Keynote Abstracts
Compulsivity in the Obsessive–Compulsive Disorder Spectrum: Cognitive Domains, Neural Circuitry and Treatment
NA Fineberg1,2,3, MM Vaghi4,5, P Banca4,5, AM Apergis-Schoute4, SR Chamberlain3,4,6, E Cinosi2,7, ET Bullmore3, BJ Sahakian3,4, TW Robbins4,5
1Hertfordshire Partnership University NHS Foundation Trust, Hertfordshire, UK
2Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
3Department of Psychiatry, School of Clinical Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
4Behavioural and Clinical Neurosciences Institute, University of Cambridge, Cambridge, UK
5Department of Psychology, University of Cambridge, Cambridge, UK
6Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
7Department of Psychiatry, Gabriele D’Annunzio University, Chieti, Italy
Background: Compulsions are stereotyped behaviours, performed according to rigid rules and designed to reduce unpleasant consequences. Obsessive–compulsive disorder (OCD) is the archetypal compulsive disorder. A focus on compulsivity is also relevant for other disorders exhibiting compulsive behaviour, e.g., obsessive–compulsive spectrum disorders and behavioural and substance addictions. These lifespan disorders are poorly understood, difficult to treat and responsible for considerable psychiatric and somatic morbidity, cost and burden to the individual and society.
Objectives: To generate biologically relevant illness models of compulsivity for improved classification, outcome prediction and treatment (psychological, pharmacological, somatic) of OCDs.
Methods: To review advances in translational research into the neurobiological underpinnings of compulsive behaviour, focusing on OCD as the exemplar disorder and touching upon natural history and treatment models, candidate neurocognitive endophenotypes and associated neural circuitry.
Findings: Growing evidence from human and animal research suggests the neurocognitive mechanisms mediating behavioural inhibition and cognitive flexibility (motor inhibition, reversal learning, set-shifting) and habit learning (shift from goal-directed to habitual responding) contribute towards vulnerability to compulsive activity in a broad range of disorders characterized by compulsivity. In OCD, distributed network perturbation appears focused around the pre-frontal cortex, caudate, putamen and associated neuro-circuitry. Promising results from a small number of treatment studies using neuro-modulation to target nodes within this frontal–striatal circuitry indicate new treatment possibilities for refractory OCDs.
Conclusions: Translational approaches are beginning to identify the neuropsychological mechanisms underpinning compulsivity as a new trans-diagnostic neuropsychiatric domain. Such developments show promise in the search for novel treatment targets for compulsive disorders.
Childhood-Onset Psychosis: Insights from Neuroimaging Studies
N Gogtay
Office of Clinical Research, National Institute of Mental Health (NIMH), National Institutes of Health (NIH), USA
Psychotic illnesses in children are rare but can be severe. Childhood-onset schizophrenia (COS), with onset of psychosis before age 13 years, is a rare form of schizophrenia that represents a more severe and chronic form of the adult-onset illness. Structural and functional magnetic resonance imaging (MRI) studies of pediatric psychoses, and COS, along with their non-psychotic siblings provide unique insights into brain development in psychotic illnesses as a whole. COS brain development shows progressive loss of gray matter volume and cortical thinning, ventricular enlargement, progressive decline in cerebellar volume and a significant but fixed deficit in hippocampal volume, findings which appear dimensionally regulated and diagnostically specific. COS also shows a slower rate of white matter growth and disrupted local connectivity strength. Sibling studies indicate that non-psychotic siblings of COS patients share many of these brain abnormalities, including decreased cortical thickness and disrupted white matter growth, yet these abnormalities normalize with age. Longitudinal neuroimaging studies remain a valuable tool for assessing the neurobiology of schizophrenia as well as other psychotic illnesses, and parallel studies in unaffected siblings provide insights into both risk and resilience in these illnesses.
Is Psychiatry Lost in Translation?
R Howard
Division of Psychiatry, University College London, London, UK
Background: As psychiatrists, we are taught that the best predictor of our patients’ future behavior is their past behavior. If we apply the same principle to the discovery of new and effective treatments for mental health disorders, it is difficult to avoid the conclusion that serendipity, rather than translational neuroscience, is likely to be the source of major advances.
Objectives: To review the evidence, using the currently available treatments for psychosis, mood and Alzheimer’s disease, of serendipity as the primary source of treatments which have represented major advances in psychiatry.
Methods: Unsystematic and idiosyncratic review of the literature.
Findings: It is hard to find effective treatments for our patients that were not discovered by accident or who are based on minor modifications of agents. Alzheimer’s disease, unusual among conditions that psychiatrists treat because it has an established pathology, has proved completely resistant to disease-modifying treatments developed to target that pathology. Within the whole of psychiatry, the cholinesterase inhibitors are the only novel treatments we have that can trace their development to a classic translational pathway. With their modest effects, these drugs have not revolutionized the care of dementia.
Conclusions: This is not an argument against translational neuroscience. However, our understanding of the brain and the underlying mechanisms of mental health disorders is still in its infancy and the potential success of translation is hampered by this. It is not necessarily unscientific to learn the lesson from our profession’s history and give chance a chance.
Addiction Psychiatry: How Can Brain Research Empower New Treatments?
D Nutt
Imperial College London, London, UK
Background: Addiction is a major health problem that costs Western societies the same as schizophrenia and depression, but has many fewer effective treatments.
Objectives: To explore the brain mechanisms of addiction and the actions of current therapies to determine how to develop new interventions and to optimize selection of current treatments according to brain functions.
Methods: Multimodal imaging with positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) studies have been conducted in people with heroin and alcohol addictions and also in pathological gamblers.
Findings: Dopamine appears not to be a major mediator of heroin addiction in humans, unlike cocaine and other stimulants. We have found evidence for both gamma-aminobutyric acid (GABA) and endorphin dysregulation in both alcohol and heroin addictions, although not in pathological gamblers. We have also developed a challenge test to measure endorphin capacity and found reduced release in pathological gamblers and are now studying this in people with alcohol and heroin addictions. New relapse prevention treatments such as neurokinin 1 (NK1) and selective dopamine receptor antagonists have been tested in fMRI models of the behaviours predictive of relapse in abstinence and show interesting profiles of activity.
Conclusions: Imaging offers a powerful way to study the brain mechanisms of addiction and hopefully will lead to the development of new treatments targeted to the underlying brain systems that underpin addiction.
Rewiring Faulty Circuits – The Role of Deep Brain Stimulation
TE Schlaepfer1,2
1Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
2The Johns Hopkins Hospital, Baltimore, MD, USA
The introduction of deep brain stimulation for treatment-resistant disorders might very well lead to the most significant development in clinical psychiatry in the last 40 years – possibly offering a rise in hope for patients to whom medicine had hitherto little to offer. Furthermore, translational research on neuromodulation will allow us to glean something about the underlying cause of patient’s illnesses before figuring out a treatment that addresses the source of the problem. Major depression offers perhaps the best example of the rapid progress being made in understanding the biology of mental illness. Studies on the underlying neurobiology of major depression have typically focused on the description of biological differences between patients and healthy subjects such as alterations of monoaminergic or endocrine systems. Psychotropic drugs work by altering neurochemistry to a large extent in widespread regions of the brain, many of which may be unrelated to depression. We believe that more focused, targeted treatment approaches that modulate specific networks in the brain will prove a more effective approach to help treatment-resistant patients. In other words, whereas the existing depression treatments approach this disease as a general brain dysfunction, a more complete and appropriate treatment will arise from thinking of depression as a dysfunction of specific brain networks that mediate mood and reward signals. A better understanding of defined dysfunctions in these networks will invariably lead to a better understanding of patients afflicted with depression and perhaps contribute to a de-stigmatization of psychiatric patients and the medical specialty treating them.
The Advantages of a Simplified Classification of Personality Disorder in International Classification of Diseases – 11 Revision
P Tyrer1, M Crawford1, R. Mulder2, L-A Clark3; on behalf of the ICD-11 Working Group
1Centre for Mental Health, Imperial College London, London, UK
2Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
3Department of Psychology, University of Notre Dame, Notre Dame, IN, USA
Background: Personality disorder, probably more than any other disorder in psychiatry, needs a dimensional system of classification. Both the current Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD) classifications create one arbitrary anchor point for personality disorder, ‘no personality disorder’ and, by implication, no personality abnormality, separated from ‘personality disorder’, of all degrees of severity.
Objectives: The revisions of Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) and ICD-11 introduce a dimensional classification. Unfortunately, the classification for DSM-5 was rejected by the American Psychological Association (APA) for many reasons (Zachar et al., 2016).
Methods and findings: The proposed ICD-11 classification is based on evidence and rests mainly on a single dimension of severity ranging from no personality dysfunction and personality difficulty at one extreme, through to mild, moderate and severe personality disorder at the other. All the current categories of personality disorder are being abolished and are replaced by domain traits – detached, anankastic, dissocial, negative-affective and disinhibited – which are important but which are not diagnostic groups (Tyrer et al., 2015).
Conclusions: There is concern that well-established diagnoses such as borderline personality disorder fit in. They need not be; those with borderline personality disorder usually demonstrate disinhibited, negative affective and sometimes dissocial traits and so can be classified accordingly, and the level of severity confirms how troubling these features are. With increasing levels of severity, there are greater numbers of manifest domain traits.
References
Tyrer P, Reed GM and Crawford MJ (2015) Classification, assessment, prevalence and effect of personality disorder. The Lancet 385: 717–726.
Zachar P, Krueger RF and Kendler KS (2016) Personality disorder in DSM-5: An oral history. Psychological Medicine 46: 1–10.
Focused Psychodynamic Therapy for Borderline Personality Disorder
F Yeomans
Weill Cornell Medical College, New York, NY, USA
Background: Borderline personality disorder (BPD) is conceptualized many ways. This lecture will present an understanding of the disorder based on the idea that the core difficulty is in the individual’s personality structure, his way of processing his experience of self in relation to others. The lecture will focus (1) on the clinical utility of this understanding of the disorder as a way of achieving improvement both in specific symptoms and in the sense of self and quality of life and (2) on the trend in the field of psychopathology to adopt this view.
This emphasis on personality structure leads to a conception of the mechanisms of change in therapy with borderline patients, specifically an increase in reflective functioning associated with more integrated and coherent concepts of self and others. Specifying mechanisms of change can help render therapy more focused and efficient.
Transference-focused psychotherapy (TFP) is a form of psychodynamic psychotherapy modified to address the borderline condition that was developed at the Personality Disorders Institute of the Weill Cornell Medical College and has been researched both there and in Munich and Vienna. An increasing body of clinical experience and research shows that TFP can help patients achieve character change.
Objectives: A main goal of this lecture will be to encourage the clinician to consider the role of personality structure in addition to specific symptoms when assessing patient. Beyond that, this lecture will introduce the theory and basic techniques of TFP, an evidence-based treatment for BPD with the objective of changing the patient’s underlying personality structure in order to improve the patient’s fundamental relation to self and others in addition to achieving symptom improvement.
Methods: Lecture format with clinical examples.
Findings: Studies of three independent samples of patients have shown that, in addition to improvement in symptoms, TFP is uniquely associated with patient improvement in the important psychological functions of reflective function, attachment security and coherence of narrative discourse.
Conclusions: Understanding and considering the role of personality structure in assessing and treating patients will help therapists achieve more comprehensive improvements in their treatment of patients with BPD. TFP is an effective therapy for patients with borderline personality structure.
Invited Speaker Abstracts
Life Has To Be Understood Backward: Why Maternal Mental Health Is Important For Society
PS Chandra
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
Although there has been a lot of emphasis on postpartum mental health and its outcomes, the role of prenatal mental health and stress on pregnancy, fetal and infant outcomes has been neglected until recently.
Antenatal depression and anxiety are common causes of prenatal stress, as are partner violence and life events. Prenatal stress occurs in nearly 30% of all pregnancies and can lead to preterm births, low birth weight and higher pregnancy-related complications. This can be due to the direct effect on the fetus through the cortisol–hypothalamic–pituitary–adrenal (HPA) axis pathway or due to nutritional causes as well as poor antenatal healthcare utilization.
Fetal programming influences not only the immediate outcomes of pregnancy; rather, by influencing the environment in utero, during different critical periods for specific outcomes, stress in the mother can alter the development of the fetus, with a permanent effect on the child. Evidence indicates that diseases that were once thought to arise in adult life are now known to have roots in prenatal and early postnatal life.
The latest studies worldwide, including data from South Asia, will be reviewed for evidence related to the impact of maternal mental health on infant, adolescent and later life psychiatric and medical problems.
Along with risk and vulnerability factors, there may be several protective factors unique to different cultures that may have important implications for prevention. Finally, the presentation will discuss how psychiatrists can help in early interventions for maternal mental health.
Early Detection and Treatment of Personality Disorder in Young People
A Chanen1,2,3
1Orygen – The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia
2Centre for Youth Mental Health, The University of Melbourne, Melbourne, VIC, Australia
3Orygen Youth Health, NorthWestern Mental Health, Melbourne, VIC, Australia
Personality disorder can be recognized early in life and is especially common and clinically significant during the extended period of development from puberty to around the middle of the third decade of life. During this period, personality disorder has the potential to disrupt the transition to adult role functioning, leading to persistent functional impairment and morbidity, as well as premature mortality. This makes the recognition and management of personality disorder in young people an important clinical task and offers opportunities to intervene to support more adaptive development. Although effective prevention and early intervention programs have been developed, these are limited to borderline and antisocial personality disorders so far. Prevention and early intervention programs based on non-specific risk factors and narrowly defined personality disorder categories are unlikely to fully achieve their aims. Rather, the prevention of personality disorder needs to be integrated with the prevention of other mental disorders. Although further research is needed to understand the numerous developmental pathways to personality disorder, it is more important to understand the complex interplay between changes in personality traits and clinical presentation over time that leads to persistent problems and adverse outcomes.
Applicability of the Recovery Model to Child and Adolescent Mental Health Services: Are We Dosing Kids with an Adult Formula?
W Chen
Department of Child and Adolescent Psychiatry, The University of Western Australia, Perth, WA, Australia
Background: The ‘National Framework for Recovery-oriented Mental Health Services’ describes Recovery as a key policy direction shaping mental health service delivery across Australia. In the Australian Mental Health Bill 2013, the provision of Recovery-oriented services is embedded within the Core Care Principles in the Charter of Mental Health; inevitably, Recovery forms a cornerstone in modernizing an innovative Child and Adolescent Mental Health Services (CAMHS). Despite extensive mapping of such journeys among adults, mainly focused on the chronic schizophrenia model, the applicability of Recovery to CAMHS has neither been rigorously evaluated nor supported by empirical evidence.
Objectives: To highlight the applicability of anomalies and knowledge gaps.
Methods: Critical literature review and expert consultation.
Findings: On the lexicon level, the term Recovery is not applicable. From the developmental perspective, a mental illness may dislocate young people (YP) from a normative life trajectory, and intervention aims to return the YP to that trajectory and not to the premorbid state. Resilience theory and valorization theory were reported as more relevant as they denote positive adaptation within the context of significant adversity. Simmonds et al. (2014) reported some convergence with adult models in the initial Recovery stages, but there was subsequent divergence. The recent literature on normative and pathological identity formation provides additional insights into specific processes that are unique and critical during adolescence, with relevance to Bourdieu’s notions of ‘social, cultural, economic and symbolic capitals’ in identity shifts. The emphasis in adult models on taking full ‘personal responsibility’ is not appropriate to YP, when parental control and adults’ guidance remain necessary. The notions of ‘hopes’ and ‘connectedness’ must be considered within the context of cognitive maturity and attachment patterns as well as developmental age, which alter the expression of attachment needs and the conceptualization of future and opportunities.
Conclusions: The available published studies and expert opinions suggest substantial divergence from adult models: Recovery in YP differs in kind rather than just degree. The findings suggest that policy makers should invest in appropriate research and appraise the available knowledge based on YP’s development.
Reference
Simonds LM, et al (2014) Adolescents with anxiety and depression: is social recovery relevant? Clinical Psychology & Psychotherapy, 21(4): p. 289–298.
Elderly Suicide in China and Hong Kong
H Chiu
Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong
Suicide rates were very high in China in the 1990s, with a unique pattern of high suicide rates in rural areas, in young females and in older people. In recent years, there has been an overall decreasing trend of suicide rates in China, but the suicide rate of elderly people in rural areas remains high. This presentation will explore this phenomenon.
In Hong Kong, the elderly suicide rate was high in the 1980s and the 1990s. A territory-wide Elderly Suicide Prevention Program was implemented in 2004. This program adopts a multifaceted service model (gatekeeper training, timely treatment of depression, aftercare for suicide attempters and case management). The program has two tiers of operation: the first comprises predominantly primary care providers and the second, specialist psychogeriatric services. Patients identified as being severely depressed or at risk of suicide by gatekeepers in the first tier were referred to this program and were provided with home visits, expedited specialist psychiatric care in a Fast Track Clinic and intensive, community psychiatric nursing services. This presentation will describe this program and the recent downward trend of elderly suicide rates in Hong Kong.
Predictors of Unscheduled Care Costs in Patients with Long-Term Conditions
E Guthrie
Manchester Mental Health and Social Care Trust (MMHSCT) and The University of Manchester, Manchester, UK
Background: Chronic physical illnesses are common in the general population, with roughly 30% of people in England suffering from at least one long-term condition (LTC). The healthcare cost for people with LTC accounts for approximately 70% of the total healthcare budget in England.
Objectives: To investigate the effect of both depression and illness representation on the total costs of unscheduled care over a 12-month prospective period for patients with LTCs in primary care.
Methods: A longitudinal cohort study of 1860 patients was conducted. The baseline measures included the Hospital Anxiety and Depression Scale (HADS) and the Brief Illness Perception Questionnaire (B-IPQ). Healthcare costs of both unscheduled care and scheduled care were obtained by detailed reviews of general practitioner records.
Findings: Both the HADS depression and the total B-IPQ subscales were independent predictors of the costs of unscheduled care when entered separately into the regression models, after controlling for all relevant variables. When entered together, the B-IPQ was a more powerful predictor. The severity of illness and previous use of unscheduled care were also independent predictors.
Conclusions: This study suggests that between one-quarter and one-third of the costs of unscheduled care for patients with LTCs are accounted for by psychological factors, which are not routinely measured in this population. This study is part of a large National Institute for Health Research programme grant, and other relevant work from the programme will be used to contextualize the results.
Homicidal Threats, Ideation and Behaviour in Adolescents: A Clinician’s View
S Harden
Forensic Adolescent Mental Health, Child and Youth Mental Health Service, Children’s Health Queensland, Brisbane, QLD, Australia
Background: Homicidal ideation or threats to harm other people are not uncommon presentations in adolescents, and these phenomena cause significant concern to clinicians, services and the wider community. Dr Scott Harden in both public and private practices has been involved in the provision of advice regarding the assessment, treatment and disposition of numerous adolescents presenting with homicidal ideation, threats and actions for more than 10 years.
Objectives and methods: The objective was to identify the current best practice with regard to responding to adolescent ideation or threats that have elements of homicidality. The recent literature with regard to assessment of this clinical issue was reviewed. Cases in recent years seen within the forensic adolescent mental health service for the southern two-thirds of Queensland were identified and reviewed. Discussion with other practitioners in the field in peer-review settings was held. General principles in the approach to the clinical problem were identified. Illustrative de-identified or public domain cases will be discussed in detail to illustrate clinical approaches.
Findings: There are three stages of response chronologically: the first is rapid assessment of threat and imminent danger, the second is more comprehensive violence risk assessment and formulation and the third is management planning and implementation.
The first stage of rapid assessment of threat often does not require specialised expertise but does require rapid gathering of collateral data from multiple sources to make a timely decision regarding the presence or absence of a high level of imminent danger and any requirement for appropriate action.
The second stage requires specialised clinicians (in a team or individual context) who have an understanding of the current scientific data predictive of violence risk and the ability to develop individual psychological risk formulations of the young people involved.
The third stage often requires a comprehensive management plan involving multiple individuals or agencies with clear communication and liaison.
Conclusions: Adolescents who make threats against others or disclose homicidal ideation require rapid assessment of the level of threat they may pose to others as well as specific interventions related to the aetiology of the threat or homicidal ideation. Clinical practice is often complex, frequently has three or more stages and may require multi-agency consultation and coordination.
Stimulation-Induced Plastic Changes of the Prefrontal Cortex in Psychiatric Disorders
M Nakamura1,2,3,4, T Saeki2, Y Noda1,5
1Kanagawa Psychiatric Center, Yokohama, Japan
2School of Medicine, Yokohama City University, Yokohama, Japan
3School of Medicine, Showa University, Tokyo, Japan
4Advanced Telecommunications Research Institute International (ATR), Kyoto, Japan
5University of Toronto, Toronto, ON, Canada
Background: Stimulation-induced neuroplasticity in the human prefrontal region has not been sufficiently elucidated due to a lack of reliable biomarkers such as motor-evoked potentials.
Objectives: The objective was to establish reliable biomarkers that could be used to help visualize neuroplasticity and thus to optimize and personalize prefrontal stimulation protocols.
Methods: Neurobiological changes followed by repetitive transcranial magnetic stimulation (rTMS) of the dorsolateral prefrontal cortex (DLPFC) were longitudinally investigated in patients with major depression, using magnetic resonance imaging (MRI), diffusion tensor imaging (DTI), resting-state electroencephalograms (EEGs) and TMS-evoked EEG potentials (TEPs). TEP measurements followed by rTMS were also applied to adult patients with autism spectrum disorder (ASD).
Findings: Voxel-based morphometry (VBM) revealed that rTMS of the left DLPFC could increase gray matter volume of the left DLPFC. Clinical responders showed an increase in gray matter volume of the left DLPFC and left anterior and subgenual cingulate cortices. Voxel-based analyses of DTI revealed that rTMS could decrease ‘gray matter’ mean diffusivity in bilateral DLPFC. Resting-state EEGs showed longitudinal enhancement of spectral power of the gamma band oscillations at the left frontal region as well as the modulation index, which reflects theta–gamma coupling. The TEP components (N45 and N100) revealed that facilitatory rTMS could enhance prefrontal TEP amplitudes for around an hour in healthy volunteers, accompanied by tentative cognitive enhancement in a working memory task. However, adult patients with ASD did not show the enhancement of TEP components and cognition.
Conclusions: The present findings could reveal candidates for biomarkers of structural and functional neuroplasticity induced by rTMS. Using these potential biomarkers, the intra-individual and inter-individual variability of prefrontal stimulation could be evaluated in clinical practice.
Protecting Our Patients’ Rights: The Central Role of Psychiatrists
C Ryan1,2
1Discipline of Psychiatry and Centre for Values, Ethics and the Law in Medicine, The University of Sydney, Sydney, NSW, Australia
2Department of Psychiatry, Westmead Hospital, Sydney, NSW, Australia
Background: Since Australia’s ratification of the Convention on the Rights of Persons with Disabilities (CRPD), all but two of its jurisdictions have taken steps to reform their mental health legislation particularly with regard to the importance of supported decision-making and decision-making capacity. While some states, such as Tasmania and Western Australia, have reformed treatment criteria so that adults cannot be subjected to psychiatric treatment if it is competently refused, other jurisdictions have reacted to this element of the Convention by reforms, which are clearly not CRPD-compliant. They have, for example, retained discriminatory treatment criteria but have revised the Act’s objects and principles in an effort to promote the importance of Convention principles.
Conclusions: Consultation-liaison psychiatrists, already well versed in assessing decision-making capacity and in providing support for decision-making in the realm of physical illness, are particularly well placed to further the aims of the CRPD at the coalface, regardless of any deficits in local legislative frameworks. This paper sets out how clinicians should operate within the new legislative environment and how consultation-liaison psychiatrists might play a particularly important role.
Enigma-ND: The Enigma Neuroimaging Genetics Project for Neurodegenerative Disease and Aussie
P Thompson
Laboratory of Neuro Imaging, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
Background: We discuss recent work by the Enhancing Neuroimaging Genetics through Meta-Analysis (ENIGMA) consortium – a global alliance of over 500 scientists spread across 200 institutions in 35 countries collectively analyzing brain imaging, clinical and genetic data.
Objectives: Initially formed to detect genetic influences on brain measures, ENIGMA has grown to over 30 working groups studying 12 major brain diseases by pooling and comparing brain data. We discuss challenges and opportunities in applying these predictors to individual subjects and new cohorts, as well as lessons we have learned in ENIGMA’s efforts so far.
Methods and findings: In some of the largest neuroimaging studies – of schizophrenia and major depression – ENIGMA has found replicable disease effects on the brain that are consistent worldwide, as well as factors that modulate disease effects. In partnership with other consortia including the Alzheimer’s Disease Neuroimaging Initiative (ADNI), Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE), IMAGEN and others, ENIGMA’s genomic screens – now numbering over 30,000 magnetic resonance imaging (MRI) scans – have revealed at least eight genetic loci that affect brain volumes. Downstream of gene findings, ENIGMA has revealed how these individual variants – and genetic variants in general – may affect both the brain and the risk for a range of diseases.
Conclusions: The ENIGMA consortium is discovering factors that consistently affect brain structure and function that will serve as future predictors linking individual brain scans and genomic data. ENIGMA is generating vast pools of normative data on brain measures – from tens of thousands of people – that may help detect deviations from normal development or aging in specific groups of subjects.
Divorce and Suicidal Risk: A Comparison between East and West
P Yip1,2
1Centre for Suicide Research and Prevention, Hong Kong
2Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong
Divorce rates in East-Asian countries have increased significantly in the past decade. While divorce is known to be detrimental to the mental well-being of the community, there is still a lack of in-depth investigation regarding suicide mortality among the divorced in East-Asian cultures.
We compare the age- and sex-adjusted suicide rates among divorced men and women from five locations: four from East-Asia (Hong Kong, Taiwan, Japan and South Korea) and one from the West (Victoria, Australia). A risk ratio was calculated and suicide rates were compared between divorced and married individuals. All ratios are reported with 95% confidence intervals.
For both men and women across age categories, the suicide rates were higher among divorced groups from East-Asian countries compared to Australia. The sex ratio was significant only for Japan and South Korea. The age trends for the divorced groups were similar for men and women from Hong Kong and Taiwan: rates decreased with age. For Japan, a rise was seen up to 40–59 years for men after which the rate declined, while for women the rate decreased with age. For South Korea, the rates increased steadily with age for men and decreased for women. For Australia, no significant variation across age groups was seen for men, but for women the rate increased to 40–59 years and then declined.
The risk ratios (divorced males and females vs their married counterparts) were generally higher for all East-Asian groups except for those older than 60 years for Hong Kong, females aged 40–59 years for Japan, males older than 60 years and females in the 40- to 59-year age groups for South Korea and males older than 60 years and females older than 40 years for Taiwan. The age trends were also different between Australia and East-Asian countries: in Australia, the ratios increased with age in contrast to the decrease with age noted for all East-Asian countries. The sex ratio of risk ratios was significant only for Japan and partly for South Korea for the 25 years and older age groups. Compared with a previous study, the risk ratios indicate a narrowing of the gap for females and a reversal of the gap for males (Australian men were three times more likely to be harmed by divorce in a previous study, but this study shows that men from Hong Kong are more at risk).
Our findings illustrate that divorced people may be at a higher risk of suicide in East-Asian cultures compared to the West. Several socio-cultural explanations are suggested. A gender difference in the risk was appreciated only for Japan. Age trends show that different factors may increase this risk within East-Asian cultures. ‘Purification’ over time of the married populations rather than a change in the protective effect of marriage may have increased the effect of divorce on suicide rates apparent for Hong Kong compared to Australia.
Populations and Disasters - How Not to Make a Bad Thing Worse
S Wessely
Chair Psychological Medicine, Institute of Psychiatry, King’s College London, President, Royal College of Psychiatrists
You might think that in a world that is so full of disasters, emergencies, terrorism and so on, psychiatrists have at least managed to work out what is the best way of managing psychological distress and disorder afterwards. And you would be wrong. This presentation will explore the many things that can go wrong, how we can make it worse, and the occasional things we do well.
Pre-Congress Workshop Abstracts
Neurodevelopmental Disorders: Focus on Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorder
V Eapen1, W Chen2, P Chan3
1The University of New South Wales, Sydney, NSW, Australia
2The University of Western Australia, Perth, WA, Australia
3Hospital Authority, Hong Kong
Background: Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) are commonly encountered neurodevelopmental disorders with unique diagnostic and management challenges.
Objectives: This workshop will focus on the following aspects:
• Clinical features of ASD and ADHD including the diagnostic process, differential diagnosis and comorbidities;
• Genetic and neurobiological factors that underpin the translation of biological vulnerability to clinically significant symptoms and behaviours;
• Integrating information in relation to the links between neuronal substrates and neuronal circuitry to cognition and behaviour;
• General principles of management including pharmacological and non-pharmacological interventions, covering early intervention to transition to adolescence.
Methods: The workshop will be divided into two half-day sessions covering ASD and ADHD, respectively.
Findings: Given that these neurodevelopmental disorders are heterogeneous in origin and clinical presentation, this session will provide a framework for understanding the overlapping and yet distinct neurodevelopmental and neuronal circuitry as well as family and environmental factors involved in the production of symptoms with consequent implications for management.
Conclusions: Better understanding of the developmental trajectory and the associated risk and resilience factors will allow a more comprehensive management of these disorders.
Transference-Focused Psychotherapy: An Evidence-Based Psychodynamic Therapy for Borderline and Narcissistic Personality Disorders
F Yeomans
Weill Cornell Medical College, New York, NY, USA
Background: The treatment of borderline and narcissistic patients is one of the most challenging areas in psychiatry. Many clinicians are intimidated by the prospect, are pessimistic about the outcome and consider stabilization of symptoms, without deep change in the personality, the best possible outcome. However, an increasing body of clinical experience and research shows that transference-focused psychotherapy (TFP) can help these patients achieve character change. TFP is a form of psychodynamic psychotherapy modified to address the borderline condition.
TFP was developed at the Personality Disorders Institute of the Weill Cornell Medical College and has been researched both there and in Munich and Vienna.
Objectives: This workshop will teach the theory of TFP and introduce the techniques that help the therapist provide effective treatment of this disorder with less chaos and stress than is usually associated with the treatment of borderline patients. The workshop will include an overview of object relations theory, which provides a way to understand the psychological structure of these patients and will go on to summarize the strategies, tactics and techniques of the therapy.
Methods: The workshop will be in a lecture format with many clinical examples and, if time permits, the viewing of a video of a session.
Findings: Studies of three independent samples of patients have shown that, in addition to improvement in symptoms, TFP is uniquely associated with patient improvement in the important psychological functions of reflective function, attachment security and coherence of narrative discourse.
Conclusions: TFP is an effective therapy for patients with borderline and narcissistic personality disorders.
Third Joint Symposium of the University of Melbourne Department of Psychiatry and Peking University Institute SF Mental Health
IP Everall1, L Lu2, C Pantelis1, H Wang2, T Lee1, M Zhao2
1Department of Psychiatry, The University of Melbourne, Parkville, VIC, Australia
2Institute of Mental Health, Peking University, Beijing, China
Background: The Department of Psychiatry, The University of Melbourne and Peking University Institute of Mental Health have after over a decade of engagement established in 2014 the University of Melbourne–Peking University Centre for Psychiatric Research and Training.
Objectives: The Joint Centre supports the mutual supervision of PhD students who will spend time undertaking research projects for their PhDs in both Melbourne and Beijing. The Centre also supports the junior post-doctoral student research exchanges between the two institutions and the organisation of an annual joint symposium.
Methods: The proposed symposium will have presentations from both institutions that will include current PhD students providing updates of their projects as well as senior researcher presenting finding from their work that may form suitable potential future collaborative research projects.
Findings: The Joint Centre is currently generating new data from the ongoing PhD projects.
Conclusions: The Joint Centre is an example of how successful joint collaborative research programmes can be carried out between research institutions in Australia and China
Psychopathology and Personality Traits Associated with Driving While Intoxicated in Beijing, China: Implications for Interventions
R-J Zhao1,*, W Sun1,2,3, L-L Zhang4, Y-P Bao5, L Huang4, Z-Q Wang6, S-J Zhou1, T Kosten7,8, H-Q Sun2,3,*
1Department of Alcohol and Drug Dependence, Beijing Hui-Long-Guan Hospital, Peking University, Beijing, China
2Peking University Sixth Hospital/Institute of Mental Health and National Clinical Research Center for Mental Disorders, Beijing, China
3Key Laboratory of Mental Health, Ministry of Health, Peking University, Beijing, China
4Beijing Municipal Department on Education-Through-Labor Assignment, Beijing, China
5National Institute on Drug Dependence, Peking University, Beijing, China
6Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
7Baylor College of Medicine, Houston, TX, USA
8Michael E. DeBakey VA Medical Center, Houston, TX, USA
*These authors contributed equally to this work.
Background and objectives: Driving while intoxicated (DWI) represents an area of grave concern in China, yet little research has focused on it or on the personality traits and psychiatric disorders among these drivers.
Methods: We enrolled 337 of 382 residents charged with DWI in a compulsory detention center in Beijing, China. All were screened for Axis I disorders by a psychiatrist using the Chinese version of the Structured Clinical Interview for the Diagnostic Statistical Manual of Mental Disorders IV-TR (SCID), the Minnesota Multiphasic Personality Inventory (MMPI-2) and the Sixteen Personality Factor Questionnaire (16PF).
Results: The subjects were all males with a mean (±standard deviation [SD]) age of 34.6 ± 8.49 years. They began drinking at 12.74 ± 8.25 years, and almost 30% met Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV) criteria for alcohol abuse or dependence (n = 95). Compared to normal controls, they showed greater social boldness, abstractedness, apprehension and tension, and poorer reasoning, sensitivity (p < 0.05), vigilance, openness to change and self-reliance. On the MMPI-2, DWI subjects showed greater hypochondriasis, psychopathic deviate, paranoia, psychasthenia, schizophrenia, and hypomania and lower social introversion.
Conclusions and scientific significance: Severe alcohol problems are more common in Beijing’s drunk drivers than in the Chinese general population. These DWI drivers also have a broad variety of traits that increase their tendency to be venturesome and socially bold while enjoying excitement and risk-taking.
Keywords
Driving while intoxicated, alcohol use disorders, epidemiological survey
Clinical Efficacy, Onset Time and Safety of Bright Light Therapy in Acute Bipolar Depression as an Adjunctive Therapy: A Randomized Controlled Trials
T Zhou, W Dang, X Yu
Peking University Institute of Mental Health, China
Background: Bright light therapy (BLT) is an effective treatment for seasonal affective disorder and non-seasonal depression. The efficacy of BLT in treating patients with bipolar disorder is still unknown.
Aims: The aim of this study was to examine the efficacy, onset time and clinical safety of BLT in treating patients with acute bipolar depression as an adjunctive therapy (trial registration at ClinicalTrials.gov: NCT02009371).
Methods: This study was a multi-center, single-blind, randomized clinical trial. In all, 74 subjects were enrolled and randomized in one of the two treatment conditions: BLT and control (dim red light therapy [dRLT]). A total of 63 subjects completed the study (33 BLT and 30 dRLT). Light therapy lasted for 2 weeks, 1 hour every morning between 6 a.m. and 9 a.m. All subjects were required to complete several scales assessments at baseline and at the end of weeks 1 and 2. The primary outcome measures were the clinical efficacy of BLT which was assessed by the reduction rate of Hamilton Depression Rating Scale (HAMD-17) scores and the onset time of BLT effect which was assessed by the reduction rate of Quick Inventory of Depressive Symptomatology–Self-Report (QIDS-SR16) scores. The secondary outcome measures were rates of switch into hypomania or mania which were measured by Young Mania Rating Scale (YMRS) and adverse events which were measured by Side Effect Rating Scale (SERS).
Results: (1) Clinical efficacy: BLT showed a significantly greater ameliorative effect on bipolar depression than the control intervention, 78.19% versus 43.33%, respectively (p = 0.01). (2) Onset time: median onset time was 4.33 days in BLT group. (3) BLT-emergent hypomania: no subjects from either group experienced symptoms of hypomania during this study. (4) Side effects: no serious adverse events were reported.
Conclusions: BLT can be considered as an effective and safe adjunctive treatment option for patients with acute bipolar depression.
Genetic Variation in the Tryptophan Hydroxylase 2 Gene Moderates Depressive Symptom Trajectories and Remission over 8 Weeks of escitalopram Treatment
Y-A Su1, J-T Li1, W-J Dai1, X-M Liao1, L-C Dong1, T-L Lu1, C Bousman2,3, T-M Si1,3
1National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital/Institute of Mental Health), and the Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
2Department of Psychiatry, Melbourne Neuropsychiatry Centre, The University of Melbourne, Parkville, VIC, Australia
3Peking University Centre for Psychiatry Research and Training and The University of Melbourne, Melbourne, Australia
Objectives: The serotonin system plays an important role in the pathogenesis of major depressive disorder (MDD), and genetic variations in serotonin-related genes affect the efficacy of antidepressants. The aim of this study was to investigate the relationship between genotypic variation in six candidate serotonergic genes (ADCY9, HTR1B, GNB3, HTR2A, TPH2 and SLC6A4) and depressive and anxiety symptom severity trajectories as well as remission following escitalopram treatment.
Methods: In total, 1066 Chinese patients with MDD were escitalopram-treated (open-label) for 8 weeks with assessments conducted before as well as at 1, 2, 4 and 8 weeks post-treatment. Linear mixed models were used to determine differences in depressive and anxiety symptom severity trajectories over the 8-week follow-up period by selected polymorphisms in the six candidate genes. Logistic regression models were used to test each polymorphism’s association with depressive and anxiety symptom remission.
Results: Eight-week depressive symptom severity trajectories were moderated by TPH2 rs4570625. Patients with the GT or GG genotype showed more favourable depressive symptom severity trajectories compared to TT genotype carriers. In addition, TPH2 rs4570625 GG carriers were more likely to achieve depressive and anxiety symptom remission compared to T-allele carriers. Polymorphisms in ADCY9, HTR1B and HTR2A were nominally associated with symptom remission but did not withstand correction for multiple comparisons.
Conclusions: These results suggested that genotypic variation in TPH2 may moderate the therapeutic response to escitalopram among Chinese patients with MDD.
Keywords
Serotonin, escitalopram, TPH2, polymorphism, efficacy
Integration of Brain Expression Quantitative Trait Loci (EQTL) and Genome-Wide Association Data Identifies A Susceptibility Locus for Major Depression Disorder at 8p21.2
H Yu1,2,3,*, X Zhang2,3,*, H Yan2,3, L Wang2,3, D Zhang2,3,4,5, W Yue2,3
1Tsinghua-Peking Joint Center for Life Sciences, School of Life Sciences, Tsinghua University, Beijing, China
2Peking University Sixth Hospital (Institute of Mental Health), Beijing, China
3National Clinical Research Center for Mental Disorders and Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
4Peking University–Tsinghua University Joint Center for Life Sciences, Beijing, China
5PKU-IDG/McGovern Institute for Brain Research, Peking University, Beijing, China
*These authors contributed equally to this work.
Genome-wide association studies (GWAS) have identified several risk variants and loci that showed robust association with major depression disorder (MDD). However, many additional susceptibility loci remain to be discovered. The susceptibility single-nucleotide polymorphisms (SNPs) might partially contribute to MDD through regulating the risk gene expression levels. To examine the impact of expression quantitative trait loci (eQTL) variants on risk of MDD, we integrated brain expression quantitative trait loci and genome-wide association data of MDD using Sherlock, a Bayesian statistical framework. Our analyses identified solute carrier family 25 (mitochondrial iron transporter), member 37 (SLC25A37) as a MDD risk gene (p = 2.03 × 10−5). Subsequent analyses confirmed the association of the SLC25A37 and its expression SNP (eSNP) in independent samples. Then, for SLC25A37 gene, we performed single-marker meta-analysis of the combined discovery and replication sample (comprising 14,543 MDD cases and 14,856 controls), and the most significant SNP was rs11995896 (p = 2.57 × 10−8). Further gene expression analysis suggested that the SLC25A37 was significantly down-regulated in
frontal cortex of MDD patients (p = 4.45 × 10−3). Protein–protein interaction analysis suggested that SLC25A37 interacts with several MDD susceptibility genes, including gamma-aminobutyric acid (GABA) B receptor, 1 (GABBR1) and FK506-binding protein 5 (FKBP5). Collectively, our results revealed that SLC25A37 might confer risk to MDD. Further investigation of the roles of SLC25A37 in the pathogenesis of MDD is warranted.
Keywords
Major depression disorder, genome-wide association study (GWAS), solute carrier family 25 (mitochondrial iron transporter), member 37 (SLC25A37), expression quantitative trait loci (eQTL)
The Distribution of Disability Attributed to Mental Disorders and Rehabilitation Service Utilization: A National Cross-Sectional Survey in China
H Chen, L Shang, Y Huang
The Sixth Hospital/Institute of Mental Health, Peking University and Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
Objective: To describe the prevalence of disability attributed to mental disorders, its population distribution and region distribution in China.
Methods: The data of the Second National Sampling Survey on Disability in 2006 were analyzed by descriptive and analytic epidemiological methods. Descriptive statistics were used to present prevalence rates of disability attributed to mental disorders by socio-demographic characteristics including ethnic groups, regions, economic zones and severity degrees. Chi-square test was used to compare distributions of disability prevalence rates. Statistical Product and Service Solutions (SPSS) 20.0 package was used to perform statistical analyses.
Results: The number of total respondents was 2,526,145. The prevalence of disability attributed to mental disorders in China was 6.3% accounting for 9.9% of all disabled people. The Han ethnic group had a significantly higher prevalence rate of disability attributed to mental disorders than those of other minorities. There were significant differences of disability prevalence rates attributed to mental disorders among the eastern, the central and the western regions, but there were no significant differences between the eastern and the western regions. The disability prevalence rates in eight economic zones were also significantly different, and the highest disability prevalence rate in the southern coastal zone was 7.1%. Significantly higher disability prevalence rates were found in rural areas compared to urban areas. Prevalence of disability attributed to mental disorders increased with age. Before the age of 65 years, the prevalence of mild disability was higher than those of other disability degrees in the same age group, followed by extremely severe disability. But the prevalence of extremely severe disability was the highest after 65 years of age. Only 14.62% of mental disability persons applied for disability certificates, and 40.66% of people with mental disability never received any rehabilitation services.
Conclusions: The prevalence of disability attributed to mental disorders was lower than those of other types of disability in China. The distributions of prevalence of disability attributed to mental disorders vary in population and region in China. Further enquiry into low rehabilitation service utilization would be beneficial to improve service level of mental rehabilitation, especially in rural China.
Early Intervention for Borderline Personality Disorder
A Chanen1,2,3
1Orygen – The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia
2Centre for Youth Mental Health, The University of Melbourne, Melbourne, VIC, Australia
3Orygen Youth Health, NorthWestern Mental Health, Melbourne, VIC, Australia.
Borderline personality disorder (BPD) is a leading candidate for developing empirically based prevention and early intervention programs because BPD is common in clinical practice, among the most functionally disabling of all mental disorders, often associated with help-seeking and responds to intervention. Moreover, BPD can be reliably diagnosed in its early stages and it demarcates a group with high levels of current and future morbidity and mortality. Data also suggest considerable flexibility and malleability of personality disorder traits in youth, making this a key developmental period during which to intervene. The Helping Young People Early (HYPE) program in Melbourne, Australia, is a novel prevention and early intervention program for BPD in youth (15- to 25-year-olds). HYPE provides early detection of personality disorder and early intervention using an integrated, team-based intervention model comprising assertive case management, general psychiatric care and cognitive analytic therapy.
This workshop will cover the current research evidence about BPD in young people and present a model for best practice early intervention services for youth with BPD and associated problems.
The learning objectives are as follows:
• Understand the rationale for early intervention for BPD;
• Understand the structure of an exemplar early intervention program for BPD;
• Understand how to screen and assess for BPD in youth;
• Understand the key principles of early intervention for BPD;
• Distinguish some factors that can interfere with treating BPD, such as working with risk and chronic self-harm;
• Provide an overview of a relational model that can assist in working collaboratively with young people with BPD.
Long-Term Psychodynamic Psychotherapy for the Trainee
L Diana1,2,3,4
1Shellharbour Hospital, Mount Warrigal, NSW, Australia
2Private Practice, Wollongong, NSW, Australia
3Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
4Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia
Background: Psychiatry trainees approach the long-term psychodynamic psychotherapy case with a mix of anticipation and trepidation. There is often little background training given before they commence the case, and they need to ‘learn as they go’.
Objectives: The aim of the workshop is to give participants an introduction to the underlying theory and practice of psychodynamic psychotherapy. While the workshop will look at the theoretical underpinnings such as attachment theory, the concept of unconscious and repressed emotions, the emphasis will be practical. At the end of the workshop, the participant will have a good theoretical and practical understanding of how to conduct a typical session. It will be emphasized that these skills can be applied generally in conducting a psychiatric interview and will make it easier to understand the patient from a psychodynamic perspective.
Methods: The emphasis will be on interactive participation. A workbook will be made available outlining the main points of the theory and practice of psychodynamic psychotherapy. Vignettes will be presented; these will be role-played and the participants will have the opportunity to take part in mock psychotherapy sessions to practise specific skills and techniques.
Findings: While psychodynamic psychotherapy is a ‘talking therapy’ which is not manualised, there are specific approaches and techniques which make this treatment understandable to the beginner.
Conclusions: At the completion of the workshop, the attendees would have learnt the basic ‘nuts and bolts’ of conducting psychodynamic psychotherapy which will give them confidence in approaching the long-term psychological methods case.
Competency Assessment: Challenges and Controversies
J Casey1, C Silberberg2, P Pun3
1Greenlane Clinical Centre, Auckland, New Zealand
2St Vincent’s Hospital, Melbourne, VIC, Australia
3The Princess Alexandra Hospital, Brisbane, QLD, Australia
Background and objectives: This full-day pre-Congress workshop, convened jointly by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Faculties of Psychiatry of Old Age and Consultation Liaison, aims to provide delegate psychiatrists and trainees with an in-depth appreciation of the complex challenges inherent in competency assessment and to enhance knowledge and skills of this topic.
Methods: In the first part of the workshop, expert speakers from the fields of old age psychiatry and consultation-liaison psychiatry will present on theoretical aspects of the determination of competency, with a focus on how this interacts with mental health acts and guardianship legislation. The program will conclude with a case-based expert panel discussion on the clinical, legal and ethical issues in the determination of competency and capacity in relation to health matters. Interactive audience participation is encouraged in the panel discussion, by way of questions and answers with the expert panelists.
Findings and conclusions: While the request to determine competency in a healthcare setting most commonly arises in the subspecialty areas of old age and consultation-liaison psychiatry, it is the contention of the organizers of this workshop that the knowledge and skills necessary to explore the level of decision-making ability of patients are relevant to the entire field of psychiatry. As such, delegate psychiatrists and trainees from a whole range of work settings cross-culturally and internationally are likely to improve their clinical practice by attending this forum, thereby updating their knowledge and understanding of this complex but important domain.
Clozapine: The Double-Edged Sword – A Workshop on the Quality and Safe Use of Clozapine
Hannah Myles1,3, Nick A Antic2,4, Robert Adams1,6, Madhu Chandratilleke4, Dennis Liu1,3, Nicholas Myles1, Jeremy Mercer2,4, Andrew Vakulin2,4, Andrew Vincent1,7, Gary Wittert1,7, Cherrie Galletly1,3
1Adelaide University, Adelaide, Australia
2Flinders University,
3Northern Adelaide Local Health Network (NALHN)
4Adelaide Institute for Sleep Health, Flinders Centre for Research Excellence, Flinders University
5NeuroSleep and Woolcock Institute of Medical Research, University of Sydney,
6The Health Observatory, Discipline of Medicine, TQEH;
7Freemasons Foundation Centre for Men’s Health
Background: Clozapine is the most effective medication for treatment-refractory schizophrenia (TRS); however, there is a significant burden of adverse drug reactions. Safe and quality prescribing of clozapine requires a fine balance between management of psychotic symptoms and amelioration of the adverse drug reactions our consumers bear.
Objectives:
1. Understanding of relevant clozapine screening, initiation and monitoring protocols;
2. Review of the evidence base for clozapine efficacy and augmentation;
3. Management of common and serious adverse drug reactions associated with clozapine, including obstructive sleep apnoea (OSA);
4. Examining the physical health comorbidities of people on clozapine.
Methods: The presenters will review the current peer-reviewed and grey literature guidelines and present an up-to-date analysis of the key features of quality and safety, with a specific focus on physical health comorbidities, OSA, augmentation strategies, management and monitoring systems, predictive treatment modelling and cardiac complications.
Findings: Clozapine is significantly more effective than other anti-psychotics for TRS early in treatment. Although monitoring focuses on preventing agranulocytosis, there are a range of other complications associated with significant comorbidities including cardiac, constipation, OSA, sialorrhoea, seizures and infection.
Conclusions: At the end of this symposium, practitioners will be proficient in the quality use of clozapine.
Civil Forensic Psychiatry Workshop
R Lewin1, Y Skinner2, J Parmegiani3, J Bertucen4
This half-day pre-Congress workshop will be the first of a series of educational programs presented at the Royal Australian and New Zealand College of Psychiatrists (RANZCP) conferences. The series is intended to provide practical clinical guidance for early and mid-career clinicians. These are clinicians developing subspecialist skills in civil forensic psychiatry.
In this initial workshop, each of four parts will commence with a short didactic presentation. This will be illustrated with case discussions, the review of a learned article or a legal case.
Some pre-reading will be provided.
Topics covered in the first seminar will include the following:
• Ethics in practice (presenter Dr Robert Lewin);
• Report preparation (presenter Dr Yvonne Skinner);
• Dealing with case referrals (presenter Dr Jeff Bertucen);
• Practical aspects of setting up a medico-legal practice (presenter Dr Julian Parmegiani).
Participants will consider the role of the independent psychiatric assessor, legal and ethical boundaries, the requirements of the expert report and the interaction with legal and psychiatric colleagues.
How to Develop a Community-Influenced Organisational Culture
R McKay1,2, G Roper1
1The Royal Australian and New Zealand College of Psychiatrists Community Collaboration Committee, Melbourne, VIC, Australia
2NSW Institute of Psychiatry, Parramatta, NSW, Australia
Background: Community member engagement, including that of consumers, families/whānau and carers, is highly valued in mental health organisations to enhance the quality, safety and effectiveness of services. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) encourages genuine engagement to incorporate the diverse needs, perspectives, concerns and values that community members bring and which help influence the RANZCP at various levels of its business.
Objectives: Members of the RANZCP Community Collaboration Committee will help develop ideas that attendees would have brought with them on:
• Where the community can provide influence in their organisations;
• How to identify appropriate skills that will enable the relative perspectives to be articulated.
Attendees will have the opportunity to take away from the workshop:
• Developed plans to move forward;
• Developed appointment selection processes for community members by utilising a participation and collaborative model.
Methods: By sharing experiences as users and members of a wider community of health services, RANZCP community members will provide examples of how they were able to bring their experiences as consumers (or their carers) of mental health services. Depending on attendees’ interests, this may focus on the mechanisms within local areas or on mechanisms within the RANZCP to shape policy such as by joining committees or by receiving funds to attend scientific conferences. In addition, clinicians will share their perspectives on the value of regular consultation with the community and their reflections on which aspects of community involvement may be the most influential in different settings.
Findings: Community members, by working in collaboration as partners with psychiatrists, have an opportunity to plan, monitor and influence their own experience in clinical practice. Research indicates that consumers who are involved in management of their care experience better health outcomes and that carers who are similarly involved help achieve better health outcomes for consumers.
Conclusions: Community members can draw on their own personal skills and healthcare experiences to influence an organisational culture that is open and community-friendly.
The Family Model: An Integrated Approach to Working with Two-Generation Mental Health Problems in Families
A Falkov
Westmead and Royal North Shore Hospitals, Sydney, NSW, Australia
Background: The prevalence of adult carers who experience mental health (MH) problems and the associated impact of their symptoms on their offspring are now well described, as is the impact of children and young people’s difficulties (especially chronic physical and MH difficulties) on parent’s/carers’ MH. Psychiatric disorder in one or more individuals within families is therefore a significant public health issue with implications for affected individuals (children, young people and parents), families, as well as clinicians and managers.
Objectives: There are, therefore, compelling reasons for improving family-focused practice. This requires systematic identification of parents and children in MH services and parent’s MH in children’s services, as well as a broader approach to assessment and intervention. This workshop will provide an overview of the Family Model, its use in different service settings and the clinical skills for supporting family-focused practice.
Methods: The workshop will consist of selected material from The Family Model Handbook (www.thefamilymodel.com), handouts, PowerPoint and clinical vignettes to support participant dialogue.
Findings: Learning objectives will include the following: information about the global implications of family MH, knowledge of and skills in using the Family Model clinically and an implementation framework for family-focused practice in MH services.
Conclusions: Any approach which reduces onset, impact and persistence of MH problems in individuals will have clinical, life quality and economic or cost–benefit advantages for families and service providers.
Art and Psychiatry, and the Art of Psychiatry: The Work of the Dax Centre
P Brous1, J Eddy2
1The Royal Australian & New Zealand College of Psychiatrists, Melbourne, VIC, Australia
2Alfred Child and Youth Mental Health Services, Melbourne, VIC, Australia
Background: The Dax Centre, at the University of Melbourne, is an educational facility constructed around the Cunningham Dax Collection.
The Collection’s 17,000 artworks were created by those with the lived experiences of mental illness or psychological trauma. It includes films produced by the Centre.
Exhibitions and innovative learning programs aim at increasing public mental health literacy and deepening understandings of mental health disorders and psychological trauma, for secondary students and for tertiary students of medicine and allied health professions.
The exhibitions are attended by about 20,000 people and 5000 students annually.
Objectives: The objectives are as follows:To demonstrate the relevance of the arts for understanding mental disorders and psychological trauma, by informing about the history and the importance of the Cunningham Dax collection, its exhibitions and programs;The work in the Cunningham Dax Collection demonstrates human creativity and resilience in the face of severe illnesses, trauma and adversity;To explore the pertinent ethical issues;To present the impact evaluations of these programs.
Methods: Relevant literature will be reviewed together with screenings of films created by the Dax Centre.The Poetry Collection will also be presented.Program evaluations will be presented.
Findings:These programs reduce stigma and enhance empathy, as the creative arts enhance public mental health literacy.Teaching utilizing the creative arts assists secondary and tertiary students to understand the scope and importance of these disorders.The clinical teaching of psychiatry can be enhanced through the media of the creative arts.
The Diagnosis of Autism in Women and Girls
T Flower1, A Livingstone2
1Monash University and Private Practice, Melbourne, VIC, Australia
2Victorian Dual Disability Service, St Vincent’s Hospital, Melbourne, VIC, Australia
Autism is diagnosed more frequently in boys than in girls at rates of approximately 5:1. The rates of diagnosis of autism spectrum disorder (ASD) are reported to be increasing, possibly as the result of increased awareness of the condition or as a result of improved diagnostic tools. The diagnosis of autism in girls and women still lags behind their male counterparts with the diagnosis often being made much later in a girl’s life. This may be because girls present differently from boys, having better social skills and a more developed sense of empathy. Girls do not line up their cars or obsess over ‘Thomas’, and if a specific history of interactions with ‘my little pony’ is not solicited, the diagnosis may be missed!
This workshop will consider the incidence of autism in women from a historical perspective and will focus on improving the participants’ ability to make the diagnosis of an ASD in girls and women in the current clinical practice. The workshop will consider many diagnoses that are often considered before the diagnosis of autism is made, such as social anxiety disorder, borderline and schizoid personality disorder and schizophrenia, through the use of de-identified case studies and vignettes. Different diagnostic instruments for autism and their appropriateness for use with girls and women will be discussed. At the end of the workshop, participants will feel confident about including a diagnosis of ASD in their diagnostic repertoire.
Leadership and Management: Trainee and Early Career Psychiatrist Workshop
N O’Connor1,2, B Kotze3,4,5, R Newton6,7, S Clark4,8
1Northern Sydney Local Health District, Sydney, NSW, Australia
2Department of Psychiatry, The University of Sydney, NSW, Australia
3Children and Young People, NSW Ministry of Health, Sydney, NSW, Australia
4Department of Psychiatry, The University of New South Wales, Sydney, NSW, Australia
5Department of Psychiatry, University of Technology Sydney, Sydney, NSW, Australia
6Austin Hospital, Melbourne, VIC, Australia
7Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
8Western Local Health District, Orange, NSW, Australia
Background: This half-day pre-Congress workshop will be run by four senior psychiatrists from the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Section of Leadership and Management who have extensive experience in leadership of mental health services.
Objectives: The workshop will provide opportunities for the attendees to consider how a range of leadership and management issues and challenges could be effectively approached and managed. The workshop will demonstrate how senior psychiatrists experienced in leadership and management deal with a range of scenarios.
Methods:
Attendees will be provided with scenarios of leadership and management issues, challenges and dilemmas. The workshop panel will lead and facilitate discussion of the scenarios and provide advice on how these could be best managed.
The workshop has the capacity for 40 participants.
Attendees will be provided with pre-workshop reading.
Conclusions: The workshop will meet the RANZCP requirements for a Leadership and Management structured training session of 4 hours.
Mindfulness for Stress Management and Well-Being in Psychiatry
M Kenny
Centre for the Treatment of Anxiety & Depression (CTAD), SA Health, Adelaide, SA, Australia
Background: Psychiatry is a high-demand environment with significant levels of responsibility for serious clinical outcomes. The 2013 beyondblue National Mental Health Survey of doctors found unacceptably high levels of depression, anxiety and burnout symptoms in both medical staff and medical students. Medical educators are beginning to ask themselves whether resilience training should be part of the preparation/orientation for working in such environments.
Objectives: In this workshop, the pathways to burnout will be explained using recent advances in knowledge from the neuroscience of stress physiology. The psychological and neuroscientific rationale for teaching mindfulness meditation in certain mental health conditions (depression, stress and anxiety) will be discussed, and the extrapolation to doctors’ self-care will be demonstrated.
Methods: This half-day workshop will be divided into two parts with a theoretical overview followed by a more practical session focusing on some short mindfulness practices to use in our everyday working lives as psychiatrists and trainees. The practices and strategies are derived from mindfulness courses that Maura Kenny specifically designed for medical staff and which have been trialled in more than 300 healthcare professionals to date in the Australian context.
Findings: Data from these mindfulness courses demonstrate reductions in stress and anxiety and were retained at follow-up.
Conclusions: Mindfulness approaches that foster resilience, compassion and well-being are increasingly being taught within healthcare settings, and the benefits for staff have been demonstrated in numerous research trials nationally and internationally.
Medico-Legal Opinion Construction
J Chalk1, N McVie2,3,4
1Private Practice, Brisbane, Australia
2Mental Health Court Queensland, Brisbane, QLD, Australia
3Forensic Psychiatry, Hunter New England Local Health District, Newcastle, NSW
Australia
4Chair, RANZCP Faculty of Forensic Psychiatry, Melbourne, VIC, Australia
This half-day workshop will focus on the elements of medico-legal report construction. The group will be highly interactive with participants drafting and discussing the elements of successful reports.
Dr McVie and Dr Chalk have both run successful workshops on medico-legal report writing. This course is aimed more at sharpening the skills that participants have already acquired.
The workshop will be a practical guide to the formulation and expression of opinion with a focus on avoiding the common pitfalls that render reports open to challenges. Both civil and criminal reports will be discussed.
Participants will need to provide a de-identified recent report that they have completed.
Vicarious Trauma, Reparative Moments and Self-Care in Trauma-Informed Therapy
G Halasz1, V Gordon2
1Monash University, Melbourne, VIC, Australia
2Children’s Court Clinic, Melbourne, VIC, Australia
Background: Mental health professionals treating traumatised patients are exposed to the risk of vicarious trauma as neurobiological mechanisms transfer trauma between patient and therapist. The therapist’s dual clinical responsibility is both patient-care and self-care while sustaining an awareness that both are exposed to re-traumatisation during the course of therapy. Self-care is often overlooked.
Objectives: Workshop participants will update their clinical skills and theoretical understanding to recognise the symptoms of vicarious trauma and associated phenomena of dissociation and enactment while learning to apply techniques to provide ‘experience-near’ reparative moments as part of self-care.
Methods: By Ogden P, Fisher J. Sensorimotor Psychotherapy, Interventions for Trauma and Attachment, New York: Norton, 2015sensorimotor psychotherapy intervention techniques for trauma therapy, participants will learn to apply techniques to promote reparative moments. Clinical vignettes from the authors’ experiences illustrate how techniques are applied during child, adolescent and adult trauma therapy for relational (Schore), developmental (van der Kolk) and complex trauma histories.
Findings: Clinical experience informed by the neurobiology of vicarious trauma and ‘dissociative attunement’ (Hopenwasser) suggests that the risk of exposure to vicarious trauma can be reduced by skilful application of reparative moments during trauma-informed therapy.
Conclusions: Participants will increase their understanding of the neurobiological mechanism involved in vicarious trauma, learning to apply clinical techniques to increase chances for reparative moments and self-care while reducing the risks of vicarious trauma.
Combined Symposium Abstracts
Working Perinatally to Change Intergenerational Pathways: Approaches to Early Intervention and Prevention are Vital to Clinicians and Government Policy
P Chandra1, E Hoehn2, AS Williams3,4, S Luty5,6, S Kinley6
1Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
2Queensland Centre for Perinatal and Infant Mental Health, Children’s Health Queensland Hospital and Health Service, Brisbane, QLD, Australia
3Perinatal and Infant Mental Health Services, Women’s and Children’s Health Network, North Adelaide, SA, Australia
4The University of Adelaide, Adelaide, SA, Australia
5University of Otago, Christchurch, New Zealand
6Mothers and Babies Service, Christchurch, New Zealand
Background: Perinatal mental health is fundamental to mental and physical health outcomes throughout life. Government policies underpin good perinatal mental health as does the clinician’s understanding of bio-psycho-sociocultural causation and management. The symposium focuses on cultural underpinnings of perinatal issues and moves to a practical understanding of advances in therapies for perinatal women. Intervening with this population promotes mental health. Increasing the knowledge of psychiatrists in this area is vital to clinical practice and to informing policy at government levels.
Objectives: To bring together multicultural speakers from perinatal and infant psychiatry to inform about policy, advocacy and therapies that have intergenerational consequences; To describe interventions to interrupt these cycles; To move toward proposed systemic/government changes which further aids the above; To ensure governmental programs that previously identified postnatal depression, anxiety and intimate partner violence move toward identification, education and treatment pathways for the whole gamut of mental health issues in families, including the effects on infants.
Methods: Four presenters will summarise recent findings about approaches that benefit the understanding of perinatal families and discuss proposals for future policies.
Findings: Solid evidence exists that intervention in the perinatal period, which includes infants, returns significant gains for families and society. The existing programs can be expanded to include treatment of a range of mental health issues. Group programs show promise.
Conclusions: Expertise exists in psychiatry to intervene early and effectively in perinatal families by identifying illness within cultural norms, educating a wider range of primary care practitioners, providing targeted care and influencing government policy.
Presenter 1
How Culture Shapes Psychiatric Disorders in Motherhood
P Chandra
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
Pregnancy and motherhood have always had deep cultural meanings, and each culture has different rituals attached to the perinatal period. There is no part of the world where psychiatric disorders in the perinatal period have not been reported. However, the labelling of these disorders depends on explanatory models related to them which may influence help seeking and treatment acceptance. In some cultures, there may be a tendency to normalise mental health problems in the postpartum as expected reactions, whereas, in others, mental health problems may be attributed to diet, the absence of prescribed rituals in pregnancy and the postpartum, and the evil eye or to being possessed by spirits.
In cultures where gender preference for a male child plays a major role for the mother’s status in society, this may be an important contributing factor. Acceptance of psychiatric treatment, myths related to breast feeding when a mother is depressed and the father’s role in support are also largely culturally determined. Indeed, culture may also influence psychopathology and clinical presentation such as the content of delusions and hallucinations.
For psychiatrists working in a multicultural setting, these insights are important to understand the context in which the mother–infant dyad may live and to help in actively engaging the mother and her family in the treatment process.
Presenter 2
The Evidence Is In: 1001 Critical Days – A Priority and an Opportunity for Mental Health Promotion, Prevention and Early Intervention That Cannot Be Ignored
E Hoehn
Queensland Centre for Perinatal and Infant Mental Health, Children’s Health Queensland Hospital and Health Service, Brisbane, QLD, Australia
Background: An evidence base has emerged highlighting the importance of pregnancy and the early years of a child’s life for setting a foundation for social and emotional well-being and resilience, and reducing the risk of the intergenerational transfer of mental health issues. Pregnancy and the early years are a public health priority and require an integrated and collective approach to achieving positive outcomes.
Objectives: To provide an overview of the 1001 Critical Days Manifesto and Coalition and to summarize the existing literature on the importance of pregnancy and the early years of a child’s life in building emotional resilience, optimizing development and reducing the likelihood of future mental health issues through promotion, prevention and early intervention.
Methods: Literature searches of the science of child development and the early years of a child’s life including an understanding of the neuroscience, the impact of trauma, the importance of sensitive and responsive care for optimal infant development and the requirement of a collaborative community and service sector that can respond to the social and emotional needs of perinatal families.
Findings: Solid evidence exists for positive returns in investing in social and emotional well-being and child development in pregnancy and the early years of a child’s life for individuals, families and society.
Conclusions: An integrated and collective response is required to ensure optimal social and emotional well-being outcomes in the perinatal period, which will become the foundation for future resilience and reduce the risk of the intergenerational transfer of mental health issues.
Presenter 3
1001 Days: Moving Australia beyond the National Perinatal Depression Initiative to Early Intervention with Families with Infants
AS Williams1,2
1Perinatal and Infant Mental Health Services, Women’s and Children’s Health Network, North Adelaide, SA, Australia
2The University of Adelaide, Adelaide, Australia
Background: Borderline personality disorder (BPD) and disorders of emotional regulation in perinatal women are present in at least 2% of the population. These disorders have traditionally had little attention in perinatal populations and have been shown to transfer intergenerationally from mother to infant.
Objectives: To summarise the existing literature on the effects of emotional dysregulation on infants and children, theories on how these effects may happen and pathways to early intervention.
Methods: Literature searches of therapies to interrupt intergenerational transfer of BPD provided theoretical input regarding helpful modes, including a validated mode of treating the maternal BPD combined with further input for the mother and infant regarding development and their relationship. Dialectical behaviour-informed therapy (DBT)-I was initiated, which combines DBT along with significant input regarding the mother–infant relationship.
Findings: Working only with mothers who are well motivated, group therapy using DBT-I has showed that not only can mothers learn better emotional regulation but also that they are able to use new skills learned in DBT to enhance their parenting relationship.
Conclusions: While longitudinal studies are needed to validate intergenerational change in infants whose mothers have commenced DBT-I with them, early indications suggest promise. Some general learnings from these groups may be useful to parents struggling with their infants at a primary care level.
Presenter 4
An Adaptation of Group Interpersonal Psychotherapy in the Perinatal Period
SE Luty1,2, S Kinley2
1University of Otago, Christchurch, New Zealand
2Mothers and Babies Service, Christchurch, New Zealand
Background: Interpersonal psychotherapy (IPT) is an effective short-term treatment for depression and has been adapted for use in the perinatal period for individuals and for groups (IPT-G). The traditionally run group has not included the infants in the sessions. Including the infants and adapting the sessions to include a focus on the mother–infant relationship and mentalising strategies may help extend the reach of the intervention and help keep the baby in mind and improve outcomes for mother and infant.
Objectives: To summarise the literature on IPT and IPT-G in the perinatal period and to describe a pilot study of IPT-G in which sessions focusing on the mother–infant relationship and mentalising strategies have been added.
Methods: We are recruiting eight mother–infant dyads to run a 10- to -16-week adapted group IPT. Depressive symptoms and the mother–infant relationship will be measured using self-report scales (Edinburgh Postnatal Depression Scale [EPDS] and Postpartum Bonding Questionnaire [PBQ]).
Findings: The progress of the group and initial findings will be presented in the symposium.
Conclusions: IPT-G is a cost-effective and patient-friendly method for targeting depressive symptoms and the mother–infant relationship. Further possible applications of, and measures within, this intervention will be discussed.
Recognition and Treatment of HIV-Associated Neurocognitive Disorder (Hand) and HIV-Related Mental Health Problems in the Asia Pacific Region
I Everall1,2, D HT Wei3, ADG Nash4, M Corr4, D Horry4, R Ng5, MP Lee6
1Department of Psychiatry, University of Melbourne, Australia
2NorthWestern Mental Health, Melbourne, Australia
3Taipei City Hospital Kunming Branch, Taipei City, Taiwan
4Royal Prince Alfred Hospital, Sydney, Australia
5Kowloon Hospital, Hong Kong
6Special Medical Services, Department of Medicine, Queen Elizabeth Hospital, Hong Kong
Background: The prevalence of infection with the human immunodeficiency virus (HIV) varies across the Asia Pacific region and there is no standardized method of detection and treatment of the neurocognitive disorder that can occur in people living with HIV.
Objectives: In this symposium we will present a proposed protocol for assessing and treating HIV-associated neurocognitive disorder (HAND) in the Asia Pacific region that can be carried out in both low and well-resourced settings. We will also present the experiences of providing a HIV liaison service in a well-resourced hospital in Hong Kong and the experience of such a service in the main HIV referral centre in Guangdong Province.
Methods: There will be four presentations:
• IP Everall will present a proposed protocol for the assessment and treatment of HAND;
• D HT Wei will present on benzodiazepines and Z-drug use among HIV-infected patients in Taiwan;
• ADG Nash,M Corr and D Horry will present on the Grooved Pegboard as a screening tool for HIV-associated neurocognitive impairment.
• R Ng and MP Lee will present the pilot HIV liaison service in Hong Kong: its service development and challenges;
Findings: The experiences of all speakers will provide information and approaches to assessment and treatment as well as the differences and similarities in the problems encountered in two liaison services.
Conclusions: This symposium will highlight approaches to assessment and treatment of HAND as well as the range of HIV-related mental health problems encountered in the Asia Pacific region.
Presenter 1
Hand in the Asia-Pacific Region Recommendations for Screening
IP Everall1
1Department of Psychiatry, University of Melbourne, North West Mental Health
HIV-associated neurocognitive disorder (HAND) could incur a significant burden on HIV patients in Asia-Pacific countries; however, the incidence is difficult to estimate due to a lack of local epidemiological data. The impact of neurocognitive impairment in HIV patients is often underestimated due to a lack of education and awareness, and there are consequently gaps in the provision of screening and diagnosis to enable earlier intervention to limit neurocognitive impairment. This review seeks to redress the imbalance by promoting awareness and education among physicians concerning the neurovirulence of HIV and thereby increase screening efforts to improve diagnosis rates and clinical outcomes for underserved patients in this region. The Asia, Australia, and Middle East (AAME) HAND Advisory Board convened expert regional representatives to review current practice and recommend appropriate measures related to the implementation of standardised screening programmes and treatment recommendations to curb the developing HAND epidemic in the region. In particular, we recommend basic neuropsychological testing protocols that could be efficiently introduced into clinical practice for routine screening. We also propose simple guidelines for the management of HAND. We believe that HAND is a significant and under-reported diagnosis in HIV patients that warrants both greater recognition and further clinical investigation of the underlying pathophysiology and the impact of HIV disease progression, with HAND being associated with worse medication adherence and therefore possibly increased risk of ARV treatment failure. Widespread screening will lead to greater recognition of HAND and earlier intervention, which may lead to improved management strategies in the future.
Presenter 2
Benzodiazepines and Z-Drug Use among HIV-Infected Patients in Taiwan
H-T Wei, (David Wei)1
1Taipei City Hospital Kunming Branch, Taiwan
Benzodiazepines (BZDs) and zolpidem, zopiclone, and zaleplon (Z-drugs) are commonly prescribed to HIV-infected patients. We included 1,081 patients with HIV infection between 1998 and 2011 from the Taiwan National Health Insurance Research Database and matched them according to age, sex, and comorbidity with uninfected controls to investigate the psychiatric diagnoses and prescriptions of BZDs and Z-drugs. Cumulative defined daily dose (cDDD) was assessed as the indicator of the duration of medication exposure. Patients exhibiting a cDDD exceeding 180 were defined as long-term users. The patients with HIV had an increased risk of any use (odds ratio (OR): 8.70, 95% confidence interval (CI): 6.82–10.97) and long-term use (OR: 5.06, 95% CI: 3.63–7.04) of BZD and Z-drugs compared with those without HIV during the follow-up after demographic data and psychiatric comorbidities were adjusted. These findings suggest that poor sleep quality among HIV infected patients were noted and that providing psychiatric services such as sleep quality enhancement for HIV-infected patients are vital.
Presenter 3
The Grooved Pegboard as a Screening Tool for HIV-Associated Neurocognitive Impairment
ADG Nash1; M Corr1; D Horry2
1Department of Psychiatry, Royal Prince Alfred Hospital, Sydney, Australia;
2Department of Neurosciences, Royal Prince Alfred Hospital, Sydney, Australia
HIV-associated neurocognitive disorder (HAND) is an important morbidity in the course of HIV infection, it is identifiable and it can be reversible. Awareness and diagnosis of HAND in HIV services has increased over recent decades, however its identification often requires significant resources and time from physicians, neuropsychologists and psychiatrists. Particularly in resource–poor settings, the rates of identification of HAND are low, so effective screening tools are needed. Research to date on screening tools in this specific area has yielded equivocal or disappointing results.
We evaluated the sensitivity and specificity of the Grooved Pegboard as a stand- alone screening test in HIV infected persons. We retrospectively audited the formal neuropsychological assessments of 24 consecutive patients who were followed in a single institution. Inclusion criteria for the past assessments were as follows: 1. initial diagnostic assessment; 2. absence of major comorbid CNS pathology (eg non-HIV infection, epilepsy) 3. absence of significant comorbid neuromuscular pathology affecting motor performance and/or dexterity. 4. able to perform Grooved Pegboard test with dominant hand.
Formal neuropsychological testing of these patients routinely included Grooved Pegboard testing, with their dominant-hand raw scores being recorded in seconds. The raw scores were compared to the neuropsychologists overall opinion as to the presence of HAND. A dominant hand cut off score of 80 seconds on the Grooved Pegboard yielded a sensitivity of 100% (95% CI: 0.54 to 1.0) and a specificity of 89% (95% CI: 0.65 to 0.99). Additionally, positive predictive value was 75% (95% CI: 0.35 to 0.97) and negative predictive value was 100% (95% CI: 0.79 to 1.0).
Our findings highlight that this brief screening tool correlates well with formal neuropsychological testing in patients suffering from HIV. Given the ease of administration, this tool could assist as a first line screen for identifying individuals with neurocognitive impairment, particularly in settings where neuropsychological testing is not available.
Presenter 4
HIV Psychiatric Liaison Clinic in Hong Kong: A Pilot Experience
R MK Ng1 and MP Lee2
1Department of Psychiatry, Kowloon Hospital, Hong Kong
2Department of Medicine, Queen Elizabeth Hospital, Hong Kong
Around 3500 HIV positive carriers are receiving physical care for their illnesses in three HIV clinics in Hong Kong. Surveys in the clinics reveal that around 30-40% of these HIV carriers are suffering from drug misuse problems. In addition, many of them are also suffering from various forms of mental health problems including depressive and anxiety disorders. Due to the stigma associated with HIV and mental illness, many patients are reluctant to seek mental health care and remain untreated for their mental illnesses. Apart from increased morbidity and mortality associated with mental illness per se, mental illness may lead to reduced adherence to anti-viral medications, increased risks of transmission of HIV to others, and increased prevalence of HIV related comorbidities. Despite public health implications of psychiatric comorbidities in HIV positive carriers, there is as yet no formally established psychiatric liaison service in HIV centres in Hong Kong. Since 2015, a new psychiatric liaison clinic was established as a pilot project in the HIV centre of Queen Elizabeth Hospital of Hong Kong. We take this opportunity to share our experience of managing this HIV psychiatric liaison clinic.
Non-Pharmacological Approaches and Modern Technology to Improve Mental Health Outcomes in Older Adults
NT Lautenschlager1,2,3
1Academic Unit for Psychiatry of Old Age, Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
2NorthWestern Mental Health, Melbourne Health, Melbourne, VIC, Australia
3School of Medicine and Pharmacology, The University of Western Australia, Perth, WA, Australia
Background: This symposium aims to highlight the recent research developments in non-pharmacological approaches and use of modern technology for older adults to improve mental health outcomes.
Objectives: To showcase recent research in this area from Melbourne, Australia, and from Hong Kong and Beijing, China.
Methods: Five presentations will be given in this joint symposium. Different research projects will be introduced, highlighting the importance of non-pharmacological approaches and the use of modern technology.
Findings: Preliminary evidence suggests that non-pharmacological approaches and use of modern technology can enhance mental health outcomes in older adults in various settings.
Conclusions: Non-pharmacological approaches and the use of modern technology should be promoted in activities for older adults to help improve mental health outcomes.
Presenter 1
Computer-Assisted Cognitive Training in Social Centers for Chinese Older Adults in Hong Kong
LCW Lam, ATC Lee, AWT Fung, PCM Wong
Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong
Background: Population ageing requires attention to the possibility of minimizing cognitive decline or even to preventing the development of neurocognitive disorder in late life. It is increasingly recognized that lifestyle activities have great impact on cognitive function in older adults with a wide spectrum of cognitive abilities. From a public health perspective, strategies that encourage the implementation of cognitively stimulating lifestyle activities would have a tremendous impact on the optimization of cognitive function in this vulnerable group.
Methods: Computer-assisted cognitive training has been experimented as interventions in randomized controlled trials for healthy older adults and those with mild neurocognitive disorders in elderly social centers in Hong Kong. Based on different conceptual frameworks, cognitive training on working memory, attention and foreign language learning is now carried out.
Findings: Preliminary observations suggest that it is possible for Chinese older adults to accept novel scenarios, including facing a touchscreen computer for work, under close guidance at social centers. Interim analysis suggests a trend toward stabilization or improvements in some paradigms. It is hoped that the cognitive outcomes will demonstrate a significant positive trend upon study completion.
Conclusions: As computer-assisted cognitive training provides a reliable and standardized platform for intervention, the identification of suitable modalities with the highest effect sizes on cognitive efficacy could be introduced to community networks as a public health intervention.
Presenter 2
Association between Leisure Activities and Cognitive Function among Community-Dwelling Older Adults
M Zhao, H Zhang, X Lv, X Yu, H Wang
Dementia Care and Research Center, Peking University Institute of Mental Health, Beijing, China
Background: The number of people living with dementia is increasing as the population ages dramatically in China. Although there is no cure for dementia, addressing modifiable risk factors remains an important strategy for preventing the incidence of dementia. Active participation in lifestyle activities is considered potentially beneficial for preserving cognitive health in older adults.
Objectives: We aimed to evaluate the association between leisure activity participation and global and domain cognitive function among community-dwelling older adults in Beijing.
Methods: In total, 269 community-dwelling older adults without dementia were recruited and administered neuropsychological battery tests and a leisure activity questionnaire.
Findings: Adjusted for age, gender and educational level, more subtypes and more frequent participation in intellectual activity were significantly associated with better global cognitive function, executive function, learning and memory. Higher frequency and greater intensity of recreational activity were significantly associated with better perceptual–motor function.
Conclusions: The findings suggest that remaining engaged in intellectual and recreational leisure activities may be potentially beneficial for preserving cognitive function in old age.
Presenter 3
Effect of Tablet-Based Multi-Domain Cognitive Training on Brain Function in Mild Cognitive Impairment
H Zhang1,2, J Wang1,2, Z Wang1,2, X Wang1,2, X Yu1,2, H Wang1,2
1Dementia Care and Research Center, Peking University Institute of Mental Health (Sixth Hospital), Beijing, China
2Beijing Municipal Key Laboratory for Translational Research on Diagnosis and Treatment of Dementia, National Clinical Research Center for Mental Disorders, Beijing, China
Background: Cognitive training may help improve cognitive performance in older adults.
Objectives: We aimed to explore the effect of tablet-based cognitive training on brain function in mild cognitive impairment (MCI).
Methods: In total, 20 patients with MCI aged 55 years or older participated in the tablet-based multi-domain cognitive training, including reasoning, memory, visuospatial function, language, calculation and attention. All subjects were administered with a cross-cultural neuropsychological test battery (CCNB) and the Stroop color-word test. Eight patients completed the 12-week training and were examined with functional magnetic resonance imaging before and after the training.
Findings: After training, an increase in the amplitude of low-frequency fluctuation (ALFF) was observed in the precentral gyrus, postcentral gyrus, inferior parietal lobule, right temporal lobe, occipital lobe, calcarine and lingual (p < 0.05). A decrease in the ALFF was detected in the superior frontal gyrus, middle frontal gyrus, inferior frontal gyrus, left superior temporal lobe, left insula, cerebellar vermis and cerebellar peduncles (p < 0.05). No significant changes were found in the of CCNB test scores or the Stroop test.
Conclusions: Our findings suggest that tablet-based multi-domain cognitive training may increase activation in the brain regions involved in memory, visuospatial function and attention, and thus might improve cognitive plasticity in MCI.
Presenter 4
Touchscreen Technology and Older Adults in Residential Care
SM Loi1,2, D Huppert2, B Hoy2, J Swan2, A Mazur2, S Hodson2, NT Lautenschlager1,2
1Academic Unit for Psychiatry of Old Age, Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
2NorthWestern Mental Health, Melbourne Health, Melbourne, VIC, Australia
Background: Touchscreen technology (TT) such as iPads have much potential to improve the quality of life in older adults, but TT has yet to be researched extensively.
Objectives: This presentation describes two projects which explored the use of TT in residential care facilities.
Methods: The first study utilised TT as a non-pharmacological intervention hypothesised to decrease challenging behaviours in 15 older adults with a variety of psychiatric and cognitive disorders (such as dementia, depression and schizophrenia) in a crossover non-randomised trial. The second study utilised TT as an educational and interactive programme for six older adults, who had also had a range of psychiatric disorders (such as bipolar affective disorder and schizoaffective disorder), which was hypothesised to improve social connectedness and self-esteem.
Findings: TT appeared to have benefits in decreasing challenging behaviours and improving social connectedness. However, there were barriers in the uptake of this technology in residential care, cited by staff.
Conclusions: Research using larger sample sizes and more training for staff may provide more robust results and provide further information in the application of TT in this setting.
Presenter 5
Physical Activity and Cognitive Impairment: Benefits and Practical Challenges
NT Lautenschlager1,2, KL Cox3
1Academic Unit for Psychiatry of Old Age, Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
2NorthWestern Mental Health, Melbourne Health, Melbourne, VIC, Australia
3School of Medicine and Pharmacology, The University of Western Australia, Perth, WA, Australia
Background: Regular physical activity is associated with multiple benefits for physical and mental health across the lifespan. More recent studies have also shown that regular physical activity can be beneficial for older adults with mild cognitive impairment and dementia.
Objectives: This paper aims to summarise the current knowledge by highlighting the relevant information necessary to translate current evidence into practice.
Methods: Evidence from the recent literature was reviewed and will be presented in conjunction with results from physical activity research trials.
Findings: Although this is a relatively new research field with gaps in the current knowledge, there is enough evidence to suggest that targeted physical activity programmes for people with cognitive impairment should be developed and translated into the community and clinical settings. Practical steps include how to assess fitness capacity and needs of the consumer, how to support behaviour change, how to select the most suitable physical activity programme and how to identify and evaluate outcomes.
Conclusions: More practical advice needs to be developed to inform communities and clinical practice on how to best start physical activity programmes for older people with cognitive impairment. Despite these existing knowledge gaps, people with cognitive impairment should not miss out on the benefits of regular physical activity.
Emotional Lability (EL) among Children with Attention Deficit Hyperactivity Disorder in Australasia: Factorial Validity, Neural Circuitry Correlates and Compassionate Mind Training
W Chen1, L Liu2,3, XY Yu2,3, F Levy4, B Tam5, L Sun2,3, YF Wang2,3
1Department of Child and Adolescent Psychiatry, The University of Western Australia, Perth, WA, Australia
2Peking University Sixth Hospital/Institute of Mental Health and National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China
3Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
4The University of New South Wales, Sydney, NSW, Australia
5Department of Clinical Psychology, Princess Margaret Hospital, South Kwai Chung, Hospital Authority, Hong Kong
Background: Emotional lability (EL) and oppositional defiance disorder (ODD) frequently co-occur with attention deficit hyperactivity disorder (ADHD). Their relationships and neurobiological underpinnings are still poorly understood.
This symposium focuses on the recent research and findings on EL and ADHD in an Australasian research network, spanning Western Australia, New South Wales, Beijing and Hong Kong.
Objectives: This symposium explores the following:The factorial validity of EL as a construct distinct and independent from ODD;The neural correlates of EL in relation to resting state connectivity of amygdalasubregions with other brain regions;The potential roles of default mode network regarding EL;The applicability of compassion mind therapy as a treatment option for children with high levels of self-criticism, shame and emotional dysregulation.
Methods: A diverse range of methods were used to investigate these objectives.
Findings: The first presentation demonstrates that EL is distinct from ‘mood/affect’ and other subdimensions of ODD by both exploratory and confirmatory analyses. The second presentation reports the deficits in connectivity between top-down networks and amygdalar subregions detected in ADHD probands with higher levels of EL. The third presentation evaluates the relevance of the default mode network in emotional regulation. The fourth presentation examines the positive treatment effects of compassion mind therapy in a pilot study of children in Hong Kong.
Conclusions: EL is a clinically important presentation among children with ADHD, despite not being captured by the current major taxonomic systems. Studies reported in this symposium advance knowledge on EL with their scientific and clinical implications explored.
Presenter 1
Is Emotional Lability Distinct from ‘Angry/Irritable Mood’, ‘Negative Affect’ or Other Subdimensions Of Oppositional Defiance Disorder?
L Liu1,2,*, W Chen3,*, S Vitorator4, L Sun1,2, XY Yu1,2, ZM Wu1,2, L Yang1,2, QJ Qian1,2, YF Wang1,2
1Peking University Sixth Hospital/Institute of Mental Health, National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China
2Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
3The Department of Child and Adolescent Psychiatry, The University of Western Australia, Perth, WA, Australia
4Biostatistics Department, Institute of Psychiatry, King’s College London, London, UK
*These authors contributed equally to this work.
Background: Emotional lability (EL) and oppositional defiance disorder (ODD) frequently co-occur with attention deficit hyperactivity disorder (ADHD). Their co-concurrence could arise from their construct overlaps; in particular, some ODD items also describe mood and emotional dyscontrol behaviours, suggestive of item similarity on face validity.
Objectives: This study evaluates whether EL merely represents the negative ‘mood/affect’ component of ODD or forms a distinct dimension.
Methods: EL and ODD data from 1317 ADHD subjects recruited from the child and adolescent psychiatric clinics of Peking University Sixth Hospital/Institute of Mental Health were analyzed by exploratory and confirmatory factor analyses.
Results: (1) Within the ADHD sample of 1317 subjects, 39.4% had ODD and 42.6% had EL; 16.6% had ODD only, 19.7% had EL only and 22.9% expressed both. (2) EL forms a separate and distinct dimension from the ‘mood/affect’ and other subdimensions of ODD whether classified by the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) model (i.e. ‘angry/irritable’) or by the model proposed by Burke and colleagues (i.e. ‘negative affect’). (3) When juxtaposed by EL items, ODD was best decomposed into two dimensions which are designated as ‘negativity’ (i.e. ‘angry’ and ‘touchy’ items) and ‘oppositional/provocative’ (i.e. the remaining six items). (4) The empirically derived three-factor structure (EL, negativity and oppositional/provocative behaviors) was invariant across gender.
Conclusions: EL is distinct from ODD and from its ‘mood/affect’ subdimensions (i.e. ‘angry/irritable’ or ‘negative affect’). In line with emerging evidence suggestive of EL as an independent construct with specific concurrent correlates and predictive validity, our findings provide further factorial validity evidence for EL as a separate construct from ODD.
Presenter 2
Integrity of Amygdala Subregion–Based Functional Networks and Emotional Lability in Drug-Naive Boys with Attention Deficit Hyperactivity Disorder
XY Yu1,2,*, L Liu1,2,*, W Chen3, QJ Cao1,2, FD Zepf3, GJ Ji4, ZM Wu1,2, L An1,2, P Wang1,2, QJ Qian1,2, YF Zang5,6, L Sun1,2, YF Wang1,2
1Peking University Sixth Hospital/Institute of Mental Health, National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China
2Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
3Department of Child and Adolescent Psychiatry, School of Paediatrics and Child Health and School of Psychiatry and Clinical Neurosciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Western Australia, Perth, WA, Australia
4Laboratory of Cognitive Neuropsychology, Department of Medical Psychology, Anhui Medical University, Hefei, China
5Center for Cognition and Brain Disorders and the Affiliated Hospital, Hangzhou Normal University, Hangzhou, China
6Zhejiang Key Laboratory for Research in Assessment of Cognitive Impairments, Hangzhou, China
*These authors contributed equally to this work.
Background: Attention deficit hyperactivity disorder (ADHD) is frequently associated with deficits in emotional self-regulation. With the amygdala being a key brain region involved in emotional regulation, recent studies demonstrated alterations of amygdala networks related to emotional lability (EL) of children with ADHD. However, the amygdala is a functionally heterogeneous structure, comprising distinct main subregions: the basolateral (BLA), centromedial (CMA) and superficial (SFA).
Objectives: This study evaluated the integrity of amygdala subregion–based functional networks in boys with ADHD and their association with EL symptoms.
Methods: This study examined resting-state functional connectivity (RSFC) of amygdala subregions using resting-state functional magnetic resonance imaging in 35 drug-naive boys with ADHD and 30 age-matched healthy boys. We also explored the relationships between the altered RSFC of amygdala subregions and EL scores in ADHD.
Findings: Widespread reduced RSFC patterns were detected between amygdala subregions and the dorsal frontoparietal cortices, temporal cortex and limbic regions in boys with ADHD. More specifically, the BLA networks were altered in RSFC with thalamus and vermis; altered RSFC of the CMA was found with the superior temporal gyrus/pole and insula, precuneus and cerebellum; and the RSFC between the SFA and the dorsal frontoparietal cortices was reduced. Among the group with ADHD, high EL scores were associated with reduced negative RSFC between the SFA and the dorsolateral prefrontal cortex, as well as the inferior parietal lobe.
Conclusions: Our findings provide preliminary evidence for diffuse alterations of amygdala subregion–based networks being associated with ADHD. Within ADHD, EL scores were associated with weaker SFA–frontoparietal networks which are involved in the hypothesized top-down (‘effortful’) regulation of emotion.
Presenter 3
Default Network, Attention Deficit Hyperactivity Disorder and Emotional Regulation
F Levy1, RB Silberstein2, A Pipingas2, M Farrow3, CK Stough2, DA Camfield2
1The University of New South Wales, Sydney, NSW, Australia
2Swinburne University, Melbourne, VIC, Australia
3Neuro-Insight Pty Ltd, Melbourne, VIC, Australia
Background: It has been suggested that the inattentiveness in attention deficit hyperactivity disorder (ADHD) is due to inadequate suppression of the default mode network (DMN), and increased activity is associated with intrusion of self-referential thoughts. A number of authors have postulated that ADHD represents a deficit in inhibition of DMN activity, but few have researched relationships with emotional regulation. The literature on the DMN and ADHD is briefly reviewed. A recent brain mapping study by Silberstein et al. utilizing a continuous performance task (CPT) A–X task that showed differences in children with ADHD in the A–X interval is cited with possible implications for emotional regulation.
Objectives: To briefly review studies of ADHD and DMN and to report on functional connectivity during an A–X CPT in a sample of 42 males with ADHD and 25 controls.
Methods: The technique of steady-state evoked potential (SSVEP) during the A–X CPT was utilized and event-related partial coherence was compared to a reference task across 2016 electrode pairs.
Findings: The control group exhibited high levels of default mode network activity during a low-demand reference task, which was suppressed during the A–X task, while the group with ADHD exhibited low levels of default mode network activity during this task.
Conclusions: The sentinel and inhibition hypotheses of DMN and ADHD are compared in relation to emotional regulation and task performance.
Presenter 4
Compassionate Mind Training in Chinese Children with High Levels of Self-Criticism in the Context of Asian Culture and Parenting Style: A Clinical Case Series in Hong Kong
B Tam1, W Chen2,3
1Department of Clinical Psychology, Princess Margaret Hospital, South Kwai Chung, Hospital Authority, Hong Kong, China
2Department of Child and Adolescent Psychiatry, School of Paediatrics and Child Health and School of Psychiatry and Clinical Neurosciences, Faculty of Medicine, Dentistry and Health Sciences, The University of Western Australia, Perth, WA, Australia
3Department of Health, Complex Attention and Hyperactivity Disorder Service (CAHDS), WA, Australia
Background: Compassionate mind training (CMT), which teaches the skills of compassion and affect regulation systems, was developed for people with high levels of shame and self-criticism. Considerable evidence pertains to the effect of authoritarian parenting style on children’s emotionality in Chinese culture. The applicability of CMT in the context of Asian culture and parenting style has not been investigated.
Objectives: The objective of the present pilot study is to evaluate the potential effectiveness of CMT in Hong Kong children with self-criticism.
Methods: Children with high levels of self-criticism were identified from consecutive referrals between January and October 2015. Quantitative and qualitative data were ascertained before and after CMT intervention.
Findings: During this period, four young male patients with high levels of self-criticism were identified. Two boys (aged 8 and 13 years) were referred with ADHD symptoms; the third patient was 15 years of age and presented with binge eating disorder; the fourth patient was 13 years of age and presented with somatic symptom disorder. The four boys were treated individually for up to 12 sessions of 50 minutes. The treatment specifically focused on self-compassion, the function of self-criticism as a safety strategy, developing empathy for one’s own distress and refocusing on compassionate images and compassionate self-talk.
All patients made positive improvements, including social and academic functions, and reduced symptoms as captured by the Strength and Difficulty Questionnaire.
Conclusions: This pilot study provides preliminary evidence that training self-soothing ability with CMT appears to reduce emotional distress and self-criticism among children in Hong Kong. Future larger studies using objective measures on shame, self-criticism and parental expressed emotion will provide further evidence of effectiveness.
The Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guideline Project and Clinical Practice Guidelines for Anxiety Disorders, Mood Disorders, Schizophrenia and Related Disorders
M Oakley Browne1,2, C Galletly1,3,4,5,6, G Andrews1,7,8, G Malhi1,9,10,11, G Carter1,12,13,14, P Hay1,15,16,17
1RANZCP Clinical Practice Guideline Steering Committee, Melbourne, VIC, Australia
2Casey Hospital, Monash Health, Melbourne, VIC, Australia
3Clinical Practice Guideline for Schizophrenia and Related Disorders Working Committee, Melbourne, VIC, Australia
4The University of Adelaide, Adelaide, SA, Australia
5Ramsay Health Care (SA) Mental Health, Adelaide, SA, Australia
6Northern Adelaide Local Health Network, Adelaide, SA, Australia
7Clinical Practice Guideline for Anxiety Disorders Working Committee, Melbourne, VIC, Australia
8The University of New South Wales, St Vincent’s Hospital, Sydney, NSW, Australia
9Clinical Practice Guideline for Mood Disorders Working Committee, Melbourne, VIC, Australia
10Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
11CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, St Leonards, NSW, Australia
12Clinical Practice Guideline for Self-Harm Working Committee, Melbourne, VIC, Australia
13Centre for Translational Neuroscience and Mental Health (CTNMH), University of Newcastle, Callaghan, NSW, Australia
14Calvary Mater Newcastle, Waratah, NSW, Australia
15Clinical Practice Guideline for Eating Disorders Working Committee, Melbourne, VIC, Australia
16School of Medicine and Centre for Health Research, University of Western Sydney, Sydney, NSW, Australia
17School of Medicine, James Cook University, Townsville, QLD, Australia
Background: In 2012, the Clinical Practice Guideline (CPG) Project commenced to systematically review and update six CPGs previously developed by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in 2005. The six original CPGs were as follows: Anorexia Nervosa, Bipolar Disorder, Deliberate Self-Harm (youth and adult), Depression, Panic Disorder and Agoraphobia, and Schizophrenia. Bipolar Disorder and Depression guidelines were revised and merged into a single CPG covering the spectrum of Mood Disorders. The Panic Disorder and Agoraphobia guideline was broadened in scope and renamed Anxiety Disorders. It was also decided to broaden the scope of the Anorexia Nervosa guideline to include a range of Eating Disorders.
Objectives: The CPG Project was undertaken 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. The CPG Project aims to promote and disseminate 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 healthcare setting.
Methods: Five CPG Working Committees (working groups) were established to review and update the CPGs. Once the working groups 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 (ANZJP) 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 the ANZJP, October 2014. The Mood Disorders CPG was published in December 2015. Schizophrenia and Related Disorders and Anxiety Disorders CPGs are to be published in 2016.
Presenter 1
Ranzcp Clinical Practice Guideline for Anxiety Disorders
C Gale1,2, G Andrews1,3, K O’Moore1,4, O Marwat1,5, C Bell1,6, G Wilkins1,7, R Rapee1,8, P Boyce1,9, L Lampe1,10,11
1Clinical Practice Guideline for Anxiety Disorders Working Committee, Melbourne, VIC, Australia
2University of Otago, Dunedin, New Zealand
3The University of New South Wales, St Vincent’s Hospital, Sydney, NSW, Australia
4St Vincent’s Hospital, Sydney, NSW, Australia
5Consultant Psychiatrist, Sydney, NSW, Australia
6University of Otago, Christchurch, New Zealand
7Consultant Psychiatry, Miranda, NSW, Australia
8Macquarie University, Sydney, NSW, Australia
9Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia
10The University of Sydney, Sydney, NSW, Australia
11Royal North Shore Hospital, Sydney, NSW, Australia
Background: Previous guidelines have not led to identifiable change in clinical practice. There have been advances in the evidence available for anxiety disorders, particularly non-pharmacological therapies. A revision and expansion of Clinical Practice Guidelines (CPGs) for Anxiety Disorders were conducted as part of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) CPG Project.
Objectives: To provide more accessible and clinically relevant guidelines for the management of anxiety disorders for psychiatrists, workers in mental health, primary care physicians and people with anxiety disorders.
Methods: A systematic review of the literature identified meta-analyses published since the RANZCP CPG for Panic Disorder and Agoraphobia in 2003. These meta-analyses informed the development of CPGs for panic disorder, generalized anxiety disorder and social anxiety disorder. From the larger review, the authors developed one-page and three-page summaries targeted towards non-specialists.
Findings: The existing CPGs have generally failed to consider adverse effects, costs and availability of treatments in Australia and New Zealand. There is now evidence to support the use of Internet-based cognitive behaviour therapy (CBT). Choice of treatment is often best guided by tolerability.
Conclusions: A stepped model of care is recommended. Initial steps incorporate clinically feasible and highly accessible treatments, such as Internet-based CBT. Practical advice for implementation of treatment recommendations may assist their translation into practice.
Presenter 2
RANZCP Clinical Practice Guideline for Mood Disorders
C Galletly1,2,3,4, D Castle1,5,6, F Dark1,7, V Humberstone1,8, A Jablensky1,9,10, E Kilackey1,6,11, J Kulkarni1,12,13, P McGorry1,6,11,14, O Nielssen1,15, N Tran1,5,6
1Clinical Practice Guideline for Schizophrenia and Related Disorders Working Committee, Melbourne, VIC, Australia
2The University of Adelaide, Adelaide, SA, Australia
3Ramsay Health Care (SA) Mental Health, Gilberton, SA, Australia
4Northern Adelaide Local Health Network, Adelaide, SA, Australia
5St Vincent’s Health and
6The University of Melbourne, Melbourne, VIC, Australia
7Metro South Mental Health Service, Macgregor, Queensland, Australia
8North Land District Health Board, Northland, New Zealand
9Centre for Clinical Research in Neuropsychiatry, The University of Western Australia, Perth, WA, Australia
10Royal Perth Hospital, Perth, WA, Australia
11Orygen, Melbourne, VIC, Australia
12The Alfred Hospital, Melbourne, VIC, Australia
13Monash University, Melbourne, VIC, Australia
14National Youth Mental Health Foundation, Melbourne, VIC, Australia
15The University of Sydney, Sydney, NSW, Australia
Background: The Clinical Practice Guideline (CPG) for Mood Disorders (The Mood Disorders CPG) was conducted as part of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) CPG Project.
Objectives: To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus, and formulate recommendations to maximise clinical salience and utility.
Methods: Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by the literature known to the mood disorders committee (MDC) (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Information was reviewed and discussed by members of the MDC and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with an interest in mood disorders.
Findings: The CPG for Mood Disorders provides up-to-date guidance and advice regarding the management of mood disorders that is informed by evidence and clinical experience. The CPG is intended for clinical use by psychiatrists, psychologists, physicians and others with an interest in mental health care.
Conclusions: The Mood Disorder guidelines are the first CPG to address both depressive and bipolar disorders. The MDC encourage the use of taking a biopsychosocial and lifestyle (BPSL) approach in assessing and formulating patients with mood disorders. The formulation should be used in choosing the evidence-based intervention for a particular patient. The CPG provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.
Presenter 3
RANZCP Clinical Practice Guideline for Schizophrenia and Related Disorders
C Galletly1,2,3,4, D Castle1,5, F Dark1,6, V Humberstone1,7, A Jablensky1,8,9, E Kilackey1,10,11, J Kulkarni1,12,13, P McGorry1,10,11,14, O Nielssen1,15, N Tran1,5
1Clinical Practice Guideline for Schizophrenia and Related Disorders Working Committee, Melbourne, VIC, Australia
2The University of Adelaide, Adelaide, SA, Australia
3Ramsay Health Care (SA) Mental Health, Gilberton, SA, Australia
4Northern Adelaide Local Health Network, Adelaide, SA, Australia
5St Vincent’s Health and The University of Melbourne, Melbourne, VIC, Australia
6Metro South Mental Health Service
7North Land District Health Board, Northland, New Zealand
8Centre for Clinical Research in Neuropsychiatry, The University of Western Australia, Perth, WA, Australia
9Royal Perth Hospital, Perth, WA, Australia
10The University of Melbourne, Melbourne, VIC, Australia
11Orygen, Melbourne, VIC, Australia
12The Alfred Hospital, Melbourne, VIC, Australia
13Monash University, Melbourne, VIC, Australia
14National Youth Mental Health Foundation, Melbourne, VIC, Australia
15The University of Sydney, Sydney, NSW, Australia
Objectives: The Clinical Practice Guideline (CPG) for schizophrenia and related disorders was conducted as part of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) CPG Project. The CPG provides a contemporary guideline for the treatment of people with schizophrenia and related disorders, based on published evidence and supplemented by expert clinical consensus.
Methods: A comprehensive literature review was conducted (2008–2014) including Cochrane reviews and relevant meta-analyses. Recent international clinical practice guidelines including the National Institute for Health and Care Excellence Clinical Guideline on Treatment and Management of Psychosis and Schizophrenia in Adults (2014) and the World Federation of Societies of Biological Psychiatry Guidelines for the Biological Treatment of Schizophrenia (2012 and 2013) were consulted.
Findings: This updated CPG was developed in accordance with best practice as outlined by the National Health and Medical Research Council. It includes assessment, staging, pharmacological management and psychosocial treatments. There are specific sections addressing management of schizophrenia and related disorders in Aboriginal and Torres Strait Islanders, Maori and Pasifika peoples.
Conclusions: This updated CPG provides a direction for addressing common clinical dilemmas that arise in the management of schizophrenia and related disorders. These recommendations do not replace clinical judgment, which must be tailored to the particular needs of each patient and clinical situation. The recommendations can be used to inform clinicians and educate patients with regard to the best judged treatment option for each individual.
Presenter 4
Expert Panel Discussion
M Oakley Browne1,2, C Gale3,4, L Lampe5,6, D Bassett7,8,9, P Boyce7,10, A Singh7,11, C Galletly12,13,14,15, D Castle15,16, N Tran15,16,17
1RANZCP CPG Steering Committee, Melbourne, VIC, Australia
2Monash Health, Melbourne, VIC, Australia
3Clinical Practice Guideline for Anxiety Disorders Working Committee, Melbourne, VIC, Australia
4University of Otago, Dunedin, New Zealand
5The University of Sydney, Sydney, NSW, Australia
6Royal North Shore Hospital, Sydney, NSW, Australia
7Clinical Practice Guideline for Mood Disorders Working Committee, Melbourne, VIC, Australia
8School of Psychiatry and Clinical Neurosciences, The University of Western Australia, Perth, WA, Australia
9School of Medicine, University of Notre Dame, Perth, WA, Australia
10Discipline of Psychiatry, Sydney Medical School, Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia
11Deakin Medical School, Deakin University, Melbourne, VIC, Australia
12Clinical Practice Guideline for Schizophrenia and Related Disorders Working Committee, Melbourne, VIC, Australia
13The University of Adelaide, Adelaide, SA, Australia
14Ramsay Health Care (SA) Mental Health, Adelaide, SA, Australia
15Northern Adelaide Local Health Network, Adelaide, SA, Australia
16St Vincent’s Health, Melbourne, VIC, Australia
17The University of Melbourne, Melbourne, VIC, Australia
Background: See ‘Clinical Practice Guidelines Project Overview’ (p. 103).
Objectives: To critically discuss the recommendations of all Clinical Practice Guidelines (CPGs) and their clinical utility.
Methods: A member of the CPG Steering Committee will Chair a general discussion of published CPGs, including a short panel discussion and question/answer session involving CPG working group members and the audience.
State of the Art: Electroconvulsive Therapy
H Sackheim1, T Schlaepfer2
1Departments of Psychiatry and Radiology, Columbia University, New York, USA
2 University Hospital Bonn, Bonn, Germany
Background: Electroconvulsive therapy (ECT) remains one of the most effective treatments for severe depression. Over the last decade there has been an enormous amount of research establishing a strong evidence base supporting the complexities of clinical practice refuting much of the stigma and shame.
Objectives: Provide state-of-the-art information about current ECT practice and future directions.
Methods: Speakers have been invited to participate in this symposium by the Congress Scientific Committee with an emphasis on local experts within the South-East-Asian region. Topics of discussion:
‘Optimising Treatment Technique in ECT’.
‘Update on Magnetic Seizure Therapy’
Findings: Information has been presented on current practice of ECT in South East Asia and that ECT treatment is well received by consumers.
Conclusions: ECT remains a powerful and modern treatment for severe depressive illness.
Optimizing Treatment Technique in ECT
H Sackheim1
1Departments of Psychiatry and Radiology, Columbia University, New York, USA
ECT has undergone dramatic improvements in treatment delivery. The universal principle in ECT had been that the generalized seizure provides the necessary and sufficient conditions for antidepressant efficacy. With the introduction of dose titration, it was demonstrated that most patients were grossly over-dosed and that at low dosage seizures could be reliably produced that lacked efficacy. A series of studies demonstrated that the efficacy and side effects of ECT were contingent on both current path (electrode placement) and current density (electrical dosage). These findings led to preferential use of high dosage, right unilateral ECT. Research on pulse width had demonstrated that cognitive effects are sharply reduced by use of an ultrabrief stimulus, without loss of efficacy. High dosage, ultrabrief right unilateral ECT is now the standard of care at many facilities. Future innovations will include titration in the current domain and the use of focal electrically administered seizure therapy (FEAST). Recent research has also demonstrated that the remission rate of ECT is improved with concomitant administration of antidepressant medications.
Patient-Rated Quality of Life after Electroconvulsive Therapy: A Multisite Naturalistic Australian Study
S Waite1, V Galvez2, A Li2, C Oxley2, D Kumar2, CN De Felice3, A Page3, G Hooke3, C Loo2
1The Queen Elizabeth Hospital, Adelaide, SA, Australia
2Black Dog Institute, The University of New South Wales, Sydney, NSW, Australia
3Perth Clinic, Perth, WA, Australia
Background: Electroconvulsive therapy (ECT) is widely accepted in the scientific literature as an effective treatment for severe psychiatric disorders. However, studies led by consumer groups and advocacy organizations mostly report lower rates of perceived benefit from ECT compared to clinician-led studies. In Australia, there is a lack of research regarding the impact of ECT on patient-rated quality of life (QOL), an important outcome variable in psychiatric disorders and a key factor in guiding decisions regarding resource allocation and patient management.
Objectives: This study examined the effects of an acute course of ECT on QOL in depressed patients.
Methods: A total of 405 patients with a major depressive episode (unipolar or bipolar) were treated with ECT at two private hospitals and one public hospital. Treatment parameters, including electrode placement (unilateral, bifrontal or bitemporal) and pulse width (brief or ultrabrief), were determined by their treating psychiatrist. Self-reported QOL was assessed at baseline and post-ECT using the Quality of Life, Enjoyment and Satisfaction Short Form (Q-LES-Q SF). The association between ECT parameters and QOL outcomes was examined with regression analysis, controlling for variables that might affect QOL outcomes.
Findings: The QOL improved significantly after the ECT course: mean pre-ECT QOL 31.7 (8.9) and mean post-ECT QOL 45.25 (10) (p < 0.0001). Multiple regression analyses found that age, ECT treatment parameters and baseline QOL were significant predictors of change in QOL.
Conclusions: ECT administered in routine hospital settings in Australia is effective in improving QOL. Collecting common clinical data sets across hospital ECT services facilitates research and may promote improvement in service provision and clinical outcomes.
Untying the Knot: Family Violence, Bullying and Suicide
M O’Connor1, C Tuncer1,2,3, P Yip4, S Xiao5
1The University of Melbourne, Melbourne, VIC, Australia
2Victorian Transcultural Mental Health, St Vincent’s Hospital, Melbourne, VIC, Australia
3Hasan Kalyoncu University, Gaziantep, Turkey
4The University of Hong Kong, Hong Kong
5Central South University, Changsha, China
Background: Domestic and family violence comprising emotional, physical, financial and sexual abuse is a known precipitant of suicide. Ethnic minority, immigrant and refugee women are at higher risk. Bullying is another type of emotional abuse and is commonly seen among the adolescent group. Bullying is a contributory factor towards suicide.
Objectives: There is a paucity of research on suicide, emotional abuse, bullying and domestic violence across cultures, in ethnic minorities, immigrants and refugees. This symposium sheds light on the complex interactions between family violence, emotional abuse and bullying as they intersect with culture, marriage and suicide.
Methods: Looking through the spectrum of different cultures, such as the South Asian immigrant women, the Turkish and Middle Eastern countries, the Hong Kong experience of homicide and suicide and the association of bullying and suicide behaviour among Chinese adolescents will be presented.
Findings: Participants will share their research and clinical experience.
Conclusions: The outcome of the discussion would provide some insight into the complexity of the global problem of family violence and suicide.
Presenter 1
Characteristics and Types of Homicide–Suicides in Hong Kong
P Yip
Department of Social Work and Social Administration, Centre for Suicide Research and Prevention, The University of Hong Kong, Hong Kong
Background: This paper makes use of the data of homicide–suicide incidences from the Coroner’s Court to perform a two-step cluster analysis.
Objectives: To perform a two-step cluster analysis to identify the number of clusters and their profiles.
Methods: External background variables are tested through post hoc tests to explore the differences among clusters.
Findings: Financial problems, disputes and domestic violence are significant precipitants of homicide and suicides in Hong Kong.
Conclusions: People associated with the precipitating factors should be the targets for intervention and prevention.
Presenter 2
Suicide, Family and Domestic Violence in Australian Immigrant Women
M O’Connor1,2, S Ibrahim2, C Tuncer1,2
1The University of Melbourne, Melbourne, VIC, Australia
2Family Violence Working Group, The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
Background: Globally, one in three women are subjected to family and domestic violence. Domestic violence is a precipitant of suicidal ideation and behaviour. Ethnic minority, immigrant and refugee women are at higher risk of violence. Research shows that being married is a high suicide risk factor for women from South Asia. There is paucity of research on the relationship between suicide and domestic violence among immigrants and refugees in Australia.
Objectives: To explore the outcome of suicidal ideation and suicidal behaviours in Australian migrants of South Asian and Middle Eastern ethnicity who are victims of family violence.
Methods: Comparison of prospective clinical data collected over 6 months among victims of two cultural groups, those from Middle-Eastern and South Asian origin, will be presented.
Findings: Factors that are common and disparate between cultural groups, and those that can improve or diminish the outcome of suicidal ideation, will be presented.
Conclusions: This paper will enhance the understanding of clinical factors that can be used to support migrant women.
Presenter 3
The Impact of Culture on the Prevention of Suicide in Family Violence: Through the Spectrum of Turkish and Middle Eastern Countries
C Tuncer1,2,3
1The University of Melbourne, Melbourne, VIC, Australia
2Victorian Transcultural Mental Health, St Vincent’s Hospital, Melbourne, VIC, Australia
3Hasan Kalyoncu University, Gaziantep, Turkey
Background: The concept of marriage in the contexts of Turkish and Middle Eastern cultures has huge implications on both the role of men and women in marriage and may cause intricate family dynamics. When dysfunctional family dynamics occur and cause different types of abuse, including emotional, physical, financial and sexual, this may lead to suicide.
Objectives: The role of family members in nuclear and/or extended families, whether they act as supports or stress factors, depending on the perception of marriage and awareness of abuse, would be influential in preventing violence and suicide.
Methods: Anthropologic literature and clinical research will be presented.
Findings: Culturally based protective factors in Turkish and Middle Eastern families against family violence and suicide will be presented.
Conclusions: This paper aims to increase the awareness of culturally based protective factors in Turkish and Middle Eastern families against family violence and suicide.
Presenter 4
The Association of Bullying and Suicide Behaviour among A Sample of Chinese Adolescents
S Xiao
Social Medicine and Psychiatry, Centre for Global Health, Central South University, Changsha, China
Background:
Objectives:
Methods:
Findings:
Conclusions:
Recovery and the Psychiatrist: The Way Forward
R McKay1,2, J Liggins1,3, L Salmon1, G Roper1
1The Royal Australian and New Zealand College of Psychiatrists Community Collaboration Committee, Melbourne, VIC, Australia
2NSW Institute of Psychiatry, Sydney, NSW, Australia
3Counties Manukau Health, Auckland, New Zealand
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) partners with people with lived experience of mental illness and carers through our Community Collaboration Committee (CCC). The committee brings together psychiatrists, consumers and carers from Australia and New Zealand to influence policy and practice, improve training and build relationships with other mental health organisations. Members also participate in other RANZCP committees and review documents that are produced by the RANZCP.
Objectives: The aim of this symposium is to highlight the benefits derived from the CCC partnership model, including the consequent development of three position statements that provide guidance for psychiatrists today: recovery and the psychiatrist, beyond impairment and recognising the impact of past mental health practices.
Methods: Through a series of presentations and panel discussions, these three topics reflect the depth of understanding that the CCC lived experience brings. The audience will engage in a stimulating dialogue on issues affecting psychiatry and mental health care, including the benefits of engagement between psychiatrists and people with lived experience of mental illness and their carers.
Findings: Many issues confront psychiatrists within the current mental health care. Open dialogue between consumers, carers and psychiatrists about the past, present and future practices, challenges and opportunities offers an important way forward to improving mental health care.
Conclusions: Engagement with the community to improve care is a key challenge that the College is committed to. Progress to date suggests that the CCC is a positive working model that would be successful outside Australasia.
Presenter 1
Recovery and the Psychiatrist
R McKay1,2, L Salmon1, G Roper1
1The Royal Australian and New Zealand College of Psychiatrists Community Collaboration Committee, Melbourne, VIC, Australia
2NSW Institute of Psychiatry, Sydney, NSW, Australia
Background: The concept of ‘recovery’ has become a mainstream principle of mental health care, applicable beyond its origins as a social movement arising from consumers with serious mental illness. A core goal of recovery is whether a person identifies as a consumer, Tangata motuhake (people with experience of mental illness or distress), or in any other way as having lived experience of mental illness. All people are entitled to live with hope and to undertake a recovery journey that leads to meaningful and contributing lives in our communities and workplaces: where a person with lived experience of mental illness is accepted, valued and appreciated – and not only survives, but thrives.
Objectives: This position statement clarifies the commitment of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and its members to promoting recovery for all people with mental illness, irrespective of age, severity of illness or treatment setting, and to the impact of mental health on care and carers. The position statement also provides a key reference point for the interpretation of training activities that incorporate the concept of recovery and for psychiatrists whose practice settings may have made the relevance of recovery to practice unclear.
Method: The position statement has been developed through review of key national documents from Australia and New Zealand, combined with the knowledge and networks of members of the Community Collaboration Committee.
Findings: The position statement and its recommendations will be presented.
Conclusions: The RANZCP acknowledges that there is no single description or definition of recovery because recovery is different for everyone. The cultural differences across Australia and New Zealand add further richness to this variation. However, central to all recovery paradigms are hope, self-determination, self-management, empowerment and advocacy.
Presenter 2
Beyond Impairment: Using Psychiatrists’ Lived Experience to Improve Care
J Liggins1,2, L Salmon1, G Roper1
1The Royal Australian and New Zealand College of Psychiatrists Community Collaboration Committee, Melbourne, VIC, Australia
2Counties Manukau Health, Auckland, New Zealand
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) values the contribution that all people with lived experience of mental illness make to improving mental health care. The RANZCP has not, however, overtly acknowledged the value that psychiatrists with a lived experience of mental illness can bring to mental health service delivery and development.
Objectives:
1. To reflect upon the importance of collaboration between psychiatrists and the community in improving practice and care;
2. To highlight the potential for psychiatrists to use lived experience of mental illness to improve care.
Methods: The development of the RANZCP’s new position statement ‘Beyond Impairment: Using psychiatrists’ lived experience of mental illness to improve care’ has its origins in the Community Collaboration Committee, prompting the reflection of psychiatrists upon this important issue. The authors will discuss their experience of the interface between personal and professional, with an emphasis on the insight and wisdom that their multivocality can bring. The key recommendations of the position statement will then be presented, and discussion is invited on their implications and implementation.
Findings: Previous emphasis has been on ensuring appropriate support for the ‘impaired practitioner’ and protection of the public. The literature related to psychiatrists’ experience of mental illness focuses on issues of impairment. Stigma means that for many health professionals, silence remains the default position (Hinshaw, 2008). Feedback from members in consultation over 2 years has been very positive about reframing this position.
Conclusions: The new position statement provides a way to challenge stigma, improve mental health care and promote the recovery of psychiatrists with lived experience of mental illness.
Reference
Hinshaw SP (ed.) (2008) Breaking the Silence Mental Health Professionals Disclose Their Personal and Family Experiences of Mental Illness. New York: Oxford University Press.
Presenter 3
Recognising the Impact of Past Mental Health Practices
R McKay1,2, L Salmon1, G Roper1
1The Royal Australian and New Zealand College of Psychiatrists Community Collaboration Committee, Melbourne, VIC, Australia
2NSW Institute of Psychiatry, Sydney, NSW, Australia
Background: The Community Collaboration Committee (CCC) has presented on the ongoing impact of previous mental healthcare practices that either intentionally or unintentionally, informed by the evidence base and culture of the time, resulted in harm and stigma towards people with mental illness, their families and carers, and the professionals working with them, including psychiatrists.
Objectives: To discuss how a statement of recognition of the impact of past mental health practices can assist in reducing the ongoing impact of these practices and encourage constructive reflection upon the ongoing challenges in safe provision of mental health care.
Methods: A position statement has been drafted in response to the discussions at previous Congresses and further consultations with College members. Audience debate regarding the most appropriate ‘next steps’ to progress actions on these issues will be invited.
Findings: Mental health care over the past 50 years has included both exemplary practice and practices that have an ongoing impact on the attitudes of the public to mental illness and psychiatry and to accessing mental health care. There is significant sensitivity by psychiatrists regarding potential public responses when the public recognises harmful practices and a desire to remove barriers that prevent that recognition.
Conclusions: Recognition of the impact of past mental health practices is a key step in promoting ongoing constructive reflective practices that reduce the risk of future harm. Ongoing engagement between psychiatrists and the community is essential in achieving this goal.
Mothers and Mothers-To-Be with Borderline Personality: Data from a Tertiary Maternity Hospital, a Community Mental Health Service and a Mother and Baby Unit in Western Australia
Women with borderline personality disorder (BPD) often face many challenges in their journeys to become mothers, and despite being seen as an at-risk group, there is a paucity of research evidence available to guide clinicians in managing them. In this symposium, we present data from a number of service settings in Western Australia. These services span the perinatal spectrum from pregnancy care to postpartum follow-up. We hope that the data may contribute to the development of a continuum of enhanced care pathways for women with BPD and their families in the perinatal period.
Presenter 1
Obstetric and Neonatal Outcomes in Women with Borderline Personality Disorder and Proposed Guidelines for Management in the Antenatal Period
C Crabb1,2,3, J Frayne1,4, P Krishnan5, B Jansen1
1King Edward Memorial Hospital, Perth, WA, Australia
2The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne VIC, Australia
3Department of Health Western Australia, Perth, WA, Australia
4School of Primary Aboriginal and Rural Health Care, The University of Western Australia, Perth, WA, Australia
5University of Notre Dame, Fremantle, WA, Australia
Background: Women with borderline personality disorder (BPD) may have difficulties accessing optimal antenatal care despite being at increased risk of adverse obstetric outcomes. Possible reasons may include reduced social stability and support systems, decreased frustration tolerance, reactivation of past traumas and negative countertransference in health providers who may see these women as ‘difficult’ patients.
Objectives: To examine the obstetric, delivery and neonatal outcomes for a cohort of pregnant women with BPD who gave birth via a specialist antenatal clinic.
Method: A retrospective case note review of 58 women who were identified as having BPD or emotionally unstable personality disorder, based on International Classification of Diseases – 10th Revision (ICD-10) criteria, who gave birth between 2008 and 2015. Analyses of demographic, social, psychiatric, obstetric and neonatal outcomes were made using the Statistical Package for the Social Sciences version 22, and where available, comparison will be made with the state-wide perinatal data. The review will also focus on antenatal care attendance and the delivery process, as well as the utilization of pre-birth planning and an innovative sensitive care plan for women with complex traumas.
Results: Descriptive data on obstetric, neonatal and psychosocial outcomes for this vulnerable cohort will be presented, the aim of which is to contribute to the available literature.
Conclusions: Pregnant women with BPD often pose complex challenges in their perinatal care and may be at heightened risk of adverse outcomes. An enhanced model of care may be needed.
Presenter 2
Psychosocial Needs of Mothers and Mothers-To-Be with Borderline Personality Disorder at a Community Mental Health Service
W Oyewopo1,2,3, R McNeill1,2, A North1,2, T Stevenson3, T Nguyen3,4
1The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne VIC, Australia
2Department of Health Western Australia, Perth, WA, Australia
3Peel and Rockingham Kwinana Mental Health Service, Rockingham, WA, Australia
4The University of Western Australia, Perth, WA, Australia
Background: Borderline personality disorder (BPD) is a severe disorder with significant psychosocial implications for mothers and mothers-to-be and their families. There is limited research into the antenatal and postnatal needs for these women, particularly in the community setting. Peel and Rockingham Kwinana Mental Health Service (MHS) has a specialist perinatal psychiatric team embedded within its community clinics. The service provides consultation and liaison, as well as psychiatric care, for women referred from the community as well as the adjacent hospitals’ obstetric departments.
Objectives: To explore the psychosocial needs of women with BPD in the perinatal period.
Methods: A retrospective case note review of all referrals from January 2013 to December 2014 to identify women who were assessed as having BPD or emotionally unstable personality disorder (EUPD), diagnosed by a psychiatrist or a senior psychiatry registrar, using International Classification of Diseases – 10th Revision (ICD-10) criteria, either as a primary presentation or as a co-morbidity. Psychosocial needs will be audited using a purpose design audit tool.
Findings: In the period of the study, 105 women were assessed and managed by the team; of these, 37 were identified as having BPD. Descriptive data including obstetric and neonatal complications, prevalence of self-harm, psychiatric co-morbidity, child protection involvement, supports, substance use and relationship variables will be presented.
Conclusions: Identifying the psychosocial need of mothers and mothers-to-be with BPDs in the perinatal period in the community will be informative in terms of service provision needs as well as further research directions.
Presenter 3
Development of a Treatment Model for Mothers with Borderline Personality Disorder at a New Mother and Baby Unit in Perth, Western Australia
T Devadason1, K Niven1, G Pace2, D Kristianopulos1, S Schutte1, M Galbally1
1Fiona Stanley Hospital, Perth, WA, Australia
2Bentley Health Service, Perth, WA, Australia
Background: Emotional dysregulation secondary to borderline personality disorder (BPD) can be exacerbated in the postnatal period, related to the developmental tasks of motherhood. In addition, infants of mothers with BPD often show a pattern of disorganized attachment that can further amplify maternal distress. There is limited research describing treatment models for BPD in the postnatal period. The Fiona Stanley Hospital Mother and Baby Unit (FSH MBU) is a new unit, offering multi-disciplinary psychiatric treatment for a broad range of mental health problems, in an inpatient setting, for women referred with their babies under the age of 1 year.
Objectives: To examine the rate of referral and admission of mothers with BPD in comparison with mothers with other diagnoses admitted to the FSH MBU and to describe the development of an evidence-informed treatment model of care for this patient group.
Methods: Retrospective case note audit of all admissions to the FSH MBU in its first 12 months (February 2015–2016), to examine psychosocial needs and outcomes and to correlate these with standardized screening tools. Furthermore, identification of treatment goals and treatment pathways for mothers with BPD will also be examined.
Findings: Mothers with BPD are frequently referred for admission to the FSH MBU due to emotional dysregulation, comorbid depressive or anxiety disorders or complex social problems impacting their ability to cope with the care of their infants. They often face multifaceted challenges that require comprehensive assessment and care.
Conclusions: Data collected and analysed will be essential to the understanding of the needs of these women and their families as well as necessary service provision. Collaboration between Australian MBUs with regard to further research and to refine current treatment models for this patient group is needed.
Presenter 4
Enhanced Care Pathways for Women with Borderline Personality Disorder in the Perinatal Period
C Crabb, B Jansen
King Edward Memorial Hospital, Perth, WA, Australia
Background: Borderline personality disorder (BPD) represents particular management challenges in the perinatal period. Difficulties faced by women with BPD who are pregnant can invoke defences that threaten the therapeutic alliance. Previous trauma can also be reactivated.
Objectives: This paper proposes a set of practical management guidelines to assist in the management of BPD in the perinatal period.
Methods: A review of the available literature and experience gained from the Department of Psychological Medicine of Women and Newborn Health Services in Western Australia, as well as data from other settings presented in this symposium, was used to formulate practical guidelines for the management of the antenatal, peripartum and postnatal course of women with BPD.
Findings and conclusions: The guidelines, where applied, have the potential to improve obstetric and psychiatric outcomes for women with BPD through consistency, continuity and collaboration and to also assist midwifery and obstetric staff in managing such women. Discussion will also focus on the need for further education, of mental health and obstetric staff alike.
Developing Entrustable Professional Activities for the Competency-Based Fellowship Program for Psychiatry in Australia and New Zealand
M Aimer1,2, W de Beer3, B Evans4, E Halley4, W Kealy-Bateman5,6,7, L Lampe8,9,10, J MacDonald11,12
1Ko Awatea, Counties Manukau District Health Board, New Zealand
2Emerge Aotearoa, Whakatane, New Zealand
3Waikato District Health Board, Hamilton, New Zealand
4RANZCP, Melbourne, VIC, Australia
5University of Wollongong, Wollongong, NSW, Australia
6Royal Prince Alfred Hospital, Sydney, NSW, Australia
7Western NSW Local Health District, Dubbo, NSW, Australia
8Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
9Northern Sydney Local Health District, Sydney, NSW, Australia
10CADE Clinic, Royal North Shore Hospital, Sydney, NSW, Australia
11University of Otago, Wellington, New Zealand
12Capital and Coast DHB, Wellington, New Zealand
Background and objectives: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) introduced the Competency-Based Fellowship Program (CBFP) in 2012, modelled on best practice for medical education. Entrustable professional activities (EPAs) (Mulder et al., 2010; Ten Cate, 2005; Ten Cate et al., 2010) were introduced as summative assessment tools. EPAs are designed to help operationalise competency-based education by integrating competencies into workplace activities. They are described as being observable and measurable in their process and their outcome reflects the trainee’s competence (Ten Cate et al., 2010); they are specialised tasks that a trainee must demonstrate their ability to perform with only distant (reactive) supervision. EPAs were introduced to help supervisors determine the competence of their trainees and to provide trainees with a framework to monitor their progress (Ten Cate, 2005). This symposium outlines the processes involved in developing EPAs for the CBFP, the rationale for their introduction and the outcomes to date.
Methods: The panel will describe the process of developing and determining the focus of each EPA. Each EPA was developed by defining the core knowledge, skills and attitudes required of the task, mapped to the Fellowship competencies. The EPAs were extensively reviewed for content, relevance and consistency with other EPAs for that stage of training (standard-setting).
Findings: Data from trainee and supervisor surveys and training records outlining the experience to date with implementation, uptake and engagement and the workplace-based assessments used to inform entrustment decisions around EPAs will be presented.
Quality assurance and future planning (conclusions): Quality assurance activities undertaken, their outcomes and future quality assurance activities planned will be outlined.
References
Mulder H, ten Cate O, Daalder R, et al. (2010) Building a competency-based workplace curriculum around entrustable professional activities: The case of physician assistant training. Medical Teacher 32: e453–e459.
Ten Cate O (2005). Entrustability of professional activities and competency-based training. Medical Education 39: 1176–1177.
Ten Cate O, Snell L and Carraccio C (2010). Medical competence: The interplay between individual ability and the health care environment. Medical Teacher 32: 669–675. [2.f end]
Progress in Neurostimulation for Psychiatry
A Aleman1, D Schutter2, M Nakamura3, C Baeken4
1University of Groningen, Groningen, The Netherlands
2Radboud University, Nijmegen, The Netherlands
3Laboratory of Neuromodulation, Kanagawa Psychiatric Center, Yokohama, Japan
4Department of Psychiatry and Medical Psychology, Ghent University, Ghent, Belgium
Background: Non-invasive neurostimulation is increasingly being applied as a treatment for psychiatric disorders. There is a need for taking stock of the most recent findings with regard to transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (TDCS).
Objectives: To present novel data from studies into the effects of non-invasive neurostimulation in depression and schizophrenia and to address underlying mechanisms and avenues for optimizing treatment effects.
Methods: Randomized controlled trials of TMS and/or TDCS in addition to empirical review and conceptual analysis.
Findings: There is evidence of improvement of symptoms after non-invasive neurostimulation, although mixed findings have been reported. Future research should address specific brain circuits tailored to the nature of the psychiatric problems in more detail and aim to predict responder status. Larger, multicenter trials are needed.
Conclusions: Non-invasive neurostimulation may yield benefits as a treatment modality in psychiatry, but it is in need of further development.
Presenter 1
Current Directions in the Treatment of Major Depressive Disorder
D Schutter
Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
Background: Non-invasive transcranial direct current stimulation (TDCS) of the human brain to improve depressive symptoms is increasingly finding its way in clinical settings as a viable form of somatic treatment.
Objectives: To examine the efficacy and mechanisms of transcranial electric stimulation.
Methods: Quantitative review of clinical trials.
Findings: Results show the mood-enhancing properties in patients with major depressive disorder. The clinical significance of these findings is limited. The lack of insights into neurophysiological mechanisms of action contributes to the heterogeneity of findings.
Conclusions: The range of the clinical applicability of TDCS in depressive disorder has yet to be established. Issues concerning the mechanistic insights into the workings of modifying brain function through neural polarization and how this process translates to its antidepressant properties call for additional research.
Presenter 2
Accelerated Theta Burst Stimulation in Treatment-Resistant Major Depressive Disorder: A Fast Road to Remission?
C Baeken1,2,3, R Duprat1,2, R De Raedt4
1Department of Psychiatry and Medical Psychology, Ghent University, Ghent, Belgium
2Ghent Experimental Psychiatry (GHEP) Lab, Ghent University, Ghent, Belgium
3Department of Psychiatry, Vrije Universiteit Brussel (VUB), Brussels, Belgium
4Department of Experimental Clinical and Health Psychology, Ghent University, Ghent, Belgium
Background: Major depressive disorder (MDD) is a severe global mental health problem. When confronted with clinical non-response, the treatment options are limited. Intensified or accelerated repetitive transcranial magnetic stimulation (rTMS) treatment algorithms are under investigation to be applied in treatment-resistant depressed (TRD) patients.
Objectives: Although intermittent theta-burst stimulation (iTBS) may have the potency to result in superior clinical outcomes in TRD compared to the classic rTMS protocols, accelerated iTBS treatment has not yet been studied.
Methods: Here, we present the results of our registered randomized double-blind sham-controlled crossover study, where we applied accelerated iTBS delivered to the left dorsolateral prefrontal cortex (DLPFC). In all, 50 TRD patients received 20 iTBS sessions spread over four successive days (five sessions/day).
Findings: We found immediate, statistically significant decreases in depressive symptoms regardless of order/type of stimulation (real/sham). Response rates increased from 28% at the end of the 2-week procedure to 38% when depression severity symptoms were assessed 2 weeks later, indicating delayed clinical effects. Importantly, 30% of these responders were considered to be in clinical remission at the end of the study.
Conclusions: Our findings indicate that only 4 days of accelerated iTBS treatment may lead to fast remission in TRD.
Presenter 3
Potential EEG Biomarkers for Neuroplasticity Induction by a Series of Prefrontal Repetitive Transcranial Magnetic Stimulation (RTMS) For Major Depression
M Nakamura1,2,3,4, Y Noda1,5
1Laboratory of Neuromodulation, Kanagawa Psychiatric Center, Yokohama, Japan
2Department of Psychiatry, School of Medicine, Yokohama City University, Yokohama, Japan
3Department of Psychiatry, School of Medicine, Showa University, Tokyo, Japan
4Computational Neuroscience Laboratories, Brain Information Communication Research Laboratory Group, Advanced Telecommunications Research Institute International (ATR), Kyoto, Japan
5Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
Background: Biomarkers for repetitive transcranial magnetic stimulation (rTMS)-induced neuroplasticity could optimize and personalize future rTMS protocol.
Objectives: Neuroplasticity that was possibly induced by rTMS on the dorsolateral prefrontal cortex (DLPFC) was longitudinally investigated in major depression using quantitative electroencephalograms (qEEGs) during wake and sleep states and also TMS-evoked potentials.
Methods: Patients with medication-resistant major depression were allocated to a rTMS protocol out of conventional 10 Hz rTMS, intermittent theta-burst stimulation (iTBS) and QPS-5. The stimulation site was the left DLPFC (BA46/9), as determined by a navigation system.
Findings: Resting-state qEEGs showed longitudinal enhancement of the spectral power of gamma band oscillations at the left frontal region and the modulation index, which reflects theta–gamma coupling, over rTMS sessions. All-night sleep EEG recordings showed localized enhancement of slow wave activity (SWA) at F3 over the initial five rTMS sessions.
Conclusions: An increase in gamma power and theta–gamma coupling during resting-state and localized SWA enhancement could suggest rTMS-induced enhancement of functional neuroplasticity.
Presenter 4
Effects of Repetitive Transcranial Magnetic Stimulation (RTMS) Over the Temporoparietal Cortex on Intrinsic Network Connectivity during a Language Task in Patients with Schizophrenia
A Aleman1, L Bais1, A Vercammen2, R Knegtering3
1Department of Neuroscience, University Medical Center, University of Groningen, Groningen, The Netherlands
2Australian Catholic University, Sydney, NSW, Australia
3Lentis Mental Health Center, Groningen, The Netherlands
Objectives: We conducted a randomized controlled trial in 36 patients with schizophrenia to investigate whether repetitive transcranial magnetic stimulation (rTMS) to the left or bilateral temporoparietal junction (TPJ) was effective in reducing auditory verbal hallucinations (AVHs). Besides reporting the clinical effects, it is also of interest to know to what degree the rTMS treatment affects brain networks when the brain is engaged in a task related to inner speech production.
Methods: We performed a task-related independent component analysis on task-related data and compared the three treatment groups before and after treatment. After excluding participants who showed too much head movement or who performed below-chance level, the data of 24 patients were suitable for analysis: left = 7, bilateral = 9 and placebo = 8. Because of these small sample sizes, only non-parametrical tests were applied.
Findings: Within these small samples, only the left rTMS group showed a trend towards a significant reduction in hallucination severity on the Positive and Negative Syndrome Scale (PANSS) item P3 (p = 0.06, two-sided). We chose the six similar independent components as in the baseline analysis and observed no group differences in changes in activation within these components. A group comparison of the effect of rTMS on the spatial contribution of brain areas within each IC revealed some differences (p = 0.001, pseudo-T > 10, k = 20). The overall patterns showed that rTMS to the left TPJ increased the contribution of brain areas to the network. In contrast, bilateral rTMS showed the opposite effect, with an exception of the left supramarginal gyrus, which is close to the stimulated area.
Conclusions: The rTMS over the temporoparietal cortex influences connectivity in brain networks subserving language processing. This could be an underlying mechanism for improving communication between brain regions important for speech monitoring. More detailed studies are needed to confirm and further analyse the putatively underlying processes. [2.g end]
Special Session by the Pacific Rim College of Psychiatrists (PRCP): Opportunities and Challenges in Pacific Rim Psychiatry
H.Herrman1, P.Udomratn2
1
President, PRCP, and Orygen, The National Centre of Excellence in Youth Mental Health and The Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
2 President Elect, PRCP, and Prince of Songkla University, Hat Yai, Songkhla, Thailand
Background: The PRCP (www.prcp.org) gathers together psychiatrists from countries bordering the Pacific Ocean. The College aims to foster national development of mental health services and support the improvement of education and research in psychiatry, through professional collaboration across these countries. It aims to cooperate with the range of disciplines working in mental health and with service users and family carers. It is particularly concerned with the reform of psychiatric care: including support and advocacy for prevention, early intervention and recovery in collaboration with primary health care.
Objectives: The session aims to consider the needs and opportunities for collaboration and knowledge exchange among colleagues and organisations across the Pacific Rim.
Methods: The session includes two short presentations on: ‘Fostering alliances with primary health care in Pacific Rim countries’ (HH); and ‘New challenges of mental health problems in Pacific Rim countries’ (PU) followed by discussion.
Findings: The keys to achieving integration of psychiatry with the health care system include engagement of psychiatry with primary health care and partnership with patients and family carers. New challenges in the region include understanding and meeting needs the mental health of migrants, and digital mental health, especially mental health problems related to technological mobile devices.
Conclusions: Discussion of these and other high priority challenges and opportunities for psychiatry around the Pacific Rim is likely to reveal benefits of collaboration across countries, professions and civil society.
Are We Supporting the Disempowered? Early Experience of Mental Health Tribunal Hearings under the New Mental Health Act in Victoria, Australia
P Weller1,2, L Brophy2,3,4, N Owens2,5, S Carey2
1Graduate School of Business and Law, RMIT University, Melbourne, VIC, Australia
2Mental Health Tribunal, Melbourne, VIC, Australia
3The Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
4 Mind Australia, Melbourne, VIC, Australia
5Victorian Institute of Forensic Mental Health, Melbourne, VIC, Australia
Background: Compulsory treatment of individuals with severe mental illness is common in public mental health services. The unique features of mental illness, including its effects on capacity to make treatment decisions, necessitate a legislative framework ensuring that those affected are afforded treatment, but in a manner that minimizes infringements on liberty. In addition to the distress and suffering caused, severe mental illness is commonly experienced as profoundly disempowering, an added dimension of difficulty that, on the journey to personal recovery, can present as an obstacle in its own right. Given that people subject to compulsory orders are, in a sense, doubly disempowered, recent developments in civil mental health legislation have been designed to embed supported decision-making (SDM), as well as other measures to maximize personal autonomy in treatment decisions. The Mental Health Act 2014 (Vic) recently enacted in Victoria, Australia, is an example of such legislation.
Objectives: To describe the origin and practical application of SDM in the operation of mental health tribunal hearings under the new Act.
Methods: Statutory interpretation of the new legislation; early qualitative research into SDM as experienced by those with mental illnesses, their carers and service staff; preliminary data into outcomes of mental health tribunal hearings; and some case vignettes of SDM in action.
Findings: The principles and practice of an SDM approach may be reflected in the operation and outcomes of tribunal hearings.
Conclusions: Although early signs are encouraging, evaluation of the impact of the new Act on long-term clinical outcomes and experiences of service users is urgently required.
Presenter 1
The Philosophical Switch to Supported Decision-Making and Its Reflection in Law
P Weller1,2
1Graduate School of Business and Law, RMIT University, Melbourne, VIC, Australia
2Mental Health Tribunal, Melbourne, VIC, Australia
Background: The Mental Health Act 2014 (Vic) is widely regarded as a legislative framework that aims to facilitate the philosophical switch to supported decision-making (SDM) in accordance with Australia’s obligations under the United Nations Convention on the Rights of Persons with Disabilities (CRPD). To achieve an SDM stance, the new legislation in Victoria replaces the fully substituted decision-making model of the previous legislation (where psychiatrists made treatment decisions for patients) with an SDM approach. The presumption of capacity, the recognition of advance statements and the inclusion of nominated persons are often referred to as the key legal mechanisms for SDM.
Objectives: The objective of this research is to identify the broader dimensions of SDM – the requirement that people with mental illness are involved in the decisions that affect them – in the Mental Health Act 2014 (Vic).
Methods: Principles of statutory interpretation are used to analyse the legislation. The starting point for the analysis is the fourth stated objective of the Act, which is to ‘enable and support persons who have mental illness or appear to have mental illness to make or participate in decisions about their assessment, treatment and recovery’ (s10(d)).
Findings: The analysis identifies a range of collaborative mechanisms that have bearing on the question of patient participation in decision-making. These mechanisms challenge the traditional dichotomy between capacity and incapacity that governed the old law.
Conclusions: Without an understanding of the broader SDM aspects of the legislation and the obligations they impose, the Victorian legislation is unlikely to fulfil its aspirational goals.
Presenter 2
Supported Decision-Making and the Mental Health Tribunal in Victoria
L Brophy1,2,3
1The Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
2Mind Australia, Melbourne, VIC, Australia
3Mental Health Tribunal, Melbourne, VIC, Australia
Background: This presentation introduces an interdisciplinary project being undertaken in Victoria, Australia, to investigate how supported decision-making (SDM) for people with severe mental health problems (SMHPs) can be used to align Australian laws and practice with international human rights obligations. The presentation is examining the experiences, views and preferences of people with SMHPs, their carers and mental health practitioners.
Objectives: To introduce findings from the interviews and explore the relevance of these findings to Mental Health Tribunal (MHT) hearings.
Methods: In all, 31 consumers have been interviewed along with 31 family members and 32 mental health practitioners, including 12 psychiatrists. Experiences and views of these participants regarding supported decision-making preferences, treatment and recovery have been systematically documented.
Findings: All participants identified opportunities and benefits in SDM, but there are both barriers and enablers to implementing SDM in practice. Mechanisms for facilitating SDM include legal or rights-based mechanisms (e.g. advance statements), interpersonal strategies, empowering consumers and supportive management and leadership.
Conclusions: The findings from this project have implications for MHT hearings, even when it has a substitute decision-making role. The hearings, as well as the preparation undertaken by all involved, offer an opportunity to embed the mechanisms that participants in this project have suggested are required. It is a place where there can be a keen awareness of the human rights of the person at the centre of the hearing, as well as an opportunity for the use of interpersonal strategies. The MHT has an opportunity to lead change through committing to SDM in all its practice.
Presenter 3
The Mental Health Act 2014 (Vic): Preliminary Comparison of Mental Health Review Board and Mental Health Tribunal Processes and Determinations
N Owens1,2
1Mental Health Tribunal, Melbourne, VIC, Australia
2Victorian Institute of Forensic Mental Health, Melbourne, VIC, Australia
Background: Under the previous Mental Health Act 1986 (Vic), the review and appeal function was carried out by the Mental Health Review Board (MHRB). The MHRB has been replaced by the Mental Health Tribunal (MHT) under the new 2014 Act. Informed by the mental health principles, there are a number of important differences in the powers and functions of the MHT including assuming the role of making treatment orders rather than reviewing orders already made by psychiatrists, the addition of an electroconvulsive therapy jurisdiction and limitations on adjournments.
Objectives: To compare the main outcomes of hearings between the MHRB and the MHT. To provide further information about the first 18 months of operation of the MHT.
Methods: Data from the last year of operation of the MHRB and the first year of the MHT were compared regarding discharge of orders, adjournments, patient and carer attendance, legal representation and setting of orders. Data from the first 18 months of operation of the MHT on duration and setting of orders made and electroconvulsive therapy (ECT) orders made were obtained.
Findings: A higher rate of discharge of orders and a reduced rate of adjournments suggest that principles of least restrictive practice and promotion of autonomy may be influencing MHT outcomes.
Conclusions: There are signs that recovery-oriented changes in the legislation are being reflected in some changes in the process of compulsory treatment as determined at the level of the mental health review tribunal. However, a thorough clinical evaluation of the 2014 Act on individual patient outcomes is required.
Presenter 4
The Mental Health Act 2014 (VIC): Early Impressions from the Perspective of a Mental Health Tribunal Psychiatrist Member
S Carey
Mental Health Tribunal, Melbourne, VIC, Australia
Background: Victoria welcomed a new Mental Health Act (MHA) in July 2014. It had been 25 years since the last MHA and modernization was necessary to bring it into line with other states and international standards. The new Act spells out a patient and recovery focus and emphasizes supported rather than substituted decision-making and ultimately less reliance on compulsory treatment. The 2014 Act establishes the Mental Health Tribunal (MHT), which takes an active role in making Treatment Orders rather than the previous review function. Each division of the MHT is a three-member interdisciplinary team that make decisions regarding whether the compulsory criteria apply to each patient and, if so, the type and duration of the Order. The new positions of full-time and part-time members were established. Dr Nick Owens and Dr Sue Carey were appointed as part-time psychiatrist members.
Objectives: To describe some challenges in the implementation of a new MHA and the opportunities for improving compulsory patient outcomes.
Methods: Working as a part-time member and visiting services frequently as a ‘liaison’ member provide a unique opportunity to be part of this change process. The MHT decision-making is described using case vignettes.
Findings: There is substantial variation in implementation of the principles and supported decision-making strategies between services. There are examples of excellent clinical leadership where compulsory patients participate in their recovery plan, and the extent of compulsory treatment is reduced.
Conclusions: Full implementation of the 2014 Act may take years and a thorough clinical evaluation of the impact of the 2014 Act is important. [3.d end]
Aussie: The Australian us Scandinavian Spanish Imaging Exchange for Neuropsychiatric Neuroimaging – Early Career Researchers
B Cartledge1, B Liberg2,3, F Wilkes1, D Jakabek4, C Owens-Walton1, B Hayhow5, BD Power6,7, N Georgiou-Karistianis8, C Nilsson9, PM Thompson10,11,12, D van Westen13,14, LO Wahlund15, M Walterfang16,17, D Velakoulis16,17, JCL Looi1,15,16,17
1Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra, ACT, Australia
2Department of Psychiatry, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, VIC, Australia
3Division of Medical Imaging and Technology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
4Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia
5School of Psychiatry and Clinical Neurosciences, Perth, WA, Australia
6University of Notre Dame, Fremantle, WA, Australia
7Hollywood Private Hospital, Perth, WA, Australia
8School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
9Clinical Memory Research Unit, Department of Clinical Medicine, Lund University, Lund, Sweden
10Imaging Genetics Center, USC Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Marina del Rey, CA, USA
11Departments of Neurology and Psychiatry, UCLA School of Medicine, Los Angeles, CA, USA
12Departments of Neurology, Psychiatry, Engineering, Radiology and Ophthalmology, University of Southern California, Los Angeles, CA, USA
13Center for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
14Diagnostic Radiology, Department of Clinical Sciences, Lund University, Lund, Sweden
15Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
16Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, VIC, Australia
17NorthWestern Mental Health, Melbourne, VIC, Australia
Background: We describe the development and output of the early-career members of the Australian US Scandinavian Spanish Imaging Exchange (AUSSIE), an international neuropsychiatric neuroimaging network focused on understanding the pathophysiology of neuropsychiatric and neurodegenerative disease embedded within clinical health care.
Objectives: To summarise the recent research output by early career researchers from within the AUSSIE network for a clinical audience and to outline a model for collaborative clinical research development.
Methods: Describe project management, methodologies and outputs from various streams in the AUSSIE network.
Findings: We describe pathophysiological understanding derived from research on frontotemporal dementia, Alzheimer’s disease, Huntington’s disease, Parkinson’s disease and related disorders, eating disorders, epilepsy and bipolar disorder in addition to outlining imaging analysis techniques used in our research.
Conclusions: We will summarise recent research using advanced structural imaging analysis in a range of disorders completed by junior researchers within the AUSSIE network.
Presenter 1
Bipolar Affective Disorder: The Striatal Morphological Correlates
B Cartledge1, C Wijeratne2,3,*, D Jakabek4, M Walterfang5,6, D Velakoulis5,6, JCL Looi1,5,6,7,*, P Sachdev8,9,*
1Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra, ACT, Australia
2Euroa Centre, Prince of Wales Hospital, Sydney, NSW, Australia
3School of Psychiatry, The University of New South Wales, Sydney, NSW, Australia
4Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia
5Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, VIC, Australia
6NorthWestern Mental Health, Melbourne, VIC, Australia
7Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
8Centre for Healthy Brain Ageing, School of Psychiatry, The University of New South Wales, Sydney, NSW, Australia
9The Neuropsychiatric Institute, Prince of Wales Hospital, Sydney, NSW, Australia
*They are joint senior authors.
Background: Strong evidence is emerging that implicates corticobasal ganglia circuit abnormalities in the expression of affective illnesses, such as bipolar affective disorder (BAD). The striatum (comprising caudate, putamen and nucleus accumbens) has been shown to be reduced in size in younger patients with BAD, and we wish to explore this in an older cohort.
Objectives: We aim to refine our understanding of the relationship between striatal morphology and the progression and features of BAD in older persons.
Methods: We are conducting a case–control study in an older population (>45 years) utilising brain magnetic resonance imaging (MRI) scans and clinical data in patients with BAD (N = 18) and healthy controls (N = 21).
Using the ANALYZE (Analyze Direct Inc.) software system and spherical harmonic (SPHARM) software, we will measure the volume and shape of the caudate and the putamen. We will analyse striatal morphology and bipolar status both between groups and within groups for clinical features of neuropsychiatric dysfunction.
Findings: We expect that striatal volume will be reduced in patients with BAD compared to controls and that within groups volume will be correlated with the severity of neuropsychological dysfunction.
Conclusions: This project will elucidate brain structural–functional correlations of BAD.
Presenter 2
Glutamatergic Neurotransmission in Psychiatric Disorders
B Liberg, M Andersson, L Farde, J Lundberg
Division of Psychiatry, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
Background: Clinical studies indicate that patients with major depressive disorder (MDD), and substance-related and addictive disorders, show alterations of glutamate neurotransmission in the frontal cortex, cingulate cortex, medial temporal lobe and the striatum. Allosteric modulators of metabotropic glutamatergic receptors (mGluR) have emerged as novel compounds in the treatment of several psychiatric disorders.
Objectives: We will outline the current knowledge on mGluR molecular neuroimaging in psychiatric disorders and show preliminary data from an ongoing study at the Karolinska Institutet PET Centre.
Methods: We are conducting prospective case–control studies to assess the effects of pharmacological treatment on mGluR5 receptor density in key regions previously implicated in MDD and alcohol dependency. We use positron emission tomography (PET) and the novel 3-(18)F-fluoro-5-(2-pyridinylethynyl)benzonitrile ([18F]FPEB) ligandto assess regional receptor density of mGluR5 in humans.
Findings: We hypothesise that we will find regional alterations in [18F]FPEB binding potential following pharmacological treatment for MDD and alcohol dependency.
Conclusions: Neurochemical imaging with [18F]FPEB-PET may elucidate the role of glutamate neurotransmission in the pathophysiology of MDD and alcohol dependency.
Presenter 3
Subcortical Shape Changes in Presymptomatic and Symptomatic Huntington Disease and Their Relationship with Clinical Measures: The Image-HD Study
F Wilkes1, Z Abaryan2, CRK Ching2,3, B Gutman2, S Madsen2, C Adamson4, ML Seal4, M Walterfang5,6, J Stout7, A Churchyard8, P Chua9, D Velakoulis5,6, G Egan7, JCL Looi1, PM Thompson2,10, N Georgiou-Karistianis7
1Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra Hospital, Canberra, ACT, Australia
2Department of Neurology, Imaging Genetics Center, University of Southern California, Marina del Rey, CA, USA
3Interdepartmental Neuroscience Graduate Program, UCLA School of Medicine, Los Angeles, CA, USA
4Murdoch Children’s Research Institute, Melbourne, VIC, Australia
5Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, VIC, Australia
6NorthWestern Mental Health, Melbourne, VIC, Australia
7School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
8Department of Neurology, Monash Medical Centre, Melbourne, VIC, Australia
9Department of Psychiatry, School of Clinical Sciences, Monash University, Monash Medical Centre, Melbourne, VIC, Australia
10Departments of Neurology, Psychiatry, Radiology, Engineering, Pediatrics and Ophthalmology, University of Southern California, Los Angeles, CA, USA
Background: Damage to one area within a neuronal circuit has been hypothesised to lead to up-stream and down-stream effects, altering both structure and measurable functional outcomes. This idea can be studied further in Huntington’s disease (HD), which involves gross atrophy of the neostriatum (caudate and putamen) and other areas, as well as progressive motor, psychiatric and cognitive disturbances.
Objectives: To investigate subcortical shape changes in HD and their relationship with clinical and neurocognitive outcomes.
Methods: In total, 36 pre-symptomatic HD participants, 37 symptomatic HD participants and 36 healthy controls were recruited as part of the Australian-based IMAGE-HD study. The caudate nucleus, putamen and hippocampus were manually traced on T1-weighted magnetic resonance imaging scans. Shapes were analysed using two measures: thickness (radial distance) and the Jacobian determinant (surface dilation ratio). Midsagittal corpus callosum thickness was also analysed using a fully automated pipeline. Correlations were performed between shape changes and clinical and neurocognitive outcomes.
Findings: There were significant differences between all three groups in neostriatal shape, while in the hippocampus shape changes occurred before symptomatic onset, and in the callosum changes were seen only in symptomatic HD. There were also significant correlations between areas of neostriatal shape change and scores on some clinical and neurocognitive measures.
Conclusions: HD is a complex and dynamic disease, involving atrophy of multiple subcortical areas at different times in the disease process. As the central hub in multiple frontostriatal circuits, neostriatal shape changes in HD are correlated with clinical and neurocognitive outcomes.
Presenter 4
Shape Analysis Using Spherical Harmonic Description with Point Distribution Models (SPHARM-PDM): A Powerful Tool for Investigating Morphological Brain Changes
D Jakabek1, MD Macfarlane2,3, AF Santillo4,5, C Owens-Walton6, BD Power7, B Hayhow8,9, M Walterfang10,11, N Georgiou-Karistianis12, S Vestberg13, D Velakoulis10,11, FA Wilkes6, C Nilsson14, D van Westen15,16, JCL Looi6,7,10,11
1Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia
2Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
3Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia
4Clinical Memory Research Unit, Department of Clinical Medicine, Lund University, Lund, Sweden
5Geriatric Psychiatry, Department of Clinical Medicine, Lund University, Lund, Sweden
6Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra, ACT, Australia
7School of Psychiatry and Clinical Neurosciences, Perth, WA, Australia
8University of Notre Dame, Fremantle, WA, Australia
9Hollywood Private Hospital, Perth, WA, Australia
10Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, VIC, Australia
11NorthWestern Mental Health, Melbourne, VIC, Australia
12School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
13Department of Psychology, Lund University, Lund, Sweden
14Clinical Memory Research Unit, Department of Clinical Medicine, Lund University, Lund, Sweden
15Center for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
16Diagnostic Radiology, Department of Clinical Sciences, Lund University, Lund, Sweden
Background: Pathology within subcortical structures is implicated in various psychiatric and neurological disorders. Associated with a loss of function is the loss of form, which can be used as biomarker of disease onset or progression. While volumetric changes can provide a global measure of subcortical structure alteration, this does not take into account regional changes. Applying shape analysis to subcortical structures allows more precise delineation of localised structural changes.
Objectives: We aimed to examine the localised structural changes in subcortical structures across a variety of disease states and to correlate changes in form and function. The process, advantages and challenges of shape analysis are discussed.
Methods: The caudate, putamen, nucleus accumbens and thalamus were manually segmented from magnetic resonance imaging in patients with Parkinson’s disease, Huntington’s disease, behavioural-variant frontotemporal dementia and bipolar disorder. Shape analysis, using the spherical harmonic description with point distribution models (SPHARM-PDM) package, is then applied to these segmentations to determine localised deformations in the surface of the structures. Examples are provided across these various diseases that highlight the associations between function and form.
Findings: Shape analysis provides a complement to volumetric analysis, providing insights into regional changes in subcortical structures. Atrophy in subregions frequently correlates with known subcortical circuits. Nevertheless, challenges with determining intersubject structure correspondence still remain.
Conclusions: Shape analysis is a powerful tool in investigating in vivo morphological brain changes. Moreover, the Australian US Scandinavian Spanish Imaging Exchange (AUSSIE) network provides a shared platform to examine these changes across a wide variety of pathophysiologies and to refine shape analysis techniques in the future.
Presenter 5
Neostriatal Morphology in Parkinson’s Disease: In Vivo Biomarkers Of Disease Progression Stages And Clinical Symptoms
C Owens-Walton1, D Jakabek2, FA Wilkes1, M Walterfang3,4, D Velakoulis3,4, D van Westen5,6,*, JCL Looi1,7,8,*, O Hansson9,10,*
1Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra, ACT, Australia
2Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia
3Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, VIC, Australia
4NorthWestern Mental Health, Melbourne, VIC, Australia
5Centre for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
6Diagnostic Radiology, Department of Clinical Sciences, Lund University, Lund, Sweden
7Department of Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, VIC, Australia
8Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
9Department of Clinical Sciences, Lund University, Malmö, Sweden
10Memory Clinic, Skåne University Hospital, Malmö, Sweden
*They are joint senior authors.
Background: Parkinson’s disease (PD) is associated with a wide range of clinical symptoms relating to fronto-striato-pallido-thalamo-cortical circuits that traverse the neostriatum. The development of successful therapeutic interventions for PD will require a deeper knowledge of disease-related neurobiological changes that take place in the PD brain, the spatio-temporal course of these changes and improved understanding of the neural circuit basis of the clinical dysfunctions that characterize the disease.
Objectives: We sought to investigate the morphological changes to the neostriatum in PD, how these changes manifest over the disease course and whether any morphological changes were correlated with measures of clinical function.
Methods: The caudate nucleus and putamen were manually traced on 3-T T1-weighted magnetic resonance imaging scans of 74 probable PD participants and 27 controls. The three-dimensional object maps were then quantitatively analysed for volume and shape. Correlations of morphology with clinical function were investigated using the participant’s performance on a range of motor and non-motor tests.
Findings: Bilateral caudate nuclei and putamina volumes were significantly smaller in the PD group compared to controls (5.5% reduction, p = 0.037 and 5.97% reduction, p = 0.039, respectively). Significant correlations were demonstrated between reduced putamina volumes and impairment in motor function as well as between reduced caudate nuclei volumes and impaired cognitive function.
Conclusions: PD involves atrophic changes to the neostriatum that are related to clinical function. This research provides support for the neostriatum as a putative biomarker in PD and reiterates the important role of neural circuitry in PD.
Overview of Advanced Training Certificate Requirements and Changes with the 2012 Fellowship Program
RANZCP Education Committee, D Ward1, J Zurek2, S Price3, M Murphy4, A Parsons5, P Fung6
1Royal North Shore Hospital, Sydney, NSW, Australia
2Tamworth Mental Health Service, Sydney, NSW, Australia
3Eastern Health, Melbourne, VIC, Australia
4St Vincent’s Hospital, Sydney, NSW, Australia
5Justice Health, Sydney, NSW, Australia
6UnitingCare Mental Health, Sydney, NSW, Australia
Background: Advanced Training Certificates have long been a part of the RANZCP pathway to fellowship. Following the completion of Basic Training, trainees have a choice of completing Generalist Advanced Training, or Advanced Training Certificates in Addiction, Adult, Child and Adolescent, Consultation Liaison, Forensic, Old Age, or Psychotherapy. The transition to the 2012 Fellowship Program has resulted in changes to each of the Advanced Training Certificate requirements.
Objectives: This symposium is an overview of the current requirements for attainment of each RANZCP Advanced Training Certificate. It will guide Trainees in their choice of Advanced Training and Fellows who may wish to complete further training.
Methods: Each Advanced Trainee Certificate representative will describe “a day in the life” of doing advanced training and outline the key assessment requirements for the 2012 curriculum. The RANZCP Education Committee and a panel of psychiatrists from the Subcommittee for Advanced Training will discuss the differences between the 2003 and 2012 curriculum and the rationale for change.
Findings: The 2012 Fellowship Program Advanced Training Certificates will continue to follow an apprenticeship model with a clinical focus along with requirements ranging from formal courses to research projects.
Conclusions: Advanced Training Certificates are an important component of the RANZCP training program for the development of subspecialty skills.
Tourette syndrome: From Pathogenesis to Management
V Eapen1, Y Nomura2, Y Kano3, B Kim4, H Wang5
1The University of New South Wales, Sydney, NSW, Australia
2Yoshiko Nomura Segawa Neurological Clinic for Children, Tokyo, Japan
3Division of Child Psychiatry, Tokyo, Japan
4Seoul National University, Seoul, South Korea
5Chang Gung Children’s Hospital, Taoyuan, Taiwan
Background: Tourette syndrome is a neuropsychiatric disorder affecting 1% of children, and it is often misunderstood and under-diagnosed.
Objectives: This session will trace the pathogenesis of Tourette syndrome from genotypes to clinical phenotypes and discuss the co-morbidities and the overlapping neuronal circuitry involvement with implications for management.
Methods: The developmental trajectories will be traced through neuroanatomical substrates and neuronal circuitry to illustrate how the genetic vulnerability translates to behaviour and implications for treatment.
Findings: A number of neurodevelopmental genes underpin the translation of genetic vulnerability to clinically significant symptoms.
• An overlapping involvement of neuronal substrates and neuronal circuitries leads to Tourette syndrome as well as co-morbidities such as attention deficit hyperactivity disorder and obsessive–compulsive disorder
• Pharmacological and behavioural approaches as well as family support form essential components of comprehensive management.
Conclusions: Understanding the developmental context for the occurrence of tics and co-morbidities has significant clinical implications for the course and outcome as well as management.
Presenter 1
From Genes to Behaviour: A Neurodevelopmental Journey in Tourette syndrome
V Eapen
School of Psychiatry, The University of New South Wales, Sydney, NSW, Australia
Background: The available research data suggest the role of fronto-striato-pallido-thalamo-cortical circuits in the pathogenesis of Tourette syndrome (TS). Also, the site and extent of involvement of these circuits are believed to determine the nature and severity of the clinical phenotypic presentations such as obsessive–compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD) and related behaviours.
Objectives: The presentation will trace the pathogenesis of neurodevelopmental disorders and the multiple neurodevelopmental trajectories that underpin the translation of genetic vulnerability to clinically significant symptoms in TS and related behaviours.
Methods: Evidence from genetic, neuroimaging and phenomenological data sets suggests that there are different subtypes of TS and OCD and that some forms of OCD are alternative phenotypic expressions of the putative TS gene(s) with gender-dependent difference in the phenotypic expression. Similar differences exist for age at onset and clinical course.
Findings: Newly emerging data suggest that the improvement in tic symptoms with age may be the result of frontal compensatory responses, with frontal cortices becoming more efficiently connected to the striatum and to the motor and sensorimotor cortices. In this regard, our findings from a transcranial magnetic stimulation study found that the cortical silent period (CSP) to motor-evoked potential (MEP) ratio (CSP/MEP ratio), an important neurophysiological indicator, significantly increased after treatment using comprehensive behavioural intervention for tics (CBIT), which suggested an enhancement of motor cortical inhibition in the fronto-striatal circuitry.
Conclusions: Future research exploring the neuronal circuitry in relation to sensorimotor gating, procedural learning and habit formation might improve our understanding of the role of neuronal maturation and brain plasticity in the course and outcome.
Presenter 2
Pathophysiology of Tourette syndrome: The Importance of Age Factors
Y Nomura
Yoshiko Nomura Neurological Clinic for Children, Tokyo, Japan
Background: Tourette syndrome (TS) is a neuropsychiatric disorder with onset in childhood. The involvement of the basal ganglia-thalamo-cortical circuit has been indicated in the pathophysiology of TS.
Objectives: To discuss the pathophysiology of TS based on age-dependent clinical features and findings using polysomnography (PSG) and the sleep–wake rhythm (SWR).
Methods: The clinical characteristics and PSG and SWR findings from patients treated at the Segawa Neurological Clinic for Children were analyzed and summarized.
Findings: We observed specific changes in age of onset of tics and co-morbidities, and age-dependent changes, through the course. The PSG evaluation showed that dopamine (DA) function is decreased at the terminal of nigrostriatal system with supersensitivity of the developmental DA receptor.
With respect to the SWR results, we found that the appearance of delayed sleep-phase disorder in teens relates to the appearance of obsessive–compulsive disorder.
With these pathophysiological considerations, we practice the treatments of TS.
Conclusions: Based on the age-related natural course of TS and the results of PSG and SWR, we raised the importance of developmental dopamine deficiency as the pathophysiology of TS. Recent speculation based on the findings of deep brain stimulation may further demonstrate the pathophysiology of TS.
Presenter 3
Impact of Sensory Phenomena on Clinical Characteristics of Patients with Tourette syndrome
Y Kano1, N Matsuda1, M Nonaka1, M Fujio1, N Kaji1, T Kono2
1The University of Tokyo, Tokyo, Japan
2National Center of Neurology and Psychiatry, Tokyo, Japan
Background: Sensory phenomena, including premonitory urges, are crucial symptoms of Tourette syndrome (TS). ‘Just right’ feelings among sensory phenomena were found more frequently in patients with TS and obsessive–compulsive disorder (OCD) than in patients with TS only. Sensory phenomena are suggested to influence of quality of life and/or global functioning in patients with TS.
Objectives: This study aimed to investigate the relationship between tics, sensory phenomena, obsessive–compulsive symptoms (OCS) and global functioning in Japanese patients with TS and changes in these features during the clinical course.
Methods: In all, 41 patients with TS were assessed using the University of São Paulo’s Sensory Phenomena Scale (USP-SPS), the Premonitory Urge for Tics Scale (PUTS), the Yale Global Tic Severity Scale (YGTSS), the Dimensional Yale–Brown Obsessive–Compulsive Scale (DY-BOCS) and the Global Assessment of Functioning (GAF) Scale. Of the 41 patients, 21 were evaluated again after 6 years 8 months, the mean duration.
Findings: USP-SPS and PUTS total scores were significantly correlated with YGTSS total and vocal tics scores. Additionally, both sensory phenomena severity scores were significantly correlated with DY-BOCS total OCS scores. Finally, the PUTS total scores were significantly and negatively correlated with GAF scores.
Conclusions: This study provides significant insight into sensory phenomena related to tics, OCS and global functioning in patients with TS.
Presenter 4
Deficits in Sensory Organization for Postural Stability in Children with Tourette syndrome
HS Wang1, WY Liu2, H Ya-Ting2, A Wong3
1Division of Pediatric Neurology, Chang Gung Children’s Hospital, Taoyuan, Taiwan
2Department of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Tao-Yuan City, Taiwan
3Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
Background: Tourette syndrome (TS) is a childhood-onset neurodevelopmental disorder characterized by motor and vocal tics for more than 1 year. Previous studies have indicated that children with TS demonstrate postural control anomalies when standing.
Objectives: The aim of this study was to compare postural stability under normal and altered sensory conditions in children with TS and healthy control (HC) children.
Methods: A convenience sample of 12 children with TS (9 boys and 3 girls; 9.4 ± 1.1 years) and 12 HC age-matched and gender-matched children (9.2 ± 1.1 years) participated in this study. The Sensory Organization Test (SOT) was used to assess postural stability under six altered sensory conditions (1. normal vision, fixed support; 2. eyes closed, fixed support; 3. vision sway-referenced, fixed support; 4. normal vision, support sway-referenced; 5. eyes closed, support surface sway-referenced; 6. both vision and support surface sway-referenced) using the SMART Balance Master® 8.2 (NeuroCom® International, Clackamas, OR, USA).
Findings: The results showed significant differences between the two groups in conditions 5 and 6 (p = 0.003 and 0.002, respectively). The mean composite equilibrium score in children with TS was significantly lower than that of HC children (p < 0.000). The results suggested that children with TS had greater difficulty in maintaining postural stability, especially when vestibular information was challenged.
Conclusions: This study provides supporting evidence for possible deficits in impaired access to vestibular information and sensorimotor integration of postural control in children with TS. Exercise for improving the above deficits may help children with TS.
Addressing Comorbid Substance Use and Mental Disorders: Diagnostic Challenges and Service Responses
DI Lubman1, J Reilly2, B McDermott2, E Cementon3, E Mullen3
1Turning Point, Eastern Health and Monash University, Melbourne, VIC, Australia
2School of Medicine and Dentistry, James Cook University, Queensland and Mental Health Service Group, Townsville Hospital & Health Service, Townsville, Queensland, Australia
3Orygen Youth Health, Melbourne, VIC, Australia
Background: Mental health conditions with comorbid substance use disorders (SUDs) are common presentations to psychiatrists and mental health services and present diagnostic challenges as well as issues for management. This symposium will consider issues relating to identification, assessment and treatment in various settings, with a particular focus on psychosis and mood disorders. It will also briefly review strategies adopted by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and its Faculty of Addiction Psychiatry to enhance the training of psychiatrists in addictions and SUDs.
Objectives: The objectives are as follows:
• Explore the relationship between methamphetamine and mental health presentations;
• Review practical service issues in identifying, assessing and treating SUDs in people with other psychiatric disorders;
• Review strategies for improving psychiatric training in addictions, including the recently developed advanced training in addictions entrustable professional activities relating to substance use comorbidity.
Methods: Data related to methamphetamine, psychosis, violence and depression will be discussed. Perspectives on identification and assessment of SUDs comorbid with other mental health disorders from two different service settings will be presented, as well as implications for training and service delivery.
Conclusions: The symposium will enhance understanding of SUDs comorbid with other mental health disorders, including diagnostic challenges and options for service delivery models and training.
Presenter 1
Methamphetamine-Induced Mental Disorders: Challenges for Assessment and Management
DI Lubman1, R McKetin2,3
1Turning Point, Eastern Health and Monash University, Melbourne, VIC, Australia
2Centre for Research on Ageing, Health and Wellbeing, Australian National University, Canberra, ACT, Australia
3National Drug and Alcohol Research Centre, The University of New South Wales, Sydney, NSW, Australia
Background: Methamphetamine users frequently report psychotic and mood symptoms, creating diagnostic challenges for clinicians in determining the most appropriate treatment approaches, particularly if methamphetamine use continues.
Objectives: To examine the relationship between methamphetamine use and mental health symptoms using a longitudinal study design.
Methods: A total of 400 participants who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV) criteria for methamphetamine dependence but who did not meet DSM-IV criteria for lifetime schizophrenia or mania were recruited from treatment services. Depressive and psychotic symptoms, violent behaviour and days of methamphetamine use in the past month were assessed using validated scales.
Findings and conclusions: Most (84%) of the sample met criteria for a depressive disorder, although the symptoms were better accounted for by psychoactive substance use in 44% of participants. There was a dose-related increase in psychosis and violent behaviour when an individual was using methamphetamine compared with when they were not. Regular methamphetamine use was also found to be associated with episodes of depression and psychosis, as well as aggressive behaviour. These findings have important implications for harm reduction approaches, as well as the assessment and management of mental health symptoms in methamphetamine-dependent users.
Presenter 2
Evaluating a Dual Diagnosis Strategy in an Adult Mental Health Service
J Reilly, B McDermott
School of Medicine and Dentistry, James Cook University and Mental Health Service Group, Townsville Hospital & Health Service, Townsville, QLD, Australia
Background: Identification, assessment and treatment of comorbid substance use disorders (SUDs) in mental health service (MHS) patient groups are recognised to be at low levels despite high prevalence of comorbidity identified in surveys and epidemiological studies. In 2008, Queensland’s Dual Diagnosis Guidelines targeted routine universal screening and comprehensive assessment of patients screening positive and established dual diagnosis (DD) co-ordinator positions in MHS. From 2010, the Townsville MHS co-ordinators implemented education focused on enhancing identification and assessment.
Objectives: To measure the effectiveness of the DD strategy, Townsville MHS analysed trends in the identification of SUDs over the duration of the implementation of the DD strategy.
Methods: Substance use specific data collected in routine clinical care identified as pragmatic effectiveness measures were Health of the Nation Outcome Scales (HoNOS) item 3 ‘Problem drinking or drug-taking’ scores and diagnoses of International Classification of Diseases – 10 Revision (ICD-10) mental and behavioural disorders due to psychoactive substance use (F10-19), primary or secondary.
Findings and conclusions: The dataset collected over 4 years includes 5616 patients: 19.3% Indigenous and 52.5% male. Over the study period, 1557 (27.7%) patients scored ≥2 on HoNOS item 3, statistically more likely in male patients (34.9% vs 19.8%, chi-squared = 158.85, p = 0.000), Aboriginal patients (37.1% vs 25.8% chi-squared = 48.65, p = 0.000) and patients who had been admitted at some time to the inpatient unit (40.9% vs 18.1%, chi-squared = 347.96, p = 0.000). The positive effects on patterns of SUD diagnosis following the clinician education intervention will be presented.
Presenter 3
Developing an Integrated Model of Care for Dual Diagnosis Treatment in a Specialist Youth Mental Health Clinic
E Mullen, E Cementon, A Roseman, D Albiston
Orygen Youth Health, Melbourne, VIC, Australia
Background: Dual diagnosis (DD), or co-occurring mental health and substance use disorders, and its association with higher rates of disability, hospitalisation, reduced engagement and adverse outcomes in young people are well recognised. The current models of care are non-integrated and potentially complicating or delaying best practice treatment.
Objectives: Our objective was to scope the need for a novel, evidence-based, high-quality model of care for DD in Orygen Youth Health, a specialist youth mental health service. It was anticipated that the model would be implemented across acute and continuing care settings.
Methods: Initial planning was informed by a literature review and evaluation of staff attitudes and competencies for DD clinical practice using a questionnaire. Consumer views were sought by interviewing the youth participation program and a Client Satisfaction Survey. A file audit was conducted to assess clinical care in the organisation.
Findings: Staff awareness of DD was good as evidenced by the utilisation of systems for DD screening and assessment; however, this did not translate into actual integrated interventions for DD. A number of barriers to integrated treatment, related to clinician competency, consumer attitudes and systemic factors, were identified.
Conclusions: Routine screening and assessment for DD at Orygen Youth Health enabled the systematic identification of co-occurring disorders in young people presenting to the organisation. Barriers to development and implementation of integrated care were consistent with the literature. A novel model of intervention was developed and implemented with support from the leadership group. The model of care will be presented and discussed.
Presenter 4
Training in Addictions among Psychiatrists: Recent Ranzcp Initiatives Including Entrustable Professional Activities in Substance Use Co-Morbidity
E Cementon, J Reilly
Subcommittee for Advanced Training in Addiction Psychiatry, The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
Background: Psychiatrists and general practitioners without actual clinical experience in specialist addiction services can feel that they lack relevant competencies.
Objectives: To consider core requirements for psychiatrists in substance use disorders (SUDs) and addictions and the Royal Australian and New Zealand College of Psychiatrists’ (RANZCP) recent development of related entrustable professional activities (EPAs) relating to substance use.
Methods: Outline recent development of EPAs in substance use and addictions, with particular emphasis on EPAs relating to co-morbid SUDs and other mental and physical health problems developed by the Subcommittee of Advanced Training in Addiction Psychiatry (SATADD);Consider possible strategies to further develop capacity in addiction among psychiatrists and other mental health clinicians.
Findings and conclusions: The training developed for basic and advanced trainees in addiction psychiatry may offer a template for further improvements in the clinical care of people with SUDs co-morbid with other mental health disorders.
RANZCP Private Practice Psychiatry Symposium: Wither Private Practice?
J King1,2,3, C Ng1,2,4, G Galambos5,6, B Pring7, P Cadzow8
1The University of Melbourne, Melbourne, VIC, Australia
2The Melbourne Clinic, Melbourne, VIC, Australia
3Section of Private Practice Psychiatry, RANZCP, Melbourne, VIC, Australia
4Asia Australia Mental Health, Melbourne, VIC, Australia
5Lawson Clinic, Sydney, NSW, Australia
6NSW Branch, RANZCP, Rozelle, NSW, Australia
7Delmont Hospital, Glen Iris, VIC, Australia
8Clear Sky Specialist Clinic, Buderim, QLD, Australia
Background: This symposium will discuss the current challenges facing private practice psychiatry in Australia. The first speaker will discuss issues relating to an academic unit in a private setting and the interaction between academia and private practice. The second will provide an update on issues around the erosion of confidentiality of psychiatric records in Australia. The third speaker will discuss the development of telepsychiatry and his own experiences. The fourth speaker will share reflections on private practice psychiatry in regional Australia. The chair will then invite questions from the audience and discuss similarities and differences in private practice in different countries.
Presenter 1
Is There A Role For Academia In Private Practice?
C Ng1,2,3
1The Melbourne Clinic, Melbourne, VIC, Australia
2The University of Melbourne, Melbourne, VIC, Australia
3Asia Australia Mental Health, Melbourne, VIC, Australia
Background: Academic units have traditionally been located in large public hospitals, with public sector psychiatrists occupying senior academic roles. In 1995, The Melbourne Clinic’s Professorial Unit began as a conjoint venture between Healthscope and the University of Melbourne, with clinical, research and teaching roles. The unit has consultant psychiatrists in private practice holding academic roles and working with research staff.
Objectives: The speaker will discuss the Professorial Unit’s 20-year history, challenges faced and future trajectories, including international collaborations.
Presenter 2
Has Psychiatrist–Patient Confidentiality Been Eroded By Subpoenas?
G Galambos
Lawson Clinic, Sydney, NSW, Australia
Background: Confidentiality is a bedrock in the doctor–patient relationship and has been treated as sacrosanct for centuries, excluding some exceptional circumstances where it is broken. It is essential in psychiatry, where patients are divulging highly personal information. This is under threat in an increasing litigious system, where lawyers subpoena entire medical records in court cases.
Objectives: The presenter will explore the reasons for the prolific use of subpoenas to gain access to psychiatric records in Australia and examine the applicable legal principles and practices at the New South Wales and Commonwealth levels, aiming to develop recommendations for Australian governments to curb the inappropriate and harmful use of subpoenas. The presenter previously spoke about this topic at Congress in 2014, which provided the impetus for the formation of a Royal Australian and New Zealand College of Psychiatrists (RANZCP) Working Group around this issue. The presenter will also discuss the work of the new RANZCP Working Group.
Presenter 3
Does Telepsychiatry Work In Private Practice?
B Pring
Delmont Hospital, Melbourne, VIC, Australia
Background: Telehealth provides exciting new opportunities for private psychiatrists. Telepsychiatry can be defined as electronic transmission of psychiatric consultations, advice or services in digital form from one location to another using a data communication link provided by third-party carrier, or carriers, and is used to provide psychiatric services from a distance. Psychiatry, by its nature, is the specialty most suited to video consultations and there is a substantial body of evidence to support the satisfaction that practitioners derive from this form of care and, more importantly, the acceptance in a very positive way of patients and consumer groups. Australia and New Zealand have been international leaders in the application of telepsychiatry techniques. Telepsychiatry can be used clinically for both assessment and treatment, is effective for case conferencing and consultation–liaison work and can be incorporated into a range of service delivery models. Telepsychiatry can enable rural and remote communities to gain access to psychiatric services as well as provide support for healthcare professionals in rural and remote locations.
Objectives: The presenter will discuss the history of telepsychiatry in Australia and his use of telepsychiatry in private practice. This will include a comparison with face-to-face consultations, advantages, limitations and future opportunities.
Presenter 4
How Do You Make Private Practice Psychiatry Work In Regional Australia?
P Cadzow
Clear Sky Specialist Clinic, Buderim, QLD, Australia
Objectives: The presenter will discuss a range of issues and present reflections on private practice psychiatry in regional Australia.
Psychiatry Training in the Global Village
K King1, B Hoadley1, HK Lee1, C Hinds2, J-P Kwasik3,4, J Devlin1
1Northern Sydney Area Health Network, Sydney, NSW, Australia
2South London and Maudsley NHS Foundation Trust, London, UK
3Melbourne Health, Melbourne, VIC, Australia
4RANZCP Trainee Representative Committee, Melbourne, VIC, Australia
Background: The Asia Pacific region is one of the most diverse and rapidly changing in the world, and this is often reflected in our local patient populations. Considering the significant ethnic, language and cultural differences, would international psychiatric experiences in the Asia Pacific region better equip trainees for individual, local and global influences?
Many Australian and New Zealand medical students complete ‘elective’ overseas rotations as part of their formal undergraduate training. Registrars in emergency medicine and general practice can continue their interest in global health by completing part of their accredited training in other countries. There have been examples of psychiatry trainees completing international rotations under the supervision of a psychiatrist accredited in both countries or after entering an approved overseas training program.
Objectives: To explore the benefits of, and barriers to, establishing international psychiatry placements for trainees in low-resource and high-resource settings across the Asia Pacific region.
Methods: We defined international psychiatry experiences as clinical, non-clinical and research experiences in a different country from the training base, with a focus on transcultural psychiatry, global mental health, public mental health and health systems. We interviewed trainees and psychiatrists who have completed overseas rotations and reviewed the literature regarding doctors’ aspirations and apprehensions towards overseas training and to understand the local, regional and global influences of international training.
Findings: Trainees in all specialties are increasingly seeking and accessing international experiences. Training exchanges may advance Asia Pacific collegial relationships and influence global mental health (Becker and Kleinman, 2013; Department of Global Health and Social Medicine, 2015; World Health Organisation, 2015). On returning home, trainees may have greater sensitivity to cultural nuances of their local area. There is a need for more cohesion between trainees to disseminate their regional experiences (Chetwood, 2015; Parker et al., 2011). There is a paucity of data on the influence of regional training on worldwide and local mental health.
Conclusions: Further conversation is essential to understanding the influence of international psychiatry training experiences in the Asia Pacific region. Trainees may be an asset in creating stronger ties with our neighbouring Colleges and thereby influence global mental health.
References
Becker AE and Kleinman A (2013) Mental health and the global agenda. New England Journal of Medicine 369: 1380–1381.
Chetwood J (2015) Foundation training overseas: how to apply and the pitfalls to avoid. British Medical Journal.
Department of Global Health and Social Medicine, Harvard University (2015) Mental health research. Available at: http://ghsm.hms.harvard.edu/research/mental-health (assessed 21 November 2015).
Parker J, Mitchell R, Mansfield S, et al. (2011) A guide to working abroad for Australian medical students and junior doctors. Medical Journal of Australia 194: 1–95.
Wai-Tong C (2015) South China Morning Post. We should stop neglecting mental health issues in Hong Kong, 1 June.
World Health Organization (2015) Mental Health Action Plan 2013–2020. Available at: http://www.who.int/mental_health/actionplan2013 (assessed 21 November 2015).
Asia Pacific Mental Health
M Hopwood
The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has held Asia Pacific Mental Health Forums since 2013 and continues to prioritise the strengthening of relationships in the Asia Pacific. 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 and methods: With mental illness contributing to approximately 13% of the world’s disease burden, it is timely that Asia Pacific leaders discuss the workforce challenges they face in servicing these needs. Planning of the medical workforce is essential to guarantee appropriate service levels, which are often compounded by the effects of natural disasters and conflict. The forum will identify strategies to effectively service the mental health needs and facilitate workforce development.
Findings and conclusions: Mental health needs throughout the Asia Pacific are diverse and the potential for regional collaboration will enhance the work of mental health practitioners. This presentation will draw on the importance of collaboration, workforce planning and development of tailored strategies to satisfy the individual mental health needs of each nation.
The Application of Optical Topography/Functional Near-Infrared Spectroscopy in Asian Psychiatric Patients
Presenter 1
Optical Topography: From Basic Research to Clinical Applications in Japan
J Schnackenberg
Hitachi Medical Corporation, Tokyo, Japan
Background: The functional near-infrared spectroscopy (fNIRS) was developed 20 years ago, starting in the early 1990s and releasing the first Food and Drug Administration (FDA)-approved clinical multi-channel system in 1998. Further development of optical topography improved the technology and extended its scope of applications in research and the clinical environment.
Objectives: To present the advances in technology behind optical topography and its applications.
Methods: In a nationwide large-scale study, a verbal fluency task (VFT)-based protocol as a supportive tool for the diagnosis of major depression, schizophrenia and bipolar disorder was developed and evaluated.
Results: The VFT protocol was able to differentiate the performance between patients suffering from major depression, schizophrenia, bipolar disorder and healthy controls.
Conclusions: Although optical topography (or fNIRS) has established itself as a viable research tool in basic research and neuroimaging, the technology has gained increasing interest in the clinical field. This has led to its approval by the Japanese health authorities in 2014 and is being increasingly used by Japanese psychiatrists.
Presenter 2
Application of Near-Infrared Spectroscopy in Taiwan
TH Lan
Department of Psychiatry, Taichung Veterans General Hospital, Taichung, Taiwan
Background: Near-infrared spectroscopy (NIRS) is used to evaluate brain function and serves as a possible candidate for a differential diagnostic tool in psychiatry. The first NIRS application in psychiatry was introduced to Taiwan around the year 2008. A short 2-month study of the use of NIRS in clinical practice by a Taiwanese psychiatrist at the Fukushima Medical University occurred in the year 2010. In 2013, the first Hitachi ETG4000 NIRS machine was installed at the Taichung Veterans General Hospital.
Objectives: To apply NIRS to assess psychiatric patients in Taiwan.
Methods: We applied NIRS to establish the norms of normal controls and populations with different psychiatric disorders. The major focus was put on first-onset schizophrenia, major depression and dementia in Taiwan. We tried the Taiwan Mandarin Phonetic Symbols version word fluency test (WFT) instead of the Japan Hiragana version WFT.
Findings: The pattern of the active stage is pretty similar between data from Japan and Taiwan. We also tried the category fluency test for aged people who did not identify Mandarin Phonetic Symbols at their school age. The application of NIRS in clinical practice, especially after the standard diagnostic interview is done, is a good differential diagnostic tool in Taiwanese patients.
Conclusions: We concluded that NIRS might be a good, low-cost diagnostic instrument for some psychiatric disorders in Taiwan. The next step will focus on the generalization to other psychiatric disorders. Also of interest for future studies is whether NIRS performance can be a prognostic biomarker after intervention with medication.
Presenter 3
The Clinical and Research Application of Optical Topography: Discovery of Diagnostic Signatures in Singaporean Patients
RC Ho
Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Background: For the past 100 years, the clinical diagnoses of psychiatric disorders have been established by clinical interviews. Diagnostic criteria such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) are changing and symptoms are subjected to the interpretation of psychiatrists. There is an urgent need to develop a cost-effective adjunctive diagnostic tool in psychiatry to provide more objective assessment of psychiatric conditions.
Objectives: To identify diagnostic signatures of different psychiatric disorders through optical topography.
Methods: Optical topography is a portable functional imaging technique and uses infrared spectroscopy to detect functional changes in the cerebral cortex during a cognitive task. We recruited 50 volunteers (40 patients and 10 healthy controls) and they performed the English version of the verbal fluency test (VFT) during optical topography. All patients had an established clinical diagnosis and continued their treatment during the period of optical topography. We compared their patterns and diagnostic signatures between Singaporean and Japanese patients.
Findings: Patients suffering from schizophrenia, bipolar disorder, major depressive disorder, borderline personality disorder and Alzheimer’s disease demonstrated significantly less oxygenated blood flow during the VFT compared to healthy controls. Singaporean patients demonstrated similar diagnostic signatures as Japanese patients.
Conclusions: Optical topography offers cost-effective functional imaging, and such a diagnostic procedure can be administered by psychiatrists. This will lead to advances and enhances objectivity in psychiatry as one of the medical specialties. The potential for future clinical and research applications will be discussed.
The Role of Spirituality in Contemporary Psychiatry: Challenges and Opportunities
M Wong1, F Wilson2, A Fernando III3, K George4,5,6,7
1School of Psychology & Psychiatry, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, VIC, Australia
2Manaaki House Community Mental Health Centre, Auckland, New Zealand
3Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
4Peter James Centre and Wantirna Health, Burwood East, VIC, Australia
5Aged Persons Mental Health, Eastern Health, Melbourne, VIC, Australia
6Deakin University, Burwood East, VIC, Australia
7Monash University, Clayton, VIC, 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 symposium aims at providing an update on the major themes and issues involved in the interface between psychiatry and spirituality and presenting a summary of the state of play in the Asia Pacific region as observed in Australia, New Zealand and Vanuatu.
Methods: This symposium provides 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 well-being. It also consists of four reports from Australia, New Zealand and Vanuatu, respectively, on how psychiatrists in the Asia Pacific region apply insights from various spiritual, cultural and faith traditions and systems to the practice of psychiatry. Challenges, issues and opportunities encountered are highlighted.
Findings: Recently published high-quality research and guidelines in the field of psychiatry and spirituality suggest a spirituality-informed approach to psychiatry and mental health is evidence-based, safe and effective. Spirituality-informed approaches to psychiatry have been and are being practiced in Australia, New Zealand and Vanuatu in ways particular to the cultural, ethnic, religious, political, clinical, organisational and medico-legal setting of each respective site. However, in contrast to the United States and the United Kingdom, there is an obvious absence of evidence-based practice guidelines for applying spirituality in clinical psychiatry in this region.
Conclusions: There is an urgent need for conducting research and providing evidence-based guidelines for spirituality-informed psychiatry in the Asia Pacific region.
Presenter 1
Research Findings and Clinical Practice Guidelines: A Review
M Wong
School of Psychology and Psychiatry, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
Background: There has been a recent surge of high-quality research, clinical data and practice guidelines in the field of psychiatry and spirituality.
Objectives: This paper provides a critical review of this body of literature to assess its relevance and applicability to clinical psychiatry.
Methods: Key papers and practice guidelines published in this area over the past decade were selected through MEDLINE and PsycLIT using ‘psychiatry’ and ‘spirituality’ as key words. Major recurrent themes are identified and critiqued.
Findings: Major findings in various publications suggest a spirituality-informed approach to psychiatry and mental health provides insights into, and 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: Data published to date on psychiatry and spirituality suggest that a spirituality-informed approach to psychiatry and mental health, when applied according to evidence-based guidelines, is effective and safe.
Presenter 2
A New Zealand Perspective
F Wilson1, A Fernando III2
1Manaaki House Community Mental Health Centre, Auckland, New Zealand
2Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
Background and objectives: To provide a preliminary overview of the interplay between spirituality and psychiatry in New Zealand.
Methods: This paper surveys the current practices in New Zealand – clinical guidelines (e.g. Takarangi Framework Cultural Competency, which includes spirituality), special interest groups (e.g. Christian Psychiatrist Group Auckland), therapeutic approaches (e.g. Buddhist mindfulness), publications, research theses and consumer perspectives – to formulate an overview of the state of play in New Zealand.
Findings: As predicted by the multicultural profile of New Zealand, there is a noticeable crossover between various religious and cultural groups.
Conclusions: It is of utmost importance and relevance to bear this spirituality diversity in mind in our delivery of psychiatric services in New Zealand.
Presenter 3
The Vanuatu Experience
K George1,2,3,4
1Peter James Centre and Wantirna Health, Burwood East, VIC, Australia
2Aged Persons Mental Health, Eastern Health, Melbourne, VIC, Australia
3Deakin University, Burwood East, VIC, Australia
4Monash University, Clayton, VIC, Australia
Background: Mental health services are very basic in Pacific Island Nations, with limited resources. The majority of Pacific Islanders have an association with the Christian Church. There is a lot of stigma and lack of understanding about psychiatric disorders within the church community.
Objectives: This paper explores how attitudes toward mental illness within the Church in Pacific Island Nations impact mental health help-seeking.
Methods: A fact-finding and service mission was arranged to the Pacific Island Nation of Vanuatu to collect data on the mental health needs and services, including the views of the church community.
Findings: There was a widely held view within the church community that mental illness was due to a weak faith, sin or demon possession. Their respected leaders are usually the first contact for help with regard to mental illness. There was also clear interest and openness toward better understanding of the nature of mental illness and the relationship between faith-based intervention and psychiatric treatment.
Conclusions: Involvement in a church community in Vanuatu and similarly in most Pacific Island Nations is integral to the lives of many Pacific Islanders. Working with the church community to provide mental health education can reduce stigma, promote acceptance and facilitate early detection and intervention.
Presenter 4
An Australian View
M Wong
School of Psychology and Psychiatry, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
Background: Australia is closer to Asia than to the West and has a cultural diversity much broader than being just a passive recipient of European heritage. Australia’s multiculturalism, ethnic plurality and historical youthfulness provide a unique perspective in matters of spirituality and psychiatry.
Objectives: This paper argues that the view from Australia regarding spirituality and psychiatry highlights the multi-layered or multi-level nature of the subject matter.
Methods: Four perspectives were used to understand the role of spirituality in psychiatry in the Australian context of medical training, health research, service delivery and community education.
Findings: There are examples in Australia for incorporating spirituality into the teaching of psychiatry, integrating spirituality into the neuroscientific research of mental health and illness, applying spirituality to facilitate the practice of compassion in psychiatry and utilising spirituality to reduce the stigma of mental illness. While these practices provide opportunities to promote a comprehensive understanding of psychiatry, a non-reductionist approach to mental health research, compassionate delivery of mental health services and de-stigmatisation of mental illness, there remain multiple ethical, legal and operational challenges.
Conclusions: Spirituality is relevant to mental health at various levels and areas of the practice of psychiatry in Australia, and leadership from mental health professional bodies is needed to define the role of spirituality and ensure the quality and safety of its application in psychiatry.
Aussie: The Australian US Scandinavian Spanish Imaging Exchange For Neuropsychiatric Neuroimaging
JCL Looi1,2,3,4, D Velakoulis3,4, PM Thompson5,6,7, M Walterfang3,4, BD Power8,9, R Molina-Ruiz10,11, AF Santillo12, N Georgiou-Karistianis13, C Nilsson14, D van Westen15,16, LO Wahlund2
1Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra, ACT, Australia
2Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
3Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, VIC, Australia
4NorthWestern Mental Health, Melbourne, VIC, Australia
5Imaging Genetics Center, USC Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Marina del Rey, CA, USA
6Departments of Neurology and Psychiatry, UCLA School of Medicine, Los Angeles, CA, USA
7Departments of Neurology, Psychiatry, Engineering, Radiology & Ophthalmology, University of Southern California, Los Angeles, CA, USA
8School of Medicine Fremantle, The University of Notre Dame Australia, Fremantle, WA, Australia
9Hollywood Private Hospital, Perth, WA, Australia
10Hospital San Carlos, Madrid, Spain
11Complutense University Medical School, Madrid, Spain
12Clinical Memory Research Unit, Department of Clinical Medicine, Lund University, Lund, Sweden
13School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
14Clinical Memory Research Unit, Department of Clinical Medicine, Lund University, Lund, Sweden
15Center for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
16Diagnostic Radiology, Department of Clinical Sciences, Lund University, Lund, Sweden
Joint Speakers represent Primary and Back-Up Speakers.
Background: We describe the development and output of an international neuropsychiatric neuroimaging network, the Australian US Scandinavian Spanish Imaging Exchange (AUSSIE), that focused on understanding the pathophysiology of neuropsychiatric and neurodegenerative disease embedded within clinical health care.
Objectives: Outline a model for collaborative clinical research and student development and summarise the findings of the last 5 years of research for a clinical audience.
Methods: Describe project management, methodologies and outputs from various streams in the AUSSIE network. The first three talks will focus on methodologies and the following three on findings from the research.
Findings: We describe pathophysiological understanding derived from research on frontotemporal dementia, Alzheimer’s disease, Huntington’s disease, Parkinson’s disease and related disorders, eating disorders, epilepsy and bipolar disorder.
Conclusions: The AUSSIE network is an innovative international research platform to advance understanding of neuropsychiatric disorders. By judicious applications of advanced structural imaging analysis, we can identify key brain structures towards the development of biomarkers.
Presenter 1
The Shape and Form of Neuropsychiatric Disease in the Brain
JCL Looi1,2,3,4, D Velakoulis3,4, PM Thompson5,6,7, M Walterfang3,4, BD Power8,9, R Molina-Ruiz10,11, A Santillo12,13, N Georgiou-Karistianis14, C Nilsson15, D van Westen16,17, LO Wahlund2
1Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra, ACT, Australia
2Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
3Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, VIC, Australia
4NorthWestern Mental Health, Melbourne, VIC, Australia
5Imaging Genetics Center, USC Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Marina del Rey, CA, USA
6Departments of Neurology and Psychiatry, UCLA School of Medicine, Los Angeles, CA, USA
7Departments of Neurology, Psychiatry, Engineering, Radiology and Ophthalmology, University of Southern California, Los Angeles, CA, USA
8School of Medicine Fremantle, The University of Notre Dame Australia, Fremantle, WA, Australia
9Hollywood Private Hospital, Perth, WA, Australia
10Hospital San Carlos, Madrid, Spain
11Complutense University Medical School, Madrid, Spain
12Clinical Memory Research Unit, Department of Clinical Medicine, Lund University, Lund, Sweden
13Geriatric Psychiatry, Department of Clinical Medicine, Lund University, Lund, Sweden
14School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, VIC, Australia
15Clinical Memory Research Unit, Department of Clinical Medicine, Lund University, Lund, Sweden
16Center for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
17Diagnostic Radiology, Department of Clinical Sciences, Lund University, Lund, Sweden
Background: We describe the methods and work flow of the Australian US Scandinavian Spanish Imaging Exchange (AUSSIE) network as an example of an innovative embedded clinical research network to conduct neuroimaging research in neuropsychiatry.
Objectives: We will describe the project planning and management of research within the network.
Methods and findings: A brief overview of the work-flow of study design, image acquisition and image analysis as a model that can be adapted by other researchers.
Conclusions: We describe an adaptable model of a virtual clinical research network that can be applied by trainee and clinical psychiatrists in real-world settings.
Presenter 2
The Corpus Callosum: Disease between the Hemispheres
M Walterfang1,2, C Adamson3, ML Seal3, FA Wilkes4, N Georgiou-Karistianis5, L-O Wahlund6, JCL Looi1,4,6, D Velakoulis1,2
1Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, VIC, Australia
2NorthWestern Mental Health, Melbourne, VIC, Australia
3Murdoch Children’s Research Institute, Melbourne, VIC, Australia
4Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra, ACT, Australia
5School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
6Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
Background: The corpus callosum is the major interhemispheric connection. It carries heterotopic (between different modality) and homotopic (linking modalities) connections that may be strategically affected in neuropsychiatric disease.
Objectives: We will outline methodologies and results of measurement of structural change in the corpus callosum as well as correlates in neuropsychiatric disorders.
Methods and findings: We describe innovative methods and findings in frontotemporal dementia, Alzheimer’s disease, bipolar disorder and schizophrenia.
Conclusions: Measurement of the corpus callosum may capture strategic change in brain structure as part of an ensemble of biomeasures that may yield a useful composite or series of biomarkers.
Presenter 3
The Thalamus: A View of Disease from a Central Chamber
BD Power1, D Jakabek2, M Walterfang3,4, D Velakoulis3,4, C Nilsson5, D van Westen6,7, AF Santillo8, JCL Looi9,10,11,12
1University of Notre Dame, Fremantle, Australia and Hollywood Private Hospital, Perth, WA, Australia
2Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia
3Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, Australia
4NorthWestern Mental Health, Melbourne, VIC, Australia
5Clinical Memory Research Unit, Department of Clinical Medicine, Lund University, Lund, Sweden
6Center for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
7Diagnostic Radiology, Department of Clinical Sciences, Lund University, Lund, Sweden
8Clinical Memory Research Unit, Department of Clinical Medicine, Lund University, Lund, Sweden
9Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra, ACT, Australia
10Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
11Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, VIC, Australia
12NorthWestern Mental Health, Melbourne, VIC, Australia
Background: The thalamus is a key component of recurrent cortico-striato-pallido-thalamo-cortical circuits primarily arising from, and feeding back to, the frontal cortex. These corticostriatal circuits, functionally responsible for cognition, emotion, motor function and behavior, are implicated in neuropsychiatric disorders.
Objectives: We aim to outline methodologies for measuring the volume and shape of thalamus and striatum as biomeasures of the structural integrity of corticostriatal circuits, as well as applications in clinical research.
Methods and findings: We describe findings of structural changes in the thalamus in neurodegenerative diseases such as frontotemporal dementia, Alzheimer’s disease, progressive supranuclear palsy and cerebrovascular disease.
Conclusions: Measurement of the thalamus may capture strategic change in brain structure as part of an ensemble of biomeasures that may yield a useful composite or series of biomarkers.
Presenter 4
Eating Disorders: Structural and Functional Changes in Impulsivity and Compulsivity
R Molina-Ruiz1,2, JCL Looi3,4,5,6, T García-Saiz7, M Rincón7, E Via8,9, M Walterfang5,6, D Velakoulis5,6, M Díaz-Marsá1,2,10,11
1Universitary Hospital Fundación Alcorcón, Madrid, Spain
2Complutense University Medical School, Madrid, Spain
3Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra, ACT, Australia
4Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
5Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, VIC, Australia
6NorthWestern Mental Health, Melbourne, VIC, Australia
7Artificial Intelligence Department, E.T.S.I. Informática, UNED, Madrid, Spain
8Department of Clinical Sciences, School of Medicine, University of Barcelona, Barcelona, Spain
9Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, VIC, Australia
10Hospital Clínico San Carlos, Madrid, Spain
11Complutense University Medical School, Madrid, Spain
Background: Impulsivity and compulsivity constructs have been understood historically as diametrically opposed; however, they are increasingly recognized to share neurophysiological and neuropsychological mechanisms. Eating disorders (ED) such as anorexia nervosa (AN) and bulimia nervosa (BN) as well as frequently comorbid disorders (borderline personality disorder [BPD]) may represent an example of extremes of the impulsive–compulsive continuum. Since emotional processing dysfunction evident in ED may be on the basis of their dysregulated eating behaviors, we aim to study the underlying neurobiological mechanisms of these processes through functional and structural imaging techniques.
Objectives: The purpose of the current neuroimaging studies was to compare differences in function and structure of cortico-striatal key brain areas involved in impulsive–compulsive disorders.
Methods: We describe innovative structural and functional neuroimaging techniques and findings in different groups of patients with disorders on the impulsive–compulsive continuum.
Findings: Greater prefrontal activity and larger volumes of striatum were found in patients with anorexia compared to controls and more impulsive groups.
Conclusions: The present studies highlight the functional relevance of specific brain areas associated with self-control in ED partially supporting the idea of AN and BN as both extremes of the impulsive–compulsive continuum. Structural differences in the striatum may represent strategic change and serve as a biomeasure of these disorders.
Presenter 5
Frontotemporal Dementia: Cortico-Striato-Thalamic Circuits
AF Santillo1,2, MD Macfarlane3,4, D Jakabek4, M Walterfang5,6, S Vestberg7, D Velakoulis5,6, FA Wilkes8, C Nilsson9, D van Westen10,11, JCL Looi5,6,8,12
1Clinical Memory Research Unit, Department of Clinical Medicine, Lund University, Lund, Sweden
2Geriatric Psychiatry, Department of Clinical Medicine, Lund University, Lund, Sweden
3Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
4Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia
5Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, Australia
6NorthWestern Mental Health, Melbourne, VIC, Australia
7Department of Psychology, Lund University, Lund, Sweden
9Clinical Memory Research Unit, Department of Clinical Medicine, Lund University, Lund, Sweden
10Center for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
11Diagnostic Radiology, Department of Clinical Sciences, Lund University, Lund, Sweden
12Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
Background: Behavioural variant frontotemporal dementia (bvFTD) is associated with changes in dorsal striatal parts of the basal ganglia (caudate nucleus and putamen), related to dysfunction in the cortico-striato-thalamic circuits which help mediate executive and motor functions.
Objectives: We aimed to determine whether the size and shape of striatal structures correlated with diagnosis of bvFTD and measures of clinical severity, behaviour and cognition.
Methods: Magnetic resonance imaging scans from 28 patients with bvFTD and 26 healthy controls were manually traced using image analysis software (ITK-SNAP). The resulting three-dimensional objects underwent volumetric analysis and shape analysis, through spherical harmonic description with point distribution models (SPHARM-PDM). Correlations with size and shape were sought with clinical measures in the bvFTD group, including the Frontal Behavioural Inventory, Clinical Dementia Rating for bvFTD, and neuropsychological measures.
Findings: Caudate nuclei and putamina were significantly smaller in the bvFTD group compared to controls, with global shape deflation in the caudate bilaterally. In the bvFTD group, shape deflations on the left, corresponding to afferent connections from dorsolateral prefrontal mediofrontal/anterior cingulate and orbitofrontal cortex, correlated with worsening disease severity. Global shape deflation in the putamen was correlated with frontal behavioural inventory scores – higher scoring on negative symptoms was associated with the left putamen, while positive symptoms were associated with the right. The results are discussed in relationship with the clinical neuroanatomy of these structures and of the emerging literature on the role of basal ganglia in bvFTD.
Conclusions: Behavioural symptoms and severity of bvFTD are correlated with abnormalities in striatal size and shape. This adds to the notion of the importance of the basal ganglia to the clinical picture of bvFTD and to the promise of imaging the striatum as a biomarker in this disease.
“I’ve Got My Letters, Now What?”: Practical Considerations For Early Career Psychiatrists
R Newton1,2
1Austin Health, Melbourne, VIC, Australia
2Senior Psychiatrist Panel, Melbourne, VIC, Australia
Includes Early Career Researcher Award
Background: The transition from trainee to junior consultant is a challenging time, often navigated alone. There are few formal settings where practical issues facing early career psychiatrists are presented. The RANZCP Section of Early Career Psychiatrists was established to support fellows in this early phase of their career.
Objectives: To discuss key practical issues facing early career psychiatrists wanting to develop careers in public and private practice. Key issues in public sector psychiatry include job search, interview skills, understanding of hospital management structures, clinical governance, funding, research, peer review groups and career progression. Some private sector issues include establishing or joining existing practices, billings, working in private inpatient units, and ongoing training. Early career psychiatrists benefit significantly from mentorship from senior psychiatrists.
Methods: A presentation explaining the approach to the management of critical incidents will raise a number of systemic managerial issues pertinent to early career psychiatrists. Following this is a senior psychiatrist panel speaking on the topic, “the most important lessons I have learnt in psychiatry”. The Early Career Researcher Award winner will also present their work.
Findings: There are many issues specific to early career psychiatrists. Issues raised in this symposium can then be further explored in regular local Early Career Psychiatrist events around Australia and NZ.
Conclusions: RANZCP Congress is an opportunity for early career psychiatrists to benefit from formal guidance and support.
Pains and Gains in Cyberspace for Developing Brains: Deliberate Self-Harm, Problematic Internet Use and Digital Competence in Young People
N Kowalenko1, C Goossens2, J Brewer3, P Tam4, W Chen5
1The University of Sydney, Sydney, NSW, Australia,
2CAMHS, Department of Health, Perth, WA, Australia
3NSW Department of Education, The University of Sydney, Sydney, NSW, Australia
4Rivendell Adolescent and Family Unit, Sydney, WA, Australia
5Department of Child and Adolescent Psychiatry, The University of Western Australia, Perth, WA, Australia
Background: Children and adolescents are at increased risk when they navigate unregulated online content and social media. The current cohort represents the first generation exposed to these technologies without prior data on the impact on developing brains. The recent literature highlights the elevated risks of deliberate self-harm (DSH) behaviours by children and adolescents as influenced by problematic Internet use (PIU) and contagion effects. However, proactive education on the explicit principles of cyber-safety may mitigate risks. This symposium addresses the pressing issues of risks and prevention in cyberspace relevant to Child and Adolescent Mental Health Services (CAMHS).
Objectives: To review problematic and beneficial use of Internet activities including social media use by children and adolescents.
Methods: Review of literature and survey data which evaluate problematic use as well as benefits and early intervention fostering children’s ‘savvy competence in cyberspace’.
Findings: The first presentation highlights the roles played by online contagion in DSH among adolescents. The second presentation reports different patterns of social media and Internet misuse by young people who self-harm. The novel concept of ‘problematic Internet contagion’ (PIC) is explored. The third presentation argues that PIU can be prevented by teaching children media/digital literacy skills and impulse control skills – as captured by ‘digital nutrition’ – analogous to education on nutrition and healthy diets. The fourth presentation provides a critical appraisal on the positive aspects of information and communications technology (ICT) and games in improving health outcomes and mental well-being.
Conclusions: Digital technology, Internet and social media use is the contemporary social norm, especially for the digital native generation. The use of ICT and social media can yield both benefits and risks, and effective education on digital competence can maximise ‘gain’ and mitigate ‘pain’.
Presentation 1
Deliberate Self-Harm and Contagion in the Australian Community: Clinical Management of Contagion Risk in Child and Adolescent Mental Health
N Kowalenko, G Culjak, S Spielman, J Crumpton, L Basil
The University of Sydney, Sydney, NSW, Australia
Background: In Australia, self-harm and suicide in children and adolescents are a concern to the whole community. The Australian Human Rights Commission (2014) national report and a national epidemiological survey of child and adolescent mental disorders (2015) reported on Internet use in a representative sample. Whereas adolescent and youth suicide rates have decreased since the mid-1990s, suicide is still a leading cause of death. Clinically, recovery of peers following the index suicide of one of their number is poorly understood and represents a period of increased risk for deliberate self-harm (DSH) and suicide contagion.
Objectives:
1. Analyse national data and key findings about non-suicidal self-injury (NSSI), suicide and Internet use
2. Present principles for the clinical management of potential clustering of DSH in adolescents in Child and Adolescent Mental Health Services (CAMHS) care
Methods:
1. Present findings from key national surveys and reports
2. Present de-identified series of cases following a peer suicide
3. Review clinical management principles
Findings: Of the 16- and 17-year-olds, one in seven report that they experienced suicidal planning in the previous 12 months. Clinical strategies to limit apparent clustering of DSH after suicide of a peer should include intervention at the level of the group: both with peer group members and with the parental group. Parental monitoring of adolescent on-line and other communications may enhance personal safety of adolescents following a peer suicide.
Conclusions: DSH is common, as is suicide planning. Potential contagion of DSH requires comprehensive clinical management. The usual boundaries of clinical confidentiality with adolescents and their families are challenged when a clinical focus on group phenomena is required.
Presentation 2
The Roles Played By Social Media in Deliberate Self-Harm Among Children and Adolescents
C Gooseens1, A Cleator2, S Dziurawiec2, and W Chen3
1CAMHS, Department of Health, Perth, WA, Australia
2School of Psychology and Exercise Science, Murdoch University, Perth, WA, Australia
3Department of Child and Adolescent Psychiatry, The University of Western Australia, Perth, WA, Australia
Background: Deliberate self-harm (DSH)-related community websites (e.g. discussion boards, personally constructed websites) and social networking groups have dramatically increased, providing young people with a host of online venues to seek information and social connections based on DSH. The patterns of DSH behaviours related to Online Social Media (OSM) use in children and adolescents are poorly understood.
Objectives: This study reviews and classifies the patterns of OSM uses relevant to DSH in Child and Adolescent Mental Health Services (CAMHS).
Methods: Thematic review of published literature and surveys conducted in Western Australia.
Findings: Thematic review of the literature on social media misuse and DSH reveals several subtypes of Internet misuse. These include the following: (1) photo/video sharing, (2) site sharing information on DSH and detection evasion methods, (3) DSH chatrooms and forum discussion (open groups versus closed groups), (4) chatrooms (often closed group) formed and used by ex and current patients of adolescent in-patient and out-patient facilities and (5) discussion groups with serious lethal risks (offering advice on lethal methods and inciting suicide). These patterns vary across geographical and cultural regions. Some DSH users report gaining a sense of understanding and support via chatroom forums and photo/video sharing and viewing – despite some at the ‘cost’ of escalating self-harm acts.
Conclusions: Different subtypes of social media misuse are identified, although it remains unknown whether these subtypes follow the pattern of a gateway/sentinel progression model – analogous to drug addiction. Furthermore, the novel concept of ‘problematic Internet contagion’ (PIC) – located in network connections contrasting with an impulse-control disorder located within a person as in problematic Internet use (PIU) – is proposed.
Presentation 3
Digital Nutrition: Principles of Balanced Sustainable Technology Use in Everyday #LYFE
J Brewer1,2
1The University of Sydney, Sydney, NSW, Australia
2NSW Department of Education, Sydney, NSW, Australia
Background: While there is a growth in the focus of digital citizenship education with regard to preventing cyber-bullying and promoting cyber-safety, little attention has been paid to preventing problematic Internet use (PIU) and teaching explicit principles of a ‘healthy digital diet’. The American Academy of Pediatrics has recently replaced prescriptive screen-time limits with descriptive principles for parenting in the digital age. This demonstrates an understanding that digital cultures are a dynamic ecosystem which may require mediation on behalf of parents and educators (who increasingly expect and relay on technology use for engagement in pedagogy). Digital nutrition is a framework for understanding how our selection of online activities and relationship to technology can be paralleled with food nutrition.
Objectives: Reviews new principles of children’s screen-based media use (SBMU) and implications for preventing emotional and behavioural issues arising over overuse, misuse and PIU.
Methods: Review of literature that demonstrates the need for early intervention into children’s SBMU and principles that provide protective factors against PIU.
Findings: Technological literacy differs from media/digital literacy skills; teaching explicit emotional regulation and impulse control skills is beneficial in preventing PIU; and peer mediation of young people’s technology use is an opportunity to empower them to maximise the benefits of digital technology.
Conclusions: Digital nutrition offers a framework for bringing together a proactive and positive way of conceptualising healthy and sustainable technology habits for young people.
Presentation 4
Positive Computing and Serious Games: A Critical Overview of the Mental and Physical Benefits of Information and Communications Technology in Young People
P Tam
Rivendell Adolescent and Family Unit, Sydney, NSW, Australia
Background: In the past 10–15 years, there has been a large, and ever-increasing, amount of quality literature in the broad field of ‘Internet psychology’. Much of the focus has tended to be on the potential harm of computer games and Internet overuse, concomitant with a concern often voiced in the general community and the media. However, the potentially positive and beneficial usage of computer technologies and game design in fields as diverse as cognitive enhancement, emotional support and physical health improvement has also attracted much research interest although this tends to be less-well publicised.
Objectives: To assess how strong the evidence is for potential positive uses of information and communications technology (ICT) and how these situate themselves within the existing patterns of youth Internet usage.
Methods: Review of key international research which examines the potential cognitive, emotional and physical health benefits of Internet and computer-based technologies. Critical appraisal of key relevant studies.
Findings: There are a large number of global studies, many of high quality, that critically evaluate the positive aspects of ICT and games, particularly in young people. Many programmes and games now exist with the key aim of improving specific health outcomes and mental well-being.
Conclusions: Internet and computer technologies will continue to increase in quality and penetration into daily life. The world of ICT and computer games is a very diverse one, and it is likely that there are still under-utilised and under-appreciated positive aspects of ICT which researchers, and clinicians, can employ to the future benefit of clients and the broader community.
An Introduction to Conducting Research in Clinical Settings
D Siskind1,2,3, S Parker1,2,3, S Kisely1,2,3
1RANZCP Committee for Research, Melbourne, VIC, Australia
2Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
3School of Medicine, The University of Queensland, Brisbane, QLD, Australia
Background: Evidence-based practice means 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 Royal Australian and New Zealand College of Psychiatrists (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 new researchers about the process of research, 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:
1. How to write a research question?
2. How to find (and get value from) a research supervisor?
3. How to design a research study and to collect and analyze data?
4. How to write up research findings with a 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 help Registrars and other new investigators in designing, implementing and completing a research project.
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
1RANZCP Committee for Research, Melbourne, VIC, Australia
2Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
3School of Medicine, The University of Queensland, Brisbane, QLD, 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
1RANZCP Committee for Research, Melbourne, VIC, Australia
2Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
3School of Medicine, The University of Queensland, Brisbane, QLD, 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 a 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 of potential supervisors who are readily accessible.
Presenter 3
An Introduction to Study Design
S Kisely1,2,3
1RANZCP Committee for Research, Melbourne, VIC, Australia
2Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
3School of Medicine, The University of Queensland, Brisbane, QLD, Australia
Background: It is important to think carefully about your study design before starting research. Being clear about your hypotheses, methods and the statistical power required will help you make sure your project can answer the research question. Documenting your 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 Royal Australian and New Zealand College of Psychiatrists (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, to 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 A View To Publication
D Siskind1,2,3
1RANZCP Committee for Research, Melbourne, VIC, Australia
2Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
3School of Medicine, The University of Queensland, Brisbane, QLD, 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 manuscript rejection. It will also consider ways 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.
State of the Art: Transcranial Magnetic Stimulation (RTMS)
T Schläepfer1, H Sackheim2, M Nakamura3
1 University Hospital Bonn, Bonn, Germany
2Departments of Psychiatry and Radiology, Columbia University, New York, USA
3Kanagawa Psychiatric Center, Yokohama, Japan
Background: Transcranial magnetic stimulation (TMS) has been one of the most intensely studied areas of neurostimulation over the last 20 years. TMS has gained a strong evidence base highlighting it as a safe alternative to electroconvulsive therapy and psychopharmacological interventions.
Objectives: This symposium is designed to provide participants with state-of-the-art information about new directions in research about rTMS and information concerning practical clinical applications of the treatment and technique.
Methods: International speakers have been invited by the Congress to provide the latest information about rTMS, highlighting achievements in Germany and South East Asia.
Topics of discussion:
‘Update rTMS and Deep TMS’
‘Review of Novel Neurostimulation Techniques’
‘Functional connectivity-based combination of neurofeedback and Neurostimulation’.
Findings: Information has been provided concerning the recent randomized controlled trials and meta-analysis concerning rTMS and how this can be applied to clinical practice.
Conclusions: rTMS is a new form of neurostimulation that has been certified as a legitimate treatment for severe mental illness in many countries around the world.
Novel Neurostimulation Techniques
H Sackheim1
1Departments of Psychiatry and Radiology, Columbia University, New York, USA
The field is brain sitmualtion is exploding with the development of novel stimulation techniques and the exploration of new indications for existing techniques. This presentation will briefly review new and critical information about a variety of brain stimulation interventions, particularly pertaining to their use in the treatment of mood disorders. Among the techniques to be briefly discussed are: invasive and non-invasive forms of vagus nerve stimulation (VNS), deep brain stimulation (DBS), new versions of transcranial magnetic stimulation (TMS), transcranial electrical stimulation (transcranial direct current stimulation [tDCS], transcranial alternating current stimulation [tACS], and transcranial random noise stimulation [tRNS], transcranial pulsed ultrasound stimulation [tPUS], and alternatives to electroconvulsive therapy (ECT), specifically Magnetic Seizure Therapy (MST) and Focal Electrically Administered Seizure Therapy (FEAST). The diversity of techniques to focally modulate network activity testifies to the vibrancy of the field.
Novel Perspectives on Obsessive–Compulsive Disorder
V Brakoulias1, D Castle2,3, N Fineberg4,5,6, L Lampe1, V Starcevic1
1Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
2The University of Melbourne, Melbourne, VIC, Australia
3St Vincent’s Hospital, Melbourne, VIC, Australia
4Highly Specialized OCD and BDD Services, Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, UK
5University of Hertfordshire, Hatfield, UK
6University of Cambridge Clinical Medical School, Addenbrookes Hospital, Cambridge, UK
Background: Obsessive–compulsive disorder (OCD) is a particularly disabling disorder with many treatment challenges.
Objectives: This symposium aims to provide novel perspectives on OCD by examining its assessment, clinical settings in which evaluation and management of OCD take place, pharmacological treatment and cognitive behavioural therapy.
Methods: Several experts in the field of OCD research have come together to discuss OCD using a number of novel approaches.
Findings: The treatment of patients with OCD can be improved by a comprehensive assessment of their specific symptoms. Such an assessment aids our understanding of the patient’s individual treatment needs. Centres specializing in treatment of patients with OCD can have their high standards of care acknowledged by being accredited by the International College of Obsessive–Compulsive Spectrum Disorders. There is good evidence for treating OCD with selective serotonin reuptake inhibitors and/or exposure and response prevention, and these treatments remain first-line. However, the complexity of OCD leads many patients to treatment resistance and to treatment with less well-validated strategies. Standard treatment approaches and treatment options for treatment-resistant patients and for those who are more severely ill are reviewed in the symposium.
Conclusions: OCD is a complex and yet treatable disorder. Novel perspectives presented in this symposium can improve the way we assess and treat patients with OCD.
Presenter 1
An Overview of the Assessment of Obsessive–Compulsive Disorder
V Starcevic
Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
Background: The conceptualisation of obsessive–compulsive disorder (OCD) has undergone changes that have affected the way this condition is assessed and diagnosed.
Objectives: To present the most important aspects of the assessment of OCD in light of the changes in its diagnostic criteria and new knowledge about OCD.
Methods: Integrative literature review.
Findings: Every assessment of OCD must take into account the heterogeneity of its manifestations and patients should be asked routinely about the symptoms from the following four groups of obsessions and compulsions: (1) contamination/cleaning, (2) doubt/checking, (3) unacceptable/taboo thoughts and (4) symmetry/ordering. In almost all cases, obsessions and compulsions occur together and a detailed enquiry is necessary when patients do not report compulsive behaviours. In such cases, it is important to ascertain whether mental compulsions are present and whether there are other strategies of coping with obsessions, such as avoidance and reassurance seeking. Patients should also be assessed for sensory phenomena. A designation of all obsessions as ego-dystonic is not adequate and clinicians need to establish whether the particular obsessions are experienced as ego-dystonic or ego-syntonic. Related to this issue is an assessment of insight. Due to the relationships between OCD and anxiety and obsessive–compulsive spectrum disorders and their implications for treatment, there is also a need to determine whether any of these conditions is present.
Conclusions: A careful assessment of OCD ensures proper diagnosis and better understanding of patient experience while taking into account co-occurring psychiatric conditions and other problems. Such a comprehensive approach can then guide treatment.
Presenter 2
Accreditation of Obsessive–Compulsive Disorder Services
NA Fineberg1,2,3, J Menchon4, J Zohar5; The International College of Obsessive–Compulsive Spectrum Disorders Working Group
1Highly Specialized OCD and BDD Services, Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, UK
2University of Hertfordshire, Hatfield, UK
3University of Cambridge Clinical Medical School, Addenbrookes Hospital, Cambridge, UK
4OCD Clinical and Research Unit, Department of Psychiatry, Bellvitge University Hospital, IDIBELL, University of Barcelona, CIBERSAM, Barcelona, Spain
5Chaim Sheba Medical Centre, Tel Aviv University, Tel Aviv, Israel
Background: Obsessive–compulsive disorder (OCD) requires highly specialized staff to detect, diagnose and properly manage the disorder. Assessment and care centres for OCD have been established, but there is no consensus regarding the key functions these units should perform.
Objectives: To promote standards, improve quality of clinical care and deliver the best treatment for patients with OCD, the International College of Obsessive-Compulsive Spectrum Disorders has developed accreditation standards for OCD centres. This initiative also aims to ensure the validity and reliability of research results provided by different facilities and countries.
Methods: Accreditation standards were selected through a highly consensual procedure that gathered a large number of opinions and points of view. This was done in an interactive and iterative way, enabling considerable feedback to be obtained from experienced therapists in the field of OCD including psychiatrists, psychologists and mental health nurses from many different countries (Turkey, South Africa, United Kingdom, Sweden, United States, Israel, The Netherlands, Bulgaria, Canada, Japan, Argentina, Hungary, Brazil and Australia). Standards were divided into (1) Recommended (i.e. those that an accredited centre would be expected to meet) and (2) Excellent (i.e. those that, while not essential for an OCD unit, would increase the quality of care).
Findings: A set of agreed standards were proposed around the following domains: facilities, human resources, training, clinical assessment, management and follow-up and key quality indicators.
Conclusions: This initiative establishes common international quality standards for OCD units, some of which are aspirational. It represents a dynamic process, open to future advances and periodic review.
Presenter 3
Treating Obsessive–Compulsive Disorder with Serotonin Reuptake Inhibitors
V Brakoulias
Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
Background: Selective serotonin reuptake inhibitors (SSRIs) are regarded as effective first-line pharmacological agents for obsessive–compulsive disorder (OCD). However, clinicians often find OCD challenging to treat with SSRIs alone.
Objectives: To encourage clinicians to optimally prescribe SSRIs or clomipramine when treating patients with OCD.
Methods: Selective literature review presented in the context of clinical experience.
Findings: Most patients (40–60%) with OCD will respond to SSRIs. Patients with OCD respond to SSRIs at a slower rate than those with depression. The dose of an SSRI can be increased at 2-week intervals depending on the patient’s response and any adverse effects. Some patients will respond to a standard dose of an SSRI, but most patients with OCD require their doses of SSRI to be increased to the higher therapeutic range. Improvements from treatment usually plateau at 12 weeks. There does not appear to be any significant advantage of one SSRI over another, but some individuals who do not respond to one SSRI may respond to another. Treatment response is relatively modest with most studies regarding a 25–35% reduction in Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) as a treatment response. Successful treatment should continue for at least 12 months as there is a significant risk of relapse when treatment is stopped. Response to SSRIs can be enhanced by adding exposure and response prevention.
Conclusions: When used optimally, high-dose SSRIs are usually effective in alleviating OCD symptoms.
Presenter 4
Improving Treatment for Obsessive–Compulsive Disorder
D Castle1,2
1The University of Melbourne, Melbourne, VIC, Australia
2St Vincent’s Hospital, Melbourne, VIC, Australia
Background: Obsessive–compulsive disorder (OCD) is an often highly disabling condition which does not respond adequately to first-line pharmacological or psychological interventions.
Objectives: To provide a clinically focused review of the biological treatment of treatment-resistant OCD.
Methods: Selective literature review and synthesis.
Findings: High-dose selective serotonin reuptake inhibitors (SSRIs) and clomipramine have good evidence-based data. Combinations of SSRIs have little support in clinical trials, but the combination of SSRIs and clomipramine can be helpful: careful clinical and cardiac monitoring is required. Certain adjunctive antipsychotics have a reasonable evidence base in OCD, but their use also needs to be weighed against the potential side effect burden. In patients with substantial generalised anxiety symptoms, clonazepam is worth considering. Of the other augmenting strategies, memantine and ondansetron appear useful in some cases and are well tolerated. Topiramate might ameliorate compulsions to some degree but is less well tolerated. If all these strategies, along with expert psychological therapy, fail, careful consideration should be given to deep brain stimulation, which has an emerging evidence base and which can result in dramatic benefits for some individuals. Gamma radiosurgery might also still have a place for some patients.
Conclusions: There is a paucity of research on how to manage patients with OCD who fail to respond adequately to first-line therapies. Brain stimulation techniques are an exciting area of development, but much more research is required into novel therapies.
Presenter 5
Cognitive Behaviour Therapy for Obsessive–Compulsive Disorder: When, What and How?
L Lampe
Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
Background: Cognitive behaviour therapy (CBT) strategies are well developed for obsessive–compulsive disorder (OCD) and have a robust efficacy literature. Nevertheless, implementing these strategies in clinical practice can be challenging.
Objectives: To briefly summarise the evidence of effectiveness, outline key and novel features of CBT for OCD and highlight key practice points, providing relevant clinical examples.
Methods: Meta-analyses were identified by searching MEDLINE, EMBASE and PsycINFO databases. This information was supplemented by clinical experience.
Findings: A number of CBT approaches have been described, and delivery methods include individual and group face-to-face, and online. CBT treatments are highly effective and therapeutic gains are maintained. CBT alone appears superior to serotonergic antidepressant pharmacotherapy alone and as effective as combination therapy; combination therapy is more effective than pharmacotherapy alone. Various clinical presentations can present challenges. A high level of skill and training is required for effective implementation, and treatment can be costly of therapist time; this has led to the development of stepped care models and alternative methods of delivery.
Conclusions: All patients with OCD, including those on pharmacotherapy, should be offered CBT. Appropriately skilled therapists are required, but a stepped care approach and alternative treatment delivery methods may have a place.
Advocacy in Mental Health
M Hopwood, A Peters
The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
With the increased political and community awareness of mental health issues in recent years, advocacy has become a priority for Royal Australian and New Zealand College of Psychiatrists (RANZCP) as well as an area of keen interest for members and stakeholders. An understanding and appreciation of the role of psychiatrists also enhance mental health service delivery and policy liaison. This symposium will explore several approaches the College has taken to advocate for a range of issues and the outcomes achieved so far.
Patient Care Advocacy – The Premature Mortality Campaign and the Results So Far
M Hopwood
The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
Since 2013, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) has committed to highlighting the premature mortality of people with serious mental illness and advocating for policy and clinical change to support better outcomes. In 2015, this involved the publication of report Keeping Body and Mind Together as well as analysis of the economic cost of this premature mortality which was estimated at 45.4 billion for Australia and 6.2 billion for New Zealand, annually.
This work has gained momentum to contribute to a growing move for change. The presentation will discuss how the project has developed, achievements and obstacles so far and the next steps for the College.
The Role of ‘Experts’ In Advocacy – RANZCP Response to the Medicare Benefits Schedule Review and Medicare Safety Net Changes
P Jenkins, R Forster
The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
The College is asked on an almost daily basis to provide input into the policy work of government and other organisations. The Practice, Policy and Partnerships Committee is the Board Committee with responsibility for actioning responses to these consultations – informed by the Board’s priorities. During 2015, the Committee oversaw more than 70 formal submissions, ranging from specific topics, such as methamphetamines use, to big picture reforms of the mental healthcare system. However, increasingly the College is not just waiting to be asked but rather taking a proactive approach, especially for issues that (1) have significant impact on members, their patients and the community and (2) present an opportunity for the College to exert influence. This presentation will discuss two recent examples of the College’s advocacy work in policy.
Collaborative Advocacy – Working Together for Change
J Allan
1The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
2Government of Queensland, Brisbane, QLD, Australia
3National Mental Health Commission, Sydney, NSW, Australia
Mental health care is a complex system, so working together across organisations, professions and with consumers is key to creating and supporting changes in clinical practice. Crucial issues are legitimacy and managing conflicts of interest. This presentation will outline several of the intersections of mental healthcare advocacy A/Prof. Allan sees in his work which encompasses responsibilities as Chief Psychiatrist in Queensland, Board Director of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) and Chair of the Safety and Quality Partnerships subcommittee of the National Mental Health Drug and Alcohol Principle Committee.
Advocating for the Profession – Increasing Community Understanding of Psychiatry
M Hopwood and A Peters
The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
Understanding the role of a psychiatrist appears to be low in the community, and this can include policymakers and health professionals. The College has been seeking to increase this understanding through media and advocacy and in 2016 plans to develop increased consumer information about mental health and psychiatry as part of the www.yourhealthinmind.info resource.
Workforce Advocacy—Supporting the Specialist Training Program
M Hopwood1, J de Wever2, A Peters1
1The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
2Communications and Advocacy, The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
The distribution of the mental health workforce is an important issue for Australia. Increased awareness of mental health conditions and a growing population have led to higher demand for psychiatric services across Australia especially impacting regional services. In 2015, the College ran a successful advocacy campaign which worked with regional MPs to support the continuation of the federal government’s Specialist Training Program.
Continuing Professional Development Redevelopment for Psychiatry in the Asia Pacific Region
CS Yong1,2, R Ng3 and JCL Looi1,4,5,6
1CME Committee, The Royal Australian and New Zealand College of Psychiatrists, Melbourne (RANZCP), VIC, Australia
2South Western Sydney Local Health District, Sydney, NSW, Australia
3The Hong Kong College of Psychiatrists, Hong Kong
4Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra, ACT, Australia
5Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, VIC, Australia
6NorthWestern Mental Health, Melbourne, VIC, Australia
Background: The setting of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Congress in Hong Kong seemed a fitting time to compare and contrast the continuing professional development (CPD) systems in Australasia and South East Asia. In both regions, medical colleges are responding to the changes in medical regulation and public expectations of the accountability of the medical professions with substantial revisions of their CPD programs.
Objectives: To examine the similarities and differences in the CPD programs of the RANZCP and the Hong Kong College of Psychiatrists (HKCP) and the motivations for change and to discuss some of the research on medical expertise as it applies to CPD.
Methods: Describe the redevelopment of the RANZCP and HKCP CPD programs and the background factors in the medical regulatory environment;
Describe the research in expertise and the theoretical underpinnings of quality improvement and appraisal as elements of a modern CPD system.
Findings: The RANZCP CPD program will move to mandating quality improvement as a core element in 2017, as well as mandating the Program for all RANZCP Fellows. The HKCP Program is similarly mandating clinical audits and quality assurance for its Fellows.
Conclusions: Most medical colleges are moving toward CPD programs which have to fulfill multiple expectations of regulators, the public and medical peers while reflecting the latest research on the cognition of expertise and competence. There are a variety of approaches globally, and the symposium has compared two such approaches.
Presenter 1
Redevelopment of the RANZCP Continuing Professional Developmentprogram: An Update
CS Yong1,2
1CME Committee, The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
2South Western Sydney Local Health District, Sydney, NSW, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) commenced a review and redevelopment plan for its continuing professional development (CPD) program in 2014. Modern CPD programs encompass several elements including self-directed learning, peer review and reflection on practice, quality improvement, and audit or outcomes measurement of practice. The College has approved major changes to the CPD program to start in 2017 which aims to incorporate many of these elements.
Objectives: To update Fellows on the work of the CPD redevelopment working group and seek engagement and discussion of planned changes in the RANZCP CPD program.
Methods: Literature review and benchmarking of medical CPD programs and outline of the 2017 changes to the CPD program.
Findings: We will summarize the changes to the CPD program in relation to best practice professional CPD. 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. There will be discussion of the Medical Board of Australia’s plans for a new revalidation system.
Conclusions: An important role of the RANZCP is to provide a modern CPD program for Fellows that is of high educational quality as well as providing assurance for the public of the continuing competence and improvement of psychiatrists.
Presenter 2
Continuing Education in the Hong Kong College of Psychiatrists: Current Status and Future Development
R Ng
The Hong Kong College of Psychiatrists, Hong Kong
Background: Since the establishment of the Hong Kong (HK) College of Psychiatrists up to the handover of HK to China, the college has established its own categories of continuing education (continuing medical education [CME]) in accordance with the requirements of the HK Academy of Medicine.
Objectives: The talk will discuss the challenges and possible solutions in helping the college fellows to obtain CME points from these new categories of CME.
Methods and findings: The categories were developed based on due consideration of the training opportunities available locally and of encouraging the college fellows in participating in college work. With a recent interest in quality improvement in HK hospitals, there is a plan to introduce quality improvement initiatives as a mandatory criterion of CME by the HK Academy of Medicine.
Conclusions: Adopting new CME categories is a challenge for college fellows.
Presenter 3
The Doctor as an Expert: Apprentice, Journeyman or Master? Is It Desirable For A Doctor To Be An Expert?
JCL Looi1,2,3,4, CS Yong1,5
1CME Committee, The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
2Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra, ACT, Australia
3Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, VIC, Australia
4NorthWestern Mental Health, Melbourne, VIC, Australia
5South Western Sydney Local Health District, Sydney, NSW, Australia.
Background: There has been much research on medical expertise, spurred by the expert performance approach developed to study skilled performance in chess and sport initially. The expert performance approach needs to be augmented by understanding the cognitive psychology of medical decision-making as an adapted subset of the research in cognitive models of human decision-making driven by economic psychology. For the medical experts, their patients and society, the maintenance and improvement of skills toward excellence is paramount to the provision of medical care.
Objectives: We examine the concept of expertise, as it relates to psychiatric practice, and continuing professional development (CPD). We propose a model that may demonstrate which elements of CPD truly contribute to the maintenance of competence, expertise and, thereby, to the safety of the public.
Methods: We review of the research on expert factors and competence in medicine, particularly with regard to CPD.
Findings: We know little about effective training for medical expertise as a consequence of problems with establishing definitions of expertise, measurement of expertise and outcomes of training. The sheer breadth of skills and knowledge required in medical practice is challenging to encompass in a model.
Conclusions: By advancing a comprehensive research program, we can better discern the seemingly numinous terrain of medical expertise, ground medical training in knowledge of the skills contained therein and thus measure the outcomes of such training. Thereby, we can advance from the constraints of competence, which may result in medical apprentices or journeymen, as opposed to the ideal of mastery through continuous development of excellence, especially in psychiatry.
Trainee and Early Career Psychiatrist Panel Presentation: There Is More Than One Way to Train a Psychiatrist
O Wong1, C Yang2, JP Kwasik3, P Fung4
1Hong Kong Trainee Association, Hong Kong
2Guangdong Trainee Association, Guangdong, China
3RANZCP Trainee Representative Committee, Melbourne, VIC, Australia
4RANZCP Section of Early Career Psychiatrists, Melbourne, VIC, Australia
Background: Australia and New Zealand, Hong Kong and Mainland China have different populations with differing mental health needs. Historical factors, medical training and health resourcing all influence the way psychiatrists are trained in these countries, but ultimately each process produces a psychiatrist.
Objectives: To better understand the differing ways that psychiatrists are trained in the Asia Pacific region. To examine the strengths and weaknesses of each process and highlight the local needs and methods in each setting. This panel presentation will lead to sharing of ideas on training methods and potentially discussions on how to improve training in each country.
Methods: Advanced trainees or early career psychiatrists from each of Australia and New Zealand, Hong Kong and Mainland China will outline the path to becoming a psychiatrist in their country. The three presentations will span the psychiatrist’s career from entry into training, through to qualifying as a consultant psychiatrist, and explore issues such as education and apprenticeship, supervision and mentoring, study, examinations and other assessments, research, subspecialisation, employment options and workplace issues. Presenters will comment on the current trends in psychiatric training and speculate on possible future directions.
Conclusions: There are significant differences in the mental health systems of these countries. Therefore, each country will have a different emphasis on each component of psychiatric training. This forum may foster mutually beneficial collaboration between trainees/early career psychiatrists from each of these countries.
E-Health and Psychiatry
RCM Ho1, MWB Zhang2
1Department of Psychological Medicine, National University Healthcare Systems (NUHS), Singapore
2National Addictions Management Service, Institute of Mental Health, Singapore
Background: With the advances in technology, it is not surprising that there are high rates of adoption of smartphones and various e-health technologies by healthcare professionals, as well as by patients. In psychiatry, a recent literature search has shown that there is a validated evidence-based research that demonstrates the efficacy of e-health for patients with the following conditions: psychosis, affective disorders, substance misuse and dementia. However, it is clear that not all psychiatrists are using these new technologies.
Objectives: The objective of this symposium is to illustrate how psychiatrists and other clinicians could make use of e-health for education, clinical research and patient care.
Methods: Actions that could be undertaken at an individual level, such as by encouraging clinicians to be directly involved in application development, and actions at an organizational level, such as involving organizations in the peer review of applications, will be discussed.
Findings: The application of e-health at an individual level and at an organizational level will be illustrated.
Conclusions: With the major advances in e-health and technologies, it is hoped that through our presentation, clinicians and psychiatrists would be more cognizant of the advantages of smartphone applications and be willing to contribute to embracing and utilizing this technology at the individual and organizational levels.
Presenter 1
A Smartphone App for Psychoeducation for Family Caregivers of People Living With Dementia: A Feasibility Study
S Chan1, M Zhang2, O Wynne1, S Jeong1, S Hunter1, A Wilson1, R Ho2
1University of Newcastle, Newcastle, NSW, Australia
2National University of Singapore, Singapore
Background: Caregivers of people living with dementia (PLWD) experience high levels of stress. The behavioural and psychological symptoms of dementia (BPSD) are known to cause more stress than cognitive and functional problems in the patient. Helping family caregivers to reduce stress and the negative impact of BPSD could enable them to remain in the caregiver role longer and delay costly early nursing home placement. Traditional face-to-face psychoeducation programmes may not be able to reach many caregivers. The use of smartphone application (app) to deliver psychoeducation could be an innovative way to support caregivers.
Objectives: This proof-of-concept project aims to develop and examine the effectiveness of a psychoeducation intervention delivered through a smartphone app for family caregivers of PLWD in managing BPSD.
Methods: This is a pilot randomized controlled trial. The app contains an information kit, animated video, audio podcast and daily monitoring. A convenience sample (n = 76) was recruited from centres in Newcastle and Singapore and was randomised into the intervention and control groups. Outcomes (BPSD, care burden, coping, gain in care) are measured at baseline, immediately after the intervention (2 months) and at the 3-month follow-up.
Findings: This presentation will discuss the development of the app and the preliminary findings.
Conclusions: The findings of this study will add credible evidence about impacts of psychoeducation delivered by app. This approach to delivering an intervention could be used in other types of chronic conditions.
Presenter 2
An Evaluation of the Evidence Base of Current Bariatric Surgery and Bariatric Psychosocial Applications
S Sockalingam1, R Ho2, M Zhang3
1Department of Psychiatry, University of Toronto, Toronto, ON, Canada
2Department of Psychological Medicine, National University Healthcare Systems (NUHS), Singapore
3National Addictions Management Service, Institute of Mental Health, Singapore
Background: To date, there are no studies that have used e-technology frameworks to evaluate bariatric smartphone applications. Apart from these limitations, other limitations include that although there are regulations in both the European Union (such as the Medical Device Directive [MDD])) and the United States (such as the Food and Drug Administration’s [FDA] proposal), these directives have yet to become official legal requirements to formally assess the quality of bariatric surgery and obesity applications. There is a paucity of literature that has evaluated the information quality of the current bariatric and obesity applications.
Objectives: Our objective was to evaluate the quality of available smartphone applications for bariatric patient care using the Silberg scale.
Methods: The two most widely used smartphone application online stores were searched in June 2014, and a total of 39 applications were evaluated.
Findings: The average Silberg score of the 39 applications was 4.0 ± 1.76. The current gaps of information quality include the lack of provision of appropriate references, full disclosure of sponsorship and accurate disclosure of whether the application has been modified in the past month.
Conclusions: This study provides a more comprehensive analysis of the available bariatric survey applications. Several gaps in information quality have been identified, and it is hoped that these will be taken into account when clinicians or developers next decide on the development of applications.
Presenter 3
Managing HIV and HBV/HCV Infections: A Smartphone Innovative Toolkit for Vietnamese People
B Tran1, R Ho2, M Zhang3
1Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
2Department of Psychological Medicine, National University Healthcare Systems (NUHS), Singapore
3National Addictions Management Service, Institute of Mental Health, Singapore
Background: Vietnam has experienced one of the fastest growing HIV epidemics among people who inject drugs (PWID) in Asia in the last decade. There are an estimated 240,000 illicit opioid users who constitute approximately half of newly detected and two-thirds of cumulative HIV cases in the country. Previous studies have also indicated a high prevalence of positive hepatitis B and C surface antigens (HB/CsAg) in the general population (9–14%) as well as among drug users (30–60%). However, this patient group was found to have delayed access and uptake of healthcare services, poorer adherence, suboptimal effects of antiretroviral treatment and increased morbidity and mortality. While treatment for these diseases is still unaffordable for most patients, health facilities lack the sufficient resources to follow up diagnosed patients, guide necessary care, determine psychiatric comorbidity and provide responsive intervention to those with clinically important deterioration in their health status.
Objectives: The objectives of the current project are to make use of new innovative smartphone technologies to help Vietnamese people diagnosed with HIV and/or hepatitis B or C virus (HBV/HCV) to monitor their health status, to improve access to services and to help with evaluation for psychiatric comorbidity.
Methods: We will implement an intervention among patients who are diagnosed with HIV and/or HBV/HCV infections and who register for care and treatment at the Hanoi Medical University Hospital and the Bach Mai Hospital. The eligibility criteria of participants include those who are (1) 18 years of age or older, (2) identified with one of the selected sites, (3) smartphone users with data plans and (4) providing their informed consent. The application will be developed using cross-platform mobile technologies.
Findings: This presentation will discuss the development of the app and the preliminary findings.
Conclusions: This research will demonstrate how e-health innovations could be applied for management of HIV and HBV/HCV infections in low- and middle-income countries.
Presenter 4
Addressing Mild Depression and Anxiety with the General Public: A Joint Canada–China Initiative
K Ho
E-Health Strategy Office, University of British Columbia, Vancouver, BC, Canada
Background: Facing mild anxiety and depression due to everyday occurrences is common for everyone. Health systems are interested in finding ways to support the public in dealing with these mild mental health challenges early and effectively to prevent worsening or deepening of the conditions.
Objectives: The objective was to identify the current practices of two different countries and to highlight the issues and the challenges.
Methods: Vancouver, Canada, and Guangzhou, People’s Republic of China, have a sister city relationship. On the occasion of the 30th anniversary, a public forum was launched in Guangzhou to engage the general public with mental health experts and policy makers from both cities to explore how Vancouver and Guangzhou have been working with citizens in addressing these conditions and to how better partner with the citizens to continue improving access to services and optimal self-management.
Findings: Best practices of the two cities, issues and challenges, lessons learned and future planning will be presented.
Conclusions: The techniques and the findings that arise from the public forum are likely to be generalizable to other settings.
Linking Genes, Cognition and Neuroimaging in Schizophrenia: Recent Findings from the Australian Schizophrenia Research Bank
C Pantelis1, I Everall1, V Cropley1, C Bousman1, S Sundram2, C Shannon Weickert3
1The University of Melbourne, Parkville, VIC, Australia
2Monash University, Clayton, VIC, Australia
3The University of New South Wales, Sydney, NSW, Australia
Background: The Australian Schizophrenia Research Bank (ASRB) is an Australian resource and storage facility of schizophrenia and healthy control-related research data collected across five Australian states and territories. The primary aim of the ASRB is to facilitate scientific research into schizophrenia by (1) collecting, storing and providing comprehensive, cross-referenced clinical, neuropsychological, genetic and brain imaging data from people with schizophrenia and healthy controls and (2) recruitment of volunteers to participate in specific schizophrenia research projects.
Objectives: To describe results from recent cognitive, neuroimaging and genetics research using this valuable data resource.
Methods: A brief history and description of the ASRB will be provided. This will be followed by a series of four talks presenting results from studies using a number of cognitive, neuroimaging and genetic methodologies with particular focus on how these methodologies can be integrated to provide a clearer understanding of the pathophysiology of schizophrenia.
Findings: Presenters will provide multimodal evidence suggesting accelerated gray and white matter aging, as well as linkages between a number of genetic polymorphisms, brain structure and cognition.
Conclusions: The ASRB is a valuable and unique resource for understanding the complex interplay between genes, cognition and brain structure. Those attending this symposium will leave with a better understanding of the ASRB and how this resource can improve and is improving our understanding of the pathophysiology of schizophrenia.
Presenter 1
Accelerated Gray and White Matter Aging in Schizophrenia
V Cropley1,2, P Klauser1,2,3, R Lenroot4,5,6, J Bruggemann4,5,6, S Sundram6,7, C Bousman1,2, A Pereira7, M Di Biase1,2, T Weickert4,5,6, C Shannon Weickert4,5,6, C Pantelis1,2, A Zalesky1,2
1Melbourne Neuropsychiatry Centre, The University of Melbourne and Melbourne Health, Melbourne, VIC, Australia
2Department of Psychiatry, The University of Melbourne, Parkville, VIC, Australia
3Brain and Mental Health Laboratory, School of Psychological Sciences and Monash Biomedical Imaging, Monash University, Clayton, VIC, Australia
4Schizophrenia Research Institute, Sydney, NSW, Australia
5Neuroscience Research Australia, Randwick, Sydney, NSW, Australia
6Department of Psychiatry, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
7Molecular Psychopharmacology Laboratory, The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
Background: Schizophrenia has been hypothesized to be a disorder of accelerated aging. Although deficits in gray and white matter have been consistently observed, less is known about their progression with age.
Objectives: To determine whether the rate of gray matter loss and white matter deterioration with aging is comparable to that seen in healthy individuals of the same age or whether the rate is accelerated or diminished in individuals with schizophrenia.
Methods: Using structural brain magnetic resonance imaging and diffusion tensor imaging in a pseudo-longitudinal design, gray matter volume (GMV) and fractional anisotropy (FA) were mapped from age 20 to 65 years in 326 individuals diagnosed with schizophrenia or schizoaffective disorder and 197 healthy controls.
Findings: GMV and FA decreased with age in people with schizophrenia and controls. Age-specific comparisons showed that GMV was significantly lower in people with schizophrenia at each age studied, but at the earliest age this loss was confined to frontotemporal regions and became widespread with increasing age. The rate of GMV loss significantly exceeded the rate of loss seen in controls at ages 30–45 years. FA was significantly reduced, and its rate of loss was steeper, in people with schizophrenia from 40 years of age, and this deterioration increased from year to year thereafter.
Conclusions: Loss of gray matter in schizophrenia is evident from early adulthood but rapidly declines during middle age and then stabilizes. Once this gray matter loss stabilizes, white matter deficits are evident and accelerate with age thereafter. These findings suggest that schizophrenia is characterized by an initial reduction in gray matter, followed by age-related accelerated white matter deterioration.
Presenter 2
Neuregulin-1 Polymorphisms Linked To Psychosis Onset Are Associated with Lateral Ventricular Volume and White Matter Integrity
CA Bousman1,2,3,4, V Cropley1, P Klauser1,5, A Pereira4, A Zalesky1, D Rothmond6,7,8, R Idrizi4, J Bruggemann6,7,8, MS Mostaid1, R Lenroot6,7,8, T Weickert6,7,8, IP Everall1,4,9, S Sundram4,9,10, C Pantelis1,4, C Shannon Weickert6,7,8
1Department of Psychiatry, Melbourne Neuropsychiatry Centre, The University of Melbourne, Parkville, VIC, Australia
2Department of General Practice, The University of Melbourne, Parkville, VIC, Australia
3Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
4Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC, Australia
5Brain and Mental Health Laboratory, School of Psychological Sciences and Monash Biomedical Imaging, Monash University, Melbourne, VIC, Australia
6Schizophrenia Research Institute, Sydney, NSW, Australia
7Schizophrenia Research Laboratory, Neuroscience Research Australia, Sydney, NSW, Australia
8School of Psychiatry, Faculty of Medicine, The University of New South Wales, Sydney, NSW, Australia
9NorthWestern Mental Health, Melbourne, VIC, Australia
10Department of Psychiatry, School of Clinical Sciences, Monash University and Monash Health, Clayton, VIC, Australia
Background: Two single-nucleotide polymorphisms (SNPs) (rs4281084 and rs12155594) within the neuregulin-1 (NRG1) schizophrenia-associated Icelandic haplotype (HapICE) region were recently shown to predict psychosis onset. However, the neurobiological changes associated with these NGR1 SNPs remain unclear.
Objectives: To determine what relationship rs4281084 and rs12155594 have with brain structure.
Methods: A multimodal approach was employed. Neuroimaging data from 333 individuals (156 controls and 177 patients) were used to identify associations of these two NRG1 SNPs with lateral ventricular volume and fractional anisotropy (FA). In addition, the number of rs4281084-A and rs12155594-T alleles for each participant was calculated and the combined allelic load examined for associations with lateral ventricular volume and FA. Finally, we explored whether each SNP independently or in combination was associated with gray matter volume, surface area and thickness throughout the brain.
Findings: For every additional rs4281084-A and/or rs12155594-T allele, FA significantly decreased in the frontal cortex, and carriers of three or more NRG1 risk alleles had significantly larger lateral ventricular volumes compared to people with fewer than three.
Conclusions: Our findings link two identified NRG1 SNPs for psychosis onset with changes in FA and lateral ventricular volume, providing insights on the neurobiological consequences associated with genetic variation within the HapICE region.
Presenter 3
A Novel 3 Cluster Cognitive Profile in Schizophrenia Associates with the Epidermal Growth Factor System Single-Nucleotide Polymorphisms
S Sundram1, V Swaminathan2,3, A Pereira2, L Churilov2, C Bousman4, V Cropley4, C Pantelis4, A Zalesky4, R Lenroot5,6, J Bruggemann6, C Shannon Weickert5,6, T Weickert5,6
1Monash University, Melbourne, VIC, Australia
2Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
3Schizophrenia Research Institute, Sydney, VIC, Australia
4The University of Melbourne, Melbourne, VIC, Australia
5The University of New South Wales, Sydney, NSW, Australia
6Neuroscience Research Australia, Sydney, NSW, Australia
Background: The epidermal growth factor (EGF) system is strongly implicated in neurodevelopment and the pathology of schizophrenia. The profile of cognitive deficits in schizophrenia is variable across populations with some patterns indicating abnormal neurodevelopment. The relationship of genetic variation in the EGF system with cognitive deficits in schizophrenia has not been well studied.
Objectives: To characterize the cognitive profile of people with schizophrenia and test the association with the EGF system single-nucleotide polymorphisms (SNPs).
Methods: Clinical and cognitive data and DNA were obtained from participants (with schizophrenia [SCZ], n = 449; healthy controls [HCs], n = 637). Cognitive performance was analysed using an unsupervised clustering algorithm, Kohonen’s self-organising map (SOM). A total of 31 SNPs in the EGF system were genotyped. Standard statistical analyses were performed.
Findings: Kohonen’s SOM provided a three-cluster solution of (1) cognitively unimpaired, (2) normal deteriorating and (3) impaired deteriorating. Clusters (2) and (3) differed from the HC group on all scales. Multinomial regression showed that cluster (1) compared to cluster (3) patients were 40 times more likely to have the NRG1 HapICE SNP (SNP8NRG221131/rs35753505) CC genotype compared to the TT genotype (p = 0.002, 95% confidence interval [CI] = 3.74, 433.12), 12 times more likely to have the NRG1 HapICE SNP (SNP8NRG243177/rs6994992) CC compared to the TT genotype (p = 0.047, 95% CI = 1.03, 147.53) and 2.67 times more likely to have the NRG1 SNP rs3934999 CC genotype compared to the non-CC genotypes (CT, TT) (p = 0.011, 95% CI = 1.258, 5.668).
Conclusions: Unsupervised agnostic clustering demonstrated three cognitive groups in a schizophrenia patient cohort. SNPs within the NRG1 gene associated with the cognitively unimpaired group suggest a protective or mitigating role in cognitive impairment in schizophrenia.
Presenter 4
Schizophrenia and Cognitive Dysfunction Associated with the Estrogen Receptor 1 Genotype
C Shannon Weickert1,2,3, JM Fullerton2,3,4, S Hu3,4,5, M Kyaw3,4,5 PR Schofield2,3,4, VJ Carr1,3, C Laughlin5, U Schall3,5, RJ Scott3,6, AV Jablensky3,7, B Mowry3,8, PT Michie3,9, SV Catts3,10, FA Henskens3,11, C Pantellis3,12, TW Weickert1,2,3
1School of Psychiatry, The University of New South Wales, Sydney, NSW, Australia
2Neuroscience Research Australia, Sydney, NSW, Australia
3Schizophrenia Research Institute, Sydney, NSW, Australia
4School of Medical Sciences, The University of New South Wales, Sydney, NSW, Australia
5Centre for Brain and Mental Health Research, University of Newcastle, Newcastle, NSW, Australia
6School of Biomedical Sciences, University of Newcastle, Newcastle, NSW, Australia
7Center for Clinical Research in Neuropsychiatry, The University of Western Australia, Perth, WA, Australia
8Queensland Centre for Mental Health, The University of Queensland, Brisbane, QLD, Australia
9School of Behavioral Science, University of Newcastle, Newcastle, NSW, Australia
10School of Medicine, The University of Queensland, Brisbane, QLD, Australia
11School of Electrical Engineering and Computer Science, University of Newcastle, Newcastle, NSW, Australia
12Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
Background: Lower levels of estrogen worsen the symptoms of schizophrenia and negatively impact human cognition. Estrogen level and sequence variation in the estrogen receptor gene modulate cognitive ability in healthy and aging adults. Cognitive deficits are common in schizophrenia, but how these may vary according to estrogen receptor genotypes is relatively unexplored.
Objectives: Previously, we found that the variation in the estrogen receptor alpha gene (estrogen receptor 1 [ESR1]) was linked to a diagnosis of schizophrenia. Here, we investigated the extent to which ESR1 gene polymorphisms are associated with schizophrenia diagnosis in a larger, predominantly Caucasian population sample and explored the link of the ESR1 genotype with other phenotypes associated with the illness, including cognitive dysfunction and symptom severity.
Methods: Clinical and neuropsychological data were collected from 933 people (n = 541 with schizophrenia, 392 control) from the Australian Schizophrenia Research Bank (ASRB). Allele discrimination was used to genotype participants across one insertion/deletion and 11 ESR1 single-nucleotide polymorphisms (SNPs).
Findings: SNP rs2077647 (C26) in exon 1 and rs2234693 (C11-PvuII) in intron 1 were significantly associated with schizophrenia (genotypic p = 0.026 and p = 0.044, respectively). Two intron 1 SNPs (rs2234693 [C11-Pvu II] and rs9340799 [Xba1]) were found to be associated with several cognitive domains, particularly memory and attention.
Conclusions: Our findings provide independent support for the association of the ESR1 gene with schizophrenia. Our results suggest that the variation in intron 1 of the ESR1 gene may impact risk of cognitive dysfunction in schizophrenia and support the theory that the brain response to sex steroids is altered in schizophrenia.
History, Philosophy and Ethics: Philosophy of Psychiatry in the 21st Century
M Wong1,2, J Arnold1,3, N McLaren1,3, S Stankevicius1,4
1Section of History Philosophy and Ethics of Psychiatry, The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
2School of Psychology and Psychiatry, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
3Private Practice, Brisbane, QLD, Australia
4Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
Background: Advances in neurosciences, philosophy, humanities and their interaction with psychiatry during the Decade of the Brain and the Decade of the Mind lead to various developments in philosophy of mind, consciousness studies, psychiatric nosology and psychopathology which, in turn, bring about significant impacts on our understanding of the nature, classification, diagnosis and treatment of mental illness.
Objectives: This symposium aims at providing an update on the major themes and issues involved in the interface between philosophy and psychiatry through contributions from members of the newly restructured Section of the History, Philosophy and Ethics of Psychiatry, Royal Australian and New Zealand College of Psychiatrists.
Methods: This symposium will provide an update on the major themes and issues in the interface between philosophy and psychiatry through a critical review of the historical, philosophical and ethical aspects of the practice of psychiatry.
Findings: Recent advances in philosophy and its interaction with neuroscience and psychiatry allow psychiatry not only to overcome its tendency to swing between ‘brainlessness’ and ‘mindlessness’ and to hold fragmented and restricted views of mental illness but also to become an academic and clinical discipline that facilitates interdisciplinary integration of the study and understanding of the person and health and well-being.
Conclusions: History, philosophy and ethics are integral aspects of psychiatry and knowledge, and insights into these disciplines will contribute to the development of psychiatry.
Presenter 1
History, Philosophy and Psychiatry: Contemporary Philosophy of Psychiatry
M Wong1,2
1Section of History Philosophy and Ethics of Psychiatry, The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
2School of Psychology and Psychiatry, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
Background: There has been a recent surge of high-quality research in the field of the philosophy of psychiatry.
Objectives: To assess the relevance of history, philosophy and ethics to contemporary psychiatry.
Methods: To summarize the various interactions between philosophy and psychiatry throughout the history of psychiatry by examining the critiques from Comte, Jaspers, James, Freud, Husserl, Ricoeur and the recent advances in neurosciences.
Findings: Philosophy, through its various arguments from ontology, epistemology, ethics and hermeneutics, has influenced the ways in which psychiatry understands the nature of wellness and illness, the process of psycho-pathogenesis and recovery, nosology, assessment, treatment and service delivery throughout its history. Privileging particular philosophical positions at the expense of other alternative views has resulted in, at different stages in the history of psychiatry, errors of ‘brainlessness’ and ‘mindlessness’.
Conclusions: A philosophy of psychiatry in the 21st century which addresses the various issues of philosophy of science, philosophy of mind and ethics that are relevant to the practice of psychiatry will contribute to the promotion of a psychiatry that is whole-person-focused, client-centered and evidence-based.
Presenter 2
Science and Critical Thinking
J Arnold1,2
1Section of History Philosophy and Ethics of Psychiatry, The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
2Private Practice, Brisbane, QLD, Australia
Background: Scientific methodology, critical thinking, logic, social constructionism, creativity and humanism provide different approaches to social science methodologies.
Objectives: To explore whether there are more useful ways of looking at research in psychiatry, particularly at the boundaries of pure science and social sciences.
Methods: A review of current social science methodologies was conducted through literature survey and critical evaluation.
Findings: Critical thinking, science, logic and constructionism offer diverse but not contradictory perspectives with regard to social science methodologies.
Conclusions: If we use critical thinking, we can create the questions and answers that we seek in psychiatry to understand individuals, communities and universal truths.
Presenter 3
The Concept of a Universal Psychiatry
N McLaren1,2
1Section of History Philosophy and Ethics of Psychiatry, The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
2Private Practice
Background: Modern psychiatry presents itself as rational, objective and universal (i.e. firmly in line with Enlightenment principles). These concepts are usually taken for granted, but that is unwise in the extreme.
Objectives: To examine the literature to determine whether this modernist approach is valid.
Methods: A selective survey of some of the most influential of recent psychiatric opinions.
Findings: There is no justification for the notion that a culture-free psychiatry is either possible or desirable.
Conclusions: Psychiatric hegemony is driven by a destructive mix of mercantilist imperatives, professional conceit and academic naivete. This does not imply we need a ‘post-modernist’ psychiatry.
Presenter 4
The Self Illusion: A Psychotherapeutic Analysis
S Stankevicius1,2
1Section of History Philosophy and Ethics of Psychiatry, The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
2
Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
Background: There are many who are afraid of so-called biological psychiatry. When we look at brain scans and neural correlates, we do not find a self to be sitting in there. With no self to treat through psychotherapy, it may seem we are left with drugs to treat the problem. This leads to the well-known distinction of psychotherapy for psychological disorders and medication for brain disorders. This is a false dichotomy.
Objectives: Psychotherapy is essentially treatment of the self, so it makes sense to understand what the self is. This talk aims to show that ‘the self’ is an illusion and how this understanding could impact the practice of psychotherapy.
Methods: Philosophical and scientific matters related to the self are explored and discussed in a simple and accessible manner. These issues and their implications are then examined in relation to psychotherapy.
Findings: Those who think that a purely biological view undermines the idea of the self are, in fact, right; it is an illusion. However, this does not undermine psychotherapy. Rather, it empowers the idea, can help explain the incredible effectiveness of it and could provide us with a direction in understanding and enhancing its effects in the future.
Conclusions: Just as cardiologists could only start treating heart disease effectively when they understood what the heart was, psychotherapists may need to understand what the self is to improve the treatment of psychiatric illness.
Neurobiology and Neuropharmacology of Psychotropic Drug Abuse
WK Tang1, Y Lin1, C Zhang1, H Liang1, WY Lai1, C Morgan2, N Fan3, C Davidson4, Q Ren5, K Hashimoto5
1Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong
2Department of Psychology, College of Life and Environmental Sciences, Washington Singer Laboratories, Exeter, UK
3Guangzhou Brain Hospital, the Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
4St George’s University of London, London, UK
5Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, Chiba, Japan
Background: Psychoactive substances such as methamphetamine and legal highs are common drugs of abuse worldwide, whereas ketamine is frequently abused in Hong Kong and other parts of China.
Objectives: To examine the neuroimaging findings, biomarkers and pharmacology of psychoactive substances.
Methods: Speakers from the United Kingdom, Hong Kong and China will share their data on the imaging, neural psychopharmacology and biomarker data in psychoactive active substances users.
Findings: In terms of neuroimaging, chronic ketamine use was associated with reduced grey and white matter volumes in certain regions of the brain. Chronic ketamine use was also associated with altered functional connectivity. With regard to biomarkers, serum levels of cytokines were also altered in chronic ketamine abusers, and brain-derived neurotrophic factor (BDNF)–tropomyosin-related kinase (TrkB) signaling in the nucleus accumbens (NAc) shell plays a key role in the behavioral abnormalities after withdrawal from repeated methamphetamine administration. Finally, some of the legal highs have a pharmacological profile that might make them more dangerous than the illicit drugs that they are sold as mimics.
Conclusions: Advance in neurobiological understanding of psychoactive substance abuse may review potential therapeutic targets for future intervention trials.
Presenter 1
Evidence of Brain Damage in Chronic Ketamine Users: A Brain Imaging Study
WK Tang, Y Lin, C Zhang, H Liang, WY Lai
Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong
Background: Ketamine is the most commonly abused drug in Hong Kong. The pattern of ketamine-induced brain damage in humans is not clear.
Objectives: The objectives of this study were to ascertain the pattern of grey and white matter volume reduction and regional metabolic and activation abnormalities in chronic ketamine users.
Methods: A total of 136 participants were recruited from October 2011 to April 2014. The participants were divided into two groups: ketamine users (79) and healthy controls (57). All participants underwent magnetic resonance imaging of the brain.
Findings: In terms of grey matter volumes, the right orbitofrontal cortex, right medial prefrontal cortex, left and right hippocampus and possibly the left orbitofrontal cortex were smaller in the ketamine group. In contrast, the volumes of the left basal ganglia, left putamen and possibly the left caudate were higher in the ketamine group. A functional connectivity examination of the default mode network revealed significantly decreased connectivity in the medial part of the bilateral superior frontal gyrus, left middle frontal gyrus, bilateral gyrus rectus, left superior temporal pole, left inferior temporal gyrus, bilateral angular gyrus and bilateral cerebellum crus II in the ketamine group. The ketamine group also displayed increased connectivity in the bilateral precuneus and right inferior occipital gyrus.
Conclusions: The results provide imaging evidence of brain damage in chronic ketamine users. Longitudinal or prospective studies would help to strengthen the evidence on the reversibility of the structural and functional brain damage caused by ketamine.
Presenter 2
Neurobiobehavioural Changes following Ketamine Use: Insights for Addiction
C Morgan
Department of Psychology, College of Life and Environmental Sciences, Washington Singer Laboratories, Exeter, UK
Background: Ketamine is rapidly becoming a popular antidepressant, yet its abuse continues to be a worldwide issue, particularly in China and the United Kingdom. Ketamine dependence is rife among users and the consequences of this are only recently beginning to be understood.
Objectives: To examine biological and behavioural changes associated with ketamine use.
Methods: We have recently collected neuroimaging data using magnetic resonance spectroscopy, functional magnetic resonance imaging and diffusion tensor imaging that suggest a variety of neurological changes following repeated heavy ketamine use.
Findings: Behavioural deficits on specific cognitive tasks are apparent in dependent ketamine users, and our data suggest that these may be related to brain network disruption from prolonged use of this N-methyl-d-aspartate (NMDA) receptor antagonist.
Conclusions: Some of these changes are suggestive of the changes in neurogenesis that might be related to the addictive capacity of the drug.
Presenter 3
Changes of Serum Cytokine Levels and their Correlation with Schizophrenia-Like Symptoms in Chronic Ketamine Users
N Fan
Guangzhou Brain Hospital, Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, China
Background: Ketamine, an N-methyl-d-aspartate (NMDA) receptor antagonist, produces schizophrenia-like symptoms in humans and worsens symptoms in patients with schizophrenia. Meanwhile, schizophrenia is associated with cytokine alterations in the immune system.
Objectives: To examine the association between serum cytokine levels and schizophrenia-like symptoms in ketamine users.
Methods: People who fulfilled the criteria of ketamine dependence and healthy control subjects were recruited. Serum cytokine levels were measured using an ELISA. The psychiatric symptoms of the ketamine users were assessed using the Positive and Negative Syndrome Scale (PANSS). Serum cytokine levels in chronic human ketamine users were measured and compared to healthy controls. The correlations between serum cytokine levels and demographics, ketamine-use characteristics and psychiatric symptoms were assessed.
Findings: Serum levels of cytokines were altered in chronic ketamine users.
Conclusions: Cytokines may play a role in schizophrenia-like symptoms in chronic ketamine users.
Presenter 4
The Neuropharmacology of Legal Highs (Bath Salts, Novel Psychoactive Substanbces)
C Davidson
St George’s University of London, London, UK
Background: Legal highs (bath salts or novel psychoactive substances [NPS]) are increasingly found to be involved in substance abuse deaths or hospital emergency room visits, especially in younger adults.
Objectives: To describe and compare the pharmacology of NPS.
Methods: Review of a series of laboratory works.
Findings: NPS can be split into a number of families: (1) synthetic cannabinoids, (2) cathinones, (3) stimulants, (4) entactogens, (5) hallucinogens, (6) dissociatives and others. In the vast majority of cases, there are no laboratory studies defining their pharmacology. In this paper, I will outline some of the techniques that we have used to characterise the pharmacology of NPS including radioligand binding, fast cyclic voltammetry in brain slices, in vivo microdialysis and behavioural studies. I will highlight what can be learned about the potential addictive and toxic effects of NPS with examples from different families of NPS. For example, we have found the NPS stimulant desoxypipradrol to be more potent at increasing dopamine efflux than cocaine. We have found benzofury (5-APB) to have effects at both the dopamine transporter and the 5-HT2A receptor, and we have found the mephedrone (4-methyl methcathinone [MCAT]) to cause reverse transport of dopamine. The new synthetic cannabinoids are much more potent at CB1 receptors than tetrahydrocannabinol (THC).
Conclusions: In conclusion, our work has shown that some of these NPS have a pharmacological profile that might make them more dangerous than the illicit drugs that they are sold as mimics.
Presenter 5
Brain-Derived Neurotrophic Factor and its Receptor Tropomyosin-Related Kinase: A Potential Therapeutic Target for Methamphetamine Abuse
Q Ren, K Hashimoto
Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, Chiba, Japan
Background: Abuse of methamphetamine (METH) is a major public health problem in the world, including Asia. METH is a powerfully addictive stimulant associated with serious health risks such as cognitive impairment, aggression, psychotic symptoms and behavior, and potential heart and brain damage. Several lines of evidence suggest the key role of brain-derived neurotrophic factor (BDNF) and its specific receptor, tropomyosin-related kinase (TrkB), signaling in the pathophysiology of depression.
Objectives: To examine the role of BDNF-TrkB signaling in METH withdrawal symptoms.
Methods: A series of studies in animals.
Findings: In 2015, we reported in Translational Psychiatry that repeated administration of METH (3 mg/kg per day for 5 days) caused depression-like behaviors in mice, and the depression-like behavior persisted for more than 2 weeks after the final administration of METH. Western blot analysis showed that BDNF levels in the nucleus accumbens (NAc) of METH-treated mice were significantly higher than those of control mice although BDNF levels in the other regions, including the prefrontal cortex and hippocampus, were no different. Furthermore, METH-induced behavioral abnormalities (depression and behavioral sensitization) could be improved after subsequent repeated administration of TrkB antagonist ANA-12, but not TrkB agonist 7,8-digydroxyflavone. Interestingly, METH-induced behavioral abnormalities (depression and behavioral sensitization) could be improved after a single bilateral infusion of ANA-12 into the NAc shell.
Conclusions: These findings suggest that BDNF-TrkB signaling in the NAc shell plays a key role in the behavioral abnormalities after withdrawal from repeated METH administration and that TrkB antagonists would be potential therapeutic drugs for METH withdrawal symptoms in humans. 7i end
Asian Federation of Psychiatric Associations (AFPA) Symposium Development of Community Services in Asia
N. Shinfuku1, P. Udomratn2, A. Javed3, W. Shen4
1Kobe University School of Medicine (Emeritus Professor), Japan
2Prince of Songkla University, Songkhla 90110, Thailand
3Pakistan Psychiatric Research Centre, Lahore, Pakistan
4Taipei Medical University, Taipei, Taiwan.
Of all the fields of medicine, psychiatry is the field that tends to be established last of all. Even if the patients we see, and their families, are not different from other medical specialties. They are the people most susceptible to prejudice, discrimination, and violation of their human rights. Yet it is certainly true that medical spending in many countries is lower on psychiatry than on any other branch of medicine. The environment surrounding psychiatry varies widely across Asia.
The Asian Federation of Psychiatric Associations: AFPA is a platform for these associations to come together and share information and expertise with each other, in order to provide better treatment to patients. It will become a platform for the leaders of each country to gather, where they can discover the solutions to the issues faced by psychiatry in their individual countries.
In the symposium, four speakers from different countries and social backgrounds introduce their community services, and their strengths and weaknesses. This provides an important occasion to exchange ideas to improve psychiatric community services in Asia.
A Substantial Peer Worker Workforce in a Psychiatric Service will Improve Patient Outcomes
N O’Connor1,2, C Ryan2,3,4, S Clark5,6, R Newton7,8, F Dark9, M Patton10
1Northern Sydney Local Health District, Sydney, NSW, Australia
2Department of Psychiatry, The University of Sydney, Sydney, NSW, Australia
3Centre for Values, Ethics and the Law in Medicine, The University of Sydney, Sydney, NSW, Australia
4Westmead Hospital, Sydney, NSW, Australia
5Western NSW Local Health District, Orange, NSW, Australia
6Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
7Austin Health, Melbourne, VIC, Australia
8The University of Melbourne, Melbourne, VIC, Australia
9Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
10Mental Health and Addictions Service, Waitemata District Health, Auckland, New Zealand
Background: Greater participation of peer workers in mental health service delivery has become policy in a number of jurisdictions. This is a strategic policy direction in New Zealand’s Ministry of Health’s 2012–2017 Mental Health and Addiction Service Development Plan and the Australian National Mental Health Commission’s Report on the National Review of Mental Health Programs and Services.
Objectives: To examine the evidence base for the effectiveness of peer workers in mental health service delivery.
Methods: The evidence for and against the efficacy of peer workers in mental health service delivery will be examined in a debate of the proposition: ‘A substantial peer worker workforce in a psychiatric service will improve patient outcomes’.
There will be an opportunity for audience questions to the speakers, and a speaker from each team will give a 2-minute summation at the end of the debate.
The audience will be asked to vote whether they are in favour of the proposition prior to the debate commencing and following the final summation of the cases for and against.
Conclusions: The case for and against peer workers as an important component of mental health service delivery is presented and discussed. The debate content will be subsequently submitted for publication in Australasian Psychiatry.
The Case For: A Substantial Peer Worker Workforce in a Psychiatric Service Will Improve Patient Outcomes
R Newton1,2, F Dark3, M Patton4
1Austin Health, Melbourne, VIC, Australia
2The University of Melbourne, Melbourne, VIC, Australia
3Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
4Mental Health and Addictions Service, Waitemata District Health, Auckland, New Zealand
Methods: The evidence and arguments for the effectiveness and benefits of peer workers in mental health services will be presented by the three speakers. The international literature and evaluations of peer worker implementation will be presented and discussed. Both teams will have the opportunity to rebut the opposing team’s views and to take questions from the audience.
The Case Against: A Substantial Peer Worker Workforce in a Psychiatric Service Will Improve Patient Outcomes
N O’Connor1,2, C Ryan2,3,4, S Clark5,6
1Northern Sydney Local Health District, Sydney, NSW, Australia
2Department of Psychiatry, The University of Sydney, Sydney, NSW, Australia
3Centre for Values, Ethics and the Law in Medicine, The University of Sydney, Sydney, NSW, Australia
4Westmead Hospital, Sydney, NSW, Australia
5Western NSW Local Health District, Orange, NSW, Australia
6Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
Methods: The evidence and arguments for the effectiveness and benefits of peer workers in mental health services will be examined and tested by the three speakers. A range of concerns about the strategy and implementation issues will be explored. Both teams will have the opportunity to rebut the opposing team’s views and to take questions from the audience.
Internet Gaming: A Cross-Country Understanding of Issues
P Dullur1,2, P Hay1,2, C Yong2, S Basu3,4, HK Le5, M Zhang6, EJ Chong7, M Sharma8
1University of Western Sydney, Sydney, NSW, Australia
2South Western Sydney Local Health District, Sydney, NSW, Australia
3Latrobe Regional Hospital, Traralgon, VIC, Australia
4Monash University, Melbourne, VIC, Australia
5New South Wales Institute of Psychiatry (NSWIOP), Sydney, NSW, Australia
6ReLive Adolescent Clinic, National Addictions Management Service (NAMS), Singapore
7TOUCH Community Cyberwellness Program, Singapore
8National Institute of Mental Health and Neurosciences, Bangalore, India
Background: Problems with technology use such as Internet gaming disorder (IGD) and problem Internet use (PIU) have emerged as significant issues lately. Despite IGD being included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) as a disorder meriting further study, little is known of psychiatrists’ opinions on the disorder. Further gaps exist in the field of the influence of social media on maladaptive behaviors including self-harm and PIU. Longitudinal follow-up of patients diagnosed as having IGD and the treatments used are other gaps.
Objectives: To explore the above in a series of papers by clinicians who work in the field of child and adolescent psychiatry.
Methods: Six presentations by clinicians from Australia, Singapore and India with a panel discussion after the presentations to interact with the audience and share mutual experiences.
Findings: The presentations will discuss a wide variety of issues ranging from diagnostic and classification of IGD, longitudinal follow-up of IGD, influence of social media and network theory on maladaptive coping behaviors and treatment issues across three different countries, Australia, India and Singapore.
Conclusions: It is expected that the symposium will be of benefit to clinicians across multiple specialties such as psychiatrists, psychologists and other mental health professionals in the management of Internet-related difficulties.
Presenter 1
Internet Gaming Disorder: A Study of Health Literacy among Psychiatrists from Australia and New Zealand
P Dullur1,2, P Hay1,2
1University of Western Sydney, Sydney, NSW, Australia
2Southwest Sydney Local Health District, Sydney, NSW, Australia
Background: Internet gaming disorder (IGD) has been included as a condition for further study in the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5). Psychiatrists remain lacking in their understanding of the disorder, and only 6% systematically ask patients about their use of Internet gaming.
Objectives: To assess health literacy among Australian and New Zealand psychiatrists on IGD.
Methods: A 24-item online survey covering various issues such as IGD, problem Internet use (PIU) and current practices was administered via SurveyMonkey. The participants (n = 287) were Royal Australian and New Zealand College of Psychiatrists’ (RANZCP) psychiatrists and trainees. Informed consent was obtained as part of the survey. Appropriate descriptive statistics were generated.
Findings: The vast majority of participants (92.75%) were familiar with the concepts of IGD and PIU and feel IGD is a mental health issue. While 40% feel IGD is not a problem across all ages in the community at present, 70% felt it will be in future. More than three-fourths feel that it is possible to be addicted to non-gaming content and roughly half feel that non-gaming problems on the Internet should be included in future classification systems. Only half felt that a substance abuse/addiction framework was best suited to explain IGD. In all, 40% support screening for IGD in routine clinical assessment. Most report that IGD occurs comorbid with other psychiatric conditions and half of the respondents felt lack of confidence in assessing and managing IGD.
Conclusions: While most psychiatrists are aware of issues with IGD and PIU, a high number lack confidence in assessing or diagnosing this condition. A number of initiatives are needed to increase clarity around diagnostic criteria, assessment and management.
Presenter 2
Social Networks, Social Media and Pro-Social Behaviours as a Preventive Measure in Adolescents with Mental Illness
C Yong
South Western Sydney Local Health District, Sydney, NSW, Australia
Background: The growth of social media has been explosive in the generations of young people who have never known a world without the Internet. Yet, the research on how the Internet promotes, mediates and reinforces social and personal health behaviours is surprisingly sparse. Child and adolescent psychiatrists encounter many young people whose self-injury, suicidal thinking, body image, mood states and addiction (both substance and behavioural addictions such as Internet gaming disorder [IGD]) appear to be mediated or influenced by their interactions with peers online, but it is unclear as to the extent of this influence compared to other better understood environmental influences. More interestingly, some work is beginning to emerge using online relationships and influences to promote pro-social behaviours and attitudes in mental health.
Objectives: This paper aims to survey the theoretical research on the role of online social networks and social media on behaviours and attitudes of young people, particularly in relation to maladaptive behaviours as found in those with eating disorders or chronic self-harming behaviours, and outline some early attempts to use online platforms to promote the growth of pro-social behaviours in target youth populations. The paper will discuss the application of theoretical models to inform the development of treatment and prevention modalities.
Methods: Literature review and systematic review.
Conclusions: The research in this area is still nascent, but given the uptake of social media use and the identification of young people with online communities, the potential for the therapeutic use of social media and other online platforms for individual care of patients and for public health interventions is large. There is an increasing number of theoretical models involving networking theory that inform these approaches.
Presenter 3
Long-Term Consequence of Excessive Use of Internet and Video Games: A Case Series
S Basu1,2
1Latrobe Regional Hospital, Traralgon, VIC, Australia
2Monash University, Melbourne, VIC, Australia
Background: There continues to be academic debate about the feasibility of the construct of the addiction to Internet and video games as a separate diagnostic entity. Most of the research shows that it exists as a co-morbid condition which is particularly difficult to define and treat. The long-term consequence of this is less researched.
Objectives: The long-term psychosocial consequences of a cohort of 10 patients.
Methods: Patients who presented to a regional Child and Adolescent Mental Health Services (CAMHS) with excessive computer games and Internet use were initially treated with psychotherapy for more than 24 months and then followed up after 4 years.
Findings: All the patients presented with chronic school refusal. All patients had a primary psychiatric diagnosis ranging from attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), post-traumatic stress disorder (PTSD), social phobia and depression. All patients had excessive Internet use or gaming in the order of more than 50 hours per week which initially started as either distraction or relief from anxiety but later became the main factor resulting in social isolation. Even with intensive individual and family interventions, the long-term prognosis remained poor, with poor school completion rates and employment history. About 80% of the patients were tried on psychotropics; 50% needed inpatient treatment. Patients with earlier contact with the service, were in a younger age group and had support from family and school had a relatively better prognosis.
Conclusions: Internet and computer use history should be mandatory for every assessment of a young person. Long-term prognosis without early intervention remains guarded. There is need for research in this area.
Presenter 4
When in Asia: What Australia Can Learn About Treating Internet Gaming Disorder from Our Asian Neighbours
HK Le
New South Wales Institute of Psychiatry (NSWIOP), Sydney, NSW, Australia
Background: In 2013, Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) included Internet gaming disorder (IGD) in Section 3 for further research,1 and Asia has been highlighted as the area where research is being conducted2. In Australia, there are no dedicated public health programs or services to treat IGD3.
Objectives: To learn from our Asian neighbors what services, treatment options and community programs are being implemented. We need to assess the effectiveness of these services and whether they can be adapted for Australian mental health services in the future.
Methods: A recent New South Wales Institute of Psychiatry (NSWIOP) Training Fellowship was conducted4 investigating clinical services to treat IGD in Singapore,5,6 India7 and South Korea. This talk will give Australian psychiatrists an insight into possible directions for local services in the future.
Findings: Our Asian neighbors have already begun treating IGD and Australia is lacking similar initiatives locally.
Conclusions: IGD is a challenging disorder to assess, formulate and treat. We must actively investigate how our Asian neighbors are treating this problem and adapt this for the Australian community.
Presenter 5
Treatment of Internet Gaming Disorder in Singapore
M Zhang1, EJ Chong2
1ReLive Adolescent Clinic, National Addictions Management Service (NAMS), Singapore
2TOUCH Community Cyberwellness Program, Singapore
Background: In 2011, the Ministry of Education, Singapore, in collaboration with the Singapore National Institute of Education and the Institute of Mental Health, published a landmark 2-year longitudinal study on 3000 school children and problematic video game use (Gentile et al., 2011).
Objectives: To give Australian psychiatrists an insight into the treatment programs available in Singapore.
Methods: From this study, the government incorporated school-based programs such as the TOUCH Community Cyberwellness program, and the National Addictions Management Service set up an adolescent addiction clinic to treat excessive Internet Gaming in teens. The presentation describes experiences of Singaporean clinicians working in the school-based and community-based programs and the treatments they offer.
Findings: About 9% of children and adolescents suffered from problematic video game use, and this was strongly associated with depression (Gentile et al., 2011). Singapore has been treating Internet gaming disorder (IGD) for a number of years, including individual therapy, group therapy and parenting groups.
Conclusions: IGD seems to be a distinct entity needing services specifically programmed toward its management across multiple settings including individual, school and community levels. These programs would have wider applications across the Asia Pacific region.
Reference
Gentile DA, Choo H, Liau A, et al. (2011) Pathological video game use among youths: A two-year longitudinal study. Pediatrics 127: e319–e329.
Presenter 6
Treatment of Internet Gaming Disorder in India
M Sharma
National Institute of Mental Health and Neurosciences, Bangalore, India
Background: Following the proliferation of Internet use in the Indian population, technology overuse is considered a major problem in India. The Indian Council of Medical Research recently surveyed over 2700 residents in Bangalore aged between 18 and 65 years about their Internet and smartphone use (Travasso, 2014).
Objectives: To give an insight into the treatment programs available in India.
Methods: A brief presentation will be given from an Indian clinician working in an outpatient-based clinic attached to one of India’s premier research institutions on the treatments they offer patients suffering from technology overuse such as Internet gaming disorder (IGD) and problem Internet use (PIU) with a focus on a multipronged approach involving individual, school and community interventions.
Findings: In the local survey, 1.3% admitted to being ‘addicted’ to the Internet, 3.5% to social networking sites and 4.1% to their mobile phones. India has set up a specialized clinic to deal with this emerging problem in society, including treating co-morbid anxiety with a Yoga program.
Conclusions: Countries need to consider adopting similar programs locally.
Reference
Travasso C (2014) India opens clinic to help people ‘addicted’ to mobile phones and video games. British Medical Journal 349: g4439.
Translational Insights into Anxiety and Behavioural Inhibition
CM Kuhn1, FD Zepf2,3, D Nutt4, SD Hood5, D Castle6, M Hopwood6
1Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC, USA
2Department of Child and Adolescent Psychiatry, School of Paediatrics and Child Health and School of Psychiatry and Clinical Neurosciences, The University of Western Australia, Perth, WA, Australia
3Specialised Child and Adolescent Mental Health Services, Department of Health in Western Australia, Perth, WA, Australia
4Division of Brain Sciences, Department of Medicine, Faculty of Medicine, Centre for Neuropsychopharmacology, Imperial College London, London, UK
5School of Psychiatry and Clinical Neurosciences, The University of Western Australia, Perth, WA, Australia
6Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
Background: Anxiety symptoms are closely linked to the changes in behavioural inhibition as suggested by studies conducted in rodents and humans. However, so far there is no complete and full mechanistic understanding of the underlying neurobiological mechanisms related to anxiety and behavioural inhibition.
Objectives: In the present symposium, speakers will target different aspects related to behavioural inhibition and anxiety-like behaviours.
Methods: Prof. Kuhn will talk about anxiety-like behaviours and their underlying neurobiological mechanisms in rodents, from a developmental viewpoint. Prof. Zepf will present a study on the neurobiological correlates of punishment-induced behavioural inhibition and their serotonergic modulation in healthy adult females. In his presentation, Prof. Nutt will cover aspects on imaging the central nervous serotonin system in patients with anxiety disorders, and Prof. Hood will present research findings related to cardiovascular responses in recovered patients with anxiety disorders.
Findings and conclusions: The outlined talks will highlight new evidence related to neurocircuitry and biological mechanisms underlying anxiety-like behaviours and behavioural inhibition.
Presenter 1
Serotonin and Anxiety in Adolescent Rats
CM Kuhn, A Arrant, CL Sánchez, QD Walker, S Sanderson
Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, NC, USA
Background and objectives: Risk-taking behaviour peaks during adolescence. Our research suggests that enhanced release of dopamine (DA) to stimulate motivated behaviour and inadequate serotonergic modulation of motivated behaviour contribute to adolescent risk-taking behaviour. Deficits in serotonergic function are associated with disinhibition, impulsive aggression and risk taking, but few studies have investigated the contribution of serotonin to adolescent risk-taking.
Methods and findings: Findings presented here will show that the lack of serotonergic inhibition of behaviour could have significant consequences for risks as diverse as impulsive self-directed aggression during initiation of selective serotonin reuptake inhibitors (SSRIs) and vulnerability to substance abuse. We will present data showing that serotonergic agonists including the indirect agonist fluoxetine, the direct 5-HT1A agonist 8-OH-DPAT and the 5HT2 agonist meta-chlorophenylpiperazine (mCPP) do not inhibit behaviour as assessed in the light/dark test and novelty-induced hypophagia models. The behavioural findings showed that serotonergic modulation of behaviour in anxiety models (which entails risk assessment and behavioural inhibition in response to threat) is less in adolescents than adults. Immaturity of both serotonergic mechanisms and downstream activation by serotonin receptors likely contributes to these behavioural findings. Serotonin content in the frontal cortex has not attained adult levels, and the indirect agonist fenfluramine, which increases extracellular 5-HT, does so less in adolescents than adults. However, immaturity of cortical–amygdala interactions may also be immature, as c-Fos activation in amygdala and cortex by 5-HT1A agonist treatment is less in adolescents than adults, although receptor number and function were not different. Finally, we show pilot data which demonstrate an additional potential risk presented by this immaturity of serotonergically mediated behavioural inhibition. The entactogen/stimulant methylenedioxymethamphetamine (MDMA), which increases synaptic serotonin and DA, is not self-administered robustly by adult rats, an effect thought to reflect serotonergic inhibition of the reinforcing effects of DA released by the drug. Pilot studies in adolescent female rats demonstrate that they readily acquire MDMA self-administration, an effect we hypothesize is mediated by a greater DA/5-HT ratio in released monoamines in the adolescent rats compared to adults.
Conclusions: Overall, these results suggest that serotonergic innervation of frontal cortex circuits that contribute to behavioural inhibition and suppression of impulsivity is relatively immature in adolescent compared to adult rats. This immaturity contributes to less behavioural inhibition in conditions of threat and could contribute to adolescent risk-taking. This state has significant implications for adolescent risk of impulsive self-harm during initiation of SSRI treatment for depression as well as for adolescent abuse of mixed DA/5-HT-releasing stimulants.
Funding
This work was supported by DA 019114.
Presenter 2
Effects of Acute Tryptophan Depletion on Aspects of Punishment Processing in the Orbitofrontal and Anterior Cingulate Cortices: A Pilot Study in Healthy Adult Females
K Helmbold1,2, M Zvyagintsev2,3, B Dahmen1, S Bubenzer-Busch1,2, TJ Gaber1,2, MJ Crockett4, M Klasen2,3, CL Sánchez1,2, A Eisert5, K Konrad1,2, U Habel2,3, B Herpertz-Dahlmann1,2, FD Zepf1,2,6
1Clinic for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, RWTH Aachen University, Aachen, Germany
2Jülich Aachen Research Alliance, JARA Translational Brain Medicine, Aachen and Jülich, Germany
3Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany
4Wellcome Trust Centre for Neuroimaging, University College London, London, UK
5Department of Pharmacy, RWTH Aachen University, Aachen, Germany
6Institute for Neuroscience and Medicine, Jülich Research Centre, Jülich, Germany
Background: The neurotransmitter serotonin (5-HT) has been shown to impact aspects of behavioural inhibition, with evidence coming from behavioural studies involving healthy adult humans. In particular, the changes in behavioural control in aversive contexts (i.e. decreased punishment-induced response inhibition) were shown to be associated with reduced central nervous serotonergic functioning. Serotonergic functioning in the brain also shows significant gender differences and interacts with sex hormones. However, the underlying neural mechanisms by which 5-HT modulates female behavioural inhibition or disinhibition remain to be uncovered.
Objectives: This study aimed to examine the underlying neural correlates of punishment-induced inhibition in healthy young adult females while controlling for the menstrual cycle phase.
Methods: Participants were 18 healthy females aged 20–31 years free of hormone intake. Measurements took place during the early follicular phase of the menstrual cycle. The study used a double-blind, placebo-controlled, within-subject repeated-measures design with two separate days of assessment: acute tryptophan depletion (ATD) was used to reduce brain 5-HT synthesis in the short term; on another day, participants received a tryptophan-balanced amino acid load (BAL) serving as a balanced control condition. Neural activity during punishment-induced inhibition in a modified Go/No-Go task implementing reward or punishment processes was recorded using functional magnetic resonance imaging (fMRI) 3 hours after administration of ATD/BAL.
Findings: Central nervous 5-HT depletion magnitude in the ventral and subgenual anterior cingulate cortices (ACCs) correlated positively with neural activation during No-Go trials in punishment conditions after BAL versus ATD administration. Differences in neural activation between ATD and BAL further correlated positively with trait impulsivity in the medial orbitofrontal cortex (mOFC) and the dorsal ACC.
Conclusions: The results indicate a complex interplay between reduced central nervous serotonergic functioning and aspects of trait impulsivity in healthy young adult females. The changes in neural activity were detected in brain areas known to be associated with emotion regulation (i.e. the subgenual ACC) and appraisal and expression of emotions, including the mOFC and the dorsal ACC. The data support the notion of a serotonergic modulation of neural circuits related to punishment-induced behavioural inhibition, emotion regulation and impulsive behaviour.
Presenter 3
Imaging the 5-HT System in Anxiety Disorders
D Nutt
Division of Brain Sciences, Department of Medicine, Faculty of Medicine, Centre for Neuropsychopharmacology, Imperial College London, London, UK
Background and objectives: Anxiety disorders can be imaged using both positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) methods. PET studies have shown abnormalities of both 5-HT and gamma-aminobutyric acid (GABA)-A receptor systems in different disorders. fMRI has identified the brain circuits underpinning the experience of anxiety.
Methods and conclusions: My talk will summarise these data and show how they can lead to better understanding and treatment of these prevalent disorders.
Presenter 4
Tryptophan Depletion Enhances Cardiovascular Responses to Stress in Recovered Patients with Anxiety Disorders
SD Hood1,2, D Hince1,2, SJC Davies1, SV Argyropoulos1, F Corchs3, A Vellianitis2, J Tannenbaum2, H Robinson2, D Christmas1,2, CJ Bell1, J Potokar1, DJ Nutt4
1Psychopharmacology Unit, University of Bristol, Bristol, UK
2School of Psychiatry and Clinical Neurosciences, The University of Western Australia, Perth, WA, Australia
3Anxiety Disorders Unit, Department and Institute of Psychiatry, School of Medicine, University of São Paulo, São Paulo, Brazil
4Division of Neurosciences and Mental Health, Imperial College London, London, UK
Background and objectives: Serotonin-promoting agents may improve the outcome of some cardiovascular disorders such as ischaemic heart disease; however, it is not known whether serotonin has direct cardioprotective effects. Previous research has shown that serotonin manipulation through acute tryptophan depletion (aTD) significantly increased the cardiovascular and psychological response to a stress challenge in selective serotonin reuptake inhibitor (SSRI) and cognitive behaviour therapy (CBT)-treated patients with anxiety disorders.
Methods: A total of 59 clinically remitted subjects formed the basis of six study groups (SSRI-remitted panic disorder, social anxiety disorder, obsessive–compulsive disorder, post-traumatic stress disorder, generalised anxiety disorder [GAD] and CBT-remitted panic disorder) studied under a standard aTD versus control, double-blind procedure. Measurements of systolic blood pressure (sBP) and diastolic blood pressure (dBP) and heart rate were undertaken at various time points during the study days. Paired sample t-tests were used to compare the cardiovascular response to a stress challenge under conditions of an aTD and non-depletion (nD).
Findings: A significant reduction in tryptophan ranging from 66% to 92% was reported throughout. In the pooled analysis, sBP (p = 0.005, diff = 6.7 mmHg, 95% confidence interval [CI] = 2.1, 11.2 mmHg) and dBP (p = 0.019, diff = 5.7 mmHg, 95% CI = −0.96, 10.4 mmHg) were significantly greater on the aTD days compared with the nD days. In contrast, hazard ratio (HR) was significantly reduced (p = 0.028, diff = −4.5 mmHg, 95% CI = −8.5, −0.51 mmHg). An analysis of variance revealed that dBP was significantly different in the GAD group compared to the rest of the anxiety disorders (F(1,56) = 6.0, p = 0.018), and sBP was trending to significance (F(1,56) = 3.9, p = 0.052). The exclusion of the GAD data from the analysis made the results for sBP and dBP more significant (p = 0.001, diff = 8.9 mmHg, 95% CI = 3.8, 13.9 mmHg) (p = 0.002, diff = 8.6 mmHg, 95% CI = 3.4, 13.8 mmHg, respectively). However, the decrease in HR was made less significant (p = 0.038, diff = −4.7 mmHg, 95% CI = −9.0, −0.26 mmHg).
Conclusions: In our pooled analysis of patients with treated anxiety disorders, depletion of brain serotonin caused a statistically significant increase in sBP and dBP and a decreased HR. Our data suggest that serotonin is important in the regulation of the cardiovascular human stress response, at least in patients with treated anxiety disorders. Implications of these findings are discussed.
Personality Disorder, Personality Domains and their Interactions with Mental State Disorder
R Mulder1, G Newton-Howes2, P Tyrer3, V Brakoulias4, L Lampe5
1Psychological Medicine, University of Otago, Christchurch, New Zealand
2Psychological Medicine, University of Otago, Wellington, New Zealand
3Psychological Medicine, Imperial College London, London, UK
4Psychological Medicine, The University of Sydney, Sydney, NSW, Australia
5Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
Background: The place of personality in the management of mental state disorder in secondary care services has become increasingly well recognized. The possibility that much of chronic psychopathology may be related to personality dysfunction or disorder has been raised in the literature, and recognition of the place of personality is the first step toward instituting treatment.
Objectives: To address understanding of how to consider personality, the overlap between personality disorder and mental state disorder, what constitutes best treatment outcomes and the place of personality in management of mental state disorder.
Methods: A variety of quantitative approaches to personality and mental state disorder, their interactions and impact on outcome will be addressed.
Findings: Personality is best considered using a dimensional model with a four-factor solution when considering patients in secondary care. This is examined in a forensic population. In depressed outpatients, dimensional models are useful in predicting social outcomes at 6 months, suggesting that this approach also has prognostic validity in general adult samples. When considering specific personality characteristics in patients with mental state disorder, there is overlap, as in the case of obsessive–compulsive personality disorder and obsessive–compulsive personality, and this may have treatment implications. These treatment implications are examined further in two randomized controlled trials that show that personality, more than other measures, predicts successful treatment.
Conclusions: Personality disorder, conceptualized dimensionally, has clinical utility in predicting a variety of health and social outcomes in patients with mental state disorder in a variety of settings.
Presenter 1
Testing the Proposed International Classification of Diseases-11 Personality Domains
R Mulder1, J Horwood1, P Joyce1, J Coid2
1Psychological Medicine, University of Otago, Christchurch, New Zealand
2Violence Prevention Research Unit, Queen Mary University, London, UK
Background: There is the possibility that the International Classification of Diseases (ICD)-11 personality domains will not reflect those found in the main body of the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5), and empirical research suggests that domains may be a more useful way to diagnose personality. This approach needs empirical support in forensic patients.
Objectives: To test the structure of the proposed ICD-11 personality disorder domains.
Methods: A series of confirmatory factor models were used to test the hypothesised ICD-11 personality domains using a sample of 600 patients with depressive and anxiety disorders who had received the Structured Clinical Interview for DSM-III-R Personality Disorders.The model was then tested in a large sample of forensic patients.
Findings: The proposed ICD-11 domains are negative affectivity, dissocial, disinhibition, detached and anankastic. The best fitting model was a four-factor model with additional factor loadings to allow some symptom parcels to load on more than one factor. The dissocial and disinhibited domains loaded on one factor; otherwise, the results appeared close to our hypothesised original domains. The results in the forensic sample will be presented.
Conclusions: There is considerable evidence that the proposed ICD-11 personality domains are valid in patients with depression and anxiety disorders and in forensic patients. Differences in the domain structure between outpatients and forensic patients will be discussed.
Presenter 2
Does Personality Disorder Predict Social Outcomes in Depressed Outpatients? Results from Four Combined Randomised Controlled Trials
G Newton-Howes
Psychological Medicine, University of Otago, Wellington, New Zealand
Background: Personality disorder and its impact on depressed patients in secondary care services have been questioned with findings suggesting significant, weak and little impact. These studies generally use reduction in psychopathology as their end point for assessing impact. Social functioning may be a better outcome assessment and more aligned with the recovery model of care.
Objectives: To assess the impact of personality on social functioning at 6 weeks and 6 months in patients treated for depressive disorder.
Methods: Data from patients enrolled in four randomised controlled trials for the treatment of depressive disorder were reanalysed to assess whether any association existed between extent of personality pathology and later social dysfunction.
Findings: Personality disorder, when measured dimensionally, correlated with a variety of measures for social dysfunction by 6 months. This remained true after accounting for baseline social dysfunction and changing depression scores.
Conclusions: Assessment of personality disorder is a useful prognostic tool. It allows clinicians to predict those who will perform more poorly in social functioning following treatment for their depression. This may allow identification of patients for whom more intensive social support is needed.
Presenter 3
The Imperfect Relationship between Obsessive–Compulsive Personality Disorder And Obsessive–Compulsive Disorder
V Brakoulias1,2,3
1The University of Sydney, Sydney, NSW, Australia
2Nepean Hospital, Penrith, NSW, Australia
3Australasian Psychiatry, Melbourne, VIC, Australia
Background: Obsessive–compulsive personality disorder (OCPD) or anankastic personality disorder is characterized by perfectionism and rigidity. Although perfectionism and rigidity can be found in some patients with obsessive–compulsive disorder (OCD), not all patients with OCD have OCPD. Hence, it is important to evaluate the differences between OCD patients with OCPD and those without OCPD.
Objectives: To present characteristics associated with patients with OCD who have OCPD and to discuss implications for management.
Methods: A total of 205 patients with OCD who participated in the Nepean OCD Study were assessed for OCPD using the MINI International Neuropsychiatric Interview. Comparisons of clinical characteristics were made between patients with OCPD and patients without OCPD.
Findings: In all, 92 (38%) patients with OCD also had OCPD. Patients with OCPD had more symmetry/ordering symptoms, unacceptable/taboo thoughts, ‘just right’ sensations and indecisiveness. They also reported more severe symptoms, but were less likely to be on medication.
Conclusions: OCPD is more commonly associated with OCD symptoms that are linked to perfectionism and intolerance of uncertainty. The diagnosis of OCPD should be considered when assessing and managing patients with OCD.
Presenter 4
How the Assessment of Personality Disorder Should Guide Treatment of Anxiety Disorders: Results from Two Randomised Trials
P Tyrer
Psychological Medicine, Imperial College London, London, UK
Background: It is generally considered good practice to assess personality status when assessing psychiatric patients, but there is a danger with the loss of Axis II from the latest Diagnostic and Statistical Manual of Mental Disorders (DSM) classification that this practice will become less common.
Objectives: To assess the prognostic clinical utility of a personality disorder diagnosis in the treatment of mental state disorder in two long-term randomised trials.
Methods: The findings of two long-term studies, the Nottingham Study of Neurotic Disorder and the Cognitive behaviour therapy for Health Anxiety in Medical Patients (CHAMP) trial, were analysed to assess the prognostic utility of personality pathology to outcome. Stability of personality assessment to long-term outcome was examined.
Findings: Evidence is presented from two randomised trials with long-term outcomes, the Nottingham Study of Neurotic Disorder and the CHAMP study, that baseline assessment of personality disorder was more valuable than any other measure in predicting the success of treatment in both the short-term and the long-term.
Conclusions: The new International Classification of Diseases (ICD)-11 classification of personality disorder has been used in both data sets, and as it is a relatively simple way of assessing personality disorder, it could be used routinely in practice.
Disorders of Social Anxiety: Problems in Classification and Conceptualization
L Lampe
Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
Background: There is continuing debate about the relationship between social anxiety disorder (SAD) and avoidant personality disorder (AVPD), and the validity of the proposed subtypes of SAD. As a chronic, pervasive disorder with an early onset, SAD presents many characteristics usually associated with personality disorder; AVPD as defined in the Diagnostic and Statistical Manual of Mental Disorders shows significant criterion overlap with SAD. Prior research suggests that self-esteem and attachment may be relevant in differentiating these disorders.
Objectives: Current and alternative models of classification and conceptualization are considered, and the state of evidence in relation to these models is briefly reviewed.
Methods: MEDLINE, EMBASE and PsycINFO databases were searched using the terms (avoidant) personality disorder, phobia, social phobia, social anxiety disorder and object relations, self-esteem.
Findings: There is evidence to support a continuum hypothesis of the relationship between SAD and AVPD, but the evidence has limitations. Alternative models have been proposed. Research aimed at understanding cognitive and emotional aspects of personality, and genetic factors in social anxiety, can inform understanding around the nature of social anxiety disorders.
Conclusions: Criterion overlap between AVPD and SAD is a key issue; some differences can be identified, but there is insufficient evidence to fully inform an alternative classificatory model.
Training Across Three Countries with a Focus on Advanced Training
P McEvoy1, S Tregenza1, P Chan2
1Women’s and Children’s Health Network, North Adelaide, SA, Australia
2The Hong Kong College of Psychiatrists, Hong Kong
Background: Stage 3 training (advanced) under the competency-based framework has commenced in 2015/2016 in New Zealand and Australia, but prior to this, Advanced Training has had an important role since 2003 in our training of psychiatrists.
Objectives: This symposium will allow a discussion of Advanced Training in New Zealand and Australia under the 2012 regulations. We will present an overview of Stage 3 training, which will include generalist and subspecialty training. This symposium will then explore the current training environment in Hong Kong and what we can learn from each other.
Conclusions: The final panel will enable both Colleges to formulate a way that training opportunities might be shared between the two countries. In particular, this discussion will be strengthened by the involvement of the current trainees and newly graduated psychiatrists.
Presenter 1
Stage 3 Advanced Training
S Tregenza
Women’s and Children’s Health Network, North Adelaide, SA, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) Fellowship is a generalist training experience, but there remain core competencies across the CanMEDS framework which trainees need to demonstrate at an advanced level. There have been recent changes to how certificate (sub-specialty) training is delivered under RANZCP training regulations.
Objectives: This will be an overview of the current generalist and sub-specialty Stage 3 training in Australia and New Zealand. The presentation will focus on a range of certificate training including Child and Adolescent Psychiatry training, in particular describing the new competency-based training.
Methods: This presentation will deliver both didactic information and the personal experiences of trainees and new fellows.
Presenter 2
Hong Kong Experience
P Chan
The Hong Kong College of Psychiatrists, Hong Kong
Methods: Dr Chan will present an overview of the current training in Hong Kong and the rationale for the Hong Kong College of Psychiatrists wanting to develop advanced training options.
Presenter 3
Panel Discussion of Training across Three Countries
P McEvoy
Women’s and Children’s Health Network, North Adelaide, SA, Australia
Objectives: The panel will enable discussion and the comparison of training in the two Colleges. Opportunities for working together will be explored to enhance training experiences. In particular, the Royal Australian and New Zealand College of Psychiatrists and the Hong Kong College of Psychiatrists are keen to develop a collaborative relationship.
An MRI a Day Keeps a Neuropsychiatrist at Play
D Velakoulis1, J Looi2, M Walterfang1, R Mocellin1, S Atherton1, B Hayhow1,3, S Adams1,4, A Lusicic1,4, D Eratne1, H Lake1, D Griner1, T Winton-Browne1, Neil Wareing1, G Matta1
1Melbourne Neuropsychiatry Centre, Royal Melbourne Hospital & University of Melbourne, Melbourne, VIC, Australia
2Australian National University Medical School, Canberra, ACT, Australia
3Fiona Stanley Hospital, Murdoch, WA, Australia
4Orygen Youth Health, Parkville, VIC, Australia
Background: Neuroimaging (including magnetic resonance imaging [MRI], single-photon emission computed tomography [SPECT] and positron emission tomography [PET]) is now an essential tool of the modern-day neuropsychiatrist. The majority of patients seen within a tertiary referral neuropsychiatry service have been referred by general psychiatrists who have already undertaken imaging investigations, but who may lack the necessary experience to interpret imaging and to integrate imaging findings into the clinical formulation.
Objectives: To highlight the role of neuroimaging in the day-to-day clinical work of a psychiatrist and to identify the clinical roles for new and old neuroimaging modalities.
Methods: We will present a broad range of clinical cases across the range of neuropsychiatry (neurodegenerative, psychosis, epilepsy, mood disorders, anxiety disorders, metabolic, infective, autoimmune and traumatic). Clinical vignettes including patient videos and neuroimaging will be used as the starting point for a review of the role of neuroimaging within each group of disorders.
Conclusions: Neuroimaging has a defined clinical role in psychiatry and the day-to-day work of psychiatrists.
Presenter 1
Younger Onset Neurodegenerative Disorders
D Velakoulis1, JCL Looi1,2, D Eratne1, G Matta1, D Griner1
1Neuropsychiatry Unit, Royal Melbourne Hospital & University of Melbourne, Melbourne, Australia
2Australian National University Medical School, Canberra, Australia
Background: Younger onset dementias, including Alzheimer’s disease, frontotemporal dementias and Huntington’s disease, will often present initially to psychiatrists. The differential diagnosis between chronic schizophrenia and a neurodegenerative disorder is a frequent clinical challenge for psychiatrists.
Objectives: To identify neuroimaging findings in younger onset neurodegenerative disorders aiding in differential diagnosis and understanding of clinical pathophysiology.
Methods: Clinical vignettes, neuroimaging and review of the literature.
Conclusions: Neuroimaging is an essential tool in the diagnosis of younger onset neurodegenerative disorders.
Presenter 2
Neurometabolic Disorders
D Velakoulis1, J Looi2, M Walterfang1, R Mocellin1, S Atherton1, B Hayhow1,3, S Adams1,4, A Lusicic1,4, D Eratne1, H Lake1, D Griner1, T Winton-Browne1, Neil Wareing1, G Matta1
1Melbourne Neuropsychiatry Centre, Royal Melbourne Hospital & University of Melbourne, Melbourne, VIC, Australia
2Australian National University Medical School, Canberra, ACT, Australia
3Fiona Stanley Hospital, Murdoch, WA, Australia
4Orygen Youth Health, Parkville, VIC, Australia
Background: Neurometabolic disorders, although rare, frequently present with psychotic disorders and other psychiatric presentations.
Objectives: To identify neuroimaging findings in neurometabolic and endocrine disorders aiding in differential diagnosis and understanding of clinical pathophysiology.
Methods: Clinical vignettes, neuroimaging and review of the literature.
Conclusions: Neuroimaging is an important tool in the diagnosis of neurometabolic disorders which often exhibit white matter involvement.
Presenter 3
Autoimmune Disorders
R Mocellin1, S Atherton1, G Matta1, H Lake1
1Neuropsychiatry Unit, Royal Melbourne Hospital & University of Melbourne, Melbourne, Australia
2Alfred Hospital, Melbourne, Australia
Background: There are increasing numbers of autoimmune disorders that are relevant to psychiatrists (N-methyl-d-aspartate [NMDA], VGK and paraneoplastic disorders) and in which neuroimaging plays a role.
Objectives: To identify clinical and neuroimaging findings in autoimmune disorders aiding in differential diagnosis and understanding of clinical pathophysiology.
Methods: Clinical vignettes, neuroimaging and review of the literature.
Conclusions: Neuroimaging can play a role in the diagnosis of autoimmune disorders, although imaging may sometimes be normal.
Presenter 4
Epilepsy and Traumatic Brain Injury
S Adams1,2, A Lusicic1,2, G Matta1, N Wareing1
1Neuropsychiatry Unit, Royal Melbourne Hospital & University of Melbourne, Melbourne, Australia
2ORYGEN, Melbourne, Australia1Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
2The University of Melbourne, Melbourne, VIC, Australia
3Orygen, Melbourne, VIC, Australia
Background: Patients with focal brain lesions, mesial temporal sclerosis and frontal lobe epilepsy may present with seizures that are misdiagnosed as psychogenic non-epileptic seizures, panic attacks or anxiety.
Objectives: To present a series of cases in which focal seizures have been misdiagnosed as psychiatric disorders.
Methods: Clinical vignettes, neuroimaging and review of the literature.
Conclusions: Neuroimaging is an important tool in the differential diagnosis of epilepsy and traumatic brain injury.
Presenter 5
Movement Disorders
B Hayhow1,2, G Matta1, S Loi1
1Neuropsychiatry Unit, Royal Melbourne Hospital & University of Melbourne, Melbourne, Australia
2Fiona Stanley Hospital, Perth, Australia
Background: Patients with Huntington’s disease, Parkinson’s disease and other movement disorders are associated with high rates of psychiatric co-morbidity and may present as having psychiatric syndromes.
Objectives: To highlight the range of psychiatric presentations in movement disorders and the role of neuroimaging.
Methods: Clinical vignettes, neuroimaging and review of the literature.
Conclusions: Movement disorders often have characteristic neuroimaging changes which assist in the diagnosis as well as understanding of the pathophysiology of the illness.
Attention Deficit Hyperactivity Disorder Diagnosis, Neurobiology and Management in Adults
M Perera1, M Bellgrove2, P Dassanayake3
1The University of Melbourne, Melbourne, VIC, Australia
2Monash University, Clayton, VIC, Australia
3The Melbourne Clinic, Richmond, VIC, Australia
Background: The symptoms of attention deficit hyperactivity disorder (ADHD) have been described over centuries. Adult patients present to psychiatrists. The condition is not well understood by some, and clinicians have problems dealing with the condition that is prevalent in different parts of the world.
Objectives: Outline historical and epidemiological aspects of ADHD, clarify diagnostic procedures and neurobiology of ADHD, and discuss management and provide guidance to clinicians in terms of managing the condition.
Methods: Evidence dealing with its prevalence and historical background will be presented. The principles of diagnosis of ADHD and co-morbid conditions will be discussed. Tools that are useful will be made available. We will provide an overview of the neurobiology of ADHD including genetics, pharmacology and brain imaging. Appropriate dosing schedules and prescribing of stimulant medicines and the other medicines will be examined. Behavioural strategies will be explored.
Findings and conclusions: ADHD is a ubiquitous condition. Diagnosis requires careful evaluation and is primarily based on clinical information. Our understanding of the neurobiology of ADHD is rapidly increasing and may inform targeted treatments in the future. Management comprises use of stimulant medicines, behavioural techniques and family work. Care with prescriptions limits misuse and diversion of stimulants. Success in treatment is rewarding both to the patient and the treating clinician.
Presenter 1
History, Prevalence and Diagnosis of Attention Deficit Hyperactivity Disorder
M Perera
The University of Melbourne, Melbourne, VIC, Australia
Background: Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder. Its symptoms were first described many centuries ago. The estimates of its prevalence vary between 5% and 10% of children in a general population and half of that in the adult. The diagnosis can be made for the first time in the adult. The condition may be co-morbid with other diagnoses.
Objectives: Demonstrate historical aspects, explore epidemiology of ADHD and discuss diagnosis in an adult and the different problems that are present when the child with ADHD transitions to an adult with ADHD.
Methods: A careful history is the cornerstone of diagnosis, with particular relevance to behavioural problems beginning in childhood. Collateral information and corroboration are required. A family history of similar behaviours is sought. Symptom checklists that are of assistance will be made known. Inquiry needs to be made regarding co-morbid conditions. If ADHD is diagnosed in childhood, the relevant documentation and review of the current problems are required.
Findings: Making a de novo diagnosis of ADHD in the adult requires careful screening and evaluation. Drug seekers for hedonistic purposes need to be eliminated. The needs of the child transitioning to adult may have changed. Co-morbid conditions will be identified.
Conclusions: ADHD persists into adulthood. Some people with ADHD are diagnosed only later in life. Care needs to be exercised in diagnosing the condition for the first time in an adult. Other medical and psychological problems need to be identified.
Presenter 2
Attention Deficit Hyperactivity Disorder and Neurobiology
M Bellgrove
Monash University, Clayton, VIC, Australia
Background: Attention deficit hyperactivity disorder (ADHD) is one of the most heritable of all mental conditions. In this talk, I will overview our current understanding of the neurobiology of ADHD including the latest findings from genetics, pharmacology and brain imaging.
Objectives: To provide a state-of-the-art overview of the neurobiology of ADHD and highlight areas for further development and the potential clinical relevance of biological insights.
Methods: Both behaviour genetic (twin studies) and molecular genetic (candidate genes, genome wide association studies [GWAS], copy number variation [CNV], sequencing) studies of ADHD will be reviewed. The pharmacology of ADHD will be reviewed including the mode of action of stimulants, where they act in the brain and their impact on cognitive functioning and neuroimaging measures.
Findings: Reliable candidate gene and GWAS findings are now emerging, and the emerging picture of the genetics of ADHD, similar to many other mental conditions, is that multiple gene variants across a range of allele frequencies contribute polygenic risk to ADHD.
Conclusions: The neuroscience of ADHD is not yet at the point where it can aid clinical decision-making, yet reliable findings are emerging. It is not inconceivable that in the future, targeting of treatments to specific clinical presentations could be aided by our understanding of the neuroscience of ADHD.
Presenter 3
Managing the Individual with Attention Deficit Hyperactivity Disorder
P Dassanayake
The Melbourne Clinic, Richmond, VIC, Australia
Background: Attention deficit hyperactivity disorder (ADHD) is one of the most treatable conditions and is rewarding when properly managed. It is primarily managed by medication within an integrative treatment model. Nevertheless, treatment can be challenging due to co-morbidities and potential for abuse of stimulants.
Objectives: To discuss management of ADHD in adult patients presenting to clinicians.
Methods: Physical examination and necessary investigations need to be performed. The integrative treatment model comprises medication, psychoeducation, psychotherapy and coaching. Methylphenidate and dexamphetamine are the two widely used stimulants with short-acting and long-acting forms available. Atomoxetine is a useful adjunct. Bupropion, guanfacine and modafinil are also used. The main psychotherapeutic approaches are behaviour therapy, mindfulness-based therapy and interpersonal therapy. ADHD coaching is a non-directive approach.
Findings: Treatment with stimulants is effective with an approximately 70% response, with symptoms due to ADHD resolving. Long-acting preparations reduce the potential for abuse. Atomoxetine is helpful when there are co-morbid psychoses or a high risk of abuse. Psychological/behavioural therapies complement treatment with medication. Coaching helps clients determine and achieve their goals.
Conclusions: Once a firm diagnosis is made, ADHD can be successfully treated with medication juxtaposed with education, behavioural techniques and coaching. Careful control of prescribing is mandatory. Co-morbid conditions need to be addressed and those secondary to ADHD resolve with successful management of the primary condition.
Internet-Related Psychopathology: Issues, Controversies and Remedies
V Starcevic1, E Aboujaoude2, P Tam3
1Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
2School of Medicine, Stanford University, Stanford, CA, USA
3Rivendell Adolescent Unit, Sydney, NSW, Australia
Background: The Internet and related technologies have had profound effects on psychopathology.
Objectives: The aim of this symposium is to examine some of the most salient negative mental health consequences of an interaction between humans and digital technology and to provide information on how such an impact could be prevented or alleviated.
Methods: Experts in the field address Internet addiction, Internet-fostered impulsivity and approaches to ensure a safe interaction with digital technology.
Findings: Although the term ‘Internet addiction’ has enjoyed unprecedented popularity, it is ultimately a flawed concept for reasons elaborated at the symposium. Easy and quick access to the activities of interest and possibility of hiding behind the mask of anonymity inherent to the digital technology may make risky behaviours more appealing and promote disinhibition, thereby setting the stage for the vulnerable person to exhibit impulsivity. The propensity towards misuse of the digital technology is the key target of the prevention and management efforts; another important component is the provision of the relevant and adequate information and ‘digital psychoeducation’.
Conclusions: Internet addiction is a deceptively appealing term with no conceptual value: it should be replaced by terms that promote conceptual rigour. Use of the Internet and related technology may be a risk factor for exacerbation or emergence of impulsive behaviour through disinhibition and quick, unimpeded gratification. Although efforts to prevent the negative consequences of our encounter with digital technology are in their infancy, several initiatives appear promising and deserve attention from all stakeholders.
Presenter 1
A Critical Approach to the Concept of Internet Addiction
V Starcevic1, E Aboujaoude2
1Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
2School of Medicine, Stanford University, Stanford, CA, USA
Background: ‘Internet addiction’ is a popular term, but the corresponding concept remains controversial.
Objectives: To re-examine the concept of Internet addiction and offer possible alternatives.
Methods: Literature review and conceptual synthesis.
Findings: The concept of Internet addiction is flawed for a number of reasons. First, addiction is usually not an adequate term as it may be applicable only to the minority of ‘Internet addicts’ who do meet the general criteria for addiction. Second, the boundary between various patterns of excessive or inappropriate Internet use and bona fide addiction has not been clearly established. Third, Internet addiction denotes an addiction to a medium or delivery mechanism, which is conceptually indefensible and cannot be presumed to exist as such; this is despite some evidence suggesting that the Internet as a medium may play a role in making certain behaviours addictive. Fourth, a separation of the Internet from other media (text messaging and gaming platforms) that may be a subject to excessive or inappropriate use is no longer tenable. Fifth, it is unclear whether Internet-related psychopathology is no more than a manifestation of underlying mental disorders. Finally, the concept of Internet addiction is too heterogeneous because it pertains to numerous behaviours (gaming, gambling, sexual activities, social networking, shopping), with artificial diagnostic distinctions between the same behaviours performed online and offline.
Conclusions: The concept of Internet addiction cannot be justified and should be replaced by terms that refer to the specific behaviours, regardless of whether these are performed online or offline.
Presenter 2
New Technologies and the Rise of the Impulsivity Trait
E Aboujaoude1, V Starcevic2
1School of Medicine, Stanford University, Stanford, CA, USA
2Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
Background: Many individuals with Internet-related psychopathology report gambling, compulsive buying or compulsive sexual behavior as the main problematic online behavior. When excessive, and causing significant distress or impairment, these behaviors have been conceptualized as impulse control disorders or behavioral addictions.
Objectives: To address whether behavioral disinhibition is being promoted by the Internet and related technologies, possibly leading to a rise in online impulsivity and, consequently, impulse control disorders.
Methods: Literature review and conceptual synthesis.
Findings: The Internet and related technologies seem to be mediating an online ‘disinhibition effect’. The barriers normally separating a potentially problematic urge from its associated act seem easier to navigate, and the act itself seems less dangerous and consequential. Online betting, shopping or ‘hooking up’ for sex are more automatic when the inconveniences of a casino, shopping mall or offline ‘cruising’ no longer constitute obstacles. Since helping impulsive patients reduce their access to situations that promote urge satisfaction is an important component of their treatment, the unlimited access offered by the Internet and related technologies can pose a challenge to their well-being. But the saturated access can also make individuals with milder impulses, or no history of impulsivity, potentially at risk for de novo impulse control disorders. Indeed, new technologies may be promoting impulsivity as a personality trait, even when criteria for an actual impulse control disorder are not met.
Conclusions: Interactions with technology may be putting individuals at risk for new or exacerbated impulse control disorders. They may also be making culture more urge-driven overall.
Presenter 3
Internet Gaming Disorder and Problematic Internet Use: Emerging Treatment Approaches
P Tam
Rivendell Adolescent Unit, Sydney, NSW, Australia
Background: Over the past two decades, Internet-related and gaming-related mental health issues have emerged, attracting much clinical, research and public interest. It is important that effective, evidence-based treatments are utilized, despite the ongoing debate about the validity of the relevant psychopathological concepts.
Objectives: To address whether there is any international consensus about effective treatments for Internet-related and gaming-related mental health issues and to examine the quality of the treatment studies.
Methods: Literature review and conceptual synthesis.
Findings: Small-scale, uncontrolled treatment studies of individuals with problematic Internet use (‘Internet addiction’) began to emerge in the early 2000s, some years after the first clinical descriptions of the condition and before any consensus on diagnosing and classifying the condition. Most studies involved young males, either at school or at university, and they generally focused on problematic gaming as the core pathology. It was recognized that the ‘world’ of the computer and Internet is highly heterogeneous, with gaming just one of its aspects; this represents an additional difficulty when evaluating treatment studies. With the development of internationally accepted diagnostic tools, some multinational, cross-cultural treatment approaches can now be systematically examined. Prevention and early intervention are also seen as important aspects of management.
Conclusions: As may be expected for a recently described disorder, most treatment studies have been methodologically weak. However, new, more carefully developed and clinically sound management approaches are emerging, and they lend themselves to a more comprehensive, rigorous testing.
Depression, Self-Efficacy and Antidepressants in Stroke
WK Tang1,2, Y Liang1, H Liang1, RC Ho3, K Mikami4, SHS Lo5, AM Chang6, JPC Chau5
1Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong
2Shenzhen Research Institute, The Chinese University of Hong Kong, Hong Kong
3Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
4Department of Psychiatry, Tokai University School of Medicine, Kanagawa, Japan
5The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
6School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
Background: Stroke is a leading cause of death worldwide. Post-stroke depression (PSD) is common after stroke.
Objectives: To examine the neurobiology of PSD and the impact of antidepressants and coping strategy on stroke recovery.
Methods: Speakers from Hong Kong, Singapore and Japan will share their neuroimaging and genetic data on PSD, the efficacy of antidepressants and coping strategies in the physical recovery of stroke patients.
Findings: Various vascular lesions play an important role in the development and outcome of PSD. The 5-HTTLPR SS genotype is also a risk factor for PSD. Stroke patients after stroke may benefit from administration of antidepressants, in particular selective serotonin reuptake inhibitors, as an additional intervention, independent of depression. Other than pharmacotherapy, building self-efficacy and positive outcome expectations, pursuing testing strategies that work best to own conditions, being open to listening and sharing experiences and praising one’s own accomplishments were essential for better managing uncertainty in stroke recovery.
Conclusions: The findings inform future development of interventions for enhancing stroke survivors’ post-stroke recovery outcomes.
Presenter 1
Vascular Lesions in Post-Stroke Depression
WK Tang1,2, Y Liang1, H Liang1
1Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong
2Shenzhen Research Institute, The Chinese University of Hong Kong, Hong Kong
Background: Post-stroke depression (PSD) is common following an acute stroke. PSD has notable impacts on the recovery of function and quality of life of stroke survivors. Although the incidence of PSD decreased with time after a stroke, the prevalence of PSD tended to be stable.
Objectives: To examine the impact of the type and location of vascular lesions on the risk, severity and outcome of PSD.
Methods: Systematic review of the literature.
Findings: Vascular factors such as diabetes, hypertension and smoking have been related to anger, cognitive impairment and depression in stroke patients, respectively. Many studies have explored the association between different types of lesions, namely, macro-infarcts, lacunar infarcts, white matter changes, and microbleeds and the incidence, severity or outcome of PSD. Lesions in the frontal lobe, basal ganglia and deep white matter seem to be particularly related to the incidence of PSD.
Conclusions: Various vascular lesions play an important role in the development and outcome of PSD.
Funding
This project was supported by the following grants: Health and Medical Research Fund, reference number: 02130726; Health and Medical Research Fund, reference number: 01120376; National Natural Science Foundation of China, reference number: 81371460; General Research Fund, reference number: 474513; General Research Fund, reference number: 473712; and a research fund from the Lui Che Woo Institute of Innovation Medicine.
Presenter 2
Polymorphisms of the Serotonin Transporter Gene and Post-Stroke Depression: A Meta-Analysis
RC Ho
Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Background: Polymorphisms of the gene encoding the serotonin transporter – specifically, length variation in the serotonin–transporter-linked polymorphic region (5-HTTLPR), a single-nucleotide polymorphism (SNP) in the 5-HTTLPR (rs25531) and a variable number of tandem repeats (VNTR) in the second intron 2 (STin2) – have been implicated in the development of post-stroke depression (PSD).
Objectives: To evaluate the association between polymorphisms of the serotonin transporter gene and PSD in the medical literature.
Methods: Random-effects meta-analyses were conducted on cross-sectional, case–control and cohort studies that examined the relationships between polymorphisms of the gene encoding the serotonin transporter and the risk of developing PSD.
Findings: Four studies comprising 260 stroke patients with PSD and 381 without PSD were included. Our analyses showed a significant and positive association between the homozygous short variation (S) allele genotype of the 5-HTTLPR (SS) and PSD (random-effects pooled odds ratio [OR] = 2.05, 95% confidence interval [CI]: 1.41, 2.98, z = 3.79, p < 0.001). Our analyses also showed a significant and negative association between the homozygous long variation (L) allele genotype of the 5-HTTLPR (LL) and PSD (random-effects OR = 0.52, 95% CI = 0.27, 0.97, z = −2.07, p = 0.039). No statistically significant association of PSD with heterozygous S and L allele genotypes for 5-HTTLPR or other polymorphisms with rs25531 and STin2 VNTR was found.
Conclusions: The 5-HTTLPR SS genotype may be a risk factor for PSD. The 5-HTTLPR LL genotype showed a significant negative association with PSD. Further research to assess the sensitivity and specificity of predicting the risk of developing PSD by screening for the 5-HTTLPR genotype in stroke patients is required.
Presenter 3
Role of Selective Serotonin Reuptake Inhibitors as an Adjunctive Treatment to Physical Recovery after Stroke
K Mikami
Department of Psychiatry, Tokai University School of Medicine, Kanagawa, Japan
Background: Depression is common after stroke, and post-stroke depression (PSD) has a negative impact on outcome in patients with stroke. There is robust evidence that heterocyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) are effective in the treatment of PSD.
Objectives: To examine the evidence of the efficacy of SSRI treatment in the physical recovery of stroke patients.
Methods: Systematic review of recent literature.
Findings: Recent prevention studies have indicated that the use of an antidepressant results in lower incidence of not only depression but also apathy characterized by a lack of motivation. Adding these positive effects of antidepressants on preventive intervention, several small studies show that antidepressant medication might be helpful in promoting recovery in stroke patients. Motor impairments are a major cause of disability after stroke, which leads to a decrease in patients’ quality of life and/or burden on their caregivers. Although standard rehabilitation facilitates recovery after stroke, additional interventions are needed. As an adjunctive treatment, there has been growing interest in the use of antidepressants to augment recovery after stroke, and evidence of this adjunctive treatment is gradually accumulating.
Conclusions: Given recent physical recovery studies, patients after stroke may benefit from administration of antidepressants, in particular SSRIs, as an additional intervention, surprisingly independent of depression. However, the pitfalls of SSRIs should be carefully considered in recent stroke patients especially for those without depression.
Presenter 4
Managing Uncertainty in Post-Stroke Recvoery: A Qualitative Study
SHS Lo1, AM Chang2, JPC Chau1
1The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
2School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
Background: The post-stroke recovery journey is individualised without set criteria for attainment. Managing uncertainty in stroke recovery can be challenging to both stroke survivors and healthcare professionals. The experience of uncertainty may lower stroke survivors’ motivation in rehabilitation and impairs their physical or psychosocial outcomes if it is not managed well.
Objectives: This study is aimed at exploring stroke survivors’ experiences and strategies for managing uncertainty in stroke recovery.
Methods: A qualitative study was conducted. A purposeful sample of 15 stroke survivors who had experienced a first or recurrent ischaemic or haemorrhagic stroke, who currently lived at home, spoke Cantonese and managed their post-stroke conditions well were recruited from a stroke support group in Hong Kong. Individual semi-structured video-taped interviews were conducted. Participants were asked about their experiences after stroke, uncertainties in stroke recovery encountered and strategies for managing the uncertainties. Data were transcribed verbatim and analysed using thematic content analysis.
Findings: In all, 15 stroke survivors (mean age = 60.9 years, standard deviation [SD] = 10.11) were interviewed. Most of the survivors were male (n = 8), were married and retired (n = 10), had experienced ischaemic stroke (n = 10) and walked with a stick (n = 7). All except three had a first-ever stroke (mean duration after first stroke = 10.4 years, SD = 7.45). Five key themes emerged: building self-efficacy in managing post-stroke physical or psychosocial challenges, nurturing positive outcome expectancy beliefs in recovery, exploring and evaluating the usefulness of strategies in better managing their conditions, engaging in sharing with people with similar conditions and praising every tiny accomplishment during periodic review of their own journey to recovery.
Conclusions: The findings indicated that building self-efficacy and positive outcome expectations, pursuing testing strategies in how to work best in one’s own conditions, being open to listening and sharing experiences and praising one’s own accomplishments were essential for the better management of uncertainty in stroke recovery. The findings inform future development of interventions for enhancing stroke survivors’ post-stroke recovery outcomes.
International Masters of Affective Neurosciences
D Nutt1, S Hood2,4, D Bassett2,4, B Hayhow3, D Hans2,4, R Clarke2,4
1Imperial College London, London, UK
2The University of Western Australia, Perth, WA, Australia
3Fiona Stanley Hospital, Perth, WA, Australia
4Sir Charles Gairdner Hospital, Perth, WA, Australia
The International Masters of Affective Neurosciences is a master’s level course run by the University of Maastricht, in collaboration with the University of Florence, the University of Bristol and the University of Western Australia. It aims to promote teaching, research and international collaboration in the field of affective neurosciences by combining supervised research with residential courses. These residential courses involve lectures and group workshops facilitated by leading international clinicians and researchers, who also supervise the research projects that follow. In this Combined Symposium, presenters, including senior academics and clinicians involved in organising and running the course as well as junior clinicians studying in the programme, will give their perspectives on this highly successful course. They will discuss the philosophies of the course, the experiences and research opportunities it provides and the importance of promoting international collaboration in this rapidly evolving field.
Presenter 1
History and Philosophy of the International Masters of Affective Neurosciences
D Nutt
Imperial College London, London, UK
The International Masters of Affective Neurosciences was founded in 1989 as an incentive of the Erasmus Programme of the European Union. Initially, it was created as a course focusing on Anxiety Disorders by the Maastricht University Laboratory for Experimental Psychiatry, as a postgraduate, advanced and research-oriented teaching programme. Since then, it has developed in close collaboration with the University of Florence and the University of Bristol, and its focus has broadened to include a more general study of affective pathology, including anxiety, depression and bipolar disorders, and suicidal and addictive conducts. This highly successful programme is at the interface between mental dysfunction as expressed by clinical pathology and by the broad field of basic and applied neurosciences.
The philosophy of this Masters is to provide small-scale, residential, conference-styled courses with international postgraduate candidates working in the field of mental health, to encourage and support research in the field of affective neuroscience. The junior attendees are brought together annually in either Florence or Maastricht, with leading scientists presenting in a series of intensive 1-week courses and seminars, which can be attended either as stand-alone courses in affective neuroscience or as part of a 2- to 4-year master’s Degree. Following these courses, candidates then participate in mentored research, a master’s dissertation and create a personal portfolio.
In this Symposium, Prof. Nutt, who has a wealth of experience in clinical research practice (and is the current Edmond J Safra Chair at the Department for Neuropsychopharmacology and Molecular Imaging at Imperial College London), will present the history and philosophy underpinning the International Masters in Affective Neurosciences.
Presenter 2
International Studies in Neurosciences: An Australian Perspective
S Hood1,2
1The University of Western Australia, Perth, WA, Australia
2Sir Charles Gairdner Hospital, Perth, WA, Australia
Having completed psychiatry training in Australia before moving to the United Kingdom (to work in the Psychopharmacology Unit at the University of Bristol/Imperial College), Prof. Hood has extensive knowledge of research and its integration with clinical practice based on international perspectives and with a particular focus on affect disorders. He has experienced the Masters of Affective Neurosciences course at every level, undertaking the Masters in Affective Neurosciences, and then subsequently returning as a lecturer and research supervisor before being appointed to the Board of Directors.
Having recently established a Memorandum of Understanding between Maastricht University and the University of Western Australia, Prof. Hood will discuss his experiences with the course and the value of forging and strengthening both national and international ties between academic institutes in order to promote, encourage and sustain Australian clinical research in the field of psychiatry.
Presenter 3
Promoting and Supporting Research and Acadaemia in Australian Neuropsychiatry
D Bassett1,2
1The University of Western Australia, Perth, WA, Australia
2Sir Charles Gairdner Hospital, Perth, WA, Australia
Psychiatry and clinical neurosciences are a rapidly evolving discipline of study. For Australian clinicians and trainees, participation in a career in research and academia is becoming increasingly difficult due to intensifying clinical demands and decreases in public funding for these activities. Clinical A/Prof. Bassett is a senior consultant psychiatrist with a career-long interest in research and clinical neurosciences, as well as a recent graduate from the International Masters in Affective Neurosciences. He will discuss the challenges facing junior psychiatrists in pursuing research opportunities in Australia, his experiences during the master’s courses in Maastricht and Florence and the benefits of a career with research facets as well as the importance of promoting and supporting research by junior psychiatrists.
Presenter 4
International Masters of Affective Neurosciences: The Student Journey
B Hayhow1, D Hans2,3, R Clarke2,3
1Fiona Stanley Hospital, Perth, WA, Australia
2The University of Western Australia, Perth, WA, Australia
3Sir Charles Gairdner Hospital, Perth, WA, Australia
The International Masters in Affective Neurosciences is an excellent course for young Australian clinicians. Consisting of small, intensive residential courses capped at 60 participants per year and set in Florence, Italy, as well as Maastricht, The Netherlands, the programme allows its students immersion in an environment where they have informal access to experienced, leading international clinicians who lecture on cutting edge developments in the field of affective neuroscience and who supervise workshops based on integration of knowledge and strengthening of research skills. In addition, it gives an opportunity for participants to meet and socialise with other international students from backgrounds in psychiatry and psychology and to form strong bonds with these colleagues.
In this symposium, three clinicians, with an interest in research and at various stages of their careers in psychiatry, discuss their research and experiences as the current postgraduate students of the International Masters in Affective Neurosciences.
Psychosocial Interventions for People with Severe Mental Illness: Perspectives on Current Practice Realities and Implications for Training and Implementation
C Harvey1,2, E Fossey3, F Dark4,5
1Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
2NorthWestern Mental Health, Melbourne, VIC, Australia
3Department of Occupational Therapy, School of Primary Health Care, Monash University, Melbourne, VIC, Australia
4Metro South Mental Health Services, Macgregor, QLD, Australia
5School Public Health, The University of Queensland, St Lucia, QLD, Australia
Background: Psychosocial interventions (PSIs) have robust evidence, are recommended in clinical practice guidelines for people with severe mental illness (SMI) and yet are not widely available in routine care. There is a particular need to disseminate psychosocial rehabilitation interventions with potential to benefit neglected subgroups of those with SMI.
Objectives: This symposium addresses the practical realities of implementing evidence-based PSIs for Australians with SMI.
Methods: First, a unique dataset derived from Australian epidemiological research will be presented, reporting (1) the extent of receipt of psychosocial interventions by Australians with psychoses and the associated personal and contextual explanatory factors, and (2) case manager views concerning the helpfulness of these interventions, and barriers to their delivery, for a sub-sample of study participants. Second, a study of the implementation of cognitive therapies into routine psychosis care in a Queensland mental health service will be presented.
Findings: Across Australia, PSIs were not widely available and their receipt was associated with service as well as consumer factors. Although case managers perceived evidence-based PSIs as helpful, alternatives were often provided. Implementation of cognitive therapies in Queensland was expanded over 3 years with contributions from staff and organizational factors.
Conclusions: A multi-level systems approach to implementing PSIs is supported. In addition to consumer characteristics, staff factors (e.g. case manager discipline, ownership of interventions) and organisational characteristics (e.g. leadership, planning) may be important for implementation of PSIs. Workforce training that increases the capacity of case managers to recognise and discuss how psychosocial interventions may meet consumer needs is required.
Presenter 1
Evidence-Based Psychosocial Interventions for Australians Living With Psychoses: Epidemiological Data on Receipt, Targeting and Explanatory Factors
C Harvey1,2, J Farhall3, J Lewis3, H Stain4
1Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
2NorthWestern Mental Health, Melbourne, VIC, Australia
3Department of Psychology and Counselling, La Trobe University, Melbourne, VIC, Australia
4School of Medicine, Pharmacy and Health, Durham University, Durham, UK
Background: Little data exist about the extent of receipt of psychosocial interventions (PSIs).
Objectives: Using data from a large representative sample of Australians living with psychotic disorders, we examined (1) receipt of PSIs over 12 months; (2) targeting of each intervention, assessed by associations with consumer suitability indicators; and (3) relationships between receipt of any PSI and consumer characteristics and service factors.
Methods: A total of 1825 participants in the 2010 Australian survey of psychosis were asked about their use of mental health services in the previous year, including receipt of evidence-based PSIs (social skills training [SST], family psycho-education [FPE], supported employment [SE], cognitive behavioural therapy [CBT], relapse prevention planning [RPP], Assertive Community Treatment [ACT]). Survey items were used to indicate eligibility for, or suitability of, each intervention, according to the literature and clinical guidelines. Regression analysis was performed to predict receipt of one or more PSIs.
Findings: PSIs were not widely received (between 2.3% for SE and 22.9% for CBT). ACT, CBT, RPP, FPE and SE were reasonably well targeted, but this was not the case for SST. Receipt of any PSI was significantly associated with personal, clinical and service factors, including persistent illness course, satisfaction with case manager and case managers who were psychologists.
Conclusions: Interventions to assist with getting work or improving relationships are especially lacking. The gap between needs and receipt is wide and requires ‘implementation effort’.
Interventions with discipline ‘ownership’ (e.g. CBT) or well-defined service models rolled out through systematic efforts (e.g. ACT) may be better implemented.
Presenter 2
From Evidence to Realities: Psychosocial Intervention Provision in Australian Routine Community Mental Health Practice
E Fossey1, C Harvey2,3, J Farhall3,4, A Wiggins3, P Ennals5
1Department of Occupational Therapy, School of Primary Health Care, Monash University, Melbourne, VIC, Australia
2Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
3NorthWestern Mental Health, Melbourne, VIC, Australia
4Department of Psychology and Counselling, La Trobe University, Melbourne, VIC, Australia
5School of Allied Health, La Trobe University, Melbourne, VIC, Australia.
Background: Treatment guidelines increasingly acknowledge the importance of psychosocial interventions (PSIs).
Objectives: This study sought to better understand the routine provision of PSIs in mental health services, using information gathered from consumers in the 2010 Australian survey of psychosis about their access to assertive community treatment, medication adherence, relapse prevention, cognitive behavioural therapy, skills training, supported employment and family interventions, and an adjunct study of case manager perspectives on the provision of the same interventions.
Methods: Interviews about the provision of PSIs and their perceived helpfulness were conducted with case managers of 33 service users who participated in the Australian survey. By linking the interview and survey data, we compared their respective perspectives of the types of PSIs provided and examined the case managers’ reasons when PSIs were not provided.
Findings: All 33 consumers received at least one evidence-based PSI in the previous 12 months, according to case managers, and when provided, case managers perceived psychosocial interventions as helpful. Agreement between case managers and service users about the provision of the specific PSIs varied, while case managers’ most frequent reasons for service users not receiving these interventions were as follows: they were not offered, they were declined by service users or alternative interventions were provided.
Conclusions: Personal and clinical factors may explain the degree of concordance between case manager and consumer perspectives. Bringing together service user and case manager reports can assist our understanding of the current access and barriers to evidence-based practices and identify workforce training and service development priorities.
Presenter 3
Implementing Cognitive Therapies into Routine Psychosis Care
F Dark1, E Newman2, V Gore-Jones2, H Whiteford1, C Harvey3,4, D Crompton5
1School of Public Health, The University of Queensland, St Lucia, QLD, Australia
2Metro South Mental Health Services, Macgregor, QLD, Australia
3Department of Psychiatry, Psychosocial Research Centre, The University of Melbourne, Melbourne, VIC, Australia
4NorthWestern Mental Health, Melbourne, VIC, Australia
5Metro South Mental Health District, Upper Mount Gravatt, QLD, Australia
Background: Comprehensive psychosis care requires access to psychosocial interventions (PSIs) as well as pharmacotherapy. Realizing this goal in routine practice has challenged mental health services. Implementation research has provided guidelines to enable service reform to incorporate evidence-based practice (EBP).
Objectives: This study evaluates the application of implementation theory to the implementation of cognitive therapies into routine psychosis care in a mental health service.
Methods: An implementation plan and committee was established in 2012 with the aim of implementing and disseminating group-based cognitive therapies for psychosis. Yearly staff surveys tracked interest and training needs. Programs were audited annually to ascertain utilization rates and program maintenance.
Findings: Over the 3-year implementation study period, access to group-based cognitive behaviour therapy (CBT) and Cognitive Remediation Therapy (CRT) was sustained and expanded in the district. After 3 years of implementation, staff attitude to evidence based practice (EBP) was weakly correlated to age of staff member and organizational culture variables of leadership and planning.
Conclusions: Implementing evidence-based therapies into routine psychosis care requires attention to the implementation drivers of workforce, leadership and organizational processes.
Lithium Phobia: Science or Superstition?
DS Goel1, S Kumar2, N Pai3, M Isaac4
1Southland Hospital, Invercargill, New Zealand
2Waikato Clinical School, University of Auckland, Hamilton, New Zealand
3University of Wollongong, Wollongong, NSW, Australia
4School of Psychiatry and Clinical Neuroscience, The University of Western Australia, Fremantle, WA, Australia
Background: The use of lithium is declining even as evidence for its efficacy grows. Is this paradox based on science, or is it rooted in psychopharmacological superstition?
Objectives: Deconstruct the current evidence base to identify reasons for the relative eclipse of lithium and propose remedial strategies.
Methods: Evidence-based evaluation of the efficacy and adverse effects associated with lithium therapy.
Findings: Incredibly, the evidence for the efficacy of lithium in the treatment and prophylaxis of bipolar disorders continues to grow, along with an ever-enlarging list of indications for its use, despite incomplete understanding of its mechanisms of action. Apart from clozapine, it is the only psychopharmacological intervention known to reduce suicidality, and lower suicide rates have been reported in regions with relatively higher levels of lithium in drinking water. Lithium may attenuate the risk of dementia in patients with bipolar disorder, indicating its possible role in the treatment of neurodegenerative disorders such as Alzheimer’s disease and Huntington’s disease. Exaggerated fears regarding the potential toxicity of lithium have been effectively addressed in recent communications which, along with an upgraded therapeutic ranking, reaffirm its role as the ‘gold standard’ in the management of bipolar disorders. Paradoxically, sodium valproate remains the most widely prescribed mood stabiliser despite sparse evidence for its effectiveness.
Conclusions: The curious paradox of lithium’s declining use, despite increasing evidence regarding its efficacy and safety, merits serious scientific inquiry. Apart from the pharmaceutical industry’s disinterest, superstitious fears regarding lithium’s toxicity and inadequate training in its use are probable contributors. Pragmatic remedial strategies are needed.
Presenter 1
Lithium: What are You Afraid of?
DS Goel
Southland Hospital, Invercargill, New Zealand
Background: The declining use of lithium despite increasing evidence regarding its efficacy appears to be driven less by science and more by psychopharmacological superstition.
Objectives: Quick review of the relevant evidence to highlight the phobias and superstitions underpinning the relative eclipse of lithium and to stimulate debate.
Methods: Evidence-based evaluation of the efficacy and adverse effects associated with lithium therapy.
Findings: While evidence for the efficacy of lithium in the treatment and prophylaxis of bipolar disorders continues to grow, along with an ever-enlarging list of indications for its use, despite incomplete understanding of its mechanisms of action, phobic fears, rooted in psychopharmacological superstition, continue to scare clinicians. Alarmist reports regarding the potential toxicity of lithium contribute to patients being denied the benefits of this versatile drug, although these misplaced fears have been effectively addressed in recent communications that reaffirm lithium’s place as the ‘gold standard’ in the management of bipolar disorders and related conditions
Conclusions: The curious paradox of lithium’s declining use, despite increasing evidence regarding its efficacy and safety, raises the vital question, ‘What are we afraid of?’ This symposium proposes to address this and related issues, with the aim of identifying factors driving this pernicious trend and generating pragmatic remedial strategies.
Presenter 2
Lithium: A Magic Ion
S Kumar
Waikato Clinical School, University of Auckland, Auckland, New Zealand
Background: Mood disorders (unipolar-depressive episodes only and bipolar disorder–mania or hypomania, usually with intermittent depressive episodes) are leading causes of global disability. The risk of suicide among patients with mood disorder is estimated to be 10 times higher than in the non-psychiatric population.
Objectives: To review the efficacy and safety of lithium in the acute and prophylactic management of mood disorder and explore its role in a range of other conditions including its antisuicidal and neuroprotective effects. Neuroprotective and mitochondrial function-enhancing effects of lithium are also reported. Epidemiological observations also suggest that rates of chronic heart disease in a population may be inversely related to lithium levels in drinking water. Experimental evidence suggests that lithium, by increasing the number of insulin receptors and insulin sensitivity at the cellular level, improves the efficiency of glucose and triglyceride metabolism. Despite such a wide range of usefulness, lithium usage appears to be declining.
Methods: Findings from a selective literature review will be presented.
Findings: This session will also review safety aspects of lithium. Higher serum lithium levels have been shown to be associated with executive dysfunction in follow-up studies. An increased risk of reduced urinary concentrating ability, hypothyroidism, hyperparathyroidism and weight gain are known. The risk of congenital malformations is uncertain; the balance of risks should be considered before lithium is withdrawn during pregnancy.
Conclusions: Monitoring recommendations will be reviewed and the potential role of lithium in the prevention of metabolic syndromes associated with newer antipsychotics now popularly used in the treatment of mood disorders will also be examined.
Presenter 3
Paradox of Lithium: As Evidence is Increasing, Use of Lithium is Decreasing!
N Pai
University of Wollongong, Wollongong, NSW, Australia
Background: According to the available evidence, lithium is the drug of choice in the treatment of acute manic episodes and preventing mainly the relapses of manic attacks rather than hampering the depressive episodes.
Objectives: This review highlights the place of lithium amid the galaxy of medications used in the treatment of bipolar disorder and the accumulated evidence to support the rationale of lithium in taking up the pivotal position. In addition, this will also highlight the various factors that determine the prescription practices as relent in psychotropic medications, lithium in particular.
Methods: Selective literature review highlighting the objectives will be used.
Findings: Far more data are available to support the utility of lithium in the maintenance treatment of bipolar disorder than for all the other commonly prescribed agents combined. Lithium is the prophylactic therapy against which all other novel therapies still are judged. There is a need to integrate new developments into standards of practice, such that the greater costs of the newer therapies to patients and society are realistically weighed against the benefits, and the potential side effects of these therapies are minimized.
Conclusions: Although lithium therapy is a lifelong experience for many patients with bipolar disorder, the frequency of its use has been on the decline due to unrelated factors.
Presenter 4
Lithium: The Way Forward
M Isaac
The University of Western Australia, Perth, WA, Australia
Background: There is wide consensus and evidence for the superior efficacy and acceptable tolerability of lithium in the management of bipolar affective disorders mood stabilizer, as compared to other mood stabilizers.
Objectives: The objectives of the presentation are to (1) explore the possible reasons why the use of lithium in the treatment of bipolar affective disorders has declined considerably over the years despite the acceptable evidence for its efficacy–tolerability balance and (2) to examine the way forward.
Methods: An extensive review of literature to examine how evidence-based is mental healthcare practice in general, and the management of bipolar disorders in particular, across the world.
Findings: Much of mental healthcare practice in many parts of the world is not strictly ‘evidence-based’. The concept of evidence-based medicine is somewhat controversial, and there is a major ‘science-to-service’ gap in the field of mental health care.
Conclusions: Ways and means of overcoming barriers to implement evidence-based practices in mental health include conducting practice-based research, translational research and generating evidence from the ‘real world’ of clinical practice. The way forward for evidence-based practice in the management of bipolar disorders, including the use of lithium, includes further research on the use of lithium, focusing on dosages and safety monitoring; holding lithium clinics; generating authentic user narratives on the efficacy of lithium; consumer and carer education and training; and exposure to psychiatrists on the use of lithium.
Mental Health in Guangdong
Yue Li
Department of Psychiatry and Asialink, The University of Melbourne, Melbourne, VIC, Australia
Background: Mental illness is a major contributor to disease burden in China. Guangdong province has a population of over 104 million. This province’s health information system is inadequate, especially the mental health work-force and service response.
Objectives: Mental illness is a major contributor to disease burden in China. Guangdong province has a population of over 104 million. This province’s health information system is inadequate, especially the mental health work-force and service response. This article describes a field survey to assess the existing mental health workforce and service capacity in Guangdong.
Methods: A total of 125 major service providers in Guangdong were identified with the capacity to treat serious mental illness at all levels of the health system. These services were approached to complete a standardised survey based on the World Health Organization (WHO) Assessment Instrument for Mental Health Systems.
Findings: The survey identified 8498 mental health workers with 72.5% working in psychiatric hospitals. Service providers reported a treatment rate of 68.8% of a total of 430,000 people registered for treatment of severe mental illness, and only 28.4% of over a million people estimated to be experiencing severe mental illness. An inadequate mental health workforce was cited as a common barrier to treatment access.
Conclusions: Guangdong province has a significant treatment gap for severe mental illness and a shortage in the mental health workforce. The distribution of the mental health workforce and facilities is imbalanced towards hospital care rather than community care.
Mental Health in Guangdong
F-J Jia
Guangdong Mental Health Center, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
Background: In Mainland China, mental health has long belonged to clinical medical field. Until 2009, the Chinese state enrolled the mental health service into the basic public health services, truly embodying its public health attributes.
Objectives: The coverage of community mental health service network is small and single-functional, which cannot meet the mental health services required by country’s basic public health services. We aim to develop the services of Guangdong Mental Health.
Methods: We integrated the community service team including mental health professionals, community healthcare workers, family members of patients, community service personnel, civilian police and so on based on the current existing community service pattern. In particular, we seized the current turning point of emphasis on strengthening the social work management; developing the education of social workers; integrating and mobilizing community resources; strengthening the training of mental health knowledge and skills for Disabled Persons’ Federation, Civil Affairs and other relevant community workers as quickly as we can; and gradually improve the multi-disciplinary mental health service team.
Findings: After several years of exploration, building this kind of mental health service system as ‘a psychiatric hospital leading, general hospital assisting, and community-based mental health’ has been a practical model in Guangdong.
Conclusions: We can forecast optimistically that after the series of gradual improvement of mental health services and regulations, the Mainland’s mental health service coverage and service capabilities will be a historic increase.
Mental Health in Guangdong
C-L Hou
Guangdong Mental Health Center, Guangdong General Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
Background: In China, maintenance treatment for clinically stable patients with schizophrenia is usually provided by primary care physicians, but their prescribing patterns have not been studied.
Objectives: This study examined the frequency as well as demographic and clinical correlates of antipsychotic polypharmacy (APP) and its impact on quality of life (QOL) in patients with schizophrenia treated in primary care in China.
Methods: A total of 623 community-dwelling patients from 18 randomly selected primary care services were interviewed. Patients’ socio-demographic and clinical characteristics, including number of hospitalizations, antipsychotic drug-induced side effects and QOL, were recorded using a standardized protocol and data collection procedure.
Findings: The rate of APP prescription was 31% (193/623). Of the patients on APP, 89.6% received two antipsychotics and 10.4% received three or more antipsychotics. Clozapine (35.6%) was the most commonly prescribed second-generation antipsychotic (SGA), while perphenazine (17.8%) was the most commonly prescribed first-generation antipsychotic (FGA). Multiple logistic regression analyses revealed that patients on APP were more likely to receive SGAs and anticholinergics, had fewer hospitalizations, younger age of onset and higher doses of antipsychotics. There were no significant differences between the two groups in any of the QOL domains.
Conclusions: Approximately one-third of Chinese patients with schizophrenia in primary care receive APP. Further examination of the rationale and appropriateness of APP and its alternatives is warranted.
Preparing the Next Generation and Reaching Out to the Community with Psychiatry Education: Innovation and Implementation
L McLean1,2, L Nash1,2,3, S Kumar1,4,5, P Boyce2
1Brain and Mind Centre, The University of Sydney – Camperdown, Sydney, NSW, Australia
2Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
3Health Education and Training Institute of NSW Health, Sydney, NSW, Australia
4Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia
5The Lawson Clinic, Sydney, NSW, Australia
Background: The need to nurture the next generation of psychiatrists begins in medical training and moves through the way we educate, support and mentor our junior doctors in their first years of practice and the basic and advanced training of our vocational trainees. We also have a strong role to play in inter-professional education and community outreach to connect with, contribute to and collaborate with efforts to promote mental health, trauma-informed care, recovery and flourishing. Innovation in pedagogy and the creative and pragmatic application of these new approaches are required.
Objectives: We aim to present projects that span much of this field and promote discussion in this important area.
Methods: Four presentations will be offered including innovative projects on (1) psychiatry terms for junior doctors, (2) a project on the flipped classroom in a new Formal Education Course for vocational trainees, (3) the development and delivery of a multi-platform resource on mood disorders and (4) the development of a Massive Open Online Course (MOOC) on Positive Psychiatry.
Findings: The current efforts at educational outreach from psychiatry and health educators are aiming at innovation and engagement with contemporary opportunities and platforms, and where evaluation is available, it suggests the promise of this approach.
Presenter 1
Psychiatry Terms for Junior Doctors: Shoot for the Stars
L Nash1,2, A Karageorge1,2, A Llewellyn1, B Kelly3, C Maddocks1, H Sandhu5, J Edwards1,4, D Burke6, K Reynolds1, T Hoang1
1The Health Education and Training Institute of NSW Health, Sydney, NSW, Australia
2The Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
3University of Newcastle, Newcastle, NSW, Australia
4Royal Prince Alfred Hospital, Sydney, NSW, Australia
5Hunter New England Psychiatry Training, Newcastle, NSW, Australia
6St Vincent’s Hospital, Sydney, NSW, Australia
Background: The need of the Australian population for psychiatry services is high, but the desire of the junior medical workforce for psychiatry as a career is low.
Objective: To develop guidelines for psychiatry terms in postgraduate years 1 and 2 (PGY1 and PGY2) to enhance the quality of these terms and to encourage the development of new terms.
Method: An audit was conducted of psychiatry and drug and alcohol terms in PGY1 and PGY2 in New South Wales in 2015 to ascertain number and site. A mixed-methods evaluation of doctors who had recently completed a PGY1 or PGY2 term in psychiatry or drug and alcohol was conducted. Eight focus groups were run and a survey was administered to junior doctors at the completion of their term in 2015/2016. The questionnaire was developed using the focus group preliminary findings and the literature.
Findings: There were 72 potential positions each term across the state. Focus group findings were that positive experiences were associated with a sense of autonomy, having a supervising psychiatrist who was a positive role model, witnessing positive patient outcomes and evidence-based care and having access to appropriate training and a variety of patients. The survey is currently being conducted.
Conclusions: The results of this study will be reported at the Congress and will inform the development of the current and future terms with a clear focus on training and appropriate clinical competencies.
Presenter 2
To Flip or Not To Flip: An Evaluation of the Flipped Classroom Approach for Psychiatry Trainees
L Nash1,2, C Austin1, R Kornhaber3, S Kumar1, T Stone1, B Saglam1, D Brown1, A Harris4, P Boyce4, R He4, L McLean1,4
1Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
2Health Education and Training Institute of NSW Health, Sydney, NSW, Australia
3Faculty of Health, School of Health Sciences, University of Tasmania, Rozelle Campus, Sydney, NSW, Australia
4Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
Background: A flipped classroom delivers teaching prior to class (e.g. via an online module/pre class reading/pre-class activities) and interactive face-to-face learning in class. However, limited evidence exists as to the efficacy of this for medical graduates, in particular postgraduate psychiatry trainees.
Objectives: To compare a flipped classroom approach in one unit of study (Clinical Psychiatry 1) with a traditional teaching style in another unit of study (Fundamental Neuroscience) within the Master of Medicine (Psychiatry) at the University of Sydney.
Method: Psychiatry trainees enrolled in both units were invited to participate in focus groups to discuss their experience of teaching in Clinical Psychiatry 1 which utilised a weekly, assessed, online discussion board prior to face-to-face teaching and specific online pre-learning mood disorder modules compared with Fundamental Neuroscience which was taught in a traditional lecture format.
Findings: In all, 30 psychiatry trainees were eligible for the study. Five took part in the focus groups. Preliminary focus group data indicate that students valued the flipped classroom with high-quality online pre-class learning and in class interaction.
Conclusions: Preliminary results indicate that a flipped classroom approach facilitates student-centred learning. Complete results will be available for presentation at the conference. Flipped classroom and online learning needs to be considered as teaching and learning options for psychiatry trainees.
Presenter 3
The Development of the Sydney Handbook of Mood Disorders
P Boyce1, R Wenchao He1, J Drobny1 and A Harris1,2
1Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
2Brain Dynamics Centre, Westmead Millennium Institute for Medical Research, Westmead, NSW, Australia
Background: Traditional multi-author textbooks are useful resources for academic study but have become less relevant in higher education. Students may avoid traditional texts in favour of Internet material, often adopting notes of a reductive nature, developed in other centres. In this presentation, we discuss an alternate approach to resource development. We harnessed the diversity and expertise of Australian psychiatry and psychology to teach undergraduates and postgraduates about mood disorders via a series of webinars that were then transformed into an Internet-based course and a traditional textbook.
Objectives: To discuss the development and delivery of a multimodal mood disorders teaching resource.
Method: After course development, content experts were approached to deliver webinar module topics designed to take approximately 20–25 minutes and were broadcast as live Internet presentations. Webinars were then edited and developed into an online course, a face-to-face workshop and a textbook.
Findings: In all, 36 national and international experts agreed to contribute to the project covering 49 different topics. During the webinar series presentation, 1687 different individuals logged on, with numbers steadily increasing over time. The related online course received excellent feedback from the limited number of students who have used it as part of the Masters of Medicine (Psychiatry) available at the University of Sydney.
Conclusions: New teaching material is difficult to develop and is frequently limited to a single-medium presentation. This approach has blended methodologies to present the current information from a wide range of experts and made this available across a number of platforms, thereby increasing the potential audience.
Presenter 4
Psychoeducation for Empowerment and Recovery: Harnessing the Power of Massive Open Online Courses
S Kumar1,2,3, L Nash1,4,5, L McLean1,5, C Austin1, T Stone1, B Saglam1
1Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
2Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia
3The Lawson Clinic, Sydney, NSW, Australia
4Health Education and Training Institute of NSW Health, Sydney, NSW, Australia
5Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
Background: Psychoeducation is an essential therapeutic intervention in clinical psychiatry, equipping patients with the valuable commodity of knowledge with which they are able to transform their own experience and move towards recovery. The recovery movement embraces peer-led education, with Australia now beginning to embrace the international trend of opening Recovery Colleges for consumers and carers, combining clinical expertise with the knowledge of ‘experts by lived experience’. Massive open online courses (MOOCs) have experienced rapid growth and have the potential to transform higher education with greater accessibility of knowledge to the community.
Objectives: To harness the potential of MOOCs to deliver community education on a massive scale, providing a psychoeducational course for consumers, carers and those with a professional or general interest in mental health and illness.
Method: The ‘Positive Psychiatry’ MOOC is under development at the Brain and Mind Centre. This will be delivered in a multimodal format incorporating video lectures and readings, integrated with interactive learning features, peer discussions and peer assessment according to current educational principles. There is an emphasis on building positive aspects of mental health for people at risk or at various stages of recovery from mental illness.
Findings and conclusions: Development of online learning requires a complex set of new skills for educators and is labour-intensive. Challenges include maintaining high-quality education for a diverse student group, streamlining the learning outcomes with suitable assessment tasks and moderating discussions in a very large student cohort. 9i end
The National Disability Insurance Scheme (NDIS)
G Smith OAM1, R Harvey2, E Bartnik3
1Western Australian Centre for Mental Health Policy Research, Department of Health, Mt Claremont, WA, Australia
2Barwon Health, The Geelong Hospital, Geelong, VIC, Australia
3National Disability Insurance Agency, Perth, WA, Australia
The National Disability Insurance Scheme is the most significant reform to the Australian health system since the introduction of Medicare. The NDIS is a fundamentally new way for providing support to people living with a disability.
People with psychosocial and intellectual disability are a vulnerable population group, at heightened risk of abuse, exploitation and discrimination. It is essential that a rigorous quality and safeguarding framework is set out ahead of the Australia-wide implementation of the NDIS.
With the NDIS due to be fully implemented by 2017, this symposium will offer a timely opportunity to learn more about the implications of the Scheme and what it means for psychiatrists, consumers and carers. The symposium will also provide an opportunity for delegates to participate in a question and answer session.
Panel Presentation Abstracts
Trainee Representative Committee Enriching the Training Experience 1: A Perspective Utilising the Canmeds Framework
D Ward1,2
1Royal North Shore Hospital, Sydney, NSW, Australia
2Trainee Representative Committee, The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
Background: The development of leadership and management skills has long been recognised as an important aspect of the psychiatry training experience. With the recent move to a CanMEDS-style curriculum, these skills have been formally mapped against the professional, advocate and manager domains.
Objectives: This presentation will be the first of six trainee presentations providing perspectives on enriching the training experience and utilising the CanMEDS framework. Areas covered during this presentation will include a discussion of the process of becoming a representative as well as both the benefits and challenges of the representational experience.
Following the five presentations, there will be a panel discussion with audience participation in order to develop new approaches to enriching the training experience in psychiatry.
Conclusions: Membership of a representative group such as a state-, territory- or New Zealand–based association of psychiatry trainees or the Trainee Representative Committee of the Royal Australian and New Zealand College of Psychiatrists provides trainees with practical opportunities to develop skills in leadership, governance, finance, chairing meetings, policy review and advocacy more broadly. The acquisition of such skills throughout the training process provides career and other benefits for the trainee, their colleagues and our patients.
Trainee Representative Committee
Enriching the Training Experience 2: A Perspective Utilising the Canmeds Framework
K McDonnell1, L Evans2
1Lakes DHB, Rotorua Hospital, Rotorua, New Zealand
2Bay of Plenty DHB, Tauranga Hospital, Tauranga, New Zealand
Background: Supervision is crucially important for psychiatry and has recently come under scrutiny because of the move to a Competency-Based Fellowship Programme (CBFP) in Australasian psychiatry. Under the new curriculum, clinical supervisors critically assess trainees using workplace-based assessments. There is a growing concern that the introduction of formative assessments may change the dynamic of the supervisor–trainee relationship.
We are developing a Stage 3 entrustable professional activity (EPA) on supervision, with specific focus on the supervisory relationship. This will enable trainees to build vital skills in education, management and mentorship, which will be well matched to the CanMEDS competency framework.
Objectives: We will describe the principles of effective supervision – referencing theoretical framework models and examining the numerous dynamic factors that can affect the effectiveness of supervision. We will explore common causes of supervisor trainee difficulties and how a better learning environment can be fostered using educational tools and self-reflective practice. Furthermore, we will explore the link between supervision and trainee welfare, as well as looking at how mentorship can be encouraged and supported through the current supervision structure.
Conclusions: The supervisor–trainee relationship has considerable power to shape future psychiatrists. The Trainee Representative Committee believes that attempting to preserve focus on fostering good working relationships in the supervisor–trainee dyad is fundamental to the success of the CBFP.
Trainee Representative Committee
Enriching the Training Experience 3: Perspectives Utilising the Canmeds Framework
Room to Move? Psychiatric Training in Private Settings
A Taylor
Alfred Health, Melbourne, VIC, Australia
Background: Psychiatrists are in shortage, with this situation projected to worsen if it is not addressed. According to the Australian Government’s National Medical Training Advisory Network (NMTAN), an increase of 16% in psychiatry first-year trainee numbers from 2016 onwards is required to address this shortfall. Any increase in trainee numbers translates to a need for increased training positions.
The discrepancy between the proportion of trainees based in private settings and the proportion of psychiatrists working in the private sector is noteworthy. In all, 55% of psychiatrists work in the private sector, yet the vast majority of training occurs in the public sector. Most psychiatry trainees will complete their training without any exposure to private settings.
Objectives: The aim of this presentation is to review the benefits of training in private settings for both trainees and psychiatry more broadly and to consider pathways through which more trainees can access these opportunities.
Methods: I have been fortunate to access two rotations in the private sector in my training thus far. This exposure has been invaluable and I will describe my personal experiences. In addition, I will explore means by which an expansion of privately based training could occur. I will be reflecting from the position of collaborator and communicator, as per two of the CanMEDS Medical Expert domains on which our competency-based curriculum is constructed.
Findings: I will present on the findings of my personal experience and my research into this area.
Conclusions: The Australian psychiatric private sector is an underutilised source of training experience. The potential benefits of expansion of this field for psychiatry trainees, patients and private services that provide these positions should not be underestimated.
Trainee Representative Committee
Enriching the Training Experience 4: A Perspective Utilising the Canmeds Framework
L Taylor1,2,3
1Neuropsychiatry Institute, Prince of Wales Hospital, Sydney, NSW, Australia
2The University of New South Wales, Sydney, NSW, Australia
3Trainee Representative Committee, Committee For Training, The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, NSW, Australia
Background: The CanMEDS Framework provides overarching structure for the 2012 Competency-Based Fellowship Program (CBFP). Competency in the scholar domain is reflected in the scholarly project requirement. The emphasis on achieving competency as a scholar mirrors the following:
• Critical role of future psychiatrists in the clinical translation of neuroscience research;
• Invaluable nature of clinical research, which cannot be completely subsumed by laboratory neuroscience research.
Clinical research in psychiatry is an identified area of need. Integrating clinical research experience and the commencement of research activity in training can be achieved via numerous avenues, which should be actively sought by trainees. The scholarly project guidelines support the pursuit of such opportunity.
Objectives: This presentation will
• Outline at a pragmatic, individualistic level one approach to integrating clinical research into training and to the establishment of a research project;
• Demonstrate that psychiatry training is enriched through direct engagement with the research process;
• Highlight the CanMEDS domain of scholar/researcher in this context;
Methods: The information presented will reflect personal training and peer experience.
Conclusions: Transition to the CBFP and the integral requirement to achieve competence as a scholar will actively foster trainee engagement in clinical research. Mandating this research requirement supports the development of greater trainee research opportunities at the clinical interface and within the context of service provision.
The current climate provides an opportune moment to maximise such opportunities with benefits at the individual trainee level through enrichment of training and, more broadly, in shaping the future landscape of clinical psychiatry.
Enriching the Training Experience 5: Perspectives Utilising the Canmeds Framework
Enriching the Trainee Experience with Extra-Clinical Volunteer Work in Non-Government Organisations and Web-Based Social Movements
JP Kwasik1,2,3,4
1RANZCP Trainee Representative Committee, Melbourne, VIC, Australia
2Young Psychiatrists Network, Athens, Greece
3Movement for Global Mental Health, Delhi, India
4NCDFREE, Melbourne, VIC, Australia
Background: Globalisation and the growth of mental health–related non-government organisations (NGOs) and web-based social movements have provided an opportunity for trainees to access novel experiences to develop non-clinical skills. There is a growing interest among trainees in public mental health and social change.
Objectives: This panel discussion will highlight several Trainee Representative Committee members’ work outside of the regular trainee experience. The panel members will cover the domains of the CanMEDS Physician Competencies Framework. My presentation will provide stimulus for trainees to consider advancing their skills in the domains of Health Advocate and Leader by finding opportunities to volunteer in public health and NGOs.
Methods: I have worked in the Department of Mental Health and Substance Abuse, World Health Organization (WHO), Geneva, and with the previous Melbourne-based Secretariat of the Movement for Global Mental Health. I am now involved with the Young Psychiatrists’ Network as the Country Co-ordinator for Australia and also with NCDFREE, a social media-based movement against chronic disease. I will provide a brief summary of my experiences working in these organisations and provide other examples available to trainees.
Findings: Extra-clinical experiences such as WHO internships and web-based social movements can enrich a trainee’s development, thereby providing skills that can be utilised within the College and also in the public and non-government sectors. Royal Australian and New Zealand College of Psychiatrists and Hong Kong trainees can play a role in fostering mental health advocacy in the Asia Pacific region.
Conclusions: Extra-clinical work that helps to develop trainee’s abilities in the domains of Health Advocate and Leader can be a valuable addition to the traditional registrar experience.
Enriching the Training Experience 5: A Perspective Utilising the Canmeds Framework
Psychiatric Trainee Representation, Global Perspectives
G Matta
St Vincent’s Mental Health Service, Melbourne, VIC, Australia
Background: There is a growing emphasis on global mental health. The experience of psychiatric trainees globally is diverse, and international collaboration can enrich learning experiences. Advocacy for trainees by trainees can shape the future of psychiatry locally and in an international arena.
Objectives: This talk will describe the goals of international trainee representation, referring to successful organisations such as the European Federation of Psychiatric Trainees (EFPT), and specifically proposes the establishment of an Asia Pacific network of psychiatric trainees.
Conclusions: There are a number of positives to be gained by international psychiatry trainee representation including cross-national research opportunities, possibility of exchange programmes, networking, promoting a positive image of psychiatry and building capacity for trainees, particularly in low- and middle-income countries.
A Global Outlook on the International Migration of Psychiatrists
E Guaia
Princess Margaret Hospital, Perth, Australia
An International Workforce in Psychiatry: Concepts and Recent Tendencies
C Zubaran
Western Sydney University, Sydney, Australia
The international migration of health care professionals has been recognized as a public health concern. A series of ‘push’ and ‘pull’ factors have been identified as a major driving force for migration of doctors. The USA, UK, Canada and Australia are the main beneficiaries of medical migration, which generates adverse consequences on health care systems in developing countries. Research evidence also reveals that international medical graduates (IMGs) face discriminatory obstacles to exercise their rights and professions in the countries they chose to practice. In order to address these challenges, the WHO Global Code of Practice on the International Recruitment of Health Personnel was adopted in 2010. The Code aims to promote voluntary principles and practices for the ethical international recruitment of health personnel and to facilitate the strengthening of health systems.
In Australia, IMGs face significant obstacles, including hindrances to obtain medical registration, and insufficient orientation about local work protocols. These hindrances were the object of a parliamentary inquiry, although the resulting recommendations have not yet been implemented. Yet, there has been significant development in the field of psychiatry, with the creation of new pathways to enable IMGs to obtain the due recognition as specialists. These advancements have evolved from advocacy initiatives by overseas trained psychiatrist as well as an improved dialogue between the College of psychiatrists and the overseas trained doctors it also represents. The scenario in Australian will be contrasted with the state of affairs both in the USA and Europe.
Conclusions: An international strategy is required to promote sustainable health care systems worldwide. Additional academic and scientific partnerships must be established between developed and developing nations in order to minimize discrepancies. There is an urgent need to review policies related to the recognition of IMG’s professional credentials. The recent advancements in Australia may indicate future directions in this filed.
Brain Drain in Junior Doctors Training In Psychiatry across Europe
M Pinto da Costa
Hospital de Magalhães Lemos, University of Porto, Porto, Portugal
Introduction: Migration of health professionals is influencing health services across countries. Data on medical migration in Europe is very limited, particularly concerning young doctors and psychiatry. To research this hot topic, the European Federation of Psychiatric Trainees (EFPT) conducted the Brain Drain study.
Objectives: To identify the impact of previous short-term mobility on international migration and to understand characteristics, patterns and reasons of migration, as well as trainees‘ perception of this migration.
Methods: In this cross-sectional European multicentre study, data were collected from 2281 psychiatric trainees across 33 countries. All participants answered to the EFPT Brain Drain survey reporting their attitudes and experiences on migration.
Results: Two-thirds of the trainees had not had a short-mobility experience in their life, but those who went abroad were satisfied with this mobility, reporting its influence in their positive attitude towards migration. Despite the majority of trainees did not have a migratory experience of more than one year, flows showed that Switzerland, United Kingdom and Sweden are amongst the countries with the greatest number of immigrant trainees. ‘’Push factors’’ to leave the country were mainly: academic and financial, whereas ‘’pull factors’’ to stay in their country were mostly academic and personal reasons.
Conclusions: The majority of trainees has considered leaving the country they currently lived in, and those that wanted to leave the country were significantly more dissatisfied with their income and most likely had previous short-mobility experiences.
Is Australia an IMG Friendly Destination? An Overview of Past, Present and Future IMG Issues
N Yakoub
Caulfield Hospital, Caulfield, Victoria, Australia
Monash Health, Victoria, Australia
The last decade has witnessed major changes in rules and regulations governing the registration process of overseas trained psychiatrists in Australia. The country remains heavily reliant on international medical graduates, particularly in rural and remote areas. This presentation provides an overview of the past and present with an outlook into the future of Australian IMGs. The focus will be on the progress made so far and the areas that need further attention from an IMG perspective. The much-debated 10-year moratorium will also be discussed in more details.
The Overseas Trained Psychiatrist Committee, an Overview of Achievement and Aspirations
E Guaia
Princess Margaret Hospital, Perth, Australia
Oral Presentation Abstracts
Towards European Psychiatry: Activities of the European Psychiatric Association
W Gaebel
European Psychiatric Association (EPA), Strasbourg, France
Background: The European Psychiatric Association (EPA) is the main association representing psychiatry in Europe addressing the interests of psychiatrists in academia, research and practice.
Objectives: EPA’s mission is to improve psychiatry throughout Europe. EPA’s activities address the interests of psychiatrists in academia, research and practice throughout all stages of career development.
Methods: In the scope of its action plan 2015–2016, EPA has established a number of initiatives towards European Psychiatry.
Findings/key activities: A close collaboration between EPA, the European Commission and the Joint Action on Mental Health and Well-Being (JAMHWB) Consortium has been established, specifically in the field of community-based mental health care.
In the field of education, EPA, European Union of Medical Specialists (UEMS), European Federation of Psychiatric Trainees (EFPT) and the World Health Organization (WHO) regional office for Europe have launched the Task Force on Education in European Psychiatry to work towards harmonization of psychiatric training curricula.
The EPA Guidance project supports the implementation of the WHO European Mental Health Action Plan (EMHAP) by developing guidance for the optimization of European mental health care and by identifying appropriate mental health service models. The implementation of EPA Guidance in European member states is one of the goals of the association.
One of EPA’s main aims is to foster the dialogue between professionals, policy makers, scientists, patients and their families and other interest groups. The annual EPA Forum is intended to bring together representatives of these groups to strengthen discussion and exchanges between them.
Conclusions: EPA’s action plan 2015–2016 covers a broad variety of activities related to the association’s mission to improve psychiatry throughout Europe. Together with other partners, the initiated projects foster interests of psychiatrists in academia, research and practice throughout Europe and beyond.
Current Status and Problems of Child and Adolescent Psychiatry in Japan
T Saito
Hokkaido University, Sapporo, Japan
Background: Despite the general consensus on the importance of child and adolescent psychiatry, the difficulty of access to child and adolescent mental health services is prominent all over the world. In Japan, particularly, there has been an increased need for child mental health services. However, there is a tremendous amount of unmet need. Mental health is an essential part of children’s and adolescents’ health, and lack of access to child and adolescent mental health services affects quality of life in children
Objectives: This paper reviews the current trends in child and adolescent psychiatry in Japan in order to develop solutions.
Methods: The authors will systemically review and summarize published articles on these issues and the current standpoint of the Japanese government on child and adolescent mental health services.
Findings: Child and adolescent psychiatry is not recognized as subspecialty, and there is no standardized training program in Japan. The lack of basic infrastructures most likely leads to lack of work force, lack of training facilities, access to child and adolescent mental health services and off-label medication issues in Japan.
Conclusions: In contrast to the United States, European countries, Australia and New Zealand, a lack of a standardized training program is a critical problem in Japanese child and adolescent psychiatry. The authors hope to develop a standardized training system and promote its implementation to solve the current problems in child and adolescent psychiatry in Japan.
Pharmacotherapy for Depression and its Transition in Japan
Y Ogushi1, H Kawasaki1, N Shinfuku2
1Department of Psychiatry, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
2Kobe University, Kobe, Japan
Background: Recently, the number of patients who suffered from depression is increasing in Japan. As the population ages, depression in elderly individuals is also getting to be popular. In addition, high suicidal rate is a big issue, which is strongly associated with symptoms of depression. Therefore, treatments for depression are responsible more than ever.
Objectives: To determine the trends and changes in prescribed antidepressants, we investigated the prescription pattern of antidepressants among selected hospitals in Japan in 2013. This is a part of international collaborative study, ‘Research on East Asia Psychotropic Prescription Patterns for Antidepressants 2, REAP-AD 2’.
Methods: In this survey, six teaching hospitals and major psychiatric hospitals in Japan participated and the data from 246 Japanese patients receiving antidepressants were analyzed. The samples were from inpatient and outpatient groups. Data were collected according to a standardized protocol agreed to by all hospitals. Multiple logistic regression analysis was used to examine the factors associated with antidepressant use among patients.
Findings: We found that there is majority of patients on newer antidepressants in Japan, and the rate of concurrent use of hypnotics and anxiolytics was high. At the symposium, we would like to show the more detailed characteristics of the antidepressant prescription pattern in Japan, with a focus on the aging population and suicide ideation.
Conclusions: We suggest the necessity for continuous monitoring of the use of antidepressants and other psychotropic agents, which provides us with useful information on the selection of drugs and for improving prescription patterns in the future.
Translating Cognitive Stimulation Therapy for People with Dementia: Experiences from New Zealand and Hong Kong
K Peri1, G Wong2, G Cheung1
1University of Auckland, Auckland, New Zealand
2The University of Hong Kong, Hong Kong
Cognitive stimulation therapy (CST) is a structured and manualised group treatment developed for people with mild-to-moderate dementia. It involves 14 themed sessions and is designed to run twice a week over a 7-week period. Sessions are aimed to actively stimulate and engage people with dementia, while providing an optimal learning environment and the social benefits of a group. A recent Cochrane review concludes that cognitive stimulation programmes can benefit cognition in people with mild-to-moderate dementia over and above medication effects, while the improvements in quality of life and well-being were promising. Developed in the United Kingdom, CST has now been adopted in 26 countries. Despite its evidence base, CST is not routinely available in New Zealand (NZ) or Hong Kong (HK).
The aim of this article is to summarise the translation of CST in NZ and HK. In NZ, the translation includes a feasibility study, development of a competency framework, training of CST facilitators and supporting dementia organizations/services to implement the treatment. We are also developing a novel intervention of combining cognitive stimulation and physical activities.
A similar process following the Formative Method for Adapting Psychotherapy is being adopted in HK, which involves generating knowledge and collaborating with local stakeholders in dementia care, and identifying implementation strategies, taking into account cultural and setting issues such as high illiteracy rates among elders. In addition, a pilot study of the translated and localised version of CST in mild Alzheimer’s disease is being conducted to investigate predictors and pathways of change.
The Symphonie Fantastique: Three Victims’ Stories With Respect to a Person Affected by Pseudologia Fantastica
R Parker1,2
1School of Medicine, Flinders University, Adelaide, SA, Australia
2Northern Territory Medical Program, Darwin, NT,Australia
Background and objectives: To review the impact of a person affected by pseudologia fantastica on three women with whom the person had interaction with in the workplace and the community. The progress of the interaction with the victims is considered in the context of Hector Berlioz’s Symphonie fantastique.
Methods and findings: The person affected by pseudologia fantastica had a profound emotional impact on three women who were roughly the same age and body type and who became known to the author. All the victims have given their consent for their stories to be told. The first two victims, both fellow health professionals, were significantly affected in an emotional and social sense. The third victim was so distressed by the attention of the affected person that she attempted suicide.
Conclusions: Pseudologia fantastica (Birch et al., 2006) is a rare psychiatric condition that can have major, potentially fatal, effects on the victims of the disorder. The forensic implications of the condition need to be further considered.
Reference
Birch C, Kellin B and Aquino E (2006) A review and case report of pseudologica fantastica. The Journal of Forensic Psychiatry and Psychology 17: 299–320.
Using Online Data in the Assessment of Psychiatric Impairment
P Young, B Webber
Sententia Discovery, Sydney, NSW, Australia
Background: Assessment of psychiatric impairment and/or disability has traditionally relied on self-reporting with limited access to objective data. This approach has significant limitations, particularly in worker’s compensation and other medico-legal contexts. Rapid adoption of social media as a means of communication and documentation of everyday interactions, as well as availability of other online data, provides a new and rich source of information that directly relates to dimensions of psychiatric function and disability.
Objectives: To develop a methodology for collecting, categorizing and interpreting online data related to real-world functioning that can provide objective information useful for clinical assessment of psychiatric impairment particularly in the context of worker’s compensation psychiatric injury claims.
Methods: We collected and categorized publicly available online data from a wide variety of sources, including social media networks, for 400 individuals who had submitted psychiatric injury claims and who had at least one psychiatric report with a completed Psychiatric Impairment Rating Scale (PIRS) by a qualified assessor. We compared observations of functioning demonstrated in online data against self-reported impairments described in clinical assessments.
Findings: We found that more than 80% of cases had sufficient available online data that were relevant to one or more domains of functioning/impairment. In 79% of these cases, we found objective observations that were contradictory or inconsistent with the degree of reported impairment in one or more PIRS categories. In 25% of cases, the level of contradictory and inconsistent observations was sufficient to support a diagnosis of malingered impairment.
Conclusions: Collection and analysis of online data is a new and useful methodology that can provide valuable objective information to assist in clinical assessment of psychiatric impairment, particularly in medico-legal and worker’s compensation settings.
The Complex Case Clinic: A Family-Focused Approach to Two-Generation Mental Illness in Families Known to Child and Youth Mental Health Services
A Falkov1,2, B Hoadley2, N Agalawatta2
1Westmead Hospital (Redbank House), Sydney, NSW, Australia
2Royal North Shore Hospital, Sydney, NSW, Australia
Background: Children and young people, particularly those with emotional, behavioural or chronic physical difficulties, can precipitate or exacerbate mental ill health in their parents/carers. In turn, adult/parental mental illness can adversely affect the development, mental health (MH) and, in some cases, the safety of offspring. These reciprocal influences between family members are well described but insufficiently incorporated into assessment and management.
There are, therefore, compelling reasons for a broader approach to achieving a family focus, which incorporates both parenting and MH needs of adult carers as well as offspring MH and well-being, across all MH services.
Objectives: This paper will describe preliminary results from the first 6 months of a pilot study (complex case clinic) in a public sector Child and Youth Mental Health Service in Northern Sydney. The focus is on families in which there are two generations experiencing mental ill health (the referred/index young person and at least one parent/carer).
Methods: The conceptual approach is based on The Family Model which provides a visual illustration of the six key elements (domains) and associated connections (arrows) involved in understanding the interplay between symptoms and relationships and the reciprocal role of relationships in determining both good and poor outcomes for all family members.
Findings: Quantitative and qualitative data will be presented to illustrate clinical outcomes for family members, as well as carer/consumer and clinician experience using The Family Model approach.
Conclusions: Implications for practice will be discussed with particular emphasis on barriers and facilitators to implementing greater family focus in service delivery.
Comparing the Time-Course of Efficacy of Lisdexamfetamine Dimesylate and Osmotic Controlled-Release Methylphenidate in Children and Adolescents with ADHD
D Coghill1, P Nagy2, G Frick3, N Naser4, J Wu3,J Newcorn5
1Division of Neuroscience, University of Dundee, Dundee, UK
2Vadaskert Child and Adolescent Psychiatry Hospital and Outpatient Clinic, Budapest, Hungary
3Shire, Wayne, PA, USA
4Shire, Sydney, NSW, Australia
5Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Background: Lisdexamfetamine dimesylate (LDX) and osmotic controlled-release methylphenidate (OROS-MPH) are stimulant treatments for attention deficit hyperactivity disorder (ADHD).
Objectives: To compare the time-course of the efficacy of LDX and OROS-MPH in children and/or adolescents with ADHD in three short-term (6–8 weeks), randomized, controlled trials.
Methods: In the studies SPD489-405 (flexible-dose) and SPD489-406 (fixed-dose), the efficacy of LDX (30–70 mg) and OROS-MPH (18–72 mg) was compared head-to-head in adolescents (13–17 years). The study SPD489-325 (flexible-dose) included children and adolescents (6–17 years) and LDX (30–70 mg) and OROS-MPH (18–54 mg) were compared post hoc. Participants were randomized 2:2:1 to LDX, OROS-MPH and placebo in SPD489-405/406 and 1:1:1 in SPD489-325. ADHD Rating Scale IV (ADHD-RS-IV) total scores were assessed at each study visit.
Findings: The differences (LDX − OROS-MPH) in a least-squares mean (95% confidence interval) changed from baseline: ADHD-RS-IV total scores were statistically significant at week 1 in all three studies (SPD489-405, −2.6 [−4.5, −0.8], p = 0.0047; SPD489-406, −2.0 [–3.8, −0.3], p = 0.0242; SPD489-325, −3.3 [−5.9, −0.6], p = 0.016), at week 6 in SPD489-406 (−3.4 [−5.4, −1.3], p = 0.0013) and at endpoint in SPD489-325 (−5.6 [−8.4, −2.7], p < 0.001), but not at week 8 in SPD489-405 (−2.1 [−4.3, 0.2], p = 0.0717). Safety profiles were consistent with those from previous studies.
Conclusions: LDX was associated with greater improvements in ADHD symptoms than OROS-MPH at week 1 in all three studies, at week 6 in SPD489-406 and at endpoint in SPD489-325, but not at week 8 in SPD489-405.
Funding
Studies were funded by Shire Development LLC.
Feasibility and Acceptability of an Online Self-Help Programme for Managing Eating Disorders in a University Health Clinic
SF Leung1, LC Ma2, J Russell3
1The Hong Kong Polytechnic University, Hong Kong
2The Chinese University of Hong Kong, Hong Kong
3The University of Sydney, Sydney, NSW, Australia
Background: Eating disorders are a global health problem with significant impact on individuals’ bio-psycho-social well-being. Self-help approaches coupled with individual interventions offer therapeutic promise. Numerous studies have shown that Internet-based self-help programmes have been effective in preventing and facilitating recovery from eating disorders, but their feasibility and acceptability in managing eating disorders in Hong Kong are unknown.
Objectives: This study aims to examine the feasibility and acceptability of an Internet-based self-help programme, Smart Eating, developed in the Asia Pacific region for improving individuals’ eating disorder psychopathology, psychological health, quality of life and motivational stages of change.
Methods: It is an ongoing trial. Participants above the age of 16 years with an eating disorder are recruited from an integrative health clinic at The Hong Kong Polytechnic University. They are randomised to either an intervention group receiving standard care plus the entire self-help programme or a control group receiving standard care with access only to the standard education provided in the programme without self-help training.
Findings: There were over 11,200 hits on the programme website in the past 6 months (April–October). Nineteen females from a non-target sample outside Hong Kong and seven females from the university clinic target sample registered in the programme. The target sample has 100% participation rate in the programme for online self-assessment. Their completion rate and compliance with the programme are pending for evaluation.
Conclusions: The preliminary findings from a small sample show that the self-help programme is feasible and acceptable for managing eating disorders. Further evaluation will be required.
When Art Meets Psychiatry
B Mijatovic, N Rupena
Mental Health Service, Bay of Plenty District Health Board, Tauranga, New Zealand
Background: The interface between art and psychiatry has always been significant and dates back over hundreds of years. Many aspects of artistic practice continue to explore territory similar to that explored by psychiatry, although from a different perspective and with different methods.
Objectives: What a portrait drawing and the answer to a single question can tell us about a person.
Methods: The young artist Nina Rupena had approached people on the streets in several metropolitan cities in Australasia and asked the question, ‘What do you wish you had known when you were younger?’ She then drew quick 10 × 15 cm portraits with their consent and recorded their answers.
Findings: People across different cultures, ages and social status were generally willing to participate in this project and share the wisdom and experience of their lives in one single answer.
Conclusions: Despite the hustle and bustle of our daily lives, when approached with an existential question, people are able to quickly identify their most important values in life. We would share those pictures and answers with you, in order to encourage you to consider your own meanings and think about how this could relate to the practice of psychiatry.
Are Psychiatrists Really Compassionate?
AT Fernando III, NS Consedine
University of Auckland, Auckland, New Zealand
Background: Compassion is an expectation of patients, regulatory bodies and physicians themselves. The Transactional Model of Physician Compassion suggests that physician, patient, external environment and clinical factors are all relevant. Because these factors vary both across different specialties and among physicians with differing degrees of experience, barriers to compassion are also likely to vary.
Objectives: We describe barriers to physician compassion as a function of specialization (psychiatry, general practice, surgery, internal medicine and pediatrics) and physician experience. We used a cross-sectional study using demographic data, specialization, practice parameters and the Barriers to Physician Compassion Questionnaire. In all, 580 New Zealand doctors were recruited, of whom 444 belonged to the targeted specialty groups.
Methods: Recruitment was by non-random convenience sampling. The sample was characterized before conducting a factorial multivariate analysis of variance (MANOVA) and further post hoc analyses. We found that a 5 (specialty grouping) × 2 (more versus less physician experience) MANOVA showed that the barriers to physician compassion varied as a function of both specialty and experience. In general, psychiatrists reported lower barriers in contrast to general practitioners and internal medicine specialists who reported greater barriers. Barriers were generally greater among less experienced doctors, but only significantly so among surgical and internal medicine specialties.
Conclusions: Documenting and investigating barriers to compassion in different specialty groups have the potential to broaden the current foci beyond the physician and inform interventions aimed at enhancing medical compassion. In addition, certain aspects of the training or practice of psychiatry that enhance compassion may mitigate barriers to compassion in other specialties.
Genetic Tests in Psychiatry, Ready for Prime Time?
A Singh1, C Bousman2, G Malhi3, S Sundram4, S Tian-Mei5, V Palmer6, L Sheffield7, C Ng2, M Hopwood2
1School of Medicine, Deakin University and Baycrest Biotechnology Pty Ltd, Geelong, VIC, Australia
2Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
3Department of Psychiatry, The University of Sydney, Melbourne, VIC, Australia
4Department of Psychiatry, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
5Peking University Institute of Mental Health, Beijing, China
6Department of General Practice, The University of Melbourne, Melbourne, VIC, Australia
7Victorian Clinical Genetics Services, The University of Melbourne and GenesFX Health Pty Ltd, Melbourne, VIC, Australia
Background: In the same year as the Human Genome Project was completed, the role of the serotonin transporter in depression was demonstrated. Yet 13 years later, widespread clinical use of genetic tests has not arisen. Given diminishing genotyping costs, companies globally have been offering genetic tests. But mixed views about their clinical utility exist – some recent guidelines suggesting consideration of such tests, other reviews advising caution. What should clinicians make of it all?
Objectives: The issues to be covered are as follows:
1. What are genetic tests in psychiatry?
2. Could they help?
3. Could they harm?
4. What is the current evidence?
5. What evidence may still be need?
6. What to advise patients wanting testing?
7. How to handle patients who get tested (without telling their doctor) and then seek advice?
8. What are the ethical issues?
9. Where do panelists see things moving in coming years?
10. Would panelists get/recommend testing, why/why not?
Methods: The sides for and against will nominate two speakers per side who will deliver succinct 10- to 15-minute talks based on supporting peer-reviewed literature (60 minutes). A panel discussion (30 minutes) with incorporated audience question cards shall follow. The panel was selected to have a range of experiences – clinical, research and commercial, with mixed views on the readiness for this technology to enter routine clinical practice. A balanced yet lively debate is ensured.
Findings and conclusions: The audience will gain a greater sense of the current state of the evidence, emerging trends, and ethical and regulatory dilemmas and have a better sense of how to handle patient enquiries about such testing.
Making the Best of it: The Reality of in Vivo Research
V Kemp1, C Fisher1, S Lawn2, M Battersby2, M Isaac1
1The University of Western Australia, Perth, WA, Australia
2Flinders University, Adelaide, SA, Australia
Background: It is well known that the physical health of people living with mental illness is poor and their health outcomes are worse than for people in the general community. Many have physical health comorbidities adding a substantial burden of disease in this already vulnerable population.
Objectives: A controlled trial of the Flinders Program of Chronic Condition Management™ (FP) was utilized to test the hypothesis that people with mental illness living in the community could be supported by their FP-trained non-government mental health support workers to self-manage their physical health co-morbidities.
Methods: At the intervention sites, 18 clients of the trained workers used the FP tools to set goals to address the health issues of clients. At the control sites, workers provided treatment as usual to 10 clients. The project was hampered by a coincidental restructuring of mental health services in Western Australia, during which there was a change in policy direction; organizational restructuring led to a high staff turnover. This accounted for the inability to recruit more participants.
Findings: Clients in the intervention group did make significant gains in some, but not all, domains of the FP. The level of support clients received depended on the service structure of the participating organizations.
Conclusions: At this time, our data suggest that the government mental health services lack the capacity to routinely monitor clients for the metabolic syndrome, and the non-government sector lacks the necessary capacity to adequately support clients to self-manage their physical health. However, there were encouraging indications that the FP might be a successful intervention under more benign circumstances.
Forced Adoption: Clinical Implications and Treatment Guideline
Harry Lovelock1, Maurice Eisenbruch2,3
1The Australian Psychological Society, Melbourne, Victoria, Australia
2School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
3Royal University of Phnom Penh, Phnom Penh, Cambodia
Background: Forced adoption policies and practices in Australia have had significant and long-term psychological effects on mothers, fathers, their children who were adopted and their families with higher rates of mental health disorders such as depression, anxiety, post-traumatic stress disorder and thoughts of suicide.
Objective: To provide an overview, based on a review of the evidence, consultations with stakeholders and expert review, of best practice psychological and psychiatric interventions for people affected by forced adoption practices in Australia.
Method: A review was undertaken of the three major reports on the experiences of people affected by forced adoption in Australia. An expanded literature review was completed. A series of individual consultation meetings with people affected by forced adoptions, representative organisations and agencies delivering support services were conducted across all Australian capital cities. An Expert Reference Group with representatives from the major mental health professions provided review and advice.
Findings: A Guidance document was developed that provides the emotional and psychological effects of forced adoption policies and practices on those affected; the evidence-based theoretical frameworks useful for guiding practice, including the conceptualisation of the experience of forced adoption within a framework of trauma, loss and grief and attachment theory; the effects of trauma and appropriate trauma-informed care for people affected by forced adoption; and evidence-based practice with people affected by forced adoption.
Conclusions: Clinicians need to understand the experiences and effects of those affected by past adoption policies and practices in Australia and how to provide evidence-informed practice as detailed in the Guidance document.
Family Healing
K Paxinos
1North West Area of Mental Health, Melbourne, VIC, Australia
Background: The topic of my presentation is ‘family healing’. I will tell the story of how our family has learned to live well when one member experiences the symptoms of schizophrenia. The anguish we all experienced and how each one of us reached the path of acceptance will be explained.
Methods: Throughout the story, I will discuss my experiences with families working as a carer/consultant within the Victorian Mental Health System. Many of these families were from multicultural communities. Their family values, cultures and religious beliefs brought challenges.
Objectives: My story will discuss how important it is for all clinicians working in the mental health system to understand these differences. I will talk about the concept of independence as it affects these communities.
Findings: Education for families is important. Communication with the family must be part of the treatment plan, and all clinicians understand and accept this. I will demonstrate personal experiences when the communication between me and the clinician was effective and not effective.
Conclusions: Mental health problems are increasing. Funding is inadequate, so the responsibility of caring has to be undertaken mostly by family members. I will demonstrate ideas for helping the family to be able to cope with caring responsibilities.
Effective communication and creating an atmosphere of understanding within the family must be part of training.
The last part of my talk is titled, ‘I welcome you all to my home’.
Mass Psychogenic Illness (MPI) - Mass Fainting in Cambodia
Maurice Eisenbruch1,2
1School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
2Royal Phnom Penh University, Phnom Penh, Cambodia
Background: Mass psychogenic illness (MPI) is an important phenomenon and is poorly understood in its cultural context. Mass fainting in garment factories in neo-liberal Cambodia is an escalating phenomenon, and its nature remains an enigma. It has been thought to be an MPI.
Objectives: The paper reports the first culturally coherent exploration of factory workers’ experiences and interpretations of mass fainting with a view to understanding MPI.
Method: Ethnographic research was undertaken in factories, clinics and temples in 2010–2015 in 45 factories in eight provinces and Phnom Penh. Participant observation of affected women, monks, factory managers and health workers explored the informants’ ‘lived’ experience of mass fainting, their cultural understandings and ritual treatments.
Findings: Episodes occurred in 34 factories, 25 fainting and 9 spirit possessions triggering it. Women attributed fainting to toxins or to supernatural causes, such as haunting ghosts at factory sites stained by Khmer Rouge atrocities, recent fatal accidents, or to local guardian spirits violated by foreign owners. Workers witnessing a co-worker fainting or being possessed felt fear and had difficulty breathing, momentary stupefaction and fainted in a cascade. When taken to clinics, some showed signs of continued ghost or spirit influence. Afterwards, monks performed cultural treatments to appease guardian spirits, extinguish bonds with ghosts and prevent recurrence.
Conclusions: Mass fainting is a singular phenomenon with motifs of contagion, forebodings, the bloody Khmer Rouge legacy, trespass as provocation, and fear and protest. The research, interweaving personal-psychodynamic and socio-cultural perspectives, is the first to capture the rich tapestry of mass fainting. The findings shed light on MPI in a cultural context.
Dracula and Psychiatric Practice
D Johns
Private Practice, Byron Bay, NSW, Australia
An illustrated PowerPoint presentation and talk by a psychiatrist in private practice in Byron Bay for the past 25 years.
First presented with a great response to my local peer review meeting in July 2014, this paper is a thought-provoking examination of the inner workings of psychiatry, how it has been portrayed in books and films and what practitioners like us can learn from this.
The paper discusses the ways in which psychiatric disorders have been portrayed in film through characters such as Cora Smith in the Postman Always Rings Twice and Norman Bates in Psycho. It brings recognition to film makers and authors who have increased our understanding of pathological human behaviour in books and films such as Silence of the Lambs and American Psycho. All these characters from the creative imagination can have a profound influence on the practice of day-to-day psychiatry and aid in the communications, indeed understanding, between patient and practitioner.
One of the most interesting creations is found in Bram Stoker’s Dracula. Written entirely in a London library, the book takes you on a journey into Transylvania and into a world of blood-sucking vampires. As Dracula is sucking blood from his victims and slowly draining them of life, is this not also a metaphor for the psychopathic individual sucking the emotions from those around them? While portraying the ultimate serial killer, Dracula is also a symbolic representation of emotional vampirism. This relates directly to the kinds of issues raised almost daily in the treatment of my patients.
The Role of the Psychiatrist in the Modern Mental Healthcare System
B Singh1,2,3,4
1Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
2The Melbourne Clinic, Melbourne, VIC, Australia
3NorthWestern Mental Health, Melbourne, VIC, Australia
4Eastern Health, Melbourne, VIC, Australia
Background: The author recently retired from senior academia and clinical leadership positions in mental health after a total of 45 years of working in mental health.
Objectives: To describe the major changes in the health and mental health systems over the past four decades and how they have affected the role of the psychiatrist.
Methods: Literature review supplemented by personal observation and anecdotes.
Findings: The role of the psychiatrist in the public mental health system is very different from 40 years ago and continues to evolve. The CanMEDS model is one way of describing the skills the psychiatrist needs to cope with this changing role.
Conclusions: Specific training modules need to be developed to assist psychiatrists to play these roles to supplement the college’s specified program in leadership and management for advanced trainees.
Collaborative Integration of Peer Support with Routine Clinical Care in Mental Health Rehabilitation: Describing a Novel Service Model and Lessons Learned in Implementation
S Parker1,2, F Dark1,2, G Vilic1, C Doyle1, B Lendich1, K McCann1, R O’Sullivan1
1Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
2School of Public Health, The University of Queensland, Brisbane, QLD, Australia
Background: Mental health policy and emerging evidence creates an imperative for the availability of peer support as part of routine care for mental health consumers. Public mental health services have been slow to adopt such roles, and where these have been made available they may be tokenistic, limiting the potential value to consumers, clinicians and services. A novel integrated staffing model designed to facilitate meaningful collaboration between peer support workers and clinical staff in the delivery of care at community-based residential mental health rehabilitation units is described, and the initial experience through implementation of this model is explored.
Objectives: Dissemination of information about a novel staffing model working to achieve synergistic gains in mental health rehabilitation through collaboration between peer support and clinical staff within a unified team.
Methods: The integrated staffing model operating at two community care units is described with reference to the rationale of this model, its key features and underlying philosophy, and the experience and lessons learned through implementation.
Findings: The integrated staffing model has implications for the ways both clinical and peer worker staff work, and consumers experience the rehabilitation process.
Conclusions: The novel integrated staffing model may provide an avenue to increase the meaningful availability of peer support in public mental health service delivery.
Who Uses Community-Based Residential Mental Health Rehabilitation Services in Australia
S Parker1,2, F Dark1
1Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
2School of Public Health, The University of Queensland, Brisbane, QLD, Australia
Background: Community care units (CCUs) provide community-based residential mental health rehabilitation in Queensland and Victoria. These services were introduced in the context of deinstitutionalization and were initially intended to provide a home for life. Over time, the focus of these units changed, with them increasingly providing transitional rehabilitation rather than habitation and support. There has been limited recent research examining these service models, and it has been hypothesized that these units are now primarily serving new long-stay consumers rather than those who were formerly institutionalized.
Objectives: To establish the characteristics of the consumers currently utilizing community-based residential rehabilitation services in Australia.
Methods: A cohort of consumers entering three CCUs in Brisbane, Australia, over a 12-month period (2015) is described. Demographic and clinical characteristics are presented, including consideration of social and cognitive functioning. The implications of the cohort characteristics are considered with reference to the existing model of service.
Findings: Most of the consumers commencing at the CCU do not have a prior experience of long-stay institutional care. The majority of consumers have a diagnosis of schizophrenia and related disorders, and there are significant comorbidities including substance use, personality disorders and autistic spectrum disorders.
Conclusions: CCUs service a different consumer group to the one originally intended. Increased clarity around the nature of the deficits and comorbidity identified in the current consumer group creates an opportunity to review and refine the current service models to achieve improved outcomes.
Ways of Knowing: Psychotherapy in Culture and Culture in Psychotherapy
M Eisenbruch
School of Clinical Sciences, Monash Health, Melbourne, VIC, Australia
Background: Almost half of Australia’s people have non-English-speaking background, but psychotherapy remains geared to the mainstream and ignorant of the stamp of culture.
Objectives: To develop an exposition of a culturally responsive framework for psychotherapy in Australia and in the region.
Methods: The presentation is based on 35 years’ experience as a psychotherapist–anthropologist in multicultural Australia and Cambodia.
Findings: The cultural cornerstones of a culturally responsive psychotherapy are presented. These include attachment theory, loss and bereavement; sanity and madness; the biological basis of mind such as cultural neuroscience; excavations of mind, especially dream analysis; local notions of cause and effect such as contagion; structures of emotion such as anger; idioms of distress as seen in dissociative states; the preternatural, shown in possession states and demonology; family therapies with ancestors; local forms such as traditional healing or religious interventions; and evil as manifested in wholesale violence against women and children.
Conclusions: A culturally responsive psychotherapy allows the clinician to identify what matters to the patient as a participant in multicultural Australia and in a global world.
Review of Psychiatric Liaison Services Provided at a Teaching Hospital in Southern Sri Lanka: A Quantitative and Qualitative Analysis
R Ratnaweera1, C Hewage2
1Teaching Hospital, Galle, Sri Lanka
2Department of Psychiatry, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
Background: General hospital staff deal with high rates of psychiatric illness. However, liaison psychiatry services are often underdeveloped and provision varies greatly. In the Teaching Hospital, Karapitiya, where this study was conducted, liaison psychiatry services were provided by general adult psychiatrists in the absence of a specialist liaison psychiatry team.
Aims: To quantitatively and qualitatively analyse services provided in liaison psychiatry.
Methods: Data collected from 191 patients using an interviewer administered questionnaire were analysed using Statistical Package for the Social Sciences (SPSS) software; a thematic analysis was also performed.
Results: The majority of referrals (75.9%) were of patients under 45 years. More women than men (60.2%) were referred. The highest numbers of referrals (71.2%) were from the medical ward and the commonest reason for referral (in 52%) was deliberate self-harm. The most prevalent diagnosis (in 27%) was depression. More than 80% were assessed within 24 hours of referral.
There was a statistically significant difference (p = 0.000) in willingness to come to the unit among patients who were informed and not informed. Patients experienced significantly greater anxiety immediately before, than after, completion of assessment (p = 0.000). Among patients who attended, 80% needed collateral information to confirm the diagnosis. Some (28.2%) patients were referred to the outpatient clinic, 22.5% were transferred to the inpatient unit and 22% were referred to the multidisciplinary team. Themes identified with regard to patient’s feelings about being referred to the psychiatrist were related to patient’s perceptions, experience, fears and the acknowledgement of the positive effects of consultation.
Conclusions: Deliberate self-harm comprised the major bulk of liaison work by the general psychiatrist. Effective communication with patients, family, referrer and the senior consultant was of utmost importance.
Hospital Consultation-Liaison Psychiatry: Reinforcing the Mind–Body Split?
P Vroegop1,2
1Counties Manukau Health, Auckland, New Zealand
2University of Auckland, Auckland, New Zealand
Background: Consultation-liaison (CL) psychiatry, psychosomatic medicine and health psychology services have been recognised as fulfilling important roles within the hospital system, including management of comorbid mental illness, emotional distress and complex cases where psychological, emotional and biomedical factors overlap. Support for clinicians, teams and units in recognising the psychosocial and relational aspects of presentation and treatment, and providing an opportunity for reflection of the clinicians’ own emotions and behaviours, is a core ‘liaison’ psychiatry or ‘embedded’ psychology function.
Objectives: CL teams within a hospital environment, especially when operating a ‘consultation’ model, may serve at times to promote rather than discourage the mind–body split inherent in the delivery of modern western medical care. This can occur by encouraging non-mental health clinicians in the general hospital setting to divest themselves of the emotional aspects of patient care. This paper outlines the evidence around whether this leads to negative outcomes, how this can best be explored and how such risks can be mitigated.
Methods: A reflective review of the relevant literature and collegial experiences was undertaken, with a focus on patient experience and the explicit and implicit roles of CL psychiatry and health psychology services utilising different models.
Findings: The concept of ‘holistic’ health care, the role of ‘physician as healer’ and the stigma of ‘mental health’ involvement are identified as significant issues impacted by the presence of CL teams. The evidence around integrated health care leading to improved patient satisfaction will be discussed.
Atypical Antipsychotics: Current Prescribing Practices in Children and Adolescents
P Rao1,2, H Wilson1,2, F Zepf1,2
1The University of Western Australia, Perth, WA, Australia
2Child and Adolescent Mental Health Service, Department of Health, Perth, WA, Australia
Background: Prescription of atypical antipsychotics in minors, by all specialists, has increased. The use has been both licensed and ‘off-label’, aimed at targeting different symptoms and clinical conditions.
Objectives: The survey aims to understand the use of antipsychotics in minors in ‘real-world’ practice and what guidance is followed to support clinical practice.
Methods: We included nearly 300 public sector Australian paediatricians, neurologists and psychiatrists. The survey contained 21 questions, in various formats, seeking to understand the current practices among prescribers, including commonly used antipsychotics, indications, dose ranges, target symptoms, duration of treatment and evidence base(s) used when making treatment decisions.
Findings: In total, 103 responses were received (approximately 35%). Approximately 61% prescribed less than monthly, and 9% prescribed at least weekly. First-line choices were risperidone (51%), quetiapine (30%) and olanzapine (18%). Reasons for discontinuation were weight gain (85%), efficacy (69%), sedation (60%), compliance and motor side-effects (each 37%).
Most responders (87%) prescribed antipsychotics for behavioural control, with 22% indicating an antipsychotic as their first-line choice; agents included risperidone (12), quetiapine and olanzapine (2 each). The commonest target symptoms were aggression (64), agitation (31), sedation (16), self-harm (15), impulsivity (13), emotional regulation (12), anger (11), anxiety (9) and disruptive behaviour (6). Duration of treatment was 6–12 months (27%), <1 month (23%), 3–6 months (19%), 1–3 months (17%) and >1 year (14%). Patient variables included age (28%), severity (25%), weight (7.5%), treatment history (7%), patient/parent preference (6.5%) and unsuccessful behaviour management (6%). Evidence bases referred to were Peer/Expert/Clinical experience (56%), National Institute for Health and Care Excellence (NICE) guidelines (20.5%), other (14%), American Academy Guidelines (7%) and no specific source (3%).
Conclusions: Atypical antipsychotics continue to be used as first-line medications for psychotic and non-psychotic presentations in minors, by a variety of specialists, despite an absence of clear evidence comparable to the adult literature.
Special Session by the Pacific Rim College of Psychiatrists: Opportunities and Challenges in Pacific Rim Psychiatry
H Herrman1,2, P Udomratn3
1PRCP and Orygen – The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia
2The Centre for Youth Mental Health, The University of Melbourne, Melbourne, VIC, Australia
3PRCP and Prince of Songkla University, Hat Yai, Thailand
Background: The Pacific Rim College of Psychiatrists (PRCP) (www.prcp.org) gathers together psychiatrists from countries bordering the Pacific Ocean. The College aims to foster national development of mental health services and support the improvement of education and research in psychiatry through professional collaboration across these countries. It aims to cooperate with the range of disciplines working in mental health and with service users and family carers. It is particularly concerned with the reform of psychiatric care including support and advocacy for prevention, early intervention and recovery in collaboration with primary health care.
Objectives: The session aims to consider the needs and opportunities for collaboration and knowledge exchange among colleagues and organisations across the Pacific Rim.
Methods: The session includes two short presentations on ‘Fostering alliances with primary health care in Pacific Rim countries’ (HH) and ‘New challenges of mental health problems in Pacific Rim countries’ (PU) followed by discussion.
Findings: The keys to achieving integration of psychiatry with the healthcare system include engagement of psychiatry with primary health care and partnership with patients and family carers. New challenges in the region include understanding and meeting needs of the mental health of migrants, and digital mental health, especially mental health problems related to technological mobile devices.
Conclusions: Discussion of these and other high-priority challenges and opportunities for psychiatry around the Pacific Rim is likely to reveal benefits of collaboration across countries, professions and civil society.
Thinking about Toddlers in a Perinatal and Infant Mental Health Service: Putting Theory into Practice
V Loftus1,2, T Winzar1
1Raphael Services, St John of God Hospital, Bendigo, VIC, Australia
2The Royal Women’s Hospital Centre for Women’s Mental Health, Parkville, VIC, Australia
Background: It is well recognized that parental mental health is a key determinant of infant and child well-being. Additionally, behavioural disturbance in infants and toddlers may be an indicator of parental mental ill health. While it is recognised that such behavioural disturbance left unaddressed may lead to long-term mental ill health and a suboptimal developmental trajectory for parent and child, there are gaps in services for toddlers and preschool-aged children. Raphael Services Bendigo is a Tier 2 specialist perinatal and infant mental health service, providing mental health care to parents and their children in the perinatal period, up to the index child’s fourth birthday. Raphael Services Bendigo aims to address the mental health needs of toddlers by providing parent–toddler psychotherapy as a key aspect of parental mental health care, with the aim of improving mental health outcomes for these children and their parents.
In this session, Dr Virginia Loftus will present a case of maternal perinatal depression and parent–toddler psychotherapy with reference to some psychotherapeutic literature.
You Can Lead a Horse to Water … From Top-Down to Collaborative Policy-Making
G Smith1,2,3
1WA Centre for Mental Health Policy Research, Department of Health Western Australia, Perth, WA, Australia
2School of Psychiatry and Clinical Neurosciences, The University of Western Australia, Perth, WA, Australia
3School of Occupational Therapy and Social Work, Curtin University, Perth, WA, Australia
Background: There has been increasing reliance on policy ‘directives’ as instruments for shaping clinical practice. However, research on policy implementation has depicted very significant gaps between the expectations of policy-makers and the actual impact that policy has had on changing clinical behaviour and reforming service delivery. Many clinicians report feelings of being overwhelmed by the sheer volume of policies, which they see as undermining their autonomy and professionalism rather than as resources to assist them in providing high-quality, safe care.
Objectives: To examine contemporary policy-making from the perspective of human motivational theory in order to understand the barriers to effective implementation and to describe an alternative collaborative approach aimed at bridging the ‘policy-to-practice’ gap.
Methods: The contemporary policy-making process and the ‘mindset’ that underpins it are analyzed, following which self-determination theory (SDT), a theory of human motivation, is examined as a potential explanatory mechanism for the limited success that policy directives have had in changing clinician behaviour.
Findings: Evidence suggests that the implementation ‘gap’ can be attributed largely to two critical factors: a view of organizational culture that does not adequately reflect its complexity and diversity, and a limited understanding of what motivates individuals and groups to change their practices.
Conclusions: An understanding of organizational culture is increasingly being viewed as essential in managing policy implementation. This paper describes an alternative approach to policy-making based on the understanding that motivational theory brings to the challenge of cultural change.
The Legal Liability of a Psychiatrist in Detaining Patients with Mental Illness in Australia: The ‘Mckenna’ Case
I Freckelton1–9, S Pang2
1Journal of Law and Medicine, Melbourne, VIC, Australia2Journal of Psychiatry, Psychology and Law, Melbourne, VIC, Australia
3The University of Melbourne, Melbourne, VIC, Australia
4Monash University, Melbourne, VIC, Australia
5La Trobe University, Melbourne, VIC, Australia
6Victorian Law Reform Commission, Melbourne, VIC, Australia
7Coronial Council of Victoria, Melbourne, VIC, Australia
8Mental Health Tribunal of Victoria, Melbourne, VIC, Australia
9Suitability Panel of Victoria, Melbourne, VIC, Australia
10NorthWestern Mental Health, Melbourne, VIC, Australia
Background: Recently, the Australian judicial system interpreted the detention powers of a psychiatrist under state mental health legislation as being to most intents and purposes immune to negligence liability. The High Court of Australia’s (HCA’s) unanimous judgment in Hunter and New England Local Health District v McKenna [2014] HCA 44 found that the duty to perform this power in accordance with statute would be inconsistent with a duty to take reasonable care in certain situations.
Objectives: Prof. Ian Freckelton QC, a leading barrister in law relating to mental health, and Sam Pang, a psychiatry trainee with a legal background, will discuss the implications of this significant case from a variety of perspectives.
Findings: The championing of the ‘least restrictive care’ principle acknowledges patient recovery and liberty, but may carry adverse consequences for patient care and professional accountability.
Opportunity and Challenge: Developing Australia’s First Regional Headspace Youth Early Psychosis Program
C Little
Headspace Darwin, Casuarina, NT, Australia
Background: Anglicare Northern Territory has operated headspace Darwin for more than 7 years—nominated as a Round 1 headspace site. In 2015, Federal government funding was released to enable the development on the headspace platform of a Youth Early Psychosis Program (hYEPP) based on the world renowned Early Psychosis Prevention and Intervention Centre (EPPIC) model. Darwin is the first Australian regional centre with these two main streams of mental health service delivery. Key features of the model include mobile assessment and outreach for young people aged 12–25 years, intensive 2–5 years of case management for first-episode psychosis (FEP), a youth and family-friendly functional recovery program involving educational and vocational support, psychoeducation, therapeutic and social group programs, complemented by peer and family support workers.
Objectives and methods: This presentation provides an overview of the unique opportunities and challenges involved in setting up the hYEPP model in a remote regional center. It has been an exciting journey of building partnerships with the existing services and engaging with the community and young people. A significant achievement has been the development of a Service Level Agreement (SLA) with the existing Public Mental Health Service to enable inpatient admissions to be facilitated under headspace psychiatrists rather than government services.
Conclusions: The hYEPP offers a unique service to young people in the greater Darwin region, many of Indigenous origin who are experiencing an FEP or are at ultra-high risk (UHR) of developing an FEP. The geographic remoteness and client demographics provide a unique opportunity to modify service provision to the needs of the community.
Unique Demographics +
Innovative Program = Exciting Outcomes for Indigenous Young People at Ultra-High Risk of Psychosis
C Little
Headspace Darwin, Casuarina, NT, Australia
Background and objectives: Treating young people at high risk of developing psychotic symptoms is an exciting prospect. The prodromal phase of the illness is associated with a diversity of mental health issues, distress and functional difficulties. This is especially so in young Indigenous clients. The presentation of possible psychotic symptoms is often accompanied by symptoms of depression, anxiety, personality disorder and substance misuse.
The difficulty is that distress and functional decline can be present for some time before the formal diagnostic criteria for a psychotic disorder are met, excluding the individuals from intervention by traditional mental health services.
Treatment in this early phase has the potential to reduce the existing symptoms and disability, improve social and vocational dysfunction and prevent or delay the onset of a psychotic disorder and minimize any alterations in brain structure that may occur during the transition from ‘at-risk’ to full threshold psychosis.
Method: My role as the first headspace Youth Early Psychosis Program (hYEPP) regional Clinical Director provides incredible opportunities to develop early intervention services for some of the most disadvantaged and complex Indigenous young people in Australia. This is illustrated by the presentation of a case history of a young person with a distinctly Northern Territory and Indigenous focus, emphasizing the encouraging possibilities and outcomes of a program focused on early intervention.
Conclusions: The implementation of the hYEPP in Darwin has opened a tremendous opportunity to improve access and provide innovative interventions for Indigenous young people at ultra-high risk of developing psychotic illnesses in the Northern Territory.
Integrating Recovery-Oriented Practice into Psychiatric Registrar Training
AC Stratford1,2,3,4
1Community Adviser Recovery and Wellbeing, Mind Australia, Melbourne, VIC, Australia
2Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
3School of Medicine, Yale University, New Haven, CT, USA
4World Health Organization, Geneva, Switzerland
Background: This paper describes a new initiative in training for psychiatry trainees in the ‘recovery’ paradigm.
Objectives: Supporting patients in their personal recovery and promoting well-being have become key principles in the delivery of specialist mental health services. This requires psychiatrists to develop (or perhaps return to) a world view that promotes a hopeful stance and acknowledges the importance of relationships when working with people experiencing mental ill health, their families and carers.
Methods: In 2011, supported by Profs Ian Everall and David Castle, the author developed and trialled training about personal recovery and well-being within psychiatry. A crucial factor was that the training was delivered by a person who has expertise both as a result of their own recovery journey and their experience in peer-support work.
Findings: In order to support a person’s mental health recovery, a strong and supportive relationship must exist that encourages ‘hope’. Research has found that power differentials work against recovery. It is important for a psychiatrist to understand that there are two experts in the relationship, one through learning and one through experience.
Conclusions: The feedback from participants has supported further national and international developments. Recovery is now a core module in the MPM/MPsych.
A Pilot Intervention to Manage Physical Health Concerns in a Mental Health Service
A Velayudhan1, K Heslop2, L Harrison1, L Ferguson1, D Wynaden2
1Fremantle Hospital Mental Health Service, Fremantle Hospital, Fremantle, WA, Australia
2School of Nursing, Curtin University, Perth, WA, Australia
Background: The adverse physical health outcomes of individuals with severe mental illness are well recognized by clinicians. Despite several guidelines recommending monitoring of physical health parameters, there is confusion over who will accept responsibility for the physical health of individuals with severe mental illness. To address the physical health needs of patients, this mental health service has initiated a physical health clinic (Wellness Clinic) staffed by a general practitioner (GP), nurse practitioner and a senior nurse.
Objectives: This study profiles the patients attending this clinic with a view to identifying a pathway to primary care management of the physical illnesses patients with severe mental illness.
Methods: An audit of medical records of all patients who attended the Wellness Clinic (the Clinic) between 1 July 2014 and 30 June 2015 was completed using a proforma collection system. Demographic data, diagnostic information, medications, metabolic screening and outcomes of these patients were collected.
Findings: There were 100 patients who attended the Clinic during this period, of whom 54 patients had an identified GP and 74 of these patients had a psychotic disorder. The 100 patients made 334 visits to the clinic. Of these, 56 patients visited the clinic more than three times. Seventy-nine patients had at least one abnormal metabolic parameter; 30% of males and 60% of women had a body mass index (BMI) >30; and 23% of patients were referred to a community GP with a management plan for ongoing care.
Conclusions: The co-location of a GP and a nurse practitioner, in addition to helping patients access medical care, appears to have the potential for improved engagement of patients in their management of physical illnesses as well as being a pathway to primary care management of physical illness.
A Retrospective Clinical Audit Relating to the Prevalence of Risk Factors and the Screening of Blood-Borne Viral Illnesses in a Cohort of Patients Presenting for a Mental Health Assessment to an Emergency Department
M Murphy, A Wong, T Tietze, R Riva, K Arrold
St Vincent’s Hospital, Sydney, NSW, Australia
Background: Clinical practice indicates that many risk factors for blood-borne viral (BBV) illness (e.g. intravenous drug use) are present in higher rates in people with mental health illnesses. In 2001, Rosenberg and others investigated the prevalence of HIV, hepatitis B (HBV) and hepatitis C (HCV) in more than 900 people with severe mental illness and found that the prevalence of HIV was 3.1% (8 times the general population), HBV was 23.4% (5 times the general population) and HCV was 19.6% (11 times the general population).
In 2013, Sanger and others found that when patients in an English in-patient psychiatric unit were offered testing for BBV 83% had the mental capacity to provide informed consent for testing and 66% of patients offered testing choose to avail themselves of the same. Sanger and others concluded that routine testing was practical and acceptable to the majority of patients.
Objectives: To identify our current level of care within the area of BBV illness screening in patients who presented for a mental health assessment in late 2014.
We aimed to answer the following questions:
• What is the number of significant risk factors for BBV?
• What is the number of patients aware of BBV status?
• What is the frequency that ‘high-risk’ patients were offered screening?
• What is the frequency that ‘high-risk’ patients were identified as potentially in a mental state facilitating discussion of BBV screening?
• How many patients underwent any blood tests?
Methods: Audit, review of chart, serology, biochemistry and urinalysis.
Sample: 300
Selection: Consecutive sample of patients presenting to Emergency Department (ED).
Findings and conclusions: Pending, ethics submitted, aiming to commence review in November 2015. The results will definitely be ready for Congress.
Innovation in Mood Disorders Management in Regional North Queensland: Improving Patient Outcome through Primary and Secondary Care Collaboration
S Sardinha1, RB Krishnaiah2, M Kirkman2
1James Cook University, Townsville, QLD, Australia
2The Townsville Hospital, Townsville, QLD, Australia
Background: Access to specialist psychiatrists in rural regional cities such as Townsville, Australia, due to a capacity issue and workforce shortage needed an innovative approach in a public sector. Five streams of specialist clinics, to address the common diagnostic groups electively with the premise that this would reduce crisis presentations and admissions, were implemented in May 2014. In this regard, a multidisciplinary ‘Mood Disorder Clinic’ was set up, which took direct referrals from general practitioners (GPs) for specialist assessment and multimodal treatment of moderately severe/unremitting affective disorders.
Objectives: The primary objective is to evaluate patient- and clinician-rated clinical outcomes on well-validated scales. The secondary objective is to evaluate the Mood Disorder Clinic in terms of impact on existing acute services and GPs’ satisfaction.
Methods: Data on pretreatment and posttreatment outcome measures of all patients in the Mood Disorder Clinic were quantitatively analysed. A cross-sectional survey of GPs’ satisfaction of the Mood Disorder Clinic will be undertaken. Data on hospital admissions for all mood disorders, pre and post set-up of a Mood Disorder Clinic will be analysed.
Findings: Preliminary findings suggest a positive clinical response in self-reported and clinician-rated measures. The Mood Disorder Clinic has the highest referrals compared to other specialist clinics and reduced inpatient hospital admissions.
Conclusions: The Mood Disorder Clinic offers an effective service for patients with unremitting/complex mood disorders with moderate disability in an area with unmet needs. Early/timely intervention has significantly reduced hospitalisation and caseload on acute care services. Limited uptake by the Aboriginal and Torres Strait Islander peoples may require a culturally appropriate approach.
Caring for Carers in a Psychiatric Crisis
M Lowe, W Conron
Central East Crisis Assessment and Treatment Team Eastern Health, Mental Health Service, Melbourne, VIC, Australia
Background: Carers and families are an integral part of a consumer’s recovery, and their involvement can have a direct effect on our consumer’s prognosis. Psychiatric crises are shared experiences for consumers, carers and families. These experiences can result in the stretching and breaking of intra-familial bonds, which can have detrimental effects on consumer recovery and family functioning. Crisis Assessment and Treatment Teams (CATTs) have a unique opportunity to provide not only management to the consumer in a psychiatric crisis but also support and education to the familial network by offering Single Session Family Therapy (SSFT) during a period of acute crisis. This paper highlights how this work has been done with several hundred families.
Objectives: The objectives of this presentation are as follows:
• Enhance familial bonds and increase resilience within the family;
• Reduce carer fatigue and burn out;
• Enhance engagement of the consumer and their family with mental health services.
Methods: Family and consumers are offered a therapy session to discuss their perspective and understanding of the crisis. The session is conducted using a family therapy approach as a single session.
Findings: Feedback has found that all families and consumers have felt that the session was beneficial in facilitating debriefing, improving communication, relieving stress, enhancing greater understanding of the crisis process, understanding the roles that family members play and developing strategies to avoid acute crises in the future.
Conclusions: SSFT provides an additional management strategy to acute psychiatric work that has benefit for consumers and their families, that is simple and economical which warrants further study.
An Evaluation of Training General Practitioners to Screen and Manage Physical Comorbidity in Adults with Severe Mental Illness
CM Cameron1, J Cumsille1, C Ehrlich1, E Kendall1, D Crompton1,2, S Kisely1,2,3
1Griffith University, Logan, QLD, Australia
2Metro South, Mount Gravatt, QLD, Australia
3School of Medicine, The University of Queensland, Brisbane, QLD, Australia
Background: The physical health of people with severe mental illness is poor. In response, Queensland Health and General Practice Queensland developed a comprehensive package of guidelines for use in primary care, and promoted their use, as part of the ACTIVATE programme.
Objectives: To assess the effects of the intervention by comparing Medical Benefits Schedule (MBS) data of patients of general practitioners (GPs) exposed to the intervention and controls who were not.
Methods: A comparison of primary care consultation and pathology data of people with severe mental illness from intervention and control areas. Negative binomial regression models were used to compare the frequency and length of GP consultations, and number and type of pathology examinations in the two areas.
Findings: We obtained the records of 103 people from intervention areas and 98 controls. Intervention and control areas were not different at baseline in terms of age and claims data, but females had higher consultation rates. After adjusting for gender, people from intervention areas had more GP consultations, especially long consultations. They also had more pathology screening for chronic diseases in accordance with implemented guideline recommendations. These benefits persisted after the end of the intervention.
Conclusions: These findings suggest that the ACTIVATE programme aimed at training GPs to screen and better manage chronic diseases in adults with severe mental illness had a positive effect and demonstrated desired changes in medical management practices by GPs in the intervention area.
An Ideal Geriatric Psychiatry Service
K George
Eastern Health, Box Hill, VIC, Australia
Background: The author visited three Commonwealth countries with socialized health care to find out about aged person’s mental health services and to compare them with services in Australia.
Objectives:
1. To describe aged person’s mental health services in the United Kingdom, Canada, New Zealand and Australia;
2. To compare and contrast aged person’s mental health services in countries with socialized health care;
3. To discuss what an ideal aged psychiatry service might look like;
Methods: As part of a sabbatical, the author visited three Commonwealth countries during the second half of 2015 to study the structure and function of aged person’s mental health services in the United Kingdom, Canada and New Zealand and to compare these services with those in Australia.
Findings: There are similarities as well as differences in the way services are structured and the way they function in similar National Health Services.
Conclusions: From the visits, the author discusses as to what an ideal aged person’s mental health service might look like.
Illusion and Reality: Research in Psychodynamic Psychotherapy
P Foulkes
Private Practice, Royal Melbourne Hospital, Melbourne, VIC, Australia
Background: In recent years, a proliferation of well-designed studies looking at the efficacy of psychodynamic psychotherapy (PDP) has emerged. The time-honoured case study and individual clinician’s observations are gradually being replaced by controlled studies.
Objectives: To determine the consequences for the theory, practice and research of PDP of the recent research findings.
Methods: This paper examines the contemporary PDP literature looking at both efficacy and effectiveness, as well as process (i.e. what works for whom, with which therapist and what techniques improve outcome). Inherent problems in methodology with all research in the subjective field of the psychotherapies will be examined.
Findings: Although PDP is found to be efficacious in a number of conditions, there are significant issues with lack of homogeneity of treatments and a failure to control for treatment alliance. Lack of correlation between the explicit theory stated and implicit theory derived from observation creates difficulties in usefulness of results.
Conclusions: Further work on design of trials looking at PDP is needed. The usefulness of this research in being able to confirm or deny theory is doubtful. Better correlation between explicit theory and clinical practice is recommended.
Modifying Cognitive Behavioural Therapy for Depression in Sri Lanka
A Rodrigo1, H Minas2, R Kakuma2, R Newton2, P de Zoysa3
1University of Kelaniya, Kelaniya, Sri Lanka
2The University of Melbourne, Melbourne, VIC, Australia
3University of Colombo, Colombo, Sri Lanka
Background: Psychotherapy is an essential treatment component of depression. However, it is practiced rarely in Sri Lanka for various reasons, not least of which is the absence of culturally appropriate psychotherapies. Culturally adapted psychotherapies are more effective than generic interventions and improve service utilisation.
Objectives: To modify a cognitive behavioural therapy (CBT) manual for depression to suit the Sri Lankan cultural context.
Methods: The CBT manual for depression was modified to suit the Sri Lankan cultural context through knowledge generated by detailed semi-structured interviews with Sri Lankan patients with depression, their carers, psychiatrists, psychologists, lay counsellors and traditional healers. A mixed method was used to interpret data gathered from participants. Modifications were finalised after discussion with a selected group of study participants.
Findings: In total, 20 patients and carers, 20 mental health professionals and eight lay counsellors and traditional healers were interviewed initially, and five participants from the above group were consulted later to finalise modifications. Accordingly, CBT sessions were made shorter with a maximum of six sessions. Sessions are directive and didactic. More emphasis is placed on education, somatic symptoms, activity scheduling, problem solving and mindfulness, while detailed formulation, core beliefs and intermediate beliefs are emphasised less. Examples from local folk stories and religious literature are used more explicitly and a lenient approach towards homework is adopted.
Conclusions: Several significant changes to the delivery, technique and content of the existing CBT manual for depression were made to make it more culturally sensitive to the Sri Lankan context. Its efficacy and feasibility are being tested.
Attachment Theory: What it is and its Clinical Significance
L Diana1,2,3,4
1Shellharbour Hospital, Mount Warrigal, NSW, Australia
2Private Practice, Wollongong, NSW, Australia
3Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
4Graduate School of Medicine, University of Wollongong, NSW, Australia
Background: Attachment theory has become increasingly influential in not only informing us on how to conduct psychotherapy but also helps us to understand and conceptualise the origin of our patients’ underlying psychopathology.
Objectives: To give a brief overview of attachment theory and its evolution, from the seminal theories of John Bowlby to the present-day work of Peter Fonagy, and its clinical relevance. At the end of the presentation, attendees will have an understanding of attachment theory, its historical background and how attachment is relevant in the development of the sense of self, of affect regulation, the capacity to mentalise and how it helps to understand clinical conditions such as medically unexplained symptoms.
Methods: To give an overview of attachment theory, starting with John Bowlby and looking at the work of Mary Ainsworth, Mary Main and Peter Fonagy; defining attachment theory and looking at the clinical significance of the Strange Situation attachment classifications as well as the Adult Attachment Interview ‘states of mind with respect to Attachment’; and concluding with how attachment theory has evolved into areas of Mentalisation and Affect Regulation.
Findings and conclusions: A knowledge of attachment theory is important in being able to fully understand the psychopathology underpinning basic concepts such as the sense of self, affect regulation, mentalisation and the capacity to emotionally connect with self and others.
The Prevalence of Autoimmune Encephalitis in Patients Presenting with First-Episode Psychosis
JG Scott1,2, D Gillis3, H Hargovan1, N Gundarpi1, A Ryan2, K Prain3, M Newman3, R Wong R3, P Parry4, S Blum5
1Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
2The University of Queensland Centre for Clinical Research, Brisbane, QLD, Australia
3Pathology Queensland, Brisbane, QLD, Australia
4Queensland Children’s Hospital, Brisbane, QLD, Australia
5Princess Alexandra Hospital, Brisbane, QLD, Australia
Background: Psychosis, a broad heterogeneous syndrome characterised by delusions and hallucinations, has a life-time prevalence of 3%. Usually, no organic cause is identified and the clinical outcome is highly variable. Recently, autoimmune anti-neuronal encephalitis has been identified as a cause of psychosis although the prevalence is undetermined.
Objectives: To assess the prevalence of autoimmune encephalitis in patients admitted to hospital for management of their first episode of psychosis.
Methods: Between 28 July 2013 and 13 May 2015, all patients aged between 12 and 50 years of age admitted to the Royal Brisbane and Women’s Hospital or the Queensland Children’s Hospital mental health services for their first presentation of psychosis were tested for anti-neuronal antibodies. Where patients were positive for plasma antibodies, neurological and immunological consultation and investigations determined the significance of the antibodies in these patients.
Findings: During the study, 151 patients were admitted and 116 consented to participate. Five patients were found to have anti-neuronal antibodies from plasma samples. Subsequent neurology review determined that four of these patients had an auto-immune encephalitis (N-methyl-d-aspartate-receptor [NMDAr] encephalitis, n = 3; and voltage-gated potassium channel [VGKC] antibody encephalitis; n = 1) and their care subsequently involved immune-modulatory therapy and tumour resection (n = 2) rather than psychiatric care.
Conclusions: Between 3% and 4% of patients admitted for a first episode of psychosis had a neuronal autoimmune disorder. Early identification of these patients and referral for appropriate treatment is critical to optimise recovery.
Hallucinations in Adolescents and Risk for Mental Disorders in Adulthood: Prospective Evidence from the MUSP Birth Cohort Study
JG Scott1,2, M Connell1, K Betts3, R Alati3, J Najman3, A Clavarino3, A Mamun3, JJ McGrath4,5
1The University of Queensland Centre for Clinical Research, Brisbane, QLD, Australia
2Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
3School of Population Health, The University of Queensland, Brisbane, QLD, Australia
4Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia
5Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Brisbane, QLD, Australia
Background: Hallucinations, once equated with serious mental disorders, are common in adolescents. Previous longitudinal studies have shown that hallucinations in adolescents are predictive of psychotic and non-psychotic disorders; however, studies have been limited by measurement of hallucinations at one time-point only and small sample sizes.
Objectives: To examine mental health outcomes at 30 years of age of young adolescents who experienced hallucinations.
Methods: Based on a longitudinal birth cohort, we examined a nested case–control study comparing the mental health of participants at age 30 years in the Mater-University of Queensland Study of Pregnancy (MUSP) who reported hallucinations at (1) 14 years only and (2) 14 and 21 years versus cohort members without hallucinations.
Findings: Hallucinations at 14 years only were not associated with an increased risk of mental disorders in adulthood. However, persistent hallucinations (at both 14 and 21 years) were associated with psychotic disorders, eating disorders and substance use disorders at 30 years. Those with persistent hallucinations were more likely to have attempted suicide in adulthood.
Conclusions: Although most adolescents who experience hallucinations do not have an increased risk of mental disorders in adulthood, those with hallucinations that persist are at increased risk of both psychotic and non-psychotic psychopathologies. Monitoring of hallucinations and intervention is indicated in adolescents when these experiences persist.
‘Neither Fish nor Fowl’: Changes to Eurasian Identity
C Parker
Warners Bay Private Hospital, Warners Bay, NSW, Australia
Background: War, trade and colonization brought China and Europe into close contact during the second half of the 19th century. As a consequence of these close encounters, mixed race relationships in Hong Kong came into being. The identity of those with mixed heritage changed with altering political and financial climates and increased populations.
Objectives: To provide a historical view of Eurasian identity with a focus on Hong Kong.
Methods: Literature searches using the words Eurasian, Eurasian identity and Hong Kong were undertaken.
Findings and conclusions: The progeny of early mixed Asian–European relationships were usually seen as undesirable and often felt shamed, such that their dual heritage was denied, sometimes for many generations. However, over the last one-and-a-half centuries with increasing globalization, attitudes towards Eurasians have changed such that, not only has dual heritage become accepted, in some situations it is viewed as desirable. Consequently, Eurasian identity no longer is viewed with shame but can be viewed with pride.
Description and Evaluation of a Leadership Development Program for Mental Health Workers from Four Pacific Island Countries
P Fung
Headspace Youth Early Psychosis Program, Sydney, NSW, Australia
Background: In Pacific Island Countries (PICs), the percentage of mentally ill people not receiving any treatment has been conservatively estimated to be greater than 90%. From 2012 to 2014, the New South Wales Institute of Psychiatry delivered a Mental Health Education Project designed to build the capacity of mental health services in four countries: Papua New Guinea, Federated States of Micronesia, Republic of Marshall Islands and Palau.
Objectives: A key component of the Mental Health Education Project was a 9-month Leadership Development Program (LDP) attended by 14 mental health workers from these four PICs. This presentation is a description and evaluation of the LDP.
Methods: The LDP was delivered in two phases, a 1-week series of leadership development workshops focusing on project management skills held in Sydney and a 9-month period of mentorship for participant project implementation. In-depth interviews, questionnaires and a focus group were used to evaluate the LDP. The data were analyzed using qualitative techniques.
Findings: All Pacific Island participants responded positively to the training in Sydney. All reported greater confidence in taking on formal or informal leadership roles in the workplace, developing project planning skills and interpersonal skills such as networking and partnerships. Participants were able to reflect on the challenges of implementing their projects in their countries and receiving mentorship.
Conclusions: The strong partnerships developed between the New South Wales Institute of Psychiatry and the Ministry of Health in all four countries contributed to the success of the LDP. An LDP focusing on project management is one method of building capacity in mental health services in PICs.
Normality, Abnormality and Mental Illness in a Cross-Cultural Perspective
A Janca
School of Psychiatry and Clinical Neurosciences, The University of Western Australia, Perth, WA, Australia
Background: Normality, abnormality and mental illness can be seen as points on a spectrum ranging from normal to psychopathological or as three separate and distinct states with clearly defined boundaries.
Objectives: To discuss concepts of normality, abnormality and mental illness in a cross-cultural perspective.
Methods: An exploratory analysis based on quantitative and qualitative data collected during development and evaluation of several psychiatric assessment instruments across different cultures and settings.
Findings: Normality, abnormality and mental illness can be defined according to different criteria including, for example, epidemiological, socio-cultural, ethico-legal and medical/clinical. From an epidemiological point of view, normality can be seen as the person being within the mid-range of a bell-shaped curve of normal population distribution. Being within socially agreed limits that define the range of normal functioning would be typical for a socio-cultural and/or ethico-legal approach to normality. A lack of significant deviation from the average values would be an example of a medical or clinical approach to what is considered to be normal in medicine and psychiatry.
Abnormality typically has a negative connotation or meaning (e.g. being anomalous, aberrant, deviant or odd). Perception of what is normal or not changes across time and space. Societal attitudes towards (ab)normality also change across cultures, generations and situations. A person has a mental illness if the person suffers from a disturbance of thought, mood, volition, perception, orientation or memory that impairs judgment or behaviour to a significant extent.
Conclusions: The concepts of normality, abnormality and mental illness vary across cultures, settings, timelines and psychiatric traditions. This variation should be taken into account when assessing and managing psychiatric patients of different cultural backgrounds.
Using Music Therapy as a Resource for Re-Forming Healthy Relationships with Music During Mental Health Recovery
J Bibb, F Baker, KS McFerran
National Music Therapy Research Unit, The University of Melbourne, Parkville, VIC, Australia
Background: The role of music therapy in influencing positive mental health recovery is well documented (Gold et al, 2005; Grocke et al., 2009). However, there is little research into the ways that people’s relationships with music can become complicated during periods of acute illness. Painful memories and emotions can be triggered by music, which can be amplified when listening to music in isolation. Patients may use music as an unhealthy resource during acute episodes of illness if they are not supported with their music use during this time.
Objectives: We aimed to gather a range of perspectives about experiences of music therapy. We hoped to better understand the processes that promote healthy relationships with music during mental health recovery in inpatient and community contexts.
Methods: This study used constructivist grounded theory methodology (Charmaz, 2014). More than 20 participants were interviewed about their experiences of music therapy and their experience of being ‘triggered’ by music in isolation and during group music therapy.
Findings: Participants reported using music therapy as a ‘resource’ for re-forming healthy emotional connections with music. Participants described using the encouraging conditions of the group context such as being with
co-patients who ‘understood’, singing ‘painful’ songs together and getting support from a music therapist to ‘de-sensitise’ songs which they previously had painful associations with.
Conclusions: Attending group music therapy during their acute episode of illness supported participants to use music as a healthy resource for their long-term mental health recovery.
References
Charmaz K (2014) Constructing Grounded Theory, 2nd Edition. Los Angeles, CA: SAGE.
Gold C, Heldal TO, Dahle T, et al. (2005) Music therapy for schizophrenia or schizophrenia-like illnesses. Cochrane Database of Systematic Reviews 2: CD004025.
Grocke D, Block S and Castle D (2009) The effect of group music therapy on quality of life for participants living with severe and enduring mental illness. Journal of Music Therapy 46: 91–104.
Waiting for Godot
D Goel, L Cruickshank
Southland Hospital, Invercargill, New Zealand
Background: More than 60 years after the serendipitous advent of chlorpromazine, despite the introduction of scores of new antipsychotic agents, there is a growing sense of frustration, of expectations belied, promises unfulfilled. Irrational antipsychotic polypharmacy rules the roost.
We ask, ‘Where, then, do we go from here? Should we keep waiting for a new miracle cure to emerge? Or should we use the best available evidence to formulate more efficient treatment strategies, using existing antipsychotic medications more effectively?’
Objectives: Comprehensive review of evidence versus real-life practice with respect to antipsychotic usage, focusing on factors contributing to the delayed or suboptimal use of clozapine and the consequent resort to non-evidence-based antipsychotic polypharmacy.
Methods: These and related issues are interrogated, including the enduring ‘delayed-onset’ hypothesis of antipsychotic action. The reasons for the suboptimal or declining use of clozapine, even as the evidence indicating its efficacy, effectiveness and safety grows, are analysed.
Findings: Superstition, rather than science, guides real-life practice in this regard, with a paradoxical expansion of restrictions on the early/optimal use of clozapine, consequent delay in its use in treatment-resistant schizophrenia and widespread, non-evidence-based antipsychotic polypharmacy.
Conclusions: The reasons underpinning this paradox are identified and remedial strategies suggested. We propose a pragmatic, evidence-based twin-pronged strategy for trialling two antipsychotic medications within a period of 24 weeks and switching to clozapine at week 25.
Improved Antidepressant Remission in Major Depression via a Pharmacokinetic Pathway Polygene Pharmacogenetic Report
A Singh1,2
1Deakin University, School of Medicine, Geelong, VIC, Australia
2Baycrest Biotechnology, Geelong, VIC, Australia
Background and objectives: Major depressive disorder (MDD) is projected to be a leading cause of disability globally by 2030. Only a minority of patients remit with antidepressants. If assay of polymorphisms influencing central nervous system (CNS) bioavailability could guide prescribers to more effectively dose patients, remission rates may improve and the burden of disease from MDD reduce. Hepatic and blood–brain barrier (BBB) polymorphisms appear to influence antidepressant CNS bioavailability.
Methods: A 12-week prospective, double-blind randomized genetically guided versus unguided trial of antidepressant dosing in Caucasian adults with MDD (n = 148) was conducted.
Findings: Subjects receiving genetically guided prescribing had a 2.52-fold greater chance of remission (95% confidence interval [CI] = 1.71, 3.73, z = 4.66, p < 0.0001). The number needed to genotype (NNG) = 3 (95% CI = 1.7, 3.5) to produce an additional remission.
Conclusions: These data suggest that a pharmacogenetic dosing report may improve antidepressant efficacy. The effect size was sufficient that translation to clinical care may arise if results are independently replicated.
Pressure to Adhere to Treatment in Hong Kong Mental Health Care – A Pilot Study
W Chan1, C Wong1, S Wahab1, T Burns2
1Department of Psychiatry, The University of Hong Kong, Hong Kong
2Department of Psychiatry, University of Oxford, Oxford, UK
Background: Pressures to adhere to treatment (‘leverage’) refers to an informal practice whereby practitioners attempt to influence patients’ treatment adherence. Little is known about the use of leverage in community psychiatric services in Hong Kong.
Objectives: To examine the prevalence of leverage in mental health care in Hong Kong and evaluate its association with patients’ sociodemographic and clinical characteristics.
Methods: A pilot study was conducted from December 2014 to February 2015. Consecutive adult patients attending a local psychiatric centre for personalised care programme, with recovery-oriented multidisciplinary case management service for patients with severe mental illness (SMI), were recruited. Using structured interviews, the four commonest forms of leverage, in areas of finance, housing, criminal justice and child custody, were evaluated. In addition, their sociodemographic and clinical characteristics were collected. Participants were also interviewed with Perceived Coercion Scale, Insight and Treatment Attitudes Questionnaire, Brief Psychiatric Rating Scale, Global Assessment of Functioning, Conjoint CAGE and Montreal Cognitive Assessment.
Findings: A total of 59 participants were recruited. Their mean age was 48.5 years, and two-thirds of them were men. On average, they have had SMI for 19.6 years. About 80% of participants were diagnosed as having schizophrenia. The remaining participants had either a depressive or bipolar affective disorder. Nearly half of the participants (N = 28) reported experiencing leverage. Financial leverage was the most commonly reported form of informal coercion (33.9%), followed by housing leverage (15.3%). Participants who were younger when they first came into contact with psychiatric services were more likely to report experiencing leverage (p < 0.05).
Conclusions: Leverage is as commonly used in Hong Kong as in other developed countries. However, the pattern of leverage employed in different mental healthcare systems varies. Understanding leverage applied onto psychiatric service users will facilitate a closer consideration of their justifications and gives insightful perspectives to the mental healthcare planning and policy making in Hong Kong.
Efficacy of Lurasidone in Bipolar Depression: Results from Two Double-Blind, Placebo-Controlled Studies
A Pikalov1, R Silva1, J Cucchiaro1, K Sarma1, J Hsu1, A Loebel1
1Sunovion Pharmaceuticals, Fort Lee, NJ, USA
2Sunovion Pharmaceuticals, Marlborough, MA, USA
Background: Lurasidone is an atypical antipsychotic approved for use in the treatment of schizophrenia and bipolar depression.
Objectives: To evaluate the impact of baseline depression severity on clinical response in patients with bipolar depression treated with lurasidone.
Methods: Patients with bipolar I depression were randomized in a 6-week monotherapy trial to lurasidone (20–60 mg/day or 80–120 mg/day) compared to placebo (total n = 505) and in a 6-week adjunctive trial to lurasidone (20–120 mg/day) compared to placebo, each adjunctive with lithium or valproate (n = 348). The primary endpoint in both studies was a change from baseline to week 6 in the Montgomery–Asberg Depression Rating Scale (MADRS) score, analyzed by mixed-effect model repeated measures (MMRM). Two baseline depression severity groups were defined post hoc: a moderate severity (MADRS = 20–29) and a high (MADRS ≥ 30) severity group.
Findings: Treatment with lurasidone significantly improved endpoint MADRS scores compared to placebo in both the monotherapy study (20–60 mg/day: p < 0.001; effect size [d] = 0.51; and 80–120 mg/day: p < 0.001; d = 0.51) and the adjunctive therapy study (p = 0.005; d = 0.34). In the monotherapy study, lurasidone effect sizes for the MADRS change at week 6 in the high and moderate severity groups were d = 0.59 (p < 0.001) and d = 0.39 (p = 0.035) for the 20–60 mg/day dosage range and d = 0.54 (p = 0.002) and d = 0.49 (p = 0.008) for the 80–120 mg/day dosage range; in adjunctive therapy study, effect sizes in the high and moderate severity groups were d = 0.24 (p = 0.10) and d = 0.39 (p = 0.033), respectively.
Conclusions: In these two short-term studies, monotherapy and adjunctive treatment with lurasidone were associated with significant improvement in depressive symptoms in both moderate and high depression severity subgroups.
Clinicaltrials.gov identifier: NCT00868699, NCT00868452.
Funding
Thid work was sponsored by Servier and Sunovion Pharmaceuticals Inc.
What Do Consumers Expect of Community-Based Residential Mental Health Rehabilitation Services? A Qualitative Analysis
S Parker1,2, F Dark1,2, E Newman1, N Korman1, C Meurk2
1Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
2School of Public Health, The University of Queensland, Brisbane, QLD, Australia
Background: Australian mental health plans and policy emphasize the central role of recovery principles in the delivery of mental health care and have increasingly made reference to the importance of the availability of peer support. These principles have shaped reforms in service delivery for more than a decade. A novel recovery-oriented staffing model integrating clinical and peer support workers within a collaborative team is being trialled at two community-based residential mental health rehabilitation services in Brisbane, Australia. Despite this, there has been limited research exploring the expectations of service users. Improved understanding of consumer expectations of such services creates opportunities to adapt these to better align with their priorities and preferences.
Objectives: To understand consumer expectations of care on commencement at community-based residential rehabilitation units.
Methods: This paper presents one part of a broader longitudinal qualitative study that takes a pragmatic approach to grounded theory analysis. Semi-structured interviews were completed with 24 consumers within 6 weeks of commencement at Community Care Units in Brisbane, Australia, by a trained independent interviewer.
Findings: Key emergent themes included (1) favourable comparison to other mental health settings, with which the consumer had engaged, and (2) positive expectations that staff would be less ‘clinical’ in their engagement with consumers. Consumers also highlighted the importance of the safety and support that they expected to be provided by the setting, as well as the recovery and transition/transformation hoped to be realized through engagement with the service.
Conclusions: Consumers have positive expectations at commencement of care at community-based residential mental health rehabilitation units. These expectations appear linked to unique concepts of recovery. Consumers’ expectations, including their comparative assessments with other mental health settings, have important implications for how experiences of care are evaluated.
The Challenge of Delivering Recovery-Oriented Residential Rehabilitation Care: A Qualitative Analysis
S Parker1,2, N Korman1, Z Rasmussen1, C Doyle1, F Dark1,2, E Newman1, C Meurk2
1Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
2School of Public Health, The University of Queensland, Brisbane, QLD, Australia
Background: National and state-based mental health plans and policy emphasize the central role of recovery principles in the delivery of mental health care. These principles have shaped reforms in service delivery for more than a decade. Despite this, the reality of working to deliver recovery-oriented practice in mental health rehabilitation from the perspective of staff has not been comprehensively explored.
Objectives: To understand the clinical staffs’ experience of the reality of working to deliver recovery-oriented mental health care within community-based residential rehabilitation settings.
Methods: This paper presents a sub-analysis of a broader longitudinal qualitative study taking a pragmatic approach to grounded theory analysis. Semi-structured interviews were completed with eight clinical staff, with at least 12-month experience working at a Community Care Unit in Brisbane, Australia, by a trained independent interviewer.
Findings: Clinical staff identified multiple challenges to the delivery of recovery-oriented care within a community-based residential rehabilitation setting, as well as tensions between the concepts of recovery and rehabilitation. External and internal pressures can impact service delivery, and competing responsibilities highlight the complexity of the recovery concept in application.
Conclusions: Working to understand the reality of working to deliver recovery-oriented care within mental health services contributes to a richer understanding of the concept; such understanding may guide a more translation of policy to practice in similar settings.
Ranzcp Study into the Welfare of Psychiatrists and Trainees: Results and Considerations for Future Practice
K Jenkins, D Alcorn
The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists’ Membership Engagement Committee has completed a broad study into the welfare of psychiatrists and trainees. The study commenced in 2014 and focused on a number of areas including job satisfaction, workplace and lifestyle stressors, personal support mechanisms, health and work–life balance. The findings of the study highlight the health issues facing doctors, the current strategies for dealing with stressors and potential action the College can take to further support its members.
Methods: The study included a literature review, an anonymous survey of members, targeted focus groups across Australia and New Zealand, consultation with branches and the New Zealand National Office, and a thread on the College’s online discussion forum.
Findings: The study identified coping strategies used by these doctors to deal with a range of stressors. Among a range of noteworthy findings, stressors were rated differently by trainees and psychiatrists. It also identified the difficulties these medical doctors face in obtaining care for themselves when ill.
Conclusions: The results of the study are a necessary element of a future intervention strategy to safeguard trainee and specialist welfare.
Mental Health and Job Satisfaction in Psychiatrists: Prevalence and Associated Factors – A Systematic Literature Review
S Rotstein, A Facey, S Jayarajah
Alfred Health, Melbourne, VIC, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists’ Membership Engagement Committee is conducting research on the mental health of its members. As part of this project, a systematic literature review was completed.
Objectives: To assess the prevalence and risk factors for stress/distress, burnout, mental illness, suicidality and drug and alcohol use among doctors working in psychiatry. Additionally, to assess the degree of job satisfaction and associated factors in this population.
Methods: A systematic literature review searching key databases (EMBASE, MEDLINE and PsychINFO) was performed in April 2015. Studies were included if they were written in the English language, published after 1999, represented primary research and assessed any of the desired outcomes in doctors working in psychiatry. Backward and forward citation searches were repeated (five times) until no further includable articles were identified.
Findings: A total of 80 studies fulfilled the inclusion criteria. These studies varied with regard to country of origin, methods, outcome and presence or absence of a comparison cohort. The majority of studies were cross-sectional in design. Job satisfaction and burnout were the most commonly investigated outcomes, while few studies investigated suicide and drug and alcohol use.
Conclusions: There are unique and significant stressors facing doctors working in psychiatry. Notably, there is a paucity of high-quality research in this field. There is scope for future investigations assessing appropriate strategies designed to prevent or reduce mental illness and maximize job satisfaction among doctors working in psychiatry.
Doctors Who Commit Suicide: Time to Move beyond Blaming Workplaces, Training Programs and Regulatory Authorities
K Jenkins
Victorian Doctors Health Program, Melbourne, VIC, Australia
Background: Suicide is the only cause of death for medical practitioners where mortality rates are greater than those of the general population. It is therefore likely that as medical practitioners, at some stage of our careers we will be affected by the suicide of one of our colleagues or classmates.
Objectives: To further understand the factors that cause medical professionals to take their own lives.
Methods: As part of clinical audit processes, the case files were reviewed of all doctors who had attended a Doctors Health Program for assessment or had been part of our follow-up programs or case managed by the program and known to have committed suicide over the past 8 years.
Findings: All who committed suicide were known to be suffering from mental illness and were receiving psychiatric treatment. Some had multiple diagnoses including with substance use disorders.
While most were known to be struggling with fulfilling their role as medical practitioners, their workplaces were largely supportive of their mental health needs. A minority of doctors were under investigation or being monitored by the regulatory authority, Australian Health Practitioner Regulation Agency (AHPRA).
While stress at work, difficulties in negotiating training requirements and conditions upon medical registration were sometimes present, symptoms associated with long-term mental health problems were more likely to be the principal reasons for these doctors’ suicides.
Conclusions: While striving for healthier workplaces, including easing the stress of training, are essential doctors’ health endeavors, this study suggests the impact is likely to be a decrease in morbidity, rather than in mortality rates.
Does the Frequency of Dosing of Long-Acting Injectable Antipsychotics Matter? A Systematic Review and Meta-Analysis
S Kisely1,2,3, E Sawyer4, G Robinson1,3, D Siskind1,2,3
1Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
2School of Medicine, The University of Queensland, Brisbane, QLD, Australia
3Griffith University, Gold Coast, QLD, Australia
4School of Medicine, James Cook University, Townsville, QLD, Australia
Background: Depot antipsychotics help to improve adherence and clinical outcomes. Dosing regimens vary but are commonly 2 and 4 weekly. The effect of administration at 2-weekly or 4-weekly intervals on subsequent compliance and outcome is unknown as previous systematic reviews and meta-analyses have either compared depots with oral medication or different depots at the same dosing frequency. This is topical because many patients are being changed from 2-weekly depot risperidone to the 4-weekly depot of its metabolite, paliperidone.
Objectives: We conducted a systematic review and meta-analysis on whether the frequency of depot administration (e.g. 2-weekly versus 4-weekly) affected compliance and outcome for an equivalent dose.
Methods: We systematically searched MEDLINE, PsycInfo, EMBASE and article bibliographies. The outcomes were health service use/cost, symptoms, quality of life and side-effects.
Findings: There were eight papers from seven studies (n = 3994) covering olanzapine, paliperidone, risperidone, Haldol and fluphenazine enanthate/decanoate with follow-up of up to 1 year. There were no differences in symptoms or quality of life between 2-weekly and 4-weekly doses. Health service use was not reported. Meta-analyses were only possible for side-effects. There were no differences in Parkinsonian symptoms, dyskinesia, akathisia or metabolic symptoms between regimes. Anticholinergic use was also the same (relative risk [RR] = 1.04; 95% confidence interval [CI] = 0.81, 1.34; two studies; n = 792).
Conclusions: There are surprisingly little data on the effect of dosing frequency for an equivalent dose on clinical outcomes and a need for long-term studies of a wide range of outcomes including cost-effectiveness. Claims for advantages of new preparations over others require careful evaluation.
Are Psychiatrists Feelings Doctors?
K Mack1, K Sevar2,3
1Northpark Private Hospital, Melbourne, VIC, Australia
2St Vincent’s Hospital, Melbourne, VIC, Australia
3Department of Psychiatry, The University of Melbourne, VIC, Australia
Background: Psychiatry has worked to establish itself as an authentic branch of medicine. Evidence-based psychiatry has emphasised the scientific basis of psychiatry with a resulting emphasis on medication and physical treatments. There has been less emphasis on psychiatrists as doctors who know about, and help with, emotional difficulties. However, recent developments in the scientific understanding of emotions may validate the return of the importance of feelings to psychiatry and the special place of psychiatry within medicine.
Objectives: To examine the importance of emotion in psychiatric diagnosis and treatment and to examine the broad base of knowledge about emotions including the evolutionary importance and ethology, the neuroanatomical pathways, the links between mind and embodied experience of affect, the normal and abnormal development of affect regulation and the relevance of this to psychiatric practice.
Methods: A literature review and consideration of the relevance of this knowledge to psychiatric practice.
Findings: Emotions are now understood as having purpose and survival value in evolutionary terms, and the neuroanatomical correlates of emotion are being revealed. The links between body and mind are being elaborated, for example, Porges’ Polyvagal theory, deeper understanding of mind–gut linkage and studies of the embodied effects of mindfulness practice all contribute to a scientific understanding of emotion.
Conclusions: This has implications for the training of psychiatrists where training has been largely focused on the service needs of public psychiatry rather than a more sophisticated development of knowledge into how to explore, understand and ultimately tolerate with the patient, distressing feelings and states of mind.
A Longitudinal Study of the Relationship between Anhedonia and Social Functioning in a Large Cohort of Patients Treated for Major Depressive Disorder by General Practitioners
D Gourion1, S Mouchabac2, F Vinckier3, A Singh4
1Private Practice, Paris, France
2Centre Hospitalier Saint-Antoine, Paris, France
3Centre Hospitalier Saint Anne, Université Paris Descartes, Paris, France
4School of Medicine, The Geelong Clinic and Deakin University, Geelong, VIC, Australia
Background: Anhedonia, a core symptom of depression and a key prognostic factor, is poorly explored in trials.
Objectives: To explore the correlation between social functioning and the course of anhedonia.
Methods: Prospective, observational, non-interventionist and open-label study carried out in France by 501 general practitioners. A total of 1570 adult outpatients with major depressive disorders (MDDs) and for whom the physician had decided to initiate treatment with agomelatine were enrolled. Patients were assessed using scales of depression (Montgomery–Asberg Depression Rating Scale [MADRS]), anhedonia (Snaith–Hamilton Pleasure Scale [SHAPS]) and social functioning (QFS) at inclusion and at 10–14 weeks.
Findings: There was a significant reduction in MADRS total score from inclusion to last visit (31.6 vs 15.1, p < 0.0001). At inclusion, 93.1% of patients had a SHAPS score of >5 (indicating severe anhedonia) compared to 19.8% at last visit.
There was also a significant improvement in social functioning in terms of satisfaction (QFS-S changed from 18.4 to 28.5) and frequency of social behaviours (QFS-F changed from 22.9 to 30.1, both p < 0.0001).
Critically, an exploratory logistic regression model highlighted several significant predictors of improvement in social functioning, of which improvement of anhedonia was the strongest (odds ratio = 7.3; p < 0.0001).
Conclusions: Reduced anhedonia appears a robust predictor of recovery of social functioning in patients with depression treated with agomelatine.
Funding
This study was supported by an unrestricted grant from Servier Laboratories.
The Psychiatry of Impunity - Transitional Justice in Cambodia
Maurice Eisenbruch
School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
Background: Psychiatrists treating a range of settings of violence – child abuse, violence against women or mass violence – need to understand the nature of impunity on the part of perpetrators that affect victims of violence. Transitional justice calls for a cultural understanding of impunity and accountability. There is a flawed assumption that mechanisms for transitional justice should be applied universally. In Cambodia, the former Khmer Rouge leadership is on trial at the Extraordinary Chambers in the Courts of Cambodia (ECCC). Victimisation has flowed from the Khmer Rouge period to the neo-liberal era and impunity is widespread at every level. Central is whether defendants and contemporary perpetrators admit their accountability or continue to hide under the cloak of impunity.
Method: Clinical ethnography over 25 years in Cambodia, working with victims and perpetrators in various settings, as well as with medical practitioners, monks, traditional healers, village heads and non-governmental organisations (NGOs) in civil society.
Findings: Some perpetrators ‘remember’ being victims of violence in a previous incarnation and were reborn as perpetrators, and some, if born with certain stigmata or if their parents failed to observe traditional codes of conduct, became prone to impunity. There are four pathways to impunity. A person enters the ‘road to ruin’ (apāyamuk), triggered by consorting with gangs and so on. The three ‘unwholesome roots’, craving (lobha), anger (dosa) and delusion (moha), poison the perpetrator’s mind. This leads to ‘clouded moral vision’ (mo baŋ) which blinds him to the effects of the atrocities. There is a breakdown in hiri-ottappa, a failure of conscience, in which perpetrators become immune to shame and externalise their blame to foreigners, their victims’ morality or astrological incompatibility and so on, in an unending display of impunity.
Conclusions: The key is to understand whether the perpetrators – Khmer Rouge defendants or contemporary perpetrators – have evil intent. There is a tension between Western and Cambodian tenets of justice, punishment and forgiveness, which adds weight to the call for a ‘bespoke’ form of transitional justice.
The Stress Systems in Depression: A Postmortem Study
A Bao1, DF Swaab2
1Department of Neurobiology, Institute of Neuroscience, School of Medicine, Zhejiang University, Zhejiang, China
2Netherlands Institute for Neuroscience, An Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, The Netherlands
Although the symptoms of depression are well characterized, the molecular mechanisms underlying this disorder are largely unknown. Factors involved in the heterogeneous pathogenesis of depression include polymorphisms in stress-related genes, gender, age, developmental history and environmental stressors as epigenetic factors. These factors may make different parts of the stress-related brain systems more vulnerable to different stressful life events or psychological stresses, causing alterations in a network of neurotransmitters and neuromodulators including amines, amino acids, nitric oxide (NO) and neuropeptides, and finally make individuals at risk of depression. The hypothalamic–pituitary–adrenal (HPA) axis has a prominent position in this network. With the postmortem brain material obtained from the Netherlands Brain Bank, we have conducted a series of studies with the aim of elucidating the specific changes in these systems in relation to special subtypes of depression. Our final destination is to set up tailor-made treatment for depressive patients on the basis of their developmental history, genetic and epigenetic background and the vulnerability in particular neurobiological systems. This presentation is a review on our findings of the changes in systems of sex steroids, receptors in the hypothalamic paraventricular nucleus, corticotrophin-releasing hormone, orexin, gamma-aminobutyric acid and NO in the etiology of depression, in relation to HPA activity, sex differences and suicide.
Healing the Heart of Recovery
J Liggins1,2
1Counties Manukau Health, Auckland, New Zealand
2University of Auckland, Auckland, New Zealand
Background: Recovery, a guiding principle of mental health services in New Zealand and Australia, has its origins in the service user movement in the era of deinstitutionalization. Patricia Deegan (1996), an early proponent, described recovery as a ‘journey of the heart’, writing evocatively of her personal experiences of illness, healing and recovery. ‘Recovery’, in the psychiatric literature, remains a contested term, being used inconsistently with varying implications for policy and practice. The recovery that I came to know as a psychiatrist was steeped in models and policy: a tick-box of competencies that told me the skills and knowledge I needed as a clinician.
Objectives: In this paper, I will argue that the translation of a once emancipatory movement (recovery), into a guiding vision for mental health services, came with risk and loss: the dilution or, indeed, disappearance of the subjectivity that lies at the heart of the lived experience of mental illness.
Methods: Drawing on the therapeutic landscape literature (Gesler, 2005), this qualitative research project utilized the notion of healing to investigate, from the service user perspective, the influence of place on recovery from mental illness. In addition to describing places they had been when unwell, participants (including the author) talked about what it was like to be unwell and how that changed in the places they identified as healing. Thematic analysis facilitated a conceptualization of healing.
Findings and conclusions: Healing, in relation to mental illness, is conceptualized as a journey of exploration that takes time and is hard work. Facilitating connection and integration, understanding and wisdom, healing is the intensely personal process at the heart of recovery.
References
Deegan PE (1996) Recovery as a journey of the heart. Psychiatric Rehabilitation Journal 19: 91–97.
Gesler WM (2005) Therapeutic landscapes: An evolving theme. Health and Place 11: 295–297.
Dementia in Australia’s Aboriginal and Torres Strait Islander Population
R Parker
Northern Territory Clinical School and School of Medicine, Flinders University, Adelaide, Australia
Background and objectives: To demonstrate and discuss factors relevant to a recognised increased prevalence of dementia in Australia’s Aboriginal and Torres Strait Islander population.
Methods and findings: Recent studies conducted in varying geographical locations in Australia appear to indicate that Aboriginal and Torres Strait Islander people have a prevalence of dementia of about three times that of the general Australian population (Parker, 2014). A literature review appears to indicate that a number of factors may account for this increased prevalence. These factors include generational trauma and its potential genetic and social influences on Aboriginal populations (Brockie et al., 2013), diabetes, increased rates of intellectual disability in childhood, a greater amount of exposure to concussive head injury (Jamieson et al., 2008), along with greater exposure to lifestyle issues such as smoking and alcohol abuse.
Conclusions: The recognised increased prevalence of dementia in Australia’s Aboriginal and Torres Strait Islander population appears to be multifactorial and strongly linked to other health inequalities in this population.
Brockie T, Heinzelmann M and Gill J (2013) A framework to examine the role of epigenetics in respect to health disparities amongst Native Americans. Nursing Practice and Research 2013: 410395.
Jamieson LM, Harrison JE and Berry JG (2008) Hospitalisation for head injury due to assault amongst Indigenous and non-Indigenous Australians July 1999–June 2005. Medical Journal of Australia 188: 576–579.
Parker R (2014) Dementia in Aboriginal and Torres Strait Islander people. Medical Journal of Australia 200: 435–436.
The Feasibility of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID-I) as a Practical and Culturally Appropriate Method of Diagnosing Mental Disorders in Indigenous Australianss
M Toombs1, N Gill1, B Nasi1, E Black1, S Kisely1, G Beccaria2, S Kondalsamy-Chennakes1, G Ranmuthugala1, N Hayman1, G Nicholson1,3
1Rural Clinical School, The University of Queensland, Toowoomba, QLD, Australia
2School of Psychology and Counselling, University of Southern Queensland, Toowoomba, QLD, Australia
3Institute for Health and Ageing, Australian Catholic University, Melbourne, VIC, Australia
Background: Although there have been many small studies of mental health in specific Indigenous Australian communities, reliable data on mental illness are mostly lacking. Studies that evaluated a range of mental illnesses using structured diagnostic assessments have not attempted to culturally validate these assessments. Therefore, it is not known whether structured diagnostic tools employed in the literature provide accurate prevalence data of mental illness in Indigenous Australians.
Objectives: To determine, in Indigenous Australians, the cultural appropriateness of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-TR Axis I Disorders (SCID-I) and to provide insight into the prevalence of mental illness in this population.
Methods: A randomly selected cohort study of participants opportunistically recruited from a regional Aboriginal Medical Service completed an SCID-I non-Patient edition, administered by a culturally educated and trained psychologist. This pilot study now informs part of a larger National Health and Medical Research Council project grant.
Findings: From a total of 53 participants, 22 (41%) had current or past depression and 9 (17%) an anxiety disorder. The anxiety disorders included generalised anxiety, panic disorder or social phobia. Other conditions such as post-traumatic stress, obsessive–compulsive or bipolar disorders were much rarer. Alcohol dependence at interview, or in the past, was the most common comorbidity (17%). The interview was acceptable to participants.
Conclusions: These preliminary data suggest that the SCID-1 is well tolerated and has the potential to be a valid diagnostic measurement tool that could be used to help support stakeholders working with Aboriginal and Torres Strait Islander people at risk of mental health disorders.
The Injured Motorist and the Psychiatrist
PW Anderson
Berry Road Forensic Practice, Sydney, NSW, Australia
Background: Psychiatrist clinicians are sometimes called to treat injured motorists and often express to me an interest in the medico-legal process and an interest in outcome.
Objectives: To shine light upon an opaque area.
Methods: A forensic psychiatrist looks anecdotally at 500 claimants assessed for psychiatric injury and impairments caused by motor vehicle accidents within the New South Wales jurisdiction, one which has been (largely) taken away from the courts. An examination is made of the claims assessment process.
Findings: Predictions about the future, largely based on stability of symptoms and impairment in the present, are sometimes wrong. Subgroups which divulge useful findings are claimants whose cases are re-opened due to unexpected deterioration and claimants assessed as permanently impaired after a first accident and then presenting a history of recovery prior to a second accident. Aspects of social background and status of claimants are highlighted. Varying attitudinal factors within claimants are found relevant.
Conclusions: The medico-legal process itself is a variable which has effects on symptoms, impairments, treatments and outcomes.
A Survey of Mental Health Exclusion Clauses in Life Insurance Policies
J Dunn
Fellow Australasian Underwriters and Claims Association, Crows Nest, NSW, Australia
Background: Many psychiatric patients complain that their applications for life insurance have been declined or limited by mental health exclusion clauses. Over a period of 15 years, the presenter has offered advice to eight life insurers and reviewed more than 12,000 psychiatric claims.
Objectives: To examine the content and effectiveness of exclusion clauses in policies.
Methods: The linguistics and impact of exclusion clauses used by six large Australian life insurers are presented and analysed.
Findings: The exclusion clauses contain direct statements about exclusion and qualifying phrases (‘directly or indirectly’, ‘as a consequence thereof’) followed by a list of both symptoms and diagnoses.
Conclusions: Many nominated exclusions are either obsolete (‘psychoneuroses’) or impractical (‘behavioural disorders’). Exclusion clauses are written when policies are sold and may have no currency when claims are made decades later. Although life insurers run at a significant loss, most fear that forceful exclusion clauses will make their policies uncompetitive. Enforcement of psychiatric exclusion clauses is rare because of (1) problems with nosology, (2) the complexity of somatic symptom disorders and (3) case law that supports the patient. From a practical perspective, expensive mental health claims are not driven by pre-existing diagnosis but by the insured person’s regression into the roles of patient, victim and claimant. These are the factors that are impossible to predict at the time of application and subsequently appear in none of the medical reports.
An Assessment of the Reliability and Validity of the Guide to the Evaluation of Psychiatric Impairment for Clinicians
MW Epstein1, D Barton2
1Consultant Psychiatrist, Melbourne, VIC, Australia
2Monash Alfred Psychiatry Research Centre and Central Clinical School, Monash University, Melbourne, VIC, Australia
Background: Reliable assessment of injuries incurred by workers or victims of transport accidents is critical to all worker’s compensation and motor accident schemes. Monetary benefits are provided on the basis of the claimant’s level of physical and psychiatric impairment. In 2014, the Victorian WorkCover Authority paid CAD88 million for impairment benefits.
Most Australian jurisdictions use the American Medical Association Guide to Permanent Impairment but not for assessment of psychiatric illness, as the method described is unworkable. Accordingly, psychiatric impairment assessment methods have been locally developed, in Victoria and South Australia, the Guide to the Evaluation of Psychiatric Impairment for Clinicians (GEPIC).
Despite the significant cost to communities, there have been no studies regarding the validity and reliability of any scale used to determine psychiatric impairment. This, therefore, will be the first occasion that any data on the reliability of any psychiatric impairment scale have been presented.
Objectives: To assess the validity and reliability of the GEPIC.
Methods: Since 2007, 114 trainees have been trained to use the GEPIC; this has involved a 3-hour session and then scoring five standardised case studies using the GEPIC, and these scores have been recorded.
Findings: The face, content and discriminant validity data will be presented. The interrater reliability utilizing Cohen’s kappa score for the GEPIC is being analyzed and the results will be presented.
Conclusions: This paper will present, for the first time, data on the validity and reliability of the GEPIC, a widely used tool for the assessment of psychiatric disability in Australia.
A Review of Australia’s Efforts in Reducing Restrictive Practices in Mental Health Services
J Allan1-3
1Mental Health Alcohol and Other Drugs Branch, Queensland Health, Brisbane, Australia
2Chair Safety and Quality Partnerships Standing Committee, Canberra, Australia
3University of Queensland, Brisbane, Australia
Background: The last 10 years has seen considerable progress in relation to seclusion data development and reduction initiatives in Australia. Part of the success has been the use of a standardized definition and national collection of data for benchmarking and quality improvement. The National Seclusion and Restraint Reduction Project has encouraged services and individuals to reconsider their practices, and there has been a flurry of activity at local, state and national levels.
Objectives: This paper describes that journey presents data from the national collection and looks at the future intentions of the Project.
Findings: The acute mental health units have progressively reduced their use of seclusion in the last 6 years from 13.8 episodes per 1000 bed days in 2009–2010 to 8.0 in 2013–2014. Despite this, an average of 5% of people admitted to specialized services still experience an episode of seclusion, and there are considerable variations across sites and age ranges. There have also been some remarkable successes, particularly when consumers have been actively involved in the response.
Conclusions: The call for ‘recovery’ challenges us to think about many other forms of restrictive practice. We are at various stages in the development of national measures of physical and mechanical restraints, continuing involuntary treatment and acute injectable medications. As seclusion once was, much of this has been considered necessary for safety or to get a good outcome. Is this true and what does the future hold?
A Retrospective Clinical Study of the Clinical and Demographic Characteristics of People Who Have an Autism Spectrum Disorder Referred To a Tertiary Mental Health Service
CND Bennett
Victorian Dual Disability Service, St Vincent’s Hospital, Melbourne, VIC, Australia
Background: Adults with autism have high rate of mental health problems, but little is known about how they present to mental health services.
Objectives:
1. To describe the characteristics of people with autism presenting to a tertiary mental health service;
2. To describe the mental health problems that people with autism present with.
Methods: An analysis of routine data collected by the service that includes basic demographic data, diagnostic data and information about mental health status.
Findings: Over 10 years, 388 people with an autism spectrum disorder (ASD) have been seen with an average age of 32 years, of whom 28% were female and 72% male; 36% had a mild intellectual disability (ID) and 30% had a moderate-to-severe ID, while 18% did not have an ID; 70% had an axis 1 diagnosis including 20% with schizophrenia; 8.7% had a diagnosis of personality disorder. At assessment, the average Health of the Nation Scale was 19.8 and Life skill profile score was 19.8. Particular difficulties were noted with aggression, social relationships and activities.
Conclusions: The results show the usual higher male excess seen in people with autism. People with moderate intellectual disability seem overrepresented. A range of diagnoses are seen and psychotic disorders are common. The scores on standardised tools indicate a population with high needs.
Psychogeriatric Services-on-Screen: A Unique E-Health Clinician-to-Clinician Solution for Under-Resourced Areas
J Huber1, D Burke1,2
1St Vincent’s Hospital, Sydney, NSW, Australia
2Mater Misericordiae University Hospital, Dublin, Ireland
Background: Mental health services in rural Australia are under-resourced and over-burdened. Given the aging population and escalating health costs, we need to innovate to solve this resourcing crisis. Psychogeriatric services-on-screen (SOS) is a unique service that offers information, advice, supervision, training, education and case conferencing to rural and remote clinicians across all disciplines, allowing them to establish a supportive professional relationship with our psychogeriatric multidisciplinary team via a web-conferencing platform. This nascent service has the potential to be a pathway for more efficient use of time for primary clinicians and specialty psychogeriatric services.
Objectives:
To describe rural clinician/user demographics, how this model satisfies unmet clinician professional needs and to improve clinician confidence;
To explore a business model that will ensure sustainability of the service;
To provide a forum in which members of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) can make comments and suggestions.
Methods: Rural and remote clinicians in three under-resourced local health districts in New South Wales and one non-governmental organisation have been provided this service in 2015. Demographic data and outcome measures (user satisfaction, clinician confidence) are collected.
Findings: Clinician confidence depends on clinician type, context of practice and number of years practicing. All users have returned to use the service more than once. The most prominent areas of need appear to be addressing and educating patients’ carers, and education and case conferencing around clinical psychogeriatric issues.
Conclusions: There is a need for the Psychogeriatric SOS model of e-health rural outreach, which may constitute a step toward the more efficient and effective use of mental health resources in rural and remote Australia.
Anticholinergic Burden in Inpatient Psychogeriatric Population: Do we Care?
M Lee1, B Zolotarev2, A Warren2, J Henderson1, M George1
1West Moreton Mental Health Services, Ipswich, QLD, Australia
2School of Medicine, The University of Queensland, Ipswich, QLD, Australia
Background: Although recent studies have found that there is significant association between anticholinergic and cognitive impairment, especially in the elderly population, there seems to be minimal emphasis on anticholinergic burden (ACB) when prescribing medications to the inpatient psychogeriatric population.
Objectives: To evaluate the prescribing patterns in an Older Person Mental Health Inpatient Unit (OPMHU), whether the ACB score on admission has been reviewed for lowest possible ACB while maintaining therapeutic effects. A protocol will be developed to ensure that ACB is reviewed for future admissions and discharges.
Methods: In all, 50 patients admitted and discharged from OPMHU meeting inclusion criteria are recruited retrospectively from 30 September 2015. Individual ACB score is calculated on admission and discharge is based on the pharmacist’s final medication summary. The patients’ mental health records are also audited for any documented ACB review by the treating team while making note of any pre-existing cognitive impairment.
Findings: The ACB has not been taken into consideration in all patients by the treating team on admission and discharge. On average, the total ACB score showed an increment of 14% on discharge (3.6) when compared to the admission score (3.16). On discharge, 50% of patients have an increased ACB score while only 10% have a reduced ACB, and 21 patients have documented cognitive impairment.
Conclusions: The study found that although ACB poses significant risks on cognitive impairment, this knowledge has not been employed pragmatically. A protocol should be developed to ensure that ACB is evaluated and managed accordingly.
Symptom Assessment Manager: Using a Computerised Program for Tracking Challenging Behaviours
SM Loi1,2,3, DG Darby4,5,6, D Huppert2, NT Lautenschlager1,2
1Academic Unit for Psychiatry of Old Age, Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
2NorthWestern Mental Health, Melbourne Health, Parkville, VIC, Australia
3St Vincent’s Aged Mental Health, St George’s Campus, Kew, VIC, Australia
4Department of Medicine, Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, VIC, Australia
5Eastern Cognitive Disorders Clinic, Box Hill, VIC, Australia
6Melbourne Health, Department of Medicine, The Royal Melbourne Hospital, Parkville, VIC, Australia
Background: Challenging behaviours, such as delusions, hallucinations, aggression and agitation, are seen in people with dementia (PWD) and other psychiatric disorders. Up to 90% of PWD will experience such behaviours during the course of their dementia. These behaviours cause much distress for carers and the people experiencing them and are associated with poorer prognosis and diminished quality of life. Accurate information regarding these behaviours such as the time, duration and possible triggers is essential for effective management. The current methods of assessing these behaviours are limited, especially in the context of time-poor staff in aged care facilities.
Objectives: The Symptom Assessment Manager (SAM) is a computerised behaviour monitoring program which was developed to address the limitations of previous methods of behaviour assessment tools.
Methods: Qualitative interviews were done with key clinicians in order to identify the essential components of such a program. The SAM was piloted with 20 patients in an inpatient psychiatric unit that admits people with a range of psychiatric problems from April 2014. It was evaluated using a quantitative questionnaire.
Findings: The program was found to be a simple, user-friendly method of tracking challenging behaviours.
Conclusions: The SAM is a novel method of monitoring challenging behaviours, which can assist in the implementation of appropriate management strategies. Further trials in different settings are required.
The Last Action Hero: Male Movie Stars and Aging
J Parmegiani
Chambers Medical Specialists, Sydney, NSW, Australia
Background: Role models can have a powerful influence on human behavior and motivate positive change where other measures have failed. Aging action heroes in movies encourage middle-aged men to remain physically fit, engaged and feeling positive. The epidemiological impact on men’s mental health can be significant.
Objectives: To investigate whether aging male actors can maintain a high degree of physical fitness and agility and the implications this can have on society. The impact of exercise on aging, mental health and general well-being will be discussed. The presentation aims to educate and entertain participants.
Methods: A number of video clips will be presented, including action sequences of Tom Cruise (age 53 years, Top Gun, Mission Impossible), Stephen Lang (age 63 years, Manhunter; Colonel Quaritch, Avatar) and the decline of Rutger Hauer (age 72 years, Blade Runner, Hobo with a Shotgun). A review of research on exercise and cognitive function will be presented.
Findings: Some actors have maintained a high degree of physical fitness, agility and healthy body mass index, whereas others have followed a more conventional path of physical decline. Aging action heroes demonstrate that men have some control over their health.
Conclusions: Movies with aging action heroes should be used to promote men’s health. Their role is to inspire and motivate.
Affective Blunting In General Practice: An Update from the Prism Audit
D Castle1, M Hopwood2
1St Vincent’s Hospital, Melbourne, Australia
2University of Melbourne, Melbourne, Australia
Background: Depressed mood (negative affect) and/ or diminished interest and pleasure (positive affect) are key symptoms in depression diagnosis. Most traditional depression rating scales focus on negative effect. However, patients are generally most concerned with the restoration of their positive mental health.
Objective: Positive Response In depression Management (PRISM) is a GP audit aiming to improve the management of patients with depression by assessing positive affect in these patients.
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 SHAPS and other validated depression rating scales.
Clinicians asked patients to compare their current emotional response with their normal emotional response (before depressive episode) in 6 different scenarios.
Findings: 1,547 GPs audited 9,096 patients. 755 GPs completed the 10 patient audit. 13% of all patients scored low in the CHEER index, while 40% and 47% of patients scored medium and high respectively. A high score indicates greater positive affect that may impact on recovery.
82% of patients were compliant with medication advice 1-3 months after initiating treatment. 1 month after audit completion, 92% of GP’s continued to assess positive affect of patients using the CHEER index.
Conclusions: The CHEER Score is a practical tool for the assessment and management of patients with depression, as is evident by the large number of GP’s who continue to use the CHEER index after completion of the PRISM audit.
The PRISM clinical audit is supported by Servier Laboratories.
Barriers to Consultation-Liaison Psychiatry Referral: Narrative Literature Review
K Chen1,2, S Larkins2
1Townsville Hospital Health Service, Townsville, QLD, Australia
2James Cook University, Townsville, QLD, Australia
Background: Consultation-liaison psychiatry (CLP) is a subspecialty of psychiatry that provides care to general hospitals. Despite mounting evidence for the involvement of CLP for inpatients with psychiatric comorbidities, referral rates from treating doctors remain low.
Objectives: This narrative review aims to understand barriers to CLP referral.
Methods: MEDLINE, PsychINFO, CINAHL and SCOPUS were searched using keywords for articles published between 1 January 1965 and 30 September 2015.
Findings: Totally, 36 eligible articles were found that contribute to this topic, and they were grouped into three categories: (1) systemic factors, (2) referrer factors and (3) patient factors.
This is the first narrative review of its kind that examines barriers to CLP referral. Interplay of these factors may need further research.
Conclusions: CLP clinicians should use the knowledge gained in this review to increase referral rates and bring about psychiatric care to non-psychiatric inpatients.
Granulocyte Colony-Stimulating Factor in the Management of Clozapine-Induced Agranulocytosis
A Gupta1, G Goh2, D Lam1, T Bastiampillai1
1Flinders Medical Centre, Adelaide, SA, Australia
2The University of Adelaide, Adelaide, SA, Australia
Background: It is well documented that clozapine can lead to agranulocytosis, a rare blood dyscrasia, defined as an absolute neutrophil count (ANC) below 500/mm3. It is characterized by leukopenia and neutropenia and can last up to roughly 3 months. In most patients, the risk of developing agranulocytosis decreases over time with the highest incidence within the first 18 weeks of initiating clozapine treatment.
Objectives: To explore the role of granulocyte colony-stimulating factor (G-CSF) in the management and prophylaxis of clozapine-induced agranulocytosis.
Methods: Literature search and review of the available peer-reviewed articles related to this topic.
Findings: G-CSF (filgastrim) has been discussed as a treatment option should agranulocytosis occur during the prescription of clozapine. The short-term use of G-CSF has been shown to be successful in restoring ANC following agranulocytosis induced by clozapine, and when used immediately after developing agranulocytosis, it has also been shown to reduce the duration of agranulocytosis (Mathewson and Lindenmayer, 2007; Nooijen et al., 2011). Ultimately, the addition of G-CSF in patients who develop clozapine blood dyscrasias may allow for continuation of clozapine treatment if other antipsychotics are less effective.
Conclusions: The management of agranulocytosis, a rare adverse effect of clozapine, is a worthwhile endeavour as it could enable practitioners to avoid withdrawing clozapine unnecessarily on the grounds of hematological dyscrasias. G-CSF appears to be a suitable option to achieve this goal.
References
Mathewson KA and Lindenmayer JP (2007) Clozapine and granulocyte colony-stimulating factor: potential for long-term combination treatment for clozapine-induced neutropenia. Journal of Clinical Psychopharmacology 27: 714–715.
Nooijen PM, Carvalho F and Flanagan RJ (2011) Haematological toxicity of clozapine and some other drugs used in psychiatry. Human Psychopharmacology 26: 112–119.
Experience of the Psychiatrist in a Multi-Disciplinary Sleep Service
CJ Blackwell1, MJ Kalucy2, S Kumar1, D Banerjee1, D Bartlett1, R Grunstein1, D O’Brien1
1
The Woolcock Clinic, Sydney, NSW, Australia
2Prince of Wales Hospital, Sydney, NSW, Australia
Background: The Woolcock Clinic is a private multi-disciplinary sleep and respiratory disorder clinic within an academic research institute associated with the University of Sydney. The focus of the clinic is the comprehensive treatment of sleep and respiratory disorders by subspecialties – sleep and respiratory medicine, neurology, psychology, ear, nose and throat (ENT) surgery, dentistry, paediatrics, endocrinology and psychiatry – as well as associated clinical support staff including sleep and Continuous Positive Airway Pressure (CPAP) technicians and exercise physiologists.
Objectives: The presentation will discuss the role of the psychiatrist in the multi-disciplinary medical clinic and the ongoing challenges associated with establishing and participating in such a service as psychiatrists.
Methods: The process of establishing a role within the clinic will be discussed and the current roles of a psychiatrist presented including profiles of the referral pattern, patients, issues and the challenges in this type of clinical practice. International experience of similar roles for the outpatient consultation-liaison psychiatrist will be compared.
Findings: Psychiatric input was sought from the inception of the Woolcock Clinic. In the past 12 months, the Clinic has seen more than 3000 outpatients and performed over 2300 sleep studies.
The demand for psychiatric services has grown for direct consultation and in liaison roles. Currently, two to three psychiatrists are available for four to five clinical sessions per week. The psychiatrists attend multi-disciplinary meetings on a very regular basis and contribute directly to teaching medical students and to broader teaching and research activities within the Woolcock Institute and Clinic.
Conclusions: Psychiatrists have been integral within the multi-disciplinary team and provide a key role in provision of comprehensive clinical care to complex patients.
Psychological Interventions for Atypical Chest Pain: Update of a Cochrane Systematic Review and Meta-Analysis
S Kisely1,2, LA Campbell3
1School of Medicine, The University of Queensland, Brisbane, QLD, Australia
2Griffith University, Gold Coast, QLD, Australia
3Maritime SPOR SUPPORT Unit, Capital Health, Halifax, NS, Canada
Background: Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. This presentation is an update of a Cochrane review originally published in 2005.
Objectives: To assess the effects of psychological interventions for chest pain, quality of life and psychological parameters in people with atypical chest pain.
Methods: We searched the Cochrane Library, MEDLINE, CINAHL, PsycINFO and BIOSIS Previews for randomised controlled trials (RCTs).
Findings: We identified 17 RCTs with 1006 randomised participants. There was a significant reduction in reports of chest pain in the first 3 months following the intervention: relative risk (RR) = 0.70 (95% confidence interval [CI] = 0.53, 0.92). This was maintained from 3 to 9 months afterwards: RR = 0.59 (95% CI = 0.45, 0.76). There was also a significant increase in the number of chest pain–free days up to 3 months following the intervention: mean difference (MD) = 3.00 (95% CI = 0.23, 5.77). This was associated with reduced chest pain frequency in the first 3 months but not subsequently. Benefits were largely restricted to cognitive-behavioural therapy (CBT). Hypnotherapy also showed promise.
Conclusions: We found a modest to moderate benefit for psychological interventions, particularly those using CBT and especially in the first 3 months after the intervention. Hypnotherapy is also a possible alternative. However, these conclusions are limited by high heterogeneity in many of the results and low numbers of participants in individual studies. The evidence for other brief interventions was less clear. Further RCTs with follow-up periods of at least 12 months are indicated.
Psychiatric Morbidity in Indigenous Peoples from Australia and the Americas: Unexpected Findings from a Systematic Review and Meta-Analysis
S Kisely1,2, E Black2, K Alichniewicz2, G Ranmuthugala2,3, S Kondalsamy-Chennakesavan2,3, D Siskind1,2, M Toombs2,3, G Nicholson2,3
1Metro South Addiction and Mental Health Service, Brisbane, QLD, Australia
2School of Medicine, The University of Queensland, Brisbane, QLD, Australia
3Centre for Health Sciences Research, University of Southern Queensland, Toowoomba, QLD, Australia
Background: Indigenous populations are often considered at high risk of psychiatric disorder, but many studies do not include direct comparisons with the general population.
Objectives: To undertake a meta-analysis of studies comparing the prevalence rates of psychiatric disorders in Indigenous populations in the Americas and Australia with those of other groups
Method: A systematic search of MEDLINE, PsycInfo, EMBASE and article bibliographies. We included empirical quantitative comparisons of the 12-month or lifetime prevalence of any psychiatric disorder in Indigenous and non-Indigenous populations.
Findings: We found 17 studies (n = 72,419) from Australia, Latin America, Canada and the United States. Indigenous people were at greater risk of concurrent post-traumatic stress disorder (odds ratio [OR] = 1.62; 95% confidence interval [CI] = 1.20, 2.1), alcohol use disorders (OR = 1.93; 95% CI = 1.50, 2.48) and substance use (OR = 2.02; 95% CI = 1.40, 2.93). However, there were no differences between Indigenous and non-Indigenous groups in the prevalence of a range of depressive and anxiety disorders. In some studies, Indigenous rates were lower. The results did not vary greatly by continent or setting (e.g. urban/rural). There were no differences in the lifetime prevalence rates of any disorders.
Conclusions: The reasons for these results are unclear. One explanation might be that assessment tools may not accurately measure psychiatric symptoms in Indigenous populations. Future research therefore must ensure that diagnostic instruments are validated for use with Indigenous people. Another possibility might be that risk factors for psychiatric illness are a complex interaction of educational, economic and socio-cultural factors that may vary from disorder to disorder. Interventions need to take into account that disadvantage is rarely due to one factor.
Psychotherapy and the Sublime: Using a Kantian Philosophy of Aesthetics in Psychotherapy
P Cadzow
Clear Sky Specialist Clinic, Buderim, QLD, Australia
Background: Psychotherapy can be understood as a creative enterprise in which the patient acquires a deeper, more complex and reflective sense of self via the interpretative and mediating efforts of the psychotherapist. Callender has argued that a Kantian Philosophy of Aesthetic Judgement can have utility in understanding the nature of a patient’s dilemma which they are attempting to resolve in psychotherapy and may provide a structure for the therapist to conceptualise the patient’s plight. The Kantian concept of ‘formal beauty’ is of a state of internal coherence and unity, and not one of superior prettiness. For patients with histories of trauma and neglect who have developed a debased sense of self or have been unable to establish a sense of a moral or just (enough) world, the process of psychotherapy can lead to an inner authenticity and self-acceptance, a state similar to Kant’s formal beauty.
Methods: The presenter will provide a brief overview of Kant’s Aesthetic Philosophy and the elements of aesthetic judgements, and then via clinical vignettes, demonstrate how aesthetic philosophy can provide a nexus for the emotional, cognitive, ethical and ‘life meaning’ which informs psychotherapeutic work.
A Protocol for Stress Reduction Training in Adults with Conversion Disorder
C Chapman1,2,3, L McLean1,2,4,5
1Western Sydney Local Health District, Sydney, NSW, Australia
2Westmead Psychotherapy Program (WPP), Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
5New South Wales Institute of Psychiatry, Sydney, NSW, Australia
4Department of Consultation-Liaison Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia
3BMRI, Caperdown, NSW, Australia
Background: Patients with conversion disorder have dysregulated stress responses. Children with these disorders have responses associated with particular symptom clusters and attachment patterns. Breathing stress reduction training, using MyCalmBeat™, has been used clinically to modify the stress response in these patients.
Objectives: This study seeks to examine in adults, with and without conversion disorder, whether 1 month of stress reduction training modifies the stress response associated with cognitive testing and whether adult attachment state of mind predicts the utilization and benefit from this stress reduction training.
Methods: An initial pilot study plans to recruit 15 patients with clinical conversion disorder and 15 healthy adults in the first year of the study. Participants have Adult Attachment Interviews at baseline. A non-invasive ear-clip measure of heart rate variability (HRV) measures cardiac RR intervals before, during and after cognitive testing with WebNeuro™. A best breathing rate is calculated by measuring HRV across a range of breathing rates. The participant is trained to use this breathing rate twice daily for 10 minutes using either an app or a watch. WebNeuro testing with simultaneous cardiac monitoring is repeated following 1 month of this practice.
Findings: We present preliminary data from the pilot study comparing utilization and benefit from the breathing stress reduction training program in terms of baseline attachment profiles.
Conclusions: It is possible, in somatically sensitive patients, to calculate psychophysiological measures of HRV from portable devices such as MyCalmBeat™ for the purposes of tracking stress responses over time under various cognitive tasks.
A Critique of Exposure Therapy for Treating Posttraumatic Stress Disorder
A Dinnen
ANTHONY DINNEN P/L, Sydney, Australia
Background: Australian war veterans and service men and women have been assessed and treated for traumatically induced psychiatric disorders over a period of 45 years. The common diagnosis in the 1970s was ‘anxiety state’, and the focus in therapy was psychoanalytic. The focus has increasingly been on the interplay of biology and environment since the 1980s when the syndrome of posttraumatic stress disorder (PTSD) was elucidated. Treatment objectives and modalities have changed so that the ‘gold standard’ today is exposure therapy (usually described by an acronym), provided by a psychologist, with the psychiatrist relegated to prescribing medication.
Objectives: To describe the methods, rationale and shortcomings of exposure therapy in this context.
Methods: A review of the biology of PTSD and its psychological and neurophysiological base;A review of the natural history of the disorder;Clinical findings after treating thousands of patients.
Findings: Most traumatized patients avoid visiting reminders of their experience. They find exposure therapy to be very distressing. Most therapists change their approach in the course of treatment for this reason. The available literature also now seems to point to problems with results.
Conclusions: Exposure therapy is hazardous and should be used parsimoniously.
PIF Presentations
Risky Business: High-Risk Sexual Behaviour in Young People with Mental Health Disorders
AA Sanchez1, BB O’Donoghue1,2
1The University of Melbourne, Melbourne, VIC, Australia
2Orygen Youth Health, Melbourne, VIC, Australia
Background: In Australian populations, both the onset of psychiatric illness and engagement in high-risk sexual behaviours peak in adolescence and young adulthood. International studies have reported a number of sexual risk factors including higher incidence of sexually transmitted infections, higher number of sexual partners and earlier age of first sexual intercourse, and inconsistent condom use and birth control in young people with mental health disorders. This has high clinical importance, as engagement in high-risk sexual behaviours can have significant consequences for the young person, which could further negatively impact their mental health. Despite this, the intersection between mental health and sexual health and its implication remains to be fully explored in Australian populations.
Objectives: This study will determine the prevalence of high-risk sexual behaviours and their consequences in young people affected by a mental health disorder attending a youth mental health service.
Methods: The study design is a cross-sectional survey conducted across four specialist teams at Orygen Youth Health. We aim to recruit 100 young people aged between 15 and 24 years, stratified according to gender, psychotic and non-psychotic disorders. The survey instruments include the Sexual Health Questionnaire, Sexual Functioning Questionnaire, Brief Psychiatric Rating Scale, Schedule of Negative Symptoms, Medication Compliance Interview and Kessler 6.
Findings: Recruitment and interviews will commence on December 2015 and the results will be available by May 2016.
Conclusions: The existing literature points towards a complex relationship between sexual health and mental health in young people. This study aims to expand our knowledge of high-risk sexual behaviours in young people with mental health disorders.
Brave New World: Pluralism and Psychiatry in the 21st Century
AA Sanchez
The University of Melbourne, Melbourne, VIC, Australia
Background: Similar to the attempt to unify quantum mechanics and general relativity, psychiatry in the 21st century faces the task of reconciling the minute, complex systems of genetics, neural circuits and biochemistry with the huge phenomena of human experience, society and its influence. Today, a number of frameworks exist that attempt to give psychiatry a theoretical foundation. With such uncertainty about the epistemology of mental illness, the philosophy of psychiatry has profound implications for its practice.
Advancements in neuroscience attempt to thoroughly deconstruct mental illness into its genetic, biochemical and neurophysiological constituents, so we can correlate abnormal brain development with observed clinical symptoms. In a way, psychiatry can use the latest tools to create mental illness piece by piece, molecule by molecule, neuron by neuron. For future psychiatrists, these advances signify a certain optimism about our ability to decode mental illness and thus provide better diagnoses and highly efficient, targeted care.
The complexities of mental illness, however, ask for a broader understanding than that provided by biological models. Psychiatrists must be finely attuned to their social milieu since understanding mental illness requires a nuanced understanding of the influence of culture and society on the individual. As invaluable as neuroscientific tools are, to attempt to understand mental illness as purely a disorder of genes, proteins and neural circuits would be to miss the forest for the trees.
It is clear that mental illness must be approached from various planes of analysis. Neither a human being nor mental illness can be understood by any one system of knowledge. This session aims to explore pluralistic models and their implications for future psychiatrists.
Unexplained Neurological Symptoms: The Patient’s Perspective
JM Ding1,2
1Department of Psychiatry, Austin Health, The University of Melbourne, Heidelberg, VIC, Australia
2Department of Psychological Medicine, Institute of Psychiatry Psychology & Neuroscience, King’s College London, Weston Education Centre, London, UK
Background: Unexplained neurological symptoms (UNS) are among the most common conditions a neurologist will encounter, but there is no consensus within the field as to what they should be called. This is important as patient acceptance is a predictor of outcome and there is evidence that patients are unhappy with the terms used. Patient understanding of the terms may be limited, however, and once explained, the terms may seem more or less offensive.
Objectives: This study aimed to elicit patients’ preferences and understanding of six frequently used terms for UNS and whether these changed once definitions were provided.
Methods: In total, 185 participants were recruited from a general medical outpatient waiting room. They were given questionnaires detailing a hypothetical situation of leg weakness, with seven labels that may be used to explain it and four possible connotations for each. We recorded responses before and after definitions were given for each of the seven terms and calculated the ‘number needed to offend’.
Results: It was found that ‘functional’ was significantly less offensive than other terms used. Understanding of the terms was generally low, however, and many of the terms became significantly more offensive once definitions were provided. This effect was especially seen in patients with poor reported understanding.
Conclusions: Much of the ‘offence’ in UNS lies not in the terminology but in the meaning those terms carry. This study replicated findings of previous studies that ‘functional’ was significantly less offensive than other common terms, even after explanation, but in common with most terms, this was partly due to patients’ limited understanding of its meaning.
Finding Light at the End of the Tunnel: A Longitudinal Study of Depressed Medical Students
B Jayawardena, Z Lyons, S Hood
School of Psychiatry and Clinical Neurosciences, The University of Western Australia, Perth, WA, Australia
Background: Few studies of depression in medical students have been able to track participants each year while maintaining anonymity. Anecdotal evidence suggests that the prevalence and severity of depression in this population are higher than in the general population.
Objectives: To follow a cohort of third-year medical students over 3 years, who have been diagnosed with depression or who are experiencing depressive symptoms, and to investigate the persistence of these symptoms as the students progress through the medical course.
Methods: In 2012, Year 3 medical students at the University of Western Australia completed a survey including demographic information and the Patient Health Questionnaire (PHQ-9). Participation was anonymous and responses were matched between years by utilising a respondent-generated de-identification matrix.
Findings: In Years 3, 4 and 5, 168, 148 and 169 students participated, respectively. A total of 114 responses could be matched between at least 2 years; 46% of students who were depressed (by PHQ-9 score) in Year 3 were also depressed in Year 4, in comparison with 5.9% of students who were not (p < 0.001). Half (50%) of the students with a clinical diagnosis of depression were depressed in Year 4, compared to 11.7% with no history (p = 0.01).
Conclusions: The findings suggest that students identified as being depressed by the PHQ-9 and by a previous clinical diagnosis in the early stages of medical school are at increased risk of recurrent and chronic depression in future years of medical school. New measures to support this group of students from the early stages of their medical education should be considered.
Predicting Outcome in Patients with First-Episode Psychosis: Pilot Study
M Kang1, B Murphy2, A Carroll3, W Brewer4
1Monash University, Melbourne, VIC, Australia
2Monash Health, Melbourne, VIC, Australia
3Swinburne University of Technology, Melbourne, VIC, Australia
4The University of Melbourne, Melbourne, VIC, Australia
Background: Schizophrenia is a heterogeneous disorder with various risk factors, but their prognostic value is poorly understood. Duration of untreated psychosis (DUP), despite being the most researched, has limited predictive power on its own. Thus, the focus has shifted to finding combinations of factors that can predict prognosis in psychotic patients.
Objectives: The study aimed to identify groups of variables useful in predicting prognosis of patients with first-episode psychosis (FEP).
Methods: Patients with FEP completed a 51-item questionnaire regarding potential prognostic factors. Data on time to hospital contact (1, 2 and 3 years) from completion of the questionnaire were collected retrospectively. This was used as a proxy measure for relapse, where early hospitalisation (within 1 year of FEP) would indicate a poor prognosis. Statistical analyses were performed to explore a fitted multivariable model of the prognostic factors for each time to hospital contact set points.
Findings: A total of 83 patients completed the questionnaire, and those without the final diagnosis of FEP were excluded (n = 57). The multivariable model that was associated with the poor outcome (AUC = 0.77 [0.64–0.91]) combined illicit substance use (p < 0.05), obstetric complications (p < 0.05), DUP >8 weeks (p = 0.05) and risk of medication non-adherence (p = 0.11). The average prognosis was associated with illicit substance use (p < 0.05), childhood milestone delay (p = 0.06)and DUP >8 weeks (p < 0.05). A better outcome (AUC = 0.72 [0.59–0.85]) was associated with illicit substance use (p < 0.05), childhood milestone delay (p < 0.05) and age at symptom onset <22 years (p < 0.05).
Conclusions: This pilot study supports the notion that groups of variables can predict the prognosis of patients with FEP, and thus, the results demonstrate the feasibility of developing a prognostic assessment tool.
Poster Presentations
A Case Report of Tramadol-Induced Mania
N Aggarwal1, NGupta2
1Sunshine Hospital, St Albans, VIC, Australia
2Country Health South Australia, Adelaide, SA, Australia
Background: Tramadol, a centrally acting synthetic opioid analgesic, has effects on norepinephrine and serotonin reuptake. In animal studies, tramadol has been shown to enhance serum levels of both neurotransmitters. There are no published reports of tramadol-induced mania in patients without a history of mood disorder.
Objectives: To present a case of tramadol-induced mania.
Methods: Our patient is a 42-year-old Asian woman who was started on tramadol for backache. After 1 week of tramadol (150 mg/day), she developed anxiety, twitching and mild fever. On psychiatric assessment, she was alert and oriented but elevated, pressured, circumstantial, grandiose and paranoid. Family members found her to be hyperactive with reduced need for sleep. She had no past psychiatric history or other medical illnesses. A first-degree relative had a history of depression. All the organic screens were negative. Tramadol was ceased and olanzapine was commenced at 5 mg/day. Her physical symptoms had subsided by the fourth day. Her mental state improved to baseline within 10 days. No further reports of relapse were noted.
Findings: In this case, the temporal relationship of tramadol commencement with onset of mania and rapid resolution with its cessation suggests that tramadol has potential to induce mania in the absence of previous mood disorder. However, our patient did have a genetic predisposition for mood disorder.
Conclusions: It is worthwhile to consider the potential of tramadol-induced mood disorder and careful titration of dose not only in patients with previous history of mood disorder but also in those with soft bipolar spectrum disorder.
Sense or Nonsense: Communicating with People with Thought Disorder
D Ash1,2, J Crichton3, S Sweeney4, C Galletly1,4,5
1The University of Adelaide, Adelaide, SA, Australia
2Central Adelaide Local Health Network, Adelaide, SA, Australia
3University of South Australia, Adelaide, SA, Australia
4Northern Adelaide Local Health Network, Adelaide, SA, Australia
5Ramsay Health Care (SA) Mental Health, Adelaide, SA, Australia
Background: Thought disorder is a common manifestation of psychotic disorders such as schizophrenia, schizoaffective disorder and mood disorders with psychosis. The clinical and research literature represents the thought disordered person as incapable of meaningful interaction with others. However, people with thought disorder do interact with psychiatrists and other clinicians about their management and various other concerns.
Objectives: To understand how psychiatrists and people with thought disorder achieve effective communication.
Methods: This study investigates the interactional accomplishments of thought disordered people in clinical interviews. These interactions are facilitated by the psychiatrist, and this study explores the strategies that psychiatrists utilise. The study uses data drawn from transcripts of 28 interviews between people with thought disorder and psychiatrists, taking place in public mental health inpatient units. The study draws on an interdisciplinary collaboration between a linguist, psychiatrists and a social worker.
Findings: Analysis of the interviews reveals an underlying structure. A number of dimensions can be identified including information sharing, rapport building, negotiation about medication, identification, negotiation of goals, exploration of phenomenology, risk assessment, assessment of insight and discharge planning.
Conclusions: This study demonstrates the capacity of people with thought disorder to achieve collaborative interaction and how psychiatrists draw on professional expertise that is central to the clinical relationship. We argue that this expertise should be reflected in the clinical, research and training literature.
Ethics of Advance Care Directives – Implications for Psychiatric Practice
G Asokan1, T Mohan2
1James Cook University, Townsville, QLD, Australia
2Flinders Medical Centre, SA, Australia
Background: The role of an Advance Care Directive has been well established in the context of the right to ‘exercise legal capacity’ of health care decisions (Goodling 2015 p45-71). What is poorly understood and defined is how the assessment of an individual’s capacity to make those decisions is established and whether or not they are fully informed of the consequences.
Objectives: To understand the regulations of determining capacity of an individual giving an ACD and the role of the substituted decision maker and witness in this context.
Methods: A review of the ‘Advance Care Directive Act 2013’ (Government of South Australian 2013 p1-39) and Regulations 2014 in the context of a particular case.
Findings: This case exemplifies the need for careful documentation and understanding of key components of capacity when it comes to decision making.
Conclusions: We advocate for a better assessment of capacity, in the context of giving an Advance Care Directive, as well as a clear protocol for giving the individual the required information to make a well informed decision regarding their health care.
References:
Goodling P. Navigating the ‘Flashing Amber Lights’ of the right to legal capacity in the united nations convention on the rights of persons with disabilities: responding to major concerns. Human Rights Law Review. 2015. 15(1): 45–71.
Government of South Australia. Advance Care Directives Act 2013. South Australian Government Gazette. March 2015. Pg 1–39.
Enhancing Metabolic Monitoring and Physical Health Outcomes in an Indigenous Remote Community
S Cameron
Mental Health Service Group, Townsville Hospital and Health Service, Townsville, QLD, Australia
Background: Metabolic syndrome is a risk factor for the development of diabetes mellitus and cardiovascular disease in the Indigenous population, while cardiovascular disease remains a leading cause of death in the Australian population (15% in 2011). As people prescribed antipsychotic medications are at increased risk of developing metabolic syndrome, Townsville Health Service has implemented an enhanced health monitoring procedure.
Objectives: The objective of the clinical audit was to determine whether clinical information was collected for each Indigenous person prescribed antipsychotics in a regional sample of the Health Service so as to determine the prevalence of metabolic syndrome in the sample population and to compare prevalence with the Australian population data. A qualitative survey exploring barriers and identifying possible opportunities for enhancing physical health monitoring (PHM) would then be completed.
Methods: A clinical audit was undertaken of health records. The sample included adults between 18 and 74 years prescribed antipsychotics between 1 July 2014 and 30 June 2015. Each record was audited to determine whether waist circumference or body mass index, fasting blood glucose, serum triglyceride, high-density lipoprotein and blood pressure had been recorded for each person within 6 months of being prescribed an antipsychotic by the Service.
Findings: Data will be analysed to determine the prevalence of metabolic syndrome in the sample population and to compare this to the Australian population data, and to explore barriers and possible strategies to enhance PHM and possible, culturally appropriate interventions.
A Pilot Study of a Group Mindfulness Program for Patients Diagnosed with Inflammatory Bowel Disease
K Sevar1,2, K Neilson1,2, M Ftanou1,2, K Monshat1,2, M Kamm1, S Knowles3, M Salzberg1,2, W Connell1, S Bell1,2, D Castle1,2
1St Vincent’s Hospital, Melbourne, VIC, Australia
2Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
3Swinburne University, Melbourne, VIC, Australia
Background: Inflammatory bowel disease (IBD) affects 75,000 Australians. There are high rates of co-morbid psychiatric illness and stress exacerbates the course of IBD. Combined medical and psychological care is warranted for patients with IBD. Mindfulness-based group interventions are effective in managing the impact of chronic illness where stress levels contribute to increased symptom severity and associated psychological difficulties.
Objectives: Provision of an 8-week mindfulness-based stress reduction (MBSR) program for patients with IBD to evaluate the feasibility of recruitment and patients’ adherence to study protocol.
Methods: A total of 39 patients were recruited from clinics at St Vincent’s Hospital, Melbourne (intervention group = 23; control group = 16). The patients participated in the MBSR program or observation only. The MBSR program consisted of 8-weekly sessions and a 1-day retreat. Questionnaires including quality of life (World Health Organization Quality of Life [WHO-QOL]), depression and anxiety (Hospital Anxiety and Depression Scale [HADS]) and symptoms of IBD and mindfulness (Five Facet Mindfulness Scale) were administered at baseline and at 2 and 8 months.
Findings: The average age was 37 years, and 60% were female and 40% male. Class attendance was 7 out of 8-weekly sessions and 79% of participants attended the 1-day retreat. A total of 83% of participants finished the program and completed the 2-month follow-up assessments. Intervention participants meditated for an average of 30 minutes/day.
The intervention group reported reduction in anxiety and depressive symptoms in comparison with controls, although these preliminary results were non-significant. Qualitative feedback provided by intervention participants was positive, describing the benefits of the program.
Conclusions: An 8-week MBSR program is feasible for patients with IBD given the high retention rates and positive qualitative findings. Further evaluation with a randomized controlled trial is warranted.
Antipsychotic-Associated Weight Gain: Patient versus Clinician Perspectives
C Murphy1, A Selvendra1,2, D Castle1,2
1The University of Melbourne, Melbourne, VIC, Australia
2St Vincent’s Hospital, Melbourne, VIC, Australia
Background: The use of second-generation antipsychotic medication has been shown to exacerbate obesity and metabolic abnormalities in individuals with serious mental illness. This associated weight gain has been shown to contribute to adverse outcomes including lower self-esteem and poor medication adherence.
Objectives: This study aims to better understand how the knowledge and attitudes of clinicians and patients affect the uptake of weight loss interventions, including bariatric surgery, for this patient population.
Method: A total of 88 clinicians and 41 patients at St Vincent’s Mental Health Service completed questionnaires regarding knowledge and attitudes towards antipsychotic-associated weight gain and related interventions. Statistical analyses compared clinician and patient responses using Mann–Whitney tests.
Findings: Clinicians noted that patients did experience weight gain as a result of antipsychotic medication and believed it lowered patient self-esteem and affected medication adherence. Clinicians did not feel confident initiating a discussion around bariatric surgery with patients.
Reducing weight was important to patients, but they found the associated strategies difficult despite feeling they had adequate knowledge on how to reduce weight through diet and exercise.
The attribution of weight gain to antipsychotic medication, the perceived impact of weight gain on medication adherence and consideration of bariatric surgery as a weight loss intervention were significantly greater in clinicians compared to patients.
Conclusions: Attitudes, skills and knowledge impact the extent to which clinicians explore weight loss strategies and also the degree to which patients and clinicians participate in related weight-loss interventions.
Subjective Recovery in Patients with First-Episode Psychosis in Hong Kong
SKW Chan, LT Sit, CLM Hui, EHM Lee, WC Chang, EYH Chen
Department of Psychiatry, The University of Hong Kong, Hong Kong
Background: Recovery is an evolving concept that can be broadly organized into two types: objective and subjective. Objective recovery is defined as the remission of clinical symptoms and improved everyday functioning, while subjective recovery is a personal understanding of recovery that varies individually. Understanding subjective recovery facilitates treatment adherence.
Objectives: The study aims to investigate the subjective determinants of perceived non-recovery to patients with first-episode psychosis in a Chinese population and the factors affecting subjective recovery.
Methods: A total of 109 patients with schizophrenia-spectrum disorder in an Early Intervention service were assessed.
Findings: Some patients (12.8%) considered themselves to have made a full recovery. ‘Cognitive dysfunction’ and ‘need to continue with medication’ were endorsed as the main reasons for perceived non-recovery. Perceived extent of recovery did not correlate with a history of relapse and hospitalization, depressive symptoms and positive and negative symptomatology, except anhedonia/asociality. Unemployment history also correlated with perceived extent of recovery. Multiple regression analysis showed that the model of anhedonia/asociality and unemployment history accounted for 7.3% of the variance of perceived extent of recovery.
Conclusions: These results highlighted the differences in the understanding of recovery between a clinician and a service user. It reflects the importance of occupational functioning to service users, and this understanding can inform the development of future treatment plans in psychosis.
The Role of Cognitive Functioning and Symptomology in Self-Stigma Formation in Psychosis
S Chan, S Kao, S Leung, C Hui, E Lee, W Chang, E Chen
The University of Hong Kong, Hong Kong
Background: Ample evidence suggests the negative effects of self-stigma on psychosis patients. Two common definitions of self-stigma imply that stereotype awareness and internalization are involved in self-stigma formation that might involve cognitive function. Cognitive function deficits are common to patients with psychosis. However, few examine the relationship between cognitive functioning and self-stigma.
Objectives: This study examines the relationship of cognitive functioning and clinical factors with self-stigma in patients with psychosis to understand self-stigma formation.
Methods: In all, 64 participants with psychosis were recruited from the outpatient clinic at a Hong Kong public hospital. The Internalized Stigma of Mental Illness Scale was used to assess participants’ self-stigma. Three cognitive tests, the Modified Wisconsin Card Sorting Test, the Forward/Backward Digit Span Test and the digit symbol subtest, were used to measure cognitive functioning. Clinical symptoms were assessed using The Positive and Negative Syndrome Scale.
Findings: A linear regression model showed that poor cognitive functioning explained 9.7% variance of overall self-stigma (F(1, 62) = 7.79, p = 0.007, R2 = 0.11, adjusted R2 = 0.097). Exploring the sub-domain of self-stigma, cognitive functioning and negative symptoms explained 16.4% of the variance in stereotype endorsement (F(1, 62) = 13.39, p = 0.001, R2 = 0.178, adjusted R2 = 0.164). Cognitive functioning and disorganization symptoms explained 7.9% of the variance in discrimination experience (F(1, 62) = 6.43, p = 0.014, R2 = 0.094, adjusted R2 = 0.079).
Conclusions: Poor cognitive functioning was related to overall self-stigma, and specific symptoms, including negative symptoms and disorganization symptoms, were also associated with particular dimensions of self-stigma. Future studies should further examine the mechanism of self-stigma formation.
References
Corrigan PW, Rafacz J and Rüsch N (2011) Examining a progressive model of self-stigma and its impact on people with serious mental illness. Psychiatry Research 189: 339–343.
De Zubicaray GI, Smith GA, Chalk JB, et al. (1998) The Modified Card Sorting Test: Test-retest stability and relationships with demographic variables in a healthy older sample. Journal of Clinical Psychology 37: 457–466.
Hong Kong Psychological Society (1989) The Wechsler Adult Intelligence Scale-Revised (Cantonese Version). Hong Kong: Hong Kong Psychological Society.
Kay S, Fiszbein A and Opler L (1987) The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulletin 13: 261–276.
Ritsher JB (2003) Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatry Research 121: 31–49.
A Qualitative Analysis of Medical Students’ Concerns and Perceptions of Their Safety on Mental Health Clinical Placements
K Dawes1, N Pai1,2, B Rayers1,2, S Thomas1, S Vella1
1University of Wollongong, Wollongong, NSW, Australia
2Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
Background: Clinicians working in inpatient mental health facilities (IMHFs) face threats to both their physical safety and the emotional impact of the environment. The majority of previous research has focused on nursing staff; little has been done to explore the safety concerns of medical students.
Objectives: This study explores the pre-placement concerns and post-placement perceptions relating to physical and emotional safety in medical students undertaking their first placement in an IMHF.
Methods: Two questionnaires were completed: a pre-placement questionnaire (n = 37) measuring students’ specific physical and emotional safety concerns and a post-placement questionnaire (n = 41) measuring their experience of physical and emotional safety. Information regarding suggestions for improving their feelings of safety on the placement was also gathered.
Findings: The qualitative responses were analysed and common themes identified. With regard to physical safety, the key pre-placement concerns were physical outbursts/aggressive patients, a recent murder, inexperience and unpredictability of patients. Pre-placement concerns pertaining to emotional safety were as follows: personal issues, emotional involvement, emotional toll, confronting and inexperience. The primary themes identified after the placement experience were as follows: agitated/aggressive patients, the recent murder, support by staff, getting to know the patients and emotional toll. Identified themes in the suggestions for improving safety were as follows: the need for more skills training, encouragement to debrief and more information on dealing with the emotional toll.
Conclusions: The key themes identified in the pre-placement concerns aligned directly with the post-placement themes. These factors need to be considered when student placements are being planned.
Internet: Bane or Boon
S Dutta, H Naidu, D Prasad, A Rajput, A Gupta
Nur Manzil Psychiatric Centre, Lucknow, India
Background: Technology, in particular electronic, media-Internet surfing, social networking, gaming and mobile phone use, is an inevitable and perhaps essential part of growing up in the current scenario. There have been mounting concerns worldwide about the physical and mental well-being of youth with respect to their increasing needs for electronic gadgets.
Objectives: An alarming trend of presentation to the outpatient department of young people with excessive Internet and mobile use and demands for sophisticated electronic equipment prompted us to study the psychiatric correlates of such behaviors.
Methods: A total of 50 individuals in the age group of 15–25 years with a major complaint of excessive Internet and/or mobile use were examined. In addition to extensive history taking and mental status examination, and relevant psychometric evaluation, these patients were also administered the Internet Addiction Test by K. Young.
Findings: Although few individuals met the criteria for Internet addiction, major depressive disorder, obsessive–compulsive disorders, dissociative-conversion disorders, borderline personality disorders, schizophrenia and bipolar disorder, conduct and oppositional defiant disorder were other prominent diagnostics categories.
Conclusions: The Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) nosological proposal for Internet addiction is a hot bed for discussion at every international psychiatric forum. Are such behaviors merely bad habits or are they pointers or precursors to major mental health issues? Apart from the psychiatric diagnoses, the psychosocial impacts of these behaviors in the form of impaired academic, socio-occupational and family functioning are tremendous.
Post-Traumatic Stress Disorder and Risk of Alzheimer’s Disease in Vietnam Veterans: Preliminary Amyloid Pet Findings From AIBL-VETS
Background: Post-traumatic stress disorder (PTSD) is prevalent in Vietnam veterans. PTSD is associated with cognitive dysfunction, including deficits in verbal recall and new learning. Epidemiological studies suggest an increased risk of dementia in veterans with PTSD. This study is a collaborative investigation between the Alzheimer’s Disease Neuroimaging Initiative (ADNI) and Australian Imaging Biomarkers and Lifestyle (AIBL) study that aims to use objective imaging measures to assess the risk of developing Alzheimer’s disease in veterans with PTSD. We report the preliminary amyloid imaging data from our Australian centre (AIBL-VETS).
Objective: To test the hypothesis that veterans with combat-associated PTSD have a higher risk of Alzheimer’s disease as measured by amyloid imaging with florbetaben positron emission tomography (PET).
Methods: We recruited veterans with PTSD as defined by the Clinicians Administered PTSD Scale (CAPS) score of 40 or above and veteran control subjects as defined by a CAPS score of less than 30. Veterans with ongoing or recent substance abuse, dementia, neurological or severe medical diseases and psychotic illnesses were excluded. Florbetaben PET was analysed with CapAIBL.
Findings: In all, 29 veterans with lifetime PTSD (19 with ongoing PTSD) and 14 healthy control Vietnam veterans have been scanned to date. The mean age was 68 years (standard deviation [SD] = 3.4), and there was no significant difference between groups. Eleven (25.6%) veterans had positive amyloid scan as determined by both the standard uptake value ratio (SUVR) with a cut-off value of 1.35 and visual inspection. An independent t-test did not show any significant difference (p = 0.941) in SUVR between the group with PTSD (mean 1.30, SD = 0.26) and the control group (mean 1.30, SD = 0.19). There was no association between either lifetime or current PTSD and positive status on PET scan. There was no correlation between SUVR and lifetime CAPS score (r = −0.006, p = 0.970). However, there was a trend towards a positive correlation between SUVR and age (r = 0.272, p = 0.077).
Conclusions: The above preliminary findings do not suggest a significant association between PTSD and amyloid deposition, an important imaging biomarker of Alzheimer’s disease. These are preliminary data, and recruitment to improve the power of the study continues.
Optimizing RUL rTMS Protocols: Is More Treatment Better?
H Ford1, B Carnell2, P Clarke3, S Gill3, C Galletly4,5,6
1School of Medicine, Flinders University, Adelaide, SA, Australia
2The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, Adelaide, SA, Australia
3rTMS service, The Adelaide Clinic, Ramsay Health Care (SA) Mental Health Services, Adelaide, SA, Australia
4Discipline of Psychiatry, The University of Adelaide, Adelaide, SA, Australia
5Ramsay Health Care (SA) Mental Health Services, Adelaide, SA, Australia
6Northern Adelaide Local Health Network, Adelaide, SA, Australia
Background: Repetitive transcranial magnetic stimulation (rTMS) is a safe and effective treatment for depression both as monotherapy and as an adjuvant to pharmacotherapy. rTMS uses magnetic pulses to generate electrical currents that directly stimulate brain regions associated with depression, usually the dorsolateral prefrontal cortex. There is similar efficacy reported between bilateral and unilateral treatments. While right and left unilateral (UL) rTMS have similar antidepressant efficacy, right unilateral (RUL) treatment has advantages with regard to safety and tolerability. However, the optimal RUL rTMS protocol is not yet defined.
Objectives: To define the optimal RUL rTMS treatment protocol by exploring the effects of extended rTMS sessions on response rate in treating major depression.
Methods: The study was conducted in a naturalistic setting comparing two first-time patient groups treated with low-frequency (1 Hz) RUL rTMS for depression 3 days/week over 6 weeks. In total, 70 patients received standard 15-minute treatment sessions and 24 patients received extended 30-minute treatment sessions. Both groups were assessed at baseline and at the end of treatment using the Hamilton Rating Scale for Depression.
Findings: Comparison between the two groups displayed an increased response rate in the extended treatment group. The remission rates were similar (see table).
Conclusions: The preliminary findings suggest benefits of extending each treatment session from 15 to 30 minutes. Data collection is ongoing at the time of Abstract release.
Medical Student Teaching in the Private Sector: An Overlooked Opportunity?
C Galletly1,2,3, C Turnbull2, R Goldney1
1The University of Adelaide, Adelaide, SA, Australia
2Ramsay Health Care (SA) Mental Health Services, Adelaide, SA, Australia
3Northern Adelaide Local Health Network, Adelaide, SA, Australia
Background: One in four psychiatric beds in Australia are located in the private sector, and more than half of Australian psychiatrists undertake private work. However, nearly all medical student teaching in psychiatry takes place in public hospitals. Clinical teaching in the public sector is increasingly difficult with reduced bed numbers and pressure for shorter length of stay.
Objectives: This paper explores learning opportunities available in the private sector. We report the South Australian experience; medical students have been taught in Ramsay Health (SA) Mental Health facilities for more than 23 years.
Methods: Ramsay Health Care (SA) began taking final-year medical students from The University of Adelaide in 1992. Students complete a 4-week rotation including drug and alcohol programs, services for the elderly, community nursing, day programs, electroconvulsive therapy and repetitive transcranial magnetic stimulation. About two-thirds of patients agree to admission by a medical student.
Findings: There are 10 medical student rotations annually; over 500 students have taken part. Tutorials are highly interactive, and students attend all clinical and educational meetings. Feedback from students and clinicians is very positive. Administrative and financial requirements to enable greater private sector involvement in medical education are discussed.
Conclusions: Clinical placements in the private sector provide a highly interactive learning experience, with exposure to a wide range of psychopathology. Our experience demonstrates that clinical teaching in private hospitals is sustainable and is well accepted by students, patients and clinicians. The private sector has the capacity to make a much greater contribution to medical student training in psychiatry.
Shell Shock or Shell Concussion?
N Ford
1Snr Clinical Lecture, Discipline of Psychiatry, University of
Adelaide, Adelaide, SA, Australia
Background: Brain injury due to the pressure wave of an explosive blast has been described as the signature wound of recent conflicts involving the Australian Defence Force. There is significant overlap with traumatic stress syndromes, and although a different etiology; synergism to produce disability. There is a significant overlap with psychologically driven traumatic stress syndromes, and synergism to produce disability. Treatment and rehabilitative approaches are discussed.
Objectives: This paper reviews the history of this type of injury and recent imaging, clinical and experimental studies (Ford and Rosenfeld, 2012; Rosenfeld and Ford, 2010) with case descriptions.
Methods: The PubMed database has been systematically reviewed, with follow-up of clinical and research publications from the First and Second World Wars.
Findings: Concussive blast causes brain injury which synergizes with traumatic stress syndromes arising from emotional trauma and makes management more complex.
Conclusions: A joint psychoeducational and physical rehabilitative approach can be effective.
References
Ford N and Rosenfeld JV (2012) Mild traumatic brain injury due to explosions; a brief overview of the mechanisms of injury and clinical considerations. Stress points. eJournal of the Australian Society for Traumatic Stress Studies 3: 5–13.
Rosenfeld JV and Ford NL (2010) Bomb blast, mild traumatic brain injury and psychiatric morbidity: A review. Injury 41: 437–443.
Mental Health Act Reform: Impact on an Acute Inpatient Unit
D Filippich, B Huang, P Goh, V Wilman, K Ashe
John Cade Unit, The Royal Melbourne Hospital, Melbourne, VIC, Australia.
Background: The new Mental Health Act 2014 (Vic) (The Act) came into force on 1 July 2014. The Act provides for the compulsory assessment and treatment of people with mental illness in Victoria. The Act, which repealed the Mental Health Act 1986 (Vic), was the result of the Victorian government’s move towards aligning domestic legislation with international human rights obligations (Persons with Disabilities and the Convention on the Rights of the Child). Legislative principles reflect the Charter of Human Rights and Responsibilities Act 2006, the United Nations Convention on the Rights of Persons with Disabilities and the Convention on the Rights of the Child (Department of Health). The Act includes checks and balances to ensure that compulsory treatment is used only where necessary and provided in the least possible restrictive manner and to minimise limitations on rights (Department of Health).
Objectives: This article aims to analyse how the changes in the Act have impacted on clinical service provision by reviewing the changes in hearing numbers across the inpatient and community setting of a Metropolitan Adult Acute Mental Health Service, as well as the impact on clinicians’ workloads.
Methods: Data relating to Mental Health Review Board (MHRB) hearing numbers for both inpatients and the community for our AMHS between 1 July 2012 and 30 June 2013 (under the Mental Health Act [MHA] 1986 legislation) were obtained from the MHRB. Data relating to hearings between 1 July 2014 and 30 June 2015 were collected through a local database.
Other information collected for the acute adult psychiatric inpatient ward was the duration of each inpatient hearing; the time clinicians spent on preparing the reports; consulting with the patients, carers, case managers or relevant parties; and attending the hearings throughout this 1-year period with the new MHA. The impact on clinicians was mainly focused on information collected from the acute psychiatric inpatient unit.
Findings: Since the introduction of the Act, the number of total hearings conducted in both inpatient and community settings has decreased from 472 to 317 (32% reduction). However, the number of hearings taking place in the inpatient setting has increased from 82 to 141 per annum. This equates to a 72% increase. Under the new MHA, 51 of the 141 hearings taking place on the inpatient setting were applications for electroconvulsive therapy (ECT).
Conclusions: It is irrefutable that the new Act has been a positive step forward in protecting and supporting the rights of consumers of mental health services. This has brought with it a shift in workload to inpatient clinical and administrative staff. However, due to financial restraints, without additional resources allocated to the clinical and administrative team, AMHSs are running the risk of not anticipating the impacts that the New MHA will have on our workforce and service. Recent tragic events among psychiatric trainees may not be a direct influence on the impact on workload, but we, as a group of mental health clinicians, need to advocate for the rights of our workers and their well-being. Improvements that could be made are consolidation of hearings (e.g. ECT and TO) where possible and increase resources on IPU to accommodate for increased workload.
References
Persons with Disabilities and the Convention on the Rights of the Child.
Department of Health (2012) A new Mental Health Act for Victoria – Summary of proposed reforms. Department of Health, Melbourne, VIC, Australia, October.
National University of Southern Patagonia, Caleta Olivia, Argentina.
About the Omission of the Psychic in Occupational Health: The Argentinian Case
L Gabriela Guerra
Background: This communication comes from a research in progress, as part of a doctoral thesis on the impact of working conditions on the mental health of workers of oil companies in the Gulf San Jorge in Patagonia, Argentina.
Objectives: The research aims to analyze the impact of working in oil production on the mental health of workers, identifying labor conditions and changes in mental health conditions (specifying potential risk factors), and the organizational aspects and family dynamics resulting from the type of occupational insertion. Also, it aims to analyze whether there are correlations between working conditions and the increased prevalence of psychological disorders, identifying relational modalities prevalent among workers, modes of extra productive sociability and the impact on mental health.
Methods: The methodology and techniques that sustain the ongoing probe, gain a qualitative perspective, with a focus on the ethnographic approach.
Findings: The analysis of the scientific and legal discourse regarding occupational health demonstrates its subordination to the hegemonic medical model (Menendez, 1978, 1990), marked by a biological perspective (a-historical) that avoids the consideration of social and political aspects, revealing its commitment to a conservative agenda of social structures.
Conclusions: There are significant discrepancies between the discourses and practices concerning ‘protection’, security and well-being of workers, highlighting the latter a strong reductionism (to the extent that underlies a naturalistic conception of the subject, which is thus reduced to the category of organism), which eludes the historical characteristics of production and the structural determinants of employment status, excluding any consideration of the subjectivity.
Reference
National University of Southern Patagonia, Caleta Olivia, Argentina.
Co-Production in Health: An Evaluation of Effectiveness
A Gupta
National Health Service, Dundee, UK
Background: Rising disease burden and patient expectations along with a reduction in resources are putting significant pressure on healthcare providers. ‘Co-production’ in health has emerged as an attractive strategy to help bridge this gap between resources and demand. A review of studies on co-production initiatives was carried out to evaluate their effectiveness according to the Institute of Health’s ‘Triple Aim’ framework.
Objectives: To evaluate the effectiveness of ‘co-production’ applied in a healthcare setting, on aspects that are strategically important for healthcare providers as per the Institute of Health’s ‘Triple Aim’ framework, to
• Improve health/reduce inequalities;
• Improve quality of care;
• Reduce costs or improve outcomes without increasing expenditure.
Methods: The Internet and databases were searched for ‘co-production in health’. The studies that fulfilled the inclusion criteria were rated on the following:
Descriptive analysis and supplementary counting methods were employed to weigh up the studies and were further tested with one-way analysis of variance.
Findings: Co-production can be applied to health care in several ways. It can improve population health and costs but may be relatively lacking in ‘experience of care’.
Conclusions: There is benefit from co-production in all three domains with the maximum benefit being derived from cost savings. Co-production can be readily ‘adopted’ and can be ‘maintained’ for 6 months or more. However, the evidence base is limited and largely qualitative.
Transparency and Due Process: A Systemic Approach to Educational Decision-Making and Appeals
A Peters, C Kalimniou
The Royal Australian and New Zealand College of Psychiatrists (RANZCP), Melbourne, VIC, Australia
Background: Transparency and due process are inseparable principles that should underpin any educational and administrative decision made within an organisation. Put simply, individuals should be provided with adequate notice of an upcoming decision, be given the ability to be heard and present to unbiased decision-makers and, once an outcome is reached, receive written findings of fact.
Objectives: It is considered best practice for organisations to place the processes and structures surrounding reviews of decisions made by their organisation at arm’s length to the committee or group that made the original decision. This ensures there is no conflict of interest and that due process is followed. An independent appeal process is an integral part of any fair system of assessment and decision-making.
Methods and findings: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has undertaken several reviews of its current processes to examine its practices as both substantive and procedural issues arise in decisions with regard to the provision of psychiatric training. The Reconsideration and Appeal Policy was developed to set out a clear and fair process for applicants to request decisions of the RANZCP to be reconsidered and appealed. This ensures that an applicant has a fair and reasonable opportunity to challenge the original decision while receiving support from the RANZCP to minimise any stress that may be experienced during this process.
Conclusions: This presentation will identify best practice methods in educational decision-making and conducting appeals. Emphasis will be placed on addressing the current challenges in developing consistent strategies to integrate effective decision-making and appeals that affect psychiatric training.
Does Maternal Immune Activation Alter the Epidermal Growth Factor System in Spiny Mouse Offspring? The Relevance to Schizophrenia
T Ketharanathan1,2, A Pereira2, U Ratnayake1,2,3, D Walker3, I Everall1, S Sundram1,2,4
1The University of Melbourne, Melbourne, VIC, Australia
2Florey Institute of Neuroscience and Mental Health, Melbourne, VIC, Australia
3Monash University, Clayton, VIC, Australia
4Monash Medical Centre, Clayton, VIC, Australia
Background: Increased vulnerability to schizophrenia may reside in environmental risk factors that operate at maternal, foetal and post-natal (PN) levels, such as those associated with immune activation and that influence neurodevelopment. One plausible mechanism may be via stress-immune activation that perturbs the epidermal growth factor (EGF) system, a system critical for neurodevelopment.
Objective: To determine whether there is an association between immune and EGF system changes in schizophrenia through a model of maternal immune activation (MIA), in spiny mouse (Acomys cahirinus) species known for precocious organogenesis.
Methods: Pregnant dams of spiny mice were administered a single, subcutaneous injection of viral mimetic Poly I:C 5 mg/kg at mid-gestation (E20) and controls were injected with phosphate-buffered saline. The offspring were killed at PN day 40 (prepubescence) and brains were assayed for protein levels of EGF system markers – epidermal growth factor receptor (EGFR) and ErbB4 receptors and the downstream signalling molecule PI3K p110δ – by Western immuno-blotting.
Findings: There were no significant differences in the EGF system markers examined between control and treated animals in the medial prefrontal cortex, caudate putamen, nucleus accumbens and dorsal and ventral hippocampus.
Conclusions: We conclude that MIA in mid-gestation does not appear to trigger EGF system changes in animal offspring of prepubescent age, but rather may point to early pre-natal periods or those at illness onset as more important risk junctures.
Depression and its Correlates in Spouses of Chinese Elderly with Dementia
KL Lee
Department of Psychiatry, The United Christian Hospital, Hong Kong
Background: Depression has been shown to be prevalent in family caregivers, especially spouses, who primarily live with elderly people with dementia (EWD) and are less likely to consider residential care. The scenario in Hong Kong has not been investigated to date.
Objectives: To investigate the prevalence of depression and factors associated with it in spouses of Chinese EWD followed up in local psychiatric outpatient clinics.
Methods: This was a cross-sectional study in which 130 consecutive community-living Chinese EWD and their spouses were recruited. Demographic, medical, psychosocial information of these couples and dementia-specific illness data were gathered from interview, available informants and medical records. Social networking was measured using the Lubben Social Network Scale (LSNS), and the perceived carer burden was measured by the Zarit Burden Interview (ZBI). Diagnoses of depressive disorders were made with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID-I).
Findings: The point prevalence of the current depression was 26.9%. Using bivariate analyses, significant covariates were identified, including female sex, negative rating of current marital relationship (as ‘bad’ or ‘very bad’), greater dementia-specific functional disability, ZBI and all neuropsychiatric symptom subgroups (except euphoria). A higher level of hyperactivity subgroup of neuropsychiatric symptoms (including agitation/aggression, irritability/lability, aberrant motor behaviour and disinhibition) and greater perceived carer burden measured by ZBI were independently associated with the current diagnoses of depression in spouses of EWD.
Conclusions: Depression is common among spouses of EWD who are attending psychogeriatric clinics in Hong Kong and it is not limited to spouses identified as primary caregivers. The identification of independent factors associated with depression can assist early detection of at-risk spouses and timely intervention can be offered to minimize psychiatric morbidity.
Trajectory of Psychotic-Like Experiences Over 2 Years in the General Population of Hong Kong
KW Lee, KW Chan, WC Chang, EHM Lee, CLM Hui, JJX Lin, E YH Chen
Department of Psychiatry, The University of Hong Kong, Hong Kong
Background: Psychotic-like experiences (PLEs) are poorly understood phenomena referring to subclinical psychotic symptoms reported by healthy individuals. Most PLEs are transient (Van Os et al., 2009), while persistent PLEs might increase the risk of developing psychosis (Dominguez et al., 2011). Examining the trajectory of PLEs and potentially related factors could provide insights into the significance of PLEs.
Objectives: This study aims to (1) explore the trajectory of PLEs over 2 years and (2) examine the difference of subjects with or without persistent PLEs.
Methods: This on-going study is a 2-year follow-up on the participants who reported PLEs in the Hong Kong Mental Morbidity Survey 2010 (HKMMS) – an epidemiological study targeted at the general population carried out in 2010–2013. PLEs were assessed by using the Psychotic Screening Questionnaire (PSQ) (Johns et al., 2004). Mood symptoms, social and occupational functioning and perceived social support were measured using the Hospital Anxiety and Depression scale (HADS) (Chan et al., 2010), Social and Occupational Functioning Scale (SOFAS) (SOFAS, 2000) and Multidimensional Scale of Perceived Social Support (MSPSS) (Chou, 2000), respectively.
Findings: In the first 85 subjects, 57 (67.1%) were female, aged from 18 to 72 years (mean = 45.11, standard deviation [SD] = 14.81)). The mean years of education was 13 years (SD = 5.24 years).
Nearly half of the patients (42/85, 49.4%) had persistent PLEs (PP) (endorsed ≥1 PSQ items at baseline [HKMMS] and follow-up). PP were significantly younger (t = 0.48, p < 0.05) than people with non-persistent PLEs (NP). No significant differences were found in education, gender and immigration.
At follow-up, there were significant differences between the two groups in SOFAS (t = 0.46, p < 0.05; PP < NP), HADS depression (t = −1.92, p < 0.01; PP > NP) and total scores (t = −2.03, p < 0.03; PP > NP).
Conclusions: In more than half of the subjects, PLEs do not persist, suggesting that the nature of PLEs is highly unstable. Differences in mood between PP and NP suggest a potential link between mood, PLEs and development of psychosis.
References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4 (DSM-IVTR). (2000). Washington, DC: APA
Chan YF, Leung DYP, Fong DYT, et al. (2010) Psychometric evaluation of the Hospital Anxiety and Depression Scale in a large community sample of adolescents in Hong Kong. Quality of Life Research 19: 865–873.
Chou K-L (2000) Assessing Chinese adolescents’ social support: The multidimensional scale of perceived social support. Personality and Individual Differences 28: 299–307.
Dominguez MDG, Wichers M, Lieb R, et al. (2011) Evidence that onset of clinical psychosis is an outcome of progressively more persistent subclinical psychotic experiences: An 8-year cohort study. Schizophrenia Bulletin 37: 84–93.
Johns LC, Cannon M, Singleton N, et al. (2004) Prevalence and correlates of self-reported psychotic symptoms in the British population. British Journal of Psychiatry 185: 298–305.
Social and Occupational Functioning Assessment Scale (SOFAS) (2000) Diagnostic and Statistical Manual of Mental Disorders (Text Revision), 4th Edition.
Van Os J, Linscott RJ, Myin-Germeys I, et al. (2009) A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. Psychological Medicine 39: 179–195.
Psychiatric Comorbidity in Patients with an Acquired Brain Injury in a New Statewide Service: The First 12 Months
D Barton1,2,3, A Dhar1,2,3, A Lingard2, G Lambert1,2,3
1Alfred Health, Melbourne, VIC, Australia
2Baker IDI Heart and Diabetes Institute, Melbourne, VIC, Australia
3Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
Background: The Acquired Brain Injury (ABI) Rehabilitation Centre at Alfred Health in Melbourne, Victoria, is a 42-bed purpose-built inpatient facility. Opened in September 2014, the Centre provides specialised treatment and care for patients recovering from an ABI. The unit aims to improve the quality of life for patients with moderate-to-severe brain injury through physical, medical and psychiatric rehabilitation. As a result, multiple specialist teams, including a psychiatric team, have been integrated within the unit.
Objectives: To present a summary of patients who were admitted to the ABI unit and referred for psychiatric care during its first 12 months of operation.
Methods: Retrospective clinical audit.
Findings: Substantial numbers of those admitted to the ABI unit were referred to the psychiatric team. Of these, the ratio of males to females was 5:3 and the mean age was 41 years. The most common admission reason was traumatic brain injuries followed by stroke. Mood and aggression were the most common reasons for referral to psychiatry and 12.5% of patients required a 1:1 nursing intervention at least once during their admission. Of psychiatric diagnosis, major depressive disorder was the most frequent and anti-depressants were the most commonly prescribed medication at discharge.
Conclusions: There was a high prevalence of psychiatric comorbidity among the observed cohort. This was reflected in the high percentage of nursing interventions, which suggests the acuity and significance of such comorbidities. Overall, this summary highlights the importance of a mental health service in order to provide safe and comprehensive rehabilitation for people with ABI.
The Mediating Role of Pain Catastrophizing: Testing the Schema-Activation Model for Patients with Chronic Pain in Hong Kong
B Lo1, E Chan2, Y Song1
1The University of Hong Kong, Hong Kong
2Alice Ho Miu Ling Nethersole Hospital, Hong Kong
Background: Pain catastrophizing refers to a tendency to negatively exaggerate a pain experience while under actual or anticipated pain. The schema-activation model posited pain catastrophizing as a maladaptive cognitive process that, once activated, engenders an enlarged perception of the potential gravity of pain and diminishes the individual’s coping capacity. Previous research has shown that pain catastrophizing functions as a powerful predictor of pain and a mediator of the relationship between physical pain and psychological distress.
Objectives: The objective of the study was to investigate the role of pain catastrophizing in the development of depression and anxiety among Chinese patients. It was hypothesized that pain catastrophizing mediates the path from pain severity to depression and anxiety.
Methods: In all, 56 outpatients (F:M = 34:22) at a local pain clinic were recruited. Participants filled in a package of questionnaires that measure pain severity, pain catastrophizing and level of depression and anxiety. Structural equation modeling was then performed to examine the model fit.
Findings: The proposed model fits our data well, χ2(9, N = 56) = 8.99, p = 0.44, goodness-of-fit index (GFI) = 0.95, adjusted goodness-of-fit index (AGFI) = 0.88. All the obtained regression weights were statistically significant at 0.01 alpha level.
Conclusions: It was concluded that pain catastrophizing mediates the relationship from pain intensity to depression and anxiety among Chinese patients with chronic pain patients. Some clinical implications on psychological components of pain management and limitations of the study are also discussed.
Relations between Meta-Parenting and Sense of Competence in Mothers of Children with Autism Spectrum Disorders
B Lo, A Leung
Department of Psychology, The University of Hong Kong, Hong Kong
Background: Meta-parenting is a new parenting construct defined as thinking about parenting practices (Holden and Hawk, 2003). Being more conscious about parenting was suggested to associate with better performance as parents. However, the underlying mechanism of how meta-parenting affects parenting qualities remains unclear from the previous literature. Dix (1991) believed that emotion regulation played a role in parents actualizing their concern during parent–child interaction. In this research, the relationship between meta-parenting, emotion regulation and the quality of interaction was explored among the Chinese mothers and their autistic children.
Objectives: It was hypothesized that (1) meta-parenting positively predicted parenting sense of competence and (2) maternal emotion regulation mediated the relationship between meta-parenting and sense of competence of parents.
Methods: A total of 104 Chinese mothers and their child (mean age = 5.31 years, standard deviation [SD] = 0.83) diagnosed with autism spectrum disorders (ASDs) participated in this study. The mothers reported their meta-parenting level, parental competence and emotion regulation in self-reported questionnaires.
Findings: Multiple regression analysis indicated that higher meta-parenting scores predicted higher parenting sense of competence (F(1, 101) = 4.36, p < 0.05). This relationship was fully mediated by the attention component in emotion regulation (z = 1.88, p < 0.05).
Conclusions: This study’s finding on significant association between meta-parenting and parenting quality is consistent with previous research. Our study also suggested that the emotion regulation process had a significant impact on the relationship between meta-parenting and sense of competence in the parent–child interaction. Clinical implications will be discussed.
References
Dix T (1991) The affective organization of parenting: adaptive and maladaptive processes. Psychological Bulletin 110: 3–25.
Holden GW and Hawk CK (2003) Meta-parenting in the journey of child rearing: A cognitive mechanism for change. In: Kuczynaski L (ed.) Handbook of Dynamics in Parent-Child Relations. Thousand Oaks, CA: SAGE, pp. 189–210.
Effects of a Positive Training Program on Young Adolescents in Hong Kong
B Lo, T Chan
The University of Hong Kong, Hong Kong
Background: Early adolescence is a critical time for risk prevention of emotion dysregulation. Positive training programs are thus important in helping early teens develop a flexible repertoire of coping in promoting mental health. However, data on evidence-based positive psychology interventions among community youths are relatively limited in Asian Chinese. This study hence aims to deliver a community program to enhance students’ understanding of basic positive psychology concepts and teach them adaptive skills (e.g. acceptance, positive thinking) that could be incorporated in daily life.
Objectives: To examine the effectiveness of a school-based positive training program in terms of enhancing students’ emotional coping strategies across time as compared to controls.
Methods: A total of 127 local secondary school students in Hong Kong participated, with 59 joining the training program and 68 joining the control group. The Cognitive Emotion Regulation Questionnaire (CERQ) was administered before and after the training period for all participating students in both groups.
Findings: Students who joined the training program had statistically significant improvements in their use of positive coping strategies as measured in the ‘acceptance’ (F(1, 125) = 4.695, p = 0.032) and ‘putting into perspective’ subscales (F(1, 125) = 3.946, p = 0.049) of CERQ as compared to the control group.
Conclusions: The findings shed light on the effectiveness of a positive training program for promoting mental well-being among Asian Chinese youths in community school setting. Limitations and future directions will be discussed.
Effect of Hypnosis on Metacognitive Awareness of Information Processing
C Wong, B Lo
The University of Hong Kong, Hong Kong
Background: Researchers suggested that metacognitive awareness could be affected by various factors such as contextual effects and mood conditions. However, not much was known about how hypnosis may impact changing metacognitive awareness. Several past reports indicate that hypnosis could alter human perception and cognitive function (e.g. pain, attention), but no study has yet explored the effect of hypnosis on metacognitive awareness.
Objectives: This study examined individuals’ estimation of their flanker task performance under different hypnotic suggestion conditions. It is hypothesized that individuals with higher hypnotic susceptibility and undergo positive suggestion will exhibit the greatest estimation accuracy.
Methods: Subjects older than 18 years of age have been recruited from the University of Hong Kong and personal connections and will be screened using the Harvard Group Scale of Hypnotic Susceptibility: Form A. Half of the participants will receive a positive suggestion (i.e. subjects will be aware of their performance in the task) and the other half a negative suggestion (i.e. subjects will be unaware of their performance in the task). They will be asked to perform the computer-based flanker task afterward.
Findings: Preliminary data analysis suggests no significant finding regarding predicted estimation accuracy. Nevertheless, there was a significant interaction effect between hypnotic susceptibility and hypnotic suggestion conditions on the mean reaction time. Participants with higher hypnotic susceptibility and who received positive suggestion had the longest reaction time.
Conclusions: The interaction effect is probably related to the strategic enactment of hypnosis (adoption of the appropriate strategy spontaneously). Implications of the findings will be discussed.
The Victorian Association of Psychiatry Trainees
G Matta1,2, J King3,4
1St Vincent’s Mental Health Service, Melbourne, VIC, Australia
2Victorian Association of Psychiatry Trainees, Melbourne, VIC, Australia
3The Melbourne Clinic, Melbourne, VIC, Australia
4Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
Background: The Victorian Association of Psychiatry Trainees (VAPT) is an association dedicated to furthering the interests of psychiatry trainees in and outside of the workplace. Membership is free and open to all Victorian trainees. Its aims are to improve work and life for psychiatry trainees through advocacy, education and connection.
VAPT advocates for trainees on issues such as examinations and well-being. It has representatives from most Victorian training sites and co-opted members on several committees of the Royal Australian and New Zealand College of Psychiatry (RANZCP). VAPT holds examination preparation nights. The website (http://vapt.org.au/) includes a collection of educational and examination resources. Through social events and the quarterly publication, Parapraxis, it aims to foster collegiality and creative expression.
Objectives:
To outline the history of VAPT, its inception dating back to the Australian and New Zealand Association of Psychiatry Trainees (ANZAPT) and the Victorian branch (VANZAPT);
To describe the goals of VAPT and to provide examples of its events, representation and publications;
To describe how to create and maintain a state, territory or national trainee association and the benefits of independent trainee representation;
To discuss the challenges and future of VAPT.
Conclusions: VAPT is an independent trainee representative body. Although RANZCP has a Trainee Representative Committee, there are benefits to independent representation that can improve the training experience. Future directions of trainee associations include the possibility of re-establishment of a national or bi-national trainee association and creation of federations of associations, for example, in the Asia Pacific region.
Mood Stabilizer and Antipsychotic Utilization among Maternal Mental Health Service Users in Pregnancy
C Møller-Olsen1, S Hatters-Friedman2,3, C Prakash1, A North3
1Auckland District Health Board, Auckland, New Zealand
2Waitemata District Health Board, Auckland, New Zealand
3University of Auckland, Auckland, New Zealand
Background: Prescribing in pregnancy has always been a difficult issue, and there remains a lack of evidence surrounding the safety of medication. In particular, there are limited data for both antipsychotic and mood stabilizing medications.
Objectives: This study aims to investigate the impact of antipsychotic and mood stabilizing medications on pregnancy and birth outcomes that will provide more definitive information and enable both clinicians and women to make an informed choice.
Methods: This retrospective review investigated 56 pregnant women who were prescribed antipsychotics or mood stabilizers at some point in their pregnancy and under the Auckland Maternal Mental Health service over the 3-year period from January 2012 until December 2014. Medication and dosing during gestation were noted. Pregnancy outcome, obstetric and perinatal complications, congenital malformations and on-going maternal mental health were recorded.
Findings: The most common diagnosis was bipolar disorder with many women having multiple diagnoses. Frequently used medications included quetiapine (n = 21), olanzapine (n = 19), risperidone (n = 5), lithium (n = 5) and lamotrigene (n = 6); with a total of 61% of mothers prescribed psychiatric polypharmacy. Eight women had gestational diabetes mellitus. Outcomes included primarily healthy term infants and also one stillbirth, three congenital abnormalities, five neonatal intensive care admissions and five preterm births. No correlation was found between medication and complications, and no patterns in complications were observed.
Conclusions: Although the sample size was small, this study reinforces the evidence supporting medication in pregnancy, which indicates that the benefit outweighs the risk in many women with severe maternal mental illness.
Long-Term Safety and Efficacy of Lisdexamfetamine Dimesylate by Age Subgroup in Children and Adolescents with Attention Deficit Hyperactivity Disorder
D Coghill1, I Hernández Otero2, P Nagy3, CA Soutullo4, A Zuddas5, B Geibel6, N Naser7, B Yan6, T Banaschewski8
1Division of Neuroscience, University of Dundee, Dundee, UK
2Unit of Child and Adolescent Mental Health (USMIJ), University Hospital Virgen de la Victoria – Maritime Hospital, Torremolinos, Malaga, Spain
3Vadaskert Child and Adolescent Psychiatry Hospital and Outpatient Clinic, Budapest, Hungary
4Child and Adolescent Psychiatry Unit, Department of Psychiatry and Medical Psychology, University of Navarra Clinic, Pamplona, Spain
5Section of Neuroscience and Clinical Pharmacology, Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
6Shire, Wayne, PA, USA
7Shire, Sydney, NSW, Australia
8Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
Background: Attention deficit hyperactivity disorder (ADHD) requires long-term management.
Objectives: To evaluate the long-term safety and efficacy of lisdexamfetamine dimesylate (LDX) in children and adolescents with ADHD in a 2-year, open-label study.
Methods: Children (6–12 years) or adolescents (13–17 years) with ADHD received once-daily, dose-optimized LDX (30, 50 or 70 mg) for 104 weeks. Safety monitoring included treatment-emergent adverse events (TEAEs) and vital signs. Efficacy was assessed as a secondary outcome.
Findings: Of the 314 participants enrolled, 191 completed the study. In the safety population (n = 314), TEAEs were reported by 89.8% of participants, led to discontinuation in 12.4% and were reported as serious by 8.9%. TEAEs reported by ≥10.0% of participants were decreased appetite, nasopharyngitis, headache, decreased weight, insomnia, initial insomnia, irritability and pyrexia. The mean (standard deviation) increases from baseline to last on-treatment assessment (LOTA) in vital signs were systolic blood pressure, 3.4 (10.33) mmHg; diastolic blood pressure, 3.2 (9.05) mmHg; pulse, 7.0 (11.60) bpm. When categorized by age, TEAEs were reported by 181 of 202 (89.6%) children and 101 of 112 (90.2%) adolescents. The mean (95% confidence interval) change from baseline to LOTA in ADHD-Rating-Scale-IV total score was −25.8 (−27.0, −24.5) in the full analysis set (n = 299), −26.3 (−27.9, −24.6) in children (n = 189) and −24.9 (−26.9, −23.0) in adolescents (n = 110); all ps < 0.001.
Conclusions: The safety profile of LDX in children and adolescents in this long-term study was similar to that reported in previous short-term and long-term studies. The efficacy of LDX was demonstrated throughout the 2-year study.
Lisdexamfetamine Dimesylate in Adults with Moderate-to-Severe Binge Eating Disorder: A Phase 3, Multicenter, Open-Label, 12-Month Extension Safety and Tolerability Trial
N. Naser1, M Gasior2, J Hudson3, J Quintero4, MC Ferreira-Cornwell2, J Radewonuk2, S McElroy5,6
1Shire Australia, Sydney, NSW, Australia
2Shire, Wayne, PA, USA
3McLean Hospital/Harvard Medical School, Belmont, CA, USA
4Hospital Universitario Infanta Leonor, Madrid, Spain
5Lindner Center of HOPE, Mason, OH, USA
6University of Cincinnati College of Medicine, Cincinnati, OH, USA
Background: A phase 3, 12-month, open-label safety extension study assessed the long-term safety and tolerability of lisdexamfetamine dimesylate (LDX) in adults with moderate-to-severe binge eating disorder (BED).
Methods: Eligible adults (18–55 years) with BED who completed one of three antecedent trials were enrolled in a 52-week open-label safety extension (dose optimization: 4 weeks [initial dose, 30 mg LDX; target doses, 50 or 70 mg LDX]; dose maintenance: 48 weeks). Safety evaluations included treatment-emergent adverse events (TEAEs), vital signs, weight and Columbia-Suicide Severity Rating Scale (C-SSRS) responses.
Findings: Of the 604 enrolled participants, 599 (521 females and 78 males) were included in the safety analysis set. Mean ± standard deviation (SD) LDX exposure was 284.3 ± 118.84 days; 344 participants (57.4%) were treated for ≥12 months. A total of 506 (84.5%) participants reported TEAEs (TEAEs leading to discontinuation, 54 [9.0%]; severe TEAEs, 42 [7.0%]; serious TEAEs, 17 [2.8%]). TEAEs reported in ≥10% of participants were dry mouth (27.2%), headache (13.2%), insomnia (12.4%) and upper respiratory tract infection (11.4%). The mean ± SD changes from an antecedent study baseline in systolic and diastolic blood pressure, pulse and weight at week 52/early termination (n = 597) were 2.19 ± 11.043 and 1.77 ± 7.848 mmHg, 6.58 ± 10.572 bpm and −7.04 ± 7.534 kg, respectively. On the C-SSRS, there were two positive responses for any active suicidal ideations and four positive responses for non-suicidal self-injurious behavior; there were no positive responses for suicidal behavior, actual suicide attempts or completed suicides.
Conclusions: The long-term safety and tolerability of LDX were generally consistent with its known safety profile.
Lisdexamfetamine Dimesylate in Adults with Moderate-To-Severe Binge Eating Disorder: A Double-Blind, Placebo-Controlled, Randomized-Withdrawal Study
N Naser1, J Hudson2, S McElroy3,4, MC Ferreira-Cornwell5, J Radewonuk5, M Gasior5
1Shire Australia, Sydney, NSW, Australia
2McLean Hospital and Harvard Medical School, Belmont, CA, USA
3Lindner Center of HOPE, Mason, OH, USA
4University of Cincinnati College of Medicine, Cincinnati, OH, USA
5Shire, Wayne, PA, USA
Background: Lisdexamfetamine dimesylate (LDX) maintenance of efficacy was assessed in adults with moderate-to-severe binge eating disorder (BED).
Methods: Adults (18–55 years) meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, TR BED criteria and having moderate-to-severe BED (≥3 binge eating days/week for 14 days before open-label baseline and Clinical Global Impressions−Severity (CGI-S) scores ≥4 at screening and open-label baseline) were eligible. Following a 12-week open-label phase (dose optimization: 4 weeks [50 or 70 mg LDX]; dose maintenance: 8 weeks), LDX responders (≤1 binge eating day/week for 4 consecutive weeks and CGI-S scores ≤2 at week 12) were randomized to placebo or continued LDX during a 26-week, double-blind, randomized-withdrawal phase. Time to relapse (≥2 binge eating days/week for two consecutive weeks and ≥2-point CGI-S score increases from randomized-withdrawal baseline) was assessed in the full analysis set (FAS) using a stratified log-rank test stratifying for 4-week cessation. Safety and tolerability assessments included treatment-emergent adverse events (TEAEs).
Findings: Of the 418 enrolled participants, 275 LDX responders (placebo, n = 138; LDX, n = 137) entered the randomized-withdrawal phase. LDX demonstrated superiority over placebo (p < 0.001) for time to relapse. Proportions of participants meeting relapse criteria were 3.7% (5/136) for LDX and 32.1% (42/131) for placebo. TEAEs reported by >5% of participants during open-label treatment were dry mouth, headache, insomnia, decreased appetite, nausea, anxiety, constipation, hyperhidrosis, feeling jittery and diarrhea.
Conclusions: Following an initial response to LDX, the risk of relapse to binge eating for more than 6 months was markedly lower with continued LDX than with placebo. The safety and tolerability of LDX were consistent with its known profile.
Mindhealthconnect: Response to the National Review of Mental Health Services and Programmes
N O’Connor1,2, M Araco3, J Gibson4, R Heffernan3
1Northern Sydney Local Health District, Sydney, NSW, Australia
2Department of Psychiatry, The University of Sydney, Sydney, NSW, Australia
3Healthdirect Australia, Sydney, NSW, Australia
Background: Mindhealthconnect is the national mental health web portal commissioned by the Australian Federal Government as part of the National E-Mental Health Strategy. Mindhealthconnect was initiated by Healthdirect Australia in July 2012. As at October 2015, mindhealthconnect has 63 information partner organisations, 33 online programmes, 2561 fact sheets and is linked to a number (20) of mental health ‘communities’. Mindhealthconnect has a Mental Health Guided Search Tool to enable users to quickly identify the most appropriate resources according to their problem and a mood monitoring tool. The mindhealthconnect website has linkage to the National Health Service Directory.
The National Review of Mental Health Programmes and Services Report highlighted the potential efficacy and cost-effectiveness benefits of increasing mental health self-care and online supports as part of a stepped-care approach, particularly among groups who are low users of face-to-face services.
Objectives: To present the new developments in mindhealthconnect in response to the National Review.
Findings: Mindhealthconnect encourages mental health self-care and online supports for a stepped-care approach, particularly among groups who are low users of face-to-face services. Examples include an online guided search tool to better surface consumer personalized and localized mental health information and connection to services, an online mood monitor and access to the National Health Services Directory.
Conclusions: Mindhealthconnect is an important resource for consumers, carers and clinicians.
Historical Descriptions of Attention Deficit Hyperactivity Disorder
D Perera
Eastern Health/Maroondah Hospital, Ringwood East, VIC, Australia
Background: Some argue that attention deficit hyperactivity disorder (ADHD) is a result of the adverse conditions of modern society and questioning it as a nosological entity. However, it appears that there are many early descriptions akin to the present-day condition.
Objectives: To determine whether the early writings described what we know today as ADHD.
Methods: A search of the literature using PubMed with key words ‘History’ and ‘ADHD’ and equivalent terms did not yield relevant articles. Hence, a strategic search was performed using cross-references as well as searching on PubMed for a known article and then obtaining related articles.
Findings: The available literature suggests the existence of this disorder dating back to the 18th century with the earliest reference to it made in the late 1700’s (Bader and Hadjikhani, 2013). Fidgety Philip and Johnny Look in the Air are from a 19th century children’s story book depicting ADHD-type behaviour (Thome and Jacobs, 2004). Minimal brain dysfunction and hyperkinetic disease of infancy, also known as Kramer -Pollnow syndrome, were all terms describing ADHD symptomology in children (Lange et al., 2010). The terminology for the syndrome has evolved and continues to be classified in the current Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) as well as the International Classification of Diseases (ICD)-10-CM.
Conclusions: Children presenting with symptoms of inattention, hyperactivity and impulsivity have been described by several authors during the last 200 years. These descriptions are consistent with the modern diagnostic criteria for ADHD. It is a condition that has an ancient history.
References
Bader M and Hadjikhani N (2013) The concept of instability: A French perspective on the concept of ADHD. Attention Deficit and Hyperactivity Disorders 6: 11–17.
Lange KW, Reichl S, Lange KM, et al. (2010) The history of attention deficit hyperactivity disorder. Attention Deficit and Hyperactivity Disorders 2: 241–255.
Thome J and Jacobs KA (2004) Attention deficit hyperactivity disorder (ADHD) in a 19th century children’s book. European Psychiatry 19: 303–306.
Efficacy and Safety of lurasidone in Patients with Schizophrenia: A Review of Clinical Studies
A Pikalov, M Tocco, J Hsu, J Cucchiaro, A Loebel
Sunovion Pharmaceuticals, Fort Lee, NJ, USA
Background: Lurasidone is an atypical antipsychotic that acts as an antagonist at D2, 5HT2A and 5HT7 receptors and demonstrates no appreciable affinity for muscarinic M1 and histamine H1 receptors.
Objectives: To review the efficacy and safety of lurasidone treatment in adult patients with schizophrenia.
Methods: Data from the lurasidone clinical development program in schizophrenia were summarized.
Findings: In five short-term studies (pooled analysis), the mean change from baseline to week 6 in the Positive and Negative Syndrome Scale (PANSS) total score was −22.6 for lurasidone (n = 1030; 40–160 mg/day dose groups pooled) and −12.8 for placebo (n = 496; p < 0.001). In two short-term, active-controlled studies, least squares mean change in PANSS total score at week 6 was not significantly different for lurasidone at 40 and 120 mg/day vs olanzapine 15 mg/day (−25.7 and −23.6 vs −28.7, respectively) or lurasidone 80 and 160 mg/day vs quetiapine XR 600 mg/day (−22.2 and −26.5 vs −27.8, respectively). The most common adverse events associated with lurasidone 20–160 mg/day (incidence ≥5% and ≥2 times placebo) in seven short-term studies (n = 1508) were somnolence, extrapyramidal symptoms, akathisia and nausea. There were minimal effects of lurasidone on weight and metabolic parameters in short-term and long-term studies. In patients without metabolic syndrome (National Cholesterol Education Program criteria) at baseline in two long-term studies, the frequency of metabolic syndrome after 12 months of treatment was lower for lurasidone compared with quetiapine XR and risperidone.
Conclusions: Lurasidone demonstrated efficacy across the dose range of 40–160 mg/day and was well tolerated in the treatment of patients with schizophrenia.
Funding
This work was sponsored by Servier Laboratories and Sunovion Pharmaceuticals, Inc.
Disclosures
A.P., M.T., J.H. J.C. and A.L. are employees of Sunovion Pharmaceuticals, Inc.
Finding Balance: Examining Anger Impulses in a Patient with Obsessive–Compulsive Disorder
D Prasad, H Naidu
Nur Manzil Psychiatric Centre, Lucknow, India
Background: Anger is defined as a person’s response to a threat or the perception of a threat against an individual or group. Various studies have been conducted to evaluate anger impulses in eating disorders, depression and anxiety disorders. Anger impulses in obsessive–compulsive disorders (OCDs) have been less documented in Indian settings. Patients with OCD usually possess a tendency to suppress anger inwardly and report more difficulty in controlling anger.
Objective: The main objective of the study was to analyze the pattern of anger in a patient diagnosed with OCD.
Method: We hereby present a case with chief complaints of mainly fear of contamination, repeated hand washing, checking, seeking reassurance and intense anger. A detailed interview and the Thematic Apperception Test were planned and conducted to gain better understanding of her anger impulses.
Findings: Family accommodation in the form of complying to reassurance acted as a catalyst in the maintenance of obsessions and compulsions. It was found that the anger impulses were mainly directed to the mother, especially in conditions when she would not comply to the checking rituals performed by the patient. Yelling, shouting, threatening and physical and verbal abuse were employed to manifest anger. Thus, anger acted as a maneuver to control the family members.
Conclusions: This paper attempts to unfold two dimensions, expression of anger in OCD and as to how family accommodation reinforces the symptoms, thereby leading to decreased self-efficacy and poor prognosis.
Review of the First 2 Years of Using A Newly Available, Long-Acting Injection Antipsychotic (Olanzapine) in South Auckland
N Pitigala, J Ramakrishnan, L Petaia
Counties Manukau District Health Board, Auckland, New Zealand
Background: Olanzapine long-acting injection (LAI) has been made available since 2013 in our mental health services for maintenance treatment of schizophrenia. There has been no systematic evaluation of the impact of its use. Review at a service level of newly introduced treatments is important to improve the quality of care provided.
Objectives: To determine the clinical characteristics of patients started on olanzapine LAI and to assess outcomes and adverse effects.
Methods: The sample will be drawn from the list of patients for whom service-level approval has been granted to use olanzapine LAI. All patients issued with approval between 1 January and 30 June 2014 will be eligible for the study. A data collection form has been designed specifically for the study and was finalized after an initial pilot. Data on sociodemographic and clinical details will be extracted from electronic records (psychiatric and general medical).
Findings: The results will be presented as descriptive statistics. Useful information on the clinical characteristics of patients started on olanzapine LAI. Sociodemographic and clinical parameters associated with outcomes and adverse effects will be presented.
Conclusions: The results from the early group of patients on whom the drug has been used may enable more targeted and clinically appropriate use in future patients.
Time to Schizophrenia Relapse in Relapse Prevention Studies of Antipsychotics Developed for Administration Daily, Once Monthly or Every Three Months
E Kim1, J Berwaerts2, I Turkoz2, S Gopal2 (non-author presenter: L Wilkinson3)
1Janssen Scientific Affairs, Titusville, FL, USA
2Janssen Research and Development, Titusville, FL, USA
3Janssen Medical and Scientific Affairs, Brisbane, QLD, Australia
Background: Long-acting injectable antipsychotics (LAIs) provide longer duration of therapeutic drug plasma levels than oral antipsychotics, potentially reducing risk for relapse of schizophrenia.
Objectives: This post hoc analysis compared time to first relapse of schizophrenia after discontinuation of oral paliperidone extended release, once-monthly paliperidone palmitate (PP1M) LAI and investigational PP once every 3 months (PP3M) LAI.
Methods: Three randomized, double-blind (DB), placebo-controlled relapse-prevention studies of oral paliperidone (n = 628), PP1M (n = 951) and PP3M (n = 620) in patients with schizophrenia were conducted over 10 years. Subjects were stabilized during an open-label (OL) phase and randomly assigned to continue active drug or switch to placebo during a DB relapse-prevention phase. Primary endpoint: time to relapse, estimated using Kaplan–Meier. Cox proportional hazard models determined risk reduction (RR) between placebo arms across studies.
Findings: A total of 101, 203 and 145 patients in the placebo arms of oral paliperidone, PP1M and PP3M studies were included. Risk of relapse of placebo-treated patients in the oral paliperidone vs PP1M studies was 0.441 (95% confidence interval [CI] = 0.313, 0.620; p < 0.001), indicating 56% RR of relapse within the PP1M compared to the oral paliperidone study. The risk of placebo-treated subjects in the oral vs PP3M study was 0.212 (95% CI = 0.140, 0.320; p < 0.001), indicating 79% RR of relapse within the PP3M compared to the oral study. Risk of relapse of placebo-treated subjects in the PP1M vs PP3M studies was 0.480 (95% CI = 0.334, 0.691; p < 0.001), indicating 52% RR of relapse within the PP3M compared to the PP1M study. The median time to relapse (days) was significantly longer following discontinuation from PP3M (395; 95% CI, 2, 4, not reached) than after discontinuation of PP1M (172; 95% CI = 134, 222) or oral paliperidone (58; 95% CI = 42, 114) (p < 0.0001).
Conclusions: This post hoc analysis suggests that following randomized discontinuation after OL stabilization, the reduction in unadjusted risk of relapse with PP3M was higher than PP1M or oral paliperidone. PP3M can confer a median protection of 395 days after sudden discontinuation.
Paliperidone Palmitate 3-Monthly Compared with 1-Monthly Formulation in Patients with Schizophrenia: Global and Asian Subpopulation Analysis of a Randomized, Double-Blind, non-Inferiority Study
A Savitz1, S Gopal1, Y Feng2, H Xu1, J Zhuo2, L Yu2, I Nuamah1, P Ravenstijn3, C Wu2, D Hough1
1Janssen Research and Development, Raritan, NJ, USA
2Janssen Research and Development, Beijing, China
3Janssen Research and Development, a Division of Janssen Pharmaceutica NV, Beerse, Belgium
Background: Paliperidone palmitate 3-monthly formulation (PP3M), a long-acting injectable antipsychotic with an extended dosing interval (four doses/year), is approved for schizophrenia treatment in the United States.
Objectives: To demonstrate non-inferiority of PP3M to PP 1-monthly formulation (PP1M) in patients with schizophrenia and to compare outcomes in the Asian subgroup with the total population.
Methods: Eligible patients (aged 18–70 years) entered a 17-week, flexible-dose, open-label (OL) phase to receive PP1M. Stabilized patients were randomized (1:1) to receive fixed doses of PP1M or PP3M (175, 263, 350 or 525 mg eq. [3.5 multiple of PP1M]) in a 48-week, double-blind (DB) phase. Primary efficacy endpoint was percentage of patients who remained relapse-free at the end of the DB phase.
Findings: Of the 1429 patients enrolled during the OL phase, 1016 (Asian subgroup: n = 344) entered the DB phase. The Kaplan–Meier estimate of difference (95% confidence interval [CI]) between PP3M and PP1M groups who remained relapse-free was similar between the total population (1.2% [−2.7%, 5.1%]) and the Asian subgroup (1.6% [−5.7%, 9.0%]); lower boundary of CI was larger than a pre-specified non-inferiority margin of −15%. The least squares mean difference (95% CI) between PP3M and PP1M for a change from baseline in the PANSS total score until the DB endpoint was similar between total population and (0.9 [−0.61, 2.34]) and the Asian subgroup (0.3 [−2.26, 2.80]). The incidence of treatment-emergent adverse events (TEAEs) was similar between those treated with PP3M and PP1M in the total population (PP3M: 67.9%, PP1M: 66.4%) and the Asian subgroup (PP3M: 81.2%, PP1M: 75.9%); the TEAE of weight increase was higher in Asian patients.
Conclusions: PP3M was non-inferior to PP1M and was tolerated similarly in both the total population and Asian patients with schizophrenia.
Learning from the Outcomes of Emergency Examination Orders, Mental Health Act, 2000, Queensland
T Sehgal1,2, M Wickramasinghe1,3, M Owens1,3, K Vigneswaran1,2, D Sammon1,4, N Wright1,5, B Motamarri1,6
1Metro South Addiction and Mental Health Service, Queensland Health, Brisbane, QLD, Australia
2Consultant Psychiatrist
3Psychiatry Registrar
4Clinical Nurse Consultant
5Nurse Clinician
6Consultant Psychiatrist and Clinical Director
Background: An Emergency Examination Order (EEO) is part of the Mental Health Act (MHA) 2000 legislation in Queensland, Australia, which authorises a police officer or an ambulance officer to take a person to an authorised mental health service for further assessment if they reasonably believe that the person has a mental illness; and because of their illness there is an imminent risk of significant physical harm to themselves or someone else. As a result, a further assessment could lead to an outcome of request and recommendation assessment under the Act or no further need of detention following assessment, which leads to revoking the EEO. We have noticed in our routine practice that the person assessed under the EEO at times is not in need of an acute mental health treatment or assessment. However, the EEO initial order is confounded at the time with substance misuse.
Objectives: To identify the outcomes of assessments under an EEO from the available data.
Methods: We looked into the data of all the EEOs assessed in our Redland Hospital, emergency department between 23 July 2015 and 14 October 2015. We looked into the outcomes of the assessments. The possible outcomes are revoking the EEO with a plan to discharge home with or without community services support, voluntary admission or admission to a mental health unit under the MHA. We also looked into the involvement of illicit substances at the time of initial presentation under the EEO.
Findings and conclusions: As the project is in progress, our findings and conclusions will be discussed at presentation.
Outpatient Prescribing Trends in Antidepressant Drugs at a General Hospital in Singapore between 2005 and 2013
T Tsang1, R Kinson2, L Tan2, K Wong2
1National Healthcare Group, Singapore
2Tan Tock Seng Hospital, Singapore
Background: Antidepressant drug use has been increasing worldwide, and there is a paucity of data from South East Asia.
Objectives: This study aims to investigate the patterns in prescribing of antidepressants within a general hospital in Singapore.
Methods: Electronic records of prescribed drugs from alternate years from 2005 to 2013 from Tan Tock Seng Hospital (TTSH) were reviewed. Antidepressant prescription use and the patient characteristics of age, gender, and patient class were examined.
Findings: A total of 37,562 patients with a mean age of 56.3 years (standard deviation [SD] ± 18.78) were enlisted in this study. There was a higher proportion of women (n = 22,651, 60.3%) and subsidized patients (n = 25,761, 71.7%). A total of 114,377 antidepressant prescriptions showed an increasing trend across the years: from 15,876 in 2005 to 29,980 in 2013. The most commonly prescribed class of antidepressants was selective serotonin reuptake inhibitors (SSRIs) (n = 53,293; 46.7%), followed by tricyclic antidepressants (TCAs) (n = 45,695; 40.0%). Nevertheless, over the 9 years, there was an overall drop in SSRI prescriptions from 57.6% (n = 9149) to 48.8% (n = 14,624) and for TCAs from 36.3% (n = 5764) to 30.4% (n = 9112). This decrease was concomitant with an increased use of noradrenergic and specific serotonergic antidepressants (NaSSAs) from 4.6% (n = 723) to 13.9% (n = 4167) and serotonin–norepinephrine reuptake inhibitors antidepressants (SNRIs) from 0.6% (n = 92) to 4.4% (n = 1308).
Conclusions: Antidepressant usage has been increasing and although SSRIs remain the most common choice, the percentage prescribed has declined. Meanwhile, there has been upward trend in prescriptions of other newer antidepressant classes such as NaSSAs and SNRIs.
The Impact of a Paediatric Consultation-Liaison Service: A Pilot Study
P Vroegop1,2
1Counties Manukau Health, Auckland, New Zealand
2University of Auckland, Auckland, New Zealand
Background: Paediatric consultation-liaison (CL) psychiatry services are present in a number of the larger children’s hospitals in Australia and New Zealand. While there is some evidence about service configuration and delivery, there are few descriptions of patient populations for these services.
Objectives: This study attempts to capture a description of the patients seen by a paediatric CL psychiatry team and is a pilot for a study that will look at whether there are identifiable differences in the outcomes of paediatric hospital inpatients according to the presence or absence of a paediatric CL team.
Methods: A review of paediatric CL services and service models/configurations was undertaken, both from the literature and informal enquiries internationally.
Utilising retrospective analysis of patient data collected across the hospital system from different data sources, consultation rates, length of stay and presenting issues were identified. An attempt was made to assess patient outcomes utilising available data sources.
Findings: Findings will be discussed, with implications for future cost–benefit analysis.
Neural Correlates of Reward Processing in Schizophrenia: A Meta-Analysis of Functional Neuroimaging Studies
P Xu1,2, N Klaasen2,*, E Opmeer2, M van Tol2, A Aleman2,3
1Institute of Affective and Social Neuroscience, Shenzhen University, Shenzhen, China
2Department of Neuroscience, Neuroimaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
3Department of Psychology, University of Groningen, Groningen, The Netherlands
Background: Impaired motivation and reward learning in patients with schizophrenia are associated with deficits in different aspects of the reward system. Although a large body of neuroimaging studies have examined the neural correlates of reward anticipation, outcome evaluation and reward learning in schizophrenia, a consistent brain pattern of dysfunction during reward processing in patients with schizophrenia remains unclear.
Objectives: To investigate the neural correlates of reward processing in schizophrenia, we conducted a systematic and quantitative meta-analysis of neuroimaging studies on different stages of reward processing in patients with schizophrenia and controls.
Methods: We examined 28 functional neuroimaging studies of reward processes in patients with schizophrenia, including reward anticipation, consummation and learning. A meta-analysis was conducted using activation likelihood estimation (ALE).
Findings: We observed several core brain areas that deactivated during reward processing in patients with schizophrenia, including the substantia nigra (SN)/ventral tegmental area (VTA), caudate, thalamus, insula and prefrontal cortex (PFC). Specifically, hypoactivaion of the caudate was involved in both anticipatory and consummatory reward processing; reduced activation of the putamen was found in both reward outcome evaluation and reward learning; activation of the SN/VTA, dorsolateral and dorsomedial PFC, and orbital frontal cortex was decreased during reward learning in patients with schizophrenia compared to controls.
Conclusions: A marked under-recruited mesocorticolimbic pathway is pivotal to the disruption of reward processing in patients with schizophrenia. While striatal dysfunction is more associated with anticipatory and consummatory reward, the dysfunctional midbrain and prefrontal areas are more important for reward learning in patients with schizophrenia.
Late-Onset Anorexia Nervosa: An Asian Perspective
Z Zhao1, K Ann, H Lee1, S Chua2, S Kwok2, S Tan1
1Department of Psychiatry, Singapore General Hospital, Singapore
2National University of Singapore, Singapore
Background: To date, there are some case reports and case series that have revealed that anorexia nervosa can arise in older age, but there is limited information about the features of the late-onset anorexia nervosa.
Objective: To study the clinical characteristics and features of patients with late-onset anorexia nervosa in Singapore.
Method: All patients with age of onset above 25 years who presented to the Eating Disorder Clinic at Singapore General Hospital between 2003 and 2014 were identified and studied retrospectively. Anorexia nervosa was defined using the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV)-TR criteria. Information on age of onset, clinical subtypes, demographic features, precipitating factors, psychiatric comorbidity and clinical prognosis was obtained directly from case notes.
Findings: In all, 31 patients with late-onset anorexia nervosa were identified. The mean age of onset was 32.26 years: 18 patients were of the restrictive subtype and 13 patients were of the binge-purge subtype. Most (94%) were female, 74% did not have family history of eating disorders, 58% were degree holders or above and 65% stayed in private property. There were 25 patients with precipitating factors, of which school or work-related stress was the most common (23%). Psychiatric comorbidity was found in 74% of patients, the commonest being major depression (48%). Eleven patients needed inpatient stay at some point in their illness. The average number of admissions was 1.64 and the average duration was 4.17 days.
Conclusions: This study was undertaken to better characterize late-onset anorexia nervosa in an Asian country, which echoed similar studies in the Western world.
Experience from a Liaison Clinic: A Biopsychosocial Model for Managing Patients with Medically Unexplained Symptoms
K Leung, M Rowett
Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
Background: Medically unexplained symptoms (MUS) are often communicated poorly to patients, leading to stigma and poor treatment compliance. Annually, more than 200 cases are referred to the liaison clinic at Roseberry Park Hospital, UK, from local trusts. However, no standardised guidelines have been established for the management of MUS.
Objectives:
1. To provide a descriptive account of our practice in managing patients with MUS;
2. To emphasise the importance of considering the whole picture on this body–mind divide;
3. To stimulate further service evaluation.
Methods: A MUS clinic sit-in session was arranged on 20 January 2014. The techniques used by the consultant-in-charge were recorded. The physician’s perspectives of the MUS-specific management approach were then obtained.
Findings: The following themes have been consistently identified:
• Acknowledgement – acknowledging the patient’s frustration helps set the tone for a psychological formulation;
• Validation – take a full history of the onset and course and enquire about illness perception;
• Exploration – discuss the emotional impact; identify co-morbid psychopathology, living arrangement and relationships; maintain a conversational style; use metaphors;
• Formulation – use a timeline to obtain the personal history (e.g. quality of relationships, childhood adversity and illnesses, events in parents’ lives);
• Explanation – reassure the patient with regard to cultural acceptability, provide a model of the symptoms, describe existing treatment evidence and give realistic expectations.
Conclusions: We have devised a descriptive account of a biopsychosocial model for the management of MUS. This has prompted further research for acceptability and validation of the described approach. An individualised and holistic approach for MUS is required as its outcome is heavily determined by the cultural and social circumstances.
Engaging the Next Generation of Psychiatrists
M Tomasic1,2
1RANZCP Recruitment into Psychiatry Working Party, Melbourne, VIC, Australia
2Centre for Disability Health, Department for Communities and Social Inclusion, Adelaide, SA, Australia
Background: It is well recognised that the psychiatry workforce in Australia and New Zealand is facing a critical shortage in meeting increasing population needs.
Objectives: This working party aims to dispel common misconceptions, raise the profile and promote psychiatry as a career choice.
Methods: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) through its Recruitment into Psychiatry Project, funded by the Commonwealth Department of Health (DoH) under the Specialist Training Program (STP), has developed a suite of initiatives to engage with medical students and graduates including the Psychiatry Interest Forum (PIF), student sponsorships to attend RANZCP conferences, PIF Ambassadors, a binational essay competition, introduction to psychiatry short courses, relationship building with university medical schools and new resources for students and their teachers.
Findings: The initiatives have been welcomed by students, graduates and universities: More than 1200 students and graduates have joined the PIF; More than 50 students have been sponsored to attend Congress; More than 100 have participated in the Introduction to psychiatry courses; Course attendees have reported a 63% increase in considering psychiatry as a career and a 96% increase in awareness of training pathways; Since the inception of the PIF in September 2013, approximately 21% of eligible PIF members have progressed into a psychiatric programme with the RANZCP. Thanks to the involvement of more than 80 fellows and trainees for the success of these initiatives.
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.
