Keynote Speaker Abstracts Including RANZCP Award Winners
Personality Disorder – Research, Reappraisal and Reformulation
A Bateman1,2,3
1Anna Freud Centre, London, UK
2University College, London, UK
3University of Copenhagen, Copenhagen, Denmark
Background: Personality disorder (PD) continues to be classified by clinicians in terms of broad categories – borderline, antisocial, avoidant. This has practical and clinical utility. But the co-occurrence of mental disorders and other PDs is the rule rather than the exception undermining the very existence of the diagnosis. Therefore, a reappraisal is now underway. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) has proposed a mixed dimensional and categorical model, whereas the International Classification of Disease, eleventh revision (ICD-11) proposes to dispense with categories altogether, triggering a fracture in the continuity of current research. I will argue that these reappraisals are flawed as they do not take account of recent findings and further reformulation is required.
Objectives: To outline the forthcoming changes to the classification of PD, to consider further evidence of the core pathology of PD, to outline PD as a disorder of resilience to adversity, and to suggest implications for current treatment of PD.
Methods: A review and comment on the current proposed classification systems, particularly the ICD-11, will suggest an explicit link between PD and compromised interpersonal or social function. This can be reversed readily with PD considered as an incapacity to adapt to changing social contexts. An individual with PD is impaired in appraising social situations, less able to extract relevant social information from their current interpersonal context, and compromised in evaluating social information to update their interpersonal schemas or expectations.
Findings: People with PD may be best understood as individuals who lack resilience due to social impairment rooted in developmental problems. Level of personal protection from adversity is commensurate with the availability of, and capacity to make use of, social and environmental support. Those least capable of appraising social contexts and learning from social experience, those we call ‘personality disordered’, will also be at greatest risk of managing adversity poorly. They become vulnerable to succumbing to social challenge and developing other mental disorders (e.g. comorbid depression) due to sensitivity to social adversity.
Conclusions: The implications for treatment of this reformulation will be discussed, particularly in terms of improving areas that remain untouched by current treatments for people with borderline PD, for example, managing social adversity and negotiating close personal relationships.
Indigenous Contributions to Mental Health
M Durie KNZM
Massey University, Palmerston North, New Zealand
Background: Māori are the Indigenous people of New Zealand. Over the past 30 years, the introduction of Māori cultural approaches to mental health theory and practice has given emphasis to the relevance of culture to mental health as well as the importance of partnerships between health agencies and community leaders.
Objectives: To improve outcomes for Māori patients and to extend the range of treatment options for Māori and for other New Zealanders.
Methods: The paper will present three case studies to illustrate the link between health outcomes and cultural inputs. The first study focuses on the acceptance of a Māori health perspective as a way of understanding health. The second describes the development of a range of facilities that have a dedicated approach to Māori. The third outlines a family-centred approach to health and well-being and its application to mental health.
Findings: Māori approaches to mental healthcare have become widely accepted in New Zealand’s mental health services, and there is increasing interest from conventional services in adopting the family-centred approach.
Conclusions: From initial scepticism and uncertainty, New Zealand has incorporated Māori health perspectives and Māori approaches to mental health treatment across the wider health sector. The parallel development of a mental health workforce that includes Māori community expertise and Māori cultural specialists has been integral to the programmes.
Risk Assessment for Suicide Prevention: Fact or Fallacy?
N Kapur
University of Manchester, Manchester, UK
Mental health services around the world are preoccupied with risk assessment. Risk assessment is used to help quantify the likelihood of future adverse events and to enable rational allocation of scarce resources and interventions. In this talk, the author will draw together the evidence from retrospective work, cohort studies, randomized controlled trials and systematic reviews carried out at the Centre for Suicide Prevention, United Kingdom, to examine the utility of risk assessment in general and risk scales in particular. One of the big questions for clinical services is, ‘If we don’t use risk assessment, what should we be doing instead?’ The author will discuss alternatives to the high-risk paradigm.
ECT in the 21St Century: Revered and Reviled
C Kellner
Icahn School of Medicine at Mount Sinai, New York, NY, USA
Background: Electroconvulsive therapy (ECT) remains the most stigmatized and controversial of all treatments in psychiatry, despite an unparalleled track record of efficacy and safety.
Objectives: To understand the role of ECT in contemporary psychiatric medicine and become familiar with current ECT techniques.
Methods: Literature review and presentation of new research findings.
Findings: Technical advances have increased the tolerability and safety of ECT; there is an expanded role for ECT in schizophrenia and catatonia; and maintenance ECT is an increasingly important part of relapse prevention.
Conclusions: ECT remains an indispensable treatment for our most severely ill patients with mood disorders, psychotic disorders and catatonia. Education about ECT will help to reduce stigma and allow appropriate access to this important treatment modality.
Learnings from the Royal Commission into Institutional Responses to Child Sexual Abuse and its Application to Psychiatry
H Milroy
Royal Commission into Institutional Responses to Child Sexual Abuse, Sydney, Australia
The work of the Royal Commission into Institutional Responses to Child Sexual Abuse has raised many issues relevant to mental health services across Australia. The experiences and learnings from private sessions, public hearings, research and policy will be shared as are relevant to the practice of psychiatry. Some of the issues raised will include the exploration of an empowering model for bearing witness, the need for greater trauma competence in services, the impact across the lifespan including suicidality and the understanding of resilience.
The information collected by the Royal Commission provides a unique insight into the lives of children across many decades within Australian Institutions, their traumatic experiences, and for many, their remarkable survival. This has many ramifications for mental health services in providing adequate, accessible, trauma-informed and culturally safe care for both child and adult survivors and their families. Many survivors of child sexual abuse have at some stage in their life come into contact with mental health services with many different service responses and outcomes. The evidence also supports the link between adversity in childhood and poor mental health outcomes and yet so often, childhood abuse is unacknowledged, ignored or dealt with inadequately.
The presentation will conclude with a discussion about implications for practice and ways forward.
The Recovery Project: The who, what, where and when of Psychological Treatments for Psychosis
T Wykes DBE
Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
Psychological treatments for anxiety and depression have been accepted for a long time as adjuncts to or instead of treatment with medication. This is not the case for psychological treatments for psychosis despite our understanding of the effects of psychological factors on the recovery trajectory. We now have a relatively strong database of evidence to suggest that psychological (or ‘talking’) treatments have effects when they are aimed at symptoms or behaviours that impede recovery. But it is not clear which treatments are more effective and when and whether certain individuals gain more from one treatment relative to another. Tailoring treatment, considering adherence and personal goals, will tax the current evidence base, but clinicians still need to make decisions, given the limited resources of healthcare systems and the available trained therapists. This lecture will describe not only what we can do now but also what novel cost-effective treatments we might be offering in soon if we can harness new technology.
Margaret Tobin Oration Abstract: A Most Unexpected Journey
D Crompton OAM1,2
1Addiction and Mental Health Services Metro South Health, Brisbane, Australia
2Australian Institute for Suicide Research and Prevention, Griffith University, Brisbane, Australia
This Margaret Tobin Oration traces a journey towards goals that focus on seeking to implement sustainable organisation change that is influenced by person centred values, a learning environment, collaboration across addiction and mental health services and the broader health system, the personal courage of all staff and a desire to undertake not just the best for today, but the best we can do anywhere, any time for our patients, families, careers and the communities we serve.
The journey occurs in an environment that recognizes organisational change is one of the most difficult challenges for a leadership team, even when the ultimate goal is provision of excellence in clinical care through excellence in research and education.
Moving beyond the broader organisation factors is the challenge of implementing evidence based care in an environment focused on recovery orientated care, not just across health services but also within individual practices.
A discussion on the challenge of implementing evidence based care into clinical care may seem strange in a discipline that seeks to emphasise its scientific foundations; yet the literature highlights that many patients do not receive evidence based care and even when a model of care, whether it be pharmacological or psychosocial is utilised there is a lack of fidelity to the guidelines.
The challenge for any leadership team is therefore to bring about organisation change that facilitates implementation of treatment that is evidence based, recovery orientated, least restrictive, focused on reduced coercive language and behaviour and with informed patients that actively contribute to their recovery and advance health directive plans. For any leadership team, the staff of a service, the organisation, the broader community and individual practitioners the realization of excellence in all these domains is not only challenging, but is also confronted by the issue of sustaining excellence in clinical care, research and education.
Senior Researcher Award Winer Abstract: Brain Network Disturbances in Affective Disorders
M Breakspear
QIMR Berghofer Medical Research Institute, Brisbane, Australia
Mood serves to adjust our internal somatic state to match the expectations we hold about our social milieu. This requires a dynamic interplay between cognition and the perception of physiological states (interoception). In this talk, I will provide evidence that mood disorders are associated with structural, functional and effective disturbances in brain networks that integrate interoception, social appraisal and cognitive control. However, unlike schizophrenia, the structural “core” of the brain is preserved. These findings position mood disorders as disturbances in the precision with which we hold interoceptive beliefs, and the degree to which we adjust our social expectations following interpersonal surprise. Networks supporting broader cognitive and perceptual dynamics are relatively preserved.
Invited Speaker Abstracts
An Update on Dementia Prevention and Treatment
H Brodaty
Centre for Healthy Brain Ageing, University of New South Wales, Sydney, Australia
The prevalence of dementia is projected to triple from more than 400,000 persons in Australia and 47 million worldwide to exceed 900,000 and 131 million, respectively, by 2050. Although there is no absolute prevention against Alzheimer’s disease specifically or dementia in general, postponement is more realistic through preventative strategies. This presentation will review the current state of research into prevention and treatment.
An estimated 30% of the population risk of Alzheimer’s disease can be attributed to potentially modifiable environmental and lifestyle factors including lack of education, smoking, physical inactivity/lack of exercise, depression, high blood pressure in midlife, obesity in midlife and diabetes (type 2). Other identified factors associated with higher rates of dementia are head injury, low birth weight for gestational age, social isolation, loss of hearing and smaller head circumference. Epidemiological studies report protective effects for physical exercise, education, complex mental activity in midlife and a Mediterranean diet characterized by high intake of antioxidants and polyphenols such as vegetables and fruit juice, extra virgin olive oil and nuts.
Evidence for prevention effectiveness has been mixed. Randomized controlled trials with hormone replacement therapy, anti-inflammatory drugs, vitamin E and the herb Ginkgo biloba have been ineffective. Beneficial effects have been demonstrated for physical exercise, computer cognitive training and adherence to the Mediterranean diet, although not all trials are positive. There is stronger evidence that attention to vascular risk factors may prevent vascular dementia. There is no evidence for any preventative strategy for other neurodegenerative dementias such as Lewy body disease or frontotemporal dementia. Avoidance of heavy alcohol use and use of protective head gear and seat belts reduce the risk of dementia secondary to head injury. Internet-delivered lifestyle and cardiovascular risk reduction interventions are being evaluated in Europe and Australia. In the United States, studies are underway focussing on amyloid beta protein toxicity mainly using antibodies to prevent participants at risk of developing clinical Alzheimer’s disease from developing clinical Alzheimer’s disease. These trials will be crucial in determining whether the currently dominant amyloid beta treatment approach represents the best path for therapeutic development.
Current medications for the treatment of Alzheimer’s disease, the cholinesterase inhibitors and memantine, are symptomatic. Despite billions of dollars invested in new drug trials, mostly aimed at disrupting the amyloid beta pathway, no disease-modifying drug has been successful. Apart from one antibody study now in a phase 2/3 trial, drug trial results in 2016 were disappointing. As Alzheimer pathology accumulates over 20–30 years before clinical diagnosis, previous trials may have commenced too late in the disease process. Current trials are targeting persons with pre-clinical Alzheimer’s disease, as defined by positron emission tomography scans or cerebrospinal fluid biomarkers, or in those who have autosomal dominant genes for Alzheimer’s disease. Researchers remain optimistic of specific Alzheimer drugs or combinations of drug treatments being discovered; pharmaceutical companies continue to invest strongly; and the general public eagerly await breakthroughs.
The Self, Adolescent Brain Development and Depression: Insights from Functional Brain Imaging
C Davey1,2
1Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia
2Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
Background: Functional magnetic resonance imaging (MRI) studies have provided important insights into the organization of the brain. One of the most significant has been the revelation of a ‘default mode’ of brain functioning supported by a network of midline cortical regions that are particularly active during introspection, including when thinking about the self. Another important insight has been that brain development occurs over a more extended period than we had thought – especially for distributed cortical networks such as the default mode network (DMN) – not ending until a person is about 30 years old. Parts of the DMN are particularly affected by depression, which commonly has its onset during the period of development from adolescence to early adulthood. The involvement of the network is consistent with the disturbance in self-related processes evident in depression.
Objectives: To review the literature – including the author’s own work – that presents recent functional MRI research on brain networks that support the self, that are disturbed by depression and that show significant development during adolescence.
Methods: A narrative review of selected functional MRI literature relevant to the objectives.
Findings: Self-appraisal processes involve regions of the DMN, although the network associated with the self can be distinguished from it. This functional specificity develops during adolescence. We have used novel connectivity methodologies to characterize interaction between DMN regions that support the self and show how they are disturbed by depression.
Conclusions: Functional MRI has provided important insights into the functional organization of the brain and into how brain networks develop. It is helping us to understand the brain basis of depression and its onset during adolescence and early adulthood.
The Australian Government’s Abuse of Refugees: what went Wrong, can Psychiatrists Help Fix it, what Resistance Teaches and Why Human Rights Matter
M Dudley
School of Psychiatry, University of New South Wales, Sydney, Australia
Background: What are human rights and why should they matter to helping professionals, doctors and psychiatrists? Doctors’ service of humanity is their moral compass, and the authority of human rights conventions and laws is substantial. Yet historical and contemporary examples – such as asylum seekers – show how laws are circumvented and state abuses of human rights may injure patients and distort medical practice.
As capitalism and instrumental rationality dominate globally, so conflict and persecution, nation states and climate change place incomparable pressures on peoples (Indigenous or other) to migrate or flee. Nation states close borders. The medical and psychiatric professions have failed to date to shift Australian Government abuses of asylum seekers. Why? What do these struggles teach us about being social change agents and the linkages between our disciplines and health, social justice and human rights?
Objectives:
Briefly assess the standing of human rights as law, philosophy and practice; and accumulated evidence of harms to patients and to clinical care standards from Australia’s asylum-seeker policies.
Trace historical and recent antecedents of Australian refugee policy through colonization/invasion, xenophobia, and excluding the feared ‘other’ from moral concern.
Briefly review how Australian refugee policy suppresses information by outsourcing operations, crusading against people smugglers and boat people, discounting trauma as a policy by-product or secondary aim and threatening whistle-blowers.
Analyse contributions of neoliberal ideology, nation states and New Public Management to public indifference and refugee mistreatment.
Ponder the history and modes of resistance, including bearing witness, hearing testimonies, recovering truth and challenging deceit.
Reflect on our disciplines’ successes, the centrality of children’s mental health and rights to those; and our failure to substantially impact government policy.
Consider underpinning foundations of justice and mental health, and strategies for effecting policy change – for example, continuing provision of reliable information and science to oppose power, ideology and ‘regimes of truth’; testimony and personal contact; legislative amendment; educational and media campaigns; interdisciplinary cooperation; pursuing contractors; civil and criminal prosecutions; withdrawing services; summits to imagine alternative approaches and models of healthcare; and pressure from outside Australia.
Methods:
Overview of empirical and narrative findings past and present regarding harms to asylum seekers, and the moral, legal and financial case against ‘fortress Australia’.
‘View from below’, being there and bearing witness.
Analysis of power, ideology and ‘regimes of truth’ supporting present policies.
Critical-historical method applied to illuminate Australian antecedents.
Reflection on what will contribute to making a difference, including justice frameworks, collective deliberation regarding goal setting, required resources and review of evidence regarding strategies that have made/may make a difference, with particular reference to initiatives involving children.
Findings: Old and new research and reports show that Australia’s policies cause significant harm, but bipartisan political support for such policies persists. Well-recognized antecedents and newer administrative forms have buttressed present policy. Doctors and psychiatrists’ (and more generally the refugee movement’s) failure to substantially impact government policy requires analysis in the context of broader social change.
Conclusions: Given the undeniable harm caused, harmful policies such as indefinite, mandatory, outsourced and offshore detention (including in client states) should be opposed. There is a need to both reappraise and appreciate our aspirations for justice.
The Reform of Mental Health
A Fels
National Mental Health Commission, Sydney, Australia
This paper will focus on the requirements for the ongoing reform of mental health policy in Australia. It will include a general discussion about some of the priorities laid out in the 2014 National Mental Health Commission report: Contributing Lives, Thriving Communities – Review of Mental Health Programmes and Services.
The paper will also discuss the issue of physical and mental health and their relationship. It will also discuss the economic cost of mental illness to the community.
Short-Term Dynamic Interpersonal Psychotherapy: In the Interest of Time and the Reduction of Morbidity
J Haliburn
Western Sydney Health District, Sydney, Australia
The model I am presenting to you today is an integrated, contemporary, relational and dynamic way of working with adolescents and adults with mental health difficulties. It is not an abbreviated long-term model nor it is a replacement therapy. It is psychodynamic and interpersonal because it takes into account dynamic issues as well as difficulties in two-person relationships, both current and developmental which are regarded as contributing to the presenting problems. It is active and structured, flexible, phase-oriented, focussed and time-limited, that is, 10 to 20 sessions each of 50-minute duration and of weekly frequency. This paper aims to give a brief history of the generational changes that short-term dynamic therapies have undergone since the 1960s, to present a brief description of what STDIP involves, to look at the research and to describe a training program which commenced at Westmead Hospital in 2011.
Why do we need another short-term model? It provides clinicians with additional skills and a way of working with patients whose difficulties do not warrant long-term therapies, who prefer a talking therapy, or have failed repeated cognitive and behavioural therapies. STDIP takes into consideration the frequent occurrence of trauma in patients and advocates a trauma-informed assessment; however, a history of trauma should not be an exclusion factor. The focus is on symptoms, rather than diagnostic groupings, and has been found to bring about significant change in reflective capacity, functioning and personality.
STDIP is an empirically supported treatment for depression (Guthrie, 1999) and is found to reduce suicidal ideation and self-harm (Guthrie et al., 2003) and has been found useful for patients with functional gastrointestinal problems (Guthrie et al., 1991). Research has shown that as with other treatments for depression, anxiety and other disorders, half of all patients treated with CBT recover substantially, while half of them fail to maintain the gains made a year following cessation of treatment (Roth and Fonagy, 2005). Yet, CBT remains the gold standard of treatment, and interpersonal therapy though accredited by the Australian Federal Government Medicare programs continues to have a low profile in Australia, and psychotherapists often know little about IPT other than it is evidence-based (Robertson et al., 2008) and in the United Kingdom it is difficult to find an IPT practitioner (Law, 2011).
Patients commonly present with depression, anxiety, academic inhibition, suicidal ideation and self-harming behaviour. Other presentations include complicated grief, functional somatic symptoms, domestic violence and parent–child problems, of which a significant proportion have been successfully treated and maintained gains achieved. It is hoped that the college will enable developing psychiatrists to receive a training in STDIP so that this time-limited intervention can help reduce morbidity that often is a consequence of the limited types of treatment and are therefore in need of frequent top-ups of the only short-term therapy, CBT, that is available in Australia.
References
Guthrie E (1999) Psychodynamic Interpersonal psychotherapy. Advances in Psychiatric Treatment 5: 135–145.
Guthrie E, Kapur N and Mackay-Jones K (2003) Predictors of outcome following brief psychodynamic therapy for deliberate self-poisoning. Australian and New Zealand Journal of Psychiatry 37: 532–536.
Guthrie E, Creed F and Dawson D (1991) A controlled trial of psychological treatment for irritable bowel syndrome. Gastroenterology 100: 450–457.
Law R (2011) Interpersonal therapy for depression. Advances in Psychiatric Treatment 17: 23–31.
Robertson M, Rushton P and Wurm C (2008) Interpersonal psychotherapy: An overview, Psychotherapy in Australia 14(3): 46–54.
Roth A and Fonagy P (2005) What Works For Whom? A Critical Review of Psychotherapy Research, 2nd ed. New York, NY: Guildford Press.
Treatment Guidelines for Adolescent Paraphilic Disorders: Opportunities to Reduce Harm
J Kasinathan1,2,3,4
1The Forensic Hospital, Justice Health, New South Wales Health, Sydney, Australia
2School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, Australia
3Centre for Mental Health Research, Australian National University, Canberra, Australia
4Level 8 Practice, Sydney, Australia
Background: Paraphilic disorders are relatively common in adolescents and youth, with fantasies and urges preceding the onset of deviant behaviour by a handful of years.
Objectives: To outline current understanding and recommended treatments for paraphilic or sexual deviant disorders in adolescents and youth.
Methods: An overview of the diagnosis, development and scope of paraphilic disorders. Evidence and an algorithm for pharmacological treatments in youth are outlined.
Findings: Research in youth is sparse, but the available evidence supports that adults and adolescents with paraphilic disorders respond favourably to psychological and pharmacological treatments.
Conclusions: The detection of paraphilic disorders in adolescents and youth presents a window of opportunity, where treatment may be provided before deviant behaviour occurs, potentially reducing the future incidence of sexual abuse.
Post-Traumatic Stress Disorder: What has been the Impact of 35 Years of Research on Forensic Practice?
A McFarlane
Centre for Traumatic Stress Studies, The University of Adelaide, Adelaide, Australia
Background: Post-traumatic stress disorder (PTSD) has now been part of diagnostic systems for 35 years during which time there has been an exponential growth of research publications. A critical test of this body of knowledge is the way that information is presented and considered in litigation settings.
Objectives: This presentation aims to highlight key issues that are of importance to the courts and the different bodies of research that have addressed these questions of interest.
Methods: Key questions that are regularly raised such as factors involved in causation, definitions of the stressor criterion, longitudinal course, prognosis and the impact of treatment will be discussed.
Findings: Some of the key findings include the demonstration of the prevalence of the delayed onset form of PTSD and the importance of cumulative stress exposure in the onset of the disorder. This is an important information in the management of the risk in emergency service populations but also highlights the long-term effects of single incident events, such as vehicle accidents on adjustment and health. The neurobiology of PTSD also raises important questions as to whether PTSD is simply a disorder of the mind or a systemic illness/neurological injury.
Conclusions: The body of literature that has been published on PTSD has contributed substantially to resolving a range of opinions and assertions about the nature and causation of the effects of traumatic stress. The courts have played a significant role in the translation of this knowledge into clinical practice and the administrative management of workforces at risk.
Managing Non-Cardiac Chest Pain: An RCT Comparing Brief CBT with Treatment as Usual
R Mulder1, J Boden1, R Troughton1, J Zarifeh1, C Lacey1, M Than1, P Tyrer2, H Tyrer1
1University of Otago, Christchurch, New Zealand
2Imperial College, London, UK
Background: The lifetime prevalence of NCCP is 20%–33% compared with 6.7% for angina. Chest pain is one of the commonest reasons for attending an emergency department (ED). There are few positive management strategies for patients with NCCP.
Objectives: To test whether NCCP-directed cognitive behavioural therapy (CBT) compared with TAU would reduce ED presentations over 12 months.
Methods: A pragmatic randomized controlled trial (RCT) with two parallel arms and equal randomization of eligible patients to three or four sessions of NCCP-directed CBT or TAU was performed. The primary outcome was ED presentations with NCCP at 3 months and 12 months following the interventions. Secondary outcomes were chest pain, health anxiety, psychological distress and social functioning.
Results: Four hundred and twenty-four patients were randomized. There was no overall difference in ED presentations. Patients with previous NCCP were less likely to present in the first 3 months. All patients had less health anxiety at 3 months, but this was no longer significant at 12 months.
Conclusions: A brief psychological intervention is feasible and acceptable to patients with NCCP. Some patients derive short-term benefits. The clinical implications of the study will be discussed.
ADHD and Related Neurocircuits: Towards a Neuroscientific Understanding of ADHD and Implications for Comorbidities
F Zepf
The University of Western Australia, Perth, Australia
Background: Attention-deficit hyperactivity disorder (ADHD) is a highly prevalent neuropsychiatric disorder in childhood and adolescence and is characterized by increased levels of hyperactivity, impulsivity and attention problems. Moreover, ADHD is a highly comorbid disorder, often associated with significant comorbidities such as conduct disorders as well as mood and anxiety disorders. In addition, in patients with an intellectual disability, ADHD symptoms can often be present, and which can complicate their clinical treatment and impact outcomes.
Objectives: Within the present talk, a neuroscience-informed approach of how to link ADHD symptoms to specific neurocircuits related to attentional processes, impulsive behaviours and motor activity will be presented.
Methods: Neurocircuits as indexed by cortico-striato-thalamo-cortical (CSTC) loops will be presented and discussed in the context of ADHD symptoms. Available treatment options linked to these CSTC neurocircuits will be outlined.
Findings and conclusions: Understanding the underlying neurocircuitries related to ADHD can inform clinical practice regarding available treatment options, as well as providing a framework for educating patients and carers about the disorder. The presence of an intellectual disability may also impact treatment response with regards to ADHD symptoms, particularly as patients with ADHD and an intellectual disability are sometimes less responsive to medical treatment than patients with ADHD without an intellectual disability. In addition, patients with an intellectual disability can be more susceptible to medication side effects. In the light of this, a neurocircuitry-guided treatment approach may be beneficial when it comes to treating ADHD symptoms in patients with an intellectual disability.
Pre-Congress Workshop Abstracts
Approaching the Critical Essay Question and the Modified Essay Questions in the RANZCP Essay-Style Examination
L Lampe, J Reddan
The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
Objectives: This workshop is designed to assist candidates to prepare for the critical essay question (CEQ) and the modified essay question components of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) essay-style examination.
Intended audience: This workshop is suitable for trainees, specialist international medical graduates (SIMGs), supervisors and directors of training.
Background: The essay-style questions test capacity for clinical reasoning, critical thinking and the ability to communicate this efficiently and effectively in a professional writing style, in a time-limited situation. These are considered essential skills for psychiatrists.
The essay-style paper includes two components: the CEQ and a number of MEQs. The CEQ focusses on the capacity to critically examine a proposition in the context of the practice of psychiatry. MEQs are more clinically focussed and aim to test the application of knowledge relevant to clinical practice. Candidates are required to pass the CEQ to be awarded an overall pass in the essay-style paper.
Methods: Members of the Committee for Examinations will discuss the approach to these question types, the required standard and how to demonstrate it (what the examiners are looking for) and will highlight skills and strategies for successfully passing this question type. Practical exercises will be used where possible.
Approaching the RANZCP Scholarly Project Assessment
J Ferguson
The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
Objectives: This workshop is designed to assist candidates to understand the nature and standard of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) scholarly project submission and assessment.
Intended audience: This workshop is suitable for trainees, supervisors and directors of training. This workshop may be particularly beneficial for supervisors to develop familiarity with the format and process of this written assessment and develop their understanding of the Committee for Examinations standards for assessment.
Methods: The workshop will include presentations by the Committee for Examination members on the common challenges faced by candidates and promote the development of strategies for successfully passing this assessment. In this workshop, attendees will be introduced to
background to the scholarly project learning objectives;
the scholarly project marking pro forma;
examiners’ commonly identified pitfalls with the scholarly project;
tips for trainees submitting a scholarly project;
tips for passing the scholarly project.
Matters of Life and Death
K Myhill1, C Mason2, B Kelly3
1Southern Adelaide Palliative Service, Adelaide, Australia
2Crown Princess Mary Cancer Centre, Sydney, Australia
3The University of Newcastle, Sydney, Australia
Background: There are significant clinical challenges facing the psychiatrist as a member of the interdisciplinary team in oncology and palliative care that involve not just specific patient care issues but also carer/family matters, team dynamics and competing paradigms.
Objectives: It is intended that the workshop will provide participants with an opportunity to explore real clinical issues encountered in day-to-day practice. Participants will be invited to consider limitations, barriers and competing priorities associated with patient management and encouraged to engage in discourse and exchange of ideas regarding methods and strategies that may benefit their own clinical practice.
Methods: Through case-based discussion (selected and prepared by the workshop presenters) and utilizing the biopsychosociocultural and spiritual framework, participants will consider various approaches in relation to pharmacological, psychotherapeutic and psychosocial interventions. Participants will be encouraged to share their own experiences to examine issues pertinent to the patient journey and the expectations of the role of the psychiatrist as a partner in holistic care.
Conclusions: It is intended that this workshop will assist in the development of a clinical network of expertise and support for psychiatrists with specialized interest in psycho-oncology, palliative care and end-of-life care.
An Update – Paediatric Psychopharmacology for 2017
M Turner
Discipline of Psychiatry, The University of Adelaide, Adelaide, Australia
Background: Recognizing increasingly complex medical and mental illness in children has brought about the need to understand medication and its role in treatment for a range of psychiatric illnesses. These include depression, anxiety, obsessive–compulsive disorder, post-traumatic stress disorder, eating disorders as well as psychosis and the large range of developmental and genetic disorders that are associated with a high rate of comorbid mental illness. Using medication as treatment in children requires detailed informed consent from the parent/carer and the child. This requires knowledge related to its evidence for benefit, the risks and side effects that are possible and the alternative options for treatment.
Objectives: To provide an overview of up-to-date information about paediatric psychopharmacology, the latest evidence and modes of practice.
Methods: A review of the literature covering medications including SSRIs, SNRIs, beta and alpha blockers, dopamine agonists and antagonists, stimulants and others.
Conclusions: This update will allow clinicians to come away with a modern view of medication and its use in child and adolescent psychiatry.
Supervising the Psychotherapy Written Case: A Workshop on the ‘Short’ Long Case
L McLean1,2,3, J Streimer3,4, V Gojak4, B Kotze2
1Brain and Mind Centre, The University of Sydney, Sydney, Australia
2Western Sydney Local Health District, Sydney, Australia
3Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, Australia
4Amaranth Centre, Sydney, Australia
Background: This full-day workshop is designed for Royal Australian and New Zealand College of Psychiatrists (RANZCP) supervisors of the Psychotherapy Written Case (PWC). The Competency-Based Fellowship Program (CBFP) has significantly changed the psychotherapy case. The PWC is now the only full written case requirement for fellowship, with higher standards applying. Supervisors and trainees report they are still coming to grips with the new requirements and process and old ‘chestnuts’, including case selection, remain.
Objectives: This Faculty of Psychotherapy workshop aims to update participants and to offer an understanding of the PWC and associated process to improve pass rates, reframing the case as a ‘short’ long psychotherapy, and offering a chance to reflect on supervisory experience.
Method: The workshop will provide a practical overview of the structure, process and challenges of the revised PWC with input from several presenters. The rearticulation of the case as a ‘short’ long psychotherapy will be argued and ‘maps’ to help case selection provided. We will explore the scaffolding needed to support trainees to pass the relational processes including supervision and case selection; review resources, including videos, for trainees and supervisors; reflect on marking criteria and issues contributing to case failures; discuss the examination process including the junior consultant standard; run a Balint-informed group considering supervision ‘problems’ whether interpersonal or systemic. There will be time for ‘questions and answers’.
Conclusions: This workshop will provide an opportunity for supervisors to be better resourced in providing PWC supervision and a chance to confer with colleagues.
Maintenance ECT: Current Best Practice
C Kellner1, S Gill2, A Weiss3
1Mount Sinai School of Medicine, New York, NY, USA
2SAPBTC and Ramsay Healthcare, Adelaide, Australia
3The University of Newcastle, Sydney, Australia
Background: This half-day workshop will focus on the current evidence base for the use of electroconvulsive therapy (ECT) as a maintenance therapy for persons with treatment-refractory ECT-responsive mental illness. Dr Kellner, one of the Congress Keynote Speakers, has published many leading articles in this field.
Objectives: Participants will be updated on the current literature on maintenance ECT and the evidence base that supports best practice in this area. Participants will be able to implement best practice guidelines in their clinical delivery of maintenance ECT.
Methods: The workshop will include seminar presentations and interactive discussions about maintenance ECT guidelines.
Findings: That maintenance ECT is an important therapeutic option for some patients and should be available as part of a modern ECT service.
Conclusions: The aim of the workshop is to develop, by the end of the workshop, consensus, best-practice, evidence-based, clinically achievable guidelines for maintenance ECT in an Australasian ECT service.
Workshop for the Accreditation and Reaccreditation of Substantial Comparability Assessors
D Neill, L Rose, B Riethmuller
The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
Background: Specialist international medical graduates (SIMGs) who are assessed by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) as substantially comparable are required to complete a 12-month placement of supervised practice to attain fellowship of the RANZCP. Among other workplace-based assessments, three case-based discussion (CbD) assessments are completed during the placement, each conducted by an accredited substantial comparability assessor.
This workshop is aimed at fellows who have been approved to become substantial comparability assessors and require the appropriate accreditation and at existing substantial comparability assessors who wish to refresh their skills to maintain their accreditation.
This workshop is not suitable for potential substantial comparability candidates, who are encouraged to attend other sessions provided by the Committee for Specialist International Medical Graduate Education (CSIMGE) members.
Fellows who are interested in becoming a substantial comparability assessor and have at least three years post-fellowship experience should contact the SIMG team by emailing comparability@ranzcp.org for details on the approval and accreditation process.
The workshop involves pre-reading and self-calibration using resources that will be provided.
Objective: To achieve competency and accreditation as a substantial comparability assessor.
Methods:
The workshop will cover
an outline of the substantial comparability placement process and requirements;
training in the responsibilities of assessors and supervisors of substantial comparability candidates;
training in the use of workplace-based assessment tools including CbD and 360° feedback via calibration exercises.
Risk Assessment and Risk Management for Borderline Personality Disorder
S Rao1,2
1Spectrum, Personality Disorder Service for Victoria, Melbourne, Australia
2Monash University, Melbourne, Australia
Background: Borderline personality disorder (BPD) impacts at least 1% of the population. It is associated with significant morbidity and mortality. About 85% of patients with BPD self-harm and unfortunately 10% complete suicide.
BPD is common in psychiatry practice with 20% prevalence in inpatient settings and 10% in community clinics.
Risk assessment and risk management of self-injury and suicide in BPD is often confusing and is known to create fear and anxiety among clinicians. This often contributes to multiple and unnecessary hospitalizations of patients with BPD and, at times, excessively restrictive care (use of the Mental Health Act).
This workshop aims to demystify risk assessment and risk management of BPD using the National Health and Medical Research Council (NHMRC) clinical practice guidelines (2013) for BPD and the clinical wisdom developed at Spectrum, a centre of clinical excellence for BPD, in Victoria, in the last two decades.
Objectives: The workshop aims to discuss the risk factors, risk assessment methods for self-harm and suicidality and their clinical management in BPD.
Methods: The workshop aims to discuss the following:
recommendations of the NHMRC clinical practice guidelines for risk assessment and risk management demonstrated with real-life case examples;
spectrums’ risk assessment methodology outlined in the NHMRC guidelines – workshop participants would have the opportunity to work on risk assessment and discuss management of a de-identified case;
the assessment of risk of self-harm and suicidality and its management in both public and private mental health settings;
differentiating the risk of self-harm from risk of suicide and their management in the context of BPD coexisting with disorders such as depression and substance abuse.
Conclusions: The workshop hopes to improve the competence of clinicians in evaluation and clinical management of risk in BPD.
References
National Health and Medical Research Council (2012) Clinical Practice Guideline for the Management of Borderline Personality Disorder. Melbourne, Australia: NHMRC.
Rao S and Broadbear J (0000) Evaluation of a new risk assessment matrix in borderline personality disorder, Australian and New Zealand Journal of Psychiatry – (submitted) 2015.
Leadership and Management: Trainee and Early Career Psychiatrist
N O’Connor1,2, R Newton3,4, S Clark5,6, A Keller7,8, M Nance9,10
1Northern Sydney Local Health District, Sydney, Australia
2Department of Psychiatry, The University of Sydney, Sydney, Australia
3Austin Hospital, Melbourne, Australia
4Department of Psychiatry, The University of New South Wales, Sydney, Australia
5Western Local Health District, Dubbo, Australia
6Faculty of Health and Medicine, The University of Newcastle, Newcastle, Australia
7Forensic and Long Bay Hospitals, Justice Health and Forensic Mental Health Network, Sydney, Australia
8University of New South Wales, Sydney, Australia
9Flinders Medical Centre, Adelaide, Australia
10Department of Psychiatry, Flinders University, Adelaide, Australia
Background: This half-day pre-Congress workshop will be run by five 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, challenges and opportunities 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: Drawing on the knowledge and experience of the workshop participants and the expertise of senior psychiatrist leaders, the principles and approaches of leadership and management will be applied to a range of scenarios of leadership and management issues, challenges and dilemmas. The workshop will use participant learning and group participation methods.
Conclusions: The workshop will meet the RANZCP requirements for a leadership and management structured training session of 4 h.
Approaching the RANZCP Psychotherapy Written Case Assessment
A Pethebridge
The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
Objectives: This workshop is designed to assist candidates to understand the nature and standard of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Psychotherapy Written Case assessment.
Intended audience: This workshop is suitable for trainees, supervisors and directors of training. This workshop will be particularly beneficial for supervisors to develop familiarity with the format and process of this written assessment and develop their understanding of the committee for examinations expectations of trainees.
Methods: The workshop will include presentations by the committee for examination members of the common challenges faced by candidates and promote the development of strategies for successfully passing this assessment. In this workshop, attendees will be introduced to the
background to PWC learning objectives;
PWC marking pro forma;
examiners’ commonly identified pitfalls with the PWC;
tips for trainees submitting a PWC;
tips for passing the PWC.
Approaching the RANZCP Objective Structured Clinical Examination Assessment (Clinical Examination)
G Robinson, S Luty
The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
Objectives: This workshop is designed to assist candidates to understand the nature and standard of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) objective structured clinical examination (OSCE) examination.
Intended audience: This workshop is suitable for trainees, specialist international medical graduates, supervisors and directors of training (DoTs). This workshop will be particularly beneficial for supervisors to develop familiarity with the format and process of the OSCE assessment and develop their understanding of the committee for examinations expectations of examination candidates.
Methods: The workshop will include presentations by the OSCE subcommittee, committee for examination members, of the common challenges faced by candidates and promote the development of strategies for successfully passing this assessment.
This workshop will also introduce candidates, supervisors and DoTs to
the process for developing an OSCE examination;
the 2012 Competency-Based Fellowship Program marking schema;
the format of the OSCE examination;
approaching the ‘medicine as related to psychiatry’ station;
approaching the ‘core clinical assessment skills’ station;
the assessment/marking of the OSCE;
tips for passing the OSCE examination.
Psychotherapy with Dyadic Relationships where Early Relational Trauma Contributes to Current Distress: Theory and Practice
J Amos1, R Wild2, C Gauvin3
1The University of South Australia, Adelaide, Australia
2Ramsey Healthcare, Brisbane, Australia
3Evolve Therapeutic Services, Brisbane, Australia
Background: Histories of relational trauma in infancy and early childhood, with or without neglect and abuse, can underpin difficulties in relationships; for example, those between parents and children, adult couples and co-parents.
Objectives: The first aim of this workshop is to present theoretical models synthesizing attachment theory, ethology, evolutionary theory, interpersonal traumatization and shame describing the pathways to relationship distress, including intimate partner violence. The second is to describe a useful clinical intervention.
Methods: The theoretical presentation draws on two models of early relational trauma constructed using a deductive analytic theory building methodology (Amos et al., 2011, 2015). The models make four predictions about the objectives of relational interventions where relational trauma is implicated in aetiology: exposure to and processing of implicitly encoded traumatized mental states; fostering self–other differentiation; managing shame; and supporting the use of togetherness and love to manage tension and distress. Participants will learn about the Adult Exploration of Attachment Interview (AEAI; Chambers, 2012), an intervention, which meets the four theoretically, predicted objectives. The workshop will include clinical illustrations and will equip participants to consider using the AEAI in their own clinical practice.
Findings: Theory can be used to make predictions about the general principles of psychotherapy, supporting the integration of basic scientific research into integrated treatment models.
Conclusions: The use of evidence-supported treatment principles supports the development of processes that can be adapted to a variety of settings, combining the benefits of manualization with the flexibility required in clinical practice.
References
Amos J, Furber G and Segal L (2011) Understanding maltreating mothers: A synthesis of relational trauma, attachment disorganization, structural dissociation of the personality and experiential avoidance. Journal of Trauma and Dissociation 12: 495–509.
Amos J, Segal L and Cantor C (2015) Entrapped mother, entrapped child: Agonic mode, hierarchy and appeasement in intergenerational abuse and neglect. Journal of Child and Family Studies 24(5): 1442–1450.
Chambers H (2012) Adult Exploration of Attachment Interview in family therapy. Australian and New Zealand Journal of Family Therapy 33(4): 309–20.
WITHDRAWN: Starting Out in Private Practice – A Psychodynamic Perspective
J Randles1,2, P Foulkes3, L Chazan4, A Rynie5
1St Vincent’s Hospital, Melbourne, Australia
2Department of Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
3Royal Melbourne Hospital, Melbourne, Australia
4Psychotherapy Training and Services, Monash Health, Melbourne, Australia
5Private Practice, Melbourne, Australia
Starting out in private practice can be daunting for those used to working in public settings. Patients are generally very ill and have frequently been admitted under certificate. Trainees become used to working in a particular way.
In the private practice domain, patients are free to leave at any time should they happen to feel dissatisfied with their treatment. In addition, many are anxious about seeing a psychiatrist and need to be encouraged to continue the work; there is an ever-present risk of patients dropping out, causing treatments to end prematurely. The work is therefore very different, and many psychiatrists struggle to make the necessary adjustment.
This workshop is likely to be of interest to colleagues who are embarking on private practice work. The intended audience is senior trainees and early career psychiatrists, with an emphasis on practitioners who want to work with patients in an ongoing way.
The workshop aims to be very practical, focussing on the common issues and problems that arise from the commencement of private practice.
For example:
setting up rooms – the consulting room, the waiting room;
intake – how to manage referrals;
assessment – how to identify suitable patients;
how to engage patients and get them interested – establishing a therapeutic alliance;
setting up appropriate boundaries;
managing practice and patient risk;
ensuring support – the role of supervision, second opinions and peer review groups;
privacy and confidentiality of clinical records – how to deal with subpoenas from lawyers.
Attracting Good rTMS Habits: A Workshop in the Practical and Clinical Application of RTMS in Psychiatry
C Galletly1,2, S Gill1, P Clarke1, T Paterson1, L Hahn1
1Ramsay Health South Australia, Adelaide, Australia
2The University of Adelaide, Adelaide, Australia
Background: In 2008, Ramsay Health South Australia set up the first transcranial magnetic stimulaion (rTMS) service in South Australia dedicated to research and clinical management of psychiatric disorders, particularly depression (Galletly et al., 2015). This service has been well accepted by both patients and referring psychiatrists and has been productive in publications. The service has adapted to new techniques, protocols, and added advances in technology, most recently theta burst stimulation (rTBS).
Objectives: This workshop aims to introduce psychiatrists interested in neurostimulation to practical aspects of setting up an rTMS service (Galletly et al., 2010) including demonstrations of the technology and use of the machine.
Methods: Delegates will be taught how to practice rTMS mapping, and a treatment session will be demonstrated.
Findings: rTMS has been embraced by private sector psychiatry in South Australia, despite a lack of recognition and reimbursement by the Federal Government of Australia. It continues to be taken up throughout clinical centres in Australia, and overseas, and is becoming established as a well-tolerated and effective neurostimulation treatment for major depression.
Conclusions: This workshop will provide delegates with an interest in neurostimulation with the template to assist them in setting up an rTMS service and the practical skills to perform rTMS.
References
Galletly et al. (2010).
Galletly et al. (2015).
How to Work with Community – To Change Culture and Practice
R McKay1,2
1Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
2New South Wales Institute of Psychiatry, Sydney, Australia
Background: Despite multiple statements that community engagement, including that of consumers, families/whanau and carers, is essential to enhance the quality, safety and effectiveness of mental health services; ‘on the ground’ this is often perceived as idealistic or ‘too difficult’. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) Community Collaboration Committee is designed to achieve genuine engagement with the diverse needs, perspectives, concerns and values that community members bring and to influence the RANZCP and its members.
Objectives: To share successful strategies in which community and mental health professionals have collaborated to improve culture and practice; identify common obstacles to effective community engagement and share strategies to overcome these; and workshop approaches to improve existing collaborative activities in services.
Methods: Highlighting international examples of using community engagement to change mental health practice and culture; exploring the use of national health and mental health standards to support change; sharing of experiences of both successes and obstacles by participants and Community Collaboration Committee members; and small group scenario workshopping.
Findings: Community members, working in partnership with psychiatrists, have an opportunity to plan, monitor and influence their own experience in clinical practice. Psychiatrists and mental health services have the opportunity to innovate and improve care. This workshop is intended to support these mutually beneficial objectives.
Conclusions: Psychiatrists, the profession of psychiatry and the community will benefit from respectful identification of both differences and commonalities in goals for service provision. This workshop is intended to use such communication to enhance collaboration and the standard of mental healthcare.
Structured Clinical Management: Psychiatric Care for Personality Disorder in General Mental Health Services
A Bateman1,2
1Anna Freud Centre, London, UK
2University College, London, UK
Background: Structured Clinical Management (SCM) is an evidence-based approach that enables generalist mental health practitioners to work effectively with people with borderline personality disorder (BPD). Skills required for implementation are currently part of mental health professional training.
SCM provides generalist mental health staff with a coherent systematic approach to working with people with BPD. SCM is based on a supportive approach with case management and advocacy support. There is an emphasis on formulation, problem-solving, effective crisis planning, medication, and emotion and impulse management.
Objectives: By the end of the workshop, participants will understand the rationale and evidence base for SCM, develop skills to treat people with personality disorder (PD) comorbid with affective and other disorders, and be able to implement strategic and core processes of SCM.
Methods: Didactic teaching and experiential learning. Video material will also be presented and discussed.
Findings: People with personality disorder report higher levels of satisfaction and better outcomes from SCM when compared with psychiatric treatment as usual
Conclusions: SCM implemented by generic mental health professionals is easily implemented in general psychiatric services and improves the outcomes for people with PD.
Reference
Bateman A and Krawitz R (2013) Borderline Personality Disorder. An Evidence-Based Guide for Generalist Mental Health Professionals. Oxford, UK: Oxford University Press.
Practical Use of Brain Imaging in Those with Suspected Dementia
J O’Brien
Department of Psychiatry, University of Cambridge, Cambridge, UK
The role of neuroimaging has radically changed over the last decade, from that of simply ruling out intracerebral pathologies that may cause cognitive impairment, to providing important information to positively support the differential diagnosis of the main subtypes of dementia, especially at the early stages. Modalities in clinical use include computed tomography (CT), magnetic resonance imaging (MRI), perfusion single-photon emission computed tomography (SPECT), glucose fluorodeoxyglucose (FDG) positron emission tomography (PET), dopaminergic ioflupane (FP-CIT) SPECT and amyloid PET, although not all modalities are either available or reimbursed in all countries.
The use of imaging is currently limited to clarifying the diagnosis, although in future it is highly likely that imaging will also be used clinically (as it is now for research) to select subjects who may be eligible for particular disease-modifying therapies.
This workshop will be divided into two parts. The first half will outline the imaging modalities available for clinical use, the situations in which they may be helpful, how they are used in applying clinical diagnostic criteria and, finally, a review of current guidelines for when to use which imaging modality. A suggested evidence-based algorithm for the use of imaging will be presented.
The second half of the workshop will focus more on the practical use of imaging to enable attendees to gain experience of looking at and interpreting scans. In particular, a brief training module on how to rate medial temporal atrophy from MRI or coronal CT scans will be presented, as well as exemplars from perfusion SPECT, FDG PET and amyloid PET scans.
The aim is that those attending will become more familiar with which imaging modalities are available, when they might best be used clinically, and to gain skills and confidence in interpreting scans, most especially in relation to the presence or absence of medial temporal lobe atrophy.
Clinical Update Abstracts
Psychotherapy in Translation: On the Application of Policies and Evidence-Based Psychotherapeutic Models for Borderline Personality Disorder in Real-World Contexts
P Cammell1, M Daubney2, A Bateman3,4
1Chair of the Subcommittee of Advanced Training in Psychotherapies, The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
2Chair, Faculty of Psychotherapy, The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
3Anna Freud Centre, London, UK
4University of Copenhagen, Copenhagen, Denmark
This psychotherapy update will discuss the issue of translating policies and evidence-based models of psychotherapy to real-world settings. Specifically, approaches to borderline personality disorder, and the adoption of evidence-based therapies in the Australian and UK (NHS) settings, will be explored. Examples will be given of a range of approaches to clinical service provision, training and research in regional settings in Australia and the United Kingdom, exploring the challenges and successful outcomes that have been experienced.
Anxiety Disorders in Clinical Practice
L Lampe1,2, V Brakoulias1,3
1Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, Australia
2CADE Clinic, Royal North Shore Hospital, St Leonards, Sydney, Australia
3Department of Psychiatry, Nepean Hospital, Penrith, Sydney, Australia
Background: Anxiety disorders are highly prevalent in the community and are associated with an often underestimated degree of impairment. Psychological treatments are regarded as first line, and advances in knowledge around cognitive maintaining factors for anxiety have improved treatment outcomes. Simultaneously, the role and effective use of pharmacological interventions has become more clearly established.
Objectives: To provide an update on key features of anxiety disorders relevant to clinical practice and to provide clinically relevant information about the causes and effective treatment of anxiety disorders.
Methods: As far as practicable, the presenters aim to tailor the material to participants, who are invited to submit topics they would like to be addressed: this can be done at the start of the session or at any time prior by email. Relevant summaries of the literature and clinical practice guidelines will be presented. Case material will be employed to illustrate aspects of the topic and will include use of online voting technology – participants are encouraged to bring their smart devices. Role play of techniques may be employed if relevant or requested.
Findings: An accurate diagnosis and assessment of initiating and especially maintaining factors in anxiety disorders and relevant comorbidities is important. Psychological treatments are first line and have the best long-term outcome. Pharmacotherapy can be effective and guidelines for use in anxiety disorders differ somewhat from depression. Novel treatments and treatment modalities show promise.
Conclusions: Anxiety disorders are satisfying to treat because people get better! Psychiatrists can update their knowledge and skills to ensure effective treatment.
The Conundrum of Improving Treatment Outcomes for PTSD: Grappling with Intersection of Neurobiology and the Social Context of Trauma
A McFarlane AO1, D Silove2
1University of Adelaide, Adelaide, Australia
2University of New South Wales, Sydney, Australia
A major conceptual challenge has been to understand how exposure to traumatic events can lead to the onset of disorder months or years later. Longitudinal studies have demonstrated that delayed-onset post-traumatic stress disorder (PTSD) is far more common than previously anticipated. Limitations of cross-sectional and short-term follow-up studies of trauma-exposed populations, methodologies that have dominated the literature about PTSD, cannot address the sequencing and mechanisms relevant to delayed-onset PTSD and its chronic outcomes. Furthermore, there is growing evidence that cumulative lifetime stress exposure is critical to the onset and course of PTSD.
Longitudinal studies highlight the tendency for PTSD to emerge and change with the passage of time, reflecting a particular pattern of clinical and underlying biological progression. In particular, prospective studies, particularly of military populations, have provided substantial evidence that a number of the biological abnormalities that underpin PTSD precede the onset of the full-blown disorder. Equally, the neurobiology of chronic unremitting PTSD needs to be differentiated from the acute disorder which in turn emerges across a spectrum of severity. It is proposed that a staging model is required to better characterize the heterogeneity of PTSD, a sine qua non if treatment outcomes are to be improved. Specifically, treatments need to be tailored to the stage of progression of the disorder in order to optimize outcomes.
These challenges in developing tailored psychotherapeutic approaches will be explored in relationship to the specific case of refugees and post-conflict populations, a field where two quite divergent models have dominated. The first depicts the experiences of torture and the social context of human rights–related trauma as a complex and sequential set of challenges which in concert undermine key psychosocial and intra-psychic systems of adaptation, the end point (of failure to adapt) being PTSD and related forms of comorbidity. The implications of this model are that a comprehensive, multidimensional and multiphasic intervention is needed for those who develop chronic or relapsing disorders.
A separate development has been the focus on developing and testing brief psychological interventions, broadly drawing on a limited cognitive behavioural/trauma-focused/stress management paradigm to treat refugees experiencing PTSD. Arguments in favour of this approach are that it has been tested on other trauma-affected populations, it is cost-effective, can be standardized and manualized, is easily taught to lay workers and fits in well with other public health interventions in low-resource settings where most refugees reside. Reconciling these divergent models represents a major challenge for the field. The ADAPT model is offered as a possible framework for bridging the gap between the two. More generally, however, there may need to be a paradigm shift to achieve a deeper and more comprehensive understanding of the traumatic stress response.
Combined Symposium Abstracts
ECT: State of the Art in the 21st Century
C Kellner1, C Loo2, D Martin2
1Icahn School of Medicine at Mount Sinai, New York, USA
2The University of New South Wales, Sydney, Australia
Background: This symposium will explore contemporary evidence in electroconvulsive therapy (ECT) by updating the current state of knowledge in ECT.
Objectives: Attendees will gain up-to-date knowledge about ECT they can use to improve their practice.
Methods: Three speakers with international reputations in ECT research will provide updates on the PRIDE study of ECT in the elderly, best practice delivery of ECT and cognitive side effects of ECT.
Findings: That ECT in the 21st century is an evolving science with new research emerging all the time and that modern ECT practitioners need to be aware of this to maintain best practice.
Conclusions: There is important information to be learned from recent research about the use of ECT in the elderly, best practice and cognitive side effects.
Presenter 1
Right Unilateral Ultrabrief Pulse Electroconvulsive Therapy for Geriatric Depression: Results of the Pride Study
C Kellner
Icahn School of Medicine at Mount Sinai, New York, NY, USA
Background: Electroconvulsive therapy (ECT) remains an important treatment modality for severe and treatment-resistant depression, particularly in older patients. PRIDE was a multicentre, National Institute of Mental Health funded, clinical trial carried out in 10 academic centres in the United States.
Objectives: To evaluate the efficacy of an acute course of right unilateral ultrabrief pulse ECT combined with venlafaxine for the treatment of geriatric depression and to compare a novel, flexible continuation ECT strategy plus medications, to medications alone, over a 6-month period.
Methods: A total of 240 patients of 60 years of age or older were recruited into the acute phase of the study; 120 remitters comprised the intent-to-treat sample in the randomized phase.
Findings: In the acute phase, 62% remitted, 10% did not remit and 28% dropped out. In the randomized phase, patients who received additional ECT had statistically significantly lower depression rating scores than patients who received medications alone.
Conclusions: Ultrabrief pulse right unilateral ECT plus venlafaxine is an effective treatment for geriatric depression. Additional ECT after remission was helpful in sustaining mood improvement in most patients. Practitioners should consider tapering, rather than abruptly stopping, acute ECT courses and be liberal in prescribing additional continuation ECT to prevent relapse.
Presenter 2
Best Practice ECT – An Update
C Loo
The University of New South Wales, Sydney, Australia
Background: There have been many advances in electroconvulsive therapy (ECT) practice in the last 20 years, and modern ECT practice requires knowledge of how these inform best clinical practice with ECT.
Objectives: For the audience to learn about best practice ECT.
Methods: Review of the literature and guidelines into ECT techniques and practice.
Findings: Decisions about ECT electrode placement, pulse width, charge dose and other treatment setting need to be informed by evidence and individualized for each patient.
Conclusions: The prescription and delivery of ECT in the 21st century requires the practitioner to follow evidence-based practice.
Presenter 3
Cognitive Side Effects of ECT
D Martin
The University of New South Wales, Sydney, Australia
Background: Managing cognitive side effects of ECT, especially memory impairment, has been the main challenge for ECT practitioners in its 75-year history.
Objectives: The audience will learn about current evidence about cognitive side effects, how to monitor these and how to minimize them.
Methods: A literature review of cognitive side effects of ECT will be presented and some research into the use of objective instruments to measure and monitor these side effects.
Findings: Quantitative measurement of cognition should be part of routine ECT practice.
Conclusions: Cognitive side effects remain the biggest adverse event with ECT, but modern techniques and best practice monitoring can help to minimize these.
RANZCP and the Asian Federation of Psychiatric Associations’ Asia-Pacific Mental Health Forum
M Hopwood1, K Jenkins1, A Javed2, Regional Guests
1The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
2Asian Federation of Psychiatric Associations, Japan
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has held Asia Pacific Mental Health Forums since 2013 and continues to prioritize the strengthening of relationships in the Asia Pacific. Delegates from more than 20 regional nations have been represented at these forums, and discussions have focussed on mental health service delivery, legislation, workforce issues and training.
Objectives and methods: The 2017 forum will provide regional leaders with the opportunity to present challenges and successes in mental health within their countries. Presentations will be followed by a round table discussion to identify opportunities for further collaboration.
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 and the development of tailored strategies to satisfy the individual mental health needs of each nation.
Are Collaborations the Key to Successful Public Sector Research?
C Galletly1,2,3, S Sujeeve1, D Liu1,2, O Schubert1,2, D Siskind4,5,6
1Northern Adelaide Local Health Network, Adelaide, Australia
2The University of Adelaide, Adelaide, Australia
3Ramsay Health Care (South Australia) Mental Health, Adelaide, Australia
4Metro South Addiction and Mental Health Service, Brisbane, Australia
5The University of Queensland School of Medicine, Brisbane, Australia
6The Royal Australian and New Zealand College of Psychiatrists Committee for Research, Melbourne, Australia
Background: There is an enormous need for clinically relevant research in public sector mental health services. These services look after people with severe, chronic disorders, who urgently require more effective care.
Objectives: To explore the barriers to successful public sector research and to demonstrate a series of collaborative strategies for developing research in public mental health services.
Methods: To describe a series of public mental health research projects, addressing the issues of lack of time, resources and funding.
Findings: Collaboration with other disciplines and academic departments is an effective method of building up successful research.
Conclusions: Research can be successfully established in public sector services, despite the substantial barriers.
Presenter 1
What Does Research Contribute to a Public Mental Health Service?
S Sujeeve
Northern Adelaide Local Health Network, Adelaide, Australia
Background: Health research has a high value to society. It can contribute important information about disease trends and risk factors, outcome of treatment or public health interventions, functional ability, pattern of care and healthcare cost. Research plays an important part in public mental health services and is the driving force for developing new treatment modalities, therapeutic interventions, evidence-based practices and needs to be looked into as a part of service development. There are challenges in integrating research within the current service delivery model.
Objectives: Healthcare professionals need to overcome the challenges and barriers that current research faces in our public mental health services and look at improving our current research activities.
Methods: As a service, we are looking at various strategies to collaborate with other health disciplines to generate evidence-based treatments in the form of clinical trials, observational studies and randomized controlled trials.
Findings: We are utilizing our research findings in developing clinical practice guidelines, healthcare policies and audit activities to implement these changes.
Conclusions: Research has become an integral part of our best practice model and evidence-based treatment. It is important to work collaboratively with other healthcare professionals to develop good evidence-based practice and encourage research activities in the public mental health system. There are challenges in terms of funding arrangements and ethical processes. However, research plays a central part in the current and future planning of healthcare services.
Presenter 2
Benefits to the Public Health Sector from Successful Clinical Trials
D Liu1,2, B Hisee1
1Northern Adelaide Local Health Network, Adelaide, Australia
2The University of Adelaide, Adelaide, Australia
Background: Clinical research contributes to the productivity of the health industry in Australia as well as improving primary and hospital care. Controlled clinical trials are the gold standard to confirm whether therapeutic interventions are safe and effective as treatments for a particular disease or condition. Staff participation in clinical trials provides a reliable pathway for skill development and training.
Objectives: To explore the mutual benefits of conducting clinical trials in the public health sector in clinical research development, introducing evidence-based clinical practice, staff skills training and to identify the barriers to conducting successful clinical trials.
Methods: We will review the experience of the clinical trials conducted from 2007 to 2016 in the Translational Research Unit (TRUNorth) of the Northern Adelaide Local Health Network Mental Health Service. We will report the process of engaging with industry, the human research ethics committee and the public health sector governance body. We will discuss the benefits of staff involvement and skill development.
Findings: Over the past 10 years, the TRUNorth research unit has successfully conducted more than 16 clinical trials including industrial-initiated and investigator-initiated trials. The clinical trials were approved by HRECs and were carried out in accordance with Good Clinical Practices Guidelines. The benefits of clinical trials were related to better consumer engagement, better infrastructure of clinical sites, and improvement of staff clinical skills.
Conclusions: Clinical trials provide mutual benefits to improve health services, clinical research, and staff skill training in public health, leading to improvements in clinical care.
Increasing Mental Health Research Impact within General Hospital Settings through Collaborative Projects with other Medical Disciplines
KO Schubert1,2, BT Baune1, B Froessler2,3
1Discipline of Psychiatry, The University of Adelaide, Northern Adelaide Mental Health Network, Adelaide, Australia
2Lyell McEwin Hospital, Elizabeth Vale, Adelaide, Australia
3Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, Australia
Background: Building clinical cohorts for mental health research can be challenging due to limitations of resources and access to patients, stigma and high levels of clinical comorbidity in public service users. The collaboration with research projects of other medical fields, and the assessment of mental health aspects for these studies, is one avenue to overcome these challenges.
Objectives: To present the potential of providing collaborative mental health assessments for a study conducted in a different field of medicine.
Methods: We formed a collaboration between the disciplines of psychiatry, acute care medicine and obstetrics and gynaecology at Lyell McEwin Hospital for a study investigating optimal doses of intravenous iron substitution in iron-deficient pregnant women (PROTECTIVE Trial). Mental health assessments were embedded into the trial but also provided independent data for the ongoing Cognitive Function and Mood Disorders Study (CoFaMS) conducted at the discipline of psychiatry.
Findings: The pooling of research resources for this project provided high levels of clinical service support, high-quality data collection and high participant throughput and retention. The target enrolment of 300 women was achieved within 2 years. Additionally, the project has provided a successful platform for higher degree research students and has subsequently attracted competitive research funding. Collected mental health data and biospecimens have been utilized for additional analyses independent of the original clinical trial.
Conclusions: Collaborative efforts with other disciplines in medical settings have the potential to greatly increase the research capacity and academic impact of mental health units in public health services.
Presenter 4
Foundations and Building Blocks
C Galletly1,2,3
1Northern Adelaide Local Health Network, Adelaide, Australia
2The University of Adelaide, Adelaide, Australia
3Ramsay Health Care (South Australia) Mental Health, Adelaide, Australia
Background: Over the last decade, the Northern Adelaide Local Health Network (NALHN) has undertaken a series of successful research projects, focussing on people with severe mental illness.
Objectives: To demonstrate how these projects have been established by collaborating with researchers from other disciplines and medical specialties locally and working with national research networks.
Methods: To briefly describe each of the projects, focussing on how the collaborations were set up and maintained over time.
Findings: NALHN has a substantial portfolio of clinically meaningful projects, providing opportunities for staff engagement in research and contributing to better patient outcomes.
Conclusions: Taking an open approach to collaborative research has been a successful strategy in overcoming the barriers of lack of time, money and resources for research.
Presenter 5
Collaborations with Junior Colleagues for Building Research Capacity in the Public Sector
D Siskind1,2,3, S Kisely1,2,3, S Parker1,2,3
1Metro South Addiction and Mental Health Service, Brisbane, Australia
2The University of Queensland School of Medicine, Brisbane, Australia
3The Royal Australian and New Zealand College of Psychiatrists Committee for Research, Melbourne, Australia
Background: The advent of the scholarly project provides an opportunity to collaborate with registrars to build research capacity within the public mental health sector. Trainees in the 2012 program are required to complete a scholarly project to meet training requirements. As such, clinical academics within the public sector can partner with registrars to design and provide supervision for discrete and achievable research projects. Medical students are increasingly realizing the training advantages associated with being involved with research while in medical school and are enthusiastic about volunteering for research experiences.
Objectives: To outline the mutual advantages to public mental health sector research of partnerships between clinical academics, trainees and medical students.
Methods: We will outline partnership projects between clinical academics, trainees and medical students and describe how to build a suitable discrete and achievable project. We will also describe the mutual obligations of supervision.
Findings: In the past 2 years at Metro South Addiction and Mental Health Service in Brisbane, we have supervised six medical students and seven trainees to project completion and have 16 registrars and eight medical students working on active projects. These projects include systematic reviews, meta-analyses, clinical trial protocols, retrospective de-identified administrative data set analysis and clinical chart reviews.
Conclusions: Supervising trainees and medical students can be a mutually beneficial undertaking within the public sector.
Psycho-Oncology and Palliative Care
L Miller1,2, C Hercus2, M Verheggen1,2, A Nowak1,2, B Kelly3, J Dwyer4, H Proskurin5, F Wilson6,7
1The University of Western Australia, Perth, Australia
2Sir Charles Gairdner Hospital, Perth, Australia
3School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia
4Psychosocial Cancer Care, St Vincent’s Hospital Melbourne, Melbourne, Australia
5Berry Road Consulting, Northern Cancer Institute, Poche Centre, Sydney, Australia
6Department of Psychiatry, Westmead Hospital, Sydney, Australia
7Department of Psychiatry, The University of Sydney, Sydney, Australia
Presenter 1
Agitation and Behavioural Disturbance in Patients with Primary and Secondary Frontal Lobe Brain Tumours – A Case Series Suggestive of Exacerbation of Anger Dysregulation Secondary to the Anticonvulsant Levetiracetam
L Miller1,2, C Hercus2, M Verheggen1,2, A Nowak1,2
1The University of Western Australia, Perth, Australia
2Sir Charles Gairdner Hospital, Perth, Australia
Background: One function of the prefrontal cortex is cortical modulation of emotion/arousal arising in the limbic system. Both primary and secondary brain tumours affecting these areas can cause personality/behavioural disturbances. The authors note that some brain tumour patients have additional contributors to disinhibiton/impulsivity and empathic attunement. One such factor may be levetiracetam, a common perioperative antiepileptic drug, which has been observed to be associated with increased agitation in a series of clinical cases.
Objectives: To describe the important functions of the frontal lobes from a relational and executive functioning perspective via a case series of patients with frontal brain tumours and their caregivers, with particular exploration of a potential effect of the anticonvulsant levetiracetam on anger dyscontrol.
Methods: A search of referrals to a consultation–liaison psychiatry service and discussion with neuro-oncology staff was undertaken to identify cases of possible levetiracetam-induced psychiatric symptoms in patients with primary and secondary brain tumours. Medical records were hand searched to exclude patients with delirium, hypomania or steroid-induced mood disturbance. A series of cases is presented with a discussion of possible aetiology.
Findings: The authors report a clinical impression of significant mood disturbance in patients with frontal lobe tumours (both primary and secondary) while treated with levetiracetam, which is associated with significant carer distress.
Conclusions: The authors propose a potential aetiology of levetiracetam-related disinhibition of limbic function causing amplified emotional responses. This may be particularly problematic in the brain tumour population due to tumour-related prefrontal dysfunction limiting the capacity for cortical modulation. This may be similarly problematic in patients with other causes of prefrontal dysfunction and has implications for the caregiver experience.
Presenter 2
Are There Holes in Holistic Care?
B Kelly
School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia
The task of integrating psychosocial care into clinical service remains a key goal in providing ‘whole patient’ cancer care. Achieving this goal requires multifaceted health service programs that include improved recognition and detection of psychiatric needs and improved access to mental health-related interventions when needed. This paper will provide an overview of current strategies to improve psychiatric care to people with cancer through health service implementation studies and will review barriers to achieving such goals.
A brief overview of evidence regarding identification of psychosocial needs of cancer patients within cancer services will be provided, including findings from Australian and international studies identifying barriers to integrating evidence-based psychosocial care into routine cancer services. The stigma of mental health–related programs remains a significant factor and strategies to address the barriers among patients and clinicians will be discussed. The paper will present recent Australian research focussing on improving integration of such care within cancer services: focussing on patient, clinician and health system factors.
Presenter 3
Through a Different Lens: Observation of a Patient’s Chemotherapy Experience by Psychiatry Registrars
J Dwyer1, H Proskurin2
1Psychosocial Cancer Care, St Vincent’s Hospital Melbourne, Melbourne, Australia
2Berry Road Consulting, Northern Cancer Institute, Poche Centre, Sydney, Australia
This paper will discuss the development of an innovative program in which Psychosocial Cancer Care fellows at St Vincent’s Hospital Melbourne had the opportunity to follow an oncology patient through their chemotherapy treatment.
The goal of this experience was to enlighten registrars as to the realities of chemotherapy in the real world, the experience of the patient and the impact of the chemotherapy environment on patients and their careers. The role of doctor is privileged near the apex of a hierarchical system, and this influences how patients understand and present information. Even those cancer patients who appear well and do not report any distress often experience a great deal of disturbance in their lives related to a cancer diagnosis and this impacts on family and friends. As well as anxiety, depression and demoralization, other effects of cancer include regression and changes in relationship dynamics that can be difficult to appreciate from the position of the doctor. The observation model aims to place the trainee into a different role where their medical status is secondary, and they join with the patient and family in their experience of cancer. This privileged role allows the observer to become attuned to the patient and their family in such a way that they experience it from within, rather than from the relatively detached position of a treating clinician.
This model is well established in many training settings where it aims to tune the trainee into the many ways in which people communicate their experience to others, where it forms the basis for academic exploration of early life development and how groups function.
The training experience methodology was of an observational process with weekly seminars held at St Vincent’s Hospital in the Cancer Day Centre to discuss the observed material and literature in the area. The observations occurred in the medical setting, and the trainee’s role was that of an observer rather than a clinician. In this model, an essential element is that the observer is restricted to observation but does not seek to contribute, treat or change the situation. Such reflective practice has been advocated as a core component of doctor training.
At the time of writing, six registrars have completed the observation, and feedback has been sought from all of the patients regarding their experience.
The presentation will outline both the development of the program and feedback on the trainee shared experience with a patient with lymphoma. This experience was informative from both a medical and psychodynamic perspective.
Presenter 4
Terminal Care in Anorexia Nervosa
F Wilson1,2
1Westmead Hospital, Sydney, Australia
2The University of Sydney, Sydney, Australia
Background: The discussion of end-of-life care in psychiatric disorders is unusual and can confront the concepts of illness, the models of care and the role of psychiatrist. Anorexia nervosa has the highest mortality rate of all psychiatric disorders. Care of those patients with severe and enduring anorexia nervosa may involve treatment withdrawal and a palliative approach. I discuss the concepts involved and the difficulties psychiatrists may have in incorporating these into current thinking.
Objectives: To discuss the approach to end-of-life decisions in anorexia nervosa and the ethical, legal and professional challenges to a psychiatrist. To discuss the role of palliation and palliative care services in the care of psychiatric patients at the end of their lives.
Methods: Two cases will be outlined. The end-of-life decision-making and the approach to palliation will be drawn from those cases. The involvement of the palliative care service and the challenges of such an approach will be discussed.
Conclusions: End-of-life issues in anorexia nervosa confront many of our ways of thinking and working as psychiatrists. The details of our approach in these patients and the collaboration with palliative care provide a starting point for discussion of end-of-life care in psychiatry.
Changing Practice in Eating Disorders – New Disorders and Less Restrictive Care
P Hay1, S Touyz2, T Wade3
1Western Sydney University, Sydney, Australia
2School of Psychology, The University of Sydney, Sydney, Australia
3Flinders University, Adelaide, Australia
Background: Since early descriptions of anorexia nervosa in young women, eating disorders have become a leading public health problem and new disorders such as binge eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID) have followed bulimia nervosa in the 20th century. Treatment has become less restrictive, but this has been inconsistently applied and the degree of permissiveness in care is not agreed.
Objectives: This symposium aims to bring together three important new studies in eating disorders and discusses the implications for clinical care within a context of providing least restrictive and recovery focussed care.
Methods: The first paper presents new data on the community prevalence and health-related quality of life of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition eating disorders in adults, including ARFID and BED. This is followed by an analytic study of treatment response in a large, multisite randomized controlled trial of three psychological therapies for anorexia nervosa. The third paper presents the results of a Delphi study attempting to inform best practice in managing compulsive exercise in people with eating disorders.
Findings: Eating disorders are common and a source of significant personal and public health burden for men as well as women, and ARFID and BED are significant problems. While less restrictive, outpatient psychological therapy may not be the best choice for those with a body mass index of <16.5. A group of experts have agreed on a more permissive approach to compulsive exercise in anorexia nervosa.
Conclusions: The symposium will conclude with an open panel discussion of the papers and how the findings inform contemporary practice, including the identification and management of new disorders such as ARFID.
Presenter 1
Prevalence and Burden of Arfid, Bed and Other Eating Disorders in the Australian Population
P Hay1, D Mitchison1,2, A Collado1, D González-Chica3, N Stocks3, S Touyz4
1Centre for Health Research, Western Sydney University, Sydney, Australia
2Centre for Emotional Health, Macquarie University, Sydney, Australia
3Discipline of General Practice, The University of Adelaide, Adelaide, Australia
4School of Psychology, The University of Sydney, Sydney, Australia
Background: Little is known about the epidemiology and impact of the new Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnoses, binge eating disorder (BED) and avoidant/restrictive food intake disorder (ARFID).
Objectives: Our aims were to determine the distribution and burden of ARFID and BED and compare it with other eating disorders.
Methods: We conducted sequential cross-sectional population survey data of adults (aged over 15 years) collected in 2014 (n = 2732) and 2015 (n = 3005). Demographic information and diagnostic features of DSM-5 eating disorders were requested including the occurrence of regular (at least weekly over the past 3 months) objective binge eating, extreme dietary restriction/fasting for weight/shape control, purging behaviours, overvaluation of shape and/or weight and the presence of an avoidant/restrictive food intake without overvaluation of shape and/or weight. In 2015, health-related quality of life was assessed with the Short form-12 item questionnaire (SF-12) and in 2014 functional impact was measured with the ‘days out of role’ question.
Findings: ARFID was uncommon (<1% of the general population), but it was associated with the highest health-related quality of life and the poorest daily function of all eating disorders. When strict criteria for distress were applied, BED was much less common than recurrent binge eating without associated distress, but its health impact was, like ARFID, very high. Both were frequent in men as well as women.
Conclusions: Identification of ARFID and BED is important as their impact is high. Clinicians need to be alert to the presence of eating disorders in all age groups and both sexes.
Presenter 2
Exercise in Anorexia Nervosa: A Delphi Study
M Noetel1, S Touyz1, L Dawson2,3, P Hay4
1School of Psychology, The University of Sydney, Sydney, Australia
2Eating Disorder Service at The Sydney Children’s Hospitals Network, Westmead, Sydney, Australia
3Westmead Clinical School, The University of Sydney, Sydney, Australia
4Centre for Health Research, School of Medicine, University of Western Sydney, Sydney, Australia
Background: Compulsive exercise behaviour is a significant factor in the aetiology, development and maintenance of eating disorders. Nonetheless, research to support the development of treatment guidelines for clinically significant exercise in anorexia nervosa (AN) remains limited.
Objectives: This study aimed to explore and synthesize expert clinical knowledge on defining, assessing and treating unhealthy exercise in adolescents with AN.
Methods: The Delphi methodology was used and 25 clinicians, who were considered experts in the treatment of AN in adolescents, were recruited. The first round of the questionnaires was comprised of five open-ended questions regarding defining, assessing and treating unhealthy exercise in adolescents with AN. Statements were derived from these data using content analysis and included as Likert-based items in two subsequent rounds, in which panellists were required to rate their level of agreement for each item.
Findings: Consensus was achieved for 49 (59.0%) of the total 83 items included in the second and third rounds of questionnaires. The panel clearly delineated features of unhealthy and healthy exercise and endorsed a number of items considered important to assess for when evaluating exercise in this clinical population. A variety of treatment approaches reached consensus. Notably, for those who are medically stable and progressing towards recovery, the panel recommended initial exercise restriction practices and reintroducing healthy exercise behaviours, rather than exercise cessation practices.
Conclusions: The current findings can serve as preliminary assessment and treatment guidelines. A unified approach to labelling and defining unhealthy exercise in the eating disorder literature and clinical settings is required.
Presenter 3
Trajectory of Weight Change over the First 12 Sessions of Outpatient Therapy for Anorexia Nervosa and Relationship to Outcome
T Wade1, K Allen2, R Crosby3, C Fairburn4, A Fursland5, P Hay6, V McIntosh7, S Touyz8, U Schmidt9, J Treasure9, S Byrne2
1School of Psychology, Flinders University, Adelaide, Australia
2School of Psychology, The University of Western Australia, Perth, Australia
3Neuropsychiatric Research Institute, Fargo, USA
4Department of Psychiatry, Oxford University, Oxford, UK
5Centre for Clinical Interventions, Perth, Australia
6School of Medicine and Centre for Health Research, Western Sydney University, Sydney, Australia
7Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
8School of Psychology, The University of Sydney, Sydney, Australia
9Department of Psychological Medicine, Kings College London, London, UK
Background: The optimal level of least restrictive care in outpatient therapy for anorexia nervosa is unknown and its practice varies widely.
Objectives: The study aimed to identify latent classes of a trajectory of change in body mass index (BMI) between assessment and the 12th session of outpatient treatment for adult anorexia nervosa.
Methods: One hundred and twenty people with anorexia nervosa were randomized to one of three outpatient therapies. The relationship between latent classes and outcome was examined, and predictors of class membership were examined.
Findings: Four latent classes were identified: two had a baseline BMI of about 17.5, but one group showed a significantly greater increase in BMI over the first 12 sessions of therapy than the other. The third and fourth classes had a baseline BMI of 16.34 and 15.26, respectively, and neither gained weight over the first 12 sessions. There were no differences between the classes in terms of therapy completion, but the class who had the greatest initial increase in BMI had significantly higher levels of remission at the end of treatment and at 12-month follow-up than the other three classes. Treatment condition did not predict class membership. The only variables to predict class membership were approach coping style and lowest weight, where the class with the best outcome had higher levels of approach coping and a higher lowest weight.
Conclusions: The extremely low levels of remission in the third and fourth classes pose the question of whether outpatient therapies for anorexia nervosa should only include people with a BMI >16.5.
Aboriginal and Torres Strait Islander Mental Health: Trauma-Informed Care
J Lee, J Egan, C Dhamarrandji, S Balaratnasingam, E McEntyre, V Dann
The Royal Australian and New Zealand College of Psychiatrists Aboriginal and Torres Strait Islander Mental Health Committee, Melbourne, Australia
Background: The Aboriginal and Torres Strait Islander Mental Health Committee advises the Royal Australian and New Zealand College of Psychiatrists (RANZCP) on issues relating to mental health in Aboriginal and Torres Strait Islander people and communities. The Committee is made up of both RANZCP fellows and community members. Aboriginal and Torres Strait Islander people and communities have experienced and continue to experience the mental health impacts of historical, transgenerational, vicarious and lived trauma.
Objectives: To highlight the importance of trauma-informed care in assessment and treatment of Aboriginal and Torres Strait Islanders.
Methods: A panel presentation of both fellows and community members from the Committee to address the necessity, training and delivery of trauma-informed care.
Findings: Principles of trauma-informed care include creating agency for the consumer in regards to their daily life, sharing power and allowing input into their treatment, having an understanding of the trauma and the impact it has on the different social groups, creating a safe environment that helps to heal in a more holistic sense. The audience will gain insights and understanding into the impact of trauma on Aboriginal and Torres Strait Islander people and communities, and how the principles of trauma-informed care can be incorporated into mental health service delivery.
Conclusions: Understanding both current and historical trauma is crucial for providing accurate and effective assessment and treatment. Psychiatrists need to demonstrate trustworthiness and create safety in their interactions with Aboriginal and Torres Strait Islanders who have faced significant colonization-related trauma. Thoughtful approaches to assessment and care provision can assist in repairing the effects of trauma and galvanize the rebuilding of resilience.
Presenter 1
A Personal Narrative
J Lee
The Royal Australian and New Zealand College of Psychiatrists Aboriginal and Torres Strait Islander Mental Health Committee, Melbourne, Australia
Background: I am the Clinical Director for Rural, Remote and Indigenous Mental Health Services in Townsville, Queensland, where I have been able to develop mental health services in rural communities. I am also the current Chair of the Aboriginal and Torres Strait Islander Mental Health Committee of the Royal Australian and New Zealand College of Psychiatrists (RANZCP).
Objectives: My passion lies in the field of clinical teaching. I am a senior lecturer at the James Cook University, and Clinical Academic and Chair for the Medical Education Committee for the Townsville Mental Health Service Group.
Methods: I have 10 years of experience providing outreach psychiatric and social and emotional well-being services to remote aboriginal communities in the lower Gulf of Carpentaria. I have also conducted webinars for rural trainees and specialist international medical graduates on cultural considerations and risk assessment.
Findings: Through my work in both rural and Aboriginal and Torres Strait Islander mental health, trauma-informed care has played a crucial part in understanding the people and the best treatment options for them.
Conclusions: I feel very privileged in the positions I have held and the areas I have been able to work in. I am particularly grateful for the opportunity to continue to learn from the shared wisdom of the Aboriginal and Torres Strait Islander elders and community members.
Presenter 2
A Personal Narrative
J Egan
The Royal Australian and New Zealand College of Psychiatrists Aboriginal and Torres Strait Islander Mental Health Committee, Melbourne, Australia
Background: I am a Yorta Yorta/Wemba Wemba man. I grew up in Shepparton, Victoria. I am employed by the Victorian Aboriginal Health Service (VAHS) for the Family Counselling Service as the Team Leader of the Mental Health Social and Emotional Wellbeing Program. I have been working for VAHS for the past 8 years.
Objectives: To provide a brief overview of my personal and work life and how this influences my care and interactions when dealing with trauma.
Methods: My role involves coordinating the day-to-day operations of the Adult Mental Health Social and Emotional Wellbeing team, organizing clinic meetings, supervising staff, attending partnership meetings and liaising between services and co-coordination of five beds at St Vincent’s Hospital Psychiatry Unit.
Findings: One of my main passions is working with our men’s group. I love sitting down with our group and hearing their stories. I feel that they get a lot out it. It is therapeutic and empowering for all involved, including the participant staff.
Conclusions: My life experiences, both personal and professional, have helped to shape my ability to effectively deal with trauma in the people I help and care for.
Presenter 3
A Personal Narrative
C Dhamarrandji
The Royal Australian and New Zealand College of Psychiatrists Aboriginal and Torres Strait Islander Mental Health Committee, Melbourne, Australia
Background: I am an Aboriginal mental health worker on Galiwinku (Elcho Island). As I have had personal experiences with mental health problems with family and community members, I think that this experience has helped me to gain a good understanding of mental health problems with Yolngu people.
Objectives: My experience has taught me to separate cultural influences from the actual illness as we are spiritual people and maintain a strong cultural way of life. Therefore, it is important to understand how to apply mental health treatments with Yolngu people.
Methods: My role is to assist people to understand mental health problems and some of the things that can cause mental health problems, such as alcohol and substance misuse, family problems, violence and stress. I address these issues in a ‘Yolngu’ way first. I assess whether the problem is more cultural and take appropriate action if need be.
Findings: I see my role as ensuring accurate assessment, diagnosis and treatment as well as making people more aware of mental health problems and how to stop them from happening. This will be achieved by education in the community and by applying practical work in patients’ daily lives such as getting them active again.
Conclusions: I would like to see a stronger workforce with more Yolngu people, focussing on being practical in the community. Doing a lot of community work to influence being active and a practical recovery process. This could include a balance – Yolngu way and Balanda (non-Aboriginal) way.
Presenter 4
A Personal Narrative
S Balaratnasingam
The Royal Australian and New Zealand College of Psychiatrists Aboriginal and Torres Strait Islander Mental Health Committee, Melbourne, Australia
Background: I undertook my postgraduate degree in medicine at the University of Western Australia in Perth and psychiatry training in Western Australia. Approximately half of my training was completed in the North West Australia and I worked in the region as a consultant psychiatrist from 2007 to 2015. Currently I live in Cairns and I am continuing my research in indigenous mental health as well as practising in forensic psychiatry. I work predominantly with Aboriginal people and I am experienced in culturally secure ways of interviewing, providing treatment and education to diverse groups of indigenous people.
Objectives: How have historical experiences shaped indigenous sense of self, both individually and on a community basis? To what extent has culture been altered as a result of colonization and how might this result in Indigenous suicide? How is regaining connectedness important in suicide prevention?
Methods: The author highlights culturally appropriate and secure psychiatric practice in rural and remote settings by drawing on personal experience and research findings.
Findings: By shifting away from the mainstream style of psychiatric assessment and treatment, to a less formal approach with a greater focus on traditional methods, creates a more secure environment and generates a better rapport, especially when dealing with different people of Indigenous descent.
Conclusions: Trauma-informed care is incredibly important particularly among different Indigenous groups. Understanding both current and historical trauma is crucial for providing accurate and effective assessment and treatment.
Presenter 5
A Personal Narrative
E McEntyre
The Royal Australian and New Zealand College of Psychiatrists Aboriginal and Torres Strait Islander Mental Health Committee, Melbourne, Australia
Background: I am an Aboriginal Goori woman through the bloodlines of the Worimi and Wonnarua peoples, the traditional land and waterway owners of the hills and plains of the Hunter Valley and coastal Port Stephens and Great Lakes of NSW.
Objectives: I am committed to professional and cultural integrity, and my work and knowledge intersects with health professionals who intend to work respectfully and responsively with Aboriginal and Torres Strait Islander peoples and communities to improve our overall health and well-being.
Methods: I am employed in many roles, improving the health and well-being of Aboriginal communities. As the mental health social worker at Biripi Aboriginal Corporation Medical Centre, I provide mental health services and trauma-informed care to Aboriginal individuals, families and communities. I am an official visitor for NSW prisons, a member of the NSW Mental Health Review Tribunal and an independent specialist director on the Board of Durri Aboriginal Corporation Medical Service. I am completing a PhD in social work and criminology (University of NSW).
Findings: Through lived and professional experience of trauma, I understand the importance of trauma-informed care for working with Aboriginal and Torres Strait Islander peoples and promote this practice across all human service systems.
Conclusions: The need for trauma-informed care and practice across all human services systems is not often viewed as pivotal by service providers, particularly in mental health. Since the first National Conference organized by the NSW Mental Health Coordinating Council (2011), there has been little ongoing promotion of trauma-informed care by government and non-government health services leading to systemic change.
Presenter 6
A Personal Narrative
V Dann
The Royal Australian and New Zealand College of Psychiatrists Aboriginal and Torres Strait Islander Mental Health Committee, Melbourne, Australia
Background: I am a Nyul man from the Dampier Peninsular, WA, and have lived and worked in Broome most of my life. I also have strong personal and professional ties to other parts of the Kimberley region.
I have worked in the area of Aboriginal Mental Health for the past 11 years. My work involves providing supervision, training and mentoring to Aboriginal staff working within our mental health service.
Objectives: My passion is to continue improving access to mental health services and achieving positive outcomes for Aboriginal and Torres Strait Islander people. I am also interested in developing culturally appropriate assessment tools and finding the right balance between utilizing mainstream treatment options as well as traditional healing in a mental health setting.
Methods: My role as Aboriginal mental health coordinator, and a community member of Broome, allows me to work closely with a variety of local service providers, both government and non-government. Some of these organizations are Aboriginal medical services, corrective services, rehab centres, remote area clinics, social and emotional well-being workers, department of housing, Centacare, population health and Aboriginal corporations.
Findings: By providing consultation and advice to the regional mental health management team in relation to cultural matters and the development of policy and guidelines, assistance is given to our service to meet the needs of Aboriginal and Torres Strait Islander consumers and carers.
Conclusions: It is important for Aboriginal mental health staff to draw on both traditional and mainstream treatments when dealing with trauma in Aboriginal and Torres Strait Islander people.
2017 RANZCP Continuing Professional Development Program: Implementation and Progression
C Yong1,2, J Looi1,3,4
1CME Committee, The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
2South Western Sydney Local Health District, Sydney, Australia
3Academic Unit of Psychiatry and Addiction Medicine, the Australian National University Medical School, Canberra, Australia
4Melbourne Neuropsychiatry Centre, Department of Psychiatry, Melbourne Medical School, Melbourne, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is implementing a redeveloped continuing professional development (CPD) program in 2017. The redeveloped program incorporates key clinically relevant CPD elements such as peer review and reflection on practice, quality improvement, audit or outcomes measurement of practice and self-directed learning. The program strengthens essential elements identified in the Medical Board of Australia’s (MBA’s) plan for revalidation.
Objectives: To update participants on the progress and implementation of the CPD program. This symposium will utilize a panel discussion approach to provide information and seek feedback. The presentation will provide participants with examples of how to meet the requirements of the program, the RANZCP online CPD system and its associated benefits.
Methods: Literature review, benchmarking of other medical CPD programs, review of revalidation requirements and overview of the implementation of the 2017 CPD program.
Findings: This symposium aims to inform fellows of the structure and benefits of the new program as well as discussing practical examples about how participants can meet their CPD program requirements. The discussion will be informed in part by the changes to the CPD program and any identified changes that have been reflected as part of the MBA’s plan for revalidation. The panel will discuss changes to the program and how the changes have been received following their implementation, particularly for those related to practice improvement and how the changes can be appropriately completed.
Conclusions: An important role of the RANZCP is to ensure that a modern CPD program for participants is available, user friendly and professionally relevant with the appropriate systems to support it. The program aims to provide a framework for maintaining competence as well as improving the clinical skills and practice of psychiatrists.
Whānau Ora – Planning Stories, Developing Plans
P Matthews1,2, T Winiata1,3, M Baker1,4, C Cole1,5
1Te Kaunihera mo ngā kaupapa Hauora Hinengaro Māori, Wellington, New Zealand
2Waitemata District Health Board, Auckland, New Zealand
3Turuki Health Care, South Auckland, New Zealand
4Te Rau Matatini, Aotearoa, New Zealand
5Northland District Health Board, Auckland, New Zealand
Background: Te Kaunihera mo ngā kaupapa Hauora Hinengaro Māori is the Committee which ensures that Māori views, issues and ideas are represented and addressed within the Royal Australian and New Zealand College of Psychiatrists (RANZCP). Te Kaunihera is made up of both RANZCP fellows and community members who have experience with mental health, either professionally or through lived experience, and are an active part of the Māori community.
Objectives: To discuss and understand a personal narrative of discovery and recovery, the National mental health and addiction strategy and the goal to become a ‘centre of excellence’ in Māori mental health.
Methods: With the presentation of these three topics, we will hopefully be able to better understand the issues that are faced by the Māori community and to search for answers that will encompass all these factors to create Hauora for all.
Findings: The Māori community is overrepresented when it comes to mental illness due to a myriad of factors. One of the ways to combat these factors is by generating discussion and awareness and collectively searching for answers.
Conclusions: To effectively develop a strategy of recovery for Māori, there are many different ideas that must first be understood. By staying informed and telling our stories, we can collectively move to a brighter future for our tangata whenua.
Presenter 1
My Personal Search, A Spiritual Awakening of Self, Discovery, Recovery: Becoming Paora Matthews
P Matthews1,2
1Te Kaunihera mo ngā kaupapa Hauora Hinengaro Māori, Wellington, New Zealand
2Waitemata District Health Board, Auckland, New Zealand
Background narrative: Let my narrative begin when I was a Tangata Whaiora (consumer of mental health services 1976–82). I come from a troubled background with trauma and isolation prevalent from birth. I struggled living here in the world, having a poor education and poor social skills with frequent admissions into a psychiatric hospital.
Experiences of self become a voice for being human. My spirit feelings are impressions that guide my mind to understanding myself. Discovery leads to recovery.
Mai te Po ki te Ao Marama (from the unknown to the known).
Objectives:Whakahokia te Mauri (recovery of the life force):
Discovery of self: self provides existence, meaningful purpose; and the other side of my unknown (subconscious).
Spiritual beings having a human experience in the physical world.
What is the purpose of being here?
Integrations of spirit, mind and body in the physical world.
Methods:
‘We are one in spirit and spirit is one with us.’
Existence allows us to experience life here in the physical world.
We are made of composite spirits, mind, body, families of humankind.
Relations are not to be judgemental, rather understanding of the experiences they are having while being human.
Findings: Recovery and discovery are interdependent. If ones Māori identity is the pathway to well-being, the Taha Wairua is my pathway to recovery, well-being and knowing myself.
Conclusions: If the Royal Australian and New Zealand College of Psychiatrists is to engage with Māori, they must take into account the Māori spiritual values. This will give an understanding of spiritual beings having a human experience in the physical world in which we live.
Presenter 2
National Mental Health and Addiction Strategy
T Winiata1,2, M Baker3
1Te Kaunihera mo ngā kaupapa Hauora Hinengaro Māori, Wellington, New Zealand
2Turuki Health Care, South Auckland, New Zealand
3Te Rau Matatini, Aotearoa, New Zealand
Background: An objective in the national mental health and addiction strategy written in 2005 was to ‘build and strengthen the capability of the primary healthcare sector to promote mental health and well-being and to respond to the needs of people with mental illness and addiction’(Minister of Health, 2005).
Overcoming barriers, whether these are financial, distance, waiting times or lack of culturally appropriate services, which impede access to mental health and addiction services for families in South Auckland is still our challenge as a general practice today.
Objectives: To provide better access to mental health and addiction services at the right level for our enrolled population within their medical home and build capacity and capability within our organization.
Methods: Sought support from family members and like-minded partners to develop services.
Accessed training opportunities for staff.
Findings: The model is still evolving but the ‘do not attend’ rates have dropped, and the uptake of programs has increased. Families can access a range of co-related services under the same roof.
Conclusions: Our narrative has had to change: it is not about targeting hard to reach families but us reaching those who find it difficult to access services.
Relationships have been developed with ‘collaborators and enablers’ and services are being delivered ‘closer to home’. Staff commitment to learning new skills has been a key success factor and we still have more to learn.
Reference
Minister of Health (2005) Te Tāhuhu – Improving Mental Health 2005–2015: The Second New Zealand Mental Health and Addiction Plan. Available at: www.moh.govt.nz (accessed 18 October 2016).
Presenter 3
Towards a Centre of Excellence in Māori Mental Health
C Cole1,2
1Te Kaunihera mo ngā kaupapa Hauora Hinengaro Māori, Wellington, New Zealand
2Northland District Health Board, Auckland, New Zealand
Background: The Northland District Health Board (DHB) has one key Māori-based community mental health team. Although the team is accomplishing good mahi (work), there are some areas of improvement to deliver better care for our Māori clients and their whānau (families). Northland has a relatively high Māori population and our DHB is small enough to implement changes quickly. We believe that in our current environment, aiming to become a ‘centre of excellence’ is realistic and something we should be working towards.
Objectives: There is significant research around the concepts of Māori mental health, but less so with the way services are run and structured to achieve good outcomes for Māori. Working from the ground up and looking at the broader system, we aim to establish a working model for designing and implementing an effective Māori mental health service.
Methods: We aim to involve, consult others and to seek a broad range of opinions before implementing changes. We will be seeking dynamic feedback and believe ongoing research is key in developing a service that remains relevant and progressive.
Findings: This idea and concept of working towards a ‘centre of excellence’ is one that has received strong support and feedback from the kaimahi (staff) and clients in its planning phases.
Conclusions: Ultimately, we want to improve the lives of our Māori clients (tāngata whai i te ora) and their whānau and want our mahi to be part of the movement that is inspiring broader changes in Indigenous mental health both in Aotearoa (New Zealand) and Australia.
Using Health Services Data to Inform the Development of Mental Health Services for People with Intellectual Disability in Australia
J Trollor1, T Abuelroos2
1University of New South Wales, Sydney, Australia
2Victorian Dual Disability Service, Melbourne, Australia
Background: People with an intellectual disability (ID) represent approximately 1% of the population (Maulik et al., 2011), but they experience a disproportionate burden of mental illness. Administrative data from mental health services can be used to understand the needs of people with an ID and to close gaps in health services access and provision.
Objectives: This symposium will present Australian data to examine the characteristics and outcomes of patients assessed by the Victorian Dual Disability Service (VDDS); use a large linked data set in NSW to examine psychiatric diagnoses, health service use and costs of people with an ID and compare these to people without an ID; and to use data and knowledge of the mental health services sector, to make recommendations regarding services development for people with an ID.
Methods: A series of presentations will present quantitative data to address each of the above objectives.
Findings: People with an ID have patterns of psychiatric comorbidity and healthcare use which differ from people without an ID, and a substantial proportion have complex needs. To meet this need, enhancements of specific services are required including equipping mainstream mental health services and developing specialist clinics.
Conclusions: Collection and analysis of administrative data from different sources assists the understanding of mental health in people with an ID and improves capacity to address gaps in the provision of services.
Reference
Maulik PK, Mascarenhas MN, Mathers CD, et al. (2011) Prevalence of intellectual disability: A meta-analysis of population-based studies. Research in Developmental Disabilities 32(2): 419–436.
Presenter 1
Can a Specialist Mental Health Service for Adults with Developmental Disabilities make a Difference?
T Abuelroos
Victorian Dual Disability Service, Melbourne, Australia
Background: Based on the principle of normalization, people with an intellectual disability (ID) are expected to access mainstream mental health services. However, there is increasing evidence that individuals with an ID do not get their needs met in the generic mental health system.
Objectives: The aim of this study was to examine the characteristics of patients assessed by the Victorian Dual Disability Service (VDDS), particularly the diagnosis, and to compare the level of health and social functioning on assessment and follow-up 3 months later using the Health of the Nation Outcome Scale (HoNOS).
Methods: All adult patients who were referred to the VDDS from 1 July 2010 to 30 June 2015 and who received an assessment by the VDDS were included. The sample was divided into two groups: group A included patients referred by the area mental health service and group B included patients referred by the disability sector without area mental health service involvement. The HoNOS scores for both groups at the point of assessment and on 3-month follow-up were compared.
Findings: Of the 439 assessments (group A = 270 and group B = 169), the mean HoNOS scores were higher for the dual disability patients compared with the Victorian psychiatric inpatients on admission (the Australian Mental Health Outcomes and Classification Network). There were few differences between group A and group B although both showed improvement in the HoNOS scores on 3-month follow-up.
Conclusions: Involving a specialist dual disability service in the mental health assessment was associated with better outcomes for this population.
Presenter 2
Higher Mental Health Services Use in People with Intellectual Disability Indicates a Need to Better Equip Services
J Trollor, P Srasuebkul, T Heintze, R Reeve, S Reppermund; National Health and Medical Research Council Partnership Team
The University of New South Wales, Sydney, Australia
Background: Mental health services use, costs and drivers are largely unknown for people with an intellectual disability (ID). Such information is critical to the planning and resourcing of appropriate clinical capacity in this area. Rigorous analyses of data have been undertaken through a large National Health and Medical Research Council Partnerships for Better Health project led by The University of New South Wales in collaboration with multiple sector partners.
Objectives: To examine mental health diagnoses and admission characteristics of people with an ID and compare these to mental health service users without an ID.
Methods: Using a large linked administrative data set from NSW, we compared mental health admission characteristics of people with and without an ID from 2005 to 2012. Regression analyses explored the drivers of frequency and cost of use of hospital services and assessed the relationship between having an ID and particular mental health diagnoses.
Findings: Compared to the people without an ID, people with an ID have different diagnostic characteristics, longer inpatient stays in mental health facilities, higher associated costs, and contribute disproportionately to very long inpatient stays.
Conclusions: These data highlight the need to equip mental health services in ID mental health and have substantial implications for mental health policy and practice.
Presenter 3
Integrating Data on Mental Health Service Provision to Improve Mental Health Services for People with an Intellectual Disability
J Trollor; National Health and Medical Research Council Partnership Team
The University of New South Wales, Sydney, Australia
Background: A National Health and Medical Research Council Partnerships for Better Health project ‘Improving the Mental Health Outcomes of People with Intellectual Disability’ is led by The University of New South Wales in collaboration with multiple sector partners. This project uses a mixed method approach including use of big data to understand the mental health needs of people with an ID; analysis of mental health policy representation of people with an ID; and qualitative research with people with an ID, carers and service providers to map the barriers and enablers of quality mental health service provision for people with an ID.
Objectives: Using and integrating the findings from the above research to describe ways to improve mental health services provision to people with an ID.
Methods: Key findings from the above research are presented and integrated with other research findings by the team including research in mental health services, primary care and knowledge of developments in health and disability services provision.
Findings: Potential ways to improve the capacity of mental health services to meet the needs of people with an ID are apparent. Key elements of health services are proposed, and an approach to the enhancement of services is discussed.
Conclusions: The mental health needs of people with an ID fit within a broader umbrella of health inequalities experienced by this group. An ID-specific national policy agenda and inclusion in health services reform is required to close this gap.
Adjustment in Extreme Circumstances: Mental Health and Well-Being of Women, Children and Families in Immigration Detention
S Mares1,2, L Newman3, C Quadrio1, R Powrie4
1School of Psychiatry, The University of New South Wales, Sydney, Australia
2Menzies School of Health Research, Darwin, Australia
3The University of Melbourne, Melbourne, Australia
4Women’s and Children’s Hospital, Adelaide, Australia
Background: There is evidence from multiple sources of the harmful effects of Australia’s immigration and border protection policies. Women, infants and children are particularly vulnerable.
Objectives:
Summarize the accumulated evidence of the harmful effects and human rights implications of Australia’s current immigration and border protection policies;
Present data from families held on Christmas Island in 2014 and clinical vignettes from women held on Nauru between 2014 and 2017;
Consider the particular vulnerabilities of women, infants and children;
Show how adults and children respond to disordered and traumatic environments and communicate their experiences;
Consider the utility and potential misuse of psychiatric terminology and diagnostic classification for adults and children in extreme circumstances.
Methods: Three papers are presented using mixed methodologies, followed by discussion:
mental health of children and parents held for a prolonged period in Australia’s offshore immigration detention facilities: analysis of Strengths and Difficulties Questionnaires (SDQ) and the Kessler Psychological Distress Scale (K10) from detained families on Christmas Island;
hope in the face of sadness – drawings by children on Christmas Island for the 2014 Australian Human Rights Commission Inquiry into Children in Immigration Detention;
interview series with women on Nauru around experiences of pregnancy, parenting and sexual violence;
discussion.
Findings: Australia’s policies cause significant harm. Distress is communicated in multiple ways. Psychiatric diagnosis has limited utility and political implications in this context.
Conclusions: Given the undeniable harm caused, these policies should be opposed.
Presenter 1
The Mental Health of Children and Parents Held for a Prolonged Period in Australia’s Offshore Immigration Detention Facilities: Secondary Analysis of a Data Set from Christmas Island
S Mares1,2
1The University of New South Wales, Sydney, Australia
2Menzies School of Health Research, Darwin, Australia
Background: There is clear evidence that immigration detention has harmful health and developmental consequences and insurmountable obstacles to undertaking research with this population in conventional ways.
Objectives: The aim is to contribute to the very limited quantitative data on the mental health of asylum-seeker parents and children during prolonged immigration detention.
Methods: Data collected by the Australian Human Rights Commission but not reported during the 2014 National Inquiry into Children in Immigration Detention were released under the Freedom of Information Act 1982 and underwent secondary analysis. The author was the Royal Australian and New Zealand College of Psychiatrists (RANZCP) consultant to the Inquiry and was involved in primary data collection. The data include 166 (131 adults and 35 adolescents (12–17 years)) complete Kessler Psychological Distress Scale (K10s), plus 70 Strengths and Difficulties Questionnaires (SDQs) for children aged 3–17 years. Parental concerns about infants aged 0–2 years are included. The average length of detention was 7.5 months.
Findings: Rates of mental disorder in adults and children resembled clinical populations. The K10 indicated 83% of adults and 85.7% of teenagers were likely to have a severe mental disorder. SDQ scores showed 75.7% of children with a high probability of psychiatric disorder. Infant concerns included emotional, developmental and regulatory difficulties.
Conclusions: This is further quantitative evidence of the profound negative impact of immigration detention on the mental health of parents and children. It is one of very few studies involving asylum seekers while held in closed detention. The acknowledged limitations highlight the practical and ethical difficulties of research with this extremely vulnerable population and the unavoidably politicized implications of the findings.
Presenter 2
Protest and Hope in the Face of Sadness – Drawings by Children on Christmas Island
S Mares1,2
1The University of New South Wales, Sydney, Australia
2Menzies School of Health Research, Darwin, Australia
Background: In February 2014, the author spent 1 week on Christmas Island as the Royal Australian and New Zealand College of Psychiatrists (RANZCP) consultant to the Australian Human Rights Commission Inquiry into Children in Immigration Detention. Semi-structured interviews were conducted with families using interpreters, and children were given paper and pencils and invited to draw pictures about their lives and their families
Objectives: To consider the experiences of detained asylum-seeking children on Christmas Island as communicated through their drawings. To identify potential indicators of resilience in the drawings.
Findings and conclusions: The drawings, by children of different ages, communicate information about Christmas Island as a place, about their experiences of loss and trauma before coming to Australia, of their sadness in detention and their fears, their anger but also their hopes for the future.
Presenter 3
Women and Maternity on Nauru – Politics and the Female Body
L Newman
The University of Melbourne, Melbourne, Australia
Background: Under current immigration law, pregnant women and infants are detained on Nauru with limited obstetric or support services. Women with health issues such as breast and gynaecological problems and complex obstetric issues have limited care options. Women also describe a high rate of sexual assault, and there have been publicized cases of delayed requests for termination following rape with resultant psychiatric disorder. Several independent reports have identified women as particularly vulnerable in remote and offshore locations and advised against keeping young infants in these areas.
Objective: To describe cases assessed over the last 12 months via telephone of women on Nauru and outline factors contributing to mental deterioration, depression and self-harm and complex trauma syndromes. Progress of cases now on the mainland will be provided.
Methods: Interview series with women on Nauru around experiences of pregnancy, parenting and sexual violence.
Findings: Female asylum seekers face issues of anxiety and ambivalence about pregnancy and maternity in detention. The impact of detention and feelings of hopelessness on early parenting are significant with resultant developmental and attachment difficulties in infants who may fail to thrive. Sexual assault is commonly described and many women report ongoing fear and lack of safety. Symptoms related to unresolved trauma are common.
Conclusions: Women asylum seekers in offshore areas are particularly vulnerable to abuse and psychological stress related to pregnancy and parenting. Immediate attention is needed to review safety issues and facilitate transfer of vulnerable women and infants to the mainland.
Leadership in Psychiatry: Are Leaders Born or Made?
H Kim1,2
1Austin Hospital, Melbourne, Australia
2The Royal Australia New Zealand College of Psychiatrists, Trainee Representative Committee, Melbourne, Australia
Background: As the health system moves from a paternalistic medical model to a patient/carer-centred multidisciplinary framework, leadership in psychiatry seems at times an increasingly complex role to understand. However, leadership remains important, with evidence suggesting that greater involvement of clinicians in leadership roles results in better patient outcomes (Mountford and Webb, 2009). Despite this, there are barriers to clinical leadership, such as clinicians not generally being selected based on their leadership potential, leadership training not being a core part of the curricula and often a lack of systematic, formal nurturing of leadership skills (Mountford and Webb, 2008). In this context, as a trainee, becoming a good leader can seem elusive and something that is gifted to those whom are lucky, rather than a skill that can be developed.
Objectives: This presentation series aims to explore core skills of leadership by discussing individual experiences of Trainee Representative Committee trainees in attempting the task of developing these skills. This is with the view to share the challenges and possible approaches.
Conclusions: Leadership in psychiatry is important, and it is a skill that can be developed to suit individual strengths, weaknesses and the specific context. Sharing personal experiences of developing leadership may be an effective way of illustrating potential ways to approach leadership as a skill.
References
Mountford J and Webb C (2008) Clinical Leadership: Unlocking High Performance in Healthcare. London: McKinsey & Co.
The academic and popular literature on leadership is truly enormous, with hundreds of competing theoretical models, many having waxed and waned in popularity over time. Empirical evidence for their accuracy is a necessary aspect of a leadership model’s acceptance, but perhaps more important is that it addresses and explains issues that are current and relevant. In this presentation, the author will summarize the social/historical contexts in which recent popular leadership theories have emerged. He will focus particularly on models that relate to the practical leadership challenges raised by the subsequent speakers. Specifically, to lay the foundations for subsequent presentations, the author will introduce the theories of transformational leadership, authentic leadership, psychological capital, servant leadership and substitutes for leadership.
Presenter 2
Charismatic Versus Authentic Leadership
H Kim1,2
1Austin Hospital, Melbourne, Australia
2The Royal Australia New Zealand College of Psychiatrists, Trainee Representative Committee (TRC), Melbourne, Australia
Background: There has been a shift in the conceptualization of leadership. ‘Charismatic leadership’ is one of the earlier concepts that tried to capture attributes or characteristics of extraordinary leaders and emphasized charisma, image and style. More recently, there have been shifts towards emphasis on character, humility, service and a more ‘authentic’ leadership style that focusses on self-awareness, relationship transparency, balanced processing and an internalized moral perspective. The authentic leadership model seems better suited to acknowledge the diversity of individuals by concentrating on self-reflection and awareness, in addition to the focus on authentic delivery rather than charismatic performance. This encouragement of individuality and, therefore, diversity may be more complementary and reflective of the diversity that can be seen in people with mental illness and clinicians.
Objectives: The aim of this presentation is to use my own personal example to illustrate a tension between the desire to present oneself advantageously as a leader by aspiring to pre-existing, traditional notions of leadership and the desire to be authentic.
Conclusions: Trainees represent a diverse population: each person has a unique set of strengths and weaknesses that should be developed into a form of leadership that capitalizes on the individuals’ characteristics and is appropriate for the context. This process may help mature a personal and authentic style of charisma rather than adhering to traditional images of leadership, which may be more effective in engaging teams and patients.
Presenter 3
Leadership Opportunities in Tasmania: Working from the Bottom Up
R Graham1,2,3
1Older Persons Mental Health Service, Tasmanian Health Service South, Hobart, Australia
2The Royal Australia New Zealand College of Psychiatrists, Trainee Representative Committee, Melbourne, Australia
3Clinical Lecturer in the School of Medicine, University of Tasmania, Hobart, Australia
Background: It can be difficult as a trainee to know where to look when trying to expand one’s leadership skills. The search for leadership opportunities seems more elusive in a regional location such as Tasmania; however, they do exist.
Objectives: This presentation will focus on the presenter’s experience of training in Tasmania and seeking out opportunities to expand their leadership skills. It will use real examples of work undertaken while a member of the TRC to advocate for regional and binational issues. Along the way, there will be a reflection on lessons learnt on how to transform passion into tangible outcomes and the toll that this can take on the individual.
Conclusions: Opportunities to expand your leadership skills as a trainee can be found if one enthusiastically ‘keep(s) an eye out’. The costs of balancing such opportunities with work–life balance and training commitments need to be considered. There is much to be gained from working in a like-minded group, especially for regional and rural-based trainees.
Presenter 4
Challenges for the Psychiatrist as Team Leader
J Green1,2
1Austin Hospital, Melbourne, Australia
2The Royal Australia New Zealand College of Psychiatrists, Trainee Representative Committee, Melbourne, Australia
Background: As doctors, we may be drawn to focus on our dyadic relationship with our patient. Yet, our profession requires much more of us. As leaders, we must navigate our relationships within a team and develop an understanding of the complex team dynamics this inevitably entails.
Objectives: There are many skills that form the basis of relationships within a team: communication, interpersonal style, engagement, assessing group dynamics and, perhaps most importantly, knowing oneself. In this way, one can aim to develop their own unique leadership style, based around their interpersonal style. This talk shall further explore these concepts.
Conclusions: In developing one’s leadership skills, a focus on relationships and team dynamics is prudent.
Presenter 5
Creating the Vision
H Kim1,2, JP Kwasik2,3
1Austin Hospital, Melbourne, Australia
2The Royal Australia New Zealand College of Psychiatrists, Trainee Representative Committee, Melbourne, Australia
3Cairns Hospital, Cairns, Australia
Background: Health systems, alongside other organizations, are restructuring to become more flat and agile to be able to respond to discontinuous and incessant drivers for change. Responding to these pressures and trying to move organizations forward requires leadership rather than authority. Leadership is arguably, in essence, an influence relationship that can be utilized to build a ‘passionate band of willing innovators’ to build movement rather than ‘forcing the unconvinced against their will’ (Satell, 2014). According to theories of leadership such as transformational leadership or ideas of change leadership, one of the key steps to building a movement is to create and communicate a passionate vision that motivates, compels and enthuses people. Indeed, Martin Luther King did not say, ‘I have a well thought-out plan’; instead, he pronounced, ‘I have a dream’ (Luther King Jr, 1963).
Objectives: This presentation will use the experience of the Chair of the Trainee Representative Committee (TRC) to illustrate the process of creating a vision to guide the TRC to advocate for trainees, liaise with the college and effect change.
Conclusions: Getting individual people to work in an effective way together can, at times, be a challenging process. Creating a shared vision is a critical step so that people are working towards the same goals, in addition to its importance in imbuing work with meaning and maintaining morale.
Object-Based Learning: Teaching Psychiatry and Medicine with Art
M Baigent1, F Salmon2, H Gaunt3
1Department of Psychiatry, Flinders University and Flinders Medical Centre, Adelaide, Australia
2Flinders University Art Museum, Flinders University, Adelaide, Australia
3The Ian Potter Museum of Art, The University of Melbourne, Melbourne, Australia
Background: Practicing as a good doctor extends beyond knowing where to find a pulse, how to take a history or what to ask to explore for symptoms of a mental disorder. Professional practice requires self-awareness, capacity for reflection, empathy, cultural awareness, powers of observation and an ability to relate complexity, which are not easily taught in medical school using traditional methods. Conquering this ‘space in between’ makes clinical practice easier – long understood to be of central importance by therapists providing psychological therapies. Groups of medical students can explore these concepts in themselves in a non-threatening setting by examining artworks (objects). Psychiatrists are well placed (although not exclusively) conceptually to lead and engage students in this type of exercise.
Objective: This practical seminar will describe what object-based learning (OBL) is and review where it is being applied in the tertiary setting, including in undergraduate medicine in psychiatry teaching.
Method: Participants will learn about the application of OBL and visit the nearby Flinders University City Gallery, where they will have the opportunity to participate in a practical exercise responding to ‘In the Saddle on the Wall’, an exhibition comprising art works and digital stories of 13 senior Aboriginal artists from the Kimberley region.
Findings: Participants find this method of learning enjoyable and worthwhile.
Conclusions: Learning from art objects has a place in modern psychiatric and medical education and is easily adapted by psychiatrists.
This is run as one symposium over two, 90-min parts. The second part of the symposium will be a practical session held at Flinders University City Gallery, Ground Floor, State Library of South Australia.
Part 1 – Adelaide Convention Centre
What is Object-Based Learning?
F Salmon
Flinders University Art Museum, Flinders University, Adelaide, Australia
Provides a definition and broad overview of object-based learning (OBL) in higher education contexts, its theoretical underpinnings and efficacy and introduces Flinders University Art Museum as a site of OBL at Flinders.
How Does Object-Based Learning Work in Psychiatry?
M Baigent
Department of Psychiatry, Flinders University and Flinders Medical Centre, Adelaide, Australia
Object-based learning is conducted in the medical course at Flinders University. What OBL works for in psychiatry, how the sessions have been conducted, and the objectives and some research evaluation findings are outlined.
Object-Based Learning in Other Health Disciplines
H Gaunt
The Ian Potter Museum of Art, The University of Melbourne, Melbourne, Australia
Describes the scope and impact of art in medical training in Australia and the United States and discusses how the use of Indigenous art in a recently delivered program for medical students provided them with a valuable opportunity to discuss their understanding of the effects of white settlement on Aboriginal health and well-being.
Part 2 – Flinders University City Gallery, Ground Floor, State Library of South Australia
Participants were led from the Adelaide Convention Centre to a nearby exhibit at the Flinders University City Gallery to experience first-hand how these sessions are conducted by participating themselves.
Introduction to the ‘In the Saddle on the Wall’ Exhibition
H Gaunt1, F Salmon2
1The Ian Potter Museum of Art, The University of Melbourne, Melbourne, Australia
2Flinders University Art Museum, Flinders University, Adelaide, Australia
The session begins with a brief introduction to the exhibition: its aims and the artists involved. Heather Gaunt will provide an overview of how the exhibition was used in a structured program at the Ian Potter Museum of Art, The University of Melbourne.
Hands on Object-Based Learning Exercise
M Baigent
Department of Psychiatry, Flinders University and Flinders Medical Centre, Adelaide, Australia
This is an engaging practical seminar in the exhibition, ‘In the Saddle on the Wall’. Participants will undergo the small group exercise involved in this object-based learning approach in a fun, thought-provoking activity.
Post-Exercise ‘Debrief’
M Baigent1, F Salmon2, H Gaunt3
1Department of Psychiatry, Flinders University and Flinders Medical Centre, Adelaide, Australia
2Flinders University Art Museum, Flinders University, Adelaide, Australia
3The Ian Potter Museum of Art, The University of Melbourne, Melbourne, Australia
Participants will have the opportunity to reflect on the experience, their thoughts about its applications in teaching and in the discipline of psychiatry.
Brain and Mind in Contemporary Psychiatry
M Wong1,2, P Kasiannan1,3, J Arnold1,3
1Section of the History, Philosophy and Ethics of Psychiatry, The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
2School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
3Private Practice
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 of mind and brain in psychiatry.
Objectives: This symposium aims at providing an update on the major themes and issues in the interface between brain and mind and their implications for the practice of psychiatry through contributions from members of the 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 brain and mind and their implications through a critical review of the philosophical, neuroscientific and clinical aspects of the practice of psychiatry.
Findings: Recent advances in philosophy and neuroscience and its interaction with psychiatry allow psychiatry to develop new perspectives and approaches to understand the brain–mind interaction and its implications for clinical psychiatry.
Conclusions: Recent advances in philosophy and neuroscience provide more integrative models for brain and mind in the practice of clinical psychiatry.
Presenter 1
Brain and Mind – Two or One?
M Wong1,2
1Section of the History, Philosophy and Ethics of Psychiatry, The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
2School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia
Background: Dualism and reductionism are the two major competitive models for the brain–mind relationship.
Objectives: To assess how recent advances in philosophy and neurosciences impact on our understanding of the brain–mind relationship and its relevance to the clinical practice of psychiatry.
Methods: To summarize the critiques on dualism and reductionism over the centuries and bring them into dialogues with recent advances in neurosciences.
Findings: Neuroscientific data on philosophy of mind, consciousness studies, psychiatric nosology and psychopathology, when interpreted through a hermeneutic approach, suggest mind is not reducible to brain and that mental health and illness is best understood with a multifaceted perspective that is related to, but different from, the more familiar biopsychosocial model.
Conclusions: Recent advances in philosophy and neurosciences reveal that a person is not nothing but brain or mind but is an embodied entity who requires a psychiatry that is whole-person focussed.
Presenter 2
Disembodied Mind and the Internet
J Arnold1,2
1Section of the History, Philosophy and Ethics of Psychiatry, The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
2Private Practice
Background: Body–mind dualism fails because one cannot locate the substance of mind or how it can relate to material substance.
Objectives: An exploration of the functional aspect of mind in the mind–body dualism argument of Descartes.
Methods: Philosophical/logical argument from a number of philosophers and neurocognitive science.
Findings: If memory is an aspect of mind and the basis of self, then an external memory is a disembodied mind. This can be experienced in a diary or blog. The Internet as repository of communal memories becomes a disembodied collective mind, even if the body no longer exists.
Conclusions: Akin to the intersubjective third space and Martin Buber’s I and Thou, this argument supports a mind–body dualism position.
Presenter 3
Quarks, Quasars and the Unconscious – Stranger than We Suppose
S Stankevicius1,2
1Section of the History, Philosophy and Ethics of Psychiatry, The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
2Royal Brisbane and Women’s Hospital, Brisbane, Australia
Background: Our nervous systems have evolved to glean a representation of reality that is useful rather than true. Although our common-sense intuitions are generally appropriate for our day-to-day lives, they are at gross odds with the very small (quantum mechanics) and very large (cosmology).
Objectives: To show that the unconscious mind, like quantum mechanics and general relativity, represents a domain of reality that we have not evolved to intuit.
Methods: To explore the environment within which humans have evolved and consider which aspects of reality were worth comprehending to confer an evolutionary advantage.
Findings: When we acknowledge that our sense of the world evolved within the certain domain of medium-sized objects moving at slow speeds and social interactions among apes, we should expect many aspects of physics and psychology to be deeply counterintuitive.
Conclusions: Our evolved understanding of the world has not necessarily been constrained by how reality ‘is’. We should be sceptical of any account of the unconscious mind that aligns well with our common sense.
Low-Intensity CBT Therapies in Australia
M Baigent1,2, M Battersby2, T Bastiampillai3
1beyondblue, Melbourne, Australia
2Department of Psychiatry, Flinders University and Flinders Medical Centre, Adelaide, Australia
3Department of Psychiatry, Flinders University, Health South Australia, Adelaide, Australia
Background: Low-intensity psychological interventions focus on mild to moderate level depression and anxiety utilizing cognitive behavioural therapy (CBT) principles. It has evidence for its efficacy and effectiveness for mild to moderate depression and anxiety. In the United Kingdom, services providing this have become an integrated component of the mental health services.
Objectives: Investigate the place of CBT in Australia.
Methods: The place of CBT in the community was investigated by beyondblue (a program called NewAccess), in a pilot, the planning for which began in 2008. Its adaptation for the emergency department (ED) setting was investigated in the busiest ED in Australia (Improving Access to Psychological Therapies – The IAPT@Flinders Service). A new workforce within the mental health services was created and trained to achieve this.
Findings: Low-intensity approaches had significant benefits in the Australian community setting and for patients presenting to the emergency department.
Conclusions: The benefits of the NewAccess approach have led the Commonwealth Government to fund each Australian Primary Healthcare Network to provide low-intensity therapy based on the model. The state government has funded the continuation of the IAPT@Flinders Service based on its effectiveness.
Presenter 1
Outcomes From the Beyondblue Newaccess Program
M Baigent1,2
1beyondblue, Melbourne, Australia
2Department of Psychiatry, Flinders University and Flinders Medical Centre, Adelaide, Australia
Background: The Doncaster trial had shown the efficacy of low-intensity cognitive behavioural therapy (CBT) for mild to moderate depression in the United Kingdom. In 2008, together with funding from ‘Movember’, beyondblue embarked on a program to examine the fit of the successful Doncaster model, then adapt it for Australia, and to test the effectiveness of its low-intensity CBT therapy approach in the Australian community.
Objectives: Establish if a place existed for a low-intensity psychological treatment service in Australia, and if so, to test its suitability for the Australian community.
Methods: Beginning with a feasibility study and then a national seminar, three Australian sites were chosen to establish pilot programs in the community. A new workforce of low-intensity coaches who had no prior mental health professional experience was trained in interventions based on CBT for anxiety and depression, social prescribing and community signposting. Under close supervision within a web-based outcome Patient Case Management Information System (PC-MIS), the three varied sites successfully established themselves and clinical and cost outcomes were evaluated.
Findings: Over the first 20 months of the trial, 1571 consented to participate in the trial and 1096 completed at least three sessions. Of those who were defined as ‘cases’ at the start, 67.5% recovered. The average number of sessions was 4.8. The cost–benefit ratio was 1.5, and the cost per treatment service for mild to moderate depression and anxiety was significantly less than the estimated costs of treatment with the better outcomes system.
Conclusions: NewAccess was a successful and highly cost-effective service and Australian adaptation of the UK low-intensity model.
Presenter 2
Coach Selection, Training and Supervision – A New Workforce and the Importance of Maintaining Therapeutic Fidelity
M Battersby
Department of Psychiatry, Flinders University and Flinders Medical Centre, Adelaide, Australia
Background: Coaches without a professional background were selected to provide low-intensity guided self-help. They constitute a new workforce for whom rigorous training and supervision is critical to achieving and maintaining safety, quality and fidelity to the model.
Objectives: Describe the selection processes, training and supervision processes and structure for low-intensity coaches.
Methods: Over 30 coaches were recruited and trained across three sites in three Australian states and territory. A 12-month training program using face-to-face and on-line modes complemented by weekly supervision using a web-based management system will be described.
Findings: Coaches from a wide range of community backgrounds with no health qualifications could be selected and provided with training and supervision to deliver high volume, safe and effective guided self-help services for anxiety and depression.
Conclusions: Low-intensity guided self-help coaches provide a new cost-effective workforce to address the low access to early interventions for people with anxiety and depression in the Australian community.
Presenter 3
Iapt@Flinders – Positive Outcomes from the Adaption of Low-Intensity CBT Focussing on Psychiatric Presentations to the Emergency Department
T Bastiampillai
Department of Psychiatry, Flinders University, Health South Australia, Adelaide, Australia
Background: There is a significant need to provide effective treatment for patients presenting to the ED in mental health crisis. We uniquely adapted the UK Improving Access to Psychological Therapies (IAPT) model to a South Australian emergency department (ED) setting.
Objectives: The telephone-based IAPT model was provided to people presenting in crisis to the EDs, with a combination of anxiety, depression, substance abuse and suicidal thinking.
Methods: The uncontrolled study, utilized session by session, before and after measures of anxiety and depression, via Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7).
Findings: A total of 347 patients were referred and 291 engaged with the service (83.9%). Treated patients reported clinically significant improvements in anxiety, depression and suicidal ideation. Uncontrolled effect sizes were moderate for anxiety (0.6) and depression (0.6).
Conclusions: The South Australian adaptation of the UK IAPT program to an ED setting was successful. This model should be considered within an Australian policy context to implement evidence-based structured psychotherapeutic (cognitive behavioural therapy) follow-up for patients presenting to the ED in crisis.
Round and Round the Mulberry Bush No More: Disrupting the Intergenerational Cycle of Mental Illness
L Segal1, J Amos1, G Swift2, P McEvoy2
1University of South Australia, Adelaide, Australia
2Women and Children’s Health Network, Adelaide, Australia
Background: Unresolved childhood distress and adult mental illness can be crippling for individuals, families and the economy. Empirical and theoretical research increasingly confirms the developmental origins of adult mental illness, highlighting the importance of disrupting these intergenerational patterns. Such an endeavour needs investment in the right therapeutic programs and service delivery systems.
Objectives: This symposium aims to explore, from interrelated perspectives, what is needed to disrupt the intergenerational transmission of mental illness.
Methods: The first presentation will explore the relationship between psychological distress and childhood trauma using data from the Longitudinal Studies of Australian and Indigenous children. This will be followed by a theoretical discussion of the mechanisms of transmission and the predicted objectives of therapies. A case study highlights how dyadic therapies offer the potential for healing two generations simultaneously. The symposium concludes with a vision for a mental health service with a focus on high-quality tertiary prevention of intergenerational transmission.
Findings: More than 75% of children (aged 4–15 years) experiencing psychological distress also experience 4+ childhood adversities (e.g. child maltreatment, parental separation, parental mental illness, multiple family stressors), all of which impact the quality of the parent–infant relationship. Theoretical work indicates that dyadic psychotherapies, as illustrated, are fundamental to effective service delivery, when embedded in appropriate service delivery systems.
Conclusions: With advances in basic science and research into the practical application of these findings, the goal of preventing adult mental illness through innovative service delivery models is within reach.
Presenter 1
Understanding the Developmental Underpinnings of Adult Mental Illness: How can this Help Us?
L Segal1, J Amos J1, G Swift2, P McEvoy2
1The University of South Australia, Adelaide, Australia
2Women and Children’s Health Network, Adelaide, Australia
Background: Mental illness is now understood as largely developmental, with its genesis in childhood, suggesting the possibility for prevention. But an effective service response requires a clear description of need.
Objectives: To estimate the prevalence of Australian children at excess risk of adolescent/adult mental illness.
Methods: We used data from the Longitudinal Study of Indigenous Children (LSIC); 1671 infants enrolled in 2008. For data from the Longitudinal Study of Australian Children (LSAC), 10,640 infants enrolled in 2003. Risks/adversities were identified from a literature review of childhood determinants of mental illness (Fryers and Brugha, 2013). The age-category prevalence of psychological distress was based on the Strengths and Difficulties Questionnaire (SDQ) or the Brief Infant Toddler Social Emotional Assessment and a multiple risk score computed using data extracted from six waves of LSIC and six waves of LSAC.
Findings: Many Australian children face multiple adversities from a young age. Over 45% of Indigenous children aged 6 to 10 years were exposed to 6+ adversities (risks for mental illness), such as domestic violence, harsh parenting, major family stresses, parental separation and parental mental illness. A clear relationship was observed between the number of adversities and psychological distress. For Australian children aged 8–13 years with an SDQ score in the extreme range, 74% had 4+ concurrent adversities, compared with 17% for children with an SDQ in the normal range.
Conclusions: Preventive action targeting the multiple risk factors often present from infancy must be a priority. This will require an integrated service system offering culturally appropriate, high-quality infant, child, adolescent and family mental health services, linked to early childhood and family support services.
Reference
Fryers T and Brugha T (2013) Childhood determinants of adult psychiatric disorder. Clinical Practice and Epidmiology in Mental Heath 9: 1–50.
Presenter 2
When Wounds from Infancy Collide
J Amos1, G Swift2, P McEvoy2, L Segal1
1University of South Australia, Adelaide, Australia
2Women and Children’s Health Network, Adelaide, Australia
Background: Research confirms that the foundational experiences, which leave adults vulnerable to mental illness, occur in the relational environments in which infants and children develop.
Objectives: To present theoretical models of the intergenerational transmission of relational trauma and the objectives of therapy predicated by the models.
Methods: A model-building approach situated in rules of logic (Wacker, 1989) was used to develop the theory, resulting in two complementary models.
Findings: The first model (Amos et al., 2011) focusses on how relational trauma in a mother’s infancy leads to persistent structural dissociation and how this is re-created in the mind of her infant. The second explores how mother–infant dyads come to rely on dominance and submission hierarchies to safely maintain proximity without intimacy (Amos et al., 2015). Together, the models suggest that avoidance of implicitly encoded; unprocessed fear and shame are central to intergenerational transmission. The models predict that effective psychotherapy will address mechanisms of defensive avoidance, process the terrifying emotional experiences driving the defences and support the emergence of safety, togetherness and love in the interactions between mother and infant/child.
Conclusions: The mechanisms that maintain safety in severely compromised mother–infant/child dyads are also the mechanisms that lead to ongoing maltreatment and the intergenerational transmission of injuries that underpin adult mental illness. Using the unique properties of the mother–infant/child relationship can be a potent approach to healing. Tertiary level, dyadic mother–infant/child psychotherapies may be the most efficient and effective approaches to the prevention of the intergenerational transmission of mental illness.
References
Amos J, Furber G and Segal L (2011) Understanding maltreating mothers: A synthesis of relational trauma, attachment disorganization, structural dissociation of the personality and experiential avoidance. Journal of Trauma and Dissociation 12: 495–509.
Amos J, Segal L and Cantor C (2015) Entrapped mother, entrapped child: Agonic mode, hierarchy and appeasement in intergenerational abuse and neglect. Journal of Child and Family Studies 24(5): 1442–1450.
Wacker JG (1998) A definition of theory: Research guidelines for different theory building research methods in operations management. Journal of Operations Management 16: 361–385.
Presenter 3
Working with Vulnerable Infants to Break the Cycle
G Swift1, P McEvoy1, J Amos2, L Segal2
1Women and Children’s Health Network, Adelaide, Australia
2University of South Australia, Adelaide, Australia
Background: The Infant Therapeutic Reunification Service (ITRS) began in September 2011. The ITRS provides early assessment and therapy for infants less than 3 years of age and their parents, where significant maltreatment and neglect has occurred, or is at risk of occurring. The ITRS seeks to determine whether reunification is viable and in the best interests of the infant. Where indicated parent–infant therapy is undertaken to reduce the impact of trauma and facilitate positive relationships leading to a safer caring environment for the infant. A recently published randomized controlled trial of parent–infant psychotherapy (PIP) for parents with mental health problems (Fonagy et al., 2016) reported favourable outcomes for PIP-treated dyads relative to the control group on several measures of parental mental health and parental representations of the baby and their relationship.
Objectives: To demonstrate through a case study how this work can benefit the developmental and mental health outcomes of vulnerable infants and their parents.
Methods: A case study will be presented.
Findings: This case study demonstrates that dyadic parent–infant psychotherapy can have positive consequences not only for infant development but also on parental representations of the child and for parental mental health.
Conclusions: The case study highlighted how dyadic therapy offers the potential for healing two generations simultaneously. Parent–infant psychotherapy is an example of an intervention which not only allows for the infant to be cared for in a safer environment by their parent but has the potential to change the mental health trajectory of the infant and the parent.
Reference
Fonagy P, Sleed M and Baradon T (2016) Randomized controlled trial of parent-infant psychotherapy for parents with mental health problems and young infants. Infant Mental Health Journal 37(2): 97–114.
Presenter 4
Implications For Child and Adolescent Mental Health Service Delivery
P McEvoy1, L Segal2, J Amos2, G Swift1
1Women and Children’s Health Network, Adelaide, Australia
2University of South Australia, Adelaide, Australia
Background: ‘Child and adolescent mental health service planning must be informed by developmental psychopathology’ (Newman and Birleson, 2012).
‘To that end the rapidly moving frontiers of developmental sciences offer an unprecedented opportunity to leverage knowledge in the service of launching a new era in early childhood policy and practice’ (Shonkoff, 2012)
Objectives: The presentation will highlight the clinical, policy and funding challenges that need to be addressed to deliver innovative and intensive therapeutic interventions from Health in partnership with other early childhood services.
Methods: The redesign of a statewide child and adolescent mental health service will be described, taking into account how we have advocated for focussing on specialist therapeutic intervention early in life to alter the developmental trajectories of children who are experiencing such adversity.
Findings: The discussion will highlight the critical involvement of stakeholders and consumers/carers in such a process. It will also demonstrate that getting ‘early intervention’ on to the broader mental health agenda when it comes to policy development and funding priorities remains challenging.
Conclusions: The knowledge and evidence that we now have in relation to the impact of early adversity later in life must inform service development and planning. Tertiary interventions are required and need ongoing evaluation.
References
Newman L and Birleson P (2012) Mental Health Planning for children and youth: Is it developmentally appropriate? Australasian Psychiatry 20(2): 91–97.
Shonkoff JP (2012) Leveraging the biology of adversity to address the roots of disparities in health and development. Proceedings of the National Academy of Sciences U S A 109(Suppl. 2): 17302–17307.
Offcuts: Children in the Longitudinal Study of Indigenous Children (LSIC) experience very high rates of adversities. In utero, nearly 50% were exposed to smoking and 22% to alcohol. As infants, 42.5% were not living with both birth parents. At any time, over two-thirds of children are in households that had experienced 3+ stressful life events in the past year, 23% lived in families with a drug or alcohol problem, 30+% were exposed to hostile parenting and 18% to domestic violence. At school, nearly 40% of children were bullied.
Comorbidity in Children and Youth
F Zepf1, J Harrison2, C Richardson2, CS Franklin3
1The University of Western Australia, Perth, Australia
2Alfred Child and Youth Mental Health Service, Melbourne, Australia
3The University of Queensland, Brisbane, Australia
Background: Children and youth with neurodevelopmental disorders are at increased risk of comorbid mental health and medical issues. They are among the most complex patients we see.
Objectives: This symposium brings together a number of viewpoints to explore some of the complex relationships between behaviour, neurodevelopmental disorders and mental health presentations in children and youth.
Methods: This symposium includes original research into the relationship between behaviour and sleep disorders, an overview of depression in young people with an intellectual disability (ID) (and the importance of a specialized assessment and treatment service), the genetics of copy number variations and their clinical significance and an overview of the mental health of young people with Down’s syndrome.
Findings: There is pleasing progress in understanding the mental health needs of young people with IDs and developmental disorders.
Conclusions: The mental health needs of young people with complex comorbid presentations require the integration of research and clinical knowledge and a close listening to the perspectives of patients and their families.
Presenter 1
Developmental Trajectories of Sleep Problems from Childhood to Adolescence both Predict and are Predicted by Emotional and Behavioural Problems
F Zepf 1, B Wang2, C Isensee2, A Becker2, J Wong1, P Eastwood3, R Huang4, K Runions1, R Stewart1, T Meyer5, L Brüni6, A Rothenberger1
1Centre and Discipline of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, The University of Western Australia, Perth, Australia
2Department of Child and Adolescent Psychiatry and Psychotherapy, University Medical Center of Goettingen, Göttingen, Germany
3Centre for Sleep Science, School of Anatomy, Physiology & Human Biology, University of Western Australia, Perth, Australia
4Telethon Kids Institute, Perth, Australia
5Department of Psychosomatic Medicine and Psychotherapy, German Centre for Cardiovascular Research, University of Goettingen, Göttingen, Germany
6Psychiatry Services Thurgau, Switzerland
Background: In children with an intellectual disability (ID), sleep problems are common and can last for significant periods of time. Moreover, regarding children without an ID, although the prevalence rates of sleep disorders at different stages of childhood and adolescence have been well established, little is known about the developmental course of general sleep problems. This also holds true for the bidirectional relationship between sleep problems and emotional as well as behavioural difficulties.
Objectives: This longitudinal study investigated the general pattern and the latent trajectory classes of general sleep problems from a large community sample aged 5 to 14 years. In addition, this study examined the predictive value of emotional/behavioural difficulties (i.e. anxiety/depression, attention problems, and aggressive behaviour) on sleep problems latent trajectory classes, and vice versa.
Methods: Participants (N = 1993) were drawn from a birth cohort of Western Australian children born between 1989 and 1991 who were followed until 14 years of age. Sleep problems were assessed at the ages of 5, 8, 10 and 14 years, whereas anxiety/depression, attention problems and aggressive behaviour were assessed at the ages of 5 and 17 years.
Results: Latent growth curve modelling revealed a decline in an overall pattern of sleep problems during the observed 10-year period. Anxiety/depression was the only baseline factor that predicted the longitudinal course of sleep problems from the ages of 5 to 14 years, with anxious and depressed participants showing faster decreasing patterns of sleep problems over time than those without anxiety or depression. Growth mixture modelling identified two classes of sleep problem trajectories: normal sleepers (89.4%) and troubled sleepers (10.6%). Gender was randomly distributed between these groups. Childhood attention problems, aggressive behaviour and the interaction between gender and anxiety/depression were significantly predictive of membership in the group of troubled sleepers. Group membership in troubled sleepers was associated with higher probability of having attention problems and aggressive behaviour in mid adolescence. Boys and girls with behavioural difficulties, and girls with emotional difficulties, were at increased risk of having sleep problems during later childhood and adolescence. Developmental trajectories of sleep problems were also predictive of behavioural difficulties in later life.
Conclusions: Findings from this study provide empirical evidence for the heterogeneity of sleep problems and their development and emphasize the importance of understanding sleep problems and their relationship to children and adolescents’ mental health. Further research on the heterogeneity of sleep problems in vulnerable populations such as children with an ID is needed to provide adequate interventions.
Presenter 2
Assessing Depression in Children and Youth with Intellectual Disability
J Harrison
Alfred Child and Youth Mental Health Service, Melbourne, Australia
Background: Rates of psychiatric disorder in young people with an ID are high, but these young people struggle to access appropriate mental health services. Many psychiatrists feel they lack expertise in diagnosing mental health conditions in this population. The problem of diagnostic overshadowing means that mental health symptoms may be falsely attributed to the ID. Families report difficulty accessing appropriate services for themselves and their young people and often complain of closed doors and limited availability of specialized expertise. Schools report similar struggles with mental health issues often presenting as behavioural problems in the classroom. In 2016, Alfred Child and Youth Mental Health Service (CYMHS) received funding from the Victorian government to establish a pilot mental health service for young people aged 12–25 years with a co-morbid ID and mental health problems. This paper reviews and discusses the assessment and treatment of depression in young people with an ID.
Objectives: To provide an overview of the Alfred CYMHS Mental Health in Intellectual Disability Initiative – Youth (MHIDI-Y). To review approaches to the detection, assessment and treatment of depression in youth with an ID.
Methods: The psychiatric literature on depression in youth with an ID will be summarized. Case examples will be discussed. Assessment and treatment of depression in this clinical population will be discussed with reference to the MHIDI-Y service, its philosophies and aims, especially the involvement of consumers and parents at all levels of service delivery.
Conclusions: The MHIDI-Y is an important pilot service, which brings together mental health expertise that is accessible and tuned to the needs of young people with an ID and their families. Depression is common in this group of young people. Specialized assessment and treatment includes an understanding of the individual, the family and the young person’s social and educational context.
Presenter 3
Genetic Testing in the assessment of Developmental Disorders: An Overview for Psychiatrists
C Richardson
Alfred Child and Youth Mental Health Service, Melbourne, Australia
Background: Genetic testing in children with developmental delay is now standard. It is an important part of establishing the cause of a child’s delay and assisting clinicians and families to understand the child’s difficulties and assist with managing treatment. Children often present to psychiatric services with this information, and it is important for psychiatrists to interpret these results. The current field of genetic analysis is complex and rapidly developing, and it can be difficult for clinicians and families to understand the information that is being given to them. This paper aims to give an overview of the use of genetic analysis used in clinical practice in the field of developmental disorders including, but not limited to, autism spectrum disorder (ASD) and intellectual disability (ID). I will provide an overview of current genetic analysis including neonatal screening for metabolic disorders, chromosome analysis, Fragile X syndrome testing and microarray.
The presentation will concentrate more specifically on microarray, a general term used for a number of tests that can identify very small changes in DNA including loss or gain of DNA segments, commonly referred to as ‘copy number variations’.
Microarray is now the recommended first-line genetic test for children with developmental delay, with approximately 15–20% of children with ASD, global developmental delay or an ID having abnormal results. It is important for psychiatrists to understand the test’s benefits and limitations and to be able to contextualize the information it gives.
The case of a child with developmental delay with abnormal microarray testing will be presented and the ways in which clinical information can assist thinking about the significance of genetic testing will be discussed. Although the tests can be sensitive and find pathology, it remains unclear in many cases to what extent these results can be helpful and meaningful to patients. Particular variations may be rare with little clinical convergence. It can be challenging to help families and young people to understand the significance of this information.
The parental experience of raising a child with a genetic diagnosis and the sophisticated role psychiatrists can play in assisting parents to make sense of the genetic information will also be highlighted.
Objectives: The aim of this presentation is to provide an up-to-date explanation of genetic analysis used in clinical practice in the field of developmental disorders. The presentation will be helpful for psychiatrists as they consider the wider impact of these results on clinical formulation and the understanding of the children who present with these abnormalities.
Methods: This presentation includes a brief introduction to the area of genetic testing, a case report and an exploration of how this information is relevant to psychiatric understanding of a child’s development. Several articles that guide clinicians through genetic analysis will be referenced. The case of a developmentally delayed child who presented to the Alfred Child and Youth Mental Health Service in Melbourne, Australia, will be discussed. Qualitative research articles that explore the role of genetic diagnosis in children with developmental delay will be discussed and the impact of genetic testing on families will be considered.
Conclusions: Genetic analysis is important to consider in diagnosing developmental disorders but it is important for psychiatrists to understand the current field of testing and the significance of the genetic information that is given to families. It is also important to consider the emotional and psychological impact of these tests on our understanding of a child’s development.
Presenter 4
Mental Health in Adolescents and Adults with Down Syndrome
C Franklin1,2
1Queensland Centre for Intellectual and Developmental Disability, MRI-UQ, The University of Queensland, Brisbane, Australia
2Mater Young Adult Health Centre Brisbane, Mater Health Services, Brisbane, Australia
Background: The transition from adolescence to adulthood is a time of increased vulnerability for all young people. Young people with Down syndrome are at increased risk of mental health problems due to factors including the challenge of transition from adolescence to adulthood.
Objectives: This presentation aims to update the psychiatrist’s knowledge of the typical presentation of common and uncommon psychiatric disorders in adolescents and young adults with Down syndrome, including depression, anxiety, psychosis and catatonia. The relationship between behavioural phenotype and symptoms of mental illness will also be discussed.
Methods: The presentation will focus on clinically relevant material that will help psychiatrists in their own clinical practice. Case material will be used to illustrate presentations, followed by an update of the current literature. A new research project will be described.
Findings and conclusions: The scant recent literature examining the mental health of adults with Down syndrome suggests a higher incidence of psychosis than previously documented and the occurrence of a syndrome of acute deterioration associated with catatonia in some cases. The mental health of young people with Down syndrome remains an under-investigated area relative to children and older adults with Down syndrome. Ongoing research holds some hope for improved future knowledge in this area.
Psychiatrists have an essential role in the diagnosis of mental illness and appropriate treatment planning for adolescents and young adults with Down syndrome.
Initiatives to Build Workforce Capacity in Intellectual Disability Mental Health
J Trollor1, A Livingstone2, C Salomon1, J Weise1, C Eagleson1, J Walsh1, R Birch1
1University of New South Wales, Sydney, Australia
2Victorian Dual Disability Service, Melbourne, Australia
Background: People with an intellectual disability (ID) represent approximately 1% of the population (Maulik et al., 2011). Compared with the general population, they experience elevated rates of mental health problems, which frequently go undiagnosed or are inappropriately treated (Einfeld et al., 2006). A significant contributor to this population’s inequitable access to mental health care is an ill-equipped workforce.
Objectives: The objectives of this symposium are to ascertain current workforce capacity in ID mental health for disability and mental health professionals, highlight barriers and enablers of service provision, and describe innovative approaches to capacity building utilizing multiple methods for professionals at specific career stages.
Methods: A series of presentations will describe quantitative and qualitative research in this field and illustrate capacity building in ID mental health. Projects will include online surveys, forums and consumer groups, roundtable discussions, Delphi surveys, and consultation with various stakeholder groups.
Findings: There have been significant developments in the understanding of workforce needs and in the development of tools that assist workforce capacity development in this area.
Conclusions: Further progress in policy development, service enhancement, and education is required to improve mental health outcomes for people with an ID.
References
Einfeld SL, Piccinin AM, Mackinnon A, et al. (2006) Psychopathology in young people with intellectual disability. Journal of the American Medical Association 296(16): 1981–1989.
Maulik PK, Mascarenhas MN, Mathers CD, et al. (2011) Prevalence of intellectual disability: A meta-analysis of population-based studies. Research in Developmental Disabilities 32(2): 419–436.
Presenter 1
Initiatives to Build Workforce Capacity in Intellectual Disability Mental Health
J Trollor, C Salomon, J Weise, C Eagleson, J Walsh, R Birch
University of New South Wales, Sydney, Australia
Background: The majority of people with an intellectual disability (ID) receive mental health care through generalist mental health services. A considerable barrier to this population receiving quality care is that mental health professionals lack the knowledge, skills and confidence to make reasonable adjustments to practice (Iacono et al., 2014).
Objectives: Research objectives were to determine the current ID mental health (IDMH) capacity within the mainstream mental health workforce and identify future training needs, identify barriers and facilitators influencing the delivery of services, and to develop IDMH e-learning modules for health professionals, an IDMH core competency framework and toolkit, and early intervention framework for cardio-metabolic risk in people with an ID.
Methods: A multi-pronged approach was used including a workforce survey of NSW Health mental health professionals, a Delphi survey to reach consensus on core competencies, a national roundtable with key experts; review of key literature and guidelines to develop e-learning modules, and adaptation of cardio-metabolic monitoring guidelines.
Findings: Mental health professionals believe it is part of their role to provide services to people with an ID. However, they do not believe care can be adequately provided within mainstream services due to inadequate resources and education. Various capacity building initiatives of the team are described with a particular focus on the public mental health workforce.
Conclusions: Findings highlight the importance of enhancing the capacity of mental health professionals to meet the needs of people with an ID. Initiatives are required to improve mental health workforce capacity.
Reference
Iacono T, Bigby C, Unsworth C, et al. (2014) A systematic review of hospital experiences of people with intellectual disability. BMC Health Services Research 14(1): 505.
Presenter 2
Lessons from Creating an Online Learning Resource for Disability Workers
A Livingstone
Victorian Dual Disability Service, Melbourne, Australia
Background: The Victorian Dual Disability Service was asked by the Victorian Office of Professional Practice to prepare a resource guide for Disability Support Workers addressing the Psychiatry of Intellectual Disability. This grew out of a recurrent series of lectures for disability staff called ‘Mind, Brain and Behaviour’ and it has been available as 12 modules freely accessible online since March 2014.
Objectives: To examine the experience of creating and maintaining a resource guide and what has been learned from this.
Methods: This talk will briefly address how we chose the specific topics to include, discuss the pattern of uptake of each module and review trends in the feedback to date.
Findings: Uptake has varied over time, and the pattern of individual modules has also varied. There was an early spike in uptake of the autism spectrum disorder (ASD) module, which has remained popular, and there is also a consistently greater uptake in the module covering behaviour management.
Conclusions: The direct carer body is engageable in e-learning, and there is a demand for learning resources in the areas of ASD and behaviour management.
Presenter 3
Equipping Psychiatrists to Meet the Mental Health Needs of People with an Intellectual Disability
C Eagleson, J Weise, R Birch, J Trollor
University of New South Wales, Sydney, Australia
Background: Psychiatrists have a key role within the mental health workforce to deliver quality care to people with an intellectual disability (ID) and mental ill health. However, psychiatrists have reported that they have received insufficient education and lack confidence in this area (Lennox and Chaplin, 1995, 1996). There have been consistent calls for advanced training in ID mental health (IDMH), including a subspecialty for psychiatrists, and a specialist tertiary service (Lennox and Chaplin, 1995, 1996; Torr et al., 2008).
Objectives: To describe a project that maps the current workforce capacity in IDMH psychiatry across Australia and New Zealand and explores the potential for providing specialist training in IDMH to trainee psychiatrists.
Methods: The methodology involves an online survey of Australian and New Zealand psychiatrists who have expertise/an interest in IDMH and analysis of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) data. Consultation around subspecialty development involves discussion with the RANZCP, whereas consensus on curriculum elements will be reached via consultation with key experts and a Delphi survey.
Findings: Survey findings will gauge the current workforce capacity in IDMH and the future training capacity in this area. Potential education options for trainee psychiatrists will be discussed including increasing IDMH content in existing curricula, recognizing IDMH as an Area of Practice, or the development of a Certificate of Advanced Training.
Conclusions: The need for psychiatrists with specialist skills in the area of ID is a key component of an accessible mental health service for people with an ID (Department of Developmental Disability Neuropsychiatry, 2014). Providing sufficient training is a vital step in meeting the mental health needs of this population.
References
Department of Developmental Disability Neuropsychiatry (2014) Accessible Mental Health Services for People with an Intellectual Disability: A Guide for Providers. Sydney, Australia: Department of Developmental Disability Neuropsychiatry.
Lennox N and Chaplin R (1995) The psychiatric care of people with intellectual disabilities: The perceptions of trainee psychiatrists and psychiatric medical officers. Australian and New Zealand Journal of Psychiatry 29(4): 632–637.
Lennox N and Chaplin R (1996) The psychiatric care of people with intellectual disabilities: The perceptions of consultant psychiatrists in Victoria. Australian and New Zealand Journal of Psychiatry 30(6): 774–780.
Torr J, Lennox N, Cooper S-A, et al. (2008) Psychiatric care of adults with intellectual disabilities: Changing perceptions over a decade. Australian and New Zealand Journal of Psychiatry 42(10): 890–897.
Advancing the Social and Emotional Well-Being of Aboriginal and Torres Strait Islander People
A Janca1, S Balaratnasingam1, J Lee2
1School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia
2Townsville Hospital, Townsville, Australia
Background: Providing culturally appropriate models of care for Aboriginal and Torres Strait Islander people is a shared vision for many healthcare professionals and the community at large. The uniquely strong link Aboriginal and Torres Strait Islander people have to their traditional culture and the maintenance of connection to country and identity were the motivation and inspiration for this work.
Objectives: Aboriginal social and emotional well-being – our mutual interest – brought together a group of experts in the field to discuss the issues facing Aboriginal and Torres Strait Islander people. Pertinent themes for Aboriginal and Torres Strait Islander people emerged, including youth engagement, improving the ability to access services, and increasing an understanding of the uniqueness of the culture. The success and appropriateness of various interventions was also discussed. In this symposium session, the expert panel hopes to have some individual presentations illuminating these themes and to also have an extended question and answer and discussion session with the audience.
Methods: Experts in Aboriginal and Torres Strait Islander health and research formed this working group and collaborate through face-to-face meetings and email correspondence to contribute to worthwhile projects.
Findings: There were areas that the expert group felt could be practical targets for a significant contribution to advancing Aboriginal social and emotional well-being. This included creation of a child and adolescent version of a Cultural Information Gathering tool, improving youth engagement, improving access to mainstream mental health services, additional initiatives to combat suicide risk, and improving the understanding of Aboriginal and Torres Strait Islander culture. These initiatives may assist in an understanding of ‘self’ for disenfranchised Aboriginal youth, improving education and preparing for meaningful employment, and helping people to accept and share their cultural values with the wider community.
Conclusions: Making services more equitable as well as enhancing access to mental health care for Aboriginal and Torres Strait Islander people is key for improving the social and emotional well-being of this group. An understanding of self, improved preparation for meaningful employment, suicide prevention, and improved youth engagement initiatives may also be important areas for intervention that may assist in contributing to improved outcomes for Aboriginal and Torres Strait Islander people.
Presenter 1
The Concept of Personality Disorder in Aboriginal and Torres Strait Islander People
A Janca
School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia
Background: Diagnoses of personality disorder (PD) are often given to Aboriginal and Torres Strait Islander people in clinical encounters in the context of various disordered behaviours and substance use.
Objectives: To examine the validity of concept and diagnosis of PD in transcultural settings using Indigenous Australians as an example.
Methods: Review of relevant literature, both internationally and within Australia, regarding the concept of PD in a transcultural setting.
Findings: There are significant deficits in comparative research on PD across cultures. There is also a dearth of information regarding Indigenous Australians and cultural applicability and clinical utility of the diagnosis of PD in this group.
Conclusions: The concept of culture is generally ignored when making a diagnosis of PD. A valid diagnosis should incorporate what would be considered understandable and adaptive behaviour in a person’s culture. In Indigenous Australian culture, making a diagnosis of a PD is complicated by historical trauma from colonization, disruption of kinship networks and ongoing effects of poverty and social marginalization.
Reference
Balaratnasingam S and Janca A (2017) Culture and personality disorder: A focus on Indigenous Australians. Current Opinion in Psychiatry 30(1): 31–35.
Presenter 2
The Kimberley Suicide Data: Implications for Suicide Prevention
S Balaratnasingam
School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia
Background: Suicide rates in Australian Aboriginal and Torres Strait Islander people are elevated nationwide. What are the historical and current drivers of suicide in this group and what approaches may help?
Objectives: Using the Kimberley region of Western Australia as an example, information will be presented regarding suicides occurring in the period 2005–2014.
Methods: This research is a de-identified retrospective audit of reported suicide deaths provided to the Kimberley Mental Health and Drug Service (KMHDS) from various community sources, including hospitals, police, Coroner’s reports and other health services during the period 2005–2014. A selective review of the literature was conducted.
Findings: Audit findings support the hypothesis that rates of Indigenous suicide in the Kimberley have dramatically increased in the last 50 years and continue to increase. There is also an overall upward trend in Indigenous youth suicide and Indigenous female suicides.
Conclusions: These findings will improve awareness of suicide risk for all clinicians working in the Kimberley and will assist in targeted delivery of mental health services within the region. The findings provide a greater potential in understanding cultural aspects of Indigenous suicide and the reasons for the growing differential rate between Indigenous and non-Indigenous people.
Reference
Campbell A, Balaratnasingam S, McHugh C et al. (2015) Alarming increase of suicide in a remote Indigenous Australian Population: An audit of data from 2005-2014. World Psychiatry 15(3): 296–297.
Presenter 3
Improving Access to Care: A Collocation Model of Service Delivery
J Lee
Townsville Hospital, Townsville, Australia
Background: Aboriginal and Torres Strait Islander Australians access mental health services more than non-Indigenous Australians, but relative rates of mental health issues are much higher. Community Controlled Health Services (CCHSs) were introduced in 1971 as a strategy for reducing access barriers to healthcare through improving cultural safety of the intervention environment. Recent efforts to improve cultural safety and culturally informed practice include developing the role of the health worker and the utilization of information and screening tools.
Objectives: To describe a collocation model of mental health service delivery that aims to improve Aboriginal and Torres Strait Islander access to culturally informed care.
Methods: The presentation will outline the collaborative process undertaken by a mental health service and a CCHS to develop a collocation mental health case management (MHCM) service that works in partnership with a social and emotional well-being (SEWB) team. The presenter will discuss how the teams work together and how the cultural information gathering tool and the here and now aboriginal assessment tool are being used to enhance cultural safety and culturally informed practice.
Findings: Apart from improving Aboriginal and Torres Strait Islander access to mental healthcare, this model also serves to improve holistic care with enhanced continuity and upskills both the SEWB and MHCM teams in their respective complementary skill sets.
Conclusions: Enhanced specialist mental healthcare access for Aboriginal and Torres Strait Islander people can be achieved through collaborative partnerships whereby a collocation service is developed.
Reference
Balaratnasingam S, Anderson L, Janca A et al. (2015) Towards culturally appropriate assessment of Aboriginal and Torres Strait Islander social and emotional well-being. Australasian Psychiatry 23(6): 626–629.
Building the Evidence Base for Recovery-Oriented Mental Health: Lessons from Developing and Implementing Treatments, Service Models and System Co-Design for People Living with Severe Mental Illnesses in Victoria, Australia
V Palmer1, M Alvarez2, N Thomas3, D Mayberry4, G Meadows4
1The University of Melbourne, Melbourne, Australia
2Orygen, The National Centre for Excellence in Youth Mental Health, Melbourne, Australia
3Swinburne University of Technology, Melbourne, Australia
4Monash University, Melbourne, Australia
Background: In 2012, the Victorian Government established a 4-year, 10-million-dollar research Mental Illness Research Fund (MIRF 2013–2017) to support multidisciplinary and cross-sector collaborative research to promote tangible improvements in service provision for people living with severe mental illness and to improve psychosocial recovery outcomes.
Objectives: Five flagship projects were funded to address innovations in treatment, service models and system co-design with the aim of building an evidence base in psychosocial recovery and a recovery-oriented mental health system.
Methods: Under the MIRF scheme, new treatment and service provision models have been user-designed and are being tested in the SMART, HORYZONS, LET’S TALK and PULSAR studies. In the CORE study, an experience-based co-design methodology that brings consumers, carers and staff together to work collaboratively to develop action plans for service improvement changes is being tested to examine the effectiveness for psychosocial recovery.
Findings: These five studies represent a world class and essential evidence base that can inform the development of recovery-oriented mental health systems and their implementation. Working across the system continuum each offers unique lessons in innovative treatment and service model developments and addresses challenges of consumer-led systems of care.
Conclusions: This symposium will share key lessons and focus on the next step for the synthesis and development of a translational model for implementing a whole-of-system recovery-oriented approach.
Presenter 1
Innovations in Technology-Based Treatments and Management for Pyschosis – Moderated Online Social Therapy (HORYZONS) and Self-Management and Recovery Technology
M Alverez1, N Thomas2
1Orygen, The National Centre for Excellence in Youth Mental Health, Melbourne, Australia.
2Swinburne University of Technology, Melbourne, Australia
Background: Technological interventions to support psychosocial recovery are increasing, but despite the opportunity for greater reach, cost-effectiveness and user-driven psychosocial recovery approaches they are challenging to implement.
Objectives: HORYZONS aims to deliver a user-designed moderated online therapy (MOST) to address the treatment and evidence gap in current first episode psychosis (FEP) service provision around social connectedness and long-term recovery. SMART is examining how digital resources can integrate with face-to-face service delivery, and, particularly, how lived experience-based multimedia and peer-to-peer connection can be used to promote personal recovery.
Methods: HORYZONS integrates peer-to-peer social networking; individually tailored therapeutic interventions; expert and peer moderation; and a positive psychology and strength-based framework, in a coherent platform designed to improve long-term outcomes and social recovery in FEP. SMART involves components including, as a main component, a randomized controlled trial (RCT) of a tablet-computer supported face-to-face recovery intervention, plus a trial of self-guided use with email coaching support and examination of use by workers in routine practice.
Findings: At the time of writing, 141 participants had been recruited into the HORYZONS RCT. Safety outcomes have been consistently strong. System usage has been remarkably high, with a total of 5762 logins (average, 104/user), 3871 posts (average 70/user), 550 therapy modules completed (average 10/user), and 65% of users being engaged with the online system for 18 months. SMART has recruited 148 people to its RCT and identified that digital resources integrate well with face-to-face specialist mental health delivery.
Conclusions: Technological innovations show promise, but challenges for wider systems implementation are evident.
Presenter 2
Improving Service Supports and Models – the let’s Talk about Children Program and Principles Unite Local Services Assisting Recovery
D Mayberry, M Goodyear, G Meadows
Monash University, Melbourne, Australia
Background: Training mental health, specialist and primary care professionals is essential in a recovery-oriented system.
Objectives: About 20% of adults with serious mental health problems are parents but little research has been focussed on the recovery journey of those who are parents and have a mental illness. The important role that primary care and family services have in supporting people can be overlooked and often professionals may not receive the training they need to give appropriate care.
Methods: Let’s Talk will evaluate the effectiveness of an intervention model of recovery for parents (Let’s Talk about Children) in three different mental health service sectors and examine the economic value of a larger roll out (longer term) of the parent recovery model. Principles unite local services assisting recovery (PULSAR) has delivered recovery-oriented practice (ROP) training to 24 general practitioners, 18 specialist mental health sites and received over 700 consumer surveys to evaluate the ROP service model effectiveness for improving outcomes.
Findings: Let’s Talk has received 137 verbal acceptances for involvement in the study and will continue to collect pilot data around the impact of the intervention on children. A central ingredient in these models is the involvement of people with lived experience in the development and facilitation of training either in design or via Lived Experience Advisory Panels.
Conclusions: Ensuring primary, secondary and tertiary services are equipped to support people with severe mental illness in their roles as parents is an essential ingredient for building recovery-oriented systems. This is further facilitated by training general practitioners and secondary care professionals in ROPs.
Presenter 3
The Engagement and Psychosocial Recovery Nexus: Testing an Experience-Based Co-Design Methodology in Community Mental Health Services
V Palmer
The University of Melbourne, Melbourne, Australia
Background: Consumer and carer engagement in service re-design, planning and evaluation is essential to building recovery-oriented mental health systems. There is a limited evidence on the models to engage consumers and carers in system re-design, how to embed these models and if engagement improves psychosocial recovery outcomes.
Objectives: The CORE study aims to test if an experience-based co-design method (MH ECO) improves psychosocial recovery outcomes for consumers living with severe mental illnesses.
Methods: A stepped-wedge cluster randomized controlled design is being used to deliver MH ECO –methodology developed by the Victorian Mental Illness Awareness Council and Tandem representing Victorian Mental Health carers – to Mental Health Community Support Service teams in Victoria. MH ECO involves finding out about good and bad service experiences and the areas for change, followed by implementation of a structured and facilitated process to co-develop action plans.
Findings: A stepped-wedge design requires an intensive engagement strategy to reduce participant drop out and burn out. Consumers and carers are comfortable with the telephone as a mode for collection of their experience stories, but this mode needs attention to methods to facilitate depth of experience data. Findings to date indicate benefits for consumers and carers in terms of empowerment and develop shared understanding between staff, consumers and carers.
Conclusions: Implementation of co-design as a service improvement method into everyday busy services requires system support to embed processes and structures at all levels of organizations. The focus on ‘experience’ in co-design should not be lost in the current wave of interest in this method.
Manifestations and Treatments of Anxiety in Japan and Australia
M Hopwood1, T Kishimoto2, V Brakoulias3, S Rehn4, Y Oyanagi5, T Tanaka5
1The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
2Department of Psychiatry, Nara Medical University, Japan
3University of Sydney, Sydney Medical School Nepean, Sydney, Australia
4University of Sydney, School of Psychology, Sydney, Australia
5Kushiro City General Hospital, Kushiro, Japan
Presenter 1
Post-Traumatic Stress Disorder: The Social, Political and Compensatory Context
M Hopwood
The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
Background: Post-traumatic stress disorder (PTSD) has a relatively high prevalence in Australia (6.4%). It is a disabling condition and is frequently associated with a range of comorbidities.
Although historically PTSD has been associated with veterans, it can follow a wide range of trauma. PTSD is unique in its classification in the DSM and other diagnostic systems in that the disorder is linked to aetiology. This has led to vigorous debate about the role of compensation systems in the frequency of diagnosis and in complicating its treatment.
Objectives: To consider how to move forward in enabling the diagnosis and treatment of this condition to occur effectively despite the complexities within which it is discussed.
Methods: This presentation will examine current trends nationally and internationally in the evolution of the diagnosis in the social, legal and government arenas.
Presenter 2
Personality Structure Change and Present Status of Psychotherapy in Japan
T Kishimoto
Department of Psychiatry, Nara Medical University, Japan
Background: Since World War II, Japanese society has been changing rapidly and paternalism-centered family system has disappeared. Rapid change of family structure has lead to change of Japanese personality structure.
Objectives: The author will describe the trend and change of personality structure and anxiety disorder from 1945 to present. The author then will discuss the significance of Morita therapy as psychotherapy for anxiety disorder in this new trend.
Methods: Chronological change events of Japanese society and its relevance on comorbidity of personality disorder, autistic spectrum disorder and new type of depression with anxiety disorder will be reported. And the author will present his insight on the significance of Morita therapy for anxiety disorder in this trend.
Findings: Psychotherapy in Japan has changed substantially and cognitive behavioral therapy is used more frequently. However, the significance of Morita therapy, very traditional Japanese psychotherapy, remains.
Conclusions: Morita therapy utilizes cognitive aspects like cognitive behavioral therapy. However, it also works on psychodynamic aspects in personality structure and supports for patients to evolve their personality.
Presenter 3
The Role of Transcranial Magnetic Stimulation for the Treatment of Obsessive–Compulsive Disorder – Results of a Meta-Analysis
V Brakoulias1, S Rehn1,2
1University of Sydney, Sydney Medical School Nepean, Sydney, Australia
2University of Sydney, School of Psychology, Sydney, Australia
Background: Obsessive–compulsive disorder (OCD) is one of the most distressing and disabling of psychiatric disorders, and new treatments are required to improve current treatment response rates. There have been several randomized controlled trials attempting to determine whether repetitive transcranial stimulation (rTMS) can help treat OCD. Some have reported that rTMS is effective, whereas others have not.
Objectives: To present and discuss a meta-analysis of randomized controlled trials to date with regards to the treatment of OCD with rTMS with a specific aim of attempting to determine the factors that may be associated with a positive treatment response.
Methods: After a systematic literature review, results of treatment trials using rTMS for OCD were subjected to meta-analysis. In order to determine specific factors that may have influenced success rates, studies were analysed according to high- or low-frequency rTMS, anatomical sites of stimulation and length of follow-up.
Findings: There have been 18 randomized controlled trials attempting to determine whether repetitive transcranial stimulation (rTMS) can help treat OCD. Overall, they showed a modest effect in reducing Y-BOCS scores with an odd ratio of treatment response of 0.23 (95% CI = 0.12–0.43, p < 0.001). Low-frequency (<1 Hz) rTMS appeared more effective than high-frequency (>5 Hz) rTMS. Stimulation of the supplementary motor area appeared more effective than stimulation over the dorsolateral prefrontal cortex. Results were better at 3-month follow-up than at 4-week follow-up. There was no publication bias.
Conclusions: The study of rTMS as an adjunctive treatment for OCD requires further investigation with this meta-analysis indicating that the low frequency rTMS and stimulation of the supplementary motor area might be more effective. The study also indicates that follow-up for 3 months after treatment would be beneficial in determining the full effect of the treatment.
Presenter 4
The Effect of Internet Use on Patients with Social Anxiety Disorder
Y Oyanagi, T Tanaka
Kushiro City General Hospital, Kushiro, Japan
Background: The spread of Internet has changed our lives and communication styles. Now, we do not necessarily communicate face-to-face. In the change of social circumstances, patients with social anxiety disorder (SAD) may diminish their anxiety and fear through using internet and then keep quality of life (QOL). The symptoms and QOL of SAD patients may be also related to the differences of Internet environment in their residential areas. However, to our knowledge, there are few reports to investigate how Internet use influences on patients with SAD.
Objectives: We examined whether the psychiatric symptoms, daily life activities, and QOL of patients with SAD were associated with Internet use and environment.
Methods: We conducted a cross-sectional study of 30 outpatients with SAD over 18 years old. The patients were required to fill in self-administered questionnaires for rating symptoms. Pearson’s product–moment correlation coefficient and multivariate analysis were used.
Findings and conclusions: We hypothesized that spending time on Internet and social circumstances are related to the score of Liebowitz Social Anxiety Scale (LSAS) Self-Report Questionnaire for Japanese of patients with SAD. The data are under analysis. It is important to take social circumstances in account for treating patients with SAD. We will present the details at the symposium.
Integration of Research into Psychiatric Practice: A Guide for New Investigators and the Scholarly Project
S Clark1, S Kisely1,2, S Parker1,2,3,4, S Suetani4, D Siskind1,2,3,4
1The Royal Australian and New Zealand College of Psychiatrists Committee for Research, Melbourne, Australia
2Metro South Addiction and Mental Health Service, Brisbane, Australia
3University of Queensland School of Medicine, Brisbane, Australia
4Queensland Centre for Mental Health Research, Brisbane, Australia
Background: Evidence-based mental health is the paradigm for the modern professional practice of psychiatry. With this, there is an increasing role for the clinician scientist in psychiatry. The skills required to undertake research can be acquired at any stage in a career, from trainee to senior fellow. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) Competency-Based Fellowship Program (CBFP) includes 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.
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 particularly useful for registrars planning their approach to the scholarly project. The symposium will provide information about how to survive in research, including addressing the following issues of how to
embed research into clinical practice;
undertake a systematic review and meta-analysis;
conduct qualitative research;
undertake research as a registrar;
disseminate the research findings.
Methods: A series of individual presentations will be followed by group discussion with the presenting panel.
Findings: Extensive information and experience will be identified to registrars and other new investigators in designing, implementing and following a research project through to completion.
Conclusions: Research can be a highly rewarding activity; the provision of information can demystify the process and create a clear pathway to success.
Presenter 1
Embedding Research into Clinical Service
S Clark
University of Adelaide, Discipline of Psychiatry, Adelaide, Australia
Background: Developing a valid research project in the context of a current high-workload, public mental health service is challenging. Key research questions can be found in the gaps in evidence that clinicians encounter in day-to-day practice. Important data are hidden in individual case presentations, case series and in aggregated service data. Existing data can be augmented, where ethical and practical, by simple targeted questionnaires, assessments and investigations. Complex studies can be implemented in clinical service with specialist academic support.
Objectives: To describe the process of developing a successful service research project.
Methods: Practical examples will be used to illustrate the process of refining a service research question; identifying sources of valid clinical data; developing tools for the collection of additional data; and obtaining ethical clearance, data access and support for data analysis.
Findings: Service research can be valuable at both a local and international level. Projects need to be well designed and targeted to fill gaps in existing evidence.
Conclusions: Busy clinicians should identify an area of interest and seek local clinical and academic support to implement achievable studies.
Presenter 2
An Introduction to Conducting Systematic Reviews and Meta-Analyses
S Kisely1,2
1The Royal Australian and New Zealand College of Psychiatrists Committee for Research, Melbourne, Australia
2Metro South Addiction and Mental Health Service, Brisbane, Australia
Background: Systematic reviews are one of the major building blocks of evidence-based medicine.
Objectives: An introduction to conducting systematic reviews and meta-analyses.
Methods: Individual presentation and facilitated group discussion.
Findings: Systematic reviews and meta-analyses of randomized controlled trials (RCTs) represent the most robust form of design in the hierarchy of research evidence. In addition, primary data do not have to be collected by the researcher themselves, and there is no need for approval from an ethics committee.
Conclusions: Systematic reviews and meta-analyses are not as daunting as they may appear, provided the scope is sufficiently narrow and an appropriate supervisor available.
Presenter 3
How to Do Qualitative Research?
S Parker1,2,3
1The Royal Australian and New Zealand College of Psychiatrists Committee for Research, Melbourne, Australia
2Metro South Addiction and Mental Health Service, Brisbane, Australia
3University of Queensland School of Medicine, Brisbane, Australia
Background: The complexity of many mental health interventions and services supports the relevance of qualitative methods. However, qualitative research is often not well understood by clinicians and researchers who are more familiar with quantitative approaches. Doing qualitative research well has the potential to enhance our understanding of mental health services, improve the implementation of evidence-based practice, and guide future research and practice developments.
Objectives: This talk will outline the value of qualitative research, with reference to complex health interventions. Practical guidance will be provided to help novice clinical researchers work towards realizing a ‘quality’ qualitative research project.
Methods: A narrative synthesis of the literature will be presented highlighting the role and value of qualitative research, types of qualitative research, and the concept of ‘quality’ in qualitative research. The presenter’s experience of leading qualitative research both as a trainee and a junior consultant will be used to illustrate pitfalls for the novice researcher.
Findings: The importance of planning, preparation, and supervision cannot be understated.
Conclusions: Undertaking qualitative research can be a rich and rewarding experience. However, doing this well takes preparation, time, cognitive flexibility and tolerance of uncertainty.
Presenter 4
Translating Clinical Curiosity into a Publishable Paper: Or How Could a Registrar Do ‘Research’ on a Shoestring Budget with Very Little Time?
S Suetani
Queensland Centre for Mental Health Research, Brisbane, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists Competency-Based Fellowship Program (CBFP) includes a scholarly project as a mandatory training requirement. However, this training requirement often needs to be met in the context of having little time and/or money as a trainee.
Objectives: To share ideas and experiences that may be useful in guiding registrars through the research requirement of training and beyond.
Methods: In this presentation, a final year registrar who has completed all of their training in CBFT will explore different and sometimes creative ways in which ‘research’ can be incorporated into psychiatry training. This is done through both personal experiences and shared experiences with registrar/junior consultant colleagues.
Findings: There are many ways in which clinical curiosity can be transformed into research output.
Conclusions: By having a better understanding of possible options in incorporating research into every-day clinical practice, registrars will be able to better plan and prepare for the mandatory research requirement in CBFP, as well as for ongoing professional development as consultants.
Presenter 5
How to Disseminate your Research Findings?
D Siskind1,2,3
1The Royal Australian and New Zealand College of Psychiatrists Committee for Research, Melbourne, Australia
2Metro South Addiction and Mental Health Service, Brisbane, Australia
3University of Queensland School of Medicine, Brisbane, Australia
Background: Sharing research findings through oral presentations, workshops or publication in a peer-reviewed academic journal can be daunting. This is especially so when one lacks familiarity with what is required.
Objectives: This presentation will provide information about the peer-review process, including how to select a journal and how to handle rejection. It will also consider other methods of dissemination such as hospital grand rounds and conferences. 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 conference abstract or 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.
RANZCP Section of Early Career Psychiatrists 2017 Congress
Background: This symposium is a presentation of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Early Career Psychiatrists (ECP) Special Interest Group Committee.
In accordance with the terms of reference for the section, the ECP section is very supportive of providing opportunities for early career fellows, and the introduction of such a symposium is one key way in which the group is supporting its members.
Objectives: The aim of this symposium is to allow ECPs an opportunity to present their work, experience and research within a dedicated symposium during Congress 2017 and to promote and encourage research among fellows in their early years of fellowship.
Presenter 1
RANZCP Early Career Psychiatrist Award Recipient Research Presentation
This presentation will be delivered by the recipient of the Early Career Psychiatrist Award. The recipient of this award will be determined in early 2017.
The presentation aims to increase the profile of the RANZCP Early Career Psychiatrist Award by providing the recipient an opportunity to present their research during a dedicated Early Career Psychiatrist Symposium at Congress.
Presenter 2
Panel Discussion: What Advice Would you have Given Yourself as an Early Career Psychiatrist?
Background: This presentation will feature lighthearted, funny and informative discussion by eminent, senior fellows with the aim of imparting to early career psychiatrists some important lessons learnt throughout their careers in psychiatry.
Presenters will be drawn from eminent fellows who are attending Congress.
The Influence of Digital Media on Clinical Issues in Mental Health
P Dullur1,2, M Sharma3, V Starcevic4, CS Yong1
1Southwest Sydney Local Health District, Sydney, Australia
2Western Sydney University, Sydney, Australia
3National Institute of Mental Health and Neurosciences, Bangalore, India
4University of Sydney, Sydney Medical School Nepean, Sydney, Australia
Background: Digital technology (e.g. Internet use, gaming) has changed the way the world functions. While research has focussed on diagnostic issues (e.g. Internet Gaming Disorder, IGD, has been included in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition as a condition for further study), extensive research is not available on the influence of digital technology on the clinical manifestation of mental illness and its management.
Objectives: To present case material on this topic.
Methods: Case materials from an international perspective will be presented. A limited literature review will be done and a clinical synthesis presented.
Findings: The influence of digital technology is explored across multiple domains (e.g. safety, addiction, anxiety, depression and psychosis), and new concepts such as cyberchondria are investigated. The IGD framework may not necessarily be the best framework to understand the influence of gaming on psychopathology. Wider issues are discussed. The Indian and Australian experience is shared. The application of the concept of Hikikomori and cyberchondria to the Australian population is explored.
Conclusions: Internet gaming considerably influences clinical presentations. This influence needs to be understood in wider contexts, such as meaning and flow, and across multiple systems, such as family, schooling and cultures. The influence of digital technology on health information is explored via the concept of cyberchondria.
Presenter 1
Digital Media and Adolescent Pathology: How Does the Online World Influence Pathology? A Case Discussion
P Dullur1,2
1Southwest Sydney Local Health District, Sydney, Australia
2Western Sydney University, Sydney, Australia
Background: Although Internet gaming disorder (IGD) has been included in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition as a condition for further study, the influence of digital media on psychopathology needs further exploration.
Objectives: To present a series of patients in whom digital media has influenced the presentation and management of psychiatric illnesses.
Methods: Limited literature review and case presentations.
Findings: Case 1 discusses influence of digital media on cyber safety and parenting. Case 2 describes how exploring a gaming history can be used to understand social anxiety and depression in an adolescent. Case 3 discusses the role of context and cognitive distortion in gaming in relation to psychopathology. Case 4 discusses medication issues in IGD in the context of related pathology.
Conclusions: The IGD framework is one aspect where gaming and digital media influences psychopathology. Wider issues including meaning and flow, context, cognitions and functioning are important when discussing electronic media and pathology. The influence of digital media on health information will be discussed.
Presenter 2
Internet Gaming: The Indian Experience
M Sharma
National Institute of Mental Health and Neurosciences, Bangalore, India
Background: Recent years have seen an increase in the use of various forms of gaming, which are associated with dysfunctions in the psychosocial area. Gaming is more frequently being used as a coping method to enhance anger control, to manage psychological problems as well as to have a feeling of well-being.
Objectives: To understand the underlying psychological reasons for manifestation of excessive use of the Internet
Methods: Case studies published from the Service for Healthy Use of technology (SHUT) clinic as well as through a review of the literature. SHUT is India’s first clinic to manage technology addiction.
Findings: The methodology revealed the presence of underlying psychological distress and excessive use of the Internet and gaming are occurring as a method to have the feeling of well-being. Users use it as a method to feel good, to overcome anxiety/sadness of mood/to feel relaxed, and to manage obsessions as well as hallucinations.
Conclusions: The case studies indicate the need to understand the psychological aspects of Internet gaming disorder.
Presenter 3
Cyberchondria: Relying on Dr Google Causes Problems Instead of Providing Desired Answers
V Starcevic
University of Sydney, Sydney Medical School Nepean, Sydney, Australia
Background: Increasing numbers of people turn to the Internet for health-related information. While this tendency has had many positive effects, its negative effects are not well understood.
Objectives: To review the present state of knowledge about the harmful searches for health-related information online.
Methods: Literature review and conceptual synthesis.
Findings: Cyberchondria is usually defined as excessive or repeated online health-related searches, driven by a need to alleviate distress or anxiety about health. It may also denote excessive or unhelpful online health-related searches that cause or worsen health anxiety. Cyberchondria is made possible by accessibility and affordability of health-related information online, but the anonymity when making online searches and facilitation of communication with like-minded individuals may also play an important role. Factors that maintain cyberchondria include erroneous beliefs that higher-ranking search results imply a higher likelihood of a particular illness, difficulty managing the abundance of online information, intolerance of uncertainty caused by ambiguous or conflicting information, expectation that the Internet is the best medium to provide ‘perfect’ explanations and difficulty distinguishing between credible and non-credible sources of health-related online information. Prevention of cyberchondria entails improving online health information literacy, construction of online evidence-based diagnostic algorithms and provision of health-related information on the Internet in a way that increases clarity and minimizes discrepancies.
Conclusions: Digital technology poses a challenge to vulnerable individuals, usually those with high levels of health anxiety or proneness to it, in terms of managing an abundance of accessible health-related information and the frequently accompanying uncertainty and confusion.
Presenter 4
Social Withdrawal and Isolation in Australian Youth – A Local Variant of Hikikomori?
CS Yong
Southwest Sydney Local Health District, Sydney, Australia
Background: Increasing numbers of young people are presenting to child and adolescent mental health services (CAMHS) with histories of increasing social isolation and withdrawal, reminiscent of the Japanese phenomenon of Hikikomori, a controversial culture-bound syndrome of prolonged and severe social withdrawal noted in the sociological and psychological literature of the past 16 years. As Internet usage has increased, there is some evidence of an online social community replacing the real-world community of Hikikomori sufferers. A few case studies are presented that suggest the phenomenon may have parallels in Australia.
Objectives: To explore the phenomenon of Hikikomori and the surrounding controversy and compare this with Australian case examples.
Methods: Case report and literature review.
Findings: The history and cultural context of the Hikikomori concept are examined. There are examples of nascent online communities of youth identifying with the concept, that extend beyond Japan, but whether these youth are the same as the prototypical Japanese youth is controversial. The Australian cases are from child and adolescent mental health services in both urban and rural settings. Common factors seem to be histories of intense interest in online gaming, autism spectrum disorder features, mood or anxiety disorders and an element of family dysfunction and social isolation.
Conclusions: The Hikikomori concept may prove useful in understanding both the origins of depressed and isolated youth in a local setting and in understanding how the Internet may be both facilitating such a response to mood problems as well as a potential means for such youth to access support and treatment.
Community Treatment Orders are Largely Ineffective and their Use Should be Scaled Back Dramatically
N O’Connor1,2, C Ryan2,3,4, A Keller5,6, G Newton-Howes7,8, M Nance9,10, L Brophy11,12
1Northern Sydney Local Health District, Sydney, Australia
2Department of Psychiatry, University of Sydney, Sydney, Australia
3Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, Australia
4Westmead Hospital, Sydney, Australia
5Forensic and Long Bay Hospitals, Justice Health and Forensic Mental Health Network, Sydney, Australia
6School of Psychiatry, University of New South Wales, Sydney, Australia
7University of Otago, Wellington, New Zealand
8Te-Upoko-me-te-Whatu-o-Te-lka, Wellington, New Zealand
9Flinders Medical Centre, Adelaide, Australia
10Department of Psychiatry, Flinders University, Adelaide, Australia
11The Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne and Director of Research, Melbourne, Australia
12Mind Australia, Melbourne, Australia
Background: The benefits and disadvantages of community treatment orders (CTOs) is a contested area in community psychiatry. There have been a small number of randomized controlled trials and a larger number of case-controlled, epidemiological and qualitative studies that show conflicting findings and complexities in relation to evaluating the effectiveness of CTOs.
Objectives: To examine the evidential and ethical basis for the use of CTOs.
Methods: The evidence for and against the efficacy of CTOs will be examined in a debate of the proposition: ‘Community Treatment Orders are largely ineffective and their use should be dramatically scaled back’.
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 if 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 CTOs as an important and frequently used component of mental health service delivery are presented and discussed. The debate content will be subsequently submitted for publication in Australasian Psychiatry.
Presenter 1
Community Treatment Orders are Largely Ineffective and their Use should be Dramatically Scaled Back – Yes
C Ryan1,2,3, G Newton-Howes4,5, L Brophy6,7
1Department of Psychiatry, University of Sydney, Sydney, Australia
2Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, Australia
3Westmead Hospital, Sydney, Australia
4University of Otago, Wellington, New Zealand
5Te-Upoko-me-te-Whatu-o-Te-lka, Wellington, New Zealand
6School of Psychiatry, University of New South Wales, Sydney, Australia
7University of Otago, Wellington, New Zealand
Methods: The evidence and arguments that community treatment orders (CTOs) are ineffective and should be abolished will be presented by the three speakers. The international literature evaluating the effectiveness of CTOs and the range of stakeholder perspectives and experiences 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.
Presenter 2
Community Treatment Orders are Largely Effective and their Use should be Dramatically Scaled Back – No
N O’Connor1,2, A Keller3,4, M Nance5,6
1Northern Sydney Local Health District, Sydney, Australia
2Department of Psychiatry, University of Sydney, Sydney, Australia
3Forensic and Long Bay Hospitals, Justice Health and Forensic Mental Health Network, Sydney, Australia
4School of Psychiatry, University of New South Wales, Sydney, Australia
5Flinders Medical Centre, Adelaide, Australia
6Department of Psychiatry, Flinders University, Adelaide, Australia
Methods: The evidence and arguments for the effectiveness and benefits of community treatment orders (CTOs) will be examined and tested by the three speakers. The alternatives to CTOs and the complexities of properly evaluating the effectiveness of CTOs will be explored. Both teams will have the opportunity to rebut the opposing team’s views and to take questions from the audience.
Walking the Tightrope or Crossing the Line? Psychiatric Perspectives from Inside and Outside Immigration Detention
J Jureidini1, P Young2, C Yong3,4, L Newman5
1Critical and Ethical Mental Health Research Group, Robinson Research Institute, University of Adelaide, Adelaide, Australia
2Private Practice, Sydney, Australia
3South Western Sydney Local Health District, Sydney, Australia
4Australian Medical Association, Canberra, Australia
5The University of Melbourne, Melbourne, Australia
Background: The harms to children, parents and adults arising from immigration detention have been acknowledged by federal government reports and officials as well as helping professionals and researchers.
Objectives: This symposium will examine the ethical dilemmas that psychiatrists confront while working with asylum seekers, and specifically as government and ex-government employees. This symposium will explore the degree of consensus among psychiatrists about the harms that arise and by-products of government immigration detention policy, about how these policies affect clinical practice and psychiatrists’ lives, and about the imperative and scope for collective action.
Methods: A series of short papers followed by a panel discussion will consider the challenges of working as a psychiatrist with asylum seekers, including work for the federal government under the current legal and policy regime.
Four brief (10 to 12-min) papers will be presented:
Can a consequentialist argument justify Australia’s immigration policy?
Walking the tightrope: The challenges of being a whistle-blower.
Resistance or retreat? The outlook and actions of the health colleges, with the Australian Medical Association as a case example.
Walking through minefields – trying to do good in a bad system.
Following these presentations, a 40-min panel discussion will occur. In the light of uniform evidence about serious harms to asylum seekers and involved workers, the Australian Border Force Act (2015) (Compilation No. 2, 16 June 2016), and the positions of professional bodies, including the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Professional Practice Guideline 12, the panel will consider the practice pressures on psychiatrists working with asylum seekers, and the scope for service withdrawal in situations where doctors and health professionals cannot practice ethically and safely, and their decisions are overruled by immigration, causing harm to asylum seekers.
Psychiatrist representatives of the Department of Immigration and Border Protection will be advised about and invited to this symposium and its parallel one, and as part of the discussion, invited to respond.
Findings: Australia’s asylum-seeker policies cause significant undeniable harms, undermine effective psychiatric practice among asylum seekers, and have provoked a significant degree of unanimity of opposition among psychiatric and other health professionals.
Conclusions: Given the undeniable harm caused, these harmful policies should be opposed. The scope of professional accommodation of, or resistance to, immigration work practices, and for collective action among psychiatrists inside and outside immigration detention against these policies, has yet to be tested.
Presenter 1
Can a Consequentialist Argument Justify Australia’s Immigration Policy?
J Jureidini
Critical and Ethical Mental Health Research Group, Robinson Research Institute, The University of Adelaide, Adelaide, Australia
Background: Australia has enacted a policy of using human suffering in immigration detention to deter potential asylum seekers. Independent of the contravention of international law, the policy has significant ethical shortcomings.
Objectives: To refute the consequentialist argument used to defend this policy.
Methods: Critical analysis of the justification of one cruelty to prevent another adverse outcome. The analysis will be applied to known and foreseen harms of immigration detention both as by-products and deliberate aims of government policy.
Conclusions: Australia’s current policy is ethically unsustainable and damaging to individuals and society.
Presenter 2
Walking the Tightrope: The Challenges of Being a Whistle-Blower
P Young
Private Practice, Sydney, Australia
Background: Experience over 3 years of developing mental health systems and services within immigration detention. Observation of causes and effects of policy changes over time. Difficulties of maintaining an ethical stance and lines of compromise. Motivations and experience of whistle-blowing.
Objectives: Provide an insider perspective of the issues and challenges of working within the immigration detention system.
Methods: Report a personal perspective including direct observations of the effects of immigration detention on asylum seekers, organizational responses and interaction with policy changes over time.
Conclusions: The current restrictions on the exercise of clinical autonomy, lack of independent oversight and restrictions on the application of key aspects of medical practice including public health and patient advocacy create a situation in which medical practitioners are not able to practice within accepted ethical standards and guidelines. This creates a situation where compliance with these restrictions is equivalent to enablement of abuse. The moral imperative for health practitioners is not to agree to work under such conditions but to speak out against them.
Presenter 3
Resistance or Retreat? The Outlook and Actions of the Health Colleges, with the AMA as a Case Example
CS Yong1,2,3
1South Western Sydney Local Health District, Sydney, Australia
2Australian Medical Association, Canberra, Australia
3Detention Health Advisory Group [disbanded], Department of Immigration and Citizenship, Canberra, Australia
Background: The medical profession has held diverse views on the politics and the ethics of Australia’s asylum-seeker policies since its introduction in the 1990s. In subsequent years, medical professional organizations such as the Australian Medical Association (AMA) have debated the ethics, professional issues and public health implications of the changing policies and impacts on asylum-seeking people arriving in Australian waters.
Objectives: To give the background and context of the AMA’s response to the Australian Government asylum-seeker policy landscape.
Methods: Discussion of the policy process and ethical debate in the AMA context.
Findings: Ultimately, the AMA has consistently highlighted the harms and impacts of the Australian Government’s policies on asylum seekers. The approaches the AMA has adopted to publicize and promulgate its views among its members and the public have varied with the changes in leadership of the AMA. There are some inherent conflicts in a membership organization promulgating a particular view on a public policy as divisive and controversial as asylum-seeker policy in Australia.
Conclusions: The AMA is no stranger to taking principled stands on controversial public policies. The changing leadership and membership democracy of an organization like the AMA mirrors the parliamentary process in some ways but differs in other crucial aspects. The core ethics of the medical profession prevail in most AMA debates and have informed its stance on asylum-seeker health.
Presenter 4
Walking Through Minefields – Trying to Do Good in a Bad System
L Newman
The University of Melbourne, Melbourne, Australia
Background: There is ongoing debate about the ethical issues involved in the provision of services in the current system of detention health. Clinicians face complex issues when they are not able to practice according to usual standards and where a system directly impacts clinical decision-making. Further, treatment is undermined by the nature of detention and the situation of prolonged lack of certainty about status. This directly contributes to mental disorder seen in detention centres.
Diagnosis and treatment is impacted by a system where human rights are violated and detainees face harsh treatment. Protest and anger are understandable in this context but are sometimes seen as a form of mental illness, which constitutes a misuse of psychiatric diagnosis. There are historical examples in other regimes where political dissent is pathologized and psychiatry colludes with oppressive systems.
Objective: To summarize the current debate about ethical engagement with the immigration detention system and to outline the complex challenges of engaging in a system where there is pressure for clinicians to work for the system as opposed to the patient.
Method: Critical review of current views around ethical dilemmas and examination of the issues of withdrawal of services.
Conclusions: The current system of immigration detention is fundamentally damaging and violates basic rights of asylum seekers and refugees. Clinicians are compromised by association with these practices even if personally well motivated, although some fail to recognize their own complicity in a damaging system. To remain silent in the face of abuse of vulnerable groups is not acceptable and not in keeping with conventions of ethical medical practice.
Neuroimaging and Biomarkers in Younger Onset Neurocognitive Disorders: What the General Psychiatrist Needs to know
D Velakoulis1, M Walterfang1,2, S Loi1,2, R Mocellin1,2
1Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, Australia
2The University of Melbourne, Melbourne, Australia
Background: A knowledge and understanding of neuroimaging and investigational biomarkers (e.g. autoantibodies, cerebrospinal fluid (CSF)) are essential tools of the modern-day neuropsychiatrist. Most patients seen within a tertiary referral neuropsychiatry service have been referred by general psychiatrists who may lack the necessary experience to interpret imaging and other findings.
Objectives: To highlight the role of neuroimaging and other biomarkers (autoimmune markers, CSF) in younger onset neurocognitive disorders.
Methods: We will present a broad range of clinical cases (neurodegenerative, metabolic, infective, autoimmune) and highlight the current role of imaging and biomarkers in these disorders. 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: Many younger onset neurocognitive disorders will present to general adult psychiatrists and a working knowledge of currently available investigations is important within psychiatric settings.
Faculty of Child and Adolescent Psychiatry Mental Health Initiatives in the Asia-Pacific Region
N Kowalenko1, B Hoadley2, J Obed3,4
1The Royal Australian and New Zealand College of Psychiatrists, Emerging Minds, Melbourne, Australia
2Advanced Trainee in Child Psychiatry, Sydney, Australia
3Ministry of Health, Port Vila, Vanuatu
4Medical Options, Luganville, Vanuatu
Background: Child and adolescent mental health needs in the Asia-Pacific are greatly underserved and remain a low priority across the region. For children, young people and their families, mental health care is very limited despite young people making up half the population.
Objectives: This symposium will describe
the approach taken to Child and Adolescent Mental Health (CAMH) development and training in the Asia-Pacific region with a particular focus on the Pacific and the partnerships formed;
the experience of training, workforce development and mentoring in Papua New Guinea, Fiji and Vanuatu from the perspective of a trainee, a Pacific psychiatry leader and a Royal Australian and New Zealand College of Psychiatrists (RANZCP) fellow;
human rights, child protection and cross-cultural issues.
Methods: There have been various approaches to improving local capacity in mental health services in the Pacific and some examples will be discussed. Paper 1 will provide an overview of the Faculty’s initiatives to date. Paper 2 describes the trainees’ experience of responding to and providing CAMH in cross-cultural settings and promoting psychiatry. Paper 3 will describe the pilot clinical support and mentoring project in Vanuatu from a local psychiatry leader’s perspective.
Findings: Limited resources demand creative responses. How the goodwill of Australian and New Zealand psychiatrists can best be harnessed, managed, expanded and sustained can now be informed by regional experience and by feedback from our regional initiatives to shape the next steps.
Conclusions: Building mental health and psychiatric capacity in Pacific Island nations is challenging, and the RANZCP can respond effectively to growing interest regionally in a number of ways. Strategies, priority setting in partnership and resource commitment are now required to build on achievements to date.
Presenter 1
Faculty of Child and Adolescent Psychiatry Working with our Regional Neighbours in the Pacific: What can we Offer?
N Kowalenko1, B Hoadley2
1The Royal Australian and New Zealand College of Psychiatrists, Emerging Minds, Melbourne, Australia
2Advanced Trainee in Child Psychiatry, Sydney, Australia
Background: Pasifika study groups have established partnerships in our region. The Faculty of Child and Adolescent Psychiatry (FCAP) has built on this to identify locally identified priorities since FCAP met together with the Pasifika Medical Association and Vanuatu Medical and Dental Association in Vanuatu in 2015. The influence of FCAP in the region has grown quickly with initiatives in Vanuatu, Sri Lanka, Fiji and Papua New Guinea with more to follow.
Promoting Child and Adolescent Mental Health (CAMH) training, workforce development and clinical support in low and middle-income countries presents many challenges.
Objectives: To provide participants with
an overview of FCAP’s initiatives in the Pacific region;
an outline for planning to address workforce needs;
potential strategic directions for the Royal Australian and New Zealand College of Psychiatrists.
Methods: A range of initiatives have been undertaken by incorporating local leadership, with local priority setting and planning and this will be described.
Findings: Regional training and mentoring varies according to local priorities. Australia’s regional commitments are changing and a focus on regional clinical training and support highlights this. Conclusions: Our region has serious challenges in building capacity to deliver appropriate psychiatric care and quality practice. Practical steps are available to begin to address this. Sustaining quality practice in our region depends on establishing and maintaining a sound human rights framework and prioritizing mental healthcare. This presents challenges not only in our own countries but also in our regional neighbourhood.
Presenter 2
Training to Teach and Teaching to Train: Experiences of Child and Adolescent Psychiatry Trainee in the Provision of CAMH Education in PNG and FIJI
B Hoadley1, N Kowalenko2
1Advanced Trainee in Child Psychiatry, Sydney, Australia
2The Royal Australian and New Zealand College of Psychiatrists, Emerging Minds, Melbourne, Australia
Objectives: This paper aims to describe a trainees’ experience in providing training for a multidisciplinary mental health workforce in Papua New Guinea (PNG) and Fiji.
Method: The Child and Adolescent Psychiatry (CAP) training provides opportunity for trainees in their final year to embark on a special interest project (SIP). The authors undertook to deliver the International Association for Child and Adolescent Psychiatry and Allied Professionals (IACAPAP) Child and Adolescent Mental Health (CAMH) ‘iCAMH’ education package to clinicians in PNG as part of this SIP.
The authors will describe the setting, the clinicians involved and the provision of education. Reflections on the dual role experienced by trainees who teach (i.e. as trainer but also as a student in supervised practice) will also be provided. Feedback from PNG and Fijian clinicians will be reviewed.
Findings:
Teaching provides a learning opportunity unlike that of the usual clinical roles.
This experience indicates that it is reasonable to expect that, with supervision, Royal Australian and New Zealand College of Psychiatrists trainees can provide education for workforce development to clinicians in the Pacific.
The dramatically different cultural aspect and resource limitations of PNG and Fiji have impacts for the translation of IACAPAP and Australasian content and styles of teaching/learning.
Conclusions: Developing roles for trainees as teachers could be advantageous both for the trainees and for populations in need; and developing appropriate support, resources, teaching/training and ongoing workforce development specific to the Pacific context, culture and resources are likely to be important.
Presenter 3
Vanuatu. Psychiatry Mentorship Program
J Obed1,2
1Ministry of Health, Port Vila, Vanuatu
2Medical Options, Luganville, Vanuatu
Background: The Vanuatu Psychiatry Mentorship Program (VPMP) was initiated in 2016 to offer mentorship and clinical support from the Faculty of Child and Adolescent Psychiatry. The VPMP is piloted by the ‘core team’ from the MindCare clinic at the Vila Central Hospital and involves three overseas psychiatry consultants.
Objectives: The VPMP aims to provide clinical support and mentoring to mental health workers in Vanuatu and wider Pacific regions.
Methods: The VPMP includes monthly teleconferences and visits from the mentors once per year. Didactic teaching and difficult cases are discussed during these online teleconferences. Consultants are also available via text messaging in emergency situations. During their visits, the consultants teach and interact with the team members on a one-to-one basis. Each mentee keeps a logbook clerking cases seen and discussed and application of knowledge acquired from this program in various activities such as community awareness and projects.
Findings: The VPMP has been greatly beneficial to the core team in terms of management of difficult cases. Despite the difficulties in communication technology, consultant support was always readily available to the team. This program has given confidence to the team in managing cases.
Conclusions: There are challenges in delivering appropriate psychiatric care and quality practice in Pacific regions and how the mentoring program can assist with this development.
Storytelling and the Psychiatrist
D Backman-Hoyle1,2, M O’Hagan2, S Lawn1
1The Royal Australian and New Zealand College of Psychiatrists Community Collaboration Committee, Melbourne, Australia
2Peerzone, Wellington, New Zealand
Background: The Community Collaboration Committee (CCC) is the main way the Royal Australian and New Zealand College of Psychiatrists (RANZCP) partners with people with lived experience of mental illness (consumers) and carers.
The CCC is made up of six RANZCP fellows (psychiatrists) and eight community members: two carers and two consumers from Australia, and two carers and two consumers from New Zealand. The CCC meets regularly throughout the year. The purpose of the CCC is to ensure that the RANZCP considers the needs, values and views of the community. This symposium addresses a key issue for the community: the ability to safely tell their story to a psychiatrist.
Objectives: To highlight barriers to psychiatrists hearing consumers’ stories, describe successful strategies that promote effective communication by consumers and carers, and promote discussion regarding how such strategies may be utilized more widely.
Methods: Presentation of three different models that promote communication of consumers’ stories in the context of the obstacles to communication that they overcome and the benefits that the community experiences from the use of the models.
Findings: Despite their expertise, psychiatrists face significant obstacles to establishing relationships with consumers in which the consumer feels safe in communicating sometimes crucial information; and the ‘right’ communication occurs with carers. The initiatives described in this symposium offer assistance in this difficult area.
Conclusions: A persons’ story is at the heart of recovery-oriented psychiatric practice. This symposium aims to highlight new initiatives that support hearing this story and better outcomes for people with experience of mental illness.
Presenter 1
Safe Storytelling
D Backman Hoyle
The Royal Australian and New Zealand College of Psychiatrists Community Collaboration Committee, Melbourne, Australia
Background: The insights and wisdom shared through stories via the voices of the lived experience are invaluable to understanding the thoughts and decisions behind the actions contemplated or experienced by those with the lived experience of suicide.
Definition of lived experience: ‘having experienced suicidal thoughts, survived a suicide attempt, cared for someone who has been suicidal, or been bereaved by suicide’.
Storytelling in a supported and nurturing environment enables people to value and then express personal experiences and lessons learnt and identify components of their story that are relevant to others wanting to reduce future deaths by suicide.
Objectives: To describe the Roses in the Ocean (RITO) Speakers Bureau, explain the storytelling program objectives and methodology, and demonstrate beneficial program results.
Methods: Presentation of RITO impacts, including alignment to personal healing and recovery outcomes. To provoke discussion on how clinicians could consider storytelling programs as an adjunct to other treatment.
Findings: There are lived experience and peer-led environments where people can learn to share their key messages through personal storytelling safely and appropriately, and ultimately re-purpose such lived experience of suicide to inform and inspire others, and to promote contemplation and reflection through the sharing of such experiences.
Conclusions: A lived experience of suicide does not need to define the future of a person no matter how traumatic. Their story can find meaning in such an experience and share this meaning as insight and wisdom to others and encourage others to continue to share their stories with others.
Presenter 2
Peer Support: Storytelling in the Context of Equality and Mutuality
M O’Hagan
Peerzone, Wellington, New Zealand
Background: Storytelling is central to the therapeutic relationship between people who use mental health services and those who are paid to help them. Unlike in many other areas of health, the stories that people in mental health services tell are centred on a crisis of being rather than a crisis of body: they are intimate stories of profoundly disrupted identity and existence. The paradox is that people are called upon to share their stories in a context of an imbalance of power. This has an enormous impact on both how the stories are told and how they are heard. Peer support is a new occupation in mental health that creates a new context for storytelling – one where there is mutuality in storytelling in a more equal relationship. This expands the opportunities for storytelling to be a source of healing.
Objectives: To familiarize psychiatrists with peer support history, values and evidence; compare storytelling in peer support and in professional relationships; and discuss the optimum relationship and environments for safe and honest storytelling.
Methods: Presentation of an overview of peer support and of perspectives on storytelling in different relational contexts.
Findings: Context determines how stories are told and how they are heard.
Conclusions: Psychiatrists who understand the context they work in from the point of view of people who use services are in a better position to develop trust and minimize power imbalances, so that stories can be freely told and humanely heard.
Presenter 3
Role of the Family
S Lawn
The Royal Australian and New Zealand College of Psychiatrists Community Collaboration Committee, Melbourne, Australia
Background: As families, we live our lives together, coming to have deeply privileged knowledge of each other in all its richness. We journey together with aspirations for our present and future lives together; we watch our children grow; we fall in love and make commitments to each other. Our lives together are rich and nuanced. When mental illness enters our lives, it is but one aspect of our knowledge of the people we know as our family member with a mental illness.
Objectives: To describe the ways that mental health carers strive for recognition of ‘the person’ despite mental illness and its impacts and explain the importance of the knowledge that family members can bring to mental healthcare that helps promote mental health recovery.
Methods: Recounting personal experiences and ways of living our lives with quality in mind so that we do not let mental illness dominate our family relationships.
Findings: Recovery work is present in the small everyday ways that we live our lives together. This offers important knowledge for mental health professionals to understand the person with mental illness in ways that are significant, yet largely ignored.
Conclusions: Collaborative inclusion of family carers in the care team is an opportunity to enhance recovery-based practice. It helps the psychiatrist to relate to and engage the person better; it enhances outcomes; and it helps minimize family carers’ sense of burden that can interfere with the family supports that are essential to recovery from mental illness.
The Effectiveness of Community Mental Health Training Programs Delivered Locally by the University of Melbourne In Shenzhen, China
H Liu1, I Everall2, H Rong1, C Ng2, D Jin1, T Liu1
1Shenzhen Mental Health Center Shenzhen Kangning Hospital, Shenzhen, China
2Department of Psychiatry, The University of Melbourne, Melbourne, Australia
Background: Since 2015, the Shenzhen Mental Health Center (SMHC) has collaborated with the Department of Psychiatry (DoP), The University of Melbourne, on the 5-year ‘Three Famous’ Program, which is sponsored by the Shenzhen Municipal Government to support the development of the city’s community mental health services development.
Objectives: To evaluate the localized training programs provided by the DoP and the working collaboration between the DoP and the SMHC.
Methods: Two approaches were employed: the work summary review – to review the work summaries from SMHC; and the focus group – eight main staff members from the SMHC and the DoP participated in the focus group to discuss the implementation of current programs and future directions.
Findings: Feedback evaluations conducted by the SMCH of staff involved in the training revealed that the training content and methods were very useful and practical for a range of clinical situations. As the learning outcomes could be translated into routine work, the program had met Shenzhen’s clinical mental health workforce needs.
Conclusions: Training programs delivered by the DoP assisted SMHC to deal with the emerging demands and challenges within the mental health system in Shenzhen. There was a positive impact on the clinicians who now embrace the principles of ‘recovery’ and enhance the community services that they provide to their patients. The collaboration between the SMHC and the DoP could result in significant progress of Shenzhen’s community mental health system in the ensuing years.
RANZCP Section of Private Practice Psychiatry 2017 Symposium
Background: Dr Michelle Atchison, Chair of the Royal Australian and New Zealand College of Psychiatrists Section of Private Practice Psychiatry, will provide an update on the work of the Section for 2016/2017.
This symposium of the SPP will focus on several issues relevant to psychiatrists in private practice including
The NDIS and Private Psychiatrists – What Do We Need to Know to Be Prepared? – Speaker TBA;
New Developments in the College’s Continuing Professional Development Requirements – How Can Private Psychiatrists Gain the New Mandatory Practice Improvement Hours? – Speaker TBA;
A Proposed Model for the Primary Healthcare Networks to Interface with Private Psychiatrists, Win-Win? – Dr Gary Galambos.
Faculty of Psychiatry of Old Age
J O’Brien1, H Brodaty2, S Macfarlane3
1Department of Psychiatry, University of Cambridge, Cambridge, UK
2Centre for Healthy Brain Ageing, University of New South Wales, Sydney, Australia
3The Dementia Centre, Hammond Care, Melbourne, Australia
The symposium will be hosted by the Faculty of Psychiatry of Old Age to provide an academic program focussed around the most current psychogeriatric research and practice. The symposium will focus on two primary domains, late-life depression and dementia care, with speakers invited because of their national and international standing as leaders in their field.
Presenter 1
Neuroinflammatory Changes in Late-Life Depression: The NIMROD Study
J O’Brien1, Li Su1, Y Faluyi1, T Fryer2, Y Hong2, G Williams2, R Arnold1, L Passamonti3, P Vázquez Rodríguez3, A Surendranathan1, RW Bevan-Jones1, F Aigbirhio2,3, JB Rowe3,4,5
1Department of Psychiatry, University of Cambridge, Cambridge, UK
2Wolfson Brain Imaging Centre, University of Cambridge, Cambridge, UK
3Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
4Medical Research Council, Cognition and Brain Sciences Unit, Cambridge, UK
5Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK
Background: Late-life depression is known to be associated with specific clinical features, such as cognitive impairments, to have a poor outcome and to be a risk factor for future dementia. Vascular factors have been implicated in aetiology, but neuroinflammation has not been well studied despite being a highly plausible mechanism and potentially tractable target. In our previous work, we have shown an increase in inflammatory cytokines in the blood in older depressed subjects. In the current study, we aimed to show whether we could demonstrate an increase in central (brain) inflammation in vivo using positron emission tomography (PET) imaging.
Methods: Within the Cambridge Neuroimaging of Inflammation in MemoRy and Other Disorders (NIMROD) study, we have recruited five older depressed subjects who had met the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for major depression and 13 controls. The subjects had full clinical and cognitive assessment and venipuncture for C-reactive protein (CRP) measurement. Brain imaging was performed with multimodal 3 T magnetic resonance imaging and, on a second visit, brain PET scanning following a bolus intravenous injection of [11C]PK-11195 (500 MBq) with 75 min of dynamic emission acquisition in three-dimensional mode. Using reference tissue modelling and kinetic analysis from the dynamic imaging, parametric region-of-interest atlas-based images of the binding potential were produced following partial volume correction for cerebrospinal fluid.
Results: Depressed (Dep) subjects and controls (Con) did not differ in age, sex ratio, education or global cognition (Mini-Mental State Examination score) but had significantly higher blood CRP levels than controls (mean, standard deviation (SD) Dep 6.4 (5.1); Con 1.0 (1.2); p < 0.05). Though largely recovered from their depression at time of imaging, depressed subjects had significantly raised PK-11195 binding compared to controls in several regions (e.g. anterior cingulate mean (SD) BP Dep 0.1183 (0.061); Con 0.0246 (0.067); p = 0.025).
Conclusions: We found evidence of both central and peripheral inflammation in older subjects with depression, with changes in areas including the anterior cingulate, known to play a key role in the regulation of mood. Neuroinflammation may be an important mechanism in late-life depression and merits further investigation as a potential target for novel therapeutics in a condition that responds poorly to conventional antidepressant therapy.
Presenter 2
An Update On Dementia Prevention and Treatment
H Brodaty
Centre for Healthy Brain Ageing, University of New South Wales, Sydney, Australia
The prevalence of dementia is projected to triple from more than 350,000 persons in Australia and 47 million worldwide to exceed 900,000 and 131 million, respectively, by 2050. Although there is no absolute prevention against Alzheimer’s disease specifically or dementia in general, postponement is more realistic through preventative strategies. This presentation will review the current state of research into prevention and treatment.
An estimated 30% of the population risk of Alzheimer’s disease can be attributed to potentially modifiable environmental and lifestyle factors including lack of education, smoking, physical inactivity/lack of exercise, depression, high blood pressure in mid-life, obesity in mid-life and diabetes (type 2). Other identified factors associated with higher rates of dementia are head injury, low birth weight for gestational age, social isolation, loss of hearing and smaller head circumference. Epidemiological studies report protective effects for physical exercise, education, complex mental activity in mid-life and a Mediterranean diet characterized by high intake of antioxidants and polyphenols such as vegetables and fruit juice, extra virgin olive oil and nuts.
Evidence for prevention effectiveness has been mixed. Randomized controlled trials with hormone replacement therapy, anti-inflammatory drugs, vitamin E and the herb Ginkgo biloba have been ineffective. Beneficial effects have been demonstrated for physical exercise, computer cognitive training, and adherence to Mediterranean diet, though not all trials are positive. There is stronger evidence that attention to vascular risk factors may prevent vascular dementia. There is no evidence for any preventative strategy for other neurodegenerative dementias such as Lewy body disease or frontotemporal dementia. Avoidance of heavy alcohol use and use of protective head gear and seat belts reduce the risk of dementia secondary to head injury. Internet-delivered lifestyle and cardiovascular risk reduction interventions are being evaluated in Europe and Australia. In the United States, studies are underway focussing on amyloid beta protein toxicity mainly using antibodies to prevent participants at risk of developing clinical Alzheimer’s from developing clinical Alzheimer’s disease. These trials will be crucial in determining whether the currently dominant amyloid beta treatment approach represents the best path for therapeutic development.
Current medications for treatment of Alzheimer’s disease, the cholinesterase inhibitors and memantine, are symptomatic. Despite billions of dollars invested in new drug trials, mostly aimed at disrupting the amyloid beta pathway, no disease-modifying drug has proven to be successful. Apart from one antibody study now in phase 2/3 trial, drug trial results in 2016 were disappointing. As Alzheimer pathology accumulates over 20–30 years before clinical diagnosis, previous trials may have commenced too late in the disease process. Current trials are targeting persons with pre-clinical Alzheimer’s as defined by PET or CSF biomarkers or who have autosomal dominant genes. Researchers remain optimistic of specific Alzheimer treatments being discovered.
Presenter 3
Treatment of Dementia with BPSD – the SBRT Experience
S Macfarlane
The Dementia Centre, Hammond Care, Melbourne, Australia
In November 2015, the Commonwealth Government-funded Severe Behaviour Response Teams (SBRT) commenced operations nationally, the first large-scale programme of its type in the world. The intent of the SBRT is to provide a rapid, responsive, nationally consistent response to severe–extreme behavioural and psychological symptoms of dementia (BPSD) arising within Commonwealth-funded residential aged care facilities (RACF). The model of care emphasizes behavioural and environmental interventions for BPSD within an intensive case-management model and aims to reduce the use of harmful medications. Care is delivered by multidisciplinary teams with expertise in BPSD management, backed up by a team of geriatricians and old-age psychiatrists. The experience of the first year of SBRT operation will be presented.
Schizophrenia and Physical Health – A Whole Body Experience
L Hahn1, S Kisely2,3,4, S Suetani5,6, Julia Lappin7,8, D Siskind2,3,4
1Royal Adelaide Hospital, University of Adelaide, Discipline of Psychiatry, Adelaide, Australia
2The Royal Australian and New Zealand College of Psychiatrists Committee for Research, Melbourne, Australia
3Metro South Addiction and Mental Health Service, Brisbane, Australia
4University of Queensland School of Medicine, Brisbane, Australia
5Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Brisbane, Australia
6Queensland Brain Institute, University of Queensland, Brisbane, Australia
7University of New South Wales, School of Psychiatry, Sydney, Australia
8Bondi Junction Early Psychosis Program, South Eastern Sydney Local Health District, Sydney, Australia
Background: Life expectancy for people with schizophrenia is 16.4 years shorter than for the general population with 35.1% of excess deaths attributable to cardiovascular disease and diabetes. Vitamin D deficiency and poor oral health are common, while over half of people treated with clozapine have metabolic syndrome.
Objectives: To review the epidemiology of key physical health problems among people with schizophrenia, including metabolic syndrome, oral health and vitamin D deficiency, and examine evidence for effective interventions.
Methods: Using data from the 2010 Survey of High Impact Psychosis (SHIP), we will examine rates of cardiovascular risk factors and vitamin D deficiency. We will review epidemiological data on dental health among people with psychosis and examine rates of metabolic syndrome among people treated with clozapine. We will review the role of glucagon-like-peptide (GLP-1) in metabolic syndrome and present data from a trial of exenatide.
Findings: People with psychosis had three to four cardiovascular risk factors. They were also 2.8 times more likely to have lost all their teeth than the general population. Nearly half of people with psychosis had vitamin D deficiency. Of the people surveyed in a clozapine clinic, 75% were overweight or obese with 68% having a high risk of developing diabetes in the next 5 years. Among obese people treated with clozapine, exenatide can assist with weight loss.
Conclusions: Cardiometabolic syndrome, dental disorders and vitamin D deficiency are significant comorbidities among people with psychosis. It is important to continue to examine new treatments to manage these and to translate existing evidence-based treatments into clinical practice.
Presenter 1
The Value of Counting Who-Defined Cardiovascular Risk Factors for Death and Disability in a National Sample of Adults with Psychosis
L Hahn1, A Mackinnon2,3,4, D Foley5, V Morgan6, A Waterreus6, G Watts7, D Castle8,9, D Liu10,11, C Galletly10,11,12
1Royal Adelaide Hospital, University of Adelaide, Discipline of Psychiatry, Adelaide, Australia
2Black Dog Institute, Sydney, Australia
3Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
4University of New South Wales, Sydney, Australia
5Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
6Neuropsychiatric Epidemiology Research Unit, School of Psychiatry and Clinical Neurosciences, The University of Western Australia, Perth, Australia
7Cardiometabolic Clinic, Department of Cardiology, Royal Perth Hospital, School of Medicine and Pharmacology, The University of Western Australia, Perth, Australia
8St Vincent’s Hospital, Melbourne, Australia
9Department of Psychiatry, The University of Melbourne, Melbourne, Australia
10Discipline of Psychiatry, School of Medicine, University of Adelaide, Adelaide, Australia
11Northern Adelaide Local Area Health Network, Adelaide, Australia
12Ramsay Health Care, Mental Health Services, Northern Adelaide Local Health Network, Adelaide, Australia
Background: The poorer health outcomes and premature mortality of people with psychotic disorders compared with the general population are well recognized. Cardiovascular disease (CVD) is the leading cause of premature death in schizophrenia. While the individual risks that contribute to CVD are known, the total number of CVD risks in people with psychosis remains unknown.
Objectives: To determine the prevalence of accumulated CVD risk factors and explore the association between multiple CVD risks, diagnoses and demographic factors, in people with psychosis.
Methods: Participant data were from the 2010 Australian survey of people living with psychotic illness and included 1156 people aged 18–64 years. A 2009 World Health Organization (WHO) report was used as a framework to determine the prevalence of the total number of eight key risk factors for CVD in men and women across three different age groups.
Findings: People aged 18–34 years had an average of 3 (standard deviation (SD) 1.30) risk factors; people aged 35–49 years and 50–64 years had an average of 4 (SD 1.38) risk factors. Women had fewer CVD risk factors than men. The number of risk factors significantly decreased in association with single marital status, current employment and significantly increased with earning a higher income.
Conclusions: This is the first study to examine the total number of CVD risk factors present in people with psychosis, using WHO-defined risk factors that contribute to morbidity and mortality. Close clinical monitoring among this population is imperative and CVD risks should be targeted by lifestyle interventions.
Presenter 2
No Mental Health without Oral Health for People with Severe Mental Illnesses
S Kisely1,2
1The Royal Australian and New Zealand College of Psychiatrists Committee for Research, Melbourne, Australia
2Metro South Addiction and Mental Health Service, Brisbane, Australia
Background: Psychiatric patients have increased comorbid physical illness. There is less information, however, on dental disease, especially tooth decay, despite lifestyle risk factors or psychotropic-induced dry mouth in this population. Left untreated, dental diseases can lead to the total loss of teeth. Importantly, poor oral health can also predispose people to chronic physical disease leading to avoidable admissions to hospital for medical causes.
Methods: We undertook a systematic search for studies on the oral health of people with severe mental illness (SMI) using MEDLINE, PsycINFO, EMBASE, and article bibliographies. Results were compared with the general population. The two outcomes were total tooth loss (edentulism) and dental decay measured through the following standardized measures: the mean number of decayed, missing, and filled teeth or surfaces.
Findings: We identified 25 studies that had sufficient data for a random-effects meta-analysis. These covered 5076 psychiatric patients and 39,545 controls, the latter from either the same study or community surveys. People with SMI had 2.8 times the odds of having lost all their teeth compared with the general community (95% confidence interval (CI) = 1.7–4.6). They also had significantly higher decayed, missing, and filled teeth (mean difference = 5.0, 95% CI = 2.5–7.4) and surfaces scores (mean difference = 14.6, 95% CI = 4.1–25.1).
Conclusions: The increased focus on the physical health of people with SMI should encompass oral health. Possible interventions could include oral health assessment conducted using standard checklists that can be completed by nondental personnel, help with oral hygiene, management of iatrogenic dry mouth, and early dental referral.
Presenter 3
Prevalence and Correlates of Suboptimal Vitamin D Status in People Living with Psychotic Disorders: Data From the Australian Survey of High Impact Psychosis
S Suetani1,2, S Saha1,2,3, D Eyles1,2, J Scott1,3,4, J McGrath1,2
1Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Brisbane, Australia
2Queensland Brain Institute, University of Queensland, Brisbane, Australia
3University of Queensland Centre for Clinical Research, University of Queensland, Brisbane, Australia
4Royal Brisbane and Women’s Hospital, Brisbane, Australia
Background: Having sufficient sera concentrations of 25-hydroxyvitamin D (25OHD) is important for a range of health outcomes including cardiometabolic diseases. Clinical studies in people with psychotic disorders suggest that a sizable proportion has suboptimal vitamin D status.
Objectives: The aim of this study was to examine the prevalence, sociodemographic and clinical correlates of vitamin D status using a large, population-based sample of adults with psychotic disorders.
Methods: Data were collected as part of the Survey of High Impact Psychosis (SHIP), a population-based survey of Australians aged 18–64 years with a psychotic disorder. The 25OHD concentration was measured in 463 participants. The 25OHD concentration was dichotomized into optimal (>50 nmol/L) and suboptimal (<50 nmol/L). The influence of a range of demographic and clinical variables on vitamin D status was examined using logistic regression.
Findings: Nearly half (43.6%) of the participants had suboptimal vitamin D status. Those with increased physical activity or positive symptoms had significantly reduced odds of having suboptimal vitamin D status. However, there were no significant associations between suboptimal vitamin D status and other psychiatric symptom measures or cardiometabolic risk factors.
Conclusions: Many people with psychotic disorders have suboptimal vitamin D status. As part of the routine assessment of physical health status, clinicians should remain mindful of vitamin D status in this vulnerable population and encourage the use of appropriate vitamin D supplements.
Presenter 4
Risk Factors for Poor Physical Health in Patients Treated with Clozapine
J Lappin1,2, A Watkins2, S Rosenbaum1,3, R Morrell2, P Ward1,4, J Curtis1,2
1University of New South Wales, School of Psychiatry, Sydney, Australia
2Bondi Junction Early Psychosis Program, South Eastern Sydney Local Health District, Sydney, Australia
3University of New South Wales, School of Medical Sciences, Sydney, Australia
4Schizophrenia Research Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia
Background: Clozapine’s efficacy in treatment-resistant schizophrenia is well established. Among its range of adverse side effects, it is a potent inducer of weight gain, glucose intolerance and dyslipidaemia. There is a need to be vigilant to these metabolic side effects, and other physical healthcare risks including polypharmacy, smoking and physical inactivity, in clients treated with clozapine.
Methods: Metabolic parameters were measured in clients of clozapine monitoring clinics across three hospital sites in the South Eastern Sydney Local Health District. Body mass index, risk for later development of diabetes (using the Australian Type 2 Diabetes Risk Assessment Tool); smoking; physical activity; and prescription of additional medications were assessed at face-to-face interview. Clients were asked to rate their interest in smoking cessation and dietary and lifestyle interventions.
Results: Of a total of 458 clients, 398 (86.9%) completed questionnaires. More than 75% of the sample rated as overweight or obese; 42.9% of clients smoked, of whom over 50% rated the importance of quitting as high; and 68% were at high risk of developing type 2 diabetes within 5 years. A total of 42% were taking an additional antipsychotic (29% excluding aripiprazole) and 23% were being treated with statin. More than 35% were interested to engage in dietary and lifestyle interventions.
Conclusions: There is an urgent need to address physical healthcare in clients on long-term clozapine treatment. Metabolic parameters indicate that there are high levels of physical comorbidity across this population. The evidence detailed here demonstrates that a proportion of clients wish to engage in improving their physical health, through both smoking cessation and dietary/lifestyle interventions.
Presenter 5
Treatment of Clozapine-Associated Obesity and Diabetes with Exenatide (CODEX) in Adults with Schizophrenia
D Siskind1,2,3
1The Royal Australian and New Zealand College of Psychiatrists Committee for Research, Melbourne, Australia
2Metro South Addiction and Mental Health Service, Brisbane, Australia
3University of Queensland School of Medicine, Brisbane, Australia
Background: Clozapine causes significant metabolic disturbances including obesity and type 2 diabetes. Recent evidence that reduced glucagon-like-peptide-1 (GLP-1) may contribute to the aetiology of clozapine-associated metabolic dysregulation suggests a potential therapeutic role for GLP-1 agonists.
Objectives: To examine recent evidence regarding GLP-1 agonists for the treatment of clozapine-associated obesity.
Methods: This randomized, controlled, open-label, pilot trial aims to evaluate the effect of exenatide on weight loss among clozapine-treated obese adults who have schizophrenia, with or without poorly controlled diabetes. Thirty outpatients will be randomized to once-weekly extended release subcutaneous exenatide or treatment as usual for 24 weeks. This trial examines the safety, tolerability and acceptability of exenatide among obese people with schizophrenia treated with clozapine, with an evaluation of change in weight, glycaemic control, psychosis severity and metabolic parameters.
Findings: Of the participants who had completed 12 weeks of the 24-week intervention, only one of the treatment-as-usual participants had lost any weight (mean weight change +0.28 kg, standard deviation (SD) 3.40), while all exenatide participants had lost weight (mean weight change: 4.55 kg, SD 3.49). The exenatide participants have reported reduced appetite and earlier satiety. The most frequently reported adverse event among the exenatide group is transient nausea in the 3 hours post injection. No other significant adverse events have been reported.
Conclusions: This is the first trial investigating GLP-1 agonists for glycaemic control and weight loss in clozapine-treated people with either diabetes or obesity. Early data suggest that the intervention is tolerable and acceptable, with suggestion of weight loss in the intervention group. If found to be effective, GLP-1 agonists could assist in reducing the cardiometabolic-associated morbidity and mortality secondary to clozapine.
Autism Spectrum Disorder in Adulthood: Essentials for Psychiatrists
C Franklin1,2, M Sellen1,2, C Nicollet1
1Queensland Centre for Intellectual and Developmental Disability, MRI-UQ, University of Queensland, Brisbane, Australia
2Mater Young Adult Health Centre Brisbane, Mater Health Services, Brisbane, Australia
Background: Autism spectrum disorder (ASD) continues to rise in prominence and popularity in the media but is still not well understood. Claims of rising prevalence are countered by concerns that overdiagnosis may be rife. At the same time, ASD can go undiagnosed, even in those presenting to mental health services. The problem is compounded by inadequate opportunities for psychiatrists in training to learn to assess and manage ASD in adults.
Objectives: This symposium examines ASD in adulthood, looking at key issues of relevance to psychiatrists: diagnosis in adulthood; comorbid mental health problems; the use of psychotherapies in adults with comorbid mental health problems; and the conceptual underpinnings and evolution of the diagnosis of ASD.
Methods: Experienced clinicians in their field will present on the following clinically relevant topics:
diagnosis of ASD in adulthood;
mental health in ASD: an update on common psychiatric comorbidities and their treatment;
psychotherapies and working with adults with ASD;
evolution of the concept of ASD and neurodiversity within psychiatry and society as a whole.
Findings: The concept and understanding of ASD continues to evolve. This has ramifications for psychiatry and psychiatrists in clinical practice. The diagnosis of autism itself can be very valuable in helping the individual with ASD and comorbid mental health problems and their psychiatrist can formulate an accurate and effective diagnosis and management plan. The current literature is expanding but significant gaps remain.
Conclusions: ASD is relevant to every subspecialty of psychiatry. Psychiatrists continue to have an essential role in the diagnosis and management of ASD and comorbid mental health problems.
Presenter 1
Autism Spectrum Disorders in Adults: Establishing a Diagnosis and Disentangling Comorbidities in Clinical Practice
M Sellen1,2
1Queensland Centre for Intellectual and Developmental Disability, MRI-UQ, University of Queensland, Brisbane, Australia
2Mater Young Adult Health Centre Brisbane, Mater Health Services, Brisbane, Australia
Background: Awareness of autism spectrum disorders (ASDs) has increased in recent years, but the primary focus remains on early detection and intervention in children. Many adults on the spectrum have missed this ‘diagnostic window’ and remain undiagnosed. These adults may present to psychiatric services with mental health concerns. Limited training opportunities and lack of clinical exposure can leave many psychiatrists feeling ill-equipped. The combination of these challenges can result in suboptimal outcomes for the patient.
Objectives: This presentation aims to assist psychiatrists in recognizing and managing ASD within the mental health context, highlighting clinically relevant diagnostic issues and common comorbidities.
Methods: This presentation will review the diagnostic methods available to assist in the diagnosis of ASD. Case material from a variety of clinical settings and the current literature will be used to describe ways to adapt clinical practice to better identify and manage ASD and comorbid illness.
Findings: Adults with undiagnosed ASD commonly present with mental health comorbidities. It is possible to distinguish ASD within a clinical setting using available diagnostic tools and methods. The diagnosis of ASD itself can provide clarity and greater self-understanding for the adult with ASD and inform their mental healthcare. Although specialized services for adults are limited, particularly for people at the extreme ends of the spectrum, there remains hope for further improvements.
Conclusions: Psychiatrists have an essential role in recognizing and managing ASD, particularly within the context of comorbid mental illness. This recognition can lead to improved treatment outcomes.
Presenter 2
Comorbid Mental Health Problems in Adults with Autism Spectrum Disorder
C Franklin1,2
1Queensland Centre for Intellectual and Developmental Disability, MRI-UQ, University of Queensland, Brisbane, Australia
2Mater Young Adult Health Centre Brisbane, Mater Health Services, Brisbane, Australia
Background: Comorbid mental health problems are often the precipitant for attendance at mental health services in adults with autism spectrum disorders (ASDs) but can be difficult to diagnose due to the effects of autism itself in addition to inadequate training in this area.
Objectives: This presentation aims to increase the psychiatrist’s awareness and understanding of major mental illnesses and how they present in adults with ASDs.
Methods: The presentation will review the current literature as it relates to comorbid mental health problems for adults with autism across all levels of functional difference.
Findings: The current literature is in need of larger scale and more robust studies in the area of comorbid mental health problems in adults with ASDs, especially in those adults with ASDs and intellectual disability (ID). Challenges include a lack of diagnostic instruments validated in the population of adults with ASDs. The existing literature suggests that both under and overdiagnosis of mental health problems occur due to the overlap and similarities in symptomatology between the core features of ASD and major mental illnesses. Suicide may be over-represented in adults with ASD but further studies are also needed in this important area.
Conclusions: Accurate diagnosis of mental health comorbidities in ASD relies on familiarity with, and understanding of, ASD and its core features.
Presenter 3
Working with Adults with Anxiety in Autism Spectrum Disorder
C Nicollet
Queensland Centre for Intellectual and Developmental Disability, MRI-UQ, University of Queensland, Brisbane, Australia
Background: Many individuals on the autism spectrum experience co-occurring mental health concerns. Anxiety has been identified as a source of major concern for adults on the spectrum. For those adults seeking support to manage their anxiety, there can be a lack of appropriate therapeutic approaches that consider the cognitive and communication differences experienced by individuals on the spectrum.
Objectives: To explore the presentation of anxiety in adults on the spectrum, and its impact on social, educational and employment domains, above and beyond the differences inherent to a diagnosis on the spectrum.
Methods: This presentation will discuss some of the common psychotherapeutic approaches including cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT). Clinical case presentations will be used to illustrate some of the ways that therapeutic approaches can be adapted to accommodate the cognitive and communication differences experienced by individuals on the autism spectrum.
Findings: Similar to the neurotypical population, adults on the autism spectrum can benefit from psychological approaches in managing anxiety. It is important for the therapist/clinician to understand the differences inherent to a diagnosis for adults on the autism spectrum and how to adapt the therapeutic approach to accommodate these differences.
Conclusions: Enhancing awareness and education of how to adapt current therapeutic approaches for adults on the spectrum will equip psychiatrists to better provide appropriate mental health services to adults on the spectrum with anxiety.
Presenter 4
The Spectrum of Autism: Is There Room for Neurodiversity in the DSM?
M Sellen1,2
1Queensland Centre for Intellectual and Developmental Disability, MRI-UQ, University of Queensland, Brisbane, Australia
2Mater Young Adult Health Centre Brisbane, Mater Health Services, Brisbane, Australia
Background: Autism has gradually moved beyond a purely medical model to encompass a social construct. Although psychiatry was once central to the diagnosis as a mental disorder, some advocates of neurodiversity question the role of psychiatry and the medical model in what is felt to be a civil rights issue.
Objectives: To understand the current concepts around autism and neurodiversity, using a historical context and recent advances to gain understanding and awareness.
Methods: This presentation will explore the history of autism within psychiatry, with reference to psychiatry’s involvement with civil rights movements. It will analyse the current concepts of autism in public perception, compared with traditional medical literature.
Findings: Neurodiversity is analogous to sexuality and gender, which have been ‘demedicalized’ to a large degree. Despite this, the medical model still prevails in autism, with a strong focus on making people ‘less autistic’, rather than on inclusion and social change. An alternative approach would allow psychiatrists to work with people on the spectrum in negotiating social and functional challenges and maximizing their unique abilities, without the need to pathologize autism itself.
Conclusions: Psychiatry has undergone historical paradigm shifts regarding other core aspects of the human experience. An understanding of neurodiversity can allow psychiatrists to maintain engagement with people on the autism spectrum.
Integrating Psychiatric Rehabilitation into Clinical Practice
H Killaspy1, C Harvey2,3, F Dark4,5, D Siskind4,5
1University College London, London, UK
2Department of Psychiatry, The University of Melbourne, Melbourne, Australia
3NorthWestern Mental Health, Melbourne, Australia
4Rehabilitation Academic Clinical Unit, MSAMHS, Brisbane, Australia
5University of Queensland, Brisbane, Australia
Background: There is increasing evidence on the efficacy of psychiatric rehabilitation services for people with severe and mental illness. However, there remain barriers in identifying consumers who might most benefit from rehabilitation interventions, on how to implement delivery of rehabilitation within mental health services and the role technology might play in service delivery.
Objectives: Provide an international overview of who benefits most from rehabilitation and how services are integrating innovative programs.
Methods: Data from the Rehabilitation Effectiveness for Activities for Life (REAL) study from the United Kingdom and the Australian Survey of High Impact Psychosis (SHIP) study will be presented. An overview of innovative technology-based rehabilitation interventions will be conducted. A panel discussion with audience questions will be held in the final half hour of the symposium.
Findings: The overall availability of a range of rehabilitation interventions is poor across Australia, ranging from 3.4% (family psychoeducation) to 21.1% (relapse prevention planning). In the United Kingdom, most National Health Service Trusts provide inpatient mental health rehabilitation services.
Conclusions: Rehabilitation services can improve functional outcomes for people with severe and persistent mental illness, but there remains a gap between service need and service implementation. Technological advances have the potential to enhance mental health rehabilitation and make it more universally available.
Presenter 1
Implementing Rehabilitation Approaches into Practice and/or Service Delivery
H Killaspy, L Marston, M King, M Lean, I Harrison, N Green, R Omar
University College London, London, UK
Background: Around 20% of people newly diagnosed with psychosis develop severe and complex problems including treatment-resistant symptoms, difficulties managing everyday activities and physical health comorbidities. In England, this group has lengthy hospital admissions and high community support needs and thus accounts for around half the total health and social care budget assigned for mental health. Despite this, there has been little research to guide clinicians and service planners in the most effective approaches. The complex psychosis research group at University College London is attempting to address this.
Objectives: To investigate the provision, quality and outcomes of services for people with complex psychosis in England.
Methods: The Rehabilitation Effectiveness for Activities for Life (REAL) study focussed on National Health Service (NHS) inpatient mental health rehabilitation services. The REAL study comprised four work streams: a national survey across England involving 133 services and over 650 service users; the development of a staff training intervention to engage service users in activities and enhance care; the evaluation of the staff training program through a cluster randomized controlled trial involving 40 services; and a naturalistic cohort study involving 350 users of 50 services.
Findings: Most NHS trusts provided inpatient mental health rehabilitation services. The quality of care provided was higher than in similar facilities across Europe and was positively associated with service users’ autonomy. Our cluster trial did not find our staff training intervention to be clinically effective (coefficient 1.44 (95% confidence interval (CI) −1.35 to 4.24); staff reverted to previous practices once the trainers stopped working alongside staff. Over half the service users in our cohort were successfully discharged from hospital over 12 months. Factors associated with this were service users’ activity levels (odds ratio (OR) 1.03, 95% CI 1.01–1.05), social skills (OR 1.13, 95% CI 1.04–1.24) and the recovery orientation of the service (OR 1.04, 95% CI 1.00–1.08).
Conclusions: NHS inpatient mental health rehabilitation services deliver high-quality care that successfully supports people with complex needs in their recovery. Changes to practice designed to enhance quality of care further require ongoing supervision and monitoring.
Presenter 2
Rehabilitation for Australians Living with Complex Psychoses: Epidemiological Data on How the Current Gap between Evidence and Implementation may be Bridged
C Harvey1,2, J Farhall2,3, S Parsons1, J Lewis3, L Brophy4,5, K Moeller-Saxone6, M Grigg5, D Siskind7
1Department of Psychiatry, The University of Melbourne, Melbourne, Australia
2NorthWestern Mental Health, Melbourne, Australia
3Department of Psychology and Counselling, La Trobe University, Melbourne, Australia
4Melbourne School of Population Health, The University of Melbourne, Melbourne, Australia
5Mind Australia, Melbourne, Australia
6Orygen Research Centre, Melbourne, Australia
7School of Medicine, The University of Queensland, Brisbane, Australia
Background: Little data exist about the rehabilitation needs of Australians living with complex psychosis (CP) and how these needs are met.
Objectives: Using data from a large representative sample of Australians living with psychotic disorders, we examined services received by Australians with CP and service gaps and factors predicting receipt of rehabilitation services and interventions in general.
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 community mental health services, non-government organizations (NGOs) and six evidence-based rehabilitation services and interventions. Regression analyses were performed to predict receipt of relevant services by Australians with CP and, conversely, to explore factors predicting receipt of rehabilitation services and interventions among all Australians living with psychoses.
Findings: A subgroup of Australians with CP, including those with significant social disability, was less likely to receive rehabilitation services from NGOs; their rehabilitation needs are poorly addressed within community mental health services. Linked with this, overall availability of a range of rehabilitation interventions is poor across Australia, ranging from 3.4% (family psychoeducation) to 21.1% (relapse prevention planning). The strongest predictor of receipt of one or more of these interventions was a service provision factor: having a psychologist as a case manager (p < 0.01, odd ratio = 2.36, confidence interval = 1.50 to 3.72).
Conclusions: Implications for how rehabilitation needs can be better addressed within the Australian service system, including wider availability and better targeting of rehabilitation according to clinical factors, will be discussed.
Presenter 3
Technology and Mental Health Rehabilitation
F Dark1,2
1School of Public Health University of Queensland, Brisbane, Australia
2Metro South Addiction and Mental Health Service, Brisbane, Australia
Background: Technology is increasingly being incorporated into health care. It has the potential to overcome the tyranny of distance and improve access to specialist services. Mental health rehabilitation is not universally available and where available is underutilized.
Objectives: To report on the current applications of technology to mental health rehabilitation.
Methods: A literature review of the current evaluations of the use of technology in mental health rehabilitation. Description of an exemplar program to demonstrate the potential of technology in this field.
Findings: The potential of technology in the field of mental health rehabilitation has not been realized. Greater attention of services and researchers to the application of technology in mental health rehabilitation is warranted.
Conclusions: Technological advances have the potential to enhance mental health rehabilitation and make it more universally available.
New Treatments for Post-Traumatic Stress Disorder
D Wallace1,2, O Nielssen2,3, A Murray4, D Said1, A McFarlane5
1Australian Defence Force Centre for Mental Health, Sydney, Australia
2University of New South Wales, Sydney, Australia
3Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
4Private Practice, Morisset, Australia
5University of Adelaide, Adelaide, Australia
Background: Post-traumatic stress disorder (PTSD) is a common and disabling psychiatric condition, for which current psychological and pharmacological treatments have variable efficacy.
Objectives: To present methods and evidence for three new modes of treatment for PTSD and a review of psychological treatments.
Methods:
To present
a comparison of the results of an online trauma-focussed treatment course for PTSD compared to the response of PTSD symptoms to an online transdiagnostic course for anxiety and depression;
the results of a trial of rivastigmine (RVST) for the treatment of chronic and treatment-resistant PTSD;
the evidence and methods for a prolonged exposure trial for treatment-resistant combat PTSD;
a review of a recent meta-analysis of the outcome of psychological therapies for PTSD.
Findings:
A transdiagnostic online treatment course for anxiety and depression achieved similar improvements in PTSD symptoms to a trauma-focussed course specifically for PTSD.
RVST is a well-tolerated and promising additional treatment for chronic forms of PTSD, at least in emergency service personnel.
Intense exposure in the presence of appropriate support has reduced the symptoms of PTSD.
A recent meta-analysis (Steencamp et al, 2015) found limited benefit from psychological therapies in PTSD among military veterans.
Conclusions:
The positive results of a transdiagnostic course for PTSD suggest that the initial treatment for the condition should be symptom focussed, rather than trauma focussed, and raise questions about the scientific validity of separating PTSD from anxiety disorders.
A further trial of RVST in groups of patients is warranted, and if similar results are achieved, a controlled trial.
A proportion of combat veterans with unremitting PTSD obtain relief from symptoms with intense re-exposure therapy.
Translating recent scientific advances to clinical practice requires better measurement of symptoms at baseline and after treatment. Adopting a stage-of-illness model might help identify appropriate treatments for PTSD.
Presenter 1
Results of Trauma-Focussed Compared to Transdiagnostic Online Treatment for PTSD Symptoms
O Nielssen1,2, L Staples1,2, B Dear1,2, N Titov1,2
1MindSpot Clinic, Sydney, Australia
2Macquarie University, Sydney, Australia
Background: Self-guided and clinician-guided online treatments have been shown to be effective for a range of high-prevalence psychiatric disorders. PTSD is one of the most common disorders in the community, but few people with symptoms of PTSD receive evidence-based care.
Objectives: To compare the results of a trauma-focussed PTSD treatment course (the PTSD course) with the results on PTSD symptoms achieved by a transdiagnostic course for anxiety and depression (the Wellbeing course). Both courses are provided by the Mindspot Clinic, a federal government-funded online treatment service, and are delivered free to Australian residents.
Methods: Results from the patients who competed the outcome measures of the PTSD course for the first 30 months of full operation of Mindspot were compared to the results of PTSD scores reported by patients who enrolled in the Wellbeing course and who reported scores on PTSD measures at assessment and completed the PTSD outcome measures.
Findings: The outcome measures for anxiety and depression from the PTSD course were similar to the self-reported scores of patients with high and low PTSD symptoms among those who completed the Wellbeing course. Effect sizes for the PTSD checklist after the PTSD course were 1.66 (standard deviation (SD) 1.22–2.08) and 2.29 (0.79–2.75) at 3-month follow-up. Effect sizes for the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) for the three groups were between 0.73 and 1.20. There were no significant differences in results for people who reported a single traumatic incident compared to those with complex trauma.
Conclusions: Given the potential for trauma-focussed treatment to exacerbate symptoms in a proportion of patients with PTSD, these results suggest the initial treatment for PTSD symptoms could be transdiagnostic treatment for anxiety and depression that does not consider the cause of symptoms. The results do not support the separation of stress disorders from other high prevalence disorders in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). The results demonstrate that online treatment is an efficient and effective way to provide evidence-based treatment to the many Australians with untreated PTSD.
Presenter 2
Rivastigmine for Chronic Treatment-Resistant PTSD
A Murray1, D Wallace2,3, O Nielssen3,4
1Private Practice, Sydney, Australia
2Australian Defence Centre for Mental Health, Sydney, Australia
3University of New South Wales, Sydney, Australia
4Macquarie University Faculty for Medicine and Health Sciences, Sydney, Australia
Background: The trial of rivastigmine (RVST) for chronic treatment-resistant post-traumatic stress disorder (PTSD) was prompted by a published case series of successful treatment of PTSD in veterans of the Iran–Iraq war.
Objectives: To report on the methods and outcomes of a trial of treatment with RVST of chronic PTSD in emergency service personnel.
Methods: RVST at daily doses of up to 12 mg orally, or 13.3 mg transdermally, were prescribed to 44 emergency service personnel (40 polices, 3 paramedics and 1 firefighter), who met the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria for PTSD, with symptoms that had been present for an average of 9.8 years.
Findings: Seven of the 44 patients discontinued medication because of side effects. The remaining 37 took the medication for an average of 26.5 weeks. Of these, 33 (89%) reported subjective benefit and 30 (81%) had objective signs of improvement. Improvement was noted in avoidance, intrusive memories and arousal symptoms. These results were unrelated to continued involvement in workplace litigation. However, scores in the 27 who completed before and after the PTSD Checklist-5 Scales showed no improvement, possibly related to the effect of continued litigation.
Conclusions: The positive result from this case series provides support for a further trial of RVST in other groups of patients with treatment-resistant PTSD.
Presenter 3
Phoenix Australia – Department of Veterans’ Affairs–Australian Defence Force Restore Trial: Prolonged Exposure Therapy for PTSD
D Said
Australian Defence Force Centre for Mental Health, Sydney, Australia
Background: The very high demands placed on professional soldiers in the last 15 years have resulted in a large number of military personnel with combat-related post-traumatic stress disorder (PTSD). Standard prolonged exposure is effective for PTSD, but Australian Defence Force (ADF) personnel and veterans may find it difficult to attend the required minimum of 10 weekly sessions. Early evidence suggests 2 weeks of intensive treatment may produce the same benefits and may make treatment more accessible.
Objectives: To describe a randomized controlled trial of prolonged exposure therapy in current serving ADF members and veterans.
Methods: Two-hundred current and ex-serving members of the ADF from three metropolitan centres will be recruited over 2 years and randomized to prolonged exposure therapy, given as either 10 weekly sessions or an intensive arm of 10 daily sessions over 2 working weeks.
Findings and conclusions: Results of the trial are pending, but intensive prolonged exposure therapy appears to be a promising, novel form of a well-established treatment for PTSD.
Presenter 4
The Need for Innovation in the Treatment of Military-Related PTSD
A McFarlane1,2
1Director, Centre for Trauma Stress Studies, University of Adelaide, Adelaide, Australia
2Professor of Psychiatry, University of Adelaide, Adelaide, Australia
A recent meta-analysis of the psychological therapies for post-traumatic stress disorder (PTSD) in military veterans highlighted their limited effect (Steenkamp et al., 2015). While current evidence-based treatments make an important contribution to the care of many patients, systematic strategies are required to address their limitations. One approach that should be adopted is the stage of illness model of disease for PTSD. There is little direction as to the optimal interventions for chronic and relapsing forms of the disorder. Similarly, the optimal interventions for subsyndromal disorder, which is a strong predictor of emerging illness, have received little attention.
A systematic approach of assessing patients prior to the commencement of treatment, and documenting predictors of treatment outcome, needs to be implemented in patients with PTSD from a range of causes. A more systematic approach to measurement of symptoms and outcomes will help identify which interventions work for particular patients and allow better translation of the advances in neuroscience to clinical practice.
This presentation will examine the current challenges in the assessment and treatment of PTSD and discuss possible strategies for improving treatment outcomes.
Reference
Steenkamp MM, Litz BT, Hoge CW, et al. (2015) Psychotherapy for military-related PTSD: A review of randomized clinical trials. JAMA 314(5): 489–500.
Does the RANZCP Need a Position Statement on Spirituality in Psychiatry?
M Wong1, K George2, A Howie3, F Wilson4
1School of Clinical Sciences at Monash Health, Faculty of Medicine Nursing & Health Sciences, Monash University, Melbourne, Australia
2Eastern Health, Melbourne, Australia
3Whitiki Maurea Māori Mental Health and Addiction Service, Waitemata District Health Board Auckland, New Zealand
4Manaaki House Community Mental Health Centre, Auckland, New Zealand
Background: The assessment of spirituality in psychiatry is increasingly emphasized in the academic literature, diagnostic manuals, and the various disciplines with which psychiatry partners in the care of the mentally ill. Consideration of a service user’s spiritual well-being is a duty stipulated in our Code of Ethics, though detailed guidance is lacking. Spiritual perspectives are valuable in the assessment of the Indigenous population. These and other considerations favour having a statement indicating the scope and limits of what the Royal Australian and New Zealand College of Psychiatrists (RANZCP) endorses regarding the assessment and approach to the management of spiritual issues in users of mental health services.
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. A spirituality-informed approach to psychiatry has been, and is being, practised in Australia and New Zealand in ways particular to the cultural, ethnic, religious, political, clinical, organizational and medicolegal 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.
Objectives: This presentation will indicate the current state of the discussion regarding the need for a statement on Spirituality in Psychiatry for the RANZCP.
Presenter 1
Spirituality in Psychiatry – Background
M Wong1, K George2
1School of Clinical Sciences at Monash Health, Faculty of Medicine Nursing & Health Sciences, Monash University, Melbourne, Australia
2Eastern Health, Melbourne, Australia
Background: At the Psychiatry and Spirituality Symposium at the International RANZCP Congress 2016, it was suggested that the Royal Australian and New Zealand College of Psychiatrists (RANZCP) develop a position statement on psychiatry and religion/spirituality. The suggestion was put through the Members’ Advisory Council and then approved by the board for preliminary investigation via consultation with the Section of the History, Philosophy and Ethics of Psychiatry (SHPEP).
Objectives: To provide an overview of the draft proposal of the Position Statement on Religion and Spirituality.
Methods: The draft proposal of RANZCP is compared to and contrasted with those of the UK Royal College of Psychiatrists and the World Psychiatric Association and in reference to key international literatures on Psychiatry and Spirituality.
Findings: The draft Position Statement acknowledges the exploration of religion and spirituality may at times constitute an essential component of clinical assessment and is particularly relevant to patients of certain cultural, ethnic and religious backgrounds. The draft Position Statement highlights that the RANZCP Code of Ethics (clauses 1.1, 1.2 and 6.3) reminds psychiatrists that they are to demonstrate respect and not discriminate against patients and not to diagnose and treat a persona as mentally ill on the basis of the person’s ethnicity and religious background. It identifies risks, provides ethical considerations and lists best practice requirements.
Conclusions: The current draft Position Statement covers the major issues in relation to psychiatry, religion and spirituality.
Presenter 2
Spirituality, Professionalism and Psychiatry
A Howie
Whitiki Maurea Māori Mental Health and Addiction Service, Waitemata District Health Board Auckland, New Zealand
Background: Detailed practice guidance is lacking in the area of psychiatry, religion and spirituality even though the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Code of Ethics requires respect and competence in assessing and treating patients with different cultural, ethnic, religious and spiritual backgrounds.
Objectives: To assess how adequately and appropriately the draft proposal of the Position Statement on Religion and Spirituality addresses the issues of professionalism in the practice of psychiatry.
Methods: The draft Position Statement is examined from the perspective of the RANZCP Code of Ethics and professional conduct with a focus on the level of clarity, specificity and evidence.
Findings: The draft Position Statement draws our attention to the risks of guidance to psychiatrists on religion and spirituality may result in the avoidance and mishandling of engagement with a patients’ religious and spiritual beliefs and practices, leading to suboptimal clinical outcomes. It highlights the religious and spiritual roots of some commonly used practices such as mindfulness-based cognitive therapy and the 12-step facilitation therapy. The draft Position Statement highlights the need for competence in the area of psychiatry, religion and spirituality because of the intrinsic spirituality of Māori, Aboriginal and Torres Strait Islander peoples as well as the increasing multiculturalism in our community through immigration and proximity to the Asia-Pacific region.
Conclusions: The current draft Position Statement addresses risks and provides ethical and professional considerations specific to the practice of psychiatry in relation to religion and spirituality not included in the RANZCP Code of Ethics.
Presenter 3
Spirituality, Psychiatry, Cultures and Faiths
F Wilson
Manaaki House Community Mental Health Centre, Auckland, New Zealand
Background: Australia and New Zealand are represented by multiculturalism and religious and spiritual diversity, which have a strong impact on the experience and presentation of mental disturbance.
Objectives: To explore how a practice of psychiatry that is informed and sensitive to the religious and spiritual background of patients can be promoted by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) draft proposal of the Position Statement on Religion and Spirituality.
Methods: The reference to spirituality, culture and faith in the draft Position Statement is examined with reference to different faith and spirituality traditions with respect to relevance and practicality.
Findings: The draft Position Statement provides a neutral and unbiased position to all cultural, religious and spiritual traditions and highlights the importance of clinical competence in psychiatrists assessing how spirituality and religious background in particular affects diagnosis, treatment and recovery.
Conclusions: The current draft Position Statement puts appropriate emphasis on the need for unbiased attitude towards and clinical competence in including spirituality and religion in the clinical practice of psychiatry.
Psychopathology and Art: The Art of Telling Our Stories
V Brakoulias1, V Starcevic1, J Harrison2, C Zubaran3
1University of Sydney, Sydney Medical School Nepean, Sydney, Australia
2Alfred Child and Youth Mental Health Service, Melbourne, Australia
3Sunnyside Clinic and Western Sydney University, Sydney, Australia
Background: Much has been written about the relationships between the arts and psychiatry.
Objectives: This symposium attempts to discuss how the arts can assist expression in psychiatry in keeping with the theme of the conference, ‘Telling our Stories’.
Methods: The relationships between the arts and psychiatry will be explored using the modalities of music, visual art and poetry.
Findings: There is a complex relationship between mental illness and creativity that needs to be further clarified. The arts can have a powerful impact on our ability to ‘tell our stories’ and to improve the way we practice psychiatry. The arts may also assist us in improving our understanding of psychopathology.
Conclusions: In our quest to better understand psychopathology and the relationship between mental illness and creativity, it is important to explore and evaluate the role of the arts.
Presenter 1
Composers on the Couch: Therapy and Musical Creativity
V Starcevic
University of Sydney, Sydney Medical School Nepean, Sydney, Australia
Background: The relationship between psychotherapeutic interventions and creativity remains controversial and poorly understood.
Objectives: To examine the relationship between psychotherapeutic interventions and musical creativity using two examples from the history of music and psychotherapy.
Methods: Review of the effects of hypnotherapy and other psychotherapeutic methods performed by Nikolai Dahl on Sergei Rachmaninov and a 1-day therapeutic intervention of Sigmund Freud on Gustav Mahler.
Findings: Rachmaninov sought treatment when he was 27 years of age, following a series of artistic setbacks that shattered his self-esteem, strengthened his tendency to doubt himself, inhibited his creativity and apparently caused a depressive episode. The intense therapy provided by Dahl (an amateur musician) lasted about 3 months and had a very positive impact on Rachmaninov’s overall mental health and creativity. Rachmaninov composed one of his most popular works shortly after therapy. In contrast, Mahler consulted Freud (a man with an ‘aversion to music’) at the age of 50 years, when he was already a well-established composer and conductor; it was precipitated by his marital problems. Mahler had a 4-hour walk with Freud during which he was ‘analysed’. Although short-term effects of this ultra-brief psychotherapeutic intervention were apparently positive, its effects on Mahler’s creativity, if any, will never be known because he died only 8 months later.
Conclusions: Effects of psychotherapy on musical creativity may vary. This seems to depend on the range of factors, including the nature of the problem for which psychotherapeutic intervention is sought, quality of the therapeutic rapport and the way in which therapy is delivered.
Presenter 2
The Art of Australasian Psychiatry
V Brakoulias
University of Sydney, Sydney Medical School Nepean, Sydney, Australia
Background: The use of artwork can greatly enhance the appeal of an academic journal and provide a powerful reflection of a desired theme.
Objectives: To present and discuss the artwork that has adorned the front covers of Australasian Psychiatry.
Methods: The Editor of Australasian Psychiatry will present the images that have been selected for the front cover of the journal since the collaboration with the Cunningham Dax Collection began in 2014. The Editor will also present the rationale for choosing images and discuss the themes that the images reflect.
Findings: The use of images of artwork from the Cunningham Dax Collection for the front covers of Australasian Psychiatry has been appreciated by readers of the journal. Common themes reflected by the artwork include distress, stigma, care, grief and hopelessness. The artwork allows the reader to reflect on the main themes and the cover art description justifies why the image was chosen for the front cover in addition to allowing readers to read the artist’s statement regarding their work. The collaboration with the Cunningham Dax Collection also supports the artists who have psychiatric disorders to continue their fine work.
Conclusions: The use of art on the covers of Australasian Psychiatry has provided a valuable opportunity to reflect on how the themes portrayed by patients with mental disorders are similar to the themes presented by authors contributing to the journal.
Presenter 3
The Poetry of Mental Illness: The Work of Francis Webb and the Poets of the Dax Poetry Collection
J Harrison
Alfred Child and Youth Mental Health Service, Melbourne, Australia
Background: In 2011, academic Toby Davidson brought together the poems of Francis Webb for the first time into a definitive Collected Poems (University of Western Australia Publishing). Webb’s poems had been out of print for 30 years, and this collection is the first edition to incorporate the poet’s final changes to several poems. Webb wrote on many subjects, as varied as colonial histories, war, the landscape and religion. He also spent nearly 20 years in mental institutions in the United Kingdom and Australia until his death in 1973. This paper will explore the experience of mental illness and mental healthcare in the poetry of Francis Webb and compare his insights with representations seen in a selection of contemporary Australian poems. The latter poetry will be sourced, with permission, from The Dax Poetry Collection, a special collection held by The Dax Centre. The aim of the paper is to explore creativity, the resilient self and developments in mental healthcare from the perspective of lived experience of mental illness.
Objectives: The paper will provide insights into what matters to patients and how experiences are transformed and communicated through poetry.
Methods: Selected poems from Webb’s Collected Poems will be discussed. A selection of contemporary poems from The Dax Poetry Collection will also be discussed. Themes of lived experience will be elaborated upon and poetic developments highlighted (e.g. themes of lyricism, individualism, politics and the resilient self).
Findings: The influence of post-modernism has had profound influence on the poetry of mental illness. The power differential between patient and institution is continually challenged, explored, and not taken for granted.
Conclusions: Poetry has a powerful voice. Poets who have experienced mental illness have much to tell us about the work of mental health and about how changes in mental health practice affect both the content and process of creativity.
Reference
Webb, F (2011) Collected Poems, Toby Davidson (ed.). Crawley, Western Australia: University of Western Australia Publishing.
Presenter 4
From Pictorial Interpretation to Clinical Intuition
C Zubaran
Sunnyside Clinic and Western Sydney University, Sydney, Australia
Objectives: In this presentation, the author will present portraits of painters who managed to capture the emotional expression of their sitters.
Methods: Works by Pierre-Auguste Renoir (1841–1919), Rembrandt van Rijn (1606–1669), and William Hogarth (1697–1764) will be shown. In addition, the historical evolution of portrait painting as well as the correlation between portraiture and science will be addressed. Finally, the author will focus on the clinical relevance of interpreting the facial expression of patients as part of a comprehensive analysis of one’s inner emotional state.
Findings: The art of portraiture has evolved alongside scientific enquiry in the process of capturing and representing the psychological content of individuals.
Conclusions: The pictorial interpretation of one’s inner emotional world, as depicted in important paintings by the Great Masters, represents an aesthetic paradigm for the investigative clinical work of psychiatrists.
‘Tjungu Tjina Ankula Kunpuringkuku’: Walking Together to Become Strong – Helping Children in Remote Aboriginal Communities: A South Australian Experience
P McEvoy, A Groome, B Sawyer, M Watson
Child and Adolescent Mental Health Services (CAMHS), Women’s and Children’s Health Network (WCHN), Adelaide, Australia
Background: Child and Adolescent Mental Health Services (CAMHS) has had a service in the Anangu Pitjantjatjara Yankunytjatjara (APY) lands since 2006. It began in response to a young person’s suicide on the lands and has evolved from a fly-in-fly-out (FIFO) model to having mental health clinicians living on the lands supported by a FIFO team.
Objectives: This symposium will explore the challenges and rewards of delivering child and adolescent mental health services in Pitjantjatjara Yankunytjatjara communities in northwest South Australia. Ideas of cultural and community accountability, partnership and capacity building will be explored and illustrated through work with at-risk youth and clinical responses to petrol sniffing among young children.
Methods: Perspectives from the clinical service director, land-based clinicians and an Aboriginal child and adolescent psychiatrist will be presented.
Presenter 1
Taking a Big Step into Remote Service Delivery: CAMHS on the APY Lands
P McEvoy
Child and Adolescent Mental Health Services (CAMHS), Women’s and Children’s Health Network (WCHN), Adelaide, Australia
Background: In 2006, Child and Adolescent Mental Health Services (CAMHS) began providing services to the Anangu Pitjantjatjara Yankunytjatjara (APY) lands through a fly-in-fly-out (FIFO) model of care. In 2010, this service delivery changed with the addition of land-based clinicians supported by a FIFO team.
Objectives: The service delivery challenges will be described. These include the reliance on Commonwealth and State funding models that are not ongoing, the way clinical governance is enacted and the need for collaborative practice with multiple agencies, government and non-government, which are in similar predicaments. Overlaying this is the critical importance of community engagement and partnership to enable the voice of the Anangu people to be heard.
Methods: The model of care on the APY lands will be articulated, enabling discussion of how these issues are addressed in such a complex and culturally rich environment.
Conclusions: CAMHS remains committed to working in the APY lands, and our service must hold the Anangu child at the centre of every decision to ensure that Anangu children can be safe on their Country.
Presenter 2
Walking with Anangu to Create Safe Spaces
A Groome, B Sawyer
Child and Adolescent Mental Health Services (CAMHS), Women’s and Children’s Health Network (WCHN), Adelaide, Australia
Background: The addition of land-based mental health clinicians has enabled the development of strong relationships with the Anangu community. This has required considerable skill and extraordinary reflective practice to ensure cultural sensitivity and accountability are central to our practice and clinical case understandings and interventions.
Objectives: The Lands-based clinicians will give a rich description of their work focussing on at-risk youth and the problem of petrol sniffing.
Methods: Supporting the discussion will be video of a community activity for young men on the Lands.
Conclusions: Walking alongside Anangu in our clinical work is essential and rewarding.
Presenter 3
Working in a Remote Aboriginal Community through the Eyes of an Indigenous Child and Adolescent Psychiatrist
M Watson
Child and Adolescent Mental Health Services (CAMHS), Women’s and Children’s Health Network (WCHN), Adelaide, Australia
Background: With environments such as the Anangu Pitjantjatjara Yankunytjatjara (APY) Lands, there is the added complexity of transgenerational trauma and the effects of this on the self, family and community. Our approach to this has been with both a land-based and fly-in-fly-out service over the last several years. The level of complexity is at times challenging and confronting for those involved. However, being an Aboriginal psychiatrist adds another dimension to this. Navigating both Indigenous and non-Indigenous world views as a clinician, and experiences evoked as an Aboriginal person, can be challenging.
Objectives and methods: As an Aboriginal person, the presenter will provide a personal and professional reflection of his experiences on the Lands, before and during his role as a psychiatrist. This in the context of the presenter being an early career psychiatrist.
Findings: Working in such an environment as an Aboriginal person adds a layer of complexity and challenges which, at times, have been confronting. However, stepping away and returning ‘when the time is right’ has been a more effective and rewarding approach.
Conclusions: Working clinically is as much about holding culture in mind in parallel. In order to address the clinical, culture needs to be appreciated. To do this requires one being receptive and perceptive to the nuances of the complexity of the environment that we work in.
The Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Project
C Galletly1,2, G Carter1,3, G Smith4, T Lambert1,5
1Members of the RANZCP Clinical Practice Guideline Steering Committee, Melbourne, Australia
2Chair, Clinical Practice Guideline for Schizophrenia and Related Disorders Working Committee, Melbourne, Australia
3Chair, Clinical Practice Guideline for Self-Harm Working Committee, Melbourne, Australia
4Deputy Chair, Practice and the Profession Portfolio, RANZCP Practice Policy and Partnerships Committee, Melbourne, Australia
5Member of the Physical Health Consensus Statement Working Committee, Melbourne, Australia
Background: In 2012, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) began reviewing and updating six RANZCP clinical practice guidelines (CPGs): Anorexia Nervosa (redrafted as Eating Disorders), Bipolar Disorder, Depression (combined with Bipolar Disorder and redrafted as Mood Disorders), Deliberate Self-Harm, Panic Disorder and Agoraphobia (to be redrafted as Anxiety), and Schizophrenia.
The importance of treating a person’s physical health, as well as mental illness, is increasingly recognized. In 2013, the RANZCP commenced developing an expert consensus statement to inform the future development of guidelines on managing physical health in people with enduring psychotic illness.
Objectives: The CPGs aim to provide evidence-based expert clinical guidance for psychiatrists and other clinicians to support the delivery of quality mental health care in Australia and New Zealand.
The expert consensus statement identifies strategies to improve the management of physical health in people with enduring psychotic illness.
Methods: Working groups were established to review available literature, develop advice and recommendations, and redraft the CPGs. The draft CPGs undergo both internal and external reviews, including consultation with consumers and carers.
Another working group, tasked with developing the Expert Consensus Statement, used the Delphi process to administer a series of surveys to expert panels.
Findings and conclusions: Guidelines published in 2014/2015 have previously been discussed at Congress.
This symposium will present on the deliberate self-harm CPG, published 2016, and the Physical Health Expert Consensus Statement.
As the CPGs near completion, the focus is moving to dissemination and implementation. The symposium will conclude with a panel discussion about implementation of the CPG recommendations.
Presenter 1
RANZCP Clinical Practice Guideline for Deliberate Self-Harm
G Carter1,2 (CPG Chair), A Page1,3, M Large1,4, S Hetrick1,5, A Joy Milner1,6, N Bendit1,7, C Walton1,8, B Draper1,9, P Hazell1,10, S Fortune1,11, J Burns1,12, G Patton1,13, M Lawrence1,14, L Dadd1,15, J Robinson1,5, H Christensen1,16
1Chair, Clinical Practice Guideline for Self-Harm Working Committee, Melbourne, Australia
2Centre for Translational Neuroscience and Mental Health (CTNMH), University of Newcastle, Newcastle, Australia
3Centre for Health Research, Western Sydney University, Sydney, Australia
4School of Psychiatry, The University of New South Wales, Sydney, Australia
5Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia
6Centre for Population Health Research, School of Health and Social Development, Deakin University, Melbourne, Australia
7School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Newcastle, Australia
8Centre for Psychotherapy, Hunter New England Mental Health Service and Centre for Translational Neuroscience and Mental Health, The University of Newcastle, Newcastle, Australia
9School of Psychiatry, The University of New South Wales, Sydney, Australia
10Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, Australia
11The University of Auckland, Auckland, New Zealand
12Young and Well Cooperative Research Centre, The University of Melbourne, Melbourne, Australia
13Department of Paediatrics, The University of Melbourne, Melbourne, Australia
14Tauranga Hospital, Bay of Plenty, New Zealand
15Mental Health and Substance Use Service, Hunter New England, NSW Health, Newcastle, Australia
16Black Dog Institute, The University of New South Wales, Sydney, Australia
Background: The CPG for deliberate self-harm (DSH) was produced as part of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Clinical Practice Guideline (CPG) Project, to update the earlier version published in 2003, and expanded to include children.
Objectives: To provide guidance for the organization and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations.
Methods: Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then formulated into consensus-based recommendations and clinical guidance. The guideline was subjected to successive review by RANZCP committees, including the community ollaboration committee, as well as consultation with expert and clinical advisors, the public, professional bodies, specialist groups and other key stakeholders with interest and expertise in DSH.
Findings: The Guideline reviews and synthesizes current evidence about the management of DSH in hospitals and the community to provide guidance on assessment, clinical treatment, aftercare and organization of services for people who self-harm. Where possible, it makes evidence-based recommendations for clinical practice. It also identifies current research needs.
Conclusions: The CPG addresses self-harm within specific population subgroups and provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus. A reference guide for clinicians has been published and a guide for the public is in-draft.
Presenter 2
Expert Consensus Statement for the Treatment, Management and Monitoring of the Physical Health of People with an Enduring Psychotic Illness
T Lambert1, N Reavley2, A Form2, M Oakley Browne2
1Collaborative Centre for Cardiometabolic Health in Psychosis, University of Sydney, Sydney, Australia
2Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
Background: In 2013, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) started work to develop an expert consensus statement to identify strategies that could be implemented for the treatment, management and monitoring of physical health in people with enduring psychotic illness.
Objectives: To use expert consensus to formulate target domains suitable for informing the development of policy and guidelines on this topic.
Methods: The Delphi method was used. Systematic research was conducted to develop a 416-item survey containing strategies that health professionals should use to treat, manage and monitor the physical health of people with an enduring psychotic illness. Three panels of Australian experts (55 clinicians, 21 carers and 20 consumers) were recruited and independently rated the items over three rounds, with strategies reaching consensus on priori-defined levels of importance.
Findings: The participation rate for the clinicians across all three rounds was 65%. Consumers/carers completed one round only due to high endorsement rates. Finally, 386 strategies were endorsed as essential or important by one or all panels. The endorsed strategies include engagement and collaborative partnerships; clinical governance; risk factors, morbidity and mortality in people with enduring psychotic illness; assessment, including initial and follow-up assessments; barriers to care; strategies to improve care of people with enduring psychotic illness; education and training; treatment recommendations; medication side-effects; and the role of health professionals.
Conclusions: The consensus statement is intended to be used by health professionals, people with an enduring psychotic illness and their families and carers. The next step needed is an implementation strategy by the RANZCP and other stakeholders.
Presenter 3
Panel Discussion: Guideline Implementation
C Galletly1,2,3,4,5, G Carter1,6,7,8, G Smith9
1Members of the RANZCP Clinical Practice Guideline Steering Committee, Melbourne, Australia
2Chair, Clinical Practice Guideline for Schizophrenia and Related Disorders Working Committee, Melbourne, Australia
3University of Adelaide, Adelaide, Australia
4Ramsay Health Care (SA) Mental Health, Adelaide, Australia
5Northern Adelaide Local Health Network, Adelaide, Australia
6Chair, Clinical Practice Guideline for Self-Harm Working Committee, Melbourne, Australia
7Centre for Translational Neuroscience and Mental Health (CTNMH), University of Newcastle, Newcastle, Australia
8Consultation–Liaison Psychiatry, Calvary Mater Newcastle, Newcastle, Australia
9Deputy Chair, Practice and the Profession Portfolio, RANZCP Practice Policy and Partnerships Committee, Melbourne, Australia
Associate Professor Geoff Smith will chair a discussion on guideline implementation with the Royal Australian and New Zealand College of Psychiatrists (RANZCP) CPG working group members and the audience.
The RANZCP, and in particular the working group members, have invested significant time, energy and expertise in producing the guidelines. Now that the guidelines are close to completion and to realize a return on investment, the project is focussing on dissemination and implementation.
Guidelines on their own are not sufficient to support evidence-based practice. Improvement to processes to achieve better outcomes requires tailored implementation to make recommendations locally relevant and usable.
Implementation locally relies on the presence of local leadership to drive change and an understanding of the local issues that need to be addressed. The role of the RANZCP is to provide tools that can be used and adapted locally, to facilitate incorporation of the guideline recommendations into standard practice.
The panel will discuss the RANZCP work to date to support implementation, including the production of webinars, clinical summaries, information for the public and the dissemination of the guidelines. This session will also provide the opportunity for an open forum on additional implementation strategies at national, jurisdictional and local levels.
Interventions for Deliberate Self-Harm Across the Lifespan: What Works?
A Davis1, N Kapur2, B Draper3, G Carter4, P Hazell5
1Royal Adelaide Hospital, Adelaide, Australia
2Centre for Suicide Prevention, Centre for Mental Health and Safety, University of Manchester, Manchester, UK
3Prince of Wales Hospital, Brisbane, Australia
4University of Newcastle, Newcastle, Australia
5University of Sydney, Sydney, Australia
Abstract: The management of deliberate self-harm (DSH) remains one of the major challenges for clinicians working in acute psychiatry. We know that there are significant adverse outcomes associated with DSH including repetition of DSH, suicide, all-cause mortality, mental health morbidity, impairment of function in many domains and impaired quality of life.
Over the years, various clinical and psychosocial interventions have been offered to patients presenting with deliberate self-harm in diverse situations, with very mixed outcomes.
This symposium will examine the evidence for the effective management of DSH in hospital and community settings, exploring in turn interventions in adults (Professor Kapur), the elderly (Professor Draper), in adults meeting criteria for borderline personality disorder (Professor Carter) and in adolescence (Professor Hazell).
The topic will be open for discussion with clinicians with experience and expertise in this area.
Presenter 1
Interventions for Deliberate Self-Harm in Adults: Beyond the Randomized Trial
N Kapur
Centre for Suicide Prevention, Centre for Mental Health and Safety, University of Manchester, Manchester, UK
Background: Self-poisoning and self-injury are major public health problems internationally, an important cause of presentation to hospital, and a major risk factor for suicide. Service provision for self-harm varies markedly, perhaps reflecting uncertainties in the evidence base.
Objectives: To discuss the most promising strategies for managing self-harm in adults of working age.
Methods: Synthesis of findings from recent systematic reviews of randomized trials, large-scale observational data, and national studies of guideline implementation.
Findings: There is reasonable evidence that psychological interventions can benefit people after self-harm. Routine aspects of management also seem to help. Evaluating the impact of clinical guidelines is challenging, but there is some evidence that such strategies can improve care and outcomes.
Conclusions: Effective psychological treatments for people who have harmed themselves do exist but the optimal therapy is uncertain. A major challenge is making interventions available within clinical services. Implementing aspects of evidence-based care may be difficult. A ‘one-size-fits-all’ approach to intervention is unlikely to be helpful.
Presenter 2
Interventions for Deliberate Self-Harm: What Works in Late Life?
B Draper1,2
1University of New South Wales, Sydney, Australia
2Aged Care Psychiatry, Eastern Suburbs Mental Health Service, Sydney, Australia
Background: Deliberate self-harm (DSH) declines with age and more closely resembles suicide than in younger age groups. Interventions for DSH in late life might contribute to suicide prevention.
Objectives: To review interventions for DSH in late life.
Methods: Systematic reviews on late-life suicidal behaviour published since 2007 were supplemented by a search of MEDLINE, PsycINFO and EMBASE databases for the period 2007–2013 using keywords (suicide, deliberate self-harm, suicide ideation, attempted suicide, old, elderly, old age).
Findings: There has been very limited research on interventions for DSH in late life with no randomized controlled trials (RCTs). A two-tiered multifaceted care management model of older suicide attempters in Hong Kong compared the 2-year suicide and suicide attempt outcomes with the pre-intervention observational phase of the study and found a reduced rate of suicide in the suicide attempters although it did not reduce the rate of reattempts. RCTs using depression and suicidal ideation as proxy outcomes have shown the benefits of general practitioner (GP) education and collaborative care models of depression management.
Conclusions: The limited evidence suggests that GP education about depression, collaborative care models of depression, and multifaceted care management of DSH in late life are effective interventions.
Presenter 3
Effective Interventions to Reduce Deliberate self-Harm in Borderline Personality Disorder
G Carter1,2
1Centre for Brain and Mental Health Research, Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
2Deptartment Consultation–Liaison Psychiatry, Calvary Mater Newcastle, Newcastle, Australia
Background: Deliberate self-harm (self-poisoning and self-injury) may be recurrent behaviours in patients meeting criteria for borderline personality disorder (BPD). Hospital-treated episodes are a common reason for service provision in the emergency department of general hospitals and a potential point of contact to engage patients in effective aftercare aimed at reducing the frequency of episodes.
Objectives: To discuss the beneficial and ineffective interventions for reducing the frequency of deliberate self-harm in adults meeting the criteria for BPD.
Methods: Synthesis of findings from recent systematic reviews of randomized trials.
Findings: There is reasonable evidence that specific psychological interventions (dialectical behaviour therapy, mentalization-based treatment, cognitive behavioural therapy) can reduce the frequency of self-harm episodes. There is limited evidence that pharmacological interventions have no effect on the frequency of episodes.
Conclusions: Effective psychological treatments producing substantial reductions in the number of episodes of deliberate self-harm in BPD do exist but the availability may be limited. A major challenge will be increasing the availability and uptake of these effective interventions, while reducing the availability of ineffective interventions that might be traditionally offered by clinical services.
Presenter 4
Interventions for Deliberate Self-Harm in Adolescents
P Hazell
Discipline of Psychiatry, Sydney Medical School, Sydney, Australia
Background: About 25% of adolescents self-harm at some time, and one in three of those will be repeaters. Historically, interventions to prevent the recurrence of deliberate self-harm (DSH) by adolescents have been ineffective.
Objectives: To critically examine systematic evidence for the effectiveness of interventions designed to reduce the recurrence of DSH among clinically referred populations of adolescents.
Methods: Electronic search of PubMed (to April 2014) using the following terms: self-harm AND review AND adolescent. We also contacted the authors of a Cochrane Review in revision to determine if there were relevant unpublished studies.
Findings: From four systematic reviews, we identified 14 relevant randomized controlled trials (RCTs), with a total of 1965 participants. We identified three further RCTs: Small, single studies of modified cognitive behavioural therapy (CBT), mentalization-based therapy (MBT) and dialectical behaviour therapy (DBT). DBT showed superiority over treatment as usual (TAU) in reducing the rate of repetition of DSH. The reviews found none of the following interventions any more effective than TAU: family intervention for suicide prevention; token allowing re-admission; home-based family intervention; compliance enhancement in hospital; skills-based treatment; youth-nominated support team; therapeutic assessment at point of presentation; and developmental group psychotherapy.
Conclusions: Modified CBT, MBT and DBT may be effective in reducing the repetition of DSH among adolescents, but the findings require replication before the treatments can be widely recommended. The goals of treatment need also to be reconsidered, since a reduction in the frequency and severity of DSH may be a more realistic outcome than complete cessation.
Yoga Therapy in Psychiatric Treatment – Different Approaches
J Carter1,2, J Henry1,3,4,5, M de Manincor6,7,8
1University of Queensland, Brisbane, Australia
2Toowong Private Hospital, Brisbane, Queensland, Australia
3The University of Southern Queensland, Toowoomba, Australia,
4The Australia Society of Hypnosis, Sydney, Australia
5Health Journeys Australia, Toowoomba, Australia
6National Institute of Complementary Medicine, University of Western Sydney,
7The Yoga Institute, Sydney, New South Wales, Australia
8The Yoga Foundation, Sydney, New South Wales, Australia
Background: Each author has been a yoga practitioner, a yoga teacher and a yoga therapist. The transition from practitioner to therapist or teacher is done through mentorship as is done in psychoanalysis. Yoga with its eight limbs has been used in the treatment of psychiatric conditions in India and in the West gradually over the last 40 years. The efficacy of yoga therapy has been supported by research.
Objectives: The objective is to demonstrate how different yoga approaches of the same and different disciplines of yoga can achieve a similar therapeutic benefit for the patient.
Methods: The first author has used a variety of treatments recommended by the major yoga schools, tai chi and qi gong as adjuncts to ordinary psychiatric treatment in Vietnam War Veterans (Carter et al., 2013). The second author has taught yoga, become a yoga therapist and taught the iRest program within her psychology practice (Money, 2016). The third author has identified key components of yoga interventions for reducing depression and anxiety in a Delphi method study (de Manincor et al., 2015) and evaluated individualized yoga for reducing depression and anxiety in a randomized controlled trial (de Manincor et al., 2016).
Findings: The findings of the first author’s research are expressed in a double-blind controlled trial of Vietnam War Veterans each suffering from PTSD. The findings indicated that the treatment was effective in even severe PTSD (Carter et al., 2013) and effective in the treatment of major depression in a previous research trial (Brown et al., 2005a, b).
Conclusions: The state of current research indicates clearly that various forms of yoga are useful in the treatment of a variety of clinical conditions including psychiatric conditions.
References
Brown RP and Gerbarg PL (2005a) Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression: Part I – neurophysiologic model. Journal of Alternative and Complementary Medicine 11(1): 189–201.
Brown RP and Gerbarg PL (2005b) Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression: Part II – clinical applications and guidelines. Journal of Alternative and Complementary Medicine 11(4): 711–717.
Carter JJ, Gerbarg PL, Brown RP, et al. (2013) Multi-component yoga breath program for Vietnam veteran posttraumatic stress disorder: Randomised controlled trial (RCT) SciTechnol 2(3): 1000108.Doi:10.4172/2324-8947.1000108
de Manincor M, Bensoussan A, Smith C, et al. (2015) Establishing key components of yoga interventions for reducing depression and anxiety, and improving well-being: A Delphi method study. BMC Complementary and Alternative Medicine 15(85): 1–10.
de Manincor M, Bensoussan A, Smith C, et al. (2016) Individualized yoga for reducing depression and anxiety, and improving well-being: A randomized controlled trial. Depression and Anxiety 33: 816–828.
Comparison (1) Original Yoga Intervention of Krishnamacharya School of Yoga (TKV Desikachar, BKS Iyengar) with Yoga Nidra in a Group Therapy Format Compared With (2) Sudarshan Kriya Yoga in Ordinary Format Randomized Controlled Trial: Both Treatments Designed for the Treatment of Post-Traumatic Stress Disorder
J Carter1, P Gerbarg2, R Brown3, R Ware4, C D’Ambrosio5, L Anand5, M Dirlea5, M Vermani5,6 M Katzman5,6,7,8,9
1Toowong Private Hospital, Brisbane, Queensland, Australia
2New York Medical College, New York, USA
3Columbia University, New York, USA
4Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
5START Clinic for the Mood and Anxiety Disorders, Toronto, Ontario, Canada
6Department of Psychology, Lakehead University, Thunder Nay, Ontario, Canada
7Northern Ontario School of Medicine, Toronto, Ontario, Canada
8University of Toronto, Toronto, Canada
9Adler Graduate Professional School, Toronto, Canada
Background: The treatment of post-traumatic stress disorder (PTSD) using traditional medical treatments is often suboptimal. Hence, a search for various treatments to supplement, at least, traditional treatments. With this background, yoga has been subjected to trials (Brown and Gerbarg, 2005a,b; Carter et al., 2013).
Objectives: The objective was to test group 1, a psychiatric group meeting using yoga (Carter and Lolas, 2002; Iyengar, 2001: 337–348; Kraftsow, 1999: 318–323; Payne and Usatine (2002)), and group 2 (randomized controlled trial (RCT)) (Brown and Gerbarg, 2012; Carter et al., 2013).
Methods: The structure of group 1 was the format of an ordinary group therapy meeting with chairs arranged in a circle and yoga mats set out like the spokes of a wheel. The psychiatrist enquires about the physical health and emotional states of each participant to design the intervention. Hence, a different program is designed for each session. Group 2 (RCT) (Brown and Garbarg, 2012; Carter et al., 2013) was the exact opposite.
Findings: Group 1 is an ongoing group (since 2001) and is run weekly every Tuesday at the local Returned and Services League (RSL) Hall, whereas group 2 (Brown and Gerbarg, 2012; Carter et al., 2013) ran according to rigid protocols. Patients from both groups benefited considerably, but the degree of improvement in group 2 (Brown and Gerbarg, 2012; Carter et al., 2013) was far more marked, with much less treatment for at least 5 years, when a refresher course was considered beneficial.
Conclusions: The Yoga Nidra component is considered beneficial by group 1 (Payne and Usatine (2002)). It took longer for this group to develop the intimacy that a normal group forms, as many of the patients had strong avoidance behaviour. However, over years, true intimacy developed, and they care for each other, even though they are still somewhat avoidant.
Group cohesion was not a major factor in group 2 (Carter et al., 2013). The early research of Carter was shown on the Catalyst Program (2003) on the ABC television station in Australia and was repeated at least 40 times, and a DVD was provided to the author J Carter.
References
Brown RP and Gerbarg PL (2005a) Sudarshan kriya yogic breathing in the treatment of stress, anxiety, and depression: Part I – neurophysiologic model. Journal of Alternative and Complementary Medicine 11(1): 189–201.
Brown RP and Gerbarg PL (2005b) Sudarshan kriya yogic breathing in the treatment of stress, anxiety, and depression: Part II – clinical applications and guidelines. Journal of Alternative and Complementary Medicine 11(4): 711–717.
Brown RP and Gerbarg PL (2012) The Healing Power of the Breath. Boston and London: Shambhala.
Carter J, Gerbarg PL, Brown RP, et al. (2013) Multi-component yoga breath program for Vietnam veteran posttraumatic stress disorder: randomised controlled trial (RCT) SciTechnol 2(3): 1000108. DOI: 10.4172/2324-8947.1000108
Carter Janis J and Lolas C (2002) Yoga – adjunct to psychiatric treatment & yoga – preventative intervention. RANZCP Conference 2002, Brisbane Convention and Exhibition Centre – sales@brisconex.com.au
Iyengar BKS (2001) Yoga: The Path to Holistic Health, The Definitive Step-by Step Guide. London, UK: Dorling Kindersley.
Gary K (1999) Yoga for Wellness. New York, USA.
Larry P, Usatine Richard P, Mary A et al. (2002) Yoga Rx: A Step by Step Program to Promote Health, Wellness and Healing for Common Ailments. New York, USA: Broadway Books.
Presenter 2
iRest as Emotional and Cognitive Empowerment Training
J Henry1,2,3,4
1The University of Southern Queensland, Toowoomba, Australia
2The University of Queensland, Brisbane, Australia
3The Australia Society of Hypnosis, Sydney, Australia
4Health Journeys Australia, Toowoomba, Australia
Background: Trauma-focussed cognitive behavioural therapy (TF-CBT) and eye movement desensitization and reprocessing (EMDR) have been recommended as first-line psychological treatments for post-traumatic stress disorder (PTSD) (ACPMH, 2013). Emerging treatment research is exploring the potential effectiveness of non-trauma focussed interventions such as Mindfulness, and Acceptance and Commitment Therapy (Phelps, 2014).
An iRest military program, based on the ancient practice of Yoga Nidra, has been described as Emotional and Cognitive Empowerment Training, ‘mental fitness gear’, to treat and possibly prevent PTSD, and with potential as a safe, effective and acceptable treatment for combat and non-combat-related PTSD (Money 2016). iRest has also been viewed as an intervention for re-shaping neural pathways critical to fostering emotional self-regulation, ethical decision-making and resiliency.
Research has shown that the iRest Yoga Nidra protocol effectively reduces PTSD, depression, anxiety, insomnia, chronic pain and chemical dependency while increasing health, resiliency and well-being. The iRest protocol was developed by Dr Richard Miller and associates of the Integration Restoration Institute California (Miller, 2016).
Objectives: As formal accredited training in iRest was only introduced into Australia in 2013, the objective was to collect qualitative data on individual differences in response to utilization of the evidence-based iRest Yoga Nidra protocol in an applied and clinical setting.
Methods: Single-subject design (Cooper et al. 2007) was utilized to collect data on individual differences in the applied setting (Kadzin, 1982).
Findings: A group of Australian service veterans in this applied study reported benefit from being introduced to the non-stigmatizing iRest, as adjunct to cognitive processing. Individual differences in preference for use of differing stages in the protocol were noted and will be briefly commented on during the presentation.
Conclusions: Magnitude or outcome research on iRest has been demonstrated in overseas studies. Process research in Australia could contribute towards identifying cognitive styles of individuals when using the iRest adjunct intervention. Application of the Sheehan and McConkey Experiential Analysis Technique (EAT) as applied by Jackson and Sheehan (1986) offers opportunity for this purpose.
References
ACPMH (2013) Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder. Melbourne, Australia: Australian Centre for Posttraumatic Mental Health.
Cooper John O, Heron Timothy E and Heward William L (2006) Applied Behavior Analysis (2nd Pearson New International Edition). Lebanon, IN: Prentice Hall.
Jackson J and Sheehan P (1986) Imaginative capacity and individual differences in hypnotic responsivity. The Australian Journal of Clinical and Experimental Hypnosis 14(2): 139–152.
Kazdin AE (1982) Single-Case Research Designs: Methods for Clinical and Applied Settings. New York: Oxford University Press.
Phelps A (2014) Treatment guidance for Common mental health disorders: Posttraumatic stress disorder. In Cover feature: Common, serious and treatable. Psychological intervention I high prevalence common mental health disorders. InPsych Volume 36, Issue 6, Melbourne, Australia. https://www.psychology.org.au/Content.aspx?ID=6211
Presenter 3
Yoga as a Treatment for Anxiety and Depression and Improving Well-Being
M de Manincor1,2,3
1Australian Health Practitioners Registration Australia, Sydney, Australia
2The Yoga Institute, Sydney, Australia
3The Yoga Foundation, Sydney, Sydney, Australia
Background: Depression and anxiety are leading causes of disability worldwide. Current treatments are primarily pharmaceutical and psychological. Questions remain about effectiveness and suitability for different people. There is increasing interest in complementary and alternative approaches, including yoga. Previous research suggests potential benefits of yoga for reducing depression and anxiety.
Objectives: The aim of this study is to investigate the effects of an individualized yoga intervention (de Manincor et al., 2015) for reducing depression and anxiety and improving well-being (de Manincor et al. 2016).
Methods: Sample of 101 people with depression and/or anxiety participated in a randomized controlled trial comparing a 6-week yoga intervention with waitlist control. Both groups continued other treatments as usual. The control group was offered the yoga following the waitlist period. Participants were also assessed at a 6-week follow-up. Measures included the Depression Anxiety and Stress Scale (DASS21), the Kessler Psychological Distress Scale (K10), the Short Form Health Survey (SF12), the Scale of Positive and Negative Experience (SPANE), the Flourishing Scale (FS), and the Connor–Davidson Resilience Scale (CDRISC2).
Findings: There were statistically significant differences between yoga and control groups on reduction of depression, total DASS and psychological distress, improved mental health, increased positive experiences, reduced negative experiences, flourishing and resilience. Differences in reduced anxiety and stress and physical health scores were not statistically significant. Benefits were maintained or continued to improve at follow-up.
Conclusions: Yoga plus regular care was effective in reducing depression compared with regular care alone and continued to improve at follow-up. Further investigation is warranted for the reduction of anxiety. Yoga may be particularly beneficial in mental healthcare in the broader community.
References
de Manincor M, Bensoussan A, Smith C, et al. (2015) Establishing key components of yoga interventions for reducing depression and anxiety, and improving well-being: A Delphi method study. BMC Complementary and Alternative Medicine 15(85): 1–10.
de Manincor M, Bensoussan A, Smith C, et al. (2016) Individualized yoga for reducing depression and anxiety, and improving well-being: A randomized controlled trial. Depression and Anxiety 33: 816–828.
Later Career Psychiatry – Retirement or Retiring?
K Jenkins, C Peisah
The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
Abstract: This symposium is an official presentation of the Membership Engagement Committee (MEC) in collaboration with the Faculty of Psychiatry of Old Age, focussing on the well-being of later career psychiatrists. The symposium will highlight the different paths and the positive ways in which psychiatrists in later stages of their careers continue to participate and contribute.
Background: The MEC reflects the strategic priorities of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) around supporting members, enhancing the value of RANZCP membership, and considering different membership groups and their respective needs from the College. The MEC has identified the need to provide more relevant information and appropriate, practical resources for members in the later stages of their careers. Following the release of the MEC’s welfare study, the Faculty of Psychiatry of Old Age approached the MEC to collaborate on content to further support the well-being of later career psychiatrists.
Objectives: The symposium aims to have a practical focus on important issues faced by psychiatrists in the latter years of their careers, providing attendees with an opportunity to explore and discuss major career transitions.
Methods: Invited speakers will present vignettes and speak to a number of themes that support the well-being of psychiatrists in later careers by providing positive examples of ways they can contribute. For example, this may include focussing on a psychiatrist in the public sector who has successfully downsized but remained active in a service; trainees and early career fellows who benefit from the reflective wisdom of older psychiatrists working part-time in their service; a psychiatrist working on a mental health review tribunal; a psychiatrist exploring other interests (e.g. in the arts); and psychiatrists in academia and private practice.
Findings: Will become evident on the day.
Biopsychosocial and More: Treating Difficult to Treat Psychotic Disorder
D Siskind1,2, F Dark1,2, N Korman1,2, S Parker1,2, S Clark3
1Metro South Addiction and Mental Health Service, Brisbane, Australia
2University of Queensland, Brisbane, Australia
3University of Adelaide, Discipline of Psychiatry, Adelaide, Australia
Background: Despite advancement in our knowledge of different treatment options for people living with psychotic disorders, many psychiatrists and public mental health services are often faced with challenging cases that do not always respond to conventional treatment guidelines.
Objectives: To explore different treatment options for people with treatment refractory schizophrenia.
Methods: Five clinical researchers who work in public mental health services will present current evidence bases for different modes of treatment available for people with psychotic disorders.
Findings: There are many potentially effective treatment options for people with treatment refractory schizophrenia.
Conclusions: Improving treatment response for people with psychotic disorders is possible. However, it requires an organizational response to provide a comprehensive care with different treatment dimensions combining biological, psychosocial interventions as well as technology utilization and physical health monitoring.
Presenter 1
Clozapine and ECT for Treatment-Refractory Schizophrenia
D Siskind1,2
1Metro South Addiction and Mental Health Service, Brisbane, Australia
2University of Queensland, Brisbane, Australia
Background: Treatment-refractory schizophrenia refers to illness that has failed to respond to two adequate trials of antipsychotic medications. For people living with treatment-refractory schizophrenia, there are limited effective biological treatments. Existing effective treatments include clozapine and electroconvulsive therapy (ECT).
Objectives: To gain a better understanding of the evidence base for the effectiveness of biological treatment for treatment-refractory schizophrenia.
Methods: We review the existing literature on prevalence of treatment-refractory schizophrenia and explore the evidence base for biological treatments including ECT and clozapine.
Findings: Meta-analytic level evidence has demonstrated that clozapine is superior to all other antipsychotics for positive symptoms associated with treatment-refractory schizophrenia. For people who fail to respond to clozapine, there is increasing evidence to support a trial of ECT for acute psychotic symptoms.
Conclusions: Although there is evidence to support the use of ECT and clozapine for treatment-refractory schizophrenia, these treatments should be combined with psychological and social interventions.
Presenter 2
Psychological Therapies for Schizophrenia: Is It Worth the Bother?
F Dark1,2
1School of Public Health University of Queensland, Brisbane, Australia
2Metro South Addiction and Mental Health Service, Brisbane, Australia
Background: Psychological interventions for psychosis are often complex, requiring attention to training, supervision and fidelity and adherence of practice. Although psychological treatments are recommended as part of routine comprehensive care for schizophrenia, access to these therapies is limited.
Objectives: To report on the implementation of two psychological therapies into routine psychosis care in a mental health service.
Methods: A mixed methods approach was taken. Programs implemented and the fidelity of these programs was examined. Administrative data were examined to estimate the impact of these therapies on service use, and pre and post measures were collected on program outcomes.
Findings: It is feasible to implement and sustain psychological therapies for psychosis. The psychological therapies implemented reduced service use as well as clinical measures of symptomatology and function.
Conclusions: Poor access to evidence-based psychological care inflates the estimates of treatment resistance in psychosis. Implementing key evidence-based psychological therapies benefits the participant and service and is “worth the bother.”
Presenter 3
Evaluating Effects of a Physical Activity Intervention Implemented at a Residential Mental Health Rehabilitation Unit
N Korman1,2, D Siskind1,2, S Shah1, F Dark1,2, K Kendall3, K Nadareishvili1
1Addiction and Mental Health Services, Metro South Health Services, Brisbane, Australia
2School of Medicine, University of Queensland, Brisbane, Australia
3Queensland University of Technology, Brisbane, Australia
Background: Patients with severe and persistent mental illness are sedentary, have high cardiometabolic risk and reduced life expectancy. Physical activity programs have demonstrated positive effects on physical and mental health in patients with severe and persistent mental illness. There are increasing examples of successful integration of physical activity programs within mental health services in Australia; however, they are not yet embedded in usual care for patients with severe and persistent mental illness. The aim of this pilot study was to evaluate the implementation of a physical activity program delivered by exercise physiology students in a mental health residential rehabilitation setting.
Methods: Participants with severe and persistent mental illness from a residential rehabilitation unit were recruited to a 10-week physical activity circuit program lead by exercise physiology students. Primary outcome was fitness as estimated by a 6-min walk test. Secondary outcomes included metabolic health, positive and negative symptoms, and quality of life.
Results: There was broad level acceptance of the program (77% completion rates), and recruitment is ongoing. Early results showed promising improvements in fitness, sedentary behaviour; minutes of exercise engaged in and negative symptoms. Metabolic outcomes did not change.
Conclusions: Preliminary results reveal physical activity programs delivered by exercise physiology students appear acceptable and feasible for severe and persistent mental illness patients in a residential rehabilitation setting. Evaluating longer term physical activity engagement is warranted along with cost–benefit analysis of such programs. Dietary intervention was not included in this study, but the addition of this and its evaluation would be warranted in future studies.
Presenter 4
An Update on Social Interventions for Schizophrenia
S Parker1,2
1School of Public Health, University of Queensland, Brisbane, Australia
2Rehabilitation Academic Clinical Unit, Metro South Addiction and Mental Health Service, Brisbane, Australia
Background: People with treatment-refractory schizophrenia often lead impoverished social and vocational lives and struggle to obtain and maintain safe and stable accommodation. The three most frequently reported challenges identified by people with schizophrenia in Australia are financial matters, loneliness/social isolation and lack of employment. Addressing these social needs should be a high priority for service providers, policy makers and the community.
Objectives: The importance of considering social factors in the epigenesis and treatment of schizophrenia will be explored, with emphasis on interventions with an established or emerging evidence base. This exploration will consider evidence and debates relating to vocational rehabilitation; meeting accommodation needs; peer or mutual support; and social change initiatives including those targeting the stigma associated with a diagnosis of schizophrenia.
Methods: A narrative review of the literature.
Findings: There are multiple evidence-based social interventions to support people with treatment-resistant schizophrenia. However, there are limitations in the extent to which policy and practice can be guided by the existing evidence base.
Conclusions: Understanding what is known about social interventions for treatment-resistant schizophrenia will place psychiatrists in a better position to advocate for service users.
Presenter 5
Are Poor Outcome Trajectories in Psychosis Predictable at First Episode?
S Clark1, O Schubert1,2, A Olagunju1, E Lyrtzis1, B Baune1
1University of Adelaide, Discipline of Psychiatry, Adelaide, Australia
2Northern Adelaide Local Health Network, Adelaide, Australia
Background: There are no methods to accurately predict outcome following the first psychotic episode (FEP). However, there is an increasing body of research identifying variables of small effect size, which when combined in multivariate models could help to identify poor outcome trajectories at FEP.
Objectives: To explore the use of probabilistic modelling for the prediction of poor outcome following FEP.
Methods: We review evidence from investigations in clinical psychiatry, neuroimaging, neurocognition, and blood biomarker research suggesting that distinct biopsychosocial patterns exist at FEP that can describe the risk of individual illness progression and functional trajectories. We construct a probabilistic model based on two key studies using the odds ratio form of Bayes Rule for prediction of long-term outcome at FEP.
Findings: In simulation, the presence of poor prognostic clinical characteristics (male gender, low education level, poor insight, poor premorbid adjustment, non-independent accommodation) plus magnetic resonance imaging characteristics indicating chronic course was sufficient to separate patients into very high (>0.8) and very low (<0.2) probability of poor outcomes.
Conclusions: More detailed longitudinal studies of the association between emerging biomarkers and long-term outcomes are required. Simple probabilistic models may be useful to help clinicians personalize early treatment decisions in psychosis. We describe a new study, the Cognitive and Functional Assessment of Psychosis Staging Study (CoFAPSS), designed to explore biopsychosocial predictors of outcome in psychosis.
The national disability insurance scheme: An Update
The National Disability Insurance Scheme (NDIS) is a fundamentally new way in Australia for providing support to people with intellectual, physical, sensory and psychosocial disabilities.
The NDIS replaces the old system of ‘block’ funds going to organizations providing support. Rather, eligible people are assessed and allocated individualized funding. The idea is that everyone’s support needs are different and that each person can exercise choice and control over which services they receive, such as personal care and support, community-based intervention and therapy services and essential equipment.
The NDIS was launched in 2013 in a number of trial sites and is now being progressively rolled out in most states and territories. When it is fully operational in 2019, the scheme will serve around 460,000 participants.
This symposium will provide an update on what the NDIS means for psychiatrists, consumers and carers. Presenters will provide examples of how the NDIS is working in their jurisdiction and its impact for consumers and carers. A panel discussion will provide the opportunity for audience questions.
Functioning in Children and Adolescents with ADHD
M Mulraney1,2,3, N Zendarski1,2, M Bisset1,4
1Murdoch Childrens Research Institute, Melbourne, Australia
2Department of Paediatrics, The University of Melbourne, Melbourne, Australia
3The Royal Children’s Hospital, Melbourne, Australia
4School of Psychology, Deakin University, Melbourne, Australia
Background: Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder of childhood, affecting approximately 5% of children worldwide (Polanczyk et al, 2007). Compared to their non-ADHD peers, children with ADHD have impaired functioning across a number of domains including social difficulties, academic underachievement, and mental health comorbidities (Efron et al., 2014). In the long term, children with ADHD are at increased risk for poor educational attainment, substance abuse, adult psychiatric disorders, and unemployment (Sciberras et al., 2009).
Objectives: To present findings from three longitudinal studies examining the functioning of children with ADHD over time.
Findings: At any given point in time, children with ADHD are functioning more poorly than their non-ADHD peers across a number of domains. Those differences continue over time, and in some cases worsen, despite most children receiving standard ADHD treatments. The presentations will highlight potentially modifiable predictors of outcome that may be targets for intervention to improve children’s trajectories.
Conclusions: Even when core ADHD symptoms are effectively managed by medication, children with ADHD continue to have significantly poorer quality of life and impaired functioning compared to their non-ADHD peers. Given the high presence of comorbidities in children with ADHD, clinicians should ensure they regularly screen for associated problems. The identification and management of comorbid health and mental health problems in children with ADHD will likely improve their functioning in both the short and long term.
References
Efron D, Sciberras E, Anderson V, et al. (2014) A controlled community study of functional status in attention-deficit/hyperactivity disorder at age 6-8. Pediatrics 134: e992–e1000.
Polanczyk G, de Lima MS, Horta BL, et al. (2007) The worldwide prevalence of ADHD: A systematic review and metaregression analysis. American Journal of Psychiatry 164: 942–948.
Sciberras E, Roos LE, Efron D (2009) Review of prospective longitudinal studies of children with ADHD: Mental health, educational, and social outcomes. Current Attention Disorders Reports 1: 171–177.
Presenter 1
Early High School Academic and Non-Academic Outcomes for Students with ADHD
N Zendarski1,2, F Mensah1,2,3, E Sciberras1,2,3,4, H Hiscock1,2,3
1Murdoch Childrens Research Institute, Melbourne, Australia
2The University of Melbourne, Melbourne, Australia
3The Royal Children’s Hospital, Melbourne, Australia
4Deakin University, Melbourne, Australia
Background: Despite the transition to high school being a potential ‘make or break’ period for children with attention-defecit/hyperactivity disorder (ADHD), a limited body of research has examined childrens’ functioning during this critical period.
Objectives: To describe the academic achievement and school engagement for young people with ADHD in early high school and identify potentially modifiable factors associated with poor transition outcomes.
Methods: Students (n = 130) in the first and third year of high school (12–15 years) were recruited from an existing cohort of children with ADHD. Academic outcomes were measured on standardized tests (National Assessment Program – Literacy and Numeracy (NAPLAN)). Measures of engagement included student attitudes to school and suspension. Multivariable regression analyses examined factors associated with academic achievement and engagement, including ADHD symptoms, emotional and behavioural problems, child depression, and family, school and sociodemographic characteristics.
Findings: Students with ADHD demonstrated significantly poorer academic functioning, lower school engagement and poorer social–emotional functioning in comparison to state benchmarks and normative data. In comparison to state data, students with ADHD in the first year of high school were less motivated (p < 0.01) and less connected to peers (p < 0.01). There were high rates of suspension in the first and third year of high school (21% versus 6%, p < 0.01). Modifiable factors associated with transition outcomes included behavioural problems, bullying, poor family management and depression.
Conclusions: Findings highlight the large achievement gap in this critical period. Interventions targeting child depression, behavioural problems and family management may enable students with ADHD to manage the high school transition period more successfully.
Presenter 2
Differences in Body Dissatisfaction and Weight Control Behaviour between Children with ADHD and Non-ADHD Controls: A Population-Based Study
M Bisset1,2, N Rinehart1, E Sciberras1,2,3
1School of Psychology, Deakin University, Melbourne, Australia
2Population Health, Murdoch Children’s Research Institute, Melbourne, Australia
3Department of Paediatrics, The University of Melbourne, Melbourne, Australia
Background: Evidence suggests an association between attention-deficit/hyperactivity disorder (ADHD) and eating disorders/pathology (Levin and Rawana 2016). However, research examining this association has utilized samples across wide age ranges, so it is unknown when these symptoms emerge.
Objectives: This study aims to compare risk factors for eating disorders/pathology in children with ADHD and non-ADHD controls at ages 8–9, 10–11 and 12–13 years.
Methods: This study uses three waves of data from the nationally representative Longitudinal Study of Australian Children (LSAC) (N = 2792–2979). ADHD was defined by hyperactivity–inattention scores > 90th percentile by both parent and teacher report on the Strengths and Difficulties Questionnaire (SDQ) (5.7–7.0% of children at any wave). Eating pathology was assessed via child report.
Findings: Although no differences in body dissatisfaction were found by ADHD status at age 8–9 years (p = 0.21), differences emerged at 10–11 years (odds ratio (OR): 1.4; 95% confidence interval (CI): 1.0–1.9; p = 0.03) and 12–13 years (OR: 1.5; 95% CI: 1.0–2.1; p = 0.03). Results held when adjusting for body mass index, gender and maternal education and also when excluding those taking ADHD medication. Engagement in weight control behaviour was associated with ADHD status at ages 10–11 years (p = 0.001) and 12–13 years (p = 0.03). Children with ADHD were more likely to try to lose weight (42% vs 34% and 40% vs 35%, respectively) or gain weight (10% vs 5% and 9% vs 5%, respectively) compared to non-ADHD controls.
Conclusions: Findings suggest that two significant risk factors for eating disorders/pathology are more prevalent in children with ADHD from 10 to 11 years, highlighting the importance of assessing for these risk factors throughout pre-adolescence during clinical encounters.
Reference
Levin RL and Rawana JS (2016) Attention-deficit/hyperactivity disorder and eating disorders across the lifespan: A systematic review of the literature. Clinical Psychology Review 50: 22–36.
Presenter 3
The Associations between Quality of Life and ADHD Symptoms Over a 12-Month Period in Children with ADHD
M Mulraney1,2,3, R Giallo1, E Sciberras1,2,4, K Lycett1, F Mensah1,2,3, D Coghill2,5
1Murdoch Children’s Research Institute, Melbourne, Australia,
2Department of Paediatrics, The University of Melbourne, Melbourne, Australia
3The Royal Children’s Hospital, Melbourne, Australia
4School of Psychology, Deakin University, Melbourne, Australia
5Department of Psychiatry, The University of Melbourne, Melbourne, Australia
Background: Children with attention-deficit/hyperactivity disorder (ADHD) typically have quality of life (QoL) ratings around 1.5–2 standard deviations (SD) below population norms. Although effective interventions that reduce ADHD symptoms also improve QoL, the QoL scores tend to remain at least 1 SD below the population average.
Objectives: To describe the relationships between ADHD symptom severity and QoL at three time points over a 12-month period.
Methods: Children aged 5–13 years with ADHD were recruited from 21 paediatric practices across Victoria, Australia (N = 392). Child QoL (parent-report using the Pediatric Quality of Life Inventory 4.0) and ADHD symptoms (both parent and teacher-report using the ADHD Rating Scale IV) were assessed at three time points across a 12-month period (0, 6 and 12 months). Data were analysed using Pearson’s correlations and autoregressive cross-lagged panel models.
Findings: Parent-reported ADHD symptoms and QoL were moderately negatively correlated at each time point (r = − 0.38 to − 0.53), but teacher-reported ADHD symptoms and QoL were only weakly negatively correlated at 6 months (r = − 0.19) and 12 months (r = − 0.25). Parent-reported ADHD symptoms predicted poorer QoL at each subsequent time point (r = − 0.10 to − 0.13), and there was a small bidirectional relationship observed between teacher-reported ADHD symptoms and QoL from 6 to 12 months.
Conclusions: Change in core ADHD symptoms over time is only one of the influences on change in QoL over time. To improve the QoL in children with ADHD, clinicians need to look beyond symptom control to identify other factors that may be influencing QoL in this population.
Gender Dysphoria: A Clinical Perspective
C Ward1,2,3, F Harte1,2,3,4, M Turner3,5,6, J Erasmus1,3, R Lyons3,6
1Gender Dysphoria Clinic, Monash Health, Melbourne, Australia
2The Albert Road Clinic, Melbourne, Australia
3Australian and New Zealand Professional Association for Transgender Health (ANZPATH), Adelaide, Australia
4The University of Melbourne, Melbourne, Australia
5University of Adelaide, Adelaide, Australia
6Private Practice, Melbourne, Australia
Background: Gender dysphoria is a prominent topic in the public domain. Reported prevalence, help-seeking and research are all increasing. There are higher rates of psychopathology, self-harm and completed suicide in this group.
Objectives: To address issues relevant to clinical psychiatric practice.
Methods: Presentation of clinical expertise by psychiatrists from diverse backgrounds, including literature review and case examples.
Findings: The history, classification, diagnostic areas and current care standards are addressed. ‘Classic’ adult cases are presented with management options. Child/adolescent issues of gender identity and broader developmental issues are explored. Current controversies are visited.
Conclusions: Gender dysphoria is a controversial and evolving field. Psychiatrists have an important and challenging role in assessment and management strategies.
Presenter 1
Gender Dysphoria: Historical Development in Psychiatry
F Harte1,2,3,4
1Australian and New Zealand Professional Association for Transgender Health (ANZPATH), Adelaide, Australia
2Albert Road Clinic, Melbourne, Australia
3Gender Dysphoria Clinic, Monash Health, Melbourne, Australia
4The University of Melbourne, Melbourne, Australia
Background: Mental health services have experienced an exponential rise in trans-identified client referrals over the past decade. This is in part due to media attention and a rapid spread of information through the Internet and emancipation of the lesbian, gay, bisexual, transgender and intersex (LGBTI) population in general.
Objectives: To review the historical development of gender diagnoses in psychiatry and the paradigm shift in clinical interventions.
Methods: A review of gender diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Disease (ICD) was undertaken along with a review of successive versions of the standards of care (SOC) published by the World Professional Association for Transgender Health (WPATH).
Findings: A diagnosis relating to gender variance was first listed in DSM-2 (1968) as transvestitism [sic] under the parent category sexual deviations. Diagnoses in the DSM, fifth edition (DSM-5) (2013) are gender dysphoria in children and gender dysphoria in adolescents and adults. The parent category is gender dysphoria. Similarly, a diagnosis relating to gender variance was first listed in the ICD, eighth revision (–ICD-8) (1965) as transvestitism [sic] and again under the parent category sexual deviations. Proposed diagnoses in the ICD, eleventh revision (ICD-11) are gender incongruence of adolescence and adulthood. The proposed diagnosis of ‘gender incongruence of childhood’ remains controversial. It is proposed to move these diagnoses out of mental and behavioural disorders.
Conclusions: Gender variance–related diagnoses in psychiatric classification systems have seen progressive de-pathologization of the condition over the past 7 decades. This is mirrored in changes to the shifting treatment paradigm resulting in less-restrictive access to clinical interventions including hormones and surgery. The changes pose significant clinical challenges for psychiatrists.
Reference
Drescher J, Cohen-Kettenis P and Winter S (2012) Minding the body: Situating gender identity diagnoses in the ICD-11. International Review of Psychiatry 24(6): 568–577.
Presenter 2
Adult Gender Dysphoria: ‘Classic Cases’
C Ward1,2
1Gender Dysphoria Clinic, Monash Health, Melbourne, Australia
2The Albert Road Clinic, Melbourne, Australia
Background: Given the recent enormous increase in the presentation of patients with gender-related issues, it is timely for a clinical overview.
Objectives: To illustrate using ‘classic cases’ female to male (FtM) and male to female (MtF) individuals with gender dysphoria as assessed and managed during their transition in a clinical psychiatric setting in alliance with a multidisciplinary team.
Methods: De-identified composite case studies.
Findings: Stereotypical cases recall a childhood history of non-gender conforming choices of play, activity and friends. Bullying is not uncommon. Dysphoria intensifies during puberty. Depressive symptoms, disorders, self-harm and suicide rates are elevated. Other comorbidities may be present. Differential diagnoses such as psychosis and paraphilias seem rare. Current transition management guidelines require a psychiatric opinion to address suitability for cross-hormone treatment in adults. Additional criteria exist for the provision of some surgery with two opinions needed for genital re-assignment. Facial and vocal cord surgery and speech therapy are options. Family, employment, discrimination, harassment, legal name change and financial issues are examples of other concomitant concerns.
Conclusions: As shown through case studies, psychiatrists have a unique potential to contribute to the burgeoning field of care in those with gender-related issues.
Reference
Bouman W, de Vries A and T’Sjoen G (2016). Gender dysphoria and gender incongruence: An evolving inter-disciplinary field. International Review of Psychiatry 28(1): 1–4.
Presenter 3
Transgender Across the Ages
M Turner1,2
1University of Adelaide, Adelaide, Australia
2Private Practice, Adelaide, Australia
Background: In child and adolescent psychiatry, we are seeing increasing numbers of children who wish to discuss gender identity. Many have read a range of websites and gone to chat rooms and come away from these with an array of knowledge and many questions. The role of the child and adolescent psychiatrist is to help provide the right information and treatment pathways as well as continue to build a strong therapeutic relationship.
Objectives: In this presentation, we will be covering some of the more pertinent areas of working with children and adolescents who present with questions around gender and gender identity. In particular, we address the assessment and treatment pathway for those younger than 18 years.
Method: A review of the Australian and international literature as well as a review of local practice.
Findings: (1) Gender identity and its changing presentations in children and adolescents. (2) Gender roles and educational environments – what schools do well and where they struggle. (3) Puberty suppression – its role in transitioning for children and the science behind its use. (4) Family work and the child – its role in gender-based work. (5) Gender and autism – the challenging decisions.
Conclusions: Working with children and adolescents with gender dysphoria presents unique issues.
Presenter 4
Gender Dysphoria: Current Controversies
J Erasmus1,2, R Lyons2,3
1Gender Dysphoria Clinic, Monash Health, Melbourne, Australia
2Australian and New Zealand Professional Association of Transgender Health (ANZPATH), Adelaide, Australia
3Private Practice, Adelaide, Australia
Background: In a field which is evolving at a rapid pace, it comes as no surprise that there are numerous controversies and clinical dilemmas that clinicians face when working with clients who experience gender dysphoria.
Objectives: To address four topics of current interest.
Methods: Literature review and clinical practice.
Findings: (1) Non-binary identities: Recent evidence suggests that up to 4.6% of individuals identify with a gender which is neither male nor female. Referral numbers for people who are seeking partial masculinization or partial feminization or even total elimination of all gender markers are increasing. Clinicians have little or no evidence base for safe and effective treatments. (2) The prevalence of autism spectrum disorder among those with gender dysphoria is eight-fold higher than the general population. Rigid preoccupation and difficulties in social interaction and communication result in significant assessment and management challenges. (3) The proposal to move gender incongruence out of the mental and behavioural disorders chapter in the International Classification of Disease, eleventh revision is seen as a significant attempt to depsychopathologize gender variance in adults. The proposal to retain the diagnosis of gender incongruence in childhood, however, has divided clinicians. (4) ‘Informed consent’ models of care emphasize the right of an individual to self-determine their gender identity and remove the requirement for a mental health assessment prior to initiating medical gender transition treatments. Although popular with consumers, these models of care concern mental health professionals.
Conclusions: The area of gender dysphoria raises ongoing controversial issues.
Panel Presentation Abstracts
Recruitment into Psychiatry – Engaging the Next Generation of Psychiatrists
M Tomasic, M Hopwood, A Willis, P Hay, D Menkes, G Byrne, K Jenkins
Recruitment into Psychiatry Working Party, The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
Background: Psychiatry has been a less popular career choice among Australasian medical students and early career doctors.
Objectives: To dispel common misconceptions, raise the profile and promote psychiatry as a vibrant and challenging career choice.
Methods: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) through its Recruitment into Psychiatry Project, supported by Commonwealth funding, has developed a suite of initiatives to engage with medical students and graduates including the Psychiatry Interest Forum (PIF), student sponsorships to attend the RANZCP Congress and NZ National conferences, dedicated PIF events, a binational essay competition, Introduction to Psychiatry short courses, and relationship building with university medical schools in Australia and New Zealand.
Findings: The initiatives have been welcomed by students, graduates and universities:
More than 1800 students and graduates have joined the PIF.
More than 100 students and graduates have been sponsored to attend the RANZCP Congress and more than 130 to attend NZ National conferences.
More than 230 participated in the Introduction to Psychiatry courses.
Course attendees 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 2013, 187 members have progressed into psychiatric training, approximately 21% of eligible PIF members.
The success of these initiatives is thanks to the involvement of more than 100 fellows and trainees.
Conclusions: The Recruitment into Psychiatry Project is successfully raising the profile of psychiatry and providing RANZCP fellows and trainees the opportunity to engage with and inspire the next generation of psychiatrists.
DSM-5 Debate: Should Internet Gaming Disorder be Included in the DSM?
The panel will include panelists divided into two teams of three. The panelists will debate on whether “Internet Gaming Disorder” (IGD) should be included in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5). Each panelist will have 8 min to present their case for or against the inclusion of IGD.
To encourage participation and engagement, the audience can vote live using real-time polling technology via the Congress App. So please download the Congress App prior to the session.
There will be 30 min of Q&A to stimulate further discussion at the end of the debate. The duration of this session will be a total of 90 min.
M Ali1, HK Le2, P Tam3, P Dullur4,5, V Starcevic6, J Juredini7
1Department of Social Work and Social Planning, Flinders University, Adelaide, Australia
2Women’s and Children’s Hospital Network, Adelaide, Australia
3Rivendell Adolescent Unit, Sydney, Australia
4Southwest Sydney Local Health District, Sydney, Australia
5School of Medicine, Western Sydney University, Sydney, Australia, Australia
6University of Sydney, Sydney, Australia
7Critical and Ethical Mental Health Research Group, University of Adelaide, Adelaide, Australia
Abstract: Since its inclusion in section 3 of the DSM-5 in 2013 as a condition for further research,1 Internet gaming disorder (IGD) has caused much controversy over its conceptualization2,3 and whether this should be included as a valid disorder, reclassified or not included at all. This live “DSM Debate” will invite speakers from Australia to either speak “for” or “against” the inclusion of IGD in the DSM. This will be an exciting session not to be missed.
Background: For example, the second Australian Department of Health Child and Adolescent Survey of Mental Health and Wellbeing4 found that adolescents with major depressive disorder had a higher prevalence of problem (addictive) Internet and Electronic Gaming behaviour. This is a fundamental IGD dilemma where we must ask ourselves; “Which came first? The chicken or the egg?” Is IGD a disorder in its own right that can lead to a major depressive episode? Does major depression and other psychiatric disorders lead to excessive use of Internet Games to cope with the dysfunction related to these disorders? Does IGD pathologize otherwise normal behaviour such as play in the context of a modern, Internet connected era?
Objectives: The audience will walk away with a better understanding of IGD and psychiatry, focusing on its conceptualization and use clinically in Australia. This will hopefully allow for greater discussion and ongoing research.
Methods: Our panelists will use their clinical experience and expertise in the field of IGD, psychiatry and research to present the current evidence for and against the inclusion of IGD in the DSM.
Findings: Please see individual speaker bios.
SPEAKER 1 FOR IGD INCLUSION
Dr Mubarak Rahamathulla is a senior lecturer in social work at Flinders University. His research interest has been on social aspects of digital technology use by young people in Australia. He conducted a survey on pathological internet use by university students and associated psychosocial issues. IGD was identified by this survey as a major challenge closely associated with many psycho-social problems of young people. Based on this research evidence and also based on the research evidences reported from other countries in the world, Mubarak will argue that IGD needs to be recognized as a psychiatric condition at the earliest possible so that young people suffering from this condition can have access to necessary mental health services in the community
SPEAKER 2 FOR IGD INCLUSION
Dr Huu Kim Le is a child and adolescent psychiatrist based in Adelaide. He conducted a 6-month Clinical Fellowship at Institute of Mental Health, Singapore, investigating internet gaming disorder at the National Addictions Management Service adolescent clinic. He has a passion for the assessment and treatment of children and adolescents with IGD. Dr Le is collaborating with local Universities in Adelaide to conduct further research and academic teaching in IGD. He also founded cgiclinic.com, a free Internet awareness website, for Australian parents, teachers and clinicians.
SPEAKER 3 FOR IGD INCLUSION
Dr Philip Tam is a Sydney-based child psychiatrist in public practice and lecturer with Sydney University. He has a long-standing clinical, teaching and advocacy interest in the challenging field of internet and computer-related disorders and regularly lectures on the topic to both specialist and general audiences. He founded the Network for Internet Investigation and Research Australia (NiIRA), a not-for-profit organization, to promote discussion, debate and dissemination of topics related to the internet and well-being. Dr Tam also sits on the DSM-5’s IGD International Working Group.
SPEAKER 1 AGAINST IGD INCLUSION
Dr Pravin Dullur is a psychiatrist based in Sydney. He conducted an online survey assess health literacy among Australian and New Zealand psychiatrists on IGD. Arguments against IGD include lack of clarity of the definition, presence of wider problems with the internet such as problematic internet use (PIU), differences between IGD and PIU, for example, prevalence, differences in gender distribution and the need for a broader category such as screen use disorder. The place of IGD and related problems under the umbrella of behavioural addictions is also discussed. Wider issues such as overlap between IGD and excessive screen time are presented.
SPEAKER 2 AGAINST IGD INCLUSION
Professor Starcevic is a psychiatrist and associate professor of psychiatry at the University of Sydney, Sydney Medical School – Nepean. He has an interest in excessive video game and Internet use and has conducted a large international online survey on video game use. He also regularly comments in ANZJP on the conceptualization of behavioural addictions such as IGD.
SPEAKER 3 AGAINST IGD INCLUSION
Professor Jon Juredini heads The Critical and Ethical Mental Health (CEMH) research group, which conducts research, teaching and advocacy in order to promote safer, more effective and more ethical research and practice in mental health. Evidence indicates that unhappiness, distress, and stress are inappropriately medicalized, resulting in overdiagnosis and the unnecessary prescription of psychiatric drugs. At the same time, there is inadequate treatment and support for people with serious chronic mental illnesses.
Conclusions: The audience will have an opportunity to decide for themselves from the evidence presented by voting live using real-time polling technology via the Congress App. The audience can vote either
‘Yes – Internet Gaming Disorder should be included in the DSM-5’
or
‘No – Internet Gaming Disorder should not be included in the DSM-5’.
We request that the audience please download the Congress App prior to the session.
References
1. DSM-5 American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders. Arlington: American Psychiatric Publishing.
2. L King and Delfabbro PH (2013) Issues for DSM-5: Video-gaming disorder? Australian and New Zealand Journal of Psychiatry 47: 20–22.
3. Starcevic V (2013). Is Internet addiction a useful concept? Australian and New Zealand Journal of Psychiatry 47(1), 16–19.
4. Lawrence D, Johnson S, Hafekost J et al. (2015) The Mental Health of Children and Adolescents. Report on the Second Australian Child and Adolescent Survey of Mental Health and Wellbeing. Canberra: Department of Health.
Oral Presentation Abstracts (including PIF Presentation and Rapid Fire Presentation)
Doubling: International Clinical Partnerships can Support Services in Developing Countries
J Jureidini
The University of Adelaide, Adelaide, Australia
Mental health professionals working in high-income usually have good salaries, and clinical and academic departments are relatively well resourced. It is often assumed that low and middle-income countries lack trained health professionals. In reality, in many jurisdictions, there are adequately trained specialists but no money to employ or support them to their full capacities.
Such therapists can be employed for a fraction of the cost of a senior mental health clinician in a high-income country. Thus, manageable sacrifice by a well-off therapist (or small group of therapists) in a wealthy country can potentially double the productivity from their salary/income.
Just as importantly, doubling can foster a partnership between two or more therapists working in very different circumstances. This will lead to mutual learning and potential exchange of materials and expertise. As well, it will provide teaching or training opportunities for other members of the clinical teams.
Partnerships might also be set up between departments or organizations rather than individuals. An academic or clinical group in each country could establish a relationship analogous to sister cities, whereby each takes interest in, and promotes the activity of, the other, with the wealthier sister also providing financial and other support.
Two established projects will be presented with a view to engage other psychiatrists to develop their own projects, or partner with clinicians in other countries who are seeking support. There are tax advantages for donors if the financial support between partners goes through a charity with tax deductibility status.
The Uthando Project, an Australian-based charity founded by Julie Stone in 2004, works in partnership with dlalanathi, a small, committed team of professionals working in KwaZulu-Natal, South Africa. The money is given to help finance training by dlalanathi to grow their work helping families and communities to build capacity to respond protectively to children in distress.
Jon Jureidini’s partnership with a trauma therapist employed by the Trauma Rehabilitation Service in Ramallah, Palestine, facilitated by Australian Palestinian Partnerships in Education and Health (APPEH).
Managing Repeated Self-Harm in Long-Term Inpatients
R Maheshwari
University of New South Wales, Sydney, Australia
Background: Repeated self-harm causes high anxiety for inpatient staff and presents a significant barrier to effective multidisciplinary team orientation to therapeutic goals for long-term inpatients with personality disorder (PD). Recent Royal Australian and New Zealand College of Psychiatrists (RANZCP) and other international, therapeutic guidelines have mostly focussed on short-term hospitalization and effective psychological treatment in the community for repeated self-harm.
Objectives: This paper will discuss a multidisciplinary model of assessment and management of repeated self-harm by people with primarily PD diagnosis in long-term inpatient settings, such as forensic units.
Methods: A case study of a female forensic patient with borderline personality disorder in a medium-secure unit with repeated self-harm and challenges for the multidisciplinary team, particularly the frontline staff. The principles and strategies based on practice guidelines, literature review and psychotherapeutic understanding are discussed.
Findings: Consistent multidisciplinary approach is a fundamental part of managing complex patients with PD in inpatient units. Repeated self-harm generates anxiety about adverse outcomes, confusion about therapeutic goals, and fragmentation in consistent team functioning. Variable knowledge and skills base among front-line multidisciplinary staff and patient’s history of interpersonal trauma and inability to form epistemic trust are all significant barriers to an effective therapeutic response. A model for management of repeated self-harm, particularly in a long-term inpatient setting, needs to include intervention for both staff and the patient.
Conclusions: A model based on clear principles and a graded algorithm for the front-line multidisciplinary staff in assessing and managing repeated self-harm is essential to maintain therapeutic focus and safety of complex long-term inpatients with PD.
Long-Term Follow-Up Study on Deep Brain Stimulation For Severe Obsessive–Compulsive Disorder
L Gabriëls1, L Luyten2, S Raymaekers1, B Nuttin2
1UPC-KU Leuven University Center for OCD, Leuven, Belgium
2KU Leuven Research Group Experimental Neurosurgery and Neuroanatomy, Leuven, Belgium
Background: Obsessive–compulsive disorder (OCD) is a severe psychiatric condition, hallmarked by obsessive thoughts and compulsive rituals that cause severe distress. In some patients, OCD remains unresponsive to both pharmacological and psychotherapeutic treatments. In 1998, we proposed deep brain stimulation (DBS) as a last-resort treatment for patients suffering from severe, treatment-resistant OCD.
Objectives: The objective of the study was to alleviate OCD symptoms by DBS and to document adverse events.
Methods: Twenty-four patients were included in a long-term follow-up study and received DBS lead implants in the anterior limb of the internal capsule (ALIC)/bed nucleus of the stria terminalis (BST). After the initial parameter optimization phase, patients entered a double-blind, randomized crossover study with either stimulation on (ON phase) or not (OFF phase). After completing both crossover arms (ON–OFF or OFF–ON), the patient could choose to be continuously stimulated. We report data on follow-up between 4 and 16 years.
Findings: We find that DBS for OCD is safe and significantly decreases obsessions, compulsions, and associated anxiety and depressive symptoms and improves global functioning in a blinded crossover trial (n = 17), after 4 years (n = 18), and at last follow-up (up to 171 months, n = 24). Moreover, our data indicate that the BST may be a better stimulation target than ALIC to alleviate OCD symptoms.
Conclusions: DBS in the BST is a promising therapeutic option for otherwise treatment-resistant patients with OCD.
Neuropsychiatric Complications of Subthalamic Nucleus Deep Brain Stimulation for Parkinson’s Disease
R Long
Flinders Medical Centre, Adelaide, Australia
Background: Deep brain stimulation (DBS) for Parkinson’s disease is an increasingly common treatment providing dramatic motor improvements and improved quality of life for sufferers. Neuropsychiatric complications occur and may be seen in patients who present to psychiatrists.
Objectives: This paper provides an understanding of neuropsychiatric complications of DBS treatment, and how to identity and manage them.
Methods: The neuroanatomical, functional and surgical aspects of DBS and complications are described. An approach to management is described.
Findings: The DBS treatment can generate complications in mood, anxiety, motivation, relationships and a significant increase in suicide risk. These can be managed.
Conclusions: Psychiatrists need an awareness of movement disorder neuropsychiatric complications and how to approach the patient living with a deep brain stimulator and Parkinson’s disease.
ECT Stimulus Titration: A Festival of Pseudoscience
S Rosenman
St John of God Health Care, Sydney, Australia
Background: Stimulus titration for electroconvulsive therapy (ECT) has become standard procedure in Australia following recommendations in most countries. The attraction of the method is that it is ‘scientific’ and precise compared with more approximate methods such as age or formula-based dosing.
Objective: To examine the history, knowledge and effects of stimulus dosing in ECT to judge again if the apparent advantages have been vindicated in research and practice. Also, to look again at the balance of advantages and disadvantages of ECT.
Findings: Stimulus dosing has failed to show better efficacy or lesser ill-effects in research settings. It exposes patients to a significantly higher number of treatments. Surprisingly, the apparent precision of stimulus dosing is illusory as, even in research settings, there are no standard parameters by which thresholds are detected nor is there agreement about multipliers of threshold dose for treatment and no ‘science’ to the recommendations. In practice, procedures vary between sites and even one site may employ multiple standards.
Conclusions: Stimulus titration appears to be pseudoscientific, and its current wide recommendation reflects assertion rather than proven advantage. This needs to be re-examined more dispassionately.
Proposal for an Advanced Training Program in ECT and Neurostimulation
S Gill1, A Weiss2,3
1Ramsay Healthcare Neurostimulation Service, South Australian Psychiatry Training Committee, Adelaide, Australia
2University of Newcastle, Newcastle, Australia
3Section of ECT and Neurostimulation (SEN), The Royal Australian and New Zealand College of Psychiatrists, Newcastle, Australia
Background: There have been many advances in knowledge in electroconvulsive therapy (ECT) and new neurostimulation techniques. Therefore, the SEN has proposed to introduce an advanced certificate in ECT and neurostimulation to provide an opportunity for stage 3 trainees, and fellows, to develop advanced specialty skills in this field.
Objectives: To present audience members with information about how this proposed advanced certificate program will be structured.
Methods: The proposed ECT/neurostimulation entrustable professional activities (EPAs) and other training requirements will be outlined and presented
Findings: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has several advanced certificates available – three focussing on specific patients’ age groups (child, adult and old age), two on specific settings (consultation–liaison and forensic), one on an area of practice (addiction) and one on an intervention (psychotherapy). An advanced certificate in ECT and neurostimulation would complement these, being the second certificate to focus on a specific and important intervention in psychiatry.
Conclusions: An advanced certificate in ECT and neurostimulation is feasible, would fit alongside other advanced training programs of the RANZCP and would offer trainees an opportunity to develop and enhance their skills in this important area.
A Whole-of-System MH&A Integration Transformation Agenda: Challenges and Early Successes
C Bensemann
Counties Manukau District Health Board, Auckland, New Zealand
Background: Counties Manukau Health has begun a whole-of-system integrated mental health and addictions service journey of development to transform our system to one of integrated, seamless person-centred care, integrated vertically with primary care and horizontally with general health services.
Objectives: Early challenges in large-scale change are described, as well as the use of the ‘model for improvement’ in testing different approaches, and early successes and failures.
Methods: We have utilized co-design, improvement science and cultural capability to inform and support the transformative process across our system.
Findings: Aligned with the district-wide locality integration approach in Counties Manukau, core specialist mental and addiction health are being devolved into locality teams with clinicians embedded within primary care and community care providers. The integration focuses on ensuring people with a serious mental illness are well engaged with primary care including to address their physical health needs, and on supporting primary care in the routine screening and treatment of people with long-term conditions and mental health comorbidity.
Key to integration is the re-design of core support services provided by the non-government organization (NGO) sector. A Māori-led integration initiative is under development to address the issues for Māori in Counties Manukau.
Self-management and recovery play important places in this agenda. Led by primary care and NGOs, experience and learning to date indicate that the successes of this approach can be rolled out across the district.
Conclusions: Large-scale change has presented significant challenges in workforce engagement and development, in system redesign and in use of enablers such as Internet technology. Improvement science has assisted in engaging staff. Early successes are described.
An Overview of the Clinical Program of Lisdexamfetamine Dimesylate for Adults with Binge Eating Disorder
B Herman1, S McElroy2,3, J Hudson4, J Kando1, T Tang1, N Naser5
1Shire, Lexington, USA
2Lindner Center of HOPE, Mason, USA
3University of Cincinnati College of Medicine, Cincinnati, USA
4McLean Hospital/Harvard Medical School, Boston, USA
5Shire Australia Pty Limited, Sydney, Australia
Objectives: To summarize the clinical program for lisdexamfetamine dimesylate (LDX) in adults with protocol-defined moderate-to-severe binge eating disorder (BED).
Methods: The short-term efficacy and tolerability of LDX were examined in 3 placebo (PBO)-controlled, double-blind studies during which participants received LDX (30, 50 or 70 mg) or PBO for 11 or 12 weeks (primary efficacy endpoint: change in binge eating days per week). Maintenance of efficacy of LDX (50 or 70 mg) was examined in a randomized-withdrawal study consisting of 12 weeks of dose-optimized open-label LDX followed by a 26-week double-blind randomized-withdrawal phase (primary efficacy endpoint: time to protocol-defined relapse to binge eating). Long-term safety and tolerability of LDX (50 or 70 mg) were assessed in a 12-month open-label extension study.
Findings: In all short-term efficacy studies, LDX significantly reduced the number of binge eating days per week at the end of the study versus PBO (all p ⩽ 0.008, except for 30 mg LDX versus PBO in a forced-dose study (p = 0.883)). In the maintenance-of-efficacy study, LDX demonstrated superiority over PBO (p < 0.001) for time to relapse. At the end of the study, 3.7% and 32.1% of LDX and PBO participants, respectively, met relapse criteria. Dry mouth, insomnia and headache were among the most frequently reported treatment-emergent adverse events with LDX across studies.
Conclusions: LDX significantly reduced binge eating days per week versus PBO in adults with BED and was associated with significantly lower risk of relapse to binge eating over 6 months than PBO. The safety and tolerability of LDX were generally consistent with its established profile.
Integrating Eating Disorders Treatment in a Public Mental Health Service
P Denborough
Alfred Child and Youth Mental Health Service, Melbourne, Australia
Background: In Victoria, access to flexible and coordinated care for people with eating disorders is limited. Affected young people and their families describe services as fragmented, confusing and delayed, making early intervention difficult and frustrating. Alfred CYMHS has addressed this issue by developing an integrated eating disorder program offering family-based treatment for young people with eating disorders.
Objectives: To describe and detail a new service model implemented in a generalist youth mental health setting; understand and explore the experiences of families in accessing the clinic and in receiving family-based therapy through the clinic; and explore change in workforce attitudes, knowledge and experience in relation to the treatment of eating disorders in a generalist mental health setting.
Methods:
Conduct a retrospective file audit of routinely collected data.
Perform qualitative research with families of young people receiving treatment.
Conduct a longitudinal workforce attitudes survey.
Findings: This presentation will demonstrate how public mental health systems can deliver accessible, effective and client-centred eating disorder treatment. It will provide an overview of service development over time aimed at increasing workforce capacity, responsiveness of service provision, improved access and better integration of all essential elements of care. The presentations will describe and discuss this service delivery initiative in the Southern region of Melbourne, looking at barriers, enablers and implications for policy and planning.
Conclusions: Data on service provision and outcomes will be discussed, along with a case example illustrating a typical case presenting for treatment at this service.
Clinical Audit: Tailor – Target Antidepressant Initiation Choice to Unlock Positive Patient Outcomes and Response
M Hopwood1, D Castle2
1The University of Melbourne, Melbourne, Australia
2St Vincent’s Hospital, Melbourne, Australia
Background: Medication adherence is critical to the efficacy of antidepressant treatments in primary care settings (van Servellen et al., 2011). Patient preferences and attitudes towards depression treatments influence adherence to antidepressant medication (ADM).
Objectives: The Target Antidepressant Initiation choice to unlock positive patient Outcomes and Response (TAILOR) was a general practitioner (GP) clinical audit aimed to assist clinicians to tailor the choice of ADM for the initial management of a patient with depression by involving the patient in all management decisions.
Methods: Patients with a new episode of depression (first episode or recurrence) and not being treated with ADM were identified by clinicians and included in the audit. A patient questionnaire aimed at identifying patient treatment preferences was completed, and an ADM was selected based on patient responses.
Findings: A total of 1273 GPs were enrolled and 4857 patients were audited. Most patients felt it was ‘important’ or ‘very important’ that their GP discussed their treatment preferences with them (49% and 49%, respectively).
Over half the patients audited (55.1%) had concerns about starting antidepressant treatment, with the risk of side effects (77.4%) and the fear of becoming dependent (52.0%) being the main concerns.
Most patients (59%) wanted to avoid weight gain, followed by reduced range of emotions (19%), sleep disturbance (16%) and sexual dysfunction (7%) associated with ADM.
Agomelatine was the most commonly prescribed agent (45%), followed by escitalopram (11%) and sertraline (10%).
Conclusions: TAILOR identified the importance of involving the patient in the ADM decision-making process.
Funding
The TAILOR clinical audit is supported by Servier Laboratories.
Reference
van Servellen G, Heise B and Ellis R (2011). Factors associated with antidepressant medication adherence and adherence-enhancement programmes: A systematic literature review. Mental Health in Family Medicine 8(4): 255–271.
Dangers of Unrecognized Psychiatric Adverse Events from Psychotropic Drugs: First Person Account, Review and Suggested Response
R Beddoe1, J Jureidini2
1Author, Melbourne, Australia
2Critical and Ethical Mental Health Research Group, Robinson Research Institute, The University of Adelaide, Adelaide, Australia
Background: All drugs cause adverse effects (AEs). Antidepressant AEs can mimic the very symptoms of the condition for which they have been prescribed. For clinician and patient alike, it can be extremely difficult to differentiate these AEs from worsening depression and/or emergence of further illness, risking a prescribing cascade. Ability to discern this difference, however, is crucial to providing optimal care.
Objectives: To increase recognition of antidepressant-induced psychiatric AEs, highlight their potential dangers, and reduce their incidence.
Methods: After being prescribed sertraline after the birth of her first child, Rebekah Beddoe’s mental state worsened, for which she was prescribed more drug therapy, with further deterioration over 2 years. Subsequently, she ceased all drug therapy and has remained symptom free for 15 years, even following a second child.
A first person account of this life-threatening prescribing cascade is complemented by a review of the current state of antidepressant pharmacovigilance.
Findings: Misinterpretation of antidepressants AEs continues irrespective of the now immense scientific and anecdotal information in circulation, exposing psychiatric patients to unnecessary drug treatment, erroneous diagnoses, delayed recovery, and enduring suffering. In turn, this leads to poor treatment outcomes for physicians and unnecessary demand on limited mental health resources.
Conclusions: In the absence of effective pharmacovigilance, a multimodal approach to collecting information about the AEs of antidepressant drugs is advocated. As well as examination of individual patient level data from randomized controlled trials and analysis of AE reports to regulatory agencies, this must include systematic and critical analysis of first-person accounts.
PTSD as an Independent Risk Factor for CHD: A Meta-Analysis
J Voisey1, D Colquhoun2, B Lawford3, R Young1, W Akosile1
1Queensland University of Technology, Brisbane, Australia
2University of Queensland, Brisbane, Australia
3Royal Brisbane Women’s Hospital, Brisbane, Australia
Background: There is increasing and consistent evidence that persons with post-traumatic stress disorder (PTSD) are not only at a higher risk of developing cardiovascular disease (CVD) but are also at risk of having a rapidly progressing illness associated with poorer prognosis.
Objective: Employing a meta-analysis, we assessed the longitudinal relationship between PTSD and coronary heart disease (CHD) as an independent factor in the aetiology of CHD.
Method: The search for relevant articles was performed searching the databases of MEDLINE, EBSCOhost and PsycINFO electronically. The search was from the beginning of each database until April 2016. The design must be prospective or at baseline have a sample in which PTSD was measured and followed up for subsequent development of CHD or CHD-related mortality. Studies must measure or assess subjects for trauma/PTSD at baseline. Studies should subsequently measure the association between PTSD and coronary artery disease or CHD.
Findings: Nine studies met our inclusion criteria (N = 151,144); the pooled hazards ratio (HR) for the magnitude of the relationship between PTSD and CHD was an HR of 1.61, and p value of 0.00 (95% confidence interval (CI): 1.46–1.77) before adjustment for depression. The HR estimate for the seven depression-adjusted estimates was 1.46, and p value of 0.00 (95% CI: 1.26–1.69).
Conclusions: This is a second and a much larger meta-analysis (nine prospective studies) demonstrating perhaps a causal association between CHD and PTSD. Future research should focus on the relationship between the treatment of PTSD and the prognosis and symptom profile of CHD. The mechanism by which PTSD leads to CHD is not fully elucidated; however, we speculate that there is possibly a shared genetic heritage, similar genes predispose individuals to both PTSD and CVD. Future research should focus on understanding the aetiological pathways that are implicated in both illnesses, and this may lead to novel treatments for CVD and PTSD.
PTSD and Dissociation
E Pilioussis1, T McHugh1, R Kanaan1,2
1The University of Melbourne, Melbourne, Australia
2Austin Health, Melbourne, Australia
Background: The dissociative subtype of post-traumatic stress disorder (PTSD) in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition is characterized by derealization, depersonalization and emotional numbing. The outcomes for the dissociative subtype are worse, and theory suggests dissociation may limit response to psychotherapy by reducing fear activation.1 However, few studies have addressed the area to date.2–6
Objective: To examine the relationship between dissociative symptoms and treatment outcomes for a long-standing psychological treatment program.
Methods: Participants were former Australian Defence Force staff with PTSD (n = 238) who completed a trauma-focussed cognitive behavioural therapy (CBT) program at the Psychological Trauma Recovery Service in Melbourne, Australia.
Data were collected at baseline and at 12 months post-treatment. The PTSD checklist (PCL) and Dissociative Experiences Scale (DES) were key outcome measures, with additional measures of anxiety, depression and anger. Analyses consisted of paired t-tests, correlations and stepwise multiple regressions.
Findings: Pre-treatment severity of PTSD was positively associated with baseline dissociation, anger, anxiety and depression. The mean pre-treatment PCL score significantly improved from 65.36 (standard deviation (SD) 9.06) to 59.15 (11.37) post-treatment (p < 0.001), though DES scores did not change significantly. There was no correlation between dissociation and PTSD treatment response (Pearson correlation = 0.004, p = 0.970). Stepwise multiple regression revealed that anger and pre-treatment PCL score explained a significant proportion of the variance in treatment response (F(2,102) = 14.576, p < 0.001), R2 = 0.222.
Conclusions: The present study does not support an effect of dissociation on response to trauma-focussed CBT, in line with other studies. Further research into the role of anger as a correlate of severity and a predictor of treatment response appears warranted.
References
1Foa EB and Kozak MJ (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin 99: 20–35.
2Cloitre M, Petkova E, Wang J, et al. (2012). An examination of the influence of a sequential treatment on the course and impact of dissociation among women with PTSD related to childhood abuse. Depress Anxiety 29: 709–717.
3Hagenaars MA, Van Minnen A and Hoogduin KA (2010). The impact of dissociation and depression on the efficacy of prolonged exposure treatment for PTSD. Behaviour Research and Therapy 48: 19–27.
4Halvorsen JO, Stenmark H, Neuner F et al. (2014). Does dissociation moderate treatment outcomes of narrative exposure therapy for PTSD? A secondary analysis from a randomized controlled clinical trial. Behaviour Research and Therapy 57: 21–28.
5Resick PA, Suvak MK, Johnides BD, et al. (2012). The impact of dissociation on PTSD treatment with cognitive processing therapy. Depress Anxiety 29: 718–730.
6Speckens AE, Ehlers A, Hackmann A, et al. (2006). Changes in intrusive memories associated with imaginal reliving in posttraumatic stress disorder. Journal of Anxiety Disorders 20: 328–341.
Cognitive Behavioural Therapy for Inflammatory Bowel Disease: 24-Month Data from a Randomized Controlled Trial
A Mikocka-Walus1,2,3, P Bampton4,5, D Hetzel6, P Hughes7, A Esterman1,8, J Andrews4,6,9
1School of Nursing and Midwifery and Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
2Department of Health Sciences, University of York, York, UK
3School of Psychology, Deakin University, Melbourne, Australia
4School of Medicine, Flinders University, Adelaide, Australia
5Department of Gastroenterology and Hepatology, Flinders Medical Centre, Adelaide, Australia
6Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
7Centre for Nutrition and Gastrointestinal Diseases, School of Medicine, University of Adelaide, Adelaide, Australia
8Australian Institute for Health and Tropical Medicine, James Cook University, Cairns, Australia
9School of Medicine, University of Adelaide, Adelaide, Australia
Background: Cognitive behavioural therapy (CBT) has been shown to alleviate symptoms of anxiety and depression in small inflammatory bowel disease (IBD) studies. However, there is a scarcity of data on the impact of CBT on physical outcomes in IBD and no studies on long-term effectiveness of CBT in this population.
Objectives: The present two-arm randomized controlled trial aimed to establish the impact of CBT on disease course after 24 months of observation.
Methods: The study compared standard care plus CBT (+CBT) with standard care alone (SC). CBT was delivered over 10 weeks, face-to-face (F2F) or online (cCBT). The data were analysed using linear mixed-effects models.
Findings: Overall, 174 patients with IBD were included (90 +CBT, 84 SC). CBT did not significantly influence disease activity as measured by disease activity indices at 24 months (Crohn’s Disease Activity Index, p = 0.92; Simple Colitis Clinical Activity Index, p = 0.88) or blood parameters (C-reactive protein, p < 0.62; haemoglobin, p = 0.77; platelet, p = 0.64; white cell count, p = 0.59) nor did CBT significantly affect mental health, coping or quality of life (all p > 0.05). In a subgroup analysis, participants with unmet needs (i.e. recently transitioned from paediatric care; with high baseline IBD activity; recently diagnosed; with poor coping; or high anxiety/depression) had significantly improved mental quality of life at 6 months as compared to SC (p = 0.034, d = 0.56).
Conclusions: CBT does not influence the course of IBD over 24 months. Given the high rate of attrition, future trials should consider a personalized approach to psychotherapy, perhaps combining online and one-to-one therapist time.
Characteristics and Management of Burning Mouth Syndrome: An Under-Recognized But Common Form of Medically Unexplained Orofacial Pain
S Kisely1,2, M Forbes3,4, E Sawyer5
1School of Medicine, The University of Queensland, Brisbane, Australia
2Griffith University, Gold Coast, Brisbane, Australia
3Department of Psychiatry, Royal Melbourne Hospital, Melbourne, Australia
4Melbourne Medical School, The University of Melbourne, Melbourne, Australia
5School of Medicine, James Cook University, Brisbane, Australia
Background: Burning mouth syndrome (BMS) is characterized by burning of the oral mucosa without underlying dental or medical causes. Symptoms can affect up to 15% of the population and are commoner in female and older patients. Clinical management is uncertain as the results of previous systematic reviews have been equivocal. However, findings for most interventions are based on searches of 5–10 years ago and do not include meta-analyses.
Objectives: To update previous meta-analyses of randomized controlled trials (RCTs) for BMS as assessed by visual analogue scales (VAS).
Methods: A systematic search of MEDLINE and EMBASE up to 2016.
Findings: Twenty-four RCTs were identified, 13 of which (n = 600) could be included in meta-analyses. The commonest interventions were alpha-lipoic acid (ALA) (eight comparisons), capsaicin, clonazepam (three comparisons each) and psychotherapy (two comparisons). ALA led to significant improvements in VAS (risk ratio (RR) = 2.25; 95% confidence interval (CI) = 1.04–4.88; n = 392; p = 0.04), while capsaicin significantly reduced pain at up to 2 months follow-up (standardized mean difference (SMD) = −0.60; 95% CI = −1.17 to −0.03; n = 78; p = 0.04) as did clonazepam (SMD = −1.44; 95% CI = −2.06 to −0.81; n = 131; p < 0.001). However, capsaicin led to prominent dyspepsia. No significant improvements were found for psychotherapy (RR = 14.28; 95% CI = 0.42–44.0; n = 74). In individual studies, capsaicin analogues, catauma and tongue-protectors showed promise.
Conclusions: ALA and capsaicin show modest benefit in the first 2 months. However, these conclusions are limited by short follow-up periods, high heterogeneity and low participant numbers in individual studies. For instance, type 2 error may explain the disappointing results for psychotherapy. Further RCTs with follow-up of at least 12 months are indicated.
Black and Ethnic Minority Patients are More Likely than White Patients to be Prescribed High Dose and Long-Acting Injectable Antipsychotics: The UK High Secure Experience
H Williams, H Blott, K Stone-Brown, J Tapp, S Heslop, M Das
Broadmoor High Secure Hospital, London, UK
Background: Previous research suggests ethnic group differences in likelihood to receive certain treatments within various psychiatric care settings.
Objectives: This study examines whether belonging to a black or other ethnic minority group is associated with increased odds of being prescribed (a) long-acting injectable (depot) antipsychotics; (b) high-dose antipsychotics; (c) multiple antipsychotics; and (d) clozapine, in comparison to white British patients in a high secure setting in the United Kingdom.
Methods: Cross-sectional data were collected for all patients in a UK High Secure Psychiatric Hospital on ethnicity, psychotropic medication dose, choice and route, and potential confounders including age, length of stay, physical health and diagnosis. Analysis involved multivariable logistic regression.
Findings: Black and ethnic minority men represented 43.9% of the hospital population, being over-represented three times from their 14% proportion of the UK general population. Strong evidence (p < 0.02) emerged that after adjusting for confounders, men in ethnic minority groups, compared to the White group, had (a) nearly double the odds of being prescribed a depot antipsychotic, odds ratio (OR) = 1.86 (95% confidence interval (CI): 1.02–3.38), p = 0.006; (b) over double the odds of being prescribed a high-dose antipsychotic, OR = 2.37 (95% CI: 1.14–4.88), p = 0.019; (c) no difference in the odds of receiving a multiple antipsychotic prescription, p = 0.37; and (d) less than half of the odds of being prescribed clozapine, OR = 0.43 (95% CI: 0.21–0.88), p = 0.02.
Conclusions: Chance, reverse causation and bias are inadequate explanations. Causative pathways or residual confounding are more likely. Ethno-psychopharmacology or illness differences are potential explanations. Possible larger societal explanations of ethnicity-based differences in prescribing also cannot be ignored.
Do Indigenous People have Uniformly Higher Rates of Psychiatric Disorder and are there Differences between Australia and New Zealand?
S Kisely1,2, E Black2, K Alichniewicz2, M Toombs2,3
1Metro South Addiction and Mental Health Service, Brisbane, Australia
2University of Queensland School of Medicine, Brisbane, Australia
3Centre for Health Sciences Research, University of Southern Queensland, Toowoomba, Australia
Background: Indigenous populations are considered at higher risk of psychiatric disorder, but many studies do not include direct comparisons with similar non-Indigenous controls.
Objective: To compare the prevalence rates of common psychiatric disorders in the Indigenous populations of Australia (Aboriginal and Torres Strait Islanders) and New Zealand (Māori) relative to the general population.
Method: A systematic search of PubMed, MEDLINE, PsycINFO, PsycArticles, ScienceDirect, EMBASE for studies comparing psychiatric morbidity in Aboriginal and Torres Strait Islanders and Māori populations to similar non-Indigenous controls was conducted.
Findings: We included 7 Australian and 10 New Zealand studies. Overall, Indigenous people in both countries did not have significantly higher rates of current, 12-month or lifetime disorders. However, in terms of specific disorders, there were differences in risk by gender, country (Australia or New Zealand) and prevalence type (current, 12-month or lifetime). For instance, Indigenous participants in both countries had significantly lower rates of simple phobias (current prevalence) but higher rates of anxiety and bipolar affective disorder (12-month prevalence). Indigenous Australians had significantly higher rates of bipolar affective disorder (current prevalence), which were not seen in New Zealand. Indigenous males in general were also at greater risk of social phobia.
Conclusions: Psychiatric morbidity was generally not higher in Indigenous people compared to non-Indigenous controls in both Australia and New Zealand. One explanation is that generalizations regarding risk of psychiatric disorders cannot be made for Indigenous people as a whole and that risks may vary according to a range of variables. It is also possible that current measurement tools do not always capture the expression of psychiatric disorders in Indigenous populations.
The Rate of Mental Health Service Use in New Zealand as Analysed By Ethnicity
R Tapsell1, C Hallett2, G Mellsop1
1University of Auckland, Auckland, New Zealand
2Research Consultant and Independent Scholar, Waikato, New Zealand
Objectives: To compare by ethnicity the rates of apparent new referrals and admissions to mental health services for selected major diagnostic groupings.
Method: Using a Ministry of Health database covering all referrals and admissions to New Zealand’s Mental Health services in 2014 and who had not been patients in the preceding 6 years, population-adjusted rates of presentation were calculated and compared across the two major New Zealand ethnic groupings.
Results: Population-corrected rates of apparently new cases of schizophrenia are more than twice as common in Māori as in non-Māori. Major depression is also significantly more common in Māori. That same trend was not evident for bipolar patients.
Conclusions: These apparently ethnically associated differences in the rates of schizophrenia and depression need both confirmation and explanation.
Increasing the Clinical Effectiveness of Empathizing with the Person with Schizophrenia
B St George
Private Practice, Sydney, Australia
Schizophrenia still confounds clinicians with regard to its biopsychosocial origins and their relationship to the clinical features of the person with schizophrenia. This presentation aims to provide an explanation of the patient’s behaviour, and how the patient may be thinking regarding our intentions, to improve clinical effectiveness in empathizing with the person with schizophrenia.
Background: Schizophrenia is a neurodevelopmental disorder that often results in severe disability and premature death. This illness still confounds clinicians with regard to its biopsychosocial origins and their relationship to the clinical features of the person with schizophrenia.
Objectives: This presentation describes how our increased understanding of the underlying biology of schizophrenia can better inform and improve our clinical effectiveness in empathizing with the person with schizophrenia. Attention will be drawn to deficits in working memory, attention and social cognition and how that affects the patient’s behaviour and how the patient may be thinking regarding our intentions with regard to the treatment strategies proposed.
Methods: The biopsychosocial factors affecting brain mechanisms that lead to particular clinical outcomes will be examined with a view to using the improved understanding of the underlying disturbances in brain function to improve effectiveness in the clinical setting.
Findings: The quality of care provided by clinicians for the person with schizophrenia can be improved through a better understanding of the underlying biology and its relationship to the full range of features of schizophrenia.
Conclusions: It is hoped that this encourages psychiatrists to review the ways in which care is provided and invest more in understanding the advances in the biopsychosocial mechanisms and the opportunities to increase the clinical effectiveness of empathizing with the person with schizophrenia.
Pharmacogenomics Comes of Age – New Evidence Leads to International Drug-Specific Recommendations for SSRIS and Tricyclic Antidepressants
L Sheffield1,2, S Mostafa1, N PuspasariI1, T Smith1, M Goh1, B Snyder1
1MyDNA Life Australia Limited, Melbourne, Australia
2Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, The University of Melbourne, Melbourne, Australia
Background: In the last 5 years, there has been considerable research increasing the level of evidence available for pharmacogenomic testing in the field of psychiatry. An extensive literature has now evolved from pharmacokinetic studies to clinical cohort studies as well as three randomized controlled trials. These have been complemented by more than 80 cost-effectiveness studies.
Objectives: To briefly review the evidence for pharmacogenomics and to evaluate the clinical recommendations for antidepressants.
Methods: The research studies have led to international recommendations on how to use pharmacogenomics in clinical practice. The first recommendations were from The Royal Dutch Pharmacists Association – Pharmacogenetics Working Group (Swen et al., 2011). These recommendations are used by the Dutch national prescribing system in Holland in combination with electronic prescribing. The second set of recommendations come from the Clinical Pharmacogenetics Implementation Consortium (CPIC) and cover selective serotonin reuptake inhibitors and tricyclic antidepressants as well as many other drugs (CPIC, 2015).
Finding: Examples from clinical practice will be given where pharmacogenomics tests and the application of the above guidelines have led to improvement in patient outcome by guiding the use of antidepressants.
Conclusions: Recommendations are now available to help guide the choice and dose of antidepressants based on pharmacogenomics testing and the specific drug(s) with which the patient is being treated.
References
CPIC (2015) Consortium (CPIC) Guideline for CYP2D6 and CYP2C19 genotypes and dosing of selective serotonin reuptake inhibitors. Clinical Pharmacology and Therapeutics 98(2): 127–134.
Swen J, Nijenhuis M, de Boer A, et al. (2011) Pharmacogenetics: From bench to byte – An update of guidelines. Clinical Pharmacology and Therapeutics 89(5): 662–673.
Paliperidone Palmitate Three-Monthly Formulation for the Management of Schizophrenia
S Gopal
Development Head, Psychiatry, Janssen Research & Development, LLC (Johnson & Johnson), Titusville, NJ, USA
Background: Long-acting therapies (LAT) may provide an effective treatment strategy for patients with early phase or first-episode schizophrenia, as well as maintaining treatment adherence in patients with chronic schizophrenia. Recent guidelines recommend LAT use earlier in the illness as a means to delay functional deterioration. Paliperidone palmitate 3-monthly (PP3M) formulation, which was recently approved by the Australian Therapeutics Goods Administration, offers a new treatment option for the management of schizophrenia. Registration in Australia was based on two key pivotal trials.
Objectives: To provide an overview of the clinical evidence demonstrating the benefits of LAT PP3M in the management of schizophrenia.
Methods: The outcomes of two PP3M pivotal trials and an observational study of monthly (PP1M) in newly diagnosed schizophrenia patients treated over a 12-month period will be reviewed in this presentation.
Findings: PP3M compared with placebo significantly delays time to first relapse in patients with schizophrenia previously treated for 4 months with PP1M and shows comparable efficacy to PP1M in patients previously stabilized on PP1M. PP3M is well tolerated with a safety profile generally consistent with other marketed formulations of paliperidone with no new safety signals identified in the trials. In young, newly diagnosed patients with schizophrenia, PP1M is associated with clinically relevant improvements in disease severity and functioning.
Conclusions: Therapeutic plasma levels are maintained with PP3M, allowing patients to achieve symptomatic and functional outcomes and improved quality of life.
Metabolic Monitoring and Management Among Clozapine Users
G Tso1, P Kumar1, T Jayasooriya1, S Kisely1,2, D Siskind1,2
1Metro South Addiction and Mental Health Service, Brisbane, Australia
2University of Queensland School of Medicine, Brisbane, Australia
Background: There is increased morbidity and mortality in people with mental illness, with physical comorbidities such as cardiometabolic disorders being a major cause for death. Mortality rates among people with schizophrenia are up to three times higher with a mortality gap of 10–20 years (Brown, 1997). Clozapine has a higher likelihood to cause weight gain and metabolic dysregulation compared to other antipsychotic drug treatments (Mitchell et al., 2013).
Objectives: This descriptive cross-sectional study endeavours to assess among clozapine users, the rates of monitoring, presence and treatment of metabolic syndrome and its components.
Methods: A chart review was conducted of all clozapine users who were followed-up in community mental health clinics at two Metro South Health Hospitals over a one-year period. Metabolic syndrome was diagnosed according to the International Diabetes Federation criteria.
Findings: We included 251 clozapine users. Only 43.4% (109/251) had data collected for all five metabolic syndrome parameters. Among these people, 45.0% (49/109) met criteria for metabolic syndrome, while 61.2% (30/49) of those with metabolic syndrome were offered appropriate treatments. Correspondence with primary care providers occurred in only 18.7% (n = 47). Non-pharmacological interventions, such as motivational interviewing and education about healthy lifestyle alternatives, occurred in 49.8% (n = 125).
Conclusions: There is growing awareness of the importance of metabolic monitoring; however, there remain specific gaps in the collaborative work among mental health services, primary care providers and clozapine users, to ensure appropriate physical health interventions.
References
Brown S (1997) Excess mortality of schizophrenia. A meta-analysis. British Journal of Psychiatry 171: 502–508.
Mitchell A, Vancampfort D, Sweers K, et al. (2013) Prevalence of metabolic syndrome and metabolic abnormalities in schizophrenia and related disorders – A systematic review and meta-analysis. Schizophrenia Bulletin 39: 306–318.
OCCAM vs HICKAM: A Case of a Neuropsychiatric Diagnostic Dilemma
D Eratne1, R Mocellin1, S Loi1, F Gaillard2, M Gonzales3, D Velakoulis1
1Neuropsychiatry Unit, The Royal Melbourne Hospital, Melbourne, Australia
2Radiology Department, The Royal Melbourne Hospital, Melbourne, Australia
3Pathology Department, The Royal Melbourne Hospital, Melbourne, Australia
Background: Occam’s razor, simplified in Samuel Shem’s House of Go to, “if you hear hoof beats, think horses not zebras’ (Shem 0000, p. XX), is a principle instilled in medical school. However, there may be times when Hickam’s dictum (patients can have as many diseases as they damn well please) may be the more appropriate principle.
Objectives, methods and findings: A 50-year-old man was referred to a neuropsychiatrist after seeing multiple specialists over an 18-month period for a complex variety of psychiatric, neurological, and cognitive symptoms. An urgent admission to the neuropsychiatry unit was arranged for diagnostic workup. Repeat magnetic resonance imaging of the brain revealed new subcortical white matter lesions. Exhaustive investigations were not consistent with Creutzfeldt–Jakob disease (CJD), autoimmune or paraneoplastic encephalitis, systemic or cerebral vasculitis, mitochondrial disorders, or Alzheimer’s disease. A brain biopsy was arranged. The biopsy was positive for ubiquitin and TDP-43, suggestive of frontotemporal lobar degeneration. However, this did not explain the neurological signs, elevated protein on cerebrospinal fluid, sensorineural hearing loss, and subcortical white matter lesions. Empirical treatment with methylprednisolone and cyclophosphamide was commenced for a possible primary cerebral vasculitis, with improvement in symptoms. A holistic and multidisciplinary approach was also able to address the multiple psychosocial issues, grief, loss, and family stress.
Conclusions: This case of potentially multiple coexisting pathologies challenges some of the concepts instilled in us at medical school. It highlights the challenges of diagnosis and treatment in a younger person with a broad constellation of symptoms, the benefits of a neuropsychiatric approach, and the importance of clinical reasoning.
PHF21B Gene: Association with Major Depressive Disorder and Modulation of the Stress Response
J Licinio J1,2, M Arcos-Burgos3,4, S Liu1,2, J Vélez3,5, C Yu1,2, B Baune6, M Jawahar6, V Arolt7, U Dannlowski7,8, A Chuah3, G Huttley3, R Fogarty1, M Lewis1,2, S Bornstein7,9, M Wong1,2
1Mind & Brain Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
2Department of Psychiatry, Flinders University School of Medicine, Adelaide, Australia
3Department of Genome Sciences, John Curtin School of Medical Research, Australian National University, Canberra, Australia
4University of Rosario International Institute of Translational Medicine, Bogotá, Colombia
5Universidad del Norte, Barranquilla, Colombia
6Discipline of Psychiatry, University of Adelaide, Adelaide, Australia.
7Department of Psychiatry and Psychotherapy, University of Münster, Münster, Germany
8Department of Psychiatry and Psychotherapy, University of Marburg, Marburg, Germany
9Medical Clinic III, Carl Gustav Carus University Hospital, Dresden University of Technology, Dresden, Germany
Background: Major depressive disorder (MDD) affects around 350 million people worldwide; however, the underlying genetic basis remains largely unknown.
Objectives: In this study, we took into account that MDD is a gene–environment disorder, in which stress is a critical component, and used whole-genome screening of functional variants to investigate the ‘missing heritability’ in MDD.
Methods: Genome-wide association studies (GWAS) using single- and multi-locus linear mixed-effect models were performed in a Los Angeles Mexican-American cohort (196 controls, 203 MDD) and in a replication European-ancestry cohort (499 controls, 473 MDD). Our analyses took into consideration the stress levels in the control populations.
Findings: We identified 44 common and rare functional variants associated with mild to moderate MDD in the Mexican-American cohort, and their pathway analysis revealed that the three top overrepresented gene ontology (GO) processes were innate immune response, glutamate receptor signalling and detection of chemical stimulus in smell sensory perception. Rare variant analysis replicated the association of the PHF21B gene in the ethnically unrelated European-ancestry cohort. Furthermore, using an animal model of stress, we found that Phf21b hippocampal gene expression is significantly decreased in animals resilient to chronic restraint stress.
Conclusions: Together, our results reveal that including stress level data enables the identification of novel rare functional variants associated with MDD. Whole-genome sequencing analyses of a subset of the cohorts revealed that European-ancestry individuals have a significantly reduced (50%) number of single nucleotide variants compared with Mexican-American individuals, and for this reason, the role of rare variants may vary across populations.
A Novel Intervention for the Treatment of ADHD in Children
A Lee1,2, C Choo1, T Lee3, CT Guan4, CG Lim2
1James Cook University, Singapore
2Institute of Mental Health, Singapore
3Duke-NUS Medical School, Singapore
4Institute for Infocomm Research, Singapore
Background: Attention-deficit hyperactivity disorder (ADHD) is one of the most common mental health disorders in children. Limitations of behavioural interventions and pharmacological treatment have led to the development of other novel interventions. Neurofeedback has shown promise in improving not only inattention symptoms but also impulsivity/hyperactivity symptoms. A feed-forward mechanism has been proposed to be more feasible in the treatment of ADHD as it trains individuals to harness their ability to pay attention and also shows promise in improving impulsivity symptoms.
Objectives: The aim of the current study is to investigate the impact of a novel intervention using (feed-forward) brain-to-computer interface (BCI) technology on an objective measure of attention and impulsivity in children with ADHD.
Methods: A total of 172 children aged 6 to 12 years (mean = 8.63, standard deviation = 1.51) with a clinical diagnosis of ADHD, inattentive or combined subtype were recruited. Participants were randomized into the waitlist-control or intervention group. Participants in the intervention group underwent 24 sessions of brain-to-computer interface technology (BCI) intervention over a period of 8 weeks, whereas participants in the control group did not receive any intervention. The Conners’ Continuous Performance Test, second edition (CPT-II) was administered to the participants before and after the treatment.
Findings: Analysis was conducted for the intervention and control groups at weeks 1 and 8.
Conclusions: Results will be discussed with a view to inform future research.
Comparison of Personality Dimensions in Adult ADHD Patients with and without a Confirmed Childhood History
U Jain1, S Jain2
1University of Rajasthan, Jaipur, India
2University of Toronto, Toronto, Canada
Background: Many patients with attention-deficit hyperactivity disorder (ADHD) are diagnosed only in adulthood and often without collateral history. This is common among females, particularly those experiencing the inattentive subtype.
Objectives: To determine if the personality dimensions in adult patients with ADHD with and without a childhood-confirmed history are consistent. This may suggest another tool to separate out the conditions from normality.
Methods: Ninety-two of 210 participants had a prior diagnosis of ADHD in this study, which included controls (36.9% no prior diagnosis of ADHD; 34.4% controls; 28.7% prior diagnosis of ADHD). The diagnosis of ADHD was based on research criteria including a Structured Clinical Inventory for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, the Adult ADHD Rating Scale and a separate clinical interview including exclusion questionnaires for comorbidity. The Temperament and Character Inventory (TCI) was used as the dependent variable, particularly the components known to stand out in ADHD adults: high novelty seeking, low self-directedness and low persistence dimensions. Comparisons were made using a χ2 analysis.
Findings: There were no significant differences in TCI dimensions (including post hoc comparisons) between the ADHD groups, but the ADHD groups were significantly different from controls (p < 0.005).
Conclusions: The TCI may be a very effective way of determining the stability of the personality components within ADHD. The presumption being that if ADHD is genetic, personality dimensions would have been affected, and these features are stable throughout life whether they came to impairment or not in childhood.
Telling Our Stories: Changing the Culture – Young People’s and Researchers’ Experiences of Youth Participation in the Research Agenda
J Farmer, C Abdelmalek, R Crook, N Fava, E Svensson, J-W Toh, T Wood, M Simmons, J Faliszewski
Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia
Background: The involvement of young people in mental health services supports the quality and relevance of the work undertaken and can provide significant health and social benefits to the young people involved (Ennis and Wykes, 2013). At Orygen, The National Centre of Excellence in Youth Mental Health, one of our key strategic aims is to put young people and their families at the forefront of everything that we do. In line with this goal, a youth engagement and participation strategy is being rolled out across the organization. The strategy aims to support meaningful partnership and engagement with young people (Domecq et al., 2014).
Objectives: This presentation will describe the work of one of the cornerstones of this Strategy, the Youth Research Council (YRC). The multimedia presentation will be led by one of the members of the YRC and will provide insights from other members of the YRC and Orygen key stakeholders, discussing the impact that young people have had on shaping the research culture and agenda by sharing their stories and experiences.
Conclusions: In line with the Congress theme of ‘Speaking our minds. Telling our stories’, the experience of Orygen, The National Centre of Excellence in Youth Mental Health, shows that young people have a wealth of experience to help shape the youth mental health research agenda. The involvement of consumer perspectives has a great deal to offer in terms of informing and enhancing future psychiatric research strategies.
References
Domecq, JP, Prutsky G, Elraiyah T, et al. (2014) Patient engagement in research: A systematic review. BMC Health Services Research 14(1): 1.
Ennis L and Wykes T (2013) Impact of patient involvement in mental health research: Longitudinal study. The British Journal of Psychiatry 203(5): 381–386.
Cognitive Function in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder Receiving Lisdexamfetamine Dimesylate in a 2-Year Safety Study
D Coghill1,2, T Banaschewski3, C Bliss4, B Robertson4, A Zuddas5
1Division of Neuroscience, University of Dundee, Dundee, UK
2Departments of Paediatrics and Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
3Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
4Shire, Lexington, USA
5Child and Adolescent Psychiatry Unit, Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Cagliari, Italy
Background: This phase 4, open-label study (study SPD489-404) was the first 2-year safety study of lisdexamfetamine dimesylate (LDX) in children and adolescents with attention-deficit/hyperactivity disorder (ADHD).
Objectives: To measure cognitive function in children and adolescents receiving LDX for 2 years in SPD489-404, using the Cambridge Neuropsychological Test Automated Battery (CANTAB).
Methods: Participants aged 6–17 years received dose-optimized, open-label LDX (30, 50 or 70 mg/day) for 104 weeks. Cognition was assessed in the safety population using four selected tests from the CANTAB (delayed matching to sample (DMS), spatial working memory (SWM), stop signal task (SST) and reaction time (RTI)). A groupwise change of >5% from baseline was considered potentially clinically significant.
Findings: Of 314 enrolled participants, 314 (100%) received LDX and were included in the safety population and 191 (60.8%) completed the study. Potentially clinically significant improvements from baseline to last on-treatment assessment (LOTA) were observed for DMS median reaction time (mean percent change, −6.5), SWM total between errors (–32.6) and SST reaction time (−25.7). Changes from baseline to LOTA did not reach potential clinical significance for DMS percent correct (mean percent change, −1.3), RTI simple median reaction time (–2.6) or RTI 5-choice median reaction time (–3.1).
Conclusions: LDX treatment over 2 years was not associated with deterioration in cognitive function in children and adolescents with ADHD. Although some improvements in cognition were observed, the lack of a control group makes these data difficult to interpret and additional studies are required.
Funding
This study was funded by Shire Development LLC.
Correlations of Symptoms, Functional Impairment and Quality of Life in Children and Adolescents with ADHD
D Coghill1,2, A Joseph3, V Sikirica4, M Kosinski5, C Bliss6, M Huss7
1Division of Neuroscience, University of Dundee, Dundee, UK
2Departments of Paediatrics and Psychiatry, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
3Shire, Zug, Switzerland
4Shire, Wayne, USA
5QualityMetric Inc., Lincoln, USA
6Shire, Lexington, USA
7Child and Adolescent Psychiatry, Johannes Gutenberg-University Mainz, Mainz, Germany
Background: Patients with attention-deficit/hyperactivity disorder (ADHD) experience impaired day-to-day functioning and poor health-related quality of life (HRQoL).
Objectives: To assess relationships between ADHD Rating Scale IV (ADHD-RS-IV; symptom-based measure), Weiss Functional Impairment Rating Scale-Parent (WFIRS-P) and Child Health and Illness Profile-Child Edition (CHIPCE:PRF; generic HRQoL instrument) outcomes in children and adolescents receiving ADHD medication.
Methods: Pearson correlation coefficients (r) were calculated post hoc for changes in ADHD-RS-IV versus WFIRS-P total scores from baseline to last on-treatment assessment in randomized, placebo-controlled trials of guanfacine extended release (GXR) with an atomoxetine (ATX) reference arm (SPD503-316) and lisdexamfetamine (LDX) with an osmotic-release oral system methylphenidate (OROS-MPH) reference arm (SPD489-325). CHIP-CE:PRF domain T-score changes from baseline were correlated with ADHD-RS-IV and WFIRS-P in SPD489-325.
Findings: During pharmacological treatment, correlations between changes in ADHD-RS-IV and WFIRS-P total scores were generally moderate (r = 0.38 to 0.56). Published effect sizes of LDX, OROS-MPH, GXR and ATX versus placebo, respectively, were larger for ADHD-RS-IV total score (1.80, 1.26, 0.76 and 0.32) than WFIRS-P total scores (0.924, 0.772, 0.44 and 0.28). Changes in CHIP-CE:PRF achievement and risk avoidance were correlated moderately with ADHD-RS-IV (r = −0.36 to −0.48) and strongly but incompletely correlated with WFIRS-P changes (r = −0.59 to −0.65). Correlation coefficients and effect sizes were both larger in these domains than in resilience, satisfaction and comfort.
Conclusions: Symptoms, functional impairment and HRQoL are related, but distinct, constructs in children and adolescents with ADHD. Treatment goals should extend beyond symptom control to include functional and HRQoL improvements.
Funding
Studies were funded by Shire Development LLC.
The Psychological Health and Disordered Eating of Chinese University Students: A Comparative Study Among Students in Hong Kong, Mainland China and Those on Exchange Programs
SF Leung1, L Ma2
1The Hong Kong Polytechnic University, Hong Kong, China
2Capital Medical University, Beijing, China
Background: Psychological distress is increasingly experienced by university students due to multiple stressors and lifestyle changes. Exchange students are further confronted with life adjustment stress in their studies. Symptoms of anxiety, depression, stress and eating disorders are commonly reported in Western studies of university students but are not widely explored in the Chinese context.
Objectives: This study examined the psychological health and disordered eating of Chinese university students and compared the difference among students in Hong Kong (HK), mainland China and those on exchange from Mainland China to HK.
Methods: The participants were recruited through personal approach at different university campuses and social network samplings. Data were collected through the Depression Anxiety and Stress Scale-21, Eating Disorder Examination-Questionnaire and the SCOFF Questionnaire administered through a ‘Smart ehealth’ website.
Findings: Of 898 participants, a substantial proportion suffered from symptoms of anxiety (n = 316, 35.2%), depression (n = 188, 20.9%) and stress (n = 145, 16.1%) and engaged in various disordered eating behaviours (n = 365, 40.6%). Among students in HK (n = 332), Mainland China (n = 207) and those on exchange programs (n = 359), there was no significant difference in their eating disorder psychopathology but a significant difference in their psychological health as revealed from the Kruskal–Wallis test. HK students experienced the highest level of anxiety, depression and stress as compared with their counterparts. A negative correlation was identified between the psychological health and duration of exchange among Mainland students reflecting a possible influence from HK’s stressful culture.
Conclusions: Given the high proportion of university students having symptoms of mental disorders and disordered eating, there is a pressing need for routine screening and timely interventions.
Subpoenas and Psychiatrist–Patient Confidentiality
P Jenkins, G Galambos, C Newlands, N O’Connor, P Foulkes, W Miles, J McMahon
The Royal Australian and New Zealand College of Psychiatrists Confidentiality of Clinical Records Working Group, Melbourne, Australia
Background: Psychiatrist–patient confidentiality is increasingly threatened by the use of legal mechanisms to access clinical records. In response to concerns raised by a number of Royal Australian and New Zealand College of Psychiatrists (RANZCP) fellows – in particular, the Faculty of Psychotherapy and the Section of Private Practice Psychiatry – the RANZCP convened a working group to articulate these concerns in a position statement that calls for evidence law reform.
Objectives: To discuss the ethical and clinical bases of psychiatrist–patient confidentiality, the impact on patients when it is breached, the use of subpoenas to breach that confidentiality, the defences against subpoenas available in different jurisdictions and the ways in which law reform could help to substantially strengthen this form of confidentiality.
Methods: The following texts were reviewed: public and private statements detailing concerns raised by psychiatrists and other counselling professions in relation to clinical record confidentiality; Evidence Acts in Australia and New Zealand and the associated case law; and commentary by parliamentarians, law reform commissions and legal academics explaining and critiquing those laws.
Findings: Across Australia, major variations exist in the defences available to protect the confidentiality of clinical records against subpoenas. Compared to New Zealand and other common law countries, the defences in Australia are weak, inconsistent and difficult to use.
Conclusions: To protect clinical records from unwanted disclosure, law reform drawing on the Australian Law Reform Commission recommendations and the New Zealand Evidence Act 2006 is both necessary and achievable. The RANZCP has published a position statement advocating for law reform and is developing guidance for RANZCP members in responding to subpoenas and other information requests.
Development of ‘A Guide to Private Psychiatry Practice’
J Powell, J King, E Bichara, C Blackwell, A Chang, J Crowe, R Mundl, B Pring, S Romans, S Staugus
The Royal Australian and New Zealand College of Psychiatrists Resources for Managing Your Practice Working Group, Melbourne, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) Quality Assurance Guideline #1 – Outpatient Psychiatric Practice (QA Guideline #1) was identified by the board as needing review. This guideline comprises a set of statements intended to provide practitioners some broad parameters by which to assess and structure their clinical practice. It was agreed that this guideline be reviewed and updated as part of the Resources for Managing Your Practice project, led by the Committee for Professional Practice.
Objectives: To develop a framework for quality assurance tailored to the needs of psychiatrists in private practice, which reflects current best practice in psychiatry in Australia and New Zealand in outpatient/private practice settings.
Methods: A working group (WG), with representation from various RANZCP Committees and Sections, was convened to review and update QA Guideline #1. The WG met face to face and by teleconference. After reviewing the QA Guideline #1, the WG decided to develop a new framework rather than modify the existing document. A Guide to Private Psychiatry Practice was drafted and went through various iterations in terms of structure and content. A draft document was sent to Committees, Faculties and Sections for consultation before approval by the Board.
Findings: A Guide to Private Psychiatric Practice presents a set of principles, guidelines and elements for private practice psychiatrists to consider in the management of their practice, assists private practice psychiatrists to support their practice management and therapeutic relationship with patients and their families/carer(s) and communicate to RANZCP members and to the general public what they can reasonably expect of private psychiatry practice.
Conclusions: The guide will be of use to private practice psychiatrists and supercedes QA Guideline #1.
Metabolic Monitoring of Patients Receiving Antipsychotics: Multisite Quality Improvement Study
A Bennett1, M Jordan1, N O’Connor2, G Carter3, V Peereboom2, A Davis4, S Karacete5, A Meaney5
1New South Wales Therapeutic Advisory Group (TAG), Sydney, Australia
2North Shore Ryde Mental Health Service, Sydney, Australia
3University of Newcastle, Newcastle, Australia
4Manly Hospital, Sydney, Australia
5Concord Centre for Mental Health, Sydney, Australia
Background: The National Quality Use of Medicines mental health (MH) indicator 7.4 ‘Percentage of patients taking antipsychotic medications who receive appropriate monitoring for the development of metabolic side effects’ measures adherence to best practice recommendations for metabolic monitoring in those taking antipsychotic medication.
Objectives: To train MH clinicians in quality improvement (QI) methodology and undertake performance assessment, benchmarking and implementation of QI strategies for routine metabolic monitoring.
Methods: Invitations to participate were sent to Australian hospitals. A multidisciplinary steering group was established. Ethics and governance approvals were obtained. Multidisciplinary local advisory groups (LAGs) guide data collection, identify barriers to best practice adherence and implement QI strategies. Site details for benchmarking were collated. Baseline audit, intervention and re-audit phases will be undertaken.
Findings: Sixteen sites across three Australian jurisdictions caring for a diverse range of patient populations (acute adult, adolescent, paediatric, forensic and psychogeriatrics) are participating. LAGs contain a pharmacist and psychiatrists (13) and nurses (11) in most. Baseline results from 12 sites range from 0% to 42% (mean 15%). Measurements of waist circumferences, fasting lipids and glucose are poor. Site feedback has identified disparities between electronic pathology requests and reports, poor use of electronic recording systems and workflow barriers.
Conclusions: Multisite studies are a useful means of providing benchmarking data to drive QI and collaborate in improvement strategy development and implementation. Baseline results demonstrate poor adherence to recommended monitoring with common barriers emerging that are locally and state driven. Barriers to governance approval and hence multisite research and benchmarking were identified.
Behavioural Addictions and the Associated Mental Health Problems and Psychopathology
V Starcevic
University of Sydney, Sydney Medical School Nepean, Sydney, Australia
Background: Behavioural addictions are conceptually controversial and their relationship with mental health problems and psychopathology is poorly understood.
Objectives: To review the relationships between personality traits, mental health issues and mental disorders on one hand and several behavioural addictions on the other. The latter include problematic Internet use, Internet gaming disorder (IGD), hypersexual disorder/compulsive sexual behaviour disorder, compulsive buying and exercise addiction.
Methods: Literature review and conceptual synthesis.
Findings: Mental health issues, personality dimensions and mental disorders are commonly associated with behavioural addictions. Although some relatively specific associations were found (e.g. between IGD and attention-deficit/hyperactivity disorder (ADHD), between compulsive buying and pathological hoarding, and between exercise addiction and eating disorders), the specificity of most associations was low. Most studies were cross-sectional and the direction of causality, if any, was uncertain. Therefore, it is unknown under what circumstances certain mental health issues predispose to the particular behavioural addiction or represent a primary problem and when they are a consequence of behavioural addictions. This review also underscores the importance of distinguishing between certain behavioural addictions and overlapping conditions; for example, between compulsive buying and bipolar disorder (mania/hypomania).
Conclusions: These findings suggest that proper conceptualization of behavioural addictions as distinct conditions or a manifestation of an underlying psychopathology will have to await results of the prospective studies. In the meantime, there are implications for treatment in terms of the importance of identifying and addressing the underlying or associated mental health problems in individuals with behavioural addictions.
The Global Burden of Mental and Substance Use Disorders
H Whiteford1,2,3
1School of Public Health, University of Queensland, Brisbane, Australia
2Queensland Centre for Mental Health Research, Brisbane, Australia
3Institute for Health Metrics and Evaluation, University of Washington, Seattle, USA
Background: The Global Burden of Disease (GBD) Studies are increasingly influential in health priority settings. The most recent study (GBD DALYs and HALE Collaborators, 2015) estimates the burden for 315 diseases and injuries across 195 countries, by sex, age and year. The study included 13 mental disorders and seven substance use disorders.
Methods: GBD studies use the disability-adjusted life year (DALY), a time-based metric measuring disability (years lived with disability, YLD) and mortality (years of life lost due to premature mortality, YLL) caused by a given disorder. GBD DALYs and HALE Collaborators (2015) updated methods and epidemiological data used in previous GBD studies.
Results: Mental and substance use disorders, as a group, are the leading cause of disability globally and make a major contribution to overall disease burden. GBD DALYs and HALE Collaborators (2015) used the most current global prevalence, incidence and death data to produce YLD, YLL and DALY estimates for each disorder in 195 countries, imputing estimates for countries without raw data.
Conclusions: GBD methodology is consistently evolving but interpreting the results requires an understanding of the limitations. GBD DALYs and HALE Collaborators (2015) findings provide important summary measures for monitoring change in the burden of mental and substance use disorders over time and for guiding investments in mental health.
References
GBD 2015 DALYs and HALE Collaborators (2015) Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: A systematic analysis for the Global Burden of Disease Study 2015. The Lancet 388(10053): 1603–1658.
Evaluation of the RANZCP 2012 Training Program
M Aimer, E Halley
The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
Aim: In December 2012, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) introduced the Competency-Based Fellowship Program (CBFP), now known as the 2012 Training Program.
Following an evaluation of the implementation of stage 1 of the program in 2013–2014, the RANZCP undertook a further evaluation of stages 1 and 2 in November 2015. The aim was to gather feedback on key areas such as entrustable professional activities (EPAs), workplace-based assessments (WBAs), assessments, examinations, regulations, supervision arrangements and the overall impact of the new program.
Method: Links to online surveys (using ‘surveymonkey’) were sent out to all active trainees and accredited supervisors in November 2015 with two follow-up reminders. The survey details were also communicated through newsletters, Psyche and via directors of training. The surveys were closed at the end of December 2015.
Results: A total of 39% of trainees and 38% of supervisors responded to the surveys. This presentation provides a summary of the results from the trainee and supervisor surveys, a comparison of the responses and key findings.
Conclusions: Overall, the results from trainees and supervisors were comparable with minimal differences across most survey items. Trainees and supervisors did, however, differ on the time taken to prepare for and complete the WBA activities and on supervision arrangements. Trainees and supervisors were found to differ in their perceptions of supervision, especially on the negotiation of learning goals and the provision of feedback.
Based on the survey responses, the RANZCP Education Committee developed a series of recommendations for action in 2016–2017.
Virtual Study Groups and Online OSCE Practices – Enabling Trainees to Enable Themselves
D Davidson1, L Evans2, H Hafiz3
1Auckland District Health Board, Auckland, New Zealand
2Bay of Plenty District Health Board, Tauranga, New Zealand
3Canterbury District Health Board, Christchurch, New Zealand
Background: Trainees face stress balancing work, family, training and assessments. It is possible to mitigate this to an extent using self-sustaining and cost-effective virtual tools and platforms (Chan et al. 2015; Fong et al., 2009).
Objectives: To discuss the virtual objective structured clinical examination (OSCE) trial by some New Zealand (NZ) trainees.
Methods: Virtual OSCEs were trialled using Google Hangout as a platform, connecting trainees across NZ. The model was then rolled out to all NZ trainees. A limited number used the model with good benefit. A literature review for such models was done.
Findings: Google Hangout is optimal with four or fewer users, adequate for an OSCE practice (one examiner, one actor, one candidate, one observer). Audio was best with one person speaking at a time. The overall ‘feel’ was almost like a ‘real’ OSCE practice.
Virtual OSCEs enabled more practices, with flexibility to participate from any location.
Conclusions: Virtual platforms may be useful for isolated rural trainees by integrating them with other colleagues and for urban trainees by doing away with travel time. The flexibility in participating from any location offers scope for increased number of practices. This is also a great way to form collegial relationships with colleagues across regions.
References
Chan T, Sennik S, Zaki A, et al. (2015) Studying with the cloud: The use of online Web-based resources to augment a traditional study group format. CJEM 17(02): 192–195.
Fong A, Sidhom M, Hayden A, et al. (2009) Virtual study groups: Internet-based collaborative revision for the FRANZCR examinations. Journal of Medical Imaging and Radiation Oncology 53(3): 301–304.
Trainee-Led Welfare Initiatives for Psychiatry Registrars in South Australia: The Well-Being Weekend
L Martin1,2, H Newton1,3, B Djurdjevic1,4
1Association of Psychiatrists in Training South Australia, Adelaide, Australia
2Flinders Medical Centre, Adelaide, Australia
3Noarlunga Health Services, Adelaide, Australia
4Women’s and Children’s Hospital, Adelaide, Australia
Background: The importance of welfare was formalized by The Association of Psychiatrists in Training South Australia (APTSA) in 2015 with the appointment of a welfare officer. Borne of robust discussions about issues impacting trainee welfare and a need for such discussions to occur in an open way that challenges associated stigma, trainees sought to hold a dedicated well-being event.
Objectives: Reflection on establishment of a ‘Well-being Weekend’ for South Australian psychiatry trainees in 2015 and 2016, and consideration of its utility in future years.
Methods: APTSA hosted its inaugural Well-being Weekend 10–11 October 2015, comprised of educational and social programs. Following its success, a second Well-being Weekend will be held 19–20 November 2016. Events were generously supported by the SA Psychiatry Branch Training Committee and the Royal Australian and New Zealand College of Psychiatrists (RANZCP) SA Branch.
Findings: The concept was well received by trainees. This enthusiasm was also reflected in participation of local Psychiatrists in the discussion panels. Twenty trainees (25% of SA trainees) attended in 2015, with 19 participating in the dinner, many staying overnight at the venue, and seven in social activities the following day. Evaluation data for 2016 are pending.
Conclusions: The 2015 Well-being Weekend promoted meaningful, honest dialogue about the difficult aspects of our work, enhancing resilience, self-care, social connections and work–life balance. APTSA look forward to hosting and evaluating the second Well-being Weekend, incorporating 2015 feedback, and identifying opportunities for improvement. We anticipate scope for expansion to include interested medical students, fellows and trainees from other disciplines.
The Flowering of Translational Research on a Mental Health Unit: An Organic Process
A Solar1,2
1University of Western Australia, Perth, Australia
2Sir Charles Gairdner Hospital Mental Health Unit, Perth, Australia
Objectives: Describe research development about how to get patients on a Mental Health Unit with treatment-resistant distressing auditory hallucinations and schizophrenia into evidence-informed community therapy.
Method: Author reflection on research processes over a 4-year period.
Findings: In preparation for a move from a voluntary to an authorized Mental Health Unit, the author met regularly with a clinical psychologist about how to increase clinical psychologists’ competence in helping people with distressing auditory hallucinations. A literature review was used to devise four ‘coping with voices’ group modules, which included an inreach information session from the hearing voices network; cognitive behavioural and talking with voices approaches; self-esteem enhancement and dealing with stigma. Translating the coping with voices group to the authorized setting was unsuccessful, so the intervention changed to individual meetings with patients, drawing on the four modules as appropriate, with the purpose of dealing with the engagement and stigma difficulties preventing them from getting into evidence-informed community therapy. In the meantime, ethics approval was granted for a randomized single-blind clinical controlled trial to test the new intervention against treatment as usual. A psychiatry trainee then agreed to be part of the project and also help with the blinded outcome data gathering. The author, while running the clinical trial, would like to interview other similar patients, until data saturation point, about why they have not already engaged with a clinical psychologist through their general practitioner to get help with their distress.
Conclusions: Research processes may not be linear.
Self-Practice/Self-Reflection – An Innovative Approach to Enhance Cognitive Behavioural Therapy Training and Therapist Self-Care
S Waite1, J Alexander2, J Bennett-Levy3
1The Queen Elizabeth Hospital, Adelaide, Australia
2Glenside Health Services, Adelaide, Australia
3University of Sydney, Sydney, Australia
Background: SP/SR is a self-experiential training strategy in which participants practice cognitive behavioural therapy (CBT) strategies on themselves and then reflect on the implications for their personal and professional lives. Although the primary aim of SP/SR has been to develop therapist competence, a recent meta-synthesis of qualitative studies indicated a range of beneficial outcomes, including therapist confidence and empathy for patients (Gale and Schröder, 2014). Furthermore, the personal benefits of SP/SR have potential for enhancing therapist self-care. Although SP/SR research has involved a range of participants with different levels of experience, there has been no research to date with doctors.
Objectives: The aim of this pilot study was to develop a viable model to integrate SP/SR into a CBT course for junior medical officers (JMOs) with an interest in pursuing psychiatry training. Outcomes were assessed in relation to personal and professional development, negative reactions and barriers to participation.
Method: JMOs and their supervisor completed an evaluation after attending a 12-week group CBT training course facilitated by a psychiatrist. The course adhered to 12 modules of self-practice CBT exercises and structured reflection questions from an SP/SR workbook (Bennett-Levy et al., 2015).
Findings: Results endorsed some of the previously reported benefits and limitations of SP/SR, as well as suggestions for improvement of the learning experience.
Conclusions: SP/SR may be a useful tool for enhancing declarative understanding of CBT and developing procedural skills, reflective ability and interpersonal skills in JMOs. Further research could be extended to psychiatry registrars and psychiatrists who aspire to enhance their therapeutic effectiveness and pay more attention to their self-care.
References
Bennett-Levy J, Thwaites R, Haarhoff B, et al. (2015) Experiencing CBT from the Inside Out: A Self-Practice/Self-Reflection Workbook for Therapists. New York: Guilford.
Gale C and Schröder T (2014) Experiences of self-practice/self-reflection in cognitive behavioural therapy: A meta-synthesis of qualitative studies. Psychology and Psychotherapy: Theory, Research and Practice 87: 373–392.
Addressing the Physical Health of People with Mental Illness: Integrating Dietitians and Exercise Physiologists into the Multidisciplinary Mental Health Team
S Rosenbaum1,2,3, S Teasdale2,4,5, L Czosnek1, A Byron5, V Schuldt5
1Exercise & Sports Science Australia, Brisbane, Australia
2University of New South Wales, Sydney, Australia
3Black Dog Institute, Sydney, Australia
4Keeping the Body in Mind Program, South Eastern Sydney Local Health District, Sydney, Australia
5Dietitians Association of Australia, Canberra, Australia
Background: People with mental illness experience high rates of comorbid physical health conditions, while poor physical health is also associated with adverse mental health outcomes. Given the established relationship between physical and mental health, there is an increased focus within psychiatric treatment on addressing modifiable cardiometabolic risk factors including sedentary behaviour and poor dietary habits. Mounting evidence demonstrates the role of allied health practitioners including dietitians and exercise physiologists in providing evidence-based interventions to improve both the physical and mental health outcomes of people with mental illness.
Objectives: Two peak Australian bodies for dietitians and exercise physiologists aimed to develop a joint position statement describing the role of each profession as part of the multidisciplinary mental health team and to identify successful examples of integration and collaboration.
Methods: A modified Delphi technique was used with four rounds of review. Representatives from each peak body contributed to the development of the statement. Expert groups including the Exercise and Sports Science Australia, Exercise Physiology Advisory Group and the Dietitians Association of Australia, Mental Health Interest Group were also consulted.
Findings and conclusions: Addressing modifiable risk factors including poor dietary habits, physical inactivity, excessive alcohol consumption, and smoking is likely to help decrease the burden of chronic disease among people with mental illness. When incorporated with evidence-based pharmacological and psychosocial and medical treatment, exercise and dietary interventions delivered by accredited practicing dietitians and accredited exercise physiologists can provide a range of physical, social, and mental health benefits for people living with a mental illness. The development of this position statement demonstrates a commitment by these allied health groups to work with psychiatrists and other members of the mental health team to improve the physical health of patients with mental illness.
From Providing a Service to Being of Service: What is Person-Centred Care?
G Smith1,2
1Centre for Mental Health Policy Research, Perth, Australia
2School of Psychiatry and Behavioural Science, University of Western Australia, Perth, Australia
Background: The term ‘person-centred care’ has been widely used in mental health, but there is no generally agreed definition and no clarity about its relationship with the concept of recovery. It has been challenging for mental health services to move beyond the rhetoric of person-centred care, underpinned by its humanistic values, to operationalize the concept.
Objectives: To explore the concept of person-centred care and its relationship with recovery and to examine the ways that it has been operationalized, focussing particularly on shared decision-making and self-directed care, two practices that have significant implications for mental health.
Methods: A literature review was conducted, particularly focussed on recent publications, searching on the terms ‘person-centred care’, ‘recovery’, ‘self-directed care’ and ‘shared decision-making’. The uptake of practices based upon the principles of person-centred care was examined as was the evidence supporting their use in mental health.
Findings: Person-centred care is increasingly being seen as a central component of recovery-orientated practice and is being operationalized within a ‘spectrum’ of new forms of practice based upon varying levels of service user empowerment. The level of shared decision-making in routine clinical practice is low, as is the uptake of self-directed care by people with mental health problems, despite the promising research support for these practices.
Conclusions: The major barrier to uptake has been staff concerns about the issues of decisional capacity and risk. This highlights the need for further research to address not only practice outcomes but also the challenges to implementation.
Neurobiological Dissection and Prediction of Psychosis with Clinically Meaningful Crosstalk between Biochemistry, Sensory-Processing and Functional Measures in Schizophrenia and Schizoaffective Disorder
S Fryar-Williams1,2,3
1Basil Hetzel Institute for Translational Medicine, Adelaide, Australia
2Youth in Mind Research Institute, Adelaide, Australia
3The Queen Elizabeth Hospital, Western Area Health, Adelaide, Australia
Background: The Mental Health Biomarker Project (2010–2016) selected commercially available biochemistry markers related to monoamine biochemistry and measures for visual and auditory processing pathways to investigate biomarkers for schizophrenia and schizoaffective disorder and their translational relationships.
Methods: Within a case–control design with multiple exclusion criteria designed to exclude organic causes and confounding variables, 67 participants independently diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, and 67 undiagnosed participants from a defined hospital, clinic and community catchment area were investigated for 30 biochemical and neurosensory putative markers. Participants underwent protocol-based diagnostic-checking, functional-rating, biological sample-collection and sensory-processing assessment. Outcome measures were analysed from blood and urine samples for monoamine neurotransmitters and vitamins, cofactors and intermediate substances known to be related to oxidative stress, and the synthesis and metabolism of monoamines. Neurocognitive assessment of visual and auditory processing was conducted at both peripheral and central levels. Data were analysed using receiver operating curve (ROC), Lowess regression, structural equation modelling and Spearman’s correlation matrix.
Results: A total of 21 putative markers across six neurobiological domains of function demonstrated biomarker status and prediction capability for schizophrenia and schizoaffective psychosis. Informative translational relationships were found between symptoms of psychosis and foundational nutritional biochemistry of indole catecholamine synthesis and metabolisms, oxidative stress and sensory processing deficits. These relationships also clearly relate to functional outcome measures and cost burden.
Conclusions: Understanding the crosstalk between layers of psychosis is a window into predicting its occurrence and reorganizing its management. Clinicians will benefit by reduced diagnostic uncertainty, providing a secure platform for earlier treatment and relapse prevention. Patients will also benefit from reduced diagnostic uncertainty, stigma and better outcomes. Families and service providers will benefit from reduced cost-care burden. The translational evidence also provides new understandings of nosology and phenomenology in psychiatry.
A Better MBS for All Australians
M Coglin
Healthscope, Melbourne, Australia
Background and objectives: The MBS Review Taskforce is undertaking an independent clinician-led review of the Medicare Benefits Schedule (MBS). This is the first comprehensive review in 30 years of the 5700 items covered in the MBS.
The priority with this review is to ensure that the items on the MBS are aligned with contemporary clinical evidence and practice and improve health outcomes for all Australians. The Taskforce will also seek to identify any services that may be unnecessary, outdated or potentially unsafe.
The Taskforce is committed to providing recommendations to government that will allow the MBS to deliver on each of these key goals:
affordable and universal access,
best practice health services,
value for the individual patient,
value for the health system.
The clinical review of MBS items, ranging from consultations to procedures and diagnostics, is carried out by discipline-specific clinical committees and working groups.
At the same time, the MBS Principles and Rules Committee appointed by the Taskforce are reviewing the enforceable rules and regulations underpinning the MBS so they are up-to-date and support contemporary clinical practice.
To date, more than 300 clinicians and nearly 60 committees and working groups have been, or are in the process of being, established and are reviewing the items, line by line.
Methods: The Taskforce has asked the clinical committees to undertake the following tasks:
Consider whether there are items that are obsolete and should be removed from the MBS.
Consider identified priority reviews of selected MBS services.
Develop a program of work to consider the balance of MBS services within its remit and items assigned.
Advise the Taskforce on relevant general MBS issues identified in the course of their deliberations.
Findings: Committees release reports with draft recommendations and invite stakeholder feedback. The recommendations do not represent the final position on items and remain subject to consideration of stakeholder feedback and the Taskforce.
The Taskforce will then deliver finalized recommendations to government throughout the review process and deliver a final report to government at the end of the MBS Review.
To ensure the MBS remains up-to-date, the Taskforce will also develop an ongoing system of review after this current review is completed.
Conclusions: We will report progress of psychiatry-related items across a number of clinical committees.
What Does Recovery Mean for Psychiatry Formal Education Courses?
R McKay1,2, A Rosso Buckton1
1Health Education and Training Institute, Sydney, Australia
2University of New South Wales, Sydney, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) Position Statement 86 Recovery and the Psychiatrist ‘acknowledges the transformative potential of recovery for all people with mental illness and the importance of adopting recovery-oriented practices’ and highlights that a recovery orientation ‘does not negate the skills and principles underlying the evidence-based biopsychosocial approach to psychiatry and may indeed encourage and empower psychiatrists to apply them together in a holistic way’.
Objectives: To describe the interpretation of key implications of recovery for a Formal Education Course (FEC), as applied in developing a new FEC delivered by the Health Education and Training Institute (HETI), the Masters of Psychiatric Medicine.
Methods: A description of key processes, content and decisions influenced by deciding that the Masters of Psychiatric Medicine would focus on supporting the development of recovery-oriented psychiatrists.
Findings: Embracing a recovery orientation necessitated a whole-of-FEC approach to equip trainees to continually adapt to working collaboratively in the context of changing relationships between psychiatrists, ‘their’ patients and community. Therefore, psychiatry trainees and general practitioners are encouraged to study (and, in the future, practise) together to develop shared knowledge and reflective thinking about recovery-oriented care. Attainment of CanMED competencies is supported through activities encouraging aligned workplace supervision to apply these within the students’ specializations. Respect for the expertise of people with lived experience necessitates that expertise being represented throughout the course.
Conclusions: Recovery perspective instills hope in consumers, carers and clinicians. It provides a welcome and positive focus for reform in psychiatry education that can only be met by a whole-of-FEC approach.
Initiatives to Enhance Psychiatry Training: the South Australian Experience
S Gill1, A Asan2, H Newton2
1Director of Training, South Australian Psychiatry Branch Training Committee (SAPBTC), Adelaide, Australia
2Trainee, South Australian Psychiatry Training Program, Adelaide, Australia
Background: South Australia (SA) has been in the unique position of having some accumulated funds from several decades of training fees for its formal education course (FEC), owing to the generous provision of pro bono teaching from psychiatrists who have not charged for their service. This has allowed the South Australian Psychiatry Branch Training Committee to develop initiatives to enhance training for psychiatry trainees in SA.
Objectives: To outline some of these initiatives, which have included funding of programs to improve trainee welfare; enhanced educational sessions from local, national, and international speakers; introduction of a variation of Balint groups for trainees, appointment of a research tutor and remediation tutor.
Methods: The structure, purpose, role descriptions, and guidelines of each initiative will be outlined. There are plans to undertake a formal evaluation process for each initiative. There will be a report on preliminary evaluation of one of the initiatives, facilitated learning groups, which are run as a modified Balint group.
Findings: These initiatives promise to enhance the experience of training for South Australian Psychiatry trainees.
Conclusions: These initiatives will hopefully become a template or model for other training regions in Australia and New Zealand to consider. Other training zones may wish to introduce or adapt some of these for their program to continue to improve the quality of psychiatry training in our two countries.
Improving the Experience of Our Interns and Residents in Psychiatry Terms
L Nash1,2,3, A Karageorge1,2
1Health Education and Training Institute of New South Wales Health, Sydney, Australia
2Brain and Mind Centre, University of Sydney, Sydney, Australia
3Western New South Wales Local Health District, Orange, Australia
Background: A recent synthesis of international literature suggests that particular aspects of medical student and junior doctor psychiatry term experiences influence their overall impression of psychiatry as a discipline, as well as their attitude towards psychiatry as a career (Karageorge et al., 2016).
Objectives: To identify and implement changes to the PGY1 and PGY2 psychiatry term in NSW that will promote an improved experience for interns and residents.
Methods:
Eight focus groups were convened and an online survey was sent to 197 doctors completing a PGY1 and PGY 2 psychiatry term across NSW in 2015–2016. There were 79 respondents (40% response rate). The survey probed favourable and unfavourable aspects of the term, career interest before and after the term, and qualitative data pertaining to specific mechanisms of influence on overall perceptions of psychiatry (Nash et al., 2016).
2)Taking survey findings into account, a multipronged implementation strategy of changes to psychiatry terms will be outlined for discussion, following a knowledge translation approach (Graham et al., 2006), including the following components:
guidelines for supervisors and junior doctors;
updated term description templates, including reference to particular items known to improve junior doctor experience of the term;
dissemination of findings from the NSW study (focus groups, online survey) to stakeholders and junior doctors across key sites in NSW via Grand Rounds, junior medical officer forums and stakeholder meetings;
to consider if workplace-based assessments are appropriate.
Discussion: This presentation will focus on implementation strategies to promote the key findings from the focus groups and survey of junior doctors to improve their experience of the psychiatry term.
References
Karageorge A, Llewellyn A, Nash L, et al (2016) Psychiatry training experiences: A narrative synthesis. Australasian Psychiatry 24(3): 308–312.
Graham ID, Logan J, Harrison MB, et al. (2006) Lost in knowledge translation: Time for a map? Journal of Continuing Education in the Health Professions 26(1): 13–24.
Nash L, Karageorge A, Llewellyn A, et al. (2016) Accentuate the positives, but don’t necessarily eliminate the negatives: A cross-sectional survey of junior doctor psychiatry terms. MedEdPublish, DOI: 10.15694/mep.2016.000110.
Enrichment Activities in the Medical School Psychiatry Program – Could this be a key to Engaging Medical Students in Psychiatry? A Study from a UK High Secure Forensic Psychiatric Hospital
M Das1,2, A Mortlock1, S Sengupta1
1Broadmoor Hospital, West London Mental Health Trust, London, UK
2Top End Mental Health Service, Darwin, Australia
Background: Psychiatry is not looked upon favourably by medical students as a career choice. Numerous studies focus on factors influencing career decision-making of medical students; however, there is limited literature regarding enrichment activities within medical school psychiatry in the United Kingdom.
Aim: To evaluate the effect of a one-day visit to a high secure forensic psychiatric hospital on medical students’ attitudes towards psychiatry, in addition to exploring students’ career intentions and the factors influencing these.
Method: Data were collected from medical students (n = 289) attending one-day structured visit to Broadmoor Hospital. Students’ career intentions and the influencing factors, prior experience of working in mental health care and sociodemographic details were ascertained. Change in attitudes was established using the 30-item Attitudes Toward Psychiatry Scale.
Results: Evaluation of 254 responses revealed a statistically significant increase in positive attitude towards psychiatry between start and end of the one-day visit. Overall, the ‘Medical school clinical attachment’ had the most influence on a career choice of psychiatry. Of the 6% who expressed a ‘Definite’ intention to pursue psychiatry, ‘Career opportunities’ was cited most frequently. For those not choosing psychiatry, ‘Patient prognosis’ was highlighted. Qualitative answers revealed views about the speciality being slow paced and emotionally difficult.
Conclusions: These findings support existing evidence that the medical school clinical attachment is key to shaping attitudes towards psychiatry. This study also shows, however, that a visit to a specialized unit outside of traditional teaching placements can have a significant positive impact not only on attitudes towards psychiatry but also towards mental illness in general.
Unlearning Assumptions – Lessons from Mentoring Rural Trainees
S Lee1, M Stewart2, D O’Connor3
1Western Sydney Local Health District, Sydney, Australia
2The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
3Monash University, Melbourne, Australia
Background: Is there a role for mentors in psychiatry training alongside supervision? Mentoring is not included in the psychiatry training model but requests persist from psychiatry trainees to help find mentors. Does mentoring have an impact in isolated settings?
Objectives: To present and discuss outcomes and implications of a Royal Australian and New Zealand College of Psychiatrists (RANZCP) program to provide mentors to trainees based in Australian regional and rural posts in 2015.
Methods: Rural and regional trainees and psychiatrists were matched as mentor–mentee pairs. All participants were invited to attend introductory and closing workshops. Outcomes were evaluated by surveys at 3, 6, 9 and 12 months, focus groups and facilitated sessions.
Findings: Survey return rates were 79–93% for trainees and 86–100% for mentors. Increase in confidence, professional development and motivation, work performance and workforce retention were positive trainee impacts reported. Reported trainee outcomes were highly consistent between mentors and trainees. The majority (97%) trainees reported the relationship as ‘very useful’ or ‘somewhat useful’. Mentors also experienced benefit. Themes of reflection, safety, ‘giving back’, unlearning assumptions and the importance of RANZCP endorsement emerged in focus group feedback. The majority of participants indicated the pairing would continue.
Conclusions: Strongly positive outcomes of mentoring were reported by trainees and psychiatrists. Implications for the supervision relationship, work engagement and RANZCP fellowship are discussed.
Computer Therapy for the Anxiety and Depression Disorders is Effective, Acceptable and Practical Healthcare: an Updated Meta-Analysis
A Basu1, G Andrews2, P Cuijpers3, M Craske4, P McEvoy5,6, C English7, J Newby8
1University of New South Wales, Sydney, Australia
2School of Psychiatry, University of New South Wales, Sydney, Australia
3Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Amsterdam, The Netherlands
4EMGO Institute for Health and Care Research, Vrije Universiteit and VU Medical Centre, Amsterdam, The Netherlands
5School of Psychology and Speech Pathology, Curtin University, Perth, Australia
6Centre for Clinical Interventions, Perth, Australia
7St George’s University of London, London, UK
8School of Psychology, University of New South Wales, Sydney, Australia
Background: In October 2010, we published a meta-analysis based on 22 randomized controlled trials of computerized/Internet-delivered cognitive behavioural therapy (cCBT/iCBT) in which it was argued that ‘computer therapy for the anxiety and depressive disorders was effective, acceptable and practical health care’ even though no data on effectiveness or practicality in routine practice or primary care was provided.
Objectives: To determine if the original conclusion is now supported.
Methods: Databases, reviews and meta-analyses were searched for randomized controlled trials of cCBT or iCBT versus a control group (e.g. care as usual, waitlist, information control, psychological placebo, pill placebo) in people who met diagnostic criteria for major depression, panic disorder, social phobia or generalized anxiety disorder. Number-randomized, superiority of treatment versus control (Hedges’ g) on primary outcome measure, length of follow-up, follow-up data, patient adherence and satisfaction/harm were extracted; risk of bias was assessed and number needed to treat (NNT) was calculated. A search for studies on effectiveness of iCBT in clinical practice was conducted.
Findings: A total of 64 trials was identified. The mean effect size (efficacy) was g = 0.80 (NNT 2.34), and benefit was evident across all four disorders. Improvement was maintained at follow-up (median 6 months). Acceptability, as indicated by adherence and satisfaction, was good. Research probity was good, and bias risk low. In addition, nine studies comparing iCBT with traditional face-to-face CBT and three comparing iCBT with bibliotherapy were identified. All three modes of treatment delivery appeared equally beneficial. The results of effectiveness studies were congruent with the results of the efficacy trials.
Conclusions: The conclusions drawn in the original meta-analysis are now supported: iCBT for the anxiety and depressive disorders is effective, acceptable and practical healthcare.
Initiating Clozapine in a Patient with Treatment-Resistant Schizophrenia and Hypertrophic Cardiomyopathy: A Case Report
A Adan Sanchez1, J Foster2, C Plymen3, S Shergill2,4,5
1The University of Melbourne, Melbourne, Australia
2National Psychosis Unit, South London and Maudsley NHS Foundation Trust, London, UK
3Division of Cardiology, King’s College Hospital NHS Foundation Trust, London, UK
4National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London, UK
5Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
Background: There is limited experience in the initiation and maintenance of clozapine for treatment-resistant schizophrenia in adults with established structural heart disease. Here we present the successful experience of treating one such patient within our service and describe a monitoring plan to ensure that these treatments can be provided safely and effectively.
Case presentation: A 36-year-old man with treatment-resistant schizophrenia and known hypertrophic cardiomyopathy (HCM) was admitted to a specialist unit for a trial of clozapine. The diagnosis of HCM was made 3 years previously following a routine electrocardiogram (ECG) and he had remained asymptomatic throughout this time.
Clozapine was started at 12.5 mg daily and up-titrated to 150 mg twice daily over 14 days as per our institutional guidelines. The patient was monitored with regular troponins, inflammatory markers and ECG. On day 18, his troponin level increased to 1371 ng/L. Creatine kinase and inflammatory markers remained stable. No changes in ECG or transthoracic echocardiogram were noted and the patient remained clinically asymptomatic.
Cardiology opinion reported that the finding of an isolated elevated troponin was likely to reflect a ‘troponin leak’ in the context of increased cardiac muscle mass associated with HCM. In the absence of any clinical compromise, it was not felt to be of concern. Clozapine was continued with good effect on mental state. The troponin gradually reduced and the patient remained well.
Conclusions: This case report suggests that clozapine can be safely introduced in pre-existing HCM, explores strategies for monitoring and highlights the importance of liaising with experienced cardiologists.
Dieting and Disordered Eating: Why the Non-Diet Approach?
S Melen
University of Queensland, Brisbane, Australia
Background: Both the medical profession and general population are well aware of the ever-increasing and urgent ‘obesity epidemic’. Alongside this epidemic is an industry dedicated to creating and selling dieting as a means of weight management. Despite the poor evidence supporting the efficacy of dieting for sustained weight loss, diets are still encouraged as a means of weight loss, including within the medical profession. However, if dieting did help people to lose weight and keep it off long term (and allegedly improve health) then surely the ‘obesity epidemic’ would not exist? Clearly something is not working.
Objectives: This presentation seeks to discuss the proposition that dieting is not an effective weight management technique and that there are appropriate alternatives. This will be done by examining the research on the effectiveness of dieting, and the harms associated with dieting (including disordered eating). The implications of a non-diet approach are then considered, particularly for people with disordered eating behaviours.
Methods: A review of the literature investigating the relationship between dieting, disordered eating, and the non-diet approach. An examination of the literature, and a discussion of clinical perspectives on the advantages and utility of the non-diet approach to weight management.
Findings: Dieting is harmful and should be discouraged as a means of weight management, particularly in people who are overweight or obese.
Conclusions: Dieting is ineffective in long-term weight management, and it contributes to disordered eating behaviours. A non-diet approach can address the weight concerns that encourage dieting, while avoiding the harmful consequences associated with dieting.
Guidance from General Practice on Dementia Prevention Knowledge Translation Priorities
M Martin-Khan, MS Alexander
University of Queensland, Brisbane, Australia
Background: General practitioners (GPs) are recognized as gatekeepers between health services provision and patients (Millard, 2008). Effective primary care for community-based patients is facilitated by public health intervention. We recognize that there are some dementia risk-reduction strategies with sufficient evidence for GPs to recommend changes in behaviour. Knowledge translation research is now required to see this evidence moved into practice (Straus et al., 2011).
Objectives: To identify key areas where the translation of existing evidence in dementia prevention may be made locally relevant to support GPs with changing practice and impacting patient outcomes.
Methods: GPs (N = 6) participated in focus groups to peruse a summary of current literature on dementia prevention and risk reduction prior to a facilitated discussion. The discussion addressed perceptions regarding the level of evidence and readiness for implementation. Participants were asked to identify three to four primary recommendations for targeted translation activities. The discussion was audio-taped, transcribed and analysed using Leximancer.
Findings: The analysis identified the dominant theme of the individual and families, and that dementia prevention discussions are both person-oriented and related to lifestyle choices. Connected themes of the GP, clinical medical practice and the community as partners in supporting health change were strong. Further theme analysis of the transcripts identified limited evidence around prevalence of dementia and the extent to which prevention activities have been successful longitudinally, including the generalizability of anticholinergic medication.
Conclusions: Priority for progression from theory to practice in dementia prevention is in bundling dementia risk reduction as another benefit of lifestyle changes when promoting prevention of chronic disease.
References
Millard F (2008) GP management of dementia – A consumer perspective. Australian Family Physician 37(1–2): 89–92.
Straus SE, Tetroe JM and Graham ID (2011) Knowledge translation is the use of knowledge in health care decision making. Journal of Clinical Epidemiology 64(1): 6–10.
The Epidemiology of Amphetamine-Type Stimulant-Related Hospital Admissions and Presentations to the Emergency Department in Hedland, Western Australia
C Monahan1, M Coleman2
1University of Western Australia, Perth, Australia
2Western Australia Country Health Service, Albany, Australia
Background: Recent research has shown an increase in the number of amphetamine-type stimulant (ATS)-related emergency presentations and hospital admissions to metropolitan centres in Australia.1 Despite the research that shows higher use of ATS in rural areas,2 limited research has examined the epidemiology of ATS-related presentations and admissions to remote regional centres.
Objectives: To determine the epidemiology of ATS-related emergency presentations and hospital admissions over a 5-year period at Hedland Health Campus (HHC) in remote WA.
Methods: A retrospective review of medical records at HHC was conducted. Records were searched for medical codes relating to ATS use. Demographic data including gender, age and Indigenous status were captured and compared to national trends.
Findings: A total of 482 ATS-related emergency department presentations were identified during the study period. Substance use disorders and substance-induced mental disorders were the most common reasons for presentation. A majority (66%) were male and 67% identified as Aboriginal or Torres Strait Islander. Sixty-four ATS-related hospital admissions were identified during the study period. Psychotic disorder was the most common reason for admission, followed by acute intoxication. Males made up 75% of admissions and more than 50% identified as Aboriginal or Torres Strait Islander. Both presentations and admissions increased each year over the study period.
Conclusions: This study showed a disproportionally high burden of ATS-related harm among Aboriginal or Torres Strait Islander people in this remote WA region. In line with national trends, the number of ATS-related emergency presentations and hospital admissions increased over the study period. Males were more likely than females to have an ATS-related presentation or admission. The study provides a guidance to clinicians, service providers and the community in formulating strategies to address the escalating harm associated with ATS use in remote locations in WA.
2. National Drug Strategy Household Survey Detailed Report: 2013. [Internet]. Canberra: Australian Institute of Health and Welfare. Cat. No.: PHE 183, http://www.aihw.gov.au/publication-detail/?id=60129549469 (2014, accessed 3 August 2015).
Chronic Pain and Medically Unexplained Symptoms in the Medico-Legal Arena
A Davis
Royal Adelaide Hospital, Adelaide, Australia
Abstract: Making sense of chronic pain and medically unexplained symptoms is an issue that constantly confronts practitioners in all fields of medicine. In the medico-legal arena, such conditions pose a major challenge to all parties engaged in trying to understand the basis of persistent and often treatment-resistant symptoms and seek reasonable outcomes for all concerned.
This presentation will offer a psychosocial perspective on the nature of chronic pain and medically unexplained symptoms and explore the complex factors that underpin the experience of these symptoms in patients, particularly in the medico-legal setting.
Metabolic Syndrome in Patients with Schizophrenia Receiving Long-Term Treatment with Lurasidone, Quetiapine XR, or Risperidone
J Newcomer1, M Tocco2, A Pikalov2, J Hsu2, J Cucchiaro2, A Loebel2
1Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
2Sunovion Pharmaceuticals Inc., Fort Lee, New Jersey, and Marlborough, Massachusetts, USA
Background: Patients with schizophrenia are at increased risk of developing metabolic syndrome, which may be exacerbated by treatment with certain antipsychotic agents.
Objectives: To evaluate metabolic syndrome occurrence during long-term lurasidone treatment.
Methods: Metabolic syndrome rates (defined by US National Cholesterol Education Program-Adult Treatment Panel III (without using drug treatment criteria)) were evaluated in adult patients with schizophrenia treated with lurasidone in two, long-term, active-controlled studies. In the quetiapine XR–controlled study, patients completing a 6-week, double-blind, placebo-controlled, fixed-dose trial of lurasidone (80 mg/day or 160 mg/day) or quetiapine XR (600 mg/day) continued on double-blind, flexibly dosed lurasidone (40–160 mg/day) or quetiapine XR (200–800 mg/day) for up to 12 months. In the risperidone-controlled study, patients received double-blind, flexibly dosed lurasidone (40–120 mg/day) or risperidone (2–6 mg/day) for up to 12 months.
Findings: Among patients without metabolic syndrome at baseline in the risperidone-controlled study, 10.3% (12/117) of lurasidone-treated patients and 23.2% (16/69) of risperidone-treated patients developed metabolic syndrome at month 12 (odds ratio (OR) = 0.340; 95% confidence interval (CI), 0.147–0.787; p = 0.012). Of patients without metabolic syndrome at baseline in the quetiapine XR–controlled study, 2.2% (2/92) of lurasidone-treated patients and 10.0% (3/30) of quetiapine XR–treated patients developed metabolic syndrome at month 12 (OR = 0.290; 95% CI, 0.042–1.994; p = not significant).
Conclusions: This post hoc analysis demonstrated that patients with schizophrenia were more likely to develop metabolic syndrome during long-term treatment with risperidone or quetiapine XR compared with lurasidone. Lurasidone was associated with a low risk for metabolic syndrome.
Funding
This study was sponsored by Servier Laboratories and Sunovion Pharmaceuticals Inc.
Disclosures
Dr Newcomer has received grant funding from the (United States) National Institutes of Health and Otsuka America Pharmaceutical Inc., served as an independent scientific member on a Data Safety Monitoring Board for Amgen Inc., and served as a consultant for Reviva Pharmaceuticals, Inc. and Sunovion Pharmaceuticals Inc.
Drs Tocco, Pikalov, Hsu, Cucchiaro, and Loebel are employees of Sunovion Pharmaceuticals Inc.
Flinders University, Department of Psychiatry, Adelaide, Australia
Background: Clozapine is the gold standard treatment for treatment-resistant schizophrenia (Kane et al., 1988). It has also been found to be helpful in conditions other than schizophrenia.
Objectives: To review the benefits of clozapine for indications other than treatment-resistant schizophrenia.
Methods: Major databases PubMed, EMBASE, Cochrane and UpToDate were searched to determine the use of clozapine beyond the usual indication of treatment-resistant schizophrenia.
Findings: Clozapine is approved by the US Food and Drug Administration for suicidality (Meltzer et al., 2003) in schizophrenia. There is also some evidence base for its use in several other indications, which include aggression (Frogley et al., 2012) and violent behaviour in psychosis, psychosis in Parkinson’s disease (Connolly and Lang, 2014), Tardive movement disorder (Hazari et al., 2013), severe borderline personality disorder (Zarzar and McEvoy, 2013), treatment-resistant bipolar mania (Ifteni et al., 2014), treatment-resistant depression (Rogoz, 2013) and catatonia (Eede Filip et al., 2005).
Conclusions: Clozapine is under-utilized for indications other than treatment-resistant schizophrenia. Clinicians should be aware that clozapine has a broad spectrum of action and to consider its use beyond treatment-resistant schizophrenia.
References
Connolly BD and Lang AE (2014) Pharmacologoic treatment of Parkinson disease: A review. Journal of the American Medical Association 311(16): 1670–1683.
Eede Filip VD, Jan VH and Arjen VD (2005) The use of atypical antipsychotics in the treatment of catatonia. European Psychiatry 20(5–6): 422–429.
Frogley C, Taylor D, Dickens G, et al. (2012) A systematic review of the evidence of clozapine’s anti-aggressive effects. International Journal of Neuropsychopharmacology 15(9): 1351–1371.
Hazari N, Kate N, Grover S, et al. (2013) Clozapine and tardive movement disorders: A review. Asian Journal of Psychiatry 6(6): 439–451.
Ifteni P, Correll CU, Nielse J, et al. (2014) Rapid clozapine titration in treatment-refractory bipolar disorder. Journal of Affectve Disorders 166: 168–172.
Kane J, Honigfeld G, Singer J, et al. (1988) Clozapine for the treatment-resistant schizophrenic. A double-blind comparison with chlorpromazine. Archives of General Psychiatry 45(9): 789–796.
Meltzer HY, Alphs L, Green AI, et al. (2003) Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Archives of General Psychiatry 60(1): 82–91.
Rogoz Z (2013) Combined treatment with atypical antipsychotics and antidepressants in treatment-resistant depression: Preclinical and clinical efficacy. Pharmacological Reports 65(6): 1535–1544.
Zarzar T and McEvoy J (2013) Clozapine for self-injurious behavior in individuals with borderline personality disorder. Therapeutic Advances in Psychopharmacology 3(5): 272–274.
Patient Experiences with Three-Monthly Paliperidone Palmitate For the Management of Schizophrenia
P Brahmbhatt
Lower North Shore Mental Health, Sydney, Australia
Background: In recent years, long-acting injectable antipsychotic (LAI) medications have expanded significantly in their development and role in the management of schizophrenia. The longest dosing interval for an LAI was approved by the Australian Therapeutic Goods Administration on 23 September 2016 as a 3-monthly formulation of paliperidone palmitate (PP3M). Administered to patients only four times in a given year, PP3M offers notable potential to extend medication exposures in patients, with important subsequent implications for their lives.
Objectives: Practical clinical experiences with PP3M in Australia will be described to provide a representative overview for the role of PP3M in the management of schizophrenia.
Methods: Case studies with PP3M will be presented and reviewed with discussion about the clinical implications of this newly available LAI treatment option.
Findings: Shared examples of PP3M use in schizophrenia illustrate substantial utility for this new treatment option to facilitate patient independence, social and societal connectedness, presumably stemming from the stability and duration of therapeutic medication levels between injections. PP3M appears also to enable healthcare professionals the ability to devote more clinical care time to psychosocial and functional aspects of patient recovery.
Conclusions: PP3M, with its 3-monthly dosing interval, presents a unique treatment option to healthcare providers not only for relapse prevention but also in enabling a greater focus of the care and recovery process on functional outcome and, ultimately, quality of life for patients with schizophrenia.
Use of Mobile Phones and Laptops by Psychiatric Inpatients: Benefits, Risks and Attitudes of Patients, Families and Staff
N O’Connor1,2, K Zantos2
1Northern Sydney Local Health District, Sydney, Australia
2Department of Psychiatry, University of Sydney, Sydney, Australia
Background: There has been little evaluation of the benefits and risks of allowing psychiatric inpatients to use their mobile phones and laptops in hospital. The issue is contested. Potential risks of allowing patients access to their electronic devices include that patients may post photographs of staff or inappropriate narratives about staff on the Internet or social media; the risk to the reputation of the patient who is very unwell using their electronic device inappropriately; and that staff will be left with the responsibility of managing the loss or damage to electronic devices. The putative benefits include that access to smart phones and laptops may assist the patient’s recovery and maintaining social connections while the patient is in hospital; and supporting patient autonomy and rights.
Objectives: The study aims to evaluate the attitudes of patients, family and staff, to explore the potential benefits and risks of allowing psychiatric inpatients controlled access to electronic devices and to inform policy and practice.
Methods: The literature on psychiatric inpatients was reviewed. A survey questionnaire was developed and administered to 100 consecutive patients and a family member and to all staff of the psychiatric emergency care centre and inpatient unit.
Findings: The findings will be analysed and presented.
Conclusions: The findings of this study will inform policy and practice in psychiatric inpatient settings.
The First 30 Months of the Mindspot Clinic: Evaluation of a National E-Mental Health Service Against Project Objectives
N Titov1,2, B Dear1,2 O Nielssen1,3
1MindSpot Clinic, Sydney, Australia
2eCentreClinic, Macquarie University, Sydney, Australia
3Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
Objective: The MindSpot Clinic provides online mental health services to Australian adults with anxiety and depression. This paper describes users of MindSpot between January 2013 and June 2015. Outcomes are considered against three key objectives: improving access to mental health services; improving public awareness of how to access services; and providing evidence-based treatments.
Methods: Website traffic data were examined to determine patterns of use. Demographic characteristics, past service utilization and reasons for contacting MindSpot were analysed. Outcomes for patients enrolled in a MindSpot treatment course were also examined. Primary outcomes were scores on the 9-Item Patient Health Questionnaire, Generalised Anxiety Disorder 7-Item, Yale–Brown Obsessive Compulsive Scale and Post-Traumatic Stress Disorder Checklist–Civilian Version, administered at assessment, post-treatment and 3-month follow-up.
Results: The website was visited by almost 500,000 Australians, of whom 33,990 adults started assessments, and 25,469 people completed assessment and were eligible for analysis. The mean age was 36.4 years (standard deviation = 13.3 years; range = 18–94 years), and 72% were female. The proportion living in rural or remote regions and who identified as Aboriginal and Torres Strait Islander closely matched national statistics. The majority (82%) reported that they were not currently in contact with mental health services. Most patients sought an assessment, information about treatment options, or referral to another service, and only 24% of those completing an assessment commenced a MindSpot treatment course. Of these, large clinical effects (Cohen’s d: 0.7–2.4; average symptom reductions: 25.5% to 61.6%) were found from assessment to follow-up on all outcome measures. Deterioration ranged from 1.0% to 4.3%.
Conclusions: Based on the number of website visits, completed assessments and treatment outcomes, MindSpot achieved its three program objectives. This model of service provision has considerable value as a complement to existing services and is proving particularly important for improving access for people not using existing services.
Hazard Perception Skills of Young Drivers with Attention-Deficit Hyperactivity Disorder can be Improved with Computer-Based Training: A Feasibility Trial
C Bruce1, C Unsworth1,2,3,4, M Dillon1, R Tay5, T Falkmer1,3,4, P Bird6, L Carey1,7
1La Trobe University, Melbourne, Australia
2Central Queensland University, Rockhampton, Australia
3Jönköping University, Jönköping, Sweden
4Curtin University, Perth, Australia
5RMIT University, Melbourne, Australia
6The Gosforth Clinic, Maroochydore, Australia
7The Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
Background: Young drivers with attention-deficit hyperactivity disorder (ADHD) are at higher risk of road traffic injuries than their peers. Increased risk correlates with poor hazard perception skill. Few studies have investigated hazard perception training using computer applications such as DriveSmart with this group of drivers.
Objectives: To: determine the magnitude of the between-group and within-subject change in hazard perception skills among young drivers with ADHD-exposed/delayed exposure to DriveSmart training and determine whether training-facilitated change in hazard perception is maintained over time.
Methods: Australian feasibility study. Twenty-five drivers with a diagnosis of ADHD were randomized to the intervention or control group. Participants in the intervention group received a computer training session using DriveSmart, while the control group watched a documentary video. The design included a delayed treatment for the control group. The participants’ hazard perception skill was measured on the University of Queensland Hazard Perception Test (HPT) post training and at 6-week follow-up.
Findings: After adjusting for baseline scores, there was a significant between-group difference (p = 0.023, partial η2 = 0.212) and a significant within-subject difference post intervention in the experimental group. There was no significant difference between post intervention and 6-week follow-up scores in the experimental group.
Conclusions: The hazard perception skills of participants improved following training and were largely sustained. We found a large effect size consistent with one prior study. A full-scale trial is feasible.
Impulsivity and Suicidal Behaviour in Young People: A Systematic Review
C McHugh1,2, R Lee1,3, D Hermens1, I Hickie1
1CRE Optymise, Brain and Mind Centre, The University of Sydney, Sydney, Australia
2Prince of Wales Hospital, Sydney, Australia
3Monash University, Melbourne, Australia
Background: Impulsivity has been identified as a potential cognitive phenotype of suicidal behaviour, the investigation of which aims to increase our understanding of the underlying neurobiology and ultimately tailor interventions accordingly. There remains much heterogeneity in the use of the term ‘impulsivity’ in research and clinical practice, which is in part due to the multifaceted nature of the concept.
Objectives: The current review aims to establish which facets of impulsivity are most frequently associated with suicidal behaviour in young people, which self-report or cognitive measures capture these and whether the character of associations changes with age and development.
Methods: This systematic review involved searching MEDLINE and PubMed for studies which measured impulsivity and suicidal behaviour in young people, published between 1970 and 2015. Studies with a mean age below 30 years of age were included. Of the 60 studies included, 50 used only a self-report measure of impulsivity and 10 used a cognitive measure.
Findings: Self-report measures were rarely broken down into their loading factors, but those that were showed more frequent associations between suicidal behaviour and negative urgency. Cognitive measures showed association was most frequent between response inhibition and delay discounting, rather than measures of attention. The literature was limited by heterogeneity of outcome measures – in particular, poor division between lifetime versus more recent or current suicidal behaviour, and of control groups, which were often not screened for mental illness.
Conclusions: Certain types of impulsivity may be more strongly associated with suicidal behaviour than others, and contribution of these factors may change with age and development. Future clinical research should be designed to investigate negative urgency, response inhibition and delay gratification aspects of impulsivity.
Exploring How a Dialectical Behaviour Therapy–Oriented Intervention Influences Treatment Outcomes for Adolescents Following an Episode of Inpatient Care: Clients and Caregivers Perspectives
C Hayes1,2, M Simmons3,4, C Simons1,2, M Hopwood1,2
1Department of Psychiatry, The University of Melbourne, Melbourne, Australia
2Albert Road Clinic, Melbourne, Australia
3Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
4Orygen Youth Health Research Centre, Melbourne, Australia
Background: Inpatient mental health units represent a significant component of acute adolescent care. Despite government policies emphasizing the importance of service user’s views, few studies have examined adolescents’ views of inpatient care (Gill et al., 2016). Dialectical behaviour therapy (DBT) is a cognitive behavioural treatment originally developed by Linehan (1993, pp. 4 for the treatment of chronically suicidal adults with borderline personality disorder (BPD) (MacPherson et al., 2013). Since then, DBT has been shown to be successful among adolescents in several settings. However, while there are studies to support that adolescents can achieve positive treatment outcomes following inpatient care, the mechanisms by which this is achieved have not been empirically established.
Objectives: Explore ‘how’ and ‘why’ a DBT-oriented intervention influences symptomatology at baseline, discharge and 6-month follow-up. Explore ‘how’ adolescent mental health stabilization is achieved.
Methods: This study uses a combination of both qualitative and quantitative methods, involving semi-structured interviews with clients and caregivers on admission to the unit, prior to discharge and at 6-month follow-up. Clients completed self-report questionnaires at each interview.
Findings: Preliminary findings are presented in the context of adolescents’ views of their own symptomatology on admission and discharge from the inpatient unit. Caregiver’s views are also exhibited to explore treatment outcomes between both time points.
Conclusions: The findings of this study can enhance existing interventions so that improved outcomes are achieved, thus impacting future research initiatives. Findings can also identify the mechanisms by which mental health stabilization is achieved, thus optimizing inpatient treatment and guiding the organization of adolescent inpatient services.
References
Gill F, Butler S and Pistrang N (2016) The experience of adolescent inpatient care and the anticipated transition to the community: Young people’s perspectives. Journal of Adolescence 46: 57–65.
Linehan M (1993) Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press, p. 4.
MacPherson HA, Cheavens JS and Fristad MA (2013) Dialectical behavior therapy for adolescents: Theory, treatment adaptations, and empirical outcomes. Clinical Child and Family Psychology Review 16(1): 59–80.
Development of a Potential Screening Measure for Adolescent Depression
M Taouk1,2, B Meiser3, D Hadzi-Pavlovic1,2, M Dudley1, P B Mitchell1,2
1School of Psychiatry, The University of New South Wales, Sydney, Australia
2Black Dog Institute, Sydney, Australia
3Lundbeck, Sydney, Australia
4Lowy Cancer Research Centre, Prince of Wales Clinical School, The University of New South Wales, Sydney, Australia
Background: Depression is a major contributor to years lived with a disability globally and poses a greater financial cost than any other psychiatric disorder (Saluja et al., 2004; Vos et al., 2012). Depression can have an immediate and long-term negative impact on adolescents; thus, the capacity to screen for depression may assist in appropriately referring at-risk youth for further evaluation (Siu and US Preventive Services Task Force, 2016).
Objectives: Few adolescent-specific depression screening instruments have been developed in recent years using multimethod approaches (qualitative and quantitative), and some of those available have limitations with an adolescent audience. We describe the development of a potential measure – the Taouk Scale for Adolescent Depression (TSAD).
Methods: Draft items were informed by findings from focus groups and reviews by adolescents and healthcare professionals, resulting in a provisional 97-item scale. This was administered to a nationwide sample of 3087 adolescents. Exploratory factor analysis (EFA) was used in a development subset to examine dimensionality of items and reduce their number, with the final item set evaluated in a validation subset.
Findings: Four factors – negative outlook, emotional distress, behavioural changes and cognitive and somatic disturbances – were obtained from EFA, resulting in a 28-item instrument, which was corroborated by confirmatory factor analysis. The final scale includes novel items not included in current measures (i.e. whether respondents wear more black clothing, take more risks and/or ‘space out’ at school).
Conclusions: The TSAD demonstrated sound psychometric properties and may have utility for future screening purposes. It appears to be a valid and reliable screening instrument for adolescent depression that includes a number of novel items. Further research is necessary to confirm its criterion validity.
References
Saluja G, Lachan R, Scheidt PC, et al. (2004) Prevalence of and risk factors for depressive symptoms among young adolescents. Archives of Pediatrics and Adolescent Medicine 158: 760–765.
Siu AL, US Preventive Services Task Force (2016) Screening for depression in children and adolescents: US preventive services taskforce recommendation statement. Pediatrics 137: e20154467.
Vos T, Flaxman AD, Naghavi M, et al. (2012) Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 380: 2163–2196.
Childhood Maltreatment and Young Adulthood Hallucinations, Delusional Experiences and Psychosis: A Longitudinal Study
A Abajobir1, J Scott2, S Kisely3, J Najman2
1School of Public Health, The University of Queensland, Brisbane, Australia
2The University of Queensland Centre for Clinical Research, Brisbane, Australia
3School of Medicine, The University of Queensland, Brisbane, Australia
Background: Child maltreatment is a public health challenge associated with a range of mental health disorders later in life. To effectively address these disorders, there is a need to understand more about the mental health consequences of different types of child maltreatment.
Objectives: This study examines the associations between prospectively substantiated child maltreatment (ages 0–14 years) and reports of hallucinations and delusional experiences at 21 years after birth. As well, we examined 12-month and lifetime psychotic disorders using data from a longitudinal birth cohort.
Methods: The study comprised 3752 participants from the Mater-University of Queensland Study of Pregnancy, a prospective Australian pre-birth cohort study. Psychotic experiences, and 12-month and lifetime psychosis were measured using the Achenbach Young Adults Self-Report, the Peter’s Delusions Inventory and Composite International Diagnostic Interview at the 21-year follow-up.
Findings: In adjusted analyses, those children who had experienced any maltreatment, who were emotionally abused and neglected, were more likely to report hallucinations and lifetime delusional experiences; and were more likely to experience lifetime psychosis than their non-abused counterparts. In expanded hierarchical models, those exposed to multiple forms of maltreatment, in particular with emotional abuse and neglect, had an increased likelihood of hallucinations and delusional experiences.
Conclusions: There is an association between child maltreatment, especially emotional abuse and neglect, and later psychosis outcomes. However, the vast majority of children experiencing childhood maltreatment do not develop psychotic experiences or psychotic disorder. Research to determine reasons for highly variable outcomes of child maltreatment is warranted.
A Lifestyle and Life Skills Intervention to Improve Cardiometabolic Health of Young People with First Episode Psychosis: Implementing the Keeping the body in Mind program as Part of Routine Care
R Morell1,2, S Rosenbaum2,3,4, A Watkins1, P Ward2, J Curtis1,2
1Keeping the Body in Mind Program, Mental Health, South Eastern Sydney Local Health District, Sydney, Australia
2School of Psychiatry, The University of New South Wales, Sydney, Australia
3School of Medical Sciences, The University of New South Wales, Sydney, Australia
4Black Dog Institute, Sydney, Australia
Background: We recently published an initial evaluation of the Bondi ‘Keeping the Body in Mind’ (KBIM) program, a multidisciplinary, 12-week intervention aimed at attenuating weight gain and improving metabolic outcomes in young people (15–25 years) recently commenced on antipsychotic medication (Curtis et al., 2016). The KBIM intervention resulted in markedly lower rates of weight gain, and no change in waist circumference compared to best-practice first episode psychosis (FEP) treatment. A majority, 87% (14/16) of the intervention group did not experience clinically significant weight gain, whereas 75% (9/12) of the comparison gained more than 7% of baseline weight.
Methods: We now report data from another cohort of young people with FEP, who have participated in the KBIM program at one of three public community mental health services in south-eastern Sydney. Rather than focussing only on those who had recently commenced treatment with antipsychotic medication, this implementation evaluation included all FEP clients who completed the 12-week intervention.
Results: Seventy-three clients were included in this analysis of data collected as part of routine care (mean age, 23 years, 31% female). The mean duration of antipsychotic treatment prior to commencing the KBIM intervention was 8 months. At baseline, 49% of the cohort was overweight or obese (versus 36% of 18–24 year olds in the general population). Post-intervention, there was no significant increase in weight and a 1.3-cm reduction in waist circumference.
Conclusions: The initial positive results achieved with the KBIM intervention have been sustained as the program transitioned into routine care. Preventing weight gain and waist circumference increase in FEP is an achievable goal that will help to reduce the life-expectancy gap for people with severe mental illness.
Reference
Curtis J, Watkins A, Rosenbaum S, et al. (2016). Evaluating an individualized lifestyle and life skills intervention to prevent antipsychotic-induced weight gain in first-episode psychosis. Early Intervention in Psychiatry 10(3), 267–276.
Mindfulness-Based Cognitive Therapy – A View From the Crossroad
G Meadows1,2,3, D Korevaar1, F Shawyer2
1Monash University, Melbourne Australia
2The University of Melbourne, Melbourne, Australia
3Monash Health, Melbourne, Australia
Background: The efficacy of mindfulness-based cognitive therapy (MBCT) in reduction of recurrence and relapse of major depressive episodes is now supported by multi-method meta-analyses of randomized controlled trials (RCTs) conducted over 20 years; evidence is developing around effectiveness and cost utility. This clinical science program can be seen as at a turning point with recent conceptual and technical additions based on evolutionary psychology, phenomenology and services research.
Objectives: To review the development of evidence for and around MBCT, so attendees understand where we have come with this evidence and where we may be going.
Methods: A narrative review drawing on key Australian work with MBCT, clinical experience and training, will explore in this context concepts of periods of normal science punctuated by paradigm shifts.
Findings: A lengthy period of normal scientific progress through accumulation of an evidence base through RCTs is, we contend, now facing tensions that may lead to paradigm shifting across four main transition points: a sceptical backlash concerned about investigator bias and undeclared side effects; mediation analyses and understandings from evolutionary psychology suggesting compassion as critical in the therapeutic process of MBCT; improved end points for investigations of effectiveness based on health economics; and a new heuristic offered by careful phenomenological inquiry into the basis of mindfulness.
Conclusions: We suggest this as an exciting time in the development of MBCT as a clinical approach, with opportunities for balanced understandings of its effectiveness, indications and contraindications, as well as opportunities to increase sophistication in practical clinical applications of mindfulness.
Psychiatry Heal Thyself: A Lifestyle Intervention Targeting Mental Health Staff to Enhance Uptake of Lifestyle Interventions for People Prescribed Antipsychotic Medication
P Ward1,2, A Watkins3, J Poole3, D Pearce4, K Fitzpatrick4, S Rosenbaum1,5, J Curtis3
1School of Psychiatry, The University of New South Wales, Sydney, Australia
2Schizophrenia Research Unit, South Western Sydney Local Health District, Sydney, Australia
3Keeping the Body in Mind Program, Mental Health, South Eastern Sydney Local Health District, Sydney, Australia
4Mental Health, South Eastern Sydney Local Health District, Sydney, Australia
5Black Dog Institute, Sydney, Australia
Background: People experiencing severe mental illness (SMI) face a shortened life expectancy of up to 20 years, primarily due to preventable cardiovascular (CV) diseases. Lifestyle interventions are effective in reducing CV risk, yet examples of service-wide interventions are lacking. Staff culture remains a barrier to the successful implementation of lifestyle interventions. The Keeping the Body in Mind (KBIM) program, established by the South Eastern Sydney Local Health District, aims to close the gap in life expectancy through multidisciplinary teams, including clinical nurse consultants, dieticians, exercise physiologists and peer support workers. Prior to the KBIM rollout, an individualized lifestyle intervention called Keeping our Staff in Mind (KoSiM) was offered to all mental health staff. KoSiM examined the effectiveness of a staff intervention to improve physical health, confidence, knowledge and attitudes of mental health staff.
Methods: Mental health staff were invited to participate in an online survey and a 4-week individualized intervention including personalized health screening and lifestyle advice, with a 16-week follow-up. Outcomes assessed included attitudes, confidence and knowledge regarding metabolic health, weight, waist circumference (WC), blood pressure, sleep, diet, physical activity and exercise capacity.
Results: Of a total of 702 mental health staff members, 204 completed the survey (29%). Among those completing the survey, 154 staff (75%) participated in the intervention. There was a significant increase in attitudes, confidence and knowledge regarding metabolic health in consumers. A mean decrease in WC of 2 ± 2.7 cm (p < 0.001) was achieved among those staff members who were overweight or obese at baseline; 75% achieved a decrease in WC. A second cohort of staff were subsequently invited to participate in the KoSIM intervention, and more than 120 have commenced the intervention.
Conclusions: Improving staff culture regarding physical health interventions is an important step in integrating lifestyle interventions into routine care.
Resource Utilisation following Enrolment in the Intensive Community Outreach Team: An Evaluation of Assertive Community Treatment Provisioning in Western Australia
S Tait, D Bromwell, G Hammond
North Metropolitan Health Service-Mental Health, WA Health, Perth, Australia
Background: Early evaluation of assertive community models found that treatment significantly reduces inpatient admissions and improves client engagement. More recent randomized controlled trial evidence has failed to show similar improvements.
Objectives: To assess overall resource utilization in 190 patients with severe and enduring mental illness treated as part of the Intensive Community Outreach Team (ICOT) in the North Metropolitan area of Perth, Western Australia. Specific aspects of care reviewed included inpatient bed days (both mental health and non-mental health), emergency department (ED) presentations, community activity (hours of clinical care) and emergency telephone contacts.
Methods: Adjusted and unadjusted utilization rates before and after enrolment was compared using negative binomial regression. Post ICOT rates on the aforementioned factors were compared to a likely utilization estimate developed using a counterfactual model based on quantile regression. Financial estimates of the efficiencies were developed.
Findings: Observed inpatient bed utilization reduced by 25 days per person year, equalling a delivered treatment efficiency of close to $6 million. The estimate of reduction based on the counterfactual estimate was higher ($7.1 million). No significant reduction in ED contacts was observed. Community contact rates increased from 33 h per person year to 65 h. Increases relative to the counterfactual were lower. Contact rates with the emergency telephone services decreased from 5.4 per person year at pre-initiation peak to 3.1 per person post.
Conclusions: ICOT delivered significant reductions in inpatient utilization and increased community provision. Monetary estimates suggest the reduction in inpatient requirements was twice as large as the ICOT operating budget.
Stories of Healing in Place
J Liggins
Counties Manukau Health, Auckland, New Zealand
Background: The landscape of mental health treatment and care in the Western world has changed almost unrecognisably over the last 50 years. Deinstitutionalization saw the closure of large, often geographically remote, public asylums to be replaced by small acute mental health units (usually co-located with general hospitals) and community outpatient clinics. The psychiatric literature contains considerable commentary on the current state of inpatient psychiatry, much of it expressing concern.
Objectives and method: In this paper, I will present findings from a qualitative study that explored, from a service user perspective, aspects of place that facilitate healing in mental health care and recovery (Liggins, 2016).
Findings: Informed by geographical concepts including therapeutic landscapes (Gesler, 2005), and enabling places/resources (Duff, 2012), place was conceptualized as a complex and inseparably recursive interplay between ourselves, the material or physical environment, the people and activities of place.
Aspects of the places identified as healing were explored within a conceptual framework of ‘what and where these places were’; ‘the physical environment’ encompassing the built structures and the natural surrounds; ‘the people we shared our journeys with’; and ‘a place of opportunities: the doings and beings of living in these places’. Stories of ‘what it was like to be unwell, and then how that changed’ provided a context for, and way of understanding, the associations between place and recovery.
Conclusions: Personal stories lie at the heart of this research; exploring the subjective experience of illness and recovery offers alternative ways of making sense of what is needed from places of care.
References
Duff C (2012) Exploring the role of ‘enabling places’ in promoting recovery from mental illness: A qualitative test of a relational model. Health and Place.
Gesler WM (2005) Therapeutic landscapes: An evolving theme. Health and Place 11(4): 295–297.
Liggins J (2016) A place for healing in mental health care and recovery. PhD Thesis (Psychiatry), University of Auckland.
Finding Sanity: John Cade, lithium and the taming of bipolar disorder
GD Moore1, A Westmore2
1Westmead Hospital, Sydney, Australia
2The University of Melbourne, Melbourne, Australia
This is the story of lithium – the salt of the earth, which tamed one of the most crippling of human mental diseases – and the story of the Australian doctor who discovered its secret.
John Cade changed the course of medicine with his discovery of lithium; yet most doctors have never heard of his name. His discovery has stopped more people from committing suicide than a thousand ‘help’ lines, yet few counsellors know of him. And it has saved hundreds of billions of dollars in healthcare costs – enough to rival a nation’s economy – but you can bet that no politician has the slightest idea of who John Cade was.
It is story worth telling; dramatic and troubled, with a twist or two. How an unassuming young doctor, recently returned from World War II, came across a remarkable discovery.
Lithium is the penicillin story of mental health; the first effective medication discovered for the treatment of a mental illness; and it is, without doubt, Australia’s greatest mental health story.
The Effect of Substantiated Childhood Maltreatment on Cannabis Use Disorders in Young Adulthood: A Cohort Study
S Kisely1,2, A Abajobir3, G Williams3, A Clavarino2,4, J Najman3
1School of Medicine, The University of Queensland, Brisbane, Australia
2Princess Alexandra Hospital, Brisbane, Australia
3School of Public Health, The University of Queensland, Brisbane, Australia
4School of Pharmacy, The University of Queensland, Brisbane, Australia
Background: Although there is evidence for an association between childhood maltreatment and adolescent cannabis use, little is known about the effects of specific forms of childhood maltreatment, particularly neglect, as well as the frequency or intensity of maltreatment.
Objectives: We investigated the association between exposure to prospectively substantiated childhood maltreatment between 0 and 14 years of age and cannabis abuse or dependence at 21 years.
Methods: Data were taken from 2550 (females = 51.6%) participants in the Mater Hospital-University of Queensland Study of Pregnancy, a pre-birth, prospective, cohort study. We linked prospectively substantiated cases of childhood maltreatment, reported to the government child protection agencies between 0 and 14 years of age, to data from the 21-year follow-up.
Findings: Exposure to any childhood maltreatment including physical abuse and/or neglect was significantly associated with subsequent cannabis abuse. The adjusted odds ratios (AORs) for early age of onset of cannabis abuse were 2.59 for any maltreatment, 2.43 for emotional abuse and 3.08 for neglect. Any childhood maltreatment, physical abuse, emotional abuse and neglect were associated with cannabis dependence with AORs of 2.22, 2.09, 1.99 and 2.42, respectively. Similarly, frequency of maltreatment substantiations was associated with a range of cannabis use disorders. Males and females were equally affected.
Conclusions: There was a substantially increased risk of cannabis abuse in people with a history of maltreatment. Physical abuse, emotional abuse, neglect and exposure to more episodes of maltreatment independently predicted cannabis use disorders.
Borderline Personality Disorder in Perinatal Famlies
A Sved Williams1,2, C Yelland1, S Hollamby1
1Women’s and Children’s Health Network, Adelaide, Australia
2The University of Adelaide, Adelaide, Australia
Background: While there has been extensive research into perinatal depression and anxiety, borderline personality disorder (BPD) in the perinatal period has been relatively under-recognized, under-diagnosed, under-treated and under-researched despite its prevalence in some settings (e.g. a mother–baby unit (MBU) in South Australia).
Objectives: To quantify the presence of BPD in an MBU, to further study its effects on mothers and their babies, and to ensure that best practice is available for these families both within the MBU and after discharge.
Methods: Five phases of work have occurred: A study regarding rates of BPD within the unit both by the mother’s self-report and clinical diagnosis, with further information obtained from a retrospective study of discharge summaries.
A review of the literature regarding effects on infants of mothers with BPD, treatment measures for inpatients with BPD and treatments for mother–infant dyads when the mother has BPD.
Development of a protocol for inpatient mothers with a BPD diagnosis which provides treatment, psychoeducation and appropriate discharge planning.
A study of the effect of infant crying on mothers.
Development of a specialized post-discharge group, mother–infant dialectical behaviour therapy (MI-DBT) for mothers with BPD and their infants.
Findings: Of patients in this MBU, 25% of patients satisfy the formal Diagnostic and Statistical Manual of Mental Disorders, fifth edition criteria for a diagnosis of BPD, and 50% self-diagnose with this condition. Further study of perinatal BPD and the effects on infants has shown the emotional dysregulation caused for many women by an infant’s (normal) dysregulation, the need for specialized protocols and the value of further staff education and supervision. For patients, a formal program that provides structure, a definitive discharge date and plan, and carer input has been beneficial. MI-DBT, albeit staff intensive and demanding for patients, has so far been highly beneficial for mothers and their infants.
Conclusions: Destigmatization of BPD, appropriate focus on diagnosis and management plans and staff training has been beneficial in this MBU for patients and staff where BPD is no longer a stigmatized diagnosis. Longer term therapy for women and their infants in this specialized setting may be justifiable in terms of not only the improvement for the woman herself but also the disruption of intergenerational transfer of problems to her infant(s). These longer term treatments may also be beneficial for many postnatal women whose problems and levels of emotional dysregulation are substantial but do not need inpatient treatment.
What is Optimal Care for Mother–Infant Pairs Affected by Postpartum Psychosis? Treatment and Outcomes in the Australian Context
R Hill, D Law, C Yelland, A Sved Williams
Helen Mayo House, Perinatal and Infant Mental Health Service, Child and Adolescent Mental Health Service, Women’s and Children’s Health Network, Adelaide, Australia
Background: Postpartum psychosis (PP) is a severe and debilitating condition that is life-threatening to both mother and baby. These families urgently need evidence-based treatments and advice on prognosis and prevention. Published studies on the topic are scant, particularly in Australia, and infant outcomes have received very little attention. Helen Mayo House’s position as the only Mother Baby Unit (MBU) in South Australia means that it oversees the treatment of virtually all cases of PP in the state.
Objectives: To investigate the nature and severity of symptoms, the types of treatments received, and the associated outcomes for South Australian mothers with PP and their babies.
Methods: We carried out a systematic audit of the individual medical records of all identified dyads admitted with the diagnosis during the period between 1 January 2012 and 31 December 2014.
Findings: The study criteria were met by 19 dyads. All achieved substantial remission by the time of discharge, with a mean length of stay of 22.7 days. Most received antipsychotic monotherapy. Infants were medically and developmentally unremarkable. Breastfeeding was maintained in 74%. Child protective services were notified in 4/19 cases.
Conclusions: Treatment at this MBU is associated with good outcomes. The literature suggests lithium use may confer higher protection against relapse so arguably should be considered sooner than seen in this cohort. Questions still to be addressed regarding the outcomes for dyads who do not receive an MBU admission; how best to guarantee consistency of treatment across Australia; and how to assure expert follow-up for future pregnancies.
Forgotten Fathers – Exploring the Stressors Faced and the Coping Strategies Utilized by Fathers Facing Traumatic Pregnancies
G Bruxner, A Kothari, J Dulhunty
Metro-North Mental Health Service, The University of Queensland, Brisbane, Australia
Background: There is a growing interest in the male partner’s experience of ‘traumatic pregnancies’ including stillbirth, serious foetal abnormalities, termination of pregnancy and life-threatening perinatal maternal and neonatal complications.
Objectives: To explore the stressors faced and the coping mechanisms utilized by fathers facing traumatic pregnancies.
Methods: A prospective qualitative study of 26 male partners of women experiencing a traumatic event in pregnancy. The fathers were interviewed by a senior psychiatrist using phone and face-to-face semi-structured interviews at 3 months after the diagnosis of an adverse outcome. Thematic analysis of the interviews was complemented by Leximancer analysis.
Findings: Common themes identified included anxiety about subsequent pregnancy, problems with provision of medical information, problems with inquiries from others about recent work absence or pregnancy progress and their partner’s need to talk over the trauma. Although the men were generally aware of the availability of support, very few of the men engaged in any professional counselling. The most common coping strategies were displacement of their own needs to their partner, wanting to ‘forget’, engagement with existing children, and religion/spirituality. Anger and irritability were reported as was increased alcohol and substance use and, in a small number, significant depressive symptoms.
Conclusions: Commonalities were observed in stressors, support utilization and in coping style. The narratives presented provide colour to the experiences of the men facing unexpected challenges to their perceptions of life, their relationships and their certainty in the future. There appears to be a reluctance of men to access professional support.
Private Stories; Public Records
A Korner
Sydney Medical School, The University of Sydney, Sydney, Australia
Westmead Psychotherapy Program, Western Sydney Local Health District, Sydney, Australia
Background: The essence of mental life is private experience that, paradoxically, develops in the public sphere. In the current digital era, protection of the privacy of patients represents a major challenge. Privacy laws focus more on legal protections of health services than protection of ‘private therapeutic space’ allowing patients to speak openly without fear their comments will be accessed by third parties. Trauma-informed care demands we provide a space where delicate matters can be discussed with openness.
Objectives: To stimulate debate around the issue of record-keeping in psychotherapy with a view to maximizing protection of confidentiality and encouraging the Royal Australian and New Zealand College of Psychiatrists (RANZCP) to develop a policy that supports the privacy of therapeutic conversations.
Methods: The practice of recording sessions for the purpose of supervision at the Westmead Psychotherapy Program and the current ‘informed consent’ document of the RANZCP are used to illustrate a distinction between recorded sessions and the standard medical record. These are contrasted with standard information about privacy laws contained in Department of Health brochures.
Findings: Laws that mandate recordings being kept as part of the medical record are in conflict with current ethical practice in psychotherapy.
Conclusions: For people learning to practice psychotherapy, the recording of sessions can provide an invaluable window for supervision, allowing trainee and supervisor to see the ‘minute particulars’ that make up the therapeutic exchange. If laws demand such a use of recording becomes part of the medical record, we risk violation of the privacy of the individual.
Mentalisation-Based Treatment for Parents of Adolescents: MBT in a General CAMHS Settings – A Pilot Study and Early Data
C Bampton1, R Steane2, L Oldham1, G Bartoli1, B George1
1Kari Centre CAMHS, Auckland, New Zealand
2St Lukes CMHC, Auckland, New Zealand
Background: Mentalization-based treatment (MBT) has been designed for the treatment of borderline personality disorder (BPD) in adults. It is a time-limited, evidenced-based psychotherapy.
MBT hypothesizes that all people lose the capacity to mentalize when they are distressed, but that this happens more frequently in those with mental illness. Mentalizing is the ability to reflect on one’s internal experience (thoughts, emotions, intentions) objectively as well as the capacity to reflect on the internal experience of others.
The investigators have observed that adolescents seen in mental health services often display a failure to mentalize regardless of diagnosis or symptoms. It is also commonly observed that their parents have difficulties in mentalizing their children.
Objectives: If parents are taught to mentalize, it will improve parental ability to support their children and will also allow parents to role model mentalizing for their children.
Methods: A trial of psychotherapy for parents/caregivers of adolescents who present to Child and Adolescent Mental Health Services (CAMHS) with a range of diagnoses. MBT was delivered in a group format to parents over 10 weeks.
Mentalizing ability, general emotional health and family function were measured before, after treatment and at 6 months post-treatment.
Findings: Indicators of family functioning and general emotional health of both parents receiving MBT-PA and their children improved after treatment.
Conclusions: Mentalization provides a method of improving outcomes in patients of CAMHS services. Delivering this in a short-term group format to parents leads to improvement in both parents and their children.
Psychosis, Psychotherapy, Public Hospital and a Forensic Patient
R Maheshwari
The University of New South Wales, Sydney, Australia
Background: Recovery is conceptualized as involving positive changes in the person’s thinking and experience about themselves as individuals, and not merely as remission of symptoms or achievement of functional gains. Forensic patients are often both the perpetrator and victim of the trauma of their criminal offending. Therapy to explore the personal meaning of mental illness and its tragic consequences can reduce the impact of treatment-resistant symptoms and provide motivation for meaningful recovery.
Objectives: This paper will discuss rationale and limitations of psychodynamic psychotherapy in a case of treatment-resistant schizophrenia as consistent with principles of recovery and offence-specific intervention in forensic psychiatry.
Methods: A case study is discussed of a forensic patient with treatment-resistant schizophrenia, who was found not guilty by reason of mental illness for a non-fatal attack on his parents. He was treated with once-a-week psychodynamic psychotherapy over a 4-year period in an open rehabilitation unit in a public psychiatric hospital. Rationale, challenges, progress and limitations are discussed.
Findings: Treatment-resistant symptoms can have subjective importance as communication of guilt, self-punishment and anxiety related to recovery. Once weekly psychodynamic psychotherapy is effective in exploring the barriers to recovery.
Conclusions: Psychodynamic psychotherapy can be an important component, with adjunct psychosocial and pharmacological interventions, in the management of treatment-resistant schizophrenia. It is particularly relevant with the recovery goals of developing new meaning and purpose in one’s life by assisting the person to grow beyond the catastrophic effects of mental illness and their criminal offending.
Gonadotrophin-Releasing Hormone Agonist Treatment for Sexual Offenders: A Systematic Review
M Das1,2, A Lewis1, D Grubin1,3, C Ross1
1Broadmoor Hospital, West London Mental Health Trust, London, UK
2Top End Mental Health Service, Darwin, Australia
3Newcastle University, Newcastle, UK
Background: Sexual offending is a significant international issue causing long-term consequences for victims, perpetrators and society.
Objectives: To review the existing research data assessing the efficacy of gonadotrophin-releasing hormone (GnRH) agonists for treating adult, male sexual offenders.
Methods: To examine studies involving participants prescribed at least 1 month of a GnRH agonist for the purposes of reducing sexual drive related to offending. The primary outcome measures were recidivism rates and sexual functioning. Secondary outcomes included assessment of side effects, adverse effects and effects on physical and interpersonal/psychiatric functioning. Studies between 1969 and April 2015 were included.
Findings: A total of 12 eligible studies (323 participants) were identified. A reduction in a variety of measures of sexual functioning and/or risk was found in all studies. Robust recidivism data were limited. Rarely was medication described as ineffectual. All studies reported side effects. Reduction in bone density and potential long-term reduction in fertility in some subjects were the most significant.
Conclusions: Due to the challenges in performing randomized control trials in this subject group, included studies were methodologically limited. However, identified studies showed promising results with respect to sexual functioning. Specific side effects remain a concern.
Improving Patient Flow on Adult Mental Health Units: A Multimodal Study of Canberra Hospital’S Acute Psychiatric Facilities
K Fenton1, A Kingsbury2, S Jayalath3
1Canberra Hospital, Canberra, Australia
2Canberra Hospital and Health Services, Health, ACT Government, Canberra, Australia
3ACT Mental Health, Justice Health and Alcohol and Drug Services, Canberra, Australia
Background: Due to increasing demands on limited resources in the healthcare system, many hospitals are working to improve patient flow, thereby increasing their effective capacity (Showell et al., 2012). Identifying barriers to patient flow provides the best available evidence to improve such flow in acute psychiatric units.
Objectives: This study aims to investigate current patterns of patient flow and barriers to discharge through the Canberra Hospital’s acute psychiatric facilities and to identify factors associated with increased length of stay (LoS).
Methods: This audit uses a multimethod design (combining focus groups, audits of flow in mental health units and retrospective data analysis on a cross section of patients) to investigate current patterns of patient flow and barriers to discharge through the Canberra Hospital Mental Health Assessment Unit (MHAU) and Adult Mental Health Unit (AMHU), and factors associated with increased LoS.
Findings: Mean LoS for MHAU and AMHU was 8.45 h and 15 days, respectively. Multiple factors were associated with an increased LoS including patient factors, certain hospital processes, and limited availability of community services.
Conclusions: These findings inform recommendations on improving patient flow on adult mental health units and future research to support increases in available funding, staffing and resources.
Reference
Showell C, Ellis L, Keen E, et al. (2012) An Evidence-Based Review and Training Resource on Smooth Patient Flow. eHealth Services Research Group, University of Tasmania, Australia (on behalf of the Ministry of Health, New South Wales)
Dopamine-Dysregulation Syndrome: A Systematic Review of Addiction to Dopamine and its Neuropsychiatric Consequences
N Warren1,2, D Nyguen3, C O’Gorman2,4, A Lehn2,4, D Siskind1,2
1Metro South Addiction and Mental Health, Brisbane, Australia
2University of Queensland, Brisbane, Australia
3Damascus Health Service, Brisbane, Australia
4Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia
Background: Dopamine-dysregulation syndrome (DDS) is an uncommon complication of the treatment of Parkinson’s disease where the use of dopaminergic medication becomes addictive despite serious movement, neuropsychiatric and psychosocial consequences.
Objectives: We aim to clarify current understanding of clinical characteristics, risk factors and management to increase the recognition of DDS.
Methods: We performed a systematic review of all published cases, case series and case–control studies between 1964 and 2016, identified through a search of PubMed, EMBASE and a secondary search of references. Cases were included if they fulfilled criteria for DDS. Case–cohort studies were also reviewed and will be further discussed.
Findings: We reviewed 389 articles and identified a total of 84 cases of DDS. There was a male predominance (81%), with an early age of onset of Parkinson’s disease (mean average 46 years). Past substance and psychiatric history was present in 14% and 23% of cases, respectively. Comorbid impulse control disorders were present in 58% and punding in 26%. There was a large variety of management strategies, with only 31% of cases documented as resolved, primarily reliant on strict caregiver supervision. Of note, sodium valproate was successful in five cases. The response to deep brain stimulation was varied.
Conclusions: DDS cases represent a diverse cohort of individuals and previously described risk factors may not be common. Treatment of DDS is complex and recurrence common. It appears that earlier diagnosis leads to better outcomes and it is recommended that greater attention and recognition be paid to the neuropsychiatric symptoms of Parkinson’s disease.
A Literature Review of Cognitive Function in Chronic Pain and Major Depressive Disorders
L Gallur1,2, S Clark1,2, A Davis1,2, BT Baune1,2
1Central Adelaide Local Health Network, Adelaide, Australia
2TheUniversity of Adelaide, Adelaide, Australia
Background: Major depressive disorder and chronic pain are both conditions that are associated with social and economic burden (Gaskin and Richard, 2011; Greenberg et al., 2015). They can be difficult to differentiate clinically, and there is a high degree of comorbidity, predictive of greater dysfunction (Bair et al., 2013). Both are associated with cognitive impairment (Baune et al., 2010; Baune and Renger 2014; Berryman et al., 2013; Moriarty et al., 2011), but this has not been evaluated in the context of comorbidity.
Objective: The objective of this study was to compare the patterns of cognitive deficits in patients with chronic pain with respect to the influence of major depressive disorder.
Methodology: A systematic review of published literature was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (Liberati et al 2009) to identify 1476 studies that explored the relationship between cognitive function, major depressive disorder and chronic pain. Seventy studies reported in English on adult humans with no confounding cognitive conditions, and measures of depression, pain severity and objective cognitive function were included in the qualitative analysis.
Findings: The studies are critically appraised with reference to the tested cognitive domain and reported measures of depression and pain severity. Limitations are noted in the lack of studies designed specifically to compare these variables, confounders such as opioid use, the overlap of symptoms on self-report measures and difficulties in isolating cognitive domains on testing.
Conclusions: Implications for psychiatrists asked to assess medically unexplained pain are discussed.
References
Bair MJ, Robinson RL, Katon W et al. (2003) Depression and pain comorbidity: A literature review. Archives of Internal Medicine 163(20): 2433–2445.
Baune B, Miller R, McAfoose J, et al. (2010) The role of cognitive impairment in general functioning in major depression. Psychiatry Research 176(2–3): 183–189.
Baune BT and Renger L (2014). Pharmacological and non-pharmacological interventions to improve cognitive dysfunction and functional ability in clinical depression—A systematic review. Psychiatry Research 219: 25–50.
Berryman C, Stanton T, Bowering K, et al. (2013) Evidence for working memory deficits in chronic pain: A systematic review and meta-analysis. Pain 154: 1181–1196.
Gaskin DJ and Richard P (2011) The economic costs of pain in the United States. In: Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US). Appendix C. Available from: https://www.ncbi.nlm.nih.gov/books/NBK92521/ (accessed 24 October 2016).
Greenberg P, Fournier A, Sisitsky T, et al. (2015) the economic burden of adults with major depressive disorder in the United States (2005 and 2010). The Journal of Clinical Psychiatry 76(2): 155–162.
Electroconvulsive Therapy in an Elderly Woman with Frontal Meningioma and Takotsubo Cardiomyopathy
M Gani1, F Parvez2
1Royal Oldham Hospital, Pennine Care NHS Foundation Trust, Manchester, UK
2Tameside General Hospital, Pennine Care NHS Foundation Trust, Manchester, UK
Background: This is a case study conducted at a Manchester hospital – Old Age Psychiatry Unit. An elderly female patient with severe depression and coexisting neurologic and cardiac conditions was successfully treated with electroconvulsive therapy (ECT).
Objectives: To share our experience of delivering ECT to an older patient with multiple comorbidities and to discuss how input from various specialties contributed to a successful outcome.
Methods: Our intervention was effective ECT management of a lady in her 70s with severe depression, pre-existing Takotsubo cardiomyopathy, and an incidentally diagnosed meningioma in the frontal area. Antidepressant and anxiolytic medicines had been tried prior to considering ECT, with minimal benefit. Treatment options were discussed with the patient and her family, and ECT decided on.
Specialists from Cardiology, Neurology and Anaesthesia were consulted and their input-integrated. ECT was administered over 12 sessions.
Findings: Four sessions into treatment her mood showed improvement, with associated reduction in anxiety. She eventually had 12 sessions of ECT, with no neurological complications and manageable but brief cardiac events; she however rapidly recovered from these. The patient was found to remain well psychiatrically and physically at her follow-up, 6 months afterwards.
Timeline:
Conclusions: Successful ECT treatment of elderly patients with multiple comorbidities is possible; a comprehensive multidisciplinary approach is vital.
Reference
Gani M and Parvez F (2016) ECT in a patient with a meningioma and Takotsubo cardiomyopathy. Progress in Neurology and Psychiatry 20(6): 15–18.
Sexual and Reproductive Challenges of Patients with Intellectual Disabilities
Y Bandara1, J King2,3, F Leow4
1Monash University, Melbourne, Australia
2Professorial Unit, The Melbourne Clinic, Melbourne, Australia
3Department of Psychiatry, The University of Melbourne, Melbourne, Australia
4Eating Disorders Unit, Royal Melbourne Hospital, Melbourne, Australia
Background: The sexual and reproductive rights of people with intellectual disabilities (ID) are often a contentious ethical issue. For medical doctors, the risks of sexually transmitted infections (STIs) and unplanned pregnancy have to be weighed against the imperative to respect the autonomy, dignity and safety of patients.
This presentation will explore the question of contraception in the context of patients with ID through discussion of a hypothetical case study. It will explore the practical implications of the patient’s sexual and reproductive rights, the issue of capacity in these situations, the history of sexual and reproductive rights abuses for people with disabilities and last, some practical points in the clinical approach of these issues for patients with ID.
Objectives and methods: The presentation will discuss ethical issues relating to sexual and reproductive rights of patients with ID through a hypothetical case study of a woman, ‘Kate’. The presentation will establish a historical context for the issue, taking into account the fraught historical interactions between the medical profession and people with ID – both globally and in Australia. It will discuss sexuality and sexual rights, as well as the ethical requirements for capacity to consent and the concept of decisional capacity in the context of reproductive rights. Finally, the presentation will aim to provide practical points to guide clinicians’ approaches to these issues for patients with ID.
Findings:
In approaching the patient with ID, the psychiatrist needs to remember the following three points.
Ensure both male and female patients have received adequate sex education
Although sex education might be an uncomfortable topic for many psychiatrists, it is vital that patients receive advice regarding: sexually transmitted infections and their consequences; the use of barrier contraception to prevent these illnesses; and reversible contraception if they are not planning to have children.
Avoid coercion in considering sterilization for patients with ID
It is important for psychiatrists to remember the history of eugenics and human rights abuse in this patient population and not to repeat this mistake. In Kate’s case, she presented with having undergone a tubal ligation. For patients who are not sterilized, the topic of sterilization may be raised by the patient or family/carers involved – it would be important to have a discussion with them about the risks and benefits of the procedure. Involving a gynaecologist or general practitioner in this process is advisable. If the patient decides to proceed with sterilization, an assessment of the patient’s capacity to make this decision should be made and informed consent without any hints of coercion should be obtained.
Consideration of red flags for court-approved sterilization
In the minority of cases, patients with ID may present with an inability to comprehend and fulfil the responsibilities of parenthood. Red flags to consider the patient for court-approved sterilization for patients are where there is a
history of several unplanned pregnancies where the children are cared for inadequately,
significant impact on the children’s developmental trajectory due to unmet physical or emotional needs,
significant history of poor family/support relationships due to family/carers having to care for children,
clear inability to care for self or others, possibly requiring institutionalization,
lack of capacity to provide consent for sterilization,
severe ID.
If several of the above red flags are present, it may be worth considering pursuing a court-approved sterilization through a medical power of attorney. Such instances are infrequent and should belong to the minority of cases seen.
Conclusions: For most patients, sterilization is not warranted and should be guarded against. However, there are some exceptional circumstances where sterilization should be considered. In these situations, the patient must give informed and free consent if they have capacity. If they do not, a court must be involved in the decision-making process.
Psychiatrists are reminded that patients with ID continue to have sexual desires, urges, behaviours and relationships and these require sensitive discussion around capacity issues, which may also involve their families, carers and other health providers.
The Association between Blood Haemoglobin and Mental Health Outcomes in Iron-Deficient Pregnant Women
C Khoshnaw1, B Froessler2,3, BT Baune1, N Hodyl4, T Butler1, O Schubert1,3
1Discipline of Psychiatry, The University of Adelaide, Adelaide, Australia
2Discipline of Acute Care Medicine, The University of Adelaide
3Northern Adelaide Local Health Network, Lyell McEwin Hospital, Elizabeth Vale, Australia
4Robinson Research Institute, The University of Adelaide, Adelaide, Australia
Background: Iron deficiency (ID) is a major nutritional disorder in pregnancy, affecting up to 30% of pregnant women and is the most common cause of iron-deficiency anaemia (IDA). IDA is associated with adverse obstetric outcomes for the mother and the child. Depressive and anxiety symptoms are common in pregnancy, and pregnant women frequently report poorer cognitive function. Whether there is an association between measures of IDA and mental health or cognition in pregnancy has not been examined before.
Objectives: We aimed to examine the relationship between haemoglobin (Hb) levels and depressive symptoms, anxiety symptoms and cognitive function in a cohort of iron-deficient pregnant women.
Methods: The study cross sectionally assessed 175 iron-deficient pregnant women in the second or third trimester. Severity of depressive and anxiety symptoms were measured by the Structured Guide for Interview of Hamilton Anxiety and Depression Scale. Common psychiatric disorders were screened for using the Mini International Neuropsychiatric Interview (MINI)-6.0.0, designed according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Cognition function was assessed using the THINC-it® cognitive assessment tool.
Findings: Hb levels in iron-deficient pregnant women were not associated with the severity of depressive or anxiety symptoms or with poor cognitive function.
Conclusions: This cohort study found no association between Hb levels and depressive/anxiety symptoms and cognition in the context of iron-deficient pregnant women, indicating that mental health outcomes in pregnancy are independent of Hb levels.
Engaging the Public with Biomarker Research for Mental Illnesses Requires Innovative Communication Approaches
M Carew1, B Dean1,2, A Bush1,2, I Cooke1
1Cooperative Research Centre for Mental Health, Melbourne, Australia
2Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
Background: The Cooperative Research Centre for Mental Health’s (CRCMH’s) community education program seeks to engage the general public with the need for early, accurate methods to diagnose mental illnesses. From 2012 to 2015, the CRCMH engaged over 1000 members of the general public with this topic through direct attendance at five events and over 100,000 people through radio broadcasts.
Objectives: To summarize learnings from our experience promoting biomarker research for mental illnesses to the general public.
Methods: The CRCMH’s community education program was delivered through five public events from 2012 to 2015. Each event sought to engage the general public with the need for early, accurate methods to diagnose mental illnesses, specifically related to Alzheimer’s disease, dementia, schizophrenia and depression. A variety of techniques were trialled to engage new audiences.
Findings:
Collaborating with mental health advocacy groups, and health and aged care organizations attracted audiences with some familiarity of the topic seeking increased understanding.
Partnerships with media were useful in extending our reach.
Promoting through well-known festivals including Melbourne Fringe Festival and Science Week brought new in-person audiences.
Development and trialling of a “find the hidden biomarker” game resulted in mixed feedback – fewer numbers engaged, but those who did, indicated a deeper understanding of the topic.
Conclusions: Engaging the public with biomarker research for mental illnesses requires innovative approaches to promote to, and communicate with, new audiences who may not self-identify with the area, and have widely varying levels of comfort with, and understanding of, scientific concepts.
The Ripple Effect of Emotional Contagion
G Tso1,2
1Metro South Addiction and Mental Health Service, Brisbane, Australia
2The University of Queensland School of Medicine, Brisbane, Australia
Background: Permeating our interactions within psychiatry and beyond is the concept of ‘emotional contagion’. Emotional contagion is a transfer of emotions with a synchronization of non-verbal expressions that can occur between two individuals, as well as within groups and organizations.
Objectives: To discuss the concept of emotional contagion and how this can impact on our practice and behaviour within a clinical setting, and within teams and organizations. To discuss strategies to minimize negative effects of emotional contagion.
Methods: A literature review was conducted and information synthesized for this presentation.
Findings: There are both benefits and detriments to the phenomenon of emotional contagion. It is one of the basic components of the experience of empathy and helps assist in the inherent understanding of our patient’s internal world. At the same time, it can result in severe emotional and mental fatigue that can negatively impact on interactions with others. Different aspects of the clinical interaction can impact emotional regulation including situation selection, situation modification, attentional deployment, cognitive change and response modulation (Gross, 1998).
Conclusions: It is important to be aware of the concept of emotional contagion within oneself and within group dynamics as it can impact on performance, outcomes and the safety and management of our patients.
Reference
Gross JJ (1998) The emerging field of emotion regulation: An integrative review. Review of General Psychology 2: 271–299.
Is Clozapine an Anti-Catatonic Agent?
G Asokan1, T Bastiampillai2
1Central Adelaide Local Health Network, Royal Adelaide Hospital, Adelaide, Australia
2SA Health, Adelaide, Australia
Background: Catatonia is a complex neuropsychiatric condition characterized by negativism, mutism and posturing. The most effective treatments are usually benzodiazepines and electroconvulsive therapy (ECT) (Sienaert et al., 2014). Most antipsychotic medications are contraindicated for catatonia; however, there is evidence that clozapine can successfully treat catatonia and that it can also be a cause of withdrawal catatonia (Cerit et al., 2012).
Objectives: We would like to review clozapine’s role in the treatment of catatonia and the evidence for clozapine withdrawal catatonia.
Methods: A literature search was conducted using PubMed, EMBASE and MEDLINE to review studies and case reports investigating clozapine as a treatment for catatonia and as a cause of withdrawal catatonia.
Findings: Nine case reports of successful clozapine treatment of catatonia were identified and 20 cases of clozapine withdrawal catatonia.
Conclusions: We identified that clozapine could be considered an anti-catatonic agent, even in cases that had not responded to benzodiazepines and ECT. It was also the only antipsychotic agent implicated in withdrawal catatonia.
References
Cerit C, Tuzun B, Akpinar E, et al. (2012) Clozapine withdrawal cations refractory to ECT: A case report. Bulletin of Clinical Psychopharmacology 22(3): 275–277.
Sienaert P, Dhossche DM, Vancampfort D, et al. (2014) A clinical review of the treatment of catatonia. Frontiers in Psychiatry 5(181): 14–22.
Pseudophaeochromocytoma: A Clinical Dilemma in Clozapine Therapy
A Sakalkale1, E MacArdle1, D Brunskil2
1Albury-Wodonga Health, Wodonga and Wangaratta, Australia
2Waikato Hospital, Hamilton, New Zealand
Objective: To prevent morbidity and mortality by an early diagnosis and monitoring of pseudopheochromocytoma (PPC), a rare side effect of clozapine.
Method: Case vignettes and a review of the psychiatric literature are presented.
Results: There are only nine previously reported cases of PPC following clozapine use. We present two new cases.
Conclusions: PPC is a serious and an under-recognized side effect of clozapine.
An early diagnosis is possible by monitoring urinary catecholamines in suspected patients with hypertension, tachycardia or other typical symptoms of sympathetic hyperactivity following commencement of clozapine therapy.
As with the development of other potentially serious side effects, the decision to continue or stop clozapine raises practical and ethical issues, often generating a clinical dilemma and a need to explicitly consider the pros and cons of treatment. If clozapine is continued, periodic long-term monitoring and appropriate treatment may be necessary to prevent serious complications of PPC.
Dopamine Phrensy? Disorganized Behavioural Activation and Punding Associated with Aripiprazole: Case Report and Review
S Williams
Several NSW Health Districts (Old Age Psychiatry), Sydney, Australia
This presentation will consider an observation of considerable clinical and theoretical significance. A patient with schizophrenia developed hoarding behaviour, presumably due to punding, after an increase in dosage of aripiprazole. More problematically his perseverative, disorganized, socially intrusive behaviours, his restlessness (but not akathisia) and his paranoid, delusional thinking also increased. Because this was not recognized as dopamine induced and was instead thought to be due to worsening psychosis, the dose of aripiprazole was further increased and the adverse effects mentioned above worsened. Later, following reduction in aripiprazole and addition of haloperidol, all of these features improved significantly but not completely.
Since 2000, an association has been recognized between dopamine agonists prescribed for Parkinson’s disease and both repetitive pointless behaviours (punding or ‘compulsive’ behaviours) and impulse control disorders (behavioural addictions). Since 2010 similar observations have been made about behavioural addictions and, to a lesser extent, punding, associated with the use of aripiprazole.
The pharmacological properties of aripiprazole explain why it could produce some of the same effects as the dopamine agonists used in Parkinson’s disease. Aripiprazole is an atypical antipsychotic drug with dopamine D2 partial agonist properties and high D2 receptor affinity.
The history of the development of concepts of punding, behavioural addiction and their apparent relation to dopamine receptors and systems will be explored through a review of the relevant literature.
The term ‘dopamine phrensy’ is suggested, half in jest, to emphasize that this phenomenon exists in its own right and is phenomenologically different from compulsive disorders, impulse control disorders or psychosis.
How to Grow Old and Die
N Jeyasingam1,2,3
1Northern Sydney Local Health District, Sydney, Australia
2Sydney University, Sydney, Australia
3Western Sydney University, Sydney, Australia
Age is a gift that few want but fewer decline. Within this ambivalence is a dearth of adequate blueprints for how to proceed with successful ageing, as well as a surprisingly large variety of perspectives as to how one should live, as though the two are mutually exclusive. This presentation summarizes some of the key theories in the area, as well as aims to provide a comprehensive approach to the last stage of life. Age is often seen as a situation of loss of power – loss of productivity, loss of relevance to society, and loss of control of oneself, and with this loss of power is a loss of identity. However, in this setting, there is a paradox of embracing this decline for the purposes of maturation of one’s identity – rather than its loss. It is argued that knowing how to die is as important as knowing how to live – in many ways, there is no difference.
A Systematic Review and Meta-Analysis of the Association Between Poor Oral Health and Substance Use
S Kisely1,2, H Baghaie1, M Forbes3,4, E Sawyer5, D Siskind1
1School of Medicine and Dentistry, The University of Queensland, Brisbane, Australia
2Griffith University, Gold Coast, Brisbane, Australia
3Department of Psychiatry, Royal Melbourne Hospital, Melbourne, Australia
4Melbourne Medical School, The University of Melbourne, Melbourne, Australia
5School of Medicine, James Cook University, Brisbane, Australia
Background: Substance use disorders (SUDs) are commonly associated with comorbid physical illness but there are less data on dental disease. This is in spite of the direct effects of substance abuse such as dry mouth, as well as the associated indirect or lifestyle effects such as poverty and lack of access to care.
Objectives: To determine the association between SUDs and poor oral health using the following standardized measures: the mean combined number of decayed, missing and filled teeth (DMFT) or surfaces (DMFS), the mean number of decayed teeth, missing teeth and filled teeth, prevalence of irreversible gum disease (periodontitis) and erosion.
Method: A systematic search for studies using MEDLINE, PsycINFO, EMBASE and article bibliographies. Results were compared with the general population.
Findings: We identified 21 studies that had sufficient data for a meta-analysis. These covered 2597 patients with SUDs and 23,301 controls, the latter from either the same study or community surveys. People with SUDs had significantly higher DMFT and DMFS scores. They presented with more decayed teeth, but fewer restorations indicating reduced access to dental care. They also had higher rates of tooth loss and a higher prevalence of periodontal disease on some measures.
Conclusions: Patients with SUDs have greater and more severe dental caries and gum disease than the general population. However, they are also less likely to have received dental care. Interventions could include early oral health assessment using standard screening tools completed by non-dental staff, early dental referral and help with oral hygiene.
Speaking Our Minds in Times of Paradigm Changes
G Halasz
School of Psychology and Psychiatry, Monash University, Melbourne, Australia
Background: The impact of the current neuroscience-led paradigm change in clinical psychiatry and psychotherapy is most evident in the ‘trauma informed care’ model of practice (Halasz, 2016 in press).
Objectives: In this time of rapid change, we need to speak of professional encounters; however, confronting such stories may be how and why we are changing our clinical practice; the challenges and stresses faced by researchers, educators and policy makers; why the ‘building blocks’ of our models of intervention and therapies are in a flux; what are the risks if we decide against the change and stick with the ‘old’ paradigm.
Methods: The presentation will highlight areas that we need to upskill why the ‘chemical imbalance’ model of mental illness is regarded as outdated.
Findings: A clinical case will illustrate how the neuroscience-led evidence in the field of trauma studies – relational, developmental, attachment, vicarious, complex and generational trauma transmission – has demanded basic changes in my approach to the assessment, formulation, moment-to-moment clinical interventions that have led to the need for ‘self-care’ against the impact of ‘vicarious trauma’ as an essential component of ‘new’ paradigm practice.
Conclusions: The clinical risks of ‘perpetuating the error’ by sticking to outdated theories and practices can be avoided if we follow the ethical principle – first, to do no harm, to our patients and to ourselves.
Reference
Halasz G (2017). Editorial. Australasian Psychiatry, in press.
Taking My Grandfather’s Axe to Psychiatric Diagnosis
S Rosenman
St John of God Health Care, Sydney, Australia
Background: My grandfather’s axe has had two heads and three handles. Is it the same axe? This is a tiny thought experiment that looks deep but it is triviality parading as depth. Simply, how are we using the word ‘same’. Importantly the useful information is contained in the descriptive first sentence.
Objectives: To examine the analogy between this thought experiment and the ordinary processes of diagnosis in psychiatry.
Findings: The description that leads towards the apparent paradox contains the information that we need to make actual decisions that might be taken. In the case of the axe, the description gives information on history, on ownership, on value or what questions we may want to answer. ‘Sameness’ is otiose (has no useful result or practical purpose). Similarly, the description of phenomena that lead to the diagnosis contains the information by which we address questions of management, treatment, capacity, standing, culpability and so on. The titular diagnosis is otiose.
Conclusions: If this argument from analogy can be sustained, the justifications given for diagnosis (e.g. communication, treatment and classification) are not illuminated and may be misinformed by current practice. If so, there are implications for the practice and teaching of psychiatry.
How do we Value Colleagues with Lived Experience of Mental Illness?
R McKay1,2, S Rotstein3
1Health Education, and Training Institute Higher Education, Sydney, Australia
2The University of New South Wales, Sydney, Australia
3Alfred Health, Melbourne, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) Position Statement 86 Recovery and the Psychiatrist states that the RANZCP ‘values psychiatrists who have been affected by mental illness…’ However, the Statement does not describe how this is achieved. Given the stigma associated with mental illness, including by psychiatrists (Adame, 2011), this area requires further exploration and consideration.
Objectives: To provide an overview of the literature regarding mental illness in psychiatrists, explore key issues to consider if psychiatrists and psychiatric trainees with experience of mental illness are to be valued and provoke discussion.
Methods: Review of relevant literature and RANZCP statements, in addition to reflection of experiences as psychiatrists and psychiatry trainees, and consideration of the potential barriers to utilizing lived experience of RANZCP members.
Findings: Psychiatrists are not immune to mental illness. Evidence suggests that psychiatrists face high rates of mental health problems. There is an emerging literature exploring how mental health professionals can choose to disclose, or not disclose, experiences of mental illness (Morgan and Lawson 2015). There is little evidence guiding how personal disclosures and lived experience can best be utilized in practice.
Conclusions: To support recovery, psychiatry must value those with mental illness who are, or aspire to be, psychiatrists. To progress this field will require individuals to demonstrate both caution and bravery in addition to strong leadership from the RANZCP.
References
Adame AL (2011) Negotiating discourses: The dialectical identities of survivor-therapists. The Humanistic Psychologist 39(4): 324.
Morgan P and Lawson J (2015) Developing guidelines for sharing lived experience of staff in health and social care. Mental Health and Social Inclusion 19(2): 78–86.
The Paradox in Stigma Reduction Discourse
G Antoce
Private Practice, Brisbane, Australia
Australian Institute for Suicide Research and Prevention, Griffith University, Brisbane, Australia
Background: The author will present an update of literature and research findings on the issue of stigma reduction in mental health/psychiatric services.
Objectives: The literature update and research findings will be followed by discussion of current paradoxes in the general approach to stigma and stigma reduction attempts (including limited service change, perpetuation of coercive approaches to treatment, stigma in practitioners and implications for training, curriculum reviews). This will encourage debates and further reflection on needed adjustments in the focus of stigma reduction campaigns as preventive approaches in psychiatry.
This is mainly a theoretical paper, so no formal findings are presented, apart from updates and paradoxes in current state of affairs in this field – it is meant to promote further discussion and new directions for research endeavours.
It’s More Than Just Sexual Health: Student Activism to Integrate a LGBTIQ Health Perspective into the University of Western Australia MD Curriculum with Evidence Drawn from the RANZCP and RACP
T Allan1, W Kealy-Bateman2
1The University of Western Australia, Perth, Australia
2University of Wollongong, Wollongong, Australia
Background: It is crucial that the medical profession elevates its efforts to meet the health needs of the lesbian, gay, bisexual, transgender, intersex and queer (LGBTIQ) community, who remain among the most vulnerable in our society. Where the matter of LGBTIQ rights may be politically contentious the medical profession should remain focussed on the evidence and in so doing generate student doctors who will go on to improve health outcomes.
Objectives: The presenters will deliver an example of a motivated Psychiatry Interest Forum (PIF) member who advocates changes to the training of student doctors.
Methods: The narrative of the social media campaign, the incorporation of the evidence from the Colleges of Physicians and Psychiatrists in Australasia and a review of the teaching were utilized to achieve change.
Findings: Just as trainees in psychiatry have become important agents in change, medical students have also increasingly become important drivers in change. Empowered by their learning and capacity to communicate and rise above the traditional power imbalance quickly via social media, they too can affect ideological and policy change in educational contexts.
Forging an Australia–Nepal Mental Health Alliance
N Burns
Bloomfield Hospital, Orange, Australia
Background: Specialist mental health services are extremely limited in Nepal, attracting just 0.17% of the public health budget (WHO and Ministry of Health, 2006). Poverty, a unique topography, infrastructure problems and climactic extremes make it difficult for most people to access services (Brenman et al., 2014). Stigma is also a major limiting factor (Risal et al., 2016). Additionally, there are few protections in legislation or governmental policy for the mentally ill.
Services are almost entirely restricted to major cities. They are predominantly run by non-government organizations, which are dependent on inconsistent funding.
Most people rely on inconsistent primary care services or spiritual healers (IASC, 2015).
Given the increasing relevance of ties between Asia and Australia, there is support for Australia’s involvement in strengthening the mental health system in Asia (Arandjelovic et al., 2016).
Objectives: To explore first-hand the status of mental health services in Nepal, establish links with local mental health services and educational institutions and develop options for enhancing service provision.
Methods:
Examination of key relevant literature.
Annual journeys to Nepal over 5 years by a multidisciplinary team of Australian mental health clinicians, meeting with local services in urban and rural settings.
Findings:
There are problems with strategic coordination of services and inter-agency communication.
Existing opportunities for training and professional development are limited.
Government mental health policy is inconsistently endorsed.
Despite these difficulties, much inspiration can be found in the enthusiasm and skill of local clinicians.
Conclusions:
Opportunities exist to enhance local service development cost effectively through strategic partnerships with local services, technological innovation and alliance with international research collaborations.
Education, training and clinical supervision are key mechanisms for service enhancement.
Targeted small-scale funding allows for innovative ways of enhancing service coordination.
Initiatives should target preferentially the very poor and those living remotely.
References
Arandjelovic et al. (2016) Mental health system development in Asia: Does Australia have a role? Australian and New Zealand Journal of Psychiatry 50(9): 834–841.
Brenman NF, Luitel NP, Mall S, et al. (2014) Demand and access to mental health services: A qualitative formative study in Nepal. Biomed Central International Health Human Rights 14: 22. DOI:10.1186/1472-698X-14-22.
Inter-Agency Standing Committee (IASC) (2015) Reference Group for Mental Health and Psychosocial Support in Emergency Settings (2015). Nepal Earthquakes 2015: Desk Review of Existing Information with Relevance to Mental Health and Psychosocial Support. Kathmandu, Nepal.
Risal et al. (2016) Anxiety and depression in Nepal: Prevalence, comorbidity and associations. Biomed Central Psychiatry 16: 102. DOI:10.1186/s12888-016-0810-0.
WHO and Ministry of Health (2006). WHO–AIMS Report on Mental Health System in Nepal. Kathmandu, Nepal: World Health Organization and Ministry of Health.
The Meaning of a Child in a Time of War: Attachment Narratives of Children of Tamil Refugee Families
L Ratnamohan
Psychiatry Research and Teaching Unit, Liverpool Hospital, Sydney, Australia
New South Wales Institute of Psychiatry, Sydney, Australia
Background: While there is an emerging literature on factors of resilience and vulnerability in children of refugee families, much less is known about the intergenerational processes that mediate these relationships. How does a refugee parent’s unresolved loss or trauma compromise their role as an attachment figure to their child? How does a refugee child evolve self-protective attachment strategies in the face of past dangers and present uncertainties? How do parent and child voice or silence incomprehensible pasts to construct meaning in the present?
Methods: The speaker will present preliminary findings from a mixed-methods study on the intergenerational determinants of attachment in 60 Tamil refugee children resettled in Sydney, Australia, in the period 2009–2014.
Findings: Although almost all the children have unresolved loss or trauma, their strategies for navigating their pasts differ. Some children bury the past while for others it is a gaping wound. Family pattern of trauma communication, parental mental illness and ongoing social stressors all influence the child’s strategy. Children with dead or missing fathers and traumatized or depressed mothers are particularly vulnerable to role reversal, internalizing symptoms and ‘at-risk’ attachment.
Conclusions: The data build on recent literature advancing an attachment-informed model of the intergenerational transmission of trauma in refugee families. Such a model offers a means of identifying ‘at-risk’ children for whom earlier intervention can be directed. Yet whether attachment theory – and its universalist tenets – is well equipped to disentangling culture, migration and trauma remains uncertain and worthy of further enquiry.
Professionalism and Communication: Two Cases of ‘Doctor’ versus ‘Judge’
G Newton-Howes
University of Otago, Wellington, New Zealand
Background: In the area of mental health, there are particular difficulties that arise when the judiciary investigate practice as societal pressures seem to demand particular responses in a way that may defy logic or lack clarity. This may be on the basis of differing understanding between legal and medical professionals. A subsequent problem may be the development of practice that is not evidence based or is in breach of ethical sensibility or law in another area.
Objectives: To examine two cases to enable some of the possible pressures that arise and lead to unhelpful or challenging problems in the delivery of mental healthcare be examined.
Methods: Analysis of the circumstance of a coronial enquiry and referral of a consultant psychiatrist to their registering body. Both outcomes carry potentially significant personal and professional consequences and are therefore ‘high stakes’.
Findings: Judicial professionals have responsibilities to enact legislative requirements and to be seen to be delivering ‘fair’ justice. The outcome of this can potentially be an unwarranted response to narrow clinical practice and become adversely risk oriented. The potential for understanding standard clinical practice may further compound this problem.
Conclusions: Review of the remit of the judiciary in regard to enquiries is needed to ensure a balanced approach that reflects not only the legal and social expectation of the judiciary but recognizes the language and landscape of mental health practice. A public mental health approach may be one mechanism to achieve this.
The Traumatic Impact of Atrocity: the Example of the Khmer Rouge
S Gill
South Australian Psychiatry Branch Training Committee (SAPBTC), Adelaide, Australia
Background: The Khmer Rouge were in power in Cambodia for a short 4 years from 1975 to 1979, but in that time managed to kill over 2 million of their own people, one-quarter of their population. The extent of the atrocities committed is unparalleled in modern history. Survivors of the Khmer Rouge have made their way to several countries as refugees, many to Australia.
Objectives: To present the origins of the Khmer Rouge, the political environment that brought them to power, the suffering of the Cambodian people under their rule and the impact of atrocities committed in their name.
Methods: Selected literature on the psychological and traumatic sequelae of this period will be presented. The focus will be on outcomes for survivors in Cambodia and refuges in countries where they have been resettled. The presenter, whose wife came to Australia as a Cambodian refugee, will also provide some personal stories from her and her families’ experience.
Findings: There is much to learn about the traumatic impact of regimes that commit horrific acts of barbarity upon their people. This can provide lessons for Australia, and the world today, as we grapple with an ever-growing number of refugees facing such dreadful situations in their own countries.
Conclusions: The Khmer Rouge was a failed state that stands alone in history for brutality committed against its own people. Cambodian refugees have suffered enormous trauma, but they can be provided with genuine assistance in resettled countries, if a dedicated and culturally sensitive service is provided for them. There is also much to learn from the resilience of people who have survived such atrocity and then flourished in their adopted countries.
Suicide and Self-Harm in Australia: Conceptual Map
J Jureidini1, A Smith2, M Raven1
1The University of Adelaide, Adelaide, Australia
2Silverline Consulting, Melbourne, Australia
Background: Suicide, attempted suicide, and self-harm are related events, but there are important differences. In particular, there are significant demographic differences, particularly gender differences, between people who attempt suicide and those who complete suicide. These differences influence healthcare use and have important implications for suicide and self-harm prevention research and interventions but are often overlooked.
Objectives: To present a conceptual map that will assist differentiation and understanding of suicide, attempted suicide and non-fatal self-harm.
Methods: Literature review and synthesis.
Findings: It is well recognized that most suicide deaths are of adult males, with higher rates among rural/remote males. Most non-fatal self-harm, including suicide attempts, involves females. Men tend to use more lethal methods and use them more effectively.
Less discussed is that many men (and, to a lesser extent, women) who suicide have no psychiatric history or known mental disorder, and the duration of the male suicidal process tends to be (much) shorter. Social determinants such as unemployment and financial problems are often major factors in mens’ distress, and they have less contact with health services, including general practitioners and mental health services. Consequently, suicide prevention strategies that focus on mental health have limited effectiveness.
Conclusions: This conceptual map will assist healthcare practitioners and welfare workers to better recognize and respond to people at risk of suicide and self-harm. It will also help to improve research, which often conflates suicide and self-harm and overemphasizes psychiatric explanations. It will also inform policymakers about the strengths and weaknesses of prevention strategies.
Implementation of a Mental Health Stepped Care Service for Adults in General Practice
J Anderson1,2, J Proudfoot1,2, K O’Moore1
1Black Dog Institute, Sydney, Australia
2The University of New South Wales, Sydney, Australia,
Background: Despite international recognition of the importance and efficiency of stepped care in mental health,1–4 this model is yet to be introduced into Australian primary care. Working closely with the local Primary Health Network (PHN) and other partners, we developed, implemented and evaluated an integrated online stepped care service for adults with anxiety and depression in general practices.
Objectives: This study aimed to design, implement and evaluate a stepped care service for Australian adults with anxiety and depression presenting to general practice.
Methods: Patients were screened via a mobile tablet in the waiting room with immediate feedback to them and their general practitioner (GP). Individuals were recommended the least intensive evidenced-based intervention likely to lead to health gain and were then stepped up (or down) the pathway according to changing needs and in response to treatment. A range of Internet, face-to-face therapy and/or pharmacotherapy interventions were recommended based on symptom severity. Online monitoring allowed appropriate feedback and follow-up. Following implementation, the acceptability and feasibility of the service was examined.
Findings: Results from the digital screening and 8-week follow-up of more than 400 patients in five general practices (with five matched control practices) will be presented. Issues surrounding ongoing clinical evaluation, management of risk, uptake and adherence, feasibility and long-term implementation will also be discussed.
Conclusions: Stepped care approaches offer a solution to delivering accessible, effective and efficient services for individuals. This presentation reports on a successful proof of this concept in the Australian primary care setting with results and implications for further research, policy and practice.
References
1O’Donnell M, et al. (2014) What are the Effective Models for Stepped Care in the Treatment of Mental Health Disorder? A Rapid Evidence Assessment. Report prepared for the Department of Veterans Affairs, Canberra, Australia.
2Bower P and Gilbody S (2005) Stepped care in psychological therapies: Access, effectiveness and efficiency. The British Journal of Psychiatry 186(1): 11–17.
3Cuijpers P, Beekman AT and Reynolds CF (2012) Preventing depression: A global priority. JAMA 307(10): 1033–1034.
4Van Straten A, Seekles W, van ‘t Veer-Tazelaar NJ, et al. (2010) Stepped care for depression in primary care: What should be offered and how? MJA 192(11): 36–39.
Ethics and the Impaired Psychiatrist
A Howie1, A Rosen2,3
1Waitemata District Health Board, Auckland, New Zealand
2University of Wollongong, Wollongong, Australia
3The University of Sydney, Sydney, Australia
Background: Theoretical and practical approaches to the situation of the impaired health practitioner continue to develop, and new legislation in different jurisdictions reflects these trends.
Objectives: To explore some ethical and philosophical issues in balancing the requirements of protecting the public and achieving a recovery-orientated rehabilitation pathway for the impaired psychiatrist or other mental health professional.
Methods: Ethical and philosophical issues in managing impaired psychiatrists (and other health professionals) are explored with reference to several themes in professional ethics, emphasizing the balance of ensuring public safety while not abandoning the recovery model for impaired clinicians. This presentation will build on published work (Howie and Rosen, 2015: 861–896) by extending the ethical and philosophical analysis and discussing updating regulatory practices in Australia and New Zealand.
Findings: Non-maleficence, professional integrity, role-differentiated moral obligation, fidelity and practical wisdom are themes common to the goals of protecting the public and optimizing the recovery pathway for the impaired clinician and may usefully inform decision-making in both areas.
Conclusions: Protecting the public and achieving the recovery goals are competing paradigms in the approach to the impaired psychiatrist (or other mental health practitioner) but may be balanced through consideration of shared ethical themes.
Reference
Howie A and Rosen A (2015) Ethical Approaches to Dealing with Impaired Health Practitioners, The Oxford Handbook of Psychiatric Ethics. Oxford: Oxford University Press.
Using an Integrated Systems Biology Approach to Characterize the Molecular Profile of Cognitive Dysfunction in People with Remitted Major Depressive Disorder
O Schubert1,2, D Stacey1,3, T Air1, G Arentz4,5, P Hoffmann4,5, BT Baune1
1Discipline of Psychiatry, The University of Adelaide, Adelaide, Australia
2Northern Adelaide Mental Health Network, Lyell McEwin Hospital, Elizabeth Vale, Adelaide, Australia
3School of Clinical Medicine, University of Cambridge, Cambridge, UK
4Adelaide Proteomics Centre, The University of Adelaide, Adelaide, Australia
5Institute for Photonics and Advanced Sensing (IPAS), The University of Adelaide, Adelaide, Australia
Background: Residual cognitive impairments are observed in a substantial proportion of patients who have recovered from an acute phase of major depressive disorder (MDD), significantly impacting on patients’ psychosocial functioning and quality of life. Cognitive dysfunction has been proposed as a potential endophenotype of MDD that is independent of the acute depressive state and is particularly active in a subgroup of patients. However, the molecular underpinnings of such a phenotype are unknown, precluding early detection and specific treatment strategies.
Objectives: To investigate the molecular blood profile of cognitive dysfunction in remitted MDD patients by pursuing an integrated approach to transcriptomic and proteomic discovery platforms.
Methods: We utilized whole-blood transcriptomic data from remitted MDD patients for weighted gene co-expression network analysis (WGCNA). Gene expression data of interest were then followed up on the protein level in patient plasma, using a targeted proteomics method (SWATH mass spectrometry (MS)). The most promising blood protein markers were identified by pathway analysis and tested further for replication using the alternative proteomic method multiple reaction monitoring (MRM) in the patient sample and in healthy controls.
Findings: WGCNA identified16 transcriptomic modules. One module was significantly correlated with poor versus better cognitive performance in remitted MDD patients, containing ribosomal genes and modulators of B-cell biology. On the plasma protein level, SWATH-MS detected 43% of module gene products. Group differences and co-expression patterns were confirmed.
Conclusions: This experimental workflow may represent an effective approach to blood biomarker discovery for psychiatric phenotypes. This study implicates pathways involved in B-cell biology in cognitive function in MDD.
People with Psychosocial Disability as Choice Makers in the Context of the NDIS
S Pollock, A Stratford
Mind Australia, Melbourne, Australia
Background: Choice and control are centre-pieces of the new National Disability Insurance Scheme (NDIS). However, the application of choice for people with psychosocial disability remains largely unexamined in the empirical literature.
Objectives: This study examines how people with psychosocial disability make choices in the context of the NDIS, how they understand themselves as choice makers and the supports they draw on in making choices. The study seeks to position people with psychosocial disability as experts in understanding the operation of choice in the NDIS.
Methods: The study will interview 20 NDIS participants with psychosocial disability, including those who have completed one or more than one NDIS plan. Using narrative interviews, respondents will explore their experiences of choice making in the NDIS, how these compare to their experience of making choices in other areas of their lives, including health systems, and how experiences and self-understandings change over subsequent plans. Undertaken in partnership with Deakin and Melbourne Universities, the research team includes people with a lived experience of mental ill health and recovery.
Findings: Field work will commence in March 2017, following ‘mini-conversations’ completed over the summer. Preliminary data from these inquiries will be presented.
Conclusions: People with psychosocial disability traditionally have had limited opportunities to exercise choice in relation to the provision of treatment and support. The NDIS offers a new opportunity for individual agency but will present challenges to individuals, those who support them and those who treat them if the promise of control and choice is to be realized.
Awareness of Suicide Risk and Communication between Healthcare Professionals and Next-of-Kin of Suicides in the Month Before Suicide
B Draper1,2, K Krysinska2, J Snowdon3, D De Leo4
1Prince of Wales Hospital, Sydney, Australia
2The University of New South Wales, Sydney, Australia
3 The University of Sydney, Sydney Australia
4Australian Institute of Suicide Research and Prevention, Griffith University, Brisbane, Australia
Background: The extent to which healthcare professionals (HCP) and next-of-kin (NOK) are aware of, and communicate concerns of, suicide risk in the month before suicide is unclear.
Objectives: To compare the awareness of explicit and indirect suicide communications of NOK and HCPs who had contact with suicides in the month before death and to establish the extent to which concerns were communicated.
Methods: Data were obtained in a psychological autopsy study of suicides aged 35 years and older in Queensland and NSW. Interviews were conducted with NOK and HCPs who had contact with the suicide. Information about the last contact, explicit and indirect suicide communications, mental health, quality of relationship and suicide history was obtained. Communications between the NOK and HCP were noted.
Findings: There were 74 suicides (mean age 54.3 years, 62% male) who had contact with an HCP and a NOK in the month before death. There were no significant differences in the knowledge of HCPs and NOK about mental health or suicide attempts. NOK were significantly more likely to be aware of indirect suicide communications such as changing the will, disposing of possessions, stockpiling pills and statements of hopelessness. The HCP had contacted the family specifically for concerns about suicidality in six cases (8.1%). Of the 40 cases in which the NOK had concerns about suicidality, contact was made in 29 cases (73%).
Conclusions: Family members are more likely to be aware of suicide warning signs than HCPs; thus, communications between the HCP and families are an essential component of suicide prevention.
Meet the MOOC – A Massive Open Online Course for Psychoeducation
S Kumar1,2,3, L Nash1,4,5, L McLean1,6
1Brain and Mind Centre, The University of Sydney, Sydney, Australia
2Woolcock Institute, The University of Sydney, Sydney, Australia
3Lawson Clinic, Sydney, Australia
4Health Education and Training Institute of New South Wales Health, Sydney, Australia
5Western New South Wales Local Health District, Sydney, Australia
6Westmead Psychotherapy Program for Complex Traumatic Disorders, Sydney, Australia
Background: The Brain and Mind Centre is launching one of the first, massive open online courses (MOOCs) at the University of Sydney, in early 2017. The MOOC, entitled Positive Psychiatry, was developed as a means of psychoeducation and community education to introduce consumers, carers and the general community to concepts of positive mental health and psychiatry.
Objectives: To provide an overview of the MOOC and to showcase highlights of this course, which is available to the public online.
Methods: The course was developed primarily in video format with associated quiz and self-assessment tasks, with the assistance of contemporary educational technologies. Expert psychiatrists, expert researchers and expert consumers highlight positive mental healthcare in social, cultural, psychological and biological domains for mental health promotion, prevention and early intervention. Material from the MOOC will be demonstrated during the session.
Conclusions: Psychoeducation is an essential task for health promotion and consumer empowerment. Psychiatrists and clinicians are constantly engaged in the task of psychoeducation for a mentally healthy lifestyle; evidence-based findings from leading experts in mental health are now freely available for communication with consumers and the general community to enable them to take action towards their own recovery.
A Systemic Model for Improving Mental Health of Children with Developmental Disabilities in Care Settings
M Usman1, W Warren2
1Consultant Psychiatrist, Adelaide, South Australia
2CEO, EBL Disability Services Inc, Adelaide, South Australia
Introduction: Children with developmental disabilities are at increased risk of mental health disorders. Australian studies identify that only 10% of these vulnerable children have access to specialized mental health services. Children in out-of-home care settings often present with complex psychopathology with high prevalence of emotional and behavioural disorders.
EBL is one of the accommodation service providers in South Australia. This is a not-for-profit organization that works with parents, government and other service providers to provide a range of accommodation for people with developmental disabilities.
We present a model developed by EBL that enhances the mental health of children with developmental disabilities.
Model used: Understanding the impact of mental health issues in children with developmental disabilities EBL, in conjunction with a consultant child and adolescent psychiatrist, developed a therapeutic team around the child. The therapeutic team directly reports to the CEO and changes suggested were implemented.
The organizational structure and the model used will be presented in detail, using two case examples.
Results: In the two case examples, significant improvement in mental, physical and social well-being was noted. There was significant reduction in the use of psychotropics, restraint and inappropriate presentations to the emergency department. The organization also noticed a high staff retention rate.
Discussion: Psychiatrists and specialized mental health team’s expertise are much needed for children in out-of-home care placements. This will lead to improvement in the physical, mental and social well-being of children with developmental disabilities.
Psychogenic Non-Epileptic Seizures in Individuals Attending Neurological Services
F Sundram1, J Campbell1, E Walker2, W Diprose3, E No4
1Department of Psychological Medicine, The University of Auckland, Grafton, Auckland, New Zealand
2Department of Neurology, Auckland City Hospital, ADHB, Auckland, New Zealand
3Department of Medicine, Whangarei Hospital, Northland DHB, Whangarei, New Zealand
4The University of Auckland, Grafton, Auckland, New Zealand
Background: Psychogenic non-epileptic seizures (PNES) are defined as episodes that superficially resemble epileptic seizures (ES) without electrophysiological evidence of abnormal neuronal activity (Hubsch et al., 2011). A number of mechanisms have been proposed including a history of abuse/neglect and psychiatric comorbidities (Asadi-Pooya and Sperling, 2015). PNES are associated with repeated investigations and unnecessary treatments (Reuber and Elgar 2003).
Objectives: To examine the symptomatology, medical and psychiatric comorbidities associated with PNES and factors related to presentation to neurological services at Auckland District Health Board, New Zealand, which provides a regional metropolitan service.
Methods: Electronic medical records and video-electroencephalography (EEG) data gathered from the telemetry unit based on synchronized acquisition (motor activity and brain electrophysiology) were retrospectively examined over 5 years (2011 to 2015 inclusive). Three groups were selected: people with PNES only (n = 60), people with combined PNES and ES (PNES + ES, n = 17) and a control group with ES only, matched by age and gender (n = 77).
Findings: People with PNES had higher rates of abuse and neglect than controls. Additionally, a Māori background, female gender, medical and psychiatric comorbidities were more frequently seen in PNES. Compared with ES controls and those with PNES + ES, people with PNES had more frequent seizures. People with PNES were also often being treated with unnecessary antiepileptic drugs.
Conclusions: To our knowledge, this is the first study in New Zealand to characterize PNES in detail. Lack of access to appropriate services for people with PNES can contribute to poorer outcomes as well as iatrogenic harm. The provision of appropriate neurology and psychiatric services better targeting needs will potentially help address PNES.
References
Asadi-Pooya A and Sperling M (2015) Epidemiology of psychogenic nonepileptic seizures. Epilepsy and Behavior 46: 60–65.
Hubsch C, Baumann C, Hingray C, et al. (2011) Clinical classification of psychogenic non-epileptic seizures based on video-EEG analysis and automatic clustering. Journal of Neurology, Neurosurgery and Psychiatry 82(9): 955–960.
Reuber M and Elgar CE (2003) Psychogenic nonepileptic seizures: Review and update. Epilepsy and Behavior 4(3): 205–216.
Adverse Incidents and Unawareness in Huntington Disease
P Wibawa1,2, P Panegyres1, D Rock3, R Zombor1, B Hayhow1, J Lee1, J Abbott1, M Dragovic2,3, SE Starkstein3,4
1Neurosciences Unit, North Metropolitan Health Service – Mental Health, Perth, Australia
2Clinical Research Centre, North Metropolitan Health Service – Mental Health, Perth, Australia
3School of Psychiatry and Clinical Neurosciences, The University of Western Australia, Perth, Australia
4Fremantle Hospital, Department of Health, Perth, Australia
Background: Unawareness, or anosognosia, is present when a patient’s perception of the obvious disease manifestation differs from that of an observer (McCusker and Loy, 2014). Up to half of Huntington disease (HD) patients have unawareness. However, little is known whether unawareness relates to any adverse outcomes.
Objectives: To evaluate any associations between unawareness in HD patients and their 12-month retrospective adverse incidents of falls, motor vehicle accidents and caregiver’s burden.
Methods: This is a cross-sectional study in a statewide neurosciences outpatient clinic. Investigator, patients and their nominated informants complete the Anosognosia Scale (Deckel and Morrison, 1996) and Adverse Incidence Questionnaire. Baseline Unified Huntington’s Disease Rating Scale, Problem Behaviour Assessment, frontal lobe battery, Mini-Mental State Examination, functional assessment and the Zarit Burden Interview are also performed.
Findings: Our preliminary analysis showed that 9 out of 19 patients were ‘unaware’, with a cut-off discrepancy score of >5 (area under the curve (AUC) 91%, p < 0.0001) on the Anosognosia Scale.
The unaware group had a higher severity of falls (unaware vs. aware, mean score 1.67 vs. 1.20), the Zarit Burden Score (mean score, 30.00 vs 21.90) and were more likely to have two or more car accidents (odds ratio (OR) 12) within the last 12 months.
Anosognosia ratings between informant and investigator are poorly correlated (r = −0.17) but become more similar with an increasing severity of falls (F = 4.86, p < 0.05) and increasing number of car accidents.
Conclusions: Unawareness is common and is associated with higher and more severe adverse incidents in Huntington disease. Therefore, it is clinically essential to assess unawareness in patients having adverse incidents and vice-versa. We will present the final findings in the presentation.
References
Deckel AW and Morrison D (1996). Evidence of a neurologically based “denial of illness” in patients with Huntington’s disease. Archives of Clinical Neuropsychology 11(4): 295–302.
McCusker E and Loy CT (2014) The Many Facets of Unawarenessin Huntington Disease. Tremor and Other Hyperkinetic Movement (N Y) 4: 257. DOI:10.7916/D8FJ2FD3.
Faculty of Psychiatry of Old Age Prize Winners Presentation
Background: This presentation is an official presentation of the work of the winners of the Faculty of Psychiatry of Old Age (FPOA) prizes.
The following three prizes are awarded by the FPOA annually with the recipients invited to present their work at the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Congress:
FPOA Basic Trainee Prize
FPOA Trainee Scholarly Project Prize
FPOA Best Mental Health Service Improvement Prize
The prizes were established in 2012 to promote excellence in advancing the quality of life in older people with mental illness by
Encouraging and promoting the highest clinical and ethical standards in the delivery of Psychiatry of Old Age services among psychiatry trainees in Australia and New Zealand;
Encouraging and promoting training in Psychiatry of Old Age of the highest standard for psychiatrists, trainee psychiatrists, medical students, related health professionals, students of related health professions and other medical practitioners.
A Pilot Study to Evaluate Correlation of Subjective Memory Complaints with Moca/Rudas and Vascular Risk Factors in an Urban Community Dwelling Population Above 50 Years of Age
J Menon1, N Gupta2
1Geriatric Care Clinic, Sri Ramachandra Medical Centre, Sri Ramachandra University, Chennai, India
2Country Health South Australia, Adelaide, Australia
Background: Early identification of individuals with Alzheimer’s disease (AD) has a significant role in the research for disease-modifying agents, better biomarkers and cost reduction. The concept of pre-clinical AD is well established. Patients in stage III pre-clinical AD have subjective complaints of cognitive difficulties but no clinical evidence of mild cognitive impairment (MCI) or dementia. However, the conversion rate to Alzheimer’s dementia in stage III pre-clinical AD can be as high as 50%. The Subjective Memory Complaints Questionnaire (SMCQ) may have some role in early identification of a high-risk population.
Objectives: To identify individuals with subjective memory complaints in an urban community using memory screening camps; compare the scores of the SMCQ with an objective measurement of cognitive functions using Montreal Cognitive Assessment (MOCA)/Rowland Universal Dementia Assessment Scale (RUDAS); and evaluate the prevalence of vascular and metabolic risk factors in the population and its relationship with cognitive impairment.
Methods: A total of 300 individuals older than 50 years of age who are voluntarily willing to participate in a screening program will be administered the SMCQ followed by cognitive function evaluation using MOCA Tamil Version or RUDAS by a trained psychologist, based on the educational status of the individuals. The Geriatric Depression Scale and a semi-structured interview will be used to rule out ongoing psychiatric complaints. Height, weight, body mass index, waist circumference, resting heart rate, blood pressure and diabetes status will also be recorded. Education regarding lifestyle modification by including regular exercise, control of hypertension, diabetes and hypercholesterolaemia will be imparted to participating individuals and families.
Statistical analysis and results: Appropriate statistical tests will be used to evaluate the data, which is being collected over a period of 6 months. Results will be discussed at the conference.
Lumbar Punctures for All? Exploring the Role of CSF Alzheimer’s Protein Biomarkers in the Diagnostic Assessment of Possible Young-Onset Dementia
D Eratne1, S Loi1, M Walterfang1, D Mocellin1, Q-X Li2, S Collins2, D Velakoulis1
1The Royal Melbourne Hospital, Melbourne, Australia
2Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
Background: A lumbar puncture for cerebrospinal fluid (CSF) analysis, including analysis for Alzheimer’s disease (AD) biomarkers, is part of the comprehensive multidisciplinary diagnostic workup of patients with younger-onset cognitive disorders admitted to the Royal Melbourne Hospital Neuropsychiatry Unit (NPU).
Objectives: To determine the clinical utility of CSF AD biomarkers in a diverse range of patients admitted to our service for diagnostic assessment of cognitive symptoms.
Methods: This was a retrospective review of patients admitted to the NPU from 2009 to 2016, who had CSF analysis for AD biomarkers (beta-amyloid, total tau, phosphorylated tau). A file review was performed to collate demographic factors; bedside cognitive and neuropsychological assessments; neuroimaging findings; diagnosis prior to, and incorporating, CSF results.
Findings: Patients (98, mean age 55 years, M:F = 2:1) had CSF AD biomarker analyses performed. The CSF findings were consistent 90% of the time with more definite tests, which were performed in 10 cases. Thirty-seven patients received an interim discharge diagnosis that was blind to CSF results (pre-CSF diagnosis) and a final discharge diagnosis incorporating CSF results (post-CSF diagnosis). When the ‘pre’ to ‘post’ CSF diagnoses were compared, preliminary findings indicated that the diagnosis had changed in 5 out of 37 (13.5%) cases. ‘Pre-CSF diagnoses’ were consistent with CSF findings 84% of the time. ‘Post-CSF diagnoses’ were consistent 94% of the time.
Conclusions: CSF Alzheimer’s biomarkers can add useful information to the assessment of younger patients with cognitive symptoms and assist in diagnosis. These results, clinical implications, utility of CSF biomarkers, further preliminary findings, and limitations of the study will be discussed.
Clinical Audit of Benzodiazepine Prescribing in an Older Person’s Mental Health Inpatient Unit
A Lane
Robina Hospital, Gold Coast Mental Health Service, Brisbane, Australia
Background: Benzodiazepines are commonly prescribed in the elderly psychiatric population and are associated with increased risks of falls and cognitive impairment (Barker et al., 2004; Gray et al., 2006; Pariente et al., 2008) and tolerance and dependence (Ashton, 2004; Voshaar et al., 2006). Benzodiazepines are indicated for the short-term relief (2–4 weeks only) of anxiety that is severe, disabling or subjecting the individual to unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic or psychotic illness (British National Formulary 2013; Committee on Safety of Medicines, 1988). Consumers and/or carers should be counselled on the risks (RANZCP, 2015). Concurrent use of benzodiazepines requires justification (RANZCP, 2015) and long-acting benzodiazepines should be avoided (eTG complete, n.d.).
Objectives: This is a clinical audit with an aim to evaluate current practice against recommended practice.
Methods: Following a literature search to identify current recommendations for benzodiazepine prescribing, audit criteria were determined and standards set. A retrospective chart audit was undertaken in elderly patients admitted to the Older Person’s Mental Health Unit (OPMHU) over a 6-month period. Inclusion criteria: all patients (male and female) aged ⩾65 years, admitted to the OPMHU between 1 February 2016 and 31 July 2016. Exclusions: patients admitted overnight for electroconvulsive therapy; patients aged <65 years and patients where the medication charts were not accessible in the computerized medical record. Fifty-one patients were identified as meeting inclusion criteria.
Findings: 3/7 audit criteria were met. The findings highlight the challenges of benzodiazepine prescribing in the elderly.
Conclusions: Recommendations for implementation included initiating education across the multidisciplinary team to raise awareness of audit findings and improving consumer and carer education, with consideration of integrating additional patient-centred resources to promote alternate non-pharmacological options.
References
Ashton H (2004) Benzodiazepine dependence. In: Haddad P, Dursan S and Deakin B (eds) Adverse Syndromes and Psychiatric Drugs. Oxford, UK: Oxford University Press, pp. 239–260.
Barker MJ, Greenwood KM, Jackson M, et al. (2004) Cognitive effects of long-term benzodiazepine use: A meta-analysis. CNS Drugs 18: 37–48.
British National Formulary 4.1 (n.d.) Hypnotics and Anxiolytics and Benzodiazepine Guidance Revised November 2013. Available at: http://www.benzo.org.uk/BNF.htm (accessed 8 August 2016).
Committee on Safety of Medicines (1988) UK Government Bulletin to Prescribing Doctors. January 1988; Current Problems 1988. Number 21: 1–2. Available at: http://www.benzo.org.uk/commit.htm (accessed 8 August 2016).
Gray SL, LaCroix AZ, Hanlon JT, et al. (2006) Benzodiazepine use and physical disability in community-dwelling older adults. J Am Geriatr Soc 54: 224–230.
Pariente A, Dartigues JF, Benichou J, et al. (2008) Benzodiazepines and injurious falls in community dwelling elders. Drugs Aging 25: 61–70.
Voshaar RC, Couvee JE, van Balkom AJ, et al. (2006) Strategies for discontinuing long-term benzodiazepine use: Meta-analysis. Br J Psychiatry 189: 213–220.
A Prevalence Study of Metabolic Syndrome in a High Secure Psychiatric Setting: The UK Experience
HK Williams1, A Igoumenou1,2, A Yadav1, M Das1
1Broadmoor High Secure Hospital, London, UK
2Violence Prevention Research Unit, Queen Mary University, London, UK
Background: Metabolic syndrome (MeS) is a constellation of lipid abnormalities, hypertension, glucose intolerance and obesity associated with morbidity and mortality. Risk factors include psychotropic medication and negative health behaviours. MeS is highly prevalent among patients with schizophrenia with estimates of between 35% and 40%, twice that in the general population. It has been recommended that health monitoring and active management be undertaken to reduce its prevalence. Intensive monitoring and management should be most practicable in high secure hospital settings, where patients are constantly supervised and teams have small case loads.
Objectives/methods: This cross-sectional study examined case records of all patients in a high secure hospital. MeS was identified by International Diabetes Federation criteria. First, prevalence was calculated. Second, regression modelling explored the associations between MeS and other variables including medications, diagnosis, smoking status and length of hospital stay.
Findings: The point prevalence of metabolic syndrome in this high secure population was 54.3%. MeS was associated with atypical antipsychotics (odds ratio (OR) = 2.88, 95% confidence interval (CI) = 1.21–6.81, p = 0.016), multiple antipsychotics (OR = 1.94, 95% CI = 1.12–3.35, p = 0.017), smoking (OR = 2.63, 95% CI = 1.09–6.34, p = 0.032) and selective serotonin reuptake inhibitor prescription (OR = 5.23, 95% CI = 1.11–24.61, p = 0.037).
Conclusions: In the most closely monitored patient environment in UK psychiatry, 54.3% of patients had MeS. This sheds doubt on the rhetoric that closer supervision of patients in community and other settings will prevent MeS. High secure patients carry a high mental health burden. The state restricts their lives more than other psychiatry patients. It is seriously concerning that the MeS physical health burden is the highest in this setting also.
Psychiatric Impairment Ratings in Children: Suggested Guidance Points
J Kasinathan1,2, Y Singh1,3, S Harden1,2
1New South Wales Health, Sydney, Australia
2Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
3The University of New South Wales, Sydney, Australia
Background: Throughout Australia and New Zealand, it has become accepted practice for psychiatric injury or disability rating scales to be applied for persons claiming psychiatric injury caused by a motor vehicle accident (MVA). All these rating scales were derived for the assessment of adults, not children. There is less clarity as to whether and how these psychiatric injury rating scales may be applied in cases of children claiming psychiatric injury caused by an MVA.
Method: We review relevant guidelines and recommended methods for assessing permanent psychiatric impairment in children.
Findings: It is possible to apply psychiatric injury rating scales for the assessment of children, provided significant caution is exercised. Guidance points and recommendations for the assessment of children will be outlined. In some cases, the effects of psychiatric injury may not be considered stable and the assessment of permanent impairment should be delayed until sufficient physical and emotional maturity occurs.
Conclusions: Psychiatric injury or disability rating scales are widely applied for adult persons claiming psychiatric injury; however, great caution must be exercised when these adult-derived rating scales are used in the assessment of children.
Poster Presentation Abstracts
Locked Wards and Culture in Psychiatry
G Antoce
Private Practice, Brisbane, Australia
The presenter will review the history of use of locked wards in psychiatry, discussing it from sociocultural perspectives and reflecting on the ongoing pragmatic justifications. A literature search and in-depth analysis of the impact of treatment setting on outcomes will be followed by discussion of alternatives and the flow-on effects for patients, staff and society.
Effect of Brexpiprazole on Long-Term Functioning in Adults with Schizophrenia: Results from a Randomized, Double-Blind, Placebo-Controlled, Maintenance Study
R Baker1, M Hobart1, A Forbes1, J Ouyang1, E Weiller2
1Otsuka Pharmaceutical Development & Commercialization, Inc., New Jersey, USA
2H. Lundbeck A/S, Copenhagen, Denmark
Background: Brexpiprazole is a partial agonist at 5-HT1A and dopamine D2 receptors, and an antagonist at 5-HT2A and noradrenaline alpha1B/2C receptors, all at similar potency (Maeda et al., 2014). The efficacy and safety of brexpiprazole for the treatment of schizophrenia have been demonstrated in two 6-week phase 3 trials (Correll et al., 2015; Kane et al., 2015) and one maintenance trial (Fleischheicker et al., 2017).
Objectives: To describe the effects of brexpiprazole on long-term functioning based on the maintenance trial.
Methods:Patients experiencing an acute exacerbation of schizophrenia were cross-titrated from current antipsychotic(s) to brexpiprazole over 1 to 4 weeks if required, before entering a 12-to-36 week stabilization phase on brexpiprazole (1 to 4 mg). Patients with stable symptoms over 12 consecutive weeks were then randomized to brexpiprazole or placebo for up to 52 weeks (maintenance phase). The primary efficacy endpoint was the time from randomization to impending relapse. Functioning was measured using the Global Assessment of Functioning (GAF) scale.
Findings: 202 patients were randomized to brexpiprazole (n=97) or placebo (n=105). The primary endpoint analysis showed a beneficial effect of brexpiprazole relative to placebo on the time to impending relapse (log-rank test: hazard ratio=0.292, p<0.0001). During the stabilization phase, GAF mean scores improved from 47.5 to 63.7 in patients later randomized to maintenance phase. From randomization to Week 52, least squares mean change was -6.0 for placebo and 0.6 for brexpiprazole (LOCF, ANCOVA; treatment difference: 6.6 [95% CI: 3.3, 9.8]; p = 0.0001).
Conclusions: Patients treated with brexpiprazole maintained the improvement in functioning that was achieved during the stabilization phase.
References
Maeda K, Sugino H, Akazawa H, et al. (2014) Brexpiprazole I: In vitro and in vivo characterization of a novel serotonin-dopamine activity modulator. Journal of Pharmacology and Experimental Therapeutics 350: 589–604.
Correll CU, Skuban A, Ouyang J, et al. (2015) Efficacy and safety of brexpiprazole for the treatment of acute schizophrenia: A 6-week randomized, double-blind, placebo-controlled trial. The American Journal of Psychiatry 172: 870–880.
Kane JM, Skuban A, Ouyang J, et al. (2015) A multicenter, randomized, double-blind, controlled phase 3 trial of fixed-dose brexpiprazole for the treatment of adults with acute schizophrenia. Schizophrenia Research 164: 127–135.
Fleischheicker et al. (2017) The International Journal of Neuropsycho-pharmacology 20: 11–21.
Atypical Mood Disorder Secondary to Dimethylamylamine Misuse
S Civadelic1, G Ang1, R Bharadwaj1,2,3,4
1Mental Health Service, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia
2Northside Macarthur Clinic, Sydney, Australia
3The University of New South Wales, Sydney, Australia
4Western Sydney University, Sydney, Australia
Background: Weight loss supplements such as ‘hydroxy elite’ often contain the banned substance 1,3-dimethylamylamine (DMAA) and are easily available online and from stores that sell body-building supplements. Both the Therapeutic and Goods Administration (TGA) and the Food and Drug Administration (FDA) caution that DMAA’s misuse and abuse potential is high and that its use is associated with significant adverse events including cardiac, nervous and psychiatric disorders.
Objectives: We report the case of a 27-year-old male who presented to our service following an attempted hanging. He reported misuse of a preparation called ‘Hydroxy Elite’ which contains, among other agents, DMAA. Over the course of this use, his family reported a marked change in his behaviour, including irritability, increased impulsivity and risk-taking, decreased sleep and aggression, culminating in a serious suicide attempt. These features gradually resolved when he ceased use of this agent. As will be detailed, an association between DMAA misuse and this psychiatric syndrome was apparent.
Conclusions: DMAA misuse in this case resulted in a serious psychiatric syndrome culminating in a serious suicide attempt. Its stimulant properties, ease of availability, promotion as a weight loss agent, potential for abuse and association with adverse psychiatric events make it essential to screen for its use particularly in young people presenting to mental health services.
Trajectories in Response to Aripiprazole Maintena Study
S Clark1,2, O Schubert1,3,A Olagunju1, E Lyrtzis1, D Watson1,2, BT Baune1
1The University of Adelaide, Discipline of Psychiatry, Adelaide, Australia
2Central Adelaide Local Health Network, Adelaide, Australia
3Northern Adelaide Local Health Network, Adelaide, Australia
Background: The antipsychotic aripiprazole has a unique pharmacological profile as a partial agonist at dopamine (D2/D3) and serotonin (5-HT1A) receptors and an antagonist at serotonin (5HT2A) receptors. The long-acting injectable form of the drug ‘Maintena’ is now available in Australia. Meta-analysis suggests the efficacy of aripiprazole is similar to that of risperidone. Clinical trials suggest rates of extra pyramidal side effects (EPSEs), metabolic syndrome and elevated prolactin equivalent to placebo. There is emerging evidence of improved cognitive function in patients treated with aripiprazole.
Objectives: We discuss the implementation of a naturalistic longitudinal study of 1-year trajectories of response to Maintena depot.
Methods: The study will follow an observational prospective design with assessment at baseline, 6 and 12 months. The inclusion criteria include 18–65 years of age; diagnosis of schizophrenia or schizoaffective disorder; and a treating psychiatrist’s decision to commence Maintena. The exclusion criteria include developmental or neurological disorder; diabetes or chronic inflammatory disease. The sample will be recruited via treating psychiatrists in the Central and Northern Adelaide Local Health Networks. We aim to recruit 70 patients and expect 40 study completers. The primary outcome measure is a change in the Positive and Negative Symptom Scale trajectory analysed by mixed modelling. The secondary outcomes are Repeatable Battery for the Assessment of Neuropsychological Status; Clinical Global Impression Scale; Hamilton Rating Scale for Depression; Columbia Suicide Severity Rating Scale; clinical outcomes (relapse, hospitalization, adverse incidents, metabolic measures, EPSEs). Experimental outcomes will be a cognitive assessment tool (THINC-it®), and inflammatory and oxidative markers.
Findings: We present interim results describing the baseline assessment of the cohort.
Conclusions: Maintena is an effective and safe medication for the treatment of psychotic illness.
Work–Life Balance and Welfare
L Evans
Royal Australian and New Zealand College of Psyhciatrists, Melbourne, Australia
Objectives: This poster will present findings on the work–life balance of psychiatrists and trainees in Australasia, from the Royal Australian and New Zealand College of Psychiatry’s study into the welfare of members in 2014.
Methods: In 2014, an online welfare survey was emailed to all the Royal Australian and New Zealand College of Psychiatrists trainees, fellows and affiliates. Following this, nine focus groups were held across Australia and New Zealand.
Findings: The analysis suggested that work–life balance can be subjectively and objectively measured. Responses indicated there are phases of good and bad work–life balance, depending on stage of career and other commitments. Work–life balance may be an indicator of the health of individuals and organizations.
Conclusions: Due to its complexity, with intrinsic and extrinsic factors involved, solutions are unlikely to be simple. Further studies are need to substantiate the findings and consider solutions.
A Randomized Controlled Trial of Mindfulness-Based Cognitive Therapy for Youth Living with Inflammatory Bowel Disease and Depression
T Ewais1,2, J. Begun1,2, J. Barclay1,2, M. Tefay1,2, A Tremellen1,2
1Mater Health, Brisbane, Australia
2The University of Queensland, Brisbane, Australia
Background: Individuals with inflammatory bowel disease (IBD) have triple the rate of mental disorders than that of the general population and youth with IBD have higher rates of depression than youth with any other chronic illness (Fuller-Thomson and Sulman, 2006). Mindfulness-based cognitive therapy (MBCT) is an evidence-based group program for treatment of depression that also holds promise in reducing systemic inflammation, normalizing gut microbiome and modulating brain neuronal connectivity (Neilson et al., 2016).
Objectives: The aim of this study is to conduct a randomized control trial (RCT) exploring benefits of MBCT for youth with IBD and depression. The primary outcome measure will be depression scores in the Depression, Anxiety and Stress Scale (DASS). Secondary outcome measures will explore the impact of the mindfulness intervention on IBD inflammatory markers, gut microbiome and functional neuronal connectivity.
Methods: IBD patients aged 16–25 years will be recruited via the IBD outpatient services at Mater Young Adult Health Centre. After completing the DASS, participants will be randomly allocated to either treatment as usual or an intervention group who will receive the MBCT.
Findings: The study has secured funding and is in the recruitment stage with preliminary results expected in May 2017.
Conclusions: This will be the first RCT exploring beneficial impact of MBCT on depression concurrent with measuring its impact on inflammation underlying both depression and IBD, gut microbiome and functional neuroimaging changes. This study therefore holds promise to further elucidate the nature of interactions between depression, inflammation, microbiome and neuroconnectivity and support novel therapeutic interventions targeting them.
References
Fuller-Thomson E and Sulman J (2006) Depression and inflammatory bowel disease: Findings from two nationally representative Canadian surveys. Inflammatory Bowel Diseases 12(8): 697–707.
Neilson K, Ftanou M, Monshat K, et al. (2016) A controlled study of a group mindfulness intervention for individuals living with inflammatory bowel disease. Inflammatory Bowel Diseases 22(3): 694–701.
Lurasidone Treatment of Major Depression with Mixed Features: Effect on Sexual Function
A Clayton1, J Tsai2, A Pikalov2, A Loebel2
1Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, USA
2Sunovion Pharmaceuticals Inc, Marlborough, USA
Background: Sexual dysfunction is common in major depressive disorder (MDD) and is frequently worsened by antidepressant treatment. Lurasidone is approved in Australia for the treatment of schizophrenia.
Objectives: To evaluate the effect of lurasidone on sexual functioning as measured by the Changes in Sexual Functioning Questionnaire (CSFQ) in patients having MDD with mixed features (MDD–MF).
Methods: Patients meeting the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision criteria for MDD, who presented with two or three manic symptoms, were randomized to 6 weeks of double-blind treatment with flexible doses of either lurasidone monotherapy at 20–60 mg/day (N = 109) or placebo (N = 100). A change from baseline in the Montgomery–Åsberg Depression Rating Scale (MADRS) total at week 6 was the primary efficacy endpoint. The CSFQ was assessed at baseline and at week 6.
Findings: At baseline, mean CSFQ scores were 35.4 and 34.1 in lurasidone and placebo groups, respectively, with sexual function rated as abnormal on the CSFQ by 77.8% and 89.8% in the lurasidone and placebo groups, respectively. Treatment with lurasidone (vs placebo) significantly improved mean MADRS total scores at week 6 (–20.5 vs −13.0; p < 0.0001) and significantly improved the CSFQ total score at week 6 (+5.1 vs +3.1; p < 0.05). Significant improvement was also noted on the CSFQ-pleasure subscale, and numerical improvement on the CSFQ-desire/frequency, desire/interest, arousal, and orgasm subscales. In a mediator analysis, improvement in sexual functioning on lurasidone was found to be mediated indirectly by improvement in depressive symptoms, with minimal direct pharmacologic effect (β = −0.03; not significant).
Conclusions: Treatment with lurasidone was associated with significant improvement in MDD-MF while also significantly improving sexual function.
Funding
Sponsored by Servier and Sunovion Pharmaceuticals Inc.
Early Schizophrenia Patients Treated with Once-Monthly Paliperidone Palmitate Over a 12-Month Period – A Retrospective Observational Study
A Schreiner1, P Bergmans2, P Cherubin3, L Hargarter1
1EMEA Medical Affairs, Janssen Cilag, Neuss, Germany
2Biostatistics and Programming, Janssen Cilag Benelux, Tilburg, Netherlands
3EMEA Medical Affairs, Janssen Cilag, Issy-les-Moulineaux, France
Background: Little is known about patient characteristics and rehospitalisation in newly diagnosed patients with schizophrenia treated with long-acting antipsychotics.
Objectives: To retrospectively explore hospitalisations, drug utilisation and clinical outcomes from medical records of young, newly diagnosed patients with schizophrenia during the first 12 months of treatment with once-monthly paliperidone palmitate (PP).
Methods: International, multicentre, retrospective, observational study. Outcomes presented are patient characteristics, reason for PP initiation and hospitalisation data.
Findings: A total of 84 patients were analysed: mean age (years) at first psychotic episode was 23.8 (standard deviation [SD] 2.6), 23.9 (SD 2.6) at first antipsychotic treatment and 24.1 (SD 2.7; range 19–29) at PP initiation. The time between the first antipsychotic treatment and PP initiation was 4.8 (SD 3.4; range 0–12) months. At PP initiation 42.9% of patients were in hospital, primarily for the management of the first episode/relapse (97.2%). The reason for the PP initiation was: LAT was favoured over oral treatment for relapse prevention (56%), partial/non-adherence with previous oral medication (20.0%), convenience (15.5%) or limited access to health care systems (2.4%). The mean time (days) between admission and initiation of PP, and between initiation of PP and discharge from hospital was 28.8 (SD 23.0) and 23.2 (SD 24.5), respectively. Most (96.4%) of patients were not hospitalised during the 12-month PP treatment period. Some (3/84) patients (3.6%) had a single hospitalisation of 15.7 (SD 8.1) days for the management of episode/relapse.
Conclusions: In this young, newly diagnosed schizophrenia population the number of hospitalisations following PP initiation was low. The main reason to initiate PP was clinicians favouring LAT over oral antipsychotic treatment for relapse prevention or due to partial/non-adherence with a previous oral treatment.
Clinical and Functional Response to Paliperidone Palmitate in Early Schizophrenia – A Retrospective Observational Study in Newly Diagnosed Patients Treated over a 12-Month Period
A Schreiner1, P Bergmans2, P Cherubin3, L Hargarter1
1EMEA Medical Affairs, Janssen Cilag, Neuss, Germany
2Biostatistics and Programming, Janssen Cilag Benelux, Tilburg, Netherlands
3EMEA Medical Affairs, Janssen Cilag, Issy-les-Moulineaux, France
Background: Data on clinical outcomes with long-acting antipsychotic treatment in young, newly diagnosed patients with schizophrenia is sparse.
Objectives: To explore hospitalisation, drug utilisation and clinical outcomes from medical records of newly diagnosed schizophrenia patients during the first 12 months of treatment with once-monthly paliperidone palmitate (PP).
Methods: International, multicentre, retrospective, observational study. The outcomes presented are: baseline (BL) characteristics and demographics, clinically relevant improvements in disease severity (i.e. ≥.20% decrease in the Positive and Negative Syndrome Scale or BPRS total score or Clinical Global Impression – Severity [CGI-S] change ≥ −2 or CGI-C ≥ 3, with no score showing worsening) and a clinically relevant functional improvement (i.e. a change in Personal and Social Performance total score ≥ +7 points or a change in GAF total score ≥ +20 points, with no score showing worsening) from BL to last-observation-carried-forward endpoint (LOCF-EP) within a 12-month documentation period; mean mode PP dose; and adverse drug reactions (ADRs).
Findings: A total of 84 patients were analysed: 69% were male; the mean age at initiation of PP was 24.1 (SD 2.7) years; the mean BL weight was 78.7 (SD 16.0) kg and 80.0 (SD 14.7) kg at LOCF-EP, with a mean change of 1.2 (SD 3.9) kg; the mean time from the first psychotic episode to the initiation of PP was 5.5 (SD 3.3) months. At LOCF-EP, 86.6% achieved a clinically relevant improvement (71/84, Kaplan–Meier median time from initiation of PP: 52.4 days). Most patients (63.4%) achieved a clinically relevant functional improvement (52/84, Kaplan–Meier median time from initiation of PP: 53.1 days). The PP mean mode maintenance dose was 96.4 (SD 19.8) mg. The ADRs reported in ≥ 5% of patients were weight increase (9.1%) and hyperprolactinaemia (5.7%).
Conclusions: Treatment with once-monthly PP was well tolerated and was associated with clinically relevant improvements in disease severity and functioning in young, newly diagnosed schizophrenia patients.
Safety of Lurasidone in Schizophrenia: A Systematic Review and Meta-Analysis of RCTs with Active Comparators
K Hagi1, T Nosaka1, A Pikalov2, A Loebel2, J Kane3
1Medical Affairs, Sumitomo Dainippon Pharma Co. Ltd, Tokyo, Japan
2Sunovion Pharmaceuticals, Inc, Marlborough, USA
3The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, New York, USA
Background: Lurasidone is a novel antipsychotic with potent binding affinity for D2, 5-HT2A and 5HT7 receptors (antagonist), moderate affinity for 5HT1A (partial agonist) and α2C receptors, and no appreciable affinity for H1 and M1 receptors. Lurasidone is approved in Australia and multiple other countries for the treatment of schizophrenia and in the United States and Canada for the treatment of bipolar disorder.
Objective: To evaluate the effect of lurasidone on key safety parameters when compared to other atypical antipsychotics.
Methods: Six randomized, placebo-controlled, active comparator studies were included in this safety meta-analysis (N = 2718 patients), including five fixed, and one flexible-dose study, with durations of up to 52 weeks. The active comparators included in the current meta-analysis were olanzapine, risperidone, quetiapine and ziprasidone. Meta-analytic metrics, including weighted mean difference (WMD), standard mean difference (SMD) and relative risk ratios, were calculated using random effects models.
Findings: Compared with atypical antipsychotics, treatment with lurasidone was associated with a significantly lower risk of weight gain (⩾7% increase; risk ratio, 0.28; p < 0.0001), less effect on total cholesterol (SMD, −0.28; p = 0.029) and triglycerides (SMD, −0.22; p = 0.024), a non-significantly less effect on low density lipoprotein cholesterol (SMD, −0.22). There was also a significantly lower risk on lurasidone of increased body weight, reported as a treatment-emergent adverse event (risk ratio, 0.29; p = 0.011), and a significantly lower risk of increased waist circumference (–1.65; p = 0.002).
Conclusions: A meta-analysis of randomized, controlled clinical trials in patients with schizophrenia demonstrated that treatment with lurasidone was associated with less weight gain and metabolic disturbances than active comparators.
Funding
This work was sponsored by Servier and Sunovion Pharmaceuticals Inc.
Efficacy of Lurasidone in Schizophrenia: A Systematic Review and Meta-Analysis of RCTs with Active Comparators
T Nosaka1, K Hagi1, A Pikalov2, A Loebel2, J Kane3
1Medical Affairs, Sumitomo Dainippon Pharma Co. Ltd, Tokyo, Japan
2Sunovion Pharmaceuticals, Inc, Marlborough, USA
3The Zucker Hillside Hospital, Psychiatry Research, North Shore – Long Island Jewish Health System, New York, USA
Background: Lurasidone is a novel antipsychotic with potent binding affinity for dopamine D2, serotonin 5-HT2A and 5-HT7 receptors (antagonist effect), and moderate affinity for 5-HT1A (partial agonist effect) and α2C receptors. Lurasidone is approved in Australia and multiple other countries for the treatment of schizophrenia and in the United States and Canada for the treatment of bipolar disorder.
Objectives: To evaluate the efficacy of lurasidone compared with atypical antipsychotics in patients with schizophrenia.
Methods: At total of four randomized, placebo-controlled, active comparator studies were included in this efficacy meta-analysis (N = 2326 patients), including three fixed and one flexible-dose study, with durations of up to 52 weeks. The active comparators included in the current meta-analysis were olanzapine, risperidone, quetiapine and ziprasidone. Meta-analytic metrics, including the weighted mean difference (WMD), were calculated using random effects models.
Findings: In an initial comparison with placebo, treatment with lurasidone demonstrated significant difference in WMDs on the Positive and Negative Syndrome Scale (PANSS) total score (–11.50; p < 0.0001), PANSS positive subscale score (–3.39; p = 0.003), PANSS negative subscale score (–5.13; p < 0.0001), PANSS general psychopathology score (–2.62; p < 0.0001) and the Clinical Global Impression – Severity score (CGI-S; −0.48; p = 0.003). Treatment with lurasidone was found to be comparable to the four atypical antipsychotics studied, with no significant difference in WMDs on the PANSS total score (1.48), PANSS positive subscale score (0.78), PANSS negative subscale score (0.68), PANSS general psychopathology score (–0.10), and the CGI-S score (0.03).
Conclusions: In this meta-analysis of short-term randomized, placebo-controlled, active comparator trials in patients with schizophrenia, treatment with lurasidone demonstrated similar efficacy compared with other atypical antipsychotics.
Funding
This study was sponsored by Servier and Sunovion Pharmaceuticals Inc.
A Case Series of Levetiracetam-Related Psychiatric Symptoms
C Hercus1, M Verheggen1, A Nowak1,2, L Miller1,2
1Sir Charles Gairdner Hospital, Perth, Australia
2The University of Western Australia, Perth, Australia
Background: One function of the prefrontal cortex is cortical modulation of emotion/arousal arising in the limbic system. Brain tumours affecting these areas can cause personality/behavioural disturbances. The authors note that some brain tumour patients have additional contributors to disinhibition/impulsivity and empathic attunement. One such factor may be levetiracetam, a common perioperative antiepileptic drug, which is discontinued due to psychiatric side effects in 7% of epileptic patients (De Smedt et al., 2007), but little data exist regarding additional risks in brain tumour patients.
Objectives: To describe a case series of glioma patients with levetiracetam-associated psychiatric symptoms and propose a potential aetiology for investigation.
Methods: A search of referrals to a consultation–liaison psychiatry service and discussion with neuro-oncology staff was undertaken to identify cases of possible levetiracetam-induced psychiatric symptoms in patients with glioma. Medical records were hand searched to exclude patients with delirium, hypomania or steroid-induced mood disturbance. A series of five cases is presented with a discussion of possible aetiology.
Findings: The authors report a clinical impression of significant mood disturbance in glioma patients being treated with levetiracetam, which appears more common than the rate reported for the epilepsy population.
Conclusions: The authors propose a potential aetiology of levetiracetam-related disinhibition of limbic function causing amplified emotional responses. This may be particularly problematic in the glioma population due to tumour-related prefrontal dysfunction limiting the patients’ capacity for cortical modulation, which may be similarly problematic in patients with other causes of prefrontal dysfunction. We propose investigation of this potential aetiology using functional neuroimaging approaches.
Reference
De Smedt T, Raedt R, Vonck K, et al. (2007) Levetiracetam: Part II, the clinical profile of a novel anticonvulsant drug. CNS Drug Reviews 13(1): 57–78.
Burnout in Psychiatrists: Risk and Protective Factors
A Hui
Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Australia
Background: Psychiatrists are at greater risk of burnout than colleagues in general medicine due to the unique nature of their work caring for the emotional needs of patients, leading to comparatively higher rates of emotional exhaustion, severe depression and physical illness.
Objectives: To identify risk and protective factors for burnout among psychiatrists
Methods: PubMed was searched with the following terms: ‘burnout AND psychiatrist’ in the title or abstract. Articles were excluded if they were not in English, did not assess burnout as an outcome, or did not identify either risk or protective factors applicable to consultant psychiatrists.
Findings: Of the 53 articles identified, 22 were excluded. Most risk factors were related to work: poor skill variety, poor task identity, low task significance, excessive workload, excessive hours, minimal time for research/audits, excessive travelling, limited access to colleagues or supervision, working with patients with personality disorders, aggression and patient suicides. Organizational factors included budget cuts, authoritarian governance styles, lack of support, system changes, team conflicts and responsibility without authority. Non-work factors included being female, young, depressed, having harm avoidance, negative affectivity and social inhibition personality traits, work–life imbalance and a negative life event in the previous year. The biggest protective factor was job satisfaction; others included working with colleagues, work variety, positive work attitude, positive patient relationships, being valued, being in management, working in an organization affiliated with an academic centre and more experience; non-work factors included social support, self-directedness and self-control.
Conclusions: Many risk factors to burnout in psychiatrists are potentially modifiable by the psychiatrist or their employing organization.
References
Ballenger-Browning KK, Schmitz KJ, Rothacker JA, et al. (2011) Predictors of burnout among military mental health providers Military Medicine 176(3): 253–260.
Baumgardt J, Moock J, Rossler W, et al. (2015) Aspects of sustainability: Cooperation, job satisfaction, and burnout among Swiss psychiatrists. Frontiers in Public Health 3: 25. DOI:103389/fpubh201500025.
Benbow SM and Jolley DJ (2002) Burnout and stress amongst old age psychiatrists. International Journal of Geriatric Psychiatry 17(8): 710–714. DOI:101002/gps647.
Braun M, Schonfeldt-Lecuona C, Freudenmann RW, et al. (2010) Depression, burnout and effort-reward imbalance among psychiatrists. Psychotherapy and Psychosomatics 79(5): 326–327. DOI:101159/000319531.
Bressi C, Porcellana M, Gambini O, et al. (2009) Burnout among psychiatrists in Milan: A multicenter survey Psychiatric Services 60(7): 985–988. DOI:101176/appips607985.
Clark GH Jr and Vaccaro JV (1987) Burnout among CMHC psychiatrists and the struggle to survive. Hospital & Community Psychiatry 38(8): 843–847.
Deary IJ, Agius RM and Sadler A (1996) Personality and stress in consultant psychiatrists. International Journal of Social Psychiatry 42(2): 112–123.
Fischer J, Kumar S and Hatcher, S (2007) What makes psychiatry such a stressful profession? A qualitative study. Australasian Psychiatry 15(5): 417–421. Doi:101080/10398560701439699.
Fothergill A, Edwards D and Burnard P (2004) Stress, burnout, coping and stress management in psychiatrists: Findings from a systematic review. International Journal of Social Psychiatry 50(1): 54–65.
Franza F, Del Buono G and Pellegrino F (2015) Psychiatric caregiver stress: Clinical implications of compassion fatigue. Psychiatria Danubina 27(Suppl 1): S321–S327.
Gabel S (2010) The role of the clinical director: Self described strategies for success and satisfaction. Psychiatry Quarterly 81(4): 279–284. DOI:101007/s11126-010-9136-0.
Gabel S (2011) Addressing demoralization in clinical staff: A true test of leadership. Journal of Nervous & Mental Disorders 199(11): 892–895. DOI:101097/NMD0b013e3182349e79.
Gabel S (2012) Demoralization in mental health organizations: Leadership and social support help. Psychiatry Quarterly 83(4): 489–496. DOI:101007/s11126-012-9217-3.
Galeazzi GM, Delmonte S, Fakhoury W, et al. (2004) Morale of mental health professionals in Community Mental Health Services of a Northern Italian Province. Epidemiologia e Psichiatria Sociale 13(3): 191–197.
Korkeila JA, Toyry S, Kumpulainen K, et al. (2003) Burnout and self-perceived health among Finnish psychiatrists and child psychiatrists: A national survey. Scandinavian Journal of Public Health 31(2): 85–91. DOI:101080/14034940210133880.
Kumar S (2007) Burnout in psychiatrists. World Psychiatry 6(3), 186–189.
Kumar S (2011) Burnout and psychiatrists: What do we know and where to from here? Epidemiology & Psychiatric Sciences 20(4): 295–301.
Kumar S, Bhagat RN, Lau T, et al. (2006) Psychiatrists in New Zealand: Are they burning out, satisfied at work and, in any case, who cares? Australasian Psychiatry 14(1): 20–23. DOI:101111/j1440-1665200602244x.
Kumar S, Hatcher S, Dutu G, et al. (2011) Stresses experienced by psychiatrists and their role in burnout: A national follow-up study. International Journal of Social Psychiatry 57(2): 166–179. DOI:01177/0020764009341211.
Kumar S, Hatcher S and Huggard P (2005) Burnout in psychiatrists: An etiological model. International Journal of Psychiatry & Medicine 35(4): 405–416.
Kumar S, Sinha P and Dutu G (2013) Being satisfied at work does affect burnout among psychiatrists: A national follow-up study from New Zealand. International Journal of Social Psychiatry 59(5): 460–467. DOI:101177/0020764012440675.
Lasalvia A, Bonetto C, Bertani M, et al. (2009) Influence of perceived organisational factors on job burnout: Survey of community mental health staff. British Journal of Psychiatry 195(6), 537–544. DOI:101192/bjpbp108060871.
Oginska-Bulik N (2006) Occupational stress and its consequences in healthcare professionals: The role of type D personality. International Journal of Occupational Medicine & Environmental Health 19(2): 113–122.
Pejuskovic B, Lecic-Tosevski D and Priebe S (2011) Burnout in psychiatrists, general practitioners and surgeons. World Psychiatry 10(1): 78.
Pejuskovic B, Lecic-Tosevski D, Priebe S, et al. (2011) Burnout syndrome among physicians – The role of personality dimensions and coping strategies. Psychiatria Danubina 23(4): 389–395.
Priebe S, Fakhoury WK, Hoffmann K, et al. (2005) Morale and job perception of community mental health professionals in Berlin and London. Social Psychiatry & Psychiatric Epidemiology 40(3): 223–232. DOI:101007/s00127-005-0880-7.
Rossi A, Cetrano G, Pertile R, et al. (2012) Burnout, compassion fatigue, and compassion satisfaction among staff in community-based mental health services. Psychiatry Research 200(2–3): 933–938. DOI:101016/jpsychres201207029.
Thomsen S, Soares J, Nolan P, et al. (1999) Feelings of professional fulfilment and exhaustion in mental health personnel: The importance of organisational and individual factors. Psychotherapy & Psychosomatics 68(3): 157–164. DOI:12325.
Umene-Nakano W, Kato TA, Kikuchi S, et al. (2013) Nationwide survey of work environment, work-life balance and burnout among psychiatrists in Japan. PLoS One 8(2): e55189. DOI:101371/journalpone0055189.
Vicentic S, Gasic MJ, Milovanovic A, et al. (2013) Burnout, quality of life and emotional profile in general practitioners and psychiatrists. Work 45(1): 129–138. DOI:103233/wor-121484.
Volpe U, Luciano M, Palumbo C, et al. (2014) Risk of burnout among early career mental health professionals. Journal of Psychiatric & Mental Health Nursing 21(9): 774–781. DOI: 101111/jpm12137.
Sublingual Ketamine for Treatment-Resistant Depression
S Hyde
Private Practice, Launceston, Australia
Background: Given the poor response of many patients to our current therapies, I set out to explore the use of the novel agent ketamine for those with treatment-resistant depression.
Objectives: My aim was to establish whether low-dose sublingual ketamine would be safe and effective.
Methods: The process was discussed with my peer review group.
Patients suffering from major depression who had responded poorly or partially to a range of standard treatments were identified.
After detailed exploration of the known costs and benefits and giving signed consent, patients received a monitored test dose in my office and then took follow-up doses at home.
Findings: A total of 22 patients have had courses of treatment with a 70% response rate and a 40% remission rate in this difficult-to-treat group. Side effects have been tolerable and there have been no issues with dependence or diversion.
Conclusions: With appropriate patient selection and monitoring, sublingual ketamine is a safe and effective option for patients with treatment-resistant depression. It is a strategy all psychiatrists can use.
Access to Healthcare by Psychiatrists, Psychiatric Trainees and Overseas Trained Psychiatrists: Findings from the RANZCP Welfare Study
K Jenkins
Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
Objectives: This poster will present findings on the challenges faced by psychiatrists and psychiatry trainees in accessing healthcare using data from the Royal Australian and New Zealand College of Psychiatrists (RANZCP) welfare study.
Methods: In 2014, an online survey was distributed to all members (fellows, associates and affiliates) of the RANZCP and a number of focus groups were held across Australia and New Zealand. A total of 1051 members responded to the survey and nine focus groups were held.
Findings: Almost all respondents indicated they had a personal general practitioner. However, there were varying factors affecting access to healthcare and the ability to take leave when unwell. These factors can be classified into internal and external barriers and included lack of time, workload, a sense of ‘letting the team down’, stigma, confidentiality, mandatory reporting requirements and knowing where to seek care.
Conclusions: The survey demonstrated there are numerous barriers facing RANZCP members in looking after their own health. Addressing these barriers will require action at multiple points in the system.
Career Satisfaction and Work Stressors in Psychiatrists and Psychiatry Trainees in Australia and New Zealand
K Jenkins, S Rotstein
Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
Objectives: This poster will present an assessment of the level of career satisfaction and factors associated with work stress in members of the Royal Australian and New Zealand College of Psychiatrists (RANZCP).
Methods: In 2014, an online survey was distributed to members of the RANZCP (including psychiatrists and psychiatry trainees). A total of 1051 members responded to the survey.
Findings: Almost 85% of respondents indicated that they were satisfied with the work they were doing at the current stage of their career. ‘Too much work to do in too little time’ emerged as a key stressor and was ranked as the number one stressor in the last 12 months by over one third of respondents. Where applicable, examinations, prospect of revalidation and training hurdles were all noted to be moderately/extremely stressful by over 50% of respondents.
Conclusions: Although the majority of psychiatrists and trainees appear to be satisfied with their current work, there are many factors creating increased work stress and affecting welfare. The RANZCP has a role in protecting the welfare of its members and is implementing a series of recommendations as a result of the survey.
Development and Implementation of a Discharge Checklist for Psychiatric Inpatients
Y Khanbhai1, M Nance1,2
1Flinders Medical Centre, Adelaide, Australia
2Flinders University, Adelaide, Australia
Background: Readmission rates within psychiatry are a commonly measured treatment outcome which may be improved by careful discharge planning. Substantial research has shown checklists are an effective measure to augment care by serving as a prompt for often-overlooked steps in the treatment pathway, such as the process of discharge.
Objectives: The project aimed to develop an effective and efficient checklist to be employed upon the discharge of psychiatric inpatients. A secondary objective was to measure readmission rates and profiles.
Methods: The study used a quasi-experimental, non-randomized, pre and post-intervention design. The checklist was designed from an evidence-based literature review in consultation with clinicians and introduced for a 3-month trial period, comparing 28-day readmission rates with the previous 3 months.
Findings: Discharge checklists were completed for 80% of patients discharged in the trial period and demographic and clinical details for pre and post-intervention groups were closely aligned. There was a small and non-significant reduction in re-admission rates.
Conclusions: Evidence in the literature suggests that discharge checklists can be effective in improving discharge planning and reducing readmissions. The lack of a significant change in this study may reflect limitations of the checklist design or its implementation as checklists may be more effective when enforced as a contemporaneous tool. This study also took place in a rapidly changing clinical environment and an interrupted time series analysis might be more sensitive to performance changes.
Victorian Association of Psychiatry Trainees Written Exam Survey
R Khanna1,2, B Visa3, G Matta2
1The University of Melbourne and Austin Health, Melbourne, Australia
2Victorian Association of Psychiatry Trainees, Melbourne, Australia
3North Western Mental Health, Melbourne, Australia
Background: The Victorian Association of Psychiatry Trainees (VAPT) surveyed the Royal Australian and New Zealand College of Psychiatrists (RANZCP) trainees who attempted the February 2016 written examinations following the recent poor pass rates.
Objectives: To benchmark trainee preparation for the written exams. To examine if the pass rates reflect prior experience in psychiatry, establish which types of exam preparation are most effective for trainees and get an indication of trainees’ perceptions of well-being and the financial costs of preparation.
Methods: A web-based survey was sent to RANZCP trainees. Responses were correlated with exam outcome and analysed using SPSS Statistics 23.
Findings: A total of 30% of the cohort responded to the survey. Trainees studied for an average of 7.75 months for the essay exam and 4.4 months for multiple choice question exam. The mean months of total psychiatry experience prior to sitting was 36.1 months. Trainees who believed that study preparation would affect outcome were more likely to pass (p = 0.029). Ratings of well-being before the release of results were also positively associated (p = 0.046) with passing. Study duration or intensity was not significantly associated with results.
Conclusions: Trainees were found to be sitting the written exams with experience commensurate with RANZCP recommendations. Although our small numbers limit our ability to give firm recommendations on preparation, it seems that favourable perceptions of the exam process are predictors of success. Our survey provides research-derived norms of study behaviour in postgraduate medical training, which have not often been described.
Methylphenidate in the Treatment of an Adolescent Female with Obsessive–Compulsive Disorder and Attention-Deficit Hyperactivity Disorder: A Case Report
J King1,2, N Dowling1,2, F Leow3
1Professorial Unit, The Melbourne Clinic, Melbourne, Australia
2The University of Melbourne, Melbourne, Australia
3Royal Melbourne Hospital, Melbourne, Australia
Background: Attention-deficit hyperactivity disorder (ADHD) and obsessive–compulsive disorder (OCD) are relatively common neuropsychiatric disorders with respective prevalence rates of 2.5–4% and 2.3%, though their co-occurrence has raised questions about their diagnoses and treatment (Abramovitch et al., 2012). Given the substantial variability in prevalence rates of ADHD-OCD comorbidity, ranging from 0% to 60% in some studies (Abramovitch et al., 2013), it is questioned whether their co-occurrence is genuine, or an artefact of ADHD-like symptoms (i.e. behavioural and /or neuropsychological impairments) being apparent due to the executive system being overloaded by OCD-specific symptoms (Abramovitch et al., 2015). Others have suggested that ADHD–OCD represents a distinct condition or subtype which leads to greater functional impairment (Geller et al., 2000) and a poorer prognosis (Granados and Riddle, 2008). While stimulant medication is regarded first-line treatment for ADHD, its use is cautioned in OCD given the potential to exacerbate symptoms (Kouris 1998). Thus, the effective treatment and management of this complex comorbidity remains unclear.
Objectives: We argue that there may be neurobiological connections between the two disorders. We highlight the neurobiological implications and clinical benefit of stimulant treatment on OCD prognosis in a patient with comorbid ADHD-OCD, through a detailed case history and discussion of the relevant literature.
Methods: We describe a case whereby a 15-year-old female with treatment-resistant OCD was treated with methylphenidate for comorbid ADHD. We describe the patient’s treatment history in detail, progress and measurement of OCD symptoms through the Yale-Brown Obsessive-Compulsive Scale (YBOCS) before and after methylphenidate.
Findings: In this case, we observed that the adjunctive use of methylphenidate resulted in enhanced treatment response to both psychological and pharmacological interventions for OCD.
Conclusions: This case highlights the need to identify and treat comorbid ADHD in OCD cases where progress has stalled.
References
Abramovitch A, Dar R, Hermesh H, et al. (2012) Comparative neuropsychology of adult obsessive-compulsive disorder and attention deficit/hyperactivity disorder: Implications for a novel executive overload model of OCD. Journal of Neuropsychology 6: 161–191.
Abramovitch A, Dar R, Mittleman A, et al. (2013) Don’t judge a book by its cover: ADHD-like symptoms in obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders 2: 53–61.
Abramovitch A, Dar R, Mittelman A, et al. (2015) Comorbidity between attention deficit/hyperactivity disorder and obsessive-compulsive disorder across the lifespan: A systematic and critical review. Harvard Review of Psychiatry 23: 245–262.
Geller D, Biederman J, Faraone SV, et al. (2000) Clinical correlates of obsessive compulsive disorder in children and adolescents referred to specialised and non-specialised clinical settings. Depression and Anxiety 11: 163–168.
Granados M and Riddle M (2008) Do all obsessive-compulsive disorder subtypes respond to medication? International Review of Psychiatry 20: 189–193.
Kouris S (1998) Methylphenidate-induced obsessive-compulsiveness. Journal of the American Academy of Child and Adolescent Psychiatry 37: 135.
Let’s Set a Fire!
X Lan, V Stanganelli, M Yiallourides, B Hansen, B Zelenka, S Spillman, L England, D Stehbens, M Gingell, C Lawson, N France, C Duncan
Child and Youth Mental Health Service, Queensland Health, Brisbane, Australia
Background: Fire setting poses devastating and costly risks to the community among adolescents in rural Australia.
Objectives: The aim of this paper is to share our intense multidisciplinary approach around an adolescent with multiple complexities.
Methods: Richard is a 14-year-old Indigenous boy raised by a single mother, not enrolled to school or engaged in any employment. He was charged with arson but placed under a forensic disability order due to temporary unfitness when 10 years of age. He was part of a gang who severely damaged a shopping centre. Since then, he has been followed by numerous stakeholders including Children and Adolescents Mental Health, Disability Services, Child Safety, Indigenous community and Non-Governmental Organization. After 6 years, he set a new fire, again in the context of progressive behavioural deterioration after his sister moved in with her baby. His enuresis, cruelty with animals, violence towards his nephew and property increased. Given his risks, he was placed under an involuntary treatment order (inpatient order) to fully assess him.
Findings: Paediatricians found short stature and delayed sexual development. His immature brain with ADHD, low IQ as well as attachment disorder led to poor mood regulation and impulse control.
From a psychological point of view, he was thought to be facing accumulative stressors that re-enacted his history of perceived abandonment, rejection and criticism. His family dynamics did not allow him to establish secure attachment.
Conclusions: Our multidisciplinary treatment, including Mentor Indigenous worker and family-based attachment therapy facilitated his improvement, avoiding imprisonment.
References
Muller DA and Stebbins A (2007) Trends & Issues in Crime and Criminal Justice No. 335. Canberra: Australian Institute of Criminology.
Putnam CT and Kirkpatrick JT (2005) Juvenile Justine Bulletine, May 2005
Gannon TA and Pina A (2010). Firesetting: Psychopathology, theory and treatment. Aggression and Violent Behavior 15: 224–238.
A Novel Approach to Psychological Well-Being and Resilience in Medical Students: Applying the Perma Framework
R Lindell-Innes, M Nguyen, M Baigent
Flinders University, Adelaide, Australia
Background: Medical students have long been known to report significant rates of mental illness, substance abuse and suicide (Guthrie et al., 1998). Previous research conducted at Flinders Medical School has found that certain stressors in the curriculum expose students to immense psychological distress. However, in reality, mental distress in medicine falls on a spectrum. A large proportion of students are happy and motivated, with only a small percentage struggling to cope and progressing to clinically diagnosable mental illness and impairment. This poses the question: Why is it that some students are more prone to mental illness than others?
The ability of some students to be impervious to significant stressors – termed ‘resilience’ – has attracted growing interest. The literature suggests that resilience can be broken down into several key themes, which cause an individual to survive psychological distress: positive emotions, engagement, relationships, meaning and accomplishment – termed ‘PERMA’ (Seligman and Csikszentmihalyi, 2000).
Objectives: This study aimed to measure the PERMA principles in Flinders medical students, devise an appropriate curriculum intervention to target areas of weakness and increase student well-being.
Methods: This study adapted a validated resilience measurement tool – termed ‘PERMA Profiler’ (Butler and Kern, 2013) – to monitor these PERMA themes and overall well-being of 227 medical students at Flinders University.
Findings: It was found that on average, students were significantly lacking in both positive emotions and positive relationships compared to a matched age group.
Conclusions: The data will be used to inform curriculum interventions in the field of medical education to target these areas, with a view to improve the psychological resilience of medical students.
References
Butler J and Kern ML (2016) The PERMA-Profiler: A brief multidimensional measure of flourishing. International Journal of Wellbeing 6(3).
Guthrie E, Black D, Bagalkote H, et al. (1998). Psychological stress and burnout in medical students: A five-year prospective longitudinal study. Journal of the Royal Society of Medicine 91(5): 237–243.
Seligman ME and Csikszentmihalyi M (2014). Positive psychology: An introduction. The Netherlands: Springer, pp. 279–298.
Improving Rates of Metabolic Monitoring on an Inpatient Psychiatric Ward
S Michael1, K MacDonald2
1St Vincent’s Hospital, Sydney, Australia
2Wollongoing Hospital, Wollongong, Australia
Background: People suffering with a severe mental illness have an average life expectancy 16 years below the general population (Lawrence et al., 2013). Cardiovascular disease is the leading cause of death in this group, and patients with severe mental illness are at much higher risk of developing metabolic syndrome (Bobes et al., 2007; De Hart et al., 2006).
Most psychiatrists do not routinely perform metabolic monitoring. Barriers include lack of knowledge, no clear protocols, lack of equipment and lack of time (Laugharne et al., 2016). On our ward, we also found the high rate of junior doctor turnover prohibitive to routine monitoring.
Objectives: We report on a quality improvement activity on an acute inpatient psychiatric ward, which aimed to increase rates of metabolic monitoring to at least 80% of eligible patients.
Methods: A multidisciplinary working party was established, and process mapping helped establish opportunities for intervention.
First, education was provided to all disciplines. Second, a nurse-led process was developed, where nurses ordered and performed testing, ensured completion and alerted doctors to abnormal or incomplete results. Ongoing links were built with other services in the hospital to promote metabolic health on the ward. Finally, consumers were involved through regular meetings to explain the changes and canvas feedback.
A file audit of compliance was performed before intervention and 12 months after.
Findings: Results show a significant increase in testing of all metabolic parameters, with a profound shift in ward culture towards prioritization of metabolic health.
Conclusions: Our results confirm that metabolic monitoring can be easily performed in a busy mental health ward through a nurse-led process with no additional funding and is acceptable to both staff and patients alike.
References
Bobes J, Arango C, Aranda P, et al. (2007) Cardiovascular and metabolic risk in outpatients with schizophrenia treated with antipsychotics: Results of the CLAMORS Study. Schizophrenia Research 90(1): 162–173.
De Hart MA, Van Winkel R, Van Eyck D, et al. (2006) Prevalence of the metabolic syndrome in patients with schizophrenia treated with antipsychotic medication. Schizophrenia Research 83(1): 87–93.
Laugharne J, Waterreus AJ, Castle DJ, et al. (2016) Screening for the metabolic syndrome in Australia: A national survey of psychiatrists’ attitudes and reported practice in patients prescribed antipsychotic drugs. Australian and New Zealand Journal of Psychiatry 42(1): 62–66.
Lawrence D, Hancock KJ and Kisely S (2013) The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: Retrospective analysis of population based registers. British Medical Journal 346: 125–139.
Fluoxetine for Maintenance of Remission and to Improve Quality of Life in Patients with Crohn’s Disease: A Pilot Randomized Placebo-Controlled Trial
A Mikocka-Walus1,2,3, P Hughes4,5, P Bampton6, A Gordon1, M Campaniello4,5, C Mavrangelos4,5, B Stewart3, A Esterman1,7, J Andrews8,9
1School of Nursing and Midwifery, The University of South Australia, Adelaide, Australia
2Department of Health Sciences, University of York, York, UK
3School of Psychology, University of Adelaide, Adelaide, Australia
4Centre for Nutrition and Gastrointestinal Diseases, School of Medicine, The University of Adelaide, Adelaide, Australia
5South Australian Health and Medical Research Institute (SAHMRI), Adelaide Australia
6Department of Gastroenterology and Hepatology, Flinders Medical Centre, Adelaide, Australia
7Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Australia
8Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
9School of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, Australia
Background: Previous studies have shown that antidepressants reduce inflammation in animal models of colitis.
Objectives: The present trial aimed to examine whether fluoxetine added to standard therapy for Crohn’s disease (CD) maintained remission, improved quality of life and/or mental health in people with CD as compared to placebo.
Methods: A parallel randomized double-blind placebo controlled trial was conducted. Participants with clinically established CD, with quiescent or only mild disease, were randomly assigned to receive either fluoxetine 20 mg daily or placebo and followed for 12 months. Participants provided blood and stool samples and completed mental health and quality of life (QoL) questionnaires. Immune functions were assessed by stimulated cytokine secretion (CD3/CD28 stimulation) and flow cytometry for cell type. Linear mixed-effects models were used to compare groups.
Findings: Of the 26 participants, 14 were randomized to receive fluoxetine and 12 to placebo. Overall, 14 (54%) participants were male. The mean age was 37.4 (standard deviation (SD) = 13.2) years. Fluoxetine had no effect on CD activity measured using either Crohn’s Disease Activity Index (F(3, 27.5) = 0.064, p = 0.978) or faecal calprotectin (FC) (F(3, 32.5) = 1.08, p = 0.371) but did have modest effects on immune function. There was no effect of fluoxetine on physical, psychological, social or environmental QoL, anxiety or depressive symptoms as compared to placebo (all p > 0.05).
Conclusions: In this small pilot clinical trial, fluoxetine was not superior to placebo in maintaining remission of CD or improving QoL.
(ID: ACTRN12612001067864)
Suggestions for Use of a Recently Published Table Which Assists in Prescribing for Patients with Special Dietary Requirements
M Murphy1,2, H Begg1,2
1Clinical Research Unit for Anxiety and Depression, St Vincent’s Hospital, Sydney, Australia
2The University of New South Wales, Sydney, Australia
Background: Nearly 20% of Australians identify with having a food avoidance (Australian Bureau of Statistics, 2014): either for religious reasons (Islam, Judaism and Hinduism), medical grounds (lactose/gluten intolerance) or ethical/personal reasons (vegan and/or vegetarianism). Accordingly, some patients wish to have the dietetic component of their medications included in the decision-making process. Psychiatrists’ engagement with this new dimension in prescribing is increasingly vital to promote consumer engagement. There is a lack of detail available to clinicians/patients regarding the suitability of mental health medications for people with dietary restrictions. Ethical concerns arise from this lack of information (Eriksson et al., 2013; Vissamsetti et al., 2012). The authors produced a quick reference table of the most commonly used mental health medications to assist.
Objectives – learn about the table: A background to the table will be provided. The most commonly prescribed Pharmaceutical Benefits Scheme (PBS) psychiatric medications are identified.
Findings of the research: The data demonstrate that 83% (i.e. 19 of the 23) of mental health medications listed contain animal products, common excipients including gelatine, animal-derived magnesium stearate, glycerol and lactose; and 30% contained gluten and 78% included lactose.
Methods for incorporating into clinical practice: Some short vignettes will be presented showing use of the table to assist in practice. It will be endeavoured to show differences in the decision-making.
Conclusions: Psychiatrists are unlikely to be aware of the level of animal products, gluten and lactose in commonly prescribed medications. The table is a tool to empower both psychiatrist and patient. Limitations are discussed.
Selected proprietary mental health medications.
Medication class (Medication trade name followed by generic name)
Explanation of the terms used and manufacturer’s response to the listed preparation:
“✓” conforms to the above descriptor
“x” does not conform to the above descriptor
“?” unclear or the preparation is produced in a factory which also manufacturers products containing the item of concern.
Uncertainty regarding the 0.5 mg tablet preparation and meat product content.
Animal-derived contents: contents of medications produced directly from an animal such as gelatine.
Animal products: components derived from animal by-products such as lactose from milk.
References
Australian Bureau of Statistics (2014) Australian Health Survey: Nutrition First Results. Foods and Nutrients 2011–12. Canberra, Australia: Australian Bureau of Statistics, p. 6.
Eriksson A, Burcharth J and Rosenberg, J (2013) Animal derived products may conflict with religious patients’ beliefs. BMC Med Ethics 14: 48. https://bmcmedethics.biomedcentral.com/
Vissamsetti B, Payne M and Payne S (2012) Inadvertent prescription of gelatin-containing oral medication: Its acceptability to patients. Postgraduate Medical Journal 88: 499–502.
Relationships between Clinical Scales (Clinical Global Impressions and the Yale–Brown Obsessive Compulsive Scale Modified for Binge Eating) and Binge Eating Days in Adults with Moderate to Severe Binge Eating Disorder in Two Phase 3 Studies
N Naser1, L Citrome2, J Kando3, C Bliss3, B Herman3
1Shire Australia Pty Limited, Sydney, Australia
2New York Medical College, New York, USA
3Shire, Lexington, USA
Objectives: To understand the clinical significance of relationships between clinical observations and clinical rating scales in individuals with binge eating disorder (BED).
Methods: Two 12-week, double-blind, placebo-controlled studies randomized adults with Diagnostic and Statistical Manual of Mental Disorders, fourth edition-TR-defined BED of protocol-defined moderate to severe severity (>3 binge eating (BE) days/week for 2 consecutive weeks and Clinical Global Impressions–Severity (CGI–S) scores ⩾4) to placebo or dose-optimized LDX (50 mg or 70 mg). Assessments included the number of BE days/week, CGI–S and CGI–Improvement (CGI–I) scores, and Yale–Brown Obsessive Compulsive Scale Modified for Binge Eating (Y–BOCS–BE) total scores. For these post hoc analyses, data were pooled across studies and treatment arms. Statistical assessments included Spearman correlations and equipercentile linking analyses (ELA). Reported p values are descriptive and not adjusted for multiplicity.
Results: At baseline, nominally significant correlations with CGI–S scores were reported for BE days/week and Y–BOCS–BE total scores (both p < 0.001). Baseline ELA further characterized the positive relationship between CGI–S and BE days/week and the Y–BOCS–BE. Nominally significant correlations with CGI–I scores were reported for changes from baseline at study endpoint for BE days/week and Y–BOCS–BE total scores (both p < 0.001). ELA for the CGI–I scores at study endpoint further characterized the positive relationship between CGI–I and changes from baseline in BE days/week and Y–BOCS–BE total score.
Conclusions: These post hoc analyses from two phase 3 studies indicate that indices of global disease severity and improvement positively correlate with BE behaviour and with the obsessive and compulsive features of BED as measured with the Y–BOCS–BE.
Evaluation of Cognitive Screening of Older People Admitted to Mackay Base Hospital
A Rana, P Ho, S Sinha
Mackay Hospital and Health Service, Mackay Base Hospital, Mackay, Australia
Background: Dementia, as the fourth leading cause of death in 2007 per the Australian Bureau of Statistics, is considered to be a significant illness that affects the physical, mental, social and economic aspects of an individual. Early identification, timely diagnosis, better care and coordination of services are required to improve the quality of life.
Objectives: To determine the prevalence of cognitive impairment in the older persons’ population in a general hospital to aid timely diagnosis of dementia and determine the effect on length of stay in hospital due to cognitive impairment.
Methods: Data from a total of 100 patients were taken from November 2015 from the general medical and rehabilitation ward in Mackay Base Hospital retrospectively. The results were categorized by demographics, reason for admission, residence prior to admission, availability of carers, known diagnosis of dementia and average length of stay.
Results: Two-thirds of the patients were male, European and older than the age of 75 years. The majority of patients were admitted due to vascular causes, followed by infection and falls. Most patients lived at home prior to admission and <1/2 had carers support. Only 25% were known to suffer from dementia prior to admission. The length of stay largely varied from 1 to 71 days with the average of 8.21days.
Conclusions: Based on these preliminary results, the lack of support and awareness of this illness is evident. The alarmingly low percentage of patients known to suffer from dementia may suggest the lack of clinical acuity and need for proper development of tools for early diagnosis.
Evaluation of Spring and Autumn School of Psychiatry in Peninsula Deanery, United Kingdom
A Rana1, M Tremaine2, M Zikri2
1Mackay Hospital and Health Service, Mackay Base Hospital, Mackay, Australia
2Devon Partnership NHS Trust, Devon, UK
Background: Recruitment into psychiatry has become a perennial problem for the speciality, recently worsened by the decreasing numbers of foundation doctors choosing to apply to speciality training.
In 2015, only 66% of core psychiatry training posts were filled at round one, the lowest of any speciality. The Peninsula deanery had the lowest recruitment from foundation training to any medical speciality (including general practitioner) at 41%. This is nearly two standard deviations below the national mean of 53%. This mean itself has steadily dropped since 2011 when the proportion was 71%.
Aims and hypothesis: To improve the numbers of doctors choosing to train in psychiatry in the Peninsula locality by organizing a bi-annual recruitment event aimed at medical students and junior doctors.
Methods: We hosted two events running from midday to early evening to maximize attendance. The events consisted of interactive talks from psychiatrists, trainees and individuals with lived experience of mental illness. We advertised this event widely within the medical and foundation schools using email and posters, as well as involving the local undergraduate psychiatry society.
Results: There has been a decrease in attendance to this event from the first event in 2014 to the most recent event in Autumn 2015. Two individuals have stated their intention to apply for Core Psychiatric Training, with a number of others expressing an interest in having a psychiatry placement during their foundation training.
Conclusions: We feel that more tenacious and inventive methods of attracting doctors and prospective doctors to the speciality are needed. With this in mind, we intend to combine our event with ‘Medfest’: an evening where films with a psychiatry theme are shown with pizza provided! We are also considering outreach to local sixth form colleges.
Evaluation of Paliperidone Palmitate Long-Acting Injectable Therapy by Duration of Illness in Patients with Schizophrenia
B Brown1, I Turkoz2, B Mancevski1, M Mathews2 (presenter: K Reeve-Parker3)
1Janssen Scientific Affairs, LLC, Titusville, USA
2Janssen Research and Development, LLC, Titusville, USA
3Janssen Medical and Scientific Affairs, Sydney, Australia
Background: Using long-acting injectable (LAI) antipsychotics earlier in schizophrenia may delay functional deterioration.
Objectives: To evaluate paliperidone palmitate (PP) LAI therapy in patients with schizophrenia by duration of illness.
Methods: Post hoc analysis of a randomized, double-blind (DB), parallel-group, non-inferiority study (NCT01515423). Participants with schizophrenia were treated with PP once-monthly (PP1M) in a 17-week open-label (OL) phase. Upon meeting clinical stabilization criteria, participants were randomized 1:1 to PP1M or PP 3-monthly (PP3M) in a 48-week relapse-prevention phase and evaluated based on duration of illness (⩽5, 6–10, and >10 years since diagnosis); PP1M and PP3M results were combined. The Positive and Negative Syndrome Scale (PANSS) and the Personal and Social Performance (PSP) Scale scores and functional remission rates (PSP > 70 from week 13 (OL) and during the DB phase for ⩾ 6months) were analysed. No adjustment was made for multiplicity.
Findings: Participants (532, 337 and 558) diagnosed with schizophrenia at ⩽5, 6–10, and >10 years ago, respectively, entered the OL phase. Of these, 379 (71.2%), 235 (69.7%) and 380 (68.1%), respectively, met clinical stabilization criteria and entered the DB phase. Significant differences were observed in the ⩽5 and 6–10 groups versus the >10 years from diagnosis group, from DB baseline to DB endpoint for the PANSS and PSP total scores (p < 0.03 for all). More patients achieved functional remission in the ⩽5 (26.4%) and the 6–10 (30.2%) years groups versus the >10 years group (18.6%).
Conclusions: Improvements were observed with PP LAIs in all subgroups, with greater improvements among patients earlier in the illness (<5 or 5-10 years) compared to those with more chronic illness (>10 years).
Switching Scenarios for Paliperidone Palmitate 3-Month Formulation in Schizophrenia: A Population Pharmacokinetic Simulation-Based Evaluation
S Gopal1, A Vermeulen2, P Nandy1, P Ravenstijn2, I Nuamah1, J Vidal1, J Berwaerts1, A Savitz1, D Hough1, M Samtani1, A Russu2 (presenter: K Reeve-Parker3)
1Janssen Research & Development, LLC, New Jersey, USA
2Janssen Research & Development, A Division of Janssen Pharmaceutica NV, Beerse, Belgium
3Janssen Medical & Scientific Affairs, Sydney, Australia
Background: Treatment switching for paliperidone palmitate 3-monthly (PP3M) was evaluated using population pharmacokinetic (POP-PK)-based simulations.
Methods: The POP-PK models for paliperidone extended release (pali-ER), PP once-monthly (PP1M) and PP3M were used to simulate predefined dosing regimens. Treatment was initiated with PP1M at 150 mg on day 1 (deltoid) and at 100 mg on day 8 (deltoid), followed by three PP1M injections at one of 4 dose levels (50, 75, 100 or 150 mg) at weeks 5, 9 and 13, in the same injection site (deltoid or gluteal). Maintenance treatment started on week 17 with either 4-weekly deltoid or gluteal PP1M injections or 12-weekly deltoid or gluteal PP3M injections at 3.5-fold dose multiple of the last PP1M injection (i.e. 175, 263, 350 or 525 mg). After stabilization on PP3M (week 65), return to PP1M or pali-ER treatment was simulated. Results were plotted as population median and 90% prediction interval of concentration–time profiles.
Findings: Paliperidone plasma exposures after switching to PP3M were similar to the corresponding doses of PP1M (50–150 mg, 4-weekly) or pali-ER (4–12 mg, daily). The interpatient variability after multiple injections of PP3M was higher compared to the variability observed for PP1M (3-month) and similar to the pali-ER. Similar paliperidone plasma exposures were obtained when patients at an apparent steady-state for PP3M (after four doses) were switched back to PP1M.
Conclusions: After switching to PP3M, the observed paliperidone plasma exposures were similar to PP1M and pali-ER and variability was also similar for PP3M and pali-ER.
Early Intervention in Cerebellar Cognitive Affective Syndrome
O Rodriguez, B Young, T Butson, R Sekhon
Gold Coast Mental Health, Brisbane, Australia
Background/Objectives: Cerebellar cognitive affective syndrome (CCAS) is a condition that arises from cerebellar lesions. CCAS can be overlooked easily by medical teams; therefore, a bibliographic review will facilitate the understanding of symptoms to effectively diagnose and provide a holistic early treatment approach.
Methods: A case report of a 72-year-old woman with bilateral cerebellar lesions with high pre-morbid function presented with classic symptoms of CCAS.
Multidisciplinary workup included medical, psychiatric, neuropsychological assessment (R-BANS (Form 1), Digit Span, Verbal fluency tests, the Hayling Test and the Delis–Kaplan Executive Function System) as well as other investigations (neuroimaging and blood tests) were conducted on the patient to confirm CCAS and to exclude other differential diagnoses.
Results: The results from the medical assessments conducted showed symptoms of cerebellar dysfunction. A psychiatric and neuropsychological review revealed aggression, irritability, disinhibition, deterioration in cognitive function and personality changes. A multidisciplinary team was formed to rehabilitate the patient; however, the patient was non-compliant with therapy. The patient was prescribed Seroquel 50 XR and she responded well to the medication.
Conclusions: This case review illustrates the challenges associated with engaging a CCAS patient in rehabilitation activities due to cognitive and mood disorders. The use of psychotropic medications can be an effective method in improving cognition and mood disorders in CCAS patients. Early psychiatry and psychological intervention can significantly improve the overall outcome of a patient diagnosed with CCAS.
Role of Physical Activity in Closing the Life Expectancy Gap of People with Mental Illness
S Rosenbaum1,2,3, K Davison1,4, A Hobson-Powell1, P Ward2
1Exercise & Sports Science Australia, Brisbane, Australia
2The University of New South Wales, Sydney, Australia
3Black Dog Institute, Sydney, Australia
4The University of South Australia, Adelaide, Australia
Background: People experiencing mental illness are at high risk of poor lifestyle factors such as physical inactivity, which contributes to a 15- to 25-year gap in life expectancy.
Objectives: We aimed to develop an international consensus statement on behalf of Exercise Sports Science Australia (ESSA), the American College of Sports Medicine (ACSM), Sport and Exercise Science New Zealand (SESNZ) and the British Association of Sport and Exercise Science (BASES) on the role of exercise interventions as a key component of a global strategy towards achieving a 50% reduction in the life expectancy gap of people experiencing mental illness by 2032.
Methods: The statement was sent to all signatory organizations for review and endorsement.
Findings and conclusions: The organizations that endorse this consensus statement commit to promoting the role of exercise interventions as a key component of a global strategy towards achieving a 50% reduction in the life expectancy gap of people experiencing mental illness by 2032. We believe that enhanced training of our members, facilitating culture change within mental health services and advocating for the provision of required infrastructure are the cornerstones of achieving this goal.
Developing a Metformin Prescribing Tool for Use in Adults with Mental Illness to Reduce Medication-Related Weight Gain and Cardiovascular Risk
C Smith1, H Myles2,3, C Galletly1,3,4
1Northern Adelaide Local Health Network, Adelaide, Australia
2Country Health South Australia, Mental Health, Adelaide, Australia
3The University of Adelaide, Adelaide, Australia
4Ramsay Health South Australia, Adelaide, Australia
Background: There is considerable evidence that metformin reduces weight gain and cardiovascular risk associated with antipsychotic medication. No local tools exist that solely assist with prescribing metformin to reduce cardiometabolic risk in adults with mental illness.
Objectives: Our aim was to develop an easy-to-use metformin prescribing tool, to enable mental health clinicians to prescribe metformin more safely and confidently.
Methods: The authors undertook a survey of clinicians and reviewed the published literature and existing guidelines concerning the use of metformin to reduce cardiometabolic risk in adults with mental illness.
Findings: A metformin prescribing tool was devised based on the literature, national cardiovascular and diabetes guidelines and Australian metformin-prescribing recommendations. The metformin-prescribing tool guides clinicians through the considerations required for the appropriate selection of the target patient population and safe prescription of metformin.
Conclusions: We have developed a novel, easy-to-use, one-page reference for busy clinicians that can be laminated and displayed in consulting rooms and psychiatric inpatient units to address the rise in cardiometabolic risk in people with mental illness.
Common Mental Disorders and Recent Physical Activity Status: Findings from a National Community Survey
S Suetani1,2,3, S Saha1,2,3, A Milad4, E Eakin4, J Scott2,5,6, J McGrath2,3
1School of Medicine, The University of Queensland, Brisbane, Australia
2Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Brisbane, Australia
3Queensland Brain Institute, The University of Queensland, Brisbane, Australia
4School of Public Health, The University of Queensland, Brisbane, Australia
5The University of Queensland Centre for Clinical Research, University of Queensland, Brisbane, Australia
6Metro North Mental Health, Royal Brisbane and Women’s Hospital, Brisbane, Australia
Background: Individuals with common mental disorders are at an increased risk of physical comorbidity and premature mortality. There is accumulating evidence to suggest that increased physical activity (PA) is associated with improved physical condition.
Objectives: To explore the association between lifetime histories of common mental disorders, delusional-like experiences and recent PA.
Methods: The study was based on the Australian National Survey of Mental Health and Wellbeing 2007 (n = 8841). The Composite International Diagnostic Interview was used to identify a lifetime and past-year history of common mental disorders and delusional-like experiences. The PA over the preceding week was estimated using the questions based on the Active Australia survey with respondents classified as either insufficiently physically active or sufficiently physically active based on national recommendations. We examined the relationship between the variables of interest using logistic regression, adjusting for potential confounding factors.
Findings: Almost half of the participants (46.0%) were classified as sufficiently physically active. Compared to those with no past mental disorder, those with lifetime or past-year history of common mental disorders did not differ on recent PA status. Furthermore, we found no significant association between the number of lifetime mental disorders or presence of delusional-like experience and recent PA status.
Conclusions: Our findings suggest that a diagnosis of common mental disorder, with or without recent symptoms and comorbid diagnoses, or even having self-ascribed perception of poor mental well-being, is not associated with insufficient PA.
First Steps to Dementia-Friendliness: A Proposed Scoping Phase Study of Resources and Needs in a Sub-Acute Ward
L Teoh
Department of Psychological Medicine, Tan Tock Seng Hospital, Singapore, Singapore
Background: Dementia Friendly Communities (DFCs) are needed to proactively enable and support persons living with dementia (Lin and Lewis 2015). Our psychogeriatric consultation liaison team will be a key driver of dementia-friendliness in our hospital, especially for inpatients who have dementia.
This significant undertaking needs to begin with a detailed needs analysis of our work setting. Our multidisciplinary team looks after persons with dementia in a 33-bed sub-acute medical ward. Distressed behaviour, specifically agitation, is the most common psychiatric need encountered.
We have begun by formulating our community-specific definition of a DFC. We propose our DFC is
A community which supports persons with dementia by using a holistic care approach, that recognizes each person’s unique identity, abilities and needs. It actively promotes a sense of well-being in both our persons with dementia and their caregivers.
Objectives and methods: A detailed proposal for a scoping study of our existing dementia care resources and needs will be presented. The study domains are aligned to key foci identified for four out of five of the United Kingdom Local Government Association’s DFC framework (Local Government Association, 2012). These are ‘the Place’, ‘the Person with dementia’, ‘the People’ and ‘the Networks’.
Areas of special focus include orientation and way-finding, asset-based approaches to care, maintaining inclusive and collaborative relationships with family caregivers and the formation of networks to drive dementia-friendliness.
Mixed methodology will be used to involve a diverse range of stakeholders. We will take particular efforts to facilitate the involvement of persons with dementia using participatory research approaches (Aldridge, 2015).
References
Aldridge J (2015) Participatory Research: Working with Vulnerable Groups in Research and Practice. Bristol, United Kingdom: Policy Press.
Lin S and Lewis FM (2015) Dementia friendly, dementia capable, and dementia positive: Concepts to prepare for the future. Gerontologist 2015(2): 237.
Local Government Association (2012) Developing Dementia-Friendly Communities – Learning and Guidance for Local Authorities. London, United Kingdom: Local Government Association.
Burden and Coping in Singaporean Family Caregivers of Persons with Dementia who Have Distressed Behaviour
L Teoh1, B Seng2, A Ang1, H Rahman1
1Tan Tock Seng Hospital, Singapore, Malaysia
2SIM University, Singapore, Malaysia
Background: Caring for a person with dementia who has distressed behaviour is associated with poorer caregiver health, increased care costs and risk of institutionalization (Etters et al., 2008; Papastavrou et al., 2007).
Objectives: To measure the degree of burden experienced by family caregivers of persons with dementia who experience distressed behaviour and identify personal and caregiving-related factors, and coping strategies associated with clinically significant burden.
Methods: Between May 2013 and June 2014, family caregivers attending the outpatient psychiatry clinic voluntarily completed an anonymous survey which included background information on the caregiver and person with dementia and self-reported scales (Revised Memory and Behaviour Problems Checklist (RMBPC); Zarit Burden Interview (ZBI); General Health Questionnaire (GHQ-28) and Brief Coping Orientations to Problems Experienced (COPE) Inventory).
Findings: The 41 caregivers were mainly female (73.17%, n = 30), mean age 53.63 ± 12.47 years and over half were married. Most (67.50%, n = 27) were in paid employment and 77.5% (n = 31) had provided care for over 3 years. Significantly, 73% (n = 30) never attended educational or support sessions.
Most (66%, n = 27) of caregivers reported clinically significant burden (ZBI score of 24 to 88 inclusive). These caregivers had significantly higher GHQ-28 scores (p = 0.0394), were more highly educated (p = 0.026) and had never utilized caregiver support services (p = 0.040) previously. They were more likely to be behaviourally disengaged (p = 0.0246). They tended to ventilate (p = 0.0211), plan (p = 0.0223) and use humour (p = 0.0247) as coping mechanisms.
Conclusions: Caregiving is a holistic challenge managed concurrently with major life roles. Multicomponent support interventions are needed to address the diverse physical and psychological demands of caregiving (Gitlin et al., 2003).
References
Etters L, Goodall D and Harrison BE (2008) Caregiver burden among dementia patient caregivers: A review of the literature. J Am Acad Nurse Pract 20(8): 423–428.
Gitlin LN, Belle SH, Burgio LD, et al. (2003) Effect of multicomponent interventions on caregiver burden and depression: The REACH multisite initiative at 6-month follow-up. Psychol Aging 18(3): 361.
Papastavrou E, Kalokerinou A, Papacostas SS, et al. (2007) Caring for a relative with dementia: Family caregiver burden. J Adv Nurs 58(5): 446–457.
The Psychiatry Interest Forum: A Success Story for the College
M Tomasic, M Hopwood, A Willis, P Hay, DB Menkes, G Byrne, K Jenkins
Recruitment into Psychiatry Working Party, The Royal Australian and New Zealand College of Psychiatrists, Melbourne, Australia
Background: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) Psychiatry Interest Forum (PIF) was first launched in September 2013 with 208 members and the current membership has now grown to over 1800. The membership is made up of medical students, junior doctors and other medical practitioners from Australia and New Zealand (NZ).
Objectives: The primary objectives of the PIF are to foster interest in psychiatry as a career, challenge common misconceptions and to increase applications to the RANZCP training program.
Methods: Review, collate and analyse membership date, attendance records for PIF activities from September 2013 to December 2016. Qualitative feedback will also be included from interviews with branch staff, fellows and trainees involved in PIF activities.
Findings: Over the past 4 years, the membership has grown significantly to engage with over 2050 medical students, junior doctors and other medical practitioners. The RANZCP has seen 188 PIF members progress into psychiatry training and the following membership engagement in PIF activities and events:
more than100 members have been supported to attend Congress;
more than 230 have participated in the Introduction to Psychiatry short courses;
130 members have participated in the Essay Competitions;
more than130 members have attended NZ National conferences;
there are more than 730 Facebook likes/ followers.
Post-event feedback from participants has been favourable and the majority have indicated the program has met their needs.
Conclusions: The PIF is a unique initiative that successfully engages medical students, junior doctors and other medical practitioners with an interest in psychiatry and/ or mental health. In terms of increasing the exposure of psychiatry as a career choice to medical students/junior doctors, the PIF program is regarded by the RANZCP as a success.
Takotsubo Cardiomyopathy Following Marital Separation in a Patient with Psychiatric Disorders
D Yint, H Ahmed
Peel Rockingham and Kwinana Mental Health Service, Rockingham, Australia
Background: Takotsubo cardiomyopathy is a life-threatening condition with mortality similar to that of myocardial infarction. It comprises a transient cardiac syndrome involving left ventricular apical akinesis that is triggered by acute psychological or physical stress. There are few case reports regarding its occurrence in psychiatric disorders.
Case presentation: We review the literature and report the case of a 49-year-old woman who developed Takotsubo cardiomyopathy in the context of acute emotional stress brought upon by marital separation on a background of a history of restricted eating as well as anxiety and personality disorder. Abnormal findings on electrocardiography and an echocardiogram confirmed the diagnosis. Her medical management was complicated by her underlying psychiatric issues, especially her panic symptoms mimicking cardiac symptomatology. Conservative medical management and consistent psychological support led to eventual recovery and the patient has been free of recurrence since.
Conclusions: Although an uncommon condition, an awareness of Takotsubo cardiomyopathy may enable treating psychiatrists to suspect and to intervene promptly when managing patients with anxiety and eating disorders especially in the postmenopausal female population.
