Keynote presentations
Keynote address 1: Trauma and Psychosis: Well-Researched, Full of Implications, Still Controversial?
J Van Os, I. Myin-Germeys, M. Wichers, Ph. Delespaul, C. Simons, T. Lataster, R. van Winkel, B. Rutten, M. Drukker
Maastricht University Medical Centre, Maastricht, The Netherlands
While it is generally accepted that about one-third of all non-psychotic mental disorders is attributable to childhood trauma and adversity, the link between trauma and psychosis remains the topic of much debate and controversy. Has the link between trauma and onset of psychotic disorder been essentially underestimated, or is the research pointing in this direction flawed? The last decade had an explosion of high-quality observational research, and variable attempts to examine the role of bias and confounding. Several remarkable findings are emerging. First, it is increasingly clear that the boundaries between ‘psychotic’ and ‘non-psychotic’ outcomes are blurred, making it unlikely for trauma to specifically affect non-psychotic outcomes. Second, the link between trauma and psychosis is remarkably consistent across study designs and groups, and it does not appear to be the result of genetic confounding. Third, there is emerging evidence, using novel network models of mental experience, shedding light on the psychological and biological mechanisms by which trauma affects psychopathology. Fourth, evidence indicates that, contrary to what is often thought, a specific treatment focus on trauma may be safe and effective.
Keynote address 2: Closing the Aboriginal and Torres Strait Islander Mental Health and Suicide Gap
Tom Calma AO
Aboriginal and Torres Strait Islander peoples have significantly higher reported rates of mental health conditions and suicide (approximately double that of other Australians). Aboriginal and Torres Strait Islander mental health is underpinned by a broader construct of health known as social and emotional wellbeing. This includes healthy connections to family, community, the spiritual dimension of existence and traditional lands. For many Aboriginal and Torres Strait Islander peoples, negative social determinants are impacting on the healthy connections that comprise social and emotional wellbeing and hence their mental health. Some are shared with other Australians - poverty and alcohol and substance use among them. Others, however, are unique - including racism, the impacts of the Stolen Generation’s policies and cultural stress. For Aboriginal and Torres Strait Islander peoples then, population mental health approaches that focus on prevention must reflect these differences. For while there is an important place for mental health services, biomedical approaches and interventions, there, too, must be an address to negative social determinants (poverty and racism) and cultural strengths must be built upon if the mental health gap is to close. Particularly in relation to suicide prevention, a whole of community approach that empowers communities to address the challenges they face, including by building on cultural strengths, is important. Because of this, Aboriginal and Torres Strait Islander mental health poses unique challenges both to the mental health system and practitioners. These challenges are best met under Aboriginal and Torres Strait Islander leadership and in partnership with communities.
Keynote address 3: Attachment and Mentalisation as Common Factors in Effective Therapeutic Practice
Mary Target
University College London, London, UK
Background: Psychotherapy research suggests what promoters of therapeutic brands (cognitive therapies, psychodynamic psychotherapies, DBT, MBT, etc.) are unwilling to accept: That generally, most ethically-based talking treatments work, and work to similar extents.
Objectives: To consider what common factors in the success or failure of a treatment may cut across brands (and be what we should in fact be focusing on training professionals to do).
Methods: An overview of psychotherapy research findings and trends will lead to a proposal about what the common factors are.
Findings: The lecture will suggest fostering of mentalisation within an attachment relationship is a key element across treatments, although not necessarily enough on its own, and not necessarily useful as the explicit aim.
Conclusions: The lecture will arrive at the position that there are many quite different ways to support capacities for mentalisation under emotional and relational stress, and different ways may suit different practitioners and patients; however, an understanding of the processes and variants of mentalisation and attachment can help to keep a treatment moving forward, and help us to see some of the common ground across the types of talking therapy.
Keynote address 4: Can We Deliver Effective Mental Health Care in the Absence of Psychiatrists?
Ricardo Araya
London School of Hygiene and Tropical Medicine, Centre for Global Mental Health, London, UK
Background: Most low-income countries have few psychiatrists to serve large populations. Some innovative solutions need to be found to provide some form of mental health care for these populations. Interestingly, some of these solutions have begun to be used in higher-income countries, in order to reduce health care costs and address the relative lack of other mental health human resources in some less well-resourced settings.
Objectives: To show results of several recent studies in low- and middle-income countries, which have attempted to address the lack of psychiatrists in those settings.
Methods: Randomized controlled trials.
Findings: Several schemes using different task-shifting strategies, mostly within collaborative stepped-care models, have shown promising results.
Conclusions: Task-shifted models may provide feasible and effective solutions to address the lack of psychiatrists and other mental health specialists in low- and middle-income countries, as well as in some higher-income countries.
Keynote address 5: Understanding Behaviour in People With Intellectual Disability: The Importance of Individual Differences
Chris Oliver
The Cerebra Centre for Neurodevelopmental Disorders, School of Psychology, University of Birmingham, Birmingham, UK
Over the last 3 decades, there has been increasing emphasis placed on the environmental influences on behavioural differences and the disorder shown by people with intellectual disability. This emphasis has been readily translated into policy and practice, with implications for service delivery and professional training; however, there has also been increasing recognition of the importance of individual differences as predictors of behavioural disorders, and these have been afforded less prominence in causal models. For example, the prevalence of a behavioural disorder is significantly higher than expected in many genetic syndromes, when the degree of intellectual disability is accounted for. Additionally, a number of behaviours cluster together at the group and population levels. Causal accounts must incorporate both environmental variables and individual differences, if they are to reflect the available empirical data. More complete accounts of the cause of behavioural disorder and differences can inform better-targeted interventions at an individual level, and also drive more strategic initiatives, such as early intervention.
Keynote address 6: Novel Frontiers in ADHD, Emotional Dysregulation and Spectrum Disorder Phenotypes
Wai Chen
Division of Clinical Neuroscience, University of Southampton, Southampton, UK
Attention deficit hyperactivity disorder (ADHD) is a common childhood neurodevelopmental disorder characterised by age-inappropriate levels of inattention, hyperactivity and impulsivity; and can persist into adulthood. Adult ADHD increases the risks of anxiety, depression, substance misuse and personality difficulties; in addition to educational, occupational, financial and social impairments. Emotional dysregulation (ED) frequently co-occurs with ADHD and can respond to ADHD medications, paralleling ADHD core symptom reduction. Notably, ED mediates the onset of subsequent depression; and ADHD with a comorbid mood disorder in adolescence increases the risk of completed suicide by three-fold. This talk posits that ‘ADHD-ED’ is a specific presentation that warrants focused research and clinical attention; and provides some recent genetic findings accounting for their association, in particular, a twin study that decomposes the genetic architecture of childhood ADHD and ED symptoms.
Furthermore, cumulative evidence suggests that ADHD itself is a continuous spectrum disorder, with sub-threshold cases carrying significant disease burden, to a degree similar to those ‘subtypes’ recognized by DSM-IV and DSM5; yet these sub-threshold cases are currently ‘diagnostically homeless’. This talk argues for taxonomic recognition of two diagnostically ‘lost tribes’:
Those of ‘ADHD + ED’; and
Those with diagnostically sub-threshold ADHD-combined symptoms (i.e. ‘moderate combined subtype’).
The third strand of this talk summarises some emerging evidence that ADHD and autism co-exist as a phenotypic continuum; and describes some clusters of syndromes along this ‘ADHD-autism spectrum’. Furthermore, the relationship between ED and oppositional defiance disorder (ODD) symptoms will also be explored.
The fourth strand reviews neuroanatomical models for ADHD-ED symptoms, while highlighting the relevant environmental factors. More specifically, the ‘Dynamic Network Connectivity’ (DNC) model describes unique neuromodulatory influences on working memory prefrontal cortical (PFC) circuits - mediated by D1, alpha 2A receptors and HCN channels - and embodies novel pharmacological and psychological treatment implications. The talk concludes with some new directions for research and development.
Pre-Congress workshops
Addictive Psychiatry: A Career Hard to Give Up!
M Montebello1,2, S Arunogiri3, M Coleman4, D Florida2,5,6, L Juckes5,7,8, S Rege9,10
1South Eastern Sydney Local Health District, Sydney, Australia
2National Drug and Alcohol Research Centre, University of NSW, Sydney, NSW, Australia
3Turning Point Drug and Alcohol, Eastern Health, Melbourne, Australia
4Great Southern Mental Health Service, Perth, Australia
5Concord Drug Health, Sydney, Australia
6The Hills Clinic, Sydney, Australia
7Northern Sydney LHD Drug and Alcohol Services, Sydney, Australia
8Wesley Private Hospital, Sydney, Australia
9Psych Scene, Australia
10Positive Psychology Wellness Centre, Melbourne, Australia
This half-day workshop is aimed at registrars interested in passing the addictions component of training and exams, as well as those considering addiction subspecialty training. It will deliver comprehensive practical insights into training and career opportunities in addiction psychiatry.
There is an increasing recognition of comorbid drug and alcohol problems across all of psychiatry. Addiction psychiatry is a rapidly-growing subspecialty field with established pathways for advanced training. Despite the high prevalence of these disorders, trainees often report lack of confidence and skills in this area.
This workshop will include:
An overview of training pathways, including progression to obtaining the Advanced Certificate in Addiction;
A practical approach to Entrustable Professional Activities (EPAS) specific to addictions;
A framework for passing the ‘addictions’ components, for both the written and clinical exams;
A panel discussion, including current trainees and addiction psychiatrists from various states, focussing on public and private sectors, academic paths, and opportunities for impacting on public health and policy.
This will be an interactive workshop, with ample opportunities for discussion, coffee and networking.
So come and see what’s so addictive about addiction psychiatry!
Mentalising People With Borderline Personality Disorder: The Why, The How and The Wherefore
J Beatson, S Rao
Spectrum Personality Disorder Service for Victoria, Melbourne, VIC, Australia
Background: Borderline personality disorder (BPD) is often regarded as difficult to treat, with poor prognosis. Effective, empirically supported treatments for BPD, including mentalisation-based treatment (MBT), are now available.
Objectives: This workshop will offer a detailed account of mentalization-based treatment (MBT) for BPD. The factors common to empirically validated treatments for BPD will also be outlined, comparing these with MBT, and reflecting on what contributes to psychic change in BPD.
Methods: Mentalization based treatment will be examined, delineating its theoretical underpinnings, techniques and research on treatment outcome. Videotapes of role-plays of MBT will be shown to illustrate key techniques. Current findings on other effective treatments for BPD will be examined to identify ingredients common to empirically validated treatments and consider these in relation to MBT.
Findings: MBT offers a theoretically coherent approach to treatment for BPD. The training required is brief and the approach intuitively relevant to clinicians experienced with BPD. MBT can be employed as a definitive form of psychotherapy. A practical guide to MBT, published in 2006, offers a manualised guide to this treatment.
The MBT principles for interacting with patients can also be employed as an ‘approach’ to people with BPD. These principles are informed by the patients’ difficulties in mentalising, and thus are ideally suited to guiding staff in the helpful ways of interacting with these patients. The approach can be applied across treatment settings and employed by clinicians from all mental health disciplines. It offers an approach that can ‘hold’ both patient and clinician, including at times of crisis.
Conclusions: Mentalization-based treatment is an effective treatment for BPD that can be applied as a definitive form of psychotherapy and an ‘approach’ employed in all contacts with patients.
Your Aboriginal Patients Need You: Your Approach Matters!
D Blurton2, C Deeble2, D Reys3, E Moore1, S Yeak1
1South Metropolitan Health Service (SMHS) Mental Health Strategy and Leadership Unit, Perth, Australia
2Peel and Rockingham Kwinana (PaRK) Mental Health Service, Perth, Australia
3Bentley Health Service Mental Health, Perth, Australia
Background: Aboriginal people represent 3% of the Australian population, yet in reports are shown to have the highest health needs. In their ‘Closing the Gap’ strategy, the Australian Government attempted to improve health outcomes in indigenous Australians. One key strategy is equipping our workforce to promote the engagement of Aboriginal communities and to ensure appropriate care is given. Mental Health Service practitioners have identified that they are unsure as to how to engage with Aboriginal clients. This can be especially challenging for non-Aboriginal mental health practitioners.
Objectives: We expect participants will gain a better cultural understanding of Aboriginal Australians and begin to examine and reflect on their own practices, to achieve better outcomes with their Aboriginal patients. The workshop will explore the role of traditional healers; the role of family and community; and explore the historical perspective, trauma and identity and their relevance in the treatment process.
Methods: This one-half day workshop will be interactive, and facilitated by trained and experienced Aboriginal mental health practitioners. Case scenarios and group discussion will be used to explore the cultural perspective in mental health issues, to achieve better patient outcomes.
Conclusions: Participants will leave with strategies to continue to achieve better engagement and outcomes with their Aboriginal clients.
Doctors as Patients: Looking After the Mental Health of Our Own Profession
K Jenkins, W Pring
Victorian Doctors Health Program, Fitzroy, VIC, Australia
As medical professionals, we are not immune to mental illness.
This will be an interactive workshop, where in small groups and as a plenary, we will address a broad range of issues pertaining to the mental health of medical practitioners.
Participants will gain an increased understanding of the specific health issues that affect medical practitioners, including mental health problems, substance abuse issues, and workplace and personal stress.
This workshop will be of value to psychiatrists who already have doctors as patients, those working in acute settings where doctors may present in crisis, and early career psychiatrists/trainees who wish to develop an interest in doctors’ health.
Part A addresses:
Causative factors for poor mental health in doctors and medical students;
Difficulties that doctors face in becoming patients; and
Barriers to good medical /psychiatric care for doctors.
Part B explores how to be a better psychiatrist for other medical professionals, by addressing the challenges faced in treating doctors, such as:
Boundary issues;
Confidentiality;
Current medico-legal requirements for mandatory reporting;
Assessing fitness to practice; and
Substance abuse and alcohol issues amongst peers and colleagues.
Discussions will be based on case material. Attendees are welcome to bring their own (de-identified) case examples.
Philosophy and Psychiatry: An Update
M Wong, J Dunphy-Blomfield
School of Psychology and Psychiatry; Faculty of Medicine, Nursing and Health Sciences; Monash University; Melbourne; Australia
Background: Advances in neurosciences, philosophy, humanities and their interaction with psychiatry during the ‘Decade of the Brain’ and the ‘Decade of the Mind’ lead to various developments in philosophy of the mind, consciousness studies, psychiatric nosology and psychopathology, which in turn bring about significant impacts on our understanding of the nature, classification, diagnosis and treatment of mental illness.
Objectives: This one-half day workshop aims at providing an update on the major themes and issues involved in the interface between philosophy and psychiatry.
Methods: This workshop will provide an overview of the history and schools of philosophy, in relation to the practice of psychiatry; and an overview of the major themes and issues in the interface between philosophy and psychiatry, through the collaborative dialogue between a psychiatrist (MW) who was an academic visitor to the Faculty of Philosophy at Oxford University in 2009, with two doctorates (in PET and MRI neuroimaging, and in philosophy and psychiatry); and a philosopher (JDB), studied and completed her doctorate in Paris, under the late French philosopher Paul Ricoeur, author of Freud and Philosophy.
Findings: Recent advances in philosophy and its interaction with neuroscience and psychiatry have allowed psychiatry not only to overcome its tendency to swing between ‘brainlessness’ and ‘mindlessness’, and to hold fragmented and restricted views of mental illness; but also, to become an academic and clinical discipline that facilitates inter-disciplinary integration of the study and understanding of the person, its health and well-being.
Conclusions: The anticipated outcome of this workshop is to enable participants to acquire basic and essential knowledge of philosophy relevant to psychiatry, and to develop skills in the application of such knowledge to the practice of psychiatry.
Royal Australian & New Zealand College of Psychiatrists (RANZCP) 2014 Examination Information Session: Approaching the RANZCP OCI/MOCI Assessment (Clinical Examination)
Viki Pascu1, Joanne Ferguson2
1Deputy Chair, Committee for Examinations, RANZCP
2Member, Committee for Examinations, RANZCP
This workshop is designed to assist candidates to understand the nature and standard of the OCI/MOCI examination. The workshop will include presentations by the Committee for Examination members, of the common challenges faced by candidates and will promote the development of strategies for successfully passing this assessment.
This workshop is also considered beneficial for supervisors to develop familiarity with the format and process of the OCI/MOCI assessments and to develop their understanding of the Committee for Examinations’ expectations of Trainee and Specialist International Medical Graduate (SIMG) candidates.
The workshop is suitable for trainees, SIMGs, supervisors and Directors of Training (DoTs).
This workshop will also introduce candidates, supervisors and DoTs to:
The format of the OCI/MOCI examination;
The assessment/marking of the OCI/MOCI; and
Tips for passing the OCI/MOCI examination.
Training Workshop for Potential Assessors for the Substantially Comparable Pathway to Fellowship for Simgs
John Allan1, Diane Neill1, Areti Tsesmelis2
1RANZCP Committee for Specialist International Medical Graduates’ Education
2RANZCP Secretariat
Background: The Royal Australian & New Zealand College of Psychiatrists (RANZCP) introduced the new Comparability Pathway (Substantial Comparability) for Specialist International Medical Graduates (SIMGs) in the second half of 2011 (www.ranzcp.org/Pre-Fellowship/Overseas-specialists/New-Applicants-(Specialist-Pathway)/Substantial-Comparability-Pathway.aspx). The assessment involves at least 12 months of supervised and peer-reviewed practice, with significant workplace-based assessment and employer support. Three Case-based Discussions (CbDs) are done in the workplace by external assessors.
This is one of a series of training workshops for potential external assessors of candidates who are seeking substantial comparability by this process. Fellows who are already supervising SIMGs involved in this pathway are encouraged to attend, as are any fellows interested in supporting SIMGs. To be appointed as an Assessor, Fellows must have at least 3 years post-Fellowship experience. The viability of this pathway depends on having sufficiently trained Assessors and Supervisors to complete all of the assessment and supervision tasks. The workshop involves pre-reading and calibration of CbD material. The responsibilities of supervisors are enhanced in this process. Training as a supervisor is completed via a different process, involving the review of written and DVD material and a teleconference. This is not suitable for potential candidates, who are encouraged to attend other sessions provided by the Committee for SIMG Education (CSIMGE) members.
Objective: To achieve competency as an Assessor in the ‘Substantially Comparable Pathway’.
Methods: This workshop will cover:
Explanation of the substantially comparable process and requirements;
Training in the responsibilities of supervisors and assessors;
Training in the use of workplace-based assessment tools, including;
‘Case-based Discussion’ and ‘360° Feedback’, via calibration exercises.
RANZCP 2014 Examination Information Session: Accredited Examiner, Clinical Examinations
Nathan Gibson
Member, Observed Interview (OCI/MOCI) Sub-committee; Member, Committee for Examinations
This workshop is designed to train Fellows to the standard required to examine Trainees and Specialist International Medical Graduates (SIMGs) in the clinical (OCI/MOCI) examination.
Attendees are required to submit to the Committee for Examinations, via the Examination Department at The Royal Australian & New Zealand College of Psychiatrists (RANZCP) Secretariat, a completed AEP nomination form, a brief curriculum vitae (CV) of 2 pages and a supporting statement.
Application documentation may be obtained via email request (exams@ranzcp.org) or from the College website (www.ranzcp.org/Resources/assessors-and-supervisors.aspx).
Completed AEP documentation is to be received by the Examinations Department by Friday, 18 April 2014.
Fellows should:
Be able to demonstrate a commitment to the professional development of psychiatry, through involvement in the training and examination of trainees/SIMGs, supervision of trainees or SIMGs, College or Branch activities;
Be a Fellow of the RANZCP for a minimum of 3 years;
Have demonstrated commitment with the supervision and/or the preparation for examinations of trainees and/or SIMGs;
Hold respect of peers, with demonstrable excellence in an area of practice/expertise (as detailed on a CV and by three referees) one of whom should be a currently serving member of the Committee for Examinations;
Have a working knowledge and be familiar with the current RANZCP Training and Assessment Regulations, and the principles of the curriculum framework.
This workshop will train and calibrate Fellows to:
Know the format of the OCI/MOCI examination;
Assess/mark the OCI/MOCI.
Please note: This session is only open to College Fellows who have submitted (to the College Secretariat Examinations Department) completed AEP nomination documentation.
Clinical Neuroimaging in Psychiatry
F Gaillard1, B Hayhow2, M Walterfang2,3, R Mocellin2,3, D Velakoulis2,3
1Department of Radiology, Royal Melbourne Hospital, Melbourne, Australia
2Melbourne Neuropsychiatry Centre, Melbourne, Australia
3Department of Psychiatry, Royal Melbourne Hospital, Melbourne, Australia
This half day workshop is targeted at both consultant and trainee psychiatrists who would like to learn more about the role of clinical neuroimaging in the differential diagnosis of neurodegenerative disorders. The session will open with an introduction to computed tomography (CT) and magnetic resonance imaging (MRI) modelled on normal studies, and will include instruction in a basic approach to study assessment, as well as discussion of the role of different imaging sequences.
The session will go on to review a selection of case studies illustrating significant positive and negative findings across a range of conditions, including Alzheimer’s disease, fronto-temporal lobar degeneration, Huntington’s disease, Parkinson’s disease plus syndromes, metabolic disorders, inflammatory disorders, vascular disorders and cerebellar syndromes.
The workshop will conclude with a brief overview of evolving neuroimaging techniques and their potential applications in both clinical research and practice. Candidate modalities may include MR perfusion, positron emission tomography (PET), SPECT and MIBG.
Interactive online study materials will be provided to all participants.
Is a Mentalisation Framework Actually Useful Within the Intensive Psychotherapeutic Setting Where It Developed?
Mary Target
University College London, London, UK
This workshop will look at aspects of the theory of self-development and affect regulation, in terms of mentalisation and attachment, as it relates to individual psychodynamic psychotherapy with the full range of patients (anxious, depressed, narcissistic etc., as opposed to the borderline psychiatric disorder (BPD) specialisation for which mentalisation-based therapy (MBT) was refined). Mary will present aspects of the theory around embodied cognition, memories of early maltreatment and the therapeutic interaction, in terms of both transference and the ‘real’ relationship. She will frame the psychotherapy setting itself, in terms of forms of psychic reality, drawing on theoretical work with Peter Fonagy and case examples from her practice.
Background: The theory of growth of mentalisation, initially within attachment and early attachment, grew out of psychoanalytic clinical work with individual adults and children, and empirical research on both parent-infant attachment and treatment outcomes. The practice of MBT has focused mainly on BPD within hospital settings, although some other applications have been developed.
Objectives: To consider whether (and if so, how) the mentalisation framework is in fact useful within the intensive, individual psychotherapeutic setting where it developed.
Methods: Theoretical work on embodied cognition, play and forms of psychic reality will be drawn on to discuss clinical material. Also, case material from participants in the workshop will be welcome. We will discuss both the understanding of psychopathology in developmental term, and techniques of intervention related to different types of disturbance.
Findings: It is expected that we will find the theory is of relevance to psychopathology and technique, but that interventions (such as interpretations versus clarifications) need to correspond to levels and severity of disturbance.
Conclusions: As always, we need to look critically at the relationship between theory and practice, formulating at an individual level, rather than applying a framework wholesale.
How to Attain Australian Indigenous Mental Health Competence: The New ‘Entrustable Professional Activities’
I Trevallion1, C Dhamarrandji2, J Dhamarrandji2, K Ryan3, J Lee4, D Cutts5, L Dadd6
1Child and Adolescent Social, Emotional & Spiritual Well-being Service, Thursday Island, Australia
2Miwatj/Ngalkanbuy Health Services, Northern Territory, NT, Australia
3Pilbara Aboriginal Drug and Alcohol Program, WA, Australia
4Townsville Health Service District, Queensland, QLD, Australia
5Northwest Mental Health Services, WA, Australia
6Hunter New England Local Health District, New South Wales, Australia
Background: The Royal Australian & New Zealand College of Psychiatrists (RANZCP) commenced implementing its new Competency-Based Fellowship Program in 2012. Progression through training involves completion of summative assessments, known as Entrustable Professional Activities (EPAs). To ensure that psychiatrists are capable of safe and competent cultural practice, two Australian Indigenous Mental Health EPAs were developed, for Stage 2 and Stage 3 training.
Objectives: This pre-Congress workshop will discuss the Australian Indigenous Mental Health EPAs, providing an overview of their content, and guidance to supervisors and trainees on approaches to complete the Stage 2 EPAs.
Methods: An introductory presentation will provide an overview of the development of these EPAs, their significance, and their intended purpose. A panel of speakers, including Aboriginal and Torres Strait Islander health workers, will then present mock scenarios based on the Stage 2 EPAs, ‘Interviewing an indigenous Australian patient’ and ‘Management plan for an indigenous Australian’. The panel will also discuss elements of these scenarios with attendees, to review what elements worked well, what was missing and what can be improved on, and to address questions raised through facilitated group discussion.
Findings and conclusions: Attendees should gain an appreciation of the skill sets that could be acquired through completion of the Australian Indigenous Mental Health EPAs, and how to supervise or acquire the relevant competencies, as well as recognize the important role these play in developing capability in safe and competent cultural practice.
Internet Gaming Disorder in Young People: A Practical Approach for Professionals
P Tam1, V Starcevic2
1Rivendell Adolescent Unit, Sydney, Australia
2University of Sydney, Sydney, Australia
Background: The complex, evolving phenomenon of Problematic Internet Use (PIU), commonly dubbed ‘internet addiction’ was first described in 1996. In subsequent years, there has been a marked increase in interest in the condition in clinical, research and general-public domains. This has culminated in a new diagnosis, Internet Gaming Disorder (IGD), being included in Section 3 of the DSM-5, released in May 2013.
Objectives: This workshop will aim to provide a balanced, considered overview of the development of the concept of PIU, and then look at international evidence on classification, co-morbidity and treatment. It will provide an update on both out- and in-patient treatment modalities, which are emerging in this country and internationally.
Methods: Through a search of relevant Australian and international journals, and reference to the clinical experience of the presenters, use of real-life de-identified case material will be employed to facilitate discussion.
Findings: PIU is a challenging, complex and controversial phenomenon, whose phenomenological and nosological status has not been fully delineated. Nonetheless, international findings, particularly in recent years, indicate that a small subgroup of internet users (mainly young male individuals) do have significant mental health difficulties associated with PIU; and that treatment is both indicated and potentially successful.
Conclusions: The formal inclusion of IGD in DSM-5 will further stimulate clinical, research and general public interest in the area. Advances in technology, and its increasing usage, will make this a condition that many clinicians, particularly those in the youth mental health field, will need to be familiar and competent with.
Reference
DL King, PH Delfabbro (2013) Issues for DSM-5: Video-gaming disorder? Australian and New Zealand Journal of Psychiatry 47: 20-22.
RANZCP 2014 Examination Information Session: Approaching the Critical Essay Question Type of the RANZCP Written Examination
Lisa Lampe
Chair, RANZCP Committee for Examinations
This workshop is designed to assist candidates to understand the nature and standard of the Critical Essay Question (CEQ) type of the Royal Australian & New Zealand College of Psychiatrists’ (RANZCP) written examination.
The ability for critical reasoning informed by biological, psychological, social and cultural knowledge, and the capacity to express this in writing, is considered to be an essential skill for a psychiatrist. The CEQ is designed to test this critical reasoning, as well as the capacity to identify and assess the relative importance, merits and drawbacks of opposing arguments, and to demonstrate awareness of different illness models. The CEQ will be a part of the written examination in both the 2003 and 2012 Fellowship programs and the standards of each will be discussed.
In the workshop, members of the Committee for Examinations will discuss the approach to this question type, the required standard and how to demonstrate it (what the examiners are looking for), and will highlight the skills and strategies for successfully passing this question type.
This workshop is also considered of value to supervisors, to assist them in supporting candidates who are preparing for the written examinations.
It is suitable for Trainees, SIMGs, Supervisors and Directors of Training.
RANZCP 2014 Examination Information Session: Approaching The RANZCP OSCE/MOSCE Assessment (Clinical Examination)
Gail Robinson
Chair, OSCE/MOSCE Sub-committee; Member, Committee for Examinations
This workshop is designed to assist candidates to understand the nature and standard of the OSCE/MOSCE examination. The workshop will include presentations by the Committee for Examination’s members about the common challenges faced by candidates and promote the development of strategies for successfully passing this assessment.
This workshop is also considered beneficial for supervisors to develop familiarity with the format and process of the OSCE/MOSCE assessments, and to develop their understanding of the Committee for Examinations’ expectations of Trainee and Specialist International Medical Graduate (SIMG) Candidates.
This workshop is suitable for trainees, SIMGs, supervisors and Directors of Training (DoTs).
This workshop will also introduce candidates, supervisors and DoTs to:
The process for developing an OSCE/MOSCE examination;
The format of the OSCE/MOSCE examination;
Approaching the medicine as related to Psychiatry Station;
The assessment/marking of the OSCE/MOSCE; and
Tips for passing the OSCE/MOSCE Examination.
Training Workshop for State Assessment Panel Members to Assess Substantial Comparability Pathway Phase II Applications
John Allan1, Diane Neill1, Areti Tsesmelis2
1RANZCP Committee for Specialist International Medical Graduate Education
2RANZCP Secretariat
Background: Following the successful trial of Phase I of the Substantial Comparability Pathway, the Royal Australia & New Zealand College of Psychiatrists’ (RANZCP) Committee for Specialist International Medical Graduate Education (CSIMGE) is now in the process of developing and implementing Phase II of this pathway. Phase II will assess all new applications from International Medical Graduates for the Specialist Pathway and any existing ECE candidates wishing to transition to Substantial Comparability in the period 2014–2016 (at which time transition will be compulsory). Phase II is anticipated to open in mid- to late 2014.
Applicants for Phase II will be assessed by interview and an assessment proforma developed and tested by CSIMGE, in consultation with all stakeholders including the OTP Committee. The proposed Phase II assessment proforma incorporates the criteria in current use (pre- and post-specialist qualifications, training and experiences), as well as additional criteria such as Training Program Standards, Accreditation Criteria, Scope of Practice as a Consultant Psychiatrist and Recognition of Prior Learning. It is proposed that each criterion will be given points, in accordance with whether it is substantially, partially or minimally comparable. Points will be lost for lack of CPD activities, lack of progression to Fellowship, or recurrent failures at RANZCP examinations (applicable for current Exemption Candidates). Existing Exemption Candidates may wish to transition to Phase II, as an alternative to the Specialist Pathway, in the period of late 2014 to 2016.
It will be the responsibility of the State Assessment Panels, currently assessing applicants for the Specialist Pathway to RANZCP Fellowship, to assess applicants for the Substantial Comparability Pathway Phase II. State Assessment Panels will be required to evaluate applications using the new assessment proforma and interview.
This workshop provides current and new State Assessment Panel members with training for assessing the applicants for Phase II.
Objective: To provide State Assessment Panel members with a clear understanding of the Substantial Comparability Phase II eligibility and assessment process, and ensure that they are competent in assessing candidates for Phase II.
This workshop will cover:
Explanation of the Substantial Comparability Pathway Phase II eligibility and assessment process and requirements;
Training in assessment of Specialist International Medical Graduates for the Substantial Comparability Pathway Phase II;
Testing of existing Exemptions Candidates, using the Substantial Comparability Pathway Phase II assessment criteria.
Symposia
Sense of Place, Spirit of Place, Loss of Place: The Impact of the Evolving Landscape on the Human Psyche
L Lutton1,2, P O’Brien3, S Lutton4
1School of Earth and Environment, University of Western Australia, WA, Australia
2Director of Urban Planning, Urbanix, Perth, WA, Australia
3Cultural Planner and Artist, Perth, WA, Australia
4Consultant Psychiatrist and Psychotherapist, ASSeTTS, Perth, WA, Australia
Background: This symposium aims to explore the concept of ‘place’ in relation to the human psyche, from the perspective of the evolution of the city and urban dwelling, to the spiritual and cultural creation of place with respect to identity, art and authenticity; and to the destructive impact, both physically and psychologically, of the loss of place.
Objectives: This symposium is a collaboration of three perspectives regarding the effect of the natural and cultural landscape on the human psyche. These perspectives are presented by three speakers; an architect and city planner, a well-known Australian artist, and a psychiatrist and author, respectively. The aim is to allow the audience to experience different approaches to understanding the relationship between place and well-being.
Method: Each presentation has a different focus. The first explores the tragedy of the transposition of the European cultural environment into Australia. The second takes that theme and explores the role of art and artists in generating a sense of place in a new landscape. The third is a case presentation, in which the dislocation of refugees from their own culture and landscape results in a profound loss of the sense of place.
Findings: The symposium will highlight the face validity of the human problem that we face locally: That of the profound effects of environment on human health.
Conclusions: The main conclusion is that research in this area is severely undervalued. A new research paradigm relating human environment to health (and in particular, mental health) is urgently in need of support and exploration.
Presentation 1: L Lutton: Sense of Place
Background: In tribal times, humans understood the symbiotic relationship between self and place. Acknowledging the spirit of natural places was part of their culture. Ancient civilisations extended this concept to include man-made places, which medieval people applied to city building, resulting in most European and Middle Eastern cities exhibiting a strong sense of place. Medieval cities were really unions of many small, self-sufficient towns, each with their own ‘heart’, which provided the community with its unique sense of identity and belonging. City planning was focussed on community interaction and connectivity. Cities of the colonised countries, such as Australia and America, are however very different. The man-place values developed over thousands of years have been surrendered in favour of vast utilitarian environments. So, what are these qualities that enrich an urban sense of place and why are they important for social and community development?
Objectives: To explore the impact of the man-place relationship on contemporary community and individual development.
Method: Review academic writings and studies, with respect to how people interact with and respond to their urban environments.
Findings: A large body of literature warns of societal problems ahead, now that more than one-half the world’s population lives in dense, soulless urban environments. Empirical studies are sparse; however, the ‘soft sciences’ have pointed the way for the ‘hard sciences’ to now interrogate deeper the growing concerns about city life, and some interesting and troubling findings are emerging.
Conclusion: The conclusion is best expressed by this quotation:
‘The city, as we imagine it, the soft city of illusion, myth, and aspiration, nightmare, is as real, maybe more real, than the hard city one can locate on maps, in statistics, in monographs on urban sociology, demography and architecture’.
—Jonathan Raban
Presentation 2: Philippa O’Brien: Spirit of Place – Archeology of Place
Philippa O’Brien has degrees in English and Fine Art (Film) and an extensive career in the arts (including painting, theatre design, large scale sculpture), as cultural planner, and as an artist in a prestigious design team for the largest, much-awarded urban design project in Australia.
Background: Like people, places are made of their experience. Aboriginal Australia was a densely woven web of places, paths, journeys and songlines; the stories contained in the heads of the living as they passed through the generations and through the landscape. Contemporary Australia has an exploding and diverse population, problematic relationships with history, and confused ideas about landscape and Australian nature. In the huge growth of new housing, mostly in large urban developments, how can the high physical living standards that these projects offer be matched with a similar level of social and psychological well-being? How can a sense of place and identity be created? Bringing together the excavation of natural and social history with the language of art offers a way forward. Art can play a part in creating an enriched, coherent public realm that also nurtures individual dialogues in very private and intimate intellectual and emotional spaces.
Objectives: The aim is to examine the power of cultural decision making and art, to intervene in the public realm, to improve the psychological health of these communities.
Method: To explore the natural and social history of place, outline the general planning of a project and then examine in detail the interactions involved in a specific art project.
Findings: The impact of cultural planning and the use of art in public space can create the layered meanings that history has given to older towns and cities, while reversing the authority-based cultural language of historical public art, and creating the intellectual and emotional space for individual identity.
Conclusion: All urban development projects should include a cultural voice in the planning programme, and ensure that art and culture continue to create a coherent and sustaining public realm that encourages a creative dialogue in both public and private spheres.
Presentation 3: S Lutton: A Loss of Place
S Lutton has worked as a consultant psychiatrist with ASSeTTS (Association of Services for Torture and Trauma Survivors) for over 18 years, in addition to full time private practice. She has also recently obtained a PhD in Classics and Ancient History from the University of WA. Her clinical interests are in trauma and long-term psychotherapy.
Background: To seek asylum is to seek refuge, to seek a place of safety. Currently, there are 44 million people who have no place. This presentation is an exploration of the psychological consequences of displacement. It is a clinical case history of a refugee seeking asylum. It led to a confrontation with human despair, shame and integrity in the seeker and the clinician as refuge was sought in both the physical and psychological worlds. The clinical impact was significant. Whilst this was a physical journey, it was also symbolic of the emotional trauma of many individuals who lose their inner sense of belonging and of place.
Objectives: The aim is to clinically explore both the onset of the psychological consequences and of the ability for repair.
Method: A clinical case history of a refugee having undergone persecution and loss of place, and seeking asylum, is explored.
Findings: The impact of displacement, dehumanization and trauma is fully highlighted, as also the potential for re-traumatisation, along with the ability for re-stabilization, with integration and re-establishment of a sense of place.
Conclusion: Persecution, despair and loss of safety is of global concern, as much as it is in everyday clinical practice. Dehumanization is occurring with increasing frequency. It is hoped by the presentation of a clinical case history, that the impact at both an individual as well as at a social and political level can be brought to greater awareness.
Early Career Psychiatrists’ Special Interest Group (ECPSIG) Symposium
SM Loi1,2, N Lautenschlager1,2, D Ames1,2, B Dow2 S Sharma
1Academic Unit for Psychiatry of Old Age, Department of Psychiatry, University of Melbourne, Saint George’s Hospital, Kew, VIC, Australia
2National Ageing Research Institute, Parkville, VIC, Australia
The aim of this symposium is to allow early career psychiatrists an opportunity to present their work and research within a dedicated symposium, during Congress 2014, and to promote and encourage research amongst Fellows in their early years of Fellowship.
In accordance with the terms of reference for the Special Interest Group (SIG), the Early Career Psychiatrists’ SIG (ECPSIG) is very supportive of providing opportunities for early career Fellows. The introduction of such a symposium is one key way in which the group is supporting its members.
In particular, the Royal Australian & New Zealand College of Psychiatrists’ (RANZCP) Early Career Psychiatrist Award Recipient and the ECPSIG’s nomination for invited session speaker status (please note that this nomination was not accepted as part of the invited session speaker nominations) have been included in this symposium, along with other members who have indicated their interest in presenting as part of such a symposium.
Presentation 1: RANZCP Early Career Psychiatrist Award Recipient Research Presentation
This presentation will be delivered by the recipient of the Early Career Psychiatrist Award. The recipient of this award was determined in early 2014.
The presentation aims to increase the profile of the Royal Australian & New Zealand College of Psychiatrists’ (RANZCP) Early Career Psychiatrist Award, by providing the recipient an opportunity to present their research during a dedicated Early Career Psychiatrist Symposium at Congress.
Further details can be provided once a recipient has been finalised in early 2014.
Presentation 2: SM Loi: Does Being a Carer Impact Negatively on Attitudes Toward Ageing?
SM Loi1,2, N Lautenschlager1,2, D Ames1,2, B Dow2
1Academic Unit for Psychiatry of Old Age, Department of Psychiatry, University of Melbourne, Normanby House, Saint George’s Hospital, Kew, VIC, Australia
2National Ageing Research Institute, Parkville, VIC, Australia
Background: There is an ageing population worldwide. Despite increased life expectancy, there are many older people with frailty and disability, requiring assistance from family carers to support them at home. Currently, there are 2.6 million carers in Australia, with 520,000 aged over 65 years. Carers are at a high risk of adverse physical and emotional outcomes, with the carers in the older age group thought to be at highest risk.
Attitudes to ageing are the internal attitudes a person may hold towards their own ageing, ageing in general and the ageing process. People develop these attitudes as a result of their own experiences and the often-prevailing negative stereotypes of being old. Negative attitudes to ageing have been associated with worse physical and mental health. It is thought that negative attitudes may be activated by a personal stressor, such as caring for someone whom demonstrates these negative aspects of ageing.
There is little known about attitudes toward ageing in older carers, which may have implications for how these attitudes may influence their mental health.
Objectives: This study examined attitudes to ageing in older carers and older non-carers; hypothesising that the carers will have more negative attitudes toward ageing.
Methods: A cross-sectional design was utilised, using the World Health Organisation (WHO) Attitudes to Ageing Questionnaire (AAQ) in the two groups.
Findings: The AAQ was completed by 93 carers and 53 non-carers. As hypothesised, the carers had significantly more negative attitudes toward ageing than the non-carers.
Conclusions: This study is one of the first to compare attitudes to ageing in carers and non-carers. Results suggested that providing care may negatively impact on carers’ attitudes toward ageing, which in turn is associated with adverse health effects in an already vulnerable group.
Presentation 3: S Sharma: Nutritional Intervention in Management of Mental Illness
Introduction: In this symposium, an attempt is made to look outside the box into additional factors that could contribute in the presentation of psychopathology and look at why some of our patients don’t respond to conventional treatment strategies.
Background: People with mental illness are often malnourished and recommendations for nutritional intervention are overridden by pharmacological methods. Even in the cases where the person may grow well, testing reveals some typical nutritional deficiencies in many important minerals, vitamins, essential fats, many amino acids and other nutrients. The majority of patients with mental illness have limited insight into their lifestyle choices and most of them don’t have a general practitioner (GP).
The dietary history of the patient is often ignored. Gut flora is something we do not think much about, and yet the number of functions the gut flora fulfils is so vital for us that if someday our digestive tracts were sterilised, we probably would not survive.
Gut and Psychology Syndrome (GAP Syndrome or GAPS) establishes the connection between the state of the patient’s gut and the functioning of the brain. This connection has been known by medics for a very long time. The father of modern psychiatry, French psychiatrist Phillipe Pinel (1745–1828), after working with mental patients for many years, concluded in 1807: ‘The primary seat of insanity generally is in the region of the stomach and intestines’. Long before him, Hippocrates (460–370 BC), the father of modern medicine, said: ‘All diseases begin in the gut!’ The more we learn with our modern scientific tools, the more we realize just how right they were.
This symposium is on an overview of the nutritional connection with common psychiatric disorders and the current evidence in support of each recommended intervention.
The NDIS, Aboriginal and Torres Strait Islanders People, and Psychiatrists
C Townsend1, G O’Brien2, J Cullen1, P White1
1Brain Injury Association of Queensland, QLD, Australia
2Specialist Disability Services Outreach and Assessment Team, Queensland State-wide Disability Services, QLD, Australia
Background: The National Disability Strategy, and National Disability Research and Development Agenda, prioritise access services for indigenous Australians. If the NDIS is presented homogeneously across Australia, it will fail. If the NDIS fails indigenous imperatives, it will fail.
Objectives: To outline the NDIS system. To demonstrate the inapplicability of this model for Aboriginal and Torres Strait Islander peoples with neurocognitive and psychiatric disabilities. To consider how psychiatrists and others will respond to the complex needs of this cohort, within a NDIS context.
Methods: The presenters are the CEO of Synapse (Brain Injury Association of QLD), who is an indigenous woman and member of peak NDIS bodies, a researcher specializing in indigenous disability, and two psychiatrists with extensive experience in the area. They will present evidence regarding the complex neurocognitive and psychiatric disabilities within this cohort, and issues associated with appropriate and effective service provision. Participants will consider how psychiatrists and other professionals can respond to these in a NDIS context.
Findings: Significant evidence gaps exist in relation to the nature, extent, experience and needs of Aboriginal and Torres Strait Islander people with complex psychiatric and neurocognitive disabilities.
Conclusions: The National Disability Agenda identifies the need to ensure that Aboriginal and Torres Strait Islander people with disability benefit from the NDIS. Unless psychiatrists and others address the significant gaps that exist in relation to Aboriginal and Torres Strait Islander peoples with psychiatric and neurocognitive disability, the NDIS will fail.
Presentation 1: An Evidence Base to Assist Implementation of the NDIS Amongst Aboriginal and Torres Strait Islander Peoples
C Townsend1, P White2, J Cullen1, G O’Brien2
1Brain Injury Association of Queensland, QLD, Australia
2Specialist Disability Services Outreach and Assessment Team, Queensland Health, Queensland State-wide Disability Services, QLD, Australia
Background: The Productivity Commission found that the disability system is underfunded, unfair and inefficient. The Council of Australian Governments (COAG) agreed to major disability services reform, through a NDIS. ID is estimated to be responsible for 5.5% of the total disease burden in Aboriginal and Torres Strait Islander Peoples. It is frequently accompanied by psychiatric and neurocognitive disorders. Effective NDIS implementation requires accurate and reliable data about these complex conditions that includes the indigenous peoples’ perspectives.
Methods: Literature pertaining to indigenous Australians who have intellectual disabilities, including those who exhibit challenging behaviours, published between 1970 and 2012, was systematically reviewed. In addition the experiences of almost 200 people with ID, and their families and carers, seen by psychiatrists in FNQ were considered.
Findings: The literature review revealed 26 articles. Key areas identified were: Indigenous Australians’ understandings of disability, aetiology and prevalence; measurement and screening; and service provision, including the criminal justice system and impaired decision making. Clinical experience indicated that indigenous adults with ID, neurocognitive and psychiatric disabilities are often cared for by families and communities without adequate services or support. Where carers are unable to cope, people are removed to mental health facilities and other accommodations lacking culturally-appropriate or adequate assessment and care. This compromises social and emotional well-being and human rights.
Conclusions: There is insufficient data addressing the prevalence, nature and consequences of complex disabilities, including ID, psychiatric and neurocognitive disorders within indigenous populations. This has serious implications for the capacity of the NDIS to address the needs of these Australians.
Presentation 2: Epidemiology of Neurocognitive Disorders in Aboriginal and Torres Strait Islander Peoples
P White2, C Townsend1, G O’Brien2, J Cullen1
1Brain Injury Association of Queensland, QLD, Australia
2Specialist Disability Services Outreach and Assessment Team, Queensland Health, Queensland State-wide Disability Services, QLD, Australia
Background: There are 7.7% of indigenous adults aged over 15 years who have ID. They are 3.2 times more likely to have ID than non-indigenous Australians. In 2011, more than one-third of indigenous users of specialist disability services nationally named ID as their primary reason for activity limitations. The co-existence of ID, neurocognitive and psychiatric disorder is thought to be high.
Objectives: To demonstrate problems associated with using existing statistical data sets to understand the prevalence and incidence of complex disability amongst indigenous Australians.
Methods: Australian key data sources containing neurocognitive-specific information were examined, including: Commonwealth State and Territory Disability Agreement National Minimum Data Set; The Survey of Disability Ageing and Carers (SDAC) and the National Census.
Findings: Existing prevalence data for indigenous peoples who have ID vary, and are thought to underestimate prevalence rates in remote and rural areas. ID was found to be common amongst indigenous people aged over 15 years with psychotic disorders, in Cape York and the Torres Strait (29.6%).
Conclusions: There is a lack of accurate data to inform policy and service development, and unique challenges associated with indigenous peoples accessing culturally-appropriate and accessible services. More in-context data collection is required that is capable of capturing and reporting detailed distributive and small-group information.
Presentation 3: Analysis of the Specialist Disability Services Assessment and Outreach Team Clinical Database
G O’Brien2, C Townsend1, J Cullen1, P White2
1Brain Injury Association of Queensland, Australia
2Specialist Disability Services Outreach and Assessment Team, Queensland Health, Queensland State-wide Disability Services, QLD, Australia
Background: The Specialist Disability Services Assessment and Outreach Team (SDSAOT) is one component of Disability Services QLD. It uses a holistic consultation-liaison approach, which is delivered by a multidisciplinary team including 3 nurses, 1 trainee in psychiatry, 2 resident medical officers and 3.5, and psychiatrists. Over 6 years, they had ~800 new clients: 200 of these people are indigenous, many of whom have other complex conditions.
Objectives: To explore whether the NDIS will result in improved mental health care for people with intellectual disabilities, especially those of indigenous origin.
Methods: The SDSAOT clinical database was scrutinised (N = 800, including 200 indigenous Australians).
Findings: All 800 subjects will be eligible to receive services under the NDIS. People with neurocognitive disorders have high rates of mental disorder, yet are poorly served by current mental health services. Unmet mental health needs are very common and most prominent among indigenous Australians, but the NDIS does not include any provision for health care.
Conclusions: On current understanding of plans for the NDIS, there is no scope for the inclusion of health assessment nor treatment. The current shortfalls in mental health care of people with intellectual disability are unlikely to be improved by the advent of the NDIS. The shortfall is likely to continue to be most marked among indigenous Australians.
Presentation 4: Innovative Approaches to Facilitate the Successful Implementation of the NDIS for Aboriginal and Torres Strait Islander People with Complex Disabilities
J Cullen1, C Townsend1, P White2, G O’Brien2
1Brain Injury Association of Queensland, Queensland, QLD, Australia
2Specialist Disability Services Outreach and Assessment Team, Queensland Health, Queensland State-wide Disability Services, Queensland, QLD, Australia
Background: Synapse is dedicated to improving the quality of life of people living with and affected by complex neurocognitive and psychiatric disorders. Our research focuses on the needs of Aboriginal and Torres Strait Islander Peoples with complex disabilities in Far North Queensland and the dearth of culturally appropriate service models available to meet their needs and those of their families and communities. Successful implementation of the NDIS amongst Aboriginal and Torres Strait Islander peoples will require approaches consistent with their experience and world view, which use language and concepts that are understandable and meaningful.
Objectives: To develop innovative, culturally-appropriate services that will facilitate the successful implementation of the NDIS for Aboriginal and Torres Strait Islander peoples with complex disabilities.
Methods: A suite of initiatives are being developed to address the needs of Aboriginal and Torres Strait Islander Peoples with complex disabilities, within the context of the NDIS. These include: the Indigenous Assessment Tool, The SAIF Project, Cape and Torres Strait Disability Service Delivery Project, Bed Block Project, and Homeless People with Disability in Cairns.
Findings: Projects undertaken by Synapse in collaboration with key stakeholders demonstrate specific, culturally-appropriate approaches to service design and implementation for Aboriginal and Torres Strait Islander peoples with complex disorders. These specific approaches and their application to the NDIS and to psychiatric practice will be considered.
Conclusions: Aboriginal and Torres Strait Islander Peoples with complex disabilities in rural and remote areas are poorly served, according to any acceptable standards of care. Innovative approaches to complex disability designed in close collaboration with indigenous and other stakeholders will support successful implementation of the NDIS. Contextual barriers will still need to be overcome.
Improving Mental Health Outcomes With Epractice
AC Page1, GR Hooke2, F Ronk2, S Kashyap1, T Parker3
1University of Western Australia, Perth, WA, Australia
2Perth Clinic, Perth, Australia
3Peoplesense, Perth, Australia
Background: The term ePractice describes the use of electronic technologies in clinical practice. There is no necessary reason why the adoption of ePractice should weaken nor undermine psychiatric practice. By contrast, ePractice has the potential to complement practice and free psychiatrists to focus on their core business of treating patients.
Objectives: Papers will outline examples of ePractice enhancing inpatient psychiatric care.
Methods: Papers will describe clinical trials of the effectiveness of ePractice.
Findings: Papers will demonstrate how ePractice can:
Improve outcomes by identifying patients who are Not On Track for optimal outcomes;
Identify potential adverse outcomes and patient risk to assist prevention; and
Monitor progress of therapeutically relevant variables during an admission.
Conclusions: ePractice can assist psychiatrists to deliver improved service, by freeing them to focus on their core business of treatment.
Presentation 1: AC Page and GR Hooke: ePractice: Using What Computers Do Best, So Psychiatrists Can Do What They Do Best
AC Page1, GR Hooke2
1University of Western Australia, Perth, WA, Australia
2Perth Clinic, Perth, Australia
Background: Psychiatrists have a long tradition of providing high-quality pharmacological and psychological treatments for mental disorders. In recent times, advances in information technology have provided a means to complement health care. As an introduction to this symposium, a patient-focused research paradigm will be outlined and its beneficial effects on patient outcomes will be highlighted.
Objectives: To illustrate the development and use of a ‘mental health thermometer’ to monitor the progress of inpatients by providing feedback to staff and patients on outcomes.
Methods: A controlled trial will be outlined, comparing mental health in patients who received feedback about their progress against a group who did not.
Findings: Outcomes of patients who received progress feedback during treatment were better than those who did not, and the rate of readmission was reduced.
Conclusions: The routine monitoring of patient progress is recommended and computerisation provides a method to achieve this goal, while enhancing the ability of staff to provide optimal treatment.
Presentation 2: GR Hooke, AC Page: Patient Progress Monitoring at the Desktop: Just the Beginning!
GR Hooke2, AC Page1
1Perth Clinic, Perth, Australia
2University of Western Australia, Perth, WA, Australia
Background: As with the humble thermometer, we are now moving to monitor patient progress using methods similar to the thermometer, but in psychiatry, patient self-reported measures can be completed in the rooms or at the point of care on a daily basis. Can this monitoring be used in psychiatry, and what else can be learnt from this approach?
Objectives: To establish a method of monitoring patient progress that is easily accessible and allows the full treatment team to be immediately informed of progress, when completed. To use touch screen technology and i-Pads to increase patient accessibility and to develop different questionnaires, to take advantage of this technology.
Conclusion: Patients are able to record their progress and risk on a daily basis, and this is immediately available at many points around the acute hospital facility, and also at the psychiatrists’ desktop or tablet. Feedback on progress is given at regular intervals, to understand treatment progress and to discuss issues and successes along the way.
Presentation 3: F Ronk, GR Hooke, AC Page: Using Clinical Significance Methodology to Monitor Outcomes in a Quick and Valid Way
F Ronk2, GR Hooke2, AC Page1
1University of Western Australia, Perth, WA, Australia
2Perth Clinic, Perth, Australia
Background: Evaluating the clinical significance, or meaningfulness, of a patient’s change allows us to reflect on the success of the treatment, to make decisions regarding post-termination/discharge planning and to evaluate overall trends in therapy success over time.
Objectives: To determine the amount of change considered clinically significant on the DASS-21 and develop practical tools allowing treatment providers to assess the clinical significance of their patients’ outcomes.
Methods: Clinical significance classifications were calculated for 1000 outpatients and 3964 inpatients on the three scales of the DASS-21.
Findings: Classifications of those recovered were related to lower symptom severity, higher perceived quality of life and higher clinician-rated functioning for inpatients. An intermediate category between recovered and improved was proposed, termed ‘recovering’. Patients classified as recovering had more severe symptoms than recovered patients, and less severe symptoms than improved patients.
Conclusions: Practical materials have been developed using a large sample of inpatients and outpatients, allowing treatment providers to quickly and easily evaluate the clinical significance of their patients’ changes on the DASS-21.
Presentation 4: S Kashyap, GR Hooke, AC Page: Managing the Risk of Self-Harm, Using Daily Monitoring
S Kashyap1 GR Hooke2, AC Page1
1University of Western Australia, Perth, WA, Australia
2Perth Clinic, Perth, Australia
Background: Despite being aware of risk factors for suicidal behaviour such as suicidal ideation; it is still difficult to predict who will display these behaviours and when. Continuously monitoring any change in these risk factors during treatment may reveal groups of patients who improve in symptoms at different rates. One or more groups may be at a higher risk of exhibiting self-injurious behaviours.
Objectives: To explore rates of improvement in subjective ratings of suicidal ideation, depression, anxiety, feelings of worthlessness and ability to cope through daily monitoring. If group tendencies exist, to then explore any relationships between groups and rates of self-harm.
Methods: Latent Growth Curve Analysis was used to check for longitudinal patterns of change between groups of inpatients at a psychiatric hospital (N = 525), and group relationships with rates of self-harm were measured.
Findings: Four distinct groups were found: Non-responders to treatment (high symptom ratings remaining high over the 14-day treatment period) were the most likely to self-harm; and the groups of Responders who began with high, medium and low symptom ratings, who were all significantly less likely to self-harm, in that order.
Conclusions: Continuous monitoring of inpatients provides a practical approach for risk management. If it is known which group any patient belongs to, their risk of self-harm can be estimated and procedures can be put in place to prevent any adverse events.
Novel Topics in ADHD and in the Spectrum Phenotypes of ADHD-Autism and of ADHD-Emotional Liability Presentations
W Chen1,2, D Silva3,4, B Jongeling4,5, K Langford6, N Rommelse7,8,9
1Division of Clinical Neuroscience, University of Southampton, Southampton, UK
2MRC SGDP, Institute of Psychiatry, King’s College London, London, UK
3Telethon Institute for Child Health Research, Centre for Child Heath Research, University of Western Australia, Perth, WA, Australia
4Department of Paediatrics, University of Western Australia, Perth, WA, Australia
5Child Development Service of Western Australia, Perth, WA, Australia
6Inside Out Occupational Therapy Group, Perth, WA, Australia
7Department of Psychiatry, Radboud UMC, the Netherlands
8Karakter Child and Adolescent Psychiatry University Center, the Netherlands
9Donders Institute for Brain, Cognition and Behaviour, the Netherlands
ADHD is a common and important yet complex neurodevelopmental disorder. This symposium focuses on some recent developments in ADHD research and its link with autism spectrum disorders.
Data from the Telethon Institute (WA) provides novel insights on early causal pathways and developmental trajectories of ADHD. Infection, head injury, burns, poisons, epilepsy, and ear and tonsillar diseases are key post-natal risk factors associated with ADHD, which significantly lowers educational attainments and worsens with the increasing age. ADHD children are more likely to have a justice record.
Emotional Liability (EL) is commonly associated with ADHD. The second study presents the findings from a twin analysis using the Manchester Twin data, which demonstrates substantial genetic overlap as a shared common latent factor accounting for EL-intellectual impairment (IA) impulsivity (IMP) symptomatic triads. EL may be regarded as the third dimension in the ‘IA-IMP-EL spectrum’ phenotype. This presentation also examines the interplay between ADHD and ASD symptoms in the expression of Emotional Lability (EL) problems. EL was strongly associated with all subtypes of ADHD, especially those with elevated HA-IMP symptoms, but there appears an ‘Inattention-ASD-EL subtype’, which is highly relevant to clinical assessment and management.
Occupational dysfunctions are often over-looked in ADHD assessments. The third presentation provides novel data from Complex ADHD Service (CAHDS) WA, which revealed their prevalence and importance. 100% of CADHS referrals had 2 or more occupational related deficits. The commonest problem was sensory integration difficulties. Parents, referrers and schools of assessed children rated these findings as clinically relevant.
The fourth study maps the long journey taken by ADHD families from initial suspicion to receiving diagnosis and treatments in WA. ‘Someone suggesting ADHD’ and ‘accessing information from multiple sources and from a professional’ appears to form two pivotal steps. The empirical findings also reveal potential barriers to accessing services. In the second part of this presentation, Autism spectrum disorder symptoms are found to be more common in children with ADHD. In contrast to previous research, autism spectrum disorder (ASD) symptoms did not differ by ADHD subtype or gender. Child and parent functioning correlates will be discussed.The last presentation examines the empirical evidence for distinct novel subtypes within ASD -ADHD spectrum disorders, their phenotypic distinctions and concurrent validity with comorbid symptoms and neurocognitive profiles. The ADHD(+ASD) subtype was found to be most strongly associated with Emotional Lability, Working Memory deficits and most functionally impaired.
It also demonstrates ASD symptoms as the rarer phenotypic expression of that risk liability, using a sophisticated family study design and familial cross-disorder analysis amongst high risk ASD and ADHD families. Furthermore, the the role of parental ASD+ADHD symptoms on parenting styles, parental stress and depressive symptoms as well as the impacts on the wellbeing of the offspring and spouse. The results highlight the increased burden of raising a child with ASD and/or ADHD; as well as its reciprocal relationship with parental ASD, ADHD and depressive symptoms.
Presentation 1: Desiree Silva: Understanding the Life Course of Attention Deficit Disorder: Population Linkage Study Western Australia
Desiree Silva1,2
1Telethon Institute for Child Health Research Centre for Child Heath Research, University of Western Australia
2Department of Paediatrics, University of Western Australia, Perth, Australia
Objectives: To provide an overview of the data linkage opportunities in Western Australia (WA) relating to Attention Deficit Disorder (ADHD) and to investigate the early risk factors, early markers, causal pathways and health, education and justice outcomes for children prescribed stimulant medication (SM) for ADHD.
Methods: Using de-identified population linked data from the stimulant notification register, midwives notification, hospital morbidity, justice records and education data, 16,883 children and adolescents aged 4-25 years diagnosed with ADHD and prescribed stimulant medication were identified and compared with 32,728 non-ADHD children.
Findings: Mothers of children who were subsequently diagnosed with ADHD and treated with SM were significantly more likely to be single, younger and smoked during pregnancy. Post natal pathways were examined using hospital morbidity data where children under 4 years subsequently diagnosed with ADHD were significantly more likely to be admitted to hospital with an infection, head injury, burns, poisons, epilepsy, and ear and tonsillar disease, compared with their non-ADHD counterparts. Children with ADHD were 3 times more likely to have a justice record compared with their non-ADHD counterparts, and at a younger age. ADHD children had significantly lower education scores for both numeracy and literacy, and these scores became progressively worse with the increasing age of the child.
Conclusions: This large population study using linked data on ADHD children can provide information on early causal pathways and outcomes which will assist policy makers and clinical practitioners better understand this common mental health condition at multiple levels.
Presentation 2: K Langford: How Important and Relevant is Occupational Dysfunction in Complex ADHD Presentations?
K Langford1, S Ho2, W Chen3,4
1Inside Out Occupational Therapy Group, Perth, WA, Australia
2CAHDS, CAMHS, Department of Health, Perth, WA, Australia
3Division of Clinical Neuroscience, University of Southampton, Southampton, UK
4MRC SGDP, Institute of Psychiatry, King’s College London, London, UK
Background: Children’s occupations are broadly grouped into their student, leisure and self-care roles. Successful functioning within these roles relies on the integration of numerous skills and abilities (performance components). Occupational dysfunctions are often over-looked in routine ADHD assessments. The Complex ADHD Service (CADHS) is a statewide Tier 4 clinic for children with severe impairments related to complex ADHD. This study examines the prevalence of performance component deficits and associated occupational dysfunction amongst CAHDS referrals.
Method: Consecutive cases assessed by CAHDS were audited. The prevalence of subtypes were recorded and computed.
Findings: The audit yielded 64 consecutive cases of Complex ADHD children assessed in CAHDS. The average age was 11, ranging from 3.5 to 16.5; 84% were boys. 100% of CADHS referrals were found to have 2 or more occupational related deficits, while 73% had 6 or more deficits (defined as scoring below 17th centile). In the break-down of subtypes, the most prevalent problem (91%) was sensory integration difficulties, 70% were sensory seekers, 80% had handwriting difficulties, 67% had planning and organizational deficits, 60% had auditory processing problems, 55% had gross motor difficulties, 51% had balance deficits, 71% had visual perceptual skill variability and 45% had an ocular motor irregularity. Parents, referrers and schools of assessed children rated these findings highly relevant and important in the assessment outcome.
Conclusion: Children with complex ADHD are very likely to have significant impairments in their occupational performance. Accurate identification and feedback of these findings to parents, educational personnel and referrers forms a major contribution in the service provided by CADHS.
Presentation 3: Wai Chen1,2: ADHD And Emotional Liability (EL): Genetic Architecture, Phenotypic Correaltions and New Perspectives
Wai Chen1,2
1Division of Clinical Neuroscience, University of Southampton, Southampton, UK
2MRC SGDP, Institute of Psychiatry, King’s College London, London, UK
Objectives: To evaluate empirical evidence for genetic substrates underlying the observed association between ADHD and Emotional Lability (EL) and phenotypic correlations of EL.
Methods: (1) Structural Equation Modeling (SEM) of Manchester twin data (age range 5-18 years) to decompose genetic architecture of Inattention (IA), Hyperactivity (HA), Impulsivity (IMP) and EL (DuPaul rating scale and Conners 10-item scale, completed by parents). (2) Latent class analysis of IMAGE ADHD probands and their siblings in relation to EL and ASD symptoms.
Findings: (1)There were moderate to strong phenotypic correlations between HI, IA and EL. Multivariate twin modeling revealed that a common pathway model best accounted for the covariance between these dimensions, represented by a highly heritable latent factor. Post-hoc analyses identified unique genetic associations of EL with IA (after controlling for HI) and with HI (after controlling for IA); confirmed that all additive genetic influences on HI, IA and EL were shared and identified a significantly stronger association of EL with the latent ADHD factor in older individuals. (2)ADHD LCA with IA, HA and IMP symptoms all shows significant association of EL, especially those with elevated HA-IMP symptoms. The ‘Moderate Combined Subtype’ ADHD latent class showed similar levels of impairments and EL expression as that of the other severe ADHD classes. Pure IA subtype of ADHD, by comparison, embodies the lowest elevated risk of EL. However, in the presence of ASD symptoms, the risk of EL is marked increased in the pure IA subtype.
Conclusions: (1) ADHD and EL share common genetic etiological factors. The finding that a single, heritable, latent factor accounted for covariation among these phenotypes indicates that their co-occurrence is primarily the result of overlapping genetic effects. EL may be regarded as the third dimension in the ‘IA-IMP-EL spectrum’ phenotype and should be a target for assessment and treatment in clinical practice. (2) All subtypes of ADHD with IA, HA and IMP symptoms were significantly associated with elevated degree of EL. The ‘Moderate Combined Subtype’ ADHD latent class showed similar levels of impairments to other severe subtypes, but these children will remain diagnostically ‘homeless’ in DSM5. In the presence of ASD symptoms, the risk of EL is markedly elevated in pure IA cases, suggestive of a specific ‘IA-ASD-EL spectrum’ subtype, indicating that ASD must be evaluated in individual with EL and pure IA subtype of ADHD within clinical settings.
Presentation 4: 4.1 Brad Jongeling: Mapping the Journey From Suspicion to Treatment: Western Australian Pilot From Australian Paediatric ADHD Study
BR Jongeling1,2, S Kaiser1,4, G Smith3, A Luangrath5, E Sciberras5, D Efron5,6,7, H Hiscock5,6,7
1Child Development Service of Western Australia, WA, Australia
2School of Paediatrics and Child Health, University of Western Australia, WA, Australia
3Telethon Institute of Child Health Research
4Princess Margaret Hospital for Children
5Murdoch Children Research Institute
6Royal Children’s hospital Melbourne, Melbourne, Australia
7University of Melbourne Department of Paediatrics, Melbourne, Australia
Introduction: Despite the high prevalence of ADHD, there are no Australian data investigating the ADHD families’ journeys and the critical steps which lead to accessing services and treatments.
Aim: To map the families’ and patient’s journeys from initial suspicion to information/service seeking processes before finally receiving diagnosis and treatments. The empirical findings may also reveal potential barriers to accessing service.
Methods: Service users’ experiences were captured by standardised instruments in the WA subsample (of a larger prospective longitudinal study, Australian Paediatric ADHD Study) recruited by paediatricians from metropolitan and regional WA. Baseline and follow-up surveys were completed online or on paper by parents, children and paediatricians.
Results: 107 children (74% male) have been recruited to the study, age ranging 4 - 15; and 76% of parents first noted anomalies (i.e. behaviour/emotions/learning) before the child’s 5th birthday (median 4 years of age). The median age of ‘someone suggesting ADHD’ was 6, and ‘receiving a formal diagnosis’ was 8, revealing a 2 year gap from concern to ‘suggested diagnosis’, and a 4 year gap to ‘actual diagnosis’. Prior to diagnosis, parents sought information on ADHD from a range of sources -internet (71%), psychologist (43%), child’s school (37%), allied health practitioner (37%), books (35%), friends (33%); and strikingly, 92% of parents reported seeking help from other ‘stepping-stone’ professionals.
Once in paediatric clinics, 70% cases required two or more consultations prior to the ADHD diagnosis. Other assessments included parent questionnaire (93%) teacher questionnaire (90%), cognitive Assessments (71%). Treatments received included medications (80%) and Behavioural intervention (88%).
Conclusion: Parents report a long journey to ADHD diagnosis. ‘Someone suggesting ADHD’ and ‘accessing information from multiple sources and from a professional’ appears to form two pivotal steps. This study reveals potential barriers in accessing service.
4.2 Social and Communication Difficulties in Children With ADHD and Non-Adhd Controls: A Community-Based Study
Brad Jongeling1,2, Jessica Green3,4, Nicole Rinehart4,5, Vicki Anderson4,6,7, Daryl Efron4,5,7, Elizabeth Schilpzand4, Jan Nicholson4,8, Emma Sciberras5,7
1Joondalup Child Development Centre, Perth, Australia
2Department of Paediatrics, University of Western Australia, Perth, WA, Australia
3School of Psychology and Psychiatry, Monash University, Clayton, Australia
4Murdoch Children’s Research Institute, Melbourne, Australia
5Deakin University, Burwood, Australia
6The Royal Children’s Hospital, Melbourne, Australia
7The University of Melbourne, Parkville, Australia
8Parenting Research Centre, Melbourne, Australia
Objectives: To examine in a community-based sample the prevalence and type of ASD symptoms in children with and without ADHD, differences in ASD symptoms by ADHD subtype and gender and to examine the correlates of autism spectrum disorder symptoms and child functioning, and autism spectrum disorder symptoms and parent/family functioning.
Methods: Participants were parents of Grade 1 children (age 6 -8 years) participating in Cohort 2 of the Children’s Attention Project. Children were assessed as positive for ADHD if they scored above the 75th centile (boys) and 80th percentile (girls) using the parent and teacher Conners’ 3 ADHD index; met diagnosis using the NIMH Diagnostic Interview Schedule for Children (DISC) IV. Children who screened negative were matched on gender and school. ASD symptoms were screened using the Social Communication Questionnaire (SCQ).
Results: Social and communication questionnaire results were significantly higher in children with ADHD. Both boys and girls with ADHD had higher SCQ total scores and SCQ subscale scores than those without ADHD. There were no significant differences in SCQ total score and SCQ subscale scores by ADHD subtype.
Conclusion: Autism spectrum disorder symptoms are more common in children with ADHD. In contrast to previous research, ASD symptoms did not differ by ADHD subtype or gender. Child and parent functioning correlates will be discussed.
Presentation 5: 5.1 Novel Subtypes With the ASD-ADHD Spectrum Disorders
Nanda Rommelse1,2,3 (acknowledgement to Jolanda van der Meer and Jan Buitelaar)
1Department of Psychiatry, Radboud UMC, the Netherlands
2Karakter Child and Adolescent Psychiatry University Center, the Netherlands
3Donders Institute for Brain, Cognition and Behaviour, the Netherlands
Objective: Autism spectrum disorders (ASD) and attention-deficit/hyperactivity disorder (ADHD) frequently co-occur. The current study examined the empirical evidence for distinct novel subtypes within ASD -ADHD spectrum disorders, their phenotypic distinctions and concurrent validity with comorbid symptoms and neurocognitive profiles.
Method: Latent class analysis was performed on Social Communication Questionnaire (SCQ) and Conners’ Parent Rating Scale (CPRS-R:L) data for 644 children and adolescents (5 through 17 years of age) originating from both a school and clinical sample. Classes were compared for comorbid symptoms and cognitive profiles of motor speed and variability, executive functioning, attention, emotion recognition, and detail-focused processing style.
Results: Latent class analysis revealed five classes: two without behavioral problems, one with only ADHD behavior, and two novel ADHD-ASD subtypes (one predominantly ‘ADHD(+ASD)’, and one predominantly ‘ASD(+ADHD)’. There was some specificity of deficits across classes with ADHD(+ASD) subtype being most strongly associated with Emotional Lability, Working Memory deficits and most functionally impaired, while ASD(+ADHD) class formed an intermediately impaired group (with superior visual spatial abilities), yet impaired emotion recognition, and ADHD-only class less impaired.
Conclusions: Our findings, if replicated, can be highly relevant to clinical practice, in particular, delineating the concurrent impairment patterns of these novel subtypes, so that children presenting to clinics can be subclassified and treated with greater precision. For research, the overlapping cognitive deficits may be used to further unravel the shared etiological underpinnings of ASD and ADHD, and the nonoverlapping deficits may indicate why some children develop ADHD despite their enhanced risk for ASD.
5.2 Are ASD Symptoms More Like ‘Gold Dust’ Within the ADHD+ASD Spectrum Disorders?
Nanda Rommelse1,2,3
1Department of Psychiatry, Radboud UMC, the Netherlands
2Karakter Child and Adolescent Psychiatry University Center, the Netherlands
3Donders Institute for Brain, Cognition and Behaviour, the Netherlands
Background: Autism spectrum disorders (ASD) and attention-deficit/hyperactivity disorder (ADHD) are both highly heritable disorders, that frequently co-occur. It remains a puzzle why ASD has lower prevalence than ADHD if both disorders share the same ‘ADHD+ASD spectrum’ risk liability.
In this study, we tested the first hypothesis that ASD is a rarer expression of that risk liability by using a cross-disorder analysis amongst high risk ASD and ADHD families. We predict ADHD symptoms to be more common in relatives of ASD families than ASD symptoms in ADHD families. Secondly, further stratification into simplex (SPX; one affected individual in the family) and multiplex (MPX; two or more affected individuals) families can test our second hypothesis which predicts broad phenotypic expressions amongst relatives from ASD and ADHD SPX families to be less common than MPX families, indicating more de novo events (genetic or environmental) in probands from SPX families.
Methods: ASD and ADHD traits were measured in 56 ASD-SPX and 31 ADHD-SPX nuclear families, 59 ASD-MPX and 171 ADHD-MPX nuclear families and 203 control nuclear families using parent-, teacher-, and self-report questionnaires.
Findings: Unaffected relatives from ASD-MPX and ADHD-MPX families displayed elevated subthreshold symptom levels of both disorders. In line with our first prediction, ADHD symptoms were more pronounced in ASD-MPX families than ASD symptoms in ADHD-MPX families. In line with our second prediction, broad phenotypic expressions in ASD-SPX families are less elevated when compared with ASD-MPX families. But ADHD SPX and MPX families are more similarly affected.
Conclusions: Familial risks for both ADHD+ASD symptoms amongst siblings are elevated regardless whether the proband has ADHD or ASD. ADHD symptoms are the commoner expression of underlying familial risks, even in ASD-SPX and ASD-MPX families. The breeding out effect is less marked amongst ASD-SPX than ADHD-SPX families.
5.3 Impacts of Parental ADHD+ASD Symptoms on Family Functioning and Effects Upon Offsprings’ and Spouses’ Wellbeing
Nanda Rommelse1,2,3 (acknowledgement to Daphne van Steijn & Jan Buitelaar)
1Department of Psychiatry, Radboud UMC, the Netherlands
2Karakter Child and Adolescent Psychiatry University Center, the Netherlands
3Donders Institute for Brain, Cognition and Behaviour, the Netherlands
Objectives: An understudied and sensitive topic nowadays is that even subthreshold symptoms of Autism Spectrum Disorder (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD) in parents may relate to their parenting styles and create increased parenting stress. The aim of this study was to explore the role of parental ASD+ADHD symptoms on parenting styles, parenting stress and depressive symptoms as well as the impact thereof on the wellbeing of the offspring and spouse.
Methods: 96 families were recruited with one child (2-20 years) with a clinical ASD (+ADHD) diagnosis, and one unaffected sibling close in age. Parental ASD, ADHD and depressive symptoms were assessed using self-reports. Parenting styles, parenting stress and family functioning were assessed with self-, spouse and/or child report.
Findings: Fathers and mothers used a more permissive and less authoritative but authoritarian parenting style for affected and unaffected children. Increased parenting stress was mainly present regarding affected offspring. Spouse correlations were found for ASD, depression, and parenting stress. Paternal ASD and maternal ADHD symptoms were related to increased parenting stress; and parental ADHD symptoms with depressive symptoms and parenting stress.
Conclusions: The results highlight the increased burden of raising a child with ASD and/or ADHD and the reciprocal relationship this has with parents’ ASD, ADHD, and depressive symptoms, and levels of stress.
Smoking Cessation in Clinical Practice
E Cementon1,2, A Baker3, D Kirby4,5,6
1NorthWestern Mental Health, Melbourne, Australia
2Western Heath, Melbourne, Australia
3University of Newcastle, Callaghan, Australia
4Alfred Psychiatry, Melbourne, Australia
5Bendigo Health Services, Bendigo, Australia
6Saint Vincent’s Health, Melbourne, Australia
Background: People with mental illness form a considerable proportion of the smoking population. Furthermore, smoking contributes to the poorer health and shorter life expectancy of people with mental illness. Smoking also results in substantial social and financial costs to patients, their families and society. Nevertheless, smokers with mental illness are less likely to be offered help to quit smoking. Smoking cessation treatment should be integrated into the overall mental health treatment plan for the patient who smokes.
Objectives: This symposium will inform psychiatrists on issues regarding smoking in people with mental illness and outline interventions to promote smoking cessation for patients, so that they may incorporate smoking cessation treatment strategies into their clinical practice.
Methods: The speakers, who come from different clinical and academic backgrounds, will provide relevant information on the nature of smoking in people with mental illness and its associated myths and misconceptions, and describe and appraise the evidence-based pharmacotherapeutic and psychosocial interventions that can be implemented for smoking cessation in patients.
Findings: Psychiatrists, and the services in which they practice, are able to inquire of their patients’ tobacco use, advise them to quit, assess their readiness to quit and tailor assistance, interventions and follow-up accordingly.
Conclusions: Psychiatrists hold important positions in clinical leadership in mental health services and are therefore in positions to advocate that we progress from the long and troubling history of smoking in the mental health field and enable access to evidence-based tobacco cessation treatments is made readily available to our patients who smoke.
Presentation 1: E Cementon1,2: What Are the Core Issues for Smokers With Mental Illness?
1Substance Use, Mental Illness Treatment Team (SUMITT), NorthWestern Mental Health, Melbourne, Australia
2Drug Health Services, Western Health, Melbourne, Australia
Background: Smoking contributes to the poorer health and shorter life expectancy of people with mental illness and results in substantial social and financial costs to patients, their families and society. Nevertheless, smokers with mental illness are less likely to be offered help to quit smoking.
Objectives: This presentation will enable psychiatrists to progress beyond the preoccupation with the long and troubling history of tobacco in the mental health field in a positive and constructive manner.
Methods: The core issues concerning smoking in people with mental illness will be outlined: epidemiology, the nature and consequences of smoking in this patient population including morbidity, mortality and the myths and misconceptions that prevail, ‘the stress paradox’, psychiatric training in smoking treatments, pharmacological considerations and some treatment outcome studies.
Findings: Smoking has substantial adverse impacts on the health of people with mental illness and the evidence base for smoking cessation treatments in this patient group is growing; however, psychiatrists are rarely offering these treatments.
Conclusions: Smoking cessation treatment should be integrated into the overall mental health treatment plan for the patient who smokes and the psychiatrist has an important role in advocating for the implementation of such interventions.
Presentation 2: A Baker: Psychosocial Components of Smoking Interventions for People With Mental Illness and/or Alcohol and Other Drug Problems
Co-Director, NHMRC Centre of Research Excellence In Mental Health and Substance Use, NHMRC Senior Research Fellow, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
Background: Rates of smoking among people with mental illness or alcohol and other drug problems are very high. Many people with co-existing mental health and alcohol and other drug problems smoke, substantially impacting upon quality of life. Accumulating evidence suggests that addressing smoking does not worsen mental health symptomatology or alcohol and other drug misuse, and may actually be beneficial.
Objectives: This presentation will increase psychiatrists’ knowledge of and confidence in addressing smoking among people with mental health problems, alcohol and other drug problems; and people with co-existing problems.
Methods: Psychosocial components of successful smoking interventions conducted among smokers with mental illness, or alcohol or other drug problems, will be presented and discussed. We will discuss case presentations of smokers with co-existing mental illness and alcohol and other drug problems.
Findings: Combined with pharmacotherapy for smoking cessation, psychosocial smoking interventions can be effective. These interventions are easily integrated into clinical practice.
Conclusions: Combined pharmacological and psychosocial interventions for smoking are recommended among people with mental illness or alcohol and other drug problems. Psychiatrists are well placed to assess and address smoking among their patients and to support other health professionals in doing so. A longer term, ‘chronic disease’ approach to smoking cessation treatment is recommended.
Presentation 3: D Kirby1,2,3: Pharmacotherapy for Smoking Cessation
1Alfred Psychiatry, Melbourne, Australia
2Bendigo Health Services, Bendigo, Australia
3Saint Vincents Health, Melbourne, Australia
Background: The World Health Organisation (WHO) recommendations stipulate that all health professionals should be able to provide accurate information, advice and access to pharmacotherapy for smoking cessation. Smokers with a comorbid mental illness should be offered the same smoking cessation interventions as have been shown to be effective in the general population, but with close monitoring and follow-up; however, many mental health professionals are unfamiliar with the range of evidence-based treatments for smoking cessation.
Three main groups of pharmacotherapy have been shown to be efficacious and superior to placebo in smoking cessation trials: nicotine replacement therapy, varenicline and buproprion. The choice of pharmacotherapy varies, depending on clinical suitability and patient choice.
Counseling, when combined with pharmacotherapy, further increases quit rates significantly.
Objectives: This presentation will focus on the three major groups of pharmacotherapy in smoking cessation, particularly those available on the PBS in Australia.
Methods: The mode of action, efficacy, and side effect profile of the major pharmacotherapies for smoking cessation will be discussed. There will also be a discussion regarding how smoking status can affect drug levels of commonly-used psychotropic medications; and hence, impact on clinical treatment.
Findings: There is a need for psychiatrists to be familiar with smoking cessation and evidence-based treatment options.
Conclusions: Psychiatrists should be actively encouraging smoking cessation and should be knowledgeable about the major pharmacotherapy options. Psychiatrists in continuing care teams are in a position of encouraging smoking cessation, monitoring patients’ reactions to medications or withdrawal symptoms, and advising general practitioners or other healthcare workers about evidence-based treatment options.
Asia Pacific Mental Health Symposium
Murray Patton, President Royal Australian and New Zealand College of Psychiatrists (RANZCP)
Maria Tomasic, Immediate Past President RANZCP
Representatives from the Japanese Society of Psychiatry and Neurology
At the Sydney Congress in 2013, we held the inaugural Asia Pacific Mental Health Forum. The Forum brought together representatives of 15 different nations from the Asia Pacific region, and was attended by presidents of psychiatric organisations and senior mental health government representatives. The 2013 Forum provided an opportunity to hear about the major challenges each country faces and discussion about how we can regionally collaborate in constructive ways, to overcome these challenges.
The College is committed to continuing to build relations with our near neighbours in the Asia Pacific, and this symposium will focus on some current collaborations and issues being discussed within the region and also provide opportunities for further interaction.
Alcohol-Related Problems in Japan
Tetsuji Cho
Mental Care Center, Prefecture of Mie
Department of Psychiatry, Nara Medical University School of Medicine
Japan Young Psychiatrists Organization (JYPO)
Patients with alcohol dependence tend to be less likely to visit medical care settings on their own. Therefore, only 5% of patients with alcohol dependence are receiving medical checkups in Japan, unfortunately. Because there are most of the inpatients with alcohol-related problems in general hospitals, this phenomenon often complicates their medical management. Additionally, a large proportion of them still go unrecognized by the clinicians as a specialised addiction.
Alcohol dependence, which is characterised by ‘loss of control’, is a chronic relapsing disorder. It has a considerable component of genetic susceptibility and is also influenced by environmental factors. Although abstinence is the most effective way to treat addiction, for most patients with alcohol dependence it is hard to stay abstinent. In addition, improvement of their quality of life is as important as their abstinence from alcohol. When their treatment goal is hard to achieve, they tend to drop out from treatment easily.
Therefore, the concept of ‘harm reduction’ is suggested. This concept is to reduce the harmful consequences associated with alcohol and/or drug misuse. For people who suffer from addiction without medical care may have more difficulties to challenge abstinence. For people who have difficulty starting abstinence, harm reduction could be a key to start treatment. If we adopt the concept of harm reduction, people with alcoholism may visit medical care more easily and medical staff could have better opportunities to make relationships with them.
The continuation of treatment would be strongly related to a good prognosis. Attending regular medical checkups is shown to be the most important factor in convalescence from alcohol dependence. In my presentation, I will show concrete cases to introduce the concept of harm reduction into Japanese society.
Attracting Indigenous Psychiatrists: Collaborations Between AIDA and RANZCP
Maria Tomasic1, Tammy Kimpton2
1Immediate Past President RANZCP; CPMC chair of the Indigenous Health Subcommittee of the Committee of Presidents of Medical Colleges (CPMC) committee.
2President Australian Indigenous Doctor’s Association (AIDA); AIDA chair of the Indigenous Health Subcommittee of the Committee of Presidents of Medical Colleges (CPMC) committee.
We will discuss the work being done to increase the number of Australian indigenous specialists with a focus on psychiatry. This involves both the direct collaboration between the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and the Australian Indigenous Doctor’s Association (AIDA) and as co-chairs of the Indigenous Health Subcommittee of the Committee of Presidents of Medical Colleges (CPMC) committee.
Raising the number of indigenous doctors and specialists is important in terms of equity, indigenous health, and also for the profession and community as a whole.
The obstacles indigenous doctors face and how these can be overcome will be discussed. The RANZCP has been relatively more successful, compared to other Colleges. We will reinforce that recruitment needs to be an active process of advocacy, encouragement and support to be successful.
Indigenous Psychiatrists: The Complexity of Walking in Multiple Worlds From the Perspective of Two Maori Psychiatrists
Donna Maree Clarke1, Mark Lawrence2
1Member Te Kaunihera mo ngā kāupapa Hauora Hinengāro Māori; General Adult Psychiatrist.
2Chair Te Kaunihera mo ngā kāupapa Hauora Hinengāro Māori; General Adult Psychiatrist for Bay of Plenty District Health Board, Tauranga, New Zealand
We will discuss two perspectives of our journey from our Maori/urban/rural communities into the world of medicine and then psychiatry. Exploring the personal and professional impact of being Maori/indigenous and in medicine.
We will discuss our perspectives in navigating the world of medicine and psychiatry, toward achieving our chosen speciality, discussing further the need for growth in the number of indigenous doctors and specialists and emphasising the need for their active engagement within their indigenous communities, which acts to fortify their resilience within the culture and the profession. This engagement can take many shapes and forms and need not be limited to a narrow definition. We reinforce the need of RANZCP to be an active process of advocacy, encouragement and support to be successful.
Adolescent Forensic Psychiatry – a Degustation
J Kasinathan1,2,3,4, Y Singh1,2
1Conjoint Lecturer, University of New South Wales, Sydney, Australia
2Adolescent Unit, Forensic Hospital, Justice Health, Sydney, Australia
3Visiting Fellow, Centre for Mental Health Research, Australian National University, Canberra, Australia
4Forensic Mental Health Service, ACT Health, Canberra, Australia
Background: Adolescent forensic psychiatry is a relatively young, growing area at the intersection of disparate fields. Few areas offer such a concentration of conceptual, practical and ethical challenges.
Objectives: This symposium offers a selection of ‘tasting plates’ into this rapidly evolving and fascinating area of psychiatry. Topics include:
Imminent aggression risk in adolescents: Is it different from adults?
Is there a case for mental health screening in the Children’s Courts?
‘Has anyone called his mum yet?’ (Welcoming family and carers into the model of care for an adolescent forensic psychiatric unit).
Evolving a model of care for an adolescent forensic psychiatric unit.
Findings:
The predictors of imminent aggression in mentally ill young offenders demonstrate partial congruity, compared to adult forensic patients. Youth-specific factors conferred greater predictive value, thus greater clinical utility in day-to-day practice.
Complexity arising from legal and health care systems may hamper much-needed diversion for mentally ill youth.
Using creative methods to engage families and carers has led to cultural shifts on an adolescent forensic psychiatric unit and ultimately, fostered better outcomes.
The care of mentally ill young offenders involves rigour, creativity, consistency and constant adaptation to engage the adolescents, their family and carers.
Conclusions: Providing clinical services for children and adolescents interacting with criminal and civil legal systems poses challenges for clinicians, whilst simultaneously offering opportunities for innovation. This symposium facilitated selected ‘tastes’ into one of the most interesting areas in psychiatry today.
Presentation 1: Imminent Aggression Risk in Adolescents: Is It Different From Adults?
J Kasinathan1,2,3,4, C Marsland2
1Conjoint Lecturer, University of New South Wales, Sydney, Australia
2Adolescent Unit, Forensic Hospital, Justice Health, Sydney, Australia
3Visiting Fellow, Centre for Mental Health Research, Australian National University, Canberra, Australia
4Forensic Mental Health Service, ACT Health, Canberra, Australia
Background: Aggressive behaviour in hospitalised adolescents presents a significant problem for staff, patients and the functioning of a psychiatric unit. The Dynamic Appraisal of Situational Aggression (DASA) is a novel empirically validated risk assessment measure designed to appraise the risk of imminent aggression (within the next 24 hours) in adult psychiatric inpatients. It had not been validated in young offenders with a serious mental illness.
Objectives: To examine the predictive validity of the DASA with additional youth-specific measures (the DASA:YV), in hospitalised young offenders with a mental illness.
Methods: Methods will be described.
Findings: The DASA:YV accurately predicted imminent aggression (i.e. interpersonal violence, verbal aggression and property aggression) in young offenders hospitalised with a mental illness. Additional youth-specific novel items conferred a greater predictive yield, compared to adult factors alone.
Conclusions: It is possible to regularly monitor the risk state of hospitalised mentally ill youth, so that heightened states can be detected early and appropriate interventions be implemented to reduce the likelihood of a violent outcome within the inpatient setting.
Presentation 2: Is There a Case for Mental Health Screening in the Children’s Courts?
J Shannon, T Anderson, C Gaskin, Y Singh
Adolescent Court and Community Team, Justice Health, NSW Health, Sydney, NSW, Australia
Background: In New South Wales, referrals to the adolescent mental health court diversion program were less than expected, given the prevalence of mental health disorders in youth in custody.
Objectives: To determine whether there are grounds for ubiquitous mental health screening for youth appearing before the Children’s Court.
Methods: An effort was made to comprehensively assess all youth presenting before two Children’s Courts in 1 month, in 2012. This sample (of youth who consented) was compared to the characteristics of ‘referrals as usual’ to the existing mental health diversion program.
Findings: Aboriginal youth, in particular with a mental disorder, were referred less often than expected, given the prevalence of mental disorder in detention. High rates of ADHD, Post Traumatic Stress Disorder (PTSD) and conduct disorders were detected.
Conclusions: A brief mental health screening tool for lawyers, Children’s Court officers and Juvenile Justice officers may improve referral rates for young offenders with a mental disorder appearing before the Children’s Court.
Presentation 3: ‘Has Anyone Called His Mum Yet?’
S Goodsell1, K Plunkett1, C Marsland1, C Stoney1, S Morgans1, Y Singh1,2, J Kasinathan1,2
1Adolescent Unit, Forensic Hospital, Justice Health, Sydney, Australia
2Conjoint Lecturer, University of New South Wales, Sydney, Australia
Background: Involvement of family and carers is integral to the engagement and treatment of young people with a mental illness. There is growing evidence supporting the inclusion of family interventions in the treatment of psychosis and conduct disorder. Working with the families of adolescents involved in the criminal justice system, within a specialist state-wide inpatient service, posed particular challenges.
Objectives: To describe initiatives in engaging families and supporting family work for a high-security adolescent inpatient forensic unit. To describe some of the challenges and opportunities encountered.
Methods: We introduced a weekly ‘Family Work Supervision Group’ to identify future direction and reflect on family work completed. We commenced ‘Welcome Meetings’, where families and carers are invited to meet the treating team. We utilised audio-visual link (AVL) facilities when face-to-face contact with families and carers was not feasible.
Findings: Feedback from families, patients and staff was universally positive. According to one patient’s father, our Welcome Meeting ‘provided assurance… talking to professionals… knowing that our son was looked after well… over [sic] years in custody, our family was never really consulted’.
Conclusions: Involving young patient’s families and carers in their treatment has created a family-inclusive culture, challenging unhelpful prejudices and fostering collaboration; and has constructed a base for future work. Using creative methods to engage families, young people and clinicians has led to the beginning of a cultural shift on our adolescent forensic psychiatric unit, and ultimately, fostered better outcomes.
Presentation 4: Evolving a Model of Care for an Adolescent Forensic Psychiatric Unit
Y Singh1,2, J Shannon2, C Gaskin1,2, J Kasinathan1,2,3,4
1Conjoint Lecturer, University of New South Wales, Sydney, Australia
2Adolescent Unit, Forensic Hospital, Justice Health, Sydney, Australia
3Visiting Fellow, Centre for Mental Health Research, Australian National University, Canberra, Australia
4Forensic Mental Health Service, ACT Health, Canberra, Australia
Background: The high-security Adolescent Forensic Psychiatric Inpatient Unit (located within the Forensic Hospital, Sydney) is the first of its kind in Australia.
Objectives: To describe the evolution of the Adolescent Unit’s model of care.
Methods: After a brief overview of the Unit’s philosophy and structure, will follow an overview of the literature in regards to pertinent models of care for this specific population.
Findings:
The development of severe mental disorders parallel vulnerability to offending, in young people.
Complexity arising from legal, juvenile justice and the health care systems may hamper much-needed access to mental health care for mentally ill youth.
The inpatient care of mentally ill young offenders necessitates strong medical leadership, innovation, creativity and rigour.
Treatment needs for mentally ill young offenders encapsulates intensive psychiatric, medical, nursing, psychological, welfare, educational and functional initiatives.
Family and carer involvement is an essential and crucial component of the recovery process.
Conclusions: Providing clinical services for mentally ill young offenders highlights the challenges for clinicians and stakeholders alike. A rigorous, efficacious and innovative model of care is required for mentally ill young offenders.
Publishing in Psychiatry
GS Malhi1, V Brakoulias2
1Editor, Australian and New Zealand Journal of Psychiatry
2Editor, Australasian Psychiatry
Background: Publishing is essential to progress in psychiatry and is regarded highly by The Royal Australian and New Zealand College of Psychiatrists (RANZCP), which promotes the dissemination of research and clinical information via its two international journals.
Objectives: To encourage the submission of high quality manuscripts and the discussion of important clinical topics in both the Australian and New Zealand Journal of Psychiatry (ANZJP) and Australasian Psychiatry (AP).
Methods: In this symposium, the editors of the ANZJP and AP will identify the scope of each of their journals, specify the criteria required for a manuscript to meet standards for publication, outline the submission and review process and detail their vision for their respective journals.
Findings: The ANZJP and AP are high quality publications that advance the cause of psychiatry, both locally and internationally. The ANZJP has a stronger focus on the science of psychiatry, whilst AP has a stronger focus on the art of psychiatry.
Conclusions: Psychiatrists should be encouraged to read both the ANZJP and AP regularly and submit high-quality, thought-provoking articles to these journals.
Presentation 1: GS Malhi: Publishing in The Australian and New Zealand Journal of Psychiatry
Background: The Australian and New Zealand Journal of Psychiatry (ANZJP) is a monthly journal. It is the academic voice of the College and as such, publishes scientific articles in all aspects of psychiatry, with a particular focus on research. It also encourages discussion of pertinent issues and topical debate.
Objectives: To familiarise authors, reviewers and clinicians with the focus of ANZJP and how they can contribute to the journal.
Methods: The Editor will provide an overview of the journal’s scope, and recent developments and innovations in the journal. He will also outline how decisions are made, as regards suitability for publication and the topics that the journal is particularly interested in publishing. This will include examples for discussion and comment.
Findings: ANZJP publishes research articles and comprehensive reviews. It focuses on important ground-breaking research, novel ideas, and research that is useful for clinicians or has potential for translation into clinical practice. The ‘Reviews’ provide up-to-date, comprehensive information on topics of interest, and this section of the journal is complimented by ‘Perspectives and Correspondence’, both of which address topical issues in psychiatry. The journal caters to academics, practicing psychiatrists and those in training.
Conclusions: ANZJP remains a must-read journal for practicing psychiatrists in Australia and New Zealand, and continues to cater for local needs whilst expanding its international profile.
Presentation 2: V Brakoulias: Publishing in Australasian Psychiatry
Background: Australasian Psychiatry (AP) is a bimonthly journal of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) that was first published in 1993. The journal publishes original research; reviews; descriptions of innovative services; comments on policy, history, politics, economics, training, ethics and the arts as they relate to mental health and mental health services; case reports; book reviews and correspondence.
Objectives: To encourage authors (including trainees and inexperienced authors) to read, write and to submit quality papers for publication in AP.
Methods: The Editor will present the scope of the journal, the instructions for authors, the criteria required for acceptance, the peer review process and the new Editor’s vision for AP. A systematic description of the types of articles that are accepted for publication will be presented, and examples of frequently downloaded and frequently cited papers will be given.
Findings: AP caters for articles relating to the art of psychiatry and articles that aim to promote excellence in the practice of psychiatry. Popular articles have described innovative conceptualizations of psychiatric phenomena and modes of service delivery. The journal has served as a starting point for further research and for researchers early in their career.
Conclusions: Regardless of their stage of career, psychiatrists striving for excellence in their practice should regularly read and seriously consider contributing to AP.
Renewing Conversations on and in Acute Care: The Blacktown ‘Feeling Safer’ Project
L McLean1-3, I Cameron1,4, D Balu1, A Baker1,4, B Maloney1,4, H Joshi1,4, L Beron1,4, W Lee4, A Harris1, A Korner1
1Sydney Medical School, University of Sydney, Sydney, Australia
2Department of Consultation-Liaison Psychiatry, RNS Hospital, Saint Leonards, Australia
3SWaGS Psychiatry Training Network
4Blacktown Acute Care Team, Western Sydney Local Health District (WSLHD), Sydney, Australia
Background: At the coalface of acute psychiatry, in the Emergency Department (ED) or during home/clinic visits, Acute Care Team clinicians are seeking to quickly engage and effectively assess, formulate and manage patients who present in crisis, often in distressed and disorganized states. While psychosis and severe mood disorder are often seen as the heartland of acute psychiatry, statistics and experience show that much acute work involves aspects of chronic or complex trauma as the primary, comorbid or complicating aspect of presentations. The Conversational Model (CM) is an integrated contemporary psychodynamic model of complex trauma, offering principles and techniques to foster the engagement of distressed patients disrupted by trauma, and to work with them collaboratively. The Westmead Psychotherapy Program (WPP), home of the CM, has recently expanded to again teach public sector clinicians, a group of who have joined forces and sought training and research help, to apply the CM to the Acute Care setting: To improve their skill sets, shift culture towards trauma-informed care and recovery and to evaluate the project.
Objectives: This symposium describes the evolution and current status of the Feeling Safer Project as an example of new conversations in general psychiatry opened up by the CM.
Methods: The presentations will describe:
The project’s evolution and the local team’s training package, building on the WPP program;
The evolution of team culture, with vignettes of clinical coalface encounters;
A mixed methods collaborative approach to evaluation.
Findings/Conclusions: The CM offers a framework for trauma-informed care in an acute setting.
Presentation 1: The Evolution of the ‘Feeling Safer’ Project: Inspirations, Aspirations and Many Conversations
I Cameron1,2, A Baker1,2, W Maloney1,2, L McLean1,3,4, A Korner1
1Westmead Psychotherapy Program (WPP), Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Blacktown Acute Care Team, Western Sydney Local Health District (WSLHD), Sydney, Australia
3Department of Consultation-Liaison Psychiatry, RNSH, Saint Leonards
4SWaGS Psychiatry Training Network
Background: In 2010, the ‘Scholarship Program’ of the Westmead Psychotherapy program again commenced training local clinicians in the Conversational Model (CM). This activity began inspiring and equipping clinicians to approach their acute work with a new vigour and an improved skill set. As a post-doctoral project, close to the heart of the initiator (IC) and collaborators, the project was a formidable challenge, but emerged from the aspirations of experienced clinicians to shift acute care culture towards a trauma-informed and recovery model and reflected the working group’s valuing of a relational and CM approach to patient care.
Objectives: This talk will describe the evolution of the project, which required considerable collaboration and liaison in its initiation and continuation.
Methods: This presentation describes the evolution and components of a new and current program, including extra in-service training, to shift clinicians to collaboratively formulate and manage acute presentations founded in an understanding of development, trauma and self. It will also describe associated systems and liaison processes and some early outcomes.
Findings: This refined approach to acute care is intensive but rewarding, potentially offering a more satisfying experience for patient, clinician and team alike.
Conclusions: In aiming to ‘walk the talk’, a team approach to applying the CM to acute care is proving helpful; but requires motivation, perspiration and much inspirational and reflective conversation.
Presentation 2: At the Coalface: Incorporating the Conversational Model of Complex Trauma Into the Work of a Community Mental Health Acute Team
I Cameron1,2, A Baker1,2, B Maloney1,2, H Joshi1,2, L Beron1,2, J Hawkins1,2, W Lee1,2, L McLean1,3,4
1Westmead Psychotherapy Program (WPP), Sydney Medical School, University of Sydney, Sydney, Australia
2Blacktown Acute Care Team, Western Sydney Local Health District (WSLHD), Sydney, Australia
3SWaGS Psychiatry Training Network
4Department of Consultation-Liaison Psychiatry, RNS Hospital, Saint Leonards, Australia
Background: Patients presenting to acute care settings are usually distressed with presentations often triggered or complicated by trauma, often chronic complex trauma. The Conversational Model (CM) offers a trauma-informed approach that focuses on quickly forming a therapeutic connection with a patient through the empathic and thoughtful use of language and an understanding of the impact of developmental and other trauma on the organization of a patient’s sense of self and their coping strategies. In an acute setting, these skills can offer a more collaborative and at times effective engagement with an acute care patient, to foster a collaborative understanding of why they are presenting now and what could be done to resolve or improve the current crisis (termed formulation and management plan). A collaborative approach potentially empowers the patient and helps the engagement in recovery processes, and helps prevent the secondary traumatisation for the patient, and vicarious trauma for the practitioner and team.
Objectives/Methods: This presentation will describe a number of vignettes from cases (de-identified and disguised) to illustrate the utility and impact of this approach in an acute care team aiming to implement a CM approach to trauma-informed acute care.
Findings: Experience to date suggests the CM offers a useful, respectful and rewarding approach to acute settings in a community mental health team’s day-to-day challenges.
Conclusions: This important area offers promise and requires more formal evaluation.
Presentation 3: Evaluating and Exploring Conversations of Care in an Acute Team: A Mixed Methods Research Collaboration
D Balu1, I Cameron1,2, A Baker1,2, W Lee2, J Haliburn1, A Korner1, S Halovic1, A Harris3, L McLean1,4,5
1Westmead Psychotherapy Program (WPP), WSLHD and Discipline of Psychiatry, SMS, University of Sydney, Sydney, Australia
2Blacktown Acute Care Team, Western Sydney Local Health District (WSLHD), Sydney, Australia
3Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
4SWaGS Psychiatry Training Network
5Department of Consultation-Liaison Psychiatry, RNS Hospital, Saint Leonards, Australia
Background: With the introduction of training in the Conversational Model (CM) for local clinicians, an important synergy between training, research and clinical service was renewed. Local clinicians trained in the CM sought to apply the CM to acute care services, bringing an opportunity for research collaboration with Westmead Psychotherapy Program (WPP), to evaluate the project in a number of ways. The CM pays particular attention to language (verbal and non-verbal, right and left hemispheric) in the clinical encounter, and the WPP already has a long history of taping sessions and evaluating aspects of process and discourse. In this context, the ‘Feeling Safer’ Project was considered as an opportunity for a mixed-methods approach that could both support local clinical needs and data gathering for a doctoral project, for the WPP.
Objectives: This project aims to evaluate and explore the introduction of a CM approach to trauma-informed care in an acute mental health care team, enquiring into the experiences of clinicians and consumers as this intervention unfolds. This will contribute to local quality assurance and to research that will explore the experience of clinicians and consumers from diverse backgrounds in relation to trauma-informed care.
Methods:
Quantitative data will be analysed from regular mental health information collected from clients with grouped data, available pre- and post- system change, and with the prospective addition of simple questionnaires (DASS, etc.), to track the efficacy of brief interventions;
Qualitative approaches will be applied to both routine written data from the encounter and to clinician and client interviews, with the latter seeking to assess the experience of this new model of care.
Findings/Conclusions: The project is currently seeking ethics approval.
Assessment and Management of Health Issues in Indigenous People
Background: Indigenous Australians endure significant adversity, leading to poor outcomes in terms of general health, mental health and psychosocial dysfunction. Increased morbidity and mortality in indigenous people are well documented. Western-based approaches to assessment and management of health in indigenous people have been of limited effectiveness, due to cultural differences.
Objectives: To describe the contemporary challenges and practical approaches to improving physical and mental health of indigenous people.
Methods: Collaborative approaches between the School of Psychiatry and Clinical Sciences, University of Western Australia, and various other institutions including Kimberley Mental Health and Drug service, Broome, have culminated in the development of unique approaches and gaining of knowledge in order to overcome the cultural barriers that hamper effective engagement and treatment of indigenous Australians. This has included the development of a screener for mental health issues (Here and Now Aboriginal Assessment), deployment of comprehensive tools and strategies to evaluate the physical health of indigenous people and culturally secure approaches to managing indigenous people in acute psychiatric services.
Findings: There are many barriers to overcome in engaging indigenous people in managing and treating their health. These may be addressed by culturally-appropriate training, using indigenous consultants and changing the approach to the history and mental state examination, when conducting psychiatric assessments. Implementing a consistent approach to measure physical health issues is also important, as there is emerging data of significant general health morbidity suggesting high risk for metabolic syndrome and cardiovascular disease.
Conclusions: Cultural differences can be addressed through training and liaison with appropriate consultants, when working with indigenous people. More systematic research is required to thoroughly evaluate the physical and mental health of indigenous people.
Presentation 1: Overcoming Barriers in Psychiatric Assessments of Indigenous People
S Balaratnasingam1,2
1Kimberley Mental Health and Drug Service, Broome, Australia
2School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, WA, Australia
Background: Western-based assessment and diagnostic procedures may lead to errors and misunderstandings. Considerable adaptations are required in the process of taking a history and mental state examination in indigenous people.
Objectives: To explore the differences in psychiatric assessments of indigenous people and meaningfully interpret the mental state examination across different cultures.
Methods: A summary of the author’s own experience as a psychiatrist in the remote Kimberley region of WA and key literature on the subject is provided.
Findings: There is a need to properly appreciate the complexity of cultural factors in psychiatric assessments and diagnosis, when working with indigenous people.
Conclusions: Gaining cultural competency in working with indigenous people and awareness of the differences to Western-based classificatory and assessment processes are required, in order for clinicians to be effective in engaging and treating indigenous people.
Presentation 2: Screening for Social and Emotional Wellbeing Among Aboriginal People
A Janca, Z Lyons
University of Western Australia, School of Psychiatry and Clinical Neurosciences, Perth, WA, Australia
Background: The assessment of social and emotional wellbeing (SEWB) among Aboriginal people is complex and challenging. There are limited tools available that can be used to assist in the assessment process.
Objective: The objective was to develop a culturally appropriate tool, suitable for screening of SEWB problems among Aboriginal adults. The tool was entitled Here and Now Aboriginal Assessment (HANAA).
Methods: The HANAA was based on 10 key domains identified from a previously-developed glossary of SEWB terms and concepts. The HANAA was implemented by initiating a semi-structured interview to cover each domain. The respondent was encouraged to tell their story in narrative form, which can be recorded by the interviewer in the space provided on the form. The aim was to rate each domain as either a ‘problem’ or ‘no problem’. At the end of the interview, a ‘recommended action’ was determined. Evaluation of the HANAA included exploration of its cultural applicability, feasibility, inter-rater agreement and concordance with the clinician’s diagnosis, on a sample of 30 Aboriginal participants.
Findings: The HANAA was well accepted by participants and easily implemented by interviewers. Reliability was good, with kappa agreements between Aboriginal and non-Aboriginal interviewers ranging from 0.5 to 1.0. Agreement between interviewers and treating clinicians in identifying the main SEWB problem and recommended course of action was good.
Conclusion: The HANAA is a culturally-appropriate tool that can be used by a range of service providers with limited mental health training, to screen for SEWB among Aboriginal people.
Presentation 3: Rivers of Recovery: A Culturally Appropriate Model for Treati NG Indigenous People With Mental Disorders
M Ozies
Kimberley Mental Health and Drug Service, Broome, Australia
Background: In 2012, Mabu Liyan, based in Broome, was opened as a purposefully built, culturally appropriate, 14-bed authorized psychiatric mental health unit, providing care to indigenous Australian people in Northwest Australia.
Objectives: To describe the work undertaken by aboriginal mental health workers in the Mabu Liyan unit and the lessons learnt.
Methods: An observational-narrative approach is taken to evaluate the culturally-secure work of indigenous mental health workers employed by Kimberley Mental Health and Drug Service, Broome.
Findings: Indigenous people respond positively to culturally-appropriate therapies to deal with the complex psychosocial issues that have affected their social and emotional wellbeing through the decades.
Conclusions: Rivers of recovery uses symbols and metaphors to assist indigenous people dealing with mental health problems. It represents a culturally-appropriate and secure model for treatment of psychiatric disorders and relapse prevention.
Presentation 4: Physical Health of Kimberley Indigenous People Suffering With Mental Health Problems
M Chapman1,2, S Stanley1, J Laugharne1
1Kimberley Mental Health and Drug Service, Broome, Australia
2School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, WA, Australia
Background: A growing body of literature describes the increased risk of physical health comorbidities in people suffering with mental illness. There is little information on whether this applies to indigenous Australians with mental illness.
Objectives: To investigate the physical health parameters of adult patients in contact with Kimberley Mental Health and Drug Service in Broome, Australia. These were mostly indigenous people.
Methods: A longitudinal (24 month) audit of patient medical records was conducted between February 2011 and March 2013, assessing waist circumference, blood pressure, fasting lipids and fasting blood glucose. Patient numbers increased from 56 at baseline (80% indigenous) to 136 at 18 months (70% indigenous), comprising the majority of mental health patients in the Kimberley region of WA.
Findings: There are considerable challenges to implementing regular monitoring of physical and metabolic profiles of aboriginal people in rural and remote communities. Preliminary assessment of the data indicates a high percentage of abnormalities at baseline and at 18 months on all four parameters, yet not all patients were assessed on a regular basis.
Conclusions: Abnormalities in metabolic profiles consistent with the non-indigenous psychiatric population were found. Improved resourcing and culturally-appropriate interventions are required in order to consistently measure physical health issues in aboriginal people suffering from mental illnesses in rural and remote settings.
Presentation 5: The Social and Emotional Wellbeing of Aboriginal Prisoners in Western Australia
S Davison1,2
1North Metropolitan Health Service - Mental Health
2School of Psychiatry and Clinical Neurosciences, University of Western Australia, WA, Australia
Background: Prisoner populations are characterised by disadvantage, stigmatisation, social exclusion, and poor physical and mental health. Aboriginal people are over-represented in the prison population. The health inequalities of Aboriginal people in the general community, compared with non-indigenous Australians are well described. Both Aboriginal and non-Aboriginal prisoners have high rates of mental and physical health problems and substance misuse problems in custody and in the community, before and after prison (Hobbs et al., 2006; Heffernan et al., 2012; Butler et al., 2007).
Objectives: This presentation will outline the specific substance misuse and mental health needs of Aboriginal prisoners in WA.
Methods: We conducted interviews with male and female prisoners in WA, about 1 week after reception to prison. We gathered information about their social and emotional wellbeing, using the questions from the National Aboriginal and Torres Strait Islanders’ Health Survey (NATSIHS), psychiatric diagnosis, and social, functional and health needs using standardised interviews.
Findings: I will present the findings about the social and emotional wellbeing, mental health and needs of Aboriginal reception prisoners in WA. We will compare the findings with the social and emotional wellbeing of the wider indigenous population, as recorded by NATSIHS, as well as with non-Aboriginal prisoners.
Conclusions: It is hoped this will stimulate discussion about how best to develop services that meet the needs of Aboriginal people, both in custody and in the community.
From Evidence to Practice, and Practice to Evidence (The New RANZCP Evidence-Based Guidelines)
M Oakley-Browne1, G Smith2, M Hopwood3, G Roper4, G Malhi5, P Hay6, C Galletly7
1Victorian Department of Health Director Clinical Quality & Safety and Chief Psychiatrist and Chair of RANZCP Committee for Therapeutic Interventions and Evidence-Based Practice and Chair of expert consensus guideline on physical health of people with enduring psychotic illness.
2WA Centre for Mental Health Policy Research, School of Psychiatry and Clinical Neurosciences, University of Western Australia, Centre for Research into Disability and Society, Curtin University; RANZCP Practice and Partnerships Committee.
3Associate Professor of Psychiatry at the University of Melbourne, and is also a Director of the Brain Disorders Program (BDP) and the Psychological Trauma Recovery Service (PTRS) at Austin Health and President-Elect at RANZCP and Chair of the PTSD Working Group.
4Consumer advisor in the mental health and community sector, Member of number of RANZCP Committees, Member of the Post-traumatic stress disorder (PTSD) working group.
5Executive and Clinical Director of the CADE Clinic and Head of the Department of Psychiatry at Royal North Shore Hospital and Professor at the University of Sydney and Senior Consultant Psychiatrist in the Northern Sydney Local Health District and Chair of Mood Disorder Clinical Practice Guideline (CPG) at RANZCP.
6Immediate past-President of the Australian Academy for Eating Disorders and a current member of the scientific committee and 2011 conference committee of the International Academy for Eating Disorders and a Chair of Eating Disorder CPG at RANZCP.
7Professor of Psychiatry at University of Adelaide and Ramsay Health Care (SA) Mental Health and Regional Director of Training, Northern Adelaide Local Health Network and Consultant Psychiatrist, Lyell McEwin Health Service and Chair of Schizophrenia CPG at RANZCP.
Background: The Royal Australian & New Zealand College of Psychiatrists (RANZCP) recently developed a website with a suite of resources to assist psychiatrists in clinical practice. The resources have utilized a variety of methodologies including:
Review of externally-produced guidelines, using the AGREE Tool (Adult attention deficit hyperactivity disorder (ADHD), Self-harm, post-traumatic stress disorder (PTSD));
Expert consensus guidelines using the Delphi Technique (Physical health of people with an enduring psychotic illness);
Update and revision of the RANZCP Clinical Guidelines series (Eating disorders, schizophrenia, mood disorders, anxiety disorders and self-harm).
This session will present and demonstrate the resources and provide an update on forthcoming developments.
Objectives: Promote to the membership a range of newly-developed clinical practice resources, explain the rationale and method behind their development, and seek feedback from clinicians. The presenters would also appreciate suggestions on topics of interest for future development.
Method: An interactive presentation will provide an overview of the development of clinical practice resources for psychiatry, their significance and their intended purpose. A panel of speakers will present the resources, explaining the methodology to review what worked well and what can be improved upon, and address the questions raised through facilitated group discussion.
Findings and conclusions: Attendees should gain an appreciation of the rationale underpinning development of RANZCP clinical resources and how to use them in practice.
New Landscapes in the Conversational Model: Process and Applications
L McLean1-3, C Marlborough1,4, V Bairstow1,5, L Grant1,5, J Hawkins1,4, S Halovic1, S Malloch1, J Haliburn1, J Stevenson1, A Korner1
1Westmead Psychotherapy Program (WPP), Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Department of Consultation-Liaison Psychiatry, RNS Hospital, Saint Leonards
3SWaGS Psychiatry Training Network
4Western Sydney Local Health District (WSLHD), Sydney, Australia
5Nepean Blue Mountains Local Health District (NBMLHD)
Background: The Conversational Model (CM) offers a contemporary psychodynamic approach to the treatment of chronic complex (relational) trauma, with demonstrated efficacy in treating Borderline Personality Disorder (BPD). The Westmead Psychotherapy Program, which has been a home for the CM, is undergoing renewal; and it is now approaching training and research in the CM in some new ways, opening up training to local clinicians and broadening the research focus, to address complex trauma more generally and with more general applications to psychiatry.
Objectives: This symposium will offer a sample of the new landscapes emerging for the CM, as it continues to explore therapy process and new applications of the model.
Methods: An initial presentation will describe the process of renewal and the establishment of a training program for local public sector mental health clinicians, many of whom choose to train in the new brief model, the Short Term Intensive Psychoanalytic Psychotherapy in the Conversational Model (STIPP-CM). The remaining presentations will showcase the research and/or clinical work of some local clinicians from the training program and faculty, demonstrating some newer aspects of the CM as it explores therapeutic process through new lenses, such as ‘Communicative Musicality’ or seeks to apply the CM in various clinical contexts, such as early psychosis intervention, anorexia nervosa, or a perinatal relational setting.
Findings/Conclusions: The CM is currently expanding to offer more options for treatment, training and research in complex traumatic disorders, with potential broader applications.
Presentation 1: Teaching Local Clinicians the Conversational Model: Process and Early Outcomes of the ‘Scholarship Program’ and ‘Walking the Talk’
L McLean1-3, A Korner1, J Haliburn1, J Stevenson1, L Crisante1, S Halovic1, M Phillips1
1Westmead Psychotherapy Program (WPP), Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Department of Consultation-Liaison Psychiatry, RNS Hospital, Saint Leonards
3SWaGS Psychiatry Training Network
Background: In 2010, in an environment of economic threat, the Faculty of the Westmead Psychotherapy Program who, in collaboration with the local health service (WSLHD), provide teaching for a Masters in Psychotherapy in the Conversational Model (CM) for the treatment of Complex Traumatic Disorders, reviewed their position on training and research. It was felt that a necessary return to the original intention of Russell Meares and Robert Hobson, to help clinicians treat ‘the difficult patient’ and to foster cultural change in the treatment of patients with complex trauma, required the program to be opened to local clinicians from the Sydney West and Greater Southern Psychiatry Training Network (SWaGS) from all professional backgrounds. In 2011, with local service support and in collaboration with SWaGS, the first students of the Scholarship Program commenced. They were enrolled in one of two courses:
A course that largely offered the curriculum of the Masters course (“Long Program”);
A new course that taught the new model of Short-Term Intensive Psychoanalytic Psychotherapy in the Conversational Model (STIPP-CM).
Objectives/Methods: This presentation describes the new program, associated processes and some early outcomes.
Findings: This broader approach to training and research is proving invaluable, beginning to enrich local clinical culture as well as stimulate the WPP’s research and training output.
Conclusions: In practicing what it teaches - the art and science of fostering collaborative conversation and the formation of relationships that foster recovery from trauma - the Program itself is being strengthened and potential crisis has become opportunity.
Presentation 2: Working for Early Recovery From Psychosis: Incorporation of the Conversational Model of Psychotherapy
V Bairstow1,2, L McLean1,3,4, M Williamson1, L Van Biene1
1Westmead Psychotherapy Program (WPP), Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Nepean Blue Mountains Local Health District (NBMLHD)
3SWaGS Psychiatry Training Network
4Department of Consultation-Liaison Psychiatry, RNS Hospital, Saint Leonards
Background: Patients presenting with their first presentation of psychosis initially need assessment and stabilization in the now well-established models of Early Psychosis Intervention (EPI); however, with stabilization comes the need and opportunity to collaboratively understand the more complex aspects of pre-existing or pre-disposing aspects of personality, trauma and interpersonal relatedness. The therapeutic challenges are to foster the development of self and relatedness, and slowly process trauma, whilst maintaining recovery and promoting functionality without triggering relapse. The Conversational Model (CM) may offer a psychotherapeutic approach to this aspect of recovery.
Objectives: This presentation aims to offer an understanding of the potential application of the CM to therapeutic work with young people with first episode psychosis, using this approach to work towards goals of ongoing recovery and the fostering of a more resilient and reflective self.
Methods: A theoretical frame incorporating EPI, the CM will be presented and then grounded in case material (de-identified and disguised).
Findings: Early experience suggests the CM offers a useful and respectful psychotherapeutic frame in early psychosis.
Conclusions: This important area warrants further investigation.
Presentation 3: Communicative Musicality and the Conversational Model: The Changing Music of the Encounter and the Self
C Marlborough1,2, S Malloch1, L McLean1,3,4
1Westmead Psychotherapy Program (WPP), Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Western Sydney Local Health District (WSLHD)
3Department of Consultation-Liaison Psychiatry, RNS Hospital, Saint Leonards
4SWaGS Psychiatry Training Network
Background: Communication skills are foundational to our humanity and the therapeutic process, and the Conversational Model (CM) pays particular attention to the various languages (verbal and non-verbal, right and left hemispheric) of the clinical encounter, with a view to fostering the emergence of self and the processing of trauma. When trauma supervenes, we know that the capacity to communicate coherently and effectively breaks down and the ‘music’ of our communications changes. The Theory of Communicative Musicality offers a framework to connect with a client’s affective states via the musical, dance-like properties of the narrative, where gestures are made through tone, rhythm, prosody and the shape of the ‘call and response’ within the dyad. This model deepens the CM understanding of the languages of relatedness in the moment-to-moment clinical encounter, and helps the clinician foster the emergent conversation and the emergent self.
Objectives: This presentation will offer an overview of the Theory of Communicative Musicality, applied to the Conversational Model, with attention to the way the ‘musical’ aspect of the encounter develops during therapy.
Methods: After outlining the theoretical frames, we will then illustrate the process with case material from therapies conducted in the CM and drawn from audio-taped sessional material that is closely analysed using the Communicative Musicality approach.
Findings: This approach can enhance the CM’s capacity to help the therapist relate to traumatized clients and foster their sense of self and their reflective capacity.
Conclusions: While further research into this area is warranted and is underway, the framework is an accessible addition to the therapeutic repertoire.
Presentation 4: Rethinking the Treatment of Anorexia Nervosa: An Argument for a Role for the Conversational Model of Psychotherapy in Collaborative Care
L Grant1,2, J Haliburn1, L McLean1
1Westmead Psychotherapy Program (WPP), Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Nepean Blue Mountains Local Health District (NBMLHD)
Background: Anorexia nervosa (AN) continues to be an illness associated with serious morbidity and mortality. A recent outpatient treatment trial has validated focal dynamic psychotherapy in bringing about more lasting gains (Zipfel et al., 2013). There is also good evidence that the therapeutic relationship is the central factor contributing to positive therapeutic outcomes. The Conversational Model (CM) offers a contemporary psychotherapeutic approach that fosters the therapeutic relationship, to promote the client’s self-development and the processing of developmental trauma. Bruch (1973) suggests that eating disorders can be manifestations of emotional distress that can be further defined as self-disorders, resulting in part from developmental deficits in self-organization and marked by self-doubt, poor body image and inadequate self-concept. The CM then theoretically may offer a useful approach.
Objectives: This presentation argues that the CM addresses self-disorder and promotes autonomy, self-value and more coherent self-organization, and may therefore be able to address the distress and deficits seen in AN.
Method: The recently dominant Cognitive-Behavioural Therapy (CBT) approach to AN will be briefly reviewed, and then the CM theoretical foundation offered. A case study (disguised and de-identified) of a client with AN, engaged in collaborative outpatient psychiatric care, will be used to demonstrate the suitability of the CM and to explore its principles, in order to understand the potential application of this model when working with clients with AN.
Findings: The CM may offer an alternative psychotherapeutic approach in the collaborative treatment of AN.
Conclusions: This approach requires further investigation.
References
Bruch H (1973) Eating Disorders: Obesity, Anorexia Nervosa and the Person Within. London: Routledge and Kegan Paul.
Zipfel S, et al. (2013) Focal psychodynamic therapy, cognitive behaviour therapy and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): Randomised controlled trial. Lancet Online, DOI: 10.1016/S0140-6736(13)61746-8.
Presentation 5: Two (or More) for the Price of One: A Better Family Outcome Following the Use of Individual Short-Term Intensive Psychoanalytic Psychotherapy in the Conversational Model (STIPP-CM)
J Hawkins1,2, L McLean1,3,4, J Haliburn1
1Westmead Psychotherapy Program (WPP), Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Western Sydney Local Health District (WSLHD)
3Department of Consultation-Liaison Psychiatry, RNS Hospital, Saint Leonards
4SWaGS Psychiatry Training Network
Background: The perinatal period can be stressful, especially when there is relational stress; however, it is also a period of plasticity, allowing an opportunity to work therapeutically for personal and relational change. Short Term Intensive Psychoanalytic Psychotherapy in the Conversational Model (STIPP-CM) applies principles of the Conversational Model (CM) to a structured psychoanalytic approach to brief therapy, usable where a patient who is communicative, coherent and cooperative enough with sufficient continuity to be able to contract short term goals and work intensively. This technique is now taught in the Westmead Psychotherapy Program (WPP) and its effectiveness is currently being evaluated. We offer the case of a woman presenting in the antenatal period, referred via Safestart screening, with psychosocial risks and an adverse attachment history, who sought to better her relationship with her partner with individual therapy (as her partner refused couples work).
Objectives: We wish to demonstrate aspects of the model and its utility, noting that in this case, positive outcomes were achieved for the woman and her family.
Method/Findings: We will provide a brief account of the STIPP-CM and then present the case, conducted by an experienced Consultation-Liaison nurse (nevertheless a novice in the STIPP-CM) and show gains achieved by the patient and reported family gains occurring during therapy. We will use fragments of transcript to show that affect regulation and reflective capacity improved. We suggest that these may have been instrumental in the relational change achieved.
Conclusions: STIPP-CM may be effective in the antenatal period and it may improve reflective capacity.
Research Initiatives at the Western Australian Mother and Baby Unit
Philippa Brown1, Janette Brooks1,3, Maree Brice-Pozzi1, Liezl Addinall2, Nadia Cunningham2, Andrew Page2
1Mother and Baby Unit, King Edward Memorial Hospital, Perth, Australia
2The University of Western Australia, Perth, WA, Australia
3Women’s Health Clinical Support Unit, King Edward Memorial Hospital, Perth, Australia
The Western Australian Mother and Baby Unit (WAMBU) opened in 2007, offering an 8-bed tertiary, authorised psychiatric treatment facility for mothers and their babies up to age 12 months. To date, 900 patients have been treated at the WAMBU. A comprehensive patient record database including demographic details, presenting symptoms, diagnosis, interview and self-reported information for all patients has been developed and maintained.
Background: Between 1984 and 2007, WA had limited facilities to treat mothers with serious mental illness, while being with their babies. The three beds available in the state system was part of a large institution and was not an attractive treatment proposition for mothers with no or little past psychiatric history. In 2007, WAMBU opened as a free-standing unit in the grounds of a women and newborn hospital. As expected, the referral rate increased sharply and the team has treated nearly 900 women with diagnoses ranging from schizophrenia and first episode psychosis, to severe depressive disorders and anxiety.
Objectives: The subspecialist facility has attracted interest from the University of Western Australia, to host postgraduate research. Current questions include:
What is postnatal psychosis?
Are there symptoms of depression in the postnatal period that are different from those in other life periods?
The relationship between borderline personality disorder and scores on the Edinburgh Postnatal Depression Scale.
Presentation 1: P Brown, L Addinall: First Episode Postnatal Psychosis at a Western Australian Mother and Baby Unit: Clinical Phenomena and Diagnostic Dilemmas
P Brown1, L Addinall2, A Page2
1Mother and Baby Unit, King Edward Memorial Hospital, Perth, Australia
2The University of Western Australia, Perth, WA, Australia
Background: Postnatal psychosis (PP) is a severe form of psychiatric illness in females, with the first onset of symptoms usually appearing within 48 hours after childbirth. First-episode PP affects 1 to 2 of every 1000 deliveries (Brockington, 1996). Until recently, not much has been written about the distinct clinical features, symptomatology and presentation of PP. Anecdotal comments seem to be readily available, but the nature of this illness does not seem to be reflected in current psychiatric diagnostic and coding language. There also seems to be little agreement as to whether the symptomatology present leads to predictable use of adult psychiatric diagnostic classification (ICD-10, DSM-IV) or whether the nature of the illness lends itself for a need of a new classification.
Objectives: To retrospectively characterize a cohort of patients for whom their first episode of psychosis occurs in the postnatal period, and to report upon the clinical features and symptomatology of this series of sufferers of first-episode psychosis.
Methods: Included in this study were 91 women admitted to the Mother and Baby Unit (MBU), a part of the Women and Newborn Health Service at the King Edward Memorial Hospital for Women (KEMH), with a diagnosis of first-episode PP. Clinical interviews and self-reporting questionnaire data of all admissions between May 2007 and May 2013 were analysed.
Findings: The risk profiles, symptomatology and clinical features of first-onset PP will be discussed.
Conclusions: The presenter will discuss the diagnostic dilemma, using the analysed data from this study.
Presentation 2: P Brown: Maternal Borderline Personality Disorder and the Edinburgh Postnatal Depression Scale
P Brown1, N Cunningham2, L Addinall2, A Page2
1Mother and Baby Unit, King Edward Memorial Hospital, Perth, Australia
2The University of Western Australia, Perth, WA, Australia
Background: Amongst the personality disorders, the most prevalent and concerning for women in the perinatal period is borderline personality disorder (BPD). BPD is characterized by a pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships and self-image (DSM-IV). Anecdotal evidence suggests that there are demographic and symptom-reporting differences between the cohort of mothers with and without BPD.
Objectives: This study aims to:
Explore and report on the discriminating features of patients with a diagnosis of BPD, compared to patients without BPD;
Investigate the relationship between high scores (severe range) on the Edinburgh Postnatal Depression Scale (EPDS) and the likelihood of having a BPD diagnosis, in comparison to women scoring in the moderate range on the EPDS.
Methods: We reviewed the primary and secondary diagnoses of 813 women who had been inpatients at the Western Australian Mother and Baby Unit (WAMBU) from 2007 to 2013. We identified 115 patients as having a DSM-IV diagnosis of BPD or borderline personality traits. Further information has been obtained from semi-structured clinical interviews, concerning the course of pregnancy, maternal stressors and obstetric factors, as well as self-reporting questionnaire data.
Findings: Data is currently being analysed: Results will be available for this presentation. Preliminary analysis indicated significant differences between the BPD and non-BPD groups concerning demographics, symptoms and responses to self-reported rating scales.
Conclusions: A description of the results of this study will be presented and discussed at this symposium.
Presentation 3: N Cunnigham: The Structure of Emotional Symptoms in the Postpartum Period: Is It Unique?
N Cunningham1, P Brown2, J Brooks1,3, A Page1
1The University of Western Australia, Perth, WA, Australia
2Mother and Baby Unit, King Edward Memorial Hospital, Perth, Australia
3Women’s Health Clinical Support Unit, King Edward Memorial Hospital, Perth, Australia
Background: Anxiety and depression are highly prevalent amongst postnatal women requiring psychiatric hospitalisation; however, there is disagreement as to whether postnatal emotional disorders are unique in their aetiology and clinical presentation, leading to confusion as to how they should be assessed and treated. Moreover, the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987), the most commonly used measure of postnatal emotional distress, has not previously been validated in a postnatal inpatient sample.
Objectives: If postnatal emotional disorders have a unique clinical presentation, the factor structure of a self-reporting measure of emotional distress should be different to that in the general population. This study aimed to explore the factor structure of the Depression Anxiety Stress Scales (DASS) (Lovibond and Lovibond, 1995) in women admitted to the Western Australian Mother and Baby Unit (WAMBU). A second aim was to assess reliability and validity of the EPDS.
Methods: The EPDS and DASS were administered to 700 patients at admission and discharge. Reliability and validity of the EPDS and DASS were examined. Confirmatory factor analysis was used to evaluate the factor structure of the DASS.
Findings: The EPDS and DASS had sound reliability and validity. The optimal fitting factor solution for the DASS was the same as in previous studies of non-postnatal populations.
Conclusions: Postnatal emotional symptoms have the same factor structure previously observed in non-postnatal populations, which is consistent with the view that postnatal emotional disorders are similar to those occurring at other times. Clinical implications of the findings will be discussed.
Presentation 4: A Mindfulness-Based Intervention for Postnatal Mental Illness
J Brooks1,2, P Brown1, M Brice-Pozzi1
1King Edward Memorial Hospital, Perth, Australia
2The University of Western Australia, Perth, WA, Australia
Background: Mindfulness-based interventions for the treatment of mental illness and/or promotion of mental health have grown dramatically since the turn of the century, when a description and de facto manualisation of the Mindfulness-Based Stress Reduction (MBSR) program, developed by the University of Massachusetts Medical School, was first published (Kabat-Zinn, 1990). Since then, there have been substantial gains made towards development of an empirical evidence base for the efficacy of mindfulness-based strategies for a wide range of psychiatric conditions.
Objectives: Given the prevalence and potential consequences of postnatal mental illness for the new mother and her family, this is an area of clinical need where mindfulness-based interventions could prove extremely effective; however, the effectiveness of such interventions for women admitted to a psychiatric in-patient facility in the postnatal period is yet to be investigated. This paper will describe the evaluation of a mindfulness-based intervention, as currently utilized at the WA Mother Baby Unit, the state’s only psychiatric in-patient facility for mothers and infants.
Methods: A mixed-method design was used, with qualitative and quantitative data gathered over a period of 7 months in 2013.
Findings: Data is currently being analysed and results will be available for presentation. Preliminary analysis indicates high levels of acceptability and efficacy for the mindfulness-based intervention. A number of valuable practical suggestions for enhancing and expanding the program were documented and are subsequently being considered.
Conclusions: A description of the intervention and the results of this evaluation will be presented at this symposium. Directions for future research and recommendations for clinical service provision will be proposed.
Depression and Suicide in Late Life: Considerations for Prevention
B Draper1, O Almeida2, S Starkstein2, N Lautenschlager3
1University of New South Wales, Sydney, Australia
2University of Western Australia, Perth, WA, Australia
3University of Melbourne, Melbourne, Australia
This symposium will focus on prevention of depression and suicide in late life by considering some of the relevant risk factors and how they interact. Brian Draper will provide a broad overview of prevention of suicide and depression from a life cycle perspective. Osvaldo Almeida will examine the role that alcohol has in late life cognitive and mood disorders. Sergio Starkstein will address the question of depression and suicide in people with dementia. Nicola Lautenschlager will examine depression in older carers along with interventions to address the problem.
Brian Draper1,2: Prevention of Depression and Suicide in Late Life: A Life-Cycle Approach
1University of New South Wales, Sydney, Australia
2Prince of Wales Hospital, Randwick, Australia
Background: The prevention of depression and suicide in older people share common proximal and distal themes.
Objectives: The presentation will examine key issues in the prevention of depression and suicide across the life cycle.
Methods: The literature related to risk factors for depression and suicide in late life will be reviewed, with a focus on significant issues in early, mid-, and late-life that could be practical targets for interventions.
Findings: In early life, interventions that address childhood adversity by reducing abuses and the impact of abuses could potentially reduce late life suicidal behaviour and mood disturbances. In mid-life, a healthy lifestyle, such as reduction of vascular risk factors, substance use and increased exercise might have late-life benefits on mood and suicidality. In late life, strategies that address the impact of social isolation, loneliness and difficulties in coping with physical disabilities have demonstrated benefit in improving mood and reducing suicide risk.
Conclusions: Prevention of depression and suicide in late life requires a multi-faceted approach that targets different stages of the life cycle.
Osvaldo Almeida: Alcohol, Forgetting and the Blues - The Effect of Alcohol on Cognition and Mood in Later Life
Almeida OP1, Hankey GJ1, Yeap BB1, Golledge J2, Flicker L1
1University of Western Australia, WA, Australia
2James Cook University
Background: Excessive alcohol consumption is associated with increased risk of depression and cognitive impairment, but it is unclear if this association is causal or is due to confounding and bias.
Objectives: This study aimed to determine if the alcohol consumption causes depression and cognitive impairment in later life.
Methods: Mendelian randomisation study, designed to investigate the triangular association between a genetic polymorphism of the alcohol dehydrogenase 1B (ADH1B rs1229984 G>A) gene, alcohol consumption and depression (assessed with the Geriatric Depression Scale 15 items) and cognitive impairment (assessed with the Mini-Mental State Examination). Participants were 3873 community-dwelling men aged 65–83 years, recruited for the Health In Men Study (HIMS).
Findings: The mean number of drinks consumed per week was 1.8, 5.9 and 8.5 for men with the AA, GA and GG genotypes. Consumption of 1 or 2 drinks per day decreased the odds of depression by 30% and 40%, whereas consumption of 6 or more drinks per day more than doubled the odds of depression (OR = 2.12; 95%CI = 1.02, 4.40). The ADH1B rs1229984 G>A polymorphism was not associated with depression (p = 0.857) and did not interact with alcohol use to modulate the risk of depression. Cognitive impairment was more prevalent among abstainers than regular drinkers (OR = 1.67; 95%CI = 1.12, 2.50), but the ADH1B rs1229984 G>A polymorphism did not decrease the odds of cognitive impairment (AA/GG OR = 1.35; 95%CI = 0.29, 6.27 and GA/GG OR = 1.05; 95%CI = 0.71, 1.55).
Conclusions: Alcohol consumption does not cause depression nor cognitive impairment in older men. Our results are consistent with the possibility, but do not prove, that regular moderate drinking may improve the mental health of older men.
Presentation: Sergio Starkstein: Depression and Suicide in Dementia
University of Western Australia, Perth, WA, Australia
Background: Depression is among the most frequent psychiatric comorbidities in Alzheimer’s disease (AD). While completed suicide is not frequent in AD, the advent of pre-symptomatic testing may have a negative impact.
Objectives: This presentation will address the phenomenology, frequency, prognosis and management of depression in AD. It will also address current estimates of suicide in AD and discuss ethical dilemmas related to pre-symptomatic testing.
Methods: Literature review and the presentation of preliminary data of a longitudinal study of depression and suicidality in AD.
Findings: About 40% of patients with AD suffer depression (either minor or major), as found in cross-sectional studies, and more than 70% of AD patients will suffer depression at some stage during the progression of the illness. Major depression in AD can be diagnosed using DSM-IV/5 diagnostic criteria. Pharmacological treatment of depression is still elusive, which may be related to strong placebo effects. Suicide is a rare event in AD and mostly affects younger individuals in the early stages of the illness, with preserved insight. The impact of pre-symptomatic testing on suicide is still unknown.
Conclusions: Depression is a frequent finding in AD, but its treatment is still elusive. The advent of pre-symptomatic testing may open new ethical dilemmas in AD and other dementias.
Nicola Lautenschlager: Depression in Older Carers
NT Lautenschlager1, B Dow2, D Ames1,2, K Moore2, S Loi1
1University of Melbourne, Melbourne, Australia
2National Ageing Research Institute, Parkville, Australia
Background: Informal carers provide approximately 80% of all care received by care recipients with disabilities or whom are frail aged. The percentage of older carers will rise in light of the ageing of the global population. Over 60% of carers experience symptoms of depression: Caring for a person with dementia is associated with the highest risk of poor mental health outcomes.
Objectives: This paper will give an overview of the current literature, focusing on interventions aiming to improve mental health of older carers.
Methods: Literature review as well as presentation of preliminary data from the IMPACCT study, a randomised controlled trial of home-based, individualised physical activity for carers with symptoms of depression and their care recipients.
Findings: There is evidence that behavioural management therapy can improve symptoms of depression in carers of care recipients with dementia, whereas education in isolation is less effective. Physical activity is shown to reduce the risk of depression and symptoms of depression in older adults in general; and therefore, may also be effective for older carers. Effective intervention studies are limited to date. Numerous barriers prevent carers from engaging in activities supporting healthy ageing.
Conclusions: Further research is needed to identify carers at high risk of poor mental health outcomes and future interventions will need to explore how to best enable older carers to engage in healthy activities to improve mental health outcomes.
Weighing the Evidence: Physical Health Problems in Mental Health Populations and How We Can Effectively Address Them
Co-Convenors: Megan Kalucy1, Philip B Ward1-3
1Early Psychosis Programme, South Eastern Sydney Local Health District, Sydney, Australia
2School of Psychiatry, University of New South Wales, Sydney, Australia
3Schizophrenia Research Unit, South Western Sydney Local Health District, Liverpool Hospital, Liverpool BC, Australia
The recent Australian National Mental Health Commission Report Card highlighted the very significant impact on life expectancy of cardiovascular disease among people living with severe mental illness: they have twice the rates of overweight/obesity, twice the rate of diabetes, two to three times the rate of tobacco use, and five times greater risk of elevated cholesterol levels than the general population. There are many factors that contribute to this poor physical health profile, including genetic risk factors, lifestyle choices linked to high levels of social deprivation and barriers to access to effective treatments (cost, availability, stigma etc.).
There has been a range of responses to the significant life expectancy reduction in this population, ranging from increased focus on assessment and monitoring of risk factors; trials of lifestyle interventions focused on increasing physical activity and fitness, and improving diet and nutritional status; the use of metformin in those with pre-diabetes and/or clinically-significant weight gain; and medication review with the aim of reducing polypharmacy involving those drugs linked to increased weight gain (including antipsychotics and mood stabilisers).
This symposium will highlight a range of challenges and interventions aimed at improving the physical health of people with severe mental illness.
Presentation 1: Weight Gain and Metabolic Problems in Patients With First Episode Psychosis
S Verma, M Subramaniam
Institute of Mental Health, Singapore
Background: Excessive weight gain, as well as glucose and lipid metabolic dysfunction, are common and clinically-relevant side effects of antipsychotic medications. They impact adherence and are associated with substantial morbidity and mortality. Although the reason for increased cardiovascular disease in schizophrenia is multifactorial, adverse metabolic side effects of antipsychotic medications play an important role. Patients with first-episode psychosis (FEP) are a particularly vulnerable group: the dual stigma of not only having a mental illness, but also being overweight, results in low self-esteem, social discrimination and isolation.
Objectives and methods: The Singapore Early Psychosis Intervention Programme undertook a study to identify the prevalence of cardiovascular risk factors in drug-naïve patients with FEP, compared to healthy controls matched for age, gender and ethnicity. We also conducted a second study examining the effects of antipsychotic treatment on weight gain and metabolic abnormalities in patients with FEP.
Findings: Mean baseline weight, body mass index (BMI), and serum levels of total cholesterol and LDL were significantly higher in controls, compared to patients. We found significant increases in BMI, serum triglycerides, low-density lipoprotein (LDL) and total cholesterol from baseline to 6 months, with 65% of patients having clinically-significant weight gain (i.e. ≥ 7% increase from baseline). Logistic regression showed lower baseline BMI, female gender and younger age were associated with clinically-significant weight gain.
Conclusions: These findings suggest that weight gain and metabolic dysfunction in FEP patients are indeed effects of antipsychotic medications, and emphasize the need for prevention and early intervention not just for treatment of FEP, but also for metabolic side effects that occur as a result of such treatment.
Presentation 2: Keeping the Body in Mind for Young People With Early Psychosis
J Curtis1,2, A Watkins1, K Samaras3, M Kalucy1, S Rosenbaum1,4, S Teasdale1, J Abbott1, J De La Torre1, PB Ward2,5
1South Eastern Sydney Local Health District, Eastern Suburbs Mental Health Programme, Sydney, Australia
2School of Psychiatry, University of New South Wales, Sydney, Australia
3Department of Endocrinology, Saint Vincent’s Hospital, Sydney, Australia
4Musculoskeletal Division, The George Institute for Global Health, Sydney University, Sydney, Australia
5South Western Sydney Local Health District, Schizophrenia Research Unit, Liverpool Hospital, Sydney, Australia
Background: It has been previously demonstrated that following initiation of atypical antipsychotic medications, a rapid deterioration of metabolic health occurs within the initial 12 weeks of the commencement of treatment.
Objectives: The Keeping the Body in Mind (KBIM) project aims to determine if a multi-disciplinary, 12-week intervention comprising exercise physiology and dietetic interventions for young people experiencing first episode psychosis can attenuate the expected decline in metabolic health.
Methods: Young people aged 15–25 admitted to the Bondi Early Psychosis Program from January 2013 onwards were eligible for referral to KBIM. Exercise physiology services were provided, as well as optional use of a supervised gym embedded within the service. Clients also received 12 weeks of one-on-one dietetic monitoring and education. Outcome measures were assessed at baseline and 12 weeks later. Paired t-tests were used to determine if significant change in metabolic outcomes occurred.
Findings: As of November 2013, 20 patients (11 male, 9 female subjects) had completed baseline assessments, with a mean age of 20.4 (SD = 2.1) years. At baseline, one male subject met criteria for metabolic syndrome, 46% of male (n = 5) and 22% (n = 2) of female subjects had no risk factors, whilst 54% (n = 6) of male and 78% (n = 7) of female subjects had one or more risk factors for metabolic syndrome. For the 12 participants with available follow-up data, the mean increase in waist circumference was 0.7 cm (95% CI −2.2 cm to 3.6 cm; p = 0.62). For weight, the mean increase was 2.0 kg (95% CI 0.2 kg to 3.8 kg; p = 0.04).
Conclusions: Preliminary data suggest that exercise physiology and dietetic interventions appear to somewhat attenuate antipsychotic-induced deterioration of metabolic health.
Presentation 3: Exercise Augmentation Compared to Usual Care for Post-Traumatic Stress Disorder: A Randomised Controlled Trial
S Rosenbaum1,2, C Sherrington1, Tiedemann A1
1Musculoskeltal Division, The George Institute for Global Health and School of Public Health, University of Sydney, Sydney, Australia
2Saint John of God Health Care Richmond Hospital, Sydney, Australia
Background: No randomised controlled trials (RCTs) have been conducted investigating the impact of exercise on post-traumatic stress disorder (PTSD).
Objectives: To investigate the impact of a 12-week exercise program for PTSD.
Methods: Inpatients with a DSM-IV diagnosis of PTSD were recruited from St John of God Health Care’s Richmond Hospital. Participants were randomised to receive either usual care (n = 42) or exercise in addition to usual care (n = 39). The intervention consisted of primarily home-based resistance training and a pedometer-walking program. Participants randomised to receive exercise augmentation completed one supervised and two unsupervised exercise sessions per week. The primary outcome measure was PTSD symptoms, obtained through the PTSD Check List - Civilian version. Secondary measures assessed depression and anxiety, mobility and strength, body composition, physical activity levels and sleep.
Findings: Participants had a mean age of 47.8 years (SD 12.1), 84% were male and 58 participants (72%) completed follow-up assessments for the primary outcome measure. Mean exercise intervention adherence was seven supervised sessions (range, 1–11). The intervention group significantly improved, compared to the control group, for PTSD symptoms (mean difference (MD)= −5.4; 95% CI −10.5 to −0.3; p = 0.04; n = 58), DASS score (–17.4; p = 0.004), waist circumference (–3.6 cm; p = 0.04), PTSD-related sleep quality (–2.5; p = 0.04) and time spent sitting (– 261 mins; p = 0.001). No statistically significant between-group differences were found for other outcomes.
Conclusion: The exercise intervention reduced PTSD and depressive symptoms at a clinically significant level, and improved body composition and sleep quality. These results support the inclusion of structured exercise in the treatment of PTSD.
Presentation 4: Physical Activity in Chinese Patients With First-Episode Psychosis and the Fitmind Exercise Campaign
E Lee1, CLM Hui1, WC Chang1, SKW Chan1, YK Li1, JTM Lee1, JJX Lin1, Eric YH Chen1,2
1Department of Psychiatry, University of Hong Kong, Hong Kong, SAR China
2State Key Laboratory of Brain and Cognitive Sciences, University of Hong Kong, Hong Kong, SAR China
Background: There has been increasing interest in studying the impact of physical activity on psychological and physical well-being and functioning in patients with first-episode psychosis. The exploration of factors that contribute to physical activity in psychosis may open up opportunities for improvement of functional outcomes.
Objectives and methods: We recruited 283 patients with first-episode psychosis from a specialized early intervention service for adult-onset psychosis (Jockey Club Early Psychosis Project) in Hong Kong.
Findings: We found that 96 (33.9%) patients were physically inactive, and 187 (66.1%) of them were physically active. Being physically inactive, having more positive and negative symptoms, and having lower household income at baseline predicted poorer functioning at 6 months.
Conclusions: Early intervention for psychosis should target to improve patients’ physical activity level, as that may help subsequent functioning. A FitMind exercise program, combined with motivational intervention, has been introduced in Hong Kong to encourage physical exercise in patients with first-episode psychosis.
Critical Psychiatry: The Politics of Mental Health
T Tietze1, A Banerjee2, H Middleton3, J Jureidini4
1Department of Emergency Psychiatry, St. Vincent’s Hospital, Sydney, Australia
2North Metropolitan Mental Health Service, Perth, Australia
3Department of Psychological Medicine, Women and Children’s Hospital, Adelaide, Australia
4University of Nottingham and Nottinghamshire Healthcare NHS Trust, Nottingham, UK
Background: This symposium intends to provide a dispassionate account of the current ills of the discipline, seen through the lens of critical psychiatry. The four presenters are consultant psychiatrists in Australia and the UK, whom are members of the Critical Psychiatry Network, a loose association of primarily UK-based psychiatrists, some of whom have published critiques of current paradigms of understanding mental illness.
Objectives: To provide an informed view of the theoretical foundations of critical psychiatry and to show how the current practice of psychiatry in the developed world is serving the purpose of interest groups aligned with neoliberal capitalism.
Methods: In a series of four papers, based on an exhaustive review of literature, the authors will initially provide an understanding of the social construction of mental illness. Subsequent authors will provide a summary of the current literature in critical psychiatry, and then will attempt to deconstruct certain aspects of the current conventional understanding of schizophrenia. The final presenter will analyse the causes for diagnostic over-expansion in mental health from a critical psychiatry perspective.
Findings: The opinions that the authors provide in their papers will build a cohesive argument in favour of critical thinking within the discipline of psychiatry.
Conclusions: Biomedical psychiatry has failed the discipline in many respects. The time has come for psychiatrists to be proficient in sociological constructs which in some cases will help them understand their patients much better than through overstated biomedical paradigms.
Presentation 1: T Tietze1,2: The Social Construction of Mental Illness
1Saint Vincent’s Hospital
2University of New South Wales School of Psychiatry, Sydney, Australia
Background: A key challenge to the scientific validity and medical status of psychiatry has been the notion that, unlike other illnesses, mental illnesses are socially constructed (i.e. merely the product of normative social judgments). This challenge was particularly strong during the heyday of the anti-psychiatry movement, but has found new life in controversies over DSM-5.
Objectives: To examine the strengths and limitations of key social construction theories of mental illness and assess whether they are commensurable with a view of psychiatry as both scientific and medical.
Methods: A selective review of key contributions to the social construction literature, including those of Erving Goffman, Thomas Szasz, Michel Foucault, Peter Sedgwick, Peter Conrad, Jerome Wakefield and Allan V Horwitz.
Findings: Most, but not all theories examined, directly challenge the medical and/or scientific status of psychiatry. Some contributors broaden their discussion by positing all illness as socially constructed. The recent ‘harmful dysfunction’ conception is a sophisticated hybrid scientific-normative theory.
Conclusions: The social construction literature is heterogenous. Despite the implicit challenge it poses to psychiatric authority, it has also helped clarify important philosophical issues about the discipline. Theories that locate mental illness as a subset of illness-in-general provide the best chance of putting social construction itself on a scientific footing, without getting mired in debates on the status of psychiatry.
Presentation 2: A Banerjee: Readings in Critical Psychiatry
North Metropolitan Mental Health Service, Perth, Australia
Background: The term ‘critical psychiatry’ came into being with the publication of David Ingleby’s book in 1981. The title of his book is also the title of this symposium.
Objectives: The aim of the paper is to retrace the history of critical psychiatry since Ingleby’s seminal publication. An attempt will be made to point out the ‘criticisms’ of critical psychiatry. Some practical suggestions as to what might be the way forward for the discipline will be discussed.
Methods: A comprehensive review of the literature related to critical psychiatry. The salient viewpoints of all prominent authors since Ingleby will be discussed.
Findings: Different strands of the argument and any differences in viewpoints among prominent authors in the field will be highlighted. The presenter will conclude with a review of the article ‘Psychiatry beyond the Current Paradigm’, written by members of the Critical Psychiatry Network in the UK and published in the British Journal of Psychiatry in 2012, and subsequent responses to it.
Conclusions: There are multiple issues of relevance that would benefit from a critical examination in psychiatry. Prominent among them are the nature and limits of mental illness, the boundaries of psychosis and mood disorder, and their methods of treatment.
A thorough analysis and acceptance of some critical psychiatry viewpoints by the mainstream is now becoming necessary. This will only embellish the discipline of psychiatry and make it more true.
Presentation 3: H Middleton1,2: ‘Illness Like Any Other’: Is This Really a Helpful Way to Construct Schizophrenia?
1School of Sociology and Social Policy, University of Nottingham, Nottingham, UK
2Nottinghamshire Healthcare NHS Trust, Nottingham, UK
Background: Publication of DSM-5 promoted considerable debate at the time: It leaves a striking legacy. Leading neuroscientists renowned for their contributions to psychiatric research reject DSM and related schemata of classification as bases for research. It would appear that those with a pioneering understanding of brain science feel that their form of knowledge does not provide constructive and applicable insight into processes underpinning the difficulties that bring people to mental health services.
Objectives: To provide an opportunity for reflection upon the adequacy, suitability and unintended consequences of medical metaphors; and the use of related language in relation to ‘mental health difficulties’. A particular focus will be those known as ‘schizophrenia’.
Methods: An interpretive epistemological approach. Current practice and related policies reflect a particular discourse and in this case, it is one that has reified a certain set of distressing experiences. Schneider’s initial account of first rank symptoms will be re-considered alongside Parson’s early account of ‘illness’ and the sick role.
Findings: Critical review of notions concerning ‘illness’, ‘medical treatment’ and ‘schizophrenia’ suggested that their conjunction in the development of a discourse locating schizophrenia as a medical condition does not do full justice to the meanings of those terms.
Conclusions: It is legitimate to criticize the construction of ‘mental health difficulties’ as ‘illnesses like any other’. Doing so has consequences, not all of them helpful. Enabling people in difficulty may better benefit from approaches such as those offered by the Hearing Voices Network and other proponents of a more ‘normalizing’ tenor.
Presentation 4: J Jureidini1,2: Diagnostic Overexpansion and the Role of Big Pharma
1University of Adelaide, Adelaide, SA, Australia
2Women’s and Children’s Hospital, North Adelaide, Australia
Background: Big Pharma provide leadership in diagnostic overexpansion, but there are a range of other interested parties who also contribute to increasing rates of psychiatric diagnosis.
Objectives: To spell out the role of various interest groups in diagnostic overexpansion.
Methods: Critical analysis of contributors to the diagnostic process.
Findings: Players include governments (e.g. as rates of mental illness have increased, apparent unemployment figures have fallen), society’s intolerance to ordinary distress, and key opinion leaders within our own profession. Each interested party might feel ‘in charge’, but this presentation will demonstrate how large pharmaceutical companies call the shots.
Conclusions: Psychiatrists who are not directly employed by a pharmaceutical company should avoid engagement with industry out of respect for the best interests of patients and the community.
Money Matters! Taking the Mystery Out of ABM, NDIS and Alternative Funding Methodologies
E Bartnik2, A Groves2,3, E Moore1, S Patchett2,3, M Pestell1, A Rosen4
1South Metropolitan Health Service, Mental Health Strategy and Leadership Unit, Perth, Australia
2Mental Health Commission, Perth, Australia
3North Metropolitan Mental Health Service, Perth, Australia
4University of Sydney, Sydney, Australia
Background: Activity-based funding (ABF) for mental health conditions is due to be introduced in the very near future. There are serious concerns that the funding methodology does not fit with the complexity of management of mental health conditions. The National Disability Insurance Scheme (NDIS) similarly does not fit with clinical reality.
Objectives: In this symposium, ABF and management will be demystified. The advantages and pitfalls of this funding methodology will be explored. Attendees will gain an understanding of the NDIS and its implication in the mental health space and explore alternative funding methodologies.
Methods: Aaron Groves has been involved at the national level in the debate around ABF and mental health and Mark Pestell led the WA Department of Health Business Improvement Project in Mental Health around ABM. They will lead the conversation around ABM. Eddie Bartnik, the former WA Mental Health Commissioner and Steve Patchett will explore the issues around the NDIS and mental health. Our third presentation will explore alternative funding methodologies that may see an appropriate level of funding given to the work in mental health.There will be time for discussion.
Conclusions: Attendees will be able to engage in informed debate about ABM, NDIS and other methodologies in order to better advocate for patients, their families and carers.
Presentation 1: A Groves, M Pestell: Activity-Based Funding and Management: What Does It Mean to You and Your Patients?
E Bartnik2, A Groves2,3, E Moore1, S Patchett2,3, M Pestell1, A Rosen4
1South Metropolitan Health Service, Mental Health Strategy and Leadership Unit, Perth, Australia
2Mental Health Commission, Perth, Australia
3North Metropolitan Mental Health Service, Perth, Australia
4University of Sydney, Sydney, Australia
Background: Activity Based Management (ABM) is an operating model for purchasing health activity. ABM relies on accurate and valid systems to collect and monitor activity. It can be used to drive transparency and incentivise the health system. Quality needs to be an important consideration and it is necessary for public sector psychiatrists and others to understand the funding of the system in which they work.
Objectives: At the end of the session, psychiatrists will have a good understand if the elements of ABF and ABM, the advantages and the limitations within a mental health or general health setting.
Methods: Aaron Groves has been involved at the national level in the debate around ABF and mental health, and Mark Pestell led the WA Department of Health Business Improvement Project in Mental Health around ABM. Their presentation will give insight into the development of this system, ABM’s relation to planning, and outline further areas of concern and future opportunities.
Conclusions: Attendees will be able to engage in informed debate about ABM, in order to better advocate for patients, their families and carers.
Presentation 2: E Bartnik, S Patchett: NDIS: Good News for People With a Mental Illness or Further Confusion?
E Bartnik2, A Groves2,3, E Moore1, S Patchett2,3, M Pestell1, A Rosen4
1South Metropolitan Health Service, Mental Health Strategy and Leadership Unit, Perth, Australia
2Mental Health Commission, Perth, Australia
3North Metropolitan Mental Health Service, Perth, Australia
4University of Sydney, Sydney, Australia
Background: The introduction of the National Disability Insurance Scheme (NDIS) was greeted with great enthusiasm in the disability sector. The detail of its application to the mental health sector is still being clarified.
Objectives: At the end of the session, attendees will have a good understanding of the elements of the NDIS, the advantages and the limitations within the mental health space.
Methods: Eddie Bartnik was the WA Mental Health Commissioner and has extensive experience in the disability sector. Steve Patchett works with the Mental Health Commission, providing clinical input into planning and the new WA Mental Health Bill. Their presentation will explore the issues around the NDIS in its current form and its issues, when applied to people with a mental illness.
Conclusions: Attendees will be able to engage in informed debate about the NDIS, in order to better advocate for patients, their families and carers.
Presentation 3: E Moore, A Rosen: What’s the Best Way to Pay for Our Mental Health?
E Bartnik2, A Groves2,3, E Moore1, S Patchett2,3, M Pestell1, A Rosen4
1South Metropolitan Health Service, Mental Health Strategy and Leadership Unit, Perth, Australia
2Mental Health Commission, Perth, Australia
3North Metropolitan Mental Health Service, Perth, Australia
4University of Sydney, Sydney, Australia
Background: There have been several suggested alternative funding methodologies presented at conferences over the past 20 years. Analysis of our use of available funds shows that the majority is spent in the acute inpatient care sector in most jurisdictions, and yet the demand continues to be only partly met.
Objectives: At the end of the session, attendees will have a good understanding of the elements of funding methodologies in mental health and will be able to critically evaluate future directions in mental health spending.
Methods: Alan Rosen is currently Clinical Associate Professor at the University of Sydney. He is well known for his work in community and social psychiatry. This presentation will explore some alternative funding methodologies and make recommendations for future directions.
Conclusions: Attendees will be able to engage in informed debate, in order to better advocate for patients, their families and carers.
Gossip and Rumour in Health Organisations: What’s to Be Done About ‘Foul Whisp’Rings are Abroad’?
Nick O’Connor1,2, Beth Kotze3,4, Victor Storm2,4,5,6
1Northern Sydney Local Health District, Sydney, Australia
2Discipline of Psychiatry, University of Sydney, Sydney, Australia
3Mental Health Children and Young People, Sydney, Australia
4Department of Psychiatry, New South Wales University
5Sydney Local Health District, Sydney, Australia
6Department of Psychiatry, University of Western Sydney, Sydney, Australia
In this overview, the authors move from examples encountered as a clinician manager to a comprehensive review of gossip and rumour, a discussion of gossip and rumour in health organisations, and finally, address management strategies for the prevention of destructive effects of rumour and gossip in health service settings.
Background: The three situations that led a busy senior clinical director to inquire into the literature on gossip and rumour are described. An analysis and synthesis of the extensive literature and cultural reference to gossip and rumour provides the background for understanding and better managing gossip in health organisations.
Objectives: To provide an understanding of gossip and rumour, and how these affect self-esteem, reputation and group relations in health organisations, with a view to more effective management approaches.
Methods: A number of searches were performed (Medline, Psychinfo, Google Scholar), supplemented by manual searches of book shops and internet sites. The literature was reviewed and thematically analysed.
Findings: Gossip is an ancient, ubiquitous and cross-cultural phenomenon which has multiple important regulatory functions that provide socio-cultural information, and promote social cohesion and the common good. Gossip also has potential for social alienation and malicious damage to reputation. Rumour is usually a means of making sense of ambiguous and uncertain situations, but like gossip it has a dark side, with potential for wedge-driving, conspiratorial sabotage and inducing moral panic.
Conclusions: A fascinating and amusing, but scholarly, presentation on an area that is relatively neglected by health professionals, but contains a number of important links to psychiatry and the importance of social identity. Recommendations for managing gossip and rumour in the workplace, and some research questions, are discussed.
Presentation 1: Nick O’Connor1,2: Gossip and Rumour: An Overview of the Social Psychology, Anthropology and Neurolinguisitic Aspects
1Northern Sydney Local Health District, Sydney, Australia
2Discipline of Psychiatry, University of Sydney, Sydney, Australia
Nick O’Connor will introduce gossip and rumour and summarize the findings of the extensive literature review the authors have undertaken. This talk will address the nature, functions, and effects of gossip and rumour. The implications of social networking and social media are discussed.
Presentation 2: Victor Storm1-4: Gossip and Rumour in Health Organisations
1Discipline of Psychiatry, University of Sydney, Sydney, Australia
2Department of Psychiatry, New South Wales University, Australia
3Sydney Local Health District, Sydney, Australia
4Department of Psychiatry, University of Western Sydney, Australia
Victor Storm will give an overview of gossip and rumour in health organisations. There are studies of gossip, mainly in nursing and the operating room. Some thoughtful exploration of the relevance to medicine, psychiatry and psychotherapy is provided and the limited empirical data are discussed.
Presentation 3: Beth Kotze1,2: What’s to Be Done About ‘Foul Whisp’Rings are Abroad’?
1Mental Health Children and Young People, Sydney, Australia
2Department of Psychiatry, New South Wales University, Australia
Beth Kotze will present a review of the literature on management strategies in relation to gossip and rumour in health organisations.
Launch of the RANZCP Reconciliation Action Plan 2014 – 2016
Royal Australian & New Zealand College of Psychiatrists (RANZCP), Aboriginal and Torres Strait Islander Mental Health Committeea
Abstract
The RANZCP is committed to reducing the inequality in mental health outcomes between indigenous and non-indigenous Australians and advocates for the provision of culturally-appropriate and culturally safe and accessible psychiatric care.
In 2012, the Aboriginal and Torres Strait Islander Mental Health Committee commenced work on the College’s Reconciliation Action Plan. This is a landmark document that sets clear goals for the College as an organisation, to systematically address the issues that impact on achieving good mental health outcomes for Aboriginal and Torres Strait Islander people.
This Congress session will introduce participants to the principles that underpin the Reconciliation Action Plan. Presentations will be made by three prominent members of the Aboriginal community in WA, including two academics and a Torres Strait Islander who has been instrumental in providing culturally-appropriate health and community services in QLD.
These academic and community presenters will discuss the broader issues of the past, present and future, social and emotional wellbeing, social determinants of health and the purpose of the Reconciliation Action Plan.
The session will be facilitated by the Chair of the Aboriginal and Torres Strait Islander Mental Health Committee. The President, Murray Patton, will launch the Reconciliation Action Plan. Copies of the Plan will be available for the audience for reference throughout the session.
aThe Members of the Aboriginal and Torres Strait Islander Mental Health Committee are:
I Trevallion1, C Dhamarrandji2, J Dhamarrandji2, K Ryan3, J Lee4, S Weigall5, D Cutts6, L Dadd7, S White8, D Devlin9, M Watson10
1Child and Adolescent Social, Emotional & Spiritual Well-being Service, Thursday Island
2Miwatj /Ngalkanbuy Health Services, Northern Territory, NT, Australia
3Pilbara Aboriginal Drug and Alcohol Program, WA, Australia
4Townsville Hospital and Health Service, Queensland, QLD, Australia
5Victorian Aboriginal Health Service, Melbourne, VIC, Australia
6Consultant Psychiatrist, Lennox Head, New South Wales, Australia
7Hunter New England Local Health District, Newcastle, New South Wales, Australia
8Greater Western Areas Health Service, New South Wales, Australia
9Hunter New England Health, New South Wales, Australia
10Western Australian Health Department, WA, Australia
Integrated Assessment in Perinatal and Infant Mental Health: A Comprehensive Competency-Based Approach to Informed Care of Parents, Infants and the Relationships They Share
C Zanetti, J Feutrill
SJGHC Subiaco Raphael Centre, Perth, Australia
Background: The Raphael Centres are the only dedicated Perinatal and Infant Mental Health (PIMH) services in WA. Provision of a comprehensive assessment of all issues pertinent to the well-being of the parent, the infant and their developing relationship is a key function. Succinct formulation leading to an integrated treatment plan capable of promoting all these aspects of shared experience follows from the initial assessment, and is subject to constant revision as the circumstances and presentation change during the period of involvement with professional care; thus, assessment is an iterative process, which often occurs in a non-explicit form, and features in all aspects of engagement with families.
Clinically-based core competencies were developed for the process of assessment in PIMH. In this symposium, we will show how these are woven into all aspects of our work. We will specifically discuss our assessment process, the utility of some of the screening tools that we use, and will focus on some specific aspects of clinical work.
Objectives: To introduce the Raphael Centre PIMH Assessment Core Competency Framework; to discuss key aspects of clinical work in PIMH; to report on relevant screening tools, using data from the assessment process used at Subiaco Raphael Centre.
Methods: Presentation of models, data and case material exemplifying an integrated PIMH assessment process.
Findings: Parents’ outcomes, and their evaluation of the assessment process, are very positive.
Conclusions: Assessment in PIMH must encompass the mental well-being of parent and infant equally, and needs to occur within an integrated theoretical and practical framework.
Presentation 1: C Zanetti, J Feutrill: Core Competencies in Perinatal Infant Mental Health Assessment
SJGHC Subiaco Raphael Centre, Perth, Australia
Background: There has been a division in training and service provided for maternal perinatal mental health, and for that of infants and young children. This artificial separation has not recognized the inextricable linking of maternal mental well-being and infant socio-emotional development. The experience of a woman, as she approaches parenthood, is of holding another growing person alongside herself at all times, and this may have a positive or negative meaning for her. It may be imagined that the experience of a baby is of feeling like everything comes together when close to the mother (and father) from whom they came into being. The huge body of evidence from attachment theory and early infancy research supports this view; hence, it is impossible to assess one person in this system without including the other. The Raphael Centre has a comprehensive assessment process, involving observation, history taking and screening tools. A set of core competencies for assessing the parent and infant together has been derived, to support clinical practice and inform professional development.
Objectives: To introduce the Raphael Centre Core Competency Framework for Assessing Perinatal and Infant Mental Health and to outline the Raphael Centre assessment process.
Methods: A literature review was conducted, other competency frameworks examined, and a series of meetings were held within an experienced PIMH team and with specialist colleagues, to discern the competencies which are exercised in the assessment process.
Findings: It is possible to discern specific competencies that support a comprehensive assessment of both parent and infant separately, and together.
Conclusions: An integrated perinatal and infant mental health assessment allows comprehensive care and treatment planning at a systemic level, and identifying the core competencies involved in this process has the potential to enhance clinical practice.
Presentation 2: C Zanetti: Using the Montgomery and Åsberg Depression Rating Scale (MADRS) to Develop a Referral Pathway for Perinatal Mental Health Disorders
SJGHC Subiaco Raphael Centre, Perth, Australia
Background: The MADRS is a well-validated, clinician-rated screening tool for depression, but has not been used very often in the perinatal context. It was introduced to the Raphael Centre assessment process to balance the possibility of patients minimizing their scores on the Edinburgh Postnatal Depression Scale (EPDS).
Objectives: To examine the utility of using a validated clinician-rated depression scale with perinatal patients
Methods: The records of 650 men and women who presented for assessment with a perinatal mental health disorder or parent-infant relationship problem to a perinatal and infant mental health service located adjacent to a private, not-for-profit hospital maternity unit were examined for the period between 2010 and 2011. All patients (635 women and 15 men) completed the EPDS, and then the MADRS was rated by various perinatal mental health clinicians performing the assessments, who were blind to the significance of the MADRS score other than as a more objective rating, to compare with the patient’s own subjective mood rating on the EPDS.
Findings: The MADRS is easily woven into a semi-structured mental health assessment for perinatal women. A MADRS score of 19/60 or above strongly predicted referral for psychiatric review, independently of EPDS score, diagnosis or gender.
Conclusions: The MADRS is an efficient, clinician-rated tool that can provide a guide for clinicians when determining an appropriate treatment or referral pathway to psychiatric review, for women and men presenting with perinatal mental health problems.
Presentation 3: C Zanetti, J Feutrill: Obsessive Compulsive Disorder in the Perinatal Period
SJGHC Subiaco Raphael Centre, Perth, Australia
Background: Obsessive compulsive symptoms and obsessive compulsive disorder (OCD) have been reported to occur with increased incidence in the perinatal period. There is even a suggestion that OCD in the perinatal period is a distinctive subtype of OCD; however, there appears to be a poor level of awareness of this increased risk within the community, and symptoms may cause high levels of distress and shame for patients, particularly when obsessions of harm to self or the infant are a prominent presenting symptom. SJG Subiaco Raphael Centre has recognized the need to explicitly assess for the presence of OCD symptoms, particularly in anxious women, and we report on the introduction of an additional item to the MADRS, to detect such symptoms.
Objectives: To describe the presentation of OCD antenatally and postnatally, using case illustrations; to discuss the current literature related to the perinatal presentation of OCD; to discuss the potential impact of maternal symptoms on the infant; and to describe appropriate approaches to treatment.
Methods: An extra question relating to obsessions and compulsions was added to the assessment interview, taken from the Comprehensive Psychopathological Rating Scale (CPRS) (Asberg et al., 1978) from which the MADRS was derived.
Findings: Data is still under collection.
Conclusions: A systematic approach to identifying obsessive and compulsive symptoms in the perinatal period is an important component of assessment of perinatal mental health, and management of the disorder must include consideration of the impact of symptoms on the infant’s developing sense of self, and on the parent-infant relationship.
Presentation 4: C Zanetti: Screening for Perinatal Mood Disorder and Parent-Infant Relationship Disturbance
SJOGHC Subiaco Raphael Centre, Perth, Australia
Background: The Edinburgh Postnatal Depression Scale (EPDS) represents a gold standard among self-report screening tools used in the perinatal period. No similar self-reporting instrument has achieved that status in screening for disturbance in the parent-infant relationship. We report on the use of the Mother Object Relations Scale Short Form (MORS-14) as part of the assessment protocol at a PIMH service. Norms for this scale have been established along two dimensions, warmth and invasion, in both British and Hungarian mothers.
Objectives: To discuss the use of a simple self-reporting scale capable of identifying problems in the maternal representations of the infant; to present findings from 157 consecutive mothers presenting for assessment to the Subiaco Raphael Centre.
Methods: Mothers completed the MORS-14 immediately prior to their assessment interview, and again at a 3-month review.
Findings: At assessment, 55% of mothers scored below cut-off (at risk) on the warmth dimension, and 42% scored high (at risk) on the invasion dimension. Low scores on warmth or high on invasion were associated with above cut-off scores on both the EPDS and the Montgomery and Åsberg Depression Rating Scale (MADRS). The MORS-14 corroborated clinical findings, and was useful as a baseline against which to measure progress in enhancing the parent-infant relationship across a number of therapeutic interventions.
Conclusions: The MORS-14 is an easy to complete, acceptable questionnaire, capable of measuring important aspects of the parent-infant relationship, and can be useful in guiding and monitoring treatment.
Presentation 5: J Feutrill, C Zanetti: Including the Infant in Perinatal Mental Health (PIMH) Care on the Maternity Ward
SJOGHC Subiaco Raphael Centre, Perth, Australia
Background: Consultation-liaison to maternity wards provides the opportunity to detect early signs of attachment difficulties and intervene early in mental health disorder for the parents. The symptoms of mental health disorder in the parents will often be influenced by their early connection and sense of knowing of their baby. Infant mental health interventions in this setting can be useful in the treatment of perinatal mental health disorder symptoms in the parents.
Interventions must be able to flexibly adapt to the busy ward environment and to other new tasks parents are learning, such as breastfeeding and settling. Liaison can provide a way of managing the competing interests intrinsic to this setting.
Objectives: To discuss considerations related to successfully identifying need, and responding to referrals on the maternity wards of a large non-government hospital. To describe the way in which infant mental health and the developing parent-infant relationship can be incorporated into PIMH assessment and care.
Methods: We examined patients’ evaluations of their initial assessment and the number of patients taking up suggested treatment options.
Findings: Most patients were very positive about their assessment experience, but women who were referred to external service providers were less positive. The majority of mothers referred to attend a mother-baby group or other service at the Raphael Centre took up this option.
Conclusions: The Raphael Centre consultation-liaison service is acceptable to mothers and has led to early take up of services by referred mothers. There is a need for further service provision for mothers with complex presentations.
Vitamins and the Mental Health of Older People: Separating Spin From Reality
A Ford, L Flicker, O Almeida
University of Western Australia, Crawley, Perth, WA, Australia
Background: Depression and cognitive impairment are major causes of disability that often overlap in later life, and treatment options are fairly limited and frequently only modestly effective. Adults and older adults worldwide consume large amounts of vitamin supplements in the hope they will increase their well-being and prevent the onset of cancer, cardiovascular events, dementia and depression. Vitamin supplements are generally safe and relatively inexpensive, and therefore an appealing preventative or adjunctive treatment option in mental health illnesses in older adults.
Objectives: This symposium will review the evidence linking certain vitamins to the causal pathway that leads to dementia, depression and other adverse health consequences in older adults and will aim to provide objective guidance for clinicians working with older adults.
Methods: The symposium will include three presentations on topics relevant to the mental health of older adults:
Vitamin B supplementation for cognitive performance and the prevention of dementia in older adults;
Nutrition and vitamin D in the health of older people, with an emphasis on depression and delaying the onset of dementia;
Vitamin B as an adjunctive treatment for depression in later life.
Conclusions: The speakers will review the available literature and present evidence from their own extensive research in this area of mental health.
Presentation 1: A Ford: B-Vitamins, Homocysteine and Cognitive Impairment in Older People: Evidence From Observational Studies and Randomised Trials
University of Western Australia, Crawley, Perth, WA, Australia
Background: Dementia is a leading cause of worldwide disability and mortality and is predicted to affect nearly one-half a million Australians by 2031. There is currently no disease-modifying treatment available; and unfortunately, little evidence that such a treatment will be forthcoming in the near future. The identification of key risk factors, and in particular, potentially modifiable factors, has thus become a health imperative. Over the past two to three decades, high total plasma homocysteine (tHcy) has been proposed as a risk factor for the development of cognitive impairment and dementia. This is important, as tHcy can be reliably lowered through simple supplementation with vitamin B12, B6 and folic acid, making it a potentially easily modifiable risk factor for dementia.
Objectives: This presentation will summarise the evidence from observation research and clinical trials linking high homocysteine with adverse cognitive outcomes in later life. Data will be presented from the speaker’s own research in this area.
Conclusions: High homocysteine is associated with cognitive impairment and dementia in older adults, but the evidence supporting this association is unclear. This is important, because homocysteine can be reliably lowered with simple, safe and cost-effective vitamin supplementation. This talk will provide insight based on the available evidence, about whether the routine supplementation with vitamin B is suggested.
Presentation 2: L Flicker: Nutrition, Consumption of Vitamins and the Role of Vitamin D for the Health of Older People
University of Western Australia, Crawley, Perth, WA, Australia
Background: Vitamin D insufficiency is a common finding in older Australians, particularly those living in residential care. Vitamin D testing is commonplace, at a cost of nearly one-half billion dollars to the Australian economy over the past 5 years. Vitamin D is essential for adequate calcium absorption and healthy bone mineralization. Vitamin D insufficiency is implicated in a variety of disease states, including osteoporosis, osteomalacia, fractures, mood dysregulation, cardiovascular disease, multiple sclerosis cognitive impairment and increased mortality, but the evidence for many of these is equivocal at best.
Objectives and methods: Professor Leon Flicker is an experienced researcher and geriatrician with multiple publications in this area. This talk will clarify the evidence linking vitamin D insufficiency with disease states in later life and separate fact from fiction. The associations between vitamin D and depression and cognitive impairment or dementia will also be examined.
Presentation 3: O Almeida: Vitamins as Adjunctive Treatment for Depression in Later Life: The B-Vitage Trial
University of Western Australia, Crawley, Perth, WA, Australia
Background: High homocysteine is associated with diverse adverse health outcomes in later life, including depression. Evidence linking high homocysteine and depression is mainly of an observational nature, with only a handful of previous small, randomised trials in the area.
Objectives and methods: This talk will review the evidence linking homocysteine with mood and present results from the B-VITAGE trial. This double blind, placebo-controlled trial enrolled patients with major depression and randomised them to 12 months of daily vitamin B12, B6 and folic acid supplementation, compared to placebo. The primary objectives of the trial were to determine if vitamin supplementation improved the response to antidepressant treatment and improved the remission rate from major depression.
Conclusions: The findings from this trial will help clinicians to decide if vitamin B supplementation is useful as adjunctive treatment for depressive symptoms in later life.
Choice and Partnership: Transforming a Child and Adolescent Mental Health Service
SD Hong1, R Golling1, M Percy1, N Coulter2
1Rockingham Kwinana Child and Adolescent Mental Health Service, Rockingham, Australia
2Child and Adolescent Health Service, Subiaco, Australia
Background: The Choice and Partnership Approach (CAPA) is a capacity and demand model of care delivery developed specifically for the child and adolescent mental health service (CAMHS) setting (York and Kingbury, 2013). Following success in the UK and New Zealand, the model captured the attention of CAMHS managers and clinicians in WA. The Rockingham Kwinana Child and Adolescent Mental Health Service (RKCAMHS) has undergone and continues to undergo transformational change through the implementation of CAPA.
Objectives: To identify, implement and evaluate capacity and demand strategies to improve access and entry for children, young people and their families to RKCAMHS. To use CAPA principles of client-centred care, clinician as facilitator, and choice to support the recovery, in developmentally appropriate ways, of young people whom attend RKCAMHS, as directed by the National Standards for Mental Health Services 2010 (Commonwealth of Australia, 2010).
Methods: Preparing to implement CAPA required whole-team development, analysis of existing referral and entry data, review of risk assessment and management, review of clinician diaries and work schedules, review of community resources, and reworking of service documents and correspondence.
Findings: The RKCAMHS team has implemented CAPA since April 2013, eliminating the waitlist. Children, young people and their families now are offered a First Meeting/Choice Appointment within 4 weeks of their referral to the service. The nature of these appointments means that families are encouraged to explore a range of options besides attending CAMHS.
Conclusions: The RKCAMHS team has used the implementation of CAPA as an opportunity for service development.
Presentation 1: N Coulter: Choice and Partnership Approach: A Camhs-Specific, Demand-Led Service Model
Child and Adolescent Health Service, Subiaco, Australia
Background: The Choice and Partnership Approach (CAPA) is a clinical system that evolved in Richmond and East Hertfordshire CAMHS and is now being widely implemented across the UK, Canada, New Zealand and parts of Australia. The approach is rooted in the theory of demand and capacity, and is part of the modernisation agenda, as outlined in the UK’s National CAMHS Review (2008). The experience of CAMHS using this approach in the UK, New Zealand and Australia has demonstrated the ability for community CAMHS to deliver more efficient and accessible services that provide multidisciplinary and multi-functional models of care.
Objectives: The aim of CAPA is to engage young people and their families in therapeutic interventions and care, whilst optimising service efficiencies and managing day-to-day demands within the service.
Methods: Rockingham CAMHS was chosen as an ‘innovation leader’, to inform the process of wider implementation across the metropolitan community CAMHS in Perth, WA. The service undertook a periodic review and redesign process to enable a safe and effective transition to the CAPA model, in April 2013.
Findings:
Significant reductions in waiting times;
Implementation of consumer- and carer-focused booking systems;
Clinical capacity balanced with demand;
All staff actively engaged in the process of improving the service.
Conclusions: All anticipated objectives have been met. It is the recommendation of the CAMHS Executive that this approach is implemented in a second wave across the remaining eleven community CAMHS in metropolitan Perth.
Presentation 2: M Percy: Rockingham Kwinana CAMHS Prior to the Implementation of CAPA
Rockingham Kwinana Child and Adolescent Mental Health Service, Rockingham, Australia
Background: In order to prepare for the implementation of CAPA, it was important to understand and document existing entry and access procedures at RKCAMHS. Prior to the implementation of CAPA, all referrals received were triaged by the Intake Officer. In most cases, this involved a telephone interview with a principal carer, sometimes also with the referred young person, and sometimes with the referrer. A completed Triage Screen document, comprising all triaged referrals from that week, would then be presented at the Intake Meeting (comprising a quorum of clinicians) for discussion and a decision of whether to accept, decline or redirect.
Objectives: To determine the demographic characteristics of the children and young people referred to RKCAMHS, the types of presenting issues cited by referrers, the sources of referral and the outcomes of referrals.
Methods: Information was gathered from the Psychiatric Services Online Information System (PSOLIS), Intake Meeting records, and Triage Screen documents.
Findings: Approximately two out of three referrals were declined and usually re-directed to another agency, often a non-government agency. The remaining referrals were assigned to either a priority or general waitlist, which caused many carers anxiety, making many referrers express their dissatisfaction to the Triage Officer. Some referred patients had been waiting for over 12 months. RKCAMHS received a significant number of referrals of indigenous people, but they were statistically under-represented in their client population.
Conclusions: Outcomes of the review indicated that both the priority and general waitlists were too long, that clinical staff levels were too low, and that the triage/intake process was too arbitrary, leading to inconsistencies in entry and access to the service.
Presentation 3: SD Hong: A Psychiatry Perspective of CAPA Implementation
Rockingham Kwinana Child and Adolescent Mental Health Service, Rockingham, Australia
Background: The perennial challenge facing mental health services is to deliver quality services with limited resources. Services can often be overwhelmed by demand, and struggle to maintain the capacity to manage growing workloads effectively. Consultant psychiatrists provide leadership within their teams to ensure the delivery of high-quality care for patients and play a key role in leading innovation and change within organisations, for the benefits of patients. This role must balance the drive for change against the possibility of increased clinical risk and address resistance to change amongst team members in effective ways.
Objectives: The objective was to examine the possibility of increased clinical risk of young people and their families in various clinical pathways of CAPA and to describe the challenges experienced by staff and clinicians throughout the transition to CAPA at RKCAMHS.
Methods: We interviewed clinicians and staff of RKCAMHS regarding their experiences with CAPA. We conducted a data analysis and reviewed risk assessment and management.
Findings: The change to CAPA was unsettling and some staff found the process stressful. Amongst some staff members there is still some negativity and anxiety regarding CAPA, 6 months after implementation.
Conclusions: Because there are various causes for resistance to change, assessment and planning requires careful consideration. Although CAPA does not increase exposure to clinical risk, it is very important to have plans to manage the risks children and young people face in different stages of treatment.
Presentation 4: R Golling: Outcomes of Introducing CAPA in the Rockingham Context
Rockingham Kwinana Child and Adolescent Mental Health Service, Rockingham, Australia
Background: Within WA and further afield, both nationally and internationally, there is a growing demand for Specialised Mental Health Services. Within WA, a significant population increase over the past 10 years and substantial forecasted future growth has placed a great strain on services to provide an ongoing high quality, consistent level of care that is responsive to the varied needs of the community. Historically, services have experienced long waiting lists, resulting in uncertainty for young people and their families regarding if and when they will be able to access services and treatment. Following the implementation of CAPA, we undertook an evaluation of service delivery data.
Objective: To provide a transparent overview of data relating to activity, including access to the service and treatment times for consultation and treatment.
Methods: Collation and analysis of data for all referrals to the service, since the inception of the service model on 1 April 2013, and monitoring of the pathways through the service to discharge.
Findings: Data indicated a significant decrease in the variance of service provision to consumers since the implementation of the service model. This led to predictable demand and capacity management, and a clearer understanding of the impacts on service provision.
Conclusions: The analysis of the journey that consumers take into and through the service has become more transparent and predictable. This led to improved lines of communication and understanding both within and external to the service. The service model has not addressed the chronic shortage in capacity; however, it has created a clear and definable analysis to promote debate with funding providers about the needs and expectations of services, given the current resource framework.
Psychiatrist-Patient Privilege - Reclaiming Confidentiality!
G Galambos1,2,3, J Levy2, B Pring, Ms KF, T Hendriks
1Chair, Private Practitioners Network, Royal Australian and New Zealand College of Psychiatrists, Australia
2The Lawson Clinic, Sydney, Australia
3Young Adult Mental Health Unit, St Vincent’s Private Hospital, Sydney, Australia
Overarching Abstract:
Background: There is growing concern amongst Australian psychiatrists that psychiatrist-patient confidentiality is being eroded by the unrestrained use of subpoenas by legal practitioners who are obtaining indiscriminate access to psychiatric records held by public and private psychiatrists and health facilities. There is also the increasing practice of life insurance companies gaining access to their clients’ health records by coercing them into signing consent under Freedom of Information legislation.
Objectives: To show that unfettered legal access to psychiatric records is inconsistent with professional ethical guidelines and risks undermining the community obtaining high quality psychiatric assessment and treatment. To argue that provisions regarding subpoenas are not working at the New South Wales or Commonwealth levels to protect psychiatrist-patient confidentiality.
Methods: We explain why psychiatrist-patient confidentiality must be preserved and outline the applicable legal principles and practices at the New South Wales State and Commonwealth levels with regard to subpoenas.
Conclusions: We formulate recommendations for Australian Governments to intervene by enacting appropriate uniform legislation to ensure psychiatric records are treated as privileged documents.
Presentation 1: Bill Pring: How Changes to Privacy Legislation Opened Up Access to Psychiatric Records to Lawyers and Actuaries: Whose Intellectual Property Are They?
Dr Bill Pring1
1AMA Observer on Private Mental Health Alliance
Privacy legislation was introduced in 2000 and seems like a good idea in a modern world where privacy is difficult to maintain. Special measures were introduced to further protect health privacy, and this seemed a good idea at the time too. Unfortunately, as a result of the legislation The confidentiality of medical records seems to have been diminished in a number of ways, and there is a risk that medical records will be dumbed down in order for doctors to protect themselves in various ways. It is clear that the doctors intellectual property in the medical record has been largely ignored, and this has a number of consequences for us as a profession. The main areas that are affected include the use by lawyers of privacy law to obtain the whole medical record of the patient, and use it in various ways which were not intended under the Privacy Act. There are also consequences in terms of medicolegal practice, where lawyers will often use privacy law to obtain records to avoid paying medico legal fees, especially to treating doctors. Because the records are being requisitioned on an increasing basis, there could be a tendency of doctors to “dumb down” their record, so that their own intellectual property interests are protected to some extent. That is counter-productive to the value of the clinical record. A number of legitimate approaches to dealing with these difficult issues will be discussed in this talk, including the legitimate use of additional records, and a stricter interpretation of “serious harm” under privacy law.
Presentation 2: Consumer Stories - Personal Experiences
Author/s: combined ‘collage’ of experiences
Presentation 3: The Advantages and Disadvantages of Easy Access to Psychiatric Records By the Family Law and Children’S Courts: What’S in the Interests of the Child?
Dr Tracie Hendriks1,2
1University of New South Wales, Sydney, Australia
2Royal Brisbane Hospital, Brisbane, Australia
Presentation 4: The Erosion of Psychiatrist-Patient Confidentiality by Subpoenas: Recommendations Around Expanding and Enforcing Privilege
J Levy1
1The Lawson Clinic, Sydney, Australia
The Evolving Landscape of Care in Complex Trauma: Psychotherapy, Neurofeedback and HRV Biofeedback, Working Together for Integration
L McLean1-3, E Cohen4,5, M Askovic6, S Stefanovic6
1Westmead Psychotherapy Program (WPP), Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Department of Consultation-Liaison Psychiatry, RNSH, Saint Leonards
3SWaGS Psychiatry Training Network
4Private Practice, Sydney, NSW, Australia
5Adults Surviving Child Abuse (ASCA)
6NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS), NSW, Australia
Background: Converging information from psychology, psychotherapy and neuroscience suggests that trauma breaks down integration at every level of systemic organization. Clinicians are then grappling with ways to approach (re)integration of experience, and the restoration of functioning and coherence in patients presenting with the sequelae of trauma. The integration of neurobiological models, including Porges’ Polyvagal Theory, with extant models of emotional and cognitive processing and organization, now offers emergent models of causation and treatment that can guide our efforts. These models suggest that multi-modal interventions offer the opportunity for both ‘top-down’ and ‘bottom-up’ approaches to personal integration and the promotion of coherence.
Objectives: This symposium offers detailed presentations from two groups of collaborators in this area of integrated assessment, and/or multimodal treatment of trauma, to demonstrate the challenges, rewards and necessary limits of working in this way to promote integration and self-regulation.
Methods: Presentations will focus on:
Integrating Biofeedback and Breathing to improve Heart Rate Variability (HRV), with psychodynamic psychotherapy in the Conversational Model;
Using electroencephalogram (EEG) and psychological assessments to formulate treatment with neurofeedback and sandplay work, in children whom are survivors of war and refugee trauma.
Findings: Integrative multimodal approaches to assessment and treatment may foster better approaches to care for patients with traumatic presentations. An integrative model of care may aid recovery, (re)integration, and the restoration of better self-regulation and functioning.
Conclusions: More research is warranted in these areas of integrated assessment and psychotherapeutic care.
Presentation 1: Integrating Biofeedback and Breathing for Heart Rate Variability (HRV) With Long-Term Intensive Psychodynamic Psychotherapy
E Cohen1,2, L McLean3-5
1Private Practice, Sydney, New South Wales, Australia
2Adults Surviving Child Abuse (ASCA)
3Westmead Psychotherapy Program (WPP), Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
4 Department of Consultation-Liaison Psychiatry, RNSH, Saint Leonards
5SWaGS Psychiatry Training Network
Background: We now understand that chronic complex trauma breaks down personal psychophysiological integration. In response, there is now an emergent trend for clinicians to integrate methods from psychotherapy, psychology, psychiatry and the neurosciences, in order to promote (re)integration in these patients. Heart Rate Variability (HRV), a window into the balance between the sympathetic and parasympathetic arms of the autonomic nervous system, is an important marker of a person’s stress system and stress response, and has become a target for intervention; however, integrating biofeedback into psychodynamic psychotherapy has particular challenges.
Objectives: In this presentation, we will discuss why and how biofeedback, regarded in the literature as beneficial in assisting self-regulation, was introduced to certain individuals with chronic complex trauma during intensive, long-term psychodynamic psychotherapy, in the Conversational Model.
Methods: We provide a brief review of the background literature, including Porges’ Polyvagal Theory, to frame integrated care in complex trauma. We explain the process of Biofeedback, in particular HRV biofeedback, giving attention to breathing and its impact on self-regulation, and present the results of our small case series (n = 8) on aspects of patient self-regulation. Several case studies from the series will be presented in more detail, to examine process and outcome. The relational framework and the importance of attunement while working to combine these two interventions will be explored.
Findings: This integrated approach was a useful way to promote integration and self-regulation in some patients suffering from chronic complex trauma.
Conclusions: This potentially useful approach now requires further examination.
Presentation 2: M Askovic, S Stefanovic: Multimodal Approach to Trauma in Children Using Eeg Assessment: Integrating Neurofeedback Treatment and Sandplay Therapy
NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS), NSW, Australia
Background: Trauma in both children and adults leads to a disintegration of aspects of self-organization and experience. In our service, treating refugee children whom are survivors of loss, trauma and/or torture, we need to optimize assessment, formulation and treatment plans for psychoneurological integration, to promote biopsychosocial recovery.
Objectives: In this presentation, we will demonstrate how a comprehensive assessment using electroencephalogram (EEG) assessment, combined with the sandplay process, can assist us to better understand the impacts of psychological trauma on all levels of a child’s functioning, formulate integrated care and plan the sequence of treatment.
Methods: We will outline our procedures of EEG and psychological assessment and then present several case vignettes to demonstrate the process and utility of this approach that is integrating neuroscience tools and a psychotherapeutic understanding, here with a focus on neurofeedback and sandplay therapy. Demonstrable EEG changes will be presented.
Findings: This integrated approach to assessment and integrated care is proving useful in children with traumatic presentations.
Conclusion: Further examination of this area of integrated assessment and treatment is warranted.
Critical Psychiatry and the Recovery Paradigm
C Quadrio1, H Middleton2, A Banerjee3, J Jureidini4
1University of New South Wales, Sydney, Australia
2School of Sociology and Social Policy, University of Nottingham and Nottinghamshire Healthcare NHS Trust, Nottingham, United Kingdom
3North Metropolitan Mental Health Service, Perth, Australia
4Department of Psychological Medicine, Women and Children’s Hospital, Adelaide, Australia
Overarching Abstract:
Background: The Recovery paradigm is well and truly established in the lexicon of mental health service delivery in Australia. Psychiatrists will have to modify their practice substantially in the coming years to become more recovery focused and psychiatric training will have to change accordingly.
Objectives: To highlight major areas in which critical psychiatry concepts could aid the discipline to be more aligned with recovery principles.
Methods: The first author will provide a critical analysis on the aetiology of psychosis from a trauma informed viewpoint. The second paper will highlight controversies regarding the evidence base for psychopharmacology through a review of two books written by prominent critical psychiatrist Joanna Moncrieff. After a brief critical analysis of the potential risks and benefits of labelling and diagnostic expansion, the session will conclude with an interview with author Kate Richards about her book ‘Madness: A Memoir’, describing her lived experience of major mental illness.
Findings: It is anticipated that the combined papers, interview and the resulting discussion with the audience will draw a link between the two concepts.
Conclusions: The paradigm change currently needed in psychiatry leading to incorporation of recovery principles will be greatly facilitated by an understanding of critical psychiatry.
Presentation 1: Give Me the Child - Trauma and Psychiatric Aetiology
Carolyn Quadrio
School of Psychiatry, University of New South Wales, NSW, Australia
Background: In the DSM III an atheoretical model of mental disorder was favoured on the basis that psychiatry did not have a model of mental disorder so symptom clusters would be described according to empirical data. Over time perhaps we lost sight of the fact that we are describing syndromes, not diseases and that there are known pathogens and toxic situations, such as child abuse and neglect, war, poverty and social and cultural dislocation. Those are the conditions in which psychological disturbances thrive; they present huge issues, perhaps beyond the remit of a medical specialty, which may explain why we have focused on more accessible and scientific pursuits, for example genetic markers and for neurotransmitter disturbances, and why we have embraced a predominantly pharmacological treatment paradigm.
Objectives: To consider the ways in which these very different priorities have become established in psychiatry and within the DSM system and to explore alternative approaches to a nosology of psychiatric disorder.
Methods: A review of data on childhood adversity/ abuse/ trauma/neglect and the role these factors play in various psychiatric disturbances and the extent to which these factors are adequately represented - or not - within the DSM system.
Findings: There is now a substantial body of literature that establishes a strong connection between childhood adversity/ abuse/ trauma/neglect and psychiatric disturbances of all kinds, including the psychoses
Conclusions: In the light of compelling data on causation it may be time for psychiatry to reconsider the direction in which the atheoretical approach has taken us.
Presentation 2: Critical Thinking Offers a More Person-Centred Approach to Drug Treatments
H Middleton
School of Sociology and Social Policy, University of Nottingham and Nottinghamshire Healthcare NHS Trust, Nottingham, UK
Background: The science supporting use of antipsychotic agents, antidepressants and mood stabilizers is not non-controversial. There are criticisms of the honesty with which trial data are presented, allegations of common interest between academics and commercial sponsors and concerns about other ways in which products have been promoted. These justify critical reappraisal of the bases upon which psycho-pharmaceuticals have acquired a reputation as effective therapies.
Objectives: Summarize two recent books (1,2). To use their interpretations of such data as the basis of a more relational, person-centred approach to the use of psychotropic medication.
Methods: The Myth of the Chemical Cure asks a number of specific questions of the science behind antipsychotic agents, antidepressants and mood stabilizers which test whether or not these agents fulfill what might expected of a therapeutic agent. The Bitterest Pill provides an account of the way in which the notion of psychosis as “correctable chemical abnormality” has been developed.
Findings: A critical reading of scientific and clinical trials findings suggests that the notion of psycho-pharmaceuticals as targeted therapeutic agents correcting abnormalities of brain chemistry over-interprets available knowledge. An historical perspective can now look back and recognize that our understanding of “anti-psychotic” agents has been shaped by commercial interests (3).
Conclusions: Psychopharmacology’s therapeutic effects might be better understood as a complex processes including the subjective experiences psycho-active agents induce, expectancy and the affirming effect of receiving a prescription. Ways in which commercial interests exploit these have to recognized if unwanted consequences are to be minimized.
References
Moncrieff J (2008). The Myth of the Chemical Cure. A Critique of Psychiatric Drug Treatment. Revised Edition. Basingstoke, England: Palgrave Macmillan.
Moncrieff J (2013). The Bitterest Pills. The Troubling Story of Antipsychotic Drugs. Basingstoke, England: Palgrave Macmillan.
Tyrer P and Kendall T (2009). The spurious advance of antipsychotic drug therapy. Lancet 373 4-5.
Presentation 3: Labelling, Psychiatric Diagnosis and Recovery
A Banerjee
North Metropolitan Mental Health Service, Perth, Australia
Background: Mental illness, we are told, is a major problem of our time (Ingleby 1980). The issue of psychiatric diagnosis and classification remains a vexed one with some leaders of the field expressing serious concern about diagnostic overinflation, their concerns coinciding with the publishing of DSM-5 (Frances 2013). Why is it then that most patients continue to actively seek a label to describe their emotional distress, and psychiatrists willingly provide them one?
Objectives: To look at the sociological underpinnings of diagnostic labelling and critically examine its relationship with recovery.
Methods: A quick review of the literature examining current controversies related to psychiatric diagnosis and labelling. The author will discuss literature related to depression, Bipolar II disorder, Autism Spectrum Disorders, ADHD and Paediatric Bipolar Disorder.
Findings: The author expects to find certain commonalities and differences with regards to causes and effects of diagnostic labelling. The issue of stigma in relation to major mental illness and that of reverse stigma in relation to some more contemporary diagnoses will be touched upon.
Conclusions: Way too much treatment is given to the normal ‘worried well’; far too little help is available for those who are really ill and desperately need it (Frances 2013). Heroic attempts at psychopharmacology and the development of abnormal illness behaviour for some of the conditions described could be inimical to the concept of recovery.
References
Ingleby JD (1980). Critical Psychiatry: The Politics of Mental Health. Pantheon Books, New York.
Frances A (2013). Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. Harper Collins, New York.
Presentation 4: Interview With Kate Richards ‘Madness: A Memoir’
J Jureidini1,2
1University of Adelaide, South Australia
2Women’s and Children’s Hospital, North Adelaide
Jon Jureidini will be in conversation with Dr Kate Richards, about her book, Madness: A Memoir. Richards’ harrowing but beautifully written memoir begins as she describes her attempt to cut off her own arm. It is a chronicle of acute psychosis and depression as experienced by the sufferer - a very astute and moving account of a terrible disorder by a fine writer, who was warmly received at the Adelaide Writer’s week.
Latest Advances in Neurostimulation
C Loo1, C Galletly2, J Lee3, F Hugo4, P Clarke5, S Hussain6, D Garside7
1University of New South Wales, Saint George Hospital, Sydney, NSW, Australia
2University of Adelaide, Northern Mental Health Service, Adelaide, Australia
3University of Western Australia, Graylands Hospital, Perth, WA, Australia
4Armadele Mental Health Service, Perth, WA, Australia
5University of Adelaide, Ramsay Health Care, Adelaide, Australia
6University of Western Australia, Queen Elizabeth II Medical Centre, Perth, WA, Australia
7Sir Charles Gairdner Hospital, Perth, WA, Australia
Background: There have been significant advances in the utility of various novel neurostimulation treatments for psychiatric disorders, despite initial skepticism about the efficacy of these novel treatments. Repetitive Transcranial Magnetic Stimulation (rTMS), Transcranial Direct Current Stimulation (tDCS) and Magnetic Seizure Therapy (MST) have gained ground in both clinical and research use.
Objectives: To present the latest advances in neurostimulation techniques in clinical and research areas.
Method: This symposium will encompass a number of presentations, to cover areas of research and clinical observations. Presentations will represent the latest research and experts’ opinions in the field, drawing on experience from Sydney, Melbourne, Adelaide and Perth; and include Q&A.
Conclusion: The symposium is an opportunity to exchange information about further advances in neurostimulation and we anticipate that it will be a useful exercise to update clinical and scientific knowledge about the subject.
Presentation 1: C Galletly1,2: Neurostimulation: Research and Service Improvement in the Private Sector
1University of Adelaide, Adelaide, Australia
2Ramsay Health Care (SA) Mental Health Services, SA, Australia
Objective: This presentation outlines the process of developing a neurostimulation service in a private hospital setting, to provide a model for similar services elsewhere in Australia and New Zealand.
Methods: We describe the practical issues involved in setting up the service, including funding, staffing, equipment, treatment protocols and associated research.
Findings: The service has been widely accepted by psychiatrists and patients.
Conclusions: Clinicians involved in the service have found both the clinical and research components rewarding.
Presentation 2: A Repetitive Transcranial Magnetic Stimulation (RTMS) Service for the Treatment of Depressive Disorders
J Lee1,2, G Price2, A Bose2
1School of Psychiatry and Clinical Neurosciences, University of WA, Perth, WA, Australia
2Statewide Department of Neurophysiology, Clinical Research Centre, North Metropolitan Health Service Mental Health, Perth, Australia
Background: In conjunction with an rTMS research program conducting clinical trials since 2005, the North Metropolitan Mental Health Service established an ‘rTMS depression treatment clinic’ in Perth, in July 2011.
Objectives: To describe the operation of the rTMS service and to assess the efficacy and safety of rTMS for depression.
Methods: The referral and assessment process is described. Pooled data, including those from a previous clinical trial, were analysed.
Findings: Referrals were predominantly from private psychiatrists of patients suffering from treatment-resistant depression. The standard treatment was for 4 weeks, but subject to extension. Assessments of efficacy were based on Hamilton Depression Rating Scale (HDRS-21) and Beck’s Depression Inventory-II (BDI) scores at baseline, 2 weeks, and following the final treatment. Additional assessments included electroencephalogram (EEG) monitoring and the Repeatable Battery for Neuropsychological Assessment (RBANS). From 179 referrals, 113 patients completed sufficient sessions (2 weeks ITT) for analysis. Of these, 45 patients gained clinical improvement (> 50% reduction in Ham 21 scores) and 34 reached remission (< 8 on HamD21). The average improvement was 35.6 ± 34%. There was a significant difference between Pre- and Post-treatment ratings for HamD (t = 8.2; p < 0.01) and BDI (t = 6.92, p < 0.01), with an Effect Size of 1.09. Four patients received maintenance rTMS and two received ‘bilateral’ rTMS (as an augmentation measure), with varied success. The rTMS treatment was generally well tolerated, with no major side effects reported.
Conclusions: rTMS is a safe and effective treatment for depressive disorders and an rTMS service can be effectively delivered in a research format and a public health setting.
Presentation 3: C Loo: Novel Brain Stimulation Techniques: A New Tool in Psychiatry
University of New South Wales, Sydney, NSW, Australia
Novel brain stimulation techniques, in particular Transcranial Magnetic Stimulation (TMS) and Transcranial Direct Current Stimulation (tDCS), are emerging as important tools in psychiatry for the investigation and treatment of disorders. In particular, they have been applied to the treatment of depression and schizophrenia, and investigation of disordered neuronal processes in these disorders. This symposium will discuss evidence for the use of TMS and tDCS in the treatment of depression and schizophrenia, and also use of TMS techniques to demonstrate abnormal cortical plasticity in psychiatric disorders. There is good evidence for the use of repetitive TMS (rTMS) to treat depression, and emerging evidence of the efficacy of tDCS in depression.
Bonvenon! Successful Multicultural Training in the Most Diverse State in Australia
E Moore1, S Yeak1, A John2,3, N Johri4, M Isaac2,5, E Kleczkowska5
1South Metropolitan Health Service, Mental Health Strategy and Leadership Unit, Perth, WA, Australia
2University of WA, Perth, WA, Australia
3Bentley Health Service, Mental Health, Perth, WA, Australia
4Armadale Health Service, Mental Health, Perth, WA, Australia
5Fremantle Health Service, Mental Health, Perth, WA, Australia
Background: WA is culturally diverse and rapidly growing. It is a requirement of the National Standards for Mental Health Services to have staff who are equipped to provide the best possible and culturally appropriate care to all consumers, their families and carers.
Objectives: This symposium will present the evolution of a very successful multicultural training program for Mental Health Services and partner organisations in WA.
Methods: The three papers describe the 10-year evolution of training in this important area, the changing process of delivery and the changing syllabus, to reflect contemporary changes in the culturally and linguistically diverse profile in WA. The papers will describe the change from fundamental mandatory training to a more advanced exploration of cultural psychiatry in our Master Class series. The decision to move fundamental training from a centralized model to a site-based model (incorporating e-learning packages and reduced face to face teaching) will be discussed. We will describe the challenges and benefits of mandatory training, the need to adapt for sustainability and to meet the changing needs and requirements of the community and our staff.
Conclusion: This was a successful model that others may wish to consider in their own states or countries.
Presentation 1: A John, S Yeak, E Moore: Development and Evaluation of Successful Multicultural Training
A John2,3, S Yeak1, E Moore1, N Johri5, M Isaac2,4, E Kleczkowska4
1South Metropolitan Health Service, Mental Health Strategy and Leadership Unit, Perth, WA, Australia 2University of WA, Perth, WA, Australia
3Bentley Health Service, Mental Health, Perth, WA, Australia
4Fremantle Health Service, Mental Health, Perth, WA, Australia
5Armadale Health Service, Mental Health, Perth, WA, Australia
Background: Cultural competency in clinical practice is necessary to deliver culturally appropriate care to our increasingly diverse population. The proportion of overseas born and ATSI patients accessing services for mental health issues through WA is significant. After extensive consultation with relevant stakeholders, we initiated a 1-day cultural competency training program for mental health staff in 2004. This evolved into the first mandatory mental health multicultural competency training in Australia.
Objectives: To equip the workforce in delivering best and culturally-appropriate care to our patients.
Methods: The training was delivered by seven experts in their respective fields. The syllabus and delivery method were regularly reviewed to meet the needs of the workforce. Various methods for systematically evaluating the benefits of the program were incorporated. We extended our training by providing more in-depth Master Classes and have provided accredited training for WA General Practitioners and WA Country Health Service staff, and our partner organisations.
Findings: Analysis of feedback and structured evaluation confirmed that our training courses are enormously popular among mental health clinicians, health service staff, government and non-government organisations. Follow-up evaluation of staff showed that these skills were retained and had improved outcomes for patients from CALD backgrounds admitted to our Mental Health Services.
Conclusions: A structured multicultural training program has equipped our workforce to deliver culturally-appropriate care.
E Moore, S Yeak: Evolution and Sustainability of Multicultural Training
E Moore1, S Yeak1, A John2,3, N Johri5, M Isaac2,4, E Kleczkowska4
1South Metropolitan Health Service, Mental Health Strategy and Leadership Unit, Perth, WA, Australia 2University of WA, Perth, WA, Australia
3Bentley Health Service, Mental Health, Perth, WA, Australia
4Fremantle Health Service, Mental Health, Perth, WA, Australia
5Armadale Health Service, Mental Health, Perth, WA, Australia
Background: At South Metropolitan Health Service, we have been delivering Fundamental Mental Health Multicultural Training (FMHMCT) since 2004. The training syllabus and delivery method are regularly reviewed by a team of experts to meet the needs of our diverse workforce. Sustainability of this training is essential to ensure our workforce continues to be equipped to deal with diverse and often clinically complex issues in mental health.
Objectives: This paper describes the process of ensuring sustainability by delivering the Fundamental MHMCT through local clinicians in a Train the Trainer (TtT) model. This allows the Multicultural MH Training team to concentrate on more advanced, in depth Master Classes, which have been identified as a need in our staff feedback.
Findings: There is a need to ensure that the quality of our existing fundamental program is not lost with the move to the TtT model. The existing syllabus and evaluation framework will be reviewed to ensure quality and standards are maintained, so that popularity of the program is not compromised. Participants reported significant gains and confidence in working with people from diverse backgrounds from the existing program, and this data can be used as a baseline for evaluation of this new method.
Conclusions: A forward thinking multicultural training program will ensure the continuity in giving our workforce the skills and competencies to deliver culturally-appropriate care.
N Johri: Spirituality: The Missing Component in Multicultural Training
N Johri2,5, S Yeak1, E Moore1, A John2,3, M Isaac2,4
1South Metropolitan Health Service, Mental Health Strategy and Leadership Unit, Perth, WA, Australia
2University of WA, Perth, WA, Australia
3Bentley Health Service, Mental Health, Perth, WA, Australia
4Fremantle Health Service, Mental Health, Perth, WA, Australia
5Armadale Health Service, Mental Health, Perth, WA, Australia
Background: Epidemiological studies reveal a virtually universal belief among psychiatric patients in a variety of religious and spiritual beliefs. The significance of religion and spirituality increases when working with multicultural clients and their families. In the 10 years of evolution of mental health multicultural training in WA, there has been a growing interest in further exploration of religion and spirituality.
Objectives: To describe the development of a master class in Religion and Spirituality, for understanding and treatment of people with a mental disorder.
Findings: Specific course content was developed from existing evidence-based, peer-reviewed literature. The first 1-day workshop was well attended and richly interactive. The evaluation confirmed the interest and need for ongoing training in this area. Further workshops, exploring in more depth particular groups, have been developed as a result of the feedback received.
Conclusions: Multicultural training is incomplete without incorporating religion and spirituality in the core module. Clinicians require structured and specific skills enhancement in understanding a plethora of diverse beliefs and practices in clients, which can then be incorporated into a holistic care plan. This module continues to evolve keeping pace with participant’s needs, feedback and expert consensus.
All About Systematic Reviews and Meta-Analyses: From Critical Appraisal to Doing a Cochrane Review
Co-Chairs/Discussants: S Kisely1,2, J Looi3, C Galletly4, M Macfarlane5,6, S Merry7, B Power8
1School of Medicine, Princess Alexandria Hospital, Woolloongabba, Brisbane, Australia
2Rural School, Toowoomba, University of Queensland, QLD, Australia
3Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra Hospital, Canberra, Australia
4Discipline of Psychiatry, School of Medicine, University of Adelaide, Adelaide, Australia
5Illawarra Local Health District, Australian National University, Australia
6University of Wollongong, Wollongong, Australia
7Department of Psychological Medicine, School of Medicine, University of Auckland, Auckland, New Zealand
8Peel and Rockingham Kwinana Mental Health Service, WA, Australia
Objectives: Systematic reviews and meta-analyses of randomised controlled trials (RCTs) are the most robust form of clinical evidence. Cochrane systematic reviews represent a gold standard for these methodologies. This symposium by members of RANZCP’s Committee for Research is an introduction to systematic reviews and meta-analyses, based on the training provided to Cochrane Review authors.
Methods: The symposium describes the Cochrane Collaboration and the steps to completing a Cochrane review, drawing on the presenters’ own experiences as the authors of Cochrane reviews and other published meta-analyses. These entail registering the title with the appropriate review group (e.g. the Depression, Anxiety and Neurosis or Schizophrenia Review Groups), completing a protocol, and undertaking the review, based on that protocol. It will explain the principles of a literature search, appraising the quality of the published data and the use of appropriate meta-analytical techniques. These include the appropriate tests for continuous and dichotomous variables (e.g. mean difference, relative risks or odds ratios), and the use of fixed and random effects models. Other topics include clustered RCTs, controlled before-and after trials, and interrupted time series in systematic reviews. Participants can then apply these principles to critically appraise a systematic review and meta-analysis.
Findings and conclusions: Participants will understand the use, limitations and applications of systematic reviews research, including when to conduct a meta-analysis, as well as be able to critically appraise a systematic review and meta-analysis. Greater skills in understanding and possibly conducting systematic reviews and meta-analyses can be useful to registrars and psychiatrists.
Clinical Reasoning and Case Formulation in Psychiatry
I Fernando
Hunter New England Area Local Health District, University of Newcastle, NSW, Australia
Background: Clinical reasoning in psychiatry encompasses three main processes: eliciting symptoms and psychopathology, diagnostic and case formulation, and formulating a management plan. Because of the highly subjective nature of psychiatry, lack of specific laboratory tests, and the complex biopsychosocial etiology of psychiatric disorders, clinical reasoning can be challenging.
Objectives: The main objective of this presentation is to introduce a methodology and clinical tools, which will assist clinicians in clinical reasoning in psychiatry.
Methods: A broader theoretical framework and software tools have been introduced for clinical reasoning in psychiatry. These include:
A diagnostic algorithm, based on the logical inferences known as abduction, deduction and induction (Fernando et al., 2013a);
A methodology known as pattern-based formulation, which uses patterns that are derived from various theories and etiological models (Fernando et al., 2011);
A software tool for assessing mental state examination and differentiating symptom clusters (Fernando and Henskens, 2013);
A web-based decision support tool for choosing treatment options by taking into account evidence base and patient preferences (Fernando et al., 2013b).
Findings: The theoretical basis of the above stated approaches and tools will be introduced and explained using clinical cases.
Conclusions: It is expected that this presentation will educate clinicians on how to deal with the complexity of the clinical reasoning in psychiatry using a systematic approach and clinical tools.
References
Fernando I and Henskens F (2013) Modelling diagnostic reasoning based on Mental State Examination, International Journal of Modeling and Optimization 3: 471–474.
Fernando I, Henskens F and Cohen M (2011) Pattern-based psychiatric case formulation: A methodology for psychiatry case formulation. Australasian Psychiatry 20: 121–126.
Fernando I, Cohen M and Henskens F (2013a) A systematic approach to clinical reasoning in psychiatry. Australasian Psychiatry 21: 224–230.
Fernando I, Henskens F, Talebian M, et al. (2013b) A simple model for evaluating medical treatment options. In: 14th ACIS International Conference on Software Engineering, Artificial Intelligence, Networking and Parallel/Distributed Computing (SNPD 2013), Honolulu, HI, USA, 1–3 July 2013.
Religion and Spirituality: A Friend or FOE?
N Johri1,2, M Isaac2,3, K Bender4
1Armadale Health Service, South Metropolitan Health Service, WA, Australia
2University of Western Australia, Perth, WA, Australia
3Fremantle Hospital, South Metropolitan Health Service, WA, Australia
4City Community Mental Health Service, Perth, WA, Australia
Background: Religion and spirituality are essential dimensions of human life and intersect with practice of psychiatry at multiple levels. This relationship is complex, and often raises sharp and contrasting opinions within the psychiatric fraternity. Psychiatry is often blamed for ignoring it for too long. In recent times, there is a renewed interest in this area, and several papers are being written in leading journals.
Objectives: To vigorously explore and discuss a comprehensive range of issues associated with the interface of religion, spirituality and psychiatric practice; and to derive a robust framework to inform contemporary psychiatric practice, aid in developing training modules for psychiatric trainees and provide direction for future research.
Methods: The first speaker will introduce the topic, highlight current controversies and agreements, and draw a broad framework of scope for this symposium, in light of personal experiences and evidence-based research. The second speaker will reference his own qualitative research study on religious beliefs, practices and experiences; and discuss other available research, all of which highlights the usefulness, benefit and positive aspects of this interface. The last speaker will discuss the potential pitfalls and dangers associated with this proposed assimilation of the interface. This will be followed by open discussion with attendees.
Conclusions: It is a challenging task to maintain the right balance in between ‘too much and too little’ in an attempt to assimilate religion and spirituality with psychiatric practice. There is no excuse to remain inert, ignorant or uninvolved about this interface in today’s world.
Presentation 1: M Isaac1,2: The Interface of Religion, Spirituality and Psychiatry
1University of Western Australia, WA, Australia
2Fremantle Hospital, South Metropolitan Health Service, WA, Australia
Background: Psychiatry has traditionally had nothing to do with religion and spirituality. At times, psychiatry was viewed as being hostile to religion and spirituality. Religious and spiritual experiences were often considered as part of psychopathology; however, during the past 2 decades, there is growing awareness that religion and spirituality can be immensely helpful to a large proportion of people to effectively cope with various stressful life events. Their role in the management of various psychiatric disorders is also increasingly researched.
Objectives: To understand the role of religion and spirituality in current psychiatric practice, as well as in the larger field of mental health.
Methods: Critical review of the evolution of the relationship between religion, spirituality and mental health during the past century.
Findings: While religious and spiritual experiences are normal for a large number of people, they may lead to mental disturbances in some, and in many with psychiatric disorders: They may be part of psychopathology. The presentation will raise numerous questions for discussion, such as: Should religious beliefs and spiritual experiences be included as part of routine psychiatric assessment? Should there be integration into routine treatment approaches, and if so, how can this be achieved? Should these be included as integral components of training of psychiatrists?
Conclusions: There is a need to recognize the importance of religion and spirituality in our patients’ lives. There is growing empirical evidence for the beneficial effects of religion and spirituality in the management of a variety of psychiatric disorders.
Presentation 2: N Johri 1,2: Religion and Spirituality: A Potential Friend
1University of Western Australia, WA, Australia
2Armadale Health Service, South Metropolitan Health Service, WA, Australia
Background: The existence of religion and spirituality is arguably as old as the human race. During the genesis of modern psychiatry, clinicians deviated away from these issues to the point where Freud termed religion as ‘universal obsessional neurosis’. The last century has seen remarkable changes in the field of psychiatry, including the revolutionary biological psychiatry, but noticeably a gentle resurgence of the lost interest in this field.
Objectives: To explore the positive aspects of the interface between religion, spirituality and psychiatric practice.
Methods: Discussion of the author’s primary research on religious beliefs, practices and experiences in psychiatric patients, a controlled study of 150 patients. Available evidence in this field will be reviewed, along with a critical appraisal of the paucity of research in this area and addressing issues in generating evidence.
Conclusions: Universality of an entire range of diverse religious beliefs in psychiatric patients is not limited to the outcome of the author’s primary research, but has robust evidence in global research. The psychiatric fraternity needs to embrace this aspect, in assessing and managing our patients and their carers, while refraining, in a professional and ethical way, from disclosing one’s own atheism, agnosticism or a firm organizational belief, as the case may be. This needs to be no different, for example, from evaluating sexual issues for our patients in a sensitive, respectful and professional approach, without any need for self-disclosure of any kind.
Presentation 3: K Bender: Religion and Spirituality: Potential Pitfalls
City Community Mental Health Service, Perth, WA, Australia
Background: In ancient human civilization, in most cultures, a priest used to represent an amalgamation of a holy person and a healer. This distinction is far more relevant in the modern world. The history of psychiatry has many stories where religion and spirituality contributed to psychiatric symptomatology and illness. Religious cults have generated specific and intense psychiatric issues among followers. In an attempt to assimilate the interface of religion and spirituality with psychiatric practice, due care has to be given to potential pitfalls.
Objectives: To explore the potentially negative aspects or pitfalls of the interface between religion, spirituality and psychiatric practice.
Methods: A review of existing evidence and expert consensus, combined with the author’s rich and firsthand experience from working overseas in a predominantly Muslim country.
Findings:
Despite several studies in the last 2 decades indicating the positive correlation between religion or spirituality and better outcomes or quality of life (Koenig, 2013), it does not necessarily translate into prescribing a specific religion or spiritual path.
Psychiatry is significantly distanced from other medical specialties, due to the inherent complexities of the brain-body and biopsychosocial aspects. Any further deviation will make us indistinguishable from the non-medical disciplines.
Traditionally, western-trained psychiatrists appeared to be in a state of denial of the context of this interface.
Conclusions: Too much of a life-saving drug can also be lethal. Incorrectly identifying psychiatric symptomatology as a genuine spiritual/religious experience has led to overgeneralised distancing from this interface. This talk will conclude by summarizing these potential pitfalls.
Bearing Witness: Is It Becoming More Difficult to Practise in an Ethical Way in Today’s Complex Environment?
J Randles1,2, P Foulkes2, J Craig3
1Department Psychiatry, University of Melbourne, Australia
2Consultant Psychiatrist and Psychoanalytic Psychotherapist in private practice, Melbourne, Australia
3Consultant Psychiatrist and Psychoanalytic Psychotherapist in Private Practice, Sydney, Australia
The last few years have seen some dramatic changes within the psychiatric practice setting in Australia: Changes that have introduced a new level of complexity into a profession already struggling to prepare its trainees for the realities of private practice. There are new item numbers for assessment and report writing, and for seeing new patients (over and above the ongoing ones). Psychiatrists are now being offered substantial financial incentives, which some may find hard to resist. Practitioners are becoming used to dealing with privacy legislation, the intricacies of which may come as a surprise to newer graduates who have been trained in the public system, where electronic records (in which patient information can be accessed by everyone, without there being much consideration) have been the norm. Now the profession needs to consider the implications posed by an ever-increasing number of detailed reports that have been written by psychiatrists and sent to general practitioners. Already many colleagues have, within the same time frame, noted a substantial increase in the number of subpoenas from lawyers keen to access the clinical file - presumably to discover these reports. Better access (which offers subsidized sessions for treatment by large numbers of psychologists with variable training and experience) has introduced a new level of complexity that makes ethical practice even more difficult.
In this symposium, we will be presenting three views (informed by feedback received from patients) of some common dilemmas encountered in private practice. The symposium will have a format that is designed to encourage feedback from, and discussion with, the audience.
Presentation 1: J Craig: What is the Current Situation? How Did We Get Here? What Do We Think of the Evolving Landscape in Mental Health?
Private practice
A brief history of the changing experience of working in a private psychotherapy-focused psychiatric practice will be presented. There are various forces that have shaped these changes, in particular, new Medicare schemes and item numbers. Examining patterns of the use of Medicare item numbers by psychiatrists gives some idea of the changes occurring. Surveys of attitudes and the experience of practitioners in the field will be presented. An account of how these changes have influenced public perception of the treatment of mental disorder in the private practice setting will be addressed. This presentation aims to present a broad overview, leading into more specific material and areas of concern addressed by the following speakers.
Presentation 2: J Randles1,2: Bearing Witness: Vast Improvement, or Potential Train Wreck?
1Honorary Fellow, Department of Psychiatry, University of Melbourne, Melbourne, Australia
2Consultant Psychiatrist and Psychoanalytic Psychotherapist in private practice, Melbourne, Australia
Psychiatric practice has been changing steadily. Psychiatrists are now performing increasing numbers of assessments and writing ever more reports, but fewer ongoing treatments are now being offered. This presents us with a problem. Our patients have always been our best teachers; it is important that we continue to receive honest feedback from the individuals we set out to help, otherwise there is a risk that we may lose our way and with it, our humanity. The relationships that we previously relied on as professionals have become more tenuous these days. General Practitioners used to have networks that could be relied on, but this has changed. As psychiatrists, we could in days past refer our patients to professionals whose work we knew to be good, or good enough. It is of particular concern that today’s psychiatry trainees are not being given the opportunity to follow up their own patients, an experience that instils in each one a firsthand understanding of what works and what doesn’t. How do we manage in the current environment, when one-off assessments become the norm? When we find ourselves working with fellow professionals whom we do not know at all, even by reputation? And when we are denied the opportunity to discover what happened as a result of our intervention? In this presentation, I aim to offer some feedback by presenting and discussing some case vignettes.
Presentation 3: P Foulkes: Holy Secrets: Confidentiality and Forced Disclosure in Psychotherapies
Consultant Psychiatrist and Psychoanalytic Psychotherapist in Private Practice, Melbourne, Australia
Background: A changing culture of third parties, e.g. insurers and the court system demanding information in the form of the clinical file, violates confidentiality of the therapeutic relationship and is leading to a steady erosion of trust in the psychiatrist’s capacity to provide a safe environment for the divulging of sensitive information.
Objectives: To explore the consequences of the existing situation and to develop strategies for the psychiatrist to respond in an ethical manner.
Methods: To examine the current medico-legal dilemmas that face psychiatrists, when faced with demands for the patient’s clinical file (e.g. by subpoena). To examine the consequences of handing the file over, through the use of case examples; to describe a literature review of the subject.
Findings: Case examples show significant impairment in trust with a reduction in effectiveness of the therapy and termination, in some cases. This is congruent with the findings of others in the literature.
Conclusions: The use of forced disclosure of information to third parties represents an ongoing threat to the effectiveness of psychotherapeutic treatment and the capacity of the psychiatric profession to maintain the trust of the public.
Novel Approaches in ECT Research and Practice
C Loo1, C Galletly2, J Lee3, F Hugo4, P Clarke5, S Hussain6, D Garside7
1University of New South Wales, Saint George Hospital, Sydney, Australia
2University of Adelaide, Northern Mental Health Service, Adelaide, Australia
3University of Western Australia, Graylands Hospital, Perth, Australia
4Armadele Mental Health Service, Perth, Australia
5University of Adelaide, Ramsay Health Care, Adelaide, Australia
6University of Western Australia, Queen Elizabeth II Medical Centre, Perth, Australia
7Sir Charles Gairdner Hospital, Perth, Australia
Background: Although there have been significant advances in the utility of various novel neurostimulation treatments for psychiatric disorders, electroconvulsive therapy (ECT) remains widely used, poorly understood and acknowledged as the most effective neurostimulation treatment in psychiatry.
Objectives: To present the latest advances in ECT techniques in clinical and research areas.
Methods: This symposium will encompass a number of presentations, to cover areas of research and clinical observations. The presentations will represent the latest research and experts’ opinions in the field, drawing on experience from Sydney, Melbourne, Adelaide and Perth. A Q&A session will be conducted.
Conclusion: The symposium is an opportunity to exchange further advances in ECT. We anticipate that it will be a useful exercise in updating clinical and scientific knowledge about the subject.
Presentation 1: Electroconvulsive Therapy: Practice Guidelines for the Assessment of Cognition
F Hugo1, S Hussain2, 3, D Garside3
1Armadale Health Service, Perth, WA, Australia
2University of Western Australia, Perth, WA, Australia
3Sir Charles Gairdner Hospital, Perth, WA, Australia
Background: Cognitive impairment is an important complication of electroconvulsive therapy (ECT). If it happens during a course of ECT, then it may require the treating clinician to change the prescription for ECT to reduce the severity of cognitive change. After a course of ECT, complete recovery of cognition is the norm within months, but some patients experience persistent changes in autobiographical memory that is associated with a decline in quality of life. It is therefore important to methodically measure cognitive status before, during and after a course of ECT.
Objectives: To find a bedside cognitive assessment battery that can be recommended as a practice guideline for the assessment of cognition before, during and after ECT.
Methods: A review of the available scientific publications on cognitive assessment during and after ECT, to find cognitive tests that have sensitivity for mild to moderate changes in cognition, and specificity for ECT-related cognitive changes. The tests should also not require special training for administration and should be relatively brief. Test retest reliability should be robust enough to administer the tests repeatedly during a course of ECT and during the months following treatment.
Findings: There are no universally accepted appropriate tests for cognitive status during and after ECT. The demands for a suitable test battery are difficult to meet. Clinicians often default to well-known tests that provide a rough estimate of cognition, such as the Mini-Mental Status Examination.
Conclusions: We propose a combination of cognitive tests for ECT practice and propose a modification of established tests.
Presentation 2: C Loo1,2: The Evidence for Ultrabrief Right Unilateral ECT: Rcts, Meta-Analysis, Clinical Data
1University of New South Wales, Sydney, NSW, Australia
2Black Dog Institute, Sydney, NSW, Australia
The effect of shortening the pulse width of the electrical stimulus when administering electroconvulsive therapy (ECT) has recently been systematically studied, with promising results. This review examines reported outcomes from three randomised controlled trials that compared ultrabrief (≤ 0.3 ms) with brief (0.5–1.5 ms) pulse width ECT, and other recent clinical trials of ultrabrief pulse width ECT. The emerging evidence for ultrabrief pulse right unilateral (RUL) ECT suggests clinically meaningful efficacy and substantially reduced neuropsychological side effects, compared with standard brief pulse ECT; this may represent a generational advance in the ECT technique; however, it is unclear if patients receiving ultrabrief pulse RUL ECT may have a slower speed of response and require additional treatments, compared with brief pulse ECT. Therefore, until further data are available, clinicians may be well advised to use brief pulse ECT in situations requiring an urgent clinical response. The evidence base for ultrabrief bilateral ECT is limited, with findings that efficacy may be reduced, compared with brief pulse width ECT. Thus, ultrabrief bilateral ECT should not be used outside the research setting.
Presentation 3: C Loo1,2: ECT Outcomes Are Linked to Neurogenesis
1University of New South Wales, Sydney, NSW, Australia
2Black Dog Institute, Sydney, NSW, Australia
Neurogenesis refers to the generation of new brain cells, which is now known to continue well into adulthood. On the basis of animal studies, deficiencies in neurogenesis were implicated in the development of depression; and stimulation of neurogenesis was proposed as one of the ways that anti-depressants may work. Using the latest technological advances in brain imaging, we will assess the merit of these theories in humans with depression, before and after treatment with ECT.
Emergency Psychiatry in Rural and Remote Australia: Governance, Liaison and Technology
N Gill1,2, M Chapman3,4, S Balaratnasingam3,4, G Neilson1, D Cutts1, S Prabhu1, P Gupte1, B McKenny5, J Johnston6, J Hindman6, E Saurman7
1Division of Mental Health, Darling Downs Hospital and Health Service, Toowoomba, QLD, Australia
2Rural Clinical School, University of Queensland, Toowoomba, QLD, Australia
3Kimberley Mental Health and Drug Service, Broome, WA, Australia
4School of Psychiatry and Clinical Neurosciences, University of WA, Perth, WA, Australia
5Rural and Remote Mental Health Service, Country Health SA, SA, Australia
6Western NSW Local Health District, NSW, Australia
7Broken Hill University Department of Rural Health, Sydney University, Australia
Background: Emergency mental health service provision in rural and remote Australia faces multiple challenges, e.g. limited availability of services and workforce to deal with psychiatric emergencies locally, poor access to specialist mental health advice and frequent need to transport patients over long distances, often with limited availability of police and ambulance services. Various mental health services all over Australia have developed innovative models of service provision to deal with these challenges.
Objectives: This symposium aims at highlighting the innovations in rural and remote emergency psychiatry in Australia. The Clinical Governance framework, as well as use of tele-psychiatry to improve clinical services in emergency settings in various rural/remote areas, will be discussed. We will share the challenges faced and lessons learned.
Methods: A review of relevant literature will be presented to contextualise the challenges and contemporary innovations in rural/remote emergency psychiatry. Presenters from different states of Australia will then present qualitative, as well as quantitative data, and draw on their own experience to highlight various strategies to improve emergency mental health care.
Findings and conclusions: Improved inter-service collaboration and communication through robust clinical governance, as well as use of tele-health facilities, can improve patient care in rural and remote emergency settings. The specific strategies used by rural and remote mental health services in different states of Australia will be discussed in the symposium.
Presentation 1: M Chapman1,2, S Balaratnasingam1,2: Harm Minimization in Remote Psychiatric Emergency Transfers in the NW of Australia
1Kimberley Mental Health and Drug Service, Broome, Australia
2School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, WA, Australia
Background: The North West (NW) of Australia is home to over 100,000 Australians, with strong indigenous representation ‘living in country’, scattered over more than 1 million square kilometres of rugged and sometimes inaccessible terrain, serviced by 10 small hospitals and many more remote nurse-led community clinics. Over the last century, there has been a tremendous reliance upon aerial recovery of the acutely mentally unwell to authorized facilities in Perth, presenting considerable logistic challenges and increased risk of medical complications. Over the last 15 years, a number of local service innovations have attempted to mitigate these risks.
Objectives: To outline the various risks inherent in remote emergency long haul mental health evacuations and chart the history of service responses to the challenges.
Methods: A review of the relevant literature, qualitatively charting the development of various quality improvements and other service innovations, combined with a quantitative analysis of various available service event/adverse event data. We also draw on the personal experience of the authors.
Findings: Incremental changes in procedural practice and quality control, together with innovation in model of care delivery have contributed to palpable improvements in risk reduction.
Conclusions: Successful risk reduction to acceptable levels in such an unforgiving and medically resource-poor landscape is reliant upon a combination of factors, including close inter-service collaboration, sound governance and adapting the model of care to the population served. Ultimately, however, there is no substitute for improved resourcing to appropriate levels, to ensure safety and acceptable quality of care.
Presentation 2: N Gill1,2, G Neilson1: Emergency Psychiatry in Rural and Remote Queensland: Service Integration and Technology
N Gill1,2, G Neilson1, D Cutts1, S Prabhu1, P Gupte1
1Division of Mental Health, Darling Downs Hospital and Health Service, Toowoomba, Australia
2Rural Clinical School, University of Queensland, Toowoomba, Australia
Background: Toowoomba Acute Mental Health Unit is the inpatient facility for both the Darling Downs and South West districts of QLD, with a catchment area larger than VIC and TAS combined. Patient transfer to Toowoomba is expensive, time consuming and removes people from their home community. Multiple strategies have been employed to treat patients in their local rural and remote communities.
Objectives: This paper outlines the strategies to decrease unnecessary patient transfers by improving integration across community and inpatient services and refocusing existing Acute Care Teams, to deliver after-hours tele-health assessment services to rural and remote emergency departments.
Methods: We examined communication processes and dynamics between the acute inpatient unit, rural/remote community mental health services, rural General Practitioners (GPs) and rural/remote hospital emergency departments. In addition, we tracked patient journeys and experiences. We implemented strategies to improve coordination between services and established a clinical governance framework. This included the option of after-hours tele-health assessments, to avoid unnecessary transfers.
Findings: The paper will report on the lessons learned, challenges encountered during the change management process and future directions for extension of services, based on the lessons learned.
Conclusions: Small changes in service delivery using available technology, supported by robust clinical governance, can result in an appreciable improvement in clinical care and reduce the impact on people’s lives in rural and remote areas.
Presentation 3: B McKenney: Psychiatric Emergency Management in Rural and Remote South Australia
1Rural and Remote Mental Health Service, Country Health South Australia, SA, Australia
Background: The rural and remote mental health service of SA provides expert assessment and management advice to country regions of the state. SA has few large regional centres and a sparsely populated remote region that poses challenges to the delivery of mental health services.
Objectives: This paper summarises the current service model, highlighting the complex liaison between local general practitioners, community mental health workers, small country hospitals and local police linking with centrally-located services, such as the state ambulance service, Royal Flying Doctor Service and Medical retrieval service.
Methods: A review of the current functioning of the service and the associated problems will be presented. Data from the introduction of the SA Digital Telehealth Network will be presented, along with data of the transfers of patients from remote regions to Adelaide.
Findings: Current issues faced in the provision of emergency services will be highlighted and discussed. We will outline future directions for service delivery, with the introduction of new services.
Conclusions: Rural and remote mental health services continue to face challenges in providing safe and effective mental health care in psychiatric emergencies. New technologies and traditional liaison skills offer prospects for improved patient care.
Presentation 4: J Johnston, J Hindman: Mental Health Emergency Care By Telehealth in Western NSW
J Johnston1, J Hindman1, E Saurman2
1Western NSW Local Health District, NSW, Australia
2Broken Hill University Department of Rural Health, Sydney University, Sydney, Australia
Background: Persons presenting with urgent mental health needs in regional, rural, and remote areas of Australia experience difficulty in timely access to appropriate mental health care, owing to distance and sparse availability of on-the-ground services. This often results in delays in achieving care or potentially avoidable admissions to distant services, with attendant disruption for families, patients and communities, and on occasion adverse outcomes such as suicide.
Objectives: The Mental Health Emergency Care - Rural Access Program (MHEC-RAP) started clinical operations in 2008, with the aim of providing easier access to services, particularly in urgent cases, and providing clinical assessment and management advice by telehealth 24/7, to smaller communities across the catchment (55% of NSW by area; population: 300,000).
Methods: By integrating an existing telephone access line with videoconferencing, 24-hour nursing analogous to an Acute Community Team, business hours and on-call psychiatrist support; MHEC-RAP delivers triage, acute and urgent assessment, decision support, training and education, and case review to patients, carers, Community Mental Health Teams, General Practitioners, and health facilities throughout the area. At the time of writing, over 3500 assessments had been performed.
Findings: About 75% of assessments were managed locally. Admissions were facilitated where needed. Acceptability was high. Education programs were well received.
Conclusions: People and professional relationships matter more than technology. Clinical governance is crucial in providing a high-quality service. This presentation will provide practical advice for others looking to set up similar services.
Creative Practitioners
S Kumar1, C Hickie2,3, L McLean4,5, M Michael6, A Pal7, N Phillips8
1Brain & Mind Research Institute (BMRI) University of Sydney, NSW, Australia
2University of Newcastle, Newcastle, Australia
3Bloomfield Hospital, Western NSW Local Health District, NSW, Australia
4Westmead Psychotherapy Program, University of Sydney, Sydney Medical School, Sydney, NSW, Australia
5Consultation-Liaison Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia
6University of New South Wales, Sydney, NSW, Australia
7Royal Prince Alfred Hospital, Sydney, NSW, Australia
8Greater Western Area Health Service, Australia
‘I propose that the means by which we can accomplish the goal of relating empathically and compassionately to our patients and their families is by regarding the humanities and the sciences as of equal relevance and as complementary… we should embark on a lifelong journey through the wonderful world of literature, the visual arts, film and music.’ (Bloch, 2005)
It has long been recognised that medicine is an art, as well as a science, and this applies even more so to psychiatry. Historically, art therapy and music therapy were a major component of the humane treatment of people with psychiatric illness. The creative arts have the potential to communicate a range of subtle and complex emotions and ideas that may be missed in straightforward verbal exchanges.
Creativity itself is difficult to define, but involves the generation of new ideas, products or methodologies and is linked to innovation and imagination. In expressive therapies, it is the creative process itself that is emphasised, rather than the end product, in contrast to traditional arts.
Many doctors and psychiatrists avidly pursue creative interests, as evidenced by the Creative Doctors’ Network in Sydney. These pursuits can enhance personal and professional wellbeing, transform difficult interactions and add a richness of empathy and perception to clinical practice.
In this symposium, a number of creative practitioners will present on a range of artistic disciplines used in their personal and professional sphere, to illustrate the therapeutic and healing potential of creativity.
Reference
Bloch S (2005) The art of psychiatry. World Psychiatry 4(3): 130–134.
Presentation 1: N Phillips: Using Cartoons to Explain Psychiatric Illness
Greater Western Area Health Service, Australia
Cartoons are an excellent way of communicating difficult ideas and emotions. I explore the reasons for this and its therapeutic potential. I will use a live demonstration of drawing on screen, to illustrate some of the basic neurobiology of the human ability to recognise cartoons. Practitioners are encouraged to draw for themselves, demonstrating how easy and effective a simple cartoon can be.
Presentation 2: C Hickie1,2, M Michael3: Acting Psychiatry
1University of Newcastle, Newcastle, Australia
2Bloomfield Hospital, Western NSW Local Health District, NSW, Australia
3University of New South Wales, Sydney, NSW, Australia
Playwrights and actors have portrayed mental illness for millennia. More recently, dramatic depictions of mental illness in films such as A Beautiful Mind have been lauded for raising awareness and promoting discussion. Actors are now commonly used for teaching and examination of students and doctors in psychiatry settings.
These actors, working from scripts and using improvisation, simulate patients with mental illness or in heightened emotional states. Students or trainees are asked to suspend disbelief and behave towards them as if they are patients. Among the rationales for this approach is that it provides a controlled environment to learn (or be tested) on skills, without exploiting or adding to the distress of patients. A common example of this approach is the RANZCP OSCE. It is conceivable that in the future every psychiatrist will have been part of a simulation.
What care should we take when using actors in psychiatry? Is it only the actor who is simulating, or are we asking students and trainees to act, as well. Are there some things for which simulation is not useful? For example, can we expect empathy in response to simulated distress?
Presentation 3: A Pal: Cinema and Psychiatry: A Case for Defending the Role of Arts in Contemporary Psychiatry
Royal Prince Alfred Hospital, Sydney, Australia
Contemporary psychiatry is focused on the brain and its role in the pathogenesis of mental illness. Models of explanation and the majority of research interest is directed towards uncovering the neural mechanisms of mental illness, to the extent that many believe psychiatry will become a sub-speciality of neurology.
The arts have historically played a much larger role in psychiatric thought and culture, and this presentation examines what one medium of art, cinema, can offer to contemporary psychiatry and its ability to respond effectively to the community’s needs and concerns. We review two films, American Psycho and Little Miss Sunshine. Cinema can be viewed as a small window into the vast landscape of dreams, hopes and desires that are present in a particular culture, and as such, provide insight into understanding individuals and their relationship to the world. Cinema is representative of art’s ability to capture a range of complex and subtle ideas about individuals that are missed in biologically-driven psychiatric research.
Presentation 4: S Kumar: Creative Writing or Therapy?
NSW Institute of Psychiatry, Sydney, NSW, Australia
‘The description of the human mind (provided by the creative writer) is indeed the domain which is most his own; he has from time immemorial been the precursor of science, and so too of scientific psychology… The creative writer cannot evade the psychiatrist nor the psychiatrist the creative writer, and the poetic treatment of a psychiatric theme can turn out to be correct without any sacrifice of its beauty.’ (Sigmund Freud)
This presentation will explore some of the interrelationships between creative writing, psychotherapy and creativity. Creative writing can be an alchemical or transformative process, where difficult or traumatic experiences are transformed into a literary work with aesthetic value, with benefits for the writer and audience. Psychoanalysis is a valuable resource for literary theory, and literature can, in turn, inform psychodynamic understandings.
The genre of creative non-fiction is increasing in popularity and includes memoir. The author’s experiences of psychiatric themes arising in a non-fiction workshop are explored. Writing can be used as a psychotherapeutic tool and also as a method to enhance creativity.
Reference
Freud S (1907) Delusions and Dreams in Jensen’s Gradiva. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol 9, pp3 -93. London: Hogarth Press.
Presentation 5: L McLean1,2: Singing for the Soul
1Westmead Psychotherapy Program, University of Sydney, Sydney Medical School, Sydney, Australia
2Consultation-Liaison Psychiatry, Royal North Shore Hospital, Sydney, Australia
Loyola McLean is a psychiatrist, psychotherapist, singer and songwriter. Loyola will perform some original songs with piano accompaniment, illustrating aspects of relationship and psychotherapy. There will be a brief a cappella performance, with the opportunity for audience participation.
Panels
Self-Stigma, Recovery and the Relationship Between Lived Experience and Practice
R McKay1,2, J Liggins3, J McMahon2,4, G Roper2
1Sydney South West Area Health Service, Sydney, Australia
2Royal Australian & New Zealand College of Psychiatrists Community Collaboration Committee
3Liaison Psychiatry, Middlemore Hospital
4Private Mental Health Consumer Carer Network, Australia
Background: The role of stigma and its impact on people with lived experience of mental illness is well recognized; however, the recognition of the impact of self-stigma in psychiatrists and other mental health professionals is a relatively new concept.
As many as one in three people experience mental illness at some time in their lives. Psychiatrists too are just as vulnerable to the devastating consequences, although this is ignored by the literature. The Mental Health Foundation of New Zealand 2008 research report Fighting Shadow separates the role of the psychiatrist or mental health professional from the experience of the person with mental illness self-stigma. Similarly, there is no literature that explores how personal experience of mental illness and recovery by psychiatrists does or should influence their practice.
Objectives: To stimulate discussion of how psychiatry and psychiatrists should integrate personal experience of mental illness with professional practice, through exploration of the impact of self stigma on personal lives and clinical practice, as it relates to practicing psychiatrists.
Method: A panel will explore relevant personal experiences and relate these to existing literature and guidance. Audience participation in discussion of constructive actions the profession may take to reduce self stigma regarding mental illness in psychiatrists, and integrate psychiatrist experiences of recovery into practice, will be encouraged.
N Judson, G Smith: Troubled Colleagues and Difficult Conversations
N Judson, E Bichara, F Leota, L Kossoff, J Kaur, J Powell, G Mathew, A Thompson, G Smith
Committee Member, Royal Australian and New Zealand College of Psychiatrists Committee for Professional Practice
Background: Whilst peer review is an important process for psychiatrists, to critically appraise and systematically assess and make judgements about their strengths and weaknesses and review the quality of their practice by obtaining the opinion of their peers, the challenge for peers is what to do when a colleague is underperforming or appears to be heading for trouble; whether this is due to unprofessional or unethical behaviour or a medical condition.
This session will build on past popular Congress presentations by the Committee for Professional Practice. This year the focus will be on strategies to adopt and how to have difficult conversations with an underperforming colleague. Practicing psychiatrists and community representatives will present an interactive session utilizing hypothetical scenarios.
Objectives: The objective of the session is to create meaningful discussion on how psychiatrists can contribute towards creating a safe working environment, whilst supporting their peers. Issues that may be raised include the early recognition of deteriorating performance in a colleague, substance abuse problems, recognizing when behaviour is unethical, exploring support networks, and discussing interventions that are appropriate and available to prevent escalation of the issue. The session will also address self-care strategies for the psychiatrist.
Methods: Using hypothetical scenarios, this session will engage participants in an energetic, question and answer style symposium, to explore the stickiest of ethical dilemmas. Participants will be invited to pose questions to an expert panel and lend their own voice to a moderated debate. The session will be informed by perspectives from Australian and New Zealand psychiatrists, trainees, medical professionals, consumers and carers, to provide a diversity of opinion that may challenge current orthodoxy.
Prescribing for Dual Disability Patients
M Hopwood1, G O’Brien2, A Livingstone3, B Tonge4, Yitz Hollander5
1University of Melbourne, Melbourne, Australia
2Griffith University Medical School, Brisbane, QLD, Australia
3Saint Vincent’s Hospital, Melbourne, Australia
4Monash University, Melbourne, Australia
5Alfred Hospital, Melbourne, Australia
Background: The Victorian Office of the Senior Practitioner approached the Victorian Branch of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) to provide an assessment tool for early career psychiatrists to diagnose and treat patients with dual disabilities. Three modules were produced: An introduction to working with patients with a dual disability, Interpreting behaviours of concern in dual disability and Reflecting upon treatment approaches.
The modules are co-badged by the Victorian Department of Health and the RANZCP. These three eLearning modules are housed on the College’s website on a public platform; the Department will also have full access to the material, as a training tool for its staff.
Objectives: To stimulate discussion on how psychiatrists can better understand the requirements of dual disability patients. To foster competency-based training and Continuing Professional Development modules for psychiatrists on key factors, when treating patients with an intellectual disability.
Methods: A panel will draw on their knowledge and experience in discussing the key objectives for trainee and early career psychiatrists to better understand the needs of intellectually-disabled patients.
Panel Discussion on the Current Issues and Models in Rural and Remote Psychiatric Service Delivery in Australasia
P O’Brien1, F Glade1, A Howie1,7, M Chapman1,2,3, G Riley6, N Gill1,4,5
1RANZCP Section of Rural Psychiatry
2Kimberley Mental Health and Drug Service, Broome, Australia
3School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia
4Division of Mental Health, Darling Downs Hospital and Health Service, Toowoomba, Australia,
5Rural Clinical School, University of Queensland, Toowoomba, Australia
6Rural Clinical School of WA Rural Clinical School of Western Australia Albany, WA, Australia
7Te Whitiki Maurea (Maori Mental Health and Drug and Alcohol Services), Waitemata District Health Board, Auckland, New Zealand
Background: 30% of the Australasian population live in regional and remote settings. Research suggests this population is at enhanced risk of mental illness, although this varies considerably both between and within regions. There is a documented disproportionate distribution of psychiatrists and associated service providers across Australasia which does not favour those outside the urban setting. Access issues are compounded by limited communications and often wide dispersal of rural population.
Objectives: To explore the historical issues and contemporary models in psychiatric service delivery in rural and remote settings across the various states, territories and regions.
Methods: This will take the form of an ‘expert panel’ discussion, led by Prof Riley and a number of colleagues from the Rural Section – RANZCP. Active audience participation in the form of both questions to the panel and comment from the floor will be encouraged to enrich the content.
Findings and Conclusions: It is hoped that this panel discussion will create a safe space in which to explore contemporary options, and propagate the dissemination of examples of new ‘best practice’. This is a discussion that is likely to generate some passion and should be of great interest to aspiring trainees and established practitioners alike.
Extended Orals
Bipolar II Disorder: Diagnosis and Management Nuances
G Parker1,2
1University of New South Wales, Sydney, NSW, Australia
2Black Dog Institute, Sydney, NSW, Australia
Background: Bipolar Disorder Type II (BP II) is a relatively new diagnosis that often goes undetected and its management is commonly extracted from Bipolar Disorder Type I (BP I), rather than being nuanced. It is a serious condition with the highest suicide rate, compared to all other psychiatric disorders.
Objectives: The presentation will review the cross-sectional and longitudinal signals weighting a BP II diagnosis, and provide a management flow chart derived from clinical experience and research findings.
Methods: The presentation will be underpinned by recent research studies and clinical nuances refined at the Black Dog Institute.
Findings: BP II appears increasingly common, can be diagnosed with some confidence and does appear to benefit from differing medication regimes than those employed for BP I patients. Management also appears differentially advanced, by adding educational and wellbeing components.
Conclusions: Detecting BPII and managing it with more disorder-specific approaches has a high success rate and is an optimistic clinical domain.
SB Harvey: Are Australians Becoming More Mentally Ill? Results From National Health Surveys Between 2001 And 2011
SB Harvey1,2, M Wang1, A Mykletun3, H Christensen2
1University of New South Wales, Sydney, NSW, Australia
2Black Dog Institute, Sydney, NSW, Australia
3Norwegian Institute of Public Health, Bergen, Norway
Background: There is a popular notion that we are in the midst of an epidemic of mental health problems, although, to date, there is limited evidence to support this.
Objectives: To assess changes in both the prevalence of common mental disorder (CMD) and rates of disability support pension (DSP) for psychiatric disorders in Australia between 2001 and 2011.
Methods: A National Health Survey was conducted in 2001, 2004, 2007 and 2011. Each survey used an identical multistage sampling methodology and assessed CMD using the 10-item Kessler Psychological Distress Scale, with probable CMD defined by a score of 30 or more. Data from the Department of Families, Housing, Community Services and Indigenous Affairs was used to calculate the percentage of the working age population receiving DSP for psychiatric conditions.
Findings: From 2001 to 2011, there were no significant changes in the overall prevalence of probable CMD. Estimated prevalence rates varied from 3.77% in 2001 to 3.58% in 2011. In contrast, over the same time period, the percentage of the working age population receiving DSP for psychiatric medical conditions increased by 30.5% (p-trend < 0.0001). The trend towards increasing functional disability associated with mental disorders was seen in both males and females (p-trend < 0.0001, for both).
Conclusions: The prevalence of CMD has remained stable between 2001 and 2011; however, over this same period, rates of DSP for psychiatric conditions have increased dramatically. The increasing separation between underlying rates of morbidity and occupational outcomes highlights the need for a greater focus on functional outcomes in mental illness.
The Service User Network (SUN) Project: An Open Access Model for People With Personality Disorder and Difficulties
B Jones
Child and Adolescent Mental Health Service, Perth, Australia
Background: The Service User Network (SUN) Project is an open access, group support model for people with personality disorder and difficulties. First implemented in 2004 in the UK as part of a Department of Health pilot study as a stand-alone model, it has subsequently been successfully replicated as part of an integrated day service model, alongside mentalisation-based therapy.
Objectives: Theoretical foundations of the SUN model will be outlined, together with examples of the clinical work undertaken. The effect upon service utilization and bed use will be described and reference made to service user testimonials.
Methods: With reference to previously published papers, data will be presented that highlights the impact of the SUN Project upon patient empowerment, emergency department use and mental health contacts. A comparison between psychiatric bed use in the 6-month and 12-month periods before and after SUN membership will be drawn, to obviate the effect upon bed use within the integrated model. As part of an integrated model, the effect upon bed use for up to 18 months of contact will be outlined.
Findings: Significant reductions in use of emergency departments, unplanned mental health contacts and psychiatric bed use followed membership to the SUN Project, alongside increased perceived patient empowerment.
Conclusions: The SUN Project model offers a structured, supportive intervention at relatively low cost that reduces unplanned use of mental health services and use of emergency departments. The model has been successfully integrated with a mentalisation-based model in a day service, which significantly reduces psychiatric bed use.
Functional Remission in Depression and Patient Satisfaction Index: Results of the Diapason Study
S Mouchabac1, P Lemoine2, FJ Baylé3
1Centre Hospitalier Saint Antoine, Paris, France
2Clinique Lyon-Lumière, Meyzieu, France
3Centre Hospitalier Sainte Anne, Paris, France
Background: A consensus is emerging for functional remission to be routinely assessed in the treatment of major depression. This is because, in many cases, clinical remission is not necessarily accompanied by optimum functioning, which would favour the rehabilitation of patients.
Objectives: The objective was to study, in depressed patients treated with agomelatine, their global clinical response and their social functioning. The Questionnaire de Fonctionnement Social (QFS) provides information on specific areas of functioning: objectively, via the frequency of social behaviours (F: Frequency index) and subjectively, via the patient’s perception of his/her social performance (S: Satisfaction index), making up a global index (G).
Methods: We followed 3139 patients over 6–8 weeks. Assessments were carried out at inclusion (C1) and at the follow-up visit (C2): QIDS-C, CGI, QFS and SDS.
Findings: At C1, the mean QIDS-C score was 17.0 ± 3.4. For the QFS-G: 72.4% of functioning was ‘poor’. The SDS global score was 21.3 ± 4.8. At C2, a reduction in the QIDS score was observed: −7.9 ± 4.7 (p <0.01). QIDS response rates were 50.2% (48.4–52.0%). Improvement on the SDS was significant and the three QFS indexes saw significant increases, but more markedly so for S (6.7 ± 6.7) than for F (4.2 ± 5.4).
Conclusions: Our results show an improvement in the social functioning of depressed patients treated with agomelatine, suggesting that a specific action of the treatment contributes to providing the patient with the possibility of better rehabilitation into his/her social, family and professional environments.
Behaviour Mentalised: A Model for In-Patient Service Reform for Children Presenting With Challenging Behaviour
B Jones
Metropolitan Health Service, Perth, WA, Australia
Background and objectives: Application of MBT to the framework of inpatient setting for young children and families, as a short-term intervention, has not previously been described in the literature. This presentation will discuss the evolution of a new partial hospitalisation model for children aged 7–13 years old, presenting with challenging behaviour.
Methods: There will be discussion, with case examples of how the model evolved, that includes the application of key psychoanalytic principles to service development. The basic underpinnings of our new service model will be highlighted, including the elements of individual- and family-focused MBT.
Findings: Important factors in adapting the MBT model to cater for disturbed young children in an inpatient care setting seemed to be provision of a reflective space for staff; integration of the MBT model with a structured model for crisis management; and creation of a transitional space with provision of a concrete crisis support plan and reward system.
The significant developmental task that faced staff was shifting away from a behavioural approach and toward a relational, attachment-focused model for complex presentations, informed by MBT. Families seemed galvanized through the process and report being better able to manage ongoing crises.
Conclusions: MBT techniques can enliven and enrich the experience of inpatient care for the child, family and professional alike. Adaptations to the MBT model, to enhance therapeutic experience of partial hospitalisation, are possible. Further outcome data is required.
Case Reports of Psychogenic Movement Disorders
C Tan1, E Guaia 2
1Princess Margaret Hospital, Perth, Australia
2Paediatric Consultation Liaison Program (PCLP), Acute Child and Adolescent Mental Health Services, CAMHS/CAHS, Perth, WA, Australia
Background: Psychogenic movement disorders (PMD) were first described in the late 19th and early 20th centuries, and have been the subject of great interest and puzzlement ever since (Gowers, 1886). PMD is a clinical syndrome, defined as the occurrence of abnormal movements that result from a psychiatric cause rather than a medical or neurologic cause (Head, 1922; Gupta and Lang, 2009). PMD is hypothesised to have a basis in faulty inhibitory circuits of motor control (Ellenstein et al., 2011). PMD worsens when patients are exposed to stressful and/or emotionally-charged situations (Ellenstein et al., 2011).
Objectives: We present cases of PMD from the Princess Margaret Hospital, to outline the common features, the diagnostic pathway leading to this and the relevant medical investigations performed.
Methods: Cases are presented in case reports.
Findings: The important features, which distinguish PMD from a medical movement disorder, include the presence of significant psychiatric features or stressors, physical findings that could not be explained neurologically in a neurological exam, and the absence of clinically-relevant findings on electroencephalogram (EEG) or magnetic resonance imaging (MRI).
Conclusions: This supports the literature on PMD that its causes are psychogenic. With more neuroimaging studies now providing a neuroanatomical explanation to PMD, hypothesised as due to faulty inhibitory circuits of motor control, the future development of pharmacotherapy for this disorder becomes a possibility.
References
Ellenstein A, Kranick SM, Hallett M (2011) An update on psychogenic movement disorders. Current Neurology and Neuroscience Reports 11: 396–403.
Gupta A and Lang AE (2009) Psychogenic movement disorders. Current Opinion in Neurology 22: 430–436.
Gowers WR. A Manual of Diseases of the Nervous System. Philadelphia: P Blakiston Son & Co; 1886.
Head H (1922) An Address On The Diagnosis of Hysteria. British Medical Journal 1: 827–829.
The Identification of Risk Markers for Self-Injurious, Aggressive and Destructive Behaviour in Children With Intellectual Disability
Paediatric Consultation Liaison as a Model of Combined Care in a Tertiary Pediatric Hospital
E Guaia, D Nicholls, J Elliot, C Halpin, HW Van Hall, W Radcliffe, S Strudwick, G Miles, G Simcock, S Carbon
Paediatric Consultation Liaison Program (PCLP), Acute Child and Adolescent Mental Health Services, CAMHS/CAHS, Perth, WA, Australia
Children and young people with acute and chronic illness are three times more susceptible to present with emotional difficulties and their vulnerability to mental health disorders is twice the general population. Attention to psychosocial issues is known to improve outcomes and prognosis in chronic illness. In addition, the prevalence of chronic illnesses and conditions is predicted to increase exponentially. PCLP is located at a state-wide children’s hospital and provides a bridge between the worlds of mental health and medical conditions.
In this symposium, we will present on the specific model of care and the diversity of mental health roles provided by the team. We will present the different roles of a PCLP service:
Assessment and management of mental health issues for paediatric inpatients and outpatients, including young people admitted with physical complications of medical conditions.
Challenges of working from the different theoretical backgrounds of medical and mental health systems, the pace of work and expectations of stakeholders.
The increasing role that PCLP has, as the knowledge of how the rate and extent of recovery is affected by psychological factors.
Presentation 1: J Elliot: Paediatric Medical Traumatic Stress
Paediatric Consultation and Liaison Program, CAMHS/CAHS, Perth, WA, Australia
Stress is the process by which an individual responds psychologically, physiologically and behaviourally to a situation that challenges or threatens well-being (Baum et al., 1981). Paediatric medical traumatic stress refers to ‘a set of psychological and physiological responses of children and their families to pain, injury, medical procedures, and invasive or frightening treatment experiences’ (National Child Traumatic Stress Network, 2003). A meta-analysis of the literature by Kahana et al. (2006) found symptoms of traumatic stress in an average of 20% for injured patients and 12% for ill children (with the notable exception of oncology rates, which are up to 25%). A recent study conducted at Princess Margaret Hospital for Children found 1 in 4 parents experienced clinically significant distress post burn injury of their child (McGarry et al., 2013).
Patient stress impedes physical recovery from injury or illness (Cohen et al., 1991; Kiecolt-Glaser et al., 1995). Whilst some components of stress associated with being unwell or injured cannot be avoided, initiatives that reduce traumatic stress in a healthcare setting can assist in the physical, as well as psychological, healing of the patient and also reduce healthcare costs.
This paper will outline the initiatives undertaken by the Paediatric Consultation and Liaison Program on paediatric medical traumatic stress. Outcomes from the ‘Comfort Kit’ initiative will be discussed, as well as the development and roles of the hospital’s multidisciplinary team, which has been set up to address paediatric medical traumatic stress.
References
Baum A, Singer JE and Baum CS (1981) Stress and the environment. Journal of Social Issues 37: 4–35.
Cohen S, Tyrrell D and Smith AP (1991) Psychological stress and susceptibility to the common cold. New England Journal of Medicine 325: 606–612.
Kahana SY, Feeny NC, Youngstrom EA, et al. (2006) Post-traumatic stress in youth experiencing illnesses and injuries: An exploratory meta-analysis. Traumatology 12: 148–161.
Kiecolt-Glaser JK, Marucha PT, Malarky WB, et al. (1995) Slowing the wound healing by psychological stress. Lancet 346 (8984): 1194–1196.
McGarry S, Girdler S, McDonald A, et al. (2013) Paediatric medical trauma: The impact on parents of burns survivors. Burns 39: 1114–1121.
Presentation 2: CM Halpin1, G Simcock1: Non-Epileptic Seizures
Consultant Child Psychiatrist, Paediatric Consultation Liaison Program, CAMHS/CAHS, Perth, Australia.
Background: Up to 30% of referrals to a PCLP service in this tertiary paediatric hospital are from neurology teams. A significant proportion of these are for advice about seizure activity that is considered to be non-epileptic in origin. With the prevalence of childhood epilepsy around 0.5%, this represents a highly significant proportion of referrals.
Objectives: To determine up-to-date best practice in the assessment, diagnosis and management of this common and often complex problem.
Methods: Literature review, reference to clinical cases.
Findings: Non-epileptic seizures (the term now preferred to ‘pseudo’-seizures) are a complex phenomenon which frequently co-occur with epilepsy. Early, accurate diagnosis is crucial, to avoid unnecessary prescription and administration of anticonvulsants. The gold standard to confirm diagnosis is video telemetry, but may not always be necessary. A comprehensive psychosocial and mental health assessment is required. Joint management protocols between neurology and PCL are required. There is evidence of response to CBT-based programmes, along with attention to other identified psychosocial stressors.
Conclusions: Non-epileptic seizures are a complex clinical phenomenon requiring comprehensive psychosocial assessment and a multimodal treatment programme, often incorporating multiple interventions. The term pseudoseizure is no longer favoured, as it suggests ‘faking’. Staff countertransference issues in the inpatient setting may require particular attention, in individual cases and via essential PCL staff education programmes.
Presentation 3: H-W Van Hall: A Psychological Adolescent Chronic Pain Group Program
Paediatric Consultation and Liaison Program, CAMHS/CAHS, Perth, WA, Australia
Chronic pain is fast becoming recognized as the most costly public health issue facing Western health systems. Gaskin and Richard (2012) provided estimates that suggested that costs to the health system and in lost productivity for adults in USA associated with pain, exceeded the combined costs associated with cancer, heart disease and diabetes.
Chronic pain is also ‘overwhelmingly prevalent’ in child and adolescent populations (King et al., 2011). Chronic pain has debilitating effects on paediatric patients and their families, and is costly and difficult to manage in health systems.
At present, scientific evidence as reflected in the Cochrane reviews and other meta-analyses support psychological treatments for chronic pain in children and adolescents (Eccleston et al., 2009). Within the range of available psychological treatments, Cognitive Behavioural Therapy (CBT) and relaxation training are current best practice.
Acceptance and commitment therapy (ACT) is considered a new wave of CBT and whilst retaining much of the structure of traditional CBT, it differs in critical ways, incorporating mindfulness and changes in philosophy. ACT improves the functioning of adult chronic pain patients in both individual and group treatment programs (Schmidt et al., 2010; Veehof et al., 2011; Wetherell et al., 2011). Whilst it is also effective through individual treatment in paediatric patients (Wicksell et al., 2005), to date little research has been conducted to evaluate the effectiveness of a group program with this population.
We developed and piloted an acceptance-based psycho-educational and experiential group program for adolescents suffering with chronic pain. Our aim is to examine the effectiveness, efficiency and sufficiency of an outpatient-based, short-term group program that incorporates adolescent and parent learning experiences for treating this as yet underserviced population in WA. We will present data on family functioning, mood, participation, pain-specific distress and school attendance.
References
Eccleston C, Palermo T, Williams A, et al. (2009) Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Data Base of Systemic Reviews Issue 2, article no CD003968. DOI: 10.1002/14651858.CD003968.pub2.
Gaskin D and Richard P (2012) The economic cost of pain in the United States. The Journal of Pain 13(8): 715–724.
King S, Chambers C, Huguet A, et al. (2011) The epidemiology of chronic pain in children and adolescents revisited: A systematic review. Pain 152: 2729–2738.
Schmidt S, Grossman P, Schwarzer B, et al. (2011) Treating fibromyalgia with mindfulness-based stress reduction: Results from a 3-armed randomized controlled trial. Pain 152: 361–369.
Veehof M, Oskam M-J, Schreurs K, et al. (2011) Acceptance-based interventions for the treatment of chronic pain: A systematic review and meta-analysis. Pain 152: 533–542.
Wetherell J, Afari N, Rutledge T, et al. (2011) A randomized, controlled trial of acceptance and commitment therapy and cognitive behavioural therapy of chronic pain. Pain 152: 2098–2107.
Wicksell R, Dahl J and Magnusson B (2005) Using Acceptance and Commitment Therapy in the rehabilitation of an adolescent female with chronic pain: A case example. Cognitive and Behavioral Practice 12: 414–423.
Presentation 4: Bridging the World between Mental Health and Medical Conditions: Motivating Young People with Type 1 Diabetes
Wendy Radcliffe, Denise Nicholls, Steve Collishaw
Acute Child and Adolescent Mental Health Services, Paediatric Consultation Liaison Program, CAMHS/CAHS
The Endocrinology and Diabetes Department at Princess Margaret Hospital for Children is a state-wide service for young people aged 0–18 years diagnosed with Type 1 diabetes, and their families. Currently, the Department has over 900 young people registered for services. Of those young people and their families, approximately 1 – 2 referral(s) a week are received for suspected mental health problems, from the Diabetes team to the Paediatric Consultation Liaison Program.
These young people present as either inpatients or outpatients, and part of the role of the Paediatric Consultation Liaison Program team is to assist the medical team to tease out whether the presentation is consistent with what is currently referred to as ‘diabetes distress’ or what may be more representative of this ongoing mental health illness and/or systemic family problem(s).
While individual work with referred patients and families will always be available to address some of the more challenging patients, a group program based on Acceptance and Commitment Therapy is currently being developed and pioneered with adolescents.
Several complex case presentations and an outline of the group format will highlight some of difficulties experienced by clinicians from the PCLP team, when bridging the world between mental health and medical conditions.
Presentation 5: S Strudwick: Brain-behaviour Relationships: Neuropsychology in a Paediatric Hospital Setting
Acute Child and Adolescent Mental Health Services, Paediatric Consultation Liaison Program, CAMHS/CAHS
Neuropsychology is the study of brain-behaviour relationships. Early attempts to extend adult practice downward to children were found to be problematic. Consequently research, theory and practice has developed over time in paediatric neuropsychology. We will describe the provision of a clinical neuropsychology assessment service within a paediatric CL setting. Neuropsychology has a longstanding role in the pre-surgical evaluation of patients with medically intractable epilepsy, and the nature of that role has changed over time. We will use research literature in this area and case examples to illustrate some of the issues with paediatric patients in the practice of clinical neuropsychology.
Presentation 6: Gordon Miles: The Phenomenology of Paediatric Medical Illness and Treatment: Insights Gained From Children’s Drawings
Paediatric Consultation and Liaison Program, CAMHS/CAHS, Perth, WA, Australia
One of the primary roles of clinical psychology in a paediatric setting is to assist children to articulate and express their experience of symptoms, diagnosis and subsequent treatment. The use of creative and artistic mediums is something that is common to children’s everyday context. Frequently they are able to express themselves with greater clarity through the medium of drawing, compared to that of expressive language.
Phenomenology is the philosophical approach concerned with investigating the structures of subjective experience and consciousness. Applying this approach as a methodology, when interpreting children’s drawings, has the potential to offer significant insights into the children’s experience of illness and treatment.
This paper will discuss the phenomenological aspects of children’s lived experience of medical illness and treatment, through the study of drawings and other artistic expressions gathered during routine clinical care. Various drawings related to the experience of symptoms, diagnosis and treatment will be presented in order to provide insights into the subjective experience of children, with a particular emphasis on paediatric oncology. Conclusions regarding the varying structures of consciousness relating to children and paediatric medical treatment will be offered.
The Identification of Risk Markers for Self-Injurious, Aggressive and Destructive Behaviour in Children With Intellectual Disability
Chris Oliver
Cerebra Centre for Neurodevelopmental Disorders, University of Birmingham, Birmingham, UK
Background: Self-injurious, aggressive and destructive behaviours occur in a significant proportion of people with intellectual disability (ID). These behaviours are persistent, resistant to intervention and associated with substantial human and service delivery costs. Early intervention targeted at high-risk children offers a potentially beneficial strategy.
Objectives: To review and document risk markers for the onset and future development of clinically significant self-injurious, aggressive and destructive behaviour.
Methods: In a series of cohort studies, we evaluated whether specific genetic syndromes, child characteristics and behavioural markers were associated with the onset and future development of clinically significant self-injurious, aggressive and destructive behaviours.
Findings: A number of genetic syndromes (Fragile X, Cornelia de Lange, Angelman, Smith-Magenis, Prader-Willi and Cri du Chat) are associated with an increased risk for the behaviours of interest. In the broader population of people with ID, a greater degree of ID, repetitive behaviours and impulsivity are also associated with these behaviours, and these markers are associated with increased risk in some genetic syndromes.
Conclusions: A number of risk markers are readily identifiable in young children with ID and can facilitate identification of children at the highest risk. The relationship between these risk markers and the behaviours of interest warrants elucidation.
Pilot Evaluation of ‘Third Wave’ Modular Group Psychotherapy for Comorbid Clients
D Florida
Concord Drug Health
Background: There is emerging evidence for ‘third-wave therapies’, in treating mental health clients’ comorbid for substance use; however, implementation of manualised evidence-based treatments is often hampered by the complexity of comorbid clients.
Objectives: This pilot attempted to adopt a modular practice elements approach, to enhance acceptability, integration and retention in the treatment of complex comorbid clients.
Methods: We developed a group-based program combining Dialectical Behaviour Therapy-Substance Abuse (DBT-S), Mindfulness Based Relapse Prevention (MBRP) and Cognitive Behavioural Relapse Prevention. Twelve out-patients attended a 3-hour weekly program for 6 months, which was co-facilitated by a clinical psychologist and an addiction psychiatrist. Pre- and post-program data were collected via a battery of assessment tools, to assess abstinence, general level of functioning, mental health and utilization of skills.
Findings and conclusions: This program was found to be highly acceptable to clients, in terms of both content and process. There was a demonstrated improvement in abstinence, general level of functioning, mental health and utilization of skills. This study is preliminary to a planned, randomised controlled trial comparing this new modular program to treatment as usual.
Cannabinoid Replacement Therapy for Management of Cannabis Withdrawal: A Randomized Controlled Trial of Nabiximols (Sativex®)
M Montebello1,2, D Allsop1, J Copeland1, N Lintzeris2, A Dunlop3, C Sadler3, G Holland3, P Muhleisen3, M Norberg1, I McGregor4
1National Drug and Alcohol Research Centre, Faculty of Medicine, University of NSW, Randwick, NSW, Australia
2Drug and Alcohol Service, South Eastern Sydney Local Health District, NSW Ministry of Health, Surry Hills, NSW, Australia
3Drug and Alcohol Clinical Services, Hunter New England Local Health District, NSW Ministry of Health, Newcastle, NSW, Australia
4School of Psychology, University of Sydney, Camperdown, Australia
Background: Cannabis use is prevalent and is associated with increasing numbers of treatment seekers for withdrawal management, despite no medications being approved for this purpose.
Objectives: To determine whether Nabiximols (Sativex) would safely reduce cannabis withdrawal symptoms and increase retention in treatment.
Methods: A randomized, controlled inpatient trial with 28-day follow-up, conducted at two inpatient units in NSW, Australia: 51 DSM-IV-TR cannabis-dependent treatment seekers received a 6-day regimen of Nabiximols or placebo, with standardised psychosocial interventions, during a 9-day admission. The Cannabis Withdrawal Scale measured withdrawal severity, retention in treatment and adverse events (AEs) were quantified.
Findings: Nabiximols significantly reduced the overall severity of cannabis withdrawal (66% reduction from baseline), relative to placebo (52% increase; F9,377.97 = 2.39; P = 0.01. Nabiximols suppressed withdrawal-related irritability, depression, cannabis cravings and loss of appetite. The Nabiximols group were more likely to remain in withdrawal treatment during medication administration (Hazard Ratio (HR) = 4.09 (95% CI 0.99–16.75); P = 0.05). Participants could not differentiate between Nabiximols and placebo whilst blinded to the treatment allocation (χ21 = 0.79; P = 0.67). The Nabiximols group did not report more adverse events (F1, 50 = 0.3; P = 0.59) nor more severe adverse events (F1,50 = 2.69; P = 0.1). Both groups reduced cannabis use at follow-up, but Nabiximols did not result in a greater reduction in cannabis use than placebo (F1, 50 = 0.1; P = 0.75), nor fewer cannabis-related problems (F1, 50 = 2.27; P = 0.14), nor a lower severity of cannabis dependence (F1, 50 = 0.006; p = 0.9).
Conclusions: Nabiximols exerted a robust and suppressive effect on cannabis withdrawal symptoms and retained patients in treatment longer than placebo.
Evidence - Based Interventions for Comorbidity: Substance Use, Mental Health and Physical Health
A Baker1 and E Cementon2,3
1University of Newcastle, Callaghan, Australia
2NorthWestern Mental Health, Melbourne, Australia
3Western Health, Melbourne, Australia
Background: Multiple substance abuse, mental health and/or physical health problems are very common among people who present for treatment in mental health, alcohol and other drug treatment settings. The first Australian National Report Card on Mental Health concluded that ‘the reduced life expectancies and poor health of people with the most severe mental illnesses… is a national disgrace and it should be a major public health concern’. The physical health of people with psychotic illnesses is poor, compared to that of the general Australian population, and life expectancy is 15 years shorter. The single largest cause of death is cardiovascular disease (CVD). Existing trials (including those conducted by the presenters) focus on two of the four main CVD risk behaviours, smoking or alcohol consumption, with promising results. Only a few trials evaluated interventions for either of the two most prevalent CVD risk behaviours, namely physical inactivity and diet.
Objectives: This symposium will inform psychiatrists on issues regarding interventions for smoking, alcohol and other drugs; poor diet; and inactivity in people with mental illness and will outline interventions to promote multiple behaviour changes. Behavioural interventions can be incorporated into clinical practice.
Methods: The speakers, who come from different clinical and academic backgrounds, will provide relevant information on the nature of physical health problems and associated health behaviours in people with mental illness. Evidence-based pharmacotherapeutic and psychosocial interventions will be outlined, to assist psychiatrists to implement multiple health behaviour change interventions among their patients.
Findings: Psychiatrists, and the services in which they practice, are able to inquire of their patients’ smoking, alcohol and other drug use, as well as their activity level and aspects of their diet. Advice and interventions can be effective in multiple health behavioural change.
Conclusions: Psychiatrists are clinical leaders who are well placed to intervene across mental and physical health. Multiple health behaviour change, combined with pharmacotherapeutic interventions, can assist patients with multiple health problems. A healthy lifestyles approach to intervention can be appealing to patients and encourage change in previously challenging domains of behaviour.
Presentation 1: A Baker: Healthy Lifestyle Interventions Among People With Psychotic Illness
Co-Director, NHMRC Centre of Research Excellence In Mental Health and Substance Use, NHMRC Senior Research Fellow, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
Background: The physical health of people diagnosed with psychotic disorders is poor, compared to that of the general Australian population, and their life expectancy is 15 years shorter. Rates of cardiovascular disease (CVD) in people diagnosed with psychotic disorders are higher than in the general population and account for more premature deaths than suicide. The four health risk behaviours that contribute to CVD (smoking, alcohol misuse, poor diet and low levels of activity) are very common among people with psychotic disorders.
Objectives: This presentation will increase psychiatrist’s knowledge of and confidence in addressing health behaviours among people with mental health problems.
Methods: Psychosocial components of successful healthy lifestyle interventions conducted among people with psychotic illness will be presented and discussed. We will discuss case presentations of patients with co-existing mental illness, alcohol and other drug problems, combined with poor diet and activity levels.
Findings: Multiple health behavioural change is feasible, attractive and achievable among people with psychotic illness. Multiple health behaviour change interventions can be relatively simple and can easily fit into usual clinical practice.
Conclusions: Healthy lifestyle interventions are recommended among people with psychotic illness. Psychiatrists are well placed to assess and address health behaviours among their patients and to support other health professionals in doing so.
Presentation 2: E Cementon1,2: Pharmacological Aspects of Healthy Lifestyle Interventions
1Substance Use, Mental Illness Treatment Team (SUMITT), NorthWestern Mental Health, Melbourne, Australia
2Drug Health Services, Western Health, Melbourne, Australia
Background: Psychiatrists have become increasingly aware of the physical health problems in people with severe mental illness and substance use disorders, and the consequences of these problems on morbidity and mortality. The relationships between physical and mental health problems and psychotropic medications are complex. Although these problems are frequently detected and identified, there are challenges in implementing effective responses.
Objectives: This presentation will provide psychiatrists with information about the pharmacological issues relevant to the development of cardiovascular disease risk factors in people with mental illness and the pharmacological interventions that may facilitate the reduction of these risk factors.
Methods: The complex relationships between physical and mental health problems and psychotropic medications will be briefly summarised. The pharmacological interventions that can address smoking, alcohol misuse, poor diet and low levels of activity will be presented and discussed.
Findings: There are pharmacotherapeutic options for psychiatrists in their management of their patients’ physical and mental health problems that are related to psychotropic medication and lifestyle.
Conclusions: Psychiatrists play a crucial role in advocating and planning for the improved management of some of the physical health problems of people with severe mental illness in the mental health setting, as well as collaborating and liaising with other health professionals, such as allied health and general practitioners.
Forensic Community Treatment Orders: Waste of Time or Exciting New Provision?
Sarah-Jane Spencer
Justice Health, NSW, Australia
Background: Over recent years, NSW forensic mental health legislation has been the subject of substantial reform. In 2009, the Mental Health Legislation Amendment (Forensic Provisions) Act 2008 came into force, resulting in the renaming of the Mental Health (Criminal Procedure) Act 1990, which included a number of important changes. One of the key additions was the Forensic Community Treatment Order (fCTO), enabling compulsory treatment in correctional centres (Feneley, 2009). Despite the apparent support of the Mental Health Review Tribunal (Feneley, 2009) only a handful of applications for fCTOs have been made (Howard, 2012).
Discussion: Mental health professionals raise a number of concerns about the fCTO provision: Its perceived lack of ‘teeth’ is often cited, as are the challenges faced when patients are released from custody and transferred to a mental health team in the community. The additional view that mentally disordered offenders should not be treated against their will in a custodial setting, is one also held by some mental health professionals; however, others argue that the practical issues that have arisen when using the fCTO provision could be overcome, and that this already disadvantaged group is not being afforded the opportunity to receive the treatment they would in the community. In some cases, this results in a repeated deterioration of individuals’ mental health, necessitating admission and resulting in potentially longer periods in custody, due to non-completion of the courses required by Parole.
Conclusions: The equivalence of care for prisoners is recognised internationally as a fundamental goal, but is difficult to achieve, not the least due to the complex health problems of those detained (Forrester et al., 2013; Levy, 2005). It could be argued that the addition of the fCTO provides equivalent safeguards and treatment to often the most complex mentally disordered offenders, but yet to date, its use has not been embraced by mental health professionals in NSW.
References
Feneley J (2009) Applying the Amended Mental Health (Forensic Provisions) Act 1990 and Rethinking the Defence of Mental Illness. Available at: www.lawlink.nsw.gov.au/lawlink/pdo/ll_pdo.nsf/vwPrint1/PDO_applyingamendedmentalhealthrethinkingdefence (accessed 7 November 2013).
Forrester A, Exworthy T, Olumoroti O, et al. (2013) Variations in prison mental health services in England and Wales. International Journal of Law and Psychiatry 36: 326–332.
Howard D (2012) MHRT Annual Report 2011–2012. Available at: www.mhrt.nsw.gov.au/assets/files/mhrt/pdf/Annualreportfinal2012.pdf (accessed 7 November 2013).
Levy M (2005) Prisoner health care provision: Reflections from Australia. International Journal of Prisoner Health 1(1): 65–73.
Sexual Offending, Psychosis and Insanity
EN McVie
Assisting Psychiatrist, Mental Health Court Queensland, QLD, Australia
Background: While persons with severe mental illness frequently come into contact with the criminal justice system, most research has focussed on the crimes of murder and violence. Sexual offending is often thought to be uncommon in persons with mental illness.
Objectives: To determine the prevalence of sexual offending in persons not found criminally responsible, due to mental illness.
Methods: Queensland (QLD) has had a unique system for determining the insanity defence for nearly 30 years, with hearings by a Supreme Court Judge and Mental Health Court. This ensures ‘capture’ of almost all cases where persons have been found to be not criminally responsible, due to mental disorder or being of unsound mind (USM) at the time of committing an offence. This paper will analyse data collected by Assisting Psychiatrists to the Mental Health court over 10 years of operation of the current Mental Health Court (2002 – 2013).
Findings: Data identifies over 2400 cases heard by the court, with over 1300 findings of USM. Of these, 110 USM findings were for persons charged with sexual offences. One-half of these had a diagnosis of a psychotic illness. The data indicates the rate of making a finding of USM where the charge is murder is 1 in 3, whereas the rate of a USM finding if the main charge is rape is approximately 1 in 10.
This presentation will also further explore the types of sexual offending and nature of the psychotic illness of persons charged with a sexual offence and found to be of USM.
Australian Guidelines for the Biological Treatment of Paraphilic Disorders
Jeremy O’Dea1,2
1Level8Practice, Sydney, Australia
2NSW Health, Justice Health and Forensic Mental Health Network, NSW, Australia
Although psychotherapeutic treatments, such as relapse prevention, are most often cited as promising treatment modalities for sex offenders, there is little evidence to date to support their efficacy. Testosterone-lowering medication is generally considered the most effective intervention in select groups of sex offenders, and in patients with paraphilic disorders and other deviant sexual behaviours.
The anti-androgen medication cyproterone acetate (Androcur®) has been licensed in Australia by the Australian Government, Department of Health, Therapeutic Goods Administration (TGA), and rebated under the Pharmaceutical Benefits Scheme by Medicare for many years, for the control of sexual deviance in an adult male. Based on the international literature, and local and international experience, other testosterone-lowering medications such as progesterone, LHRH agonists and SSRI antidepressant medications are also being prescribed ‘off label’ for these groups of patients.
Whilst there are some internationally published guidelines for the use of these medications for these indications, in Australia there appears to be limited formal clinical consensus as to guidelines for the use of these medications in these patient groups.
Based on current literature and clinical experience in the prescription of these medications for these groups of patients, this presentation aims to open the debate on these clinical matters. With reference to international guidelines and experience, clinical guidelines as to the appropriate patient groups to be prescribed these medications, dosage regimes, clinically-appropriate monitoring and measurement of clinical outcomes will be proposed for consideration and discussion. Ethical concerns with the prescription of these medications in these settings will be canvassed.
The Mentally Ill as Victims of Crime and Violence
K Dean1,2
1School of Psychiatry, University of New South Wales, NSW, Australia
2Justice Health and Forensic Mental Health Network, NSW, Australia
Background: Individuals with mental illness, particularly severe mental illnesses such as schizophrenia, are well known to be at elevated risk of crime and violence perpetration, but little is known about their risk of criminal and violent victimization. Evidence emerging in recent years from the UK and USA indicates that the risk of the latter may actually be greater than the former. Such victimization risk is largely ignored by researchers, clinicians and the legal system.
Objectives: Data from studies in the UK and NSW, Australia will be presented to demonstrate what is currently known about the prevalence, nature/context and impact of victimization experienced by those with mental illness in different settings.
Methods: The studies presented utilised a range of methodologies/samples, including a birth cohort, a cross-sectional survey and an incarcerated sample. The focus of studies has been to establish the risk of victimization among those with mental illness.
Findings: Overall, studies to date in a variety of settings, and using varying methodologies, have consistently found the risk of criminal and violent victimization to be elevated among those with mental illness.
Conclusions: The elevated risk of victimization among those with mental illness has been largely ignored until recently, but emerging evidence is consistent in finding strikingly high risks for this group, which has important implications for researchers, clinicians and those working in criminal justice settings. These findings also challenge the widespread and stigmatizing perceptions that those with mental illness predominantly present a risk of harm to others.
Using Avoidable Admissions to Measure the Quality of Care for Physical and Oral Comorbid Disease in Psychiatric Disorders
S Kisely1,2,3, C Ehrlich3, E Kendall3, D Lawrence4
1School of Medicine, University of Queensland, QLD, Australia
2Metro South Health Service, Woolloongabba, QLD, Australia
3Griffith Institute of Health, Griffith University, QLD, Australia
4The University of Western Australia, Perth, WA, Australia
Objectives: Psychiatric patients have high rates of mortality from physical illness, which may partly be due to inequitable access to many specialised procedures. Quality of care for comorbid physical disorder can also be assessed by the number of avoidable admissions. These are admissions for physical conditions which, with appropriate primary care, should not become sufficiently serious to require inpatient treatment. They include diabetes, cardiovascular disorders and dental diseases. Avoidable admissions have been used to assess healthcare provision for marginalised groups, such as Aboriginal patients, but have not been applied to people with severe mental illness.
Method: A population-based record-linkage analysis of all new psychiatric presentations to state-based facilities in Queensland over 5 years. Avoidable admissions were compared by psychiatric severity and diagnosis.
Results: We identified 58,470 patients, of whom 51% were male. Affective disorders were the commonest diagnostic category (n = 16,876). We found that 3103 subjects had at least one avoidable admission, the commonest being for diabetes (n = 6086) and angina (n = 2620). There were 1702 avoidable admissions for dental reasons. Patients with dementia had the highest proportion of avoidable admissions, especially diabetes (13% versus 4% for other diagnoses). After adjusting for socio-demographics, people with dementia had 4 times the odds of an avoidable admission for diabetes (95%CI 2.78–4.92) or lung disease (95%CI 2.23–9.46), and nearly 3 times the odds for angina (OR = 2.74; 95%CI = 1.60–4.69).
Conclusions: Avoidable admissions are higher in many psychiatric diagnoses, especially dementia. The particular association between dementia and diabetes may be due to the metabolic consequences of the antipsychotics that are commonly prescribed to them.
Earthquake-Induced Broken Heart Syndrome : Is It a Psychosomatic Disorder?
Cameron Lacey1, Paul Bridgman2, Vicky Cameron3, Roger Mulder1, Julie Zarifeh4, Martin Kennedy5
1Department of Psychological Medicine, University of Otago, Christchurch
2Cardiology Department, Canterbury District Health Board, Christchurch
3Department of Medicine, University of Otago, Christchurch
4Psychiatric Consultation Service, Canterbury District Health Board, Christchurch
5Department of Pathology, University of Otago, Christchurch
Background: The major Canterbury, NZ earthquakes in 2010 and 2011 triggered case clusters of a rare condition called broken heart syndrome (also known as stress cardiomyopathy or Takotsubo cardiomyopathy). The cause of this condition remains unknown, but psychiatric illnesses have been proposed as risk factors.
Objectives: To investigate if psychiatric risk factors or genetic factors are associated with the development of broken heart syndrome.
Methods: We systematically assessed two groups of cases (people who developed sporadic and earthquake-related broken heart syndrome) and compared them to a control group of healthy volunteers. We assessed potential psychiatric risk factors and performed DNA exome sequencing, to identify the genetic causes of this disorder.
Findings: The resulting very well characterised, tightly homogenous cohort of 30 patients with earthquake-related broken heart syndrome is unprecedented. Almost all patients presenting with the condition were post-menopausal females, consistent with other reports. We found that of 10 psychiatric risk factors examined, only ‘neuroticism’ significantly differed between participants with broken heart syndrome and healthy volunteers.
Conclusions: This suggested that the clinical assessment of psychiatric risk factors is unlikely to assist identification of patients at increased risk of broken heart syndrome. This presentation will also provide an overview of our efforts to identify a genetic risk for this condition.
How an Interface Between Acute Psychiatric Services and an Emergency Department Has Improved the Management of Acute Behavioural Disturbance
V Drinkwater1, L Calver2, C Bjorksten3, G Isbister4, R Gupta5
1Nurse Manager, Hunter New England Mental Health Services, LDH
2Clinical Trial Coordinator (Research), Calvary Mater Newcastle
3Hunter New England Mental Health Services - Pharmacy Services
4Clinical Toxicology Services, Calvary Mater Newcastle
5Psychiatric Emergency Services, Hunter New England Mental Health Service
Background: Acute Behavioural Disturbance (ABD) is a common problem in both mental health and general hospitals, with the highest number of incidents occurring in Acute Psychiatric Wards and Emergency Departments (ED).
Objectives: Hunter New England Local Health District - Mater Mental Health Centre and the Calvary Mater Newcastle established an interface in 2011, by establishing a project team to conduct a research project, and developing evidence-based guidelines and systems to improve the management of ABD.
Methods:
Development and completion of a Randomized Controlled Trial (RCT) comparing the effectiveness of medications used in Rapid Tranquilisation (Parenteral Sedation) for the treatment of ABD, the HORD study;
Introduction and development of the Sedation Assessment Tool (SAT), to improve the monitoring and safety of patients.
Findings: This paper describes an interface and interaction between staff from separate organisations, resulting in:
Development of an approved Clinical Guideline for the Management of ABD in Mental Health Units;
Publication of a prospective study of high-dose sedation for rapid tranquilisation of ABDs in an acute mental health unit;
Completion of a RCT: The HORD Study (publication pending).
Conclusions: The project team and research projects conducted made a significant impact, in terms of:
Changing clinical practice amongst nursing and medical staff managing ABD;
Supporting the development of an evidence-based clinical guideline;
Improved patient and staff safety in the management of ABD.
Depression and Chronic Kidney Disease
A Bautovich1,2, I Katz3,4, M Smith1,6, C K Loo1,4,6, S B Harvey 1,4,6
1School of Psychiatry, University of New South Wales, Sydney, NSW, Australia
2NSW Institute of Psychiatry, Westmead, NSW, Australia
3Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
4Saint George’s Hospital, Kogarah, Australia
5Black Dog Institute, Sydney, NSW, Australia
Background: Until recently, the bulk of the academic literature addressing the overlap between mental health and chronic physical illness tended to focus on cardiovascular disease and depression; however, there have recently been a number of large studies published, which suggest that the associations between depression and several other chronic somatic conditions, including renal disease, are equally important.
Objectives: To review the recent academic literature surrounding the prevalence, aetiopathology, associations and management of depression in chronic kidney disease (CKD).
Methods: We conducted electronic searches of the following databases: MEDLINE, EMBASE and PsycINFO. The main search terms were: depression, mood disorders, depressive disorder or mental illness; in combination with kidney disease, renal insufficiency, dialysis and kidney failure.
Findings: Recent studies find the prevalence of interview-defined depression amongst those with CKD to be around 20%. The interactions between depression and CKD are complex, bidirectional and multifactorial. Depression in CKD is shown to be associated with multiple poor outcomes, including increased mortality and hospitalisation, as well as poorer treatment compliance and quality of life. Clinical evaluation of depression in patients with CKD can be challenging; however, once a diagnosis is made, a range of treatment modalities can be considered. Guidelines for the use of anti-depressants in CKD were developed as part of this review.
Conclusions: Depression is common in CKD and is associated with a significant risk of adverse outcomes. We are in the process of conducting a study of screening and treating depression amongst those with CKD, the results of which will also be presented.
Prior Preparation and Presentation Prevents Poor Performance - Well Not Exactly.’- The Parallel Processes and Erratic Journey in Implementing a Standardised Pathway to Care for Extended Care and Assertive Outreach Consumers
S Tait1, D Bromwell2
1Joondalup MHS Western Australia
2North Metro MHS Mt Hawthorn WA
Background: Pathways to Care were developed over 3 years, targeting consumers in the community and hospital who utilized the most in-patient time and required Intensive Assertive Outreach in the community. The Pathways and KPIs were informed by similar services in Australia and overseas, and finalised with significant involvement of a wide range of disciplines.
Objectives: To describe briefly the models of specialised Extended Care services within a large tertiary hospital and Intensive Clinical Outreach Teams (community), working with standardised assessment processes, outcome measures and review processes. This was part of a service-wide re-configuration of services, to promote contemporary practices.
Methods: Audits of long-term in-patients, identified in-patient cohorts, identified target community cohorts, adoption of standardised instruments to measure change in function and pathology, adoption of needs assessment instruments, on-line and face-to-face educational packages for staff and implementation of working parties. Audit of activity and completion of KPIs.
Findings (descriptive): Hospital cultural and structural issues consistently interfered with effective ‘roll out’ of the model in the hospital. In the community, islands of resistance with reluctance to refer appropriate consumers or for newly formed teams to comply with a standardised model of care slowed progress.
Conclusions: The topography of a split executive and historical legacies and attitudes delay implementation of rational evidence-based services that are accepted as standard in other parts of Australia and overseas.
New Zealand Mental Health: Integration or Disintegration?
James D Reardon
Counties Manukau District Health Board, Papakura, New Zealand
Background: Counties Manukau is in the area in South Auckland, with a population of 500,000 people, that is currently served by an inpatient facility and by four separate County Mental Health Clinics located throughout the county.
Objectives: Counties Manukau serves as a typical example of the provision of mental health services in the 22 District Health boards that are scattered throughout New Zealand. In addition, it serves a large population of Maori and Pacific Islanders, reflecting the cross-cultural concerns of providing psychiatric care.
Methods: The author worked in the CMDHB system for over 5 years; however, he brings over 40 years of experience as an American psychiatrist to his observations of mental health care. His current knowledge of American psychiatric practices gives him a unique opportunity to observe and evaluate services in New Zealand.
Findings: Management is non-medical. As a result, social and cultural aspects of psychiatric care prevail and dominate clinical decisions relating to the provision of psychiatric services. The provision of specialty psychiatric services is slowed and hampered by the multitude of administrative duties required of psychiatrists.
Conclusions: The current mental health system in New Zealand is bureaucratically managed and burdened by a managerial style that is non-medical and is based on the concept of caring for the chronically mentally ill. Obstacles to integration are massive and reflect the inability of psychiatrists to lead their own specialty.
The Claassen Institute of Psychiatry for Medical Students: An Innovative Strategy to Improve Recruitment to Psychiatry
Z Lyons
University of Western Australia, School of Psychiatry and Clinical Neurosciences, Perth, Australia
Background: Despite exposure to psychiatry in most medical courses, starting in the preclinical years and progressing to clinical clerkships, attitudes towards psychiatry in general, and to psychiatry as a career are regarded negatively by medical students. This results in low levels of recruitment to psychiatry training programmes. In order to improve recruitment, psychiatry curricula need to develop innovative teaching and learning strategies to attract more students towards a career in psychiatry.
Objectives: A novel enrichment programme, the Claassen Institute of Psychiatry for Medical Students, was developed by the School of Psychiatry and Clinical Neurosciences at the University of Western Australia. The Institute aims to provide students thinking about psychiatry as their career choice with the opportunity to learn more about specialty areas of psychiatry.
Methods: The Institute is an intensive, week-long programme. Interactive seminars each morning cover a range of diverse topics, as well as current contemporary themes. In the afternoons, students attend elective sessions at community and hospital-based mental health service providers. There is a student-led debate and interactive stigma discussion.
Findings: Since 2008, 100 students have attended the Institute. Evaluation has found significant increases in the level of student interest and knowledge in psychiatry at the end of the programme, compared with baseline. The number of students definitely considering psychiatry as a career also increased significantly, from 56 at baseline to 76 by the end of the week.
Conclusions: The Institute is an innovative enrichment programme that is successful in improving students’ attitudes towards psychiatry as a career option.
‘Private Practice or Practice in Private?’ Exploring an Initiative for the Uninitiated
Saibal Guha, Marina Costigan
MARSAI Clinic, Belmont Private Hospital, Brisbane, Australia
Background: Private psychiatric practice in Australia remains a very comfortable and attractive proposition, although there are a variety of perceptions available around how the psychiatrists in the public sector view such a practice. There are certain ‘practice model’ issues, with individual variations that may have created a number of understandable ‘myths’. These initially deterred the author, a long-time public psychiatrist, to consider a shift to this sector. The scoping for a shift by the author in 2011 was met with ambiguity around which model to follow. Unable to find any suitable answer, the author worked out an evolving model that is more aligned to patient journey, and also optimises clinical time.
Objectives: The objective of this study was to evaluate this novel private practice model in detail.
Methods: An online, anonymous patient satisfaction and service evaluation questionnaire was sent to randomly selected 100 patients, who were involved with my private practice between 1 May 2012 and 31 September 2013.
Findings: The findings of the evaluation will be discussed in this presentation.
Conclusions: Private Practice models in psychiatry across Australia are diverse in their setups and governance. For the uninitiated, not much information is usually available on the set-up aspects. This may lead to anxiety around the ‘privacy’ around these models and considerable variance in practice parameters. This model attempts to ‘marry up’ patient care with effective clinical governance, to make it rewarding for the practitioner, as well as enhance patient satisfaction. The attempted evaluation of this model is a possible indicator of the benefits and shortfalls of this initiative.
Coming to Terms With History: ‘Apology’ Versus ‘Acknowledgment’. What Is the Difference?
R Miller
Honorary Fellow, Department of Psychological Medicine, University of Otago, Wellington, New Zealand
At the RANZCP Congress in Hobart in 2012, I organised a 90-minute symposium entitled ‘Laying the Ghosts of the Asylum Era: Anger Resolution in Psychiatry’ ( Report available at: www.robertmiller-octspan.co.nz (Octspan side). It is clear from evidence presented and discussed around this topic that the profession of psychiatry was one of those involved, mainly indirectly, in some of the abuses that occurred in the asylums of the past. To help the profession develop a totally different future role for itself, it must also be aware of the historical roots of the profession. I therefore ask: How does the profession come to terms with its own history? Some would call for an official apology. I want to argue against this proposal. The alternative, for which I use the word ‘Acknowledgment’, is gentler in tone, but in the end, more powerful. It implies a commitment to learn as much as possible about what went wrong in the past, why it went wrong (including professional attitudes and organizational cultures), and from this knowledge base, to formulate the strongest possible policies to prevent a return to those attitudes and cultures. Furthermore, in advocating acknowledgment rather than apology, there is an implicit connection with a more holistic view of human nature and human societies, from which many other positive outcomes may grow within the mental health field.
Separation of Passion and Reason in the Twentieth Century: Their Reunion in the Twenty-First
Sid Williams
Several NSW Local Health Districts (HNELHD, MLHD, SWSLHD)
David Hume, in the eighteenth century, argued against the concept that human lives involved a ‘combat of passion and reason’ and against the associated belief that we should ‘give preference to reason’ over passion (emotion).
Four propositions will be made and supported by an account of a history of psychology and psychiatry in the twentieth century. The propositions are:
That the theoretical paradigms beneath psychology and psychiatry neglected the significance of human emotions throughout most of the twentieth century;
That these disciplines also neglected family and other human relationships in the same period;
That these two related blind spots originated partly in the rise of scientific, mechanistic and reductionist paradigms, which distrusted subjectivity and distrusted the apparent unruliness of emotions and social behaviour;
That the scotomata also had origins in Western Judaeo-Christian concepts and beliefs, which assumed that emotions and bodily feelings were dangerous, mostly sinful and could only be overcome by human reason, will and/or the grace of God.
Evidence will be drawn from the history of: theories of association, introspective and Gestalt psychology, psychoanalysis, localisationist and reductionist neuroanatomy and neurophysiology, discovery of reflexes, conditioned reflexes, behaviourism, behaviour therapy, cognitive behaviour therapy and cognitive science. It will be argued that these influences and paradigms have been balanced and broadened in the later years of the twentieth century, by ethology and neuroethology, social psychology, social cognition and social neuroscience, narrative therapies, acceptance and commitment therapy, and mindfulness.
Early History of Psychiatry at Saint Vincent’s Hospital, Melbourne: Doctors or Devils?
M Pickles
Psychiatrist, Private Practice, Melbourne and Sydney, Australia
Background: This paper is based on personal experiences at Saint Vincent’s Hospital, Melbourne, from 1962 to 1995, first as a Registrar and then as a qualified Psychiatrist. At that time, psychiatry was viewed with a mixture of suspicion, derision and contempt, and prejudice against psychiatrists and psychiatric patients was endemic throughout the hospital. Nuns and clergy tended towards suspicion, viewing patients with mental illnesses as possessed by the devil and the psychiatrists who treated them as ‘agents of the devil’. Senior medical colleagues and superintendents, who did not acknowledge psychiatry as a legitimate and serious branch of medicine, were contemptuous of psychiatrists and their patients. This, in turn, led medical students and residents to treat the profession, and psychiatric patients, with derision; administrative staff to be generally unsupportive; and hospital management to withhold resources. Across the board, there was a general belief that all psychiatrists were a bit ‘mad’!
Objective: To ensure the historical record of this period of pioneering psychiatry in this hospital is preserved.
Method: Personal historical record.
Findings: There were major problems treating Catholics with serious psychiatric illness, due to prejudice.
Conclusion: The turning point for Saint Vincent’s Psychiatric Ward came in the form of psychiatrist Eric Seal, whom had been both a Jesuit priest and a neurosurgeon, thus earning the respect of nuns and clergy, and senior medical ‘non-psychiatrist’ colleagues alike.
Evolving and Integrating: Can Psychotherapy Become More Acceptable and Useful to the General Psychiatrist?
J Penman
Retired, Perth, Australia
Background: It is a personal observation that during their early training while attending psychotherapy supervision groups, lectures and individual supervision of their long case, a majority of registrars have an interest in modern approaches to psychodynamic psychotherapy and its application. So what happens later to dissuade them?
Objectives: To look at how psychodynamic theory has evolved, become more integrated, and see how this ‘experience near’ approach is more readily acceptable to the registrar and patient than one that is ‘experience distant’.
Methods: Briefly look at the ideas of Freud, Klein, and the object relations theorists; then the introduction of attachment theory, self-psychology and the concept of mentalisation, as applied in psychotherapy. Also, the consequences of the explosion in the neurology of relationships and the ideas of the theory of complexity will be discussed in this context. After exploring the importance of ‘something more than interpretation’, how these newer ideas can be applied both to formal long-term or short-term psychodynamic psychotherapy will be discussed, along with, most importantly, how they can be applied in any contact with any patient.
Findings: The integration of attachment theory and self-psychology provides an understanding of how to engage a patient so that they feel ‘met as a person’; and thus, the development of a truly therapeutic alliance.
Conclusions: Research needs to be done on the training of registrars in the concepts of psychodynamic psychotherapy and what happens later, to lessen their acceptance of this form of treatment.
Brief Psychodynamic Psychotherapy for the Elderly: A Case Series
N Jeyasingam
Sydney University, Northern Sydney Area Health Service, Australia
Psychodynamic psychotherapy is an increasingly rare commodity to find in psychiatric practice, but has never been seen to have a prominent role with respect to the older patient. This presentation discusses the changing recent literature regarding this concept, and discusses three case studies from the author’s own experience demonstrating successful outcomes with limited-session psychodynamic psychotherapy for older patients. Issues of patient selection, and why the older patient may in fact be more likely to benefit from this intervention, are also discussed.
Narcissism’s Echos: Individual, Interpersonal and Societal Deadness and the Dream of Awakening
R Adams
Perth Clinic
Background: Narcissistic psychopathology darkens and deadens the personal, interpersonal, social and political worlds. Relational psychoanalysis has enlivened theoretical approaches to the understanding and treatment of narcissistic states (Mitchell, 1986), while social psychology, cultural studies and philosophy also grapple with understanding the causes and effects of the inability to empathize with others. Painful and dangerous results of narcissism include the spectrum from inhibited intrapsychic experience to political conflict, war and climate change. It is noted that spiritual contributions to the project of change in these registers has been relatively neglected.
Objectives: This paper proposes the enrichment of psychotherapy theory - and psychoanalytically-informed political thought - using an interweaving of Jewish metaphors and stories, relational and feminist theory. Its purpose is to ‘dream’ ourselves awake into new hope for the treatment of narcissism in individuals, groups and society.
Methods: Literature on narcissism emerging from relational psychoanalysis, social psychology and political theory are reviewed. Stories and parables from Jewish Chassidic sources are brought to bear on understanding the suffering of individuals and groups that result from a lack in aliveness and empathy.
Findings: Religious metaphors and stories, even in the absence of religious belief, enliven and expand psychoanalytic and political thought.
Conclusions: Hope for the treatment of the deadening effects of narcissism in individuals, groups and societies, as well as within theory itself, can be provided by engagement with the metaphors drawn from Jewish spiritual sources.
Reference
Mitchell SA (1986). The wings of Icarus; illusion and the problem of narcissism. Contemporary Psychoanalysis 22(1),107–132.
Developments in Psychotherapy for Borderline Personality Disorder: Application of Common Factors From Empirically Supported Treatments
J Beatson1,2, S Rao1,3
1Spectrum Personality Disorder Service for Victoria, Melbourne, Australia
2University of Melbourne Department of Medicine, Dentistry and Health Sciences, Melbourne, Australia
3Monash University, Melbourne, Australia
Background: Exciting developments in the field of borderline personality disorder (BPD) include findings from RCTs that generalist treatments that include factors common to the specific empirically supported psychotherapeutic treatments for the disorder, can be effective.
These findings bring hope that when treatment for BPD in general psychiatric settings incorporates these factors, treatment outcome for the patients can be optimized.
Objectives: To outline in detail the factors common to empirically-supported psychotherapies for BPD, and offer a rationale for their effectiveness, based in current findings, with respect to the aetiology, including the neurobiology, of BPD.
Methods: Findings from empirically-supported treatments for BPD will be summarized and discussed.
Findings: The factors common to empirically-supported treatments for BPD can be applied, without major modification of current treatment approaches, in general psychiatric settings.
Conclusions: Recent research in the treatment of BPD offers hope of improved outcome for patients with BPD, the majority of whom are treated in general psychiatric settings. The psychotherapeutic approaches outlined do not require extensive and expensive psychotherapy training, rendering them applicable across the field of psychiatry.
The Emotional Experience of Parents and Nurses in a South Australian Neonatal Intensive Care Unit
M Turner1,2, A Chur Hansen1, H Winefield1
1School of Psychology, University of Adelaide, SA. Austalia
2Child, Youth and Womens’ Health Network, SA, Australia
Background: The parent experience of the neonatal intensive care unit (NICU) is often distressing and overwhelming, and emotional supports are offered to assist parents with their NICU journey. In this research, a professionally facilitated NICU support group had been developed to provide preventative and supportive mental health care to parents.
Objectives: This research assesses the emotional support needs for parents, based on their view of the NICU experience, and triangulates this with the NICU nursing view of support.
Methods: This research uses thematic analysis to examine parent interviews, during and after their baby’s NICU stay, and NICU nurse interviews. We had 73 parents complete a Parent Stress Scale NICU while their babies were in the NICU. These results are triangulated.
Findings: parents feel overwhelmed with the complexities of the NICU, their challenging relationship with their baby and nursing staff. Ongoing concerns about the baby dying, even after discharge, remain strong themes. Nursing staff felt that at times they were unable to provide emotional support and that parents’ needs are highly individual and complex. Further training and support for nurses was highlighted. The support group was seen as an important element of the NICU.
Conclusions We present these study results and make reflection upon the appropriate support for parents, support and training for NICU nursing staff.
Peri-Partners: The Peninsula Perinatal Mental Health Partnership Project
L Smith1,2, P Yardley1
1Peninsula Health, Victoria, Australia
2Raphael Centre Berwick, Saint John of God Healthcare, Victoria, Australia
Background: The award-winning Peninsula Perinatal Mental Health Partnership Project, established in 2011, is leading the way in addressing the gaps in identifying and supporting women in the antenatal/postnatal period who are at risk of mental health problems. This is particularly important in light of reduction in other perinatal mental health services in the local area.
Methods: Peninsula Health, Maternal and Child Health (MCH), General Practice Network and Medicare Local formed a partnership, and collaboratively and innovatively developed and implemented a project that includes screening women routinely in the perinatal period with the Edinburgh Postnatal Depression Scale (EPDS), training the health professions in assessment of mental health, implementing specific referral pathways and resources for services and developing a GP Linkage Service for women without a GP.
Findings: Findings from the pre-survey and two post-implementation surveys (2012 and 2013) will be discussed, including:
A significant increase in MCH/midwives screening with EPDS;
A 100% increase in women identified as at risk of mental health problems;
A significant increase in referral to specialist services;
An average of 4 women/week assisted to access appropriate GPs;
100% of clients found the service ‘helpful or very helpful’;
> 350 health professionals received training and 75% report overall improvement in accessing services;
Ongoing 12 monthly education of health professionals continues to forge links between services.
Conclusion: The success and importance of Peri-Partners has been recognized by healthcare awards and it is having a significant positive impact on the well-being of women and their infants at this crucial life stage.
Care and Connect: Early Parenting and Prescribing With Prematurity
B Harrison1, H Jepsen1,2
1Raphael Centre, Saint John of God Hospital Murdoch, Perth, Australia
2Western Australia Infant Mental Health Association (WAIMHA), WA, Australia
Parents of premature infants have considerably higher rates of post-partum anxiety and depressive disorders and anxious parenting styles in this group have been consistently reported. Social and emotional developmental and mental health outcomes for premature infants are worse than for full-term infants. We describe a brief universal assessment and early parenting program that we have developed in a private maternity special care nursery setting, for parents of very low body weight (VLBW) and LBW infants. The program utilises the presence of the infant to discuss traumatic projections and current early parenting concerns, as the family transitions to home from a medically-supported setting. Specific signs of infant dysregulation, compared to normal infant state changes or expected signs of prematurity are discussed with parents, in order to enhance reflection on their infant’s cues. In addition, maternal psychopathology and psychiatric medication specific needs are assessed, which provides an opportunity to ensure safe and judicious postnatal maternal medication use and exposure in the premature infants. A brief overview of the principles of prescribing in the setting of prematurity and specific case examples from the program are discussed.
The Process of Obtaining Informed Consent When Prescribing Psychopharmacology In Pregnancy
Martien Snellen1, Geoff Thompson2, Neill Murdoch3
1Mercy Hospital for Women
2Austin Health
3Victorian Bar
As with most things, in order to understand a modern concept, it is useful to have knowledge as to its historical evolution. To comprehend fully the ethical and legal principle of informed consent in the context of the provision of psychopharmacological treatment in pregnancy, this is essential. It is a story of transformation that began with the Beneficence model that is characterised by maximum physician discretion, and ends with the Autonomy model that emphasises increased patient involvement in the construction and consideration of a risk:benefit analysis, when any particular medical treatment is considered.
The current approach to decision making in medicine is governed by the informed consent doctrine that aims to philosophically and legally preserve a patient’s right to self-determination. It was once considered ill advised to include patients in treatment decision-making: Now it is mandatory. The history of the concept of informed consent is also the history of the nature of the doctor-patient relationship and discloses a shift in the focus of control from one to the other.
The presentation will examine the evolution of the modern concept of informed consent, suggesting that it is a process, not a moment; and guidelines will be offered as to why, how and when it can be achieved in the Australian medico-legal and medico-ethical context, when prescribing psychotropic medications during pregnancy.
Mental Health Law: Western Australia and England Compared
N Hills
University of Western Australia, WA, Australia
‘Mental health professionals have a particular responsibility to ensure that older people with mental health problems are involved to the maximum degree in decisions about their treatment and care, to safeguard their patients’ rights and to combat ageism and elder abuse.’
Old Age Psychiatry, Recent Realisations. Available at: www.wpa.org.net
Consistent with the above statement from the website of the World Psychiatric Association, Old Age Section, my research has examined the legislation and protective procedures in WA that apply to older people, where decision-making capacity is impaired.
Mental health and substitute decision-making law and procedures in WA originated in England during the colonial era. In each country these have diverged, becoming complex and costly in England, while in WA they remain at present, comparatively simple and inexpensive; however this may be achieved in WA at an unacceptable risk to fairness, natural justice and human rights. A balance has to be struck between effective protective procedures and the cost of implementation of suitable safeguards to protect the liberty and safety of older persons.
An online survey of selected old age psychiatrists in each country, designed to gauge their opinion on selected mental health law topics, was carried out; and the results are summarised here. This paper reports an overview of the findings, with additional observations on the adequacy of current WA legislation and procedures. The presentation concludes with recommendations for improved safeguards in WA.
A Probabilist Approach to Assess and Manage Depression Risk in Later Life
OP Almeida
University of Western Australia, WA, Australia
Background: Depression is a common and disabling disorder that affects people of all ages. The causes of depression are not well understood, but consistent information about risk factors is available. These include familial predisposition, certain lifestyle choices, clinical morbidities and exposure to various forms of stress. Stepped care programs have succeed in reducing the prevalence of depression in people with depressive disorders, as well as the incidence of depression in people with subthreshold depressive symptoms; however, despite their established efficacy, they have not been adopted widely into clinical practice, because of policy and financial constraints. Recent epidemiological evidence indicates that a more systematic approach to the management of risk factors might be a practical and effective strategy to reduce the prevalence of depression in the community, but trial data are not yet available.
Objectives: To present a risk management model for the assessment, prevention and treatment of depression in later life.
Methods: This presentation will report data from cross-sectional and cohort studies designed to identify modifiable risk factors for depression, as well as the results of randomised, placebo-controlled trials designed to reduce the prevalence of depression in later life.
Findings: The author used the results of observational studies to build risk matrices that can be used to guide the assessment and management of people with or at risk of depression. Some aspects of these matrices were tested in randomised clinical trials and the author will present the results of these studies.
Conclusions: Depression is not the deterministic result of a small number of biochemical abnormalities or of cerebrovascular disease. Instead, depression is the probabilistic outcome of the interaction between multiple vulnerabilities and environmental exposures, some of which are amenable to change. Probabilistic modes can be used to guide data-driven strategies, to reduce the prevalence of depression in later life.
Presentations By the Winners of the 3 FPOA Awards
The RANZCP’s Faculty of Psychiatry of Old Age Psychiatric Trainee Prize for Scholarly Project, Best Mental Health Service Improvement Prize and Basic Psychiatric Trainee Prize, were established in 2012 to promote excellence in advancing the Quality of Life in Older People with Mental Illness by:
Encouraging and promoting the highest clinical and ethical standards in the delivery of Psychiatry of Old Age services amongst psychiatry trainees in Australia and New Zealand.
Encouraging and promoting training in Psychiatry of Old Age of the highest standard for psychiatrists, trainee psychiatrists, medical students, related health professionals, students of related health professions and other medical practitioners.
The winners of these awards present their winning work during the College Congress.
The Politics of Insanity
E Ratcliff
Private practice, Launceston, Tasmania (TAS)
Background: The idea that giving something a name confers power over it is fundamental to all fields of knowledge, and to every activity that can be derived from them. It is particularly potent in medicine, because of the importance of diagnosis in developing an understanding of disease and determining treatment. Nosology has primitive origins, pre-scientific ideas persist within it, and it remains subject to fashions, notwithstanding aspiration towards scientific objectivity. There is a current convergence of concerns between the profession and the educated community about the widening scope of psychiatric nosology, as particularly manifest in DSM 5, and the expansion of recognised indications for psychotropic drugs. A generation after the movements described as ‘Anti-psychiatry’, a new wave of critical opinion concerning psychiatry is emerging.
Objectives: To examine these phenomena from an historical and epistemological perspective, and suggest implications for psychiatric practice and professional policy.
Methods: A critical review of the development of nosological systems and their competitors within psychiatry, and of their principal critics within and without the profession.
Findings: That an informed public that is both hopeful and fearful about the activities of our profession is likely to be adversely influenced by cogent criticism of concepts that are useful to the profession, but of dubious scientific validity.
Conclusions: That all attempts at a systematic nosology have unintended consequences, some of which may be harmful to the profession, its patients and to science.
Shell Shock and the Murder House: WWI Traumatic Metaphors
G Borlase
University of Sydney, Sydney, Australia
Background: Shell shock is a metaphor and linguistic device that emerged during World War I (WWI) to describe the consequences of modern industrialised war on the human mind and body, but also the impact on the consciousness of British society (Mosse, 2000).
The murder house is a metaphor used in New Zealand (NZ) to describe a visit to the school dental clinic or the dentist. The origins of this metaphor have perplexed the dental profession for many years and the image is worthy of further exploration (Cartwright, 2010).
Objectives: To compare the origins and meanings of these two distinct metaphors.
Methods: This paper reviews the origins of the shell shock metaphor contained in the literature. Utilising a similar frame, it explores the possible origins and implications of the murder house metaphor in NZ.
Findings: Shell shock encompasses not only the experience of battlefield trauma, but represents the history of the British Officer Corps and the war itself. The murder house metaphor contains the experience of WWI NZ soldiers, the history of the NZ dental profession and the impact of both on the consciousness of NZ.
Conclusions: Shell shock and the murder house metaphors share similar origins.
References
Mosse GL (2000) Shell-shock as a social disease. Journal of Contemporary History 35(1): S101–108.
Cartwright S (2010) The media and the Murder House. New Zealand Dental Journal 106: 7–12.
Mental Health Screening and Outcome Measures in Immigration Detention
P Young
International Health and Medical Services
Background: The mental health of people in Immigration Detention in Australia is an issue of considerable public interest and controversy. Since 2009, under Government Policy, all people entering Immigration Detention have undergone initial and periodic mental health screening while in detention. Results of this screening program and other relevant mental health outcomes are presented for people in Australian Immigration Detention Facilities and Offshore Processing Centres.
Objectives: To demonstrate the applicability and utility of routine screening and outcome measurement in immigration detention settings.
Methods: Data was drawn from electronic medical records, including the results of routine screening instruments and other mental health outcome indicators routinely collected as part of usual delivery of mental health services. Results are compared over time in different immigration detention settings.
Findings: Screening instruments and other mental health outcome measures show deterioration in mental health status over time, with differential rates of psychiatric morbidity according to the detention setting. Use of routine screening instruments is feasible and useful in the immigration detention setting. The utility of current screening instruments is limited by a lack of clinician-based; however, results correlate broadly with other mental health outcome measures.
Conclusions: Routine mental health screening of persons entering immigration can provide valuable data to inform clinical care, service planning and policy development. Differential effects can be demonstrated in different immigration detention environments. There is scope for further refinement of mental health outcome measurement in immigration detention and benchmarking against other mental health settings.
The Cost of Hope: Mental Health Consequences of Seeking Asylum in Australia
S Sundram1,2,3 and D Hocking1
1Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
2Northern Psychiatry Research Centre, Melbourne, Australia
3University of Melbourne, Melbourne, Australia
Background: Seeking asylum in Australia has captured the social and political imagination and triggered an increasingly polemical debate about this country’s role and obligation to those seeking protection. Although a necessarily strong focus of attention has been immigration detention, the majority of asylum seekers (AS) live in the community on limited support. Their potential psychological vulnerability and straitened social circumstances place them at risk for mental disorders.
Objectives: To evaluate the social, environmental and policy factors that influence psychiatric morbidity in AS in Australia.
Methods: Clinical and symptom data were collected from AS attending the Asylum Seeker Resource Centre in Melbourne, Australia, using a range of psychometric questionnaires and a structured diagnostic interview. In addition, socio-demographic data including factors pertinent to the refugee determination process (RDP) were collected and immigration policy changes examined.
Findings: Community-based AS in Australia have rates of mental disorder and psychiatric symptoms much higher than the general community. These are in part due to pre-migration and migration traumas; however, post-migration experiences appear to contribute significantly to the prevalence of these disorders. Of particular note is the role that RDP rejections contribute to post-traumatic stress disorder (PTSD) and unemployment to major depression, both factors that are heavily influenced by policy.
Conclusions: The mental health of AS is fragile, with high rates of disorder, which have implications for long-term outcomes, given that the majority in Australia are granted protection. It is imperative, therefore, to advocate for measures to reduce the psychiatric impact of social factors for this vulnerable group.
A Meta-Analysis of Deep Brain Stimulation for Psychiatric Disorders
S Kisely1,2,3, K Hall1, D Siskind1,2, J Frater2, S Olsen2, D Crompton2
1School of Medicine, University of Queensland, QLD, Australia
2Princess Alexandria Hospital, Woolloongabba, QLD, Australia
3Griffith Institute of Health, Griffith University, QLD, Australia
Background: Deep brain stimulation (DBS) is increasingly being applied to psychiatric disorders, such as obsessive-compulsive disorder (OCD), major depression and anorexia nervosa. Double-blind, randomised controlled trials of active versus sham treatment have been limited to small numbers.
Objectives: We undertook a systematic review and meta-analysis on the effectiveness of DBS in psychiatric conditions.
Method: A systematic literature search for double-blind, randomised controlled trials of active versus sham treatment, using PubMed/Medline and EMBASE up till April 2013. Where possible, we combined results from studies in a meta-analysis. We assessed differences in final values between the active and sham treatments for parallel-group studies and compared the results of paired analyses in changes from baseline score for cross-over designs.
Results: Five studies met our inclusion criteria, all of which were of obsessive-compulsive disorder; therefore, 44 subjects provided data for the meta-analysis. The main outcome was a reduction in obsessive symptoms, as measured by the Yale-Brown Obsessive Compulsive Scale. Patients on active, as opposed to sham, treatment had a significantly lower mean score (MD – 8.93; 95% confidence interval (CI) −13.35 to – 5.76; P < 0.001), representing partial remission. There was also a statistically significant difference between active and sham treatments for two studies using the Hamilton Rating Scale for Depression (MD – 7.89; 95% CI – 13.86 to – 1.91; P = 0.01); however, one-third of patients experienced significant adverse effects (n = 16).
Conclusions: DBS showed promise for treatment-resistant OCD, but there are insufficient randomised controlled data for other psychiatric conditions. It remains an experimental treatment for severe, medically-refractory conditions, till further data are available.
Neostriatal Volume Changes in Huntington Disease Are Related to Motor and Cognitive Test Scores: The Image-HD Study
FA Wilkes1, JCL Looi1, M Walterfang2,3, D Velakoulis2,3, JC Stout4, A Churchyard5, P Chua4, GF Egan4, N Georgiou-Karistianis4
1Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra Hospital, Canberra, Australia
2Melbourne Neuropsychiatry Centre, Royal Melbourne Hospital, Melbourne, Australia
3University of Melbourne, Melbourne, Australia
4School of Psychology and Psychiatry, Monash University, Melbourne, Australia
5Department of Neurology, Monash Medical Centre, Melbourne, Australia
Background: Huntington disease (HD) involves atrophy of the neostriatum, as well as progressive motor, psychiatric and cognitive disturbances. As the neostriatum is involved in frontostriatal re-entrant circuits subserving motor, cognitive and emotional functions, we hypothesised that volume changes in the neostriatum would be related to such functional measures.
Objectives: To determine if neostriatal volumes, as a biomarker, correlate with relevant motor, cognitive and neuropsychiatric functional measures.
Methods: T1-weighted MRI scans from the IMAGE-HD baseline dataset were manually traced to produce neostriatal volumes for 36 individuals with pre-symptomatic HD, 37 with symptomatic HD, and 36 controls (intra-rater intra-class correlation, 0.88 – 0.98). Volumes were correlated with scores of motor function (speeded tapping and self-paced tapping), executive function (Symbol Digit Modalities Test and Stroop speeded word), the University of Pennsylvania Smell Identification Test (UPSIT) and the Beck Depression Inventory-II (BDI-II): Hierarchical regression was used, with age, gender and intracranial volume entered first and volumes entered at the second step.
Findings: Volumes were significantly different between all three groups, with control > pre-symptomatic > symptomatic HD (p < 0.01). Neostriatal volume made a significant contribution to variance in all of the measures, except for BDI-II (p < 0.01). Putamen volume was significantly correlated with scores on motor and executive function tasks (p < 0.05) and caudate was significantly correlated with UPSIT scores (p < 0.05).
Conclusions: These correlations with motor and executive function tasks may be explained by the multiple frontostriatal circuits in which the neostriatum is involved; we plan further shape analysis to reveal which areas within the striatum correlate with these functional changes.
Anti-NMDA Receptor Encephalopathy, an Essential Differential Diagnosis in Atypical Psychosis
G Pearson
Currumbin Clinic, Gold Coast, Australia
Background: The recent discovery of a potentially fatal, yet readily treatable auto-immune encephalopathy affecting the NMDA receptor has been largely examined in the neurological literature. Yet 80% of these cases present to psychiatric services for initial treatment, due to the presence of psychotic, behavioural or mood symptoms in the initial stages of the illness. Knowledge of the characteristic presentation and the relative ease of the rapid biochemical confirmation of this condition are essential for any child or adult psychiatrist.
Objectives: To examine the presentation, cause, detection and treatment of this important condition and to illustrate the importance of the NMDA receptor in current neuropsychopharmacological theory. Present a case of relapsing and remitting anti-NMDA receptor encephalopathy, which was detected after repeated presentations with psychosis over 13 years, and which responded well to immunotherapy.
Methods: Literature review and case presentation of a 36-year old woman with repeated presentations with atypical psychoses, who demonstrated a dramatic response to immunotherapy after the diagnosis of anti-NMDA receptor encephalopathy was confirmed.
Conclusions: Awareness and early detection of this potentially fatal condition, which presents with predominantly psychiatric symptomatology, may vastly improve the outcome for patients presenting with this newly-recognised neuropsychiatric condition.
Catatonia and Neuroleptic Malignant Syndrome
J Lee1,2,3
1School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia
2Graylands Hospital, Perth, Australia
3Neurosciences Unit, Perth, Australia
Background: Increasing attention has been directed to the close relationship between catatonia and neuroleptic malignant syndrome (NMS).
Objectives: To provide a critical overview of our understanding of the relationship between catatonia and NMS, and its clinical implications.
Methods: To review published data on various conceptualisations of NMS and the relationship between catatonia and NMS.
Findings: Earlier authors regarded NMS as an extrapyramidal syndrome. The conceptualisation of NMS as a subtype of a more generalized spectrum of hyperthermic disorders (including malignant hyperthermia and malignant catatonia) later gained wide acceptance. Recent attention was directed more to the relationship between catatonia and NMS. The considerable overlap in symptomatology, laboratory findings, treatments and putative pathophysiology between NMS and malignant catatonia, the progression of antecedent catatonia into NMS following exposure to neuroleptics, and the presence of catatonic symptoms in NMS episodes led to the hypothesis that NMS is a severe variant of catatonia; and catatonia and NMS are on the same spectrum; however, a competing hypothesis, supported by prospective data has been proposed: That NMS is a heterogeneous condition with catatonic variants and non-catatonic hyperthermic extrapyramidal reactions to neuroleptics. The NMS catatonic variants include malignant neuroleptic-induced catatonia and ‘neuroleptic-converted catatonia’. Catatonic NMS and non-catatonic NMS differ in symptomatology, clinical course and treatment responses.
Conclusions: Catatonia and NMS are two closely-related syndromes. Further studies are needed to ascertain if NMS is a severe variant of catatonia or a heterogeneous condition including catatonic and non-catatonic variants.
Making a Difference for Maori Rangatahi (Youth) in New Zealand
A Sokratov
Te Kaunihera Committee RANZCP, Waitemata DHB, Mental Health Services Group
Background: This presentation provides an example of how international obligations can be translated into practice that supports and promotes wellness for an indigenous population, in this case, New Zealand Maori Rangatahi (Youth). In 2013, New Zealand’s Mental Health Commissioner, along with other international commissioners, signed a communiqué in support of the Wharerata Declaration. This declaration defines best practice as a combination of cultural and clinical approaches to improve the cultural competence of the workforce, strengthen indigenous outcomes and leadership.
Objectives: The objective is to use this context to show how a project sponsored by the Mental Health Commissioner was undertaken within this framework, involving site visits of services provided to Maori youth and the learning generated, which was intended to be shared with the youth mental health sector in New Zealand, to improve outcomes and wellbeing.
Findings: Site visits were undertaken involving eight services throughout New Zealand, including urban, rural, District Health Board, NGO and Health Promotion sites. The project identified strengths in services, which included service models based on Maori values and philosophies, the use of cultural interventions, and processes in engagement and service delivery. Also noted were common challenges.
Conclusions: The Wharerata Declaration and its principles provide a sound foundation for promoting indigenous leadership, in service development and delivery, to support positive wellbeing and outcomes for Maori Rangatahi.
How Do We Ensure That Cultural Competence is Practiced and Maintained in the Mental Health Workforce?
CM Milne1, P Tangitu2
1Te Moemoea, Matawaia, Northland, New Zealand
2Lakes DHB, Rotorua, North Island, New Zealand
Both people are Te Kaunihera Maori of the RANZCP, New Zealand
Background: Māori have the right to the highest attainable standard of health and high quality, timely healthcare. This is a basic human right (United Nations, 1948), but it is further conferred upon Māori as an indigenous right (Hunt, 2006; United Nations, 2007).
The persistent disparities in health outcomes for Māori are now well documented. Ethnic disparities in health outcomes are further compounded by the lack of health system responsiveness and the under-representation of Māori in the health workforce (Robson and Reid, 2007).
Increasing the number of Māori in the health workforce will ensure clients have an increased chance of engaging with a Māori health professional when seeking health care, which research has found leads to improved health outcomes (Ratima and Wikaire, 2011).
Objectives: The presentation will aim to provide the audience with an overview of the Mental Health and Addictions workforce in New Zealand, their needs in regard to training and development, to ensure the delivery of clinical cultural best practice. The focus will be on two examples of New Zealand pioneered initiatives to address cultural competency: the Mauriora course for health professionals and the Takarangi Competency Framework.
Conclusion: In recent years, the pursuit of equity has become an explicit goal of the health system. Ultimately, solutions lie in upholding the indigenous rights of Māori. Tino Rangatiratanga denotes the right to self-determination, to self-management, to leadership and to control of Māori futures by Māori.
Is Autism Rare in Very Remote Aboriginal Communities?
G O’Brien, P White
Specialist Disability Services Assessment and Outreach Team (SDSAOT), Queensland State-wide Disability Services, Brisbane, QLD, Australia
Background: Autism has a 10% prevalence in intellectual disability. Anecdotal advice suggested that this might not be true of indigenous Australian communities.
Objectives: To determine the prevalence of autism among adults with intellectual disability within indigenous communities.
Methods: The population reported on are the indigenous peoples of Torres Strait, the western Cape York lowlands and Gulf country. The sample comprised some 200 people from these communities, referred for mental health assessment in the context of intellectual disability. Clinical assessment was carried out by the authors in the participants’ naturalistic contexts: their homes and/or places of accustomed activity/recreation. Diagnosis was made according to the ICD-10 Diagnostic Criteria for Learning Disability. Developmental assessment supplied level/severity of intellectual disability, according to ICD-10. Results were compared to the results of diagnostic assessments of other populations of people with intellectual disability within Queensland.
Findings: Of the sample assessed to date, some 200 people with intellectual disability and associated mental health problems spread over 11 mainland communities and 8 islands. In the mainland group, no cases of autism have been identified. This is in contrast to our data on the wider population of people with intellectual disability on the Queensland mainland. It is also in contrast with the results of assessments carried out among the indigenous Communities of the Torres Straits.
Conclusions: These preliminary findings from this clinical study suggest that autism may be less endemic among these indigenous Australians. The possible reasons for this are discussed. The findings require to be further investigated by more systematic study.
The Prevalence of Depression in Older Aboriginal People Living in the Kimberley
S Fenner1, L Flicker2, D LoGiudice3, O Almeida2, D Atkinson2, L Skeaf2, R Malay2, Z Hyde2
1Royal Perth Hospital, Perth, Australia
2University of Western Australia, Perth/Broome, Australia
3Melbourne Health, Melbourne, Australia
Background: The Kimberley Healthy Adults Project (KHAP) previously investigated the prevalence of illness and disability among older Aboriginal people (aged > 45 years) living in the Kimberley Region of Western Australia (WA). In 2012 – 2013, the KHAP team repeated the original survey, this time also screening for depression.
Objectives: To determine the sensitivity and specificity of a new depression screening tool and determine the prevalence of depression in this sample.
Methods: Research staff administered a new depression screening instrument, with a similar structure to the PHQ-9, to a semi-purposefully selected sample from seven Kimberley communities. An informant for each participant was also interviewed. An experienced old age psychiatrist (SF) interviewed each participant who had scored 9 or higher on the screening instrument or who the study staff identified as possibly depressed. In addition, 10% of the survey participants who were not thought to have a psychiatric diagnosis were reviewed. The resulting clinical diagnosis was reviewed by a consensus diagnostic review panel.
Findings: Of the 211 respondents who were free of cognitive impairment, 47 (22.3%) scored 9 or more on the modified screening instrument. Of those, 11.2% met DSM-IV criteria for Major Depressive Disorder and an additional 3.5% had significant sub-syndromal depressive symptoms. The screening instrument had a sensitivity of 76.5%, specificity of 83.8% and the area under the receiver operator curve was 0.80.
Conclusions: The prevalence rates of depression and depressive symptoms in older Aboriginal people from the KHAP study are considerably higher than in the general population. The depression screening instrument appears to be an effective screening tool.
Antipsychotics and Real Life Correlates: Effectiveness and Efficacy
S Dey, D Menkes, Z Obertova, G Mellsop
Waikato Hospital and Clinical School
Background: Antipsychotic medications are central to the treatment of schizophrenia, supported by a substantial literature available on efficacy, tolerability and cost. The use of these medications has been largely based on short-term efficacy trials under experimental conditions. Clinicians have become more sceptical about such efficacy evidence, and it has become apparent that in real life there are marked variations in treatment practice.
Study objectives: This non-interventional ‘audit’ study aimed to examine the pharmaceuticals actually prescribed to inpatients who were discharged with a diagnosis of schizophrenia, and to analyse those variables in relation to clinical outcome, over the subsequent 24 months.
Method: The study cohort consisted of 450 patients discharged from inpatient psychiatric units with a diagnosis of schizophrenia or related disorder (ICD-10), from July 2009 to December 2011. Subsequent service use (re-hospitalization to any NZ inpatient facilities and/or CMHS) in the two years post-discharge was extracted from the national mental health database. The discharge information will include patient and clinician characteristics, antipsychotic drug, route and dosage, chlorpromazine equivalent dose, other prescribed psychotropics, Mental Health Act status and any evidence of metabolic monitoring.
Analysis: We will report our analysis of the discharge prescribing and correlates with subsequent service use.
Discussion: The results will be presented in terms of effectiveness versus efficacy, and the contributions of drug, dose and administration route based on real life data.
Clinical Guidelines for the Physical Care of Mental Health Consumers: Multi-Site Service Evaluation Project 2013
S Stanley, J Laugharne
Community, Culture and Mental Health Unit; School of Psychiatry and Clinical Neuroscience; The University of Western Australia; Perth, Australia
Background: It is now well-known that people with a mental illness are two and one-half times more likely to die from preventable physical illness than the general population. Despite this knowledge, physical health screening and on-going monitoring is sub-standard.
Objectives: This project evaluated the introduction of the Clinical Guidelines for the Physical Care of Mental Health Consumers: Assessment and Monitoring Package (developed in 2010) in diverse settings across Western Australia (WA). The pilot also sought to gather feedback on physical health assessment for mental health consumers from mental health staff, to assist with the identification of barriers and solutions.
Methods: A longitudinal audit of physical health screening forms and patient medical records was conducted at three sites: Fremantle Hospital and Health Services: Adult Mental Health Service (inpatients/outpatients), Kimberley Mental Health and Drug Service (rural/indigenous), and the Peel and Rockingham/Kwinana Mental Health Service (Assertive Community Treatment).
Findings: At baseline and by final audit, only one-half of the patients at the Fremantle and PaRK sites had a physical health assessment form in their medical file and little information was detailed on those forms. The Kimberley site had 100% form compliance, and had begun implementation of the complete package tools by their 18-month audit period.
Conclusions: The Clinical Guidelines packages were fully available to each site, yet services preferred to use their own screening tools, which typically did not cover all aspects of evidence-based physical health assessment and monitoring for mental health patients. Overall, the personalised site screening tools were poorly adhered to.
Blood Brain Barrier Polymorphism Predicts Escitalopram Dose Needed for Remission in Major Depression
Ajeet B Singh1,2, Chad A Bousman2,3,4,5, Chee H Ng2, Keith Byron, Michael Berk1,2,5,7
1Deakin University, IMPACT Strategic Research Centre, School of Medicine, Geelong, Australia
2The University of Melbourne, Department of Psychiatry, Parkville, Australia
3The University of Melbourne, Department of General Practice, Parkville, Australia
4Swinburne University of Technology, Centre for Human Psychopharmacology, Hawthorne, Australia
5Florey Institute for Neuroscience and Mental Health, Parkville, Australia
6Healthscope Pathology, Clayton, VIC, Australia
7Orygen Youth Health Research Centre, Centre for Youth Mental Health, Parkville, Australia
Background: The adenosine triphosphate (ATP)-binding cassette family of transporter proteins, subfamily B (MDR/TAP), member 1 (ABCB1) (P-glycoprotein) transporter is a key component of the blood-brain barrier. Many antidepressants are subject to ABCB1 efflux.
Objectives: To investigate functional polymorphisms of ABCB1 that may influence central nervous system (CNS) bioavailability of antidepressants that are subject to efflux with differential efficacy and the dosing needed. Single nucleotide polymorphisms (SNPs) at rs1045642 (C3435T) of ABCB1 have been associated with efflux pump efficiency. This may explain part of the inter-individual variation in the antidepressant dose needed to remit.
Methods: Individuals (N = 113) with Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV or Fourth Edition) major depressive disorder (MDD) were treated with escitalopram (ESC) or venlafaxine (VEN) over 8 weeks. The 17-item Hamilton Depression Rating Scale was assessed serially and blind to genotype. SNP rs1045642 of ABCB1, along with two SNPs previously reported to be in linkage disequilibrium with it (rs2032582 and rs1128503) were genotyped. Demographic features, clinical features, P450 metaboliser status and 5-HTTLPR (serotonin transporter-linked promoter region) genotype were controlled for.
Findings: Carriers of rs1045642 TT needed on average 11 mg of ESC to remit, whereas TC and CC carriers required 24 and 19 mg, respectively (P = 0.0001). This equates to a 2.0-fold (95% CI 1.5 – 3.4; P < 0.001) greater ESC dose needed to remit for C carriers, compared with TT carriers, at rs1045642. Of the VEN-treated subjects carrying TT genotype at rs1045642, 73.3% remitted, as compared with 12.5% for the CC genotype (OR = 6.69; 95% CI 1.72 – 25.9, P = 0.006).
Conclusions: These data suggested that the antidepressant dosage needed to remit can be predicted by an ABCB1 SNP. This has potential clinical translation implications for dose selection and remission from MDD.
Clozapine: Safety Implications of Increased Usage
Dan Siskind1,2, Samantha Hollingworth3, Karl Winckel3,4, Amanda Wheeler5
1Queensland Centre for Mental Health Research, School of Public Health, University of Queensland, QLD, Australia
2Metro South Addiction and Mental Health Services
3School of Pharmacy, University of Queensland, QLD, Australia
4Princess Alexandra Hospital
5Griffith Health Institute, Griffith University
Background: Clozapine is well established as the most clinically effective therapy for people with treatment-resistant schizophrenia, supported by guidelines from NICE, RANZCP and others. Clozapine usage in this consumer group has previously been low. This is likely associated with concerns of serious adverse drug reactions (ADR), in particular blood dyscrasias, although more recently, gastric and cardiac ADRs were identified as a major concern.
Methods: The aim was to examine clozapine use within Queensland over the last 10 years and to analyse reported ADRs. Data was extracted from statewide hospital pharmacy dispensing records. Correlations between increased use and ADRs will be investigated. The ramifications of increased clozapine use, in terms of safe and quality usage will be discussed.
Results: Clozapine dispensing increased 71% from 2004 to 2012. Concomitantly, there was a 770% increase in the number of documented serious ADRs, from 7 in 2004 to 61 in 2012. This included 23 cardiac ADRs in 2012, compared to only one in 2004. Whilst this increased use of clozapine may be appropriate, the increase in reported ADRs, including cardiac ADRs, is concerning. Careful consideration of resourcing of monitoring and management systems, as well as development, acceptance, standardisation and resourcing of monitoring guidance is required. We will present feasible recommendations.
Conclusions: Clozapine usage and reported ADRs have increased significantly over the last decade. The potential for adverse outcomes associated with this gold-standard treatment should be considered by clinicians and service managers alike. Robust monitoring, management and reporting systems for ADRs are required.
Appraisal of Burden of Care in Primary Family Caregivers of People With Schizophrenia in Abeokuta, Nigeria
L Sakeeb
Neuropsychiatric Hospital, Aro, Abeokuta, Nigeria
Background: In Nigeria, family members are the significant primary caregivers of persons affected by mental illnesses. They combine this role with taking care of their own immediate family and personal needs, which places a significant burden of care on them. Despite this important role, family caregivers’ needs are often neglected by the health care system.
Objectives: The objective of the study was to determine the level of burden of care and its predictors among the primary family caregivers of patients with schizophrenia.
Methods: Through probabilistic simple random sampling, 429 schizophrenia patients and their primary caregivers (n = 429) were interviewed with Zarit’s Caregiver Burden Scale (ZCBS) and a designed socio-demographic and patient clinical characteristics questionnaire.
Findings: High burden of care was experienced by 39.9% of the primary caregivers. The mean age of the primary caregivers was 45.78 (SD 12.95) and 52.3% of the primary caregivers were female, while parents and siblings constituted 51.5% and 23.6%, respectively. A high percentage of the respondents had financial assistance (69.5%), helpers (80.9%) and the intention to continue caring (95.3%) for their sick loved ones. About two-thirds (69.5%) of the caregivers felt more concerned about the high cost of treatment. The best predictors of the level of burden were availability of a helper, number of previous psychiatric hospital admissions, and the perception of patient functioning by the caregivers.
Conclusions: There is a substantial burden of care amongst primary family caregivers of people with schizophrenia and the associated predictors reinforce the need for comprehensive mental health care involving focus on the family mental health of the sufferers.
Where is the Line Between a Psychotic and a Spiritual Experience?
A Djurkov
Te Rawhiti CMHC, Counties Manukau DHB, Auckland, New Zealand
Background: Spiritual patients are fascinating and challenging.
Objectives: Soon after the start of my psychiatric career, I developed an interest in that area and since I have aimed to improve my understanding of these patients.
Methods: Case Studies: I will present three cases, showing typical presentations in the interface between psychiatry and spirituality - spiritual conversion, conversations with God and spiritual fasting. I will include part of the discussions I had with my patients. Despite of the fact that their clinical pictures were suggestive of a mental illness, I felt obliged to answer their challenging questions, in order to build therapeutic alliance.
My sources of knowledge were The Internet, The Bible and discussions with a cleric.
Findings: The answer is clear: Often there is no clear line.
Conclusions: We should not aim for an antagonistic dichotomous view of the spiritual and psychotic experiences. To support that statement, I encourage exploration of the life stories of past religious figures like Jesus, Moses and Paul, and also of the contemporary Indian spiritual leader Sri Ramana Maharshi. Their stories suggest that they could have been diagnosed with psychosis if they had come to the attention of a psychiatric clinic today.
Reclaiming the Place of Healing: An Autoethnographic Exploration
J Liggins1,2
1Counties Manukau Health, Auckland, New Zealand
2University of Auckland, Auckland, New Zealand
‘We walk across the car park to the mental health unit, hospital security trailing behind ready to give chase should she decide to run. The fresh air and sunshine is a welcome respite from the controlled chaos of the Emergency Department. I can see the effects of the overdose have worn off, but I sense her on-going despair. As we enter the unit through the swipe-carded (swipe-guarded) door I wonder what she will make of this place. Will she feel safe?’ (Liggins et al., 2012)
Drawing on the concept of therapeutic landscapes (Gesler, 1992), describing the physical, social and symbolic aspects of place that promote healing, this paper will present selected findings of my current PhD research. First applied to places of pilgrimage, an increasingly multidisciplinary body of research has utilized the therapeutic landscape concept to consider a range of places including green-spaces, countryside retreats and hospitals.
The qualitative methodology of autoethnography, challenging the traditional notion of the objective, emotionally uninvolved researcher, has allowed me to place my experience as service-user and psychiatrist alongside the experiences of other service-users, to explore ‘what makes a place a place of healing for the treatment of mental illness.’ In this paper, presented autoethnographically, I will discuss emerging links between place, mental illness and healing, encouraging you to listen with your heart as well as your mind.
References
Gesler WM (1992) Therapeutic landscapes: Medical issues in light of the new cultural geography. Social Science and Medicine 34(7): 735–746.
Liggins J, Kearns RA and Adams PJ (2012) Using autoethnography to reclaim the ‘place of healing’ in mental health care. Social Science and Medicine. 91: 105–109.
Spirituality, Religion and Mental Health
Davide Bertorelli
Consultant Psychiatrist, Waikato DHB, New Zealand
Spirituality plays a crucial role in well-being and psychiatric care, nevertheless, it remain an overlooked aspect. It’s a subject of high interest for many service users, clinicians and researchers.
My presentation explores the nature of spirituality, its relationship to religion and its importance in clinical practice. It investigates also the factors driving the spirituality agenda, in relation to mental health:
Service users and carer’s views;
Legislation and policies;
Identity and diversity of ethnicity of belief systems;
Changes in professional approaches and understanding;
Ethical issues;
Research findings.
I have had a longstanding interest in this topic, gained in different multicultural settings (Europe, America and NZ), where I worked for many years as a psychiatrist.
Perceptions of Training in Rural NSW
L Nash1,2,3,4, C Hickie1,2,5,6, M Earle1, S Clark1,2,6
1Rural Project of NSW Branch RANZCP, Sydney, NSW, Australia
2Western NSW Local Health District, Bloomfield Hospital, Orange, NSW, Australia
3NSW Health Education and Training Institute, Sydney, NSW, Australia
4Brain and Mind Research Institute, University of Sydney, Sydney, Australia
5Hunter New England Local Health District, Newcastle, Australia
6University of Newcastle, Newcastle, Australia
Background: To promote the rural psychiatry workforce, we need excellent training programmes provided in rural areas.
Objectives: To examine the training experience of psychiatry trainees in rural NSW in 2013.
Methods: All rural trainees in NSW (both rural based and rotating from metropolitan sites) and key psychiatrists involved in their training were invited to complete a questionnaire.
Findings: Responses were received from 26 rural psychiatry trainees (18 rural-based and 8 rotating from city areas) and 37 psychiatrists involved in training in a rural area.
Trainees described the positive and negative experiences of rural training. Their experience of supervision, consultant input and their Site Coordinator of training was generally very positive. Their experience of other aspects of training and education in rural areas was often negative, with 52% of trainees feeling at a disadvantage most or all of the time, due to fewer registrar peers and 60% feeling educational isolation most or all of the time.
Trainees and psychiatrists were asked to rate the components of rural training necessary for a good training experience and their perception of what was currently delivered in their positions. Services fell short on almost all items, with large discrepancies between what was delivered and what was considered important.
Conclusions: Efforts of the RANZCP, state and federal governments to enhance the rural workforce needs to continue to support rural trainees. A program to enhance training in rural areas should be informed by the views and experiences of current trainees and the psychiatrists who teach them.
Operational Psychiatry: Acute Psychiatry in the Afghanistan Combat Zone
J Lane1, J Kerr2
1Australian Army, Hobart, Australia
2US Navy, San Diego, USA
Abstract: There is a significant amount of literature on the burden of mental illness of veterans on return from active duty deployments; however, there is a relative paucity of data regarding what service personnel present with whilst they are actually in a combat zone. The present clinical service review was a descriptive study involving sequential review of the notes during the period of July to August 2013, from all providers at the NATO Role 3 Multi-National Medical Unit (Role 3) at Kandahar, Afghanistan. The objective of this review was to identify common complaints, diagnoses, treatment and disposition of personnel, in order to identify the burden of acute illnesses and issues faced by service personnel whilst in a combat zone. Interestingly, the majority of these complaints included problems with sleep, mood regulation, along with situational and interpersonal problems, as opposed to what might be perceived as more likely problems such as acute stress reactions. Relatively few personnel were evacuated on mental health grounds and these were primarily for suicidal ideation. The main benefit of this study is that battle-related and trauma-related disorders were relatively rare, despite a large proportion of patients having diagnoses of post-traumatic stress disorder (PTSD). This is in stark contrast to the general perception that PTSD is the major problem related to operational service. These findings suggest that mental health treatment services for veterans should prioritize the initial treatment focus on basic issues, such as adjustment disorders, affect regulation, and management of personal and interpersonal stressors.
Use of Ketamine for Aeromedical Retrievals of Psychiatric Patients in Remote Communities in Central Australia
Chris Turnbull1 and Richard Johnson2
1Central Australian Mental Health Service, Alice Springs, Australia
2Retrieval Service, Alice Springs Hospital, Alice Springs, Australia
Background: The central Australian Mental Health Service provides psychiatric care for Alice Springs, southern NT and northern SA, covering an area of 500,000 square kilometres. Many residents live in remote communities with limited access to psychiatric services. Psychiatric emergencies often require aeromedical evacuation to Alice Springs. Historically, agitated patients have required sedation and intubation for transfer, resulting in significant medical risks including aspiration, airway compromise and ICU admission. Ketamine administration has been used for pre-hospital sedation, to avoid intubation prior to ambulance transfer in other contexts, and has recently been trialed by several aeromedical retrieval services in Australia. Ketamine has a demonstrated ability to affect the mental state, with a capacity to induce psychosis, but has a recently-demonstrated ability to ameliorate depressive symptoms.
Objectives: We aim to assess the safety and viability of using ketamine as a ‘first line’ treatment for psychiatric aeromedical retrievals from remote areas.
Methods: We used a retrospective file audit to review outcomes for 24 patients retrieved without intubation, using ketamine sedation, in comparison to a historical control group retrieved using intubation.
Findings: Ketamine retrieval reduced intensive care unit (ICU) admissions of psychiatric patients and allowed for earlier assessment and transfer to a mental health unit.
Conclusions: Ketamine sedation reduces medical complications in aeromedical retrievals of acutely unwell psychiatric patients in remote locations.
The Need for Specialist Mental Health Services for People With an Intellectual Disability in Australia
Chad Bennett and Andrew Pridding
Victorian Dual Disability Service, St Vincent’s Hospital, Melbourne, Australia
Since de-institutionalisation, it has been expected that people with intellectual disability access generic service; however, people with intellectual disability experience barriers in accessing services and have a higher number of health needs than the rest of the population. Furthermore, the assessment and management of mental health issues is often complicated by communication and cognitive deficits. Services lack the infrastructure to meet the particular needs of this population and mental health professionals lack confidence in managing this group, due to lack of exposure and training. These difficulties are compounded by a lack of policy at the national and state levels. As a consequence, people with intellectual disability have high levels of unmet mental health needs. This paper aims to explore the impact of this, and it argues that a specialist service model is required to meet the needs of this population. Consideration of a service model includes a review of policy, legislation, infrastructure and the types of services that could be delivered.
Understanding Systemic Problems in Providing Mental Health Services to People With an Intellectual Disability and Co-Morbid Mental Disorders in Victoria
C Bennett
Victorian Dual Disability Service, Saint Vincent’s Hospital, Melbourne, Australia
Background: People with intellectual disability (ID) have high levels of mental health need. Generic services have difficulty responding to these needs, due to a range of patient, professional and service system factors, as well as some of the conceptual issues underpinning policy and legislation. These issues are discussed and where possible, put into a Victorian context, with the intention of informing service development in the area of Dual Disability (co-morbid mental disorders in people with intellectual disability).
Objectives: The objective of this paper is to explore the difficulties the services system in Victoria (VIC) has, in responding to people with intellectual disability and mental health problems, and to identify the underlying assumptions that have led to these.
Methods: Selective literature review.
Conclusions: The services system needs to develop a model that recognises the high rates of mental disorder in persons with ID and their long-term nature, and approaches the behavioural disorders in persons with ID as mental health problems that require treatment.
A Historical Perspective of Intellectual Disability Mental Health (IDMH) Services in New South Wales
A Mohan1,2, J Weise1, J Trollor1
1Department of Developmental Disability Neuropsychiatry, University of New South Wales, Sydney, NSW, Australia
2Neuropsychiatric Institute, Prince of Wales Hospital, Randwick, Australia
Background: Over 400,000 Australians have an intellectual disability (ID). Many (57%) suffer from psychiatric illness or mental disorder. The disability rights movement of the 1960s led to a transition from institutional to community-based care.
This evolution of mental health (MH) services for persons with an ID in NSW has yet to be well documented. The experiences of professionals and advocates at the front line of service delivery could be explored to guide development of accessible MH services for this important minority group.
Objectives:
Establish the historical experience of key individuals involved in providing and facilitating access to MH services for PWID in NSW, extracting elements that enhance these services.
Establish strengths and weaknesses of IDMH services in NSW.
Methods: A series of semi-structured interviews conducted with key health and disability professionals and advocates, exploring areas relevant to answering the questions above. Category and thematic analysis were undertaken and emergent themes collated.
Findings: Most participants agreed the move to community-based care has, in principle, been a step in the right direction. The lack of consultation with stake-holders, including general practitioners and mental health services, coupled with short-sighted development of key infrastructural elements in the community were raised as significant reasons for the current deficiencies and accessibility issues that plague health care delivery to persons with ID.
Conclusions: Current developments in health services to persons with ID must heed the lessons from past initiatives. Systematic exploration of the views of key individuals affords an opportunity to do this effectively.
Neurocognitive Disability Amongst Homeless Aboriginal and Torres Strait Islander Peoples: Preliminary Findings
G O’Brien1, C Townsend-White2,3, J Cullen2, P White1, A Webster1
1Specialist Disability Services Assessment and Outreach Team (SDSAOT), Queensland Health, Queensland State-wide Disability Services, Brisbane, Australia
2Synapse, West End, QLD
3School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Cairns, QLD, Australia
Background: Indigenous people are significantly over-represented in disability and homeless populations. The number of homeless indigenous people with neurocognitive disabilities is unknown, but thought to be significant. People with neurocognitive disabilities are undiagnosed; are not registered as eligible for disability support; and their needs are not incorporated in homeless policy, service models and community responses.
Objectives:
To determine the rate of homelessness among indigenous people in the Cairns District, Far North Queensland;
To ascertain the proportion of such indigenous people who have neurocognitive disability.
To explore their service experience.
Methods:
Homelessness rates are determined by combining statutory data with insights gained from culturally-appropriate community consultations, including representatives of the local indigenous peoples;
Prevalence is established employing culturally safe and appropriate clinical assessments, including neurocognitive, psychiatric and functional assessments;
For a purposeful sub-sample, narrative reflection of service experience is explored, triangulated from individuals to the Elders and significant extended family members.
Findings:
We identified 348 homeless indigenous people in the local area;
Preliminary findings on rates of neurocognitive disability will be presented;
It is striking to find that there are 36 unique services associated with homelessness in Cairns. The service experience of selected informative individuals will be described.
Conclusions: These preliminary findings emphasize the extent of homelessness among indigenous peoples, and especially the hidden morbidity of neurocognitive disability therein; these matters are being explored in a major ongoing study.
Recovery From Psychosis
L Achimovich
Private Psychiatrist, Fremantle, WA
Schizophrenia and other psychoses have been treated as an illness with very little chance of remission, especially in the last 30 years. Though there have been a number of centres working towards recovery, stabilisation with medication is the norm. There is now a vigorous movement towards recovery, largely because of the work of service users themselves. The paper addresses the burgeoning interest in recovery from psychosis, particularly the work of Seikkula, Lehtinen and colleagues in Finland. The paper also suggests reasons for the lack of successful treatment.
Background: The work of Loren Mosher, Bertram Karon, Mary Boyle, Steven Rose, John Read and colleagues shows both a clinical and a research basis for recovery from psychosis.
Objectives: The objective is to provide a contribution to a more hopeful view of recovery from psychosis, involving family therapy, minimal medication, listening to service users NGOs and learning new paradigms, if and when they are needed.
Methods: Three brief case studies will be outlined, demonstrating clinical management and aiming at recovery, rather than stabilisation.
Findings: The causes of psychosis are many; however, contemporary psychiatry can be invigorated using present recovery research, and treatment involving early intervention and minimal use of medication.
Conclusions: Recovery from psychosis is an exciting process for psychiatrists to consider. It involves having many skills and much patience, but the outcomes are worth the effort.
‘Will I Need My Stethoscope?’ – Evolving Landscapes From a Traditional to a Strengths Model, Within a Public Mental Health Rehabilitation Team
S Shankar1, M Aguey-Zinsou2
1Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, Australia
2Prince of Wales Hospital, South-East Sydney Local Health District, Sydney, Australia
Background: There has been a push within the mental health community for a new paradigm of care (Australian Government, 2010; Barber ME, 2012). There has been a corresponding rise in the popularity of a recovery-oriented approach (ROA) (Barber ME, 2012), particularly with the application of the Strengths Model (SM), a recovery-oriented model.
Objectives:
To explain the ROA and SM;
To describe their practical application within a Community Mental Health Rehabilitation Team (CMHRT);
To delineate the role of a psychiatrist within ROA;
To highlight the pros and cons of each model;
To provide clinical examples;
To present clinician and consumer feedback.
Methods: ROA and SM were implemented within a CMHRT using education, ongoing training, management support and regular supervision groups. The clinicians then implemented this new paradigm of clinical work with their consumers. Both clinicians and consumers provided feedback.
Findings: There was general positive support for the SM from both clinicians and consumers.
Conclusions: The ROA and SM appear to be viable models for community mental health services. This may address consumer concerns with traditional models of care. Further research is required on clinical outcomes with the SM.
References
1. Australian Government (2010) National Standards for Mental Health Services. Available at: http://www.health.gov.au/internet/main/publishing.nsf/Content/CFA833CB8C1AA178CA257BF0001E7520/$File/servst10v2.pdf
2. Barber ME (2012) Recovery as the new medical model for psychiatry. Psychiatric Services 63(3): 278–279. (doi: 10.1176/appi.ps.201100248)
Case Studies in Bullying and Stigma: Issues in the Consumer/Peer Workforce
Vivien Kemp
University of Western Australia, Perth, WA, Australia
Background: Both Australia’s The Roadmap for National Mental Health Reform 2012 – 2022, and Western Australia’s Mental Health 2020 Strategic Policy advocate the development of the consumer peer workforce. Many mental health service organisations across Australia now employ consumers in a variety of peer roles. There is some evidence that these peer workers face stigma and bullying in their workplaces from mental health professionals. To date, the issue has not received noticeable attention in the literature.
Objectives: This paper explores whether the stigma that some consumer peer workers face is one aspect of workplace bullying or whether stigma is a stand-alone issue unrelated to workplace bullying.
Methods: A series of case studies will be presented and examined, to determine if each case is evidence of workplace bullying or stigma, or both.
Findings: Using a person’s mental illness to either stigmatise or bully them is a misuse of power in the workplace.
Conclusions: Much still needs to be done to lessen stigma and bullying in the workplace, so that consumer peer workers can effectively contribute to the delivery of mental health services. Organisations would do well to implement strategies that not only reduce stigma, but mitigate workplace bullying towards consumer peer workers.
Recovery: The Challenge for Psychiatry
Rachel Perkins
BA, MPhil (Clinical Psychology), PhD, OBE National Implementing Recovery through Organisational Change (ImROC) Programme, London, UK
Everyone who experiences mental health problems faces the challenge of recovery: Rebuilding a meaningful, satisfying and contributing life. The challenge for psychiatry and psychiatric services is to assist people in this journey. Typically, services think of mental health services as a largely clinical challenge, and focus on clinical interventions to alleviate problems; however, while effective treatment and therapy may be important, mental health problems also constitute a major personal and social challenge, both for the individual and those who are close to them. In a world where prejudice, discrimination and exclusion remain rife, where people facing mental health challenges are routinely devalued and marginalised, it is often the personal and social arenas that present the biggest barriers to recovery. This presentation will explore the major changes in culture and practice that are required – in the overarching purpose of services, the relationships between services/clinicians and those whom they serve, and the relationship between psychiatric services and communities - if we are genuinely to support people in their journeys of recovery.
The Thalamus as a Putative Biomarker in Neuropsychiatry: Validation of a Protocol For Manual Segmentation of the Thalamus on Magnetic Resonance Imaging Scans
BD Power1,2, FA Wilkes3, M Hunter-Dickson3, D Van Westen4,5, A Santillo6, M Walterfang7,8, C Nilsson4,5, D Velakoulis7,8, JCL Looi3
1School of Psychiatry and Clinical Neurosciences, University of Western Australia, WA, Australia
2Peel and Rockingham Kwinana Mental Health Service, WA, Australia
3Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra Hospital, Canberra, Australia
4Centre for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
5Diagnostic Radiology, Department of Clinical Sciences, Lund University, Lund, Sweden
6Clinical Memory Research Unit, Department of Clinical Sciences, Lund University, Lund, Sweden
7Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, Australia
8Melbourne Neuropsychiatry Centre, University of Melbourne, Melbourne, Australia
Background: The thalamus is a critical ‘hub’ in the subcortical connectome, worthy of further investigation in various neuropsychiatric disorders.
Objectives: To present and validate a protocol for manual segmentation of the thalamus on T1-weighted magnetic resonance imaging (MRI) scans, using image analysis software.
Methods: The MRI scans of five controls from Lund University Hospital and Landskrona Hospital, Sweden were randomly selected from this cohort for inclusion in this validation study. MRIs were performed using a 3.0T Philips MR scanner, with an eight-channel head coil, and high resolution images were acquired using a T1-weighted turbo field echo (T1 TFE) pulse sequence, with resulting voxel size 1 x 1 x 1mm3. Manual segmentation of the left and right thalami and area measurement was performed on 175 contiguous slices, using ANALYZE 11.0 (Mayo BIR) software. Reliability of image analysis was performed by measuring intra-class correlations between initial and repeated segmentation of the left and right thalami in 5 subjects.
Findings: Intra-rater reliability was conducted by two raters. The intra-class correlation for the two tracers was 0.95 (0.79 – 0.99 95%CI), F = 51.35, p value < 0.01; and 0.98 (0.92 – 0.99 95%CI), F = 115.76, p value < 0.01. The inter-class correlation between the two tracers was 0.92 (0.80 – 0.97 95%CI), F = 22.48, p value < 0.01.
Conclusions: The thalamic manual segmentation method described here references robust neuroanatomical landmarks and has good inter and intra-rater reliability. Mapping thalamic morphology using this method in various neuropsychiatric disorders may provide important information regarding the onset, progression, and when disease-modifying agents are available, treatment response.
A Comparison of Neurocognition and Social Cognition in Chronic Schizophrenia and Frontotemporal Dementia
D Velakoulis1,2, HM Chan1,3, M Walterfang1,2, R Mocellin1,2, C Pantelis2, J Neath1, W Kelso1, R Stolwyk3
1Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, Australia
2Neuropsychiatry Centre University of Melbourne and Melbourne Health, Melbourne, Australia
3Royal Melbourne Hospital, Melbourne, Australia
Background: Chronic schizophrenia and frontotemporal dementia are considered to be quite different disorders aetiologically, but can sometimes be hard to differentiate clinically, especially in younger people. A series of recent studies identified clinical, neuroimaging, genetic and cognitive similarities between the two disorders. Few studies have compared the two disorders directly, on measures of neurocognition or social cognition.
Objectives: To investigate the neurocognitive and social cognitive profiles of patients with chronic schizophrenia and frontotemporal dementia.
Methods: The study consisted of retrospective and prospective arms. In the retrospective arm, we identified patients referred to the Neuropsychiatry Unit with chronic schizophrenia (n = 26) for investigation of cognitive decline. These patients were then compared to a group of patients with frontotemporal dementia (n = 34) on neurocognitive measures. The second arm of the study prospectively examined the same two populations and a healthy control group (chronic schizophrenia n = 20, frontotemporal dementia n = 12 and healthy control subjects n = 18), using a standardised cognitive battery and an assessment of social cognition (TASIT).
Findings: The cognitive profiles and the degree of cognitive deficit of patients with chronic schizophrenia and frontotemporal dementia overlapped significantly, though we identified differences between the two disorders that could aid in the clinical differentiation of the two disorders.
Conclusions: Our study identified that there exists a group of patients with chronic schizophrenia who have cognitive and social cognitive profiles that are more similar than different to patients with frontotemporal dementia. These findings have implications for clinical diagnosis. They support previous research and clinical observations that the ‘dementia’ of chronic schizophrenia is of a frontotemporal type.
Review of Pet Scans in Dementia and a Study on Diagnostic and Management Impact of FDG PET Scan, in a Memory Disorder Clinic
Alby Elias1, Christopher Rowe 2
1,2Austin Centre for PET studies, Melbourne, VIC, Australia
Background: The Alzheimer’s disease process begins 20–30 years before dementia. Fluoro-Deoxy-Glucose (FDG) Positron Emission Tomography (PET) and beta-amyloid PET scans allow early diagnosis of Alzheimer’s disease, so that therapeutic agents can produce a better outcome. Little is known about the management impact of FDG PET in a naturalistic setting.
Objective: To determine the impact of FDG PET on the diagnosis and management of dementia.
Methods: This was a prospective management impact study. We had 194 consecutive patients referred from a memory clinic for FDG PET who participated in the study. Diagnosis and management plans were compared before and after the release of the PET findings. The degree of impact was classified, based on change in diagnosis, dementia subtype or treatment status.
Findings: FDG PET had moderate to high impact on the diagnosis and management in 85 (44%) participants. Diagnosis changed from probable neurodegenerative disease in 27 patients to a non-degenerative diagnosis and vice versa in 12 patients. Dementia type changed in 46 (23.7%) participants and prescription of cholinesterase inhibitors in 33 patients (17%).
The number of uncertain diagnoses reduced from 58 to 35 (p < 0.001; Chi-square = 15.12), and very probable diagnoses increased from 5 to 42 (p < 0.001; Chi-square = 1.01). The Mini Mental State Examination (MMSE) score was higher in those whom had high diagnostic impact (26.3 ± 3.1 versus 23.9 ± 5.1; p < 0.05).
Conclusions: The management impact of FDG PET is higher in those with greater diagnostic uncertainty and less severe cognitive impairment, suggesting its usefulness as an adjunct investigation for the diagnosis and management of suspected or early dementia in a naturalistic setting.
Depression and Suicide in Contemporary Japan
Shigenobu Kanba
Neuropsychiatry, Kyushu University, Fukuoka, Japan
Until the 1970s, the push for capitalist economics was an obvious value shared by Japanese, who sought material and economic wealth and convenience when recovering from the war. Based on this set of values, the Japanese system coupled lifetime employment and trade within affiliated groups by an industry protected by government policies. The secular ethics of Shuchaku-kisitu (Typus Melancholics) personalities had an affinity for this type of environment, and they took center stage in the ethics of many people; however, in the early 1990s, the collapse of the ‘bubble’ economy and the rapid fall in stock and land prices led to the abolishment of the ‘convoy system’. In the second half of the 1990s, the Japanese system (lifetime employment, seniority system and family enterprises) broke down. In 1997, a major securities company and bank failed. In 1998, the number of suicides rose from 23,000 to 32,000 (particularly in 50–64 year old males in large cities). Utilitarian business management by stockholders and ‘survival of the fittest’ pressure were loaded on both companies and workers.
It is difficult for Shuchaku-kisitu (Typus Melancholics) to find a place of their own when the trend in society overall is not toward an orientation of regularity and order, but toward free pursuit of self gain, without constraint by the existing order (modern capitalist society).
On the contrary, characteristics of depression in recent years were formulated by Tarumi (2004). We are beginning to see the appearance of not only a group that corresponds to Shuchaku-kisitu, but also many people who do not belong to that group. They are people who were not seen in the past ‘work-oriented’ age. Rather than being sticklers for norms, they dislike being bound by norms, and are whom present with depression, complaining of constant fatigue and loss of interest. This tends to be seen more in younger people.
Reference
Kato TA, Shinfuku N, Sartorius N, Kanba S (2012) Are Japan’s youth hikikomori and depression spreading abroad? Lancet 2011 378: 1070.
Using Scripted Videos to Teach the ‘One-Minute Preceptor Model’ of Teaching
C Hickie1,2,3 B Kelly2,3, L Nash4,5,6
1Western NSW Local Health District, Bloomfield Hospital, Orange, Australia
2HNET Psychiatry, Hunter New England Local Health District, Newcastle, Australia
3University of Newcastle, Newcastle, Australia
4Rural Project of NSW Branch RANZCP, Sydney, Australia
5NSW Health Education and Training Institute, Sydney, Australia
6Brain and Mind Research Institute, University of Sydney, Sydney, Australia
Background: Psychiatry trainees teach medical students on clinical placements and welcome a program to improve their teaching skills (Hickie, 2013). The one-minute preceptor model is a useful model for clinical teaching in psychiatry (Tsao, 2010). Targeted workshops can improve teaching skills (Hickie, 2013).
Objectives: To develop and test a resource for teaching psychiatry trainees clinical teaching skills.
Methods: Informed by clinical psychiatrists (active in medical education) and a survey of NSW psychiatry trainees five common and important teaching encounters were selected for script development. Each film depicted an encounter between a student and a trainee. Professional actors played the roles.
In workshops targeted at improving teaching skills, the films were screened for psychiatry trainees. Films were screened and paused at crucial teaching points, to allow for discussion of participants’ own teaching experiences and reactions to challenges presented in the dramatised encounters. The micro-skills of teaching were demonstrated.
Findings: Brief segments of the videos will be screened. Workshop participants’ responses to the videos will be presented. The effect of the workshop on participants’ views of the importance of the teaching role, their self-assessed confidence in the role and their understanding of the students learning needs will be reported.
Conclusions: Videos are an engaging resource for teaching psychiatry trainees clinical teaching skills.
References
1Hickie C, Nash L, Kelly B (2013) The role of psychiatry trainees as clinical teachers of medical students in psychiatry. Australasian Psychiatry 21: 583–586.
2Tsao C (2010) One-Minute Preceptor Model: Brief description and application in psychiatric education. Academic Psychiatry 34: 317–318.
Good and Getting Better: The Committee for Educational Quality and Reporting (CEQR) Review Of Continuing Professional Development (CPD) in the RANZCP
Joanna Macdonald1,2, Choong-Siew Yong2, Elaine Halley2, Scott Fletcher2
1School of Psychological Medicine, University of Otago, Wellington, New Zealand
2The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
Background: The Committee for Educational Quality and Reporting (CEQR) is a subcommittee of the Education Committee, with the responsibility for quality improvement and assurance of the Education Committee’s activities, monitoring of its activities and reporting to key internal and external bodies. Its major review for 2012 – 2013 focused on the Continuing Professional Development (CPD) activities of the College.
Objectives: To review the CPD activities of the College and suggest areas for improvement.
Methods: The CEQR considered that the CPD activities included the continuing medical education (CME) programme, as well as the College’s scientific publications and the Congress. The review involved establishing a comparison with suitable benchmarks, reviewing the available feedback from past Congresses, and considering the quality criteria used by the Publications Committee.
Findings: The CME programme compares very favourably with other Colleges, in terms of its structure, the requirements of participants and continuous updating of its policies. The feedback gathered at Congress gives little indication of its educational value for participants, despite CPD being the main reason for attending, for many participants. While the journals are clearly improving, their ranking in terms of their Impact Factor, their value to the Fellowship as a tool for continuing education is unclear.
Conclusions: Suggestions will be discussed for improving the feedback from Fellows regarding the Congress and journals, to enable assessment of their role and value as parts of Fellows’ continuing education, and for means by which these key activities can better assist Fellows’ continuing education.
Expectations and Obligations for Continuing Professional Development in a Changing Environment: Possible Directions for the RANZCP
CS Yong1,2
1Chair, Continuing Medical Education Committee, RANZCP, Melbourne, Australia
2School of Medicine, University of Western Sydney, Sydney, Australia
Background: The issue of revalidation for medical registration is drawing attention to the place of Continuing Professional Development (CPD) in ensuring doctors’ fitness for practice. Public comments from medical regulators and patient safety advocates have cast doubt on the ability of existing College CPD programmes to prepare Fellows for a more tightly-regulated environment in the future. There has been considerable development of tools and approaches to improve CPD beyond knowledge and skills acquisition, to embrace patient safety, examination of practice and feedback mechanisms on individual performance.
Objectives: To review medical CPD programs and recent developments in the literature. Exploration of possible directions for the RANZCP CPD program.
Methods: The CME Committee reviewed CPD programs throughout Australasia and overseas. The Committee is also discussing new developments for assisting Fellows to undertake practice reviews and other quality measures.
Findings: Modern opinion on CPD emphasizes mechanisms for practice review, audit and multisource feedback, rather than knowledge acquisition, as essential to assure patients and regulators of safe, competent practitioners.
Conclusions: The RANZCP CPD program will face considerable challenges in any new regulatory environment in Australia or New Zealand. In revising the CPD program, there will be opportunities to build a modern, peer-designed system that could enhance patient safety, improve psychiatrists’ performance and reassure the public.
The Use of Balint Groups to Aid Reflective Practice in Psychiatry Trainees
S Stanek1 L McLean1-3, S Halovic1, A Korner1
1Westmead Psychotherapy Program (WPP), Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Department of Consultation-Liaison Psychiatry, RNS Hospital, Saint Leonards
3SWaGS Psychiatry Training Network
Background: A Balint group is a form of case discussion group originally developed by Michael Balint in the 1950s for doctors, as a way of helping them to manage patients they were struggling to help. They aim to help clinicians reflect creatively on the therapeutic relationship; however, there has been limited evaluation of the capacity to improve reflective functioning, and of the phenomenon of participation in the Balint group and its effects on ongoing practice.
Objectives:
To offer a brief review of Balint groups;
To design an evaluation of a Balint case discussion group for Psychiatry trainees, that will measure a change in reflective functioning;
To explore the ‘lived experience’ of participation in a Balint group;
To offer an account of the preliminary experience of setting up and running a Balint Group, by an Advanced Trainee.
Methods: The current design is a prospective mixed-methods study, using pre- and post-measures: self-reporting questionnaires (MBI, GRAS, ProQol) and the Adult Attachment Interview, scored for Reflective functioning. A separate, qualitative interview will explore the lived experience of Balint group participation and subsequent integration of this experience into the clinician’s clinical practice.
Findings and conclusions: We are currently running a pilot program and are awaiting full implementation of the design.
The Privacy Act and Psychiatry: Unintended Consequences
Bill Pring
AMA Observer on Private Mental Health Alliance
Privacy legislation was introduced in the year 2000 and seemed like a good idea in a modern world, where privacy is difficult to maintain. Special measures were introduced to further protect health privacy; this seemed a good idea at the time, too. Unfortunately, as a result of the legislation, the confidentiality of medical records seems to have diminished in a number of ways, and there is a risk that medical records will be dumbed down, in order for doctors to protect themselves in various ways. It is clear that the doctors’ intellectual property in the medical record has been largely ignored, and this has a number of consequences for us as a profession. The main areas that are affected include the use by lawyers of privacy law to obtain the whole medical record of the patient, to use it in various ways which were not intended under the Privacy Act. There are also consequences in terms of medico-legal practice, where lawyers will often use privacy law to obtain records, to avoid paying medico-legal fees, especially to treating doctors. Because the records are being requisitioned on an increasing basis, there could be a tendency of doctors to ‘dumb down’ their record, so that their own intellectual property interests are protected to some extent. That is counter-productive to the value of the clinical record. A number of legitimate approaches to dealing with these difficult issues will be discussed in this talk, including the legitimate use of additional records, and a stricter interpretation of ‘serious harm’ under privacy law.
Accessible Mental Health Services for People With an Intellectual Disability: The Launch of a National Guide for Providers
J Trollor, A Ching
Department of Developmental Disability Neuropsychiatry, School of Psychiatry, University of NSW Medicine, NSW, Australia
Background: Australians with an intellectual disability (ID) experience high rates of mental disorders and poor access to mental health care. Mental health professionals report a lack of knowledge and expertise in ID and mental health. To improve the quality of mental health care for people with an ID, funding was obtained from the Australian Government Department of Health, to develop ‘The Guide’: Accessible Mental Health Services for People with an Intellectual Disability: A Guide for Providers.
Objectives: This presentation will outline the steps that mental health professionals and service providers can undertake to deliver high-quality mental health care to people with an ID and will be the official launch of The Guide.
Method: Development of The Guide was informed by literature searches, a series of stakeholder surveys, focus groups and consultations with a Core Reference Group. An initial draft of The Guide was also reviewed at the National Roundtable on the Mental Health of People with ID, in May 2013. The final draft was approved by the Australian Government Department of Health.
Findings: This Guide offers a practical framework by which mental health professionals and services can improve mental health care for people with an ID. The Guide includes an outline of guiding principles to underpin practice, core components of service provision and reasonable adjustments for inclusive practice.
Conclusions: The Guide will be an important resource for practitioners and services, and will assist in improving accessibility and quality of services for people with an ID. Further progress depends on implementation of key elements of The Guide.
A Guide to National ADHD Guidelines: Best Practice for the ADHD Clinician
R Paterson
Private Practice Psychiatry, Perth, Australia
Background: The RANZCP has guidelines for the management of child attention deficit hyperactivity disorder (ADHD) and adult ADHD (published in 2009 and 2012, respectively), but they both have shortcomings. The child ADHD guideline is past its review by date and the adult ADHD guideline simply refers the reader to the Canadian and British guidelines. The NHMRC ADHD guidelines were ready for release in 2009, but were never finally approved and, instead, the NHMRC released a much briefer and more general document, The Clinical Practice Points, relating to children and adolescents only. Where does this leave a clinician needing guidance on ADHD?
Objectives: I will briefly summarise how this situation came about and guide the clinician to a best practice ‘distillate’ of the various guidelines.
Methods: Review of the two NHMRC guidelines, as well as the Canadian and British guidelines.
Findings Best practice conclusions drawn.
Conclusions: NHMRC Draft Guidelines (2009) should be released ASAP, ideally after a modest update of the latest research and DSM 5 criteria.
References
Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA) (2011) Canadian ADHD Practice Guidelines, 3rd edition. Toronto, ON: CADDRA.
National Health and Medical Research Council (NHMRC) (2009) Draft Australian Guidelines on Attention Deficit Hyperactivity Disorder. Canberra: NHMRC.
National Health and Medical Research Council (NHMRC) (2012) Clinical Practice Points on the diagnosis, assessment and management of attention deficit hyperactivity disorder in children and adolescents. Canberra: Commonwealth of Australia.
National Institute for Health and Care Excellence (NICE) (2008) Diagnosis and management of ADHD in children, young people and adults. Clinical Guideline 72. NICE: Manchester.
Adult ADHD - Why Is It So Hard to Get a Workable Public Sector Model of Care?
N Gibson
Office of the Chief Psychiatrist, WA Department of Health, East Perth, Australia
Background: Adult attention deficit hyperactivity disorder (ADHD) remains a controversial issue within the public, political and clinical consciousness. Significant variations in stimulant prescribing and regulation across jurisdictions have fuelled this debate, and DSM5 has served to heighten the polarity and polemic within various communities.
Commissioning Guides, such as those by the National Institute for Health and Care Excellence, are helpful; but they do not fully reflect the Australian healthcare structure. Professional debates in this space often describe clinical strategies well. Despite this, practical issues faced by individuals and families remain active when public policy, statutory regulation and existing clinical models impact on access to stimulant prescription and other therapy modalities within a public mental health structure, where comorbidity and complexity are common.
Objectives: To compare public sector adult ADHD treatment frameworks across Australian jurisdictions.
Methods: Comparative jurisdictional stimulant regulation and clinical models will be considered.
Length of Stay in a Psychiatric Emergency Care Centre (PECC)
J Seymour1, V Brakoulias2,3, J Lee1, V Starcevic2,3
1Nepean Blue Mountains Local Health District, Sydney, Australia
2The University of Sydney, Sydney, Australia
3Nepean Hospital, Sydney, Australia
Background: Psychiatric emergency care centres (PECCs) have become a common mode of time-limited acute psychiatric service delivery within our rapidly-evolving mental health service landscape. Understanding the predictors of length of stay in PECCs is important in refining the admission criteria of PECCs and enhancing discharge planning from these units.
Objectives: To describe PECCs and to discuss patient length-of-stay predictors.
Methods: Demographic and clinical characteristics were recorded retrospectively, via file audit, in 477 patients who were admitted to a PECC within a 6-month period. Associations between these variables and length of stay were analysed using logistic regression.
Findings: The most common reason for presenting to the PECC was for suicidal ideation and the most frequent diagnosis was an adjustment disorder. Length of stay in the PECC was predicted by: medical complications arising in the PECC, absconding behaviour, diagnosis of depression and being brought in by family members. Aggression within the PECC and previous contact with mental health services predicted a shorter stay.
Conclusions: Length of stay in the PECC is predicted by a number of variables that are different from those that predict length of stay in an acute psychiatric unit. A comprehensive assessment of these variables, prior to admission, may decrease the length of stay in the PECC and improve efficiency of acute psychiatric services.
Service User Perspectives on Direct-To-Consumer Advertising (DTCA)
DB Menkes1,3, S Rostron2, K Ware3, A Sokratov4, R Duggal5
1University of Auckland, NZ
2Te Pou, Hamilton, NZ
3Waikato District Health Board, Hamilton, NZ
4Waitemata District Health Board, Auckland, NZ
5Hauora Waikato, Hamilton, NZ
Background: Marketing of pharmaceutical products reflects an important component of a multi-billion dollar industry. Countries in the industrialised world, with the exception of NZ and the USA, prohibit direct-to-consumer advertising (DTCA) of prescription medicines. Companies have tried, without success, to extend the practice to Canada, Europe and elsewhere. In NZ, the practice is controversial: attempts to get it banned have been unsuccessful, in part due to industry lobbying. Over several months in 2013, three NZ television channels carried adverts for a long-acting antipsychotic injection, Risperdal Consta.
Objectives and method: We canvassed and analysed opinions of service users about this ad and DTCA in general.
Findings: Examples of DTCA in NZ will be presented, including the ad for Risperdal Consta, shown in 2013. Service user responses to this ad were overwhelmingly negative: examples will be presented. Evident themes included concerns about:
Unbalanced drug information;
Drug company motivations;
Over-emphasis of medical model treatments, and neglect of other modalities;
Impacts on services users, families and the doctor-patient relationship;
Decision-making during episodes of illness.
Conclusions: Service user and clinician perspectives regarding DTCA appear similar in NZ, challenging company assertions that the ads are designed to provide information and present positive, de-stigmatising images. While critical of DTCA, service users affirmed the importance of unbiased information, the doctor-patient relationship and shared decision making. We hope these results will help clarify service users’ information needs and encourage political responses to DTCA.
Randomised Controlled Evidence for the Effectiveness of Community Treatment Orders: An Update of a Cochrane Systematic Review
S Kisely1,2,3
1School of Medicine, University of Queensland, QLD, Australia
2Metro South Health Service, Woolloongabba, QLD, Australia
3Griffith Institute of Health, Griffith University, QLD, Australia
Background: It is unclear whether community treatment orders (CTOs) for people with severe mental illnesses can reduce health service use, or improve clinical and social outcomes. Randomised controlled trials (RCTs) of CTOs are rare, because of ethical and logistical concerns.
Objectives: To update an earlier Cochrane systematic review of RCTs in patients on CTOs.
Method: A systematic literature search of the Cochrane Schizophrenia Group Register, Science Citation Index, PubMed/Medline and EMBASE, up till April 2013. Inclusion criteria were studies comparing compulsory community treatment with standard care, including those where controls received voluntary care for the majority of the trial.
Results: Three studies provided 749 subjects for the meta-analysis. Two compared compulsory treatment with entirely voluntary care, while the third had controls receiving voluntary treatment for the bulk of the time (medians of 257 versus 8 days, respectively, for initial randomised legal compulsion; and 262 versus 103, over the course of the study). Compared to controls, CTOs did not reduce hospital admissions (RR = 0.98; 95%CI = 0.83 to 1.17) or bed-days (MD = − 16.36; 95%CI = − 40.1 to 8.05) in the subsequent 12 months. Neither were there significant differences in psychiatric symptoms (MD = − 0.37; 95%CI = − 2.84 to 2.20) or Global Assessment of Functioning (MD = −1.36; 95%CI = −4.07 to 1.35). Sensitivity analyses of the effect of only including the two studies that compared compulsory treatment with entirely voluntary care made no difference to the results.
Conclusions: CTOs do not lead to significant differences in readmission, social functioning or symptomatology, compared with the standard care. Their use should be reviewed.
Community Treatment Orders in Psychiatry: Some Ethical Pitfalls
G Newton-Howes1, J Matthewson2
1University of Otago, Wellington, New Zealand
2Massey University, Auckland, New Zealand
Background: The use of community treatment orders (CTOs) is already a common practice in New Zealand and Australia, and is increasingly common throughout the world; however, there is at best modest evidence of positive benefits from CTOs. Significant ethical issues arise in their application.
Objectives: To consider the potential ethical risks associated with the application of CTOs and to canvass potential practical considerations, to minimise these risks.
Methods: A critical assessment of the cogency of various arguments presented in support of CTOs, both on in-principle and clinical grounds.
Findings: We contend that CTOs are inherently coercive. Coercion in a clinical setting is not morally unacceptable per se, but it does introduce a number of significant ethical issues. Given the coercive nature of CTOs, this means justification for their use is a highly demanding task. We contend that the arguments given in favour of current CTO use are insufficient for this task, especially given that a lack of capacity is not required for their application. A remedy for this issue would be to alter current practice, to ensure that CTOs are only used where a lack of capacity is clearly demonstrated, indicating the need for a beneficent approach.
The use of CTOs to treat ‘disorders of mind’ or other legally-defined terms is also unjustifiable, as there is no evidence of treatment efficacy regarding such categories. A remedy for this problem would be to ensure that mental disorders are identified and that evidence-based treatments for them are established, before a CTO is requested or granted. Similarly, it is difficult to defend the argument that a CTO is better than hospital-based treatment. The use of a CTO is not a treatment, and in any case, presumably if a patient requires a hospital-based approach, this would be taken irrespective of legal detention in the community. Finally, there are significant ethical issues when the same doctor may assess the need for a CTO and subsequently enact treatment, as there can be a conflict of interest in these two acts. A straightforward remedy for this would be to separate the two roles.
Conclusions: Despite their increased use and legal basis, there are a number of significant ethical issues regarding the use of CTOs in many jurisdictions. Most of these issues have solutions that would be simple to enact in law and place into routine psychiatric practice. This approach recognises the difficulties of managing psychiatric patients in many parts of the world, balancing the need for best care, whilst still protecting their fundamental rights.
The Western Australian Mental Health Bill: A Template for Discussion of Binational RANZCP Mental Health Legislation Principles
N Gibson
Office of the Chief Psychiatrist, East Perth, WA, Australia
Background: After 10 years of review processes, a new Mental Health Bill was placed before the Western Australian (WA) Parliament, in October 2013. This Bill has been the subject of discussion since 2002, not only locally in WA, through three major public and stakeholder consultations, but also in the national legal academic debate and within Australian medical and psychiatric journals. During that time, a range of other Australian States and Territories have passed and implemented new mental health legislation, as have jurisdictions within the UK.
In late 2012, the General Council of the RANZCP agreed to undertake a process to draft a College position on the broad principles that should underpin the development of future mental health laws. These principles are yet to be released. It remains a critical task of the RANZCP to define these principles.
Objectives:
To outline how the iterative process with the WA Mental Health Bill might inform broad principles;
Propose key mental health legislation in principle areas relevant to the role of the RANZCP.
Methods: By referencing the WA Mental Health Bill, comparative interstate legislation, previous ideal national mental health legislation principles; as well as contemporary legal, ethical and clinical perspectives across Australia, a framework of principles is assembled.
Mental Health Legislation Across Countries: A Comparison of Australia and South Asia
M Isaac
The University of Western Australia, Perth, Australia
Background: Mental health legislations vary widely across countries. Many countries who have ratified the United Nations (UN) Convention on the Rights of Persons with Disabilities (UNCRPD) are currently reviewing their mental health legislations, to align them with the UNCRPD. This is an opportune time to review the status of mental health reforms, legislations and human rights violations of the mentally ill in various countries.
Objectives: As part of a sabbatical research project, mental health policy, reforms and legislation of Australia, in particular, Western Australia (WA) was compared with those of contrastingly different resource settings in nine countries in South Asia, with the objective of learning lessons, if any.
Methods: Non-systematic reviews of empirical studies, published and unpublished papers, reports, documents, governmental policy statements, various case studies and gray literature, semi-structured key informant and stakeholder interviews and site visits.
Findings: While the mental health legislations of Australia, as well as most of the South Asian countries, evolved from the British Lunacy Acts, very few changes have occurred in the mental health laws of many South Asian countries. They do not reflect international standards and lag far behind universally-accepted values and principles. There are numerous challenges in the application of international values, principles and standards to national contexts of the low and middle income countries.
Conclusion: Legislation in the field of mental health, as well as its implementation, can never be considered in isolation; but only in the context of the larger constitutional guarantees for health, education and social welfare, and socioeconomic and cultural realities of the region.
Cochrane Systematic Reviewing for the Uninitiated: An Interactive Demo
M Jayaram1, S Polzmacher2, A Wolff2, K Koch3, K Mansi4, E Haynes4, CE Adams4
1University of Melbourne, Melbourne, Australia
2University of Applied Sciences, Ulm, Germany
3School of Medicine, University of Nottingham, Nottingham, UK
4Cochrane Schizophrenia Group, University of Nottingham, Nottingham, UK
Background: Systematic reviews completed meticulously provide the highest quality of evidence. This process is laborious (hundreds to thousands of man-hours), time consuming (~2 years to publication) and requires an active, interested work force. In 2010, there were 75 randomised trials published daily and with this number growing year after year, it seems humanly impossible to stay on top. We need quick quality systematic reviews to assimilate this.
Objectives: To evaluate whether inexperienced medical students, with aid of technology and judicious supervision, could complete systematic reviews quickly.
Methods: We recruited a school leaver and a medical student and provided free online training (sites.google.com/site/revmantutorial1). Two computer programmers interested in JAVA built a bespoke automated writing tool (Rev Man HAL).
Findings: Students watched videos and required 8 hours of supervision time in total. Rev Man HAL can write a readable, acceptable results section in 35 seconds, once the data extraction is completed. A high-quality Cochrane review can be completed in 1 month.
Conclusions: Enthusiastic, inexperienced people can complete high-quality systematic reviews quickly in an error free, readable and scientific manner. Perhaps we can yet stay on top of the surf without drowning in the volume of literature coming through every day.
References
Adams CE, Polzmacher S, Wolff A (2013) Systematic reviews: Work that needs to be done and not be done. Journal of Evidence-Based Medicine 6: 232–235. doi: 10.1111/jebm.12072.
Koch K, Mansi K, Haynes E, et al. (2013) Trifluoperazine versus placebo for schizophrenia. Cochrane Database Systematic Reviews.
Posters
The Use of Spin and Bias in the Early Intervention in Psychosis Literature
A Amos1,2
1University of Queensland, Brisbane, QLD, Australia
2Gold Coast Hospital, Southport, Australia
Background: The early intervention in psychosis literature has recently appropriated terms with aetiological implications, such as ‘staging’ and ‘pluripotent’, from oncology; without adopting the methodological rigour of oncological research. Oncology research maintains this rigour, inter alia, by testing for bias and spin.
Objectives: This study was designed to detect possible use of reporting bias and spin in the early intervention in psychosis literature.
Methods:
Sources: Articles were selected from PubMed searches for ‘early intervention in psychosis’, ‘duration of untreated psychosis’, ‘first-episode psychosis’, ‘ultra-high risk’, and ‘at risk mental state’ between 1 January 2000 and 31 May 2013.
Selection: We selected 38 randomised controlled trials (RCTs) and quasi-experimental papers reporting results from early intervention in psychosis paradigms for inclusion.
Data Extraction: The articles were examined for evidence of inappropriate reporting of primary and secondary end-points in the abstract (reporting bias) and presentation as positive, despite negative primary end-points (spin).
Findings: While 13% of early intervention articles reported positive primary end-points, abstracts implied that 76% were positive. There was evidence of bias in 58% and spin in 66% of the articles.
Conclusions: There was a high prevalence of spin and bias in the early intervention in psychosis literature, compared to previous findings in the oncological literature. The most common techniques were: changing the primary end-point or focusing on secondary end-points when the primary end-point was negative, as well as reporting analyses using only a subset of the data. There appears to be a need for greater scrutiny of the early intervention literature by editors, peer reviewers and critical readers of the literature.
My Medicines and Me Questionnaire (M3Q): A Novel Tool for the Assessment of Subjective Experiences of Side Effects in Mental Health Consumers
D Ashoorian1, R Davidson2, D Rock3 and R Clifford1
1University of Western Australia, Perth, WA, Australia
2Health Department of Western Australia, Perth, WA, Australia
3North Metropolitan Health Services - Mental Health, Perth, WA, Australia
Objective: To assess the suitability of using the My Medicines and Me Questionnaire (M3Q) as a self-reported questionnaire for mental health consumers to express the range and subjective experience of side effects associated with their psychotropic medications.
Methods: Following ethics approval, questionnaires were administered amongst six adult mental health clinics, from March 2013 to April 2013. The M3Q was previously validated and consists of open- and closed-ended questions. Following the implementation of various recruitment strategies, consumers were recruited and provided written informed consent.
Findings: We recruited 205 consumers. The average completion time for the questionnaire was 15 minutes (SD = 6.5). Only 11 (5%) consumers required assistance for completion. The three most commonly reported side effects were sedation (77%), difficulty waking up (59%) and anxiety (55%). In contrast, the three side effects ranked as most bothersome were weight gain (23%), followed by feeling tired during the day (22%) and difficulty falling asleep (14%). The M3Q provided consumers with the opportunity to write about the impact these side effects had on their lives. Over one-half (53%) of the consumers reported thinking of stopping their medication; of these, 64% had actually stopped taking their medication at some point. Side effects were the most common reason given for non-adherence.
Conclusions: The M3Q was completed within a reasonable time frame, with little need for clarification, allowing consumers to easily express their subjective experiences with side effects and to contrast the most common side effects with the most bothersome. Further research involving clinician review of completed questionnaires will examine the clinical application of the M3Q.
No Longer on Clozapine: Where Are They Now?
H De Silva1, N Pai1,2
1University of Wollongong, Wollongong, Australia
2The Wollongong Hospital, Wollongong, Australia
Background: While clozapine is well known for its efficacy in treatment-resistant schizophrenia, the challenges of side effects and non-adherence make management of these patients more difficult. This is an explorative study done in regional NSW, focusing on the patients who discontinue clozapine.
Objectives: The aim of this study is to determine why patients ceased clozapine. We also aimed to determine their attitude towards the drug, the length of treatment prior to ceasing the drug, their ongoing involvement with the health service and current medications.
Methods: This was a study conducted on patients who ceased clozapine in the Illawarra Shoalhaven region, during the past 5 years (2008–2013). Retrospectively, we determined the reasons for ceasing clozapine and the duration of treatment. Prospectively, patients were asked to complete a drug attitude inventory survey, to determine their attitude towards clozapine. They were then interviewed and their medical records reviewed, to determine their current medications and mental health status.
Findings: Most patients who drop out of treatment, do so within the first year. We discuss the reasons for non-compliance, patient attitudes towards the drug and the patient’s decision to cease clozapine.
Conclusions: The current management regime of the patients whom had ceased clozapine is interesting to note. Did they have treatment-resistant schizophrenia? Do we need to redefine treatment resistance?
Functional Impairment in Children and Adolescents With Attention Deficit Hyperactivity Disorder: Results From Short- And Long-Term Studies of Lisdexamfetamine Dimesylate
L Doddamani1, P Hodgkins2, B Adeyi2, LA Squires2, R Civil2, DR Coghill3
1Mildura Base Hospital, Mildura, VIC, Australia
2Shire, Wayne, PA, USA
3Division of Neuroscience, University of Dundee, Dundee, UK
Doddamani is a neurodevelopmental paediatrician and the clinical lead for paediatric neurodevelopmental services at Mildura Base Hospital. Before joining Mildura Base Hospital, Doddamani led the attention deficit hyperactivity disorder (ADHD) services for Great Yarmouth and Waveney, UK; was Honorary Senior Lecturer at the University of East Anglia, Norwich, UK; and served as a member of various ADHD advisory boards. Doddamani has participated in several national and international research projects and has presented both locally and nationally on topics related to his special interests, which include gender differences in ADHD, ADHD in preschool children, autism spectrum disorders, sleep problems and obesity.
Background: The prodrug stimulant lisdexamfetamine dimesylate (LDX) is an effective, long-acting treatment for the symptoms of ADHD. Management of ADHD should address day-to-day functioning, as well as symptoms.
Objective: Evaluate functional outcomes from two international, double-blind, randomised trials (SPD489–325 and SPD489–326) in patients with ADHD, aged 6–17 years.
Methods: In SPD489–325, patients received placebo or optimized doses of LDX or the reference treatment, osmotic-release oral system methylphenidate (OROS-MPH) for ≤ 7 weeks. Statistical comparison of LDX versus OROS-MPH was not pre-specified. In SPD489–326, a ≥ 26-week open-label LDX treatment period preceded a 6-week, placebo-controlled, randomized-withdrawal period. The change in Weiss Functional Impairment Ratings Scale-Parent Report (WFIRS-P) scores was a secondary efficacy outcome.
Findings: In SPD489–325 (N = 317), nominally significant placebo-adjusted effects of LDX were observed in the WFIRS-P Family, Learning and School, Social Activities and Risky Activities domains and in the total (effect size (ES) 0.924; p < 0.001); OROS-MPH effects were significant in all domains and in the total (ES 0.772; p < 0.001). In SPD489–326, WFIRS-P scores were improved or stable in the open-label period (N = 262). In the randomised-withdrawal period (N = 153), scores worsened in the placebo group, but not the LDX group; with LDX significantly more effective at the endpoint, in the Family, Learning and School, and Risky Activities domains (all p < 0.001) and in the total (ES 0.908; p < 0.001).
Conclusions: Short-term treatment with LDX or OROS-MPH led to improved functional impairment scores in children and adolescents with ADHD. The benefits of LDX were maintained during continued long-term treatment, as demonstrated by the worsening of scores following withdrawal to placebo.
Facilitated Discharge Program: A Pilot Project to Improve Access to Acute Psychiatric Beds in a General Hospital
L Fernandes¹, G Shymko¹, R Malvathu²
¹PaRK Mental Health Service, Rockingham, Australia
2Rockingham General Hospital, Rockingham, Australia
Background: Pressure for acute mental health beds is a reality across WA, and transfer of patients under the Mental Health Act to other units from the Rockingham and Peel areas is often difficult. Such patients often remain in a busy Emergency Department (ED) in excess of 24 hours. Managing acutely ill psychiatric patients in EDs is challenging and has a risk of adverse clinical incidents.
This project offers an innovative approach to the management of beds, to enable rapid access to a psychiatric ward for the most acutely unwell patients in the hospital.
Methods: We developed a collaborative partnership between the departments of Psychiatry, General Medicine and Emergency Medicine. Psychiatric inpatients who are sufficiently recovered to be near discharge, are transferred to the medical ward. Psychiatric care of transferred patients remained uninterrupted, as these patients continued to access the psychiatric unit during daytime hours.
Findings: We report on the formation of this pathway, including guidelines on patient selection and a protocol for handover. A case study and relevant data will be presented, to illustrate the unique collaboration.
Conclusions: Careful patient selection has ensured successful implementation in the first 15 months. The pilot project was commended by the Australian Council for Health Standards, at the Hospital’s recent Accreditation visit, as an example of a collaborative effort.
Managing Diabetes With a Little Help From CL
L Fernandes¹, G Shymko¹, M Schlaeppi², G Fegan²
¹PaRK Mental Health Service, Rockingham, Australia
2Rockingham General Hospital, Rockingham, Australia
Background: Management of diabetes requires high levels of motivation, compliance and resilience from patients. Early identification and treatment of co-morbid psychiatric conditions is essential to chronic disease management. The integration of a Consultation-Liaison (CL) team into a diabetes service improves access to mental health services. This poster charts the experience of a CL team providing an integrated outpatient clinic in the Diabetes Service of a general hospital.
Objectives: We aimed to improve access and acceptability of mental health care to patients, by being part of the diabetes care team.
Methods: We developed a collaborative approach to managing patients requiring input from a mental health professional. Referral criteria and pathways were agreed upon. Diabetes Nurse Educators played a key role in identifying patients. The CL team assess patients on the premises of the diabetes clinic, and provide pharmacological and psychological interventions.
Findings: Data from the first 12 months, and individual case studies, will be presented to illustrate the value of this model of care. Feedback from consumers and stakeholders will also be presented. Effective management of psychiatric disorders improved patient compliance with diabetes management, resulting in better clinical indicators for diabetes.
Reduction in unplanned admissions to the hospital was another positive outcome.
Conclusions: Integrated care for patients with chronic diseases provides a patient-focused and effective model of health care delivery.
Preliminary Investigation of Biomarkers for Schizophrenia and Psychosis
Stephanie S Fryar-Williams1, Natasha J Radcliffe2,3
1Youth In Mind Research Institute, Australia
2University of Adelaide, The Queen Elizabeth Hospital, Adelaide, Australia
3Basil Hetzel Translational Research Institute, Woodville, SA, Australia
Background: Dissatisfaction with current descriptive systems and staging methods for prediction of psychosis has prompted an alternative, more-biological approach.
Objectives: To explore biomarkers for schizophrenic the Mental Health Biomarker Project (2010-2014) sought to use neuroscience based biomarkers to construct a bio-physiological template of schizophrenia which collectively recognised and quantitatively confirmed aspects of the substrate of this serious mental illness.
Methods: A range of biochemical and neuro-physiological measures were investigated for their capacity to reach biomarker status by splitting between a control (n 67) and patient (n 67) population, in a case-control study design.
Urine samples were analysed for neurotransmitters and a haeme oxidative stress marker hydroxyhaemopyrroline-2-one. Blood samples were analysed for selected metabolic intermediates and vitamin & mineral cofactors. Cognitive and sensory processing measures in auditory and visual domains were assessed using simple office based equipment and procedures that take half an hour to administer.
Results: After Receiver Operating Curve analysis, 23 measures reached biomarkers status 17 biomarkers grouped into 5 functional-domains, for elevated neurotransmitter levels, oxidative stress and deficits in nutrition, visual and auditory function, composed a model of schizophrenia/ psychosis which demonstrated a sensitivity of 73 to 93 per cent and a specificity of 80 to 96 per cent. condition, at the 95% level of significance. A further 6 markers formed a supplementary Middle Ear panel. Regression modelling uncovered interesting translational cross-domain and panel-component influences.
Conclusions: Catecholamine neurotransmitter elevations, oxidative stress, deficits in nutrition, sensory processing and sensory end-organ function separately and collectively form part of the substrate for schizophrenic psychosis and distinguish between persons with and without this condition The combined model of these biomarkers holds promise for development of a diagnostic confirmation and predictive test for schizophrenia and psychosis and further research to confirm these biomarkers is warranted.
Nucleus Accumbens Volume and Depression in Parkinson’s Disease
B Hayhow1,2, S Brockman1, K Schruers3, D Velakoulis2, S Starkstein1
1School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, WA, Australia
2Melbourne Neuropsychiatry Centre, Melbourne, Australia
3Maastricht University, Maastricht, The Netherlands
Background: Depression affects between 40–50% of patients diagnosed with Parkinson’s disease (PD) and predicts increased patient distress, faster progression of motor and cognitive symptoms, increased disability and increased caregiver burden.
Objectives: This study investigates the correlation between depression in PD and volume loss in the nucleus accumbens, based on known associations between depression and nucleus accumbens dysfunction in patients with primary major depression.
Methods: This study analyses data obtained from a consecutive series of 70 patients with idiopathic Parkinson’s disease and a consecutive series of 50 age-comparable controls. Diagnoses of major and minor depression were made using DSM-IV TR clinical criteria, with additional clinical outcome measures obtained using the Unified Parkinson Disease Rating Scale (UPDRS), Hamilton Depression Rating Scale (HAM-D), Mini-Mental State Exam (MMSE), Cognitive Quick Learning Test (CQLT) and a structured quality of life questionnaire (PDQ-39).
Magnetic resonance imaging (MRI) data for all patients were obtained on a 1.5T Siemens Avanto system. Whole brain and nucleus accumbens volumes were calculated in a virtual environment, using BRAINS2 analytic software. A statistical analysis of findings was performed in SPSS, using a linear regression model, and an analysis of variance (ANOVA) for between-group variation.
Findings: To be advised (analysis in progress).
Audit of Monitoring for Metabolic Side Effects: A Template for National Benchmarking
M Jayaram1, N Thomas1,2, C Pantelis1,2
1University of Melbourne, Melbourne, Australia
2Melbourne Health, Melbourne, Australia
Background: Severe mental illness (SMI) is associated with a reduction in lifespan of up to 25 years, compared to the general population. SMI sufferers often require long-term multiple psychotropic medications. Literature reviews demonstrate an increased association between antipsychotics and metabolic syndrome/cardiovascular disorders. Regular monitoring of metabolic side effects may help increase lifespan for SMI patients.
Objectives: To evaluate feasibility for a national benchmarking audit. The POMH-UK team, and Royal College of Psychiatrists, London have established a track record of quality improvement programs and will assist our pilot.
Methods: There is broad organizational support for this quality improvement initiative. Following local discussions, we agreed to initiate data collection at the Adult Mental Health Rehabilitation Unit of Sunshine Hospital and document the measurement of blood pressure, body mass index (BMI), HbA1c and plasma lipids in the preceding 12 months. The anonymised data will feed into a secure server (SNAP) for analysis by an expert team, who will have no access to patient-identifiable information.
Findings: Data collection will begin soon: Results will be presented at the congress. We will pool data from partner organizations that have expressed an interest, and this will form the initial baseline for national benchmarking.
Conclusions: Demonstrating feasibility will encourage other organizations to voluntarily participate in this benchmarking exercise, and provide a platform to share good practice and further improve quality of care. We hope this will also be of interest to RANZCP and hope to work alongside them, to roll out nationally, if successful in demonstrating a sustainable improvement in clinical care.
Depression in Medical Students and Their General Practitioner Relationship: Preliminary Findings of a Longitudinal Study
Binu Jayawardena
School of Psychiatry and Clinical Neurosciences, University of Western Australia, WA, Australia
Objective: The objective of the study was to investigate the student-general practitioner relationship; determine the frequency and severity of self-reported depressive symptoms and global functioning; and to investigate stressors reported over a 12-month period, in two groups of medical students, a pre-clinical (Year 3) and clinical (Year 6) cohort.
Methods: Participants were medical students at the University of WA. Several questionnaires were administered, including a Medical Student Depression Questionnaire (MSDQ), the Patient Health Questionnaire-9 (PHQ-9) and a modified Global Assessment of Functioning (GAF). Descriptive statistics and independent t-tests were used to analyse data. The survey will be repeated in both cohorts, over the next 2 years.
Results: The survey was responded to by 168 pre-clinical and 76 clinical students. The year 3 students had a significantly higher mean score on the PHQ-9, compared with the year 6 students (p = 0.008). Students (both year groups combined) with a regular general practitioner (GP) had significantly higher PHQ-9 total scores (p = 0.053), compared with those without a regular GP. Less than 30% of students said they would seek medical help for persisting symptoms of depression. Stressors associated with depressive symptoms were significant for: relationship breakdown (p < 0.001), financial hardship (p < 0.001), academic failure (p < 0.002), obtaining special consideration from the Faculty (p < 0.001) and sexual assault (p < 0.029).
Conclusion: There may be a benefit in identifying these students who are at a higher risk of developing depression or suicidal ideation, and streamlining their access to mental health and counselling services, to assist them.
Are We Measuring the Right Stuff? Systematic Evaluation of Cognitive Functions of Patients With Schizophrenia Admitted to a Treatment and Rehabilitation Unit
Alexander John, Kim Yeak, Marie Sevastos, Helen Ayres, Danka Sokolowska, Trevor Gee, Elizabeth Moore
Background: Cognitive deficits (CD) are core features of schizophrenia and are robust predictors of community functioning and various other outcomes; however, the significance of comprehensive assessment of cognitive functions in schizophrenia is often underestimated in clinical practice.
Objective: To evaluate systematically the nature and extent of CD among patients with schizophrenia spectrum disorders admitted to an in-patient treatment and rehabilitation unit.
Methods: Cognitive functions of 80 consecutive patients with schizophrenia or schizoaffective disorder who were admitted to the John Milne Centre, Bentley Health Service, WA, Australia, were evaluated at admission, using the instrument Brief Assessment of Cognition in Schizophrenia (BACS).
Findings: The mean age of our sample was 31 years (SD 10) and the average length of stay was 153 days (SD 87). The mean BACS composite score was −1.99 SD lower than the controls. Utilising relevant cut-off scores, 28% of patients could be classified as cognitively not impaired, 25% each as mildly and moderately impaired, and 22% as severely impaired; however, the extent of impairment varied considerably among the different test components with symbol coding, digit sequencing and verbal memory showing more severe deficits, compared to verbal fluency and Tower of London tests.
Conclusions: Though often neglected in clinical practice, significant CD are present in a high proportion of patients with schizophrenia. The nature of CD varies considerably among patients and some domains are more severely affected than others. Comprehensive assessment of cognitive functions, using a standard tool, should be an integral component of clinical evaluation of patients with schizophrenia at psychiatric rehabilitation services.
Antidepressants for Pregnant and Breastfeeding Mothers: Do General Practitioners and Psychiatrists Agree?
L Kean1, M Huthwaite2
1Lower Central North Island Psychiatric Training Scheme, Wellington, NZ
2University of Otago, Wellington, NZ
Background: Treating depression in the perinatal period has positive implications for the well-being of mother and child. The decision to prescribe an antidepressant to a pregnant or breastfeeding mother; however, is an emotive process which requires reliance upon a changeable evidence base. Our recent study of psychiatrist prescribing habits revealed consistency in the importance of teratogenicity and breast milk levels when choosing an antidepressant, yet there were conflicting views on which medications were safe to prescribe. Prescribing for mothers at a primary care level can present different factors to consider, ranging from severity of the illness (e.g. higher prevalence of milder disorders) to the experience of the clinician in making these decisions.
Objectives: To understand the similarities and differences between general practitioners (GPs) and psychiatrists when prescribing in the perinatal period, with a view to educational interventions.
Methods: Clinicians were invited by email to complete an online survey. They were asked to consider antidepressants for two clinical vignettes: A mother in her first trimester of pregnancy and a mother who is breastfeeding. Medications of choice and avoidance were compiled, as well as the reasons for these prescribing choices and sources consulted.
Findings: In this presentation, we compare and contrast prescribing practices between these two groups of clinicians. We reflect upon the commonalities, as well as the unique characteristics of each group and how this impacts upon their prescribing decisions.
Conclusions: Prescribing for pregnant and breastfeeding mothers is complicated. The contrasting views amongst primary and secondary care clinicians reflects the diversity of the evidence base.
Students Passionate About Mental Health: The Story So Far
I Lim, Students Passionate About Mental Health Committee
University of Western Australia, WA, Australia
Background: Fear and misunderstanding of mental health-related issues has led to the stigmatisation of people diagnosed with mental disorders, their families, mental health professionals and associated institutions. The effects of stigma are extensive and detrimental. Students Passionate About Mental Health (SPAMH) was founded in 2011 by medical students from the University of Western Australia (UWA) with a strong interest in mental health-related stigma.
Objectives: SPAMH aims to communicate the importance of mental health to general health and wellbeing, equip students with the knowledge and skills to be effective advocates for mental health, and fight mental health-related stigma in creative ways.
Methods: SPAMH operates with the support of the Western Australian Medical Students’ Society and the UWA School of Psychiatry and Clinical Neurosciences. Events are organised throughout the year, focusing on engaging students and the wider community in a frank discourse about mental health and stigma.
Findings: SPAMH’s flagship event is its Q&A Forum, featuring an interactive panel discussion involving some of Australia’s most insightful and influential mental health figures. The Coffee Club series consists of informal meetings of students and special guests to chat about challenging mental health topics. R-U-OK? Day is a nation-wide event encouraging regular, meaningful conversations, with activities on the UWA campus proudly led by SPAMH.
Conclusions: SPAMH has drawn significant attention from within and beyond the medical community. As the SPAMH profile grows, it must broaden its student membership base, engage with other mental health interest groups, innovate new ways to fight stigma, and be a voice for compassion and understanding.
Some Peculiarities in Diagnosing Delirium in Elderly Patients of a General Hospital By Different Medical Specialists
A Merkin1, E Dinov2, I Nikiforov1
1Institute for Advanced Studies, Federal Medical-Biological Agency of Russia, Moscow, Russia
2Department of Applied Psychology and Psychotherapy, Peoples’ Friendship University of Russia, Moscow, Russia
Background: Delirium (confused state) is common in geriatric inpatients in the general hospital. It is one of the most significant syndromes of cognitive dysfunction in people of senior age. The diagnosis of delirium presents a serious challenge both to non-psychiatrist specialists and even to psychiatrists. Therefore, delirium is often misdiagnosed.
Objectives: To compare recognition of delirium by medical specialist non-psychiatrists (general medical staff: physicians and nurses) and trained psychiatrists, among patients of 65 years and older in a general hospital.
Methods: We studied a total of 164 inpatients. Delirium was diagnosed based on ICD-10 criteria. We used the Mini-Mental State Examination (MMSE) scale as a metric of the degree of the disorder of cognitive function. We used the Inter-rater Agreement Test for Nominal Values for statistical analysis.
Findings: We found 28% of the studied population to be delirious. The rate of delirium misdiagnosis by specialist non-psychiatrists in the Traumatology Unit was 29%, comparable to rates published from research elsewhere. In contrast, the rate of incorrect diagnoses in the studied population in the entire studied sample was 8% by the psychiatrist; and of over-diagnosis, 22% by non-psychiatrist specialists in the General Medicine Unit.
Conclusions: The discrepancy in delirium diagnoses by specialist non-psychiatrists is due to their reliance on personal clinical experience and is primarily caused by their insufficient in-depth knowledge of delirium and underuse of standard psychiatric scales. Our results highlight the need for psychiatry training of general medical staff, to improve their recognition and treatment of mental illnesses.
Burnout Syndrome in Medical Professionals
A Merkin1, Y Brandt2, E Dinov3, I Nikiforov1
1Institute for Advanced Studies, Federal Medical-Biological Agency of Russia, Moscow, Russia
2University of New Mexico, Albuquerque, NM, USA
3Department of Applied Psychology and Psychotherapy, Peoples’ Friendship University of Russia, Moscow, Russia
Background: Burnout of medical professionals is one of the primary causes of leaving from a medical area or premature retirement (resignation). Burnout has negative effects on work performance and patient care. Burnout has been associated with unhealthy behaviours, such as alcohol abuse; increases in smoking and coffee consumption; and familial, social, and economic problems. Due to the shortage of medical specialists, burnout syndrome continues to sustain international research interest.
Objectives: To determine the severity of burnout syndrome in different groups of medical professionals: medical doctors and lecturers of medicine.
Methods: We studied a total of 30 practicing doctors (therapists and neurologists) and 30 lecturers of medicine. We used the Maslach Burnout Inventory (MBI) for measuring burnout.
Findings: The medical doctors’ group had higher severity of burnout syndrome, in the emotional exhaustion and depersonalisation domains, while the lecturers’ group had a higher level of the personal accomplishment domain. The highest factors for burnout syndrome, according to the MBI, are the emotional exhaustion and personal accomplishment domains in both surveyed groups.
Conclusions: We present significant results showing unequal severity of burnout syndrome and significance of different factors in its development, in different groups of medical professionals.
Psychotic Symptoms in Patients Presenting to an Urban Psychiatry of Old Age (POA) Service in Ireland
K Mullin1,2, M Wrigley1, A Lynch1,2
1Department of Psychiatry of Old Age, Dublin North City Mental Health Services, Dublin, Republic of Ireland
2University College Dublin, Dublin, Republic of Ireland
Background: There is little evidence regarding psychotic symptoms in the elderly and no systematised trials regarding assessment and management of psychosis in old age.
Objectives: To analyse characteristics of patients referred to a Psychiatry of Old Age (POA) Service with psychotic symptoms.
Methods: A retrospective study examining patients referred over 6 months. Clinical and demographic data were collected and entered into a database. Those with psychotic symptoms were extracted and analysed.
Results: We found that 66 of 450 patients (15%) had psychotic symptoms. The age range was 65–98 years (mean 79 years). Referral sources included General Practitioners (48%), Geriatric Medicine (27%) and hospital wards (24%); and 58% of patients were seen within 7 days of referral, 32% within 8–21 days and 10% were seen after 21 days. There were a wide variety of diagnoses, including: dementia (67%), delirium (35%), depression (11%) and primary psychotic disorders (9%). The dual diagnosis rate was 30%. Regarding delusions, 49 patients (74%) had delusional symptoms, with 41 (62%) having paranoid delusions. Hallucinations were present in 32 cases (48%), with visual hallucinations in 23 cases (35%), auditory hallucinations in 6 cases (9%) and a combination in 3 cases (5%). Also, 23% had delusions and hallucinations. Follow-up was organised in 47 patients (71%).
Conclusions: Psychotic symptoms are associated with a variety of diagnoses, both functional and organic. These cases involved clinical complexity, reflected in the rate of dual diagnoses and variety of referral sources. The phenomenology of psychotic symptoms was distinctive, compared to reports of younger patients with psychosis. This will inform further study of psychosis in the elderly.
Right Unilateral Ultrabrief ECT in the Elderly: A Case Series
S Narchal1, A Harris2,3, B Allen3
1St. Joseph’s Hospital, St. Vincent’s and Mater Health, NSW, Australia
2Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
3Department of Psychiatry, Westmead Hospital
Background: The use of electroconvulsive therapy (ECT) in the treatment of mental disorders has been limited, especially in the elderly, by cognitive side effects. Recent evidence suggests a reduction in these effects with good clinical outcomes using ultra-brief pulse ECT (Mayur and Harris, 2011; Sackheim et al., 2008).
Objectives: To examine the use, effect and adverse effects of Right Unilateral Ultra-brief (RUL(UB)) ECT in the elderly population.
Methods: We reviewed the medical records of patients over 65 years of age, whom received RUL(UB) ECT at Westmead hospital between 21 May and 21 December 2012. Indication for ECT, threshold stimulus charge, number of ECT treatments, seizure duration, and post-ECT mental state, including cognitive assessment and side effects experienced, were examined. Observed clinical improvement was measured on the Clinical Global Impression scale.
Findings: Ten elderly patients received RUL(UB) ECT for indications of major depression with psychotic and melancholic features, or schizophrenia. The mean number of treatments required were 11.5; with a mean threshold stimulus charge of 24mC and average CGI score at admission and completion of treatment of 5.9 and 2.1, respectively. No major side effects and minimal post ECT confusion was noted.
Conclusions: RUL(UB) ECT in the elderly is an effective treatment, with minimal cognitive side effects.
References
Sackeim H, et al. (2008) Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. Brain Stimulation 1: 71–83.
Mayur P and Harris A (2011) Comparison of anti-depressant effects between brief and ultra-brief pulse unilateral electroconvulsive therapy: Brief report of randomised double blind trial. Journal of ECT 27: 59–60.
The Impact of Personality on Recovery From Mental Distress
G Newton-Howes, S Gordon
Otago University, Wellington, New Zealand
Background: The recovery model of care is gaining recognition in psychiatric practice, with policy in many parts of the world stating it is the paradigm under which psychiatric services should develop. It places the subjective process of well-being as primary, as opposed to amelioration of symptoms. Personality is known to have a significant impact on how people adapt to illness. In much the same way, personality is likely to have a moderating impact on recovery from mental distress.
Objectives: To systematically review the literature to investigate the impact of personality dimensions on the speed and extent of recovery from mental distress.
Methods: A systematic review of the literature following PRISMA search guidelines was undertaken. Extraction of personality and recovery variables for meta-analysis was planned, if sufficient data was available.
Findings: There is a dearth of literature that examines the impact of personality on recovery from mental distress. The few papers that report on personality do not allow for meta-analysis and have mixed findings. The extant literature is primarily focused on the potential negative impact of personality.
Conclusions: The impact of personality on recovery is poorly understood. Focusing primarily on the impact of personality disorder on recovery is inconsistent with moving from a focus on treating illness towards promoting well-being. Amplifying strengths and resources, in addition to identifying and addressing challenges, is required. This is a major weakness in our understanding of what helps and hinders recovery, the formal and official goal of psychiatric services in Australia and New Zealand.
Hypomania After Subthalamic Nucleus Deep Brain Stimulation for Advanced Parkinson’s Disease
F Novais, C Dias, M Coelho
Department of Neuroscience, Hospital de Santa Maria, Lisbon, Portugal
Background: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an effective treatment for Parkinson’s disease (PD), but can lead to adverse effects, including psychiatric disturbance.
Objectives: To describe a patient with stimulation-induced hypomania and to review the literature on the frequency, mechanisms and therapeutic options for this side effect.
Methods: Case report and review of literature, using the MEDLINE/PUBMED database with combinations of the keywords: Parkinson disease, DBS–STN and hypomania.
Conclusions: This case re-enforces that ventral contacts may induce hypomania in PD patients submitted to STN-DBS, and points towards the need for research of psychiatric adverse events after DBS.
Findings: A 47 year-old male subject reproducibly developed stimulation-induced hypomania when using ventrally-located contacts; and he was unaware of his mood disturbance. He experienced dramatic improvement in his motor Parkinsonism and did not complain of any side effects, although his family reported detrimental hypomanic behaviour. To control hypomania while maintaining the best motor benefits, stimulation parameters were readjusted and clozapine was introduced, which was successfully achieved.
STN-DBS has been associated with psychiatric manifestations (mania, 4%). It is believed that dopamine dysregulation has a role in the etiology of post-DBS mania.
The adjustment of stimulation parameters appears to reverse the DBS-induced mania in many of the cases reported in literature. When no improvement occurs, clozapine is an alternative.
References
Saleh C (2011) How to treat DBS-induced mania? Journal of the Neurological Sciences 301: 116.
Schilbach L, et al. (2012) Pharmacological treatment of deep brain stimulation-induced hypomania leads to clinical remission while preserving motor benefits. Neurocase 18: 152–159.
MindhealthConnect: The National Mental Health Web Portal
Nick O’Connor1,2, Maureen Robinson3
1Northern Sydney Local Health District, Sydney, Australia
2Discipline of Psychiatry, University of Sydney, Sydney, Australia
3Healthdirect Australia, Australia
Background: MindHealthConnect (MHC) is the national mental health web portal commissioned by the Australian Federal Government as part of the National E-Mental Health Strategy. MindHealthConnect was initiated by Healthdirect Australia in July 2012. As at November 2013, MindHealthConnect has 18 partner organisations, 22 online programs, 414 fact sheets and is linked to a number of mental health ‘communities’. MindHealthConnect has developed a Mental Health Guided Search Tool to enable users to quickly identify the most appropriate resources according to their problem. The MHC website has linkage to the National Health Service Directory. The web portal has undergone an external evaluation, as part of the developmental phase.
Objectives: To describe and demonstrate the MindHealthConnect web portal. To report on the development, clinical governance, activity and performance data.
Methods: This report is from a fellow of the College, who has been a member of the Clinical Governance Advisory Group of Healthdirect Australia since 2007, and a member of the MHC Service Improvement and Development, the Committee from start-up and the General Manager of Clinical Governance of Healthdirect Australia.
Findings: The performance activity and formative evaluation of the Guided Search Tool are presented.
Conclusions: The functionality, usability and extensive resources of the MHC provides a central, integrative component of e-mental health for Australians and is an important resource for clinicians and the community.
Survey of Atypical Antipsychotic Use Amongst CAMHS Prescribers
P Rao1, I Chakrabarti2, P Sigalas3
1CAHS, Fremantle CAMHS, Department of Health, Fremantle, WA, Australia
2Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
3Northern Deanery, Newcastle upon Tyne, UK
Background: In the last decade, the use of atypical antipsychotics in children has increased. The use has been both licensed and ‘off label’, targeting different symptoms and clinical conditions. Most research around safety and efficacy has been conducted in adults with repeated calls for such research in children being in vain.
Objectives: This survey aims to describe current prescribing practices in the ‘real world’ and to compare the results with existing research, to evaluate the lessons learnt.
Methods: The survey consisted of a semi-structured questionnaire that aimed to evaluate the current practices of CAMHS prescribers. The 31questionniares sent out yielded 24 completed returns (77.41%). A literature search yielded articles that described prescribing trends over the last decade. Survey results were compared with the literature.
Findings: The commonest indication for atypicals was psychosis (75%). Others included behavioral control (50%), tics (37.5%), attention deficit hyperactivity disorder (ADHD) and anxiety. Atypicals were the commonest first-line medications for behavioural control, with Risperidone (54%) being the preferred agent. Second-line medications included Quetiapine (7%) and Olanzapine (15%). Doses were lower for behavioral control and the atypicals were trialled for up to 8 weeks with duration of treatment extending to 9 months. The most common target symptoms were aggression (85%), agitation (54%) and anxiety (54%), when used for non-psychotic presentations. Most prescribers cited peer/expert opinion and own clinical experience as the evidence base for their use.
Conclusions: Atypicals continue to be used as first-line medications for psychotic and non-psychotic behavioural presentations, in spite of the absence of clear evidence and repeated calls for in depth research in this population.
An Exploration of the Ethical Arguments Around the Absolute Ban on Smoking for Detained Patients
Oliver Rooke
University of Auckland and Waitemata DHB, Auckland, New Zealand
Background: The RANZCP code of ethics states, in respect of detained patients, that ‘psychiatrists shall be especially mindful of respect for autonomy’. The RANZCP is also encouraging psychiatrists to address the inequities in the physical health of our patients and in particular, to address the high rates of smoking tobacco. Most services now have policies to encourage and support patients in smoking cessation. In some hospitals, the ‘fight against tobacco’ has also included the banning of smoking in hospital buildings or grounds, making it impossible for detained patients to smoke. This issue was recently brought before the Auckland courts. The judge dismissed the complainant’s case – that stopping her from smoking whilst detained under the MHA was illegal; however, in his summary, he wrote that he had deliberately declined to comment on the ethics of the ban.
Ethical standards are higher than legal standards. The ethical arguments for and against the ban have not been widely published nor disseminated. The issue has the potential for affecting the reputation and standing of all psychiatrists.
Objectives: To explore the ethical principles involved and then to examine the strength of the scientific evidence for both the beneficence and the maleficence of the ban, and for the effectiveness of nicotine replacement therapy at reducing the distress of withdrawal.
Family Genetics of Alcohol Dependence: A Case Control Study Among First and Second Degree Relatives (FDR and SDR)
Saddichha S1, Murthy P2
1NAMHS, NWMH, Melbourne Health, VIC, Australia
2NIMHANS, Bangalore, India
Background: Environmental and genetic influences can influence presentations of different disorders among alcohol-dependent probands.
Objectives: This study aimed to evaluate the co-morbidity of substance use and other psychiatric disorders among probands, and first degree and second degree relatives of patients with alcohol dependence, and compare them with a normal control group.
Methods: Using the Semi-Structured Assessment for Genetics of Alcoholism (SSAGA) Interview schedule, 50 probands with alcohol dependence, their first-degree relatives (FDRs) (n = 237) and second-degree relatives (SDRs) (n = 526), were evaluated for co-morbidity and co-aggregation of substance use and other psychiatric disorders. This was compared with a normal population group comprising 50 individuals, their FDRs (n = 286) and SDRs (n = 519). Both the Individual Assessment Module and Family History Assessment Module were applied for the diagnosis of individual disorders. The odds ratio (OR) was then calculated to evaluate the increased risk, if any, among the study group.
Findings: The study showed that there was an increased prevalence and risk of tobacco dependence (86%; OR 10.9), attention-deficit hyperactivity disorder (ADHD) (40%; OR 32.7), oppositional defiance disorder (ODD) (20%; OR 12.2) and suicidal behaviour (14%; OR 2.2) among the probands with alcohol dependence, when compared to the normal population. Among FDRs and SDRs, there was an increased co-aggregation and risk of tobacco dependence (13–22%; OR 4.3), alcohol dependence (14–20%; OR 4–12), depression (2–3%; OR 4.5–8.7) and antisocial personality disorder (ASPD) (0.8%; OR 2), when compared to the FDRs and SDRs of the normal control group.
Conclusions: The study concluded that alcohol dependence, tobacco dependence, suicidal behavior, depression and antisocial personality disorder co-aggregated in families of alcohol dependence, representing two different sub-phenotypes, which are inherently inheritable.
High-Impact Child Abuse May Predict Risk of Elevated Suicidality During Antidepressant Initiation
Ajeet B Singh1,2, Chad A Bousman2,3,4,5, Chee H Ng2 and Michael Berk1,2,5,6
1IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, Australia
2Department of Psychiatry, University of Melbourne, Parkville, Australia
3Department of General Practice, University of Melbourne, Parkville, Australia
4Centre for Human Psychopharmacology, Swineburne University of Technology, Hawthorne, Australia
5Florey Institute for Neuroscience and Mental Health, Parkville, Australia
6Orygen Youth Health Research Centre, Centre for Youth Mental Health, Parkville, Australia
Background: Concerns have emerged that initiation of an antidepressant can lead to or exacerbate suicidality. If those more at risk could be identified prior to treatment, risk management could be assisted.
Objectives: We studied the role of child abuse and ongoing emotional impact from abuse on suicidality risk during the first week of antidepressant treatment. The hypothesis was that subjects with high-impact child abuse would have greater elevation of suicidality during the first week of treatment.
Methods: We initiated 51 subjects on either venlafaxine (VEN) or escitalopram (ESC), for major depressive disorder (MDD), and had pre-treatment suicidality assessed with the reasons for living scale (RFLS), which was repeated after 1 week of treatment. Several clinical, demographic and genotype variables were controlled for. The 15-item Impact of Event Scale (IES-15) was administered to subjects reporting abuse, to dichotomise the abuse group into low and high (IES-15 ≥ 26) impact groups, for sub-analysis as per the scale’s rating guidelines.
Findings: Subjects reporting no child abuse exposure were less likely to have increased suicidality during the first week of antidepressant treatment (7.6%), compared to subjects with low-impact abuse (38.5%; p = 0.041) and high-impact abuse (58.3%; p = 0.009). Only high-impact abuse predicted increased suicidality, after adjustment for potential confounders, such as depression severity (OR = 31.5, 95% CI = 1.3 to 748.7; p = 0.03).
Conclusions: If these findings are replicated in larger samples, child abuse history could become an important element for assessing risk benefit balance, when initiating antidepressants, and may help guide the level of patient review needed during antidepressant initiation.
Psychomotor Depressive Symptoms May Differentially Respond to Venlafaxine, But Norepinephrine Transporter Polymorphisms Do Not Appear Associated With Differential SSRI to SNRI Efficacy in Major Depression
Ajeet B Singh1,2, Chad A Bousman2,3,4,5, Chee H Ng2, Keith Byron, Michael Berk1,2,5,7
1Deakin University, IMPACT Strategic Research Centre, School of Medicine, Geelong, Australia
2The University of Melbourne, Department of Psychiatry, Parkville, Australia
3The University of Melbourne, Department of General Practice, Parkville, Australia
4Swinburne University of Technology, Centre for Human Psychopharmacology, Hawthorne, Australia
5Florey Institute for Neuroscience and Mental Health, Parkville, Australia
6Healthscope Pathology, Clayton, VIC, Australia
7Orygen Youth Health Research Centre, Centre for Youth Mental Health, Parkville, Australia
Background: Predicting differential antidepressant efficacy remains an elusive goal in major depressive disorder (MDD).
Objectives: Firstly, to examine if psychomotor retardation symptoms (item 8 on the 17-item Hamilton Depression Rating Scale) improve preferentially with venlafaxine (VEN) over escitalopram (ESC) treatment. Secondly, whether the 18-item CORE psychomotor signs scale predicts antidepressant remission. Finally, to investigate the role of two norepinephrine transporter gene (NET) polymorphisms (rs2242446 and rs5569) on antidepressant efficacy.
Methods: Adults diagnosed with Diagnostic and Statistical Manual of Mental Disorders, 4th edition for MDD (n = 113) were treated with ESC or VEN prospectively, for 8 weeks, and rated serially with the Hamilton Depression Rating Scale. In a subsample (n = 51) of patients from one of the three recruitment sites, the CORE psychomotor signs scale was also administered at baseline.
Findings: Participants treated with VEN had significantly greater reduction in psychomotor retardation symptoms than those treated with ESC. The CORE scale did not predict antidepressant response nor remission. Neither NET polymorphism moderated the antidepressant’s efficacy.
Conclusions: Findings suggest possible preferential utility of a selective serotonin and noradrenaline reuptake inhibitor in cases of MDD presenting with greater psychomotor retardation. The moderate to small sample size here made a Type II error risk possible, and the negative findings need to be interpreted with caution. The positive finding of preferential efficacy of VEN for psychomotor retardation symptoms has potential translational utility.
Landscaping the Working Environment for Schizophrenia
A Solar1,2
1University of Western Australia, Perth, WA, Australia
2Sir Charles Gairdner Hospital, Perth, WA, Australia
Background: The individual placement and support (IPS) approach to Supported Employment (SE) can be more effective than traditional rehabilitation in getting a patient with schizophrenia, who wants a chance to work, into regular employment. Employment has benefits for physical and mental health.
Objectives: Analyse feasibility and shape of a voluntary IPS linkage intervention for schizophrenia, initiated from a mental health unit (MHU).
Methods: We interviewed 20 MHU patients with chronic schizophrenia, with informed consent, about getting employment.
Findings: No patients were in paid or volunteer work. We found that 17 subjects acknowledged the possibly of people with schizophrenia working in regular workplaces, with support, and 9 described the positive benefits of work. While 11 wanted paid competitive work with support, none knew about the IPS approach. Nine subjects described an accessible individual support pathway to competitive employment. Three had considered volunteer work and could each describe an individual support pathway to volunteer work.
Of the other 6 subjects who never wanted to engage in paid work nor volunteer work, 5 were aged between 56 and 65 years old. The only exception was aged 35, and happy with his life on a disability pension, with support from a community clinic.
Conclusions: Just over 50% of those studied did want competitive work and support to find it. Only a minority, who wanted competitive work, could not describe accessible support pathways. The evidence-based IPS approach could be offered to the group who wanted competitive work, in addition to treatment as usual, increasing the chances of employment’s positive benefits for mental and physical health.
A Review of Antipsychotic Polypharmacy, High-Dose Prescribing and Evaluation of Adherence to Local Physical Health Monitoring Guidelines, Within the Assertive Community Team (ACT) at Rockingham Kwinana Mental Health Service
D Vecchio, C Spence
ACT Team Rockingham Kwinana Mental Health Service, Rockingham, WA, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recommend against using combination antipsychotics and advise that the use of high doses should be evidence-based. Despite this, antipsychotic polypharmacy and high-dose prescribing remains a common treatment strategy in clinical practice.
Objectives: We aimed to identify the prevalence of antipsychotic polypharmacy and high-dose prescribing in an Assertive Community Team (ACT) population and establish whether physical health monitoring met local protocols.
Methods: Patients under the care of ACT for 1 year from 2012–2013 were identified and those with a diagnosis of a psychotic illness were included.
Clinical records were retrospectively reviewed and medication regimens were documented. Polypharmacy existed if the patient was prescribed more than one antipsychotic. High-dose prescribing was determined using the maximum recommended doses according to the British National Formulary and calculating the cumulative percentage of antipsychotic prescribed.
Information regarding monitoring of physical health parameters, liaison with General Practitioners (GPs) and documentation of the rationale and consent procedures were recorded.
Findings: For this study, 38 patients met the inclusion criteria. Of these, 16 patients (42%) were prescribed antipsychotic polypharmacy and 13 patients (34%) were on high-dose antipsychotics. Documentation of physical health monitoring and the rationale for prescribing was frequently missing. Liaison with the GP occurred in 45% of cases; informed consent was not documented.
Conclusions: Antipsychotic polypharmacy and high-dose prescribing are common and physical health monitoring is generally poor. Prescribing practices should be clearly documented and supported by an evidence base. Involvement of GPs, pharmacists, patients and carers is crucial.
References
North Metropolitan Health Service (2013) Antipsychotic polypharmacy. Graylands Hospital Drug Bulletin 20(2): ISSN 1323–125.
Royal Australian and New Zealand College of Psychiatrists (2005) Clinical Practice Guidelines Team for the Treatment of Schizophrenia and Related Disorders. Australian and New Zealand Journal of Psychiatry 39:1–30.
The Recovery Model in Psychiatric Intensive Care: What Does the Consumer Say?
S Suetani1,2, D Ash2,3, M Halpin3, T Singh1,3
1The Queen Elizabeth Hospital, Adelaide, Australia
2University of Adelaide, Adelaide, Australia
3Glenside Hospital, Adelaide, Australia
Background: It is now generally accepted that recovery-based practice should be incorporated into all aspects of service delivery, including acute services. Cedars Psychiatric Intensive Care Unit (PICU) is a 10-bed unit that provides services for Adelaide and rural areas of SA. The application of a recovery model in a PICU is ideally reflected in a more positive experience of the unit by consumers.
Objectives: An exit interview was designed to discover more about the experience of consumers in the unit, particularly in relation to recovery-based practices that had been implemented over the past 2 years.
Methods: The exit interview offered consumers the opportunity to express their views about admission to the unit, their relationship with staff, their treatment, their experience of coercive interventions, and the perceived shortcomings and strengths of the unit.
Findings: Individuals varied widely in their experience of the unit. Recurring themes that emerged from the analysis of consumer narratives included the importance of establishing positive relationships with staff and adequate discussion and communication about the treatment options.
Conclusions: Implementation of recovery-based practice in a PICU is a challenging, yet achievable task. A systematic review process, such as that described in the current study, is useful to further improve consumer experience and enhance the likelihood of developing positive, collaborative relationships with mental health staff.
Detection of GILZ, IL-6 And TNF- A in the Context of Depression Subtypes
A Thiagarajah1, L Eades1, R Thomas1, E Guymer2, S Jones1,Y Yang1, J Harris1, E Morand 1,2, D Clarke1,2, M Leech1,2
1Monash University, Melbourne, Australia
2Monash Medical Centre, Melbourne, Australia
Background: Depression is characterised by a complex pathophysiology. Categorising depression according to subtypes, such as ‘anhedonia’ and ‘demoralisation’, may aid in identifying biomarkers relevant to depression (Clarke et al., 2000). One such biomarker is glucocorticoid-induced leucine zipper (GILZ), which is part of the hypothalamic-pituitary-adrenal axis, and may be abnormal in depression. GILZ is associated with interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNF-α) (Beaulieu and Morand, 2011).
Objectives: As GILZ could relate to depression, we aimed to compare GILZ levels across depression subtypes in depressed patients and controls. We further aimed to co-measure IL-6 and TNF-α, to contextualise the GILZ readings.
Methods: Participants from outpatient clinics were assessed for depression with validated depression scales, and were compared to healthy staff. Polymerase chain reaction (PCR) was used to quantify gene expression in peripheral blood mononuclear cells (PBMC).
Findings: We assessed 46 depressed patients and 23 controls. GILZ was higher in severe anhedonia, compared to mild anhedonia (p ≤ 0.025). In contrast, GILZ expression did not differ across the categories of demoralisation severity. The GILZ:IL-6 (p ≤ 0.035) and GILZ:TNF-α (p ≤ 0.005) ratios were higher in depressed patients, compared to controls.
Conclusions: The association of high GILZ and anhedonia infers that categorising depression into subtypes assists in clarifying its pathophysiology. Additionally, co-measuring biomarker clusters may increase our understanding of depression.
References
Beaulieu E and Morand EF (2011) Role of GILZ in immune regulation, glucocorticoid actions and rheumatoid arthritis. Nature Reviews Rheumatology. Doi:10.1038/nrrheum.2011.59.
Clarke DM, Mackinnon AJ, Smith GC, et al. (2000) Dimensions of psychopathology in the medically ill: A latent trait analysis. Psychosomatics 2000; 41(5): 418–425.
Early Effect of Agomelatine on Self-Referential Processing in Acute Depressed Patients: A FMRI Study
Servier Laboratories (aust) PTY LTD
P Fossati1, M Jabourian2, J Laredo2, N Allailli1, S Lehericy3, P Delavaeau4
1Psychiatry, CNRS USR 3246 & CR-ICM & APHP G Hospital Pitié Salpétrière, Paris
2Neuroscience ISIS, Servier, Suresnes,
3Neuroradiology, CENIR & CR-ICM,
4Psychiatry, CNRS USR 3246 & CR-ICM, Paris, France
Background: Increased self-focus, the tendency to excessively appraise stimuli as strongly related to oneself, is a core feature of major depression. In major depressive disorder, increased self-focus is associated with abnormal dorsal and ventral medial prefrontal activity, as well as increased dorsolateral prefrontal activity.
Objectives: Although Lemogne et al. (2010) suggested that medial prefrontal activity does not change after reduction of depressive symptoms, sensitivity of brain regions involved in self-referential processing to antidepressants is unknown. The main goal here was to assess with fMRI early effects of agomelatine on self-referential processing in depressed patients.
Methods: We scanned 25 acute depressed patients and 14 healthy controls before and after 7 days of treatment, while performing self-referential processing tasks using emotional pictures. Patients were randomised to agomelatine 25mg/day (n =13) or placebo (n = 12); healthy controls received placebo. Subjects were asked to evaluate pictures according to different conditions: Self (Does the picture relate to you?), General (Is the picture positive or negative?). Depression was assessed with the Hamilton Scale.
Findings: Depressed patients, compared to controls at baseline, showed hyperactivity in the dorsolateral prefrontal cortex, dorsal anterior cingulate and ventrolateral prefrontal cortex (VLPFC). After 7 days treatment, agomelatine, compared to placebo, normalised the hyperactivity of VLPFC to the healthy volunteers’ level.
Conclusions: Agomelatine targets specific brain structures, namely VLPFC, involved in automatic regulation of emotion during self-referential processing. These changes in brain activity at day 7 could contribute to the early clinical effects of agomelatine, suggesting an early setup of the brain for long-term response and remission of depression.
Deep Brain Stimulation for Obsessive Compulsive Disorder: The First Three Australian Cases
D Velakoulis1,2,3, A Evans1,4, M Walterfang1,2,3, R Mocellin1,2,3, S Mangelsdorf1, R Bittar5
1Neuropsychiatry Unit, Royal Melbourne Hospital
2Melbourne Neuropsychiatry Centre, University of Melbourne and Melbourne Health
3Department of Neurology, Royal Melbourne Hospital
4Department of Neurosurgery, Royal Melbourne Hospital
Background: Deep brain stimulation (DBS) for treatment-refractory obsessive-compulsive disorder (OCD) was first reported in 1999. Since that time, less than 100 such procedures have been reported.
Objectives: Report our experience with the first three cases (of DBS for treating OCD) in Australia, at the Royal Melbourne Hospital.
Methods: Three patients with severe, treatment-refractory OCD underwent DBS targeted at the nucleus accumbens, bilaterally. We obtained clinical ratings before and after DBS, for a minimum of 18 months.
Findings: All three patients (2 men,1 woman; mean age 54) showed significant, clinically-relevant improvement across a broad range of rating scales (38% reduction in YBOCS) and in terms of self-reported and carer-reported function.
Conclusions: Our initial results mirror those from larger overseas centres and suggest that DBS may be an effective therapeutic intervention for carefully selected patients with severe OCD.
Strategies Aimed at Reducing the 28-Day Readmission Rate in a Regional Mental Health Inpatient Facility
J Wann1,2, N Gill1,3, G Neilson1, D Aldons1
1Division of Mental Health, Darling Downs Hospital and Health Service, Toowoomba, Australia
2Faculty of Nursing, University of Southern Queensland, Toowoomba, Australia
3Rural Clinical School, University of Queensland, Toowoomba, Australia
Background: A 28-day readmission rate is the key performance indicator (KPI) used to monitor service performance, according to the Fourth National Mental Health Plan (2009 – 2014) (Australian Health Ministers, 2009). The 28-day mental health readmission rates that exceed the stipulated target may reflect service inefficiencies with regards to inadequacies in inpatient treatment and post-discharge follow-up (NMHWG Drafting Group, 2005). The KPI target for hospital and health services in Queensland has recently reduced from 14% to 12%, to ensure optimal service provision.
Objectives: The objective of the study was to identify factors that contribute to increased proportions of consumers requiring readmission to a mental health inpatient facility, within 28 days of discharge. This project will also aim to reduce the readmission rate below 12%, through implementation of various consumer-focused strategies and interventions.
Methods: This is a mixed methods study, using both quantitative and qualitative methods. Quantitative data will be collected through chart audits of all consumers requiring readmission, within 28 days, to the inpatient mental health unit. Qualitative data will be obtained from patient interviews with those consumers requiring readmission within 28 days and focus groups of relevant stakeholders. Information and data will then be analysed, to determine the reasons for 28-day readmissions. Consumer-focused interventions aimed at optimising the discharge process, post-discharge follow-up and community support would then be developed.
Findings/conclusions: Findings from the chart audits, consumer interviews and focus groups will be presented at the Congress.
References
Australian Health Ministers (2009) Fourth National Mental Health Plan. Canberra: Commonwealth of Australia. Available at: www.health.gov.au/internet/main/publishing.nsf/Content/9A5A0E8BDFC55D3BCA257BF0001C1B1C/$File/plan09v2.pdf (accessed 15 November 2013).
NMHWG Information Strategy Committee Performance Indicator Drafting Group (2005) Key Performance Indicators for Australian Public Mental Health Services. Report, ISC Discussion paper no.6. Canberra: Australian Government Department of Health and Ageing. Available at: www.health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-k-pi-toc~mental-pubs-k-pi-app~mental-pubs-k-pi-app-a~mental-pubs-k-pi-app-a-1 (accessed 15 November 2013).
A Case Series of REM Behaviour Disorder, an Important and Highly Treatable Disorder With a Long Diagnostic Latency
R Weeks1,2, J D’Costa1,2, V Aiyappan1,2, C Chai-Coetzer1,2, N Antic1,2
1Adelaide Institute for Sleep Health, Repatriation General Hospital, Daw Park, SA, Australia
2School of Medicine, Flinders University of South Australia, Bedford Park, SA, Australia
Background: REM Behaviour Disorder (RBD) is a parasomnia associated with the α-synucleinopathies that affects mainly older males and is characterised by violent sleep behaviour associated with dream enactment.
Objectives: To describe demographic, clinical and polysomnographic (PSG) features and treatment outcomes in RBD.
Methods: Retrospective series of new cases of definite or probable RBD, as defined by International Classification of Sleep Disorders, Revised (ICSD-R) criteria, seen at the Adelaide Institute for Sleep Health from 2003–2010. Cases were identified by database search, with subsequent review of case notes and original raw PSG data, to confirm diagnosis.
Findings: We identified 28 patients (24 were male), with a mean age of 66 (range, 45–80). Mean diagnostic latency was 7.5 years (0.25–40). Sleep-related injury (bruising, laceration and fracture-dislocation) was documented in 11 of these patients (39%). Twelve patients (43%) had moderate-to-severe obstructive sleep apnoea, with persistent RBD symptoms despite CPAP therapy. Four patients had an α-synucleinopathy at initial presentation. Clonazepam (mean dose 0.5mg) resulted in effective symptom control in 86% of patients.
Conclusions: This case series highlights the long latency between symptom onset and diagnosis. We describe characteristic features and key clinical associations, particularly with the α-synucleinopathies. Specific PSG features are necessary for the diagnosis. Clonazepam is a highly effective and well-tolerated treatment.
References
Gagnon JF, et al. (2006) Rapid-eye-movement sleep behaviour disorder and neurodegenerative diseases. Lancet Neurol 5(7): 424–432.
Schenck CH and Mahowald MW (1990) A polysomnographic, neurologic, psychiatric and clinical outcome report on 70 consecutive cases with REM sleep behaviour disorder. Cleveland Clinic Journal of Medicine 57: S9-S23.
The Take Up of Postnatal Services (TUPS) Study
C Zanetti1,2
Saint John of God Healthcare, Subiaco Raphael Centre, Perth, Australia
University of Notre Dame, Fremantle, Australia
Background: Screening for postnatal mental health is aimed at providing early intervention to promote well-being and mitigate potential chronicity of symptoms. Take up of services is a useful measure of the success of screening efforts and can guide service provision; however, few studies have directly examined service take up; and many focus on maternal physical, rather than mental, health. The Take Up of Postnatal Services (TUPS) study will examine the frequency of a range of problems in postnatal women that reflect difficulties likely to affect their mental health and their adjustment to motherhood.
Objectives: Explore the extent of the mothers’ uptake of services suggested, after a problem in some area of the transition to parenthood has been identified. Establish a baseline of the extent to which women currently take up services for help with a problem in some area of the transition to parenthood. Examine mothers’ reasons for not taking up available services.
Methods: All mothers who delivered within the Perth private sector during a 6-month period will be invited to participate in a retrospective, on-line survey of their experiences and preferences with regards to service uptake, for a range of problems that have been found to be important to mothers of new babies.
Findings: The framework and progress of the study will be described.
Conclusions: There is a need for a baseline against which screening efficacy and service provision can be measured. Further research aimed at women who delivered within the public sector would be valuable for the purposes of research, policy and service development.
Palm-SCH-3010 Final Analysis: Group A, Non- Acute, Recent Versus Chronic Schizophrenia Patients, Switched From Oral Aps
Once Monthly Paliperidone Palmitate – Tolerability and Treatment Response in Recently Diagnosed Versus Chronic Non-Acute Schizophrenia Patients Switched From Previously Unsuccessful Treatment With Oral Antipsychotics
L Hargarter1, P Bergmans2, P Cherubin3, E Rancans4, Y Bez5, E Parellada6, B Carpiniello7, P Vidailhet8, A Schreiner1
1EMEA Medical Affairs, Janssen Cilag, Neuss, Germany
2Biostatistics & Programming, Janssen Cilag Benelux, Tilburg, Netherlands
3EMEA Medical Affairs, Janssen Cilag, Issy-les-Moulineaux, France
4Department of Psychiatry and Narcology, Riga Stradins University, Riga, Latvia
5Dicle University Medical Faculty - Diyarbakir – Turkey
6Hospital Clínic de Barcelona - Barcelona – Spain
7Clinica Psichiatrica - Università di Cagliari - Cagliari – Italy
8Centre Hospitalier Régional Universitaire de Strasbourg - Strasbourg – France;
Introduction: To explore tolerability and treatment response of flexible doses of once monthly paliperidone palmitate (PP) in recently diagnosed versus chronic adult non-acute schizophrenia patients previously unsuccessfully treated with oral antipsychotics.
Methods: International prospective 6-month open-label study exploring non-acute but symptomatic patients, stratified by years since diagnosis [recently diagnosed (≤3 years) or chronic (>3 years)]. Outcomes were changes from baseline to endpoint in Positive and Negative Syndrome Scale (PANSS) total score, Clinical Global Impression-Change Scale (CGI-C), Extrapyramidal Symptom Rating Scale (ESRS) and adverse events (AEs).
Results: N=233 recently diagnosed (63.9% male, mean age 32.2±10.3 years, mean time since diagnosis 1.2±0.9 years) and n=360 chronic patients (62.5% male, mean age 42.4±11.0, mean time since diagnosis 13.9±9.3 years) were included in the analyses. 77.7% and 72.5% of the patients, respectively, completed the study. Mean mode maintenance doses of PP were comparable between subgroups (100.6±33.0 mg eq and 105.1±32.6 mg eq). 71% of recently diagnosed and 59% of chronic patients showed a response measured by decrease of ≥20% in PANSS total score at endpoint. Mean change in PANSS total score at endpoint (-15.1±15.6 and -9.6±15.7, respectively), but also in PANSS positive (-3.6 vs. -2.3), negative (-4.4 vs. -2.9) and general subscores (-7.1 vs. -4.4) was numerically but consistently higher in recently diagnosed patients. At endpoint, 52.4% of recently diagnosed patients were rated much or very much improved on CGI-C compared to 38.1% in the chronic group. TEAEs identified in ≥5% in both subgroups (recently diagnosed vs. chronic) were injection site pain (12.9% vs. 11.9%), insomnia (9.9% vs. 7.8%), anxiety (6.4% vs. 6.9%), and headache (6.0% vs.5.3%).
Conclusions: These data suggest that recently diagnosed and chronic patients previously unsuccessfully treated with oral antipsychotics may benefit from paliperidone palmitate, with recently diagnosed patients showing consistently higher treatment response, and lower disease severity at endpoint.
Palm-SCH-3010 Final Analysis: Group B RLAT: Non-Acute Patients Switching From Long-Acting Risperidone Treatment (RLAT) to Paliperidone Palmitate
Flexibly Dosed Paliperidone Palmitate in Non-Acute But Symptomatic Patients With Schizophrenia Previously Unsuccessfully Treated With Long-Acting Injectable Risperidone
A Schreiner1, P Bergmans2, P-M Llorca3, G Corrivetti4, B Cosar5, P Cherubin6, L Hargarter1
1EMEA Medical Affairs, Janssen Cilag, Neuss, Germany
2Biometrics and Reporting, Janssen Cilag Benelux, Tilburg, Netherlands
3CHRU Clermont-Ferrand, Hôpital Gabriel Montpied, Clermont-Ferrand, France
4U.O.S.M. Distretto D, Faiano, Italy
5Gazi University Medical Faculty, Ankara, Turkey
6EMEA Medical Affairs, Janssen Cilag, Issy-les-Moulineaux, France
Introduction: To explore tolerability, safety and treatment response of flexibly dosed paliperidone palmitate (PP) in adult non-acute but symptomatic patients with an established diagnosis of schizophrenia previously unsuccessfully treated with long-acting injectable risperidone treatment (RLAT).
Methods: International, prospective 6-month open-label study. Major outcomes were clinical response (percentage of patients with ≥20% improvement in Positive and Negative Syndrome Scale (PANSS) total score at endpoint), functioning (Personal and Social Performance scale (PSP)), Extrapyramidal Symptom Rating Scale (ESRS), sleep quality, daytime drowsiness and treatment-emergent adverse events (TEAEs).
Results: The intent-to-treat population comprised 56 patients previously treated with RLAT (64.3% male, mean age 39.9±11.0 years, 71.4% paranoid schizophrenia, mean BMI 28.5±5.8 kg/m2. 71.4% of patients completed the 6-month study. Withdrawal of consent (8.9%) and adverse events (10.7%) were the most frequent reasons for early discontinuation. The median mode maintenance dose of PP was 100 mg eq. Mean PANSS baseline total score was 67.5±20.7 and decreased by -9.2 points on average at endpoint (95% confidence interval -15.0; -3.5, p<0.0001). At endpoint, 61.1% of patients had improved as measured by ≥20% in PANSS total score compared to baseline. Patient functioning in PSP increased by 5.2±15.3 points (p=0.0163). Sleep quality and daytime drowsiness improved significantly (both p<0.0292). Extrapyramidal symptoms in ESRS significantly improved from 3.5±7.1 at baseline to 2.5±6.4 at endpoint (p=0.0038). Concomitant use of anticholinergic medications decreased from 7.1% at baseline to 5.4% at endpoint. TEAEs reported in ≥5% of patients were psychotic disorder (10.7%), injection site pain, headache, schizophrenia, anxiety (7.1% each), constipation and somnolence (5.4% each). Mean body weight decreased by 0.9±4.5 kg from baseline to endpoint.
Conclusion: These data suggest that paliperidone palmitate is associated with a meaningful clinical response and functional improvement and is well tolerated with less EPS in non-acute, symptomatic schizophrenia patients previously unsuccessfully treated with RLAT.
Palm-SCH-3010 Final Analysis: Primary Efficacy Outcome Group C (Acute Patients Switching From Oral Antipsychotic to Paliperidone Palmitate)
Paliperidone Palmitate in Acute Patients With Schizophrenia – Treatment Response, Safety and Tolerability: A Prospective Flexible Dose Study in Patients Previously Unsuccessfully Treated With Oral Antipsychotics
A Schreiner1, P Bergmans2, P Cherubin3, E Rancans4, Y Bez5, E Parellada6, B Carpiniello7, P Vidailhet8, L Hargarter1
1EMEA Medical Affairs, Janssen Cilag, Neuss, Germany
2Biostatistics & Programming, Janssen Cilag Benelux, Tilburg, Netherlands
3EMEA Medical Affairs, Janssen Cilag, Issy-les-Moulineaux, France
4Department of Psychiatry and Narcology, Riga Stradins University, Riga, Latvia
5Dicle University Medical Faculty, Diyarbakir, Turkey
6Hospital Clínic de Barcelona, Barcelona, Spain
7Clinica Psichiatrica, Università di Cagliari, Cagliari, Italy
8Centre Hospitalier Régional Universitaire de Strasbourg, Strasbourg, France
Introduction: Exploring treatment outcomes with once-monthly paliperidone palmitate (PP) in more representative patients with schizophrenia may guide recommendations for use of and transition to PP. This study explores tolerability, safety and treatment response of flexible doses of PP in adult patients with an acute exacerbation of schizophrenia previously unsuccessfully treated with oral antipsychotics.
Methods: International prospective 6-month, open-label study. Outcome parameters were change in Positive and Negative Syndrome Scale (PANSS) total score, Clinical Global Impression-Severity Scale (CGI-S), adverse events (AEs), and weight change.
Results: 212 acute patients (ITT, intent-to-treat population): 59.0% male, mean age 36.4 ±12.1 years, 85.4% paranoid schizophrenia were enrolled. Main reason for transition from prior oral antipsychotic treatment was lack of efficacy in 45.8% of patients. 70.3% of patients completed the 6-month study. Most frequent reasons for early discontinuation were subject choice (9.4%), AE (9.0%), loss to follow-up (4.7%) and lack of efficacy (2.8%). Recommended initiation regimen of PP (150 mg eq on day 1 and 100 mg eq on day 8) was administered in 92.9% of subjects. Mean baseline PANSS total score decreased from 98.5±20.1 as of day 8 of treatment to 67.4±24.0 at endpoint (mean change -31.0±28.97; 95% confidence interval [CI]-35.0;-27.1; p<0.0001). 66.7% of patients improved ≥30% in PANSS total score and percentage of patients rated markedly ill or worse in CGI-S decreased from 75.1% at baseline to 20.5% at endpoint. AEs reported in ≥5% were injection site pain (13.7%), insomnia (10.8%), psychotic disorder (10.4%), headache (6.1%) and anxiety (6.1%). Mean weight change at endpoint was 2.6±5.6 kg (95%CI 1.8; 3.4).
Conclusions: These data support results from previous randomized controlled studies that flexibly dosed paliperidone palmitate is well tolerated and associated with an early and clinically relevant treatment response in acute schizophrenia patients previously unsuccessfully treated with oral antipsychotics.
Flight of Ideas – Death of a Definition: A Discussion on Phenomenology
N Jeyasingam1
1Sydney University, Northern Sydney Area Health Service
Phenomenology provides the foundations on which the functions of modern psychiatry stand. It also provides a common language for the assessment of patients, and for the education of the next generation of psychiatrists. However, phenomenology is not anchored in independent clinicopathological correlates, and therefore it is vulnerable to subtle alterations over time. This presentation briefly discusses some concepts regarding phenomenology and attempts to comment on the various definitions available under the common descriptor termed ‘flight of ideas’. It is asserted that without appropriate monitoring and teaching of these basic descriptors and recognising the value of historical observations, serious inconsistencies will continue to arise in clinical theory and practice, which may prove difficult to rectify.
Background: Discusses the philosophical underpinning of phenomenology and identifies that the mental state descriptor ‘flight of ideas’ has actually had several different definitions over the years, so much that its original intention and description, and by extension diagnostic validity, has been lost.
