family – friendly culture within an adult mental health service. An interactive format will encourage participants to develop strategies for cultural change in their own work organisations.
Blacket J, Callaly T
Psychiatric and Substance Use Diagnoses Referred from Three Settings to a New Dual Diagnosis Program
Barwon Health, Department of Psychiatry, Victoria
Bloch S (Chair)
Schubert Winterreise
University of Melbourne, St Vincent's Hospital
Baritone: Michael Leighton Jones
Director of Music, Trinity College, University of Melbourne
Piano: Stephen McIntyre
Associate Professor of Piano, University of Melbourne
Schubert's Winter Journey, the Winterreise, is one of the masterpieces of the European Romantic Movement. A setting of the poems of Wilhelm Muller (1794–1827), Franz Schubert (1797–1828) finally completed the work in 1827. Stephen McIntyre, Associate professor of Piano at the University of Melbourne, and Michael Leighton Jones, baritone, and Director of Music at Trinity College (University of Melbourne) take us on the profound journey of Schubert's great song cycle. Their recent performance of this work at the 1999 Melbourne International Festival was received with critical acclaim. After introducing and then performing the Winterreise, the two artists will join the audience in a discussion of song and its relation to the innermost self, exploring how music can reveal and illuminate the experience of sorrow, separation, loss and facing death. A plenary session has been set aside for the performance and discussion.
Blumbergs P C
Altered States of Consciousness and Axonal Injury following Head Trauma
Neuropathology Laboratory, Institute of Medical & Veterinary Science, Adelaide, South Australia
The parallel anatomically and neurochemically distinct neuronal networks mediating awareness and arousal may be differentially damaged in traumatic brain injury leading to a spectrum of altered states of consciousness. Dysfunction of both the arousal and awareness neural circuitry results in transient (concussive syndromes) or prolonged loss of consciousness whereas damage to the awareness mechanisms and relative preservation of the arousal networks results in the post-traumatic vegetative state. The vegetative state represents a type of “locked-out” syndrome characterised by lack of awareness of the external world in association with preserved sleep-wake cycles and cardio-respiratory functions. Diffuse injury of the axons (Diffuse Axonal Injury or DAI) connecting these parallel circuits is the most common pathologic finding in patients with prolonged post-traumatic coma, the vegetative state and severe neurologic disability after head injury. Recent immunocytochemical studies using antibodies to amyloid precursor protein (APP), a molecule important in synaptic plasticity and transported in the fast axoplasmic transport stream, have also shown axonal abnormalities in mild concussive head injury. Multi-focal APP immunopositive axonal injury (AI) was present in a series of 8 such patients who died of unrelated causes. The demonstration of structural axonal abnormalities by these new techniques indicates that there may be an underlying organic basis to the post-concussional syndrome. Axonal damage was present in the fornices of all these patients and it is of interest that memory disturbances are a prominent feature of the post-concussion syndrome.
A better understanding of the complex cytoskeletal and neurochemical events leading to axonal disconnection over a number of hours has led to successful experimental therapeutic interventions limiting the severity of AI.
Bowd D
Let's Talk about Us – Aboriginality and Psychiatry Giving Meaning to Each Other
Senior Project Officer, Forging Links, Aboriginal Services Division, SA Department of Human Services, South Australia
“Since therapists, no less than patients, must confront the givens of existence, the professional posture of disinterested objectivity, so necessary to scientific objectivity, is inappropriate. We psychotherapists simply cannot cluck with sympathy and exhort patients to struggle resolutely with their problems. We cannot say to them ‘you’ and ‘your’ problems. Instead, we must speak of ‘us’ and ‘our’ problems, because our life, our existence, will always be riveted to death, love to loss, freedom to fear, and growth to separation. We are, all of us, in this together”
These are the words of Jewish American Psychiatrist Irvin Yalom, taken from his book “Love's Executioner and Other Tales of Psychotherapy”. The placing of the practitioner in the milieu of life highlights the presence and influence of individual differences in the relationship between doctor and patient. The very construction of clinical objectivity is one with a cultural context, and is inherently limited in its application to those who are not of the culture from which modern Psychiatry has sprung. The notion of division and separateness has followed Aboriginal peoples to the margins of Australian society. Now, only unification and togetherness can bring Aboriginal peoples into the fold, valued as Australian citizens whilst remaining Aboriginal. Psychiatry must actively engage with Aboriginality for each to give meaning to the other. This is simultaneously the process and the outcome of reconciliation.
Boyce P, Stanek S, Gilchrist J
Postpartum Melancholia: Clinical Descriptions of a Distinct Type of Postnatal Depression
Department of Psychological Medicine, University of Sydney, Nepean Hospital, New South Wales
Postnatal Depression is a common disorder affecting between 10 and 15% of women in the first six months postpartum. The clinical picture of postnatal depression is generally considered to be that of non-melancholic major depression, with risk factors being predominantly psychosocial. There are however, many women who do not present with this typical clinical picture of postnatal depression. In this paper we will report on the clinical presentation of women who present with a melancholic type of depression. This form of depression arises earlier than the more typical postnatal depression. It is characterised by symptoms of melancholia with psychomotor change, particularly agitation. These women often have an obsessional premorbid personality type, a family history of depression and generally are in a stable and supportive relationship. They respond well to tricyclic antidepressants or ECT but do tend to relapse into depression following subsequent pregnancies.
The relationship of this form of postnatal depression to the more typical form of postnatal depression and puerperal psychosis will be discussed. The clinical similarities between this clinical presentation and that of earlier descriptions of involution of melancholia will be raised as will the role of oestrogen changes contributing to the onset of this disorder.
Braddock L E
Internal Objects: A Philosophical View
Oxford, United Kingdom
Internal objects no longer excite psychoanalytic controversy, although no satisfactory theoretical resolution has been achieved. While remaining central to Kleinian thought, and basic in understanding object relations theory, internal objects still pose serious difficulties in conceptualisation. These prejudice not only theoretical understanding in psychoanalysis but also a clear articulation of the theory about the mind which lies behind psychoanalysis and which deserves more philosophical interest that it can in its present form attract. The philosophical defence of psychoanalysis as a theory within philosophical naturalism about the mind, and the potential contribution which psychoanalytic psychology can make to philosophy of mind are projects of interest to both philosophers and psychoanalysts.
Both component terms in “internal object” are ambiguous. As Freud presents the matter in “Mourning and Melancholia” the love object, after being lost as a person in the world is “reinstated” in the ego, which it is then “internal” in the sense of being mental or representational, the non-existent object or content of thought. But it is in a second sense internal in the sense of being thought, in phantasy, to be a real object taken into the body by the oral route; the internal object is the content of a phantasy of oral incorporation of a real existent object. This dual equivocation, in the two senses of both “internal” and “object” can, charitably, be taken as an excessively compressed explanation of the move from the real object in the world, to the representation of an object.
Kleinian theory offers a partial expansion of this move in casual terms, in the claim that sensory experience of the instinctual object is something which the infant's sensorium is “programmed” to assemble into a recognisable unity. This unity then supplies the content of phantasy; it is in this way that phantasy can be the “psychic representative of instinct” in Isaacs’ words. A way to expand this further is to say, that such a sensory experiential unity comes into mind as phantasy when it calls up some appropriate way to apprehend it in thought through a casual process. Contributions from both psychoanalytic and philosophical psychology can be brought together to elucidate this claim about a casual process, as part of a theory of the mind within philosophical naturalism.
Braddock L E
The Imagination in Philosophy and Psychiatry
Oxford, United Kingdom
The paper aims to show how philosophical discussion of the imagination can provide clarification of concepts in clinically motivated psychologies, with particular reference to the psychoanalytic concept of phantasy.
Imagination is a familiar concept of the ordinary psychology which structures our thinking about the mind. The capacity for imagining is seen as part of such everyday activities as planning, playing and pretending. It figures in our ordinary understanding of how we engage with the arts, as well as in theories about them. In psychiatry and psychoanalysis the concept of imagination enters into clinically motivated psychologies constructed to help in the explanation of psychopathology. Such theorising is driven by the need for a more or less systematic organisation of clinical data for purposes of classification, prediction and intervention, and is generally modelled on and taken to be scientific in nature. However, this sort of theory construction also borrows explanatory resources from disciplines in the study of human culture, in particular the arts. This then provides one route for introduction of literary concepts, such as that of narrative, into clinically driven theorising about the mind. Imagination as an ordinary psychological concept can also enter a theory such as psychoanalytic psychology, through an asserted equivalence with intra-theoretic concepts such as phantasy. What might be the contribution here of a philosophical discussion of the imagination? The variable degree of systematisation in clinically driven theorising suggests that one contribution of philosophy to theory building in psychiatry and psychoanalysis is through method. There is a need to make theory more systematic and to minimise problems arising from the patching of concepts from different disciplines and from ordinary psychology. However, philosophy has more to offer here than intellectual quality control, since the philosophy of the imagination presents interesting problems of relevance to psychology. One is, that the philosophical analysis of the concept involves a complexity which is in tension, both with the immediacy and apparent transparency of our experience of imaginative activity, and with the facility of very young children for imaginative activity. A second problem is, that the seemingly essential privacy and subjective character of imaginative states challenges the predominant philosophical view which takes the mind as a real thing and our knowledge of it, as of all real things, as dependent on our experience of it as a real thing while denying that introspection can be a privileged source of knowledge. Discussion of these questions helps define the explanatory role of the imagination in intra-theoretic concepts such as phantasy and narrative.
Braddock L E
What is in An Unconscious
Oxford, United Kingdom
“Philosophical defense and critique of the Freudian unconscious has been wide-ranging over the past 25 years. A recent defense of the concept's coherence, by Sebastian Gardner, provides a suitable starting point for general discussion”.
Bray A
Responsibility and Personality Disorder
Central Sydney Area Health Service, New South Wales
The question of whether human beings can reasonably be considered responsible for their actions in a deterministic universe has occupied philosophers for millennia. This paper discusses philosophical theories of responsibility, from Aristotle to the present day. The issue is of particular relevance to psychiatry, as psychiatrists often encounter patients who appear unable to behave responsibly. I will consider the nature of responsibility and the function of this concept in our society, in order to examine the question of whether people with severe personality disorders should be held responsible for their actions.
Brown J P
Psychobiology of Posttraumatic Stress
Private Practice, Kew, Victoria
One hundred years following the seminal work of Janet and Freud the field of posttraumatic stress is again contributing potent diagnostic and therapeutic paradigms. Conceptualization and management in this field is now multimodal, integrating neurobiological and psychosocial domains. Aetiological models of psychological trauma draw on concepts of memory, divided consciousness, and the hierarchical organization of the central nervous system. Professor Russell Meares assimilates concepts from neurophilosophy and neurobiology into a model of uncoupling of consciousness characterizing posttraumatic dissociation. He integrates the work of Huglings Jackson and Pierre Janet with the contemporary studies of Tulving and Schacter on memory and Edelman and Damasio on the relationships between cognition and emotion. Professor Sandy McFarlane examines psychoneuroendocrinological associations in posttraumatic stress. Models of kindling and of stress-induced oscillation are examined, and he uses the concept of allostasis to describe the simultaneous augmentation and inhibition of biological stress responses that obtains with trauma. Professor Barry Nurcombe describes the psychobiological dimensions of information processing fundamental to a comprehensive biopsychosocial model of posttraumatic stress. He shows how limbic system overload following the experience of child sexual abuse results in the development of diverse psychopathology, notably dissociation.
The ISTSS guidelines regard pharmacotherapy as a front line treatment, to be integrated with treatment modalities addressing other dimensions of posttraumatic disorders. Professor Philip Morris critically reviews drug studies. In particular he examines theories of kindling, and assesses the potential therapeutic contribution of anti-kindling agents. Finally, Dr Paul Brown examines the phenomenology and etiology of hallucinations in posttraumatic spectrum disorders. He bases his approach on a historical and clinical survey, which serves as a prelude to the summary and overview of this symposium by the doyen of psychiatric historians, Dr German Berrios.
Buist A, Janson H
Childhood Abuse, Depression and Parenting
University of Melbourne, Austin Repatriation Medical Centre, Victoria
Childhood abuse predisposes to depression; its occurrence in the postpartum period potentially disrupts the mother-child relationship, with ongoing ramifications for the relationship and child development. Little work has looked at this, in particular at the interplay of childhood abuse and subsequent maternal depression has on parenting, with the potential for the transmission from generation to generation.
A three year follow up study of women with postpartum depression, half of whom had a history of sexual abuse, will be presented. The recruitment phase of this study has been reported [ANZJ Psych 1998]; the recently completed follow up will be presented. Forty five women participated in the follow up study when their child was 2 ½ to 3 ½ years old. Twenty seven partners also participated. Results gave support for the hypothesis that an abuse history was associated with a longer term and more severe illness, but did not support any effect on relationships long term. The initial significantly impaired mother-infant relationship postpartum in the abuse group was not maintained at follow up, but was predictive of later depression. Regression analysis suggested significant links between mood, parenting stress and child outcome. The male partners of the abuse group women rated their children as being more disturbed, and though there was no cognitive differences between children, scores in both groups were low.
A small subgroup of physically and emotionally abused women will also be reported on; implications for management and further research will also be discussed.
Burke D, Sengoz A, Luu T
Delusional Jealousy in the Elderly: A Matched Case-Control Study
New South Wales Institute of Psychiatry, Sydney
Burrows G D, Coman G J
Group Telephone Counselling for Problem Gamblers
Austin Hospital, Heidelberg, Victoria
Provision of psychological and psychiatric counselling has undergone a true metamorphosis in recent years. Long past is the time where interventions were only provided one-to-one and face-to-face. Patient consultations may take place in a number of different ways. These include one-to-one, and in open (participants come and go from session to session) and closed (same participants for a fixed number of sessions) group sessions. In addition, a number of different methods for the delivery of counselling services are now available. These include telephone, video and internet consultations.
The aim of this University of Melbourne study is to examine the effectiveness of group telephone counselling, using Telstra Conferlink technology and facilities.
Interim results suggest that group telephone interventions are helpful in reducing patients gambling attitudes and behaviours and gambling related difficulties. Patients trait anxiety scores reduced significantly immediately following the program and at six month follow-up, and state anxiety reduced significantly at six months follow-up. Further, patients need for or dependence on money from gambling reduced significantly and their cynicism about their prospects of winning increased significantly. Patients perception of control over their gambling behaviour, their belief in gambling systems and perceived control over gambling outcomes all improved but not to a significant degree.
Callaly T, Trauer T
Comparison of Three Consumer Rated Outcome Measures: HoNOS-SR, BASIS-32 and MHI.
Director of Psychiatry, Barwon Health; Community & Mental Health, Geelong, Victoria
More consumers reported taking a shorter time to complete the BASIS-32 than each of the other measures. All three consumer rated measures were judged to be easy or very easy to complete. There was no association between ease of completion and self-rated severity of disorder. Most consumers thought it would be a good idea that the consumer rated outcome measure be completed every 6 months. This endorsement was higher for the HoNOS-SR than for the other two scales.
In a comparison between the HoNOS-SR and the clinician's HoNOS, there were low agreements between the clinicians perception of severity of problems and the consumers report for item 6 (hallucinations/delusions), item 7 (depressed mood), item 10 (activities of daily living) and item 11 (accommodation problems) with the consumers reporting a significantly higher rating on the last 3 items. There were moderately strong correlations between the total scores of the consumer self-rated scales and the total score of the HoNOS completed by the case manager.
Callaly T, Trauer T, Blacket J
Prevalence of CO-MORBID Psychiatric Illness in Persons Commencing Methadone Maintenance
Director of Psychiatry, Barwon Health; Community & Mental Health, Geelong, Victoria
Caper R
Knowledge and Fantasy
Psychoanalyst, California, United States of America
In this paper, the author argues that the capacity to learn and to acquire new knowledge depends on two factors: the perceptual apparatus and the capacity to fantasize. The latter is as important as the former, and defects in the latter produce a kind of conceptual blindness, just as defects in the former produce a perceptual blindness. Each type of defect is as fatal to learning as the other. In addition, the author argues that learning about oneself and one's inner world in the clinical setting is highly analogous to learning about the external world in the classical scientific sense.
These points are illustrated with clinical examples and with examples from the history of science.
Carr V J, Barnard R E, Lewin T J, Walton J
Schizophrenia as a Primary Care Disorder
Centre for Mental Health Studies, University of Newcastle, New South Wales
Three-quarters of general practitioners (GPs) treat patients with schizophrenia, the typical GP providing care for three such patients. The GP treated prevalence for schizophrenia has been estimated to be 3.6 per 1000 adults. Although the prevalence of schizophrenia is relatively low, the burden of disease represented by schizophrenia is high, and the level of service utilisation by these patients is also high. In fact, 83% of people with schizophrenia attend their GP at least once a year, the mean number of visits being 11.8 per year. With the increased national focus on partnerships between public mental health services and GPs, as well as the implementation of various ‘shared care’ models for providing community treatment, it is timely to examine the perspective of GPs in their role as health care providers for this group of patients. The findings of a study of schizophrenia in general practice conducted in Newcastle and the Hunter region of NSW are presented to shed some light on the experience of GPs in treating schizophrenia.
GPs who treat patients with schizophrenia tended to be younger and more recent medical graduates. They regarded regular employment as second only to medication in degree of helpfulness for the person with schizophrenia, which is ironic in light of the greater than 70% rate of unemployment in these people. GPs regarded psychological treatments as least helpful, an opinion at variance with contemporary literature on the efficacy of psychosocial treatments for schizophrenia.
The main problems identified by GPs in treating patients with schizophrenia were medication non-compliance; inadequate communication with, and poor accessibility of, mental health services; impaired understanding or insight on the patient's part; their own lack of training in this area; and the patient's family or other relationship problems. Almost 20% reported that contacts with psychiatrists were unhelpful. GPs clearly identified several roles for themselves in the treatment of schizophrenia, including: the provision of ongoing management and treatment monitoring; identification of warning signs of relapse and relapse prevention; caring for the patient's general health; providing specialist referrals when necessary; and liaison with the patient's family and the provision of support to the family.
One way of optimising the community treatment of people with schizophrenia would be to attend to the experience of GPs in this context and devise interventions that address the problems perceived by GPs in the care of patients with this illness.
Carr V, Johnston P, Rajkumar S, Lewin T
Patterns of Service Utilisation in Relation to Substance Abuse and Disability in Schizophrenia and other Psychoses
Centre for Mental Health Studies, University of Newcastle, New South Wales
A multi-centre census study of psychotic disorders in Australia screened 5710 people aged 18–64 of whom 66.5% were positive for psychosis. Nine hundred and eighty people were interviewed using the Diagnostic Interview for Psychosis (DIP), a composite instrument consisting of demographic and social functioning measures, OPCRIT-SCAN diagnostic measures, and assessment of health and community service utilisation. Data were analysed for 858 subjects who met ICD-10 criteria for a psychotic disorder. Five service utilisation variables (specialist mental health inpatient, outpatient, emergency and rehabilitation services, and general practitioners) were examined in relation to demographic information, diagnosis, substance abuse and disability. The diagnostic groups in the sample were: schizophrenia, 51.9%; schizoaffective disorder, 11.1%; bipolar/mania, 12.9%; severe depression with psychosis, 7.7%; and other psychoses, 16.4%.
Diagnosis bore little relationship to patterns of service use, but those with schizophrenia were less likely to use emergency psychiatric services than the other diagnostic groups. Lifetime alcohol abuse or dependence was associated only with increased likelihood of using psychiatric emergency and rehabilitation services, whereas lifetime cannabis abuse or dependence was associated with greater likelihood of using all mental health services. Increased levels of social disability were associated with lower likelihood of using psychiatric inpatient and emergency services. General practitioners provided a major source of mental health care for patients with psychotic disorders, but did so for a group who were comparatively older and less disabled.
Castle D
Body Dysmorphic Disorder: Ugliness is in the Eye of the Beholder
Clinical Director, Mental Health, Fremantle Hospital & Health Service, Fremantle, Western Australia
Concern with physical appearance, whilst common in the general population, only rarely reaches an intensity sufficient for it to be called a disorder. It is Morselli to whom is attributed the introduction of the term dysmorphophobia to describe those individuals with extreme overconcern with physical appearance, with concomitant distress and negative impact on daily functioning. Morselli's term has been superceded Body Dysmorphic Disorder (BDD), which is classified in DSM-IV with the somatoform disorders. There are no definitive studies of the prevalence of BDD in the general population, though figures of around 2% are cited. Many sufferers never come to the attention of mental health professionals, instead seeking help from cosmetic surgeons or dermatologists. BDD shows extensive psychiatric co-morbidity, including depression and anxiety. Of particular interest is the overlap between BDD and OCD, evidence that these disorders are linked on a putative OCD spectrum. Indeed, the effective treatments for BDD are similar to those for OCD, namely cognitive-behavioral treatment (CBT), and serotonergic antidepressants such as the selective serotonin reuptake inhibitors (SSRIs), and clomipramine. The belief that one is ugly can result in significant distress and impairment of functioning. As mental health professionals, we should raise the profile of this disorder, so that effective and appropriate treatment can be provided.
Chaplow D G
The Shop Front Window – the Forensic Report and the Importance of Adequate Expert Testimony
Director, Regional Forensic Psychiatry Services, Avondale, Auckland, New Zealand
Even for those psychiatrists who eschew “forensic” psychiatry, the day of reckoning will eventually see them in court to give evidence, either by agreement or under subpoena. This may be as “witness to fact”; as a clinician or as an “expert”.
Expert testimony is one of the “shop windows” to psychiatry and is often the yard stick by which the whole profession is judged. A recent well publicised discussion throughout the Australian media is testimony to this. Expertise is defined by the court and involves assisting the court to reach a better decision that it might do otherwise, without that expertise. Given testimony requires a knowledge of the legal system, a sound ethical sense, an ability to convey complex issues simply and an appreciation of one's own limitations. It often also involves report writing which is an art in itself.
This presentation aims to make the inevitable bearable and the ‘science’ of psychiatry is more credible.
Chen L
Review of Ethnic Identity and Its Relationship to Mental Health
Princess Alexandra Hospital, Brisbane, Queensland
Dr Lifeng Chen will address the various meanings of ethnic identity and review the data on its relationship to mental health. She will present some recent empirical data suggesting that there may be two dimensions to ethnic identity, each of which relate differently to issues of mental health and acculturation.
Clare A
Looking Outward: Society and Psychiatry
St Patrick's Hospital, Dublin, Ireland
The movement during the past thirty years of the clinical and research focus of
psychiatry out of the large mental hospital and into smaller hospitals, units and
community-based facilities has had and continues to have many foreseen and
unforeseen consequences. One consequence is the growing awareness of the adverse
consequences of
As studies showing the high prevalence of mental illness are publicised more widely, a realisation is developing on the part of the public of the significance of mental ill-health, its impact on personal and social development, its causes and theories of its causes and the pressing need for prevention and of effective treatment. Mental illness and psychiatry have never before received such passionate scrutiny and critical examination by society. Society has never been so influenced by the findings and the theories that characterise modern psychiatry. The implications of these developments form the subject matter of this lecture.
Clark C R, McFarlane A C, Morris P, Egan G F, Weber D L, Sonkkilla C, Marcina J, Tochon-Danguy H J
Neurobiological Evidence of Everyday Working Memory Dysfunction in Ptsd Using Pet and High-Density Eeg
Cognitive Neuroscience Laboratory and School of Psychology, Flinders University, South Australia
The breakdown of working memory function in post-traumatic stress disorder in relation to everyday, non-traumatic stimuli is well appreciated by clinicians. But persuasive, neurobiological indices of such dysfunction are still lacking, despite earlier derivations of abnormal event-related brain processes from scalp electro-physiology. The present study investigated the location and function of brain structures involved in working memory operations to trauma-neutral stimuli using positron emission tomography (PET) and high-density electroencephalography (EEG). Ten patients and matched controls completed a task requiring the updating of working memory stores with newly relevant visuoverbal information. Overall during task performance, patients showed decreased global CBF relative to controls, indicating generally reduced resource availability. During the act of updating working memory, patients failed to demonstrate the normal enhanced activation of regions of the left inferior parietal cortex associated with phonological coding, or in the left dorsolateral prefrontal cortex associated with monitoring and manipulation of verbal working memory content. They did however show a normal increase of activation in homologous regions on the right. But unlike controls, patients additionally showed increased activation bilaterally in regions of the superior parietal lobe associated with visuospatial coding. Event-related scalp current flows obtained under the same test conditions provided a number of indices of affected function. Early coding processes were clearly abnormal, with frontal negativity absent and left parietal activity more dominant, between 230 and 430ms following word onset. The later and more substantive bilateral involvement of parietal regions in working memory updating at around 575ms was noticeably absent in patients and replaced by enhanced activity in right frontal regions that extended with poor closure for over 400ms. This corresponds to the noticeable reduction in patients between frontal and parietal regions in event-related covariance. This study provides a number of neurobiological indices of poor and inefficient executive control over the updating of working memory in PTSD and demonstrates differential coding of trauma-neutral information relevant to everyday working memory function, with increased emphasis on the use of somatosensory based codes.
Clark M, Hecker J, Cleland E, Field C, Berndt A
The Effect of Dementia on Driving Performance
Repatriation General Hospital, Daw Park, South Australia
This paper reports on the progress of a study designed to examine the association between the on-road driving performance of patients with dementia and their neuropsychological test performance. There is much current interest in the contribution of dementing illnesses such as Alzheimer's disease (AD) to increased road accident risk. Medical practitioners in Australia are currently under no legal obligation to report persons diagnosed with dementia, but there is pressure to adopt a similar approach to that used in California, where physicians are required to report a diagnosis of dementia to the state motor vehicle authority, which then makes a decision regarding the patient's capacity to drive. There is evidence that drivers with dementia have a higher accident risk than age-matched controls, but this finding has not always been replicated. The equivocal nature of research findings is at least partly due to methodological flaws, such as inadequate sample sizes, no controls or poorly matched controls, unreliable sources of crash data, inappropriate outcome measures, and failing to account for the generally lower road exposure of elderly drivers with dementia. Moreover, the results of neuropsychological testing have not correlated consistently enough with on-road performance or crash data to be valid predictors. The current study avoids a number of common methodological problems. Participants are patients with a diagnosis of AD, drawn from the Memory Disorders Study Unit at Repatriation General Hospital in Adelaide. All participants have a current driving licence, and are given a standard battery of neuropsychological tests chosen for their likely association with driving performance. A standardised on-road assessment of driving ability is conducted by an occupational therapist with specific expertise in driving assessment, after which a recommendation is made about the participant's safety as a driver. The study also considers the psychosocial impact on patients and their spouses of being required to cease driving. About one third of a planned 114 patients have so far been assessed, of whom about half have failed the driving assessment. Neuropsychological test performance strongly discriminates those patients who have passed from those who have failed. However, it is important to distinguish those tests which relate mainly to cognitive decline from those which tap specific deterioration in skills required for driving. This paper considers the implications of these preliminary findings.
Clarke DM
Demoralization: An Important Construct for Psychiatry
Monash University Department of Psychological Medicine, Monash Medical Centre, Melbourne, Victoria
Jerome Frank introduced demoralization as a concept of importance for psychiatry. Since then, it has been largely ignored, or treated as a mild form of depression, a non-specific distress syndrome, or a normal response to an adverse situation much like grief. The literature surrounding the concept of demoralization is reviewed and presented to demonstrate that it is none of the above but an important and well-defined clinical entity. Rather than causing distress and suffering, it is the essence of distress and suffering. It can be observed and described by a stable set of phenomena and is differentiated from depression phenomenologically. It occurs in the presence of physical illness and mental illness; is associated with feelings of giving-up and a desire to die; is determined by a range of personal, situational and interpersonal factors; and responds to psychological and social interventions. It is concluded that an emphasis on the usual categories of mental illness that ignores demoralization will miss the wood (suffering) for the trees (symptoms).
Coade S
Purro Birik (Healthy Spirit). Koori Mental Health Policy Project
Victorian Aboriginal Community Controlled Health Organization, Victoria
The “Purro Birik” Koon Mental Health Policy Project commenced in October 1997. The primary aim of the project is to consult with Aboriginal communities and public mental health services, and propose strategies to improve mental health services to Aboriginal people in Victoria.
The project brief identifies four policy documents as the context for completing the project. The four documents are:
Ways Forward, The National Consultancy Report on Aboriginal and Torres Strait Islander Mental health (Swan and Raphael 1995);
Achieving Improved Aboriginal Health Outcomes: An Approach to Reform (Victorian Department of Human Services and Victorian Aboriginal Community Controlled Health Organisation, 1996);
Agreement on Aboriginal and Torres Strait Islander Health (Victorian Minister for Health, Commonwealth Minister of State for Health and Family Services, Aboriginal and Torres Strait Islander Commission, and Victorian Aboriginal Community Controlled Health Organisation 1996):
Victoria's Mental Health Service Framework for Service Delivery (Victorian Mental Health Branch 1994).
This discussion paper describes the project and the service delivery environment, summarises the issues raised throughout the consultation process, and finally recommends improvements based on the information provided and the outcome of the consultations. While the consultations recognised some local examples of services working together effectively, much still needs to be done to increase the capacity of Koori health services to respond to the social, emotional and cultural needs of communities, and of mental health services to consistently provide an accessible, culturally appropriate, effective response to Koori people experiencing mental illness.
The issues raised through the consultations with Koori health services and public mental health services have been grouped into nine categories:
accessibility and responsiveness of mental health services
quality and effectiveness of mental health services
culturally appropriate service provision
service development issues
workforce development issues
capability of services
accountability
community control issues
co-ordination and planning.
This discussion paper expands on each of these areas. The improvement strategies proposed through the consultation process have been grouped as:
local partnerships
co-ordination and planning
training
service development
resourcing.
Codyre D
Much Ado about Nothing? – Error, Variance and Evidence: Should Psychiatry be Taking Quality Improvement Seriously?
R.A.N.Z.C.P. QI Committee
Part I “Why should we be interested in QI let alone getting serious about it?” The issues of the psychiatric evidence-based, practice variance, reliability of clinical decision-making, and medical error are examined in a manner which counterpoints participant viewpoints, experience and beliefs, with relevant thought-provoking data. The wider medical and social context of quality developments in the healthcare sector is highlighted.
Part II - “What does all the QI gobbledygook mean in real life/practice?” A framework for thinking about QI in clinical practice is presented, and practical application of the various QI tools discussed with particular reference to the use of Clinical Pathways.
Part III “Cookbook Medicine or Best Care for Individuals? – Why all this QI stuff is so hard for us in health”. The basis for the widely acknowledged difficulty in successfully implementing quality methods in the health sector is examined, and critical success factors identified. The relative risks and benefits of the current push to ensure healthcare quality are examined, and the case is put for Psychiatrists taking the lead in this endeavour.
Condon J, Boyce P, Corkindale C, Fields S
An Investigation of the Mental Health of Men during the Postnatal Period
Department of Psychiatry, Repatriation Hospital, Daw Park, South Australia
We are reporting on work in progress of “The First Time Fathers’ Study” a large-scale, longitudinal investigation of the mental health of men over the transition to parenthood up to the first postnatal year. We believe this to be the first methodologically-sound investigation of these issues to be conducted in Australia or elsewhere. This NH&MRC funded research is being conducted jointly in South Australia and New South Wales.
The prime objective of this study is to clearly define the changes in men's mental health and well-being, together with changes in health-related behaviours, during the first postnatal years and possible risk factors for any adverse changes.
We are presenting the baseline data gathered from 250 expectant fathers in relationships where neither partner has had any previous children. The instruments used reflect a broad conceptualisation of mental health, and assess a variety of psychological phenomena. In addition to anxiety and depression, we report on alcohol use, sexual satisfaction, relationship functioning, foetal attachment, lifestyle satisfaction and quality of life. Subjects who score above cut-off on any one of three screening instruments are interviewed using the CIDI. Possible beneficial effects of the transition to parenthood are also assessed. We also present some data on the female partners.
Contractor N S
One Little Secret – the Air Points!
Community Mental Health Service, Porirua, Wellington, New Zealand
During the process of a thorough psychiatric assessment, my patient expressed some interesting comments and views which led me to explore how cultural beliefs influenced her understanding of the illness. These cultural beliefs produced several obstacles in her treatment. Interesting transference and countertransference issues were recognised and the case was formulated on the basis of the patient's cultural background.
Psychiatric interventions were based on a ‘liason model'. I found myself in a privileged situation to untie the cultural knots and release tensions between medical staff on one hand and the patient and her family on the other. Central players in the drama were recognised. As a psychiatrist, I adapted to the demands of this unique situation and demonstrated flexibility, changing roles as required. This meant a tight rope walk while endeavoring to maintain professional role boundaries.
The goals of the management included rapport – building, providing support and education and managing crisis situations. The various interactions and interventions one needs to put in place in such stressful and complex situations are highlighted. The various psychiatric and non-psychiatric interventions achieved respite and relief for the medical team, who were then able to focus on and work towards the best interest of the patient.
The patient and her family, once on the verge of leaving the country out of frustration, decided against it and stayed on. Their patience and cooperation following that contributed immensely to the overall favourable outcome.
The medical team achieved remarkable results in the woman's medical and neurosurgical treatment, which allowed for effective rehabilitation to follow. The woman is now back to a normal life, to the extent that she is able to support her husband at work as well as care for her new arrival.
The psychiatrist, quietly and painstakingly worked alongside the medical team. Thus by adopting a multidimensional and practical approach, a psychiatrist can experience a successful and rewarding outcome.
Coverdale J, Nairn R, Claasen D
What is the Role of Intertextuality in Media Depictions of Mental Illness?
Department of Psychiatry, University of Auckland, Auckland, New Zealand
Coverdale J, Turbott S
Sexual and Physical Abuse Histories of Chronically Ill Psychiatric Outpatients
Department of Psychiatry, University of Auckland, Auckland, New Zealand
Coverdale J, Turbott S
Sexually Transmitted Infections Risk Behaviours of Men with Mental Disorders
Department of Psychiatry, University of Auckland, Auckland, New Zealand
Cramond W A
Could it be Psychological? Pre-Consultation/Liaison Psychiatry –Some Adelaide Memories.
Emeritus Professor, Adelaide
Mindful of the aphorism that a knowledge of the past is of value to the present and the future, this paper reflects on the experiences arising from the introduction of clinical psychiatry units into two South Australian teaching hospitals some thirty-five years ago. A psychosomatic approach and psychodynamic insights into what appeared as purely organic problems raised tensions and resistances that required time, patience and tolerance to resolve. Descriptions are given with clinical examples of the role psychiatry played in the development of the Interdisciplinary Team and of the issues that arose in the early days of what came to be called Consultation/Liaison Psychiatry in this state.
Croke S J, Buist A E, Norman T R, Burrows G D
Presence of Olanzapine in Breast Milk
Austin & Repatriation Medical Centre, University of Melbourne, Victoria
There is generally a great shortage of evidence based information to assist clinicians in making their choice of treatments in this patient group. For example, of all other studies reporting levels of antipsychotic agents in breast milk only two have had larger cohorts than that presented here and some popular agents have not been reported on at all. The knowledge base developed so far, and its limitations, is discussed.
Cullen M J, Wilson A J, Baker J
Telephone Mental Health Triage and Case Management – Outcome Data from the First Two Years of Operation of the Greater Murray Accessline
Joint Managing Directors with High Performance Healthcare; Visiting Medical Officer at South Eastern Area Health Service, New South Wales
Curnow R
Despair and Redemption in Wagner's “Ring”
Psychoanalyst, Adelaide, South Australia
In creating his music-drama, “The Ring of the Nibelung”, Richard Wagner was influenced by his reading of Greek tragedy – particularly the three interconnected plays that constitute “The Oresteia” of Aeschylus. Using this structure, Wagner created in “The Ring” a series of interlinked dramas which follows the fortunes of a profoundly dysfunctional family. Both Aeschylus and Wagner are concerned with the moral sequelae of choices that are made following an initial irrevocable act. This talk, illustrated with brief excerpts from “The Ring”, will focus on aspects of the moral dilemma, and discuss Wagner's dramatic solutions which provide a radically different conclusion to that found in Aeschylus’ tragedy. The ambiguous tone of the final scene of “The Ring” is part of the endless fascination of Wagner's many-faceted masterpiece.
Curran J
Adolescents and Young Adults with Asperger Disorder and Autistic Disorder – a Clinical Psychiatric Perspective
Dual Disability Program, Intellectually Disabled Services Council, South Australia
The paper describes the presentation, assessment and management of common psychiatric disorders in adults with Autism Spectrum Disorders (PDDS) including Asperger Disorder.
Curran J, Rymill A, Henley I
Partnerships: Old Enemies, New Friends?
Dual Disability Program, Intellectually Disabled Services Council, South Australia
The poster presentations describe and evaluate:
an innovative intersectoral linkage project between mental health and intellectual disability services in South Australia;
a training system that builds partnerships around service users with mental illness and intellectual disability;
a model of a decision making process called the GAP MAP (Global Assessment of Psychopathology Management of the Assessment Process) that facilitates team work across agencies working with clients with intellectual disability and disturbed behaviour.
Davis A
Suicide Prevention – Have We Made a Difference
Clinical Senior Lecturer, Department of Psychiatry, University of Adelaide, South Australia
Despite the expansion of mental health services and major developments in the treatment of mental illness over the last three decades, the suicide rate in Australia has remained high. There have been particular concerns about suicide in young men over this time, a problem shared by many western countries.
This symposium will focus on the issue of suicide prevention, and ask the question, “Have we made a difference?”, over these decades. We will examine current suicide and attempted suicide rates in Australia, and explore trends amongst adolescents. We will examine the clinical syndromes associated with suicidal behaviour, and highlight the challenging issue of co-morbidity in high risk groups. We will discuss the impact of social changes on suicide rates, and present a critical summary of the National Suicide Prevention Strategy, looking at national plans for intervention over the next decade. We will present a critical evaluation of major intervention studies, seeking to identify creative interventions that have “made a difference” in various parts of the world.
Finally, we will raise the fundamental issue of the College's response to suicidal behaviour, and the potential benefits of special interest group amongst the membership.
Dawson E M
Action in the Public Interest Reveals Unacceptable Aspects of New South Wales Statutory Medical Investigative and Disciplinary Systems
Private Practice, Pymble, New South Wales
Anomalies need to be understood and addressed for the healthy development of the profession and for the benefit of the public we serve. I detail here concerns about aspects both of the relevant legislation and of the policies, functions and functioning of the NSW Health Care Complaints Commission (HCCC) and the NSW Medical Board – concerns arising from personal experience over the past nine years. As a psychiatrist colleague I was first an ignored and therefore dissatisfied complainant; then an unsuccessful appellant, obstructed in the Supreme Court by vigorous use of a legal technicality; and more recently a successful applicant in the NSW Administrative Decisions Tribunal (ADT). These matters are already documented in the public domain. On 30 July 1999 the NSW ADT handed down a decision now published on the Internet at www.lawlink.nswgov.au/adt, finalising Dawson v The Commissioner, Health Care Complaints Commission. The Commissioner was ordered to provide within one week the list of psychiatrists on the Commission's Peer Review Register, a list by then refused for over two years and spuriously held exempt under the NSW Freedom of Information Act (FOI). My own submission – that disclosure of the list is in the public interest – sufficed without need for legal advice or representation. It is now established that the Commission can only approach the necessary degree of perceived and real accountability, when the list of professionals it privileges and empowers is open to public scrutiny and appraisal. These psychiatrists are in a position to advise the HCCC during initial assessment of complaints, to provide peer review reports on the Commission's documented investigations and to give advice relevant to Commission decisions, recommendations and activities, about or in the course of Committee and Tribunal disciplinary hearings. The current bureaucratic NSW complaints system began in 1984 as the Complaints Unit of the NSW Health Commission, becoming the ‘independent’ Health Care Complaints Commission under its own Act in 1994. For fifteen years these agencies have kept secret the lists of potential advisers and reviewers – lists drawn up by vague, now unidentifiable differing methods, at unknown times and for unknown precipitating reasons from the various specialties within medicine and from other health professions. An agency's potential vulnerability to corrupt influence in such circumstances is obvious. It has become increasingly clear during the 1990s that official handling of even gross departures from proper standards may still miscarry just as badly as when the first complaints about the now notorious Chelmsford Hospital were pigeonholed at NSW Health in 1978. It is now ten years since a Royal Commission inquired into events at that hospital and since the NSW Branch of the College addressed the theme “After Chelmsford Where Now for the Profession?” In this paper I describe the route taken by one member and suggest future paths for the College itself.
de Beer, W A
The “Religiosity Gap”: A New Zealand Perspective
Department of Psychiatry, Waikato Hospital, Hamilton, New Zealand
There are many explanations put forward why psychiatrists neglect the area of the spiritual in the psychiatric assessment. Two reasons that are often cited include: the emphasis on psychiatry solely as a scientific model; and the presence of a “religiosity gap” (or spiritual gap) between clinicians and their patients. The presence of a religiosity gap has been found in studies in the USA and UK. However, to the author's knowledge, no similar studies have been conducted in New Zealand to demonstrate the presence of this gap.
The purpose of the pilot survey was to comment on whether a religiosity or spiritual gap exists between a sample of psychiatrists (and trainee psychiatrists) and a sample of consecutive inpatients in Hamilton by completion of a semi-structured questionnaire to each group.
A group of psychiatric inpatients reported beliefs in God more frequently than the sample of psychiatrists in the sample. Atheism and agnosticism were more frequently reported in the sample of psychiatrists. This would suggest the presence of a religiosity gap and is in keeping with those studies conducted elsewhere. However, the presence of a spirituality gap was not that evident. Two-thirds of the inpatients felt that their current symptomatology could be related to either spiritual or religious issues. Yet in a review on the frequency of spiritual history taking on assessment, only 11% of patients were asked about their beliefs by the psychiatrist.
Psychiatrists confirmed that these beliefs were important in the psychiatric assessment. Yet, they only occasionally took a spiritual history as part of their assessment. The author concludes that even though psychiatrists acknowledge the importance of taking spiritual information; a “PRACTICAL GAP” exists: Psychiatrists are hesitant to translate their understanding of the importance of the religious or spiritual beliefs into their daily clinical practice.
Poor teaching and lack of practical skills may be blamed for this practical gap. Ninety-four percent of psychiatrists had not received formal training on this topic in their postgraduate programme. This will hopefully serve as a recommendation to co-ordinators of training schemes to address this issue during training.
De Saxe I
Creativity and Colitis
Private Practice, New South Wales
Based on the experience of a single patient, as well as a recent research in neurophysiology, this paper postulates that the “old” notion of a link between the psyche and ulcerative colitis (1) may, indeed, have much validity.
The case history will be described in some detail, followed by a discussion which links the patient's emotional/neurological experiences with the changes in his physiological functioning.
This new biological model, based on Schore's research (2), has major implications for the understanding and treatment of conditions which have somatic and psychic components.
References:
1. Engel G L
Studies of ulcerative colitis: II. The nature of the psychological processes Amer J Med 19 231–255/ 1955.
2. Schore A N
Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development. 1999. Lawrence Erlbaum Assoc.
De Saxe I
Looking Inward: What's Troubling Little Johnny
Private Practice, New South Wales
It is a speculative paradox that the Australian Prime Minister is so resistant to rapprochement with the Aboriginal people, yet embraces another group with a history of persecution, the Jewish people.
This speculative psychoanalytic biography attempts to understand the psychodynamic mechanisms which might have given rise to these paradoxical attitudes in the leader of the nation.
Psychoanalytic biography eg: (1), has been much maligned in Australia (eg: by journalist Paddy McGuiness and centre-right think-tank director, Gerard Henderson), yet as psychiatrists we have the possibility of contributing to the national discourse by applying psychoanalytic principles to our society and leaders.
Reference:
1. Brett J. Robert Menzies’ Forgotten People. 1992. Macmillan Australia.
Denson L
Unusual Dementias
Clinical Psychology Department, Royal Adelaide Hospital, Department of Psychology, The University of Adelaide, South Australia
As the population ages and new investigative procedures are developed, dementias are both more prevalent and better understood. In addition to the common dementias (Alzheimer's disease, frontal lobe dementias, vascular dementia) the clinician must now be able to recognise those which are less well known (including lobar cortical atrophies, subcortical dementias and prion diseases). Unusual dementias will be discussed and references provided. Neuropsychological findings in a case of unusual dementia will be described.
Devi M B N
Music, Mental Health and Creativity
National Institute of Mental Health and Neurosciences, India
To study the relationship between mind and music in relevance to psychiatric morbidity among students of music.
To study whether music has a preventive and protective effect on the sample representing the vulnerable age group (adolescence; adulthood).
A personal data proforma including exposure to music, selection of music as a subject and family background of music was used.
A self administered questionnaire – Goldberg's General Health Questionnaire (60 item version) was used for detection of psychometric illness for the I stage screening. (The questionnaire was adopted from – The Detection of Psychometric Illness by Questionnaire, Institute of Psychiatry Maudsley Monograph.)
For detection of cases – The Present State Examination (PSE) devised by Wing and his colleagues (1974 full version) was used for GHQ positive cases and for a percentage of negative cases.
A physical examination was done for all the cases whom PSE was administered to rule out any assorted organic illness.
Students choice of music as subject of study and family background of music have shown statistically significant relationship to psychiatric morbidity.
Students who chose music as first choice were found to have less psychiatric morbidity.
The study has shown low prevalence compared to other studies. Music can be identified as a positive factor adjunct to education and recreation facilities for the students, thereby enabling to promote creativity.
Djokovic O, Fell K
Cct West's Clozapine Clinic
Affiliated Member
Over the later part of 1999 CCT West trialed a monthly clozapine clinic for 20 clients. The clinic had three aims:
To provide a client focus, supportive environment that would improve medication compliance through education and peer support.
To reduce error in medication monitoring and dispensing.
To reduce Community Mental Health nurses casework.
We hypothesised that the clozapine clinics would prove to be more cost effective in the provision of clinical monitoring and assist clients’ with social and living skills.
Both qualitative and quantitative data was collected over the past eight months. The results suggest that the clinic has been highly successful in achieving the above aims. Two clients have moved on to further study and employment. Clinical staff have reported improvement in clients’ social functioning. There was 100% attendance at the clinic.
There have been a number of referrals to the clinic, which has resulted in a second clinic being established in February 2000. If additional resources can be found further clinics are being considered for outlying locations to increase accessibility.
Draper B
Who Should See the Elderly in General Hospitals – Old Age Or Consultation – Liaison Psychiatry?
Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Randwick, New South Wales
The most frequently mentioned reasons for consultation are ‘depressive symptoms’, ‘confusion, dementia’, ‘discharge advice and placement’, ‘mental state evaluation/competency assessment’ and ‘behavioural problems'. Older patients are less frequently referred for assessment of suicide risk and psychogenic causes of physical symptoms. Organic mental disorders are reported in 44% (median) of referrals, with dementia accounting for 30% and delirium 14%. Depression is found in 27% of referrals, with around half of these cases due to major depression. Anxiety, adjustment and somatoform disorders occur in 8% of referrals, substance abuse 5%, personality disorders 4%, and schizophrenia/paranoid disorders 3%. No diagnosis was made in 7%. In comparison with younger CL referrals, fewer older patients are diagnosed with substance abuse, anxiety, somatoform and personality disorders or have ‘no diagnosis'.
The most frequent management recommendation was for psychotropic medication in 44% of referrals. The use of psychotherapy was variable and ‘ward management and
The most frequent management recommendation was for psychotropic medication in 44% of referrals. The use of psychotherapy was variable and ‘ward management and advice’ was mentioned irregularly. Many older referrals are recommended to have a further medical review or investigations. The main difference found between old age and CL psychiatry was that in around 30% of referrals, old age psychiatry services are asked to give discharge advice, particularly about placement, and are more likely to arrange community psychiatric follow-up. This extended care approach is the most effective style of service delivery for the elderly.
D'souza R
A Satisfaction Study of General Practitioners, and Community Mental Health Workers in Rural and Remote Areas with the Use of Telemedicine for Managing Their Psychiatric Patients
Statewide Mental Health Service, Glenside Campus, South Australia
Duffy J
Therapeutic Potential and Challenges of the Management of Opioid Dependency in the General Practice Setting
Flinders University, Department of Public Health, Bedford Park, South Australia
A pivotal aim in the current philosophy on opioid dependency is to increase retention in treatment in order to provide options that enhance relapse prevention outcomes. In view of the excess demand over supply for in-patient treatment services, there is significant potential for treatment to be conducted in the general practice setting. This presentation will examine the primary health care significance of a shared care approach to treating opioid dependency. Case examples will be used to illustrate the potential of innovative pharmacotherapies for treating illicit opioid dependency in the general practice setting with particular reference to the diagnosis of co-existing psychiatric disorders.
The treatment goal for opioid dependency is not necessarily to achieve total abstinence. Rather, it is to minimise the disruptive effects upon psychological and social well being and to reduce risks to individual and public health. Opioid replacement therapies reduce illicit opiate use, drug-related crime, and HIV risk practices. Clinical trials have demonstrated that buprenorphine is an effective pharmacotherapy for illicit opiate use. Moreover, it is likely that it will be available for prescription by Australian general practitioners in the near future.
Both pharmacological and nonpharmacological characteristics of the treatment approach influence relapse prevention outcomes. Yet, many people with an opioid dependency lack the cognitive-behavioural skills or resources necessary to make vital lifestyle changes and often leave treatment before these skills and resources are developed. Furthermore, the presence of psychiatric co-morbidity complicates prognosis and the success of opioid replacement treatment may be mitigated by a failure to diagnose these disorders.
The implications of a treatment approach to opioid dependency grounded in principles of continuity of care are profound. Clinical care and relapse prevention outcomes can be improved if GPs can identify opioid dependent patients with a co-existing psychiatric co-morbidity and refer them for specialist treatment. Conversely, structural and GP barriers may impede the diagnostic potential of the general practice consultation and reduce the efficacy of opioid replacement therapies. These barriers include the fee for service payment structure, lack of GP training and GP personal characteristics such as attitudes towards drug use, as well as a lack of integration of mental health services with primary health care structures and psychiatry.
Significant therapeutic potential exists in a comprehensive approach to the diagnosis of concurrent opioid dependency and psychiatric or mental health disorders that can be initiated in the general practice setting. The challenge is to both provide GPs with the necessary diagnostic training and tools and to facilitate better integration of services between general practice and mental health.
Duke M
My First Twelve Months in An Urban Aboriginal Mental Health Service
Victorian Aboriginal Health Service, Victoria
Eagar K
National Demonstration Projects in Integrated Mental Health Care –Overview and Developments
Director of the Centre for Health Service Development, University of Wollongong, New South Wales
Planning is well under-way for the establishment of National Demonstration Projects in Integrated Mental Health Services (MHIP for short). The basic MHIP model is for public sector mental health services and private psychiatrists to work together in the development of an integrated service model for the population of a defined area. Some projects also include local general practitioners, non-government services and private hospitals. The aim is to create a more flexible integrated framework within which mental health care can be delivered and to optimise outcomes for consumers.
The projects are being implemented in three phases:
Detailed design and planning phase
Implementation Phase
Wind down and final report phase
This paper will discuss the goals and the processes that underpin MHIP It will summarise the approach being pursued by each of the demonstration projects and will discuss some key issues such as the funding and clinical models that are being evaluated.
Edmonds C A, Baigent M
Responding to Amphetamine Use
National Centre for Education and Training on Addictions, Drug and Alcohol Services Council SA, South Australia
Amphetamine use and consequent harm has risen sharply in recent years in Australia. It is common for patients presenting to psychiatric services to use amphetamines which may (or not) contribute to the presenting problems.
The aim of this workshop is to provide participants with a comprehensive understanding of the issues associated with amphetamine use encountered in clinical practice and ways of responding to these. In addition it would serve as a template for those participants intending to provide similar educational activities. Written materials covering much of the content will be distributed to participants. Based in part on the Go to Whoa training package (an initiative of the Ministerial Council on Drug Strategy, authors Pead J, Lintzeris N, and Churchill A.) this workshop will employ an interactive style to cover amphetamine use – patterns, problems and stopping. Using a combination of overheads, video vignettes and exercises, participants will explore attitudes to amphetamine use and users, assessment of harms associated with use and features of intoxication, crash and withdrawal. The workshop will include clinical responses to each of these issues and encourage participant input and discussion.
At the conclusion of the workshop it is anticipated that participants will have an understanding of amphetamine use in Australia, recognise its consequent harms and feel better able to provide an appropriate response.
Edmonds L K, Walsh A E S, Mantell K, Ryan E, Yeates M
Mental Health and Wellbeing Issues for Maori Women
Ellen S R, Morris P L P, Olver J S, Reutens D, Norman T R, Tochon-Danguy H J, Constant E, Ignatiadis S, McFarlane A C, Egan G F, Burrows G D
A Positron Emission Tomography Study of Benzodiazepine Receptors in Post-Traumatic Stress Disorder
University of Melbourne, Department of Psychiatry, Austin and Repatriation Medical Centre, Victoria
This current study aims to compare the Bmax and Kd of BZD receptors in subjects with PTSD and normal control subjects.
Elliott M J
The Politics of Heroin Trials in Australia
Parliamentary Leader South Australia, Member of the Legislative Council, Australian Democrats, South Australia
This paper draws on fourteen years of state parliamentary experience as well as a qualitative research project in Switzerland and the Netherlands to discuss the key political challenges facing heroin law reform in Australia. Central to this paper is the assumption that drug laws were introduced to protect citizens and that this intention has not been well served by the increased emphasis on drug use as a justice issue. With specific reference to the recent well publicised political shift toward heroin trials and safe injecting rooms in some states, this paper identifies key issues in redefining heroin use as a health issue. The paper concludes with recommendations for new approaches to the politics of heroin trials in Australia.
Fallo T, Pigazzini M
Totem and Sacrifice
Clinical Psychologist, Migrant Health Service, Adelaide, South Australia
An understanding of the meaning of sacrifice is crucial in clinical work, above all in working with migrants and refugees. Sacrifice implies that people put aside his/her personal goals and private life, in favor of the family, the community or the nation's interests. The sacrificing of Isaac and Iphygenie are the mythological expression of socia supremacy upon the subject.
The authors compare the notion of sacrifice with that of the Totem, because in the totemic cultures, like the Australian aboriginal, there is no trace of sacrifice. Totem, a very important quality of living systems declared by ancestors, became a fundamental aspect of social organisation. Every person is equally essential in the living system as well every quality, law or rule. Totemic belonging is the historical evolution and affirmation of subjectivity.
After a brief introduction of the principle of correspondence, recently reintroduced by E. O. Wilson as Consilience, the authors discuss the idea of duality of nature within indigenous cultures. This dual organisation involves the entire activity of thinking and living. A subject is part of the kinship as well of his own Totem and this belonging promotes personal growth and protects his/her from social intrusions.
Further, the authors connect totemic identity with the psychological concept of personal identity. In the modern world, the subject has to cope on his or her own with dangerous intrusions by kinship or any other, small or large, social organisation. Migrants or refugees have many other losses, including the sense of the value of the community, and so it is more difficult for them to cope with personal needs. This encourages us to reevaluate the idea of totemic belonging in the modern world.
Ferguson J
Psychosis and Substance Use Project in Csahs
Drug and Alcohol Department, Rozelle Hospital, Rozelle, New South Wales
Substance use, abuse and dependence amongst the clients of Central Sydney Area Mental Health Service (CSAMHS) was highlighted as a core issue in 1995. At that time, Bergen et al found substance use disorders to be a contributing factor for 58% of client's aged 18–29 presenting to acute psychiatric services in CSAHS.
The current project is a collaboration between the Central Sydney Drug and Alcohol Service and Mental Health Service and evolved to focus on clients of the Mental Health service with comorbid psychosis and substance problems.
The project has moved through several phases: an exploratory phase 1996–7, a strategy and education phase 1997–99, and now a clinically based implementation phase.
Phase 1 involved identifying, clinically and administratively, the impact of substance use disorders on mental health clients and services. The major aim of Phase 2 was to develop a strategy to best meet the clinical needs of this client group. This involved:
a literature review (Siegfried 1998) and collation of local project activities to help direct best practice in dual disorder management,
investigating the competencies and needs of mental health staff in regards to this client group,
(Siegfried et al 1999) and development and implementation of a relevant education program,
development of a policy for CSAHS to ensure effective service delivery and encouragement of research in the topic.
The project has worked within the themes from the Second National Mental Health Plan – prevention, partnerships in service reform and quality and effectiveness.
Vital to the project has been a linked network of committees. This has facilitated administrative support, provided consultation and clinical support within the staff and with other interested parties including NGOs, and a working party to assist the project officer. Phase 3 of the project, commencing Feb 2000 shifts the focus to design and delivery of clinical services to ensure effective, accurate identification and management of comorbidity. There is an emphasis on partnerships with other services e.g. NGOs and D&A services. This paper will discuss the concepts underlying the evolution of the project and it's linkage to the National Mental Health Strategy; the project's achievements, outcomes and difficulties in Phase 2 and plans for the future.
Fernando A T III
Rapid, Safe and Stable Antidepressant Response with Desipramine Augmentation of Serotonergic Agents
Consultant Psychiatrist for Auckland Healthcare; Crisis Service, Taylor Centre; Early Intervention Service, Taylor Centre; Continuing Care Outpatient Clinic, Taylor Centre; Clinical Lecturer, Auckland University School of Medicine, Auckland, New Zealand
Firestone A
Placebo: A New Contextual Paradigm – the “Healing Field”
Hon Senior Lecturer, Monash University Dept of Psychological Medicine, Melbourne, Victoria
In this presentation material from the drug, psychotherapy, and anthropology literatures is brought together. A brief account of the colourful cultural history of Placebo will show the shifts in the concept with changing medical times. For pharmacology, Placebo has represented the credulity of the patient, contrasted with the medical scientist's impartial objectivity.
Today, thanks to medical anthropology, and as part of our overall post-modern epistemology, the influence on patients of doctors’ own beliefs and behaviours is better appreciated.
The term “healing response” will be used in place of the pejorative “placebo response”. It is best regarded as resulting from human faith and trust, in a culturally supported authority; which in our culture until now has been of a benevolent parent-like kind.
Meta-analyses show that the greatest effect size is due to the healing response. In antidepressant trials for example, it averages twice the effect size of the drug effect.
Evidence for the importance of a “Healing Field” is summarized: It has been found that no “placebo reactor” personality type exists: returning focus to context-specific effects.
Large differences in results, found between participating centres in drug trials, have been attributed to systematic differences between researchers’ own attitudes and behaviours.
Such a revision of our thinking has a number of important consequences.
Firstly, medical teaching should give centrality to the healing response and ensure that it is not perceived as a shadow of a drug effect. In particular, the misconception that drug effect outweighs relationship issues, should be exposed.
Secondly, the clinical implications for trans-cultural work need to be studied.
Thirdly, drug trials with a placebo arm become unethical if blinding is lost.
Time permitting, interesting recent developments of some of these ideas which are already in the literature, will be presented.
Fisher R B, Lippincott R C
Managed Health Care: Right Diagnosis, Wrong Treatment
Associate Professor. Department of Psychiatry and Neurology, Tulane University School of Medicine, New Orleans, Louisiana, USA
The health care environment in the United States is rapidly changing due to dramatic advances in the understanding of disease and technology and the unrelenting pursuit of cost containment. The incentive based “Fee-for-Service” system that rewards the unbundling of clinical services has been replaced by a system controlled by business-minded administrators who have had little training in health matters and who reward providers primarily for controlling costs often to the detriment of health care.
Both proponents and detractors of “Managed Care” generally agree that the process of health care delivery in the past was too often wasteful and that changes were necessary. The costs of health care were rising much more rapidly than inflation and the costs of other social services. This is a problem facing not only United States but many if not most developed countries.
The rubric “Managed Care” usually refers to the capitation process: a fixed amount of money is given to a managed care provider to meet, for the purposes of our discussion, all psychiatric needs that an enrolee might have. Fixed pre-care payments assure the Payer of predictable expenditures by reducing incentives to the Provider to expend treatment resources. Capitation also encourages the development of prevention programs, and discourages the placement of patients in more restrictive (and thus expensive) care than is necessary.
The consequences of Managed Care have been mixed: On the positive side, the runaway rise in health care expenditures has been slowed and in some areas reduced; administrative efficiencies have resulted as streams of overlapping paperwork requirements have been curtailed; the scientifically inexplicable variance among regions as to health care needs and outcomes has been reduced, with a consequent improvement in care and costs. On the negative side, patients have been unhappy with a restriction on choices of providers, the imposition of apparently arbitrary exclusion of certain types of coverage, and the perception that managed care has depersonalised and thus dehumanised mental health services. Further, providers are also unhappy with dramatically reduced reimbursement and with officious, uninformed, and intrusive bureaucratic requirements.
The authors believe that it is possible to identify those features in the Managed Care system which are salutary and should be retained and built upon. We will examine the advantages and possible difficulties with Single-Payer systems and the performance of both For-Profit and the Not-For-Profit (QANGOs) Managed Care Organisations (MCOs). We will identify those features of each which represent the best and worse aspects of managed care. We will also identify factors that should be contemplated before managed care is implemented in a region: the role of Clinical Guidelines or Standards in buffering the constant quest for cost-savings or profits; the importance of “choice” for the consumer; and the absolute necessity of involving both consumers and providers in the development of any new health care system. Finally, we will address the concept of “profit” for both the “For-Profit” and “QANGO” sectors and explore ways that earnings achieved by both approaches might be returned to health care to support training and research.
Foulkes P
Psychotherapy Teaching in Psychiatric Training
Private Practice, Albert Road Clinic, Victoria
There is considerable uncertainty about the extent of training in the different psychotherapies that psychiatric trainees received in their training. There is considerable anecdotal evidence from both teachers and trainees that the level of psychotherapy teaching has declined in standard and quantity in recent years. However there has been no objective evaluation until now.
Foulkes P
Supportive Therapy: Out of the Cold
Private Practice, Albert Road Clinic, Victoria
Supportive therapy (ST) has always occupied a rather uncertain place in the pantheon of psycho-therapies, usually being an uncertain definition and being reserved for those patients who are not identified as being worthy recipients of all the other therapies. It is a therapy for the excluded – a Cinderella of therapies. At the same time more severely disturbed patients who are not suitable for other formal therapies require a therapeutic approach from their psychiatrist that is matched to their needs, rather than fitting into a therapeutic Procrustean bed. Supportive therapy can be such an approach.
In this presentation a review of the literature is summarised in order to show the different definitions and concepts that are encompassed by the term of supportive therapy. These include both dynamic and non-dynamic sources. The definitions range from non-specific approaches inherent in the case of any patient to more circumscribed treatments for specific disorders such as psychosis (eg. problem solving) to variants of dynamic therapy. An argument is made that ST can be conceptualised best not as a uniting entity, but rather as a constellation of approaches and techniques, the exact nature of which will be different for different patients.
However, there are certain basic underlying principles not just of the techniques involved but of the nature of the psychopathology that would benefit from ST. The notion of “constructive therapy” being used in order to address deficit states and distortions of intrapsychic functioning involving the existence of pathological organisational structures at family and individual system levels is discussed. Use of material from work with an individual patient with a family is presented as an illustration with discussion of the information between therapist and patient/family.
Techniques used include a specific attunement to the emotional states linked to the Winnicottion concept of the true self and an ability to both discern destructive impulses emanating from a pathological organisation and not to collude with such impulses. The creation of a safe place, an asylum where the patient's needs are kept in mind is a central principle of treatment. ‘Support’ then is essentially for the emotionally reactive true self which must first be recognised. The role of inter-objectivity and counter transference is discussed. Recent findings from mother-infant studies and new developmental research are integrated in order to provide a theoretical basis for the essential principles of ST.
Fraser A
Ethical Issues Raised by the Conception of the Mentally Ill as Not Morally Responsible
Director Mood Disorders Service, Waitemata Health; Senior Lecturer (Hon), Auckland School of Medicine, Auckland, New Zealand
The insanity defence is based upon the belief that some persons who have committed a crime do not deserve punishment because they suffer from a mental illness. On the basis that mental illness decreases a person's capacity for autonomous decision making due to diminished competency society has long regarded the mentally ill paternalistically. This justifies both involuntary treatment laws and laws providing for exculpation on the grounds of mental illness.
Among the outcomes ascribed to the insanity defence are psychiatric preventive detention, increased stigmatisation of the mentally ill, and reduced resources for the voluntary patient. Strong views are held by both proponents for and the opponents of the current law. In a pluralistic society law is always a compromise, and never an absolute. It behooves us as experts in the field of mental illness and its effects to participate in the debate about whether the current compromise is the best.
This paper proffers the view that paternalistic interventions on behalf of the mentally ill offender are more likely to result in greater harm to the greater number of mentally ill persons. Such harm includes diversion of resources from treatment to detention, discouragement of potential patients from seeking help voluntarily, and institutionalisation of beliefs that the mentally ill are less able.
Freidin J, Buhc T, Wragg A
The Impact of New Technologies on who we are and how we Work
Alfred Hospital, Central East Mental Health Service, Victoria
As new technologies such as the internet and hand held digital cameras become part of everyday life and clinical work, there can be unforeseen impact on the way we see ourselves, our patients and our work. Two examples of this will be discussed in the workshop. The Inner South Homeless Team filmed their work for ten weeks as part of an ABC documentary on nurses, which will be broadcast in late 2000. They discovered the process of filming caused changes in their patients, themselves and their relationship to their work identity. In a separate project, interviews with adolescent girls about their use of internet chat rooms demonstrated a significant and troubling impact on identity development.
Through presentations, discussion, and showing of some of the unedited film made available by the ABC, several issues will be explored. This will include the nature of the changes seen, the possibility that the changes can be seen as large group phenomena with blurring of identity boundaries, the use of new technology in community education and health promotion, and the potential to use new technologies in treating patients.
Friedman E, Selzer R, Nahamkes J, Macfarlane S, Serry N, Talman P
“Radiotherapy” – Sunday Morning Psychiatry
Freelance Writer, The Age, Victoria
Radiotherapy is a program run by a group of doctors on Melbourne radio station 3RRR. The program explores psychiatric and medical issues in a relaxed, conversational setting. It goes to air each Sunday morning at 10 am and runs for one hour. Radiotherapy creates a lively forum for the discussion of mental health issues, encompassing a range of views from psychiatrists and health care practitioners working in diverse fields in the community.
The orientation of Radiotherapy is broad. It seeks to deconstruct mental illness; a subject often demonised in the community and media. The program has tackled subjects such as schizophrenia, post-natal depression, post-traumatic stress disorder and most of the other DSM-IV categories. Other topics have included heroin trials, youth suicide, child abuse, gambling, alcoholism, developmental issues, the changing face of masculinity, the vagaries of evidence based medicine, medical ethics and freedom of information. The program seeks to dissolve public prejudices about mental illness, dealing with the subject in a frank, informed manner.
Radiotherapy also explores the nexus between psychiatry and culture. Popular psychiatric terms that have found their way into the vernacular are explained and contextualised. Significant events, like the death of Princess Diana, the Port Arthur tragedy and the massacre at Columbine High School in the US are mined for both their cultural and psychiatric implications.
Creativity and psychiatry is an important focus of the program. Regular segments explore psychiatry in the cinema (eg: Rambo, Silence of the Lambs, Star Wars) and the depiction of mental illness in the arts and media.
Radiotherapy also tackles the changing face of health care and the implications of these changes of both patients and doctors.
The program seeks to be bold, eclectic and irreverent but never at the expense of patients. But it often does at the expense of the doctors themselves. This creates a robustly “human” face for doctors, who are mythologised in the community.
Esteemed guests on Radiotherapy have included Sir Gustav Nossel, Michael Wooldridge, Sandra Hacker, Oliver Sachs and Rob Sitch.
The presentation will chart the history of Radiotherapy, the response of listeners, a sampling of segments and an exploration of why people would want to listen to a team of disgruntled doctors so early on a Sunday morning.
Galambos G
A Doctors’ Mental Health Web Site Resource
Rozelle Hospital, Central Sydney Area Mental Health Service, St John of God Hospital, Burwood, New South Wales
Medical practitioners are at risk of developing distinct patterns of mental health problems and they have a reduced likelihood of obtaining early and optimal treatment for them. These problems stem from vulnerability factors within doctors, unique occupational stress factors, and factors relating to the culture of the medical community that impinge upon the therapeutic relationship between doctor patient and treating psychiatrist.
This Internet Web site resource devoted to the subject of doctors’ mental health was developed by the author as part of a prevention, early intervention and education program that aims to reduce the morbidity and mortality of mental disorder in doctors. Educational materials, including a literature review, and policies, strategies and guidelines were developed by the NSW Doctors’ Mental Health Implementation Committee as part of its campaign to reduce the morbidity and mortality of mental disorder in doctors.
The NSW Doctors’ Mental Health Implementation Committee was established in December 1997 to follow on from the work of a Working Group that had been in existence from 1996. These committees, which consisted of over 30 doctors representing the constituent groups of the medical community, were established as a joint initiative of the NSW Health Department and the Australian Medical Association's NSW Branch. The Medical Benevolent Association of NSW, a charitable medical organisation, agreed to sponsor and maintain the resource. The poster display presents a simple diagrammatic plan outlining the structure of the Web site.
Gale C, Coverdale J, Simpson S
Responding to Threats and Violent Acts by Patients against Psychiatry Trainees
Department of Psychiatry, University of Auckland, Auckland, New Zealand
Galletly C, Clark C R, McFarlane A C, Weber D L
The Effects of Treatment with Clozapine on Erp Indices of Working Memory in Schizophrenia
University of Adelaide, Department of Psychiatry, The Queen Elizabeth Hospital, Woodville, South Australia
ERPs were recorded from 26 subjects with schizophrenia and matched controls using a two-in-a-row paradigm. Tones of differing frequencies were presented with equal probability in pseudorandom order, with repeated tones defined as targets. This design obliged subjects to update working memory with each non-target to ensure accurate target detection. In the schizophrenic group, working memory updating was associated with bilateral frontoparietal diminution in P300, and posterior-temporal reduction in the late slow wave. In addition, there was a bilateral posterior diminution in P300 to targets. ERP recording was repeated in 12 schizophrenic subjects treated with clozapine. Clozapine treatment resulted in reduced symptoms, improvement on neuropsychological test performance and increased P2 and P3 amplitude. There was also an increase in later slow wave amplitude to successfully detected targets. These results suggest that schizophrenia is associated with abnormalities in the modulation and use of working memory content that may respond positively to clozapine treatment.
Gaughwin M, Gill S, Ryan P, Buckley N, Kuhn M, Hooper J
Should Heroin Users be Detained under a Mental Health Act When They Overdose on Heroin?
Royal Adelaide Hospital, University of Adelaide, South Australia
Overall we ask.
What choices do we need to make?
What information is enough for us to make reasoned choices? We met as a group to consider this question and asked the Treatments Ethics Committee of the Royal Adelaide Hospital to examine the question also, thereby enhancing the deliberative process. We analysed data on presentations of overdose on heroin to the Royal Adelaide Hospital.
George T
Depression in Pregnancy
Clinical Associate Professor, The Prince Charles Hospital, Brisbane, Queensland
Pregnancy has long been regarded as offering a degree of protection against the onset of Depression. However, recent data would appear to indicate that this is no longer as true as it was once thought.
Uncertainty regarding the differential risks posed by those women with a unipolar and bipolar illness adds to the complexity of this question. The issue assumes considerable importance in the management of those women with a prior history of these disorders during pregnancy.
This paper will briefly discuss the emerging data on this topic.
Gershevitch C
Transcultural Mental Health – the Commonweatlh Department of Health and Aged Care's Contribution to Facilitating New Partnerships
Partnerships in Service Reform Section, Mental Health & Special Programs Branch; Commonwealth Department of Health & Aged Care, Canberra
With the endorsement by all Australian Health Ministers in 1992 of the National Mental Health Strategy (NMHS), the Commonwealth, for the first time, became an active participant in the mental health sector in Australia. Under the Strategy State and Territory Governments they retain responsibility for mental health legislation, planning and delivering services, and various health, allied and specialised mental health practitioners in delivering quality care. The Commonwealth has undertaken a national leadership, co-ordination and facilitation role supporting information sharing, targeted research and project activities.
The Commonwealth Department, as a centralised agency with portfolio responsibility spanning the entire health sector, is also in an excellent position to assist mental health service providers and planners to develop more effective partnerships with their colleagues working generally in health and allied industries.
In this session you will hear about a range of Commonwealth initiatives, which have also been identified as significant themes in the conference program, as well as a brief summary of the NMHS and related national initiatives. This presentation will be an overview of interest to anybody who wishes to know how the Commonwealth is currently contributing to:
transcultural mental health (in particular, the activities of the NMHS-funded Australian Transcultural Mental Health Network),
suicide prevention in culturally and linguistically diverse populations (a report on the Commonwealth sponsored transcultural suicide prevention conference held in Sydney in March 2000),
how the National Mental Health Promotion and Prevention Action Plan, the Depression Action Plan, and National Suicide Prevention Strategy will support national activities in transcultural mental health, and
comorbidity in mental illness and substance use (a report on the national comorbidity workshop convened by the Commonwealth and held in Canberra in March 2000).
Information will also be provided on recently completed crisis intervention and forensic reports, on the mental health National Indigenous Strategy, primary care psychiatry and consumer/carer participation in policy development at the Commonwealth level.
Gill S
Mortality with Electroconvulsive Therapy in Medically Unwell Patients –Three Case Reports
Royal Adelaide Hospital, Adelaide, South Australia
Gillett G (Debate facilitator), Mason C, Hay P (Chairs)
Ethics Hypothetical: A Dilemma in Medical Research
Professor Gillett is Professor of Medical Ethics at the University of Otago and has special interests in euthanasia and discontinuation of treatment; foundations of medical ethics; philosophical and ethical aspects of psychiatry and post-modern bioethics. He is from The Bioethics Centre which was established at the University in 1988. Which is New Zealand's only centre for healthcare ethics. Panel members for the hypothetical debate will include Professor Sidney Bloch, who has a distinguished background in the area of psychiatric ethics; Dr Annette Braunack-Mayer from the Department of Public Health (University of Adelaide) who teaches ethics to undergraduates;, Dr Paul Brown with an interest in ethics and psychological trauma, and the ethics of drug treatment in psychiatry; Dr Anne Hall who has a longstanding interest in philosophy and ethics and is a past member (1992–1997) of the Professional Practices Committee of the R.A.N.Z.C.P.; Dr Michael James who has a background in clinical science and is current Chair of the Royal Adelaide Hospital Research Ethics Committee; Mr Bernard McCair who is the immediate past president of the Schizophrenia Fellowship and Operations Manager for the Uniting Church Wesley Mental Health Services; Cheryl McDonald from the Medical Defence Association of South Australia and Dr Richenda Webb who brings a perspective from Medical Administration (currently at The Modbury Hospital). Expect to hear lively and thought-provoking debate!
Groom G, Young L
The National Primary Mental Health Care Initiative: Building Partnerships between General Practice and Psychiatry Services
This paper describes the National Primary Mental Health Care Initiative. The initiative is the result of comprehensive research activity identified in the Primary Care Psychiatry Report: The Last Frontier (1997) and followed consultations with stakeholders which confirmed the key role of General Practitioners (GPs) in Primary Mental Health Care (PMHC) and the need for partnerships between general practitioners and specialist mental health service providers. In responding to this research and subsequent planning forums, the Commonwealth Minister for Health, Dr Michael Wooldridge, in March 1999, approved $3m for a National Mental Health Strategy initiative to provide GPs with education in PMHC and better link GPs with specialist mental health services – public, private and non-government.
The PMHC initiative is multi-dimensional and includes:
a National Reference Group;
a national education clearing house on mental health and primary care,
the placement of Mental Health Development & Liaison Officers (DLOs) in all State Based Organisations (SBOs) of divisions of general practice from July 1999 to June 2001;
$2m “incentive” funding for divisions on a State/Territory pro rata basis from July 1999 to June 2001; and
Identified Coordinators in all State & Territory Mental Health Units,
The National Reference Group is comprised of representatives of all major provider, consumer and carer stakeholders, including GP's, public and private psychiatry services, consumers and carers. It oversees the development of the initiative and related primary care activities.
The National Education Clearing House, the Primary mental health care Australian Resource Centre (PARC) is located with the National Information Service of the General Practice Evaluation Program, Hinders University. PARC have developed a database and information service accessible through a specific World Wide Web site. The Department's State and Territory Offices coordinate the education incentive funding and the funding for the DLOs. The DLOs assist divisions of general practice and their GPs to access information on PMHC, progress mental health initiatives and better link them with specialist mental health services. The PMHC incentive funding is in addition to divisions’ outcomes based block grants through the General Practice Strategy, and in addition to funding from other sources. Priority is being given to demonstrated good practice models, shared care, high priority clinical areas, communication & diagnostic skills training, and inter-divisional and state-wide projects.
Coordinators have been identified in all State and Territory Mental Health Units to progress the initiative with some states contributing substantial funding to improving primary mental health care.
Hafner R J
Consultation-Liaison Psychiatry: An Analysis of 12 Months Work within 3 Different Group General Practices
Psychiatrist in Private Practice, Kensington Park, South Australia
Hall A
‘Bush Psychiatry’ in Westland New Zealand
Seaview Hospital (Coast Health Care), Hokitika, Westland, New Zealand
The West Coast is a coastal strip 650 kilometres long with a scattered total population of 33,000. It is separated by a high mountain pass from the nearest city (Christchurch) which is over three hours drive away. It is a very beautiful place with wild beaches, huge rivers, lakes and glaciers, forests and the high Southern Alps on the skyline. Traffic is minimal.
There used to be just one psychiatrist, two when I arrived. There are now two full-time (Foreign Medical Graduates) and two New Zealand psychiatrists doing four tenths each. There is an inpatient ward and Community Mental Health Centres in two small towns staffed mainly be nurses. Domiciliary psychiatric nurses visits all areas monthly.
Seven years experiences as a bush psychiatrist after a mainly academic career proves that one needs to be a better psychiatrist than city colleagues. Everything has to be dealt with – patients can't be ‘Handed on’ and neither can they be ignored.
Problems common to all isolated areas are the on call duties, the sheer distances and lack of public transport, the low socioeconomic status of the population, and difficulties with recruitment and CME. Positives are the clinical challenges, the great people and spirit in the community and the best nursing staff I have ever worked with.
Examples of clinical challenges include: four men presenting with depression related to being undiscovered paedophiliacs; intractable depression in a man living four hours drive away with only a district general nurse available; foreign tourists (non English speaking) presenting with acute relapse of psychotic illness; an 86 year old with organic psychosis and inadequate medical investigations available; and a number of highly visible duat diagnosis patients (Alcohol and drug abuse and psychosis).
CME: This is from journals, audio-digest tapes, the internet, telemedicine, peer review groups by telephone and videoconference, and use of locum psychiatrists as peer review.
Recruitment problems arise as with all rural doctors and other professionals, because of the challenge of the work, the professional and cultural isolation and children's schooling.
Harley J (Chair)
The Management of Violent Brain Injured Persons
Public Advocate, South Australia
This session looks into the difficulties surrounding the management of persons who have a brain injury and are itinerant and/or violent and do not fit easily within the various legislative requirements which set the parameters for treatment and care of the mentally disabled.
Harrison J
Poetry Café
Alfred Hospital, Child and Adolescent Mental Health, Melbourne, Victoria
Open readings of poetry in a congenial cafe environment. The reading may comprise the reader's own work or a favourite poet's. Visiting poets: Lisa Bellear, Dr Craig Powell, Dorothy Porter and Dr Peter Goldsworthy will feature, each reading for 10 minutes. Others are requested to read to a time-limit of 5 minutes each. Dr Jennifer Harrison will MC the event.
Harrison J
Poetry Symposium
Alfred Hospital, Child and Adolescent Mental Health, Melbourne, Victoria
What A Piece Of Work. Looking at poetry and its relationship to emotion, memory and psychiatry will be Dr Craig Powell, Lisa Bellear, and Dorothy Porter and Dr Jennifer Harrison as participating chair. Each participant will present a 15 minute paper. There will be 30 minutes at the end of the session for questions and discussion. The title of the session takes its name from Dorothy Porter's recently published verse novel.
Hatcher S
Using Email with Patients: Problems and Opportunities
Waitemata Health, Liaison Psychiatry, North Shore Hospital, Takapuna, New Zealand
The objective of this workshop is to discuss psychiatrists’ experiences of using email with patients; to highlight potential problems and opportunities, and to discuss whether the College should produce guidelines on this issue and if so what they should be. Particular problems could include breaching boundaries in psychotherapy and loss of confidentiality. Opportunities involve more convenient communication with patients and the potential for a different form of dialogue with email. The literature on this topic will be reviewed to assess its relevance to Australasian psychiatry.
Hawker F
Bush Psychiatry Symposium
Director Telemedicine, Director Clinical Service Development and Support, Rural and Remote Mental Health Services of South Australia, Glenside Hospital, Eastwood, South Australia
To practise psychiatry in rural and remote regions takes guts, tenacity and ingenuity, as well as a love of the bush and/or wide open spaces. The psychiatrist living and working in a rural and remote community, is confronted with special issues regarding small communities and the difficulties faced in obtaining and providing collegial support and ongoing professional development.
Every survey looking at health issues in rural and remote regions, lists inadequate Mental Health Services as a priority State and Federal Governments have been working hard to develop incentive packages to attract and retain health care providers into rural regions, but there has been little or no attempt to address the disincentives for psychiatrists to live and work in the country. Despite the disincentives, there are a number of our colleagues who do choose the challenge and adventure of working in ‘the bush'.
This symposium will present a unique opportunity to hear some of the personal views and experiences of psychiatrists who live and work in rural and remote communities. New Zealand and every State of Australia will be represented. Videoconferencing will be used throughout the sessions, to link up with Broome WA, to enable the Broome psychiatrists to participate and present within the symposium.
These personal ‘snapshots’ of Bush Psychiatry will be set in the context of an initial overview of Rural and Remote Psychiatry and presentations of different models of clinical service delivery from otherwise city based psychiatrists.
The Symposium concludes with a presentation and panel discussion to challenge the College and Fellows, to more actively recognise and address the strengths and the needs of Bush Psychiatry.
Hay P
Book Club: The Surgeon of Crowthorne
University of Adelaide, Department of Psychiatry, Adelaide, South Australia
If you haven't read ‘The Surgeon of Crowthorne’ by now, it is time to do so! Subtitled A Tale of Murder, Madness and the Love of Words, it is a fascinating account of Dr W.C. Minor, a surgeon in the American Civil War who developed a major mental illness, and later went on to make an extraordinary contribution to the development of the Oxford English Dictionary. This was done from his confinement in Broadmoor as Patient ‘Number 742'.
The book raises many questions: forensic, clinical, biographical and literary. As one reviewer, Christopher Hart, wrote: ‘Simon Winchester … has dug up a strange and extraordinary life story and turned it into a compelling piece of historical detective work. He never really penetrates into the central mystery of Minor's madness, because no-one can. The mystery remains, inviolable, and makes his tale all the more darkly compelling.’
The Book Club will be based in the ambience of The Village Green. There will be a short introduction to Simon Winchester, and the background to the writing of the book, followed by an open discussion.
Hay P J
Eating Disorders through History: Time for a Change in Perspective?
University of Adelaide, Department of Psychiatry, Adelaide, South Australia
There has been a rise in the incidence of eating disorders over this century, with their concomitant “establishment” in psychiatry nosology. This paper presents some facets of the historical and cultural background to this increase, with an argument for a shift in emphasis from histories of anorexia nervosa or bulimia nervosa, into histories of broader issues of psychological and physiological vulnerability factors for these disorders.
The paper first summarises the separate histories of anorexia nervosa and bulimia nervosa as currently defined in psychiatric nosology, and second discusses their distribution and determinants over time, and space. Third is presented the argument, namely instead of looking for forms of “eating disorders” in historic medical papers, to look for patterns over time in the ways young men and women resolve psychological conflict, at factors that protect them from self-imposed dietary restraint and at issues important in maintaining and promoting self-esteem and self-worth.
Hay P, Kent J
Noel Coward: View from a Psychiatrist's “Chair”
The University of Adelaide, Department of Psychiatry, Adelaide, South Australia
Noel Coward (1899–1973) was born in the twilight years of the Victorian era, and lived through some of the most tumultuous years in English history. A gifted actor, playwright, and composer his first professional appearance was at the age of 12. As he wrote: “… a little advertisement appeared in the Daily Mirror. Mother read it aloud to me while I was having breakfast. It stated that a talented boy of attractive appearance was required to appear in a production of an all-children fairy play. This seemed to dispose of all argument. I was a talented boy, God knows, and, when washed and smarmed down a bit, passably attractive.” (Present Indicative, 1937: Part 1) In this session a personal history of Coward will be viewed from an analytical perspective, drawing from his two autobiographies, Present Indicative (dedicated “to my mother”; 1937) and Future Indefinite (1954), and other biographical material. The presentation will include review of his “brief and inglorious” army service, maternal and other personal relationships, development of his literary career, and struggles with his perceived media image as a “talented, neurotic, sophisticated playboy”.
Hay P J, Marley J, Lemar S
Ethical Issues in Psychiatric Surveys
The University of Adelaide, Department of Psychiatry, Adelaide, South Australia
All respondents provided a reason for participation, 37 (51%) a single reason, 34 (47%) two reasons and two three reasons. The commonest reason was a general altruism, namely to help the survey, or to help people with eating disorders, or the like (n = 48, 64%). The next most common was to obtain some help for themselves (n = 25, 34%). Seven (all who had been selected randomly for interview) participated in order to specifically help someone they knew with an eating disorder. Seventeen participated out of general interest in the subject and one because she “didn't like to say no”.
All of the 45 (62%) respondents who returned the questionnaire confirmed that the information they were told about the study reflected what they were asked to do. Thirty-five (48%) did not think the study made any difference to the way they felt about themselves or their life in general, 10 (14%) felt better, and no-one felt worse. Only 13 (18%) reported that the survey had changed their eating habits.
Hazell P
Melancholia and Music (Workshop)
Director, Child and Youth Mental Health Service, Wallsend, New South Wales
Philip Hazell (Violin)
Discipline of Psychiatry, Faculty of Medicine and Health Sciences, University of Newcastle, Callaghan, NSW
Andrew Bisits (Violin)
Discipline of Reproductive Medicine, Faculty of Medicine and Health Sciences, University of Newcastle, NSW
Carolyn Hackworthy (Viola)
General Practitioner, Nelson Bay, NSW
Murray Webber (Cello)
John Hunter Children's Hospital, Newcastle, NSW
Why do major chords sound happy and minor chords sound sad? How does music take on emotional meaning? These and other questions will be answered by the presenters using live and recorded music examples as they explore the mechanisms by which music can invoke a melancholic mood. Featured in the presentation will be live performances of Beethoven's String Quartet Op 18, No 6, 4th movement (“La Melanconia”), Smetana's String Quartet in E minor (“From My Life”), 3rd movement and Barber's Adagio for Strings. The performers are the Dead Nigels (String Quartet), a Newcastle based ensemble who support their musical habit through the practice of medicine.
Hecker J
Alzheimer's Disease: To Treat or not to Treat
Memory Disorders Unit, Repatriation General Hospital, Daw Park, South Australia
Development of the first antidementia therapies over the last 10 years has been based on the predominant cholinergic neurotransmitter deficit in Alzheimer's disease. Two cholinesterase inhibitors are currently marketed in Australia for treatment of mild-moderate Alzheimer's disease. Donepezil (Aricept) is a significant advance on the first drug of its class, tacrine (Cognex) because of improved gastro-intestinal tolerance, lack of hepatotoxicity and a single daily dosing regime. Growing evidence from clinical trials with cholinesterase inhibitors support positive outcomes in cognition, functional activities and behavioural and neuropsychiatric symptoms in Alzheimer's disease. The effect of these drugs in vascular dementia and diffuse Lewy body disease is under investigation.
A number of other agents are currently under study for a potential role in the prevention or treatment of Alzheimer's disease. These include the muscarinic agonists, anti-oxidants (including Vitamin E), non-steroidal anti-inflammatory drugs, oestrogen, metabolic enhancers and nerve growth factors. Pre-clinical development is directed towards genetic manipulation of known risk factors or prevention of beta amyloid and tau deposition. From a practical viewpoint, national guidelines for antidementia therapy are currently being developed by representatives of the Faculty of Psychiatry of Old Age, the Society for Geriatric Medicine and the Association of Neurology.
Henderson A S
Australia's National Mental Health Strategy
Centre for Mental Health Research, The Australian National University, Canberra
Herriot PM, Blessing WW, Battersby MW
Measurement of Cutaneous Vasomotor Responses by Laser Doppler Flowmetry
Herrman H, Tanaghow A, Cameron C, Adams N, Mitchell K, Olivieri R
Consumer Participation – a Joint Project Examining Parental Views of the Effects of Their Illness/Hospitalisation on Their Children
Kalucy R, Thomas L, Parry T, Haynes C, Smith A
Department of Psychiatry, Flinders Medical Centre, South Australia
The first author has a small Consumer Advisory Group which meets every one to two months over a period of eighteen months. Early on in these meetings the consumers advised that a major concern for them was the wellbeing of their children while they were actively ill or acutely ill or when they were hospitalised. The first author and the consumers applied for funding for a family impact study examining this issue.
Only 40% of consumers who were approached to take part in the study agreed to take part and a number of these who did take part did not agree to be interviewed but filled out the survey form anonymously.
The findings included,
A great degree of severity of “domestic” disability, especially in the first one to two months after hospitalisation.
A great deal of suspiciousness about the purpose of the project.
A strong tendency towards denial of difficulties.
Different responses according to the degree of wellness of the consumer.
A strong tendency to not discuss their illnesses with their family or within the family.
Herrman H, Tanaghow A, Cameron C, Adams N, Mitchell K, Olivieri R
Services in Two Cities: Homeless People Living with Mental Illness
Professor, Director of Psychiatry, St Vincent's Mental Health Service, Fitzroy, Victoria
The workshop will present for discussion the work of mental health service teams in Melbourne and Adelaide established in response to the situation of homeless people living with mental illness. The services and teams in these two cities have distinctive and shared features. The workshop will encourage discussion among the presenters and with the audience after a number of brief presentations highlighting the themes of teamwork in this setting, service links, consultation and liaison, and engagement of the clientele.
The multi-disciplinary panel will provide an overview of
the need for services among homeless people with mental illness;
a description of the service systems in Melbourne and Adelaide;
the characteristics of the work of the teams, including the salience of the links with accommodation and social services, primary and general health services, the wider mental health service, drug and alcohol services and other government and non-government services;
the lessons and challenges of engaging clients.
The presenters will welcome the comments of people working in similar services in other cities, and hope to discern the value of teamwork and the perspectives of different disciplines and service sectors in a combined approach to this challenging area,
Hewland R
Towards Shared Care of Mental Health Services — on the Sunshine Coast in South-East Queensland
Coastal Community Mental Health Team, Sunshine Coast District Health Services, Queensland
Hopwood M, Morris P L P, Debenham P, Bonwick R, Parkin I, Ignatiadis S, Norman T, Burrows G D
An Open Label Trial of Venlafaxine in War Veterans with Chronic Post Traumatic Stress Disorder
Veterans Psychiatry Unit, Austin and Repatriation Medical Centre; Department of Psychiatry, University of Melbourne, Victoria
Efficacy was monitored by utilising the Clinic Global Impression (CGI), the Montgomery and Asberg Depression Rating Scale (MADRS) and the Impact of Event Scale (IES).
Hundertmark J, Brayley J, Gill S
Interactive Discussion of Consultation Liaison Cases
Department of Psychiatry, Flinders Medical Centre, Bedford Park, South Australia
Three case vignettes will be discussed using XTOL interactive voting technology. Each audience member will have a key pad which allows them to vote on management options as the case unfolds. The first case will be one of a man with alcoholic cirrhosis presenting for liver transplantation. The second case is of a young man who presents with multiple psychiatric problems following severe traumatic brain injury. The third case involves a man with tetraplegia admitted to a spinal injuries unit who in spite of his paralysis becomes dangerous to staff.
Ilchef R, Wright M, Lonie C
Correlates of Psychiatric Morbidity in Acute Spinal Cord Injury
Royal North Shore Hospital, NSW
Jablensky A
What Has Epidemiology Taught Us about the Nature of Schizophrenia?
University Department of Psychiatry, University of Western Australia
I will attempt to give my reading of the main contributions of epidemiology, globally, to a slowly emerging, multifactorial understanding of this puzzling and distressing disorder. I will also refer to my own research, conducted previously within the WHO framework and currently in Australia.
Jablensky A, McGrath J, Herrman H, Castle D, Gureje O, Carr V, Morgan V, Korten A, Harvey C
Psychotic Disorders in Urban Australia: A National Study 1996–1998
University Department of Psychiatry, University of Western Australia
Jager A D
Development of a Forensic Psychiatric Service in Tasmania
Senior Lecturer in Forensic Psychiatry, University of Tasmania, Tasmania
The proposed service will include provision of psychiatric care to individuals with mental disorders who have a current involvement with the criminal justice system, both in prison and in the community, treatment of sex offenders and court liaison services. The planning process has become the focus of intense scrutiny following events in the last 3 years, in which Risdon Prison has seen a rash of ear amputations (8 individuals in an 18 month period) followed by 4 apparent suicides in a 5 month period. These events provided the catalyst for an Ombudsman's enquiry into Risdon Prison. Its findings and recommendations are expected in the first half of 2000.
James J E
Selected Psychological and Emotional Effects of Life-Long Consumption of Caffeine
National University of Ireland, Galway, Ireland
The main mechanism of action of caffeine is well established as being antagonism of endogenous adenosine. However, despite being the most widely consumed psychoactive substances in the world, there is considerable confusion regarding the effects of caffeine. Contrary to sanguine attitudes of the past, there is increasing evidence that life-long consumption of caffeine (as contained in coffee, tea and some soft drinks) is potentially harmful to health. In particular, habitual use of caffeine is a likely cardiovascular risk factor, and the drug may retard intrauterine fetal growth when consumed during pregnancy. In addition, caffeine interacts adversely with some therapeutic drugs, and may contribute to the development of osteoporosis by stimulating elimination of calcium. When faced with evidence of harmful effects, caffeine consumers (and producers of caffeine products) tend to reason that the risks are acceptable in light of perceived benefits. In particular, caffeine is widely believed to contribute to improved psychomotor and cognitive performance. However, empirical evidence of such benefits is far from consistent. Moreover, we have shown that many previous empirical reports of positive effects share a serious methodological flaw. Recent empirical studies conducted independently by ourselves and others cast doubt on whether caffeine enhances human performance. In this paper, evidence will be presented based on objective indices of performance, and self-reported mood, headache, and sleep in healthy male and female participants in double-blind placebo controlled trials. We found no evidence that caffeine improved performance under controlled conditions. On the contrary, performance was found to be significantly impaired following overnight caffeine abstinence. With regard to subjective effects, participants reported feeling more alert and less tired (not associated with improvements in objective performance, immediately after ingesting caffeine, and increased frequency and severity of headaches during periods of short-term withdrawal. If caffeine does have any beneficial effects on performance, these probably occur indirectly. Caffeine produces delay in sleep onset, thereby possibly improving performance temporarily in persons whose performance is degraded by fatigue. In general, however, it appears that caffeine ingestion restores (to normal levels) performance which has been degraded by brief periods of caffeine withdrawal. This is, the consumer's impression that caffeine produces absolute improvements in performance is actually illusory, and a symptom of caffeine dependence.
Janakiramaiah N, Gangadhar B N, Vedamurthachar
Enhancing Wellbeing through Yoga: A Potential Strategy for Positive Mental Health
Department of Psychiatry, National Institute for Mental Health and Neurosciences, Bangalore
Traditional methods for life-style change, in particular yoga and meditation, are noted Sudarshan Kriya, a technique of yogic rhythms of breathing, developed by Pundit Ravishankar was evaluated for its effect on wellbeing.
500 participants, apparently normal, who took a basic course of Sudarshan Kriya were admitted Mental Health Inventory (MHI) before, at one month and at two months. Significant enhancement of wellbeing factor scores occurred suggesting the potential induction of positive mental health in these participants.
Janca A
Diagnosis, Assessment and Prevalence of Somatoform Disorders across Cultures and Settings
Department of Psychiatry and Behavioural Science, University of Western Australia
Several years ago, the World Health Organisation (WHO) launched an international study of somatoform disorders with the following objectives: 1 To explore cross-cultural applicability of ICD 10 and DSM-IV diagnostic criteria for somatoform disorders; 2. To develop ICD-10 and DSM IV based diagnostic instruments for the assessment of somatoform disorders and test their psychometric properties in different cultures and settings; and 3. To assess prevalence rates and culture-specific characteristics of somatoform disorders in different parts of the world.
The methods used in this WHO project included. 1. An expert review of the literature on somatization; 2. A mail questionnaire survey of opinion leaders in the areas of psychiatric nosology, cross-cultural psychiatry and somatization; 3. Development of somatoform disorders assessment instruments including Somato form Disorders Schedule, Somatoform Disorders Checklist and Somatoform Disorders Screener; 4. Organisation of an international field trial of these diagnostic instruments; and 5. An epidemiological survey of somatoform disorders in the following countries: Brazil, Bulgaria, China, Estonia, Germany, India, Italy, Japan, UK, USA and Zimbabwe.
The results of this WHO project showed the following: 1. The ICD-10 and DSM-IV diagnostic concepts of somatoform disorders are generally applicable for use across cultures, provided that their users in particular settings pay attention to a number of culture-specific symptoms of somatoform disorders, which do not appear in these diagnostic systems; 2. WHO instruments for the assessment of somatoform disorders are cross culturally appropriate and reliable diagnostic tools that can be administered by non-clinician interviewers without compromising the ability to document the prevalence of somatoform disorders; 3. The most frequently seen and the most indicative symptoms of somatoform disorders in different parts of the world are multiple pains and aches; and 4. Somatization as phenomenon is present in all the cultures, but prevalence rates of specific ICD-10 and DSM-IV diagnostic categories of somatoform disorders vary substantially across cultures and settings.
Johnson G
Diagnostic Dilemmas
Department of Psychiatry, University of Sydney, New South Wales
The major operational criteria for the diagnosis of Bipolar I Disorder is an episode of mania. However, in the majority of patients the onset episode is one of depression and many patients are initially diagnosed and treated as major depression. 80% of patients with an onset of depression change polarity at the second or third episode of illness and within five years of onset to become bipolar (1). Early age onset, family history of bipolar disorder and clinical features such as psychomotor retardation have been reported to distinguish bipolar from unipolar depressive disorder. In adolescence the onset episode of mania may be associated with psychotic features and may be initially misdiagnosed as schizophrenia (2). Diagnosis of Bipolar II Disorder may depend on historical evidence where observable changes in behaviour and duration of symptoms may be insufficient for a diagnosis of hypo-mania. Switch into hypomania associated with antidepressant treatment has been reported more commonly in bipolar than in unipolar patients and may represent a spontaneous event indicative of bipolarity (2). A recent clinical review utilising DSM IV criteria in inpatients reported 42% of bipolar patients carried other diagnoses prior to admission, mainly unipolar disorder. Mood stabilisers were under-utilised and antidepressants over-utilised (4). Bipolar Disorder is characterised by high frequency of episodes and rapid cycling may occur in 5–15% of patients. Co-morbidity with anxiety disorders, substance abuse/dependence and personality disorders may confound diagnosis. Case histories illustrating diagnostic dilemmas will be presented.
References:
1. Johnson G, Hunt G. (1979) Australian and New Zealand Journal of Psychiatry 13:57–63.
2. Bashir M, Russell J, Johnson G. (1987) Australian and New Zealand Journal of Psychiatry 21: 36–46.
3. Peet M. (1994) British Journal of Psychiatry 164: 549.
4. Ghaemi et al (1997) Psychopharmacology Bulletin 33: 527.
Jolly D, Hay P
Anorexia Nervosa and Coprophagia
Psychiatry Registrar, Royal Adelaide Hospital, Adelaide, South Australia
The case report describes a 16 year old girl, admitted to hospital for management of severe anorexia nervosa, who developed coprophagia. The case will be discussed with reference to the unusual presentation of coprophagia, and later development of psychosis.
She made good medium term progress but has been re-admitted three years later with a psychosis.
Jones B L
Access Canterbury – a Mental Health/General Practice Integration Initiative
Access Canterbury was established in Christchurch by the formation of a partnership between the Health Funding Authority, Pegasus Medical Group (an Independent Practice Association) and the Mental Health Division of Healthlink South.
This talk describes the process by which Access Canterbury examined in detail the problems at the Mental Health/General Practice interface, General Practice education, and shared care. Special attention has been paid to Maori health care, transitions in care, referral and discharge, and communications.
Recommendations from the project teams were finalised in December 1999 after three months of frequent meetings. A large meeting of all participants in the project teams discussed the recommendations in detail early in 2000 and new teams were formed to begin the phase of activation. The chosen projects and progress to date are described.
Differences between Australia and New Zealand General Practice funding and the limited availability of psychiatrists are outlined to demonstrate the need for modification of overseas integration models.
Jurd S, Latt N, Wutzke S
Naltrexone in the Treatment of Alcohol Dependence
Royal North Shore Hospital, St Leonards, New South Wales
At least six different research groups have shown naltrexone to be superior to placebo in the treatment of alcohol dependence when combined with standardised psychosocial interventions. The effects have been noted to be clinically as well as statistically significant. The transfer of that data set to the average clinic or office setting is a substantial step. Our group undertook a study which attempted to answer the question of whether the addition of naltrexone (compared to placebo) added value to standard outpatient care. Subjects were advised to seek counselling, attend AA, and sometimes took other medications, thus simulating a situation much more like standard practice.
We recruited 105 male and female subjects, and randomly assigned them to naltrexone or placebo in a double blind design for the first three months and then all subjects took naltrexone from months 3 to 6. Psychosis, but not depression was an exclusion criterion, as was overt alcohol related brain damage. Subjects were reviewed at regular intervals by one of us (mostly NL) and seemed to gain much from this support (from early results of our compliance survey). Results will be presented as time to relapse, changes in craving scale scores, retention in treatment and effects on liver function tests. Clinical experience gained during the study was invaluable in developing effective use of this medicine, and reinforced the impression that there is a clinically significant effect.
Jureidini J
What is in An Unconscious?
Department of Psychological Medicine, Women's & Children's Hospital, Adelaide, South Australia
Cognitive scientists are inclined to dismiss psychoanalytic ideas when they prove to be deficient in the light of current knowledge. Yet connectionist accounts of consciousness, such as the one offered by Dr O'Brien offer an exciting opportunity to expand and refine psychoanalytic concepts such as the unconscious and repression. I will show that whilst some other psychoanalytic concepts are simply wrong, the central importance of unconscious life is supported by current cognitive science.
Kalucy R
Some Necessary Conditions for a Successful Research Endeavour with Indigenous People – the Development of a “Public Good” Collaborative Research Centre in Aboriginal Health
Department of Psychiatry, Flinders Medical Centre, South Australia
This paper describes an eighteen year process of attempting to get good and effective health research programs for Indigenous peoples that were acceptable to Indigenous communities (urban or rural and remote). The paper describes the role of the NH&MRC in the 80s leading eventually to an attempt to form a collaborative research centre in about 1986. This and a subsequent attempt in the early 90s both failed. A third attempt in 95/96 eventually succeeded and over the past two years the CRC has gradually developed into a vigorous and effective organisation.
Amongst the turning points that eventually lead to this success, were,
The acceptance that the Board of the CRC would have to have an Indigenous person as their Chair.
That the Board would have to have a majority of Indigenous people as members.
That the research appraisal process was very fairly seen to be the Board's responsibility.
That the ethics appraisal process was very firmly seen to be the Board's responsibility.
An explicit and shared appreciation of the problems and responsibilities of Board members was fundamental. 6. The development of a rational outcome based health research policy was critical.
The author, who is the actual Visitor to the CRC, has received permission from the Chairperson of the Board (Lowitja O'Donohue) to describe the unfolding of these developments. There is much, I think, to be learnt which could be applied in other situations where grave mistrust often exists between research workers and Indigenous peoples.
Kalucy R
The Australian Medical Workforce Advisory Committee – Review of the Psychiatric Workforce
Department of Psychiatry, Flinders Medical Centre, South Australia
The Australian Medical Workforce Advisory Committee (AMWAC) is a committee of the Australian Health Minister's Advisory Committee (AHMAC).
Australian government policy aims at ensuring equitable access for Australians to good medical care. Within this context AMWAC systematically assess the adequacy of the workforce for all medical specialities. Psychiatry was reviewed in 1999. The author was the Chairman of the Review Committee.
All Psychiatrists working in Australia were sent a survey and just over 60% replied. General practitioners and consumers were also surveyed and interviewed. Experts in various aspects of psychiatry were consulted with the particular aim of exploring future trends and their impact on the workforce.
The main findings were,
That by the Year 2004 there would be a deficiency in psychiatrists (as expressed per 10,000 of the population) if there wasn't a small rise in training posts.
Nonetheless, the absolute number of psychiatrists per capita in Australia is higher than that recommended by the World Health Organisation.
There was a very marked maldistribution of psychiatrists so that the outer suburbs of large cities and the rural and remote sector were grossly under-serviced.
Access to psychiatric opinion was assessed by general practitioners as being very inadequate as it was by consumers. The psychiatrist estimates of waiting times was an average of 35 days for an ordinary new appointment and seven days for an emergency appointment.
Data was presented which suggested that psychiatrists on average see a new patient seven or more times whereas as a consultant physician sees a new patient twice in the year following their referral.
Estimates for the needs of sub-specialties could not be made but it is clear that there could be major problems in the future, perhaps particularly in areas such as intellectual handicap.
Eighteen recommendations were made and the findings and the recommendations will be discussed at the presentation.
Kalucy R (Chair)
Video Conferencing, Its Use for Treatment and by Tribunals
Senior Clinical Director of Division of Mental Health
This session will examine the feasibility and effectiveness of the use of video equipment in the provisions of the psychiatric services in remote areas. As well as examine the effectiveness of a video conferencing system as used by the various Mental Health Tribunals throughout Australia.
Kalucy R, Thomas L, Parry T, Haynes C, Smith A
Consumer Participation – a Joint Project Examining Parental Views of the Effects of Their Illness/Hospitalisation on Their Children.
Department of Psychiatry, Flinders Medical Centre, South Australia
The first author has a small Consumer Advisory Group which meets every one to two months over a period of eighteen months. Early on in these meetings the consumers advised that a major concern for them was the wellbeing of their children while they were actively ill or acutely ill or when they were hospitalised. The first author and the consumers applied for funding for a family impact study examining this issue.
Only 40% of consumers who were approached to take part in the study agreed to take part and a number of these who did take part did not agree to be interviewed but filled out the survey form anonymously.
The findings included,
A great degree of severity of “domestic” disability, especially in the first one to two months after hospitalisation.
A great deal of suspiciousness about the purpose of the project.
A strong tendency towards denial of difficulties.
Different responses according to the degree of wellness of the consumer.
A strong tendency to not discuss their illnesses with their family or within the family.
Mental health workers had very limited contact with the children of these consumers.
Families who have another parent or other good support, such as grandparents, suffered less negative impact than those without that support.
These findings and the issues associated with having consumers as co-investigators will be discussed.
Keller A, Sara G
“Access – a New Service Delivery Model for Mental Health Triage and Assessment”
Division of Mental Health, Sutherland Hospital, NSW
In integrated mental health services, the function of triage has traditionally been an auxiliary role, performed occasionally by clinicians with another primary role (e.g. Case Management). This can lead to clinicians inexperienced in mental health triage making idiosyncratic decisions about the service response, often based on the presumed diagnosis rather than risk and disability issues. Likewise, the task of performing new assessments has often been delegated to a disparate group of clinicians, working in different parts of the service and not approaching the assessment task with a common method or purpose.
Consumers frequently complain that mental health services are difficult to access and not tailored to their specific needs. Primary care practitioners mention that they have considerable difficulty in getting their patients seen, and when they are eventually seen they receive little or no information about the outcome of the assessment. Recently, some services have attempted to assign the twin tasks of triage and assessment to an independent team, created for this specific purpose. However, the capacity of such teams to function effectively can be compromised if the service requires it to take on other roles, such as crisis intervention or short term case management.
This paper describes the process of developing and implementing a new team within a mental health service whose role it is to perform the functions of triage and assessment. The philosophy of the service is to prioritise risk and disability, and place less emphasis on diagnosis, when determining the need to provide assessment and treatment. Allied to this is improving the links with primary care and other external service providers, to ensure that patients receive continuity of care and referral to appropriate services. The paper will also present preliminary data looking at patterns of referral, response times, and assessment outcomes. Comparisons will be made with the previous method of conducting triage and assessment utilised by the service.
Kelly B, Leigh R, Varghese F, Badger S, Pelusi D
Clinical Dilemmas in the Care of Patients with Serious Physical Illness: The Role of the Psychiatrist in End-of-Life Care
Department of Psychiatry, University of Queensland, Queensland
This symposium will review a number of clinical dilemmas commonly faced by psychiatrists working with physically ill patients, with a particular emphasis on end of-life care. This includes the range of psychological factors affecting the appraisal of illness and medical care by patients, their families and those providing their treatment. The symposium will comprise 1) Preliminary findings from a study investigating the clinical factors associated with the wish to hasten death among terminally ill patients, conducted within general hospital and hospice based palliative care services. Data from semi-structured interviews with a sample of 30 patients and 30 of their treating doctors will be presented. 2) Family factors in end-of life care and their relevance to clinical practice and potential psychiatric interventions will be outlined from a critical review of current literature and evidence. Implications for research in this field will be discussed. 3) Case examples illustrating the challenges facing psychiatrists involved in the care of patients with severe physical illness, with particular focus on complex decisionmaking. This will include the impact of recent legislative changes (eg advanced health care directives and living wills). The psychiatric issues are broad and extended beyond the tasks of recog-nition of psychiatric disorder or determination of competence, but include the impact of family factors on end-of-life decisions, and the broad range of psychological and emotional issues for health care staff negotiating these tasks. The themes emerging from this study will be outlined; the importance of the patient's relationship with doctors and the medical environment, their relationship with family and friends, the perceived impact on key areas of the patients life, and factors in their adjustment to illness.
Kenny M, Livingstone A
The Role of Case Conceptualisation in Cognitive Therapy
Director, Cognitive Therapy Unit, Flinders Medical Centre, South Australia
The case conceptualisation in cognitive therapy is a hypothesis about the psychological mechanisms underlying the patient's overt problems. In the cognitive therapy model, this conceptualisation acts as a guide to treatment which also educates and involves the patient.
As well as guiding the choice and timing of interventions, an accurate conceptualisation predicts obstacles in therapy and explains non-compliance. Alternatively, revising the formulation may unblock therapy that is not progressing.
The workshop will teach a methodology for developing case conceptualisations as well as how to match relevant CT interventions to overt problems and underlying mechanisms.
Kent M L, Hartstone M D
Trial of a Structured Cognitive Behaviour Group Therapy Program for Patients with Borderline Personality Disorder
Department of Psychiatry, Woodleigh House, Modbury Hospital, Adelaide, South Australia
To trial a cognitive behavioural group therapy program designed for patients with borderline personality disorder.
To evaluate its appropriateness and suitability for the South Australian public mental health system.
To evaluate outcomes in terms of objective symptom change.
To evaluate patient and group leader satisfaction with the program.
Self report questionnaires assessing symptom severity were administered at the beginning and completion of the group program.
Patients and group leaders were administered a semi-structured interview which provided additional material for qualitative evaluation.
Group sessions were conducted as outlined by Marsha Linehan with emphasis on patient participation, acquisition and reiteration of new skill development and regular reporting of homework achievements.
Kerr R A
Use of Thyroxine to Augment Response in Affective Disorder
Psychiatrist, Private Practice, Queensland
There has been continuing debate over the usefulness of various thyroid hormones in the treatment of Affective Disorders for at least three decades. Recently Goodwin (1998) suggested that raising the free thyroxine level (T4) by supplementation with thyroxine to the upper quarter of the normal range in patients with poorly controlled Bipolar Disorder or refractory Major Depressive Disorder produces marked improvement in 50% or more of these patients. In this study the effectiveness of this manoeuvre and its practicability in clinical practice was investigated.
Over 50 patients in a private practice setting with incompletely controlled Bipolar Disorder, Major Depressive Disorder and fluctuating depression were studied. These include both long term and recent patients and some already taking thyroxine. Thyroid Stimulating Hormone (TSH), Free Thyroxine (T4), and Triiodothyronine (T3) were measured initially and six weeks after each increase in dose of thyroxine. Some patients with constant depression completed depression rating scales. Changes in symptomatology and life style as well as changes in therapy sessions were recorded.
The initial mean free thyroxine level in 57 patients was 12.4 (range 7.8 to 25.7) which is at the lower end of the normal range for this laboratory (normal range 11 to 25). Impressive rates of improvement in energy, thinking, mood, sleep, weight loss, panic symptoms, sexuality and physical symptoms of hypothyroidism will be described as well as free thyroxine levels necessary to produce significant change. In ail cases TSH levels were in the normal range before treatment but suppressed in all patients given thyroxine. Some problems in initiating treatment and determining the appropriate dose of thyroxine will be discussed.
Kirkby K C
Computer and Internet Aids to Treatment of Anxiety Disorders
Department of Psychiatry, University of Tasmania
There is a rising tide of information technology in everyday life, including home computers, Internet and touch phones. A variety of programs for treating anxiety disorders have been evaluated, both in Australasia and overseas. Information sources covering anxiety problems are now available on the Internet and are increasing in number and scope. The results of outcome evaluations on computer-aided programs for’ anxiety disorders is reviewed. This covers a range of delivery methods including desktop and hand held computers, Internet, and Interactive Voice Response (IVR) using touch phones. Most studies show positive treatment effects, though a limited number of studies use standard therapist administered treatments as a comparator. Examples of Internet based material are presented, evaluation studies in this area are in their infancy. A substantial amount of material is already available directly to the interested consumer and is of direct relevance as an ancillary to current clinical practice.
Kirkby K C
The Brain and Mental Illness: Somaticist Perspectives in Early Nineteenth Century German Psychiatry
Department of Psychiatry, University of Tasmania
Two centuries ago as psychiatry emerged as a medical discipline, there was lively debate as to whether abnormalities of the brain, or moral influences were primary causes of psychiatric illness. This debate remains lively today, though nowadays the discussion of moral and theological issues has been substantially displaced by the language of psychology. Key concepts of the Somaticist theories of early nineteenth century German psychiatry are illustrated through the writings of JB Friedreich and contrasted with the Mentalist perspective of JC Heinroth. Friedreich, in the 1820s, held that all mental disease is the direct result of abnormal brain structure. He argued against Heinroth's view that mental disease originates in sin. On close inspection their arguments differ mainly in relation to some key tenets as to whether the soul is immutable and immortal or not. Whilst this may appear banal to a modern secular thinker, this is an early version of debates to the present day about the validity of concepts such as the ‘ghost in the machine’ and ‘emergent phenomena'.
Kirmayer L
Rethinking Psychiatry with Indigenous Peoples
McGill University, Montreal, Canada
Around the world, indigenous peoples have experienced rapid culture change, marginalisation and absorption into a global economy with little regard for their autonomy. Cultural discontinuity has been linked to high rates of depression, alcoholism, suicide, and violence in many communities, with the most dramatic impact on youth.
This paper will explore issues in the mental health of the indigenous peoples of Canada, the First Nations and Inuit, with particular focus on the Inuit and Cree of Quebec. The history of the European colonisation of North America is a harrowing tale of decimation of the indigenous population by infectious disease, warfare, and active suppression of culture and identity that was tantamount to genocide. Economic, political, and religious institutions of the European settlers all contributed to this displacement and oppression.
Over the last century, Canadian government policies including forced sedenterisation, relocation, residential schools, and bureaucratic control resulted in social and psychological devaluation and marginalisation of indigenous populations. This has had complex effects on the structure of indigenous communities and on individual and collective identity. Ongoing transformations of identity and community have led some groups to do well while others face catastrophe. In many cases, the health of the community appears to be linked to the sense of local control and cultural continuity. Recent successes in negotiating land claims and local government, as well as forms of cultural renewal hold out hope for improvements in health status. Attempts to recover power and maintain cultural tradition must contend with the political, economic and cultural realities of consumer capitalism, technocratic control and globalisation. A cultural perspective can contribute to rethinking appropriate forms of mental health services and health promotion that respond to the dilemmas created by this complex history and social context. Cultural psychiatry also provides a critique of the way in which psychiatric theory and practice convey implicit values of the dominant society. Examples from clinical, epidemiological and ethnographic research with the Inuit will illustrate the way in which culture shapes the experience and expression of psychiatric disorders, healing practices and the response to conventional psychiatric services. Research and program development must be fully collaborative through partnerships in which the power and control are largely in the hands of indigenous communities.
A briefer summary would emphasize that we need to rethink the focus of psychiatry if we wish to be of help to indigenous peoples to take into account
community and family rather than predominately individual focus
powerful social and environmental determinants of health
impact of racism and systematic exclusion
differing cultural concepts of the person that center on ecological and spiritual dimensions of the self
need for self-direction and control of services.
The perspectives I will present are based on clinical work and research conducted in collaboration with Quebec's indigenous peoples since 1987. We have an interdisciplinary research team that involves a partnership with First Nations and Inuit organizations. More information can be found at our website.
Kisely S
Implications for Gp Liaison Services of Physical and Psychiatric Co-Morbidity
University of Western Australia
Kisely S, Axten C
Collaboration between General & Old Age Psychiatrists in the Provision of a Consultation-Liaison Service
Fremantle Hospital, Western Australia
Kisely S, Wood A
A Consultation-Liaison Service by Visiting Psychiatrists: Esperance's Experience
University of Western Australia
Koopowitz L F
Development of a Scale to Measure Temporo-Limbic Dysfunction: Preliminary Findings
Department of Psychiatry, University of Adelaide, South Australia
Temporo-limbic dysfunction may be conceptualised as an impairment or vulnerability in certain areas of temporo-limbic circuitry. It may manifest with a characteristic set of symptoms including paroxysmal emotional, mnesic, dissociative, perceptual, and autonomic disturbances. The draft TLD, an instrument developed to identify a full range of clinical phenomena suggestive of temporo-limbic dysfunction, has been used in the clinical setting. The purpose of this paper is to present preliminary data related to its use.
Of 546 attendees to a psychiatric private practice, 128 (23.4%) were found to have experienced significant temporo-limbic occurrences. The most common features were dissociative episodes, dejà vu, premonitions, jamais vu, and fleeting tactile hallucinations.
Three hundred and sixty five of these patients underwent routine scalp electroencephalograph (EEG) recordings. Seventy-six were reported as abnormal, 44 showing focal temporal lobe changes. The mean score on the draft TLD for those with abnormal EEGs was significantly higher than the mean draft TLD score for those with normal EEG recordings (64.5 ± SD38.5 compared to 30.5 ± SD36; p < 0.0001). Of the 106 patients who went on to have an 8-hour ambulatory scalp EEG recording, 58 were reported as abnormal, with 53 displaying temporal lobe changes. Seven out of 27 (25.9%) with no or equivocal evidence of TLD had abnormal ambulatory EEGs, compared to 51 out of 79 (64.5%) who showed significant evidence of TLD. A strong correlation was found between abnormality of routine or ambulatory EEG, and the clinical uncovering of phenomena suggestive of temporo-limbic dysfunction.
Thirty-seven patients who had completed a revised version of the draft TLD underwent single photon emission computerised tomography (SPECT) as part of their clinical work up. In 32 of these patients the revised draft TLD suggested extremely strong evidence of temporo-limbic dysfunction. Of these, 29 (90.6%) were reported to have abnormal SPECT scans, 24 (82.8%) showing perfusion abnormalities in the temporal lobes. Of the five patients who did not score highly on the draft TLD, only one SPECT was reported as being abnormal.
Taken together, these findings demonstrated preliminary clinical evidence that features suggestive of temporo-limbic dysfunction occur relatively frequently among psychiatric patients, and that they are associated with abnormal measures of neurophysiology and functional neuroimaging. However, there are major limitations in that these findings have only been based on naturalistic clinical observations. There were no control groups, and the temporo-limbic dysfunction scales had not been formally tested for reliability or validity. More scientifically rigorous studies are in progress.
Korner A J
The Interpersonal Mind and the Ownership of Feeling
Department of Psychological Medicine, University of Sydney at Nepean Hospital, New South Wales
Heidegger's conception of being a “person-in-the-world” and of being “thrown into” a complex environment are taken as a starting point for a model of mind that is irreducibly interpersonal in nature. Mind cannot be separated from environment and therefore cannot be equated to brain, which can be conceived of as separate from environment. Nor, however, can mind be separated from brain.
Psychoanalytic and psychological literature have problems in trying to formulate biological understanding of psychological processes when focus is maintained on internal mechanisms. Although it is possible to talk in terms of “having a mind of one's own”, this statement includes an irreducible environmental component. In contrast, feelings arise within the individual person. Feelings, a product of the interaction of the person-in-the-world, are more truly identifiable as existing only within individuals.
It is therefore proposed that a rational approach to the study of the biology of psychological processes would be advanced by considering the bodily/mental feelings that arise out of interactions with the environment as a “basic” unit for examination in research. Of particular importance in this regard will be the feelings that arise out of interpersonal interaction.
Korten A
One Month and 12 Month Prevalence Rates of Psychotic Disorders
Australian National University, Canberra
One of the main aims of the study was to estimate the one month and 12 month prevalence rates of psychotic disorders in urban areas of Australia. Four clearly delimited geographical sites participated. Persons likely to be suffering from a psychotic disorder were identified by screening patients using in-and outpatient psychiatric services, GPs, private psychiatrists and also people living in marginal accommodation or using support services for the homeless, Intensive screening over a census month was followed by second phase interviews with samples of patients that established diagnoses. These data provided the basis for comprehensive one month prevalence figures. Additionally, record searches identified people who had used mainstream services in the 11 previous months but had not been seen in the census month. These provided some indication of the possible difference between 1 month and 12 month prevalence data.
The survey indicated that between 4 and 7 per 1000 persons at risk suffered a psychotic disorder during a one month period. Of these, between 3 and 5 per 1000 are estimated to have sought treatment in mainstream psychiatric services, 1–2 per 1000 were treated by GPs or private psychiatrists while fewer than 0.25 per 1000 were unknown to services, except in the inner city area of Melbourne (1.3 per 1000). Up to 80% of patients seen by mainstream service providers in any one year are seen during a one month period. There were notable differences in age and sex patterns and between the participating sites. Questions of the validity of the rates and the extent to which they may be extrapolated and compared will be discussed.
Krawitz R
Borderline Personality Disorder: The Concept of Risk-Taking in Clinical Practice
FRANZCP Spectrum, Personality Disorder Service for Victoria, Melbourne; RREAL, Resource team for borderline syndrome, Waitemata Health, Auckland, New Zealand
The facilitator will present a 20-minute paper intended as a catalyst for discussion. The remaining time (over an hour) will be unstructured, providing participants with an opportunity to discuss the topic. This may include hearing how people have grappled with the issues in the past and how we individually and collectively may deal with the issues involved in the future.
Krawitz R
Borderline Personality Disorder: Clinician Attitude Change following Brief Training
FRANZCP, Spectrum, Personality Disorder Service for Victoria, Melbourne; RREAL, Resource team for borderline syndrome, Waitemata Health, Auckland, New Zealand
Lammersma J
Training/Educating Psychiatrists and Trainees on Consumer/Carer Issues, Indigenous Issues, and Working in Teams with other Professionals
Chair, Board of Professional & Community Relations – Consumer Liaison Committee – Royal Australian and New Zealand College of Psychiatrists
Members of the Board of Professional and Community Relations will lead the discussion in this interactive workshop focusing on training and education.
Lammersma J
Who Has the Power? Do Partnerships between Psychiatrists and Consumers and Carers Produce Better Outcomes?
Chair, Board of Professional & Community Relations – Consumer Liaison Committee – Royal Australian and New Zealand College of Psychiatrists
Dr Noel Wilton, Chair of the Board of Professional and Community Relations, will chair this session. He will introduce the topic by giving background information on the development of the Board and its function.
The session will consist of a panel discussion. The panel will be composed of members of the Board. Panel members include Ms Pauline Hinds, Ms Leonie Manns, Mr Jim Crowe, Dr John McGrath, Dr Neil Phillips and Dr Jo Lammersma. Ms Pauline Hinds and Ms Leonie Mann are both very active and well known in the consumer movement in New Zealand and Australia respectively. Mr Jim Crowe is a carer and the current president of World Fellowship for Schizophrenia. Dr John McGrath is a carer who is chair of the Mental Health Council of Australia. Each panel member will present a brief personal perspective on the topic.
Members of the panel will then discuss questions and comments from the audience. The emphasis is on the examining the relationship between psychiatrists and consumers and carers. It will look at both the positive and negative aspects of this.
Lyndon R W
Transcranial Magnetic Stimulation – Progress So Far
University of Sydney, New South Wales
Transcranial magnetic stimulation (TMS) is a method of inducing an electrical current and depolarisation of neurons in the brain by the external application of magnetic energy. Originally described by Barker in 1985, TMS was developed as a method of inducing motor evoked potentials and later used to study central motor conduction time and the somatotopic organisation of the motor cortex. Rapid rate TMS (rTMS) became possible in 1990 with the development of machines which could deliver pulses of magnetic energy at frequencies of up to 60Hz. Since 1995, much interest has been generated in the potential use of rTMS for the treatment of depression and other psychiatric illnesses. Over the last five years both clinical and basic science research into rTMS in psychiatry have expanded dramatically, with the participation of major research centres in the USA, Europe, Scandinavia and Israel, as well as Australia.
At present, numerous studies support the efficacy of rTMS as an anti-depressant, though many questions still remain. There is as yet no general agreement regarding the selection of appropriate patients, the treatment parameters to be used or the frequency and duration of treatment. Adequate controlled studies have been difficult to conduct because of the lack of a generally accepted placebo condition and results have been conflicting. Nevertheless, some patients appear to achieve a convincing and robust clinical response and clinicians and researches are generally optimistic about the eventual usefulness of TMS in psychiatric practice. An important issue yet to be resolved is the relationship, if any, between the effects of TMS and ECT on neurophysiology and depressive illness.
This presentation will briefly review the development and current status of TMS, focussing on neurophysiological effects, safety issues, basic science and animal studies and clinical trials in the treatment of depression. A short video demonstration of a treatment session will be shown.
Lyndon R W, Johnson G F S, Fallon E
The Efficacy of Electroconvulsive Therapy Revisited: Results of Treatment at a Mood Disorders Unit
Department of Psychological Medicine, University of Sydney, Mood Disorders Unit, Northside Clinic, New South Wales
In current patient populations, the rates of remission of depression following ECT may be lower than traditional expectations[1]. Early studies suggested an expected remission rate of 80–90%, whereas more recent studies indicate current remission rates are of the order of 50–60%[2]. One reason for this discrepancy may be that modern studies examine populations which are often highly medication resistant. Patients currently prescribed ECT have frequently failed several courses of anti-depressants, perhaps predicting that the illness will also be refractory to ECT.
MacDonald A
“Drawing and Painting for the Graphically Challenged”
Senior Clinical Lecturer, Department of Psychological Medicine, Wellington School of Medicine; Consultant Psychiatrist, Te Whare Marie Maori Mental Health Service; Pember House Community Mental Health Team, Wellington, New Zealand
An interactive, experiential workshop for up to 15 participants which will unveil your repressed/hidden skills in the graphic arts by introducing you to the cognitive and optical techniques. In addition there will be an introduction to painting and the various media for the cost conscious and busy psychiatrist. Participants should bring pencil and drawing paper. They can expect to leave with graphic skills and the making of a new addiction.
MacDonald J
Qualitative Research: Part of Psychiatry's Cultural Heritage
Department of Psychological Medicine, Wellington School of Medicine, University of Otago, New Zealand
Qualitative research techniques have been utilised in psychiatry since Freud derived his theories based on case studies. The case report is, however, only one of the many techniques subsumed under the heading of qualitative research, which includes, inter alia, individual interviews, focus groups, participant observation and analysis of documentation. However, psychiatrists have generally been taught only the techniques and principles of quantitative research, in keeping with their scientific, medical training. The dominance of this particular epistemological approach in psychiatry is now under some challenge as psychiatrists and other researchers in the area explore different approaches to gathering and analysing data. As a consequence, reports on research in which qualitative methods have been used are beginning to appear in some of the psychiatric literature (notably the ANZ Journal of Psychiatry).
This workshop is intended as a basic introduction to qualitative research for participants who are unfamiliar with these approaches.
To introduce participants to the key theoretical underpinnings and concepts of qualitative research.
To explore the contribution that qualitative research can make to psychiatric research and generation of knowledge.
Some key concepts of qualitative research will be discussed, and their relevance to psychiatry outlined with examples. The relative merits of quantitative and qualitative approaches for answering different types of research questions will be examined. Some of the common criticisms of qualitative research will be discussed and critiqued.
MacDonald J
The Mystery of the Case History – Handy Hints to Help you Pass Your Case Histories at the First Submission
Director of Training, Senior Lecturer, Dept of Psychological Medicine, Wellington School of Medicine, University of Otago, New Zealand
The skills required to successfully write the case histories should not be seen as mysterious or secret. This brief presentation will spell out the general and specific factors which examiners look for when marking case histories. Factors which often lead to failure will be exemplified. There will be a brief opportunity for questions.
Joanna MacDonald was a member of the Committee for Examinations from 1990–1996. Since that time she has been an ex officio member of the Committee in her role as the Chair of the Case Histories Subcommittee. She is the Director of Training in Wellington, and a senior lecturer in the Dept. of Psychological Medicine at the Wellington School of Medicine.
Macfarlane S
Building a Better Horror Movie: Kleinian Symbolism in Ridley Scott's “Alien”
Psychiatry Registrar, Frankston Hospital, Victoria
Why are we attracted by horror movies? Psychoanalysts would argue that our attraction is the result of repetition-compulsion, and that those horror films which most successfully reproduce our early childhood anxieties are the most successful at the box-office, with fans returning to view them time and again. “Alien” (1979) is considered by many to be a classic of the genre. Gabbard and Gabbard, in their book “Psychiatry and the Cinema,” view the film through a Kleinian lens in an attempt to explain its effectiveness as a work of horror.
Dr. Macfarlane will present, discuss and expand upon the Gabbards’ work with the use of humour and a visual presentation in this seminar presentation. When not actively working as a psychiatry registrar, Dr. Macfarlane presents a weekly segment on Psychiatry in the movies on the Melbourne radio programme “Radiotherapy.”
Manser T
The Medical Benefits Schedule New Items
EPC Senior Project Officer, SA Divisions of General Practice Incorporated, South Australia
The Enhanced Primary Care Package (EPC) was announced in the 1999/2000 Commonwealth budget. One initiative of the package was the introduction of new Medicare Benefits Schedule items on 1 November 1999.
These new items cover health assessments, care planning and case conferencing.
HEALTH ASSESSMENT
If a patient is over 75 years of age, or over 55 years of age if they are an Aboriginal or Torres Strait Islander, then they are eligible for a health assessment to be done by their GP.
The health assessment can be done in the patient's home or in the surgery.
Health assessments focus on the collection of information about the medical, physical, psychological and social function of people.
A health assessment can be done once a year per patient.
CASE CONFERENCES
If a patient has a chronic medical condition that will last for 6 months or more, or has existed for 6 months, then they are eligible for a case conference.
Case conferences are designated times for GPs to discuss the patients care needs with a minimum of two other care providers, given patient consent. Some of these providers may already be providing care to the patient. Others may be involved because the GP believes the patient may benefit from other kinds of care.
A GP may request a psychiatrist to be involved in a case conference either face to face or via teleconference.
A GP can also be requested to participate in a case conference organised by another care provider and can claim under the new MBS items.
CARE PLANS
If a patient has a chronic medical condition that will last for 6 months or more, or has existed for 6 months, then they are eligible for a care plan.
A care plan is a comprehensive plan that is developed by the GP and two other care providers in discussion with the patient. A GP may request a psychiatrist to be involved in the development of a care plan.
The care plan will set out the health needs of the patient and the kind of services and supports needed to meet them. Strategies and goals will be agreed to by the patient and all the participants in the process.
A GP can also be invited to participate in the development of a care plan by another provider and will be able to claim a rebate from the MBS.
Manuel C, Clifton D, Pretor P
Activity Analysis in a Metropolitan Emergency Psychiatric Service
Monash Medical Centre, Clayton, Victoria
The results of this activity analysis demonstrate a high rate of psychiatric morbidity and an approximately even dispersion across community and hospital-based outcomes. Some 48% either admitted or seen on the ward and 52% were subsequently community treated or discharged. The high proportion of hospital-based assessments of psychiatric crisis in patients leads us to speculate on the possible perception of medical model of severe mental illness and reliance on the hospital system for relief of distress. However controlled studies incorporating appropriate rating scales are necessary to measure patient's perception of psychiatric emergency assessments and treatments.
Mares SP
Child and Adolescent Psychiatry Training in Nsw — a Review of the Last 10 Years
Director of Training, Child, Adolescent and Family Psychiatry, New South Wales Institute of Psychiatry
In the decade between 1989 and 1999, 51 Child and Adolescent Psychiatrists completed training in NSW. In 1999, as part of a broader review of Child and Adolescent Psychiatry training in NSW, the NSW Institute of Psychiatry conducted a study of the demographics, work profiles, career pathways and destinations of this group and examined their recollections of training.
Graduates were asked, in focus groups and questionnaire, to reflect on the content and the process of their training and how well training had prepared them for their current role. They were also asked to make recommendations about future training, including key topic areas and modes of training delivery. Demographics and work profiles were compared with data on general RANZCP membership, current general psychiatry trainees in NSW and what is known about members of the Faculty of Child and Adolescent Psychiatry.
The paper will present the findings of the study and look at current directions in Child and Adolescent Psychiatry training in NSW.
Martin G
Out of the Blues: Suicide Prevention and Depression in Young People
Flinders University, South Australia
Clinical Depression plays a key role in the suicide of young people. In 1996, the Australian National Health & Medical Research Council published guidelines for the management of Depression in young people aged 15–24 years. These have been disseminated widely to professionals in Australia; as well, comic style booklets are available for young people. The guidelines were based on a commissioned review of published work from 1985 to 1994. Consensus suggested the case for medication use in young people was at best unproven; available evidence for the use of tricyclics suggested they were little better than placebo and few studies dedicated to the use of Selective Serotonin Reuptake Inhibitors and other drugs had been completed on young people Overall the greatest evidence seemed to point to the use of Cognitive Behavioural Therapy as the treatment of choice, though this in part related to the quantity of careful research completed on CBT.
This paper briefly reviews the international literature from 1994 to date regarding treatment of depression in young people, including studies completed on adults which include young people. It seeks to discover whether the conclusions on ‘good’ or ‘best’ practice are any more clear since the 1994 reviews and, in particular how they apply to atypical presentations – for instance those often seen in young men. These conclusions are then set against a discussion of the clinical project Mood Disorders Unit funded under the Australian National Suicide Prevention Strategy.
McConnell K
Climb Everest and Die
Psychiatry Registrar, Royal Hobart Hospital, Tasmania
The Author, an experienced mountain climber, will describe an ascent of the North Ridge of Mount Everest.
This extreme altitude produces two extreme medical illnesses, high altitude pulmonary oedema (HAPE) and high altitude cerebral oedema (HACE). Both illnesses require emergency therapy and carry a high morbidity rate. In his years of mountain climbing, the author has treated over 100 cases of HAPE and HACE. A review of the literature on HAPE and HACE, combined personal experiences, will provide a comprehensive insight into therapy and sequelea, illustrated by a case occurring at 7000m/23000ft high on Mount Everest.
McFarlane A C
Neuroimaging and Memory in Ptsd
Department of Psychiatry, University of Adelaide, South Australia
Post traumatic stress disorder is a disorder which is centred around an individual's capacity to organise environmental perceptions into integrated holes. This begs the question whether the primary difficulty in this condition is one of information processing. A history of the investigation of this question, using event related potentials and more recently PET studies will be discussed. The central question, is whether there is a primary disorder of working memory which secondarily effects the processing of traumatic memories or whether this dysfunction is restricted to the management of trauma related memories. This methodology also provides a way of investigating the uniqueness of the information processing disorder in PTSD compared with other anxiety, disorders, such as panic. The emerging research has important implications for the way that psychiatric disorders are conceptualised. For example, we tend to presume that the neurocognitive deficits in schizophrenia are specific to that disorder. However, a significant number of these people have post traumatic stress disorder which raises the question as to whether there is a stress related biology in schizophrenia and its nature can be informed by the research from the trauma field.
McFarlane A C
The Way Trauma Moulds the Language of Literature
Department of Psychiatry, University of Adelaide, South Australia
Psychiatrists are verbal people and can easily over value the world of language. The irony of traumatic experience is that both individuals and cultures have an enormous difficulty in expressing their experience. When attempts are made it is very difficult to evoke the true empathy of those who are ignorant of personal horror.
The failure of the collective experience of the suffering of the First World War, the war to end all wars, is an indication of the frailty of language to change human behaviour. Fusell studied the literature which emerged out of the First World War and the struggle entailed in reaching some language which could express what had occurred. The interesting conclusion was that it was almost as though these experiences were locked out of the world of day to day communication. This paper will discuss how the study of trauma has got a great deal to learn from the study of literature in understanding something of this barrier to expression. Equally, as Robert Graves reflected as a result of his friendship with Rivers, literature has a great deal to learn from science in developing a language about the nature of memory and human suffering. One of the dilemmas, is that we wish to escape brutality in what we read, but to hide from the reality of suffering means that we are vulnerable to the constant revisitation of war and social violence. Literature plays a critical role in picking away at this shroud. To quote, “The sole purpose of language is to express our ignorance more precisely”.
McKendrick J H, Thorpe M, Thorpe L, Charles S, Thorpe A, Singh B
Working Together 1: Innovative Mental Health Research in Aboriginal Communities
Resource Unit for Indigenous Mental Health Education and Research, Department of Psychiatry, University of Melbourne
Unfortunately there is little documentation of the nature and patterns of the mental health problems experienced by indigenous peoples or their needs in terms of services. The psychiatric literature about these groups is diverse. Comparisons between studies and cultural groups are bedeviled by differences in methodology, classification of disorder, and sample selection. Most have taken an epidemiological or clinical descriptive approach, using Western diagnostic categories. Few have worked together with the indigenous people to develop ways of looking at the mental health problems they experience which takes into account indigenous views of health and illness and incorporates the social and cultural with the psychological and emotional. This paper describes unique, innovative mental health research conducted with two Aboriginal communities in the south east of Australia. The major objective of our research was to document the nature and patterns of mental health problems experienced by members of these communities. The methods were designed to achieve the objectives in a way that accurately reflected the lives of the people of the Aboriginal communities in which the studies were done, their language, their ways of talking about health and illness and the ways they viewed life events and stressors. At the same time we were careful to ensure that the research methods were scientifically sound and the measures of psychiatric morbidity, and social and cultural factors were reliable and valid. The first study followed a random sample of adult Aboriginal general practice attenders over a three-year period. The second, which culminated in a mental health survey of a random community sample of adults was preceded by the development and conduct of a training program for Aboriginal mental health researchers, a census of the local Aboriginal community, and the conduct of intensive individual and group interviews. Local Aboriginal researchers were involved in all aspects of both studies. The results of the studies were sobering. In general respondents were severely socially and economically disadvantaged. Rates of psychiatric morbidity were several times higher than those found in general practice or community samples in western populations. There was an association between certain adverse factors and increased rates of psychiatric morbidity. Similarly other factors were associated with lower rates of morbidity.
The studies will be described in detail and the implications for further research and program development examined.
McKendrick J H, Thorpe M, Thorpe L, Hall S, Thorpe A, Singh B
Working Together 2: A Unique, Innovative Program for the Promotion of Indigenous Mental Health
Resource Unit for Indigenous Mental Health Education and Research, Department of Psychiatry, University of Melbourne
The Resource Unit for Indigenous Mental Health Education and Research (RUIMHER) provides a model for the formation of working partnerships between Aboriginal communities, mainstream mental health services and academic institutions. The Unit aims to contribute to the well being of Aboriginal people by:
placing the mental health of Aboriginal peoples in a historical, social and cultural context
assisting Aboriginal peoples in development of mental health programs for their communities
facilitation of equal access to mainstream mental health services for Aboriginal people.
The RUIMHER team consists of Aboriginal and non Aboriginal mental health professionals who have expertise in Aboriginal health and mental health and academic and clinical psychiatry; ongoing involvement in Aboriginal community activities; input to Indigenous mental health policy and planning. RUIMHER research, education and training, and health promotion and prevention activities are practice based and driven by needs as identified by Aboriginal communities.
The RUIMHER team works with Aboriginal communities to develop and facilitate implementation of broad range mental health programs, which meet their specific needs. The RUIMHER team works with mainstream mental health services and educational/training institutions to assist them to better meet the needs of, and to become more accessible, to Aboriginal people. These are matters which underpin the achievement of good health outcomes for Aboriginal people and further the objectives of the National Aboriginal Mental Health Action Plan and the Framework agreements between Federal and State Governments, and peak Aboriginal Community Controlled Health bodies. This paper discusses the RUIMHER model in detail using our education and training programs to illustrate the ways in which we work as a team. RUIMHER has developed an Education program in indigenous mental health, which is flexible and suitable for Indigenous and non-indigenous health and mental health professionals and students of the health professions. The objectives of the Program are to increase awareness and understanding of Aboriginal culture and mental health; provide a good quality training program for Aboriginal health and mental health workers and mainstream health professionals and students; promote provision of appropriate services to Aboriginal people by Aboriginal specific and mainstream mental health services; promote partnerships between Aboriginal and non-Aboriginal people in good quality mental health services.
McLean L M, Streimer J
Optional Personal Therapy: How Does the Trainee Psychiatrist Process the Therapeutic Relationship?
Department of Psychological Medicine; Department of Consultation-Liaison Psychiatry, Royal North Shore Hospital, New South Wales
Most trainee psychiatrists begin their experience as a psychotherapist in a psychiatric setting with little personal experience of the process of psychotherapy. In a climate where personal psychotherapy is not mandatory for trainees, but where clearly career choice means trainees are often interested in the psychological, how then do we make sense of the experiences of patients and ourselves? Is supervision sufficient when confronted with the new, the different, that which is difficult to understand? Or do we dream, create, play, pray, meditate, talk or think it through? Do we do it alone, with loved ones, with peers or mentors? How much of the experience is common and what is unique to the individual and his/her cultural origins? Prompted by the apparent near silence on the issue (as opposed to the issue of skill-building for the therapist) in both formal and informal discussions in the psychiatric community and in the formal literature, this workshop will open this question for discussion.
McLean L M, Tennant C, Ward C, Tofler G, Berry G
Mood and Coronary Heart Disease: Mediating Haemostatic Risk Factors
Department of Psychological Medicine, Royal North Shore Hospital, New South Wales
There is a growing body of evidence which suggests that mood states and traits such as depression, anxiety, anger and personality are independent risk factors for Coronary Heart Disease (CHD). Some of this evidence points to mood having a causal role in CHD as well as complicating the outcome in those with existing CHD. One possible way in which negative emotions may increase CHD risk is via effects on haemostasis, through promotion of a prothrombotic, inflammatory blood profile and platelet hyperreactivity. In this paper the relevant literature on the above negative affects and their haemostatic links to CHD is reviewed, including the relevance of Type-D personality, to justify a research rationale. It is argued that one way in which mood has its effect is via these haemostatic risk factors rather than through effects on traditional risk factors alone. A proposal is then outlined for a longitudinal study of 6 months observation of a group of subjects (target n = 105) to be treated by their General Practitioner for major depression but without known CHD. The impact of the resolution of depressed mood on a number of pre-treatment measures of haemostasis and platelet function will be examined including fibrinogen, Von Willebrand's Factor, C-reactive protein. Tissue Plasminogen Activator, PAI-I, P-selectin, platelet micro-granules, b-thromboglobulin and blood/plasma viscosity. The impact of the resolution of their state of depression upon other state and trait negative affects will also be measured to chart covariance A case-control component provided by a group without depressed mood (target n = 63) and matched for age, gender, smoking and socio-economic status will allow a cross-sectional, between groups analysis and some comparison of state versus trait affects. Conventional cardiovascular risk factors and other psychosocial risk factors including chronic life stressors will be measured and monitored to assess covariance. The study may form the first enrollment for a longer cohort study. The pilot study is planned to commence in mid 2000.
McNaughton L
A Mirror on Our History
Policy Officer, Aboriginal Health & Medical Research Council of New South Wales (AH&MRC)
Lola was born in Tingha, Northern NSW, and is a member of the Anaiwan and Gamilaroi peoples. She was stolen from her family, extended family, community and country at 4 years of age and taken to the “Cootamundra Aboriginal Girls Training Home”. Lola was not to see her family again until 1980 when there was a family reunification facilitated through Link-Up (NSW) Aboriginal Corporation the community organisation that reunites Aboriginal people who were taken from their families through government policies. She has been a member of Link-Up (NSW) since 1985 and was elected Secretary, then President, during the period 1987–1989. Lola was invited as a keynote speaker to the International Conference on Grief and Bereavement held at Sydney University in 1992.
It was in a voluntary capacity that Lola assisted Link-Up (NSW) in 1994 to arrange a State Reunion for Aboriginal people removed from their families. She then worked fulltime at Link-Up as a Research Caseworker until 1998.
In 1996 she was nominated to the National Indigenous Advisory Council to the Human Rights Commission in its Inquiry into the Separation of Aboriginal People from Their Families which became the 1997 parliamentary report Bringing Them Home. As part of this community initiative Lola travelled extensively throughout NSW facilitating forums for Aboriginal people to bring their concerns to the notice of the Commissioners for inclusion in the Recommendations of the Inquiry.
Lola is a NSW representative on the National Sorry Day Committee and a member of the Stolen Generations Memorial Foundation.
McNaughton L (Chair)
Film: “Cry from the Heart”
Policy Officer, Aboriginal Health & Medical Research Council of New South Wales
Producer & Director: Jeni Kendell, Gaia Films
Cry From The Heart is a personal story and journey of one Aboriginal family who suffered terrible trauma, grief and loss through forcible separation from their family. With open hearts and extraordinary courage Chris, Lola and Frank Edwards tell their story. No words strike deeper into the heart than the words “Stolen Children”. The horror for both mother and child, Alice, Gordon, Lola and Coral Edwards were taken from their Tingha home in 1951. The children were put into institutions. Alice came back to Tingha when she was 18, met Henry Haines and had 3 children. She was pregnant with her 4th child, Christopher, when Henry died. Life fell apart and the same welfare that took her away now came for her children. The little ones were put into white foster families and homes. Chris, Alice's baby, was only 8 months old.
Cry From The Heart takes up Chris’ story of alienation abuse and loss, leading to his 10 year imprisonment becoming one of NSW's most dangerous inmates. After a suicide attempt and in the depths of depression Chris decides to turn his life around. He begins the journey of healing to break the cycle of damage that has haunted his family for generations. Chris a brilliant artist has decided to be there truly for his own child and listen to the cry from his heart.
“To lose yourself, to find yourself, to see yourself anew – that is the journey.”
McNaughton L*, Tapsell R** (Convenors)
Walking Together, Working Together: Open Forum
* Aboriginal Health & Medical Research Council of New South Wales
** Mason Clinic, Auckland, New Zealand
The last session devoted to Aboriginal, Maori and Torres Strait Islander mental health will bring together the ideas and enthusiasm generated in earlier sessions. It is an open forum and we invite everyone to attend and contribute to the discussion. This session should help us find ways of working together, so that we can better understand and address the burden of ill health and early death borne by Aboriginal, Maori and Torres Strait Islander people.
Meadows G, Burgess P, Harvey C, Fossey E
Perceived Need for Mental Health Care, Findings from the Australian Survey of Mental Health and Well-Being
Senior Lecturer, Department of Psychiatry, University of Melbourne; Principal Specialist, Northwest Health Care, Royal Park Hospital, Parkville, Victoria
The National Survey of Mental Health and Well-being was an initiative of the Commonwealth Government of Australia as an effort to collect standardised and valid information to guide mental health policy and planning. The survey instrument, a computerised interview, was designed to detect and describe psychiatric morbidity, associated disability, service use, and “perceived need for care”. The latter construct was sampled with an instrument designed for this survey, the Perceived Need for Care Questionnaire (PNCQ). The entire instrument was administered to a sample of 10641 of the Australian population in mid 1997. The authors can now report findings from the survey. Overall the survey found a one year period prevalence of 17.7% for all psychiatric diagnoses in the Australian population.
The survey estimated that 13.8% of Australian population have an expressed need for mental health care. The group who both met interview criteria for a psychiatric diagnosis, and expressed perceived need make up 9.9% of the population. An estimated 11.0% of the population are cases of untreated prevalence. A minority of this group, (3.6% of the population) expressed perceived need for mental health care. Among persons using services, those without a psychiatric diagnosis from interview (4.4% of population) showed higher levels of need than did the 6 7% of the population who met interview criteria and used services.
The findings of this survey highlight the mismatch between need for mental health care as defined by the population, and that found if untreated prevalence is employed as a definition of unmet need. They suggest that treatment in the absence of diagnosis may often represent successful intervention. This might include successful prevention, and induction or maintenance of remission. Efforts to increase uptake of services within groups of the population not currently served, but who appear to have a disorder, should be conducted with the awareness, at least in Australia, that the majority in this category do not see themselves as having needs for mental health care.
Milroy H
Race and Self-Disclosure
Acting Consultant Psychiatrist, Bentley Family Clinic, Western Australia
Most patients do not expect to be seen by an Aboriginal doctor. If the doctor's Aboriginality is not clearly evident from the beginning of the contact, then is the patient falsely reassured about who they are seeing? The fact that my own Aboriginality is usually not recognised has allowed a unique opportunity to develop whereby patients have expressed racist attitudes towards Aboriginal people expecting that the “white” doctor will agree. This particular issue was highlighted by many of my patients who openly expressed their dislike and fear of Aboriginal people without realising I was one of them. On the other side of the story however, was the great sense of relief, often expressed by Aboriginal patients when they became aware of my background and felt they would be “understood”.
When is the disclosure of racial background appropriate or is it never so?
Should racist attitudes as expressed by patients be challenged by the psychiatrist?
Will the patient feel betrayed or foolish if they find out the doctor's racial background later on?
Straddling the great divide between black and white is an impossible position and often requires the constant shifting between camps depending on the circumstances. I have attempted to look at these issues by discussing a range of experiences with both “white” and “black” patients as well as with staff members. My recent experiences in child and adolescent mental health services has also prompted a closer look at the effect of these attitudes on the marginalisation of aboriginal children in the school environment. These experiences have certainly heightened my awareness of the entrenched nature of racist attitudes towards Aboriginal people that continue to exist in a wide variety of settings.
Minas H, Mans L (Speakers)
Working with Our Neighbours
Fellows of the College in Australia and New Zealand have been doing a lot of work in countries close to Australia, in PNG, the islands of Oceania, and in the countries of East and South-East Asia, notably Vietnam and China. It is important for Fellows to know what each other is doing and possibly coordinate our effort. If it is possible to have collaborative projects in these countries it would even be better. We should take the occasion of the College Congress to update ourselves of such undertakings. In the absence of Graham Mellsop, Chair of the Regional Issues Committee of the College, Eng-Seong Tan will chair the session.
Mitchell P
Anticonvulsants in the Treatment of Bipolar Disorder
School of Psychiatry, University of New South Wales, Administrative Director, Mood Disorders Unit, Prince of Wales Hospital, New South Wales
While lithium is an effective mood stabiliser still in widespread clinical use, a significant proportion of patients either respond poorly or are unable to tolerate its adverse effects. In the 1960s and 1970s preliminary reports of the possible effectiveness of carbamazepine and valproate began to appear, with confirmatory controlled studies being undertaken in the 1980s and 1990s. In recent years, further putative mood stabilising agents have been described, in particular some of the newer anticonvulsants and the atypical antipsychotics. This paper critically evaluates the current evidential basis for claims for the efficacy of these compounds in bipolar disorder.
Mohr C
Collaboration –Together We Can Find the Way in Dual Diagnosis
Centre for Developmental Disability Health Victoria, Monash University, Victoria
Service systems in health and community agencies are struggling to deliver mental health services to adults with an intellectual disability. Many professionals feel ill-equipped to assess and treat mental health disorders in this population. This case study describes the collaborative effort required to meet the complex health needs of a client with an intellectual disability and her family, and the role played by a specialist service. The key elements of the successful interagency collaboration are outlined, and included good communication, adequate resourcing, and a willingness to resolve dynamic tensions and learn from each other.
Morgan V
Who Will Have a Good Outcome among Persons with Psychotic Illness
Department of Psychiatry & Behavioural Science, University of Western Australia
Morkell D, Kisely S, Castle D
Psychiatric Aspects of Dysmorphic Concern: A Pilot Study of Outpatients Attending for Cosmetic Plastic Surgery
Fremantle Hospital, Western Australia
Patients also completed the General Health Questionnaire (GHQ) and Brief Psychiatric Rating Scale (BPRS). GHQ cases as were defined by a threshold of 4. Patients were divided into high & low scorers on the DCQ and BPRS on the basis of their respective median scores.
Mottaghipour Y, Bickerton A
The Pyramid of Family Care: A Framework for Family Involvement with Adult Mental Health Services
Sutherland Division of Mental Health, New South Wales
Working with families of patients with mental illness has proven to be effective in reducing the relapse rate for patients and the distress level of families. The development of interventions for families such as psychoeducation and family therapy by specially trained clinicians has inadvertently compartmentalised family work. There is no general framework available for adult mental health professionals on incorporating family work in their everyday practice.
The Pyramid of Family Care was developed as part of the “Working With Families” Project in Sutherland Division of Mental Health. The Pyramid provides a framework for family involvement with mental health services.
The Pyramid of Family Care is based on the same conceptual work as Maslow's Hierarchy of Needs. The bottom level includes the family's needs for basic information and orientation about the mental health service. This contrasts with the top level which includes highly specialised interventions such as intensive family therapy.
This hierarchical model assumes that significant clinical gain can be made by broad application of simple interventions and techniques, and conversely that applying specialised techniques within a service will fail to produce broad benefits without a foundation of basic skills and approaches.
The pyramid of family care is designed to empower professionals to involve all the families of patients who come into contact with the mental health service based on the family's level of needs. This paper will expand on this model of family care. The different levels of the pyramid will be discussed and a minimal level of care defined. The implications for the use of this model in training will be illustrated.
Moyle R
Beyond the Security Patient's Hospital – the Evolving Role of Forensic Psychiatry to the Community
Director Forensic Psychiatry, Queensland Health and Royal Brisbane Hospital
Forensic Psychiatry was born when courts ambivalently invited those who ran large institutions (alienists) to explain the state of mind of people appearing most notably for capital crime. Psychiatrists have since been accused of usurping the court's role. The Insanity Defence has never been popular. Justice required it. But it wasn't thought to serve justice to imprison those found insane irrespective of the finding. Security hospitals were built. Forensic Psychiatry has diverged somewhat since then and is now redefining its boundaries. The evolution is described and predicted.
Mullen P E, Burgess P, Wallace C, Palmer S
Community Care and Criminal Offending in Schizophrenia
Victorian Institute of Forensic Mental Health; Mental Health Research Institute of Victoria; Department Psychological Medicine, Monash University, Victoria
The introduction of community care in psychiatry is widely thought to have resulted in more offending among the seriously mentally ill. This view affects public policy towards and public perceptions of such people. We investigated the association between the introduction of community care and the pattern of offending in patients with schizophrenia in Victoria, Australia.
Compared with controls, significantly more of those with schizophrenia were convicted at least once for all categories of criminal offending except sexual offences (relative risk of offending in 1975 = 3.5 [95% CI 2.0–5.5], p = 0.001, in 1985 = 3.0 [1.9–4.9], p = 0.001). Among men, more offences were committed in the 1985 group than the 1975 group, but this was matched by a similar increase in convictions among the community controls. Those with schizophrenia who had also received treatment for substance abuse accounted for a disproportionate amount of offending.
Increased rates in criminal conviction for those with schizophrenia over the last 20 years are consistent with changes in the pattern of offending in the general community. Deinstitutionalisation does not adequately explain such change.
Murray A, Newman L, Parkinson J
Psychotherapy and Gender-Identity Disorders – Issues in Assessment and Intervention
Private Practice, Merewether, New South Wales
Nadarajah J
Promotion of Psychological Well-Being of Small and Family Business Owners
Consultant Psychiatrist, Graylands Hospital, Western Australia
Newton J R, Cheung P, Farhall J, Trauer T
An Evaluation of the Victorian Community Care Units (Ccus): A 1-Year Follow up Study of 125 Long Stay In-Patients Discharged to Community Care
Frankston Hospital and Monash University, Department of Psychological Medicine, Victoria
Since 1995 this major project has been evaluating the clinical outcome of 125 long stay in-patients who were transferred to purpose built Community Care Units upon the closure of the NEMPS/Larundel long stay wards.
Patient data were collected pre-move, 1 month post-move, and 1 year post move; staff, relatives and carers views were obtained pre and 1 year post-move.
Comprehensive assessments of demographic information, symptom severity, disability, quality of life, patient attitudes, social networks, aggressive behaviour and living environment were obtained by trained research assistants using standardised instruments (PANSS, LSP, GAF, LQOL, PAQ, SOAS, SNA, RPP).
The main diagnosis was schizophrenia, mean number of hospitalisations was 12 and the mean length of the index admission was 7.75 years. The patient group had high levels of symptom severity, disability, and co-morbidity. The vast majority of this severely ill group could be maintained in the community care units. The post-move community settings were much less restrictive in their practices and the patients were much more satisfied with their living situation. Levels of symptoms and disability showed little change but there was a highly significant decrease in aggressive behaviour. Patients and relatives expressed a clear preference for the CCUs at 1 year.
Noore F, Sundaraj S, Shaw O, Wynn P, Barber P, Castro M, Whyte D, Glanville C
Psychiatric and Medical Aspects of Patients with Chronic Or Recurrent Abdominal Pain
Nepean Hospital, New South Wales
Noseworthy S, Welsh B, Masters A, Hopkins J
Involving Families in Care, Assessment and Treatment Processes – Development and Implementation of Guidelines in New Zealand
New Zealand Community Liaison Committee, R.A.N.Z.C.P., New Zealand
Guidelines for involving families/whânau of mental health consumers/tangata whai ora in care, assessment, and treatment processes were published by New Zealand's Health Funding Authority and Ministry of Health in early 2000. The guidelines were written by the NZ Community Liaison Committee of the RANZCP. These guidelines have been developed to assist mental health staff to work effectively with families, and to assist families in working relationships with mental health services and staff.
In discussing families. Blueprint for Mental Health Services in New Zealand states:
“People with serious mental illness are not ill in isolation. Their families, extended whänau, and significant others, whatever they think about the illness, cannot escape being affected by it. The lives of people with serious mental illness are inextricably involved with the lives of those they love and care for, and the lives of those who love and care about them. Beyond the immediate family are other relatives, friends, neighbours, and workmates who may have a role in the life of the person and need, therefore, to be part of the healing or maintenance programme.”
Research has conclusively shown that there are significant clinical, social, and economic advantages in providing mental health services in a family inclusive way. Many families wish to be involved in assisting the recovery of their family member. They want mental health staff to work in ways that are inclusive of families. This involves mental health staff working alongside families – sharing information, planning, and decision making with the family and consumer, and providing support and education when necessary. There are many complex cultural, ethical, legal, financial, organisational, and treatment issues affecting involvement of families in care, assessment, and treatment processes. There has been and still is potential for conflict over aspirations, rights and responsibilities regarding consumer privacy and family involvement.
Implementation of the family involvement guidelines may have implications for resource allocation, organisational change, and staff training. This may involve short term costs, but this will lead to longer term savings through improvement in services. Implementation of the guidelines may be enhanced through involvement of family representatives in governance of mental health services – for example, in policy development, planning, service reviews, and staff training.
The process of development of the guidelines, plans for their implementation, and attitude of the mental health sector to the guidelines will be discussed by members of the NZ Community Liaison Committee of the RANZCP.
O'Brien E
Examinations Seminar
Chair, RANZCP Examinations Committee
This programme will have a significant trainee focus, with sessions that have a ‘Meet The Expert’, or ‘Blind Tutorial’ format, in which trainees will be able to interact with keynote speakers, such as Professor German Berrios.
This session will be devoted to making the examination process transparent. It will include workshops looking at Case History writing, and the College Dissertation. In addition ‘The Revenge of the Trainees’ will see members of the Examinations Committee sit a Consultancy Viva.
O'Brien G
What's in An Unconscious?
Department of Philosophy, University of Adelaide, South Australia
At the very core of psychoanalytically-inclined psychiatry, both in its theory and its practice, is a commitment to the cognitive unconscious: a subterranean region of our minds inhabited by unconscious contents whose causal activity has a profound impact on our conscious mental life and behaviour. Over the years, however, the difficulties associated with investigating this mental underworld have been legion, with theorists reduced to speculating about its nature and workings on the slimmest and most indirect of evidence. For all its importance in psychoanalytic thought, the cognitive unconscious remains terra incognita.
In this paper I will consider whether new light can be thrown on the structure and function of the unconscious by recent theoretical developments in cognitive science. In particular, I will consider whether the account of the unconscious emerging from the neurocomputational conception of human cognition is compatible with the general tenets of psychoanalytic theory.
O'Brien K
Contemporary Attitudes to Crime, Mental Health and Rehabilitation: Help Or Hinderance?
Director, Forensic Mental Health Services, South Australia
Some of the prevailing attitudes in Australia towards crime, mental health and rehabilitation are considered. Mentions is made bout the current controversy concerning the policing of drugs and the liberalisation of their dispensing and availability. Similarly, reference is made to the gambling industry and the significant health and social costs associated with this. Addictive behaviors contribute to criminogenic activity as do other influences such as personality variables and the psychosocial millieu of the would-be offender. Possible helpful interventions to disrupt the nexus between adverse genetic and environmental “inheritance” and future offending behaviour are explored. Finally, a plea is made for greater co-operation, support and understanding between key agencies and individuals.
O'Dea J F
The Management of Suicidal Behaviour within the Correctional Setting – Clinical and Ethical Issues
Senior Visiting Forensic Psychiatrist, The Paddington Practice, New South Wales
The high rate of suicide and deliberate self harm behaviour in prisons emerged into the public arena in Australia in the 1980's with the focus on Aboriginal Deaths in Custody. The Royal Commission into Aboriginal Deaths in Custody recommended a number of measures to address this problem including the commissioning of “safe cells” to contain this behaviour.
“Safe cells” are prison cells in which the practical means of a person harming themselves are removed. Therefore the cell is usually bare with hanging points minimised. Perspex glass and/or a video camera are fitted in the cell to allow constant observation of the inmate by a prison officer. The inmate has personal items removed and may be stripped or given tear proof clothing and sheets. He or she is then observed in isolation. Detention in a “safe cell” is typically seen by inmates as a form of punishment. Within NSW correctional settings psychiatrists and other health professionals have been conscripted into assuming responsibility for suicidal inmates and those exhibiting other deliberate self harm behaviour within metropolitan and regional prisons. They have been expected to authorise the placement of inmates in these so called “safe cells” Alternative options for the care of these inmates have not been, as a rule, made available.
The significant ethical and clinical issues this raises for psychiatrists and other health professionals is discussed and appropriate responses explored.
A consultation liaison model of psychiatric input to corrective services to help them manage inmates in general, and suicidal inmates and those displaying deliberate self harm behaviour in particular, is proposed.
Olver J S, Reutens D C, Maruff P, Burrows G D, Norman T R, Ellen S R, Pantelis C, Tochon-Danguy H, Ackermann U, Stekelenberg N
Frontal-Subcortical Circuits in Obsessive-Compulsive Disorder: Role of the Dopamine D1 Receptor
Department of Psychiatry, Austin and Repatriation Medical Centre, University of Melbourne, Heidelberg, Victoria
Obsessive-Compulsive Disorder (OCD) is increasingly being recognized as a neurobiological disorder. Serotonergic mechanisms have been proposed on the basis of a partial response of patients to drugs which block the neuronal uptake of serotonin. Further evidence for a serotonergic abnormality is lacking. The major competing theory in the pathophysiology of OCD involves the neurotransmitter dopamine. OCD symptoms are frequently found in neuropsychiatric disorders involving the dopamine rich regions of the basal ganglia, dopamine agonists worsen OCD, peripheral models of central dopaminergic function are abnormal in OCD, urinary excretion of HVA is elevated and neurophysiological studies suggest dopamine-related gating abnormalities in OCD. The Dopamine D1receptor is implicated in OCD following the finding of specific spatial working memory abnormalities in a series of neuropsychological studies. Spatial working memory is known to depend on the integrity of D1receptor function in the Dorso-lateral Prefrontal Cortex (DLPFC) of primates. This study aims to examine the role of dopamine in patients with OCD and in particular to test the hypothesis that there is an up-regulation of dopamine D1 receptors in the DLPFC which correlates with spatial working memory deficits in OCD.
O'shea K
Torres Strait Islander Mental Health: Current Issues
Torres Strait Islander Mental Health Worker, Project Officer, School of Mental Health, Wolston Park Hospital, Queensland
There are special mental health issues which Torres Strait Islanders face and are working on. As the Torres Strait Islander culture is different from Aboriginal culture, different mental health issues and problems emerge and different ways of dealing with them have been developed. Ken O'shea is a Torres Strait Islander mental health worker and member of the College's Aboriginal and Torres Strait Islander mental health committee. He has experience in both Aboriginal and Torres Strait Islander mental health and he is active in developing a mental health training curriculum. Ken will talk about what is happening in the Torres Strait Islander community.
Pantelis C, Velakoulis D, Maruff P, Kyrios M
Neurobiology of Psychiatric Disorders: Recent Work in Schizophrenia, Ocd and Adhd
Cognitive Neuropsychiatry Research Unit, The Mental Health Research Unit, Parkville, Victoria
I will provide an overview of work in these areas with a focus on neuropsychology, functional and structural neuroimaging. The approach we have taken is to use probes of particular circuits involving frontal and subcortical systems in these disorders and we have been interested to examine the relative contribution of each circuit to the deficits observed and how these relate to the phenomena of each disorder.
Parker R
An Investigation of Suicide in the “Top End” of the Northern Territory for 1991–1998 through a Review of Coronial Records
Darwin Urban Mental Health Services
The “Top End” of the Northern Territory comprises approximately two thirds of the Northern Territory's land mass. It contains 79% of the Territory's population.
The Northern Territory Coroner considered that one hundred and eighty six people had committed suicide in the “Top End” for the period 1991 1998. One hundred and eighty one of the determinations were audited using a modified form of the West Australian Coroner's Database investigation instrument.
The primary purpose of the investigation was to ascertain whether there were differences in suicide of Aboriginal and non Aboriginal people in the region for this period.
Factors that influenced the audit were the Northern Territory Coroner's legal definition of suicide and the comparative youth of the “Top End” population generally, with Aboriginal people being younger still from the remainder of the population. There were also a large proportion of Aboriginal people living in rural areas.
The results of the survey, with a high proportion of deaths by hanging (particularly so in Aboriginal people) reflect recent national trends in youth suicide and rural suicide. There were no significant differences in histories of observed mental illness or alcohol abuse between the Aboriginal and non Aboriginal populations. However, there were a greater proportion of Aboriginal people who had a history of previous self harm prior to suicide. Within the Aboriginal population, there were regional differences in respect to suicide risk. North East Arnhem land continued to have a relatively high risk which may reflect local cultural or genetic factors.
However, there appears to be a recent increase in cluster suicides in certain Aboriginal communities, particularly the Tiwi of Bathurst and Melville Islands which reflects similar phenomena observed in other Aboriginal communities such as the Kimberley region of Western Australia and Cape York region of Queensland.
Pathé M, Mullen P, Purcell R
A Workshop on Stalkers and Their Victims
Department of Psychological Medicine, Monash University; Victorian Institute of Forensic Mental Health, Victoria
Stalking began to be used in the late 1980's by the media in California to describe those who persistently followed or otherwise intruded on the famous. The word stalking captured the public imagination. It's usage rapidly expanded first to over the harassment of women by ex-partners and then to a wide range of situations characterised by repeated unwanted approaches and communications which were fear inducing. Stalking is now established as a specific type of offending, a new category of fear, a new form of victimisation as well as a subject studied by behavioural scientists.
This presentation will be based on the clinical and research work undertaken by our group over the last six years at our clinic in Melbourne. This has included studies of the impact of stalking on victims, a clinical study of nearly 200 stalkers, studies on false claims to have been stalked, studies on stalking by proxy, studies on same gender stalkers and an epidemiological study to look at the prevalence and impact of stalking in the general community. This work will be placed in the context of the rapidly expanding research on stalking now being undertaken in most Western Nations.
Paton M B, Tobin M, Hudson-Jessop P
Integrating Public and Private Psychiatric Practice: From National Agenda to Personal Experience
Consultant Psychiatrist, St George Division of Psychiatry and Mental Health, South-Eastern Area Health Service, Sydney, New South Wales
Successive National Mental Health Policies have focussed on the need to reform mental health care delivery. Most recently this has included the re-integration of private psychiatrists within the public sector, promoting a specialist psychiatrist role, increasing access to psychiatrists for people with a major mental illness, and promoting access to psychiatrists in areas where psychiatrists are under supplied.
This paper describes a model in which the private psychiatrist provides an integrating clinical role across public, private and primary mental health care settings, in an area under supplied with psychiatrists, focussing on patients with a major mental illness and emphasising a consultant role to referring General Practitioners. This model developed logically from an integrated public sector mental health service, which in preceding years had undergone structural and organisational changes, including improving collaboration with General Practitioners, changing from generic case management to assertive team management of public sector clients, and redefining public psychiatrists roles. An initial pilot of this model is described, including the practical steps undertaken to achieve this. Evaluation of this continuing pilot is presented, updating a previously published report, including the demographics of the patient group, patient diagnoses, GP referral patterns, and billing patterns across the group. This data is discussed, highlighting the advantages and limitations of the model, and the implications for wider application of such models of integrated care nationally.
Paton M B, Wright M, Large M, Trenaman A, Horrocks C
Non-Resident Psychiatrists and Rural Mental Health Services: An Evolving Model of Service Delivery
Wagga Wagga Base Hospital and Community Health Centre, Greater Murray Health Service, Wagga Wagga, New South Wales
Provision of adequate mental health services in rural and remote NSW presents a number of difficulties for managers, clients and their families, mental health professionals, and other health professionals Some of the difficulties frequently described include those of attracting and retaining on staff a critical mass of mental health professionals, helping those staff to maintain appropriate skill levels and to address issues of professional isolation, geographical access problems resulting from distances to be covered by clients/staff, and transport and communication difficulties. The authors of this presentation work in an area health service in rural NSW centred on a regional base hospital and serving a catchment population of more than 100,000 people. There is an integrated community/hospital service which includes a 14 bed inpatient unit and 5 community mental health centres. The psychiatrists working in this regional centre are all nonresident and have been providing a service as a group for the last two years.
This paper outlines an evolving mental health service model which utilises non-resident psychiatrists, and will present some of the challenges which have been encountered during the evolution of this model, solutions (current and proposed), strengths and weaknesses. The availability and usage of telecommunications technology will be discussed.
Pearson C
A Paediatrician's View of Adhd
Head of Department General Medicine, Women's & Children's Hospital, Adelaide, South Australia
General paediatricians now find that approximately a third of initial presentations are primarily behavioural and that a further number have behavioural issues as a significant contributor. In school age children, the major behavioural diagnosis is ADHD and they would in general follow the NHMRC guidelines to manage this condition. Paediatricians use the combination of history, DSM-IV and behavioural questionnaires to reach the diagnosis. The management would ordinarily include both behavioural strategies and medication unless behavioural techniques proved sufficient. Unfortunately the training of General Paediatricians in behavioural management techniques is often quite patchy. They will often seek to involve other mental health professionals. The question should be asked why paediatricians use medication quite early in their dealings with a child who is believed to have ADHD. It is usually assumed to relate to the training that they have, their usual role of dealing with health crises that need urgent intervention and expectations of the child's parents that may also be reinforced by the child's teacher.
Finally the question should also be asked, “Should there be a more collaborative model for dealing with children with ADHD?”
Rupert Peters Ngankari, Andy Tjilari Ngankari Maggie Kavanagh Coordinator and Interpreter
Ngankaris: Traditional Healers
Ngaanyatjarra Pitjantjatjara Yankunytjatjara (NPY) Women's Council Aboriginal Corporation
Chair: Brian Dixon
Executive Director, Aboriginal Services Division, Dept of Human Services, Adelaide
A Ngankari is a very special person they know all about sickness they can look at someone inside and see their sickness. They can look and see that someone is unhappy or mad or something is wrong with their head, from looking at their face and say, “I can see that problem”. Sometimes a person's spirit can leave them, go outside them and sit down somewhere else. This can make the person weak and sad and lethargic. That Ngankari can find that spirit and grab it and put it back inside that person, and that makes them strong again. Or sometimes that spirit is in the wrong place in the body and the Ngankari moves it back into the right place. Rupert Peters and Andy Tjilari are Ngankaris, based in the Fregon Community though travelling extensively to work in the cross-border region of South Australia, Northern Territory and Western Australia. Among many roles, the Ngankaris provide service to Anangu with mental health or emotional problems. Such problems are presently defined very generally as rama rama (mad, not responsible for one's actions), kata kura (bad head, funny in the head, can't think straight), tjuni kura (very upset, feeling bad) and tjituru tjituru pulka (sad, depressed, experiencing grief).
A whitefella doctor can use an X-ray and look inside someone but they won't see what that Ngankari sees. The Ngankari is a really important one.
Phillips J
What is ‘Primary Care Psychiatry'? Can and Should Psychiatrists Practice Primary Care Psychiatry and If So, How?
President R.A.N.Z.C.P.
There is increasing international and national recognition of the important role that the General Practitioner plays in the early detection and treatment of mental health problems in the population. There has been millions of dollars channelled into GP education in mental health care and considerable sustained Federal attention focused on ways of enticing GPs to take a more active role with psychiatric patients. The joint consultative paper, Primary Care Psychiatry: the Last Frontier, outlined and highlighted these issues and made extensive and far reaching recommendations on the needs to improve medical undergraduate and general practitioner training and CME with regard to mental health care. The need to improve the interface between the GPs and public mental health services was also stressed, but there was remarkably little reference to the role of psychiatrists and how psychiatrists can and should work with GPs.
In Canada and the UK there has been considerable interest and activity for many years in the different ways that psychiatrists can work with primary care providers. Interest and activity in this area has been relatively slow to develop within Australia. Isn't it time that the College took a greater leadership role in raising awareness and challenging its fellows to break out of the traditional modes of practice? This workshop will have a panel of experts comprising both psychiatrists and GPs, all with extensive experience and personal commitment to the concepts of ‘Primary Care Psychiatry'. Our President, Jonathan Phillips will chair the workshop and introduce the issues and define the concept of ‘Primary Care Psychiatry'. Three questions will be put to the panel, ensuring that both the GP and Psychiatrist perspective is obtained. These questions are:
What are the educational needs of GPs/Psychiatrists to practice Primary Care Psychiatry?
What are the models of how psychiatrists can work to support Primary Care Psychiatry?
What State and Federal resources are needed to support Primary Care Psychiatry?
There will be discussion from the floor after each question is addressed and from this it is hoped that key points will emerge that will form the basis of a College Position Paper on this important area.
Phillips N
The Biggest Health Problem Facing Australia
Consultant Psychiatrist to Daruk Aboriginal Community Controlled Medical Service, Chairman of the R.A.N.Z.C.P. Aboriginal and Torres Strait Islander Mental Health Committee, New South Wales
Is the burden of death and disease borne by Aboriginal and Torres Strait Islander people the biggest health problem in Australia? Maybe it is. It is certainly up there with smoking, although there are far more smokers. Smoking knocks some eight years off your life expectancy while being one of the original Australians knocks at least 18 years off your life expectancy.
To a very large extent these health problems are related to history. They are related to loss of land and destruction of cultures, families and communities. Maori people also face severe health problems, many of which have the same connections with colonisation. Mental health and social and emotional problems contribute to the cycle of alienation, misery and death at every turn.
If we look at Australia it might be said that, even if the state of health of the original Australians is not the biggest health problem this country faces, it is certainly the most shameful.
At this RANZCP Congress in the year 2000 we will take time to talk about these things. We'll be talking and walking and working with Aboriginal, Maori and Torres Strait Islander people. We must go together on this great journey to challenge illness and death because, if we don't go together, we will all be lost.
Phillips N
Shrink Ink: Cartooning for Psychiatrists
Consultant Psychiatrist to Daruk Aboriginal Community Controlled Medical Service, Chairman of the R.A.N.Z.C.P. Aboriginal and Torres Strait Islander Mental Health Committee
Cartoons have a remarkable capacity to tell a story with a few strokes of the pen, to reveal the dynamics and to convey emotion. You don't need to be a fine artist to draw cartoons and you certainly don't need straight lines. This informal, hands on workshop conducted by Neil Phillips will reveal some of the tricks of cartooning and show how it can be a useful art for psychiatrists and other mental health professionals.
Pigazzini M
The Measurement and Visualization of the Psycho-Therapeutic Process
IPA Psychoanalyst, Visiting Research Fellow, Adelaide University, Department of Psychiatry, Royal Adelaide Hospital, South Australia
Freud's original intention in writing Project for a Scientific Psychology was to develop the discipline of psychology as a science of nature founded on quantitative data. In 1915–1916 he stressed this view in Metapsychology and finally in 1938 with Analysis Terminable and Interminable. He never abandoned this goal. This study is an attempt to proceed with this goal involving modern science and in particular the field of non-linearity.
It is argued that psychoanalysis and psychoanalytically oriented psychotherapy are recursive patterns and can be measured and visualized as a set of data by a mathematical model which uses non-linear dynamic system theory. The author conducted a one year pilot study with 10 subjects, 3 of whom were undergoing psychoanalysis. Based upon the theory of non-linearity a grid was constructed from 21 variables representing the therapeutic process. Each variable on the grid has 5 intervals, disposed within 3 phase-spaces which represents a deterministic evolution.
Using the time series measurement and plotting variables or combinations of variables, information was obtained which aided in identifying, discussing and comparing:
changes taking place in the therapeutic process,
inferences about patterns of change,
common features of changes over time,
effectiveness of treatment,
different approaches,
predictions regarding treatment outcomes.
Pols R (Chair)
Debate: The Drug Companies Are Here to Help You
Senior Lecturer, Flinders University of South Australia, School of Medicine; Flinders Medical Centre Pain Management Unit; Centre for Anxiety and Related Disorders; Department of Psychiatry, Flinders Medical Centre, Bedford Park, South Australia
This lively debate will be chaired by Dr Rene Pols and feature Professor John Strang, Dr Stephen Jurd and Dr Jon Jureidini speaking in the negative, and Professor Graham Burrows, Dr Anne Sved Williams and Dr Darryl Bassett speaking in the affirmative. Drug companies have become an integral part of our clinical and research work in psychiatry and these speakers represent a broad representation of thinkers in our field.
Pols R G, Battersby M, Pers P, Gill S
Somatisation in Work Related Compensable Injury–An Interactive Workshop
Senior Lecturer, Flinders University of South Australia, School of Medicine and Flinders Medical Centre Pain Management Unit and Centre for Anxiety & Related Disorders; Department of Psychiatry, Flinders Medical Centre, Bedford Park, South Australia
Keynote Speaker: Kirmayer L
to review recent work on somatisation
to present a framework for understanding somatisation in work related chronic pain disorders
to present a framework for the management of somatisation in these patients
to receive feedback from the panel
Participants will have available a handbook to assist with the workshop process.
Pols R G, Battersby M, Tolchard B, McDonald J
Somatisation Project: The Recognition and Management of Somatisation in Hospital and General Practice (Gp)
Senior Lecturer, Flinders University of South Australia; School of Medicine and Flinders Medical Centre Pain Management Unit Centre for Anxiety & Related Disorders; Department of Psychiatry, Flinders Medical Centre, Bedford Park, South Australia
The Somatisation Project (SP) was one of eight sub-projects of the South Australian HealthPlus Coordinated Care Trial. This trial involved the enrolment of an original cohort of 4,600 subjects. Of these, 124 subjects (89 intervention and 35 controls) suffering from GP diagnosed somatisation disorder (SD) constituted the SP cohort. One of the tasks required by the trial was to develop evidence-based, clinical protocols for systematic use at the GP level. The aims of the trial were to coordinate the care of patients suffering from chronic and complex disorders using systematic, behavioural care planning; the use of clinical care protocols and the provision of a designated care coordinator (GP), supported by a service coordinator.
describe the development of the somatisation project
present the findings and implication from the audit of 5826 case records
describe the development of the “containment” protocol for use in GP
present some preliminary outcome data.
A Clinical Audit: A total of 5,826 casenotes were audited by the research team. Of these 1,105 or (19%) of selected patients were considered to be likely to be suffering from a psychiatric disorder which was presenting with unexplained, or poorly explained physical symptoms. Whilst a significant proportion of these patients suffered anxiety or depressive disorders the majority had a clear somatisation disorder.
A containment approach to management: The reference group evaluated the approaches advocated for somatisation in a review and recommended a theoretical model to be used in the trial. This model was then developed as a clinical algorithm and constituted the initial guidelines for management for the patients enrolled in the project. Over the next 10 months it was subjected to further review by a reference group of experienced GPs, who translated the guidelines into an algorithm.
Assessment, involvement and preliminary outcomes: Subjects were enrolled on the basis of GP diagnosis of SD. They were then assessed by means of the computerised version of the CIDI and psychometric evaluation, after which they were randomised to intervention or control groups. The intervention group received coordinated care and the controls best standard care. Outcomes were assessed by monitoring all service use and psychometric evaluation at 12 months and at the completion of the trial.
It is also apparent that unexplained physical symptoms are potent source of health anxiety. The relationship between SD and anxiety disorders requires further study as the avoidant behaviour of these patients is very similar to that by patients suffering anxiety disorders.
The process used to develop the “containment” algorithm and its associated GP education program was an interesting example of the role for consultation–liaison psychiatry at the primary health care level. GPs found the model useful from conceptual, educational and practical perspectives.
The improvement in intervention subjects occurred whilst protocols were being developed and GPs were being educated in their use. It is likely that systematic intervention by well-trained GPs could do better.
There are important implications in this project for clinical services in general hospitals and general practice.
Prendergast J, Austin M P
“Baby Blues Busters”; Training Early Childhood Nurses in Cognitive Behavioural Therapy for Post-Natal Depression and Evaluating Outcome in a Randomised Controlled Trial
Paediatric Mental Health, Liverpool, New South Wales
Primary Mental Health Development Officers, State-Based Organisations of Divisions of General Practice
Primary Mental Health Care: The Role for the General Practice Divisions Program
Education ‘incentives’ funds, and
Employment of a Primary Mental Health Care Development Officer in each state base organisation.
The Development Officers will provide key support in both the development of and support for the role of General Practitioners in primary mental health care. Their activities include:
Assisting GPs and divisions to co-ordinate, access and develop mental health education and training initiatives (including utilisation of the PMHS ‘incentive’ funds);
Supporting GPs and divisions in the development and maintenance of appropriate mental health care initiatives, including shared care programs and consultation-liaison arrangements with mental health services;
Fostering linkages between GPs, divisions and mental health care service providers, including public, private and non-government/psychiatric disability support services; and
Liaising closely with the Australian Centre for Resources in Primary Mental Health Care to provide information to GPs and divisions about the most appropriate education and training resources.
Demonstrated improvements in mental health outcomes for consumers;
A substantial number of GPs with demonstrated skills, knowledge and experience in consultation, diagnosis and treatment of consumers with mental health problems and conditions; and
Demonstrated improved links, and shared care arrangements, between GPs and specialist mental health services- public, private and non-government.
Quadrio C
Correctional Psychiatry
Director of Mental Health Services; Corrections Health Services, New South Wales
The increasing numbers of mentally ill in correctional settings indicates that Transinstitutionalization is a reality. If prisons are not to become the new back wards, there will need to be activity from within the profession.
This paper will explore the clinical, social, political and ethical issues surrounding this phenomenon. It is hoped that psychiatrists interested in advocacy and social justice for the mentally ill will be interested in participating in the debate.
Quadrio C (Convenor)
Symposium – Issues for the Practice of Psychiatry in Correctional Settings
Director of Mental Health Services; Corrections Health Services, New South Wales
Increasing rates of imprisonment in our society are heralding also increasing numbers of mentally ill in correctional settings. The practice of psychiatry in this very difficult context is fraught with problems, clinical and ethical. This series of papers is intended to highlight some of those difficulties.
Raeside C W J
Post-Traumatic Stress Disorder in Perpetrators of Violent Crime
South Australian Forensic Mental Health Service
Whilst much research and attention has rightly been focussed on victims of violent crime there is evidence that in some cases the perpetrator/offender may be traumatised by witnessing their own actions. In both military and criminal studies rates of PTSD have been found to be higher in those who committed more serious violence. The implications for diagnosis, treatment, and rehabilitation together with legal issues such as mental competence will be explored.
Ramachandra S
Personality and Mental Health of Creative Artists
Associate Professor of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bangalore, India
Therefore, it was necessary to select such tests which would throw light on the areas that were chosen in the present study (i.e, personality and mental health). In the words of Guilford no single test of creative ability can be expected to give a composite picture Hence, the following tests were selected for the study:
Biographical data sheet,
Wallach-Kogan Battery of Creativity Instruments (1972),
Rorschach Ink blot test (Klopfer Bruno, 1954),
Sacks Sentence Completion Test (1950),
Delusions Symptoms States Inventory (Foulds, and Bedford, 1977).
The creative group of subjects were selected for the criterion of manifest creativity in the form of original contribution in the area of their chosen field. The artists hailed from fine arts subjects like music, poetry, painting, literature, drama, and dance. The neurotic subjects were taken from the outpatient department of the Institute. The normal group consisted of such individuals in the community who were not known for the presence of either creativity or psychopathology.
The tests were administered individually, scoring and interpretation of the tests were carried out according to the Manuals. Summary of the results: The creative subjects performed significantly better on Wallach-Kogan tests than normals and neurotics. The age of creative subjects did not affect the performance on the test. On Rorschach test they were found to have rich imagination. They indicated the ability to make use of unconscious resources and give expression to the inner experiences an artist touch without detriment to their own ego. They were capable of viewing their problems and conflicts objectively and dispassionately in spite of having oppositional tendencies at the intellectual level. On Sentence Completion Test they were found to be withdrawing, neither having a desire to interfere with others, nor tolerating others’ interference with them. They showed strong and positive self-concept.
On Delusions Symptoms – States Inventory they happened to have some degree of anxiety and depression, though less than the neurotic group, and slightly more than the normal group. Thus the results indicated differences between the creative group and the normal and neurotic groups on the above tests.
Read P
The Drug Court Trial in Nsw
This paper presents a brief overview of the model of the Drug Court Trial that commenced in New South Wales in February 1999 and makes brief comment on the models in operation in the United States.
The Drug Court programme is a novel approach in which the traditional concepts of voluntary treatment motivated by an individual's desire to stop drug use are challenged. Here, a variety of factors, including arrest and the certainty of imprisonment unless participating on the programme add a coercive force to treatment. The programme itself has, as part of its structure, legal sanctions for relapse as well as a reward for attainment of treatment goals. There are challenges for the medical treatment providers. The requirement to work multidisciplinary teams such as the Department of Public Prosecution, Probation and Parole and Legal Aid is outside our normal experience. The challenge of accepting that the structure created by the intersection of these symptoms can itself be seen as therapeutic and containing by our patients may require a paradigm shift.
The past ten years have seen within the legal setting the development of the concept of therapeutic jurisprudence. The Drug Court Programme highlights many of these issues. There is a challenge to psychiatry to participate and contribute to improved and changing models of management for individuals who become involved in the justice and correctional system.
Reichard O
Coping, Creativity and Culture
Consultant Psychiatrist, Private Practice, Burwood, New South Wales
Robertson M
An Introduction to Interpersonal Therapy
Wesley Mental Health Services, New South Wales
Interpersonal Therapy (Klerman and Weissman 1984) is manual based on focal psychosocial intervention. Since it's original use as an experimental treatment for depression in the USA in the 1970s and 80s it has gained increasing popularity and empirical support as both a clinical intervention as well as a research tool. This course (a repeat of a successful workshop offered at the Perth Congress 1999) aims to introduce participants to the background theory, structure and clinical techniques in IPT. This year's presentation will have a stronger clinical component in order to help participants reconcile theory with the realities of clinical practice.
Robertson M
Psychosocial Management of Bipolar Disorder
Royal Prince Alfred Hospital, New South Wales
Despite optimal pharmocological treatment a significant number of patients with Bipolar Disorder (BAD) still suffer high rates of relapse as well as considerable psychosocial morbidity. There is only a small literature in the psychotherapy of BAD, however, a few key studies demonstrate the potential efficacy of psychosocial interventions in the illness. From the point of view of Evidence Based Medicine the greatest support exists for interventions in the realm of Psychoeducational approaches, Cognitive Behavioural therapy and to a lesser degree Family therapy. New approaches such as Interpersonal and Social Rhythm therapy, Behavioural Family Management and Group therapy are under investigation, with promising pilot data. This paper will, having clinically evaluated the key studies in the field, propose some guidelines for clinicians to formulate psychosocial management approaches to BAD, in addition to appropriate pharmacotherapy.
Robertson S, Mayne K, Anderson B, Freidin J, O'Brien E, Redwin R, Tobin M
The Revised Maintenance of Professional Standards Program for 2001
MOPS Program Coordinator, R.A.N.Z.C.P
The Medical Boards in Australia are following the lead of the Medical Council of New Zealand by moving towards recertification and the proposal that specialists participate in their College's continuing education and professional development program as a condition of registration. Getting our Maintenance of Professional Standards Program right is, therefore, of great importance. The Program needs to meet the continuing education needs of all psychiatrists whether in clinical practice or in related areas such as administration, academia or research. Evaluation of the current MOPS Program has been underway for the past 6 months and many psychiatrists have participated in this process by responding to the MOPS Interest Survey and by attending focus groups held in Ballarat, Melbourne, Sydney, Brisbane and New Zealand. Having considered the feedback from Fellows derived through this consultative process, the MOPS Evaluation Steering Committee have proposed a number of changes to the Program. These changes will be presented providing Fellows with the opportunity to develop a clear understanding of the revised Program, to make comment on this and to present their concerns for consideration. It is hoped that Fellows will take this opportunity to learn more about the MOPS Program and to contribute to the evaluation and revision of the current Program
Copies of revised Program will be available at the MOPS Program stand in the exhibition area or in your satchel.
Rolfe T J, Kulkarni J, Fitzgerald P, Williams S, Montgomery W, Jafari A, Corteling N, de Castella A, Hopkins S, Thomas A
Assessment of Cannabis Use in Schizophrenia, Baseline Results from the Scap Study
Dual Diagnosis Resource Centre & Psychiatry Research Centre, Dandenong Area Mental Health Service, Dandenong, Victoria
Cannabis is the most commonly used illicit drug in Australia. At least 25% people with Schizophrenia use cannabis on a regular basis. To date no research in Australia, and little overseas, has attempted to routinely assess the impact of cannabis use on outcome of Schizophrenia. This has been hampered by the lack of suitable measurement tools for cannabis use in this population. Two questionnaires have been developed to assess cannabis use in a routine and structured manner. The first questionnaire measures quantity, frequency, method and type of use, as well as recording some symptoms of possible dependence. The second questionnaire looks at circumstances of use and reasons for use, with the aim of tailoring potential interventions to an individual persons needs. The questionnaires are being used in conjunction with an outcome study in 300 people with Schizophrenia to be conducted over a three year follow-up period, the Schizophrenia Care and Assessment Program (SCAP).
Baseline results for the first 300 people enrolled in the study will be presented, including symptom profile, as measured by the Positive and Negative Symptom Assessment Scale (PANSS), Montgomery-Asberg Depression Rating Scale (MADRS) and Quality of Life Scale (QLS). The results confirm that cannabis use is common, about one quarter of the sample used cannabis during the last month. Young males are commonly smoking large quantities of high potency cannabis. Most cannabis users have used for more than 5 years. However, summary indicators such as the PANSS, show no significant differences between cannabis users and non-users. Cannabis users readily report of their reasons for use, as worsening of psychotic and/or depressive symptoms is not commonly reported. The usefulness of self-report in guiding intervention strategies will be discussed.
Romans S, Rajiah J
Teenagers in Transition – Psychological, Geographical and Cultural, a Transcultural Perspective
Department of Psychological Medicine, Dunedin, New Zealand
The process of migration poses challenges and demands adaptation for those involved, especially if they are at a sensitive developmental stage. It also imposes responsibilities on the host culture. Research suggests that migrant groups often have a higher prevalence of psychiatric illness than either the population of origin or of settlement. Overall it is acknowledged that the migration experience itself is stressful but depends on what is being left behind eg. atrocious political conditions for political refugees and what is found on arrival. The varied ‘push and pull’ factors for each migrant individual and group account for the diverse research results. Two in-depth case studies of migrants in mid-adolescence who were referred to our local psychiatric services are examined. These cases were selected to determine common factors that might explain why they came to the attention of the psychiatric services. The authors also want to raise for discussion the responsibilities of the New Zealand community to those newly emigrated, given the potential contributions which migrants can make and the implications for psychiatric services. We call for more informative research in the area of migration and mental health.
Rosen A, Herrman H, Rafalowicz E, Wilson J (Joint Chairs)
Integrated Service Psychiatrists’ Meeting, April 2000
Director of Service, Royal North Shore Hospital & Community Adult Mental Health Services, Chatswood Community Health Centre, Chatswood, New South Wales
Comprehensive Area Service Psychiatrists (CASP) Special Interest Group has been meeting and running workshops for many years in NSW. CASP functions as an independent political advocacy body as well as a support group and information exchange network for psychiatrists working full or part time in, or consulting to, the public sector.
At THEMHS 1998 in Hobart, an informal meeting of psychiatrists involved in such service, from different parts of Australia and New Zealand, resolved that we should have a network meeting twice a year, at both THEMHS and the R.A.N.Z.C.P. Congress. This will be the inaugural formal meeting of this network. The agenda for this meeting may include reviewing The Role of the Psychiatrist in the Interdisciplinary Team, and the potential impact of integrating public, private and non-government psychiatric services at a local or area level; and other factors pertaining to enhancing and sustaining the involvement of psychiatrists in local mental health services.
At THEMHS 1999 in Melbourne a very successful and invigorating inaugural formal meeting was held in which the draft position paper by the Professional Liaison Committee of the R.A.N.Z.C.P. was discussed in detail as well as the following other topics:
Status and Pay Differentials
Loneliness of the long-distance psychiatrist
The Leadership Rose
Australia vs NZ Differences
It was resolved that we should continue to meet twice a year at both R.A.N.Z.C.P. Congress and THEMHS Conference.
Rosenman S, Korten A, Medway J, Evans M
The Utility of Categorical Diagnosis Compared with Dimensional Presentations of Psychosis
Psychiatric Epidemiology Research Centre, Australian National University, Canberra
Rosenman S J
Postmodernism and Psychiatric Diagnosis
Canberra Psychiatry Group
Operational diagnosis, and especially the DSM-III, brought technology into psychiatry. It aligned psychiatry with the practices of other branches of medicine and with grand science in the Modernist tradition. Modernism, the final flower of the Enlightenment, moved through the European intellectual landscape of the 19th and 20th centuries, – a search for the underlying “essential truth” of the structure of the world. Modernism came late to medicine, which continues as a modernist exercise even though “post-modernism” has undermined many of the intellectual certainties of the present generation. Modernist assumptions remain the intellectual ground on which psychiatrists walk so we are not aware of them as assumptions; rather they are woven imperceptibly as ‘reality’ into our knowledge of our professional world.
This light paper takes the form of fables taken from other intellectual areas – architecture, geodesy, music – to look for alternative constructions of truth and meaning. The paper examines some aspects of truth as it may apply to psychiatric diagnosis. It also attempts to show how “post-modern” approaches to knowledge may be accommodated in psychiatry.
Russell J, Abraham S, Hammerfald K, Gross G, Beumont P
Reproductive Function of Anorexia Nervosa Patients 6–10 Years after Treatment
Clinical Associate Professor, Department of Psychological Medicine, University of Sydney, New South Wales
Arguably the most striking endocrine consequences of anorexia nervosa are reproductive. These underpin and are associated with the problems with bones and growth. The time course of anorexia nervosa and its prevalence give rise to concern as to long term effects on reproductive function. Hence participants in a longitudinal study of anorexia nervosa were assessed specifically from this perspective.
Thirty nine female patients treated 6–10 years earlier for anorexia nervosa who were recently reviewed in a follow up study were recontacted and a semi structured telephone interview carried out using a questionnaire employed in 2 earlier studies. A matched control group was also studied. Mean BMI before treatment was 15.5 kg/m2, mean BMI following treatment was 19.0 kg/m2 and mean BMI at follow up was 20.4 kg/m. Eighty percent of former patients were judged to have a good or intermediate outcome using the Morgan Russell criteria. Outcome with respect to psychological parameters and bone density was better in the group in whom initial post refeeding BMI exceeded 19.0 kg/m2. In comparison to controls, there were similar numbers of former patients achieving at least one pregnancy and similar numbers of live births. However the total number of pregnancies in the control group was more than 50% greater than in the former patient group where only one reported having had a termination of pregnancy compared to 6 in the control group. In the patient group more had received treatment for infertility, had experienced severe vomiting and nausea during pregnancy and/or been diagnosed as having a baby small for gestational age. There were no reported differences in prematurity, congenital defects and spontaneous abortion. Although prepregnancy weights were similar to those of controls, former patients were lower in weight currently and at the end of pregnancy with lower weight gain during pregnancy. This suggests a lasting impediment to fat repletion although as a group there were also prominent concerns about weight, shape and food which may have influenced eating behaviour. The slightly shorter length of gestation is also of interest. Depression related to pregnancy and at any time was more frequently reported in former patients. They were also mote likely to have accessed treatment than were control women.
A past history of anorexia nervosa warrants particularly careful assessment of nutrition and mood with appropriate support throughout the antenatal and post natal periods. The effect on bone density of earlier anorexia nervosa continues to be of concern as do the long term sequelae. Uncertainty still prevails as to what constitutes full recovery and as to how this can best be promoted.
Russell J, Gross G, Beaumont P, Touyz S, Roach P, Aslani A, Hansen R, Allen B
What Weight is the Right Weight in Anorexia Nervosa? Outcome after 6–10 Years
Clinical Associate Professor, Department of Psychological Medicine, University of Sydney, New South Wales
In anorexia nervosa the level of optimal weight restoration necessary for full recovery has been unclear. In this study, an attempt was made to follow up 61 female patients hospitalised between 1989 and 1992 for treatment of anorexia nervosa. Using in vivo neutron capture analysis, total body nitrogen was measured at the commencement of nutritional rehabilitation (mean BMI 15 kg/m2) and after weight gain when, following an average stay of 11 weeks, the mean BMI was 19 kg/m2.
Follow up information was gathered from 50 patients (82%). All participants were assessed clinically and psychologically; weight and treatment history over the intervening period was documented. Thirty nine women were remeasured for total body nitrogen along with the two parameters unavailable at study commencement: bone mineral density using dual-energy-x-ray absorptiometry (DEXA) and total body potassium using a whole body counter.
A comparison was made between the outcomes of patients who reached a BMI of 19 or more during hospitalisation and those who failed to do so. Results indicate a good general outcome in 68% of patients with restoration of weight and reproductive function. Total body nitrogen was restored in the majority of patients indicated by an average nitrogen index of 0.97. However, bone mineral density remained suboptimal in all participants who had a DEXA measurement and totaly body potassium was reduced compared to a group age and sex matched normal controls. Patients who reached a BMI of 19 or higher had a significantly higher bone mineral density and better results in a number of psychological parameters than those who left hospital prematurely. Although the majority of subjects no longer met the criteria for anorexia nervosa in terms of low weight and amenorrhoea, a low discharge weight on index hospitalisation seemed to correlate with persisting body shape and weight concerns at the time of follow up Overall, these data support the contention that prompt adequate weight restoration confers prognostic benefit.
Ryan E
Nga Tai E Rua: The Maori Health/Mental Health Interface
Maori Community Psychiatrist; Director of Area Mental Health Services; Maori Health Commissioner; Chair Ngai Tahu Development Corporation, Christchurch, New Zealand
For over two decades participants in health planning have been concerned at the significant and sustained disparity of health status between Maori and other New Zealanders. It is now accepted that the most significant Maori health problem is that of poor mental health, reflecting the impact of acculturation and loss of identity; poverty; and the impact of rapid societal change on the Maori people. Health and social services have made little effective response to these disparities; it is now evident that the application of a standardised approach to service delivery based on orthodox practice does not adequately address the needs of Maori.
Erihana Ryan is a psychiatrist and Fellow of this college. Her particular interest in psychiatry and public health is the practice of Maori health and it's interface with general mental health services. She has participated in a wide range of practice models for Maori, and has been instrumental in the development of alternative services for Maori, and in alternative models of practice that incorporate a Maori paradigm into the response to the needs of Maori who have serious mental disorders,
In this paper Dr Ryan will describe the societal factors that contribute to the disparity of health experience for Maori in Aotearoa/New Zealand, and discuss models of practice from both mainstream and Maori providers that show an alternative model of practice for psychiatrists and mental health services.
Sachdev P
Is the Reduction of Mental Phenomena An Attainable Goal?
School of Psychiatry, University of New South Wales, & Neuropsychiatric Institute, The Prince of Wales Hospital, Sydney, New South Wales
In science, whenever a lower level explanation is sufficient, it becomes paramount. This paper addresses the proposition that the same will happen for human behaviour. The author considers different kinds of reductionism, and determines intratheoretic reductionism to be of salience in the current debate. The criticisms of a neurophysiological understanding of mental phenomena are discussed. It is argued that reductionism is a valid approach within the constraints of our current understanding of brain function. Such an approach would not result in a bottom-up explanatory strategy alone. A top-down approach will remain valid, and psychological theories will continue to hold currency. Top-down treatment strategies will also continue to play a role in therapy, and the empirical test will decide the relative merits of intervention at the molecular, cellular, network or mental levels. This approach will lead to a psychiatry in which the debates of mental vs. physical, psychological vs. organic will lose their relevance.
Sachdev P
Psychosis and Epilepsy: The Status of the Association
University of New South Wales & Neuropsychiatric Institute, Prince of Wales Hospital, Sydney, New South Wales
The author will provide a critical synthesis of the literature on the association of epilepsy and schizophrenia-like psychosis (SLP). The ictal, post-ictal and brief inter-ictal psychoses will initially be discussed. The recent interest in post-ictal psychosis has opened up an important avenue for research. Many aspects of chronic inter-ictal SLP remain controversial. Some suggested risk factors are severe and intractable epilepsy, epilepsy of early onset, secondary generalization of seizures, certain anticonvulsant drugs, and temporal lobectomy. It is likely that structural brain abnormalities, e.g., cortical dysgenesis or diffuse brain lesions, underlie both epilepsy and psychosis, and that the seizures modify the presentation of psychosis, and vice versa, thus producing a clinical picture of both an affinity and an antagonism between the two disorders.
Sachdev P
The Neurobiology of Psychodynamic Theory: Freud's Project Revisited
University of New South Wales & Neuropsychiatric Institute, Prince of Wales Hospital, Sydney, New South Wales
Early in his career, Freud wanted to develop a psychology for neurologists which was grounded in neuroscience, and he presented a model in 1895 entitled “Project for a Scientific Psychology”. His subsequent theories moved away from this objective, and in his later life he attempted to destroy this document even though he never gave up the wish of replacing psychological terms with physiological ones. If one considers the status of neuroscientific knowledge in late 19th century, it is not surprising that Freud abandoned his quest. As we enter the 21st century, however, the situation is quite different, and a neuroscientific psychology seems almost within our grasp. In exploring a neuroscientific framework of the mind, many psychoanalytical concepts must be modified and others abandoned. The concept of the unconscious mind must be understood in terms of implicit memory and non-dominant brain function, the preconscious as a frontal lobe function, psychological determinancy as a consequence of conditioning, historical personality development in terms of critical periods, attachment etc. The concept of defense mechanisms can be couched in neuroscientific terms, but many aspects of Freudian theory, in particular the psycho-sexual stages, stretch scientific credibility. The dialogue between neuroscience and psychoanalysis has begun in earnest, and psychoanalysis will be richer if it adopts both the method and the view of neuroscience. The ability of psychoanalysis to inform the biology of the mind should not, on the other hand, be under-estimated.
Salzberg M R
The Neuropsychiatry of Dreaming: A Critique and Integration of the Work of Solms and Winson
University of Melbourne, Department of Psychiatry, St Vincent's Hospital, Melbourne, Victoria
The recent work of Solms, “The neuropsychology of dreams: a clinico-anatomical study” (1997), is a very important piece of research and theory. In the psychoanalytic world dreams have never lost their preeminent status. But in the neuroscientific world dreams have been construed as essentially meaningless in theories such as the “activation-synthesis” model of Hobson and McCarley and the “reverse learning” theory of Crick and Mitchison. Solms’ research moves the theory of dreaming beyond both psychoanalytic and current neuroscientific approaches and helps reinstate dreaming as an important higher cognitive function. In his clinical study of a heterogeneous sample of 361 neurological patients, seen in neuropsychological practice over 4 years, Solms studied not the content but the form of dreaming. He examined the neuroanatomical and neurobehavioural correlates of symptoms such as global cessation of dreaming, nonvisual dreaming, confusion between dreams and reality and recurring nightmares. His book exhaustively reviews the neurological literature, starting with the classic cases of Charcot and Wilbrand, but also taking in much of the neurobiological theorising over the century. The book culminates in a speculative model of the normal dream process, which in turn suggests a number of rational and testable hypotheses for further research. There are obvious limitations to Solms’ research, such as the potential for observer bias, but it stands out as model of creative and rigorous clinical research and deserves to be replicated and extended.
Solms views the dream process as “… a third contrivance designed to protect the state of sleep” (the other two being the profound deactivation or inhibition of sensory and motor systems). It comes into play partly when the other two contrivances fail (e.g., external sensory stimuli above a certain threshold) and partly when the other two contrivances are unable “… to block the arousing effects of endogenous stimuli during sleep”, particularly endogenous stimuli that activate “the curiosity-interest-expectancy (appetitive) circuits of the mediobasal frontal region.” A key limitation of Solms’ theory is that he has little to say about the potentially arousing “endogenous stimuli” that may activate the dream process. In this regard, and somewhat curiously, Solms does not refer to the neurobiological work in recent years implicating dreaming in memory processes in both experimental animals and humans. Nor does he refer to the work of the neurobiologist Winson, who attempted an integration of psychoanalytic dream theory and these neurobiological findings (in “Brain and psyche” (1986)).
Sara G
Looking beyond the Virtual Institution – Challenges for “Community” Psychiatry
Division of Mental Health, Sutherland Hospital, New South Wales
In the second a system of care for depression is being developed. This system involves provision of a range of treatment resources and other supports to GPs, systematic coordination of GPs and the public mental health service as an identified “Depression Treatment Network” and changes to triage, assessment and treatment processes within the mental health service. Some of the difficulties encountered and lessons being learned in developing these systems will be discussed.
Sawyer M G, Graetz B W, Whaites L, Arney F, Baghurst P, Kosky R
Initial Results from the Child An Adolescent Component of the National Study of Mental Health and Well-Being
National Collaborating Group, Department of Psychiatry, Flinders Medical Centre, Bedford Park, South Australia
Schimmel P W
Mind over Matter?
Private Practice, Roseville, New South Wales
Although the words ‘mind’ and ‘brain’ have distinct and differing meanings, there is a tendency in psychiatric discourse to use them interchangeably, conflating their meanings as if they refer to one and the same thing. This blurring of meaning often seems to be accompanied by an assumption that the so-called ‘mind/body’ or ‘mind/ brain’ problem no longer exists; this assumption being based on the fact that the available data from biological research suggest that some ‘identity’ exists between cerebral brain events and mental events. The assumption that the ‘mind/brain’ problem has been solved, or will eventually be solved, by scientific method has also had a significant influence within philosophy and psychology during the last century, as reflected in the ascendance of behaviourist and materialist doctrines. The end of the twentieth century seems however to have marked the beginning of a trend in the opposite direction, with influential philosophers insisting upon the conceptual distinction between mental events and brain events, and that ‘mental’ cannot be reduced to ‘material'.
This paper reviews the debate and argues that in essence the ‘mind/brain’ problem is a conceptual and philosophical one, and that data from scientific research alone, while relevant to the formulation of the problem, cannot provide its ‘solution'. Just how mind and brain may be two aspects of a single reality remains a conceptual mystery, the solution of which, if indeed there is one, is a problem of metaphysics rather than physics. The paper also provides some examples from the contemporary psychiatric literature of the process of attempted conflation between mind and brain, and of me conceptual confusion that results.
Schioldann J A
Did Lithium Therapy of Affective Disorders Turn One Hundred and Forty Or Fifty?
University of Adelaide, Department of Psychiatry, Adelaide, South Australia
The (re)discovery by John F. Cade, in 1949, of lithium's antimanic properties is considered to be ‘one of the major medical discoveries of the 20th century'. Notwithstanding its striking effects, claims originally received little attention by psychiatry until 1954 when Mogens Schou of Risskov, Denmark, and his co-workers confirmed them in the first placebo-controlled double-blind trial in psycho-pharmacology In 1967 Schou and Basstrup suggested that lithium had prophylactic properties against recurrent affective disorders (bipolar and unipolar). This hypothesis sparked fierce controversy in the international medical press, and was characterized as a ‘therapeutic myth'. Finally, in 1970 71, they confirmed the hypothesis – and lithium prophylaxis was hailed as ‘one of the most important advances in modern psychiatry'. Introduced into medicine by A. Garrod in 1859 for the treatment of uric acid diathesis, comprising ‘gouty mania’, Hammond of New York, reported its use in acute mania in 1871. From 1874 to 1907, the Danish brothers Carl and Fritz Lange treated ‘periodical depression’, in their opinion a manifestation of the uric acid diathesis, with lithium, both in its acute phase and for its prevention. Unfortunately, their ingenious observations were ignored by psychiatry and eventually fell into oblivion.
Schönauer-Cejpek M
Treating Bulimics with Dbt – a New Concept
University Hospital Graz, Department of Psychiatry, Auenbruggerplatz 22, Austria
According to Marsha M. Linehan, Dialetic Behavioural Psychotherapy (DBT) is a very specific way of treating patients suffering from a borderline personality disorder using a multimodal model combining techniques of various psychotherapeutic schools.
In follow up studies (Archives of General Psychiatry 1991, 1993) Marsha M. Linehan showed that using this model of group psychotherapy leads to a reduction of self-injuring (parasuicidal gestures, drug and substance abuse, eating disorders) and internal stress as well as to an improvement in the quality of life. At the Department of Psychiatry of the University Hospital in Graz, a modified form of Marsha M. Linehan's concept is used in the treatment of bulimic patients.
Bulimic women show feelings of inner tension, very similar to the feelings of tension arising in borderline patients, and a feeling of release as soon as they make the decision to vomit. In Graz, we use a combination of skills training in groups (in order to achieve a reduction of bingeing and purging attacks) and individual psychotherapy (psychotherapists of different school who work in private practice). Information is shared regularly between psychotherapists and skills trainers through intervision groups (Advanced Linehan-concept, Braga 1999)
keywords: Dialectic Behavioural Psychotherapy, bulimia nervosa, skills training.
Schuhmacher Smith C
The Consumer Perspective and the Impact of the Stolen Generation
Aboriginal Consumer Representative, New South Wales
Increasing numbers of Aboriginal people are working and studying in the areas of health, mental health and welfare. Many of these people have been directly affected by having been taken away themselves or by having family members taken. As the issues arising from the Stolen Generations are dealt with in places of study and work many Aboriginal people are finding it difficult to cope. Cynthia Smith Schuhmacher, an Aboriginal consumer representative and member of the College's Aboriginal and Torres Strait Island mental health committee, has been working with those who find dealing with the stones of the Stolen Generation confronting and personally painful.
Seiboth C
Primary Care Psychiatry a Model of Shared Care
Mental Health Programs Officer, Adelaide Northern Division of General Practice
The Adelaide Northern Division of General Practice (ANDGP) has adopted an innovative model of Shared Care for psychiatric patients in primary care settings. The Shared Care model has been developed by ANDGP members and by psychiatrists from mental health services based in Adelaide's northern suburbs. The main objectives of the Shared Care model have been to improve the continuity of care for psychiatric patients and to increase GP's skills in the assessment and management of mental health disorders.
ANDGP has implemented a range of strategies to achieve these objectives including:
Joint consultations
Lunchtime clinical meetings
Case conferences
Clinical attachments
Information & skills based workshops
The Shared Care model was first developed and implemented in 1995 and has continued to be refined to its present format. The poster display will showcase vignettes of how psychiatrists can work closely with GPs to improve patient mental health outcomes. The poster will display the results from the ANDGP Shared Care model, highlighting the benefits of adopting such an approach.
Seidel G
Mad Scenes in 19Th Century Opera
Acting Director, Downey House Psychogeriatric Unit, Glenside Hospital, South Australia
Many complex relationships can be found between themes in Psychiatry and the rich repertoire of lyric opera. In this paper the author has chosen to study ‘mad scenes’ in 19th century opera in which composers were fond of giving deranged heroines spectacular opportunities for vocal display. These scenes are studies by looking at the predominant themes, the ‘phenomenology’, apparent treatment and outcome, and the way music is used to portray madness. The author attempts to correlate these findings with contemporaneous developments in psychiatry, thought and society.
Shephard I (Chair)
Open Forum
President, Guardianship Board, South Australia
This session will provide an unique opportunity to raise any issue involving Mental Health Tribunals and how their decisions relate to the provision of services. Questions on notice should be submitted to the President, Guardianship Board of South Australia, 85 North East Road, Collinswood 5082 prior to 19th April, but questions without notice will be accepted from the floor on the day.
Shields R, Bashir M
Moving Forward Together – Working in Partnership for Aboriginal Health and Mental Health
Head of Aboriginal Mental Health Unit, Central Sydney Area Health Service, New South Wales
The historic Partnership Agreement established by the NSW Minister for Health in 1997 between Aboriginal community controlled and mainstream health has set a positive model towards optimal mental health care delivery. Fundamental to an effective partnership is the unconditional commitment and determination by mainstream participants to ensure that Aboriginal people will have access to high quality care of at least the standard available to non-Aboriginal communities.
Mental health is an integral part of general health. It maybe particularly influenced by experiences of unresolved loss and grief. Emotional distress and mental health problems can impact greatly on physical health and in turn, poor physical health will adversely affect mental health and well-being.
The impact on Aboriginal health of history, culture, past and continuing episodes of trauma and disadvantage must be understood and acknowledged by any mainstream professional who seeks to contribute to a genuine partnership.
An effective mainstream worker therefore, regardless of past qualifications and training must regard himself as a student who will receive a new special education to which he contributes unqualified respect.
Before initiating a service, the expectations of community members must be clarified and the specific needs of each individual community should be explored in consultation. Flexibility in approach is critical, with a capacity to work along side community team members and to be comfortable with both young patients and seniors. Complex situations are not uncommon and may require strong advocacy on behalf of patients across several government sectors. Skills as wide ranging as family counselling, forensic assessment and use of the new technologies are required. Approaches in partnerships in both urban and rural settings will be considered.
Shillito M, Hay P, Game P
Psychiatric and Psychosocial Adjustment following Gastric Bypass Surgery for Severe Obesity
Department of Psychiatry, The Royal Adelaide Hospital, The University of Adelaide, South Australia
Singh B
Looking Outward – Australia in the Global Village
Cato Professor & Head, Department of Psychiatry, The University of Melbourne, Clinical Director North Western Health Mental Health Program, Victoria
Globalisation has come into focus around the world in the past decade in many areas of human activity. Publications such as World Mental Health and The Global Burden of Disease, have played a role in putting mental health on the world health agenda. Australasian psychiatry has a particular part that it can play in the Asia Pacific region. Australia and New Zealand are two of few established market economies in the Asia Pacific Region. Both have benefited from their traditions and natural resources to build strong medical professional bodies and health systems – in particular psychiatry and mental health care systems.
They have a great deal to offer, as well as to learn from the region constituting almost 40% of the world's population.
In this presentation I will describe initiatives in place that Australasian psychiatry is making, as well as further potential opportunities.
A particular organisation that could facilitate our involvement is the Pacific Rim College of Psychiatrists, which is rethinking its role and structure and will continue to do so under my Presidency 2001–2003.
Smith G (Workshop Moderator)
Speakers: Gold J, Hacker S, Croft G, Darby E
Self-Disclosure in Psychiatry Revisited
Renal Consultation-Liaison Psychiatrist, Monash University, Victoria
The prevailing ethical standard in Psychiatry regarding self-disclosure of personal issues to patients is based largely on psychoanalytic theory of practice. This holds that disclosure about personal details and beliefs should be confined to that which cannot be avoided, but that details discovered by patients in other ways should be acknowledged and dealt with. Changes in society's views are leading to a demand for greater openness. Psychiatrists have always had to deal with enquiries about their ethnic background and religious beliefs, but now face questions about their marital status, parental status, gender preference, and attitude towards various social issues. Rural psychiatrists have always had to deal with extensive knowledge of their private lives by the public. Illness in the psychiatrist now presents a greater challenge with respect to openness. There is a need to revisit the issue of self-disclosure. This Workshop will do so by exploring the ways in which psychiatrists are handling the challenges to self-disclosure practices. There will be discussion of the theoretical underpinning of self-disclosure behaviour, and of the ethical and practical issues that are likely to ensue from changes in practice.
There will be presentations on the following:
Illness in the psychiatrist
The psychiatrist who is a public figure
The psychiatrist working with gay and lesbian patients
The rural psychiatrist This will be followed by audience participation in general discussion.
Smith G C, Macasey P, Trauer T
Screening and Monitoring in Renal Dialysis and Transplant Patients Using the Sf36 and Patient Health Questionnaire
Renal Consultation-Liaison Psychiatry Service, Southern Healthcare Network; Department of Psychological Medicine, Monash University, Victoria
Snars J, Tobin M J, Keller A
Strategic Leadership and Management Skills – Development in Psychiatry
Mental Health Services, St Georges Hospital, Kogarah, New South Wales
There were three parts to the methodology, these were:
Generations of a discussion paper to engage the broad fellowship.
Review of literature about clinician management and review of programs designed to address these issues.
Survey of attitudes, knowledge and interest of the broad fellowship in leadership and management for psychiatrists.
The fellowship survey was conducted by a structured telephone interview. The interview examined five key areas; the impact of structural and strategic reform; management education, training and development; the transition from clinician to clinician-manager; relationships between clinicians, clinical managers and non-clinical managers; and the skills, knowledge and competencies required by psychiatrists in leadership roles.
The discussion paper in Australasian Psychiatry generated interest which was evidenced by informal feedback to the steering committee.
The review of current programs and literature identified commonalities across several countries regarding knowledge and skills required by clinicians in management and leadership positions.
Several current training/development programs have been identified as having usefulness for psychiatrists.
The survey illustrated a recognition that all psychiatrists must be able to demonstrate skills in leadership across a wide range of issues in mental health care in Australia and New Zealand. However, for those psychiatrists engaged in management, there was general agreement among survey respondents mat psychiatrists did not feel well equipped to make the transition from clinician to clinician-manager. Yet their preferred model for mental health service management in the future supported psychiatrist –managers.
We identified a trend towards increased involvement of psychiatrists in leadership and management roles, particularly with respect to increased emphasis on multi-disciplinary care, consumer involvement, and increased accountability of clinicians. However, success in these roles may be limited if psychiatry training does not equip them with the skills required for effective leadership and management in an increasingly complex health environment. A preference was expressed for training to be made available through short courses, work based activities or monitoring. University post-graduate qualifications in management were seen as a requirement limited to those who chose a career path in this field.
Spielman R
Psychoanalysis and Attachment Theory: Partners Or Rivals
Private Practice, Paddington, New South Wales
Psychoanalytic theories from their outset have had much to say about the relevance of parent-child relationships to the development of adult mental states of mind and adult psychopathology. Freud's earliest theories concerned the relationships to both parents, and Kleinian theory highly refined the importance of early mother-infant experience. All these theories were derived from psychoanalytic observation and treatment of adults initially, and subsequently, quite young children.
The advent of Attachment Theory from the work of John Bowlby, Mary Ainsworth, Mary Main and many others, as well as other developmental theories has seen the operationalisation of these newer theories and the heavy reliance on observations of the youngest of infants in their actual relationships with their mothers and other caregivers. The development of standardised methods of observation and scoring has provided a rather more objective basis for studying these earliest relationships, which stand in contrast to the essentially subjective methods typical of psychoanalytic observation and theory development.
This paper will explore to what extent the newer theories provide challenges to or support for the mainstream psychoanalytic theories – or whether psychoanalytic theories and practice continue to address a realm of experience as yet not approachable in any other way.
Stein S, Kenny M.
Alfred Hitchcock's Vertigo
Psychoanalyst, South Australia
Nobody who is interested in psychodynamics should miss this opportunity to see how different therapists think and work on the same ‘case’, presented for all to see on the screen. The film Vertigo will be followed by discussion and questions. If you have seen the film, so much the better. The events at the beginning are particularly significant and another viewing might reveal previously unnoticed aspects in the main character. Dr Sam Stein, Psychoanalyst, and Dr Maura Kenny, Cognitive Therapist, will lead a discussion based on the events as depicted in the film.
It is recommended that you attend both sessions to participate in the discussion.
Steinbrenner B, Schöenauer-Cejpek M, Althuber P, Steinbrenner J, Zapotoczky H G
Anorexia Nervosa: The Later, the Better – is There a Connection between Age of Onset and the Prognos
University Hospital Graz, Department of Psychiatry, Austria
Patients with anorexia nervosa (according to DSM IV) are experienced very differently in psychiatric contact. One group appears considerably more approachable, easier to motivate and shows more awareness for their problem (Type I). The other group attracts attention by peculiar rigidity (Type II).
This study was performed in order to show a connection between age of onset of anorexia nervosa, the conduct of the disease and later ability for psychotherapy.
20 patients were interviewed in person and with questionnaires concerning their symptomatology, history of disease, former treatments, body perception and motivation for psychotherapy. Besides FbeK (Fragebogen zur Beurteilung des eigenen Körpers, Strauß & Richter-Appelt) and FMP (Fragebogen zur Messung der Psychotherapiemotivation, Schneider, Bader & Beisenhez) two questionnaires developed by our team were used.
Type I anorexics show later age of onset (mean age 20 years) and better prognosis than Type II (early beginning of anorexia, mean age 15 years). The hypothesis of two different types of patients was confirmed by the inquiry. Type I patients have significantly higher social competence and coping strategies. These women find easier access to psychotherapy and are less likely to drop out of therapy than Type II patients with earlier onset of anorexia nervosa.
keywords: age of onset, anorexia nervosa, prognosis.
Storm V
Adhd – a Joint Position Statement
Chair, Faculty of Child & Adolescent Psychiatry, R.A.N.Z.C.P.
This presentation is aimed to stimulate debate and discussion amongst Faculty and College Fellows.
There has been considerable debate about the clinical entity of ADHD. Some of this is well informed, based on good research whilst other aspects have been alarmist, especially in the popular press. One aspect that has been consistently demonstrated in population surveys is the presence of a fairly constant rate of disruptive behaviour, characterised by inattention, distractability, poor concentration and sometimes excessive activity of around 5–10%, more commonly in boys.
Another fact that has been well demonstrated scientifically is the good clinical response to stimulant medication by children who suffer with these symptoms to the extent they severely impact on their school and home life.
What has not been resolved are the precise diagnostic criteria which should apply for treatment. In an earlier presentation to Congress (1995) NSW figures demonstrated treatment rates for ADHD varying by factors of 40 fold between various centres across the State. Also there has been a significant increase in the overall rate of prescription of stimulants across Australia, particularly in WA and NSW.
The NHMRC issued guidelines on ADHD in 1997, which amongst a range of other literature on this topic. Drawing on these references the Faculty of Child & Adolescent Psychiatry R.A.N.Z.C.P. and the Division of Paediatrics R.A.C.P. are working together to draw up a joint College position statement on ADHD, to advise Fellows of both Colleges.
It is hoped that within the framework of this presentation and subsequent discussion, useful contribution to the joint statement will follow.
Strang J
Opiate Detoxification: Evolving Practice
Director, National Addiction Centre, London
Opiate detoxification has classically been managed by tapering doses of a substitute opiate such as methadone, as in 21 day methadone detoxifications in the US. Following growing awareness of deficiencies with the standard methadone detoxification, revisions to this approach were undertaken through the 1980s in the UK which will be summarised. During the 1970s the search for alternative approaches led to exploration in the US of the possible management of heroin detoxification under cover with clonidine, although its use was largely restricted to an inpatient setting because of the pronounced hypotensive effect. In the UK, lofexidine (a clonidine analogue) was introduced and studied and has been found to be broadly equivalent to clonidine in its effectiveness but without the same degree of hypotensive complications, thus giving it a profile which would seem to be much more suitable for community and outpatient use – the recent studies of lofexidine will be summarised in this presentation. More radically, the duration of the opiate withdrawal syndrome has been attacked through antagonist provocation (naloxone, naltrexone) with an immediate onset of full-blown withdrawal syndrome but with an apparent earlier recovery. Given the distress experienced with this approach, it has often been accompanied by heavy sedation or general anaesthesia, and the subsequent spread of such antagonist-provoked opiate detoxification under anaesthesia has become the subject of heated current debate.
Finally, the influence of setting has also been studied, with the identification of major differences between inpatient and outpatient completion rates, and between the results achieved with specialist teams compared with general psychiatric services. The findings will be presented and their implications discussed.
Strang J
Preventing Opiate Overdose: Recent Innovative Proposals from the Uk and Australia
Director, National Addiction Centre, London
The mortality rate amongst opiate addicts is markedly greater than for the age-matched non-addicted population – the mortality rate being estimated to be 10–20 times higher. Overdose is a major cause of these premature deaths. Recent studies in the UK and Australia have re-examined opiate overdose, and have particularly used the method of interviews with treatment and non-treatment samples in order to explore the circumstances of personal overdoses amongst survivors, as well as gathering information on witnessed instances of non-fatal and fatal overdose. History of overdose is typically reported by at least half of the opiate addicts in treatment, and by a third of the (typically younger and earlier) community samples. Whilst a small proportion of the overdoses reflect genuine suicidal intent, the vast majority are non-intentional overdoses. In the UK context where there are perhaps equal numbers of heroin users who “chase the dragon” as inject, it is striking that virtually all of the reports of overdose were found amongst the heroin users who injected (i.e. virtually no reports of overdose amongst heroin chasers).
New approaches to overdose prevention must now be considered. Most overdoses have occurred in the company of friends, and in a domestic situation. Hence there is the possibility of teaching and empowering drug misusers themselves to initiate resuscitation procedures such as “rescue breathing” and placing the overdose victim in the lateral recovery position whilst awaiting an ambulance and this training and empowerment could reasonably be extended also to parents and other family members with whom the opiate misuser may live. Additionally, consideration is now being given to the possible distribution to opiate addicts themselves (and to their families) of take-home emergency supplies of the opiate antagonist, naloxone, accompanied by training in its emergency administration after first calling an ambulance and secondly establishing a clear airway and breathing. The feasibility and acceptability of this latter proposal will be particularly explored in the presentation.
Streimer J, Burek R, Price M
Cancer Patients & Clinicians Assessment of Psychological Comorbidity
Private Practice, Sydney, New South Wales
Our study examined and compared how well cancer patients and treating physicians detect psychological comorbidity. Baseline comorbidity was determined using the Brief Symptom Inventory (BSI). Psychological cases thus detected were interviewed by an experienced clinician to establish a psychiatric diagnosis. All patients and their primary physicians-oncologists and haematologists were asked to rate patient distress and coping. One hundred consecutive admissions with active neoplastic disease were studied. Forty three percent of patients reached caseness on BSI. The majority of these were diagnosed as depressed. Fifty five percent had Adjustment Disorders of depressed or mixed depressed/anxious type, a further 18% having other depressive disorders. Patients’ self-ratings revealed about half (56%) reported some degree of distress and 52% reported coping less than well. Surprisingly, clinicians rated patients significantly more distressed and coping less well than patients rated themselves. There was a significantly strong correlation between severity of physical illness and patients’ assessment of distress and coping, but far weaker correlation with clinicians’ ratings. Further, patients with significant psychological morbidity perceived themselves poorer at communicating distress than did non-cases.
The strongest predictor of psychological comorbidity was patients’ estimation of coping. On regression analysis, patients coping correctly predicted 81.4% of BSI cases and 70.2% of non-cases, with an overall prediction rate of 75%. The false negative prediction rate was low (8%) and the false positive rate 17%. Clinician ratings did not significantly add to the identification of comorbidity. Other recent research has found a similar discrepancy between patient and staff estimation of psychological morbidity but was unable to differentiate whether this was due to clinicians’ over estimation of distress or patients’ underestimation and “positive illusions” about coping (Merluzzi et al 1997). Reports in the literature have shown that clinicians generally have difficulty identifying psychological comorbidity, especially depression in cancer patients (Passik et al 1998).
Our study demonstrates that patient estimation of coping is the better discriminator and this estimation can predict much of the psychiatric comorbidity. These results suggest that clinicians’ screening for significant psychological and psychiatric comorbidity could be improved by relying on their patients’ responses to simple questions about distress, especially depression and whether they are having any difficulty coping.
The finding that dichotomised questions about coping detected BSI caseness 75% of the time, supports other research which found responses to the single question. “Are you depressed?” in patients with advanced cancer, more accurate than more complex screening instruments (Chochinov et al 1997).
References:
Merluzzi T, & Sanchez M (1997) Perceptions of coping behaviours by persons with cancer and health care providers. Psycho-Oncology, 6: 197–203.
Passik S, Dugan W, McDonald M, Rosenfeld B, Theobald D, Edgerton S (1998) Oncologists recognition of depression in their patients with cancer. Journal of Clinical Oncology, 16: 1594–1600.
Chochinov H, Wilson K, Enns M, Lander S (1997) Are you depressed? Screening for depression in the terminally ill. American Journal of Psychiatry, 154: 674–676.
Sugarman R
Social Withdrawal and Rapid Cycling Mood Disorders: Impetus for the Biopsychosocial Model
Brenthurst Centre for Rehabilitation Medicine, South Africa
The author examines the phenomenon of social withdrawal, and the links to rapid cycling moods. Using the models and theories of Antonio Damasio and Russell Barkley, as well as Leslie Koopowitz locally, the work examines the executive functions of the prefrontal cortex, defining the nature of self-regulation of action and emotion within an evolutionary process, and from the perspective of social Darwinism. The paper concludes by integrating the work of several recent researchers on the Mind/Brain dilemma, and encourages the emergence of a unitary biopsychosocial approach in psychiatry.
Sved Williams A E
Balint Groups for General Practitioners: Are They Worthwhile?
Women's and Children's Hospital, Adelaide, South Australia
Take-up rates of those attending initial meeting
Attendance rates of those agreeing to participate
Focus group at completion
Change over time on measures of stress and occupational functioning, including:
Depression, Anxiety, Stress Scale (DASS)
Maslach Burnout Scale
Counselling Skills Scale
Sved Williams A
Psychotropic Medications Prescribed in Pregnancy and Lactation: Trends in Puerperal Psychosis Abstract Body
Women's and Children's Hospital, Adelaide, South Australia
Significant differences were found in several parameters measured:
Awareness of effective prophylaxis for puerperal psychosis
Psychotropic medication chosen between specialist groups
Prophylactic medication chosen by perinatal psychiatrists.
Swartz L
Culture, Social Change and Mental Health: A View from South Africa
University of Cape Town, South Africa
In these postmodern times it has become little more than a cliché to say that there are many perspectives on culture and mental health, that reality and identity are contested, that globalisation brings with it both greater uniformity and greater fragmentation than we have been aware of before. But what are the implications of all this for how we work? How do we struggle to find our own paths and identities in this world of alternatives? Cultural relativism is easy to talk about but much more difficult to practice where there are fundamental clashes of perspective. Is it our job to embrace the alternatives offered by the people with whom we work, or to offer alternatives to them?
In this paper I present a challenge to consider the political context of mental health care. I draw from my own experience and research but the issues are relevant in other contexts. In the first section of this paper I discuss some of our current work in an informal settlement in South Africa, and the complex cultural and political questions this study raises for us. In the second section I consider the issue of language and mental health and some of the reasons for the almost universal silence on this issue. This leads to a broader discussion of the question of resistance to change in health systems and the need to understand cultural dynamics. The question of transformation of the professions themselves is also considered. Finally, I argue that an integrated understanding of culture and trauma is essential to any attempts to improve mental health services for minorities and in developing countries.
Tamasese K, Bush A, Waldegrave C
Ole Taeao Afua: The New Morning – a Qualitative Investigation into Samoan Perspectives on Mental Health and Culturally Appropriate Services
Pacific Island Coordinator, The Family Centre Social Policy Research Unit, Wellington, New Zealand
This workshop will:
further develop the findings of this study set out in the plenary address
introduce a second study carried out by Allister Bush that explored with psychiatrists in Wellington the similarities, differences and implications of the Samoan views of self and their own views
introduce the Just Therapy approach, developed at the Family Centre and now widely used internationally, as offering a culturally appropriate and safe way to address the issues of therapy raised in the two studies.
The first section will address a number of the ethical issues cultural research raises and further explore the methodology and findings of the study, set out in the plenary presentation, in greater depth. This research inquires into Samoan descriptions of mental health and well being, their experiences of the New Zealand mental health system and their conceptions of a culturally appropriate mental health service for their people.
The second section will introduce the linked investigation carried out by Allister Bush. Its aims have been to describe psychiatrists’ perspectives on the meaning of self in common psychiatric usage, to explore similarities and differences between this and Samoan views of self, and to examine the implications of the differences described, for the theory and practice of clinical psychiatry. A focus group of New Zealand based psychiatrists was convened for three sessions. Participants were exposed to a Samoan view of self during the study. Transcripts were analysed using a content and inductive analysis method. A process of cultural accountability was included in the research design.
The third section will introduce the Just Therapy approach as offering a culturally appropriate and safe way to address the issues of therapy raised in the two studies. The Family Centre regularly run workshops and other teaching events on this approach throughout Australasia, Europe, North America, the Pacific and on occasions other continents. A Just Therapy is one that takes into account the cultural, gender and socio-economic contexts of the persons seeking help. They consider that therapists have a responsibility to find appropriate ways of addressing these issues in therapy and in the health systems as a whole, in a manner that will affirm people's sense of cultural belonging and lead to self determining outcomes.
Tamasese K, Waldegrave C
Ole Taeao Afua: The New Morning. Samoan Perspectives on Mental Health
Pacific Island Coordinator, The Family Centre Social Policy Research Unit, Wellington, New Zealand
This presentation will outline the methodology and findings of a qualitative investigation into Samoan perspectives on mental health and culturally appropriate services. Funded by the Health Research Council, this research inquires into Samoan descriptions of mental health and well being, their experiences of the New Zealand mental health system and their conceptions of a culturally appropriate mental health service for their people.
Tan E-S (Chair), Speakers: Minas H, Mans, L
Working with Our Neighbours.
Fellows of the College in Australia and New Zealand have been doing a lot of work in countries close to Australia, in PNG, the islands of Oceania, and in the countries of East and South-East Asia, notably Vietnam and China. It is important for Fellows to know what each other is doing and possibly coordinate our effort. If it is possible to have collaborative projects in these countries it would even be better. We should take the occasion of the College Congress to update ourselves of such undertakings. In the absence of Graham Mellsop, Chair of the Regional Issues Committee of the College, Eng-Seong Tan will chair the session.
Tan M
Roles and Functions of Psychiatry Medical Staff in Two Services
St Vincent's Mental Health Service, Melbourne, Victoria
Tanaghow A, Isaac D, Harris R, Winter A, Puszet P, Hamann H, Organ B, Grigg M
Building a Platform for Partnership between St Vincent's Mental Health Service and Divisions of General Practice – Systemic Approach
St Vincent's Mental Health Service, Melbourne, Victoria
A National Mental Health Strategy promoted the development of a partnership between the Area Mental Health Service and general practitioners. These shared care programs were based on an ad hoc project-based approach. We at St Vincent's Mental Health Service (SVMHS) developed a systemic approach for the development of effective partnership with general practitioners. A General Practice Shared Care Committee was established which included leadership from the Clinical Director within the SVMHS, a representation from both Divisions of General Practice (between the Inner East and Melbourne Division), St Vincent's Hospital General Practice Liaison doctor and senior SVMHS clinicians. A Shared Care Committee has focused on developing a systematic approach to promote long term changes. The systemic approach included developing GP shared care policy which covered the following procedures.
Co-ordination of care including referrals from GPs to St Vincent's Mental Health Service, care planning and on-going management, transfer of care and involvement of GPs in care planning and case conferences. The Committee developed a special joint multidisciplinary shared care plan adopting the changes in Medicare Benefits Schedule items.
Secondary consultation ensuring the GPs have access to a specialised psychiatric opinion.
Ensuring that SVMHS patients have access to general practitioners.
Addressing issues of confidentiality.
Education and training including coordinating regular training opportunities for GPs on mental health related topics and ensuring that relevant issues to working with GPs and shared care are integrated in the training program for SVMHS clinicians.
Maintaining a GP database.
Evaluation and developing key performance indicators within the organisation. Part of the systemic approach is to implement an information system to ensure the routine transfer of information to all GPs in the area.
Tapsell R McNaughton L* (Convenors)
Walking Together, Working Together: Open Forum
Mason Clinic, Auckland, New Zealand, *Aboriginal Health & Medical Research Council of New South Wales
The last session devoted to Aboriginal, Maori and Torres Strait Islander mental health will bring together the ideas and enthusiasm generated in earlier sessions. It is an open forum and we invite everyone to attend and contribute to the discussion. This session should help us find ways of working together, so that we can better understand and address the burden of ill health and early death borne by Aboriginal, Maori and Torres Strait Islander people.
Terranova-Cecchini R
Cultural Sensitivity in Psychiatry: A Transcultural Practice Experiences in Italy
Transcultural Institute for Health, Foundation Cecchini Pace, Milano, Italy
The idea of the relationship between psychiatry and the society in which the psychiatrists live and practice has been developed by many schools: social psychiatry, cultural psychiatry, culture and personality, psychoantropology, and so on. Modern cultural studies have introduced the concept of an integrated developmental process through which ego and context interact, a perspective which is compatible with advances in the neurosciences.
The DSM IV has officially acknowledged the influence of cultural models in psychiatric diagnosis. Such models include a range of cultural patterns in which are embedded the thoughts of members of differing social classes; regional, local, and metropolitan communities; professional groups and so on. Though transcultural psychiatry traditionally applied to non-Western peoples, it is increasingly important that transcultural sciences be applied to Western social contexts as well, especially now that our contemporary world so often comprises an interplay between foreign and indigenous cultures.
A recognition of the importance of cultural sensitivity led transcultural psychiatry to develop more sophisticated methods for diagnosis, therapy, and rehabilitation. These include the cultural life history, the resetting of the patient's cultural beliefs according to a changing world, and the creative use of cultural symbols. This paper draws on the author's experience in Madagascar, North Africa and Central America, as well as her work in founding the Transcultural Institute for Health, which has focused on enhancing research and educational methodology in the field of transcultural science.
Tolchard B, Battersby M
Evaluation of the Intensive Therapy Service for Problem Gamblers An In-Patient Program
Department of Psychiatry, Flinders Medical Centre, Bedford Park, South Australia
The Intensive Therapy Service for Problem Gamblers (part of the Centre for Anxiety and Related Disorders) is a state wide service funded through the breakeven program from a direct donation by the Australian Hotels Association. The fund is managed currently by the Gamblers Rehabilitation Fund (GRF). Initially the service at Flinders was set up to primarily provide outpatient treatment for gamblers throughout the state with a minimal in-patient function. Within the first year of the service's inception it became clear that there was a greater need for a coordinated in-patient program. Extra funding was sought and awarded by the GRF allowing the service to employ a second therapist. This paper will describe the process of referral, treatment and follow-up of patients admitted to the in-patient service. Outcomes of those admitted will be described and subsequent status of the clients explored. The paper will focus upon the practical application of Cognitive-Behavioral Psychotherapy with in-patients. Qualitative data will be presented looking at the success of the service and explore the extent to which the in-patients differ from outpatients. General psychopathology and emotional issues related to this particular client group will be discussed. However, the future care of this group of patients will be considered with recommendations made.
Trailer J
Adult Attention Deficit Hyperactivity Disorder: A Clinical Approach to a Controversial Neuropsychiatric Disorder
The Neuropsychiatry of Attention Deficit Hyperactivity Disorder, Neuropsychiatric Institute, Prince of Wales Hospital, New South Wales
Significant psychosocial impairment has been demonstrated in adults with ADHD and this may be reduced with appropriate treatment. Furthermore, high rates of co-morbid psychiatric disorder have been documented in association with this disorder, underscoring the relevance of the diagnosis to adult psychiatric practice. There is emerging literature to support the efficacy of specific treatments for adult ADHD, including stimulant medications and some antidepressants. There has been limited formal study of other treatment modalities. The issue of stimulant dosing remains controversial in adults. A case for a modest dosing strategy (e.g. up to 0.5 mg/kg/day of dexamphetamine) will be made with reference to relevant pharmacokinetic and behavioural data.
Tucker P
Suicide Risk in Substance-Abusing Populations
Department of Psychiatry, Westmead Hospital, Westmead, New South Wales
Twohig N (Chair)
Mental Illness, Health and Safety Vs Health Or Safety
Member, Guardianship Board, South Australia
This session will examine critically the various tests provided within the different jurisdictions and endeavour to ascertain whether the differences really matter when it comes to the delivery of services.
Vamos M, Deveney D, Langford M, Sue D
A Pilot Study of a Nurse Based Consultation-Liaison Service for Smaller Hospitals
Clinical Director, CL Psychiatry, Hunter Mental Health Service, New Lambton, New South Wales
Traditionally, CL services have been primarily staffed by psychiatrists and their registrars, with other mental health professionals added when possible. This has precluded the establishment of CL Psychiatry in smaller services.
A pilot project in the Newcastle area has developed a nurse-based service for 3 smaller general hospitals. Each hospital has a full-time mental health nurse who is supervised by the Director of the service. The first 6 months of the service are presented in terms of;
organisational structure
referral numbers
patient characteristics
referrer response
Difficulties faced included training packages for the nurses, their initial sense of isolation and uncertainty, the difference of the demands in a general hospital, and the challenges of setting up clear lines of responsibility. At the hospital level, adequate communication and information proved to be challenging and some doctors were initially unhappy at the idea of consultations being provided by nurses. There were also budget-related conflicts. Implications for further service development, and opportunities for training are discussed.
Van Altworst S, Pahi J, Tapsell R
Identity and Relatedness: A Workshop Investigating Issues in the Rehabilitation of Maori Forensic Patients
Senior Trainee, Mason Clinic, Auckland Regional Forensic Psychiatry Services, Auckland, New Zealand
Maori are the indigenous people of Aotearoa (New Zealand). This workshop will investigate some of the contemporary challenges in the rehabilitation of a group of young Maori men with multiple disabilities, a record of serious offending, an underlying lack of any firm sense of identity and little sense of relatedness to others or to their environment.
Short presentations will be made by the authors as a means of setting the background to this session. These will examine Maori identity from a traditional perspective, discuss the loss of identity, over time, from both an individual as well as a collective perspective and outline some of the ways in which we might begin to integrate traditional cultural perspectives into high quality forensic psychiatric rehabilitation.
It is hoped that discussion will examine these concepts both in terms of their specific relevance to this group as well as in terms of their general relevance to the treatment and rehabilitation of indigenous groups.
Vance A, Luk E, Maruff P, Costin J, Birleson P
Children with Adhd, Combined Type, Odd and Anxiety: Increased Neurodevelopmental Deficits (Ndds)
Department of Psychological Medicine, Monash University; Maroondah Child and Adolescent Mental Health Service, Australia; Mental Health Research Institute of Victoria
Varghese F T (convenor)
Ethnic Identity and the Self - Implications for Psychotherapy
Princess Alexandra Hospital, Brisbane, Queensland
Participants: Chen L, Princess Alexandra Hospital, Brisbane, Queensland; Ayonrinde A O, Maudsley Hospital, London, United Kingdom; Varghese F T. Discussant: Gold J H, Canada
This symposium will focus on the meaning of ethnic identity and its relationship to mental health. The issue of whether ethnic identity is part of what constitutes the ‘core self is explored and attention drawn to the particular issues of psychotherapy across ethnic and racial lines and its implications for transference and counter-transference.
Dr Lifeng Chen will address the various meanings of ethnic identity and review the data on its relationship to mental health. She will present some recent empirical data suggesting that there may be two dimensions to ethnic identity, each of which relate differently to issues of mental health and acculturation.
Dr F Varghese will discuss whether ethnic identity is part of the core self of an individual or an ‘accoutrement’ of the self as part of the external manifestation of identity. It is suggested that while elements of ethnic identity and in particular racial identity may be an essential part of the core self, a focus on ethnic identity may represent a ‘false self that disguises pathological aspects of self. Clinical case material illustrating these issues will be presented along with an examination of the influence of ethnic identity on the manifestations of transference and countertransference.
Dr Ayonrinde will address the ethnic and cultural dimensions in therapeutic transactions from the point of view of a black minority psychiatrist working in a predominantly white multicultural society. He will discuss the role of ethnic and cultural similarity and difference in the therapeutic process, with emphasis on the meaning of ‘difference’ as a substrate of clinical transactions. The black ethnic minority psychiatrist is in a unique position oscillating between being perceived as either ‘black’, ‘white’ or shades of grey.
Varghese F T
Ethnic Identity: Core Identity Or “Accoutrement”?
Princess Alexandra Hospital, Brisbane, Queensland
Dr F Varghese will discuss whether ethnic identity is part of the core self of an individual or an “accoutrement” of the self as part of the external manifestation of identity. It is suggested that while elements of ethnic identity and in particular racial identity may be an essential part of the core self, a focus on ethnic identity may represent a “false self that disguises pathological aspects of self. Clinical case material illustrating these issues will be presented along with an examination of the influence of ethnic identity on the manifestations of transference and countertransference.
Velakoulis D
The Role of Neuroimaging in Clinical Neuropsychiatry
Neuropsychiatry Unit, Royal Melbourne Hospital; Cognitive Neuropsychiatry Unit, Mental Health Research Institute, Victoria
Structural (MRI, CT) and functional (PET, SPECT, MRS) neuroimaging techniques are important tools in the clinical investigation of patients with neuropsychiatric disorders. The role of neuroimaging within a neuropsychiatry unit will be discussed using data and illustrative cases from a neuropsychiatry inpatient unit. The clinical utility of structural neuroimaging in schizophrenia will also be addressed based on a recent study of over 300 MRI scans in patients with chronic schizophrenia, first-episode psychosis and normal controls.
Walter G
Taking Flight from the Cuckoo's Nest
Department of Psychological Medicine, University of Sydney, Rivendell Unit, Central Sydney Mental Health Services, Sydney, New South Wales
There is increasing interest in the way our profession, consumers and carers are depicted in the media. Some portrayals have been subtle and sympathetic but all too often we find ourselves viewing a series of negative images that seem to reproduce stigma through age-old stereotypes of mad patients and mad doctors. Dr Garry Walter and Dr Alan Rosen are convening a workshop that will also include Dr Mark Welch and Ms Leone Manns; audiovisual presentations will be used to consider a range of examples of “psychocinematics” (cinema's depiction of psychiatry) from movies here and abroad. The workshop will also canvass the ways in which consumers, carers and psychiatrists might respond to these representations, and also the manner in which the media seeks to defend its portrayal of psychiatry.
Walter G, Bloch S
Not Too Creative, Please: Publishing Ethics in Psychiatry
Department of Psychological Medicine, University of Sydney, Sydney, New South Wales; Psychiatry Department, University of Melbourne, Melbourne, Victoria
Walter G, Martin J, Kirkby K, Pridmore S
Transcranial Magnetic Stimulation: Experience, Knowledge and Attitudes of Recipients
Department of Psychological Medicine, University of Sydney and the Rivendell Unit, Central Sydney Mental Health Services, Sydney, New South Wales, Discipline of Psychiatry, University of Tasmania and Royal Hobart Hospital, Tasmania
Walter G, Rey JM, Harding A
Psychiatrists’ Experience and Views regarding St. Johns’ Wort and “Alternative” Treatments
Department of Psychological Medicine, University of Sydney and the Rivendell Unit, Central Sydney Mental Health Services, Sydney, New South Wales
Weiner R
Electrode Placement, Stimulus Dosing, and Eeg Monitoring with Ect
Duke University, United States of America
Weiner R
New American Recommendations on the Practice of Electroconvulsive Therapy
Duke University, United States of America
Welsh B
Peace and Protection – a Consumer and Research View of Seclusion
Community Liaison Committee, New Zealand
The Australian New Zealand Royal College of Psychiatrists New Zealand Community Liaison Committee asked me to prepare a paper to present the Congress on Seclusion from a research and consumer view point.
I have been a consumer for 23 years with diagnoses ranging from schizophrenia through schizo-effective to currently a bipolar diagnosis. I have spent 2 years committed to Lake Alice Psychiatric Hospital including 4 months in the national secure unit, I have also had several other acute psychotic admissions into acute units giving me significant experience of being secluded. I have a Bachelor of Agricultural Science degree and have owned and operated a very successful dairy farm for 15 years. I also have a Post Graduate Diploma in Psychology and am currently working as a Consumer Advisor and a Project Manager Mental Health for the Health Funding Authority in New Zealand.
My presentation will examine the research findings on seclusion and relate them to my and others consumer experience. This will lead on to some suggestions and recommendations as to how to manage psychotic and difficult behavior in relation to seclusion.
Whiteford H
Human Development and Economic Growth: How Does Mental Health Relate?
Kratzmann Professor in Psychiatry, University of Queensland
Mental disorders are prevalent, cause considerable disability and rank high on the league table of world disease burden. This paper argues that, by extension, they are a significant impediment to human development and productivity. Cost effective interventions exist to reduce the disability associated with these disorders. Further, enhanced mental well-being can be achieved not only by the treatment of mental disorders but also by a range of mental health promotion measures. Reduction in psychopathology and the promoting of psychological health contributes to enhancing the individual attributes necessary for the constructive social interaction which underpin social cohesiveness. The contribution mental health programs can make to enhancing both human and social capital provide a basis for understanding their role in the broader sphere of human development and economic productivity. However, additional research is necessary to better understand these relationships and how to maximise the social and economic benefits of mental health programs.
Wigg L, Herriot P
A Comparison of Skin Blood Flow and Skin Conductance Response in the Measurement of Autonomic Arousal
Department of Psychiatry, Flinders Medical Centre, Bedford Park, South Australia
Wilhelm K, Kotze B, Arnold K, Hudson B, Macloughlainn A
Targetting Delirium: A Hospital Wide C/L Psychiatry Initiative
St Vincent's Hospital, Sydney, New South Wales
Delirium is a common problem in general hospitals, with high morbidity and mortality. It is often poorly recognised and managed. The C/L Psychiatry team at St Vincent's Hospital, Sydney has introduced a hospital wide program to improve the recognition and management of delirium, providing increased resources for hospital staff and the patient's visitors. The program is based on use of the Delirium Rating Scale, with educational workshops for the wards, flowcharts and guidelines for medication and behavioural interventions for the medical and nursing staff and an information sheet for relatives and friends.
The material has been distributed hospital wide. The process will be discussed and has been very well received. Some early evaluation data will be presented.
Wilhelm K, Schnieden V, Kotze B
Choosing Your Options: A Creative Approach to Deliberate Self Harm
St Vincent's Hospital, Sydney, New South Wales
Follow up of patients with deliberate self harm has been shown to be challenging. Deliberate self harm (DSH) accounts for 1–5% of public hospital admissions. There have been major public health initiatives in many countries regarding suicide and deliberate self harm. Within Australia, Policy Guidelines state that the first few weeks following discharge is a period of greatly increased risk for most patients with suicidal behaviour and it is recommended that patients with intermediate or high risk of suicide that are not admitted should be given an appointment within 24 hours and those with low risk within 24–48 hours.
A Clinic has been set up at St Vincent's and Prince of Wales Hospitals in mid 1998 as a collaborative project, to provide a structured program of three appointments (the first on the next working day after the suicide attempt). Those attending ED with DSH at either hospital were given a “Green Card” for the Clinic in C/L Psychiatry at their respective hospital. The first appointment consists of a diagnostic and risk assessment, followed by an invitation for patients to select treatment options that were the most appropriate for them from a series of problem areas. A further two sessions working in one or two of the identified areas were then negotiated. About 200 patients were referred to both clinics over the past 18 months, of whom over 70% attended. The non-attenders were followed up assertively by the designated “Green Card” clinician. The nominated problem areas in order of frequency were: Relationship difficulties, Problem solving difficulties, Dealing with grief and loss (each about 20%); Drug and alcohol and gambling problems, Negative droughts (each 10–15%); Self esteem, Difficulty dealing with traumatic events (each 5–10 %). The commonest interventions used were implementation of problem solving skills, training on assertion skills, a simple cognitive therapy technique, and strategies for dealing with grief.
Referrals were then either sent back to the GP or to a private psychiatrist, community services, other counsellors, drug and alcohol facilities, as determined in the sessions.
The service has enhanced the profile of patients with DSH and emphasised the seriousness of their actions to the ED and assessing registrars. Data from the first 200 referrals will be presented, with discussion about the experience in the Clinic and plans for the next stage of the program.
Wilton N
Who Has the Power? Do Partnerships between Psychiatrists and Consumers and Carers Produce Better Outcomes?
Chair, Board of Professional and Community Relations, R.A.N.Z.C.P.
This plenary session will involve a panel discussion, the panel comprising a number of members of the Board of Professional and Community Relations. Panel members will discuss the topic from their own individual experiences. Dr Wilton will then open the session for comments from the audience and lead the discussion between audience and panel members.
Worley P, Lange R, Beilby J, Burgess B
Is Case Conferencing a Retention Rates Winner for Rural Gps and Mental Health Workers?
Department of General Practice, University of Adelaide
The Mental Health Case Conferencing Project was a 2 year, statewide, Commonwealth funded project covering eight South Australian Rural Divisions of General Practice. The project commenced in October 1997, following a successful pilot project conducted in the Mid North Division of General Practice in 1995. Case conferencing provides a multidisciplinary team approach in the rural primary health care setting. It gives the opportunity for General Practitioners, Psychiatrists, and Mental Health Workers to meet, review patient care and plan a comprehensive management plan.
It was observed during the Mental Health Case Conferencing Project that case conferencing in providing an opportunity for health professional to work collaboratively, could provide a mechanism for professional support for the isolated rural health professionals. The poster presents the results of a questionnaire survey of rural GPs and mental health teams which explored this issue.
Worley P, Lange R, Beilby J, Burgess T
Mental Health Case Conferencing in Rural Practice – Great Solution but An Evaluation Dilemma
Department of General Practice, University of Adelaide
Case conferencing provides a multidisciplinary team approach in the rural primary health care setting. It gives the opportunity for General Practitioners, Psychiatrists, and Mental Health Workers to meet, review patient care and plan a comprehensive management plan, and provides an innovative strategy to address the critical shortage of mental health resources for rural communities. However, proving the effectiveness of the intervention was found to be challenging.
The Mental Health Case Conferencing Project was a 2 year, statewide, Commonwealth funded project covering eight South Australian Rural Divisions of General Practice. The project commenced in October 1997, following a successful pilot project conducted in the Mid North Division of General Practice in 1995. The poster discusses the background to the mental health case conferencing project and the dilemmas faced in constructing a suitable qualitative and quantitative evaluation framework. (This poster was presented at GPEP in May 1998).
Xenophon N
Gambling Symposium – Gambling: A Politician's Reflections on the Productivity Commission Report
Independent Member of the Legislative Council of the South Australian Parliament
This paper will reflect on the Productivity Commission's report regarding the impact of gambling on Australian society and the social cost connected to it. The legislative context and the potential for reform will be discussed with particular reference to the issue of problem gambling.
Yellowlees P
The Future of Psychiatry Includes the End of Public and Private Practice as We Know Them in 2000
University of Queensland, Royal Brisbane Hospital, Queensland
The ubiquitous availability of information via the internet and other sources will inevitably mean that psychiatrists of the future will have to radically alter their work practices. We will need to market our skills and expertise as the power of the doctor patient shifts inexorably towards patients who will control and manage their own disorders, and increasingly insist on quality care delivered in an accountable fashion. Psychiatrists in public and private practice, which will become increasingly mixed, will work with General Practice Divisions on an area or district process servicing the patients of the division and increasingly providing expert consultancy and teaching services to primary care providers within integrated services who will in future deliver even more mental health care than at present. The measurement of outcomes, and the use of pathways and guidelines will be routine and psychiatrists will need to prove their effectiveness as clinicians, supervisors and teachers for other clinicians working in a primary care environment, as will all other specialist practitioners. Those psychiatrists who are unable to prove their effectiveness will be significantly disadvantaged in this environment. Traditional one to one psychiatric therapy, particularly dynamic psychotherapy, will become increasingly rare as the use of evidence based treatments is demanded by patients, unless the efficacy of this type of care can be definitively proven. The effective use of information technology will lead to better psychiatric care in future, but requires considerable adjustment from all of us as we alter our work practices and concentrate more on patients with significant disabilities, while patients with lesser levels of disabilities will be treated, hopefully with our supervision, by other providers, unless we can prove that we can do it more effectively ourselves. The internet will change psychiatric practice more rapidly and completely than any other single event in the past century and psychiatrists who remain offline will soon be seen to be out of touch.
Yellowlees P
The Practice of Australian Psychiatrists in 2010
University of Queensland, Royal Brisbane Hospital, Queensland
The work of Australian psychiatrists will change radically over the next few years as a result of external financial pressures, the rise of consumerism and technological change. Psychiatrists will increasingly become clinical consultants in the traditional sense, with much of their roles being in clinical leadership, teaching and supervision. They will need to be service delivery experts in mental health, and will gradually become more and more integrated into primary care systems, particularly within general practice divisions in both private and public sectors. The rise of the “informed patient” and ubiquitous Internet access will mean that psychiatrists have to move to a different way of working and marketing themselves, as well as demonstrating clear evidence of their value, and of the level of the clinical outcomes. These changes are exciting, interesting and need to be embraced so that, as a profession, psychiatrists retain clear disciplinary leadership and clinical relevance.