Computational Psychiatry and the Mentalization of Others
R Montague1,2
1Wellcome Trust Centre for Neuroimaging, University College London, London, UK
2Virginia Tech Carilion Research Institute and Department of Physics, Virginia Tech, Roanoke, USA
Background: Developmental disorders, personality disorders, and brain injury can impair the capacity to model others around us. This includes the sophisticated ability to do image management – that is, build accurate models of others’ model of us. This capacity is essential in order to appreciate the impact of social gestures we emit toward others. This talk will examine new approaches to modeling these capacities, show the specific way they can break down in Borderline Personality Disorder, and offer a view of how simple forms of social reciprocation might be used to characterize these issues in the future.
Objectives:
Understand the nature of reciprocal interactions among humans and how these can be used as probes of mental dysfunction;
Understand how simple games of economic exchange are being used to probe mentalization capacities;
Understand broadly the new approaches being used in computational psychiatry.
Methods: Stylized games of reciprocation, computational models of mentalization, and functional brain imaging.
Findings: Healthy human subjects show repeatable and characteristic patterns of brain response when reciprocating with others and these capacities can be captured in simple computational models. These same models can also be used to identify specific deficits in subjects possessing an impaired capacity for mentalization and might one day be turned into diagnostic tools.
Conclusions: Impairments in social exchange characterize a range of mental dysfunction. These impairments can be identified using models of social exchange and mentalization. Early work in this area shows that computational modeling may bring new diagnostic tools to the important problem of understanding how we understand others and how this can break down.
What Can Population-Based Studies Bring to Insights About the Human Ageing Brain and Our Ageing Societies?
C Brayne
Cambridge Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
This talk will outline the challenges of our time and the recognition that global ageing is one of these. Dementia is the key brain disorder closely linked to ageing and it remains contentious whether it is age dependent or an age-related disorder. Dementia and cognitive decline are associated with functional decline and loss of independence. The talk will discuss how different research approaches inform our understanding of the dementia syndrome and how population-based studies have contributed specific insights as well as how these insights fit and challenge different research approaches. The potential for primary, secondary and tertiary prevention of dementia will be discussed and the strength of the evidence for these. Integration of approaches is suggested as the way forward to avoid earlier costly blind alleys and future harm.
Advice for Measurers And Thinkers: Announcing the New Science of Gaps
J Braithwaite
Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
Background: Psychiatrists are indeed measurers and thinkers, but they are first and foremost people—and they make the same fundamental error that everyone does. That mistake, a function of the way the brain works, is to think about things and concrete entities rather than looking in the gaps between these things and entities. Here, we attempt to sort out this problem.
Objectives: This keynote address aims to explicate a new science of gaps. Gaps are weightless, colourless and odourless—something you rarely recognise, and don’t give a second thought about when you do. And yet they structure your life, your relationships, your beliefs, and the universe. There are far more gaps than things, and far more gaps between ideas, and concepts, than we ever imagine.
Methods: We will look through world history, examining some of the great minds who were gap-thinkers. We will see what we can learn from these intellectual leaders, and look to whether we, too, can become accomplished gap-thinkers.
Findings: Looking at gaps where others don’t represents a novel and rewarding way of looking at the world. I hope we will find that such an approach, on detailed inspection, is useful for Congress participants.
Conclusions: Welcome to the world of gaps. Becoming a gap-thinker requires a little bit of effort, but, more importantly, a willingness to take a new slant on what is already seen, naturally, because of our hard-wired cognitive architecture. But it might be exceedingly rewarding to make the transition.
Beyond Mars and Venus: New Scientific Understanding of the Gender Galaxy
C Fine
University of Melbourne, Melbourne, Australia
In recent decades, research from behavioural science and neuroscience has undermined an essentialist “Mars versus Venus” view of the sexes. Four key insights for understanding male/female differences in humans have emerged from this research. These overthrow traditional essentialist assumptions of large, distinct, fixed, timeless and deep-rooted behavioural and brain differences between the sexes. Taking their place are the principles of overlapping distributions, “mosaics” of masculine and feminine characteristics in brain and behaviour, contingency of differences across time, place and context, and the “entanglement” of the individual’s biology with gendered experiences. I will summarise some of the empirical evidence for these key principles, and discuss their implications for scientific models and research.
An Agenda for Indigenous Empowerment
N Pearson
Cape York Institute, Cairns, Australia
Disempowerment of our people is manifested at the personal level: in the lives of Indigenous individuals, families and communities. But this disempowerment is not just a manifestation of personal history: it is a manifestation of structural disempowerment.
From Consulting Rooms to Global Research: Clinical Psychiatrists Who Research
J Scott1,2
1The University of Queensland Centre for Clinical Research, Herston, Australia
2Metro North Mental Health, Herston, Australia
It has been consistently shown that services engaging in medical research provide better health care to the patients they serve whilst simultaneously advancing knowledge. Psychiatrists are recognised as clinical leaders in mental health; however, most are not directly involved in clinical research. For many, barriers to research participation include a perceived lack of opportunity for involvement or lack of knowledge as to how to conduct research. Psychiatric research can take many forms and arguably endless opportunities are available to psychiatrists interested in pursuing their fascinating clinical observations. Whilst providing an update on some aspects of Australian research in early psychosis, public health promotion and the burden of disease attributable to childhood mental disorders, this talk will discuss opportunities for psychiatrists and trainees to engage in research.
Pre-Congress Workshops
Medico-Legal Report Writing
J Chalk1, N McVie2
1Private Practice, Brisbane, Australia
2Mental Health Court Queensland, Brisbane, Australia; Forensic Psychiatry, Hunter New England Local Health District, Newcastle, Australia; Chair, RANZCP Faculty of Forensic Psychiatry
This workshop will cover the general principles of medico-legal report writing, and the specifics of preparing reports in both criminal and civil matters.
The revised RANZCP Professional Practice Guideline “Developing reports and conducting independent medical examinations in medico-legal settings”, due to be released in early 2015, will be referenced.
The workshop is intended to be interactive, with some short report writing-related exercises. Participants are encouraged to bring examples of reports or prepared questions on the topic, for discussion.
Background and objectives: This full-day pre-Congress workshop aims to provide advanced trainees in consultation-liaison psychiatry within Australia and New Zealand with a broad overview of the sub-specialty, meeting the academic objectives of the advanced training certificate.
Methods: Expert speakers from Queensland in the fields of transplant assessment, neuropsychiatry, psycho-oncology, chronic pain, hepatitis C, sleep disorders and palliative care will present on these sub-specialist areas during the academic session. The program will conclude with an expert panel discussion on ethical issues in consultation-liaison psychiatry, with case vignettes highlighting the complex issues of autonomy in palliative care settings, disclosure in transplant assessments and divided loyalties within multiple systems of health care.
Findings and conclusions: The RANZCP sub-specialty of consultation-liaison psychiatry continues to attract trainees who are drawn to the academic stimulation and system complexities of the discipline. This pre-Congress workshop will provide a forum where such advanced trainees can gather at a binational level, updating their knowledge and understanding of the field.
Is Formulation Still Notable for its Absence than its Observance?
M Daubney1, J Randles2, C Greaves3, P Foulkes4, P Cammell5, R Kalucy5
1Griffith University, Logan Campus, Meadowbrook, Australia
2Private Practice, Melbourne, Australia
3Private Practice, Brisbane, Australia
4Private Practice, Melbourne, Australia
5Flinders University, Adelaide, Australia
Background: At the 2009 College Congress, a presentation suggested that formulation is often notable for its absence rather than its observance (Korner et al., 2009). The most recent edition of a textbook of general psychiatry states that formulation skills are for those in specialist training to acquire and have as much relevance to the generalist as a formulation based on the patient’s serotonergic receptor status (Johnstone et al., 2010). A formulation may take different forms, but overall is a multilevel integrative statement that provides an aetiological understanding of factors contributing to the presentation and informs the development of a comprehensive intervention plan. Whilst the use of the formulation is emphasized in psychotherapy literature and training, it has relevance and use in general psychiatry.
Objectives: To enhance the understanding of and effectiveness of training in the process of formulation, and to discuss its relevance more broadly in treatment.
Methods: Members of the Section of Psychotherapy will present a half-day interactive workshop on formulation, covering:
A historical overview of the place of formulation;
Formulations will be presented from different perspectives;
Discussion of the relevance of the formulation in both psychotherapy and general psychiatry.
Findings and conclusions: We hope to maximize the use and effectiveness of formulation in psychiatric practice.
References
Johnstone E, Owens D, Lawrie S, et al. (2010) Companion to Psychiatric Studies, 8th edn. Edinburgh: Elsevier. p. 221.
Korner A., Bendit N, Ptok U, et al. (2009) Formulation, conversation and therapeutic engagement. Australian and New Zealand Journal of Psychiatry 43 (Suppl. 1): A32.
Mental Health: New Alignments for a New Generation Service Model
N O’Connor1,2, J Crawshaw3, D Butt4, H Whiteford5, S Pontonio6,7,8, R Vine9,10
1Northern Sydney Local Health District, Sydney, Australia
2Discipline of Psychiatry, University of Sydney, Sydney, Australia
3Ministry of Health, Wellington, New Zealand
4National Mental Health Commission, Canberra, Australia
5Faculty of Medicine and Biomedical Sciences, School of Public Health, University of Queensland, Herston, Australia
6Health Nexus Pty Ltd, Melbourne, Australia
7National Institute of Organisation Dynamics Australia, Melbourne, Australia
8Pontonio Consulting Group, Melbourne, Australia
9NorthWestern Mental Health, Melbourne Health, Melbourne, Australia
10Department of Psychiatry, University of Melbourne Health, Melbourne, Australia
Background: In spite of broad agreement around the principles of improved mental health service delivery, there remain a number of challenges related to:
Changing funding models;
Lack of connectivity between sectors involved in service delivery;
A lack of coherent care models.
These factors mitigate against significant advances in developing an integrated, ‘whole of health’, ‘whole of government’ approach. Different philosophies of care abound, performance measures are not supporting improvement and innovation, and there is a significant gap between best practice models of care and service delivery. The result is less than optimal care for patients.
In recent decades, the Australian mental health system has undergone extensive reform. This reform presents both challenges and opportunities for the mental health system and its clinical leaders.
Key challenges for psychiatry include:
Harnessing influential thought leaders to shape policy;
Promoting evidence-based practice;
Developing new ways to achieve continuity of care for optimal patient outcomes.
Objectives: Mental health can benefit from a critical appraisal of the impact of new funding models in other health sectors. In better understanding these system drivers, we can discuss how the mental health system may best respond to these changes.
Methods: Through facilitated discussion, we will discuss how best to respond to the current challenges for the mental health system and what steps we could take now to move towards improved, more integrated service delivery models:
Findings: The output of the workshop will be presented to wider conference participants (further abstract to be submitted for this) in a panel discussion.
Conclusions: Participants will be better informed of the implications of mental health and funding reform for best practice patient care.
Congress attendees will be invited to join collaboratives/participate in specific initiatives/projects back in the field of practice, to demonstrate the potential benefits and improvements that can be achieved through redesigning systems of care at a local level. Clinical leaders will be engaged to discuss the role that they can play in driving policy and system changes.
Using Routine Outcome Measurement in Practice and Supervision
R McKay1, S Kisely2, T Coombs3,4
1School of Psychiatry, University of New South Wales, Sydney, Australia
2School of Medicine University of Queensland, Brisbane, Australia
3Mental Health Illawarra Shoalhaven Local Health District, Wollongong, Australia
4Fellow Australian Health Services Research Institute, University of Wollongong, Wollongong, Australia
Background: Australia and New Zealand both have mandated systems for routine outcome measurement within public mental health services. A comprehensive 2014 review of the Australian system highlighted both support for routine outcome measurement and a need to spread good practice in the use of the mandated measures in practice. At the same time, the mandated measures are under evaluation in Australia for inclusion within activity-based funding processes. The RANZCP has completed two online modules to assist trainees in improving their knowledge and skills in this important area of practice.
Objectives:
To familiarise participants with the content and learning objectives of the RANZCP online training.
To increase participants’ confidence and skills in using the supervision relationship to attain the competencies outlined in the online training.
To share and increase knowledge of successful strategies to practically use the standard mandated measures in clinical practice, service improvement and research.
Methods:
Participants will be provided with links to pre-reading and external online training resources, but participation will not be dependent upon completion of these.
Elements of the RANZCP training resources will be explored and then methods to use in supervision workshopped in small groups with the assistance of additional vignette-type material.
Groups will share strategies considered useful in implementing the training.
Findings: Strategies identified as useful during the workshop will be made available for wider use.
Training Workshop for State Assessment Panel Members to Assess Specialist Pathway Applications
M Fogarty1, V Lakra1, A 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 Committee for Specialist International Medical Graduate Education (CSIMGE) opened Phase II of the Substantial Comparability Pathway in July 2014.
Applicants for Phase II are assessed based on an assessment proforma developed and tested by the CSIMGE in consultation with all stakeholders, including the OTP Representative Committee. The 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. Each criterion is given points in accordance with whether it is substantially, partially or not comparable. Points are also taken off for lack of CPD activities or progress to Fellowship or recurrent failures at the clinical examination (applicable for current Exemptions Candidates).
It is the responsibility of the State Assessment Panels to assess applicants for the Specialist Pathway. State Assessment Panels will be required to evaluate applications using the new assessment proforma. Based on the total points achieved and any gaps in applicants’ training, they will identify the necessary requirements candidates will be expected to complete to progress towards Fellowship.
This workshop will be an opportunity to provide current and new State Assessment Panel members training for assessing applicants for Specialist Pathway.
Objective: To provide State Assessment Panel members with a clear understanding of the Specialist Pathway assessment process and ensure they are competent in assessing candidates.
The workshop will cover:
An explanation of the Specialist Pathway eligibility and assessment process and requirements.
RANZCP 2015 Examination Information Session Approaching The Critical Essay Question and the Modified Essay Questions in the RANZCP Written Examination
L Lampe1, J Ferguson2
1Chair, RANZCP Committee for Examinations
2Member, Written Sub-committee, Member, RANZCP Committee for Examinations
Objective: This workshop is designed to assist candidates to prepare for the Critical Essay Question (CEQ) and the Modified Essay Question (MEQ) components of the RANZCP written examination.
Intended audience: These workshops are suitable for Trainees, SIMGs, Supervisors and Directors of Training.
Background: The essay-style questions test capacity for clinical reasoning, critical thinking and the ability to communicate this efficiently and effectively in a professional writing style. The paper includes two components, the CEQ and a number of MEQs.
The CEQ tests ability for critical reasoning and the capacity to express this in writing, which is considered to be an essential skill for a psychiatrist. In the 2012 Fellowship program the essay-style paper will be decoupled from the multiple choice-style paper, but candidates will be required to pass the CEQ in order to be awarded an overall pass in the essay-style paper.
MEQs aim to test the application of knowledge relevant to clinical practice.
Methods: Members of the Committee for Examinations will discuss the approach to these question types, the required standard and how to demonstrate it (what the examiners are looking for), and will highlight skills and strategies for successfully passing this question type. Practical exercises will be used where possible.
Note that practical exercises will be based on the 2003 Fellowship Program standard. However, as appropriate through the workshop reference will be made to changes that will occur when the essay-style paper is offered in the 2012 Fellowship Program.
Please note that this information session is free of charge to all Congress attendees.
Psychiatry and Spirituality: An Update
M Wong
School of Psychology and Psychiatry, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
Background: While recent advances in philosophy and its interaction with neuroscience and psychiatry have helped psychiatry address its tendency to swing between “brainlessness” and “mindlessness” to a certain extent, many patients, carers and practitioners in the field continue to be concerned that the contemporary practice of psychiatry remains in a state of “spiritual neglect” or “spiritual ambivalence”, resulting in fragmented views of the person, restricted views of mental illness and reductionist rather than whole-person approaches to management.
Objectives: This half-day workshop aims at providing an update on the major themes and issues involved in the interface between psychiatry and spirituality.
Methods: At this workshop, Associate Professor Wong, a psychiatrist trained in neuropsychiatry with two doctorates in PET and MRI neuroimaging, and philosophy and theology, respectively, will provide a review of the latest research in the field of psychiatry and spirituality and an overview of various current applications of spirituality in the practice of clinical psychiatry and promotion of mental health and wellbeing.
Findings: Recent surges of high-quality research and clinical data in the study of psychiatry and spirituality suggest a spirituality-informed approach to psychiatry and mental health has significant impact on prevalence and incidence of mental health problems, diagnosis and formulation, efficacy of intervention, compliance with treatment, relapse prevention, rehabilitation, recovery, health promotion, help-seeking behaviour and cost-effectiveness of service delivery.
Conclusions: The anticipated outcome of this workshop is to enable participants to acquire basic and essential knowledge of the study of spirituality in relation to psychiatry and to develop skills in the application of such knowledge to the practice of psychiatry.
Safe Work Australia: Workplace Bullying
M Williamson
MMed Faculty, Westmead, University of Sydney, Sydney, Australia
Background: Safe Work Australia was established by the Safe Work Australia Act 2008 as a tripartite body funded by Commonwealth States and Territories, and made an Australian Government Statutory Agency on 1 November 2009. Its legislative program has been actively developing responses to workplace bullying with recent notable publications in 2013 (Safe Work Austrlia 2013a). Workplace bullying is an epidemic, its incidence is increasing and its impact on the mental health of employees and management is extreme. This is an area which College members should become familiar with as it will increasingly affect clinical practice.
Objectives:
To provide an update and review of recent Safe Work Australia reports on workplace bullying;
To raise awareness of the social and clinical significance of workplace bullying;
To promote understanding of workplace bullying;
To assist in clinical management of those presenting with complaints of workplace bullying.
Methods:
Review of recent Safe Work Australia publication of draft model codes of safety and work practice in relation to workplace bullying reform;
Discussion of Safe Work Australia in the clinical context;
Consideration of clinical cases of reported bullying.
Findings: Safe Work Australia is a serious legislative response to workplace bullying. Mental health clinicians need to be competent in assessing, treating and managing the effects of workplace bullying. Safe Work Australia (2013b) is an optimum source of information on workplace bullying.
Conclusion: Safe Work Australia continues to respond to workplace bullying and its clinical implications for mental health. College support for the Legislative and Educational Program of Safe Work Australia is recommended.
Background: The injunction to see things and ourselves as we really are is as old as civilization. Yet everywhere we are subjected to forces that bias our thinking without us being aware of them. We end up not understanding our lives and repeating old solutions to new problems and wondering why things don’t work out well.
This seminar introduces a novel therapeutic approach that helps us decode complex clinical information in our patients’ stories and ultimately in the transference and countertransference. We use this knowledge to reveal the truth behind the biases and repetition compulsions that causes blocks in our lives and in therapy.
Objectives: At the end of this workshop participants will:
Understand the historical and cultural imperatives to authentic knowledge;
Understand the theoretical approach to this therapeutic technique;
Be able to take a different sort of psychiatric history that identifies patterns and biases;
Use this information to help their patients see why they are psychologically ‘stuck’.
Methods: Candidates will be taken through a new method of history taking. They will be shown how to listen for patterns and to see clinical data as complex codes that conceal all our biases.
Findings: This new ‘take’ on therapy makes us more expert at helping people see their lives and problems as they really are.
Conclusions: This therapy is derived from traditional psychotherapies. It doesn’t replace them. It enhances their efficacy by allowing practitioners to overcome road-blocks in therapy by helping patients see things ‘as they really are’.
RANZCP 2015 Examination Information Session Approaching the RANZCP OSCE/MOSCE Assessment (Clinical Examination)
G Robinson
Chair, RANZCP OSCE/MOSCE Sub-committee; Member, RANZCP 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 Examinations members of 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 develop their understanding of the Committee for Examinations expectations of Trainee and SIMG Candidates.
It is suitable for trainees, SIMGs, supervisors and Directors of Training.
This workshop will also introduce candidates, supervisors and Directors of Training to:
The process for developing an OSCE/MOSCE examination;
The 2012 CBFP marking schema;
The format of the OSCE/MOSCE examination;
Approaching the Medicine as related to Psychiatry Station;
The assessment/marking of the OSCE/MOSCE;
Tips for passing the OSCE/MOSCE Examination.
Please note that this information session is free of charge to all Congress attendees.
Beyond Impairment: Using the Lived Experience of Mental Illness by Psychiatrists to Improve Care
R McKay1,4, J Liggins2, J McMahon3,4, G Roper4
1University of New South Wales, Sydney, Australia
2Liaison Psychiatry, Middlemore Hospital, Auckland, New Zealand
3Private Mental Health Consumer Carer Network (Australia), Australia
4RANZCP Community Collaboration Committee
Background: Psychiatrists are just as vulnerable as the rest of the population to mental illness. The limited literature that exists largely focuses upon impairment and how this should be managed. There is increasing recognition of the importance of incorporating lessons from individuals with lived experience of mental illness into both direct mental health care and actions to improve the quality of this care; however, there is minimal literature that explores how these concepts apply to psychiatrists with personal experience of mental illness. The RANZCP Community Collaboration Committee is exploring options to redress this gap and look ‘Beyond impairment’.
Objectives:
Identify key issues that require guidance or further exploration for the lived experience of mental illness by psychiatrists to improve mental health care;
Inform the potential development of a position statement regarding utilising the lived experience of psychiatrists;
Discuss future actions that may be appropriate;
Allow participants to share relevant experiences.
Methods:
Presentation of literature and issues to consider including in a position statement;
Discussion of material in the context of participant experiences: whether from the perspectives of lived experience of mental illness, carer, psychiatrist, or a combination of these.
Findings: Feedback will be used to confirm key themes to include in a position statement. This will be followed by discussion of potential future actions; together with potential benefits and risks of such actions.
Conclusions: This workshop is seen as a key opportunity to shape how the lived experience of psychiatrists contributes to better mental health care.
Training Workshop for Potential Assessors for the Substantially Comparable Pathway to Fellowship for SIMGs
M Fogarty1, V Lakra1, A Tsesmelis2
1RANZCP Committee for Specialist International Medical Graduate Education
2RANZCP Secretariat
Background: The RANZCP Substantial Comparability Pathway to Fellowship involves at least 12 months of supervised and peer-reviewed practice with a significant workplace-based assessment and employer support.
Three Case based Discussions (CbDs) are done in the workplace by external Assessors after candidates have attempted a formative Case based Discussion assessment with the supervisor. This is one of a series of training workshops for potential external assessors of Substantial Comparability Pathway candidates. Fellows who are already supervising Specialist International Medical Graduate (SIMG) candidates involved in this pathway are encouraged to attend, as are any Fellows interested in supporting SIMG candidates in general. To be appointed as an Assessor, Fellows must have at least three years post-Fellowship experience and have an interest in and previous experience in supporting SIMG psychiatrists.
The viability of the Substantial Comparability Pathway depends on having sufficient trained Assessors and Supervisors to complete all the assessment and supervision tasks. The workshop involves pre-reading and calibration of CbD material. The responsibilities of Supervisors are enhanced in this process and training as a Supervisor is completed via a different process involving 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 Specialist International Medical Graduate Education (CSIMGE) members.
Objective: To achieve competency as an Assessor for the Phase II Substantial Comparability Pathway to RANZCP Fellowship.
Methods: The workshop will cover:
Explanation of the Substantial Comparability Pathway process and requirements;
Training in the responsibilities of Supervisors and Assessors;
Training in the use of workplace-based assessment tools including CbD and 360° feedback via calibration exercises.
Out of the Horse’s Mouth: A New Psychotherapeutic Treatment Modality
A Kriegeskotten1,2, H Ohlsen2,3
1NCYP (Northside Child & Youth Psychiatry), Brisbane, Australia
2Equiliberty Equine Assisted Psychotherapy, Brisbane, Australia
3Horse Sense for Humans, Brisbane, Australia
This is a hands-on workshop introducing you to Equine Assisted Psychotherapy. You will be interacting with horses in an arena under the guidance of a therapeutic team consisting of a psychiatrist and an Equine Specialist trained in the EAGALA model of Equine Assisted Psychotherapy, and of course a few horses. We will also discuss the theory of this treatment modality.
Equine Assisted Psychotherapy is similar to expressive psychotherapy. It is based on experiencing rather than talking, but here horses help facilitate the psychotherapeutic process. Even difficult to engage clients find that they cannot resist these living, breathing, powerful animals.
Horses are prey animals and evolved in the presence of predators. To survive they developed exquisitely tuned senses. They can even sense the heart beat and breathing rate and therefore are able to sense the emotional state of others around them, even when these emotions are subconscious or suppressed. Horses naturally reflect each other’s emotions via behaviour and body language. They are masters of the here and now (mindfulness). These natural skills of horses can be used therapeutically. In a way the horse in therapy is a conscious half-tonne biofeedback machine for the human client. This workshop aims to highlight the potential use and strengths of this type of therapy.
In this full-day workshop you can have a range of experiences, from deep relaxation that comes with empathic attunement with the horse, to the excitement of joining with your team and the horses to work on a task together.
For this workshop you do not require prior knowledge of horses. There is no riding involved as all the activities take place from the ground. For your own safety you’ll need to wear enclosed shoes or boots to keep your toes safe. This workshop takes place at a Riding for Disabled facility with their well-handled horses. Please dress according to the weather. We have a roof over the arena, but no air-conditioning.
Symposium Presentations
Neuropsychiatric Aspects of Parkinson’s Disease
PE Mosley1,2,3,4, R Marsh1,2,3, N Dissanayaka1,5,6, H Subramanian1, A Carter7, W Hall8, T Coyne9, P Silburn1,3
1UQ Centre for Clinical Research, University of Queensland, Herston, Australia
2Department of Psychiatry, Royal Brisbane and Women’s Hospital, Herston, Australia
3Neurosciences Queensland, St Andrew’s War Memorial Hospital, Spring Hill, Australia
4Systems Neuroscience Group, QIMR Berghofer Medical Research Institute, Herston, Australia
5Neurology Research Centre, Department of Neurology, Royal Brisbane and Women’s Hospital, Herston, Australia
6School of Psychology, University of Queensland, Brisbane, Australia
7School of Psychological Sciences, Monash University, Melbourne, Australia
8Centre for Youth Substance Abuse Research, University of Queensland, Herston, Australia
9BrizBrain & Spine, Spring Hill, Australia
Background: Parkinson’s disease (PD) is the second most common neurological disorder affecting Australians and New Zealanders. Thirty Australians are diagnosed with PD every day, with an annual cost to the Australian economy of $775 million.
PD has also been described as the quintessential neuropsychiatric disorder, on account of the numerous psychiatric symptoms that may arise from neurodegeneration, dopaminergic denervation and treatment with dopaminergic therapy. Issues such as depression, anxiety, psychosis, apathy, impulse-control disorders and dementia may lead to additional disability and magnify carer burden. Technologies such as deep brain stimulation (DBS) offer greater symptom relief and improved quality of life but can also be complicated by psychiatric side effects. Personality change due to disease, medication or neurosurgical intervention raises challenging ethical questions of autonomy, authenticity and harm that can be examined in this framework.
Objectives: To introduce the field of neuropsychiatry as it pertains to the care of individuals with PD. Taking stock of our knowledge about the link between neurological changes and psychiatric symptoms, to outline how this may assist us in the future treatment of psychiatric syndromes.
Methods: Local experts in the management of PD cover the key aspects in diagnosis and treatment of neuropsychiatric presentations. Leading neuroethicists discuss ethical challenges arising from unwanted effects of treatment. Clinicians from the Asia-Pacific Centre for Neuromodulation, the largest DBS centre in Australasia, introduce DBS for PD, what we can learn from psychiatric complications and where our experience in DBS for PD may lead in the treatment of psychiatric syndromes.
Presenter 1
Care Priorities in Parkinson’s Disease
R Marsh1,2,3
1UQ Centre for Clinical Research, University of Queensland, Herston, Australia
2Department of Psychiatry, Royal Brisbane and Women’s Hospital, Herston, Australia
3Neurosciences Queensland, St Andrew’s War Memorial Hospital, Spring Hill, Australia
Background: Parkinson’s disease (PD) is historically conceptualized as a movement disorder. Due to the enormous contribution of non-motor symptoms (NMS) to quality of life (QoL) measures in PD, NMS have become an increasing focus of clinical and research attention. The rise in the awareness of NMS, concurrent with increasing treatment options with associated neuropsychiatric risk, has complicated the assessment and management of this heterogeneous syndrome.
PD is both a fluctuating and inexorably degenerative disorder. When this is overlaid upon the diagnostic and treatment difficulties inherent in the care of the medically ill, a bewildering matrix of interacting disease and treatment considerations can confront the clinician.
Objectives: To describe an approach drawn from psychiatry’s tradition of case-based formulation and the biopsychosocial model, employing simple data visualization.
Methods: A brief overview of the more common NMS in PD will be presented. I offer an approach to the assessment of the PD patient with an emphasis on ‘burden of disease’, reconciled with current evidence in the treatment of NMS in PD. With the aid of illustrative vignettes and simple data visualization, I demonstrate the utility of a longitudinal, patient- and family-centred, biopsychosocial approach.
Findings: More favourable QoL outcomes in both the short- and long-term management of NMS in PD may be possible with serial, comprehensive consideration of patient- and family-centred issues.
Conclusion: The assessment and management of NMS in PD may be amenable to an approach drawn from traditional methods of psychiatric formulation and enhanced by simple data visualization techniques.
Presenter 2
Phenomenology and Treatment of Anxiety and Depression in Parkinson’s Disease
N Dissanayaka1,2,3
1UQ Centre for Clinical Research, University of Queensland, Herston, Australia
2Neurology Research Centre, Department of Neurology, Royal Brisbane and Women’s Hospital, Herston, Australia
3School of Psychology, University of Queensland, Brisbane, Australia
Background: Anxiety and depression contribute to increased disability and poorer quality of life in Parkinson’s disease (PD). There is an overlap of symptoms between PD and anxiety/depression, and the relationship between motor fluctuations and mood and anxiety is complex. Consequently, these non-motor manifestations are often under-diagnosed and under-treated in PD. There is a need to identify PD-specific characteristics of anxiety and depression to improve assessment. Together with pharmacotherapy, psychotherapy interventions addressing PD-specific symptomatology are required for more effective treatment of depression and anxiety in PD.
Objectives: To identify subtypes of anxiety and depression in PD, and to develop tailored psychotherapy treatment.
Methods: A semi-structured interview was conducted in 90 PD patients to profile DSM-IV and subsyndromal anxiety and depression subtypes. The chronology was investigated in relation to a diagnosis of PD. Several psychotherapy interventions including cognitive behavioural therapy (CBT) and mindfulness were developed targeting PD-specific symptoms of anxiety and depression. Both CBT and mindfulness were trialled in two independent samples of PD patients.
Findings: In addition to a DSM-IV diagnosis of anxiety and depressive disorders, a subsyndromal subtype of anxiety unique to PD is characterised in 27% of patients. PD-specific symptomatology was prominent in the subsyndromal anxiety group, and the onset was predominantly seen after a diagnosis of PD. Both CBT and mindfulness interventions significantly reduced anxiety and depression in PD.
Conclusions: Identifying PD-specific symptomatology of anxiety and mood disturbances is important when assessing patients. Tailored psychotherapy interventions show promising outcomes to reduce anxiety and depression in PD.
Presenter 3
Clinical, Ethical and Legal Implications of Impulse Control Disorders in Parkinson’s Disease
A Carter1, W Hall2
1School of Psychological Sciences, Monash University, Melbourne, Australia
2Centre for Youth Substance Abuse Research, University of Queensland, Herston, Australia
Background: Impulse control disorders (ICDs) are an under-recognised condition in Parkinson’s disease (PD). Almost one in five patients prescribed dopamine agonists for PD will develop an ICD, such as pathological gambling and hypersexuality. The ability for dopamine replacement therapy (DRT) to cause compulsive behaviours raises a number of ethical and clinical questions: Under what circumstances is it ethical to prescribe a medication that may induce harmful compulsive behaviours? Are individuals treated with DRT morally responsible and hence culpable for harmful behaviour related to their medication?
Objectives: To determine whether ICDs can be caused by DRT and examine the implications for clinicians treating PD.
Methods: We review the clinical literature on ICDs in PD and provide evidence that dopamine agonists play a causal role in ICDs. We consider the ethical and legal implications for professionals dealing with medication-induced ICDs by reflecting on a recent legal case study.
Findings: There is strong evidence that dopamine agonists play a causal role in ICDs in PD, although not all patients develop them, suggesting that other factors are implicated. Further research is needed to understand how dopamine agonists cause ICDs and to develop effective treatments that are currently lacking (other than withdrawing a life-saving medication). These conditions also raise significant challenges for the judicial system.
Conclusions: These findings highlight the need to prescribe these medications with care, identify those at risk and take steps to minimize the consequences of compulsive behaviour. Collaboration with addiction researchers may assist in the development of more effective treatment.
Presenter 4
Deep Brain Stimulation: A Window Into the Human Brain
T Coyne3, P Silburn1,2
1UQ Centre for Clinical Research, University of Queensland, Herston, Australia
2Neurosciences Queensland, St Andrew’s War Memorial Hospital, Spring Hill, Australia
3BrizBrain & Spine, Spring Hill, Queensland, Australia
Background: Deep brain stimulation (DBS) is a minimally invasive, reversible, functional neurosurgical intervention with increasing application in brain disorders such as Parkinson’s disease (PD), dystonia, epilepsy and chronic pain. It is a promising experimental therapy for intractable psychiatric conditions such as obsessive-compulsive disorder (OCD) and depression.
Objectives: To provide an expert introduction to this technology from the perspective of the lead neurosurgeon and lead neurologist at the Asia-Pacific Centre for Neuromodulation, the largest DBS centre in Australasia.
Methods: We outline the stereotactic neurosurgical technique, including target localisation, imaging, electrophysiological recording and device programming, in DBS for PD. We also describe how this technology can be used to dynamically study the conscious human brain at a neuronal and neural network level.
Findings: We report findings from our research in PD that has revealed how circuits in deep brain nuclei interact in the coordination of human gait. We discuss how we have adapted this methodology to study the neural correlates of obsessive-compulsive behaviour in the first Australasian double-blind, randomised, placebo-controlled trial of DBS for OCD.
Presenter 5
Impulsivity and Personality Change After Deep Brain Stimulation for Parkinson’s Disease
PE Mosley1,2,3,4
1UQ Centre for Clinical Research, University of Queensland, Herston, Australia
2Department of Psychiatry, Royal Brisbane and Women’s Hospital, Herston, Australia
3Neurosciences Queensland, St Andrew’s War Memorial Hospital, Spring Hill, Australia
4Systems Neuroscience Group, QIMR Berghofer Medical Research Institute, Herston, Australia
Background: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an established treatment for the motor symptoms of Parkinson’s disease (PD). A minority of patients experience postoperative psychiatric symptoms, temporally linked to the onset or adjustment of neurostimulation. These attenuate the gains in quality of life observed after DBS. One cluster of symptoms includes hypomania, coarsening of personality, lack of empathy, impulsivity and compulsive behaviours, with a postoperative prevalence of 10–20%. Many clinicians are now aware of this post-DBS syndrome, although its phenomenological and neuropsychological aspects, and the connection with stimulation parameters, have not been extensively described.
Objectives: To report findings from a longitudinal cohort study examining the characteristics of this post-DBS syndrome from a multidimensional perspective.
Methods: Behavioural change was assessed serially using a range of validated instruments. Impulsivity was assessed serially using neuropsychological tools. Compulsive behaviours were identified in a semi-structured interview. The patient’s spouse rated caregiver burden and marital satisfaction. A further semi-structured interview investigated the experience and meaning of postoperative personality change. Stimulation fields were modelled and correlated with the patient’s neuroanatomy using the Medtronic Optivise program and diffusion tensor imaging.
Findings: DBS of the STN may be associated with a sustained but reversible personality change, connected to stimulation parameters and the volume of activated tissue. The patient and his spouse may evaluate these changes differently.
Conclusions: Post-DBS personality change has biological underpinnings. However, the patient may view them as an opportunity to revisit an “authentic” personality hitherto disrupted by PD.
Presenter 6
Deep Brain Stimulation and Psychiatric Syndromes in Parkinson’s Disease: Neuronal Mechanisms
H Subramanian1
1UQ Centre for Clinical Research, University of Queensland, Herston, Australia
Background: Parkinson’s disease (PD) presents with a heterogeneous pattern of neurological symptoms and psychiatric syndromes. These include depression, anxiety, cognitive impairment, and speech and vocalisation deficits. Many of these patients experience severe disease states. These can precede motor symptoms of PD and delay its diagnosis. These psychiatric syndromes may be triggered by alterations to neurotransmission in multiple brain areas and are associated with a range of autonomic disturbances (elevated blood pressure, aberrations in vagal tone, ataxic breathing, stress and urge incontinence).
Objectives: To describe the significance of two key brain regions in the pathogenesis of psychiatric symptoms in PD.
Methods: I describe the mechanism of action of deep brain stimulation (DBS) in the anterior cingulate cortex and the midbrain periaqueductal gray (PAG) using animal models. The experimental focus is on the effect of DBS on specific psychiatric syndromes such as anxiety and depression and its motor maps.
Findings and conclusions: The ACC is implicated in the pathology of many mental disorders and could be the critical mediator of psychiatric syndromes seen in PD, whilst the PAG is the nucleus through which motor and autonomic deficits of psychiatric syndromes (including speech and vocalisation deficits) manifest. The findings will refine and enhance the design of neuromodulatory therapeutic interventions for PD in humans.
Eating Disorders Bench to Bedside: New Findings and Novel Directions
F Zepf1, P Hay2, S Touyz3, W Ward4
1Department of Child and Adolescent Psychiatry, University of Western Australia, Perth, Australia; Department of Specialised Child and Adolescent Mental Health Services, Department of Health in Western Australia, Perth, Australia
2School of Medicine and Centre for Health Research, University of Western Sydney, Sydney, Australia; School of Medicine, James Cook University, Townsville, Australia
3School of Psychology and Centre for Eating and Dieting Disorders, Sydney, Australia
4Eating Disorders Service, Royal Brisbane and Women’s Hospital, Brisbane, Australia; University of Queensland, Brisbane, Australia
Background: Eating disorders are increasing in prevalence. Major challenges continue in the understanding of the neurobiology, determinants and treatment of both classic disorders such as anorexia nervosa and the newly introduced DSM-5 disorders such as binge eating disorder.
Objectives: The aim of this symposium is to present a distillation of recent research in eating disorders, new directions in understanding of their distribution and determinants and new treatments. Professor Zepf will present findings on sex differences in the neuromodulation of appetite via serotonergic action on leptin receptor levels. Professor Hay will present new data on the community prevalence and socio-demographic correlates of DSM-5 eating disorders. Professor Touyz will present recent work on the under-recognition and rising problem of eating disorders in males and approaches to management, and Dr Ward will conclude with an overview of a trial of a novel new therapy, deep brain stimulation, and discussion of putative mechanisms of its use in eating disorders.
Presenter 1
Interaction Between the Leptin Axis and Central Nervous Serotonin Synthesis in Healthy Adult Females
FD Zepf1,2,3,4,5, VLS Dingerkus1,2, K Helmbold1,2, S Bubenzer-Busch1,2, CS Biskup1,2, B Herpertz-Dahlmann1,2, M Schaab6, J Kratzsch6, A Eisert7, L Rink8, U Hagenah1, TJ Gaber1,2
1Department of Child and Adolescent Psychiatry. University of Western Australia, Perth, Australia
2Specialised Child and Adolescent Mental Health Services, Department of Health in Western Australia, Perth, Australia
3Clinic for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, RWTH Aachen University, Aachen, Germany
4JARA Translational Brain Medicine, Aachen and Jülich, Germany
5Institute for Neuroscience and Medicine, Jülich Research Center, Jülich, Germany
6Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University of Leipzig, Leipzig, Germany
7Department of Pharmacy, RWTH Aachen University Hospital, Aachen, Germany
8Department of Immunology, RWTH Aachen University Hospital, Aachen, Germany
Background: Serotonin (5-HT) and the hormone leptin have been linked to the underlying neurobiology of appetite and hunger regulation, and with evidence coming from animal and cellular research. However, direct evidence linking these two separate pathways in humans is still lacking.
Objectives: To study the relationship between central nervous synthesis of 5-HT and different parameters of the leptin axis in healthy adult subjects.
Methods: We examined the effects of an acutely reduced brain 5-HT synthesis due to acute tryptophan depletion (ATD) on peripheral levels of soluble leptin receptor (sOb-R), the main high-affinity leptin binding protein, in healthy adults, using an exploratory approach.
Findings: In the present sample, women, but not men, showed reduced sOb-R concentrations after ATD administration.
Conclusions: With females showing reduced baseline levels of central nervous 5-HT synthesis compared to males, diminished brain 5-HT synthesis as induced by ATD administration affected the leptin axis through the sOb-R only in females, thereby potentially influencing their vulnerability to dysfunctional appetite regulation and comorbid mood symptoms. We suggest a model for the interaction between central nervous 5-HT synthesis and the leptin axis, possibly via immunological pathways, which should be the subject of further research.
Presenter 2
The Prevalance and Socio-Demographic Distribution of DSM-5 Eating Disorders in Australia
P Hay, F Girosi
School of Medicine and Centre for Health Research, University of Western Sydney, Sydney, Australia
Background: New DSM-5 diagnostic criteria for eating disorders were published in 2013. Adolescent cohort studies in the Australian community indicate that the point prevalence of DSM-5 eating disorders may be as high as 15% in females and 3% in males.
Objectives: The present study aims were to determine the 3-month prevalence of DSM-5 disorders in a representative sample of Australian older adolescents and adults. Second aims were to explore demographic correlates of these disorders; specifically age, gender, household income and education level distributions.
Methods: We conducted and merged sequential cross-sectional population survey data of adults (aged over 15 years) collected in 2008 and 2009 (n = 6041). Demographic information and the occurrence of regular (at least weekly over the past 3 months) objective binge eating, extreme dietary restriction, purging behaviours and overvaluation of shape and/or weight were asked.
Findings: The 3-month prevalence of anorexia nervosa and of bulimia nervosa were both under 1% but prevalence of binge eating disorder and other specified and unspecified eating disorders was around 5%. The prevalence of people with binge eating disorder that included presence of overvaluation of weight/shape was 1.8%. While people with anorexia nervosa were younger than others, the median age was in the third decade and for all other eating disorders was in the fourth or fifth decade. Eating disorders were distributed throughout all income and educational groups and both sexes.
Conclusions: The findings support the ‘democratisation’ of eating disorders and the relatively high prevalence of binge eating disorder compared to other eating disorders.
Presenter 3
Males With Eating Disorders: From Anorexia Nervosa to Muscle Dysmorphia and Beyond
S Touyz, S Griffiths, S Murray
School of Psychology and Centre for Eating and Dieting Disorders, Sydney, Australia
Background: Eating disorders in males are understudied, under-recognised and misunderstood. Despite evidence that males constitute 25–33% of diagnoses of anorexia and bulimia nervosa, and up to 50% of diagnoses of binge eating disorder, limited research has focused on the “male experience” of eating and body image concerns.
Objectives: We present evidence that disordered eating behaviours are increasingly more rapid in men than in women, particularly with regard to binge eating.
Methods: We further present a clinical comparison of men with anorexia nervosa and muscle dysmorphia (“reverse anorexia”) and review community-held attitudes and beliefs about people with these conditions.
Findings and conclusions: We conclude with a discussion of clinical treatment guidelines for males with eating disorders.
Presenter 4
Establishing a Deep Brain Stimulation Trial for Patients With Anorexia Nervosa
W Ward1,2, P Silburn1,3,4, R Marsh2,4, C Randall2, P Mosley2,3
1University of Queensland, Brisbane, Australia
2Royal Brisbane and Women’s Hospital, Brisbane, Australia
3Asia-Pacific Centre for Neuromodulation, Brisbane, Australia
4St Andrews War Memorial Hospital, Spring Hill, Australia
Background: Anorexia nervosa has the highest mortality rate of all psychiatric disorders. A significant minority of patients fail to respond to the best available current evidence-based treatments. Deep brain stimulation (DBS) is an established, efficacious treatment for neurological disorders such as Parkinson’s disease. In the last decade it has been applied as an experimental treatment for intractable psychiatric disorders such as depression and obsessive-compulsive disorder, based on a model of severe psychiatric illness as pathological network dysfunction. Treatment-resistant anorexia nervosa is another candidate disorder, with promising results from two small open trials reported in the scientific literature.
Objectives: To report on progress in establishing a trial of DBS for Treatment-resistant Severe and Enduring Anorexia Nervosa at the Asia-Pacific Centre for Neuromodulation. The centre has accumulated significant experience in monitoring efficacy and safety of this treatment in Parkinson’s disease, and has recently had ethics approval for a trial of DBS for obsessive-compulsive disorder.
Methods: This presentation will include details on progress of seeking regulatory and ethics committee approval for such a trial, measures for monitoring efficacy and safety, as well as details of candidate deep brain structures for stimulation based on literature to date.
Findings and conclusions: Ethical and legal issues, clinical safety and the putative neuromodulatory effects of DBS in people with eating disorders will be discussed.
Autism Spectrum Disorder: Essentials for Psychiatrists
C Franklin1, M Gattas2,3, D Dossetor4,5, N Lennox1
1Queensland Centre for Intellectual and Developmental Disability, MRI/UQ, University of Queensland, Brisbane, Australia
2Brisbane Genetics, Wesley Medical Centre, Brisbane, Australia
3Genetics Health Queensland, Royal Brisbane and Women’s Hospital, Brisbane, Australia
4Sydney Children’s Hospital Network, Sydney, Australia
5Sydney Medical School, University of Sydney, Sydney, Australia
Background: Autism Spectrum Disorder is a rapidly evolving and expanding field due to numerous avenues of research across several disciples of medicine and allied health. People with autism are vulnerable to a range of psychiatric disorders throughout their lifetime and psychiatrists are increasingly asked to assess and manage people who present with autism spectrum disorders.
Objectives: This symposium examines Autism Spectrum Disorder from a number of perspectives that are relevant to the clinical practice of psychiatry: clinical genetics, developmental psychiatry, and the physical and mental health of people with autism spectrum disorders.
Methods: Experienced specialists in their field will present clinically relevant material:
Autism and clinical genetics;
Autism: A developmental psychiatry perspective;
Physical health in autism: Common conditions and their management;
Mental health in autism: An update on the common psychiatric disorders and their treatment.
Findings: There are a number of different specialist medical perspectives on autism spectrum disorders that can inform and enhance psychiatric care of people with autism spectrum disorders.
Conclusions: Psychiatrists, as medical specialists, have an essential role in the assessment and management of the complex health problems associated with autism spectrum disorder.
Presenter 1
Genetics and Autism Spectrum Disoder
M Gattas1,2
1Brisbane Genetics, Wesley Medical Centre, Brisbane, Australia
2Genetics Health Queensland, Royal Brisbane and Women’s Hospital, Brisbane, Australia
Background: Twin and other family studies have long identified genetic factors as having an important role in the aetiology of autism spectrum disorders (ASD). The technology of gene testing is evolving rapidly, and this is shedding some light on what is a complex issue from a genetic point of view.
Objectives: The objective is to provide psychiatrists with a better understanding of the new gene testing technologies that are entering clinical practice, and to review some of the findings from research studies where this technology has already been used.
Methods: A brief overview of historical and current methods used in genome analysis will be provided. The perspective will be from a clinical rather than a laboratory point of view.
Findings: There is no single gene for autism. On the contrary, many areas of the genome have been implicated as contributing to this phenotype. Systems biology approaches can broadly group some of the genes identified into three broad groups: genes involved in formation of synapses, genes affecting transcription of other genes, and genes affecting chromatin or how the DNA is packaged in cell nuclei.
Conclusions: Understanding the molecular biology of autism will also assist in treating a range of other adverse neuro-cognitive impairments such as epilepsy, psychosis, neurosis and intellectual impairment. This may not be so surprising to psychiatrists who have long recognized these disorders as common comorbidities in the same patient.
Presenter 2
ASD and Developmental Psychiatry: Experience of Children’s Hospital at Westmead
D Dossetor1,2
1Sydney Children’s Hospital Network, Sydney, Australia
2Sydney Medical School, University of Sydney, Sydney, Australia
Background: Children with developmental disabilities including autism spectrum disorders (ASD) often have complex clinical needs. Traditionally there have not been specialised services, and children and adolescents with ASD have been expected to access generalist services. In this context, a unique developmental psychiatry clinical team was developed at Children’s Hospital Westmead (CHW) and later expanded to include the CHW School-Link. This team represents a collaboration between CHW, the Children’s Team of Statewide Behaviour Intervention Service of NSW Disability Services (SBIS) and NSW Department of Education.
Objectives: This session will use the description of the existing specialist service built on a collaboration between the health, disability and education sectors and the projects it has achieved to reflect on the complexity of this clinical area. This will lead to a discussion about the service model that is most effective at meeting the complex needs of children and adolescents with developmental disabilities.
Methods: Four major projects will be described: an evidence-based developmental framework and multidisciplinary training curriculum to promote the mental health of children and adolescents with intellectual and developmental disabilities, a school-based intervention for children with ASD (Emotion Based Social Skills Training), Stepping Stones (a group intervention targeting mental health promotion), and a clinical review of 150 clinical cases seen by the service.
Findings: The positive outcomes from each of these four projects described show the potential for therapeutic gain in this challenging population. Much innovation and clinical benefit can be achieved by multidisciplinary multiagency collaborative partnerships, where skills and resources are shared.
Conclusions: Such a collaborative clinical subspecialty service provision provides a best-practice model and would seem to be clinically highly cost-effective, but may not survive the ‘free market economy’ of the NDIS.
Presenter 3
Physical Health in Autism: Common Conditions and Their Management
N Lennox
Queensland Centre for Intellectual and Developmental Disability, University of Queensland, Brisbane, Australia
Background: People with autism often have comorbid physical health conditions that can be communicated to others in unusual ways including changes in behaviour. This communication style can be difficult to interpret and, along with other barriers to healthcare, can result in missed diagnosis and consequent absent or inadequate management.
Objectives: This presentation aims to present the associated comorbidities experienced by people with autism and to describe the healthcare experiences of people with autism and the perceptions of health professionals who have an interest in this population. Finally, the presenter will discuss how a psychiatrist can improve the healthcare experience of people with autism and increase the recognition and maximize the treatment of potential underlying physical conditions.
Methods: We have undertaken a literature search of the grey and academic literature and explored what resources are currently available to physical and mental health professionals. The views of health professionals and adults with autism spectrum disorder have been sought by questionnaires, interviews and the reading of first-hand accounts written by people who live with autism spectrum disorder or those of their family.
Findings: To improve the healthcare provided to people with autism spectrum disorder requires an understanding of their neurosensory profile, and how this and other aspects of the disorder influence communication of their needs. In addition, comorbid physical and mental health conditions are common and need to be considered in any healthcare interaction.
Conclusions: Providing psychiatric care to people with autism spectrum disorder can be challenging; however, there exists a significant opportunity to improve the physical and mental health of this population, through an understanding of their experience of life, their communication style and a knowledge of common comorbidities and their management.
Presenter 4
Mental Health in Adults With Autism Spectrum Disorder
C Franklin
Queensland Centre for Intellectual and Developmental Disability, University of Queensland, Brisbane, Australia
Background: The assessment and management of psychiatric disorders can be especially challenging in people with autism spectrum disorder (ASD) due to associated difficulties in communication and social relatedness. There is very little psychiatric training in this area in Australia and New Zealand and many psychiatrists feel ill-equipped to manage patients who present with ASD.
Objectives: This presentation aims to update the psychiatrist’s knowledge of the typical presentation and appropriate management of common psychiatric disorders in ASD.
Methods: The presentation will focus on clinically relevant material that will help psychiatrists in their own clinical practice. Case material will be used to illustrate common presentations, followed by an update of the current literature, with emphasis on intervention and treatment options.
Findings and conclusions: There have been recent innovations and advances in some areas of treatment of psychiatric disorders in ASD, especially for those with ASD Level 1 (previously known as Asperger’s syndrome). Intervention for people with more severe ASD remains an underdeveloped area but current research holds some hope for future improvements. Psychiatrists have an essential role in both the diagnosis of mental illness and appropriate treatment planning for people with ASD.
Transitions for Psychiatrists: Later Career Stages
Membership Engagement Committee Symposium
This symposium is an official presentation of the Membership Engagement Committee (MEC), focusing on later career transitions. The symposium will include presentations from four senior Fellows, each of whom has expertise in major career transitions. The focus of the symposium is on issues related to transitioning into a new career phase or towards retirement.
Background: In response to needs expressed by members of the College, the MEC has organised this symposium as the first of an ongoing series, helping members with relevant information and appropriate, practical resources at various stages of their careers.
Objectives: The symposium aims to have a practical focus on important issues faced by psychiatrists, providing attendees with an opportunity to explore and discuss major career transitions relevant to latter stages of their careers.
Methods: Four senior Fellows will speak on the following topics:
Successful ageing, with specific reference to psychiatrists and doctors;
Psychological aspects of transitions and changes later in life,
Winding down a practice, cutting back or changing roles,
Cognitive and physical problems that may challenge the ability to continue practice.
Following the presentations, there will be a formal panel discussion of questions and issues raised by attendees. Attendees are encouraged to bring questions and contribute their own experiences to the discussion.
Presenter 1
Winding Down a Practice, Cutting Back or Changing Roles
D Neill
Presenter 2
Cognitive and Physical Problems That May Challenge the Ability to Continue Practice
C Wijeratne
Presenter 3
Sucessful Ageing, With Specific Reference to Psychiatrists and Doctors
C Peisah
Presenter 4
Psychological Aspects of Transitions and Changes Later in Life
J Randles
What Should the New Generation of Mental Health Services Be and How Do We Get There?
N O’Connor1,2, J Crawshaw3, D Butt4, S Pontonio5,6, R Vine7
1Northern Sydney Local Health District, Sydney, Australia
2Discipline of Psychiatry, University of Sydney, Sydney, Australia
3Ministry of Health New Zealand, Wellington, New Zealand
4National Mental Health Commission, Canberra, Australia
5Pontonio Consulting Group, Melbourne, Australia
6National Institute of Organisation Dynamics Australia (NIODA), Melbourne, Australia
7North Western Mental Health, Melbourne, Australia
Background: The symposium will present the outcomes of the Pre-Congress Workshop that explored the key issues facing mental health service systems in Australia and New Zealand.
In spite of broad agreement around the principles of improved mental health service delivery, there remain a number of challenges related to:
Different levels of government, funding different programs,
Lack of connectivity between independent sectors involved in service delivery, for example, acute sector, primary care sector, not for profit and other NGO support services,
A notable lack of standardized care models in different jurisdictions.
Key challenges for psychiatry include:
Harnessing influential thought leaders to shape policy,
Driving an agenda to integrate existing models,
Promoting evidence-based practice,
Developing new ways to achieve continuity of care for optimal individual/patient outcomes.
Objectives: The symposium aims to present the ideas generated in the Pre-Congress Workshop for discussion by the expert panel and symposium participants. The facilitated panel discussion and audience participation will test the ideas generated in the Pre-Congress Workshop and explore actions required of psychiatrists involved in leadership and management. The symposium is aimed at all psychiatrists and trainees involved or interested in leadership roles at various levels in the mental health system.
Methods: The panellists will be asked to present what they see as the leadership priorities in relation to implementing the new generation of mental health services. The panellists will each address the symposium for 10 minutes. This will be followed by a facilitated discussion with audience participation.
Findings: Agreed priorities and actions will be documented during the symposium and will inform an article to be submitted to Australasian Psychiatry and to be reported back to the College Board.
Conclusions: Psychiatrists have important leadership roles and can influence the mental health reform agenda and its implementation.
Presenter 1
What Should the New Generation of Mental Health Services Be and How Do We Get There?
J Crawshaw
Ministry of Health New Zealand, Wellington, Wellington, New Zealand
Background: John Crawshaw has had a longstanding interest in leadership and management in psychiatry. He has held senior leadership positions in a number of jurisdictions in New Zealand and Australia.
Conclusions: Dr Crawshaw will speak about the need to define leadership competencies, develop systems and programs to develop and support psychiatrists as leaders and senior managers, and how we might create the best conditions for ensuring the next generation of psychiatrist leaders.
Presenter 2
What Should the New Generation of Mental Health Services Be and How Do We Get There?
D Butt
National Mental Health Commission, Canberra, Australia
Background: David Butt has 30 years of experience in the health system at Executive level.
Conclusions: David will focus on the national mental health policy within the context of health reform, reflecting on the key drivers of this policy and the implications to mental health service delivery.
Presenter 3
What Should the New Generation of Mental Health Services Be and How Do We Get There?
S Pontonio1,2
1Pontonio Consulting Group, Melbourne, Australia
2National Institute of Organisation Dynamics Australia (NIODA), Melbourne, Australia
Background: Silvio Pontonio has extensive experience working in health systems in Victoria and developing innovative models of care under a range of funding arrangements.
Conclusions: The time has come for major change in the national mental health system, but what might act as a circuit breaker or vehicle for this change?
Activity Based Funding (ABF) will provide opportunities and potential threats for the mental health sector. Drawing on real world experiences and observations of the impacts of ABF in the Victorian public health system, Silvio will explore:
The lessons from the Victorian ABF experience and what it may offer other sectors including mental health,
How ABF in Victoria facilitated clinical, administrative and policy leaders to join forces to drive innovations in models of care,
Opportunities to develop integrated models by adopting inter-sectoral partnerships.
Presenter 4
What Should the New Generation of Mental Health Services Be and How Do We Get There?
R Vine
North Western Mental Health, Melbourne, Australia
Background: Ruth Vine is Executive Director, North West Mental Health, Melbourne and has previously been the Chief Psychiatrist of Victoria.
Conclusions: Ruth will address an emerging issue:
Despite the presence of mental health legislation and evidence of increasing acuity and pressure on inpatient services – especially high dependency areas – mental health leaders have struggled to articulate how and why there should be government and community support for clinical services for those with severe and often enduring mental illness. Emphasis on de-stigmatising and increasing community awareness of mental health may have perversely lead to greater stigmatisation of those with severe illness and a downgrading of the importance and effectiveness of clinical intervention. Psychiatrists need to find a way of acknowledging the risks associated with severe illness, such as suicide, violence and homelessness, while also reassuring that with effective interventions all three can be mitigated.
Presenter 5
What Should the New Generation of Mental Health Services Be and How Do We Get There?
N O’Connor1,2
1Northern Sydney Local Health District, Sydney, Australia
2University of Sydney, Sydney, Australia
Background: Nick O’Connor is Clinical Director at the North Shore Ryde Mental Health Service and Chair of the RANZCP Bi-national Special Interest Group Leadership and Management.
Conclusions: Nick will facilitate the discussion around the issues that arose from the Pre-Congress Workshop, and the priorities identified by the expert panel and symposium participants. The outcome of the symposium will be a clearer idea about what specific actions psychiatrists might take at a range of levels to promote the reform and development required for better mental health outcomes.
Time, Culture and Psychiatric Diagnosis
S Balaratnasingam1,2, A Janca1, M Chapman1,2
1Kimberley Mental Health and Drug Service, Broome, Australia
2School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia
Background: Time is implicit in psychiatric diagnosis and integral to human existence, yet given little explicit attention.
Objectives: Enhance awareness of time from a number of theoretical perspectives with a focus on clinical utility.
Methods: Personal reflections and review of relevant literature regarding psychiatric aspects of time.
Findings: Appreciating the implicit and explicit aspects of time in clinical practice will enhance psychiatric diagnosis and therapeutic interventions.
Conclusions: The concept of time is central to psychiatric practice and its impact needs to be appreciated to a greater extent.
Presenter 1
Time and Culture
S Balaratnasingam1,2
1Kimberley Mental Health and Drug Service, Broome, Australia
2School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia
Background: The concept of time is implicitly and intricately involved in all aspects of clinical work in psychiatry. An awareness of differing views of time across persons, cultures and clinical disorders can significantly enhance the richness of psychiatric practice as well as the effectiveness of clinicians in the field.
Objectives: To explore the concepts of time from varying theoretical orientations (phenomenology, physics, psychiatry, psychotherapy) with a focus on Australian aboriginal concepts of time.
Methods: The author’s own experience as a psychiatrist in the remote Kimberley region of Western Australia and key literature on the subject are summarized.
Findings: As described by Karl Jaspers in 1913, time is a fundamental and universal human experience which is central to our sense of existence and vitality. An understanding of different concepts of time is usefully and clinically relevant, especially in transcultural settings.
Conclusions: Notion, perception and definition of the concept of time are often neglected in psychiatric practice. Practising clinicians need to bear this concept of time as it is relevant to both the science and the art of psychiatry.
Presenter 2
Time and Psychiatric Nosology
A Janca
School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia
Background: Both DSM and ICD classification systems use time as a vehicle to group and classify mental disorders into acute, chronic, episodic etc.
Objectives: The author will explore the central concept of time in psychiatric diagnosis. In both DSM and ICD, the time criterion is used as an integral component of inclusion and exclusion criteria for making specific psychiatric diagnoses. Certain aspects of time such as onset, recency, duration and frequency are often used as diagnostic and/or severity thresholds in clinical psychiatric settings. Finally, the timelines sometimes serve as arbitrary nosological boundaries that delineate normality from psychopathology (e.g. culturally acceptable length of bereavement process).
Methods: The author’s own experience in developing sections of the World Health Organization’s ICD-10 diagnostic classificatory system and literature of relevant literature will be discussed.
Findings: Time is an integral part of psychiatric diagnosis and more attention needs to be paid to this key criterion.
Conclusions: “Linear” and “non-linear” concepts of time have significant impact on the classification, diagnosis and assessment of mental disorders across different cultures and settings, and psychiatrists would benefit from an enhanced awareness of its role.
Presenter 3
Time as the Great Healer
M Chapman1,2
1Kimberley Mental Health and Drug Service, Broome, Australia
2School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia
Background: ‘Nobody has any time any more’ – a common refrain in today’s technically advanced society, and frequently heard in the clinical setting. A curious paradox in the age of ‘time-saving devices’. Conceptions of time pervade descriptions and experiences across the contemporary spectrum of ‘therapeutic intervention’ in psychiatry, as well as in service provision, measurement and configuration. From ‘brief interventions’ to ‘long cases’, ‘four hour rules’ to ‘numbers of bed-days’, ‘28-day readmission rates’ and ‘7-day follow-ups’, time has become a primary therapeutic measuring stick.
Objectives: Explore the role of time in the health lexicon with an emphasis on roles and the meanings of time as a parameter in the realm of therapeutic intervention and resource allocation.
Methods: Review of relevant health literature and author’s experience as medical director, clinician, researcher and psychotherapist.
Findings: The time dimension is ever more critical in the quest for quantification of therapeutic intervention and this has consequences for our models of care and resource distribution.
Conclusions: Time has become a proxy for ‘cost’. The rise of linear time measurement as an ‘obsessive-compulsive symptom’, whilst covertly embedded in our conceptual, therapeutic and administrative systems, may be seen amongst other things as a prime marker and arbiter, as well as a consequence of our resource limitations and therapeutic models. Its rise is driven by our need to measure and quantify ‘activity’. As such it helps to fabricate our ‘hall of mirrors’ view of how best we should ‘provide care’.
RANZCP Advocacy to Improve the Physical Health and Life Expectancy of People With Severe Mental Illness
M Patton1, S Kisely2, W Miles3, G Roper4, Facilitator: D Siskind5
1President, Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, Australia
2School of Medicine, University of Queensland, Brisbane, Australia
3North Shore Hospital, Auckland, New Zealand
4Community Representative, RANZCP Consumer Collaboration Committee, Melbourne, Australia
5School of Medicine, University of Queensland, Brisbane, Australia
The RANZCP has been aware for some time that mental illness and various comorbid medical conditions, some arising from the treatments we prescribe, are amongst the most serious causes of disability in Australia and New Zealand. Research continues to demonstrate that the poor physical health of people with mental illness seriously impacts upon their quality of life and their life expectancy. The reasons are diverse including lifestyle, psychotropic side effects, stigma and difficulties in access to appropriate medical care.
Psychiatrists are responsible not just for the clinical care of consumers but also for providing clinical leadership, teaching and training, researching, and advocating for better psychiatric health in the community.
In 2014 the College published the first in a series of reports (available on the RANZCP website) which aim to engage Fellows, government and the wider community with this issue through policy review, economic modelling, case studies and consultation. This session explores the evidence base, clinical concerns, consumer experience and advocacy agenda for the College’s work in this area, and provides an opportunity for members to hear about the ongoing project and provide input for this work going forward.
Psychiatry Education Symposium: Fostering the Next Generation
L McLean1,2,3,4, L Nash1,5, S Kumar1, A Dwyer2,6, C Hickie7,8, B Kelly7
1Brain and Mind Research Institute, University of Sydney, Sydney, Australia
2Sydney Medical School, University of Sydney, Parramatta, Australia
3Sydney West and Greater Southern Psychiatry Training Network, Parramatta, Australia
4Consultation-Liaison Psychiatry, Royal North Shore Hospital, Sydney, Australia
5Health Education Training Institute, Sydney, Australia
6New South Wales Institute of Psychiatry, Parramatta, Australia
7University of Newcastle, Newcastle, Australia
8Western NSW Local Health District, Orange, Australia
Background: Psychiatry is a great area of medical need, requiring suitable high-quality training in many settings to prepare doctors to deliver this specialized care, and the integration of many kinds of knowledge and skill.
Objectives and methods: This symposium will offer talks on aspects of psychiatry training:
A discussion of the way philosophy and conceptual frames will be realized in a proposed new Formal Education Course (FEC) for Psychiatry Training in a Master of Medicine (Psychiatry) Programme at the Brain and Mind Research Institute (BMRI);
A discussion of active learning in the new BMRI FEC;
A report on a research project on teaching in psychiatry describing the design, delivery and evaluation of a module to help trainees prepare for an Entrustable Professional Activity in the CBFP aimed at that fundamental medical skill, particularly honed in psychiatry, the therapeutic alliance;
A report on a project that offered research and intervention in psychiatry teaching by junior doctors and trainees.
Presenter 1
A New Psychiatry Formal Education Course: Concepts and Philosophies
L McLean1,2,3,4
1Brain and Mind Research Institute, University of Sydney, Sydney, Australia
2Sydney Medical School, University of Sydney, Parramatta, Australia
3Sydney West and Greater Southern Psychiatry Training Network, Parramatta, Australia
4Consultation-Liaison Psychiatry, Royal North Shore Hospital, Sydney, Australia
This talk will present the underlying philosophy and conceptual frames for a new Formal Education Course, developed as the Master of Medicine (Psychiatry) Programme at the Brain and Mind Research Institute (BMRI), University of Sydney The course has been accredited by the Royal Australian and New Zealand College of Psychiatrists. Set in the interdisciplinary/multidisciplinary environment of the BMRI, where researchers, clinicians and consumers collaborate, the course, with several pathways, aims to offer a training that will prepare the next generation of psychiatrists by: enhancing the neuroscientific and integrative medicine basis of psychiatry training; embedding the biopsychosociocultural model of psychiatry into trainees’ thinking and practice, along with the recovery model and trauma-informed care; providing opportunities to form interdisciplinary networks and collaboration through shared units of study with students from other disciplines; enabling students to access academic presentations of the latest research by visiting international and national experts; using learning and teaching methodologies with an emphasis on engaged enquiry, including research-enriched and community-engaged learning and teaching (ReLT and CeLT); providing opportunities for non-Sydney-based and outer metropolitan/shift-affected trainees to participate using online technologies; offering the chance for research training and projects in psychiatry. Samples of course outlines, learning outcomes and teaching formats will be described to illustrate how the philosophies and objectives intend to be realized. Ways of evaluating the overarching educational outcomes of the course are currently under development.
Presenter 2
Update on Higher Education: The Importance of Active Learning
S Kumar
Brain and Mind Research Institute, University of Sydney, Sydney, Australia
Background: The world of education has embraced active learning and research. Problem-based learning is well known to recent graduates of medical schools, incorporating collaborative, case-based learning to promote effective thinking in students. The University of Sydney advocates engaged inquiry as a signature learning experience to foster a deep approach to learning. Psychiatry trainees are, however, involuntarily detained in a formal education course, which seems to negate some adult learning principles.
Objectives and methods: This paper will report on forays into the world of higher education, philosophies and research to ask the question: How can we best harness the power of active learning strategies to assist trainees in developing the competencies required for a reflective, communicative and evidence-based practice?
Findings and conclusions: Trainees may need a blended learning approach but this will require active evaluation.
Presenter 3
A Brief Training Module Focusing on the Therapeutic Alliance: Description and Outcomes
A Dwyer1,2,3, L McLean1,3,4,5, M Bowden6, K Egan7
1Sydney Medical School, University of Sydney, Parramatta, Australia
2St John of God Hospital, Richmond, Australia
3Sydney West and Greater Southern Psychiatry Training Network, Parramatta, Australia
4Brain and Mind Research Institute, University of Sydney, Sydney, Australia
5Consultation-Liaison Psychiatry, Royal North Shore Hospital, Sydney, Australia
6Children’s Hospital Westmead, Westmead, Australia
7Southeast Sydney and Illawarra Psychiatry Training Network, Randwick, Australia
Background: Establishing a therapeutic alliance is one of the fundamental skills in medicine, particularly in psychiatry. This has been recognized in the development of the Competency Based Fellowship Program (CBFP) of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) by the development of an Entrustable Professional Activity (EPA) in the therapeutic alliance. How this skill can best be taught, however, is not clear, particularly considering time and resource constraints in medical education settings. The NSW Institute of Psychiatry (NSWIOP) funded a fellowship in medical education and psychotherapy in 2014 to encourage the development and appraisal of a brief training module in the development of the therapeutic alliance for basic psychiatry trainees. The module’s effectiveness was designed to be measured in an open trial by pre and post teaching scale scores of the Working Alliance Inventory (therapist form) (WAI-T) and the Groningen Reflective Ability Scale (GRAS) for both participants and a control group.
Objectives and methods: This presentation will describe the development of the module, barriers to its implementation, and the initial process and outcomes of its implementation.
Findings and conclusions: Delivering teaching in the difficult service settings of psychiatry remains a challenge.
Presenter 4
Evaluation of a Workshop to Increase Trainee Teaching Capacity
L Nash1,2, C Hickie3,4, B Kelly3
1Brain and Mind Research Institute of University of Sydney, Sydney, Australia
2Health Education Training Institute (HETI), Sydney, Australia
3University of Newcastle, Newcastle, Australia
4Western NSW Local Health District, Orange, Australia
Background: A collaborative mixed methods project between University of Newcastle, the NSW Institute of Psychiatry and Western NSW Local Health District was conducted in 2012–2014 to investigate the teaching experience of basic psychiatry trainees and to explore ways to increase their teaching capacity.
Objectives and methods: Methods and results of the project will be presented. The respondents identified key areas that needed tuition, with the following rating highly: 1) difficult scenarios with medical students; 2) managing clinical teaching in a time-efficient manner. This led to phase 2 of the project, in which workshops were delivered in rural and metropolitan NSW to address these concerns. In addition, funding was received in 2013 from HETI and Health Workforce Australia to make five short films as workshop teaching aids. The initial research findings informed these films, which can be used to teach psychiatry trainees, junior doctors and consultants to enhance teaching capacity. Evaluation feedback (mixed methods) was collected after each workshop and will be presented.
Findings: We found that 96% of trainees had a medical student attached to them on clinical rotation, yet only 20% had received any teaching tuition. The 2013 workshops used difficult scenario role plays and the 2014 workshops used the films and role plays. The 2012 study results have been published and presented at conferences and the films have been presented at national and international conferences.
Conclusions: Symposium participants will have the opportunity to view a workshop film and be given details of free online access.
Engaging the Next Generation of Psychiatrists
M Tomasic1,2,3, E Halley4, G Byrne5,6, A Willis7, AA Sanchez8, B Jayawardena9
1Chair, RANZCP Recruitment into Psychiatry Working Party
2Immediate Past President, RANZCP
3Centre for Disability Health, Department for Communities and Social Inclusion, Adelaide, Australia
4General Manager, Education and Training, RANZCP
5School of Medicine, University of Queensland, Herston, Australia
6Geriatric Psychiatry, Royal Brisbane and Women’s Hospital, Herston, Australia
7Wellington Community Mental Health Team, Wellington, New Zealand
8University of Melbourne, Melbourne, Australia
9University of Western Australia, Perth, Australia
Background: Research shows that psychiatry has had an image problem amongst many medical students and graduates. This presentation highlights work being undertaken by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) to turn this around.
Objectives: Increasing numbers of medical students graduating presents an opportunity to raise the profile of psychiatry, dispel common misconceptions and position psychiatry as a potential career.
Methods: The RANZCP, through its Recruitment into Psychiatry Project, supported by Commonwealth funding, has developed a suite of initiatives to engage with medical students and graduates including:
The Psychiatry Interest Forum (PIF);
Student sponsorships to attend the RANZCP Congress;
Dedicated PIF conference events;
A bi-national essay competition;
Introduction to Psychiatry short courses;
Relationship building with university medical schools;
New resources for students and their teachers.
Findings: The initiatives have been welcomed by students, graduates and universities:
Over 1,000 students and graduates have joined the PIF;
Over 30 students have been sponsored to attend Congress;
78 attendees participated in the Introduction to Psychiatry courses (over 200 applications were received);
Course attendees reported a 63% increase in considering psychiatry as a career and a 96% increase in awareness of training pathways.
The success of these initiatives is thanks to the involvement of over 70 Fellows and trainees.
Conclusions: The Recruitment into Psychiatry Project is successfully raising the profile of psychiatry and providing RANZCP Fellows and trainees the opportunity to engage with and inspire the next generation of psychiatrists.
The RANZCP Clinical Practice Guidelines and Their Implementation
M Oakley Browne1,2, G Smith1,3,4
1Royal Australian and New Zealand College of Psychiatrists
2Department of Psychiatry, School of Medicine, University of Tasmania, Hobart, Australia
3School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia
4Centre for Research into Disability and Society, Curtin University, Perth, Australia
Background: In 2012, the Clinical Practice Guidelines Project commenced to systematically review and update six Clinical Practice Guidelines (CPGs) previously developed by the Royal Australian and New Zealand College of Psychiatrists in 2005. In addition, consensus-based guidelines on the physical health care of people with enduring psychotic illness have been developed.
Objectives: The aims of this symposium are to provide an update on the CPG Project and to discuss the plans for dissemination and implementation of the guidelines once they are released.
Methods: The CPGs were put through a robust review and redevelopment process. The consensus-based guidelines on the physical health care of people with enduring psychotic illness were produced using the Delphi method.
Findings: The Eating Disorders CPG was published in November 2014, with the CPGs for Schizophrenia, Deliberate Self Harm and Mood Disorders expected to be published early in 2015. The consensus-based guidelines on the physical health care of people with enduring psychotic illness will also be published in 2015.
Presenter 1
Current Status of the RANZCP Clinical Practice Guidelines Project
M Oakley Brown1,2
1Royal Australian and New Zealand College of Psychiatrists
2Department of Psychiatry, School of Medicine, University of Tasmania, Hobart, Australia
Background: The Clinical Practice Guidelines Project was commenced to systematically review and update six Clinical Practice Guidelines (CPGs) previously developed by the Royal Australian and New Zealand College of Psychiatrists in 2005. The six original CPGs were: Anorexia Nervosa; Bipolar Disorder; Deliberate Self Harm (youth and adult); Depression; Panic Disorder and Agoraphobia; and Schizophrenia. It was decided to merge the Bipolar Disorder and Depression guidelines into a single guideline covering the spectrum of Mood Disorders. It was also decided to broaden the scope of the Anorexia Nervosa guideline to include the range of Eating Disorders.
Objectives: The aims of the CPG Project were to develop usable and accessible resource documents based on the latest international evidence-based practice to enable quality psychiatric and mental health care in Australasia and New Zealand, and to promote and disseminate the developed resources to better inform consumers, carers and mental health clinicians about appropriate, and inappropriate, treatment options for the Australasian and New Zealand psychiatric/mental health care setting.
Methods: Five working groups (WGs) were established to review and update the CPGs. Once the WGs had produced a first draft of the CPGs, they went through various rounds of internal and external review before being submitted to the Australian and New Zealand Journal of Psychiatry for publication. Consumer and carer versions of the revised CPGs are also being developed to complement the full guidelines.
Findings: The Eating Disorders CPG was published in November 2014, with the CPGs for Schizophrenia, Deliberate Self Harm and Mood Disorders expected to be published early in 2015. The key recommendations of each published CPG will be discussed.
Presenter 2
Physical Health Care of People With Enduring Psychotic Illness
M Oakley Browne1,2, T Lambert3, N Reavley4, A Jorm4
1Royal Australian and New Zealand College of Psychiatrists
2Department of Psychiatry, School of Medicine, University of Tasmania, Australia
3 Concord Centre for Cardiometabolic Health in Psychosis, University of Sydney, Sydney, Australia
4Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
Background: People with enduring psychotic illness have high mortality rates, with a 1.5–5 times higher risk of developing cardiometabolic risks compared to the general population. The issues are compounded by a dearth of evidence on the efficacy of screening, assessment, monitoring and management approaches for this population. The case for clinical guidance is compelling.
Objectives: To develop consensus-based guidelines that are inclusive and respectful of the perspectives of clinicians, people with enduring psychosis, and families and carers.
Methods: The Delphi expert consensus method was used. A systematic review of websites, books and journal articles was conducted to develop a 416-item survey containing strategies that health professionals should use to treat, manage and monitor the physical health of people with an enduring psychotic illness. Three panels of Australian experts (55 clinicians, 21 carers and 20 consumers) were recruited and independently rated the items over three rounds, with strategies reaching consensus on importance written into the guidelines
Findings: Following three rounds of surveys, clinicians endorsed 386 of the 430 items (89%). In the first-round survey, the people with enduring psychotic illness and carers endorsed all 117 items (100%). The endorsed strategies provided information on: engagement and collaborative partnerships; clinical governance; risk factors, morbidity and mortality in people with enduring psychotic illness; assessment, including initial and follow-up assessments; barriers to care; strategies to improve care of people with enduring psychotic illness; education and training; treatment recommendations; medication side-effects; and the role of health professionals.
Conclusions: The guidelines are intended to be used by health professionals, people with an enduring psychotic illness, and their families and carers. It is hoped that they may inform policy and practice in organisations supporting people with enduring psychotic illness.
Presenter 2
Implementation of Clinical Practice Guidelines
M Oakley Brown1,2, G Smith1,3,4
1RANZCP Committee for Therapeutic Interventions and Evidence-Based Practice
2Department of Psychiatry, School of Medicine, University of Tasmania, Hobart, Australia
3School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia
4Centre for Research into Disability and Society, Curtin University, Perth, Australia
Background: On completion, the Clinical Practice Guidelines Project will have systematically reviewed and updated six Clinical Practice Guidelines (CPGs) previously developed by the RANZCP. However, the development and publication of guidelines does not in itself ensure their use in practice and consideration must be given to dissemination and implementation. The success of clinical guidelines in changing practice and patient outcomes depends on factors such as the methods used to develop the guidelines, the dissemination and implementation strategies used, the methods used to evaluate effectiveness, the methods used to update the guidelines and the clinical setting.
Objectives: The RANZCP intends to follow the release of its CPGs with strategies for implantation and evaluation.
Methods: The following six key implementation processes have been identified: planning, educating, financing, restructuring, managing quality, and attending to policy context. There is also a need to overcome barriers at the service, patient and illness levels, emphasising the need for service reorganisation, communication enhancement, improved training and education, better incentives, accreditation rigour, and government leadership.
Findings: Interventions that could be implemented are:
Decision-support systems and other reminders;
Interactive educational meetings (local workshops; workshops at annual congress);
Clinically focused e-learning modules for CPD;
Local opinion leaders/local consensus quality improvement audit and feedback tool(s);
Patient mediated
Evaluation surveys should be developed and administered at 6 months and 12 months post-release and dissemination of the CPGs and should assess how well the guidelines are known and valued by users, the extent to which the recommendations are applied and the extent to which the application leads improved care.
Conclusions: As passive dissemination methods alone are less likely to lead to changes in professional behaviour, a formal structured implementation process must be developed which draws on the available evidence relating to behaviour change among healthcare professionals and the effectiveness of different dissemination and implementation strategies.
Integration of Research Into Psychiatric Practice: A Guide for New Investigators and the Scholarly Project
D Siskind1,2,3,4, S Parker1,2,3,4, S Kisely1,2, M Macfarlane1,5,6
1RANZCP Committee for Research
2Metro South Addiction and Mental Health Service, Brisbane, Australia
3School of Medicine, University of Queensland, Brisbane, Australia
4Queensland Centre for Mental Health Research, Wacol, Australia
5Australia Graduate School of Medicine, University of Wollongong, Wollongong, Australia
6Illawarra Shoalhaven Local Health District, Wollongong, Australia
Background: Evidence-based mental health is the paradigm for the modern professional practice of psychiatry. With this, there is an increasing role for the clinician scientist in psychiatry. The skills required to undertake research can be acquired at any stage in a career, from trainee to senior Fellow. The research changes to the RANZCP Competency Based Fellowship Program (CBFP) have introduced a Scholarly Project as a mandatory training requirement. The integrated clinical psychiatrist-scientist is the aspiration for including research training in the RANZCP CBFP. Practically, this means a psychiatrist should have well-developed skills for interpreting, explaining and applying research in practice.
Pathways through which Registrars and Fellows can be supported to incorporate research into their training and clinical practice are not always clear. The introduction of the Scholarly Project now requires trainees to gain experience in research methods; there has been a degree of uncertainty expressed by trainees as to how this can be realized. This presentation aims to inform novice researchers about the process of research, pathways to realizing a project, as well as relevant supports including funding opportunities.
Objectives: This symposium is targeted at both Registrars and Fellows who have an interest in better integration of research with their clinical practice. It will be of particular assistance to registrars planning their approach to the Scholarly Project. The symposium will provide information about how to survive in research, including addressing the following questions:
How to write a research question?
How to find (and get value from) a research supervisor?
How to design a research study, and to collect and analyse data?
How to write up research findings with view to publication?
Methods: A series of individual presentations will be followed by group discussion with the presenting panel.
Findings: Extensive information and experience will be identified to Registrars and other new investigators in designing, implementing and following a research project through to completion.
Conclusions: Research can be a highly rewarding activity; the provision of information can demystify the process and create a clear pathway to success.
Presenter 1
How to Write a Research Question?
D Siskind1,2,3,4
1RANZCP Committee for Research
2Metro South Addiction and Mental Health Service, Brisbane, Australia
3School of Medicine, University of Queensland, Brisbane, Australia
4Queensland Centre for Mental Health Research, Wacol, Australia
Background: Research can seem daunting, especially for trainees and early career researchers. This paper focuses on how to formulate and begin a research project in the framework of the Scholarly Project.
Objectives: Attendees will increase their understanding of how to formulate a clear and operationalized research question.
Methods: Individual presentation and facilitated group discussion.
Findings: Formulating a research question is a critical component to commencing a successful research project.
Conclusions: Through systematic planning, early career researchers and other clinicians can plan and conduct research suitable for the Scholarly Project or other research activity.
Presenter 2
How to Find (And Get Value From) a Research Supervisor?
S Parker1,2,3,4
1RANZCP Committee for Research
2Metro South Addiction and Mental Health Service, Brisbane, Australia
3School of Medicine, University of Queensland, Brisbane, Australia
4Queensland Centre for Mental Health Research, Wacol, Australia
Background: Supervision is a critical component required for one to have a good start in research. Trainees considering the Scholarly Project will need to be able to identify and effectively work with a supervisor who fits with both their interests and learning needs.
Objectives: Attendees will gain practice knowledge and confidence in the process of identifying, approaching and working with a research supervisor.
Methods: Individual presentation and facilitated group discussion.
Findings: Supervision is critical component of supporting the successful completion of the Scholarly Project, and there is value in planning the process of identifying and working with a supervisor.
Conclusions: Identifying a research supervisor will depend on the interests, learning goals and learning style of the trainee, as well as the interests and skills sets of potential supervisors who are readily accessible.
Presenter 3
How to Design a Research Study, and to Collect and Analyse Data?
S Kisely1,2,3
1RANZCP Committee for Research
2Metro South Addiction and Mental Health Service, Brisbane, Australia
3School of Medicine, University of Queensland, Brisbane, Australia
Background: It is important to think carefully about your study design before starting research. Being clear about the hypotheses, methods and the statistical power required will help you make sure the project can answer the research question. Documenting the design will help in the process of ethics approval, an important aspect of the research process that is discussed. Funding is also discussed, including the RANZCP-funded New Investigator Grant.
Objectives: To explore the practical aspects of quantitative study design, including enhanced participant understanding of how to develop relevant hypotheses, identify and implement an appropriate methodology and to consider issues such as statistical power and ethics.
Methods: Individual presentation and facilitated group discussion.
Findings: Research design flows logically from the research question; careful planning can reduce unexpected frustrations in the research process.
Conclusions: Through careful planning, based on formulation of a research question, early career researchers can design and conduct quantitative research projects within the framework of the Scholarly Project or in their own independent projects.
Presenter 4
How to Write Up Research Findings With View to Publication?
M Macfarlane1,2,3
1RANZCP Committee for Research
2Metro South Addiction and Mental Health Service, Brisbane, Australia
2Australia Graduate School of Medicine, University of Wollongong, Wollongong, Australia
3Illawarra Shoalhaven Local Health District, Wollongong, Australia
Background: The process of writing up research with view to publication in a peer-reviewed academic journal can be daunting. This is especially so when one lacks familiarity with what is required and the steps that can be taken to increase the likelihood of acceptance.
Objectives: This presentation will provide information about the peer-review process, including how to select a journal and how to handle rejection. It will also consider ways that in which attention to study design and the way a paper is drafted might facilitate the acceptance of the final paper. The aim is to demystify the peer-review process and increase participants’ confidence in approaching this.
Methods: Individual presentation and facilitated group discussion.
Findings: Awareness of the processes associated with preparing a paper for publication in a peer-reviewed journal will increase the likelihood of acceptance and reduce the associated frustration. The peer-review process can facilitate iterative improvement in both the quality of a research paper and one’s skills as a researcher.
Conclusions: By understanding the process of peer review, early career researchers will be able to better plan and prepare research for publication and dissemination.
The Conversational Model: Perspectives, Process and Phenomena
L McLean1,2,3,4, C Marlborough1,4, C Chapman1,7, A Korner1,5, G Lianos1,6, J Haliburn1,6
1Westmead Psychotherapy Program, Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Brain and Mind Research Institute, University of Sydney, Sydney, Australia
3Department of Consultation-Liaison Psychiatry, Royal North Shore Hospital, St Leonards, Australia
4Western Sydney Local Health District (WSLHD), Parramatta and Blacktown, Australia
5Nepean Blue Mountains Local Health District (NBMLHD), Nepean, Australia
6Private Practice, Sydney, Australia
7New South Wales Institute of Psychiatry, Parramatta, Australia
Background: The Conversational Model (CM) emerged around 30 years ago as a synthesis of evidence from research and practice in psychoanalytic approaches, neuroscience, philosophy, development and linguistics to provide a creative base from which to explore how self is formed in connected relationship and conversation, how it is broken down or restricted by trauma and how it is restored through psychotherapy. While initially focused on the treatment of borderline personality disorder in long-term intensive psychodynamic psychotherapy, the model’s perspective on the importance of relational approaches and non-specific therapeutic factors has been applied to acute mental health, both in-patient and community, to short-term dynamic psychotherapy, to group work and to couples work across many diagnoses and presentations for which trauma is a significant factor.
Objectives and methods: We will offer several papers on different aspects on work and thinking within the Model that represent conversations between the CM perspective and aspects of theory, research or practice in a number of fields.
Findings: As a teaching, research and clinical service, the Westmead Psychotherapy Program reaches out through the Masters of Psychotherapy Program and to local clinicians through its Scholarship Program and liaison activities to encourage the application of the CM’s perspective and to engage in dialogue from within this open model.
Conclusions: The CM perspective can be applied across many domains to help understand and hone what works for whom and why; its theoretical underpinnings provide a rich field for integrative neuroscience approaches to phenomenology, process and practice.
Presenter 1
The Sound and the Story: Reflections Upon the Musicality of Communication and the Conversational Model
C Marlborough1,2
1Westmead Psychotherapy Program, Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Scholarship Program, Western Sydney Local Health District (WSLHD), Parramatta, Australia
Background: Communication skills are fundamental to human interaction and the therapeutic process. The Conversational Model (CM) pays equal attention to the narrative and affective components of communicative exchanges within the therapeutic dyad, with a view to fostering the emergence of self and the processing of trauma. When trauma occurs, the capacity to communicate coherently and effectively can become fragmented and incoherent. The Theory of Communicative Musicality offers a framework to connect with a client’s affective states through the musical properties of the narrative via the development of the therapist’s ability to identify, acknowledge and respond to changes in the patient’s volume, tone and tempo, with regards to the immediate phrasing and broader context of communicative exchanges.
Objectives: This presentation will offer an overview of the theory of Communicative Musicality applied to the CM with attention to the way the “musical” aspects of the encounter are present and develop during therapy.
Methods: After outlining the theoretical frames we will then illustrate the process with case material from therapy conducted in the CM and drawn from audio-taped sessional material that is closely analysed using the Communicative Musicality approach, with particular attention paid to changes in the volume, tone, tempo and phrasing of communicative exchanges.
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 underway, the framework is an accessible addition to the therapeutic repertoire.
Presenter 2
What is Psychotherapy? – a Conversational Model Enquiry
G Lianos1,2, L McLean1,3,4,5
1Westmead Psychotherapy Program, Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Private Practice, Sydney, Australia
3Brain and Mind Research Institute, University of Sydney, Sydney, Australia
4Department of Consultation-Liaison Psychiatry, Royal North Shore Hospital, St Leonards, Australia
5Sydney West and Greater Southern Psychiatry Training Network, Western Sydney Local Health District (WSLHD), Parramatta, Australia
Background: There are many psychotherapies and many have been shown to be effective, with the relational quality consistently found to be a central predictor of success. In the light of this, and using a Conversation Model-based perspective, how could we now define psychotherapy?
Objectives and methods: This paper will aim to explore the phenomenon of psychotherapy through an examination of theory and practice, grounded in case-based examples, offered from the perspective of the Conversational Model. It will then offer the opportunity for discussion with attendees on the nature of psychotherapy.
Findings and conclusions: The story of how we grow in relationship and how we examine and track this process is still unfolding, but review, reflection and reappraisal and authenticity are essential to the art and the science of psychotherapy.
Presenter 3
Identifying and Managing Dissociation
C Chapman1,6, L McLean1,2,3,4, A Korner1,2,5, J Haliburn1,2
1Cumberland Hospital, Western Sydney Local Health District (WSLHD), Sydney, Australia
2Westmead Psychotherapy Program, Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
3Brain and Mind Research Institute, University of Sydney, Sydney, Australia
4Department of Consultation-Liaison Psychiatry, Royal North Shore Hospital, St Leonards, Australia
5Nepean Blue Mountains Local Health District (NBMLHD), Nepean, Australia
6New South Wales Institute of Psychiatry, Parramatta, Australia
Background: Dissociation refers to experiences that signify a breakdown of integrated consciousness, often involving feeling detached from reality and occurring on a continuum, ranging from benign daydream-like experiences to completely disorientating fugues. Conceptualized at times as the result of trauma, dissociation frequently occurs in patients with complex trauma histories, such as those seeking assistance from the Westmead Psychotherapy Program (WPP).
Objectives: This presentation involves case vignettes from a senior psychiatry trainee’s experience identifying and managing patients for whom dissociation is a major symptom, while under supervision in the Special Training Position (STP) at the WPP at Cumberland Hospital. The aim is to give an idea of the types of descriptions that might be used by a patient when describing these dissociative experiences, the impairment that is caused and some methods that have been found useful for alleviating distress associated with these experiences.
Methods: De-identified vignettes will be presented drawn from clinical experiences of both inpatients and outpatients who report experiences consistent with dissociation.
Findings: Patients with dissociative experiences often hide their symptoms fearing they might be labelled “crazy”. Skills obtained in the STP have provided opportunities for psychoeducation not only with patients but with staff unskilled in managing dissociation, leading to more effective patient management.
Conclusions: The STP has allowed an experience in identification and management of dissociation, an area in which trainees often receive scant education in other contexts.
Presenter 4
The Music and the Dance: Measurement and Change in Psychotherapy by Adapting Using Care-Index and AAI Markers
L McLean1,2,3,4, A Korner1,2,5
1Westmead Psychotherapy Program, Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Brain and Mind Research Institute, University of Sydney, Sydney, Australia
3Department of Consultation-Liaison Psychiatry, Royal North Shore Hospital, St Leonards, Australia
4Sydney West and Greater Southern Psychiatry Training Network, Parramatta, Australia
5Nepean Blue Mountains Local Health District (NBMLHD), Nepean, Australia
Background: Human beings develop in connected relationships, commencing with the touch, gaze, voice and affective tone of the proto-conversation and the sequencing of activities that tend to care, safety, comfort and play, extending to the therapeutic context where psychotherapy is the base for a healing relationship fostering post-traumatic transformation. Connectivity is constructed at every level of the individual and interpersonal systems: neurons fire and wire together, autonomic nervous systems are in conversation and the “soft wiring” and intrapersonal connections slowly unfold. Languages of words and music and gesture develop and weave through our relational life, becoming connected with our inner voice and musings, tracking the trajectory of our development: the joy of companionship, the pride of achievement and the vicissitudes of trauma and loss. Parent-infant and attachment research has something to offer in operationalizing the individual and dyadic state and their change over time in our psychotherapeutic conversations.
Objectives and methods: This talk aims to illustrate the utility of the CARE-Index, examining the music and dance of dyads, and the Adult Attachment Interview, scored via linguistic markers, markers of reflective functioning, and indicators of states of mind, in assessing the therapeutic interchange and the resolution of trauma. These approaches will be outlined and then applied to an adult psychotherapy context, taking examples from earlier and later sessional material to demonstrate change.
Findings and conclusions: These ways of measuring the music and the dance of the dyad are helpful to the therapist seeking to reflectively track process and change.
The 2014 RANZCP Clinical Practice Guideline Project and CPG for Eating Disorders
G Malhi1, M Oakley-Browne1, P Hay1,2,3, C Galletly1, G Carter1, G Andrews1, D Chinn2,4, D Forbes2,5, S Madden2,6, R Newton2,7, L Surgenor1,8, S Touyz 1,9, W Ward1,10, F Zepf11, C Gray12, N Fagermo13
1RANZCP 2014 CPG Steering Committee
2RANZCP Eating Disorders CPG Working Group
3School of Medicine and Centre for Health Research, University of Western Sydney, Sydney, Australia; School of Medicine, James Cook University, Townsville, Australia
4Capital and Coast District Health Board, Wellington, New Zealand
5School of Pediatrics and Child Health, University of Western Australia, Perth, Australia
6Eating Disorders Service, Sydney Children’s Hospital Network, Westmead, Australia; School of Psychiatry, University of Sydney, Sydney, Australia
7Mental Health CSU, Austin Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia
8Department of Psychological Medicine, University of Otago at Christchurch, Christchurch, New Zealand
9School of Psychology and Centre for Eating and Dieting Disorders, Sydney, Australia
10Eating Disorders Service, Royal Brisbane and Women’s Hospital, Brisbane, Australia; University of Queensland, Brisbane, Australia
11Department of Child and Adolescent Psychiatry, University of Western Australia, Perth, Australia; Department of Specialised Child and Adolescent Mental Health Services, University of Western Australia, Perth, Australia
12Consultation Liaison Psychiatry, The Prince Charles Hospital, Brisbane, Australia
13Royal Brisbane and Women’s Hospital, Brisbane, Australia
Background: This clinical practice guideline (CPG) was conducted as part of the RANZCP CGP Project 2013–2014.
Objectives: To describe the CGP development process, to report on progress and describe and debate the utility of the eating disorder CPG with external experts.
Methods: Following a presentation of the guidelines development from the CPG Steering Committee and the eating disorder CPG (from the CPG Working Group) there will be three brief presentations from external discussants. Professor Zepf will discuss the CPG for anorexia nervosa from the perspective of a child and adolescent psychiatrist with an interest in eating disorders, Dr Curt Gray from the perspective of a consultation liaison psychiatrist in a general hospital and Dr Narelle Fagermo from the perspective of an adult physician in a general hospital with and without a specialist eating disorder service. There will then be the opportunity for general discussion.
Presenter 1
Clinical Practice Guidelines Project (CPG Project) Overview
CPG Steering Committee: G Malhi1, M Oakley-Browne1, P Hay1,2,3
1RANZCP 2014 CPG Steering Committee
2RANZCP Eating Disorders CPG Working Group
3School of Medicine and Centre for Health Research, University of Western Sydney, Sydney, Australia; School of Medicine, James Cook University, Townsville, Australia
Background: In 2012, the Clinical Practice Guidelines Project commenced to systematically review and update six Clinical Practice Guidelines (CPGs) previously developed by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in 2005. The six original CPGs were: Anorexia Nervosa; Bipolar Disorder; Deliberate Self Harm (youth and adult); Depression; Panic Disorder and Agoraphobia; and Schizophrenia. It was decided to merge the Bipolar Disorder and Depression guidelines into a single guideline covering the spectrum of Mood Disorders. It was also decided to broaden the scope of the Anorexia Nervosa guideline to include the range of Eating Disorders.
Objectives: The aims of the CPG Project were to develop usable and accessible resource documents based on the latest international evidence-based practice to enable quality psychiatric and mental health care in Australasia and New Zealand and to promote and disseminate the developed resources to better inform consumers, carers and mental health clinicians about appropriate, and inappropriate, treatment options for the Australasian and New Zealand psychiatric/mental health care setting.
Methods: Five working groups (WGs) were established to review and update the CPGs. Once the WGs had produced a first draft of the CPGs, they moved through various rounds of internal and external review before being submitted to the Australian and New Zealand Journal of Psychiatry for publication. Consumer and carer versions of the revised CPGs will also be developed to complement the full guidelines.
Findings and conclusions: The Eating Disorders CPG was published in November 2014 with the CPGs for Schizophrenia, Deliberate Self Harm and Mood Disorders expected to be published early in 2015.
Presenter 2
RANZCP Clinical Practice Guidelines for Eating Disorders
CPG Working Group: P Hay1,2,3, C Galletly1, G Carter1, G Andrews1, D Chinn2,4, D Forbes2,5 S Madden2,6, R Newton2,7, L Surgenor1,8, S Touyz1,9, W Ward1,10
1RANZCP 2014 CPG Steering Committee
2RANZCP Eating Disorders CPG Working Group
3School of Medicine and Centre for Health Research, University of Western Sydney, Sydney, Australia; School of Medicine, James Cook University, Townsville, Australia
4Capital and Coast District Health Board, Wellington, New Zealand
5School of Pediatrics and Child Health, University of Western Australia, Perth, Australia
6Eating Disorders Service, Sydney Children’s Hospital Network, Westmead, Australia; School of Psychiatry, University of Sydney, Sydney, Australia
7Mental Health CSU, Austin Health, Melbourne, Australia; University of Melbourne, Melbourne, Australia
8Department of Psychological Medicine, University of Otago at Christchurch, Christchurch, New Zealand
9School of Psychology and Centre for Eating and Dieting Disorders, Sydney, Australia
10Eating Disorders Service, Royal Brisbane and Women’s Hospital, Brisbane, Australia; University of Queensland, Brisbane, Australia
Background: The clinical practice guideline (CPG) was conducted as part of the RANZCP CGP Project 2013-2014.
Objectives: To provide contemporary guidelines for the treatment of people with eating disorders.
Methods: In accordance with NHMRC best practice, literature for treatments were sourced from the previous RANZCP CPG reviews (dated to 2009) and updated with a systematic review (dated 2008–2013). A multidisciplinary group prepared draft CPG which then underwent expert, community and stakeholder consultation.
Findings: In anorexia nervosa (AN) the CPG recommends outpatient or day patient treatment in most instances, with hospital admission for those at risk of medical and/or psychological compromise, and with consideration of nutritional, medical and psychological aspects, the use of family-based therapies in younger people and specialist therapist-led manualised based psychological therapies in all age groups that include longer term follow-up. Harm minimisation is recommended in chronic AN. In bulimia nervosa (BN) and binge eating disorder (BED) the CPG recommends an individual psychological therapy, for which the best evidence is for therapist-led CBT. There is also a role for CBT adapted for internet delivery, or CBT in a non-specialist guided self-help form. Medications that may be helpful either as an adjunctive or alternative treatment option include an antidepressant, topiramate, or orlistat (the last for people with comorbid obesity). There are no trials to guide treatment of avoidant/restrictive food intake disorder (ARFID).
Conclusions: Specific evidence-based psychological and pharmacological treatments are recommended for most eating disorders but more trials are needed for specific therapies in AN and research is urgently needed for all aspects of ARFID assessment and management.
Presenter 3
RANZCP Guidelines for Eating Disorders: Clincal Practice Utility
Expert discussion panel: W Ward1,2, F Zepf3, C Gray4, N Fagermo5
1RANZCP 2014 CPG Steering Committee
2Eating Disorders Service, Royal Brisbane and Women’s Hospital, Brisbane, Australia; University of Queensland, Brisbane, Australia
3Department of Child and Adolescent Psychiatry University of Western Australia, Perth, Australia; Department of Specialised Child and Adolescent Mental Health Services, Perth, Australia
4Consultation Liaison Psychiatry, The Prince Charles Hospital, Brisbane, Australia
5Royal Brisbane and Women’s Hospital, Brisbane, Australia
Background and objectives: To critically discuss the recommendations of the eating disorders CPG and their clinical utility.
Methods: Professor Zepf will discuss the CPG for anorexia nervosa from the perspective of a child and adolescent psychiatrist with an interest in eating disorders, Dr Curt Gray from the perspective of a consultation liaison psychiatrist in a general hospital and Dr Narelle Fagermo from the perspective of an adult physician in a general hospital with and without a specialist eating disorder service.
Findings and conclusions: Members of the CPG Steering Committee will chair a general discussion.
The Cinema of Addiction
P Athanasos1,2,5, G Cape3, R Neild1, S Suetani2,4
1Flinders University, Adelaide, Australia
2The Queen Elizabeth Hospital, Adelaide, Australia
3Community Alcohol and Drug Service, Dunedin, New Zealand
4University of Adelaide, Adelaide, Australia
5Griffith University, Logan City, Australia
Background: Cinematic representations play an essential role in the way society understands substance use, manufacturing and dealing. Traditionally, a character that is portrayed using or dealing in illicit drugs carries the immediate recognition of someone who is deviant, corrupt or untrustworthy. Yet there are other prevalent stereotypes as described by Cape (2003). These include tragic hero, rebellious free spirit, demonized addict/homicidal maniac or humorous/comedic user.
Objectives: In the following symposium we will examine addiction in the cinema from US/UK perspectives, Australia/New Zealand perspectives and the representation of women and families.
Methods: A selective review of a number of movies and television series prominently portraying alcohol and other drug use building on the work of Cape (2003). Aims for participants will include the identification of stereotypes portrayed in cinema and television and the audience will be encouraged to contrast these findings with their experience in vigorous audience participation. An interactive discussion will lead to enhanced appreciation of the role of media such as cinema in developing social expectations and stigma and the potential effects of these factors on greater health and policy outcomes.
Findings: There are specific stereotypes identified in movies of both substance users and substance dealers. These stereotypes vary depending on the prevailing drug policies of the country of origin and have changed over time. Clear societal roles for drug users are identified.
Conclusions: Movies, as a medium for mass communication, continue to have a predominant influence on the public and perpetuate popular mythologies regarding alcohol and other drug use.
1Community Alcohol and Drug Service, Dunedin, New Zealand
2Flinders University, Adelaide, Australia
3The Queen Elizabeth Hospital, Adelaide, Australia
4University of Adelaide, Adelaide, Australia
Background: This presentation views stereotypes present in UK and US cinema and television series.
Objectives: The relationship between portrayals of drug users, drug dealers, current drug treatment and drug control policy is explored. An exploration of the stability of stereotypes over time is undertaken. There is a particular focus on the impact of the television series Breaking Bad, the James Bond film series, narco-culture, recent US changes in cannabis legislation and recent UK changes in opioid maintenance policy.
Methods: A selection of UK and US cinema and television is reviewed. Social context is addressed as a construct for stereotypes of drug users and drug dealers. The prominent role that cinema can play in establishing social norms is discussed. Stereotypes of people who use drugs and others involved in the drug trade are examined and reviewed against the socio-political context at the time the films were made. Historical changes in the policy stance of these countries are superimposed on identified stereotypes.
Findings: Stereotypes have remained relatively stable over time and it is proposed this is a reflection of and interaction with the socio-cultural context in which these movies have been made. Discussion and
Conclusions: Reflections on the marketing of movies, social expectations and the impact of social tropes are made and this is contrasted with ideas of revelatory film making as a perspective on current culture. An ongoing framework for the evaluation of stereotypes is proposed.
Presenter 2
The Cinema of Addiction – Australia/New Zealand Perspectives
S Suetani1,2, P Athanasos1,3, G Cape4 R Neild3
1The Queen Elizabeth Hospital, Adelaide, Australia
2University of Adelaide, Adelaide, Australia
3Flinders University, Adelaide, Australia
4Community Alcohol and Drug Service, Dunedin, New Zealand
Background: This presentation explores the stereotypes present in movies made in Australia and New Zealand.
Methods: A selection of Australian and New Zealand cinema and television series (Candy, Boy, Underbelly) is reviewed for representations of people who use drugs and drug dealers. Presentations of people who use drugs and people who market drugs are viewed against the context of the harm reduction policies in place in both countries. The role of cinematic constructs of drug use is explored including the strength of stereotype portrayals in providing social norms to the community at large.
Findings: Australian and New Zealand movies demonstrate the influence of a harm reduction climate. Individuals are demonstrated accessing harm reduction treatments and these treatments are positively framed. However, there remains an element of a “cautionary tale” in these movies as rehabilitation is not shown to return individuals to life opportunities equivalent to non-drug users.
Conclusions: The enlarging Australasian film industry has included portrayals of drug users and drug dealers. These characterisations are consistent with the socio-political context in which film making occurs. Sensitivity to people who use drugs in Australasian cinema is not conveyed without social comment. These social comments are in keeping with current social norms around drug use.
Presenter 3
The Cinema of Addiction – Women and Parenting
R Neild1, P Athanasos1,2, G Cape3, S Suetani2,4
1Flinders University, Adelaide, Australia
2The Queen Elizabeth Hospital, Adelaide, Australia
3Community Alcohol and Drug Service, Dunedin, New Zealand
4University of Adelaide, Adelaide, Australia
Background: The cinematic presentation of women who use drugs and women who are parents who use drugs is explored.
Methods: Movies in which drug use is portrayed are selectively reviewed. The portrayal of female drug users is contrasted with the male drug users. Gender roles and norms are explored as an explanation for these differences. Cultural differences, regional differences and similarities are highlighted. The interaction between the roles of women and drug use are explored with particular reference to parenting. Explanations about how cinema interacts with social context to form social constructs of drug users, parents and women are offered. The significance of cinematic reinforcement of stigma and the potential health and social consequences of this are discussed.
Findings: The portrayal of women who use drugs does differ from the depiction of male drug users. Gender roles are consistent with differences seen between male and female people who use drugs in movies. The depiction of parenting by people who use drugs strongly communicates the message that parenting is incompatible with drug use.
Conclusions: Movies play an important role in reinforcing gender stereotypes as well as stereotypes about people who use drugs. As a reflection of the society that is portrayed, cinema is a potentially important tool in depicting expected social norms and reinforcing stigma for those who fall outside cultural norms. This has health and social implications
Engaging Families and Carers to Support Recovery
J Powell1,2, D Ross3, M Jessop4
1Metro North Mental Health Service, Chermside, Australia
2University of Queensland, Brisbane, Australia
3Partners in Recovery, Medicare Local, Melbourne, Australia
4Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
Background: Extensive research supports the role of family focused approaches within the adult mental health setting. This includes both families of adult consumers with mental illness and parents with mental illness and their families. This requires the effective engagement of carers and family members to support recovery. This is an important focus when the client is a parent. Challenges within the parenting role can impact significantly on parents’ recovery and need to be considered in treatment planning.
Objectives: The presentation will explore the following areas
Factors that influence successful engagement;
The importance of engaging families through a lived experience presentation;
Responding to the parenting role in mental health service delivery;
Introduction to evidence-based intervention “Let’s Talk about Children”.
Methods: The symposium includes a discussion of a study of carer engagement within an AMHS, lived experience by a consumer, case vignettes and video material from online training.
Findings: Clinicians and carers both agree on the importance of involving carers and families in the health care provided to consumers. Both groups identify barriers to this involvement and strategies to overcome these. Involving carers and families in a family focused approach can promote effective communication and problem solving within families surrounding mental illness. “Let’s Talk about Children” highlights the benefit of this approach for both parents and their children.
Conclusions: Focusing on the effective engagement of consumer and families is often essential for recovery and enables family focused interventions. There are effective family focused interventions that improve outcome for both parents and children that can be used in the AMHS.
Presenter 1
Carer Engagement Within Mental Health
J Powell1,2
1Metro North Mental Health Service, Chermside, Australia
2University of Queensland, Brisbane, Australia
Background: Policies at a national and state level have resulted in positive attitudes to collaboration with carers; however, this appears not to have translated into major practice change in the mental health setting.
Objectives: The aim of the study was to better understand the experience of both mental health service providers and carers of people receiving services from public mental health services with respect to communication between service providers and families and carers.
Methods: This was a qualitative study by which data was collected through semi-structured interviews with service providers and carers of people receiving treatment from public mental health services.
Findings: Participants in this study strongly endorsed the value and importance of the relationship between families and carers and clinicians. Carers viewed themselves as information sources for professionals, as support for the consumers, and carers’ concerns needed to be acknowledged and accepted. Clinicians identified that carers provided important information relevant to the assessment and effective treatment of the patient and that families are relevant to outcomes and safety of the person with mental illness.
Both groups were aware of significant barriers to effective communication. Families and carers were typically more dissatisfied with the quality of communication than were clinicians. There were important differences in what the two groups identified as the main barriers. Both groups identified strategies to assist in overcoming these barriers.
Conclusions: This study suggests that effective engagement is time consuming, that service systems may not do enough to support this collaboration and that whilst clinicians recognise that carers are important they are not seen as a priority in settings with multiple competing demands. A number of recommendations are made to address these findings.
Presenter 2
Navigating the Parenting Role While Having a Mental Illness
D Ross
Partners in Recovery, Medicare Local, Melbourne, Australia
Background: Parents experiencing mental health problems often face many challenges related to the impact on their parenting role. The need for support from family and other carers can be essential in supporting recovery. The presenter will discuss her experience of being a parent with young children at the time of onset of mental illness.
Objectives: The presentation will explore:
Approaches to providing clinical care that have been helpful in her recovery;
The importance of engaging partners;
The need to consider the parenting role in treatment planning;
Understanding and responding to the impact of separation from children through the course of treatment.
Methods: Presentation of lived experience.
Findings: The presentation highlights the importance of consumers “feeling listened to” and understanding their stage recovery in treatment planning. An approach that considered her needs as a parent and that of her family was essential to her recovery.
Conclusions: The outcome for parents and their families can be improved through effectively engaging carers and other supports people, and providing a family focused approach.
Presenter 3
Family Focused Practice With Parents With Mental Illness
M Jessop
Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
Background: There has been increasing evidence of the benefits of family focused interventions when working with parents with mental illness and their families. These interventions address the bidirectional impact of parental mental illness on both parent and child outcome. In response to this, National COPMI has developed a range of resources and online training to support evidence-based family focused approaches. While the evaluation of these initiatives in Australia is in the early stages, the clinical experience is building supporting the benefits of these approaches.
Objectives: The presentation will introduce the method, Let’s Talk, and the resources available. The role of this intervention when working with parents with mental illness will be highlighted.
Methods: Case vignettes and video material will be used to highlight aspects of this intervention and the potential role within the adult mental health setting.
Findings: The approach utilized within Let’s Talk has been effective in overcoming some of the barriers to engagement in family focused work. It provides a framework for clinicians to support consumers in their parenting role, respond the needs of children and reduce the bidirectional impact of parental mental illness.
Conclusions: The experience of these interventions is promising with regard to potential benefit to both the consumer and their family. Factors that will support implementation need further exploration.
Development, Implementation and Sharing Learnings Around Improved Practices & Reflections on Future Opportunities in Relation to Use of the Framework for Mental Health in Multicultural Australia
H Vayani1, R Prasad-Ildes2, H Minas3
1Mental Health in Multicultural Australia, Brisbane, Australia
2Queensland Transcultural Mental Health Centre, Brisbane, Australia
3University of Melbourne, Melbourne, Australia
Background: The Mental Health in Multicultural Australia (MHiMA) project provides a national focus for advice and support to service providers and governments on mental health and suicide prevention for people from culturally and linguistically diverse (CALD) backgrounds. The symposium will focus on work undertaken by MHiMA: the development and implementation of a framework to support improvements in the provision of mental health care to CALD consumers in acute inpatient settings and the collection and analysis of data around CALD consumers accessing acute mental health care.
Objectives:
Present an overview of the development of the Framework, its implementation in selected inpatient units across the country and the outcomes in relation to culturally responsive service delivery;
Present reflections on challenges, learnings and opportunities to utilise the Framework in the future beyond acute inpatient settings.
Methods: The symposium will chart the development of the Framework, its implementation into a number of inpatient units across the country, as well as reflect on future opportunities related to its increased use in collaboration with CALD mental health consumers at state/territory, hospital and ward levels.
Findings:
The Framework has been a focal point in getting mental health staff engaged in considering the importance of culturally responsive care,
Engagement with the Framework has resulted in existing and/or new processes being developed to strengthen the quality of care delivered to CALD mental health consumers.
Conclusions: The MHiMA project has made a valuable contribution in supporting mental health services to improve the care of consumers from CALD backgrounds and will continue to provide advice, and support to service providers and government.
Presenter 1
Development of the Framework for Mental Health in Multicultural Australia
H Vayani
Mental Health in Multicultural Australia, Brisbane, Australia
Background: The Framework for Mental Health in Multicultural Australia (the Framework) was developed in 2013/14 as a quality improvement tool that built on the National Cultural Competency Tool (2010). The Framework is cross-referenced to the National Standards for Mental Health Services (2010) and National Safety and Quality Health Service (NSQHS) Standards.
Objectives:
Describe the process of consultation and development of the Framework;
Present the process of engaging and developing supporting training to implement the Framework as part of the targeted implementation phase undertaken in 2014/15.
Methods: Engagement with the Framework by states and territories across Australia was achieved through formally inviting state and territory Ministers and Mental Health Branches to engage with the Framework through formal correspondence and face to face meetings. This engagement enabled the business case to put forward around using the Framework as a quality improvement tool to drive understanding around service access and ascertain the quality of care delivered to culturally and linguistically diverse (CALD) clients in inpatient units by facilitating linkages with local mental health services that self-selected to engage in implementation of the Framework in 2014/15.
Findings: This presentation will outline how successful engagement resulted in initial approval by state and territory mental health branches to engage with the Framework implementation project in 2014/15.
Conclusion: This paper will make an important contribution to the understanding of how to effectively engage with state and territory mental health branches in securing buy-in for uptake of the new national Framework for Mental Health in Multicultural Australia.
Presenter 2
Implementation of the Framework for Mental Health in Multicultural Australia
R Prasad-Ildes
Queensland Transcultural Mental Health Centre, Brisbane, Australia
Background: The Framework for Mental Health in Multicultural Australia assists services to evaluate their cultural responsiveness via an online self-assessment tool and develop strategies and actions to improve service delivery as part of routine practice. A targeted implementation of the Framework was conducted in selected inpatient units across Australia in 2014/15.
Objectives:
Describe the process for implementation of the Framework across selected inpatient units in Australia;
Present the outcomes of the Framework implementation in relation to culturally responsive service delivery.
Methods: The Framework was developed and implemented in 9 inpatient sites across Australia. Units conducted an organisational assessment (OCRAS) to determine their current level of cultural responsiveness. The OCRAS scores were then used to guide the development and implementation of an action plan to improve delivery of care for culturally and linguistically diverse (CALD) consumers.
Findings: This paper will present case examples of specific actions undertaken by inpatient units and the key success factors and lessons learnt about improving cultural responsiveness.
Conclusions: This paper will make an important contribution to the understanding of what cultural responsiveness means in inpatient units based on information obtained from a targeted implementation of the new national Framework for Mental Health in Multicultural Australia.
Presenter 3
Indentification of Data Gaps Highlighted Through Implementation of the Framework and What a New Australia-Wide Mental Health Classification System Should Address to Inform Understanding Around Access and Outcomes of Mental Health Care for Pepople From Cultural and Linguistically Diverse Backgrounds
H Minas
University of Melbourne, Melbourne, Australia
Background: The Framework for Mental Health in Multicultural Australia assists services to evaluate their cultural responsiveness via an online self assessment tool and develop strategies and actions to improve service delivery as part of routine practice. A targeted implementation of the Framework was conducted in selected inpatient units across Australia in 2014-15.
Objectives:
CALD consumers and carers sharing their reflections on how the Framework has assisted in promoting culturally responsive care.
CALD consumers and carers sharing their reflections on where use of the Framework could be expanded.
Reflections and strategic opportunities for use of the Framework post targeted implementation of the framework in acute inpatient settings.
Methods: CALD consumers and carers were consulted and involved in the development of the Framework. When the Framework was implemented across acute inpatient units a number of sites focused on improving engagement with CALD consumers and carers as part of their efforts to guide improvements in culturally responsive care.
Findings: This paper will present case examples of specific actions undertaken by inpatient units and the key success factors and lessons learnt about improving cultural responsiveness by partnering with CALD consumers and carers.
Conclusions: This paper will make an important contribution to the understanding of how the Framework assisted acute inpatients in improving cultural responsiveness and reflect on opportunities for the Framework to be utilised in states and territories where there has been no uptake. It will also outline reflections and strategic opportunities for use of the Framework across the continuum of care in mental health and across human services more broadly.
The Conversational Model: Psychosociocultural Dialogues (or Busman’s Holiday)
L McLean1,2,3, A Korner1,4,5, D Loasby1,6, S Mundy1,7
1Westmead Psychotherapy Program, Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Brain and Mind Research Institute, University of Sydney, Sydney, Australia
3Department of Consultation-Liaison Psychiatry, Royal North Shore Hospital, St Leonards, Australia
4Western Sydney Local Health District (WSLHD), Parramatta and Blacktown, Australia
5Nepean Blue Mountains Local Health District (NBMLHD), Nepean, Australia
6Children’s Hospital Westmead, Westmead, Australia
7Private Practice, Blue Mountains and Sydney, Australia
Background: The Conversational Model (CM) is a psychodynamic perspective that draws on an integration of work from many fields that underpin interpersonal neurobiology to work the rich seams of self and trauma. It encourages a creative relational approach to psychotherapy for the development of self and its restoration from trauma.
Objectives and methods: We will offer several papers on applying the Model creatively: 1) a fresh examination of an old psychoanalytic text (The Strange Case of Dr Jekyll and Mr Hyde); 2) a conversation with Heidegger; 3) an exploration of the model as applied to normal and expansive human development; 4) a brief summary of the CM, and an expositional short film and performance of the theme song of the CM at the Westmead Psychotherapy Program as it seeks to “Give Big Words Away!”
Findings and conclusions: The CM’s perspective offers a base from which to dialogue with psychology, society and culture and honour central aims of fostering resonant and playful conversation.
Presenter 1
The Strange Case (of Jekyll and Hyde)
A Korner1,2,3
1Westmead Psychotherapy Program, Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Western Sydney Local Health District (WSLHD), Blacktown and Parramatta, Australia
3Nepean Blue Mountains Local Health District (NBMLHD), Nepean, Australia
The uncanny, the realm of alienation, and associated destructive behaviours, are sometimes encountered in psychotherapeutic work. While this range of experience is, in many ways, aversive, it is also often associated with a sense of fascination. While fact is often said to be “stranger than fiction”, in this talk the subject will be approached through the lens of the “double life” with reference to the fictional work of Robert Louis Stevenson, “The Strange Case of Dr Jekyll and Mr Hyde”.
Presenter 2
Conversations With Heidegger: An Intersubjective Experience of Authenticity
D Loasby1,2
1Westmead Psychotherapy Program, Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Children’s Hospital Westmead, Westmead, Australia
Background: One of the challenging aims of a Conversational Model (CM) approach to psychotherapy is that of authenticity, a topic on which Heidegger has much to say. Really being there, “Dasein”, has much in common with the intense “moments of meeting” that are described in contemporary psychodynamic psychotherapy. This is magnified when the conversation about Heidegger becomes a focus for these authentic “moments of meeting” between patient and therapist.
Objectives and methods: This paper will explore a CM-inspired conversation with Heidegger, begun initially during a therapy conducted from the CM perspective and developed as a Master’s thesis as a capstone for training within the Program.
Findings and conclusions: The dialogue encouraged by the CM perspective between therapist and patient is mirrored by the interchange it can foster across fields of inquiry, a dialogue that is only fruitful, however, if the engagement is truly authentic.
Presenter 3
Fully Human, Fully Alive: A Dialogue With the Conversational Model on Optimising Human Developmnt
S Mundy1,2
1Westmead Psychotherapy Program, Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Private Practice, Blue Mountains and Sydney, Australia
Background: The Conversational Model (CM) perspective integrates many bodies of thinking to speak to the impact of trauma on the development and unfolding of self and the restoration of self within a connected relational conversation. However, it may also have something to say about the optimal flourishing of self within the matrix of supportive relationships and an internal reflective and mindful conversation. This connects with literatures and disciplines that suggest pathways to optimize personal human development.
Objectives and methods: This paper will explore the way the CM might be applied to the fostering of personal human flourishing.
Findings and conclusions: A conversation with an integrative model of personal development and its vicissitudes, such as the CM, provides guidelines to optimal as well as clinical pathways of human flourishing.
Presenter 4
The Conversational Model Theme Song: In Pursuit of Playful Reflexivity and Call and Response
L McLean1,2,3,4
1Westmead Psychotherapy Program, Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Brain and Mind Research Institute, University of Sydney, Sydney, Australia
3Department of Consultation-Liaison Psychiatry, Royal North Shore Hospital, St Leonards, Australia
4Sydney West and Greater Southern Psychiatry Training Network, Sydney, Australia
Background: Each year the Westmead Hospital holds its Oscars and asks Hospital Departments to submit a small film that creatively captures their work. In 2014 the Westmead Psychotherapy Program took this as a challenge to demonstrate both content and process, especially the creation of a play space.
Objectives and methods: This talk will present a brief summary of the principles of the Conversational Model, the short 5-minute film submitted to the competition in 2014 and then reprise the performance of the main theme song, with an expectation that the audience might join the song/throng and together we will “Give Big Words Away!”
Findings and conclusions: Conversation, creativity and communal experience are central to human life and form a key part of the Conversational Model perspective.
Mood Dysregulation and Executive Function Deficits – How the Management of Adults With ADHD can Inform General Psychiatry
H Morgan1, R Paterson2, P Bird3, R Edwards4,M Kneebone5
1Mindcare Centre, Sydney, Australia
2Private Practice, Nedlands, Australia
3Gosforth Clinic, Maroochydore, Australia
4Private Practice, Wellington, New Zealand
5Private Practice, Hunters Hill, Sydney, Australia
Background: Mood dysregulation is a core feature of a number of general psychiatric disorders which can make diagnosis challenging in patients presenting with Mood Disorders, Personality Disorders, Substance Use Disorders, ADHD, Intellectual Disability, and Autism Spectrum Disorders. Similarly, executive function deficits occur across these disorders, cause significant impairment and distress, and add to the challenge of assessment and diagnosis. Compounding these diagnostic challenges is that most patients present with comorbid conditions. Following diagnosis, clinicians then need to choose which diagnosis to prioritise for treatment. Adults with ADHD provide a great paradigm for helping psychiatrists to navigate diagnosis and treatment of such patients.
Objectives: To provide clinically useful assessment tools and materials with practical clinical advice to improve psychiatrists’ awareness and confidence in assessment, diagnosis, and treatment of patients who present with mood dysregulation and executive function deficits.
Methods: The panel all have extensive experience in the assessment and treatment of ADHD and will present informative material relating to different interests in their clinical practice.
Findings: Being aware of the differences as well as the similarities in symptoms of mood dysregulation and executive function that exist between general psychiatric disorders is important in determining a diagnosis.
Conclusions: General psychiatrists can learn much from working with patients with adult ADHD. These patients have significant problems with emotional dysregulation and executive dysfunction and commonly present with comorbid conditions that may also require treatment.
Presenter 1
Practical Tools for Assessment and Diagnosis of Mood Dysregulation and Executive Dysfunction
H Morgan
Mindcare Centre, Sydney, Australia
Psychiatrists have been slow to embrace the use of questionnaires as part of their routine clinical assessment. The Ritvo Autism Asperger Diagnostic Scale-Revised (RAADS-R), a scale to assist the diagnosis of autism; The Internal State Scale (ISS v.2), a scale to assess manic and depressive symptoms; and the Adult ADHD Self-Report Scale (ASRS-v1.1), a WHO ADHD screening instrument, will be presented, showing how they have been applied in a case series of patients demonstrating their clinical utility. The questionnaires will be available to members of the audience.
Presenter 2
Use of Stimulant Medication in General Psychiatry
R Paterson
Private Practice, Nedlands, Australia
Stimulant medication has been used for decades in psychiatry for treatment of a range of conditions. More recently there has been interest in use of stimulant medication in the treatment of melancholic depression and Bipolar Disorder. The utility of stimulant medication application in general psychiatry will be discussed.
Presenter 3
Autism Spectrum Disorders – New Treatments
P Bird
Gosforth Clinic, Maroochydore, Australia
Clinicians are becoming more familiar with the diagnosis of Autism Spectrum Disorders. Whilst the diagnosis of these disorders is becoming more common we lack available evidence-based treatment for these conditions. New treatments currently being trialled for treatment of Autism Spectrum Disorders will be presented.
Presenter 4
Treatment of Adults With ADHD in Public Hospital / Community Health Setting
R Edwards
Private Practice, Wellington, New Zealand
Treatment of adults with ADHD in the public system in Australia is currently very limited. Unlike Australia, New Zealand has a small number of psychiatrists in private practice, and adult patients with ADHD are being treated in the public hospital system. The current assessment and treatment programs offered in a community health setting will be discussed.
Presenter 5
Treatment of Adults with Intellectual Disability and ADHD
M Kneebone
Private Practice, Hunters Hill, Sydney, Australia
Patients with Intellectual Disability are a particularly challenging group of patients to assess and manage. ADHD occurs more commonly in these patients compared to the general population, and the assessment, diagnosis and treatment in this group will be presented.
STP Training Posts in Psychiatry: Lessons Learned and What Next?
D O’Connor1, K Turner2, C Gee3, V Krigovsky4, R Harvey5, N Jayarajan6
1Chair, RANZCP STP Reference Committee
2Gold Coast Mental Health Service, Gold Coast, Australia
3Toowong Private Hospital, Brisbane, Australia
4Top End Mental Health Service, Darwin, Australia
5Barwon Health, Geelong, Australia
6Remote Area Mental Health Service, Cairns and Hinterland Mental Health and ATOD Service, Cairns, Australia
Background: The Specialist Training for Psychiatrists (STP) Project is an essential and critical project for the Royal Australian and New Zealand College of Psychiatrists (RANZCP), providing additional training posts across Australia. Commencing in 2009, the RANZCP is currently contracted to the end of 2015 with the Commonwealth Department of Health to manage more than 160 training posts (STP Posts) that provide training experiences beyond traditional public teaching hospital settings.
This session will present a range of experiences and lessons learned from private, public and rural health services participating in the STP Project, as well as a trainee perspective of working in an STP Post.
Objectives:
To demonstrate the different and diverse settings that the STP Project is enabling training experience and delivery of patient care;
To share and discuss lessons learned in how to successfully manage STP Posts that meet the objectives of the Commonwealth and RANZCP training requirements, as well as service needs;
To discuss the future of the STP beyond 2015.
Method: Interactive presentations will demonstrate the diversity of settings, experiences and approaches to STP Posts and provide opportunity for questions and discussion about the STP Project.
Findings:
Presenters will share their findings and lessons learned in hosting an STP Post, including challenges and tips for managing administration, funding and reporting.
Presenters will showcase the expanded training settings that the STP Project enables.
Presenters will discuss the experience of trainees in STP Posts and the impact on health care delivery.
Conclusions: Attendees, both experienced and new to the STP Project, will hear a range of approaches and join the discussion on how to make the most of the STP opportunity. Importantly, this session will provide the opportunity for discussion about the future of the STP Project.
Challenges in Psychiatry Across the Pacific – a Symposium From the West Pacific Division of the UK Royal College of Psychiatrists
S Kisely1,2, I Soosay3, K George4
1Metro South Addiction and Mental Health Service, Brisbane, Australia
2School of Medicine, University of Queensland, Brisbane, Australia
3Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
4Eastern Health, Melbourne, Australia
Background: The Royal College of Psychiatrists is the professional medical body responsible for supporting psychiatrists throughout their careers, from training through to retirement, and in setting and raising standards of psychiatry in the United Kingdom. The College is an independent professional membership organisation and registered charity representing over 15,000 psychiatrists in the United Kingdom and internationally. In 2004, the College set up several International Divisions to facilitate the exchange of information and to promote discussion about psychiatry within a specified geographical area outside the United Kingdom and Ireland. This includes a Division for the West Pacific covering Australasia, Oceania and East Asia.
Objectives: This symposium aims to illustrate the diversity of psychiatric practice within the region. It features talks on somatisation in East Asia, the role of religion and spirituality in mental health presentations in Pacific Islands, and mental health issues on Niue and other small Pacific nations.
Methods: A series of individual presentations will be followed by group discussion with the presenting panel.
Findings: Psychiatric practice in the Western Pacific is diverse.
Conclusions: Lessons learnt may be applied to other countries in the region.
Presenter 1
An International Comparison of Somatisation in East Asia
S Kisely1,2
1Metro South Addiction and Mental Health Service, Brisbane, Australia
2School of Medicine, University of Queensland, Brisbane, Australia
Background: The relationship between medically explained and unexplained symptoms may vary across countries.
Objectives: To compare the epidemiology and clinical features of somatoform disorders and medically explained and unexplained somatic symptoms in Japan and China with other cultures and countries.
Method: A two-phase stratified sampling strategy in primary care facilities from 14 different countries (n = 5447, aged between 16 and 65), two of which were in East Asia (Shanghai and Nagasaki)
Results: At all sites, the number of current somatic symptoms (whether medically explained or not) was strongly associated with current psychological distress. Although somatic symptoms did cluster into meaningful groups (gastrointestinal, neurological/conversion, autonomic, and musculoskeletal), these symptom groups did not show differential association with psychological distress. Individual somatic symptoms and symptom clusters across sites did not reveal clear patterns of association according to geography or level of economic development. One year later, somatic symptoms in both categories were associated with greater social and psychiatric morbidity
Conclusions: These data show a strong association between somatic symptoms and psychological distress, which did not vary across disparate cultures and levels of economic development. Cultural factors, however, may influence the meaning attached to symptoms or the likelihood of presentation for health care.
Presenter 2
Mental Health Issues on Niue and Other Small Pacific Nations
I Soosay
Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
Background: The small island state of Niue (population 1600) shares many of the challenges faced by small Pacific Island nations in meeting the mental health needs of their people. This talk aims to outline these challenges and the strategies that are being explored to address them.
Objectives: To describe the mental health needs of Niue and the strategies for mental health capacity building.
Method: A description of the mental health needs of Niue illustrated by case vignettes.
Results: An overview of the mental health plan and strategy to meet these needs.
Conclusions: Small Pacific Island states are re-orientating their health services to meet the needs of their populations. Limited resources, geographic isolation and the need to mitigate the effects of climate change are driving the way they are rising to this challenge and will require new approaches in mental health service delivery.
Presenter 3
The Role of the Church in Mental Health Presentations in Pacific Islands
K George
Eastern Health, Melbourne, Australia
Background: The Church is very important in the lives of Pacific Islanders and this has an impact when it comes to the presentation of mental health problems and delivery of care.
Objectives: The aim of this paper was to gain an understanding of the mental health needs and services in Vanuatu, and examine the importance of the Church in the lives of the local people and the part the Church can play in mental health service delivery.
Method: The author visited Vanuatu to gain an understanding of the mental health needs and services in Vanuatu. This was followed by interaction with a number of churches to find out the views of church leaders about mental illness and their interest to learn about mental illness. A questionnaire was completed by 80 individuals, who were also involved in some training.
Results: There was widely held view that mental illness was due to a weak faith, sin or demon possession. However, there is a desire and an interest among churches to have a better understanding about mental illness.
Conclusions: Churches in Vanuatu can and need to be mobilized to make mental health service delivery successful in the country. This will be the case in most Pacific Island Nations.
A Trauma Informed Community Acute Care Team Approach: Blacktown Access & Acute Mental Health Team’s Feeling Safer Project
A Baker1,2, I Cameron1,3, B Moloney1,4, C Winspear1,5, C Chapman1,3, L McLean1,4,5,6
1Westmead Psychotherapy Program, Western Sydney Local Health District (WSLHD) and Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Blacktown Access & Acute Mental Health Team, WSLHD, Blacktown, Australia
3New South Wales Institute of Psychiatry, Parramatta, Australia.
4Brain and Mind Research Institute, University of Sydney, Sydney, Australia
5Sydney West and Greater Southern Psychiatry Training Network, Western Sydney Local Health District (WSLHD), Parramatta, Australia
6Consultation-Liaison Psychiatry, Royal North Shore Hospital, St Leonards, Australia
Background: The Feeling Safer Project is an innovative project which has enabled our acute care team to more effectively care for the complex needs of consumers presenting in crisis to Blacktown Mental Health Service. The project has integrated trauma informed and recovery approaches into the team’s well established community crisis care method. The team utilised the Conversational Model (CM), a psychotherapeutic approach for complex trauma. The techniques of the CM have shown initial effectiveness in our clinical work. It is manualised and applicable for use in short and time-limited therapies. It is an approach that values meaningful, individualised and humane relationships that are founded in respect and empathy. It seeks to be conscious of the asymmetrical power of therapy, and the tempo and language of the therapist is adapted to the fluctuating mental capacities of the Consumer.
Objectives and methods: With the aim of sharing our process, various members of the multi-disciplinary team and project team will speak to their experiences as the approach has unfolded.
Findings and conclusions: The implementation of the Feeling Safer project for the Acute Team has been a career highlight for many of us. This approach has provided a better standard of care for the consumer, and rewards the clinician with a greater sense of proficiency and job satisfaction.
Presenter 1
Feeling Safer Project: The Manager’s Approach
A Baker1,2
1Westmead Psychotherapy Program, Western Sydney Local Health District (WSLHD) and Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Blacktown Access & Acute Mental Health Team, WSLHD, Blacktown, Australia
This paper will discuss the approach taken as team manager to the implementation of an innovative model of care. I will discuss how the Conversational Model has been both the model of choice for the clinical work but also for our approach to staff development and supervision. In particular I will explore the methods we drew on to introduce a more reflective and self-responsible clinical practice to our work. It has been truly rewarding experience to support the team in their training, and in the team developing a working understanding of the Conversational Model. I see the results of the project when I hear the staff speaking the language of recovery, and showing a much more sophisticated understanding of the far-reaching effects of trauma.
Presenter 2
Feeling Safer Project: The Project Leader’s Approach
I Cameron1,2,3
1Westmead Psychotherapy Program, Western Sydney Local Health District (WSLHD) and Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Blacktown Access & Acute Mental Health Team, WSLHD, Blacktown, Australia
3Private Practice, Sydney, Australia
This paper will give an overview of the theoretical underpinnings of the Blacktown Community Acute Care Team’s Feeling Safer Project. This will include outlining our approach to Crisis theory, recovery, trauma-informed care, and the Conversational Model. In particular I will discuss the statistics behind what is our core business in acute community mental health and our goals when we implement a crisis intervention.
Presenter 3
Feeling Safer Project: Listening With an Ear for Trauma and Really Connecting (Being There)
B Moloney1,2
1Westmead Psychotherapy Program, Western Sydney Local Health District (WSLHD) and Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Blacktown Access & Acute Mental Health Team, WSLHD, Blacktown, Australia
My section of work will discuss the application of our trauma-informed acute care method at the clinical coalface through my experience as a Clinical Nurse Consultant (CNC). I will describe the key elements of our approach including: our particular approach to listening and empathy, the language used by the clinicians, how we explore a client’s traumatic past, our conceptualisation of dissociation, and some ideas on containment.
Presenter 4
Feeling Safer Project: A Senior Clinician’s Experience
C Winspear1,2
1Westmead Psychotherapy Program, Western Sydney Local Health District (WSLHD) and Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Blacktown Access & Acute Mental Health Team, WSLHD, Blacktown, Australia
I am an experienced and senior clinician in mental health that has worked in the public and private mental systems, and at Blacktown for the past number of years as a Clinical Nurse Specialist (CNS). I will give an account of my mostly positive experiences in adopting this new model of care and some of the key aspects of the model I have found useful in my clinical work.
Presenter 5
Feeling Safer Conversations: The Supervisory Approach
L McLean1,2,3,4, C Chapman1,5
1Westmead Psychotherapy Program, Western Sydney Local Health District (WSLHD) and Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
2Brain and Mind Research Institute, University of Sydney, Sydney, Australia
3Sydney West and Greater Southern Psychiatry Training Network, Western Sydney Local Health District (WSLHD), Parramatta, Australia
4Consultation-Liaison Psychiatry, Royal North Shore Hospital, St Leonards, Australia
5New South Wales Institute of Psychiatry, Parramatta, Australia
This paper will discuss the supervisory approach for the Feeling Safer project. The Conversational Model (CM) approach is to provide supervision that is compatible with the model: collaborative conversations that foster the development of self and the integration of trauma. Coming from a background in Consultation-Liaison Psychiatry and Psychotherapy, the supervisor considered ways to offer supervision to the project leader and to the team that would allow the co-creation of a space that would foster cohesion amidst an agenda of change and the ongoing challenges of the turbulent clinical environment of acute psychiatric care. In this case this has been realized as fortnightly conversations with the project leader and separately with the team. The latter were videoconferenced and to some extent reflected through writing-up and circulating annotations on these conversations. These “yarns” have offered containment, small doses of didactic learning on the CM, amplification of the positive and much reflective space. This has been a deeply joyful experience of an innovative model of collaborative care that, as the CM suggests, aimed to use “what is given” and watch for “what happens next”. The co-facilitating support of a participant observer in the form of a senior trainee in psychiatry and psychotherapy provided an invaluable second set of ears and eyes and (documenting) hands.
Where Are You in the Fight Against Family Violence?
M O’Connor1, C Kezelman2, D Walsh3, K Hegarty1
1University of Melbourne, Melbourne, Australia
2Adults Surviving Child Abuse, Sydney, Australia
3University of Queensland, Brisbane, Australia
Background: The Victorian Branch established a working group to look at the issue of family violence (FV) deaths in September 2014. The aim of the group is to educate health professionals on FV and improve outcomes for people impacted by it.
FV is a highly complex social problem with serious health consequences (WHO 2005/2008). One in three women and one in seven men are victims of FV (ABS 2012, 2005). Men and women with all types of mental disorders report a high prevalence and increased odds of domestic violence compared to people without mental disorder.
Studies show that despite the common presence of FV among mental health patients, services have been reported to give little consideration to the role of domestic violence in precipitating or exacerbating mental illness (Trevillone 2013, 2014). There is a need for mental health services to establish appropriate strategies, responses and training programs to address FV.
Objectives: To stimulate discussion on how psychiatrists can better understand FV and to foster a multidisciplinary platform for health professionals to better understand and respond to patients who are experiencing FV.
Methods: A cross sector panel of health professionals with expertise in Family Violence, including social workers will draw on their knowledge and experience in discussing the key objectives for training psychiatrist and other health professionals to better understand FV and refer victims to the support they require (WHO 2013).
Australian Bureau of Statistics & Australian Institute of Health and Welfare (2005) The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples. ABS Cat No 4704.0. Australian Bureau of Statistics and Australian Institute of Health and Welfare. Commonwealth of Australia.
Trevillion K, Hughes B, Feder G, et al (2014) Disclosure of domestic violence in mental health settings: a qualitative meta-synthesis. Int Rev Psychiatry 26: 430–444.
Trevillion K and Agnew-Davies R (2013) Interventions for mental health users who experience domestic violence. In: Howard LM, Feder G and Agnew-Davies R (eds). Domestic violence and mental health. London: Royal College of Psychiatrists.
World Health Organization (2008) Intimate partner violence and women’s physical and mental health in the multi-country study on women’s health and domestic violence: an observational study. The Lancet 371: 1165–1172.
World Health Organization (2005) WHO multi-country study on women’s health and domestic violence against women: Initial results on prevalence, health outcomes and women’s responses. Geneva: World Health Organization.
Identifying and Responding to Domestic Violence in Clinical Practice
K Hegarty
University of Melbourne, Melbourne, Australia
Background: Domestic or family violence is a common hidden problem in mental health practice.
Objectives: To describe the evidence for how to identify and respond to domestic violence in clinical practice.
Methods: Overview of systematic reviews conducted by Cochrane and the World Health Organization.
Findings: There is limited evidence to guide practice but consensus guidelines suggest that all mental health practitioners should be asking about family violence and responding to such disclosures in a non-judgemental way that assists women on a pathway to safety and support.
Conclusions: Family violence can be addressed in psychiatric settings. All mental health professionals need to be trained to ask and respond to patients experiencing family violence.
Presenter 2
Social-Cultural Distress in Domestic Violence and Psychopathology- A Qualitative Study in a Migrant Group
M O’Connor
University of Melbourne, Melbourne, Australia
Background: Young adult women in many parts of the world have higher levels of common mental disorders than men. The exacerbation of domestic violence (DV) by migration is a salient social determinant of poor mental health. Ecological models describe DV-contributing factors as operating at the individual, family, cultural and societal levels. There is an urgent need to assess the impact of DV, the interplay among the above-mentioned factors and its contribution to mental illness in Australian-Indian families, particularly in view of the 17 suicides/homicides between 2012 and 2014 in this community from Victoria.
Objectives: To demonstrate ethnic variations in socio-cultural dynamics that underlie DV and are known to precipitate and perpetuate associated social-psychological distress and psychopathology.
Methods: In this qualitative study a modified Forum Theater approach captures the voices of women living in the community as they describe how DV contributes to their social, emotional and mental difficulties.
Findings: A deep understanding of specific social and cultural data was obtained which can assist in designing prevention and response strategies.
Conclusions: DV-induced social and psychological distress can turn into psychopathology, mental illness, suicidal and homicidal behaviours. Migrant communities are particularly vulnerable. Specific understanding of social and cultural data is essential to design accurate response and prevention programs
Presenter 3
Developing a Trauma-Informed Service Response to Domestic Violence
C Kezelman
Adults Surviving Child Abuse, Sydney, Australia
Background: As co-author for the ASCA Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery and an advocate for the broad-based implementation of trauma-informed policy and practice across health and human service sectors, I feel passionate about the need for a comprehensive trauma-informed service response to family violence. The intersection between domestic violence and child abuse is substantive, with past and current trauma compounding one another for those affected. The impacts are cumulative. When working with such clients, who often have comorbid mental health presentations and challenging psychosocial health issues, it is crucial to use a trauma-informed lens.
Objectives: This presentation aims to raise awareness about trauma, traumatic stress and its dynamics, the impacts of trauma and the ways people cope. It will challenge the single diagnostic lens of symptoms and signs and ask practitioners to consider the question: ‘What happened to you?’ rather than solely that of ‘What is wrong with you?’
Methods: It will provide basic information around the neurobiology of trauma and attachment and the principles of trauma-informed practice and consider how to implement them into daily practice.
Findings: The presentation will highlight the benefits of trauma-informed practice for both practitioner/worker and patient/client in terms of enhanced outcomes and minimization of the risk for re-traumatisation for clients and vicarious traumatization for practitioners.
Conclusions: The presentation will provide the basis for further discussion around the opportunities and challenges for introducing trauma-informed models of practice in responding to people impacted by family violence.
Presenter 4
Building Pathways Between Domestic and Family Violence Services and Mental Health
D Walsh
Faculty of Heath and Behavioural Sciences, University of Queensland, St Lucia, Australia
Background: It is a long held view that being a victim of chronic or enduring domestic violence will have significant consequences on a person’s mental health. This paper will discuss service system use by victims of domestic and family violence and report on a project that has been designed to strengthen links between the silos of domestic violence and mental health services.
Objectives: The aim of this paper is to describe how women use and don’t use the domestic violence and mental health systems. Understanding entry points, service use and the factors that facilitate and hinder access to services will assist professionals who work with women.
Methods: This paper is based on the literature and 20 years’ practice experience in the field.
Findings: Being a victim of domestic violence can introduce women to a range of silo service systems. These can include the domestic violence, child protection, housing, legal and mental health systems. When these services work collaboratively on behalf of women it enhances their ability to navigate through a very complex service system, resulting in better mental health outcomes.
Conclusions: Leaving a domestically violent relationship is potentially dangerous for your health and mental health. When services understand each other and work collaboratively outcomes for women and children will improve.
Private Practitioners Network Special Interest Group Symposium – Brave New Worlds: Evolving Paradigms of Care in Private Practice – Part 1
C Simons1,2,3, G Galambos4,5,6,7, S Blair-West2,8, J King2,9,10
1RANZCP Affiliate
2Department of Psychiatry, University of Melbourne, Melbourne, Australia
3Adolescent Services, Albert Road Clinic, Melbourne, Australia
4Young Adult Mental Health Unit, St Vincent’s Private Hospital, Sydney, Australia
5Deputy Chair, RANZCP Private Practice Network
6The Lawson Clinic, Sydney, Australia
7University of New South Wales, Sydney, Australia
8Anxiety and Depression Program, OCD Program, The Melbourne Clinic, Richmond, Australia
9Chair, RANZCP Private Practitioners Network Special Interest Group
10Professorial Unit, The Melbourne Clinic, Richmond, Australia
Background: This symposium of the Private Practitioners Network Special Interest Group will focus on innovative models of care in private practice. The symposium will discuss different models of care, as well as the lessons learnt through the process of establishing new units or programs.
Contrary to popular belief, private psychiatry has many opportunities for developing new models of care for patients and their families. This symposium’s speakers will explore their personal experiences in developing and running some of these, as well as the challenges and pitfalls they have faced along the way.
The symposium will feature presentations from private psychiatrists who have established new units or programs.
Dr Simons will discuss the establishment of Australia’s only private adolescent psychiatric unit and Dr Galambos the establishment of a private young adult unit, while Dr Blair-West will talk about The Melbourne Clinic’s OCD inpatient program. Dr King will discuss some of the issues relating to having psychiatry trainees in private settings.
Objectives: This symposium will feature presentations from private psychiatrists who have worked to implement new models of care including the following: Dr Christine Simons, Child and Adolescent Psychiatrist and Director of the Adolescent Unit at Albert Road Clinic, Victoria Dr Scott Blair-West, Director of the OCD Program, The Melbourne Clinic, Victoria.
Presenter 1
The Goldilocks Principle of Adolescent Inpatient Units: Trying to Get It “Just Right”
C Simons1,2,3
1RANZCP Affiliate
2Department of Psychiatry, University of Melbourne, Melbourne, Australia
3Adolescent Services, Albert Road Clinic, Melbourne, Australia
Background: The Pathways Unit at the Albert Road Clinic in Melbourne is a 10-bed Adolescent Inpatient Unit in the private sector. The inpatient unit is part of an Adolescent Service that also includes several Day Programs and an Outreach service. Inpatients are aged 13–23 years and have a wide range of psychiatric difficulties. As the new Medical Director in 2006, I embarked on a restructure and the implementation of a new program based on Dialectical Behaviour Therapy (DBT).
Objectives: From the perspective of involvement in Child and Adolescent Inpatient Units in both public and private settings, including the Warneford Hospital, Oxford, England, the Adelaide Women’s and Children’s Hospital and the Albert Road Clinic, Melbourne, this presentation considers the ideas that influenced the redevelopment and the content of this program.
Method: The tasks of initially engaging staff and psychiatrists to the changes and patterns that maintain the intensity and integrity are mentioned. The style of the Unit and the content of the program will be described in detail, both in overview and also as they impact on an individual admission.
Findings: Research has identified that inpatient units function better, and offer better outcomes, when they follow a theoretical basis. The choice of DBT is discussed, including its flexibility to incorporate other therapeutic modalities including art therapy, narrative therapy, sensory modulation and family therapy. DBT has shown effectiveness for staff training, enabling increased participation in therapy delivery.
Conclusions: The current program based on DBT implemented in the Pathways Adolescent Unit is offering valued outcomes to a varied population of young patients and their families. The benefits are thought to accrue from a perspective based in validation, ways of pacing therapy, training in both self-skills and patterns of problem solving, combined with unit patterns offering containment, consistency and cohesion.
Presenter 2
Establishing a Private Young Adult Mental Health Unit in Sydney
G Galambos1,2,3,4
1Young Adult Mental Health Unit, St Vincent’s Private Hospital, Sydney, Australia
2Deputy Chair, RANZCP Private Practice Network
3The Lawson Clinic, Sydney, Australia
4University of New South Wales, Sydney, Australia
The author will provide a qualitative analysis from the perspective of an admitting psychiatrist exploring clinical, administrative and practical issues arising in the initial two years following the establishment of a subspecialty 20-bed young adult unit in a private hospital in Sydney developed for 16–25 year olds with mood, anxiety and psychotic disorders, utilising a multidisciplinary inpatient and day patient treatment framework.
Presenter 3
Brave New Worlds: Evolving Paradigms of Care in Private Practice
S Blair-West1,2
1Department of Psychiatry, University of Melbourne, Melbourne, Australia
2Anxiety and Depression Program, OCD Program, The Melbourne Clinic, Richmond, Australia
In the 1980s the Behavioural Program was developed at The Melbourne Clinic, a large private psychiatric hospital in Melbourne, as a CBT-based Inpatient Program to treat patients with treatment-resistant anxiety and depressive disorders. Created by the Clinical Psychology Department with input from a psychiatrist Medical Director, the program ran as a four-week intensive inpatient program for 20 years before I was appointed Medical Director in May 2002. It quickly became clear that the program catered poorly for patients with Obsessive-Compulsive Disorder (OCD) given an absence of intensive behavioural and Exposure and Response Prevention (ERP) treatments.
In 2003 the then Clinical Director Dr Chris Mogan and I visited the OCD institute at McLean Hospital at the Harvard Medical School in Boston and resolved to develop a similar OCD-specific program to run on alternating fortnights with the current ADP Program for depression. The Program commenced in 2005 and is the only OCD-specific Inpatient Program in Australasia. Careful planning of our program was required to adapt aspects of the McLean program to our own specific circumstances. Two years of detailed planning and lengthy interdisciplinary consultation was required to develop a program featuring psycho-education in groups and ERP in both group and individual settings.
The program now runs for approximately 30 weeks per calendar year, accepts referrals Australia-wide, provides second opinions for difficult cases and acts as a final treatment phase prior to consideration for Deep Brain Stimulation (DBS) treatment for severely unwell patients.
Discussion will include:
The role of the private psychiatrist in the planning, set up and implementation of such a program;
Adapting treatment plans from the United States situation to Australia;
The need to develop a strong and inclusive team culture;
Managing expectations of patients, families and external treaters;
Education of other staff in the hospital in OCD and its treatment;
Managing a group who demand freedom in an increasingly restrictive and security conscious hospital;
Providing as much direct supervision and coaching as possible;
Planning for discharge, follow-up and preventing relapse issues;
Continuing liaison with external treaters.
Conclusion: The presentation will provide a historical account of the development of the program as well as discussing the issues in planning, set up and subsequent implementation. Specific issues will be addressed as listed and questions welcomed.
Private Practitioners Network Special Interest Group Symposium – Brave New Worlds: Evolving Paradigms of Care in Private Practice – Part 2
Presenter 4
Psychiatry Trainees in Private Practice
J King1,2,3
1Chair, RANZCP Private Practitioners Network Special Interest Group
2Professorial Unit, The Melbourne Clinic, Australia
3Department of Psychiatry, The University of Melbourne, Melbourne, Australia
Around 66% of psychiatrists have some form of private practice. Despite this, psychiatry trainees spent most of their training in the public sector, with the majority never having worked in a private practice environment. As such, many trainees are inadequately exposed to mood and anxiety disorders, which are predominantly seen in private psychiatric settings, and the logistical, practical and ethical challenges of private practice. This presentation will focus on experiences having psychiatry trainees in a private psychiatric hospital, the differences from the public sector, and the challenges of making this viable and valuable for all parties.
Where Are We Three Years After the ‘Lost in the Labyrinth Report’? The New Pathway to Achieve Fellowship for Overseas Trained Psychiatrist and the Support Program
J Allan1, D Neill2, V Garg3, E Guaia4, S Douglas5
1Chair, RANZCP Committee for Specialist International Medical Graduate Education (CSIMGE), Brisbane, Australia
2Deputy Chair, RANZCP CSIMGE and Substantial Comparability Assessment/Review Panel (SCARP); Member, Victorian State Assessment Panel (SAP), Melbourne, Australia
3Illawarra, Shoalhaven Local Health District, University of Wollongong, Wollongong, Australia
4Deputy Chair, RANZCP Overseas Trained Psychiatrist Committee (OTPC); Princess Margaret Hospital, Perth, Australia
5Australian International Medical Graduate (IMG) Support, Advice and Advocacy Network, Canberra, Australia
Background: In 2012, the Standing Committee on Health and Ageing tabled its report on the inquiry into Registration Processes and Support for Overseas Trained Doctors entitled Lost in the Labyrinth: Report on the inquiry into registration process and support for overseas trained doctors. This follows significant reforms in the requirements for OTP/SIMGs gaining fellowship in Australia. At any one time there are over 200 SIMGs on the path to Fellowship and each year up to 30% of new Fellows are SIMGs. Amongst the Specialist Colleges, RANZCP has one of the largest cohorts of SIMGs.
The Overseas Trained Psychiatrist Committee (OTPC) is a committee of the RANZCP that directly reports to the General Council on matters pertaining to the overseas trained psychiatrist (OTP) in Australia and New Zealand. The Committee for Specialist International Medical Graduate Education (CSIMGE) is part of the RANZCP Education Committee. The CSIMGE and the OTPC have worked closely with the support of all the other relevant committees to implement new pathways for OTPs wanting to move to work in Australia and New Zealand. The SIMG Upskilling Project uses funds from the Australian Government to provide direct support for SIMGs in obtaining fellowship.
Presentations from committee members of CSIMGE, OTPC and SIMG upskilling working party and from the Australian IMG Support, Advice and Advocacy Network will present the new pathways and their alignment with the AMC new standards for specialist registration and the future change towards a more appropriate assessment of OTPs and the alignment to the competence-based fellowship 2012. The support program and the current situation with all the other specialist colleges will also be presented. The involvement of the OTPC and experiences of OTPs will be presented.
Objectives: This symposium will present the current achievements but, as well, the difficulties faced by OTPs on their journey. It will also discuss and seek comment on future directions for SIMG pathways to Fellowship and the supports required for this.
Methods: The presenters will:
Report on the Substantial Comparability Pathway phases one and two, and explain the WBA process;
Discuss the intentions for new methods of assessment for partially comparable SIMGs;
Report the journey of the OTPC in the last six years, importantly focusing on the work done post May 2011;
Consider the WBA obstacles and review implementation in other colleges;
Report on the SIMG upskilling project and consider the value of supports to SIMGs;
There will be a panel discussion around the future of SIMGs and the College
Presenter 1
Recent History of OTP Path to Fellowship: The Case for Change
J Allan
Chair, RANZCP CSIMGE, Brisbane, Australia
Background: The RANZCP has always had a special pathway for OTP/SIMGs to obtain Fellowship, and hundreds of current Fellows have come via this. From the time of “Special Exams” in the 1980s to Modified Clinical Exams of recent times, we have sought a perfect solution. All of these processes have been plagued by a high failure rate (at times >80%) and results which do not bear witness to the skills and training of many of the candidates. Australian and New Zealand Medical Boards and their successors have demanded the demonstration of comparability for registration but the AMC also requires comparability for Fellowship.
In the face of concerns about an unfair system which excluded many potential Fellows and protests from OTP/SIMGs in 2008 the newly created Board of Education sought a new system of comparability assessment.
Objectives:
Provide an overview of changes to entry, support, examinations and other pathways to fellowship of the College focusing on the work of SIMGE in the last 7 years;
Consider the goals and objectives of the College in dealing with OTPs/SIMGs;
Discussion of the reasons why changes were introduced and some background to choices made for State Assessment Panels (SAPs) and Substantial Comparability Pathway (SCP) and supports offered.
Findings: This session will also discuss the SIMG Support programs which have been funded by the Australian Government and other formal and informal mechanisms.
Conclusions: The OTP/IMG was in need of reform and required substantial change by from the College and Fellows to achieve this.
Presenter 2
The Changing Face of Comparability Assessment, 2008 – Future
D Neill
Deputy Chair, RANZCP CSIMGE and SCARP; member, Victorian SAP, Melbourne, Australia
Background: Commencing 2008, CSIMGE reformed the processes of IMG progress to Fellowship to: strengthen education and support for IMGs; expect universal, committed progression to Fellowship by IMGs; broaden the methods and mechanisms of determining comparability of training, qualification and experience; provide an alternative pathway to Fellowship for IMGs determined as substantially comparable – the Substantial Comparability Pathway (SCP).
Achievements 2009–2014 are: implementation and consolidation of State Assessment Panels (SAPs); design, trial, evaluation, and expansion of SCP, now in phase II; formation and operation of the Substantial Comparability Assessment/Review Panel (SCARP).
Objectives: To summarize the work of SAPs, SCP and SCARP, and scope their future.
Methods: Key data will be presented alongside a descriptive narrative of the function of SAPs, SCP and SCARP.
Findings:SAP: Has 50 members in six Panels, nominated by Branches, and trained, accredited and mentored by CSIMGE. A three-member Panel is constituted in a monthly schedule. Each application is assessed by audit of application papers, semi structured interview, consensus decision on comparability and gaps, and a comparability score, including weighting for further learning in post specialization training and experience. Final recommendations of comparability and any specific training/experience requirements are made to CSIMGE.
SCP: Development phase 2009–2010 comprised research, tool selection and development, pathway design, assessor training, accreditation and resource development.
Phase I (a) commenced February 2011 with 23 candidates. Phases 1(a)–(c) total, 2011–2014, is 56. Outcomes will be reported. Phase II expands the accepted qualifications and opened September 2014; 42 candidates were accepted; 37 (maximum assessment capacity) commenced in November 2014; 5 start in November 2015.
SCARP: Oversights individual candidate progress, and assessment processes and outcomes; manages any problems arising, and confirms the results. Its composition, functions and outcomes will be described.
Conclusions: The IMG pathway to Fellowship has been reformed; SAP, SCP and SCARP are the buttresses of the assessment component. Future needs are enabling full integration with the 2012 Fellowship Program, consolidation, and attention to audit and support of Panels.
Presenter 3
The Overseas Trained Psychiatrist Committee: From Melbourne (2008) to Brisbane (2014)
E Guaia1, V Garg2
1Deputy Chair, RANZCP OTPC, Princess Margaret Hospital, Perth, Australia
2Illawarra Shoalhaven Local Health District, University of Wollongong, Wollongong, Australia
Background: It was realized that Australia and New Zealand had a significant proportion of workforce contributed by OTPs and there was a felt need to include them in the College Governance system, and this committee was formed in 2008. The Overseas Trained Psychiatrist Committee (OTPC) is a committee of the RANZCP that directly reports to the General Council on matters pertaining to the overseas trained psychiatrist (OTP) in Australia and New Zealand. Since its inception, the OTPC has been represented in many Boards and Committees and has contributed extensively through advocacy in many broad matters, and most importantly the Substantial Comparability Pathway.
Objectives: The main objective of this presentation is to capture the journey of the OTPC in the last six years
Methods: We summarize the work done by the OTPC in the last six years, but more importantly focus on the work done post May 2011.
Findings: The OTPC is formed by OTPs (whether Fellow or Non-Fellow) in Australia and New Zealand. The members represent in many Boards and Committees. The most important representation has been on the Specialist International Medical Graduate Examination Committee (SIMGE) and Board of Education. The most important contribution over the last five years has been working collaboratively with the SIMGE in developing and implementing the Substantial Comparability Pathway that was initially piloted on a restricted group of IMGs and now is being expanded broadly to include wider qualifications. There has been a significant advocacy to get funding and support IMGs in rural and remote areas. Other areas of contribution and advocacy will be highlighted.
Conclusions: The OTPC has come a long way over the last six years and the progress made over the last three years is exponentially high, and we hope to contribute more and more in the coming years.
Presenter 4
The WBA Obstacles and Implementation in Other Colleges: A Review
S Douglas
Australian IMG Support, Advice and Advocacy Network, Canberra, Australia
Background: The need for Overseas Trained Specialists (OTSs) to pass fellowship exams has been a major barrier to obtaining Australian qualifications. OTSs are at a disadvantage over Australian trained trainees with regard to passing fellowship exams. First, many are highly experienced doctors who have not had to take exams for many years. Experienced doctors also have a harder time articulating what they know and do, as this knowledge has become deeply integrated in their knowledge. Finally, OTSs often do not have the educational support and the ability to take study leave that is available to Australian and New Zealand trainees. The workplace based assessment (WBA) is a more valid means of assessing professional competence than examinations as it examines the doctor’s real time practice. The Lost in the Labyrinth report recommended that exams should be reserved for new graduates or those for whom there are concerns about their professional performance
Objectives: To determine the scope of the use of WBA for OTSs and the barriers to implementation of WBA across the Colleges.
Methods: Colleges will be contacted by mail and phone to determine the extent of the use of WBA as well as the challenges in implementing this form of assessment.
Conclusions: The above information will be presented with a focus on the comparison between the RANZCP and other Colleges.
Generalists and (Sub)-Specialists: Has the Balance Swung Too Far? Are the Scales Weighted Equally in Metropolitan and Regional Settings?
J Reilly, J Lee, M Mohiuddin
Mental Health Service Group, Townsville Hospital & Health Service, Townsville, Australia
Background: Medical specialisation and its inevitable hand-maiden, sub-specialisation, has been associated with significant advances in effectiveness of health service delivery, facilitating high-quality assessment and effective evidence-based health care in addition to targeted research. It does come at a potential cost of fragmentation of service delivery with focus on organ systems or service delivery structures rather than holistic care. The balance between generalist care and specialisation is influenced by many factors not necessarily related to most cost-effective clinical service delivery and certainly including training structures.
Objectives:
To stimulate discussion about impacts of subspecialisation on RANZCP training and on service delivery to people with mental illness, particularly in regional settings.
To consider possible benefits and risks of more generalist psychiatric care, including existing barriers to training in and maintenance of sub-specialist skills for generalists.
Methods: The speakers will consider this topic from various perspectives, including historical trends, those of other Medical Colleges, service development and delivery, psychiatric training and particularly addiction, child and adolescent, and old age psychiatry as sub-specialties. They will use their current roles of psychiatric trainee, psychiatrists and service directors from a regional centre to do so and to outline the strategies being used in Townsville and the surrounding area to provide generalist and sub-specialty care.
The audience will be encouraged to discuss personal experiences of generalist vs sub-specialist psychiatry and of access to sub-specialty knowledge and skills and the relevance of sub-specialty training, and the strategies used by or planned in other services, including their outcomes. We anticipate this will be of particular relevance to psychiatrists working in rural and remote settings, but believe it is important for all.
Conclusion: The symposium will enhance understanding of possible generalist and sub-specialist models of care and encourage discussion about the impact of further sub-specialisation in psychiatry and a possible shift to generalist training with associated training and service delivery requirements.
Presenter 1
Medical Generalists and (Sub)-Specialists: A Brief History and Overview of Recent Approaches
J Reilly
Mental Health Service Group, Townsville Hospital & Health Service, Townsville, Australia
Background: The harmful consequences of medical specialisation can include inappropriate or unnecessary assessment and treatment and lack of access to services due to associated de-skilling of more generalist health providers and services. At an individual patient level this can lead to inappropriate or unnecessary assessment and treatment and to a lack of clinical oversight of complex cases involving multiple specialties. More systemically, in areas less well served by specialists such as rural and remote regions, application of sub-specialty models of care from metropolitan settings can paradoxically lead to reduced access to services, compounded by the de-skilling of more generalist health providers and services by training and service networks developed to facilitate sub-specialty training.
Objectives: To understand the wider context of the long-standing and wide-ranging debate on the generalist vs specialist continuum and consider its current impact in RANZCP training, particularly in rural and remote areas.
Methods: Targeted review of medical literature in relation to generalist vs specialist care with a particular focus on general physicians, advanced skills for general practitioners and RANZCP generalist training.
Findings and conclusions: This presentation will set the scene for more specific focus on generalist and sub-specialist models of service delivery and associated training requirements.
Presenter 2
Enhancing Generalist Skills in Rural and Remote Psychiatrists
J Lee
Rural, Remote and Indigenous MHS, Mental Health Service Group, Townsville Hospital & Health Service, Townsville, Australia
Background: In Australia, 81% of the psychiatric workforce services 66% of the population, while 19% services the remaining 34%, those who live in rural and remote Australia. This serves as a platform for understanding the access barrier to sub-specialty psychiatric services for those who live outside metropolitan centres. Whilst telehealth psychiatry services, nurse practitioners and general practitioners with advanced skills training have been effective in closing this gap, they cannot fully replace the value of face-to-face specialist consultations.
Objectives: To stimulate discussion about strategies for enhancing sub-specialty knowledge, skills and practice in clinicians who work in rural and remote settings.
Methods: The development of a mental health service across several rural and remote communities within Townsville Hospital and Health Service district will be considered, including needs for service, identified service gaps and strategies to address these, including development of generalist and sub-specialty skills among psychiatrists and other clinicians. Issues encountered thus far will be discussed, including clinical governance and oversight, impact of service structure changes, training needs and formal and informal training opportunities.
Findings and conclusions: To acquire a better understanding of the need for a training model to be developed for psychiatrists who work in rural and remote settings to have a generalist focus, necessitating enhanced sub-specialty knowledge and skills, and to propose a potential training model to meet this need.
Presenter 3
Addictions and Mental Health Services: A Brief Overview of Recent History in Queensland
J Reilly
Mental Health Service Group, Townsville Hospital & Health Service, Townsville, Australia
Background: The longstanding breach in many states between public sector mental health services (MHS) and clinical addiction services has been associated with loss of capacity and de-skilling of psychiatrists in addiction, contributing to lack of training pathways in addiction psychiatry. Developing Hospital and Health Service structures in Queensland have supported the reunion of MHS and Alcohol, Tobacco and Other Drugs Services (ATODS). This has necessitated the development of clinical capacity in addictions among psychiatrists and other clinicians in addition to applicable clinical governance processes. ATODS model of care historically has hovered between primary and secondary care, with associated de-skilling of primary care services.
Objectives: To stimulate discussion about strategies for enhancing subspecialty knowledge, skills and practice in addictions in clinicians who work in rural and remote settings.
Methods: We will consider addictions as a specific example of the issues highlighted by Dr Lee. We will outline existing service delivery structures and gaps in Queensland. We will identify core requirements for psychiatrists to work as clinicians in addiction services, whether as sub-specialists or generalists, and consider strategies for up-skilling psychiatrists, other mental health clinicians and general practitioners in addictions.
Findings and conclusions: Linkages between psychiatry and addictions need further nurturing. RANZCP training and the attitudes of psychiatrists will play a vital role in the reunions and the recognition of addictions as a core component of psychiatry.
Presenter 4
Developing Capacity in Addictions in Rural and Remote Health Services: A North Queensland Perspective
M Mohiuddin
Mental Health Service Group, Townsville Hospital & Health Service, Townsville, Australia
Background: The longstanding breach in many states between public sector mental health services (MHS) and clinical addiction services has been associated with loss of capacity and de-skilling of psychiatrists in addictions, contributing to lack of training pathways in addiction psychiatry. Developing Hospital and Health Service structures in Queensland have supported the reunion of MHS and Alcohol, Tobacco and Other Drugs Services (ATODS). This has necessitated the development of clinical capacity in addictions among psychiatrists and other clinicians in addition to applicable clinical governance processes.
Objectives: To identify core requirements for psychiatrists to work as clinicians in addiction services, whether as sub-specialists or generalists, in rural and remote areas, though with possible applicability in some metropolitan areas.
Methods: Outline the experience of the Rural, Remote and Indigenous (RRI) MHS of Townsville in modifying previous models of service delivery in addictions. Explain strategies to develop addiction capacity in the psychiatrists and other mental health clinicians of the RRI MHS and their implementation to date. Explain how this process has been incorporated into personal training in Addiction Psychiatry.
Findings: Current status of addictions services in the RRI will be outlined. Difficulties experienced in the process will be highlighted in addition to achievements thus far.
Conclusion: The process to date and the training package developed for addiction psychiatry in rural and remote settings offers a template for other trainees and other services wishing to develop such capacity.
Early Career Psychiatrists Special Interest Group Symposium
N Mills1,2, E Nelson3, J Scott4, J Whitfield1, N Martin1, M Wright1, N Wray2, E Byrne2, J Martin5,6, RANZCP Early Career Psychiatrists Award recipient
1QIMR Berghofer Medical Research Institute, Brisbane, Australia
2Queensland Brain Institute, University of Queensland, St Lucia, Australia
3Department of Psychiatry, Washington University School of Medicine, St Louis, USA
4University of Queensland Centre for Clinical Research, Herston, Australia
5Moonah Park Residential Aged Care Facility, Mitchelton, Australia
6Toowong Specialist Clinic, Toowong, Australia
Background: This symposium is a presentation of the Early Career Psychiatrists Special Interest Group Committee.
In accordance with the terms of reference for the Special Interest Group, the Early Career Psychiatrists Special Interest Group is very supportive of providing opportunities for early career Fellows and the introduction of such a symposium is one key way in which the group is supporting its members.
Objectives: The aim of this symposium is to allow early career psychiatrists an opportunity to present their work, experience and research within a dedicated symposium during Congress 2015 and to promote and encourage research amongst Fellows in their early years of Fellowship.
Presenter 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 will be determined in early 2015.
The presentation aims to increase the profile of the RANZCP Early Career Psychiatrist Award by providing the recipient an opportunity to present their research during a dedicated Early Career Psychiatrist Symposium at Congress.
Presenter 2
Investigating the Relationship Between C-Reactive Protein Genetic Profile Scores and Depression
N Mills1,2, E Nelson3, J Scott4, J Whitfield1, N Martin1, M Wright1, N Wray2, E Byrne2
1QIMR Berghofer Medical Research Institute, Brisbane, Australia
2Queensland Brain Institute, University of Queensland, St Lucia, Australia
3Department of Psychiatry, Washington University School of Medicine, St Louis, USA
4University of Queensland Centre for Clinical Research, Herston, Australia
Background: C-reactive protein (CRP) levels have been associated with Major Depressive Disorder (MDD) and childhood trauma. Genetic variants associated with CRP have been identified through genome-wide association studies (GWAS). Here we explore the phenotypic and genetic relationship between CRP, MDD and childhood trauma.
Methods: Assessment of a total of 18,411 adults, as part of three population-based surveys of twins from the Australian Twin Registry conducted at QIMR Berghofer Medical Research Institute (QIMR) included lifetime diagnosis of MDD (DSM-IV), and an evaluation of trauma (child sexual abuse (CSA) and child physical abuse (CPA) prior to the age of 18 years). Of these, 8,521 individuals had CRP measures, 6,612 had both CRP and GWAS data. CRP GWAS results from the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) (Psaty et al., 2009) were used to generate genetic profile scores for CRP in the QIMR sample based on SNPs with p values < 0.001. We tested for association between CRP genetic risk profiles and CRP and MDD phenotypes.
Results: The relationship between CRP and MDD was moderated by sex, CSA, and body mass index (BMI). CRP profile scores predicted CRP in the QIMR sample, with 18% of the variance of CRP explained. CRP profile scores did not predict MDD status.
Conclusion: We replicated published associations between MDD and CRP moderated by sex and CSA. We found no evidence that this relationship reflected genetic differences between individuals in CRP.
Reference
Psaty BM, O’Donnell CJ, et al. (2009) Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) Consortium Design of Prospective Meta-Analyses of Genome-Wide Association Studies From 5 Cohorts. Circulation-Cardiovascular Genetics 2: 73–U128.
Presenter 3
Transitions in Early Career Psychiatry
J Martin1,2
1Moonah Park Residential Aged Care Facility, Mitchelton, Australia
2Toowong Specialist Clinic, Toowong, Australia
Background: This presentation will explore challenges faced by many psychiatrists in their early years of fellowship, as well as issues regarding different transitions during this period. The aim of the presentation reflects the College’s strategic priorities around supporting members, enhancing the value of College membership, and considering different membership groups and their respective needs from the College.
The symposium aims to have a practical focus on important issues faced by psychiatrists in the early years of their careers, providing attendees with an opportunity to explore and discuss major career transitions.
Objectives: Among other topics, the presentation will focus on the following:
Transitioning from public to private practice;
Juggling work and family commitments;
Achieving work-life balance.
Presenter 4
The Most Important Things I’ve Learnt in Psychiatry
Background: This presentation will feature lighthearted, funny and informative discussion by eminent, senior fellows with the aim of imparting to ECPs some important lessons learnt throughout their careers in psychiatry.
Presenters will be drawn from eminent fellows who are attending Congress and will be identified once Early Bird Registrations have closed and an idea of those already attending Congress is known.
Mental Health in the Australian Defence Force (ADF) and the Role of the ADF Centre for Mental Health
D Morton1, D Wallace2, J Costello2, D Said2
1Department of Defence, Campbell Park, Canberra, Australia
2Australian Defence Force Centre for Mental Health, HMAS PENGUIN, Mosman, Australia
Background: Over 45,000 members of the ADF have served in conflict areas or peacekeeping operations since 1999. Many more have also served on disaster relief and humanitarian assistance operations across the world.
Objectives: This symposium will provide an overview of the potential mental health impacts of operational experience on serving members and those who have transitioned to civilian life, and will review mental health and rehabilitation services provided by the ADF.
Methods: It will provide an overview of the prevalence of mental health disorders and discuss the strengths and weaknesses of mental health services in the ADF. It will describe the role of the ADF Centre for Mental Health and some of its programs: in particular, the work of the Second Opinion Clinic, a national, tertiary referral service; and the implementation of the Recognising Early Signs of Emerging Traumatic Stress (RESET) Program, an innovative, psychological skills development program for members considered to be at risk of development of Posttraumatic Stress Disorder.
Findings: Following the Dunt Review of Mental Health Services, the ADF embarked on a four-year plan to reform services. This included the development of the ADF Mental Health and Wellbeing Strategy, implemented via the Mental Health and Wellbeing Action Plan. Through partnerships with the Department of Veterans’ Affairs (DVA) and key civilian organisations, it has undertaken major research programs to determine the nature and prevalence of mental disorders. A range of key mental health and rehabilitation service delivery programs have been implemented.
Conclusions: The ADF and DVA are working to provide high-quality mental health care to serving members and those who transition to civilian life.
Presenter 1
Mental Health in the Australian Defence Force
D Morton
Department of Defence, Campbell Park, Canberra, Australia
Background: Over 45,000 members of the ADF have served in conflict areas or peacekeeping operations since 1999. Many more have also served on disaster relief and humanitarian assistance operations across the world.
Objectives: This presentation will provide an overview of the potential mental health impacts of these duties on serving members and will also describe the reform of ADF mental health services and their provision to personnel.
Methods: A description of the reform of ADF Mental Health Services following the Dunt Review is provided. The resultant initiatives included: the growth and up-skilling of mental health personnel; the development of the ADF Centre for Mental Health; major research programs, in partnership with the Department of Veterans Affairs and key civilian organisations, into the prevalence of disorders in serving members and veterans; the development of the ADF Mental Health and Wellbeing Strategy, implemented through the Mental Health and Wellbeing Action Plan; and the delivery of prevention, mental health service delivery and rehabilitation programs.
Findings: A range of key mental health and rehabilitation service delivery programs have been implemented.
Conclusions: The ADF and DVA are working to provide high-quality mental health care to serving members and those who transition to civilian life.
Presenter 2
The Australian Defence Force (ADF) Centre for Mental Health
J Costello
Australian Defence Force Centre for Mental Health, HMAS PENGUIN, Mosman, Australia
Background: The ADF Centre for Mental Health (ADFCMH) was established in 2010 as part of the mental health reform program initiated by the Dunt Review. The centre’s mandate supports the ADF Mental Health and Well Being Plan 2012–2015 by enhancing the mental health workforce and improving the quality of mental health care in the ADF.
Objectives: This presentation will describe the establishment, mission, roles and responsibilities of the ADFCMH.
Methods: The ADFCMH Clinical Consultancy Services, Mental Health Workforce Clinical Skilling Framework, Clinical Programs and strategic partnerships will be outlined.
Findings: The ADFCMH is a national asset that provides mental health consultancy services, trains and up-skills the ADF mental health workforce, and provides expert advice to command, Joint Health Command and the Single Services in the review and management of complex mental health presentations.
Conclusions: The ADF is committed to achieving capability through mental fitness; the ADFCMH operationalises this intent by supporting the interaction between ADF members, families, command, and health providers throughout the Force Generation Cycle.
Presenter 3
The Australian Defence Force (ADF) Centre for Mental Health Second Opinion Clinic
D Wallace
Australian Defence Force Centre for Mental Health, HMAS PENGUIN, Mosman, Australia
Background: The ADF Centre for Mental Health was established as part of the Australian Government’s response to the 2009 Dunt Review of Mental Health services in the ADF. The key duties of the Centre include the provision of expert clinical advice, assessment and treatment services for complex mental health cases. The Centre was also tasked to become a hub for telepsychiatry services to the ADF. A second opinion clinic was developed to meet these requirements.
Objectives: To describe the establishment and work of a national, military, mental health tertiary referral clinic and to evaluate its performance through surveys of referring medical practitioners and patients.
Method: A retrospective file review of the first 50 patients seen at the clinic was performed. Referrer satisfaction was assessed using an in-house questionnaire, based on the Primary Care Assessment Survey developed by The Health Institute of the New England Medical Centre. Patient satisfaction was gauged using the existing Defence Health Service Outpatient Satisfaction Survey.
Findings: Patients seen were complex and appropriate referrals. Almost a quarter of patients were assessed by telepsychiatry. Major Depression, Alcohol Disorders, Bipolar II Disorder and PTSD were the most common disorders seen. The diagnosis was changed in half of the patients seen, resulting in significantly different clinical management and administrative outcomes. High levels of satisfaction with the service were reported by referrers and patients.
Conclusions: The ADF Centre for Mental Health Second Opinion Clinic provides an important, specialised clinical service, which supports good practice by performing the sort of detailed assessment that may be impractical for referrer doctors. It is well received by referrers and consumers.
Presenter 4
The Recognising Early Signs of Emerging Traumatic Stress (Reset) Program
D Said
Australian Defence Force Centre for Mental Health, HMAS PENGUIN, Mosman, Australia
Background: Defence personnel are often exposed to potentially traumatic events in the course of their duties. Defence personnel receive training across the continuum of their employment in adaptive coping and resilience.
A percentage of Defence personnel experience sub-syndromal symptoms following exposure to potentially traumatic events. One of the unique characteristics of Defence personnel is that they are highly trainable and have levels of self-efficacy.
Recognising Early Symptoms of Emerging Traumatic Stress (RESET) is a cross-over point between mental health prevention and early intervention that provides Defence personnel with an evidence-informed, skill-based intervention for sub-clinical presentations.
Objectives: This symposium will provide an overview of the RESET program.
Methods: The six modules of RESET which focus on skill development and self-management of symptoms will be outlined.
Findings: The RESET program focuses on delivering several core empirically derived skill sets that have been shown to help with a variety of mild symptomatology. Research indicates that a skills-building approach is more effective than supportive counselling. RESET is effectively a skills-training model designed to increase self-efficacy.
Conclusions: The ADF is working to provide high-quality tailored mental health care to serving members. The principles and techniques of RESET meet four basic standards. They are: (1) consistent with research evidence on risk and resilience following stressful events; (2) applicable in a wide variety of settings; (3) appropriate for Defence personnel returning from deployment; and (4) culturally informed and delivered in a flexible manner with a skills focus rather than pathology focus.
The Philosophy of Addictive Disorders
N Levy1, D Murphy2, S Rosenman3 (Moderator)
1Florey Institute of Neuroscience and Mental Health, Melbourne, Australia; Oxford Centre for Neuroethics, Oxford, UK
2University of Sydney, Sydney, Australia
3St John of God Health Service, Sydney, Australia; Chair, RANZCP Special Interest Group for History, Philosophy and Ethics in Psychiatry
Background: The concept of addictive behaviours underlies and unifies theorising and practice in relation to behaviours as disparate as substance use, gambling, sex and eating. The validity of this assumed unification needs to be explored lest an invalid concept become a block to progress.
Objectives: To examine the current concepts of addictive behaviours and the evidence that allows us to approach them as coherent concept and the evidence that they are incoherent.
Methods: A philosophical analysis of the concepts will precede a review of the current behavioural, neurophysiological, and familial evidence for coherence and incoherence.
Practitioners will be asked to comment on their practical experience that illuminates these questions and problems.
Findings: To be developed in the course of the symposium.
Conclusions: To be developed in the course of the symposium.
Presenter 1
The Philosophy of Addictive Disorders
N Levy
Florey Institute of Neuroscience and Mental Health, Melbourne, Australia; Oxford Centre for Neuroethics, Oxford, UK
Many people, including psychiatrists, find addiction deeply puzzling. Why would a seemingly rational agent who recognizes that they have better reason to abstain from taking drugs nevertheless continue to consume them, sometimes at great personal costs to themselves?
Because addiction is puzzling, we are tempted to explain it as the product of dramatic alteration of brain functioning. In this paper, I’ll suggest that the pathological brain alterations underlying addiction represent a dysfunction of a normal brain mechanism. The alterations in behaviour can be seen in all people, addicted or not, under some conditions. Addiction just broadens the range of circumstances in which these behaviours occur.
Presenter 2
The Philosophy of Addictive Disorders
D Murphy
University of Sydney, Sydney, Australia
Many sceptics about the disease model of addiction seemingly share the assumption that chosen behaviour is not pathological; it is a normative violation, but not in the way characteristic of disease. But many mental illnesses seem to configure the motivational structure of sufferers. I suggest that the crucial question about the disease model is whether the motivational structure of the addict is just normally irrational or irrational due to pathology. Addicts often seem to resolve the trade-off between short-term pleasure and long-term harm via wishful thinking, through acting as though the long-term problems are not a consideration. But resolving a conflict between options by just adopting a belief that bad consequences will not follow if I choose one option is seriously irrational in a way that goes beyond ordinary frailties of thought and into magical thinking. This suggests that the neurocognitive rewiring that goes on in addiction takes the subject beyond ordinary irrationality and into something psychotic enough for us to view alcoholism as a distinct disease category rather than something continuous with ordinary irrationality.
Presenter 3
The Philosophy of Addictive Disorders
S Rosenman
St John of God Health Service, Sydney, Australia; Chair, RANZCP Special Interest Group for History, Philosophy and Ethics in Psychiatry
This is primarily the moderation of the discussion initiated by the principal speakers. The moderator will introduce the speakers, encourage and manage the discussion between them and with the audience. The moderator himself believes that the discussion of addiction cannot proceed without closer philosophical examination of motivational states, and very subtle discriminations need to be made in management. This is often not made in standard treatment approaches.
Expanded Treatment Options for Schizophrenia and Schizoaffective Disorder: Evidence From 15 Biomarkers
S Fryar-Williams1,2,3,4, N Saunders5,6,7, M Mack8,9,10
1University of Adelaide, Adelaide, Australia
2Queen Elizabeth Hospital, Woodville, Australia
3Basil Hetzel Institute for Translational Health Research, Woodville, Australia
4Youth In Mind Research Institute, Norwood, Australia
5University of Sydney, Sydney, Australia
6 Mind and Memory Centre, Tweed Heads, Australia
7Applied Neuroscience Society of Australasia (ANSA), Australia
8Melbourne Graduate School of Education, University of Melbourne, Melbourne, Australia
9Monash University, Melbourne, Australia
10Listen and Learn Centre, Melbourne, Australia
Overarching abstract and background: Schizophrenia and schizoaffective disorder are allied conditions within the clinical setting. The Mental Health Biomarker Project (2010–2014) sought to investigate putative markers with a high possibility of being associated with these conditions in neurophysiological tests and proximal and remote biochemical pathways related to neurotransmitter synthesis and metabolism.
Methods: A case-control design used highly characterised cases of functional schizophrenia and schizoaffective disorder, combined with commercially available biochemistry tests and easily procurable neurophysiological and cognitive assessment methods that are easily administered in a 45-minute clinic consultation.
Findings: Quantitative evidence for 15 biomarkers formed a five-domain model of schizophrenia and schizoaffective disorder, with 82% sensitivity and 90% specificity, at 95% level of confidence. The biomarkers themselves were found to be translationally linked in a manner that supports the dysconnectivity theory of schizophrenia. Duration of illness correlates indicated that abnormal biomarkers are present at the first episode of disease presentation, implying that scope exists for strategically sequenced, biomarker-guided remediation in the first-episode phase of schizophrenia and schizoaffective disorder.
Conclusions: Findings relate to a much required advance in psychiatry – a quantified, multi-domain model for serious mental illness that is theoretically understandable, translationally informative and treatment-relevant. The biomarkers have implications for personalised, targeted treatment of schizophrenia and schizoaffective disorder, using an expanded range of currently available treatment options in biochemical and sensory processing domains.
Presenter 1
Potential for Biochemical and Nutritional Remediation in Schizophrenia and Schizoaffective Disorder
S Fryar-Williams1,2,3,4
1University of Adelaide, Adelaide, Australia
2Queen Elizabeth Hospital, Woodville, Australia
3Basil Hetzel Institute for Translational Health Research, Woodville, Australia
4Youth In Mind Research Institute, Adelaide, Australia
Abstract: Nutritional and biochemical correction of biomarker abnormalities in schizophrenia and schizoaffective disorder.
Background: The Mental Health Biomarker Project (2010–2014) explored enzymes and vitamin and mineral enzyme cofactors related to pathways linking neurotransmitter synthesis and metabolism in schizophrenia and schizoaffective disorder.
Objectives: To explain research and literature evidence for biochemical pathways related to schizophrenia and schizoaffective disorder and the theory linking evidence with biochemical and nutritional treatment options.
Findings: Abnormalities in pathways related to monoamine synthesis and metabolism and oxidative stress protection pathways and cofactors for enzymes in these pathways were found to be biomarkers differentiating cases from controls.
Conclusions: There is potential for informed, judicious biochemical and nutritional treatment to augment conventional pharmacotherapy for schizophrenia and schizoaffective disorder.
Presenter 2
Scope for Broader Therapeutic Approaches to Improve Working-Memory Deficit in Schizophrenia and its Mood Components
N Saunders1,2,3
1University of Sydney, Sydney, Australia
2Mind and Memory Centre, Tweed Heads, Australia
3Applied Neuroscience Society of Australasia (ANSA), Australia
Abstract and background: Working memory deficit is a consistent hallmark in schizophrenia, along with delayed auditory and visual speed of processing. These are remediable conditions.
Objectives: To present research and literature evidence for new treatment methods to enhance working memory and speed of sensory processing.
Methods and findings: Literature and research evidence across a number of domains demonstrate the efficacy of targeted brain games, transcranial stimulation and neuro-feedback, for working memory and speed of processing enhancement in schizophrenia and affective disorders.
Conclusions: There is scope for several new techniques to remediate working memory and sensory speed deficits in schizophrenia and schizoaffective disorder.
Presenter 3
Dichotic Listening as a Function of Inter-Hemispheric Interaction and Connectivity and its Relationship to Schizophrenia Treatment
M Mack1,2,3
1Melbourne Graduate School of Education, University of Melbourne, Melbourne, Australia
2Monash University, Melbourne, Australia
3Listen and Learn centre, Melbourne, Australia
Abstract and background: Dichotic listening disorder is a remediable condition that has been found as a biomarker in schizophrenia along with findings indicating cerebral circuit disconnectivity. The Dichotic Listening Test is a test of lateralized temporal lobe language function as well as a test of auditory inter-hemispheric interaction and connectivity.
Objectives: Research and literature review explores the relationship between dichotic listening and schizophrenia and dichotic listening remediation, and demonstrates available techniques for dichotic listening correction.
Method: A behavioural test and treatment applications for normalizing hemispheric lateralization of speech sound perception (dichotic listening), whereby two different stimuli are presented to the left and right ears simultaneously which may vary in volume, frequency and timing, and the individual is required to separate the auditory information and perform a task called auditory separation and integration.
Findings: Dichotic listening improvement.
Conclusions: Dichotic listening remediation techniques are available and have potential to enhance function in schizophrenia and schizoaffective disorder.
Panel Presentations
Changing Minds – the Inside Story of a Documentary About Psychiatric Care and Treatment
V Storm1,2,4,5,6, M Cross2, C Jones2, N Vella2, J Yeandel2, A Black3, J Wilks3, P Henty3, K Holden3
1Sydney Local Health Districts, Camperdown, Australia
2South West Sydney Local Health District, Liverpool, Australia
3Northern Pictures, Moore Park, Australia
4University of Western Sydney, Sydney, Australia
5University of New South Wales, Sydney, Australia
6University of Sydney, Sydney, Australia
Background: In October 2014, during Mental Health Week, the ABC broadcast a three-part documentary “Changing Minds…”. It followed the care of several people through their acute inpatient stay at Liverpool Hospital and in all but one instance their return home. This symposium seeks to describe how this was achieved and with use of some material from the program discuss benefits and any possible negative results from such an exercise.
Objective: This symposium will outline the process involved in the development of television documentary following the care of patients in the care of the Liverpool Mental Health Service and discuss aspects of the actual content, from psychiatric, nursing, service user, television production, communication and legal perspectives.
Method: Two of the authors (VS and JW) had attempted to develop a similar project some years earlier at another venue. In late 2013, AB approached MC with the object of filming a real life story of the operations of a mental health unit. Complex negotiations ensued with the Health Service management, staff, patients and other regulatory agencies, including the NSW Mental Health Review Tribunal. The footage was filmed throughout the course of care during April–June 2014.The process of obtaining consent and re-confirming consent post filming will be described.
Findings: Patients willingly sought to participate in the program. Staff, overall, were initially less willing and some objected on the basis that patients would both be unwilling to be filmed and could not give valid consent. However, the eager interest of patients to participate persuaded staff that this project was a worthwhile venture. The program was aired on ABC Television over three consecutive nights (7–9 October 2014) during Mental Health Week. The national broadcaster ran a series of radio and television programs under the theme of “Mental As…” for the whole week, including fundraising for mental health research. www.abc.net.au/tv/programs/changing-minds-the-inside-story/
Public response was very positive and people living with mental illness felt proud that their stories were being aired and heard.
Conclusion: A live television documentary can be filmed with necessary consent procedures in an acute psychiatry unit. The outcome has proved positive for participants and the public. It helps break down misunderstanding and promotes public acceptance of the realities of mental illness.
This presentation will include some short excerpts from the program, with Q&A between the presentation panel and the audience.
Asia Pacific Mental Health
M Patton1, Regional Guests
1The Royal Australian and New Zealand College of Psychiatrists
Background: The Royal Australian and New Zealand College of Psychiatrists has held Asia Pacific Mental Health Forums in 2013 and 2014. Delegates from 20 regional nations have been represented at these forums and discussions have focused on mental health service delivery, legislation and workforce issues.
Objectives:
To consider the range of issues faced by mental health practitioners and services in the Asia Pacific region.
To discuss possible initiatives around service and workforce development, the physical health of people with mental illness and community engagement.
Methods: This presentation will draw on the issues discussed at previous Asia Pacific Mental Health Forums, along with the experience of the regional guests participating in this symposium.
Findings and conclusions: Mental health delivery throughout the Asia Pacific is diverse; however, there is much scope for collaborative work to enhance the work of mental health practitioners in the region.
What Can People With a Diagnosis of BPD Teach Us?
J McMahon1, S Lawn1,2, A Chanen3,4
1RANZCP Community Collaboration Committee
2Flinders University, Adelaide, Australia
3Helping Young People Early, Melbourne, Australia
4Orygen Youth Health, Melbourne, Australia
Background: Though people with mental illness often experience stigma, consumers with a diagnosis of borderline personality disorder (BPD) have traditionally endured not only societal stigma but extreme levels of exclusion and disapproval from within psychiatric services themselves. Families have had to fight for services, even for family members in crisis, and there is a great deal of confusion about treatment efficacy.
Objectives: To create meaningful discussion on the valuable lessons that can be learned about mental health care generally from reflecting on experiences and attempts to provide effective services and support to people with a BPD diagnosis.
Method: A panel will explore relevant personal experiences and relate these to existing literature and guidance.
Findings: Providing support and effective treatment to people with a BPD diagnosis can be extremely challenging for psychiatrists, other mental health professionals and families, confronting their core values and efforts on multiple levels. The issues experienced by people with a BPD diagnosis provide the sharp focused lens through which we can learn much about how to respond to and support people with mental illness generally.
Conclusions: Attendees will gain an enhanced appreciation of their individual professional practice with patients with a BPD diagnosis and patients with mental illness, more broadly.
In Training Assessment and the Observed Clinical Activity
W Kealy-Bateman, L Lampe, G Cheung, J Cutbush, S Gill, V Pascu, G Robinson, D Tracy
The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
The Observed Clinical Activity (OCA) is a RANZCP approved formative assessment tool under the 2012 Training Program. It is a mandatory requirement for each six-month rotation from rotation one, 2015. It covers a range of competencies and requires direct feedback to the trainees to assist them to improve performance. For monitoring and quality improvement of the OCA, the OCA Working Group has been set up and it is a joint working party of the Committee for Training and Committee for Examinations.
This session will be led by the Chair and Deputy Chair of the OCA Working Group and will look at the following:
The place of the OCA in the 2012 Fellowship Program;
Standard setting for the OCA across the three stages of training;
The relationship of the OCA to the In-Training Assessment (ITA) as a global assessment of trainee progress;
Use of the OCA form.
The workshop will also briefly cover:
Integrating other Workplace Based Activities (WBAs) to inform the global impression of the trainee as part of the ITA;
Delivery of feedback to trainees who have performed below the standard required to demonstrate competence in a WBA.
The session will provide a comprehensive introduction to the new assessment tool and provide supervisors with a better understanding of its importance in relation to training requirements.
Department of Veterans’ Affairs (DVA) Clinical Reference Group: Working Together to Improve Veteran Mental Health and Psychological Wellbeing
D Wallace1, S Hodson2, M Hopwood3
1Australian Defence Force Centre for Mental Health, Sydney, Australia
2Department of Veterans’ Affairs, Canberra, Australia
3University of Melbourne, Melbourne, Australia
Background: With the drawdown of troops from Afghanistan and a decade of high operational tempo, the Department of Veterans’ Affairs, the Department of Defence and service providers are positioning to meet the challenge of responding to the psychological health needs of contemporary veterans. Currently there are about 46,000 veterans who have an accepted mental health condition and nearly 29,000 of those have a stress disorder, including PTSD. This number does not include current serving members who have not yet commenced the claim process.
Objectives: This session will discuss the unique aspects and challenges of dealing with military mental health and the role psychiatry plays in the continuum of support. This continuum ranges from self-help resources, mental health literacy training as well as primary through to tertiary treatment programs. The session will discuss the latest evidence and the cycle of mental health support and treatment from recruitment, service career, to post-discharge. The panel will provide perspectives from the Australian Defence Force, the Department of Veterans’ Affairs and clinical practice.
Sustaining Indigenous Mental Health Services Through Self-Care
S Balaratnasingam1, D Clarke1, M Milne2, D Rangihuna2, K Ryan1, I Trevallion1
1RANZCP Aboriginal and Torres Strait Islander Mental Health Committee
2RANZCP Te Kaunihera mo ngā kaupapa Hauora Hinengaro Māori
Background: Clinician burnout is a major issue for psychiatrists, impacting on both physical and emotional wellbeing. This is exacerbated for those working in Indigenous communities, who may be working in isolated locations or conducting fly-in-fly-out work.
Objectives: To stimulate discussion around systems of enhancing clinician and team resilience by developing sustainable Indigenous mental health services. The session will also look at maintaining one’s own physical, emotional and spiritual wellbeing with emphasis on the importance of self-care, having good peer support systems and maintaining self-awareness.
Methods: A panel of speakers representing Maori and Aboriginal and Torres Strait islander peoples will share personal experiences reflecting on barriers faced whilst working in an Indigenous setting, how these were overcome and the importance of self-care. The session will be interactive, with audience participation encouraged in discussions around constructive actions that could be taken to enhance clinical and team resilience in order to increase sustainability of services.
Findings and conclusions: Attendees should gain a deeper understanding of the importance of self-care, how it impacts on services in Indigenous mental health settings and actions individuals can take to maintaining one’s physical, emotional and spiritual wellbeing.
Site Accreditation Visits
D McKay1,3, D Alcorn2,3, Trainees of the College
1Chair, RANZCP Accreditation Committee
2Deputy Chair, RANZCP Accreditation Committee
3The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
Background: The Accreditation Committee (AC) of the Education Committee is responsible for the accreditation of RANZCP training programs in Australia and New Zealand. The AC recognises the critical importance of the accreditation of training programs as a core component in the College delivering a quality training experience to trainees. Site visitor panels, composed of Fellows and Trainees with a strong interest and experience in training issues, are appointed by the AC.
Method: This session will be led by College Trainees accompanied by experienced Fellows and members of the AC. The session will be composed of vignettes and panel discussion. The session is particularly aimed at Trainees interested in the accreditation of training programs, and Fellows are also welcome.
Objectives: To explore accreditation issues as follows:
How an accreditation visit ensures training programs meet the accreditation standards;
Site visit processes, and how the various elements of a site visit are conducted;
The importance of each element of a site visit in relation to the accreditation standards;
Ways in which the compliance and quality elements of accreditation are complementary;
Assessment of performance against the accreditation standards;
Provision of constructive feedback to the program;
Involving accountable stakeholders in a transparent and consistent accreditation process;
Action taken, and the consequences, in the event that a program fails to meet a standard.
Oral Presentations
Disorders Inborn: The Neuropsychiatry of Neurometabolic Disorders
M Walterfang1,2
1University of Melbourne, Melbourne, Australia
2Royal Melbourne Hospital, Melbourne, Australia
Background: Metabolic disorders that affect the central nervous system can present in childhood, adolescence or adulthood as a phenocopy of a major psychiatric syndrome such as psychosis, depression, anxiety or mania. An understanding and awareness of secondary syndromes in metabolic disorders is of great importance as it can lead to the early diagnosis of such disorders. Many of these metabolic disorders are progressive and may have illness-modifying treatments available. Earlier diagnosis may prevent or delay damage to the central nervous system and allow for the institution of appropriate treatment and appropriate family and genetic counselling.
Objectives: To review the available literature on the prevalence and neurobiology of psychiatric illness in neurometabolic disorders and propose models for understanding progressive and episodic psychiatric illness in these disorders.
Methods: Selective literature review and synthesis.
Findings: Metabolic disorders appear to result in neuropsychiatric illness either through disruption of late neurodevelopmental processes or via chronic or acute disruption of excitatory/inhibitory or monoaminergic neurotransmitter systems. Treatment considerations include treatment resistance, the increased propensity for side-effects and the possibility of some treatments worsening the underlying disorder.
Conclusions: Identification of neurometabolic disorders that present as secondary psychiatric syndromes is essential, particularly in psychotic disorders associated with cognitive or neurological impairment, or in episodic unexplained psychiatric illness.
The Catastrophic Reaction: Fresh Appraisal of a Useful But Neglected Concept
S Williams
Several NSW Local Health Districts (HNELHD, MLHD, SWSLHD), Australia
Background: Recent textbooks give scant or no attention to the useful clinical phenomenon of the catastrophic reaction.
Presentation: A catastrophic reaction can occur when a person is so overwhelmed by physiological arousal that they are temporarily unable to function adequately. It is a common phenomenon, indeed, it does occur without associated brain pathology. Despite commonly held conceptions it is not necessarily an extreme reaction. Observation of a catastrophic reaction during clinical assessment can provide a clue to the presence and nature of underlying brain pathology. It may indicate subcortical microvascular pathology, may lead to a misdiagnosis of anxiety or depressive disorder in late life and is often a significant contributor to behaviours of concern associated with major or minor neurocognitive disorders including the ‘dementias’, vascular cerebral pathology, traumatic brain injury, autism spectrum disorder and intellectual disability. Understanding the nature of this phenomenon can assist family and professional carers to cope with the vicissitudes of caring and may also help in avoiding or managing behaviours of concern with minimal or no pharmacological intervention.
Some recent books on neuropsychiatry, psychiatry of old age and dementia are reviewed for material about this phenomenon – and found to be often lacking.
A brief history of the concept, first introduced by Goldstein in 1934, will be provided.
Mental Health Implications for Older Adults After Natural Disasters – A Systematic Review and Meta-Analysis
D Siskind1,2,3, G Parker4, D Lie1, M Martin-Khan3, B Raphael5,6, D Crompton1,2, S Kisely1,2,3,7
1Metro South Division of Mental Health, Brisbane, Australia
2Diamantina Health Partners: Centre for Neuroscience Recovery and Mental Health, Brisbane, Australia
3School of Medicine, University of Queensland, Brisbane, Australia
4Royal Brisbane and Women’s Hospital, Brisbane, Australia
5School of Medicine, University of Western Sydney, Sydney, Australia
6School of Medicine, Australian National University, Canberra, Australia
7Griffith Institute of Health, Griffith University, Brisbane, Australia
Background: Natural disasters affect the health and wellbeing of adults throughout the world. There is some debate in the literature as to whether older persons have increased risk of mental health outcomes after exposure to natural disasters when compared to younger adults. To date, no systematic review has evaluated this.
Objectives: We aimed to synthesise the available evidence on the impact of natural disasters on the mental health and psychological distress experienced by older adults.
Methods: A meta-analysis was conducted on papers identified through a systematic review. The primary outcomes measured were post-traumatic stress disorder (PTSD), depression, anxiety disorders, and adjustment disorder.
Findings: We identified six papers with sufficient data for a random effects meta-analysis. Older adults were 2.11 times more likely to experience PTSD symptoms when exposed to natural disasters when compared to younger adults.
Conclusions: Recent decades have seen a global rise in the numbers of older adults affected by natural disasters, implying that an increasing number of the older adults will find themselves “in harm’s way” amid community disruption and distress. Mental health service providers need to be prepared to meet the mental health needs of older persons, and be particularly vigilant after natural disasters to ensure, in particular, early detection and management of PTSD.
Randomised Controlled Evidence for the Effect of Community Treatment Orders on Social Outcomes and Coercion: An Update of a Cochrane Systematic Review
S Kisely1,2,3
1School of Medicine, University of Queensland, Brisbane, Australia
2Metro South Health Service, Woolloongabba, Australia
3Griffith Institute of Health, Griffith University, Brisbane, 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. A previous meta-analysis of the three RCTs to date showed no significant effects on readmission, functioning or symptomatology.
Objectives: To update an earlier Cochrane systematic review of RCTs on CTOs to include social outcomes and perceived coercion.
Method: systematic literature search of the Cochrane Schizophrenia Group Register, Science Citation Index, PubMed/Medline and EMBASE up to September 2014. Inclusion criteria were studies comparing CTOs with standard care, including those where controls received voluntary care for most of the trial. Dichotomous and continuous outcomes were combined using the generic-inverse method to calculate odds ratios (OR).
Results: Three studies provided 652 subjects for the meta-analysis. Two compared compulsory treatment with entirely voluntary care, while the third had controls receiving voluntary treatment for most of the time (medians of 257 vs 8 days respectively for initial randomised legal compulsion and 262 vs 103 over the whole study). Compared to controls, CTOs did not improve social outcomes such as housing or employment (OR = 0.95, 95% CI = 0.74–1.21; n = 652). On the other hand, CTO cases did not report increased coercion (OR = 0.96, 95% CI = 0.63–1.45; n = 598). Only including the two studies comparing compulsory treatment with entirely voluntary care did not alter the results.
Conclusions: CTOs do not improve social outcomes but they do not worsen coercion either.
Carer Perspectives on the Experience of Care: Implications for Rights Based/Recovery Oriented Mental Health Legislation
R Vine1, A Komiti2
1NorthWestern Mental Health, Melbourne Health, Melbourne, Australia
2Department of Psychiatry, the University of Melbourne, Melbourne, Australia
Background: There is limited evidence for the effectiveness of Community Treatment Orders (CTOs) and their use continues to be subject to debate. Shifts in policy and legislation may lead to use of fewer CTOs of shorter duration. We do not know the impact of such change on the consumer or their carers.
Objective: To determine the views and experiences of carers of people with severe mental illness in regard to CTOs.
Method: Questionnaires were posted using the mailing lists of two well established carer support organisations in Victoria. The questionnaires included information about the person with a mental illness, the carer and their experience of care (ECI) and knowledge of recovery (RKI).
Findings: Two hundred and seventy-eight questionnaires were sent and 63 returned, of which 62 provided valid data. Those who responded were predominantly female (90%) and older (mean age 63 years) and were the carer of a person with a severe and recurrent mental illness. Sixty percent had experience of caring for a person on a CTO. Most felt the CTO had been of benefit and in 89% the person relapsed and needed further treatment when the CTO was stopped.
Conclusion: Mental health legislation is shifting to bring a greater focus on rights, individual choice and autonomy in line with recovery oriented care. This study describes the impact of severe mental illness on carers and the need to take their experience into account when considering the impact of determinations regarding treatment under a CTO.
Improving the Quality of Junior Doctor Training Experiences in Psychiatry: A Narrative Review
A Llewellyn1, A Karageorge1,2, L Nash1,2, B Kelly3, J Edwards1, H Sandhu3, C Maddocks1
1Health Education and Training Institute NSW, Sydney, Australia
2Brain and Mind Research Institute, University of Sydney, Sydney, Australia
3University of Newcastle, Newcastle, Australia
Background: Prevocational training during the intern (PGY1) and resident (PGY2) years is known to have a strong influence over career choice. Psychiatry is often presented as an optional experience at this stage, meaning that the duration and quality of exposure can vary. Increasing clinical exposure to psychiatry combined with a focus on quality of the experience has been associated with increased recruitment to vocational training programs.
Objectives: To review recent literature to identify factors associated with favourable psychiatry training experiences undertaken by prevocational doctors (PGY1/PGY2 and international equivalents) and medical students. This review was intended to inform the content of a future survey evaluating junior doctor experiences of psychiatry rotations in NSW.
Methods: Given the range of literature, a narrative synthesis was the method with an iterative process of literature search, review and synthesis employed.
Findings: Thirty-two papers were identified for inclusion. From our synthesis, 20 factors were identified as having a positive effect on views of psychiatry as a career and 10 factors identified as having a negative effect. Factors could be grouped under the following themes: patient, training/education, senior staff support and role definition, with additional themes of autonomy and responsibility staff as role models for positive factors and additional theme of others for negative factors.
Conclusions: Several areas of further research emerge from this study. However, the one theme that emerges most consistently is the need to better understand how and in what ways the training experience influences student perceptions of psychiatry.
Cognitive Function and the Ability to Practise Medicine: A Question of Competence
K Jenkins
Victorian Doctors’ Health Program, Fitzroy, Australia
Background: Evaluation and management of medical practitioners with cognitive problems is a recognized issue worldwide. Increasingly, treating psychiatrists, doctors’ health programs and regulatory authorities are faced with the assessment of doctors who for various reasons have had a change in cognitive function and wish to continue to practise medicine.
Objectives: To explore factors affecting a doctor’s capacity to be a competent medical practitioner.
Methods: The files of all doctors attending the Victorian Doctors’ Health Program, who were recognized as having cognitive problems over the past 7 years, were reviewed: data was collected with respect to presenting symptoms, reasons for and type of change in cognitive function, assessment, management, and outcome.
The range of clinical issues, challenges in management and factors affecting outcome are presented and illustrated with case examples.
Findings: A wide range of diagnoses caused changes in cognitive functioning, including cerebrovascular accident, traumatic head injury and age-related cognitive decline. Whether a doctor can safely continue to practise medicine depends not only on their cognitive capacity but also on their medical sub-specialty and field of practice.
Formal assessment of cognitive functioning can inform management but cannot be relied upon as a predicator of ability to continue to practice medicine. A multi-disciplinary approach to management is essential and successful return to work is best achieved with in supportive workplace.
For those unable to return to work, adjustment to not being a doctor can be devastating.
Conclusions: A change in cognitive capacity does not necessarily preclude a doctor from competent medical practice. Facilitating a successful return to work requires thorough clinical assessment together with authentic assessment in the workplace setting.
Using C-Reactive Protein Genetic Profile Scores to Predict Risk of Anxiety
N Mills1,2, J Scott3, J Whitfield1, M Wright1, N Martin1, N Wray2, E Byrne2
1QIMR Berghofer Medical Research Institute, Brisbane, Australia
2Queensland Brain Institute, University of Queensland, Brisbane, Australia
3University of Queensland Centre for Clinical Research, Brisbane, Australia
Background: Anxiety is often comorbid with Major Depressive Disorder (MDD). An association between raised levels of the inflammatory marker C-reactive protein (CRP) and MDD has been demonstrated. Few studies have evaluated whether there is an association between CRP and anxiety, particularly in individuals with comorbid MDD.
Objectives: To investigate the phenotypic relationship between (i) CRP and anxiety disorders (Generalised Anxiety Disorder (GAD), Social Phobia, Obsessive-Compulsive Disorder (OCD), Panic Disorder, and Agoraphobia); and (ii) CRP and anxiety and comorbid MDD. We also explore whether those who carry more genetic variants known to increase CRP are more likely to suffer from an anxiety disorder or MDD.
Methods: A total of 2,475 twins and their siblings were assessed for anxiety disorders (GAD, Social Phobia, OCD, Panic Disorder and Agoraphobia), MDD and Dysthymic Disorder (DSM-IV criteria) at QIMR Berghofer Medical Research Institute (QIMR). Of these individuals, 1,985 also had CRP data. CRP genome-wide association studies results from the Cohorts for Heart and Aging Research in Genomic Epidemiology (Psaty et al., 2009) were used to generate genetic profile scores for CRP in the QIMR sample. We tested for an association between CRP genetic risk profiles and CRP and anxiety phenotypes.
Findings: CRP was nominally associated with GAD, but the association was not significant after accounting for body mass index.
Conclusions: CRP is associated with GAD in this community sample of twins. CRP genetic profile scores did not predict anxiety (or comorbid MDD); however, power may have been a limitation.
Reference
Psaty BM, O’Donnell CJ, et al. (2009) Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) Consortium Design of Prospective Meta-Analyses of Genome-Wide Association Studies From 5 Cohorts. Circulation-Cardiovascular Genetics 2: 73–U128.
The Auckland Regional Youth Forensic Service: A Clinical Audit of Court Ordered Evaluations With a Focus on Fitness to Stand Trial
C Armstrong1,2, S Hatters-Friedman2,3
1Regional Youth Forensic Service, Auckland District Health Board, Auckland, New Zealand
2University of Auckland, Auckland, New Zealand
3Mason Clinic, Waitemata District Health Board, Auckland, New Zealand
Background: The demographic and other characteristics of young people referred for assessment by Forensic Mental Health Services are infrequently studied, resulting in a paucity of information about this group, particularly in Australasia. International literature which might provide a useful context for court-appointed evaluators must be treated with caution, as the legal context within which this takes place can vary greatly between jurisdictions.
Objectives: To conduct original research in this area which may inform courts, court-appointed assessors and legislators about the issues faced by young people referred for formal assessment by the Courts.
Methods: Over a period of one year, between February 2012 and February 2013, a total of 366 individuals between the ages of 12 and 18 were referred for assessment. Of these, 119 were for Court Reports pursuant to Section 333 of the Children, Young Persons and their Families Act 1989 (n = 119, 33.5%). Demographic data, report characteristics, charges and outcomes of reports were collated and analysed.
Findings and conclusions: Key findings include a high proportion of male evaluees (88%) and a mean age of 15.6 years.
Fourteen youth were opined unfit to stand trial, with a high proportion not engaged in education of any kind. The most common diagnosis amongst those opined unfit was Mental Retardation. A significant proportion of those opined unfit to stand trial did not receive a diagnosis of any mental disorder – in these cases an argument was put forward that the young persons concerned suffered from a constellation of difficulties including cognitive and developmental immaturity.
Are Psychiatrists Trained in Leadership Skills?
AJM Van Zeist-Jongman
Waikato District Health Board, Hamilton, New Zealand
Background: Psychiatrists constantly need leadership skills in their work. Previous literature shows that early career psychiatrists felt inadequately prepared for the leadership aspects of their role. This research bridges a 12-year gap with existing literature.
Objectives: To investigate how early career psychiatrists in 2014 value the leadership skill education in their vocational training to become psychiatrists.
Methods: Psychiatrists in New Zealand and Australia who graduated from one of the regional institutes of training since 2008 were invited to take part in a survey.
Findings: Respondents consider themselves not adequately prepared for the leadership, management and administrative tasks and roles they have as psychiatrists, with preparation for management tasks scoring the lowest. They valued as most useful to have opportunity to practice with a leadership role, to be able to observe ‘leaders at work’, to have a supervisor with special interests and skills in leadership and management, and to have a formal teaching program on leadership and management. They stated that formal teaching sessions should be given throughout the entire 5 years of the training program, not just at the end, and should be given by experienced leaders.
Conclusions: This research shows that leadership skills training in the education of psychiatrists should contain both practical experience with leadership and management roles and formal teaching sessions on leadership and management skills development. A model for improvement of the leadership and management skills education in the training of psychiatrists in New Zealand and Australia has been formulated.
The Mentally Ill in Custody: An Insidious Public Health Concern
E Heffernan
University of Queensland, Brisbane, Australia
Background: The prevalence of mental disorder amongst people in custody is markedly higher than it is for the general community. Despite this, across Australia, there appears to be an inconsistency and inadequacy in the available mental health service responses.
Objectives: To illustrate the prevalence of mental disorder amongst people in custody in Australia and the mortality and morbidity for this group in the transition back to the community, highlighting why this is a public health problem.
Methods: Research findings from Queensland, other relevant Australian literature, national benchmarking and clinical experience will be used to inform the presentation.
Findings: Many individuals with serious mental disorders flow through the Australian prison system annually. They suffer high rates of mortality and morbidity in transition to the community, evidenced by suicide, overdose, mental illness relapse and hospital admission rates that are far higher than would be expected for the general community. There are insufficient mental health services provided to meet the needs of these individuals.
Conclusions: From a public health perspective it is essential to provide adequately resourced and equitable mental health services to people in custody. This can be readily justified from an individual health, community health, ethical, financial and criminal justice framework.
Genetic Analysis in the Assessment of Developmental Disorders: A Series of Case Reports From the Experience of a Metropolitan Neuropsychiatry Clinic
C Richardson, J Harrison
Alfred Child and Youth Mental Health Service, Melbourne, Australia
Background: A chromosome change is identified when there are differences between a person’s DNA and the control DNA. Sometimes, it can be difficult to interpret results. Microarrays are useful in that they are able to detect much smaller changes than routine karyotypes. In general a microarray analysis can be used to learn more precise information about abnormalities that have already been diagnosed by karyotype.
The Neuropsychiatry clinic at Alfred Health accepts a wide range of referrals of children who have developmental, neurological and psychiatric disorders. It has been routine in the last four years to request a genetic analysis, including microarray, in order to inform and direct assessment and management. It has been difficult to interpret the results or their clinical significance in this emerging area of study. Of the variations we have observed there has been an extremely low number of cases reported and generally little clinical experience documented.
Objectives: The aim of this presentation is to present an up-to-date explanation of genetic analysis currently used in clinical practice in the field of developmental disorders. It is our aim to share the case reports and genetic analysis of these cases we have encountered with the hope to add to the broader knowledge base and contribute to a discussion regarding the role of genetics and genetic analysis in the assessment, diagnosis and development of developmental disorders.
Methods: The structure of the presentation will include a brief introduction to the area and a presentation of three case reports of children with developmental disorders with the following genetic abnormalities found: a male karyotype with an interstitial duplication from chromosome region 17q12, a male karyotype with a copy number gain of 15q13.3q14 and a female karyotype with interstitial duplication from chromosome 5q14.1. The research in area of each abnormality will be briefly examined and the clinical relevance to our cases will be explored.
Findings: All three patients presented were diagnosed with a developmental disorder and it is important to consider the genetic findings when explaining aetiology, diagnosis and ongoing treatment.
Conclusions: Genetic analysis is important to consider in developmental disorders and further research in this area is greatly needed.
The Impact of DSM-5 on the Diagnosis of Eating Disorders
H Caudle1, C Pang2, R Newton1,2
1Austin Hospital, Melbourne, Australia
2University of Melbourne, Melbourne, Australia
Background: DSM-IV has previously caused concern due to a large proportion of patients diagnosed with Eating Disorder Not Otherwise Specified (EDNOS) and a reliance on subjective reports of a distortion of body image and fear of weight gain as well as the presence of amenorrhoea. The change in the DSM-5 criteria attempts to address this problem.
Objectives: The purpose of this study was to examine the impact of the DSM-5 criteria on the diagnosis of eating disorder patients previously diagnosed under the DSM-IV criteria.
Methods: The 285 participants were recruited from a specialised eating disorder clinic in Australia. DSM-IV diagnoses of anorexia nervosa, bulimia nervosa and EDNOS were compared with retrospectively applied DSM-5 diagnoses of anorexia, bulimia and other specified feeding or eating disorder (OSFED). Assessment methods included structured clinical interviews and self-ratings of eating disorder and other psychiatric symptoms.
Findings: We observed a 23.5% reduction in an unspecified eating disorder diagnosis with the implementation of DSM-5. The removal of criterion D (amenorrhoea) was the main factor for transition from a DSM-IV EDNOS diagnosis to a DSM-5 anorexia nervosa diagnosis.
Conclusions: The DSM-5 diagnostic criteria for eating disorders significantly reduce the incidence of unspecified eating disorders in the eating disorder population. However, there remain problems with the DSM-5 anorexia nervosa criteria that require clarification.
Personality and Psychological Distress in the Experience of Atrial Fibrillation Symptoms
K Wick1, T Walters2,3, M Mearns2, G Tan3, C Bryant1,4, J Kalman2,3
1Centre for Women’s Mental Health, Royal Women’s Hospital, Melbourne, Australia
2Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
3Department of Medicine, University of Melbourne, Melbourne, Australia
4School of Psychological Sciences, University of Melbourne, Melbourne, Australia
Background: Atrial fibrillation (AF) is the most common sustained arrhythmia. Psychological factors have been associated with AF symptom severity.
Objectives: We aimed to determine the effect on AF symptoms and quality of life (QOL) of personality factors (perceived stress, Type D personality and trait anxiety) and symptoms of psychological distress. We studied change over time in AF symptoms and distress.
Methods: The 101 participants (24 AF-free (group 1), 57 paroxysmal/early persistent AF (groups 2 and 3), 20 longstanding persistent AF (group 4)) underwent assessment of AF symptom severity (AFSS scores) and QOL (SF-36 PCS & MCS), plus assessments of personality (PSS, Type D scale, STAI-2) and psychological distress (HADS, STAI-1). Assessment of symptoms and distress was repeated at 4, 8 and 12 months. Nineteen participants underwent AF catheter ablation after initial assessment (group 3). Medical management of all participants was optimized.
Findings: At baseline, perceived stress, Type D personality, trait anxiety and psychological distress were all strongly associated with more severe AF symptoms and depressed QOL (% of variance in dependent variables accounted for 6–63%, p < 0.01 for all models). 89% remained AF-free after catheter ablation. Over 12 months there was significant improvement in AF symptom and QOL scores only in group 3 (p < 0.01 for all). There was significant improvement in all measures of psychological distress only in the ablation group (p < 0.05 for all).
Conclusions: Both personality and psychological distress are associated with severe AF symptoms and impaired QOL. Parallel improvement in AF symptoms and distress after AF ablation indicates personality factors predispose to more severe AF symptoms and thence psychological distress.
A Correlation Between Mood and Heart Rate Variability in People With and Without Coronary Heart Disease
NJC Stapelberg1, DL Neumann2, DHK Shum2, H McConnell3, I Hamilton-Craig3
1School of Applied Psychology, School of Medicine and Griffith Health Institute, Griffith University, Gold Coast, Australia; The Gold Coast Hospital and Health Service, Gold Coast, Australia
2School of Applied Psychology and Behavioural Basis of Health Program, Griffith Health Institute, Griffith University, Gold Coast, Australia
3School of Medicine, Griffith University, Gold Coast, Australia
Background: Heart rate variability (HRV) is a potential biological marker for major depressive disorder (MDD) in people with and without coronary heart disease (CHD). Depression has predominantly been examined as a categorical variable and compared to limited numbers of HRV measures. Confounders, particularly gender, methodological differences and small sample size. have previously yielded heterogeneous findings.
Objectives: This study aimed to ascertain if linear correlations exist between psychometric test scores and several HRV measures in people with and without CHD.
Methods: Multiple linear regression analysis was used to correlate HRV measures with psychometric measures of mood and anxiety as continuous variables, with covariation for age and gender, in 48 participants with CHD, 39 without CHD and the entire cohort of 87 participants. Forty-seven time domain, frequency domain and non-linear HRV measures from 24-hour cardiac recordings were examined.
Findings: Mood is correlated with longer term HRV measures, with covariation of age and gender in the entire study cohort. In the CHD cohort, mood is correlated with short and longer term HRV measures with covariation of age. In the non-CHD cohort mood is correlated with longer term HRV measures only, which is not consistent with some findings in the literature.
Conclusions: This study is small and gender is unevenly distributed across CHD and non-CHD cohorts. The results obtained for the non-CHD cohort may be confounded by gender. People with CHD are also likely to be in a different stable state of autonomic control from people without CHD, which may also explain differences in the results.
Systems Biology in Major Depression: From Physiome to Pathome, From the Psycho-Immune-Neuroendocrine Network to Chronic Illness Networks
NJC Stapelberg1, DL Neumann2, DHK Shum2, H McConnell3, I Hamilton-Craig3
1School of Applied Psychology, School of Medicine and Griffith Health Institute, Griffith University, Gold Coast, Australia; The Gold Coast Hospital and Health Service, Gold Coast, Australia
2School of Applied Psychology and Behavioural Basis of Health Program, Griffith Health Institute, Griffith University, Gold Coast, Australia
3School of Medicine, Griffith University, Gold Coast, Australia
Background: There are numerous linked physiological pathways which regulate metabolism, energy expenditure and levels of activity in organisms. Collectively they comprise a physiome, which describes the physiological dynamics and functional behaviour of the intact organism. The psycho-immune-neuroendocrine (PINE) network is a physiome comprising four systems: immune function, autonomic nervous system function, endocrine function and the central nervous system (CNS). These processes form a network which can be studied using a systems biology approach.
Objectives: The aim of this review is to apply a systems biology model to the PINE physiome. Additionally, this work characterizes the PINE pathome, a description of the interrelationships of pathophysiological processes which arise when the PINE physiome is disrupted by chronic stress.
Methods: An extensive review of the literature was used to construct topographical maps of the PINE physiome and PINE pathome, and to establish how disruptions in the network of normal physiology can give rise to pathophysiology which links several medical diseases with major depressive disorder (MDD).
Findings and conclusions: Homeostasis of the PINE physiome can be disrupted by chronic stress, on a background of genetic and developmental diathesis factors, resulting in the PINE pathome. MDD, coronary heart disease, type 2 diabetes, stroke, hypertension and atherosclerosis can arise within the PINE pathome. These illnesses act to maintain the PINE pathome in a stable pathological state, giving rise to a stable, chronic illness network. Implications of these models and the importance of adopting a systems approach to understanding the relationship between diseases in the chronic illness network are discussed.
A Comparison of Electroconvulsive Therapy Between Rural and Urban Populations
N Johnston
Hunter New England Local Health District, Tamworth, Australia
Background: Mental health outcomes are poorer in rural and remote regions in Australia. This study investigates a novel aspect of this disparity by comparing the use of Electroconvulsive Therapy (ECT) between rural and urban populations.
Objectives: To investigate whether there are delays in the time it takes for rural patients to receive ECT compared to urban patients.
Methods: This study was a retrospective cohort study. The medical records of all patients (n = 54) that received an acute course of ECT at two rural and two urban psychiatric hospitals in the year 2010 were reviewed.
Findings: There were significant differences from symptoms onset to when patients received ECT. Urban patients waited 17.61 weeks (SE = 3.86), and rural patients waited 39.60 weeks (p = 0.031). There was a significant delay in the average time it took from when a patient received a diagnosis to when they received ECT, with urban patients waiting 5.08 weeks and rural patients waiting 23.38 weeks (p = 0.014). There were corresponding significant delays in the time it took for rural patients to be admitted to hospital for their illness compared to urban patients. There were no significant differences in the average times it took for urban and rural patients to receive ECT once they had been admitted to the facilities.
Conclusions: This study shows that patients in rural areas receive ECT later in their acute illness. These delays appear to be related to delays in accessing inpatient admission in rural areas. Once admitted to hospital, there were no differences in treatment progress.
An Evaluation of the Relationship Between Crystal Methamphetamine Use and Psychosis Amongst Clients of a Youth-Specific Psychosis Service in North-Eastern Melbourne
P Frederick1, L Allen1,2
1University of Melbourne, Melbourne, Australia
2Austin Health, Heidelberg, Australia
Background: The North-East Youth Early Psychosis Service (NEYEPS) provides an early intervention service for young persons aged 16–25 from the North-Eastern region of Melbourne who have experienced psychosis. This research evaluates the association between crystal methamphetamine (“ice”) use and the onset of psychosis amongst current NEYEPS clients and a previous cohort.
Objectives: To determine whether the current cohort of NEYEPS clients are more likely to have used ice in the context of their index psychotic episode than a previous cohort.
Methods: Electronic medical records were used to retrospectively identify NEYEPS clients who used ice within 28 days prior to the onset of psychotic symptoms. The current cohort, extending from 2012–2014, and a previous cohort, extending from 2008–2010, were compared to identify any changes in the frequency of ice use and its relationship to the onset of psychosis.
Findings: The audit was completed using client lists as of August 2014. At this time, the NEYEPS program had 35 clients, of whom 14 (40%) had used ice within the 28 days prior to their index psychotic episode. The 2008–2010 cohort had a total of 39 eligible clients, of whom just one (2.6%) had used ice within 28 days prior to the onset of their index psychotic episode.
Conclusions: Over just a four-year period, clients of NEYEPS have become over 15 times more likely to have used ice within 28 days prior to the onset of psychosis, suggesting a growing role for ice as a precipitant of psychosis in this age group.
The Role of Mental Illness in the Harassment of New Zealand Politicians
S Every-Palmer, J Barry-Walsh
Capital and Coast District Health Board, Wellington, New Zealand
Background: Due to their public profiles and the nature of their work, politicians are more vulnerable to threats, harassment and assault than the general population. The small, but significantly elevated risk of violence to politicians is predominantly due not to terrorists or politically or criminally motivated extremists, but to fixated individuals with untreated serious mental disorders, usually psychosis (James et al., 2011; Mullen et al., 2009).
Objectives: To ascertain the frequency, nature and effect of unwanted harassment of politicians in New Zealand and the role of mental illness plays in this harassment.
Methods: 102/121 New Zealand Members of Parliament (MPs) were surveyed. Quantitative and qualitative data was collected on MPs’ experiences of harassing and stalking behaviours.
Findings: Eighty-seven percent of respondents reported unwanted harassment ranging from disturbing communication to physical violence, with most experiencing harassment in multiple modalities on multiple occasions. Half of MPs had been personally approached by their harassers. Forty-eight percent of MPs had been threatened and 15% had been attacked. Some of these incidents were serious and involved weapons including guns, Molotov cocktails and blunt instruments. One in three MPs had been targeted at their homes. The majority of those who harassed MPs were judged to be mentally ill and in need of treatment.
Conclusions: Psychiatric morbidity may sometimes manifest through harassment of public figures. This harassment has significant psychosocial cost for both the victim and the perpetrator and represents an opportunity for mental health intervention.
References
James DV, Mullen PE, Meloy JR, et al. (2011) Stalkers and harassers of British royalty: An exploration of proxy behaviours for violence. Behavioural Sciences and The Law 29: 64–80.
Mullen PE, James DV, Meloy JR, et al. (2009) The fixated and the pursuit of public figures. Journal of Forensic Psychiatry and Psychology 20: 33–47.
The Introverted Leader: Oxymoron or Opportunity?
M Fryer
Child and Adolescent Psychiatrist, Queensland Health, Brisbane, Australia
Personality can be characterised in many ways and across multiple dimensions. One such dimension that is widely and popularly accepted is the Introversion-Extraversion continuum.
The classic western ideal of a leader tends to align with the extravert: outgoing, talkative, charismatic, assertive, vibrant, confident, quick to action, dynamic. However, many successful companies are run by introverted leaders, Bill Gates of Microsoft being a classic example. This talk will discuss the strengths and weaknesses of extravert and introvert leaders and put forward the argument that introverted leadership should be valued and encouraged.
Caregiver Burden and Depression Among Caregivers of Autism Presenting to a Specialist Child Mental Health Service in Sri Lanka
V Jayawardena1, S Kisely2, H Perera3
1West Moreton Hospital and Health Service, Ipswich, Australia
2University of Queensland, Herston, Australia
3Department of Psychological Medicine, University of Colombo, Sri Lanka
Background: Caregivers of children with autism are known to rate themselves with higher caregiver burden than caregivers of children with other developmental disabilities. High caregiver burden can result in psychological distress and depression, which in turn can affect the care of the child with autism.
Objectives: To assess the caregiver burden, psychological distress and prevalence of depression in caregivers of children with autism in comparison with those of children with medical illnesses.
Methods: A cross-sectional descriptive study done in a specialist child mental health unit and a specialist paediatric outpatient clinic during January to April 2011. An interviewer administered questionnaire and the GHQ-28 were administered to the caregiver. All caregivers were assessed using ICD-10 diagnostic criteria for depression.
Findings: There were 106 caregivers in the study group, and 106 age- and sex-matched caregivers in the control group. The former had a statistically significant higher level of education, family income and work status than the latter group. Burden was perceived by 98.2% and 90.6% of caregivers of children with autistic and medical illnesses, respectively. The prevalence of depression in caregivers was 23.6% and 12.3% in the autistic and medical illness groups, respectively. Caregiver burden (p < 0.001), severe psychological distress (p = 0.003) and prevalence of depression (p < 0.001) were higher in the caregivers of autistic children. Caregiver age and absence of supports had a significant association with depression.
Conclusions: One quarter had depression. This was significantly higher compared with caregivers of medically ill children.
A Framework for a Specialist Mental Health Service Model for Adults With Developmental Disabilities in Australia
C Bennett
Victorian Dual Disability Service, St Vincent’s Hospital, Melbourne, Australia
Background: It is increasingly recognised that adults with developmental disabilities (Autism and Intellectual Disability) have high levels of mental health needs which are difficult to meet in the current service system; however, it is not clear how these needs could be better met. This paper reviews how the mental health needs of this population differ from the rest of the population and why it is difficult for the current mental health service system to meet these. The evidence for different service models is also reviewed. Based on these reviews, this paper proposes a framework for a specialist mental health service model for adults with developmental disabilities.
Objectives: To describe a framework for a specialist mental health service for adults with developmental disabilities in Australia.
Methods: Selective literature review.
Conclusions: A framework for a specialist mental health service for adults with developmental disabilities is described.
Mental Health and Wellbeing in Advanced Age: LiLACS NZ
N Kerse1, M McDonald2, A Rolleston2, K Hayman1, M Muru-Lanning3
1School of Population Health, University of Auckland, Auckland, New Zealand
2Te Kupenga Hauora Māori, University of Auckland, Auckland, New Zealand
3James Henare Research Centre, University of Auckland, Auckland, New Zealand
Background: Mental health in ageing may be impacted by previous trauma, current circumstances and health events.
Objectives: To describe mental wellbeing in Māori and non-Māori in advanced age, and examine correlates.
Methods: Participants: 414 Māori 80–90 years and 523 non-Māori 85 years from a total population cohort, 57% participation rate at inception in 2010; 75% retention.
In-depth qualitative interviews provided perspectives of Māori about wellness and written qualitative responses of Māori and non-Māori provided reflections on “What are the highlights of this stage of life for you?”.
Quantitative measures included “Have you ever had a major psychological stress event that has affected you in the long term?”; depressive symptoms (GDS), Mental Health Related Quality of Life (MHRQOL SF-12) at baseline, 12, 24 months; covariates: deprivation, gender, age, comorbidities (15 verified diagnoses), living arrangements were completed in a comprehensive health interview. Impact on mental health and wellbeing were examined using regression models.
Findings: Qualitative results suggested resilience in advanced age. MHRQOL was good (54 for Māori and non-Māori). 905 of 927 participants answered the prior psychological stress question; 19% (women 22%, men 15%) reported a psychological event; death of loved one and illness of family were common, and discrimination was reported by Māori.
At baseline, prior psychological stress was independently associated with worse depressive symptoms (β2 -0.37, p <0.001) adjusting for all covariates. Over 24 months the impact of prior psychological stress continued to adversely impact depressive symptoms.
Conclusions: Mental wellbeing in advanced age persists despite comorbidities and is impacted by prior events.
Private Psychiatry as Funded Through Medicare Considered in Terms of Social Equity
G Meadows1, J Enticott1, G Russell1, B Inder1, R Gurr2,3
1Monash University, Melbourne, Australia
2University of New South Wales, Sydney, Australia
3Royal Brisbane Hospital, Brisbane, Australia
Background: The RANZCP code of ethics, point 11.1 reads: ‘Psychiatrists shall be prepared to contribute to improving mental health services and promoting the just allocation of health resources for patients with emotional problems or psychiatric disorders’. The latest National Mental Health Report, reporting data for 2010–2011, found that the Commonwealth Government supplied $852 million in Medical Benefits Schedule (MBS) reimbursements to support mental health services, comprising 12.4% of all Government spending for mental health. Concern has been expressed through the years about the justice of distribution of these resources. Generally, research tends to indicate that psychiatric morbidity and needs for care are higher in urban areas with socio-economic disadvantage while the funding dynamics of the MBS may favour areas with greater socio-economic advantage.
Objectives: To provide information on the geographic distribution of use of mental health-specific MBS items by postcode of residence analysed with consideration of principles of social justice.
Methods: This team, through a Freedom of Information request, gained access to four years (2007–2011) of national Medicare data on mental health items as provided by postcode of residence. Social equity of individual medical MBS items, for psychiatrists and also GPs, were quantitatively assessed using a concentration index approach.
Findings: Some heavily used psychiatry consultation items in this analysis show inequitable properties while GP items and psychiatrists provision of shared care planning perform better on this measure.
Conclusions: The findings will be considered in the context of theories of social justice, and challenges for the ethics of psychiatry considered.
More Than a Cup of Tea: An Evaluation of an Intervention Program Empowering Parents to be Effective Members of the Treating Team for Young People With Eating Disorders
N O’Brien, M Hunter
Bayside Child and Youth Mental Health Service, Brisbane, Australia
Background: Bayside Child and Youth Mental Health Service (BCYMHS), a community treatment team in Brisbane, delivers a 6-week 12-hour parent/carer skills-based training group for families with a young person affected by an eating disorder, based on Dr Janet Treasure’s work at the Maudsley hospital (Treasure et al., 2007).
Objectives: Collaborative care for adolescents has repeatedly been indicated as more effective than individual therapy alone, including parents and carers as a crucial part of the treating team. Treasure’s New Maudsley approach aims to help carers to understand eating disorders, learn communication skills that inhibit the maintenance of the disorder and develop positive coping strategies.
Methods: BCYMHS has run six groups with a total of 46 carers since 2012. Pre and post measures have gathered qualitative and quantitative outcomes.
Findings: Qualitative outcome measures indicate overwhelmingly positive acceptance and utility of the program, particularly feeling more connected to family members and being aware of strategies to support the young person. Pre and post quantitative measures with parents also indicate change across clinical categories on the DASS. Feedback from clinicians has also indicated that the group has increased consistency and collaboration of care across BCYMHS, inpatient wards, and the family. A video recording of carer and consumer perspectives will form part of the presentation.
Conclusions: The inclusion of a group for parents and carers, based on Treasure et al.’s work at the Maudsley, has had significant benefits for family members, consumers and clinicians in the treatment of young people with eating disorders.
Bestiality: Contemporary Psychiatric Perspectives
J Barry-Walsh, D Sullivan2,3,4
1Capital and Coast District Health Board (Te Korowai Whariki), Wellington, New Zealand
2Forensicare, Melbourne, Australia
3Swinburne University, Melbourne, Australia
4Department of Psychiatry, University of Melbourne, Melbourne, Australia
Background: Bestiality is reportedly rare and there is little published in the clinical literature on the topic. However, we contend that sexual interactions with animals are more frequent than is realised, in part due to limited ascertainment or questioning. Furthermore, the clinical literature available often reflects a bygone era of lonesome goat-herders or similar far from female company, or deviants from small or western isles with ovine, equine or marsupial preferences. In the 21st Century there is evidence that bestiality is a preferential sexual interest for some, which, although still rare, has been strengthened by internet communication, and overlaps with mental disorder.
Objectives: Many psychiatrists do not know much about sex with animals, and this presentation will provide them with a comprehensive review of the history and evolution of bestiality, a thorough review of the research, and contemporary perspectives and case studies.
High Fidelity Simulation in Undergraduate Child and Adolescent Psychiatry Teaching
M Dunbar1, J Jureidini1, R Marchand2
1Paediatric Mental Health Training Unit, University of Adelaide, Adelaide, Australia
2 Flinders University, Adelaide, Australia
Background: Whilst simulation has been a commonly applied teaching method in medical training for some time, realistic simulation of psychiatric work has been less prevalent. A key obstacle in generating psychiatric simulation experiences relates to the depth of background narrative required for actors to reflexively portray characters, and the complexity of phenomenological detail required to make the simulation feel immersive.
Objectives: In this oral presentation we will describe the evolution of an undergraduate teaching program in Child and Adolescent Psychiatry using a purpose-built simulation lab within the Paediatric Mental Health Training Unit Adelaide. We will describe the role of character-based improvisation in our teaching workflow.
Methods: A character-based improvisation process is used in drama filmmaking to create ‘whole characters’ – characters not just defined by a screenplay, but who exist as ‘standalone’ fictional persons with defined personalities and identities. In our setting, characters are constructed jointly by psychiatrist, director and actor, utilizing a systemized improvisation process. The depth of knowledge the actor has about their character makes for a more authentic clinical experience for students, since the ‘patient’s’ ‘affect’ is supported by detailed family history and a ready knowledge of specific events in the character’s time-line.
Findings: This presentation will examine outcomes achieved by adapting the character-based improvisation process for use in medical training vignettes. Course structure, and integration of cutting-edge video tagging technology to enhance the debriefing process, will also be detailed.
Initial Validation of the Hypersexuality Observer-Rated Scoring Scale (HOSS)
D Davidson1, G Cheung2, K Jansen1
1Auckland District Health Board, Auckland, New Zealand
2University of Auckland, Auckland, New Zealand
Background: Hypersexual behaviour is not uncommon in psychiatric presentations and is a known side effect of pro-dopaminergics. Antipsychotics may dampen this behaviour. However, we have reported a reverse effect with risperidone (Davidson et al., 2013). Benefits to early recognition include lowering risks to family relationships, social embarrassment, job loss and forensic problems.
The Hypersexuality Observer-rated Scoring Scale (HOSS) is a new instrument developed to measure hypersexual behaviour in people with mental illness, in the domains of language, behaviour, stimulation from sexualized visual cues, complaints, socio-economic and biological consequences, as a continuum from normal with graded escalation. It does not measure innate symptoms of sexual drive or sexual dysfunction.
Objectives: To evaluate the validity and reliability of the HOSS in psychiatric inpatients.
Methods: The 100 consenting patients from the adult inpatient unit in Auckland City Hospital were recruited. The primary nurse of the participant scored them on the HOSS (at Time 1) and NPI (Sec H 4-6) to measure concurrent validity, and scored them again on the HOSS at Time 2 to measure test-retest reliability. The researcher scored the participant once on the HOSS to measure rater-inter-rater reliability.
Findings: Statistical analysis showed very strong Pearson’s correlations of 0.899 for concurrent validity, 0.983 for test-retest reliability and 0.948 for rater-inter-rater reliability. The Cronbach’s alpha showed strong internal consistency at 0.753. Levene’s test for variances showed zero variance for domains E and F.
Conclusions: The HOSS may be a valid and reliable instrument for use by trained mental health staff, to measure hypersexual behaviour in mental health patients.
References
Davidson CKD, Johnson T and Jansen J (2013) Risperidone-induced hypersexuality. British Journal of Psychiatry 203: 233. DOI: 10.1192/bjp.203.3.233
Optimizing Olanzapine Dose: Can Modeling and Simulation Help?
T Polasek1, P Korprasertthworn1, L Mignone1, A McLachlan2, J Miners1, G Tucker3,4, A Rowland1
1Flinders University, Adelaide, Australia
2University of Sydney, Sydney, Australia
3University of Sheffield, Sheffield, UK
4Simcyp Ltd., Sheffield, UK
Background: Despite large variability in pharmacokinetics (PK) and a well-defined therapeutic window (20–80 ng/ml), concentration monitoring of olanzapine (OLZ) is rarely used to guide dosing. Simcyp® is a software program used in drug development to predict the PK of drug candidates. However, its utility to predict PK in the clinic is less clear.
Objectives: To determine whether Simcyp® can predict the PK of OLZ.
Methods: Up-to-date in vitro techniques were used to characterize the enzymes responsible for OLZ metabolism. A model for OLZ was developed in Simcyp®. Single- and multiple-dose simulations were conducted and the results compared with clinical PK studies and a database of OLZ trough concentrations (n = 170). The impact of patient variables known to influence the PK of OLZ was also simulated.
Findings: UGT1A4, CYP1A2 and FMO3 mainly catalysed the formation of OLZ-10-N-glucuronide, 7-hydroxy-OLZ and OLZ-N-oxide, respectively. A previously uncharacterized contribution of CYP2C8 to OLZ N-demethylation was demonstrated (~30% of oxidative metabolism). Simulated PK parameters for OLZ were comparable to clinical studies in healthy volunteers, both in terms of population mean and variability. Simulations also predicted the degree of inter-patient variability in steady-state OLZ trough concentrations. Predicted OLZ clearance decreased with increasing adult age and was lower in men (p < 0.05) and Chinese individuals (p < 0.001).
Conclusions: Modelling and simulation accurately predicted the PK of OLZ. When variables that influence OLZ PK are known for a particular patient (age, gender, CYP1A2 activity), this approach may be a rapid and non-invasive way to optimize OLZ dose.
Depression and Self-Care Attitudes Among Medical Students and Interns: A Longitudinal Study
B Jayawardena
School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia
Background: Few published studies have investigated depression in medical students and interns. Anecdotal evidence suggests that the prevalence and severity of depression in this cohort is higher than the general population.
Objectives: To follow cohorts of third year and final year medical students from the University of Western Australia to (i) investigate the relationship with their general practitioner; (ii) determine the frequency and severity of self-reported depressive symptoms and global functioning; and (iii) investigate stressors reported over a 12-month period.
Methods: In 2012, preclinical (Year 3) and final year (Year 6) medical students at the University of Western Australia completed a survey which included demographic information; information regarding general practitioner (GP) relationship; life stressors, the Patient Health Questionnaire (PHQ) and Global Assessment of Functioning (GAF). The survey was repeated a year later when the cohort had transitioned to clinical years and internship at tertiary hospitals in Western Australia.
Findings: 76 Year 6 and 168 Year 3 students participated in 2012, and 148 Year 4 students and 113 medical interns in 2013. On the PHQ, there was an increase in self-reported mild–severe depression in interns (35.4% of interns vs 27.1% of final year students). 37% of interns reported that they would seek help from a GP for depression. In the Year 3–4 cohort, there was a significant decline in self-reported depression from Year 3 to Year 4. However, there was a significant increase in the reporting of suicidal thoughts.
Conclusions: Suicidal ideation was significantly higher among students in Year 4. This suggests higher levels of psychological distress due to the transition from the preclinical to clinical phase of the medical course. Medical students appear to be less engaged with their GPs after graduation. Only a third of respondents would seek medical help for depression. Given that several interns also reported severe depressive symptoms, new measures to improve engagement with primary care and self-awareness of mental health in this cohort should be considered.
The Psychedelic Renaissance: Emerging Data on the Use of Psychedelic Drugs in Addiction, End of Life Anxiety and PTSD
S Coilparampil
University of Western Australia, Perth, Australia
Background: There is a long history of research interest in the therapeutic benefits of ‘psychedelic’ drugs including D-lysergic acid diethylamide (LSD), psilocybin (the active component in ‘magic mushrooms’) and MDMA (ecstasy). Studies in psychiatry during the 1950s and 1960s reported benefits from their use in the treatment of a variety of disorders including schizophrenia, Obsessive-Compulsive Disorder and alcoholism. However, inconsistent and adverse findings along with the widespread abuse of psychedelic drugs resulted in a ban on their use in clinical practice.
Renewed research interest emerged with the landmark Johns Hopkins study on psilocybin in 2008. Further studies since then have examined the effectiveness of psilocybin in helping people to quit smoking and the effectiveness of psilocybin/LSD-assisted psychotherapy in the treatment of anxiety associated with end-stage cancer.
The Multidisciplinary Association for Psychedelic Science (MAPS) has been a source of funding for international trials of psychedelic drugs, particularly trials that have focused on the use of MDMA in war veterans suffering from treatment resistant Post-traumatic Stress Disorder.
Objectives: To increase awareness of the therapeutic use of psychedelic drugs and to encourage further research within Australia.
Methods: A review of the current literature on psychedelic drug research.
Findings: There is a growing body of evidence showing that psychedelic drugs can make a major contribution to effective treatment in psychiatry.
Conclusions: Many arguments against the use of psychedelic drugs are moral rather than medical. Further research and investigation is needed to lift the taboo on these drugs and reveal their potential benefits.
Performance of Three Commonly Used Bedside Cognitive Screening Tools
L Walsh1, A Clugston2, M Croucher3, S Gee3, D Malone4, E Mau5, A Sims6, G Cheung1
1University of Auckland, Auckland, New Zealand
2Auckland District Health Board, Auckland, New Zealand
3Canterbury District Health Board, Christchurch, New Zealand
4Lakes District Health Board, Rotorua, New Zealand
5Waikato District Health Board, Hamilton, New Zealand
6Capital and Coast District Health Board, Wellington, New Zealand
Background: The Mini Mental State Examination (MMSE) is the most widely used bedside cognitive screening tool in New Zealand and overseas. The MMSE is now copyrighted and carries a cost for each administration. Clinicians are using alternative cognitive screening tools but most of these have yet to be formally validated in New Zealand.
Objective: To investigate the sensitivity, specificity and optimal cut-off point of three cognitive screening tools: Montreal Cognitive Assessment (MoCA), Rowland Universal Dementia Assessment Scale (RUDAS), and Addenbrooke’s Cognitive Assessment Version III (ACE-III), in the diagnosis of mild dementia. ACE-III is a relatively new version with only one validation study currently published in the literature.
Methods: 37 participants with mild dementia (age ⩾ 65 and MMSE ⩾ 20) and 47 controls (age ⩾ 65 and MMSE ⩾ 24) were recruited in five localities (Auckland, Christchurch, Waikato, Rotorua and Wellington). All participants lived at home and spoke English as a first language/bilingual. The cognitive screening tools were administered to each participant in random order.
Findings: All three tools discriminated well between cases of mild dementia and controls. The optimal cut-off point for ACE-III was ⩽ 76 (sensitivity = 81.1%, specificity = 85.1%); MoCA ⩽ 20 (sensitivity = 78.4%, specificity = 83.0%); and RUDAS ⩽ 23 (sensitivity = 78.4%, specificity = 85.1%). No statistical differences were found between the areas under the ROC curve of ACE-III, MoCA and RUDAS.
Conclusions: This is the first New Zealand study to provide optimal cut-off points of these three cognitive screening tools. It shows all three tools are valid cognitive screening tools that demonstrate similar abilities to screen for dementia.
Over the Rainbow: Reframing LGBTI Health in Medical Education
AA Sanchez
Australian Medical Students’ Association LGBTI Health Officer, University of Melbourne MDQueer LGBTI Health Club, Melbourne, Australia
Background: The cultural norms of sexuality, sex and gender have changed radically within the past three decades. Despite this, lesbian, gay, bisexual, transgender and intersex (LGBTI) individuals experience a range of mental health disparities compared to the general population, including increased risk of suicide, depression and anxiety. Some of the factors identified in previous research include discrimination within healthcare settings and lack of cultural competency amongst doctors; patients often report having to educate mental health practitioners around their identity and health concerns, with many experiencing lack of support, open hostility and verbal abuse from medical professionals.
Nonetheless, the most recent survey conducted from Australian medical students in 2013 suggest a growing trend to improve cultural competency around LGBTI individuals. Many believe that LGBTI health is important and would like more teaching on the topic than they are currently receiving. A number of local and national initiatives have arisen within Australian medical schools to address this deficit, reframing the way in which healthcare to LGBTI individuals is delivered.
Objectives: This presentation will explore the changing perspectives towards LGBTI health in the next generation of doctors. By delivering more inclusive and affirmative healthcare, medical students hope to make a positive impact in the mental health and well-being of LGBTI individuals. This session will focus on the great initiatives already in place, as well as the renewed future of LGBTI health within medical education.
Systematic Review and Meta-Analysis of Clozapine for Treatment Refractory Schizophrenia
D Siskind1,2, L McCartney1, R Goldschlager1, S Kisely1,2
1Metro South Addiction and Mental Health Service, Brisbane, Australia
2School of Medicine, University of Queensland Brisbane, Australia
Background: Clozapine is the gold standard medication for treatment refractory schizophrenia (TRS). TRS is defined as two failed adequate trials of anti-psychotic medication. Although clozapine has been compared to other anti-psychotic medication, there has been no systematic review and meta-analysis looking specifically at clozapine for TRS.
Objectives: We aimed to conduct a systematic review and meta-analysis of clozapine versus other anti-psychotic medications for people with TRS.
Methods: We searched the Cochrane Schizophrenia Group’s trial register, PubMed and Embase for clozapine, RCTs and clinical trials, and did hand searches of recent meta-analyses of clozapine vs other anti-psychotics for all people with schizophrenia. Studies were included if they compared clozapine to another anti-psychotic and were limited to TRS. Data was extracted from included articles and analysed using RevMan.
Findings: 2482 articles were identified in the search. 2296 were excluded at title and abstract level, 153 were excluded at full text level, leaving 33 articles with data on any outcome data. Total BPRS score was lower for the clozapine group at 6 weeks (OR 7.74, 95% CI 4.22–11.25) and at 12 weeks (OR 3.49, 95% CI 0.65–6.34).
Conclusions: For reduction of psychotic symptoms in the first 6–12 weeks of treatment, clozapine demonstrates significant improvement compared to other anti-psychotic medications.
Dots and Digits: The Science and Art of Managing Conversion Disorder
S Steele1,2
1University of Queensland, Brisbane, Australia
2Royal Brisbane Hospital, Brisbane, Australia
Background: Conversion Disorder remains poorly understood (Rofe and Rofe, 2013) and under-diagnosed (Fricke-Neef and Spitzer, 2013) despite being clearly described in the medical literature for over two millennia (Allin et al., 2005). It presents in myriad ways (Dula and DeNaples, 1995), making it one of the great masqueraders of psychiatric diagnosis.
Once diagnosed, clinicians require particular clinical skills to manage Conversion Disorder successfully.
Objectives: To assist psychiatrists and psychiatry registrars to correctly identify and manage Conversion Disorder.
Methods: Twenty-minute oral presentation including brief case presentation followed by review of the current literature regarding diagnosis and management of Conversion Disorder.
Findings: Expert communication skills are required to communicate the diagnosis to the sufferer (Cottencin 2014) and engage them in the development and implementation of a personally tailored management plan. The literature suggests that Conversion Disorder requires a complex multi-disciplinary approach to achieve optimal outcomes for patients (Rosebush and Mazurek 2011).
Conclusions: Conversion Disorder is a complex condition requiring good clinical acumen to make the diagnosis, expert communication skills to communicate the diagnosis to the sufferer, and a multidisciplinary approach to management. The literature suggests that these skills will offer the sufferer the best chances of recovery.
References
Allin M, Streeruwitz A and Curtis V (2005) Progress in understanding conversion disorder. Neuropsychiatric Disease and Treatment 1(3): 205–209.
Cottencin O (2014) Conversion disorders: Psychiatric and psychotherapeutic aspects. Clinical Neurophysiology 44(4): 405–410.
Dula D and DeNaples L (1995) Emergency department presentation of patients with conversion disorder. Academic Emergency Medicine 2(2): 120–123.
Fricke-Neef C and Spitzer C (2013) Conversion disorders. Der Nervenarzt 84(3): 395–406.
Rofe Y and Rofe Y (2013) Conversion disorder. Europe’s Journal of Psychology 9. DOI: 10.5964/ejop.v9i4.621.
Rosebush P and Mazurek M (2011) Treatment of conversion disorder in the 21st century: Have we moved beyond the couch? Current Treatment Options in Neurology 13(3): 255–266.
A Mental Health Unit Therapy Group for People With Psychotic Spectrum Disorder: “The Coping With Voices Group”
A Solar1,2, K Harwood2
1Sir Charles Gairdner Hospital, Perth, Australia
2University of Western Australia, Perth, Australia
Background: There is an unmet need to support the engagement of some people with psychotic spectrum disorder into evidence-based therapy in the community.
Objective: Distil principles of and initiate voluntary weekly 1 hour therapy group for people with psychotic spectrum disorder on a Mental Health Unit (MHU) to improve coping mechanisms and possible connection with a suitable therapist in the community.
Methods: A literature review of the evidence for therapeutic techniques people with psychotic spectrum disorder might find helpful to manage auditory hallucinations and a monthly 1 hour supervision meeting between author (AS) and group’s lead clinical psychologist (KH) over a 21 month period led to the successful initiation of a voluntary weekly therapy group.
Findings: Published studies demonstrate therapy can improve outcomes for psychotic spectrum disorder. The core principles for the unstructured, flexible group involve provision of a therapeutic space; empowerment; education; opportunistic reality testing; exploration of useful coping strategies; simplified hearing voices network handout based on distraction, self-soothing, behavioural and lifestyle strategies; mindfulness exercise; CBT exercise developing mentalisation capacity; before and after individual clinical psychology assessment. Regular discussion between author (AS) and lead clinical psychologist (KH) revealed surmountable barriers to therapy group initiation were MHU culture change; staff fears about risk; engagement difficulties.
Conclusions: There is evidence therapy may improve outcome in psychotic spectrum disorder. It is possible to develop and sustain a weekly 1 hour clinical psychology-led therapy group for patients with psychotic spectrum disorder on a MHU that may improve their coping and engagement with therapy in the community.
Climate Change and Mental Health
S Every-Palmer, S McBride
Capital and Coast District Health Board, Wellington, New Zealand
Background: Anthropogenic warming of the climate system is now recognized as “unequivocal” and considered by the Lancet/UCL Commission to be “the greatest threat to human health of the 21st century” (Costello et al., 2009). Many of the postulated health impacts of climate change involve mental health. However, to date, psychiatry as a profession has not engaged well with this issue.
Objectives: To consider (i) the likely impact of climate change on population mental health based on current best evidence and (ii) the role of psychiatry in climate change mitigation.
Methods: Systematic review of extant literature on climate change and mental health.
Findings: We present the evidence around the predicted psychiatric morbidity and mortality associated with climate change, with an emphasis on Australasian data. We argue that the effects of climate change are already starting to impact on the psycho-social, economic and cultural determinants of mental health, and that these effects are likely to increase exponentially over time. The most significant implications will be for disadvantaged individual and communities. We discuss the complex psychological and political factors behind the world’s struggle to address climate change.
Conclusions: Climate change is likely to have a significant impact on population mental health. Psychiatrists, both individually and collectively, have a role to play in preparing for, and developing mitigation strategies against these effects.
References
Costello A, Abbas M, Allen A, et al. (2009) Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 373: 1693–1733.
From the Mind to the Heart: Cardio-Psychiatry or Psycho-Cardiology?
D Bertorelli
Waikato District Health Board, Hamilton, New Zealand
My presentation aims to help bridge the gap in modern medicine that divides those who care for disorders of the mind from those who care for disorders of the heart. History of medicine and the profusion of research over the past two decades show us how the cardiovascular system and psychological distress are intimately connected.
Some large epidemiological studies (the Global Burden of Disease Study, the Interheart Study etc.) have established the epidemiologic parity of depression and coronary disease as related public health problems worldwide and that mental health has a more significant impact on life expectancy than smoking and obesity.
The concept of “psychosocial risk” captures the importance of stress and depression for the prediction of cardiovascular risk around the world.
There is an extensive overlap between the risk factors for heart disease and for chronic mental illnesses (smoking, physical activity, social isolation, diabetes, inflammation, obesity, hypertension, sleep disturbance).
Using an innovative bio-psycho-social-spiritual/cultural approach, my presentation explores the mutual interactions between mind and heart:
Psychiatric lens on various cardiac conditions;
Cardiology lens on various psychiatric conditions;
How the heart influences the brain and vice versa;
Mind and heart correlations according to various spiritual traditions;
Suggestions for holistic prevention and treatments.
I am a Senior Consultant Psychiatrist and I have also a specialty in Cardiology. I have had a longstanding interest in this topic, gained in different multicultural settings (Europe, America and New Zealand), where I have worked for many years.
Cognitive Versus Exposure Therapy for Problem Gambling: A Randomised Controlled Trial
M Battersby
Flinders University, Adelaide, Australia
Background: Maladaptive gambling behaviour is harmful to individuals, families and communities, with consequences including financial ruin, broken marriages, problems with the law, depression, anxiety and suicide.
Objectives: To evaluate differential efficacy of cognitive therapy (CT) and exposure-based (behavioural) therapy (ET) for adult problem gamblers using electronic gaming machines.
Methods: A two-group randomised, parallel design with assignment of eligible participants to CT or ET at a South Australian gambling therapy service. Four experienced psychotherapists administered interventions. Primary outcome was rated by participants using Victorian Gambling Screen (VGS) harm to self sub-scale with validated cut score 21+ (score range: 0–60) indicative of problem gambling. An intent-to-treat analysis was used to estimate between-group difference in VGS across intervention to 6 month follow-up.
Findings: Eighty-seven participants started intervention (CT = 44; ET = 43), 51 (59%) completed intervention (CT = 30; ET=21) and 59 (68%) provided post-intervention data. Therapist fidelity to treatment manuals was excellent. Both groups experienced comparable 12 week VGS scores (mean difference -0.18, 95% CI: -4.48–4.11) and 6 month follow-up (mean difference 1.47, 95% CI: -4.46–7.39). Within-group reduction (improvement) in mean VGS was significant across study period (p < 0.001) from baseline (CT 38.96 vs ET 37.59) to 12 weeks (CT 19.18 vs ET 20.10) and 6 month follow-up (CT 4.60 vs ET 6.56).
Conclusions: Cognitive and exposure therapies are both viable and effective treatments for problem gambling. Large-scale trials are needed to compare them individually and combined to enhance retention rates, reduce drop-out and evaluate long-term outcomes.
How to Get Mentally Ill Medical Specialists Back to Work
B Parsonage
Private Practice, Port Macquarie, Australia
Background: Treating doctors suffering from mental illness is an important role for psychiatrists. Treating medical specialists, especially procedural specialists, is associated with particular challenges. The skills for doing this work are not commonly taught to trainee psychiatrists and there is little information in the literature to guide clinicians who unexpectedly find themselves faced with a senior medical colleague who requires their help.
Objectives: To share information about treating doctors and to provide a practical guide to help psychiatrists effectively treat doctors, including procedural specialists, and to facilitate their return to work.
Methods: A literature review was conducted and my experience of treating six GPs and six medical specialists was summarized.
Findings: There are a number of particular challenges which distinguish treating doctors from treating psychiatric patients generally. Special considerations must be made when determining when it is safe for procedural specialists, who work independently and with a high level of individual responsibility, to return to work.
Conclusions: Having a practical guide to deal with unexpected situations helps in management. How initial contact is dealt with, engagement with the patient’s partner and forming a return to work team with the patient and a professional colleague of the patient are important factors in enabling recovery and achieving a successful return to work for doctors who suffer a mental illness.
Poisonings and Attempted Suicide in Routine Emergency Department Data, a Linkage Study
R Gribble1, AS Neale2,3, K Podzebenko1,5, M Holton1, T Green4
1Consultation-Liaison Psychiatry Service, Department of Psychiatry, Royal Prince Alfred Hospital, Camperdown, Australia
2Consultation-Liaison Psychiatry, Concord Repatriation General Hospital, Concord, Australia
3Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
4Emergency Department, Royal Prince Alfred Hospital, Camperdown, Australia
5Precision Health, Kew, Australia
Background: Episodes of attempted suicide or deliberate self-harm most frequently present in Emergency Departments (EDs) and 80% involve poisonings. Not all ED presentations receiving poisoning diagnoses will be attempted suicide but referral to Mental Health is likely to identify the majority assessed as such by ED clinicians.
Objectives: To use data linking ED diagnosis and Mental Health referral to investigate the prevalence of attempted suicide in presentations with poisoning diagnoses and to consider their patterns of repetition and the rate of non-poisoning presentation.
Methods: Mental Health referral was identified and recorded alongside the data collected routinely in the study ED (including ICD diagnoses) about all presentations over 7½ years.
Findings: 1.4% of ED presentations received poisoning diagnoses. 1538 (38%) of 4983 poisoning presentations were clinically referred to Mental Health (consistent with Victorian Emergency Minimum Dataset data). 29% of all presentations occurred in patients with more than one such presentation, but this represented only 11.5% of patients. Mental Health referral occurred in 28% of instances when a patients had only a single poisoning presentation; if there was more than one, 56% of episodes resulted in referral. The majority of patients with more than one poisoning episode had more non-poisoning than poisoning presentations.
Conclusions: Information about clinical referral to Mental Health identifies a group of attempted suicides within routine ED data and should be collected. Most patients who present with poisonings do not repeat and the pattern of their care seeking in ED is not well characterized by their presentations with poisonings. This questions a treatment paradigm focused on recurrence.
The Classification of Challenging Behaviour and Mental Illness in People With Intellectual Disability
CND Bennett
Victorian Dual Disability Service, St Vincent’s Hospital, Melbourne, Australia
Background: It is well recognised that people with intellectual disability can present with behaviours that are difficult for carers to respond to. Examples include aggression, destructive behaviour, self- injury, non-compliance, screaming, faecal smearing and wandering among others. It is also well recognised that people with intellectual disability are at high risk of developing mental illness. Behaviours thought to be secondary to a mental disorder are seen as the core business of mental health services; however, people with intellectual disability are often excluded from mental health services on the basis that their presentation is ‘behavioural’ and ‘due to the intellectual disability’ and service disputes are often based on the distinction between challenging behaviour and mental illness. The implication is that the challenging behaviours seen in people with intellectual disability are somehow different from those seen in people with mental illness or other mental disorders and require different treatment and management paradigms. Thus it is of both practical and theoretical interest to examine the relationship between these different concepts.
Objectives: This paper aims to explore the relationship between the two concepts and the implications of this.
Methods: Review of relevant literature.
Findings: Challenging behaviours can be thought of as a symptom of a presenting disorder.
Conclusions: That the challenging behaviours in people with intellectual disability should be considered a symptom of a mental disorder.
Case Histories of Older Psychiatric Patients and Their Relatives
M Pickles
Private Practice, Melbourne and Sydney, Australia
Background: This paper is based on more than 30 years’ experience in private practice, treating older people with psychiatric illnesses.
Objectives: To present case histories that highlight different areas of difficulty for older psychiatric patients and their relatives whom I have treated.
Methods: Case studies of older patients who have had long-term psychiatric illnesses that developed earlier in life. For these patients, the ageing process (which can include additional psychiatric illnesses affecting older people generally) may interact with and/or exacerbate original psychiatric conditions.
Findings: When cultural background is added to the mix, treatment of older people with psychiatric illnesses becomes more complex. Some behaviours that have been tolerated or seen as appropriate when the person was younger (e.g. displaying anger) may be misinterpreted by healthcare staff unused to behavioural cultural norms. In addition to problems experienced by older psychiatric patients, regardless of whether their problems are long term or brought on by the onset of old age, many relatives of psychiatric patients run into trouble as they get older. While they may have coped with a spouse, parent or child with psychiatric illness when younger, this can become problematic as they get older and they can end up requiring psychiatric treatment themselves.
Conclusions: Onset of psychiatric problems in relatives may exacerbate psychiatric problems of patients for whom they care, who may react negatively to perceptions of withdrawal of support to which they have become accustomed; and actions of culturally insensitive healthcare staff can further exacerbate problems for patients and relatives.
Exposure Therapy in Patients With Cognitive Impairment
P Dham1, M Baigent2, A Larsen3
1Rural and Remote Mental Health Services, Glenside, Australia
2Centre for Anxiety Related Disorders, Flinders Medical Centre and Flinders University, Bedford Park, Australia
3Statewide Gambling Therapy Service, Flinders, Australia
Introduction: Use of exposure therapy in patients with cognitive impairment raises a number of interesting questions about its application in terms of patients’ ability to understand and retain the rationale, their ability to practise homework tasks and if the learning is feasible and sustained. This case report discusses the successful use of behavioural (exposure) therapy for gambling disorder in a man with early Alzheimer’s dementia. It further explores the neurobiology and broader application.
Case report: Mr J, a 56 year old man, was admitted for two-week intensive exposure therapy at the Statewide Gambling Therapy Service unit of Flinders Medical Centre in March 2014. Problem gambling that dates back to his youth was complicated by the diagnosis of early dementia of Alzheimer’s type diagnosed in 2011 with mild cognitive impairment.
He was engaged in behavioural therapy with some modifications to the routine protocol. In spite of the evident cognitive deficits, especially on recall, he responded well in terms of reduction of his urge and remained abstinent from gambling on 6 weeks follow-up post discharge.
Discussion: We discuss the theories about exposure therapy (1–5), neurobiology of learning (6), role of prefrontal cortex in behavioural regulation (7) and a recent functional MRI based study of treatment with exposure therapy for spider phobia that shows lasting functional changes in the prefrontal cortex and amygdala (8). We further discuss the application of exposure therapy in gambling (9–11) and for PTSD in cognitive impairment (12,13).
Response to exposure therapy that involves new learning in patients with cognitive impairment reflects on alternate pathways to learning or alternatively highlights the capacity for neural adaptation. Positive response deters us from making nihilistic assumptions about its application in patients with cognitive impairment. This further encourages study of psychological and behavioral therapies for bringing about lasting neurobiological changes in patients with cognitive impairment.
2. Groves PM and Thompson RF. Habituation: A dual-process theory. Psychol Rev. 1970; 77: 419–450.
3. Mowrer OH. Learning theory and behavior. New York: John Wiley and Sons, 1960.
4. Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychol Rev. 1977; 84: 191–215.
5. Foa EB and Kozak MJ. Emotional processing of fear: exposure to corrective information. Psychol Bull. 1986; 99: 20–35.
6. Kandel E. In search of memory: The emergence of new science of mind. New York: WW Norton, 2007.
7. Morgan MA, Romanski LM and LeDoux JE. Extinction of emotional learning. Contribution of medial prefrontal cortex. Neurosci Lett. 1993; 163: 109–113.
8. Hauner KK, Mineka S, Voss JL and Paller KA. Exposure therapy triggers lasting reorganization of neural fear processing. Proc Natl Acad Sci USA 2012; 109: 9203–9208.
9. Battersby M, Smith D, Harvey P and Pols R. Cognitive versus exposure therapy for problem gambling: A pilot randomised control trial, Final report. North Melbourne: Victorian Responsible Gambling Foundation, July 2013.
10. Riley B, Smith D and Oakes J. Exposure therapy for problem gambling in rural communities: A program model and early outcomes. Aust J Rural Health. 2011; 19: 142–146.
11. Smith D, Harvey P, Battersby M, et al. Treatment outcomes and predictors of drop out for problem gamblers in South Australia: A cohort study. Aust N Z J Psychiatry. 2010; 44: 911–920.
12. Duax JM, Perrine BW, et al. Prolonged exposure therapy for a Vietnam veteran with PTSD and early-stage dementia Cogn Behav Pract. 2013; 20: 64–73.
13. Jones RSP and Banks R. Behavioural treatment of PTSD in a person with intellectual disability. Eur J Behav Anal. 2007; 8: 251: 256.
Older Caucasian Females Are More Likely to Leave Suicide Notes
G Cheung, S Merry, F Sundram
University of Auckland, Auckland, New Zealand
Background: Suicide notes provide an invaluable opportunity to understand the motives and state of mind of individuals who proceed to suicide. Findings on the characteristics of suicide note-writers compared to non-writers in the literature are inconsistent. There have been no previous New Zealand studies examining this phenomenon in older people.
Objectives: The aim of this study is to compare the socio-demographic and clinical variables of older people who left a suicide note versus those who did not.
Methods: The Coronial Services of New Zealand provided records of all suicide cases (n = 225) aged 65 years and over between July 2007 and December 2012. We were able to determine whether there was a suicide note written in 212 cases.
Findings: 88 (41.5%) older people left a suicide note. Bivariate analysis found that females (p = 0.006) and Caucasian individuals (0.003) were more likely to leave a suicide note. Suicide note-writers were also more likely to use non-violent methods (p = 0.001). However, only female gender (OR = 2.778, 95% CI = 1.357–5.687, p = 0.005) and ethnicity (OR = 0.073, 95% CI = 0.009–0.590; p = 0.014) remained significant predictive variables of suicide note writing in the logistic regression model. Results of a thematic analysis of the content of suicide notes will be presented.
Conclusions: Caucasian females are most likely to write a suicide note before they proceed with non-violent self-harm. This may suggest an opportunity for communicating their motives and/or distress to their families/friends; however, other demographic variables are similar to those who do not complete suicide notes.
Toward New Treatments for Early-Onset Conduct Disorders in Children With Limited Pro Social Emotions
M Dadds
University of New South Wales, Sydney, Australia
Background: Parent training interventions are the gold standard for treating child conduct problems, and Australia has a proud history of developing evidence-based treatments. The underlying models of parenting that drive these treatments, however, are typically limited to teaching parents to use effective discipline and positive engagement, attachment, and rewards with the child.
Objectives: This talk will focus on new research that attempts to fit and match different parenting styles to different needs of individual children with early-onset behavioural problems.
Methods: Specifically, I will present clinical studies looking at emotional engagement and eye contact in children with conduct problems and impairments in empathy (or limited prosocial emotions in DSM-5).
Findings: Such children have difficulties with emotional engagement, especially mutual eye gaze, with caregivers. New treatments might involve intense reciprocated eye contact to work with parents of such young children. I will show preliminary results from an innovative parent training treatment that incorporates these techniques to help reverse these problems.
Conclusions: Children with early-onset behavioural problems are a mixed group. Those with limited prosocial emotions have problems with the mechanics of emotional engagement. New treatments may benefit from incorporating a focus on this deficit.
Combination Pharmacotherapy for Psychiatric Disorders in Children and Adolescents: Prevalence, Efficacy, Risks and Research Needs
E Jureidini1, J Jureidini2,3, A Tonkin3
1Concord Centre for Mental Health, Sydney, Australia
2Women’s and Children’s Hospital, Adelaide, Australia
3University of Adelaide, Adelaide, Australia
Background: Since 2013, when we published a review of combination pharmacotherapy for psychiatric disorders in children and adolescents in Paediatric Drugs, over 30 more articles addressing polypharmacy in child psychiatry have been published.
Objectives: This narrative review of the available literature on the efficacy and safety of using polypharmacy to treat paediatric psychiatric disorders aims to provide a comprehensive and up to date analysis of the current evidence to support the increasing use of concomitant therapies in child and adolescent psychiatry.
Methods: Narrative review based on comprehensive literature searches and examination of bibliographies of relevant articles.
Findings: In 2013, only 20 randomised controlled trials (RCTs) addressing the efficacy of polypharmacy in paediatric psychiatry existed, with a total number of participants of less than 2000. Subsequent publications will be comprehensively reviewed and an updated analysis of the risks, prevalence and efficacy of concomitant therapies in child and adolescent psychiatry will be provided to attendees.
Conclusions: On the whole, the published literature fails to convincingly support the level of use of concomitant medication in child psychiatry. Furthermore, many of these RCTs demonstrated higher rates of adverse effects, particularly when one of the prescribed medications was an SSRI. Guidelines will be provided to support safe and appropriate concomitant prescribing.
Defragmenting Paediatric Anorexia Nervosa: Flinders Medical Centre Paediatric Eating Disorder Program
S Suetani1,2,3, M Batterham3, M Yiu3
1Central Adelaide Local Health Network, Adelaide, Australia
2University of Adelaide, Adelaide, Australia
3Flinders Medical Centre, Adelaide, Australia
Background: Anorexia nervosa in childhood and adolescence is a serious psychiatric condition with high morbidity and mortality rates that significantly affect both the physical and psychological wellbeing of the patients and their families. Despite its degree of seriousness, there is relatively limited evidence for effective treatment, especially in the medically unstable phase of the illness.
Objectives: To describe the establishment and main characteristics of the Flinders Medical Centre Eating Disorder Program (FMC EDP) in a paediatric ward.
Methods: The FMC EDP is supported by a multi-disciplinary team of paediatricians, nurses, dieticians, physiotherapists, occupational therapists and psychologists, as well as a psychiatrist, a psychiatry registrar, a social work therapist and a nurse clinical practice consultant.
This paper will be presented by three members of the FMC EDP team: a psychiatry registrar, a consultant psychiatrist and a consultant paediatrician. The presentation will consist of an overview of the program as well as specific roles that each presenter has within the program.
Findings: Since the implementation of the FMC EDP, the number of total admissions each year reduced from 69 to 36, over the past three years. The number of patients requiring multiple admissions also reduced, from 14 to 7 per year, over the same time period.
Conclusions: While we acknowledge that the FMC EDP is still in its infancy, the early outcomes are promising. It is hoped that our model of care can provide a sustainable, long term contribution to the management of this difficult to treat illness.
Aboriginal Art and Artists: Health and Wellbeing
J Pettigrew
Katherine Mental Health Service, Katherine, Australia
Background: Aboriginal art and artists are a visible part of Indigenous culture theoretically easily available to non-Indigenous people who can visit a rock art site or purchase a painting online without much appreciation of regional differences or the responsibilities of the artist.
Objectives: To discuss the role, responsibilities and restrictions that influence a traditional Aboriginal artist and how this interacts with personal and community wellbeing.
Methods: Interviews with artists, managers of art centres and personal experience.
Findings: Traditional art seeks to connect people to the earth, to country. If that connection is strong then all else falls into place; peace of mind, strong relationships and strong community. Paintings tell a story, are practical not purely decorative and serve a function far beyond the artist’s preferences. To be an artist is to be invited, trained, and directed with restrictions on subject matter according to gender and how far advanced one is in ceremony and seniority. Just as there are many regional differences in language, geography and wildlife, so art reflects strong regional differences.
Conclusions: The perspective and approach of traditional artists varies from that of the typical contemporary artist who is using art as a vehicle of personal expression. There is considerable scope for misunderstanding the function of traditional art and inappropriate use of motifs and styles in trying to convey contemporary health messages. Random use of Aboriginal motifs and art is more likely to cause confusion and alienation than understanding.
Psychiatry Consult Liaison and the Substance Abusing Trauma Admission
W Milchak
Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, USA
Background: Every patient admitted to this large teaching hospital’s Trauma Surgery Department that has a blood alcohol level (BAL) of 0.08 or higher and those with positive toxicology screens for illicit drugs are evaluated by the Psychiatry Consult Liaison substance abuse consultant.
Objectives:
Demonstrate the relationship between alcohol and specific traumatic injuries.
Identify the demographics and diagnostics of the substance abusing trauma patient.
Explain the role of the addictions consultant and review intervention outcomes.
Methods: A total of 202 substance abuse evaluations were examined across a two-year period.
Findings: Motor vehicle accidents dominate the type of trauma. Various alcohol related assaults and falls are the second most represented types of traumas. The mean BAL is nearly 3 times the legal threshold for drunk driving. The illicit drug most often present is cannabis. Diagnostically, over 83% of the patients seen meet the DSM-IV-TR criteria for alcohol abuse or dependence. Despite the high BALs and meeting the criteria for a substance use disorder, less than 30% have had some level of formal substance abuse treatment. Patients largely reside within the contemplative stage of change regarding their drinking.
Conclusions: The relationship between substance abuse and traumatic injury is staggering. Trauma patients present an excellent opportunity for brief interventions. Few medical centres formally address this issue and psychiatry consult liaison is uniquely positioned to provide this service.
Incidence of Mental Ill Health Among Prisoners
K Dean1,2, D Korobanova2
1University of New South Wales, Sydney, Australia
2Justice Health & Forensic Mental Health Network, Sydney, Australia
Background: Prisoners are well known to have elevated rates of a wide range of mental disorders, but studies to date have almost universally employed cross-sectional designs while the course of mental disorders and the incidence of new mental disorders is largely unknown. While those entering prison are known to be vulnerable to the development of mental disorder and may have prior history of mental ill health, the excess of prevalent mental disorders among prisoners may not be fully accounted for on this basis. Imprisonment itself may be a candidate environmental risk factor for development of new or relapse of existing mental disorder, particularly among those with vulnerabilities.
Objectives: To establish the presence of self-report mental ill health among a sample of reception prisoners and to subsequently follow individuals up during their imprisonment over a 6-month period to identify development of new mental health problems or deterioration in existing mental health problems.
Methods: A random sample of 700 inmates coming into a reception prison in NSW were interviewed to provide self-report current and past mental health information and then re-interviewed if still in prison at three further time points. Data is currently being entered and analysed.
Findings: Results of baseline rates of current and past mental ill health will be reported followed by estimates of new mental ill health incidence (in person days) and, among those with baseline presence of mental disorder, change in symptoms during follow-up will be presented.
Conclusions: Conclusions arising from the findings reported will be discussed, particularly in terms of the implications for in-prison delivery of mental health assessment and management and the need to improve identification of vulnerability to in-prison incident mental disorder.
Expert Guidelines on the Diagnosis and Treatment of Post-Traumatic Stress Disorder Amongst Emergency Service Workers
SB Harvey1,2, G Devilly3, D Forbes4, N Glozier5, A McFarlane6, J Phillips7, M Sim8, Z Steel1,9, R Bryant1
1University of New South Wales, Sydney, Australia
2Black Dog Institute, Sydney, Australia
3Griffith University, Mt Gravatt, Australia
4Australian Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia
5Brain and Mind Research Institute, University of Sydney, Sydney, Australia
6Centre for Traumatic Stress Studies, University of Adelaide, Adelaide, Australia
7Private Practice, Sydney, Australia
8Monash Centre for Occupational & Environmental Health (MonCOEH), Monash University, Melbourne, Australia
9St John of God Healthcare, Sydney, Australia
Background: Emergency workers perform a vital role in our society. They protect the rule of law, ensure our safety and provide assistance in emergencies. However, there is an increasing realization that many emergency workers suffer ongoing psychological consequences from repeated exposure to trauma, with around one in 10 having symptoms consistent with post-traumatic stress disorder (PTSD). To date there is very little guidance on how specific issues related to emergency service work should be dealt with in the diagnosis and management of PTSD.
Objectives: To develop guidelines on the treatment and diagnosis of PTSD in emergency service workers.
Methods: A panel of nine of Australia’s leading experts in PTSD was assembled, with expertise in psychiatry, clinical psychology, general practice, epidemiology and occupational medicine. Data from a range of previously published systematic reviews was combined with expert opinion to form detailed consensus guidelines.
Findings: PTSD amongst emergency service workers often relates to cumulative exposure to multiple traumas, rather than a single event. As a result, PTSD may present in unique ways and treatment plans often need to be modified. Based on the available evidence, recommendations are made regarding diagnosis and assessment, treatment planning, treatment settings, psychological interventions, pharmacological treatment and treatment sequencing. Particular emphasis is given to how treatment can be modified to improve occupational function and return to work rates amongst emergency service workers.
Conclusions: To the best of our knowledge, these are the first PTSD diagnosis and treatment guidelines written specifically for emergency workers anywhere in the world.
Bipolar Disorder Kids & Sibs Study: Neuroimaging Findings in Young People at High Risk for Bipolar Disorder
RK Lenroot1,2, G Roberts1, J Fullerton2, B Overs1, P Schofield2, P Mitchell1
1University of New South Wales, Sydney, Australia
2Neuroscience Research Australia, Sydney, Australia
Background: Bipolar disorder is highly heritable. Although bipolar disorder is typically diagnosed in young adulthood, many affected individuals have had emotional or behavioural symptoms for years before, suggesting that these genetic vulnerabilities affect their neurodevelopmental trajectory long before their first manic episode.
Objectives: Determine how increased genetic risk for bipolar disorder alters brain development in adolescents and young adults using structural magnetic resonance imaging (sMRI).
Methods: sMRI scans, genetic and clinical data were obtained from 78 healthy controls (HC) (35 male, age 22 ± 4 years) and 87 at risk (AR) for bipolar disorder with a first degree relative with bipolar disorder (30 male, age 20 ± 5 years). Scans were processed and cortical thickness measured using Freesurfer. A polygenic risk score (PRS) was calculated based on 36 SNPs previously implicated in bipolar disorder risk from prior evidence of genetic association from the Psychiatric Genetics Consortium (Sklar et al., 2011). Analyses included group comparison between AR and HC using ANOVA, modelling of effects of PRS on cortical thickness, and exploration of subgroups identified using topographic data analysis (TDA).
Findings: Group comparison showed regions of increased thickness in AR in regions including the insula and inferior parietal. Increasing PRS was associated with thicker cortex in AR but not HC in several regions including the medial prefrontal cortex. TDA identified a subgroup of AR with cortical thickness differences associated with increased risk of an anxiety disorder.
Conclusions: Elevated genetic risk for bipolar disorder has significant effects on cortical development.
The Development of an EEG-Neurofeedback Device for Domestic Use in the Treatment of ADHD
E Knospe1, T Gaber1, C Goffin2, A Janß2, K Radermacher2, A Böhm3, S Leonhart3, H Lüttke4, P Weber4, KSchellhorn5, F Zepf6,7
1Clinic for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, RWTH Aachen University, Aachen, Germany
2Faculty of Mechanical Engineering, Helmholtz Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
3Medical Information Technology, Helmholtz Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
4Hasomed GmbH, Magdeburg, Germany
5neuroConn GmbH, Ilmenau, Germany
6Department of Child and Adolescent Psychiatry, University of Western Australia, Perth, Australia
7Specialised Child and Adolescent Mental Health Services, Department of Health in Western Australia, Perth, Australia
Background: Currently, psychostimulants are part of a multimodal treatment approach for attention-deficit/hyperactivity disorder (ADHD). However, non-pharmacological interventions and treatment approaches are necessary because of non-responsiveness to medication, side effects, non-compliance of patients and reservations of parents against the use of psychotropic agents. Increasing evidence suggests that EEG-based neurofeedback training (NFT) is such an alternative.
Objectives: Our intention is to develop a NFT-based treatment approach for ADHD symptoms that is practical, affordable and accessible for patients in need. We aim to develop a NFT device for domestic use and that does not warrant the immediate presence of a clinician. For the intended purpose, various developments in terms of usability, durability, and safety are required and need to be compared to clinician-operated NFT systems.
Methods: The development of a portable NFT device for domestic use by an interdisciplinary joint venture of three University institutes and two industrial partners was funded by the German Federal Ministry for Economic Affairs and Energy.
Findings: Regarding the new NFT system, the following sub-components need to be developed: a new headset including electrodes, a signal amplifier, signal processing and user interface software, and treatment-related training protocols.
Conclusions: All developed components of the new NFT system meet the basic requirements for a domestic NFT-related treatment of ADHD symptoms independent of the immediate presence of a clinician. A detailed analysis of the performance of the main components and the complete unit is part of an ongoing process which is scheduled to be completed in late 2015.
Why Oral Health Concerns Psychiatrists – a Meta-Analysis of the Dental Consequences of Bulimia and Anorexia
S Kisely1,2,3, H Baghaie3, R Lalloo4, NW Johnson2
1School of Medicine, University of Queensland, Brisbane, Australia
2Griffith Health Institute, Gold Coast, Australia; Griffith University, Brisbane, Australia
3School of Dentistry, University of Queensland, Brisbane, Australia
4Australian Centre for Population Oral Health, School of Dentistry, University of Adelaide, Adelaide, Australia
Background: There is a well-established link between oral pathology and eating disorders (EDs) in the presence of self-induced vomiting (SIV). There are less data in the absence of SIV in spite of risk factors such as psychotropic-induced dry mouth, nutritional deficiency or acidic diet.
Objectives: To determine the association between EDs and poor oral health including any difference between patients with, and without, SIV.
Method: A systematic search of MEDLINE, PsycINFO, EMBASE and article bibliographies, Outcomes were dental erosion, salivary gland function, and the mean number of decayed, missing and filled teeth or surfaces (DMFS).
Findings: Ten studies had sufficient data for a random-effects meta-analysis. These covered 556 psychiatric patients and 556 controls (n = 1112 patients). Patients with ED had 5 times the odds of dental erosion compared to controls (95% CI = 3.31–7.58), especially those with SIV (OR = 7.32). They also had significantly higher DMFS scores (mean difference = 3.07; 95% CI = 0.66–5.48) and reduced salivary flow (OR = 2.24; 95% CI = 1.44–3.51).
Conclusions: These findings highlight the importance of collaboration between dental and medical practitioners. Dentists may be the first clinician to suspect an ED given patients’ reluctance to present for psychiatric treatment, while mental health clinicians should be aware of the oral consequences of inappropriate diet, psychotropic medication and SIV.
Case Study: Holding Up the Mirror to Narcissism
L Ng
Regional Forensic Psychiatry Services, Auckland, New Zealand
The process of dynamically informed psychotherapy and creation of an analytic space with a forensic patient with a major mental illness and personality disorder will be recounted. The traverse of shifts in developmental stages and confrontation of difficult material are sources of reflection, in terms of parallel processes observed during the course of the therapy. The power of transformation, healing and reconciliation are further considered in the progression of treatment, the nurture in a supervisory relationship, termination of therapy and the emergence of the voices of the patient and therapist. The themes and gifts of therapy are discussed from the therapist’s perspective.
Background: The experience of medium-term psychotherapy with a patient in a forensic setting is described.
Objectives: To reflect on the process and dynamics of the therapeutic work undertaken, with particular regard to parallel processes.
Method: The author undertook 80 hours of psychotherapy with a forensic patient with a history of schizophrenia, head injury, personality disorder and methamphetamine and cannabis misuse.
Findings and conclusions: Holding up the mirror to narcissism is a reflective endeavour and facilitated by self-reflection and supervision. The grittiness of working through as a series of daunting and difficult tasks is both challenging and valuable. This material is presented to the audience as experiential ‘grist for the mill’.
Kant’s Sublime: Aesthetics and Psychiatry
J Arnold
Private Practice, Spring Hill, Australia
Objectives: Kant, aesthetics and the art of psychiatry.
Methods: Philosophical argument.
Findings: As below.
Conclusions: His childhood had pagan influences and his early years were under the influence of Emmanuel Swedenborg. His arguments are motivated by Old Testament quotes, yet he lived in era of Scholasticism. This is a historical exploration of Kant’s project. He wrote an early treatise on the Sublime and the Beautiful and then withdrew from public life. When he came back he set about to write his tripartite treatise. Mostly his work on pure and practical reasoning is read. The capstone to the three papers was on the Sublime, beautiful and picturesque, so this is seen as an anomaly and attempt to talk about aesthetics. I argue that Kant meant this to be esoteric and compares with the practical and beautiful. The art of psychiatry, right brain function, is an aesthetic of sublime. Rationality, the god Logos and left brain function, is picturesque and sometimes beautiful. By seeing his project in context and holistically, his work is no longer dry and difficult but becomes deep and highly relevant discourse.
Modelling Containment in Where the Wild Things Are (1963) and Outside Over There (1981)
D Brass
Austin Health, Melbourne, Australia
Background: Picture books, with their multiple verbal and non-verbal narrative layers, often depict children in the process of learning to contain their emotions. The thinking parent delivers the narrative, the ‘real life’ situation of reading aloud echoing the narrative.
Objectives:
Consider the role of containment in narratives offered to children in picture books.
Discuss whether parental reading aloud reinforces the containment within the narrative by modelling it in the external world.
Demonstrate these concepts by close analysis of two examples.
Methods: Analysis of two contrasting picture books (Where the Wild Things Are (1963) and Outside Over There (1981)) informed by Melanie Klein and Wilfred Bion, as well as psychological and educational literature on reading aloud.
Findings: These books offer contrasting positions for their child-protagonists: one is contained, able to dream and cope with his emotions; the other is anxious and uncontained, regressing to a paranoid-schizoid position. The parental voice delivering these narratives echoes the thinking mother in the first story and may enable the child to tolerate the chaos of the second.
Conclusions: These models of containment at work may be vitally important for the developing mind. Since picture books are often read to the pre-literate child, the situation of reading may help the child internalise a parental container by demonstrating the reader-parent’s capacity to cope with disordered narrative. Reading picture books aloud enacts containment. It also demonstrates and strengthens the parental capacity for reverie.
Free Will Versus Psychiatry
S Stankevicius
Royal Brisbane Hospital, Brisbane, Australia
Background: Free will is a current topic of considerable interest. It is central to our idea of human nature, seeming to touch every important aspect of our lives. Debate surrounding free will typically hinges on two points of contention: whether our common ideas of free will are correct, and whether the idea of free will is necessary for our society to function, regardless of its existence.
Objectives: This talk aims to dispel myths surrounding the idea of free will. Furthermore, it intends to show that by moving away from free will, we will move towards an improved psychiatric specialty and society.
Methods: Philosophical and scientific matters related to free will are explored and discussed in a simple and accessible manner. These issues and their implications are examined specifically in relation to psychiatry.
Findings: Our subjective experience of free will is an illusion. This is of profound importance, as the idea of free will greatly contributes to the stigma of mental health patients, is responsible for the shame that mental health patients feel about themselves, and negatively affects how psychiatrists view mental illness.
Conclusions: By acknowledging that free will is an illusion, we realise there are reasons for how people think and act, whether or not we can currently identify those reasons. This can be truly transformative – not only for psychiatry, but for every single one of us.
Measuring and Thinking About the Mental Health Harms of Immigration Detention
P Young
Western NSW Local Health District Bloomfield Hospital, Orange, Australia
Background: Mental health screening of people in immigration detention has enabled quantification of the rates and severity of mental disorder in detained asylum seeker populations and to track this over time.
Objectives:
Report the results of mental health screening of child and adult asylum seekers in Australian Immigration Detention facilities.
Quantify effects of restrictive immigration detention on mental health over time.
Describe the characteristics of immigration detention that result in harm to mental health and to increased rates of psychiatric disorder in detained asylum seekers.
Methods: The Australian Human Rights Commission Inquiry (AHRC) into Children in Immigration Detention compelled the Department of Immigration and Border Protection to release previously suppressed mental health screening data. This data, representing the only recent data set available on this population, includes HoNOS, K-10 and HoNOSCA scores as well as Harvard Trauma Questionnaire results from people identified as survivors of torture and trauma.
Findings: Mental distress and disorder occur in detained asylum seekers at considerably higher rates than in the Australian population. Incidence and severity of disorder increase over time in detention, with a high correlation between subjective and objective measures. Further analysis indicates that the prevalence of mental disorder highly correlates with the social and environmental conditions of detention.
Conclusions: There are identifiable factors within immigration detention that cause harm to mental health of detainees over time. These factors result in an unacceptably high excess risk of mental disorder when detention persists greater than six months.
Mental health screening results from immigration detention should be reported in accordance with public mental health services in Australia.
Clinicians are ethically responsible to advocate to policy makers when these policies result in measurable health harms.
The Art and Science of Treating Transgender Teens: United States and International Guidelines
R Pleak1,2
1Hofstra North Shore-LIJ School of Medicine, New York, USA
2American Academy of Child and Adolescent Psychiatry, Washington DC, USA
Background: Most clinicians lack experience and/or expertise in assessing and working with gender minority youth. Over the past several years in many countries, more and more clinicians have been asked to assess and work with gender variant, transgender, queer, and questioning youth. These youth and their families have unique and challenging issues; they are little understood by many and are victims of harassment, discrimination, and rejection by families, peers, schools, and providers. They can suffer from isolation, distress, depression, and suicidality at higher rates than the general population.
Objectives: Attendees will become familiar with the most recent United States and International Psychiatric and Endocrinologic Guidelines for treating transgender adolescents, and be able to access and apply these guidelines in clinical work.
Methods: Three major guidelines published in 2012 address the psychiatric and endocrinologic needs of transgender teenagers. Guidelines issued by the American Academy of Child and Adolescent Psychiatry (AACAP), the American Psychiatric Association (APA), and the World Professional Association for Transgender Health will be described, with suggestions of incorporating these into clinical practice, using case examples.
Findings: The presenter helped author the AACAP and APA guidelines with many colleagues; their collective experience was instrumental in shaping these guidelines for practical clinical utility based on sound evidence. These guidelines are especially useful in teaching and supervising trainees and clinicians less experienced in working with gender variant youth.
Conclusions: These recent guidelines can be very helpful for all clinicians for assessing, treating, and advocating for transgender youth and their families.
Therapeutic Communities for Personality Disorders
L Sauaia
Ashburn Clinic, Dunedin, New Zealand
Background: Therapeutic Communities (TCs) were developed in the 1940s to address difficulties in social reintegration consequent to emotional disturbance. Among the mental illnesses associated to both social and emotional impairments, Personality Disorders (PDs) stand out for their social disruptiveness and complex treatment requirements. TCs approach emotional dysfunctions psychotherapeutically, also offering a structured social organization that replicates actual social interactions previously experienced by patients. Although TCs represent an old-fashioned milieu, those assets are suitable to treat PDs.
Objectives: Discuss TCs’ suitability to treat PDs and review the scientific literature on the theme.
Methods: The main articles and texts about PDs treatment in TCs were reviewed. In addition, the long-standing experience of Ashburn Clinic in treating patients with PDs was compared with literature data.
Findings: The reviewed literature suggests that TCs serve as suitable structured settings to implement psychotherapeutic treatment. Despite the diversity among TCs, the essential purpose focuses on conveying psychotherapy (mainly in group settings) in socially active – and often emotionally loaded – environments. When properly engaged, patients appear to benefit from treatment, in spite of this not being accurately evidenced. The modest evidence-based available data does not mean, however, inefficiency of treatment offered by TCs.
Conclusions: TCs have offered for decades a suitable treatment structure for patients with PDs. Inconsistencies among outcome data should not be interpreted as treatment inefficiency, but rather consequent to the complexity of both environment and disorder.
Registrars as Teachers: Incorporating the Teaching of Medical Students Into Registrar Training in Psychiatry
N Nair, J Macks
Hunter New England Training, Hunter New England Mental Health, Newcastle, Australia
Background: For many doctors, their undergraduate psychiatry rotation may be the only formal teaching they ever receive in psychiatry (Hickie et al., 2013). However, in all avenues of medicine they will encounter patients with mental health problems. Medical students value clinically oriented face to face teaching in psychiatry (Lampe et al., 2010). Clinical placements provide the opportunity for role modelling by clinicians and integration of students into clinical teams (Conn et al., 2012). Psychiatry trainees, while expected to teach, generally do not receive any formal training in teaching (Hickie et al., 2013).
Objectives: To discuss how the role of medical educator can be used to enhance the teaching–learning experience in psychiatry.
Methods: In the past year, as medical education fellows in psychiatry, we have been involved in teaching second and fifth year medical students from the University of Newcastle. A key component of this role is inspiring and coordinating registrars to become involved in the teaching program.
Findings: We will provide reflections on a year in medical education – the positives and the challenges.
Conclusions: The recent introduction of the 2012 competence-based outcomes model in psychiatry training brings an opportunity to integrate the teaching–learning process for medical students and psychiatry trainees. We propose medical student teaching could be considered as an Entrustable Professional Activity (EPA) and outline how this might occur. Formalising teaching activities as a component of training may improve the learning experiences of students and registrars alike, helping to increase interest in psychiatry as a career and shape attitudes within the wider medical community towards psychiatry.
References
Hickie C, Nash L and Kelly B (2013) The role of trainees as clinical teachers of medical students in psychiatry. Australasian Psychiatry 21: 583–586.
Lampe L, Coulston C, Walter G, et al. (2010) Up close and personal: Medical students prefer face-to-face teaching in psychiatry. Australasian Psychiatry 18: 354–360.
Conn JJ, Lake FR, McColl GJ, et al. (2012) Clinical teaching and learning: From theory and research to application. Medical Journal of Australia 196: 527.
Treatment of Schizophrenia in Asia: Realities and Challenges
N Shinfuku1,2,3
1Kobe University School of Medicine, Kobe, Japan
2Honorary Member, World Psychiatric Association (WPA)
3Immediate Past President, Asian Federation of Psychiatric Associations
Background: In the past three decades, major changes took place in psychiatry and mental health services globally and in Asia. They are, among others, a shift from hospital centred services to community based services, a development of national mental health policies, and paying more attention to human rights of persons with mental illness. However, the real situation differs greatly country by country. We still have many challenges to improve services for persons with schizophrenia in Asia.
Objectives: To recommend Asian colleagues to work together for the betterment of mental health services in Asia.
Methods: I worked as WHO Regional Adviser in Mental Health for 13 years and acted as WPA Zonal Representative for East Asia. I have obtained a number of findings on the realities of mental health services in Asia through these experiences.
Findings: The first finding is that there is an enormous gap in health and socioeconomic conditions between developed and developing countries in Asia. These factors affect also the challenges for the treatment of schizophrenia in different countries.
Conclusions: Un-chain of schizophrenic patients is still a major challenge in some countries. On the other hand, several countries are keeping schizophrenic patients for far too long durations at psychiatric institutions. Asia sees both a shortage and the abuse of psychiatric services.
Child Psychoeducation After the Great East Japan Earthquake
N Fukuchi1,2
1Japanese Society of Psychiatry and Neurology, Tokyo, Japan
2Miyagi Disaster Mental Health Care Center, Miyagi, Japan
Background: On 11 March 2011, Japan was struck by the Great East Japan Earthquake and tsunami. The earthquake and tsunami caused tremendous damage and traumatized a huge number of people, including children.
Objective: The aim of this study was to examine the effect of psychoeducation for children in the relief of their psychological symptoms.
Method: We conducted psychoeducation in the form of outdoor camp activities that utilized objects of enjoyment in traditional Japanese culture. The activities included (1) learning how emotions are formed and the need to be aware of one’s feelings with the “Picture Story” and (2) abdominal breathing with the “Blowing Pipe”. We used the Post Traumatic Stress Symptoms for Children 15 items (PTSSC-15) as a self-report questionnaire on traumatic symptoms and measurement of children’s daily life pre- and post-intervention.
Findings: The camps were held five times (July 2011, Oct 2011, Oct 2012, Oct 2013 and Oct 2014). The participants included 124 children (64 boys and 60 girls), aged between 4 and 12 years (mean = 8.3 years). Participants were characterized as “Lost their home” (26.7%), “Lost their family members” (35.6%) and “Witnessed the tsunami” (27.7%). Of the children, 54 (53.4%) scored above the cut-off for the high risk category. Across the five interventions, the pre-intervention mean of the PTSSC-15 scores was 23.8 (SD 14.9), and post-intervention mean was 21.5 (SD 14.6) (p = 0.03).
Conclusions: This result might indicate that the psychological burden of children was reduced after attending the camp activities which included the psychoeducational intervention.
Cerebral Response to Non-Verbal Affective Vocalizations and Cross-Cultural Differences by Asian and Caucasian Listeners: An FMRI Study
M Koeda1, D Fleming2, Y Okubo1, P Belin3
1Department of Neuropsychiatry, Nippon Medical School, Tokyo, Japan
2Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
3Faculty of Medicine, Aix Marseille University, Marseille, France
Background: In clinical psychiatry, if we could evaluate brain function in a specific emotional state, i.e. depressive state, beyond the culture, it would become a quite useful measurement. However, we reported a cross-cultural effect between Canadian and Japanese participants in processing of angry and pleased vocalizations in contrast to happy and sad vocalizations. Further, it is unclear whether a cross-cultural effect exists in brain functions during emotional processing.
Objective: We aimed to investigate cerebral responses to affective vocalizations between Caucasians and Asians to clarify cross-cultural effect in emotional brain function.
Methods: The 20 Caucasian and 20 Asian healthy subjects, from whom informed consent was obtained, participated in this study. They were scanned by fMRI while listening to non-verbal affective vocalizations (angry, happy, pleased, sad, neutral). Participants judged the type of valence (positive, neutral, negative). fMRI data were analysed based on the full factorial model with main factors of emotion, vocalizations (Caucasian/Asian vocalizations), and group (Caucasian/Asian subjects) implemented in SPM8.
Findings: Concerning cognitive function, response time and accuracy were not significantly different between Caucasian and Asian participants in our present study. As for brain function, although main effect of group was not significantly observed, main effect of emotion in the inferior frontal gyrus, superior temporal gyrus, and amygdala was observed (p < 0.05). Further, interaction effect between emotion and group was observed in the parahippocampus and middle temporal gyrus (p < 0.05).
Conclusions: These findings suggest we should consider that the cerebral response to some affective vocalizations proceeded as culture-specific signals in evaluation of brain function during emotional processing.
Depression and Astrology in Sri Lanka
A Rodrigo1, CA Wijesinghe1, VK Batuwana2, BVS Ruwanpriya2, HS Somadasa2, DGBMS Dasanayake2, KALA Kuruppuarachchi2
1University of Kelaniya, Ragama, Sri Lanka
2North Colombo Teaching Hospital, Ragama, Sri Lanka
Background: Depressive disorder is a serious, recurrent mental illness associated with diminished role-functioning and quality of life. Better understanding of the vulnerability and maintaining factors is vital in prevention and improvement of treatment for depression. The role of cognitive biases in the development, maintenance, and recurrence of depression is well documented. Astrology is an integral part of Sri Lankan culture and the cognitive bias related to astrological beliefs may be important in the management of depression. This phenomenon has not been studied before.
Objectives: To compare cognitive bias regarding astrological beliefs in patients with depression and non-depressed individuals.
Methods: Case–control study involving 143 randomly selected persons with depression treated at North Colombo Teaching Hospital, Sri Lanka and 150 non-depressed demographically and socioeconomically comparable individuals.
Findings: In both case and control groups the majority were females, 57% and 54%, and average ages were 41.4 years and 47.2 years respectively. There was no significant difference between the proportions who believed in astrology in the two groups. However, more people in the depressed group casted their horoscopes last year (25% vs 6%, p < 0.05), recalled negative astrological predictions (60% vs 16%, p < 0.05), sought astrological remedies (47% vs 6%, p < 0.01) and believed those remedies were helpful (28% vs 3%, p < 0.01). 23% of depressed participants believed that being in an inauspicious period was an obstacle to getting better.
Conclusions: Cognitive biases regarding astrological beliefs are common among Sri Lankan people with depression and play a significant role in maintaining depression. Exploration and addressing such beliefs may be important in treatment.
The Arts Are a Powerful Communication Tool Working Interculturally
T Kimpton
Australian Indigenous Doctors’ Association (AIDA), Australia
Background: For thousands of years, Indigenous people have accessed the arts as an integral expression of cultural interaction. We do this through rituals, routines, healing practices, celebrations and continuation of traditions which are intrinsically linked through music, dance, song and paintings on a spiritual basis. These activities are purposeful and have meanings on a number of levels, including the building, reinforcement and strengthening of self and identity.
Objective: The arts are fundamental to developing emotional, social and cultural skills, and can influence the shaping of our spiritual, physical and cognitive growth. This paper will discuss how accessing culture through the arts contributes to developing cultural safety strategies in your practice.
Method: Oral presentation exploring AIDA’s work, and the supporting evidence, on how cultural safety can be strengthened by the medical workforce by incorporating elements of the arts.
Findings: Experiences of other cultures can bring enjoyment as well as discomfort. If the focus is on respecting the validity of other cultures, practitioners can become skilled in being an intercultural communicator, as valuing diversity is an important way of addressing issues of structural oppression. As medical scientists, reflecting on different cultural contexts is an important practice, as it facilitates personal and professional growth, inclusive of appropriate behaviour and communication styles. To achieve this, practitioners must have access to these experiences by gaining knowledge and skills. This forms part of AIDA’s platform to inform medical education, training and workforce advances.
Conclusions: Respecting cultural ways of working through the arts can be utilised in a range of ways. Participants will leave with strategies on how to further their own learning, knowledge and skills in cultural safety, drawing on the arts as a tool of empowerment.
Contemporary Risks for Psychiatrists
D Gallagher1, J Tiller2
1Medical Indemnity Protection Society
2University of Melbourne, Melbourne, Australia
Background: Contemporary psychiatry presents practitioners with some new and emerging challenges. Complaints and regulator supervision are increasing within a ‘blame and claim’ culture. Practitioners need to be informed and understand these risks. Various strategies can be adopted to minimize complaints and claims and mitigate outcomes.
Objectives: To increase awareness and understanding of clinico-legal risks for psychiatrists in both public and private practice and highlight emerging trends, and to implement proactive and pre-emptive strategies
Methods: This presentation will highlight the national law for practitioners, its codes, guidelines and policies. The focus will be on major risks for psychiatrists including:
The workshop will explain how practitioners will be judged should any notification (voluntary or mandatory) be made. The emphasis will be on the role of AHPRA, which is to protect the health and safety of the public by ensuring that only health practitioners who are suitably trained and qualified to practice in a competent and ethical manner are registered.
Findings: Recent trends show increased complaints and claims. This is due to increased consumer awareness, media interest, increased regulation, monitoring and supervision.
Conclusions: Practitioners who practice in accordance with the required codes of conduct and implement fundamental clinico-legal principles can be adequately defended against allegations of suboptimal behaviour and care.
RANZCP CPD Redevelopment – Progress and New Directions
C-S Yong1, JCL Looi2,3
1Chair, RANZCP Committee for Continuing Medical Education
2Australian National University Medical School, Canberra, Australia
3Deputy Chair, RANZCP Committee for Continuing Medical Education
Background: Revalidation and recertification requirements for medical practitioners are becoming more stringent around the world. This occurs in the context of societal and legislative impetus for quality measures of physician competence and maintenance of skills. In this environment, medical colleges are reviewing their CPD programs in anticipation of the potential revalidation scheme of the Medical Board of Australia. Accordingly, the RANZCP commenced a review and redevelopment plan for its CPD program in 2014. Modern CPD programs encompass several essential elements, including self-directed learning, peer review and reflection on practice, quality improvement, and audit or outcomes measurement of practice. The RANZCP has undertaken to modernize its program in anticipation of possible future changes in requirements for medical registration in Australia and New Zealand.
Objectives: To update Fellows on the work of the CPD redevelopment working group and seek engagement from and discussion of potential changes in the RANZCP CPD program in the context of incipient revalidation processes.
Methods: Literature review and benchmarking of medical CPD programs and outline of work plans for redevelopment.
Findings: We will summarize the findings of the CPD redevelopment working group in relation to best practice professional CPD and discuss the priorities in the review process. There has been extensive work on developing tools for clinical audit, multisource feedback and quality improvement in general practice and procedural specialties, but relatively little work in adapting these to psychiatric practice in the private sector in which many Fellows work.
Conclusions: The RANZCP has important roles in identifying and developing relevant tools for CPD for Fellows and in advocating to the medical regulation authorities for revalidation schemes that are pragmatic and efficient, whilst providing assurance for the public of the continuing competence and improvement of psychiatrists.
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.
Psychiatric Disorders in NSW Prisoners With Intellectual Disability and Borderline Intellectual Functioning: Results From the MHDCD Study
KA Johnson1,2
1University of New South Wales, Sydney, Australia
2The Wollongong Hospital, Wollongong, Australia
Background: Prisoners with intellectual disability (ID; IQ < 70) experience higher rates of mental illness. Little is known about the rates of psychiatric disorders of people with borderline intellectual functioning (BD; IQ 70–80).
Objectives: To analyse the rates of psychiatric disorders in 2731 prisoners in the NSW Prison System.
Methods: This was a cross-sectional, anonymized record linkage study. 2731 prisoners in the NSW Criminal Justice System were matched to NSW Health admission records. Psychiatric diagnoses of the BD group (n = 780) were compared to groups with no disability (No CD; n = 1268) and ID (n = 680).
Findings: The BD group was more likely to receive a psychiatric diagnosis overall. The BD and ID groups had higher rates of psychotic disorders, dissocial personality disorder, post-traumatic stress disorder and substance misuse. Common psychiatric disorders, e.g. depression, were present at unusually low rates in all groups. BD and ID groups did not differ significantly in terms of rates of diagnoses and demographic variables.
Conclusions: Prisoners with BD represent a vulnerable group, with rates of psychiatric illness comparable to prisoners with ID. A distinction between BD and ID may have little utility. The high rates of certain disorders and low rates of some common mental illnesses reflect diagnostic challenges specific to this population and biases of agencies towards prisoners in general.
Antidepressant Response in Depressed Patients With and Without Generalised Anxiety Disorder or Psychotic Comorbidity: The Dimension Study
S Hood1, P Courtet2, G Vaiva3, E Corruble4, P Llorca5, P Gorwood6, F Bayle6
1University of Western Australia, Perth, Australia
2CHU de Montpellier, Montpellier, France
3Michel Fontan Hospital, Lille, France
4Bicêtre Hospital, Le Kremlin Bicêtre, France
5University Hospital, Clermont-Ferrand, France
6Centre Hospitalier Sainte-Anne, Paris, France
Background: About one third of depressed patients present a comorbid anxiety disorder, which is associated with increased severity of the depression and decreased response to treatment, resulting in a greater burden. The DIMENSION study aimed to observe changes in antidepressant response in a naturalistically followed sample of depressed patients, with and without comorbid anxiety.
Methods: A total of 1854 adult outpatients with Major Depressive Disorder enrolled in psychiatric care sites and who were receiving agomelatine were assessed at inclusion and at Weeks 4–8 using the following instruments: MINI (Mini International Neuropsychiatric Interview), QIDS-C (Quick Inventory of Depressive Symptomatology − Clinician-rated), CGI (Clinical Global Impression scale), and in terms of their functioning GAF (Global Assessment of Functioning) and ILSS (Independent Living Skills Survey).
Findings: Compared with patients with pure depression (n = 633), those with anxious depression (n = 392) were more often female (68.6% vs 61.4%, p = 0.02) and older (45.9 ± 11.5 vs 43.8 ± 11.4, p = 0.004). They presented more frequently with recurrent depression (64% vs 51.9%, p < 0.001), a history of suicide attempts (29.9% vs 19.6%, p < 0.001) and a comorbid somatic condition (35.4% vs 23.8%, p < 0.001), in particular obesity (9.1% vs 3.9%, p = 0.002). Duration of current episode and age at depression onset did not differ between the two groups. At baseline, comorbid patients exhibited a greater severity of depression (mean QIDS-C = 17.2 ± 3.4 vs 16.3 ± 3.3, p < 0.001 and CGI-Severity 4.9 ± 0.7 vs 4.8 ± 0.7, p = 0.027) and a poorer level of functioning (mean GAF = 52.0 ± 8.5 vs 54.6 ± 9.5, p < 0.001). Global QIDS improvement with treatment progression (−8.5 ± 4.9 and −8.5 ± 4.4) and the response rates at the second visit (50% improvement on the QIDS after approximately 7 weeks) were similar for both groups: 52.2% in anxious depression and 57% in pure depression, whereas remission rates (QIDS < 6) were significantly higher in pure depression (32.9% vs 26.5%, p = 0.03). The CGI-Improvement score was higher in anxious depression than in pure depression (2.5 ± 1.0 vs 2.4 ± 0.9, p = 0.02). GAF improvement also did not differ between the groups. When analysing the outcome of each QIDS-measured depressive symptom, all of the sub-scores had improved in both groups. Interestingly, the improvement in sleep disorder was higher with pure depression than with anxious depression (−1.2 ± 0.9 vs −1.1 ± 0.8, p = 0.01), whereas the decrease in suicidal ideation was higher with anxious depression than with pure depression (−0.6 ± 0.8 vs −0.5 ± 0.7, p = 0.02). Decrease in suicidal ideation was significantly correlated with CGI improvement (r = 0.40, p < 0.001).
Conclusions: In a sample of depressed patients comorbid with Generalized Anxiety Disorder, agomelatine produced a clinical improvement comparable with that observed in patients with pure depression. Interestingly, in comorbid patients, who were at higher risk of suicidal behaviour, the decrease in suicidal ideation was more pronounced.
Domestic Violence – the Hidden Epidemic: Implications for Mental Heatlh Care
K Hegarty
Department of General Practice, University of Melbourne, Melbourne, Australia
Background: Intimate partner violence and abuse is a common hidden problem for patients presenting for mental health care. It is as common as depression but has not received the same amount of attention in education, practice or policy. Women who experience intimate partner abuse are more likely to experience mental health diagnoses. It is a major cause of morbidity and mortality. In mental health settings it receives very little attention.
Objectives: This presentaiton will overview how to identify patients experienicng intimate partner violence and how to respond.
Methods: Utilising systematic literature reviews and World Health Organization guidelines for health practitioners, this presentation will discuss this major public health issue. In particular, it will describe how common it is in clinical practice, and the association between intimate partner abuse and mental health. The presentation will also answer the following: Should we be asking all women? How should we be asking women? Should we be asking men? How should we respond if women disclose? Who else should be involved in the care? How do we keep women and children safe? What evidence do we need in this under-researched area?
Findings: Women’s expectations and experiences of care will be highlighted. Women who have been abused show enormous strength and resilience on their varied pathways to recovery.
Conclusion: Health practitioners need to be alert to this underlying psychosocial issue. The hidden epidemic has to be addressed if we are to ensure children grow up in safe and non-violent households.
30 Years of Intergenerational Transmission of Trauma: Personal and Professional Reflections
G Halasz
School of Psychology and Psychiatry, Monash University, Melbourne, Australia
Background: The current concept of ‘psychological trauma’ is a cobbled and confusing construct. Controversies surround distinctions between ‘psychic’ versus ‘real’ trauma, ‘objective’ or ‘subjective’ criteria, and whether trauma in infancy, variously labelled ‘relational’, ‘developmental’ or ‘attachment’ trauma, has similar underlying physiological mechanisms as adult trauma.
Objectives: Based on a critical review of the current status of ‘relational trauma’ advanced by Schore (2012), whose book addresses the Conference theme – The Science of the Art of Psychotherapy, I will argue for the urgent need to reconsider psychiatric thinking and formulations for long-term psychiatric psychotherapy where patients and/or therapists experienced intergenerational trauma, like the ‘Stolen Generation’ or children of genocide (Holocaust) survivors, like myself.
Methods: The current DSM-5 (2013) criteria for trauma and stressor-related disorders coupled with advances in neuroscience and psychoanalysis make it imperative for clinicians to reformulate trauma treatment based on principles of ‘right-brain-to-right-brain’ re-regulation.
Findings: As evidence accumulates from developmental psychopathology, attachment research and the emerging field of behavioural epigenetics, contemporary trauma treatments are now becoming more ‘science-based’ than ‘art’.
Conclusions: As the complex biological mechanisms involved in traumatic experiences across the life-cycle, and trauma transmission across generations, accumulates further scientific evidence, psychiatry’s paradigm for trauma therapy is gradually shifting from art to science.
References
American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (5th ed). Washington, DC.
Schore AN (2012) The Science of the Art of Psychotherapy. New York: W W Norton.
The Prevalence and Correlates of Childhood Trauma in Patients With Early Psychosis
J Scott1,2, M Duhig1,2,3, L Hides4
1University of Queensland Centre for Clinical Research, Herston, Australia
2Metro North Mental Health, Herston, Australia
3Queensland Centre for Mental Health Research, Wacol, Australia
4School of Psychology and Counselling, Queensland University of Technology, Kelvin Grove, Australia
Background: Maltreatment in childhood has been shown to be more common in patients with psychotic disorders. Few studies have examined the effects of childhood trauma on patients with early psychosis.
Objectives: To describe the prevalence and demographic, clinical and functional correlates of childhood trauma in patients attending early psychosis clinics.
Methods: Participants were recruited from outpatients attending four early psychosis services in Queensland, Australia. Exposure to childhood trauma was assessed using the Childhood Trauma Questionnaire (CTQ). Psychopathology was measured using the Positive and Negative Syndrome Scale and the Depression, Anxiety and Stress Scale. Social and vocational functioning and substance use were also assessed.
Findings: Over three quarters of patients reported exposure to any childhood trauma. Emotional, physical and sexual abuse were reported by 54%, 21% and 19% of patients, respectively, while 57% and 28% of patients reported emotional and physical neglect. Female participants were significantly more likely to be exposed to emotional and sexual abuse. Exposure to childhood trauma was correlated with positive psychotic symptoms and higher levels of depressive, anxiety and stress symptoms; however, it had no impact on social or vocational functioning.
Conclusions: Exposure to childhood trauma was common in patients with early psychosis, and associated with higher levels of positive psychotic symptoms and psychological distress. Existing recommendations that standard clinical assessment of patients with early psychosis should include inquiry into exposure to childhood trauma are supported.
The Art and Science of Pharmacological Treatment for Obsessive-Compulsive Disorder (OCD)
V Brakoulias1,2,3
1University of Sydney, Sydney, Australia
2Nepean Hospital, Penrith, Australia
3Editor, Australasian Psychiatry
Background: Although the standard approach to treating obsessive-compulsive disorder (OCD) involved high-dose selective serotonin reuptake inhibitors (SSRIs), the treatment of patients with OCD can present many challenges.
Objectives: To present evidence-based pharmacological strategies to treat OCD, whilst discussing these from a clinical perspective.
Methods: A systematic literature review will be presented with an emphasis on the use of SSRIs, clomipramine and antipsychotic augmentation for the treatment of OCD.
Findings: Symptoms of OCD can be significantly reduced with the use of high-dose SSRIs over 8–12 weeks. Remission of symptoms is rare and OCD has a relapsing and remitting course in many patients. Clomipramine is an effective medication for the alleviation of OCD symptoms; however, it has considerable adverse effects and is not used as a first line agent. Antipsychotic augmentation of high-dose SSRIs can be effective in some patients. Antipsychotics are used off label and at low doses, but more studies are needed to determine whether particular doses or types of antipsychotic medication have advantages over others. The use of anticonvulsants and glutamatergic agents requires further evaluation. Patients with OCD have varying symptoms, levels of insight and co-occurring disorders, and these should be considered when treating patients with OCD.
Conclusions: OCD is treated effectively with high-dose SSRIs in most cases. Occasionally other strategies need to be trialled, but the evidence base for these strategies needs further development. Treatment plans need to be tailored to individual patients.
Meta-Analysis of the Association Between Suicidal Ideation and Later Suicide Among Patients With Either a Schizophrenia Spectrum Psychosis or a Mood Disorder
C Chapman1, K Mullin2, C Ryan3, A Kuffel4,O Nielssen5, M Large5
1Prince of Wales Hospital, Sydney, Australia
2Middlemore Hospital, Auckland, New Zealand
3University of Sydney, Sydney, Australia
4Spremberg Hospital, Spremberg, Germany
5University of New South Wales, Sydney, Australia
Background: Studies of patients with a mix of psychiatric diagnoses have suggested a modest or weak association between suicidal ideation and later suicide.
Objectives: This study examines whether association between expressed suicidal ideation and suicide varies with diagnosis.
Methods: A systematic meta-analysis of studies reporting association between suicidal ideation and suicide in ‘mood disorders’, or ‘schizophrenia spectrum psychosis’ patients.
Findings: Suicidal ideation was strongly associated with suicide among patients with schizophrenia spectrum psychosis (14 studies reporting on 567 suicides, OR = 6.49, 95% confidence interval (CI) 3.82–11.02). The association between suicidal ideation and suicide among patients with mood disorders (11 studies reporting on 860 suicides, OR = 1.49, 95% CI 0.92–2.42) was not significant. Diagnostic group made a significant contribution to between-study heterogeneity (Q-value = 16.2, df = 1, p < 0.001), indicating a significant difference in the strength of the associations between suicidal ideation and suicide between groups. Meta-regression and multiple meta-regression suggested that methodological issues in the primary research did not explain the findings. Suicidal ideation was weakly but significantly associated with suicide among studies of patients with mood disorders over periods of follow-up of <10 years.
Conclusions: Although our findings suggest that the association between suicidal ideation and later suicide is stronger in schizophrenia spectrum psychosis than in mood disorders, this result should be interpreted cautiously due to the high degree of between-study heterogeneity and because studies that used stronger methods of reporting had a weaker association between suicidal ideation and suicide.
Telepsychotherapy: A Discussion on the Role of Video-Conferencing Technology in Long-Term Therapy
P Golding
Private Practice, Melbourne, Australia
Background: Telepsychiatry has been a growing field that has offered much support and guidance to rural doctors and patients. Telepsychotherapy, or psychotherapy provided over videoconferencing technology, is now becoming more available and the implications require consideration.
Objectives: This oral presentation aims to open discussion on the role of telepsychotherapy through clinical cases and reflection on five years’ experience in this field.
Methods: Case review of several different patients with whom telepsychotherapy has been used, including the role and impact of this technology with each patient. A discussion of the perceived benefits, limitations and recommendations for practice in this field.
Findings: Patients’ need for telepsychotherapy comes in varied forms, as does their access to technology and Medicare support. Psychotherapy and its framework expands to include technological glitches and settings outside of the therapist’s immediate control. Barriers such as lost non-verbal communication are contrasted with changes in the range of emotional tone when patients are in their own environment.
Conclusions: Detailed briefing prior to undertaking telepsychotherapy should include an understanding of how the framework of psychotherapy both applies and is modified through the use of this technology. Telepsychotherapy offers improved access to therapy in a range of situations for long-term therapy patients. Psychotherapists should be considering it as an option, especially for rural patients, patients requiring continuity of care during a transitional phase and when patients’ attendance conflicts with other rehabilitation focuses.
Psychiatry and Film: ‘Medfest’ – the Medical Film Festival and its Impact on Attitudes and Recruitment to Psychiatry
K Ahmed1, D Bennett2, N Halder3, P Byrne4
1Liverpool Hospital, Sydney, Australia
2University of Aberdeen, Aberdeen, UK
3Manchester University, Manchester, UK
4Homerton University Hospital, London, UK
Background: There have been longstanding concerns over the proportion of medical graduates entering psychiatry as a profession (Brockington and Mumford, 2002). Negative perceptions of psychiatrists have been identified as a key discouraging factor for medical students (Lyons, 2013).
Objective: It was proposed that a national film festival organised by psychiatrists could improve attendees’ views toward psychiatry and psychiatrists and, for medical students, increase the number considering psychiatry as a career.
Methods: ‘Medfest’ held events at nine UK universities in 2011 and was marketed using emails, social networking sites, a website (www.medfest.co.uk) and posters. The programme consisted of short films (The Family Doctor, Shadowscan, Beards & Bow Ties) and panelist discussions. Data was gathered using an anonymous ‘before and after’ questionnaire.
Results: 450 attendees across all sites returned 377 feedback forms (84% response). Views of psychiatry and psychiatrists were significantly more likely to change for the better than for the worse towards both psychiatry (p < 0.001) and psychiatrists (p < 0.001). Post-event, 46% of the 232 medical students that attended were more likely to consider a career in psychiatry.
Conclusions: Since its inaugural run, Medfest has become an annual event, expanding year on year. In 2014, 31 events were held in the UK, Ireland, Latvia and Australia plus two music events and an art exhibition. The festival has received favourable reviews (e.g. in The Lancet; Holmes, 2011) and our poster has featured on the cover of the British Journal of Psychiatry. This talk will outline the inception and development of the festival, films screened and plans for the future.
References
Brockington I and Mumford D (2002) Recruitment into psychiatry. British Journal of Psychiatry 180: 307–312.
Holmes D (2011) Falling from their pedestal–doctors on film. The Lancet 377: 1825.
Lyons Z (2013) Attitudes of medical students toward psychiatry and psychiatry as a career: A systematic review. Academic Psychiatry 37: 150–157.
When Wounds From Infancy Collide. Parallel Parent and Child Therapy (P-PACT): A Dyadic Psychotherapy for Mothers and Their Children Aged 3–12 Years Caught in Intergenerational Cycles of Neglect and Abuse
J Amos1,2, G Furber2, L Segal2, C Cantor3
1Women’s and Children’s Health Network Child and Adolescent Mental Health Service, Adelaide, Australia
2Health Economics and Social Policy Group, School of Population Health, University of South Australia, Adelaide, Australia
3Department of Psychiatry, University of Queensland, Brisbane, Australia
Background: Treatment options are limited for mothers and children where the child has severe disturbances of emotion and behaviour, there is suspected or confirmed maltreatment by the mother, and the mother has an unresolved history of childhood maltreatment.
Objectives: Parallel Parent and Child Therapy (P-PACT) is dyadic psychotherapy for this population. The aim of this presentation is to describe how P-PACT works.
Methods: We synthesized findings from neurobiology, attachment theory, learning theory, trauma, ethology and evolutionary theory to construct a model of the mechanisms leading to and maintaining the intractable distress in these dyads. This model was used to predict key objectives for therapy, against which we mapped P-PACT.
Findings: The model hypothesizes that maltreatment arises from the mother’s need to avoid reactivation of distress related to her early trauma, by her infant’s need for deep emotional responsiveness. Maltreatment is maintained when mother and child adopt dominance and submission hierarchies instead of security and love to navigate their relationship, an adaptation that impairs self-development. Mapping revealed that P-PACT, in particular the novel use of a one-way screen, operates as an exposure and response prevention protocol, safely disrupting the dominance and submission hierarchies and supporting the emergence and integration of the implicitly encoded, unprocessed relational distress in both mother and child.
Conclusions: P-PACT interrupts intergenerational cycles of neglect and abuse, where trauma is relational, implicitly encoded, unavailable for conscious recall, and where self-development in mother and child is impaired.
Legally Coerced Breach of Confidentiality
EFC Stamp
Private Practice, Mt Evelyn, Australia
Background: Central to clinical practice is the assurance of confidentiality. This is hallowed by historical convention, fiduciary obligation and professional functioning and potentially enforced by the laws of malpractice. The State can demand breach of that confidentiality for purposes of accountability or legal process as part of “the Social Contract”. This presents an ethical dilemma for the psychiatrist, a practical problem for the patient and questions of reasonableness and proportionality for third parties seeking breach of confidentiality.
Objectives: To consider an agenda for my consideration of appropriate guidelines that provides equity to the competing participants.
Methods:
To review circumstances in which the dilemma occurs.
To weigh the competing arguments.
To postulate potential solutions.
Findings: The current situation is unnecessarily intrusive of patients’ confidentiality, destructive of clinical practice and lacks professional discrimination. It is open to abuse by expediency and consequent injury to patients.
Conclusions: There is a case for a multi-professional dialogue to develop processes that ensure the competing demands can be addressed in a way that the profession can “do no harm to anyone”.
Validity of the Audio Recorded Cognitive Screen (ARCS) in the Assessment of Individuals Undergoing Electroconvulsive Therapy (ECT)
A Weiss1, P Schofield2, N Brown3, R Wainwright3, S Hansen1, C Newton3
1Calvary Mater Hospital, Waratah, Australia
2Neuropsychiatry Service, Calvary Mater Hospital, Waratah, Australia
3Lakeside Clinic, Warner’s Bay Private Hospital, Warner’s Bay, Australia
Background: Electroconvulsive therapy (ECT) is a treatment for severe depression that can cause side effects including cognitive problems. The measurement of cognition during the course of ECT can be helpful in detecting unwanted side effects. A comprehensive cognitive assessment is time consuming. Audio Recorded Cognitive Screen (ARCS) is a cognitive assessment instrument that is administered without a clinician. It has been well validated in other conditions such as multiple sclerosis and psychosis. A formal validation study is required before it can be widely recommended as an instrument for tracking cognitive changes during ECT. Confounding factors include apathy and depression.
Objectives: To validate the ARCS by comparing it with another well-validated cognitive assessment measure, the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Correlations between corresponding tests in the ARCS and RBANS will range from 0.4–0.7. Measures of apathy and depression will not significantly alter the association between ARCS and RBANS scores.
Methods: Participants older than 18 who were undergoing ECT and consented to the study were allocated to four testing sessions, two before treatment commenced and two after treatment 6. They were randomly allocated to commence with ARCS first then RBANS, with the reverse order at the next testing session. Apathy Scale and Profile of Mood States Short form (POMSSF) measured apathy and depression on both occasions.
Findings: Correlations between corresponding tests showed no difference without any significant change when controlled for apathy and depression.
Conclusions: The ARCS is a useful test to consider when assessing cognitive impairment during ECT.
Misson Accomplished
FTH Que
Berends-Que-Performance and QI Performance Management, Arnhem, The Netherlands
Background: Psychiatrists are medical specialists and well trained in a problem-solving approach: diagnosis, treatment plan, treatment, evaluation and so on. Most of us work in a changing environment, which makes changes in the organization necessary. For these changes the cooperation of others is needed. When we encounter problems we often do something similar to the process described above. And unfortunately this often does not work well: mission not accomplished.
In this workshop I will present a solution-focused method, in which the drivers for change are: personal mission and vision and the process of finding the mutual ground for the necessary change. This process involves finding a collective ambition (= overlaps in personal missions + a shared vision) and finding shared goals and a shared strategy. I will show that the dual process model (preconscious processing which results in biases) and an MBCT model (awareness and consciousness) are useful instruments for facilitating this process.
Objectives:
The participant:
Knows what her/his personal mission and what her/his vision is;
Is more aware of her/his biases (attentional, in cognitions, in behaviour);
Is capable of using the solution-focused model for organizational change: mission accomplished!
Methods: Homework before the session.
An interactive oral presentation, which is combined with moments of reflection and with moments where participants work together on a case of one of the participants.
If needed, agreement to work on a case after the workshop.
Measuring the Quality Use of Antipsychotic Medicines in Acute Mental Healthcare
A Bennett1, K Kerr1, R McKay2,3, N O’Connor4,5, G Carter6,7
1NSW Therapeutic Advisory Group, Sydney, Australia
2South Western Sydney Local Health District, Sydney, Australia
3University of New South Wales, Sydney, Australia
4Northern Sydney Local Health District, Sydney, Australia
5University of Sydney, Sydney, Australia
6Calvary Mater Hospital, Newcastle, Australia
7University of Newcastle, Newcastle, Australia
Background: Gaps in the safe and evidence-based use of antipsychotics can increase risk of patient harm. Measurement enables hospitals to quantify these gaps and implement quality improvement strategies.
Objectives: To identify gaps in the quality use of antipsychotics in patients receiving acute mental healthcare.
Methods: A cross-sectional multi-site study design with retrospective data extraction from inpatient case notes and discharge summaries using indicators and standardised data collection tools was undertaken. Australian hospitals caring for acute mental healthcare patients were invited to participate in field-testing two indicators measuring appropriate metabolic monitoring of antipsychotics and antipsychotic polypharmacy. Sites provided collated results and completed a questionnaire regarding indicator usefulness and measurability.
Findings: Four hospitals in two states tested ‘Percentage of patients taking antipsychotic medications who receive appropriate monitoring for the development of metabolic side effects’ (n = 16–44). Results ranged from 0–12.5%. Ten hospitals in four states tested ‘Percentage of patients prescribed two or more regular antipsychotic medications at hospital discharge’ (n = 11–187). Results ranged from 9–31%. Poor documentation and the need to access multiple data sources were barriers to data collection. Hospitals found the indicators useful, measurable and valid with the potential for guiding quality improvement projects and intra- and inter-hospital comparisons.
Conclusions: Gaps in the quality use of antipsychotics were identified. There is keen interest in the use of these indicators. Barriers should be addressed to enable regular and routine indicator measurement to promote improvement in quality use of antipsychotics and assist hospitals to demonstrate their performance against national safety and quality standards.
The Policy and Evidence Informing Queensland’s Mental Health Bill 2014
W Kingswell
Queensland Department of Health, Brisbane, Australia
Background: The Queensland Mental Health Act 2000 is inconsistent with contemporary thought on human rights and the United Nations (2006) Convention on the Rights of Persons with Disabilities.
Objectives: The Mental Health Bill 2014 (MHB) will improve and maintain the health and wellbeing of persons with a mental illness without capacity to consent to treatment or care. When appropriate the MHB will enable patients to be diverted from the criminal justice system to health care at any point in the process and provide necessary mental health care.
By improving the criteria necessary for a person to be placed on a treatment authority and focusing on a person’s lack of capacity to consent to treatment, the MHB strengthens patient rights. The MHB will emphasize assisted decision making for those with impaired capacity. The MHB will direct that when a person’s health care needs can be met by another assisted decision-making tool such as an advance health directive, then that must occur.
Methods: A patient with impaired capacity will be able to nominate a ‘Nominated Support Person’ to be given patient notices, discuss confidential patient information, and support the patient or represent the patient at hearings of the Mental Health Review Tribunal. The MHB establishes a requirement for legal representation to be provided in certain matters before the tribunal and requires services to provide ‘Independent Patient Rights Advisors’ and make them available to all involuntary patients in inpatient services.
The Bill requires authorised doctors to involve family, carers and other support persons in decisions about the patient’s treatment and care, subject to patient’s right to privacy.
Findings and conclusions: The Bill safeguards the person’s rights and promotes recovery of a person with mental illness, and their ability to live in the community, without the need for involuntary treatment or care.
The Mindspot Cinic: An Accessible and Effective Online Treatment for Anxiety and Depression
O Nielssen1,2, B Dear1, N Titov1
1MindSpot Clinic, Macquarie University, Sydney, Australia
2University of New South Wales, Sydney, Australia
Objectives: A large proportion of people who meet diagnostic criteria for anxiety disorders and depression receive no treatment. The main objective of the present study was to assess the clinical impact of freely available online psychological treatments for anxiety and depression by measuring the outcomes of people who used an online national mental health clinic in Australia over a one-year period.
Design: A prospective uncontrolled trial of all people who began assessments at the MindSpot Clinic and who provided consent for data to be analysed and reported. The primary outcome measures were the Kessler Psychological Distress Scale (K-10), the Patient Health Questionnaire 9-Item (PHQ-9) and the Generalized Anxiety Disorder 7-Item (GAD-7).
Setting: A national online mental health service providing assessment and treatment to adults across Australia.
Participants: 10,294 people commenced an assessment in the 2013 calendar year. Of the 7173 eligible for analysis, 2134/7173 (29.8%) enrolled in treatment. All adult Australian residents were eligible, unless acutely suicidal or already engaged in regular psychotherapy for treatment of anxiety or depression. The service was provided at no cost to participants.
Interventions: Based on principal symptom, participants were invited to complete one of four psychological treatment courses that had been previously evaluated in randomised controlled trials. All treatment courses are based on principles of cognitive behavioural and interpersonal therapy, and comprise 4–6 lessons completed over 8 weeks of treatment. Participants receive weekly support from a therapist via telephone or secure email. The primary endpoint was 8 weeks after the start of treatment (post-treatment), and the secondary endpoint was 3 months after completing treatment (follow-up).
Findings: Of 7173 eligible participants, 2134 enrolled in a course and 1630 (76.4%) completed one of the four courses. A third (35.3%) reported that they had never previously sought treatment. Mixed-models analyses from assessment to post-treatment revealed a significant main effect for Time on the PHQ-9 (F2,2944 = 147.72, p < .001), and GAD-7 (F2,2946.08 = 127.13, p < .001). Large uncontrolled effect sizes from assessment to follow-up (Cohen’s d range = 1.36–1.66, CI = 1.09–2.07) were found for three of the treatment courses, consistent with the results of controlled clinical trials, and a moderate uncontrolled effect size was found for the remaining course (d range = 0.67–0.72, CI = 0.08–1.29). Therapists spent on average 111.77 minutes (SD 61.56) with each person over the duration of treatment. At follow-up, rates of reliable recovery were 49.5% on the PHQ-9 and 46.7% on the GAD-7, compared with rates of reliable deterioration of 2.0% and 3.8% on the PHQ-9 and GAD-7, respectively.
Conclusions: The results of this study indicate that an online mental health service treating large numbers of unselected patients produced outcomes comparable with the results of clinical trials. These interventions were accessed by a large cross-section of the population, many of whom were not otherwise accessing treatment. The results demonstrate the feasibility and effectiveness of providing low-cost online treatment to large numbers of people with potentially disabling anxiety and depression.
The Effect of the Increase in ‘Alcopops’ Tax on Presentations to Emergency Departments for Psychological and Physical Alcohol-Related Harms in Young Queenslanders
S Kisely1, D Lawrence2
1University of Queensland, Brisbane, Australia
2University of Western Australia, Perth, Australia
Background: Raising duty on alcohol across the board can reduce morbidity and mortality from alcohol use. However, the effectiveness is less certain for measures that target specific types of alcohol beverage in isolation. One Australian example was the increase in alcopops favoured by young people, to curb risky drinking in this demographic.
Objectives: To measure alcohol-related health harms presenting to emergency departments (EDs) in Queensland following the tax increase.
Methods: We compared 15–29 year olds presenting to EDs for alcohol-related harms with the following ED controls: (1) 15–29 year olds with asthma or appendicitis; and (2) 30–49 year olds with alcohol-related harms. We analysed data over a 5-year period (April 2005–April 2010) using a time series analysis. This covered three years before, and two years after, the tax increase. We investigated both mental and behavioural consequences (F10 codes), and intentional/unintentional injuries (S and T codes).
Findings: We fitted an ARIMA (auto-regressive integrated moving average) model to test for a change following the increased ‘alcopops’ tax in April 2008. There was no significant decrease in alcohol-related ED presentations in 15–29 year olds compared to any of the controls. We found similar results for males and females, narrow and broad definitions of alcohol-related harms, under-19s, and ED presentations at night-time and weekends.
Conclusions: The increase in tax on ‘alcopops’ did not result in any reduction in alcohol-related harms in this population. Targeting particular alcoholic drinks may therefore not be as effective as more comprehensive policies such as minimum unit pricing for alcohol.
Amphetamine Intoxication and Withdrawal Management Guidelines for Acute Hospital Settings
KS Loke1, D Castle2, M Lloyd-Jones2, P Bosanac2, J Karro2, N Fraser2
1Nexus Dual Diagnosis Service, Melbourne, Australia
2St Vincent’s Hospital, Melbourne, Australia
Background: Amphetamine intoxication is becoming an increasingly prevalent problem in emergency departments and psychiatric inpatient units in Victoria. Some of these presentations are associated with acute arousal with agitation and aggression, which pose a risk to treating staff as well as the patients themselves.
Objectives: To provide a quick reference guide for medical and nursing staff who need to manage acute arousal, withdrawal and post-acute/chronic presentations related to amphetamine-type stimulants in acute hospital settings.
Methods: A literature search was conducted on various protocols to manage acute presentations of amphetamine intoxication in acute medical settings. Medical and nursing colleagues in Emergency medicine/Toxicology, Addiction Medicine and Psychiatry were consulted. The existing generic acute arousal protocol for the acute inpatient service was reviewed.
Findings: Various acute medical problems that can be caused by stimulants require screening. Behavioural and psychopharmacological strategies can be used to manage and prevent escalation of acute arousal. Stage-matched strategies to deal with amphetamine use disorders can be implemented in the post-acute phase.
Conclusions: An abbreviated protocol for managing the acute and post-acute phases of amphetamine intoxication and withdrawal was designed for use in psychiatric inpatient units and emergency departments.
Why Do Queensland Psychiatric Patients Have Higher Cancer Mortality Rates When Cancer Incidence is the Same as for the General Population?
S Kisely1,2,3, S Forsyth1, D Lawrence4
1University of Queensland, Brisbane, Australia
2Metro South Health Service, Woolloongabba, Australia
3Griffith Institute of Health, Griffith University, Brisbane, Australia
4University of Western Australia, Perth, Australia
Objectives: Psychiatric patients in Queensland have the highest reported rates of mortality from physical illness in Australia when compared with the general population. They also have higher rates of avoidable admissions for cardio-metabolic disorders. There is no information on cancer incidence or mortality even though people with mental illness may have lifestyle factors associated with increased cancer risk.
Method: A population-based record-linkage analysis to compare cancer incidence and mortality in psychiatric patients with that for the general Queensland population, using a historical cohort to calculate age and sex-standardised rate ratios (RRs) and hazard ratios (HRs). Mental health records were linked with cancer registrations and death records from 2002.
Results: There were 97,692 new cancer cases, of which 3349 occurred in people with mental illness. 1560 cases died. Mortality was elevated for people who had ever been psychiatric outpatients (HR = 1.67; 95% CI = 1.48–1.89) or inpatients (HR = 2.53; 95% CI = 2.26–2.84). By contrast, cancer incidence was the same as for the general population for most psychiatric disorders. Incidence rates were actually lower for dementia (HR = 0.79; 95% CI = 0.69–0.90) and schizophrenia (HR = 0.85; 95% CI = 0.72–0.99).
Conclusions: Lifestyle, such as alcohol or tobacco use, would not explain our findings that people with mental illness are no more likely than the general population to develop cancer but more likely to die of it. Other factors may be the difficulty in differentiating medically explained and unexplained symptoms, greater case fatality, or inequity in access to specialist procedures. The study highlights the need for improved cancer screening, detection and intervention in this population.
Looking Back: Towards the Future of Psychiatry
J Jamaludin
Psychiatry Registrar, Royal Australian and New Zealand College of Psychiatrists
Background: Since the advent of the discipline in the early 18th century, the construct of Psychiatry has experienced many waves of restructuring. Each passing century brought about radicalisation in the understanding of mental illness and its treatment. Within its history, progression and digression occurred in turn, optimism and pessimism waxed and waned, and humanity triumphed and lost. Not dissimilar to today, such were the ways in which time, alongside external forces of funding, prestige, stigma, politics, technology and social hierarchy, coloured the history and survival of Psychiatry.
Conclusions: This article highlights the journey of Psychiatry as a branch of medicine and its survival through shifting eras, and the way in which, with the introduction of the Recovery Model of care, it may have come full circle.
Australia’s Deadliest Town
J Pettigrew
Katherine Mental Health Service, Katherine, Australia
Background: A McCrindle Research Summary in 2014 on deaths and funerals in Australia identified Katherine as having the highest death rate of any town in Australia.
Objectives: Determine the causes of this statistic and the impact on the community.
Methods: Research of demographics and statistics as well as interviews with residents affected personally and professionally.
Findings: The contributors to a death rate of 13.6 per thousand are varied and complex. The Northern Territory overall has the highest rate of fatal pedestrian accidents, smoking, alcohol consumption, drowning and suicide compared to other states. Katherine, with a young population, has double the death rate of Darwin. Local fatalities come from murder, manslaughter, motor vehicle accidents, other accidents such as crocodile attacks and falls, drowning and disease. Personal experience can distort perception. The Cancer Council undertook a survey due to a perception that there was an abnormally high incidence of cancer in the region. They did not find statistics to support that. However, the logistics related to treatment of severe trauma and cancer may mean treatment is delayed or prematurely abandoned.
Conclusions: Most Katherine residents will have attended several funerals in the past year and for some with strong community connections it can be as many as six in 12 months. Although the effect of multiple bereavements and repeated trauma has an adverse impact on mental health, at the same time there is community cohesion and support.
Perceptions of Pregnant Women Regarding Antidepressant and Anxiolytic Drugs in Pregnancy
G Bruxner1,2, J De Laat2, J Dulhunty2,3, A Kothari2,3
1Caboolture Hospital, Brisbane, Australia
2Redcliffe Hospital, Brisbane, Australia
3University of Queensland, Brisbane, Australia
Background: It is estimated that 18% of Australian women may experience an anxiety disorder and 5% a major depressive episode in their life. The decision to continue or cease antidepressant and anxiolytic medications during pregnancy can be complex. The risks of ceasing medications have to be weighed against potential risks to the baby with continuing.
Objectives: The aim of this study was to explore attitudes toward antidepressant and anxiolytic use and associated decision-making by pregnant women.
Methods: We conducted an observational study at an outer metropolitan hospital in Brisbane, Queensland. Pregnant women presenting for their first antenatal clinic visit were invited to complete an electronic questionnaire. Participants were asked about current or previous antidepressant and anxiolytic medication use, influences on drug decision-making and the adequacy of information received. Perceptions were measured on a 7-point Likert scale.
Findings: 503 pregnant women were surveyed. The background prevalence of anxiety and depression was 30.0%, with 9.3% of respondents currently using antidepressant or anxiolytic medications. 66.0% ceased these medications during or while trying to become pregnant, most commonly due to potential side effects to the baby, health professional advice and symptomatology that was under control. Decision-making was most strongly influenced by general practitioners, family and the internet. Only 55.3% of women were completely satisfied with the information provided.
Conclusions: Our results suggest perceived deficits in the adequacy and reliability of information available to pregnant women in psychotropic drug decision-making. A better understanding of these factors involved in decision-making will assist health professionals to support pregnant women to make informed decisions most conducive to the health of the patient and her child.
Depression and Function – Insights From Naturalistic Studies Using Agomelatine
P Llorca1, D Gourion2, Presenter: N Glozier3,4
1Centre Hospitalier Universitaire Clermont-Ferrand, France
2Private Practice, Paris, France
3Sydney Medical School, The University of Sydney, Sydney, Australia
4Brain and Mind Research Institute, Camperdown, Australia
Background: Anhedonia, defined as reduction or loss of interest and pleasure, is a core symptom of major depressive disorder (MDD). Moreover, anhedonia is linked to the neural processes of motivation, anticipation, reward, and decision-making.
Objectives: The HEDONIE study aimed to explore the patterns and course of anhedonia in MDD patients treated with agomelatine, using a specific scale (SHAPS: Snaith-Hamilton Pleasure Scale).
Methods: 1513 outpatients treated with agomelatine were included in a non-interventional study and followed up over 10–12 weeks by 297 French psychiatrists with a private practice. Assessments were carried out at inclusion (C1), 6 weeks (C2), and at 10–12 weeks (C3) using the Quick Inventory Depression Symptomatology-self rating (QIDS-SR), the Montgomery-Åsberg Depression Rating Scale (MADRS), the SHAPS, the Clinical Global Impression (CGI), and the Sheehan Disability Scale (SDS).
Findings: The mean baseline score was -17.5 ± 4.2 on the QIDS-SR and 32.7 ± 7.1 on the MADRS. The mean SHAPS score was 9.8 ± 3.6 and 86.8% of the patients had a SHAPS score above 5, which can be considered as a severe anhedonia. Patients with a SHAPS score above 5 had a score on the QIDS-SR of 17.9 ± 4.0. The QIDS-SR score was 14.8 ± 4.7 for patients with a SHAPS score < 5. The SDS total score was 22.2 ± 4.6.
At the last visit (after approximately 10 weeks), reductions were observed in the QIDS score (-11.1 ± 5.6, p < 0.0001) and the MADRS score (-21.3 ± 9.3, p < 0.0001). Response rates (50% improvement on the scale) were 74.4% [-72.1%; -76.6%] and 77.5% [75.3%; 79.6%] on the QIDS and MADRS, respectively. 48.2% [45.6%; 50.7%] of patients were in remission (QIDS-SR <6) and 51.9% [49.3%; 54.5%] had a MADRS score ⩽ 10. When analysing the outcome of each QIDS-measured depressive symptom, all of the sub-scores had significantly improved. The greatest decreases were seen in the items mood and involvement in activities.
The SHAPS score was significantly reduced (-7.0 ± 4.6, p < 0.0001). The SHAPS remission rates (SHAPS score ⩽3 and SHAPS score ⩽ 2) were, respectively, 68% [65.6%; 70.4%] and 58.3% [55.8%; 60.8%]. Improvement on the SDS was significant (p < 0.0001) in the three dimensions (reductions in the items work/school: -4.1 ± 2.7, family life: -4.3 ± 2.8, and social life: -4.3 ± 2.7). And even more important reductions in the three SDS items were observed in patients with a baseline SHAPS score above 5. The correlation between improvement of anhedonia and improvement of functioning (SDS) was strong (r = 0.642; p < 0.0001).
Conclusions: The prevalence of anhedonia is high in MDD patients. Anhedonia is associated with the severity of depression and functional impairments. Agomelatine effectively improved mood, anhedonia and functioning. The improvement of anhedonia was robustly correlated with improvement in functioning.
Margaret Tobin Oration: We’Ve Got to Stop Doing This – Simple Tricks to Keep Us on the Slow Road to Recovery
J Allan1,2
1Mental Health Alcohol and other Drugs Branch, Queensland Health Brisbane, Australia
2University of Queensland, Brisbane, Australia
One of the things about being the boss is that besides doing the occasional bit of good is that you get involved in lots of bad things. We say that our aim is to make things better. Sometimes we can make a change; mostly we don’t respond to the obvious and we stick to our old ways even when they have been shown to be unhelpful or even harmful. The condemnation of psychiatry is littered with things we continue to do despite knowing better e.g. seclusion and restraint, bad therapies, self aggrandizement, failing to see the person dying in front of you, misuse of medications or failure to use the right ones. We blame the system for things that should be under our control. Our failure to come to grips with the system and our place in it is probably the thing that drives most people out of public psychiatry. We can appear to be ambivalent about applying the evidence to the situation in front of us. What’s so hard about listening to consumers and their families; what’s so hard about practicing what we preach? How do we have influence where it matters? Why do we act like recovery is not something that we care about? There are polices and tactics that work, based on our core skills as psychiatrists, like understanding, empathy and the correctly timed intervention. This talk is about how to make policy and governance work for you for clinical outcomes. It is about targeting your efforts plus overcoming inertia and fears, using your skills to be a leader. It draws on experiences from Ward 10B, locked wards, smoking reduction, seclusion and restraint, Aboriginal and Torres Strait islander mental health, and dealing with governments amongst many things. It draws on art and science for one story of recovery in psychiatry.
Senior Research Award: Investigating the Complex Relationships Between Physical and Psychiatric Disorder – Why it Matters to People With Mental Illness
S Kisely
School of Medicine, University of Queensland
Mortality is 70 per cent higher in people who have treatment for any psychological disorder. Chronic physical disorders such as cardiovascular disease and cancer are the main cause, the risk being 10 times that of suicide yet receiving far less attention. Lifestyle, such as alcohol or tobacco use, side-effects of psychotropic medication and reduced access to general medical care have all been suggested as explanation of increased mortality in this group. However, lifestyle would not explain the finding that for some cancers incidence is no higher than that of the general population while the corresponding mortality rates are. Other factors may be the difficulty in differentiating medically explained and unexplained, greater case fatality, or inequity in access to specialist procedures. In spite of their increased mortality, psychiatric patients' chance of receiving specialist procedures such as cardiac surgery are up to half that of the general population.
Film Presentation
The Inheritance
J MacDonald (Director), P Ellis (Discussant)1
1University of Otago, Wellington, New Zealand
This film, “An intimate story of a courageous family ultimately strengthened despite a dehumanising hereditary disease that takes no prisoners”, is being shown by permission of the filmmakers and family at the centre of the story. It was very favourably received at the Wellington International Film Festival: “Truly one of the most moving and inspirational stories I have ever witnessed on the big screen.” Cathy Stephenson – DomPost
After the showing there will be an opportunity for reflection and discussion.
“Discovering that I have not escaped the family inheritance (a hereditary neurodegenerative disease), I set out on a journey to honour my mother and find hope for my child.
I uncover the horrors of dying from Huntington’s disease and discover stories of those who have killed themselves as first symptoms appear, not wanting to deteriorate as they have seen parents or siblings do. We witness the everyday heroism of people facing up to this disease. We meet foremost scientists racing to find a cure, historians and prominent personalities from the Huntington’s Disease Global Community.
I discover a profound tale of unconditional love as I visit my Mum who fights silently every day with my Dad by her side.
I struggle to face up to the reality of such an inevitable demise for so many of my family and the harrowing possibility that my son might have inherited it. But as my family strains under this impossible pressure we find that we are even stronger than we thought.” – Bridget Lyon, Editor
Poster Presentations
Prevalence of Depression, Anxiety and Burnout in Graduate Entry Medical Students and its Relationship to the Academic Year
M Baigent, C Abi-Abdallah, R Achal
Flinders University Medical School, Adelaide, Australia
Background: Numerous studies over the past decade have shown that medical students are more susceptible to depression, anxiety and burnout when compared to age-matched non-medical students in the general population. Identifying the multifactorial causes provides medical schools options to integrate wellbeing programs to provide students with tools to cope with the stresses of medicine.
Objectives: To identify if trends exist within the academic year when students are most vulnerable to feelings of depression, anxiety and burnout.
Methods: Over two years, the same questionnaires were sent to postgraduate students from years I to IV over various time points in the academic year. The students were asked to anonymously answer the Kessler Psychological Distress Scale (K 10), the Perceived Stress Scale (PSS), Maslach Burnout Inventory (MBI) and the Neff Self Compassion Scale. Approximately 20% of each year level provided responses to the surveys.
Findings: Early on in the year, feelings of burnout are low, with an upward trend towards the end of the year. Feelings of depression and anxiety are consistently high across year levels and throughout the academic year. There was also a high percentage of students who had poor self-compassion, which was again consistent throughout the academic year.
Conclusions: These findings suggest that well-being interventions should be introduced early in the medical course, to provide students with coping mechanisms at the start of their training. This will allow them to build on these skills, openly discuss any issues they may have, as well as diminish the stigma regarding mental illness and medicine.
Prevalance of Child Psychiatric Illness in an Outpatient Clinic in a Tertiary Care Centre in Pakistan
M Qadeer, A Ali, B Saad
Liaquat National Hospital and Medical College, Karachi, Pakistan
Background: A nationwide study on the prevalence of child psychiatric illness is not known in Pakistan. The prevalence of child psychiatric disorders was estimated among the population aged 16 years and below based on gender, presenting complaints, family structure, school problems, comorbidities, presence or absence of depression and severity of disease based on the type of treatment prescribed.
Objectives: To present data from a general paediatric psychiatry clinic, including presenting symptoms, the relationship between symptoms and diagnoses, and prevalence of child psychiatric illnesses in Pakistan.
Method: This retrospective chart review was conducted at the Child Psychiatry clinic in Liaquat National Hospital and Medical College, Karachi, Pakistan. 274 child psychiatry cases, who were seen between 2012 and 2014, were reviewed, among which 239 cases were analysable. A maximum of two diagnoses was assigned to each case according to the standard guidelines in the DSM-IV.
Findings: Psychiatric disorders were more frequently seen in boys (61.50%) as compared to girls (38.49%). The five most common psychiatric disorders that were seen in children in Pakistan, according to their decreasing order of frequency, are attention deficit and disruptive behaviour disorders (18.82%), learning disorders (16.31%), adjustment disorders (12.97%), mood disorders (10.46%) and communication disorders (9.20%). The graph below shows the abovementioned common psychiatric disorders that were seen in an outpatient child psychiatry clinic in Liaquat National Hospital and Medical College, Karachi, Pakistan.
Conclusions: The result of our study shows that the pattern of child mental health in Pakistan is similar to that of western countries, with attention deficit and disruptive behaviour disorders being the most common. Early detection and treatment can help in reducing the health care burden, as earlier interventions in psychiatric disorders often portend a better prognosis.
Teaching Medical Students Clinical History Taking Content: A Systematic Review
H Alyami1, B Su’a2, F Sundram3, M Alyami4, MP Lyndon5, TC Yu6, MA Henning6, AG Hill2
1Centre of Health Systems Innovation and Improvement (Ko Awatea) and Auckland Regional Psychiatric Training Programme, Auckland, New Zealand
2South Auckland Clinical School, University of Auckland, Auckland, New Zealand
3Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
4Department of Psychology, Massey University, Auckland, New Zealand
5Ko Awatea – Counties Manukau District Health Board, Auckland, New Zealand
6Centre of Medical and Health Sciences Education, University of Auckland, Auckland, New Zealand
Context: Clinical history taking content and communication skills are the cornerstones of the medical interview. While there is a great awareness of how communication skills should be taught, history taking content teaching methods remain unclear.
Objectives: To identify educational interventions that improved the teaching of history taking content and their impact on academic performance.
Methods: Using four databases, a literature search covered the period between 1980 and 2014. Trials focusing on improving medical student history taking content, rather than communication skills, were included. Studies were critically appraised using a standard abstraction summary sheet.
Results: Four randomised controlled trials and two quasi-experimental studies were included. All interventions were additional to traditional teaching methods amongst medical students from years 1 to 4 of medical programmes. Two studies investigated the use of online video demonstrations while two other studies examined the use of computer and mannequin-based human patient simulations. One study investigated the use of a virtual clinic platform while the last study used a written structured history taking pro forma. Outcome measures included: Objective Structured Clinical Examination (OSCE), Standardised Patient Encounters, written tests and case histories. Overall, five of the six studies showed a positive impact on medical student performance.
Conclusions: Although there are only a limited number of heterogeneous studies exploring how history taking content is taught to medical students, the majority of these showed a positive impact on student performance in objective assessments. The majority of these educational interventions utilised e-learning methods. More rigorous research on innovative educational interventions targeting history taking content is needed.
A Guide to the Management of Minors Presenting out of Hours to the Emergency Department With Mental Health Difficulties
KM Beckmann1,2, Graphics by Z. Hume
1School of Medicine, Griffith University, Logan Campus, Logan, Australia
2Child and Youth Mental Health Services Logan, Academic Clinical Unit Logan, Metro South HHS, Logan, Australia
Background: Assessing and managing mental health issues in minors in the emergency department (ED) can be different from the management of adults. This may cause confusion to staff in an ED.
Objectives: This poster gives an overview of some of the Commonwealth-based legal concepts which apply to minors, with reference to basic medical standards such as good medical practice. The aim is to give personnel working in ED out-of-hours templates of how to clarify and streamline reflection on client management and reduce potential confusion about the diverse legal frameworks that pertain to mental health care of minors.
Methods: The author draws on his experience from when on call for ED at the local hospital.
Findings: Practice points are emphasised that apply to the management of minors, whichever jurisdiction.
Conclusions: In addition to a standard mental health assessment, a mental health clinician assessing a child out of hours may wish to consider custody and guardianship, competency of the minor, and take developmental stage and child safety issues of the minor into consideration. With respect to management, the clinician may wish to consider which route of disposition from the ED is best. It is unlikely that only one single option or one single legal framework only will need to be considered. Likely several agencies and legal frameworks will need to be drawn upon. This poster raises awareness of the main options and gives a template to assist with assessment and management of the child or adolescent presenting with mental health concerns out of hours to the ED.
Shame and Guilt
K M Beckmann1,2
1School of Medicine, Griffith University, Logan Campus, Logan, Australia
2Member, Queensland Philosophy History Ethics and Psychiatry Specialist Interest Group
Background: Shame and guilt are archaic concepts that already occupied thinkers in antiquity.
Objectives: Provide an overview on the concepts of shame and guilt over the centuries.
Methods: Review shame and guilt in a philosophy, history, ethics and psychiatry context.
Findings: A narrative is presented, starting in antiquity and ending in present time, that shame and guilt are quintessential concepts that have been subject to contemplation through the ages. These concepts continue to play a salient role in recent and contemporary psychiatry.
Conclusions: Shame and guilt are concepts that preoccupied science and art over the millennia and continue as useful concepts to the present day.
Development of Indicators for the Quality Use of Medicines in Acute Mental Healthcare
A Bennett1, K Kerr1, R McKay2,3, B O’Connor4,5, G Carter6,7
1NSW Therapeutic Advisory Group, Sydney, Australia
2South Western Sydney Local Health District, Sydney, Australia
3University of New South Wales, Sydney, Australia
4Northern Sydney Local Health District, Sydney, Australia
5University of Sydney, Sydney, Australia
6Calvary Mater Hospital, Newcastle, Australia
7University of Newcastle, Newcastle, Australia
Background: There are well-recognised gaps in the quality use of medicines (QUM) in mental healthcare, with potential to impact morbidity and mortality. QUM measurement enables hospitals to quantify these gaps and implement quality improvement strategies.
Objective: To develop indicators to measure QUM in acute mental healthcare and tools to facilitate their use.
Methods: A literature search and consultation process identified existing Australian and international indicators relating to medicines use in mental healthcare. A multidisciplinary Expert Advisory Group (EAG) reviewed indicators for their applicability to Australian practice. Alternative indicators were discussed. Sixteen indicators addressed significant QUM gaps in Australian settings. Five were selected for field-testing: prescription of ‘when required’ psychotropics; lithium monitoring; provision of verbal and written information on newly initiated regular psychotropic medications; metabolic monitoring of antipsychotics; and antipsychotic polypharmacy. Data collection tools assisted measurement standardisation. Sites provided collated results and completed a feedback questionnaire for each indicator.
Findings: Each indicator was piloted in a minimum of four hospitals across three states. Results and feedback were reviewed by the EAG; all indicators were found to be valid, useful, measurable and relevant. Data collection tools identified key components of each indicator to assist quality improvement initiatives. Five indicators and data collection tools were finalised.
Conclusions: Five new indicators and data collection tools for measurement of QUM in acute mental healthcare have been made freely available to Australian hospitals. Indicator measurement will promote improvement in the QUM in acute mental healthcare and assist organisations demonstrate their performance against national safety and quality standards.
Serotonergic Modulation of Default Mode Network Functional Connectivity With Superior Premotor and Somatosensory Cortical Areas in Children and Adolescents With ADHD and Healthy Controls
CS Biskup1,2,3+, K Helmbold1,2+, D Baurmann1,2,3, M Klasen4, B Herpertz-Dahlmann1,2, TJ Gaber1,2, S Bubenzer1,2,3, GR Fink3,5, FD Zepf1,6,7
1Clinic for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, RWTH Aachen University, Aachen, Germany
2JARA Translational Brain Medicine, Aachen and Jülich, Germany
3Institute for Neuroscience and Medicine, Jülich Research Centre, Jülich, Germany
4Clinic for Psychiatry, Psychosomatics and Psychotherapy, RWTH Aachen University, Aachen, Germany
5Department of Neurology, University of Cologne, Cologne, Germany
6Department of Child and Adolescent Psychiatry, University of Western Australia, Perth, Australia
7Specialised Child and Adolescent Mental Health Services, Department of Health in Western Australia, Perth, Australia
+These authors contributed equally to this work
Background: The default mode network (DMN) is active during random episodic silent thought in healthy humans. The neurotransmitter serotonin (5-HT) in particular has been suggested to influence the DMN. Acute tryptophan depletion (ATD) is a neurodietary method of challenging the central nervous 5-HT.
Objectives: The present work studied the effects of a short-term reduction in central nervous 5-HT synthesis by ATD on fMRI-based resting state functional connectivity (FC) of the DMN in children and adolescents with ADHD and healthy controls.
Methods: Boys with ADHD (N = 12) and healthy controls (N = 10) (all 12–17 years) were subjected to ATD, diminishing central nervous 5-HT synthesis and a balanced amino acid load (BAL) serving as a control condition. Three hours after challenge intake (ATD/BAL) resting-state fMRI scans were obtained.
Findings: In controls, after ATD administration FC of the right superior premotor cortex with the DMN was increased, and this relationship was inverse in patients with ADHD as indexed by a highly significant group-by-challenge interaction. Moreover, highly significant effects of challenge administration on FC of the left superior somatosensory cortex with the DMN as well as a group-by-challenge interaction effect were observed.
Conclusions: A serotonergic modulation of the right superior premotor cortex seems to be relevant for motor planning function. This could be relevant regarding changes in neural planning capacity for motor activity in ADHD. While altered sensory perception in patients with ADHD has been described, these results hint towards an altered serotonergic modulation in terms of altered stimuli perception in patients with ADHD.
The Revolving Door of the Mental Health Observation Area (MHOA): An Analysis of Readmissions to a Rapid Psychiatric Assessment Service
J Bui1, H Chan1, J Davies2, S Hood2, S Hussain2
1University of Western Australia, Perth, Australia
2Sir Charles Gairdner Hospital, Perth, Australia
Background: The Mental Health Observation Area (MHOA) at Sir Charles Gairdner Hospital is the first rapid psychiatric assessment unit in Western Australia. It functions as a low stimulus environment for the assessment and discharge planning of psychiatric patients. The MHOA was designed to reduce Emergency Department length of stay for such patients and reduce psychiatric readmission rates; however, multiple re-admissions to the unit have been noted since its opening in 2014.
Objectives: The aim of the study is to review the rates and reasons for readmission within 28 days of initial presentation to the MHOA (a key performance indicator) during the first 6 months of operation.
Methods: Retrospective analysis of patients’ initial admission and consequent readmission to the MHOA. Review of patient demographics (i.e. age, gender, principal diagnosis, comorbid issues and social circumstances) and their contribution to cause of readmission.
Findings: Between February and July 2014 there were 696 admissions to MHOA, 44 (7%) of which were representations within 28 days of initial discharge. 51% of representations had a primary diagnosis of a personality disorder or ‘situational crisis’ and 57% of readmissions were related to actual or self-harm ideation. 14% of readmissions were secondary to social circumstances.
Conclusions: This data highlights MHOA’s emerging role in crisis containment and resolution in those with personality disorders, who often represent in crisis. It indicates that MHOA may benefit from the introduction of a structured admission programme for this group with input from social work, welfare and psychology (as piloted in Royal Perth Hospital) and this may reduce the frequency of representations.
Feasibility of Discharge to Primary Care of Patients on Long-Term Depot Antipsychotic
A Castelino
Counties Manukau District Health Board, Auckland, New Zealand
Background: Long-acting antipsychotic injections play an important role in maintaining stability in severe mental illness. If patients on such stable treatment can be safely transferred to primary care for GP follow-up, potentially secondary care services may be able to target resources for more intensive work with unwell patients. There are no clear guidelines for such transfer of patients. Literature in this area is scant. Barriers and criteria to facilitate discharge of patients on clozapine to GP care have been identified in a previous study.
Objectives: Determine the characteristics of patients receiving depot antipsychotics within an urban community mental health team. To identify correlates and characteristics of those patients who could be discharged to GP care.
Methods: A retrospective observational study utilising case file reviews. A questionnaire was developed specifically for this, including sociodemographic and clinical characteristics of the patients, resource utilisation in administering depot antipsychotic and clinical opinion on suitability of discharge to GP.
Findings: 72 case files (51 men, 21 women) were included in the study. The commonest diagnosis was schizophrenia (71%) and risperidone was the most often used depot (71%). Eight patients were seen only by the psychiatrist and all others had non-psychiatrist case managers. Fourteen (19%) of the patients were deemed suitable for discharge to primary care. Minimum period of one year of stability, having good cognitive function and insight, and absence of high risk history were associated with suitability for discharge.
Conclusions: This study found nearly a fifth of patients on depot antipsychotics were judged suitable for discharge to primary care by psychiatrists.
Raising the Profile of Affective Blunting in General Practice
D Castle1, M Hopwood2, A Crawford3
1St Vincent’s Hospital, Melbourne, Australia
2University of Melbourne, Melbourne, Australia
3Servier Laboratories, Melbourne, Australia
Background: Current guidelines (APA, 2013; RACGP, 2012) identify depressed mood (negative affect) and/or diminished interest and pleasure (positive affect) as the key symptoms for depression diagnosis. Most traditional depression rating scales focus on negative affect. In depression, negative affect and positive affect may not have a strong correlation (Watson et al., 1999). It has been shown that patients are most concerned with the restoration of their positive mental health in their recovery from depression (Zimmerman et al., 2006).
Objectives: Positive Response in Depression Management (PRISM) is a GP audit aiming to improve management of patients with depression by looking at diagnosis, and assessment of return to health. The Castle Hopwood Emotional Experience Response (CHEER) Index used in PRISM is designed to measure positive affect and emotional response that may impact on recovery.
Methods: The CHEER Index is based on validated scales and asks patients with depression to rate, as compared to normal (before depressive episode), their:
Emotional response to a sad event, e.g. watching a sad movie, news of a friend/family member’s illness;
Emotional response to good things that happen in life such as a good day at work, or at home;
Enjoyment in the simple things such as the smell of a flower or a home cooked meal;
Enjoyment in doing things make you happy such as a hobby or interest, or seeing friends/family;
Enjoyment in physical sexual intimacy of any kind;
Pleasure in helping others and receiving their praise
CHEER Index Calculation: normal score 0; less OR greater than normal score 1.
Suspected impact of depression on positive affect:
Low 0–2;
Medium 3–4;
High 5–6.
Findings: Of 6576 patients audited, 13% scored low, 41% medium and 46% high on the CHEER Index. 562 GPs completed the audit, 203 providing feedback. All but one are continuing to use an assessment of both negative and positive affect in the initial assessment of patients who present with depression.
Conclusions: The CHEER Score helps gauge patients’ positive emotional health, and is practical for use in a GP setting. The CHEER Index is appropriate to use in patient follow-up consultations to assess positive mental health progression with treatment and may facilitate patient discussion regarding the outcomes they hope to achieve.
References
APA (2013) Diagnostic and statistical manual of mental disorders. 5th edn. Arlington: American Psychiatric Association.
RACGP (2012) Guidelines for preventive activities in general practice. 8th edn. East Melbourne: Royal Australian College of General Practitioners.
Watson D, et al. (1999) The two general activation systems of affect: Structural findings, evolutionary considerations, and psychobiological evidence. Journal of Personality and Social Psychology 76: 820–838.
Zimmerman M, et al. (2006) How should remission from depression be defined? The depressed patient’s perspective. American Journal of Psychiatry 163: 148–150.
Disclosure
The PRISM clinical audit is supported by Servier Laboratories
A Study of Psychosocial Factors and Other Determinants of Quality of Life in Epilepsy
D Creado, J Mani, A Naik
Kokilaben Dhirubhai Ambani Hospital and Research Centre, Mumbai, India
Background: Patient care in epilepsy is essentially focused on seizure control to improve quality of life (QOL) based on data restricted to QOL in patients with medically refractory seizures. Few studies have systematically analysed QOL and its determinants in medically treated epilepsy.
Objectives:
To characterize QOL in a cohort of adult patients with epilepsy at a tertiary care hospital.
To analyse the epilepsy-related medical and psychosocial determinants of QOL.
Methods: An observational study, approved by the Institutional Ethics Committee, where patients between 18 and 65 years old diagnosed with epilepsy were randomly selected from the epilepsy clinic. Medical details were collected using a semi-structured questionnaire along with standardized tools administered to 79 patients who gave written informed consent:
QOLIE 10 – Quality of Life in Epilepsy;
Liverpool Seizure Severity Scale (LSS);
Psychiatric Health Questionnaire (PHQ 9);
Brief Psychiatric Rating Scale (BPRS);
Generalised Anxiety Disorder Scale (GAD);
Kuppuswamy Socioeconomic Rating scale.
Using the QOLIE-10 score as a continuous measure dependent variable in a linear regression model with univariate and multivariate analysis for independent predictor variables that were tested with χ2 test for statistical significance where indicated using a p value of 0.05 with software SAS v9.2.
Findings: Psychosocial determinants (BPRS; beta = 0.35, p < 0.01) and health perception (PHQ-9; beta = 0.33, p < 0.01) appeared to influence QOL more significantly compared to seizure severity (LSS; beta = 0.20, p < 0.05).
Conclusions:
QOL in epilepsy is determined by seizure severity and frequency but psychopathology and patient perception emerged as more significant factors.
Early diagnosis, psycho-education and management of associated psychopathology may improve QOL.
Does Clinical Placement Location Affect Medical Student Exam Performance in Psychiatry?
K Dawes, A Lethbridge, N Pai
University of Wollongong, Wollongong, Australia
Background: One of the many challenges in managing student clinical placements is trying to ensure equity of opportunity and experience in regards to meeting the curriculum objectives. Students often complain that they have been disadvantaged by their clinical placement due to variations in patient population and acuity, the availability of consultants, registrars and other health care staff to guide learning, and the presence of other students from all disciplines who compete for opportunities.
Objectives: To identify if there is a relationship between psychiatry placement location in the Illawarra Shoalhaven Local Health District (ISLHD) and end of year psychiatry exam results for medical students from the University of Wollongong.
Methods: We compared psychiatry oral and written exam results for six cohorts of students, from 2009 to 2014, across four different placement locations in the ISLHD (N = 450) using one-way multivariate analysis of variance.
Findings: The multivariate effect of placement location was not significant (Pillai’s Trace = .013, F(6,892) = .994, p = .428). Univariate ANOVAs on the individual outcome variables were also non-significant (written exam scores, F(3, 446) = 1.373, p = .250; oral exam scores F(3,446) = .789, p = .501).
Conclusions: Maintaining the quality and consistency of clinical placements will always be a challenge due to limited and varied opportunities, student numbers, and the dynamic nature of both the workforce and the patient populations. However, based on our findings, within our region there is no difference in placement location in regards to end of year psychiatry exam results.
Post Hoc Comparison of Lisdexamfetamine Dimesylate and Osmotic-Release Oral System Methylphenidate: Symptoms, Health-Related Quality of Life and Functional Impairment in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder
L Doddamani1, V Sikirica2, B Caballero3, B Adeyi2, N Naser4, D Coghill5
1Mildura Base Hospital, Mildura, Australia
2Shire, Wayne, USA
3Shire, Zug, Switzerland
4Shire, Sydney, Australia
5University of Dundee, Dundee, UK
Background: Lisdexamfetamine dimesylate (LDX) is the first amphetamine prodrug for the treatment of attention-deficit/hyperactivity disorder (ADHD). Study SPD489-325 was a multinational study which evaluated the efficacy and safety of LDX in children and adolescents with ADHD.
Objectives: To compare post hoc the effect of LDX and osmotic-release oral system methylphenidate (OROS-MPH) on symptoms, health-related quality of life (HRQoL) and functional impairment in children and adolescents with ADHD.
Methods: In this double-blind, parallel-group trial, patients (aged 6–17 years) with ADHD were randomized 1:1:1 to once-daily LDX, placebo or OROS-MPH (included as a reference arm). Symptoms, HRQoL and functional impairment were assessed using the ADHD Rating Scale IV (ADHD-RS-IV), Child Health and Illness Profile-Child Edition: Parent Report Form (CHIP-CE:PRF) and the Weiss Functional Impairment Rating Scale-Parent (WFIRS-P), respectively. The comparison of LDX and OROS-MPH was not pre-specified.
Findings: Of 336 patients randomized, 317 comprised the full analysis set. At endpoint, LDX was statistically significantly more effective than OROS-MPH in reducing ADHD-RS-IV total score (effect size 0.54; p < 0.001) as well as Hyperactivity/Impulsivity (effect size 0.495; p < 0.001) and Inattention (effect size 0.497; p <0.001) subscale scores. LDX was also significantly more effective than OROS-MPH in improving the primary HRQoL outcome (Achievement domain of CHIP-CE:PRF (effect size 0.368; p = 0.024)) and functional impairment (WFIRS-P Learning and School domain only (effect size 0.339; p = 0.034)).
Conclusions: LDX was more effective than OROS-MPH in improving the symptoms of hyperactivity/impulsivity and inattention, HRQoL (CHIP-CE:PRF, Achievement domain) and functional impairment (WFIRS-P, Learning and School domain) in children and adolescents with ADHD.
Psychological Features in Patients With and Without Irritable Bowel Syndrome: A Case-Control Study Using Symptom Checklist 90 Revised
N Farzaneh1, F Fadai2, B Moghimi-Dehkordi3,N Naderi3
1Qazvin Medical University, Qazvin, Iran
2University of Social Welfare and Rehabilitation Science, Tehran, Iran
3Shahid Beheshti University of Medical Sciences, Tehran, Iran
Background: Recent studies have demonstrated that a high proportion of irritable bowel syndrome (IBS) patients show an association with psychological factors. A few studies were conducted on the investigation of psychological features of IBS patients in Iran.
Objectives: We aimed to evaluate the relationship of psychological distress with IBS in outpatient subjects.
Method: 153 consecutive outpatients met Rome III criteria and 163 controls were entered into the study and invited to complete the Symptom Checklist 90-Revised (SCL-90-R) instrument in order to assess psychological distress. Univariate (t-test and Chi-square) and multivariate (logistic regression) methods were used for data analysis.
Findings: A significant association of IBS with all nine subscales and three global indices including Global Severity Index (GSI), Positive Symptom Distress Index (PSDI) and Positive Symptom Total (PST) of the SCL-90-R was detected. Patients with IBS reported significantly higher levels of poor appetite, trouble falling asleep, thoughts of death or dying, early morning awakening, disturbed sleep and feelings of guilt compared to the controls. Multivariate analysis indicated that interpersonal sensitivity, somatization, paranoid ideation, depression and phobic anxiety subscales and PST, PSDI and GSI global indices were significantly associated with IBS (age, gender, educational level, marital status, employment status, smoking, alcohol use).
Conclusions: Psychological features are strongly associated with IBS; notably, interpersonal sensitivity, somatization, paranoid ideation, depression, phobic anxiety, and all global indices including PST, PSDI and GSI are significantly associated with IBS. So, the appropriate psychological assessment in these patients is critically important.
Bio-Neurological Signatures for Symptoms of Psychosis in Schizophrenia and Schizoaffective Disorder
S Fryar-Williams1,2,3,4
1University of Adelaide, Adelaide, Australia
2Queen Elizabeth Hospital, Woodville, Australia
3Basil Hetzel Institute of Translational Health, Woodville, Australia
4Youth In Mind Research Institute, Norwood, Australia
Schizophrenia and schizoaffective disorder are allied conditions within overlapping symptoms. Many of their behavioural and affective symptoms, such as delusions, hallucinations, suicidality and hostility, pose management problems for mental health workers, therefore, understanding components of these symptoms in neuro-bio-physiological terms would be a helpful adjunct to their effective management in the clinical setting.
Background: The Mental Health Biomarker Project arose from a 2009 pilot study where more than three abnormal biomarkers in areas of biochemistry and auditory processing were found to be significantly associated with a diagnosis of schizophrenia (n = 15).
Objectives: The Mental Health Biomarker Project (2010–2014) sought to validate these findings and find further biomarkers to describe the various symptoms of these conditions, using neurophysiological tests and biochemical markers within proximal and remote biochemical pathways related to neurotransmitter synthesis and metabolism.
Methods: In a case-control discovery design (n = 134), using highly characterised cases of functional schizophrenia and schizoaffective disorder, commercially available biochemistry tests and neurophysiological and cognitive assessment methods, administered in a 30 minute clinic consultation, assessed a range of outcome measures that were analysed by ROC analysis for their ability to achieve biomarker status by differentiating between patient and control samples.
Findings: 21 biomarkers were discovered that formed a multi-domain model of schizophrenia and schizoaffective disorder, with 82% sensitivity and 90% specificity, at 95% level of confidence. By Spearman’s correlation analysis, the biomarkers were then allocated to the various symptoms of psychosis and the mood components of schizoaffective disorder, to form a model of schizophrenia symptoms with analytical and face-validity in terms of the dysconnectivity hypothesis of psychosis.
Conclusions: These preliminary findings of discrete bio-neurological signatures for affective and behavioural components of psychosis represent a new approach to phenomenology whereby symptoms associated with psychosis are teased apart and understood in terms of bio-neurological function, allowing a theoretically understandable, broader approach to management.
Human Rights Based Mental Health Care – Legislation and Practice
N Gill1,2
1Rural Clinical School, School of Medicine, University of Queensland, Toowoomba, Australia
2School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
Background: Various Australian states, just as many other countries around the globe, are in the process of amending their Mental Health Acts to comply with the human rights approach adopted by the United Nations Convention on Rights of Persons with Disabilities (UN CRPD). UN CRPD, which Australia as well as New Zealand ratified in 2008, specifically mentions inclusion of mental disabilities in its Article 1. It has been hailed as the ‘dawn of a new era’ in disability rights and has metamorphosed the status of a person with disability from ‘an object of welfare’ to ‘a subject with rights’.
Objectives: This paper will highlight the challenges and opportunities for human rights based mental health care and generate debate on sensitive issues, e.g. right to autonomy versus right to treatment, economic implications of a human rights approach to mental health care, risk versus capacity based legislation and medical model versus social model.
Methods: International conventions and documents regarding human rights and principles of mental health legislation will be discussed. The literature and opinions regarding challenges, opportunities and controversies in this field will be highlighted.
Findings: While legislative framework may form the basis of reform, what is required is a wider cultural change and acknowledgement of the human rights of people with mental disabilities, not only by health professionals and the legal fraternity, but also by the society at large.
Conclusions: It is crucial for mental health professionals as well as other stakeholders to be well versed in the contemporary human rights discourse, as the human rights framework may be the royal road to mental health advocacy.
A Study of Heart Rate Variability in Bipolar Affective Disorder I and Recurrent Major Depressive Disorder, During Remission and Over the Bedtime Period
R Clarke1, D Hans1, D Bassett1, S Hood1, S Bassett1, D Nutt2
1School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia
2Psychopharmacology Unit, Imperial College London, London, UK
Background: Changes in autonomic nervous system regulation are believed to contribute adversely to a number of major medical disorders (Benarroch, 1993; Riganello et al., 2012). As autonomic function is in part regulated by cortical networks, disordered autonomic regulation reflects aspects of function in these areas (Kemp and Quintana, 2013; Olley et al., 2005).
Objective: This study examines the association between Heart Rate Variability (HRV) as a measure of autonomic function during the bedtime period in three groups of subjects, one with Bipolar Affective Disorder I (BPAD I) and one with recurrent Major Depressive Disorder (rMDD), both in remission, and a control group of healthy subjects.
Methods: Strict inclusion and exclusion criteria were employed and the diagnoses and current remission were confirmed. Sleep quality was measured and a list of medications compiled. The potential confounding effects of psychotropic medication were analysed.
Findings: Parasympathetic and sympathetic activities were significantly reduced in both groups of mood disorder subjects, although reduction was most marked in parasympathetic drive and most consistent in the depressed subject group. While the contribution of psychotropic medications was recognised, the evidence suggests the changes in HRV were due predominantly to the history of recurrent mood disorder.
Conclusion: HRV is significantly reduced during remission and during the bedtime period in subjects who have suffered from BPAD I and rMDD. Our study provides evidence that this is substantially related to the impact of these disorders. These findings have important implications for the physical and psychological health of patients with these disorders, as well as the potential to help clarify the pathophysiology of BPAD I and rMDD.
References
Benarroch EE (1993) The central autonomic network: Functional organization, dysfunction, and perspective. Mayo Clinic Proceedings 68(10): 988–1001.
Kemp AH and Quintana DS. (2013) The relationship between mental and physical health: Insights from the study of heart rate variability. International Journal of Psychophysiology 89(3): 288–296.
Olley A, Malhi GS, Mitchell PB, et al. (2005) When euthymia is just not good enough: The neuropsychology of bipolar disorder. Journal of Nervous and Mental Disease 193(5): 323–330.
Riganello F, Dolce G and Sannita WG (2012) Heart rate variability and the central autonomic network in the severe disorder of consciousness. Journal of Rehabilitation Medicine 44(6): 495–501.
The Use of Mental Health Services by Medical Students at the University of Western Australia (UWA)
I Marley, M Still, G Ryan, Z Lyons, S Hood
School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia
Background: Psychological problems among medical students are common. Little is known about the services accessed for mental health problems by students.
Objective: This study aimed to (i) explore effectiveness of services available to medical students at UWA who experience mental health problems, (ii) identify barriers to service use, and (iii) identify gaps in service provision.
Method: An online survey was developed. Students were invited by email to participate. The survey was piloted prior to administration. As an incentive to participate, respondents could choose to enter a draw to win an Amazon voucher.
Findings: 286 students in Years 4, 5 and 6 responded to the survey (41% response rate). Sixty-two percent reported experiencing mental health problems. The Associate Dean of Student Affairs, GPs, psychiatrists and psychologists were the most effective mental health services reported by students. The main barriers to accessing services were lack of time (46%) and affordability (34%). To improve services, students suggested that common rooms are made available at placement sites, advice to address the transition from medical student to junior doctor given, and advice and strategies to help with mental health and wellbeing issues.
Conclusions: Medical faculties should work towards improving access to mental health services for medical students. GPs are commonly used and should screen for distress among medical students. Strategies aimed at reducing stigma and raising awareness of mental health issues should be encouraged. Services that teach effective coping strategies and address the transition from medical student to junior doctor may improve student mental health.
Efficacy and Safety of Extended-Release Guanfacine Hydrochloride in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder: A Randomized, Double-Blind, Multicentre, Placebo- And Active-Reference Phase 3 Study
M Huss1, A Hervas2, M Johnson3, F McNicholas4, J van Stralen5, S Sreckovic6, A Lyne7, R Bloomfield7, V Sikirica8, N Naser9, B Robertson8
1Child and Adolescent Psychiatry, Johannes Gutenberg-University Mainz, Mainz, Germany
2Child and Adolescent Mental Health Unit, University Hospital Mútua de Terrassa, UETD; Hospital Sant Joan de Deu, Barcelona, Spain
3The Gillberg Neuropsychiatry Centre at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
4Department of Child and Adolescent Psychiatry, Our Lady’s Children’s Hospital, Dublin, Ireland
5Center for Pediatric Excellence, Ottawa, Canada
6Shire, Eysins, Switzerland
7Shire, Basingstoke, UK
8Shire, Wayne, PA, USA
9Shire Australia Pty Ltd, Sydney, Australia
Background: Guanfacine extended-release (GXR), a selective α2A-adrenergic agonist, is a non-stimulant treatment for attention-deficit/hyperactivity disorder (ADHD), approved in the USA (children/adolescents) and in Canada (children).
Objectives: To assess the efficacy (symptoms) and safety of dose-optimized GXR compared with placebo in children/adolescents with ADHD. An atomoxetine (ATX) arm was included to provide reference data.
Methods: Children/adolescents (6–17 years) with ADHD were randomized at baseline to dose-optimized GXR (0.05–0.12 mg/kg/day: 6–12 years: 1–4 mg/day; 13–17 years: 1–7 mg/day), ATX (10–100 mg/day) or placebo for 4 or 7 weeks. The primary efficacy measure was change from baseline in ADHD Rating Scale version IV (ADHD-RS-IV) total score. A secondary measure was the proportion of children/adolescents with a response (⩾ 30% reduction from baseline in ADHD-RS-IV and a Clinical Global Impression-Improvement of 1–2). An ad-hoc analysis investigated onset of efficacy (ADHD-RS-IV). Safety assessments included treatment-emergent adverse events (TEAEs).
Findings: A total of 272 (80.5%) children/adolescents completed the study. Significant placebo-adjusted differences were observed in least squares mean change from baseline in ADHD-RS-IV score (GXR: −8.9, p < 0.001; ATX: −3.8, p < 0.05). Compared with placebo (42.3%), response rate was higher in both the GXR (64.3%; p < 0.001) and ATX (55.4%; p = 0.017) groups. Onset of efficacy was seen at Visit 3/Week1 for GXR (p = 0.003) and Visit 5/Week3 for ATX (p = 0.024). Most common GXR TEAEs were somnolence, headache and fatigue; 70.1% of GXR patients reported mild-to-moderate TEAEs.
Conclusions: GXR ⩽ 7 mg/day was effective and well tolerated in children/adolescents with ADHD, consistent with previous studies.
Disclosure
Study funded by Shire Development, LLC
ClinicalTrials.gov (NCT01244490) and EudraCT (2010-018579-12)
Extended-Release Guanfacine Hydrochloride in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder: A Double-Blind, Placebo-Controlled, Multicentre, Phase 3 Randomized Withdrawal Study
M Huss1, J Newcorn2, V Harpin3, M Johnson4, J Ramos-Quiroga5, J van Stralen6, B Dutray7, S Sreckovic8, A Lyne9, R Bloomfield9, V Sikirica10, N Naser11, B Robertson10
1Child and Adolescent Psychiatry, Johannes Gutenberg-University Mainz, Mainz, Germany
2Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, USA
3Ryegate Children’s Centre, Sheffield, UK
4The Gillberg Neuropsychiatry Centre at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
5Department of Psychiatry (CIBERSAM), Hospital Universitari Vall d’Hebron, Barcelona, Spain
6Center for Pediatric Excellence, Ottawa, Canada
7Pôle de Psychiatrie Enfant Adolescent, Centre Hospitalier de Rouffach, Rouffach, France
8Shire, Eysins, Switzerland
9Shire, Basingstoke, UK
10Shire, Wayne, USA
11Shire Australia Pty Ltd, Sydney, Australia
Background: Guanfacine extended-release (GXR), a selective α2A-adrenergic agonist, is a non-stimulant medication for attention-deficit/hyperactivity disorder (ADHD) approved in the USA for children/adolescents and in Canada for children.
Objectives: To evaluate long-term maintenance of GXR efficacy in children/adolescents with ADHD.
Methods: Children/adolescents (6–17 years) with ADHD received open-label GXR (1–7 mg/day). After 13 weeks, responders were randomized to receive GXR or placebo in the double-blind randomized withdrawal phase (RWP). The primary endpoint was treatment failure (⩾ 50% increase in ADHD-Rating Scale-IV total score and ⩾ 2-point increase in Clinical Global Impression-Severity, compared with RWP baseline, at two consecutive visits). Failure rates at each RWP visit, for the overall population and by age group (children, 6–12 years; adolescents, 13–17 years), were assessed in an additional analysis. Safety assessments included treatment-emergent adverse events (TEAEs).
Findings: Of 528 patients enrolled, 316 (60.0%) entered the RWP. At study end (Visit 23/Week 39), treatment failure had occurred in 49.3% and 64.9% of the GXR and placebo groups, respectively (p = 0.006). The difference in favour of GXR was evident from Visit 18/Week 21 (36.0% vs 53.6%; p = 0.001) and was maintained for the duration of the study (p = 0.001–0.006). When assessed by age group, treatment failure rates at study end were lower with GXR than placebo for children (51.3% vs 69.9%; p = 0.005) and adolescents (43.2% vs 50.0%; p = 0.536). During the RWP, the most common GXR TEAEs were headache, somnolence and nasopharyngitis.
Conclusions: GXR demonstrated long-term maintenance of efficacy versus placebo in children/adolescents with ADHD, and was well tolerated.
Disclosure
Study funded by Shire Development, LLC
ClinicalTrials.gov (NCT01081145) and EudraCT (2010-018579-12)
A Taste for Blood: Revenge and the Psychological Theatre of the Noh Plays of Japan
J Kirszenbla
The Alfred Hospital, Melbourne, Australia
Literature and Drama are recognised sources of illumination into the conflicts, passions, self-deceptions and existential crises in our lives. Playwrights and writers have often made madness central to plots and narratives and in doing so have provided insights into the lives of the mentally ill that cannot always be convincingly or expressively captured in the theories and nosologies that underpin psychiatry.
In this poster, these truisms are turned on their heads. Instead, a case vignette is used to illuminate a classic art form that is opaque, perplexing, alien and obscure to a Western audience – the Noh plays of Japan.
A Focus on Physical Comorbidty Improves Length of Stay and Safety on a Psychogeriatric Ward
D Lie1,2
1Metro South Addiction and Mental Health Services, Brisbane, Australia
2Diamantina Health Partners, Brisbane, Australia
Grevillea Length of Stay Study (GLOSS)
A 16-bed acute public psychogeriatric ward at a major metropolitan hospital faced significant access block, high nursing costs and experienced increasing adverse medical events over a three-year period. A multimodal quality improvement initiative has succeeded in producing lasting reductions in adverse events, length of stay and costs over a period of four years subsequent to the initiative.
The core interventions were:
Improving clinical handover and communication;
Improving the use of allied health staff;
Creating a target group and screening process for people at high risk of medical comorbidity;
Education of medical staff on use of 1:1 nursing;
Restructuring medical staffing across the District working in Older Persons’ Mental Health;
Orientation of rotating medical staff on the significance of early detection of high physical dependency and complex medical care needs;
Changing from a nurse allocation to team nursing model;
Setting thresholds for escalation to senior management before admitting patients requiring defined levels of physical disability and medical care needs.
Data are presented outlining length of stay patterns, adverse event data and financial savings over an eight-year period before and after the intervention.
Continuation Right Unilateral Ultrabrief Electroconvulsive Therapy – A Naturalistic Study of Effectiveness at 6 Months
P Mayur1,2, A Harris2,3
1Cumberland Hospital, Westmead, Sydney, Australia
2Department of Psychiatry, University of Sydney, Sydney, Australia
3Westmead Hospital, Westmead, Sydney, Australia
Background: Continuation electroconvulsive therapy (C-ECT) is the extension of ECT beyond the acute course to prevent a relapse. Ultrabrief right unilateral ECT in an acute course of thrice weekly treatment is an effective antidepressant strategy, but much less is known about its effectiveness during the continuation stage of treatment at a lower frequency of sessions.
Objectives: The primary outcome was rates of ‘All-Cause Discontinuation’ from ultrabrief ECT. Secondary outcomes were time in months of discontinuation and relapse rate of depression as defined by the Montgomery-Åsberg Depression Score of greater than 10.
Methods: Over an 18 month period from March 2013 to August 2014, consecutive patients with treatment resistant Major Depression who started a continuation course of 0.3 ms 6 times threshold right unilateral ultrabrief ECT were systematically followed up for 6 months. All patients received continuation pharmacotherapy.
Findings: Fifteen patients started a course of continuation 6 times threshold right unilateral ultrabrief ECT. At the outset all patients had remitted from Major Depression with a Montgomery-Åsberg Depression Score of less than 10. In 11 patients (73%) the pulse width remained unchanged throughout the continuation course. In four (27%), there was a switch to a pulse width of 0.5 ms. All continued to receive right unilateral ECT. In 100% of cases the switch in the pulse width occurred during the first month of the continuation phase. Nine patients completed 6 months. None of the patients relapsed into Major Depression at the end of their course.
Conclusions: This study explored the effectiveness of ultrabrief ECT during the continuation phase of treatment in a homogenous group of patients with treatment refractory Major Depression. There was a robust retention rate of patients within the ultrabrief pulse width modality. It appears that the maximum likelihood of switch to a different modality of ECT is within the first month. However, firm conclusions cannot be drawn from this preliminary report due to its modest sample size.
Mindfulness-Based Cognitive Therapy and the Role of Psychiatry
G Meadows, F Shawyer
Monash University, Melbourne, Australia
Background: Mindfulness-based cognitive therapy (MBCT) now has established efficacy and effectiveness in reducing risk of major depression where people have had recurrent episodes. The evidence base for this includes multiple RCTs, with a multi-site pragmatic trial led by the authors reported in 2014 in the ANZJP. Something of a consensus position exists in the field about training requirements for practitioners, as set out in guidelines from the UK, where it has for some years been included in NICE guidelines. As primarily a group-based intervention, it can be challenging to implement in typical mental health care settings and existing MBS items are not well suited to delivery.
Objectives: To orient psychiatrists to MBCT, enabling consideration of how to select and prepare patients for possible participation and to inform regarding training requirements.
Methods: After briefly summarising the evidence base, including key results from the recent Australian study, consideration will be given to the pragmatics of MBCT in clinical practice including availability, applicability of MBS items and the development of an individual delivery model.
Findings: While the evidence base is strong, there is very variable availability of MBCT, and widely available funding streams are not well suited to supporting its delivery.
Conclusions: Psychiatrists in adult practice seeing patients with depression should be aware of MBCT as a technique, and should have capacity to prepare patients for it and support them through it. Among this profession delivery of MBCT is likely to remain a minority pursuit but there are possible system reforms that could encourage this.
The General Practice Mental Health Standards Collaboration Enters its Teens
G Meadows1, M Rawlin2
1Monash University, Melbourne, Australia
2University of Sydney, Sydney, Australia
Background: The General Practice Mental Health Standards Collaboration (GPMHSC), funded since 2001 by the Commonwealth Department of Health, includes representatives from general practice, psychiatry, psychology and the community. It operates under the auspices of the Royal Australian College of General Practitioners. The GPMHSC, responsible for standards of education and training for the Better Access initiative, also promotes development and uptake of quality professional development in mental health for GPs.
Objectives: To assist psychiatrists in better understanding the work of the GPMHSC and through this the contribution GPs do and can make to mental health care in the community.
Methods: This presentation will take a narrative approach, enriched by key data items, to describing the work of the Collaboration and how its contributions have developed through time.
Findings: From commencement the GPMHSC has committed to collaborative involvement of consumers and carers in development and delivery of training programs. Over 22,000 GPs have completed Mental Health Skills Training (MHST) as specified by the GPMHSC, so being eligible to use better remunerated MBS items for treatment planning. Over 800 are compliant with requirements for delivery of Focused Psychological Strategies. Recent GPMHSC activities include innovation in MHST training with a modular pathway and supporting development and evaluation of Templates for GP use in Mental Health Treatment Planning.
Conclusions: The GPMHSC is a significant formative influence on primary mental health care in Australia. The GP is a critically important provider of mental health care in communities and awareness of GPMHSC initiatives can assist psychiatrists in collaborative working with GPs.
“Don’t Ask Don’t Tell” – the Cannabis Dilemma in Liver Transplantation
W Milchak
Department of Psychiatry, Pennsylvania State University College of Medicine, Hershey, USA
Background: The Medical School has a well-established liver transplantation service. Prior to 2011, liver transplant patients who continued to smoke cannabis were removed from the transplant waiting list. Lawsuits and the shifting sands of the overarching cannabis debate have muddied the waters and subsequently, transplant centres are faced with ethical and legal dilemmas.
Objectives:
Communicate prior and current policy and practice in relation to cannabis use and liver transplantation;
Identify the various responses across US transplant centres;
Discuss the impact of medical cannabis and legalization upon liver transplantation.
Methods: A survey was distributed to 91 liver transplant centres across the US. Questions sought to identify policies and practices regarding cannabis use across these programs. Following an analysis of the survey responses, the information was presented to a workshop at the Annual North American Liver Transplant Social Workers Conference.
Findings: As more states adopt medical and legal cannabis laws, what was a few years ago an automatic rule-out for liver transplant finds the vast majority of centres changing their policies or adopting a “don’t ask don’t tell” unwritten policy. The medical contraindications may be few, but those within the addictions realm raise concerns with continued use of cannabis by patients with substance dependence. Transplant centres residing within states where cannabis use remains illegal are further challenged in this debate.
Setting Up an Addictions-Focused Training Program for General Practitioners
SM Mohiuddin
Mental Health Service Group, Townsville Hospital and Health Service, Townsville, Australia
Background: In Australia, there are 16.3 FTE psychiatrists per 100,000 population for ‘Major cities’ while there are only 3.9 FTE psychiatrists for ‘Outer Regional’ areas. This emphasizes the access barrier to sub-specialty psychiatric services such as addictions services for those who live outside metropolitan centres.
Townsville, with a population of approximately 180,000, is classified as ‘RA-3, outer regional area’. The Mental Health Service Group, with an integrated Alcohol Tobacco and Other Drug Services (ATODS), has taken numerous steps to meet an increasing demand for substance use, gambling and persistent pain assessment and intervention services. These include up-skilling Generalist Psychiatrists, accrediting advanced training positions for addictions sub-specialty training, and setting up a training program for General Practitioners (GPs).
Objectives: To provide an insight into the systematic approach used in setting up an addictions-focused training program for GPs in a regional setting. To also discuss the barriers encountered during the development and implementation of this program.
Methods: The steps of the project included: planning; consultation with GPs to identify learning needs as well as barriers to engagement; design of training program; allocation of resources; accreditation for CPD points; marketing; recruitment and commencement.
Findings and conclusions: This is an innovative approach by a mental health service to meet the high demands of addictions problems in a regional area. The presentation aims to describe the methodology undertaken to set up a training program for GPs in order to improve access to clinical care.
Strategies to Manage Weight Gain in People Treated With Antipsychotic Medications
SM Mohiuddin
Mental Health Service Group, Townsville Hospital and Health Service, Townsville, Australia
Background: Antipsychotics can cause numerous side effects, including weight gain and metabolic derangements that are often difficult to manage. Weight gain has become a major concern in the treatment of psychosis because it may adversely affect treatment adherence and clinical outcomes and is associated with reduced quality of life, social stigma, and greater morbidity and mortality.
Objectives: To identify the available pharmacological and non-pharmacological treatments for managing weight gain in people treated with antipsychotic medications, and propose an algorithm for their use in clinical practice.
Method: Comprehensive literature search to review the current research and evidence-based interventions available. This includes pharmacological, psychological and surgical interventions, as well as other options such as nutritional counselling and exercise. Based on the findings, the author will propose a structured approach that will assist the treating team in managing weight gain in a systematic manner.
Findings: Non-pharmacological interventions remain the first line treatment. Switching to a weight-neutral antipsychotic and avoiding poly-pharmacy is an effective choice. Addition of metformin has shown to have good evidence for both reduction as well as prevention of weight gain. Surgery is not routinely recommended.
Conclusions: The presentation will aim to provide an understanding of the options available for the management of weight gain, and propose a practical stepwise approach for use in routine clinical practice.
Diagnosing Delirium in ICU Patients
B Saad1,2, H Mohsin1, P Khatri1, AY Shaikh1, M Qadeer1, A Ali1, TM Amanullah1
1Liaquat National Hospital, Karachi, Pakistan
2South City Hospital, Karachi, Pakistan
Background: Delirium is underdiagnosed in the ICU setting despite being frequent. Difficulty in communicating with patients on mechanical ventilation makes clinical analysis problematic, further complicated by lack of a validated instrument for delirium.
Objectives: To study the prevalence of delirium in critically ill patients of a tertiary care hospital using the CAM-ICU assessment instrument.
Methods: In a prospective cohort study, delirium was assessed in 500 patients from ICUs of different specialties in a tertiary care hospital of Karachi. Two techniques were implemented, DSM-IV, Diagnostic and Statistical Manual of Mental Disorders criteria and CAM-ICU, Confusion Assessment Method of the Intensive Care Unit. After exclusion, 300 patients were examined and the results were compared. The prevalence of delirium was estimated including the factors affecting its prognosis.
Findings: In comparison of results from DSM and CAM-ICU, 41 (13.66%) tested positive on CAM-ICU, while only 15 (5%) tested positive according to DSM. The sensitivity of CAM-ICU proved to be 80.8% with a specificity of 89.8% (p < 0.005). Eleven patients who tested positive required mechanical ventilation. The mean age of the patients was 57.62 ± 14.98 years, out of which 22 (53.65%) were males and 19 (46.35%) were females.
Conclusions: Screening for delirium is required for patients in the ICU setting because it adversely affects the prognosis. The protocol of diagnosis should be easy to administer, cost-effective, quick and not require highly trained personnel. If routinely done it can improve the quality of care in ICU settings.
Delivering Best Outcomes for Migrant Women With Mental Disorders: A Successful Partnership Between Government and Non-Government Agencies
E Moore1, S Yeak1, M Korica2
1South Metropolitan Health Service, Mental Health Strategy and Leadership Unit, Perth, Australia
2Fremantle Multicultural Centre, Fremantle, Australia
Background: Migration is associated with significant mental disorder. The complexity of the migrant experience may include language difficulties, different cultural expectations, limited family support and the need to navigate around different systems to access health care, financial assistance and legal systems.
Method: This review defined the collaborative pathways and analysed outcomes over the last 10 years achieved by our publicly funded mental health services and a dynamic community-managed organisation delivering services to migrant women.
Findings:
The findings included:
Staff at the Fremantle Multicultural Centre (FMC) gained skills in appropriately recognising mental disorder that required specialist intervention;
Staff at South Metropolitan Health Service were more aware of the trauma associated with migration and more likely to choose appropriate socialisation through the FMC rather than “medicalise” the response to migration;
Pathways to appropriate care for migrant women were facilitated;
Family and carer needs were identified and supported.
The strategies needed to develop and sustain the partnership included:
Strong and stable leadership;
Clear role delineation;
Regular review of roles;
Joint staff development opportunities;
Co-production with carers and consumers.
Conclusion: The successful strategies in this long-standing partnership can be applied in other jurisdictions to improve outcomes for this cohort and their families.
Lisdexamfetamine Dimesylate for Adults With Moderate to Severe Binge Eating Disorder: Results of Two Randomized Controlled Safety and Efficacy Trials
N Naser1, S McElroy2, J Hudson3, MC Ferreira-Cornwell4, J Radewonuk4, M Gasior4
1Shire PLC, Dublin, Ireland
2Lindner Center of HOPE, Mason, USA; University of Cincinnati College of Medicine, Cincinnati, USA
3McLean Hospital/Harvard Medical School, Belmont, USA
4Shire Development LLC, Wayne, USA
Background: Lisdexamfetamine dimesylate (LDX), a d-amphetamine prodrug, may reduce binge eating frequency in individuals with binge eating disorder (BED).
Objectives: To evaluate the efficacy of LDX for BED in adults with protocol-defined moderate to severe binge eating and to assess safety and tolerability.
Methods: Two multicentre, double-blind, placebo-controlled studies randomized adults (study 1, n = 383; study 2, n = 390) meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision BED criteria. Participants were randomized (1:1) to dose titration with placebo or LDX (50 or 70 mg/day); the optimized dose was maintained to the end of double-blind treatment (week 12 or early termination). The primary efficacy endpoint, change in binge eating days/week from baseline to weeks 11–12, was assessed with mixed-effects models for repeated measures. Safety and tolerability endpoints included treatment-emergent adverse events (TEAEs) and vital signs.
Findings: The LS mean (95% CI) treatment difference for change in binge eating days/week from baseline to weeks 11−12 significantly favoured LDX (study 1: –1.35 [–1.70, –1.01]; study 2: –1.66 [–2.04, –1.28]; both p < 0.001). Statistically significant improvements favouring LDX were seen for key secondary endpoints (all p ⩽ 0.002) in both studies. TEAEs reported by ⩾10% of LDX participants in both studies were dry mouth, insomnia and headache; mean pulse and blood pressure changes were consistent with the known effects of LDX.
Conclusions: Dose-optimized LDX significantly reduced binge eating days/week versus placebo in adults with BED. The safety and tolerability profile of LDX was generally consistent with its profile in adults with ADHD.
NSW Mental Health Act Documentation – Are We Getting it Right?
N O’Connor1,2, J Corish1, C Olmstead1, A Belford1
1Northern Sydney Local Health District, Sydney, Australia
2 Department of Psychiatry, University of Sydney, Sydney, Australia
Background: There is considerable variability in the training and experience of professionals authorised to use the NSW Mental Health Act (MHA). This appears to be associated with variable practice and variable compliance with the requirements of the legislation.
Objectives: To determine the appropriateness and utility of the certificates issued under the MHA and compliance with the requirements of the MHA. The analysis also compares MHA documentation by different groups of Health professionals and police.
Methods: The MHA certificates associated with 100 consecutive involuntary Emergency Department presentations were audited.
Findings: Considerable variability exists between professional groups in terms of the level of detail, appropriateness, utility and compliance of MHA certificates. A number failed to meet the requirements of the MHA, potentially invalidating the involuntary detention of these patients. Information provided by clinical staff was typically superior in informing initial risk assessment and emergency management.
Conclusions: A number of patients are presently being detained under invalid MHA certificates. Educational initiatives that aim to improve awareness of the MHA’s requirements and the potential uses of the information they contain could encourage professionals who complete these certificates to do so in a more appropriate and clinically useful manner.
Experiences of Stigma and Discrimination Among People With Schizophrenia: A Cross-Sectional Study
CL O’Reilly1, TF Chen1, D Paul2, R McCahon2, S Shankar2, A Rosen3,4,5, J Ye1
1Faculty of Pharmacy, University of Sydney, Sydney, Australia
2Assertive Outreach Team, Lower North Shore Mental Health, Northern Sydney Local Health District, Sydney, Australia
3Brain and Mind Research Institute, University of Sydney, Sydney, Australia
4School of Public Health, University of Wollongong, Wollongong, Australia
5Centre for Rural and Remote Mental Health Services, University of Newcastle, Newcastle, Australia
Background: Mental health stigma is known to be a highly prevalent and significant challenge in mental healthcare, yet little is known how this manifests in discrimination for people living with severe and persistent mental illness.
Objectives: To describe the experiences of stigma and discrimination among people living with schizophrenia in NSW and explore levels of experienced, anticipated and positive discrimination.
Methods: This cross-sectional study used the Discrimination and Stigma Scale (DISC) to conduct structured face-to-face interviews with people with schizophrenia. The DISC is a quantitative and qualitative instrument used to explore and measure levels of negative, anticipated and positive discrimination. Relevant clinical history and socio-demographic information were also collected.
Findings: Fifty participants were interviewed, the majority being male (72%), with a mean age of 49 years. Forty participants (80%) experienced negative discrimination in at least one life domain. Negative discrimination was most common in being avoided or shunned (50%) by neighbours (48%) and family (46%). Experienced discrimination from mental health staff was reported from 42%, compared to 18% whilst getting help for physical health problems. Anticipated discrimination was common, with half of participants feeling the need to conceal their mental health diagnosis.
Conclusions: Discrimination experienced in everyday aspects of life is highly prevalent among people with schizophrenia. Interestingly, participants often stopped themselves in life activities due to anticipated discrimination even without previous experienced discrimination. Most experiences of unfair treatment by mental health staff could be attributed to involuntary treatment. Further research is needed to design and evaluate interventions to reduce mental health stigma and discrimination.
Clozapine and Constipation
H Oh1, S Suetani1,2, S Clark2,3, O Schubert2,4
1The Queen Elizabeth Hospital, Adelaide, Australia
2University of Adelaide, Adelaide, Australia
3Central Adelaide Local Health Network – Western Community Mental Health Centre, Woodville, Australia
4Northern Adelaide Local Health Network – Northern Community Mental Health Centre, Salisbury, Australia
Background: Constipation is a common side effect of clozapine with significant adverse consequences.
Objectives: To provide an overview of constipation in the context of clozapine treatment, including effective screening and interventional strategies as well as its significance.
Methods: PubMed and PsycINFO were searched for publications relevant to clozapine and constipation. Articles that were published in peer-reviewed journals, written in English and exploring the relationship between clozapine and constipation were included in the review.
Findings:Epidemiology – 14–65% of patients treated with clozapine reportedly experience constipation, at any stage of treatment.
Possible underlying mechanism – Anticholinergic and antiserotonergic properties of clozapine were reported to be major factors in constipation. Concomitant anticholinergic medications and sedentary lifestyle were additional contributing factors.
Screening and monitoring – While taking regular bowel history and physical examination were the mainstay of screening strategy, other tools such as the Bristol Stool form scale, abdominal X-ray, measurement of BMI, abdominal girth and serum anticholinergic activity can be utilized.
Intervention and treatment – Non-pharmacological interventions such as education, high-fibre diet, adequate hydration and physical exercise were effective. Pharmacological intervention included use of softening and osmotic laxatives. Bulk forming or stimulating agents were less favoured. Bethanechol and lubiprostone could provide additional benefits, as well as dose reduction or slow titration of clozapine.
Complications – Untreated constipation can progress to significant conditions such as bowel obstruction, ischaemia/infarction, perforation, paralytic ileus, necrotizing colitis and even death.
Conclusion: Further studies that explore a more effective way of monitoring and managing constipation to prevent complications would benefit patients who are on long-term clozapine.
The Alltrials Campaign: Why the College Should Reconsider Signing the Petition
P Parry
University of Queensland, Brisbane, Australia
Background: The “AllTrials” campaign is an initiative of the Cochrane Collaboration, Centre for Evidence-Based Medicine, PLoS journals, BMJ and others. The motto is: “All trials registered, all results reported”. A campaign headline is: “Medicine is broken, we need your help to fix it”. The Cochrane Collaboration decided only a complete overhaul can provide evidence-based medicine; hence AllTrials.
By November 2014 over 81,000 individuals and 522 medical and academic organisations including RCPsych and most British medical colleges had signed. The Australian Medical Students Association signed.
The RANZCP stated in the October issue of Psyche that “the College supports the principles underpinning AllTrials” but “decided not to formally endorse the initiative”.
Objectives: To deepen the debate regarding AllTrials.
Methods: Details about AllTrials are compared to the College’s reasons for not endorsing.
Findings: Reported in Psyche: “RANZCP sought feedback from the NHMRC, other Australian medical colleges, the editors of the College Journals...” Not endorsed due to: “public dissemination of data and privacy issues for research participants, feasibility of certain requirements relating to timelines for publication of research results and operational issues relating to implementation. RANZCP will continue to support the national registers...”
However: (1) AllTrials addresses privacy issues. (2) Timeline for results publication to registers is consistent with www.clinicaltrials.gov. Negative results are scientifically important. (3) Audits of national registers reveal poor compliance. AllTrials is for internationally standardised enforceable coordination of regulated websites, not replacing them. (4) The other college actively debating the issue, the Australasian College of Emergency Medicine, signed. (5) AllTrials seeks release of past trial data – vital information for current medications.
Conclusions: AllTrials, supported by hundreds of organisations, aims to maximise evidence-based medicine. The concerns expressed in Psyche appear answerable. A wider debate amongst RANZCP members appears warranted.
Retrospective Comparison of Right Unilateral Ultra-Brief Pulse With Brief Pulse Ect in Older Adults(Over 65) With Depression
J Ramalingam1, S Thangapandian1, K George2, A Elias3
1Central Coast Local Health District, Wyong, Australia
2Peter James Centre and Wantirna Health, Forest Hill, Australia
3Goulburn Valley Health, Shepparton, Australia
Background: Right unilateral ultrabrief pulse ECT (RUL-UB) in adults is at least as effective as right unilateral and bilateral brief pulse width treatments and has fewer cognitive side effects. There is no published data on outcomes for older adults.
Objectives: To compare response, remission and switch (to other pulse width and/or electrode placement) rates and number of treatments between groups receiving RUL-UB, bitemporal brief (BT), bifrontal brief (BF) and right unilateral brief (RUL-B).
Method: Data was collected from case notes in three centres. There were 133 cases in total, grouped as RUL-UB (50), BT (43), BF (23), RUL-B (17). Each centre had a preferred electrode placement and pulse width.
Findings: Apart from age, the groups did not differ significantly on sex distribution, proportion of bipolar depression and psychotic symptoms.
56% of patients in RUL-UB switched compared to 12.5% in RUL-B, 4.9% in BT and none in BF (p < 0.0001).
When we considered patients who switched as treatment failures, remission rates were significantly different (p < 0.0001), 40% in RUL-UB, 81.3% in RUL-B, 73.9% in BF and 78.0% in BT.
Mean number of treatments in each group was significantly different (p < 0.0001), 12.02 in RUL-UB, 10.2 in RUL-B, 7 in BF and 7.5 in BT. Post hoc analysis indicated that RUL-UB differed significantly from BT and BF.
Final response and remission rates including patients who switched were 98% and 82% in RUL-UB, 100% and 93.8% in RUL-B, 100% and 73.9% in BF, and 97.7% and 83.7% in BT.
Conclusions: The majority commencing RUL-UB switched and received 4–5 more treatments compared to bilateral placement.
Heritability, a Key to the Misunderstanding of Genetics
S Rosenman
St John of God Health Care, Burwood, Australia
Background: ‘Heritability’ of schizophrenia is 80% in various studies. This justifies the extraordinary investment in the genetics of various psychiatric conditions. Heritability is a technical statistic which describes the variance of a characteristic in a population and does not explain the occurrence of the character. The heritability of two-leggedness is zero.
Objectives: To explain the nature of the heritability statistic and illuminate how the misunderstanding of it feeds into the misunderstanding of the nature of genetic explanation in psychiatry.
Methods: The paper explains the concept of the statistic and illuminates how its misapprehension slithers through the professional and popular understanding of genetics in psychiatry.
Findings: Heritability gives an approximate idea of the innate and environmental components of variation in populations. It does not tell us what is inherited or how genetic differences are translated into phenotypic difference.
Conclusions: The misunderstanding of this statistic lights the way to the misunderstanding of genetics in general and the misunderstanding of genetic explanation in psychiatry, ‘nature vs. nurture’ and the ‘bio-psycho-social model’.
Anorexia Nervosa in a Pakistani Adolescent Female in the Context of Bullying and Family Problems: A Literature Review
A Yousuf Shaikh1, B Saad2, B Hager3
1Liaquat National Hospital & Medical College, Karachi, Pakistan
2Department of Psychiatry, Liaquat National Hospital & Medical College, Karachi, Pakistan
3Department of Psychiatry, University of New Mexico, Albuquerque, USA
Background: Anorexia nervosa is a rare disorder with a lifetime prevalence rate of 0.5 % in the adolescent population in United States. It has been defined in the new DSM-5 with three core features that include restriction of energy intake relative to requirement, leading to significant low body weight, an intense fear of gaining weight or becoming fat and a disturbance in the way in which one’s body weight or image is experienced. We came across a case of anorexia nervosa in a 13-year-old Pakistani female in the context of bullying and family problems, who manifested the entire criteria as per DSM-IV.
Objectives: To report a case of a Pakistani adolescent female who presented with anorexia nervosa, in the context of bullying and family problems, and review of literature.
Methods: A review of the American Academy of Child and Adolescent Psychiatry practice parameters, along with literature review from Journal of the American Academy of Child and Adolescent Psychiatry and other sources via PubMed.
Findings: Consistent with anorexia nervosa.
Conclusions: Anorexia nervosa is a rare disorder found across all cultures. It is a chronic, potentially life-threatening disorder characterized by remission and relapses which can make working with these patients challenging.
Bullying and family problems are known risk factors for anorexia nervosa. As child psychiatrists we should work towards actively promoting awareness of this disorder in the context of bullying and social pressures and institute early interventions to minimize the risk of developing anorexia nervosa.
Measuring and Thinking About Metabolic Risk for Patients of a Community Mental Health Team – a Clinical Practice Improvement (CPI) Project
S Shankar, K Barfoot, R McCahon, M Medway, D Paul, M Treanor
Lower North Shore Assertive Outreach Team (AOT), Northern Sydney Local Health District, Sydney, Australia
Background: There is increasing evidence of the link between mental health and adverse physical health (AIHW, 2012; Scott and Happell, 2011). Our team is an intensive outreach team providing community mental health services to clients with major mental illnesses aged 18–65.
Objectives:
To increase case manager involvement in physical health care;
To improve the identification of physical health concerns of 100% of AOT clients through Metabolic Monitoring over 12 months.
Methods: Staff members attended a meeting to identify barriers and solutions to good physical health. Following this, a resource folder was created, and the CPI team provided regular support. To achieve Objective 2, a goal of 6-monthly monitoring of physical measurements and blood tests was set.
Findings: A file audit ascertaining adherence to the monitoring goal revealed an improvement from 40% at baseline to 77% at 12 months. AOT client participation in monitoring was 86.6% at baseline, 85.7% at 6 months and 80.7% at 12 months. 58.1% were identified as having metabolic syndrome at baseline, and 56% at 12 months. Barriers to monitoring were patient or illness factors, e.g. motivation or disorganisation, and resource factors, e.g. staff member availability.
Conclusions: The physical health of the mentally unwell is recognised as an area of concern. Our CPI demonstrates that mental health clinicians can and do have a role in the monitoring of the physical health of our clients, a vulnerable group who may not be able to advocate for themselves.
References
AIHW (2012) Comorbidity of mental disorders and physical conditions 2007. Cat. no. PHE 155. Canberra: AIHW.
Scott D and Happell B (2011) The high prevalence of poor physical health and unhealthy lifestyle behaviours in individuals with severe mental illness. Issues in Mental Health Nursing 32: 589–597.
“Will I Need My Stethoscope?” – Measuring and Thinking About Moving 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, 2012). There has been a corresponding rise in the popularity of a ‘Recovery Oriented Approach’ (ROA) (Barber, 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.
Barber ME (2012) Recovery as the new medical model for psychiatry. Psychiatric Services 63: 278-279. DOI: 10.1176/appi.ps.201100248
Reported Clozapine-Related Adverse Drug Reactions in Australia 1993–2013
D Siskind1,2, A Kolomensky2, K Winckel3,4, A Wheeler5, S Hollingworth3
1Metro South Addiction and Mental Health Service, Brisbane, Australia
2School of Medicine, University of Queensland, Brisbane, Australia
3Pharmacy Australia Centre of Excellence, Brisbane, Australia
4Princess Alexandra Hospital, Brisbane, Australia
5Griffith Health Institute, Brisbane, Australia
Background: Clozapine is the gold standard medication for treatment-refractory schizophrenia (TRS). Its benefits for this patient population need to be weighed against its potentially life-threatening adverse drug reactions (ADRs). The most notable of these are haematological (neutropenia and agranulocytosis) and cardiovascular (myocarditis and cardiomyopathy).
Objectives: To track the rates of reporting of clozapine ADRs in Australia using data from the Therapeutic Goods Administration (TGA).
Methods: Using data from the TGA Database of Adverse Event Notifications (DAEN), we examined all reported clozapine ADRs from the reintroduction of clozapine in 1993 to 2013. ADRs were grouped by organ class and tracked by year over the 20-year data collection period.
Findings: There were 7092 ADRs reported to the TGA DAEN involving clozapine. Of these, approximately one-third involved haematological ADRs and two-fifths involved cardiovascular ADRs. There was a spike in reporting of cardiovascular ADRs in 2000, after the publication in 1999 of the case series of myocarditis in the Lancet by Kilian et al.’s group from Sydney. Cardiovascular ADRs have continued to increase over the study period, while haematological ADRs remain comparatively stable.
Conclusions: Clozapine ADRs remain a barrier to treatment for people with TRS. Rates of reported haematological ADRs are higher than for other ADRs. Previously published reports suggest that the rates of myocarditis are higher in Australia than in other countries. This could be in part due to a possible over-diagnosis of clozapine-induced myocarditis in Australia.
Reference
Kilian JG, Kerr K, Lawrence C and Celermajer DS (1999) Myocarditis and cardiomyopathy associated with clozapine. The Lancet 354(9193): 1841–1845.
Childhood Abuse and Onset of Psychosis in Adulthood
V Sivalingam, V Tanwani
General Psychiatry, Institute of Mental Health, Singapore
Objectives: Explaining the possible correlation in childhood perceived abuse and development of paranoid psychosis in early adulthood.
Methods: A case report.
Results: We present the case/example of a young female patient whose early life experiences of perceived abuse by parents have culminated into a paranoid disorder/personality and a possible correlation between these. The patient developed symptoms of paranoid psychosis in early adulthood on the background of significantly unstable/discordant family dynamics and now has started waging an internet warfare against her parents. Psychobiosocial treatments have been making little inroads into her recovery.
Conclusion: This case report possibly explains the linkage between the possible development of early psychosis and childhood perceived abuse.
Neuropsychiatric Manifestation of Corona Radiata Infarct
V Sivalingam, V Tanwani
General Psychiatry, Institute of Mental Health, Singapore
Objectives: To explain the symptomatology of corona radiata infarct.
Methods: A case report.
Results: Lacunar infarcts are often considered benign as they do not usually cause clinically significant neurological/neuropsychiatric deficits. In this presentation, we highlight the case of a middle-aged female who developed psychiatric symptoms from lacunar infarcts in the corona radiata, necessitating pharmacological intervention. The possible association of lacunar infarct in corona radiata with neuropsychiatric symptoms may help in dealing with these patients with psychiatric symptoms more effectively.
Conclusion: This case report possibly explains the linkage between the possible neuropsychiatric presentation of corona radiata infarct necessitating pharmacological intervention.
Effectiveness of CTOs Applied by PaRK Mental Health Services
J Eatt, Y Yint, M Sewell, D Vecchio
Rockingham Kwinana Mental Health Service, Rockingham, Australia
Background: Following the UK-based OCTET study there has been debate about the effectiveness of Community Treatment Orders (CTOs). Australia and New Zealand have comparatively high numbers of patients on CTOs.
Objectives: Our study aims to examine the effectiveness of all the CTOs applied by Peel and Rockingham (PaRK) mental health services over the past years. Outcome measures will include readmission rate, time to readmission and length of stay in hospital. We will look at adverse incidents and risks before and after the person was subject to a CTO.
Methods: Twenty-five patients who were under CTO were identified. Information from the PSOLIS database regarding the current and previous Mental Health Act orders was compared with mental health admission dates recorded on the ISOFT Clinical Manager Program. There was also access to clinical notes. The number of admissions prior to and since the first CTO were recorded. Data was also collected to examine and compare the length of admission before and after the commencement of CTO, the time to readmission and the occurrence of significant clinical incidents pre and post CTO. We endeavour to have access approved for the same clients at other services in the state.
Findings: Our preliminary impression from the data is that following being subject to a CTO, the majority of patients had a reduced number of admissions and fewer adverse incidents.
Conclusions: Yet to be reached.
The Creation of the Chair of Psychiatry at the University of Sydney and the Tenure of Sir John Macpherson – the First Professor of Psychiatry in Australasia
R White
Discipline of Psychiatry, Central Clinical School, University of Sydney, Sydney, Australia
This presentation examines factors leading to the creation of the Chair of Psychiatry at the University of Sydney and the appointment, in July 1922, of Sir John Macpherson as its first incumbent. Macpherson had completed a stellar career in the United Kingdom that included Presidency of the Medico-Psychological Association (1910) and Commissionership of Lunacy for Scotland, an appointment that he relinquished in 1921. The presentation reviews Macpherson’s main achievements in New South Wales during his 54 months in the Chair. The presentation also examines Macpherson’s psychiatric interests, philosophy and values, as displayed in his writings, in contemporary accounts of his professional life, and in the Maudsley Lecture that he delivered in 1928. The presenter concludes with an appraisal of the importance of Macpherson’s tenure as the Foundation Professor of Psychiatry at the University of Sydney – and the first Professor of Psychiatry in Australasia.
