Sedation Guidelines for Acute Severe Behavioural Disturbance
N O’Connor1,2, J Corish3
1Northern Sydney Local Health District, New South Wales, Sydney, Australia2Department of Psychiatry, University of Sydney, New South Wales Sydney, Australia3South Coast Private Hospital, Wollongong, Australia, 4Graduate School of Medicine, University of Wollongong, Wollongong, Australia
Background: The safe management of patients with an acute behavioural disturbance is a problem frequently encountered by clinicians in a hospital setting. Often, the cause of the disturbance is multifactorial with contributions from substance misuse, pre-existing psychiatric conditions, physical health problems and situational or personality factors. A number of guidelines and protocols exist to provide advice concerning safe sedation and monitoring. In 2014 RANZCP fellows were requested to forward protocols for the pharmacological treatment of ASBD to the authors for review and analysis.
Objectives: To report back on the range of medications and dosages currently being used in Australasia for the sedation of ASBD. To report on the recent literature in relation to safe and effective sedation of the patient with ASBD.
Methods: The sedation guidelines were analyzed in relation to choice of first, second and third line medications, means of administration, dosage.
A literature review focused on the practical clinical aspects of the pharmacological management of ASBD and recent advances in our knowledge of the agents used.
Findings: Thirty five pharmacological management protocols for the ASBD patient were received and analysed. A number of recent Australian studies were identified that provide new evidence in relation to the safe and effective management of the ASBD patient.
Conclusions: The benefits and disadvantages of benzodiazepines and first generation and atypical antipsychotic medications in ASBD are presented and discussed.
Integrating Evidence Based Practice and Lived Experience
R McKay1, 2
1New South Wales Institute of Psychiatry, New South Wales, Sydney, Australia 2University of New South Wales, New South Wales, Sydney, Australia
Background: There are increasing calls for incorporation of the ‘lessons of lived experience’ into mental health planning, management and care. The recognition of ‘Peer Workers’ as an important future part of the current (in some locations) and future mental health workforce reinforces this concept. However there is limited conceptual guidance regarding how to develop systemic evidence from lived experience, or how to integrate this evidence into broader ‘evidence based practice’ in mental health.
Objectives: To present a conceptual framework for integrating evidence from lived experience into broader evidence based practice in psychiatry and mental health.
Methods: Review of the concepts of ‘lived experience’, ‘peer workers’ and what is considered to be their evidence bases. Review of the underlying principles of interprofessional learning and practice.
Findings: There is an increasing literature regarding the common elements of ‘personal recovery’, which can be conceptualised as a core initial evidence base regarding lived experience. The concepts of interprofessional learning and practice can be used to start to incorporate this evidence into evidence based practice; and consider how traditional evidence bases may influence the development of a stronger evidence base for utilising ‘lessons of lived experience ’
Conclusions: Psychiatry will continue to evolve through improved understanding of the neurosciences. Developing models to integrate such knowledge with a more systematic understanding of lived experience should assist applying this science in a manner acceptable to more of those who experience mental illness.
Deep Brain Stimulation for Obsessive Compulsive Disorder: The Royal Melbourne Hospital 2011-2016
D Velakoulis1,2, A Evans1,3, M Walterfang1,2, R Mocellin1,2, S Mangelsdorf1, R Bittar4
1Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, Australia,
2Neuropsychiatry Centre University of Melbourne and Melbourne Health, Melbourne, Australia
3Department of Neurology, Royal Melbourne Hospital, Melbourne Australia, Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Australia
Background: The first Australian deep brain stimulation procedure for OCD was undertaken in 2010 at the Royal Melbourne Hospital. To date have performed 7 cases, 5 of which have at least 12 months of follow up data available.
Objectives: To report our experience with the first five DBS cases the Royal Melbourne Hospital.
Methods: Five patients with severe treatment refractory OCD underwent deep brain stimulation targeted at the nucleus acumens bilaterally. Clinical and cognitive ratings have been obtained before DBS and serially following DBS.
Findings: Three of five patients (Patients 1, 2 and 3) have exhibited clinically significant improvements while two (Patients 4 and 5) have shown fluctuating symptoms.
Conclusions: Patient’s outcomes are consistent with the international literature i.e about 60% of subjects exhibit a 60% improvement in their OCD symptoms.
Changes in the Age Patterns of Suicide in Hong Kong, Australia and New Zealand
J Snowdon1, A Zhilan2, H Chiu2, J Phillips3, T Yamauchi4, Y Conwell5
1University of Sydney, New South Wales, Sydney, Australia
2The Chinese University of Hong Kong, Hong Kong
3Rutgers, The State University of New Jersey, USA
4Center for Suicide Prevention, National Institute of Mental Health, Tokyo, Japan
5University of Rochester, New York, USA
Background: Differences between countries’ age patterns of suicide are partly (and maybe largely) attributable to variations between populations in the degree to which psychosocial, environmental and biological factors affect suicide rates across the age-range and over time.
Objectives:
To examine differences in male and female age patterns of suicide reported by Hong Kong, Australia and New Zealand, and compare them with relevant data reported by other countries (particularly China, United States, England & Wales, and Japan).
To provoke discussion concerning reasons for differences.
Methods: Suicide data were obtained from the Australian Bureau of Statistics and equivalent sources in the other named countries. Male and female suicide rates of age-groups from 10-14 years up to 85+ years over 5-year periods up to 2009-2013 were graphed and compared.
Findings: Age patterns of suicide differ between genders, between populations, and over time. For example, late life suicide rates have halved in Hong Kong, Australia and New Zealand over the last few decades. Increased Hong Kong suicide rates of young men did not reach the recent peaks recorded in Australia and New Zealand. Over the last 50 years, the male pattern in Australia and New Zealand has changed from upward-sloping to bimodal, and the female from convex to uniform (flat), while Hong Kong patterns have remained upward-sloping*.
Conclusions: Comparisons of age patterns of suicide foster discussion concerning factors that contribute to causation of suicide, and thus to ideas about preventative approaches.
Reference
*Da Viega FA, Saraiva CB (2003). Crisis 24, 56–67.
Review of the Cannabis-Psychosis Association
A. Pascoe1
1Darling Downs Hospital and Health Service, Toowoomba, Australia
Background: This review was completed to meet the Research Project requirements of the RANZCP Advanced Training in Addiction Psychiatry. It was prompted by the observation whilst working with a metropolitan early psychosis service that a high proportion of patients reported co-morbid cannabis use at the time of presentation. There have also been longstanding suspicions that a relationship exists between cannabis use and mental illness.
Objectives: The review set out to explore two questions. Firstly, does the existing literature support the cannabis-psychosis association and secondly, what is the presumed nature of this association (i.e. is cannabis causal)?
Methods: A literature search was conducted of the PsychINFO and MEDLINE complete databases using the Boolean search phrase “cannabis AND psychosis AND cause” with result limits of peer reviewed journal/journal article and English language publications only. The final searches were conducted in December 2014 yielding 159 results and 132 results on the PsychINFO and MEDLINE complete databases respectively. After review of abstracts from all unique search results as well as selection of relevant publications from journal article reference lists, 136 journal articles deemed relevant to the objective questions were selected for full-text review. There was considerable heterogeneity in research quality reflecting the inherent heterogeneity and obstacles present in cannabis-psychosis research.
Findings: Experimental research provides consistent evidence that cannabis intoxication is associated with onset, persistence or exacerbation of psychotic symptoms time-limited to the period of intoxication. Heterogeneous epidemiological research supports that cannabis use is associated with later onset of psychosis with systematic reviews and meta-analyses finding cannabis users have roughly twice the odds of later developing psychosis than non-users. The association appears more pronounced for more severe forms of psychosis, for those people with heavier cannabis use and who commence cannabis use at a younger age, and for those people who are already predisposed to developing psychosis. With respect to the nature of the association, additional epidemiological research suggests that cannabis is probably insufficient to independently cause psychosis but rather acts as a contributory cause in the onset and persistence of psychosis by way of interacting with and moderating the effect of other genetic and environmental risk factors. Genetic risk for psychosis is likely the result of numerous genetic variations as opposed to single gene polymorphisms, and urbanicity and developmental trauma appear to be environmental exposures that are also contributory causes for psychosis, although how they interact with and moderate the effect of cannabis use on psychosis requires further investigation.
Conclusions: The literature reviewed supports an association between cannabis use and later development of psychosis. This conclusion is based predominantly on the findings of a number of large epidemiological studies, which is the most appropriate research approach to assessing such an association due to the illegal status of cannabis in many jurisdictions, the low prevalence of psychotic disorders in the general population and also amongst cannabis users, and a suspected time lag of several years between onset of cannabis use and later onset of psychosis. Cannabis also appears to be a contributory causal factor in the onset and persistence of psychosis with epidemiological studies consistently finding cannabis use predates the onset of positive psychotic symptoms, the association remains following controlling for a number of potential observed and unobserved confounders, the association is generally stronger in heavier cannabis users, the association is relatively consistent across studies and meta-analyses, and experimental evidence has shown that acute tetrahydrocannabinol (THC) can trigger transient psychotic symptoms. There are also a number of biologically plausible explanations for cannabis use being a contributory cause for psychosis onset and persistence with a gene-environment interaction model providing the most consistent explanatory model across the literature. Research on synthetic CB1 receptor agonists may provide greater insight into the nature of the cannabis-psychosis association and epidemiological research in jurisdictions where cannabis is legal provides a unique opportunity to expand the research on the cannabis-psychosis association.
Outcomes of a Unique Residential Rehabilitation Program from Rural Australia
V Phutane1, R Bhat1, 3, D Cahill2, P Ewert1, W Brown1
1Goulburn Valley Health, Shepparton, Australia.
2MI Fellowship, Shepparton, Victoria, Australia
3Department of Rural Health, Melbourne Medical School, The University of Melbourne, Shepparton, Australia
Background: The Specialist Residential Rehabilitation Program (SRRP) is the only such program in Victoria, and possibly in Australia, established with a partnership between the Goulburn Valley Area Mental Health Services (GVAMHS), a rural area mental health service, and MI Fellowship, a major mental health community support service in Victoria.
Objectives: To assess the characteristics and outcomes of participants attending residential rehabilitation at SRRP over more than a decade.
Methods: A total of 113 patients with severe mental illness who participated in SRRP during 2001 to 2013 were analysed. Routinely collected clinical data from a state-wide database were used. The difference between number and days of inpatient admissions was analysed using one sample t-test.
Findings: The mean age of patients was 33.97 (standard deviation (SD) 11.35) years and the majority were males (68%). The median duration of SRRP admission was 228 days (range: 6–820 days). When some participants had more than one stay in SRRP, the SRRP admission ⩾ 90 days was taken to be the index admission. Participants had a significant reduction both in the number of inpatient admissions and admission duration from before and after SRRP admission (7.32 versus 4.77; t = 8.542; p < 0.001) and days (170.79 versus 98.56; t = 8.286; p < 0.001). We will present detailed results on functional outcomes in the conference.
Conclusions: A partnership model of psychiatric rehabilitation is effective in reducing inpatients for people with severe mental illnesses. We believe that the marriage of two perspectives – the clinical, and social and community welfare – is central to the success of this program, leading to a genuinely recovery-oriented perspective.
A 20-Year History of Telepsychiatry in South Australia: from Inception to Integration
DS Mosler1
1Rural and Remote Mental Health Service, Country Health South Australia, Local Health Network, Adelaide, Australia
Background: The South Australian Rural Mental Health Sector has developed a rich history of the use of remote and telepsychiatry, in order to manage the challenge of providing mental health care across vast distances, including regions with differing demographics and needs.
Objectives: This paper aims to demonstrate the history and growth of telepsychiatry in South Australia, as part of the integrated model of care that will continue to remain a focus for the state-wide country mental health network.
Methods: A review of statistical and qualitative data relating to the development of telepsychiatry within this service.
Findings: The telepsychiatry service has expanded from a pilot project in 1994, with 3 rural sites, to a 106-site inclusive psychiatric network, providing many of the essential services that metropolitan counterpart services are able to provide. This model of care that has become embraced by the key stakeholders involved with the service, to the extent that the number of sessions per year has grown steadily from 400 sessions per year during its first three years, to over 2600 per year in recent years.
Conclusions: The resultant impact of the establishment of this model of care on the rural sector can be observed by the graphical representations, within the body of this paper. The evidence, based on the data relating to the provision of dedicated psychiatric and registrar level of care, verifies the notion that a small injection of skilled resources can lead to a critical-mass effect and a substantial improvement in the quality of care for the community.
Psyching Up Australia’s Telepsychiatry for Rural Youth
Y Shah1, SD Shah2, S McKenzie2
1University of Queensland, Queensland, Australia
Background: Mental health has been an Australian national health priority since 1996. Yet the prevalence of mental illness for Australian adults is still remarkably high, and even more so for Australian youth. There is a disproportionately higher mental illness burden and suicide rate for youth living in rural Australia.
Objectives: This paper presents a systematic review of the literature assessing the viability of telepsychiatry as a service delivery modality for youth living in rural Australia.
Methods: The literature search was limited to the demographic of youth living in rural Australia and to articles published in peer-reviewed journals. Of the 91 articles that were reviewed, eight articles were included. It was decided that the themes emerged could be categorised under the advantages of accessibility, efficiency and acceptability and the disadvantages of technical problems and impersonal colleague relations.
Findings: Overall, there was great homogeneity supporting the notion that telepsychiatry’s advantages of accessibility, efficiency and acceptability outweigh the disadvantages of technical difficulties and perceived impersonal college relations.
Conclusions: Telepsychiatry was found to be a viable service delivery modality for youth living in rural Australia. However, the paucity of Australian research on the most effective management and components incorporated into telepsychiatry needs to be addressed. This should help spur government policy direction and guidelines to initiate, improve and evaluate telepsychiatry services, enabling reduction of the mental illness burden, particularly for youth living in rural Australia.
A Secular Approach to Psychotherapy
S Stankevicius1, 2
1
Royal Brisbane and Women’s Hospital, Brisbane, Australia
2
Section of History, Philosophy and Ethics of Psychiatry, Royal Australian and New Zealand College of Psychiatrists, Australia
Background: Despite the specific and complicated claims of various psychoanalytical schools, there is no clear evidence that any one theoretical framework is superior over another. Furthermore, many other forms of psychotherapy have been shown to be equally effective, without requiring in-depth knowledge of psychoanalytical theory. There must be some underlying principle at play.
Objectives: This talk aims to show that the various psychoanalytical ideologies are needlessly damaging the reputation of psychotherapy and the wider psychiatric community. As a result, psychiatrists need to discuss, study and approach psychotherapy and its benefits in purely non-sectarian terms.
Methods: Intellectual and ethical matters related to psychoanalytic theory are explored and discussed in a simple and accessible manner. These issues and their implications are then examined in relation to psychotherapy and psychiatry.
Findings: Making the distinction between psychoanalysis and psychotherapy will benefit psychiatry in multiple ways. First, it honestly admits that various claims of psychoanalysis are not only independently misguided, they are collectively incompatible. Second, it will combat the widely held view of psychiatry as a pseudoscientific medical specialty. Third, it will help distil, amplify and export the most therapeutically salient aspects of psychoanalysis. Just as one can experience transcendental experiences through secular meditation without believing any of the many competing religious ideologies, psychotherapeutic gains can be achieved without subscribing to any psychoanalytic school.
Conclusion: The benefits of psychoanalysis can be gained in ways that are not hostile to understanding psychopathology scientifically. For this, we need a secular approach to psychotherapy.
Pregnancy and Mental Illness: Implications for Clinical Practice
M Galbally1,2, P Boyce3, G Blankley1
1Mercy Hospital for Women, Melbourne, VIC, Australia
2Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC,
Australia
3University of Sydney, Sydney, NSW, Australia
Background: The low prevalence mental disorders including Schizophrenia, Bipolar Disorder and Borderline Personality Disorder have been less of a focus within perinatal mental health research and clinical service development. This symposium will provide an overview of the research basis for these disorders in the perinatal period, treatments and current clinical practice recommendations
Objectives: This symposium will examine interventions and child outcomes for Schizophrenia, Bipolar Disorder and Borderline Personality Disorder in pregnancy. The three key mental health components of care in pregnancy are: 1. identification of mental illness, 2. balancing the risks and benefits of treatments for mother and fetus, and 3. consideration of the impact on the future child’s development of effective management of antenatal mental illness. This symposium will place our current knowledge on Schizophrenia, Borderline Personality Disorder and Bipolar Disorder in pregnancy in this clinical context and make recommendations for future research.
Methods: The first paper will discuss the management of Schizophrenia in pregnancy with a focus on treatment choice and current evidence base. The subsequent two papers will discuss the risks and understanding of the effects of Borderline Personality Disorder and Bipolar Disorder in pregnancy. These two papers will also present specific data collected in Australia relevant to this topic.
Findings: Maternal Schizophrenia, Bipolar Disorder and Borderline Personality Disorder
depression may have an adverse impact on perinatal outcomes. However, there is only limited research available on these mental disorders in pregnancy with a particular lack of research on developmental outcomes for offspring.
Conclusions: Management of maternal mental illness in pregnancy is of paramount importance for both mother and child. Further research on proposed models of care and interventions in pregnancy requires a focus both on maternal health and wellbeing but also on the longer term implications for child development to elucidate the best practice management for these disorders in pregnancy for mother and child.
Presenter 1
Management of Schizophrenia Over the Perinatal Period
P Boyce1
1Discipline of Psychiatry, Sydney Medical School, Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
Background: Women with Schizophrenia present with special challenges for clinicians over the perinatal period.
Objectives: To discuss the specific difficulties for women over the perinatal period with reference to how their symptoms may impact upon pregnancy and the postpartum period, how medications should be managed and strategies to optimise the mother-infant interaction.
Methods: The key literature associated with management of women with Schizophrenia over the perinatal period will be reviewed along with the clinical experience of the presenters in managing women in this situation.
Findings: Whilst there are specific difficulties associated in the perinatal period in women with severe mental illness, the majority of these can be managed using a collaborative approach with careful attention to the safety of medications in pregnancy, control of symptoms of mental illness, and the adequate provision of support in the postpartum period, wall help in managing women over this difficult period. Collaboration with child protection agencies is essential, particular when a removal is suggested.
Conclusions: Whilst managing women with severe mental illness over the perinatal period is challenging, it can also be very rewarding. Careful management is an exemplar of early intervention as risks for the developing foetus and infant can be minimised. Women with severe mental illness are able to care for their infants with appropriate support.
Presenter 2
Borderline Personality Disorder in the Perinatal Period
G Blankley1 J Power1 M Snellen1
1Mercy Hospital for Women, Melbourne, VIC, Australia
Background: There is only limited information on Borderline Personality Disorder across the perinatal period and even less guidance for mental health and obstetric services managing these women.
Objectives: The aims of the paper are firstly to review the literature for the management of Borderline Personality Disorder (BPD) across the perinatal period and secondly to conduct a retrospective study of clinical files on pregnancy and neonatal outcomes in order to develop guidelines for management of BPD across pregnancy and the postpartum.
Methods: A literature search and review was conducted to find original research, published reviews and guidelines for research on the course and outcomes of women with BPD during the perinatal period, management of BPD in the perinatal period, and finally any empirical based therapies developed and trialed for perinatal women with BPD.
Presented will also be retrospective data from a tertiary maternity setting on outcomes for women with Borderline Personality Disorder in pregnancy. A brief overview of local management guidelines will also be presented.
Findings: Borderline Personality Disorder (BPD) is a serious mental illness with a lifetime prevalence of 6% that is associated with significant co morbidity. While there is a body of literature that describes the issues that women with BPD have as parents with a focus n the developmental issues for their infants there is very limited research to date across pregnancy. The data obtained from the clinical files supported the need to develop clinical guidelines for the management of BPD across the perinatal period and an overview of these guidelines will be presented.
Conclusions: Borderline Personality Disorder is a serious psychiatric condition associated with considerable psychosocial impairment and comorbidity. It carries specific risks for the mother and infant across the perinatal period and requires further future research.
Presenter 3
Bipolar Disorder and Pregnancy
M Galbally1,2 J Power1 M Snellen1
1Mercy Hospital for Women, Melbourne, VIC, Australia
2Department of Obstetrics and Gynaecology, University of Melbourne
Background: Bipolar Disorder and Postpartum Psychosis are serious conditions in pregnancy with implications from both illness and treatments for poorer pregnancy; neonatal and longer term developmental outcomes. Relapse rates without treatment are high and choice of treatment important to both keep women well and ensure minimal impact on offspring.
Objectives: This paper will present both literature on the natural course for Bipolar Disorder and for Postpartum Psychosis in pregnancy and the early postpartum, treatment options and risks/benefits and management recommendations. Finally, data collected within a tertiary maternity hospital that has a specialized antenatal clinic for women with Schizophrenia and Bipolar Disorder will be presented.
Methods: A review of literature and current guidelines across several services will be undertaken. Retrospective data drawn from a specialized antenatal clinic will be analyzed for pregnancy and neonatal complications.
Findings: Bipolar Disorder and Postpartum Psychosis are both specifically associated with perinatal risks. However, the treatment recommendations for these two conditions differ across pregnancy and the postpartum.
Conclusions: The further development of research and clinical guidance for management of Bipolar Disorder and Postpartum Psychosis is an important area of mental health to ensure better pregnancy and offspring outcomes.
